Dental Plan - OFFICE OF GROUP INSURANCE

All Dental benefits utilize a PPO provider network regardless of the type of medical plan you have selected. Deductibles and benefit payments are based on allowable charges. Review the Dental Plan Contract posted below for details on waiting periods, exclusions and benefit amounts. Your Group Number for the Blue Cross dental plan is 10040000

NOTE: Orthodontic services are for eligible dependent children up to age 19 if the treatment has begun by age 17.

Deductibles and Benefit Limits are per benefit period, except the Orthodontic Benefit Limit which is a lifetime limit.

Important Links

The links below provide information further detailing the State’s current dental plan.

FY25/FY26 Dental Benefit Summary
FY25 Dental Policy & Contract
Premiums
Finding a Dental Provider
Contact Blue Cross at 800-358-5527

Dental Plan Comparison

Plan Year Benefit: $1,500 maximum per member benefit
• Deductible: $50 per member (except listed preventive services)
• Pediatric Orthodontia Benefit: $1,000 lifetime maximum

Type	Covered Service (see contract for full list)	In-Network Contracting Providers – PPO	Out-of-Network Providers
Preventative & Diagnostic	Oral exam & cleanings	100%, no deductible	70% after deductible
Basic	Fillings, extractions, root canals, etc.	80% after deductible	50% after deductible
Major	Crowns, bridges, dentures	50% after deductible	50% after deductible
Orthodontic (Pediatric)	Pediatric benefit only	50% after deductible	50% after deductible
Other		80% after deductible	70% after deductible