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Federal Employee
Dental and Vision Options
2016 Guide for
Presbyterian Health Plan Members
What is the cost?
Monthly
Annual
Employee
$6.00
$63.00
Employee +
1 Dependent
$10.50
$118.00
Employee + Family
$15.50
$172.00
What are the advantages
of this plan?
• No deductibles
• No claim forms
• No pre-enrollment exams
• No prior authorization required
• Pre-existing conditions covered
• No limits on the amount
of benefits
• No waiting periods for
dental benefits
• Over 1,400 dental providers
throughout New Mexico.
Who are the providers?
For a Sandia Plan Provider Listing
please refer to our website:
www.benefitsource.org
Value Added Benefit
Federal employees enrolled in the
Presbyterian Health Plan are automatically
enrolled in our Value Added Benefit
Program at no additional cost. Visit our
website for more details on this program.
Who is eligible for this plan?
BenefitSource matches the eligibility requirements established for the Federal
Employee Health Benefit Program. Federal employees, their spouses and their
unmarried dependent children up to age 26 are eligible to participate. Dependent
children over the age of 26 may be eligible due to developmental or physical
disability; proof of such must be provided.
What do I do in an emergency?
In case of a dental emergency, contact your participating dentist directly. If this dentist
is unavailable for emergency treatment (palliative treatment to control pain, bleeding
or infection) within 24 hours of the onset of the dental emergency, members may
obtain emergency care from any licensed dentist to prevent further harm. Follow-up
treatment must be provided by a participating dentist. BenefitSource will provide
$20 reimbursement for emergency services upon written request with proper
documentation, within 30 days of service.
Option 1: Sandia Plan
The Sandia Plan is the most economic dental plan option. Members obtain dental services from our ever expanding
panel of participating dentists. Members enjoy guaranteed low, pre-set fees on almost all types of dental work.
Savings from 20%–60% are available for most basic and major dental services. Plan discounts are designed to
encourage proper dental care by promoting early detection and regular dental health maintenance.
When using Sandia Plan dentists,
compare your savings for these services:
With no
Coverage
(you pay)
Sandia
Plan
(you pay)
YOU SAVE
Exam (Initial)
$80
$43
$37
Bitewing 4 films (x-rays)
$53
$35
$18
Adult teeth cleaning
$100
$60
$40
Child teeth cleaning
$60
$42
$18
Silver filling 1 surface
$120
$76
$44
Resin white filling 1 surface
$145
$91
$54
Root canal molar
$940
$725
$215
Crown (cap)
$930
$765
$165
Extraction, Routine
$125
$73
$52
Denture upper/lower
$1,525
$1,012
$513
Braces (Child)
$6,000
$5,028
$972
What is the cost?
Monthly
Employee
$28.56
Employee + 1 Dependent
$55.20
Employee + Family
$92.80
What are the advantages
of this plan?
• Freedom to see any
licensed dentist
• Over 1,800 PPO dental providers
throughout New Mexico
• No In-Network deductibles
• 6 month waiting period
for Major services
• $1,000 annual maximum
per person
.
Who are the providers?
For the most current PPO provider
listing, please refer to our website:
www.benefitsource.org.
Be sure to ask about our
stand alone Orthodontic
Edge Plan.
Who is eligible for this plan?
BenefitSource matches the eligibility
requirements established for the Federal
Employee Health Benefit Program.
How do I obtain services?
Upon enrollment, you will receive a dental ID
Card. To receive care, simply call your dentist
for an appointment and present your card.
Plan benefits:
When using participating PPO dental providers, members pay the listed In-Network
PPO fee directly to the dental office at the time of service. If members obtain dental
services from non-participating dental providers (out of network), the plan will pay the
amount listed, but the dental office will balance bill members for any differences in fees.
