SOUTHERN CALIFORNIA DRUG BENEFIT FUND Gold and Platinum...OE 2020 – Platinum/Gold Plan Description and the evidence of coverage booklets provided by Kaiser, UnitedHealthcare (formerly

SOUTHERN CALIFORNIA DRUG BENEFIT FUND

SUMMARY OF THE PLATINUM AND GOLD PLANS

As of January 1, 2020 ThisdocumentisintendedmerelyasasummaryoftheGoldandPlatinumhealthcareplansofferedbytheSouthernCaliforniaDrugBenefitFund. Forexclusionsandrestrictions,you

shouldreadtheSummaryPlanDescriptionandtheevidenceofcoveragebookletsprovidedbyKaiser,UnitedHealthcare(formerlyPacifiCare),andUnitedConcordia.

OE2020–Platinum/GoldPlan

SOUTHERN CALIFORNIA DRUG BENEFIT FUND SUMMARYOFTHEPLATINUMANDGOLDPLANSASOFJANUARY1,2020

SECTION PAGE

CONTACT INFORMATION.......................................................................................................................................................................1ELIGIBILITYRULES.........................................................................................................................................................................2

ELIGIBILITYREQUIREMENT...........................................................................................................................................................2WORKINGSPOUSERULE.............................................................................................................................................................2

DEATHBENEFITS...........................................................................................................................................................................2MEDICALBENEFITS.......................................................................................................................................................................3

HOSPITALBENEFIT.....................................................................................................................................................................6PROFESSIONALSERVICES.............................................................................................................................................................8MENTALHEALTHANDSUBSTANCEABUSEBENEFITS.........................................................................................................................11MEDICALSUPPLIESANDEQUIPMENT.............................................................................................................................................11OTHERSERVICESANDBENEFITS...................................................................................................................................................12

PRESCRIPTIONDRUGBENEFITS....................................................................................................................................................12DENTALBENEFITS.........................................................................................................................................................................13PLANEXCLUSIONS........................................................................................................................................................................14

ThisdocumentisintendedmerelyasasummaryoftheGoldandPlatinumhealthcareplansofferedbytheSouthernCaliforniaDrugBenefitFund. Forexclusionsandrestrictions,youshouldreadtheSummaryPlanDescriptionandtheevidenceofcoveragebookletsprovidedbyKaiser,UnitedHealthcare(formerlyPacifiCare),andUnitedConcordia.

OE2020–Platinum/GoldPlan

SOUTHERN CALIFORNIA DRUG BENEFIT

ThisdocumentisintendedmerelyasasummaryoftheGoldandPlatinumhealthcareplansofferedbytheSouthernCaliforniaDrugBenefitFund. Forexclusionsandrestrictions,youshouldreadtheSummaryPlanDescriptionandtheevidenceofcoveragebookletsprovidedbyKaiser,UnitedHealthcare(formerlyPacifiCare),andUnitedConcordia.DescriptionandtheevidenceofcoveragebookletsprovidedbyKaiser,UnitedHealthcare(formerlyPacifiCare),andUnitedConcordia.OE2020–Platinum/GoldPlan Page1of15

SUMMARYOFTHEPLATINUMANDGOLDPLANSASOFJANUARY1,2020

CONTACT INFORMATION

TrustFundOffice 877-999-8329 www.ufcwdrugtrust.org AnthemBlueCrossPrudentBuyer 800-227-3641 www.anthem.com/ca/home.html BlueCard 800-810-2583(800-810-BLUE) www.bcbs.com DeltaDental 800-765-6003 www.deltadentalins.com HMCHealthWorks 866-268-2510 https://hmc.personaladvantage.com (AccessCode:SCDBF) Kaiser 800-464-4000 www.kp.org OptumRx 800-788-7871 www.optumrx.com PodiatryPlan,Inc. 800-367-7762 www.podiatryplan.com UnitedConcordia 800-937-6432 www.unitedconcordia.com UnitedHealthcare (UHC) 800-624-8822 www.MyUHC.com

SOUTHERN CALIFORNIA DRUG BENEFIT


ELIGIBILITY RULES

SUMMARYOFTHEPLATINUMANDGOLDPLANSASOFJANUARY1,2020

ELIGIBILITYREQUIREMENT AllEmployees Onceyouareeligible,youmustcontinuetoworktheQualifyingHoursduringeachmonthtomaintainyoureligibility,toestablisheligibilityfor

otherbenefits,andtoestablishand/ormaintaineligibilityforyourDependents.Youarealsorequiredtopaymonthly(orweekly)contributions(alsocalled“premiums”)inordertomaintainyourcoverage.

