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SOUTHERN CALIFORNIA DRUG BENEFIT FUND
SUMMARY OF THE PLATINUM AND GOLD PLANS
As of January 1, 2020 ThisdocumentisintendedmerelyasasummaryoftheGoldandPlatinumhealthcareplansofferedbytheSouthernCaliforniaDrugBenefitFund. Forexclusionsandrestrictions,you
shouldreadtheSummaryPlanDescriptionandtheevidenceofcoveragebookletsprovidedbyKaiser,UnitedHealthcare(formerlyPacifiCare),andUnitedConcordia.
OE2020–Platinum/GoldPlan
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SOUTHERN CALIFORNIA DRUG BENEFIT FUND SUMMARYOFTHEPLATINUMANDGOLDPLANSASOFJANUARY1,2020
SECTION PAGE
CONTACT INFORMATION.......................................................................................................................................................................1ELIGIBILITYRULES.........................................................................................................................................................................2
ELIGIBILITYREQUIREMENT...........................................................................................................................................................2WORKINGSPOUSERULE.............................................................................................................................................................2
DEATHBENEFITS...........................................................................................................................................................................2MEDICALBENEFITS.......................................................................................................................................................................3
HOSPITALBENEFIT.....................................................................................................................................................................6PROFESSIONALSERVICES.............................................................................................................................................................8MENTALHEALTHANDSUBSTANCEABUSEBENEFITS.........................................................................................................................11MEDICALSUPPLIESANDEQUIPMENT.............................................................................................................................................11OTHERSERVICESANDBENEFITS...................................................................................................................................................12
PRESCRIPTIONDRUGBENEFITS....................................................................................................................................................12DENTALBENEFITS.........................................................................................................................................................................13PLANEXCLUSIONS........................................................................................................................................................................14
ThisdocumentisintendedmerelyasasummaryoftheGoldandPlatinumhealthcareplansofferedbytheSouthernCaliforniaDrugBenefitFund. Forexclusionsandrestrictions,youshouldreadtheSummaryPlanDescriptionandtheevidenceofcoveragebookletsprovidedbyKaiser,UnitedHealthcare(formerlyPacifiCare),andUnitedConcordia.
OE2020–Platinum/GoldPlan
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SOUTHERN CALIFORNIA DRUG BENEFIT
ThisdocumentisintendedmerelyasasummaryoftheGoldandPlatinumhealthcareplansofferedbytheSouthernCaliforniaDrugBenefitFund. Forexclusionsandrestrictions,youshouldreadtheSummaryPlanDescriptionandtheevidenceofcoveragebookletsprovidedbyKaiser,UnitedHealthcare(formerlyPacifiCare),andUnitedConcordia.DescriptionandtheevidenceofcoveragebookletsprovidedbyKaiser,UnitedHealthcare(formerlyPacifiCare),andUnitedConcordia.OE2020–Platinum/GoldPlan Page1of15
SUMMARYOFTHEPLATINUMANDGOLDPLANSASOFJANUARY1,2020
CONTACT INFORMATION
TrustFundOffice 877-999-8329 www.ufcwdrugtrust.org AnthemBlueCrossPrudentBuyer 800-227-3641 www.anthem.com/ca/home.html BlueCard 800-810-2583(800-810-BLUE) www.bcbs.com DeltaDental 800-765-6003 www.deltadentalins.com HMCHealthWorks 866-268-2510 https://hmc.personaladvantage.com (AccessCode:SCDBF) Kaiser 800-464-4000 www.kp.org OptumRx 800-788-7871 www.optumrx.com PodiatryPlan,Inc. 800-367-7762 www.podiatryplan.com UnitedConcordia 800-937-6432 www.unitedconcordia.com UnitedHealthcare (UHC) 800-624-8822 www.MyUHC.com
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SOUTHERN CALIFORNIA DRUG BENEFIT
ThisdocumentisintendedmerelyasasummaryoftheGoldandPlatinumhealthcareplansofferedbytheSouthernCaliforniaDrugBenefitFund. Forexclusionsandrestrictions,youshouldreadtheSummaryPlanDescriptionandtheevidenceofcoveragebookletsprovidedbyKaiser,UnitedHealthcare(formerlyPacifiCare),andUnitedConcordia.DescriptionandtheevidenceofcoveragebookletsprovidedbyKaiser,UnitedHealthcare(formerlyPacifiCare),andUnitedConcordia.OE2020–Platinum/GoldPlan Page2of15
ELIGIBILITY RULES
SUMMARYOFTHEPLATINUMANDGOLDPLANSASOFJANUARY1,2020
ELIGIBILITYREQUIREMENT AllEmployees Onceyouareeligible,youmustcontinuetoworktheQualifyingHoursduringeachmonthtomaintainyoureligibility,toestablisheligibilityfor
otherbenefits,andtoestablishand/ormaintaineligibilityforyourDependents.Youarealsorequiredtopaymonthly(orweekly)contributions(alsocalled“premiums”)inordertomaintainyourcoverage.
EmployeeContribution/EmployeePremium
AllEmployeesarerequiredtopaypremiumstowardsthecostofcoverage.Thesepremiums(alsocalled“EmployeeContributions”)willgenerallybepaidviapayrolldeduction(self-paywillbeavailableforparticipantsforwhomapayrolldeductionisnottaken).YoumustcompleteanauthorizationformtoallowyourEmployertodeductyourcontributionamountandpayittotheFund.MonthlyEmployeecontributionsmustbepaidbytheendofthemonthbeforethemonthofcoverage.Forexample,forcoverageinJuly,yourcontributionmustbepaidbytheendofJune.Ifyourcontributionsarenottimelypaid,youwilllosecoverage.
Theamountofyourmonthlycontributionisasfollows:Ø $30.33permonth($7perweek)forEmployee-onlycoverage.Ø $47.67permonth($11perweek)forEmployeeplusoneormorechildren.Ø $65.00permonth($15perweek)forEmployeeplusspouseorDomesticPartner,withorwithoutchildren.
Note: Youarepermittedtoopt-outofdentaland/orvisioncoverageforyourselfandyourfamily. However,droppingyourdentaland/orvisioncoveragewillnotreduceyourEmployeepremium. ContacttheFundOfficeformoreinformation.
WORKINGSPOUSERULE WorkingSpouseRule(alsoapplicabletoDomesticPartners)
FormarriedEmployeesandEmployeeswithDomesticPartners(theuseoftheterm“spouse”inthissectionincludesDomesticPartners): Ifyourspouse’semployeroffershealthcarecoverage,yourspousemustenrollinthatemployer’scoveragethatiscomparabletoyourcoverageunderthisFund,evenifyourspouseisrequiredtocontributetowardthecostofthatcoverage. Ifyourspouse’semployerdoesnotoffercoveragethatiscomparabletoyourcoveragefromtheFund,yourspousemustenrollinthebestcoverageavailablethroughhisorheremployer.Ifyourspouseiseligibleformedical,prescriptiondrug,dental,and/orvisionbenefitsthroughhisorheremployerbutfailstoenroll,thisPlanwillpayonly40%ofitsnormalbenefits(i.e.thisPlanwillreduceitspaymentamountby60%)undertheIndemnityMedicalPlan,PrescriptionDrugPlanand/orIndemnityDentalPlan.
