Anthem Blue Dental PPO Voluntary Option 2V Summary of Benefits Annual Benefit Limit: $1500 Annual Member Deductible: $50 PPO Dentist $50 Non-PPO Dentist Family Coverage Deductible Limit 3 times Annual Member Deductible Summary of Benefits This Summary provides you with brief descriptions of your benefits and the benefit payment percentages. For more complete information, see your Anthem Blue Dental PPO Voluntary Certificate. For a covered dental service, this Plan will pay the applicable percentage (shown in the Plan s Percentage column) of the Anthem Blue Cross and Blue Shield Maximum Allowable Amount for that service (up to the annual benefit limit). If your dental coverage includes optional benefits such as orthodontics, a page describing the optional benefit will be attached to this Summary of Benefits. Please contact a dental customer service representative to verify your dental coverage and any optional benefits. Annual Benefit Limit $1500 per member Benefit Plan s Percentage Benefit Waiting Period Type 1 Diagnostic and preventive services (No deductible) Type 2 Filling of cavities/basic services Type 3 Removable Prosthodontic services Type 4 Fixed Prosthodontic services Type 5 Oral Surgery services Type 6 Endodontic services Type 7 Periodontic services Type 8 Orthodontic services PPO Non-PPO Dentist Dentist 100% 100% 0 months 80% 80% 3 months 50% 50% 12 months 50% 50% 12 months 80% 80% 6 months 50% 50% 12 months 50% 50% 12 months This is an optional benefit; see the separate Summary of Benefits for Optional Coverage to determine if purchased by your employer. Please see the back of this page for additional information. Anthem Blue Cross and Blue Shield Dental Customer Service: 1-800-627-0004 An independent licensee of the Blue Cross and Blue Shield Association. Anthem Blue Cross and Blue Shield is the trade name of Rocky Mountain Hospital and Medical Service, Inc. Registered marks Blue Cross and Blue Shield Association.
Anthem Blue Dental PPO Voluntary Summary of Benefits for Optional Coverage Orthodontic Services $1000 This is not a contract; it is a partial listing of benefits and services. All covered services are subject to the conditions, exclusions, qualifications, limitations, terms and provisions of the Anthem Blue Dental PPO Voluntary Certificate and the Summary of Benefits. For a covered dental service, this coverage will pay the applicable percentage (shown in the Plan s Percentage column) of the Anthem Blue Cross and Blue Shield Dental Maximum Allowable Amount for that service (up to the lifetime orthodontia maximum). Please contact customer service at 1-800-627-0004 to verify your dental coverage. Benefit Lifetime Orthodontia Maximum Type 8 Orthodontic Services Plan s Percentage (PPO Dentist and Non-PPO Dentist) $1000 combined for network and non-network providers 50% coinsurance Covered Services Limited Orthodontic Treatment of adolescent dentition Comprehensive Orthodontic Treatment of the adolescent dentition Removable Appliance Therapy Fixed Appliance Therapy Pre-orthodontic Treatment Periodic Orthodontic Treatment visit (as part of contract) Orthodontic Retention (removal of appliances, construction and placement of retainers Benefit Waiting Period Limited to Dependent Children up to the age of 19. Anthem Blue Cross and Blue Shield Dental Customer Service: (800) 627-0004 An independent licensee of the Blue Cross and Blue Shield Association. Anthem Blue Cross and Blue Shield is the trade name of Rocky Mountain Hospital and Medical Service, Inc. Registered marks Blue Cross and Blue Shield Association.
