Important Medical & Dental Changes Coming January 1, 2019

Transcription

1 Open Enrollment: November 1-21, 2018 Important Medical & Dental Changes Coming January 1, 2019 What s Inside What s New Starting January 1, What Does this Mean for You? 3 No Change to Vision Benefits 3 Why Is the Trust Fund Making These Changes? 4 Why Keep Kaiser? 5 About the New Anthem PPO 5 How Will the New Anthem PPO Pay Benefits? 7 Prescription Drug Administrator for Anthem PPO 9 About Anthem s Explanation of Benefits (EOB) Statement 10 Anthem s Continuity of Care/ Transition of Care Program 11 About the Kaiser HMO 12 About the New UHC Dental Plan Options 15 Questions? 16 Glossary of Healthcare Terms 16

2 What s New Starting January 1, 2019 NEW! SAME! New Anthem Preferred Provider Organization (PPO) replaces: All Health Maintenance Organizations (HMOs) except Kaiser, UnitedHealthcare (UHC) PPO and Exclusive Provider Organization (EPO), and Current Anthem PPO. Kaiser HMO will continue to be available in California and Colorado. Are you currently enrolled in any medical plan except the Kaiser HMO? Then, if you take no action, you ll be enrolled automatically in the new Anthem PPO. Or, choose the Kaiser HMO during Open Enrollment. Are you currently enrolled in the Kaiser HMO? Then, if you take no action, you ll be automatically enrolled in the Kaiser HMO. Or, choose the new Anthem PPO during Open Enrollment. Are you not enrolled in any Southwest Carpenters Trust Fund medical plan as of October 31, 2018? Do you want to enroll for coverage effective January 1, 2019? Then, complete an enrollment form to enroll in the Anthem PPO or Kaiser HMO. SAME! NEW! NEW! Express Scripts (ESI) will administer prescription drug coverage under the Anthem PPO. Kaiser will continue administering prescription drug coverage under their plan. Are you changing to the Anthem PPO for 2019 but your provider isn t in Anthem s network? If you re being treated for a serious or chronic illness or certain condition that s expected to last past December 31, 2018, then Anthem s dedicated transition team can help. (See page 15.) The Trust Fund s current dental plan options will be replaced by new, enhanced options effective January 1, 2019, all administered by UnitedHealthcare (UHC). (See page 11.) No Change to Vision Benefits SAME! Vision benefits will remain the same for They will continue to be administered through UnitedHealthcare, no matter which medical plan you are enrolled in. 2 Southwest Carpenters Trust Fund

3 What Does this Mean for You? Medical Coverage If You Don t live in California or Colorado and are now enrolled in any Southwest Carpenters Trust Fund medical plan, Live in California or Colorado and are now enrolled in the Anthem PPO, UnitedHealthcare HMO or UnitedHealthcare EPO, Live in California or Colorado and are now enrolled in the Kaiser HMO, Are eligible but not enrolled in any Southwest Carpenters Trust Fund medical plan as of October 31, 2018, Here s What Will Happen You ll be enrolled automatically in the Anthem PPO for coverage effective January 1, You ll be enrolled automatically in the Anthem PPO for coverage effective January 1, 2019, or You can choose the Kaiser HMO during Open Enrollment for coverage effective January 1, You ll be enrolled automatically in the Kaiser HMO for coverage effective January 1, 2019, or You can choose the Anthem PPO during Open Enrollment for coverage effective January 1, You ll need to complete an enrollment form to enroll in the Anthem PPO or the Kaiser HMO effective January 1, Dental Coverage If You Are now enrolled in any Southwest Carpenters Trust Fund dental plan, Are eligible but not enrolled in any Southwest Carpenters Trust Fund dental plan as of October 31, 2018, Here s What Will Happen You ll be enrolled automatically in one of the enhanced UHC dental copayment plans* for coverage effective January 1, 2019, or You can choose the UHC DPPO during Open Enrollment for coverage effective January 1, You ll need to complete an enrollment form to enroll in a dental plan effective January 1, *The copayment plans are not available in all states. If you live in a state where a copayment plan is not available, you will be enrolled automatically in the UHC DPPO for coverage effective January 1, For more information on all dental plans, see page 15. See the Glossary of Healthcare Terms on page 16 for key healthcare definitions. About Dental and Vision Coverage You ll have two new and improved dental plan options for (See page 15.) Vision coverage through UnitedHealthcare will continue unchanged. Southwest Carpenters Trust Fund 3

