2016 Active Member Benefit Booklet
DADE COUNTY
FIRE FIGHTERS
INSURANCE TRUST
2 0 16
Open Enrollment
“DMO Dental & VisionCare provider”
M e d i c a l + P P O D e nta l Pro vi de r
“Our Health Insurance Plan, We Can Control the Cost”
USE IT-DON’T ABUSE IT
Important Notices
Your Health Plan excludes treatment for any injury or sickness that is eligible for benefits under
Worker’s Compensation. When seeking treatment for such injuries do not provide your United
HealthCare insurance information to the facility. If it is determined that monies for such
benefits were paid by the Plan, the Trust reserves the right to initiate recovery efforts against
you for these fraudulent charges. You may be held liable for the cost of all treatment given. If
your injury is denied by Workers Compensation, please contact the Local 1403 Benefits Officer.
If you have a change in status (divorce, marriage, birth of a child, adoption, court order,
ineligibility of a dependent child) it is your responsibility to notify and provide proper
documentation to the Trust office within 30 days of the event to add or terminate a
dependent. Coverage of an ex-spouse as a dependent under your Plan is considered fraud
and you will be liable for all claims paid on their behalf.
Under the new HealthCare Reform Act your children may continue as a dependent up to the
age of 26. Coverage will be terminated on last day of the month they turn 26. In some cases,
coverage may be extended to age 30 for additional premium. Contact the Trust office for
further details.
Please be advised that the Plan’s Summary of Benefits & Coverage (SBC) as well as the
Summary Plan Description (SPD) are available to you on-line at www.local1403.org or a copy
can be provided upon request.
Grandfathered Plan Status - The Dade County Fire Fighters Insurance Trust Fund believes this
plan is a "grandfathered health plan" under the Patient Protection and Affordable Care Act (the
Affordable Care Act). As permitted by the Affordable Care Act, a grandfathered health plan can
preserve certain basic health coverage that was already in effect when that law was enacted.
Being a grandfathered health plan means that your plan may not include certain consumer
protections of the Affordable Care Act that apply to other plans, for example, the requirement for
the provision of preventive health services without any cost sharing. However, grandfathered
health plans must comply with certain other consumer protections in the Affordable Care Act,
for example, the elimination of lifetime limits on benefits. Questions regarding which
protections apply and which protections do not apply to a grandfathered health plan and what
might cause a plan to change from grandfathered health plan status can be directed to the plan
administrator at Dade County Fire Fighters Insurance Trust Fund, 8000 NW 21 Street, Suite 222,
Miami, Fl 33122 or by calling 786-437-2560.
Benefit Summary
Dade County Fire Fighters
Insurance Trust
2016 Choice Plus (High Option)
We know that when people are informed about their health and health care, they can make better health care
decisions. We want to help you understand more about your health care and the resources that are available
.
•
myuhc.com® – Take advantage of easy, time-saving online tools. You can check your eligibility, benefits,
claims, claim payments, search for a doctor and hospital and much, much more.
• Customer Care telephone support – Need more help? Call customer care using the toll-free number on the
back of your ID card. Get answers to your benefit questions or receive help looking for doctor or hospital.
2016 Bi-Weekly Premium w/choice of dental (Humana DMO or UHC PPO)
Medical
Dental
EMPLOYEE
$34.95
$0.00
EMP+SP
$284.95
$2.00
EMP+CHILD/REN
$264.95
$1.00
FAMILY
$329.95
$3.00
Benefit Summary is intended only to highlight your Benefits and should not be relied upon to fully determine coverage. This benefit
plan may not cover all of your health care expenses. More complete description of Benefits and the terms under which they are
provided are contained in the Summary Plan Description (SPD).
If this Benefit Summary conflicts in any way with the Summary Plan Description issued to your employer, the SPD shall prevail.
Where Benefits are subject to day, visit and/or dollar limits, such limits apply to the combined use of Benefits whether in-Network or
out-of-Network, except where mandated by state law.
Deductible must be met for all services where co-insurance applies.
Prior Notification is required for certain services.
PLAN HIGHLIGHTS
L Types of Coverage
Individual Deductible
Family Deductible
Network Benefits
Non-Network Benefits DP
$300.00 per year
$600.00 per year
$500.00 per year
$1,000.00 per year
>Member Co-payments do not accumulate towards the Annual Deductible
>All individual Deductible amounts will count towards the family Deductible, but an individual will not have to pay more than the
individual Deductible amount.
Individual Maximum
$1,000.00 per year
Family Maximum
$2,000.00 per year
>The Out-of-Pocket Maximum does not include the Annual Deductible.
Doctor’s Office Visits
Physician Office Visit
$2,000.00 per year
$3,000.00 per year
$25.00 per visit
20% of Eligible Expenses
Specialist Physician Office Visit
$35.00 per visit
20% of Eligible Expenses
Injections in Physician’s Office
$25.00 per visit
20% per injection
MOST COMMONLY USED BENEFITS
L Types of Coverage
2016 Choice Plus (High Option)
Network Benefits
Non-Network Benefits
10% of Eligible Expenses
20% of Eligible Expenses
Maternity Services
Hospital/Delivery
>No Copayment applies to Physician office visits for prenatal care after the first visit.
>Notification is required if Inpatient Stay exceeds 48 hours following a normal vaginal delivery or 96 hours following a cesarean
section delivery.
Spinal Treatment
Chiropractic
$35.00 co-pay per visit
20% of Eligible Expenses
> Benefits include diagnosis and related services and are limited to one visit and treatment per day. Network and Non-Network
Benefits are limited to 30 visits per calendar year.
Accupuncture/Massage Therapy
Out of Network Only
20% of Eligible Expenses
30 visits per calendar year
$0.00 per visit
20% of Eligible Expenses
Laboratory Services - Outpatient
LabCorp is Exclusive in-network lab
>Lab services billed in-network through hospital or Outpatient Facility will be subject to deductible & 10% co-insurance
Outpatient Surgery, Diagnostic & Therapeutic Services
Outpatient Surgery
(Colonoscopy – not subject to Deductible)
10% of Eligible Expenses
20% of Eligible Expenses
Outpatient Diagnostic - Radiology/Xray
(Mammograms – not subject to Deductible)
10% of Eligible Expenses
20% of Eligible Expenses
Outpatient Diagnostic/Therapeutic Services
(CT & PET Scans, MRI & Nuclear Medicine)
$50.00 co-payment
20% of Eligible Expenses
$35.00 per visit
20% of Eligible Expenses
$225.00 per visit
$225.00 per visit
Urgent Care Services
Emergency Room
Hospital – Inpatient Stay
10% of Eligible Expenses
>Prior Notification is required. Deductibles and Co-Insurance will apply to services rendered.
20% of Eligible Expenses
Professional Fees for Surgical & Medical Services
10% of Eligible Expenses
20% of Eligible Expenses
10% of Eligible Expenses
20% of Eligible Expenses
10% of Eligible Expenses
20% of Eligible Expenses
Ground Transportation
10% of Eligible Expenses
Same as Network Benefit
Air Transportation
10% of Eligible Expenses
Same as Network Benefit
Transplant Services
Reconstructive Procedures
Ambulance Services – Emergency Only
MOST COMMONLY USED BENEFITS
L Types of Coverage
2016 Choice Plus (High Option)
Network Benefits
Non-Network Benefits
Dental Services – Accident Only
10% of Eligible Expenses
>Prior notification is required before follow-up treatment begins.
Same as Network Benefit
Home Health Care
10% of Eligible Expenses
20% of Eligible Expenses
> Network and Non-Network Benefits are limited to 60 visits for skilled care services per calendar year.
Hospice Care
10% of Eligible Expenses
20% of Eligible Expenses
> Network & Non-Network Benefits are limited to 360 days during the entire period of time a Covered Person is covered under the
Plan.
Rehabilitation Services – Outpatient Therapy
$35.00 co-pay per visit
20% of Eligible Expenses
>Network and Non-Network Benefits are limited as follows: 30 visits of physical therapy; 30 visits of occupational therapy; 30 visits
of speech therapy; 30 visits of pulmonary rehabilitation; and 36 visits of cardiac rehabilitation per calendar year.
> Pediatric/Child- Up to 60 visits based on approved treatment plan.
Skilled Nursing Facility/Inpatient Rehabilitation Facility Services
10% of Eligible Expenses
> Network and Non-Network Benefits are limited to 120 days per calendar year.
20% of Eligible Expenses
Durable Medical Equipment
10% of Eligible Expenses
20% of Eligible Expenses
> Network and Non-Network Benefits for Durable Medical Equipment are limited to $10,000 per calendar year.
>*Prior notification is required when the cost is more than $1,000
Orthotics
$100.00 co-pay
20% of Eligible Expenses
> Limited to one (1) pair every calendar year
Prosthetic Devices
10% of Eligible Expenses
20% of Eligible Expenses
>Network and Non-Network Benefits for prosthetic devices are limited to $10,000 per calendar year
Eye Examinations
$35.00 co-pay per visit
>Refractive eye examinations are limited to one every calendar year.
Laser Corrective Surgery (Employee Only)
20% of Eligible Expenses
Up to $800.00 Per Eye
Behavioral Health Services
Mental Health & Substance Abuse
Services - Outpatient
$35.00 co-pay per visit (individual)
$25.00 co-pay per visit (group)
20% of Eligible Expenses
Mental Health & Substance Abuse –
Inpatient & Intermediate Treatment
10% of Eligible Expenses
20% of Eligible Expenses
Residential Treatment
10% of Eligible Expenses
20% of Eligible Expenses
> Must receive prior authorization through United Behavioral Health/Mental Health Designee for inpatient & Residential.
PLAN EXCLUSIONS/NOT COVERED
Except as may be specifically provided in Section 1 of the Summary Plan Description (SPD) or
through a Rider to the Plan, the following are not covered:
A. Alternative Treatments
Hypnotism; rolfing; aromatherapy; and other forms of alternative treatment.
B. Comfort or Convenience
Personal comfort or convenience items or services such as television; telephone; barber or
beauty service; guest service; supplies, equipment and similar incidental services and supplies
for personal comfort including air conditioners, air purifiers and filters, batteries and battery
chargers, dehumidifiers and humidifiers; devices or computers to assist in communication and
speech.
C. Dental
Except as specifically described as covered in Section 1 of the SPD for services to repair a
sound natural tooth that has documented accident-related damage, dental services are
excluded. There is no coverage for services provided for the prevention, diagnosis, and
treatment of the teeth, jawbones or gums (including extraction, restoration, and replacement
of teeth, medical or surgical treatments of dental conditions, and services to improve dental
clinical outcomes). Dental implants and dental braces are excluded. Dental x-rays, supplies and
appliances and all associated expenses arising out of such dental services (including
hospitalizations and anesthesia) are excluded, except as might otherwise be required for
transplant preparation, initiation of immunosuppressives, or the direct treatment of acute
traumatic Injury, cancer, or cleft palate. Treatment for congenitally missing, malpositioned, or
super numerary teeth is excluded, even if part of a Congenital Anomaly.
D. Drugs
Prescription drug products for outpatient use that are filled by a prescription order or refill.
Self-injectable medications. Non-injectable medications given in a Physician’s office except as
required in an Emergency. Over-the-counter drugs and treatments.
E. Experimental, Investigational or Unproven Services
Experimental, Investigational or Unproven Services are excluded. The fact that an
Experimental, Investigational or Unproven Service, treatment, device or pharmacological
regimen is the only available treatment for a particular condition will not result in Benefits if
the procedure is considered to be Experimental, Investigational or Unproven in the treatment
of that particular condition.
F. Foot Care
Routine foot care (including the cutting or removal of corns and calluses); nail trimming,
cutting, or debriding; hygienic and preventive maintenance foot care; treatment of flat feet or
subluxation of the foot.
G. Medical Supplies and Appliances
Devices used specifically as safety items or to affect performance primarily in sports-related
activities. Prescribed or non-prescribed medical supplies and disposable supplies including but
not limited to elastic stockings, ace bandages, gauze and dressings, syringes and diabetic test
strips. Tubings and masks are not covered except when used with Durable Medical Equipment
as described in Section 1 of the SPD.
H. Mental Health/Substance Abuse
Services performed in connection with conditions not classified in the current edition of the
Diagnostic and Statistical Manual of the American Psychiatric Association. Services that extend
beyond the period necessary for short-term evaluation, diagnosis, treatment, or crisis
intervention. Mental Health treatment of insomnia and other sleep disorders, neurological
disorders, and other disorders with a known physical basis.
Treatment of conduct and impulse control disorders, personality disorders, paraphilias and
other Mental Illnesses that will not substantially improve beyond the current level of
functioning, or that are not subject to favorable modification or management according to
prevailing national standards of clinical practice, as reasonably determined by the Mental
Health/Substance Abuse Designee.
Services utilizing methadone treatment as maintenance, L.A.A.M. (1-Alpha-Acetyl-Methadol),
Cyclazocine, or their equivalents. Treatment provided in connection with or to comply with
involuntary commitments, police detentions and other similar arrangements, unless
authorized by the Mental Health/Substance Abuse Designee. Services or supplies that in the
reasonable judgment of the Mental Health/Substance Abuse Designee are not, for example,
consistent with certain national standards or professional research further described in
Section 2 of the SPD.
I. Nutrition
Megavitamin and nutrition based therapy; nutritional counseling for either individuals or
groups. Enteral feedings and other nutritional and electrolyte supplements, including infant
formula and donor breast milk.
J. Physical Appearance
Cosmetic Procedures including, but not limited to, pharmacological regimens; nutritional
procedures or treatments; salabrasion, chemosurgery and other such skin abrasion procedures
associated with the removal of scars, tattoos, and/or which are performed as a treatment for
acne. Replacement of an existing breast implant is excluded if the earlier breast implant was a
Cosmetic Procedure. (Replacement of an existing breast implant is considered reconstructive if
the initial breast implant followed mastectomy.)
2016 Choice Plus (HIGH OPTION)
Physical conditioning programs such as athletic training, bodybuilding, exercise, fitness,
flexibility, and diversion or general motivation. Weight loss programs for medical and nonmedical reasons. Wigs, regardless of the reason for the hair loss.
