Blue Dental PPO Plus 100/80/50/50-1000 SG · 15560MI0430002
Blue Cross Blue Shield of Michigan offers this marketplace health insurance plan (Plan ID 15560MI0430002) so you can compare premiums, coverage levels, and provider access against other health plan insurance options. Use the modules below to decide whether this is the best health insurance plan for your household or if another insurance health plan fits better.
Marketplace enrollment for 2025 coverage typically runs Nov 1 – Jan 15 (dates may vary slightly in Michigan). Submit changes before the deadline to avoid a coverage gap.
Enroll by Dec 15 for Jan 1 starts.
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Special Enrollment Periods
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Report the event within 60 days.
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CSR & subsidy reminders
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Enter accurate income to maximize Advanced Premium Tax Credits.
Standard High Off Exchange Plan plans like this one keep deductibles and copays lower if you qualify.
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Track the official identifiers, documents, and filing dates tied to this plan. Open the marketing or formulary links whenever you need the latest PDF from the issuer.
Review the network branding plus the number of in-network clinicians we track from issuer filings. Counts update with each CMS import (Tue, 02 Dec 2025 06:13 GMT).
All providers in MichiganN/A
PCPs in MichiganN/A
Telehealth supportData pending
Nationwide providersN/A
N/A doctors statewideN/A PCPsN/A OB/GYN
Provider network(s)
['MIN003']
Providers
Michigan
All US states
All
N/A
N/A
PCP
N/A
N/A
Allergy
N/A
N/A
OB/GYN
N/A
N/A
Dentists
N/A
N/A
Drug coverage overview
0 drugs tracked
Inspect tier distribution plus authorization, step therapy, and quantity-limit counts sourced from HealthPorta’s formulary import.
Prior authorization
Drugs
Required
0
Not Required
0
Step therapy
Drugs
Required
0
Not Required
0
Quantity limits
Drugs
Has Limit
0
No Limit
0
Customer highlights
What stands out for members
Issuer: Blue Cross Blue Shield of Michigan · Plan ID 15560MI0430002 · 2025 filing.
Variant 15560MI0430002-00 (Standard Off Exchange Plan) currently displayed.
Use the cards on this page to explore network stats, drug coverage, and cost-sharing details.
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Benefits
Covered services & limitations
Pregnancy & family
Maternity, newborn, pediatric dental and vision extras.
Basic Dental Care - Child
20.00% Coinsurance after deductible
Tier 1 in-network20.00% Coinsurance after deductible
Out-of-network20.00% Coinsurance after deductible
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.
Exclusions: nan
Major Dental Care - Child
50.00% Coinsurance after deductible
Tier 1 in-network50.00% Coinsurance after deductible
Out-of-network50.00% Coinsurance after deductible
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. Pediatric members are defined as members age 18 or younger when their coverage begins.
Tier 1 in-network20.00% Coinsurance after deductible
Out-of-network20.00% Coinsurance after deductible
Emergency palliative treatment for temporary pain relief
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.
Basic Dental Care - Adult
20.00% Coinsurance after deductible
Tier 1 in-network20.00% Coinsurance after deductible
Out-of-network20.00% Coinsurance after deductible
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.
Exclusions: nan
Dental Check-Up for Children
No Charge
Tier 1 in-networkNo Charge
Out-of-networkNo Charge
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.
Exclusions: nan
Major Dental Care - Adult
50.00% Coinsurance after deductible
Tier 1 in-network50.00% Coinsurance after deductible
Out-of-network50.00% Coinsurance after deductible
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.
Exclusions: nan
Orthodontia - Adult
Coverage details pending
nan
Exclusions: nan
Orthodontia - Child
50.00%
Tier 1 in-network50.00%
Out-of-network50.00%
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.
Exclusions: nan
Routine Dental Services (Adult)
No Charge
Tier 1 in-networkNo Charge
Out-of-networkNo Charge
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.
Exclusions: nan
Variant attributes
Blue Dental PPO Plus 100/80/50/50-1000 SG · Variant 15560MI0430002-00
Plan identifiers & tier
Issuer-provided metadata for this variant.
