OPERATING ENGINEERS HEALTH & WELFARE FUND BENEFIT PLANS SUMMARY COMPARISON FOR ACTIVE and RETIRED PARTICIPANTS

Transcription

1 PPO Plan For Non-PPO Providers Employee Premium None None None None None Explanation of Plans and Options Available to You Deductible Annual Out-of-Pocket If you choose a doctor who is not contracted with Anthem Blue Cross the Plan will pay the following benefits according to Plan rules The treatment must be a covered service $500 per individual per ; maximum $1,500 per family (Applicable to Most Services) Out of Network $6,000 per individual; $12,000 per family per If you use Anthem Blue Cross PPO providers, the Plan will pay the following benefits according to Plan rules Treatment must be rendered by a PPO contract provider and be a covered service $250 per individual per ; maximum $750 per family (Applicable to Most Services) In-Network $3,000 per individual; $6,000 per family per If you enroll in this plan you must use Kaiser facilities for all of your medical care If you enroll in this plan you must choose a participating medical group where you must go for all your medical care None None None $1,500 per individual $3,000 for two or more family members $1,500 per individual $3,000 for two family members $4,500 for three or more family members Calendar Year None None None None None If you enroll in this plan, you must choose a participating medical group where you must go for all your medical care $6,500 per individual Pre-Existing Condition Limitations None None None None None

2 PPO Plan Operating Engineers Kaiser Permanente Plan PROFESSIONAL SERVICES: Office Visits Plan pays $15 per visit. the contracted after a $20 co-pay per visit $25 co-pay per visit $25 co-pay per visit $5 co-pay per visit Hospital Visits the contracted $250 co-pay per admission $250 co-pay per admission Inpatient $100 co-pay per admission Outpatient $50 co-pay per admission Lab and X-Ray Therapy - Acupuncture & Chiropractic (Note: The combined 26 visit limit on the FFS and PPO plans is a combined limit. You do not receive a separate benefit of 26 visits under each plan.) reasonable Plan pays $15 per visit with a combined limit of 26 visits per the contracted Chiropractic - Plan pays 50% of the contracted Acupuncture - the contracted after a $20 co-pay per visit All services have a combined limit of 26 visits per calendar year Speech Therapy Plan pays $15 per visit the contracted Routine Physicals Plan covers 70% of reasonable to a maximum payment of $150 for one annual routine physical Plan covers 90% of the contracted to a maximum payment of $175 for one annual routine physical $10 co-pay per service $25 co-pay per visit (see Kaiser s Summary of Benefits for complete details) (see Health Net s Summary of Benefits of complete details) $5 co-pay per service $25 co-pay per visit No Charge $10 co-pay per visit $25 co-pay per visit $25 co-pay per visit $10 co-pay per visit $10 co-pay per visit. (see s Summary of Benefits for complete details) Surgeon the contracted Assistant Surgeon Anesthetist Urgent Care Services Plan pays 20% of payable to primary surgeon for one or more assistant surgeons. Plan pays 10% of payable to primary surgeon for physician assistant services performed as an assistant surgeon (Only if surgery warrants an Assistant Surgeon) the contracted (Only if surgery warrants an Assistant Surgeon) the contracted the contracted $35 per occurrence Not covered $35 per occurrence $20 per occurrence within service area $40 per occurrence outside of service area

3 HOSPITAL SERVICES: Inpatient Care Semi-Private Room and Misc. Charges Outpatient Care Emergency Room Care Non Emergency PPO Plan Plan pays $15 for Emergency Room Visit, 70% of reasonable for Lab and X-ray services contracted contracted $100 per admission $50 co-pay per visit Emergency Room Care Emergency related contracted $50 co-pay per visit Surgical Facility contracted $250 co-pay per procedure $250 co-pay per occurrence $50 co-pay per occurrence Inpatient Mental Health Care contracted of 45 days per of 30 days per $100 per admission of 30 days per Inpatient Alcohol and Substance Abuse Care contracted $250 per inpatient admission for detoxification. $100 co-pay per admission for transitional residential recovery services Detoxification only of $9,000 per of 60 days per, not to exceed 120 days in any 5 year period Skilled Nursing Facility Plan pays 80% of reasonable. Limited to 60 covered days per condition contracted. Limited to 60 covered days per condition 100 days per benefit period 100 days per 100 days per

4 PPO Plan OTHER SERVICES: Ambulance reasonable Plan pays 80% of the contract $50 per trip $50 per trip $50 per trip Hearing Aids Plan pays 100% to a maximum of $1,000 per aid (x2), once every 3 years See Fee-for-Service Plan option Not covered Not covered Not covered Durable Medical Equipment Prosthetic Appliances reasonable not to exceed purchase price reasonable the contract not to exceed purchase price contract In accordance with formulary Covered on a case by case basis Plan pays $200 per device with a lifetime maximum of $10,000, including repairs

