Breadcrumb Home Funding Graduate Student Employment Agreement Appendix B Appendix B Dental Plan Provisions Co-payment: Plan/Member Diagnostic and Preventive Services: 100% / 0% Routine and Restorative Services: 80% / 20% after $25 deductible per year for single, $75 for family Major Restorative Care: 50% / 50% after $25 deductible per year for single, $75 for family Orthodontics: No coverage Maximum annual benefit of $1,000 per person, exclusive of accident care covered under Medicaid.