Download Plan NDV05

We’re Committed To Providing You With Great Dental Care Benefits
Dental care is an essential part of your comprehensive
health care coverage and well-being. Dental insurance
can be an important safeguard for you and your family.
Regular diagnostic and preventive services such as
oral examinations, cleanings and X-rays are important
for maintaining good dental health and may reduce the
risk of disease and more costly dental problems.
How the Plan Works
Your National Voluntary Scheduled Dental Plan is a
preferred provider organization (PPO) plan from
Anthem Blue Cross Life and Health Insurance
Company.
The National Voluntary Scheduled Dental Plan
provides you with the freedom to select virtually any
licensed dentist. You are responsible for the calendar
year deductible and for any amount over the maximum
payment that is shown in the Reimbursement Schedule.
The maximum payments Anthem Blue Cross
Life and Health Insurance Company will pay for
covered services are shown in the Reimbursement
Schedule. For example: If you have a complete set of
intraoral X-rays taken, the maximum payment Anthem
Blue Cross Life and Health Insurance Company will
pay for them is $43. If the dentist charges you more
than $43, you are responsible for the balance of
the cost.
Participating Dentist
If you choose a PPO participating dentist, you can take
advantage of negotiated rates. The negotiated rate is
the amount a participating dentist agrees to accept as
payment in full for covered services. The negotiated
rate is usually lower than the participating dentist’s
normal charge. And, your participating dentist will not
charge you more than the dental negotiated rate.
By choosing a participating dentist, you will not be
responsible for any amount in excess of the negotiated
rate for covered services.
However, you are responsible for the difference
between the maximum payment amount that is shown
in the Reimbursement Schedule and the dentist’s
negotiated rate for covered services.
anthem.com/ca
Anthem Blue Cross Life and Health Insurance Company
Dental Benefits
National Voluntary
Scheduled Dental Plan NDV05
Please note that you must verify that the dentist
you choose is a member of the National PPO
Dental network.
Non-Participating Dentist
If you choose a non-participating dentist,
a licensed dentist who does not participate in our
National PPO Dental network, you are not eligible for
negotiated rates and your out-of-pocket expenses may
be greater. You are responsible for any amount over
the Maximum Payment Amount that is shown in the
Reimbursement Schedule. You may also be asked to
pay your portion of the bill at the time of service and
submit claim forms for reimbursement.
If you have a particular dentist in mind and he or she is
not in the directory, you may call the toll-free Customer
Service number on your ID card to see if the dentist
has recently joined the network.
Late Entrant Waiting Period
If you do not enroll in your dental plan within 31 days of
your eligibility date, you will be subject to a Late
Entrant Waiting Period. This means that you will not be
covered immediately for certain dental services.
Details of the Late Entrant Waiting Period can be found
in the Exclusions and Limitations section of this
document.
Filing a Claim
When you use a participating dentist, you do not need
to submit a claim form for covered dental expenses.
Your participating dentist will complete and submit the
claim form to us. We will pay the benefits of the plan
directly to your dentist. If your dentist is not in the
network, you must complete and submit your own
claim forms.
SC10894
Effective 3/2005
Printed 6/13/2008
Dental Deductible
A deductible is the amount of money you pay for a
covered dental expense prior to benefits being paid
under the plan. Only charges that are considered a
covered dental expense will apply toward satisfaction
of the deductible. Please refer to the deductible amount
in the chart.
Pre-Authorization
When the anticipated expense for any course of
treatment exceeds $350, it is recommended that you
submit a request for pre-authorization. If you use a
participating dentist, your dentist will submit the
authorization form for you. If your dentist is not part of
the network, you will have to submit a pre-authorization
form to your dentist for completion and then send it to
us for approval.
Conditions of Service
Services must be provided by a licensed dentist and
must be for the prevention and treatment of dental
disease, defect or injury, and are subject to any
Exclusions and Limitations or Annual Maximum
specified under the plan.
Customer Service
A Customer Service Representative is available to
answer your questions and inquiries at (800) 627-0004.
Annual Maximum
Dental benefits are limited to a maximum payment for
expenses incurred by each insured person during a
calendar year. Please refer to the amount on the chart.
