Laborers Health & Welfare Trust for Southern California

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1 Laborers Health & Welfare Trust for Southern California Summary of Benefits for Active Participants and their Eligible Dependents PPO Plan MEDICAL DENTAL VISION PRESCRIPTION DRUGS YOU MUST ENROLL TO RECEIVE COVERAGE 4399 Santa Anita Avenue, Suite 200 El Monte, CA T Office Hours: 8:00 a.m. to 5:00 p.m. Telephone Hours: 7:00 a.m. to 6:00 p.m. PPO Plan_Rev. February 2015

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3 Laborers Health and Welfare Trust for Southern California Table of Contents SECTION I PLAN HIGHLIGHTS PPO Plan Highlights...3 SECTION II COVERED PREVENTIVE SERVICES Pregnancy/Postpartum...4 Newborn...4 Well-Baby/Child Visits...5 Infectious Disease...5 Cancer Screening/Prevention/Treatment...6 Cardiovascular...6 Diabetes...6 Alcohol Misuse...6 Vitamin Supplements...7 Mental Health...7 Osteoporosis...7 Tobacco...7 Diet Counseling...7 Definitions of Terms...8 SECTION III SUMMARY OF BENEFITS Ambulance...10 Hospital Inpatient Services...10 Hospital Emergency Room Services...10 Skilled Nursing Facility...10 Surgical Services Ambulatory or Outpatient Surgical Facility...12 X-Rays, Lab and other Diagnostic Tests...12 Hospice Care Inpatient or Outpatient...13 Home Health Care...13 Family Planning and Maternity Care...14 Services Subject to a Per Visit Copayment...14 Durable Medical Equipment/External Prosthetic or Orthotic Devies...15 Organ and Tissue Transplants - Non Investigational...16 Prescription Drugs...17 Group Life Insurance...17 PPO Dental Benefits...18 DeltaCare Dental Benefits...19 SECTION IV BLUE VIEW VISION BENEFIT PLANS Blue View Vision Plan for PPO...24 Blue View Vision Reimbursement Form (Fax/ /Mail-in) Tear-out...26 (Active PPO Plan_Rev. January 2014) Page 1

4 Page 2 (Active PPO Plan_Rev. January 2014)

5 Laborers Health and Welfare Trust for Southern California PPO Plan Highlights PPO Plan Helpful Considerations Obtaining services from participating health care providers, doctors, hospitals, dentists and other health care professionals, contracted with, greatly reduces your out-of-pocket costs. Using non-contracted health care providers will substantially increase your out-of-pocket costs. All Services must be medically necessary. Many services must be pre-authorized. If no pre-authorization is obtained when required, payment for services may be denied. Your health care provider should contact Anthem Blue Cross for pre-authorization information and instructions. Pre-admission Certificate should be obtained for Hospital Stay. Pre-admission Certification coverage does not guarantee coverage. A pre-authorized dental procedure or a pre-authorized orthodontic procedure request is good for 90 days only. (See Summary Plan Description) You may contact the Trust Fund Office if you have any questions. Your dependent children are now covered to age 26 even if they have other coverage. Your annual deductible is $250 for each individual up to a maximum of $750 for the family. Office visits and certain other professional services have a $20 copayment when using contracted providers and a $30 copayment when using noncontracted providers. Your annual limit for covered out-of-pocket expenses is $6,600 for each individual up to a maximum of $13,200 for the family. There is no overall annual maximum limit for covered benefits. You may have other out-of-pocket expenses if you use non-contracted providers. A medical necessity determination by Anthem Blue Cross does not guarantee coverage. Service must be covered by the Plan and you must be eligible at the time of service. (Active PPO Plan_Rev. January 2014) Page 3

