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Todays Agenda • Managed Care Plans – S700A Lo and S500A Hi Commonly Covered Procedures Managed Care Plan Features Specialty Referral Process 2015 Monthly Rates • Tools Member Services Dental Website: www.MySolstice.net 2
Your Dental Benefit Offerings at a Glance DHMO Plan Name S700A Lo S500A Hi Solstice Participating Solstice Participating Network Dentist Dentist Maximum None None Benefit Adult and Child Adult and Child Orthodontia services at a copay services at a copay 3
Managed Care Plans - DHMO 4
Option #1 Managed Care Plan S700A Lo : Commonly Covered Procedures BENEFIT Plan S700A Lo Deductible None Calendar Year Maximum None Claim Forms None Rosters None Primary Dentist Required None Diagnostic/Preventive You Pay Comprehensive Oral Evaluation (D0150) No Charge Periodic Oral Evaluation (D0120) No Charge Routine Prophylaxis (cleaning) - adult (D1110) No Charge - (1 per 6 months) Palliative (emergency) treatment of dental pain (D9110) No Charge X-ray – bitewings - four films (D0274) No Charge - (1 per 12 months) Topical application of fluoride (D1208) No Charge - (1 per 12 months) Extraction of erupted tooth or exposed root (simple extractions) (D7140) $20 Amalgam (fillings) – 1 surface, primary or permanent (D2140) No Charge 5
Option #1 Managed Care Plans S700A Lo : Commonly Covered Procedures Plan S700A Lo Basic/Restorative Procedures You Pay Endodontic therapy (root canal) – anterior (excluding final restoration) (D3310) $110 Endodontic therapy (root canal) – molar (excluding final restoration) (D3330) $245 Application of sealant per tooth – (D1351) No Charge Major Procedures Crowns – porcelain fused to noble metal (D2752) $245 + Complete dentures – mandibular (D5120) $325 + Pontic (bridge) – porcelain fused to predominantly base metal (D6241) $245 + Periodontics Periodontal scaling and root planing – 4 or more contiguous teeth per quad (D4341) $50 per quadrant + Orthodontics Pre-orthodontic treatment visit (D8660) $35 Comprehensive treatment of transitional dentition (D8070) $2,200 Comprehensive treatment of adolescent transitional dentition (D8080) $2,250 Comprehensive treatment of adult dentition (D8090) $2,350 + See Exclusions and Limitations for information on additional cost for lab and materials fees 6
Option #2 Managed Care Plan S500A Hi : Commonly Covered Procedures BENEFIT Plan S500A Hi Deductible None Calendar Year Maximum None Claim Forms None Rosters None Primary Dentist Required None Diagnostic/Preventive You Pay Comprehensive Oral Evaluation (D0150) No Charge Periodic Oral Evaluation (D0120) No Charge Routine Prophylaxis (cleaning) - adult (D1110) No Charge - (1 per 6 months) Palliative (emergency) treatment of dental pain (D9110) No Charge X-ray – bitewings - four films (D0274) No Charge - (1 per 12 months) Topical application of fluoride (D1208) No Charge - (1 per 12 months) Extraction of erupted tooth or exposed root (simple extractions) (D7140) $10 Amalgam (fillings) – 1 surface, primary or permanent (D2140) No Charge 7
Option #2 Managed Care Plans S500A Hi : Commonly Covered Procedures Plan S500A Hi Basic/Restorative Procedures You Pay Endodontic therapy (root canal) – anterior (excluding final restoration) (D3310) $100 Endodontic therapy (root canal) – molar (excluding final restoration) (D3330) $225 Application of sealant per tooth – (D1351) No Charge Major Procedures Crowns – porcelain fused to noble metal (D2752) $240 + Complete dentures – mandibular (D5120) $260 + Pontic (bridge) – porcelain fused to predominantly base metal (D6241) $240 + Periodontics Periodontal scaling and root planing – 4 or more contiguous teeth per quad (D4341) $45 per quadrant + Orthodontics Pre-orthodontic treatment visit (D8660) $35 Comprehensive treatment of transitional dentition (D8070) $2,000 Comprehensive treatment of adolescent transitional dentition (D8080) $2,050 Comprehensive treatment of adult dentition (D8090) $2,150 + See Exclusions and Limitations for information on additional cost for lab and materials fees 8
Managed Care Plan Features The Manage Care Plan offer: No deductible and no maximums. No waiting period. Open Access Provider Network. No Rosters! 2 free routine cleanings a year (one every six months). 2 free evaluations a year (one every six months). Emergency visits outside Florida are payable up to $100 per occurrence, toward the abatement of pain. Most X-rays are available at no additional cost to the member. Discount Implant Service Included. Orthodontic services coverage available for children and adults. 9
Manage Care Plan Specialty Care Process 10
Managed Care Plan Rates Monthly Rates Option #1 Option #2 Tier S700A Lo S500A Hi $7.93 $13.68 Employee Only Employee + One Dependent $13.11 $25.42 Employee + $19.38 $37.13 Two or More Dependents 11
Tools 12 212
Customer Service Customer Service Center • Available from 8:00 a.m. to 6:00 EST Monday – Friday Support for non-English speakers. AT&T language line support more than 170 languages. Toll-free teletypewriter (TTY) service for the deaf and hearing impaired members. Our entire customer service team is able to fully interact with this system. Interactive Voice Response (IVR) System • Provider Locator, benefit information and eligibility. Toll-free, 24 hours a day, seven day a week. Toll-free Number 1.855.557.4120 Our commitment to customer service 13
Award Winning Websites: MySolstice.net and SolsticeBenefits.com • Dental Locator • Find general dentists and specialists • Print maps and driving directions • Plan Information • Verify eligibility • View benefit summary • Order an ID card • Answers to common dental questions about plans • Member Schedule of Benefits Claims Information Review claim status and history Link to Explanation of Benefits (EOB) Dental Education An A-Z guide of dental terminology and dental care tips Monthly Member Newsletters 14
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