Anthem Blue Dental PPO
Colorado

Anthem Blue Dental PPO Plan Rates
One Adult	$36.91
Two Adults	$73.82
Adult with One Child	$58.94
Adult with Two Children	$80.97
Adult with Three or More Children	$103.00
Family (One Child)	$95.85
Family (Two Children)	$117.88
Family (Three or More Children)	$139.91
One Child	$22.03
Two Children	$44.06
Three or More Children	$66.09
Order Brochure and Application Call us or send us an email with your name and home address or email address, and we will mail or email you an application to complete.  Anthem does not offer an online application for this standalone dental insurance product.

Procedure	In-Network Plan Pays	Out-of-Network Plan Pays
Preventive & Diagnostic Care Deductible is Waived for These Services No Waiting Period
Periodic Oral Exam	100%	$26.00
Bitewing X-Rays (Single Film)	100%	$16.00
Bitewing X-Rays (2 Films)	100%	$27.00
Single (Periapical) X-Rays	100%	$14.00
Single X-Rays (Each Additional Film)	100%	$14.00
Bitewing X-Rays (4 Films)	100%	$36.00
Full Mouth X-Rays (Limited to 1 Set Every 5 years)	100%	$65.00
Routine Cleaning (Limited to 2 Per Adult Per Year)	100%	$54.00
Routine Cleaning (Limited to 2 Per Child Per Year)	100%	$38.00
Cleaning with Fluoride (Limited to 2 Per Child Per Year)	100%	$57.00
Sealants Per Tooth	100%	$32.00
Basic Dental Care Calendar Year Deductible of $50 Per Person Applies (Maximum of Three Deductibles Per Family) 6 Month Waiting Period
Filling (1 Surface)	80%	$62.00
Filling (2 Surfaces)	80%	$78.00
Filling (3 Surfaces)	80%	$118.00
Major Dental Care Calendar Year Deductible of $50 Per Person Applies (Maximum of Three Deductibles Per Family) 12 Month Waiting Period
Extraction (Erupted Tooth or Exposed Root)	50%	$42.00
Surgical Removal of Erupted Tooth	50%	$74.00
Removal of Impacted Tooth (Soft Tissue)	50%	$74.00
Removal of Impacted Tooth (Partial Bony)	50%	$106.00
Removal of Impacted Tooth (Complete Bony)	50%	$124.00
Four or More Scaling/Root Planing per Quadrant	50%	$104.00
Gingivectomy (1 to 3 Teeth per Quadrant)	50%	$91.00
Gingivectomy (4 or More Contiguous Teeth/Quadrant)	50%	$152.00
Anterior Root Canal	50%	$261.00
Bicuspid Root Canal (2 Canals)	50%	$279.00
Molar Root Canal (3 Canals)	50%	$333.00
Crown (Porcelain Fused to High Noble Metal)	50%	$328.00
Pontic (Porcelain Fused to High Noble Metal)	50%	$328.00
Upper Parial Denture Cast with Metal Resin	50%	$475.00
Complete Maxillary Denture	50%	$510.00

PPO Dental Plan Coverage for Individuals and Families
The Anthem Blue Dental PPO Plan for individuals and families is designed to help promote good oral hygiene and preventive care, and to offer you convenient, affordable dental coverage. 

The Anthem Blue Dental PPO Plan features coverage for routine checkups, X-rays, and cleanings that begins the day your policy becomes effective.

You will be covered for fillings after six continuous months of coverage, and for major dental care after 12 continuous months of coverage, offering significant cost savings on procedures such as root canals, crowns and dentures.

With the Anthem Blue Dental PPO Plan, you may visit any dentist you choose.  However, your out-of-pocket costs will be lower if you choose dentists in the Anthem Blue Dental PPO Network.  The annual maximum amount of coverage per person per year is $1000.

How the Plan Works
When you choose an in-network dental provider, you'll receive services at Anthem Blue Cross and Blue Shield's negotiated discounted rates.  We still provide benefits when  you choose an out-of-network dentist; however, your out-of-pocket expenses may be higher, because our negotiated fees don't apply to out-of-network providers.  You're responsible for any charges exceeding the stated benefit amount for both in-network and out-of-network dentists.

Your current dentist may already be an in-network provider.  For an up-to-date listing of dental providers in the Anthem Blue Dental PPO Plan, go to http://provider-directory.anthem.com/awp/landing.asp

When visiting an out-of-network dentist, Anthem lets you know up front how much the plan pays for covered services.  This means you may calculate how much you'll have to pay once you've determined your dentist's fee for a specific procedure.

If your current dentist isn't in the network and you want him or her to join the network, please contact Anthem at the address or phone number below:

Anthem Network Services
P.O. Box 9069
Oxnard, CA 93031-9069
888-209-7852

Eligibility and Enrollment
To be eligible for enrollment, you must meet all of the following requirements:

• You must be a resident of the state of Colorado
• You must be a resident of the USA for at least 6 months
• You must not be enrolled in any other Anthem Blue Cross and Blue Shield Individual or Group Dental Plan
• You must be age 64 or younger

Plan Effective Date
You may choose your effective date; either immediately upon approval or the first of the month following approval or a later date.  Your plan effective date will be printed on the ID card you'll receive once your enrollment is approved.