| Plan Details | ||
|---|---|---|
| Plan Name | DPPO Buy-Up Plan (HBC) | |
| Effective Dates | Jan 01, 2024 to Jan 01, 2026 | |
| Benefits | In-Network | Out-of-Network |
| Annual Deductible/Individual | $25 | $75 |
| Annual Deductible/Family | $75 | $225.00 |
| Annual Plan Maximum | $2000 | $2000 |
| Lifetime Orthodontia Plan Maximum | $2000 | $2000 |
| Diagnostic and Preventive Services | 0% | 80% |
| Basic Services | 90% After Deductible | 70% After Deductible |
| Major Services | 60% After Deductible | 50% After Deductible |
| Orthodontia Services | 50% | 50% |
| Ortho Dependent Children | Covered | Covered |
| Ortho Adults (and Covered Full-Time Students, if Eligible) | Covered | Covered |
| Annual Deductible/Individual | $25 TX & MS | $25 |
| Annual Deductible/Family | $75 | $75 |
| Annual Plan Maximum | $2000 | $2000 |
| Lifetime Orthodontia Plan Maximum | $2000 | $2000 |
| Diagnostic and Preventive Services | 0% | 0% |
| Basic Services | 10% after deductible | 10% after deductible |
| Endodontic Treatment | 10% after deductible | 10% after deductible |
| Periodontic Treatment | 10% after deductible | 10% after deductible |
| Major Services | 40% after deductible | 40% after deductible |
| Orthodontia Services | 50% | 50% |
| Ortho Dependent Children | covered | covered |
| Ortho Adults (and Covered Full-Time Students, if Eligible) | covered | covered |