LAPRA 2018/19 Benefits Guide for Active Members

13 2018/2019 LAPRA Dental Plans At-a-Glance 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, 2018. 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) Up to 24 months of standard orthodontic care * 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. Coverage Category 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