Fast Facts:

Dental Plan Side-By-Side Comparison

$2,000 Max Plan with Orthodontia $1,000 Max Plan with Orthodontia

PLAN FEATURE In-Network Out-of-Network In-Network Out-of-Network

Deductible: Per Person $50 $50 $50 $50

Deductible: Maximum Family
$150 $150 $150 $150
Deductible
Annual Maximum Benefit $2,000 $2,000 $1,000 $1,000

Preventive Care

100%, 100%, 100%, 100%,

Prophylaxis
no deductible no deductible no deductible no deductible

Oral Exams 100%, no deductible 100%, no deductible 100%, no deductible 100%, no deductible

Problem-Focused Exams 100%, no deductible 100%, no deductible 100%, no deductible 100%, no deductible

Consultations 100%, no deductible 100%, no deductible 100%, no deductible 100%, no deductible

Periodontal Maintenance 100%, no deductible 100%, no deductible 100%, no deductible 100%, no deductible

Fluoride Application 100%, no deductible 100%, no deductible 100%, no deductible 100%, no deductible

X-Rays 100%, no deductible 100%, no deductible 100%, no deductible 100%, no deductible

Basic Services

Palliative Care 90%, after deductible 90%, after deductible 80%, after deductible 80%, after deductible

Space Maintainers 90%, after deductible 90%, after deductible 80%, after deductible 80%, after deductible

Sealants 90%, after deductible 90%, after deductible 80%, after deductible 80%, after deductible
Fillings (amalgams/direct
90%, after deductible 90%, after deductible 80%, after deductible 80%, after deductible
composites)
Stainless Steel Crowns 90%, after deductible 90%, after deductible 80%, after deductible 80%, after deductible

Extractions
90%, after deductible 90%, after deductible 80%, after deductible 80%, after deductible
(non-impactions)

Scaling and Root Planning 90%, after deductible 90%, after deductible 80%, after deductible 80%, after deductible

Full Mouth Debridement 90%, after deductible 90%, after deductible 80%, after deductible 80%, after deductible

Incision and Drainage of Abscess 90%, after deductible 90%, after deductible 80%, after deductible 80%, after deductible

Sedative Fillings 90%, after deductible 90%, after deductible 80%, after deductible 80%, after deductible

Endodontics (non-molar) 90%, after deductible 90%, after deductible 80%, after deductible 80%, after deductible

1
 Fast Facts:
Dental Plan Side-By-Side Comparison

$2,000 Max Plan with Orthodontia $1,000 Max Plan with Orthodontia

PLAN FEATURE In-Network Out-of-Network In-Network Out-of-Network

Major Services

Extractions — Impactions 60%, after deductible 60%, after deductible 50%, after deductible 50%, after deductible

Veneers 60%, after deductible 60%, after deductible 50%, after deductible 50%, after deductible

Inlays, Onlays and Crowns 60%, after deductible 60%, after deductible 50%, after deductible 50%, after deductible

Post and Core Retention 60%, after deductible 60%, after deductible 50%, after deductible 50%, after deductible

Core Build-Up 60%, after deductible 60%, after deductible 50%, after deductible 50%, after deductible

Bridges 60%, after deductible 60%, after deductible 50%, after deductible 50%, after deductible

Crown and Bridge Recements 60%, after deductible 60%, after deductible 50%, after deductible 50%, after deductible

Dentures 60%, after deductible 60%, after deductible 50%, after deductible 50%, after deductible

Denture Relines 60%, after deductible 60%, after deductible 50%, after deductible 50%, after deductible

Denture Rebase 60%, after deductible 60%, after deductible 50%, after deductible 50%, after deductible

Dental Implants 60%, after deductible 60%, after deductible 50%, after deductible 50%, after deductible

Occlusal guards (bruxism) 60%, after deductible 60%, after deductible 50%, after deductible 50%, after deductible

Endodontics (molar) 60%, after deductible 60%, after deductible 50%, after deductible 50%, after deductible

Periodontal Surgery 60%, after deductible 60%, after deductible 50%, after deductible 50%, after deductible

Gingivoplasty/Gingivectomy 60%, after deductible 60%, after deductible 50%, after deductible 50%, after deductible

Osseous Surgery 60%, after deductible 60%, after deductible 50%, after deductible 50%, after deductible

General Anesthesia and IV Sedation 60%, after deductible 60%, after deductible 50%, after deductible 50%, after deductible

Other Plan Provisions

Coverage based Coverage based Coverage based Coverage based
Emergency Dental Care
on service type on service type on service type on service type
Temporomandibular Joint Disorders
Not covered Not covered Not covered Not covered
(TMJ)
Cosmetic Services/Procedures Not covered Not covered Not covered Not covered

Orthodontic Services
Children only, Children only, Children only, Children only,
Eligibility
under age 19 under age 19 under age 19 under age 19
Deductible Does not apply Does not apply Does not apply Does not apply

Orthodontia coverage 50%, no deductible 50%, no deductible 50%, no deductible 50%, no deductible
Orthodontic Lifetime Maximum (per
person; combined for in- and out-of- $2,000 $2,000 $1,000 $1,000
network care) 2