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Value Added Benefit Guide Book Exclusively for Presbyterian Senior Plan Members Supplemental Dental, Vision, and Hearing Programs Complementary and Alternative Medicine Wellness and Senior Services

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Page 1: Value Added Benefit Guide Book - Benefit Source€¦ · Value Added Benefit Guide Book Exclusively for Presbyterian Senior Plan Members Supplemental Dental, Vision, and Hearing Programs

Value Added Benefit Guide BookExclusively for Presbyterian Senior Plan Members

Supplemental Dental, Vision, and Hearing ProgramsComplementary and Alternative Medicine

Wellness and Senior Services

Page 2: Value Added Benefit Guide Book - Benefit Source€¦ · Value Added Benefit Guide Book Exclusively for Presbyterian Senior Plan Members Supplemental Dental, Vision, and Hearing Programs

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Sandia Dental Plan Something to smile aboutYou are automatically enrolled in the BenefitSource Sandia Dental Plan at no additional monthly premium cost. This plan is a network based referral plan that provides for savings from 20% to 60%, depending on the type of dental care.

Advantages of the Sandia Plan • Low, guaranteed pre-set fees • Hassle – free • No deductibles • No claim forms • No pre-existing condition exclusions • No waiting periods for dental care• No maximum benefit

Supplemental Dental, Vision, and Hearing Programs

When using Sandia Plan dentists, compare your savings for these services:

With no Coverage(you pay)

Sandia Plan(you pay)

YOU SAVE

9310 Consultation $75 No charge $750150 Exam (initial) $80 $43 $370274 Bitewing 4 films (x-rays) $53 $35 $181110 Adult teeth cleaning $100 $60 $282140 Silver filling 1 surface $120 $76 $442330 Resin white filling 1 surface $145 $91 $543330 Root canal molar $940 $725 $2152750 Crown (cap) $930 $765 $1655110 Denture upper/lower $1,525 $1,012 $5135213 Partial denture $1,125 $951 $174

This is an abbreviated schedule of dental fees. A complete fee schedule will be mailed with your ID card once enrolled. Or visit our website:

www.benefitsource.org for a current list of Sandia Plan Dentists and a complete fee schedule. Members with coverage through a previous

employer, union group or other retirement program should exhaust those dental benefits first. This program is not offered nor guaranteed under

Presbyterian’s contract with Medicare. As such, these services are not subject to the Medicare appeals process. Disputes regarding this product

may be subject to the Presbyterian Medicare Grievance Process.

Page 3: Value Added Benefit Guide Book - Benefit Source€¦ · Value Added Benefit Guide Book Exclusively for Presbyterian Senior Plan Members Supplemental Dental, Vision, and Hearing Programs

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Plan benefits:When using participating PPO Dental Providers, you pay the listed in-network PPO fee directly to the dental office at the time

of service. If you obtain dental services from non-participating dental providers (out-of-network), the plan pays the amount

listed, but the dental office may balance bill you for any differences in fees.

In-Network Benefit

(you pay)

Out-of-Network Benefit

(plan pays to dental office)

1110 Prophy-adult cleaning $17 $52

0150 Initial exam $0 $49

0270 Bitewings single $0 $15

0274 Bitewings four $0 $39

0330 Panoramic x-ray $17 $52

2140 Amalgam 1 surface $36 $53

2330 Resin white filling 1 surface $39 $59

3330 Root canal molar $485 $208

2750 Crown high noble metal $561 $240

5213 Upper/lower partial $750 $321

5110/5120 Denture lower/upper $802 $344

7210 Extraction/oral surgery-erupted $108 $46

BenefitSource Elite Plan enrollment form on following page.

Elite Dental Plan Something else to smile aboutThe Elite Dental Plan is a comprehensive dental indemnity plan specifically designed for Presbyterian Senior Plan members that prefer complete freedom of choice to use any licensed dentist.

