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.
|Deductible (The amount you must pay before the plan begins paying benefits for non-preventive care.)|
|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: Children up to age 26 only||50% after deductible2|
|Annual maximum (The most the plan will pay in a calendar year.)|
|Orthodontia lifetime maximum (The most the plan will pay for orthodontia per lifetime.)|
- 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.
Here are your premium costs for the Dental PPO.
|Employee only||$12.35||$26.75||Employee and children||$31.10||$67.39|
|Employee and spouse||$26.04||$56.43|