BENEFITS
PORTAL
PORTAL
Dental benefit summary
BENEFITS AND COVERED SERVICES
In- PPO
Out-of-PPO
DIAGNOSTIC & PREVENTIVE BENEFITS
-- Oral examinations, routine cleanings, x-rays, fluoride treatment, space maintainers, specialist consultations. Additional services for pregnant women may be available.
100%
100%
(of Negotiated Fee)**
(of Negotiated Fee)**
BASIC BENEFITS
-- Fillings, root canals, periodontics (gum treatment), tissue removal (biopsy), sealants, oral surgery (extractions)
80%
80%
(of Negotiated Fee)**
(of Negotiated Fee)**
CROWNS, OTHER CAST RESTORATIONS
-- Crowns, inlays, onlays and cast restorations
50%
50%
(of Negotiated Fee)**
(of Negotiated Fee)**
PROSTHODONTICS
-- Bridges, partial dentures, full dentures
50%
50%
(of Negotiated Fee)**
(of Negotiated Fee)**
*** While the benefits pay 80% of negotiated fee, please be aware that you will pay more when you
See an out of network dentist on this plan. (Please refer to the benefit summary for more details)
See an out of network dentist on this plan. (Please refer to the benefit summary for more details)
Your benefits are provided by :
