Ancillary Solutions PRODUCT - Home - LABI Benefits...

01MK5262 R11/14 Blue Cross and Blue Shield of Louisiana is incorporated as Louisiana Health Service & Indemnity Company and an independent licensee of the Blue Cross and Blue Shield Association.

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Southern National Life Insurance Company, Inc. is a subsidiary of Blue Cross and Blue Shield of Louisiana, independent licensees of the Blue Cross and Blue Shield Association.

Bundle up & save

We know how important the right benefit package can be to recruiting and retaining quality employees. That’s why we have partnered with Blue Cross and its subsidiaries to offer you the Blue Bundle. Employers have the option to bundle employee benefits with affordable, high-quality health and wellness benefits.

With one team to administer all your benefits, you save time, and time is money.

Your LABI membership and support allow you to impact decisions of the legislative,

executive, regulatory and judicial branches of state government on a broad range of

issues that affect your bottom line. LABI keeps you informed when your group’s interests

are threatened, provides you with valuable compliance information and gives you access

to business decision-making tools. LABI’s efforts on a single issue could save your group

thousands of dollars! Your LABI membership can also save you money by providing you

with access to multiple benefit plans.

pROTeCTInGdReaMs FOR THe FuTuRe

TOdaY

SOLUTION.SOURCE.BILL.ONE

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LiefSouthern National Life is an independent licensee

of the Blue Cross and Blue Shield Association.

OFFeRInG YOuR eMplOYees peaCe OF MInd

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Whether your company has two employees or 10,000, we have plans that fit.

Life insurance is something that no one likes to think about. All the same, 86 percent of Americans believe that life insurance is something most people need, and most of us have some.1 That’s the good news.

The bad news is that most Americans don’t have enough. More than a third don’t have any life insurance at all, and those who are insured have coverage equal to less than four times their annual income.2 Most experts believe that coverage equal to 10 times one’s annual income is a more reasonable rule of thumb.

1 LIMRA and LIFE Foundation 2011 Insurance Barometer Study 2 LIMRA International, Trends in Life Insurance Ownership, 2011

BasIC GROup TeRM lIFe/ad&d

Employee and dependent life coverage paid for by

the employer.

Did you know…

• Stronglifeinsurancecoverageisessentialtocreatingarobustandcompetitive benefit package for your employees.

• Lifeinsuranceoffersyouremployeesandtheirfamiliesasafeguardfrommany unexpected expenses if something should happen to them.

• Employerscanofferthishigh-valuebenefitatagreatpriceandemployer-funded plans generally count as a business deduction for employers.

vOlunTaRY TeRM lIFe/ad&d

Optional employee and dependent life coverage paid for by the employee

through the convenience of payroll deduction.

Did you know…

• Voluntaryplansofferextravaluetoemployeesatnoaddedcosttotheemployer’s company. Premiums are payroll-deducted, which means benefits are convenient for employees and economical for employers.

• VoluntaryTermLifeinsuranceisawaytoprovidethesameprotectionasourBasic Group Term Life in a way that is cost-effective to both employers and their employees.

• EmployerscanofferVoluntaryTermLifecoveragewithanyBasicLifeplanorasa stand-alone plan.

• Thisoptionallowsemployeestopurchaseadditionalcoverageabovewhatan employer may offer with our Basic Life insurance. This helps provide financial stability and would protect employees’ families from some unexpected expenses, if something were to happen to them.

vOlunTaRY HIGH-lIMIT ad&d

Accidental Death & Dismemberment (AD&D) coverage provides protection

for accidents.

Why add Voluntary High-Limit AD&D?

• It’safactoflife–accidentshappen.BychoosingVoluntaryHigh-LimitAccidental Death & Dismemberment (AD&D) coverage, employees can give themselves and their family members 24-hour protection in case of accidental loss of life, limb, hearing or sight.

• WeofferVoluntaryAD&Dcoveragetoemployersandtheiremployeesatlow, affordable rates. This option can also be offered with any group life insurance coverage or as a stand-alone plan.

• JustlikewithourVoluntaryLifecoverage,premiumsarepaidforbytheemployee through payroll deduction.

• Thisplanrequiresnounderwritingandit’sallguaranteedissue!

lIFe BeneFITs

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COnTRIBuTORY

vOlunTaRY

100% Participation Required


Greater of 25% or 10 eligible enrolled

plan Options • Employee Only

• Employee + Spouse

• Employee, Spouse and Child

standard Features • Accelerated Death Benefit (living benefit)

• Terminally ill employees can receive up to 50% of their voluntary life insurance benefit up to $125,000 while they are still living, if they are given a terminal diagnosis of 12 months or less.

• Premium waiver

• Coverage may continue without paying premium if the employee becomes disabled prior to age 60.

• Conversion Privilege

• Employees/dependents may apply to convert all or part of their group life insurance to an individual policy, if they terminate or are no longer eligible for coverage.

• Portability standard with Voluntary Product

• The option to continue a portion or all of their life insurance coverage when employees leave employment.

Optional Features • Accidental death & dismemberment

• Accident benefits are equal to the amount of life benefits for accidents resulting in loss of life, limbs, hearing or sight.

• Seat belt benefit pays an additional 10% of the principal sum amount to a maximum of $10,000.

• Air bag banafit pays an additional 5% of the principal sum amount to a maximum of $5,000, if seat belt is also used.

