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Benefits Summary Prime and Complete Dental For New York Employer Groups Choice of Dental Program Choose either Dental Prime, which uses our lower cost contracted network or Dental Complete, our even larger contracted network. Then select your plan design below. PLAN DESIGNS AVAILABLE TO SMALL GROUPS WITH 2-50 EMPLOYEES Passive or Active In-network Out-of-network Annual Deductible Choice Annual Maximum Choice Endodontic, Periodontal and Oral Surgery Category Orthodontic Coverage (Ortho) Waiting Periods (Major and Ortho) Annual Maximum Carryover Value Dental plans – coverage for the basics like cleanings, exams, X-rays and fillings. Passive 100% D&P 80% Basic 0% Major 100% D&P 80% Basic 0% Major $50 $500 or $1,000 Basic Not covered None Not available Active 100% D&P 80% Basic 0% Major 80% D&P 60% Basic 0% Major $50 $500 or $1,000 Not covered Not covered None Not available Classic Dental plans – coverage for basic dental services, plus additional coverage for most major services, all with generous annual maximums. Plus, annual maximum carryover options. Passive 100% D&P 80% Basic 50% Major 100% D&P 80% Basic 50% Major $25 or $50 $1,000 or $1,500 Basic or Major 50% child only, 50% child or adult, or not covered None Optional Active 100% D&P 80% Basic 50% Major 80% D&P 60% Basic 50% Major $25 or $50 $1,000 or $1,500 Basic or Major 50% child only, 50% child or adult, or not covered None Optional Enhanced Dental plans – the greatest level of coverage, with choices for even higher annual maximums and lower coinsurance amounts. Plus, annual maximum carryover options. Passive 100% D&P 90% Basic 60% Major 100% D&P 90% Basic 60% Major $25 or $50 $2,000 Basic 50% child only, 50% child or adult, or not covered None Optional Active 100% D&P 90% Basic 60% Major 80% D&P 70% Basic 50% Major $25 or $50 $2,000 Basic 50% child only, 50% child or adult, or not covered None Optional Voluntary Dental plans – access to high-quality, comprehensive dental coverage for your employees at little or no cost to you. Plus, annual maximum carryover options. Passive 100% D&P 80% Basic 50% Major 100% D&P 80% Basic 50% Major $25 or $50 $1,000 or $1,500 Major 50% child only, or note covered 12 month Optional Active 100% D&P 80% Basic 50% Major 80% D&P 60% Basic 50% Major $25 or $50 $1,000 or $1,500 Major 50% child only, or note covered 12 month Optional 20335NYEENEBS Rev. 6/11 Services provided by Empire HealthChoice HMO, Inc. and/or Empire HealthChoice Assurance, Inc., licensees of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield plans. 1 Plan Description Deductible Waived for diagnostic & preventive Family deductible equals three individual deductibles. Ortho lifetime maximum For plans with orthodontic coverage, per member lifetime maximum equal to the plan’s annual maximum Waiting period for voluntary plans 12 month waiting period applies for major and orthodontic services. Waived if employer shows prior comparable coverage with enrollment paperwork. Dependent age limit Up to age 26 or 30 Out-of-network Reimbursement Option to pay Maximum Allowable Charge (MAC) or 90th percentile Participation Guidelines (For employers with 2-50 employees) Employer-paid: options from 50% to 100% of net eligible employees at 10% increments. Voluntary: minimum participation of 2 enrolled employees. Dual Option: not available Ortho: minimum 10 enrolled employees. PLAN DESIGNS AVAILABLE TO LARGE GROUPS WITH 51 OR MORE EMPLOYEES Plan Design Options Active plan options (Different coinsurances in-network and out-of-network available) Passive plan options (Same coinsurances in-network and out-of-network) Diagnostic and preventative Coinsurance Options: 100%, 95%, 90%, 85%, 80%, 75%, 70%, 65%, 60%, 55% or 50% Basic Services Coinsurance Options: 100%, 95%, 90%, 85%, 80%, 75%, 70%, 65%, 60%, 55%, 50%, or not covered Major services Coinsurance Options: 100%, 95%, 90%, 85%, 80%, 75%, 70%, 65%, 60%, 55%, 50%, or not covered $0, $15, $20, $25, $30, $35, $40, $45, $50, $55, $60, $65, $70, $75 , $80, $85, $90, $95, $100 or a $100 Lifetime Maximum Deductible – contract or calendar year option May be waived for D&P; Family aggregate options: 2X , 3X or none Annual maximum – contract or calendar year option $500; $750; $1,000; $1,250; $1,500; $1,750; $2,000; $2,250 or $2,500 Benefit categories Endodontic, periodontal and oral surgery Orthodontic coverage Options to not cover, child only or adult and child Annual maximum and orthodontic maximum do not have to be the same Out-of-network dentist reimbursement Basic or Major Coinsurance Options: Lifetime Maximum: 100%, 95%, 90%, 85%, 80%, 75%, 70%, 65%, 60%, 55%, 50%, or not covered $500; $750; $1000; $1,250; $1,500; $2,000; $2,225 or $2,500 Maximum Allowable Charge (MAC) or 50th, 60th, 70th, 80th 90th percentile Waiting periods Basic, Major or Orthodontic Services may have different waiting periods For voluntary plans Major and Orthodontic services have a 12-month waiting period. Waiting period is waived if employer shows prior comparable coverage with enrollment paperwork. Annual maximum carryover Dependent age limit Out-of-network Reimbursement None, 6 or 12 months for Basic and Major Services None or 12 months for Orthodontic Services Optional Up to age 23, 26 or 30 Option to pay Maximum Allowable Charge (MAC) or percentile (50th, 60th, 70th, 80th, or 90th) Participation Guidelines (For employers with 51 or more employees) Employer-paid: minimum 60% participation of net eligible employees Voluntary: minimum participation of 2 enrolled employees. Dual Option: - Employer-paid plans: minimum of 5 employees must enroll in each of the two options, employee-only rate tier must have at least 20% rate differential, and all other group participation guidelines apply. - For Voluntary plans: dual option is not available. Ortho: minimum 10 enrolled employees. 