6 COVERED PREVENTIVE SERVICES The listed covered preventive services come from the U.S. Preventive Services Task Force These Preventive Services, Related Office Visits and Lab Work are covered under the PPO Plan and are only available to participants in the PPO Plan when using a participating provider. PPO Plan Contracted with Not Contracted with Pregnancy/Postpartum Alcohol misuse screening and counseling Anemia screening Bacteriuria screening (12 to 16 weeks) Breastfeeding counseling Chlamydial infection screening Gonorrhea screening Hepatitis B screening RH incompatibility screening (First pre-natal visit and at weeks gestation two-visit limit) Newborn Gonorrhea screening Hearing loss screening Hemoglobinopathies screening Hypothyroidism screening Phenylketonuria screening No copayment 100% of Contracted Rate No copayment 100% of Contracted Rate Page 4 (Active PPO Plan_Rev. January 2014)

7 COVERED PREVENTIVE SERVICES The listed covered preventive services come from the U.S. Preventive Services Task Force These Preventive Services, Related Office Visits and Lab Work are covered under the PPO Plan and are only available to participants in the PPO Plan when using a participating provider. PPO Plan Contracted with Not Contracted with Well-Baby/Child Visits Annual exam and recommended immunizations to age 17 Dental carries chemoprevention when participants live in an area where there is lack of fluoride in the drinking water Depression screening ages 12 to 18 Iron supplement for ages 6 to 18 Obesity screening and counseling Visual acuity screening up to age 5 No copayment 100% of the Contracted Rate Infectious Disease Gonorrhea screening for women HIV screening STI screening and counseling Syphilis screening No copayment 100% of the Contracted Rate (Active PPO Plan_Rev. January 2014) Page 5

8 COVERED PREVENTIVE SERVICES The listed covered preventive services come from the U.S. Preventive Services Task Force These Preventive Services, Related Office Visits and Lab Work are covered under the PPO Plan and are only available to participants in the PPO Plan when using a participating provider. Contracted with PPO Plan Not Contracted with Cancer Screening/Prevention/Treatment BRCA 1 and BRCA 2 screening for women with a family history of breast cancer Breast cancer chemoprevention for women at high risk Breast cancer screening Cervical cancer screening Prostate cancer screening once every 2 years Colorectal cancer screening age 50 to 70 once every 5 years Cardiovascular Abdominal aortic aneurysm screening Aspirin regimen for men age 45 to 79; and for women age 55 to 75 Blood pressure screening ages 19 and older Cholesterol screening for men age 35 and older and for women age 45 and older Diabetes Diabetes screening No copayment 100% of Contracted Rate No copayment 100% of Contracted Rate No copayment Alcohol Misuse Screening and counseling for adults 100% of Contracted Rate No copayment 100% of the Contracted Rate Page 6 (Active PPO Plan_Rev. January 2014)

9 COVERED PREVENTIVE SERVICES The listed covered preventive services come from the U.S. Preventive Services Task Force These Preventive Services, Related Office Visits and Lab Work are covered under the PPO Plan and are only available to participants in the PPO Plan when using a participating provider. Contracted with PPO Plan Not Contracted with Vitamin Supplements Daily folic acid supplement for women capable of becoming pregnant Mental Health Depression screening for ages 18 or older Osteoporosis Routine screening for women age 65 and older Screening at age 60 for women at risk Tobacco Tobacco use screening Tobacco cessation intervention Diet Counseling For adults with hyperlipidemia and other known risk factors for Cardio Vascular Disease and diet-related chronic diseases No copayment 100% of the Contracted Rate No copayment 100% of the Contracted Rate No copayment 100% of the Contracted Rate No copayment 100% of the Contracted Rate No copayment 100% of the Contracted Rate (Active PPO Plan_Rev. January 2014) Page 7

