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| Benefits | Preferred Provider Organization (PPO) Plan Available • Uniform Dental Plan (Group #3000) |
Managed-Care Plans Available • DeltaCare (Group #3100) • Willamette Dental |
| Annual deductible | Enrollee pays $50 per person/ $150 per family, except for diagnostic and preventive | No deductible |
| Annual maximum | $1,750 plan reimbursement per person; except as otherwise specified for orthodontia, nonsurgical TMJ, and orthognathic surgery | No general plan maximum |
| Dentures | 50%, PPO and out of state; 40%, non-PPO (dental plan payment) | Enrollee pays $140 copay, complete upper or lower |
| Endodontics (root canals) | 80%, PPO and out of state; 70%, non-PPO (dental plan payment) | Enrollee pays between $100 and $150 copay |
| Nonsurgical TMJ | 70%; $500 lifetime maximum (dental plan payment) | 70%; $1,000 annual maximum and $5,000 lifetime maximum (dental plan payment) |
| Oral surgery | 80%, PPO and out of state; 70%, non-PPO (dental plan payment) | Extraction of erupted teeth: Enrollee pays between $10 and $50 copay |
| Orthodontia | 50%; $1,750 lifetime maximum (dental plan payment) | Maximum enrollee copay per case: $1,500 |
| Orthognathic surgery | 70%; $5,000 lifetime maximum (dental plan payment) | 70%; $5,000 lifetime maximum (dental plan payment) |
| Periodontic services | 80%, PPO and out of state; 70%, non-PPO (dental plan payment) | Enrollee pays between $15 and $100 copay |
| Preventive/ diagnostic |
100%, PPO; 90%, out of state; 80%, non-PPO (dental plan payment) | 100% (dental plan payment) |
| Restorative crowns | 50%, PPO and out of state; 40%, non-PPO (dental plan payment) | Enrollee pays between $100 and $175 copay |
| Restorative fillings | 80%, PPO and out of state; 70%, non-PPO (dental plan payment) | Enrollee pays between $10 and $50 copay |
