Page 14 - HM Benefits Guide 2019 CA

Dental Plans

Anthem Blue Cross | PPO Dental Plans
Unless you elect otherwise, we’ll auto-enroll you in the PPO (Low) plan at NO COST to you
We offer the choice of two PPO dental options*
With both plans, you may see the dentist of your choice; however, it’s less expensive to see an in-
network dentist (one that has a contract with Anthem). If you select a non-network dentists, you are
responsible for any costs not covered by the plan.

Anthem Blue Cross Anthem Blue Cross
PPO (Low) PPO (High)
Network Name Dental Non-Network Dental Non-Network
Complete Complete
Dental Benefits
Calendar Year Maximum Benefit $1,000 $1,000 $1,500 $1,500
Annual Deductible
• Individual $100 $150 $50 $100
• Family 3x Individual 3x Individual 3x Individual 3x Individual
Preventive Services No Charge No Charge** No Charge No Charge**
Basic Services Deductible, Deductible, Deductible, Deductible,
30% 50%** 10% 20%**
Major Services Deductible, Deductible, Deductible, Deductible,
50% 50%** 40% 50%**
Orthodontia
• Covered Members Not Covered Not Covered Adults/ Adults/
• Coinsurance N/A N/A Children Children
• Lifetime Maximum Benefit N/A N/A 50% 50%
$1,500 $1,500
*You must actively opt-out in PlanSource if you wish to decline dental benefits.
**Non-network reimbursement: 80th percentile.

Finding a Provider
Go to www.anthem.com/ca. Refer to the “Dental Complete” network.

Tip: Ask your dentist for a predetermination if dental charges are expected to exceed $300.
Predetermination allows you and your dentist to know up front what your payment will be for
any service that may be in question.

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