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 BCBSTX 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, simple extractions, oral surgery 20% after deductible2
Major: Crowns, complex extractions, oral surgery, root canal therapy, bridges 50% after deductible2
Orthodontics: Dependent children only 50% after deductible2
Annual maximum (The most the plan will pay in a calendar year.)
Per person $1,500
  1. Routine exams, cleanings and X-rays are two per calendar year.
  2. 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