K. Providers
Services performed by a provider with your same legal residence or who is a family member by
birth or marriage, including spouse, brother, sister, parent or child. This includes any service
the provider may perform on himself or herself. Services provided at a free-standing or
Hospital-based diagnostic facility without an order written by a Physician or other provider as
further described in Section 2 of the SPD (this exclusion does not apply to mammography
testing).
L. Reproduction
Health services and associated expenses for infertility treatments.
Surrogate parenting. The reversal of voluntary sterilization.
M. Services Provided under Another Plan
Health services for which other coverage is required by federal, state or local law to be
purchased or provided through other arrangements, including but not limited to coverage
required by workers’ compensation, no-fault automobile insurance, or similar legislation. If
coverage under workers’ compensation or similar legislation is optional because you could
elect it, or could have it elected for you, Benefits will not be paid for any Injury, Mental Illness
or Sickness that would have been covered under workers’ compensation or similar legislation
had that coverage been elected.
Health services for treatment of military service-related disabilities, when you are legally
entitled to other coverage and facilities are reasonably available to you. Health services while
on active military duty.
N. Transplants
Section 1 of the SPD. Any solid organ transplant that is performed as a treatment for cancer.
Health services connected with the removal of an organ or tissue from you for purposes of a
transplant to another person. Health services for transplants involving mechanical or animal
organs.
Any multiple organ transplant not listed as a Covered Health Service in Section 1 of the SPD.
O. Travel
Health services provided in a foreign country, unless required as Emergency Health Services.
Travel or transportation expenses, even though prescribed by a Physician. Some travel
expenses related to covered transplantation services may be reimbursed at our discretion.
P. Vision and Hearing
Purchase cost of eye glasses, contact lenses, or hearing aids. Fitting charge for hearing aids,
eye glasses or contact lenses. Eye exercise therapy. Surgery that is intended to allow you to
see better without glasses or other vision correction including radial keratotomy, laser, and
other refractive eye surgery.
Q. Other Exclusions
Health services and supplies that do not meet the definition of a Covered Health Service - see
definition in Section 10 of the SPD.
Physical, psychiatric or psychological examinations, testing, vaccinations, immunizations or
treatments otherwise covered under the Plan, when such services are: (1) required solely for
purposes of career, education, sports or camp, travel, employment, insurance, marriage or
adoption; (2) relating to judicial or administrative proceedings or orders; (3) conducted for
purposes of medical research; or (4) to obtain or maintain a license of any type.
Health services received as a result of war or any act of war, whether declared or undeclared
or caused during service in the armed forces of any country.
Health services received after the date your coverage under the Plan ends, including health
services for medical conditions arising prior to the date your coverage under the Plan ends.
Health services for which you have no legal responsibility to pay, or for which a charge would
not ordinarily be made in the absence of coverage under the Plan.
In the event that a Non-Network provider waives Copayments and/or the Annual Deductible
for a particular health service, no Benefits are provided for the health service for which
Copayments and/or the Annual Deductible are waived.
Charges in excess of Eligible Expenses or in excess of any specified limitation.
Services for the evaluation and treatment of temporomandibular joint syndrome (TMJ),
whether the services are considered to be medical or dental in nature.
Upper and lower jaw bone surgery except as required for direct treatment of acute traumatic
Injury or cancer. Orthognathic surgery, jaw alignment, and treatment for the
temporomandibular joint, except as a treatment of obstructive sleep apnea.
Growth hormone therapy; sex transformation operations; treatment of benign gynecomastia
(abnormal breast enlargement in males); medical and surgical treatment of excessive sweating
(hyperhidrosis); medical and surgical treatment for snoring, except when provided as part of
treatment for documented obstructive sleep apnea. Oral appliances for snoring.
Custodial care; domiciliary care; private duty nursing; respite care; rest cures.
Psychosurgery. Speech therapy except as required for treatment of a speech impediment or
speech dysfunction that results from Injury, stroke or Congenital Anomaly.
This summary of Benefits is intended only to highlight your Benefits and should not be relied upon to fully determine coverage. This plan may not cover all your health care
expenses. Please refer to the Summary Plan Description for a complete listing of services, limitations, exclusions and a description of all the terms and conditions of coverage. If this
description conflicts in any way with the Summary Plan Description, the Summary Plan Description prevails. Terms that are capitalized in the Benefit Summary are defined in the
Summary Plan Description.
Benefit Summary
Dade County Fire Fighters
Insurance Trust
2016 Choice Plus (Low Option)
We know that when people are informed about their health and health care, they can make better health care
decisions. We want to help you understand more about your health care and the resources that are available
.
•
myuhc.com® – Take advantage of easy, time-saving online tools. You can check your eligibility, benefits,
claims, claim payments, search for a doctor and hospital and much, much more.
• Customer Care telephone support – Need more help? Call customer care using the toll-free number on the
back of your ID card. Get answers to your benefit questions or receive help looking for doctor or hospital.
2016 Bi-Weekly Premium w/choice of dental (Humana DMO or UHC PPO)
Medical
Dental
Employee
$34.95
$0.00
EMP+SP
$209.95
$2.00
EMP+CHILD/REN
$194.95
$1.00
Family
$259.95
$3.00
Benefit Summary is intended only to highlight your Benefits and should not be relied upon to fully determine coverage.
This benefit plan may not cover all of your health care expenses. More complete description of Benefits and the terms
under which they are provided are contained in the Summary Plan Description (SPD).
If this Benefit Summary conflicts in any way with the Summary Plan Description issued to your employer, the SPD shall
prevail.
Network health care services under this benefit plan are covered only when provided, arranged, or authorized by a
Network Physician.
Prior Notification is required for certain services.
Your Choice Plus (low option) Plan offers limited out of network coverage. Other
than Emergencies, Out of Network Benefits may result in significant deductible and
out of pocket expense. Based on a lower bi-weekly premium and the high
deductible this Plan is not intended to be utilized for out of network services.
PLAN HIGHLIGHTS
L Types of Coverage
Network Benefits
DP
$10,000 deductible applies to out of network benefits along with a 50% co-insurance
>Member Co-payments do not accumulate towards the Annual Deductible
Individual Maximum
$1,500.00 per year
Family Maximum
$3,000.00 per year
> Only Hospital Inpatient Co-Pays apply toward Out-of -Pocket maximum.
MOST COMMONLY USED NETWORK BENEFITS
L Types of Coverage
2016 Choice Plus (Low Option)
Network Benefits
Doctor’s Office Visits
Physician Office Visit
$25.00 per visit
Specialist Physician Office Visit
$35.00 per visit
Injections in Physician’s Office
$25.00 per visit
Maternity Services
Hospital/Delivery
$150.00 co-pay per day
>No Copayment applies to Physician office visits for prenatal care after the first visit.
>Notification is required if Inpatient Stay exceeds 48 hours following a normal vaginal delivery or 96 hours following a cesarean
section delivery.
>Maximum $600.00 per admission
Spinal Treatment
Chiropractic
$35.00 co-pay per visit
> Benefits include diagnosis and related services and are limited to one visit and treatment per day.
> Benefits are limited to 30 visits per calendar year.
Laboratory Services - Outpatient
LabCorp is Exclusive in-network lab
$0.00 per visit
Outpatient Surgery, Diagnostic & Therapeutic Services
Outpatient Surgery
$125.00 co-pay
Outpatient Diagnostic - Radiology/Xray
(including Mammograms, colonoscopy & endoscopy )
$0.00 co-pay
Outpatient Diagnostic/Therapeutic Services
(CT & PET Scans, MRI & Nuclear Medicine)
$50.00 co-pay
Urgent Care Services
$35.00 co-pay per visit
Emergency Room
$225.00 co-pay per visit
Hospital – Inpatient Stay
$150.00 co-pay per day
>Prior Notification is required.
>Maximum $600.00 per admission
Professional Fees for Surgical & Medical Services
Included in Hospital Co-pay
Transplant Services
$0.00 co-pay
Ambulance Services – Emergency Only
Ground Transportation
$0.00 co-pay
Air Transportation
$0.00 co-pay
MOST COMMONLY USED NETWORK BENEFITS
L Types of Coverage
2016 Choice Plus (Low Option)
Network Benefits
Dental Services – Accident Only
$0.00 co-pay
>Prior notification is required before follow-up treatment begins.
Home Health Care
$0.00 co-pay
> Benefits are Limited to 60 visits for skilled care services per calendar year.
Hospice Care
$0.00 co-pay
> Benefits are limited to 360 days during the entire period of time a Covered Person is covered under the Plan.
Rehabilitation Services – Outpatient Therapy
$35.00 co-pay per visit
>Benefits are limited as follows: 30 visits of physical therapy; 30 visits of occupational therapy; 30 visits of speech therapy; 30 visits
of pulmonary rehabilitation; and 36 visits of cardiac rehabilitation per calendar year.
> Pediatric/Child- Up to 60 visits based on approved treatment plan.
Skilled Nursing Facility/Inpatient Rehabilitation Facility Services
$0.00 co-pay
> Benefits are limited to 120 days per calendar year.
Durable Medical Equipment
$0.00 co-pay
> Benefits for Durable Medical Equipment are limited to $10,000 per calendar year.
>*Prior notification is required when the cost is more than $1,000
Orthotics
$100.00 co-pay
> Limited to one (1) pair every calendar year
Prosthetic Devices
$0.00 co-pay
>Benefits for prosthetic devices are limited to $10,000 per calendar year
Eye Examinations
$35.00 co-pay per visit
>Refractive eye examinations are limited to one every calendar year.
Behavioral Health Services
Mental Health & Substance Abuse
Services - Outpatient
$35.00 co-pay per visit (individual)
$25.00 co-pay per visit (group)
Mental Health & Substance Abuse –
Inpatient & Intermediate Treatment
$150.00 co-pay per day
Residential Treatment
$150.00 co-pay per day
> Must receive prior authorization through United Behavioral Health/Mental Health Designee for inpatient & Residential.
>Maximum $600.00 per admission
PLAN EXCLUSIONS/NOT COVERED
Except as may be specifically provided in Section 1 of the Summary Plan Description (SPD) or
through a Rider to the Plan, the following are not covered:
A. Alternative Treatments
Acupressure; hypnotism; rolfing; massage therapy; aromatherapy; acupuncture; and other
forms of alternative treatment.
B. Comfort or Convenience
Personal comfort or convenience items or services such as television; telephone; barber or
beauty service; guest service; supplies, equipment and similar incidental services and supplies
for personal comfort including air conditioners, air purifiers and filters, batteries and battery
chargers, dehumidifiers and humidifiers; devices or computers to assist in communication and
speech.
C. Dental
Except as specifically described as covered in Section 1 of the SPD for services to repair a
sound natural tooth that has documented accident-related damage, dental services are
excluded. There is no coverage for services provided for the prevention, diagnosis, and
treatment of the teeth, jawbones or gums (including extraction, restoration, and replacement
of teeth, medical or surgical treatments of dental conditions, and services to improve dental
clinical outcomes). Dental implants and dental braces are excluded. Dental x-rays, supplies
and appliances and all associated expenses arising out of such dental services (including
hospitalizations and anesthesia) are excluded, except as might otherwise be required for
transplant preparation, initiation of immunosuppressives, or the direct treatment of acute
traumatic Injury, cancer, or cleft palate. Treatment for congenitally missing, malpositioned, or
super numerary teeth is excluded, even if part of a Congenital Anomaly.
D. Drugs
Prescription drug products for outpatient use that are filled by a prescription order or refill.
Self-injectable medications. Non-injectable medications given in a Physician’s office except as
required in an Emergency. Over-the-counter drugs and treatments.
E. Experimental, Investigational or Unproven Services
Experimental, Investigational or Unproven Services are excluded. The fact that an
Experimental, Investigational or Unproven Service, treatment, device or pharmacological
regimen is the only available treatment for a particular condition will not result in Benefits if
the procedure is considered to be Experimental, Investigational or Unproven in the treatment
of that particular condition.
F. Foot Care
Routine foot care (including the cutting or removal of corns and calluses); nail trimming,
cutting, or debriding; hygienic and preventive maintenance foot care; treatment of flat feet or
subluxation of the foot.
G. Medical Supplies and Appliances
Devices used specifically as safety items or to affect performance primarily in sports-related
activities. Prescribed or non-prescribed medical supplies and disposable supplies including but
not limited to elastic stockings, ace bandages, gauze and dressings, syringes and diabetic test
strips. Tubings and masks are not covered except when used with Durable Medical Equipment
as described in Section 1 of the SPD.
H. Mental Health/Substance Abuse
Services performed in connection with conditions not classified in the current edition of the
Diagnostic and Statistical Manual of the American Psychiatric Association. Services that extend
beyond the period necessary for short-term evaluation, diagnosis, treatment, or crisis
intervention. Mental Health treatment of insomnia and other sleep disorders, neurological
disorders, and other disorders with a known physical basis.
Treatment of conduct and impulse control disorders, personality disorders, paraphilias and
other Mental Illnesses that will not substantially improve beyond the current level of
functioning, or that are not subject to favorable modification or management according to
prevailing national standards of clinical practice, as reasonably determined by the Mental
Health/Substance Abuse Designee.
Services utilizing methadone treatment as maintenance, L.A.A.M. (1-Alpha-Acetyl-Methadol),
Cyclazocine, or their equivalents. Treatment provided in connection with or to comply with
involuntary commitments, police detentions and other similar arrangements, unless
authorized by the Mental Health/Substance Abuse Designee. Services or supplies that in the
reasonable judgment of the Mental Health/Substance Abuse Designee are not, for example,
consistent with certain national standards or professional research further described in
Section 2 of the SPD.
I. Nutrition
Megavitamin and nutrition based therapy; nutritional counseling for either individuals or
groups. Enteral feedings and other nutritional and electrolyte supplements, including infant
formula and donor breast milk.
J. Physical Appearance
Cosmetic Procedures including, but not limited to, pharmacological regimens; nutritional
procedures or treatments; salabrasion, chemosurgery and other such skin abrasion procedures
associated with the removal of scars, tattoos, and/or which are performed as a treatment for
acne. Replacement of an existing breast implant is excluded if the earlier breast implant was a
Cosmetic Procedure. (Replacement of an existing breast implant is considered reconstructive if
the initial breast implant followed mastectomy.)
