southern california drug benefit fund plus...southern california drug benefit fund platinum plus...
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SOUTHERN CALIFORNIA DRUG BENEFIT FUND PLATINUM PLUS PLAN SUMMARY
AS OF JANUARY 1, 2018
This group health plan believes this plan is a "grandfathered health plan" under the Patient Protection and Affordable Care Act (the Affordable Care Act). As permitted by the Affordable Care Act, a grandfathered health plan can preserve certain basic health coverage that was already in effect when that law was enacted. Being a grandfathered health plan means that your plan may not include certain consumer protections of the Affordable Care Act that apply to other plans, for example, the requirement for the provision of preventive health services without any cost sharing. However, grandfathered health plans must comply with certain other consumer protections in the Affordable Care Act, for example, the elimination of lifetime limits on benefits.
Questions regarding which protections apply and which protections do not apply to a grandfathered health plan and what might cause a plan to change from grandfathered health plan status can be directed to the plan administrator by phone or in writing at So. California Drug Benefit Fund, 2220 Hyperion Avenue, Los Angeles, CA 90027, (323) 666-8910. You may also contact the Employee Benefits Security Administration, U.S. Department of Labor at 1-866-444-3272 or www.dol.gov/ebsa/healthreform. This Web site has a table summarizing which protections do and do not apply to grandfathered health plans.
SOUTHERN CALIFORNIA DRUG BENEFIT FUND PLATINUMPLUSPLANSUMMARYASOFJANUARY1,2018
OE 2018 - Platinum Plus Plan L
SECTION PAGE
CONTACT INFORMATION ....................................................................................................................................................................................... 1
ELIGIBILITY RULES .................................................................................................................................................................................................. 2
ESTABLISHING ELIGIBILITY & COVERAGE COMMENCEMENT ......................................................................................................... 2
WORKING SPOUSE RULE AND COORDINATION OF BENEFITS ........................................................................................................ 2
DEATH BENEFITS ..................................................................................................................................................................................................... 2
MEDICAL BENEFITS ................................................................................................................................................................................................. 3
HOSPITAL BENEFITS .................................................................................................................................................................................. 4
PROFESSIONAL SERVICES ....................................................................................................................................................................... 5
MENTAL HEALTH AND SUBSTANCE ABUSE BENEFITS ...................................................................................................................... 8
MEDICAL SUPPLIES AND EQUIPMENT ................................................................................................................................................... 9
OTHER SERVICES AND BENEFITS .......................................................................................................................................................... 9
PRESCRIPTION DRUG BENEFITS ....................................................................................................................................................................... 10
DENTAL BENEFITS ................................................................................................................................................................................................. 11
ORTHODONTIC BENEFITS .................................................................................................................................................................................... 11
PLAN EXCLUSIONS ................................................................................................................................................................................................ 12
SOUTHERN CALIFORNIA DRUG BENEFIT FUND PLATINUMPLUSPLANSUMMARYASOFJANUARY1,2018
Page 1 of 13
CONTACT INFORMATION
TrustFundOffice 877-999-8329 www.ufcwdrugtrust.org
AnthemBlueCrossPrudentBuyer 800-227-3641 www.anthem.com/ca/home.html
BlueCard 800-810-BLUE(800-810-2583) www.bcbs.com
DeltaDental 800-765-6003 www.deltadentalins.com
Kaiser 800-464-4000 www.kp.org
HMCHealthWorks 866-268-2510 https://hmc.personaladvantage.com(AccessCode:SCDBF)
PodiatryPlanofCalifornia(PPOC) 800-367-7762 www.podiatryplan.com
OptumRx 800-788-7871 www.optumrx.com
UnitedHealthcare(UHC) 800-624-8822 www.MyUHC.com
UnitedConcordia 800-937-6432 www.unitedconcordia.com
This document is intended merely as a summary of the Platinum Plus health care plan offered by the Southern California Drug Benefit Fund. For exclusions and restrictions, you should read the Summary Plan Description and the evidence of coverage booklets provided by
Kaiser, UnitedHealthcare, and United Concordia.
SOUTHERN CALIFORNIA DRUG BENEFIT FUND PLATINUMPLUSPLANSUMMARYASOFJANUARY1,2018
ThisdocumentisintendedmerelyasasummaryofthePlatinumPlushealthcareplanofferedbytheSouthernCaliforniaDrugBenefitFund.Forexclusionsandrestrictions,youshouldreadtheSummaryPlanDescriptionandtheevidenceofcoveragebookletsprovidedbyKaiser,UnitedHealthcare(formerlyPacifiCare),andUnitedConcordia.
