Download CPE 054 CoPower SUITE HMO Standard Plan Highlights

CoPower SUITE Standard
TM
DHMO Plan Highlights
At CoPower, we make understanding and using your benefits easy. Below is helpful
information about your chosen plan:
Highlights
With more than 140 years of
experience in the insurance
business and 90 years in
the group benefits business,
MetLife is positioned to meet
its obligations to your clients
and their employees both today
and in the future. MetLife is the
largest administrator of dental
benefit plans among all single
commercial carriers,1 providing
dental plan administration for
nearly 22 million people.2
FOR CLAIM INFO:
MetLife Dental Claims
Phone: (877) 638-3379
www.metlife.com/dental
PLAN ADMINISTRATION:
For plan coverage, benefits, or
eligiblity, contact a CoPower
Group Service Representative
Monday through Friday,
8:00 am to 5:00 pm PST.
T: 888.920.2322
E: [email protected]
www.copower.com
• The DHMO plan offers more than 400 covered services.
• Dependent Children/Students are covered up to age 26.
• Benefits are payable immediately from the start date of an individual’s benefits.
MANAGED DENTAL PLAN (MET185A - CALIFORNIA)
Code
Description
Copayment
Office Visit
Diagnostic Treatment
D0120
Periodic Oral Evaluation – Established Patient
$0
D0150
Comprehensive Oral Evaluation – New or Established Patient
$0
D0210
Intra-oral – Complete Series (Including Bite-wings)
$0
D0274
Bite-wings – Four Films
$0
Prophylaxis – Adult
$0
D1120
Prophylaxis – Child
$0
D1351
Sealant – per tooth
$0
D2140
Amalgam – One Surface, Primary or Permanent
$0
D2330
Resin-Based Composite – One Surface, Anterior
$0
D2391
Resin-Based Composite – One Surface, Posterior
$30
D2750
Crown – Porcelain Fused to High Noble Metal
$185
D2751
Crown – Porcelain Fused to Predominantly Base Metal
$185
D3220
Therapeutic Pulpotomy (excluding final restoration) –
Removal of pulp coronal to the dentinocemental junction
and application of medicament
$10
D3330
Endodontic therapy, Molar (excluding final restoration)
$200
Preventive Services
D1110
Restorative Services
Crowns
Endodontics
LIMRA data, based on enrolled lives as
1
of 12/31/13
MetLife data as of December, 2013
2
CoPower SUITE Standard
TM
DHMO Plan Highlights
Periodontics
DO I NEED
AN ID CARD?
Members who enroll under
MetLife Dental will receive ID
cards. ID cards are sent directly
to members and contain all the
necessary information to use
the MetLife Dental coverage.
D4260
Osseous Surgery (Including Flap Entry and closure) – Four or
more contiguous teeth or tooth bounded spaces per quadrant
$295
D4341
Periodontal scaling and root planing –
Four or more teeth per quadrant
$40
D4910
Periodontal Maintenance
$30
D5110
Complete Denture - Maxillary
$210
D5120
Complete Denture - Mandibular
$210
D5211
Maxillary partial denture – resin base
(including any conventional clasps, rests and teeth)
$240
D5212
Mandibular partial denture – resin based
(including any conventional clasps, rests and teeth)
$240
D6010
Surgical placement of implant body: endosteal implant
$1,005
D6059
Abutment supported porcelain fused to metal crown
(high noble metal)
$660
Prosthodontics
Implants
FINDING A
PROVIDER
Need help finding a MetLife
HMO dentist in your
area? CoPower is here to
help. The DHMO dental
network includes over 8,400
participating network dentist
access points in California.
Simply visit copower.com and
click on the Quick Link for
“Find a Provider” to quickly and
easily find the HMO provider in
your network for you.
