| This is an overview of coverage. Please refer to the Universal Exclusions and Limitations reference sheet for additional plan provisions. A comprehensive description of coverage, benefits and limitations is contained in the Combined Evidence of Coverage and Disclosure Form. |
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| DIAGNOSTIC CARE: |
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| Oral Exams |
| No Charge |
| X-rays |
| No Charge |
| |
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| PREVENTIVE CARE: |
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| Prophylaxis - adult and child |
| No charge* |
| Topical Fluoride - child |
| No charge |
| Sealant - per tooth |
|
Member copay $25 |
| |
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| RESTORATIVE CARE: Fillings - permanent |
| |
| 1 surface amalgam |
|
Member copay $54 |
| 2 surfaces amalgam |
|
Member copay $64 |
| Available for groups with 10 or more eligible employees enrolled in Anthem blue cross Medical Coverage, a minimum of 25% participation by eligible employees and employee and dependent premiums collected through payroll deduction. |
| |
| 3 surfaces amalgam |
|
Member copay $75 |
| 4 or more surfaces amalgam |
|
Member copay $89 |
| |
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| ORTHODONTIC CARE: |
| |
| Child |
|
Member copay $2,870 |
| Adult |
|
Member copay $3,045 |
| Retention |
|
Member copay $300 |
| |
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| PROSTHODONTIC CARE: |
| |
| Denture - broken tooth repair, each tooth |
|
Member copay $57 |
| Crown - porcelain with high noble metal |
|
Member copay $432 |
| Complete upper or lower dentures |
|
Member copay $577 |
| Amounts
listed are the MEMBER'S RESPONSIBILITY TO PAY. These copayments
apply only to services rendered by a Participating Dentist. Services
provided by a Participating Specialist are included on a separate
schedule in the dental plan contract. |
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| Partial denture |
|
Member copay $430 |
| |
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| COSMETIC CARE - RESIN FILLING: |
| |
| - permanent, one surface, posterior |
|
Member copay $75 |
| Labial
veneer (laminate) -chair side |
|
Member copay $187 |
| |
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| ENDODONTIC CARE: |
| |
| Root canal - anterior |
|
Member copay $289 |
| Root canal - bicuspid |
|
Member copay $341 |
| Root canal - molar |
|
Member copay $459 |
| Pulpotomy |
|
Member copay $62 |
| |
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| PERIODONTAL CARE: |
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| DENTAL NETWORK AVAILABILITY: |
|
The Anthem blue cross Dental Saver Select
HMO(SM) Plan has participating dental providers in the following
counties:
San Diego, Orange, Los Angeles, Santa Barbara, San Luis Obispo, Solano, Sonoma, San Francisco, Marin, Contra Costa, Alameda, Santa Clara, Sacramento, and San Joaquin. |
| Scaling/root
planning - per quadrant |
|
Member copay $101 |
| Gingivectomy - per tooth |
|
Member copay $72 |
| Gingivectomy - per quadrant |
|
Member copay $194 |
| Osseous surgery - per quadrant |
|
Member copay $520 |
| |
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| ORAL SURGERY: |
| |
| Single extraction |
|
Member copay $60 |
| Impaction - soft tissue |
|
Member copay $136 |
| Impaction - partial bony |
|
Member copay $176 |
| Impaction - full bony |
|
Member copay $200 |
| |
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| OTHER SERVICES: |
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| COUNTIES with LIMITED AVAILABILITY: |
| Ventura, Riverside, El Dorado, San Bernardino, Kern, Fresno, Kings, Monterey, Placer, San Mateo, Santa Cruz, and Tulare. |
| Office visit after hours |
|
Member copay $56 |
| Local anesthesia |
|
Member copay $14 |
| General anesthesia |
|
Member copay $15** |
| Access to Providers |
| Network providers only |
| Annual Maximum Benefit |
| Unlimited |
| Annual Deductible |
| None |
| Office Visit |
|
Member copay $5 |
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