Value Added Benefit Guide BookExclusively for Presbyterian Senior Plan Members

Supplemental Dental, Vision, and Hearing ProgramsComplementary and Alternative Medicine

Wellness and Senior Services

*Medicare has neither reviewed nor endorsed this information

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Sandia Dental Plan Something to smile aboutYou are automatically enrolled in the BenefitSource Sandia Dental Plan at no additional monthly premium cost. This plan is a network based referral plan that provides for savings from 20% to 60%, depending on the type of dental care.

Advantages of the Sandia Plan • Low, guaranteed pre-set fees • Hassle – free • No deductibles • No claim forms • No pre-existing condition exclusions • No waiting periods for dental care• No maximum benefit

Supplemental Dental, Vision, and Hearing Programs

When using Sandia Plan dentists, compare your savings for these services:

With no Coverage(you pay)

Sandia Plan(you pay)

YOU SAVE

9310 Consultation $75 No charge $75

0150 Exam (initial) $80 $43 $37

0274 Bitewing 4 films (x-rays) $53 $35 $18

1110 Adult teeth cleaning $100 $60 $28

2140 Silver filling 1 surface $120 $76 $44

2330 Resin white filling 1 surface $145 $91 $54

3330 Root canal molar $940 $725 $215

2750 Crown (cap) $930 $765 $165

5110 Denture upper/lower $1,525 $1,012 $513

5213 Partial denture $1,125 $951 $174

This is an abbreviated schedule of dental fees. A complete fee schedule will be mailed with your ID card once enrolled. Or visit our website: www.benefitsource.org for a current list of Sandia Plan Dentists and a complete fee schedule. Members with coverage through a previous employer, union group or other retirement program should exhaust those dental benefits first. This program is not offered nor guaranteed under Presbyterian’s contract with Medicare. As such, these services are not subject to the Medicare appeals process. Disputes regarding this product may be subject to the Presbyterian Medicare Grievance Process.

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Plan benefits:When using participating PPO Dental Providers, you pay the listed in-network PPO fee directly to the dental office at the time of service. If you obtain dental services from non-participating dental providers (out-of-network), the plan pays the amount listed, but the dental office may balance bill you for any differences in fees.

In-Network Benefit(you pay)

Out-of-Network Benefit(plan pays to dental office)

1110 Prophy-adult cleaning $17 $52

0150 Initial exam $0 $49

0270 Bitewings single $0 $15

0274 Bitewings four $0 $39

0330 Panoramic x-ray $17 $52

2140 Amalgam 1 surface $36 $53

2330 Resin white filling 1 surface $39 $59

3330 Root canal molar $485 $208

2750 Crown high noble metal $561 $240

5213 Upper/lower partial $750 $321

5110/5120 Denture lower/upper $802 $344

7210 Extraction/oral surgery-erupted $108 $46

BenefitSource Elite Plan enrollment form on following page.

Elite Dental Plan Something else to smile aboutThe Elite Dental Plan is a comprehensive dental indemnity plan specifically designed for Presbyterian Senior Plan members that prefer complete freedom of choice to use any licensed dentist.

As a PPO dental plan, the Elite Plan provides greater savings when obtaining care from our PPO Dental Providers but still has excellent coverage when going out of network for dental care.

Advantage of the Elite Dental Plan • Freedom to see any licensed dentist • Low monthly premium of $35.35 per person • No deductible for in-network dentists for preventive

and diagnostic care• Low, $50 annual deductible for in network dental care • $75 annual deductible for out-of-network dental care • Out of pocket costs limited to guaranteed pre-set

fee schedule for in-network services• 6 month waiting period for major (class III) services• $1,000 annual maximum per person

Visit benefitsource.org or call 888.862.8659 or 505.237.1501 for a current list of providers and complete fee schedule.

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Supplemental Dental, Vision, and Hearing Programs

Elite Dental Plan – Enrollment form

BenefitSource Elite Plan Only Enrollment Authorization Form

Social Security Number Last Name First Name

Date of Birth Sex Home Telephone Alternate Telephone

Home Address City State Zip

Email Address Effective Date

Payment Option for the Elite Plan must be selected.

PAYMENT CHoICE: Please check one. Please make checks payable to BenefitSource, Inc. (For 1/1/14 enrollment only.)

Annual Payment ($424.20) Check Visa MasterCard Discover

Credit Card # Exp. Date CVV#

I have enclosed my Annual Payment of $424.20.

I hereby authorize the release of my dental records to BenefitSource, Inc. for use in quality review program.

Member’s Signature X Date

Monthly Bank Draft ($35.35) Please charge my bank account monthly. Checking Savings

Routing # Account #

I have enclosed a check for my first month’s payment of $35.35 ad a voided check.

