Houston Prevention Advantage Plan Book

Transcription

WellnessShieldTM
WELCOME!
Welcome to Your Houston GoldTM Plan!
(TEXAS: Administrated by Dorsey Discount Services; Administered by Careington International in all states other than Texas)
We hope you will enjoy your new membership. You now have access to thousands of local and
national providers.
Your membership is simple and easy to use. You may begin saving money as soon as you receive this
membership packet. It is quick and easy to locate participating providers in your area by using the toll-free
number listed in your membership literature or the attached provider lists. Simply present your membership
card at provider locations to receive immediate savings. Refer to this booklet for complete information on the
use of each service.
We believe in customer satisfaction. Please keep the WellnessShieldTM Plan Membership booklet in a safe
place for future reference. Put your membership cards in your wallet so they are with you at all times. This will
help you if you need to call us for information.
If you have any questions or need assistance in using your new membership services, contact us at
281-580-4111 in the Houston Metropolitan Area or 800-880-4343. Our office is open from 8:30 a.m. to
5:00 p.m. Monday through Thursday, and 8:30 a.m. to 2:00 p.m. on Friday. If you cannot contact us directly,
please leave a message and we will return your call in a timely manner.
.FNCFS4FSWJDFT#JMMJOH*ORVJSJFTt
This package of services is not a substitute for comprehensive health insurance.
ii
Your Houston Gold PlanTM Membership Book
WellnessShieldTM
Table of Contents
Table of Contents
Introduction
Disclosures. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2-3
Listing of All Services with Toll-Free Numbers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4-5
Basic Services
CallMD. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6-7
DDS Dental Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8-9
DDS – Vision Care (Local Plan) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Vision Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Prescription Drug Plan (Pharmacies) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. AmeriSave Mail Order Prescription Drug Plan (Brand Name Savings) . . . . . . . . . . . . 1
DDS Hearing Aids and Audiology Services. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Local Laboratory Services and Imaging (MRI/CT Scan) . . . . . . . . . . . . . . . . . . . . . . . . . 1
Laboratory Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Nutritional Supplements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . DDS Chiropractic and Alternative Medical Network . . . . . . . . . . . . . . . . . . . . . . . . . 2
Preventative Services
Free Annual Comprehensive Blood Study . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
Laboratory Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
HOU WS G
09/2012
1
WellnessShieldTM
Terms and Conditions
Disclosures
This discount health care card is NOT insurance.
WellnessShieldTM Service is not available in WA, VT and MT.
RENEWAL CONDITIONS: By joining a plan,
plan, you
youare
are
authorizing Dorsey
Dorsey Discount
DiscountServices
Servicesto
tobill
billyour
your
credit card or checking
checkingaccount
accountfor
forthe
theplan
planyou
youhave
have
selected. This
This charge
chargeshall
shallremain
remainininforce
forceuntil
untilyou
you
notify Dorsey
Dorsey Discount
DiscountServices
Servicesof
ofrequest
requesttotocancel.
cancel.
By joining, you
you indicate
indicateyou
youhave
haveread
readthe
theterms
termsand
and
conditions of the plan.
plan.This
Thisplan
planwill
willautomatically
automatically
renew
at the
the end
end of
ofyour
yourmembership
membershipterm
termon
onan
an
renew at
annual
basis,
and
your
credit
card
or
bank
account
annual basis, and your credit card or bank account
will
automatically charged
chargedor
ordrafted
draftedfor
forthe
the
will be
be automatically
appropriate
amount.
appropriate amount.
Termination
Conditions:Dorsey
DorseyDiscount
DiscountServices
Services
Termination Conditions:
and Careington
Careingtonreserves
reservesthe
theright
righttototerminate
terminate
plan
members
from
its
plan
for
any
reason,
plan members from its plan for any reason,
including
non-payment.
including non-payment.
Cancellation Conditions:
Cancellation
Conditions:You
Youhave
havethe
theright
righttoto
cancel within the
the first
first 30
30days
daysfrom
fromthe
thedate
dateyou
youjoin
join
the plan to use
use the
the plan
planrisk-free.
risk-free.
FL Residents: You have the right to cancel within
FL Residents: You have the right to cancel within
the first 30 days after effective date. If for any
the first 30 days after effective date. If for any
reason during this time period you are dissatisfied
reason during this time period you are dissatisfied
with the plan and wish to cancel and obtain a refund,
with
the plan and wish to cancel and obtain a refund,
you must
you
must submit
submit aa written
writtencancellation
cancellationrequest.
request.
Dorsey
Discount
Services
will
Dorsey Discount Services willaccept
acceptand
andcancel
cancel
plan
memberships
at
any
time
during
the
plan memberships at any time during the
membership period
membership
periodand
andwill
willcease
ceasecollecting
collecting
membership
fees
in
a
reasonable
amount
membership fees in a reasonable amountofof
time, but
time,
but no
no later
later than
than 30
30days
daysafter
afterreceiving
receivingaa
cancellation notice.
cancellation
notice. Please
Please send
sendaacancellation
cancellation
letter and a request
for
refund
with
request for refund withyour
yourname
name
and member
member number
numberto
toDorsey
DorseyDiscount
DiscountServices,
Services,
14413 Cornerstone
Cornerstone Village Drive,
14413
Drive, Houston,
Houston,Texas
Texas
77014 or
or fax to: (281)
(281) 580-0933.
580-0933. You may
77014
may also
alsosubmit
submit
cancellation by email:
email: www.wellnessshield.com.
cs@dorseydiscountservices.com.
If Dorsey Discount Services is billing you quarterly,
semi-annually or annually, Dorsey Discount Services
2
Ifwill,
Dorsey
Discount
is billing
youmembership
quarterly,
in the
event ofServices
cancellation
of the
semi-annually
ormake
annually,
Dorseyreimbursement
Discount Services
by either party,
a pro-rata
will,
in the
eventcharges
of cancellation
of the membership
of the
periodic
to the member.
by either party, make a pro-rata reimbursement of
Description
of Services:
see the enclosed
the
periodic charges
to the Please
member.
materials for a specific description of the programs
Description
ofpurchased.
Services: Please see the enclosed
that you have
materials for a specific description of the programs
Limitations,
Exclusions & Exceptions: Savings
that
you have purchased.
are based upon the provider’s normal fees.
Limitations,
Exclusions
& Exceptions:
Savings
Actual savings
will vary depending
upon
location
are
based
upon
the
provider’s
normal
fees.
and specific services or products purchased. Please
Actual
savings
will vary
depending
upon location
verify such
services
with
each individual
provider.
and
specific
services
or
products
purchased.
The discounts contained herein may not bePlease
used in
verify
such services
with
eachdiscount
individual
provider.
conjunction
with any
other
plan
or program.
The
discounts
contained
herein
may not
be used
All listed
or quoted
prices
are current
prices
by
in
conjunctionproviders
with any other
discount
or
participating
and subject
toplan
change
without notice.
Any
performed
byprices
a
program.
All listed
or procedures
quoted prices
are current
non-participating
provider
aresubject
not discounted.
by
