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Dental Blue PPO Plan
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It's All About Simplicity

Quick QuoteDental Blue PlansComprehensive dental benefits for you and your family. Regular dental checkups and cleanings are important to your overall health. They also help you feel better about yourself. That;s why they're 100% covered within your plan network by Dental Blue.

No matter which plan you choose, the network will include some of the best dental care around. Dental Blue has thousands of dentists, and every one is a credentialed provider. Also, every contracted specialits (such as oral surgeons and periodontists) can be found in all three Dental Blue network tiers.

The Dental Blue Plans - With Dental Blue, you have three choices of plan designs. Blue Basic 100, Blue Essential 100 and Blue Essential 200.
 
DENTAL PLANS
  Blue Basic 100 Blue Essential 100 Blue Essential 200 ALL PLANS
Plan Network Dental Blue 100 Dental Blue 100

Dental Blue 100 &
Dental Blue 200

 Benefit from negotiated rates at Dental Blue providers
Preventive and diagnostic care 100% covered within plan network 100% covered within plan network 100% covered within plan network No waiting period; no deductible in or out of network; covers two routine cleanings and oral exams per year; molar/bicuspid x-rays; full mouth x-rays covered once every 5 years
Minor restorative dental care 80% covered within plan network after $50 deductible** Pays set amount within plan network and out of network after $50 deductible** Pays set amount within plan network and out of network after $50 deductible** No waiting periods
Major restorative dental care Not covered Pays set amount within plan network and out of network after $50 deductible** Pays set amount within plan network and out of network after $50 deductible** 12 month waiting period with Dental Blue Essential plans

Dental Blue Rates** All deductibles are per member per calendar year

Preventive and diagnostic care: Services that help your dentist make sure your teeth and gums are healthy. Routine checkups, cleanings, x-rays, oral evaluations, flouride applications.

Basic Plan: filings and space maintainers are included in Minor Restorative dental care; extractions are not covered.

Essential Plans: fillings and extractions are included in Minor Restorative dental care; space maintainers are included in Preventive and Diagnostic dental care.

Major restorative dental care: Crowns, bridges, root canals and dentures

Anthem Blue Cross Blue Shield of Indiana
Dental Blue Application

Indiana Dental Blue ApplicationTo apply for coverage simply download, print, complete and FAX the application to FAX# (415) 651-8696:

HOW TO APPLY:

  1. Select Dental Blue Plan from the brochure available above
  2. Download & Print the application file to the right - You cannot apply for a STAND ALONE Dental plan online - you must print, complete and FAX the application to us.
  3. Be sure to select credit and complete the card payment section of the application
  4. FAX completed applications to (415) 651-8696

MAILING ADDRESS

Application Processing
P O Box 6374
Jackson Hole, WY 83002

FAX # (415) 651-8696

If you want a specific effective date please indicate this on your dental application.

IMPORTANT APPLICATION NOTE

All applications must be faxed to us at the FAX number above and the processing time is typically 3-5 business days. Once you are enrolled in the Dental plan you will receive a policy with ID cards in the mail.
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Dental Blue PPO
 
P O Box 6374 Jackson Hole, WY 83002-6374
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