Anthem Dental Complete Summary of Benefits

Transcription

1 Anthem Dental Complete Summary of Benefits Albemarle High and Low Anthem Dental Complete Plans Effective October 1, 2016-September 30, 2017 The Dental coverage is a separate offering and is not automatically included with Anthem Medical coverage.

2 Your Summary of Benefits Albemarle County & Public Schools Anthem Dental Complete High Plan Version 07/15/16 - Hi Plan - Complete MAC Effective 10/01/16-9/30/17 WELCOME TO YOUR DENTAL PLAN! This benefit summary outlines how your dental plan works and provides you with a quick reference of your dental plan benefits. For complete coverage details, please refer to your employee benefits booklet. Dental coverage you can count on Your Anthem dental plan lets you visit any licensed dentist or specialist you want - with costs that are normally lower when you choose one within our large network. Savings beyond your dental plan benefits - you get more for your money. You pay our negotiated rate for covered services from in-network dentists even if you exceed your annual benefit maximum. YOUR DENTAL PLAN AT A GLANCE In-Network Out-of-Network Annual Benefit Maximum Contract Year Per insured person $2,000 $2,000 Diagnostic & Preventive applies to Annual Maximum Annual Maximum Carryover Orthodontic Lifetime Benefit Maximum Per eligible insured person $1,500 $1,500 Annual Deductible (The Deductible does not apply to Orthodontic Services) Per insured person Contract Year Family maximum $50 3X Individual Deductible Waived for Diagnostic/Preventive Services & Ortho Yes Yes Out-of-Network Reimbursement Options: Complete (MAC) $50 3X Individual Dental Services In-Network Out-of-Network Waiting Period Anthem Pays: Anthem Pays: Diagnostic and Preventive Services Periodic oral exam Teeth cleaning (prophylaxis) Bitewing X-rays: 1X per 12 months Intraoral X-rays Basic Services Amalgam (silver-colored) Filling Front composite (tooth-colored) Filling Back composite Filling, Covered as Composites Simple Extractions Endodontics Root Canal Periodontics Scaling and root planing Oral Surgery Surgical Extractions Major Services Crowns Prosthodontics Dentures Bridges 100% Coinsurance 100% Coinsurance Waiting Period 80% Coinsurance 80% Coinsurance Waiting Period 80% Coinsurance 80% Coinsurance Waiting Period 80% Coinsurance 80% Coinsurance Waiting Period 80% Coinsurance 80% Coinsurance Waiting Period 60% Coinsurance 60% Coinsurance Waiting Period 60% Coinsurance 60% Coinsurance Waiting Period Dental implants Standard - Covered Prosthetic Repairs/Adjustments 80% Coinsurance 80% Coinsurance Waiting Period Orthodontic Services Dependent Children Only* 50% Coinsurance 50% Coinsurance Waiting Periods This is not a contract; it is a partial listing of benefits and services. All covered services are subject to the conditions, limitations, exclusions, terms and provisions of your employee benefits booklet. In the event of a discrepancy between the information in this summary and the employee booklet, the employee booklet will prevail. *Child orthodontic coverage begins at age eight and runs through age 18. This means that the child must have been banded between the ages of eight and 19 in order to receive coverage. If children are dependents until age 19, they can continue to receive coverage, but they must have been banded before age 19. VA_PCLG_ASO-Custom

