Blue Dental EPO 100/80/50/50 SG - 15560MI0470001 Health Insurance Plan
Blue Cross Blue Shield of Michigan Mutual Insurance Company health insurance plan with the Plan ID 15560MI0470001. The plan is called Blue Dental EPO 100/80/50/50 SG.
| Health Insurance Plan ID | 15560MI0470001 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2025 | ||||||||||||||||||
| State | Michigan | ||||||||||||||||||
| Health Insurance Issuer | Blue Cross Blue Shield of Michigan Mutual Insurance Company | ||||||||||||||||||
| Health Insurance Plan Variant | 15560MI0470001-00 | ||||||||||||||||||
| Provider Network(s) | ['MIN003'] | ||||||||||||||||||
| In Network Doctors
*The data available in our database based on Health Insurance Company Open Data (update: Thu, 21 Nov 2024 00:44 GMT). |
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| Available Variants of the Health Plan | |||||||||||||||||||
| Last Plan Update Date | Wed, 14 Aug 2024 00:00 GMT | ||||||||||||||||||
| Last Import Date | Thu, 21 Nov 2024 00:44 GMT |
Benefits of Blue Dental EPO 100/80/50/50 SG Health Insurance Plan, 15560MI0470001-00
| Benefit | Covered | In Network | Out Of Network |
|---|---|---|---|
| Accidental Dental
Exclusions: 6-month waiting period waived for emergency palliative treatment. Benefit only applies to MOOP for pediatric members. Pediatric members are defined as members age 18 or younger when their coverage begins. Emergency palliative treatment for temporary pain relief |
YES | 20.00% Coinsurance after deductible |
100.00% |
| Basic Dental Care - Adult
Limit: 1.0 Procedure(s) per 3 Years Scaling and root planing - 1x per quadrant, per 36 months. Fillings - 1x per 24 months for primary teeth, 1x per 48 months for permanent teeth. Periodontal maintenance - 2x per calendar year in combination with routine prohylaxis (cleaning). Root canals - 1x per lifetime per tooth. Simple and surgical extractions - 1x per lifetime. Members age 19 or older when their coverage begins are considered non-pediatric. |
YES | 20.00% Coinsurance after deductible |
100.00% |
| Basic Dental Care - Child
Limit: 1.0 Procedure(s) per 2 Years Scaling and root planing - 1x per quadrant, per 24 months. Fillings - 1x per 24 months for primary teeth, 1x per 48 months for permanent teeth. Periodontal maintenance - 3x per calendar year in combination with routine prohylaxis (cleaning). Root canals - 1x per lifetime per tooth. Simple and surgical extractions - 1x per lifetime. Pediatric members are defined as members age 18 or younger when their coverage begins. |
YES | 20.00% Coinsurance after deductible |
100.00% |
| Dental Check-Up for Children
Limit: 3.0 Procedure(s) per Year Prophylaxis (Cleaning) - 3x per calendar year. Exams - 2x per calendar year. Bitewing X-rays - One set (up to 4) per calendar year. Fluoride - 2x per calendar year. Sealants - 1x per permanent molars, every 3 years. Pediatric members are defined as members age 18 or younger when their coverage begins. |
YES | No Charge |
100.00% |
| Major Dental Care - Adult
Limit: 1.0 Procedure(s) per 3 Years Covered Periodontal surgery services - 1x every 36 months per quadrant. Onlays, crowns, veneers - 1x every 60 months. Bridges and dentures - 1x every 84 months. Implants - 1x per tooth, per lifetime, excluding 3rd molars. Members age 19 or older when their coverage begins are considered non-pediatric. |
YES | 50.00% Coinsurance after deductible |
100.00% |
| Major Dental Care - Child
Limit: 1.0 Procedure(s) per 3 Years Exclusions: Implants are not covered. Covered Periodontal surgery services - 1x every 36 months per quadrant. Onlays, crowns, veneers - 1x every 60 months. Bridges and dentures - 1x every 84 months. Pediatric members are defined as members age 18 or younger when their coverage begins. |
YES | 50.00% Coinsurance after deductible |
100.00% |
| Orthodontia - Adult
|
NO | ||
| Orthodontia - Child
Limit: 9999.0 Procedure(s) per Lifetime All orthodontic treatment is payable based on the lifetime maximum dollars available to the member. Orthodontic services are payable only for members up to age 19. |
YES | 50.00% |
100.00% |
| Routine Dental Services (Adult)
Limit: 2.0 Procedure(s) per Year Prophylaxis (Cleaning)- 2x per calendar year. Exams - 2x per calendar year. Bitewing X-rays - One set (up to 4) per calendar year. Fluoride - not covered. Sealants - not covered. Members age 19 or older when their coverage begins are considered non-pediatric. |
