Blue Cross Blue Shield of Michigan Personal Blue Dental Options |
Benefits-at-a-Glance |
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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. |
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Copays and dollar maximums
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Personal Blue Dental
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Personal Blue Dental Plus |
Copays
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In-Network
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In-Network |
Out-of-Network |
. Class I services
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25%
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25% |
25% |
. Class II services
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50%
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50% |
50% |
. Class III services
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50%
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50% |
50% |
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. Class IV services
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Not applicable
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Dollar maximums, deductibles & panel options
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. Annual maximum (for Class I, II and III services)
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$1,250 per member for all covered services
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$1,000 per member for all covered services
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. Lifetime maximum (for Class IV services)
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Not applicable
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. Deductible (For Class II and III services)
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Per calendar year $50 single/$100 family (two or more people)
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. Panel Option
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Closed – DenteMax only
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Open – Any dentist
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. Waiting Period
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6-month waiting period on Class II & III - applied on the effective date of dental coverage
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Personal Blue Dental
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Personal Blue Dental Plus
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Class I – Preventive Services
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In-Network
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Out-of-Network
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In-Network
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Out-of-Network
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Oral Exam
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Covered - 75%, two per calendar year
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Not covered
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Covered - 75%, two per calendar year
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Covered - 75%, two per calendar year
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Bitewing X-rays
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Covered - 75%, one set every 24 months
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Not covered
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Covered - 75%, one set every 12 months
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Covered - 75%, one set every 12 months
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Full-mouth or Panoramic X-rays
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Covered - 75%, Full mouth series once every 60 mos.; panoramic X-ray once every 84 months
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Not covered
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Covered - 75%, Full mouth series once every 60 months; panoramic X-ray once every 84 months
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Covered - 75%, Full mouth series once every 60 months; panoramic X-ray once every 84 months
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Prophylaxis (teeth cleaning)
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Covered - 75%, twice per calendar year
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Not covered
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Covered - 75%, twice per calendar year
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Covered - 75%, twice per calendar year
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Fluoride Treatment
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Covered - 75%, once per calendar year through age 14
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Not covered
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Covered - 75%, once per calendar year through age 14
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Covered - 75%, once per calendar year through age 14
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Space Maintainers
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Covered - 75%, once per quadrant per lifetime, under age 19
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Not covered
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Covered - 75%, once per quadrant per lifetime, under age 19
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Covered - 75%, once per quadrant per lifetime, under age 19
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Palliative Emergency Treatment
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Covered - 75%
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Not covered
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Covered - 75%
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Covered - 75%
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Pit and Fissure Sealants - for members age 16 or under
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Covered - 75%, once per tooth every 36 months when applied to the first and second permanent molars
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Not covered
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Covered - 75%, once per tooth every 36 months when applied to the first and second permanent molars
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Covered - 75%, once per tooth every 36 months when applied to the first and second permanent molars
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Personal Blue Dental |
Personal Blue Dental Plus |
Class II – Basic Restorative Services
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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
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Fillings – permanent teeth
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Covered – 50%, once every 48 months |
Not covered |
Covered – 50%, once every 48 months |
Covered – 50%, once every 48 months |
Fillings – primary teeth
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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
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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
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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
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Covered – 50% |
Not covered |
Covered – 50% |
Covered – 50% |
Root canal treatment – permanent tooth
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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
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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
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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
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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
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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
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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
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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
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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%.
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Personal Blue Dental |
Personal Blue Dental Plus |
Class III – Major Restorative Services
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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
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Removable dentures (complete and partial)
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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
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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
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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 |
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Personal Blue Dental
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Personal Blue Dental Plus
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Class IV – Orthodontic Services
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In-Network
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Out-of-Network
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In-Network
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Out-of-Network
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Minor treatment for tooth guidance appliances
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Not covered
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Not covered
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Not covered
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Not covered
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Minor treatment to control harmful habits
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Not covered
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Not covered
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Not covered
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Not covered
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Interceptive and comprehensive orthodontic treatment
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Not covered
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Not covered
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Not covered
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Not covered
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Post-treatment stabilization
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Not covered
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Not covered
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Not covered
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Not covered
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Cephalometric film (skull) and diagnostic photos
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Not covered
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Not covered
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Not covered
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Not covered
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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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