2023 Blue DentalSM PPO 80/50/50
Want the freedom to choose any licensed dentist? This all-ages dental plan helps cover care when you see a dentist who isn’t in our preferred network, but it’s easy to find dental professionals who are.
Overview
About this plan
There are more than 3,600 Tier 1 PPO dentists in Michigan, and more than 130,000 nationwide. But there may be times you want to see a dentist who's not in the preferred network. This plan gives you the choice to see out-of-network dentists, but you pay more out of pocket.
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 Tier 1 PPO in-network dentist.
Monthly premiums
To give you an accurate price, we'll need some information. Find a plan to get a quote.
Deductible
Class I services have no deductible. There is a deductible for Class II and III services only. Class IV services are not covered.
| In Network | Out of Network | |
| One member | You pay $25 | You pay $50 |
| Two members | You pay $50 | You pay $100 |
| Three members | You pay $75 | You pay $150 |
Your deductible is the amount you pay for dental services each year before your insurance begins to pay.
Coinsurance
| In Network | Out of Network | |
| Class I | You pay 20% | You pay 50% |
| Class II | You pay 50% after deductible | You pay 50% after deductible |
| Class III | You pay 50% after deductible | You pay 50% after deductible |
| Class IV | You pay 100% | You pay 100% |
Your coinsurance is your share of the costs of a service. It's usually figured as a percentage of the amount we allow to be charged for services. You start paying coinsurance after you’ve met your plan’s deductible.
Annual benefit maximum for adult dental care
| In Network | Out of Network |
| $1,200 for each adult | Up to $800 of the $1,200 in-network total can be used toward out-of-network care. |
This is the limit on what your plan pays for dental care benefits for members who are 19 or older when their plan starts. After reaching that limit for the year, you pay for 100% of your dental care.
Annual out-of-pocket max for pediatric dental care
| In Network | Out of Network | |
| One member | You pay no more than $375 | Not applicable |
| Two members or more | You pay no more than $750 | Not applicable |
This out-of-pocket maximum is the most you’ll have to pay during a calendar year for covered pediatric dental services. Once you’ve reached this out-of-pocket maximum, your plan pays 100 percent of the allowed amount.
Agent compensation
Members can find information about agent commissions.
Related documents
Eligibility
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 Tier 1 PPO in-network dentist.
Class I coverage
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 | Out of Network |
| You pay 20% | You pay 50% |
Teeth cleaning (prophylaxis)
Cleanings are covered twice a year.
| In Network | Out of Network |
| You pay 20% | You pay 50% |
Bitewing X-rays
A set of four films is covered once a year.
| In Network | Out of Network |
| You pay 20% | You pay 50% |
Fluoride treatments
Not covered
Class II coverage
Basic services 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 | Out of Network |
| You pay 50% | You pay 50% |
Fillings
Limited to once every 24 months for primary teeth, and once every 48 months for permanent teeth.
| In Network | Out of Network |
| You pay 50% | You pay 50% |
Simple extractions
| In Network | Out of Network |
| You pay 50% | You pay 50% |
Root canals
Covered once per tooth per lifetime.
| In Network | Out of Network |
| You pay 50% | You pay 50% |
Class III coverage
Major 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 | Out of Network |
| You pay 50% | You pay 50% |
Crowns, onlays, veneer fillings
Covered once per tooth every 60 months.
| In Network | Out of Network |
| You pay 50% | You pay 50% |
Bridges and dentures
Covered once per arch every 84 months.
| In Network | Out of Network |
| You pay 50% | You pay 50% |
Implants
Not covered
Class IV coverage
Orthodontic services
Not covered
Eligibility for 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 Tier 1 PPO in-network dentist.
Class I coverage
Preventive care like exams and cleanings.
Dental exams
Visits are covered twice a year.
| In Network | Out of Network | |
| You pay 20% before meeting your out-of-pocket max, and $0 after meeting your out-of-pocket max. | You pay 50% |
Teeth cleaning (prophylaxis)
Cleanings are covered three times a year.
| In Network | Out of Network | |
| You pay 20% before meeting your out-of-pocket max, and $0 after meeting your out-of-pocket max. | You pay 50% |
Bitewing X-rays
A set of four films is covered once a year.
| In Network | Out of Network | |
| You pay 20% before meeting your out-of-pocket max, and $0 after meeting your out-of-pocket max. | 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 | Out of Network | |
| You pay 20% before meeting your out-of-pocket max, and $0 after meeting your out-of-pocket max. | You pay 50% |
Class II coverage
Basic services like fillings and root canals.
