Quick facts
Deductible (in-network)
$0
Out-of-network: $75
Family deductible
There is no family deductible limit
Annual benefit maximum (in-network)
$1,500
Preventive & diagnostic (Class A) — you pay, in-network
0%
Orthodontia — you pay
50%
Basic services (Class B) — you pay, in-network
45%
Major services (Class C) — you pay, in-network
65%
Implant maximum
No separate implant maximum under the Standard Option (the annual benefit maximum applies)
More details (1)
Orthodontia lifetime maximum (in-network)
$2,000 for dependents
Amounts are in-network unless noted.
Carrier contact
1-800-555-0199 — member services
Group number: 88410
Your member ID card: check the carrier website or app, or ask HR for a copy.