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LAPRA Dental Options
The table below provides an overview of the key benefits 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.
Benefit Feature
Anthem Blue Cross
PPO Dental Plan
Anthem Blue Cross
HMO Dental Plan
(California Residents Only)
Providers
PPO Network
Non-PPO Network*
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.
Click here for the
LAPRA 2017-2018 Medical &
Dental
monthly pr
emium
r
ates
.
An i
nsert
is also
included
in your enrollment packet
.