Value Added Benefit Guide Book Exclusively for Presbyterian Senior Plan Members Supplemental Dental, Vision, and Hearing Programs Complementary and Alternative Medicine Wellness and Senior Services
Supplemental Dental, Vision, and Hearing Programs Sandia Dental Plan Something to smile about You are automatically enrolled in the BenefitSource Sandia Dental Plan at no additional monthly premium cost. This plan is a network based referral plan that provides for savings from 20% to 60%, depending on the type of dental care. Advantages of the Sandia Plan Low, guaranteed pre-set fees Hassle free No deductibles No claim forms No pre-existing condition exclusions No waiting periods for dental care No maximum benefit When using Sandia Plan dentists, compare your savings for these services: With no Coverage (you pay) Sandia Plan (you pay) YOU SAVE 9310 Consultation $75 No charge $75 0150 Exam (initial) $80 $43 $37 0274 Bitewing 4 films (x-rays) $53 $35 $18 1110 Adult teeth cleaning $100 $60 $28 2140 Silver filling 1 surface $120 $76 $44 2330 Resin white filling 1 surface $145 $91 $54 3330 Root canal molar $940 $725 $215 2750 Crown (cap) $930 $765 $165 5110 Denture upper/lower $1,525 $1,012 $513 5213 Partial denture $1,125 $951 $174 This is an abbreviated schedule of dental fees. A complete fee schedule will be mailed with your ID card once enrolled. Or visit our website: www.benefitsource.org for a current list of Sandia Plan Dentists and a complete fee schedule. Members with coverage through a previous employer, union group or other retirement program should exhaust those dental benefits first. This program is not offered nor guaranteed under Presbyterian s contract with Medicare. As such, these services are not subject to the Medicare appeals process. Disputes regarding this product may be subject to the Presbyterian Medicare Grievance Process. 2
Elite Dental Plan Something else to smile about The Elite Dental Plan is a comprehensive dental indemnity plan specifically designed for Presbyterian Senior Plan members that prefer complete freedom of choice to use any licensed dentist. As a PPO dental plan, the Elite Plan provides greater savings when obtaining care from our PPO Dental Providers but still has excellent coverage when going out of network for dental care. Advantage of the Elite Dental Plan Freedom to see any licensed dentist Low monthly premium of $35.35 per person No deductible for in-network dentists for preventive and diagnostic care Low, $50 annual deductible for in network dental care $75 annual deductible for out-of-network dental care Out of pocket costs limited to guaranteed pre-set fee schedule for in-network services 6 month waiting period for major (class III) services $1,000 annual maximum per person Plan benefits: When using participating PPO Dental Providers, you pay the listed in-network PPO fee directly to the dental office at the time of service. If you obtain dental services from non-participating dental providers (out-of-network), the plan pays the amount listed, but the dental office may balance bill you for any differences in fees. In-Network Benefit (you pay) Out-of-Network Benefit (plan pays to dental office) 1110 Prophy-adult cleaning $17 $52 0150 Initial exam $0 $49 0270 Bitewings single $0 $15 0274 Bitewings four $0 $39 0330 Panoramic x-ray $17 $52 2140 Amalgam 1 surface $36 $53 2330 Resin white filling 1 surface $39 $59 3330 Root canal molar $485 $208 2750 Crown high noble metal $561 $240 5213 Upper/lower partial $750 $321 5110/5120 Denture lower/upper $802 $344 7210 Extraction/oral surgery-erupted $108 $46 BenefitSource Elite Plan enrollment form on following page. Visit benefitsource.org or call 888.862.8659 or 505.237.1501 for a current list of providers and complete fee schedule. 3
Supplemental Dental, Vision, and Hearing Programs Elite Dental Plan Enrollment form BenefitSource Elite Plan Only Enrollment Authorization Form Social Security Number Last Name First Name Detach Here. Date of Birth Sex Home Telephone Alternate Telephone Home Address City State Zip Email Address Payment Option for the Elite Plan must be selected. Payment Choice: Please check one. Please make checks payable to BenefitSource, Inc. (For 1/1/14 enrollment only.) Annual Payment ($424.20) Check Visa MasterCard Discover Credit Card # Exp. Date CVV# I have enclosed my Annual Payment of $424.20. I hereby authorize the release of my dental records to BenefitSource, Inc. for use in quality review program. Member s Signature X Date Monthly Bank Draft ($35.35) Please charge my bank account monthly. Checking Savings Routing # Account # I have enclosed a check for my first month s payment of $35.35 ad a voided check. Draft Authorization / BenefitSource, Inc. Member Agreement Unless I have elected annual payment, I hereby authorize BenefitSource to charge my bank account each month th applicable membership fee to be credited to my account with BenefitSource. This authority is to remain in full force and effect until I notify BenefitSource in writing of it s termination following my 12 month contract. (My bank is authorized to make corrections should any be necessary). I have read and understand the terms and conditions of the authorization. I hereby authorize the release of my dental records to BenefitSource, Inc. for use in quality review program. Member s Signature X Date Internal Use Only PSENIOR ELITE Post Date Effective Date Payment Ref 4
