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Below explanation is for California plan only

Anthem Blue Cross Senior SelectHMO Insurance
(877) 566-5454 Toll Free

Anthem Blue Cross SENIOR DENTAL HMO PLAN MONTHLY RATES (Age 65+)

	Saver SelectHMO	SelectHMO	Premier SelectHMO
Single	$9	$13	$16
Two Party ¹	$18	$26	$32

Anthem Blue Cross SENIOR DENTAL HMO PLAN BENEFIT SUMMARY (Age 65+)

	Dental Saver	Dental	Dental Premier
	SelectHMO copays	SelectHMO copays	SelectHMO copays
Office Visit	$5	$5	$5
DIAGNOSTIC CARE
Oral Exams	No Charge	No Charge	No Charge
X-rays	No Charge	No Charge	No Charge
PREVENTIVE CARE
Topical Fluoride - child	No Charge	No Charge	No Charge
Prophylaxis - adult & child	No Charge ²	No Charge ²	No Charge ²
RESTORATIVE CARE
1-Surface Amalgam (filling)	$54	No Charge ³	No Charge ³
2-Surface Amalgam (filling)	$64	No Charge ³	No Charge ³
3-Surface Amalgam (filling)	$75	No Charge ³	No Charge ³
4-Surface Amalgam (filling)	$89	No Charge ³	No Charge ³
PERIODONTAL CARE
Scaling/Root Planing   per quadrant	$101	$101	No Charge ³
ORTHODONTIC CARE
Adult	$3,045	$3,045	$3,045
Retention	$300	$300	$300
PROSTHODONTIC CARE
Denture (broken tooth repair)	$57	$57	$57
OTHER SERVICES
Office Visit after hours	$56	$56	$56
Local Anesthesia	$14	$14	$14
General Anesthesia	$150	$150	$150
COSMETIC CARE
Resin Filling	$75	$75	$75
Labial Veneer	$187	$187	$187
ENDODONTIC CARE
Root Canal - Anterior	$289	$289	$289
Root Canal - Bicuspid	$341	$341	$341
Root Canal - Molar	$459	$459	$459
Pulpotomy	$62	$62	$62
PERIODONTAL CARE
Gingivtomy - per tooth	$72	$72	$72
Gingivtomy - per quadrant	$194	$194	$194
Osseous Surgery - per quadrant	$520	$520	$520
ORAL SURGERY
Extraction - erupted tooth or exposed root	$60	$60	No Charge ³
Impaction - soft tissue	$136	$136	$136
Impaction - partial bony	$176	$176	$176
Impaction - complete bony	$200	$200	$200
PROSTHODONTIC CARE
Crowns	$432	$432	$432
Complete Upper or Lower Dentures	$577	$577	$577
Partial Denture	$430	$430	$430

¹ Eligible dependents include: spouse; unmarried child under age 19; unmarried child ages 19 to 23 who qualifies as a dependent for federal tax purposes.

² First two treatments in 12 consecutive months. All additional treatments within a 12-month period require co-payments of $44 for adults and $35 for children.

³ You must meet a six-month waiting period before these benefits are payable.

  Download Your Dental HMO Brochure/Application  
DOWNLOAD YOUR SelectHMO APPLICATION

Please choose a primary dentist to put on your application

Or you can fill in this form to have your Anthem Blue Cross Senior SelectHMO Dental Insurance brochure with pricing & application mailed to you. Or just call us Toll-free at 877-Look4Life (877-566-5454).

Anthem Blue Cross Senior HMO Dental Insurance Coverage Requested
Our Ages 65+	My Age or DOB       Spouse's Age
People Covered	-- Please Select -- Me Only Me and 1 Child Me and Children Me and Spouse Family

Customer Information
Full Full Name
E-mail
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