Federal Employees-Non-FEHB

Transcription

1 C ALIFORNIA Federal Employees-Non-FEHB More Choices. More Coverage. More Savings. At PacifiCare, we understand that you want comprehensive coverage at an affordable price. That s why we are offering you the opportunity to benefit from enhanced dental and vision coverage. Whether you are looking for dental coverage, vision benefits, or both, PacifiCare s plans are designed to make maintaining your health easier, more convenient and more cost-effective for you and your family. If you are enrolled in PacifiCare s medical plan, you are automatically enrolled in a dental indemnity plan and eyewear vision plan. Now you have the opportunity to purchase enhanced dental and vision benefits for greater coverage. Plus, if you are not enrolled in PacifiCare s medical plan, it s not too late to receive dental or vision coverage with these comprehensive, affordable plans. Enjoy extensive dental benefits Receive preventive services, from exams to crowns, at low or no cost. Benefit from generous orthodontia discounts. Enjoy lower out-of-pocket costs for services. Receive reimbursements for covered emergency treatment (less any applicable copayments). Receive comprehensive vision services May be used in addition to the eyewear plan included in the medical plan. Receive substantial savings on eye exams and quality prescription eyewear. Enjoy the convenience of one-stop shopping: Receive your exam and eyewear from the same provider under this plan. Obtain lower costs for in-network services. It s Easy To Enroll Just follow the directions and complete the application on the last page of this brochure. Enjoy the freedom of choosing dental or vision separately or benefit from the convenience of choosing both. With PacifiCare s dental and vision plans, you have the peace of mind knowing that you and your family are well covered no matter which plan you choose.

2 C ALIFORNIA - Federal Employee Non- FEHB Plans WE GIVE YOU SOMETHING TO Smile about! PacifiCare SignatureValue SM (HMO) Dental 142 plan Benefit from generous savings with PacifiCare s Dental 142 enhanced coverage plan. You can see how much you ll save per service in the table below. Federal Employee Non-FEHB Plan Benefits Comparison PACIFICARE SIGNATUREVALUE (HMO) DENTAL 142 Take advantage of greater out-of-pocket savings when you join this dental plan. You ll receive care from a fully credentialed dental provider who is a member of our network. Even better, an orthodontia benefit is included. P r o c e d u r e Your Cost With Dental 142 Your Cost Without Dental 142 Exam $0 $38 X-rays, complete series $0 $94 Routine teeth cleaning $0 $65 Filling 2 surfaces $10 $114 Procelain with metal crown $250 $817 Denture, Upper $195 $1,140 Benefits are not coordinated with the dental plan included with the PacifiCare medical plan. Savings for the Whole Family Every family member in your household may participate in the PacifiCare SignatureValue program, including your spouse and unmarried dependent children up to age 22. Plus, each family member can choose a different provider from our large network. And there is no annual maximum, no matter how often your family uses the program. All copayments listed in the Summary of Benefits are paid by the member directly to their assigned dental office. Brace Yourself: Receive Orthodontia Discounts Straight teeth are important, not only for a great-looking smile, but for the lifelong health of your teeth, gums and mouth. That s why Dental 142 includes a value-priced orthodontic program. Plus, orthodontics is available for both adults and children. Most orthodontists accept payment plans, so you just pay a specially negotiated fee, startup, retention and final records fees.

