Employee Benefit Options Guide. Plan Year January 1 through December 31, Dental and Vision Plan Information for OSU/A&M System Employees

Transcription

1 Employee Benefit ptions Guide lan Year 2013 January 1 through December 31, 2013 Dental and Vision lan nformation for U/&M ystem Employees

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3 klahoma tate University/&M ystem Monthly remiums for lan Year January 1, December 31, 2013 DET EMYEE Y EMYEE & UE EMYEE & CHD EE & UE & CHD EMYEE & CHDRE FMY HealthChoice Dental $31.38 $62.76 $58.28 $89.66 $98.34 $ ssurant Freedom referred $28.84 $57.50 $50.34 $79.00 $86.64 $ ssurant Heritage lus with B (repaid) $11.74 $20.60 $19.34 $28.20 $26.94 $35.80 ssurant Heritage ecure (repaid) $7.20 $13.18 $12.40 $18.38 $17.58 $23.56 CG Dental Care lan (repaid) $9.26 $15.32 $16.34 $22.40 $24.58 $30.64 Delta Dental $33.64 $67.26 $62.90 $96.52 $ $ Delta Dental remier $40.66 $81.32 $76.06 $ $ $ Delta Dental Choice $15.06 $49.24 $49.50 $83.68 $98.66 $ V EMYEE Y EMYEE & UE EMYEE & CHD EE & UE & CHD EMYEE & CHDRE FMY Humana/CompBenefits VisionCare lan $6.76 $11.82 $10.34 $15.40 $11.22 $16.28 rimary Vision Care ervices (VC) $9.26 $17.26 $17.76 $25.76 $20.00 $28.00 uperior Vision ervices $7.14 $14.24 $13.86 $20.96 $20.94 $28.04 UnitedHealthcare Vision $8.18 $13.98 $12.78 $18.56 $15.16 $20.96 Vision ervice lan (V) $8.94 $14.90 $14.66 $20.64 $21.82 $ CHGE lan changes are indicated by bold text in the Comparison of Benefits charts. Dental lan Changes HealthChoice Dental lan The plan year maximum is being increased from $2,000 to $2,500. Vision lan Changes uperior Vision lan There is a for standard progressive lenses in-etwork, and the lan will pay up to $49 out-of- etwork. There is a 5% to 50% discount off surgical fees for laser vision correction. 3

4 D E T C M R Your Costs for etwork ervices nnual Deductible Diagnostic & reventive Care ex: cleaning, routine oral exam llowed Charges Basic Care ex: extractions, oral surgery llowed Charges Major Care ex: dentures, bridge work llowed Charges rthodontic Care llowed Charges lan Year Maximum Filing Claims CMR F BEEFT FR DET HealthChoice Dental etwork: $25 Basic and Major services combined on-etwork: $25 reventive, Basic, and Major services combined plus amounts above llowed Charges etwork: $0 on-etwork: $0 of llowed Charges after deductible etwork: 15% on-etwork: 30% plus amounts above llowed Charges etwork: 40% on-etwork: 50% plus amounts above llowed Charges etwork: 50% on-etwork: 50% plus amounts above llowed Charges 12-month waiting period may o lifetime maximum for etwork or non-etwork Covered for members under age 19 and members age 19 and older with TMD etwork and non-etwork: $2,500 per person, per year etwork: o claims to file on-etwork: You file claims ssurant Employee Benefits Freedom referred $25 per person, per policy year, waived for in-etwork preventive services etwork: $0 lan pays 100% of negotiated fee o deductible on-etwork: $0 lan pays 100% of usual and etwork: 15% lan pays 85% of usual and on-etwork: 30% lan pays 70% of usual and etwork: 40% lan pays 60% of usual and on-etwork: 50% lan pays 50% of usual and etwork: 40% lan pays 60% of negotiated fee on-etwork: 50% lan pays 50% of usual and deductible applies etwork and non-etwork: $2,000 lifetime maximum Coverage only for dependent children under age month waiting period may $2,000 per person, per policy year Member/provider must file claims ssurant Employee Benefits Heritage lus & Heritage ecure o deductibles o charge for routine cleaning (once every 6 months) o charge for topical fluoride application (up to age 18) o charge for periodic oral evaluations Fillings Minor oral surgery Refer to the copayment schedule for each plan Root canal eriodontal Crowns Refer to the copayment schedule for each plan 25% discount dults and children o annual maximum for general dentist o claims to file This is only a sample of the services covered by each plan. For services that are not listed in this comparison chart, contact each plan. ee Help ines on the back page for contact information. lan Year 2013 Comparison Chart 4

