Benefits-Network Provider* | BASIC PLAN | PREMIERE PLAN |
---|---|---|
Covered Services: | Preventive, Diagnostic, Restorative and Adjunctive Services | Preventive, Diagnostic, Restorative, Adjunctive, Endodontics, Periodontics, and Oral Surgery Services |
Type I | 100% - No waiting period and No deductible | 100% - No waiting period and No deductible |
Type II | 50% - 6 month waiting period | 80% - 6 month waiting period |
Type III | Not covered - network discounts | 60% - 12 month waiting period |
Calendar year deductible | $100/person - 3 max per family | $50/person - 3 max per family |
Calendar year maximum | $1,000 per person $5,000 per family |
$1,200 per person $6,000 per family |
0-64 MONTHLY PREMIUMS* | BASIC | PREMIERE |
---|---|---|
Adult | $19 | $39 |
Child | $16 | $28 |
65-99 MONTHLY PREMIUMS* | BASIC | PREMIERE |
---|---|---|
Adult | $21 | $43 |
VISION � Network Provider** | |
---|---|
Eye Exam (per 12 month period) | 100%, no copay |
Standard, Uncoated Plastic Lenses (in lieu of contact lenses) | $10 copay |
Frames (in lieu of contact lenses) | $10 copay with $120 allowance |
Corrective Contact Lenses (in lieu of standard uncoated plastic lenses and frames) | $10 copay with $120 allowance |
0-64 MONTHLY PREMIUMS | |
---|---|
Individual | $9 |
2 Persons | $16 |
Family | $25 |
65-99 MONTHLY PREMIUMS | BASIC |
---|---|
Individual | $10 |
2 Persons | $18 |