Plan benefits and underwriting guidelines

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Plan benefits and underwriting guidelines

  1. 1. Plan Benefits andUnderwriting Guidelines dental medical vision life disability
  2. 2. Table of ContentsPPO Dental and IndemnityPlus Plans 4 PPO Dental Plan Summary - National 4 IndemnityPlus Dental Plan Summary - National 5 PPO Dental Plan Summary - Utah 6 IndemnityPlus Dental Plan Summary - Utah 7 Dental Networks 8 The Fine Print 8 Exclusions 9HDHP Medical Plans 10 HSA-Compatible High Deductible Health Plan Summary 10 The Fine Print 11 Exclusions 11Vision PPO and Indemnity Plans 12 Vision PPO Plan Summary 12 Vision Indemnity Plan Summary 12 The Fine Print 13 Access Vision Exclusions 14 Vision PPO Exclusions 14Group Term Life Plans 15 Group Term Life Plan Summary 15 The Fine Print 16Short Term Disability 17 Short Term Disability Plan Summary 17 The Fine Print 18
  3. 3. PPO Dental and IndemnityPlus Plans Group Sizes 2 or More PPO Dental Plan Summary - National Available in AZ, CA, DC, FL, IL, IN, MD, MI, MO, NE, NV, OH, TX AND PA. Texas reimbursement is based on Maximum Allowable Charge (MAC) only. Out-of-Network for Texas is paid as In-Network. MAC is available in AZ, CA, NV and TX only. UCR is available in all states except Texas. Plan Design PPO Dental High Plan Mid Plan Basic Plan Value Plan Out-of- Out-of- Out-of- Out-of- Benefits In- Network In- Network In- Network In- Network Network (Does not Network (Does not Network (Does not Network (Does not apply to TX) apply to TX) apply to TX) apply to TX) $2,500 $2,000 $2,000 $1,500 $1,500 $1,500 $1,500 $1,500 $2,000 $1,500 $1,500 $1,000 $1,000 $1,000 $1,000 $1,000 Calendar Year Maximum $1,500 $1,000 $1,000 $1,000 $500 $500 $500 $500 $1,000 $1,000 $0, $25, $50, $75 or $100 Calendar Year Deductible (3 per family max) (Waived on Preventive Services.) Class I: Preventive Services – Routine oral exam, cleanings, fluoride treatment for children, bitewing 100% 100% 100% 80% 100% 80% 100% 80% x-rays, panoramic/full mouth x-rays, sealants Class II: Basic Services – Fillings (amalgam, porcelain & plastic), anterior & posterior composites, anesthesia (general or IV sedation), emergency 90% 80% 80% 80% 80% 50% 50% 20% palliative treatment, space maintainers for children, limited oral exam, pathology, oral surgery Class III: Major Services – Crowns & gold fillings, inlays, onlays and pontics, fixed bridges, implants, 60% 50% 50% 50% 0% 0% 0% 0% complete and partial dentures Endodontics Class II or Class III Periodontics Class II or Class III 12 month waiting period applies to major Waiting Periods and orthodontic services None (Waived for qualifying groups.) Special Dental Accident Benefit $1,000 maximum per accident to sound, natural teeth UCR at 80th or 90th Percentile or MAC Out-of-Network Reimbursement (MAC available in Arizona, California and Nevada. Texas is MAC only and is paid as in-network.) Orthodontics (optional) 50% $1,000 Lifetime / $500 Calendar Year Child Only Orthodontic Benefit Option (Dependent children through age 18) Maximum or $1,500 Lifetime / $750 Calendar Year Maximum Not offered Adult/Child Orthodontia Benefit Option $1,000 Lifetime / $500 Calendar Year Maximum Child Good Vision Benefit Covers 50% of UCR for an eye exam once (Included with orthodontia) every 12 months for children through 18 Child Orthodontia is available for groups with 5 or more employees enrolling. Adult Orthodontia is available for employer-sponsored groups with 25 or more employees enrolling.4 www.bestlife.com | 800.237.8543
  4. 4. IndemnityPlus Dental Plan Summary - NationalAvailable in AK, AL, AR, AZ, CA, CO, DC, FL, GA, HI, ID, IL, IN, KS, KY, LA, MD, MI, MO, MS, MT, NC, ND, NE, NM, NV, OH, OK, OR, PA, SC, SD, TN,TX, VA, WA and WY.MAC is available in AZ, CA and NV. Plan Design IndemnityPlus Benefits High Plan Mid Plan Basic Plan Value Plan $2,500 $2,000 $1,500 $1,500 $2,000 $1,500 $1,000 $1,000 Calendar Year Maximum $1,500 $1,200 $500 $500 $1,000 $1,000 Calendar Year Deductible $0, $25, $50, $75 or $100 (3 per family max) (Waived on Preventive Services.) Class I: Preventive Services – Routine oral exam, cleanings, fluoride treatment for children, bitewing 100% 100% 100% 100% x-rays, panoramic/full mouth x-rays, sealants Class II: Basic Services – Fillings (amalgam, porcelain & plastic), anterior & posterior composites, anesthesia (general or IV sedation), emergency 90% 80% 80% 50% palliative treatment, space maintainers for children, limited oral exam, pathology, oral surgery Class III: Major Services – Crowns & gold fillings, inlays, onlays and pontics, fixed bridges, implants, 60% 50% 0% 0% complete and partial dentures Endodontics Class II or Class III Periodontics Class II or Class III 12 month waiting period applies to major and Waiting Periods orthodontic services None (Waived for qualifying groups.) Special Dental Accident Benefit $1,000 maximum per accident to sound, natural teeth UCR at 80th or 90th Percentile or MAC Out-of-Network Reimbursement (MAC available in Arizona, California and Nevada) Orthodontics (optional) 50% $1,000 Lifetime / $500 Calendar Year Child Only Orthodontic Benefit Option (Dependent children through age 18) Maximum or $1,500 Lifetime / $750 Calendar Year Maximum Not offered Adult/Child Orthodontia Benefit Option $1,000 Lifetime / $500 Calendar Year Maximum Child Good Vision Benefit Covers 50% of UCR for an eye exam once (Included with orthodontia) every 12 months for children through 18Child Orthodontia is available for groups with 5 or more employees enrolling. Adult Orthodontia is available for employer-sponsored groups with 25 or more employees enrolling. www.bestlife.com | 800.237.8543 5
