Page 10 - CW Driver Benefit Guide 2019 MAIN

BENEFITS ENROLLMENT GUIDE

DENTAL OPTIONS

Option 1: DHMO Dental Plan
As an Anthem Blue Cross DHMO member, you are required to select a general dentist 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 necessary referral. For covered
procedures, you’ll 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 your dental care. This will show the applicable copays that apply
to all of the dental services that are covered under this plan.

Option 2: PPO Dental Plan
The Anthem Blue Cross PPO plan is a preferred provider dental plan. The benefits cover a wide range of dental
services. 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.

Option 1: Option 2:
Plan Features DHMO Dental Plan PPO Dental Plan
Network Name DentalNet Dental Complete Non-Network
Calendar Year Maximum Benefit Unlimited $2,000
Annual Deductible
- Individual / Family None / None $50 / 3x Individual
Cost Sharing Copay Schedule* Coinsurance (Plan Pays)
Diagnostic and Preventive Services $0-$60 100% 100%
Deductible Waived Deductible Waived
Basic Services
- Fillings $0-$55 Copay 90% 80%
- Endodontics $5-$150 Copay 90% 80%
- Periodontics $0-$185 Copay 90% 80%
Major Services
- Crowns $125 Copay Plus Cost 60% 50%
for Gold or Metal
- Prosthetics (Dentures) $125-315 Copay 60% 50%
Orthodontia 24 Month Banding
- Children $1,695 Copay 50% to $1,500 Lifetime Maximum
- Adults $1,895 Copay 50% to $1,500 Lifetime Maximum

*The table shows samples of copays for some services. Please refer to your DentalNet plan booklet for a
complete list of copays per service.

NOTE: 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.

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