Crowns / Fixed Bridges
D6241
Pontic – Procelain fused to predominantly base metal
$185
D6750
Crown - Porcelain fused to predominantly base metal
$185
D7140
Extraction, erupted tooth or exposed root
(elevation and/or forceps removal)
$0
D7210
Extraction, erupted tooth or exposed root
(elevation and/or forceps removal)
$30
D7220
Removal of impacted tooth – soft tissue
$45
D7240
Removal of impacted tooth – completely bony
$80
D8020
Limited orthodontic treatment of the transitional dentition
$725
D8030
Limited orthodontic treatment of the adolescent dentition
$725
D8040
Limited orthodontic treatment of the adult dentition
$725
D8070
Comprehensive orthodontic treatment of the transitional
dentition
$1,695
D8080
Comprehensive orthodontic treatment of the adolescent
dentition
$1,695
D8090
Comprehensive orthodontic treatment of the adult dentition
$1,695
Oral Surgery
Orthodontics
Like most group benefit programs, benefit programs offered by MetLife and its affiliates contain certain exclusions,
exceptions, waiting periods, reductions, limitations and terms for keeping them in force. Please contact MetLife or
your plan administrator for complete details. This summary provides an overview of your plan’s benefits. These
benefits are subject to the terms and conditions of the group insurance policy and are subject to each state’s laws
and availability. Specific details regarding these provisions can be found in the insurance certificate.
Metropolitan Life Insurance Company, New York, NY 10166
Vision Plan
This vision plan includes in- and out-of-network benefits as listed below; if you visit a network
provider, you will receive the maximum benefit. If you choose to see an out-of-network
provider, you will be reimbursed for services as indicated in the “Out-of-network Coverage”
section of this schedule.
The SUITE Vision Coverage
VSP provides affordable,
high-quality eyecare plans
that promote visual wellness
and improve members’ quality
of life. Their plans even over
advanced vision correction
procedures, including surgery.
With more than 29,000 VSP
doctors in over 21,000 offices
across the country—that’s
50,000 points of access for
members—a doctor is an
average of only four miles from
where members live and work.
FOR CLAIM INFO:
VSP Vision Contact Information
T: (800) 877-7195
Monday through Friday,
5:00 AM to 7:00 PM, PST
PLAN
ADMINISTRATION:
For plan coverage, benefits, or
eligiblity, contact a CoPower
Group Service Representative
Monday through Friday,
8:00 am to 5:00 pm PST.
T: 888.920.2322
E: [email protected]
www.copower.com
Through VSP, you will receive:
• Complete eyecare and wellness solution
• Reduced healthcare costs over time
• Lowest out-of-pocket costs
VSP also offers additional eyecare services specifically to members with Type 1 Diabetes.
The benefits in their Diabetic Eyecare Program include medical follow-up exams, specialized
screenings and tests, medically necessary retinal imaging, and diabetic retinopathy. Members
never need a referral and pay only a $5 copay for services. The Diabetic Care benefit will
include Type 2 Diabetes, and members pay a total copay of $20.
VISION COVERAGE
SUITE Vision Choice Plan B $25
In-Network
$25
Annual Copayment
Eye Exam
Out-of-network
Covered in full
Reimbursed up to $45
Single Vision
Covered in full
Reimbursed up to $30
Bifocal
Covered in full
Reimbursed up to $50
Trifocal
Covered in full
Reimbursed up to $65
Frames
$150 allowance
Reimbursed up to $70
Contact Lenses
(in lieu of lenses and a frame)
$150 allowance
Reimbursed up to $105
Lenses by Type
(Glass or Plastic)
Frequency of Services
Eye Exam
12 months
Lenses
12 months
Frames
24 months
Contact Lenses
(in lieu of lenses and a frame)
12 months
Finding a VSP Participating Eye Doctor: Simply go to www.vsp.com and look for the “Find A
VSP Doctor” box on the right side of the page. Enter your zip code, and click “Search” to see a
list of participating providers.
Please refer to your Certificate of Insurance for details on the process and administration
of your coverage. SUITEVision Choice Plan C is underwritten by VSP. VSP is not affiliated with
Metropolitan Life Insurance Company or its affiliates.
Do I Need a VSP ID Card?
Tell your provider you have VSP coverage. No ID card is necessary.
Basic Life
Your employer provides you with Basic Life insurance coverage and Accidental Death and Dismemberment insurance in the amount of $25,000. In
addition, the following features are available to all members.
Accelerated Benefits Option1
You can receive up to 80% of your Basic Term Life insurance proceeds to a maximum of $500,000 in the event that you become terminally ill and are
diagnosed with less than 12 months to live.
Conversion
All Group Term Life insurance benefits are convertable to an Individual Whole Life insurance policy if your coverage terminates in whole or in part
due to your retirement, termination of employment, or a change in your employee class.
Portability
You may be eligible to continue your employee term life insurance under a different group policy if your coverage terminates in whole or in part due
to your retirement or termination of employment. The minimum benefit that can be continued is $20,000; maximums will apply.