Code
Description
In-Network PPO Fee
(Member Pays)
Out-of-Network
(Plan Pays)
D0120 Periodic oral evaluation
$0
$32
D0150 Comprehensive oral eval
$0
$49
D0274 Bitewings four films
$0
$39
D1110
Prophylaxis adult (cleaning)
$17
$52
D1120 Prophylaxis child (cleaning)
$8
$38
D2140 Silver amalgam filling–1 surface
$36
$53
D2160 Silver amalgam filling–3 surface
$54
$80
D2330 White resin filling–1 surf. anterior
$39
$59
D2332 White resin filling–3 surf. anterior
$60
$89
D2510 Inlay metallic 1 surface
$304
$130
D2750 Crown porcelain high noble metal
$561
$240
D2751 Crown porcelain base metal
$466
$200
D2950 Core build-up including any pins
$111
$47
D3110 Pulp cap direct (excl. final rest.)
$34
$15
D3310 Root canal anterior (excl. final rest.)
$302
$130
D3330 Root canal-molar (excl. final rest.)
$485
$208
D4341 Perio scaling & root planing (4+)
$116
$50
D4342 Perio scaling & root planing (1-3)
$70
$30
D4910 Periodontal maintenance
$67
$29
D5110
Complete denture upper
$802
$344
D5120 Complete denture lower
$802
$344
D5650 Add tooth to existing partial
$75
$32
D7210 Surgical removal of erupted tooth
$108
$46
D7220 Remov impacted tooth–soft tis.
$119
$51
D7240 Remov impacted tooth comp bony
$190
$82
This is only a summary of the benefit fee schedule. Visit our website:
www.benefitsource.org for a complete fee schedule.
Option 2: Elite Plan
The Elite Plan is a comprehensive indemnity dental plan. When obtaining service from our list of PPO dental offices,
members have
no deductibles and enjoy significant out of pocket savings on most dental fees. If members choose
to use non-PPO dental offices, there is still excellent insurance coverage with no deductibles for diagnostic and
preventive services and a low $50 annual deductible for all other services.
This plan is underwritten by Companion Life and administered by Total Dental Administrators.
Who is eligible for this plan?
BenefitSource matches the eligibility requirements established for the Federal
Employee Health Benefit Program. Federal employees, their spouses and their
unmarried dependent children up to age 26 are eligible to participate. Dependent
children over the age of 26 may be eligible due to developmental or physical
disability; proof of such must be provided.
SERVICE TYPE
DESCRIPTION
Class I: Diagnostic/Preventive
Covered at 100% In-Network
Covered at 80% Out-of-Network
No waiting period.
Oral exams, Cleanings, Fluoride treatment, Space
maintainers, Sealants Palliative emergency
treatment, dental x-rays
Class II: Basic Services
Covered at 75% In-Network
Covered at 60% Out-of-Network
No waiting period.
Silver fillings, Restorations (fillings), Anterior
composite white fillings
Class III: Major Services
Covered at 45% In-Network
Covered at 40% Out-of-Network
6 month waiting period from date of enrollment.
Crowns, Bridges, Dentures, Inlays, Other prosthetic
services, Oral surgery, Extractions, Anesthesia (in
conjunction with oral surgery), Endodontic services,
Periodontal services
Class IV: Orthodontic
Covered at 50% In-Network
Covered at 50% Out-of-Network
24 month waiting period from date of enrollment.
Up to age 19 only, lifetime maximum of $1,000
How do I receive care?
Upon enrollment, you will receive a dental ID card. This will be a separate card from
your health plan member ID Card. To receive care, simply call your dentist for an
appointment and present your dental plan ID card.
For your protection, a predetermination of benefits is recommended for treatment
plans that exceed $300. This benefit helps members better understand their
coverage. It explains which recommended procedures will be covered and
of what amount. Members should submit the treatment plan for review and a
predetermination of benefits before receiving the service.
What is the cost?
Monthly
Employee
$28.51
Employee + 1 Dependent
$54.95
Employee + Family
$96.56
What are the advantages
of this plan?
