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Teeth cleaning (3 per year)

100%

100%

100%

100%

Topical fluoride (under age 19)

100%

100%

100%

100%

Space maintainers (under age 14)

100%

100%

100%

100%

Sealants (under age 14)

50%

70%

100%

Not Covered

Radiographs

90%

100%

100%

Not Covered

Brush Biopsy

100%

100%

N/A

100%

Oral Surgery

90%

90%

100%

100%

Extractions

90%

100%

100%

Not Covered

Minor Restoratives

90%

100%

100%

Not Covered

Major Restoratives

90%

90%

100%

Not Covered

Endodontics

90%

100%

100%

Not Covered

Periodontics

90%

100%

100%

Not Covered

Prosthodontics

50%

70%

100%

Not Covered

Prosthodontics Repair

50%

100%

100%

Not Covered

Annual (Oct. – Sept.) Lifetime Orthodontics

$1,500

$1,500

None

None

$1,500

$1,500

None

N/A

State of Michigan

Dental Care Options

Covered Services (does not apply to members represented

by MSPTA T01)

Diagnostic Exams and Consultations (2 per year)

Preventive Services

Comparison of Dental Care Options

  • *

    If you have the State Dental Plan as your dental coverage, the level of coverage is determined by the

provider you choose. To verify that a Dentist is a Participating Dentist, you can use Delta Dental’s online Dentist Directory at www.deltadentalmi.com or call (800) 524-0150.

This benefit summary is a brief explanation only. All plan provisions (including exclusions and limitations) are subject to the specific terms of the State and Preventive Dental Plans and the Group Dental Services Agreement (Midwestern Dental Plans, Inc.).

60%

75%

100%

Not Covered

60%

75%

$1,250 co-pay

Not Covered

State Dental Plan (Delta)

Orthodontics

  • Up to age 19

  • 19 and over

Benefit Maximums

Premier/Non -Part*

PPO*

100%

100%

DMO Plan (Midwestern)

Preventive Dental Plan (Delta)

100%

100%

10

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