Blue Shield’s 2014 Medicare sales event H0504_13_200 08162013 S2468_13_200 08162013 1 Agenda • Blue Shield Accomplishments •What you need to know – updates and commissions • MA-PD Plans • Medicare Supplement Plans • PDP Plans • Specialty Benefits •Q&A 2 Recent Accomplishments • Affordability mission – 2% pledge • 4 Star quality rating* • Medicare Advantage County Expansion *Applies to Blue Shield’s 2013 MAPD and PDP plans. Medicare evaluates plans based on a 5-Star rating system. Star Ratings are calculated each year and may change from one year to the next. 3 What you need to know for the 2014 MA-PD and PDP Annual Election Period (AEP) 4 Things to remember….. • Annual Election Period (AEP) 2014 MA-PD and PDP applications accepted 10/15/2013 through 12/7/2013 for a 1/1/2014 effective date Applications cannot be submitted prior to 10/15/2013, except for initial coverage individuals who can submit as early as 10/1/2013 for a 1/1/2014 effective date • Medicare Advantage Disenrollment Period (MADP) MA plan enrollees may disenroll from 1/1/2014 through 2/14/2014 and return to Original Medicare (may also enroll in a PDP plan during this time) • Applications must be submitted in a timely manner Submit to Blue Shield within 24 hours of the applicant getting it to you • A member packet must be provided whenever an application is provided to a prospect Must include Plan Rating info, Summary of Benefits and MultiLanguage insert 5 Certification and Events • Producer must complete an annual Medicare Certification (i.e through AHIP) as well as Blue Shield’s MA-PD and PDP product-specific training prior to a sale (no exceptions, & no commissions will be paid to non-certified brokers) – In order to receive commissions on Blue Shield products, you must be individually appointed by Blue Shield or endorsed by an agency appointed by Blue Shield prior to submitting applications • Get Your $100 AHIP Reimbursement – Sell five Blue Shield MA-PD plan enrollments in order to be reimbursed a maximum of $100. PDP & Medicare Supplement Plan Sales DO NOT QUALIFY for reimbursement. • Sales Event Reporting – Please use the latest Master Sales Event template. 6 Commissions Update 7 2014 Commissions • MA-PD – $532 new, $266 renewal • PDP – $56 new, $28 renewal • Medicare Supplement Plans– 20% first year, 10% renewal Lifetime Renewals were added in 2013 for MA-PD and PDP in addition to Medicare Supplement Plans. 8 2014 Blue Shield 65 Plus HMO benefit changes 9 2014 Blue Shield 65 Plus HMO and Blue Shield 65 Plus Choice Plan HMO benefit changes For the 2014 benefit year, Blue Shield has lowered the member cost-sharing for Skilled Nursing Care in the following plans: Benefit: Skilled Nursing Care (covered up to 100 days per benefit period) Blue Shield 65 Plus HMO Los Angeles (partial) & Orange Counties Blue Shield 65 Plus Choice Plan HMO Los Angeles (partial) & Orange Counties Blue Shield 65 Plus HMO Riverside County (partial) Blue Shield 65 Plus HMO San Bernardino County (partial) Blue Shield 65 Plus HMO Ventura County (partial) Blue Shield 65 Plus HMO San Diego County (full) Blue Shield 65 Plus HMO Sacramento County (partial) Member cost-sharing amount Member cost-sharing amount 2013 2014 Days 1-10: $0 Days 11-100: $85 per day The copay is applicable per admission Days 1-20: $0 Days 21-100: $75 per day The copay is applicable per admission Days 1-10: $0 Days 11-100: $75 per day The copay is applicable per admission Days 1-20: $0 Days 21-100: $50 per day The copay is applicable per admission Days 1-10: $50 per day Days 11-100: $100 per day The copay is applicable per admission Days 1-20: $0 per day Days 21-100: $100 per day The copay is applicable per admission Days 1-10 : $50 per day Days 11-100: $100 per day The copay is applicable per admission Days 