Premera DentalBlueTM FOR ALASKA GROUPS WITH 2+ EMPLOYEES

Transcription

1 Premera DentalBlueTM FOR ALASKA GROUPS WITH 2+ EMPLOYEES January 2015

2 Dental product options that let you build a comprehensive benefits package Premera Blue Cross Blue Shield of Alaska offers a range of dental plans offering choice and flexibility, allowing employers to offer a more attractive and comprehensive employee benefits package. Our dental portfolio: Provides dental care with no deductibles for cleanings, routine exams and X-rays, and fluoride treatments Gives employers a wide-range of coverage options to strike the right balance between coverage and cost Requires no claim forms for members to complete and members experience no balance billing when they visit network dentists Offers stand-alone product options for groups with five or more employees Provides employer-sponsored and voluntary dental plan options Offers uncommon enrollment between medical and dental Includes free online tools that offer a wealth of dental health information such as the Dental Health Center, Dental Cost Estimator, and easy access to our dental provider directory. Network strength and accessibility The strength of our dental network and access to nation-wide contracted dental providers makes it easy for employees to find the right dentist for their needs, which translates into greater savings for in-network services. With a Premera DentalBlue plan, employees have access to one of the largest dental provider networks in Alaska. Providers in our network accept our allowable charges as payment in full, which can save members money. Providers not in our network may charge back to the member the difference between our allowable charge and their billed charge. Ease of administration Packaged coverage offers administrative ease for producers, employers and employees one sales team, one carrier, one bill, one ID card, one customer service line, one website. It just makes sense. Members never need an authorization or referral to see a general dentist or specialist. When using a network provider there are never any claim forms to complete.

3 METALLIC PLAN HIGHLIGHTS OPTIMA PREFERENCE ESSENTIALS PREVENTIVE Access to nationwide contracted dental provider Freedom to choose any licensed dental provider Include preventive services with no deductibles Provide comprehensive benefits for major services Available to groups with 2 to 4 enrolled employees Available to groups with 5 or more enrolled employees Optional orthodontia coverage available for groups with 26 or more enrolled employees Voluntary-funded plan option Available as packaged or stand-alone product Note: For a summary of plan benefits and limitations, see plan details to follow. Option only available if group has only dental coverage with us. Research shows that good oral health habits and regular preventive care helps prevent periodontitis, and can reduce the risk of other health conditions like diabetes or cardiovascular disease.

4 Balance Kids Dental Plan With the Balance Kids Dental Plan, employers provide their employees with maximum flexibility in provider choice for their children s dental care. This plan is available to groups who purchase Premera medical plans; Adult dental plans are available as stand-alone products. With the Balance Kids Dental Plan, employers can offer the children under age 19 of enrolled employees: Maximum flexibility and cost savings because our provider network includes any licensed or certified dental care provider Diagnostic and preventive services, including routine exams, cleanings, fluoride, and x-rays to keep children s teeth healthy Basic services, including fillings, extractions, and up to four periodontal maintenance cleanings per year Major services such as crowns, root canals, and implants without a waiting period COVERED SERVICES Annual deductible $40 Individual Deductible PCY Out-of-pocket maximum $350 Individual PCY; $700 (2 or more) DIAGNOSTIC AND PREVENTIVE PEDIATRIC DENTAL PLAN In-network Out-of-network Cleanings Limited to 2 PCY Fluoride treatments Two every 12 months Routine bitewings 1 set every 6 months Routine oral exams Limited to 2 PCY Routine X-rays Complete series or panoramic x-ray once every 5 years Sealants Once every 3CY Space maintainers BASIC Emergency palliative treatment Fillings Periodontal maintenance Limited to 4 times in 12 months Oral surgery including surgical extractions Stainless steel crowns Under age 15 limited to 1 per tooth in 60 months Reline/rebase dentures and bridges Periodontal scaling Limited to once per quandrant every 24 months Simple extractions MAJOR Crowns Single restoration, every 60 months Endodontic (root canal) treatment Periodontal surgery Once every 36 months Implants Once every 60 months General anesthesia Limited to covered dental procedures at a dental care provider's office when dentally necessary Dentures, partials, and fixed bridges and crowns Once every 60 months ORTHODONTICS 24-month waiting period Cleft lip and palate when medically necessary 0% 30% 20% 40% 50% 50% 50% 50% 4

