VOXX 2024 OE Guide - FINAL

BENEFIT

IN-NETWORK ONLY

IN-NETWORK

OUT-OF-NETWORK

Annual Deductible

N/A $5 office visit copay

Individual: $25 Employee +1: $25 each Family: $75

Individual: $50 Employee +1: $50 each Family: $150

Benefit Maximum

Unlimited

Individual: $4,000 Annual Orthodontia (Lifetime): $1,500

Individual: $4,000 Annual Orthodontia (Lifetime): $1,500

Diagnostic & Preventive Services Prophylaxis (Cleanings); Oral Examinations; X-rays; Bitewings

100%

100% (deductible waived)

80% (deductible waived)

Basic Services Endodontics; Periodontics

100%

90% after deductible

60% after deductible

Major Services Bridge and Dentures; Surgical Removal of Tooth; Molar Root Canal Therapy

60%

50% after deductible

50% after deductible

Orthodontic Services (children only to age 19)

50% (deductible waived)

50% (deductible waived)

$1,500 copay

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