Anthem Blue Cross Blue Shield PPO Plan - Teamworks at Home ...

Dental care
The Plan covers BlueCard PPO providers Out-of-network providers
• Accident-related dental services from
a physician or dentist for the treatment
of an injury to sound, natural teeth
• Treatment of cleft lip and palate when
the service is scheduled or initiated
before the child turns 19
• Surgical and nonsurgical treatment
of temporomandibular joint disorder
(TMJ) and craniomandibular disorder
You pay 20% after you satisfy
the deductible�
Other notes:
• Please see the “Notifcation requirements” section on
page 7�
• You must use a BlueCard PPO provider to obtain the
highest level of coverage�
• Accident-related dental services, treatment, or
restoration of sound natural teeth if services are
performed within 12 months of the date of injury�
Coverage is limited to the initial treatment (or course
of treatment) or initial restoration� Coverage for
treatment or restoration is limited to reimplantation
of original sound natural teeth and crowns, fllings,
and bridges required to restore the sound natural
teeth damaged by the accident� Covered services
are determined based on established medical
policies, as determined by Anthem BCBS, which are
subject to periodic review and modifcation by the
medical directors�
• The Plan covers anesthesia and inpatient and
outpatient hospital facility charges for dental care
provided to a covered person who is a child under age
fve, is severely disabled, or has a medical condition
that requires hospitalization or general anesthesia for
dental treatment� For facility charges, please refer to
the “Hospital inpatient” section on page 20 or the
“Hospital outpatient” section on page 21� Covered
services are determined based on established medical
policies, as determined by Anthem BCBS, which
are subject to periodic review and modifcation
by the medical directors� Oral surgeon or dentist
professional fees are not covered�
• Treatment for cleft lip and palate includes inpatient
and outpatient expenses arising from medical and
dental treatment, including orthodontia and oral
surgery� For medical services, please refer to the
“Hospital inpatient” section on page 20, the
“Hospital outpatient” section on page 21, and the
“Physician services” section on page 30�
You pay 40% after you satisfy
the deductible�
• Treatment for cleft lip and palate is limited to services
that are scheduled or initiated before the dependent
child turns age 19�
• Services for nonsurgical treatment of
temporomandibular joint disorder (TMJ) and
craniomandibular disorder include removable
appliances for TMJ� Covered services do not include
fxed or removable appliances that involve movement
or repositioning of the teeth or operative restoration
of the teeth or prosthetics�
• Orthognathic surgery is covered for the treatment of
TMJ and craniomandibular disorder, as determined
by Anthem BCBS’s medical policy criteria�
• Bone grafts for the purpose of reconstruction of
the jaw and for treatment of cleft lip and palate
is a covered service, but not for the sole purpose
of supporting a dental implant, dentures, or
dental prosthesis�
• A sound natural tooth is a viable tooth (including
natural supporting structures) that is free from
disease that would prevent continual function of
the tooth for at least one year� In the case of primary
(baby) teeth, the tooth must have a life expectancy
of one year� A dental implant is not a sound
natural tooth�
• Dependent child is defned by the age limit for
a dependent child or student dependent child,
whichever is later, if applicable, as specifed in
the Plan�
• You pay all charges that exceed the allowed amount
as determined by Anthem BCBS when you use an
out-of-network provider�
Anthem Blue Cross Blue Shield PPO Plan 15