As a PPO dental plan, the Elite Plan provides greater

savings when obtaining care from our PPO Dental Providers

but still has excellent coverage when going out of network

for dental care.

Advantage of the Elite Dental Plan • Freedom to see any licensed dentist • Low monthly premium of $35.35 per person • No deductible for in-network dentists for preventive

and diagnostic care• Low, $50 annual deductible for in network dental care • $75 annual deductible for out-of-network dental care • Out of pocket costs limited to guaranteed pre-set

fee schedule for in-network services• 6 month waiting period for major (class III) services• $1,000 annual maximum per person

Visit benefitsource.org or call 888.862.8659 or 505.237.1501 for a current list of providers and complete fee schedule.

Page 4: Value Added Benefit Guide Book - Benefit Source€¦ · Value Added Benefit Guide Book Exclusively for Presbyterian Senior Plan Members Supplemental Dental, Vision, and Hearing Programs

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Supplemental Dental, Vision, and Hearing Programs

Deta

ch H

ere.Elite Dental Plan – Enrollment form

BenefitSource Elite Plan Only Enrollment Authorization Form

Social Security Number Last Name First Name

Date of Birth Sex Home Telephone Alternate Telephone

Home Address City State Zip

Email Address

Payment Option for the Elite Plan must be selected.

PAYMENT CHoICE: Please check one. Please make checks payable to BenefitSource, Inc. (For 1/1/14 enrollment only.)

Annual Payment ($424.20) Check Visa MasterCard Discover

Credit Card # Exp. Date CVV#

I have enclosed my Annual Payment of $424.20.

I hereby authorize the release of my dental records to BenefitSource, Inc. for use in quality review program.

Member’s Signature X Date

Monthly Bank Draft ($35.35) Please charge my bank account monthly. Checking Savings

Routing # Account #

I have enclosed a check for my first month’s payment of $35.35 ad a voided check.

Draft Authorization / BenefitSource, Inc. Member Agreement Unless I have elected annual payment, I hereby authorize BenefitSource to charge my bank account each month th applicable membership fee to be credited to my account with BenefitSource. This authority is to remain in full force and effect until I notify BenefitSource in writing of it’s termination following my 12 month contract. (My bank is authorized to make corrections should any be necessary). I have read and understand the terms and conditions of the authorization. I hereby authorize the release of my dental records to BenefitSource, Inc. for use in quality review program.

Member’s Signature X Date

IntErnAl USE Only PSEnIOr ElItE

Post Date

Effective Date

Payment Ref

Page 5: Value Added Benefit Guide Book - Benefit Source€¦ · Value Added Benefit Guide Book Exclusively for Presbyterian Senior Plan Members Supplemental Dental, Vision, and Hearing Programs

Visit benefitsource.org or call 888.862.8659 or 505.237.1501 for a current list of Vision (CAM) providers and complete fee schedule. 5

Vision Care For coverage related to vision exams, services related to cataract surgery, or for refractive correction, Presbyterian Senior Plan and Presbyterian Medicare Supplement Plan members should refer to their Medical Summary Plan Description.

BenefitSource, through a special arrangement with Eye

Associates of New Mexico and Vision Care Direct, provides

the following discounted schedule of benefits for vision

materials as needed outside of those listed previously.

Hearing HardwareYou are automatically eligible to receive discounts on hearing hardware and appliances. These discounts vary by provider but include 25% to 50 % savings on hearing aids, special discounts for hearing aid batteries, and fixed co-payments for a complete hearing evaluation.

Visit our website: www.benefitsource.org for a current list

of Audiology Care Centers and sources for hearing aid

hardware. You must contact the provider directly and identify

yourself as a Presbyterian Senior Plan member to learn

applicable discounts through BenefitSource.

