BlueCare Dental PPO^SM (Small Group) Plans

To help you make an informed decision about your dental coverage, a Small Group (1 to 50 employees) Summary of Dental Benefits document is available for each of our fully insured plans. The summary describes key features such as:

• Program basics
• Covered services
• Orthodontic services

Pediatric dental coverage is included in all small group qualified health plans as an essential health benefit embedded into the medical plan.

2019 Fully Insured Small Group Summary of Dental Benefits

Contributory

• BlueCare Dental PPO - DTXHR01  
• BlueCare Dental PPO - DTXHR02 
• BlueCare Dental PPO - DTXHR03 
• BlueCare Dental PPO - DTXHR04 
• BlueCare Dental PPO - DTXLR05 
• BlueCare Dental PPO - DTXLR06 
• BlueCare Dental PPO - DTXLR07 
• BlueCare Dental PPO - DTXLM08  
• BlueCare Dental PPO - DTXHM09 
• BlueCare Dental PPO - DTXLM10  
• BlueCare Dental PPO - DTXHM11 
• BlueCare Dental PPO - DTXHR20 

Voluntary

• BlueCare Dental PPO - DTXHR12 
• BlueCare Dental PPO - DTXHM13 
• BlueCare Dental PPO - DTXHM15 
• BlueCare Dental PPO - DTXHR21 
• BlueCare Dental PPO - DTXHR22 
• BlueCare Dental PPO - DTXLR23 
• BlueCare Dental PPO - DTXLM24 

2019 Embedded Pediatric Dental Benefit for Medical Plans

• TX PPO Medical Plan 
• TX HMO Medical Plan 

All information represents an overview of coverage.  It's not a complete list of what is covered or excluded.  Information is subject to change.  The full terms of coverage are located in the insurance policy.

Contact your Blue Cross and Blue Shield representative with questions at any time.

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