Premera DentalBlueTM FOR ALASKA GROUPS WITH 2+ EMPLOYEES

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1 Premera DentalBlueTM FOR ALASKA GROUPS WITH 2+ EMPLOYEES January 2016

2 Dental product options for a more attractive benefits package Premera Blue Cross Blue Shield of Alaska dental plans offer the choice and flexibility that employers and their employees are looking for to complement their medical plan. Research shows that good oral health habits and regular preventive care helps prevent periodontitis, and can reduce the risk of other health conditions such as diabetes or cardiovascular disease. Our dental portfolio: Provides dental care with no deductibles for cleanings, routine exams, 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 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, and realize 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. Members never need an authorization or referral to see a general dentist or specialist. 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.

3 METALLIC PLAN HIGHLIGHTS ADULT DENTAL OPTIMA ADULT DENTAL PREFERENCE ADULT DENTAL ESSENTIALS ADULT DENTAL 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.

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 (under the age of 19) dental care. Employers can offer the children under age 19 of enrolled 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 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 once every 6 months Fluoride treatments limited to 2 treatments every 12 months Bitewings 1 set every 6 months Routine oral exams limited to once every 6 months Complete series or panoramic x-ray once every 60 months Sealants on permanent molars once every 36 months Space maintainers BASIC Emergency palliative treatment Fillings consisting of amalgam and resin-based composite Periodontal maintenance limited to 4 visits every 12 months Oral surgery including surgical extractions Prefabricated stainless steel and prefabricated porcelain crowns on primary teeth, under age 15, limited to once per tooth every 60 months Reline/rebase dentures limited to once every 36 months Periodontal scaling limited to once per quandrant every 24 months Simple extractions General anesthesia or intravenous conscious sedation MAJOR Crowns, onlays, inlays, and labial veneers once per tooth, every 60 months Endodontic (root canal) treatment Periodontal surgery once every 36 months Implants once every 60 months Dentures, partials, and fixed partial dentures (bridges) once every 60 months ORTHODONTICS 24-month waiting period Medically necessary orthodontics such as cleft palate or cleft lip must receive prior authorization before services are received. 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 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 ADULT DENTAL 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 or intravenous sedation 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 treatments 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 once per tooth in a 2 calendar year period 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+ 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 ADULT DENTAL 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 or intravenous sedation 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 once per tooth in a 2 calendar year period 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 dental plans allow employers to offer their workforce a valuable group dental benefit without having to fund it. These plans provide a wide range of benefits for diagnostic and preventive services. Members can choose any licensed or certified dental-care provider from our network. Adult Dental Essentials is available to groups with two or more employees. (Minimum participation is the greater of two employees or 30 percent of eligible employees.) Dental coverage at group rates Plan can be funded 100 percent by employees, or elect to fund a portion of premiums (up to 50 percent) Reduced employee benefit expenses Enhanced benefit offerings to attract and retain employees COVERED SERVICES FOR GROUPS 2+ 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 ADULT 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 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 once per tooth in a 2 calendar year period Full-mouth debridement limited to once every 3 calendar years General anesthesia or intravenous sedation 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. Adult Dental Preventive is available as a voluntary or employersponsored plan design to groups of two 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 two employees or 30 percent of eligible employees. Valuable preventive coverage at an affordable cost to encourage good oral habits and better overall health Voluntary or employer-sponsored plan design options COVERED SERVICES FOR GROUPS 2+ Benefits apply after calendar year deductible is met, unless otherwise noted. Deductible and coinsurance represent member s cost share PCY = Per calendar year ADULT DENTAL 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 Enhancements and optional benefits available 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 ADULT DENTAL OPTIMA ADULT DENTAL PREFERENCE Covered under basic instead of major services 2 ADULT DENTAL ESSENTIALS ADULT DENTAL 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. 2 On Adult Dental Essentials, option available only for groups 5+ 9

10 10 For grandfathered and non-grandfathered groups

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 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 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 or intravenous sedation limited to covered dental procedures at a dental-care provider s office when dentally necessary Oral surgery including simple and surgical extractions 20% 20% 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 once per tooth in a 2 calendar year period 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% 50% Recementing and repair of crowns, inlays, bridgework and dentures 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+ 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 ADULT DENTAL 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 or intravenous sedation 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 once per tooth in a 2 calendar year period 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 two or more employees. (Minimum participation is the greater of two employees or 30 percent of eligible employees.) Dental coverage at group rates Plan can be funded 100 percent by employees or elect to fund a portion of premiums (up to 50 percent) Reduced employee benefit expenses Enhanced benefit offerings to attract and retain employees COVERED SERVICES FOR GROUPS 2+ 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 once per tooth Full-mouth debridement limited to once every 3 calendar years General anesthesia or intravenous sedation 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. Dental Preventive is available as a employer-sponsored or voluntary plan design to groups of two 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 two employees or 30 percent of eligible employees. Valuable preventive coverage at an affordable cost that will proactively encourage good oral habits and better overall health outcomes Voluntary or employer-sponsored plan design options FOR GROUPS 2+ 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 Enhancements and other optional benefits available 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 5 DENTAL ESSENTIALS Optional N/A N/A DENTAL PREVENTIVE N/A ORTHODONTIA 2 Diagnostic services and active/retention treatment including appliances Covered in full 3 up to lifetime maximum Monthly orthodontic adjustments including retention treatment 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 Deductible and exams and X-rays, occlusal guards and surgical coinsurance apply procedures, manipulations under anesthesia 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. 5 On Dental Essentials, option available only for groups 5+ 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 Premera Blue Cross Blue Shield of Alaska 2550 Denali St. Suite 1404 Anchorage, AK premera.com ( )

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