Solutions. Ancillary. Product

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1 Ancillary Product Solutions 01MK5262 R11/14 Blue Cross and Blue Shield of Louisiana is incorporated as Louisiana Health Service & Indemnity Company and an independent licensee of the Blue Cross and Blue Shield Association.

2 PROTECTING DREAMS FOR THE FUTURE TODAY Your LABI membership and support allow you to impact decisions of the legislative, executive, regulatory and judicial branches of state government on a broad range of issues that affect your bottom line. LABI keeps you informed when your group s interests are threatened, provides you with valuable compliance information and gives you access to business decision-making tools. LABI s efforts on a single issue could save your group thousands of dollars! Your LABI membership can also save you money by providing you with access to multiple benefit plans. Bundle up & save We know how important the right benefit package can be to recruiting and retaining quality employees. That s why we have partnered with Blue Cross and its subsidiaries to offer you the Blue Bundle. Employers have the option to bundle employee benefits with affordable, high-quality health and wellness benefits. With one team to administer all your benefits, you save time, and time is money. SOLUTION. SOURCE. ONE BILL. Southern National Life Insurance Company, Inc. is a subsidiary of Blue Cross and Blue Shield of Louisiana, independent licensees of the Blue Cross and Blue Shield Association.

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4 Lie f Southern National Life is an independent licensee of the Blue Cross and Blue Shield Association.

5 offering your employees peace of mind Whether your company has two employees or 10,000, we have plans that fit. Life insurance is something that no one likes to think about. All the same, 86 percent of Americans believe that life insurance is something most people need, and most of us have some. 1 That s the good news. The bad news is that most Americans don t have enough. More than a third don t have any life insurance at all, and those who are insured have coverage equal to less than four times their annual income. 2 Most experts believe that coverage equal to 10 times one s annual income is a more reasonable rule of thumb. Basic Group Term Life/AD&D Employee and dependent life coverage paid for by the employer. Did you know Strong life insurance coverage is essential to creating a robust and competitive benefit package for your employees. Life insurance offers your employees and their families a safeguard from many unexpected expenses if something should happen to them. Employers can offer this high-value benefit at a great price and employer-funded plans generally count as a business deduction for employers. VOLUNTARY TERM LIFE/AD&D Optional employee and dependent life coverage paid for by the employee through the convenience of payroll deduction. Did you know Voluntary plans offer extra value to employees at no added cost to the employer s company. Premiums are payroll-deducted, which means benefits are convenient for employees and economical for employers. Voluntary Term Life insurance is a way to provide the same protection as our Basic Group Term Life in a way that is cost-effective to both employers and their employees. Employers can offer Voluntary Term Life coverage with any Basic Life plan or as a stand-alone plan. This option allows employees to purchase additional coverage above what an employer may offer with our Basic Life insurance. This helps provide financial stability and would protect employees families from some unexpected expenses, if something were to happen to them. Voluntary high-limit AD&D Accidental Death & Dismemberment (AD&D) coverage provides protection for accidents. Why add Voluntary High-Limit AD&D? It s a fact of life accidents happen. By choosing Voluntary High-Limit Accidental Death & Dismemberment (AD&D) coverage, employees can give themselves and their family members 24-hour protection in case of accidental loss of life, limb, hearing or sight. We offer Voluntary AD&D coverage to employers and their employees at low, affordable rates. This option can also be offered with any group life insurance coverage or as a stand-alone plan. Just like with our Voluntary Life coverage, premiums are paid for by the employee through payroll deduction. This plan requires no underwriting and it s all guaranteed issue! 1 LIMRA and LIFE Foundation 2011 Insurance Barometer Study 2 LIMRA International, Trends in Life Insurance Ownership,

6 Life Benefits Group Contributory Voluntary 100% Participation Required 75% Participation Required Greater of 25% or 10 eligible enrolled Plan Options Employee Only Employee + Spouse Employee, Spouse and Child Standard Features Accelerated Death Benefit (living benefit) Terminally ill employees can receive up to 50% of their voluntary life insurance benefit up to $125,000 while they are still living, if they are given a terminal diagnosis of 12 months or less. Premium waiver Coverage may continue without paying premium if the employee becomes disabled prior to age 60. Conversion Privilege Employees/dependents may apply to convert all or part of their group life insurance to an individual policy, if they terminate or are no longer eligible for coverage. Portability standard with Voluntary Product The option to continue a portion or all of their life insurance coverage when employees leave employment. Optional Features Accidental death & dismemberment Accident benefits are equal to the amount of life benefits for accidents resulting in loss of life, limbs, hearing or sight. Seat belt benefit pays an additional 10% of the principal sum amount to a maximum of $10,000. Air bag banafit pays an additional 5% of the principal sum amount to a maximum of $5,000, if seat belt is also used. Exposure and disappearance benefit allows covered benefits to be paid within 12 months of disappearance, if due to a forced landing, stranding, sinking or wrecking of a conveyance. 5

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8 Lie f Dsabi i lity Southern National Life is an independent licensee of the Blue Cross and Blue Shield Association. 7