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ELIGIBILITY RULES
ESTABLISHINGELIGIBILITY&COVERAGECOMMENCEMENTAllEmployees Ifyouworkanaverageof23ormorehoursperweek(“QualifyingHours”)for3consecutivemonths,youandyourdependentswillbecome
eligibleforallbenefits,exceptorthodonticbenefits,onthefirstdayofthemonthafter2skipmonths.Forexample,ifyouworkQualifyingHoursinJanuary,FebruaryandMarch,youandyourdependentswillbeeligibleforbenefits,exceptOrthodontic,onJune1.Newlyeligibleparticipants,exceptforKaiserEmployees,arerequiredtoenrollintheIndemnityMedicalPlanandwillbeeligibletoenrollinanHMOplanonthe2ndannualopenenrollmentaftertheirdateofhire.Orthodonticcoveragewillbeavailabletoyouandyourdependentsafteryouhave9consecutivemonthsofeligibilityinthePlatinumPlusPlan.
MaintainingEligibility Onceyoubecomeeligible,youmustcontinuetoworktheQualifyingHoursduringeachmonthtomaintaineligibilityforyourselfandyoureligibledependents.
WORKINGSPOUSERULEANDCOORDINATIONOFBENEFITSWorkingSpouseRule(alsoapplicabletoDomesticPartners)
FormarriedEmployeesandEmployeeswithDomesticPartners(theuseoftheterm“spouse”inthissectionincludesDomesticPartners):Ifyourspouse’semployeroffershealthcarecoverage,yourspousemustenrollinthatemployer’scoveragethatiscomparabletoyourcoverageunderthisFund,evenifheorsheisrequiredtopaysomeorallofthecostofthatcoverage.Ifyourspouse’semployerdoesnotoffercoveragethatiscomparabletoyourcoveragefromtheFund,yourspousemustenrollinthebestcoverageavailablethroughhisorheremployer.Ifyourspouseiseligibleformedical,prescriptiondrug,dental,and/orvisionbenefitsthroughhisorheremployerbutfailstoenroll,thisPlanwillpayonly40%ofitsnormalbenefits(i.e.itwillreduceitspaymentamountby60%)undertheIndemnityMedicalPlan,IndemnityPrescriptionDrugPlan,IndemnityDentalPlan,andIndemnityVisionPlan.ThisruledoesnotapplyifbothspousesareeligibleforcoverageasEmployeesofcontributingEmployersandonespousehaselectedcoveragefor“EmployeeplusspouseorDomesticPartner”.PleasecontacttheFundOfficeformoreinformation.
DEATH BENEFITS Employee Greaterof$15,000ortheamountofsalaryreceivedduringthemostrecent12months.
Dependent $2,000
SOUTHERN CALIFORNIA DRUG BENEFIT FUND PLATINUMPLUSPLANSUMMARYASOFJANUARY1,2018
ThisdocumentisintendedmerelyasasummaryofthePlatinumPlushealthcareplanofferedbytheSouthernCaliforniaDrugBenefitFund.Forexclusionsandrestrictions,youshouldreadtheSummaryPlanDescriptionandtheevidenceofcoveragebookletsprovidedbyKaiser,UnitedHealthcare(formerlyPacifiCare),andUnitedConcordia.
OE 2018 - Platinum Plus Plan Page 3 of 13
MEDICAL BENEFITS
INDEMNITYPLAN UNITEDHEALTHCARE(UHC)
KAISER PPO (In Network) Non-PPO (Out of Network)
HowthePlanWorks Formostofficevisits,youmustpaya$10copaypervisit.ThenthePlanpays100%ofContractRates1.WhenyouuseaPPOproviderforpreventiveandwellnessservices,thePlanwillpay100%ofContractRatesforallofthepreventivecareandimmunizationserviceslistedinthePlan’scurrentPreventiveCareGuidelines,whichisavailablefromtheFundOffice.ThereisnocopaymentaslongasservicesarereceivedfromPPOproviders.
Formostservices,thePlanpaysbothBasicandMajorMedicalbenefits.BasicMedicalBenefitsarepaidfirst.AfterBasicMedicalbenefitshavebeenexhausted,youmustsatisfytherequiredCalendarYearDeductible(“Deductible”),thenthePlanpaysapercentageoftheremainingAllowedAmount2asaMajorMedicalBenefit.Forsomeservicesandsupplies,specificdollarlimitsareimposed.YouareresponsibleforanyremainingbalanceaftertheallowedBasicandMajorMedicalbenefitsarepaid.
HospitalandprofessionalservicesaregenerallyprovidedatnochargeifreceivedatHMOcontractedfacilitiesandprovidedbyHMOproviders.Refertoeachbenefitbelowforexceptions.
HospitalandprofessionalservicesaregenerallyprovidedatnochargeifreceivedatHMOcontractedfacilitiesandprovidedbyHMOproviders.Refertoeachbenefitbelowforexceptions.
Refertoeachbenefitbelowforexceptions.
PreferredProviderNetwork(PPO)
IfyouliveinCalifornia,yourpreferredprovidernetwork(“PPO”)istheAnthemBlueCrossPrudentBuyernetwork.IfyouoryourdependentsliveoutsideofCalifornia,orifyouaretravelingoutsideCalifornia,yourPPOnetworkofhospitalsanddoctorsistheNationalBlueCardnetwork.TheBlueCardnetworkisavailableinall50states.YouarestronglyencouragedtouseaPPOprovider.ThePlanpaysahigherlevelofbenefitswhenyouuseaPPOphysicianorhospital.YoumaychoosetousehospitalsandphysicianswhodonotbelongtothePPOnetworks.However,thePlanpaysalowerlevelofbenefitsfornon-PPOproviders,andyouwillhavehigherout-of-pocketexpenses.TofindaPPOprovidernearestyou,callAnthemBlueCrossPrudentBuyerat800-227-3641orBlueCardAccessat800-810-BLUE.
