2018 Standalone Dental and Vision Plans for Adults Age 19 and Older

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2018 Adult dental and vision plansIndependence 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 plansIndependence offers two Adult Dental plans: Adult Dental Preferred and Adult Dental Premier with Preventive Incentive. Both plans include:

Adult Vision plansIndependence 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:

Next step: Apply!There are several ways to enroll in Independence adult dental and vision plans:

• Visit ibxmedicare.com/dentalvision• Complete the application in your enrollment kit and return it in the postage-paid envelope provided.

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 a.m. ‒ 5 p.m.

Questions? Contact your broker or call Independence at 1-866-459-9612 (TTY/TDD: 711)

Flexibility to see any dentist you want, nationally

One of the largest dental networks in the country with over 62,000 unique dentists at over 244,000 access points nationwide

100-percent coverage for routine preventive care

Coverage for most basic and major dental services, such as fillings and root canals

Discounts on non-covered services with some participating providers

Low- or no-cost frames from the Davis Vision Exclusive Collection available at most participating providers

Option to use an allowance toward frames or contact lenses, in lieu of eyeglasses

Access to a national provider network with over 60,000 access points

Discounts on other services, including laser vision correction

2 2018 Standalone Dental and Vision Plans for Adults Age 19 and Older

Choose your Adult Dental planIf 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.

Adult Dental plan monthly premiums per memberAge Adult Dental Preferred Adult Dental Premier with

Preventive Incentive19–25 $17.55 $31.42

26–39 $18.65 $33.38

40–49 $21.94 $39.27

50–63 $25.78 $46.14

64+ $26.33 $47.12

1 Payment is based on the Maximum Allowable Charge (MAC) for the specific covered service. 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 ibx4you.com/dentalprovider, 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.

Save Money with Network DentistsFind a network dentist in the Concordia Advantage network2 at ibx4you.com/dentalprovider

Adult Dental plan comparison Adult Dental PreferredAdult Dental Premier

with Preventive Incentive

Deductible You pay $50 per individualYou pay $150 per family

You pay $50 per individualYou 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 treatment, consultations

You pay $0; Not subject to deductible; No waiting period You pay $0; Not subject to deductible; No waiting period

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 and older

1 set per 18 months

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; 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

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Adult Vision plan comparison Vision Care 100 Vision Care 180In-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

Non-collection frame allowance Up to $100, 20% discount on overage3

Up to $130, or up to $1804 at Visionworks, 20% discount on overage3

Lens options You pay You pay

Clear plastic single-vision, lined bifocal, trifocal, or lenticular lenses (any Rx) $0 $0

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 (instead of eyeglasses) Benefit Benefit

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 overage3 Up to $130, plus 15% discount on overage3

Medically necessary contact lenses (with prior approval): Materials, evaluation, fitting, and follow-up care

Included Included

Choose your Adult Vision planIf you are looking for a basic plan that gives you discounts on glasses and an allowance toward contact lenses, consider Vision Care 100.

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.

4 2018 Standalone Dental and Vision Plans for Adults Age 19 and Older

Adult Vision plan comparison Vision Care 100 Vision Care 180Out 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

Find network vision providers Visit ibx.com/visionprovider

Adult Vision plan monthly premiumsFamily tier Vision Care 100 Vision Care 180Individual $13.21 $14.17

Individual + one dependent $26.41 $28.33

Individual + two or more dependents $39.62 $42.50

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. GeoBlue is the administrator of coverage provided under insurance policies issued by 4 Ever Life International Limited, Bermuda, an independent licensee of the Blue Cross Blue Shield Association.

Planning to travel internationally?Make sure you are properly covered. Visit ibxmedicare.com/global or call 1-855-481-6647 (TTY: 711) to learn more about international health insurance from GeoBlue.

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Urdu:

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Mon-Khmer, Cambodian: សូ�េ��្ត ចប់�រ�មណ៍៖ ្របសិនេបើអនកនិ�យ���ន-ែខមរ ���ែខមរ េនះជំនួយែផនក��នឹងមនផ្តល់ជូនដល់េ�កអនកេ�យ�តគិតៃថ្ល។ ទូរសពទេទេលខ 1-800-275-2583។

6 2018 Standalone Dental and Vision Plans for Adults Age 19 and Older

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Discrimination is Against the Law

This Plan complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. This Plan does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. This Plan provides:

Free aids and services to people with disabilities to communicate effectively with us, such as: qualified sign language interpreters, and written information in other formats (large print, audio, accessible electronic formats, other formats).

Free language services to people whose primary language is not English, such as: qualified interpreters and information written in other languages.

If you need these services, contact our Civil Rights Coordinator. If you believe that This Plan has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with our Civil Rights Coordinator. You can file a grievance in the following ways: In person or by mail: ATTN: Civil Rights Coordinator, 1901 Market St reet , Ph i lade lph ia , PA 19103, By phone: 1-888-377-3933 (TTY: 711) By fax: 215-761-0245, By email: civilrightscoordinator@1901market.com. If you need help filing a grievance, our Civil Rights Coordinator is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf or by mail or phone at: U.S. Department of Health and Human Services, 200 Independence Avenue SW., Room 509F, HHH Building, Washington, DC 20201, 1-800-368-1019, 800-537-7697 (TDD). Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

Independence Blue Cross offers products through its subsidiaries Independence Hospital Indemnity Plan, Keystone Health Plan East, and QCC Insurance Company, and with Highmark Blue Shield — independent licensees of the Blue Cross and Blue Shield Association.

18863 207669 (11/17)