EmployeeContribution/EmployeePremium

AllEmployeesarerequiredtopaypremiumstowardsthecostofcoverage.Thesepremiums(alsocalled“EmployeeContributions”)willgenerallybepaidviapayrolldeduction(self-paywillbeavailableforparticipantsforwhomapayrolldeductionisnottaken).YoumustcompleteanauthorizationformtoallowyourEmployertodeductyourcontributionamountandpayittotheFund.MonthlyEmployeecontributionsmustbepaidbytheendofthemonthbeforethemonthofcoverage.Forexample,forcoverageinJuly,yourcontributionmustbepaidbytheendofJune.Ifyourcontributionsarenottimelypaid,youwilllosecoverage.

Theamountofyourmonthlycontributionisasfollows:Ø $30.33permonth($7perweek)forEmployee-onlycoverage.Ø $47.67permonth($11perweek)forEmployeeplusoneormorechildren.Ø $65.00permonth($15perweek)forEmployeeplusspouseorDomesticPartner,withorwithoutchildren.

Note: Youarepermittedtoopt-outofdentaland/orvisioncoverageforyourselfandyourfamily. However,droppingyourdentaland/orvisioncoveragewillnotreduceyourEmployeepremium. ContacttheFundOfficeformoreinformation.

WORKINGSPOUSERULE WorkingSpouseRule(alsoapplicabletoDomesticPartners)

FormarriedEmployeesandEmployeeswithDomesticPartners(theuseoftheterm“spouse”inthissectionincludesDomesticPartners): Ifyourspouse’semployeroffershealthcarecoverage,yourspousemustenrollinthatemployer’scoveragethatiscomparabletoyourcoverageunderthisFund,evenifyourspouseisrequiredtocontributetowardthecostofthatcoverage. Ifyourspouse’semployerdoesnotoffercoveragethatiscomparabletoyourcoveragefromtheFund,yourspousemustenrollinthebestcoverageavailablethroughhisorheremployer.Ifyourspouseiseligibleformedical,prescriptiondrug,dental,and/orvisionbenefitsthroughhisorheremployerbutfailstoenroll,thisPlanwillpayonly40%ofitsnormalbenefits(i.e.thisPlanwillreduceitspaymentamountby60%)undertheIndemnityMedicalPlan,PrescriptionDrugPlanand/orIndemnityDentalPlan.

ThisruledoesnotapplyifbothspousesareeligibleforcoverageasEmployeesofcontributingEmployersandonespousehaselectedcoveragefor“EmployeeplusspouseorDomesticPartner”. PleasecontacttheFundOfficeformoreinformation.

DEATH BENEFITS

Employee Greaterof$15,000ortheamountofsalaryreceivedduringthemostrecent12months. Dependent $2,000


SOUTHERN CALIFORNIA DRUG BENEFIT SUMMARYOFTHEPLATINUMANDGOLDPLANSASOFJANUARY1,2020

2202020 MEDICAL BENEFITS

INDEMNITYPLAN UNITEDHEALTHCARE(UHC)FLEXHMO

KAISER

PPO (In Network) Non-PPO (Out of Network) HowthePlanworks

Generally,youmustsatisfytheCalendarYearDeductible(“Deductible”)beforethePlanpaysanybenefits. TheexpensesyoupayforusingaPPOprovider,exceptcopaysforofficevisitsandhospitalstays,willapplytowardthePPODeductible. Theexpensesyoupayforusinganon-PPOprovider,exceptforcopaysforhospitalstaysandchargesthatexceedtheAllowedAmounts,willapplytowardthenon-PPODeductible.AftertherequiredDeductibleissatisfied,thePlangenerallypays80%ofContractRates1ifyouuseaPPOproviderand50%oftheAllowedAmount2ifyouuseanon-PPOprovider.Forsomeservicesandsupplies,specificdollarlimitsareimposedthatcouldresultintheFundpayinglessthanthesepercentages.

