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