  5. 5. PPO Dental Plan Summary - Utah Available in UT only. Plan Design Dental PPO Plans Premium Plan Classic Plan Basic Plan Value Plan Benefits In- Out-of- In- Out-of- In- Out-of- In- Out-of- Network Network Network Network Network Network Network Network $1,500 $1,500 $1,500 $1,500 $1,500 $1,500 $1,500 $1,500 Calendar Year Maximum $1,500 $1,000 $1,500 $1,000 $1,000 $1,000 $1,000 $1,000 $1,000 $1,000 $1,000 $1,000 $500 $500 $500 $500 Individual Calendar Year Deductible $0, $25, $50, $75 or $100 (3 per family max) (Waived on Preventive Services.) Lifetime Deductible Option $100 Lifetime Deductible in lieu of a Calendar Year Deductible Class I: Preventive Services - Routine oral exam, cleanings, fluoride treatment for children, bitewing x-rays, panoramic/full 100% 100% 100% 80% 100% 80% 100% 80% mouth x-rays, sealants Class II: Basic Services - Fillings (amalgam, porcelain & plastic), anterior & posterior composites, anesthesia (general or IV sedation), emergency palliative treatment, 90% 80% 80% 60% 80% 50% 50% 20% space maintainers for children, limited oral exam, pathology, oral surgery Class III: Major Services - Crowns & gold fillings, inlays, onlays & pontics, fixed bridges, implants, complete & partial 60% 50% 50% 50% 0% 0% 0% 0% dentures Oral Surgery Class II or Class III Endodontics Class II or Class III Periodontics Class II or Class III 12 month waiting period applies to major Waiting Periods and orthodontic services None (Waived for qualifying groups.) Special Dental Accident Benefit $1,000 maximum per accident to sound, natural teeth Out-of-Network Reimbursement UCR at 80th, 90th Percentile or MAC Orthodontics (optional) 50% $1,000 Lifetime / $500 Calendar Year Maximum Child Only Orthodontic Benefit Option (Dependent children through age 18) or $1,500 Lifetime / $750 Calendar Year Maximum $1,000 Lifetime / $500 Calendar Year Maximum Not offered Adult/Child Orthodontia Benefit Option or $1,500 Lifetime / $750 Calendar Year Maximum Child Good Vision Benefit Covers 50% of UCR for an eye exam once every (Included with orthodontia) 12 months for children through 18 Child Orthodontia is available for groups with 5 or more employees enrolling. Adult Orthodontia is available for employer-contributory groups with 25 or more employees enrolling.6 www.bestlife.com | 800.237.8543
  6. 6. IndemnityPlus Dental Plan Summary - UtahAvailable in UT only. Plan Design Dental Indemnity Plans Benefits Premium Plan Classic Plan Basic Plan Value Plan $1,500 $1,500 $1,500 $1,500 Calendar Year Maximum $1,000 $1,000 $1,000 $1,000 $500 $500 Individual Calendar Year Deductible $0, $25, $50, $75 or $100 (3 per family max) (Waived on Preventive Services.) Lifetime Deductible Option $100 Lifetime Deductible in lieu of a Calendar Year Deductible Class I: Preventive Services - Routine oral exam, cleanings, fluoride treatment for children, bitewing x-rays, panoramic/full 100% 100% 100% 100% mouth x-rays, sealants Class II: Basic Services - Fillings (amalgam, porcelain & plastic), anterior & posterior composites, anesthesia (general or IV sedation), emergency palliative treatment, 90% 80% 80% 50% space maintainers for children, limited oral exam, pathology, oral surgery Class III: Major Services - Crowns & gold fillings, inlays, onlays & pontics, fixed bridges, implants, complete & partial 60% 50% 0% 0% dentures Oral Surgery Class II or Class III Endodontics Class II or Class III Periodontics Class II or Class III 12 month waiting period applies to major and Waiting Periods orthodontic services None (Waived for qualifying groups.) Special Dental Accident Benefit $1,000 maximum per accident to sound, natural teeth Out-of-Network Reimbursement UCR at 80th, 90th Percentile or MAC Orthodontics (optional) 50% $1,000 Lifetime / $500 Calendar Year Maximum Child Only Orthodontic Benefit Option (Dependent children through age 18) or $1,500 Lifetime / $750 Calendar Year Maximum $1,000 Lifetime / $500 Calendar Year Maximum Not offered Adult/Child Orthodontia Benefit Option or $1,500 Lifetime / $750 Calendar Year Maximum Child Good Vision Benefit Covers 50% of UCR for an eye exam once every (Included with orthodontia) 12 months for children through 18Child Orthodontia is available for groups with 5 or more employees enrolling. Adult Orthodontia is available for employer-contributory groups with 25 or more employees enrolling. www.bestlife.com | 800.237.8543 7
  7. 7. Dental Networks Usual, Customary and Reasonable Claims payments are based on the usual, customary and reasonable (UCR) charge for covered dental services and supplies. UCR is determined by the fee commonly The BEST Life dental plans offer access to national and charged specifically for the severity and nature of the treatment within the regional PPO networks. dentist’s particular geographic area. In-network claims are paid by the UCR fees listed in the preferred provider fee schedule. Out-of-network claims payments are based either on the UCR or on a fee level that is within the same range of fees Network States of Coverage Products/Plans customarily charged for the services or supplies in the geographic area concerned. DenteMax National PPO & Indemnity Diversified Dental Maximum Allowable Charge (MAC) NV PPO & Indemnity On plans with the MAC option, bases claims payments are based on the fees Services (DDS) listed in the preferred provider fee schedule, or on a set fee level based on what First Dental Health is customarily charged for dental services or supplies in the geographic area. For CA PPO & Indemnity (FDH) in-network claims, preferred providers have agreed to accept payment based on the preferred provider fee schedule as payment in full. Any amounts over the Maverest Dental IN PPO & Indemnity maximum allowable charge (MAC) for out-of-network claims will be the Alliance responsibility of the patient. Total Dental AZ*, UT PPO & Indemnity Advance Notice of Dental Treatment Administrators (TDA) Any course of treatment a provider estimates to be in excess of $500 must be CONNECTION D.C., FL , MD, MO, NE, reported to the company for predetermination prior to the treatment being PPO Plans Only Dental PA & TX rendered. A predetermination is an estimate of how benefits will be processed. *Network available for PPO plans only. Extension of Dental Benefits We will continue to pay dental benefits for 30 days following the termination date of the employee or dependent coverage if the expenses incurred would have The Fine Print been eligible for payment had coverage remained in effect; and (1) the impression for a prosthetic device or modification had been taken before termination and delivered and installed within 30 days following the termination of coverage; or Employee Effective Date (2) in the treatment of root canal therapy, where the pulp chamber was opened before termination. An employee’s coverage will take effect: ƒƒ the date the group’s coverage takes effect if the employee’s enrollment On Termination of Coverage card is received within 31 days of that date and if there are no waiting periods Employee and dependent coverage will terminate on the earliest of the following to satisfy. events: ƒƒ the first day of the calendar month following the date the waiting period On 1. The last day of the month in which active employment ceases, unless the is met. The employee’s enrollment card must be received within 31 days after employee is on leave of absence, temporary layoff or total disability and the satisfying the waiting period. If an employee is not working full-time on the employer decides to continue paying for coverage. date he or she would otherwise become covered, the employee will not be 2. The last day of the month in which the employee and/or dependent ceases eligible for coverage until he or she returns to active work. to be eligible for insurance. New employee hires can join the plan the first of the month after the date of hire, 3. The date the employer ceases to be a participating employer. if elected by the employer on the employer application. 