Enrollment Guide. For more information about your plan, Call the Enrollment P a g e. Underwritten by:

Transcription

1 Enrollment Guide Underwritten by: Minimum Essential Coverage Offered in tandem with Voluntary Limited Benefit Health Insurance Limited Benefit Health Insurance Vision Prescription Drugs Life No Deductibles No Co-pays First Dollar Coverage For more information about your plan, Call the Enrollment IMPORTANT Crescent Limited Benefit Health programs are not comprehensive major medical insurance plans. Policy forms are intended to comply fully with all applicable state insurance statutes and regulations. Because of differing state requirements, benefits, terms and conditions may vary by state from the description according to the approved plan sponsor location and/or the insured s state of residence. Companion Life Limited Benefit Health Insurance Policy Number MMP P a g e

2 PART 1 MINIMUM ESSENTIAL COVERAGE All employees can prevent being taxed the greater of the $695 penalty or 2.5% of adjusted household income by enrolling the MEC only plan. Patient Protection and Affordable Care Act ( PPACA ) compliance: The plan will at all times be in compliance with PPACA rules and regulations. Notes regarding the plan: This plan provides coverage for Preventive Services. Claims will be processed based upon the Billing practices of your healthcare provider. Services that are not Preventive Services as Defined by the Patient Protection and Affordable Care Act ( PPACA ) will not be covered By the plan. Network provider service payments will be based on the applicable network access agreement and non-network provider services will be paid based on the reasonable and customary amount. SCHEDULE OF BENEFITS MEC PLAN Minimum Essential Coverage Benefits Network Non-network 18 Preventive Services For Adults 100% 40% 23 Preventive Services For Women 100% 40% 26 Preventive Services For Children 100% 40% PPO Network FIRST HEALTH DEDUCTIBLES NETWORK NON-NETWORK Individual None None Family None None COINSURANCE NETWORK NON-NETWORK Plan Pays 100% Plan Pays 40% LIFETIME MAXIMUM None ANNUAL MAXIMUM None GENERAL EXCLUSIONS TO THE PLAN Covered expenses do not include and no benefits are payable for the following: 1. Charges that the participant is not legally required to pay for or charges which would not have been made if this coverage had not existed. 2. Non-network charges that are in excess of the reasonable and customary rates for the services as determined by the plan. 3. Charges for a covered person that are reimbursed, that could be reimbursed, or that could have been reimbursed as part of a clinical trial, by any public program, Such as Medicare or Medicaid, even if the person could have, but does not, elect To be covered by that public program. 4. Treatment or services provided by anyone other than a healthcare provider as Defined herein unless specifically stated in the plan. 5. Services that are not preventive services will not be covered by the plan. 6. Investigatory and experimental treatment, services, and supplies, unless provided for herein. 7. Services for the treatment of an illness or injury shall not be covered by the plan. 2 P a g e

3 MINIMUM ESSENTIAL COVERAGE BENEFITS 18 MEC COVERED PREVENTIVE SERVICES FOR ADULTS 1. Abdominal Aortic Aneurysm one time screening for age Alcohol Misuse screening and counseling 3. Aspirin use for men ages and for women ages to prevent Cardio Vascular Disease when prescribed by a physician. 4. Blood Pressure screening for all adults 5. Cholesterol screening for all adults starting at age 50 limited to one every 5 years. 6. Colorectal Cancer screening for adults starting at age Depression screening for adults 8. Type 2 Diabetes screening for adults 9. Diet counseling for adults 10. Hepatitis B screening for adults 11. Hepatitis C screening for adults 12. Human Immunodeficiency Virus (HIV) screening for all adults 13. Immunization vaccines for adults: Hepatitis A Hepatitis B Herpes Zoster Human Papillomavirus (HPV) Influenza (Flu Shot) Measles, Mumps, Rubella Meningococcal Pneumococcal Tetanus, Diptheria, Pertussis Varicella 14. Lung Cancer screening for adults 15. Obesity screening and counseling for adults 16. Sexually Transmitted Infection (STI) prevention counseling for adults 17. Syphilis screening for all adults 18. Tobacco Use screening for all adults and cessation interventions for tobacco users 23 MEC COVERED PREVENTIVE SERVICES FOR WOMEN, INCLUDING PREGNANT WOMEN 1. Anemia screening on a routine basis for pregnant women 2. Breast Cancer Genetic Test Risk Assessment and counseling/testing (BRCA) for women 3. Breast Cancer Mammography screenings every year for women age 40 and over 4. Breast Cancer Chemoprevention counseling for women 5. Breast Cancer Preventive Medications for women 6. Breastfeeding comprehensive support and counseling from trained providers, as well as access to breastfeeding supplies, for pregnant and nursing women. 7. Cervical Cancer screening 8. Chlamydia Infection screening 9. Contraception: Food and Drug Administration-approved contraceptive methods, sterilization procedures, and patient education and counseling, as prescribed by a health care provider for women with reproductive capacity (not including abortifacient drugs). Only Generic birth control prescriptions are covered by this Plan. 10. Domestic and interpersonal violence screening and counseling for all women 11. Folic Acid supplements for women who may become pregnant. 12. Gestational diabetes screening for women weeks pregnant 13. Gonorrhea screening for women 14. Hepatitis B screening for women at their first prenatal visit 15. Human Immunodeficiency Virus (HIV) screening and counseling for sexually active women 16. Human Papillomavirus (HPV) DNA Test every three years for women with normal cytology results who are 30 or older 17. Osteporosis screening for women over age 60 3 P a g e

