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Personal Blue Dental PlusSM

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Personal Blue Dental and Personal Blue Dental Plus

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  In-Network Out-of-Network
Preventive Services
Oral exams Covered – 75%, two per calendar year
Bitewing X-rays Covered – 75%, one set every 24 months for Personal Blue Dental

Covered – 75%, one set every 12 months for Personal Blue Dental Plus
Full-mouth and panoramic X-rays Covered – 75%, full mouth once every 60 months; panoramic once every 84 months
Teeth cleaning Covered – 75%, twice per calendar year
Fluoride treatment Covered – 75%, once per calendar year through age 14
Space maintainers Covered – 75%, one per quadrant of the mouth per lifetime, under age 19
Palliative emergency treatment Covered – 75%
Pit and fissure sealants — for members age 16 or under Covered – 75%, once per tooth every 36 months when applied to the first and second permanent molars

  In-Network Out-of-Network
Basic Services
Fillings — permanent teeth Covered – 50%, once every 48 months
Fillings — primary teeth Covered – 50%, once every 24 months
Onlays, crowns and veneer fillings — permanent teeth Covered – 50%, once every 84 months per tooth, payable for members age 12 and older
Recementing of crowns, veneers, inlays, onlays and bridges Covered – 50%, three per calendar year after six months from original restoration
Oral surgery, including extractions Covered – 50%
Root canal treatment — permanent tooth Covered – 50%, once every 12 months for tooth with one or more canals
Scaling and root planing Covered – 50%, once every 36 months per quadrant of the mouth
Limited occlusal adjustments Covered – 50%, up to five times in a 60-month period
Occlusal biteguards Covered – 50%, one every 60 months
General anesthesia or IV sedation Covered – 50%, when medically necessary and performed with oral or dental surgery
Adjustment of dentures Covered – 50%, six months or more after it is delivered
Oral surgery, including extractions Covered – 50%
Relining or rebasing of partial or complete dentures Covered – 50%, once every 36 months per arch six months or more after initial delivery
Tissue conditioning Covered – 50%, once every 36 months per arch
Repairs and adjustment of partial or complete dentures Covered – Included in fee for a new denture or partial within six months of initial delivery. After six months – covered at 50%

  In-Network Out-of-Network
Restorative Services
Removable dentures (complete and partial) Covered – 50% once every 60 months
Bridges (fixed partial dentures) Covered – 50% once every 60 months, payable for members age 16 and older
Endosteal implants — for members age 16 or older who are covered at the time of the actual implant placement Covered – 50% once per tooth in a member lifetime when implant placement is for teeth numbered 2 through 15 and 18 through 31


Copay, Deductible and Dollar Maximums

The copay percentage is applied to the BCBSM-approved amount, not the provider's fee. The copay amounts shown below apply to in-network services only since services received out-of-network are not covered.

Copay
Preventive Services 25%
Basic Restorative Services 50%
Major Restorative Services 50%
Deductible
Preventive Services $0
Basic Restorative Services $50 single/$100 family
Major Restorative Services $50 single/$100 family
Waiting period 6-month waiting period is applied on the effective date of dental coverage for basic and major restorative services; preventive services are not subject to a waiting period
Dollar maximums
Annual maximum $1,000 per member for all covered services received in-network
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This is intended as an easy-to-read summary. It is not a contract. Additional limitations and exclusions may apply to covered services. For an official description of benefits, please see the applicable Blue Cross Blue Shield of Michigan certificate and riders. Payment amounts are based on the BCBSM-approved amount, less any applicable deductible and/or copay amounts required by the plan. This coverage is provided pursuant to a contract entered into in the state of Michigan and shall be construed under the jurisdiction and according to the laws of the state of Michigan.

For nonurgent, complex or expensive dental treatment such as crowns, bridges or dentures, members should encourage their dentist to submit the claim to BCBSM for predetermination before treatment begins. Services received outside the dental network are not covered.
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