• Exposure and disappearance benefit allows covered benefits to be paid within 12 months of disappearance, if due to a forced landing, stranding, sinking or wrecking of a conveyance.

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Southern National Life is an independent licensee of the Blue Cross and Blue Shield Association.

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These are alarming statistics. It just goes to show how important protection against lost income can be to a workforce.

Unfortunately, many people have not planned for the financial burden they will face if they should become disabled

and unable to work for an extended period of time.

Helping employees stay at work.

Ourdisabilitycoverageencouragesemployeestocontinueworkingaslongastheyaresafelyable–protectingtheir

eligibility for benefits and without penalty.

• Employeesareabletosatisfytheeliminationperiodwithonlyalossofduties.

• Wecanextendtheeliminationperioduptoayearfordisabledemployeeswhodonotmeettheearningslossamount.

• Anemployeedoesn’thavetobetotallydisabledtoreceivebenefits.

• Ourdisabilitycoverageallowsdisabledemployeestoreturntoworkforuptoone-halfoftheeliminationperiod

without restarting it if they are unable to endure their return to work.

Protecting employers and employees.

Ourdisabilitycoveragehelpsprotectemployees,whichinturnprotectstheemployer’scompany.Hereareafew

highlights–seethisbookletformorespecificdetails.

• Ourdisabilitycoveragedoesnothavelimitationsforsymptomsthatareself-reportedorsubjective.Wemanageall

employees’ claims carefully and effectively.

• Thereisa“treatment-free”periodwithinthepre-existingconditionlimitation.Duringthisperiod,iftheemployee

does not receive treatment for the pre-existing condition, he or she may qualify for benefits before completing the

continuous days of coverage period.

Almost 3 in 10 workers entering the workforce will become

disabled before age 67.

National Safety Council, Injury Facts, 2010 Ed.

Approximately 90% of disabling accidents and illnesses are not work related; therefore, not covered by workers’ compensation.

Council for Disability Awareness, CDA 2010 Long Term Disability Claims Review

In the last 10 minutes, 490 Americans became

disabled.US Social Security Administration,

Social Security Basic Facts, Aug. 2009

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paYCHeCk COveRaGeIMpaCT OF dIsaBIlITY On THe wORkFORCe

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lOnG-TeRM dIsaBIlITY

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COnTRIBuTORY

vOlunTaRY




standard Features • Waiverofpremium

• Survivorincomebenefit

• Returntoworkincentive

• Workplacemodification

• Disabilityguidance(EAP)

• Mental,nervousandsubstanceabusecoverage

Optional Features • Costoflivingadjustment

• ActivitiesofDailyLiving

• Accidentaldismemberment/lossofsightbenefit

• 24monthsownoccupationandanyoccupationthereafter

• Lossofoneoressentialdutyduringeliminationperiod

product eligibility • Mustbeinbusinessaminimumof2years

• Mustnotinsuremorethan50%immediatefamilymembers

• Canbewrittenstand-aloneorwithanyotherlifeordisabilityproduct

sHORT-TeRM dIsaBIlITY

GROup

COnTRIBuTORY

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Features • Group-NoPre-existinglimitation

• Continuityofcoverage

• Maternityincluded

Optional Features • Totallydisabledordisabledandworking

• Lossofdutiesandincome

• Mustbeinbusinessfor2years

• Mustnotinsuremorethan50%immediatefamilymembers• GroupSTDcanonlybewrittenwithGTL;stand-aloneSTDisnotavailable

STDCLAIM

LTDCLAIM

At the mid point of STD, the claim is given to an LTD analyst who manages the end of the STD

claim, gathers LTD information and develops a plan for ongoing claim

management.

seaMless dIsaBIlITY ClaIM TRansITIOn

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The above illustration assumes disability insurance premiums are not deducted on a pre-tax basis in an employer-sponsored cafeteria plan. Blue Cross and Blue Shield of Louisiana is not engaged in rendering tax, legal or investment advice. We recommend you seek the guidance of a tax professional or financial advisor.

HOw aRe BeneFITs

Taxed?

Non-Contributory Employer pays 100%

.............................. No .............................. Yes

Contributory Employer pays 50% Employee pays 50%

.............................. 50% .............................. 50%

Voluntary Employee pays 100%

.............................. Yes .............................. No

pReMIuM TaxaBle?wHO paYs THe pReMIuM? BeneFIT TaxaBle?

TelepHOnIC sTd InTake

Telephonic Intake analyst

Gathers information from employee.

Contacts the employer.

short-Term disability analyst

Reviews employee’s claim based on automatic system prompt or

referral from intake analyst.

Utilizes specialized resources to make decisions and determines ongoing

case management plan.

dedicated Rehabilitation expert

Reviews claims for return to work potential at specific intervals.

Coordinates with employee, physician and employer to facilitate faster,

smoother return to work.

Dsabi ityli

When an employee becomes disabled, coming back to work is often a long and bumpy road. Our disability coverage provides support to help smooth out the bumps and make a healthy return to work easier for employers and their employees.

Our Disability Guidance service provides insured employees, whether disabled or actively at work, with Long-Term Disability up to five counseling sessions per year that give confidential support for emotional, legal and financial issues.

eMplOYee assIsTanCe pROGRaM

Telephonic assessments and counseling that include confidential sessions with a counselor, financial planner and/or an attorney.

24-hour access to counselors with master’s or doctoral degrees in counseling via a dedicated toll-free phone number 365 days a year.