Continuing Coverage
As required by federal law, certain restrictions and
conditions apply to continue coverage and are
described in your Certificate.
Summary of Benefits
Calendar Year Deductible
$50/insured person; maximum of
three separate deductibles/family
Annual Maximum
$1,000
Predetermination of Benefits
Covered Expense
PPO Dentists
Non-PPO Dentists
Covered Services
Charges in excess of $350
Plan payments apply to the lesser of the charges billed by the provider or the following:
Amounts in the Reimbursement Schedule under Maximum Payment.
When using a participating dentist, insured persons are responsible for the difference, if any, between
the maximum payment in the Reimbursement Schedule and the negotiated rate.
Amounts in the Reimbursement Schedule under Maximum Payment
When using a non-participating dentist, insured persons are responsible for any amount over
the maximum payment amount.
Please see the Reimbursement Schedule.
Any procedures not listed in this reimbursement schedule are not covered.
Reimbursement Schedule
Covered Services
Diagnostic
0120 – Periodic oral evaluation
0140 – Limited oral evaluation – problem focused
0150 – Comprehensive oral examinations – new or established patient
0160 – Detailed & extensive oral evaluation – problem focused, by report
0170 – Re-evaluation – Limited problem focused (not post-operative visit)
0180 – Comprehensive periodontal evaluation – new or established patient
0210 – X-rays – intraoral – complete series (including bitewings)
0220 – X-rays – intraoral – periapical – first film
0230 – X-rays – intraoral – periapical – each additional film
0240 – X-rays – intraoral – occlusal film
0250 – X-rays – extraoral – first film
0260 – X-rays – extraoral – each additional film
0270 – X-rays – bitewing – single film
0272 – X-rays – bitewings – two films
0274 – X-rays – bitewing – four films
Maximum Payment
$12
$22
$21
$29
$29
$22
$43
$7
$6
$11
$18
$16
$7
$13
$18
Covered Services
Diagnostic (continued)
0277 – X-rays – vertical bitewings – seven to eight films
0290 – X-rays – posterior-anterior or lateral skull & facial bone survey firm
0330 – X-rays – panoramic film
0340 – X-rays – cephalometric film
0460 – Pulp vitality tests
0470 – Diagnostic casts
9310 – Consultation
Preventive
1110 – Prophylaxis – adult
1120 – Prophylaxis – child
1201 – Topical application of fluoride – child (including prophylaxis)
1203 – Topical application of fluoride – child (excluding prophylaxis)
1204 – Topical application of fluoride – adult (excluding prophylaxis)
1205 – Topical application of fluoride – adult (including prophylaxis)
1351 – Sealants – per tooth
1510 – Space maintainers – fixed - unilateral
1515 – Space maintainers – fixed - bilateral
1520 – Space maintainers – removable - unilateral
1525 – Space maintainers – removable - bilateral
1550 – Recementation of space maintainer
2140 – Fillings, amalgams – one surface, primary or permanent
2150 – Fillings, amalgams – two surfaces, primary or permanent
2160 – Fillings, amalgams – three surfaces, primary or permanent
2161 – Fillings, amalgams – four or more surfaces, primary or permanent
Restorative
2330 – Resin – one surface, anterior
2331 – Resin – two surfaces, anterior
2332 – Resin – three surfaces, anterior
2335 – Resin – four or more surfaces or involving incisal angle (anterior)
2390 – Resin – based composite crown, anterior
2391 – Resin – based composite, one surface, posterior
2392 – Resin – based composite, two surfaces, posterior
2393 – Resin – based composite, three surfaces, posterior
2394 – Resin – based composite, four or more surfaces, posterior
2930 – Prefabricated stainless steel crown – primary tooth
2931 – Prefabricated stainless steel crown – permanent tooth
2932 – Prefabricated resin crown
2933 – Prefabricated stainless steel crown with resin window
2940 – Sedative filling
Endodontics
3220 – Therapeutic pulpotomy (excluding final restoration)