participating providers
and
to change
From time
to time,
providers
may offer
without
notice.
Any certain
procedures
performed
by
products
or
services
to
the
general
public
at prices
a non-participating provider are not discounted.
lowertime
thantothe
discounted
prices available
through
From
time,
certain providers
may offer
this
program.
In
such
event,
members
will
be
products or services to the general public at prices
charged
price. prices
Discounts
on professional
lower
thanthe
thelowest
discounted
available
through
services
are
not
available
where
prohibited
this program. In such event, members will be by law.
This planthe
does
not price.
discount
all procedures.
charged
lowest
Discounts
on professional
Providers
are
subject
to
change
without
services are not available where prohibitednotice
by law.
andplan
services
in some
states. It is the
This
doesmay
not vary
discount
all procedures.
member’s responsibility to verify that the provider
Providers are subject to change without notice
is a participant in the plan. At any time Dorsey
and services may vary in some states. It is the
Discount Services has the right to eliminate a
member’s responsibility to verify that the provider
Participating Professional from the respective network
is a participant in the plan. At any time Dorsey
in which they are associated and may substitute
Discount Services has the right to eliminate a
Provider networks at its sole discretion. Dorsey
Participating
Professional
the respective
Discount Services
cannotfrom
guarantee
the continued
network
in which
they
are associated
participation
of any
provider.
If he orand
shemay
leaves
substitute
Provider
networks
at
its
sole
discretion.
the plan, you will need to select another
provider.
Providers contracted by Dorsey Discount Services are
WellnessShieldTM
Terms and Conditions
Disclosures
solely
for the professional
advicethe
Dorseyresponsible
Discount Services
cannot guarantee
and
treatment
renderedof
toany
members
and
Dorsey
continued
participation
provider.
If he
or
Discount
Services
disclaims
any
liability
with
respect
she leaves the plan, you will need to select another
to
such matters. Services and service providers may
provider. Providers contracted by Dorsey Discount
change or be discontinued at anytime with notice as
Services are solely responsible for the professional
required by law.
advice and treatment rendered to members and
Dorsey Discount
ServicesIf disclaims
any
Complaint
Procedure:
you would
likeliability
to file
respector
togrievance
such matters.
Services
andplan
service
awith
complaint
regarding
your
providers mayyou
change
be discontinued
at anytime
membership,
mustorsubmit
your grievance
with
notice
required
by law.Services,
in
writing
to:asDorsey
Discount
14413 Cornerstone Village Drive, Houston,Texas
Complaint Procedure: If you would like to file
77014. All complaints or grievances are documented
a complaint or grievance regarding your plan
in the monthly Quality Assurance log along with
membership, you must submit your grievance
the date and content of the complaint or grievance.
in writing to: Dorsey Discount Services,
Members
have the right to request an appeal of
14413
Cornerstone
Village Drive,
Houston,
Texas
the
complaint
and grievance
resolution.
Appeals
77014.
All
complaints
or
grievances
are
documented
will be sent to the Committee and will be entitled
in athe
monthly
Quality
log along with
to
second
review
withAssurance
different individuals.
After
the
date
and
content
of
the
complaint
or grievance.
completing the complaint resolution process
and
Members
have
the
right
to
request
an
appeal
of
you remain dissatisfied, you may contact your state
the complaint
and grievance resolution. Appeals
insurance
department.
will be sent to the Committee and will be entitled
TX
All complaints
willindividuals.
be completed
to aResidents:
second review
with different
within
72
hours
of
receipt
with
the
exception of
After completing the complaint resolution
billing
inquiries
that
require
further
process and you remain dissatisfied,research
you mayor
documentation.
contact your state insurance department.
Disclosures:
THIS
PLAN IS NOT
THIS IS
TX Residents:
All complaints
willINSURANCE.
be completed
NOT
A MEDICARE
PLAN.of
within
72 hours ofPRESCRIPTION
receipt with theDRUG
exception
inquiries
require
further
research
*billing
This plan
does that
not meet
the
minimum
creditable
or
documentation.
coverage requirements under M.G.L. c. 111M and
956 CMR 5.00. The plan provides discounts at
certain health care providers for medical services.
The range of discounts will vary depending on the
type of provider and service. The plan does not
make payments directly to the providers of medical
services. Plan members are obligated to pay for all
health care services but will receive a discount from
those health care providers who have contracted
Disclosures:
with the discount medical plan organization. You may
THIS
PLAN
IS of
NOT
INSURANCE.
THIS care
IS NOT
A
access
a list
participating
health
providers
at
MEDICARE
PRESCRIPTION Upon
DRUG request
PLAN.* the plan will
www.wellnessshield.com.
make
available
a written
listminimum
of participating
health
This
plan
does not
meet the
creditable
care
providers.
You
have
the
right
to
cancel
within
coverage requirements under M.G.L. c. 111M and the
firstCMR
30 days
of membership
956
5.00.after
The receipt
plan provides
discountsmaterials
at
and receive a full refund, less a nominal processing fee
certain health care providers for medical services.
(nominal fee for MD residents is $5). Discount Medical
The range of discounts will vary depending on the
Plan Organization and administrator: Careington
type of provider and service. The plan does not
International Corporation, 7400 Gaylord Parkway,
make payments directly to the providers of medical
Frisco,TX 75034; phone 800-441-0380. The program
services. Plan members are obligated to pay for all
and its administrators have no liability for providing
health
care services
but will
a discount
from
or guaranteeing
service
byreceive
providers
or the quality
those
health
care
providers
who
have
contracted
of service rendered by providers. This program is
with
discount
medical plan
organization.
You may
not the
available
in Montana
and Vermont.
*Medicare
access
a
list
of
participating
health
care
providers
statement applies to MD residents when pharmacyat
www.wellnessshield.com.
Upon request the plan will
discounts are part of program.
make available a written list of participating health
FLORIDA
RESIDENTS:
PLAN
NOT INSURANCE.
care
providers.
You have THIS
the right
toIScancel
within
Thefirst
plan
certain health
care
the
30provides
days afterdiscounts
receipt ofatmembership
materials
providers
for
medical
services.
The
range
of
discounts
and receive a full refund, less a nominal processing fee
will varyfee
depending
on the type
ofDiscount
providerMedical
and
(nominal
for MD residents
is $5).
service.
The plan and
doesadministrator:
not make payments
directly to
Plan
Organization
Careington
the
providers
of
medical
services.
Plan
members
International Corporation, 7400 Gaylord Parkway, are
obligated
to payphone
for all800-441-0380.
health care services but will
Frisco,
TX 75034;
receive a discount from those health care providers
The
and its administrators
have no
liability
whoprogram
have contracted
with the discount
medical
plan
for
providing
or
guaranteeing
service
by
providers
organization. You may access a list of participating
orhealth
the quality
of serviceonline
rendered
bythe
providers.
care providers
using
websiteThis
printed
program
not availableIDincard.
Montana
and Vermont.
on your is
membership
Discount
Medical
Plan Organization and Administrator: Careington