Referrals to resources and services in callers’ communities are provided, such as community and governmental agencies serving the disabled, homemaker services, assistive equipment and day care for children and elderly parents.

Employees are provided access to self-assessment tools, information and other resources through a password-protected interactive website.

dIsaBIlITY GuIde: suppORTInG a HealTHY ReTuRn TO wORk

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IN-NETWORK BENEFITS (when visiting a Davis Vision Provider) VISION PLAN OPTIONS

plan 1 plan 2 plan 3

Frequency - Once Every:

EyeHealthExaminationIncludingDilation(whenprofessionallyindicated) 12 Months 12 Months 12 Months

Spectacle Lenses 12 Months 12 Months 12 Months

Frame 12 Months 24 Months 24 Months

Contact Lens Evaluation, Fitting and Follow Up 12 Months 12 Months 12 Months

Contact Lenses (in lieu of eyeglasses) 12 Months 12 Months 12 Months

Copayments

EyeHealthExamination $0 $0 $10

Eyewear (Spectacle Lenses and/or Frames) $0 $15 $25

OuT OF NETWORK BENEFITS Member reimbursment schedule applies

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BeneFITs YOu Can seestandard vision Benefits

national network Networkofmorethan45,000providersincluding optometrists, ophthalmologists and regional retail locations.

eye exams Your employees pay little or no copayment for a comprehensive eye exam.

eyeglass lenses Your employees pay little or no copayment for single vision, bifocal or trifocal lenses.

eyeglass frames Your employees pay little or no copayment for frames fromtheDavisVisionCollection*,orreceiveuptoa$175 allowance toward the cost of other frames. *Collection is available at most participating independent provider offices.

Contact lenses Your employees pay no copayment for contact lenses and receive up to a $150 allowance toward the cost of contact lenses.

lasik surgery Your employees may access discounts from participating providers but this is not an insured benefit.

DavisVisionisanindependentcompanythatprovidesanextensivenetworkofvisioncareprovidersonbehalfofBlueCrossandBlueShieldofLouisiana.

(WhenvisitingaDavisVisionnetworkprovider)

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There’s no such thing as a plan that’s too good. That’s why each of our vision plans is packed with

features that don’t cost you or your employees anything extra.

One-year breakage warranty Eyeglasses covered by your plan come with a one-year for eyeglasses warranty for repair or replacement, which begins on the date you receive your glasses. Your plan covers:

• Spectaclelenses

• DavisVisionCollectionframes

• Nationalretailerframes,whereexclusivecollectionis not displayed

Medically necessary contacts Your provider may presrcibe contact lenses in lieu of eyeglasses for treatment of certain conditions. When contact lenses are medically necessary, they will be covered subject to prior approval and applicable copayments and allowances.

Replacement contact lens It’s easy to replace your contacts through the Lens 1-2-3 program mailorderprogram.Justcall1-800-LENS-123orvisit www.lens123.com with your prescription to get started.

20% discount At most of our network retailers, you’ll get a 20%1 discount on items not covered by your plan, like second pairs, sunglasses, etc. In most cases, disposable contact lenses are available at a 10%1 discount.

laser vision correction You can get up to 25% off of the cost of laser vision discounts correction surgery when you use doctors in the Eye Centers of Excellence network.

For consistency and accuracy, when adding vision benefits to existing medical insurance with a first-of-the-month billing date, the new benefits will have a first-of-the-month effective date. The same applies for groups with a 15th-of-the-month billing date.

Eligibility for actively at work, full-time employees requires a minimum of 30 hours per week for our medical, vision and other ancillary products.

Groups may only choose one vision plan and one premium funding contribution type.

General Conditions

Features

Groups with 2-9 eligible employees may only choose employer-paid contribution.

employer-paid:

Contributory:

voluntary:

100% Employer funding 100% of eligible employees must enroll

25%-99% Employer funding Greater of 75% or 10 eligible employees must enroll

0%-24% Employer funding Greater of 25% or five eligible employees must enroll for groups with 10-50 eligible employees

Greater of 25% or 10 eligible employees enrolled for groups with more than 50 eligible employees

Contribution Requirements participation Requirements

1 Discount not available at Walmart, Sam’s Club, and Costco locations.

Vision Plan #1 Effective January 1, 2015

*Discounts are not available at Wal-Mart, Sam’s Club or Costco locations. ** Polycarbonate lenses are covered in full for dependent children, monocular patients and patients with prescriptions >=+\ 6.0 diopters. NOTE: Members must use a Davis Vision network Provider. Out of network benefits are not available.

In-Network Benefits Frequency – Once Every: Eye Health Examination including Dilation (when professionally indicated) 12 Months Spectacle Lenses 12 Months Frames 12 Months Contact Lens Evaluation, Fitting & Follow Up 12 Months Contact Lenses (in lieu of eyeglasses) 12 Months Copayments Eye Health Examination $0 Eyewear (Spectacle Lenses and/or Frames) $0 Eyeglass Benefit – Frames Average Retail Value

Frame Up to $175 Allowance up to $175 Plus a 20% discount on any overage that may apply*

Davis Vision Collection Frame (in lieu of Allowance) Fashion Level (up to $125) Up to $125 Included Designer Lever (Up to $175) Up to $175 Included Premier Level (Up to $225) Up to $225 $25 Copayment Eyeglass Benefit – Spectacle Lenses Clear plastic single vision, bifocal, trifocal or lenticular lenses (any Rx) $60 - $120 Included