4. The day before the due date of any premium that remains unpaid at the end Dependent Eligibility of the grace period. Eligible dependents include spouse and dependent children. The definition of 5. The date the policy terminates. dependent may vary by state. Refer to the certificate of insurance or your sales 6. The date the number of insured employees of a participating employer falls representative for details. below two. Dependent Effective Date An eligible dependent’s insurance will take effect on the later of the following: ƒƒ an eligible employee enrolls their eligible dependents at the time of the If employee’s initial enrollment, then the dependent effective date is the same as the employee’s effective date. ƒƒ after the eligible employee’s initial enrollment, the employee acquires an If eligible dependent, then the acquired dependent effective date is the first day of the calendar month following the dependent enrollment date provided the enrollment is made within 31 days of the dependent initial eligibility date. Late Entrants To The Plan If an employee or dependent enrolls for coverage 31 days or more after becoming eligible, he or she will be considered a late entrant and only eligible for: ƒƒPreventive services during the first 12 months of continuous coverage. ƒƒPreventive services and 50% of Basic services not to exceed a maximum of $500 during the second 12 months of continuous coverage. ƒƒMajor services when the employee or dependent is no longer a late entrant.8 www.bestlife.com | 800.237.8543
  8. 8. Exclusions 26. The extraction of immature erupting third molars and non-pathologic, asymptomatic third molar extractions. 27. Expenses for gross debridement allowed one time at the beginning of theNo payments will be made for and covered dental expenses do not include: periodontal treatment plan prior to pocket depth charting. 1. Treatment by someone other than a doctor of medical dentistry or a doctor 28. Surgical procedures incidental to orthodontic treatment, including but not of dental surgery, except where performed by a licensed hygienist under the limited to, extraction of teeth solely for orthodontic reasons, exposure of direction of a doctor of medical dentistry or a doctor of dental surgery. impacted teeth, correction of micrognathia or macrognathia or repair of 2. Expenses incurred while on active duty with any military, naval or air force of cleft palate. any country or international organization. 29. Any service or procedure not commonly found within the scope of practice 3. An appliance used to repair or replace missing teeth, or modification of an by a licensed dentist. Such procedures are identified within the current CDT appliance, where an impression was made before the patient was covered; a codes. crown, bridge or other lab fabricated restorations for which the tooth was 30. Temporary services are considered an integral part of the final services rather prepared before the patient was covered; root canal therapy if the pulp than a separate service and are therefore not eligible for benefits. chamber was opened before the patient was covered. 31. X-rays are considered an integral part of the endodontic procedure rather 4. Pulp capping, if in conjunction with the installation of inlays, onlays or than a separate service and are therefore not eligible for benefits. crowns, fillings or other lab fabricated restorations; including but not limited 32. Expenses incurred for a core buildup will only be considered in conjunction to inlays, onlays and crowns, preventative tests and examinations diagnostic with a crown. casts and oral cancer screenings, and expenses incurred for sedative fillings, 33. Chemotherapeutic agents and any other experimental procedures. including charges for prescribed drugs, pre‑medication or analgesia. 34. Expenses incurred for veneers and related procedures. 5. Replacement of a lost or stolen or discarded prosthetic device. 6. Dental services and supplies which are given primarily for cosmetic reasons including alteration or extraction of functional natural teeth for the purpose of changing appearance and replacement of restorations previously performed for cosmetic reasons. 7. The initial installation of a prosthetic device (a fixed bridge, implant, or denture), including crowns and inlays which form abutments, to replace teeth missing before coverage under the policy, except when it also replaces a tooth that is extracted while covered unless such installation commences after remained continuously covered under this plan for at least three years immediately prior to the date such installation commences. 8. Expenses incurred for orthodontic treatment and orthodontia type procedures unless such procedures are covered under an orthodontic rider. 9. Expenses incurred as a result of participating in a riot or insurrection or the commission of a felony.10. Charges in excess of usual, reasonable and customary charges or in excess of the calendar year maximum amount stated in the schedule of dental benefits section of this plan, or in excess of the preferred provider fee schedule.11. Services and supplies not reasonably necessary, or not otherwise specifically listed as an eligible expense.12. Charges for service provided for temporomandibular joint dysfunction (TMJ), expenses incurred for congenital or developmental malformations.13. Services and supplies covered under any workers’ compensation act or similar law, expenses incurred due to treatment rendered by the employer.14. Services and supplies performed outside of the U.S.15. Implants, implant services and implant supported prosthetics are not covered for patients under the age of 16.16. Any services or supplies for correction or alteration of occlusion, or any occlusal adjustments, expenses incurred for night guards or any other appliances for the correction of harmful habits.17. Expenses for safe fees (gloves, masks, surgical scrubs and sterilization).18. Expenses incurred due to treatment rendered by a family member. For the purpose of this limitation, family member includes, but is not limited