1 Summary of Benefits and Rate Guide For plans effective January 1, 2015 Anthem Specialty Product Overview Dental Plans Vision Plans Life Plans Rates Enrollment Checklist Part of the CoPower SELECT portfolio of dental, vision, and life plans underwritten by Anthem and available through CoPower, Inc.
2 CoPower Simple. Anthem Strong. It s big news. Anthem Blue Cross is part of CoPower s California offerings. The addition of Anthem Blue Cross (Anthem) products to CoPower s portfolio means you ll be able to offer your clients a complete line of dental, vision, and life coverages from Anthem, one of the most trusted carriers in the nation. Combine that with the simplicity, superior service, and one-stop shopping that CoPower has become renowned for, and it s a win-win situation for you and your clients. The CoPower Advantage: CoPower VANTAGE, a portfolio of value-added products free to all CoPower members CoPower s outstanding customer service Empower, CoPower s online administrative system CoPower administers the following Anthem plans 1 : Dental Basic, Standard, High Option PPO Plans Dental Net DHMO and Voluntary DHMO Plans Dental Blue PPO Plans Dental PPO Voluntary Blue View Vision Plans Life, Dependent Life, and AD&D Plans CoPower offers an exclusive 6% discount, available for groups purchasing an Anthem dental plan plus vision and/or life 2 About Anthem Blue Cross Anthem Blue Cross is one of the nation s largest health benefits companies with nearly 68,000,000 people served by our affiliate companies, including nearly 37,000,000 enrolled in our family of health plans. Going all the way back to our roots in 1936, Anthem has set the standard to provide excellent customer service quality products to our members. As America s valued health partner, our excellent service is a direct reflection of our trustworthiness, accountability, and easy-to-do business with. 2
3 Dental Coverage No two smiles are the same. That s why you need a dental plan that s unique. We ll help you find the right mix of benefits that your employees need for brighter, healthier smiles. With an Anthem dental plan, you can count on: Solid coverage at a good price. Benefits that make sense for dental health and total health. Service you can trust. Strong network access. And all of our dental plans include great member support services, including: 24/7 online access to their claim and benefit information. International Emergency Dental Program 3 for members who travel outside of the U.S. With one call, we can help them find a credentialed, English-speaking dentist for urgent dental care and even help with translation services when they call the dentist s office. Dental health materials that focus on teaching members the importance of dental health. 1 Discount on Life plan only available for groups of 10+. Anthem Medical and Anthem Ancillary bills will be received separately if enrolled under both. 2 Dental Prime and Complete, Voluntary Life, and Disability plans are not administered by CoPower. 3 The International Emergency Dental Program is managed by DeCare Dental. DeCare Dental is an independent company offering dental management services to Anthem Blue Cross. 3
4 Dental PPO Plans Our Dental Blue PPO plans offer: More than 13,000 dentists with more than 34,000 access points in California and nearly 40,500 dentists with 106,900 access points nationwide. Cleanings, exams, and X-rays at no cost when using in-network dentists. Fillings at 80% (or even 90%) when using in-network dentists. More extensive services like oral surgery, crowns, and root canals. Orthodontic services covered on most plans. No waiting periods. An extra cleaning or periodontal maintenance procedure each year for members who are pregnant or living with diabetes. This chart is an overview of coverage. A comprehensive description of coverage, benefits, exclusions and limitations can be found in the Combined Evidence of Coverage and Disclosure Form. DENTAL BLUE PPO PLANS Silver Silver Plus Gold Gold Plus Platinum Platinum Plus