3 Emergency dental treatment for the international traveler As an Anthem dental member, you and your eligible, covered dependents automatically have access to the International Emergency Dental Program.** With this program, you may receive emergency dental care from our listing of credentialed dentists while traveling or working nearly anywhere in the world. ** The International Emergency Dental Program is managed by DeCare Dental, which is an independent company offering dental-management services to Anthem Blue Cross Life and Health Insurance Company. Promoting healthy mouths for members who are pregnant or living with diabetes If you are pregnant or living with diabetes, you can sign up to receive one additional dental cleaning or periodontal maintenance procedure per year. Finding a dentist is easy. To select a dentist by name or location: Go to anthem.com/mydentalvision or the website listed on the back of your ID card. Call the toll-free customer service number listed on the back of your ID card. TO CONTACT US: Call Refer to the toll-free number indicated on the back of your plan ID card to speak with a U.S.-based customer service representative during normal business hours. Calling after hours? We may still be able to assist you with our interactive voice-response system. Limitations & Exclusions Write Refer to the back of your plan ID card for the address. Limitations Below is a partial listing of dental plan limitations when these services are covered under your plan. Please see your certificate of coverage for a full list. Diagnostic and Preventive Services Oral evaluations (exam) Limited to two per 12 Months Teeth cleaning (prophylaxis) Limited to two per 12 Months Intraoral X-rays, single film Limited to four films per 12-month period Complete series X-rays (panoramic or full-mouth) Coverage Every 3 Years Topical fluoride application Limited to once every 12 months for members through age 18 Sealants Limited to first and second molars once every 24 months per tooth for members through age 15; sealants will be covered under Basic Services. Basic and/or Major Services*** Fillings Limited to once per surface per tooth in any 24 months Space Maintainers Limited to extracted primary posterior teeth once per lifetime per tooth for members through age 16; Space Maintainers will be covered under Diagnostic and Preventive Services. Crowns Limited to once per tooth in a seven-year period Fixed or removable prosthodontics dentures, partials, bridges, tooth implants Covered once in any seven-year period; benefits are provided for the replacement of an existing bridge, denture or partial for members age 16 or older if the appliance is seven years old or older and cannot be made serviceable. Root canal therapy Limited to once per lifetime per tooth; coverage is for permanent teeth only. Periodontal surgery Limited to one complex service per single tooth or quadrant in any 36 months, and only if the pocket depth of the tooth is five millimeters or greater Periodontal scaling and root planing Limited to once per quadrant in 24 months when the tooth pocket has a depth of four millimeters or greater Brush Biopsy t Covered ***Waiting periods for endodontic, periodontic and oral surgery services may differ from other Basic Services or Major Services under the same dental plan. There is a waiting period of up to 24 months for replacement of congenitally missing teeth or teeth extracted prior to coverage under this plan. Exclusions Below is a partial listing of noncovered services under your dental plan. Please see your certificate of coverage for a full list. Services provided before or after the term of this coverage Services received before your effective date or after your coverage ends, unless otherwise specified in the employee benefits booklet Orthodontics (unless included as part of your dental plan benefits) Orthodontic braces, appliances and all related services Cosmetic dentistry Services provided by dentists solely for the purpose of improving the appearance of the tooth when tooth structure and function are satisfactory and no pathologic conditions (cavities) exist Drugs and medications Intravenous conscious sedation, IV sedation and general anesthesia when performed with nonsurgical dental care Analgesia, analgesic agents, anxiolysis nitrous oxide, therapeutic drug injections, medicines or drugs for nonsurgical or surgical dental care except that intravenous conscious sedation is eligible as a separate benefit when performed in conjunction with complex surgical services. Extractions - Surgical removal of third molars (wisdom teeth) that do not exhibit symptoms or impact the oral health of the member ADDITIONAL LIMITATION FOR ORTHODONTIC SERVICES Orthodontia Limited to one course of treatment per member per lifetime The in-network dental providers mentioned in this communication are independently contracted providers who exercise independent professional judgment. They are not agents or employees of Anthem Blue Cross Life and Health Insurance Company. Anthem BCBS is the trade name for Anthem Health Plans, Inc., an independent licensee of the Blue Cross and Blue Shield Association.

4 Choice of dentists While your dental plan lets you choose any dentist, you may end up paying more for a service if you visit an out-of-network dentist. Here s why: In-network dentists have agreed to payment rates for various services and cannot charge you more. On the other hand, out-of-network dentists don t have a contract with us and are able to bill you for the difference between the total amount we allow to be paid for a service called the maximum allowed amount and the amount they usually charge for a service. When they bill you for this difference, it s called balance billing. How Anthem dental decides on maximum allowed amounts For services from an out-of-network dentist, the maximum allowed amount is determined in one of the following ways: Out-of-network dental fee schedule/rate developed by Anthem, which may be updated based on such things as reimbursement amounts accepted by dentists contracted with our dental plans, or other industry cost and usage data Information provided by a third-party vendor that shows comparable costs for dental services In-network dentist fee schedule Here s an example of higher costs for out-of-network dental services 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 gets a crown from an out-of-network dentist, who charges $1,200 for the service and bills Anthem for that amount. Anthem s maximum allowed amount for this dental service is $800. That means there will be a $400 difference, which the dentist can balance bill Ted. Since Ted will also need to pay $400 coinsurance, the total he ll pay the out-of-network dentist is $800. Here s the math: Dentist s charge: $1,200 Anthem s maximum allowed amount: $800 Anthem pays 50%: $400 Ted pays 50% (coinsurance): $400 Balance Ted owes the provider: $1,200 - $800 = $400 Ted s total cost: $400 coinsurance + $400 provider balance = $800 In the example, if Ted had gone to an in-network dentist, his cost would be only $400 for the coinsurance because he would not have been balance billed the $400 difference.

