Dental PPO

Feature	Coverage
Preventive Treatment	100% with no annual deductible1 Includes oral exams, cleanings and X-rays (subject to limitations) as well as emergency treatment
Basic Treatment	80% after annual deductible1 Includes basic cavity filings, root canal therapy and oral surgery Includes periodontic treatment Includes nonsurgical TMJ treatment, up to individual lifetime maximum benefit of $2,000
Major Treatment2	50% after annual deductible1 Includes crowns, dentures and bridgework
Orthodontia2,3	50% after annual deductible, up to individual lifetime maximum benefit of $1,5001
Annual Deductible (applies to Basic, Major and Orthodontia treatment only)
Individual Family	$75 $150
Annual Maximum Benefit	$1,200 per person

 

1	Reasonable and customary limits apply to out-of-network providers.
2	You become eligible for these benefits only after you have been covered by an HCA dental plan option for a period of at least 12 months.
3	Orthodontic coverage is available to you and all covered dependents.

You will be responsible for any amounts over the reasonable and customary charges when you use an out-of-network provider.