Frames Member Pays

For all frames under $100.00 $75.00For all frames over $100.00 $75.00Receives an additional 10% discount on amount over $100

Lenses (Plastic CR-39)*

Single Vision – per pair $68.00Bifocal – per pair $89.00Trifocal – per pair $120.00Progressive Power

Standard $109.00(Access, Adapter, AF Mini, Continuous Vue, Freedom, Sola VIP, Sola XL, TruVision, Ao Pro, Continua Premium Plus, Seiko P6, Progressive Elegance, Visuality)

Preferred $212.00(Ao Compact, Kodak, Multigressive, Natural, outlook, Varilux Panamic, Varilus Comfort, Hoya Summit, Summit CD, Essilor ovation)

Premier $230.00(Definity, Ellipse, Gradal Top, Percepta, Physio, Sola one, Comfort 360, Physio 360 and Ellipse 360)

Lens Options 20% Discount

Tints, Anti-reflective, basic or upgraded scratch coats and other enhancements are available.

Contact Lenses Member Pays

Conventional Contact Lenses*(Does not include examination fee)Includes lenses and a minimum of 3 follow-up visits

Standard Hard or Soft Daily Wear Sphere $165.00Gas Permeable Sphere $190.00Soft Extended Wear 15% Discount

Disposables* (Does not include examination fee)Includes lenses and a minimum of 3 follow-up visits

Disposable Wear; Daily Wear (includes two 6 packs) $142.00one Day Disposable (includes two 90 packs) $169.00Toric & Bifocal Disposable 15% discountExtended Wear Disposable 15% discount

*The fitting fee is to be paid on the date of the exam if contact

lenses are not immediately purchased. However, if contact lenses

are purchased within two months of the exam, that fitting fee will

be deducted from the amount owed on the lenses.

Contact Lenses, Duplicate/ReplacementDisposable Wear Replacement 20% Discountone Day Disposable 20% Discount

Sun Glasses (on most styles) 15% Discount

Refractive Surgery Procedures 15% Discount

Page 6: Value Added Benefit Guide Book - Benefit Source€¦ · Value Added Benefit Guide Book Exclusively for Presbyterian Senior Plan Members Supplemental Dental, Vision, and Hearing Programs

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AcupunctureThis is an ancient treatment that involves balancing the 5 main forms of vital energy flow through the human body. Treatment involves the use of small, thin, sterile needles that are inserted into specific “reflex points” to relieve pain, sleep disorders, stress, low energy and digestive problems. Through a holistic approach to treatment, nutritional and exercise guidance may also be included.

Presbyterian Senior Care medical plan may include limited

coverage for acupuncture services. Refer to your summary

plan description for updated coverage details. This service is

available for acupuncture services either not covered under

your medical plan or if benefits are exhausted.

Chiropractic CareThis is a form of medical treatment through manipulation or careful movement of various body parts. Chiropractic care can be helpful for pain management, improvement in the function of nervous, skeletal and muscular systems, and improvement in mobility.

Presbyterian Senior Care medical plan may include limited

coverage for chiropractic care. Refer to your summary plan

description for updated coverage details. This service is

available for Chiropractic services either not covered under

your medical plan or if benefits are exhausted.

Chiropractic Services:

CPT Code Description Fee Schedule

99201 Problem focused history and examination–straight forward $11.00

99203 Detailed history and examination–low complexity $17.00

99204 Comprehensive history and examination – moderate complexity $17.00

98940 Chiropractic manipulative treatment spinal, one to two regions $34.00

98941 Spinal, three to four regions $36.00

98943 Extraspinal, one or more regions $26.00

97012 Traction, Mechanical $16.00

97014 Electrical Stimulation (unattended) $16.00

97110 Therapeutic Exercise, 15 Min. $18.00

72040 Cervical 3 Views (x-ray) $34.00

72100 Spine, Lumbosacral Anteroposterior and Lateral (x-ray) $34.00

This is an abbreviated schedule of fees for chiropractic care. Visit our website: www.benefitsource.org for a complete fee schedule and the most

current list of participating Chiropractic providers. Presbyterian Senior Care medical plan may include limited coverage for chiropractic care. Refer

to your summary plan description for updated coverage details. This service is available for Chiropractic services either not covered under your

medical plan or if benefits are exhausted.

