Page 10 - Humano EE Guide 06-20

Dental Plan Choices

Anthem Blue Cross | PPO Plan
This plan offers 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.

Anthem Blue Cross
Plan Name PPO
1
Network Name Dental Complete Non-Network
Dental Benefits
Calendar Year Maximum Benefit $1,500
Annual Deductible
- Individual $50
- Family $150
Preventive Services No Charge No Charge
Basic (Restorative) Services Ded, 10% Ded, 20%
Endodontics Ded, 10% Ded, 20%

Periodontics Ded, 10% Ded, 20%
Extractions Ded, 10% Ded, 20%
Major (Restorative) Services Ded, 40% Ded, 50%
Prosthodontics Ded, 40% Ded, 50%
Repairs / Adjustments Ded, 40% Ded, 50%
Orthodontia
- Child 50% / $1,500 Lifetime Benefit Maximum
- Adult Not Covered
1 Dentists who are out-of-network have not agreed to pricing, and may bill you for the difference between what
Anthem Blue Cross pays them and what the dentist usually charges.

Note:
We strongly recommend you ask your
dentist for a predetermination if total Finding a Dental Provider
charges are expected to exceed $300. Go to www.anthem.com/ca or call (888) 209-7852.
Predetermination enables you and your Refer to the “Dental Complete” network when
dentist to know in advance what the prompted.
payment will be for any service that may
be in question.

10 Employee Benefits