International Corporation, 7400 Gaylord Parkway,
*Medicare
applies
to MD residents when
Frisco, TXstatement
75034; phone:
800-441-0380.
pharmacy discounts are part of program.
The program and its administrators have no liability
for providing or guaranteeing service by providers or
the quality of service rendered by providers.
3
Services Available Plus Toll-Free Numbers,
Listed Plan-by-Plan.
Basic WellnessShieldTM Plan (purple section)
$BMM.%. . . . . . . . . . . . . . . . . . . . . . . . . DDS %FOUBM . . . . . . . . . . . . . . . . . . . . . . . 3
DDS Vision . . . . . . . . . . . . . . . . . . . . . . . . . 800-880-4343
DDS Local Pharmacies Help Desk . . . . 800-361-4542
AmeriSave Pharmacy
www.DorseyRx.com
Benefit Manager (mail order) . . . . . . 800-342-0941
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Code: 179.G
Newport Audiology/Hearing Aids . . . 877-412-1383
Local Labs and Imaging . . . . . . . . .800-880-4343
SwansonNutritionalSupplements. . 800-437-4148
. . . . . . . . . . . . . . . . . . . . . . . . When calling, use the term:
“Partners’ Promotional Code is $"3&.”
DDS Chiropractic and
"MUFSOBUJWF.FEJDJOF
Direct Lab Services . . . . . . . . . . . . . . . . . 800-908-0000
(Free Annual Blood Profile &
All Other Lab Work)
For any questions regarding any plan, call the
DDS Customer Service telephone toll-free at
800-880-4343
5
WellnessShieldTM
CallMD
$BMM.%'BNJMZ.FEJDBM
$POTVMUBUJPO/FUXPSL
What Is CallMD?
CallMD is a national network of medical doctors
available for consultation and may write a prescription
for a non-narcotic or non-controlled medication at any
time day or night.* CallMD is staffed with registered
nurses to speak to members regarding their medical
needs and to arrange consultations with CallMD
doctors 24 hours per day/7 days per week at no charge
up to 12 calls. All additional calls are at a reduced rate
of $35.00 per call.
"EEJUJPOBM4FSWJDFT*ODMVEFE
1.'JMF.% A personal health profile accessible via
a secure line over the internet. When a member
contacts the Physician Access Hotline for the
first time, a registered nurse asks the member to
provide a full medical history. This history is stored
via FileMD, which is HIPAA-compliant, and creates
an Electronic Medical Record. This gives members
the convenience of releasing medical data,
6
updating information, and storing documents
(eg. Insurance Cards, Consent Forms, Power of
Attorneys, Living Wills, etc.)
2. 'BNJMZ,FZT A personal data organizer software
program that allows the member to conveniently
organize, record, and store financial, health
and other vital personal information without
compromising privacy. This program downloads
onto the member’s computer in a “notebook”
user-friendly format for easy access and updates.
Member can store data such as family health
records (immunizations, surgeries, genealogy,
etc), which help with the transition of a new
doctor or updating your current doctors records.
Another feature of Family keys is the financial
tool. Members can organize financial services
accounts, insurance policies, retirement accounts,
and includes a financial calculator to amortize
mortgages, personal loans, interest rates, etc.
WellnessShieldTM
CallMD
What Is CallMD? (continued)
)PXUP"DDFTT:PVS%JTDPVOUT
1. Call Toll Free at 1-866-568-6720, a registered
nurse will verify your membership in the
CallMD program.
2. The nurse will document information about
your medical history and your current medical
concern or issue.
3. That medical information is sent to a licensed
doctor in your state of residence.
4. A CallMD doctor and the nurse who took
your medical information will contact the
call center within 45 minutes but no longer than
3 hours to complete your doctor consultation.
A Call MD doctor will complete a diagnosis form
that is available in you Electronic Medical Record
for future use.
5. A CallMD doctor can write an Rx (where allowed
by law) when sufficient medical history is available.
CallMD cannot write Rx for narcotics or DEA
controlled substances
*Description of Services by State:
2. Oklahoma: Can provide a doctor consultation and
write Rx to all member ages in this state if there is
The description of CallMD services by state listed below are as of
evidence of member’s physical on file that was
the date of this contract and are subject to change at any time.
performed by a Oklahoma licensed physician within
1. Florida: Can provide a doctor consultation and write
1 year of the member’s call.
Rx to all member ages in this state if there is evidence
3. All other 46 states, Washington DC and Puerto Rico:
of member’s physical on file that was performed
Can provide a doctor consultation and at the CallMD
by a Florida licensed physician within 1 year of the
doctor’s discretion write a Rx for a non-narcotic
Note: member’s
Missouri –call.
Consultations can be done, but no prescription drugs can
be authorized.
on non-DEA
controlled drug.
7
Wellness ShieldTM
DDS Dental – Schedule of Discounts
General Dentists Schedule of Discounts
What Are Your DDS Dental Discounts?
There is no separate charge for the following:
Administrative expenses, dental supplies, nutritional counseling, oral hygiene instruction, equipment and
instruments necessary for treatment, sterilization charges, periodontal probing (procedure to determine
gum disease), temporary crowns created in the office with a permanent crown, and local anesthesia.
Description
OFFICE VISIT FEE (PER VISIT)
PREVENTIVE AND DIAGNOSTIC
1. All exams (initial, recall, or emergency)
2. Routine adult cleaning - includes polishing and routine scaling
3. Routine cleaning child (up to 12 years old) - includes polishing and routine scaling
4. Fluoride treatment (with cleaning)
5. Fluoride 9DUQLVK
6. Periodontal maintenance procedures (cleaning performed after gum therapy)
7. Panoramic x-ray (a single x-ray of the whole mouth)
8. Complete series of x-rays (including bite-wings)
. All other x-rays per ÀOP
RESTORATIVE DENTISTRY
1. Amalgam Fillings (composed of a mixture of silver and other metals)
1 Surface ÀOOLQJ
2 Surface ÀOOLQJ
3 Surface ÀOOLQJ
4 Surface ÀOOLQJ
&RPSRVLWHV (tooth colored ÀOOLQJV IURQW or back teeth
1 Surface ÀOOLQJ
2 Surface ÀOOLQJ
3 Surface ÀOOLQJ
4 Surface ÀOOLQJ
Roo Canals
Anterior [front] teeth (does not include build-up or crown)
Bicuspid teeth (does not include build-up or crown)
Molars (does not include build-up or crown)
1RWH'LIÀFXOWURRWFDQDOVDUHRIWHQUHIHUUHGWRDVSHFLDOLVWHQGRGRQWLVW
7KHVSHFLDOLVW·VQRUPDOIHHVZLOOEHGLVFRXQWHG
Normal Fee
$ - $
$ - $
$ - $
Dorsey Fee
$12
$ - $
$ - $
$ - $
$2 - $
$2 - $2
50% Discount
$
$
$
$
$
$
$
$
$1 - $1
$ - $
$ - $
$ - $
$
$
30% Discount
30% Discount
$ - $
$ - $
$ - $
$ - $
$ - $
$ - $
30% Discount
30% Discount
$ - $
$ - $
$ - $
$
$
30% Discount
$ - $
$ - $
$ - $
$ - $
$ - $
$ - $
$
$
$
$
$
$
3..
&URZQV DQG À[HG EULGJHV EULGJHV are FURZQV fused WRJHWKHUH
Crowns made of all metal (nonprecious metal)
Crowns made of all metal (semiprecious metal)
Crowns made of all metal (precious metal)
Crowns made of porcelain and nonprecious metal
Crowns made of porcelain and semiprecious metal
Crowns made of porcelain and precious metal
H all lab fees included in price
8
TM
TM
Wellness Shield
WellnessShield
DDS
Dentalof– Dental
Schedule
of Discounts
Schedule
Discounts
Descri
ptionNormal Fee
Description
Dorsey Fee
5. Build-ups ÀOOLQJV GRQH DIWHU URRW FDQDOV DQG RIWHQ EHIRUH FURZQV to UHVWRUH
loss of a large amount of tooth structure)
Normal Fee
Dorsey Fee
$ - $
30% Discount
COSMETIC DENTISTRY
Cosmetic bonding, whitening, all porcelain crowns, and porcelain laminate veneers
25% Discount
NON ROUTINE GUM TREATMENTS (NONSURGICAL)
Includes gross scaling, deep scaling and root planing, or other gum treatments
