Plan Benefits Denbrella Dental Plan Preventative Services e.g., exams, cleanings, X-rays Not included Member Responsibility Base Level amount member pays $300 per calendar year (Preventative costs do not count towards meeting the member responsibility) Plan Reimbursement Covered expenses are reimbursed 100% above base level $2,500 annual maximum per member (Plan reimbursement is available after an initial 6 month waiting period) Network of providers No network, use any dentist Coordination of benefits Plan doesn’t coordinate benefits with other dental plans (If traditional dental insurance is active, dental insurance must be used prior to any reimbursements from the Denbrella program) Services not covered:ExamsCleanings (preventative)X-rays (bitewings; preventative)ImplantsTeeth whiteningOrthodontics (child and adult)Services covered: Fluoride (up to age 16)SealantsSpace maintainersFillingsSimple extractionsX-rays (panoramic & medically necessary)Oral surgeryRoot canals (endodontics)Gum disease treatment (periodontics)CrownsBridgesDentures

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Suggested Plan

$19 per month or $205 per year

Save 10% by paying annually!

Member only

Denbrella is not insurance. It is a pooling of consumer dollars to pay for basic and major services. Members pay a monthly membership fee per person in the household up to a 4 per person max cost. There is no limit to the number of household members, however members must be the primary person in the household, spouse, and/or any qualified dependents. Age limit of members is through age 64. There are no sign-up fees or annual membership fees.

Plan Details

Plan Benefits	Denbrella Dental Plan
Preventative Services e.g., exams, cleanings, X-rays	Not included
Member Responsibility Base Level amount member pays	$300 per calendar year (Preventative costs do not count towards meeting the member responsibility)
Plan Reimbursement Covered expenses are reimbursed 100% above base level	$2,500 annual maximum per member (Plan reimbursement is available after an initial 6 month waiting period)
Network of providers	No network, use any dentist
Coordination of benefits	Plan doesn’t coordinate benefits with other dental plans (If traditional dental insurance is active, dental insurance must be used prior to any reimbursements from the Denbrella program)

Services not covered:

Exams
Cleanings (preventative)
X-rays (bitewings; preventative)
Implants
Teeth whitening
Orthodontics (child and adult)

Services covered:

Fluoride (up to age 16)
Sealants
Space maintainers
Fillings
Simple extractions
X-rays (panoramic & medically necessary)
Oral surgery
Root canals (endodontics)
Gum disease treatment (periodontics)
Crowns
Bridges
Dentures

Suggested Plan

$39 per month or $420 per year

Save 10% by paying annually!

Member +1

Plan Details

Plan Benefits	Denbrella Dental Plan
Preventative Services e.g., exams, cleanings, X-rays	Not included
Member Responsibility Base Level amount member pays	$300 per calendar year (Preventative costs do not count towards meeting the member responsibility)
Plan Reimbursement Covered expenses are reimbursed 100% above base level	$2,500 annual maximum per member (Plan reimbursement is available after an initial 6 month waiting period)
Network of providers	No network, use any dentist
Coordination of benefits	Plan doesn’t coordinate benefits with other dental plans (If traditional dental insurance is active, dental insurance must be used prior to any reimbursements from the Denbrella program)

Services not covered:

Exams
Cleanings (preventative)
X-rays (bitewings; preventative)
Implants
Teeth whitening
Orthodontics (child and adult)

Services covered:

Fluoride (up to age 16)
Sealants
Space maintainers
Fillings
Simple extractions
X-rays (panoramic & medically necessary)
Oral surgery
Root canals (endodontics)
Gum disease treatment (periodontics)
Crowns
Bridges
Dentures

Suggested Plan

$79 per month or $850 per year

Save 10% by paying annually!

Family

Plan Details

Plan Benefits	Denbrella Dental Plan
Preventative Services e.g., exams, cleanings, X-rays	Not included
Member Responsibility Base Level amount member pays	$300 per calendar year (Preventative costs do not count towards meeting the member responsibility)
Plan Reimbursement Covered expenses are reimbursed 100% above base level	$2,500 annual maximum per member (Plan reimbursement is available after an initial 6 month waiting period)
Network of providers	No network, use any dentist
Coordination of benefits	Plan doesn’t coordinate benefits with other dental plans (If traditional dental insurance is active, dental insurance must be used prior to any reimbursements from the Denbrella program)

Services not covered:

Exams
Cleanings (preventative)
X-rays (bitewings; preventative)
Implants
Teeth whitening
Orthodontics (child and adult)

Services covered:

Fluoride (up to age 16)
Sealants
Space maintainers
Fillings
Simple extractions
X-rays (panoramic & medically necessary)
Oral surgery
Root canals (endodontics)
Gum disease treatment (periodontics)
Crowns
Bridges
Dentures

Applicant Information

Name*

First Last

Birth Date*

Gender*

Marital Status*

Address*

Street Address Address Line 2 City State ZIP Code

Phone*

Secondary Phone Number

Confirm Plan & Make Payment

Suggested Plan

$19 per month or $205 per year

Save 10% by paying annually!

