Individual Dental Plans

Good oral health is a key part of your overall health. Look over our dental plans to find the one with the preventive, basic, and major services that are right for you.

  • Prices and benefits are for each individual looking for a plan.
  • Benefits are for services received from participating providers.
  • Dollar amounts or percentages listed are the member’s out-of-pocket cost for adults 19 years and older.

Dental Plus Plan (for people 65 years and better)

Plan Deductible Calendar year maximum Maximum out-of-pocket Monthly premiums
Adult

Plan Benefits

  (amount you pay)

Preventive

Exams: 0%

X-rays: 0%

Cleanings: 0%

Routine/Basic

Silver Fillings: 20%

White Fillings: 20%

Major

Crowns: 50%

Waiting period(s)

Six Month Routine/Basic
12 Month Major

All plan benefits shown are based on Eligible Charges. Services received from a nonparticipating provider will likely result in higher out-of-pocket expenses.

$251 $1,000 Does not apply $44.77 / single
$89.55 / two party

1. Deductible applies to basic and major services only.

Preferred Provider Plans

Get the freedom to choose your own dentist. See a PPP participating dentist for lower out-of-pocket costs.

Plan Deductible Calendar year maximum Maximum out-of-pocket Monthly premiums
PPP Pediatric Essential
Pediatric

Plan Benefits

  (amount you pay)

Preventive

Exams: 0%

X-rays: 0%

Cleanings: 0%

Fluoride: 0%

Routine/Basic

Fillings: 30%

Periodontal: 30% Scaling and Root Planing

Root Canals: 30%

Major

Crowns: 50% Noble Metal Crowns

Waiting period(s)

None

* Members ages 19-20 aren’t eligible for pediatric dental plan benefits.

$0 Does not apply $350 child / $700 (2+ children) maximum $40.16 / ages 0 - 18*
PPP Basic
Pediatric

Plan Benefits

  (amount you pay)

Preventive

Exams: 10%

X-rays: 10%

Cleanings: 10%

Fluoride: 10%

Routine/Basic

Fillings: 40%

Periodontal: 40% Scaling and Root Planing

Root Canals: 40%

Major

Crowns: 60% Noble Metal Crowns

Waiting period(s)

None

* Members ages 19-20 aren’t eligible for pediatric dental plan benefits.

$25 Does not apply $350 child / $700 (2+ children) maximum $33.51 / ages 0 - 18
Adult

Plan Benefits

  (amount you pay)

Preventive

Exams: 10%

X-rays: 10%

Cleanings: 10%

Routine/Basic

Fillings: 40%

Periodontal: Not a Benefit

Root Canals: Not a Benefit

Major

Crowns: Not a Benefit

Waiting period(s)

Six Month Basic

$25 $1,000 Does not apply $33.51 / ages 19 - 20
$16.21 / age 21+
PPP High
Pediatric

Plan Benefits

  (amount you pay)

Preventive

Exams: 0%

X-rays: 0%

Cleanings: 0%

Fluoride: 0%

Routine/Basic

Fillings: 30%

Periodontal: 30% Scaling and Root Planing

Root Canals: 30%

Major

Crowns: 50% Noble Metal Crowns

Waiting period(s)

None

* Members ages 19-20 aren’t eligible for pediatric dental plan benefits.

$0 Does not apply $350 child / $700 (2+ children) maximum $39.91 / ages 0 - 18
Adult

Plan Benefits

  (amount you pay)

Preventive

Exams: 0%

X-rays: 0%

Cleanings: 0%

Routine/Basic

Fillings: 30%

Major

Crowns: 50%

Periodontal: 50%

Root Canals: 50%

Waiting period(s)

Six Month Basic

12 Month Major

$0 $1,000 Does not apply $39.91 / ages 19 - 20
$33.57 / age 21+

Health Maintenance Organization Plans

See dentists in our HMO health center network.

Plan Deductible Calendar year maximum Maximum out-of-pocket Monthly premiums
HMO Basic
Pediatric

Plan Benefits

  (amount you pay)

Preventive

Exams: $10

X-rays: $10 & Up

Cleanings: $10

Fluoride: $5

Routine/Basic

Fillings: $40 & Up

Periodontal: $90 & Up Scaling and Root Planing

Root Canals: $285

Major

Crowns: $225 & Up Noble Metal Crowns

Waiting period(s)

None

* Members ages 19-20 aren’t eligible for pediatric dental plan benefits.

