Page 11 - KNCH Benefits Guide 2019 - Final

DENTAL INSURANCE

ANTHEM | PPO DENTAL PLAN
Available in all states
With the Anthem PPO Dental plan, you may visit a PPO dentist and benefit from the negotiated rate or visit a non-network
dentist. When you utilize a PPO dentist, your out-of-pocket expenses will be less. You may also obtain services using a non-
network dentist; however, you will be responsible for the difference between the covered amount and the actual charges and
you may be responsible for filing claims.

Anthem
Plan Features PPO
Network PPO Network Non-Network*

DENTAL BENEFITS Dental Complete
Calendar Year Maximum Benefit $2,000

Annual Deductible
Individual $50 $50
Family 3x Individual 3x Individual
Waived for Preventative Services Yes Yes
Preventive Services (Plan Pays) 100% 100%
Oral Exams, Cleanings, Routine X-Rays, Fluoride Application, Deductible waived Deductible waived
Sealants, Full-mouth X-Rays
Basic Services (Plan Pays) 100% 80%
Fillings, Space Maintainers (non-orthodontic), Oral Surgery -
Simple & Uncomplicated Extractions, Surgical & Non-Surgical
Periodontics, Root Canal Therapy / Endodontics, Brush Biopsy

Major Services (Plan Pays) 60% 50%
Crowns, Inlays, Onlays, Dentures, Implants, Bridges, Relines,
Rebases, and Adjustments, Repairs - Bridges, Crowns, and
Inlays

Orthodontia
Covered Family Members Adult & Children
Coinsurance 50%
Lifetime Benefit Maximum $1,500

*If you reside in TX, non-network benefits will mirror PPO Network benefits.

PLEASE NOTE
We strongly recommend you ask your dentist for a predetermination if total charges are expected to exceed $300.
Predetermination enables you and your dentist to know in advance what the payment will be for any service that may be
in question.

FINDING A DENTAL PROVIDER:
Go to www.anthem.com. Select “Dental Complete” or call 844.729.1565

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