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Anthem Blue Cross | PPO Plans
Our dental plans offer you the freedom and flexibility to use the dentist of your choice. However, you will maximize your benefits and reduce your out-of-
pocket costs if you choose a dentist who participates in the Anthem Blue Cross network. When you utilize a network dentist, your out-of-pocket expenses
will be less, however, you will usually pay the lowest amount for services when you visit a PPO dentist. If you obtain services using a non-network dentist,
you will be responsible for the difference between the covered amount and the actual charges and you may be responsible for filing claims. The chart
below provides a high-level overview of your dental plan.

Option 1 Option 2 Note:
We strongly recommend
Anthem Blue Cross Anthem Blue Cross you ask your dentist for a
Plan Name PPO High PPO Low predetermination if total

Network Name Dental Complete Non-Network Dental Complete Non-Network charges are expected to
exceed $300.
Dental Benefits Predetermination enables
you and your dentist to
Calendar Year Maximum Benefit $1,500 $1,500 $1,000 $1,000
know in advance what the
Annual Deductible payment will be for any
- Individual $50 $100 $100 $150 service that may be in
- Family $150 $300 $300 $450 question.
Preventive Services No Charge No Charge* No Charge No Charge*

Basic Services Deductible, 10% Deductible, 20%* Deductible, 30% Deductible, 50%*
Major Services Deductible, 35% Deductible, 50%* Deductible, 50% Deductible, 50%*

Orthodontia
- Child 50% / $1,500 Lifetime Benefit Maximum Not Covered
- Adult 50% / $1,500 Lifetime Benefit Maximum Not Covered

*Dentists who are out-of-network have not agreed
to pricing, and may bill you for the difference Finding a Dental Provider
between what Anthem pays them and what the Go to www.anthem.com/ca or call (877) 567-1804. Refer to the Anthem
dentist usually charges. Dental Complete network when prompted.