Draft Authorization / BenefitSource, Inc. Member Agreement Unless I have elected annual payment, I hereby authorize BenefitSource to charge my bank account each month th applicable membership fee to be credited to my account with BenefitSource. This authority is to remain in full force and effect until I notify BenefitSource in writing of it’s termination following my 12 month contract. (My bank is authorized to make corrections should any be necessary). I have read and understand the terms and conditions of the authorization. I hereby authorize the release of my dental records to BenefitSource, Inc. for use in quality review program.

Member’s Signature X Date

IntErnAl USE Only PSEnIOr ElItE

Post Date

Effective Date

Payment Ref

Vision Care For coverage related to vision exams, services related to cataract surgery, or for refractive correction, Presbyterian Senior Plan and Presbyterian Medicare Supplement Plan members should refer to their Medical Summary Plan Description.

BenefitSource, through a special arrangement with Eye Associates of New Mexico and Vision Care Direct, provides the following discounted schedule of benefits for vision materials as needed outside of those listed previously.

Hearing HardwareYou are automatically eligible to receive discounts on hearing hardware and appliances. These discounts vary by provider but include 25% to 50 % savings on hearing aids, special discounts for hearing aid batteries, and fixed co-payments for a complete hearing evaluation.

Visit our website: www.benefitsource.org for a current list of Audiology Care Centers and sources for hearing aid hardware. You must contact the provider directly and identify yourself as a Presbyterian Senior Plan member to learn applicable discounts through BenefitSource.

Frames Member PaysFor all frames under $100.00 $75.00For all frames over $100.00 $75.00Receives an additional 10% discount on amount over $100

Lenses (Plastic CR-39)*Single Vision – per pair $68.00Bifocal – per pair $89.00Trifocal – per pair $120.00Progressive Power

Standard $109.00(Access, Adapter, AF Mini, Continuous Vue, Freedom, Sola VIP, Sola XL, TruVision, Ao Pro, Continua Premium Plus, Seiko P6, Progressive Elegance, Visuality)

Preferred $212.00(Ao Compact, Kodak, Multigressive, Natural, outlook, Varilux Panamic, Varilus Comfort, Hoya Summit, Summit CD, Essilor ovation)

Premier $230.00(Definity, Ellipse, Gradal Top, Percepta, Physio, Sola one, Comfort 360, Physio 360 and Ellipse 360)

Lens Options 20% DiscountTints, Anti-reflective, basic or upgraded scratch coats and other enhancements are available.

Contact Lenses Member PaysConventional Contact Lenses*(Does not include examination fee)Includes lenses and a minimum of 3 follow-up visits

Standard Hard or Soft Daily Wear Sphere $165.00Gas Permeable Sphere $190.00Soft Extended Wear 15% Discount

Disposables* (Does not include examination fee)Includes lenses and a minimum of 3 follow-up visits

Disposable Wear; Daily Wear (includes two 6 packs) $142.00one Day Disposable (includes two 90 packs) $169.00Toric & Bifocal Disposable 15% discountExtended Wear Disposable 15% discount

*The fitting fee is to be paid on the date of the exam if contact lenses are not immediately purchased. However, if contact lenses are purchased within two months of the exam, that fitting fee will be deducted from the amount owed on the lenses.

Contact Lenses, Duplicate/ReplacementDisposable Wear Replacement 20% Discountone Day Disposable 20% Discount

Sun Glasses (on most styles) 15% DiscountRefractive Surgery Procedures 15% Discount

Visit benefitsource.org or call 888.862.8659 or 505.237.1501 for a current list of Vision (CAM) providers and complete fee schedule.

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Chiropractic CareThis is a form of medical treatment through manipulation or careful movement of various body parts. Chiropractic care can be helpful for pain management, improvement in the function of nervous, skeletal and muscular systems, and improvement in mobility.

Presbyterian Senior Care medical plan may include limited coverage for chiropractic care. Refer to your summary plan description for updated coverage details. This service is available for Chiropractic services either not covered under your medical plan or if benefits are exhausted.

AcupunctureThis is an ancient treatment that involves balancing the 5 main forms of vital energy flow through the human body. Treatment involves the use of small, thin, sterile needles that are inserted into specific “reflex points” to relieve pain, sleep disorders, stress, low energy and digestive problems. Through a holistic approach to treatment, nutritional and exercise guidance may also be included.

Chiropractic Services:

CPT Code Description Fee Schedule

99201 Problem focused history and examination–straight forward $11.00

99203 Detailed history and examination–low complexity $17.00

99204 Comprehensive history and examination – moderate complexity $17.00

98940 Chiropractic manipulative treatment spinal, one to two regions $34.00

98941 Spinal, three to four regions $36.00

98943 Extraspinal, one or more regions $26.00

97012 Traction, Mechanical $16.00

97014 Electrical Stimulation (unattended) $16.00

97110 Therapeutic Exercise, 15 Min. $18.00

72040 Cervical 3 Views (x-ray) $34.00

72100 Spine, Lumbosacral Anteroposterior and Lateral (x-ray) $34.00

This is an abbreviated schedule of fees for chiropractic care. Visit our website: www.benefitsource.org for a complete fee schedule and the most current list of participating Chiropractic providers. Presbyterian Senior Care medical plan may include limited coverage for chiropractic care. Refer to your summary plan description for updated coverage details. This service is available for Chiropractic services either not covered under your medical plan or if benefits are exhausted.