ThisruledoesnotapplyifbothspousesareeligibleforcoverageasEmployeesofcontributingEmployersandonespousehaselectedcoveragefor“EmployeeplusspouseorDomesticPartner”. PleasecontacttheFundOfficeformoreinformation.
DEATH BENEFITS
Employee Greaterof$15,000ortheamountofsalaryreceivedduringthemostrecent12months. Dependent $2,000
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ThisdocumentisintendedmerelyasasummaryoftheGoldandPlatinumhealthcareplansofferedbytheSouthernCaliforniaDrugBenefitFund. Forexclusionsandrestrictions,youshouldreadtheSummaryPlanDescriptionandtheevidenceofcoveragebookletsprovidedbyKaiser,UnitedHealthcare(formerlyPacifiCare),andUnitedConcordia.DescriptionandtheevidenceofcoveragebookletsprovidedbyKaiser,UnitedHealthcare(formerlyPacifiCare),andUnitedConcordia.OE2020–Platinum/GoldPlan Page3of15
SOUTHERN CALIFORNIA DRUG BENEFIT SUMMARYOFTHEPLATINUMANDGOLDPLANSASOFJANUARY1,2020
2202020 MEDICAL BENEFITS
INDEMNITYPLAN UNITEDHEALTHCARE(UHC)FLEXHMO
KAISER
PPO (In Network) Non-PPO (Out of Network) HowthePlanworks
Generally,youmustsatisfytheCalendarYearDeductible(“Deductible”)beforethePlanpaysanybenefits. TheexpensesyoupayforusingaPPOprovider,exceptcopaysforofficevisitsandhospitalstays,willapplytowardthePPODeductible. Theexpensesyoupayforusinganon-PPOprovider,exceptforcopaysforhospitalstaysandchargesthatexceedtheAllowedAmounts,willapplytowardthenon-PPODeductible.AftertherequiredDeductibleissatisfied,thePlangenerallypays80%ofContractRates1ifyouuseaPPOproviderand50%oftheAllowedAmount2ifyouuseanon-PPOprovider.Forsomeservicesandsupplies,specificdollarlimitsareimposedthatcouldresultintheFundpayinglessthanthesepercentages.
Foreachhospitalstay,youmustfirstpaya$100copay.WhenyouuseaPPOfacility,youareresponsiblefor20%oftheremainingContractRatesafterthePlanpays80%ofthebalance. Whenyouuseanon-PPOfacility,thePlanpays50%oftheAllowedAmount,andyouareresponsiblefortheremaining50%oftheAllowedAmountplusanychargesthatexceedtheAllowedAmount.
PPOofficevisitsarenotsubjecttotheDeductible.ThePlanpays100%oftheContractRatesafteryoupaya$20copaypervisit. WhenyouuseaPPOproviderforpreventiveandwellnessservices,thePlanwillpay100%ofContractRatesforallofthepreventivecareandimmunizationserviceslistedinthePlan’scurrentPreventiveCareGuidelines(availablefromtheFundOffice).ThereisnoDeductibleandnocopayaslongasthepreventiveservicesarereceivedfromPPOproviders.
ForotherPPOservices,onceyourtotalmedicalout-of-pocketexpenseshavereachedtheCalendarYearOut-of-PocketMaximum(“OOPMax”),thePlangenerallywillpay100%ofContractRatesfortheremainderofthecalendaryear. YourDeductibleandcertainotherexpensesdonotcounttowardtheOOPMax.
Thereisnolimitonout-of-pocketexpenseswhenyouusenon-PPOProviders.
TheUHCFlexHMOoffersachoiceofthreeNetworks.YouandyourfamilymembersmustbeenrolledinthesameNetwork. YoumayonlychangeyournetworkduringOpenEnrollment(unlessyouoraDependenthascertainspecialenrollmentrights).
ForallNetworks,yougenerallymustsatisfytheCalendarYearDeductible(“Deductible”)beforetheplanpaysanybenefits.TheDeductibleis$500perindividual($1,000perfamily).
Theamountyoupayforservicesdependsonthenetworkyouchoose.YoupaythelowestifyouchooseNetwork1. Network2andNetwork3havehighercopaymentsandcoinsurance.
Formostofficevisits,youpayacopayment.Forotherservices,youwillpayapercentageofCoveredCharges.3
Preventivecareservices,suchasyourannualphysicalexams,arecoveredat100%withnocopayandarenotsubjecttotheDeductible.
OnceyouhavepaidtheCalendarYearOut-of-PocketMaximum(“OOPMax”),allcarefromUHCwillgenerallybecoveredinfull.Youmustkeeprecords(receipts)ofyourcopaysandcoinsurancetoprovideasprooftoUHCthatyouhavereachedyourOOPMax.
Formostservices,youpayacopayeverytimeyouusetheservice. However,hospitalstaysandoutpatientsurgeryaresubjecttoaCalendarYearDeductible(“Deductible”).
Forhospitalstaysandoutpatientsurgeries,onceyouhavesatisfiedtheDeductible,Kaiserwillgenerallypay80%ofCoveredCharges3;youareresponsiblefortheremaining20%. Specificcopays,coinsuranceanddeductibleamountsareoutlinedbelow.
Onceyourout-of-pocketexpensesreachtheCalendarYearOut-of-PocketMaximum(“OOPMax”),allcarewillgenerallybecoveredinfullfortheremainderoftheCalendarYear.
Youmustkeeprecords(receipts)ofyourcopaysandcoinsurancetoprovideasprooftoKaiserthatyouhavereachedyourOOPMax.
1 TheamountthatthePPOProvider (PrudentBuyerNetworkortheBlueCardProgram)hasagreedbycontract toacceptforservicesprovided.
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ThisdocumentisintendedmerelyasasummaryoftheGoldandPlatinumhealthcareplansofferedbytheSouthernCaliforniaDrugBenefitFund. Forexclusionsandrestrictions,youshouldreadtheSummaryPlanDescriptionandtheevidenceofcoveragebookletsprovidedbyKaiser,UnitedHealthcare(formerlyPacifiCare),andUnitedConcordia.DescriptionandtheevidenceofcoveragebookletsprovidedbyKaiser,UnitedHealthcare(formerlyPacifiCare),andUnitedConcordia.OE2020–Platinum/GoldPlan Page4of15
SOUTHERN CALIFORNIA DRUG BENEFIT SUMMARYOFTHEPLATINUMANDGOLDPLANSASOFJANUARY1,2020
2202020 MEDICAL BENEFITS
INDEMNITYPLAN UNITEDHEALTHCARE(UHC)FLEXHMO
KAISER
PPO (In Network) Non-PPO (Out of Network) PreferredProviderNetwork(PPO)
IfyouliveinCalifornia,yourpreferredprovidernetwork(“PPO”)istheAnthemBlueCrossofCaliforniaPrudentBuyernetwork.
IfyouoryourdependentsliveoutsideofCalifornia,orifyouaretravelingoutsideCalifornia,yourPPOnetworkofhospitalsanddoctorsistheNationalBlueCardnetwork. TheBlueCardnetworkisavailableinall50states.