Waiver of Premiums for Total Disability (Continued Protection)
You may be eligible for waiver of your Basic Term Life and Personal AD&D insurance premium due to total disability before age 60. Total disability
means your inability to do your job and any other job for which you are fit by education, training or experience, due to injury or sickness. Your waiver
will begin after you have satisfied a 9-month waiting period. The Waiver of Premium will end on the earliest of your turning age 65, death or recovery.
There is a one year participation requirement for new participants.
Delivering The Promise®
Delivering The Promise® provides beneficiaries with support and assistance such as filing life insurance claims and consultation to help with the
financial details and questions that arise upon the loss of a loved one.
MetLife’s Center for Special Needs Planning2
MetLife’s Center for Special Needs Planning helps families with special needs dependents plan and prepare for the complex financial, social,
emotional, and educational issues facing them.
Total Control Account®3
The Total Control Account® settlement option provides your loved ones with a safe, convenient way to manage life or accident policy proceeds for
claim payments of $5,000 or more, backed by the financial strength of Metropolitan Life Insurance Company. They’ll have immediate access to all of
their proceeds, through an interest bearing account with unlimited draft-writing privileges.
What is Not Covered?
This plan does not provide payment of benefits for death caused by suicide within the first two years of the effective date of the certificate, or
payment of increased benefits for death caused by suicide within two years of an increase in coverage. Please note that a reduction schedule may
apply. Please see your plan administrator or certificate for specific details.
Accidental Death & Dismemberment Coverage (AD&D)
This valuable coverage is available to you even if you already have accident insurance. It provides benefits beyond your disability or life insurance
for losses due to covered accidents — while commuting, traveling by public or private transportation and during business trips. MetLife’s AD&D
insurance pays you benefits if you suffer a covered accident that results in paralysis or the loss of a limb, speech, hearing or sight, or brain damage
or coma. If you suffer a covered fatal accident, benefits will be paid to your beneficiary.
Coverage Amounts for You
Your employer provides you with AD&D insurance in an amount equal to your
Basic Life coverage amount of $25,000 at no cost to you.
Table of Covered Losses
This AD&D insurance pays benefits for covered losses that are the result of
an accidental injury or loss of life. The full amount of your AD&D coverage is
called the “Full Amount” and is equal to the benefit payable to the loss of life.
The maximum amount payable for all Covered Losses sustained in any one
accident is capped at 100% of the Full Amount.
Standard Additional Benefits Include
Air Bag Benefit: Benefit can be increased by 5% of the Full Amount up to
$10,000. Payable if an insured person dies as a result of injuries sustained
in an accident while driving or riding in a private passenger car that was
equipped with air bags.
Seat Belt Benefit: Benefit can be increased by 10% of the Full Amount up
to $25,000. Payable if an insured person dies as a result of injuries sustained
in an accident while driving or riding in a private passenger car and wearing a
properly fastened seat belt (or a child restraint if the insured is a child).
Common Carrier Benefit: The additional amount payable is 100% of the
Full Amount. Payable if an insured person dies as a result of injuries sustained
while traveling in a Common Carrier.
Covered Losses
Life
Hand
Foot
Arm
Leg
Sight of one eye
Thumb & index finger of same hand
Speech & hearing
Speech or hearing
Paralysis of both arms and both legs
Paralysis of both legs
Paralysis of the arm & leg on either side of the body
Paralysis of one arm or leg
Brain Damage
Coma
Percent of
Full Amount
100%
50%
50%
75%
75%
50%
25%
100%
50%
100%
50%
50%
25%
100%
1% monthly
up to 60
months
Accidental Death and Dismemberment Insurance (AD&D) (cont.)
Child Care Center Benefit: Provides funds for your eligible dependent children, 12 years old or younger, to attend a licensed child care facility for
up to four consecutive years if you should suffer a fatal accident. The yearly benefit for each eligible child is equal to $5,000 or the actual amount of
child care costs incurred (whichever is less), and cannot exceed an overall total of 12% of the Full Amount. In order to be eligible, dependent children
must be enrolled in a licensed child care center at the time of your accidental death.
What Is Not Covered?
