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.