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BENEFITS CHART

Compare your premium costs to the benefits for each plan option to determine which plan is right for you.

Benefits Chart Benefits Chart - High Option
High Option High Option Standard Option
What you pay for common services
IN-NETWORK OUT-OF-NETWORK IN-NETWORK OUT-OF-NETWORK
Class A (Basic) Services e.g., exams, cleanings, X-rays, sealants You pay nothing You pay 10% You pay nothing You pay 40%
Class B (Intermediate) Services e.g., oral surgery, fillings, gum scaling You pay 30% You pay 40% You pay 45% You pay 60%
Class C (Major) Services e.g., crowns, bridges, implants, root canals, dentures You pay 50% You pay 60% You pay 65% You pay 80%
Class D (Orthodontics) Services Adults & Children You pay 50% up to $3,500 lifetime maximum per person You pay 50% up to $3,500 lifetime maximum per person You pay 50% up to $2,500 lifetime maximum per person You pay 50% up to $1,250 lifetime maximum per person
Annual Deductible
for Class A, B and C Services
Does not apply to Class D (Orthodontics)
You pay
no deductible
You pay $50
per person
You pay
no deductible
You pay $75
per person
Annual Maximum Benefits
for Class A, B and C Services
Does not apply to Class D (Orthodontics)
No benefit limit We pay up to
$3,000 per person
We pay up to
$1,500 per person
We pay up to
$750 per person
Benefits Chart - Standard Option
Standard Option
What you pay for common services
IN-NETWORK OUT-OF-NETWORK
Class A (Basic) Services e.g., exams, cleanings, X-rays, sealants You pay nothing You pay 40%
Class B (Intermediate) Services e.g., oral surgery, fillings, gum scaling You pay 45% You pay 60%
Class C (Major) Services e.g., crowns, bridges, implants, root canals, dentures You pay 65% You pay 80%
Class D (Orthodontics) Services Adults & Children You pay 50% up to $2,500 lifetime maximum per person You pay 50% up to $1,250 lifetime maximum per person
Annual Deductible
for Class A, B and C Services
Does not apply to Class D (Orthodontics)
You pay
no deductible.
You pay $75
per person
Annual Maximum
for Class A, B and C Services
Does not apply to Class D (Orthodontics)
We pay up to
$1,500 per person
We pay up to
$750 per person

Found a plan that works for you? Enroll now through BENEFEDS.com or call 1-877-888-FEDS (3337); TTY: 1-877-889-5680.

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