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Basic Dental PPO

The Basic Dental PPO (DPPO) plan includes most preventive procedures at low or no cost to you, and these services are not subject to the annual maximum. However, you pay 15% coinsurance for basic restorative services and 50% coinsurance for major restorative services. These payments are subject to the annual maximum. Orthodontia is not covered under this plan.

The coverage includes:

  • DPPO & Out-of-Network Annual Deductible: $50 individual, $150 family
  • Annual Benefit Maximum: $2,000 individual
  • Dental implants and medically necessary night guards are included as covered major services (plan pays 50%) and count towards the annual benefit maximum
  • Preventive procedures are not subject to the annual maximum benefit.
Service
Your Cost
Preventive & Diagnostic Services
DPPO Advantage Provider: 0%
DPPO & Out-of-Network Provider: 0%1
Basic Restorative Services
DPPO Advantage Provider: 15%
DPPO & Out-of-Network Provider: 15%1
Major Restorative Services
DPPO Advantage Provider: 50%
DPPO & Out-of-Network Provider: 50%1
Orthodontia
Not covered under this plan

For detailed descriptions of our three dental plans, download our 2017 Dental Plan Handbook. 2018 handbooks are available in January.

View the plan summaries:

1If the provider’s fees exceed the regular and customary charges allowed in the plan, you may be billed for the balance.

Health benefits are offered through plans maintained by Church Pension Group Services Corporation (doing business as The Episcopal Church Medical Trust), 19 East 34th Street, New York, NY 10016.

The Episcopal Church Medical Trust Disclaimer