9 paycheck coverage Impact of disability on the workforce Almost 3 in 10 workers entering the workforce will become disabled before age 67. National Safety Council, Injury Facts, 2010 Ed. In the last 10 minutes, 490 Americans became disabled. US Social Security Administration, Social Security Basic Facts, Aug Approximately 90% of disabling accidents and illnesses are not work related; therefore, not covered by workers compensation. Council for Disability Awareness, CDA 2010 Long Term Disability Claims Review These are alarming statistics. It just goes to show how important protection against lost income can be to a workforce. Unfortunately, many people have not planned for the financial burden they will face if they should become disabled and unable to work for an extended period of time. Helping employees stay at work. Our disability coverage encourages employees to continue working as long as they are safely able protecting their eligibility for benefits and without penalty. Employees are able to satisfy the elimination period with only a loss of duties. We can extend the elimination period up to a year for disabled employees who do not meet the earnings loss amount. An employee doesn t have to be totally disabled to receive benefits. Our disability coverage allows disabled employees to return to work for up to one-half of the elimination period without restarting it if they are unable to endure their return to work. Protecting employers and employees. Our disability coverage helps protect employees, which in turn protects the employer s company. Here are a few highlights see this booklet for more specific details. Our disability coverage does not have limitations for symptoms that are self-reported or subjective. We manage all employees claims carefully and effectively. There is a treatment-free period within the pre-existing condition limitation. During this period, if the employee does not receive treatment for the pre-existing condition, he or she may qualify for benefits before completing the continuous days of coverage period. 8

10 Dsabi i lity short-term Disability Group Contributory Voluntary 100% Participation Required 75% Participation Required Greater of 25% or 10 eligible enrolled Features Group - No Pre-existing limitation Continuity of coverage Maternity included Optional Features Totally disabled or disabled and working Loss of duties and income Must be in business for 2 years Must not insure more than 50% immediate family members Group STD can only be written with GTL; stand-alone STD is not available LONG-term Disability Group Contributory Voluntary Standard Features Waiver of premium Survivor income benefit Return to work incentive Workplace modification Disability guidance (EAP) Mental, nervous and substance abuse coverage 100% Participation Required 75% Participation Required Greater of 25% or 10 eligible enrolled Optional Features Cost of living adjustment Activities of Daily Living Accidental dismemberment/loss of sight benefit 24 months own occupation and any occupation thereafter Loss of one or essential duty during elimination period Product Eligibility Must be in business a minimum of 2 years Must not insure more than 50% immediate family members Can be written stand-alone or with any other life or disability product 9

11 WHO PAYS THE PREMIUM? PREMIUM TAXABLE? BENEFIT TAXABLE? how are benefits taxed? Non-Contributory Employer pays 100% Contributory Employer pays 50% Employee pays 50%... No... Yes... 50%... 50% Voluntary Employee pays 100%... Yes... No The above illustration assumes disability insurance premiums are not deducted on a pre-tax basis in an employer-sponsored cafeteria plan. Blue Cross and Blue Shield of Louisiana is not engaged in rendering tax, legal or investment advice. We recommend you seek the guidance of a tax professional or financial advisor. STD CLAIM SEAMLESS DISABILITY CLAIM TRANSITION At the mid point of STD, the claim is given to an LTD analyst who manages the end of the STD claim, gathers LTD information and develops a plan for ongoing claim management. LTD CLAIM telephonic std intake Telephonic Intake Analyst Gathers information from employee. Contacts the employer. Short-Term Disability Analyst Reviews employee s claim based on automatic system prompt or referral from intake analyst. Utilizes specialized resources to make decisions and determines ongoing case management plan. Dedicated Rehabilitation Expert Reviews claims for return to work potential at specific intervals. Coordinates with employee, physician and employer to facilitate faster, smoother return to work. 10

12 Dsabi i lity Disability guide: supporting a healthy return to work When an employee becomes disabled, coming back to work is often a long and bumpy road. Our disability coverage provides support to help smooth out the bumps and make a healthy return to work easier for employers and their employees. Our Disability Guidance service provides insured employees, whether disabled or actively at work, with Long-Term Disability up to five counseling sessions per year that give confidential support for emotional, legal and financial issues. EMPLOYEE ASSISTANCE PROGRAM Telephonic assessments and counseling that include confidential sessions with a counselor, financial planner and/or an attorney. 24-hour access to counselors with master s or doctoral degrees in counseling via a dedicated toll-free phone number 365 days a year. Referrals to resources and services in callers communities are provided, such as community and governmental agencies serving the disabled, homemaker services, assistive equipment and day care for children and elderly parents. Employees are provided access to self-assessment tools, information and other resources through a password-protected interactive website. 11