5 PRESCRIPTION DRUGS: Contract Prescription Card Walk-in (30 Day Supply) At CVS Caremark Participating Pharmacies At participating pharmacies your co-pay is $10 for a Generic drug, $25 for a Preferred Brand Name drug and $40 for a Non-Preferred Brand Name drug. If there is a Generic equivalent for the Brand Name Drug, you will pay the co-pay PLUS 50% of the Brand Name and generic drugs PPO Plan At participating pharmacies your co-pay is $10 for a Generic drug, $25 for a Preferred Brand Name drug and $40 for a Non-Preferred Brand Name drug. If there is a Generic equivalent for the Brand Name Drug, you will pay the co-pay PLUS 50% of the Brand Name and generic drugs. Operating Engineers Kaiser Permanente Plan For Generic drugs at participating pharmacies you pay $10 for up to a 30 day supply, $20 for a 31 to 60 day supply, or $30 for a 61 to 100 day supply For Brand drugs at participating pharmacies you pay $20 for up to a 30 day supply, $40 for a 31 to 60 day supply or $60 for a 61 to 100 day supply At participating pharmacies you pay $10 for a Generic drug on the Health Net Recommended Drug List (RDL). For a RDL Brand Name drug you pay $30. For a drug not listed on the RDL you pay 50% of the drug cost At participating pharmacies you pay $7 for a Preferred Generic drug. For a Preferred Brand name drug with NO Generic equivalent you pay $30 Non-Preferred Generic or Non- Preferred Brand $50 per prescription Contract Prescription Card Mail Order (90 Day Supply) At the CVS Caremark Mail Order Pharmacy At the CVS Caremark Mail Order Pharmacy your co-pay is $25 for a Generic drug, $62.50 for a Preferred Brand Name drug and $100 for a Non-Preferred Brand Name drug. If there is a Generic equivalent to the Brand Name Drug, you will pay the co-pay PLUS 50% of the Brand Name and generic drugs At the CVS Caremark Mail Order Pharmacy your co-pay is $25 for a Generic drug, $62.50 for a Preferred Brand Name drug and $100 for a Non-Preferred Brand Name drug. If there is a Generic equivalent to the Brand Name Drug, you will pay the co-pay PLUS 50% of the Brand Name and generic drugs. For Generic drugs through mail order you pay $10 for up to a 30 day supply or $20 for a 31 to 100 day supply You pay twice the applicable co-pay as outlined above You pay twice the applicable co-pay as outlined above Fee-For-Service Prescription Drug Plan (Non-Participating Pharmacies) Plan pays 80% of reasonable after satisfaction of deductible. You may obtain a max of 60 days of any one drug, after that you must use the contracting pharmacies for additional refills. Continued purchases at NONparticipating pharmacies will be denied Plan pays 80% of reasonable after satisfaction of deductible. You may obtain a max of 60 days of any one drug, after that you must use the contracting pharmacies for additional refills. Continued purchases at NONparticipating pharmacies will be denied Not applicable Not applicable Not applicable

6 PPO Plan United Concordia Advantage Plan - DPPO United Concordia Concordia Plus - DHMO Delta Dental PMI - DHMO DENTAL/ORTHODONTIA CARE: Deductible $25 per person, per, $75 per family per (Combined dental/orthodontia deductible) $25 per person, per, $75 per family per (Combined dental/orthodontia deductible) Dental Services: $25 per person, per, $75 per family per Orthodontic Services: $100 per person, per, $300 per family per No deductible No deductible Dental Coverage Plan pays 100% of the non contract fee schedule. (approx. 60% of cost) Any balance remaining is patient co-pay Adult Benefit (19 years of age and older) is $6,000 in any two (2) year period, per person Plan pays 100% Adult Benefit (19 years of age and older) is $6,000 in any two (2) year period, per person Plan pays 100% In- Network Plan pays 50% Out-of- Network Calendar Year Benefit : $3,000 In-Network/Per Person $1,000 Out-of- Network/Per Person Plan pays 100% on most covered services coverage and copay s coverage and copay s Orthodontia Coverage Plan pays 50% of up to a lifetime maximum benefit of $2,000 Dependent Children only Plan pays 50% up to $995. Co-pay is also 50% up to $995 Lifetime maximum benefit of $2,000 Dependent Children only Plan pays 50% In and Out-of-Network Lifetime maximum benefit of $2,000 in and Out-of-Network Dependent Children only coverage and copay s Dependent Children and Adults coverage and copay s Dependent Children and Adults

7 PPO Plan Operating Engineers VISION CARE: Eye Examination $15 deductible $15 deductible $25 co-pay per visit $25 co-pay per visit Not Covered See Fee for Service Plan benefits Exam covered once every 12 months Exam covered once every 12 months Eye Lenses / Frames Lenses covered once every Lenses covered once every Lenses covered once every Lenses covered once every Lenses covered once every Frames covered once every Frames covered once every Frames covered once every Frames covered once every Frames covered once every (Local 12 Member) Only: Extra pair of glasses or lenses every for a $65 co-pay SPECIAL NOTES: Exclusions. Please refer to your Plan Booklet for complete details Exclusions. Please refer to your Plan Booklet for complete details Exclusions. Please refer to your Plan Booklet for complete details Exclusions. Please refer to your Plan Booklet for complete details Exclusions. Please refer to your Plan Booklet for complete details _mbd_me