USBenefits Choice Dental Plans
Covered Benefits | Superior Choice Plan | Balanced Choice Plan | Essential Choice Plan | ||||
---|---|---|---|---|---|---|---|
In-Network | Out-of-Network | In-Network | Out-of-Network | In-Network | Out-of-Network | ||
Deductible3 x the family max (Waived for Preventive Services) |
$0/$25/$50 | $0/$25/$50 | $0/$25/$50 | ||||
Calendar Year Maximum | $3,000/ $2,500/ $2,000/ $1,500 | $2,500/ $2,000/ $1,500/ $1,000 | $1,500/ $1,000/ $500 | ||||
Class I: Preventive & Diagnostic Services (deductible waived) | |||||||
In-Network | Out-of-Network | In-Network | Out-of-Network | In-Network | Out-of-Network | ||
|
100% | 100% | 100% | 100% | 100% | 100% | |
Class II: Basic Services (deductible applies) | |||||||
|
90% | 90% | 80% | 80% | 80% | 80% | |
Class III: Major Services (deductible applies) | |||||||
|
60% | 60% | 50% | 50% | 0% | 0% | |
Endodontic Services:
|
Available in Class II Basic Services or Class III Major Services | ||||||
Periodontal Services:
|
Available in Class II Basic Services or Class III Major Services | ||||||
Oral Surgery
|
Available in Class II Basic Services or Class III Major Services | ||||||
Class IV: Child Orthodontia (deductible waived) | |||||||
Child orthodontia coverage at 50% to a lifetime maximum of $1,500 or $2,000 for dependent children through age 18. *Orthodontia coverage not available on Essential plans. |
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Out-of-Network Reimbursement: | |||||||
Choose between the 90th% of UCR (Usual, Customary & Reasonable) or a MAC (Maximum Allowable Charge) schedule. |
This table is only provided as a quick glance comparison. Coverage levels vary based on your specific plan. Choice dental plans are available in the following states: AZ, DC, GA, HI, IA, IL, IN, KS, LA, MD, MI, MO, MS, ND, NE, NV, OH, OK, PA, SC, SD, TX, UT, VA, WV and WY. To learn more contact your sales specialist.