2016 Choice Plus (LOW OPTION)
Physical conditioning programs such as athletic training, bodybuilding, exercise, fitness,
flexibility, and diversion or general motivation. Weight loss programs for medical and nonmedical reasons. Wigs, regardless of the reason for the hair loss.
K. Providers
Services performed by a provider with your same legal residence or who is a family member by
birth or marriage, including spouse, brother, sister, parent or child. This includes any service
the provider may perform on himself or herself. Services provided at a free-standing or
Hospital-based diagnostic facility without an order written by a Physician or other provider as
further described in Section 2 of the SPD (this exclusion does not apply to mammography
testing).
L. Reproduction
Health services and associated expenses for infertility treatments. Surrogate parenting. The
reversal of voluntary sterilization.
M. Services Provided under Another Plan
Health services for which other coverage is required by federal, state or local law to be
purchased or provided through other arrangements, including but not limited to coverage
required by workers’ compensation, no-fault automobile insurance, or similar legislation. If
coverage under workers’ compensation or similar legislation is optional because you could
elect it, or could have it elected for you, Benefits will not be paid for any Injury, Mental Illness
or Sickness that would have been covered under workers’ compensation or similar legislation
had that coverage been elected.
Health services for treatment of military service-related disabilities, when you are legally
entitled to other coverage and facilities are reasonably available to you. Health services while
on active military duty.
N. Transplants
Section 1 of the SPD. Any solid organ transplant that is performed as a treatment for cancer.
Health services connected with the removal of an organ or tissue from you for purposes of a
transplant to another person. Health services for transplants involving mechanical or animal
organs.
Any multiple organ transplant not listed as a Covered Health Service in Section 1 of the SPD.
O. Travel
Health services provided in a foreign country, unless required as Emergency Health Services.
Travel or transportation expenses, even though prescribed by a Physician. Some travel
expenses related to covered transplantation services may be reimbursed at our discretion.
P. Vision and Hearing
Purchase cost of eye glasses, contact lenses, or hearing aids. Fitting charge for hearing aids,
eye glasses or contact lenses. Eye exercise therapy. Surgery that is intended to allow you to
see better without glasses or other vision correction including radial keratotomy, laser, and
other refractive eye surgery.
Q. Other Exclusions
Health services and supplies that do not meet the definition of a Covered Health Service - see
definition in Section 10 of the SPD.
Physical, psychiatric or psychological examinations, testing, vaccinations, immunizations or
treatments otherwise covered under the Plan, when such services are: (1) required solely for
purposes of career, education, sports or camp, travel, employment, insurance, marriage or
adoption; (2) relating to judicial or administrative proceedings or orders; (3) conducted for
purposes of medical research; or (4) to obtain or maintain a license of any type.
Health services received as a result of war or any act of war, whether declared or undeclared
or caused during service in the armed forces of any country.
Health services received after the date your coverage under the Plan ends, including health
services for medical conditions arising prior to the date your coverage under the Plan ends.
Health services for which you have no legal responsibility to pay, or for which a charge would
not ordinarily be made in the absence of coverage under the Plan.
In the event that a Non-Network provider waives Copayments and/or the Annual Deductible
for a particular health service, no Benefits are provided for the health service for which
Copayments and/or the Annual Deductible are waived.
Charges in excess of Eligible Expenses or in excess of any specified limitation.
Services for the evaluation and treatment of temporomandibular joint syndrome (TMJ),
whether the services are considered to be medical or dental in nature.
Upper and lower jaw bone surgery except as required for direct treatment of acute traumatic
Injury or cancer. Orthognathic surgery, jaw alignment, and treatment for the
temporomandibular joint, except as a treatment of obstructive sleep apnea.
Growth hormone therapy; sex transformation operations; treatment of benign gynecomastia
(abnormal breast enlargement in males); medical and surgical treatment of excessive sweating
(hyperhidrosis); medical and surgical treatment for snoring, except when provided as part of
treatment for documented obstructive sleep apnea. Oral appliances for snoring.
Custodial care; domiciliary care; private duty nursing; respite care; rest cures.
Psychosurgery. Speech therapy except as required for treatment of a speech impediment or
speech dysfunction that results from Injury, stroke or Congenital Anomaly.
This summary of Benefits is intended only to highlight your Benefits and should not be relied upon to fully determine coverage. This plan may not cover all your health care
expenses. Please refer to the Summary Plan Description for a complete listing of services, limitations, exclusions and a description of all the terms and conditions of coverage. If this
description conflicts in any way with the Summary Plan Description, the Summary Plan Description prevails. Terms that are capitalized in the Benefit Summary are defined in the
Summary Plan Description.
Your benefit at a glance
Home Delivery
Retail (in network)
Generics
$5.00
$15.00
Preferred brands
$67.50
$30.00
Non-preferred brands (no generic)
$130.00
$55.00
Growth hormones / Self injectables
10% Co-pay (generic or brand)
Specialty pharmacy by Acrredo
<After a certain number of purchases at retail, some drugs may cost you more. Refer to your prescription benefit materials for your retail refill allowance.>
<ANNUAL
S25has
PRESCRIPTION
MUST
BE MET PRIOR
TO CO-PAYS
TAKING EFFECT.
DEDUCTIBLE
APPLIES
TO EACH
AND DEPENDENS>
<Your
benefit
a deductible. DEDUCTIBLE
The deductible
and out-of-pocket
maximum
are coordinated
between
home delivery
and retail.
The COVERED
deductibleMEMBER
is not included
as
part of the out-of-pocket maximum.>
<Your benefit has a deductible. the deductible and out-ol·pocket maximum are coordinated between home delivery and retail. The deductible is not included as part of the out·of·pocket maximum.>
SAVING WITH HOME DELIVERY
When you get maintenance medications (those prescription drugs you take regularly) at a retail pharmacy, you could
be paying more than you need to. Use Express Scripts home delivery pharmacy services* for drugs to treat an ongoing
condition (3 months or longer). We will deliver up to a 90-day supply right to you with free standard shipping.
SAVING WITH GENERICS
FDA-approved generics are as safe and effective as their brand-name counterparts. If you’re taking a brand-name drug,
talk to your doctor and ask whether a less expensive generic drug could treat your condition. If your doctor agrees, ask your
doctor to write a new prescription for the generic that you can fill through your prescription benefit.
Home delivery... it’s quick and easy
Call us at 800-698-3757
We’ll contact your doctor to get a new 90-day prescription
for home delivery.
Manage your prescriptions online and on the go
or
Talk to your doctor
Ask your doctor for a new prescription for up to a 90-day supply. Have your
doctor call us at !"#$$"%&%"'(#( for instructions on how to fax your prescription.
Register on Express-Scripts.com
Download the Express Scripts mobile app
Receive prescription reminders
!
!
Search for potential lower-cost options using My Rx Choices®
!
!
Receive prescription and drug interaction alerts
!
!
Show your virtual ID card at the retail pharmacy
!
Contact a pharmacist
!
Check your coverage, claims and balances
!
Print claim forms, order forms and fax forms
!
© 2013 Express Scripts Holding Company. All rights reserved. OT44079G
*Includes services provided by the Medco Pharmacy® and the Express Scripts Pharmacy.SM
Dade County Fire Fighters Insurance Trust Fund
Important Benefit Update
Attention Member
IMPORTANT:
If you have not received your Welcome Kit with your ID cards, please
present this letter to your Express Scripts network pharmacist to
accurately process your prescriptions.
If you have any questions about your new prescription benefit program, please contact Express Scripts’
Customer Service at 1-855-747-5794.
Notice to Express Scripts Participating Pharmacies
As of January 1, 2016, Dade County Fire Fighters Insurance Trust Fund’s pharmacy benefit program will
be administered by Express Scripts. To simplify your prescription processing, please link the cardholder
and all members of their family to Express Scripts.
Please follow the action steps listed below to enter the claim.
Step 1
Enter Bin #: 003858
Step 2
Enter Processor Control: A4
Step 3
Enter Rx Group #: DCFIRE1
Step 4
Enter 9 digit member ID # (Employee SSN)
Step 5
Enter the member’s date of birth
NEED
ASSISTANCE?
Pharmacist, if you have any questions while processing the
claim, please call the Express Scripts’ Pharmacy Help Desk
1-800-922-1557
The Express Scripts Mobile App:
The
Express
Scripts
Pharmacy
That
GoesMobile
Farther.App:
The
Express
Scripts
Mobile
Pharmacy That Goes Farther.App:
Pharmacy That Goes Farther.
SM
SM
SM
You’re just a click away from staying on track with your
You’re
just awith
clicktheaway
fromScripts
stayingmobile
on track
medications
Express
app.with
You your
can
You’re
just
a
click
away
from
staying
on
track
with
your
medications
with
the
Express
Scripts
mobile
app.
You
can
view orders, check drug interactions or even find the closest
medications
with
the
Express
Scripts
mobile
app.
You
can
view
check
interactions
or even
thekeep
closest
retailorders,
pharmacy
in drug
seconds,
so you can
keepfind
track,
on
view
drug
interactions
or even
thekeep
closest
retailorders,
pharmacy
in feeling
seconds,
so you can
keepfind
track,
on
schedule
andcheck
keep
good.
retail
pharmacy
in feeling
seconds,
so you can keep track, keep on
schedule
and keep
good.
Search
“Express
Scripts”
in your app store or scan the
scheduleforand
keep feeling
good.
Search
for
“Express
Scripts”
in your
store for
or scan
the
QR code from your mobile device
and app
download
free today.
Search
for
“Express
Scripts”
in
your
app
store
or
scan
the
QR code from your mobile device and download for free today.
QR code from your mobile device and download for free today.
Scan this QR code to download the
Express
mobile
app, or gothe
to
Scan thisScripts
QR code
to download
Express-Scripts.com/mobileapp.
Express
Scripts
mobile
app,
or
go
to
Scan this QR code to download the
*Some
features
may
not
be
available
for
all
benefit
plans.
Express-Scripts.com/mobileapp.
Express Scripts mobile app, or go to
Available for iPhone , Android , Windows Phone and
*Some features may not be available
for allmobile
benefitdevices.
plans.
Express-Scripts.com/mobileapp.
Blackberry
®
™
®
®
Available for iPhone®, Android™, Windows Phone® and
*Some features may not be available
for®allmobile
benefitdevices.
plans.
Blackberry
Available for iPhone®, Android™, Windows Phone® and
Blackberry® mobile devices.
References:
1.
U.S. Food and Drug Administration. http://www.fda.gov/regulatoryinformation/
References:
1. legislation/federalfooddrugandcosmeticactfdcact/significantamendmentstothefdcact/
U.S. Food and Drug Administration. http://www.fda.gov/regulatoryinformation/
References:
Accessed August
5, 2014.
legislation/federalfooddrugandcosmeticactfdcact/significantamendmentstothefdcact/
1. fdasia/ucm310992.htm.
U.S.
Food and Drug Administration.
http://www.fda.gov/regulatoryinformation/
fdasia/ucm310992.htm.
Accessed August
5, 2014.
legislation/federalfooddrugandcosmeticactfdcact/significantamendmentstothefdcact/
2. U.S.
Food and Drug Administration.
http://www.fda.gov/Drugs/ResourcesForYou.
fdasia/ucm310992.htm.
5, 2014.
Accessed
August
5, Administration.
2014.Accessed August
2. U.S.
Food and
Drug
http://www.fda.gov/Drugs/ResourcesForYou.
Accessed
August
5, Administration.
2014.
2. U.S.
Food and
Drug
http://www.fda.gov/Drugs/ResourcesForYou.
Accessed August 5, 2014.
© 2014 Express Scripts Holding Company All Rights Reserved. BR45298C
© 2014 Express Scripts Holding Company All Rights Reserved. BR45298C
© 2014 Express Scripts Holding Company All Rights Reserved. BR45298C
Your
Guide
to
Generics
Your
Guide
to
Your Guide to Generics
Generics
Get the same health
Get
the same
health
benefits
and pay
less.
Get
the
same
health
benefits and pay
less.
benefits and pay less.
Proven safety and savings
Ask your doctor about generics
Medications should be affordable. That’s why FDA-approved generic
drugs are a great option. They’re safe, effective alternatives
to brand-name drugs – and typically cost much less.
Each year, more brand-name drugs lose their patent protection, which
means less expensive generics can be made and prescribed. Ask your
doctor if a generic drug is right for you. If one isn’t available, ask your
doctor about another preferred alternative – a medication with
different ingredients that can treat the same condition.
FDA-approved generic drugs:
sCost about 50% to 70% less than brand-name drugs1
s(AVETHESAMEACTIVEINGREDIENTSASTHEIRBRANDNAMEEQUALS
s7ORKTHESAMEWAY
s(AVETHESAMEQUALITYSTRENGTHANDPURITY
Nearly 8 in 10 prescriptions filled in the U.S. are generics.2
Generics also have a truly big advantage over newer medications.
By the time a generic becomes available, it’s already been
prescribed as a brand-name drug for an average of 17 years – so
it has proved its safety and effectiveness.
A healthy difference
You and your doctor make the decisions about your medication.
Keep in mind, though, you might see a big cost difference between
GENERICANDBRANDNAMEDRUGS(ERESWHATYOULLTYPICALLYPAY
under your plan:
Generic drugs
Preferred brand-name drugs
Nonpreferred brand-name drugs
$
$$
$$$
Preferred brand-name drugs can also
save you money.
If your doctor feels a generic won’t work for you or if one isn’t
available, your doctor can prescribe a preferred brand-name drug.
While they might have higher copayments than generics, they’ll
still cost you less than nonpreferred brand-name drugs.
&OR QUESTIONS ABOUT GENERICS OR TO SEE WHAT MEDICATIONS ARE
preferred by your plan, log in to Express-Scripts.com or call the
number on your member ID card.
