Blue Dental Preferred Certified- $1,000 Annual Benefit Maximum per Adult, 100%/80%/50% coinsurance, $50 deductible · 97176LA0390002
Louisiana Health Service & Indemnity Company offers this marketplace health insurance plan (Plan ID 97176LA0390002) so you can compare premiums, coverage levels, and provider access against other health plan insurance options. Use the modules below to decide whether this is the best health insurance plan for your household or if another insurance health plan fits better.
Marketplace enrollment for 2025 coverage typically runs Nov 1 – Jan 15 (dates may vary slightly in Louisiana). Submit changes before the deadline to avoid a coverage gap.
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Special Enrollment Periods
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Report the event within 60 days.
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Enter accurate income to maximize Advanced Premium Tax Credits.
Standard High Off Exchange Plan plans like this one keep deductibles and copays lower if you qualify.
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More from Louisiana Health Service & Indemnity Company
Track the official identifiers, documents, and filing dates tied to this plan. Open the marketing or formulary links whenever you need the latest PDF from the issuer.
Review the network branding plus the number of in-network clinicians we track from issuer filings. Counts update with each CMS import (Tue, 02 Dec 2025 06:13 GMT).
All providers in LouisianaN/A
PCPs in LouisianaN/A
Telehealth supportData pending
Nationwide providersN/A
N/A doctors statewideN/A PCPsN/A OB/GYN
Provider network(s)
['LAN002']
Providers
Louisiana
All US states
All
N/A
N/A
PCP
N/A
N/A
Allergy
N/A
N/A
OB/GYN
N/A
N/A
Dentists
N/A
N/A
Drug coverage overview
0 drugs tracked
Inspect tier distribution plus authorization, step therapy, and quantity-limit counts sourced from HealthPorta’s formulary import.
Prior authorization
Drugs
Required
0
Not Required
0
Step therapy
Drugs
Required
0
Not Required
0
Quantity limits
Drugs
Has Limit
0
No Limit
0
Customer highlights
What stands out for members
Issuer: Louisiana Health Service & Indemnity Company · Plan ID 97176LA0390002 · 2025 filing.
Variant 97176LA0390002-00 (Standard Off Exchange Plan) currently displayed.
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Benefits
Covered services & limitations
Pregnancy & family
Maternity, newborn, pediatric dental and vision extras.
Basic Dental Care - Child
20.00% Coinsurance after deductible
Tier 1 in-network20.00% Coinsurance after deductible
Out-of-network20.00% Coinsurance after deductible
Amalgam Restorations (Metal Fillings) and Resin-Based Composite Restorations (White Fillings), Endodontics, Periodontics, Oral Surgery, Adjustments and Repairs of Prosthodontics and Other Prosthodontic Services (including Relining and Rebasing of Dentures). No waiting period applies. OON coinsurance, member is responsible for any difference between the charge and the paid amount
Exclusions: nan
Major Dental Care - Child
50.00% Coinsurance after deductible
Tier 1 in-network50.00% Coinsurance after deductible
Out-of-network50.00% Coinsurance after deductible
Inlays, Onlays and Crowns are limited to one per tooth every 60 months. Prosthetic Dentures are limited to one every 60 months. OON coinsurance, member is responsible for any difference between the charge and the paid amount.
Emergency Palliative Treatment. OON coinsurance, member is responsible for any difference between the charge and the paid amount.
Exclusions: nan
Accidental Dental - Child
No Charge
Tier 1 in-networkNo Charge
Out-of-networkNo Charge
Emergency Palliative Treatment. OON coinsurance, member is responsible for any difference between the charge and the paid amount.
Exclusions: nan
Basic Dental Care - Adult
20.00% Coinsurance after deductible
Tier 1 in-network20.00% Coinsurance after deductible
Out-of-network20.00% Coinsurance after deductible
Amalgam Restorations (Metal Fillings) and Resin-Based Composite Restorations (White Fillings), Endodontics (6-month waiting period applies). Periodontics and Oral Surgery (12-month waiting period applies). OON coinsurance, member is responsible for any difference between the charge and the paid amount.
