ANTHEM INSURANCE COMPANY    

http://www.anthem.com
(866) 589-0578
Claim Form (PDF)
Summary Plan Description (PDF)

DESCRIPTION:  There is a $50 employee or $100 employee & family deductible. Preventative cleaning & examination two times per calendar year is paid at 100% with no deductible.  X-rays, fillings, crowns, oral surgery is paid at 50% with in-network providers and 50% of UCR with out-of-network providers.  There is a calendar year maximum of $1250.    Orthodontia coverage is available to dependent children up to age 19 only.  There is a $50 deductible, coinsurance 50%, and a lifetime benefit maximum of $750.

COSTS:  Premiums are taken on a pre-tax basis; i.e., there are no federal or state taxes taken from your share of the premium.

Annual costs as follows:
Employee Only - $33.72
Employee + Spouse - $64.44
Employee + Child(ren) - $77.28
Family - $107.76