Covered Services The following is a partial listing of Covered Services, benefit waiting periods, and limitations. If the dental service a Member is receiving is not indicated below, the Member may telephone Anthem s dental customer service department toll free at the telephone number indicated on the Member s identification card for more information. Procedure Code Exams Procedure Description Procedure Type Benefit Waiting Period Months D0460 Pulp Vitality Testing 1 0 D0470 Diagnostic Casts 1 0 D0120 Periodic Oral Evaluation 1 0 D0140 Limited Oral Evaluation - Problem Focused 1 0 D0150 Comprehensive Oral Evaluation 1 0 D0180 Comprehensive periodontal evaluation - new or established patient 1 0 Radiographs Bitewings D0220 Intraoral - Periapical - First Film 1 0 D0230 Intraoral - Periapical - Each additional Film 1 0 D0240 Intraoral - Occlusal Film 1 0 D0250 Extraoral - First Film 1 0 D0260 Extraoral - Each additional Film 1 0 D0270 Bitewing - Single Film 1 0 D0272 Bitewings - Two Films 1 0 D0274 Bitewings - Four Films 1 0 D0277 Vertical Bitewings 1 0 Radiographs FMX D0210 Intraoral - Complete Series (including Bitewings) 2 3 D0330 Panoramic Film 2 3 Cleanings D1110 Prophylaxis - Adult 1 0 D1120 Prophylaxis - Child 1 0 Fluoride D1201 Topical Application of Fluoride (including Prophylaxis) - Child 1 0 D1203 Topical Application of Fluoride (Prophylaxis not included) - Child 1 0 Sealants D1351 Sealant - per tooth 2 3 Space Maintainers D1510 Space Maintainer - Fixed - Unilateral 2 3 D1515 Space Maintainer - Fixed - Bilateral 2 3 D1520 Space Maintainer - Removable - Unilateral 2 3 D1525 Space Maintainer - Removable - Bilateral 2 3 D1550 Recementation of Space Maintainer 2 3 Palliative Treatment D9110 Palliative (emergency) treatment of dental pain - minor procedure 2 3
Procedure Code Procedure Description Procedure Type Benefit Waiting Period Months Fillings D2140 Amalgam - One surface, primary or permanent 2 3 D2150 Amalgam - Two surfaces, primary or permanent 2 3 D2160 Amalgam - Three surfaces, primary or permanent 2 3 D2161 Amalgam - Four or more surfaces, primary or permanent 2 3 D2330 Resin - One surface, Anterior 2 3 D2331 Resin - Two surfaces, Anterior 2 3 D2332 Resin - Three surfaces, Anterior 2 3 D2335 Resin - Four or more surfaces or involving incisal angle (Anterior) 2 3 D2391 Resin-based composite - one surface, posterior 2 3 D2392 Resin-based composite - two surfaces, posterior 2 3 D2393 Resin-based composite - three surfaces, posterior 2 3 D2394 Resin-Based composite - four or more surfaces, posterior 2 3 Single Tooth Restorations D2510 Inlay - Metallic - One surface 4 12 D2720 Crown - Resin with High Noble Metal 4 12 D2721 Crown - Resin with Predominantly Base Metal 4 12 D2750 Crown - Porcelain Fused to High Noble Metal 4 12 D2751 Crown - Porcelain Fused to Predominantly Base Metal 4 12 D2780 Crown-3/4 Cast High Noble metal 4 12 D2781 Crown - 3/4 Cast High predominantly Base Metal 4 12 D2920 Recement Crown 4 12 D2930 Prefabricated Stainless Steel Crown - Primary tooth 4 12 D2950 Core Buildup, including any pins 4 12 Endodontics D3220 Therapeutic Pulpotomy (excluding final restoration) 6 12 D3310 Anterior (excluding final restoration) 6 12 D3320 Bicuspid (excluding final restoration) 6 12 D3330 Molar (excluding final restoration) 6 12 D3346 Retreatment of previous Root Canal Therapy - Anterior 6 12 D3347 Retreatment of previous Root Canal Therapy - Bicuspid 6 12 D3348 Retreatment of previous Root Canal Therapy - Molar 6 12 D3410 Apicoectomy/Periradicular Surgery - Anterior 6 12 D3421 Apicoectomy/Periradicular Surgery - Bicuspid (first root) 6 12 D3425 Apicoectomy/Periradicular Surgery - Molar (first root) 6 12 D3920 Hemisection (including any root removal), not including Root Canal Therapy 6 12 Periodontics D4210 Gingivectomy or Gingivoplasty - per quadrant 7 12 D4260 Osseous Surgery (including Flap Entry and Closure) - per quadrant 7 12 D4341 Periodontal Scaling and Root Planing, per quadrant 7 12 D4355 Full Mouth Debridement to enable Comprehensive Periodontal 7 12 evaluation and Diagnosis D4910 Periodontal Maintenance Procedures (following active therapy) 7 12
