State of Michigan

PPO

State of Michigan

Standard

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.