Anthem Blue Cross INDIVIDUAL DENTAL BLUE HIGHLIGHTS
DENTAL SERVICE
(In Network) |
100 Basic |
200 Essential |
100 Plus |
200 Plus |
| Annual Deductible (single/family) |
$25 |
$50/$150 |
$50/$150 |
$50/$150 |
Waived for Preventive &
Diagnostic Services |
Yes |
Yes |
Yes |
Yes |
| Annual Maximum |
$500 |
$1000 |
$1000 |
$1000 |
Preventive &
Diagnostic Services |
100%
(cleanings, exams, X-rays, sealents, space mantainers) |
100%
(cleanings, exams, X-rays, sealents, space mantainers) |
100%
(cleanings, exams, X-rays, sealents) |
100%
(cleanings, exams, X-rays, sealents) |
| Basic Services |
80% - Fillings
50% - (Stainless steel crowns, pulpotomies) |
Fee Schedule * |
80%
(Fillings, space maintainers) |
80%
(Fillings, space maintainers) |
| Major Services |
Not covered |
Fee Schedule * |
50%
(oral surgery, endodontics, periodontics, prosthodontics) |
50%
(oral surgery, endodontics, periodontics, prosthodontics) |
| Orthodontics |
Not covered |
Not covered |
Not covered |
Not covered |
| Waiting Periods for Services |
None |
3 months for Basic
12 months for Major Services |
6 months for Major Services |
3 months for Basic
12 months for Major Services |
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