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Blue Cross Blue Shield of Michigan Personal Blue Dental Options
Benefits-at-a-Glance
Get Quotes and Apply Online for Blue Cross Blue Shield of Michigan Dental Insurance
This is intended as an easy-to-read summary. It is not a contract. Additional limitations and exclusions may apply to covered services. For a complete description of benefits, please see the applicable Blue Cross Blue Shield of Michigan certificates and riders. Payment amounts are based on the Blue Cross Blue Shield of Michigan approved amount or the fee negotiated for this program, less any applicable deductible and/or copay amounts required by your plan. This coverage is provided pursuant to a contract entered into in the state of Michigan and will be construed under the jurisdiction of and according to the laws of the state of Michigan.

 
Blue Cross Blue Shield of Michigan Dental and Health Insurance Instant Quotes and Online Application
Blue Cross Blue Shield of Michigan Dental and Health Insurance Instant Quotes and Online Application

Copays and dollar maximums

Personal Blue Dental

Personal Blue Dental Plus

Copays

In-Network

In-Network

Out-of-Network

. Class I services

25%

25%

25%

. Class II services

50%

50%

50%

. Class III services

50%

50%

50%

   

. Class IV services

Not applicable

Dollar maximums, deductibles & panel options

. Annual maximum (for Class I, II and III services)

$1,250 per member for all covered services

$1,000 per member for all covered services

. Lifetime maximum (for Class IV services)

Not applicable

. Deductible (For Class II and III services)

Per calendar year $50 single/$100 family (two or more people)

. Panel Option

Closed – DenteMax only

Open – Any dentist

. Waiting Period

6-month waiting period on Class II & III - applied on the effective date of dental coverage

 

Personal Blue Dental

Personal Blue Dental Plus

Class I – Preventive Services

In-Network

Out-of-Network

In-Network

Out-of-Network

Oral Exam

Covered - 75%, two per calendar year

Not covered

Covered - 75%, two per calendar year

Covered - 75%, two per calendar year

Bitewing X-rays

Covered - 75%, one set every 24 months

Not covered

Covered - 75%, one set every 12 months

Covered - 75%, one set every 12 months

Full-mouth or Panoramic X-rays

Covered - 75%, Full mouth series once every 60 mos.; panoramic X-ray once every 84 months

Not covered

Covered - 75%, Full mouth series once every 60 months; panoramic X-ray once every 84 months

Covered - 75%, Full mouth series once every 60 months; panoramic X-ray once every 84 months

Prophylaxis (teeth cleaning)

Covered - 75%, twice per calendar year

Not covered

Covered - 75%, twice per calendar year

Covered - 75%, twice per calendar year

Fluoride Treatment

Covered - 75%, once per calendar year through age 14

Not covered

Covered - 75%, once per calendar year through age 14

Covered - 75%, once per calendar year through age 14

Space Maintainers

Covered - 75%, once per quadrant per lifetime, under age 19

Not covered

Covered - 75%, once per quadrant per lifetime, under age 19

Covered - 75%, once per quadrant per lifetime, under age 19

Palliative Emergency Treatment

Covered - 75%

Not covered

Covered - 75%

Covered - 75%

Pit and Fissure Sealants - for members age 16 or under

Covered - 75%, once per tooth every 36 months when applied to the first and second permanent molars

Not covered

Covered - 75%, once per tooth every 36 months when applied to the first and second permanent molars

Covered - 75%, once per tooth every 36 months when applied to the first and second permanent molars

  Blue Cross Blue Shield of Michigan Dental and Health Insurance Instant Quotes and Online Application Blue Cross Blue Shield of Michigan Dental and Health Insurance Instant Quotes and Online Application

Personal Blue Dental

Personal Blue Dental Plus

Class II – Basic Restorative Services

In-Network

Out-of-Network

In-Network

Out-of-Network

Note: 6-month waiting period on Class II Services - applied on the effective date of your dental coverage

Fillings – permanent teeth

Covered – 50%, once every 48 months

Not covered

Covered – 50%, once every 48 months

Covered – 50%, once every 48 months

Fillings – primary teeth

Covered – 50%, once every 24 months

Not covered

Covered – 50%, once every 24 months

Covered – 50%, once every 24 months

Onlays, crowns and veneer fillings – permanent teeth

Covered – 50%, once every 84 months per tooth, payable for members age 12 or older

Not covered

Covered – 50%, once every 84 months per tooth, payable for members age 12 or older

Covered – 50%, once every 84 months per tooth, payable for members age 12 or older

