Page 4 - Identity MSO 2021 Employee Benefits - Semi Monthly
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Identity MSO
2021 Employee Benefits Brochure
***A full-network plan (Access +) which includes UCLA and Cedar Sinai is available as well. Benefits will remain the same but monthly
premium will be greater.
NEW! Blue Shield Dental Plans
DHMO Low DHMO High DPPO
In-Network In-Network In-Network*
Annual Benefit Maximum Unlimited Unlimited $1,500
Calendar Year Deductible:
Individual / Family None None $50 / $150
Preventive & Diagnostic:
Office Exams / Cleanings / X- See fee schedule See fee schedule Covered 100%**
Rays
Basic Services:
Fillings / Root Canal / Oral See fee schedule See fee schedule 20%
Surgery
Major Services:
Crowns / Dentures / Bridges See fee schedule See fee schedule 50%
Orthodontia $1,800 child $1,400 child 50% up to $1,500 lifetime
$2,650 adult $1,700 adult max (adult & child)**
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*Out of Network services are covered up to the 90 percentile of reasonable & customary. Member is responsible for
any charges above allowable amounts. Out of network annual max is $1,500.
**Deductible waived.
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