| Plan Details | ||
|---|---|---|
| Plan Name | Premium PPO 2250 | |
| Effective Dates | Jan 01, 2025 to Jan 01, 2026 | |
| Benefits | In-Network | Out-of-Network |
| Annual Deductible/Individual | $50 | $50 |
| Annual Deductible/Family | $150 | $150 |
| Annual Plan Maximum | $2,250 | $2,250 |
| Lifetime Orthodontia Plan Maximum | $1,000 | $1,000 |
| Diagnostic and Preventive Services | 0% deductible does not apply | 0% deductible does not apply |
| Basic Services | 10% | 10% |
| Major Services | 40% | 40% |
| Orthodontia Services | 50% deductible does not apply | 50% deductible does not apply |
| Ortho Dependent Children | Covered up to age 26 | Covered up to age 26 |
| Ortho Adults | Covered | Covered |