MiCSC - State of Michigan Dental Plan Features

	State of Michigan	PPO	State of Michigan	Standard
	Plan Pays	You Pay	Plan Pays	You Pay
DIAGNOSTIC	100%	0%	100%	0%
Includes oral examinations and emergency palliative treatment.
Oral examinations are limited to two times in a plan year.
PREVENTIVE	100%		0%	100%
Includes prophylaxes, space maintainers and topical applications of fluoride.
Prophylaxes (teeth cleaning) are limited to three times in a plan year.
(Scientific and Engineering Unit: Limited to two times in a plan year.)
RADIOGRAPHS	100%	0%	90%	10%
X-rays as required and in conjunction with the diagnosis of a specific condition
requiring treatment.
SEALANTS	70%	30%	50%	50%
Dental sealants to prevent decay of permanent molars for dependents under age 14.
MINOR RESTORATIVE	100%	0%	90%	10%
Includes amalgams (silver fillings) and resin restorations.
EXTRACTIONS	100%	0%	90%	10%
Simple and complex tooth extractions.
ORAL SURGERY	90%	10%	90%	10%
Surgical dental procedures, including pre-operative and post-operative care,
but not including extractions.
ENDODONTICS	100%	0%	90%	10%
Procedures employed by dentists to treat teeth with diseased or damaged nerves
(for example, root canals).
PERIODONTICS	100%	0%	90%	10%
Procedures employed by dentists to treat diseases of the gums and supporting
structures of the teeth.
MAJOR RESTORATIVE	90%	10%	90%	10%
Includes cast restorations (crowns), but only when the teeth cannot be restored
with another filling material.
COSMETIC BONDING	90%	10%	90%	10%
Cosmetic restoration of the eight front teeth, if damaged by specific conditions.
For dependents ages 8-19.
(For Administrative Support, Human Services Unit and Non-Exclusively Represented
Employees ONLY.)
PROSTHODONTICS	70%	30%	50%	50%
Includes procedures for the construction of bridges, partial dentures and complete
dentures that replace missing natural teeth and relines to prosthetic appliances.
PROSTHODONTIC REPAIR	100%	0%	50%	50%
Repairs to prosthetic appliances.
ORTHODONTICS	75%	25%	60%	40%
Treatment and procedures required for the correction of malposed teeth.

The maximum dollar amount that the plan pays during each plan year (October - September) for each covered person is $1,000. For orthodontic care, the plan pays a lifetime maximum of $1,500 for each eligible person.