Annual maximum $1,000 $1,500 $1,500 $1,500 $2,000 $2,000 Annual deductible Waived in-network for diagnostic and preventive $50/$150 $50/$150 $50/$150 $50/$150 $50/$150 $50/$150 services (Single/Family) Out-of-network reimbursement 80th percentile 80th percentile 80th percentile Network In Out In Out In Out In Out In Out In Out Diagnostic and preventive (cleanings, exams, X-rays) Minor restorative (fillings) Major restorative Oral surgery (tooth extraction) Endodontics (root canal therapy) Periodontics (scaling/root planing) Prosthodontics (crowns, bridges, and dentures) Orthodontics (adult and child) 100% 80% 100% 80% 100% 80% 100% 80% 100% 100% 100% 100% 80% 60% 80% 60% 80% 60% 80% 60% 90% 80% 90% 80% 50% 50% 80% 60% 50% 50% 80% 60% 60% 50% 90% 80% 50% 50% 80% 60% 50% 50% 80% 60% 60% 50% 90% 80% 50% 50% 80% 60% 50% 50% 80% 60% 60% 50% 90% 80% 50% 50% 50% 50% 50% 50% 50% 50% 60% 50% 60% 50% 50% up to $1,000 Not covered 50% up to $1,000 50% up to $1,000 50% up to $1,500 Waiting periods No waiting periods No waiting periods No waiting periods 50% up to $1,500 4
5 Dental PPO Plans (continued) DENTAL PPO PLAN Basic Option PPO Standard Option PPO High Option PPO Annual maximum $1,000 $1,000 $2,000 Annual deductible Waived in-network for diagnostic and preventive services (Single/Family) $75/$225 $50/$150 $50/$150 Out-of-network reimbursement Fee Schedule Fee Schedule Fee Schedule Network In Out In Out In Out Diagnostic and preventive (cleanings, exams, X-rays) 100% 50% 100% 80% 100% 80% Minor restorative (fillings) 50% 50% 80% 80% 80% 80% Major restorative Oral surgery (tooth extraction) Endodontics (root canal therapy) Periodontics (scaling/root planing) Prosthodontics (crowns, bridges, & dentures) Orthodontics (adult and child) Waiting periods (Periodontic and Prosthodontic services) 50% 50% 50% 50% 80% 80% 50% 50% 50% 50% 80% 80% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% Not covered Not covered 50% up to $1, months 12 months 12 months VOUNTARY PPO PLAN In-Network Max Plan Payment Out-of-Network Max Plan Payment Annual benefit maximum - calendar year $1000 / insured person $1000 / insured person Annual deductible - calendar year (per person / family) $50/$150 $50/$150 Waiting Periods Diagnostic and Preventive Services* Periodic oral evaluation (0120) 100% $16 Prophylaxis (cleaning) Adult (1110) 100% $35 Prophylaxis (cleaning) Child (1120) 100% $22 Bitewing X-rays four films (0274) 100% $21 Intraoral X-rays complete series (0210) 100% $45 Restorative Services* Filling, amalgam, two surfaces (2150) $37 $37 6 months Oral surgery, e.g., tooth extraction, simple (7110) $32 $32 6 months Endodontics, e.g., root canal, molar (3330) $185 $ months Periodontics, e.g., scaling and root planing, per quadrant (4341) $36 $36 12 months Prosthodontics Services* Crown, porcelain fused to high noble metal (2750) $200 $ months Denture, complete, upper or lower (5110/5120) $260 $ months Orthodontic Services Not covered Not covered *Lesser of billed charge or stated amount. 5
6 Dental DHMO Plans Our Dental Net DHMO plans have: No annual maximums 4 or deductibles No waiting periods Low or no copays for nearly 300 different services, including: Cleanings, exams, and X-rays Composite (tooth-colored) fillings on any tooth Orthodontic services for both children and adults Special treatments for kids, like sealants for children up to age 15 and fluoride treatments up to age 18 to protect teeth from decay and promote better dental health. Brush biopsy benefits, which may help diagnose oral cancer when combined with a lab analysis and a surgical biopsy with lab analysis. Extra services for members who are pregnant or living with diabetes. Over 10,200 general dentist and specialist access points throughout California This chart is an overview of coverage. A comprehensive description of coverage, benefits, exclusions and limitations can be found in the Combined Evidence of Coverage and Disclosure Form. DENTAL DHMO PLANS CDT code Benefit Plan 2000A Plan 2000B Plan 2000C Diagnostic