State of Texas Dental Choice PlanSM (PPO) Coverage
Choose any dentist. You will receive higher benefits if using a participating dentist through the preferred provider network.
Table explains the features and coverage for the State of Texas Dental Choice Plan (PPO)
| |
Participating Dentist |
Non-Participating Dentist |
| Deductibles |
Preventive - $0 for you and family
Combined Basic/Major/ Prosthodonic - $50 for you; $150 for family
Orthodontic services - no deductible
|
Preventive - $50 for you;$150 for family
Combined Basic/Major/ Prosthodonic - $100 for you; $300 for family
Orthodontic services - no deductible |
| Copays |
You pay nothing for diagnostic and preventive services. |
You pay 10% of allowed amount for preventive services up to maximum benefit after deductible is met. |
| Maximum benefit |
$1,500 Calendar Year maximum (excludes orthodontic services)
$1,500 Lifetime Benefit for orthodontic services
|
| Cleanings/Oral Exams |
0% - Two (2) cleanings/oral exams per calendar year are covered at 100%.
|
10% of the allowed amount after deductible is met. Two (2) cleanings/oral exams per calendar year are allowed. |
| Orthodontic coverage |
Orthodontic services are only available to dependents age 19 or younger. You pay 50% of allowed amount.
|
Orthodontic services are only available to dependents age 19 or younger. You pay 50% of the allowed amount. May be required to pay the difference between the allowed amount and billed charges. |
Note: You don't have to satisfy a deductible at the end of one year and a deductible at the start of another year.
Filing Claims
Claims should be filed within 90 days of the date of service. The State of Texas Dental Choice PlanSM will not accept a claim submitted later than 18 months after the expenses were incurred or date of service. Send copies of your provider’s itemized bill to file your claim. Special claim forms are not required.
You can appeal a decision with a Texas Employees Group Benefits Program (GBP) insurance carrier. Additional guidelines are provided in writing to members during the appeals process. More information about the appeals process.
