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LAPRA Dental Options
The table below provides an overview of the key benefits and bi-weekly contributions provided through the
LAPRA Dental Plans. Refer to the Anthem Blue Cross PPO Dental Plan or HMO Dental Plan materials for a
complete description of the LAPRA dental benefits including terms of coverage, exclusions and limitations.
Your Cost for Dental Per Pay Period
Your cost for Dental is based on your selected plan and coverage category as well as the amount of the City of
Los Angeles subsidy. The table below reflects the member cost per pay period effective July 1, 2017.
Benefit Feature
Anthem Blue Cross
PPO Dental Plan
Anthem Blue Cross
HMO Dental Plan
(California Residents Only)
Providers
Network Providers
Non-Network Providers*
HMO Dental Providers Only
Calendar Year Deductible
None
$25 per person
$50 per family
(waived for Preventive
& Diagnostic)
None
Calendar Year Maximum
$2,000 per person
(excluding Orthodontia)
None
Preventive & Diagnostic
• Cleanings
• Exams
• X-rays
• Sealants
100% (3/year)
100%
100%
100%
100% (3/year)
100%
100%
100%
No Charge
No Charge
No Charge
$10 co-pay per tooth
Basic
• Extractions
• Fillings
• Root Canal
• Oral Surgery
90%
90%
90%
90%
80%
80%
80%
80%
No Charge
No Charge
$0-$180 co-pay per tooth
$0-$200 co-pay per tooth
Major
• Crowns & Bridges
• Dentures
• Implants
60%
60%
60%
60%
60%
60%
$100-$200 co-pay per tooth
$150-$200 co-pay per tooth
n/a
Orthodontia
(including adults and
children)
50%
50%
$1,750 co-pay (child)
$1,750 co-pay (adult)
(Services exceeding a 24-month treatment
period will require additional co-pays.)
Orthodontia
Lifetime Maximum
$1,750 per person (Includes $300 for
pre-orthodontic visit and treatment plan)
n/a
* For
non-network providers
, benefits are based on the customary and reasonable charge. You are responsible for any difference between the
amount charged and the customary and reasonable charge, plus any deductible and/or coinsurance amount.
Anthem Blue Cross
PPO Dental Plan
Anthem Blue Cross
HMO Dental Plan
(California Residents Only)
Single
$0.00
$0.00
2-Party
$13.50
$11.50
Family
$16.00
$14.50