Anthem Dental Blue - for Indiana Residents

There are limits on the number of dental services Anthem will cover under the Dental Blue plans.  Limitations applicable to some of the most common services are:

• Oral Evaluations - Limited to two per calendar year
• Prophylaxis or Periodontal Prophylaxis - Limited to two treatments per calendar year
• Fluoride - Limited to two per calendar year for children up to age 19
• X-rays - Limited to one set of full-mouth x-rays or its equivalent in a 5-year period.  Periapical x-rays are limited to 4 films per year
• Bitewing X-rays - Limited to one set of up to 4 films twice per calendar year
• Sealants - Limited to children under 16 years for permanent unrestored first and second molars.  Treatment is limited to one application per tooth per lifetime
• Space Maintainers - Limited to once per quadrant per lifetime for children up to age 16.  Includes all adjustments within six months of placement
• Restorations - Limited to once per surface per tooth every 24 months
• Periodontal Scaling - Limited to once per quadrant every 24 months
• Periodontal Surgery - Limited to one time per quadrant in a 36-month period
• Root Canal Therapy - Limited to one treatment per tooth for initial treatment and one retreatment per tooth - for permanent teeth only.
• Stainless Steel Crowns - Limited to primary teeth only.  Once per tooth in any 5 years
• Crowns - Limited to once per tooth in any five years
• Removable Complete and Partial Dentures - Limited to once in five years.  Benefits are payable for either complete or immediate dentures, but not both.
• General Anesthesia - Covered only when used in conjunction with covered oral surgical procedures

Here's a partial list of exclusions under the Anthem Dental Blue plans:

• For any prescribed drugs, pre-medication or analgesia including charges for nitrous oxide or any similar local anesthetic when the charge is made separately
• Forocclusal guards
• For bleaching of non-vital discolored teeth
• For crown buildups on the same tooth as an amalgam or composite restoration that was done within the same Calendar Year
• For procedures to alter, restore or maintain occlusion, change vertical dimension, and replace or stabilize tooth structure lost by attrition, abrasion, erosion or bruxism
• Harmful habit appliances For services related to diagnosis or treatment related to the temporomandibular joint (TMJ)
• For implants and all adjunctive services performed in conjunction with the placement or removal of implants including but not limited to surgery, cleanings, maintenance and prosthetics placed on implants
• For infection control procedures, if billed separately
• For precision attachments
• For prefabricated resin crown or stainless steel crown with resin window
• For pulpotomy on permanent teeth
• For replacement of a prosthodontic Appliance (fixed or removable) more often than once in any five-year period , whether under this contract or under any prior dental coverage
• For root canal therapy on deciduous teeth
• For sealants on restored teeth (occlusal surface)
• For temporary/interim prosthodontia or appliances (temporary crowns, bridges, partials, dentures, etc.)
• For biopsies
• For services or supplies not specifically listed in the Covered Services section of the Individual Dental Contract