Page 7 - NickCo Hospitality_2017 EE Benefits Guide_Hourly Associates_12.08.16
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BENEFITS
Dental Insurance
Anthem Blue Cross | PPO Dental Plan
With the Anthem Blue Cross Preferred Provider Organiza on (PPO) dental plan, you may visit a PPO den st and benefit from the
nego ated rate or visit a non‐network den st. When you u lize a PPO den st, your out‐of‐pocket expenses will be less. You may
also obtain services using a non‐network den st; 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 Blue Cross
Plan Name PPO Plan
Network Name Anthem Dental Complete Non‐Network
Dental Benefits
Calendar Year Maximum $1,500 $1,500
Deduc ble (Annual)
‐ Individual $50 $50
‐ Family $150 $150
Preven ve No Charge No Charge (UCR)
Exams, X‐Rays, Cleanings
Basic Services Deduc ble, 20% Deduc ble, 20% (UCR)
Fillings, Oral Surgery, Endodon cs, Periodon cs
Major Services Deduc ble, 50% Deduc ble, 50% (UCR)
Crowns, Dentures, and Bridges
Orthodon a
‐ Covered Members Children Only
‐ Coinsurance 50%
‐ Life me Benefit Maximum $1,000
Finding a Dental Provider
Go to www.anthem.com/ca or call (877) 567‐1804. Refer to the “Dental Complete” network when prompted.
Tips For Using Your Dental Benefits
Use contracted network providers when possible.
If you choose to see a den st outside of the network, you’ll be reimbursed based on Usual and Customary (UCR) charges at
the 80th percen le. You would be responsible for any amounts over the UCR as well as any coinsurance.
Ask for a predetermination of benefits.
We strongly recommend you ask your den st for a predetermina on if total charges are expected to exceed $300.
Predetermina on enables you and your den st to know in advance what the payment will be for any service that may be in
ques on.
Have dental checkups regularly.
Rou ne dental visits not only preserve your smile, but they can provide an opportunity for the early detec on of serious
diseases such as diabetes.
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