DENTAL INSURANCE

Strong teeth and gums are an important part of good health, which is why the CHEIBA Trust offers you and your eligible

dependents the choice of two comprehensive dental plans through Anthem.

Anthem Blue Dental PPO Plus
Anthem Blue Dental PPO
PLAN HIGHLIGHTS

In Network
Out of Network
In Network
Out of Network
Annual Maximum (per member)
$2,000
$2,000
$2,000
$2,000
Annual Deductible (individual/family)
$25 / $75
$25 / $75
$0
$50 / $150

Plan Pays
Plan Pays
Diagnostic & Preventive Services (deductible does not apply)
Diagnostic & Preventive services do not accumulate towards annual maximum
Services include:





Oral evaluations





X-Rays
100%
100%
100%
80%

Cleanings (Benefit includes (3) three annual cleanings for adults only)

Specified space maintainers
Restorative/General Services (deductible applies)




Services include:





Emergency palliative treatment
80%
80%
80%
60%

General anesthesia

Amalgam and anterior composite restorations
Endodontic Services (deductible applies)




Services include:
80%
80%
80%
60%

Root canal therapy
Oral Surgery Services (deductible applies)




Services include:
80%
80%
80%
60%

Simple and surgical tooth extractions
Periodontal Services (deductible applies)




Services include
80%
80%
80%
60%

Gingivectomy

Osseous surgery
Prosthodontic Services (deductible applies)




Services include





Crowns/onlays
50%
50%
50%
40%

Removable or fixed partials or dentures

Implants
Orthodontic Services





Adults
50% up to $1,500 ¹
50% up to $1,500 ¹
50% up to $1,500 ¹
40% up to $1,500 ¹

Children
50% up to $1,000 ¹
50% up to $1,000 ¹
50% up to $1,000 ¹
40% up to $1,000 ¹
¹ Lifetime Maximum – the cumulative dollar amount the plan will pay for orthodontic treatment incurred by an individual enrollee for the life of the plan. For family coverage, each individual covered under the plan is subject to the
lifetime maximum.

NOTE: This is only an overview of your dental plan choices. Review the specific dental brochures pertaining to each plan for further details and explanations. If discrepancies are found, depend upon the certificate of coverage
itself for accuracy.
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DENTAL INSURANCE

Helpful Information to Help You Decide Which Plan/Network to Choose


Dental PPO
Dental PPO+
Number of In-Network
Access Points: over 4,300
Access Points: over 5,000
Providers
Unique Providers: over 1,700
Unique Providers: over 2,100
Access Points = the number of locations when Anthem has In-Network Providers.
Unique Providers = the number of individual providers in the network.

Both of your dental plan options are Preferred Provider Organizations (PPO) and offer you flexibility to
select the dentist of our choice or a dentist within the extensive Anthem dental network throughout
Colorado. While your dental plan lets you choose any dentist, you may end up paying more for a service if
Routine preventive care such as
regular exams and cleanings can
you visit an out-of-network dentist. Here’s why:
help prevent the incidence of

higher cost treatments and
In-network dentists have agreed to payment rates for various services and cannot charge you more. On
medical related issues. Dental
coverage wil provide you and
the other hand, out-of-network dentists do not have a contract with Anthem and are able to bill you for
your family affordable options
the difference between the total amount Anthem allows to be paid for a service - the maximum allowed
for overall health.
cost- and the amount they usually charge for a service. When they bill you for this difference, it is called
balance billing.”

EXAMPLE: (this is an example only. Your experience may be different, depending on your insurance plan, the services you receive and the
dentist who provides the services.)
Ted needs to get a crown and his plan allows him 50% coinsurance for either in or out-of-network services.
The cost for this service is $1,200.
Here’s the Math:
Out-Of-Network Provider
In-Network Provider

Dentist Charge:
$1,200
Dentist Charge:
$1,200
Under your dental plans, Diagnostic
Anthem’s Maximum

Anthem’s Maximum

& Preventive services such as exams,
Allowed Cost
$800
Allowed Cost
$800
Anthem Pays 50%
$400
Anthem Pays 50%
$400
cleanings, x-rays and more do not
Ted Pays 50%

Ted Pays 50%
$400
count
towards
your
annual
coinsurance
$400
coinsurance
maximum – leaving you with more
Balance Ted Owes the
$400 (difference between


Provider
charge and allowed
Provider Write Off:
$400
benefit dollars to use for other
amount)
covered dental procedures.
$400 provider balance



Ted’s Total Cost
+$400 coinsurance =$800
Ted’s Total Cost
$400 coinsurance

Minimize your out-of-pocket expense for dental care by asking your dentist for
a pre-treatment estimate before you agree to receive services for costly
procedures such as crowns, periodontal surgery and wisdom tooth extractions.
A pre-treatment estimate will not only allow you to confirm if the treatment is
covered, it will also help you to know what your cost of the treatment will be, if
you will exceed your maximum and how to best plan your payment portion. In-
network providers are responsible for obtaining a pre-treatment estimate, if
requested. If you use an out-of-network provider, you are responsible for


making sure the provider submits a written treatment plan, with the required


documentation for services to Anthem.
The PPO+ plan is a good choice

for members who live in rural

After receiving treatment from a dentist, you will receive a summary of
locations and need a larger
services that shows how much Anthem paid and what your cost share is. This
network to find an in-network
Explanation of Benefits (EOB) should always be read thoroughly and Anthem
provider.
should be contacted if there are any questions. The EOB will also indicate how
Or, if no in-network provider is
much of your deductible you have met as well as how close you are to reaching
within close proximity, the higher
your plan’s annual maximum.
coinsurance level should help
offset the member’s out-of-
To search for participating dental providers online, please visit www.anthem.com:
pocket costs on the balance

billing.

Select Find A Doctor

Select a state: (choose from drop down menu)

Select a plan/network: Dental PPO or Dental PPO Plus

Choose Select and Continue

Complete fields for provider type, specialty and location


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