Accidental Death & Dismemberment insurance does not include payment for any loss which is caused by or contributed to by: physical or mental
illness, diagnosis of or treatment of the illness; an infection, unless caused by an external wound accidentally sustained; suicide or attempted suicide;
injuring oneself on purpose; the voluntary intake or use by any means of any drug, medication or sedative, unless taken as prescribed by a doctor or
an over-the-counter drug taken as directed; voluntary intake of alcohol in combination with any drug, medication or sedative; war, whether declared
or undeclared, or act of war, insurrection, rebellion or riot; committing or trying to commit a felony; any poison, fumes or gas, voluntarily taken,
administered or absorbed; service in the armed forces of any country or international authority, except the United States National Guard; operating,
learning to operate, or serving as a member of a crew of an aircraft; while in any aircraft for the purpose of descent from such aircraft while in flight
(except for self preservation); or operating a vehicle or device while intoxicated as defined by the laws of the jurisdiction in which the accident occurs.
Who Can Be A Designated Beneficiary?
You can select any beneficiary(ies) other than your employer, and you may change your beneficiary(ies) at any time. You can also designate more
than one beneficiary.
About Your Coverage Effective Date
You must be Actively at Work on the date your coverage becomes effective. If Actively at Work requirements are met, coverage will become effective
on the first of the month following the receipt of your completed application for all requests that do not require additional medical information. A
request for Your amount that requires additional medical information and is not approved by the date listed above will not be effective until the later
of the date that notice is received that MetLife has approved the coverage or increase if you meet Actively at Work requirements on that date, or
the date that Actively at Work requirements are met after MetLife has approved the coverage or increase. The coverage for your spouse/domestic
partner and eligible child(ren) will take effect on the date they are no longer confined, receiving or applying for disability benefits from any source or
hospitalized.
Life and AD&D coverages are provided under a group insurance policy (Policy Form GPNP99-TRUST) issued to your employer by MetLife. Life and AD&D
coverages under your employer’s plan terminates when your employment ceases when your Life and AD&D contributions cease, or upon termination of the
group contract. Should your life insurance coverage terminate for reasons other than non-payment of premium, you may convert it to a MetLife individual
permanent policy without providing medical evidence of insurability.
CoPower VANTAGE
CoPower VANTAGE is a portfolio of value-add services, available free of cost to all CoPower members!
Discount Rx Card
FREE discount prescription card to members with up to 75% discounts on prescription drugs (discounts average roughly 30%).
Honored at more than 56,000 pharmacies!
Wild at Work
Stretch your paychecks with money-saving offers and exclusive discounts. Members enjoy savings on dining, theme parks, shopping and a host of
other services. Includes discounts on amusement parks, Direct TV, Legal Zoom, Restaurant Gift Cards, Hotel Deals, and Car Rental & Airfare.
To learn more on how you can take advantage of these free services and offerings, visit www.copower.com/vantage.
CoPower VANTAGE services are not provided by or endorsed by Metropolitan Life Insurance Company or its affiliates.
1 The Accelerated Benefits Option is subject to state availability and regulation. The accelerated life insurance benefits offered under your certificate are intended
to qualify for favorable federal tax treatment. If the accelerated benefits qualify for favorable tax treatment, the benefits will be excludable from your income
and not subject to federal taxation.
This information was written as a supplement to the marketing of life insurance products. Tax laws relating to accelerated benefits are complex and limitations
may apply. You are advised to consult with and rely on an independent tax advisor about your own particular circumstances.
Receipt of accelerated benefits may affect your eligibility, or that of your spouse or your family, for public assistance programs such as medical assistance
(Medicaid), Temporary Assistance to Needy Families (TANF), Supplementary Social Security Income (SSI) and drug assistance programs. You are advised to
consult with social service agencies concerning the effect that receipt of accelerated benefits will have on public assistance eligibility for you, your spouse or your
family.
2 Investment advisory services offered by MetLife Securities, Inc., 200 Park Avenue, NY, NY 10166.
3 Subject to state law, and/or group policyholder direction, the Total Control Account is provided for all Life and AD&D benefits of $5,000 or more. The TCA is not
insured by the Federal Deposit Insurance Corporation or any government agency. The assets backing the TCA are maintained in MetLife’s general account and
are subject to MetLife’s creditors. MetLife bears the investment risk of the assets backing the TCA, and expects to earn income sufficient to pay interest to TCA
Accountholders and to provide a profit on the operation of the TCAs. Guarantees are subject to the financial strength and claims paying ability of MetLife.
CPE054 5/15