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Value Plan 3

PPO Dental Claims Reimbursement

Sample Member Experience
Dentist Average Charge Plan Pays You Pay
Non‐
Procedure Network Non‐Network Network Non‐Network Network Network *

Deductible is waived for Preventive Waived Waived
Preventive:
Bitewings X‐Rays ‐ Two
Films $27 $38 100% 100% $0 $0

Preventive:
Teeth Cleaning ‐ Adult $57 $82 100% 100% $0 $0
Preventive:
Periodic Oral
Examination $31 $44 100% 100% $0 $0
Deductible is waived for Preventive, but applies to Basic & Major services $50 $50
Basic:
Filling ‐ Two Surfaces 80% after 80% after
Permanent and Primary $102 $145 $50 Ded $50 Ded $60 $69
Major:
Root Canal Therapy ‐ 50% after 50% after
Molar $706 $1,008 $50 Ded $50 Ded $353 $504
Total $922 $1,317 $413 $573
Savings $160

► Illustration assumes national average charges and a 30% network discount

► Actual out-of-network reimbursement basis is limited to network fee schedule. * The dentist can
bill the patient for the difference between the fee schedule and the actual charge.

2017‐45682 (exp. 9/19)

Incomplete without Brochure ABJ23179 Page 3/3