3 A Summary of Benefits and Copayments PREVENTIVE SERVICES Preventive Services Member Pays Office visit... $ X-rays, full mouth... No Charge X-rays, single film... No Charge X-rays, each additional film... No Charge 01110/01120 Teeth cleaning - adult or child... No Charge Topical fluoride (including cleaning) - child... No Charge Sealant - per tooth (under age 18)... $ Diagnostic casts (non-orthodontic)... $ Emergency treatment (palliative)... $ Office visit (after hours)... $20.00 ROUTINE SERVICES Restorative Dentistry Amalgam restorations (cavities involving primary and permanent teeth) One tooth surface - primary... $ One tooth surface - permanent... $ Two tooth surfaces - primary... $ Two tooth surfaces - permanent... $ Three tooth surfaces - primary... $ Three tooth surfaces - permanent... $ Pin retention, in addition to final restoration - per tooth... $ Sedative filling... $5.00 Oral Surgery Extractions Single tooth uncomplicated non-orthodontic)... $ Each additional tooth - same visit... $ Removal of impacted tooth - soft tissue... $ Removal of impacted tooth - partially bony... $ Removal of impacted tooth - completely bony... $ Surgical removal of an erupted tooth... $ Biopsy of oral tissue (hard)... $ Biopsy of oral tissue (soft)... $ Alveoloplasty, in conjunction with extractions per quadrant... $ Alveoloplasty, not in conjunction with extractions per quadrant... $ General anesthesia first 30 minutes... $ General anesthesia each additional 15 minutes... $ Intravenous sedation... $ Endodontics Pulp capping (direct)... $ Pulp capping (indirect)... $ Therapeutic pulpotomy... $12.00 Root canals (per tooth) Anterior (excluding final restoration)... $ Bicuspid (excluding final restoration)... $ Molar (excluding final restoration)... $ ROUTINE SERVICES (CONT D) Periodontics Member Pays Gingival curettage, root planing - per quadrant... $ Gingivectomy - per quadrant... $ Mucogingival surgery - per quadrant... $ Gingivectomy - per tooth... $ Perio recall including prophy... $ Occlusion adjustment (complete)... No Charge MAJOR SERVICES Crowns Stainless steel crown - primary tooth... $ Resin crown (not for molars)... $ Full metal crown... $ /4 metal crown*... $ Porcelain crown (not for molars)... $ Porcelain with metal crown (not for molars) *... $ Porcelain with metal crown (for molars) *... $ Cast post & core, in addition to crown*... $ Prefabricated post & core, in addition to crown... $45.00 Pontics Pontic, cast metal (base)... $ Pontic, porcelain with metal*... $ Inlay recementation... $ Crown recementation... $ Bridge recementation... $12.00 Prosthetics Dentures and partials Complete denture, upper or lower... $ Partial denture, upper or lower with resin base... $ Adjustment... No Charge Repair... $ Add tooth or clasp... $ Reline (chairside)... $ Reline (lab processed)... $ Fixed space maintainer (band type)... $ Removable acrylic space maintainer... $55.00 Dentist may charge $20.00 for broken appointments if not notified at least 24 hours in advance. * Plus actual lab cost of precious metal. ORTHODONTICS The orthodontic benefit covers: consultation, all necessary appliances, banding, and monthly office visits for 24 months. Class I (teeth straightening)... $1, Class II (correction of overbite)... $1, Class III (correction of underbite)... $1, Specific copayment levels have also been set for start-up and retention services. Orthodontic treatment must be provided by a PacifiCare Dental Panel Orthodontist. A referral must be submitted by your assigned dental provider to PacifiCare Dental. Refer to the Evidence of Coverage and Disclosure Form booklet and the Orthodontic Information Sheet for complete details of benefits, exclusions, limitations, and plan description. Copyright PacifiCare Dental Dental Limitations Full denture and partial denture replacement: only when dentures cannot be made serviceable. Cleanings: once every six months. Full mouth x-rays: once every two years. Pedodontic referrals (through age 18 as necessary): referral covered to 51% of specialist s fees. Administration of I.V. sedation or general anesthesia: limited to covered oral surgical procedures involving one or more impacted teeth (soft tissue, partial bony or complete bony impaction). Dental Exclusions Dispensing of drugs (prescription or over-the-counter). Teeth extracted for orthodontic purposes. Treatment of Temporomandibular Joint Syndrome (TMJ). Oral surgery requiring the setting of fractures or dislocations. Treatment of malignancies, cysts, or neoplasms. Cosmetic dentistry. Lost or stolen dentures or orthodontic appliances.

