2025 Blue DentalSM PPO 100/70/50 (80/60/50)
With this plan, preventive care like exams and cleanings is covered 100 percent when you see a Tier 1 PPO dentist. There's also no deductible for other services in the network.
Overview
About this plan
With PPO 100/70/50 (80/60/50), when you see a Tier 1 PPO dentist, preventive care like exams and cleanings is covered 100 percent. And unlike PPO Plus 80/60/50, there's no deductible for other services in the network. 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.
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.
One member
You pay $0
You pay $50
Two members
You pay $0
You pay $100
Three members
You pay $0
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 $0
You pay 20%
Class II
You pay 30%
You pay 40% after deductible
Class III
You pay 50%
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 $1,000 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 $425
Not applicable
Two members or more
You pay no more than $850
Not applicable
This out-of-pocket maximum is the most you’ll have to pay during a calendar year for covered pediatric dental services. Once you’ve reached this out-of-pocket maximum, your plan pays 100 percent of the allowed amount.
Agent compensation
Members can find information about agent commissions.
Related documents
Eligibility
Adult members are age 19 or older at the start of the coverage year.
Plan benefits
For dental care, you can go to any licensed dentist and this plan will share the cost. But you'll pay less if you see a Tier 1 PPO in-network dentist.
Class I coverage
Preventive care like exams and cleanings. There is no waiting period for Class I services.
Dental exams
Visits are covered twice a year.
In Network
Out of Network
You pay 0$
You pay 20%
Teeth cleaning (prophylaxis)
Cleanings are covered twice a year.
In Network
Out of Network
You pay 0$
You pay 20%
Bitewing X-rays
A set of four films is covered once a year.
In Network
Out of Network
You pay 0$
You pay 20%
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 30%
You pay 40% 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 30%
You pay 40% after deductible
Simple extractions
In Network
Out of Network
You pay 30%
You pay 40% after deductible
Root canals
Covered once per tooth per lifetime.
In Network
Out of Network
You pay 30%
You pay 40% after deductible
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% after deductible
Crowns, onlays, veneer fillings
Covered once per tooth every 60 months.
In Network
Out of Network
You pay 50%
You pay 50% after deductible
Bridges and dentures
Covered once per arch every 84 months.
In Network
Out of Network
You pay 50%
You pay 50% after deductible
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 $0
You pay 20%
Teeth cleaning (prophylaxis)
Cleanings are covered twice a year.
In Network
Out of Network
You pay $0
You pay 20%
Bitewing X-rays
A set of four films is covered once a year.
In Network
Out of Network
You pay $0
You pay 20%
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 20%
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 30% after deductible before meeting your out-of-pocket max, and $0 after meeting your out-of-pocket max.
You pay 40%
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 30% before meeting your out-of-pocket max, and $0 after meeting your out-of-pocket max.
You pay 40%
Periodontal maintenance
Limited to three times a year in combination with routine cleaning.
In Network
Out of Network
You pay 30% after deductible before meeting your out-of-pocket max, and $0 after meeting your out-of-pocket max.
You pay 40% 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 30% after deductible before meeting your out-of-pocket max, and $0 after meeting your out-of-pocket max.
You pay 40% after deductible
Simple extractions
In Network
Out of Network
You pay 30% after deductible before meeting your out-of-pocket max, and $0 after meeting your out-of-pocket max.
You pay 40% after deductible
Root canals
Covered once per tooth per lifetime.
In Network
Out of Network
You pay 30% after deductible before meeting your out-of-pocket max, and $0 after meeting your out-of-pocket max.
You pay 40% after deductible
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% 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.
Class IV coverage
Orthodontic services
Not covered
Overview
About this plan
With PPO 100/70/50 (80/60/50), when you see a Tier 1 PPO dentist, preventive care like exams and cleanings is covered 100 percent. And unlike PPO Plus 80/60/50, there's no deductible for other services in the network. 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.
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.
One member
You pay $0
You pay $50
Two members
You pay $0
You pay $100
Three members
You pay $0
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 $0
You pay 20%
Class II
You pay 30%
You pay 40% after deductible
Class III
You pay 50%
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 $1,000 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 $425
Not applicable
Two members or more
You pay no more than $850
Not applicable
This out-of-pocket maximum is the most you’ll have to pay during a calendar year for covered pediatric dental services. Once you’ve reached this out-of-pocket maximum, your plan pays 100 percent of the allowed amount.
Agent compensation
Members can find information about agent commissions.
Related documents
Eligibility
Adult members are age 19 or older at the start of the coverage year.
Plan benefits
For dental care, you can go to any licensed dentist and this plan will share the cost. But you'll pay less if you see a Tier 1 PPO in-network dentist.
Class I coverage
Preventive care like exams and cleanings. There is no waiting period for Class I services.
Dental exams
Visits are covered twice a year.
In Network
Out of Network
You pay 0$
You pay 20%
Teeth cleaning (prophylaxis)
Cleanings are covered twice a year.
In Network
Out of Network
You pay 0$
You pay 20%
Bitewing X-rays
A set of four films is covered once a year.
In Network
Out of Network
You pay 0$
You pay 20%
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 30%
You pay 40% 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 30%
You pay 40% after deductible
Simple extractions
In Network
Out of Network
You pay 30%
You pay 40% after deductible
Root canals
Covered once per tooth per lifetime.
In Network
Out of Network
You pay 30%
You pay 40% after deductible
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% after deductible
Crowns, onlays, veneer fillings
Covered once per tooth every 60 months.
In Network
Out of Network
You pay 50%
You pay 50% after deductible
Bridges and dentures
Covered once per arch every 84 months.
In Network
Out of Network
You pay 50%
You pay 50% after deductible
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 $0
You pay 20%
Teeth cleaning (prophylaxis)
Cleanings are covered twice a year.
In Network
Out of Network
You pay $0
You pay 20%
Bitewing X-rays
A set of four films is covered once a year.
In Network
Out of Network
You pay $0
You pay 20%
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 20%
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 30% after deductible before meeting your out-of-pocket max, and $0 after meeting your out-of-pocket max.
You pay 40%
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 30% before meeting your out-of-pocket max, and $0 after meeting your out-of-pocket max.
You pay 40%
Periodontal maintenance
Limited to three times a year in combination with routine cleaning.
In Network
Out of Network
You pay 30% after deductible before meeting your out-of-pocket max, and $0 after meeting your out-of-pocket max.
You pay 40% 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 30% after deductible before meeting your out-of-pocket max, and $0 after meeting your out-of-pocket max.
You pay 40% after deductible
Simple extractions
In Network
Out of Network
You pay 30% after deductible before meeting your out-of-pocket max, and $0 after meeting your out-of-pocket max.
You pay 40% after deductible
Root canals
Covered once per tooth per lifetime.
In Network
Out of Network
You pay 30% after deductible before meeting your out-of-pocket max, and $0 after meeting your out-of-pocket max.
You pay 40% after deductible
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% 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.
Class IV coverage
Orthodontic services
Not covered
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