2015 Benefit Guide

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DENTAL INSURANCE
Anthem Dental Employee Cost
Type of Coverage
Per
Paycheck Cost
Employee Only $4
Employee & Spouse $8
Employee & Child(ren) $10
Employee & Family $15
Anthem Dental
PPO
In-Network
Out-of-Network
Providers Benefit
Calendar Year
Deductible  Applied to Basic and Major services
$50 individual
$150 family
$50 individual
$150 family
Annual
Maximum
 Applied to Preventive, Basic and Major services $1,000 $1,000
Preventive
Services
 Oral examinations
 Bitewing and Intraoral x-rays
 Full mouth x-rays
 Topical fluoride treatments
 Sealants
100% 80%
Basic
Services
 Fillings
 Simple Extractions
 Endodontics
 Periodontics
80% 60%
Major
Services
 Dentures
 Crowns
 Inlays
 Onlays
50% 50%
Orthodontia  Covers child orthodontia to age 19
50% up to $1,000
Lifetime maximum
(No deductible)
50% up to $1,000
Lifetime maximum
(No deductible)
Anthem Website
You can access an online directory by going to
■ Click on “Find a Doctor” on the right side of the page
■ You may search as a Guest or by logging in as a Member
■ Indicate the state in which you are searching for a provider
■ Choose Dental as the type of care you are looking for
■ Choose Dental Complete as the plan name
■ You can narrow down your list of providers by specifying a
specialty and the zip code
■ Hit the Search button to display your results