Orthodox Health Plans

PPO Dental Summary

Plan Features                         In-Network          Out-of-Network

Plan Deductible (per calendar year;                      $50 Individual                         $50 Individual

Applies to all covered services)                                 $150 Family                            $150 Family

Routine Oral Exams, Prophylaxis,                                          100%                                       100% 

Diagnostic X-Rays                                              (Deductible waived)             (Deductible waived)

Fluoride Treatment (for dependent children to age 15)      

General Dental Expenses*                                   90% after deductible          80% after deductible

Crown, Inlays, Gold Fillings                                60% after deductible          50% after deductible

Fixed Bridgework and Orthodontia

Calendar year maximum                                                                      $1,500 per person

Orthodontia Lifetime Maximum                                                          $1,500 per person

Orthodontia Eligibility                                                                        Dependent children to age 19 only

  *General Dental Expenses-Includes non-surgical extractions; fillings; general anesthetics; non-surgical endodontic treatment; non-surgical periodontal treatment; initial installation of dentures; space maintainers (dependent children only); repair or recementing of crowns, inlays, bridgework or dentures; relining of dentures; and administration of drugs for prevention, alleviation or cure of disease or pain.

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