5 Your Summary of Benefits Albemarle County & Public Schools Anthem Dental Complete Low Plan Effective 10/01/16-9/30/17 Version 07/15/16 - Lo Plan - Complete MAC WELCOME TO YOUR DENTAL PLAN! This benefit summary outlines how your dental plan works and provides you with a quick reference of your dental plan benefits. For complete coverage details, please refer to your employee benefits booklet. Dental coverage you can count on Your Anthem dental plan lets you visit any licensed dentist or specialist you want - with costs that are normally lower when you choose one within our large network. Savings beyond your dental plan benefits - you get more for your money. You pay our negotiated rate for covered services from in-network dentists even if you exceed your annual benefit maximum. YOUR DENTAL PLAN AT A GLANCE In-Network Out-of-Network Annual Benefit Maximum Contract Year Per insured person $1,500 $1,500 Diagnostic & Preventive applies to Annual Maximum Annual Maximum Carryover Orthodontic Lifetime Benefit Maximum Per eligible insured person N/A N/A Annual Deductible Per insured person Contract Year Family maximum $25 3X Individual Deductible Waived for Diagnostic/Preventive Services Yes Yes Out-of-Network Reimbursement Options: Complete (MAC) $25 3X Individual Dental Services In-Network Out-of-Network Waiting Period Anthem Pays: Anthem Pays: Diagnostic and Preventive Services Periodic oral exam Teeth cleaning (prophylaxis) Bitewing X-rays: 1X per 12 months Intraoral X-rays Basic Services Amalgam (silver-colored) Filling Front composite (tooth-colored) Filling Back composite Filling, Covered as Composites Simple Extractions Endodontics Root Canal Periodontics Scaling and root planing Oral Surgery Surgical Extractions Major Services Crowns Prosthodontics Dentures Bridges 100% Coinsurance 100% Coinsurance Waiting Period 80% Coinsurance 80% Coinsurance Waiting Period 80% Coinsurance 80% Coinsurance Waiting Period 80% Coinsurance 80% Coinsurance Waiting Period 80% Coinsurance 80% Coinsurance Waiting Period t Covered t Covered Waiting Period t Covered t Covered Waiting Period Dental implants t Covered Prosthetic Repairs/Adjustments 80% Coinsurance 80% Coinsurance Waiting Period Orthodontic Services ne t Covered t Covered N/A This is not a contract; it is a partial listing of benefits and services. All covered services are subject to the conditions, limitations, exclusions, terms and provisions of your employee benefits booklet. In the event of a discrepancy between the information in this summary and the employee booklet, the employee booklet will prevail. VA_PCLG_ASO-Custom