2 2 Benefit Description Time Frames Comments Diagnostic and Preventive (D&P) Services Oral exams of any type (including emergency and specialist) Covered 2 times per calendar year Full mouth/panoramic X-rays 1 every 60 months Bitewing X-rays One series of films per 12-month period for Members to age 18; and one series of films per 24-month period for Members age 18 and older Periapical X-rays 4 per 12-month period Routine cleanings 2 routine cleanings or periodontal maintenance per calendar year Topical fluoride application 1 per 12-month period to age 19 Sealants Once per 24-month period to age 16 Sealants once per 24-month period to age 16 For 1st and 2nd molars. Unless quoted otherwise, standard coverage for sealants is considered a D&P Service. Restorations XXAmalgams XXComposite restorations Limited to only 1 service per tooth surface per 24-month period Unless quoted otherwise, coverage for a composite restoration on a posterior (back) tooth is limited to the allowance for the equivalent amalgam restoration. The member is responsible for the difference in cost between the composite and the amalgam filling. Large groups may elect to cover composite restorations on posterior teeth based on the composite allowance. Space maintainers Covered 1 time per lifetime to the age of 17 Covered for extracted primary posterior (back) teeth. Repair or replacement of lost/broken appliances are not a covered benefit. Covered 1 time every 36 months for Members age 20 to 40. Limited to 1 per 12-month period per Member age 40 and above. Brush Biopsy coverage is considered a standard benefit; however, large groups have the option to not cover this service. Root canals 1 time per tooth per lifetime On permanent teeth only Periodontal maintenance 2 cleanings or periodontal maintenance per calendar year Cleanings paid at the preventive coinsurance Periodontal scaling and root planing Covered 1 time per 36 months if the tooth has a pocket depth of 4 millimeters or greater Osseous surgery Only 1 complex surgical periodontal service is covered per 36-month period per single tooth or multiple teeth in the same quadrant and only if the pocket depth of the tooth is 5 millimeters or greater Periodontal maintenance paid at the periodontal coinsurance Basic Services Emergency treatment for the relief of pain Basic extractions Brush biopsy Endodontic, Periodontal and Oral Surgery Surgical extraction Surgical removal of 3rd molars (wisdom teeth) are only covered when there are symptoms of oral pathology General anesthesia or intravenous sedation When given in conjunction with a complex surgical service See the certificate for additional endodontic, periodontic, and oral surgery procedures that may be covered under the plan. The benefit description is intended to be a brief outline of coverage. The entire provisions of benefits and exclusions are contained in the Group Contract. In the event of a conflict between the Group Contract and this description, the terms of the Group Contract will prevail. 3 Benefit Description Time Frames Comments Major Restorative Services Permanent crowns or onlays Covered 1 time per 7 year period Removable prosthetic services (dentures and partials) Covered 1 time per 7 year period All prosthetic services are subject to a 12 month missing tooth exclusion Fixed prosthetic services (bridge) Covered 1 time per 7 year period All prosthetic services are subject to a 12 month missing tooth exclusion Single tooth implant body, abutment and crown Covered 1 time per 7 year period Implants are covered as a major restorative service. All prosthetic services are subject to a 12 month missing tooth exclusion. For members age 16 and over. Coverage includes only the single surgical placement of the implant body, implant abutment and implant/abutment supported crown. Implants are considered a standard benefit for small groups. Large group may choose to cover implants or not. See your certificate for additional major restorative procedures that may be covered under your plan. Orthodontics Optional coverage for classic, enhanced, and voluntary plans. Child only coverage covers children up to age 19. XXChoice of child only (8 up to age 19), child and adult, or no coverage. XXOrthodontia is not an option for Value plans. Annual Maximum Carryover Unused benefit dollars in one year can be carried over into the next coverage year Optional plan feature for classic, enhanced, and voluntary plans. XX$250 maximum carryover per member per year. XXAt the end of each year, carryover will be recorded in a separate Carryover Account. Once the Carryover Account has reached $1,000 per member, no further amounts will accumulate. XXAnnual maximum carryover is not an option for Value plans. Following requirements must be met: XXMember must be enrolled under this plan for a full calendar year, and XXMember must have submitted at least one claim for the coverage year, and XXMember did not exceed $500 in covered services applied to their annual maximum. The benefit description is intended to be a brief outline of coverage. The entire provisions of benefits and exclusions are contained in the Group Contract. In the event of a conflict between the Group Contract and this description, the terms of the Group Contract will prevail. When selecting a dental carrier, please consider the Dental Prime and Complete Value-Added benefits. For details, talk to your Empire representative or visit empireblue.com. XX Easy-to-access information. With Empire you have 24/7 online access to your dental claim and benefit information. XX International dental emergency care: members traveling outside the U.S., automatically have coverage for emergency dental services through a worldwide network of English-speaking dentists. XX Education materials to promote dental health. XX Healthy discounts for your employees: savings on alternative medicines, vision products, and fitness club memberships through our SpecialOffers program. 4