4 C ALIFORNIA - Federal Employee Non- FEHB Plans SEE CLEARLY...CHOOSE ENHANCED Vision Benefits PacifiCare SignatureOptions SM (PPO) Vision 495 plan Vision Care Made Easy Receive generous savings with PacifiCare s Vision 495 plan. With this full-service vision plan, you receive eyewear, plus the added benefit of exam coverage. And if you have vision coverage through your PacifiCare medical plan, you can increase your coverage with Vision 495. That s right, we ve made it that much easier and convenient for you to solve your vision needs. Getting Started Just choose the vision provider you d like to see and make an appointment. You do not need a claim form if you see an in-network provider. If you choose an out-of-network provider, call Member Service at for a claim form. Affordable Eyewear We ve put the control back into your capable hands. You decide how much to pay based on your options in the Schedule of Benefits on the following page. With an in-network provider you can get basic eyeglasses at no charge. You choose the frames and any additional charges for lens types are noted. (A Material Copayment applies. Refer to the Schedule of Benefits on the following page.) Contacts or Eyeglasses If you prefer contact lenses for cosmetic reasons, you can receive an allowance toward contacts in lieu of eyeglasses. Choose Your Location Save time with one-stop shopping by receiving your exam and eyewear through the same network provider when you use the Vision 495 plan. You can still use your out-of-network benefit, but the greatest value is through in-network providers. Plus, enjoy the convenience of using retail providers such as Sears Optical, JCPenney Optical, Target Optical and Pearle Vision in addition to many independent vision care providers. Direct inquiries to: Cole Vision Services, P.O. Box 8056, Twinsburg, OH , Phone: Underwritten by PacifiCare Life and Health Insurance Company, Inc.

5 Schedule of Benefits IN-NETWORK OUT-OF-NETWORK Examinations Comprehensive Examination No charge to member $35 member allowance Frames Retail Frames $100 member allowance $40 member allowance Lenses after material copay: Single Vision No charge to member $25 member allowance Bifocal No charge to member $38 member allowance Trifocal No charge to member $50 member allowance Lenticular (Aspheric SV and BF) No charge to member $120 member allowance Lens Add-Ons Tints, Solid Color: Pink or Rose #1 or #2 No charge to member Member pays all costs above the plan lens allowances All Other Lens Options 20%-60% retail discount at participating providers Contact Lenses (Materials & Fitting) Medically Necessary No charge to member $200 member allowance (see certificate of coverage for guidelines follow-up visits are not included) Cosmetic Purposes $85 member allowance $70 member allowance LASIK Vision Correction Discounts Apply Not Covered Material Copayment Per Person $25 $25 Benefits for all Covered Services shall not exceed the limits set forth in the Schedule of Benefits. Benefits are subject to Exclusions and Limitations as specified in the Policy. Covered Services and Materials One comprehensive eye examination during any 12-month period. One pair of lenses in a 24-consecutive-month period. One set of frames in a 24-consecutive-month period. One pair of contact lenses when provided in lieu of other eyewear once every 24 consecutive months. Medically necessary contact lenses when required for Anisometropia or Keratoconus, or following cataract surgery, or when visual acuity cannot be corrected to 20/70 in the better eye with conventional-type lenses. Special lens styles and features listed in the Schedule of Benefits.

6 C ALIFORNIA - Federal Employee Non- FEHB Plans Federal Employee Non-FEHB Dental and Vision Premiums Enjoy comprehensive dental and vision coverage at a price that fits into your family s budget. Discover what your low premiums would be for both plans in the table below. Federal Employee Non-FEHB Dental and Vision Premiums C ALIFORNIA 2005 PACIFICARE SIGNATUREVALUE DENTAL 142 FEDERAL PLAN Monthly Auto Pay Annual Payment Subscriber $17.13 $ Couple $33.09 $ Family $48.77 $ PACIFICARE SIGNATUREOPTIONS VISION 495 PLAN Monthly Auto Pay Annual Payment Subscriber $5.53 $66.36 Couple $11.13 $ Family $16.71 $ PACIFICARE SIGNATUREVALUE DENTAL AND SIGNATUREOPTIONS VISION COMBINED PREMIUM Monthly Auto Pay Annual Payment Subscriber $22.66 $ Couple $44.22 $ Family $65.48 $ Complete the Member Enrollment form. Select which payment option you wish Monthly Auto Pay or Annual Payment. Follow the directions on the form. Direct Vision inquiries to: Cole Vision Services, P.O. Box 8056, Twinsburg, OH , Phone: Direct Dental inquiries to: PacifiCare Dental s Member Service Department at PDV PDVCA1181

