Dental

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

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 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 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 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 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 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)

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

EPO

EPO High Plan

EPO Low Plan

Managed Care
Managed Care High Plan
Managed Care Low Plan

Managed Care

Managed Care High Plan

Managed Care Low Plan


Comprehensive Dental Program
Basic Dental Program
Pediatric Dental Program
Pediatric Dental Program

Comprehensive Dental Program

Basic Dental Program

Pediatric Dental Program

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Independence Blue Cross is a subsidiary of Independence Health Group, Inc. ‐ independent licensees of the Blue Cross and Blue Shield Association, serving the health insurance needs of Philadelphia and southeastern Pennsylvania.

Dental Benefit SummariesGroups 51-992024

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