Download Anthem Blue Dental PPO Plus Voluntary Summary of Benefits for

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