10 Definitions Used in Section III Summary of Benefits Plan Allowable Charge. The higher of the nearest contracted rate or usual, customary and reasonable amount. Reasonable and Customary (R&C) and Usual, Customary and Reasonable (UCR) means the fee regularly charged for treatments or supplies covered under the Plan to the extent such fee does not exceed the general level of charges by others who render or furnish such services, treatments or supplies in the locality where the charge is incurred, for illness or injury comparable in nature and severity. The term locality means a county or such greater geographically significant area as is necessary to establish a representative cross section of providers regularly furnishing the type of treatment, services or supplies for which the charge was made. A charge is Usual if it is the charge made by the health care provider to most private patients for the particular service. A charge is Customary if it is within the normal range of charges made by most health care providers of similar training and experience for the same service in the geographical area involved. A charge is Reasonable if it meets the above requirements or is justified in certain circumstances of a particular case and is within the amount of a provider s charge which could have been reasonably expected to have been paid by a person in the patient s income bracket. If such health care provider s charge is in excess of that which would be payable under any insurance or benefit coverage or beyond a patient s personal ability to pay, this Plan then retains the right to limit its reimbursement to criteria in general usage in determining appropriate payment or to that which such provider has agreed to accept as payment in full, contractually or otherwise, from any other payment source providing the same or similar benefit coverage or insurance. The Plan determines UCR based on information acquired from third parties. If a UCR determination is contested, the Plan will consider additional information submitted to the Plan during the appeal process. PPO Plan. The Plan s PPO is the of California Prudent Buyer PPO. The PPO is a network of heath care facilities and medical professionals that have agreed to provide your medical care anywhere within that service area at contracted rates. When you receive the services of a PPO network provider, you must first meet an annual deductible and pay certain co-payments and coinsurance amounts and the Plan pays the provider based on a contracted rate. By using a PPO network provider, you will not be balance billed for any amounts that are over and above your deductible, co-payment and co-insurance amounts, provided that you received covered services under the Plan. If you enroll in the PPO Plan, you may also go to any provider outside of the network. However, it will cost you more because your benefits will be reduced and there may be no provider discounts available. Page 8 (Active PPO Plan_Rev. January 2014)

11 SECTION III Summary of Benefits PPO PLAN DENTAL BENEFITS (Active PPO Active PPO Plan_Rev. October 2012) Page 9

12 SUMMARY OF MEDICAL BENEFITS PPO PLAN Contracted with PPO Plan Not Contracted with Ambulance (used to transport from the place where participant is injured by an accident or stricken by a disease to the first nearest hospital where treatment is given) Professional Ground Ambulance Service Subject to calendar year deductible 80% of the Contracted Rate Subject to calendar year deductible 90% of the Plan Allowable Charge Hospital Inpatient Services Pre-authorization required Room and board Other necessary inpatient services Medical/Surgical Mental Health/Chemical Dependency Hospital Emergency Room Services Emergency must be documented Medical/Surgical Mental Health/Chemical Dependency $200 copayment 90% of the Contracted Rate if pre-authorized $75 copayment (waived if admitted) 80% of the Contracted Rate $200 copayment 80% of the Plan Allowable Charge $75 copayment (waived if admitted) 90% of the Plan Allowable Charge Skilled Nursing Facility / Residential Treatment Facility Pre-authorization required Room and board Other necessary services Medical/Surgical Mental Health/Chemical Dependency $200 copayment $200 copayment waived if discharged directly from inpatient hospital to skilled nursing facility $200 copayment $200 copayment waived if discharged directly from inpatient hospital to skilled nursing facility (Continued on page 11) (Continued on page 11) (Continued on page 11) Page 10 (Active PPO Plan_Rev. January 2014)

13 SUMMARY OF MEDICAL BENEFITS PPO PLAN PPO Plan Contracted with Not Contracted with Skilled Nursing Facility / Residential Treatment Facility (Cont.) Pre-authorization required Room and board Other necessary services Medical/Surgical Mental Health/Chemical Dependency 90% of the Contracted Rate Active employees limited to 70 days and dependents limited to 31 days including time in hospital 80% of the Plan Allowable Charge Active employees limited to 70 days and dependents limited to 31 days including time in hospital (Continued from page 10) (See page 10 for copayment) (See page 10 for copayment) Surgical Services Pre-authorization may be required contact Subject to $250 calendar year deductible Subject to $250 calendar year deductible Covers surgeon, assistant surgeon, physician assistant, and anesthesiologist 80% of the Contracted Rate 80% of Plan Allowable Charge Services are covered when rendered inpatient hospital, outpatient hospital, ambulatory surgical center or physician office (Active PPO Plan_Rev. January 2014) Page 11