7 Cut here PacifiCare SignatureValue SM Dental Plan PacifiCare SignatureOptions SM Vision Plan Enrollment For Federal Employees - California INSTRUCTIONS FOR COMPLETING ENROLLMENT FORM Check all appropriate boxes and print all information clearly. Applicant: Fill out section completely. Dependents: All dependents you wish to be covered should be listed in this section. Dental 142 Plan Federal applicants must select a dental provider. Method of Payment: Please indicate your preferred method of payment. Be sure to include a check payable to PACIFICARE DENTAL AND VISION ADMINISTRATORS for your annual premium. If you prefer the convenient pre-authorized monthly method of payment, you must also complete and sign the Pre-Authorized Payment Application on the following page. Complete the Pre-Authorized Payment Application only if you want your monthly premium deducted from your checking account. Terms and Conditions: Read the Terms and Conditions on the following page and sign in the box at the X on the bottom of the sheet. This form must be signed for coverage to be effective. Your payment and completed enrollment form must be received by the 20th of the month for coverage to be effective the 1st of the following month. APPLICANT (You) Please complete all sections. This form cannot be processed if information is incomplete. Last Name First Name MI Sex Date of Birth Social Security Number Home Phone # Work Phone # M F / / - - ( )- - ( )- - Mailing Address City State Zip For Federal Employees Only - Employer: Employer Phone # ( )- - Agency DEPENDENTS (Your spouse and/or children) Dental 142- Federal Plan, List Provider Group Number & Dentist Name - Relationship (spouse, daughter, son) Last Name First Name MI 1 Sex Date of Birth Social Security Number Dental 142 Plan List Provider Group Number & Dentist Name* M F / / Relationship (spouse, daughter, son) Last Name First Name MI 2 Sex Date of Birth Social Security Number Dental 142 Plan List Provider Group Number & Dentist Name* M F / / Relationship (spouse, daughter, son) Last Name First Name MI 3 Sex Date of Birth Social Security Number Dental 142 Plan List Provider Group Number & Dentist Name* M F / / Relationship (spouse, daughter, son) Last Name First Name MI 4 Sex Date of Birth Social Security Number Dental 142 Plan List Provider Group Number & Dentist Name* M F / / PLAN SELECTION Please complete all sections. This form cannot be processed if information is incomplete. 142 Federal Dental Plan (HMO)* 495 Full Service Vision Plan** Combined Dental & Vision (142- Federal & 495 plans purchased together) Please refer to the Premium Sheet included with this application for the 142 Dental Plan premiums. Please refer to the Premium Sheet included with this application for the 495 Vision Plan premiums. Or refer to the Premium Sheet for the Combined Dental and Vision premium amount. * This plan not available in all counties. Please check the dentist listing for available dentists. I understand that I must receive all care from a network dentist. PAYMENT METHOD Pre-authorized Payment (Complete Pre-authorized Payment Application on back and include voided check) Please complete all sections. This form cannot be processed if information is incomplete. I understand and agree to the terms and conditions on the following page. Annual payment (include check payable to PacifiCare Dental and Vision Administrators for your annual premium) X Enrollee Signature Date DA IPLAN PPO.CA Mail to: Attn: LC PacifiCare Dental and Vision Administrators Post Office Box Santa Ana, CA Customer Service: *Offered by PacifiCare Dental **Underwritten by PacifiCare Life and Health Insurance Company Inc.