$0 Does not apply $350 child / $700 (2+ children) maximum $21.81 / ages 0 - 18
Adult

Plan Benefits

  (amount you pay)

Preventive

Exams: $10

X-rays: $10 & Up

Cleanings: $10

Routine/Basic

Fillings: $40 & Up

Periodontal: $90 & Up

Root Canals: $285

Major

Crowns: $225 & Up

Waiting period(s)

12 Month Major

$0 Does not apply Does not apply $21.81 / ages 19 - 20
$20.76 / age 21+

2016 Plans

Dental Plus Plan (for people 65 years and better)

Plan Deductible Calendar year maximum Maximum out-of-pocket Monthly premiums
Adult

Plan Benefits

  (amount you pay)

Preventive

Exams: 0%

X-rays: 0%

Cleanings: 0%

Routine/Basic

Silver Fillings: 20%

White Fillings: 20%

Major

Crowns: 50%

Waiting period(s)

Six Month Routine/Basic
12 Month Major

All plan benefits shown are based on Eligible Charges. Services received from a nonparticipating provider will likely result in higher out-of-pocket expenses.

$251 $1,000 Does not apply $44.77 / single
$89.55 / two party

1. Deductible applies to basic and major services only.

Preferred Provider Plans

Get the freedom to choose your own dentist. See a PPP participating dentist for lower out-of-pocket costs.

* Members ages 19-20 aren’t eligible for pediatric dental plan benefits.

Plan Deductible Calendar year maximum Maximum out-of-pocket Monthly premiums
PPP Pediatric Essential
Pediatric

Plan Benefits

  (amount you pay)

Preventive

Exams: 0%

X-rays: 0%

Cleanings: 0%

Fluoride: 0%

Routine/Basic

Fillings: 30%

Periodontal: 30%

Root Canals: 30%

Major

Crowns: 50%

Waiting period(s)

24 Month Medically Necessary Orthodontia

* Members ages 19-20 aren’t eligible for pediatric dental plan benefits.

$0 Does not apply $350 child / $700 (2+ children) maximum $39.37 / ages 0 - 18*
PPP Basic
Pediatric

Plan Benefits

  (amount you pay)

Preventive

Exams: 10%

X-rays: 10%

Cleanings: 10%

Fluoride: 10%

Routine/Basic

Fillings: 40%

Periodontal: 40%

Root Canals: 40%

Major

Crowns: 60%

Waiting period(s)

24 Month Medically Necessary Orthodontia

$25 Does not apply $350 child / $700 (2+ children) maximum $32.85 / ages 0 - 18
Adult

Plan Benefits

  (amount you pay)

Preventive

Exams: 10%

X-rays: 10%

Cleanings: 10%

Routine/Basic

Fillings: 40%

Periodontal: Not a Benefit

Root Canals: Not a Benefit

Major

Crowns: Not a Benefit

Waiting period(s)

Six Month Basic

$25 $1,000 Does not apply $32.85 / ages 19 - 20
$15.89 / age 21+
PPP High
Pediatric

Plan Benefits

  (amount you pay)

Preventive

Exams: 0%

X-rays: 0%

Cleanings: 0%

Fluoride: 0%

Routine/Basic

Fillings: 30%

Periodontal: 30%

Root Canals: 30%

Major

Crowns: 50%

Waiting period(s)

24 Month Medically Necessary Orthodontia

$0 Does not apply $350 child / $700 (2+ children) maximum $39.13 / ages 0 - 18
Adult

Plan Benefits

  (amount you pay)

Preventive

Exams: 0%

X-rays: 0%

Cleanings: 0%

Routine/Basic

Fillings: 30%

Major

Crowns: 50%

Periodontal: 50%

Root Canals: 50%

Waiting period(s)

Six Month Basic

12 Month Major

$0 $1,000 Does not apply $39.13 / ages 19 - 20
$32.91 / age 21+

Health Maintenance Organization Plans

See dentists in our HMO health center network.

* Members ages 19-20 aren’t eligible for pediatric dental plan benefits.

Plan Deductible Calendar year maximum Maximum out-of-pocket Monthly premiums
HMO Basic
Pediatric

Plan Benefits

  (amount you pay)

Preventive

Exams: $10

X-rays: $10 & Up

Cleanings: $10

Fluoride: $5

Routine/Basic

Fillings: $40 & Up

Periodontal: $20 & Up

Root Canals: $285

Major

Crowns: $225 & Up

Waiting period(s)

24 Month Medically Necessary Orthodontia

$0 Does not apply $350 child / $700 (2+ children) maximum $21.39 / ages 0 - 18
Adult

Plan Benefits

  (amount you pay)

Preventive

Exams: $10

X-rays: $10 & Up

Cleanings: $10

Routine/Basic

Fillings: $40 & Up

Periodontal: $20 & Up

Root Canals: $285

Major

Crowns: $225 & Up

Waiting period(s)

12 Month Major

$0 Does not apply Does not apply $21.39 / ages 19 - 20
$20.35 / age 21+