Foreachhospitalstay,youmustfirstpaya$100copay.WhenyouuseaPPOfacility,youareresponsiblefor20%oftheremainingContractRatesafterthePlanpays80%ofthebalance. Whenyouuseanon-PPOfacility,thePlanpays50%oftheAllowedAmount,andyouareresponsiblefortheremaining50%oftheAllowedAmountplusanychargesthatexceedtheAllowedAmount.

PPOofficevisitsarenotsubjecttotheDeductible.ThePlanpays100%oftheContractRatesafteryoupaya$20copaypervisit. WhenyouuseaPPOproviderforpreventiveandwellnessservices,thePlanwillpay100%ofContractRatesforallofthepreventivecareandimmunizationserviceslistedinthePlan’scurrentPreventiveCareGuidelines(availablefromtheFundOffice).ThereisnoDeductibleandnocopayaslongasthepreventiveservicesarereceivedfromPPOproviders.

ForotherPPOservices,onceyourtotalmedicalout-of-pocketexpenseshavereachedtheCalendarYearOut-of-PocketMaximum(“OOPMax”),thePlangenerallywillpay100%ofContractRatesfortheremainderofthecalendaryear. YourDeductibleandcertainotherexpensesdonotcounttowardtheOOPMax.

Thereisnolimitonout-of-pocketexpenseswhenyouusenon-PPOProviders.

TheUHCFlexHMOoffersachoiceofthreeNetworks.YouandyourfamilymembersmustbeenrolledinthesameNetwork. YoumayonlychangeyournetworkduringOpenEnrollment(unlessyouoraDependenthascertainspecialenrollmentrights).

ForallNetworks,yougenerallymustsatisfytheCalendarYearDeductible(“Deductible”)beforetheplanpaysanybenefits.TheDeductibleis$500perindividual($1,000perfamily).

Theamountyoupayforservicesdependsonthenetworkyouchoose.YoupaythelowestifyouchooseNetwork1. Network2andNetwork3havehighercopaymentsandcoinsurance.

Formostofficevisits,youpayacopayment.Forotherservices,youwillpayapercentageofCoveredCharges.3

Preventivecareservices,suchasyourannualphysicalexams,arecoveredat100%withnocopayandarenotsubjecttotheDeductible.

OnceyouhavepaidtheCalendarYearOut-of-PocketMaximum(“OOPMax”),allcarefromUHCwillgenerallybecoveredinfull.Youmustkeeprecords(receipts)ofyourcopaysandcoinsurancetoprovideasprooftoUHCthatyouhavereachedyourOOPMax.

Formostservices,youpayacopayeverytimeyouusetheservice. However,hospitalstaysandoutpatientsurgeryaresubjecttoaCalendarYearDeductible(“Deductible”).

Forhospitalstaysandoutpatientsurgeries,onceyouhavesatisfiedtheDeductible,Kaiserwillgenerallypay80%ofCoveredCharges3;youareresponsiblefortheremaining20%. Specificcopays,coinsuranceanddeductibleamountsareoutlinedbelow.

Onceyourout-of-pocketexpensesreachtheCalendarYearOut-of-PocketMaximum(“OOPMax”),allcarewillgenerallybecoveredinfullfortheremainderoftheCalendarYear.

Youmustkeeprecords(receipts)ofyourcopaysandcoinsurancetoprovideasprooftoKaiserthatyouhavereachedyourOOPMax.

1 TheamountthatthePPOProvider (PrudentBuyerNetworkortheBlueCardProgram)hasagreedbycontract toacceptforservicesprovided.





KAISER

PPO (In Network) Non-PPO (Out of Network) PreferredProviderNetwork(PPO)

IfyouliveinCalifornia,yourpreferredprovidernetwork(“PPO”)istheAnthemBlueCrossofCaliforniaPrudentBuyernetwork.

IfyouoryourdependentsliveoutsideofCalifornia,orifyouaretravelingoutsideCalifornia,yourPPOnetworkofhospitalsanddoctorsistheNationalBlueCardnetwork. TheBlueCardnetworkisavailableinall50states.

YouarestronglyencouragedtouseaPPOprovider. ThePlanpaysahigherlevelofbenefitswhenyouuseaPPOphysicianorhospital. YoumaychoosetousehospitalsandphysicianswhodonotbelongtothePPOnetworks. However,thePlanpaysalowerlevelofbenefitsfornon-PPOproviders,andyouwillhavehigherout-of-pocketexpenses.TofindaPPOprovidernearestyou,callAnthemBlueCrossPrudentBuyerat800-227-3641orBlueCardAccessat800-810-BLUE.

