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Basics for Families and Individuals

DHMO

Out of Network benefits are based on a covered fee schedule.

Preventive Care

In Network
You Pay
Exams, cleaning, X-rays, topical fluoride
100%

Restorative Services

After 6 month waiting period
In Network
You Pay
Fillings
Amalgam-One Surface; primary or permanent
60%
Diagnostic Services
60%
The coinsurance/copayment amounts listed are examples and may be found on the Schedule of Benefits. This plan may not be available in all Counties. Please visit the See Plans and Prices section at www.healthcare.gov to confirm availability in your area.

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