4 18. Rh Incompatability screening for all pregnant women and follow-up testing 19. Sexually Transmitted Infections counseling 20. Syphilis screening 21. Tobacco Use screening and interventions for all women, and expanded counseling for pregnant tobacco users 22. Urinary tract or other infection screening for pregnant women; Bacteriuria 23. Well-woman visits to obtain recommended preventive services 26 MEC COVERED PREVENTIVE SERVICES FOR CHILDREN 1. Autism screening for children at 18 and 24 months 2. Behavioral assessments for children limited to 5 assessments up to age Blood Pressure screening 4. Cervical Dysplasia screening 5. Dental Caries prevention for children up to age 5 by the application of fluoride varnish from primary care physicians. 6. Depression screening for adolescents 7. Developmental screening for children under age 3 8. Dyslipidemia screening for children. 9. Fluoride Chemoprevention supplements for children without fluoride in their water source 10. Gonorrhea preventive medication for the eyes of all newborns 11. Hearing screening for all newborns 12. Height, Weight and Body Mass Index measurements for children 13. Hematocrit or Hemoglobin screening for children 14. Hemoglobinopathies or Sickle Cell screening for newborns 15. Human Immunodeficiency Virus (HIV) screening for adolescents 16. Hypothyroidism screening for newborns. 17. Immunization vaccines for children from birth to age doses, recommended ages, and recommended populations vary: Diptheria, Tetanus, Pertussis Haemophilus influenza type B Hepatitis A Hepatitis B Human Papillomavirus (HPV) Inactivated Poliovirus Influenza (Flu Shot) Measles, Mumps, Rubella Meningococcal Pneumococcal Rotavirus Varicella 18. Iron supplements for children up to 12 months at risk for anemia 19. Lead screening for children 20. Medical History for all children throughout development at the following ages: 0 to 11 months, 1 to 4 years, 5 to 10 years, 11 to 14 years, and 15 to 17 years. 21. Obesity screening and counseling 22. Oral Health risk assessment for young children up to age Phenylketonuria (PKU) screening in newborns 24. Sexually Transmitted Infection (STI) prevention counseling and screening for adolescents. 25. Skin Cancer behavioral counseling for young adults 26. Tuberculin testing for children 4 P a g e