5 Adult Dental Optima With Adult Dental Optima, employers can choose from an array of deductible and coinsurance cost-share options while offering employees maximum flexibility in provider choice. Adult Dental Optima is available to groups from two to four employees with 100 percent participation. For groups of five or more, minimum participation is the greater of five employees or 50 percent of eligible employees. COVERED SERVICES FOR GROUPS 2 9 With Adult Dental Optima, employers can offer employees: Maximum flexibility because they can choose any licensed or certified dental-care provider and benefit from the cost savings our network provides Diagnostic and preventive services including routine exams, cleanings, fluoride, and X-rays Benefits apply after calendar year deductible is met, unless otherwise noted. Deductible and coinsurance represent member s cost share PCY = Per calendar year CHOOSE ONE OF THE OPTIMA PLANS Basic services including fillings, extractions, and up to four periodontal maintenance cleanings per year Major services including crowns, inlays, dentures, and implants without a waiting period Maximum allowance per person, PCY $1,000 or $1,500 $1,000 or $1,500 FOR GROUPS 10+ Individual: $0 $50 Family: $0 $150 Individual: $0 $50 Family: $0 $150 Maximum allowance per person, PCY $1,000, $1,500 or $2,000 $1,000, $1,500 or $2,000 ROUTINE DIAGNOSTIC AND PREVENTIVE Cleanings limited to 2 PCY Emergency and non-routine exams limited to 1 PCY Fluoride treatments limited to 2 applications PCY for members under the age of 20 Routine oral exams limited to 2 PCY Space maintainers for members under age 20 X-rays including bitewing X-rays. Complete series or panoramic X-ray once per 36 consecutive months BASIC Emergency palliative treatment Fillings limited to once per tooth surface every 24 consecutive months General anesthesia limited to covered dental procedures at a dental-care provider s office when dentally necessary Oral surgery including simple and surgical extractions Periodontal maintenance limited to 4 visits PCY MAJOR Implants, dentures, partials and fixed bridges replacements for dentures, partials & fixed bridges limited to once every 5 calendar years Endodontic (root canal) treatment limited to 2 per arch when performed in conjunction with overdentures Full-mouth debridement limited to once every 3 calendar years Inlays, onlays and crowns replacements limited to once per tooth every 5 years Periodontal scaling limited to once per quadrant every 2 calendar years Recementing and repair of crowns, inlays, bridgework and dentures 0% 20% 20% 20% 50% 50% Note: Coinsurance amounts based on allowable charges. Balance billing may apply if a provider is not contracting with Premera. Annual deductible waived for diagnostic and preventive services. 5

6 Adult Dental Preference With Adult Dental Preference plans, employers choose a deductible and coinsurance cost-share option, and provide employees with choice and control over their out-of-pocket spending. When members use contracted dental network providers, they receive their plan s highest benefit level, and enjoy the cost savings these networks offer. Or, they can use an out-of-network provider at a reduced benefit level, if they prefer. COVERED SERVICES FOR GROUPS 5+ With Adult Dental Preference, employers can offer employees: Maximum flexibility because they can choose any licensed or certified dentalcare provider and benefit from the cost savings our network provides Diagnostic and preventive services including routine exams, cleanings, fluoride and X-rays Benefits apply after calendar year deductible is met, unless otherwise noted. Deductible and coinsurance represent member s cost share PCY = Per calendar year CHOOSE ONE OF THE PREFERENCE PLANS Basic services including fillings, extractions and up to four periodontal maintenance cleanings per year Major services including crowns, inlays, dentures and implants without a waiting period 0* Family: $1,500* Maximum allowance per person, PCY $1,000, $1,500 or $2,000 $1,000, $1,500 or $2,000 In-network Out-of-network In-network Out-of-network ROUTINE DIAGNOSTIC AND PREVENTIVE Cleanings limited to 2 PCY Emergency and non-routine exams limited to 1 PCY Fluoride treatments limited to 2 applications PCY for members under the age of 20 0% 20% 0% 20% Routine oral exams limited to 2 PCY Space maintainers for members under age 20 X-rays including bitewing X-rays. Complete series or panoramic X-ray once per 36 consecutive months BASIC Emergency palliative treatment Fillings limited to once per tooth surface every 24 consecutive months General anesthesia limited to covered dental procedures at a dental-care provider s office when dentally necessary Oral surgery including simple and surgical extractions 20% 40% 20% 40% Periodontal maintenance limited to 4 visits PCY MAJOR Implants, dentures, partials and fixed bridges replacements for dentures, partials & fixed bridges limited to once every 5 calendar years Endodontic (root canal) treatment limited to 2 per arch when performed in conjunction with overdentures Full-mouth debridement limited to once every 3 calendar years Inlays, onlays and crowns replacements limited to once per tooth every 5 years Periodontal scaling limited to once per quadrant every 2 calendar years 50% 60% 50% 60% Recementing and repair of crowns, inlays, bridgework and dentures Note: Coinsurance amounts based on allowable charges. Balance billing may apply if a provider is not contracting with Premera. Annual deductible waived for diagnostic and preventive services. * Deductible applies to major services only. 6

