Download Anthem Blue Dental PPO Voluntary Option 2V Summary of Benefits

Anthem Blue Dental PPO Voluntary
Option 2V
Summary of Benefits
Annual Benefit Limit: $1,500 per member
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 Charge for that service (up to the annual benefit limit).
Benefit
Plan’s Percentage
Type 1 Diagnostic and preventive services
PPO
Dentist
Non-PPO
Dentist
100%
100%
80%
80%
50%
50%
50%
50%
80%
80%
50%
50%
50%
50%
50%
50%
(No deductible)
Type 2 Filling of cavities/Basic services
(Deductible applies)
Type 3 Removable Prosthodontic services
(Deductible applies)
Type 4 Fixed Prosthodontic services
(Deductible applies)
Type 5 Oral Surgery services
(Deductible applies)
Type 6 Endodontic services
(Deductible applies)
Type 7 Periodontic services
(Deductible applies)
Type 8 Orthodontic services
(Deductible applies)
Limited to Dependent Children up to the age of 19.
Lifetime Orthodontia Maximum is $1,000 combined PPO and
Non-PPO Dentists.
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
Customer Service: 800-627-0004
98912 (7-05)
BW71 SOB-1105
1
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
1
0
D0460
Pulp Vitality Testing
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
D0230
Intraoral - Periapical - First Film
Intraoral - Periapical - Each additional Film
1
1
0
0
D0240
D0250
Intraoral - Occlusal Film
Extraoral - First Film
1
1
0
0
D0260
Extraoral - Each additional Film
1
0
D0270
Bitewing - Single Film
1
0
D0272
D0274
Bitewings - Two Films
Bitewings - Four Films
1
1
0
0
D0277
Vertical Bitewings
1
0
Intraoral - Complete Series (including Bitewings)
Panoramic Film
2
2
3
3
D1110
Prophylaxis - Adult
1
0
D1120
Prophylaxis - Child
1
0
Topical Application of Fluoride (including Prophylaxis) Child
Topical Application of Fluoride (Prophylaxis not included)
- Child
1
0
1
0
Sealant - per tooth
2
3
Radiographs – FMX
D0210
D0330
Cleanings
Fluoride
D1201
D1203
Sealants
D1351
Space Maintainers
D1510
Space Maintainer - Fixed - Unilateral
2
3
D1515
D1520
Space Maintainer - Fixed - Bilateral
Space Maintainer - Removable - Unilateral
2
2
3
3
D1525
D1550
Space Maintainer - Removable - Bilateral
Recementation of Space Maintainer
2
2
3
3
2
3
Palliative Treatment
D9110
Palliative (emergency) treatment of dental pain - minor
procedure
Anthem Blue Dental PPO Voluntary
Customer Service: 800-627-0004
98912 (7-05)
BW71 SOB-1105
2
Fillings
D2140
D2150
Amalgam - One surface, primary or permanent
Amalgam - Two surfaces, primary or permanent
2
2
3
3
D2160
D2161
Amalgam - Three surfaces, primary or permanent
Amalgam - Four or more surfaces, primary or permanent
2
2
3
3
D2330
Resin - One surface, Anterior
2
3
D2331
Resin - Two surfaces, Anterior
2
3
D2332
D2335
2
2
3
3
D2391
D2392
Resin - Three surfaces, Anterior
Resin - Four or more surfaces or involving incisal angle
(Anterior)
Resin-based composite - one surface, posterior
Resin-based composite - two surfaces, posterior
2
2
3
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
D3310
Therapeutic Pulpotomy (excluding final restoration)
Anterior (excluding final restoration)
6
6
12
12
D3320
D3330
Bicuspid (excluding final restoration)
Molar (excluding final restoration)
6
6
12
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
Periodontal Scaling and Root Planing, per quadrant
7
12
7
12
7
12
7
12
D4341
D4355
D4910
Full Mouth Debridement to enable Comprehensive
Periodontal evaluation and Diagnosis
Periodontal Maintenance Procedures (following active
therapy)
Anthem Blue Dental PPO Voluntary
Customer Service: 800-627-0004
98912 (7-05)
BW71 SOB-1105
3
Removable Prosthodontics
D5110
Complete Denture - Maxillary
3
12
D5120
Complete Denture - Mandibular
3
12
D5211
Maxillary Partial Denture - Resin Base (including any
conventional clasps, rests and teeth)
Mandibular Partial Denture - Resin Base (including any
conventional clasps,rests and teeth)
3
12
3
12
D5212
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
D5720
Rebase Complete Mandibular Denture
Rebase Maxillary Partial Denture
3
3
12
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
5
6
D7220
Extraction, erupted tooth or exposed root (elevation
and/or forceps removal)
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
5
6
5
6
5
6
D9220
Alveoloplasty in conjunction with Extractions - per
quadrant
Alveoloplasty not in conjunction with Extractions - per
quadrant
Frenulectomy (Frenectomy or Frenotomy) - separate
procedure
General Anesthesia - first 30 minutes
5
6
D9221
General Anesthesia - each additional 15 minutes
5
6
Oral Surgery
D7140
D7320
D7960
Anthem Blue Dental PPO Voluntary
Customer Service: 800-627-0004
98912 (7-05)
BW71 SOB-1105
4
Orthodontic Services
D8030
Limited Orthodontic Treatment of adolescent dentition
8
18
D8080
8
18
D8210
Comprehensive Orthodontic Treatment of the adolescent
dentition
Removable Appliance Therapy
8
18
D8220
Fixed Appliance Therapy
8
18
D8660
Pre-orthodontic Treatment
8
18
D8670
Periodic Orthodontic Treatment visit (as part of contract)
8
18
D8680
Orthodontic Retention (removal of appliances,
construction and placement of retainers
8
18
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 24 month 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.
Anthem Blue Dental PPO Voluntary
Customer Service: 800-627-0004
98912 (7-05)
BW71 SOB-1105
5
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 ................................................................ 18 months
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 a 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.
Anthem Blue Dental PPO Voluntary
Customer Service: 800-627-0004
98912 (7-05)
BW71 SOB-1105
6
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 Allowable Charge. 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. 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 Allowable
Charge 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.
Anthem Blue Dental PPO Voluntary
Customer Service: 800-627-0004
98912 (7-05)
BW71 SOB-1105
7