4 What Should I Do if I m New to the Anthem PPO? Check that your doctor, hospital, lab and other healthcare facilities are in Anthem s PPO network. If they re not, you ll pay more when you need to access care. Because Anthem s network is so large, many providers will be in-network. To find an in-network provider, visit anthem.com/ca and follow these steps: If you ARE registered on the site: ccselect the Member icon and sign in. ccunder Useful Tools (on the right), select Find a Doctor. ccselect the type of doctor or medical professional, area of specialty and location, plus the name of the doctor or medical professional, if available. ccselect Search. If you ARE NOT registered on the site: ccselect Menu. ccselect Find a Doctor. ccselect Blue Cross PPO (Prudent Buyer) Large Group. ccselect the type of doctor or medical professional, area of specialty and location, plus the name of the doctor or medical professional, if available. ccselect Search. Or, call Anthem: (833) Call Express Scripts at (800) to check that any prescription drugs you take are on the Express Scripts formulary (the list of covered drugs). If they re not, you ll pay more for them. If the drug you re taking is not on the Express Scripts formulary, contact your doctor to discuss alternative/preferred medications. Why Is the Trust Fund Making These Changes? Medical and prescription drug costs are rising across the country. The Trust Fund is making every effort to manage these costs while providing competitive benefits. The new Anthem PPO will help manage rising costs because the plan will now be self-funded. Self-funded means the Trust Fund will be responsible for paying participants healthcare claims versus paying premiums for individuals covered under the plan. Anthem will only process the claims. The Trust Fund will no longer pay high insurance premiums to insurance carriers like Anthem. Instead, Anthem will be paid a much lower fee to process claims. Plus, the Trust Fund will save on Affordable Care Act fees, estimated to be $4.5 million this year alone, since self-funded plans aren t required to pay these fees. These savings will help the Trust Fund better manage rising costs and continue to offer competitive healthcare coverage in the coming years. 4 Southwest Carpenters Trust Fund

5 Why Keep Kaiser? Although the Trust Fund s other HMOs will be discontinued, the Kaiser HMO in California and Colorado will continue. The Trust Fund has a long, trusted relationship with Kaiser and is excited to continue working with them. They, too, are making cost-effective changes to their plan, many of which will benefit you in See page 12 for details. In addition, Kaiser: Has a large network (most HMOs don t), so there are lots of doctors, hospitals, labs and other healthcare facilities to choose from Has their own pharmacy (which saves you money), plus Kaiser pharmacies are conveniently located in their medical buildings, so you avoid a trip to a retail pharmacy Is good at managing healthcare costs, which helps you save money when you need care Is a non-profit organization, so the Trust Fund pays lower Affordable Care Act fees (required by the federal government) About the New Anthem PPO What Are the Anthem PPO Enhancements? You ll pay less for in-network services under the new Anthem PPO than the current Anthem PPO: Plan Feature Current Anthem PPO Enhanced Anthem PPO Effective January 1, 2019 In-network calendar year deductible $500 per person/$1,500 family maximum $300 per person/$900 family maximum In-network calendar year out-of-pocket maximum In-network coinsurance what you pay for most covered services after you meet the calendar year deductible $5,600 per person/$11,200 family maximum 20% 10% $2,500 per person/$5,000 family maximum Southwest Carpenters Trust Fund 5