8 ENROLLMENT CHECKLIST (Make sure your application is complete) This form cannot be processed if information is incomplete and will be returned. Please use this checklist to include all necessary information to process your enrollment form. Applicant: If you have selected the Monthly Auto Pay Signature Method of Payment method of payment please also: Social Security Number (Include a check payable to PacifiCare Complete and sign Pre-authorized Address h Dental and Vision Administrators for h Payment Application below Date of birth h your annual premium) Include one voided check Dental 142 Plan - Federal Plan(s) you wish to enroll in Be sure to read the terms and conditions below and sign in the box (reverse page) at the X. Include a check payable to PacifiCare Dental and Vision Administrators for annual premium. TERMS AND CONDITIONS (Please read and sign on reverse page) California law prohibits an HIV test from being required or used by health insurance companies as a condition of obtaining health insurance coverage. Enrollment in the Vision plan is subject to regulatory approval. For PacifiCare 495 vision plan participants: PacifiCare Dental and Vision Administrators and PacifiCare Life and Health Insurance Company (collectively referred to herein as PacifiCare, We or Us ) uses binding arbitration to resolve any and all disputes between PacifiCare and the applicant, including, but not limited to, allegations against PacifiCare of medical malpractice (that is as to whether any vision services rendered under the PacifiCare plan were unnecessary or unauthorized or were improperly, negligently or incompetently rendered) and other disputes relating to the delivery of services under the PacifiCare plan. PacifiCare and applicant each understand and expressly agree that by entering into the PacifiCare plan and agreeing to be bound by the PacifiCare Life and Health Insurance Company Policy. PacifiCare and applicant are each voluntarily giving up their constitutional right to have all such disputes decided in a court of law before a jury, and instead are accepting the use of binding arbitration. Applicant further understands that any disputes between applicant and a PacifiCare contracting provider, including, but not limited to, claims against a PacifiCare contracting provider for medical malpractice, are not governed by the PacifiCare Life and Health Insurance Company Policy. However, PacifiCare and applicant each expressly agree that the existence of any disputes between applicant and a PacifiCare contracting provider for medical malpractice, shall in no way affect the obligation to submit to binding arbitration all disputes between applicant and PacifiCare. Each term of the Policy is for a twelve (12) month period. You are responsible for making payments for vision benefits up to the end of your Policy term. If we cancel our Policy with you because We have not received proper payment or you decide to terminate your coverage prior to the end of the Policy term for any reason other than death or entry into military service, you will be charged a $25.00 vision plan administrative fee for termination prior to your contract term. When coverage is cancelled by you or by us, you will be issued a pro rated refund if applicable based upon your termination date, less the administrative fee. If your contract has been cancelled for any reason, you may reinstate with no lapse in coverage as long as all of the following conditions are met: 1. You have not previously reinstated within the most recent contract year. 2. A written request to reinstate is received within 30 days of the initial termination notification. 3. All past due premiums including the $25 administrative fee must be paid in full to PacifiCare Dental and Vision Administrators within 30 days of the initial termination notification. If you do not meet these conditions for reinstatement, then your reinstatement request will be denied. You will be able to reapply for Vision benefits at the next open enrollment period after one calendar year from the date of termination. For All Participants: If your membership or that of a dependent terminates for any reason, it is the applicant or the applicant s family s responsibility to notify PacifiCare Dental and Vision Administrators. PacifiCare Dental and Vision Administrators will not retroactively reimburse premiums for a period longer than 3 months. Our Pre-authorized Payment Plan PRE-AUTHORIZED PAYMENT APPLICATION Complete this section only if you want your monthly premium automatically deducted from your checking account. It s the forget-proof method of paying your premium almost as easy as payroll deduction. Just authorize us to debit your personal checking account each month. We ll do the rest. There will be no more paper work for you and no more checks to write. No worries about monthly late-payment charges. And you ll save on postage and envelopes. It s easy, reliable, and automatic. Authorized Agreement for Pre-arranged Payments (Debits) Account No. (please enclose one voided check) I (we) hereby authorize PACIFICARE DENTAL AND VISION ADMINISTRATORS to initiate debit entries to my (our) checking account indicated below, and the bank named below, herein called BANK, to debit the same to such account. Bank Name Bank Phone Street Address City State Zip This authority is to remain in full force and effect until BANK has received written notification from me (or either of us) of its termination in such time and in such manner as to afford BANK a reasonable opportunity to act on it. A customer has the right to have the amount of an erroneous debit immediately credited to his account by BANK up to 15 days following issuance of statement of account or 45 days after the charge, whichever comes first. Name (print clearly) Social Security No. Signature Date Cut here DA IPLAN PPO.CA