Western PA/Susquehanna Member Guide

26 To find a participating dental provider, log in to My Health OnLine and click Find Care. You can also call your Health Care Concierge team for assistance. 26 Dental benefits Make sure to take advantage of all the dental benefits your plan has to offer: 5 • Two oral exams, two cleanings, and one bitewing x-ray per year • One panoramic x-ray every 36 months • Some plans also have a comprehensive dental allowance or standard allowance for fillings and simple tooth extractions Plan Oral exam and cleaning (two per year) One bitewing x-ray per year One panoramic x-ray every 36 months Dental allowance per year HMO Premier Rx (HMO) $0 copay $0 copay $0 copay $600 for comprehensive dental services with 50% coinsurance HMO Deductible with Rx (HMO) $0 copay $0 copay $0 copay $1,250 for comprehensive dental services with 50% coinsurance HMO Rx Choice (HMO) $0 copay $0 copay $0 copay $2,500 for comprehensive dental services with 50% coinsurance HMO Rx (HMO) $0 copay $0 copay $0 copay $3,000 for comprehensive dental services with 50% coinsurance HMO Rx Enhanced (HMO) $15 copay $15 copay $15 copay Not covered PPO High Deductible with Rx (PPO) IN: $15 copay OUT: 50% coinsurance IN: $15 copay OUT: 50% coinsurance IN: $15 copay OUT: 50% coinsurance IN/OUT: $175 PPO Rx Enhanced (PPO) IN: $15 copay OUT: 50% coinsurance IN: $15 copay OUT: 50% coinsurance IN: $15 copay OUT: 50% coinsurance Not covered