6 What Does the Enhanced Anthem PPO Offer? What Anthem Offers Large, nationwide network of providers In-network and out-of-network coverage No referrals Customer service-oriented Member Services team available 12 hours/day Special team dedicated to continuation of care/transition of care More services and tools Mobile app Easy-to-use website Benefit to You Choose from the same Anthem network available through the current plan, with lots of doctors, hospitals, labs and other healthcare facilities. Receive in-network care almost anywhere in the US. See any doctor and get benefits (but, stay in-network and get the greatest benefit). See any specialist any time. Speak to a team member Monday through Friday, 8:00 a.m. to 8:00 p.m. PT. Get help from Anthem if your provider is not in the Anthem network and you re being treated for a serious or chronic illness or certain condition that s expected to last past December 31, 2018 (see page 11). Use Anthem tools to navigate the healthcare system, pay less and get more, and receive care more conveniently (see page 14). Use the Anthem app to access benefits information, manage claims, find doctors, hospitals, labs and other healthcare facilities and get a new ID card. Spend less time searching for what you need. How Will the Enhanced Anthem PPO Work? For most covered expenses, you pay the calendar year deductible before the plan starts paying benefits. Once you pay the calendar year deductible, you pay a percentage of covered expenses and the plan pays the rest, until you reach the calendar year out-of-pocket maximum. Then, the plan pays 100% of covered expenses for the rest of the calendar year. However, the plan pays 100% of the cost of in-network routine preventive care (like your annual physical) and related lab fees and tests with no deductible or copay. 6 Southwest Carpenters Trust Fund

7 How Will the New Anthem PPO Pay Benefits? Anthem Preferred Provider Organization (PPO) Plan Effective January 1, 2019 AVAILABLE IN ALL STATES What YOU Pay Plan Feature In-Network Out-of-Network Calendar Year Deductible (applies to all medical benefits unless noted otherwise) Calendar Year Out-of-Pocket Maximum (includes deductibles and most copays & coinsurance) $300 per person/$900 family maximum $500 per person/$1,500 family maximum $2,500 per person/$5,000 family maximum None, except for emergency care Inpatient 10% 50% Outpatient Surgery 10% Emergency Room (copay waived if admitted) Ambulance Services (deductible does not apply) Extended Care Facility $250 copay per visit, then 10% 50% ($5,000 maximum allowable per session) $250 copay per visit, then 10% (50% if not true emergency) $50 per trip $0 for first 30 days; 10% thereafter for room and board and 10% for other services; 180-day limit per disability Preventive Care Office Visit $0; deductible does not apply 50% Physical Exam, Screenings, Laboratory and Other Tests & Immunizations $0; deductible does not apply 50% Physician Inpatient Surgery 10% 10% Physician Outpatient Surgery 10% 50% Physician Hospital Visits 10% 50% Physician Office Visits 10% 50% Second Surgical Opinion from a Specialist $0 (up to $150 charge); deductible does not apply Maternity (certain pregnancy-related services are covered under the Preventive Same as any illness; no coverage for enrolled children Services benefit at 100% if in-network) Diagnostic X-ray & Lab (Outpatient) 10% 50% Durable Medical Equipment and Corrective Appliances 10% 50% Southwest Carpenters Trust Fund 7

8 AVAILABLE IN ALL STATES What YOU Pay Plan Feature In-Network Out-of-Network Home Healthcare/Nursing Care (at home) Chiropractor Physical Therapy (short-term outpatient) Limited to 20 visits per calendar year in-network and out-of-network combined Speech Therapy (short-term outpatient) Limited to 130 visits per lifetime in-network and out-of-network combined 10% 50% $0, up $10 per visit; 100% above $10 per visit; limited to 24 visits per calendar year 10% 50% 10% 50% Other Covered Services and Supplies 10% 50% How Benefits Are Coordinated With Other Coverage If you or your dependents are covered under a Southwest Carpenters Trust Fund plan and another group medical plan, benefits will be coordinated between the plans. For details on how coordination of benefits works, visit carpenterssw.org/en/faqs/open-enrollment. Comparing Enhanced Anthem PPO In-Network to Out-of-Network Benefits In-network providers have contracted with Anthem to charge discounted fees for their services. Out-of-network providers have no agreement with Anthem and may charge significantly higher amounts. This example shows how using in-network providers can lower your out-of-pocket costs. It compares the cost of in-network vs. out-of-network hospital care for an outpatient procedure and assumes the annual deductible has been met. Plan Feature In-Network Hospital Out-of-Network Hospital Hospital expenses for a one-day outpatient hospital stay $10,000 (reflects PPO in-network discounted fee) $15,000 Plan pays $9,000 (90%) $7,500 (50%) You pay $1,000 (10%) $7,500 (50%) You save $6,500 by using an in-network hospital. 8 Southwest Carpenters Trust Fund