to, the insured’s lawful spouse, child, parent, step-parent, grandparent, brother, sister, cousin or in-law.19. Expenses for services for which the insured would not legally have to pay if there were no insurance.20. Services not completed on or before the date of termination must be completed within 30-days of the termination date, unless such services are covered under the extension of dental benefits.21. If the insured or any dependents transfer from the care of one dentist to another dentist during the course of treatment, or if more than one dentist renders services for one dental procedure, the amount liable is only for the amount it would have been had one dentist rendered the services.22. Expenses that are applied toward satisfaction of a deductible, if any.23. For all procedures that are begun prior to your effective date but not completed.24. Adjustment, repairs or relines of prostheses for a period of one year from initial placement if the prostheses were paid for under this plan.25. If multiple endodontic treatments are necessary on the same tooth within a period of one year, the allowance will be made for only one procedure. www.bestlife.com | 800.237.8543 9
  9. 9. HDHP Medical Plans Group Sizes 2-50 HSA-Compatible High Deductible Health Plan Summary Available in AZ, GA, ID, IL, IN, MO, MT, NV, OH, OK, TN, TX and UT. In-Network Out-of-Network Preventive Office Visits (includes annual routine physical exam, screenings and immunizations, prostate and colorectal cancer screening/ 100% 100% testing, flu shot, pap smear and mammogram) Baby/Child Wellness Visits (includes exams, screenings, 100% 100% immunizations and vaccinations, lab and X-ray through age 17) Physician Office Visit - Professional Fee (includes Lab and X-ray Deductible, then Coinsurance Deductible, then Coinsurance when performed by Physician on the same day of visit) Physician Office Visit, Other than Professional Fee Deductible, then Coinsurance Deductible, then Coinsurance Lab and X-ray Services Deductible, then Coinsurance Deductible, then Coinsurance Emergency Ambulance Services Deductible, then Coinsurance Deductible, then Coinsurance Hospital Charges Deductible, then Coinsurance Deductible, then Coinsurance Emergency Room Deductible, then Coinsurance Deductible, then In-network Coinsurance Urgent Care (facility or clinic) Deductible, then Coinsurance Deductible, then Coinsurance Outpatient Surgery (facility or hospital) Deductible, then Coinsurance Deductible, then Coinsurance CVS Caremark Prescription Coverage Deductible, then Coinsurance Deductible, then Coinsurance These services are subject to change upon notification of the United States Department of Health and Human Services. Our high deductible health plans are HSA-compatible. Contributions to an HSA are tax deductible and employer contributions are not counted as taxable income. Account withdrawals also are not taxed when used for qualifying medical expenses. Meanwhile, the money remaining in the account at the end of the year belongs to the member and is rolled over to the next year. Even if the member changes jobs, the account stays with that individual. Check current HSA limits at www.treasury.gov/resource-center. Health Solutions - High Deductible Health Plans Individual Calendar Year Deductible ‰‰ $2,500 ‰‰ $4,000 (2 member family max) ‰‰ $3,000 ‰‰ $5,000 Family Deductible Aggregate Aggregate Individual Out-of- Individual Out-of- Coinsurance Coinsurance Pocket Max Pocket Max Coinsurance Levels and Out-of- Pocket Maximum1 ‰‰ In / 80% Out 100% $0 In / $2K Out ‰‰ In / 80% Out 100% $0 In / $2K Out (2 member family max) ‰‰ In / 70% Out 90% $500 In / $3K Out ‰‰ In / 70% Out 90% $500 In / $3K Out ‰‰ In / 60% Out 80% $1K In / $4K Out Prescription Coverage Discount Card, costs will be applied to deductible, then coinsurance As any other illness or sickness (optional for groups of 2-14; mandatory for groups with 15+ may vary by state) Maternity q Yes q No 1 Deductible does not apply to out-of-pocket maximum.10 www.bestlife.com | 800.237.8543
  10. 10. The Fine Print ExclusionsBusiness Eligibility The following is a summary list of services and supplies that are not generally covered. Please note that the certificate of insurance may contain exceptions toApplications from all industries will be reviewed for eligibility. Some businesses or this list based on state mandates or the plan design purchased and should beindustries may be subject to special rates, based on the hazards associated with consulted.certain industries. Any special rates applied because of industry or healthconditions are applied in accordance with the small group laws of your state. For Unless provided by endorsement or specifically included as a covered service, thespecific details, please refer to the medical underwriting guidelines. following are not covered:Employee Eligibility ƒƒAcupuncture, unless used in lieu of anesthesia.Eligible employees are defined as: ƒƒAdministration of drugs. ƒƒ injury or illness that occurs in the course of or during participation in a An ƒƒFull-time. criminal activity or riot, or that is self-inflicted, including attempted suicide. ƒƒActive employees working at least 30 hours a week (may vary by state). ƒƒBreast reduction. ƒƒWho are paid a salary or earnings from which federal, state and Social Security ƒƒChelation therapy services or supplies. taxes are withheld (may vary by state). ƒƒComplications arising out of services or supplies or injuries or illnesses not ƒƒPartners and owners working 30 hours a week or more are also eligible for covered. coverage (may vary by state). ƒƒCosmetic services or supplies.There must be an employer-employee relationship in a bona-fide, full-time ƒƒCourt order services or supplies.business pursuit. 