TherearethreenetworkchoiceswiththeUHCFlexHMO,Network1,2,or3.Youandallofyourfamilymembersmustbeenrolledinthesamenetwork.Onceanetworkischosen,youandyourfamilymemberswillhaveaccessonlytoProvidersinthatnetwork.Eachfamilymembermayindividuallyselectaprimarycarephysician(“PCP”)withinthechosennetwork.

IfyoudonotlivewithintheserviceareaoftheFlexHMO,i.e.,ifyoudonothaveaccesstoaPCPfromNetworks1,2,or3,youwillparticipateandchooseaPCPfromtheSignatureValueAdvantageNetwork.YourbenefitswillbethesameasthoseunderNetwork1.

ServicesrenderedbyaProviderwhoisnotinyourchosennetworkarenotcovered. Ifanemergencyoccurs,emergencyproceduresandbenefitsapply.

YoumustuseKaiserproviders. Servicesrenderedbynon-Kaiserprovidersarenotcovered.

Ifanemergencyoccurs,emergencyproceduresandbenefitsapply.

PreauthorizationandUtilizationReview

WhenPreauthorizationorUtilizationReviewisrequired,yourdoctororhospitalmustcontactPrudentBuyer/BlueCardat800-274-7767. PPOhospitalswilldothisautomatically.Youshouldconfirmthatyourotherproviders,includingnon-PPOhospitals,havedonethis.

SeeUHC’sEvidenceofCoverage SeeKaiser’sEvidenceofCoverage.

2 Inmostcases, theAllowedAmount istheallowance thattheFundhasdetermined isanappropriate payment fortheMedically Necessary service(s) rendered totheparticipant intheprovider's geographic area.Where theprovider's charge islessthantheFund'sallowance fortheservice(s) provided, theAllowedAmount istheprovider's billedamount. TheBoardofTrustees, oritsdesignee, hasdiscretion todetermine theAllowedAmount.

3 TheamountthattheHMOhasdetermined tobeanappropriate charge fortheserviceprovided.





KAISER

PPO (In Network) Non-PPO (Out of Network) CalendarYearDeductible(“Deductible”)

$500perperson,$1,000perfamily;maynotbesatisfiedbyofficevisitorhospitalcopays.

PlatinumPlan:$1,000perperson,$2,000perfamily;GoldPlan:$2,000perperson,$4,000perfamily;maynotbesatisfiedbyhospitalcopaysorchargesthatexceedtheFund'sAllowedAmounts.

$500perperson,$1,000perfamilyCertainserviceswillnotbecovereduntilyoumeetyourDeductible.TheDeductibleappliestomanyservices,includingmostinpatientservicesandoutpatientsurgery.Itdoesnotapplytopreventivecare,someoutpatientservices,andemergencyorurgentcareservices.OnlyamountsincurredforcoveredservicesthataresubjecttotheDeductiblewillcounttowardstheDeductible.SeeyourEvidenceofCoveragefromUHCformoreinformation.

$500perperson,$1,000perfamily.Appliestomostservices.Notapplicabletodoctor’sofficevisitsandpreventivecare.SeeKaiser’sEvidenceofCoverageformoreinformation.

OnlyamountsincurredforcoveredservicesthataresubjecttotheDeductiblewillcounttowardstheDeductible.

PlanCoinsuranceandParticipantCoinsurance

AfteryouhavesatisfiedtheDeductible,thePlanpays80%ofContractRatesformostservices.Youareresponsiblefortheremaining20%ofContractRates.Refertoeachbenefitbelowforexceptions.Formostservices,thePlanwillpay100%ofContractRatesafteryoureachthemedicalout-of-pocketmaximumforthecalendaryear.

AfteryouhavesatisfiedtheDeductible,thePlanpays50%oftheAllowedAmountformostservices.Youareresponsibleforthebalanceoftheproviderbill.Non-PPOprovidersoftenchargemorethanthePlan’sAllowedAmount.Whenthathappens,youareresponsiblefor50%oftheAllowedAmountand100%ofanychargesthatexceedtheAllowedAmount.

AppliestoInpatientHospitalizationandoutpatientsurgery.AfteryousatisfytheDeductible,UHCwillgenerallypay:

Network1:80%ofCoveredChargesNetwork2:75%ofCoveredChargesNetwork3:70%ofCoveredCharges.