Vision Care For coverage related to vision exams, services related to cataract surgery, or for refractive correction, Presbyterian Senior Plan and Presbyterian Medicare Supplement Plan members should refer to their Medical Summary Plan Description. BenefitSource, through a special arrangement with Eye Associates of New Mexico and Vision Care Direct, provides the following discounted schedule of benefits for vision materials as needed outside of those listed previously. Hearing Hardware You are automatically eligible to receive discounts on hearing hardware and appliances. These discounts vary by provider but include 25% to 50 % savings on hearing aids, special discounts for hearing aid batteries, and fixed co-payments for a complete hearing evaluation. Visit our website: www.benefitsource.org for a current list of Audiology Care Centers and sources for hearing aid hardware. You must contact the provider directly and identify yourself as a Presbyterian Senior Plan member to learn applicable discounts through BenefitSource. Frames Member Pays For all frames under $100.00 $75.00 For all frames over $100.00 $75.00 Receives an additional 10% discount on amount over $100 Lenses (Plastic CR-39)* Single Vision per pair $68.00 Bifocal per pair $89.00 Trifocal per pair $120.00 Progressive Power Standard $109.00 (Access, Adapter, AF Mini, Continuous Vue, Freedom, Sola VIP, Sola XL, TruVision, AO Pro, Continua Premium Plus, Seiko P6, Progressive Elegance, Visuality) Preferred $212.00 (AO Compact, Kodak, Multigressive, Natural, Outlook, Varilux Panamic, Varilus Comfort, Hoya Summit, Summit CD, Essilor Ovation) Premier $230.00 (Definity, Ellipse, Gradal Top, Percepta, Physio, Sola One, Comfort 360, Physio 360 and Ellipse 360) Lens Options 20% Discount Tints, Anti-reflective, basic or upgraded scratch coats and other enhancements are available. Contact Lenses Member Pays Conventional Contact Lenses* (Does not include examination fee) Includes lenses and a minimum of 3 follow-up visits Standard Hard or Soft Daily Wear Sphere $165.00 Gas Permeable Sphere $190.00 Soft Extended Wear 15% Discount Disposables* (Does not include examination fee) Includes lenses and a minimum of 3 follow-up visits Disposable Wear; Daily Wear (includes two 6 packs) $142.00 One Day Disposable (includes two 90 packs) $169.00 Toric & Bifocal Disposable 15% discount Extended Wear Disposable 15% discount *The fitting fee is to be paid on the date of the exam if contact lenses are not immediately purchased. However, if contact lenses are purchased within two months of the exam, that fitting fee will be deducted from the amount owed on the lenses. Contact Lenses, Duplicate/Replacement Disposable Wear Replacement One Day Disposable Sun Glasses (on most styles) Refractive Surgery Procedures 20% Discount 20% Discount 15% Discount 15% Discount Visit benefitsource.org or call 888.862.8659 or 505.237.1501 for a current list of Vision (CAM) providers and complete fee schedule. 5
Complementary and Alternative Medicine Acupuncture This is an ancient treatment that involves balancing the 5 main forms of vital energy flow through the human body. Treatment involves the use of small, thin, sterile needles that are inserted into specific reflex points to relieve pain, sleep disorders, stress, low energy and digestive problems. Through a holistic approach to treatment, nutritional and exercise guidance may also be included. Fee Schedule Initial Visit $60.00 Re-ocurring Visits $50.00 per visit Chiropractic Care This is a form of medical treatment through manipulation or careful movement of various body parts. Chiropractic care can be helpful for pain management, improvement in the function of nervous, skeletal and muscular systems, and improvement in mobility. Presbyterian Senior Care medical plan may include limited coverage for chiropractic care. Refer to your summary plan description for updated coverage details. This service is available for Chiropractic services either not covered under your medical plan or if benefits are exhausted. Presbyterian Senior Care medical plan may include limited coverage for acupuncture services. Refer to your summary plan description for updated coverage details. This service is available for acupuncture services either not covered under your medical plan or if benefits are exhausted. Chiropractic Services: CPT Code Description Fee Schedule 99201 Problem focused history and examination