1099 individuals are not eligible unless permitted by the state. ƒƒDental care.States permitting 1099 individuals include ID, IL, MO, NV, TN, TX and UT. ƒƒDurable medical equipment charges not specifically named as a coveredDependent Eligibility service.Eligible dependents include spouses and dependent children. Dependent children ƒƒEligible expenses in excess of Medicare RBRVS fee schedule or usual andare eligible for coverage until they reach 26, which may be extended under customary.certain circumstances according to your state law. The definition of dependent ƒƒEmployer provided services or supplies.may vary by state. Refer to the certificate of insurance or your sales representative ƒƒInjury or illness arising out of employment for wage or profit, or service orfor details. supply required as a prerequisite to or as a part of employment. ƒƒExpenses where payment is not required, due to coverage by other insurance,Out-of-Network Charges except Medicaid, or which would not have been billed if no insurance coverageCovered expenses incurred for out-of-network services where in-network or were in place.wraparound network benefits do not apply are limited to: the limited fee ƒƒExpenses incurred before the effective date of coverage under the Policy orschedule, or if no schedule exists for the services, the average cost of service after coverage under the Policy terminates, regardless of the date of the injurybased on the RBRVS. Benefit payables are subject to the plan deductibles and or illness.coinsurance percentages. The covered person is responsible for any uncoveredout-of-pocket expenses. ƒƒExperimental or investigational services or supplies. ƒƒFoot care services in connection with corns, calluses, fallen arches, weak feet,Review Program foot strain, symptomatic foot complaints or other foot care, includingThe following covered services will require a review before a member receives orthopedic, orthoses, shoe or orthotics.them: ƒƒGovernment facility services or supplies, unless there is a legal obligation to pay. ƒƒ inpatient admissions. All ƒƒGrowth hormones. ƒƒEmergency admissions. Must obtain review within 24 hours, or as soon as possible, after the admission. ƒƒServices or supplies provided in preparation of or for a gender change. ƒƒNon-emergency inpatient admissions. Must obtain review at least 5 days ƒƒHearing impairment or loss. before the admission date. ƒƒHospital admission room and board charges for diagnostic or evaluation ƒƒExtended stay review for continued stays after a review is obtained for an procedures. inpatient admission and member is admitted as an inpatient. Must obtain ƒƒInfertility services, including impotence, erectile dysfunction and fertilization. review before original admission period expires. ƒƒServices or supplies provided by a member of the employee’s family or a ƒƒ any outpatient surgery procedures, MRIs, CAT scans, PET Scans, nuclear For person residing in the employee’s residence. imaging and transplants. Must obtain review at least 5 days prior to scheduled ƒƒInjury or illness that occurs during active service in any armed forces or procedure. auxiliary units. ƒƒ any outpatient procedures requiring review. Must obtain review at least 5 For ƒƒInjuries or Illnesses arising out of any war, declared or undeclared, or act of days prior to scheduled procedure. war or terrorism.Failure to obtain a required review for a procedure could result in a reduction of ƒƒLearning disability or impairment services.benefits and additional financial responsibility to the member. ƒƒNon-covered services. ƒƒNon-covered expenses for transportation.Pre-existing Conditions ƒƒNon-medically necessary services or supplies.A pre-existing condition is a condition, other than pregnancy, for which a provider ƒƒOver the counter supplies, except diabetic supplies.recommended or provided medical advice, diagnosis, care or treatment withinthe six month period prior to the effective date. Expenses incurred for pre-existing ƒƒServices or supplies for the care of a pre-existing condition.conditions are not considered eligible until coverage has been in effect for 12 ƒƒPrivate duty nursing services, except for covered home health care services.consecutive months or 18 months for a late enrollee. The pre-existing condition ƒƒReversal of sterilization.exclusion period will be reduced by the number of days under credible coverage ƒƒUnbundled charges.without a 63-day break, immediately prior to their effective date. The period ofcontinuous coverage shall not include any waiting period. The exclusionary time ƒƒUvulopalatopharyngoplasty.periods, prior treatment periods, time periods between prior coverage and new ƒƒVeterans Administration hospital services or supplies for armed servicecoverage, and credit for qualifying prior coverage may vary according to the connected disabilities.applicable laws of the employer’s state. ƒƒVision impairment or loss services or supplies. ƒƒTreatment for addiction to tobacco, alcohol, drugs or any addictive substances. www.bestlife.com | 800.237.8543 11
  11. 11. Vision PPO and Indemnity Plans Group Sizes 5 or More Vision PPO Plan Summary Available in AK, AL, AR, AZ, CA, CO, DC, FL, GA, HI, ID, IL, IN, KS, KY, LA, MD, MI, MO, MS, MT, NC, ND, NE, NM, NV, OH, OK, OR, PA, SC, SD, TN, TX, UT VA, WA and WY. Option 1 Option 2 In-Network Out-of-Network In-Network Out-of-Network Annual Eye Exam $10 copay Up to $42 Annual Eye Exam $10 copay Up to $42 Fit and Follow-up Exams Covered in full Up to $40 Fit and Follow-up Exams Up to $55 copay No benefit $130 allowance, $130 allowance, Frames 20% off amount over Up to $65 Frames 20% off amount over Up to $65 allowance allowance Lenses Lenses Single $10 copay Up to $35 Single $25 copay Up to $35 Bifocal $10 copay Up to $40 Bifocal $25 copay Up to $40 Trifocal $10 copay Up to $65 Trifocal $25 copay Up to $65 Progressive $75 copay Up to $40 Progressive $90 copay Up to $40 $75 copay, $90 copay, $120 allowance, $120 allowance, Premium Progressive Up to $40 Premium Progressive Up to $40 20% off amount over 20% off amount over allowance allowance Contacts Contacts $130 allowance, $130 allowance, Elective - Conventional 15% off amount over Up to $104 Elective - Conventional 15% off amount over Up to $104 allowance allowance Elective - Disposable $130 allowance Up to $104 Elective - Disposable $130 allowance Up to $104 Medically Necessary Covered in full Up to $200 Medically Necessary Covered in full Up to $200 Lens Options Lens Options UV Coating $15 copay No benefit UV Coating $15 copay No benefit Tine - Solid and Gradient $15 copay No benefit Tine - Solid and Gradient $15 copay No benefit Scratch-resistant $15 copay No benefit Scratch-resistant $15 copay No benefit Polycarbonate $40 copay No benefit Polycarbonate $40 copay No benefit Anti-reflective $45 copay No benefit Anti-reflective $45 copay No benefit Other add-ons and Other add-ons and services 20% off amount No benefit services 20% off amount No benefit Lenses or Contacts 12 Lenses or Contacts 12 Lenses or Contacts 12 Lenses or Contacts 12 Frequencies in Months Frequencies in Months Frames 12 or 24 Frames 12 or 24 Frames 12 or 24 Frames 12 or 24 Vision Indemnity Plan Summary Available in AK, AL, AR, AZ, CA, CO, DC, FL, GA, HI, ID, IL, IN, KS, KY, LA, MD, MI, MO, MS, MT, NC, ND, NE, NM, NV, OH, OK, OR, PA, SC, SD, TN, TX, UT VA, WA and WY. Option 1 Option 2 Frequency Options Frequency Options Plan Benefit Plan Benefit A B C D A B C D Yearly Deductible Options $0, $10 or $25 Yearly Deductible Options $0, $10 or $25 Annual Eye Exam $60 Allowance 12 12 12 12 Annual Eye Exam $60 Allowance 12 12 12 12 Frames $80 Allowance 12 24 24 24 Frames $100 Allowance 12 24 24 24 Lenses Lenses Single $35 Allowance Single $45 Allowance 12 12 12 24 12 12 12 24 Bifocal $55 Allowance Bifocal $65 Allowance Trifocal $65 Allowance Trifocal $75 Allowance Contacts Contacts Elective $125 Allowance 12 12 24 24 Elective $125 Allowance 12 12 24 24 Medically Necessary $200 Allowance 12 12 24 24 Medically Necessary $200 Allowance 12 12 24 2412 www.bestlife.com | 800.237.8543
