Preventive, Diagnostic & Basic Services
Find the plan that's best for your 2-9 enrolled group
PPO calendar year maximum$1,000 or $1,250
per enrollee
Premier & Out of Network calendar year maximum$1,000 or $1,250
per enrollee
Deductible$50/$150
Per person/per family (excluding P&D)
Preventive & Diagnostic
Oral exams/evaluations100%
2 per calendar year
Cleanings100%
2 per calendar year
Bitewing X-rays100%
2 per calendar year (through age 18); 1 per calendar year (19+)
Full mouth X-rays100%
1 per 5 years
Sealants100%
Once in a 24-month period per tooth (through age 14)
Topical fluoride100%
2 per calendar year (through age 18)
Space maintainers100%
1 per arch per lifetime (through age 13)
Basic Services
Fillings80%
Repeat restorations of same surface payable once in 2 years
Composite/resin restorations80%
Composite resin restorations will be covered on all teeth
Simple extractions80%
1 per lifetime per tooth
Root canal therapy80%
1 per lifetime per tooth
Periodontal maintenance80%
2 per calendar year
Scaling and root planing80%
1 per 2 years per quadrant
Periodontal surgeries80%
1 per 3 years per quadrant
Oral surgery80%
Frequencies vary by procedure code
OrthodonticsNot covered
Waiting PeriodsNone
Plan Details
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PPO calendar year maximum$1,000 or $1,250
per enrollee
Premier & Out of Network calendar year maximum$750 or $1,000
per enrollee
Deductible$50/$150
Per person/per family (excluding P&D)
Preventive & Diagnostic
Oral exams/evaluations100%
2 per calendar year
Cleanings100%
2 per calendar year
Bitewing X-rays100%
2 per calendar year (through 18); 1 per calendar year (19+)
Full mouth X-rays100%
1 per 5 years
Sealants100%
Once in a 24-month period per tooth (through age 14)
Topical fluoride100%
2 per calendar year (through age 18)
Space maintainers100%
1 per arch per lifetime (through age 13)
Basic Services
Fillings80%
Repeat restorations of same surface payable once in 2 years
Composite/resin restorations80%
Composite resin restorations will be covered on all teeth
Simple extractions80%
1 per lifetime per tooth
Root canal therapy80%
1 per lifetime per tooth
Periodontal maintenance80%
2 per calendar year
Scaling and root planing80%
1 per 2 years per quadrant
Periodontal surgeries80%
1 per 3 years per quadrant
Oral surgery80%
Frequencies vary by procedure code
OrthodonticsNot covered
Waiting PeriodsNone
Plan Details
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* These are benefit highlights only. Additional exclusions and limitations may apply. Monthly premiums shown are examples only of our lowest monthly rates per employee for employee only coverage. Actual rates vary based on plan choice, your location, and number of people insured. For full details of plans, benefits and pricing, please contact one of our account executives.