6 Emergency dental treatment for the international traveler As an Anthem dental member, you and your eligible, covered dependents automatically have access to the International Emergency Dental Program.** With this program, you may receive emergency dental care from our listing of credentialed dentists while traveling or working nearly anywhere in the world. ** The International Emergency Dental Program is managed by DeCare Dental, which is an independent company offering dental-management services to Anthem Blue Cross Life and Health Insurance Company. Promoting healthy mouths for members who are pregnant or living with diabetes If you are pregnant or living with diabetes, you can sign up to receive one additional dental cleaning or periodontal maintenance procedure per year. Finding a dentist is easy. To select a dentist by name or location: Go to anthem.com/mydentalvision or the website listed on the back of your ID card. Call the toll-free customer service number listed on the back of your ID card. TO CONTACT US: Call Refer to the toll-free number indicated on the back of your plan ID card to speak with a U.S.-based customer service representative during normal business hours. Calling after hours? We may still be able to assist you with our interactive voice-response system. Limitations & Exclusions Write Refer to the back of your plan ID card for the address. Limitations Below is a partial listing of dental plan limitations when these services are covered under your plan. Please see your certificate of coverage for a full list. Diagnostic and Preventive Services Oral evaluations (exam) Limited to two per 12 Months Teeth cleaning (prophylaxis) Limited to two per 12 Months Intraoral X-rays, single film Limited to four films per 12-month period Complete series X-rays (panoramic or full-mouth) Coverage Every 3 Years Topical fluoride application Limited to once every 12 months for members through age 18 Sealants Limited to first and second molars once every 24 months per tooth for members through age 15; sealants will be covered under Basic Services. Basic and/or Major Services*** Fillings Limited to once per surface per tooth in any 24 months Space Maintainers Limited to extracted primary posterior teeth once per lifetime per tooth for members through age 16; Space Maintainers will be covered under Diagnostic and Preventive Services. Crowns Limited to once per tooth in a seven-year period Fixed or removable prosthodontics dentures, partials, bridges Covered once in any seven-year period; benefits are provided for the replacement of an existing bridge, denture or partial for members age 16 or older if the appliance is seven years old or older and cannot be made serviceable. Root canal therapy Limited to once per lifetime per tooth; coverage is for permanent teeth only. Periodontal surgery Limited to one complex service per single tooth or quadrant in any 36 months, and only if the pocket depth of the tooth is five millimeters or greater Periodontal scaling and root planing Limited to once per quadrant in 24 months when the tooth pocket has a depth of four millimeters or greater Brush Biopsy t Covered ***Waiting periods for endodontic, periodontic and oral surgery services may differ from other Basic Services or Major Services under the same dental plan. There is a waiting period of up to 24 months for replacement of congenitally missing teeth or teeth extracted prior to coverage under this plan. Exclusions Below is a partial listing of noncovered services under your dental plan. Please see your certificate of coverage for a full list. Services provided before or after the term of this coverage Services received before your effective date or after your coverage ends, unless otherwise specified in the employee benefits booklet Orthodontics (unless included as part of your dental plan benefits) Orthodontic braces, appliances and all related services Cosmetic dentistry Services provided by dentists solely for the purpose of improving the appearance of the tooth when tooth structure and function are satisfactory and no pathologic conditions (cavities) exist Drugs and medications Intravenous conscious sedation, IV sedation and general anesthesia when performed with nonsurgical dental care Analgesia, analgesic agents, anxiolysis nitrous oxide, therapeutic drug injections, medicines or drugs for nonsurgical or surgical dental care except that intravenous conscious sedation is eligible as a separate benefit when performed in conjunction with complex surgical services. Extractions - Surgical removal of third molars (wisdom teeth) that do not exhibit symptoms or impact the oral health of the member The in-network dental providers mentioned in this communication are independently contracted providers who exercise independent professional judgment. They are not agents or employees of Anthem Blue Cross Life and Health Insurance Company. Anthem BCBS is the trade name for Anthem Health Plans, Inc., an independent licensee of the Blue Cross and Blue Shield Association.

7 Choice of dentists While your dental plan lets you choose any dentist, you may end up paying more for a service if you visit an out-of-network dentist. Here s why: In-network dentists have agreed to payment rates for various services and cannot charge you more. On the other hand, out-of-network dentists don t have a contract with us and are able to bill you for the difference between the total amount we allow to be paid for a service called the maximum allowed amount and the amount they usually charge for a service. When they bill you for this difference, it s called balance billing. How Anthem dental decides on maximum allowed amounts For services from an out-of-network dentist, the maximum allowed amount is determined in one of the following ways: Out-of-network dental fee schedule/rate developed by Anthem, which may be updated based on such things as reimbursement amounts accepted by dentists contracted with our dental plans, or other industry cost and usage data Information provided by a third-party vendor that shows comparable costs for dental services In-network dentist fee schedule Here s an example of higher costs for out-of-network dental services 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 gets a crown from an out-of-network dentist, who charges $1,200 for the service and bills Anthem for that amount. Anthem s maximum allowed amount for this dental service is $800. That means there will be a $400 difference, which the dentist can balance bill Ted. Since Ted will also need to pay $400 coinsurance, the total he ll pay the out-of-network dentist is $800. Here s the math: Dentist s charge: $1,200 Anthem s maximum allowed amount: $800 Anthem pays 50%: $400 Ted pays 50% (coinsurance): $400 Balance Ted owes the provider: $1,200 - $800 = $400 Ted s total cost: $400 coinsurance + $400 provider balance = $800 In the example, if Ted had gone to an in-network dentist, his cost would be only $400 for the coinsurance because he would not have been balance billed the $400 difference.

