Blue Dental℠ PPO Plus 80/60/50 With Vision
2019 plan year
Overview
About this plan
Get the coverage you need to complete your health care plus worry less about whether that care is in network. Dental care for the whole family is covered. In or out of network, your plan shares the same portion of the cost. This plan also covers vision care for adults, like exams, eyeglasses or contacts.
Availability
You can buy this plan if you live in any Michigan county.
Unlike most other Blue Cross plans, Blue Dental PPO Plus 80/60/50 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 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.
Who's covered
This plan covers dental care for all ages.
Vision coverage is for adults age 19 and older as of plan effective date. Why doesn't this plan cover children? Because of health care reform, all medical plans you purchase yourself must include pediatric vision care.
Monthly premiums
To give you an accurate price, we'll need some information. Find a plan to get a quote.
Deductible for dental care
Class I services have no deductible. There is a deductible for Class II and III services only. Class IV is not covered.
In network
One member: You pay $75.
Two members: You pay $150.
Three members: You pay $225.
Out of network
One member: You pay $75.
Two members: You pay $150.
Three members: You pay $225.
Coinsurance for dental care
In network
Class I: You pay 20%.
Class II: You pay 40% after deductible.
Class III: You pay 50% after deductible.
Class IV: You pay 100%.
Out of network
Class I: You pay 20%.
Class II: You pay 40% after deductible.
Class III: You pay 50% after deductible.
Class IV: You pay 100%.
Annual benefit maximum for adult dental care
In network
$1,000 for each adult
Out of network
$1,000 for each adult.
Annual out-of-pocket max for pediatric dental care
Dental benefits for pediatric members work differently than they do for adults. When you see a dentist in the preferred network, there's a limit on your share of the costs each year. That's called an out-of-pocket max.
In network
- One member: You pay no more than $350.
- Two or more members: You pay no more than $700.
Out of network
Not applicable
Adult vision care
Coverage includes:
- One eye exam each calendar year.
- One pair of standard frames every other calendar year.
You choose between coverage for prescription glasses (lenses and frame) or contact lenses, but not both:
- Contacts covered once each calendar year, or
- One pair of standard lenses covered once each calendar year
Costs include:
- Copay starts at $10 for an eye exam by an in-network provider.
- If you go to an in-network provider you pay the difference for frames or contacts that cost more than $130.
See vision tab for details.
Related documents
For even more details about this plan, see:
Certificates are legal documents that describe the benefits of a health insurance plan. Your plan might have different benefits and limitations than those listed in this document.
Adult Dental
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 PPO in-network dentist.
Class I
Preventive care like exams and cleanings
There is no waiting period for Class 1 services.
Dental exams
Visits are covered twice a year.
In network
You pay 20%.
Out of network
You pay 20%.
Teeth cleaning (prophylaxis)
Visits are covered twice a year. A third visit is covered for members with specific medical conditions.
In network
You pay 20%.
Out of network
You pay 20%.
Bitewing X-rays
A set of four films is covered once a year.
In network
You pay 20%.
Out of network
You pay 20%.
Fluoride treatments
Not covered
Class II
Basic restorative work 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. A third visit is covered for members with adverse medical conditions.
In network
You pay 40% after deductible.
Out of network
You pay 40% after deductible.
Fillings
Limited to once every 24 months for primary teeth, and once every 48 months for permanent teeth.
In network
You pay 40% after deductible.
Out of network
You pay 40% after deductible.
Simple extraction
In network
You pay 40% after deductible.
Out of network
You pay 40% after deductible.
Root canals
Coverage is once a lifetime per tooth.
In network
You pay 40% after deductible.
Out of network
You pay 40% after deductible.
Class III
Major restorative work like dentures 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
You pay 50% after deductible.
Out of network
You pay 50% after deductible.
Crowns, onlays, veneer fillings
Coverage is once every 84 months for members age 12 and older.
In network
You pay 50% after deductible.
Out of network
You pay 50% after deductible.
Bridges and dentures
Coverage is once every 84 months.
In network
You pay 50% after deductible.
Out of network
You pay 50% after deductible.
Implants
Not covered
Class IV
Orthodontic services
Not covered
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 PPO in-network dentist.
