BlueDental Plus and BlueDental Basic Benefit Summaries - Virginia

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

Spanish benefit summaries are available upon request. Please contact your CareFirst sales representative for more information.

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 SUM2616 (No Ortho)
SUM2628 (With Ortho)
2 100/80/80/50 80/60/60/35 $1,500 SUM2617 (No Ortho)
SUM2629 (With Ortho)
3 100/80/50/50 100/80/50/50 $1,500 SUM2618 (No Ortho)
SUM2630 (With Ortho)
4 100/80/50/50 80/60/35/35 $1,500 SUM2619 (No Ortho)
SUM2631 (With Ortho)
5 100/80/80/50 100/80/80/50 $2,000 SUM2620 (No Ortho)
SUM2632 (With Ortho)
6 100/80/80/50 80/60/60/35 $2,000 SUM2621 (No Ortho)
SUM2633 (With Ortho)
7 100/80/50/50 100/80/50/50 $2,000 SUM2622 (No Ortho)
SUM2634 (With Ortho)
8 100/80/50/50 80/60/35/35 $2,000 SUM2623 (No Ortho)
SUM2635 (With Ortho)

 

BlueDental Plus 51+ (Employer-Sponsored or Voluntary)

* Note: Plan options 1-8 are available as both Employer-Sponsored1 or Voluntary2. Plan options 9-19 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 SUM2616
$800 SUM6045
$1,000 SUM6047
$1,200 SUM6049
$1,500 SUM2628
$2,000 SUM6051
Plan 21, 2 100/80/80/50 80/60/60/35 $1,500 N/A SUM2617
$800 SUM6053
$1,000 SUM6055
$1,200 SUM6057
$1,500 SUM2629
$2,000 SUM6059
Plan 31, 2 100/80/50/50 100/80/50/50 $1,500 N/A SUM2618
$800 SUM6077
$1,000 SUM6079
$1,200 SUM6081
$1,500 SUM2630
$2,000 SUM6083
Plan 41, 2 100/80/50/50 80/60/35/35 $1,500 N/A SUM2619
$800 SUM6085
$1,000 SUM6087
$1,200 SUM6089
$1,500 SUM2631
$2,000 SUM6091
Plan 51, 2 100/80/80/50 100/80/80/50 $2,000 N/A SUM2620
$800 SUM6061
$1,000 SUM6063
$1,200 SUM6065
$1,500 SUM2632
$2,000 SUM6067
Plan 61, 2 100/80/80/50 80/60/60/35 $2,000 N/A SUM2621
$800 SUM6069
$1,000 SUM6071
$1,200 SUM6073
$1,500 SUM2633
$2,000 SUM6075
Plan 71, 2 100/80/50/50 100/80/50/50 $2,000 N/A SUM2622
$800 SUM6093
$1,000 SUM6095
$1,200 SUM6097
$1,500 SUM2634
$2,000 SUM6099
Plan 81, 2 100/80/80/50 80/60/35/35 $2,000 N/A SUM2623
$800 SUM6101
$1,000 SUM6103
$1,200 SUM6105
$1,500 SUM2635
$2,000 SUM6107
Plan 91 100/80/50/50 100/80/50/50 $1,000 N/A SUM5985
$800 SUM5987
$1,000 SUM5989
$1,200 SUM5991
$1,500 SUM5993
$2,000 SUM5995
Plan 101 100/80/80/50 100/80/80/50 $1,000 N/A SUM5913
$800 SUM5915
$1,000 SUM5917
$1,200 SUM5919
$1,500 SUM5921
$2,000 SUM5923
Plan 111 100/80/50/50 100/80/50/50 $1,500 N/A SUM5997
$800 SUM5999
$1,000 SUM6001
$1,200 SUM6003
$1,500 SUM6005
$2,000 SUM6007
Plan 121 100/80/80/50 100/80/80/50 $1,500 N/A SUM5925
$800 SUM5927
$1,000 SUM5929
$1,200 SUM5931
$1,500 SUM5933
$2,000 SUM5935
Plan 131 100/90/60/60

100/90/60/60

 $1,500 N/A SUM6009
$800 SUM6011
$1,000 SUM6013
$1,200 SUM6015
$1,500 SUM6017
$2,000 SUM6019
Plan 141 100/90/60/60 100/90/60/60 $1,500 N/A SUM6021
$800 SUM6023
$1,000 SUM6025
$1,200 SUM6027
$1,500 SUM6029
$2,000 SUM6031
Plan 151 100/90/90/60 100/90/90/60 $1,500 N/A SUM5937
$800 SUM5939
$1,000 SUM5941
$1,200 SUM5943
$1,500 SUM5945
$2,000 SUM5947
Plan 161 100/90/90/60 100/90/90/60 $1,500 N/A SUM5949
$800 SUM5951
$1,000 SUM5953
$1,200 SUM5955
$1,500 SUM5957
$2,000 SUM5959
Plan 171 100/90/60/60 100/90/60/60 $2,000 N/A SUM6033
$800 SUM6035
$1,000 SUM6037
$1,200 SUM6039
$1,500 SUM6041
$2,000 SUM6043
Plan 181 100/90/90/60 100/90/90/60 $2,000 N/A SUM5961
$800 SUM5963
$1,000 SUM5965
$1,200 SUM5967
$1,500 SUM5969
$2,000 SUM5971
Plan 191 100/90/90/60 100/90/90/60 $2,000 N/A SUM5973
$800 SUM5975
$1,000 SUM5977
$1,200 SUM5979
$1,500 SUM5981
$2,000 SUM5983

 

BlueDental Basic (Employer-Sponsored or Voluntary)

Plan In-Network Out-of-Network Annual Max Dental Summary
1 100/80/0 80/60/0 $1,000 SUM2579 (No Ortho)

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