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HSA Plan

Network

20% coinsurance after deductible

Non-Network

40% coinsurance after deductible

PPO 750 Plan

Network

20% coinsurance after deductible

Non-Network

40% coinsurance after deductible

PPO 1250 Plan

Network

20% coinsurance after deductible

Non-Network

40% coinsurance after deductible

Jaw surgery, includes Temporomandibular Joint (TMJ) and prognathism.

Covered for Specific Conditions

  • Acute traumatic injury and post-surgical sequela;
  • Cancerous or non-cancerous tumors and cysts, cancer and post-surgical sequela; or
  • Cleft lip/palate (for cleft lip/palate related jaw surgery).

Preauthorization by medical plan required.


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