25% Discount
DENTURES
Dentures - full or partial dentures (includes lab fees)
Minimum fee for a full denture after discount is $600. Minimum fee for a
partial denture is $700. Adjustments and try-in visits are at no additional fee
RWKHU WKDQ WKH QRUPDO RIÀFH visit IHH
$ - $
30% Discount
ORAL SURGERY (EXTRACTIONS)
25% Discount
ORTHODONTICS
Orthodontics (braces, specialist or general dentist minimum fee $3000)
Full cases, $4300 or more
Full cases under $4300
30% Discount
25% Discount
NITROUS OXIDE (LAUGHING GAS - WHERE AVAILABLE)
PALIATIVE (EMERGENCY TREATMENT OF DENTAL PAIN)
ALL OTHER PROCEDURES NOT LISTED ABOVE
$ - $
$ - $
$
50% Discount
25% Discount
* Normal Fee represents the 50th-th percentile in Houston, Texas as of February 20.
** Dorsey Fees reflect the percentage discount off your dentist’s normal fees.
Special Notes
1. Coordination of Products: Dorsey Discount Services is NOT an insurance company or dental HMO. The Dorsey services are designed to supplement the
exclusions and limitations of dental insurance policies. This means that you can use Dorsey once you have reached your maximum limit on your dental
insurance policy. Dorsey can also be used for dental procedures not covered by your dental insurance. It is the Dorsey policy not to submit Dorsey fees
to insurance companies.
2. Missed Appointments without 24-hour notice: Too many missed appointments may result in cancellation of membership. A missed appointment
charge will be made of $10 per 15 minutes with a maximum charge of $40.
3. Specialists’ charges: Specialists’ charges for oral surgery, periodontics (gum problems), and pedodontics (children’s specialist) are discounted 20% - 25%
off normal fees. Endodontics (root canals) are discounted 20% off normal fees. Orthodontics by Orthodontists are discounted 25% - 30%. This includes
the braces, records, initial exams, x-rays, casts, consultation and retainers, etc. Not all specialists are available in every area. Call 1-800-880-4343 for
specialists near you.
5. Your Dorsey membership may be cancelled if your account with the provider is not paid in a timely manner.
6. Fees are subject to change without notice.
Dorsey Discount Services - Exclusions & Limitations
GENERAL LIMITATIONS
t "OZNFEJDBMQSPDFEVSFTSFRVJSJOHPSBMTVSHFSZ
t %JTQFOTJOHPGESVHT
t "OZEFOUBMUSFBUNFOUSFRVJSJOHIPTQJUBMJ[BUJPO
t "OZXPSLXIJDIJTOPUBCMFUPCFQFSGPSNFECFDBVTFPGIFBMUIQSPCMFNT
as indicated by the member’s physician or the Dorsey dentist.
t "OZUSFBUNFOUSFRVFTUFEPSBQQMJBODFNBEFXIJDIJOUIFPQJOJPOPG
the treating dentist is not necessary for maintaining or improving the
eligible member’s health.
t "OZUSFBUNFOUDPWFSFEPSQSPWJEFECZ8PSLFST$PNQFOTBUJPOPS
employer’s liability laws by a federal or state government agency
or provided without cost by any municipality, county or other
governmental subdivision.
t "OZQSPDFEVSFDPOTJEFSFEUPCFFYQFSJNFOUBMCZUIFQSPWJEJOHEFOUJTU
t "OZEFOUBMDBSFQSPWJEFECZBOPOQBSUJDJQBUJOHHFOFSBMEFOUJTU
or specialist.
t %FOUBMUSFBUNFOUBOEFYQFOTFTJODVSSFEGPSUSFBUNFOUTUBSUFEQSJPSUP
the member’s eligibility to receive services under this plan, or started
after a member’s termination.
t (FOFSBMBOFTUIFTJBBOEJOUSBWFOPVTTFEBUJPOBSFEJTDPVOUFEBU
dentist’s discretion.
t 5IFGFFQFSYSBZEPFTOPUDPWFS5.+öMNT5IFZBSFDPWFSFE
at a 25% discount.
t 1SPQSJFUBSZUFDIOPMPHJFTEFMJWFSFEUISPVHI%FOUBMPóDFTFH#SJUF4NJMF
Invisalign are discounted at dentist’s discretion.
ORTHODONTIC PLAN LIMITATIONS
t 1BUJFOUTVOEFSDVSSFOUUSFBUNFOUJOPSUIPEPOUJDTBUUIFUJNFPGKPJOJOH
Dorsey are not eligible for treatment under this plan.
t 'BJMVSFUPGPMMPXQSFTDSJCFEUSFBUNFOUPSBDDJEFOUTPDDVSSJOHEVSJOHUIF
treatment may result in extra fees.
t *GZPVSNFNCFSTIJQUFSNJOBUFTZPVXJMMCFSFTQPOTJCMFGPSUIFQBZNFOU
of the balance due for treatment at the dentist’s normal fee.
9
WellnessShieldTM
DDS Vision Care and Local Providers
DDS Vision Plan – Houston and Surrounding Area
What Are Your DDS Vision Plan Services?
BDDFTTUPUIF%%47JTJPO1MBOEFUBJMFECFMPX
Eyewear Optometrists
Eyewear Optometrists
Receive a 25% discount off Exams and Materials (excluding disposable contacts) at these participating Optical Providers.
Receive a 25% discount off Exams and Materials (excluding disposables) at these participating Optical Providers.
SURROUNDING AREAS
1246 Budget Opticals of America
404 University TEXAS
Drive East
BEAUMONT/EAST
College Station, TX 77840
(979)
(BUFXBZ&ZF"TTPDJBUFT
693-2891
(BUFXBZ
1018 Eyeland
#FBVNPOU59
David
Boeckman, OD
(409)M.835-2041
Awalt, OD
David
.+.BZOBSE0%
Mary
OD327
710Hamill,
Highway
1422
B Loop
West
Silsbee,
TX336
77656
Conroe,
TX
77304
(409) 385-2811
(936) 756-2001
LA PORTE/PASADENA
1102 M. J. Maynard, OD
1175 710
L. Highway
A. Frazier,327
OD
9500 Spencer
Silsbee,
TX 77656Highway
La Porte,
TX 77571
(409)
385-2811
(281) 476-5107
1114 Gateway Eye Associates
.BSWJO#B[B0%
138 Gateway
4904 Fairmont
Beaumont, TX 77701
Pasadena, TX 77505
(409) 835-2041
(281) 998-2020
1281
South Texas
Optical
SOUTHEAST
HOUSTON/ALVIN
2100 Regional Medical Drive
1021 Wharton,
Paul Marcaccio,
TX 77488OD
Lisa532-6702
Maxwell, OD
(979)
4DBSTEBMF#MWE
BAY AREA
Houston, TX 77089
(281) 484-3937
1175 L. A. Frazier, OD
1307 9500
Stanbridge
EyeCenter
Spencer Highway
Nguyen
(Hue), OD
LaLisa
Porte,
TX 77571
9210
Highway 6 South
(281)
476-5107
4VJUF(
1117 Berkeley
EyeTX
Center
Houston,
77083
George
L. Hall, OD
(832) 328-1971
Glenmont
17100
(FPSHF)BMM0%
Suite B
1046 Hercules
Webster, TX 77598
Houston, TX 77058
(281) 488-0070
(281) 488-0070
1012
Williams, OD
Floyd
4QBDF$JUZ7JTJPO$FOUFS
910
West Main
(FPSHF-)BMM0%
League
City, TX 77573
(MFONPOU1BSL%SJWF
(281)
332-1041
4VJUF#
8FCTUFS59
NORTHWEST
(281) 488-0070
1342
On Eye Care
Hands
'MPZE8JMMJBNT0%
Spencer
Obie, OD
8FTU.BJO
12200
Northwest
League
City, TXFreeway
77573
Suite
360
(281)
332-1041
TX 77092
Houston,
'MPZE8JMMJBNT0%
(713)
700688-5777
South Friendswood Drive
Suite A
Friendswood, TX 77546
(281) 482-2237
1242 Copperfield TSO
1022 Woodlands Vision Center
1021 Paul Marcaccio, OD
Perry Soli, OD
Ronald Sachs, OD
Lisa Maxwell, OD
8506 Highway 6 North
580 Sawdust Road
12303 Scarsdale Blvd.
1066 Houston,
PearlandTX
TSO
1002 Allan
Panzer,
OD
NORTHWEST
HOUSTON
77095
Spring,
TX 77380
Houston,
TX 77089
Ingrid
Hillard,
OD
#FFDIOVU
(281) 550-3600
(281) 367-4966
(281) 484-3937
5
FSSZ4(MBTFS0%
&BTU#SPBEXBZ
Houston, TX 77096
12200 Northwest Freeway
1157 Russell
Bond,
1336 (713)
VisionMann
Pearland,
TX OD
77581
664-4760
SOUTH
Suite 360
28437
Tomball Parkway
Mann, OD
(281) 997-2629
#Andrew
FMMBJSF.FEJDBM1MB[B
TX 77092
1001 Houston,
A.C. Marcaccio,
OD
TX 77375
25248 Grogans Park Drive
Tomball,
7JTUB&ZF$FOUFS
%BWJE"+BDPCTPO0%
(713)
688-5777
Russell
Malik, OD
(281)
351-0744Chu, OD
The Woodlands,
77380
Lili Christine
5420
Dashwood TX
Drive
7640
Bellfort
1256
Surgical
Eye
Associates,
P.A.
(281) 207
298-2020
4ZMWJB#SPXO0%
Suite
1341 Mark
R. Richardson, R. Ph., OD, P.A.
Houston, TX 77061
/PSUI-PPQ8FTU
#SPBEXBZ
TX Group
77081
23110
Kuykendahl Rd.
1311 Houston,
Klein Vision
(713)500
645-6666
Suite
Suite100
A
(713)
Suite
David665-2015
Boeckman, OD
Houston, TX 77008
Pearland,TXTX77389
77584
1231 Floyd Williams, OD
Tomball,
David
Way, OD
MISSOURI
CITY/STAFFORD/
(713)
869-6400
(713)717-3937
436-0106
700 South Friendswood Drive
(832)
21195 Kuykendahl Road
SUGAR LAND
1259 Surgical
Suite AEye Associates, P.A.
Spring, TX 77379
5PEBZT7JTJPO
1241 Family Eye Center
1229
Campbell TX
Road
1105 Eye
Trends
Friendswood,
77546
(281)
370-4444
%JBOOF#%BP0%
1524 Willowbrook Mall
Houston,
TX 77055
4UVBSU#.JMMFS0%
(281) 482-2237
&#SPBEXBZ
Houston, TX 77070
(713)
467-6600
6134
Highway
6
NORTHEAST
Pearland, TX 77581
1066 Pearland TSO
(281) 955-9999
Missouri City, TX 77459
$PQQFSöFME540
(281) 485-2020
Ingrid Hillard, OD
1340 (281)
