BlueDental Plus and BlueDental Basic Benefit Summaries - District of Columbia

Benefit summaries are now available for the health plans listed below. Please check the site frequently for summary updates.

Please note: Not all services and procedures are covered by your benefits contract. Benefit summaries are for comparison purposes only and does not create rights not given through the benefit plan.

NOTE: Employers can consult with a CareFirst account executive to explore other plan options that fit their organization's benefit needs.

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BlueDental Plus 1-50 (Employer-Sponsored or Voluntary)


Plan* In-Network Out-of-Network Annual Max Dental Summary
1 100/80/80/50 100/80/80/50 $1,500 SUM2580  (No Ortho)
SUM2592  (With Ortho)
2 100/80/80/50 80/60/60/35 $1,500 SUM2581  (No Ortho)
SUM2593  (With Ortho)
3 100/80/50/50 100/80/50/50 $1,500 SUM2582  (No Ortho)
SUM2594  (With Ortho)
4 100/80/50/50 80/60/35/35 $1,500 SUM2583  (No Ortho)
SUM2595  (With Ortho)
5 100/80/80/50 100/80/80/50 $2,000 SUM2584  (No Ortho)
SUM2596  (With Ortho)
6 100/80/80/50 80/60/60/35 $2,000 SUM2585  (No Ortho)
SUM2597  (With Ortho)
7 100/80/50/50 100/80/50/50 $2,000 SUM2586  (No Ortho)
SUM2598  (With Ortho)
8 100/80/50/50 80/60/35/35 $2,000 SUM2587  (No Ortho)
SUM2599  (With Ortho)

 

BlueDental Plus 51+ (Employer-Sponsored or Voluntary)

* Note: Plan options 1-8 are available as both Employer-Sponsored1 or Voluntary2. Plan options 9-20 are only available as Employer-Sponsored.

Plan* In-Network
(Preventive & Diagnostic/
Basic/Major Surgical/
Major Restorative)		 Out-of-Network
(Preventive & Diagnostic/
Basic/Major Surgical/
Major Restorative)		 Annual Max Orthodontic Lifetime Maximum Dental Summary
Plan 11,2 100/80/80/50 100/80/80/50 $1,500 N/A SUM2580
$800 SUM6044
$1,000 SUM6046
$1200 SUM6048
$1,500 SUM2592
$2,000 SUM6050
Plan 21,2 100/80/80/50 80/60/60/35 $1,500 N/A SUM2581
$800 SUM6052
$1,000 SUM6054
$1,200 SUM6056
$1,500 SUM2593
$2,000 SUM6058
Plan 31,2 100/80/50/50 100/80/50/50 $1,500 N/A SUM2582
$800 SUM6076
$1000 SUM6078
$1,200 SUM6080
$1,500 SUM2594
$2,000 SUM6082
Plan 41,2 100/80/50/50 80/60/35/35 $1,500 N/A SUM2583
$800 SUM6084
$1000 SUM6086
$1,200 SUM6088
$1,500 SUM2595
$2,000 SUM6090
Plan 51,2 100/80/80/50 100/80/80/50 $2,000 N/A SUM2584
$800 SUM6060
$1000 SUM6062
$1,200 SUM6064
$1,500 SUM2596
$2,000 SUM6066
Plan 61,2 100/80/80/50 80/60/60/35 $2,000 N/A SUM2585
$800 SUM6068
$1000 SUM6070
$1,200 SUM6072
$1,500 SUM2597
$2,000 SUM6074
Plan 71,2 100/80/50/50 100/80/50/50 $2,000 N/A SUM2586
$800 SUM6092
$1000 SUM6094
$1,200 SUM6096
$1,500 SUM2598
$2,000 SUM6098
Plan 81,2 100/80/50/50 80/60/35/35 $2,000 N/A SUM2587
$800 SUM6100
$1000 SUM6102
$1,200 SUM6104
$1,500 SUM2599
$2,000 SUM6106
Plan 91 100/80/50/50 100/80/50/50 $1,000 N/A SUM5984
$800 SUM5986
$1000 SUM5988
$1,200 SUM5990
$1,500 SUM5992
$2,000 SUM5994
Plan 101 100/80/80/50 100/80/80/50 $1,000 N/A SUM5912
$800 SUM5914
$1000 SUM5916
$1,200 SUM5918
$1,500 SUM5920
$2,000 SUM5922
Plan 111 100/80/50/50 100/80/50/50 $1,500 N/A SUM5996
$800 SUM5998
$1000 SUM6000
$1,200 SUM6002
$1,500 SUM6004
$2,000 SUM6006
Plan 121 100/80/80/50 100/80/80/50 $1,500 N/A SUM5924
$800 SUM5926
$1000 SUM5928
$1,200 SUM5930
$1,500 SUM5932
$2,000 SUM5934
Plan 131 100/90/60/60

100/90/60/60

 $1,500 N/A SUM6008
$800 SUM6010
$1000 SUM6012
$1,200 SUM6014
$1,500 SUM6016
$2,000 SUM6018
Plan 141 100/90/60/60 100/90/60/60 $1,500 N/A SUM6020
$800 SUM6022
$1000 SUM6024
$1,200 SUM6026
$1,500 SUM6028
$2,000 SUM6030
Plan 151 100/90/90/60 100/90/90/60 $1,500 N/A SUM5936
$800 SUM5938
$1000 SUM5940
$1,200 SUM5942
$1,500 SUM5944
$2,000 SUM5946
Plan 161 100/90/90/60 100/90/90/60 $1,500 N/A SUM5948
$800 SUM5950
$1000 SUM5952
$1,200 SUM5954
$1,500 SUM5956
$2,000 SUM5958
Plan 171 100/90/60/60 100/90/60/60 $2,000 N/A SUM6032
$800 SUM6034
$1000 SUM6036
$1,200 SUM6038
$1,500 SUM6040
$2,000 SUM6042
Plan 181 100/90/90/60 100/90/90/60 $2,000 N/A SUM5960
$800 SUM5962
$1000 SUM5964
$1,200 SUM5966
$1,500 SUM5968
$2,000 SUM5970
Plan 191 100/90/90/60 100/90/90/60 $2,000 N/A SUM5972
$800 SUM5974
$1000 SUM5976
$1,200 SUM5978
$1,500 SUM5980
$2,000 SUM5982
Plan 201 100/80/80/50 100/80/80/50 $5,000 N/A SUM6811
$800 SUM6815
$1000 SUM6817
$1,200 SUM6819
$1,500 SUM6812
$2,000 SUM6821

 

BlueDental Basic (Employer-Sponsored or Voluntary)

PlanIn-NetworkOut-of-NetworkAnnual MaxDental Summary
1 100/80/0 80/60/0 $1,000 SUM2578 (No Ortho)

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