straight forward $11.00 99203 Detailed history and examination low complexity $17.00 99204 Comprehensive history and examination moderate complexity $17.00 98940 Chiropractic manipulative treatment spinal, one to two regions $34.00 98941 Spinal, three to four regions $36.00 98943 Extraspinal, one or more regions $26.00 97012 Traction, Mechanical $16.00 97014 Electrical Stimulation (unattended) $16.00 97110 Therapeutic Exercise, 15 Min. $18.00 72040 Cervical 3 Views (x-ray) $34.00 72100 Spine, Lumbosacral Anteroposterior and Lateral (x-ray) $34.00 This is an abbreviated schedule of fees for chiropractic care. Visit our website: www.benefitsource.org for a complete fee schedule and the most current list of participating Chiropractic providers. Presbyterian Senior Care medical plan may include limited coverage for chiropractic care. Refer to your summary plan description for updated coverage details. This service is available for Chiropractic services either not covered under your medical plan or if benefits are exhausted. 6
You are automatically eligible to access the discounted fees and networks for Complementary and Alternative Medicine. Massage Therapy This is a form of therapy through soft tissue manipulation that is helpful in relieving pain associated with arthritis, sports injuries, myofascial pain, headache, stress, circulatory problems, gastrointestinal disorders, or chronic and acute pain. Massage techniques include: Deep tissue massage to relieve chronic tension Myofascial release to release muscular tension in the fascia Reflexology, particularly focused on hands and feet that may be linked to organs, nerves and glands Shiatsu and Acupressure that treat points along acupuncture meridians to relieve pain Swedish massage for tension relief and circulation improvement Trigger Point Therapy (Myotherapy or Neuro-muscular therapy) to relieve cycles of chronic pain Sports massage Fee Schedule 1/2 Hour Session $27.00 1 Hour Session $46.00 1 1/2 Hour Session $58.00 Wellness Services Jenny Craig Weight Management Program This is a comprehensive weight management program. Members learn how to eat the foods they want, develop a healthy and enjoyable eating style, increase energy levels through simple activity, and build more balance into their lives. The results are optimal weight loss and well-being. BenefitSource members pay only $99 for a one year weight loss program (saving you $300). Just contact Jenny Craig and identify yourself as a Presbyterian Senior Plan member to receive this discount. Please visit benefitsource.org for a current list of Jenny Craig centers. Visit benefitsource.org or call 888.862.8659 or 505.237.1501 for a current list of providers and complete fee schedule. 7
Senior Services Non-Medical Home Health Care The number 1 goal of today s seniors is to remain at home for as long as possible. Consequently, non-medical home health care focuses on helping seniors with daily, non-medical activities. Most of these services are not reimbursed by Medicare or other traditional medical insurance plans. BenefitSource has contracted with a variety of local home care providers to fulfill this goal. Presbyterian Senior Plan members will receive a 7% savings on billed home care services which include: Bathing and dressing Transferring and toileting Companionship and custodial care Medications monitoring Light cleaning and meal preparation Transportation, laundry, and hobbies Meals on Wheels Meals on Wheels of Albuquerque home delivers meals to those who are home bound or otherwise unable to obtain proper, nutritional meals on their own. Seven different menu options for each day are designed to meet special medical or therapeutic needs of their client base. This program enables seniors to retain independence, maintain or improve health, and helps them stay at home and out of expensive long-term care facilities. BenefitSource Presbyterian Senior Plan members receive a discount off the normal price per meal. Fee Schedule First 10 Meals (paid upon delivery) $57.50 Meals Thereafter $5.75 Visit our website: www.benefitsource.org for a current list of participating home care providers. When contacting the home care provider of choice, simply inform them you are a BenefitSource member through Presbyterian Senior Health Plan to receive your savings. ISOTOPES BUY 1 GET 1 FREE Buy 1 Reserved Level Ticket at Regular Price and receive another Reserved Level ticket FREE! 2014 Isotopes Baseball Ticket Offer Good for 2014 Regular Season Monday thru Thursday Non-Restricted Home Games No Upgrades Seating is based on availability This offer is only valid at the Isotopes Park Box Office This pass must be presented to redeem your ticket at the Isotopes Park Box Office Retain this coupon for multiple uses at the Isotopes Park Box Office For more information, please contact us at: 1804 Juan NE, Suite A, Albuquerque, NM 87112 888 862 8659 505 237 1501 benefitsource.org