Dental
1. Select Dependents
2. Choose a plan
Selected Plans:
Delta Dental PPO
Delta Dental Insurance Company
Effective Start Date:
12/01/2019
Your cost:
$4.62
per pay period
Your Employer Pays $4.62
per pay period
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OR
I want to waive Dental coverage
Your Elected
Benefits
Per Pay (Biweekly)
$0.00
Medical Plan PPO
Anthem
Anthem
Your Cost:
$69.23 per pay
Plan Description
This is a PPO plan with Anthem. PPO plans provide richer benefits at a higher cost, and also allow subscribers to visit a larger network of doctors and facilities.
Coverage
Covered Services | In-Network | Out-of-Network |
---|---|---|
Coverage Basic
Annual Individual Deductible
Annual Family Deductible
Individual Out-of-Pocket Max
Family Out-of-Pocket Max
|
$3,000
$6,000
$4,000
$8,000
|
$6,000
$12,000
$8,000
$16,000
|
Physician / Medical Services
Preventive Services
Primary Care Physician
Specialist
Diagnostic Imaging
Prental/Postnatal Care
Diagnostic Lab
|
$0
100% after deductible
100% after deductible
100% after deductible
100% after deductible
100% after deductible
|
no coverage
70% after deductible
70% after deductible
70% after deductible
70% after deductible
70% after deductible
|
Hospital Services
Inpatient Hospital
Outpatient Hospital
Inpatient Facility
Outpatient Facility
|
100% after deductible
100% after deductible
100% after deductible
100% after deductible
|
70% after deductible
70% after deductible
70% after deductible
70% after deductible
|
Emergency Care Services
Emergency Room
Emergency Transportation
Urgent Care
Ambulance
|
100% after deductible
100% after deductible
100% after deductible
100% after deductible
|
100% after deductible
100% after deductible
70% after deductible
70% after deductible
|
Prescription Drugs
Retail Generic Drugs
Retail Preferred Brand Drugs
Retail Non-Preferred Brand Drugs
Retail Specialty Drugs
|
$10 (after deductible)
$40 (after deductible)
$40 (after deductible)
20% to $250 max (after deductible)
|
not covered
not covered
not covered
not covered
|
No additional notes
Web Link
Anthem WebsiteWeb Link
Find a DoctorCustomer Service
888-777-7777
Documents
Gold $1000 PPO SBCCompare Plans
Plans |
Anthem
Medical Plan PPO |
UnitedHealthcare
Medical Plan HDHP |
---|
Plans |
Anthem
Medical Plan PPO
KP Silver $ 1000 |
UnitedHealthcare
Medical Plan HDHP
UHC HDHP Bronze HSA |
---|---|---|
Per Pay Cost | $ 70.50 | $ 50.00 |
Coverage Basics Annual Individual Deductible
Annual Family Deductible
Coinsurance |
$ 1,000
$ 2,000
20%
|
$ 3,000
$ 6,000
10%
|
Physician / Medical Services
Preventive Services Primary Care Physician Specialist |
$ 0
$ 25 copay
$ 45 copay
|
$ 0
10% after deductible
10% after deductible
|
Hospital Services Inpatient Hospital Outpatient Hospital |
20% after deductible
20% after deductible
|
10% after deductible
10% after deductible
|
Emergency Care Services Emergency Room Urgent Care |
$ 100 copay
$ 45 copay
|
$ 250 copay
$ 100 copay
|
Extended Care Services Home Health Care Hospice Services |
20% after deductible
20% after deductible
|
10% after deductible
10% after deductible
|
Additional Services Mental Health/Substance Abuse
Inpatient Mental Health/Substance Abuse
Outpatient Child Dental Care |
$ 20 copay after deductible
$ 45 copay
20% after deductible
|
10% after deductible
10% after deductible
10% after deductible
|
Prescription Drugs Prescription Deductible Retail Supply Limit Retail Generic Drugs Retail Preferred Brand Drugs
Retail Non-Preferred Brand
Drugs |
0%
30 days
$ 5 copay
$ 10 copay
$ 20 copay
|
Included with Medical
30 days
$ 20 copay
$ 50 copay
$ 75 copay
|