Why 9 out of 10 patients like
HOME DELIVERY
1
for maintenance medication
BETTER
CARE
SAVINGS
CONVENIENCE
GREATER
MORE
UP TO
AUTOMATIC
REFILLS
19
%
and prescription renewals
make it easy to have
medications on hand
BETTER
ADHERENCE
to prescribed therapy2
than through retail
pharmacies
Access to
Cutting-edge technology and
techniques achieve greater than
99.99
SPECIALIST
% DISPENSING
Express Scripts Mobile App
Quick access to refills,
renewals and more
SAVE
3
MONTHLY TRIPS
TO THE RETAIL PHARMACY
with each 90-day home delivery fill
PHARMACISTS
ACCURACY
trained and experienced in the
medications used to treat
particular conditions
24/7
PROTECTIVE AND
INSULATED
PACKAGING
ensures safe
delivery of
temperaturesensitive
drugs.
A 90-day
prescription
usually costs
less than three
30-day fills at
retail; members
can save an
average of
%3
29
Wholesale
purchasing and
pharmacy
automation
achieves
LOWER
COSTS
pharmacist phone
consultations from the
COMFORT AND
PRIVACY OF HOME
Express-Scripts.com
Convenient tools
for managing
prescriptions
Free Standard Shipping
Express delivery available
If everyone used home delivery,
THE U.S. COULD SAVE $96.3 BILLION
each year 4
National Consumer Survey of Adults with Prescription Drug Coverage published by the Pharmaceutical Care Management Association, 2010. “Maintenance medications” refer to drugs
taken over a sustained period of time to treat chronic conditions.
Iyengar RI, Henderson RR, Visaria J, Frazee SG. Dispensing Channel and Medication Adherence: Evidence Across Three Therapy Classes. Am J Manag Care. October 2013. Patients
taking high blood cholesterol medications were 19% more adherent when receiving them through home delivery pharmacies.
3
Average percentage savings figure based on analysis of actual January-March 2012 claims for clients with a retail pharmacy and mail pharmacy benefit, excluding Medicare clients and
clients participating in mandatory mail programs; savings may vary.
4
Express Scripts 2011 Drug Trend Report, p. 11
1
2
© 2013 Express Scripts Holding Company. All Rights Reserved. 13-0800
For more Express Scripts research, visit:
http://Lab.Express-Scripts.com.
Your health plan recommends home delivery from the Express Scripts PharmacySM.
Home delivery is easy, safe and convenient
Get up to a 90-day supply of your medicine for a single home delivery copayment by using home delivery
for the prescriptions you take regularly. This valuable part of your prescription benefit includes free
standard shipping.
Get started
Let Us Help You
Do It Yourself
1. Complete a home delivery order form1
To transfer from a retail pharmacy, sign in at
Express-Scripts.com or
OR
2. Get a 90-day prescription from your doctor
plus refills for up to one year (if applicable)
3. Include your home delivery copayment
(acceptable forms include credit/debit card,
check or money order)2
Speak to a prescription benefits specialist
4. Mail your form and prescription to
Express Scripts at the address on the form
800.698.3757
(7:30 a.m. – 5 p.m., Central, Monday-Friday)
You can also have your doctor ePrescribe or fax
your prescription.
Your medication will usually arrive by mail within 8 days of receipt of your initial prescription.
Get refills
Choose Worry-Free Fills®
and we’ll automatically refill for you.
OR
Order a refill online or by phone 24/7
when you have 30 days (or one month)
of medication remaining
so you don’t run out.
Join the millions of Americans who already enjoy the safety and convenience
of home delivery from the Express Scripts Pharmacy.
If you have any questions about home delivery from the Express Scripts Pharmacy or your
prescription benefit, please call the number on your member ID card.
1
2
Visit Express-Scripts.com and click on “Forms” or call the phone number on your member ID card to request a home delivery order form.
Contact Express Scripts at the phone number on your member ID card if you don’t know your home delivery copayment.
© 2014 Express Scripts Holding Company. All Rights Reserved. 13EME22267 FS44562S
2016
DADE COUNTY FIRE FIGHTERS INSURANCE TRUST
UHC DENTAL OPTIONS PPO SUMMARY OF BENEFITS
EMPLOYEE ONLY
$0.00
EMPLOYEE+SPOUSE
$2.00
EMPLOYEE+FAMILY
EMPLOYEE+CHILD/REN
$3.00
Non-Orthodontics
In-Network
$1.00
Orthodontics
Out-of-Network
In-Network
Out-of-Network
Individual Annual Deductible
$25
$50
$0
$0
Family Annual Deductible
$75
$150
$0
$0
Maximum
(combined for both In-Network and
Out-of-Network services)
$1,800 per
person per
calendar year
$1,800 per person
per calendar year
$2,250 per person
per lifetime
$2,250 per person
per lifetime
Annual deductible applies to preventive and diagnostic services
No
Annual deductible applies to orthodontic services
No
For new enrollees, a 12-month waiting period applies to major services & orthodontics
No
Orthodontic eligibility requirement
Child/ Adult
InNetwork
Plan
Covered Services
Pays*
PREVENTIVE AND DIAGNOSTIC DENTAL SERVICES
Periodic Oral Examinations
100%
Bitewing X-rays
100%
Complete Series or Panorex X-rays
100%
Dental Prophylaxis (Cleanings)
100%
Fluoride Treatments
100%
Out-ofNetwork
Plan
Pays**
Two per Calendar Year
One series of films per year.
One time per 36 months.
Two per Calendar Year
For covered persons under the age of 16
years, 2 per Calendar Year
Sealants
100%
80%
For covered persons under the age of 16
years, once per first or second permanent
molar every 5 years.
BASIC DENTAL SERVICES (Minor Restorative, Endodontics, Periodontics and Oral Surgery)
Amalgam Restorations (Fillings)
80%
80%
One restoration allowed per surface every
3 years.
Composite Resin Restorations (Fillings)
80%
80%
One restoration allowed per surface every
3 years.
Space Maintainers
80%
80%
For covered persons under the age of 16
years, once per lifetime.
Root Canal Treatment
80%
80%
Once per site per lifetime.
Root Planing
80%
80%
Once every 24 months per quadrant.
Periodontal Surgery
80%
80%
Once every 36 months per site.
Simple Extraction
80%
80%
Surgical Extraction including Impacted
80%
80%
Wisdom Teeth
1/1/2016
80%
80%
80%
80%
80%
Benefit Guidelines
General Anesthesia
Palliative Treatment (Relief of Pain)
80%
80%
80%
80%
When clinically necessary.
Covered as a separate benefit only if no
other services except exam and X-rays
were performed during the visit.
MAJOR DENTAL SERVICES
Crowns
Fixed Bridges
50%
50%
50%
50%
Full Dentures
50%
50%
Inlays and Onlays
Partial Dentures
50%
50%
50%
50%
Relining Dentures
50%
50%
Repairs to Full Dentures, Partial
Dentures, Bridges
ORTHODONTIC SERVICES
Diagnose or correct misalignment of
the teeth or bite including Phase I and
Phase II
50%
50%
Once every 5 years.
Once every 5 years (alternate benefits for a
partial denture may be applied).
Once every 5 years; no allowance for
overdentures or customized dentures.
Once every 5 years.
Once every 5 years; no allowance for
precision or semi precision attachments.
Once every year after the 6 month period
following initial insertion.
For repairs or adjustments done after 12
months following the initial insertion.
50%
50%
Preauthorization required.
*The in-network percentage of benefits is based on the discounted fee negotiated with the provider.
**The out-of-network percentage of benefits is based on the usual and customary rates prevailing in the geographic area in
which the expenses are incurred.
The material contained in the above table is for informational purposes only and is not an offer of coverage. Please note that
the above table provides only a brief, general description of coverage and does not constitute a contract. For a complete
listing of your coverage, including exclusions and limitations relating to your coverage, please refer to your Certificate of
Coverage or contact your benefits administrator. If differences exist between this Summary of Benefits and your Certificate of
Coverage/benefits administrator, the certificate/benefits administrator will govern. All terms and conditions of coverage are
subject to applicable state and federal laws. State mandates regarding benefit levels and age limitations may supersede plan
design features.
You may contact United HealthCare PPO dental customer service at 877-816-3596 for any questions
regarding benefits, claims, in-network provider verification, or replacement identification cards. The
in-network dental options PPO provider listing is available on-line either at www.myuhcdental.com or
by registering on www.myuhc.com.
1/1/2016
HumanaDental
Florida
Prepaid HS195 Plan with Implants
Feel good about choosing
a HumanaDental plan
The HumanaDental HS Series dental plan has you covered
for any circumstance. Whether you simply need routine
dental care or unexpected dental treatment, you know
what to expect with HumanaDental.
Tips to ensure a
healthy mouth
F No waiting periods
F No claims to file
F No annual maximums
FUse a soft-bristled toothbrush
FChoose toothpaste with fluoride
FBrush for at least two minutes
twice a day
FFloss daily
FWatch for signs of periodontal
disease such as red, swollen, or
tender gums
FVisit a dentist regularly for exams
and cleanings
Use your HumanaDental benefits
After you enroll in a plan and receive your ID card, you
can manage your plan information on your personal
home page on HumanaDental.com.
F You have the freedom to select any participating
general dentist as your primary care dentist. To select
a dental provider from our network, simply visit
HumanaDental.com. Once there, you can also check
your benefits, email us and get a new or temporary ID
card. If you prefer, contact us at 1-800-342-5209.
F Life without claim forms! With the HumanaDental
Prepaid plan you pay your dentist directly,
when applicable.
F Your primary dentist will provide all of your routine
dental care and you will pay any copayment or
discounted charges at the time of service.
Good health starts with a
healthy mouth
Make dental visits a priority
One of the first lines of defense in overall health is dental
care. Regular dental cleanings can help manage problems
throughout the body, such as heart disease, diabetes,
and stroke. In fact, a healthy mouth can add 6.4 years
to RealAge® life expectancy.1 The HumanaDental Prepaid
plan enables you to take better care of your teeth, and
you’ll pay less for your dental care doing so.
Questions?
Check out HumanaDental.com
Go to MyDentalIQ.com
Call 1-800-233-4013, Monday through
Friday, 8 a.m. to 6 p.m.
(TDD: 1-800-325-2025).
Take a health risk assessment that immediately rates your
dental health knowledge. You’ll receive a personalized
action plan with health tips. You can print a copy of your
scorecard to discuss with your dentist at your next visit.
For exclusions and limitations, please review the Specialty
Benefits Regulatory and Technical Information Guide
available at Disclosure.Humana.com.
1
FL52438HDI 3/13
Dr. Michael Roizen, RealAge.com
Page 1 of 6
HumanaDental Prepaid HS195 Plan with Implants
The HumanaDental Prepaid plans focus on maintaining oral health, prevention and cost-containment. Members may
see a primary care dentist as often as necessary. There are no yearly maximums, no deductibles to meet and no waiting
periods. HS plans copayments for listed procedures are applicable only at a participating general dentist.
A primary care dentist (PCD) may decide that a member needs to see a contracted dental specialist. No referral is
necessary to see a network specialist.
.#!'*'1211#04'!#1BShould members need a specialist, (i.e., endodontist, oral surgeon, periodontist, pediatric dentist),
they may be referred by a participating general dentist, or members can self-refer to any participating specialist. For HS
plans, copayment amounts are applicable when treatment is performed by participating specialists.
Summary of services
Services marked with a single asterisk (*) below also require separate payment of laboratory charges, not to exceed
$200. The laboratory charges must be paid to the plan dentist in addition to any applicable copayment for the service.
..-',2+#,21
#+ #0.71
D9310 Consultation (diagnostic service provided by
dentist other than practitioner
providing treatment) . . . . . . . . . . . . . . . . . . . . . . . . . . .
D9430 Office visit (normal hours) . . . . . . . . . . . . . . . . . . . . . .
D9440 Office visit (after regularly scheduled hours) . . . .
D9999 Broken appointments (without 24 hr. notice,
per 15 min)—maximum $40 per broken
appointment. No charge will be made due
to emergencies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
'%,-12'!
no charge
no charge
$ 30.00
$ 10.00
#+ #0.71
D0120 Periodic oral examination
(two per calendar year) . . . . . . . . . . . . . . . . . . . . . . . .
D0140 Limited/comprehensive/detailed and extensive
oral eval . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
D0145 Oral evaluation for a patient under three years
of age and counseling with primary caregiver . . .
D0150 Limited/comprehensive/detailed and extensive
oral eval (two per calendar year). . . . . . . . . . . . . . . .
D0160 Limited/comprehensive/detailed and extensive
oral eval . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
D0170 Re-evaluation—problem focused
(not post-operative visit) . . . . . . . . . . . . . . . . . . . . . . .
D0180 Comprehensive periodontal evaluation
(two per calendar year) . . . . . . . . . . . . . . . . . . . . . . . .
D0210 X-ray intraoral—complete series including
bitewings (once per three calendar years) . . . . . .
D0220 X-ray intraoral—periapical, first film . . . . . . . . . . . .
D0230 X-ray intraoral—periapical, each additional film .
D0240 X-rays intraoral—occlusal film . . . . . . . . . . . . . . . . . .
D0250 Extraoral—first film . . . . . . . . . . . . . . . . . . . . . . . . . . . .
D0260 Extraoral—each additional film . . . . . . . . . . . . . . . . .
D0270 X-ray bitewing—single film
(two per calendar year) . . . . . . . . . . . . . . . . . . . . . . . .
D0272 X-ray bitewings—two films
(two per calendar year) . . . . . . . . . . . . . . . . . . . . . . . .
D0273 X-ray bitewings—three films
(two per calendar year) . . . . . . . . . . . . . . . . . . . . . . . .
no charge
no charge
no charge
no charge
no charge
no charge
no charge
no charge
no charge
no charge
no charge
no charge
no charge
no charge
no charge
no charge
D0274 Bitewings—four films (two per calendar year) . . .
D0277 X-ray bitewings, vertical—seven to eight films
(two per calendar year) . . . . . . . . . . . . . . . . . . . . . . . .
D0330 Panoramic film (once per three calendar years) .
D0350 Oral/facial photography images . . . . . . . . . . . . . . . .
D0415 Collect microorganisms culture & sensitivity . . . .
D0425 Caries susceptibility tests . . . . . . . . . . . . . . . . . . . . . . .
D0431 Oral cancer screening using a special light source .
