Behavior Frontiers offers a Dental PPO plan through Anthem Blue Cross which gives you the ability to obtain dental care services from the dentist of your choice. In order to receive the highest level of coverage under the plan, simply obtain care from an in-network provider. DENTAL
Dental PPO Plan
Out-of-Network 1
In-Network
$50 single
$50 single
Calendar Year Deductible
$150 family
$150 family
Waived for Preventive Care?
Yes
Yes
Calendar Year Maximum Benefit
$1,500 per person
$1,500 per person
Diagnostic/Preventive - Oral Exams, Routine Cleanings/Most X-Rays, Sealants Basic Services - Fillings, Root Canals, Scaling and Root Planing, Extractions, Periodontal Surgery
30 %
No charge
10% after deductible
50% after deductible
Major Services - Crowns, Dentures
40% after deductible
50% after deductible
Orthodontia - Child Only (through age 18)
50% after deductible
50% after deductible
Orthodontia - Lifetime Maximum
$1,000 per person
Coinsurance percentages shown in the above plan descriptions represent the amount paid by the member. 1. Members are responsible for all charges above Anthem’s allowable amounts when using non -
Behavior Frontiers offers a Vision plan through Anthem Blue Cross. You will get the best value from your vision care plan when you visit an Anthem Blue Cross network provider. VISION
Blue View Vision Plan
Frequency Limits
Every 12 months Every 24 months Every 12 months Every 12 months
Exam Frames Lenses Contacts
In-Network
Out-of-Network Reimbursement
Exam
$10 copay
Up to $49
Frames
$130 allowance then 20% off any remaining balance
Up to $50
Single Vision Lenses
No charge
Up to $35
Bifocal Lenses
No charge
Up to $49
Trifocal Lenses
No charge
Up to $74
Elective Contact Lenses (Non- Disposable)
$130 allowance then 15% off any remaining balance
Up to $92
Medically Necessary Contact Lenses
No charge
Up to $250
8 | Behavior Frontiers Benefits Guide
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