Dental Indemnity USA

Policy Form Number: IND DEN-2

The Individual Dental Indemnity plan is available as an optional benefit with your Individual Blue Cross Blue Shield of Texas health insurance plan. There is an additional premium for the Individual Dental Indemnity plan.

Dental Indemnity USA can be used to provide dental benefits to:

• An individual
• An individual, plus spouse
• An individual, plus child(ren)
• An individual plus spouse and child(ren)

Upon enrolling in the plan, members will receive a fulfillment package inclusive of all of the dental procedures covered under the plan. The fee schedule of benefits will identify the maximum allowable benefit members can receive when a procedure is performed. The dollar amount assigned to each procedure is the maximum any member can receive, not to exceed actual charges.

A $50 deductible, based on fee schedule allowances, will apply for dental procedures or services received by a covered individual during each benefit year. For family coverage, the maximum deductible amount is $150. Deductible amounts do not apply to such procedures as oral exams, cleaning, fluoride treatments, sealants, and x-rays.

Covered individuals must be enrolled in the Dental Indemnity USA plan for 12 months before receiving dental benefits in the following coverage categories; major restorative, periodontics, removable prosthetics, fixed bridge and orthodontia.

• Dental Outline of Coverage