2023 Dental Plans
Standard Plan
Individual
Standard
In-Network Individual dental deductible
$75
Out-of-network Individual dental deductible
$150
In-network Individual maximum out-of-pocket (MOOP)
$375 per child, N/A for adults
In-network and Out-of-network individual maximum coverage allowance
$1,000 for adults, N/A for children
Family
In-network Family dental deductible
$225
Out-of-network Family dental deductible
$450
In-network Family maximum out-of-pocket (MOOP)
$750 per family, N/A for adults
In-network and Out-of-network Family Maximum coverage allowance
$2,000 for adults, N/A for children
Class A: Diagnostic/Preventative
In-Network Coverage
0%
Out-of-Network Coverage
50% after deductible
Waiting Period
N/A
Class B: Basic/Restorative
In-Network Coverage
20% after deductible
Out-of-Network Coverage
60% after deductible
Waiting Period
6 months for adults, N/A for children
Class C: Major
In-network Coverage
50% after deductible
Out-of-Network Coverage
75% after deductible
Waiting Period
12 months for adults, N/A for children
Class D: Child-only Orthodontics
In-Network Coverage
50% after deductible
Out-of-Network Coverage
50% after deductible
Waiting Period
N/A
The out-of-pocket maximum is the sum of the dental deductible and any coinsurance percentage of covered expenses, as shown in your Evidence of Coverage.
Some services listed above may require prior authorization to be filed. Refer to our Evidence of Coverage for more information.
Some services listed above may require prior authorization to be filed. Refer to our Evidence of Coverage for more information.