PEEHIPOptional Insurance Plans

Dental | Cancer | Hospital Indemnity | Vision

October 1, 2017

Administered by

Southland Benefit Solutions, LLC

Post Office Box 1250 • Tuscaloosa, Alabama 35403 • Telephone 205/343-12501-800-476-0677 • www.SouthlandPEEHIP.com

There are four optional plans offered through the Public Education Employees’ Health Insurance Program (PEEHIP). Claims administration is provided through Southland Benefit Solutions. All optional coverages must be retained for the entire insurable year, i.e. until the end of September 30. New employees employed during the open enrollment period cannot enroll in the optional plan(s) on their date of employment and cancel the plans October 1 of that same year. If a member is enrolled in more than one of the optional coverages, the contracts must be all family or all single plans. Members enrolled in family optional plan(s) cannot change to single optional plan(s) outside of the open enrollment period unless all dependent(s) become ineligible due to age, death or divorce.

Dental PlanThis plan covers diagnostic and preventative services, as well as basic and major dental services. Diagnostic and preventative services are not subject to a deductible and are covered at 100% (based on Alabama reasonable and customary charges) -- oral examinations, cleaning of teeth, fluoride applications for insured children to age 19, space maintainers, x-rays, and emergency office visits. Routine cleaning visits are limited to two times per plan year. Basic and major services are covered at 80% for individual coverage and 60% for family coverage with $25 deductible for family coverage (based on Alabama reasonable and customary charges) -- fillings, general anesthetics, oral surgery not covered under a Group Medical Program, periodontics, endodontics, dentures, bridgework, and crowns. The family coverage deductible for basic and major services is applied per person, per plan year with a maximum of three (3) per family.

The dental plan administered by Southland will continue to offer a dental network program known as “DentaNet.” Under the DentaNet program members have the opportunity to use network dentists and save money. However, members enrolled in the dental plan still have the freedom to use any dentist.

All dental services are subject to a maximum of $1,250 per year for individual coverage and $1,000 per person per year for family coverage. Dental coverage does not cover pre-existing dentures or bridgework, neither does it provide orthodontia benefits. The dental coverage does not cover the replacement of natural teeth removed before a member’s coverage is effective. This plan does not cover temporary partials, implants and temporary crowns.

Cancer PlanThis plan covers cancer disease only. Other diseases and accidents are not covered. Benefits are provided regardless of other insurance. Benefits are paid directly to the insured unless assigned. Coverage provides $250 per day for the first 90 consecutive days of hospital confinement, $500 per day thereafter. Actual surgical charges are paid up to the amounts in the surgical schedule. The lifetime maximum benefit for radiation and chemotherapy coverage is $10,000. This benefit covers actual charges for cobalt therapy, x-ray therapy, or chemotherapy injections (excluding diagnostic tests). Benefits are also provided for Hospice care, anesthesia, blood and plasma, nursing services, attending physician, prosthetic devices, and ambulance trips. Leukemia to pay a maximum of $5000 per year for blood and plasma.

OPTIONAL COVERAGES

Hospital Indemnity PlanThis plan provides a per day benefit when the insured is confined as an in-patient in the hospital. In-hosptial benefits (per day) under this plan do not cover charges for out-patient, same day surgery unless the insured is admitted on an in-patient basis and charged for a private or semi-private room, or for an observation room for a period of more than 24 continuous hours. The In-Hospital Benefit is $150.00 per day for individual coverage and $75.00 per day for family coverage. It also provides a per day benefit for intensive care ($300/$150), and convalescent care ($150/$75). In addition, there is supplemental accident coverage. The reimbursement for accident(s) is limited to a maximum of $1,000.00 per plan per year for each covered individual.

Inclusive in the $1,000.00 maximum benefit, per covered individual per plan year, are covered charges due to, or for, treatment of accidental injury by adjustment or manipulation of the spine or soft tissues.

a. $25.00 per visitb. Two visits in any seven consecutive days (all accidental injuries and Qualified Practitioners combined):c. Thirty visits per plan year (all accidental injuries and Practitioners combined.

In-hospital benefits are limited to 365 days. Convalescent care benefits are limited to a lifetime benefit of 90 days. This plan does not cover assisted living facilities. Cancer and maternity admissions are covered as any other illness.

Ambulance benefits are limited to $100.00 per trip to or from a hospital where the insured is confined as an in-patient. There is no lifetime maximum.

Benefits for treatment of mental or nervous disorders and alcoholism and/or drug addiction treatment are limited to a maximum of 14 days confinement in a Hospital as an in-patient per plan year. Alcoholism an/or drug addiction treatment is further limited to a maximum of one admission of not more than 14 days confinement as an in-patient per plan year. This benefit is further limited to a lifetime maximum of two (2) admissions of not more than 14 days per admission for the treatment of substance abuse.