5 PART 2 INDEMNITY MEDICAL COVERAGE & PRESCRIPTION DRUGS This benefits guide is designed to assist you in learning about your benefit program. Becoming educated on our plans will help you understand the plan and features you have selected for you and your family. If you have any questions regarding the benefit features, please contact the Equipoint Partners customer service team at BENEFITS MINDLANCE 750 OUT-PATIENT BENEFITS Physician's Office Visit (5 per covered person per year) $75 Health Screening (3 per covered person per year) $75 Emergency Room (1 visit per year for Sickness) $75 DXL test (3 covered test per person per year) $75 HOSPITAL & SURGICAL FOR IN & OUTPATIENT COVERAGE Hospital Admission - Limit 2 per year $750 Hospital Confinement days per calendar year $750 Intensive Care 30 days per calendar year $750 Surgical Schedule % (4.5 times of amount listed in schedule) Schedule up to ($2,250) Anesthesia - 25% (of surgical scheduled Amt.) 25% ($563) Ambulatory Surgery Center (per day) $150 LIFE INSURANCE Life Insurance - Employee $10,000 AD&D Insurance - Employee $10,000 Dependent Life - Spouse $1,000 Dependent Life - Child age 15-days to 6-months $200 Dependent Life - Child age 6-months to 25-years $1,000 CRITICAL ILLNESS Category 1 - Benefit Amount $5,000 Heart Attack, Stroke, Major Organ Transplant of the Heart or Combination Transplant including Heart 100% Coronary Bypass Surgery 25% Angioplasty 10% Category 2 Benefit Amount $5,000 Invasive Cancer 100% Cancer In Situ 25% Category 3 Benefit Amount $5,000 Major Organ Transplant (not covered in Category 1), End-Stage Renal Failure, Advanced Alzheimer s Disease, Blindness, Paralysis, Severe Burn, Accidental Loss of Speech, Motor Neuron Disease, including ALS and Coma MMP 2050 Form number for Companion s Employer Limited Benefit Health Insurance Policy 100% 5 P a g e

6 VALUE ADDED BENEFITS* MINDLANCE 750 $10 Preferred Generic $30 Preferred Brand Name Rx (RX-EMP-3500) Included EyeMed Standard Vision Program $10 Co-pay Eye Exam every 12 months (VGRP-300) AmeriDoc Telemedicine Services Included Included Careington POS Dental Discount Program Adult Family Wellness Lab Discount Program Included Included Included Imaging Discount Program (CT Scans and MRI s) $2,500 Accident Medical Coverage** No Annual Limit ($100 Deductible Per Occurrence) Included Included $5,000 Accidental Death** Included MINDLANCE WITH MEC - PER PAY (26 PAY) RATES MINDLANCE MEC Individual $89.54 Individual + Spouse $ Individual + Child(ren) $ Family $ PER PAY (26 PAY) RATES MEC ONLY Individual $11.08 Individual + Spouse $28.15 Individual + Child(ren) $28.15 Family $45.23 The premium rates include a charge for the Value Added Benefit Programs, Pharmacy Benefits, PPO fee and administrative services provided by Equipoint Partners. * The Value Added Benefits, except for Prescription Drug and Vision programs, is neither underwritten nor insured by Companion Life Insurance Company. **Accident Medical coverage is not available in all states; Consumer Alliance USA is the policy holder for this coverage. This information is a brief description of the important features of the plan. It is not a contract. Terms and conditions of coverage will be set forth in the group policy and adopted by each participating employer group. The group policy is subject to the laws of the jurisdiction in which it is issued. The availability of this offer may change. Please keep this material as a reference and refer to the Certificate of Insurance for additional specific details. Some provisions, benefits, exclusions or limitations listed herein may vary, depending on the approved plan sponsor location or a member s state of residence. 6 P a g e

