You can select any dentist of your choice. To receive the plan’s highest level of benefits and pay the lowest out-of-pocket costs, use an Anthem PPO Dental 100/200/300 plan network dentist.
Calendar-Year Maximum Benefit is $1,000 per person, except dependent children under age 19 for whom there is no calendar year dental maximum except for the Orthodontia lifetime maximum benefit.
View the Dental Provider Instructions here.
Your vision benefits are provided through VSP. You will get the highest level of care, including a WellVision Exam – a comprehensive exam designed to detect eye and health conditions. When you see a VSP provider, you’ll get the most out of your benefit, have lower out-of-pocket costs, and your satisfaction is guaranteed.
Using your vision benefits:
- Register at vsp.com. Once your plan is effective, review your benefit information.
- Find an eyecare provider who is right for you. The decision is yours to make – choose a VSP provider or any out-of-network provider. To find a VSP provider, visit vsp.com or call (800) 877-7195.
- At your appointment, tell them you have VSP. There is no ID card necessary. If you would like a card as a reference, you can print one on vsp.com.
- There are no claim forms to complete when you see a VSP provider.
1. $30 for one hearing examination in a 24-month period.
2. The first $500 for each hearing device paid in full and 50% of any additional up to a maximum of $1,000 Plan payment.
3. Limit of two hearing devices in a two-year period.
Effective August 1, 2014, the Plan will cover 100% of the costs for in-network smoking cessation benefits associated with screening for tobacco use, and two (2) cessation attempts per calendar year. For each smoking cessation attempt, the Plan will cover four (4) counseling sessions, and a 9O-day supply of Food and Drug Administration (FDA)-approved cessation medications when prescribed by your healthcare provider. The Plan will cover 60% of out-of-network smoking cessation benefits, with the same calendar year limits on counseling sessions and prescription medications.
- Application for Coverage as a Retiree for Health & Welfare Benefits Prefunded
- Application for Coverage as a Retiree for Health & Welfare Benefits Retiree
- Dental Claim Form
- Hartford Enrollment Form
- Health Net ENR Form
- Health Net Prescription Drug Plan Enrollment Form
- Kaiser HMO Enrollment Form
- Outpatient Rx Enrollment Form
- SSA CMS Application form L564
- United Healthcare Enrollment Form
- United HealthCare Enrollment Request Form
- United Healthcare Prescription Drug Plan Enrollment Form
- Dental PPO Plan Summary of Benefits
- GRIP II WA GRH Hartford Summary of Coverage
- Hartford IBEW Medical Benefit Chart 3777
- Hartford Summary of Coverage
- Health Net Schedule of Benefits and Coverage
- Kaiser Permanente Chiropractic Plan
- Kaiser Permanente Summary of Benefits
- United Healthcare Benefit Highlights
- Vision Benefits Summary
- VSP at your fingertips
- VSP Grievance Process Notice