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.

2020 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
• BlueCare Dental PPO - DTXHM27
• BlueCare Dental PPO - DTXLR28

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
• BlueCare Dental PPO - DTXHM29
• BlueCare Dental PPO - DTXLR30

2020 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 can be found in the insurance policy.

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