Blue Solutions® Standalone Dental Plans 2025Small Employer

Forms are in pdf format.

New IBX Dental Portfolio Plans

PPO Preventive
Preventive PPO 100%/0%/0%/0% $1000 (MAC)
Preventive PPO 100%/0%/0%/0% $1000 (UCR)

PPO Preferred
Preferred PPO 100%/50%/0%/0% $1000 (MAC)
Preferred PPO 100%/50%/0%/0% $1000 (UCR)

PPO Value
Value PPO 80%/50%/20%/0% $1000 Low (MAC)
Value PPO 80%/50%/20%/0% $1000 Low (UCR)
Value PPO 80%/50%/20%/50% $1000 Low (MAC)
Value PPO 80%/50%/20%/50% $1000 Low (UCR)

PPO Active
Active PPO 100%/80%/50%/0% $1000 (MAC)
Active PPO 100%/80%/50%/0% $1000 (UCR)
Active PPO 100%/80%/50%/0% $1500 (MAC)
Active PPO 100%/80%/50%/0% $1500 (UCR)
Active PPO 100%/90%/60%/0% $1000 (MAC)
Active PPO 100%/90%/60%/0% $1000 (UCR)
Active PPO 100%/90%/60%/0% $1500 (MAC)
Active PPO 100%/90%/60%/0% $1500 (UCR)

PPO Premier
Premier PPO 100%/80%/50%/0% $1000 Low (MAC)
Premier PPO 100%/80%/50%/0% $1000 Low (UCR)
Premier PPO 100%/80%/50%/50% $1000 Low (MAC)
Premier PPO 100%/80%/50%/50% $1000 Low (UCR)
Premier PPO 100%/80%/50%/0% $1000 (MAC)
Premier PPO 100%/80%/50%/50% $1000 (UCR)
Premier PPO 100%/80%/50%/50% $1000 (MAC)
Premier PPO 100%/80%/50%/50% $1000 (UCR)
Premier PPO 100%/80%/50%/0% $1500 (MAC)
Premier PPO 100%/80%/50%/0% $1500 (UCR)
Premier PPO 100%/80%/50%/50% $1500 (MAC)
Premier PPO 100%/80%/50%/50% $1500 (UCR)
Premier PPO 100%/80%/50%/50% $2000 (MAC)
Premier PPO 100%/80%/50%/50% $2000 (UCR)
Premier PPO 100%/80%/50%/50% $2500(MAC)
Premier PPO 100%/80%/50%/50% $2500(UCR)
Premier PPO 100%/80%/50%/50% $3000 (MAC)
Premier PPO 100%/80%/50%/50% $3000 (UCR)

PPO Deluxe
Deluxe PPO 100%/90%/60%/0% $1500 (MAC)
Deluxe PPO 100%/90%/60%/0% $1500 (UCR)
Deluxe PPO 100%/90%/60%/50% $1500 (MAC)
Deluxe PPO 100%/90%/60%/50% $1500 (UCR)
Deluxe PPO 100%/90%/60%/0% $2000 (MAC)
Deluxe PPO 100%/90%/60%/0% $2000 (UCR)
Deluxe PPO 100%/90%/60%/50% $2000 (MAC)
Deluxe PPO 100%/90%/60%/50% $2000 (UCR)
Deluxe PPO 100%/90%/60%/50% $2500 (MAC)
Deluxe PPO 100%/90%/60%/50% $2500 (UCR)
Deluxe PPO 100%/90%/60%/50% $3000 (MAC)
Deluxe PPO 100%/90%/60%/50% $3000 (UCR)

PPO Elite
Elite PPO 100%/100%/50%/0% $2000 (MAC)
Elite PPO 100%/100%/50%/0% $2000 (UCR)
Elite PPO 100%/100%/50%/50% $2000 (MAC)
Elite PPO 100%/100%/50%/50% $2000 (UCR)

EPO
EPO High Plan
EPO Low Plan

Managed Care
Managed Care High Plan
Managed Care Low Plan

Legacy Dental Plans
Standalone Dental Preferred Family PPO
Standalone Dental Premier Family PPO
Standalone Dental Deluxe Family PPO
Standalone Dental Adult Preventive PPO
Standalone Dental Adult Preferred PPO
Standalone Dental Adult Premier PPO with Preventive Incentive
Standalone Adult Managed Care Dental Plan Schedule of Copayments

Legacy Dental Pediatric Copay Schedule
Pediatric Dental Managed Care Schedule of Copayments