Complementary and Alternative Medicine / Wellness Services

Fee Schedule

Initial Visit $60.00

Re-ocurring Visits $50.00 per visit

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You are automatically eligible to access the discounted fees and networks for Complementary and Alternative Medicine.

Massage TherapyThis is a form of therapy through soft tissue manipulation

that is helpful in relieving pain associated with arthritis,

sports injuries, myofascial pain, headache, stress, circulatory

problems, gastrointestinal disorders, or chronic and acute pain.

Massage techniques include:• Deep tissue massage to relieve chronic tension• Myofascial release to release muscular tension

in the fascia• Reflexology, particularly focused on hands and feet

that may be linked to organs, nerves and glands• Shiatsu and Acupressure that treat points along

acupuncture meridians to relieve pain• Swedish massage for tension relief and

circulation improvement• Trigger Point Therapy (Myotherapy or Neuro-

muscular therapy) to relieve cycles of chronic pain• Sports massage

Naprapathic MedicineThis is a process that employs manual medicine, nutritional counseling and therapeutic modalities, for the purpose of treating pain caused by connective tissue disorders.

Jenny Craig Weight Management ProgramThis is a comprehensive weight management program. Members learn how to eat the foods they want, develop a healthy and enjoyable eating style, increase energy levels through simple activity, and build more balance into their lives. The results are optimal weight loss and well-being. BenefitSource members have a special discount with Jenny Craig; simply identify yourself as a Presbyterian Senior Plan member to learn more about this discount.

Please visit benefitsource.org for a current description of discounts and a list of Jenny Craig centers.

FitshopFitshop helps members achieve their fitness goals by

providing individualized nutrition plans designed to

accommodate a members schedule and goals. Cost of

the program is normally $299 a month, however with

BenefitSource, members get 50% off and only pay $149

($150 savings!).

For more information, or to schedule a Free Body Composition Analysis, please visit our website at fitshopnm.com or call 505.872.3348.

Fee Schedule

1/2 Hour Session $27.00

1 Hour Session $46.00

1 1/2 Hour Session $58.00

Fee Schedule

1/2 Hour Session $50.00 per visit

Visit benefitsource.org or call 888.862.8659 or 505.237.1501 for a current list of providers and complete fee schedule.

Presbyterian Senior Care medical plan may include limited coverage for acupuncture services. Refer to your summary plan description for updated coverage details. This service is available for acupuncture services either not covered under your medical plan or if benefits are exhausted.

Membership includes:• Weekly Nutrition Plans• Weekly Exercise Plans• Recipes• Snack Tips• Weekly Weigh-Ins• Accountability & Support• Weekly Measurements

• Progress Photos• Access to Group

Workout Sessions• 10% Discount at all

Nutrishop Locations• Water Bottle• Guaranteed Results

Non-Medical Home Health CareThe number 1 goal of today’s seniors is to remain at home for as long as possible. Consequently, non-medical home health care focuses on helping seniors with daily, non-medical activities. Most of these services are not reimbursed by Medicare or other traditional medical insurance plans. BenefitSource has contracted with a variety of local home care providers to fulfill this goal.

Presbyterian Senior Plan members will receive a 7% savings on billed home care services which include:• Bathing and dressing• Transferring and toileting• Companionship and custodial care• Medications monitoring• Light cleaning and meal preparation• Transportation, laundry, and hobbies

Visit our website: www.benefitsource.org for a current list of participating home care providers. When contacting the home care provider of choice, simply inform them you are a BenefitSource member through Presbyterian Senior Health Plan to receive your savings.

Meals on WheelsMeals on Wheels of Albuquerque home delivers meals to those who are home bound or otherwise unable to obtain proper, nutritional meals on their own. Seven different menu options for each day are designed to meet special medical or therapeutic needs of their client base. This program enables seniors to retain independence, maintain or improve health, and helps them stay at home and out of expensive long-term care facilities. BenefitSource Presbyterian Senior Plan members receive a discount off the normal price per meal.

Vision, Hearing and HomeSafety TechnologyAssisted technology that will help you hear, see and maintain independence. Through ATS Resources, a non-profit organization, you are eligible to receive a 10% discount.

Conversation Amplifiers MacularAmplified Telephones RetinitisHelp Alerts GlaucomaDoorbell Alerts Low VisionTV ListeningFall AlertsLarge Group Listening

Please call 877.287.0608 tall free or 505.222.0608 for more information.

Senior Services

Fee Schedule

First 10 Meals (paid upon delivery) $57.50

Meals Thereafter $5.75

For more information, please contact us at: 1804 Juan Tabo NE, Suite A, Albuquerque, NM 87112

888 862 8659 | 505 237 1501 | benefitsource.org

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