How the PDP Option Pays Benefits

Please Note: The way benefits are paid depends on whether you receive your care in-network or out-of-network. The following chart shows how the PDP Option pays benefits.


Benefit Provision	In-Network	Out-of-Network
Annual Deductible
Preventive	None	None
Restorative	$50 individual; $150 family	$100 individual; $300 family
Orthodontia	None	None
Preventive (no deductible)	100% coverage*	90% coverage*
Oral exams	Maximum two per calendar year	Maximum two per calendar year
Prophylaxis (cleaning)	Maximum two per calendar year	Maximum two per calendar year
Fluoride	Maximum one per calendar year, and only covered for participants who are under age 19	Maximum one per calendar year, and only covered for participants who are under age 19
Full mouth X-ray	Maximum one per every 60 months	Maximum one per every 60 months
Bitewing X-ray	Maximum one per calendar year**	Maximum one per calendar year**
Sealants	Maximum two treatments per tooth (permanent molars only) per lifetime; under age 19	Maximum two treatments per tooth (permanent molars only) per lifetime; and only covered for participants who are under age 19
Basic restorative (fillings, extractions, periodontal, oral surgery, anesthesia, including non-intravenous conscious sedation when medically necessary)	80% coverage, after deductible*	70% coverage, after deductible*
Major restorative (dentures, inlays, onlays, crowns, bridges, root canal)	60% coverage, after deductible*	50% coverage, after deductible*
Orthodontia ***	50% coverage*	50% coverage*
Maximum Benefits
Combined annual for preventive and restorative	Maximum $2,000****	Maximum $1,500****
Lifetime for orthodontia	Maximum $2,500****	Maximum $2,000****

* All in-network percentages above apply to dentists' negotiated fees. All out-of-network percentages apply to reasonable and customary (R&C) charges.

** Two times per calendar year for covered participants under age 19.

*** For covered children under age 19. Please see "Orthodontic Covered Services" for additional information.

**** Reflects a combined amount for both in-network and out-of-network; includes any benefits already applied to any lifetime maximum for orthodontia under the Dental Plan.

Please Note: Wherever benefits are limited to a certain number of visits, combined in-network and out-of-network visits will count toward the benefit limit. For more details on coverage limitations, see "What Is Not Covered."