services Member s Copay D0120 Periodic oral exams $0 $0 $0 D0210 Intraoral X-rays - complete series (including bitewings) $0 $0 $0 Preventive services D1110 or Teeth cleaning (prophylaxis) adult or child 2 per year $0 $0 $0 D1120 D1208 Topical fluoride, covered to age 18 $0 $0 $0 D1351 Sealants, per tooth, through age 15 $7 $5 $0 Restorative services, fillings (permanent) D2140 Amalgam (silver colored) one-surface fillings $0 $0 $0 D2330 Resin-based composite (tooth-colored) fillings on anterior (front) tooth, $0 $0 $0 one surface D2391 Resin-based composite (tooth-colored) fillings on posterior (back) tooth, $30 $20 $10 one surface D2393 Resin-based composite (tooth-colored) fillings on posterior (back) tooth, $55 $45 $30 three surfaces Oral surgery services D7140 Simple extraction of erupted tooth or exposed root $15 $5 $5 D7210 Surgical extraction of erupted tooth $30 $25 $20 D7220 Removal of impacted tooth - soft tissue $50 $45 $40 D7230 Removal of impacted tooth - partial bony $70 $60 $50 D7240 Removal of impacted tooth - completely bony $100 $70 $60 4 There is no maximum or age limitation for pediatric dentistry performed by your participating dental office. If in the professional judgment of your participating dentist or in professional review by plan it is determined that the participating dentist is unable to render care to a child, referral to a pediatric dentist would be a benefit under the age of five with a $750 maximum. Exceptions are made on a pre-approval basis only. 6
7 Dental DHMO Plans (continued) This chart is an overview of coverage. A comprehensive description of coverage, benefits, exclusions and limitations can be found in the Combined Evidence of Coverage and Disclosure Form. DENTAL DHMO PLANS CDT code Benefit Plan 2000A Plan 2000B Plan 2000C Endodontic services Member s Copay D3220 Therapeutic pulpotomy (excluding final restoration) $20 $15 $10 D3310 Root canal: anterior (front tooth) (excluding final restoration) $90 $70 $65 D3320 Root canal: bicuspid (excluding final restoration) $125 $80 $75 D3330 Root canal: molar (excluding final restoration) $160 $140 $130 D4210 Gingivectomy: four or more contiguous teeth, per quadrant $95 $70 $55 D4211 Gingivectomy: one to three teeth touching each other (contiguous), per $48 $20 $15 quadrant D4261 Osseous surgery, one to three contiguous teeth, per quadrant $150 $115 $90 D4342 Periodontal scaling and root planing, per quadrant, one to three teeth $23 $15 $10 D4910 Periodontal maintenance $25 $13 $13 D2750 Crown: porcelain fused to high noble metal (i.e., gold) $175* $170* $90* D5110 or Complete upper or lower denture $175 $150 $125 D5120 D5211 or Partial upper or lower denture, resin base (including conventional clasps, $150 $125 $100 D5212 rests and teeth) D5730, D5731, Denture reline: chair side $40 $20 $0 D5740 or D5741 D6240 Pontic (bridge), porcelain fused to high noble metal (i.e., gold) $175* $150* $125* 24 months of standard orthodontic coverage, exclusive of records/retention fees Orthodontic Service D8080 Child (through age 17) $1,695 $1,695 $1,695 D8090 Adult $1,895 $1,895 $1,895 D8680 Retention (placement of retainers) $200 $200 $200 Out-of-area emergency care maximum payment $100 All charges over $100 Other Services D9215 Local anesthesia $0 $0 $0 D9220 General anesthesia first 30 minutes $160 $145 $130 D9440 Office visit: after hours $25 $25 $25 D9940 Occlusal guards (mouth guards) $100 $75 $50 *Plus costs for noble or high noble metal, not to exceed $125, and/or costs for porcelain, not to exceed $100. 7
