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Anthem Blue Dental PPO Plus 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 Plus 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 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 Plan’s Percentage (PPO Dentist and Non-PPO Dentist) $1000 combined for network and non-network providers 50% coinsurance Benefit Waiting Period 12 months 12 months 12 months 12 months 12 months 12 months 12 months 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. 05-00039 Anthem Blue Dental PPO Plus Voluntary – Orthodontic Services $1000 BW93-ORT-1105