7 CRESCENT LIMITED BENEFIT HEALTH PLAN LIMITATION AND EXCLUSIONS With respect to all of the benefits provided under the policy, no benefits will be payable as the result of: (a) suicide or any attempt thereat, while sane or insane. [if any covered person, sane or insane, should die by suicide within two years (one year in Colorado and North Dakota) of his or her effective date of coverage, life insurance benefits will not be payable; (in Missouri, the reference to insanity does not apply and suicide is no defense to payment under this policy where the covered person is a Missouri citizen unless the company can show that the covered person intended suicide when he or she applied for coverage, regardless of any language to the contrary in the policy.)] (b) any intentionally self-inflicted injury or sickness; (c) rest care or rehabilitative care and treatment; (d) cosmetic surgery or care or treatment solely for cosmetic purposes, or complications therefrom. This exclusion does not apply to cosmetic surgery resulting from a covered accident if initial treatment of the covered person is begun within 12 months of the date of the accident; (e) immunization shots and routine examinations such as: health exams; periodic check-ups; pre-marital exams; and routine physicals; (f) routine newborn care, including routine nursery charges; (g) voluntary abortion, except with respect to the insured or covered dependent spouse: (1) where such person s life would be endangered if the fetus were carried to term; or (2) where medical complications have arisen from an abortion; (h) pregnancy of a dependent child, unless required by law; (i) the treatment of: (1) mental illness; (2) functional or organic nervous disorder, regardless of cause; (3) alcohol abuse; (4) drug use, unless such drugs were taken on the advice of a physician and taken as prescribed, for more than 10 days in any calendar year, with respect to payment of the daily in-hospital indemnity benefit; (j) participation in a riot, civil commotion, civil disobedience, or unlawful assembly. This does not include a loss which occurs while acting in a lawful manner within the scope of authority; (k) committing, attempting to commit, or taking part in a felony or assault, or engaging in an illegal occupation; (l) participation in a contest of speed in power driven vehicles, parachuting, parasailing, bungee-jumping, or hang gliding; (m) air travel, except: (1) as a fare-paying passenger on a commercial airline on a regularly scheduled route; or (2) as a passenger for transportation only and not as a pilot or crew member; (n) any accident occurring as a result of the covered person being intoxicated (where the blood alcohol content meets the legal presumption of intoxication under the law of the state where the accident took place); (o) sex changes; (p) experimental treatments or surgery; (q) the reversal of tubal ligation and vasectomies; (r) artificial insemination, in vitro fertilization, and test tube fertilization, including any related testing, medications, or physician s services, unless required by law; (s) treatment of exogenous obesity or weight control; (t) an act of war, whether declared or undeclared, or while performing police duty as a member of any military or naval organization. This exclusion includes accident sustained or sickness contracted while in the service of any military, naval or air force of any country engaged in war. The company will refund the pro rata unearned premium for any such period the covered person is not covered; (u) accident or sickness arising out of and in the course of any occupation for compensation, wage or profit. Expenses which are payable under occupational disease law or similar law, whether or not application for such benefits has been made; (v) pre-existing conditions, except as described in the schedule; or (w) air or ground ambulance service. (x) for loss incurred, care or treatment received, or hospital confinement occurring outside of the united states or its possessions. In addition to the exclusions and limitations for all coverages, the following are not covered under the out-patient physician office visit indemnity benefit and the outpatient diagnostic x-ray and laboratory indemnity benefit: (a) visits made, examinations given, or x-rays or laboratory tests performed as an in-patient while confined to a hospital; (b) routine eye examinations or fitting of glasses; (c) fitting of hearing aids; (d) dental examinations or dental care other than expenses resulting from accidental injury; and (e) benefits which are provided under any other part of the policy. 7 P a g e

8 BENEFIT DESCRIPTIONS AND DEFINITIONS HOSPITAL BENEFITS Daily In-Hospital Indemnity Benefit - If a Covered Person, while insured, is Confined in a Hospital as a result of Accident or Sickness, the Company will pay the Daily In-Hospital Indemnity Benefit amount, as shown in the Schedule, for each day of Confinement, for up to the Maximum Number of Days of Confinement, as shown in the Schedule. Intensive Care Benefit - pays double the daily hospital benefit for intensive care confinement while in the hospital, up to 30 days per calendar year. Initial Hospital Admission Benefit - pays a lump sum Hospital Admission Benefit if an Insured Person is admitted as an inpatient to a Hospital for treatment of Sickness or Injury. PHYSICIAN & OTHER MEDICAL BENEFITS Doctor s Office Visits pays the amount selected per doctor s office visit for treatment of an injury or sickness, up to the number of visits selected per covered person per calendar year. Diagnostic, X-Ray and Laboratory pays the amount selected per visit for medically necessary diagnostic testing and x-rays of injury or sickness performed in a doctor s office or outpatient facility, up to the number of visits selected per covered person per calendar year. Wellness Visits (Preventive Care) for Adults and Children pays the amount selected per doctor s office visit for well care, up to the number of visits selected, per covered person, per calendar year. Well care includes physical examinations, assessments, and screenings. Ground Ambulance Service Indemnity Benefit - If a Covered Person requires the use of Ground Ambulance Service for transportation to or from a Hospital as a result of Accident or Sickness, the Company will pay the Ground Ambulance Service Indemnity Benefit, as shown in the Schedule, up to the maximum number of trips, as shown in the Schedule. Air ambulance transportation will be payable only if medically necessary and to the nearest facility equipped to handle the Covered Person s Accident or Sickness. Ground Ambulance Service means physical transportation in an appropriate vehicle registered to a licensed medical transportation service. Supplemental Accident Benefit - If a Covered Person has an Accident while Insured under the Policy, a Supplemental Accident Benefit will be provided if: (a) the Accident resulted in injury to the person; and (b) the charges are: (1) incurred during the 90-day period after the date of the Accident: and (2)not excluded under the terms of the Policy; and (3)not reimbursed in full under any other provision(s) of the Policy. After any and all other benefits are payable under the Policy, the Company will pay the remaining actual expense incurred, if any, for the necessary care and treatment of the Accident. The maximum amount payable will not exceed the amount shown in the Schedule of Benefits. Surgical Indemnity Benefit - If a Covered Person has a covered surgery performed, the Company will pay the Surgical Indemnity Benefit amount. This amount is based on the Payment Factor amount, as shown in the Schedule of Surgical Indemnity Benefits, times the number of Surgical Procedure Units, as shown in the Schedule. Anesthesia Indemnity Benefit - If the Surgical Indemnity Benefit is payable, the Company will pay the Anesthesia Indemnity Benefit amount, as shown in the Schedule, for the administration of anesthesia. Life Insurance - If a Covered Person dies, the Company will pay the Death Benefit, subject to the provisions of the Policy. This benefit is shown in the Schedule. Payment will be made in one lump sum to the Beneficiary (or to the Insured in the event of a covered Dependent s death). Where can I locate providers? Provider and facilities can be located on the First Health web 8 P a g e