3221 – Gross pulp debridement primary & permanent teeth
3230 – Pulp therapy (resorbable filling) – anterior, primary tooth
(excluding final restoration)
3240 – Pulp therapy (resorbable filling) – posterior, primary tooth
(excluding final restoration)
3310 – Anterior root canal therapy (excluding final restoration)
3320 – Bicuspid root canal therapy (excluding final restoration)
3330 – Molar root canal therapy (excluding final restoration)
3331 – Treatment of root canal obstruction, non-surgical access
3332 – Incomplete endodontic therapy (inoperable or fractured tooth)
3333 – Internal root repair of perforation defects
3346 – Retreatment of previous root canal therapy - anterior
3347 – Retreatment of previous root canal therapy - bicuspid
3348 – Retreatment of previous root canal therapy - molar
3410 – Apicoectomy/periradicular surgery – anterior
3421 – Apicoectomy/periradicular surgery – bicuspid (first root)
3425 – Apicoectomy/periradicular surgery – molar (first root)
3426 – Apicoectomy/periradicular surgery – each additional tooth
3430 – Retrograde filling – per root
3450 – Root amputation – per root
3920 – Hemisection (including any root removal), not including
root canal therapy
Maximum Payment
$16
$17
$35
$37
$14
$29
$14
$30
$22
$27
$10
$9
$30
$18
$83
$143
$51
$151
$17
$31
$42
$53
$57
$38
$48
$61
$70
$76
$39
$55
$69
$76
$42
$48
$41
$63
$15
$24
$11
$33
$31
$110
$133
$168
$11
$11
$11
$112
$149
$192
$88
$141
$126
$32
$34
$96
$36
Covered Services
Periodontics
4210 – Gingivectomy/Gingivoplasty – four or more
continguous teeth or bounded teeth spaces
4211 – Gingivectomy/Gingivoplasty – one to three teeth, per quadrant
4220 – Gingival curettage, surgical, per quadrant, by report
4240 – Gingival flap procedure, including root planing – four or more continguous teeth or
bounded teeth spaces
4241 – Gingival flap procedure, including root planing – one to three
teeth per quadrant
4245 – Apically positioned flap
4249 – Clinical crown lengthening – Hard tissue
4260 – Osseous surgery (including flap entry & closure) – four or more
Maximum Payment
$48
$29
$23
$83
$83
$99
$113
$205
continguous teeth or bounded teeth spaces
4261 – Osseous surgery (including flap entry & closure) – one to three
$205
teeth per quadrant
4263 – Bone replacement graft – first site in quadrant
4264 – Bone replacement graft – each additional site in quadrant
4265 – Biologic materials to aid in soft and osseous tissue regeneration
4266 – Guided tissue regeneration – resorbable barrier, per site
4267 – Guided tissue regeneration – non-resorbable barrier, per site
4270 – Pedicle soft tissue graft procedure
4271 – Free soft tissue graft procedure (including donor site surgery)
4273 – Subepithelial connective tissue graft procedure
4274 – Distal or proximal wedge procedure
4275 – Soft tissue allograft
4276 – Combined connective tissue & double pedicle graft
4341 – Periodontal scaling/root planing – four or more
$70
$80
$108
$108
$115
$186
$175
$228
$133
$175
$228
$39
continguous teeth or bounded teeth spaces
4342 – Periodontal scaling/root planing – one to three teeth, per quadrant
4355 – Full mouth debridement to enable
comprehensive periodontal evaluation/diagnosis
4381 – Localized delivery of chemotherapeutic agents
4910 – Periodontal maintenance procedures (following active therapy)
4920 – Unscheduled dressing change
$39
$27
$29
$22
$5
(by someone other than treating dentist)
Oral Surgery
7111 – Coronal remnants – deciduous tooth
7140 – Extraction, erupted tooth or exposed root (elevation and/or
forceps removal)
7210 – Surgical removal of erupted tooth
7220 – Removal of impacted tooth – soft tissue
7230 – Removal of impacted tooth – partial bony
7240 – Removal of impacted tooth – completely bony
7241 – Removal of impacted tooth – completely bony,
with unusual surgical complications
7250 – Surgical removal of residual tooth roots (cutting procedure)
7270 – Tooth reimplantation
7272 – Tooth transplantation
