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 |
|
| Contact Lenses (Every 12 Months) * Medically Necessary * Elective * Contact lenses are in place of lenses and frames |
$25 Copay |
Up to $210 |
| Frames * Frequency - every 24 months |
Up to $130 |
Up to $70 |
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| Life Insurance Life/AD&D |
Anthem |
|
| * Life Insurance Benefit * Accidental Death Benefit |
$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 |
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| You will automatically be enrolled in Resource Advisor if you enroll in either Anthem Dental Plans |