YouarestronglyencouragedtouseaPPOprovider. ThePlanpaysahigherlevelofbenefitswhenyouuseaPPOphysicianorhospital. YoumaychoosetousehospitalsandphysicianswhodonotbelongtothePPOnetworks. However,thePlanpaysalowerlevelofbenefitsfornon-PPOproviders,andyouwillhavehigherout-of-pocketexpenses.TofindaPPOprovidernearestyou,callAnthemBlueCrossPrudentBuyerat800-227-3641orBlueCardAccessat800-810-BLUE.
TherearethreenetworkchoiceswiththeUHCFlexHMO,Network1,2,or3.Youandallofyourfamilymembersmustbeenrolledinthesamenetwork.Onceanetworkischosen,youandyourfamilymemberswillhaveaccessonlytoProvidersinthatnetwork.Eachfamilymembermayindividuallyselectaprimarycarephysician(“PCP”)withinthechosennetwork.
IfyoudonotlivewithintheserviceareaoftheFlexHMO,i.e.,ifyoudonothaveaccesstoaPCPfromNetworks1,2,or3,youwillparticipateandchooseaPCPfromtheSignatureValueAdvantageNetwork.YourbenefitswillbethesameasthoseunderNetwork1.
ServicesrenderedbyaProviderwhoisnotinyourchosennetworkarenotcovered. Ifanemergencyoccurs,emergencyproceduresandbenefitsapply.
YoumustuseKaiserproviders. Servicesrenderedbynon-Kaiserprovidersarenotcovered.
Ifanemergencyoccurs,emergencyproceduresandbenefitsapply.
PreauthorizationandUtilizationReview
WhenPreauthorizationorUtilizationReviewisrequired,yourdoctororhospitalmustcontactPrudentBuyer/BlueCardat800-274-7767. PPOhospitalswilldothisautomatically.Youshouldconfirmthatyourotherproviders,includingnon-PPOhospitals,havedonethis.
SeeUHC’sEvidenceofCoverage SeeKaiser’sEvidenceofCoverage.
2 Inmostcases, theAllowedAmount istheallowance thattheFundhasdetermined isanappropriate payment fortheMedically Necessary service(s) rendered totheparticipant intheprovider's geographic area.Where theprovider's charge islessthantheFund'sallowance fortheservice(s) provided, theAllowedAmount istheprovider's billedamount. TheBoardofTrustees, oritsdesignee, hasdiscretion todetermine theAllowedAmount.
3 TheamountthattheHMOhasdetermined tobeanappropriate charge fortheserviceprovided.
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ThisdocumentisintendedmerelyasasummaryoftheGoldandPlatinumhealthcareplansofferedbytheSouthernCaliforniaDrugBenefitFund. Forexclusionsandrestrictions,youshouldreadtheSummaryPlanDescriptionandtheevidenceofcoveragebookletsprovidedbyKaiser,UnitedHealthcare(formerlyPacifiCare),andUnitedConcordia.DescriptionandtheevidenceofcoveragebookletsprovidedbyKaiser,UnitedHealthcare(formerlyPacifiCare),andUnitedConcordia.OE2020–Platinum/GoldPlan Page5of15
SOUTHERN CALIFORNIA DRUG BENEFIT SUMMARYOFTHEPLATINUMANDGOLDPLANSASOFJANUARY1,2020
2202020 MEDICAL BENEFITS
INDEMNITYPLAN UNITEDHEALTHCARE(UHC)FLEXHMO
KAISER
PPO (In Network) Non-PPO (Out of Network) CalendarYearDeductible(“Deductible”)
$500perperson,$1,000perfamily;maynotbesatisfiedbyofficevisitorhospitalcopays.
PlatinumPlan:$1,000perperson,$2,000perfamily;GoldPlan:$2,000perperson,$4,000perfamily;maynotbesatisfiedbyhospitalcopaysorchargesthatexceedtheFund'sAllowedAmounts.
$500perperson,$1,000perfamilyCertainserviceswillnotbecovereduntilyoumeetyourDeductible.TheDeductibleappliestomanyservices,includingmostinpatientservicesandoutpatientsurgery.Itdoesnotapplytopreventivecare,someoutpatientservices,andemergencyorurgentcareservices.OnlyamountsincurredforcoveredservicesthataresubjecttotheDeductiblewillcounttowardstheDeductible.SeeyourEvidenceofCoveragefromUHCformoreinformation.
$500perperson,$1,000perfamily.Appliestomostservices.Notapplicabletodoctor’sofficevisitsandpreventivecare.SeeKaiser’sEvidenceofCoverageformoreinformation.
OnlyamountsincurredforcoveredservicesthataresubjecttotheDeductiblewillcounttowardstheDeductible.
PlanCoinsuranceandParticipantCoinsurance
AfteryouhavesatisfiedtheDeductible,thePlanpays80%ofContractRatesformostservices.Youareresponsiblefortheremaining20%ofContractRates.Refertoeachbenefitbelowforexceptions.Formostservices,thePlanwillpay100%ofContractRatesafteryoureachthemedicalout-of-pocketmaximumforthecalendaryear.
AfteryouhavesatisfiedtheDeductible,thePlanpays50%oftheAllowedAmountformostservices.Youareresponsibleforthebalanceoftheproviderbill.Non-PPOprovidersoftenchargemorethanthePlan’sAllowedAmount.Whenthathappens,youareresponsiblefor50%oftheAllowedAmountand100%ofanychargesthatexceedtheAllowedAmount.
AppliestoInpatientHospitalizationandoutpatientsurgery.AfteryousatisfytheDeductible,UHCwillgenerallypay:
Network1:80%ofCoveredChargesNetwork2:75%ofCoveredChargesNetwork3:70%ofCoveredCharges.
Youareresponsiblefortheremaining20%-30%ofCoveredChargesuntilyoureachyourannualOut-of-PocketMaximum.
AftertheDeductible,Kaiserwillpay80%ofCoveredChargesforservicessubjecttoCoinsurance.Youareresponsiblefor20%coinsuranceuntilyoureachyourannualOut-of-PocketMaximum.
ServicessubjecttoCoinsuranceinclude,butarenotlimitedto,InpatientHospitalization,OutpatientSurgery,InpatientMentalHealth,InpatientChemicalDependencyandemergencyroomvisits.
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ThisdocumentisintendedmerelyasasummaryoftheGoldandPlatinumhealthcareplansofferedbytheSouthernCaliforniaDrugBenefitFund. Forexclusionsandrestrictions,youshouldreadtheSummaryPlanDescriptionandtheevidenceofcoveragebookletsprovidedbyKaiser,UnitedHealthcare(formerlyPacifiCare),andUnitedConcordia.DescriptionandtheevidenceofcoveragebookletsprovidedbyKaiser,UnitedHealthcare(formerlyPacifiCare),andUnitedConcordia.OE2020–Platinum/GoldPlan Page6of15
SOUTHERN CALIFORNIA DRUG BENEFIT SUMMARYOFTHEPLATINUMANDGOLDPLANSASOFJANUARY1,2020
2202020 MEDICAL BENEFITS
INDEMNITYPLAN UNITEDHEALTHCARE(UHC)FLEXHMO
KAISER
PPO (In Network) Non-PPO (Out of Network) MedicalOut-of-PocketMaximumPerCalendarYear(“OOPMax”)
AftertheDeductible,participantcoinsuranceandcopaysaccumulatetoatotalOOPMaximumof$2,000perperson,$6,000perfamily(notincludingthedeductible).