8 Dental Program Guidelines PROGRAM GUIDELINES Group Size Employer Contributions Participation Rate Guarantee Industry Loads Waiting Period for Services Anthem Dental Plans No DE-9C required. Voluntary: 5-50 Defined Contribution: $15 per employee. Defined Contribution Select: More than $15 per employee. Traditional Contribution: Minimum of 50% of EE premium. 75% of eligible employees. Voluntary: 3 or 25% whichever is greater 12 months Out-of-State No more than 49% Voluntary: California Only No industry load for dental or vision; industry load applies to life on 10+ groups Dental Net, Dental Blue: None; All Other plans and Voluntary: 12 month wait. Waived with proof of 12 consecutive months of prior group coverage with no lapse in coverage. Eligible Dependents Dependent children are eligible until age 26. Carve-outs Eligible Employees Not eligible 1099 Employees Not eligible Product Combinations Voluntary Orthodontics Open Enrollment Terminations Administrative Fees Full time, permanent eligible employees working 30 or more hours per week. Groups currently enrolled with Anthem Dental, Vision, and/or Life are not eligible for administration through CoPower. Employer may select to offer all dental plans or they may designate any number of plans for employees to select from. Voluntary plans cannot be offered alongside employer paid plans. Built in for all plans except the Dental Blue Silver Plus , Standard PPO, and Basic PPO. Voluntary PPO includes child orthodontic coverage for groups with 10+ enrolling. Yes Coverage will end on the last day of the month when primary enrollee is no longer eligible for coverage. Dependent coverage will end at the same time as the primary enrollee or when the dependent is no longer eligible. None 8
9 Vision Coverage Better vision means better health. Increase your employees productivity with the right vision plan: Blue View Vision SM Blue View Vision and Blue View Vision Plus feature: A broad network with over 30,000 private practice doctors and more than 25,000 locations, including the nation s leading retail stores like LensCrafters, Sears Optical SM, Target Optical, and JCPenney Optical. The convenience of popular national stores with evening and weekend hours. Your employees can even get an eye exam at one location and purchase eyewear from another. Savings of 15% to 40% on unlimited purchases of most extra pairs of eyewear, normal contact lenses, lens treatments, specialized lenses and other accessories even after they ve exhausted their covered benefits. Your employees can also enjoy: Factory scratch coating on eyeglass lenses included at no extra cost. Transitions and polycarbonate lenses for kids under 19 years old at no extra cost. Transitions lenses for adults at a fixed price of $75. Tiered pricing for premium progressive lenses and premium antireflective coatings, limiting members out-of-pocket costs. Easy-to-use benefits. In-network providers verify eligibility and handle all of the paperwork. All your employees have to do is make an appointment with a network provider, show the member ID card at the visit, and pay any deductible and copay amounts or balances for non-covered services and/or materials. Vision Program Guidelines VISION PROGRAM GUIDELINES Anthem Blue View Group Size 2 50 Stand Alone Yes Rate Guarantee 24 months Administrative Fees None Contribution Minimum 50% of employee cost Participation Minimum 75% of eligible employees. If 100% employer paid then 100% participation required. Voluntary Plan Contribution 0 49 employer contribution; may be 100% employee paid. Voluntary Plan Participation Minimum 10 enrolled Out-of-State 49% maximum Carve-Outs Not eligible 1099 Employees Not eligible Owner Only Groups Not allowed. Must have at least one non-spouse, "common law" EE on the DE 9C. Industry Loads None Open Enrollment Yes Dependent Eligibility Up to age 26. 9
10 Vision Benefits This chart is an overview of coverage. A comprehensive description of coverage, benefits, exclusions and limitations can be found in the Combined Evidence of Coverage and Disclosure Form. VISION BENEFIT INFORMATION Benefits Blue View Vision* Blue View Vision Plus* In-network copay $25 $15 Eye exam Every 12 months Every 12 months Lenses Every 24 months Every 12 months Contact lenses Every 24 months Every 12 months Frames Every 24 months Every 12 months In-network Benefits Blue View Vision and Blue View Vision Plus* Benefits In-Network Out-of-Network Eye exam Covered up to a comprehensive-level exam with