2025 Blue DentalSM PPO 100/50/50 (50/50/50) with Vision
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 has copays as low as $10.
Overview
About this plan
This plan provides everyone in the family with dental care and adults age 19 and older with dental and vision care for one monthly payment. It also gives you the choice to see out-of-network dentists and vision providers, but you pay more out of pocket.
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 (50/50/50) 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 Tier 1 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.
Monthly premiums
To give you an accurate price, we'll need some information. Find a plan to get a quote.
Deductible for dental care
Your deductible is the amount you pay for dental services each year before your insurance begins to pay.
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 for dental care
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
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 $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.
Adult vision care
Coverage includes:
- One eye exam every 12 months
- One pair of standard frames every 24 months
You choose between coverage for prescription glasses (lenses and frame) or contact lenses, but not both:
- Contacts covered once every 12 months, or
- One pair of standard lenses covered once every 12 months
Costs include:
- Copay is $10 for an eye exam by an in-network provider.
- If you go to an in-network provider, the copay for glasses is $25 and you have a $130 allowance for frames or elective contact lenses.
Agent compensation
Members can find information about agent commissions.
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 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.
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% 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
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% 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.
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 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
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%
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% after deductible 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% 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
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
In-network benefits
When you go to an eye doctor who participates with VSP, that's called getting your care in network. Find a VSP eye doctor.
You're also covered when you go to an eye doctor who doesn't participate with VSP, but you'll pay more. That's called getting your care out of network.
Annual allowance
There's a limit on what your plan pays toward the cost of eyeglasses or contacts. It's called an annual allowance. Once you've reached that limit, you're responsible for paying all costs.
Eye exams
Eye exams are covered once every every 12 months.
In Network
Out of Network
You pay $10
You pay $10 plus any costs over $45.
Lenses and frames
Every 12 months this plan shares the costs for prescription eyeglasses or contact lenses, but not both.
Standard lenses
Standard lenses prescribed by an eye doctor, optometrist or optician are covered once every 12 months.
A single copay applies to both lenses and frames.
In Network
Out of Network
You pay $25
You pay $25, plus the costs listed below.
Single vision lenses: You pay costs over $30.
Bifocal lenses: You pay costs over $50.
Trifocal lenses: You pay costs over $65.
Standard frames
Standard frames are covered once every 12 months.
A single copay applies to both lenses and frames.
In Network
Out of Network
You pay $25, plus costs over $150.
You pay $25, plus costs over $70.
Contact lenses
Every 12 months, this plan shares the costs for eyeglasses or contact lenses, not both.
Elective contact lenses
Elective contact lenses are prescribed by an eye doctor, optometrist or optician to improve vision. They are covered once every 12 months.
In Network
Out of Network
You pay any costs over $130
You pay any costs over $105
Medically necessary contact lenses
Medically necessary contact lenses are for people with eye conditions that may be a side effect of an operation or from certain genetically related disorders. They are covered once every 12 months.
In Network
Out of Network
You pay $25
You pay $25 plus costs over $210
Overview
About this plan
This plan provides everyone in the family with dental care and adults age 19 and older with dental and vision care for one monthly payment. It also gives you the choice to see out-of-network dentists and vision providers, but you pay more out of pocket.
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 (50/50/50) 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 Tier 1 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.
Monthly premiums
To give you an accurate price, we'll need some information. Find a plan to get a quote.
Deductible for dental care
Your deductible is the amount you pay for dental services each year before your insurance begins to pay.
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 for dental care
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
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 $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.
Adult vision care
Coverage includes:
- One eye exam every 12 months
- One pair of standard frames every 24 months
You choose between coverage for prescription glasses (lenses and frame) or contact lenses, but not both:
- Contacts covered once every 12 months, or
- One pair of standard lenses covered once every 12 months
Costs include:
- Copay is $10 for an eye exam by an in-network provider.
- If you go to an in-network provider, the copay for glasses is $25 and you have a $130 allowance for frames or elective contact lenses.
Agent compensation
Members can find information about agent commissions.
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 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.
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% 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
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% 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.
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 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
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%
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% after deductible 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% 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
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
In-network benefits
When you go to an eye doctor who participates with VSP, that's called getting your care in network. Find a VSP eye doctor.
You're also covered when you go to an eye doctor who doesn't participate with VSP, but you'll pay more. That's called getting your care out of network.
Annual allowance
There's a limit on what your plan pays toward the cost of eyeglasses or contacts. It's called an annual allowance. Once you've reached that limit, you're responsible for paying all costs.
Eye exams
Eye exams are covered once every every 12 months.
In Network
Out of Network
You pay $10
You pay $10 plus any costs over $45.
Lenses and frames
Every 12 months this plan shares the costs for prescription eyeglasses or contact lenses, but not both.
Standard lenses
Standard lenses prescribed by an eye doctor, optometrist or optician are covered once every 12 months.
A single copay applies to both lenses and frames.
In Network
Out of Network
You pay $25
You pay $25, plus the costs listed below.
Single vision lenses: You pay costs over $30.
Bifocal lenses: You pay costs over $50.
Trifocal lenses: You pay costs over $65.
Standard frames
Standard frames are covered once every 12 months.
A single copay applies to both lenses and frames.
In Network
Out of Network
You pay $25, plus costs over $150.
You pay $25, plus costs over $70.
Contact lenses
Every 12 months, this plan shares the costs for eyeglasses or contact lenses, not both.
Elective contact lenses
Elective contact lenses are prescribed by an eye doctor, optometrist or optician to improve vision. They are covered once every 12 months.
In Network
Out of Network
You pay any costs over $130
You pay any costs over $105
Medically necessary contact lenses
Medically necessary contact lenses are for people with eye conditions that may be a side effect of an operation or from certain genetically related disorders. They are covered once every 12 months.
In Network
Out of Network
You pay $25
You pay $25 plus costs over $210
Actions
Download or print your benefit information.
Need medical coverage?
Open enrollment is closed but you can get or change coverage for the remainder of 2025 if you've had one of these qualifying life events.
Health plan advisors
Call us at 1-855-237-3501 for help choosing the right plan
Have questions? Our Health Plan Advisors are ready to help. TTY users call 711.