YoumustuseanUHCHMOprovider.Servicesrenderedbynon-UHCprovidersarenotcovered.IfanemergencyoccursoutsideofUHC’sserviceareas,emergencyproceduresandbenefitsapply.
YoumustuseaKaiserprovider.Servicesrenderedbynon-Kaiserprovidersarenotcovered.IfanemergencyoccursoutsideoftheHMOs’serviceareas,emergencyproceduresandbenefitsapply.
1TheamountthatthePPOProvider(PrudentBuyerNetworkortheBlueCardProgram)hasagreedbycontracttoacceptfortheservicesprovided.2Inmostcases,theAllowedAmountistheallowancethattheFundhasdeterminedisanappropriatepaymentfortheMedicallyNecessaryservice(s)renderedtotheparticipantintheprovider'sgeographicarea.Wheretheprovider'schargeislessthantheFund'sallowancefortheservice(s)provided,theAllowedAmountistheprovider'sbilledamount.TheBoardofTrustees,oritsdesignee,hasdiscretiontodeterminetheAllowedAmount.
SOUTHERN CALIFORNIA DRUG BENEFIT FUND PLATINUMPLUSPLANSUMMARYASOFJANUARY1,2018
ThisdocumentisintendedmerelyasasummaryofthePlatinumPlushealthcareplanofferedbytheSouthernCaliforniaDrugBenefitFund.Forexclusionsandrestrictions,youshouldreadtheSummaryPlanDescriptionandtheevidenceofcoveragebookletsprovidedbyKaiser,UnitedHealthcare(formerlyPacifiCare),andUnitedConcordia.
OE 2018 - Platinum Plus Plan Page 4 of 13
MEDICAL BENEFITS
INDEMNITYPLAN UNITEDHEALTHCARE(UHC)
KAISER PPO (In Network) Non-PPO (Out of Network)
Pre-AuthorizationandUtilizationReview
WhenPre-authorizationorUtilizationReviewisrequired,yourdoctororhospitalmustcontactPrudentBuyer/BlueCardat800-274-7767.PPOhospitalswilldothisautomatically.Youshouldconfirmthatyourotherproviders,includingnon-PPOhospitals,havedonethis.
SeeUHC’sEvidenceofCoverage.
SeeKaiser’sEvidenceofCoverage
CalendarYearDeductible(“Deductible”)
None $50perpersonpercalendaryearbeforeMajorMedicalpaymentsapply.
Notapplicable Notapplicable
Annual/LifetimeMaximum
None
HOSPITALBENEFITSHospitalInpatientServices(includingRoomandBoard,andAncillaryServices)
Planpays100%ofContractRatesupto120daysperdisability,includingICUandchildbirth.After120days,80%ofContractRatesPrudentBuyer/BlueCardprovidersareresponsibleforobtainingallPre-authorizationandUtilizationReview.
Planpays50%oftheAllowedAmountupto120daysperdisability,includingICUonly(excludeschildbirth).After120days,Planpays80%oftheAllowedAmount.Allhospitaladmissions,exceptforchildbirthoremergencyconfinements,mustbepreauthorizedbyPrudentBuyer/BlueCard.Call800-274-7767forPreauthorization.BenefitswillbereducedifyoufailtoobtainrequiredPreauthorization.Unauthorizeddaysarenotcovered.
100%covered 100%covered
HospitalEmergencyRoom(Facilityonly,PhysicianchargesarepayableunderPhysicianHospitalVisits)
Planpays100%ofContractRates
Foraccident,Planpays85%oftheAllowedAmount.Forillness,68%oftheAllowedAmount.
$35copay,waivedifadmittedasinpatient.ReasonablechargesforemergencyservicesreceivedoutsideUHCserviceareasarecoveredsubjecttocopayments.
100%covered
HospitalOutpatientFacilityCharges
Planpays100%ofContractRates Planpays85%oftheAllowedAmount. 100%covered 100%covered
SOUTHERN CALIFORNIA DRUG BENEFIT FUND PLATINUMPLUSPLANSUMMARYASOFJANUARY1,2018
ThisdocumentisintendedmerelyasasummaryofthePlatinumPlushealthcareplanofferedbytheSouthernCaliforniaDrugBenefitFund.Forexclusionsandrestrictions,youshouldreadtheSummaryPlanDescriptionandtheevidenceofcoveragebookletsprovidedbyKaiser,UnitedHealthcare(formerlyPacifiCare),andUnitedConcordia.
OE 2018 - Platinum Plus Plan Page 5 of 13
MEDICAL BENEFITS
INDEMNITYPLAN UNITEDHEALTHCARE(UHC)
KAISER PPO (In Network) Non-PPO (Out of Network)
PhysicianHospitalVisits Planpays100%ofContractRates BasicMedicalpaysupto$25.50perday.MajorMedicalpays80%oftheremainingAllowedAmountafterDeductible.
