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
Adult (Age 19+)= $23
 
Child (through age 18)= $33
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 and 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††
  • Crowns, inlays, onlays and dentures
Not covered Not covered 50% 50% 50%* 50%*
Orthodontic Services†† 
  • Coverage for children*
  • 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

*This benefit is only available up to the end of the month in which the member turns 19.
** Benefits listed apply to in-network services.
*** The lifetime maximum only applies to Dental Blue Select.

180-day waiting period applies. (This waiting period does not apply to members up to the end of the month in which the member turns 19, enrolled in Dental Blue Plus.) †† 365-day waiting period applies. (This waiting period does not apply to members up to the end of the month in which the member turns 19, enrolled in Dental Blue Plus. Dental Blue Plus members have a 24-month waiting period up to the end of the month in which the member turns 19 for medically necessary orthodontic.