2018 Presbyterian Health Plan Federal Employee Dental & Vision Options

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1 2018 Presbyterian Health Plan Federal Employee Dental & Vision Options For more information: 1804 Juan Tabo NE, Suite A, Albuquerque, NM benefitsource.org These benefits are neither offered nor guaranteed under contract with FEHB program, but are made available to all enrollees and family members who become members of the Presbyterian Federal Health Plan.

2 Option 1: Sandia Plan The Sandia Plan is the most economic dental plan option. Members obtain dental services from our ever expanding panel of participating dentists. Members enjoy guaranteed low, pre-set fees on almost all types of dental work. Savings from 20% 60% are available for most basic and major dental services. Plan discounts are designed to encourage proper dental care by promoting early detection and regular dental health maintenance. What is the cost? Monthly Annual Employee $6.50 $69.00 Employee + 1 Dependent $11.25 $ Employee + Family $16.50 $ What are the advantages of this plan? No deductibles No claim forms No pre-enrollment exams No prior authorization required Pre-existing conditions covered No limits on the amount of benefits No waiting periods for dental benefits Over 1,400 dental providers throughout New Mexico. Who are the providers? For a Sandia Plan Provider Listing please refer to our website: Value Added Benefit Federal employees enrolled in the Presbyterian Health Plan are automatically enrolled in our Value Added Benefit Program at no additional cost. Visit our website for more details on this program. Who is eligible for this plan? BenefitSource matches the eligibility requirements established for the Federal Employee Health Benefit Program. Federal employees, their spouses and their unmarried dependent children up to age 26 are eligible to participate. Dependent children over the age of 26 may be eligible due to developmental or physical disability; proof of such must be provided. What do I do in an emergency? In case of a dental emergency, contact your participating dentist directly. If this dentist is unavailable for emergency treatment (palliative treatment to control pain, bleeding or infection) within 24 hours of the onset of the dental emergency, members may obtain emergency care from any licensed dentist to prevent further harm. Follow-up treatment must be provided by a participating dentist. BenefitSource will provide $20 reimbursement for emergency services upon written request with proper documentation, within 30 days of service. When using Sandia Plan dentists, compare your savings for these services: With no Coverage (you pay) Sandia Plan (you pay) YOU SAVE Exam (Initial) $80 $43 $37 Bitewing 4 films (x-rays) $53 $35 $18 Adult teeth cleaning $100 $60 $40 Child teeth cleaning $60 $42 $18 Silver filling 1 surface $120 $76 $44 Resin white filling 1 surface $145 $91 $54 Root canal molar $940 $725 $215 Crown (cap) $930 $765 $165 Extraction, Routine $125 $73 $52 Denture upper/lower $1,525 $1,012 $513 Braces (Child) $6,000 $5,028 $972 This is an abbreviated schedule of dental fees. A complete Sandia fee schedule will be mailed with your ID card once enrollment has been processed. Or visit our website: to review the complete fee schedule.

3 Option 2: Elite Plan The Elite Plan is a comprehensive indemnity dental plan. When obtaining service from our list of PPO dental offices, members have no deductibles and enjoy significant out of pocket savings on most dental fees. If members choose to use non-ppo dental offices, there is still excellent insurance coverage with no deductibles for diagnostic and preventive services and a low $50 annual deductible for all other services. What is the cost? Monthly Employee $29.14 Employee + 1 Dependent $56.30 Employee + Family $94.66 What are the advantages of this plan? Freedom to see any licensed dentist Over 1,800 PPO dental providers throughout New Mexico No In-Network deductibles 6 month waiting period for Major services $1,200 annual maximum per person. Who are the providers? For the most current PPO provider listing, please refer to our website: Who is eligible for this plan? BenefitSource matches the eligibility requirements established for the Federal Employee Health Benefit Program. How do I obtain services? Upon enrollment, you will receive a dental ID Card. To receive care, simply call your dentist for an appointment and present your card. Be sure to ask about our stand alone Orthodontic Edge Plan. This plan is underwritten by Companion Life and administered by Total Dental Administrators. Plan benefits: When using participating PPO dental providers, members pay the listed In-Network PPO fee directly to the dental office at the time of service. If members obtain dental services from non-participating dental providers (out of network), the plan will pay the amount listed, but the dental office will balance bill members for any differences in fees. DIAGNOSTIC/ PREVENTIVE RESTORATIVE FIXED PROSTHODONTICS ENDODONTICS PERIODONTICS REMOVABLE PROSTHODONTICS ORAL SURGERY Code Description In-Network PPO Fee (Member Pays) Out-of-Network (Plan Pays) D0120 Periodic oral evaluation $0 $32 D0150 Comprehensive oral eval $0 $49 D0274 Bitewings four films $0 $39 D1110 Prophylaxis adult (cleaning) $17 $52 D1120 Prophylaxis child (cleaning) $8 $38 D2140 Silver amalgam filling 1 surface $36 $53 D2160 Silver amalgam filling 3 surface $54 $80 D2330 White resin filling 1 surf. anterior $39 $59 D2332 White resin filling 3 surf. anterior $60 $89 D2510 Inlay metallic 1 surface $304 $130 D2750 Crown porcelain high noble metal $561 $240 D2751 Crown porcelain base metal $466 $200 D2950 Core build-up including any pins $111 $47 D3110 Pulp cap direct (excl. final rest.) $34 $15 D3310 Root canal anterior (excl. final rest.) $302 $130 D3330 Root canal-molar (excl. final rest.) $485 $208 D4341 Perio scaling & root planing (4+) $116 $50 D4342 Perio scaling & root planing (1-3) $70 $30 D4910 Periodontal maintenance $67 $29 D5110 Complete denture upper $802 $344 D5120 Complete denture lower $802 $344 D5650 Add tooth to existing partial $75 $32 D7210 Surgical removal of erupted tooth $108 $46 D7220 Remov impacted tooth soft tis. $119 $51 D7240 Remov impacted tooth comp bony $190 $82 This is only a summary of the benefit fee schedule. Visit our website: for a complete fee schedule.