7280 – Surgical exposure of impacted or unerupted tooth
7281 – Surgical exposure of impacted or unerupted tooth to aid eruption
7282 – Primary closure of a sinus perforation
7290 – Surgical repositioning of teeth
7310 – Alveoloplasty in conjunction with extractions – per quadrant
7320 – Alveoloplasty not in conjunction with extractions – per quadrant
7450 – Removal of benign odontogenic cyst or tumor– lesion diameter up to 1.25 cm
7451 – Removal of benign odontogenic cyst or tumor
– lesion diameter greater than 1.25 cm
7485 – Surgical reduction of osseous tuberosity
7510 – Incision & drainage of abscess – Intraoral soft tissue
7520 – Incision & drainage of abscess – Extraoral soft tissue
7960 – Frenulectomy (frenectomy or frenotomy) – separate procedure
7970 – Excision of hyperplastic tissue – per arch
7971 – Excision of pericoronal gingiva
7972 – Surgical reduction of fibrous tuberosity
7995 – Synthetic graft – mandible or facial bones, by report
$20
$20
$39
$55
$72
$82
$105
$35
$61
$372
$102
$78
$78
$66
$32
$44
$64
$100
$133
$21
$23
$73
$34
$22
$137
$60
Covered Services
Prosthodontics
2510 – Inlay – metallic – one surface
2520 – Inlay – metallic – two surfaces
2530 – Inlay – metallic – three or more surfaces
2542 – Onlay – metallic – two surfaces
2543 – Onlay – metallic – three surfaces
2544 – Onlay – metallic – four or more surfaces
2610 – Inlay – porcelain/ceramic – one surface
2620 – Inlay – porcelain/ceramic – two surfaces
2630 – Inlay – porcelain/ceramic – three or more surfaces
2642 – Onlay – porcelain/ceramic – two surfaces
2643 – Onlay – porcelain/ceramic – three surfaces
2644 – Onlay – porcelain/ceramic – four or more surfaces
2650 – Inlay – composite/resin – one surface (laboratory processed)
2651 – Inlay – composite/resin – two surfaces (laboratory processed)
2652 – Inlay – composite/resin – three or more surfaces (laboratory processed)
2662 – Onlay – composite/resin – two surfaces (laboratory processed)
2663 – Onlay – composite/resin – three surfaces (laboratory processed)
2664 – Onlay – composite/resin – four or more surfaces (laboratory processed)
2710 – Crown – resin (laboratory)
2720 – Crown – resin with high noble metal
2721 – Crown – resin with predominantly base metal
2722 – Crown – resin with noble metal
2740 – Crown – porcelain/ceramic substrate
2750 – Crown – porcelain fused to high noble metal
2751 – Crown – porcelain fused to predominantly base metal
2752 – Crown – porcelain fused to noble metal
2780 – Crown – cast high noble metal
2781 – Crown – cast high predominantly base metal
2782 – Crown – cast noble metal
2783 – Crown – cast porcelain/ceramic
2790 – Crown – Full cast high noble metal
2791 – Crown – Full cast predominantly base metal
2792 – Crown – Full cast noble metal
2810 – Crown – ¾ cast metalic
2910 – Recement inlay
2920 – Recement crown
2950 – Core buildup, including any pins
2951 – Pin retention – per tooth, in addition to restoration
2952 – Cast post and core in addition to crown
2953 – Each additional cast post (same tooth)
2954 – Prefabricated post and core in addition to crown
2955 – Post removal (not in conjunction with endodontic therapy)
2957 – Each additional prefab post (same tooth)
2960 – Labial veneer (laminate) – chairside
2961 – Labial veneer (resin laminate) – laboratory
2962 – Labial veneer (porcelain laminate) – laboratory
2970 – Temporary crown (fractured tooth)
2980 – Repair of crown, by report
6210 – Pontic – Cast high noble metal
6211 – Pontic – Cast predominantly base metal
6212 – Pontic – Cast noble metal
6240 – Pontic – Porcelain fused to high noble metal
6241 – Pontic – Porcelain fused to predominantly base metal
6242 – Pontic – Porcelain fused to noble metal
6245 – Pontic – Porcelain/ceramic
6250 – Pontic – Resin with high noble metal
6251 – Pontic – Resin with predominantly base metal
6252 – Pontic – Resin with noble metal
6545 – Retainer – Cast metal for resin fixed prosthesis
6548 – Retainer – Porcelain/ceramic (resin bonded fixed prosthesis)