100%covered 100%covered
SkilledNursingFacility(Medicareapproved)
Maximumbenefitof42.5%ofthesemiprivateroomrateoftheprevioushospitalstay,forupto2timestheunusednumberofalloweddaysperdisability.Thenumberofalloweddaysis120daysminusthenumberofdaysspentinthehospital.PatientmustbetransferredintotheSkilledNursingFacilitywithin14daysofacutecarehospitalstaylastingatleast3days.MustbeapprovedbyPrudentBuyer/BlueCard.
Asprescribedatdesignatedfacilities.100%covered,limitedto100dayspercalendaryearfromthefirsttreatmentperdisability.
Asprescribedatdesignatedfacilities.100%covered,limitedto100daysperbenefitperiod.
Ambulance Planpays100%ofContractRates/AllowedAmount. 100%covered 100%covered
OutpatientSurgicalCenters
Planpays100%ofContractRates
Planpaysamaximumof$350persurgery.Youareresponsibleforanychargesthatexceed$350.Anychargesinexcessofthe$350donotcounttowardtheDeductible.
100%covered 100%covered
MustbePre-authorizedbyPrudentBuyer/BlueCard.
PROFESSIONALSERVICESPreventiveCare Planpays100%ofContractRates,no
copaymentisrequired.AfterDeductible,Planpays85%oftheAllowedAmount.
100%covered 100%covered
CoverageisprovidedforthePreventiveandWellnessserviceslistedin,andsubjecttothefrequencydescribedin,theDrugBenefitFund’sPreventiveCareGuidelines.Breastfeedingdevices(e.g.breastpumps)arecoveredat100%onlyifpurchasedandobtainedthroughanAnthemPrudentBuyerapprovedDurableMedicalEquipmentvendor.
SOUTHERN CALIFORNIA DRUG BENEFIT FUND PLATINUMPLUSPLANSUMMARYASOFJANUARY1,2018
ThisdocumentisintendedmerelyasasummaryofthePlatinumPlushealthcareplanofferedbytheSouthernCaliforniaDrugBenefitFund.Forexclusionsandrestrictions,youshouldreadtheSummaryPlanDescriptionandtheevidenceofcoveragebookletsprovidedbyKaiser,UnitedHealthcare(formerlyPacifiCare),andUnitedConcordia.
OE 2018 - Platinum Plus Plan Page 6 of 13
MEDICAL BENEFITS
INDEMNITYPLAN UNITEDHEALTHCARE(UHC)
KAISER PPO (In Network) Non-PPO (Out of Network)
PhysicianOfficeVisits $10copaypervisit BasicMedicalpaysupto$25.50pervisituptoa$300maximumpercalendaryear.Benefitsbeginonthe1stvisitforeachaccidentand2ndvisitforeachillness.AfterBasicMedicalandDeductiblehavebeensatisfied,MajorMedicalpays80%oftheremainingAllowedAmount.
100%covered 100%covered
Specialist $10copaypervisit BasicMedicalpaysupto$60pervisitforeachaccidentandeachillnesswhenreferredbyattendingphysician.NoMajorMedicalispayable.
100%covered 100%covered
Surgeon,AssistantSurgeon
100%ofContractRates BasicMedicalbenefitsarepaidaccordingtoascheduleofcharges.Excesscharges,afterBasicMedicalandDeductible,arecoveredunderMajorMedicalat80%oftheAllowedAmount
100%covered 100%covered
Anesthesiologist 100%ofContractRates Ifprovidedinahospitaloroutpatientsurgicalfacility,85%oftheAllowedAmount.Ifprovidedinaphysician’soffice,BasicMedicalpays$21.25pervisitandnoMajorMedicalispayable.
100%covered 100%covered
OutpatientX-rayandLaboratory
100%ofContractRates BasicMedicalpays85%oftheAllowedAmountupto$750maximumperaccidentorpercalendaryearforallillnesses.MajorMedicalpays75%oftheremainingAllowedAmountafterDeductible.
100%covered 100%covered
Injections 100%ofContractRates InjectionsarepayableasanOfficeVisitandcounttowardOfficeVisitmaximum.
100%covered 100%covered
MustbesuppliedandadministeredbyPhysician’soffice.Self-injectablesarecoveredunderPrescriptionDrugbenefits.
SOUTHERN CALIFORNIA DRUG BENEFIT FUND PLATINUMPLUSPLANSUMMARYASOFJANUARY1,2018
ThisdocumentisintendedmerelyasasummaryofthePlatinumPlushealthcareplanofferedbytheSouthernCaliforniaDrugBenefitFund.Forexclusionsandrestrictions,youshouldreadtheSummaryPlanDescriptionandtheevidenceofcoveragebookletsprovidedbyKaiser,UnitedHealthcare(formerlyPacifiCare),andUnitedConcordia.