7 Adult Dental Essentials Adult Dental Essentials voluntary plans allow employers the opportunity to offer their workforce a valuable group dental benefit without having to fund it. It offers a wide range of benefits for diagnostic and preventive services. Members can choose any licensed or certified dental-care provider and benefit from the cost savings our network provides. Adult Dental Essentials is available to groups with five or more employees. Minimum participation is the greater of five employees or 30 percent of eligible employees. With Adult Dental Essentials employers can: Provide employees the opportunity to purchase dental coverage at group rates Offer a plan that can be funded 100 percent by employees, or elect to fund a portion of premiums (up to 50 percent) Reduce employee benefit expenses Enhance benefit offerings to attract and retain employees COVERED SERVICES FOR GROUPS 5+ Benefits apply after calendar year deductible is met, unless otherwise noted. Deductible and coinsurance represent member s cost share PCY = Per calendar year CHOOSE ONE OF THE ESSENTIALS PLANS ROUTINE DIAGNOSTIC AND PREVENTIVE Cleanings limited to 2 PCY Maximum allowance per person, PCY $1,000 or $1,500 $1,000 Fluoride treatments limited to 2 applications PCY for members under the age of 20 0% 20% Routine oral exams limited to 2 PCY X-rays including bitewing X-rays. Complete series or panoramic X-ray once per 36 consecutive months BASIC Emergency and non-routine exams limited to 1 PCY Emergency palliative treatment Fillings limited to once per tooth surface every 24 consecutive months Periodontal maintenance limited to 4 visits PCY 20% 20% Recementing of crowns, inlays, bridgework and dentures Simple and surgical extractions Space maintainers for members under age 20 MAJOR* Dentures, partials and fixed bridges replacements limited to once every 5 calendar years Endodontic (root canal) treatment limited to 2 per arch when performed in conjunction with overdentures Full-mouth debridement limited to once every 3 calendar years General anesthesia limited to covered dental procedures at a dental-care provider s office when dentally necessary 50% 50% Inlays, onlays and crowns replacements limited to once per tooth every 5 years Oral surgery Periodontal scaling once per quadrant every 2 calendar years Repair of crowns, inlays, bridgework and dentures Note: Coinsurance amounts based on allowable charges. Balance billing may apply if a provider is not contracting with Premera. Annual deductible waived for diagnostic and preventive services. * A 12-month waiting period applies to members who have not had continuous comparable dental coverage under the group s prior dental plan. 7

8 Adult Dental Preventive With Adult Dental Preventive, members can use any licensed or certified dental-care provider and will benefit from 100 percent coverage and no deductibles. Good oral hygiene can help prevent periodontitis and the risk of other health conditions. Adult Dental Preventive is available as a voluntary or employersponsored plan design to groups of five or more employees. With an employer-sponsored Adult Dental Preventive plan design, minimum participation is the greater of five employees or 50 percent of eligible employees. With a voluntary Adult Dental Preventive plan design, minimum participation is the greater of five employees or 30 percent of eligible employees. With Adult Dental Preventive, employers can: Provide valuable preventive coverage at an affordable cost that will proactively encourage good oral habits and better overall health outcomes Choose between voluntary or employer-sponsored plan design options COVERED SERVICES FOR GROUPS 5+ Benefits apply after calendar year deductible is met, unless otherwise noted. Deductible and coinsurance represent member s cost share PCY = Per calendar year PREVENTIVE PLAN Individual: $0 Family: $0 ROUTINE DIAGNOSTIC AND PREVENTIVE Cleanings limited to 2 PCY Maximum allowance per person, PCY $500 Fluoride treatments limited to 2 applications PCY for members under the age of 20 Routine oral exams limited to 2 PCY 0% Routine X-rays including bitewing X-rays. Complete series or panoramic X-ray once per 36 consecutive months Note: Coinsurance amounts based on allowable charges. Balance billing may apply if a provider is not contracting with Premera. Annual deductible waived for diagnostic and preventive services. 8

