Page 12 - EMSAR 2022 Benefits Guide
P. 12
Dental Insurance
BlueCross BlueShield of Texas | Group
Number: 328019
Good oral care enhances overall physical health,
appearance and mental well-being. Problems with
the teeth and gums are common and easily treated.
Keep your teeth healthy and your smile bright.
Buy-Up Plan
In-Network Beneits Base Plan PPO
PPO
BlueCare BlueCare Dental
Network Name
Dental PPO PPO
Calendar Year Deductible
Individual $50 $50
Family $150 $150
Calendar Year Maximum $1,250 $2,250
Orthodontia Life $1,000 $1,000
Maximum
Services
Preventive Services Plus 100% 100%
Basic Services 80% 80%
Endodontics/Periodontics 80% 80%
Major Services 50% 50%
Orthodontic Services (Children up to the age of 19 only)
Orthodontia 50% 50%
Orthodontia Lifetime $1,000 $1,000
Maximum
Payroll Deduction
Per Pay Period (26) Base Plan Buy-Up Plan
Associate Only $7.29 $13.25
Associate & Spouse $15.09 $29.22
Associate & Children $18.33 $32.01
Associate & Family $29.77 $51.44
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BlueCross BlueShield of Texas | Group
Number: 328019
Good oral care enhances overall physical health,
appearance and mental well-being. Problems with
the teeth and gums are common and easily treated.
Keep your teeth healthy and your smile bright.
Buy-Up Plan
In-Network Beneits Base Plan PPO
PPO
BlueCare BlueCare Dental
Network Name
Dental PPO PPO
Calendar Year Deductible
Individual $50 $50
Family $150 $150
Calendar Year Maximum $1,250 $2,250
Orthodontia Life $1,000 $1,000
Maximum
Services
Preventive Services Plus 100% 100%
Basic Services 80% 80%
Endodontics/Periodontics 80% 80%
Major Services 50% 50%
Orthodontic Services (Children up to the age of 19 only)
Orthodontia 50% 50%
Orthodontia Lifetime $1,000 $1,000
Maximum
Payroll Deduction
Per Pay Period (26) Base Plan Buy-Up Plan
Associate Only $7.29 $13.25
Associate & Spouse $15.09 $29.22
Associate & Children $18.33 $32.01
Associate & Family $29.77 $51.44
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