| Plan Details | ||
|---|---|---|
| Plan Name | DPPO Core Plan (HBC) | |
| Effective Dates | Jan 01, 2024 to Jan 01, 2026 | |
| Benefits | In-Network | Out-of-Network |
| Annual Deductible/Individual | $50 | $150 |
| Annual Deductible/Family | $150 | $450.00 |
| Annual Plan Maximum | $1500 | $1500 |
| Lifetime Orthodontia Plan Maximum | N/A | N/A |
| Diagnostic and Preventive Services | 0% | 80% |
| Basic Services | 80% After Deductible | 60% After Deductible |
| Major Services | 50% After Deductible | 50% After Deductible |
| Orthodontia Services | Not Covered | Not Covered |
| Ortho Dependent Children | Not Covered | Not Covered |
| Ortho Adults (and Covered Full-Time Students, if Eligible) | Not Covered | Not Covered |
| Annual Deductible/Individual | $50 TX & MS | $50 |
| Annual Deductible/Family | $150 | $150 |
| Annual Plan Maximum | $1500 | $1500 |
| Lifetime Orthodontia Plan Maximum | N/A | N/A |
| Diagnostic and Preventive Services | 0% | 0% |
| Basic Services | 20% after deductible | 20% after deductible |
| Endodontic Treatment | 20% after deductible | 20% after deductible |
| Periodontic Treatment | 20% after deductible | 20% after deductible |
| Major Services | 50% after deductible | 50% after deductible |
| Orthodontia Services | not covered | not covered |
| Ortho Dependent Children | not covered | not covered |
| Ortho Adults (and Covered Full-Time Students, if Eligible) | not covered | not covered |