  12. 12. EyeMed Discount EyeMed Vision Care® discount program includes discounts The Fine Print off of exams, eyeglasses, progressive lenses, UV coating, Employee Eligibility tints, polycarbonates, contacts and laser vision correction. Eligibility is based on, but not limited to the following: QualSight® LASIK ƒƒThere must be an employee-employer relationship. ƒƒ central office and a regular place of business where the maintenance of A Members are automatically eligible to access the QualSight payroll and insurance is performed. LASIK network for discounts of 40-50% off the national ƒƒ eligible employees must be full-time and working at least 30 hours per All average charge for laser eye surgery. week. The following employees are generally not eligible: ƒƒPart-time, seasonal, retired or pensioned employees, leased, consultants, employees covered under collective bargaining agreements and employees Option 3 who are paid as 1099 employees. In-Network Out-of-Network ƒƒDirectors or stockholders who do not work full-time or at least 30 hours per week in the business.Annual Eye Exam $10 copay Up to $42 Employee Effective DateFit and Follow-up Exams Up to $55 copay No benefit Insurance will take effect on the later of: $100 allowance,Frames 20% off amount over Up to $50 ƒƒ date the employer group becomes effective if initial enrollment cards are The allowance received within 31 days of this date.Lenses ƒƒThe first day of the next calendar month following the date a full-time employee completes the waiting period as elected by the employer an Single $25 copay Up to $35 enrollment card must be received within 31 days of this day. Bifocal $25 copay Up to $40 ƒƒ first of the month after the date of hire, if this option is elected by the The Trifocal $25 copay Up to $65 employer on the master application. Progressive $90 copay Up to $40 Dependent Eligibility $90 copay, Eligible dependents include spouse and dependent children. The definition of $120 allowance, dependent may vary by state. Refer to the certificate of insurance or your sales Premium Progressive Up to $40 20% off amount over representative for details. allowanceContacts Dependent Effective Date Dependent insurance will take effect on the later of: $115 allowance, Elective - Conventional 15% off amount over Up to $92 ƒƒ date the insurance is effective if the enrollment card is received within 31 The allowance days of that date. Elective - Disposable $115 allowance Up to $92 ƒƒ first day of the next calendar month following the date the employee The Medically Necessary Covered in full Up to $200 enrolled his or her dependents, provided the enrollment is made within 31 days of the dependents first becoming eligible (must be provided in writing).Lens Options UV Coating $15 copay No benefit Late Entrants to the Plan If an employee or a dependent enrolls for coverage 31 days or more after Tine - Solid and Gradient $15 copay No benefit becoming eligible, he or she will be considered a late entrant and eligible for no Scratch-resistant $15 copay No benefit more than $75 of vision care benefits during the first 12 months of continuous Polycarbonate $40 copay No benefit coverage. Anti-reflective $45 copay No benefit Coordination of Benefits Other add-ons and services 20% off amount No benefit Benefits will be coordinated with the benefits of any other group vision plan to which the individual is entitled. Lenses or Contacts 12 Lenses or Contacts 12Frequencies in Months Frames 12 or 24 Frames 12 or 24 Termination of Coverage Employee and dependent coverage will terminate on the earliest of the following events: 1. The last day of the month in which active employment ceases, unless the employee is on leave of absence, temporary layoff or total disability and the employer decides to continue paying for coverage. Option 3 2. The last day of the month in which the employee and/or dependent ceases to be eligible for insurance. Frequency Options Plan Benefit 3. The date the employer ceases to be a Participating Employer. A B C D 4. The day before the due date of any premium that remains unpaid at the endYearly Deductible Options $0, $10 or $25 of the grace period.Annual Eye Exam $60 Allowance 12 12 12 12 5. The date the policy terminates.Frames $115 Allowance 12 24 24 24 6. The date the number of insured employees of a Participating Employer fallsLenses below five. Single $55 Allowance 12 12 12 24 Bifocal $75 Allowance Trifocal $85 AllowanceContacts Elective $125 Allowance 12 12 24 24 Medically Necessary $200 Allowance 12 12 24 24 www.bestlife.com | 800.237.8543 13
  13. 13. Underwriting Information Vision PPO Exclusions Participation Requirements To be entitled to benefits for lenses and visual analysis, lenses must be prescribed and visual analysis must be performed by a legally qualified ophthalmologist, On groups where the employer pays 100% of the employee and/or dependent optometrist or physician acting within the scope of his or her license. premiums, 100% of all employees/dependents must participate. (Waived if other lines of coverage are purchased.) No benefit shall be payable except as otherwise provided herein or on account of: Employer-sponsored: For 5 or more lives, 60% participation of eligible employees for employees with other group vision coverage, a refusal card must 1. Services for which no charge is made or for which the insured is not required be completed. These employees will not be counted toward the participation to pay or any eye examination furnished by or paid under or for any requirement. government, federal or state, dominion or provincial, or any political subdivisions thereof, or any glasses or frames for which the insured has been Voluntary: For 5 or more lives, 20% participation of eligible employees or may be reimbursed under any group hospitalization or medical expense reimbursement insurance plan, to the extent of any such payment or Contribution Requirements reimbursement. Employer-sponsored: 50% and above for EEs and 0% and above for 2. Charges for services due to occupational accidents or sickness covered by Dependents workers’ compensation. Voluntary: Less than 50% of EE premium 3. More than one pair of lenses, frames, contact lenses or examination per person per benefit period. Underwriting Rights Reserved 4. Cosmetic lens enhancements such as tints, ultraviolet coating, scratch coating The insurance company reserves the right to require additional information before or anti-reflection coating. acting on an individual’s or group’s request for coverage. The insurance company 5. Safety glasses or goggles. reserves the right to decline any particular case or applicant regardless of size. Approval of all enrollment and employee eligibility requirements must be met 6. Services performed by an optometrist, ophthalmologist or physician beyond before insurance can be put in force. the scope of their applicable licenses. 