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DENTAL INSURANCE

HMO Dental Plan
With the Health Maintenance Organization (HMO) Dental 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
Note procedures, you'll pay the pre-set copay described in your HMO plan booklet. Please keep a copy of
We strongly rec- your booklet to refer to when utilizing your dental care. This will show the applicable copays that
ommend you ask apply to all of the dental services that are covered under this plan.
your dentist for a
predetermination PPO Dental Plan
if total charges With the Anthem Dental Complete Preferred Provider Organization (PPO) Dental plan, you may visit
are expected to a PPO dentist and benefit from the negotiated rate or visit a non-network dentist. When you utilize a
exceed $300. PPO dentist, your out-of-pocket expenses will be less.
Predetermination
enables you and You may also obtain services using a non-network dentist; however, you will be responsible for the
your dentist to difference between the covered amount and the actual charges and you may be responsible for
know in advance filing claims.
what the pay-
ment will be for
any service that
may be in ques- ANTHEM 2000C ANTHEM DENTAL COMPLETE
tion. Plan Features HMO Plan PPO Plan

DHMO Network Network Non-Network

Calendar Year Maximum Unlimited $1,500

Deductible (Annual) Waived for Preventive Services
- Individual / Family $0 / $0 $50 / $150

Preventive (Plan Pays) 100% 100% 100%

Basic Services (Plan Pays) See Copay Schedule 90% 80%

Major Services (Plan See Copay Schedule 60% 50%
Pays)

Orthodontia $1,695 Copay Child and Adult
Child and Adult 50% with $1,500 Lifetime Max

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