Texas DHMO Plan
Pacific Union Dental

Premium Rates

Participants	Bi-Weekly	Monthly	Quarterly
Employee Only	6.00	12.93	38.79
Employee + 1	10.00	21.37	64.11
Family	15.00	31.47	94.41

 

Texas DHMO Plan

(All forms are in PDF format. If you cannot
print a form, please call 1-800-221-3083
and we will be glad to mail forms to you.)

Form / Link	Purpose
Enrollment Form	To participate in the Texas DMHO Plan, an Enrollment Form must be completed, signed and mailed to Mass Benefits Consultants, Inc. You must choose a dentist and include his/her ID Number on the Enrollment Form.
TX Dentists	This chart lists all participating DHMO dentists. The dentists are listed by their office zip code. If you have any problems finding a dentist, please call National Pacific Dental 1-877-905-0990.
Benefit Schedule	The Benefit Schedule lists the co-payment amounts for dental services. If you have any questions regarding a co-payment amount, call National Pacific Dental 1-877-905-0990.
Direct Deposit Form	Complete this form if you want to pay by payroll deduction and your Payroll office processes the form.
Employee Express Form	Use this information if you want to pay by payroll deduction and you must start the deduction yourself through HR Links or Employee Express online.
Monthly Bank Draft	Complete and return this form with a voided check to pay your premium on a monthly basis.
Claims	There are no claim forms required for the DHMO plan. The co-payment amounts are listed in the Benefit Schedule.