9 Optional benefits available Enhancements and other options for all Premera DentalBlue plans Our optional dental coverage offers employers extra flexibility in designing their benefit coverage. OPTIONAL BENEFITS BENEFIT ENHANCEMENT RIDER Endodontic (root canal), periodontal scaling and surgical periodontal treatment ORTHODONTIA 1 OPTIMA PREFERENCE Covered under basic instead of major services ESSENTIALS PREVENTIVE NA Diagnostic services and active/retention treatment including appliances Monthly orthodontic adjustments including retention treatment Covered in full 1 up to lifetime maximum N/A NA Lifetime maximum per person (choose one) $1,000 or $1,500 Age limit No age limit 1 Benefits provided at 100 percent of allowable charges; not subject to deductible or coinsurance. Available only with 26 or more enrolled employees. 9

10 10 For grandfathered and non-grandfathered groups with 2+ employees

11 Dental Optima With Dental Optima, employers can choose from an array of deductible and coinsurance cost-share options while offering employees maximum flexibility in provider choice. Dental Optima is available to groups from two to four employees with 100 percent participation. For groups of five or more, minimum participation is the greater of five employees or 50 percent of eligible employees. COVERED SERVICES FOR GROUPS 2 9 With Dental Optima, employers can offer employees: Maximum flexibility because they can choose any licensed or certified dentalcare provider and benefit from the cost savings our network provides Diagnostic and preventive services including routine exams, cleanings, fluoride, X-rays and sealants Basic services including fillings, extractions, and up to four periodontal maintenance cleanings per year Benefits apply after calendar year deductible is met, unless otherwise noted. Deductible and coinsurance represent member s cost share PCY = Per calendar year CHOOSE ONE OF THE DENTAL OPTIMA PLANS Major services including crowns, inlays, dentures, and implants without a waiting period As an optional enhancement to the plan to encourage routine dental care, choose to have routine diagnostic and preventive services that will not accrue toward the maximum allowance.* Maximum allowance per person, PCY $1,000 or $1,500 $1,000 or $1,500 FOR GROUPS 10+ Individual: $0 $50 Family: $0 $150 Individual: $0 $50 Family: $0 $150 Maximum allowance per person, PCY $1,000, $1,500, $2,000 or $2,500* $1,000, $1,500, $2,000 or $2,500* ROUTINE DIAGNOSTIC AND PREVENTIVE Cleanings limited to 2 PCY Emergency and non-routine exams limited to 1 PCY Fluoride treatments limited to 2 applications PCY for members under the age of 20 Routine oral exams limited to 2 PCY Sealants for members under age 19 Space maintainers for members under age 20 X-rays including bitewing X-rays. Complete series or panoramic X-ray once per 36 consecutive months BASIC Emergency palliative treatment Fillings limited to once per tooth surface every 24 consecutive months General anesthesia limited to covered dental procedures at a dental-care provider s office when dentally necessary Oral surgery including simple and surgical extractions Periodontal maintenance limited to 4 visits PCY MAJOR Implants, dentures, partials and fixed bridges replacements for dentures, partials & fixed bridges limited to once every 5 calendar years Endodontic (root canal) treatment limited to 2 per arch when performed in conjunction with overdentures Full-mouth debridement limited to once every 3 calendar years Inlays, onlays and crowns replacements limited to once per tooth every 5 years Periodontal scaling limited to once per quadrant every 2 calendar years Recementing and repair of crowns, inlays, bridgework and dentures 0% 20% 20% 20% 50% 50% Note: Coinsurance amounts based on allowable charges. Only available for Groups 51+. Balance billing may apply if a provider is not contracting with Premera. *Only available for groups Annual deductible waived for diagnostic and preventive services. 11