7. Services incurred as a result of sickness or injury. 8. Special procedures such as orthoptics, vision training or subnormal vision aids. Access Vision Exclusions 9. Plain or prescription sunglasses or other special purpose vision aids. 10. Medical or surgical treatment of eyes. To be entitled to benefits for lenses and visual analysis, lenses must be prescribed 11. Replacement of lost or broken lenses and/or frames. and visual analysis must be performed by a legally qualified ophthalmologist or 12. Duplicate glasses or frames. legally qualified optometrist. 13. Services or materials not specifically listed in the schedule of vision benefits. No payments will be made for and covered vision expenses do not include: 14. Care, including prescribed medications, that would be deemed an eligible ƒƒServices for which no charge is made or for which the insured is not required expense under major medical or other insurance program. to pay, or any eye examination furnished by or paid for by any government. 15. Any services performed prior to the effective date, or after the coverage This includes glasses or frames for which the individual has been reimbursed termination date. under any group hospitalization or medical reimbursement insurance plan. 16. Services not recommended by a provider or which are not required for ƒƒCharges due to occupational accidents or sickness covered by workers’ necessary care and treatment, or which do not have uniform professional compensation. endorsement. ƒƒCosmetic lens enhancements such as tints, UV coating, scratch coating or 17. Services performed by a member of the patient’s immediate family, or a anti-reflective coating. person who resides in the patient’s home. ƒƒSafety glasses or goggles. 18. Charges for failure to keep a scheduled appointment, or for completion of ƒƒServices performed by an optometrist or ophthalmologist beyond the scope claim forms. of their applicable licenses. 19. Orthoptic or vision training, subnormal vision aids and any associated ƒƒServices incurred as a result of sickness or injury. supplemental testing. ƒƒSpecial procedures such as orthoptics, vision training or subnormal vision 20. Aniseikonic lenses. aids. 21. Medical and/or surgical treatment of the eye, eyes or supporting structure. ƒƒPlain or prescription sunglasses or other special purpose vision aids. 22. Non-prescription lenses and non-prescription sunglasses. ƒƒMedical or surgical treatment of eyes. 23. Two pair of glasses in lieu of bifocals. ƒƒReplacement of lost or broken frames and lenses. 24. Comprehensive eye exams not performed by either an optometrist, ƒƒDuplicate glasses or frames. ophthalmologist or a physician acting within the scope of his or her license. ƒƒServices or materials not specifically listed in the schedule of vision care 25. Lenses that are not prescribed by either an optometrist, ophthalmogist or benefits. physician acting within the scope of his or her license. ƒƒCare (including prescribed medication) that would be deemed an eligible expense under major medical or other insurance programs, including workers’ compensation. ƒƒAny service performed prior to the effective date or after the coverage termination date. ƒƒServices not recommended by a provider or which are not required for necessary care and treatment; or which do not have uniform professional endorsement. ƒƒServices performed by a member of the patient’s immediate family, or a person who resides in the patient’s home. ƒƒCharges for failure to keep a scheduled appointment or for completion of claim forms.14 www.bestlife.com | 800.237.8543
  14. 14. Group Term Life Plans Group Sizes 2 or MoreGroup Term Life Plan SummaryAvailable in AK, AL, AR, AZ, CA, CO, DC, FL, GA, HI, ID, IL, IN, KS, KY, LA, MD, MI, MO, MS, MT, NC, ND, NE, NM, NV, OH, OK, OR, PA, SC, SD, TN, TX,UT, VA, WA and WY. BEST Life Gold BEST Life Silver BEST Life Bronze (Employer-contributory) (Voluntary) (Employer-contributory) Employer Contribution 25% minimum Not applicable 25% minimum Flat schedules up to $100,000 2-9: $10,000 or $15,000 Class Schedules 10+: Increments of $10,000 to $500,000, Basic Life Schedules Salaried Schedules not to exceed 5 times employee salary $10,000, $15,000, $20,000 or $25,000 Additional amounts available with Additional amounts available with Evidence of Insurability Evidence of Insurability 2-9: $15,000 Upwards of $75,000, based on 2-4: $15,000 Guarantee Issue 10+: Upwards of $75,000 based on participation and group size 5-9: $25,000 participation and group size Non-contributory: 100% Non-contributory: 100% Participation Not Applicable Contributory: 75% minimum Contributory: 75% minimum Waiver of Premium Provision to Age 60 Waiver of Premium Provision to Age 60 Accelerated Death Benefit 75% to Accelerated Death Benefit 75% to Waiver of Premium Provision to Age 60 Plan Features $250,000 max $250,000 max Conversion Conversion Conversion 65 - 35% 65 - 35% 65 - 35% Age Reductions 70 - 50% 70 - 50% 70 - 50% (From original 75 - 65% 75 - 65% 75 - 65% amount) 80 - 80% 80 - 80% 80 - 80% 85 - 90% 85 - 90% 85 - 90% Spouse: increments of $5,000, up to Spouse: $5,000 or $10,000 $10,000 or 50% of employee coverage, Spouse: $10,000 Dependent Children ages 6 months to 25: not to exceed $50,000 Children ages 6 months to 25: Basic Life Coverage increments of $1,000 up to $5,000 Children ages 6 months to 25: increments of $1,000 up to $5,000 Children 14 days to 6 months: $1,000 increments of $1,000 up to $5,000 Children 14 days to 6 months: $1,000 Children 14 days to 6 months: $1,000 AD&D Option Includes Seat Belt & Air Bag Benefit Includes Seat Belt & Air Bag Benefit (For employees Available on basic and supplemental only) Available on basic and supplemental Available on basic and supplemental Accelerated Allows up to 75% or a maximum of $250,000 of life insurance benefits to be paid prior to the death of the participant. Death Benefit Available for 10+ only Supplemental / Voluntary Life for employee and dependents The following available to groups of 50+ only: Critical Illness Supplemental / Voluntary Life for Supplemental / Voluntary Life for Other Options employee and dependents employee and dependents Cancer Care Day Care Benefit Repatriation of Remains Benefit Exposure and DisappearanceDisclaimer: Life insurance applications submitted in conjunction with a BEST Life medical plan application are subject to evidence of insurability. www.bestlife.com | 800.237.8543 15
