Overview
About this plan
PPO Pediatric 80/50/50 covers those who are 18 or younger when the plan starts. When you see a dentist in our preferred network, you’ll pay only 20 percent of the cost for basics like cleanings and fluoride treatments.
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 a PPO in-network dentist.
Who's covered
This plan only covers dental care for pediatric members.
Monthly premiums
To give you an accurate price, we'll need some information. Find a plan to get a quote.
Deductible for dental care
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
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 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.
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
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 a PPO in-network dentist.
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 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
You pay 50%.
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
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 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
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.
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
You pay 50% after deductible.
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
You pay 50% after deductible.
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
You pay 50% after deductible.
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
You pay 50% after deductible.
Implants
Not covered
Class IV
Orthodontic services
Not covered