12 Dental Preference With Dental Preference plans, employers choose a deductible and coinsurance cost-share option, and provide employees with choice and control over their out-of-pocket spending. When members use contracted dental network providers, they receive their plan s highest benefit level, and enjoy the cost savings these networks offer. Or, they can use an out-of-network provider at a reduced benefit level, if they prefer. COVERED SERVICES FOR GROUPS 5+ With Dental Preference, employers can offer employees: Maximum flexibility because they can choose any licensed or certified dentalcare provider and benefit from the cost savings our network provides Diagnostic and preventive services including routine exams, cleanings, fluoride, and X-rays Benefits apply after calendar year deductible is met, unless otherwise noted. Deductible and coinsurance represent member s cost share PCY = Per calendar year CHOOSE ONE OF THE PREFERENCE PLANS Basic services including fillings, extractions, and up to four periodontal maintenance cleanings per year Major services including crowns, inlays, dentures, and implants without a waiting period 0* Family: $1,500* Maximum allowance per person, PCY $1,000, $1,500 or $2,000 $1,000, $1,500 or $2,000 ROUTINE DIAGNOSTIC AND PREVENTIVE In-network Out-of-network In-network Out-of-network Cleanings limited to 2 PCY Emergency and non-routine exams limited to 1 PCY Fluoride treatments limited to 2 applications PCY for members under the age of 20 Routine oral exams limited to 2 PCY 0% 20% 0% 20% Sealants for members under age 19 Space maintainers for members under age 20 X-rays including bitewing X-rays. Complete series or panoramic X-ray once per 36 consecutive months BASIC Emergency palliative treatment Fillings limited to once per tooth surface every 24 consecutive months General anesthesia limited to covered dental procedures at a dental-care provider s office when dentally necessary Oral surgery including simple and surgical extractions 20% 40% 20% 40% Periodontal maintenance limited to 4 visits PCY MAJOR Implants, dentures, partials and fixed bridges replacements for dentures, partials & fixed bridges limited to once every 5 calendar years Endodontic (root canal) treatment limited to 2 per arch when performed in conjunction with overdentures Full-mouth debridement limited to once every 3 calendar years Inlays, onlays and crowns replacements limited to once per tooth every 5 years Periodontal scaling limited to once per quadrant every 2 calendar years 50% 60% 50% 60% Recementing and repair of crowns, inlays, bridgework and dentures Note: Coinsurance amounts based on allowable charges. Balance billing may apply if a provider is not contracting with Premera. Annual deductible waived for diagnostic and preventive services. * Deductible applies to major services only. 12

13 Dental Essentials Dental Essentials voluntary plans allow employers the opportunity to offer their workforce a valuable group dental benefit without having to fund it. It offers a wide range of benefits for diagnostic and preventive services. Members can choose any licensed or certified dental-care provider and benefit from the cost savings our network provides. Dental Essentials is available to groups with five or more employees. Minimum participation is the greater of five employees or 30 percent of eligible employees. With Dental Essentials employers can: Provide employees the opportunity to purchase dental coverage at group rates Offer a plan that can be funded 100 percent by employees or elect to fund a portion of premiums (up to 50 percent) Reduce employee benefit expenses Enhance benefit offerings to attract and retain employees COVERED SERVICES FOR GROUPS 5+ Benefits apply after calendar year deductible is met, unless otherwise noted. Deductible and coinsurance represent member s cost share PCY = Per calendar year CHOOSE ONE OF THE DENTAL ESSENTIALS PLANS ROUTINE DIAGNOSTIC AND PREVENTIVE Cleanings limited to 2 PCY Maximum allowance per person, PCY $1,000 or $1,500 $1,000 Fluoride treatments limited to 2 applications PCY for members under the age of 20 Routine oral exams limited to 2 PCY 0% 20% Sealants for members under age 19 X-rays including bitewing X-rays. Complete series or panoramic X-ray once per 36 consecutive months BASIC Emergency and non-routine exams limited to 1 PCY Emergency palliative treatment Fillings limited to once per tooth surface every 24 consecutive months Periodontal maintenance limited to 4 visits PCY 20% 20% Recementing of crowns, inlays, bridgework and dentures Simple and surgical extractions Space maintainers for members under age 20 MAJOR* Dentures, partials and fixed bridges replacements limited to once every 5 calendar years Endodontic (root canal) treatment limited to 2 per arch when performed in conjunction with overdentures Full-mouth debridement limited to once every 3 calendar years General anesthesia limited to covered dental procedures at a dental-care provider s office when dentally necessary 50% 50% Inlays, onlays and crowns replacements limited to once per tooth every 5 years Oral surgery Periodontal scaling once per quadrant every 2 calendar years Repair of crowns, inlays, bridgework and dentures Note: Coinsurance amounts based on allowable charges. Balance billing may apply if a provider is not contracting with Premera. Annual deductible waived for diagnostic and preventive services. * A 12-month waiting period applies to members who have not had continuous comparable dental coverage under the group s prior dental plan. 13

