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Federal Employee Dental and Vision Options

2016 Guide for Presbyterian Health Plan Members

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.

What is the cost?Monthly Annual

Employee $6.00 $63.00

Employee +

1 Dependent

$10.50 $118.00

Employee + Family $15.50 $172.00

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:

www.benefitsource.org

Value Added BenefitFederal 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.

Option 1: Sandia PlanThe 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.

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 $37Bitewing 4 films (x-rays) $53 $35 $18Adult teeth cleaning $100 $60 $40Child teeth cleaning $60 $42 $18Silver filling 1 surface $120 $76 $44Resin white filling 1 surface $145 $91 $54Root canal molar $940 $725 $215Crown (cap) $930 $765 $165Extraction, Routine $125 $73 $52Denture upper/lower $1,525 $1,012 $513Braces (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:

www.benefitsource.org to review the complete fee schedule.

What is the cost?Monthly

Employee $28.56

Employee + 1 Dependent $55.20

Employee + Family $92.80

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• $1,000 annual maximum

per person.

Who are the providers?For the most current PPO provider

listing, please refer to our website:

www.benefitsource.org.

Be sure to ask about our stand alone Orthodontic Edge Plan.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.

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.

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:

www.benefitsource.org for a complete fee schedule.

Option 2: Elite PlanThe 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.

This plan is underwritten by Companion Life and administered by Total Dental Administrators.

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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/PreventiveCovered at 100% In-Network

Covered at 80% Out-of-Network

No waiting period.Oral exams, Cleanings, Fluoride treatment, Space

maintainers, Sealants Palliative emergency

treatment, dental x-rays

Class II: Basic ServicesCovered at 75% In-Network

Covered at 60% Out-of-Network

No waiting period.Silver fillings, Restorations (fillings), Anterior

composite white fillings

Class III: Major ServicesCovered at 45% In-Network

Covered at 40% Out-of-Network

6 month waiting period from date of enrollment.Crowns, Bridges, Dentures, Inlays, Other prosthetic

services, Oral surgery, Extractions, Anesthesia (in

conjunction with oral surgery), Endodontic services,

Periodontal services

Class IV: OrthodonticCovered at 50% In-Network

Covered at 50% Out-of-Network

24 month waiting period from date of enrollment.Up to age 19 only, lifetime maximum of $1,000

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.

What is the cost?Monthly

Employee $28.51

Employee + 1 Dependent $54.95

Employee + Family $96.56

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:

www.benefitsource.org.

Option 3: PPO Dental PlanThis 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.

This dental plan is underwritten by Companion Life and administered by Total Dental Administrators.

Federal Employee Vision BenefitFederal employees enrolled on the PHP High Option Medical Plan will automatically have a new benefit for vision care. This benefit includes an eye exam for a $0 copay in-network ($35 allowance for out-of-network).* These members may elect the buy-up plan that provides coverage for expenses for vision correction materials, such as contact lenses and eye glasses.* Federal Employees that enroll in other PHP medical plans have the option to purchase the Gold 150 Vision Plan which is a comprehensive vision plan that includes coverage for a vision exam and for corrective eyewear.**

* This plan is provided by EyeMed.

** This plan is provided by Superior Vision.

Vision OptionsEYEMED IMBEDDED PLAN:

This plan is automatically included with the PHP High Option Medical Plan for no additional cost.

EYEMED MATERIALS ONLY BUY-UP OPTION:*

Monthly

Employee $4.33

Employee + 1 Dependent $7.33

Employee + Family $10.30

SUPERIOR VISION GOLD 150 PLAN:**

Monthly

Employee $7.30

Employee + 1 Dependent $12.45

Employee + Family $18.30

The charts below are summaries only. For a complete disclosure of vision benefits for all three options visit our website www.benefitsource.org.

EYEMED MATERIALS ONLY BUY-UP OPTION:*

Vision Care Services In-NetworkOut-of-Network Reimbursement

Frame Any available frame at provider location

$0 Copay; $150 Allowance, 20% off balance over $150

$75

Standard Plastic Lenses:Single VisionBifocalTrifocalStandard Progressive

$20 Copay$20 Copay$20 Copay$85 Copay

$25$40$55$40

Lens Options:UV TreatmentTint (Solid and Gradient)

$15$15

N/AN/A

Contact Lenses: (Contact lens allowance includes materials only)Conventional

Disposable

Medically Necessary

$0 Copay; $150 allowance, 15% off balance over $150$0 Copay; $150 allowance, plus balance over $150$0 Copay, Paid-in-Full

$120

$120

$210

SUPERIOR VISION GOLD 150 PLAN:**

Service / Material Participating ProviderNon-Participating

Provider

Vision Examination(1 every 12 mnths)

Paid in full Up to $35.00 retail value

Frame (1 every 24 mnths) Up to $150.00 retail value Up to $70.00 retail value

Lenses (1 every 12 mnths)Single VisionStandard BifocalStandard Trifocal

Paid in fullPaid in fullPaid in full

Up to $25.00 retail valueUp to $40.00 retail valueUp to $45.00 retail value

Contact Lenses (1 every 12 mnths)ElectiveMedically Required

Up to $175.00Paid in full

Up to $80.00 retail valueUp to $150.00 retail value

Who are the providers?Please visit our website, www.benefitsource.org, for a Participating Provider in your area.

EXAM

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$10

EYEW

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$25

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 1ANNUAL 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.

• 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.

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 VisionMONTHLY 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.

How to Join