9 For Anthem PPO Members: Prescription Drug Administrator Will Be Express Scripts Express Scripts: Processes claims for retail (store) and mail order prescriptions, Is a separate organization from Anthem, Is the largest independent manager of pharmacy benefits in the US and one of the country s largest pharmacies, serving more than 85 million people, Offers a network that includes retail chains like Sav-On, Smith s, Wal-Mart, Safeway and CVS; regional drug store chains; and thousands of independently-owned pharmacies, and Has free Standard delivery for prescriptions filled through the Express Scripts Pharmacy SM. Prescriptions are delivered to your home. On the go? Download the Express Scripts app from the App Store or Google Play. Find out if your pharmacy participates in Express Scripts network: log in at expressscripts.com and choose Find a Pharmacy from the menu under Prescriptions. You can also call (800) Manage Your Prescription Benefits Online, 24/7 Starting January 1, 2019, visit expressscripts.com, register using your member ID number, and you can: Check mail order status with tracking Refill a mail order prescription Enroll in automatic refills Find ways to save money Transfer a prescription from a retail pharmacy to mail order View claims, balances and prescription history Check for drug interactions and sign up for online medicine alerts Get instant access to your digital member ID card Plan Feature Calendar Year Out-of-Pocket Maximum Generic What YOU Pay Participating Retail Pharmacy (Up to a 30-day Supply) $10 copay ($0 no copay for prescription contraceptives) $1,000 per person/$2,000 per family Formulary Brand $40 copay $100 copay Non-Formulary Brand $60 copay $150 copay Specialty $50 copay $100 copay Formulary/Non-Formulary Brand When Generic Equivalent IS Available Brand copay PLUS difference in cost between brand and generic Mail Order from Express Scripts Pharmacy (31- to 90-day Supply) $25 copay ($0 no copay for prescription contraceptives) Brand copay PLUS difference in cost between brand and generic Southwest Carpenters Trust Fund 9

10 Express Scripts by Mail Required for Long-Term ( Maintenance ) Drugs After filling a long-term prescription drug twice at a participating retail pharmacy, you must fill your prescription through the Express Scripts Pharmacy to receive plan benefits. Otherwise, you ll pay the full cost of the prescription. Long-term drugs are those prescribed by your doctor for ongoing conditions like high blood pressure or high cholesterol typically for 31 days or more. To get started with mail order as of January 1, ask your doctor to write your prescription for a three-month supply with refills as needed, instead of a one-month supply with refills. Then, choose one of these ways to order: E-Prescribing (the fastest way for Express Scripts to receive your order). Ask your doctor to e-prescribe your prescription to Express Scripts. Fax. Only doctors can fax prescriptions; the fax number is (800) expressscripts.com. Log in and choose Pharmacy options under the Prescriptions menu. The Express Scripts Pharmacy will contact your doctor for a 90-day prescription. Phone. Call (800) In most cases, Express Scripts will be able to contact your doctor to arrange for your first home delivery supply. Typically, first-time prescription are delivered within 8 to 11 days after your prescription is received; refills take less time, especially if ordered online. About Anthem s Explanation of Benefits (EOB) Statement You ll get an Explanation of Benefits (EOB) statement each time you receive care in-network or out-of-network. (See the sample at right.) EOB Sample The EOB will show: How much your doctor, hospital, lab or other healthcare facility charged, and the discounted fee (if you received in-network care), How much the plan pays, If you owe money, What you ve paid toward your deductible for the c urrent calendar year, The amount applied to your deductible for your claim, and The amount not covered and why (such as services not covered under the plan or charges exceeding the allowed amount for this service in your area). Check your EOB carefully to make sure the amount you owe is correct! Payment at Time of Service Under the Anthem PPO Note that Anthem in-network providers can only charge you for copays or services not covered by the plan at the time of service. They cannot charge you deductible or coinsurance amounts until your claim is processed and the EOB is sent to you. For example, if you have an office visit with an Anthem PPO doctor, the doctor s office cannot charge you for the deductible and 10% coinsurance until you receive your EOB. However, if the doctor performs a service not covered by the plan such as a botox injection, the doctor s office can charge you for that service at the time you receive it. 10 Southwest Carpenters Trust Fund

