PPO plan

Blue Dental PPO Extra

2017 plan year

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

Overview

About this plan 

With PPO Extra, when you see an in-network dentist, preventive care like exams and cleanings is covered 100 percent. And unlike PPO Plus Standard, there's no deductible for other services in the network. And if you want to see an out-of-network dental professional, you’re still covered.


Availability 

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


Plan type 

PPO. For dental care, you can go to any licensed dentist and this plan will share the cost. But you'll pay less if you see an in-network dentist.


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 $0.
Two members: You pay $0.
Three or more members: You pay $0.

Out of network

One member: You pay $50.
Two members: You pay $100.
Three or more members: You pay $150.


Coinsurance for dental care  What is coinsurance?

In network

Class I: You pay 0%.
Class II: You pay 30%.
Class III: You pay 50%.
Class IV: You pay 100%.

Out of network

Class I: You pay 20%.
Class II: You pay 40% after deductible.
Class III: You pay 50% after deductible.
Class IV: You pay 100%.


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

In network

$1,200 for each adult

Out of network

Up to $1,000 of the $1,200 in-network total can be used toward out-of-network care.


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 plan is a PPO, you're covered when you go to a dentist who doesn't take this plan, but you'll pay more. 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 $0.

Out of network

You pay 20%.

Teeth cleaning (prophylaxis) 

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

In network

You pay $0.

Out of network

You pay 20%.


Bitewing X-rays 

A set of four films is covered once a year.

In network

You pay $0.

Out of network

You pay 20%.


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 30%.

Out of network

You pay 40% after deductible.

Fillings 

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


In network

You pay 30%.

Out of network

You pay 40% after deductible.


Simple extraction 

In network

You pay 30%.

Out of network

You pay 40% after deductible.

Root canals 

Coverage is once a lifetime per tooth.

In network

You pay 30%.

Out of network

You pay 40% after deductible.

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%.

Out of network

You pay 50% after deductible.


Crowns, onlays, veneer fillings 

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

In network

You pay 50%.

Out of network

You pay 50% after deductible.

Bridges and dentures 

Coverage is once every 84 months.

In network

You pay 50%.

Out of network

You pay 50% after deductible.


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 plan is a PPO, you're covered when you go to a dentist who doesn't take this plan, but you'll pay more. 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 $0.

Out of network

You pay 20%.

Teeth cleaning (prophylaxis) 

Cleanings are covered three times a year.

In network

You pay $0.

Out of network

You pay 20%.

Bitewing X-rays 

A set of four films is covered once a year.

In network

You pay $0.

Out of network

You pay 20%.

Fluoride treatments 

Fluoride treatments are covered twice a year.

In network

You pay $0.

Out of network

You pay 20%.


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 30% before meeting your out-of-pocket max.

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

Out of network

You pay 40% after deductible.

Fillings 

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

In network

You pay 30% before meeting your out-of-pocket max.

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

Out of network

You pay 40% after deductible.

Simple extraction 

In network

You pay 30% before meeting your out-of-pocket max.

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

Out of network

You pay 40% after deductible.

Root canals 

Coverage is once a lifetime per tooth.

In network

You pay 30% before meeting your out-of-pocket max.

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

Out of network

You pay 40% after deductible.

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 30% before meeting your out-of-pocket max.

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

Out of network

You pay 40% after deductible.

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% before meeting your out-of-pocket max.

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

Out of network

You pay 50% after deductible.

Crowns, onlays, veneer fillings 

Coverage is once every 84 months per tooth.

In network

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

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

Out of network

You pay 50% after deductible.

Bridges and dentures 

Coverage is once every 84 months.

In network

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

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

Out of network

You pay 50% after deductible.

Implants 

Not covered

Class IV 

Orthodontic services

Not covered