| Services Covered |
Year
1 |
Year
2 |
Year
3 |
Type 1: Diagnostic & Preventive Services
- Oral exams
- X-rays
- Cleanings
- Fluoride treatments
- Space maintainers
|
80% |
90% |
100% |
Type 2: Basic Services
- Fillings
- Palliative care
- Denture repair
- Sealants
- General anesthesia
|
60% |
70% |
80% |
Type 3: Major Services
- Simple extractions
- Endodontics
- Periodontics
- Complex oral surgery
- Crowns, Inlays/Onlays, Bridges,
Dentures
|
25% |
30% |
50% |
| Monthly
Rates* |
Member |
$33.22 |
Member + Family |
$75.72 |
Deductible
(Deductible waived for Type 1: Diagnostic and Preventive Services) |
$50 per
person per calendar year
|
| Annual Maximum |
$1,000
per person per calendar year |
*Rates include a $2.00 Monthly Billing Fee and are
valid through 3/31/2011
