Deductible $50 individual
$100 family
Annual Maximum Benefit (excludes orthodontia) $2,500 per person
Type of Service Plan Pays
Preventive Care Covered 100% in-network
Basic Care 20%
Major Care 50%
Orthodontia 50%
Orthodontia lifetime maximum (The lifetime orthodontia max is separate from the annual maximum. The orthodontia benefit is only available for individuals up through age 19.) $2,500