Benefits for Members of Individual or Family Plans

Blue Dental^SM coverage is available as an Optional Benefit covering diagnostic and preventive care, minor restorative care, and major restorative care.

Blue Dental Network

When you’re in the Blue Dental service area, which includes the entire state of Iowa, visit a dentist who participates in our Blue Dental network.

Dental Health Alliance (DHA) Network

If you reside or travel outside the Blue Dental service area, you can visit a dentist who is part of the national DHA network. The DHA network includes more than 24,000 dentists in 38,000 locations through DHA.* Just show your ID card to the DHA dentist to receive the same advantages you receive when visiting a Blue Dental provider.

Covered Services
Check-ups and Teeth Cleaning

• Bitewing x-rays—once every 12 consecutive months
• Dental cleaning/prophylaxis—twice per benefit period
• Full-mouth x-rays—once every five consecutive years
• Occlusal and extraoral x-rays
• Oral evaluations—twice per benefit period
• Periapical x-rays
• Space maintainers—only for dependent children under age 15
• Topical fluoride applications—for dependent children under the age of 19, once every 12 consecutive months
• Topical sealant applications—for eligible dependent children under age 15; once per permanent first and second molars in a lifetime

Cavity Repair and Tooth Extractions

• Contour of bone (alveoloplasty)
• Emergency treatment for the relief of pain or infection of dental origin
• General anesthesia/sedation billed by the operating dentist for covered oral surgery
• Limited occlusal adjustment
• Restoring decayed or fractured teeth
• Routine oral surgery
• Wisdom teeth extractions

Major Restorative

• Crowns
• Endodontics
• Onlays and Inlays
• Periodontics

Exclusions
There is no coverage for:

• Bridges
• Congenital deformities
• Cosmetic procedures
• Dentures
• Implants
• Local anesthesia when billed separately
• Occlusal adjustment
• Orthodontics

When you first apply for one of our Alliance Select plans, you will have the opportunity to choose Blue Dental coverage. If you choose not to enroll in Blue Dental coverage when you first apply for Alliance Select coverage, you will not be eligible to enroll in Blue Dental coverage at a later date unless you have an event that allows you to add a person to your policy. Following our acceptance of your application and issuance to you of the Alliance Select and Blue Dental policies, if you decide to terminate the policies, you will not be eligible for a medical policy with the same deductible. You may apply for a medical policy with a different deductible amount, subject to our applicable medical underwriting guidelines.

Your Payment Obligations

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Wellmark Blue Cross and Blue Shield is an Independent Licensee of the Blue Cross and Blue Shield Association doing business in Iowa and South Dakota. Blue Cross®, Blue Shield®, and the Cross® and Shield® symbols are registered marks of the Blue Cross and Blue Shield Association, an Association of Independent Blue Cross and Blue Shield Plans.