| Plan Details | ||
|---|---|---|
| Plan Name | PPO | |
| Effective Dates | Jan 01, 2025 to Jan 01, 2026 | |
| Benefits | In-Network | Out-of-Network |
| Annual Deductible/Individual | $40 | $50 |
| Annual Deductible/Family | $120 | $150 |
| Annual Plan Maximum | $1,500 | $1,500 |
| Lifetime Orthodontia Plan Maximum | $1,500 | $1,000 |
| Diagnostic and Preventive Services | 0% deductible does not apply | 20% deductible does not apply |
| Basic Services | 20% | 20% |
| Endodontic Treatment | 20% | 20% |
| Periodontic Treatment | 20% | 20% |
| Major Services | 50% | 50% |
| Orthodontia Services | 50% deductible does not apply | 50% deductible does not apply |
| Ortho Dependent Children | Covered | Covered |
| Ortho Adults | Covered | Covered |