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Dental & Orthodontia PPO

The Dental & Orthodontia PPO (DPPO) plan includes most preventive procedures at low or no cost to you. Preventive procedures are not subject to the annual maximum. You pay 15% coinsurance on basic and major restorative services, which are subject to the annual maximum, and 50% coinsurance on orthodontia services subject to the lifetime orthodontia maximum.

The coverage includes:

  • DPPO and Out-of-Network Annual Deductible: $25 individual, $75 family
  • Annual Benefit Maximum: $2,000 individual
  • Lifetime Orthodontic Maximum: $1,500 individual
  • Dental implants and medically necessary night guards are included as covered major services (plan pays 85%) 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: 15%
DPPO & Out-of-Network Provider: 15%1
Orthodontia
DPPO Advantage Provider: 50%
DPPO & Out-of-Network Provider: 50%
(up to the $1,500 separate lifetime maximum)1

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