Benefits at a Glance

Preventive Benefits
Preventive, diagnostic and radiographic benefits do not require a deductible or a waiting period. And when you visit a network dentist, we cover these benefits at 100% of our allowable charge - your coinsurance is 0%. We cover 50% of the allowable charge when you visit a dentist outside the network.

Covered Service	Frequency	Coinsurance InOut-ofnetwork network
Diagnostic (Oral exams)	Two per year	0%	50%
Set of bitewing X-rays	One per year (not in same year as full mouth x-ray)	0%	50%
Full mouth X-rays (Age 5 and over)	One every three years	0%	50%
Preventive (Includes cleanings, topical fluoride treatments for children under age 16, space maintainers for children under age 12)	Two dental cleanings per year	0%	50%

Anthem Individual Dental has an annual maximum benefit of $1,000 per covered person every calendar year the policy is in effect. This applies to preventive, restorative and complex benefits.

Restorative and Complex Benefits
Restorative and complex services have waiting periods before services are covered. You pay a $50 annual deductible with an in-network dentist, and a separate $100 annual deductible when you go out-of-network.

Covered Service	Waiting Period	Coinsurance In-Out-ofnetwork network		Deductible In-Out-ofnetwork network
Restorative Services (fillings)	6 months	50%	50%	$50	$100
Simple Extractions
Adjunctive Services (Emergency treatment of dental pain for minor procedure, general anesthesia with oral surgery)
Oral Surgery (Includes root removal, treatment of abscess)	18 months
Prosthodontic Services (Onlays, crowns, dentures)
Endodontic Services (Root canals)
Periodontal Services (Includes periodontal cleaning, scaling, root planing)

Dental Policy Terms and Limitations

Rates subject to change without notice

How the Plan Works:

No Health Underwriting!
You can enroll in this plan regardless of your health–
there are no medical questions to answer.
Save Money with Our Network of Dentists–
or Pick the Dentist You Want!
To get the highest level of benefits, choose from our network
of participating dentists. Of course, you’re also free to
choose a dental provider outside the network, but your
share of the cost may be greater.
Preventive Benefits are Covered in Full!
When you visit a network dentist, you have no deductible
or coinsurance to pay for any covered preventive or
diagnostic service.
It’s Convenient!
When you visit a network dentist, there’s virtually NO
paperwork! Your claims are automatically filed for you, in
most cases.* To reduce your paperwork even more, you
can take advantage of our automatic bank draft service,
and have your premium drafted from your bank account
monthly. Or, you can choose another payment method –
we offer quarterly, semi-annual and annual billing.
Best of All
Anthem Individual Dental is available exclusively from
Virginia’s largest health insurer,** Anthem Blue Cross and
Blue Shield.
*This added feature is not guaranteed by your policy and can be modified or discontinued at our discretion.
** Anthem Market Research, October 2004.
2

* Based on 2006 National Dental Advisory Service Fee Report.

** This portion of the plan is not an insurance product. In-network providers typically charge reduced rates within these ranges. Member charges are based on CareFirst allowances with the participating providers. Since rates vary by provider, members should check with their participating dentist to determine the costs of specific procedures. Members must pay these reduced rates directly to the provider during the office visit.

Please see the brochure for details of the benefits

Restorative and Complex Benefits Restorative and complex services have waiting periods before services are covered. You pay a $50 annual deductible with an in-network dentist, and a separate $100 annual deductible when you go out-of-network.

Rates subject to change without notice

How the Plan Works:

Restorative and Complex Benefits
Restorative and complex services have waiting periods before services are covered. You pay a $50 annual deductible with an in-network dentist, and a separate $100 annual deductible when you go out-of-network.