dilation as necessary after Reimbursed up to $49 exam copay Lenses Standard plastic lenses in single vision, bifocal or trifocal including factory scratch coating, polycarbonate lenses for kids under 19 and Transitions lenses for kids under 19; additional charge for progressive lenses. Single vision Covered in full Reimbursed up to $35 Bifocal lenses Covered in full Reimbursed up to $49 Trifocal lenses Covered in full Reimbursed up to $74 Progressive lenses Standard $65 Reimbursed up to $49 Premium Tier 1 $91 n/a Premium Tier 2 $97 n/a Premium Tier 3 $103 n/a Transitions lenses $75 for adults; no charge for children under age 19 n/a Frames Covered up to $120 retail value. 20% off the balance over the allowance Reimbursed up to $50 Contact lenses - Elective Benefit allowance applies to materials; discount available on fit and follow-up Conventional Covered up to $115 allowance, 15% off balance over allowance Reimbursed up to $92 Disposable Covered up to $115 allowance Reimbursed up to $92 Contact lenses - Non-elective** Covered in full Reimbursed up to $250 Additional savings Savings available from participating providers * Coverage for these vision PPO plans include choice of eyeglass lenses OR contact lenses, not both. ** Non-elective contact lenses are those prescribed for extreme visual acuity or other functional problems not treatable by eyeglass lenses. 10
11 Life Coverage Your employees deserve peace of mind. Give your employees the valuable benefit of life insurance, knowing it s backed by the strength and stability of one of the most respected names in the industry Anthem Blue Cross Life and Health Insurance Company. Basic term life coverage. When you offer basic term life, your employees and their families will gain extra financial support if there s an untimely death or great physical loss (such as the loss of a limb). You can select a level of basic term life coverage from $25,000 to $300,000. With all levels, AD&D benefits are included automatically. The life benefit is payable if a member dies at any time. And the automatic AD&D feature gives employees an extra benefit equal to the amount of the life benefit if there s an accidental death or a serious qualifying accident. With the Living Benefit, members who have 12 months or less to live can ask for up to 50% of their death benefit. Extras included with AD&D coverage: Annual yearly college education benefit for eligible dependents. The benefit adds the lesser of 25% of the coverage amount or $12,000 to the AD&D benefit. A seat belt provision that adds the lesser of 10% of the coverage amount or $25,000 to the AD&D benefit. If an employee dies more than 75 miles from home, the AD&D coverage provides a benefit of up to $5,000 to bring the remains back home. Dependent life coverage. You can choose to offer one of two dependent life plans. Both pay a benefit to employees if their covered dependent dies. Our member assistance programs. Resource Advisor gives employees and their families access to confidential support and resources that they may need to deal with any problems they re facing before they become an emotional or financial burden. Services are free and include: Face-to-face counseling Telephone counseling Online support Identity theft victim recovery services Beneficiary Companion services. With one phone call, beneficiaries (executors of the estate) can get help to settle the estate. This gives them more time to focus on healing. Grief counseling and legal and financial counseling are also available. Travel assistance is available 24/7 through the multilingual Europe Assistance USA Coordination Center. When employees are traveling more than 100 miles from home, they can get help with: Emergency medical assistance Travel services Pre-departure information. All active employees with life and AD&D coverage, as well as their dependents, can use travel assistance. 11
