Enrollment Form

HMO Schedule of Benefits

PPO Schedule of Benefits

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Dental Benefits

There are 2 dental plans to choose from: HMO or PPO. The benefits for the PPO are outlined below, or they can be downloaded from the links to the left. The HMO Schedule of Benefits is more specific and can be downloaded in the links to the left.

 

 

 

 

	PPO (In-Network)
Calendar Year Maximum	$1,000 (excludes Class I)
Calendar Year Deductible	$25 per person $75 per family
Class I Initial/Routine Oral Exam, Teeth Cleaning & Routine Scaling, Fluoride Treatment, Sealant, X-rays as part of a general exam, Emergency Treatment	100% covered(no deductible)
Class II Problem-focused Exams & Related X-rays, Fillings, General Anesthetics, Space Maintainers	90% covered after deductible
Class III Crowns, Removable & Fixed Bridges, Complete & Partial Dentures, Oral Surgery, Periodontics, Endodontics	60% covered after deductible