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USBenefits PPO Dental Plans

Show PPO Dental Plans
Covered Benefits Superior PPO Plan Balanced PPO Plan Essential PPO Plan
  In-Network Out-of-Network In-Network Out-of-Network In-Network Out-of-Network

Deductible

3 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
  • –
    Routine Oral Exams
  • –
    Cleanings (1 per 6 months)
  • –
    Fluoride for dependent children
  • –
    Bitewing x-rays
  • –
    Full mouth x-rays
  • –
    Emergency palliative treatment
  • – Sealants for dependent children (under age 14)
 100% 100% 100% 80% 100% 80%
Class II: Basic Services (deductible applies)
  • –
    Fillings
  • – Space maintainers for dependent children (under age 14)
 90% 80% 80% 80% 80% 50%
Class III: Major Services (deductible applies)
  • –
    Prosthodontics
  • –
    Crowns
  • –
    Inlays
  • –
    Onlays
  • –
    Fixed bridge
  • –
    Complete and partial dentures
60% 50% 50% 50% 0% 0%

Endodontic Services:

  • –
    Root canal therapy
  • –
    Pulp capping and pulpotomy
  • –
    Simple extractions, abscesses
Available in Class II Basic Services or Class III Major Services

Periodontal Services:

  • Periodontal treatment &
    treatment of other diseases of
    the gums and tissues of the mouth.
  • –
    Periodontal scaling
  • –
    Periodontal root planning
  • –
    Periodontal maintenance
Available in Class II Basic Services or Class III Major Services

Oral Surgery

  • –
    Simple and complex extractions
  • –
    Anesthesia or IV sedation
 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.
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.PPO dental plans are available in the following states: AZ, DC, HI, IA, IL, IN, KS, MD, MI, MO, MS, ND, NE, NV, OH, OK, SC, SD, UT, WV and WY. To learn more contact your sales specialist.