Plan
Plan Name:
Anthem Dental Family, NS, OON, Prime Network, Dep25, Adult/Family Dental
Issuer Name:
Anthem Blue Cross (Dental Upstate)
HIOS ID:
44113NY0440003
Annual Benefit Maximum:
$750
Plan Brochure Link:
Out of Network Coverage:
Y
Dental Plan Type
Dental Plan Type:
Adult & Family Dental Plan
Plan Information
Dep Age:
Age 25
Plan Type:
PPO
Standard or Non-Standard Plan:
Non-Standard
Waiting Periods:
No
Deductible Adult Individual:
$50
Limit Description:
Pediatric: 1 exam per 6 months; Adult: 2 exams per year; 1 complete set of x-rays per 60 months; cleanings 2 per year; fillings 1 per 24 months; scaling, planing, gingivotomy or gingivoplasty, gum surgery and tissue grafting 1 per 36 months; root canal 1
Lifetime Benefit Maximum:
None
Coverage Level:
Family
Benefits Excluded from In Network MOOP:
N/A
Benefits Excluded from Out of Network MOOP:
N/A
FDP In Network Cost Sharing Adult Benefits
FDP Office Visit With No Additional Services - Adult:
CP: Not Covered
FDP Oral Evaluation - Adult:
CI: 0% AD
FDP Complete Set of X-Rays - Adult:
CI: 0% AD
FDP Topical Fluoride - Adult:
CP: Not Covered
FDP Polishing - Adult:
CI: 0% AD
FDP Sealant (per tooth) - Adult:
CP: Not Covered
FDP Spacers - Adult:
CP: Not Covered
FDP Simple Extraction - Adult:
CI: 50% Coins AD
FDP Fillings - Adult:
CI: 50% Coins AD
FDP Single Restoration Crowns - Adult:
CI: 50% Coins AD
FDP Pulp Cap - Adult:
CP: Not Covered
FDP Bonding - Adult:
CP: Not Covered
FDP Root Canal - Adult:
CI: 50% Coins AD
FDP In Network Cost Sharing Adult Benefits
FDP MOOP Adult Individual:
None
FDP Deductible 2+ Adult Members:
$50 per adult
FDP MOOP 2+ Members:
None
FDP Additional In Network Cost Sharing Adult Benefits
FDPA Scaling - Adult:
CI: 50% Coins AD
FDPA Gingivectomy or Gingivoplasty - Adult:
CI: 50% Coins AD
FDPA Gum Surgery - Adult:
CI: 50% Coins AD
FDPA Routine Braces - Adult:
CP: Not Covered
FDPA Partial Dentures - Adult:
CI: 50% Coins AD
FDPA Complete Dentures - Adult:
CI: 50% Coins AD
FDPA Dental Implants - Adults:
CI: 50% Coins AD
FDPA Bridges - Adults:
CI: 50% Coins AD
FDPA Veneers - Adult:
CP: Not Covered
FDPA TMJ - Adult:
CP: Not Covered
FDP In Network Cost Sharing Pediatric Benefits
FDP Deductible Pediatric Individual:
$25
FDP MOOP Pediatric Individual:
$375
FDP Deductible Pediatric 2+ Children:
$25 per child
FDP MOOP Pediatric 2+ Children:
$750
FDP Dental Check-Up - Child:
CI: 25% AD
FDP Basic Dental Care - Child:
CI: 25% AD
FDP Orthodontia - Child:
CI: 50% Coins AD
FDP Cosmetic Orthodontia - Child:
CI: Not Covered
FDP Major Dental Care - Child:
CI: 50% Coins AD
FDP Out of Network Cost Sharing Adult Benefits
FDP Deductible Adult Individual (Out of Network Cost Sharing Adult Benefits):
$50
FDP MOOP Adult Individual (Out of Network Cost Sharing Adult Benefits):
None
FDP Deductible 2+ Members (Out of Network Cost Sharing Adult Benefits):
$50 per adult
FDP MOOP 2+ Members (Out of Network Cost Sharing Adult Benefits):
None
FDP Office Visit With No Additional Services - Adult (Out of Network Cost Sharing Adult Benefits):
CP: Not Covered
FDP Oral Evaluation - Adult (Out of Network Cost Sharing Adult Benefits):
CI: 50% Coins AD
