2024 Blue DentalSM PPO 100/50/50 (50/50/50)
This all-ages dental plan covers 100 percent of preventive services like exams and cleanings when you see a Tier 1 PPO in-network dentist, and also helps cover care when you see a dentist who isn’t in our preferred network.
There are more than 3,600 Tier 1 PPO dentists in Michigan, and thousands more nationwide. This all-ages dental plan covers 100 percent of preventive services like exams and cleanings when you see one of those in-network dentists. It also gives you the freedom to choose any dentist you want by helping to cover the cost of care when you see a dentist who isn't in our PPO network.
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 $0 | 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 |
$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.
In Network | Out of Network | |
One member | You pay no more than $400 | Not applicable |
Two members or more | You pay no more than $800 | 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.
Adult members are age 19 or older at the start of the coverage year.
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. There is no waiting period for Class I services.
Dental exams
Visits are covered twice a year.
In Network | Out of Network |
You pay $0 | You pay 50% |
Teeth cleaning (prophylaxis)
Cleanings are covered twice a year.
In Network | Out of Network |
You pay $0 | You pay 50% |
Bitewing X-rays
A set of four films is covered once a year.
In Network | Out of Network |
You pay $0 | You pay 50% |
Fluoride treatments
Not covered
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% after deductible | You pay 50% after deductible |
Fillings
Limited to once per tooth and surface every 24 months for primary teeth, and once per tooth and surface every 48 months for permanent teeth.
In Network | Out of Network |
You pay 50% after deductible | You pay 50% after deductible |
Simple extractions
In Network | Out of Network |
You pay 50% after deductible | You pay 50% after deductible |
Root canals
Covered once per tooth per lifetime.
In Network | Out of Network |
You pay 50% after deductible | You pay 50% after deductible |
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% after deductible | You pay 50% after deductible |
Crowns, onlays, veneer fillings
Covered once per tooth every 60 months.
In Network | Out of Network |
You pay 50% after deductible | You pay 50% after deductible |
Bridges and dentures
Covered once per arch every 84 months.
In Network | Out of Network |
You pay 50% after deductible | You pay 50% after deductible |
Implants
Not covered
Orthodontic services
Not covered
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 $0. | You pay 50% |
Teeth cleaning (prophylaxis)
Cleanings are covered three times a year.
In Network | Out of Network | |
You pay $0. | You pay 50% |
Bitewing X-rays
A set of four films is covered once a year.
In Network | Out of Network | |
You pay $0. | 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 $0. | 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% after deductible before meeting your out-of-pocket max, and $0 after meeting your out-of-pocket max. | You pay 50% after deductible |
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% after deductible before meeting your out-of-pocket max, and $0 after meeting your out-of-pocket max. | You pay 50% after deductible |
Periodontal maintenance
Limited to three times a year in combination with routine cleaning.
In Network | Out of Network | |
You pay 50% after deductible before meeting your out-of-pocket max, and $0 after meeting your out-of-pocket max. | You pay 50% after deductible |
Fillings
Limited to once per tooth and surface every 24 months for primary teeth, and once per tooth and surface every 48 months for permanent teeth.
In Network | Out of Network | |
You pay 50% after deductible before meeting your out-of-pocket max, and $0 after meeting your out-of-pocket max. | You pay 50% after deductible |
Simple extractions
In Network | Out of Network | |
You pay 50% after deductible before meeting your out-of-pocket max, and $0 after meeting your out-of-pocket max. | You pay 50% after deductible |
Root canals
Covered once per tooth per lifetime.
In Network | Out of Network | |
You pay 50% after deductible before meeting your out-of-pocket max, and $0 after meeting your out-of-pocket max. | You pay 50% after deductible |
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% after deductible before meeting your out-of-pocket max, and $0 after meeting your out-of-pocket max. | You pay 50% after deductible |
Crowns, onlays, veneer fillings
Covered once per tooth every 60 months.
