Page 9 - Benefits Guide TeleSign 2020

Dental Insurance

Anthem Blue Cross | PPO
This plan offers you the freedom and flexibility to use the dentist of your choice. However, you will maximize your benefits and
reduce your out-of-pocket costs if you choose a dentist who participates in the Anthem Blue Cross Dental Complete network. If you
obtain services using a non-network dentist, you will be responsible for paying the dentist up front and submitting a claim to
Anthem for reimbursement. Anthem will not pay out-of-network providers directly. You may also be responsible for the difference
between the covered amount and the actual charges. The chart below provides a high-level overview of your dental plan.

Anthem Blue Cross
PPO Plan

Network Name Dental Complete Non-Network
Dental Benefits

Calendar Year Maximum $2,500 $2,500
Deductible (Annual)
- Individual $50 $50
- Family $150 $150

(deductible waived for preventive care) (deductible waived for preventive care)

Preventive (Plan Pays)
No charge No charge*
Exams, X-Rays, Cleanings
Basic Services (Plan Pays)
Deductible, then 10% Deductible, then 20%*
Fillings, Oral Surgery,
Major Services (Plan Pays)
Deductible, then 40% Deductible, then 50%*
Crowns, Prosthetics
Orthodontia (child only) 50% to $1,500 lifetime benefit maximum
*Dentists who are out-of-network have not agreed to any set pricing, and may bill you for the difference between what Anthem
Blue Cross pays them and what the dentist usually charges.

Finding a Dental Provider
• Go to www.anthem.com/ca
• Select “Find a Doctor”
• Search as a guest and answer the questions
• Refer to the “Dental Complete” network

Helpful Tip
We strongly recommend you ask your dentist for a predetermination if the total charges are expected to exceed $200. A
predetermination enables you and your dentist to know in advance what the payment will be for any planned service.

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