Procedure Code Procedure Description Procedure Type Benefit Waiting Period Months Removable Prosthodontics D5110 Complete Denture - Maxillary 3 12 D5120 Complete Denture - Mandibular 3 12 D5211 Maxillary Partial Denture - Resin Base (including any conventional 3 12 clasps, rests and teeth) D5212 Mandibular Partial Denture - Resin Base (including any conventional clasps, rests and teeth) 3 12 Prosthodontics Repairs D5410 Adjust Complete Denture - Maxillary 3 12 D5411 Adjust Complete Denture - Mandibular 3 12 D5421 Adjust Partial Denture - Maxillary 3 12 D5422 Adjust Partial Denture - Mandibular 3 12 D5510 Repair broken Complete Denture Base 3 12 D5710 Rebase Complete Maxillary Denture 3 12 D5711 Rebase Complete Mandibular Denture 3 12 D5720 Rebase Maxillary Partial Denture 3 12 D5721 Rebase Mandibular Partial Denture 3 12 D5730 Reline Complete Maxillary Denture (chairside) 3 12 D5731 Reline Complete Mandibular Denture (chairside) 3 12 D5740 Reline Maxillary Partial Denture (chairside) 3 12 D5741 Reline mandibular Partial Denture (chairside) 3 12 D5851 Tissue Conditioning, Mandibular 3 12 Fixed Prosthodontics D6210 Pontic - Cast High Noble Metal 4 12 D6211 Pontic - Cast Predominantly Base Metal 4 12 D6240 Pontic - Porcelain fused to High Noble Metal 4 12 D6241 Pontic - Porcelain fused to Predominantly Base Metal 4 12 D6250 Pontic - Resin with High Noble Metal 4 12 D6251 Pontic - Resin with Predominantly Base Metal 4 12 D6720 Crown - Resin with High Noble Metal 4 12 D6721 Crown - Resin with Predominantly Base Metal 4 12 D6750 Crown - Porcelain fused to High Noble Metal 4 12 D6751 Crown - Porcelain fused to Predominantly Base Metal 4 12 D6780 Crown - 3/4 Cast High Noble Metal 4 12 D6781 Crown - 3/4 Cast Predominately Based Metal 4 12 D6930 Recement Fixed Partial Denture 4 12 Oral Surgery D7140 Extraction, erupted tooth or exposed root (elevation and/or forceps 5 6 removal) D7220 Removal of Impacted tooth - Soft Tissue 5 6 D7230 Removal of Impacted tooth - Partially Bony 5 6 D7240 Removal of Impacted tooth - Completely Bony 5 6 D7310 Alveoloplasty in conjunction with Extractions - per quadrant 5 6 D7320 Alveoloplasty not in conjunction with Extractions - per quadrant 5 6 D7960 Frenulectomy (Frenectomy or Frenotomy) - separate procedure 5 6 D9220 General Anesthesia - first 30 minutes 5 6 D9221 General Anesthesia - each additional 15 minutes 5 6
Limitations Benefits for Covered Services are limited as follows: Prefabricated stainless steel crowns for primary teeth of Members under age 16 are limited to one per tooth in a 5 year period. Crowns, inlays, onlays or cast restorations on the same tooth are limited to once every 5 years of the original placement. Bitewing x-rays are limited to 2 series for standard in a Benefit Year. Vertical bitewings limited to eight (8) films in a 60 month period. Full-mouth X-rays or its equivalent are limited to 1 set in a 3 year period. Periapical x-rays submitted individually will be combined and paid up to the amount of a full mouth series. Oral exams are limited to 2 in any combination, per Benefit Year. Prophylaxis or periodontal prophylaxis treatments, singly or in combination, are limited to 2 treatments in a Benefit Year. Osseous surgery, including flap entry and closure, is limited to one time per quadrant in a 36 month period. Gingivectomy or gingivoplasty is limited to one time per quadrant in a 24month period. Periodontal scaling and root planning is limited to one time per quadrant in a 24 month period. Sealants are limited to Members between 6 and 18 years of age for permanent, unrestored first and second molars. Treatment is limited to once every 36 months per tooth. Restorations are limited to one per tooth in a 24 month period. Replacement of existing restoration is limited to replacement within 24 months of the original placement. Topical application of sodium fluoride or stannous fluoride to the teeth is limited to once in a 12 month period and only for Members under the age of 19. Emergency treatment of dental pain is limited to once in a 12 month period. Replacement of a partial denture, full denture, or fixed bridge (including a Maryland bridge) or the addition of teeth to a partial denture is limited to: a. Replacement at least 5 years after the initial date of insertion of the current full or partial denture or Maryland bridge; or b. Replacement at least 5 years after the initial date of insertion of an existing fixed bridge; or c. The replacement prosthesis or the addition of a tooth to a partial denture is required by the Necessary extraction of a functioning natural tooth while the Covered Person was covered by this plan, provided that tooth was not an abutment to an existing partial denture or Maryland Bridge that is less than 5 years old or to an existing fixed bridge that is less than 5 years old. The replacement of crowns, cast restorations, inlays, onlays or other laboratory prepared restorations within 5 years of the date of insertion; or the replacement of a labial veneer restoration within 5 years of the date of insertion.