12 Life Benefits This chart is an overview of coverage. A comprehensive description of coverage, benefits, exclusions and limitations can be found in the Combined Evidence of Coverage and Disclosure Form. LIFE BENEFIT INFORMATION Basic Term Life - Choose one of three options: Benefit Amounts Available Employer Contributions and Participation Requirements Guaranteed Issue Guidelines Schedule A: Flat dollar amounts for all employees You select one flat dollar amount for all employees Schedule B: Life benefits graded by job title* You select one amount in $1,000 increments for Class I employees (officers, managers, supervisors) and another amount for Class II employees (all others). Schedule B is available to groups of only. Schedule C: Salary based life insurance you select either 1 or 2 times* the employee s annual salary. All employees must have the same salary schedule. Salary based benefits have a minimum benefit of $25,000 and maximum benefits of: Groups of 2-9: up to $100,000 Groups of 10-19: up to $250,000 Groups of 20-50: up to $300,000 Groups of 2-9: $25,000, $30,000 or $50,000 Groups of 10-19: $25,000, $30,000, $50,000 or $100,000 Groups of 20-50: $25,000 to $300,000 If employer pays between 25% and 99%, then 75% employee participation is required. If employer pays 100%, then 100% employee participation is required. Groups of 2-9: $30,000 Groups of 10-50: varies by group, see Anthem proposal for each group Dependent Life Coverage options available: Groups of 2-19: $10,000/$5,000 Option: $10,000 for spouse, $5,000 for children. Available only if employee life benefit is $20,000 or more. $5,000 /$2,500 Option: $5,000 for spouse, $2,500 for children. In addition, groups of can also choose: $20,000/$10,000 Option: $20,000 for spouse, $10,000 for children. $15,000/$7,500 Option: $15,000 for spouse, $7,500 for children. $2,000/$1,000 Option: $2,000 for spouse, $1,000 for children. Groups of 2-19: $10,000/$5,000 or $5,000/$2,500 Groups of 20-50: $20,000/$10,000, $15,000/$7,500, $10,000/$5,000, $5,000/$2,500 or $2,000/$1,000 Employer is not required to contribute toward the cost of dependent life coverage. If employees are paying part of the premium, at least 75% of all eligible employees with dependents must participate in dependent life coverage. All amounts are Guaranteed Issue. Children are eligible for coverage from 15 days to 26 years of age. AD&D benefits are not available with dependent life coverage. Rates are guaranteed for 12 months. Basic Life Age Reduction Schedule is as follows: 35% at age 65 and 50% at age 70. AD&D benefits are not available with dependent life coverage. Voluntary Supplemental Life not administered. * Job title descriptions shown are examples. You may use them as a guideline or provide your own. There must be at least one person in each class (job description). Only one benefit schedule may be offered. The benefit amount for Class I can t be more than $300,000 per employee and can t be more than 2.5 times the benefit amount for Class II. Groups of 2-9, 1 times salary and 1 class only. 12
13 Dental Rates Dental rates valid through 12/31/15 DENTAL BLUE RATES Silver Gold Platinum Areas 1,2,7 3,6,8 4,5,9 1,2,7 3,6,8 4,5,9 1,2,7 3,6,8 4,5,9 Employee Only Group Size Employee & Spouse Group Size Employee & Child Group Size Employee & Children Group Size Family Group Size DENTAL BLUE PLUS RATES Silver Plus Gold Plus Platinum Plus Areas 1,2,7 3,6,8 4,5,9 1,2,7 3,6,8 4,5,9 1,2,7 3,6,8 4,5,9 Employee Only Group Size Employee & Spouse Group Size Employee & Child Group Size Employee & Children Group Size Family Group Size BASIC/STANDARD/HIGH OPTION DENTAL PPO Basic Option Dental PPO Standard Option Dental PPO High Option Dental PPO Areas 1,2,7 3,6,8 4,5,9 1,2,7 3,6,8 4,5,9 1,2,7 3,6,8 4,5,9 Employee Only Employee & Spouse Employee & Child Employee & Children Family
