Page 5 - MarketCast 2021 EB Brochure - California

Anthem Dental Plans

DHMO DPPO
In-Network In-Network Out-of-Network*

Annual Benefit Maximum Unlimited $1,250 $1,250

Calendar Year Deductible:
$50 / $150 $50 / $150
Individual / Family None

Preventive & Diagnostic: Covered 100%** 80%**
Office Exams / Cleanings / X-Rays See fee schedule

Basic Services: 80% 60%
Fillings / Root Canal / Oral Surgery See fee schedule

Major Services:
Crowns / Dentures / Bridges See fee schedule 50% 40%

50% up to $1,000 50% up to $1,000
Orthodontia $1,695 child
$1,895 adult lifetime max (child lifetime max (child
only)**
only)**

th
*Out of Network services are covered up to the 90 percentile of reasonable & customary. Member is
responsible for any charges above allowable amounts. Out of network annual max is $1,250. Please refer to
carrier summary for detailed out of network benefits.
**Deductible waived

MarketCast 2021 Employee Benefits Brochure Page 4