Health Access Solutions, Health Access Benefit (HAB)
* Reimbursement for screenings and preventive services, including annual wellness exams and physician-recommended wellness laboratory services, with an easy claim submittal process
* Unlimited access to very low-cost prescriptions
* Additional reimbursement for preventive dental and vision exams, mental health counseling, and more.
* Affordable premium
Preventive Care - Included with your Health Access coverage
* Preventive physician visits and services at no cost after reimbursement
* Preventive vision exams
* Preventive dental services
Discount Prescriptions - Included with your Health Access coverage
* Find the best price at over 65,000 pharmacies nationwide – major national chains and local pharmacies
* Access to Manufacturer Savings and Patient Assistance Programs
* Access to international pharmacies
Additional Benefits
* Reimbursement for physical health, including gym memberships
* Reimbursement for weight loss/nutrition programs
* Mental health counseling benefit
* Tobacco cessation benefit

Delta Dental PPO

Diagnostic/Preventive – Delta pays 100%	Basic – Delta pays 60%
Oral evaluations twice in a 12-month period	Fillings – Amalgam (silver), Composite (white)
Bitewing X-Rays once in a 12-month period	Routine Extractions
Brush Biopsy once in a 12-month period	Periodontal Cleaning (Maintenance procedures)
Cleanings twice in a 12-month period	Space maintainers to age 15
Fluoride twice in a 12-month period to age 15	Full-mouth/panoramic x-rays once in a 5-year period
Sealant application to permanent molars, once in a lifetime per tooth for children to age 15

Delta Vision

Member co-pay $10; plan pays balance

Contact Lens Fit – Member pays up to $55

Premium contact lenses fit and follow up – 10% discount off retail;

Frames every 24 months - $130 allowance, then 20% off balance

Standard plastic lenses – Member co-pay $25, plan pays balance

Contact lenses every 12 month - $130 allowance, 15% off balance (conventional), $130 allowance, member pays balance (disposable), Paid in full (medically  necessary)

Laser Vision Correction, Lasik or PRK – 15% off retail price or 5% off promotional price

 

I hereby request coverage for me and all dependents as indicated on this form and authorize my employer to make necessary deductions from my earnings unless indicated otherwise. I understand that if I do not enroll when first eligible, I will not be able to obtain coverage in the future except at annual enrollment or within 30 days of a family status change as listed below:

1. Marriage; 2. Divorce or legal separation; 3. Death of a spouse or dependent; 4. Birth or adoption of a child; 5. Termination or commencement of spouse’s employment; 6. A change in employment status of the employee or his/her spouse from part-time to full-time or full-time to part-time; 7. The taking of an unpaid leave of absence by the employee or his/her spouse; 8. A significant change in the health coverage of the employee or his/her spouse’s employment.

I certify that all the information furnished by me is true and correct. I understand that if I have provided any false, incomplete or misleading information, then my coverage under this plan may result in a denial of all benefits. I understand that all benefits are subject to the terms and conditions stated in the certificates.

Notice: a person may be committing insurance fraud if he or she submits an application or claim containing a false or deceptive statement with intent to defraud (or knowing that he or she is helping to defraud) an insurance company.

I hereby authorize all providers, Third Party Payers, utilization review agencies, my employer and state or federal agencies to exchange all demographic, medical, mental health, AIDS and HIV, and substance abuse information as necessary for claims processing, clinical studies, care management, plan administration, or benefit administration. I understand any information will be used only after issuance of plan coverage and will have no effect on determination of eligibility to enroll. I give this consent for myself and any eligible family member listed on this application for who I am authorized to do so. I understand that failure to sign this authorization may be a basis for enrollment or benefit denial. I understand that I am entitled to receive a copy of this authorization. I further understand that this authorization will remain in effect until coverage under the plan ends or I give written notice to carrier that I want to revoke this authorization. I understand the revocation of this authorization may be a basis for denying benefits.

• The plan year is the twelve-consecutive month period ending December 31 provided, however, for the year in which the plan becomes effective, the period ending on such date may be less than twelve months.
• I agree to have my net salary reduced in accordance with the elections designated by the Payroll Authorization (below).
• In the event of missed payroll deductions, I authorize my employer to deduct contributions in addition to the weekly deduction(s) thereby maintaining my participation in all benefits elected by this authorization.
• Contributions are for the benefit plans covered by these agreements. Even though my contributions may change from time to time, this agreement will remain in force until further notice.
• I have read and understand the above. By way of the Payroll Authorization I am allowing my employer to adjust the deductions in my paycheck applicable to the benefit elections for Plan Year that this election form applies to.

You must be actively working to be eligible and enroll in benefits.