Dental Orthodontia Coverage
Dental
The Dental Plan is designed to help employees and their family members maintain good dental health through regular preventive care and assist in paying larger dental expenses.
- Fiscal Year Deductible: $25 per covered person
- Coinsurance: Plan pays 80%, Employees pay 20%
- Benefit Maximum: $1,000 per person per fiscal year
Each year, employees must satisfy a fiscal year deductible. After that, when covered dental charges are incurred, the plan pays a percentage of the customary and reasonable charges up to the benefit maximum. Employees are responsible for the coinsurance payment (and any amount over the customary and reasonable charge).
Covered Dental Expenses
Preventive treatment includes:
• oral examinations, but not more than twice a year
• cleaning and scaling of teeth, but not more than twice a year
• full mouth x-rays, once every 36 month
• four supplementary bitewing x-rays a year
• application of fluoride, but not more than once a year
Basic and major treatment includes:
• amalgam (silver) fillings to restore decayed or accidentally broken teeth, including replacement of fillings
• simple extractions and surgical extractions (not including impacted teeth, which are covered under the medical plan)
• periodontal scaling (cleaning below the gum line)
• root canal therapy
• pulpal therapy and pulp capping
• other surgery on the teeth except surgical removal of a tumor or cyst, or cutting and draining on abscess or cyst
• rebasing or relining of partial or full dentures if performed more than six months after installation, but not more than once in 24 months
• repair of crowns, inlays, onlays, partial or full dentures and fixed bridgework, to include recementing crowns, inlays and onlays
• emergency dental treatment for relief of pain
• general anesthetics and the process of administering them, including intravenous sedations when furnished for surgical procedures
• initial installation of a partial or full denture of fixed bridgework to replace a natural tooth that has been extracted (Installation includes the denture and adjustments made to it for the first six months, and fixed bridgework, including inlays and crowns needed as abutments)
• replacement of existing or full denture, fixed bridgework or the addition of teeth to a partial denture or fixed bridgework if: the replacement or addition will replace one or more teeth; in the case of a partial denture or fixed bridgework was installed; in the case of a partial or full denture or fixed bridgework, the denture or bridgework was installed while the patient was covered under this dental plan, and replacement occurs at least five years after installation; or the denture being replaced in an immediate full denture that cannot be made permanent, and replacement by a permanent full denture occurs within 12 months from the date the immediate full denture was installed.
• Gold fillings, crowns, inlays and onlays to restore decayed or broken teeth only when teeth cannot be restored with regular fillings
• Replacement of gold fillings, crowns, inlays and onlays installed while the patient was covered under this plan when replacement occurs at least five years after installation or it is needed to repair or relieve an injury caused by an accident while the patient is covered under this dental plan
• Gingivectomy (removal of infected gum tissues around the teeth)
• Osseous (bone) surgery
• Pedicle soft tissue grafts (gum grafts to cover exposed root)
• Occlusal (bite) adjustments and guards
• Other gingival (gum) surgery except surgical removal or a tumor or cyst, or cutting and draining of an abscess or cyst
Dental and Orthodontia
You may choose Dental/Orthodontic coverage for yourself and/or your dependents. Orthodontia coverage includes Dental (as listed above) and Orthodontia (for the treatment of irregularities of the teeth such as alignment and occlusion, including the use of braces) as follows:
- Coinsurance: Plan Pays 50%, You Pay 50%
- Benefit Maximum: $1,000 Lifetime Maximum
The plan will pay 50% of covered expenses up to $1,000. This amount applies to each covered person separately, up to a lifetime benefit of $1,000. The Orthodontic Plan only covers expenses that begin after your coverage begins.
Covered Orthodontic Expenses
Coverage includes:
• complete orthodontic examination
• orthodontic appliance, including impressions, installation and adjustments for the first six months after installation for: minor treatment for tooth guidance; and interceptive orthodontic treatment
• comprehensive orthodontic treatment of transitional or permanent dentition, including initial placement or the orthodontic appliance and subsequent active orthodontic treatment
Premiums
Premiums for dental or dental orthodontia are deducted on a pre-tax basis.
ID Cards
Once enrolled in coverage, you may register with anthem.com or download the Sydney℠ Health mobile app to access your digital member ID card. You may use your digital ID card anytime you need care. It works just like a printed card and you can email, fax or download from your anthem account or Sydney℠ Health mobile app. For even easier access, you can add it to the digital wallet on your phone.
If you'd like a printed ID card, you can request one anytime by calling 1-833-363-1431.