OE 2018 - Platinum Plus Plan Page 7 of 13
MEDICAL BENEFITS
INDEMNITYPLAN UNITEDHEALTHCARE(UHC)
KAISER PPO (In Network) Non-PPO (Out of Network)
PhysicalTherapy 100%ofContractRates BasicMedicalpaysupto$25.50pervisit,upto$300maximumpercalendaryear.MajorMedicalpays80%oftheremainingAllowedAmountafterDeductible.
100%covered 100%covered
SubjecttoUtilizationReviewbyPrudentBuyer/BlueCardforMedicalNecessity.
SpeechTherapy $10copaypervisit.Preauthorizationrequired.
Notcovered. 100%covered 100%covered
ChiropracticCareandAcupuncture
Planpays$25.50pervisit,nomorethanonevisitperday,uptoacombinedmaximumof$500percalendaryearforofficevisitsand$150percalendaryearforx-rayandlaboratory.
Notcovered. Notcovered.
Podiatry YoumustuseapodiatristonthePodiatryPlanOrganizationofCalifornia(PPOC)panel.Youpay$65forthefirstofficevisitunlessvisitisforemergency,trauma,oradiabeticcondition.ThereafterthePlanpays100%ofContractRates.Uptoamaximumof8visitspercalendaryear.Nobenefitsarepaidfornon-PPOCpodiatrists.OutsideCalifornia,usetheBlueCardnetwork.
Notcovered. 100%coveredifreferredbyyourprimarycarephysiciantoapodiatristinyourHMO.
100%coveredifreferredbyyourprimarycarephysiciantoapodiatristinyourHMO.
SpecialPodiatryBenefit NotApplicable Aseparate$120calendaryearbenefitisavailableregardlessofwhetheryouareenrolledinanHMOMedicalPlanortheIndemnityMedicalPlan.Thebenefitisforofficecallsandcharges(includingx-rays)bynon-networkprovidersincurredforthenon-surgicaltreatmentofchronicfootconditionssuchasweakorfallenarches,flatorpronatedfeet,halluxvalgus,metatarsalgia,orfootstrainandtoenailtrimmingandsurgicaltreatmentinvolvingdebridementofpainfulclavi.
ReconstructiveSurgeryFollowingMastectomy
100%coveredforreconstructionofthebreastonwhichamastectomyisperformed,surgeryontheotherbreasttoprovideasymmetricalappearance,andprosthesesandservicesinconnectionwithphysicalcomplicationsofallstagesofmastectomy,includinglymphedemas.
ObesityBypassSurgery CoveredundertheHospitalandSurgicalbenefitsifpre-authorizedasMedicallyNecessary
CoveredifdeterminedMedicallyNecessaryandauthorized.
SOUTHERN CALIFORNIA DRUG BENEFIT FUND PLATINUMPLUSPLANSUMMARYASOFJANUARY1,2018
ThisdocumentisintendedmerelyasasummaryofthePlatinumPlushealthcareplanofferedbytheSouthernCaliforniaDrugBenefitFund.Forexclusionsandrestrictions,youshouldreadtheSummaryPlanDescriptionandtheevidenceofcoveragebookletsprovidedbyKaiser,UnitedHealthcare(formerlyPacifiCare),andUnitedConcordia.
OE 2018 - Platinum Plus Plan Page 8 of 13
MEDICAL BENEFITS
INDEMNITYPLAN UNITEDHEALTHCARE(UHC)
KAISER PPO (In Network) Non-PPO (Out of Network)
OrganandTissueTransplants
CoveredonlyiftransplantisperformedatanAnthemBlueCrossapprovedCenterofExpertise,thetransplantrecipientisaplanparticipant,andthetransplantispreauthorized.Undercertaincircumstances,donorsearch,organortissueprocurement,anddonorexpensesarecovereduptoacombinedlifetimemaximumof$30,000.
Notcovered. Musthavereferraltotransplantfacility.Subjecttoplancopaymentsandcoverage.
HomeHealthCare RegisterednurseexpensesorlicensedvocationalnursewhenprescribedbyaphysicianasbeingMedicallyNecessaryarecoveredat80%.Pre-AuthorizationbyPrudentBuyer/BlueCardisrequired.ServicesandsuppliesprovidedinlieuoftheservicesthatwouldhavebeencoveredundertheplanifconfinementhadbeeninahospitalorSkilledNursingFacilityarecovered.Homemakerservicesarenotcovered.
100%covered,upto100visitspercalendaryear.
100%covered,upto100visitspercalendaryear.
MENTALHEALTHANDSUBSTANCEABUSEBENEFITSProviderNetwork CoverageisadministeredbyHMCHealthWorks(“HMC”).Youarestrongly
encouragedtocontactHMCat866-268-2510beforereceivingservices.Allinpatienttreatment,exceptemergencyhospitalization,mustbepreauthorizedbyHMC.Preauthorizationisalsorequiredforintensiveoutpatientprograms,ECT,psychologicaltestingneuropsychologicaltestingandpartialhospitalization.