6600 – Inlay – porcelain/ceramic – two surfaces
6601 – Inlay – porcelain/ceramic – three surfaces
6602 – Inlay – cast high noble metal – two surfaces
6603 – Inlay – cast high noble metal – three or more surfaces
6604 – Inlay – cast predominantly base metal – two surfaces
6605 – Inlay – cast predominantly base metal – three or more surfaces
6606 – Inlay – cast noble metal – two surfaces
Maximum Payment
$93
$173
$162
$98
$109
$113
$96
$193
$187
$85
$105
$125
$91
$83
$105
$107
$111
$115
$61
$128
$98
$151
$202
$196
$186
$188
$201
$174
$175
$202
$195
$169
$170
$193
$15
$14
$36
$9
$66
$66
$55
$49
$55
$62
$132
$170
$31
$41
$200
$180
$162
$192
$178
$176
$202
$198
$223
$198
$59
$202
$172
$192
$172
$192
$172
$192
$172
Covered Services
Prosthodontics (continued)
6607 – Inlay – cast noble metal – three or more surfaces
6608 – Onlay – porcelain/ceramic – two surfaces
6609 – Onlay – porcelain/ceramic – three surfaces
6610 – Onlay – cast high noble metal – two surfaces
6611 – Onlay – cast high noble metal – three or more surfaces
6612 – Onlay – cast predominantly base metal – two surfaces
6613 – Onlay – cast predominantly base metal – three or more surfaces
6614 – Onlay – cast noble metal – two or more surfaces
6615 – Onlay – cast noble metal – three or more surfaces
6720 – Crown – resin with high noble metal
6721 – Crown – resin with predominantly base metal
6722 – Crown – resin with noble metal
6740 – Crown – Porcelain/ceramic
6750 – Crown – porcelain fused to high noble metal
6751 – Crown – porcelain fused to predominantly base metal
6752 – Crown – porcelain fused to noble metal
6780 – Crown – cast high noble metal
6781 – Crown – cast predominantly base metal
6782 – Crown – cast noble metal
6783 – Crown – porcelain/ceramic
6790 – Crown – Full cast high noble metal
6791 – Crown – Full cast predominantly base metal
6792 – Crown – Full cast noble metal
6920 – Connector bar
6930 – Recement fixed partial denture
6972 – Prefabricated post and core in addition to fixed partial denture retainer
6973 – Core buildup for retainer, including any pins
6975 – Coping – metal
6976 – Each additional cast post (same tooth)
6977 – Each additional prefab post (same tooth)
6980 – Fixed partial denture repair, by report
5110 – Complete denture (maxillary)
5120 – Complete denture (mandibular)
5130/5140 – Immediate denture (maxillary or mandibular)
5211 – Partial denture (maxillary)
– resin base (including any conventional clasps, rests & teeth)
5212 – Partial denture (mandibular)
– resin base (including any conventional clasps, rests & teeth)
5213 – Partial denture (maxillary)
– cast metal framework with resin denture bases
5214 – Partial denture (mandibular)
– cast metal framework with resin denture bases
5281 – Removable unilateral partial denture
– one piece cast metal (including clasps & teeth)
5410 – Adjust complete denture (maxillary)
5411 – Adjust complete denture (mandibular)
5421 – Adjust partial denture (maxillary)
5422 – Adjust partial denture (mandibular)
5510 – Repair broken complete denture base
5520 – Replace missing or broken teeth – complete denture (each tooth)
5610 – Repair resin denture base
5620 – Repair cast framework
5630 – Repair or replace broken clasp
5640 – Replace broken teeth – (per tooth)
5650 – Add tooth to existing partial denture
5660 – Add clasp to existing partial denture
5670 – Replace all teeth and acrylic
on cast metal framework (maxillary)
5671 – Replace all teeth and acrylic
on cast metal framework (mandibular)
5710 – Rebase complete denture (maxillary)
5711 – Rebase complete denture (mandibular)
5720 – Rebase partial denture (maxillary)
5721 – Rebase partial denture (mandibular)
5730 – Complete denture reline – chairside (maxillary)
5731 – Complete denture reline – chairside (mandibular)
5740 – Partial denture reline – chairside (maxillary)
5741 – Partial denture reline – chairside (mandibular)
Maximum Payment
$192
$98
$109
$98
$109
