Dental Plan at a Glance
Here’s a look at what’s covered and what you pay. You can see any provider, but you will save money if you use Blue Cross Blue Shield in-network providers. Find one by visiting bcbstx.com or calling 800-521-2227.
Here’s a look at what you will pay when you need care.
Dental PPO | |
Deductible (The amount you must pay before the plan begins paying benefits for non-preventive care.) | |
Individual | $100 |
Family | $300 |
You pay | |
Preventive:1 Routine exams, cleanings and X-rays | $0, no deductible2 |
Basic: Fillings, extractions, oral surgery | 20% after deductible2 |
Major: Crowns, inlays and onlays, implants, fixed bridge restorations, dentures | 50% after deductible2 |
Orthodontia: Adults and children up to age 19 | 50% after deductible2 |
Annual maximum (The most the plan will pay in a calendar year.) | |
Per person | $1,500 |
Orthodontia lifetime maximum (The most the plan will pay for orthodontia per lifetime.) | |
Per person | $1,500 |
- Routine exams, cleanings and X-rays are 2 per calendar year.
- Out-of-network benefits are paid according to a “reasonable and customary” schedule. If you use an out-of-network dentist, you could receive an additional bill for the difference between what the plan pays and what the dentist charges.
Paycheck Costs
Here are your premium costs for the Dental PPO.
Dental PPO | ||
Bi-weekly | Monthly | |
Employee only | $13.15 | $28.49 |
Employee and spouse | $27.73 | $60.09 |
Employee and children | $33.13 | $71.78 |
Employee and family | $47.72 | $103.40 |