Dental Coverage - Anthem DPPO Plans
DPPO “LOW”
DPPO “HIGH”
DPPO “PREMIUM”
Plan Highlights
Out-of- Network*
Out-of- Network*
Out-of- Network*
In-Network
In-Network
In-Network
Annual Calendar Year Deductible Individual / Family
$50 / $150 $75 / $225 $50 / $150 $75 / $225 $50 / $150 $50 / $150
$1,000 per covered member
$1,500 per covered member
$5,000 per covered member
Annual Maximum Benefit
Preventive Services • Oral examinations, X-rays, Cleanings • Topical fluoride treatment
Plan reimburses
Plan reimburses
Plan reimburses 100% of MAC**; deductible waived Plan reimburses 80% of MAC**; after deductible Plan reimburses 50% of MAC**; after deductible
Plan pays 100%; deductible waived
Plan pays 100%; deductible waived
Plan pays 100%; deductible waived
100% of the 90th
100% of the 90th
(through age 14, one per calendar year) • Sealants (through age 14, one per tooth in 60 months) Basic Services • Anesthesia • Amalgam & composite fillings • Periodontal Maintenance • Repair & Maintenance of Crowns, Bridges, & Dentures • Root Canal • Periodontal Scaling & Root Planning • Oral surgery - simple extractions Major Services (excludes orthodontia services) • Bridgework • Dentures • Inlays and Onlays • Single Crowns
percentile*; deductible waived
percentile*; deductible waived
Plan reimburses 80% of the 90th percentile*; after deductible Plan reimburses 30% of the 90th percentile*; after deductible
Plan reimburses 80% of the 90th percentile*; after deductible Plan reimburses 50% of the 90th percentile*; after deductible
Plan pays 80%; after deductible
Plan pays 80%; after deductible
Plan pays 80%; after deductible
Plan pays 30%; after deductible
Plan pays 50%; after deductible
Plan pays 50%; after deductible
Children Only Plan pays 50% up to $1,000 per covered member; once a lifetime
Adults & Children Plan pays 50% up to $1,500 per covered member; once a lifetime
Orthodontia • Lifetime Maximum
Not covered
(Children up to age 26)
* Since, by definition, many dentists’ usual fees are below the 90th percentile fee, reimbursement is always based on the lesser of the dentist’s billed fee for a given procedure or the 90th percentile fee. This means that 90 percent of dentists’ billed fees will be covered in full relative to the group plan ** The reimbursement for services provided by an out-of-network dentist is capped at the Maximum Allowable Charge (MAC). For example, if you visit an out-of-network dentist who charges $150 for a cleaning (covered at 100%), but the MAC is set at $100, insurance will cover $100 and you will be responsible for the remaining $50 coinsurance level.
The above information is a summary only. Please refer to your Evidence of Coverage for complete details of Plan benefits, limitations and exclusions.
Benefits Guide 2025-26 13
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