$98
$109
$98
$109
$222
$186
$162
$202
$197
$182
$182
$217
$174
$175
$202
$194
$174
$166
$60
$19
$43
$32
$102
$66
$55
$38
$225
$232
$254
$190
$205
$282
$278
$142
$11
$9
$13
$10
$22
$21
$23
$30
$32
$19
$27
$33
$90
$100
$74
$91
$90
$100
$45
$38
$37
$42
5750 – Complete denture reline – laboratory (maxillary)
5751 – Complete denture reline – laboratory (mandibular)
Covered Services
Prosthodontics (continued)
5760 – Partial denture reline – laboratory (maxillary)
5761 – Partial denture reline – laboratory (mandibular)
5820 – Interim partial denture (maxillary)
5821 – Interim partial denture (mandibular)
5850 – Tissue conditioning (maxillary)
5851 – Tissue conditioning (mandibular)
5860 – Overdenture – complete, by report
5861 – Overdenture – partial, by report
5875 – Modification of removable prosthesis (following implant surgery)
6053 – Implant/abutment supported removable denture for completely edentulous arch
6054 – Implant/abutment supported removable denture for partially edentulous arch
6059 – Abutment supported porcelain fused to metal crown (high noble)
6060 – Abutment supported porcelain fused to metal crown (pred base metal)
6061 – Abutment supported porcelain fused to metal crown (noble)
6062 – Abutment supported cast metal crown (high noble)
6063 – Abutment supported cast metal crown (pred base metal)
6064 – Abutment supported cast metal crown (noble)
6065 – Implant supported porcelain/ceramic crown
6066 – Implant supported porcelain fused to metal crown
6067 – Implant supported metal crown
6068 – Abutment supported retainer, porcelain/ceramic
6069 – Abutment supported retainer, porcelain fused to metal (high noble)
6070 – Abutment supported retainer, porcelain fused
to metal (pred base metal)
6071 – Abutment supported retainer, porcelain fused
to metal (noble)
6072 – Abutment supported retainer, cast metal (high noble)
6073 – Abutment supported retainer, cast metal (pred base metal)
6074 – Abutment supported retainer, cast metal (noble)
6075 – Implant supported retainer, ceramic
6076 – Implant supported retainer, porcelain fused to metal
6077 – Implant supported retainer, cast metal
6078 – Implant/abutment supported fixed denture
6079 – Implant/abutment supported fixed denture
Other Services
9110 – Palliative (emergency) treatment of dental pain
– minor procedure
9220 – Deep sedation/general anesthesia
– first 30 minutes
9221 – Deep sedation/general anesthesia
– each additional 15 minutes
9230 – Analgesia (anxiolysis, inhalation of nitrous oxide)
9430 – Office visits for observation
(during regularly scheduled hours)
9440 – Office visits – after regularly scheduled hours
9450 – Case presentation, detailed & extensive treatment planning
9930 – Treatment of complications (post-surgical)
– unusual circumstances, by report
9940 – Occlusal guard, by report
9951 – Occlusal adjustment – limited
9952 – Occlusal adjustment – complete
$72
$70
Maximum Payment
$63
$65
$77
$99
$34
$22
$293
$237
$30
$225
$282
$296
$273
$273
$291
$256
$249
$303
$296
$291
$303
$296
$273
$273
$291
$256
$249
$303
$296
$291
$225
$282
$18
$49
$17
$7
$10
$17
$7
$7
$123
$13
$114
This Summary of Benefits is a brief review of benefits. Once enrolled, insured persons will receive the Certificate of Insurance,
which explains the exclusions and limitations, as well as the full range of covered services of the plan, in detail.
National Voluntary Scheduled Dental Plan Exclusions & Limitations
Services Provided Before or After the Term of This Coverage. Services received before the
insured person’s effective date. Services received after the insured person’s coverage ends, as
specified as covered in the Certificate.
Experimental or Investigative Procedures. Any procedures which are considered experimental
or investigative or which are not widely accepted as proven and effective procedures within the
organized dental community.
Medically Necessary. Any services or supplies which are not medically necessary.