14 Dental Rates (continued) VOLUNTARY DENTAL PPO All Areas Employee Only 45 Employee & Spouse 92 Employee & Child 71 Employee & Children 99 Family 141 DENTAL HMO RATES Dental Net Plan 2000A Dental Net Plan 2000B Dental Net Plan 2000C Areas 1,2,3,7 4,5,6,9 8 1,2,3,7 4,5,6,9 8 1,2,3,7 4,5,6,9 8 Employee Only Employee & Spouse Employee & Child Employee & Children Family VOLUNTARY DENTAL HMO RATES Dental Net Voluntary Plan 2000A Dental Net Voluntary Plan 2000B Dental Net Voluntary Plan 2000C Areas 1,2,3,7 4,5,6,9 8 1,2,3,7 4,5,6,9 8 1,2,3,7 4,5,6,9 8 Employee Only Employee & Spouse Employee & Child Employee & Children Family AREAS DENTAL BLUE, DENTAL PPO AND DENTAL HMO PLANS 1 Amador (except 95629, 95646), Calaveras, Mono, Monterey 2 Alpine, Amador (95646 only), Butte (except 95980), Del Norte, El Dorado (zip codes beginning with 961), Inyo, Lassen, Marin, Modoc, Nevada, Placer, Sacramento (94243, 94253, 95857, 95873), San Benito, San Juaquin, San Mateo, Shasta, Sierra, Siskiyou, Solano, Stanislaus (except 95329), Tehama, Trinity, Yuba (95977 only) 3 Alameda, Amador (95629 only), Butte (except 95980), Colusa, Contra Costa, El Dorado (zip codes begining with 956, 957), Glenn, Humbolt, Lake, Mendocino, Napa, Sacramento (except 94243, 94253, 95857, 95873), San Francisco, Santa Clara, Santa Cruz, Sonoma, Stanislaus, (95329 only), Sutter, Tuolumne, Yolo, Yuba (except 95977) 4 Orange, Riverside (92883 only) 5 Los Angeles (except zip codes beginning with , 915, 917, 918 and 935), Ventura (zip codes beginning with 913 only) 6 Imperial, Los Angeles (91798 only), Riverside (except 92883), San Bernardino (except 93558), San Diego 7 Fresno, Kern, Kings, Madera, Mariposa, Merced, San Bernardino (93558 only), Tulare 8 San Luis Obispo, Santa Barbera, Ventura (except zip codes beginning with 913) 9 Los Angeles (zip codes beginning with , 915, 917, 918 and 935) 14
15 Vision Rates Vision rates valid through 12/31/15 BLUE VIEW VISION PLAN RATES Employer Paid Voluntary Blue View Vision Blue View Vision Plus Blue View Vision Blue View Vision Plus Employee Only Employee & Spouse Employee & Children Family Life Rates Life rates valid through 12/31/15 LIFE AND AD&D RATES FOR GROUP SIZE 2-9 Age Male Female and over Rate is per $1000 of coverage. AD&D is not available for dependents. Optional Group Dependent Life rates valid through 12/31/15 OPTIONAL DEPENDENT LIFE COVERAGE $5,000 spouse; $2,500 children 6 months to 26 years; $500 children under 6 months $3 per family This option is available only if employee life benefit is $20,000 or more. $10,000 spouse; $5,000 children 6 months to 26 years; $1,000 children under 6 months $6 per family Life products underwritten by Anthem Blue Cross Life and Health Insurance Company. For groups with eligible employees, the employee basic life rate is based on the group s composite rate. The composite rate is determined by the characteristics of the group and is calculated by rating systems. CoPower offers an exclusive 6% discount, available for groups purchasing an Anthem dental plan plus vision and/or life. 15
16 Anthem Blue Cross Enrollment Checklist Anthem Employer Application Premium Check (only required if submitting ancillary without medical coverage) Prior Carrier Bill Anthem Employee Enrollment Forms Summary of Benefits and Coverage (only required if applying for PPO Dental plans with waiting periods) CoPower Administration Authorization Form Note: No DE-9C required for ancillary only groups. Carrier Contact Information: Anthem Blue Cross (877) Plan Administration: CoPower 1600 W. Hillsdale Blvd. San Mateo, California T: E: CoPower provides third-party administrative services in connection with Anthem Blue Cross products. Prime, Complete, and Supplemental life plans are excluded from CoPower administration. Dental HMO products underwritten by Anthem Blue Cross; dental PPO, vision and life products underwritten by Anthem Blue Cross Life and Health Insurance Company. Anthem Blue Cross is the trade name of Blue Cross of California. Anthem Blue Cross and Anthem Blue Cross Life and Health Insurance Company are independent licensees of the Blue Cross Association. ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross name and symbol are registered marks of the Blue Cross Association. CPE /14
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