  15. 15. The Fine Print Ineligible Industries for 2-9 SIC Description 1011-1500 Mining Employee Effective Date 2111-2141 Tobacco products Insurance coverage will take effect on the later of: 2411-2429 Logging and sawmills ƒƒ date the employer becomes a participating employer if the employee’s The 2431 Millwork enrollment card is received within 31 days after that date. 2892 Explosives ƒƒ first day of the next calendar month following the date the waiting period The 3111 Leather tanning and finishing elected by the participating employer is completed. The employee’s enrollment card must be received within 31 days after satisfying the waiting period. If an 3292 Asbestos products employee is not working full-time for the firm on the date he or she would 4111-4216 Local and interurban passenger transit otherwise become covered, the employee will not be covered until he or she 4512-4581 Aviation and related services returns to full-time work. 491-497 Electric, gas, water, etc. ƒƒ first day of the next calendar month following the date evidence of The 5992 Florists insurability is approved, if required. Evidence of insurability will be required if 7231 Beauty shop the enrollment card is received more than 31 days after first becoming eligible or if applying for Supplemental Life Insurance coverage. 7241 Barber shops 7381 Detective and armored car services Dependent Coverage 7382 Security systems services Eligible dependents include spouse and unmarried dependent children. Dependent children are covered until age 20, extended through age 25 if they are 7542 Car washes full-time students. The definition of dependent may vary by state. Refer to the 7922-7929 Amusement and recreation certificate of insurance or your sales representative for details. 7948 Racing, including track operations 8059 Drug and alcohol treatment centers Dependent Effective Date 8111 Legal services Dependent coverage will take effect on the later of: 8611-8651 Membership organizations/associations ƒƒThe date the employee’s insurance is effective if the enrollment card is 8811 Private households received within 31 days after that date. 9233-9229 Correctional institutions, fire protection, public order and ƒƒ first day of the next calendar year month following the date the employee The safety, n.e.c. enrolled, in writing, his or her dependents for insurance, provided the enrollment is made within 31 days of the dependents first becoming eligible. ƒƒThe first of the month following the date the dependent evidence of Ineligible Industries for 10+ insurability is approved, if required. Evidence of insurability will be required if SIC Description the dependent enrollment card is received more than 31 days after first 1011-1500 Mining becoming eligible. 2111-2141 Tobacco products Late Entrants To The Plan 2411-2429 Logging and sawmills If an employee or dependent enrolls for coverage 31 days or more after becoming 2892 Explosives eligible, he or she will be considered a late entrant. The employee or dependent 3111 Leather tanning and finishing must complete and submit evidence of insurability. 4512-4581 Aviation and related services Termination of Coverage 7381 Detective and armored car services Group Term Life benefits will terminate on the earliest of the following dates: 7922-7929 Amusement and recreation ƒƒ last day of the month in which the employee ceases active employment, The 7948 Racing, including track operations unless the employee is on leave of absence, temporary layoff, injured or sick. 8059 Drug and alcohol treatment centers The employer may continue insurance by paying the required premiums, but 8611-8651 Membership organizations/associations not beyond the following limits. 8811 Private households -- months approved leave of absence. Three 9233-9229 Correctional institutions, fire protection, public order and -- Temporary layoff, the end of the month following the month in which safety, n.e.c. the layoff occurred. -- months of approved leave due to a disease or injury. Three AD&D Exclusions ƒƒ last day of the month in which employee ceases to be in an eligible The class. No amount will be payable for loss caused or contributed to by: ƒƒ date of the expiration of the period for which the last required premium The ƒƒSuicide, or any attempt thereof, while sane or insane. payment was due and not paid. ƒƒDrugs, poison, gas or fumes voluntarily taken, absorbed or inhaled which are ƒƒ date the policy terminates. The not administered on the advice of a physician. Conversion Privilege ƒƒBodily or mental infirmity or disease in any form, or medical or surgical treatment therefore. Conversion privilege to individual policy is available without evidence of insurability if an employee has been covered under the policy continuously for ƒƒBacterial infection, other than infection occurring simultaneously with or five years. The individual policy will be issued only if application is made and first through an accidental cut or wound. premium is paid within 31 days after the termination of insurance. See schedule ƒƒCommission of any crime. of benefits for complete information. ƒƒRiot, insurrection or war, declared or undeclared. For more information, please refer to the group term life underwriting ƒƒService in the military, naval or air forces of any country at war, declared or guidelines. undeclared. ƒƒTravel or flight in any kind of aircraft including falling or otherwise descending from or with any aircraft in flight, while participating in aviation training in any aircraft, or as a pilot, officer or other member of the crew of any aircraft. ƒƒBodily injury resulting from intoxication or from the voluntary use of narcotics which are not administered on the advice of a physician.16 www.bestlife.com | 800.237.8543

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