Page 15 - Veritone EE Guide OOS_ 2019

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.