PPO plan

Blue Dental PPO Standard With Vision

2017 plan year

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

Overview

About this plan 

This plan picks up where most medical insurance leaves off. You get dental coverage for all ages, and adult vision care with copays as low as $10. Your monthly payments will be higher compared to our EPO With Vision plan, but everyone in the family has dental and vision care for one monthly payment. 


Availability 

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

Unlike most other Blue Cross plans, Blue Dental PPO Standard with Vision isn't available on healthcare.gov.


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.

VSP. For vision care, you can go to any eye doctor and this plan will share the cost. But you'll pay less if you see a VSP eye doctor.


Who's covered 

This plan covers dental care for all ages.

Vision coverage is for adults age 19 and older as of plan effective date. Why doesn't this plan cover children? Because of health care reform, all medical plans you purchase yourself must include pediatric vision care.


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

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


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

Class I: You pay 50%.
Class II: You pay 50% 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 $800 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


Adult vision care 

Coverage includes:

  • One eye exam each calendar year
  • One pair of standard frames every other calendar year

You choose between coverage for prescription glasses (lenses and frame) or contact lenses, but not both:

  • Contacts covered once each calendar year, or
  • One pair of standard lenses covered once each calendar year


Costs include:

  • Copay starts at $10 for an eye exam by an in-network provider.  
  • If you go to an in-network provider you pay the difference for frames or contacts that cost more than $130.

See vision tab for details.


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 1 services.


Dental exams 

Visits are covered twice a year.

In network

You pay 20%.

Out of network

You pay 50%.

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

You pay 50%.


Bitewing X-rays 

A set of four films is covered once a year.

In network

You pay 20%.

Out of network

You pay 50%.


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

You pay 50% after deductible.

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

You pay 50% after deductible.


Simple extraction 

In network

You pay 50% after deductible.

Out of network

You pay 50% after deductible.

Root canals 

Coverage is once a lifetime per tooth.

In network

You pay 50% after deductible.

Out of network

You pay 50% 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% after deductible.

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% after deductible.

Out of network

You pay 50% after deductible.

Bridges and dentures 

Coverage is once every 84 months.

In network

You pay 50% after deductible.

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

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

Out of network

You pay 50%.

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

You pay 50%.

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

You pay 50%.

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

You pay 50%.


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

You pay 50% after deductible.

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

You pay 50% after deductible.

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

You pay 50% after deductible.

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

You pay 50% 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 50% after deductible 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.

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

You pay 50% after deductible.

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

You pay 50% after deductible.

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

You pay 50% after deductible.

Implants 

Not covered

Class IV 

Orthodontic services

Not covered

Adult Vision

This plan covers vision care for adults only. Why doesn't it cover children?

Because of health care reform, all medical plans you purchase yourself must include pediatric vision care.

In-network benefits 

When you go to an eye doctor that accepts this plan, that's called getting your care in network.

This plan shares the cost if you go to an eye doctor that doesn't take this plan. That's called getting your care out of network.


Eye exam 

Coverage is one exam a year.

In network

You pay $10.

Out-of-Network

You pay $10 plus any costs over $34.

Lenses and frames 

Each calendar year this plan shares the costs for prescription eyeglasses or contact lenses, but not both.

Standard lenses  What are standard lenses?

Standard lenses prescribed by an eye doctor, optometrist or optician are covered once a year. 

In network

You pay $25.

A single copay applies to both lenses and frames.

Out of network

You pay $25, plus the costs listed below.

A single copay applies to both lenses and frames.

Single vision lenses: You pay costs over $17.

Bifocal lenses: You pay costs over $30.

Trifocal lenses: You pay costs over $43.

Standard frames 

Standard frames are covered once every 24 months..

In network

You pay $25 plus costs over $130.

A single copay applies to both lenses and frames.

Out-of-Network

You pay $25 plus costs over $38.25.

A single copay applies to both lenses and frames.

Contact lenses 

Each year, this plan shares the costs for eyeglasses or contact lenses, not both.

Elective contact lenses  What are elective contact lenses?

Elective contact lenses are covered once a year.

In network

You pay any costs over $130.

Out-of-Network

You pay any costs over $100.

Medically necessary contact lenses  What are medically necessary contact lenses?

Medically necessary contact lenses are covered once a year.

In network

You pay $25.

Out-of-Network

You pay $25 plus costs over $210.