Dental benefits are covered separately from the HDHP plan and have a separate plan year deductible. Your dental coverage is not subject to the HDHP deductible. You pay the dental deductible as shown before the plan pays for services.
| Plan Pays $1,500 Maximum Per Person Each Plan Year (Applies to all covered dental services except Orthodontic Services) | In-Network You Pay | |
| Deductible - per plan year | - One person |
$25 $50 $75 |
| Diagnostic and preventive services | Twice-a-year visits to the dentist for oral examinations, x-rays, and cleanings | $0, no deductible |
| Primary services | Fillings, oral surgery, periodontal services, scaling, repair of dentures, root canals, and other endodontic services, and recementing of existing crowns and bridges | 20% coinsurance after deductible |
| Complex restorative | Inlays, onlays, crowns, dentures, bridges, relining dentures for a better fit, and implants | 50% coinsurance after deductible |
| Orthodontic services (Plan pays $1,500 maximum per lifetime per enrolled member) |
Services to correct a handicapping malocclusion (a severe deviation from the normal range of positioning of the teeth), tooth guidance and harmful habit appliances, interceptive treatment, surgical exposure of unerupted teeth when performed for orthodontic purposes, orthodontic x-rays, and orthodontic evaluations when no treatment is initiated. | 50% coinsurance after deductible |
| Out-of-network care | For services by a non-network dentist, you pay the applicable deductible or coinsurance plus any amounts above the allowable charge. Claims payments are made directly to the member, unless the member assigns benefits to the provider. | |
| Questions Anthem Blue Cross and Blue Shield (804) 355-8506 in Richmond 1-800-552-2682 outside Richmond www.anthem.com click on Members and then Virginia |
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To locate a Provider www.anthem.com |
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