Dominion National - Elite PPO Basic
Benefits Resources |
|---|
| Provider Directory |
| Summary of Benefits and Coverage (Not Available) |
| Download Plan Brochure |
Summary |
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| Plan Name | Elite PPO Basic |
| Plan Type | PPO |
| Plan Tier | LOW |
Deductible & Out-of-Pocket Max |
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|---|---|
| Dental Deductible (Family) |
$200 (In Network) $200 (Out-of-Network) $200 (Combined In & Out of Network) |
| Dental Deductible (Individual) |
$100 (In Network) $100 (Out-of-Network) $100 (Combined In & Out of Network) |
| Child Dental Out-Of-Pocket Maximum (Family) |
$750 (In Network) |
| Child Dental Out-Of-Pocket Maximum (Individual) |
$375 (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