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Health & Wellness

A total-health solution that surrounds everyone with the help they need to live healthier, feel better and save money doing it.

Standard Plan Designs

PW_AD049675

Dental Program

The following plan designs are in their standard form. You have the flexibility to customize the plans to best meet your clients' needs. Click on a Plan Number to see a Summary of Benefits for that Plan option. 
Employee Funded Plans ( Voluntary Plans ) 

Large Group Plans 
Annual Deductible 
Annual Maximum 
In-Network Dental   Coinsurance* 
Child Ortho? 
Number 
   
Preventive 
Basic 
Major 
Coinsurance 
7500DV** 
$50 
$1,000 
100% 
50% 
50% 
NO ORTHO 
$50 
$1,000 
100% 
80% 
50% 
NO ORTHO 
$50 
$1,500 
100% 
80% 
50% 
$50 COINS 
$50 
$1,500 
100% 
80% 
50% 
NO ORTHO 
$50 
$1,000 
75%|100% 
60%|80% 
25%|50% 
50% COINS 
$50 
$1,000 
100% 
80% 
50% 
50% COINS 
$50 
$1,000 
100% 
80% 
50% 
NO ORTHO 
$50 
$1,000 
100% 
80% 
0% 
NO ORTHO 
 
*See plan summary for out-of-network details. **Out of Network Fee Schedule  
Large Group Book Rates and Regional Definitions 
4th Qtr 2005 Voluntary Dental Plan Rates
1st Qtr 2006 Voluntary Dental Plan Rates
Employer Funded Plans 

Plan Number 
Annual Deductible 
Preventive Services 
Basic Services 
Major Services 
101 
$50 
100% 
100% 
60% 
102 
$50 
100% 
100% 
50% 
103 
$50 
100% 
90% 
60% 
104 
$50 
100% 
80% 
50% 
105 
$50 
100% 
80% 
50% 
106 
$50 
100% 
80% 
60% 
107 
$50 
100% 
80% 
50% 
108 
$50 
100% 
80% 
50% 
109 
$50 
100% 
80% 
50% 
110 
$50 
80% 
80% 
50% 
111 
$50 
100% 
80% 
50% 
112 
$50 
100% 
80% 
50% 
113 
$50 
100% 
80% 
60% 
114 
$50 
100% 
80% 
50% 
115 
$50 
100% 
80% 
50% 
116 
$50 
100% 
80% 
50% 
117 
$50 
80% 
80% 
50% 
118 
$50 
100% 
80% 
60% 
119 
$50 
100% 
50% 
50% 
120 
$50 
80% 
50% 
50% 
121 
$50 
100% 
80% 
N/A 
122 
$50 
80% 
80% 
N/A 
123 
$50 
100% 
50% 
N/A 
124 
$50 
80% 
80% 
N/A 
 

Plan Number 
Annual Deductible 
Preventive Services 
Basic Services 
Major Services 
Ortho Services 
125 
$50 
100% 
80% 
50% 
50% 
126 
$50 
100% 
80% 
50% 
50% 
127 
$50 
100% 
80% 
50% 
50% 
128 
$50 
100% 
80% 
50% 
50% 
129 
$50 
100% 
80% 
50% 
50% 
130 
$50 
100% 
80% 
50% 
50% 
131 
$50 
80% 
80% 
50% 
50% 
132 
$50 
100% 
80% 
60% 
50% 
133 
$50 
100% 
50% 
50% 
50% 
134 
$50 
80% 
50% 
50% 
50% 
135 
$50 
100% 
80% 
50% 
50% 
 
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Blue Cross and Blue Shield of Georgia, Inc. and Blue Cross Blue Shield Healthcare Plan of Georgia, Inc. are independent licensees of the Blue Cross and Blue Shield Association. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association.