1-20: $0 per day Days 21-100: $100 per day The copay is applicable per admission Days 1-10: $50 per day Days 11-100: $100 per day The copay is applicable per admission Days 1-20: $0 per day Days 21-100: $75 per day The copay is applicable per admission Days 1-10: $0 Days 11-100: $100 per day The copay is applicable per admission Days 1-20: $0 Days 21-100: $100 per day The copay is applicable per admission Days 1-10: $50 per day Days 11-100: $100 per day The copay is applicable per admission Days 1-20: $50 per day Days 21-100: $100 per day The copay is applicable per admission 12 2014 Blue Shield 65 Plus HMO and Blue Shield 65 Plus Choice Plan HMO benefit changes For the 2014 benefit year: • Blue Shield 65 Plus HMO members will have the option of adding an Optional Supplemental Dental HMO Plan for a set monthly premium! • Blue Shield 65 Plus CHOICE Plan HMO will include embedded dental benefits at no additional cost, AND members will also have the option of adding an Optional Supplemental Dental HMO Plan for a set monthly premium. Benefit: 2014 MAPD Dental Plans Embedded Dental Benefit Optional Supplemental Dental HMO Plan Premium: $12.20 per month Blue Shield 65 Plus Choice Plan HMO Los Angeles (partial) & Orange Counties Specific ADA codes covered. Copay varies by ADA codes. (See EOC for details) Blue Shield 65 Plus HMO ALL COUNTIES Not Covered 13 Available for a monthly premium Specific ADA codes covered. Copay varies by ADA codes. (See EOC for details) Available for a monthly premium Specific ADA codes covered. Copay varies by ADA codes. (See EOC for details) 2014 Blue Shield 65 Plus HMO County Expansions 42 Blue Shield 65 Plus 2014 County Expansions For the 2014 benefit year, Blue Shield 65 Plus HMO will expand into 3 new counties with competitive benefits: New counties as of 2014: – Contra Costa County (Partial) - Blue Shield 65 Plus (HMO) – Fresno County- Blue Shield 65 Plus (HMO) – Santa Clara County (Partial) - Blue Shield 65 Plus (HMO) Contra Costa Santa Clara Fresno 43 blue shield 65 plus (HMO) benefits For the 2014 benefit year, Blue Shield’s MAPD plans in the new counties will include the following Maximum Out-of-Pocket (MOOP) amounts: Benefits Annual out-of-pocket maximum (Medicare Parts A and B covered services) Blue Shield 65 Plus (HMO) Blue Shield 65 Plus (HMO) Blue Shield 65 Plus (HMO) Contra Costa County (partial) Fresno County Santa Clara County (partial) New county as of 2014 New county as of 2014 New county as of 2014 $2,900 $2,900 $2,900 $0 $0 $0 Monthly Plan Premium (Members must continue to pay their monthly Medicare Part B premium) 44 blue shield 65 plus (HMO) benefits Benefits Inpatient Hospital Care Inpatient Mental Health Care Skilled Nursing Facility Blue Shield 65 Plus (HMO) Blue Shield 65 Plus (HMO) Blue Shield 65 Plus (HMO) Contra Costa County (partial) Fresno County Santa Clara County (partial) New county as of 2014 New county as of 2014 New county as of 2014 Days 1-5: $125 copay/day Days 1-5: $160 copay/day Days 1-5: $125 copay/day Days 6-90: $0 copay/day Days 6-90: $0 copay/day Days 6-90: $0 copay/day No limit to the number of covered days/benefit period* No limit to the number of covered days/benefit period* No limit to the number of covered days/benefit period* $900 per stay (150 days each benefit period up to 190-day limit) $900 per stay (150 days each benefit period up to 190-day limit) $900 per stay (150 days each benefit period up to 190-day limit) Member pays 100% of costs for days 151 and over unless a new benefit period begins Member pays 100% of costs for days 151 and over unless a new benefit period begins Member pays 100% of costs for days 151 and over unless a new benefit period begins Up to 190 days in a Medicarecertified Psychiatric Hospital in a lifetime Up to 190 days