Premiums,non-coveredexpenses,chargesinexcessofbenefitmaximums,andexpensesyoupayforprescriptiondrugs,visioncare,dentalcare,hearingaids,chiropracticandacupuncturedonotcounttowardstheOOPMaxandarenotpaidbythePlanat100%intheeventyoureachtheOOPMax.
Nomaximum. $2,000perperson,$4,000perfamily(includesthedeductible).Premiums,non-coveredexpenses,chargesinexcessofbenefitmaximums,andcopaymentspaidforcertainCoveredServicesarenotapplicabletoaMember’sAnnualCopaymentMaximum(“OOPMax”);theseservicesarespecifiedintheScheduleofBenefits.PleaserefertoUHC’sScheduleofBenefitsformoreinformation.
Inaddition,expensesyoupayforhearingaids,andchiropracticandacupuncture(providedthroughtheFund),prescriptiondrugs,visioncare,anddentalcaredonotcounttowardstheOOPMax.
$2,000perperson,$4,000perfamily(includesthedeductible).
Premiums,non-coveredexpenses,chargesinexcessofbenefitmaximums,andexpensesyoupayforhearingaid,chiropracticandacupuncture(providedthroughtheFund),prescriptiondrugs,visioncare,anddentalcaredonotcounttowardstheOOPMax.
NoAnnualandLifetimeMaximum HOSPITALBENEFITS HospitalInpatientServices(includingRoomandBoardandAncillaryServices)
AftertheDeductibleand$100copayperadmission,thePlanpays80%ofContractRates.
PrudentBuyer/BlueCardprovidersareresponsibleforobtainingallPreauthorizationandUtilizationReview.
CopaydoesnotcounttowardDeductible.
AftertheDeductibleand$100copayperadmission,thePlanpays50%oftheAllowedAmount. Allhospitaladmissions,exceptforchildbirthoremergencyhospitalizations,mustbepreauthorizedbyPrudentBuyer/BlueCard.YoumustnotifyAnthemwithin72hoursofanemergencyadmission. Call800-810-BLUEforPreauthorization(outsideCalifornia).InCalifornia,call800-274-7767. BenefitswillbereducedifyoufailtoobtainPreauthorization.CopaydoesnotcounttowardDeductible.
AftertheDeductible,UHCpays:Network1:80%ofCoveredChargesNetwork2:75%ofCoveredChargesNetwork3:70%ofCoveredCharges
AftertheDeductible,Kaiserpays80%ofCoveredCharges
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ThisdocumentisintendedmerelyasasummaryoftheGoldandPlatinumhealthcareplansofferedbytheSouthernCaliforniaDrugBenefitFund. Forexclusionsandrestrictions,youshouldreadtheSummaryPlanDescriptionandtheevidenceofcoveragebookletsprovidedbyKaiser,UnitedHealthcare(formerlyPacifiCare),andUnitedConcordia.DescriptionandtheevidenceofcoveragebookletsprovidedbyKaiser,UnitedHealthcare(formerlyPacifiCare),andUnitedConcordia.OE2020–Platinum/GoldPlan Page7of15
SOUTHERN CALIFORNIA DRUG BENEFIT SUMMARYOFTHEPLATINUMANDGOLDPLANSASOFJANUARY1,2020
2202020 MEDICAL BENEFITS
INDEMNITYPLAN UNITEDHEALTHCARE(UHC)FLEXHMO
KAISER
PPO (In Network) Non-PPO (Out of Network) HospitalOutpatientFacilityCharges
AftertheDeductible,thePlanpays80%ofContractRates.
AftertheDeductible,thePlanpays50%oftheAllowedAmount.
AftertheDeductible,UHCpays:Network1:80%ofCoveredChargesNetwork2:75%ofCoveredChargesNetwork3:70%ofCoveredCharges
AftertheDeductible,Kaiserpays80%ofCoveredCharges.
SkilledNursingFacility(Medicareapproved)
AftertheDeductible,thePlanpays80%ofContractRates.
AftertheDeductible,thePlanpays50%oftheAllowedAmount.
AftertheDeductible,UHCpays:Network1:80%ofCoveredChargesNetwork2:75%ofCoveredChargesNetwork3:70%ofCoveredChargesLimitof100consecutivedaysperCalendarYearfromthefirsttreatmentperdisability.
Asprescribedatdesignatedfacilities.AftertheDeductible,Kaiserpays80%ofCoveredCharges. Limitedto100daysperbenefitperiod.
MustbepreauthorizedbyPrudentBuyer/BlueCard. Limitedto240daysperdisability.
PhysicianHospitalVisits
AftertheDeductible,thePlanpays80%ofContractRates.
AftertheDeductible,thePlanpays50%oftheAllowedAmount.
AftertheDeductible,UHCpays:Network1:80%ofCoveredChargesNetwork2:75%ofCoveredChargesNetwork3:70%ofCoveredCharges
AftertheDeductible,Kaiserpays80%ofCoveredCharges.
EmergencyRoomServices(Facility,PhysicianandAncillaryServices)
AftertheDeductible,thePlanpays80%ofContractRates.
AftertheDeductible,ifthepatienthasan“emergencymedicalcondition”,thePlanpays80%oftheAllowedAmount,otherwise50%oftheAllowedAmount.
Network1:$100copaypervisitNetwork2:$150copaypervisitNetwork3:$200copaypervisit
AftertheDeductible,Kaiserpays80%ofCoveredCharges.
DeterminationofPPOversusnon-PPOwillbemadebasedonthestatusofthehospital.
OutpatientSurgicalCenters
AftertheDeductible,thePlanpays80%ofContractRates.
AftertheDeductible,thePlanpays50%oftheAllowedAmount,uptoamaximumof$350peroperation.Anychargesinexcessofthis$350maximumdonotcounttowardtheDeductible.
AftertheDeductible,UHCpays:Network1:80%ofCoveredChargesNetwork2:75%ofCoveredChargesNetwork3:70%ofCoveredCharges
AftertheDeductible,Kaiserpays80%ofCoveredCharges.
MustbePreauthorizedbyPrudentBuyer/BlueCard.
Ambulance AftertheDeductible,thePlanpays80%ofContractRates/AllowedAmountifadmittedorifthedefinitionof“emergency”issatisfied;otherwise50%ofContractRates/AllowedAmount.
UHCpays100%ofcoveredcharges. AftertheDeductible,$150copaypertrip.
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ThisdocumentisintendedmerelyasasummaryoftheGoldandPlatinumhealthcareplansofferedbytheSouthernCaliforniaDrugBenefitFund. Forexclusionsandrestrictions,youshouldreadtheSummaryPlanDescriptionandtheevidenceofcoveragebookletsprovidedbyKaiser,UnitedHealthcare(formerlyPacifiCare),andUnitedConcordia.DescriptionandtheevidenceofcoveragebookletsprovidedbyKaiser,UnitedHealthcare(formerlyPacifiCare),andUnitedConcordia.OE2020–Platinum/GoldPlan Page8of15
SOUTHERN CALIFORNIA DRUG BENEFIT SUMMARYOFTHEPLATINUMANDGOLDPLANSASOFJANUARY1,2020
2202020 MEDICAL BENEFITS
INDEMNITYPLAN UNITEDHEALTHCARE(UHC)FLEXHMO
KAISER
PPO (In Network) Non-PPO (Out of Network) UrgentCare $20copaypervisit,notsubjectto
theDeductible.CopaydoesnotcounttowardDeductible.