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15 BENEFITS you can see Standard Vision Benefits (When visiting a Davis Vision network provider) National network Eye exams Eyeglass lenses Eyeglass frames Contact lenses Lasik surgery Network of more than 45,000 providers including optometrists, ophthalmologists and regional retail locations. Your employees pay little or no copayment for a comprehensive eye exam. Your employees pay little or no copayment for single vision, bifocal or trifocal lenses. Your employees pay little or no copayment for frames from the Davis Vision Collection*, or receive up to a $175 allowance toward the cost of other frames. *Collection is available at most participating independent provider offices. Your employees pay no copayment for contact lenses and receive up to a $150 allowance toward the cost of contact lenses. Your employees may access discounts from participating providers but this is not an insured benefit. IN-NETWORK BENEFITS (when visiting a Davis Vision Provider) VISION PLAN OPTIONS PLAN 1 PLAN 2 PLAN 3 Frequency - Once Every: Eye Health Examination Including Dilation (when professionally indicated) 12 Months 12 Months 12 Months Spectacle Lenses 12 Months 12 Months 12 Months Frame 12 Months 24 Months 24 Months Contact Lens Evaluation, Fitting and Follow Up 12 Months 12 Months 12 Months Contact Lenses (in lieu of eyeglasses) 12 Months 12 Months 12 Months Copayments Eye Health Examination $0 $0 $10 Eyewear (Spectacle Lenses and/or Frames) $0 $15 $25 Out of Network Benefits Member reimbursment schedule applies Davis Vision is an independent company that provides an extensive network of vision care providers on behalf of Blue Cross and Blue Shield of Louisiana. 14

16 Contribution Requirements Participation Requirements Employer-paid: Contributory: Voluntary: 100% Employer funding 100% of eligible employees must enroll 25%-99% Employer funding Greater of 75% or 10 eligible employees must enroll 0%-24% Employer funding Greater of 25% or five eligible employees must enroll for groups with eligible employees Greater of 25% or 10 eligible employees enrolled for groups with more than 50 eligible employees Groups with 2-9 eligible employees may only choose employer-paid contribution. There s no such thing as a plan that s too good. That s why each of our vision plans is packed with features that don t cost you or your employees anything extra. One-year breakage warranty for eyeglasses Features Eyeglasses covered by your plan come with a one-year warranty for repair or replacement, which begins on the date you receive your glasses. Your plan covers: Spectacle lenses Davis Vision Collection frames National retailer frames, where exclusive collection is not displayed Medically necessary contacts Your provider may presrcibe contact lenses in lieu of eyeglasses for treatment of certain conditions. When contact lenses are medically necessary, they will be covered subject to prior approval and applicable copayments and allowances. Replacement contact lens It s easy to replace your contacts through the Lens program mail order program. Just call LENS-123 or visit with your prescription to get started. 20% discount At most of our network retailers, you ll get a 20% 1 discount on items not covered by your plan, like second pairs, sunglasses, etc. In most cases, disposable contact lenses are available at a 10% 1 discount. Laser vision correction discounts You can get up to 25% off of the cost of laser vision correction surgery when you use doctors in the Eye Centers of Excellence network. 1 Discount not available at Walmart, Sam s Club, and Costco locations. General Conditions For consistency and accuracy, when adding vision benefits to existing medical insurance with a first-of-the-month billing date, the new benefits will have a first-of-themonth effective date. The same applies for groups with a 15 th -of-the-month billing date. Eligibility for actively at work, full-time employees requires a minimum of 30 hours per week for our medical, vision and other ancillary products. Groups may only choose one vision plan and one premium funding contribution type. 15

17 Vision Plan #1 Effective January 1, 2015 In-Network Benefits Frequency Once Every: Eye Health Examination including Dilation (when professionally indicated) 12 Months Spectacle Lenses 12 Months Frames 12 Months Contact Lens Evaluation, Fitting & Follow Up 12 Months Contact Lenses (in lieu of eyeglasses) 12 Months Copayments Eye Health Examination $0 Eyewear (Spectacle Lenses and/or Frames) $0 Eyeglass Benefit Frames Average Retail Value Frame Up to $175 Allowance up to $175 Plus a 20% discount on any overage that may apply* Davis Vision Collection Frame (in lieu of Allowance) Fashion Level (up to $125) Up to $125 Included Designer Lever (Up to $175) Up to $175 Included Premier Level (Up to $225) Up to $225 $25 Copayment Eyeglass Benefit Spectacle Lenses Clear plastic single vision, bifocal, trifocal or lenticular lenses (any Rx) $60 - $120 Included Choice of glass or plastic lenses $30 - $35 Included Oversize Lenses $20 Included Fashion and gradient tinting of plastic lenses $20 Included Polycarbonate Lenses** $60 - $75 $0 or $30 Scratch Protection $30 - $60 Included Ultraviolet Coating $25 - $30 $12 Standard Anti-Reflective (AR) Coating $50 - $70 $35 Premium AR Coating $65 - $90 $48 Ultra AR Coating $100 -$125 $60 Standard Progressive Lenses $150 - $195 $50 Premium Progressives $195 - $300 $90 Ultra Progressives $370 $140 Intermediate-Vision Lenses $150 -$175 $30 Blended Segment Lenses $40 - $50 $20 High-Index Lenses $90 - $150 $55 Polarized Lenses $95 - $110 $75 Photo chromic Glass Lenses $30 - $60 $20 Plastic Photosensitive Lenses $95 - $150 $65 Scratch Protection Plan: Single Vision I Multifocal Lenses $20 $40 Contact Lens Benefits (in lieu of eyeglasses) Prescription Contact Lenses (Materials): Allowance up to $150 Plus a 15% discount on any overage that may apply* Evaluation and Fitting Fees Standard Contact Lens Type Included Evaluation and Fitting Fees Specialty Contact Lens Type Allowance up to $60 Plus a 15% discount on any overage that may apply* Medically Necessary Contact Lenses (with prior approval) Materials, Evaluation and Fitting Fees Included Out-of-Network Benefits Member Reimbursement Applies *Discounts are not available at Wal-Mart, Sam s Club or Costco locations. ** Polycarbonate lenses are covered in full for dependent children, monocular patients and patients with prescriptions >=+\ 6.0 diopters. NOTE: Members must use a Davis Vision network Provider. Out of network benefits are not available.