Member only

Plan Details

Plan Benefits	Denbrella Dental Plan
Preventative Services e.g., exams, cleanings, X-rays	Not included
Member Responsibility Base Level amount member pays	$300 per calendar year (Preventative costs do not count towards meeting the member responsibility)
Plan Reimbursement Covered expenses are reimbursed 100% above base level	$2,500 annual maximum per member (Plan reimbursement is available after an initial 6 month waiting period)
Network of providers	No network, use any dentist
Coordination of benefits	Plan doesn’t coordinate benefits with other dental plans (If traditional dental insurance is active, dental insurance must be used prior to any reimbursements from the Denbrella program)

Services not covered:

Exams
Cleanings (preventative)
X-rays (bitewings; preventative)
Implants
Teeth whitening
Orthodontics (child and adult)

Services covered:

Fluoride (up to age 16)
Sealants
Space maintainers
Fillings
Simple extractions
X-rays (panoramic & medically necessary)
Oral surgery
Root canals (endodontics)
Gum disease treatment (periodontics)
Crowns
Bridges
Dentures

Suggested Plan

$39 per month or $420 per year

Save 10% by paying annually!

Member +1

Plan Details

Plan Benefits	Denbrella Dental Plan
Preventative Services e.g., exams, cleanings, X-rays	Not included
Member Responsibility Base Level amount member pays	$300 per calendar year (Preventative costs do not count towards meeting the member responsibility)
Plan Reimbursement Covered expenses are reimbursed 100% above base level	$2,500 annual maximum per member (Plan reimbursement is available after an initial 6 month waiting period)
Network of providers	No network, use any dentist
Coordination of benefits	Plan doesn’t coordinate benefits with other dental plans (If traditional dental insurance is active, dental insurance must be used prior to any reimbursements from the Denbrella program)

Services not covered:

Exams
Cleanings (preventative)
X-rays (bitewings; preventative)
Implants
Teeth whitening
Orthodontics (child and adult)

Services covered:

Fluoride (up to age 16)
Sealants
Space maintainers
Fillings
Simple extractions
X-rays (panoramic & medically necessary)
Oral surgery
Root canals (endodontics)
Gum disease treatment (periodontics)
Crowns
Bridges
Dentures

Suggested Plan

$79 per month or $850 per year

Save 10% by paying annually!

Family

Plan Details

Plan Benefits	Denbrella Dental Plan
Preventative Services e.g., exams, cleanings, X-rays	Not included
Member Responsibility Base Level amount member pays	$300 per calendar year (Preventative costs do not count towards meeting the member responsibility)
Plan Reimbursement Covered expenses are reimbursed 100% above base level	$2,500 annual maximum per member (Plan reimbursement is available after an initial 6 month waiting period)
Network of providers	No network, use any dentist
Coordination of benefits	Plan doesn’t coordinate benefits with other dental plans (If traditional dental insurance is active, dental insurance must be used prior to any reimbursements from the Denbrella program)

Services not covered:

Exams
Cleanings (preventative)
X-rays (bitewings; preventative)
Implants
Teeth whitening
Orthodontics (child and adult)

Services covered:

Fluoride (up to age 16)
Sealants
Space maintainers
Fillings
Simple extractions
X-rays (panoramic & medically necessary)
Oral surgery
Root canals (endodontics)
Gum disease treatment (periodontics)
Crowns
Bridges
Dentures

Select Payment Plan*

Monthly - $19/mo

Annually - $205/yr

Select Payment Plan*

Monthly - $39/mo

Annually - $420/yr

Select Payment Plan*

Monthly - $79/mo

Annually - $850/yr

3% Transaction Fee

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3% Transaction Fee

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3% Transaction Fee

Price: $0.00

Total Due

Billing Address*

Street Address Address Line 2 City State ZIP Code

Credit Card

Disclosure and Acknowledgment*

Thank you for choosing Denbrella. We appreciate your trust and confidence in us to help you with your dental expenses. Please read the following carefully and sign to confirm your understanding and agreement.

Denbrella is not an insurance product. Denbrella is not a substitute for professional dental advice, diagnosis, or treatment. Always seek the advice of your dentist or qualified healthcare provider with any questions regarding your oral health. Denbrella is provided without warranties of any kind, either express or implied.

I understand that payment of dental services is ultimately a responsibility between my dentist office and me. Further I understand I am responsible for any charges not covered by Denbrella including member share amounts and services not included in my plan.

Regarding specific plan benefits, I understand that:

Reimbursements are paid from a pooled fund of member fees.

Member fees will be paid through automatic withdraw or credit card charge. No direct billing is available.

The Denbrella plan has an initial 6-month waiting period before I am eligible to submit for reimbursement.

Services completed in the initial waiting period are not eligible for reimbursement.

Each member within my family has his/her own $300 member responsibility prior to eligibility for reimbursement.

Reimbursements are only for covered basic and major expenses as outlined in the plan benefits. Most preventative benefits are not eligible for reimbursement to include (but not limited to) exams, cleanings, and preventative x-rays.

The time limit is 6 months from the date service to request reimbursement unless an exception is otherwise given by Denbrella.

All benefits regardless of when the member enrolls in Denbrella are based on a calendar year. Benefits and member responsibility resets on January 1st.

If I have other dental plans and/or dental insurance policies, I understand that:

If requested, I must provide complete and accurate information for other dental plans and/or insurance I may have.

I must use any other dental plans and/or dental insurance plan benefits prior to submitting for reimbursement from Denbrella. Additionally, I will provide proof to Denbrella that other dental coverage has been used prior to receiving any reimbursements.

Denbrella will coordinate benefits based on the information I provide.

Any remaining balance after Denbrella reimbursement is my responsibility.

This acknowledgment does not guarantee coverage or payment by Denbrella. Final determination of benefits are made by Denbrella.

I have read and agree to the acknowledgement above.

Please review your selections and information before submitting. If you have questions, contact us HERE.

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