Youareresponsiblefortheremaining20%-30%ofCoveredChargesuntilyoureachyourannualOut-of-PocketMaximum.

AftertheDeductible,Kaiserwillpay80%ofCoveredChargesforservicessubjecttoCoinsurance.Youareresponsiblefor20%coinsuranceuntilyoureachyourannualOut-of-PocketMaximum.

ServicessubjecttoCoinsuranceinclude,butarenotlimitedto,InpatientHospitalization,OutpatientSurgery,InpatientMentalHealth,InpatientChemicalDependencyandemergencyroomvisits.





KAISER

PPO (In Network) Non-PPO (Out of Network) MedicalOut-of-PocketMaximumPerCalendarYear(“OOPMax”)

AftertheDeductible,participantcoinsuranceandcopaysaccumulatetoatotalOOPMaximumof$2,000perperson,$6,000perfamily(notincludingthedeductible).

Premiums,non-coveredexpenses,chargesinexcessofbenefitmaximums,andexpensesyoupayforprescriptiondrugs,visioncare,dentalcare,hearingaids,chiropracticandacupuncturedonotcounttowardstheOOPMaxandarenotpaidbythePlanat100%intheeventyoureachtheOOPMax.

Nomaximum. $2,000perperson,$4,000perfamily(includesthedeductible).Premiums,non-coveredexpenses,chargesinexcessofbenefitmaximums,andcopaymentspaidforcertainCoveredServicesarenotapplicabletoaMember’sAnnualCopaymentMaximum(“OOPMax”);theseservicesarespecifiedintheScheduleofBenefits.PleaserefertoUHC’sScheduleofBenefitsformoreinformation.

Inaddition,expensesyoupayforhearingaids,andchiropracticandacupuncture(providedthroughtheFund),prescriptiondrugs,visioncare,anddentalcaredonotcounttowardstheOOPMax.

$2,000perperson,$4,000perfamily(includesthedeductible).

Premiums,non-coveredexpenses,chargesinexcessofbenefitmaximums,andexpensesyoupayforhearingaid,chiropracticandacupuncture(providedthroughtheFund),prescriptiondrugs,visioncare,anddentalcaredonotcounttowardstheOOPMax.

NoAnnualandLifetimeMaximum HOSPITALBENEFITS HospitalInpatientServices(includingRoomandBoardandAncillaryServices)

AftertheDeductibleand$100copayperadmission,thePlanpays80%ofContractRates.

PrudentBuyer/BlueCardprovidersareresponsibleforobtainingallPreauthorizationandUtilizationReview.

CopaydoesnotcounttowardDeductible.

AftertheDeductibleand$100copayperadmission,thePlanpays50%oftheAllowedAmount. Allhospitaladmissions,exceptforchildbirthoremergencyhospitalizations,mustbepreauthorizedbyPrudentBuyer/BlueCard.YoumustnotifyAnthemwithin72hoursofanemergencyadmission. Call800-810-BLUEforPreauthorization(outsideCalifornia).InCalifornia,call800-274-7767. BenefitswillbereducedifyoufailtoobtainPreauthorization.CopaydoesnotcounttowardDeductible.

AftertheDeductible,UHCpays:Network1:80%ofCoveredChargesNetwork2:75%ofCoveredChargesNetwork3:70%ofCoveredCharges

AftertheDeductible,Kaiserpays80%ofCoveredCharges





KAISER

PPO (In Network) Non-PPO (Out of Network) HospitalOutpatientFacilityCharges

AftertheDeductible,thePlanpays80%ofContractRates.

AftertheDeductible,thePlanpays50%oftheAllowedAmount.


AftertheDeductible,Kaiserpays80%ofCoveredCharges.

SkilledNursingFacility(Medicareapproved)



AftertheDeductible,UHCpays:Network1:80%ofCoveredChargesNetwork2:75%ofCoveredChargesNetwork3:70%ofCoveredChargesLimitof100consecutivedaysperCalendarYearfromthefirsttreatmentperdisability.

Asprescribedatdesignatedfacilities.AftertheDeductible,Kaiserpays80%ofCoveredCharges. Limitedto100daysperbenefitperiod.

MustbepreauthorizedbyPrudentBuyer/BlueCard. Limitedto240daysperdisability.