9 VALUE ADDED BENEFIT PROGRAMS The added coverages and services, except for the prescription drug and vision benefits, are neither underwritten nor provided by Companion Life Insurance Company. Companion assumes no responsibility or liability for any of the listed services, the providers of the services, the quality of the services, the delivery of the services, or the outcomes of the services. Questions or concerns about the services should be addressed directly to the providers. CO-PAY PRESCRIPTION DRUG COVERAGE RX 10/30 PLAN $10 Co-pay for Preferred Generic drugs $30 Co-pay for Preferred Brand Name $30 Generic Mail Order (90 day supply) $90 Brand Name Mail Order (90 day supply) $200 individual monthly - $400 family monthly max. Over 65,000 pharmacies nationwide. ACCIDENT MEDICAL WITH AD&D** ACCIDENT MEDICAL If you are injured in a covered accident and receive treatment from a physician, you are eligible for benefits during the benefit period of 52 weeks; you will be paid up to $2,500 for X-rays, Physician Services, Emergency Room Services, Supplies and Appliances. This benefit is available on a per occurrence basis with a $100 deductible per event. ACCIDENTAL DEATH AND DISMEMBERMENT These plans also include $5,000 of AD&D coverage. See certificate for breakdown of benefits. Group Accident Medical is NOT available in all states. ACCIDENT MEDICAL GENERAL EXCLUSIONS A loss shall not be a Covered Loss if it is caused by, contributed to, or resulted from: 1. Suicide or any attempt at suicide or intentionally self-inflicted Injury or any attempt at intentionally self-inflicted injury. 2. War or any act of war, whether declared or undeclared. 3. Involvement in any type of active military service. 4. Illness or disease, regardless of how contracted, medical or surgical treatment of illness or disease; or complications following the surgical treatment of illness or disease; except for Accidental ingestion of contaminated foods. 5. Participation in the commission or attempted commission of a crime, any felony, an assault, insurrection or riot. 6. Being intoxicated. a. A Covered Person will be conclusively presumed to be intoxicated if the level of alcohol in his or her blood exceeds the amount at which a person is presumed, under the law of the locale in which the Accident occurred, to be intoxicated, if operating a motor vehicle. b. An autopsy report from a licensed medical examiner, law enforcement officer reports, or similar items will be considered proof of the Covered Person s intoxication. 7. Being under the influence of any prescription drug, controlled substance, or hallucinogen, unless such prescription drug, controlled substance, or hallucinogen was prescribed by a Physician and taken in accordance with the prescribed dosage. 8. Travel or flight in any aircraft except as a fare-paying passenger on a regularly scheduled charter or commercial flight. 9. Release, whether or not Accidental, or by any person unlawfully or intentionally, of nuclear energy or radiation, including sickness or disease resulting from such release. 10. A cardiovascular event or stroke caused by exertion prior to or at the same time as an Accident 11. Any condition for which the Insured is entitled to benefits under any Workers' compensation. 9 P a g e