AftertheDeductible,thePlanpays50%oftheAllowedAmount.
WithinYourMedicalGroup:Network1:$20copaypervisitNetwork2:$35copaypervisitNetwork3:$40copaypervisit
OutsideofYourMedicalGroup:Network1:$50copaypervisitNetwork2:$75copaypervisitNetwork3:$100copaypervisit
$20copaypervisit.
PROFESSIONALSERVICES PhysicianOfficeVisits(PrimaryCareandSpecialist)
$20copaypervisit,notsubjecttotheDeductible. CopaydoesnotcounttowardtheDeductible.
AftertheDeductible,thePlanpays50%oftheAllowedAmount.
Network1:$20copaypervisitNetwork2:$35copaypervisitNetwork3:$40copaypervisit
$20copaypervisit.
Surgeon,AssistantSurgeon,&Anesthetist
AftertheDeductible,thePlanpays80%ofContractRates.
AftertheDeductible,thePlanpays50%oftheAllowedAmount.
CoveredunderHospitalization. AftertheDeductible,Kaiserpays80%ofCoveredCharges.
PreventiveCareServices
Planpays100%ofContractRates,notsubjectto theDeductibleandnocopayisrequired.
AftertheDeductible,thePlanpays50%oftheAllowedAmount.
UHCpays100%ofCoveredCharges,notsubjecttocopayorDeductible.
Kaiserpays100%,notsubjecttocopayorDeductible.
Coverageisprovidedfortheservices,screeningsandexamslisted,andsubjecttothefrequencydescribed,intheFund’sPreventiveCareGuidelines.BreastpumpsmustbepurchasedandobtainedthroughaPPODurableMedicalEquipmentvendor,otherwisethereisnocoverage.
OutpatientX-rayandLaboratory
AftertheDeductible,thePlanpays80%ofContractRates.
AftertheDeductible,thePlanpays50%oftheAllowedAmount.
WhenavailablethroughandauthorizedbyyourParticipatingMedicalGroup,UHCpays100%
Formostx-raysandlabs:AftertheDeductible,$10copayperencounter.ForMRI,MostCT,PetScans:AftertheDeductible,$50copayperprocedure
SpeechTherapyVisits
$20copaypervisit,notsubjecttotheDeductible. Limitedto24visitspercalendaryear. Preauthorizationisrequired.
Notcovered. Network1:$20copaypervisitNetwork2:$35copaypervisitNetwork3:$40copaypervisit
AftertheDeductible,$20copaypervisit.
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ThisdocumentisintendedmerelyasasummaryoftheGoldandPlatinumhealthcareplansofferedbytheSouthernCaliforniaDrugBenefitFund. Forexclusionsandrestrictions,youshouldreadtheSummaryPlanDescriptionandtheevidenceofcoveragebookletsprovidedbyKaiser,UnitedHealthcare(formerlyPacifiCare),andUnitedConcordia.DescriptionandtheevidenceofcoveragebookletsprovidedbyKaiser,UnitedHealthcare(formerlyPacifiCare),andUnitedConcordia.OE2020–Platinum/GoldPlan Page9of15
SOUTHERN CALIFORNIA DRUG BENEFIT SUMMARYOFTHEPLATINUMANDGOLDPLANSASOFJANUARY1,2020
2202020 MEDICAL BENEFITS
INDEMNITYPLAN UNITEDHEALTHCARE(UHC)FLEXHMO
KAISER
PPO (In Network) Non-PPO (Out of Network) PhysicalTherapyVisits
AftertheDeductible,thePlanpays80%ofContractRates.Preauthorizationrequired.
AftertheDeductible,thePlanpays50%oftheAllowedAmount.Preauthorizationrequired.
Network1:$20copaypervisitNetwork2:$35copaypervisitNetwork3:$40copaypervisit
AftertheDeductible,$20copaypervisit.
SubjecttoUtilizationReviewbyPrudentBuyer/BlueCardforMedicalNecessity. Benefitpaymentislimitedtoamaximumof25visitspercalendaryear.
Injections AftertheDeductible,thePlanpays80%ofContractRates.
AftertheDeductible,thePlanpays50%oftheAllowedAmount.
Officevisitcopaymayapply. Officevisitcopaymayapply.
MustbesuppliedandadministeredbyPhysician’soffice. Self-injectablesarecoveredunderPrescriptionDrugbenefits.
ChiropracticCareandAcupuncture
NotsubjecttotheDeductible.Planpaysa$25.50benefitpervisit,nomorethanonevisitperday,uptoacombinedmaximumof$500percalendaryearforofficevisitsand$150percalendaryearforx-rayandlaboratory.
Notcovered. Notcovered.
ObesityBypassSurgery
CoveredundertheHospitalandSurgicalbenefitsifPreauthorizedasMedicallyNecessary.
CoveredunderNon-PPOHospitalandNon-PPOsurgicalbenefits(includingNon-PPOOutpatientSurgicalCenters)ifPreauthorizedasMedicallyNecessary.
CoveredifdeterminedMedicallyNecessaryandauthorized.
OrganandTissueTransplants
AftertheDeductible,thePlanpays80%ofContractRates.CoveredonlyiftransplantisperformedatanAnthemBlueCross-approvedCenterofExpertise,thetransplantrecipientisaPlanParticipant,andthetransplantisPreauthorized.Undercertaincircumstances,donorsearch,organortissueprocurement,anddonorexpensesarecovereduptoacombinedlifetimemaximumof$30,000.
Notcovered. Musthavereferraltotransplantfacility.SubjecttoplanDeductible,copays,coinsuranceandcoverage.
Musthavereferraltotransplantfacility.AftertheDeductible,subjecttoplanCoinsuranceandcoverage.
Page 12
ThisdocumentisintendedmerelyasasummaryoftheGoldandPlatinumhealthcareplansofferedbytheSouthernCaliforniaDrugBenefitFund. Forexclusionsandrestrictions,youshouldreadtheSummaryPlanDescriptionandtheevidenceofcoveragebookletsprovidedbyKaiser,UnitedHealthcare(formerlyPacifiCare),andUnitedConcordia.DescriptionandtheevidenceofcoveragebookletsprovidedbyKaiser,UnitedHealthcare(formerlyPacifiCare),andUnitedConcordia.OE2020–Platinum/GoldPlan Page10of15
SOUTHERN CALIFORNIA DRUG BENEFIT SUMMARYOFTHEPLATINUMANDGOLDPLANSASOFJANUARY1,2020
2202020 MEDICAL BENEFITS
INDEMNITYPLAN UNITEDHEALTHCARE(UHC)FLEXHMO
KAISER
PPO (In Network) Non-PPO (Out of Network) Podiatry Youmustuseapodiatrist
contractedbyPodiatryPlan,Inc.Youpay$65forthefirstofficevisitunlessvisitisforemergency,trauma,oradiabeticcondition.ThereafterthePlanpays100%ofContractRates. Limitedtoamaximumof8visitspercalendaryear. Nobenefitsarepaidfornon-PodiatryPlanpodiatrists.
