Dental Services In-Network Out-of-Network Waiting Period Anthem Pays: Anthem Pays: Diagnostic and Preventive Services 100% Coinsurance 100% Coinsurance No Waiting Period ● Periodic oral exam ○ Limited to 2 per 12 months ● Teeth cleaning (prophylaxis) ○ Limited to two per 12 months combined with periodontal maintenance ● Bitewing X-rays ○ Limited to one set per 12 months ● Full-Mouth or Panoramic X-rays ○ Limited to one per 60 months ● Fluoride application ○ 1 per 12 months through age 18 ● Sealant application ○ 1 per 60 months; through age 18 ● Space maintainer insertion ○ Limited to one per tooth space per lifetime through age 18 Basic (Restorative) Services 90% Coinsurance 80% Coinsurance No Waiting Period ● Consultation (second opinion); only with X-rays and no other services ○ Limited to one per 12 months ● Amalgam (silver-colored) filling ○ Limited to one per tooth surface per 24 months ● Composite (tooth-colored) filling ○ Limited to one per tooth surface per 24 months posterior (back) fillings paid as an amalgam (silver-colored filling) ● Brush Biopsy (cancer test) ○ Limited to one per 12 months; all ages Endodontics (Non-Surgical) 90% Coinsurance 80% Coinsurance No Waiting Period ● Root Canal (permanent teeth only) ○ Limited to 1 per tooth per lifetime; permanent teeth only Endodontics (Surgical) 90% Coinsurance 80% Coinsurance No Waiting Period ● Apicoectomy and apexification ○ Limited to 1 per tooth per lifetime; permanent teeth only Periodontics (Non-Surgical) 90% Coinsurance 80% Coinsurance No Waiting Period ● Periodontal maintenance ○ Limited to two per 12 months combined with teeth cleanings ● Scaling and root planning; when the tooth pocket has a depth of four millimeters or greater ○ Limited to one per quadrant per 24 months Periodontics (Surgical) 90% Coinsurance 80% Coinsurance No Waiting Period ● Periodontal surgery (osseous, gingivectomy, graft procedures) ○ Limited to one per quadrant per 36 months Oral Surgery (Simple) 90% Coinsurance 80% Coinsurance No Waiting Period ● Simple extraction ○ Limited to one per tooth per lifetime Oral Surgery (Complex) 90% Coinsurance 80% Coinsurance No Waiting Period ● Surgical extraction ○ Limited to one per tooth per lifetime Major (Restorative) Services 60% Coinsurance 50% Coinsurance No Waiting Period ● Crowns, onlays, veneers ○ Limited to one per tooth/arch per 60 months Prosthodontics 60% Coinsurance 50% Coinsurance No Waiting Period ● Dentures and bridges ○ Limited to one per tooth/arch per 60 months ● Implant placement ○ Limited to one per tooth/arch per 60 months ● Implant prosthodontics ○ Limited to one per tooth/arch per 60 months as a non-implant crown, bridge, and/or denture Repairs/Adjustments 60% Coinsurance 50% Coinsurance No Waiting Period ● Crown, denture, bridge repairs ○ Limited to one per 12 months; 6 months after placement ● Denture and bridge adjustments: ○ 2 per 12 months; 6 months after placement Anthem Blue Cross Life and Health Insurance Company is an independent licensee of the Blue Cross Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc. QuoteID: 00942573 Page 2 of 3