Workers’ Compensation. Any work-related conditions if benefits are recovered or can be
recovered either by adjudication, settlement or otherwise under any workers’ compensation,
employer’s liability law or occupational disease law, even if the insured person does not claim
those benefits.
Government Programs. Services provided by or payment made by any local, state, county or
federal government agency, including Medicare and any foreign government agency.
No Charge Services. Services received for which no charge is made to the insured person or for
which no charge would be made to the insured person in the absence of insurance coverage.
Results of War. Disease contracted or injuries sustained as a result of war, declared or
undeclared, or from exposure to nuclear energy, whether or not the result of war.
Provider Related to Insured Person. Professional services received from a person who lives in
the insured person’s home or who is related to the insured person by blood or marriage.
Excess Expense. Any amounts in excess of covered dental expense or the Dental
Benefit Maximums.
Professionally Acceptable Treatment. If more than one treatment plan would be considered
acceptable services for a dental condition, any amount exceeding the cost of the least expensive
professionally acceptable treatment plan is not covered.
Transfer of Care. If the insured person transfers from the care of one dentist to another dentist
during the course of treatment, or if more than one dentist renders services for one dental
procedure, we shall be liable only for the amount we would have been liable for had one dentist
rendered the services.
Hospital Charges. Hospital costs and any additional charges by the dentist for hospital treatment.
Services Not Included as a Covered Procedure. Services not specifically provided for by the
plan unless they are similar in nature to an included procedure. In such event, the benefit payable
will be based on the most nearly comparable services included.
Treatment By An Unlicensed Dentist. Charges for treatment by other than a licensed dentist or
physician except charges for dental prophylaxis performed by a licensed dental hygienist, under the
supervision and direction of a dentist.
Treatment of the Joint of the Jaw and/or Occlusion Services. Diagnosis, services, supplies or
appliances provided in connection with any of the following:

Any treatment to alter, correct, fix, improve, remove, replace, reposition, restore or
otherwise treat the joint of the jaw (temporomandibular joint) or associated musculature,
nerves and other tissues for any reason or by any means; or

Any treatment, including crowns, caps and/or bridges to change the way the upper and
lower teeth meet (occlusion); or

Treatment to change vertical dimension (the space between the upper and lower jaw) for
any reason or by any means including the restoration of vertical dimension because teeth
have worn down.
Vertical Dimension and Attrition. Procedures requiring appliances or restorations (other than
those for replacement of structure lost due to dental decay) that are necessary to alter, restore or
maintain occlusion. These include, but are not limited to:

changing the vertical dimension

replacing or stabilizing tooth structure lost by attrition, abrasion, or erosion

realignment of teeth

gnathological recording

occlusal equilibration

periodontal splinting
Prosthetic Replacements. Replacement of an existing fixed or removable prosthesis, is not a
benefit if the replacement occurs within five years of the original placement, unless the prosthesis is
a stayplate used during the healing period for recently extracted anterior teeth. Replacement of a
removable partial will be allowed if the partial is no longer useable, cannot be made serviceable and
meets the five year requirement.
Crown Replacements. Crowns, inlays, onlays or cast restorations on the same tooth in excess of
once every five years of the original replacement.
Prosthetic Repairs. Repairs, adjustments or relines of full or partial dentures, or other prostheses
are not covered for a period of six months from the initial placement if they were paid for under this
plan. Adjustments or repairs are limited to once in a 12-month period. Rebase and reline are limited
to once in a 24-month period. Mandibular tissue conditioning is limited to once per quadrant in a
12-month period. Recement of an existing crown is not a benefit if done within 6 months of
initial placement.
Lost or Stolen Dentures or Appliances. Replacement of existing full or partial dentures or
prosthetic appliances which have been lost or stolen if replacement occurs within five years of the
original placement.
Space Maintainers. Limited to children under age 16. Use of space maintainers in excess of one
treatment per lifetime, which includes one adjustment within six months of placement.
Prosthetics (patients under 16 years old). Fixed bridges, removable cast partials, cast crowns,
with or without veneers, and inlays for patients under sixteen years old. Prefabricated stainless
steel crowns for primary teeth of children under age 16 are limited to one per tooth in a
5-year period.
Implants. Implants (materials implanted into or on bone or soft tissue) or the removal of implants.
