Dental Blue 100 &
Dental Blue 200

** 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 Ohio
Dental Blue Application

To 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.