Blue Cross Dental - Individual & Family Plans
EASY ACCESS TO NETWORK PROVIDERS
Blue Cross Dental plans utilize the United Concordia Advantage Plus 2.0 national network, one of the largest dental networks in the nation.
Nationwide coverage not available in all states.
United Concordia researches facilities and costs in each area, carefully screening each dentist to ensure our network offers the best dental care. United Concordia is one of the first dental carriers to receive the URACís Health Network Accreditation. This mark of distinction recognizes commitment to quality health care.
Blue Cross and Blue Shield of Minnesota makes it easy to protect your oral health with a wide range of dental plan options. All Blue Cross Dental plans cover preventive dental care and commonly used services as part of your routine dental visit. Whether you chose Value, Preferred or Freedom, each Blue Cross Dental plan is designed to complement your health care package.

BLUE CROSS DENTAL PLANS:
Value Plans
A great choice for those who want the lowest cost plan, Value Plans provide full coverage for important preventive and diagnostic procedures. Some also provide coverage for fillings and other basic services.
Preferred Plan
This comprehensive plan drives savings by encouraging members to see a network provider. Members enjoy richer coverage levels when they see a dentist in the network.
Freedom Plan
This plan is designed for those looking for a comprehensive plan that offers coverage for a broad range of services and equal coverage levels in or out of network.
Enrollment in Blue Cross Dental plans can be done at any time. Coverage is generally effective the first of the month following receipt of the application.
VALUE PREFERRED FREEDOM
Standard Enhanced Premium
Plan benefits Equal coinsurance in and out of network* In network Out of network Equal coinsurance in and out of network*
Contract year deductible
- Deductible does not apply to preventive and diagnostic services, services covered at 100%, or orthodontia, when applicable
$0 $50 per individual
/ $150 per family
$0 $50 per individual** $50 per individual** $50 per individual**
Annual maximum per member $1,000 $1,500
PREVENTIVE AND DIAGNOSTIC Waiting period
Exams and cleanings
- 2 every 12 months (unless noted)
None 100%
1 every 12 months
100%
1 every 12 months
100% 100% 80% 100%
Fluoride treatments None 100% 80% 100%
X-rays (bitewing and full mouth) None 100% 80% 100%
Sealants None Not covered 100% 80% 100%
BASIC RESTORATIVE Waiting period
Amalgam (silver) and composite (white) fillings 6 months Not covered 60% 50% 80% 60% 80%
Space maintainers 6 months Not covered 100% 80% 60% 80%
Surgical/non-surgical periodontics
- Includes treatment of gum disease
12 months Not covered 80% 60% 50%
Endodontics
- Includes root canal
12 months Not covered 60% 50% 80% 60% 50%
Simple/surgical extractions 6 months Not covered 60% 50% 80% 60% 80%
Complex oral surgery 12 months Not covered 50% 80% 60% 80%
General anesthesia 12 months Not covered 50% 80% 60% 80%
Repairs
- Includes bridges and dentures
6 months Not covered 50% 80% 60% 80%
MAJOR Waiting period
Inlays, onlays, crowns
- Every five years for the same tooth
12 months Not covered 50%
Prosthetics
- Includes bridges and dentures
12 months Not covered 50%
TMD (temporal mandibular disorder) 12 months 50%

* When members receive services from nonparticipating providers, they are responsible for the difference between the allowed amount and the billed charge.
**Preferred and Freedom plans have individual deductibles only.
These plans provide dental coverage only.
Blue Cross Dental plans include coverage for certain pediatric dental services. This plan is not exchange-certified and does not qualify as the pediatric dental essential health benefit under the Affordable Care Act.
Discounts may apply. Network dentists may elect to discount non-covered services.
Consult our online provider directory at bluecrossmn.com/findadentist to search for a dentist. Dentists with a black box (n) next to their name accept allowances for services not covered by the benefit plan, including services rendered after the annual maximum has been exceeded; not available in all areas.
Members can cancel at any time with the cancellation being effective the first of the month following the notification. The exception is cancellation due to death, which will be effective the date of death. Voluntary termination will result in having to satisfy a lockout period of three years before an individual is eligible to re-enroll.

Blue Cross Dental Rates
REGION 1 -
(ZIP codes between 55000 and 55599)
REGION 2 -
(ZIP codes between 55600 and 56899)
VALUE PLANS
- Standard $20.28 single
$40.05 single + 1
$60.84 family
$21.53 single
$42.52 single + 1
$64.59 family
- Enhanced $29.84 single
$58.93 single + 1
$89.52 family
$31.69 single
$62.59 single + 1
$95.07 family
- Premium $32.15 single
$63.50 single + 1
$96.45 family
$34.14 single
$67.43 single + 1
$102.42 family
PREFERRED PLAN $42.11 single
$83.17 single + 1
$126.33 family
$44.71 single
$88.30 single + 1
$134.13 family
FREEDOM PLAN $45.42 single
$89.70 single + 1
$136.26 family
$48.23 single
$95.25 single + 1
$144.69 family

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