Vision Care PlanThis plan provides coverage for one examination in any plan year (actual charges up to $40), one new prescription or replacement prescription for lenses per plan year (up to $50 for single vision, $75 for bifocals), one new prescription or replacement of contacts per plan year (up to $100 for contact lenses), and one new or replacement set of frames per plan year (up to $60). The policy will pay for either glasses or contacts, but not both in any plan year. The PEEHIP Vision Care Plan is not a network plan; therefore, members are able to utilize any eyecare professional and receive the same level of benefits. However, when members elect any one of PEEHIP's optional plans (vision, dental, cancer, or indemnity), they are also eligible to receive savings through VisionChoice®. VisionChoice® is an eyecare savings plan designed to save members money on a wide array of vision products and services! VisionChoice® eliminates eyecare sticker shock because participating providers have agreed to offer their services at prices considerably lower than their normal fees.

IMPORTANTThis is a Summary of Benefits.

Members should refer to the PEEHIP booklet for detailedinformation and limitations

GENERAL INFORMATIONPlan Administrator: The Plan Administrator for the optional plans is Southland Benefit Solutions - P.O. Box 1250 - Tuscaloosa, Alabama 35403. (1-800-476-0677)

“PLAN YEAR” means a period which begins October 1st through the next September 30th. This applies to all plans.

Coordination of Benefits: The Hospital Indemnity and Cancer Supplemental Plans do not have a coordination of benefits provision. However, benefits are coordinated under the dental and vision plans. PEEHIP Dental benefits will be secondary to all other Dental coverages available to a claimant. If an enrolled member is covered under more than one group plan or is entitled to any other source, the total amount that is payable under all plans will not be more than 100% of the maximum allowable expenses.

Hospital Indemnity, Cancer, Dental and Vision excludes expenses for which the individual is not required to make payment, including but not limited to, reductions or readjustments to the charges made by the health care provider.

Insurance Commences: Insurance commences upon the application and final approval by the administrative staff of the Public Education Employees’ Health Insurance Program.

I.D. Card: Southland Benefit Solutions will provide as quickly after enrollment as possible.

Claim Forms: Claim forms can be downloaded from our website, www.SouthlandPEEHIP.com.

PAYMENT AND CLAIM FILING LIMITATION: All claims must be submitted in writing and must be received by the Plan Administrator no later than 365 days following the date covered expenses are incurred. If a claim is not submitted and received by the Plan Administrator within this period, the claim for that benefit will not be paid.

Website Address: www.SouthlandPEEHIP.com

WHY YOU SHOULD USE THE “DENTANET” NETWORK OF DENTISTS...

DentaNet, the dental network provided by Southland Benefit Solutions offers PEEHIP members and their families the largest independent statewide network of preferred dentists. Although members can choose any dentist they like, using a DentaNet dentist saves PEEHIP members money.

DentaNet dentists do not balance bill PEEHIP members the difference between the DentaNet negotiated fee schedule and what they normally charge. Additionally, services that require a co-pay, are also based on the DentaNet negotiated fee schedule...so PEEHIP members will save all the way around.

Visit “www.SouthlandPEEHIP.com”to find a network dentist near you and start saving today.

Note: In order to obtain the DentaNet network savings described above, you must have PEEHIP Dental Plan Coveage.

Amplifon Hearing Health Care Southland Benefit Solutions and Amplifon Hearing have teamed up to provide discounted hearing aids and hearing healthcare services to members, and their families, who are enrolled in at least one optional PEEHIP plan.

Benefits at a Glance• Dramatic discounts on over 2,000 models of hearing aids• 40% off all hearing services provided by one of our providers• 60-day no risk trial• 1 year of free care• 12 month no interest financing• Loss and damage protection• Hearing aids available from 10 industry-leading manufacturers• Lowest price guarantee on over 2,000 brand name hearing aids• 2 years of free batteries• 3 year warranty

EligibilityAll members who have at least one optional PEEHIP plan are eligible.

Monthly Plan CostVoluntary participation at NO CHARGE for both single and family coverage.

Call 1-888-669-2177 or visit amplifonusa.com/sbs

Amplifon will explain the process and help you schedule an appointment.Amplifon will send information to you and the provider, ensuring your discount is activated.

Step 2

Step 3

Just Follow These Steps...Call Amplifon at 1-888-669-2177 to find a provider near you.Step 1

Amplifon Benefit Program Frequently Asked Questions

Who is Eligible?All members who have at least one optional PEEHIP plan are eligible for the Amplifon Benefit Program.

Who does it cover?The Amplifon Benefit Program covers you and your extended family. Anyone in your family can activate the discount by calling 1-888-669-2177.

Are there membership and/or discount cards?No, you just have to call 1-888-669-2177. A patient care advocate will locate a provider in your area and schedule you an appointment. They will send information to you and the provider, ensuring your discount is activated when you arrive for your appointment.

If I already have a provider, how can I find out if they are in Amplifon's network?You can locate Amplifon providers in your area by calling 1-888-669-2177 or by visiting amplifonusa.com/sbs.

Is Amplifon the hearing aid manufacturer?No, Amplifon is partners with 10 industry-leading hearing aid manufacturers. The Amplifon Benefit Program simply allows you to purchase a hearing aid from one of the world's best brands at a deeply discounted price.

Why should I use Amplifon?Amplifon has a lowest price guarantee. If you find the same hearing aid at a lower price, they'll beat it by 5%.

