BlueCross BlueShield of Wisconsin Dental Plan

• Dental Plans Brochure
• Application

With the BCBSWI dental plans, you’ll get dental coverage on day one with no deductible deductible required for check-ups, cleanings and other preventive services. Most important, costs are typically reduced when you receive care from any BCBSWI participating network dentists. However, you also have the option to see any dentist not in the network, but your out-of-pocket costs may be higher.

Some highlights of Dental Indemnity USA coverage:

• Coverage can be used to provide dental benefits to an individual, spouse, children or any combination of dependents.
• A $50 deductible, based on fee schedule allowances, applies for dental procedures or services received by a covered individual during each benefit year.
• Maximum deductible amount of $150 for family coverage.
• Deductibles do not apply to oral exams, cleanings, fluoride treatments, sealants and X-rays.
• $1,000 orthodontia benefit for children under 19 years old
• For more information on coverage and benefits, view the Dental Outline of Coverage.

Eligibility Requirements

You must enroll in a BCBSWI health plan in order to enroll in the dental plan.

You have up to 31 days from the effective date of your policy to enroll.

All members on that health plan must be enrolled in Dental Indemnity USA.

Once your dental plan is dropped for any reason, you cannot re-enroll unless you reapply for a new health insurance plan.

There are three ways to enroll in BlueCare Dental PPO:

• Select ‘YES’ next to the Dental option when you apply online for any qualifying Blue Cross and Blue Shield of Wisconsin health plan.
• Download a paper application and email to [email protected] or fax to 847-220-9280. 
• Call us at (312) 726-6565

* Includes insured, spouse, and three or more children
1. This document does not contain a complete listing of the exclusion, limitations and conditions that apply to the benefits shown. For full information refer to the member’s certificate of
benefits booklet.
2. Annual maximum does not apply to members under age 21.
3. Rates subject to change.
4. Region 1 rates apply to members residing in the following counties: Archer, Austin, Bastrop, Brazoria, Caldwell, Chambers, Clay, Collin, Dallas, Delta, Denton, Ellis, Fort Bend,
Galveston, Grayson, Harris, Hays, Hunt, Johnson, Kaufman, Liberty, Montgomery, Parker, Rockwall, San Jacinto, Tarrant, Travis, Waller, Wichita, Williamson and Wise.
5. Region 2 rates apply to all members residing in counties outside Region 1
6 Out of Pocket Maximum only applies to members under age 21.
7. The plans listed above refer to the following plans on your Outline of Coverage: 01 = 1A, 02 = 1B, 03 = 2A, 96 = 4 Kids 1A, 97 = 4 Kids 1B
All benefits are based upon the Allowable Amount, which is the amount determined by BCBSWI as the maximum amount eligible for payment of benefits. A Contracting Dentist cannotbalance bill for charges in excess of the Allowable Amount. Benefits for services provided by a Non-Contracting Dentist will be based upon the same Allowable Amount, and it is likely that the Non-Contracting Dentist will balance bill for amounts above this, resulting in higher out-of-pocket expenses.