Dental Plan Documents

Individual & Family Dental Plan Overviews

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Individual BlueDental Plan Overview

Individual & Family Dental Benefit Books

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BlueDental PPO Preventive
BlueDental PPO Classic
BlueDental PPO Plus
BlueDental PPO Select
BlueDental Prime PPO Classic
BlueDental Prime PPO Plus
BlueDental DHMO Classic
BlueDental DHMO Plus

Employer Group Dental Plan Summaries and Riders

The Summary of Benefits and Coverage (SBC) provides a concise description of what services your plan covers along with what you will pay for covered benefits.

#100 #124 PPO 50 1500 P2 MAC 10+
#101 #125 PPO 25 2000 A2 MAC 10+
#102 #126 PPO 25 2000 P2 MAC 10+
#103 #127 PPO 50 1000 A290 10+
#104 #128 PPO 50 1000 P290 10+
#105 #129 PPO 50 1500 A290 10+
#106 #130 PPO 50 1500 P290 10+
#107 #131 PPO 25 2000 A290 10+
#108 #132 PPO 25 2000 P290 10+
#25 #37 PPO 50 1000 A MAC 2 to 9
#26 #38 PPO 50 1000 P MAC 2 to 9
#27 #39 PPO 50 1500 A MAC 2 to 9
#28 #40 PPO 50 1500 P MAC 2 to 9
#29 #41 PPO 25 2000 A MAC 2 to 9
#30 #42 PPO 25 2000 P MAC 2 to 9
#31 #43 PPO 50 1000 A90 2 to 9
#32 #44 PPO 50 1000 P90 2 to 9
#33 #45 PPO 50 1500 A90 2 to 9
#34 #46 PPO 50 1500 P90 2 to 9
#35 #47 PPO 25 2000 A90 2 to 9
#36 #48 PPO 25 2000 P90 2 to 9
#85 #109 PPO 50 1000 A MAC 10+
#86 #110 PPO 50 1000 P MAC 10+
#87 #111 PPO 50 1500 A MAC 10+
#88 #112 PPO 50 1500 P MAC 10+
#89 #113 PPO 25 2000 A MAC 10+
#90 #114 PPO 25 2000 P MAC 10+
#91 #115 PPO 50 1000 A90 10+
#92 #116 PPO 50 1000 P90 10+
#93 #117 PPO 50 1500 A90 10+
#94 #118 PPO 50 1500 P90 10+
#95 #119 PPO 25 2000 A90 10+
#96 #120 PPO 25 2000 P90 10+
#98 #122 PPO 50 1000 P2 MAC 10+
#99 #123 PPO 50 1500 A2 MAC 10+

#1 #7 PPO 50 1000 A MAC for 2 to 9
#2 #8 PPO 50 1500 A MAC for 2 to 9
#3 #9 PPO 25 2000 A MAC for 2 to 9
#4 #10 PPO 50 1000 A90 2 to 9
#5 #11 PPO 50 1500 A90 2 to 9
#6 #12 PPO 25 2000 A90 2 to 9
#49 #61 PPO 50 1000 A MAC 10+
#50 #62 PPO 50 1500 A MAC 10+
#51 #63 PPO 25 2000 A MAC 10+
#52 #64 PPO 50 1000 A90 10+
#53 #65 PPO 50 1500 A90 10+
#54 #66 PPO 25 2000 A90 10+
#55 #67 PPO 50 1000 A2 MAC 10+
#56 #68 PPO 50 1500 A2 MAC 10+
#57 #69 PPO 25 2000 A2 MAC 10+
#58 #70 PPO 50 1000 A290 10+
#59 #71 PPO 50 1500 A290 10+
#60 #72 PPO 25 2000 A290 10+

2020 Effective - 2018 GRP BlueDental PPO Assignment of Benefits Rider 10+
2020 Effective - 2018 GRP BlueDental PPO Assignment of Benefits Rider 2 to 9
2020 Effective - 2019 GRP BlueDental PPO Assignment of Benefits Rider 10+
2020 Effective - 2019 GRP BlueDental PPO Assignment of Benefits Rider 2 to 9

Plan 1 1000 Adult and Child
Plan 2 1500 Adult and Child
Plan 3 2000 Adult and Child
Plan 4 1000 Child Only
Plan 5 1500 Child Only
Plan 6 2000 Child Only

BlueDental Prime PPO High 20
BlueDental Prime PPO High 50
BlueDental Prime PPO Standard 20
BlueDental Prime PPO Standard 50