18 Vision Plan #2 Effective January 1, 2015 In-Network Benefits Frequency Once Every: Eye Health Examination including Dilation (when professionally indicated) 12 Months Spectacle Lenses 12 Months Frames 24 Months Contact Lens Evaluation, Fitting & Follow Up 12 Months Contact Lenses (in lieu of eyeglasses) 12 Months Copayments Eye Health Examination $0 Eyewear (Spectacle Lenses and/or Frames) $15 Eyeglass Benefit Frames Average Retail Value Frame Up to $175 Allowance up to $175 Plus a 20% discount on any overage that may apply* Davis Vision Collection Frame (in lieu of Allowance) Fashion Level (up to $125) Up to $125 Included Designer Lever (Up to $175) Up to $175 Included Premier Level (Up to $225) Up to $225 $25 Copayment Eyeglass Benefit Spectacle Lenses Clear plastic single vision, bifocal, trifocal or lenticular lenses (any Rx) $60 - $120 Included Choice of glass or plastic lenses $30 - $35 Included Oversize Lenses $20 Included Fashion and gradient tinting of plastic lenses $20 Included Polycarbonate Lenses** $60 - $75 $0 or $30 Scratch Protection $30 - $60 Included Ultraviolet Coating $25 - $30 $12 Standard Anti-Reflective (AR) Coating $50 - $70 $35 Premium AR Coating $65 - $90 $48 Ultra AR Coating $100 -$125 $60 Standard Progressive Lenses $150 - $195 $50 Premium Progressives $195 - $300 $90 Ultra Progressives $370 $140 Intermediate-Vision Lenses $150 -$175 $30 Blended Segment Lenses $40 - $50 $20 High-Index Lenses $90 - $150 $55 Polarized Lenses $95 - $110 $75 Photo chromic Glass Lenses $30 - $60 $20 Plastic Photosensitive Lenses $95 - $150 $65 Scratch Protection Plan: Single Vision I Multifocal Lenses $20 $40 Contact Lens Benefits (in lieu of eyeglasses) Prescription Contact Lenses (Materials): Allowance up to $150 Plus a 15% discount on any overage that may apply* Evaluation and Fitting Fees Standard Contact Lens Type Included Evaluation and Fitting Fees Specialty Contact Lens Type Allowance up to $60 Plus a 15% discount on any overage that may apply* Medically Necessary Contact Lenses (with prior approval) Materials, Evaluation and Fitting Fees Included Out-of-Network Benefits Member Reimbursement Applies *Discounts are not available at Wal-Mart, Sam s Club or Costco locations. ** Polycarbonate lenses are covered in full for dependent children, monocular patients and patients with prescriptions >=+\ 6.0 diopters. NOTE: Members must use a Davis Vision network Provider. Out of network benefits are not available.

