EPO plan

Blue Dental EPO 80/50/50

2022 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 our nationwide PPO 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 a PPO 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. Find a plan to get a quote.

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 $375.
  • Two or more members: You pay no more than $750.

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 

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

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)

Cleanings are covered twice a year.

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

Limited to twice a year in combination with routine cleaning.

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 extractions

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 services like crowns 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

Covered once per tooth every 60 months.

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 

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

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 for members to the end of the month of their 19th birthday.

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

Limited to three times a year in combination with routine cleaning.

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 extractions

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

Sealants

Sealants are covered once per fully erupted first and second permanent molar every 36 months for members to the end of the month of their 16th birthday.

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 services like crowns 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

Covered once per tooth every 60 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

Bridges and dentures

Complete dentures covered once every 84 months; partial dentures and bridges covered once every 84 months for members age 16 and older.

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