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Benefits

Dental Insurance

Anthem Blue Cross | PPO Dental Plan
With the Anthem Blue Cross Preferred Provider Organization (PPO) dental plan, you may visit a PPO dentist and benefit from the
negotiated rate or visit a non‐network dentist. When you utilize a PPO dentist, your out-of-pocket expenses will be less. You may
also obtain services using a non-network dentist; however, you will be responsible for the difference between the covered amount
and the actual charges and you may be responsible for filing claims.

Anthem Blue Cross
Plan Name PPO
Network Name Dental Complete Non-Network
Dental Benefits
Calendar Year Maximum Per Individual $1,500
with $250 Maximum Rollover*
Deductible (Annual)
- Individual $50
- Family $150

Preventive (Plan Pays) 100% 80% of UCR
Exams, X-Rays, Cleanings deductible waived deductible waived

Basic Services (Plan Pays) 80% 70% of UCR
Fillings, Oral Surgery, Endodontics, Periodontics, Root
Canals
Major Services (Plan Pays) 50% 40% of UCR
Crowns, Prosthetics

Orthodontia
- Covered Members Children & Adults
- Copay N/A
- Coinsurance 50%
- Lifetime Benefit Maximum Per Individual $1,500

*Maximum Rollover
At the end of the year, Anthem Blue Cross will add up all of your paid dental claims. If you have at least one claim, and your claims
do not exceed $500, then you qualify for a $250 rollover reward to use for the next dental plan year. If you don’t use this money the
next year, it carries over year after year. You will receive $250 each year that you qualify until your rollover account reaches $1,000.

Finding a Dental Provider
Go to www.anthem.com/ca or call (877) 567-1804. Refer to the “Dental Complete” network when prompted.

Note
We strongly recommend you ask your dentist for a predetermination of total charges. Predetermination enables you and your
dentist to know in advance what the payment will be for any service that you may be undergoing.

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