ENROLLMENT HEALTH AND WELLNESS 35 The table below highlights the key benefits under each dental option when using an Anthem Dental Complete provider or an out-of-network provider. Coverage for all dental services (except diagnostic and preventive services) begins after the annual deductible. Items in ORANGE are the differences between the dental options. Tools and Resources Anthem maintains eligibility and processes dental claims. Contact member services at 844-852-1561 for questions. Access MyScrippsHealthPlan.com for information about the Anthem Dental Complete network providers and dental plan benefits. Scripps Dental Options Scripps Dental Plan Dental Buy-up Option Feature PPO Network Provider Out-of-Network Provider PPO Network Provider Out-of-Network Provider Annual Deductible per Individual (waived for Diagnostic and Preventive Services) $50 $100 $50 $100 Maximum Benefit per Year $1,800 per individual (excluding Orthodontia) $2,200 per individual (excluding Orthodontia) Diagnostic & Preventive Services • Oral exams, cleanings and bite-wing x-rays (2 exams/cleanings per 12-month period); sealants for dependents ages 6 to 14 100%* 90%** 100%* 90%** Basic Services • Oral Surgery — Extractions • Restorative — Fillings • Endodontic/Periodontal • Repair of crowns, bridges, & dentures 80%* 80%* 80%* 80%* 70%** 70%** 70%** 70%** 80%* 80%* 80%* 80%* 70%** 70%** 70%** 70%** Major Services • Crowns, jackets & cast restorations 50%* 40%** 60%* 50%** Cosmetic Dentistry • Dental implants N/A N/A 60%* 50%** Orthodontic Services (no age limit) 50%* 50%** 50%* 50%** $1,800 lifetime maximum per individual $2,000 lifetime maximum per individual * Percentage applies to negotiated fees. ** Percentage applies to usual, customary and reasonable charges.
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