Compare Dental Plan Coverage Highlights*

 

 

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MONTHLY PREMIUMS Dental Blue® Dental Blue® Select Dental Blue® Plus
Self 
 Self plus one 
Family 
$21
$42
$75
$32
$66
$129

 

To determine your premium, call us at 1-855-890-7416 or go to HealthCare.gov.

 

Calendar Year Deductible $50 per person $50 per person $40 per person
Calendar Year Maximum Benefits
(The most we will pay each year)
$1,000 per person $1,500 per person $1,000 per person (age 19 and over)
No maximum for children up to age 19
Pediatric Out-of-Pocket Maximum
(The most you will pay each year)
Not applicable Not applicable $350 (one child up to age 19)
$700 (two or more children up to age 19)

 
 

 

 
Dental Blue®
Dental Blue® Select
Dental Blue® Plus
COVERED BENEFITS*
After you meet your deductible:
YOU PAY
WE PAY
YOU PAY
WE PAY
YOU PAY
WE PAY

Diagnostic and Preventive Services (No waiting period)

  • Dental exams & x-rays
  • Routine cleanings
$0
100%
$0
100%
$0
100%
Basic Services†

 

  • Fillings
  • Simple tooth extractions
  • Root canal (non-surgical)
  • Emergency treatment for pain
  • Repairs to crowns an dentures
    (fixed partials and removable)
25%
75%
20%
80%
20%
80%
Major Services††
  • Oral surgery
  • General anesthesia
  • Periodontic exams
  • Removal of diseased tissues and bones
50%
50%
50%
50%
50%
50%

Additional Major Services††

  • Crown, inlays, onlays and dentures
Not covered
Not covered
50%
50%
50%
(This benefit is
available only for
children up to
age 19)
50%
(This benefit is
available only for
children up to
age 19)

Orthodontic Services†† 

  • Coverage for children up to age 19
  • Limited to a lifetime maximum of $1,500
Not covered
Not covered
60%
after you
meet a $150
orthodontic
deductible
40%
after you
meet a $150
orthodontic
deductible
50%
after you meet a
$150 orthodontic
deductible when
deemed medically
necessary
50%
after you meet a
$150 orthodontic
deductible when
deemed medically
necessary

*Benefits listed apply to in-network services.
† 180-day waiting period applies (this waiting period does not apply to members up to age 19, enrolled in Dental Blue Plus).
† 365-day waiting period applies (this waiting period does not apply to members up to age 19, enrolled in Dental Blue Plus. Dental Blue Plus members up to age 19 have a 24-month waiting period for medically necessary orthodontic services).