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Below form is for California plan only

Anthem Blue Cross Dental Insurance 
(877)566-5454 Toll Free
SIDE-BY-SIDE COMPARISON OF THE PLANS
DENTAL BLUE BASIC PPO
DENTAL BLUE ENHANCED PPO
DENTAL SelectHMO
In-network
Out-of-network
In-network
Out-of-network
In-network only
Annual Deductible $25 $50/$150 None
Waived for diagnostic & preventive services Yes No Yes No N/A
Annual Maximum $500 $1,250 No
Diagnostic & Preventive Services such as Cleanings, exams & X-rays 100% 80% 100% 80% No copayment for these services, a $5 office visit copayment will apply
BASIC SERVICES
Fillings 80% 60% 80% 60% No copayment for most fillings
Other Minor Restorative Not covered Copayments ranging from $31 to $187 depending on procedure
MAJOR SERVICES
Oral Surgery Not covered 50% Copayments for most commonly performed procedures range
from $36 to $223
Endodontics 50% - limited to pulpotomies
on primary teeth only		 50% Copayments:
Anterior root canal² - $289
Molar root canal² - $459
Periodontics Not covered 50% Gingivectomy² -per tooth-
$72 copayment
Prosthodontics 50% - limited to stainless steel crowns
on primary teeth only		 50% Copayment:
Crown² - $432
Partial denture² - $430
Orthodontics Not covered Children only 50%,
$100 Deductible, $500 per year/
$1,000 lifetime maximum		 Child-$2,870 copay
Adult-$3,045 copay
Retention-$210 copay
In-Network Reimbursement Dental Blue 100 fee schedule Dental Blue 100 fee schedule Dental SelectHMO
fee schedule
Out-of-Network ¹ Reimbursement Dental Blue 100 fee schedule Dental Blue 100 fee schedule None
Waiting Periods No waiting period for cleanings, exams & X-rays; 6 month waiting period for all other covered services No waiting period for cleanings, exams & X-rays; 6 month waiting period for basic services; 12 month months for major services 6 month waiting period for fillings for which there is no member copayment
Brochures Dental Blue PPO Brochure SelectHMO Brochure
Applications Dental Blue PPO Application SelectHMO Application

¹ While Dental Blue PPO plan members can see any dentist they want, they do have the potential for lower costs when they choose a dentist in the Dental Blue 100 network. This is because in-network dentists have agreed to accept our fee schedule for services rendered. If a member chooses to see a dentist outside the Dental Blue 100 network, they can be balance billed the difference between our in-network negotiated rates and their dentist's rates.
² Chart reflects copayments when services are rendered by a participating dental office. Amounts may differ if services are obtained through a participating specialty office.

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Dental Blue PPO Application

SelectHMO Application

Anthem Blue Cross Dentist Database


Or you can fill in this form to have your Anthem Blue Cross Dental Insurance brochure with pricing & application mailed to you. Further information on our plans is shown below. Or just call us Toll-free at 877-Look4Life (877-566-5454).
Anthem Blue Cross PPO Dental Insurance Coverage Requested
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Barricks Insurance Services
13900 NW Passage #302, Marina Del Rey, CA 90292
Phone:   (310) 827-7286    |   Fax:   (310) 827-0256
Toll-Free 1-877-Look4Life  (1-877-566-5454)

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