Dental Amounts shown below are your responsibility. Only In-Network benefits are shown BCBSOK - High Plan BCBS - Low Plan Plan Year Deductible $25 per person $75 per family $50 per person $150 per family Preventive & Diagnostic Care Covered in Full Deductible Waived Covered in Full Deductible Waived Basic Care 15% after Deductible Non-Network: 30% 15% after Deductible Non-Network: 30% Major & Restorative Care 40% after Deductible Non-Network: 50% 50% after Deductible Non-Network: 50% Plan Year Maximum Per Person $2,500 $1,500 Orthodontia (Children under 19) 50% after Deductible 50% after Deductible Orthodontic Lifetime Maximum $5,000 per Person $1,500 per Person Cigna - High Plan Cigna - Low Plan Plan Year Deductible No Deductible / $0 Copay No Deductible / $5 Copay Preventive & Diagnostic Care $0 Copay + Fees for Procedures $5 Copay + Fees for Procedures Routine Cleaning No Charge, Every 6 Months No Charge, Every 6 Months Basic Care $0 Copay + Fees for Procedures $5 Copay + Fees for Procedures Major & Restorative Care $0 Copay + Fees for Procedures $5 Copay + Fees for Procedures Plan Year Maximum Per Person Unlimited Unlimited Orthodontia (Children and Adults) $0 Copay + Fees for Procedures $5 Copay + Fees for Procedures Orthodontic Out-Of-Pocket Max $2,040 Child $2,370 Adult $2,472 Child $3,384 Adult Amounts shown below are your responsibility. Only In-Network benefits are shown For full list of charges, see Patient Charge Schedule OKIV9.