Dental Benefits

Deductible (Individual/Family)

$25 / $50

Annual Maximum Benefit per Person

$1,500

Diagnostic & Preventative Care
• Oral evaluations - twice per benefit period

• Bitewing x-rays - twice per benefit period for dependents under age 18; once each 12 months for
adults age 18 and over

• Full mouth or panoramic x-rays - once each 5 years

• Cleanings - UNLIMITED!

• Topical fluoride - twice per benefit period for dependents under age 19

• Space Maintainers - for dependents under age 14

• Sealants - once per tooth, per lifetime for dependents under age 16

Covered at 100%

Basic Services (subject to deductible)
• Ancillary - 1 emergency exam per benefit period for relief of pain

• Oral surgery (includes pre & post operative care)

• Fillings

• Periodontics

• Endodontics - root canal treatments and root canal fillings

Covered at 80%

Major Services
(subject to deductible)

• Bridges (includes repairs & adjustments)

• Crowns

• Partial and complete dentures

• Implants

Covered at 50%

Orthodontics (subject to deductible)
• Orthodontic appliances and treatment for dependent children under age 19

• Lifetime maximum benefit for orthodontic services is $1,500 per enrollee (Payment for
orthodontic services not included in annual maximum)

Covered at 50%

Right Start 4 Kids
Children, age 12 and under, receive coverage at 100% for all services covered under the plan. Not subject to deductible,
but the plan’s annual maximum and frequencies/limitations apply. Excludes orthodontics. Must see an in-network provider
or the plan’s underlying contract applies including waiting periods, deductibles and coinsurance levels.

Employee Only

$24.79

$15.21

$7.61

$3.51

Family

$66.62

$58.38

$29.19

$13.48