14 SUMMARY OF MEDICAL BENEFITS PPO PLAN PPO Plan Contracted with Not Contracted with Ambulatory or Outpatient Surgical Facility Pre-authorization required Subject to $250 calendar year deductible Subject to $250 calendar year deductible 80% of the Contracted Rate 80% of $1,950 for facilities in Kern, San Luis Obispo and Santa Barbara Counties 80% of $2,340 in Ventura County 80% of $2,450 for facilities in Riverside and San Bernardino Counties 80% of $2,900 in Los Angeles and Orange Counties X-Rays, Lab and other Diagnostic Tests Pre-authorization may be required contact Fee for interpreting Subject to $250 calendar year deductible 80% of the Contracted Rate 80% of $2,450 in San Diego County Subject to $250 calendar year deductible 80% of the Plan Allowable Charge Page 12 (Active PPO Plan_Rev. January 2014)

15 SUMMARY OF MEDICAL BENEFITS PPO PLAN PPO Plan Contracted with Not Contracted with Hospice Care Inpatient or Outpatient Pre-authorization required Life expectancy of six months or less Up to 210 days of hospice care in a hospice and outpatient services delivered by the Hospice Subject to $250 calendar year deductible 80% of the Contracted Rate Subject to $250 calendar year deductible 80% of the Plan Allowable Charge Home Health Care Pre-authorization required Care must be supervised by a physician Nursing services must be provided by or supervised by a Registered Nurse Services must begin within 7 days of discharge from a hospital Limited to 100 visits per year Subject to $250 calendar year deductible 80% of the Contracted Rate Subject to $250 calendar year deductible 80% of the Plan Allowable Charge (Active PPO Plan_Rev. January 2014) Page 13

16 SUMMARY OF MEDICAL BENEFITS PPO PLAN PPO Plan Contracted with Not Contracted with Family Planning and Maternity Care Limited to member and spouse Ante-partum, delivery and postpartum care Abortion Infertility services See hospital inpatient services Subject to $250 calendar year deductible 80% of the Contracted Rate if pre-authorized when required Subject to $250 calendar year deductible 80% of the Plan Allowable Charge Services Subject to a Per Visit Copayment Office Visit Urgent Care Visit $20 copayment 100% of the Contracted Rate $20 copayment $30 copayment 100% of the UCR amount $30 copayment Annual Physical Exam Visits *A visit shall consist of a, b, or c. (a) Office visit with related lab work; (b) Colorectal Cancer Screening age 50 to 70 every 5 years; (c) Mammogram Screening age 40 to 70 every two years Well Baby Care 100% of the Contracted Rate See Covered Preventive Services Well-Baby/Child 100% of the Contracted Rate 100% of the UCR amount Center for Disease Control (CDC) recommended Immunizations Allergy Injections 100% of the Contracted Rate 100% of the UCR amount Hearing Tests Hearing Aid and routine testing not covered 80% of the Contracted Rate 80% of the Contracted Rate Diabetes Education Page 14 (Active PPO Plan_Rev. January 2014)

