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| Eligibility | Individuals and family members not enrolled in Flexible Blue II or Individual Care Blue Plus* |
| Monthly Rate | Starting at $44.09 |
| Copay: | Preventive services: 25 percent Basic restorative services: 50 percent Major restorative services: 50 percent |
| Deductible: | $50 single/$100 family (two or more) per calendar year on basic and restorative services |
| Annual Maximums: | $1,000 per member for all covered services |
| Waiting Period: | 6-month waiting period on Class II – Basic Restorative and Class III – Major Restorative services, applied on the effective date of dental coverage |