5 CMR F BEEFT FR DET CG Dental Care lan (repaid) o deductible or plan maximum $5 office copay applies ealant: $15 per tooth o charge for routine cleaning once every 6 months o charge for topical fluoride application (through age 18) o charge for periodic oral evaluations malgam: ne surface, permanent teeth $21 Delta Dental n-etwork and ut-of-etwork $25 per person, per year, applies to Basic and Major Care only $0 of allowable amounts o deductible applies 15% of allowable amounts after deductible Delta Dental remier n-etwork and ut-of-etwork $50 per person, per year, applies to Diagnostic, reventive, Basic, and Major Care $0 of allowable amounts after deductible 30% of allowable amounts after deductible Delta Dental Choice etwork $100 per person, per year, applies to Major Care only (evel 4) chedule of covered services and copays Copay examples: Routine cleaning $5 eriodic oral evaluation $5 Topical fluoride application (up to age 19) $5 chedule of covered services and copays Copay example: malgam - one surface, primary or permanent tooth $12 D E T Root canal, anterior: $355 eriodontal/scaling/root planing 1-3 teeth (per quadrant): $71 $2,280 out-of-pocket for children through age 18 $3,120 out-of-pocket for adults 24-month treatment excludes orthodontic treatment plan and banding 40% of allowable amounts after deductible 40% of allowable amounts, up to lifetime maximum of $2,000 o deductible o waiting period rthodontic benefits are available to the employee and their lawful spouse and eligible dependent children 50% of allowable amounts after deductible 40% of allowable amounts, up to lifetime maximum of $2,000 o deductible o waiting period rthodontic benefits are available to the employee and their lawful spouse and eligible dependent children chedule of covered services and copays Copay examples: Crown - porcelain/ceramic substrate $241 Complete denture - maxillary $320 You pay amounts in excess of $50 per month ifetime maximum up to $1,800 o deductible o waiting period rthodontic benefits are available to the employee and their lawful spouse and eligible dependent children o maximum $2,500 per person, per year $3,000 per person, per year $2,000 per person, per year o claims to file Claims are filed by participating dentists Claims are filed by participating dentists Claims are filed by participating dentists C M R This is only a sample of the services covered by each plan. For services that are not listed in this comparison chart, contact each plan. ee Help ines on back page for contact information. 5 lan Year 2013 Comparison Chart

6 V Covered ervices Eye Exams enses er air CMR F BEEFT FR V Humana/CompBenefits n-etwork $10 copay ne exam for eyeglasses or contacts every calendar year for single/ multi-focal lenses VisionCare lan etwork lan pays up to $35; one exam every calendar year lan pays up to: $25 single $40 bifocals $60 trifocals $100 lenticular n-etwork o imit to frequency You pay wholesale cost with no limit on number of pairs rimary Vision Care ervices, nc. ut-of- ut-of- etwork lan pays up to $40 imit one exam You pay normal doctor s fee, reimbursed up to $60 for one set of lenses and frames annually C M R Frames Contact enses aser Vision Correction, up to plan limits. ne set of frames every calendar year $130 allowance for conventional or disposable lenses and fitting fee in lieu of all other benefits every calendar year Medically necessary contacts, plan pays 100% Discount thru TC, member will pay no more than $895 per eye for conventional asik, $1,295 custom plus bladeless when services are rendered by a TC network provider TE: Humana: The contact lens benefit provides a $130 yearly allowance for the annual vision exam to evaluate eye health, contact lens exam for fitting and evaluation, and the purchase of either conventional or disposable contacts. f a member prefers contact lenses, the plan provides the contact lens allowance in lieu of all other benefits. nstead, if a member opts for lenses and frames during the plan year a applies for these two material items. More than 23,000 frames are covered in full by the with in-network providers. Exams, lenses, and frame benefits are provided once every 12 months. klahoma City asiklus Traditional ntralase (bladeless) with a one year plan with insurance discount is $695 per eye equals lan pays up to $45 $130 allowance for contacts and fitting fee in lieu of all other benefits Medically necessary contacts, plan pays up to $210 o benefit $1,390. Traditional ntralase (bladeless) with a lifetime plan with insurance discount is $1,395 per eye equals $2,790. CustomVue ntralase (bladeless) with lifetime plan with insurance discount is $1, per eye equals $3, VC: Member must select either in-network or out-of-network for entire plan year. nnetwork services are unlimited. ut-of-network services (one eye exam, one set of eyeglasses or contacts) are limited to once annually. $50 service fee applies to soft contact lens fittings; a $75 service fee applies to rigid or gas permeable contact lens fittings; and a $150 service fee applies to hybrid contact lens fittings. imple replacements are not assessed with these fees. imitations/exclusions include the following: 1) Medical eye care, 2) Vision lan Year 2013 Comparison Chart 6 You pay wholesale cost. o limit to number of frames You pay wholesale cost for annual supply of contacts Minimum 10% discount nationwide at The aser Center (TC). avings of $1,000 on asik between June 1 ept. 30, 2013, at TC in KC and Tulsa. Call VC for details You pay normal doctor s fee, reimbursed up to $60 for one set of lenses and frames per year imit of one set annually in lieu of eyeglasses You pay normal doctor s fees reimbursed up to $60 o benefit therapy, 3) on routine vision services and tests, 4) uxury frames (wholesale cost of frame exceeds $100, 5) remium prescription lenses, and 6) on prescription eye wear. For more information, call *uperior: Materials copay applies to lenses and/or frames. Discounts for lens add-ons will be given by contracted providers with a D in their listing. nline, in-network contact lens materials available at Exams, lenses, and frames are provided once per calendar year. rogressive enses (no-line bifocals) you pay the difference between the retail price of the selected progressive lens and the retail price of the provider s lined trifocal. The difference may also be subject to a discount. tandard contact lens fitting applies to an existing contact lens user who wears disposable, daily wear, or extended wear lenses