Recementing of crowns, veneers, inlays, onlays and bridges

Covered – 50%, three times per tooth per calendar year after six months from original restoration

Not covered

Covered – 50%, three times per tooth per calendar year after six months from original restoration

Covered – 50%, three times per tooth per calendar year after six months from original restoration

Oral surgery including extractions

Covered – 50%

Not covered

Covered – 50%

Covered – 50%

Root canal treatment – permanent tooth

Covered – 50%, once every 12 months for tooth with one or more canals

Not covered

Covered – 50%, once every 12 months for tooth with one or more canals

Covered – 50%, once every 12 months for tooth with one or more canals

Scaling and root planing

Covered – 50%, once every 36 months per quadrant

Not covered

Covered – 50%, once every 36 months per quadrant

Covered – 50%, once every 36 months per quadrant

Limited occlusal adjustments

Covered – 50%, limited occlusal adjustments covered up to five times in a 60-month period

Not covered

Covered – 50%, limited occlusal adjustments covered up to five times in a 60-month period

Covered – 50%, limited occlusal adjustments covered up to five times in a 60-month period

Occlusal biteguards

Covered – 50%, one every 60 months

Not covered

Covered – 50%, one every 60 months

Covered – 50%, one every 60 months

General anesthesia or IV sedation

Covered – 50%, when medically or dentally necessary and performed with oral or dental surgery

Not covered

Covered – 50%, when medically or dentally necessary and performed with oral or dental surgery

Covered – 50%, when medically or dentally necessary and performed with oral or dental surgery

Relining or rebasing of partials or complete dentures

Covered – 50%, once every 36 months per arch six months or more after initial delivery

Not covered

Covered – 50%, once every 36 months per arch six months or more after initial delivery

Covered – 50%, once every 36 months per arch six months or more after initial delivery

Tissue conditioning

Covered – 50%, once every 36 months per arch

Not covered

Covered – 50%, once every 36 months per arch

Covered – 50%, once every 36 months per arch

Repair and adjustments of partial or complete dentures

Covered – Included in fee for a new denture or partial within six months of initial delivery. After six months - covered at 50%.

Not covered

Covered – Included in fee for a new denture or partial within six months of initial delivery. After six months - covered at 50%.

Covered – Included in fee for a new denture or partial within six months of initial delivery. After six months - covered at 50%.

 

Personal Blue Dental

Personal Blue Dental Plus

Class III – Major Restorative Services

In-Network

Out-of-Network

In-Network

Out-of-Network

Note: 6-month waiting period on Class III Services - applied on the effective date of your dental coverage

Removable dentures (complete and partial)

Covered – 50% once every 60 months

Not covered

Covered – 50% once every 60 months

Covered – 50% once every

60 months

Bridges (fixed partial dentures) – for members age 16 or older

Covered – 50%, once every 60 months

Not covered

Covered – 50%, once every 60 months

Covered – 50%, once every 60 months

Endosteal implants – for members age 16 or older who are covered at the time of the actual implant placement

Covered – 50%, once per tooth in a member lifetime when implant placement is for teeth numbered 2 through 15 and 18 through 31

Not covered

Covered – 50%, once per tooth in a member lifetime when implant placement is for teeth numbered 2 through 15 and 18 through 31

Covered – 50%, once per tooth in a member lifetime when implant placement is for teeth numbered 2 through 15 and 18 through 31

Personal Blue Dental

Personal Blue Dental Plus

Class IV – Orthodontic Services

In-Network

Out-of-Network

In-Network

Out-of-Network

Minor treatment for tooth guidance appliances

Not covered

Not covered

Not covered

Not covered

Minor treatment to control harmful habits

Not covered

Not covered

Not covered

Not covered

Interceptive and comprehensive orthodontic treatment

Not covered

Not covered

Not covered

Not covered

Post-treatment stabilization

Not covered

Not covered

Not covered

Not covered

Cephalometric film (skull) and diagnostic photos

Not covered

Not covered

Not covered

Not covered

Note: For non-urgent, complex or expensive dental treatment such as crowns, bridges or dentures, members should encourage their dentist to submit the claim to Blue Cross for predetermination before treatment begins. Personal Blue Dental members: If you receive care from a non-network dentist, you will be billed for the entire charge. Personal Blue Dental Plus members: If you receive care from a nonparticipating dentist, you may be billed for the difference between our approved amount and the dentist’s charge.

Blue Cross Blue Shield of Michigan is a nonprofit corporation and independent licensee of the Blue Cross and Blue Shield Association.

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