17 SUMMARY OF MEDICAL BENEFITS PPO PLAN PPO Plan Contracted with Not Contracted with Therapeutic Services (Subject to copayment if office visit is billed) Chiropractic Services 100% of the Contracted Rate Limited to 24 visits per calendar year 100% of the UCR amount Limited to 24 visits per calendar year Acupuncture Limited to 12 visits Must be administered by M.D. 100% of the Contracted Rate 100% of the UCR amount Physical Therapy Occupational and Speech Therapy 100% of the Contracted Rate Limited to 32 visits per calendar year 100% of the Contracted Rate Limited to 42 visits per calendar year 100% of the UCR amount Limited to 32 visits per calendar year 100% of the UCR amount Limited to 42 visits per calendar year Outpatient Cardiac Rehabilitation Therapy Visits 100% of the Contracted Rate Limited to 32 visits within six months of open heart surgery 100% of the UCR amount Limited to 32 visits within six months of open heart surgery Durable Medical Equipment/External Prosthetic or Orthotic Devices (Some items require pre-authorization) Subject to medical review Must be medically necessary Rental will be considered up to the purchase price 80% of the Contracted Rate Subject to calendar year deductible 80% of the UCR amount Subject to calendar year deductible (Active PPO Plan_Rev. January 2014) Page 15

18 SUMMARY OF MEDICAL BENEFITS PPO PLAN Contracted with PPO Plan Not Contracted with Organ and Tissue Transplants - Non Investigational Hospital Inpatient services Must be pre-authorized $200 copayment 90% of the Contracted Rate Limited to kidney and cornea transplants only $200 copayment 80% of the Plan Allowable Charge Limited to kidney and cornea transplants only Office Visits $20 copayment 100% of the Contracted Rate $30 copayment 100% of the UCR amount Surgeon, assistant surgeon, anesthesiologist Must be pre-authorized Subject to $250 calendar year deductible 90% of the Contracted Rate Subject to $250 calendar year deductible 80% of the Plan Allowable Charge Page 16 (Active PPO Plan_Rev. January 2014)

19 SUMMARY OF PRESCRIPTION DRUG BENEFITS PPO PLAN OPTUM Rx PRESCRIPTION DRUGS Category Mail Order Purchase Retail Purchase Drugs related to treatment of sexual dysfunction Generic $10 copayment for up 20% of retail cost up to a 90-day supply to a 30-day supply Generic injectable 20% of mail order cost Brand $20 copayment for up 20% of retail cost up to a 90-day supply to a 30-day supply Brand injectable 20% of mail order cost Formulary link for Active Participants d=lscret2631&page=&par= GROUP LIFE INSURANCE BENEFITS Group Life Insurance Benefits for Active Employee and Eligible Dependents (You must complete a beneficiary designation card and submit it to the Trust Fund Office. Beneficiary should immediately send a letter and a certified copy of the death certificate to the Trust Fund Office to file a death claim. See Summary of Plan Description for more information.) Benefit Employee: $10,000 Spouse: $5,000 Children: $5,000 (Active PPO Plan_Rev. January 2014) Page 17

20 SUMMARY OF PPO DENTAL BENEFITS PPO Dental Benefits Benefit Payable The Plan pays 80% of the Network Contracted Rate for Preventive, Basic and Major services. Use of an out-of-network provider will greatly increase your out-of-pocket expense Calendar-Year Maximum $2,500 for participants age 19 and older There is no overall annual maximum limit for covered services for participants under the age of 19. Deductible $25 per person per calendar year (waived for prophylaxis) $75 per family per calendar year Pre-authorization Pre-authorization is required for treatment plans exceeding $500 Waiting Period Orthodontics Orthodontic Maximum None Plan pays 80% of the Network Contracted Rate $3,000 life-time maximum. Page 18 (Active PPO Plan_Rev. January 2014)