FDP Complete Set of X-Rays - Adult (Out of Network Cost Sharing Adult Benefits):
CI: 50% Coins AD
FDP Prophylaxis - Adult (Out of Network Cost Sharing Adult Benefits):
CI: 50% Coins AD
FDP Topical Fluoride - Adult (Out of Network Cost Sharing Adult Benefits):
CP: Not Covered
FDP Polishing - Adult (Out of Network Cost Sharing Adult Benefits):
CI: 50% Coins AD
FDP Sealant (per tooth) - Adult (Out of Network Cost Sharing Adult Benefits):
CP: Not Covered
FDP Spacers - Adult (Out of Network Cost Sharing Adult Benefits):
CP: Not Covered
FDP Simple Extraction - Adult (Out of Network Cost Sharing Adult Benefits):
CI: 50% Coins AD
FDP Fillings - Adult (Out of Network Cost Sharing Adult Benefits):
CI: 50% Coins AD
FDP Single Restoration Crowns - Adult (Out of Network Cost Sharing Adult Benefits):
CI: 50% Coins AD
FDP Pulp Cap - Adult (Out of Network Cost Sharing Adult Benefits):
CP: Not Covered
FDP Bonding - Adult (Out of Network Cost Sharing Adult Benefits):
CP: Not Covered
FDP Root Canal - Adult (Out of Network Cost Sharing Adult Benefits):
CP: Not Covered
FDP Scaling - Adult (Out of Network Cost Sharing Adult Benefits):
CI: 50% Coins AD
FDP Additional Out of Network Cost Sharing Adult Benefits
FDP Gingivectomy or Gingivoplasty - Adult:
CI: 50% Coins AD
FDP Gum Surgery - Adult:
CI: 50% Coins AD
FDP Tissue Grafting - Adult:
CI: 50% Coins AD
FDP Routine Braces - Adult:
CP: Not Covered
FDP Partial Dentures - Adult:
CI: 50% Coins AD
FDP Complete Dentures - Adult:
CI: 50% Coins AD
FDP Dental Implants - Adults:
CI: 50% Coins AD
FDP Bridges - Adults:
CI: 50% Coins AD
FDP Veneers - Adult:
CP: Not Covered
FDP TMJ - Adult:
CP: Not Covered
FDP Out of Network Cost Sharing Pediatric Benefits
FDP Deductible Pediatric Individual (Out of Network Cost Sharing Pediatric Benefits):
$25
FDP MOOP Pediatric Individual (Out of Network Cost Sharing Pediatric Benefits):
None
FDP Deductible Pediatric 2+ Children (Out of Network Cost Sharing Pediatric Benefits):
$25 per child
FDP MOOP Pediatric 2+ Children (Out of Network Cost Sharing Pediatric Benefits):
None
FDP Dental Check-Up - Child (Out of Network Cost Sharing Pediatric Benefits):
CI: 25% AD
FDP Basic Dental Care - Child (Out of Network Cost Sharing Pediatric Benefits):
CI: 25% AD
FDP Orthodontia - Child (Out of Network Cost Sharing Pediatric Benefits):
CI: 50% Coins AD
FDP Cosmetic Orthodontia - Child (Out of Network Cost Sharing Pediatric Benefits):
CI: Not Covered
FDP Major Dental Care - Child (Out of Network Cost Sharing Pediatric Benefits):
CI: 50% Coins AD
FDP Network Information (Family Dental)
FDP Out of Country Coverage:
Y
FDP Out of Country Coverage Description:
Out of Country covered services are reimbursed as out-of-network benefits.
FDP Out of Service Area Coverage:
Y
FDP Out of Service Area Coverage Description:
If a member does not use a network dentist, services will be reimbursed at the out-of-network level.
FDP National Network:
Y
FDP Network Name:
Dental Prime
Counties
Albany:
$47.52
Clinton:
$47.52
Essex:
$47.52
Fulton:
$47.52
Montgomery:
$47.52
Rensselaer:
$47.52
Saratoga:
$47.52
Schenectady:
$47.52
Schoharie:
$47.52
Warren:
$47.52
Washington:
$47.52