However, if implants are provided in connection with a covered prosthetic appliance, we will allow
the cost of a standard complete or partial denture, or a bridge, toward the cost of the implants and
the prosthetic appliances.
Malignancies and Neoplasms. Services for treatment of malignancies and neoplasms.
Cosmetic Dentistry. Any services performed for cosmetic purposes, unless they are for correction
of functional disorders or as a result of an accidental injury occurring while the insured person was
covered for dental benefits under this plan.
Congenital or Developmental Malformation. Services to correct a congenital or developmental
malformation including, but not limited to, cleft palate, maxillary and mandibular (upper and lower
jaw) malformations, enamel hypoplasia (lack of development), fluorosis (discoloration of the teeth)
and anodontia (congenitally missing teeth).
X-rays. More than one set of full-mouth x-rays or its equivalent in a 36-month period. Periapical
and bitewing x-rays submitted individually will be combined and paid up to the amount of a full
mouth series.
Bitewing X-rays. Bitewing x-rays in excess of two series for standard in a calendar year. Vertical
bitewings limited to 8 films in a 60-month period.
Oral Exams. Oral exams are limited to two, in any combination, per calendar year.
Prophylaxis or Periodontal Prophylaxis. Prophylaxis or periodontal prophylaxis treatments,
singly or in combination, exceeding two treatments in a calendar year.
Periodontics. Osseous surgery, including flap entry and closure, exceeding one time per quadrant
in 36-month period. Gingivectomy or gingivoplasty exceeding one time per quadrant in a 24-month
period. Full mouth debridement limited to one time at the beginning of a periodontal treatment plan,
prior to pocket depth charting.
Periodontal scaling. Periodontal scaling exceeding one time per quadrant in a 24-month period.
Sealants. Sealants are limited to children between 6 and 18 years of age for permanent
unrestored first and second molars. Treatment is limited to once every 36 months per tooth.
Prescription Drugs and Medications. Any prescribed drugs, pre-medication or analgesia.
Root Canal Therapy. Root canal therapy in excess of one treatment per tooth for initial treatment
and one retreatment per tooth.
Oral Hygiene. Oral hygiene instruction.
Oral Surgery. Extraction of third molars (wisdom teeth) if the patient is under the age of 16.
Alveoloplasty or frenulectomy are limited to once per quadrant or arch in an insured
person’s lifetime.
Teeth Lost Prior to this Coverage. Teeth lost prior to coverage under this plan are not eligible for
prosthetic replacement unless the prosthetic replacement replaces one or more eligible natural
teeth lost during the term of this coverage.
Precision Attachments. Precision attachments and the replacement of part of a precision
attachment, magnetic retention or overdenture attachments.
Overdentures. Overdentures and related services, including root canal therapy on teeth
supporting an overdenture.
Third Molars. The replacement of extracted or missing third molars/wisdom teeth.
Restorations. Restorations exceeding one per tooth in a 24-month period. Replacement of
existing restoration if replacement occurs within 24 months of the original placement.
Harmful Habit Appliances. Fixed and removable appliances to inhibit thumb sucking.
Fluoride. Topical application of sodium fluoride or stannous fluoride to the teeth is limited to once
in a 12-month period.
Palliative Treatment. Emergency treatment of dental pain is limited to once in a 12-month period.
Orthodontics. Orthodontic braces, appliances and all related services.
Late Entrant Waiting Periods
If the insured person does not enroll within 31 days of eligibility date, the following late entrant
waiting periods will apply to services for:

Preventive and Diagnostic
None
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Restorative
6 months
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Oral Surgery
12 months

Periodontics, Endodontics, or Prosthodontics
12 months
Third Party Liability
Anthem Blue Cross Life and Health Insurance Company is entitled to reimbursement of benefits
paid if the insured person recovers damages from a legally liable third party.
Coordination of Benefits
The benefits of this plan may be reduced if the insured person has any other group dental
coverage so that the services received from all group coverages do not exceed 100% of the
covered expense.
Anthem Blue Cross Life and Health Insurance Company is an independent licensee of the
Blue Cross Association. ® ANTHEM is a registered trademark. ® The Blue Cross name and
symbol are registered marks of the Blue Cross Association.