Page 8 - ASMS Employee Guide 2017

Dental Insurance

Anthem Blue Cross| DHMO Dental Plan
With the Dental Health Maintenance Organization (DHMO) plan through Anthem Blue Cross, you are
required to select a general dentist who is a member of the Dental Net HMO network to provide
your dental care. You will contact your general dentist for all of your dental needs, such as routine
check-ups and emergency situations. If specialty care is needed, your general dentist will provide the
Note necessary referral. For covered procedures, You will pay the pre-set copay or coinsurance fee
described in your DHMO plan booklet. Please keep a copy of your booklet to refer to when utilizing
We strongly rec- your dental care. This will show the applicable copays that apply to all of the dental services that are
ommend you ask covered under this plan.
your dentist for a
predetermination if Anthem Blue Cross| PPO Dental Plan
total charges are
expected to exceed With the Anthem Blue Cross Preferred Provider Organization (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
$300. Predetermi-
dentist from Anthem’s Dental Complete PPO network, your out-of-pocket expenses will be less. You
nation enables you
and your dentist to may also obtain services using a non-network dentist; however, you will be responsible for the
know in advance difference between the covered amount and the actual charges and you may be responsible for
what the payment filing claims.
will be for any ser-
vice that may be in ANTHEM BLUE CROSS ANTHEM BLUE CROSS
question. Plan Features DHMO Plan PPO Plan
Network Dental Net HMO Dental Complete Non-Network

Calendar Year Maximum Unlimited $1,500 $1,250

Deductible (Annual)
- Individual / Family None $50 / $150 $50 / $150

Deductible Waived for N/A Yes No
Preventive

Preventive (Plan Pays) 100% 100% 80%
Exams, X-Rays, Cleanings

Basic Services (Plan Pays) See Copay Schedule 80% 60%
Fillings, Oral Surgery
Major Services (Plan Pays) See Copay Schedule 50% 40%
Crowns, Prosthetics,
Endodontics, Periodontics
Orthodontia
- Covered Members Children & Adults Not Covered
- Copay $1,695 / $1,895 N/A
- Coinsurance N/A N/A
- Lifetime Benefit Max N/A

FINDING A MEDICAL PROVIDER:
Go to www.anthem.com/ca or call Member Services at (866) 207-9878 to find a
provider near you. To search, please click on MENU, then click: > FIND A DOCTOR

DHMO participants should select the Dental Net HMO Network or call (800) 627-0004
PPO participants should select the Dental Complete Network or call (877) 567-1804

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