Your Dental benefits are provided through Delta Dental.
Your Vision benefits are provided through VSP.
Your Chemical Dependency benefits are provided through the Beat It! EAP.
LEVEL ONE |
LEVEL TWO |
|
PPO PROVIDERS |
OUT OF NETWORK |
|
| Deductible Individual | $0 (eff. 1/1/10) |
$250 |
| Deductible Family | $0 (eff. 1/1/10) |
$500 |
| Annual Out-of-Pocket Maximum | The out of pocket maximum is $1,250 per individual and $2,500 per family. (eff. 1/1/10) |
The out of pocket maximum is $2,000 per individual and $4,000 per family. |
Deductible and office visit copayments do not apply to the out of pocket maximum. |
Deductible and office visit copayments do not apply to the out of pocket maximum. |
|
| LIFETIME MAXIMUM | $2,000,000 per individual |
$2,000,000 per individual |
BENEFITS FOR COVERED SERVICES |
BENEFITS FOR COVERED SERVICES |
|
| Physician Services | ||
| Office visits | $15 COPAYMENT |
$15 COPAYMENT |
| Hospital/Skilled Nursing visits | 90% |
60% |
| Specialists | $15 COPAYMENT |
$15 COPAYMENT |
| Surgeon/Asst. Surgeon | 90% |
60% |
| Anesthesiologist | 90% |
60% |
| Diagnostic X-ray & Labs | 90% |
60% |
| Preventive Care | ||
| Routine Physical Exam | 90%, up to $200 annual maximum |
60%, up to $200 annual maximum |
| Well Baby Care | 90%, Covered from birth to age 3 |
60%, Covered from birth to age 3 |
| Immunizations | 90%, Covered from birth to age 3 |
60%, Covered from birth to age 3 |
| Hospital/Surgical Services | ||
| Inpatient*** | 90% |
60% |
| Outpatient | 90% |
60% |
| Emergency Services | ||
| Ambulance | 90% |
90% |
| Emergency Room | 90% after $50 copay, |
60% after $50 copay, |
Waived if Admitted |
Waived if Admitted |
|
| Maternity Services: | ||
| Hospital Benefits – Delivery*** | 90% |
60% |
| Outpatient Physician Services | 90% |
60% |
| Surgical Services | 90% |
60% |
| Prescription Drugs | ||
| Retail Purchase Limit of 2 fills per medication at a retail pharmacy, not to exceed 30 day supplies for each fill |
$5 Generic/$15 Preferred Brand/$25 Non-Preferred Brand |
$5 Generic/$15 Preferred Brand/$25 Non-Preferred Brand |
| Generic or Brand maximum amount | 30 day supply |
30 day supply |
| Mail Order Purchase Required for all maintenance medications, after 2 fills at a retail pharmacy, not to exceed 90 day supplies. |
$10 Generic and $30 Preferred Brand/$50 Non-Preferred Brand |
$10 Generic and $30 Preferred Brand/$50 Non-Preferred Brand |
| Generic or Brand maximum amount | 90 day supply |
90 day supply |
**IMPORTANT: The IBEW Local 617 drug plan requires utilization of the mail order pharmacy for medications taken on a long term basis. Copayments increase two fold upon the third prescription fill for any medication not filled by the plan's mail order pharmacy. Copayments are reduced by one third for ninety day supplies obtained through the mail order pharmacy. All new (first time) prescriptions for long term medications should first be filled at a local retail pharmacy for the first two fills, to evaluate efficacy and tolerability, before ninety day maintenance supplies are ordered through the mail order pharmacy. |
||
| Substance Abuse Treatment | ||
For inpatient or outpatient services for substance abuse treatment, please contact UAS at 408-288-4400 |
For inpatient or outpatient services for substance abuse treatment, please contact UAS at 408-288-4400 |
|
| Hospital Benefits – *** | 90%, max 30 days per calendar year |
60%, max 30 days per calendar year |
| Outpatient Physician Services |
90%** |
60% ** |
| Mental and Nervous (excludes severe mental disorders) | ||
| Hospital Benefits – *** | 90%, max 30 days per calendar year |
60%, max 30 days per calendar year |
| Outpatient Physician Services |
90%** |
60% ** |
| Chiropractic Services and Acupuncture Services | ||
|
90%** |
60%** |
|
| Continued Care Services | ||
| Home Health Care | 90%** |
60%** |
| Skilled Nursing Facility | Following discharge from an acute care facility, plan pays 90%. |
Following discharge from an acute care facility, plan pays 60%. |
| Physical Therapy | ||
90%** |
60%** |
|
| Speech Therapy | ||
90%** |
60%** |
|
**Note: There is a 30 visit per calendar year limit for these services
***Note: Precertification of services is required for non-emergency hospital admissions.
On an annual basis, the Board of Trustees evaluate the renewals received from our vendor partners to determine market competitiveness. This past renewal was unacceptable and the Board of Trustees decided to market the program. After reviewing all the opportunities, the Board of Trustees decided to move to a self-funded program which provides the Board of Trustees important financial data to ensure the long term viability of the Health & Welfare program.
The Prudent Buyer Network is a Preferred Provider Organization (PPO) that is owned and operated by Anthem Blue Cross of California. The Prudent Buyer Network (PPO Providers) is an organization that operates under contract with the Administrator to provide hospital, medical and surgical services at agreed upon allowances. Prudent Buyer providers are located in California.
Prudent Buyer Allowances is the dollar amount allowed for each particular type of medical service by Prudent Buyer Providers. Prudent Buyer providers (PPO) have agreed to accept the allowance as full payment for service for Self Funded PPO Plan members, although they will often list a higher fee.
Usual Customary and Reasonable (UCR) is a range of fees which are usually charged and received for the given treatment by doctors of similar training within the appropriate geographic area.
The lifetime maximum is the total, “lifetime”, amount of available benefits for you under the program. Each of your dependents have their own “lifetime” maximum. The restoration benefit is an amount of $1,500 per year which will be added back (restored) each year you are covered under the plan.
On an annual basis, you may seek the services of your provider to conduct a routine physical. A routine physical is a periodic comprehensive preventive medicine reevaluation and management of an individual.
The eligible reimbursed expenses will vary depending on the age, gender, history, examination, risk factor reduction interventions and ordering of appropriate immunizations, laboratory/diagnostic procedures.
For 2 times the retail co-pay, you receive 3 times the medication by using the Mail Order Service available through US-RxCare. It is common to use these services for ongoing needed medications. Please contact US-RxCare directly at 775-786-6007 for any questions regarding your prescription drug plan.
Your Administrator, United Administrative Services, has been approved by Anthem Blue Cross of California (Prudent Buyer Network) to process claims utilizing the Prudent Buyer Network (PPO) discounts. After seeking services through a Prudent Buyer (PPO) network, your provider will send all necessary paperwork to Prudent Buyer (PPO), who will in turn work with UAS to provide the specifics of reimbursement. UAS will process the claim and send an explanation of benefits on how the claim was processed.
Please contact United Administrative Services directly at 408-288-4400 should you have any questions on your claim. Anthem Blue Cross cannot answer any questions about your specific claim.