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Home Voluntary PPO Dental Plus Plan (G892)
Voluntary PPO Dental Plus Plan (G892)

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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.

PREVENTIVE and DIAGNOSTIC CARE:
COVERAGE BEGINS UPON APPROVAL OF YOUR APPLICATION.

Comprehensive oral evaluation
Participating
100%
Non-Participating
$16
Periodic oral exam
(limited to two per member per year)
Participating
100%
Non-Participating
$16
Initial oral evaluation-problem focused
Participating
100%
Non-Participating
$16
Bitewing X-rays - single film
Participating
100%
Non-Participating
$12
Bitewing X-rays - two films
Participating
100%
Non-Participating
$15
Single (periapical) X-rays - first film
Participating
100%
Non-Participating
$9
Single X-rays - additional films
Participating
100%
Non-Participating
$9
Bitewing X-rays - four films
Participating
100%
Non-Participating
$21
Full mouth X-rays
(limited to one set every 3 years)
Participating
100%
Non-Participating
$45
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.

Routine cleaning - adult
(limited to two per year per adult per year)
Participating
100%
Non-Participating
$35
Routine cleaning - child
(limited to two per child per year)
Participating
100%
Non-Participating
$22
Cleaning with fluoride
(limited to two per child per year)
Participating
100%
Non-Participating
$35
Topical fluoride only
(limited to two per child per year)
Participating
100%
Non-Participating
$15


BASIC DENTAL CARE:
COVERAGE BEGINS AFTER THE POLICY HAS BEEN IN EFFECT FOR SIX CONTINUOUS MONTHS.

Filling - one surface, primary
Participating
$26
Non-Participating
$26
Filling - one surface, permanent
Participating
$28
Non-Participating
$28
Filling - two surfaces, primary
Participating
$34
Non-Participating
$34
Filling - two surfaces, permanent
Participating
$37
Non-Participating
$37
Filling - three surfaces, primary
Participating
$40
Non-Participating
$40
If a combined total of 10 or more employees enroll in the Small Group Voluntary PPO Dental Plan and/or the Dental Saver Select HMO Plan, child orthodontic benefits (up to $500 lifetime maximum per child) will be added to the Voluntary PPO Dental Plan at no additional cost.

Filling - three surfaces, permanent
Participating
$42
Non-Participating
$42
Filling - four or more surfaces, primary
Participating
$47
Non-Participating
$47
Filling - four or more surfaces, permanent
Participating
$50
Non-Participating
$50
Extraction - single tooth (simple)
Participating
$32
Non-Participating
$32
Extraction - each additional tooth (simple)
Participating
$32
Non-Participating
$32
Surgical extraction
Participating
$60
Non-Participating
$60
Removal of impacted tooth - soft tissue/partial bony/complete bony
Participating
$80/$95/$120
Non-Participating
$80/$95/$120


MAJOR DENTAL CARE:
COVERAGE BEGINS AFTER THE POLICY HAS BEEN IN EFFECT FOR 12 CONTINUOUS MONTHS.

Scaling/root planning per quadrant
Participating
$36
Non-Participating
$36
Gingivectomy - per tooth/per quadrant
Participating
$32/$115
Non-Participating
$32/$115
AMOUNTS LISTED ARE WHAT THE PLAN PAYS. The plan pays either the specified amount, or the actual amount charged by your dentist, whichever is lower. You pay any charges in excess of the stated benefit.

Root canal - one canal
Participating
$120
Non-Participating
$120
Root canal - two canals
Participating
$145
Non-Participating
$145
Root canal - three canals
Participating
$185
Non-Participating
$185
Crown (except stainless steel)
Participating
$200
Non-Participating
$200
Stainless steel crown
Participating
$50
Non-Participating
$50
Pontic
Participating
$200
Non-Participating
$200
Complete denture (upper or lower)
Participating
$260
Non-Participating
$260
Partial denture (upper or lower)
Participating
$240
Non-Participating
$240
Denture reline (chair side)
Participating
$60
Non-Participating
$60
Denture reline (lab)
Participating
$80
Non-Participating
$80
DENTAL NETWORK AVAILABILITY:
The Anthem blue cross Small Group Voluntary PPO Dental Plan, provided by BC Life & Health Insurance Company, is available throughout the state of California. However, please note that eligible benefits are only payable at the non-participating provider level for the following

Annual Maximum Benefit per calendar year
Participating
$1,000/member
(benefits paid after the deductible and applicable waiting periods are met)
Non-Participating
$1,000/member
(benefits paid after the deductible and applicable waiting periods are met)
Annual Deductible per calendar year
Participating
$50/person (3-member maximum)
Non-Participating
$50/person (3-member maximum)


ORTHODONTIC CARE:
COVERAGE BEGINS UPON APPROVAL OF YOUR APPLICATION.

Child Orthodontics
Participating
Up to $500 lifetime maximum per child
(participating and non-participating dentists combined)
Non-Participating
Up to $500 lifetime maximum per child
(participating and non-participating dentists combined)


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