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DENTAL PLAN CHOICES






       Anthem Blue Cross | PPO Plans

       Our dental plans offer you the freedom and flexibility to use the dentist of your choice. However, you will maximize your benefits and reduce your out-of-pocket
       costs if you choose a dentist who participates in the Anthem Blue Cross network. When you utilize a network dentist, your out-of-pocket expenses will be less,
       however,  you  will  usually  pay  the  lowest  amount  for  services  when  you  visit  a  PPO  dentist.  If  you  obtain  services  using  a  non-network  dentist,  you  will  be
       responsible for the difference between the covered amount and the actual charges and you may be responsible for filing claims. The chart below provides a high-
       level overview of your dental plan.

                                                        Option 1                                  Option 2
                                                  Anthem Blue Cross                         Anthem Blue Cross
       Plan Name                                        PPO High                                  PPO Low

       Network Name                       Dental Complete       Non-Network         Dental Complete       Non-Network          Note:
                                                                                                                               We strongly recommend you
       Dental Benefits                                                                                                         ask your dentist for a
       Calendar Year Maximum Benefit            $1,500              $1,500                $1,000             $1,000            predetermination if total
                                                                                                                               charges are expected to
       Annual Deductible                                                                                                       exceed $300.
        - Individual                             $50                 $100                 $100                $150             Predetermination enables
        - Family                                $150                 $300                 $300                $450
                                                                                                                               you and your dentist to know
       Preventive Services                    No Charge           No Charge*            No Charge          No Charge*          in advance what the
       Basic Services                      Deductible, 10%     Deductible, 20%*      Deductible, 30%     Deductible, 50%*      payment will be for any
                                                                                                                               service that may be in
       Major Services                      Deductible, 35%     Deductible, 50%*      Deductible, 50%     Deductible, 50%*
       Orthodontia
        - Child                            50% / $1,500 Lifetime Benefit Maximum                 Not Covered
        - Adult                            50% / $1,500 Lifetime Benefit Maximum                 Not Covered

       *Dentists who are out-of-network have not agreed to
       pricing, and may bill you for the difference between                                                              Finding a Dental Provider
       what Anthem pays them and what the dentist usually                      Go to www.anthem.com/ca or call (877) 567-1804. Refer to the Anthem Dental
       charges.                                                                                                        Complete network when prompted.






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