CoverageisadministeredbyHMCHealthWorks(“HMC”).Allservicesandtreatmentsmustbepre-approvedbyHMC(866-268-2510)andprovidedbyHMCnetworkproviders.Nocoverageforservicesandtreatmentsbynon-HMCproviders.
CoverageisprovidedthroughKaiser.ParticipantsmustuseKaiserfacilitiesandproviders.
MentalHealthInpatient
100%ofContractRates Planpays50%ofAllowedAmountforfirst120days;after120days,Planpays80%oftheAllowedAmount
100%covered 100%covered
MentalHealthOutpatient
First5visits:100%coveredAfter5thvisit:$10copaypervisit
Planpays$25.50pervisitthen80%oftheremainingAllowedAmount
100%covered 100%covered
SOUTHERN CALIFORNIA DRUG BENEFIT FUND PLATINUMPLUSPLANSUMMARYASOFJANUARY1,2018
ThisdocumentisintendedmerelyasasummaryofthePlatinumPlushealthcareplanofferedbytheSouthernCaliforniaDrugBenefitFund.Forexclusionsandrestrictions,youshouldreadtheSummaryPlanDescriptionandtheevidenceofcoveragebookletsprovidedbyKaiser,UnitedHealthcare(formerlyPacifiCare),andUnitedConcordia.
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MEDICAL BENEFITS
INDEMNITYPLAN UNITEDHEALTHCARE(UHC)
KAISER PPO (In Network) Non-PPO (Out of Network)
SubstanceAbuseInpatient
Detoxification,InpatientRehabilitation,Day/EveningHospital,andIntensiveOutpatientProgram:100%ofContractRates
Detoxification,InpatientRehabilitation,Day/EveningHospital,andIntensiveOutpatientProgram:Planpays50%ofAllowedAmountforfirst120days;after120days,Planpays80%oftheAllowedAmount
100%covered InpatientDetoxification:100%coveredTransitionalResidentialRecoveryServices:$100copayperadmission
SubstanceAbuseOutpatient
100%covered Planpays$25.50pervisitthen80%oftheremainingAllowedAmount.
100%covered 100%covered
MEDICALSUPPLIESANDEQUIPMENTOutpatientSurgicalSupplies
100%ofContractRates BasicMedicalpaysupto$21.25pervisitforsupplies,splintsanddressingsforsurgeryinaphysician’soffice.NoMajorMedicalispayable.
100%covered
OrthopedicAppliances Reimbursementof100%ofContractRatesorAllowedAmountforpurchaseorrentalprescribedbyaphysician,uptoonceeverycalendaryear.
HearingAids Forpatientswhosephysicianhascertifiedahearinglossthatmaybelessenedbytheuseofahearingaid.ThePlanpays80%oftheAllowedAmountforphysicianexaminationandinstrumentupto$750maximumforeachear,notmoreoftenthanonceduringany12-monthperiod.
DurableMedicalEquipment
ThePlanpays80%ofContractRates ThePlanpays80%oftheAllowedAmount.
100%coveredduringastayinahospitalorSkilledNursingFacility.
100%coveredduringastayinahospitalorSkilledNursingFacility.DurablemedicalequipmentforhomeuseiscoveredinaccordancewithKaiser'sdurablemedicalequipmentformularyguidelines.
OTHERSERVICESANDBENEFITSPediatricVisionCare(uptoage19)
RoutineEyeexamsarecoveredat100%upto$135perexam.However,amountspaidforroutineeyeexamswillreducetheannualframeandlensbenefit.
RoutineEyeExamsarecoveredthroughtheHMOat100%.IfyougooutsideyourHMOforroutineeyeexams,theFundwillpay100%upto$135perexam.However,amountspaidbytheFundwillreducethe$135annualframeandlensbenefit.
A$135maximumbenefitforframesandlenseseachcalendaryear.
SOUTHERN CALIFORNIA DRUG BENEFIT FUND PLATINUMPLUSPLANSUMMARYASOFJANUARY1,2018
ThisdocumentisintendedmerelyasasummaryofthePlatinumPlushealthcareplanofferedbytheSouthernCaliforniaDrugBenefitFund.Forexclusionsandrestrictions,youshouldreadtheSummaryPlanDescriptionandtheevidenceofcoveragebookletsprovidedbyKaiser,UnitedHealthcare(formerlyPacifiCare),andUnitedConcordia.
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MEDICAL BENEFITS
INDEMNITYPLAN UNITEDHEALTHCARE(UHC)
KAISER PPO (In Network) Non-PPO (Out of Network)
AdultVisionCare(forage19andover)
A$135maximumbenefittobeusedforeyeexaminationsand/orframesandlenseseachcalendaryear.ForKaiserandUHC,ifeyeexamisobtainedthroughtheHMO,the$135IndemnityPlanbenefitcanbeappliedtoframesand/orlenses.Note:Youarepermittedtoopt-outofvisioncoverageforyourselfandyourDependents.ContacttheFundOfficeformoreinformation.
AdditionalAccidentalInjuryBenefit
InadditiontootherPlanbenefitsamaximumof$300ispayableforContractRates/AllowedAmountsforMedicallyNecessaryservicesandsuppliesincurredwithin90daysofanaccidentasaresultoftheaccident.
