Page 10 - JFSLA - Benefits Guide 2018-2019 (5.29.18)

Benefits

Dental Insurance

Anthem | DHMO Dental Plan
With the Dental Health Maintenance Organization (DHMO) plan through Anthem, you are required to select a general dentist to
provide your dental care. You will contact your general dentist for all of your dental needs, such as routine check-ups and
emergency situations. If specialty care is needed, your general dentist will provide the necessary referral. For covered procedures,
you'll pay the pre-set copay or coinsurance fee described in your DHMO plan booklet. Please keep a copy of your booklet to refer
to when utilizing your dental care. This will show the applicable copays that apply to all of the dental services that are covered
under your plan.

Anthem | PPO Dental Plan
With the Anthem Preferred Provider Organization (PPO) Dental plan, you may visit a PPO dentist and benefit from the negotiated
rate or visit a non-network dentist. When you utilize a PPO dentist, your out-of-pocket expenses will be less. You may also obtain
services using a non-network dentist; however, you will be responsible for the difference between the covered amount and the
actual charges, and you may be responsible for filing claims.

Carrier Anthem Anthem

Plan Name Dental HMO 2000C Dental Complete PPO
Network Name
Anthem Dental Net® In-Network Out-of-
Network

Dental Benefits
Calendar Year Maximum Unlimited $2,000 $1,000
Annual Deductible
- Individual $0 $50
- Family $0 $150

Preventive Services (Plan Pays) 100% for Most Services 100% 80%

See Copay Schedule
Basic Services (Plan Pays) See Copay Schedule 80% 80%

Major Services (Plan Pays) See Copay Schedule 50% 50%

Orthodontia
- Children $1,695 60% Max $1,000 60% Max $1,000
- Adults $1,895 60% Max $1,000 60% Max $1,000

Finding a Dental Provider
www.anthem.com/ca: From the Anthem website, scroll down and click on the blue link labeled “Find a doctor>.”
Next, under “Search as Guest?” click on “Search by Selecting a Plan or Network.” Under “What type of care are you
searching for?” select “Dental.” Under “What state do you want to search in?” select your state of residence, and
under Select a plan/network, select the network listed under “Dental.” Refer to the applicable network names
(shown above and also on page 5 of this guide) when you are prompted to select a plan. You may search by name
or specialty under “Whose name is:” and “Who specializes in:”

10