Dental and Vision Benefit Plans

2020 Anthem Dental Group# 165970 and VSP Vision Benefit Summaries - both are self-funded plans
EFFECTIVE JANUARY 1, 2020

Dental Benefits                                                                                    Low Option                                      High Option

 

In Network

Non Network

In Network

Non Network

Calendar Year Deductible
   * Per person, waived for Preventive Care

$50

$50

$50

$50

Annual Benefit Maximum
   * Per Covered Person

$1,000

$1,000

$1,500

$1,500

Preventive Service (deductible waived)
   * Office Visits/Cleanings
   * Fluoride Treatment

100%

80%

100%

100%

Diagnostic Services
   * Oral Examinations, emergency exams
   * X-rays
   * Diagnostic Consultation

100%

80%

100%

100%

Basic Restorative Services
   * Fillings: Amalgam, Silicate, Acrylic
   * Oral Surgery - Simple extractions, stainless steel crowns
   * Endodontic Services/Root Canal Therapy
   * Periodontal Services

80%

60%

90%

80%

Major Services - after six months of continuous coverage
   * Prosthodontics, removable and fixed
   * Implants
   * Lifetime Maximum Benefits $1,000

Not Covered

Not Covered

60%

50%

Orthodontics
   *Orthodontic extractions, full or partial bands, appliances       
   * Lifetime Maximum Benefit $1,500

Not Covered

Not Covered

50%

50%



 VSP Vision Benefits
                                                                                                                                                                                          Core Vision Plan

 

   In Network

Out of Network

Exam Only
   * Frequency - every 12 months

$10 Copay

Up to $50

Buy Up Plan

Examination
  * 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
$25 Copay


Up to $50
Up to $75
Up to $100
Up to $125

Contact Lenses (Every 12 Months)
   * Medically Necessary
   * Elective
   * Contact lenses are in place of lenses and frames

$25 Copay
Up to $130

Up to $210
Up to $105

Frames
   * Frequency - every 24 months

Up to $130
then 20% off
amount over
maximum allowance

Up to $70




Life Insurance
Life/AD&D

Anthem


   * Life Insurance Benefit
   * Accidental Death Benefit

$15,000
$15,000


You will automatically be enrolled in Life Insurance when you enroll in either of the Anthem dental plans.

 

Resource Adviser Employee Assistance Plan
You will automatically be enrolled in Resource Advisor if you enroll in either Anthem Dental Plans