Dental and Vision Plan Options and Summaries
(These are self-funded plans EFFECTIVE JANUARY 1, 2023
Group Name: Synod of the Pacific
Anthem Dental Member Services: (877) 567-1804 Anthem Plan #: 1659700003 (high) / 1659700005 (low)
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.
| Anthem Dental Benefits Complete Network | In Network | Out Of Network | In Network | Out Of Network |
| Benefits | Low Plan | High Plan | ||
| Calendar Year Deductible IndividualFamily | $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% |
VISION OPTIONS
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
Summary of Benefits and Coverages (SBC’s) can be found at: https://drive.google.com/drive/folders/19vnM0dY8AdwsJDbHO-Gn2mDNLSdq1E7_?usp=sharing
*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 |
Up to $50 |
| Contact Lenses+
Frequency: Every 12 Months
Elective
Medically Necessary |
Up to $130 $25 Copay |
Up to $105 |
| 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) can be found at: https://drive.google.com/drive/folders/19vnM0dY8AdwsJDbHO-Gn2mDNLSdq1E7_?usp=sharing
IMPORTANT NOTE: This information is intended as a summary only; benefits may contain limitations and exclusions. Benefits cannot be guaranteed in advance and are subject to change by the insurer without notice. If a conflict exists between this summary and the policy, the policy will be controlling