Late Entrant If an Eligible Person or eligible Dependent does not enroll within 31 days after the eligible employee s date of hire or within 31 days of the expiration of the waiting period, the Member is a late enrollee. Following the Member s Effective Date as a late enrollee, the Member must complete the period of continuous coverage as follows: Preventive and Diagnostic... 0 months Filling of cavities/basic services... 6 months Removable Prosthodontics... 12 months Fixed Prosthodontics... 12 months Oral Surgery... 6 months Endodontics... 12 months Periodontics... 12 months Orthodontics... 24 months Benefit Waiting Period Benefit Waiting Period is the period of continuous coverage under this plan that a Member must complete following his or her Effective Date before dental benefits are payable for Covered Services. No payment will be made for expenses incurred during the Benefit Waiting Period as follows: Preventive and Diagnostic... 0 months Filling of cavities/basic services... 3 months Removable Prosthodontics... 12 months Fixed Prosthodontics... 12 months Oral Surgery... 6 months Endodontics... 12 months Periodontics... 12 months Orthodontics... Choice in Dentist Selection You may choose your general dentist from anywhere in the United States or abroad. You may visit the specialist of your choice without any referrals from your general dentist and you may change dentists as often as you like without notifying Anthem Blue Cross and Blue Shield. However, when you choose an Anthem Blue Cross and Blue Shield PPO dentist, you may have less out-of-pocket costs through lower (or no) deductibles and increased benefit payment percentages. When you select one of Anthem Blue Cross and Blue Shield s participating dentists, our dentists will: File the claim form with Anthem Blue Cross and Blue Shield for you. You are responsible for filling out the top portion of the claim form while at the dentist s office. Accept payment directly from Anthem Blue Cross and Blue Shield. You are responsible for working out the payment of your portion of the charges with your dentist. Anthem Blue Cross and Blue Shield will pay our portion directly to the dentist and send you an explanation of benefits. Not bill more than the amount their contract with Anthem Blue Cross and Blue Shield allows. This means if the procedure is a covered benefit, Anthem Blue Cross and Blue Shield will pay the percentage stated on this Summary of Benefits sheet, up to your Plan s annual benefit limit and applicable lifetime orthodontic maximum. You choose the benefits and savings you want: Your coverage is greatest when you visit an Anthem Blue Cross and Blue Shield PPO dentist. Anthem Blue Cross and Blue Shield PPO dentists have agreed to charge within our maximum allowance. This ensures that you will not be charged more than your coinsurance percentage for covered services up to your Plan s annual benefit limit.
If you choose a non-ppo dentist, you still have coverage. However, your benefit percentage may be reduced and you may have a larger Coinsurance. You will be responsible for: 1) paying the dentist directly, unless you assign your benefits; 2) paying any difference between Anthem Blue Cross and Blue Shield s maximum allowance and the dentist s billed/charged amount; and 3) filing the claim with Anthem Blue Cross and Blue Shield. Assigning Benefits (Sending Payment Directly to a Non-PPO Dentist) If you authorize insurance payments directly to a non-ppo dentist, Anthem Cross and Blue Shield will send the benefit payment directly to the dentist. If you do not authorize direct payment, Anthem Blue Cross and Blue Shield will send the benefit payment to you and you will be responsible for providing payment to the dentist. Least Costly Procedure Anthem Blue Cross and Blue Shield covers the least expensive treatment for covered services as accepted by the American Dental Association (ADA). For example, Anthem Blue Cross and Blue Shield covers amalgam fillings (silvercolored fillings) on posterior teeth. If you choose a composite resin filling (tooth-colored filling), you pay the difference. Pretreatment Estimate When your dentist prescribes services exceeding $350, we recommend he/she submit a treatment plan to Anthem Blue Cross and Blue Shield. Anthem Blue Cross and Blue Shield will then supply you with pretreatment estimate identifying Anthem Blue Cross and Blue Shield s financial liability for the services submitted. A pretreatment estimate does not guarantee benefits will be allowed for the service in question. Anthem Blue Cross and Blue Shield will honor all valid pretreatment estimates provided that the terms and conditions of the dental plan benefit booklet and the member s eligibility requirements are met. When to Call Customer Service Please call us with any questions or concerns you have about your PPO dental plan. Call us toll-free Monday through Thursday, 8:00 A.M. to 4:30 P.M., Friday, 8:30 A.M. to 4:30 P.M.; at: 1-800-627-0004 Our Commitment to You We are committed to providing you and your family a quality dental plan and outstanding customer service. Thank you for your participation in our dental program; we look forward to providing you exceptional dental benefits. This Summary of Benefits is subject to the provisions of the group s dental contract and cannot modify or affect the group s dental contract in any way, nor shall you accrue any rights because of any statement in, or omission from, this Summary.