in a Medicarecertified Psychiatric Hospital in a lifetime Up to 190 days in a Medicarecertified Psychiatric Hospital in a lifetime Days 1-20: $0 copay/day Days 21-100: $100 copay/day Days 1-20: $0 copay/day Days 21-100: $100 copay/day Days 1-20: $0 copay/day Days 21-100: $100 copay/day Copays applicable per admission Copays applicable per admission Copays applicable per admission 100 covered days/benefit period* No prior hospital stay is required 100 covered days/benefit period* 100 covered days/benefit period* No prior hospital stay is required No prior hospital stay is required Primary Care Physician Visits $0 copay/visit $0 copay/visit $0 copay/visit Specialist Visit $8 copay/visit $10 copay/visit $9 copay/visit *Benefit Period : A Benefit Period begins with the first day of the Medicare-covered Inpatient Hospital stay or Skilled Nursing Facility stay and ends with the close of a period of 60 consecutive days, during which you are not an Inpatient of a Hospital or Skilled Nursing Facility. 45 blue shield 65 plus (HMO) benefits Benefits Blue Shield 65 Plus (HMO) Blue Shield 65 Plus (HMO) Blue Shield 65 Plus (HMO) Contra Costa County (partial) Fresno County Santa Clara County (partial) New county as of 2014 New county as of 2014 New county as of 2014 $0 copay $0 copay $0 copay (office visit copay may apply) (office visit copay may apply) (office visit copay may apply) Outpatient Substance Abuse Care $30 copay/individual or group session $30 copay/individual or group session $30 copay/individual or group session Outpatient Hospital Services $50 copay/visit at an ambulatory surgical center $50 copay/visit at an ambulatory surgical center $150 copay/visit at an outpatient hospital facility $150 copay/visit at an outpatient hospital facility $50 copay/visit at an ambulatory surgical center $100 copay/visit at an outpatient hospital facility Ambulance (each way) $150 copay/trip $175 copay/trip $250 copay/trip Emergency Care $65 copay/visit $65 copay/visit $65 copay/visit Worldwide coverage Worldwide coverage Worldwide coverage $10,000 combined annual limit for covered emergency care or urgently needed care outside the U.S. $10,000 combined annual limit for covered emergency care or urgently needed care outside the U.S. $10,000 combined annual limit for covered emergency care or urgently needed care outside the U.S. Annual Wellness Visit (1 exam every 12 months) 46 blue shield 65 plus (HMO) benefits Benefits Blue Shield 65 Plus (HMO) Blue Shield 65 Plus (HMO) Blue Shield 65 Plus (HMO) Contra Costa County (partial) Fresno County Santa Clara County (partial) New county as of 2014 New county as of 2014 New county as of 2014 $15 copay/visit (within plan service area) $15 copay/visit (within plan service area) $15 copay/visit (within plan service area) $15 copay/visit (outside plan service area but within US) $15 copay/visit (outside plan service area but within US) $15 copay/visit (outside plan service area but within US) $65 copay/visit (outside US) $65 copay/visit (outside US) $65 copay/visit (outside US) Worldwide coverage $10,000 combined annual limit for covered emergency care or urgently needed care outside the U.S. Worldwide coverage $10,000 combined annual limit for covered emergency care or urgently needed care outside the U.S. Worldwide coverage $10,000 combined annual limit for covered emergency care or urgently needed care outside the U.S. Outpatient Rehabilitation Services (PT/OT/ST) $20 copay/visit $20 copay/visit $20 copay/visit Durable Medical Equipment (DME) 20% of Medicare-allowable amount per item per month 20% of Medicare-allowable amount per item per month 20% of Medicare-allowable amount per item per month Urgent Care 47 blue shield 65 plus (HMO) benefits Benefits Blue Shield 65 Plus (HMO) Blue Shield 65 