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 | Out of Network | |
| You pay 50% before meeting your out-of-pocket max, and $0 after meeting your out-of-pocket max. | You pay 50% |
Space maintainers
Space maintainers are covered once per quadrant every two years for members to the end of the month of their 15th birthday.
| In Network | Out of Network | |
| You pay 50% before meeting your out-of-pocket max, and $0 after meeting your out-of-pocket max. | You pay 50% |
Periodontal maintenance
Limited to three times a year in combination with routine cleaning.
| In Network | Out of Network | |
| You pay 50% before meeting your out-of-pocket max, and $0 after meeting your out-of-pocket max. | You pay 50% |
Fillings
Limited to once every 24 months for primary teeth, and once every 48 months for permanent teeth.
| In Network | Out of Network | |
| You pay 50% before meeting your out-of-pocket max, and $0 after meeting your out-of-pocket max. | You pay 50% |
Simple extractions
| In Network | Out of Network | |
| You pay 50% before meeting your out-of-pocket max, and $0 after meeting your out-of-pocket max. | You pay 50% |
Root canals
Covered once per tooth per lifetime.
| In Network | Out of Network | |
| You pay 50% before meeting your out-of-pocket max, and $0 after meeting your out-of-pocket max. | You pay 50% |
Class III coverage
Major services like crowns and bridges.
Oral surgery
This includes all oral surgery except simple extractions, which are covered in Class II.
| In Network | Out of Network | |
| You pay 50% before meeting your out-of-pocket max, and $0 after meeting your out-of-pocket max. | You pay 50% |
Crowns, onlays, veneer fillings
Covered once per tooth every 60 months.
| In Network | Out of Network | |
| You pay 50% before meeting your out-of-pocket max, and $0 after meeting your out-of-pocket max. | You pay 50% |
Bridges and dentures
Complete dentures covered once per arch every 84 months; partial dentures and bridges covered once per arch every 84 months for members age 16 and older.
| In Network | Out of Network | |
| You pay 50% before meeting your out-of-pocket max, and $0 after meeting your out-of-pocket max. | You pay 50% |
Implants
Not covered
Class IV coverage
Orthodontic services
Not covered
Overview
About this plan
There are more than 3,600 Tier 1 PPO dentists in Michigan, and more than 130,000 nationwide. But there may be times you want to see a dentist who's not in the preferred network. This plan gives you the choice to see out-of-network dentists, but you pay more out of pocket.
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 Tier 1 PPO in-network dentist.
Monthly premiums
To give you an accurate price, we'll need some information. Find a plan to get a quote.
Deductible
Class I services have no deductible. There is a deductible for Class II and III services only. Class IV services are not covered.
| In Network | Out of Network | |
| One member | You pay $25 | You pay $50 |
| Two members | You pay $50 | You pay $100 |
| Three members | You pay $75 | You pay $150 |
Your deductible is the amount you pay for dental services each year before your insurance begins to pay.
Coinsurance
| In Network | Out of Network | |
| Class I | You pay 20% | You pay 50% |
| Class II | You pay 50% after deductible | You pay 50% after deductible |
| Class III | You pay 50% after deductible | You pay 50% after deductible |
| Class IV | You pay 100% | You pay 100% |
Your coinsurance is your share of the costs of a service. It's usually figured as a percentage of the amount we allow to be charged for services. You start paying coinsurance after you’ve met your plan’s deductible.
Annual benefit maximum for adult dental care
| In Network | Out of Network |
| $1,200 for each adult | Up to $800 of the $1,200 in-network total can be used toward out-of-network care. |
This is the limit on what your plan pays for dental care benefits for members who are 19 or older when their plan starts. After reaching that limit for the year, you pay for 100% of your dental care.
Annual out-of-pocket max for pediatric dental care
| In Network | Out of Network | |
| One member | You pay no more than $375 | Not applicable |
| Two members or more | You pay no more than $750 | Not applicable |
This out-of-pocket maximum is the most you’ll have to pay during a calendar year for covered pediatric dental services. Once you’ve reached this out-of-pocket maximum, your plan pays 100 percent of the allowed amount.
Agent compensation
Members can find information about agent commissions.
Related documents
Eligibility
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 Tier 1 PPO in-network dentist.
