Dental & Vision Benefit Plans

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

DENTAL BENEFITS

DENTAL BENEFITSLOW OPTIONHIGH OPTION
 In NetworkNon NetworkIn NetworkNon 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 CoveredNot Covered60%50%
Orthodontics
*Orthodontic extractions, full or partial bands, appliances
* Lifetime Maximum Benefit $1,500
Not CoveredNot Covered50%50%

VSP VISION BENEFITS

CORE VISION PLAN
 IN NETWORKOUT OF NETWORK
Exam Only
* Frequency – every 12 months
$10 CopayUp to $50
BUY UP PLAN
Examination
* Frequency – every 12 months
$10 CopayUp to $50
Lenses
* Frequency – every 12 months Single VisionBifocalTrifocalLenticular

$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/ACCIDENTAL DEATH

Insurer: Anthem

POLICYBENEFIT
 Life Insurance Benefit$15,000
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

You will automatically be enrolled in Resource Advisor if you enroll in either Anthem Dental Plans