OutsideCalifornia,usetheBlueCardnetwork.
Notcovered AftertheDeductible,Network1:$20copaypervisitNetwork2:$35copaypervisitNetwork3:$40copaypervisit
$20copaypervisit.Referralisrequired.
SpecialPodiatryBenefit
NotApplicable. Aseparate$120calendaryearbenefitisavailableregardlessofwhetheryouareenrolledinanHMOMedicalPlanortheIndemnityMedicalPlan. Thebenefitisforofficecallsandcharges(includingx-rays)bynon-networkprovidersincurredforthenon-surgicaltreatmentofchronicfootconditionssuchasweakorfallenarches,flatorpronatedfeet,halluxvalgus,metatarsalgia,orfootstrainandtoenailtrimmingandsurgicaltreatmentinvolvingdebridementofpainfulclavi.
ReconstructiveSurgeryFollowingMastectomy
AftertheDeductible,thePlanpays80%ofContractRates.
AftertheDeductible,thePlanpays50%oftheAllowedAmount.
AftertheDeductible,UHCpays:Network1:80%ofCoveredChargesNetwork2:75%ofCoveredChargesNetwork3:70%ofCoveredCharges
AftertheDeductible,Kaiserpays80%ofCoveredCharges.
Reconstructionofthebreastonwhichamastectomyisperformed,surgeryontheotherbreasttoprovideasymmetricalappearance,andprosthesesandservicesinconnectionwithphysicalcomplicationsofallstagesofmastectomy,includinglymphedemas.
HomeHealthCare
ThePlanpays80%ofContractRates,notsubjecttoDeductible.
ThePlanpays80%ofAllowedAmount,notsubjecttoDeductible.
UHCpays100%upto100visitspercalendaryear. Kaiserpays100%upto100visitspercalendaryear.
CoverageisprovidedforRegisteredNurseexpensesorlicensedvocationalnursewhenprescribedbyaphysicianasbeingMedicallyNecessary.PreauthorizationbyPrudentBuyer/BlueCardisrequired.ServicesandsuppliesprovidedinlieuoftheservicesthatwouldhavebeencoveredunderthePlanifconfinementhadbeeninahospitalorSkilledNursingFacilityarecovered. Homemakerservicesarenotcovered.
Page 13
ThisdocumentisintendedmerelyasasummaryoftheGoldandPlatinumhealthcareplansofferedbytheSouthernCaliforniaDrugBenefitFund. Forexclusionsandrestrictions,youshouldreadtheSummaryPlanDescriptionandtheevidenceofcoveragebookletsprovidedbyKaiser,UnitedHealthcare(formerlyPacifiCare),andUnitedConcordia.DescriptionandtheevidenceofcoveragebookletsprovidedbyKaiser,UnitedHealthcare(formerlyPacifiCare),andUnitedConcordia.OE2020–Platinum/GoldPlan Page11of15
SOUTHERN CALIFORNIA DRUG BENEFIT SUMMARYOFTHEPLATINUMANDGOLDPLANSASOFJANUARY1,2020
2202020 MEDICAL BENEFITS
INDEMNITYPLAN UNITEDHEALTHCARE(UHC)FLEXHMO
KAISER
PPO (In Network) Non-PPO (Out of Network) MENTALHEALTHANDSUBSTANCEABUSEBENEFITS ProviderNetwork
CoverageisadministeredbyHMCHealthWorks(HMC).Beforereceivingtreatments,youarestronglyencouragedtocontactHMCat866-268-2510.Preauthorizationisrequiredforallinpatienttreatments(exceptemergencyhospitalization),intensiveoutpatientprograms,ECT,psychologicaltestingandneuropsychologicaltesting.
CoverageisadministeredbyHMCHealthWorks(HMC). Allservicesandtreatmentsmustbepre-approvedbyHMC(866-268-2510)andprovidedbyHMCnetworkproviders. Nocoverageforservicesandtreatmentsbynon-HMCapprovedproviders.
CoverageisprovidedthroughKaiser.ParticipantsmustuseKaiserfacilitiesandproviders.
MentalHealthInpatient
AftertheDeductible,thePlanpays80%ofHMCContractRates.
AftertheDeductible,thePlanpays50%ofAllowedAmount.
AfterDeductible,thePlanpays80%ofHMCContractRates.
AftertheDeductible,Kaiserpays80%ofCoveredCharges.
MentalHealthOutpatient
$20copayperofficevisit,notsubjecttotheDeductible;otherservicesat80%ofHMCContractRates.
AftertheDeductible,thePlanpays50%oftheAllowedAmount.
$20copaypervisit,notsubjecttotheDeductible. $20copayperindividualvisitor$10copaypergroupvisit,notsubjecttotheDeductible.
SubstanceAbuseInpatient
AftertheDeductible,thePlanpays80%ofHMCContractRates.
AftertheDeductible,thePlanpays50%ofAllowedAmount.
AftertheDeductible,thePlanpays80%ofHMCContractRates.
Detoxification:AftertheDeductible,Kaiserpays80%ofCoveredCharges.
SubstanceAbuseOutpatient
$20copayperofficevisit,notsubjecttotheDeductible;otherservicesat80%ofHMCContractRates.
AftertheDeductible,thePlanpays50%oftheAllowedAmount.
$20copaypervisit,notsubjecttotheDeductible $20copayperindividualvisitor$5copaypergroupvisit,notsubjecttotheDeductible.
MEDICALSUPPLIESANDEQUIPMENT OutpatientMedical&SurgicalSupplies
AftertheDeductible,thePlanpays80%ofContractRates.
AftertheDeductible,thePlanpays50%oftheAllowedAmountupto$21.25maximum.
UHCpays100%ofCoveredCharges. AftertheDeductible,Kaiserpays80%ofCoveredCharges
OrthopedicAppliances
Reimbursementof100%ofContractRatesorAllowedAmountforpurchaseorrentalprescribedbyaphysician,uptoonceeachcalendaryear.
HearingAids Forpatientswhosephysicianhascertifiedahearinglossthatmaybelessenedbytheuseofahearingaid. ThePlanpays80%ofAllowedAmountforphysicianexaminationandinstrumentupto$750maximumforeachear,notmoreoftenthanonceduringany12-monthperiod.
DurableMedicalEquipment
ThePlanpays80%ofContractRates.
ThePlanpays80%oftheAllowedAmount.
UHCpays100%ofCoveredCharges,upto$5,000maximumpercalendaryear.
Kaiserpays80%ofCoveredCharges(notsubjecttotheDeductible).DurablemedicalequipmentforhomeuseisgenerallycoveredinaccordancewithKaiser'sformularyguidelines.
Page 14
ThisdocumentisintendedmerelyasasummaryoftheGoldandPlatinumhealthcareplansofferedbytheSouthernCaliforniaDrugBenefitFund. Forexclusionsandrestrictions,youshouldreadtheSummaryPlanDescriptionandtheevidenceofcoveragebookletsprovidedbyKaiser,UnitedHealthcare(formerlyPacifiCare),andUnitedConcordia.DescriptionandtheevidenceofcoveragebookletsprovidedbyKaiser,UnitedHealthcare(formerlyPacifiCare),andUnitedConcordia.OE2020–Platinum/GoldPlan Page12of15
SOUTHERN CALIFORNIA DRUG BENEFIT SUMMARYOFTHEPLATINUMANDGOLDPLANSASOFJANUARY1,2020
2202020 MEDICAL BENEFITS
INDEMNITYPLAN UNITEDHEALTHCARE(UHC)FLEXHMO
KAISER
PPO (In Network) Non-PPO (Out of Network) OTHERSERVICESANDBENEFITS PediatricVisionCare(uptoage19)
RoutineEyeexamsarecoveredat100%upto$135perexam. However,amountspaidforroutineeyeexamswillreducetheannualframeandlensbenefit.