Plus (HMO) Blue Shield 65 Plus (HMO) Contra Costa County (partial) Fresno County New county as of 2014 New county as of 2014 Santa Clara County (partial) Chiropractic (Medicarecovered) $8 copay/visit $10 copay/visit $9 copay/visit Podiatry (Routine) Not covered Not covered Not covered $8 copay/visit $10 copay/visit $9 copay/visit $30 copay/ individual or group therapy visit $30 copay/ individual or group therapy visit $30 copay/ individual or group therapy visit $0 copay $0 copay $0 copay (office visit copay may apply) (office visit copay may apply) (office visit copay may apply) $50 copay $50 copay $50 copay (office visit copay may apply) (office visit copay may apply) (office visit copay may apply) Podiatry (Medicare-covered) Outpatient Mental Health Care Basic Diagnostic Tests, X-Rays, Supplies, Blood, & Lab (Including EKGs) Diagnostic Radiology Services (e.g., MRIs, PET scans, CT scans, Nuclear Medicine studies, Myelogram, Cardiac Stress Tests, Cystogram, Angiogram, SPECT) 48 New county as of 2014 blue shield 65 plus (HMO) benefits Benefits Diabetes Self-Management Training Diabetes Supplies Therapeutic Radiology Services (e.g., radiation therapy, radium and isotope therapy, chemotherapy) Blue Shield 65 Plus (HMO) Blue Shield 65 Plus (HMO) Blue Shield 65 Plus (HMO) Contra Costa County (partial) Fresno County Santa Clara County (partial) New county as of 2014 New county as of 2014 New county as of 2014 $0 copay $0 copay $0 copay $0 copay $0 copay (regardless of where the supplies are obtained) (regardless of where the supplies are obtained) (regardless of where the supplies are obtained) 20% of the Medicare-allowable amount 20% of the Medicare-allowable amount 20% of the Medicare-allowable amount (office visit copay may apply) (office visit copay may apply) (office visit copay may apply) 10% of the Medicare-allowable amount/treatment 20% of the Medicare-allowable amount for drugs used/treatment 10% of the Medicare-allowable amount/treatment 20% of the Medicare-allowable amount for drugs used/treatment 10% of the Medicare-allowable amount/treatment 20% of the Medicare-allowable amount for drugs used/treatment Dialysis Treatments 49 $0 copay blue shield 65 plus (HMO) benefits Benefits Blue Shield 65 Plus (HMO) Blue Shield 65 Plus (HMO) Contra Costa County (partial) Fresno County New county as of 2014 New county as of 2014 $0 copay $0 copay $0 copay (office visit copay may apply) (office visit copay may apply) (office visit copay may apply) $20 copay (1 every year) $20copay (1 every year) $20 copay (1 every year) Medicare-covered Eye Wear $0 copay $0 copay $0 copay Eyeglass Lenses (one set of medically necessary uncoated lenses or standard anti-reflective lenses every 12 months) $20 copay $20 copay $20 copay Eyeglass Frames (one set of frames every 24 months) $20 copay (up to $75 retail value) $20 copay (up to $75 retail value) $20 copay (up to $75 retail value) SilverSneakers Fitness Program Basic health club membership/fitness classes Basic health club membership/fitness classes Basic health club membership/fitness classes $0 copay $0 copay $0 copay $0 copay $0 copay $0 copay Medicare-covered Hearing Exam Routine Eye Exam NurseHelp 24/7 50 Blue Shield 65 Plus (HMO) Santa Clara County (partial) New county as of 2014 blue shield 65 plus (HMO) benefits Benefits Blue Shield 65 Plus (HMO) Blue Shield 65 Plus (HMO) Blue Shield 65 Plus (HMO) Contra Costa County (partial) Fresno County Santa Clara County (partial) New county as of 2014 New county as of 2014 New county as of 2014 Retail In-Network Preferred or Other Network Pharmacy 30-day Supply Tier 1: Preferred Generic Drugs $5 copay $5 copay $5 copay Tier 2: Preferred Brand Drugs $45 copay $45 copay $45 copay Tier 3: Non-Preferred Brand Drugs $90 copay $90 copay $90 copay Tier 4: Injectable Drugs 25% of Blue Shield's contracted rate 25% of Blue Shield's contracted rate 25% of Blue Shield's contracted rate Tier 5: Specialty Tier Drugs 33% of Blue Shield's contracted rate 33% of Blue Shield's contracted rate 33% of Blue Shield's contracted rate *Part D drug formularies vary by plan. Refer to Blue Shield 65 Plus HMO and Blue Shield 65 Plus Choice HMO plan formulary lists for details. 