19 Vision Plan #3 Effective January 1, 2015 In-Network Benefits Frequency Once Every: Eye Health Examination including Dilation (when professionally indicated) 12 Months Spectacle Lenses 12 Months Frames 24 Months Contact Lens Evaluation, Fitting & Follow Up 12 Months Contact Lenses (in lieu of eyeglasses) 12 Months Copayments Eye Health Examination $10 Eyewear (Spectacle Lenses and/or Frames) $25 Eyeglass Benefit Frames Average Retail Value Frame Up to $175 Allowance up to $175 Plus a 20% discount on any overage that may apply* Davis Vision Collection Frame (in lieu of Allowance) Fashion Level (up to $125) Up to $125 Included Designer Lever (Up to $175) Up to $175 Included Premier Level (Up to $225) Up to $225 $25 Copayment Eyeglass Benefit Spectacle Lenses Clear plastic single vision, bifocal, trifocal or lenticular lenses (any Rx) $60 - $120 Included Choice of glass or plastic lenses $30 - $35 Included Oversize Lenses $20 Included Fashion and gradient tinting of plastic lenses $20 Included Polycarbonate Lenses** $60 - $75 $0 or $30 Scratch Protection $30 - $60 Included Ultraviolet Coating $25 - $30 $12 Standard Anti-Reflective (AR) Coating $50 - $70 $35 Premium AR Coating $65 - $90 $48 Ultra AR Coating $100 -$125 $60 Standard Progressive Lenses $150 - $195 $50 Premium Progressives $195 - $300 $90 Ultra Progressives $370 $140 Intermediate-Vision Lenses $150 -$175 $30 Blended Segment Lenses $40 - $50 $20 High-Index Lenses $90 - $150 $55 Polarized Lenses $95 - $110 $75 Photo chromic Glass Lenses $30 - $60 $20 Plastic Photosensitive Lenses $95 - $150 $65 Scratch Protection Plan: Single Vision I Multifocal Lenses $20 $40 Contact Lens Benefits (in lieu of eyeglasses) Prescription Contact Lenses (Materials): Allowance up to $150 Plus a 15% discount on any overage that may apply* Evaluation and Fitting Fees Standard Contact Lens Type Included Evaluation and Fitting Fees Specialty Contact Lens Type Allowance up to $60 Plus a 15% discount on any overage that may apply* Medically Necessary Contact Lenses (with prior approval) Materials, Evaluation and Fitting Fees Included Out-of-Network Benefits Member Reimbursement Applies * Discounts are not available at Wal-Mart, Sam s Club or Costco locations. ** Polycarbonate lenses are covered in full for dependent children, monocular patients and patients with prescriptions >=+\ 6.0 diopters. NOTE: Members must use a Davis Vision network Provider. Out of network benefits are not available.

20 VISION Rate Card Employer Paid 100% Employer Funding RATES FUNDED PLAN 1 PLAN 2 PLAN 3 Employee $ 6.18 $ 5.65 $ 4.66 Employee and Spouse $ $ $ 8.29 Employee and Children $ $ $ Family $ $ $ Contributory 25% - 99% Employer Funding RATES FUNDED PLAN 1 PLAN 2 PLAN 3 Employee $ 7.84 $ 6.67 $ 5.92 Employee and Spouse $ $ $ Employee and Children $ $ $ Family $ $ $ Voluntary 0% - 24% Employer Funding RATES FUNDED PLAN 1 PLAN 2 PLAN 3 Employee $ 9.51 $ 7.36 $ 6.87 Employee and Spouse $ $ $ Employee and Children $ $ $ Family $ $ $ Rates for groups with eligible employees. 01MK5201 R09/14 Blue Cross and Blue Shield of Louisiana is an independent licensee of the Blue Cross and Blue Shield Association and incorporated as Louisiana Health Service & Indemnity Company.

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23 BENEFITS THAT MAKE your employees smile DID YOU KNOW? 164 million work hours are lost every year to dental health issues. 1 Nearly 75 percent of American adults suffer from various forms of gum disease from simple inflammation to severe cases and don t even know it. 2 More than 90 percent of all systemic diseases have oral health symptoms. 3 People with dental coverage exhibit healthier behaviors and better oral health habits including brushing with fluoride toothpaste twice a day, flossing daily and visiting the dentist regularly report from Pew Center 2 American Dental Hygienist Association 3 Academy of General Dentistry report from NADP Protecting Your Employees Oral Health With the recent research showing how important oral health is to overall health, having a dental insurer who is dedicated to affordable, quality dental care is more important than ever. Whether you re looking for a dental plan to fit a business budget or your employees checkbooks, Blue Cross has the solution. Regardless of the dental plan you choose, making the decision to secure dental coverage for your employees is the right choice. 18

24 LABI dental plans Blue Cross and Blue Shield of Louisiana HAS a dental solution that s right for you Ideal for individuals and families that do not have dental insurance offered through their employer. Blue Dental for individuals Utilizes the Advantage Plus PPO Network, an extensive network of nationwide dentists. Choose from three Certified and three Traditional plans offering reliable and convenient dental coverage. Available for groups with a reported Medical Loss Ratio (MLR) employee count of 50 or fewer employees. Blue Dental for small groups Utilizes the Advantage Plus PPO Network, an extensive network of nationwide dentists. Allows employers to give their employees the benefits they want with little or no costs to the employer. Choose from three Certified and three Traditional plans that offer a variety of comprehensive dental services. Available for groups with a reported MLR employee count of 51+ employees or groups with ASO medical. Large Group Dental Utilizes the Blue Cross Dental Network, giving your employees the freedom to choose from a large network of Louisiana dentists. Several cost-effective standardized dental plans are available Customized plans are also available based on group size. Fully-insured and ASO funding options are available. 19