Class I coverage
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 | Out of Network |
| You pay 20% | You pay 50% |
Teeth cleaning (prophylaxis)
Cleanings are covered twice a year.
| In Network | Out of Network |
| You pay 20% | You pay 50% |
Bitewing X-rays
A set of four films is covered once a year.
| In Network | Out of Network |
| You pay 20% | You pay 50% |
Fluoride treatments
Not covered
Class II coverage
Basic services 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 | Out of Network |
| You pay 50% | You pay 50% |
Fillings
Limited to once every 24 months for primary teeth, and once every 48 months for permanent teeth.
| In Network | Out of Network |
| You pay 50% | You pay 50% |
Simple extractions
| In Network | Out of Network |
| You pay 50% | You pay 50% |
Root canals
Covered once per tooth per lifetime.
| In Network | Out of Network |
| You pay 50% | You pay 50% |
Class III coverage
Major 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 | Out of Network |
| You pay 50% | You pay 50% |
Crowns, onlays, veneer fillings
Covered once per tooth every 60 months.
| In Network | Out of Network |
| You pay 50% | You pay 50% |
Bridges and dentures
Covered once per arch every 84 months.
| In Network | Out of Network |
| You pay 50% | You pay 50% |
Implants
Not covered
Class IV coverage
Orthodontic services
Not covered
Eligibility for 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 Tier 1 PPO in-network dentist.
Class I coverage
Preventive care like exams and cleanings.
Dental exams
Visits are covered twice a year.
| In Network | Out of Network | |
| You pay 20% before meeting your out-of-pocket max, and $0 after meeting your out-of-pocket max. | You pay 50% |
Teeth cleaning (prophylaxis)
Cleanings are covered three times a year.
| In Network | Out of Network | |
| You pay 20% before meeting your out-of-pocket max, and $0 after meeting your out-of-pocket max. | You pay 50% |
Bitewing X-rays
A set of four films is covered once a year.
| In Network | Out of Network | |
| You pay 20% before meeting your out-of-pocket max, and $0 after meeting your out-of-pocket max. | 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 | Out of Network | |
| You pay 20% before meeting your out-of-pocket max, and $0 after meeting your out-of-pocket max. | You pay 50% |
Class II coverage
Basic services like fillings and root canals.
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 | Out of Network | |
| You pay 50% before meeting your out-of-pocket max, and $0 after meeting your out-of-pocket max. | You pay 50% |
Space maintainers
Space maintainers are covered once per quadrant every two years for members to the end of the month of their 15th birthday.
| In Network | Out of Network | |
| You pay 50% before meeting your out-of-pocket max, and $0 after meeting your out-of-pocket max. | You pay 50% |
Periodontal maintenance
Limited to three times a year in combination with routine cleaning.
| In Network | Out of Network | |
| You pay 50% before meeting your out-of-pocket max, and $0 after meeting your out-of-pocket max. | You pay 50% |
Fillings
Limited to once every 24 months for primary teeth, and once every 48 months for permanent teeth.
| In Network | Out of Network | |
| You pay 50% before meeting your out-of-pocket max, and $0 after meeting your out-of-pocket max. | You pay 50% |
Simple extractions
| In Network | Out of Network | |
| You pay 50% before meeting your out-of-pocket max, and $0 after meeting your out-of-pocket max. | You pay 50% |
Root canals
Covered once per tooth per lifetime.
| In Network | Out of Network | |
| You pay 50% before meeting your out-of-pocket max, and $0 after meeting your out-of-pocket max. | You pay 50% |
Class III coverage
Major services like crowns and bridges.
Oral surgery
This includes all oral surgery except simple extractions, which are covered in Class II.
| In Network | Out of Network | |
| You pay 50% before meeting your out-of-pocket max, and $0 after meeting your out-of-pocket max. | You pay 50% |
Crowns, onlays, veneer fillings
Covered once per tooth every 60 months.
| In Network | Out of Network | |
| You pay 50% before meeting your out-of-pocket max, and $0 after meeting your out-of-pocket max. | You pay 50% |
Bridges and dentures
Complete dentures covered once per arch every 84 months; partial dentures and bridges covered once per arch every 84 months for members age 16 and older.
| In Network | Out of Network | |
| You pay 50% before meeting your out-of-pocket max, and $0 after meeting your out-of-pocket max. | You pay 50% |
Implants
Not covered
Class IV coverage
Orthodontic services
Not covered
Actions
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Need medical coverage?
Open enrollment is closed. You may still be able to get 2023 coverage through special enrollment if you've had a qualifying life event. You are also eligible for a health plan if you lost Medicaid coverage.
Health plan advisors
Call us at 1-855-237-3501 for help choosing the right plan
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