PhysicianHospitalVisits





EmergencyRoomServices(Facility,PhysicianandAncillaryServices)


AftertheDeductible,ifthepatienthasan“emergencymedicalcondition”,thePlanpays80%oftheAllowedAmount,otherwise50%oftheAllowedAmount.

Network1:$100copaypervisitNetwork2:$150copaypervisitNetwork3:$200copaypervisit


DeterminationofPPOversusnon-PPOwillbemadebasedonthestatusofthehospital.

OutpatientSurgicalCenters


AftertheDeductible,thePlanpays50%oftheAllowedAmount,uptoamaximumof$350peroperation.Anychargesinexcessofthis$350maximumdonotcounttowardtheDeductible.



MustbePreauthorizedbyPrudentBuyer/BlueCard.

Ambulance AftertheDeductible,thePlanpays80%ofContractRates/AllowedAmountifadmittedorifthedefinitionof“emergency”issatisfied;otherwise50%ofContractRates/AllowedAmount.

UHCpays100%ofcoveredcharges. AftertheDeductible,$150copaypertrip.





KAISER

PPO (In Network) Non-PPO (Out of Network) UrgentCare $20copaypervisit,notsubjectto

theDeductible.CopaydoesnotcounttowardDeductible.


WithinYourMedicalGroup:Network1:$20copaypervisitNetwork2:$35copaypervisitNetwork3:$40copaypervisit

OutsideofYourMedicalGroup:Network1:$50copaypervisitNetwork2:$75copaypervisitNetwork3:$100copaypervisit

$20copaypervisit.

PROFESSIONALSERVICES PhysicianOfficeVisits(PrimaryCareandSpecialist)

$20copaypervisit,notsubjecttotheDeductible. CopaydoesnotcounttowardtheDeductible.



$20copaypervisit.

Surgeon,AssistantSurgeon,&Anesthetist



CoveredunderHospitalization. AftertheDeductible,Kaiserpays80%ofCoveredCharges.

PreventiveCareServices

Planpays100%ofContractRates,notsubjectto theDeductibleandnocopayisrequired.


UHCpays100%ofCoveredCharges,notsubjecttocopayorDeductible.

Kaiserpays100%,notsubjecttocopayorDeductible.

Coverageisprovidedfortheservices,screeningsandexamslisted,andsubjecttothefrequencydescribed,intheFund’sPreventiveCareGuidelines.BreastpumpsmustbepurchasedandobtainedthroughaPPODurableMedicalEquipmentvendor,otherwisethereisnocoverage.

OutpatientX-rayandLaboratory



WhenavailablethroughandauthorizedbyyourParticipatingMedicalGroup,UHCpays100%

Formostx-raysandlabs:AftertheDeductible,$10copayperencounter.ForMRI,MostCT,PetScans:AftertheDeductible,$50copayperprocedure

SpeechTherapyVisits

$20copaypervisit,notsubjecttotheDeductible. Limitedto24visitspercalendaryear. Preauthorizationisrequired.

Notcovered. Network1:$20copaypervisitNetwork2:$35copaypervisitNetwork3:$40copaypervisit

AftertheDeductible,$20copaypervisit.





KAISER

PPO (In Network) Non-PPO (Out of Network) PhysicalTherapyVisits

AftertheDeductible,thePlanpays80%ofContractRates.Preauthorizationrequired.

AftertheDeductible,thePlanpays50%oftheAllowedAmount.Preauthorizationrequired.


AftertheDeductible,$20copaypervisit.

SubjecttoUtilizationReviewbyPrudentBuyer/BlueCardforMedicalNecessity. Benefitpaymentislimitedtoamaximumof25visitspercalendaryear.

Injections AftertheDeductible,thePlanpays80%ofContractRates.


Officevisitcopaymayapply. Officevisitcopaymayapply.

MustbesuppliedandadministeredbyPhysician’soffice. Self-injectablesarecoveredunderPrescriptionDrugbenefits.

ChiropracticCareandAcupuncture

NotsubjecttotheDeductible.Planpaysa$25.50benefitpervisit,nomorethanonevisitperday,uptoacombinedmaximumof$500percalendaryearforofficevisitsand$150percalendaryearforx-rayandlaboratory.

Notcovered. Notcovered.

ObesityBypassSurgery

CoveredundertheHospitalandSurgicalbenefitsifPreauthorizedasMedicallyNecessary.

