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Below explanation is for California plan only

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

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

	Northern California	Southern California -   (Los Angeles, Orange,   Riverside, San Bernardino,    San Diego, Ventura)
Subscriber Only	$30	$35
Subscriber & Spouse	$60	$70

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

Preventive & Diagnostic Care Procedures	Participating Dentist	Non-Participating Dentist
Initial Oral Exam	100%	$21
Periodic Oral Exam (Limit 2 per member per year)	100%	$15
Emergency Oral Exam	100%	$21
Bitewing X-rays - single film	100%	$14
Bitewing X-rays - two films	100%	$15
Single (periapical) X-rays - first film	100%	$11
Single X-rays - additional films	100%	$  7
Bitewing X-rays - four films	100%	$22
Full mouth X-rays (Limit one set every 3 years)	100%	$51
Routine cleaning (Limit 2 per adult per year)	100%	$33

Basic & Major Dental Care - After the calendar year deductible has been satisfied, benefits are paid according to the following schedules. Although the schedule is the same for both Participating and Non-participating providers, you may experience greater out-of-pocket expense as the negotiated feew do not apply to Non-participating providers. You are responsible for any charges in excess of the stated benefits.

Coverage begins after the policy has been in effect for three continuous months

Basic Dental Care Procedures	Plan Pays
Filling - one surface	$  34
Filling - two surfaces	$  44
Filling - three surfaces	$  58
Filling - four or more surfaces	$  67
Extraction - erupted tooth or exposed root	$  39
Surgical removal of erupted tooth	$  39
Removal of impacted tooth - soft tissue	$  94
Removal of impacted tooth - partial bony	$127
Removal of impacted tooth - complete bony	$168

Coverage begins after the policy has been in effect for twelve continuous months

Major Dental Care Procedures	Plan Pays
Scaling/root planing per quadrant	$  38
Gingivectomy - one to three teeth	$  33
Gingivectomy - per quadrant (four or more contiguous teeth)	$133
Root Canal - 1 canal	$133
Root Canal - 2 canals	$167
Root Canal - 3 canals	$221
Crown (except stainless steel)	$244
Pontic	$244
Complete denture (upper or lower)	$323
Partial denture (upper or lower)	$279
Denture reline (chairside)	$  67
Denture reline (lab)	$  88

  Download Your Dental PPO Brochure  
DOWNLOAD YOUR DENTAL PPO APPLICATION

Anthem Blue Cross Dentist Database

Or you can fill in this form to have your Anthem Blue Cross Senior Dental PPO Insurance brochure with pricing & application mailed to you. Further information on our plans is shown below. Or just call us Toll-free at 877-Look4Life (877-566-5454).

Anthem Blue Cross Senior Dental PPO Insurance Coverage Requested
Our Ages (over age 65)	My Age or DOB       Spouse's Age
People Covered	-- Please Select -- Me Only Me and Spouse

Customer Information
Full Full Name
E-mail
Street Address
City
County
State
Zip Code
Home Phone
Work Phone
FAX

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