Page 16 - SunWest EE Guide 09-19 Outside CA

Dental Plan

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
Network Name Dental Complete Non-Network

Dental Benefits
Calendar Year Maximum Benefit $1,500 $1,000

Annual Deductible
- Individual $50 $50
- Family $150 $150
Preventive Services No Charge No Charge*

Basic Services Deductible, 20% Deductible, 30%*
Major Services Deductible, 50% Deductible, 50%*
Orthodontia
- Child 50% / $1,000 Lifetime Benefit Maximum
- Adult 50% / $1,000 Lifetime Benefit Maximum
*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.
Predetermination enables you and your Go to www.anthem.com/ca.
dentist to know in advance what the  PPO: Refer to the “Dental Complete” network
payment will be for any service that may
be in question.

16 Employee Benefits