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State of Texas Dental Choice Plan (PPO) Coverage
SM

Administered by HumanaDental.

Choose any dentist. You will receive higher benefits if using a participating dentist through the preferred provider network.

Participating Dentist Non-Participating Dentist

Preventive - $0 for you and family Preventive - $50 for you;$150 for family
Combined Basic/Major/ Prosthodonic - $50 for you; Combined Basic/Major/ Prosthodonic - $100 for y
Deductibles
$150 for family $300 for family
Orthodontic services - no deductible Orthodontic services - no deductible

You pay 10% of allowed amount for preventive
You pay nothing for diagnostic and preventive
Copays services up to maximum benefit after deductible
services.
met.
$2,000 Calendar Year maximum (excludes orthodontic services) Once the Calendar Year Maximum Benefit for Basic
Maximum and Major services is met, the plan will pay 40% of covered services for the remainder of the calendar year for in-
benefit
network dental providers only. $2,000 Lifetime Benefit for orthodontic services
10% of the allowed amount after deductible is
Cleanings/Oral 0% - Two (2) cleanings/oral exams per calendar Two (2) cleanings/oral exams per calendar year
Exams year are covered at 100%.
allowed.

There is no age limit for Orthodontic services, Orthodontic services are only available to
Humana will allow 50% of the covered dependents age 19 or younger. Humana will allow
Orthodontic orthodontia services, up to: the lifetime 50% of th covered orthodontia services, up to the
coverage maximum. lifetime maximum. You may be required to pay the
difference between the allowed amount and billed
charges

Note: If you are a State of Texas Dental Choice Plan SM (PPO) participant, any covered dental expenses that applied t
deductible during the last three months (October-December) of the calendar year will apply to your deductible in the
calendar year. This means you don't have to satisfy a deductible at the end of one year and a deductible at the start
another year.

Filing Claims

Claims should be filed within 90 days of the date of service. The State of Texas Dental Choice Plan SM will not accept
claim submitted later than 18 months after the expenses were incurred or date of service. Send copies of your provid
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 guid
are provided in writing to members during the appeals process. More information about the appeals process.

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