| 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 |