D0460 Pulp vitality tests
(not covered if a root canal is performed) . . . . . . .
D0470 Diagnostic casts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
D0472 Pathology report—gross examination of lesion. .
D0473 Pathology report—microscopic examination
of lesion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
D0474 Pathology report—microscopic examination
of lesion and area . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
0#4#,2'4#
no charge
no charge
no charge
no charge
no charge
$ 50.00
no charge
no charge
no charge
no charge
no charge
#+ #0.71
D1110 Prophylaxis—adult, routine (two per calendar
year, by primary care dentist) . . . . . . . . . . . . . . . . . . .
D1111 Additional—adult prophylaxis, with or without
fluoride (maximum of two additional per year) . .
D1120 Prophylaxis—child, routine
(two per calendar year) . . . . . . . . . . . . . . . . . . . . . . . .
D1121 Additional—child prophylaxis, with or without
fluoride (maximum of two additional per year) . .
D1203 Topical application of fluoride (not including
prophylaxis)—child (up to 16 years of age)
(two per calendar year) . . . . . . . . . . . . . . . . . . . . . . . .
D1204 Topical application of fluoride—adult
(two per calendar year, by primary care dentist) .
D1206 Topical fluoride varnish (for child <16)
(two per calendar year) . . . . . . . . . . . . . . . . . . . . . . . .
D1310 Nutrition counseling for the control or avoidance
of dental disease. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
D1320 Tobacco counseling services for the control or
prevention of oral disease . . . . . . . . . . . . . . . . . . . . . .
D1330 Oral hygiene instruction . . . . . . . . . . . . . . . . . . . . . . . .
D1351 Sealant—per tooth
(permanent teeth only to age 16) . . . . . . . . . . . . . .
Current Dental Terminology © 2007 American Dental Association. All rights reserved.
FL52438HDI 3/13
no charge
no charge
$ 35.00
no charge
$ 25.00
no charge
no charge
no charge
no charge
no charge
no charge
no charge
Page 2 of 6
D1510* Space maintainer—fixed, unilateral
(through age 14) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
D1515* Space maintainer—fixed, bilateral
(through age 14) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
D1520* Space maintainer—removable, unilateral
(through age 14) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
D1525* Space maintainer—removable, bilateral
(through age 14) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
D1550 Recementation of space maintainer . . . . . . . . . . . .
D1555 Removal of fixed space maintainer . . . . . . . . . . . . .
#12-02'4#
Amalgam—one surface, primary or permanent .
Amalgam—two surfaces, primary or permanent .
Amalgam—three surfaces, primary or permanent. .
Amalgam—four or more surfaces, primary
or permanent . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
D2940 Sedative filling . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
$ 35.00
$ 35.00
$ 15.00
$ 15.00
no charge
no charge
no charge
no charge
no charge
#+ #0.71
D2330
D2331
D2332
D2335
Resin based composite—one surface, anterior . .
Resin based composite—two surfaces, anterior .
Resin based composite—three surfaces, anterior . .
Resin based composite—four or more surfaces
or involving incisal angle (anterior) . . . . . . . . . . . . .
D2390 Resin based composite crown, anterior . . . . . . . . .
D2391 Resin based composite—one surface, posterior .
D2392 Resin based composite—two surfaces, posterior .
D2393 Resin based composite—three surfaces, posterior .
D2394 Resin based composite—four or more
surfaces, posterior . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
D2510* Inlay—metallic, one surface . . . . . . . . . . . . . . . . . . .
D2520* Inlay—metallic, two surfaces . . . . . . . . . . . . . . . . . .
D2530* Inlay—metallic, three or more surfaces . . . . . . . . .
D2542* Onlay—metallic, two surfaces . . . . . . . . . . . . . . . . .
D2543* Onlay—metallic, three surfaces . . . . . . . . . . . . . . . .
D2544* Onlay—metallic, four or more surfaces . . . . . . . . .
D2610* Inlay—porcelain/ceramic, one surface . . . . . . . . . .
D2620* Inlay—porcelain/ceramic, two surfaces . . . . . . . . .
D2630* Inlay—porcelain/ceramic, three or more surfaces .
D2642* Onlay—porcelain/ceramic, two surfaces . . . . . . . .
D2643* Onlay—porcelain/ceramic, three surfaces. . . . . . .
D2644* Onlay—porcelain/ceramic, four or more surfaces .
D2650* Inlay—resin based composite, one surface . . . . .
D2651* Inlay—resin based composite, two surfaces . . . .
D2652* Inlay—resin based composite, three or
more surfaces . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
D2662* Onlay—resin based composite, two surfaces . . . .
D2663* Onlay—resin based composite, three surfaces . .
D2664* Onlay—resin based composite, four or
more surfaces . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
0-5,," 0'"%#
(limited to one per tooth every five years)
$ 25.00
#+ #0.71
D2140
D2150
D2160
D2161
#1',0#12-02'4#
(inlays and onlays limited to
one per tooth every five years)
$ 25.00
no charge
no charge
no charge
no charge
$ 30.00
$ 30.00
$ 45.00
$ 65.00
$ 65.00
$225.00
$ 235.00
$ 245.00
$ 245.00
$ 260.00
$ 270.00
$ 245.00
$ 245.00
$ 245.00
$ 245.00
$ 245.00
$ 245.00
$ 245.00
$ 245.00
$ 245.00
$ 245.00
$ 245.00
$ 245.00
#+ #0.71
D2710* Crown—resin based composite, indirect . . . . . . . .
D2712* Crown—3/4 resin based composite, indirect . . . .
D2720* Crown—resin with high noble metal . . . . . . . . . . . .
D2721 Crown—resin with predominantly base metal. . .
D2722* Crown—resin with noble metal . . . . . . . . . . . . . . . . .
D2740* Crown—porcelain/ceramic substrate . . . . . . . . . . .
$ 245.00
$ 245.00
$ 245.00
$ 245.00
$ 245.00
$ 245.00
D2750* Crown—porcelain fused to high noble metal . . . .
D2751 Crown—porcelain fused to predominantly
base metal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
D2752* Crown—porcelain fused to noble metal . . . . . . . . .
D2780* Crown—3/4 cast high noble metal . . . . . . . . . . . . . .
D2781 Crown—3/4 cast predominantly base metal . . . .
D2782* Crown—3/4 cast noble metal. . . . . . . . . . . . . . . . . . .
D2783* Crown—3/4 porcelain/ceramic . . . . . . . . . . . . . . . . .
D2790* Crown—full cast high noble metal . . . . . . . . . . . . . .
D2791 Crown—full cast predominantly base metal . . . .
D2792* Crown—full cast noble metal . . . . . . . . . . . . . . . . . . .
D2794* Crown—titanium . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
D2799 Provisional crown . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
D2910 Recement inlay, onlay or veneer . . . . . . . . . . . . . . . .
D2915 Recement cast or prefabricated post and core . .
D2920 Recement crown . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
D2930 Prefabricated stainless steel crown—
primary tooth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
D2931 Prefabricated stainless steel crown—
permanent tooth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
D2932 Prefabricated resin crown. . . . . . . . . . . . . . . . . . . . . . .
D2933 Prefabricated stainless steel crown with
resin window . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
D2950 Core buildup, including any pins . . . . . . . . . . . . . . . .
D2951 Pin retention—per tooth, in addition to restoration.
D2952* Cast post and core in addition to crown . . . . . . . . .
D2953* Each additional cast post—same tooth . . . . . . . . .
D2954 Prefabricated post and core in addition to crown .
D2955 Post removal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
D2957 Each additional prefabricated post—same
tooth, base metal post . . . . . . . . . . . . . . . . . . . . . . . . .
D2960 Labial veneer (resin laminate)—chairside . . . . . . .
D2961* Labial veneer (resin laminate)—laboratory . . . . . .
D2962* Labial veneer (porcelain laminate)—laboratory .
D2970 Temporary crown (fractured tooth) . . . . . . . . . . . . .
D2971 Additional procedure—new crown existing
partial denture . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
D2980 Crown repair . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
D6940 Stress breaker . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
D6950 Precision attachment . . . . . . . . . . . . . . . . . . . . . . . . . .
D6970* Cast post and core, in addition to fixed partial
denture retainer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
D6972 Prefabricated post and core in addition to fixed
partial denture retainer, base metal post . . . . . . . .
D6976* Each additional cast post—same tooth . . . . . . . . .
D6977 Each additional prefabricated post—same tooth .
D6980* Fixed partial denture repair, by report . . . . . . . . . . .
0-12&-"-,2'!1H$'6#"J
(replacement limited to every five
years, adjustments once per year)
$ 245.00
$ 245.00
$ 245.00
$ 245.00
$ 245.00
$ 245.00
$ 245.00
$ 245.00
$ 245.00
$ 245.00
no charge
no charge
no charge
no charge
$ 25.00
$ 25.00
$ 45.00
$
$
$
$
$
$
$
45.00
70.00
10.00
50.00
50.00
30.00
10.00
$ 30.00
$ 250.00
$ 300.00
$ 350.00
no charge
$ 50.00
no charge
$ 110.00
$ 195.00
$ 50.00
$
$
$
$
30.00
40.00
40.00
45.00
#+ #0.71
D6210* Pontic—cast high noble metal. . . . . . . . . . . . . . . . . .
D6211 Pontic—cast predominantly base metal . . . . . . . .
D6212* Pontic—cast noble metal . . . . . . . . . . . . . . . . . . . . . .
D6240* Pontic—porcelain fused to high noble metal . . . .
D6241 Pontic—porcelain fused to predominantly
base metal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
D6242* Pontic—porcelain fused to noble metal . . . . . . . . .
D6750* Crown—porcelain fused to high noble metal . . . .
D6751 Crown—porcelain fused to predominantly
base metal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
D6752* Crown—porcelain fused to noble metal . . . . . . . . .
Current Dental Terminology © 2007 American Dental Association. All rights reserved.
FL52438HDI 3/13
$ 245.00
$ 245.00
$ 245.00
$ 245.00
$ 245.00
$ 245.00
$ 245.00
$ 245.00
$ 245.00
$ 245.00
Page 3 of 6
D6790* Crown—full cast high noble metal . . . . . . . . . . . . . .
D6791 Crown—full cast predominantly base metal . . . .
D6792* Crown—full cast noble metal . . . . . . . . . . . . . . . . . . .
D6794* Crown—titanium . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
D6930 Recement fixed partial denture (per unit) . . . . . . .
D6973 Core buildup for retainer, including any pins . . . . .
0-12&-"-,2'!1
(replacement limited to every five years)
D3110
D3120
D3220
D3221
D3230
D3240
D3310
D3320
D3330
D3331
D3332
D3333
D3346
D3347
D3348
D3351
D3352
D3353
$ 325.00
$ 325.00
$ 350.00
$ 350.00
$ 400.00
$ 400.00
D3410 Apicoectomy/periradicular surgery—anterior . . .
D3421 Apicoectomy/periradicular surgery—bicuspid
(first root) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
D3425 Apicoectomy/periradicular surgery—molar
(first root) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
D3426 Apicoectomy/periradicular surgery
(each additional root) . . . . . . . . . . . . . . . . . . . . . . . . . .
D3430 Retrograde filling—per root . . . . . . . . . . . . . . . . . . . . .
D3450 Root amputation—per root
(not covered in conjunction with procedure D3920) .
D3910 Surgical procedure to isolate tooth with
rubber dam . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
D3920 Hemisection not included in root canal therapy .
D3950 Root canal prepare and fit preformed
dowel/post . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
$ 425.00
#0'-"-,2'!1H%3+20#2+#,2J
#+ #0.71
D5110* Complete denture—maxillary . . . . . . . . . . . . . . . . . .
D5120* Complete denture—mandibular. . . . . . . . . . . . . . . .
D5130* Immediate denture—maxillary . . . . . . . . . . . . . . . .
D5140* Immediate denture—mandibular . . . . . . . . . . . . . .
D5211* Maxillary partial denture—resin base . . . . . . . . . . .
D5212* Mandibular partial denture—resin base . . . . . . . . .
D5213* Maxillary partial denture—cast metal framework, resin denture bases . . . . . . . . . . . . . . . . . . . . . .
D5214* Mandibular partial denture—cast metal framework, resin denture bases . . . . . . . . . . . . . . . . . . . . . .
D5225* Maxillary partial denture—flexible
(including clasps, rests and teeth) . . . . . . . . . . . . . .
D5226* Mandibular partial denture—flexible
(including clasps, rests and teeth) . . . . . . . . . . . . . .
D5281* Removable partial denture—one piece
cast metal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
D5410 Adjust complete denture—maxillary . . . . . . . . . . .
D5411 Adjust complete denture—mandibular . . . . . . . . .
D5421 Adjust partial denture—maxillary . . . . . . . . . . . . . .
D5422 Adjust partial denture—mandibular . . . . . . . . . . . .
D5660* Add clasp to existing partial denture . . . . . . . . . . . .
,"-"-,2'!1
(each procedure limited to
once per tooth per life)
$ 245.00
$ 245.00
$ 245.00
$ 245.00
no charge
$ 10.00
$ 425.00
$ 425.00
$ 425.00
$ 300.00
$ 10.00
$ 10.00
$ 10.00
$ 10.00
$ 35.00
#+ #0.71
Pulp cap—direct (excluding final restoration). . . .
Pulp cap—indirect (excluding final restoration) . .
Therapeutic pulpotomy . . . . . . . . . . . . . . . . . . . . . . . .
Pulpal debridement, primary and
permanent teeth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Pulpal therapy (resorbable filling)—anterior,
primary tooth (excluding final restoration) . . . . . .
Pulpal therapy (resorbable filling)—posterior,
primary tooth (excluding final restoration) . . . . . .
Root canal therapy—anterior
(excluding final restoration) . . . . . . . . . . . . . . . . . . . .
Root canal therapy—bicuspid
(excluding final restoration) . . . . . . . . . . . . . . . . . . . .
Root canal therapy—molar
(excluding final restoration) . . . . . . . . . . . . . . . . . . . .
Treatment of root canal obstruction—
non-surgical access . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Incomplete endodontic therapy—inoperable or
fractured tooth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Internal root repair of perforation defects . . . . . . .