Exclusions: nan
Dental Check-Up for Children
No Charge
Tier 1 in-networkNo Charge
Out-of-networkNo Charge
Limit: 1.0 Visit(s) per 6 Months
One periodic, limited problem-focused, or comprehensive oral exam every 6 months. Oral cleanings (Prophylaxis) limited to one every 6 months. One additional cleaning during the Policy Year will be allowed for Members that are under the care of a medical professional during pregnancy. OON coinsurance, member is responsible for any difference between the charge and the paid amount.
Exclusions: nan
Major Dental Care - Adult
50.00% Coinsurance after deductible
Tier 1 in-network50.00% Coinsurance after deductible
Out-of-network50.00% Coinsurance after deductible
Inlays, Onlays and Crowns are limited to one per tooth every 60 months. 12-month waiting period applies. OON coinsurance, member is responsible for any difference between the charge and the paid amount.
Exclusions: nan
Orthodontia - Adult
Coverage details pending
Not Covered
Exclusions: nan
Orthodontia - Child
50.00% Coinsurance after deductible
Tier 1 in-network50.00% Coinsurance after deductible
Out-of-network50.00% Coinsurance after deductible
All orthodontic services require Authorization, a written plan of care, and must be rendered by a Provider. Orthodontic treatment must be considered medically necessary. Orthodontic services for cosmetic purposes are not covered. No waiting period applies. OON coinsurance, member is responsible for any difference between the charge and the paid amount.
Exclusions: nan
Routine Dental Services (Adult)
No Charge
Tier 1 in-networkNo Charge
Out-of-networkNo Charge
Oral Cleanings (Prophylaxis) limited to two every 12 months. One additional cleaning during the Policy Year will be allowed for Members that are under the care of a medical professional during pregnancy. Two periodic or comprehensive oral exams every 12 months. OON coinsurance, member is responsible for any difference between the charge and the paid amount.
Exclusions: nan
Variant attributes
Blue Dental Preferred Certified- $1,000 Annual Benefit Maximum per Adult, 100%/80%/50% coinsurance, $50 deductible · Variant 97176LA0390002-00
Plan identifiers & tier
Issuer-provided metadata for this variant.
Business Year
2025
CSR Variation Type
Standard High Off Exchange Plan
HIOS Product ID
97176LA039
Metal Level
High
Plan ID (Standard Component ID with Variant)
97176LA0390002-00
Plan Marketing Name
Blue Dental Preferred Certified- $1,000 Annual Benefit Maximum per Adult, 100%/80%/50% coinsurance, $50 deductible
Plan Variant Marketing Name
Blue Dental Preferred Certified- $1,000 Annual Benefit Maximum per Adult, 100%/80%/50% coinsurance, $50 deductible
Issuer & service area
Issuer-provided metadata for this variant.
Issuer ID
97176
Issuer Marketplace Marketing Name
Blue Cross and Blue Shield of Louisiana
Market Coverage
Individual
Multiple In Network Tiers
No
National Network
Yes
Network ID
LAN002
Out of Country Coverage
No
Out of Service Area Coverage
Yes
Out of Service Area Coverage Description
Coverage available for covered benefits
Service Area ID
LAS002
State Code
LA
Cost sharing & actuarial values
Issuer-provided metadata for this variant.