52 blue shield 65 plus (HMO) benefits Benefits Gap Coverage (for all plans) Blue Shield 65 Plus (HMO) Blue Shield 65 Plus (HMO) Contra Costa County (partial) Fresno County New county as of 2014 New county as of 2014 Blue Shield 65 Plus (HMO) Santa Clara County (partial) New county as of 2014 Tier 1- Preferred Generic Drugs: members will pay the same copayments referenced in previous slides. Generic Drugs in Tiers 2-5, : members are responsible for 72% coinsurance through the Medicare Coverage Gap Discount Program Brand Name Drugs in Tiers 2 through 5: members are responsible for 47.5% coinsurance through the Medicare Coverage Gap Discount Program Catastrophic Coverage - For drug costs after member's true out of pocket (TrOOP) costs reach $4,750. The greater of $2.55 for generic (including brand drugs treated as generic) and $6.35 for all other drugs, or 5% coinsurance The greater of $2.55 for generic (including brand drugs treated as generic) and $6.35 for all other drugs, or 5% coinsurance 58 The greater of $2.55 for generic (including brand drugs treated as generic) and $6.35 for all other drugs, or 5% coinsurance Blue Shield Medicare Supplement Plans ‹#› 2014 Blue Shield Medicare Supplement plans Blue Shield offers 7 of the 2010 standardized plans: A, C, D, F, & K High Deductible F &N –Affordable monthly rates –A wide choice of plans –The freedom to select their own doctors –Plans are age banded in pricing –All plans include the basic core benefit –Blue Shield offers the SilverSneakers Fitness Program at no additional cost 60 Welcome to Medicare rate savings New to Medicare? Then we want to welcome you! •Beginning December 1st, 2012, new member can save $15 each month for the first 12 months* on the Blue Shield Medicare Supplement plan rates if he/she is new to Medicare Part B To qualify: •The member must be age 65 or older •Blue Shield must receive the application within 6 months of the date he/she first enrolled for benefits under Medicare Part B Welcome to Medicare Rate Savings is available for all Medicare Supplement plans offered by Blue Shield *These additional monthly savings are due to increased efficiencies from administering Medicare Supplement plans under this program/service are passed on to the subscriber. For more information, refer to the Producer Information Booklet or contact your Blue Shield of California Regional Sales Manager 61 Easy$PaySM Program • No checks to write • No postage to pay • If your clients choose to use our Easy$PaySM method of automatic deductions for payment of their monthly dues, they save $3 per month* Note: Automatic deductions are available through checking or savings accounts only. • Current Easy$PaySM members will automatically receive the $3 savings** *These additional monthly savings are due to increased efficiencies from administering Medicare Supplement plans under this program/service are passed on to the subscriber. **For more information, refer to the Producer Information Booklet or contact your Blue Shield of California Regional Sales Manager 62 Blue Shield extends its Medicare Supplement Plan Special Open Enrollment Period • Blue Shield of California is pleased to extend its Medicare Supplement plan Special Open Enrollment period through June 30, 2014. • Your clients currently enrolled in a Medicare Supplement plan qualify, and may transfer to any open