None None
PRESCRIPTION DRUG BENEFITS
INDEMNITYPLANUNITEDHEALTHCARE
(UHC)NON-KAISEREMPLOYEESENROLLEDINKAISER
KAISEREMPLOYEESENROLLEDINKAISER
ParticipatingPharmacy AllParticipantsmustuseSoCADrugFundParticipatingPharmacies.(SeeseparateDirectoryatwww.ufcwdrugtrust.orgunder“Downloads”)
MustuseKaiserpharmacies.
Out-of-PocketMaximum Therewillbenoout-of-pocketlimitontheparticipant’sexpenses.
MaximumDaysSupply Maximum30dayssupplyperprescription.Formaintenancedrugsincertaintherapeuticclassifications,a90-daysupplymaybeobtained.
Maximum100dayssupplyperprescription.
GenericPreventiveCareDrugs(includingFDAapprovedcontraceptives)
Planpays100%foraspirin,fluoridesupplement,folicacid,ironsupplement,andfemalecontraceptives;prescriptionrequiredforOTCavailabledrugs.Brandnameiscoveredwhereagenericisunavailableormedicallyinappropriate,butmustbeauthorizedbyOptumRx.Ageandfrequencylimitsapply.
100%covered,prescriptionrequired.
Generic $5copayperprescription. $5copayperprescription.
Brand $5copayperprescriptionifnogenericequivalentisavailable.$8copayperprescriptionifagenericequivalentisavailablebutyourdoctorindicates“dispenseaswritten.”Ifagenericequivalentisavailableandyourdoctordoesnotindicate“dispenseaswritten,”youmustpaythecostdifferencebetweenthegenericdrugandthebrandnamedrugplusthe$8copay.
$5copayperprescription.
Self-administeredInjectables
ThePlanpays80%ofOptumRx’sContractRate.AuthorizationrequiredthroughOptumRx.ForUHCenrollees,injectablesthatareprescribedbyUHCphysiciansandprovidedbyUHCarecoveredat100%bytheUHCplanandnotcoveredunderthePrescriptionDrugPlan.
$5copayperprescription.
SOUTHERN CALIFORNIA DRUG BENEFIT FUND PLATINUMPLUSPLANSUMMARYASOFJANUARY1,2018
ThisdocumentisintendedmerelyasasummaryofthePlatinumPlushealthcareplanofferedbytheSouthernCaliforniaDrugBenefitFund.Forexclusionsandrestrictions,youshouldreadtheSummaryPlanDescriptionandtheevidenceofcoveragebookletsprovidedbyKaiser,UnitedHealthcare(formerlyPacifiCare),andUnitedConcordia.
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DENTAL BENEFITS
INDEMNITYDENTALPLAN UNITEDCONCORDIAChoiceofProvider Youmayselectanydentistofyourchoice.UsingaDeltaPPOdentistwillloweryourout-of-
pocketexpenses.YoumustusetheUnitedConcordiadentalofficeinwhichyouareenrolled.
CalendarYearDeductible $50perperson;$150perfamily.Notapplicabletoroutinepreventiveanddiagnosticprocedures.
None.
CoveredCharges ForDeltaPPOdentists,thePlanpaysthelesseroftheDeltaPPOContractRatesortheamountlistedintheScheduleofAllowances.ForDeltaPremierdentists,thePlanpaysthelesseroftheDeltaPremierfiledfeesortheamountlistedintheScheduleofAllowances.Fornon-DeltaDentaldentists,thePlanpaysthelesseroftheamountbilledbythedentistortheamountlistedintheScheduleofAllowances.ScheduleofAllowancesisestablishedbytheTrusteesandadjustedannually(seeseparatescheduleatwww.ufcwdrugtrust.orgunder“Downloads”).
UnitedConcordia’sScheduleofBenefits.
Note:Youarepermittedtoopt-outofdentalbenefitsforyourselfandyourDependents.ContacttheFundOfficeformoreinformation.
ORTHODONTIC BENEFITS
CONTRACTEDORTHODONTISTS NON-CONTRACTEDORTHODONTISTSPrecertificationRequired AlltreatmentplansmustbeapprovedbythePlan’sOrthodonticConsultantbeforetreatmentbegins.Iftreatmentbeginsbefore
precertification,nobenefitswillbepaid.ContacttheFundOfficeformoreinformation.
FullTreatment ThePlanallowanceis$3,200.ThePlanpays$3,000ofthecontractrateafteryourcopaymentof$200.
Planpays80%ofchargesupto$3,000maximum.
LimitedTreatment Planpays80%ofthecontractrate.Youareresponsibleforthebalanceofthecontractrate.
Planpays80%ofchargesupto$2,600maximum.
PhaseOneTreatment ThePlanallowanceis$1,250.ThePlanpays$1,050ofthecontractrateafteryourcopaymentof$200
Planpays75%ofchargesupto$2,500maximum.
DevelopmentSupervision ThePlanallowanceis$270.ThePlanpays$220afteryourcopaymentof$50. Planpays80%ofchargesupto$270maximum.