8 How your new dental plan handles dental work in progress Did you or your company recently switch to Anthem Blue Cross and Blue Shield (Anthem) Dental Prime and Dental Complete for dental coverage? If so, you may have some questions about how Anthem will take care of dental work you already started under your former carrier. Here are some examples to help explain the process: Example 1 Standard dental services (includes root canals, bridges, dentures and crowns) Let s say your dentist gave you a cost estimate for a crown. At the time, you were insured by your former carrier. In a few weeks, you have an appointment to have the crown completed, but now, you re with Anthem. In this case, Anthem will honor your former carrier s pre-estimate for the service, but only to decide coverage. The claim will be paid based on whether your provider is in or out of the network under your Dental Prime and Dental Complete plan. For all non-orthodontic services that started before the effective date of your dental plan, payment of a claim will be based on when the service was finished. Pricing and network status are not guaranteed. They re based on the provider s network status with Dental Prime and Dental Complete. When you submit your claim to Anthem for a Dental Prime or Dental Complete plan, make sure to include your former plan s pre-estimate. We ll use that to decide coverage. Example 2 n-dhmo* orthodontic services (includes braces: standard and Invisalign ) If you or your child are in the middle of an active orthodontic treatment, like having bands placed, the provider needs to give us a copy of the original claim. It should include the: Treatment type (procedure number). Total fee for treatment. Number of months treatment will take place. Provider s signature. The payment amount is based on the number of months of active treatment that are left. Any amount your former carrier paid will only be deducted if that is put into the system by the time you change to your new plan. For members who used to be covered under a DHMO ortho plan, we recommend that the orthodontic provider contact us. DHMO plans have unique payment methods that need to be reviewed MUMENABS Rev. 10/14

9 Example of orthodontic service costs Treatment plan length and cost 24 months for $5,200 Remaining months of treatment 10 months Monthly treatment costs $5,200/24 months = $ monthly Ineligible monthly cost 14 months x $ = $3, Eligible treatment cost $5,200 - $3, = $2, Amount Anthem pays $2, x 50% = $1, te: The total amount Anthem pays will be limited to the total Lifetime Orthodontic Maximum, minus any prior carrier history, if put into the system. Standard ortho payment schedule: $500 to $1,500 lifetime orthodontic maximum = two equal payments (banding and six months after banding) $1,500 + lifetime orthodontic maximum = three equal payments (banding, six months after banding and 12 months after banding) Mailing address: Anthem Dental Claims P.O. Box 1115 Minneapolis, MN Questions If you need more information, visit anthem.com/mydentalvision. * Dental health maintenance organization. Anthem Blue Cross and Blue Shield is the trade name of: In Colorado: Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc. In Connecticut: Anthem Health Plans, Inc. In Indiana: Anthem Insurance Companies, Inc. In Kentucky: Anthem Health Plans of Kentucky, Inc. In Maine: Anthem Health Plans of Maine, Inc. In Missouri (excluding 30 counties in the Kansas City area): RightCHOICE Managed Care, Inc. (RIT), and Healthy Alliance Life Insurance Company (HALIC). RIT and certain affiliates administer non-hmo benefits underwritten by HALIC. RIT and certain affiliates only provide administrative services for self-funded plans and do not underwrite benefits. In Nevada: Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc., dba HMO Nevada. In New Hampshire: Anthem Health Plans of New Hampshire, Inc. In Ohio: Community Insurance Company. In Virginia: Anthem Health Plans of Virginia, Inc. trades as Anthem Blue Cross and Blue Shield in Virginia, and its service area is all of Virginia except for the City of Fairfax, the Town of Vienna, and the area east of State Route 123. In Wisconsin: Blue Cross Blue Shield of Wisconsin (BCBSWi), which underwrites or administers the PPO and indemnity policies; Compcare Health Services Insurance Corporation (Compcare), which underwrites or administers the HMO policies; and Compcare and BCBSWi collectively, which underwrite or administer the POS policies. Independent licensees of the Blue Cross and Blue Shield Association. ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association.

