PCEA Employees Dental Summary

Provider

Summary

ODS - Incentive                              

Preventive and Basic Services

• 1st year – 70% to annual maximum *

• 2nd year – 80% to annual maximum *

• 3rd year – 90% to annual maximum *

• 4th year – 100% to annual maximum *

• Major Services – 50% to annual maximum

• Orthodontia - $1,000 lifetime maximum per enrollee

• Calendar year maximum - $1,000 per enrollee

* provided the enrollee visits the dentist at least once during the calendar year

ODS - Traditional           

• Preventive Services – 100% to annual maximum

• Basic Services – 80% to annual maximum

• Major Services – 60% to annual maximum

• Orthodontia - $1,000 lifetime maximum per enrollee

• Calendar year maximum - $1,500 per enrollee

Forms/Documents    

Links

ODS Summary Plan Document Traditional

ODS Summary Plan Document Incentive

Website