What's the Difference Between EPO and PPO Dental Plans?

Shopping for dental insurance in Michigan, or have dental coverage through your employer? This explains how Blue Cross Blue Shield of Michigan's Blue Dental^SM plans work so you can choose the best one for you and your family.

A Blue Dental PPO plan works like medical PPO plans do with in-network and out-of-network coverage. With a Blue Dental PPO plan:

• You can see any licensed dentist and your dental plan will share the cost.
• You'll pay less when you see a dentist in our PPO network.
• You’ll pay more when you see a dentist outside our PPO network.

Blue Dental EPO stands for exclusive provider organization. A Blue Dental EPO plan only covers services from in-network PPO dentists and doesn't cover any out-of-network care. This increases savings, making your costs lower.

The more a plan pays for out-of-network care, the higher your costs will be. If you go out of network, you could be charged for the difference between what Blue Cross pays and what your dentist charges.

If you want the freedom to see dentists outside our PPO network, a Blue Dental PPO plan could be best for you. If you want the most savings by only seeing a PPO network dentist, a Blue Dental EPO plan could be better for you.

Want to know if your dentist is in network? Just use our online search.

Whether you choose a PPO or an EPO dental plan affects how much your monthly payment will be. The dentist you choose determines how much you'll pay for services.

• Tier 1 PPO (in-network) dentists – You'll save the most when you see a PPO dentist who participates in network. Network discounts average 40%. If you have an EPO plan, you can only see dentists in this network.
• Tier 2 participating non-PPO (out-of-network) dentists – Although they're not part of our network, you'll still save if you see a dentist who participates with us on a per-claim basis. EPO plans don't cover services from Tier 2 dentists.
• Nonparticiatping dentists – You pay the dentist in full. You may need to file a claim after the service, if the dentist didn't submit on your behalf and we reimburse you for the share of the cost your dental plan covers. If the dentist charges more than we pay for a service, you’ll need to make up the difference. EPO plans don't cover services from nonparticipating dentists.

When you have a Blue Dental plan, there are no copays for dental care. Whether or not you have to pay a deductible depends on the dental plan and the kind of dental care you get. Blue Dental deductibles are very low when compared to medical plans and you'll never pay a deductible for Class I preventive care like dental cleanings.

Blue Dental plans do have coinsurance and the amounts vary from plan to plan.

If you purchase your dental plan directly from Blue Cross, you can see your out-of-pocket costs for dental care by looking on the benefits tab of our Blue Dental plans. If you purchase your dental plan through your employer, please refer to your human resources or benefits department for more information on dental coverage and costs.

What's the difference between an out-of-pocket maximum and a benefit maximum?

An out-of-pocket maximum is the most you'll have to pay during a policy period, usually a year, for services you receive. Everything you pay for health care for everyone on the dental plan goes toward your out-of-pocket maximum. Once you reach your out-of-pocket maximum, your dental plan begins to pay 100% of the allowed amount.

Dental coverage works differently.

Only dental care for pediatric members has an out-of-pocket maximum, which only applies to services provided by PPO dentists. Pediatric members must be age 18 or younger when the dental plan starts.

Nonpediatric dental coverage for members who are age 19 and older has an annual benefit maximum. That's the most your dental plan will pay during a policy period, usually a year, for dental care each adult on the plan receives. Once you reach your benefit maximum, you pay 100% for dental care.