11 Anthem s Continuity of Care/Transition of Care Program If you ll be covered under the Anthem PPO and your healthcare provider is not in Anthem s network, and you re being treated for a serious or chronic illness or certain condition that s expected to last past December 31, 2018, Anthem has a dedicated team to help you. Plus, you may be eligible for Anthem s Continuity/Transition of Care Assistance Program, which covers certain out-of-network care at the in-network benefits level. You may request Continuity/Transition of Care Assistance if you: Are being treated for an acute medical condition* or a serious chronic condition** Have surgery or another procedure that was authorized by your current plan and is scheduled to occur within 180 days after January 1, 2019 Are pregnant (regardless of trimester) Have a terminal illness Are being treated for a behavioral health condition Have a newborn child between the ages of birth and 36 months who is receiving treatment (healthcare services related to the child s condition may be provided for a time necessary to complete a course of treatment and to arrange for a safe transfer to a network provider) *Acute medical condition: Sudden onset of symptoms from an illness, injury or other medical problem that requires prompt medical attention and lasts for a limited time. **Serious chronic condition: Disease, illness or other medical problem (such as cancer) that is serious and continues without getting better completely or worsens, or requires ongoing treatment to keep it from happening again or prevent it from getting worse. To Request Continuity of Care/Transition of Care Assistance from Anthem: OR Call Anthem: (877) Complete the Continuity of Care/Transition of Care Request Form (available from Anthem or at carpenterssw.org/en/ forms-docs). Then, fax it to Anthem: (877) Southwest Carpenters Trust Fund 11

12 About the Kaiser HMO How Is Kaiser HMO Coverage Changing? Kaiser HMO coverage will change as follows: Plan Feature Doctor office visit copays (decrease) Specialist office visit copays (decrease) Calendar year out-of-pocket maximum (increase) Hospital deductible (new) Inpatient hospital, outpatient hospital and emergency room services (uniformity) Prescription drugs: retail preferred brand up to 30-day supply (decrease in CA) Prescription drugs: retail specialty up to 30-day supply (decrease) Prescription drugs: mail order preferred brand up to 100-day supply (decrease in CA) Current Kaiser HMO CA: $20 CO: $20 plus 10% for procedures performed CA: $40 CO: $30 plus 10% for procedures performed CA: $1,500 per person/ $3,000 family maximum CO: $2,000 per person/ $4,000 family maximum None CA and CO: various copays CA: $35 CO: $30 CA: $35 CO: 20% up to $250 per drug CA: $70 CO: $60 Kaiser HMO Effective January 1, 2019 CA and CO: $10 CA and CO: $20 CA and CO: $2,500 per person/ $5,000 family maximum CA and CO: $300 per person/ $600 family maximum CA and CO: 10% after calendar year deductible CA and CO: $30 CA and CO: $30 CA and CO: $60 For 2019 Kaiser HMO coverage details, visit bit.ly/2019-medical-plans. 12 Southwest Carpenters Trust Fund

13 What s the Difference Between the Kaiser HMO and the New Anthem PPO? Plan Feature Kaiser HMO Anthem PPO How does this plan provide care? Primary Care Provider (PCP) required? PCP referral needed to see specialist/ go to hospital? Benefits paid for care from non-network doctors, hospitals, labs and other healthcare facilities? Provides comprehensive medical coverage for care from Kaiser HMO network doctors, hospitals, labs and other healthcare facilities, plus prescription drug coverage. Benefits ARE NOT paid for care from non-kaiser network providers (except in cases of life-threatening emergency). Encourages members to choose a personal physician who will provide or coordinate all medical services. You re free to change doctors any time, for any reason. CA: Referrals needed for specialists except for obstetrics/gynecology, optometry, most psychiatry or substance use disorder treatment. CO: Referrals not needed for specialists. CA and CO: Referrals needed for hospitalization, except life-threatening emergencies. No, except for life-threatening emergencies. Emergencies covered? Yes Yes Coverage for out-of-state care? No, but you re covered for emergency and urgent care anywhere in the world. Kaiser helps members get care when they are traveling in another Kaiser Permanente service area, traveling in the US but outside a Kaiser Permanente service area, or traveling internationally. Yes Pay calendar year deductible before plan pays benefits? Routine preventive care covered at 100%? For details, call the Away from Home Travel Line at (951) or visit kp.org/travel. Only for hospital services. Yes How are prescription drugs covered? Copay only. Copay only. Mail order drugs covered? Yes Yes Need to file claims? No claims processing is handled internally at Kaiser. Provides comprehensive medical coverage for care from PPO network doctors, hospitals, labs and other healthcare facilities that agree to charge lower, negotiated fees for covered medical services. Lower benefits are paid for care from non-ppo network providers than from network providers. Prescription drug coverage is administered by Express Scripts. No No Yes (but you pay more for out-of-network care). Yes (except for in-network preventive care). Yes in-network; covered 50% out-of-network. No, if you receive in-network care; yes, if you receive out-of-network care. Southwest Carpenters Trust Fund 13

