Personal Blue Dental Benefits-at-a-Glance
Download Personal Blue Dental Benefits (106K PDF)
| |
In-Network |
Out-of-Network |
| Preventive Services |
| Oral exams |
Covered – 75% twice per calendar year |
Not covered |
| Bitewing X-rays |
Covered – 75% one set every 12 months |
Not covered |
| Full-mouth and panoramic X-rays |
Covered – 75%, full mouth once every 60 months; panoramic once every 84 months |
Not covered |
| Teeth cleaning |
Covered – 75% twice per calendar year |
Not covered |
| Fluoride treatment |
Covered – 75% once per calendar year through age 14 |
Not covered |
| Space maintainers |
Covered – 75% one per quadrant of the mouth per lifetime, under age 19 |
Not covered |
| Palliative emergency treatment |
Covered – 75% |
Not covered |
| 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 |
| Basic Services |
| Fillings — permanent teeth |
Covered – 50% once every 48 months |
Not covered |
| Fillings — primary teeth |
Covered – 50% once every 24 months |
Not covered |
| Onlays, crowns and veneer fillings — permanent teeth |
Covered – 50% once every 84 months per tooth, payable for members age 12 and older |
Not covered |
| Recementing of crowns, veneers, inlays, onlays and bridges |
Covered – 50% three per calendar year |
Not covered |
| Root canal treatnment - permanent tooth |
Covered – 50% once every 12 months for teeth with one or more canals |
Not covered |
| Scaling and root planing |
Covered – 50% once every 36 months per quadrant of the mouth |
Not covered |
| Limited occlusal adjustments |
Covered – 50% up to five times in a 60-month period |
Not covered |
| Occlusal biteguards |
Covered – 50% one every 60 months |
Not covered |
| General anesthesia or IV sedation |
Covered – 50% when medically necessary and performed with oral or dental surgery |
Not covered |
| Adjustment of dentures |
Covered – 50%, six months or more after it is delivered |
Not covered |
| Oral surgery, including extractions |
Covered – 50% |
Not covered |
| Relining or rebasing of partial or complete dentures |
Covered – 50% once every 36 months per arch six months or more after initial delivery |
Not covered |
| Tissue conditioning |
Covered – 50% once every 36 months per arch |
Not covered |
| Repairs and adjustment 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 |
| Restorative Services |
| Removable dentures (complete and partial) |
Covered – 50% once every 60 months |
Not covered |
| Bridges (fixed partial dentures) |
Covered – 50% once every 60 months, payable for members age 16 and older |
Not covered |
| 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 |
Copay and Dollar Maximums
The copay percentage is applied to the BCBSM-approved amount, not the provider's fee. The copay amounts shown below apply to in-network services only since services received out-of-network are not covered.
| Copay |
| Preventive Services |
25% |
| Basic Services |
50% |
| Restorative Services |
50% |
| Deductible |
| Preventive Services |
$0 |
| Basic Restorative Services |
$50 single/$100 family |
| Major Restorative Services |
$50 single/$100 family |
| Waiting period |
6-month waiting period is applied on the effective date of dental coverage for basic and major restorative services; preventive services are not subject to a waiting period. |
| Dollar maximums |
| Annual maximum |
$1250 per member for all covered services received in-network |
| Lifetime maximums |
None |
This is intended as an easy-to-read summary. It is not a contract. Additional limitations and exclusions may apply to covered services. For an official description of benefits, please see the applicable Blue Cross Blue Shield of Michigan certificate and riders. Payment amounts are based on the
BCBSM-approved amount, less any applicable deductible and/or copay amounts required by the plan. This coverage is provided pursuant to a contract entered into in the state of Michigan and shall be construed under the jurisdiction and according to the laws of the state of Michigan.
For nonurgent, complex or expensive dental treatment such as crowns, bridges or dentures, members should encourage their dentist to submit the claim to
BCBSM for predetermination before treatment begins. Services received outside the dental network are not covered.
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