Complementary and Alternative Medicine

Fee Schedule

Initial Visit $60.00

Re-ocurring Visits $50.00 per visit

Page 7: Value Added Benefit Guide Book - Benefit Source€¦ · Value Added Benefit Guide Book Exclusively for Presbyterian Senior Plan Members Supplemental Dental, Vision, and Hearing Programs

Visit benefitsource.org or call 888.862.8659 or 505.237.1501 for a current list of providers and complete fee schedule. 7

You are automatically eligible to access the discounted fees and networks for Complementary and Alternative Medicine.

Massage TherapyThis is a form of therapy through soft tissue manipulation that is helpful in relieving pain associated with arthritis, sports injuries, myofascial pain, headache, stress, circulatory problems, gastrointestinal disorders, or chronic and acute pain.

Massage techniques include:• Deep tissue massage to relieve chronic tension• Myofascial release to release muscular tension in the fascia• Reflexology, particularly focused on hands and feet that

may be linked to organs, nerves and glands• Shiatsu and Acupressure that treat points along

acupuncture meridians to relieve pain• Swedish massage for tension relief and circulation

improvement• Trigger Point Therapy (Myotherapy or Neuro-muscular

therapy) to relieve cycles of chronic pain• Sports massage

Jenny Craig Weight Management ProgramThis is a comprehensive weight management program. Members learn how to eat the foods they want, develop a healthy and enjoyable eating style, increase energy levels through simple activity, and build more balance into their lives. The results are optimal weight loss and well-being. BenefitSource members pay only $99 for a one year weight loss program (saving you $300). Just contact Jenny Craig and identify yourself as a Presbyterian Senior Plan member to receive this discount.

Please visit benefitsource.org for a current list of Jenny

Craig centers.

Fee Schedule

1/2 Hour Session $27.00

1 Hour Session $46.00

1 1/2 Hour Session $58.00

Wellness Services

Page 8: Value Added Benefit Guide Book - Benefit Source€¦ · Value Added Benefit Guide Book Exclusively for Presbyterian Senior Plan Members Supplemental Dental, Vision, and Hearing Programs

For more information, please contact us at:1804 Juan NE, Suite A, Albuquerque, NM 87112 888 862 8659 | 505 237 1501

benefitsource.org

Non-Medical Home Health CareThe number 1 goal of today’s seniors is to remain at home for as long as possible. Consequently, non-medical home health care focuses on helping seniors with daily, non-medical activities. Most of these services are not reimbursed by Medicare or other traditional medical insurance plans. BenefitSource has contracted with a variety of local home care providers to fulfill this goal.

Presbyterian Senior Plan members will receive a 7%

savings on billed home care services which include:• Bathing and dressing• Transferring and toileting• Companionship and custodial care• Medications monitoring• Light cleaning and meal preparation• Transportation, laundry, and hobbies

Visit our website: www.benefitsource.org for a current list

of participating home care providers. When contacting the

home care provider of choice, simply inform them you are a

BenefitSource member through Presbyterian Senior Health

Plan to receive your savings.

Meals on WheelsMeals on Wheels of Albuquerque home delivers meals to those who are home bound or otherwise unable to obtain proper, nutritional meals on their own. Seven different menu options for each day are designed to meet special medical or therapeutic needs of their client base. This program enables seniors to retain independence, maintain or improve health, and helps them stay at home and out of expensive long-term care facilities. BenefitSource Presbyterian Senior Plan members receive a discount off the normal price per meal.

Senior Services

Fee Schedule

First 10 Meals (paid upon delivery) $57.50

Meals Thereafter $5.75

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at the Isotopes Park Box Office• Retain this coupon for multiple uses at the

Isotopes Park Box Office