TSO 499-2020
Perry
Soli, OD
1299
Spectrum
EyeCare
1023 Lewis A. Landsman, OD
3232 East Broadway
Mark R. Richardson, R. Ph., OD, P.A.
8506
Highway 6 North
1036 Robert
Le,
OD
Thuy
ODOD
ChadTran,
Moffit,
3103 FM 1960 Rd. W., Suite V
Pearland, TX 77581
Houston,
TX 77095
13879
Southwest
7758
Tidwell,
Suite
12435
2625W.
South
Loop,
Hwy
Humble,
TX 77338Feeway
(281) 997-2629
(281)
550-3600
Stafford,
TX 77478
Houston,
77040
Alvin, TXTX
77511
(281) 443-0340
1337 Spectrum
Vista EyeEyeCare
Center
(281) 277-3100
(713)
1299
(281)690-8439
585-8453
Lili Tran,
Christine
Thuy
OD Chu, OD
DOWNTOWN
1339
Town Square Eye Associates
DOWNTOWN
HOUSTON
Sylvia Brown, OD
NORTH
85JEXFMM4VJUF
(FPSHF/;BJCBR0%
1277 Garcia & Associates
10505 Broadway
Houston,
TX 77040
Alain Tran, OD
(BSDJB"TTPDJBUFT
1262 Vista
Optical
Charles Garcia, M.D.
Suite A
713-690-8439
Long Nguyen, OD
$IBSMFT(BSDJB.%
7007
Interstate 45
1315 St. Joseph Parkway
Pearland, TX 77584
$JUZ8BML
4U+PTFQI1BSLXBZ
7JTUB0QUJDBM
Suite 125
Medical Plaza 1
(713) 436-0106
Sugar
Land, TX 77479
Medical Plaza
1
7007
Interstate 45
Houston,
TX 77076
Houston, TX 77002
(281)
265-2000
Houston,
TX 77002
125 Vision
1340Suite
Today’s
(713)
697-8904
(713) 659-3937
(713) 659-3937
Houston,
TXDao,
77076
Dianne B.
OD
MEMORIAL/TOWN & COUNTRY
1010 Berkeley Eye Center
1025 TSO
(713)
3227697-8904
E. Broadway
SOUTHRobert
HOUSTON
Reid, OD
+PTFQI#MBDLCVSO0%
4850 South Main Street
Pearland,
TX 77581
1241 Family
Eye Center
1025 4444
TSO 1960 West
&4BN)PVTUPO1LXZ
Houston, TX 77002
(281) 485-2020
8JMMPXCSPPL.BMM
Suite
485012-B
South Main Street
Suite
(713) A523-5109
Houston,
TX
77070 OD
Houston,
1023 Lewis A. Landsman,
Houston,TX
TX77068
77002
Houston, TX 77015
(281)
955-9999
INNER(713)
LOOP450-4484
(281)
$IBE.PóU0%
(713)894-2020
523-5109
#FSLMFZ&ZF$FOUFS
2625 South Loop, Hwy 35
1026 .Pearle
Vision
FNPSJBM7JTJPO
1257 SurgicalHOUSTON/BELLAIRE
Eye Associates, P.A.
SOUTHWEST
Robert
OD
Alvin,Reid,
TX 77511
6737 Stella
Peggy
Hart,Link
OD, FAAO
821 Peakwood, Suite 101
8FTU
(281) 585-8453
Houston,
1FBSMF7JTJPO
Houston, TX 77005
#.FNPSJBM%SJWF
TX 77090
4VJUF#
4UFMMB-JOL
(713) 432-1137
Houston,
TX 77079
(281)
537-0100
SOUTHWEST
Houston, TX 77068
Houston, TX 77005
(281) 496-1635
(281) 894-2020
1256
Surgical
Eye
Associates,
P.A.
1169 Burt
OD
(713)Denton,
432-1137
1002
Allan Panzer, OD
1019 Larry
1631 Spitzberg,
North LoopOD
West
Little York, Suite B-6
TOMBALL/WHARTON/
4760 Beechnut
3500
%POOB.+BT[LPXTLJ0%
14441
Memorial
Drive
Suite 500
Houston,
TX
77093
COLLEGE
STATIONTX 77096
Houston,
6706 Marinette
Suite
13 TX 77008
Houston,
(713)
697-3760
(713) 664-4760
Houston,
TX 77036
Houston,
TX 77079
3VTTFMM#POE0%
(713) 869-6400
(713)
777-5367
1024 K.
Marcha,
OD
(281) 497-2988
10035PNCBMM1BSLXBZ
Donna M. Jaszkowski, OD
Greenspoint
1001 12122
A.C. Marcaccio,
ODDrive
SOUTHEAST
Tomball,
TX 77375
6706 Marinette
Houston,
TX 77060
3VTTFMM.BMJL0%
(281)
351-0744
Houston,
TX 77036
1020 Marvin Baza, OD
(281)
875-5439
#FMMGPSU
(713)
777-5367
1281 South Texas Optical
4904 Fairmont
Houston, TX 77061
2100
Regional
Medical Drive
Pasadena, TX 77505
(713) 645-6666
8IBSUPO59
(281) 998-2020
(979) 532-6702
1123
Bellaire Medical Plaza
David A. Jacobson, OD
5420 Dashwood Drive
#VEHFU0QUJDBMTPG"NFSJDB
Suite 207
404Houston,
University
TXDrive
77081East
College
(713)Station,
665-2015TX 77840
(979) 693-2891
1105 Eye Trends
NORTH
HOUSTON/CONROE
Stuart B. Miller, OD
6134 Highway
6
1257 Surgical
Eye Associates,
P.A.
Missouri City, TX 77459
1FBLXPPE4VJUF
(281) 499-2020
Houston,
TX 77090
(281) 537-0100
1036 Robert Le, OD
#VSU%FOUPO0%
13879 Southwest Feeway
-JUUMF:PSL4VJUF#
Stafford, TX 77478
Houston,
TX 77093
(281) 277-3100
(713) 697-3760
1339 Town Square Eye Associates
1024 K. Marcha, OD
George N. Zaibaq, OD
(SFFOTQPJOU%SJWF
Alain Tran, OD
Houston,
TX 77060
Long Nguyen, OD
(281)
875-5439
16200 City Walk
8PPEMBOET7JTJPO$FOUFS
Sugar Land, TX 77479
Ronald
OD
(281)Sachs,
265-2000
580 Sawdust Road
1091Spring,
Joseph
Blackburn,
OD
TX 77380
5655
E. Sam Houston Pkwy.
(281)
367-4966
Suite A
,MFJO7JTJPO(SPVQ
Houston, TX 77015
%BWJE#PFDLNBO0%
(713) 450-4484
%BWJE8BZ0%
,VZLFOEBIM3PBE
WEST
Spring, TX 77379
1019(281)
Larry
Spitzberg, OD
370-4444
14441 Memorial Drive
8BMUFS3PTFO0%
Suite 13
&BTU4VJUF7
Houston,
TX 77079
Humble,
TX 77338
(281)
497-2988
(281)
443-0340
Stanbridge EyeCenter
13077JTJPO.BOO
Lisa Nguyen
(Hue), OD
Andrew
Mann, OD
9210 Highway 6 South
(SPHBOT1BSL%SJWF
Suite G
5IF8PPEMBOET59
Houston,
TX 77083
(281)
298-2020
(832) 328-1971
1018 Eyeland
1338%BWJE.#PFDLNBO0%
Memorial Vision
David
Awalt,
ODOD, FAAO
Peggy
Hart,
Mary
Hamill,Memorial
OD
14032-B
Drive
#-PPQ8FTU
Houston, TX 77079
Conroe,
TX
77304
(281) 496-1635
(936) 756-2001
1259 Surgical Eye Associates, P.A.
1229 Campbell Road
Houston, TX 77055
(713) 467-6600
Vision Plan
Eyeglass Exam
10% Discount
Upgrades and Lens Options
Everyday low prices
Dialation
$10.00
Frames and Lenses
25% Discount. Including Designer brands,
(varies by state)
single vision, bifocal and trifocal lenses.
Children’s Eyewear Collection
Starts as low as $79.00 (frames and polycarbonate lenses)
3FDFJWF&$$".BOBHFE7JTJPO$BSFBCPWFNFOUJPOFEEJTDPVOUTUISPVHI%PSTFZ%JTDPVOU4FSWJDFT'PSB7JTJPOXPSLTOFBSZPVHPUP
www.ecca.com or call 800-340-0129
1
WellnessShieldTM
Vision Plan
Vision: EyeMed Vision Care
800-290-0523
What Is The EyeMed Vision Care Plan?
Members save 20% to 40% off the retail price of
eyewear with the EyeMed Vision Care Access Plan D
discount program. Members are eligible for discounts
on exams, eyeglasses and contact lenses from
more than 50,000
40,000 providers nationwide including
independent optometrists, ophthalmologists,
opticians, and leading optical retailers such as
LensCrafters®, Sears Optical® Target Optical®,
JCPenney® Optical, and most Pearle Vision® locations.
How to Access Your Discounts
Step 1: Locate the EyeMed provider most
convenient for you by calling our Customer Service
at (800) 290-0523 or by visiting our Web site at
XXXDBSFJOHUPODPN.
Step 2: Schedule an appointment. When making an
appointment tell the provider you are an EyeMed
member and provide your name, name of your
organization or plan and your member number.
Step 3: When you arrive, identify yourself
as an EyeMed member and present your
membership card.
1
WellnessShieldTM
Vision Plan
EyeMed Vision Care Plan (continued)
Program Description
Vision Care Service
Exam
Exam with Dilation as Necessary
Member Discount
$5 off comprehensive exam
$10 off contact lens exam
Complete Pair Eyeglasses Purchase Discounts*:
Frames, lenses and lens options purchased in the same transaction
Frames
Any available frame at provider location 35% off the retail price
Standard Plastic Lenses:
Single Vision
$50
Bifocal
$70
Trifocal
$105
Lens Options
UV Coating
$15
Standard Scratch Resistant Coating
$15
Tint (Solid and Gradient
$15
Standard Polycarbonate
$40
Standard Anti-Reflective Coating
$45
Standard Progressive (Add-on bifocal)
$65
Other Add-Ons and Services
20% off the retail price
Contact Lenses: (discounts applies to materials only)
Conventional
Laser Vision Correction:
LASIK or PRK from U.S. Laser Network
-or5% off the promotional price
'SBNFMFOTFTBOEMFOTPQUJPOTEJTDPVOUTBQQMZPOMZXIFOQVSDIBTJOH
BDPNQMFUFQBJSPGFZFHMBTTFT*GQVSDIBTFETFQBSBUFMZNFNCFSTSFDFJWF
PòUIFSFUBJMQSJDF
Laser Vision Correction
EyeMed and LCA-Vision have arranged to provide this
discount to all EyeMed members through one of the
largest laser networks available, the U.S. Laser Network.
Members are entitled to 15% off the retail price or
1
Vision Care Service Member Discount
Sample Savings Chart
Vision Care Service
Retail Price* Member Cost Savings
Exam
Eye Exam
$100
$95
$5
Lenses
Single Vision Lenses
$120
$50
$70
Frame
Example
$150
$98
$52
Lens Options
Standard Scratch