21 DeltaCare USA Plan CAA01 - Description of Benefits and Copayments Text that appears in italics below is specifically intended to clarify the delivery of benefits under the DeltaCare USA program and is not to be interpreted as CDT-2009 procedure codes, descriptors or nomenclature that are under copyright by the American Dental Association. The American Dental Association may periodically change CDT codes or definitions. Such updated codes, descriptors and nomenclature may be used to describe these covered procedures in compliance with federal legislation. You may call Delta Dental Customer Service at , from 5 a.m. to 6 p.m., Monday through Friday, Pacific Time, for a copy of the Evidence of Coverage prior to enrollment or visit deltadentalins.com. Code Diagnostic Description Enrollee Pays Code Restorative Description D0120 Periodic oral evaluation - established patient No cost D2140 Amalgam - one surface, primary or permanent D0140 Limited oral evaluation - problem focused No cost D2150 Amalgam - two surfaces, primary or permanent D0150 D0210 Comprehensive oral evaluation - new or established patient Intraoral radiographs - complete series (including bitewings) - limited to 1 series every 24 months Enrollee Pays No cost No cost No cost D2160 Amalgam - three surfaces, primary or permanent No cost No cost D2750 Crown - porcelain fused to high $ noble metal 1 D0220 Intraoral - periapical first film No cost D2790 Crown - full cast high noble metal 1 $ D0272 Bitewings radiographs - two films No cost Endodontics D0330 Panoramic film No cost D3310 Root canal - endodontic therapy, anterior tooth (excluding final restoration) 3 Preventive D3320 Root canal - endodontic therapy, bicuspid tooth (excluding final restoration) 3 D1110 Prophylaxis cleaning - adult - 1 per 6 month period No cost Periodontics No cost No cost D1120 Prophylaxis cleaning - child - 1 per 6 month period No cost D4210 Gingivectomy or gingivoplasty - four or more contiguous teeth or tooth bounded space per quadrant D1203 Topical application of fluoride - child - to age 19; 1 per 6 month period D1351 Sealant - per tooth - limited to permanent molars through age 5 No cost No cost D4341 Periodontal scaling and root planing - four or more teeth per quadrant - limited to 4 quadrants during any 12 consecutive months No cost No cost 1 Replacement is subject to a limitation requiring the existing restoration to be 5+ years old. 3 A benefit for permanent teeth only. How your DeltaCare USA program works. Your selected contract dentist will take care of your dental care needs. If you require treatment from a specialist, your contract dentist will handle the referral for you. After you have enrolled, you will receive a Delta Dental membership packet that includes an identification card and an Evidence of Coverage booklet that fully describes the benefits of your dental program. Also included in this packet are the name, address and phone number of your contract dentist. Simply call the dental facility to make an appointment. Under the DeltaCare USA program, many services are covered at no cost, while others have copayments (amount you pay your contract dentist) for certain benefits. See the Description of Benefits and Copayments for a list of your benefits. Please note: Dental services that are not performed by your selected contract dentist, or are not covered under provisions for emergency care below, must be preauthorized by Delta Dental to be covered by your DeltaCare USA program. The summary of benefits shown above are performed as deemed appropriate by the attending Contract Dentist subject to the limitations and exclusions of the program. Enrollees should discuss all treatment options with their Contract Dentist prior to services being rendered. (Active PPO Plan_Rev. January 2014) Page 19

22 SECTION IV Blue View Vision sm Benefit Plans The Blue View Vision SM Benefit pages are provided to help you select your vision care services. Blue View Vision Reimbursement Form For additional Blue View Vision Reimbursement Form, please duplicate the tear-out form If you go to an out-of-network provider for services or materials, you must fax, , or mail in your Reimbursement Form. (See Blue View Vision form for details.) (Active PPO Plan_Rev. October 2012) Page 20

23 (Active PPO Plan_Rev. January 2014) Page 21

24 Blue View Vision sm BV C4 Custom Plan for Laborers Health & Welfare Trust Fund Page 22 (Active PPO Plan_Rev. January 2014)

25 (Active PPO Plan_Rev. January 2014) Page 23

26 Page 24 (Active PPO Plan_Rev. January 2014)

27 (Active PPO Plan_Rev. January 2014) Page 25

28 Page 26 (Active PPO Plan_Rev. January 2014)

29 Member Names and Address Member Notes and Numbers (Active PPO Plan_Rev. January 2014) Page 27

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