PPO Plan
In-Network		Plan APlan B
Annual maximum benefit for preventive, basic and major covered services$2,000 per person$1,250 per person$1,000 per person
Late Entrant Provision (see definition here)AppliesAppliesApplies
Preventive:All three plans cover:   
  • 2 routine exams per year
  • 2 routine prophylaxis (cleanings) per year
  • Space maintainers
  • X-rays
  • Fluoride treatments for children under age 19
No deductible

Covered in full up to the MAC1.		No deductible

Covered in full up to U&C2.		No deductible

Pays a predetermined fixed amount3 based on procedure received.
Basic:All three plans cover:   
  • Fillings
  • Sealants
  • Full or partial denture repair
  • Anesthesia for oral surgery
  • Removal of teeth
No deductible;
Reimbursement at:
  • 80% of MAC1 during first year of coverage
  • 90% of MAC1 during second year of coverage if a covered procedure is received during the first year
  • 100% of MAC1 thereafter if a covered procedure is received in the second and following years
After $100 lifetime deductible per person;
Reimbursement at:
  • 80% of U&C2 during first year of coverage
  • 90% of U&C2 during second year of coverage if a covered procedure is received during the first year
  • 100% of U&C2 thereafter if a covered procedure is received in the second and following years
After a combined basic and major annual deductible of $50 per person, the plan pays a predetermined fixed amount3 based on procedure received.
Major:All three plans cover:   
  • Crowns
  • Bridgework
  • Partial or full dentures
  • Dentures, prosthodontics, and inlays
  • Periodontal maintenance (periodontal cleaning) and gum treatment
  • Endodontic procedures (root canals, etc.)
After a $50 calendar year deductible per person;
Reimbursement at:
  • 50% of MAC1
  • 65% of MAC1 for periodontic or gum treatment
  • 65% of MAC1 for endodontic procedures
After a $75 calendar year deductible per person;
Reimbursement at:
  • 50% of U&C2
  • 65% of U&C2 for periodontic or gum treatment
  • 65% of U&C2 for endodontic procedures
After a combined basic and major annual deductible of $50 per person, the plan pays a predetermined fixed amount3 based on procedure received.
Orthodontia:   
All three plans cover orthodontia only if treatment begins after the participant becomes covered by a Duke Dental Plan.No deductible.

50% of U&C2

$1,000 lifetime orthodontia maximum benefit per person (adults and children)		No deductible.

50% of U&C2

$1,000 lifetime orthodontia maximum benefit per person (adults and children)		No deductible.

50% of U&C2

$750 lifetime orthodontia maximum benefit per person (adults and children)
  1. All payments are based on the Maximum Allowable Charges (MAC). PPO dentists have agreed to accept the contracted fee (MAC) as the maximum charge.
  2. All payments are based on the usual and customary (U&C) allowable charge. You are responsible for charges over U&C.
  3. The fee schedule, or reimbursement for each type of dental procedure, is available on the Ameritas website at ameritas.com.