Resistant and UV Coating
$40
$30
$10
TOTAL
$410
$273
$137
5IJTDIBSUSFøFDUTBTBNQMFTBWJOHTBOEBDUVBMSFUBJMQSJDJOH
XJMMWBSZCZMPDBUJPO
5% off the promotional price of LASIK or PRK
procedures, whichever is the greater discount.
Replacement Contact Lenses by Mail
EyeMed members may order replacement
contact lenses via the Internet and have them
mailed directly to the member’s home. This
service is for replacement contact lenses only,
and the EyeMed discount does not apply.
The member’s initial pair of contact lenses must
still be purchased from their eye care provider
to ensure proper fit and follow-up care. Visit
XXXFZFNFEDPOUBDUTDPN for more information
or to place an order.
WellnessShieldTM
Vision Plan
Vision: EyeMed Vision Care
800-290-0523
National LASIK Network (LCA-VISION) [EyeMed, continued]
LASIK can provide freedom for many individuals
who wear glasses or contact lenses. The National
Lasik Network surgeons have performed over
1,000,000 procedures to correct nearsightedness,
farsightedness, and astigmatism. The medical
professionals at National Lasik Network will work
with you to create a personalized vision plan to
achieve optimal vision.
Member Pricing:
t 4JHOJöDBOU4BWJOHTBOEB'SFFJOJUJBMDPOTVMUBUJPO
t "MMJOOFUXPSLQSPWJEFSTFYUFOE
the following discounts
t PòTUBOEBSEQSJDFT03
off promotional prices
Featured Pricing:
t &YDMVTJWFMZBWBJMBCMFXJUIiGFBUVSFE
providers” (locations nationwide):
Program Description
Technology
Traditional LASIK
with IntraLase
Set Price
$695 per eye*
/FBSTJHIUFECFUUFSUIBO
XJUIBTUJHNBUJTN
CFUUFSUIBOBOEPUIFS
SFTUSJDUJPOTBQQMZ
Enhancements
Free enhancements
for one year
Traditional LASIK
with IntraLase
$1,395 per eye
Free enhancements
for life
Custom or
Wavelight LASIK
with IntraLase
$1.895 per eye
Free enhancements
for life
NATIONAL LASIK NETWORK
(LCA-VISION)
Careington International Corporation has a
preferred pricing plan for LASIK eye surgery
through the National Lasik Network with over
570 locations nationwide. The arrangement with
the National Lasik Network means you can have
LASIK vision correction surgery at a significantly
reduced rate.
To locate a provider or to obtain additional
information, please call 1-866-921-2106 or
visit our website at XXXDBSFJOHUPOMBTJLDPN
4PNF3FTUSJDUJPOT.BZ"QQMZ
1
WellnessShieldTM
Prescription Drug Plan
Prescription Drug Plan
Pharmacies
About Your National Prescription Plan
v
Normal Savings 10% up to 60%
v Over 53,000 Pharmacies Available Nationally
v Pharmacies Available Include:
"MCFSUTPOTt#SPPLTIJSF#SPUIFSTt$74t
$PTUDPt%SVH&NQPSJVNt)&#t,.BSUt
1VCMJYt3BOEBMMTt3JUF"JEt5PN5IVNCt
5BSHFUt7POTt8BMHSFFOTt
8BMNBSUt8JOO%JYJFtBOE.PSF
v Pet Medications also included in program.
How To Use This Program:
At your local pharmacy, simply show your I.D. Card to receive
your discount.
Online, go to www.DorseyRx.com. To find a participating pharmacy, click
“Pharmacies Near You”. Then search by Pharmacy Name or Zip Code.
You can also limit distance from your zip code. Click GO.
To check pricing by pharmacy, click “Prescription Pricing” and enter
your Group ID: DDS, your Zip Code and Drug Name (generics, if available,
will be automatically listed). Click GO. Select (at bottom) your dosage and
strength. Adjust quantity if needed for a 30-day supply. Then
click “Get Prices”. You will see the 90-day mail-order supply in
box labeled Mail Order Pricing: IPS. The box below that lists
the closest pharmacy near you with drug price. You can click
your choice of other pharmacies near you below that box
for their price.
Different pharmacies may have different pricing.
If you need to use your card before the effective date
on your card, go to www.DorseyRx.com, click on
“Become a Member Today”. Fill in information and click
“Submit Form”. An immediately effective pharmacy card
will be emailed to you, usually within 30 minutes. If this
does not happen, call 727-526-0317 to speak directly
with Member Services.
Questions, call: Dorsey Discount Services at 800-880-4343.
For the greatest savings on brand name prescriptions, see following page.
1
WellnessShieldTM
AmeriSave Mail-Order Prescription Plan
AmeriSave Pharmacy
Benefit Manager
800-342-0941
About AmeriSave
Home Delivery
Your prescriptions are mailed from the
pharmacy directly to your address. Shipping
time is from 10 to 18 days. To allow for delivery,
order early.
At Refill Time
AmeriSave calls you each time your refill order
is due, approximately 3 weeks before you run
out of your prescription.
Pet Meds Available
Drug & Strength
AmeriSave, located in Omaha, NE, is a Pharmacy Benefit
Manager. In other words, AmeriSave is a Pharmacy Provider.
We send your prescriptions to large discount pharmacies while
passing the savings on to you averaging 50% – 70%.
How Can Prices Be So Low?
Your order is filled at the best nation-wide price. AmeriSave finds
the pharmacy that provides the highest quality drugs at the
lowest price and passes that savings on to you.
About The Quality
AmeriSave’s pharmacies supply the finest quality of medications.
We offer unconditional superiority. . . no exceptions when it
comes to excellence and grade.
More On Low Prices
AmeriSave offers BIG discounts. Across the board, AmeriSave’s
prices are 50% to 70% lower than your local pharmacy.
Advair
Singulair 10MG
Boniva 150MG
Actos 30MG
Crestor 20MG
30-Day
Pharmacy
Price
30-Day
AmeriSave
Price
$260.99
$164.99
$141.99
$287.99
$172.99
$68-$88
$50-$65
$41-$60
$65-$99
$58-$69
How To Order
1. Just Call 1-800-342-0941
2. Identify yourself as a WellnessShieldTM
Member using code 179G.
ALWAYS ENTER OR SAY CODE 179G
TO GET YOUR DISCOUNT
Full Refund Guarantee
Upon receipt of your order, if you are dissatisfied
for ANY reason, return your order and receive
a FULL REFUND. No questions asked. Other
pharmacies do not refund.
1
WellnessShieldTM
DDS Hearing Aids and Audiology Services
Newport Audiology
877-412-1383
About Your Hearing Aid Plan:
Getting Your Hearing
Checked is Important
for any Age...
Newport Audiology, with
locations in 50 States with
over 2500 locations, is
committed to the
improvement of hearing
for each and every
WellnessShieldTM Member.
If you suspect that your
hearing, or one of your family
members’ hearing could be
improved, this plan is for you.
Hearing loss that can be helped
with a hearing aid expands that
individual’s life!
How to Access
Your Newport Audiology
Services are easy to access:
Call 877-412-1383 to find
the location nearest you,
or go to website:
www.newportaudiology.com
When making appointment,
tell operator that you are a
WellnessShieldTM member,
and have your I.D. Card with
you at time of appointment.
Your Plan Offers:
Cost for
Member:
Usual Cost for General Public:
t
t
t
t
t
*OJUJBM&YBN. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $119
5XPZFBSTVQQMZPGCBUUFSJFT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $98
5XPZFBSNBOVGBDUVSFSTXBSSBOUZ-PTT%BNBHF
. . . . . . .$350
6OMJNJUFEGPMMPXVQWJTJUT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$439
(6 visits)
4FSWJDF4BUJTGBDUJPO(VBSBOUFF
FREE
FREE
FREE
FREE
FREE
PLUS!
35% Discount for Members on the Cost of Hearing Devices
WellnessShieldTM
Local Laboratory Services & Imaging
Lab Services
- Sample
Savings
What
is “Your
Health
Lab”?
Sample Fees on Lab Services
Common Profiles
Normal Fee Range
DDS Cash Price
Women’s Health Screen (Chem Profile, Lipid, Thyroid, CBC)
$331 – $435
$60
Common
Profiles
Normal
Fee
Range
DDS Cash
PriceRange
Common
Profiles
Normal
Fee
Men’s
Health Screen
(Chem Profile, Lipid, Thyroid, CBC)
$331 – $435
$60
Women/Men’s Health Screen
Men’s
Health
Screen
with
PSA
$371
–
$522
$80
Women’s Health Screen (Chem
Profile,
CBC)
$331
– $435
(Chem Profile,
Lipid,Lipid,
Thyroid,Thyroid,
CBC)
$ 70.00
General Health Screen (Chem Profile, Lipid)