14 Dental Preventive With Dental Preventive, members can use any licensed or certified dental-care provider and will benefit from 100 percent coverage and no deductibles. Good oral hygiene can help prevent periodontitis and the risk of other health conditions. Dental Preventive is available as a voluntary or employer-sponsored plan design to groups of five or more employees. With an employersponsored Dental Preventive plan design, minimum participation is the greater of five employees or 50 percent of eligible employees. With a voluntary Dental Preventive plan design, minimum participation is the greater of five employees or 30 percent of eligible employees. With Dental Preventive, employers can: Provide valuable preventive coverage at an affordable cost that will proactively encourage good oral habits and better overall health outcomes Choose between voluntary or employer-sponsored plan design options FOR GROUPS 5+ Benefits apply after calendar year deductible is met, unless otherwise noted. Deductible and coinsurance represent member s cost share PCY = Per calendar year DENTAL PREVENTIVE PLAN Individual: $0 Family: $0 Maximum allowance per person, PCY $500 ROUTINE DIAGNOSTIC AND PREVENTIVE Cleanings limited to 2 PCY Fluoride treatments limited to 2 applications PCY for members under the age of 20 Routine oral exams limited to 2 PCY Routine X-rays including bitewing X-rays. Complete series or panoramic X-ray once per 36 consecutive months Sealants for members under age 19 0% Note: Coinsurance amounts based on allowable charges. Balance billing may apply if a provider is not contracting with Premera. Annual deductible waived for diagnostic and preventive services. 14

15 Optional benefits available Enhancements and other options for all Premera DentalBlue plans Our optional dental coverage offers employers extra flexibility in designing their benefit coverage. OPTIONAL BENEFITS BENEFIT ENHANCEMENT RIDERS Endodontic (root canal), periodontal scaling and surgical periodontal treatment Routine diagnostic and preventive services 1 do not accrue toward the maximum allowance DENTAL OPTIMA DENTAL PREFERENCE Covered under basic instead of major services DENTAL ESSENTIALS Optional N/A N/A PREVENTIVE N/A ORTHODONTIA 2 Diagnostic services and active/retention treatment including appliances Monthly orthodontic adjustments including retention treatment Covered in full 3 up to lifetime maximum Lifetime maximum per person (choose one) $1,000 or $1,500 Age limit (choose one) No age limit or under age 19 N/A N/A TEMPOROMANDIBULAR JOINT DISORDER 4 exams and X-rays, occlusal guards and surgical procedures, manipulations under anesthesia Deductible and coinsurance apply Annual benefit maximum $1,000 Lifetime maximum per person $5,000 N/A N/A N/A 1 Only available for groups Available only with 26 or more enrolled employees. 3 Benefits provided at 100 percent of allowable charges; not subject to deductible or coinsurance. 4 Option available only with Optima plans with 200 or more employees. Balance billing may apply if a provider is not contracting with Premera. This brochure is not a contract. It is only a summary of the major benefits provided by these plans. For full coverage provisions, including a description of waiting periods, limitations and exclusions, please contact your Premera sales representative. 15

16 5BIG Reasons Your clients will know they made the right decision in choosing Premera as their dental plan. We ve proudly served Alaskans since 1952 and understand the demands of living here. Members get broad, in-network provider choice here, and outside. Choose us, and you re supporting the local economy we live, work, and love it here. You ll get dedicated, friendly service from people who speak Alaskan. Manage one plan instead of two when you add a dental plan to your Premera health plan. Premera Blue Cross Blue Shield of Alaska 2550 Denali St. Suite 1404 Anchorage, AK premera.com ( )