Quick facts
Deductible (Class A/Orthodontics)
$0
Family Deductible
There is no family deductible limit
Annual Benefit Maximum
In-Network $1,500 / Out-of-Network $1,000
Class A Basic Services Coinsurance (In/Out-Network)
0% in-network / 40% out-of-network
Orthodontic Coinsurance (In/Out-Network)
50% in-network / 50% out-of-network
Class B Intermediate Services Coinsurance (In/Out-Network)
45% in-network / 60% out-of-network
Implant Only Maximum
A separate implant maximum does not apply under the Standard Option
Class C Major Services Coinsurance (In/Out-Network)
65% in-network / 80% out-of-network
Carrier contact
855-410-3255 — member services
Your member ID card: check the carrier website or app, or ask HR for a copy.
Confirm details with your carrier for current plan information.