Retreatment of previous root canal
therapy—anterior . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Retreatment of previous root canal
therapy—bicuspid . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Retreatment of previous root canal
therapy—molar . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Apexification/recalcification—initial visit . . . . . . . .
Apexification/recalcification—interim . . . . . . . . . .
Apexification/recalcification—final visit . . . . . . . . .
$ 5.00
$ 5.00
$ 30.00
$ 55.00
$ 40.00
$ 40.00
$ 100.00
$ 152.00
$ 210.00
$ 85.00
$ 96.00
$ 85.00
$ 180.00
$ 280.00
$ 325.00
$ 70.00
$ 70.00
$ 70.00
$ 95.00
$ 95.00
$ 95.00
$ 60.00
$ 60.00
$ 95.00
$ 19.00
$ 90.00
$ 15.00
#+ #0.71
D4210 Gingivectomy/gingivoplasty per quadrant . . . . . . $ 110.00
D4211 Gingivectomy/gingivoplasty per tooth . . . . . . . . . . $ 83.00
D4240 Gingival flap, including root planing—four or
more teeth, per quadrant . . . . . . . . . . . . . . . . . . . . . . $ 150.00
D4241 Gingival flap, including root planing—one to
three teeth, per quadrant . . . . . . . . . . . . . . . . . . . . . . $ 113.00
D4245 Apically positioned flap . . . . . . . . . . . . . . . . . . . . . . . . . $ 165.00
D4249 Clinical crown lengthening—hard tissue . . . . . . . . $ 150.00
D4260 Osseous surgery—four or more teeth or
bounded spaces, per quadrant . . . . . . . . . . . . . . . . . $ 300.00
D4261 Osseous surgery—one to three teeth, per quadrant . $ 225.00
D4263 Bone replacement graft—first site in quadrant . . $ 180.00
D4264 Bone replacement graft—each additional site in
quadrant bone . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 95.00
D4265 Biological materials which can aid soft and
osseous tissue regeneration . . . . . . . . . . . . . . . . . . . . $ 95.00
D4266 Guided tissue regeneration—resorbable barrier,
per site. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 215.00
D4267 Guided tissue regeneration—nonresorbable
barrier, per site (includes membrane removal) . . $ 255.00
D4270 Pedicle soft tissue graft procedure . . . . . . . . . . . . . . $245.00
D4271 Free soft tissue graft procedure
(including donor site surgery). . . . . . . . . . . . . . . . . . . $ 245.00
D4273 Subeptithelial connective tissue graft, tooth . . . . $ 75.00
D4274 Distal or proximal wedge procedure. . . . . . . . . . . . . $ 100.00
D4275 Soft tissue allograft . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 380.00
D4320 Provisional splinting—intracoronal . . . . . . . . . . . . . . $ 95.00
D4321 Provisional splinting—extracoronal . . . . . . . . . . . . . $ 85.00
D4341 Periodontal scaling and root planing, per quadrant
(a maximum of four quadrants will be paid in
any combinations, per 24 calendar months for
procedures D4341 and D4342) . . . . . . . . . . . . . . . . . $ 50.00
D4342 Periodontal scaling and root planing one to three
teeth per quadrant (a maximum of four quadrants
will be paid in any combinations, per 24 calendar
months for procedures D4341 and D4342) . . . . . . $ 38.00
D4355 Full mouth debridement to enable comprehensive
evaluation and diagnosis
(once per five calendar years) . . . . . . . . . . . . . . . . . . $ 50.00
D4381 Localized delivery of chemotherapeutic agents
(per tooth) (limited to once per tooth per 12
months to a maximum of three tooth sites per
quadrant, and performed no less than three
months following active periodontal therapy) . . . . $ 65.00
D4910 Periodontal maintenance
(covered only after active periodontal therapy) . $ 40.00
Current Dental Terminology © 2007 American Dental Association. All rights reserved.
FL52438HDI 3/13
Page 4 of 6
D4911 Additional periodontal maintenance procedures
(beyond two per 12 months) . . . . . . . . . . . . . . . . . . . $ 55.00
620!2'-,1G-0*,"+6'**-$!'*130%#07 #+ #0.71
D7111
D7140
D7210
D7220
D7230
D7240
D7241
D7250
D7270
D7280
D7282
D7283
D7285
D7286
D7287
D7288
D7310
D7311
D7320
D7321
D7471
D7472
D7473
D7485
D7510
D7511
D7520
D7521
D7910
D7960
D7963
D7970
D7971
Coronal remnants, deciduous tooth. . . . . . . . . . . . . $ 5.00
Extraction, erupted tooth or exposed tooth . . . . . $ 5.00
Surgical removal of erupted tooth . . . . . . . . . . . . . . $ 30.00
Removal of impacted tooth—soft tissue . . . . . . . . $ 50.00
Removal of impacted tooth—partially bony. . . . . $ 65.00
Removal of impacted tooth—completely bony. . $ 80.00
Removal of impacted tooth—completely bony,
unusual complications by report. . . . . . . . . . . . . . . . $ 100.00
Surgical removal of residual tooth roots . . . . . . . . . $ 40.00
Tooth stabilization of accidentally avulsed or
displaced tooth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 50.00
Surgical access of an unerupted tooth
(excluding wisdom teeth) . . . . . . . . . . . . . . . . . . . . . . $ 100.00
Mobilization of erupted or malposed tooth to
aid eruption . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 90.00
Placement of device to facilitate eruption of
impacted tooth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 90.00
Biopsy of oral tissue—hard (bone, tooth) . . . . . . . $ 150.00
Biopsy of oral tissue—soft (all others) . . . . . . . . . . $ 60.00
Exfoliative cytological sample collection . . . . . . . . $ 50.00
Brush biopsy—transepithelial sample collection. . $ 50.00
Alveoloplasty in conjunction with
extractions—per quadrant . . . . . . . . . . . . . . . . . . . . . $ 40.00
Alveoloplasty in conjunction with extractions—
one to three teeth or tooth spaces, per quadrant . $ 15.00
Alveoloplasty not in conjunction with
extractions—per quadrant . . . . . . . . . . . . . . . . . . . . . $ 60.00
Alveoloplasty not in conjunction with
extractions—one to three teeth or tooth
spaces, per quadrant . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 25.00
Removal of lateral exostosis (maxilla or mandible) . $ 80.00
Removal of torus palatinus . . . . . . . . . . . . . . . . . . . . . $ 60.00
Removal of torus mandibularis . . . . . . . . . . . . . . . . . $ 60.00
Surgical reduction of osseous tuberosity . . . . . . . . $ 60.00
Incision and drainage of abscess—
intraoral soft tissue . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 35.00
Incision and drainage of abscess—intraoral soft
tissue, complicated
(includes drainage of multiple fascial spaces). . . . . . .$ 35.00
Incision and drainage of abscess—extraoral
soft tissue. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 35.00
Incision and drainage of abscess—extraoral soft
tissue, complicated
(includes drainage of multiple fascial spaces). . . . . . .$ 35.00
Suture of recent small wounds up to 5 cm. . . . . . . $ 25.00
Frenulectomy (frenectomy or frenotomy)—
separate procedure . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 50.00
Frenuloplasty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 50.00
Excision hyperplastic tissue—per arch . . . . . . . . . . $ 55.00
Excision of pericoronoal gingiva. . . . . . . . . . . . . . . . . $ 40.00
#.'012-.0-12&#2'!1
#+ #0.71
D5510* Repair broken complete denture base . . . . . . . . . .
D5520* Replace missing or broken teeth—complete
denture (each tooth) . . . . . . . . . . . . . . . . . . . . . . . . . . .
D5610* Repair resin denture base . . . . . . . . . . . . . . . . . . . . . .
D5620* Repair cast framework . . . . . . . . . . . . . . . . . . . . . . . . .
D5630* Repair or replace broken clasp . . . . . . . . . . . . . . . . . .
D5640* Replace broken teeth—per tooth . . . . . . . . . . . . . . .
$ 35.00
$
$
$
$
$
35.00
35.00
35.00
35.00
35.00
D5650* Add tooth to existing partial denture . . . . . . . . . . .
D5670* Replace all teeth and acrylic
framework—maxillary . . . . . . . . . . . . . . . . . . . . . . . . .
D5671* Replace all teeth and acrylic
framework—mandibular . . . . . . . . . . . . . . . . . . . . . . .
D5710* Rebase complete maxillary denture . . . . . . . . . . . .
D5711* Rebase complete mandibular denture . . . . . . . . . .
D5720* Rebase maxillary partial denture . . . . . . . . . . . . . . .
D5721* Rebase mandibular partial denture . . . . . . . . . . . . .
D5730 Reline complete maxillary denture (chairside). . .
D5731 Reline complete mandibular denture (chairside) .
D5740 Reline maxillary partial denture (chairside) . . . . . .
D5741 Reline mandibular partial denture (chairside) . . .
D5750* Reline complete maxillary denture (laboratory) .
D5751* Reline complete mandibular denture (laboratory) .
D5760* Reline maxillary partial denture (laboratory) . . . .
D5761* Reline mandibular partial denture (laboratory) . .
D5810* Interim complete denture (maxillary). . . . . . . . . . .
D5811* Interim complete denture (mandibular) . . . . . . . .
D5820* Interim partial denture (maxillary) . . . . . . . . . . . . . .
D5821* Interim partial denture (mandibular) . . . . . . . . . . .
D5850 Tissue conditioning, maxillary . . . . . . . . . . . . . . . . . .
D5851 Tissue conditioning, mandibular . . . . . . . . . . . . . . . .
D5862* Precision attachment, by report . . . . . . . . . . . . . . . .
D6214* Pontic titanium . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
D6245* Pontic—porcelain/ceramic . . . . . . . . . . . . . . . . . . . . .
D6250* Pontic—resin with high noble metal . . . . . . . . . . . .
D6251 Pontic—resin with predominantly base metal . .
D6252* Pontic—resin with noble metal . . . . . . . . . . . . . . . . .
D6253* Provisional pontic . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
D6545* Retainer—cast metal, resin bonded
fixed prosthesis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
D6600* Inlay—porcelain/ceramic, two surfaces . . . . . . . . .
D6601* Inlay—porcelain/ceramic, three or more surfaces .
D6602* Inlay—cast high noble metal, two surfaces . . . . .
D6603* Inlay—cast high noble metal, three or
more surfaces . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
D6604 Inlay—cast predominantly base metal,
two surfaces . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
D6605 Inlay—cast predominantly base metal, three or
more surfaces . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
D6606* Inlay—cast noble metal, two surfaces . . . . . . . . . .
D6607* Inlay—cast noble metal, three or more surfaces .
D6608* Onlay—porcelain/ceramic, two surfaces . . . . . . . .
D6609* Onlay—porcelain/ceramic, three or more surfaces .
D6610* Onlay—cast high noble metal, two surfaces . . . .
D6611* Onlay—cast high noble metal, three or
more surfaces . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
D6612 Onlay—cast predominantly base metal,
two surfaces . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
D6613 Onlay—cast predominantly base metal, three
or more surfaces . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
D6614* Onlay—cast noble metal, two surfaces . . . . . . . . .
D6615* Onlay—cast noble metal, three or more surfaces . .
D6710* Crown—indirect resin based composition . . . . . . .
D6720* Crown—resin with high noble metal . . . . . . . . . . . .
D6721 Crown—resin with predominantly base metal. . .
D6722* Crown—resin with noble metal . . . . . . . . . . . . . . . . .
D6740* Crown—porcelain/ceramic . . . . . . . . . . . . . . . . . . . . .
D6780* Crown—3/4 cast high noble metal . . . . . . . . . . . . . .
D6781 Crown—3/4 cast predominantly base metal . . . .
D6782* Crown—3/4 cast noble metal. . . . . . . . . . . . . . . . . . .
D6783* Crown—3/4 porcelain/ceramic, denture . . . . . . . .
Current Dental Terminology © 2007 American Dental Association. All rights reserved.
FL52438HDI 3/13
$ 35.00
$ 165.00
$ 165.00
$ 75.00
$ 75.00
$ 75.00
$ 75.00
$ 65.00
$ 65.00
$ 65.00
$ 65.00
$ 85.00
$ 85.00
$ 85.00
$ 85.00
$ 230.00
$ 230.00
$ 160.00
$ 170.00
$ 20.00
$ 20.00
$ 160.00
$ 245.00
$ 245.00
$ 245.00
$ 245.00
$ 245.00
no charge
$150.00
$ 245.00
$ 245.00
$ 245.00
$ 245.00
$ 245.00
$ 245.00
$ 245.00
$ 245.00
$ 245.00
$ 245.00
$ 245.00
$ 245.00
$ 245.00
$ 245.00
$ 245.00
$ 245.00
$ 245.00
$ 245.00
$ 245.00
$ 245.00
$ 245.00
$ 245.00
$ 245.00
$ 245.00
$ 245.00
Page 5 of 6
"(3,!2'4#%#,#0*1#04'!#
#+ #0.71
D9110 Palliative (emergency) treatment of dental
pain—minor procedure . . . . . . . . . . . . . . . . . . . . . . . .
D9120 Fixed partial denture sectioning . . . . . . . . . . . . . . . .
D9210 Local anesthesia not in conjunction with operative
or surgical procedures . . . . . . . . . . . . . . . . . . . . . . . . . .
D9211 Regional block anesthesia . . . . . . . . . . . . . . . . . . . . . .
D9212 Trigeminal division block anesthesia . . . . . . . . . . . .
D9215 Local anesthesia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
D9220 General anesthesia—first 30 minutes (limited
to the removal of partial, or complete boney
impacted teeth) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
D9221 General anesthesia—additional 15 minutes
(limited to the removal of partial, or complete
boney impacted teeth) . . . . . . . . . . . . . . . . . . . . . . . . .
D9230 Analgesia (nitrous oxide), per 15 minutes . . . . . . .
D9241 I.V. conscious sedation—first 30 minutes
(limited to the removal of partial, or complete
boney impacted teeth) . . . . . . . . . . . . . . . . . . . . . . . . .
D9242 I.V. conscious sedation—additional 15 minutes
(limited to the removal of partial, or complete
boney impacted teeth) . . . . . . . . . . . . . . . . . . . . . . . . .