$132 – $183 $331 – $435$40
Men’s
Screen
(Chem
Lipid,
Thyroid,
CBC) $ 80 – $111 $371 – $522$24
Health Screen
with
PSA
Lipid
Profile Health
(Cholesterol,
Trig, HDL,
LDL,Men’s
VDL)Profile,
Complete
Risk Profile
$ 80 – $111
Men’sHeart
Health
Screen withLipid
PSAProfile (Cholesterol, Trig, HDL, LDL, VDL)
(Lipid profile, Homocysteine, C-Reactive Protein)
$165 – $236
$58
Complete
Heart
Risk
Profile
(Lipid
profile,
General
Liver
Function Health Screen (Chem Profile, Lipid)
$ 47 – $ 66
$16
Homocysteine, C-Reactive Protein)
$165 – $236
Thyroid
Profile
$176 – $230
$25
Lipid
Profile (Cholesterol,Liver
Trig,Function
HDL, LDL, VDL)
Anemia Profile (CBC, Retic, B12, Folate, Iron TIBC)
$214 – $306 $ 47 – $ 66$70
Complete
Risk
$176 - $200$95
Menopause
ProfileHeart
(Estradiol,
FSH,Profile
LH) Thyroid Profile
$240 – $344
STD Panel
(Chlam,
GC, HIV,Homocysteine,
RPR)
$292 – $381Normal Fee Range
$75
(Lipid
profile,
Protein)
CommonC-Reactive
Test
Hepatitis Acute (ABC) Panel
$180 – $249
$77
Urinalysis
$14 – $16
Liver
Function
Basic Metabolic Panel
$ 38 – $ 52
$13
CBC (Complete Blood Count)
$34 – $38 $17
Comprehensive
Metabolic Panel
$ 52 – $ 72
Thyroid Profile
$331
– $435
$ 80.00
$ 30.00
$371
– $522
$132
– $183
$ 70.00
$ $80
–
20.00$111
DDS Cash Price
$60
$60
$80
$40
$24
$ 20.00
$58
$ $475.00
– $ 66
$16
$ 20.00
$176 – $230
$25
Common
Test Profile (CBC, Retic, B12, Folate, Iron TIBC)
Normal Fee Range
DDS Cash Price
Anemia
$214 – $306
$70
HIV-1
70 –7$103
$14 Serve You
YOUR
HEALTH LAB $—
Locations To
Menopause
Profile
(Estradiol,
FSH,
LH)
$240
–
$344
$95
Drug Screen, Qualitate/Multi
$ 78 – $129
$18
Urinalysis
$ 14 – $ 16
$ 4
STD Panel
(Chlam,
GC, HIV, MEDICAL
RPR) CENTER HOUSTON LOCATION
$292 – $381 THE WOODLANDS, $75
SOUTHWEST
HOUSTON
LOCATION
KATY, TEXAS LOCATION
TEXAS
CBC (Complete
BloodSuite
Count)
$ 34 – $ 38
$12
9000
SW
Freeway,
180
7580
Fannin,
Suite
101
21238
Kingsland
LOCATION
Hepatitis
Acute
(ABC)
Panel
$180
–
$249
$77
Routine Venipuncture
$ 15.00
Houston,
TX 77074
Houston, TX 77054
Katy, TX 77450$ 3
374 College Park Drive
Basic
Metabolic Panel
$ 38 – $ 52 The Woodlands, TX $13
(713)
771-9667
(713) 791-9252
(281) 647-6677
77384
Monday
- Friday, 7:30am Metabolic
- 5:30pm
Monday
Monday - Friday, 9:00am - 5:00pm
Comprehensive
Panel - Wednesday, 8:00am - 5:30pm
$ 52 – $ 72 (936) 271-5643 $17
Saturday, 9:00am - 3:00pm
Thursday - Friday, 8:00am - 4:30pm
(closed daily for lunch - 1:00pm - 1:30pm)
Common Test
9889 Bellaire Blvd., Suite 103
HIV-1TX 77036
Houston,
SUGAR LAND, TEXAS LOCATION
(713)
777-7966
3531 Town Center Blvd., #101
Drug
Screen, Qualitate/Multi
Monday - Friday, 10:00am - 6:00pm Sugar Land, TX 77479
Urinalysis
(Inside
Urgent Care)
(281) 242-0571
CBC (Complete Blood Count)
Routine Venipuncture
$165
$236
DDS
Cash–Price
SPRING, TEXAS LOCATION
(Inside Integra
Medical
Normal Fee Range
DDS
CashClinic)
Price
26222 Interstate 45
$
70
–
$103
$14
North Spring, TX 77386
(281) 419-9320
$ 78 – $129
$18
$
14
–
$
16
$ 4
(Inside Doctor D’s Urgent Care)
DDS Imaging Price Schedule with Rice Diagnostics*
$ 34 – $ 38
$ 15.00
$12
$ 3
YOUR HEALTH LAB — 7 Locations To Serve You
MRI - $400
without
Contrast
Range: $1300 - $4500
SOUTHWEST HOUSTON LOCATION
MEDICAL
CENTER
SUGAR LAND, TEXASNormal
LOCATION
SPRING/WOODLANDS, TEXAS LOCATION
$500
with Contrast
Normal
$6000Interstate 45 North
9000 SW Freeway, Suite 180
HOUSTON
LOCATION
3531 Town Center Blvd.,
#101 Range: $2000 - 26222
CT Scan -7580
$350Fannin,
without
Houston, TX 77074
SuiteContrast
101
Sugar Land, TX 77479 Normal Range: $800 - $1200
Spring, TX 77386
(713) 771-9667
TX 77054
(281) 242-0571
(281) 419-9320
CT Scan -Houston,
$400 with
Contrast
Normal Range: $900 - $2000
Monday – Friday, 7:30am – 5:30pmX Ray - $40
(713) 791-9252
Monday – Friday, 9:00am
– 5:00pm
Monday – Friday, 8:00am – 5:00pm
Normal
Range: $ 80 - 140
Saturday, 9:00am – 3:00pm
Monday – Wednesday, 8:00am – 5:30pm
6MUSBTPVOE"CEPNFO$PNQMFUF
/PSNBM3BOHF (Inside Doctor D’s Urgent Care)
Thursday – -Friday,
– 4:30pm
KATY, TEXAS LOCATION
Nuclear medicine
$4508:00am
- BoneScan
Normal Range: $900 - $3000
9889 Bellaire Blvd., Suite 103
(closed daily for lunch –
21238 Kingsland
374 College Park Drive
(Includes
interpretation
by
Radiologists,
and
is
included
in
prices
above.)
Houston, TX 77036
1:00pm – 1:30pm)
Katy, TX 77450
The Woodlands, TX 77384
* Doctors’ Order Needed
(713) 777-7966
(281) 647-6677
4-PPQ8FTU4VJUF)PVTUPO59t
(Inside Urgent Care)
(936) 271-5643
(Inside Integra Medical Clinic)
WellnessShieldTM
National Laboratory Services
800-908-0000
What is Direct Labs?
Discount Details:
Substantial Savings On
All Laboratory Services!
The earlier a problem is detected, the easier and more
likely that it is treatable. Managed care companies as
well as Medicare and Medicaid have refused to pay
for blood tests without symptoms of disease – which
eliminates wellness testing for most people.
Type of Blood Test
Comprehensive
Wellness Profile
Thyroid Panel w/TSH
PSA
Retail Price Your Price Your Savings
$529
$548
$220
$220
$107
$107
$77.00
$77.00
$36.00
$36.00
$39.00
$39.00
$452.00
$471.00
$184.00
$184.00
$ 68.00
1. Call 800-908-0000, press “0”.
2. You must indicate
indicateour
ourgroup
groupname,
name, “Careington”,
Dorsey
Services.
offeredDiscount
by “Dorsey
Discount Services”.
3. For your lab work to be discounted, it must be
ordered through Direct Laboratory Services, (DLT)
and not drawn at the doctor’s office. You do not
need a doctor’s prescription to order this series
of tests. However, if your doctor does give you a
prescription for the tests, fax or call it in to Direct
Laboratory Services, (DLT).
4. Direct Laboratory Services, (DLT) will send
you a requisition form and refer you to the closest
lab in your area.
5. DO NOT GO TO THE LAB WITHOUT THE
DISCOUNT LAB TEST REQUISITION FORM IN HAND.
WellnessShieldTM
Nutritional Supplements
Swanson Health Products
800-437-4148
About Your Savings:
Swanson Health Products partners with
Dorsey Discount Services to bring Members
the best available product.
Lee Swanson, President of Swanson Health
Products, and Michael Stern, CEO of DDS, work
together to help people become healthier and in
better shape, and one of the first ways to assure
this is to help members afford the best vitamins
and supplements in the world.
Swanson Health Products sells discount vitamins
and supplements, organic foods, natural skincare
products, homeopathic remedies and more at
the lowest possible prices. We guarantee it—we
guarantee our prices, our service and our quality.
“Besides treating our customers
well,” said Lee, “we are in the
unique position of being able to
offer products direct to customers
without going through a middleman. Because of that fact, we are
Lee Swanson,
President,
able to save customers 50% to
Swanson Health Products
70% on their nutritional supplement
expenditures. And those savings are on some of the
highest quality products in the world. We bend over
backwards to bring the finest ingredients to our
customers at the best prices possible.”
Swanson sells directly to YOU, taking out the
middleman. Your savings are from 50% to 70% on
their nutritional supplements for some of the highest
quality products in the world.
As a WellnessShieldTM Member, your savings are even
GREATER! When ordering your supplements, give
your member code for an additional 10% Savings!
Michael Stern,
Founder & CEO,
Dorsey Discount Services
Michael states, “Swanson Health
Products and DDS have joined forces to
bring about positive change in health
care services and costs. Our savings
plans not only save money and time
but also provide access to one-on-one
support.”
With this Great Team, YOU reap the benefits!
How To Use This Service:
