2018 Standalone Dental and Vision Plans for Adults

1 2018 Standalone Dental and Vision Plans for Adults Age 19 and Older 2018 Adult Dental and Vision Plans Independence Blue Cross (Independence) offers Standalone Dental and Vision Plans for Adults age 19 and older to complement individual medical Plans . These Plans help you achieve good oral and Vision health and can be purchased any time during the year, with or without a medical plan . Adult Dental Plans Independence offers two Adult Dental Plans : Adult Dental Preferred and Adult Dental Premier with Preventive Incentive. Both Plans include: lexibility to see F ne of the largest O 00-percent 1 Coverage for most Discounts on any dentist you Dental networks in coverage for routine basic and major Dental non-covered want, nationally the country with over preventive care services, such as services with some 62,000 unique dentists fillings and root canals participating providers at over 244,000 access.

2 Points nationwide Adult Vision Plans Independence offers two Adult Vision Plans : Vision Care 100 and Vision Care 180. Both Plans offer 100-percent coverage for a routine annual eye exam with a participating provider, plus: Low- or no-cost frames Option to use an Access to a national Discounts on other from the Davis Vision allowance toward provider network services, including Exclusive Collection frames or contact with over 60,000 laser Vision correction available at most lenses, in lieu access points participating providers of eyeglasses Next step: Apply! There are several ways to enroll in Independence adult Dental and Vision Plans : Visit Complete the application in your enrollment kit and return it in the postage-paid envelope provided.

3 Separate applications and payments are required for Dental and Vision Plans . Stop by Independence LIVE on the 2nd floor of 1919 Market Street in Philadelphia for help from a licensed sales agent, Monday through Friday, 8 5 Questions? Contact your broker or call Independence at 1-866-459-9612 (TT Y/TDD: 711). 1. Choose your Adult Dental plan If you're looking for Adult Dental coverage that covers preventive services (such as exams and cleanings) and basic services (such as fillings and root canals), then the Adult Dental Preferred plan is for you. If you are looking to stretch your benefit dollars further and get the the added protection of lower out-of-pocket costs and coverage for major services, such as crowns and dentures, the Adult Dental Premier with Preventive Incentive is the plan for you.

4 Adult Dental Premier Adult Dental plan comparison Adult Dental Preferred with Preventive Incentive Deductible You pay $50 per individual You pay $50 per individual You pay $150 per family You pay $150 per family Annual maximum $1,000 per individual $1,000 per individual Preventive Incentive Not applicable Benefits paid for exams, cleanings, X-rays, and emergency treatments do not count toward the annual maximum. Network Concordia Advantage1 Concordia Advantage1. Preventive & diagnostic services Exams, cleanings, X-rays, emergency You pay $0; Not subject to deductible; No waiting period You pay $0; Not subject to deductible; No waiting period treatment, consultations Frequency Exams 1 per 12 months 1 per 6 months Cleanings 1 per 12 months 1 per 6 months Bitewing X-rays 1 set per 24 months, age 19 to 29; 1 set per 3 years, age 30 1 set per 18 months and older Full mouth X-rays 1 per lifetime (new patients only) 1 per 5 years Basic services Fillings You pay 50%, after deductible; No waiting period You pay 20%, after deductible; No waiting period Root canals, periodontics, oral surgery You pay 50%, after deductible; 12-month waiting period You pay 20%, after deductible.

5 12-month waiting period Extractions You pay 50%, after deductible; No waiting period You pay 20%, after deductible; No waiting period Major services Crowns, dentures Not covered You pay 50%, after deductible; 12-month waiting period Crown and denture repairs You pay 50%, after deductible; 12-month waiting period You pay 20%, after deductible; 12-month waiting period Save Money with Network Dentists Find a network dentist in the Concordia Advantage network at 2. Adult Dental plan monthly premiums per member Age Adult Dental Preferred Adult Dental Premier with Preventive Incentive 19 25 $ $ 26 39 $ $ 40 49 $ $ 50 63 $ $ 64+ $ $ 1 Payment is based on the Maximum Allowable Charge (MAC) for the specific covered service.