LifetimeMaximumBenefit $3,000
SOUTHERN CALIFORNIA DRUG BENEFIT FUND PLATINUMPLUSPLANSUMMARYASOFJANUARY1,2018
ThisdocumentisintendedmerelyasasummaryofthePlatinumPlushealthcareplanofferedbytheSouthernCaliforniaDrugBenefitFund.Forexclusionsandrestrictions,youshouldreadtheSummaryPlanDescriptionandtheevidenceofcoveragebookletsprovidedbyKaiser,UnitedHealthcare(formerlyPacifiCare),andUnitedConcordia.
OE 2018 - Platinum Plus Plan Page 12 of 13
PLAN EXCLUSIONS
INDEMNITYPLAN KAISER&UNITEDHEALTHCARE
ExcludedMedicalServices 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;» Speechtherapy,exceptfromaPPOprovider;» Anyservicesorsuppliesnotrecommendedandapprovedbyalegallyqualifiedphysicianorsurgeon,
dentist,mentalhealthprofessional,podiatristonthePPOCpanel,orchiropractorperformingserviceswithinthelegalscopeoftheirpractices;
» ConditionscoveredbyWorkers’Compensationorincurredinthecourseofemployment,includingself-employment;
» PenileprosthesisunlesspreauthorizedbyAnthemBlueCross;» Pregnancyexpensesofdependentchildrenorexpensesforconditionsarisingfrompregnancyof
dependentchildren,exceptpreventivecareexpenses;
PleaserefertotheEvidenceofCoveragebookletsprovidedbyKaiserandUnitedHealthcare.
SOUTHERN CALIFORNIA DRUG BENEFIT FUND PLATINUMPLUSPLANSUMMARYASOFJANUARY1,2018
ThisdocumentisintendedmerelyasasummaryofthePlatinumPlushealthcareplanofferedbytheSouthernCaliforniaDrugBenefitFund.Forexclusionsandrestrictions,youshouldreadtheSummaryPlanDescriptionandtheevidenceofcoveragebookletsprovidedbyKaiser,UnitedHealthcare(formerlyPacifiCare),andUnitedConcordia.
OE 2018 - Platinum Plus Plan Page 13 of 13
PLAN EXCLUSIONS
INDEMNITYPLAN KAISER&UNITEDHEALTHCARE
ExcludedMedicalServices(cont’d)
» Surgicalcorrectionofrefractiveproblemsincludingradialkeratotomyunlessvisioncannotbecorrectedthrougheyeglassesorcontactlenses;
» Expensesincurredforanyconditionwherethereexistsnoinjuryorsickness,exceptthatthisexclusiondoesnotapplytobenefitsspecificallyprovided,suchashospicecare,sterilizationprocedures,andpreventivecarebenefits;
» Takehomedrugswhendischargedfromthehospital;» Expensesincurredbyatransplantdonorwhoisnoteligibleundertheplan(exceptforbenefits
specificallyprovided);» OrganortissuetransplantsperformedatafacilitythatisnotanAnthemBlueCrossCenterof
Expertise;» Expensesincurredbyanorganortissuedonorwhenthetransplantrecipientisnotaplanparticipant.» Vocationaltesting,evaluationandcounseling;» Injuriesresultingfromanyformofwarfareorinvasion;» Nobenefitswillbeprovidedforpodiatriccarereceivedfromanon-PPOCpodiatrist(ifyouliveoutside
ofCalifornianopodiatrybenefitswillbeprovidedunlessyouuseaBlueCardnetworkpodiatrist), exceptforthespecialpodiatrybenefit.Inaddition,benefitsforpodiatriccarearelimitedtothosespecificallydescribed;
» Claimsfiledmorethanoneyearafterthedateonwhichserviceswereincurred;» ServicesorsuppliesthatarenotNecessaryTreatment.
PleaserefertotheEvidenceofCoveragebookletsprovidedbyKaiserandUnitedHealthcare.
ThirdPartyLiability IfaParticipantobtainsarecoveryfromathirdpartythatisinanymannerrelatedtoclaimspaidbytheTrust,theParticipantwillreimbursetheTrustfromsuchrecoveryinanamountnotinexcessofthepaymentsmadeortobemadebytheFund.
PleaserefertotheEvidenceofCoveragebookletsprovidedbyKaiserandUnitedHealthcare.
DentalExclusions FortheIndemnityDentalPlan,pleasereadtheIndemnityScheduleofAllowancesforDentalProcedures(updatedeachJanuary).ForUnitedConcordia,pleaserefertheEvidenceofCoveragebookletprovidedbyUnitedConcordia.
PrescriptionDrugExclusions PleasecontacttheFundOffice.
SOUTHERN CALIFORNIA DRUG BENEFIT FUND 2220 HYPERION AVENUE • LOS ANGELES, CALIFORNIA 90027
TEL (323) 666-8910 • FAX (323) 663-9495 • WWW.UFCWDRUGTRUST.ORG
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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 at http://www.hhs.gov/ocr/office/file/index.html.
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