Quick facts
Deductible (Class A/Orthodontics)
$0
Annual Benefit Maximum
In-Network: Unlimited; Out-of-Network: $3,000
Class A Basic (Preventive/Diagnostic) Coinsurance
In-Network: 0%; Out-of-Network: 10%
Orthodontics Coinsurance
In-Network: 50%; Out-of-Network: 50%
Deductible - Class B/C In-Network
$0
Deductible - Class B/C Out-of-Network
$50
Class B Intermediate Coinsurance
In-Network: 30%; Out-of-Network: 40%
Class C Major Coinsurance
In-Network: 50%; Out-of-Network: 60%
More details (2)
Implant Maximum
$2,500 per person per calendar year (in-network or out-of-network combined)
Lifetime Orthodontic Maximum
$3,500 for dependents up to 21 (or 23 if full-time student) or 22 for civilian dependents; $2,000 for members and spouses (in-network and out-of-network)
Carrier contact
855-410-3255 — member services
Your member ID card: check the carrier website or app, or ask HR for a copy.
Plan documents
Confirm details with your carrier for current plan information.