Choice of glass or plastic lenses $30 - $35 Included Oversize Lenses $20 Included Fashion and gradient tinting of plastic lenses $20 Included Polycarbonate Lenses** $60 - $75 $0 or $30 Scratch Protection $30 - $60 Included Ultraviolet Coating $25 - $30 $12 Standard Anti-Reflective (AR) Coating $50 - $70 $35 Premium AR Coating $65 - $90 $48 Ultra AR Coating $100 -$125 $60 Standard Progressive Lenses $150 - $195 $50 Premium Progressives $195 - $300 $90 Ultra Progressives $370 $140 Intermediate-Vision Lenses $150 -$175 $30 Blended Segment Lenses $40 - $50 $20 High-Index Lenses $90 - $150 $55 Polarized Lenses $95 - $110 $75 Photo chromic Glass Lenses $30 - $60 $20 Plastic Photosensitive Lenses $95 - $150 $65 Scratch Protection Plan: Single Vision I Multifocal Lenses $20|$40 Contact Lens Benefits (in lieu of eyeglasses)

Prescription Contact Lenses (Materials): Allowance up to $150 Plus a 15% discount on any overage that may apply*

Evaluation and Fitting Fees – Standard Contact Lens Type Included

Evaluation and Fitting Fees – Specialty Contact Lens Type Allowance up to $60 Plus a 15% discount on any overage that may apply*

Medically Necessary Contact Lenses (with prior approval) Materials, Evaluation and Fitting Fees Included

Out-of-Network Benefits Member Reimbursement Applies


*Discounts are not available at Wal-Mart, Sam’s Club or Costco locations.

** Polycarbonate lenses are covered in full for dependent children, monocular patients and patients with prescriptions >=+\ 6.0 diopters.

NOTE: Members must use a Davis Vision network Provider. Out of network benefits are not available.

In-Network Benefits Frequency – Once Every:

Eye Health Examination including Dilation (when professionally indicated) 12 Months

Spectacle Lenses 12 Months

Frames 24 Months

Contact Lens Evaluation, Fitting & Follow Up 12 Months

Contact Lenses (in lieu of eyeglasses) 12 Months

Copayments

Eye Health Examination $0

Eyewear (Spectacle Lenses and/or Frames) $15

Eyeglass Benefit – Frames Average Retail Value

Frame Up to $175 Allowance up to $175

Plus a 20% discount on any overage that may apply*

Davis Vision Collection Frame (in lieu of Allowance)

Fashion Level (up to $125) Up to $125 Included

Designer Lever (Up to $175) Up to $175 Included

Premier Level (Up to $225) Up to $225 $25 Copayment

Eyeglass Benefit – Spectacle Lenses

Clear plastic single vision, bifocal, trifocal or

lenticular lenses (any Rx) $60 - $120 Included

Choice of glass or plastic lenses $30 - $35 Included

Oversize Lenses $20 Included

Fashion and gradient tinting of plastic lenses $20 Included

Polycarbonate Lenses** $60 - $75 $0 or $30

Scratch Protection $30 - $60 Included

Ultraviolet Coating $25 - $30 $12

Standard Anti-Reflective (AR) Coating $50 - $70 $35

Premium AR Coating $65 - $90 $48

Ultra AR Coating $100 -$125 $60

Standard Progressive Lenses $150 - $195 $50

Premium Progressives $195 - $300 $90

Ultra Progressives $370 $140

Intermediate-Vision Lenses $150 -$175 $30

Blended Segment Lenses $40 - $50 $20

High-Index Lenses $90 - $150 $55

Polarized Lenses $95 - $110 $75

Photo chromic Glass Lenses $30 - $60 $20

Plastic Photosensitive Lenses $95 - $150 $65

Scratch Protection Plan: Single Vision I Multifocal Lenses $20|$40

Contact Lens Benefits (in lieu of eyeglasses)

Prescription Contact Lenses (Materials): Allowance up to $150



Evaluation and Fitting Fees – Specialty Contact Lens Type Allowance up to $60


Medically Necessary Contact Lenses (with prior approval)

Materials, Evaluation and Fitting Fees Included



* Discounts are not available at Wal-Mart, Sam’s Club or Costco locations. ** Polycarbonate lenses are covered in full for dependent children, monocular patients and patients with prescriptions >=+\ 6.0 diopters. NOTE: Members must use a Davis Vision network Provider. Out of network benefits are not available.

In-Network Benefits Frequency – Once Every: Eye Health Examination including Dilation (when professionally indicated) 12 Months Spectacle Lenses 12 Months Frames 24 Months Contact Lens Evaluation, Fitting & Follow Up 12 Months Contact Lenses (in lieu of eyeglasses) 12 Months Copayments Eye Health Examination $10 Eyewear (Spectacle Lenses and/or Frames) $25 Eyeglass Benefit – Frames Average Retail Value

Frame Up to $175 Allowance up to $175 Plus a 20% discount on any overage that may apply*

Davis Vision Collection Frame (in lieu of Allowance) Fashion Level (up to $125) Up to $125 Included Designer Lever (Up to $175) Up to $175 Included Premier Level (Up to $225) Up to $225 $25 Copayment Eyeglass Benefit – Spectacle Lenses Clear plastic single vision, bifocal, trifocal or lenticular lenses (any Rx) $60 - $120 Included