10 PATIENT ADVOCACY Your medical program includes a service called Patient Advocacy provided by The Karis Group, which can provide tremendous help and reassurance when members are faced with large medical bills. This service links members to negotiating professionals who help them resolve their bills with medical providers, whether in or outside of the network or whether it s after one has been scheduled for admission or once a member has a bill in hand. MEC FREQUENTLY ASKED QUESTIONS Q: New MEC plans, why have I not heard about this before. A: HHS just released the regulations in late 2012, thus it took time to review the regulations. Q. If I receive my coverage from my spouse s employer, will I have minimum essential coverage? A: Yes. Employer-sponsored coverage is generally minimum essential coverage. If an employee enrolls in employersponsored coverage for himself and his family, the employee and all of the covered family members have minimum essential coverage. Q: What happens if I do not have minimum essential coverage and I cannot afford to make the payment with my tax return? A: The IRS routinely works with taxpayers who owe amounts they cannot afford to pay. The law prohibits the IRS from using liens or levies to collect any payment you owe related to the individual responsibility provision, if you, your spouse or a dependent included on your tax return does not have minimum essential coverage. INDEMNITY MEDICAL FREQUENTLY ASKED QUESTIONS Q: Are pre-existing conditions covered by the Limited Benefit Health Insurance? A: Yes, pre-existing conditions are covered. Q: How does my medical plan work? A: The plan you have been issued is called a Limited Benefit Health Insurance plan. This is NOT MAJOR MEDICAL INSURANCE; nor is it intended to replace major medical insurance. The limited benefit health insurance plan pays a scheduled amount for various medical services. Q: Is this Major Medical Insurance? A: No. Limited Benefit Health Insurance plans offer limited benefit medical reimbursement coverage for basic medical expenses at an affordable cost. Unlike major medical, these plans do not coordinate benefits, so it pays regardless of any other coverage the covered person may have. Q: If my doctor is not listed as a PPO provider, will that change the benefit I will receive? A: No. the plan will pay the same benefits in your schedule of benefits whether you go to a PPO provider or a Non-PPO provider. You are free to use any licensed provider or hospital of your choice. If you go to a participating PPO provider, chances are your benefits will go further and cover more of the bill. Q: Why should I use a PPO Provider? A: By utilizing an in-network provider, you may reduce your out-of-pocket expense because the PPO provider will charge a negotiated reduced fee for his / her service. Q: Do these plans cover Maternity? A: Yes. Maternity is covered the same as any other sickness benefit and will pay subject to the limits of the plan chosen. Q: What is my co-payment amount? Is there a deductible? A: One of the great features of your limited benefit health insurance plan is that there are NO deductibles or co-payments. 10 P a g e

11 Careington Discount Dental As a member, you may take advantage of savings offered by an industry leader in dental care. Careington International Corporation is one of the most recognized professional dental networks in the nation and boasts a provider network of over 62,000 participating dentists. Average annual savings of $1,200 per family on dental work Over 62,000 providers nationwide Save 20% to 50% on most dental procedures including routine oral exams, unlimited cleanings, and major work such as dentures, root canals, and crowns Orthodontics included for both children and adults at a 20% savings Cosmetic dentistry such as bonding and veneers also included All specialties included Endodontics, Oral Surgery, Orthodontics, Pediatric Dentistry, Periodontics, and Prosthodontics a 20% reduction on normal fees where available All dentists must meet highly selective credentialing standards based on education, background, license standing and other requirements Members may visit any participating dentist on the plan and change providers at any time How to Access Your Discounts Step 1: To locate a participating provider, call toll-free or visit us online at to access our online provider search. Step 2: Call to make an appointment with the participating provider. You must show your membership card at the time of visit to receive your discount. Step 3: Pay your bill. You are responsible for the total bill, less the applicable savings, at the time service is rendered. Sample Savings* Code Description Plan Cost** Regular Cost** Savings 0120 Periodic Oral Evaluation $23 $47 51% 0274 Bitewings-Four Films $29 $59 51% 1110 Prophylaxis-Adult (light) $45 $86 48% 1120 Prophylaxis-Child $32 $63 49% 2160 Amalgam-Three Surface, Primary or Permanent $95 $197 52% 2750 Crown-Porcelain Fused to High Noble Metal $577 $ % 3330 Root Canal-Molar (Excluding Final Restoration) $558 $941 41% 4341 Periodontial Scaling and Root Planing $119 $237 50% 7140 Extraction-Erupted Tooth or Exposed Root $74 $156 53% 8080 Comprehensive Orthodontic Treatment 20% Discount $5,443 20% *These fees represent the CI-5 fee schedule. Normal cost is based on the 80th percentile of the National Dental Advisory Service Comprehensive Fee Report for **Prices subject to change 11 P a g e

