Overview
About this plan
This plan picks up where most medical insurance leaves off. Preventive dental care like exams and cleanings are covered at 100 percent when you see an in-network dentist, and adult vision care with copays as low as $10. Your monthly payments will be higher compared to our EPO 80/50/50 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 100/50/50 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 a PPO 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's 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. 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 0%.
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
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
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
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 eyeglass lenses covered once each calendar year
Costs include:
- Copays are $10 for eye exams and $25 for glasses or contact lenses when you see 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
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
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 50%.
Teeth cleaning (prophylaxis)
Cleanings are covered twice a year.
In network
You pay 0%.
Out of network
You pay 50%.
Bitewing X-rays
A set of four films is covered once a year.
In network
You pay 0%.
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
Limited to twice a year in combination with routine cleaning.
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 extractions
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 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
You pay 50% after deductible.
Crowns, onlays, veneer fillings
Covered once per tooth every 60 months.
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
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 $0.
Out of network
You pay 50%.
Teeth cleaning (prophylaxis)
Cleanings are covered three times a year.
In network
You pay $0 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 $0 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 $0 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
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 who participates with VSP, that's called getting your care in network. For vision care, you can go to any eye doctor and this plan will share the cost. You're also covered when you go to an eye doctor who doesn't participate with VSP. But you'll pay less if you see a VSP eye doctor.
Eye exam
Eye exams are covered once every calendar year.
In network
You pay $10.
Out of network
You pay $10 plus any costs over $45.
Lenses and frames
Each year, this plan shares the cost for eyeglass lenses or contact lenses, but not both. Standard frames are covered once every two calendar years.
Standard lenses
Standard lenses prescribed by an eye doctor, optometrist or optician are covered once every calendar 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 $30.
Bifocal lenses: You pay costs over $50.
Trifocal lenses: You pay costs over $60.
Standard frames
Standard frames are covered once every two calendar years.
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 $70.
A single copay applies to both lenses and frames.
Contact lenses
Each year, this plan shares the cost for eyeglass lenses or contact lenses, but not both.
Elective contact lenses
Elective contact lenses are covered once every calendar year.
In network
You pay any costs over $130.
Out of network
You pay any costs over $105.
Medically necessary contact lenses
Medically necessary contact lenses are covered once every calendar year.
In network
You pay $25.
Out of network
You pay $25 plus costs over $210.
