EPO plan

Blue Dental EPO Standard

2017 plan year

You can buy this plan if you live in any Michigan county except Keweenaw.

Overview

About this plan 

Your monthly payments for this all-ages dental plan will be lower than our other plans. That’s because it’s an EPO, which means it only covers care you get from dentists in the plan’s nationwide preferred network. These dentists give you the most savings on services such as cleanings, X-rays and fillings.


Availability 

You can buy this plan if you live in any Michigan county except Keweenaw.


Plan type 

EPO. Your dental care is only covered if you see an in-network dentist. There's no out-of-network coverage.


Who's covered 

This plan covers dental care for all ages.


Monthly premiums 

To give you an accurate price, we'll need some information. Use the link below to see if you are eligible for help in lowering your monthly cost.


Deductible for dental care  What's a deductible?

Class I services have no deductible. There is a deductible for Class II and III services only. Class IV is not covered.

In network

One member: You pay $25.
Two members: You pay $50.
Three members: You pay $75.

Out of network

Not covered 


Coinsurance for dental care  What is coinsurance?

In network

Class I: You pay 20%.
Class II: You pay 50% after deductible.
Class III: You pay 50% after deductible.
Class IV: You pay 100%.

Out of network

Not covered 


Annual benefit maximum for adult dental care  What is an annual benefit maximum?

In network

$1,200 for each adult

Out of network

Not covered


Annual out-of-pocket max for pediatric dental care  What is an annual out-of-pocket max for pediatric dental care?

In network

  • One member: You pay no more than $350.
  • Two or more members: You pay no more than $700.

Out of network

Not applicable



Related documents 

For even more details about this plan, see:

Certificates are legal documents that describe the benefits of a health insurance plan. Your plan might have different benefits and limitations than those listed in this document.

Adult Dental

Adult members are age 19 or older at the start of the coverage year.

Plan benefits 

When you go to a dentist who accepts this plan, that's called getting your care in network.

Because this is an EPO plan, it only covers in-network dental care. You'll pay all costs if you go to a dentist who doesn't take this plan. That's called getting your care out of network.


Class I 

Preventive care like exams and cleanings

There is no waiting period for Class I services.


Dental exams 

Visits are covered twice a year.

In network

You pay 20%.

Out of network

Not covered

Teeth cleaning (prophylaxis) 

Visits are covered twice a year. A third visit is covered for members with specific medical conditions.

In network

You pay 20%.

Out of network

Not covered


Bitewing X-rays 

A set of four films is covered once a year.

In network

You pay 20%.

Out of network

Not covered


Fluoride treatments 

Not covered

Class II 

Basic restorative work like fillings and root canals

These services are covered six months after you first join a Blue Dental plan.


Periodontal maintenance  What is periodontal maintenance?

Limited to twice a year in combination with routine cleaning. A third visit is covered for members with adverse medical conditions.

In network

You pay 50% after deductible.

Out of network

Not covered

Fillings 

Limited to once every 24 months for primary teeth, and once every 48 months for permanent teeth.

In network

You pay 50% after deductible.

Out of network

Not covered


Simple extraction 

In network

You pay 50% after deductible.

Out of network

Not covered

Root canals 

Coverage is once a lifetime per tooth.

In network

You pay 50% after deductible.

Out of network

Not covered

Class III 

Major restorative work like dentures and bridges

These services are covered 12 months after you first join a Blue Dental plan.


Oral surgery 

This includes all oral surgery except simple extractions, which are covered in Class II.

In network

You pay 50% after deductible.

Out of network

Not covered


Crowns, onlays, veneer fillings 

Coverage is once every 84 months for members age 12 and older.

In network

You pay 50% after deductible.

Out of network

Not covered

Bridges and dentures 

Coverage is once every 84 months.

In network

You pay 50% after deductible.

Out of network

Not covered


Implants 

Not covered


Class IV 

Orthodontic services

Not covered


Pediatric Dental

Children can get pediatric benefits until the end of the calendar year in which they turn 19.

There is no waiting period for pediatric dental.

Plan benefits 

When you go to a dentist who accepts this plan, that's called getting your care in network.

Because this is an EPO plan, it only covers in-network dental care. You'll pay all costs if you go to a dentist who doesn't take this plan. That's called getting your care out of network.


Class I 

Preventive care like exams and cleanings


Dental exams 

Exams are covered twice a year.

In network

You pay 20% before meeting your out-of-pocket max.

You pay $0 after meeting your out-of-pocket max.

Out of network

Not covered

Teeth cleaning (prophylaxis) 

Cleanings are covered three times a year.

In network

You pay 20% before meeting your out-of-pocket max.

You pay $0 after meeting your out-of-pocket max.

Out of network

Not covered

Bitewing X-rays 

A set of four films is covered once a year.

In network

You pay 20% before meeting your out-of-pocket max.

You pay $0 after meeting your out-of-pocket max.

Out of network

Not covered

Fluoride treatments 

Fluoride treatments are covered twice a year.

In network

You pay 20% before meeting your out-of-pocket max.

You pay $0 after meeting your out-of-pocket max.

Out of network

Not covered


Class II 

Basic restorative work like fillings and root canals

Periodontal maintenance  What is periodontal maintenance?

Limited to twice a year in combination with routine cleaning. A third visit is covered for members with adverse medical conditions.

In network

You pay 50% after deductible before meeting your out-of-pocket max.

You pay $0 after meeting your out-of-pocket max.

Out of network

Not covered

Fillings 

Limited to once every 24 months for primary teeth, and once every 48 months for permanent teeth.

In network

You pay 50% after deductible before meeting your out-of-pocket max.

You pay $0 after meeting your out-of-pocket max.

Out of network

Not covered

Simple extraction 

In network

You pay 50% after deductible before meeting your out-of-pocket max.

You pay $0 after meeting your out-of-pocket max.

Out of network

Not covered

Root canals 

Coverage is once a lifetime per tooth.

In network

You pay 50% after deductible before meeting your out-of-pocket max.

You pay $0 after meeting your out-of-pocket max.

Out of network

Not covered

Pit and fissure sealants  What are pit and fissure sealants?

Coverage is once per tooth every three years when applied to the first and second permanent molars.

In network

You pay 50% after deductible before meeting your out-of-pocket max.

You pay $0 after meeting your out-of-pocket max.

Out of network

Not covered

Class III 

Major restorative work like dentures and bridges

Oral surgery 

This includes all oral surgery except simple extractions, which are covered in Class II.

In network

You pay 50% after deductible before meeting your out-of-pocket max.

You pay $0 after meeting your out-of-pocket max.

Out of network

Not covered

Crowns, onlays, veneer fillings 

Coverage is once every 84 months per tooth.

In network

You pay 50% after deductible before meeting your out-of-pocket max.

You pay $0 after meeting your out-of-pocket max.

Out of network

Not covered

Bridges and dentures 

Coverage is once every 84 months.

In network

You pay 50% after deductible before meeting your out-of-pocket max.

You pay $0 after meeting your out-of-pocket max.

Out of network

Not covered

Implants 

Not covered

Class IV 

Orthodontic services

Not covered