12 THIS DISCOUNT DENTAL BENEFIT IS NOT INSURANCE Disclosures: 1. THIS PLAN IS NOT INSURANCE. THIS IS NOT A MEDICARE PRESCRIPTION DRUG PLAN.* 2. This plan does not meet the minimum creditable coverage requirements under M.G.L. c. 111M and 956 CMR The plan provides discounts at certain health care providers for medical services. The range of discounts will vary depending on the type of provider and service. The plan does not make payments directly to the providers of medical services. 4. Plan members are obligated to pay for all health care services but will receive a discount from those health care providers who have contracted with the discount medical plan organization. 5. You may access a list of participating health care providers at Upon request the plan will make available a written list of participating health care providers. 6. You have the right to cancel within the first 30 days after receipt of membership materials and receive a full refund; less a nominal processing fee (nominal fee for MD residents is $5). Discount Medical Plan Organization and administrator: Careington International Corporation, 7400 Gaylord Parkway, Frisco, TX 75034; phone The program and its administrators have no liability for providing or guaranteeing service by providers or the quality of service rendered by providers. This program is not available in Montana and Vermont. *Medicare statement applies to MD residents when pharmacy discounts are part of program. 12 P a g e

13 EYEMED Vision by Design What is Vision by Design? It's a managed vision care program combining unlimited choice with high quality and significant value. Vision by Design is underwritten by Companion Life Insurance Company. The provider network, customer service and claim administration is through EyeMed Vision Care. Extensive Provider Network Unlike other programs that may restrict provider options, Vision by Design offers a nationwide network of convenient, accessible options for eye care. Companion Life, in association with EyeMed Vision Care, offers easy access to thousands of conveniently located vision care providers including optometrists, ophthamologists, opticians and many leading optical retailers, such as LensCrafters, Target Optical, and most Sears Optical, and Pearl Vision, locations. Access to more than 35,000 vision care providers at 18,000 convenient locations nationwide Evening and weekend hours at many locations Choice of thousands of fashionable, designer frames No appointment necessary, and service in about an hour in most locations Quality Vision Care - EyeMed has a firm commitment to quality and patient satisfaction. All EyeMed Vision Care providers must meet NCQA credentialing standards. Providers are monitored through EyeMed's Quality Assurance Program and recredentialing process. Quality Products - Vision by Design members have unlimited choice of available eyewear products. Our members are free to select from any available frame including designer frames by Luxottica, such as Vogue, Brooks Brothers, Anne Klein, and many more. Superior Value - Members enjoy savings of up to 40% off retail prices, with continued savings after the initial benefits have been used. Service Excellence - EyeMed focuses on delivering service excellence throughout all areas of program administration, featuring call center representatives available seven days a week, including evenings. They combine innovative solutions with the most current technology to enhance the administrative experience for both clients and members.*premium Contact Lens Fitting -all lens designs, materials and specialty fittings other than Standard (ex.: toric, multifocal, etc.) **Once in a 12 month period defined by last date of service. (Contact Lenses are in Lieu of EyeGlass Lenses). Vision Care Services Exam with Dilation (as necessary): Contact Lens fit and Follow-up: (Contact lens fit and two follow-up visits are available once a comprehensive eye exam has been completed) Standard Premium* Frames: Any available frame at provider location Standard Plastic Lenses: Single Bifocal Trifocal Lens Options: UV Coating Tint (Solid and Gradient) Standard Scratch Resistant Coating Standard Polycarbonate Standard Anti-Reflective Coating Standard Progressive (Add-on to Bifocal) Other Add-Ons and Services Contact Lenses: (Material only) In Network $10 Copay N/A N/A In Network Only 35% off retail price when complete pair of Eyeglasses purchased; otherwise 20% discount. Member Pays: $50 $70 $105 Member Pays: $15 $15 $15 $40 $45 $65 20% off retail Conventional: 15% off retail price Medically Necessary Frequency: Examination Frame Lenses or Contact Lenses N/A 12 months** Unlimited Unlimited 13 P a g e