• Freedom to see any
licensed dentist
• Over 1,800 dental providers
throughout New Mexico
• $1,200 annual maximum
per person
• Local customer service
Who are the providers?
For the most current PPO provider
listing, please refer to our website:
www.benefitsource.org.
Option 3: PPO Dental Plan
This plan is a traditional dental indemnity plan with the freedom of choice to see any licensed dentist. When using
PPO Dental Plan providers, members have lower out of pocket costs and no balance billing for dental services. There
is no waiting period for preventive and basic dental services and a 6 month waiting period (from date of enrollment)
for major services. There is no deductible for Class I services and a $50 annual deductible per person, with a
maximum of $150 per family, for Class II and Class III services. Payment is based upon maximum allowable charge
of In-Network Providers.
Federal Employee Vision Benefit
Federal employees enrolled on the PHP High Option Medical Plan will automatically have a new benefit for vision care.
This benefit includes an eye exam for a $0 copay in-network ($35 allowance for out-of-network).* These members may
elect the buy-up plan that provides coverage for expenses for vision correction materials, such as contact lenses and
eye glasses.* Federal Employees that enroll in other PHP medical plans have the option to purchase the Gold 150 Vision
Plan which is a comprehensive vision plan that includes coverage for a vision exam and for corrective eyewear.**
*
This plan is provided by EyeMed.
** This plan is provided by Superior Vision.
Vision Options
E Y E M E D IM BE DDE D PL A N :
This plan is automatically included with
the PHP High Option Medical Plan for no
additional cost.
E Y E M E D M ATE R I A L S ON LY
BU Y- U P OP TION :*
Monthly
Employee
$4.33
Employee + 1 Dependent
$7.33
Employee + Family
$10.30
S U PE R IOR V I S ION
GOLD 150 PL A N :* *
Monthly
Employee
$7.30
Employee + 1 Dependent
$12.45
Employee + Family
$18.30
The charts below are summaries only. For a complete disclosure of vision
benefits for all three options visit our website www.benefitsource.org.
E Y E M E D M ATE R I A L S ON LY BU Y- U P OP TION :*
Vision Care Services
In-Network
Out-of-Network
Reimbursement
Frame
Any available frame at provider location
$0 Copay; $150 Allowance,
20% off balance over $150
$75
Standard Plastic Lenses:
Single Vision
Bifocal
Trifocal
Standard Progressive
$20 Copay
$20 Copay
$20 Copay
$85 Copay
$25
$40
$55
$40
Lens Options:
UV Treatment
Tint (Solid and Gradient)
$15
$15
N/A
N/A
Contact Lenses: (Contact lens allowance
includes materials only)
Conventional
Disposable
Medically Necessary
$0 Copay; $150 allowance,
15% off balance over $150
$0 Copay; $150 allowance,
plus balance over $150
$0 Copay, Paid-in-Full
$120
$120
$210
S U PE R IOR V I S ION GOLD 150 PL A N :* *
Service / Material
Participating Provider
Non-Participating
Provider
Vision Examination
(1 every 12 mnths)
Paid in full
Up to $35.00 retail value
Frame (1 every 24 mnths)
Up to $150.00 retail value Up to $70.00 retail value
Lenses (1 every 12 mnths)
Single Vision
Standard Bifocal
Standard Trifocal
Paid in full
Paid in full
Paid in full
Up to $25.00 retail value
Up to $40.00 retail value
Up to $45.00 retail value
Contact Lenses (1 every 12 mnths)
Elective
Medically Required
Up to $175.00
Paid in full
Up to $80.00 retail value
Up to $150.00 retail value
Who are the providers?
Please visit our website,
www.benefitsource.org, for a
Participating Provider in your area.
How do I join Option 1?
1. Simply review the entire brochure. Complete and sign the attached Enrollment/Authorization Form. 2. If your Enrollment/Authorization Form and payment
are received at BenefitSource by the 23rd of the month, your coverage will be effective the 1st day of the following month. Forms received after the 23rd of the month will be effective on the 1st day of the 2nd following month.
