BlueDental Premium

Comprehensive dental plus an option for orthodontics

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Consider this plan if

You want to offer your employees a step up from basic coverage.

Coverage available for

Individuals
Families

Plan features

Covered Preventive Services*

Oral exams
Prophylaxis (teeth scaling and polishing)
Diagnostic
Topical fluoride application
Radiographs (X-rays/films)

*These covered prevention services are excluded from the benefit maximums.

Covered Basic Services

Sealants
Emergency oral evaluations, palliative treatment
Fillings
Anesthesia
Simple extractions
Endodontics
Periodontics

Covered Major Services

Crowns, inlays or onlays
Dentures (full and partial)
Bridges, replacement of lost, defective bridges
Occlusal guards (treatment of bruxism)
Implants

Orthodontia Services

Orthodontia option available

Plan highlights

Plan is available with or without orthodontia coverage
Provides access to one of the nation's most extensive dental networks
Preventive services are a focus
Coverage offered through a partnership with United Concordia Dental (UCD)
Employers must contribute a minimum of 50% of the cost of each employee's individual premium payment

Additional information

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BlueDental Premium

BlueDental Premium+

Available to groups of 10 employees or more

Deductibles

Member
Family

$50
$100

Annual Maximums

Member
Family

$1,000

Orthodontic Lifetime Maximums

Member
Family

Not covered

$1,500

Services

Diagnostic

Exam¹

80%

Radiographs

Bitewing X-rays
Full Mouth/Panoramic X-rays
Occlusal Films

80%

Preventive

Cleanings (Prophylaxis)¹
Fluoride¹
Sealants
Space Maintainers

80%

Restorative

Amalgam Restorations
Fillings

80%

Crowns adn Repairs
Inlays, Onlays and Repairs

50%

Endodontic

Endodontic Therapy
Root Canal Retreatment
Apioectomy/Periradicular

80%

Periodontal

Surgical/Nonsurgical Periodontics
Root Canal Retreatment

80%

Prosthodontic

Removable Complete/Partial Dentures
Fixed Partial Dentures (Bridges)
Adjustments/Repairs of Dentures

50%

Implant

Surgical Placement
Supporting Structures
Treatment of Implant Defects
Fixed Partial/Removable Denture

50%

Cone-Beam CT Images

80%

Removal of Teeth

Simple and Surgical Extractions

80%

Complex Oral Surgery

50%

Adjunctive General

Consultations
General Anesthesia, Nitrous Oxide, IV Sedation
Palliative Treatment (Emergency)

80%

Orthodontic

Orthodontic Services

Not covered

50%²

Employer Contribution: To qualify for group dental plan, the employer must contribute a minimum of 50% toward the individual contract premium payment.

For further details on the coverage, including exclusions, any reductions or limitations and the terms under which the benefit plan may be continued, see your account executive. United Concordia Companies, Inc. is an independent company providing dental benefit administration services and access to provider network for the Blue Cross Blue Shield of North Dakota dental products.

¹Covered service does not apply to benefit maximums
²Deductible does not apply

Our Partners in Health:
Members
Providers
Producers

Fargo (Headquarters)
4510 13th Ave. S.
Fargo, N.D., 58121