25 small GROUP Dental Covera ge If you are like most employers, you consider dental coverage an essential part of your employees overall health care plan. Our Blue Dental Traditional and Certified plan options offer a wide range of benefits and services that will encourage your employees to be the healthiest and most productive they can be. NEW Traditional blue dental plans We are excited to offer three new Traditional Blue Dental Plans that include comprehensive coverage for adults and children, along with optional cosmetic orthodontic coverage for dependents. These plans are designed for small groups whose required pediatric dental essential health benefits (EHBs) are satisfied through the group s qualified health plan. Plan A Plan B Plan B Ortho Provides excellent coverage for Diagnostic and Preventive services, along with Basic Services. All benefits covered in Plan A are included in Plan B. In addition, Plan B includes coverage for Major Services. Plan B Ortho includes the same benefits as Plan B, with the addition of dependent orthodontic coverage up to age 19. Each Traditional plan includes: Preventive care incentives to encourage routine oral care. Charges for diagnostic and preventive services, like cleaning and x-rays, will not count toward the annual maximum, leaving more benefit dollars for other covered dental procedures. Choice of $1,000, $1,500 or $2,000 annual benefit maximum per member $50 per member deductible/$150 per family No waiting periods Participation: Employer Paid: 100% of eligible employees must enroll (group size 2 50) Contributory: Greater of 70% or 10 eligible must enroll (group size 10 50) Voluntary: Greater of 20% or 10 eligible must enroll (group size 10-50) 20

26 Certified Blue Dental Plans Three Certified Blue Dental plan options are also available, which are CMS certified and include all the required pediatric dental EHBs. If your small group medical policy does not include the pediatric EHB requirements, then a certified Blue Dental plan is right for you. Preferred Plus Preferred Essential Preferred Plus has the highest adult annual benefit maximum of $1,500 and a $50 annual deductible per member. The Preferred plan covers the same services as Preferred Plus, but with a lower adult annual benefit maximum of $1,000, with a $50 annual deductible per member. This lower cost plan option offers a $1,000 annual benefit maximum, $75 annual deductible per adult and $50 annual deductible per child, and a slightly lower level of coverage. Each Certified plan option includes: An unlimited annual benefit maximum and no waiting periods for the majority of dental services for children under age 21. Traditional and medically necessary orthodontia for dependents up to age 21 Participation: Greater of 20% or 10 eligible employees with a minimum of 2 eligible employees enrolled (group size 2-50) Blue Dental Plans: Certified vs. traditional Pediatric Dental Essential Health Benefits CERTIFIED Blue Dental Plans Preferred Plus, Preferred and Essential Includes all the required Pediatric Dental EHBs traditional Blue Dental Plans Plan A, Plan B and Plan B Ortho Does not include Pediatric Dental EHBs Benefits Separate benefits for adults and children under age 21 Same benefits for adults and children Child Orthodontia Medically necessary and traditional ortho up to age 21; 24-month waiting period Traditional ortho up to age 19; no waiting period Waiting Periods Adult waiting period applies No waiting periods for adults or children Premiums Premium reflects rates per covered persons (members level premium) Tier-rated premiums (employee/spouse/child/family) 21

27 ADVANTAGE PLUS PPO network With Blue Dental, our members may access the Advantage Plus PPO Network*. This extensive dental network of nationwide dentists provides our members: Access to over 900 dentists and 1,600 locations throughout Louisiana Access to over 78,000 credentialed dentists nationally 45% of all dentists nationwide participate in-network Strong rural and suburban focus Over 99% of dentists in-network are accepting new patients Find a dentist: To find a dentist in the Advantage Plus PPO Network, visit If your dentist is not currently participating in the network, you can nominate your dentist by calling *Advantage Plus Network PPO is administered by United Concordia Companies, Inc. United Concordia is an independent company that administers dental benefits on behalf of Blue Cross and Blue Shield of Louisiana members. Visit an Advantage Plus Network Dentist for Maximum Value Although you can use any licensed dentist with a Blue Dental plan, a network dentist will: Save your employees money: Network dentists have agreed to accept the Blue Cross payment, plus your deductible and coinsurance, as payment in full for covered services. They will not bill for any balance over that amount. Save your employees time: Network dentists automatically file claims with us, so it s one less thing for your employees to do. Since we pay dentists directly, there s no waiting for reimbursement. Give your employees freedom: Neither your employees nor their family members are tied to one dentist. With access to the extensive Advantage Plus network, all family members can choose a dentist they like. 22

28 LARGE GROUP Dental Covera ge Blue Cross and Blue Shield of Louisiana has seven dental options for large employers that offer a variety of dental services. Large Group Dental Coverage Product of Blue Cross and Blue Shield of Louisiana Choose the Plan that is Right For Your Group Seven dental plans to choose from Deductibles per benefit period range from $50 to $100 Maximum benefits per benefit period range from $1,000 to $2,000 Diagnostic and Preventive Services are covered at 100% with no waiting periods Basic Services are covered at 80% and coverage for Major Services ranges between 50% and 60% Coverage for Major Services ranges between 50% and 60% Traditional orthodontia is covered in some plans Product Eligibility Large groups with a reported Medical Loss Ratio (MLR) employee count of 51+ employees or groups with ASO medical are eligible to purchase large group dental Employer contribution is 50% of employee cost 50% participation is required BLUE CROSS DENTAL NETWORK The Blue Cross Dental Network is a large network of dentists linked together with Blue Cross to bring our members a more cost-effective dental plan. For a list of dentists in your area, go to All benefits are based on allowable charges for covered services and participating dentists have agreed to accept the Blue Cross payment (plus your deductible and coinsurance) as payment in full for covered services. They will not bill for any balance over that amount. All claims payments go directly to the participating dentist for covered services rendered. If you choose a non-participating dentist, you may have to file your own claims and be responsible for paying the dentist for all charges. This amount may include any difference between the Blue Cross allowable charge and the fee charged by the dentist. 23

