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.

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 9-20 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 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
Plan 201 100/80/80/50 100/80/80/50 $5,000 N/A SUM6813
$800 SUM6816
$1,000 SUM6818
$1,200 SUM6820
$1,500 SUM6814
$2,000 SUM6822

 

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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