Capital Blue Cross - Dental PPO Loyalty Plan
Benefits Resources |
|---|
| Provider Directory |
| Summary of Benefits and Coverage |
| Download Plan Brochure |
Summary |
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|---|---|
| Plan Name | Dental PPO Loyalty Plan |
| Plan Type | PPO |
| Plan Tier | LOW |
Deductible & Out-of-Pocket Max |
|
|---|---|
| Dental Deductible (Family) | Not Applicable |
| Dental Deductible (Individual) | $75 (Combined In & Out of Network) |
| Child Dental Out-Of-Pocket Maximum (Family) |
$700 (In Network) |
| Child Dental Out-Of-Pocket Maximum (Individual) |
$350 (In Network) |
Routine Dental Services (Adult)
In Network
Out-of-Network
Dental Check Up (Child)
In Network
Out-of-Network
Basic Dental Care (Child)
In Network
Out-of-Network
Orthodontia(Child)
In Network
Out-of-Network
Major Dental Care (Child)
In Network
Out-of-Network
Basic Dental Care (Adult)
In Network
Out-of-Network
Orthodontia(Adult)
In Network
Out-of-Network
Major Dental Care (Adult)
In Network
Out-of-Network
Accidental Dental
In Network
Out-of-Network