A$135maximumbenefitforframesandlenseseachcalendaryear.
UHCpays100%ofCoveredChargesforRoutineEyeExams.
Kaiserpays100%ofCoveredChargesforRoutineEyeExams.
TheFundprovidesa$135maximumbenefitforframesandlenseseachcalendaryear.IfyougooutsideyourHMOforroutineeyeexams,theFundwillpay100%upto$135perexam.However,amountspaidbytheFundforeyeexamswillreducethe$135annualframeandlensbenefit.
AdultsVisionCare(age19andover)
A$135maximumbenefitforroutineeyeexamsand/orframesandlenseseachcalendaryear. ForKaiserandUHC,ifeyeexamisobtainedthroughyourHMO,the$135Fundbenefitcanbeusedforframesandlenses. ForKaiserEnrollees:routineeyeexamsobtainedthroughKaiserarecoveredat100%(notsubjecttoDeductibleorcopay). ForUHCEnrollees:routineeyeexamsthroughUHCaresubjecttocopays.Note: Youarepermittedtoopt-outofvisioncoverageforyourselfandyourDependents.However,optingoutofvisionbenefitswillnotchangetheamountofyourEmployeecontribution/premiums.
AdditionalAccidentalInjuryBenefit
InadditiontootherPlanbenefits,amaximumof$300ispayableforContractRates/AllowedAmountsforMedicallyNecessaryservicesandsuppliesincurredwithin90daysofanaccidentasaresultoftheaccident.
None.
PRESCRIPTION DRUG BENEFITS
ParticipatingPharmacy AllParticipantsmustuseSoCADrugFundParticipatingPharmacies.(SeeseparateDirectoryatwww.ufcwdrugtrust.orgunder“Downloads”) CalendarYearDeductible None. Out-of-PocketMaximum IndemnityMedicalPlanEnrollees:$5,400individual;$8,800familyperyearforprescriptionsfilledatparticipatingpharmacies
Kaiser/UHCEnrollees: $5,900individual;$11,800familyperyearforprescriptionsfilledatparticipatingpharmacies
MaximumDaysSupply Maximum30dayssupplyperprescription. Formaintenancedrugsincertaintherapeuticclassifications,a90-daysupplymaybeobtained. GenericPreventiveCareDrugs(includingFDAapprovedcontraceptives)
Planpays100%foraspirin,fluoridesupplement,folicacid,statinpreventivemedication,tobaccocessationproducts,breastcancerpreventivemedication,preparationproducts for colon cancer screening test, and female contraceptives;prescription required for OTC available drugs. Brand namewill becoveredwhenagenericisunavailableormedicallyinappropriate,butmustbeauthorizedbyOptumRx. Ageandfrequencylimitsapply.
Generic PlatinumPlan:$8copayperprescription;GoldPlan:$12copayperprescription.
Page 15
ThisdocumentisintendedmerelyasasummaryoftheGoldandPlatinumhealthcareplansofferedbytheSouthernCaliforniaDrugBenefitFund. Forexclusionsandrestrictions,youshouldreadtheSummaryPlanDescriptionandtheevidenceofcoveragebookletsprovidedbyKaiser,UnitedHealthcare(formerlyPacifiCare),andUnitedConcordia.DescriptionandtheevidenceofcoveragebookletsprovidedbyKaiser,UnitedHealthcare(formerlyPacifiCare),andUnitedConcordia.OE2020–Platinum/GoldPlan Page13of15
SOUTHERN CALIFORNIA DRUG BENEFIT SUMMARYOFTHEPLATINUMANDGOLDPLANSASOFJANUARY1,
PRESCRIPTION DRUG BENEFITS
FormularyBrand PlatinumPlan:$25copayperprescription;GoldPlan:$30copayperprescription.Thesecopaysareonlyapplicablewhennogenericequivalentisavailableorifyourdoctorindicates“dispenseaswritten.”
Ifagenericequivalentisavailableandyourdoctordoesnotindicate“dispenseaswritten,”youmustpaythecostdifferencebetweenthegenericdrugandthebrand-namedrugplustheapplicablecopay($25or$30).
Non-formularyBrand PlatinumPlan:$45copayperprescription;GoldPlan:$50copayperprescription. Injectables ThePlanpays80%ofOptumRx’sContractRate. AuthorizationrequiredthroughOptumRx.
ForUHCenrollees,injectablesthatareprescribedbyUHCphysiciansandprovidedbyUHCarecoveredat100%bytheUHCplanandarenotcoveredunderthePrescriptionDrugPlan.
DENTAL BENEFITS
INDEMNITYDENTALPLAN UNITEDCONCORDIA ChoiceofProvider Youmayselectanydentistofyourchoice. UsingaDeltaDentalPPOdentistwillloweryourout-of-pocket
expenses. YoumustusetheUnitedConcordiadentalofficeinwhichyouareenrolled.
CalendarYearDeductible $75perperson;$225perfamily. Notapplicabletoroutinepreventativeanddiagnosticprocedures. None. CoveredCharges ForDeltaPPOdentists,thePlanpaysthelesseroftheDeltaPPOContractRatesortheamountlistedinthe
ScheduleofAllowances.ForDeltaPremierdentists,thePlanpaysthelesseroftheDeltaPremierFiledFeesortheamountlistedintheScheduleofAllowances.Fornon-DeltaDentaldentists,thePlanpaysthelesseroftheamountbilledbythedentistortheamountlistedintheScheduleofAllowances.ScheduleofAllowancesisestablishedbytheTrusteesandadjustedannually(seeseparatescheduleatwww.ufcwdrugtrust.orgunder”Downloads”).
Note: Youarepermittedtoopt-outofdentalcoverageforyourselfandyourDependents.ContacttheFundOfficeformoreinformation.
SeeUnitedConcordia’sScheduleofBenefits.
MaximumBenefit $1,800perpersonpercalendaryearforadultsage19andolder. Nomaximum.