In Network | Out of Network | |
You pay 50% after deductible before meeting your out-of-pocket max, and $0 after meeting your out-of-pocket max. | You pay 50% after deductible |
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% after deductible before meeting your out-of-pocket max, and $0 after meeting your out-of-pocket max. | You pay 50% after deductible |
Implants
Not covered
Orthodontic services
Not covered
There are more than 3,600 Tier 1 PPO dentists in Michigan, and thousands more nationwide. This all-ages dental plan covers 100 percent of preventive services like exams and cleanings when you see one of those in-network dentists. It also gives you the freedom to choose any dentist you want by helping to cover the cost of care when you see a dentist who isn't in our PPO network.
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 $0 | 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 |
$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.
In Network | Out of Network | |
One member | You pay no more than $400 | Not applicable |
Two members or more | You pay no more than $800 | 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.
Adult members are age 19 or older at the start of the coverage year.
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. There is no waiting period for Class I services.
Dental exams
Visits are covered twice a year.
In Network | Out of Network |
You pay $0 | You pay 50% |
Teeth cleaning (prophylaxis)
Cleanings are covered twice a year.
In Network | Out of Network |
You pay $0 | You pay 50% |
Bitewing X-rays
A set of four films is covered once a year.
In Network | Out of Network |
You pay $0 | You pay 50% |
Fluoride treatments
Not covered
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% after deductible | You pay 50% after deductible |
Fillings
Limited to once per tooth and surface every 24 months for primary teeth, and once per tooth and surface every 48 months for permanent teeth.
In Network | Out of Network |
You pay 50% after deductible | You pay 50% after deductible |
Simple extractions
In Network | Out of Network |
You pay 50% after deductible | You pay 50% after deductible |
Root canals
Covered once per tooth per lifetime.
In Network | Out of Network |
You pay 50% after deductible | You pay 50% after deductible |
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% after deductible | You pay 50% after deductible |
Crowns, onlays, veneer fillings
Covered once per tooth every 60 months.
In Network | Out of Network |
You pay 50% after deductible | You pay 50% after deductible |
Bridges and dentures
Covered once per arch every 84 months.
In Network | Out of Network |
You pay 50% after deductible | You pay 50% after deductible |
Implants
Not covered
Orthodontic services
Not covered
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 $0. | You pay 50% |
Teeth cleaning (prophylaxis)
Cleanings are covered three times a year.
In Network | Out of Network | |
You pay $0. | You pay 50% |
Bitewing X-rays
A set of four films is covered once a year.
In Network | Out of Network | |
You pay $0. | 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 $0. | 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% after deductible before meeting your out-of-pocket max, and $0 after meeting your out-of-pocket max. | You pay 50% after deductible |
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% after deductible before meeting your out-of-pocket max, and $0 after meeting your out-of-pocket max. | You pay 50% after deductible |
Periodontal maintenance
Limited to three times a year in combination with routine cleaning.
In Network | Out of Network | |
You pay 50% after deductible before meeting your out-of-pocket max, and $0 after meeting your out-of-pocket max. | You pay 50% after deductible |
Fillings
Limited to once per tooth and surface every 24 months for primary teeth, and once per tooth and surface every 48 months for permanent teeth.
In Network | Out of Network | |
You pay 50% after deductible before meeting your out-of-pocket max, and $0 after meeting your out-of-pocket max. | You pay 50% after deductible |
Simple extractions
In Network | Out of Network | |
You pay 50% after deductible before meeting your out-of-pocket max, and $0 after meeting your out-of-pocket max. | You pay 50% after deductible |
Root canals
Covered once per tooth per lifetime.
In Network | Out of Network | |
You pay 50% after deductible before meeting your out-of-pocket max, and $0 after meeting your out-of-pocket max. | You pay 50% after deductible |
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% after deductible before meeting your out-of-pocket max, and $0 after meeting your out-of-pocket max. | You pay 50% after deductible |
Crowns, onlays, veneer fillings
Covered once per tooth every 60 months.
In Network | Out of Network | |
You pay 50% after deductible before meeting your out-of-pocket max, and $0 after meeting your out-of-pocket max. | You pay 50% after deductible |
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% after deductible before meeting your out-of-pocket max, and $0 after meeting your out-of-pocket max. | You pay 50% after deductible |
Implants
Not covered
Orthodontic services
Not covered
Download or print your benefit information.
Health plan advisors
Have questions? Our Health Plan Advisors are ready to help. TTY users call 711.