Class I
Preventive care like exams and cleanings.
Dental exams
Exams are covered twice a year.
In network
You pay 20% before meeting your out-of-pocket max.
You pay $0 after meeting your out-of-pocket max.
Out of network
You pay 20%.
Teeth cleaning (prophylaxis)
Cleanings are covered three times a year.
In network
You pay 20% before meeting your out-of-pocket max.
You pay $0 after meeting your out-of-pocket max.
Out of network
You pay 20%.
Bitewing X-rays
A set of four films is covered once a year.
In network
You pay 20% before meeting your out-of-pocket max.
You pay $0 after meeting your out-of-pocket max.
Out of network
You pay 20%.
Fluoride treatments
Fluoride treatments are covered twice a year.
In network
You pay 20% before meeting your out-of-pocket max.
You pay $0 after meeting your out-of-pocket max.
Out of network
You pay 20%.
Class II
Basic restorative work like fillings and root canals.
Periodontal maintenance
Limited to three times a year in combination with routine cleaning.
In network
You pay 40% before meeting your out-of-pocket max.
You pay $0 after meeting your out-of-pocket max.
Out of network
You pay 40% after deductible.
Fillings
Limited to once every 24 months for primary teeth, and once every 48 months for permanent teeth.
In network
You pay 40% before meeting your out-of-pocket max.
You pay $0 after meeting your out-of-pocket max.
Out of network
You pay 40% after deductible.
Simple extraction
In network
You pay 40% before meeting your out-of-pocket max.
You pay $0 after meeting your out-of-pocket max.
Out of network
You pay 40% after deductible.
Root canals
Coverage is once a lifetime per tooth.
In network
You pay 40% before meeting your out-of-pocket max.
You pay $0 after meeting your out-of-pocket max.
Out of network
You pay 40% after deductible.
Sealants
Coverage is once per tooth every three years when applied to the first and second permanent molars.
In network
You pay 40% before meeting your out-of-pocket max.
You pay $0 after meeting your out-of-pocket max.
Out of network
You pay 40% after deductible.
Class III
Major restorative work like dentures and bridges
Oral surgery
This includes all oral surgery except simple extractions, which are covered in Class II.
In network
You pay 50% before meeting your out-of-pocket max.
You pay $0 after meeting your out-of-pocket max.
Out of network
You pay 50% after deductible.
Crowns, onlays, veneer fillings
Coverage is once every 84 months per tooth.
In network
You pay 50% before meeting your out-of-pocket max.
You pay $0 after meeting your out-of-pocket max.
Out of network
You pay 50% after deductible.
Bridges and dentures
Coverage is once every 84 months.
In network
You pay 50% before meeting your out-of-pocket max.
You pay $0 after meeting your out-of-pocket max.
Out of network
You pay 50% after deductible.
Implants
Not covered
Class IV
Orthodontic services
Not covered
Adult Vision
This plan covers vision care for adults only. Why doesn't it cover children?
Because of health care reform, all medical plans you purchase yourself must include pediatric vision care.
In-network benefits
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.
Eye exam
Coverage is one exam a year.
In network
You pay $10.
Out of network
You pay $10 plus any costs over $34.
Lenses and frames
Each calendar year 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 a year.
In network
You pay $25.
A single copay applies to both lenses and frames.
Out of network
You pay $25, plus the costs listed below.
A single copay applies to both lenses and frames.
Single vision lenses: You pay costs over $17.
Bifocal lenses: You pay costs over $30.
Trifocal lenses: You pay costs over $43.
Standard frames
Standard frames are covered once every 24 months.
In network
You pay $25 plus costs over $130.
A single copay applies to both lenses and frames.
Out of network
You pay $25 plus costs over $38.25.
A single copay applies to both lenses and frames.
Contact lenses
Each year, this plan shares the costs for eyeglasses or contact lenses, not both.
Elective contact lenses
Elective contact lenses are covered once a year.
In network
You pay any costs over $130.
Out of network
You pay any costs over $100.
Medically necessary contact lenses
Medically necessary contact lenses are covered once a year.
In network
You pay $25.
Out of network
You pay $25 plus costs over $210.
