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 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
  1. Routine exams, cleanings and X-rays are 2 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 $11.65 $25.25
Employee and children $29.36 $63.62
Employee and spouse $24.59 $53.27
Family $42.30 $91.65