10 Anthem Whole Health Connection for dental Healthier teeth can mean better overall health Eligible members get an extra dental cleaning or periodontal maintenance procedure! Any member who participates in Anthem Dental Blue, 1 Dental Prime and Dental Complete plans 2 and is actively managed in one of our Diabetic or Maternal Health Care Management programs through his or her Anthem health plan is eligible for an additional dental cleaning or periodontal maintenance procedure per benefit period. We ve also extended this benefit to other conditions, including: Heart conditions heart disease, an enlarged heart, and mitral or aortic valve prolapse Organ or bone marrow transplant Cancer (any type) treated with chemotherapy Head or neck cancer treated with chemotherapy and/or radiation therapy All eligible members have to do to get their extra dental cleaning or periodontal maintenance procedure is visit their dentist and submit their claim. It will already be a part of their dental coverage if they are being actively managed in one of our health care management programs. Did you know more than 90% of the body s diseases first show signs and symptoms in the mouth? 3 That s why good dental health and the right dental coverage is important. Dental health might affect, be affected by or contribute to various diseases and conditions. Benefits to members living with diabetes Did you know gum disease makes it more difficult for people with diabetes to control their blood sugar? High glucose (blood sugar) levels in saliva allow bad bacteria to grow. These bacteria along with food, create plaque, which can cause tooth decay, cavities, gum disease and bad breath. 4 Regular periodontal care can prevent and better control gum disease and blood sugar levels by having a positive impact on hemoglobin A1C MUEENABS VPOD Rev. 01/16

11 Benefits to pregnant members Hormonal changes associated with pregnancy increase a woman s risk for gingivitis or periodontal disease. Frequent visits to the dentist can help pregnant women maintain good dental health. In the last months of pregnancy, a woman might be uncomfortable sitting in a dental chair, so the best time for treatment is between weeks 14 and 20. Dental care is beneficial to the mom s health and her baby s. 6 Benefits for heart health Researchers have found a connection between heart health and periodontal disease. Older adults who have more than four periodontal-disease-causing bacteria in their mouths tend to have thicker carotid arteries, a strong predictor of stroke and heart attack. 7 So regular visits to the dentist more often could protect more than just a great smile. Benefits for organ transplant patients People who get organ transplants should wait to have dental treatment for at least three months after the transplant, unless it s an emergency. Serious complications are more likely right after surgery. It s important for patients to avoid dental work so that the organ isn t rejected because of any infections, including in the mouth. Three to six months after a transplant and once the doctors clear the patient for dental treatment, patients can have dental work with the dentist following any necessary precautions. 8 Benefits for cancer patients Side effects from chemotherapy often happen if a person s mouth is not healthy before treatment starts. Patients can help avoid serious dental problems by going to a dentist before chemotherapy begins. The best time to see a dentist is about one month before chemotherapy starts. If they have started chemotherapy without going to a dentist first, they should go as soon as they can. 9 The value of integrated health and dental benefits Many consumers don t fully understand the relationship between dental care and overall health. However, studies have shown a direct link between dental and overall health. Our ConditionCare programs generate a return on investment (ROI) of 2:1. For every $1 invested, employers can realize $2 in savings. 10 At the same time, many plans and employers are analyzing both health and dental claims to identify potential savings while improving members health outcomes. Studies have shown that members living with diabetes while receiving periodontal treatment for active disease had the lowest spending, regardless of medical compliance. More is better. Anthem Whole Health Connection SM allows members who have health and dental plans to enjoy more complete health profiles. Sources 1 Dental Blue not available in CO, ME, NH, NV and VA. 2 Extra cleaning benefit applies to: Dental Prime and Dental Complete products and Dental Blue products (excluding plans sold in CO, CT, ME, NH, NV, NY, VA). Extra cleaning benefits does not apply to Affordable Health Care products. 3 Academy of General Dentistry Know Your Teeth website: Warning Signs in the Mouth Can Save Lives. (Rev. January 2012): knowyourteeth.com. 4 The National Institute of Diabetes and Digestive and Kidney Diseases website: Prevent diabetes problems: Keep your mouth healthy (accessed December 2015): niddk.nih.gov/health-information/health-topics/diabetes/prevent-diabetes-problems/pages/keepyour-mouth-healthy.aspx 5 Diabetes and Periodontal (Gum) Disease, Johns Hopkins University 6 Office on Women s Health, U.S. Department of Health and Human Services website: Oral health fact sheet (accessed July 2012): womenshealth.gov/publications/our-publications/fact-sheet/oral-health.html#g 7 The National Institute of Dental and Craniofacial Research website Study Finds Direct Association Between Cardiovascular Disease and Periodontal Bacteria (accessed February 2005): nidcr.nih.gov/research/researchresults/newsreleases/archived NewsReleases/NRY2005/PR htm?_ga= The National Institute of Dental and Craniofacial Research website Dental management of the organ or stem cell transplant patient (accessed June 2014): nidcr.nih.gov/oralhealth/topics/organtransplantationoralhealth/organtransplantprof.htm 9 The National Institute of Dental and Craniofacial Research website Chemotherapy and Your Mouth (accessed August 2013): nidcr.nih.gov/oralhealth/topics/cancertreatment/chemotherapyyourmouth.htm? 10 ConditionCare programs; Anthem Health and Wellness Solutions data study and Actuarial validation, Anthem Blue Cross and Blue Shield is the trade name of: In Colorado: Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc. In Connecticut: Anthem Health Plans, Inc. In Indiana: Anthem Insurance Companies, Inc. In Kentucky: Anthem Health Plans of Kentucky, Inc. In Maine: Anthem Health Plans of Maine, Inc. In Missouri (excluding 30 counties in the Kansas City area): RightCHOICE Managed Care, Inc. (RIT), and Healthy Alliance Life Insurance Company (HALIC). RIT and certain affiliates administer non-hmo benefits underwritten by HALIC. RIT and certain affiliates only provide administrative services for self-funded plans and do not underwrite benefits. In Nevada: Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc., dba HMO Nevada. In New Hampshire: Anthem Health Plans of New Hampshire, Inc. In Ohio: Community Insurance Company. In Virginia: Anthem Health Plans of Virginia, Inc. trades as Anthem Blue Cross and Blue Shield in Virginia, and its service area is all of Virginia except for the City of Fairfax, the Town of Vienna, and the area east of State Route 123. In Wisconsin: Blue Cross Blue Shield of Wisconsin (BCBSWi), which underwrites or administers the PPO and indemnity policies; Compcare Health Services Insurance Corporation (Compcare), which underwrites or administers the HMO policies; and Compcare and BCBSWi collectively, which underwrite or administer the POS policies. Independent licensees of the Blue Cross and Blue Shield Association. ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association.

