Page 9 - Open Sky BROCHURE - HOURLY 2021-2022

9/1/2021-8/31/2022 Employee Benefits Brochure
Hourly

Dental Plan – Anthem

In-Network Cost shown
In-Network Out-of-Network
Your Copay/ Coinsurance

Annual Benefit Maximum $2,000

Calendar Year Deductible:
$50 / $150
Individual / Family $50 / $150

Preventive & Diagnostic:

100% covered 90% covered
Office Exams / Cleanings / X-Rays

Basic Services:

Fillings / Extractions 80% covered 80% covered

Endodontics / Root Canal 50% covered 50% covered

Major Services:
50% covered
Crowns / Dentures / Bridges 50% covered

Orthodontia Not covered

*Please refer to carrier benefit summaries for more detailed information & out-of-network benefits

**If you do not see a PPO provider, and your provider charges more than the PPO provider’s allowable fee, you
will be responsible for the excess charges. Out of network annual max is $2,000.

Visit https://www.anthem.com/find-care/ to find an in-network provider. Continue as a Guest and Select Dental
Complete as your network.

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