Page 14 - PetVet 2022 Master Benefits Guide_CA Final

Dental

PetVet offers comprehensive dental coverage through Anthem BlueCross

BlueShield. You have the choice between the following three dental plan options.

High Plan Medium Plan Low Plan
In & Out-of-Network In & Out-of-Network In & Out-of-Network Only
Annual Deductible
Single / Family $50 / $150 $50 / $150 None
Annual Maximum
Per Person $2,500 $1,500 $750
Services
Preventive / Diagnostic 100% 100% 100%

Basic Services 90% after deductible 80% after deductible 80%

Major Services 60% after deductible 50% after deductible Not Covered

Orthodontia
Eligible Members Adults & Children Children to age 18

Not Covered
Benefit 50% No Deductible 50% No Deductible
Lifetime Maximum $2,500 $1,500
Out-of-Network Services
th
Reimbursement 90 Percentile 90 Percentile 90 Percentile
th
th
 All benefits information outlined are subject to plan provisions and contract details. The highlighted
benefits are only a brief summary. Please refer to the Summary Plan Description (SPD) for full details.

 Deductibles, Out-of-Pocket Maximums and frequencies will run on a calendar year basis (1/1 – 12/31)
 Balance Billing may apply with out-of-network providers

Want To Find a Participating Provider?

Visit www.anthem.com then select “Find a Doctor” and choose the Dental Complete

network. Then narrow your search by name, specialty or geographic area.

14