|Premium Option||Basic Option|
|Annual Deductible||$50 Individual
|Calendar-year Maximum||$2,500 per person||$1,250 per person|
|Diagnostic & Preventive Services
Exams, two cleanings per year, x-rays, topical fluoride treatments for children 1x/year to age 15, sealants once every 60 months to age 19
|Covered at 100% (no deductible)||Covered at 100% (no deductible)|
Extractions, fillings and oral surgery except removal of wisdom teeth, repair or recementing of crowns, and relining of dentures
|Plan pays 80% after deductible||Plan pays 80% after deductible|
Inlays, first installation of bridgework, dentures and crowns, implants, removal of impacted teeth
|Plan pays 50% after deductible||Plan pays 50% after deductible|
|Orthodontia||Plan pays 50% up to a lifetime maximum of $1,500
Dependent children and adults.
|Plan pays 50% up to a lifetime maximum of $1,000
Dependent children only up to age 19.