6 Network dentists accept contracted MACs as payment in full. If you choose to use a non-network dentist, you may pay the difference between the amount the plan pays and the amount charged by the non-network dentist. 2 When searching , dentists with the symbol accept plan allowances for non-covered services, including services that go over your annual maximum. Independence Blue Cross Dental Plans are administered by United Concordia Companies, Inc., an independent company. This is a summary only. A full description of benefits exclusions, and limitations is provided in the policy. 2018 Standalone Dental and Vision Plans for Adults Age 19 and Older 2. Choose your Adult Vision plan If you are looking for a basic plan that gives you discounts on glasses and an allowance toward contact lenses, consider Vision Care 100.

7 If you are looking for greater discounts, lower out-of-pocket costs, and a higher allowance for frames or contact lenses, consider Vision Care 180. Adult Vision plan comparison Vision Care 100 Vision Care 180. In-network benefits You pay You pay Frequency (exam and hardware) Once every calendar year Once every calendar year Copays for exam and lenses $0 $0. Frame Davis Vision Exclusive Frame Collection (instead of allowance): Fashion selection $0 copay $0 copay Designer selection $15 copay $0 copay Premier selection $40 copay $25 copay Up to $100, Up to $130, or up to $1804 at Visionworks, Non-collection frame allowance 20% discount on overage3 20% discount on overage3. Lens options You pay You pay Clear plastic single- Vision , lined bifocal, trifocal, $0 $0.

8 Or lenticular lenses (any Rx). Tinting of plastic lenses $15 $0. Scratch-resistant coating $0 $0. Polycarbonate lenses $35 $30. Ultraviolet coating $0 $0. Anti-reflective (AR) coating $40 /$55 /$69 $35/ $48/ $60. Progressive lenses $65/$105/$140 $50/$90/$140. High-index lenses $60 $55. Transition lenses (Plastic photosensitive) $70 $65. Polarized lenses $75 $75. Contact lens benefit Benefit Benefit (instead of eyeglasses). Davis Vision Contact Lens Collection (instead of allowance). Disposable 4 boxes/multi-packs 4 boxes/multi-packs Planned replacement 2 boxes/multi-boxes 2 boxes/multi-packs Evaluation, fitting, and follow-up care Included Included Non-collection contact lenses: Materials allowance Up to $100, plus 15% discount on overage 3.

9 Up to $130, plus 15% discount on overage3. Medically necessary contact lenses (with prior approval): Materials, evaluation, fitting, and Included Included follow-up care 3. Find network Vision providers Visit Adult Vision plan comparison Vision Care 100 Vision Care 180. Out of network Reimbursable amount (Up to) Reimbursable amount (Up to). Eye examination $40 $40. Frame $50 $50. Lenses: Single/bifocal-progressive/trifocal $40 /$60/$80 $40/$60/$80. Elective contact lenses $80 $105. Medically necessary contact lenses $225 $225. Adult Vision plan monthly premiums Family tier Vision Care 100 Vision Care 180. Individual $ $ Individual + one dependent $ $ Individual + two or more dependents $ $ Planning to travel internationally?

10 Make sure you are properly covered. Visit or call 1-855-481-6647 (TTY: 711) to learn more about international health insurance from GeoBlue. 3 Member is responsible for balance. Discount not available at Walmart , Sam's Club, and Costco. 4 Enhanced Frame allowance available at all Visionworks locations nationwide. There is a 30 day waiting period for all new Vision plan contracts with original effective dates of January 1, 2018 and later. Independence Vision Plans are administered by Davis Vision , an independent company. An affiliate of Independence Blue Cross has a financial interest in Visionworks. GeoBlue is the trade name of Worldwide Insurance Services, LLC (Worldwide Services Insurance Agency, LLC in California and New York), an independent licensee of the Blue Cross and Blue Shield Association.