D9248 Non-intravenous conscious sedation . . . . . . . . . . .
D9450 Case presentation, detailed and extensive
treatment planning . . . . . . . . . . . . . . . . . . . . . . . . . . . .
D9610 Non-intravenous conscious sedation . . . . . . . . . . .
D9612 Therapeutic parenteral drugs, two or more
administrations, different medications . . . . . . . . .
D9630 Other drugs and/or medicaments, by report . . . .
D9910 Application of desensitizing medicament . . . . . . .
D9940 Occlusal guard, by report . . . . . . . . . . . . . . . . . . . . . . .
D9942 Repair and/or reline of occlusal guard . . . . . . . . . . .
D9951 Occlusal adjustment—limited . . . . . . . . . . . . . . . . . .
D9952 Occlusal adjustment—complete . . . . . . . . . . . . . . .
*#!&',%
$ 10.00
no charge
no charge
no charge
no charge
no charge
$ 150.00
$ 45.00
$ 15.00
$ 150.00
$ 45.00
$ 15.00
no charge
$ 15.00
02&-"-,2'!1
#+ #0.71
D8070 Comprehensive orthodontic treatment of the
transitional dentition. . . . . . . . . . . . . . . . . . . . . . . . . . $ 1,850.00
Consultation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . no charge
Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 35.00
Records/treatment planning. . . . . . . . . . . . . . . . . . . $ 250.00
D8080 Comprehensive orthodontic treatment of the
adolescent dentition . . . . . . . . . . . . . . . . . . . . . . . . . . $ 1,850.00
Consultation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . no charge
Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 35.00
Records/treatment planning. . . . . . . . . . . . . . . . . . . $ 250.00
D8090 Comprehensive orthodontic treatment of the
adult dentition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 1,850.00
D8680 Orthodontic retention (removal of appliances,
construction and placement of retainer(s)) . . . . $ 300.00
D8693 Rebonding or recementing; and/or repair, as required, of
fixed retainers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . no charge
+.*,21(available for groups 10+ enrolled)
-4#0%#$-0'+.*,21B
F +.*,21,"'+.*,213..-02#".0-12&#1#1!-4#0#"
at a 50% coinsurance
F ,,3*6'+3+#,#$'2-$zqAupp
F '$#2'+#6'+3+#,#$'2-$zqpAppp
$ 25.00
$ 15.00
$ 15.00
$ 85.00
$ 40.00
$ 30.00
$ 100.00
#+ #0.71
D9972 External bleaching—per arch . . . . . . . . . . . . . . . . . . . $ 125.00
NOTE:
F -2**.02'!'.2',%"#,2'121.#0$-0+***'12#".0-!#"30#1A',!*3"',%+*%+1@*#1#!-,13*27-30"#,2'12.0'-02-
treatment for availabilty of services.
F ,*'12#".0-!#"30#10#4'* *#2!#02',.02'!'.2',%"#,2'121313*$##*#11mp|@'1'23+,#,2*@!-+2-$',"
a participating dentist who offers the discount on non-covered services.
F &#,!0-5,,"G-0 0'"%#5-0)#6!##"11'63,'21',2&#1+#20#2+#,2.*,A2&#.2'#,2+7 #!&0%#",
additional $75 per unit
F -+#!-4#0#"1#04'!#10#27.'!**7-,*7-$$#0#" 71.#!'*'12H*')#+,7-0*130%#07.0-!#"30#1J
F ""'2'-,*#6!*31'-,1,"*'+'22'-,10#*'12#"*-,%5'2&$3**.*,',$-0+2'-,',7-30!#02'$'!2#-$ #,#$'21@$7-3
do not have a certificate of benefits, please review the Specialty Benefits Regulatory and Technical Information Guide
available at Disclosure.Humana.com.
Current Dental Terminology © 2007 American Dental Association. All rights reserved.
Insured or administered by CompBenefits Company
Humana.com
FL52438HDI 3/13
Page 6 of 6
See things more clearly with
a Humana vision plan.
A thorough
health
exam
prevent vision
andhealth,
also detect
Offering
a eye
vision
plan
not can
onlyhelp
promotes
goodloss,
vision
but more
may serious
also
reduce
total
healthcare
costs
over
time.
A
thorough
eye
health
exam
diseases. You can feel good knowing Humana vision plans encourage prevention,can
early
help prevent
vision loss, and also detect more serious diseases. You can feel
diagnosis,
and treatment.
good knowing Humana vision plans encourage prevention, early diagnosis,
and treatment.
tHumana
vision plan is offered by Dade County Firefighters Insurance Trust as
F an
Offer
a Humana
vision
plan lat
little orpremium..
no additional cost to your
optional
benefit at
a nominal
bi-weekly
benefits budget.
tHumana' s unique network is one of the largest with more than 35,000 participating
F optometrist,
Add vision to
your Humanaand
medical
dental
plan and save with
ophthalmologist,
nationalorretail
locations.
our multiline discounts.
tYou will get deep discounts (wholesale pricing) no matter which in-network provider
F Our unique network is one of the largest with more than
you choose. Plus, you’ll receive discounts on Lasik procedures.
35,000 participating optometrist, ophthalmologist, and
national
tThere
areretail
lots oflocations.
frame choices with access to exclusive lines of designer frames, such
®
®
as,
Ralph
Lauren,
Dolce&Gabbana,
Oakley,®(wholesale
Prada, and Ray-Ban
F Your employees will
get deep discounts
pricing) .
no matter
provider
tYou
can takewhich
care ofin-network
eye exams and
framesthey
all inchoose.
one visit.Plus,
Manythey’ll
locations offer night
receive discounts on Lasik procedures.
and weekend appointments to fit your schedule.
F There are lots of frame choices with access to exclusive lines of
designer frames, such as, Ralph Lauren,® Dolce&Gabbana, Oakley,®
Prada, and Ra 2016 Humana VisionCare Bi-weekly Premium
FSingle
Your employees
care of eye exams
and frames all
in one visit.
- $2.47 can takeMember+1
- $4.93
Family
- $8.16
Many locations offer night and weekend appointments to fit your schedule.
A vision plan is one of
the top five most desired
benefits, after medical
insurance, by employees,
according to LIMRA
International.
HumanaVision
Vision Care Plan
HumanaVision
Florida
Florida
HumanaVision
Vision Care Plan
Vision Care Plan
Exam with dilation as necessary
Lenses
Exam with dilation as necessary
F Single
Lenses
F Bifocal
F Single
F Trifocal
F Bifocal
Frames
F
Trifocal
1
Contact
Frames lenses
F Elective (conventional
and disposable)2
Contact
lenses1
3
See a participating provider
See a nonparticipating provider
100%
after $10 copay
See a participating
provider
$35
See allowance
a nonparticipating provider
$35 allowanceSee a participating provider
100% after $10 copay
100% after
$15with
copaydilation as necessary
$25 allowance100% after $10 copay
Exam
100% after $15 copay
$40 allowance
Lenses
100% after
$15 copay
$25 allowance
100% after $15 copay
$60 allowance
100% after
F Single
$15 copay
$40 allowance100% after $15 copay
$45
wholesale
$45 allowance
retail allowance
100%
after
$15allowance
copay
$60
F Bifocal
100% after $15 copay
F Trifocal
100% after $15 copay
$45 wholesale
allowance
$45 retail allowance
$120 allowance
$120 allowance
$45 wholesale allowance
Frames
1
F Medically necessary (limit one pair) 2
100%
$210 allowance
Contact lenses
F Elective (conventional and disposable)
$120 allowance
$120 allowance
Frequency
(based
on
date
of
service)
3
2
F Medically necessary (limit one pair)
100% F Elective (conventional and disposable)
$210 allowance
$120 allowance
F Examination
Once every
12
months
Once
every
12 100%
months
3
F
Medically
necessary
(limit
one
pair)
Frequency (based on date of service)
F Lenses or contact lenses
Once every 12 months
Once every 12 months
Frequency
(based on date of
service)
F Frame
Examination
Once every
every
12 months
Once
every 12
12 months
F
Once
12
months
Once
every
months
F
Lenses
or
contact
lenses
Once
every
12
months
Once
every
12
months
F
Examination
Once
every 12 months
Additional plan discounts
F
Once
12 months
Once every
12 Once
months
F Lenses
or including:
contact lenses
every 12 months
F Frame
Members receive additional fixed copayments
onevery
lens
options
anti-reflective
and scratch-resistant
Additional
F Frame
Once every 12 months
coatings.plan discounts
F Members receive
additional
lens
options
anti-reflective
and
scratch-resistant
also receive
a 20%fixed
retailcopayments
discount on on
a second
pair plan
ofincluding:
eyeglasses.
This discount
is available
for 12 months
Additional
discounts
coatings.
after the covered eye exam and available through F
the
networkreceive
provider
who soldfixed
the initial
pair of eyeglasses.
Members
additional
copayments
on lens options including: a
F Members
also
receive polycarbonate
a 20% retail discount
on at
a second
pairfor
of dependents
eyeglasses. This
is available
After copay,
standard
available
no charge
less discount
than 19 years
old. for 12 months
coatings.
after
the
covered
eye
exam
and
available
through
the
network
provider
who
sold
the
initial
pair
of
eyeglasses.
F Members
also receive
a 20%inretail
discount
onbenefits
a second pair of eyeglasses
1
If a member prefers contact lenses, the plan provides
an allowance
for contacts
lieu of
all other
F After copay, standard polycarbonate available at no charge
forcovered
dependents
less than
19 years old.
after
the
eye
exam
and
available
through
the network provider w
(including frames) (Vision Care Plan only).
1
F
After
copay,
standard
polycarbonate
available
at
no
charge for dependent
2 If a member prefers contact lenses, the plan provides an allowance for contacts in lieu of all other benefits
The contact lens allowance applies to professional services (evaluation and fitting fee) and materials. Members
1
(including
frames)
(Vision
Careon
Plan
only). professional
If a member
contact
the plan
provides
an allowance for con
receive a 15
percent
discount
in-network
services.prefers
The discount
forlenses,
professional
services
is available
2
The
contact
lens
allowance
applies
to
professional
services
(evaluation
and
fitting
fee)
and
materials.
Members
(including
frames)
(Vision
Care
Plan
only).
for 12 months after the covered eye exam.
3 receive a 15 percent discount on in-network professional
services.
The
discount
for
professional
services
is available
Theone
contact
lens
allowance
applies
to professional
services
Benefit provides coverage for professional services2and
pair of
medically
necessary
contact
lenses with
prior(evaluation an
for
12
months
after
the
covered
eye
exam.
receive
a
15
percent
discount
on
in-network
professional
services. The disc
plan authorization.
3
Benefit provides coverage for professional services and
pair of medically
necessary
for one
12 months
after the covered
eyecontact
exam. lenses with prior
3
plan authorization.
Benefit provides coverage for professional services and one pair of medica
HumanaVision Lasik discount
plan authorization.
We have contracted with many well-known facilities and eye doctors to offer Lasik procedures at substantially reduced
fees. You can take advantage of these low fees when procedures are done by network providers. The network locations
listed below offer the following prices (per eye):
Vision Care Plan
Conventional / Traditional
Custom
TLC
888-358-3937
(designated
locations only)
LasikPlus
866-757-8082
QualSight
LASIK
855-456-2020
FL51514HVC 313
*with IntraLaseTM
$895
$1,295
$1,895*
$695*
LasikPlus free
enhancements
for 1 year
$1,395*
LasikPlus free
enhancements
for life
$1,895*
LasikPlus free enhancements for
life
$895
QualSight free
enhancements
for 1 year
$1,295
with QualSight
Lifetime
Assurance Plan
$1,995*
with QualSight
Lifetime
Assurance Plan
$1,320
FL51514HVC 313
How does the wholesale frame allowance work?
You can also use independent
Lasik provider network doctors to
receive a 10% discount from usual
and customary prices and pay
no more than $1,800 per eye for
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Page 1 of 3
Page 1 of 3
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Page 2 of 3
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Finding a provider is easy.
Call Customer Care at 1-866-537-0229
or go to HumanaVisionCare.com.
To offer the widest choice, HumanaVision also includes independent optometrists
and ophthalmologists located throughout the country. For a complete listing of
providers near you, visit humanavisioncare.com.
Looking for a great pair of glasses to fit your unique personality and lifestyle?
LensCrafters is the right place for you. You can choose from a wide selection of
fashion frames including the latest designers like Prada®, Versace®, Burberry ®, and
Dolce & Gabbana®. Add the latest lens technology for that great pair of glasses.
More than 850 locations nationwide. Visit lenscrafters.com for the latest styles
and trends and your nearest location.
Pearle Vision continues the legacy of personalized eye care that Dr. Stanley Pearle
started over 45 years ago. Combine that with a great selection of frames and lens
options and over 750 convenient locations to make Pearle Vision a great place for
your family’s eye care. Go to pearlevision.com to learn more.
Sears Optical has been helping families see better and look great at the right price
for over 45 years. Everything you love and trust about Sears is what you’ll find
at Sears Optical — professional service, stylish selection of frames and the latest
contact lens advancements, quality, and great value for the entire family. Satisfaction
guaranteed or your money back. More than 850 Sears Optical locations are
conveniently located nationwide. Visit searsoptical.com for one near you.
Your eyes. Your style. Target Optical provides fashion for less than you’ve come
to expect from Target, with the care of a professional independent doctor of
optometry. You can choose from a huge selection of frames and sunglasses, including
brands like Mossimo®, Vogue®, and Versus®. The latest contact lens technology is also
available at affordable prices. Visit target.com for more information.
JCPenney Optical is a full-service optical center conveniently located in more
than 350 JCPenney department stores. Choose from hundreds of frames that will
inspire and reflect your lifestyle, including exclusive designer brands such as Bisou
Bisou®, a.n.a.®, Liz & Co.®, and Arizona®. JCPenney Optical also offers eye exams,
contact lenses, and non-prescription sunwear to meet all of your eyewear needs.
Insured by Humana Insurance Company, CompBenefits Insurance Company, CompBenefits of HumanaDental Insurance Company,
CompBenefits Company, or The Dental Concern, Inc.
