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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
You pay
IN-NETWORK OUT-OF-NETWORK IN-NETWORK OUT-OF-NETWORK
Class A (Basic) Services e.g., exams, cleanings, X-rays, sealants Nothing 10% Nothing 40%
Class B (Intermediate) Services e.g., oral surgery, fillings, gum scaling 30% 40% 45% 60%
Class C (Major) Services e.g., crowns, bridges, implants, root canals, dentures 50% 60% 65% 80%
Annual Deductible for Class A, B and C Services Does not apply to Class D (Orthodontics) $0 $50 per person $0 $75 per person
Class D (Orthodontics) Services Adults & Children 50% up to $3,500 lifetime maximum per person 50% up to $3,500 lifetime maximum per person 50% up to $2,500 lifetime maximum per person 50% up to $1,250 lifetime maximum per person
Annual Maximum Benefits for Class A, B and C Services Does not apply to Class D (Orthodontics) Unlimited maximum per person We pay $3,000 per person We pay $1,500 per person We pay $750 per person
Benefits Chart - Standard Option
Standard Option
You pay
IN-NETWORK OUT-OF-NETWORK
Class A (Basic) Services e.g., exams, cleanings, X-rays, sealants Nothing 40%
Class B (Intermediate) Services e.g., oral surgery, fillings, gum scaling 45% 60%
Class C (Major) Services e.g., crowns, bridges, implants, root canals, dentures 65% 80%
Annual Deductible for Class A, B and C Services Does not apply to Class D (Orthodontics) $0 $75 per person
Class D (Orthodontics) Services Adults & Children 50% up to $2,500 lifetime maximum per person 50% up to $1,250 lifetime maximum per person
Annual Maximum Benefits for Class A, B and C Services Does not apply to Class D (Orthodontics) We pay $1,500 per person We pay $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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