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 Max.

$1,000 per person

$1,000 per person

$1,500 per person

$1,500 per person

Diagnostic & 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



Up to $130
$25 Copay



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

Benefits

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)
 
(Please click on the links below to view the 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

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

 

$25 Copay

 

Up to $50

 

Bifocal

 

$25 Copay

 

Up to $75

 

Trifocal

 

$25 Copay

 

Up to $100

 

Lenticular

 

$25 Copay

 

Up to$125

Note: Percentages and dollar

 

 

amounts are after Copayment.

 

 

Contact Lenses*

 

 

Frequency: Every 12 Months

 

 

Elective

Up to $130

Up to $105

Medically Necessary

$25 Copay

Up to $210

*Contact lenses are in place

 

 

of lenses and frame.

 

 

Frames

 

Frequency: Every 24 Months

Up to $130;

 

20% off amount over Max

Up to $70


Summary of Benefits and Coverages (SBC's) (Please click on the links below to view the SBC's)