Dental Plan
Taking good care of your mouth, teeth and gums is an integral part of good health. Proper oral and dental hygiene can help prevent tooth decay, gum disease and even lower the risk of heart disease.
Your dental plan covers preventive cleanings twice per year in addition to comprehensive coverage for most basic and restorative procedures.
Provider: Anthem
Group # W10955
Member Service: (866) 589-0578
Coverage Benefits
| In-Network | Out-of-Network | |
|---|---|---|
| Annual Deductible (Single / Family) | $50 / $100 | $50 / $100 |
| Calendar Year Maximum | $1,000 per member | $1,000 per member |
| Diagnostic & Preventive | NCS*; No deductible | NCS*; No deductible |
| Minor Restorative | 20% after deductible | 20% after deductible |
| Oral Surgery | 20% after deductible | 20% after deductible |
| Endodontic Services | 20% after deductible | 20% after deductible |
| Periodontal Services | 20% after deductible | 20% after deductible |
| Prosthodontic Services | 50% after deductible | 50% after deductible |
| Orthodontic Services | 50% | 50% |
| Orthodontic Maximum | $1,000 per member | $1,000 per member |
| Orthodontic Age Limit | Child to Age 19 | Child to Age 19 |
*NCS (No Cost Share) means no deductible, copayment or coinsurance up to the maximum allowable amount. However, a member may be responsible for any balance due after the plan payment, including, but not limited to, benefits that reflect No Cost Share.
