Dental and Vision Plan Options and Summaries

2022 Anthem Dental Group# 165970 and VSP Vision Benefit Summaries – both are self-funded plans EFFECTIVE JANUARY 1, 2022

DENTAL OPTIONS BUNDLED WITH FLAT $15,000 LIFE & ADD BENEFIT

ANTHEM DENTAL BENEFITS COMPLETE NETWORK LOW PLAN HIGH PLAN
  In Network Out of Network In Network Out of Network
Deductible $50 per person $50 per person $50 per person $50 per person
Annual Benefit Maximum $1,000 per person $1,000 per person $1,500 per person $1,500 per person
Diagnostic and Preventive 100% 80% 100% 100%
Basic 80% 60% 90% 80%
Major Not Covered Not Covered 60% 50%
Orthodontia (adult & children) Not Covered Not Covered 50% 50%

VISION OPTIONS

VSP DIRECT In Network Out of Network
Core Vision Plan
Exam Only (every 12 months) $10 Copay Up to $50
BUY UP VISION PLAN
Includes Core Vision benefits in addition to the benefits below:
Lenses (Every 12 months)
Single Vision, Bifocal, Trifocal, Lenticular
$25 Copay Up to $55 – $125 depending on Lenses
Contact Lenses (Every 12 Months)
Contact lenses are in place of lenses and frames
Elective
Medically Necessary
$25 Copay
Up to $130
Up to $210
Up to $105

Anthem Dental Plan Options

The Synod of the Pacific offers a choice of dental plans with Anthem Employee Benefits. When an employee enrolls in either the low option dental plan or the high option plan, they will automatically be enrolled in a life insurance benefit of up to $15,000 and the Resource Advisor Employee Assistance Plan at no additional cost.

To find a dental provider in your area, go to: www.anthem.com/ca/findadoctor, search as a Guest, answer questions selecting “Dental Complete” as the Plan/Network.

Group Name: Synod of the Pacific

Anthem Dental Member Services: (877) 567-1804

Plan #: 1659700003(high) / 1659700005 (low)

Anthem Dental Benefits Complete Network In Network Out of Network In Network Out of Network
 Life Insurance Benefit Low Plan High Plan
Calendar Year Deductible
Individual
Family
$50 per person $50 per person $50 per person $50 per person
Annual Benefit Maximum
Per covered person
$1,000 $1,000 $1,500 $1,500
Diagnostic & Preventive
(Deductible Waived)
Oral exams, emergency exams, X-rays, fluoride treatments, sealants to age 19, space maintainers to age 19.
100% 80% 100% 100%
Basic Restorative
Fillings, simple extractions, stainless steel crowns, oral surgery, root canal therapy, periodontics and general anesthesia and intravenous sedation.
80% 60% 90% 80%
Major Restorative
Crowns, inlays and onlays, full and partial dentures, dental prosthetic repairs, bridges, dental implants, and TMJ benefits ($1,000 lifetime maximum benefit).
Not Covered Not Covered 60% 50%
Orthodontia
Orthodontic extractions, full or partial bands, appliances (removable and fixed) ($1,500 lifetime maximum).
Not Covered Not Covered 50% 50%

Summary of Benefits and Coverages (SBC’s)

*Note – Dental and Life Insurance come as a package deal through the Synod*

VSP Vision Plan Options

The Synod of the Pacific offers a choice of a Core Vision Plan or a Buy-up Vision Plan (which includes Core). These plans utilize the VSP network. Please visit https://vsp.com/ to find providers in your area.

VSP Member Services:  (800) 877-7195

Group #30085406

Vision Benefits – VSP In Network Out of Network
Core Vision Plan
Exam Only (every 12 months)
Frequency: Every 12 Months
Discounts available for lenses and frames, see plan.
$10 Copay Up to $50
BUY UP VISION PLAN
Includes Core Vision benefits in addition to the benefits below:
Exam
Frequency: Every 12 Months
$10 Copay Up to $50
Lenses
Frequency: Every 12 Months
Single Vision*
Bifocal*
Trifocal*
Lenticular*


$25 Copay
$25 Copay
$25 Copay
$25 Copay


Up to $50
Up to $75
Up to $100
Up to $125
Contact Lenses+
Frequency: Every 12 Months
Elective
Medically Necessary


Up to $130
$25 Copay


Up to $105
Up to $210
Frames
Frequency: Every 24 Months

Up to $130
$20 off amount over Max

Up to $70

* Note: Percentages and dollar amounts are after copayment.

+ Contact Lenses are in place of lenses and frame.

Summary of Benefits and Coverages (SBC’s)