4 Option 3: PPO Dental Plan This plan is a traditional dental indemnity plan with the freedom of choice to see any licensed dentist. When using PPO Dental Plan providers, members have lower out of pocket costs and no balance billing for dental services. There is no waiting period for preventive and basic dental services and a 6 month waiting period (from date of enrollment) for major services. There is no deductible for Class I services and a $50 annual deductible per person, with a maximum of $150 per family, for Class II and Class III services. Payment is based upon maximum allowable charge of In-Network Providers. What is the cost? Monthly Employee $29.28 Employee + 1 Dependent $56.42 Employee + Family $99.18 What are the advantages of this plan? Freedom to see any licensed dentist Over 1,800 dental providers throughout New Mexico $1,200 annual maximum per person Local customer service Who are the providers? For the most current PPO provider listing, please refer to our website: This dental plan is underwritten by Companion Life and administered by Total Dental Administrators. Who is eligible for this plan? BenefitSource matches the eligibility requirements established for the Federal Employee Health Benefit Program. Federal employees, their spouses and their unmarried dependent children up to age 26 are eligible to participate. Dependent children over the age of 26 may be eligible due to developmental or physical disability; proof of such must be provided. SERVICE TYPE DESCRIPTION Class I: Diagnostic/Preventive No waiting period. Covered at 100% In-Network Oral exams, Cleanings, Fluoride treatment, Space Covered at 80% Out-of-Network maintainers, Sealants Palliative emergency treatment, dental x-rays Class II: Basic Services No waiting period. Covered at 80% In-Network Silver fillings, Restorations (fillings), Anterior Covered at 60% Out-of-Network composite white fillings Class III: Major Services 6 month waiting period from date of enrollment. Covered at 50% In-Network Crowns, Bridges, Dentures, Inlays, Other prosthetic Covered at 40% Out-of-Network services, Oral surgery, Extractions, Anesthesia (in conjunction with oral surgery), Endodontic services, Periodontal services Class IV: Orthodontic 24 month waiting period from date of enrollment. Covered at 50% In-Network Up to age 19 only, lifetime maximum of $1,000 Covered at 50% Out-of-Network How do I receive care? Upon enrollment, you will receive a dental ID card. This will be a separate card from your health plan member ID Card. To receive care, simply call your dentist for an appointment and present your dental plan ID card. For your protection, a predetermination of benefits is recommended for treatment plans that exceed $300. This benefit helps members better understand their coverage. It explains which recommended procedures will be covered and of what amount. Members should submit the treatment plan for review and a predetermination of benefits before receiving the service.

5 Federal Employee Vision Benefit Vision Materials Option: BenefitSource and Vision Care Direct have teamed up to provide Federal employees enrolled on Presbyterian Health Plan the option to purchase a vision materials plan. This will help with purchasing eye glass frames, a variety of lenses for eye glasses or contact lenses. Vision Plan Monthly Rates Buying eye glasses or contact lenses can be very costly. For the low monthly rate Employee $7.98 Employee + 1 Dependent Vision Plan Allowance and Frequency listed below, Presbyterian Health Plan members enrolled on the Federal Employee Health Benefit Program can enroll on this materials only vision plan. The plan provides excellent coverage for eye glass frames, most lenses or contact lenses. Enrolled members are able to use this vision materials plan once every 12 months. Materials Allowance Frame Allowance Lenses Contact Lenses $12.64 Employee + Child $14.56 Employee +Family $24.62 $15 Materials Payment at the time of service $130 frame allowance Member responsible for amount exceeding $130 Single Vision, Flat Top 25/28 Bifocal, Flat Top 7x25: 7x28 Trifocal or Lenticular. Progressive multifocal member pays difference of retail price of progressive and trifocal. Lens enhancements, tints, anti-reflective, scratch coats customary charge. Contact lens allowance of $130 instead of eye glasses may be applied toward materials and fitting Vision Providers The vision materials benefit listed in this summary are available from participating Vision Care Direct providers. Visit benefitsource.org and follow the links to VCD Provider information for the most current list of participating vision care providers. When using non-participating vision providers, there is still coverage for frames up to $35 and for lenses at a modified schedule. Please visit benefisource.org for a complete list of out of network benefits: Questions This is only a summary of plan benefits. Please visit benefitsource.org for a full description of the plan, allowances, limitations and exclusions. To enroll, visit benefitsource.org and follow the links to Presbyterian Federal Employee Benefit Programs to download and complete the enrollment and authorization form, or contact our office for a packet of information. * This plan is provided by Vision Care direct. Updated vision care provider directory can be found at