7 uperior Vision lan n-etwork CMR F BEEFT FR V etwork $10 copay lan pays: $34 phthalmologist, $26 ptometrist tandard rogressive: *ee notes below then plan pays up to $125 retail lan pays up to $120 all contacts Medically necessary contacts covered in full (Contact lens fit copay: tandard $25, after copay, covered in full; specialty $25, after copay, plan pays up to $50) 5% - 50% Discount off surgical fees lan pays: ingle up to $26 Bifocals up to $39 Trifocals up to $49 enticular up to $78 tandard rogressive: Up to $49 *ee notes below lan pays up to $68 lan pays up to $100 all contacts; $210 medically necessary contacts (Contact lens fit copay: tandard not covered; specialty not covered) o benefit only. The pecialty contact lens fitting applies to new contact lens wearers and/or a member who wears toric, gas permeable, or multifocal lenses. UHCVision: For either glasses or contact lenses, there is one $25 materials copay. n lieu of lenses and frames, you may select contact lenses. Covered contact lens benefit includes the fitting/evaluation fee, contact lenses, and up to two follow-up visits. f covered disposable contact lenses are chosen, up to six boxes (depending on prescription) are included when obtained from a network provider. t is important to note that UHC covered contact lenses may vary by provider. hould you choose contact lenses outside the covered selection, a $150 allowance will be applied toward the fitting/evaluation fees and purchase UnitedHealthcare Vision n-etwork 7 etwork $10 copay Reimbursement up to $40 tandard single vision, lined bifocal & trifocal lenses covered in full cratch resistant & UV coating, tints polycarbonate lenses, are also covered in full $130 retail frame allowance on coveredin-full qualifying lenses (covers fittings and evaluation fees, contact lenses and up to 2 follow-up visits) *ee notes below 15% discount off the usual & price, 5% off promotional price ingle up to $40 Bifocals up to $60 Trifocals up to $80 enticular up to $80 Reimbursement up to $45 Reimbursement up to $150 elective contact lenses; $210 medically necessary contact lenses o benefit of contact lenses (material copay does not ). Toric and gas permeable contact lenses are examples of contact lenses that are outside of our covered contacts. ecessary contacts are covered-in-full after applicable copay. Exams, lenses, and frame benefits provided once every calendar year. V: Exam, lenses, and frame benefit provided annually. The $25 materials copay applies to lenses or frames, but not to both. Copays/prices listed are for standard lens options. remium lens options will vary. f you choose a frame valued at more than your allowance, you ll save 20% on your out-of-pocket costs when you use a V doctor. Contact lenses are in lieu of spectacle lenses and frame. The $120 in-network allowance applies to the contact lenses. With a V provider, the contact lens Vision ervice lan (V) n-etwork ut-of- ut-of- ut-of- etwork $10 copay $10 copay lan pays up to $35 applies to lenses or frames. ingle vision, lined bifocal, and trifocal lenses covered in full. verage 35% to 40% discount on lens options then plan pays up to $120 lan pays up to $120 conventional or disposable Medically necessary contacts covered in full then plan pays: ingle up to $25 Bifocals up to $40 Trifocals up to $55 enticular up to $80, then plan pays up to $45 lan pays up to $105 conventional or disposable $210 medically necessary contacts 15% average o benefit off usual and price or 5% off the laser center s promotional price lan utilizes the V ignature provider network exam (fitting and evaluation) is covered in full after a copay up to $60. The $105 out-ofnetwork allowance applies to the contacts and contact lens exam. Your contact lens exam is performed in addition to your routine eye exam to check for eye health risks associated with improper wearing or fitting of contacts. rescription glasses - 30% off additional complete pairs of glasses and sunglasses, including lens options, from the same V doctor on the same day as your WellVision Exam. r get 20% off from any V doctor within 12 months from your last WellVision Exam. Contact V or visit vsp.com to learn about retail chain ffiliate roviders. lan Year 2013 Comparison Chart V C M R

8 Dental lans Help ines HealthChoice Dental klahoma City rea ll ther reas or ssurant, nc. Dental Freedom referred repaid Heritage lans CG repaid Dental ll reas Toll-free Hearing mpaired Relay vc Delta Dental klahoma City rea ll ther reas Vision lans Help ines Humana/CompBenefits VisionCare lan ll reas TDD ll reas rimary Vision Care ervices (VC) ll reas TDD ll reas uperior Vision lan ll reas TDD UnitedHealthcare Vision ll reas TDD ll reas Vision ervice lan (V) ll reas TDD ll reas