Choice of glass or plastic lenses $30 - $35 Included Oversize Lenses $20 Included Fashion and gradient tinting of plastic lenses $20 Included Polycarbonate Lenses** $60 - $75 $0 or $30 Scratch Protection $30 - $60 Included Ultraviolet Coating $25 - $30 $12 Standard Anti-Reflective (AR) Coating $50 - $70 $35 Premium AR Coating $65 - $90 $48 Ultra AR Coating $100 -$125 $60 Standard Progressive Lenses $150 - $195 $50 Premium Progressives $195 - $300 $90 Ultra Progressives $370 $140 Intermediate-Vision Lenses $150 -$175 $30 Blended Segment Lenses $40 - $50 $20 High-Index Lenses $90 - $150 $55 Polarized Lenses $95 - $110 $75 Photo chromic Glass Lenses $30 - $60 $20 Plastic Photosensitive Lenses $95 - $150 $65 Scratch Protection Plan: Single Vision I Multifocal Lenses $20|$40 Contact Lens Benefits (in lieu of eyeglasses)

Prescription Contact Lenses (Materials): Allowance up to $150 Plus a 15% discount on any overage that may apply*


Evaluation and Fitting Fees – Specialty Contact Lens Type Allowance up to $60 Plus a 15% discount on any overage that may apply*

Medically Necessary Contact Lenses (with prior approval) Materials, Evaluation and Fitting Fees Included


VISION Rate CaRd

RATES FUNDED PLAN 1 PLAN 2 PLAN 3

Employee $ 6.18 $ 5.65 $ 4.66

Employee and Spouse $ 11.00 $ 10.06 $ 8.29

Employee and Children $ 14.52 $ 13.28 $ 10.95

Family $ 21.07 $ 19.27 $ 15.89

employer Paid100% Employer Funding


Employee $ 7.84 $ 6.67 $ 5.92



Family $ 27.52 $ 23.41 $ 20.78

Contributory

25% - 99% Employer Funding


Employee $ 9.51 $ 7.36 $ 6.87



Family $ 35.19 $ 27.23 $ 25.42

Voluntary

0% - 24% Employer Funding

Blue Cross and Blue Shield of Louisiana is an independent licensee of the Blue Cross and Blue Shield Association and incorporated as Louisiana Health Service & Indemnity Company.01MK5201 R09/14

Rates for groups with 2-500 eligible employees.

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D ntaleGROUP

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• 164millionworkhoursarelosteveryyeartodentalhealthissues.1

• Nearly75percentofAmericanadultssufferfromvariousformsofgumdisease–fromsimpleinflammationtoseverecases–anddon’tevenknowit.2

• Morethan90percentofallsystemicdiseaseshaveoralhealthsymptoms.3

• Peoplewithdentalcoverageexhibithealthierbehaviorsandbetteroralhealthhabits–includingbrushingwithfluoridetoothpastetwiceaday,flossingdailyandvisiting the dentist regularly.4

12010 report from Pew Center 2AmericanDentalHygienistAssociation 3Academy of General Dentistry 42009reportfromNADP

dId YOu knOw?

BeneFITs THaT Make YOuR eMplOYees sMIle

protecting Your employees’ Oral Health

With the recent research showing how important oral health is to overall health, having a dental insurer who is dedicated to affordable, quality dental care is more important than ever.

Whether you’re looking for a dental plan to fit a business budget or your employees’ checkbooks, Blue Cross has the solution.

Regardless of the dental plan you choose, making the decision to secure dental coverage for your employees is the right choice.

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laBI denTal plans

Blue CROss and Blue sHIeld OF lOuIsIana Has a denTal sOluTIOn THaT’s RIGHT FOR YOu

• Available for groups with a reported Medical Loss Ratio (MLR) employee count of 50 or fewer employees.

• UtilizestheAdvantagePlusPPONetwork,anextensivenetworkof nationwide dentists.

• Allows employers to give their employees the benefits they want with little or no costs to the employer.

• Choose from three Certified and three Traditional plans that offer a variety of comprehensive dental services.

• Available for groups with a reported MLR employee count of 51+ employees or groups with ASO medical.

• UtilizestheBlueCrossDentalNetwork,givingyouremployeesthe freedom to choose from a large network of Louisiana dentists.

• Several cost-effective standardized dental plans are available Customized plans are also available based on group size.

• Fully-insured and ASO funding options are available.

• Ideal for individuals and families that do not have dental insurance offered through their employer.

• UtilizestheAdvantagePlusPPONetwork,anextensivenetworkof nationwide dentists.

• Choose from three Certified and three Traditional plans offering reliable and convenient dental coverage.

Blue denTal FOR sMall GROups

laRGe GROup denTal

Blue denTal FOR IndIvIduals

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D ntale C verao gesmall GROUP

If you are like most employers, you consider

dental coverage an essential part of your

employees’ overall health care plan. Our Blue

dental Traditional and Certified plan options

offer a wide range of benefits and services

that will encourage your employees to be the

healthiest and most productive they can be.

We are excited to offer three new Traditional Blue Dental Plans that include comprehensive coverage for adults and children, along with optional cosmetic orthodontic coverage for dependents. These plans are designed for small groupswhoserequiredpediatricdentalessentialhealthbenefits(EHBs)aresatisfiedthroughthegroup’squalified

health plan.

plan a plan B plan B Ortho

Provides excellent coverage for Diagnostic and Preventive services, along with Basic Services.