How much does the program cost?The Amplifon Benefit Program is provided at no extra cost to members who have at least one optional PEEHIP plan.

Call 1-888-669-2177 or visit amplifonusa.com/sbs

is a Southland network of ParticipatingDentists benefiting PEEHIP members

Here Are The Top 3 Reasons To Use OneOf Our Participating Dentists:

THEY SAVE MONEY

THEY SAVE MONEY

THEY SAVE & MONEY

DentaNet is one of the largest independent dental networks in the State of Alabama.The network is designed to save you money.

One important reason you purchase benefits is to save money.

For a listing of Statewide DentaNet providers, visit

www.SouthlandPEEHIP.com

DentaNetis a Southland Benefit network of Participating

Dentists that benefit PEEHIP members

Here Are The Top 3 Reasons To Use OneOf Our Participating Dentists:

THEY SAVE MONEY

THEY SAVE MONEY

THEY SAVE & MONEY

DentaNet is one of the largest independent dental networks in the State of Alabama.The network is designed to save you money.

One important reason you purchase benefits is to save money.

DentaNet is the network of participating dentists

designed to benefit PEEHIP members.

DentaNet is one of the largest dental

networks in the state of Alabama.

By using DentaNet providers, PEEHIP

members save money.

QUESTION: ARE YOU SAVING MONEY?If you participate in the PEEHIP Dental Plan, you probably

purchased dental insurance to save money.

DentaNet providers are all over the state.

To find a participating DentaNet provider in your

area, visit www.SouthlandPEEHIP.com

or call us, toll-free, at 1-800-476-0677 today.

You’ll be glad you did.

For a listing of Statewide DentaNet providers, visit

www.SouthlandPEEHIP.com

is a Southland network of ParticipatingDentists benefiting PEEHIP members

Here Are The Top 3 Reasons To Use OneOf Our Participating Dentists:

THEY SAVE MONEY

THEY SAVE MONEY

THEY SAVE & MONEY

DentaNet is one of the largest independent dental networks in the State of Alabama.The network is designed to save you money.

One important reason you purchase benefits is to save money.

For a listing of Statewide DentaNet providers, visit

www.SouthlandPEEHIP.com

YOU WILL SEE THE SAVINGS. VisionChoice® is an eyecare savings plan designed to save members money on a wide array of vision products and services! VisionChoice® eliminates eyecare sticker shock because participating providers have agreed to offer their services at prices considerably lower than their normal fees.

Benefits at a Glance • No plan limitations so you can use the plan as often

as you want.• No waiting periods so you can use the plan as soon

as you join.• No claim forms to file so you save time and money.• No deductibles to meet before using the plan.• No extra cost for scratch resistant and UV coatings.• Save up to 61% off the retail price for eyewear so

buying a second pair is easy.• Discounts on vision laser correction when performed

by a participating specialty provider.• 20% discount off contact lens fittings, training and

follow-up appointments.

Participating Providers Members must use a participating VisionChoice® Provider to receive benefits. To locate a Provider, visit our website at www.southlandvision.com or call our Member Services toll free number at (800) 476-3010.

Eligibility All members who have at least one optional PEEHIP plan are eligible.

Claim Forms .There are no claim forms to complete because VisionChoice® is a discount program. The benefits are received directly from the provider at time of purchase!

Monthly Plan Cost Voluntary participation at NO CHARGE for either single or family coverage.

The following is a partial listing of the savings members may receive when visiting a participating VisionChoice® provider (frame selection and retail prices will vary by Provider):

Partial listing of Eyewear Choices

*RetailPrice

Vision Choice Price

Member Saves

Professional Services Compreshensive Exam $ 85.00 $ 59.00 31%

Frames VisionChoice Frame $ 75.00 $ 35.00 53% Revolution (IMFT26) $ 214.00 $ 150.42 30% Kate Spade (Dacey) $ 186.00 $ 108.50 42% Nike (4040) $ 299.00 $ 174.91 42%

Lens Options Scratch resistant coating $ 20.00 $ 0.00 100% UV coating $ 25.00 $ 0.00 100% Crizal AR coating $ 150.00 $ 120.00 20%

Plastic CR-39 Lenses Single vision $ 104.00 $ 48.00 54% Bifocal (FT-28) $ 126.00 $ 75.00 40% Trifocal (7x28) $ 188.00 $ 100.00 47% Younger Image $ 320.00 $ 120.00 62% Varilux Comfort $ 334.00 $ 170.00 49%

Polycarbonate Lenses Single vision $ 148.00 $ 56.00 62% Bifocal (FT-28) $ 195.00 $ 86.00 56% Trifocal (7x28) $ 260.00 $ 123.00 53% Varilux Comfort $ 380.00 $ 210.00 45%

High Index Lenses Single vision $ 338.00 $ 136.00 60% Bifocal (FT-28) $ 466.00 $ 136.00 71% Varilux Comfort $ 470.00 $ 295.00 37%

* Retail fees based on local survey of fees

VisionChoice® 07/2014

** VisionChoice® discounts do not reflect PEEHIP benefit amounts, but may be used in conjunction with your PEEHIP vision plan when using a participating provider.