2023 Blue DentalSM PPO Pediatric 80/50/50
This plan covers dental care for 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.
This pediatric dental plan is for members who are 18 or younger when the plan starts. It provides access to care from more than 3,600 Tier 1 PPO dentists in Michigan, and more than 130,000 nationwide. This plan also gives you the choice to see out-of-network dentists, but you pay more out of pocket.
You can buy this plan if you live in any Michigan county.
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.
To give you an accurate price, we'll need some information. Find a plan to get a quote.
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.
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.
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.
Members can find information about agent commissions.
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.
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.
Preventive care like exams and cleanings.
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 three times 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
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% | You pay 50% |
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% | 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% | You pay 50% |
Periodontal maintenance
Limited to three times 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% |
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% | 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
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% | You pay 50% |
Implants
Not covered
Orthodontic services
Not covered
This pediatric dental plan is for members who are 18 or younger when the plan starts. It provides access to care from more than 3,600 Tier 1 PPO dentists in Michigan, and more than 130,000 nationwide. This plan also gives you the choice to see out-of-network dentists, but you pay more out of pocket.
You can buy this plan if you live in any Michigan county.
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.
To give you an accurate price, we'll need some information. Find a plan to get a quote.
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.
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.
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.
Members can find information about agent commissions.
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.
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.
Preventive care like exams and cleanings.
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 three times 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
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% | You pay 50% |
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% | 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% | You pay 50% |
Periodontal maintenance
Limited to three times 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% |
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% | 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
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% | You pay 50% |
Implants
Not covered
Orthodontic services
Not covered
Download or print your benefit information.
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
Have questions? Our Health Plan Advisors are ready to help. TTY users call 711.