3800 Centerpoint Drive / tel / 907-258-5065 /
Suite 940 / 888-669-2583 toll-free
Anchorage, AK 99503-5825 / fax / 907-258-1619

GROUP MASTER APPLICATION BENEFIT SELECTIONS

SMALL GROUP / /
This form is part of the Group Master Application /

GROUP NAME

All cost shares represent the member’s share of the cost.
GROUP ID
(Completed by Premera Blue Cross Blue Shield of Alaska)
1. /

BENEFIT COVERAGE SELECTION

If you are differentiating your benefit coverage selection by class of employee, you will need to complete a benefit coverage selection worksheet
for each separate class of employee you wish to cover. What class does this worksheet cover?
All Employees / Management / Salaried / Hourly / Part-time / Full-time / Other, please specify
2. /

MEDICAL PLAN OPTIONS

Note: If this plan is for dental only, complete only section 4 of this form.

A. / Renewal Groups Only
Renew as is – no medical/RX benefit changes; form complete: stop here.

Renew with changes – complete option(s) below:

Consult your Producer or Premera Account Manager if you have questions concerning your plan’s grandfathering status.

B. / Select PPO
Select Gold 500 / Select Silver 2000
Select Gold 1000 / Select Silver 3000
Select Gold 1500
C. / Select Qualified
Select Qualified Silver 2700
Select Qualified Bronze 5250
D. / Plus PPO
Plus Gold 500 / Plus Silver 2000 / Plus Bronze 5500
Plus Gold 1000 / Plus Silver 2500 / Plus Bronze 6350
Plus Gold 1500 / Plus Silver 3000
E. / Plus PPO with Family Dental (dental coverage for all ages, includes pediatric dental)
Plus Silver 2500 + family dental
Plus Bronze 6350 + family dental
F. / Plus Qualified
Plus Qualified Gold 1500
Plus Qualified Silver 2700
Plus Qualified Bronze 5250
F. / Plus HSA
Plus HSA Silver 4000*
G. / Plus HSA with Family Dental (dental coverage for all ages, includes pediatric dental)
Plus HSA Silver 4000 + family dental*
Required Annual Employer HSA Account Contributions:
Plus HSA Silver 4000: $500 IND / $1000* FAM
3. / Adult Vision Benefit Options
Vision exam/test and hardware, subject to $350 maximum per cal year
Not Covered
4. / Adult Dental Plan Options —(Use for Metallic Groups Only)
Note: These optional dental benefits are available to members age 19 and older. These plans are not available with medical plans that include family dental.
A. / Adult Dental Optima —Available for Groups with 2-9 Enrolled Employees
Note: The deductible is waived for Preventive and Diagnostic services.
Adult Dental Optima 1000 Max
Adult Dental Optima 1500 Max
Adult Dental Optima 1500 Max Enhanced*
*Enhanced plan covers endodontic and periodontal treatment under basic services
B. / Adult Dental Optima - Available for Groups with 10+ Enrolled Employees
Note: The deductible is waived for Preventive and Diagnostic services.
Adult Dental Optima 1000 Max
Adult Dental Optima 1500 Max
Adult Dental Optima 1500 Max Enhanced*
Adult Dental Optima 2000 Max Enhanced*
Adult Dental Optima 2500 Max Enhanced*
*Enhanced plans cover endodontic and periodontal treatment under basic services
C. / Adult Voluntary Dental Plan —Available for Groups with 2+ Enrolled Employees
Note: The deductible is waived for Preventive and Diagnostic services. Includes 12-month waiting period for major services
Adult Dental Optima Voluntary 1000 Max
D. / Adult Orthodontia Benefit Options
Note: Option only available to non-voluntary, Adult Optima groups with 26 or more employees enrolled that have selected a dental benefit.
Not Covered
$1,500 overall lifetime limit
E. / Not Covered
5. / Family Dental Plan Options (USE For reNEWing grandfathered and transition plan Groups only)
Note: These optional dental benefits are available with any medical plan option including HSA Qualified plans.
A. / Not Covered
B. / Renewal Groups
Renew as is — no benefit changes; form complete; stop here.
C. / Dental Optima —Available for Group Sizes with 2-9 Enrolled Employees
Note: The deductible is waived for Preventive and Diagnostic services.
DOpt $50 ($150) / 0% - 20% - 50% / $1,000 / DOpt $50 ($150) / 20% - 20% - 50% / $1,000
DOpt $50 ($150) / 0% - 20% - 50% / $1,500 / DOpt $50 ($150) / 20% - 20% - 50% / $1,500
D. / Dental Optima - Available for 10+ Enrolled Employees and Freestanding Dental Groups
Note: The deductible, if any, is waived for Preventive and Diagnostic services.
DOpt $0 ($0) / 0% - 20% - 50% / $1,000 / DOpt $50 ($150) / 0% - 20% - 50% / $1,000
DOpt $0 ($0) / 0% - 20% - 50% / $1,500 / DOpt $50 ($150) / 0% - 20% - 50% / $1,500
DOpt $0 ($0) / 0% - 20% - 50% / $2,000 / DOpt $50 ($150) / 0% - 20% - 50% / $2,000
DOpt $0 ($0) / 20% - 20% - 50% / $1,000 / DOpt $50 ($150) / 20% - 20% - 50% / $1,000
DOpt $0 ($0) / 20% - 20% - 50% / $1,500 / DOpt $50 ($150) / 20% - 20% - 50% / $1,500
DOpt $0 ($0) / 20% - 20% - 50% / $2,000 / DOpt $50 ($150) / 20% - 20% - 50% / $2,000
E. / Dental Preventive —Available for Groups with 5+ Enrolled Employees
DP $0 ($0) / 0% - NC - NC / $500
F. / Dental Preference —Available for Groups with 5+ Enrolled Employees
Note: The deductible is waived for Preventive and Diagnostic services. Coinsurance shown is in-network.
DPF $50 ($150) / 0% - 20% - 50% / $1,000
DPF $50 ($150) / 0% - 20% - 50% / $1,500
DPF $50 ($150) / 0% - 20% - 50% / $2,000
G. / Dental Preference High Deductible —Available for Groups with 5+ Enrolled Employees
Note: The deductible is waived for Preventive and Diagnostic and Basic services. Coinsurance shown is in-network.
DHP $500 ($1500) / 0% - 20% - 50% / $1,000
DHP $500 ($1500) / 0% - 20% - 50% / $1,500
DHP $500 ($1500) / 0% - 20% - 50% / $2,000
H. / Voluntary Plans —Available for Groups with 2+ Enrolled Employees
1. / Dental Essentials
Note: Includes 12-month waiting period for major services
DE $50 ($150) / 0% - 20% - 50% / $1,000
DE $50 ($150) / 20% - 20% - 50% / $1,000
DE $50 ($150) / 0% - 20% - 50% / $1,500
2. / Preventive
DPV $0 ($0) / 0% - NC - NC / $500
I. / Orthodontia Benefit Options
Note: Option only available to Optima and Preference groups with 26 or more employees enrolled that have selected a dental benefit.
Not Covered
$1,000 overall lifetime limit
$1,000 overall lifetime limit; to age 19
$1,500 overall lifetime limit
$1,500 overall lifetime limit; to age 19
J. / Benefit Enhancement Rider — Endodontic and Periodontal Treatment from Major Services to Basic Services
Note: Option only available to Optima, Preference and Essentials (5+ enrolled employees) groups.
Buy-Up Endodontic and Periodontal Treatment from Major Services to Basic Services
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