🔸 $50 annual deductible for basic and major services (per person)

🔸 $150 Max (per family)

🔸 No deductible for preventative services.

🔸 Routine Exam (2 per 12 months)

🔸 Cleaning (2 per 12 months)

🔸 Bitewing X-rays (1 per 12 months)

🔸 Fluoride for children under age 16 (1 per 12 months)

🔸 Full Mouth/Panoramic X-rays (1 per 3 years)

🔸 Restorative Amalgams (fillings)

🔸 Sealants (ages 6 through 16)

🔸 Simple Extractions

🔸 Space Maintainers (child under 16)

🔸 Onlays

🔸 Oral Surgery

🔸 Denture Repair

🔸 Implants

🔸 Dentures (1 appliance per 5 years)

🔸 Crowns (1 per tooth, per 7 years)

🔸 Bridge (1 per 7 years)

🔸 Periodontics (surgical)

🔸 Crown Repair

🔸 Complex Extractions

🔸 Endodontics (nonsurgical)

🔸 Anesthesia

🔸 Periodontics (surgical)

Copay

$20 Exam / $25 Materials per Covered Person per Office Visit

Benefit

Frequency

Exam:

Every 12 months

Lenses:

Every 12 months

Frame:

Every 24 months

Benefit

Participating Provider

Non-Participating Provider

WellVision Exam

Covered after $20 Exam Copay

Up to $45 after $10 Exam Copay

Contact Lens Exam

15% Savings on a contact lens exam

Frame Allowance

$200 allowance for a wide selection of frames or $220 allowance on a featured frame brand

Lenses

Participating Provider

Non-Participating Provider

Single Vision

Covered after $25 materials Copay

Up to $30.00

Lined BiFocal

Covered after $25 materials Copay

Up to $50.00

Lined TriFocal

Covered after $25 materials Copay

Up to $65.00

Progressives

Covered after additional $50 Copay

Up to $150.00

Impact-Resistant (polycarbonate) lenses for children

Fully covered after Copay (Up to age 18)

Contacts (instead of glasses)

$150 allowance every 12 months for contacts and contact lens exam (fitting and evaluation)

$105 allowance every 12 months for contacts and contact lens exam (fitting and evaluation)

Discounts & Savings