29 Small Group Certified Blue Dental Plans Effective January 1, 2015 BENEFITS CERTIFIED DENTAL PLAN OPTIONS Preferred Plus Preferred Essential Deductible (per Adult Member per calendar year) 1 $50 $50 $75 Deductible (per Member under age 21 per calendar year) 1 $50 $50 $50 Adult Annual Benefit Maximum- Members age 21 & older $1,500 $1,000 $1,000 Child Annual Benefit Maximum- Members under age 21 Unlimited Unlimited Unlimited Child Out of Pocket Yearly Maximum- Members under age 21 (Applies to In-Network Services Only) Lifetime Maximum Traditional Orthodontia- Members under age 21 $350 for 1 Child $700 for 2 or more Children $350 for 1 Child $700 for 2 or more Children $350 for 1 Child $700 for 2 or more Children $1,000 $1,000 $1,000 Child 2 No Waiting Period Adult Adult Waiting Period Child 2 No Waiting Period Adult Adult Waiting Period Child 2 No Waiting Period Adult Adult Waiting Period COVERED SERVICES CONTRACT PAYS Routine Oral Exams and Cleanings 1 100% 100% None 100% 100% None 100% 100% None Oral X-Rays 1 80% 100% None 80% 100% None 80% 50% None Fluoride Treatments, Sealants 1 80% Not Covered 80% Not Covered 80% Not Covered Palliative Treatment (Emergency) 1 80% 80% None 80% 80% None 80% 80% None Space Maintainers 80% Not Covered 80% Not Covered 80% Not Covered Basic Restorative (Amalgam, Resin Fillings) 50% 80% 6 months 50% 80% 6 months 50% 50% 6 months Oral Surgery, Surgical Extractions 50% 80% 12 months 50% 80% 12 months 50% 50% 12 months Simple Extractions 50% 80% None 50% 80% None 50% 50% None Periodontics Surgical and Non-Surgical 50% 80% 12 months 50% 80% 12 months 50% 50% 12 months Endodontics 50% 80% 6 months 50% 80% 6 months 50% 50% 6 months Crown Repairs 50% 50% 12 months 50% 50% 12 months 50% 50% 12 months Crowns, Prosthetics (Bridges, Dentures) 50% 50% 12 months 50% 50% 12 months 50% 50% 12 months Implants (Members under age 21 only) Must meet Dental Necessity Requirements 50% Not Covered 50% Not Covered 50% Not Covered Orthodontics (Members under age 21 only) Medically Necessary Traditional 50% 24-month wait 50% 24-month wait 1 Does not apply to Diagnostic and Preventative Services 2 Members under age 21. Certain benefits are limited to children of younger age than 18. See contract and schedule of benefits for coverage exclusions and limitations. Not Covered Not Covered 50% 24-month wait 50% 24-month wait Not Covered Not Covered 50% 24-month wait 50% 24-month wait Not Covered Not Covered The Preferred Plus, Preferred and Essential plans are Exchange certified and include all the required pediatric dental essential health benefits (PDEHB). Product Eligibility & Participation Small groups with a reported Medical Loss Ratio (MLR) employee count of 50 or less are eligible to purchase Minimum of 2 benefit eligible employees to be enrolled as minimum participation Employer contribution is 0% - 100% of employee cost Participation is greater of 20% or 10 enrolled Network Child Out of Pocket Yearly Maximum only accumulates for benefits paid to a participating network provider. To take full advantage of the Blue Dental coverage, members should choose a dentist who participates in the Advantage Plus Network*. To find out if a dentist participates in the Advantage Plus Network, visit If members choose to visit an out-of-network dentist, they may be subject to higher fees and may be required to submit their claims. *Advantage Plus Network PPO is administered by United Concordia Companies, Inc. United Concordia is an independent company that administers dental benefits on behalf of Blue Cross and Blue Shield of Louisiana members.