Business Year
2025
CSR Variation Type
Standard High Off Exchange Plan
HIOS Product ID
15560MI043
Metal Level
High
Plan ID (Standard Component ID with Variant)
15560MI0430002-00
Plan Marketing Name
Blue Dental PPO Plus 100/80/50/50-1000 SG
Plan Variant Marketing Name
Blue Dental PPO Plus 100/80/50/50-1000 SG
Issuer & service area
Issuer-provided metadata for this variant.
Issuer ID
15560
Issuer Marketplace Marketing Name
Blue Cross Blue Shield of Michigan Mutual Insurance Company
Market Coverage
SHOP (Small Group)
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
Yes
Out of Service Area Coverage Description
Any licensed dentist in the US can participate in the Tier 2 par per claim Blue Par Select arrangement. Similar to PPO, dentists accept Blue Cross' approved amount for covered services as payment in full, less deductible or any coinsurance.
Service Area ID
MIS009
State Code
MI
Cost sharing & actuarial values
Issuer-provided metadata for this variant.
Begin Primary Care Deductible Coinsurance After Number Of Copays
0
Inpatient Copayment Maximum Days
0
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
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
Additional attributes
Issuer-provided metadata for this variant.
Begin Primary Care Cost-Sharing After Number Of Visits
0
Child-Only Offering
Allows Adult and Child-Only
Composite Rating Offered
No
Dental Only Plan
Yes
First Tier Utilization
100%
Import Date
2024-08-14 20:01:41
Guaranteed Rate
Guaranteed Rate
New/Existing Plan
Existing
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
$75 per group
Medical EHB Deductible, Out of Network, Family Per Person
$25 per person
Medical EHB Deductible, Out of Network, Individual
$25
Plan Effective Date
2025-01-01
Plan Level Exclusions
$1,000 annual benefit maximum for members age 19 or older when coverage begins. $1,000 lifetime orthodontic benefit maximum for members up to age 19.
Plan Type
PPO
QHP/Non QHP
Off the Exchange
Source Name
SERFF
Plan ID
15560MI0430002
Copay & coinsurance
Pharmacy cost sharing by tier
Drug tier
Pharmacy type
Copay amount
Copay option
Coinsurance rate
Coinsurance option
Mail order
Questions & answers
Frequently asked questions
How do I choose the right ACA plan in Michigan?
Blue Dental PPO Plus 100/80/50/50-1000 SG (15560MI0430002) is a High PPO from Blue Cross Blue Shield of Michigan in Michigan for the 2025 coverage year.
Compare it against other options with the HealthPorta plan finder to confirm premiums, deductibles, and network access fit your household.
Does Blue Dental PPO Plus 100/80/50/50-1000 SG support telehealth or virtual urgent care?
The issuer has not published telehealth details yet. Review the Summary of Benefits and Coverage to confirm if virtual visits are included.
Is Blue Dental PPO Plus 100/80/50/50-1000 SG HSA-eligible and does it include dental or vision coverage?
HSA eligibility is not published; check the Summary of Benefits or ask the issuer.
Dental add-ons: Adult, Child.
Vision coverage is not listed for this plan.
Does Blue Dental PPO Plus 100/80/50/50-1000 SG support mail-order prescriptions?
Mail order coverage is not listed for this plan, so confirm with the issuer before relying on home delivery.
Is there out-of-country coverage for Blue Dental PPO Plus 100/80/50/50-1000 SG?
Yes, limited out-of-country coverage is available. Review the Summary of Benefits for reimbursement steps. Details: Emergency
Does Blue Dental PPO Plus 100/80/50/50-1000 SG cover care outside the service area?
Yes, you have limited out-of-area coverage. See the plan documents for referral and prior authorization rules. Details: Any licensed dentist in the US can participate in the Tier 2 par per claim Blue Par Select arrangement. Similar to PPO, dentists accept Blue Cross' approved amount for covered services as payment in full, less deductible or any coinsurance.
How do I enroll in or manage payments for Blue Dental PPO Plus 100/80/50/50-1000 SG?
Use HealthPorta to shortlist plans, then finish enrollment through Healthcare.gov or your state-based marketplace.
Disclaimer: Based on the Tue, 02 Dec 2025 06:13 GMT HealthPorta import from CMS issuer filings. Data is best-effort and should be validated with the issuer directly. Sources: CMS.gov and the HealthPorta Healthcare MRF API.