Medicare Supplement plan offering benefits equal to or lesser than those provided in their current plan without going through underwriting. • Individuals enrolled in another carrier’s plan just submit a new application without having to complete a health questionnaire*. Current Blue Shield members must simply complete the Guaranteed Acceptance Application Form to take advantage of this special open enrollment period. *Individuals currently enrolled in a Medicare Supplement plan from another carrier must submit a replacement of coverage form along with the new application. 63 2014 Blue Shield Medicare Prescription Drug Plans (PDP) ‹#› 2014 Blue Shield Part D (PDP) Plan changes Effective January 1, 2014, Blue Shield will continue to offer two PDP plans: Blue Shield Medicare Enhanced Plan Blue Shield Medicare Basic Plan 65 Blue Shield Medicare Prescription Drug Plans (PDP) •Blue Shield Medicare Enhanced Plan (PDP) •Blue Shield Medicare Basic Plan (PDP) Benefit Monthly Plan Premium Annual Deductible Blue Shield Medicare Enhanced Plan (PDP) Blue Shield Medicare Basic Plan (PDP) 6 Tiers 6 Tiers $74.40 $42.80 (2013: $72.50) (2013: $53.40) $0 $310 (2013: $325) * Blue Shield Medicare Prescription Drug Plans have different Part D drug formularies. Refer to the Blue Shield Medicare Enhanced Plan and Blue Shield Medicare Basic Plan formulary lists for details. 66 Blue Shield Medicare Prescription Drug Plans (PDP) Blue Shield Medicare Enhanced Plan (PDP) Blue Shield Medicare Basic Plan (PDP) Tier 1: Preferred Generic Drugs Retail 30-day supply – preferred or other network pharmacy Retail 90-day supply – preferred network pharmacy Retail 90-day supply – other network pharmacy Retail 30-day supply – out-of-network pharmacy Long Term Care pharmacy 31-day supply Mail Service 90-day supply 67 $2 copay $0 copay (2013: $5 copay) (2013: $4 copay) $4 copay $0 copay (2013: $10 copay) (2013: $8 copay) $6 copay $0 copay (2013: $15 copay) (2013: $12 copay) $2 copay $0 copay (2013: $5 copay) (2013: $4 copay) $2 copay $0 copay (2013: $5 copay) (2013: $4 copay) $4 copay $0 copay (2013: $10 copay) (2013: $8 copay) Blue Shield Medicare Prescription Drug Plans (PDP) Blue Shield Medicare Enhanced Plan (PDP) Blue Shield Medicare Basic Plan (PDP) Tier 2: Non-Preferred Generic Drugs Retail 30-day supply – preferred or other network pharmacy Retail 90-day supply – preferred network pharmacy Retail 90-day supply – other network pharmacy Retail 30-day supply – out-of-network pharmacy Long Term Care pharmacy 31-day supply Mail Service 90-day supply 68 $6 copay $5 copay (2013: $5 copay) (2013: $4 copay) $12 copay $10 copay (2013: $10 copay) (2013: $8 copay) $18 copay $15 copay (2013: $15 copay) (2013: $12 copay) $6 copay $5 copay (2013: $5 copay) (2013: $4 copay) $6 copay $5 copay (2013: $5 copay) (2013: $4 copay) $12 copay $10 copay (2013: $10 copay) (2013: $8 copay) Blue Shield Medicare Prescription Drug Plans (PDP) Blue Shield Medicare Enhanced Plan (PDP) Blue Shield Medicare Basic Plan (PDP) Tier 3: Preferred Brand Drugs Retail 30-day supply – preferred or other network pharmacy Retail 90-day supply – preferred network pharmacy Retail 90-day supply – other network pharmacy Retail 30-day supply – out-of-network pharmacy Long Term Care pharmacy 31-day supply Mail Service 90-day supply 69 $40 copay $45 copay (2013: $45 copay) (2013: $37 copay) $80 copay $90 copay (2013: $90 copay) (2013: $74 copay) $120 copay $135 copay (2013: $135 copay) (2013: $111 copay) $40 copay $90 copay (2013: $45 copay) (2013: $74 copay) $40 copay $45 copay (2013: $45 copay) (2013: $37copay) $80 copay $90 copay (2013: $90 copay) (2013: $74 copay) Blue Shield Medicare Prescription Drug Plans (PDP) Blue Shield Medicare Enhanced Plan (PDP) Blue Shield Medicare Basic Plan (PDP) Tier 4: Non-Preferred Brand Drugs Retail 30-day supply – preferred or other network pharmacy Retail 90-day supply – preferred network pharmacy Retail 90-day supply – other network pharmacy Retail 30-day supply – out-of-network pharmacy Long Term Care pharmacy 31-day supply Mail Service 90-day supply 70 $88 copay $90 copay (2013: $90 copay) (2013: $76 copay) $176 copay $180 copay (2013: $180 copay) (2013: $152 copay) $264 copay $270 copay (2013: $270 copay) (2013: $228 copay) $88 copay $90 copay (2013: $90 copay) (2013: $76 copay) $88 copay $90 copay (2013: $90 copay) (2013: $76 copay) $176 copay $180 copay (2013: $180 copay) (2013: $152 copay) Blue Shield Medicare Prescription Drug Plans (PDP) PLAN Blue Shield Medicare Enhanced Plan (PDP) Blue Shield Medicare Basic Plan (PDP) Tiers 1-6: Members are responsible for no more than 72% of the cost for generic drugs and 47.5% of negotiated price through manufacturer discounts on brand name drugs Tiers 1-6: Members are responsible for no more than 72% of the cost for generic drugs and 47.5% of negotiated price through manufacturer discounts on brand name drugs Benefit Coverage Gap (after total yearly drug costs reach $2,850) 74 • • New Optional Supplemental Dental HMO plan As part of Blue Shield 65 Plus in 2014, we will be offering a NEW optional supplemental Dental HMO plan for a low monthly premium of $12.20. Benefit Summary (see Evidence of Coverage for a complete list of covered services, exclusions and limitations): 2014 – Optional Supplemental Dental HMO Plan ADA Code Diagnostic services Office visit Comprehensive oral exams X-rays – intraoral complete series (including bitewings) – once every 24 months Preventive care Prophylaxis (cleanings, one every 6 months) Restorative services One-surface composite (filling) Crown (porcelain fused to noble metal) Endodontics Anterior root canal Molar root canal ADA Code* Member Copay1 None D0150 D0210 $0 $5 $0 D1110 $5 D2330 D2750 $11 $2752 D3310 $1953 D3330 $3353 *ADA codes are procedure codes established by the American Dental Association for efficient processing and reporting of dental claims 1All services must be performed, prescribed or authorized by a network Dentist. If a member needs to see a specialist, they must get a referral from their dentist to receive covered services. 2 Members will pay the copayment plus the cost of precious or semi-precious metals. Porcelain on molar crowns is not a covered benefit. 3Member copayment will be higher if this service is performed by a specialist. 80 80 New Optional Supplemental Dental HMO plan • Benefit Summary, continued (see Evidence of Coverage for a complete list of covered services, exclusions and limitations): 2014 – Optional Supplemental Dental HMO Plan ADA Code Periodontics Osseous surgery/four or more teeth per quadrant Periodontal root planing/four or more teeth per quadrant Prosthetics Bridge pontic/false tooth – porcelain fused to high noble metal (per unit) Bridge retainer – porcelain fused to high noble metal (per unit) Complete denture (upper or lower) Oral surgery Extraction (single tooth) Removal of impacted tooth (complete bony) ADA Code* Member Copay1 D4260 $293 D4341 $45 D6240 $2102 D6750 $2752 D5110/D5120 $285 D7111 D7240 $10 $80 *ADA codes are procedure codes established by the American Dental Association for efficient processing and reporting of dental claims 1All services must be performed, prescribed or authorized by a network Dentist. If a member needs to see a specialist, they must get a referral from their dentist to receive covered services. 2 Members will pay the copayment plus the cost of precious or semi-precious metals. Porcelain on molar crowns is not a covered benefit. 3Member copayment will be higher if this service is performed by a specialist. 81 81 82