LAPRA 2018/19 Benefits Guide for Retired Members

13 Dental The Dental Plans cover preventive, basic, and major services, as well as orthodontia. Two options are available: • Anthem Blue Cross PPO Dental Plan • Anthem Blue Cross HMO Dental Plan (for California residents only) Anthem Blue Cross PPO Dental Plan With the Anthem Blue Cross PPO Dental Plan you can visit any dentist and receive benefits; however, you will receive the greatest value for your dollar when you use network dentists. All dentists nationwide participating in the Anthem Blue Cross Dental Blue Complete Network 100, 200 or 300 are considered Network dentists* under the LAPRA PPO Dental Plan. Network dentists have contracted with the plan to provide services at reduced rates, so using these dentists will save you money. Plus, deductibles do not apply when you use in-network dentists. If you choose a non-network dentist, the plan will still provide benefits, but your out-of-pocket expenses may be higher, because the Anthem Blue Cross negotiated fees do not apply to non-network dentists. There is no deductible for non-network preventive and diagnostic services. IMPORTANT: When using a non-network provider under the Anthem Blue Cross PPO Dental Plan, the maximum allowable charge is based on the customary and reasonable charge for professional services as determined by Anthem Blue Cross. Members are responsible for any difference between the non-network provider’s actual charge and the maximum allowable charge, as well as any deductible and/ or coinsurance percentage. Anthem Blue Cross HMO Dental Plan The HMO Dental Plan offers comprehensive coverage designed to fit your family’s budget. All services must be performed by an Anthem Blue Cross HMO Dental provider in order to be covered. Many services are covered at 100%, while others require a co-pay. Deductibles and calendar year maximums do not apply. Each family member may choose a different primary dentist and should be listed on your enrollment form. If you do not list a primary dentist on your enrollment form, Anthem Blue Cross will automatically assign one to you within 30 miles from your home address. If you’re not satisfied with Anthem Blue Cross’ selection, you should call Anthem Blue Cross at 866-527-5801 to request a change in primary dentist. This plan is only available to California residents. * All claims incurred in Idaho or Montana will be paid as in-network. Something to Smile About The Anthem Blue Cross PPO Dental Plan is designed for individuals and families to promote good oral hygiene and offer convenient, affordable dental coverage. Highlights of the plan include: • Access to a broad nationwide network of preferred dentists with in-network coverage available in most geographic locations regardless of state residency • No deductible with network providers • No deductible for Preventive and Diagnostic services (network and non-network) • Calendar year maximum of $2,000 per person • Lifetime maximum of $1,750 for orthodontia • Three cleanings per calendar year covered at 100% (one additional cleaning per calendar year for pregnant women) • Freedom to choose any dentist To find an Anthem Blue Cross dental provider in your area, follow the instructions on page 9.