Page 9 - FINAL Crane Country Day School 2017-18 Benefits Guide

Dental Plan 9

Anthem | PPO Dental Plan

With the Anthem 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 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 PPO Dental

In-Network Out-of-Network

You Pay You Pay
Plan Basics

Annual Deductible Individual: $25 Individual: $25
Family: $75 Family: $75

Annual Benefit Maximum $4,000

Preventive and Diagnostic Services
Oral Exams, X-rays, Cleanings Deductible waived, 100% Deductible, 100%

Basic Services
Basic Restorative, Extractions, Oral Surgery Deductible, 80% Deductible, 80%

Major Services
Inlays, Onlays, Crowns and Prosthetics Deductible, 50% Deductible, 50%

Orthodontia Services
For Children Only Deductible, 50% Deductible, 50%

Lifetime Maximum $1,500 $1,500

* Footnote: This is only a summary of benefits. Please refer to plan documents for full details.

To Find an Anthem Provider: www.anthem.com/ca