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Dental Plans
Choose from Two 2020 Plan Options
Dental Blue
®
Dental Blue
®
Select
Self
$
21
per month
Self Plus One
$
42
per month
Family
$
75
per month
Enroll Now
Self
$
32
per month
Self Plus One
$
66
per month
Family
$
129
per month
Enroll Now
Dental
Blue
®
Enroll Now
Self
$
21
per month
Self Plus One
$
42
per month
Family
$
75
per month
Dental
Blue
®
Select
Enroll Now
Self
$
32
per month
Self Plus One
$
66
per month
Family
$
129
per month
Calendar Year Deductible
$50 per member
$50 per member
Annual Maximum Benefits
$1,000 per member
$1,500 per member
Diagnostic and Preventive Services
(No waiting period)
Covered at 100%
subject to deductible
Covered at 100%
subject to deductible
Basic Services*
Covered at 75%
subject to deductible
Covered at 80%
subject to deductible
Major Services**
Covered at 50%
subject to deductible
Covered at 50%
subject to deductible
Additional Major Services**
Not covered
Covered at 50%
subject to deductible
Orthodontic
Services**
Not covered
Covered at 40%
subject to deductible
*180-day waiting period
**365-day waiting period
Diagnostic and Preventive Services
Dental exams and X-rays
Routine cleanings
Basic Services
Fillings
Simple tooth extractions
Root canal (non-surgical)
Emergency treatment for pain
Repairs to crowns, inlays, onlays, fixed partial and removable dentures
Major Services
Oral surgery
General anesthesia
Periodontic exams
Removal of diseased gum tissue and bone
Additional Major Services
Crowns, inlays, onlays, bridges and dentures
Orthodontic Services
Coverage for dependent children up to age 19
Limited lifetime maximum of $1,500
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