PPO Dental Plan

ARA PREFERRED - PPO
THRU HEALTHPLEX - DENTCARE

HEALTHPLEX - PPO

	In-Network	Out-of-Network
Deductible	$50	$50
Family Deductible	$150	$150
Deductible Waived for Diagnostic & Preventive	Yes	Yes
Contract Year Maximum	$1,500	$1,500
Diagnostic Services	100%	80%
Basic Preventive Services	100%	80%
Basic Restorative Services	80%	80%
Periodontal Services	80%	80%
Endodontic Services	80%	80%
Oral Surgery Services	80%	80%
Prosthetics Repairs	80%	80%
Crowns and Bridges*	60%	50%
Dentures*	60%	50%
Major Periodontal Services*	60%	50%

 * There is a 12 month waiting period for coverage on these services, unless waived as noted above.

Note: The basis for all benefit payments will be the Healthplex PPO Schedule of Allowances. To determine the actual amount payable for any covered procedure, multiply the appropriate percentage shown above by the Healthplex PPO Fee or by the dentist's fee charged, whichever is less.

Monthly Healthplex Dental PPO Rates

 

Individual	$37.00
Couple	$71.00
Family	$99.00

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