12 How to Guide: To Find a Provider STEP 1: Go to STEP 2: Click on Find Dental Providers (middle of page) STEP 3: Click on Anthem Dental Complete STEP 4: Select a Specialty (if needed); Click Next STEP 5: Enter your criteria for the provider search and click on View Results STEP 6: To lookup a provider by name, click on Lookup by Name at the top of the page STEP 7: On the Search Results page, you can: Download Results; Print a PDF of your results; and Start a new search Anthem Blue Cross and Blue Shield is the trade name of: In Colorado and Nevada: Rocky Mountain Hospital and Medical Service, Inc. In Connecticut: Anthem Health Plans, Inc. In Indiana: Anthem Insurance Companies, Inc. In Kentucky: Anthem Health Plans of Kentucky, Inc. In Maine: Anthem Health Plans of Maine, Inc. In Missouri (excluding 30 counties in the Kansas City area): RightCHOICE Managed Care, Inc. (RIT), Healthy Alliance Life Insurance Company (HALIC), and HMO Missouri, Inc. RIT and certain affiliates administer non-hmo benefits underwritten by HALIC and HMO benefits underwritten by HMO Missouri, Inc. RIT and certain affiliates only provide administrative services for self-funded plans and do not underwrite benefits. In New Hampshire: Anthem Health Plans of New Hampshire, Inc. In Ohio: Community Insurance Company. In Virginia (excluding the City of Fairfax, the Town of Vienna and the area east of State Route 123.): Anthem Health Plans of Virginia, Inc. In Wisconsin: Blue Cross Blue Shield of Wisconsin ( BCBSWi ), which underwrites or administers the PPO and indemnity policies; Compcare Health Services Insurance Corporation ("Compcare"), which underwrites or administers the HMO policies; and Compcare and BCBSWi collectively, which underwrite or administer the POS policies. Independent licensees of the Blue Cross and Blue Shield Association. ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association. Anthem_10_2013

13 Albemarle County and Public Schools Dental Provider mination Form Today s Date Patient Name Address City State Zip Phone Number( ) My name may be used when contacting my dentist? Yes Dentist Name This form can be used to nominate your dental provider if they are not already in the Anthem Dental Complete network. You can confirm if your dental provider is in-network by either visiting or call the customer service number listed on the back of your dental insurance card. or Fax mination Form to: providernomination@anthem.com Attn: Network Development Fax # Dentist Address City State Zip Dentist Phone Number(