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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