Your new Swanson Health Products Services are easy to access. Call 800-437-4148 and use the term: “Partners’
Promotional Code is SWAN 709”, to get the additional 10% savings!
Go to website at www.swansonvitamins.com to see the many items offered!
WellnessShieldTM
Chiropractic and Alternative Medical Network
DDS Alternative Provider Network
Local Providers for Natural Health Care
t
t
t
t
4FMFDUZPVSQSPWJEFSBOEDBMMUPNBLFBOBQQPJOUNFOU4UBUFZPVSOBNFBOE8FMMOFTT4IJFMETM member ID number.
"SSJWFNJOVUFTFBSMZGPSZPVSöSTUBQQPJOUNFOU
*GZPVNVTUDBODFMZPVSBQQPJOUNFOUDBMMIPVSTJOBEWBODFUPBWPJEBCSPLFOBQQPJOUNFOUDIBSHF
1BZUIFEJTDPVOUFEGFFTBUUIFUJNFPGUIFUSFBUNFOU%JTDPVOUTSBOHFCFUXFFO.JOJNVNGFF
CHIROPRACTORS
Greg Alexander, DC
16116 Stuebner-Airline Road
Spring, TX 77379
(281) 367-2225
www.activator.com
Woodway Wellness
Terry A. Smedstead, DC
J. D. Haynes, DC
4801 Woodway, Suite 175E
Houston, TX 77056
(713) 622-2225
www.woodwaywellness.com
Delgado Chiropractic Center
Alan E. Delgado, DC
3810 Fairmont Parkway, Suite H
Pasadena, TX 77504
(281) 487-3999
Durett Chiropractic and
Natural Health Care Clinic
Sherry Durrett, DC, DPHCS, LCP, FASA
Cheryl West Hinds, DC
7036 FM 1960
Houston, TX 77090
(281) 444-1000
www.drdurrett.com
Dr. Jamie Marshall
33300 Egypt Lane, Suite B-400
Magnolia, TX 77354
(281) 789-4182
Back to You Mobile Chiropractic Care
Stuart B Holifield, DC
Houston Location:
2646 S Loop (610) West #255
Houston, TX 77004
(832) 264-5425
Leo Grim
1406 Vermont Street
Houston, TX 77006
(713) 522-6336
leogrim@wholehealthassoc.com
GALVESTON LOCATION:
2311 Ave. N1/2
Galveston, TX 77550
(832) 264-5425
www.bck2you.com
Institute for Physical
and Alternative Medicine
Lance Durrett
26603 I-45
(281) 367-6900
Complete Care Chiropractic
and Wellness Center
BAY AREA LOCATION:
Arlan Hill, DC, NPH, DACBN
560 Blossom St. #B
Webster, TX 77598
(281) 557-7200
(713) 962-2418
Woodlands Pain Relief Center
Rob A. Mayer, DC PA
25301 Interstate 45 N.
(281) 363-2182
WEST HOUSTON LOCATION:
6750 W. Loop S. #420
Bellaire, TX 77401
(713) 962-2418
www.gcih.net
The Hayden Institute
Dr. Chase Hayden
11455 Fallbrook Dr. #301A
Houston, TX 77380
(281) 367-6900
chase@haydeninstitute.com
Southerland
Chiropractic & Wellness
Dale Sutherland
3206 Manvel Road (FM 1128)
Pearland, TX
(281) 997-8788
West University Wellness
Sherman Yeager. DC
5180 Buffalo Speedway
Houston, TX 77005
(713) 490-2225
www.westuwellness.com
2
WellnessShieldTM
Chiropractic and Alternative Medical Network
DDS Alternative Provider Network
Local Providers for Natural Health Care (continued)
Conroe Family Chiropractic
Dr. H. Kala Eulitt
3401 W. Davis, Ste. A-2
Conroe, TX 77304
(936) 494-1222
THE JOINT –
THE CHIROPRACTIC PLACE
1st Visit - $19
4 visits per month - $49 (approximately
12.50 per visit)
Numerous Locations opening in 2012
Call for information 800-880-4343
Current Locations:
Bunker Hill
9778 Katy Frwy., Ste. 325
Houston TX 77055
(713) 461-5030
River Oaks
2621 Shepherd, Ste. 145
Houston TX 77098
(713) 520-5030
Cy-Fair
12020 FM 1960 W
Houston, Texas 77065
(281) 517-0800
Katy
19740 Katy Freeway
Houston TX 77094
(281) 398-3700
2
NUTRITIONISTS
WEIGHT LOSS PROGRAM
Cynthia Tait
1406 Vermont
Houston, TX 77006
(713) 522-6336
Better Body for Me
Rick Goltz
3091 College Park Dr., Suite 190
The Woodlands TX 77384
(281) 236-7012
NATUROPATHS
Holistic Health Alternatives
Dawn Ewing PhD, CTN, CCT, CNM
17207 Kuykendall #151
Houston, TX 77379
(281) 251-4411
www.drdawn.net
Nutritional Transitions
Nettie Ramsay ND
10819 Sugar Hill Drive
Houston, TX 77042
(281) 794-5255
www.nutrans.net
Today’s Health Matters
Lyn F. Wagner
22503 Katy Freeway #5
Katy, TX 77450
(281) 687-2181
Atwell Medical Center
Dr. Vadas
6915 Atwell Dr.
Houston, TX 77081
(713) 664-7800
Cleo Phillips, ND
29903 Hawthorne Drive
Spring, TX 77386
(281) 788-7939
THERMOGRAPHY
Holistic Health Alternatives
Dawn Ewing PhD, CTN, CCT, CNM
17207 Kuykendall #151
Houston, TX 77379
(281) 251-4411
www.drdawn.net
WellnessShieldTM
Free Annual Comprehensive Blood Study
Free Annual Blood Study
800-908-0000
What
Our
Comprehensive
Wellness
Profile?
About is
Your
Free
Annual Comprehensive
Blood
Study
Prevention
Preventionisisthe
thekey
keytotoreform
reformthe
theU.S.
U.S.health
healthcare
care
system.
system.A A“treatment-oriented
“treatment-orientedsystem”
system”will
willcontinue
continue to
to
escalate
escalatehealth
healthcosts
costsbeyond
beyondour
ourreach.
reach.Prevention
Prevention saves
lives
solives
takeso
charge
of yourofhealth!
You now
saves
take charge
your health.
Youhave
nowa lifeTM
have aoption
life saving
option
you.
With your
saving
available
toavailable
you. Withtothis
WellnessShield
TM
you may
advantage
WellnessShield
Plan,
you may takePlan,
advantage
oftake
a Free
Annual of a
free
Annual
Wellness
Test
valued
at
over
Comprehensive Blood Study with almost$529.
50 tests. One
OneBlood
Wellness
Profile
per adult
per year,
a
Free
Study
per adult
per year,
withwith
a maximum
of
maximum
of two
perStudy
family.Panels included:
two
per family.
Blood
LiverPanel
1.1.Liver
2.
KidneyPanel
2. Kidney
CBC’s
3.3.Complete
Blood Count (CBC) Panel
Electrolytes& Fluids Panel
4.4.Electrolytes
Glucose
5.5.Blood
Glucose (Diabetes) Test
6.
Bones
6. Bones & Minerals Panel
Minerals
7.7.Thyroid
w/TSH Panel
LipidPanel
Panels
8.8.Lipid
Labreport
reportofofblood
bloodtest
testresults
results
9.9.Lab
Discount Details:
1. Call 800-908-0000, press “0”.
2. You must indicate our group name, “Careington”,
offered by “Dorsey Discount Services”.
3. For your lab work to be discounted, it must
be ordered through Direct Laboratory Services,
(DLT) and not drawn at the doctor’s office.
You do not need a doctor’s prescription to
order this series of tests.
However, if your doctor does give you a
prescription for the tests, fax or call it in to
Direct Laboratory Services, (DLT).
you a requisition form and refer you to the
closest lab in your area.
DISCOUNT LAB TEST REQUISITION FORM
IN HAND.
Not Available in Hawaii, New Jersey, New York, Rhode Island, Vermont, Montana & Washington.
2
WellnessShieldTM
800-908-0000
What is Direct Labs?
Discount Details:
Substantial Savings On
All Laboratory Services!
The earlier a problem is detected, the easier and more
likely that it is treatable. Managed care companies as
well as Medicare and Medicaid have refused to pay
for blood tests without symptoms of disease – which
eliminates wellness testing for most people.
Type of Blood Test
Comprehensive
Wellness Profile
Thyroid Panel w/TSH
PSA
2
Retail Price Your Price Your Savings
$529
$548
$220
$220
$107
$107
$77.00
$77.00
$36.00
$36.00
$39.00
$39.00
$452.00
$471.00
$184.00
$184.00
$ 68.00
1. Call 800-908-0000, press “0”.
2. You must indicate our group name, “Careington”,
offered by “Dorsey Discount Services”.
3. For your lab work to be discounted, it must be
ordered through Direct Laboratory Services, (DLT)
and not drawn at the doctor’s office. You do not
need a doctor’s prescription to order this series
of tests. However, if your doctor does give you a
prescription for the tests, fax or call it in to Direct
Laboratory Services, (DLT).
you a requisition form and refer you to the closest
lab in your area.
DISCOUNT LAB TEST REQUISITION FORM IN HAND.
Your Houston Gold PlanTM Membership
Book
From Our
Family
To Yours.
Houston
34
Hou WS G
05/12
Dorsey Discount Services
P.O. Box 683006
Houston, TX 77268

Houston Prevention Advantage Plan Book

Transcription

Similar documents

Brochure

Flyer-9300_Synott

Special Thanks to the participating RESTAURANTS

Woodway Collection

city of houston_case study

Greater Houston Port Bureau, Capt. Bill Diehl

GranQuartz

DiverseWorks presents L`esprit de l`escalier June 29 – August 17

Happy Hour - Houston Metropolitan Chamber of Commerce

Houston Rap Tapes