14 Companion Life's Vision by Design Additional Discounts: Members will receive a 20% discount on items not covered by the plan at network Providers, which may not be combined with any other discounts or promotional offers, and the discount does not apply to EyeMed Provider's professional services, or contact lenses. Retail prices may vary by location. Members also receive a 40% discount off complete pair of eyeglass purchases (frames, lenses, and lens options purchased in the same transaction) and a 15% discount off conventional contact lenses once the funded benefits have been used. After initial purchase, replacement contact lenses may be obtained via the Internet at substantial savings and mailed directly to the member. Details are available at The contact lens benefit allowance is not applicable to this service. Laser vision correction (Lasik or PRK) savings of 15%off retail or 5%off promotional price nationwide.* Overview of Vision by Design Plans: Vision Essentials (Exam + Discount) Provides members with a paid in full exam and substantial point of sale discounts for frames, lenses and contact lenses. Discount applies when a complete pair of eyeglasses ** is purchased; otherwise the discount is 20% off the retail price. Choice of copay available for the exam, and material purchases are unlimited. Lenses Providers are given the freedom to recommend whichever lens brands or options they believe offer the best ocular clarity. They are also free to choose any fabrication laboratory, assuring quality service and convenience. Frames Vision by Design provides total flexibility to choose eyeglass frames that meet any taste, need, or lifestyle. You may choose from any frame available at your provider location. Most providers carry frames by Luxottica, the world leader in eyeglass design and manufacturing. The Luxottica collection of eyewear includes the most reputable and prestigious names in the optical fashion world. Vision Select includes Out of Network benefits. Out of Network claim forms may be obtained by printing a copy from the EyeMed web site or by calling EyeMed's Customer Care Center. Simply pay in full at the time of service and then submit the claim form and receipts to EyeMed for reimbursement. *Since Lasik or PRK vision correction is an elective procedure, performed by specially trained providers, this discount may not always be available from a provider in your immediate location. For a location near you and the discount authorization, please call LASER6. **Complete pair of eyeglasses: frames, lenses, and lens options purchased in the same transaction. Plan Limitations/Exclusions Orthoptic or vision training, subnormal vision aids, and any associated supplemental testing. Aniseikonic lenses Medical and/or surgical treatment of the eye, eyes, or supporting structures Corrective eyewear required by an employer as a condition of employment, and safety eyewear unless specifically covered under plan Services provided as a result of any Workers Compensation law Plano non-prescription lenses and non-prescription sunglasses (except 20% discount) Services or materials provided by any other group benefit providing for vision care Two pair of glasses in lieu of bifocals Benefit is not available on those frames where the manufacturer prohibits a discount This summary contains only a brief description of the benefits. It is not the contract. Rates and provisions are subject to change. Actual coverage is subject to the terms and conditions of the contract when it becomes effective, and actual contract language will be reflected in each employee's Certificate of Coverage. 14 P a g e

15 To enhance your coverage, we have partnered with a preferred provider organization, First Health; to offer members access to over 500,000 providers nationwide with savings up to 40% on your provider bills if you choose to see a network provider. You may use network or non-network providers; however, you can take advantage of additional discounts by using network providers. Your decision to use network or non-network providers will have no impact on the indemnity benefit amount payable under your coverage. When visiting a network provider, you must present a current identification card to validate your participation in the network. How to locate a PPO provider via the Web Log on to: How to locate a PPO provider via the Call Center Call Customer Service at What to pay the provider? In Network: If you elect to assign benefits to provider: 1. Upon arrival, identify yourself at the front desk, and present your network identification card. 2. The provider will send an itemized bill and claim form to TCC for payment. You may still be required to make a payment based on the benefits payable and the difference between the discounted cost and the claim payment to provider. If you choose not to assign benefits directly to the provider: 1. At the conclusion of your visit the office staff will bill you for the full insurance amount. File Hard Copy Medical Claims To: First Health, P. O. Box Eagan, MN Electronic Payor ID: Dental claims - filed hardcopy to: TCC of South Carolina PO Box Charleston, SC Out of Network: If you elect to assign benefits to provider: 1. Present your ID card to provider. Provider will call to confirm eligibility. 2. Provider will bill you for the difference between full cost and the insurance benefit payable under the Crescent Plan. Provider will send claim form to: TCC of South Carolina PO Box Charleston, SC If you choose not to assign benefits directly to the provider: 1. You will be billed for the full amount by the provider at point of service. 2. You will send claim form with itemized bill/proof to the following address for payment of the physician visit benefit. In the event of an emergency call 911 or go to the nearest emergency facility! 15 P a g e