GCA0AV3HH
CHOICE PLUS (Low Option Plan)
CHOICE PLUS (High Option Plan)
TYPE OF COVERAGE
FIRST NAME
Child 4
Child-3
Child-2
Child-1
Spouse
Employee
Last Name
OTHER INSURANCE
First Name
Employee Plus Family
Sex
DATE OF HIRE
8
Medicare Number
DATE SUBMITTED
Social Security Number
HEALTH/CHANGE EFF. DATE
N
Y
Terminate Spouse/Child (complete Sec 5)
Add Spouse/Child (complete Sec 5)
Social Security #
(
)
Married
M
F
M
F
M
F
M
F
M
F
Sex
Y
N
Y
N
Y
N
Y
N
Handicapped
________________________________
Reinstatement - Reason
________________________________
Surviving Spouse
Former Employee SSN
________________________________
COBRA Continuee
Former Employee SSN
________________________________
Open Enrollment
AUTHORIZATION
Date of Birth
(Mo./Day/Yr.)
_____________________________
Terminate All Coverage - Reason
Name Change (complete Sec 5)
Address (enter above)
)
WORK PHONE NUMBER
(
HOME PHONE NUMBER
Single
MARITAL STATUS
TYPE OF CHANGE
ACTIVE MEMBER
ZIP CODE
SOCIAL SECURITY NUMBER
������
GRP/SUBGRP/BNFT GRP
PLAN VARIATION/SUB
REPORTING CODE/BRANCH
EMPLOYER SIGNATURE
X Signature ________________________________________________________ Date ______________
On behalf of myself and anyone enrolled on or added to this form (“Us”), I authorize any health care professional or entity to give The United HealthCare Insurance Company and its affiliates
(and the employer) or any of their designees (“United HealthCare”), any and all records or information pertaining to medical history or services rendered to Us for any administrative purpose,
including evaluation of an application or a claim, and for any analytical or research purposes. I also authorize on behalf of Us the use of a Social Security Number for purpose of identification. I
understand and agree that any omissions or incorrect statements made on this application may invalidate my and/or my dependent’s coverage. I further understand that coverage will become
effective only on the date specified by the Insurer or Plan Administrator after it has been approved by the Insurer or Plan Administrator and after the full premium has been paid. By signing this
form, I hereby certify that all the information provided is true and correct.
If my employer’s plan is a contributory plan, I direct my employer to deduct the amount of any required contribution from my pay. I can cancel this direction in writing at any time.
NOTICE OF ENROLLMENT RIGHTS
I understand that if I and/or my dependents, if any, waive coverage and desire to participate in the plan at a later date, coverage may be subject to treatment as a late enrollee. I further
understand that if I decline enrollment for myself or dependents (including my spouse) because of other health coverage, I may in the future be able to enroll myself or my dependents in this
plan, provided that I request enrollment within 30 days after such coverage ends. In addition, if a new dependent relationship forms as a result of marriage, birth, adoption or placement for
adoption, I may be able to enroll myself and my dependents provided that I request enrollment within 30 days after such marriage, birth, adoption, or placement for adoption.
Health insurance or medical services benefits provided or administered by The United HealthCare Insurance Company, Hartford, CT.
7
MI
4
FULL TIME
STATE
DATE OF BIRTH
TO BE COMPLETED BY EMPLOYER
POLICY NUMBER
Part B Effective Date
Other Company’s Name and Phone Number
Part A Effective Date
Other Company’s Policy Number and Effective Date
Date of Birth
Person’s Name with Other Health Plan
N
Y
Employee Plus Child/ren
Employee Plus Spouse
Employee Only
On the day your coverage begins, will any family members, including those not listed above, be
covered by any other health benefit plan, health or dental insurance, Medicare or Medicaid?
Is another person legally responsible for coverage for your children?
If you answered yes to either of the questions above, please complete the following:
6
(A) Add
(T) Term
(C) Chg
5
*Note: If you are declining coverage for yourself or your dependants, because
of coverage under other health coverage, you are required to complete this
section. Your failure to do so may cause you or your dependents to be
considered late enrollees if you enroll in this plan at a later date.
Male
Female
EMPLOYEE INFORMATION
SEX
3 WHO SHOULD BE COVERED
CITY
MI
PLEASE READ INSTRUCTIONS ON REVERSE SIDE. PLEASE PRINT CLEARLY.
Enrollment Application and Change Form
EMAIL ADDRESS
I decline coverage for myself
I decline coverage for my dependents
Reason:
Covered under another plan.
Other: ________________ (See Sec 7&8)
2
DADE COUNTY FIRE FIGHTERS
INSURANCE TRUST
EMPLOYER NAME
HOME ADDRESS
LAST NAME
1
REQUEST FOR CHANGE
NEW COVERAGE
Loss of Eligibility - Children under Age 26
1. Becoming eligible for employer-issued medical coverage.
2. Entering Military Service.
Printed 01/01/2016
• Marriage\Divorce (Ex-spouse & step-children cease to be eligible as of the last day of month final divorce decree is signed by Judge
• Birth of a child
• Adoption of a child or placement for adoption
• Beginning or end of employment of a spouse (resulting in gain or loss of insurance coverage)
• Ineligibility of dependent child – (Eligibility for employer issued health coverage for active military)
• Employment change from full-time to part-time or vice versa (employee or spouse)
• Unpaid LOA (employee or spouse)
• Medicare/Medicaid/Florida Kid Care
• Spouse’s employer’s open enrollment
• Significant change in health coverage due to spouse’s employment.
How do I make a change to my health plan mid-year? Once the open enrollment period closes, you may add or delete dependents to your health plan only under
limited circumstances (a qualifying event). Changes must be reported within 30 days of a qualifying event. You must provide proper documentation and complete a
Miami-Dade Change in Status (CIS) form and a UHC Enrollee Change form to the Trust Office. Election changes must be consistent with the event and result in loss or
gain of insurance coverage. Mid-year changes from one health plan to another are not permitted. A partial list of permitted mid-year changes appears below.
Change In Status/Mid-Year Plan Changes
Use this form and follow the instructions for each section below. Please make sure that all applicable fields are completely and accurately filled out.
Check appropriate box to indicate if you are enrolling for the first time or making a change.
SECTION 1
Complete all information.
SECTION 2
Check the coverage plan you would like (Choice Plus Plan Low Option (former HMO Plan) or High Option (former PPO Plan)
SECTION 3
Select who should be covered on the plan.(Copy of marriage and birth certificates must be provided for covered dependents)
SECTION 4
Complete this section if you are making a change. Select the box which indicates the type of change you are making.
SECTION 5
Fill in the appropriate action code for completing this form:
A = To add a dependent to your benefit plan.
T = To terminate yourself or a dependent’s coverage.
C = To change information about yourself or a dependent.
Print your full name and the names of your covered dependents, if any. If any member listed has another health plan, check the box
marked COB (Coordination of Benefits) and complete Section 7. Provide Social Security Number, date of birth, and sex for each dependent
and check the appropriate boxes indicating if a dependent is handipcapped or a full-time student. (If you have more than 4 dependents,
please attach an additional enrollment form.)
SECTION 6
This section must be completed for all new enrollments or coverage changes.
SECTION 7
The employee must sign and date this form in order for it to be processed.
SECTION 8
This section is to be completed by the employer’s benefit representative.
Enrollment Application and Change Form
Instructions
UnitedHealthcare Dental
®
UnitedHealthcare Dental® Enrollment Form
SOCIAL SECURITY NUMBER
EMPLOYEE ID NUMBER (if different than SSN)
LAST NAME
FIRST NAME
❑ Enroll
❑ Address Change
Date of Change
MI
ADDRESS
Work (
❑ Employee Only
PLAN COVERAGE
❑ Change
❑ Number Change
/
ENROLLEE’S
DATE OF BIRTH
CITY
TELEPHONE NIMBER
Home (
)
❑ Cancel
/
STATE
ZIP
❑ Male
❑ Single
)
❑ Employee + Spouse
❑ Employee + Children
❑ Female
❑ Married
❑ Family
Dade County Firefighters Insurance Trust - Dental Options PPO - Group#204581
INFORMATION FOR DEPENDENT COVERAGE
Spouse & Unmarried Dependent Children Only (Include Date of Birth)
Last Name
First Name
MI
Relationship**
❑ Wife
❑ Husband
❑ Son
❑ Daughter
❑ Son
❑ Daughter
❑ Son
❑ Daughter
❑ Son
❑ Daughter
Date of Birth
Social Security Number
(Your choice of dental is included in bi-weekly premium)
EMPLOYER INFORMATION - TO BE FILLED OUT BY EMPLOYER
COMPANY NAME:
ENROLLMENT:
❑ New Hire
Dade County Firefighters Insurance Trust
❑ Other
DATE OF HIRE:
(Mo/Day/Yr) _____/_____/ _____
POLICY NUMBER:
204581
ENROLLEE EFFECTIVE DATE:
(Mo/Day/Yr _____/_____/ _____
CLASS CODE:
PLAN CARIATION/REPORTING CODE:
PLAN CODE:
0005
ACTIVE
EMPLOYMENT AUTHORIZATION
I confirm that the information I have provided on this form is complete and accurate.
I understand that the dental benefit plan I have selected provides reimbursement for certain dental costs which are more fully described in the current Certificate of
Coverage or Summary Plan Description. I understand there may be instances where treatment decisions made by my dentist or me or dental expenses which I
have incurred may not be covered by my dental benefit plan.
I understand that information collected in connection with administration of the benefit plan may be used to bring to my attention health products or services that
might be valuable to me and otherwise as permitted by law. I understand that you may combine that information with other information so that it is no longer
individually identifiable and use it for commercial and other purposes.
I understand that if I and/or my dependents, if any, waive coverage and desire to participate in the plan at a later date, coverage may be subject to treatment as a
late enrollee and may apply at the next open enrollment period. I further understand that if I decline enrollment for myself or my dependents (including my spouse)
because of other dental coverage, I may in the future be able to enroll myself or my dependents in this plan, provided that I request enrollment within 30 days after
such coverage ends. In addition, if a new dependent relationship forms as a result of marriage, birth, adoption or placement for adoption, I may be able to enroll
myself and my dependent provided that I request enrollment within 30 days after such marriage, birth, adoption, or placement for adoption.
Any person who knowingly and with intent to injure, defraud, or deceive any insurer, files a statement of claim or an application containing any false, incomplete or
misleading information is guilty of a felony of the third degree.
The Certificate provides dental benefits only. Review your Certificate carefully.
SIGNATURE:
DATE:
UnitedHealthcare Dental insurance products are either underwritten or provided by: United HealthCare Insurance Company, Hartford, Connecticut (except in New York), United
Health Care Insurance Company of New York, Hauppauge, New York (New York only), or United Healthcare Services, Inc. UnitedHealthcare Dental Select HMO product is provided or
administered by the following UnitedHealth Group companies: Dental Benefit Providers, Inc., Dental Benefit Providers of California, Inc., Dental Benefit Providers of Illinois, Inc.,
Dental Benefit Providers of Maryland, Inc. and/or Dental Benefit Providers of New Jersey, Inc.
100-2659 10/05 ©2005 United HealthCare Services, Inc.
Benefits Enrollment Form
Group Name:
* Dental Facility Needed To Assign Dental Provider
Please complete the following information:
Social Security No.
Last Name
First
Home Address
Middle
Gender
Home Phone
State
City
ZIP Code
Date of Birth
Facility Number *
Business Phone
List All Your Eligible Dependents That Are To Be Covered
First
MI
Last
Sex
Facility Number *
Birth Date
Spouse:
M
F
/
/
Child:
M
F
/
/
Child:
M
F
/
/
Child:
M
F
/
/
Child:
M
F
/
/
Child:
M
F
/
/
Child:
Effective Date
M
F
/
/
Plan Code
Group Number
Your E-mail Address
Agent Code
January 1, 2016
PLEASE CHECK
YOUR CHOICE
Dental Plan
PLAN HS 95
Group#
Vision Plan
Group#
DHMO Dental included in premium
Employee Only
Employee + Spouse
Employee + Children
Employee + Family
Signature: X
Date:
Optional Coverage
DADE COUNTY FIRE FIGHTERS INSURANCE TRUST
STANDARD LIFE INSURANCE COMPANY
ACTIVE MEMBER POLICY #645783
Member Name:_______
Sex:
Date of Birth:_____/_____/________ Social Security # ______ - _____ - ____
Station: ______ A B C 40 hr.
Hire Date:____/_____/________
Home Phone: (______) _______ Address
Male
or
Female
(Circle)
Employee ID#____________________
Cell# (_____) _______ -
______
E-mail Address
City
State:
Zip Code:
________
As a participant/member of the Dade County Fire Fighters Insurance Trust you are entitled to a Life Insurance
benefit equal to:
One Time your Annual Salary for Normal Death Benefit
Two Times your Annual Salary for Accidental Death (ON & OFF DUTY)
Primary Beneficiary (ies)
Name and Address
Percent %
Relationship
Date of Birth
Social Security#
Contingent Beneficiary (ies)
Name and Address
Percent %
Relationship
Date of Birth
Social Security#
Proper notarization and signature must be obtained to validate beneficiary designations.
Signature
Date
State of Florida
SS:
County of Miami-Dade
Before me on this ________ day of ___________________, 20______ personally appeared the above individual and swore the
information contained herein to be true and of his/her free will.
Notary Public, State of Florida
Personally Known
Produced Identification
Identification Produced
________
Any person who knowingly & with intent to defraud, submits an application, files a statement of claim containing any material false or misleading
information, commits a fraudulent act, which is a crime. Subject to revocation by me by written notice to my employer, I request the coverage
provided from time to time by my employers group plan(s), as elected above and authorize deductions (if any) from my wages.
***Underwritten by STANDARD LIFE INSURANCE COMPANY, PORTLAND, OR****
Dade County Fire Fighters Insurance Trust
8000 NW 21 STREET
MIAMI, FLORIDA 33122-1605
Phone: 305-593-6100
Fax: 786-437-2574
2016 Active Member Benefit Booklet
Information contained herein does not constitute an insurance certificate or policy.
Plan participants will be provided with Identification cards prior to January 1st effective date