6 How to Join How do I join Option 1? 1. Simply review the entire brochure. Complete and sign the attached Enrollment/Authorization Form. 2. If your Enrollment/Authorization Form and payment are received at BenefitSource by the 23rd of the month, your coverage will be effective the 1st day of the following month. Forms received after the 23rd of the month will be effective on the 1st day of the 2nd following month. 3. Mail your completed Enrollment/Authorization Form with the correct payment to BenefitSource. 4. You must maintain coverage for a full twelve (12) month period. Please note, as with all coverages, membership fees are non-refundable. By electing coverage through BenefitSource you are agreeing to maintain coverage for a full 12 months. If your health plan coverage should terminate mid-year, your dental policy still remains under the 12 month contract and cannot be terminated until your contract year has been met. Payment options Option 1 ANNUAL PAYMENT You may pay the entire annual membership fee by check, money order, MasterCard, Visa or Discover Cards. MONTHLY BANK DRAFT If you wish to pay the membership fee on a monthly basis, payment must be made by Monthly Electronic Fund Transfer. To initiate the Monthly Bank Draft option, complete the attached Enrollment/Authorization Form and provide a check made out to BenefitSource for the 1st months payment. In addition, please include a voided check from the bank you wish to have the membership fees drafted. Each month your premium will be automatically drafted from your bank account typically between the 23rd and 28th of the month for the next month s coverage. No monthly checks, no postage, no statements. The Monthly Bank Draft option is reliable and automatic! BenefitSource will make reasonable efforts to collect unpaid premiums by sending written notice after the date that delinquent charges are due. Failure to pay any delinquent premiums will result in termination of coverage. How do I join Options 2, 3 and Vision? 1. Review entire brochure, complete and sign the attached Enrollment/Authorization Form. Return your Enrollment/Authorization Form with payment for the appropriate amount to BenefitSource. 2. Enrollment Forms must be received by December 31st to begin coverage January 1st. The next opportunity to enroll in either the Option 2 or 3 will not be until the next open enrollment season. Only new Presbyterian Federal Health Plan members may enroll after open enrollment has ended and must do so within the first sixty days of enrollment in the health plan. 3. We require that you maintain your vision coverage for a full twelve (12) month period. Please note, as with all coverages, membership fees are non-refundable. Each renewal year indicates a new 12 month period. Payment options Options 2, 3 and Vision MONTHLY BANK DRAFT (For Options 2, 3 and Vision) Payment must be made by Monthly Electronic Fund Transfer. To initiate the Monthly Bank Draft option, complete the attached Enrollment/Authorization Form and provide a check made out to BenefitSource for the 1st month s payment. In addition, please include a voided check from the bank you wish to have the membership fees drafted. Each month your premium will be automatically drafted from your bank account between the 23rd and 28th of the month for the next month s coverage. No monthly checks, no postage, no statements. The Monthly Bank Draft option is reliable and automatic! BenefitSource will make reasonable efforts to collect unpaid premiums by sending written notice after the date that delinquent charges are due. Failure to pay any delinquent premiums will result in termination of coverage. The 12 month benefit period is continuous and therefore does not allow for any lapse in coverage. Any additional charges to your account due to insufficient funds or overdraft fees will be the members responsibility and will not be refunded by BenefitSource. TERMINATION OF COVERAGE (OPTION 2 AND 3) If you would like to cancel your dental coverage, you must submit a written cancellation request. If you cancel your membership as a Presbyterian Federal Health Plan member and you want to terminate your dental coverage, you must also notify BenefitSource in writing. All written cancellation requests received by the 23rd of the month will become effective the first day of the following month. Any cancellation requests received after the 23rd will take effect on the 1st of the 2nd following month. Any Bank Draft member who elects to terminate their dental coverage will not be refunded any drafted premium. Any option 2 or 3 Plan members who terminate their dental plan coverage mid-year will be permanently restricted from re-enrolling in these plans. The 12 month contract period is continuous and therefore does not allow for any lapse in coverage. Any additional charges to your account due to insufficient funds or overdraft fees will be the members responsibility and will not be refunded by BenefitSource.