All benefits covered in Plan A are included in Plan B. In addition, Plan B includes coverage for Major Services.

Plan B Ortho includes the same benefits as Plan B, with the addition of dependent orthodontic coverage up to age 19.

each Traditional plan includes:

• preventive care incentives to encourage routine oral care. Charges for diagnostic and preventive services, like cleaning and x-rays, will not count toward the annual maximum, leaving more benefit dollars for other covered dental procedures.

• Choice of $1,000, $1,500 or $2,000 annual benefit maximum per member

• $50 per member deductible/$150 per family

• no waiting periods

participation:

•EmployerPaid:100%ofeligibleemployeesmustenroll(groupsize2–50)

•Contributory:Greaterof70%or10eligiblemustenroll(groupsize10–50)

•Voluntary:Greaterof20%or10eligiblemustenroll(groupsize10-50)

NEW TRadITIOnal Blue denTal plans

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Three Certified Blue Dental plan options are also available, which are CMS certified and include all the required pediatricdentalEHBs.IfyoursmallgroupmedicalpolicydoesnotincludethepediatricEHBrequirements,thenacertified Blue Dental plan is right for you.

preferred plus preferred essential

Preferred Plus has the highest adult annual benefit maximum of $1,500 and a $50 annual deductible per member.

The Preferred plan covers the same services as Preferred Plus, but with a lower adult annual benefit maximum of $1,000, with a $50 annual deductible per member.

This lower cost plan option offers a $1,000 annual benefit maximum, $75 annual deductible per adult and $50 annual deductible per child, and a slightly lower level of coverage.

each Certified plan option includes:

• an unlimited annual benefit maximum and no waiting periods for the majority of dental services for children under age 21.

• Traditional and medically necessary orthodontia for dependents up to age 21

participation:

• Greaterof20%or10eligibleemployeeswithaminimumof2eligibleemployeesenrolled(groupsize2-50)

CeRTIFIed Blue denTal plans

CeRTIFIed Blue denTal plansPreferred Plus, Preferred and Essential

TRadITIOnal Blue denTal plansPlan A, Plan B and Plan B Ortho

Pediatric Dental Essential Health Benefits

Includes all the required Pediatric DentalEHBs

DoesnotincludePediatricDentalEHBs

Benefits Separate benefits for adults and children under age 21

Same benefits for adults and children

Child Orthodontia Medically necessary and traditional orthouptoage21;24-monthwaitingperiod

Traditionalorthouptoage19;no waiting period

Waiting Periods Adult waiting period applies Nowaitingperiodsforadultsorchildren

Premiums Premium reflects rates per covered persons (members level premium)

Tier-rated premiums (employee/spouse/child/family)

Blue denTal plans: CeRTIFIed vS. TRadITIOnal

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save your employees money:

save your employees time:

Give your employees freedom:

NetworkdentistshaveagreedtoaccepttheBlueCrosspayment,plusyourdeductible and coinsurance, as payment in full for covered services. They will not bill for any balance over that amount.

Networkdentistsautomaticallyfileclaimswithus,soit’sonelessthingfor your employees to do. Since we pay dentists directly, there’s no waiting for reimbursement.

Neitheryouremployeesnortheirfamilymembersaretiedtoonedentist.With access to the extensive Advantage Plus network, all family members can choose a dentist they like.

Although you can use any licensed dentist with a Blue Dental plan, a network dentist will:

visit an advantage plus network dentist for Maximum value

With Blue Dental, our members may access the Advantage Plus PPO Network*. This extensive dental network of nationwide dentists provides our members:

•Accesstoover900dentistsand1,600locationsthroughoutLouisiana

•Accesstoover78,000credentialeddentistsnationally

•45%ofalldentistsnationwideparticipatein-network

•Strongruralandsuburbanfocus

•Over99%ofdentistsin-networkareacceptingnewpatients

*AdvantagePlusNetworkPPOisadministeredbyUnitedConcordiaCompanies,Inc.UnitedConcordiaisanindependentcompanythatadministersdentalbenefitsonbehalfofBlueCross and Blue Shield of Louisiana members.

advanTaGe plus ppO neTwORk

Find a dentist: TofindadentistintheAdvantagePlusPPONetwork,visitwww.bcbsla.com/FindADoctor. If your dentist is not currently participating in the network, you can nominate your dentist by calling 1-800-332-0366.

23

Blue Cross and Blue shield of louisiana has seven dental options

for large employers that offer a variety of dental services.

D ntale C verao geLARGE GROUP

CHOOse THe plan THaT Is RIGHT FOR YOuR GROup

•Seven dental plans to choose from

•Deductiblesperbenefitperiodrangefrom$50to$100

•Maximumbenefitsperbenefitperiodrangefrom$1,000to$2,000

•DiagnosticandPreventiveServicesarecoveredat100%withnowaitingperiods

•BasicServicesarecoveredat80%andcoverageforMajorServicesrangesbetween50%and60%

•CoverageforMajorServicesrangesbetween50%and60%

•Traditionalorthodontiaiscoveredinsomeplans

product eligibility

•Large groups with a reported Medical Loss Ratio (MLR) employee count of 51+ employees or groups with ASO medical are

eligible to purchase large group dental

•Employercontributionis50%ofemployeecost

•50%participationisrequired

laRGe GROup denTal COveRaGe

Product of Blue Cross and Blue Shield of Louisiana

TheBlueCrossDentalNetworkisalargenetworkofdentistslinkedtogetherwithBlueCrosstobringourmembersa more cost-effective dental plan. For a list of dentists in your area, go to www.bcbsla.com/FindaDoctor.