3. Mail your completed Enrollment/Authorization Form with the correct payment to BenefitSource. 4. You must maintain coverage for a full twelve (12)
month period. Please note, as with all coverages, membership fees are non-refundable. By electing coverage through BenefitSource you are agreeing to maintain coverage for a full 12 months. If your health plan coverage should terminate mid-year, your dental policy still remains under the 12 month contract and cannot be terminated until your contract year has been met.
Payment options – Option 1
A N N UA L PAY M E NT
• You may pay the entire annual membership fee by check, money order, MasterCard, Visa or Discover Cards.
MONTH LY BA N K DR A F T
• If you wish to pay the membership fee on a monthly basis, payment must be made by Monthly Electronic Fund Transfer. To initiate the Monthly Bank Draft option, complete the attached Enrollment/Authorization Form and provide a check made out to BenefitSource for the 1st months payment. In addition, please include a voided check from the bank you wish to have the membership fees drafted. Each month your premium will be automatically drafted from your bank account typically between the 23rd and 28th of the month for the next month’s coverage. No monthly checks, no postage, no statements. The Monthly Bank Draft option is reliable and automatic!
• BenefitSource will make reasonable efforts to collect unpaid premiums by sending written notice after the date that delinquent charges are due. Failure to pay any delinquent premiums will result in termination of coverage. • The 12 month contract period is continuous and
therefore does not allow for any lapse in coverage. Any additional charges to your account due to insufficient funds or overdraft fees will be the members responsibility and will not be refunded by BenefitSource.
How do I join Options 2, 3 and Vision?
1. Review entire brochure, complete and sign the attached Enrollment/Authorization Form. Return your Enrollment/Authorization Form with payment for the appropriate amount to BenefitSource.
2. Enrollment Forms must be received by December 31st to begin coverage January 1st. The next opportunity to enroll in either the Option 2 or 3 will not be until the next open enrollment season. Only new Presbyterian Federal Health Plan members may enroll after open enrollment has ended and must do so within the first sixty days of enrollment in the health plan.
3. We require that you maintain your vision coverage for a full twelve (12) month period. Please note, as with all coverages, membership fees are non-refundable. Each renewal year indicates a new 12 month period.
Payment options – Options 2, 3 and Vision
MONTH LY BA N K DR A F T (For Options 2, 3 and Vision)
• Payment must be made by Monthly Electronic Fund Transfer. To initiate the Monthly Bank Draft option, complete the attached Enrollment/Authorization Form and provide a check made out to BenefitSource for the 1st month’s payment. In addition, please include a voided check from the bank you wish to have the membership fees drafted. Each month your premium will be automatically drafted from your bank account between the 23rd and 28th of the month for the next month’s coverage. No monthly checks, no postage, no statements. The Monthly Bank Draft option is reliable and automatic!
• BenefitSource will make reasonable efforts to collect unpaid premiums by sending written notice after the date that delinquent charges are due. Failure to pay any delinquent premiums will result in termination of coverage. The 12 month benefit period is continuous and therefore does not allow for any lapse in coverage. • Any additional charges to your account due to insufficient funds or overdraft fees will
be the members responsibility and will not be refunded by BenefitSource.
TE R M I N ATION OF COV E R AG E (OP TION 2 A N D 3)
• If you would like to cancel your dental coverage, you must submit a written
cancellation request. If you cancel your membership as a Presbyterian Federal Health Plan member and you want to terminate your dental coverage, you must also notify BenefitSource in writing. All written cancellation requests received by the 23rd of the month will become effective the first day of the following month. Any cancellation requests received after the 23rd will take effect on the 1st of the 2nd following month. Any Bank Draft member who elects to terminate their dental coverage will not be refunded any drafted premium.
• Any option 2 or 3 Plan members who terminate their dental plan coverage mid-year will be permanently restricted from re-enrolling in these plans.