14 What Does the Kaiser HMO Offer? One-stop-shop Integrated care What Kaiser Has to Offer Large network of doctors, hospitals, labs and other healthcare providers Choose a primary care provider (PCP) specific to you Referrals for specialties vary by state Copays for most healthcare services and treatment Mobile app Easy-to-use website Benefit to You All your medical care including routine care, specialty care, urgent care and prescription drugs is provided by Kaiser. Kaiser doctors, nurses, pharmacies and specialists are all connected to each other, and to you, through your electronic health record. So they know important things about you and your health like your medical history, what medications you re taking and when you re due for a screening. Chances are very good there s a Kaiser provider near you. Your PCP will get to know you and your health issues, and help manage your care. He/she may specialize in: Adult medicine/internal medicine, Family medicine, Pediatrics/adolescent medicine (for children up to 18), and Obstetrics/gynecology. You re free to change doctors any time, for any reason. You can also see different doctors at different locations whatever works best for you. CA: You can make an appointment directly for: Obstetrics/gynecology, Optometry, Psychiatry, and Chemical dependency or addiction care. CO: You can make an appointment directly for most specialties. What you pay when you need care is more predictable and easier to manage. your doctor, view labs, schedule appointments, refill prescriptions, find doctors, hospitals, labs and other healthcare facilities and access your ID card. Get all the information you need about the plan in one place, online, 24/7 find providers, refill and track your prescriptions, check your plan coverage and benefits, manage claims and learn about available health and wellness programs. Anthem and Kaiser Apps, and Special Services! Go to the App Store or Google Play and download the Anthem BC Anywhere app or the Kaiser Permanente app. You can use these apps to find a doctor, check your claims, refill a prescription and so much more when you re on the go! Anthem and Kaiser also offer special services, like a cost estimator tool, 24/7 Nurseline, video visits with US-based and board-certified doctors, and many other valuable services. Visit the 2019 Open Enrollment page on carpenterssw.org for details. 14 Southwest Carpenters Trust Fund

15 About the New UHC Dental Plan Options The Trust Fund s current dental plan options will be replaced by these new options effective January 1, 2019, all administered by UnitedHealthcare (UHC): Two copayment plans: the Select Managed Care Direct Compensation (DC) Plan in California and Nevada, or the In-Network Only (INO) Plan (also known as a DHMO Plan) in all other states*, or Dental Preferred Provider Organization (DPPO), available in all states. The new dental plans offer these enhancements over the current dental plans: For 2019, in most states you will have a choice between one of the two copayment plans (DC or INO) and the DPPO. Under the copayment plans, your copays for most dental services will be either the same as or less than the copays under the current DHMOs. Under the new DPPO, you can choose from a larger network of dentists than under the current DHMO and new copayment plans. It s likely that the network dentists you use now are in the DPPO network. Also, the DPPO gives you access to non-network dentists. All UHC dental plans pay for diagnostic and preventive services at 100%, so you ll have no out-of-pocket costs for these routine services. * The UHC INO is not available in Alaska, Alabama, Arkansas, Connecticut, Georgia, Hawaii, Idaho, Illinois, Kansas, Kentucky, Louisiana, Maryland, Maine, Missouri, Mississippi, Montana, New Mexico, North Carolina, North Dakota, Oklahoma, Texas and Vermont. If you live in any of these states, you will be enrolled automatically in the UHC DPPO for coverage effective January 1, Below is a comparison of how the dental plans will pay benefits. See the Glossary of Healthcare Terms on page 16 for definitions of key terms used in this chart. Plan Feature Diagnostic and Preventive Care (e.g., routine cleanings, exams and x-rays) What YOU Pay Dental Preferred Provider Organization (DPPO) Select Managed Care Direct Compensation (DC) Plan and In-Network Only (INO) Plan In-Network Out-of-Network In-Network Only $0 covered in full 50%; deductible does not apply $0 covered in full Calendar Year Deductible $50 per person/$150 family maximum None Basic Services (e.g., filling, crown) 50% Copay only, based on benefits schedule** Major Services (e.g., root canal, oral surgery, dentures) 50% Copay only, based on benefits schedule** Orthodontic Services (e.g., braces children and adults) 50% Copay only, based on benefits schedule** Annual Benefit Maximum $2,000 per person CA and NV: None All other states: $2,000 per person CA and NV: $1,500 copay Orthodontic Benefit ** For the DC and INO copay schedule, visit welcometouhc.com/csac. Lifetime benefit maximum: $2,000 per person All other states: Lifetime benefit maximum: $2,000 per person Southwest Carpenters Trust Fund 15