• Allbenefitsarebasedonallowablechargesforcoveredservicesandparticipatingdentistshaveagreedtoacceptthe Blue Cross payment (plus your deductible and coinsurance) as payment in full for covered services. They will not bill for any balance over that amount. All claims payments go directly to the participating dentist for covered services rendered.

• Ifyouchooseanon-participatingdentist,youmayhavetofileyourownclaimsandberesponsibleforpayingthedentist for all charges. This amount may include any difference between the Blue Cross allowable charge and the fee charged by the dentist.

Blue CROss denTal neTwORk

Small Group Certified Blue Dental Plans

Effective January 1, 2015

The Preferred Plus, Preferred and Essential plans are Exchange certified and include all the required pediatric dental essential health benefits (PDEHB).

Product Eligibility & Participation • Small groups with a reported Medical Loss Ratio (MLR) employee count of 50 or less are eligible to purchase • Minimum of 2 benefit eligible employees to be enrolled as minimum participation • Employer contribution is 0% - 100% of employee cost • Participation is greater of 20% or 10 enrolled

Network

• Child Out of Pocket Yearly Maximum only accumulates for benefits paid to a participating network provider. • To take full advantage of the Blue Dental coverage, members should choose a dentist who participates in the Advantage Plus Network*. • To find out if a dentist participates in the Advantage Plus Network, visit www.bcbsla.com/findadoctor. • If members choose to visit an out-of-network dentist, they may be subject to higher fees and may be required to submit their claims.

*Advantage Plus Network PPO is administered by United Concordia Companies, Inc. United Concordia is an independent company that administers dental benefits on behalf of Blue Cross and Blue Shield of Louisiana members.

BENEFITS CERTIFIED DENTAL PLAN OPTIONS

Preferred Plus Preferred Essential

Deductible (per Adult Member per calendar year)1 $50 $50 $75

Deductible (per Member under age 21 per calendar year)1 $50 $50 $50

Adult Annual Benefit Maximum- Members age 21 & older $1,500 $1,000 $1,000

Child Annual Benefit Maximum- Members under age 21 Unlimited Unlimited Unlimited

Child Out of Pocket Yearly Maximum- Members under age 21 (Applies to In-Network Services Only)

$350 for 1 Child $700 for 2 or more Children



Lifetime Maximum Traditional Orthodontia- Members under age 21 $1,000 $1,000 $1,000

Child2 No Waiting

Period Adult

Adult Waiting Period

Child2 No Waiting

Period Adult

Adult Waiting Period

Child2 No Waiting

Period

Adult Adult

Waiting Period

COVERED SERVICES CONTRACT PAYS Routine Oral Exams and Cleanings1 100% 100% None 100% 100% None 100% 100% None

Oral X-Rays1 80% 100% None 80% 100% None 80% 50% None

Fluoride Treatments, Sealants1 80% Not Covered 80% Not Covered 80% Not Covered

Palliative Treatment (Emergency)1 80% 80% None 80% 80% None 80% 80% None

Space Maintainers 80% Not Covered 80% Not Covered 80% Not Covered

Basic Restorative (Amalgam, Resin Fillings) 50% 80% 6 months 50% 80% 6 months 50% 50% 6 months

Oral Surgery, Surgical Extractions 50% 80% 12 months 50% 80% 12 months 50% 50% 12 months

Simple Extractions 50% 80% None 50% 80% None 50% 50% None

Periodontics – Surgical and Non-Surgical 50% 80% 12 months 50% 80% 12 months 50% 50% 12 months

Endodontics 50% 80% 6 months 50% 80% 6 months 50% 50% 6 months

Crown Repairs 50% 50% 12 months 50% 50% 12 months 50% 50% 12 months

Crowns, Prosthetics (Bridges, Dentures) 50% 50% 12 months 50% 50% 12 months 50% 50% 12 months

Implants (Members under age 21 only) Must meet Dental Necessity Requirements 50% Not Covered 50% Not Covered 50% Not Covered

Orthodontics (Members under age 21 only)

Medically Necessary 50% 24-month wait Not Covered 50%

24-month wait Not Covered 50% 24-month wait Not Covered

Traditional 50% 24-month wait Not Covered 50%

24-month wait Not Covered 50% 24-month wait Not Covered

1 Does not apply to Diagnostic and Preventative Services 2 Members under age 21. Certain benefits are limited to children of younger age than 18. See contract and schedule of benefits for coverage exclusions and limitations.

http://www.bcbsla.com/findadoctor


Small Group Traditional Blue Dental Plans

Effective January 1, 2015

1 Does not apply to Diagnostic and Preventative Services

See contract and schedule of benefits for coverage exclusions and limitations. Product Eligibility • Small groups with a reported Medical Loss Ratio (MLR) employee count of 50 or less are eligible to purchase • Minimum of 2 benefit eligible employees to be enrolled as minimum participation • 2-9 Employer Paid Only- 100% participation • 10-50 Employer Paid- 100% participation, Contributory- greater 70% or 10 enrolled, Voluntary- greater 20% or 10 enrolled

Network

• To take full advantage of the Blue Dental coverage, members should choose a dentist who participates in the Advantage Plus Network*.