Begin Primary Care Deductible Coinsurance After Number Of Copays
0
Inpatient Copayment Maximum Days
0
Maximum Out of Pocket for Medical EHB Benefits, Combined In/Out Network, Family Per Group
per group not applicable
Maximum Out of Pocket for Medical EHB Benefits, Combined In/Out Network, Family Per Person
per person not applicable
Maximum Out of Pocket for Medical EHB Benefits, Combined In/Out
Not Applicable
Maximum Out of Pocket for Medical EHB Benefits, In Network (Tier 1), Family Per Group
$700 per group
Maximum Out of Pocket for Medical EHB Benefits, In Network (Tier 1), Family Per Person
$350 per person
Maximum Out of Pocket for Medical EHB Benefits, In Network (Tier 1), Individual
$350
Maximum Out of Pocket for Medical EHB Benefits, Out of Network, Family Per Group
per group not applicable
Maximum Out of Pocket for Medical EHB Benefits, Out of Network, Family Per Person
per person not applicable
Maximum Out of Pocket for Medical EHB Benefits, Out of Network, Individual
Begin Primary Care Cost-Sharing After Number Of Visits
0
Child-Only Offering
Allows Adult and Child-Only
Composite Rating Offered
No
Dental Only Plan
Yes
EHB Apportionment for Pediatric Dental
1.0
First Tier Utilization
100%
Import Date
2024-09-11 01:01:35
Guaranteed Rate
Guaranteed Rate
New/Existing Plan
Existing
Medical EHB Deductible, Combined In/Out of Network, Family Per Group
per group not applicable
Medical EHB Deductible, Combined In/Out of Network, Family Per Person
per person not applicable
Medical EHB Deductible, Combined In/Out of Network, Individual
Not Applicable
Medical EHB Deductible, In Network (Tier 1), Family Per Group
per group not applicable
Medical EHB Deductible, In Network (Tier 1), Family Per Person
per person not applicable
Medical EHB Deductible, In Network (Tier 1), Individual
$50
Medical EHB Deductible, Out of Network, Family Per Group
per group not applicable
Medical EHB Deductible, Out of Network, Family Per Person
per person not applicable
Medical EHB Deductible, Out of Network, Individual
Not Applicable
Plan Effective Date
2025-01-01
Plan Expiration Date
2025-12-31
Plan Type
PPO
QHP/Non QHP
Both
Source Name
HIOS
Plan ID
97176LA0390002
Copay & coinsurance
Pharmacy cost sharing by tier
Drug tier
Pharmacy type
Copay amount
Copay option
Coinsurance rate
Coinsurance option
Mail order
Questions & answers
Frequently asked questions
How do I choose the right ACA plan in Louisiana?
Blue Dental Preferred Certified- $1,000 Annual Benefit Maximum per Adult, 100%/80%/50% coinsurance, $50 deductible (97176LA0390002) is a High PPO from Louisiana Health Service & Indemnity Company in Louisiana for the 2025 coverage year.
Compare it against other options with the HealthPorta plan finder to confirm premiums, deductibles, and network access fit your household.
Does Blue Dental Preferred Certified- $1,000 Annual Benefit Maximum per Adult, 100%/80%/50% coinsurance, $50 deductible support telehealth or virtual urgent care?
The issuer has not published telehealth details yet. Review the Summary of Benefits and Coverage to confirm if virtual visits are included.
Is Blue Dental Preferred Certified- $1,000 Annual Benefit Maximum per Adult, 100%/80%/50% coinsurance, $50 deductible HSA-eligible and does it include dental or vision coverage?
HSA eligibility is not published; check the Summary of Benefits or ask the issuer.
Dental add-ons: Adult, Child.
Vision coverage is not listed for this plan.
Does Blue Dental Preferred Certified- $1,000 Annual Benefit Maximum per Adult, 100%/80%/50% coinsurance, $50 deductible support mail-order prescriptions?
Mail order coverage is not listed for this plan, so confirm with the issuer before relying on home delivery.
Is there out-of-country coverage for Blue Dental Preferred Certified- $1,000 Annual Benefit Maximum per Adult, 100%/80%/50% coinsurance, $50 deductible?
No, out-of-country services are not covered for this plan.
Does Blue Dental Preferred Certified- $1,000 Annual Benefit Maximum per Adult, 100%/80%/50% coinsurance, $50 deductible cover care outside the service area?
Yes, you have limited out-of-area coverage. See the plan documents for referral and prior authorization rules. Details: Coverage available for covered benefits
How do I enroll in or manage payments for Blue Dental Preferred Certified- $1,000 Annual Benefit Maximum per Adult, 100%/80%/50% coinsurance, $50 deductible?
Disclaimer: Based on the Tue, 02 Dec 2025 06:13 GMT HealthPorta import from CMS issuer filings. Data is best-effort and should be validated with the issuer directly. Sources: CMS.gov and the HealthPorta Healthcare MRF API.
