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. | |