Page 16
SOUTHERN CALIFORNIA DRUG BENEFIT SUMMARYOFTHEPLATINUMANDGOLDPLANSASOFJANUARY1,
PLAN EXCLUSIONS
ThisdocumentisintendedmerelyasasummaryoftheGoldandPlatinumhealthcareplansofferedbytheSouthernCaliforniaDrugBenefitFund. Forexclusionsandrestrictions,youshouldreadtheSummaryPlanDescriptionandtheevidenceofcoveragebookletsprovidedbyKaiser,UnitedHealthcare(formerlyPacifiCare),andUnitedConcordia.DescriptionandtheevidenceofcoveragebookletsprovidedbyKaiser,UnitedHealthcare(formerlyPacifiCare),andUnitedConcordia.OE2019–Platinum/GoldPlan Page14of15
INDEMNITYPLAN KAISER&UNITEDHEALTHCARE ExcludedServices ThePlandoesnotpaybenefitsforthefollowing:
§ ChargesinexcessofContractRates;or,asapplicable,theAllowedAmount;§ Replacementofartificialeyes;§ Orthognathicsurgery;§ Cosmetictreatmentorsurgeryandcomplicationsresultingfromanysuchprocedure,exceptforrepair
ofdamagecausedbyaccidentalbodilyinjury(restorativesurgeryperformedduringorfollowingmutilativesurgerywhichwasrequiredasaresultofillnessorinjuryisnotconsideredcosmetic);
§ ChargesmadebyrelativesofanyoneintheParticipant'shousehold,exceptforCoveredChargeswhichconstituteout-of-pocketexpensestosuchproviders;
§ Experimentaltreatment,proceduresandtherapiesandanycomplicationsarisingfromsuchtreatment;
§ Custodialcareregardlessofthetypeoffacilityand/orprovider;§ Eyeexaminationsincludingrefractionsandfittingofglasses,hearingaids,healthaids,artificiallimbs,
andorthopedicappliances,exceptasspecificallycovered;§ AnysuppliesorservicesfurnishedbyahospitalorfacilityoperatedbytheU.S.Governmentorany
authorizedagencythereof,orfurnishedattheexpenseofsuchGovernmentoragency;§ Anyexpensesconnectedwithanyformofartificialinsemination,anynon-surgicaltreatmentfor
infertilityafterdiagnosis,anyexpensesconnectedwithorresultingfromsurrogatemothersorspermbanks,orthereversalofvoluntaryinfertility;
§ Servicesandsuppliesforwhichnochargeismade,orforwhichoneisnotrequiredtopay;§ Anyservicesorsuppliesnotrecommendedandapprovedbyalegallyqualifiedphysicianorsurgeon,
dentist,mentalhealthprofessional,podiatristonthePodiatryPlanpanel,orchiropractorperformingserviceswithinthelegalscopeoftheirpractices;
§ ConditionscoveredbyWorkers’Compensationorincurredinthecourseofemployment,includingself-employment;
§ PenileprosthesisunlesspreauthorizedbyAnthemBlueCross;§ Pregnancyexpensesofdependentchildrenorexpensesforconditionsarisingfrompregnancyof
dependentchildren,exceptpreventivecareexpenses;
§ Surgicalcorrectionofrefractiveproblemsincludingradialkeratotomyunlessvisioncannotbecorrectedthrougheyeglassesorcontactlenses;
PleaserefertotheEvidenceofCoveragebookletsprovidedbyKaiserandUnitedHealthcare.
Page 17
SOUTHERN CALIFORNIA DRUG BENEFIT SUMMARYOFTHEPLATINUMANDGOLDPLANSASOFJANUARY1,
PLAN EXCLUSIONS
ThisdocumentisintendedmerelyasasummaryoftheGoldandPlatinumhealthcareplansofferedbytheSouthernCaliforniaDrugBenefitFund. Forexclusionsandrestrictions,youshouldreadtheSummaryPlanDescriptionandtheevidenceofcoveragebookletsprovidedbyKaiser,UnitedHealthcare(formerlyPacifiCare),andUnitedConcordia.DescriptionandtheevidenceofcoveragebookletsprovidedbyKaiser,UnitedHealthcare(formerlyPacifiCare),andUnitedConcordia.OE2019–Platinum/GoldPlan Page15of15
INDEMNITYPLAN KAISER&UNITEDHEALTHCARE ExcludedServices(cont’d) § Expensesincurredforanyconditionwherethereexistsnoinjuryorsickness,exceptthatthisexclusion
doesnotapplytobenefitsspecificallyprovided,suchashospicecare,sterilizationprocedures,andpreventivecarebenefits;
§ Speechtherapy,exceptfromaPPOprovider;§ Takehomedrugswhendischargedfromthehospital;§ ExpensesincurredbyatransplantdonorwhoisnoteligibleunderthePlan(exceptforbenefits
specificallyprovided);§ OrganortissuetransplantsperformedatafacilitythatisnotanAnthemBlueCrossCenterof
Expertise;§ ExpensesincurredbyanorganortissuedonorwhenthetransplantrecipientisnotaPlanparticipant.§ Vocationaltesting,evaluationandcounseling;§ Injuriesresultingfromanyformofwarfareorinvasion;§ Nobenefitswillbeprovidedforpodiatriccarereceivedfromanon-PodiatryPlan,Inc.podiatrist(ifyou
liveoutsideofCalifornianopodiatrybenefitswillbeprovidedunlessyouuseaBlueCardnetworkpodiatrist),exceptforthespecialpodiatrybenefit. Inaddition,benefitsforpodiatriccarearelimitedtothosespecificallydescribed;
§ Claimsfiledmorethanoneyearafterthedateonwhichserviceswereincurred;§ ServicesorsuppliesthatarenotNecessaryTreatment.
PleaserefertotheEvidenceofCoveragebookletsprovidedbyKaiserandUnitedHealthcare.
ThirdPartyLiability IfaParticipantobtainsarecoveryfromathirdpartythatisinanymannerrelatedtoclaimspaidbytheFund,theParticipantwillreimbursetheFundfromsuchrecoveryinanamountnotinexcessofthepaymentsmadeortobemadebytheFund.
PleaserefertotheEvidenceofCoveragebookletsprovidedbyKaiserandUnitedHealthcare.
DentalExclusions FortheIndemnityDentalPlan,pleasereadtheIndemnityScheduleofAllowancesforDentalProcedures(updatedeachJanuary).FortheUnitedConcordiaPlan,pleaserefertheEvidenceofCoveragebookletprovidedbyUnitedConcordia.
PrescriptionDrugExclusions PleasecontacttheFundOffice.
Page 18
SOUTHERN CALIFORNIA DRUG BENEFIT FUND 2220 HYPERION AVENUE • LOS ANGELES, CALIFORNIA 90027
TEL (323) 666-8910 • FAX (323) 663-9495 • WWW.UFCWDRUGTRUST.ORG
1
Nondiscrimination Notice & Language Assistance
The Southern California Drug Benefit Fund (the “Plan”) does not discriminate on the basis of race, color, national origin, age, disability, or sex. The Plan provides free aids and services to people with disabilities, such as qualified sign language interpreters for individuals with disabilities and information in alternative formats (large print, audio), when necessary to ensure equal opportunity to participate.
The Plan also provides free language assistance services, such as qualified interpreters and oral interpretation, when such services are necessary to provide meaningful access to individuals with limited English proficiency. If you need these services, contact the Plan’s Civil Rights Coordinator at:
Southern California Drug Benefit Fund P.O. Box 27920 Los Angeles, CA 90027-0920 Phone: (323) 666-8910, ext. 234 Fax: (323) 663-9495
If you believe that the Plan has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with the Fund’s Civil Rights Coordinator, at the address listed above. You can file a grievance in person, by mail, or by fax. If you need help filing a grievance, the Civil Rights Coordinator can help.
You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil 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, D.C. 20201, 1-800-368-1019, 800-537-7697 (TDD). Complaint forms are available athttp://www.hhs.gov/ocr/office/file/index.html.
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October 15, 2016
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