YES | No Charge |
100.00% |
Blue Dental EPO 100/80/50/50 SG Health Insurance Plan Variant 15560MI0470001-00 Attributes
| Plan Attribute | Value |
|---|---|
| Begin Primary Care Cost-Sharing After Number Of Visits | 0 |
| Begin Primary Care Deductible Coinsurance After Number Of Copays | 0 |
| Business Year | 2025 |
| Child-Only Offering | Allows Adult and Child-Only |
| Composite Rating Offered | No |
| CSR Variation Type | Standard High Off Exchange Plan |
| Dental Only Plan | Yes |
| First Tier Utilization | 100% |
| HIOS Product ID | 15560MI047 |
| Import Date | 2024-08-14 20:01:41 |
| Inpatient Copayment Maximum Days | 0 |
| Guaranteed Rate | Guaranteed Rate |
| New/Existing Plan | Existing |
| Issuer ID | 15560 |
| Issuer Marketplace Marketing Name | Blue Cross Blue Shield of Michigan Mutual Insurance Company |
| Market Coverage | SHOP (Small Group) |
| Maximum Out of Pocket for Medical EHB Benefits, Combined In/Out Network, Family Per Group | $850 per group |
| Maximum Out of Pocket for Medical EHB Benefits, Combined In/Out Network, Family Per Person | $425 per person |
| Maximum Out of Pocket for Medical EHB Benefits, Combined In/Out | $425 |
| Medical EHB Deductible, Combined In/Out of Network, Family Per Group | $75 per group |
| Medical EHB Deductible, Combined In/Out of Network, Family Per Person | $25 per person |
| Medical EHB Deductible, Combined In/Out of Network, Individual | $25 |
| Medical EHB Deductible, In Network (Tier 1), Family Per Group | $75 per group |
| Medical EHB Deductible, In Network (Tier 1), Family Per Person | $25 per person |
| Medical EHB Deductible, In Network (Tier 1), Individual | $25 |
| Medical EHB Deductible, Out of Network, Family Per Group | per group not applicable |
| Medical EHB Deductible, Out of Network, Family Per Person | per person not applicable |
| Medical EHB Deductible, Out of Network, Individual | Not Applicable |
| Maximum Out of Pocket for Medical EHB Benefits, In Network (Tier 1), Family Per Group | $850 per group |
| Maximum Out of Pocket for Medical EHB Benefits, In Network (Tier 1), Family Per Person | $425 per person |
| Maximum Out of Pocket for Medical EHB Benefits, In Network (Tier 1), Individual | $425 |
| Maximum Out of Pocket for Medical EHB Benefits, Out of Network, Family Per Group | per group not applicable |
| Maximum Out of Pocket for Medical EHB Benefits, Out of Network, Family Per Person | per person not applicable |
| Maximum Out of Pocket for Medical EHB Benefits, Out of Network, Individual | Not Applicable |
| Metal Level | High |
| Multiple In Network Tiers | No |
| National Network | Yes |
| Network ID | MIN003 |
| Out of Country Coverage | Yes |
| Out of Country Coverage Description | Emergency |
| Out of Service Area Coverage | No |
| Plan Effective Date | 2025-01-01 |
| Plan ID (Standard Component ID with Variant) | 15560MI0470001-00 |
| Plan Level Exclusions | $1,250 annual benefit maximum for members age 19 or older when coverage begins. Plan excludes coverage for services performed by non-PPO (out-of-network) dentists. $1,250 lifetime orthodontic benefit maximum for members up to age 19. |
| Plan Marketing Name | Blue Dental EPO 100/80/50/50 SG |
| Plan Type | EPO |
| Plan Variant Marketing Name | Blue Dental EPO 100/80/50/50 SG |
| QHP/Non QHP | Off the Exchange |
| Service Area ID | MIS008 |
| Source Name | SERFF |
| Plan ID | 15560MI0470001 |
| State Code | MI |
Copay & Coinsurance of Blue Dental EPO 100/80/50/50 SG Health Insurance Plan, 15560MI0470001
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
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Frequently Asked Questions(FAQ) about Blue Dental EPO 100/80/50/50 SG, 15560MI0470001 Health Insurance Plan, 15560MI0470001
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Does Blue Dental EPO 100/80/50/50 SG Health Insurance Plan, 15560MI0470001 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (15560MI0470001) Health Insurance Plan, Variant (15560MI0470001-00) have Out Of Country Coverage?
Does (15560MI0470001) Health Insurance Plan, Variant (15560MI0470001-00) have Out of Service Area Coverage?
Disclaimer: This is based on the import(Date: Thu, 21 Nov 2024 00:44 GMT) of the data from Healthcare Issuers listed by CMS. While we make every effort to ensure that data is accurate, you should assume all results are unvalidated. Source: CMS.gov, HealthPorta HEALTHCARE MRF API