Dental health services triple choice gold plan fee schedule

The benefits of the dental plan are based on cost sharing features that include a deductible and coinsurance. Plan benefits and your out-of-pocket costs will differ depending on the provider you choose.

The member deductible on combined basic and major restorative services is $25 for individuals and $75 for families. $2500 calendar year maximum benefit for preventative, basic, and major restorative services.

Preventative Services covered at 100%

Basic Restorative Services covered at 85%

Major Restorative Services Covered at 60%

Orthodontic Services covered at 50%

This dental plan is the same for Active and Medicare members.