16 Questions? Resource Website Phone Number Customer Service Hours Southwest Carpenters Trust Fund carpenterssw.org (213) or (800) M-F 8:00 a.m. to 5:00 p.m. PT Anthem Member Services anthem.com/ca (833) M-F 8:00 a.m. to 8:00 p.m. PT Express Scripts (prescriptions for Anthem members) expressscripts.com (800) Kaiser California kp.org (800) hours/day; 7 days/week except holidays 24 hours/day; 7 days/week except holidays Kaiser Colorado kp.org (844) M-F 8:00 a.m. to 6:00 p.m. MT UnitedHealthcare Dental Member Services welcometouhc.com/csac (800) M-F 4:30 a.m. to 6:00 p.m. PT UnitedHealthcare Vision Member Services myuhcvision.com (800) M-F 5:00 a.m. to 8:00 p.m. PT Glossary of Healthcare Terms Calendar Year Deductible. The amount you pay for covered medical care and services each plan year before the plan pays benefits. Once you ve met the deductible, you share the cost of covered medical care and services with the plan through coinsurance or copays. Calendar Year Out-of-Pocket Maximum. The most you pay out-of-pocket each plan year for covered healthcare expenses. When you meet the out-of-pocket maximum, the plan will pay 100% of covered expenses for the rest of the plan year. Coinsurance. The percentage of the cost you pay when you receive certain covered healthcare services. Generally, you start paying coinsurance after you meet your calendar year deductible. (See calendar year deductible above.) Copay. The flat-dollar amount you pay when you receive certain covered healthcare services or when you fill a prescription. Dental Preferred Provider Organization (DPPO): A dental plan that pays benefits when you receive care from in-network or out-of-network providers. The plan pays higher benefits for in-network care. Direct Compensation (DC) Plan: This refers to UnitedHealthcare s copayment dental plan that pays benefits only when you see network providers (except for emergencies); it s available only in California and Nevada. The Plan s full name is the Select Managed Care Direct Compensation Plan. EOB. The Explanation of Benefits statement sent to you by your health plan administrator. This explains the payments made for the healthcare treatments and/or services provided to you or your covered dependents. It also shows what you may owe. An EOB is not a bill for healthcare services. Exclusive Provider Organization (EPO): A medical plan that pays benefits only when you see in-network providers and receive in-network services (except for emergency care). Generally, you can see any in-network provider without a referral from your primary care provider. Health Maintenance Organization (HMO): A medical plan that pays benefits only when you see in-network providers and receive in-network services (except for emergency care). In-Network-Only (INO) Plan: This refers to UnitedHealthcare s copayment dental plan (also known as a Dental Health Maintenance Organization, or DHMO Plan). This plan pays benefits only when you see network providers (except for emergencies); it s available in all states except California and Nevada. Preferred Provider Organization (PPO): A medical plan that pays benefits when you receive care from in-network or out-of-network providers. The plan pays higher benefits for in-network care. For definitions of other common healthcare terms, visit bit.ly/en-glossary. The information provided in this booklet is of a general nature only and does not replace or alter the official rules and policies contained in the plan documents that legally govern the terms and operation of the Southwest Carpenters Health and Welfare Trust Fund. If this publication differs in any way from the official plan documents, the official plan documents will govern. Receipt of this publication does not guarantee eligibility for benefits. The Trustees have the right to modify benefits at any time. August 2018