• To find out if a dentist participates in the Advantage Plus Network, visit www.bcbsla.com/findadoctor. • If members choose to visit an out-of-network dentist, they may be subject to higher fees and may be required to submit their

claims. *Advantage Plus Network is administered by United Concordia Companies, Inc. United Concordia is an independent company

TRADITIONAL DENTAL PLAN OPTIONS

Benefits

Plan A Plan B Plan B Ortho

Contract Year Deductible per Member/per Family1 $50/$150 Not applied to D&P

$50/$150 Not applied to D&P

$50/$150 Not applied to D&P

Annual Benefit Maximum per Member (INN & OON) $1000, $1500 or $2000 $1000, $1500 or $2000 $1000, $1500 or $2000 OOP Yearly Max per Member/per Family Unlimited Unlimited Unlimited

Lifetime Maximum Orthodontia Per Member (Up to age 19) N/A N/A $1000 or $1500

COVERED SERVICES CONTRACT PAYS

Diagnostic and Preventive Services Benefit

Coinsurance Waiting Period

Benefit Coinsurance

Waiting Period

Benefit Coinsurance

Waiting Period

Routine Oral Exams and Cleanings1 100% None 100% None 100% None

All Oral X-Rays1 100% None 100% None 100% None Oral Cleanings1 100% None 100% None 100% None Fluoride Treatments1 100% None 100% None 100% None Sealants1 100% None 100% None 100% None Palliative Treatment (Emergency)1 100% None 100% None 100% None

Basic Services Benefit

Coinsurance Waiting Period

Benefit Coinsurance

Waiting Period

Benefit Coinsurance

Waiting Period

Space Maintainers 80% None 80% None 80% None

Basic Restorative (Amalgam, Resin Fillings) 80% None 80% None 80% None Endodontic Therapy 80% None 80% None 80% None Root Canal 80% None 80% None 80% None Non-Surgical Periodontics 80% None 80% None 80% None Surgical Periodontics 80% None 80% None 80% None Simple Extractions 80% None 80% None 80% None Surgical Extractions 80% None 80% None 80% None Oral Surgery 80% None 80% None 80% None General Anesthesia/Sedation 80% None 80% None 80% None Crown Repair 80% None 80% None 80% None Adjustments and Repairs of Prosthetics 80% None 80% None 80% None

Major Services Benefit Coinsurance

Waiting Period

Benefit Coinsurance

Waiting Period

Benefit Coinsurance

Waiting Period

Prosthetics Dentures and Bridges 0% None 50% None 50% None Inlays, Onlays and Crowns 0% None 50% None 50% None Orthodontia (Traditional- dependent children up to age 19) Not Covered N/A Not covered N/A 50% None


Small Group Embedded Child Dental Benefit Benefits reflect effective dates beginning January 1, 2015

Benefits apply to under age 19 with embedded pediatric dental benefits in medical policy.

BENEFIT DESIGN DEDUCTIBLE AND COINSURANCE

Network

Advantage Plus Network*

Deductible (per Member per calendar year)1

$25

Annual Benefit Maximum

Unlimited

Out of Pocket Annual Maximum In and out of Network

Combined with Medical Annual Maximums

In and out of Network

COVERED SERVICES No Waiting Period

Routine Oral Exams and Cleanings1

100%

All Oral X-Rays1

100%

Fluoride Treatments, Sealants1

100%

Palliative Treatment (Emergency)1

80%

Space Maintainers

80%

Basic Restorative (Amalgam, Resin Fillings)

80%

Crown Repairs

80%

Endodontic (Root Canals, etc.)

80%

Oral Surgery, Surgical Extractions

80%

Simple Extractions

80%

Periodontics – Surgical and Non-Surgical

80%

Crowns, Prosthetics (Bridges, Dentures)

50%

Implants Must meet Dental Necessity Requirements

50%

Orthodontics (Medically Necessary)

50%

1 Does not apply to Diagnostic and Services

*Advantage Plus Network is administered by United Concordia Companies, Inc. United Concordia is an independent company that

administers dental benefits on behalf of Blue Cross and Blue Shield of Louisiana members

This is only an outline. All benefits are subject to the terms and conditions of the Contract. In the case of a discrepancy, the Contract will prevail.

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1-800-495-Blue (2583)We’reavailableMondaythroughFriday,8a.m.–5p.m.

www.bcbsla.comFind help online 24 hours a day.

5525 Reitz ave.Baton Rouge, louisiana 70809

We have eight regional offices around the state. Find us at any of the following locations. We’d love to see you.

phone

Online

Mail

local

We’re easy to find and happy to help you. If you need to reach us:

Alexandria

318-448-16604508 Coliseum Blvd., Suite A

Alexandria, LA 71303

Baton Rouge

225-295-25565525 Reitz Ave.

Baton Rouge, LA 70809-3802

Houma

985-223-34991437 St. Charles Street, Suite 135

Houma,LA70360

Lafayette

337-232-75275501JohnstonSt.,Suite200

Lafayette, LA 70503

Lake Charles

337-562-0595219 West Prien Lake Road

Lake Charles, LA 70601-8450

Monroe

318-323-14793130 Mercedes Dr. Monroe, LA 71201

New Orleans

504-832-58003501NorthCausewayBlvd.,Suite600

Metairie, LA 70002

Shreveport

318-795-0573411 Ashley Ridge Blvd. Shreveport, LA 71106

Regional Offices

CusTOMeR seRvICe

Contact your Blue Cross Regional office for more product information and rates.More info

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