| |
High Plan
|
Medium Plan
|
Basic Plan
|
Calendar Year Maximum
|
$2,500
|
$2,000
|
$1,000
|
| $2,000
|
$1,500
|
$750
|
|
| $1,500
|
$1,200
|
$500
|
|
| $1,000
|
$1,000
|
|
|
Class I Preventive ServicesRoutine oral exam, cleanings, fluoride treatment for children, x-rays, sealants |
100% coverage for |
100% coverage for |
80% coverage for |
| Deductible
|
$0
|
$0
|
$0
|
| Waiting period |
No
|
No
|
No
|
Class II Basic ServicesFillings (amalgam, porcelain & plastic), general anesthesia, emergency palliative treatment, space maintainers for children, pathology |
90% coverage for |
80% coverage for |
80% coverage for eligible expenses |
| Deductible
|
$0, $25, $50, $75 or $100 per calendar year, |
$0, $25, $50, $75 or $100 per calendar year, |
$0, $25, $50, $75 or $100 per calendar year, |
| Waiting period
|
No
|
No
|
No
|
Class
III Major Services
Crowns & gold fillings, inlays, onlays and pontics, fixed bridges, complete & partial dentures |
60% coverage for |
50% coverage for |
50% coverage for |
| Deductible
|
Calendar year |
Calendar year |
Calendar year |
| Waiting period
|
12 months, unless waived |
12 months, unless waived
|
12 months, unless waived |
Oral
Surgery
|
Class
II
|
Class
II
|
Simple & surgical extractions under Class II, other oral surgery under Class III |
| Periodontics/Endodontics
|
Class II or Class III
|
Class II or Class III
|
Class
II or Class III
|
Class IV Orthodontics (optional)
|
50% coverage for eligible expenses
|
50% coverage for eligible expenses
|
50% coverage for eligible expenses
|
| Waiting period
|
12 months, unless waived |
12 months, unless waived |
12 months, unless waived |
| Child/Adult Lifetime Maximum Benefit Availability
|
Child & adult ($1,000) or |
Child
& adult ($1,000) or |
Child
only ($1,500 or $1,000)
|
Special
Dental Accident Benefit covers
injury to sound, natural teeth
|
$1,000 maximum per accident
|
$1,000 maximum per accident
|
$1,000 maximum per accident
|
ChildrenŐs Good Vision Benefit1 |
Yes
|
Yes
|
Yes
|
Reimbursement Level |
80th
or 90th percentile
|
80th
or 90th percentile
|
80th
or 90th percentile
|
|