BENEFITS AT-A-GLANCE
| Class I Services | |
| Oral exams | Covered - 75%, twice per calendar year |
| Bitewing X-rays | Covered - 75%, twice per calendar year |
| Full-mouth and Panoramic X-rays | Covered - 75%, once every 60 months |
| Prophylaxis (teeth cleaning) | Covered - 75%, twice per calendar year |
| Fluoride Treatment | Covered - 75%, twice per calendar year |
| Space Maintainers | Covered - 75%, one per quadrant per lifetime, up to age 19 |
| Palliative Emergency Treatment | Covered - 75% |
| Class II Services | |
| Fillings - permanent teeth | Covered - 50%, once every 24 months, per tooth |
| Fillings - primary teeth | Covered - 50%, once every 12 months, per tooth |
| Inlays, Onlays, Crowns and Gold Fillings - permanent teeth | Covered - 50%, once every 60 months, per tooth. Payable for members age 12 and older |
| Recementing of Inlays, Onlays, Crowns and Bridges | Covered - 50%, three per calendar year |
| Root Canal Therapy | Covered - 50%, once every 12 months for teeth with one or more canals |
| Periodontal Scaling and Planing | Covered - 50%, once every 24 months |
| Occlusal Adjustment | Covered - 50%, up to five times in a 60-month period |
| Periodontic Appliances or Biteguards | Covered - 50%, once every 12 months |
| General Anesthesia or IV Sedation | Covered - 50%, when medically necessary and performed with oral or dental surgery |
| Extractions - simple and surgical | Covered - 50% |
| Relining or Rebasing of Partials or Dentures | Covered - 50%, once every 36 months per arch |
| Tissue Conditioning | Covered - 50%, once every 36 months per arch |
| Repairs to Existing Partials or Dentures | Covered - 50%, up to one-half of the approved amount for a new denture in any 12-month period |
| Class III Services | |
| Removable Dentures and Partials | Covered - 50%, once every 60 months |
| Fixed Bridges | Covered - 50%, once every 60 months, payable for members age 16 and older |
| Copays and Dollar Maximums | |
| Copays - Class I Services | 25% |
| Copays - Class II Services | 50% |
| Copays - Class III Services | 50% |
| Annual Maximum on Class I, II and III Services | $1000 per member / $3,000 per family |
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 Blue Shield of Michigan for predetermination before treatment begins.
This is intended as an easy-to-read summary. It is not a contract. An official description of benefits is contained in applicable Blue Cross Blue Shield certificate and riders. Payment amounts are based on the Blue Cross Blue Shield 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.
