Page 50 - Takoma Park Benefits Guide 2022

Dental Benefits (continued)

CareFirst Traditional Dental Plan 1

» Choose from a large national network to participating dentists.
» In-Network and Out-of-Network coverage

» Please refer to summary plan description for more details and for cost breakdown refer
to “Frequently Asked Questions”.

Dental Summary

CareFirst Traditional
Benefits
Dental Plan 1
In-Network
Referral Needed No
Class I

Preventive/Diagnostic Pd @ 80%
Class II Deductible then
Basic Services Pd @ 50%
Class III Deductible then
Major Services - Surgical Pd @ 50%
Class IV Deductible then
Major Services - Restorative Pd @ 50%

Class V
Orthodontic Services - Lifetime Maximum N/A

Deductible (Class II, III & IV)
Individual $50
Family $150
Out-of-Network
Class I
Preventive/Diagnostic Pd @ 80%
Class II Deductible then

Basic Services Pd @ 50%
Class III Deductible then

Major Services - Surgical Pd @ 50%
Class IV Deductible then
Major Services - Restorative Pd @ 50%
Class V N/A
Orthodontic Services - Lifetime Maximum
Deductible (Class II, III & IV)
Individual $50
Family $150