30 Small Group Traditional Blue Dental Plans Effective January 1, 2015 TRADITIONAL DENTAL PLAN OPTIONS Benefits Plan A Plan B Plan B Ortho Contract Year Deductible per Member/per Family 1 $50/$150 Not applied to D&P $50/$150 Not applied to D&P $50/$150 Not applied to D&P Annual Benefit Maximum per Member (INN & OON) $1000, $1500 or $2000 $1000, $1500 or $2000 $1000, $1500 or $2000 OOP Yearly Max per Member/per Family Unlimited Unlimited Unlimited Lifetime Maximum Orthodontia Per Member (Up to age 19) N/A N/A $1000 or $1500 COVERED SERVICES CONTRACT PAYS Benefit Waiting Benefit Waiting Benefit Waiting Diagnostic and Preventive Services Coinsurance Period Coinsurance Period Coinsurance Period Routine Oral Exams and Cleanings 1 100% None 100% None 100% None All Oral X-Rays 1 100% None 100% None 100% None Oral Cleanings 1 100% None 100% None 100% None Fluoride Treatments 1 100% None 100% None 100% None Sealants 1 100% None 100% None 100% None Palliative Treatment (Emergency) 1 100% None 100% None 100% None Basic Services Benefit Waiting Benefit Waiting Benefit Waiting Coinsurance Period Coinsurance Period Coinsurance Period Space Maintainers 80% None 80% None 80% None Basic Restorative (Amalgam, Resin Fillings) 80% None 80% None 80% None Endodontic Therapy 80% None 80% None 80% None Root Canal 80% None 80% None 80% None Non-Surgical Periodontics 80% None 80% None 80% None Surgical Periodontics 80% None 80% None 80% None Simple Extractions 80% None 80% None 80% None Surgical Extractions 80% None 80% None 80% None Oral Surgery 80% None 80% None 80% None General Anesthesia/Sedation 80% None 80% None 80% None Crown Repair 80% None 80% None 80% None Adjustments and Repairs of Prosthetics 80% None 80% None 80% None Benefit Waiting Benefit Waiting Benefit Waiting Major Services Coinsurance Period Coinsurance Period Coinsurance Period Prosthetics Dentures and Bridges 0% None 50% None 50% None Inlays, Onlays and Crowns 0% None 50% None 50% None Orthodontia (Traditional- dependent children up to age 19) Not Covered N/A Not covered N/A 50% None 1 Does not apply to Diagnostic and Preventative Services See contract and schedule of benefits for coverage exclusions and limitations. Product Eligibility Small groups with a reported Medical Loss Ratio (MLR) employee count of 50 or less are eligible to purchase Minimum of 2 benefit eligible employees to be enrolled as minimum participation 2-9 Employer Paid Only- 100% participation Employer Paid- 100% participation, Contributory- greater 70% or 10 enrolled, Voluntary- greater 20% or 10 enrolled Network To take full advantage of the Blue Dental coverage, members should choose a dentist who participates in the Advantage Plus Network*. To find out if a dentist participates in the Advantage Plus Network, visit If members choose to visit an out-of-network dentist, they may be subject to higher fees and may be required to submit their claims. *Advantage Plus Network is administered by United Concordia Companies, Inc. United Concordia is an independent company

31 BENEFIT DESIGN Small Group Embedded Child Dental Benefit Benefits reflect effective dates beginning January 1, 2015 Benefits apply to under age 19 with embedded pediatric dental benefits in medical policy. DEDUCTIBLE AND COINSURANCE Network Advantage Plus Network* Deductible (per Member per calendar year) 1 $25 Annual Benefit Maximum Out of Pocket Annual Maximum In and out of Network COVERED SERVICES Unlimited Combined with Medical Annual Maximums In and out of Network No Waiting Period Routine Oral Exams and Cleanings 1 100% All Oral X-Rays 1 100% Fluoride Treatments, Sealants 1 100% Palliative Treatment (Emergency) 1 80% Space Maintainers 80% Basic Restorative (Amalgam, Resin Fillings) 80% Crown Repairs 80% Endodontic (Root Canals, etc.) 80% Oral Surgery, Surgical Extractions 80% Simple Extractions 80% Periodontics Surgical and Non-Surgical 80% Crowns, Prosthetics (Bridges, Dentures) 50% Implants Must meet Dental Necessity Requirements 50% Orthodontics (Medically Necessary) 50% 1 Does not apply to Diagnostic and Services *Advantage Plus Network is administered by United Concordia Companies, Inc. United Concordia is an independent company that administers dental benefits on behalf of Blue Cross and Blue Shield of Louisiana members This is only an outline. All benefits are subject to the terms and conditions of the Contract. In the case of a discrepancy, the Contract will prevail.

32 Customer Service We re easy to find and happy to help you. If you need to reach us: Phone BLUE (2583) We re available Monday through Friday, 8 a.m. 5 p.m. Online Find help online 24 hours a day. Mail 5525 Reitz Ave. Baton Rouge, Louisiana Local We have eight regional offices around the state. Find us at any of the following locations. We d love to see you. More info Contact your Blue Cross Regional office for more product information and rates. Regional Offices Alexandria Coliseum Blvd., Suite A Alexandria, LA Baton Rouge Reitz Ave. Baton Rouge, LA Houma St. Charles Street, Suite 135 Houma, LA Lafayette Johnston St., Suite 200 Lafayette, LA Lake Charles West Prien Lake Road Lake Charles, LA Monroe Mercedes Dr. Monroe, LA New Orleans North Causeway Blvd., Suite 600 Metairie, LA Shreveport Ashley Ridge Blvd. Shreveport, LA

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