2018 Standalone Dental and Vision Plans for Adults Age 19 and Older - IBXMedicare.com
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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
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 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 (TT Y/TDD: 711)
1Choose 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.
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; 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 ibx4you.com/dentalprovider
2
Adult Dental plan monthly premiums per member
Age Adult Dental Preferred Adult Dental Premier with
Preventive Incentive
19–25 $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.
2018 Standalone Dental and Vision Plans for Adults Age 19 and Older 2Choose 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.
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
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
Up to $130, plus 15% discount on overage3
Medically necessary contact lenses (with prior
approval): Materials, evaluation, fitting, and Included Included
follow-up care
3Find network vision providers
Visit ibx.com/visionprovider
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 $13.21 $14.17
Individual + one dependent $26.41 $28.33
Individual + two or more dependents $39.62 $42.50
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.
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.
2018 Standalone Dental and Vision Plans for Adults Age 19 and Older 4Language Assistance Services
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sa wika nang walang bayad. Tumawag sa
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协助服务。致电 1-800-275-2583。
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sẽ cung cấp dịch vụ hỗ trợ ngôn ngữ miễn phí cho タンスサービス（無料）をご利用いただけます。
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skorzystać z bezpłatnej pomocy językowej. Zadzwoń
pod numer 1-800-275-2583. Navajo: D77 baa ak0 n7n7zin: D77 saad bee y1n7[ti’go
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disponibili servizi di assistenza linguistica gratuiti.
Chiamare il numero 1-800-275-2583. Urdu:
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فإن خدمات المساعدة اللغوية، إذا كنت تتحدث اللغة العربية:ملحوظة مفت ميں زبان معاون خدمات دستياب ہيں۔ کال کريں
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Y0041_HM_17_47643 Accepted 10/14/2016 Taglines as of 10/14/2016
5Discrimination is Against the Law
If you need these services, contact our Civil Rights
This Plan complies with applicable Federal civil rights Coordinator. If you believe that This Plan has failed
laws and does not discriminate on the basis of race, to provide these services or discriminated in another
color, national origin, age, disability, or sex. This Plan way on the basis of race, color, national origin, age,
does not exclude people or treat them differently disability, or sex, you can file a grievance with our Civil
because of race, color, national origin, age, disability, Rights Coordinator. You can file a grievance in the
or sex. following ways: In person or by mail: ATTN: Civil
Rights Coordinator, 1 9 0 1 M a r k e t S t r e e t ,
This Plan provides: P h i l a d e l p h i a , P A 1 9 1 0 3 , By phone: 1-888-377-
Free aids and services to people with disabilities 3933 (TTY: 711) By fax: 215-761-0245, By email:
to communicate effectively with us, such as: civilrightscoordinator@1901market.com. If you need
qualified sign language interpreters, and written help filing a grievance, our Civil Rights Coordinator is
information in other formats (large print, audio, available to help you.
accessible electronic formats, other formats).
Free language services to people whose You can also file a civil rights complaint with the U.S.
primary language is not English, such as: Department of Health and Human Services, Office for
qualified interpreters and information written in Civil Rights electronically through the Office for Civil
other languages. 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.
Y0041_HM_17_47643 Accepted 10/14/2016 Taglines as of 10/14/2016
2018 Standalone Dental and Vision Plans for Adults Age 19 and Older 6Independence 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)You can also read