CoveredunderNon-PPOHospitalandNon-PPOsurgicalbenefits(includingNon-PPOOutpatientSurgicalCenters)ifPreauthorizedasMedicallyNecessary.

CoveredifdeterminedMedicallyNecessaryandauthorized.

OrganandTissueTransplants

AftertheDeductible,thePlanpays80%ofContractRates.CoveredonlyiftransplantisperformedatanAnthemBlueCross-approvedCenterofExpertise,thetransplantrecipientisaPlanParticipant,andthetransplantisPreauthorized.Undercertaincircumstances,donorsearch,organortissueprocurement,anddonorexpensesarecovereduptoacombinedlifetimemaximumof$30,000.

Notcovered. Musthavereferraltotransplantfacility.SubjecttoplanDeductible,copays,coinsuranceandcoverage.

Musthavereferraltotransplantfacility.AftertheDeductible,subjecttoplanCoinsuranceandcoverage.





KAISER

PPO (In Network) Non-PPO (Out of Network) Podiatry Youmustuseapodiatrist

contractedbyPodiatryPlan,Inc.Youpay$65forthefirstofficevisitunlessvisitisforemergency,trauma,oradiabeticcondition.ThereafterthePlanpays100%ofContractRates. Limitedtoamaximumof8visitspercalendaryear. Nobenefitsarepaidfornon-PodiatryPlanpodiatrists.

OutsideCalifornia,usetheBlueCardnetwork.

Notcovered AftertheDeductible,Network1:$20copaypervisitNetwork2:$35copaypervisitNetwork3:$40copaypervisit

$20copaypervisit.Referralisrequired.

SpecialPodiatryBenefit

NotApplicable. Aseparate$120calendaryearbenefitisavailableregardlessofwhetheryouareenrolledinanHMOMedicalPlanortheIndemnityMedicalPlan. Thebenefitisforofficecallsandcharges(includingx-rays)bynon-networkprovidersincurredforthenon-surgicaltreatmentofchronicfootconditionssuchasweakorfallenarches,flatorpronatedfeet,halluxvalgus,metatarsalgia,orfootstrainandtoenailtrimmingandsurgicaltreatmentinvolvingdebridementofpainfulclavi.

ReconstructiveSurgeryFollowingMastectomy





Reconstructionofthebreastonwhichamastectomyisperformed,surgeryontheotherbreasttoprovideasymmetricalappearance,andprosthesesandservicesinconnectionwithphysicalcomplicationsofallstagesofmastectomy,includinglymphedemas.

HomeHealthCare

ThePlanpays80%ofContractRates,notsubjecttoDeductible.

ThePlanpays80%ofAllowedAmount,notsubjecttoDeductible.

UHCpays100%upto100visitspercalendaryear. Kaiserpays100%upto100visitspercalendaryear.

CoverageisprovidedforRegisteredNurseexpensesorlicensedvocationalnursewhenprescribedbyaphysicianasbeingMedicallyNecessary.PreauthorizationbyPrudentBuyer/BlueCardisrequired.ServicesandsuppliesprovidedinlieuoftheservicesthatwouldhavebeencoveredunderthePlanifconfinementhadbeeninahospitalorSkilledNursingFacilityarecovered. Homemakerservicesarenotcovered.





KAISER

PPO (In Network) Non-PPO (Out of Network) MENTALHEALTHANDSUBSTANCEABUSEBENEFITS ProviderNetwork

CoverageisadministeredbyHMCHealthWorks(HMC).Beforereceivingtreatments,youarestronglyencouragedtocontactHMCat866-268-2510.Preauthorizationisrequiredforallinpatienttreatments(exceptemergencyhospitalization),intensiveoutpatientprograms,ECT,psychologicaltestingandneuropsychologicaltesting.

CoverageisadministeredbyHMCHealthWorks(HMC). Allservicesandtreatmentsmustbepre-approvedbyHMC(866-268-2510)andprovidedbyHMCnetworkproviders. Nocoverageforservicesandtreatmentsbynon-HMCapprovedproviders.

CoverageisprovidedthroughKaiser.ParticipantsmustuseKaiserfacilitiesandproviders.

MentalHealthInpatient

AftertheDeductible,thePlanpays80%ofHMCContractRates.

AftertheDeductible,thePlanpays50%ofAllowedAmount.

AfterDeductible,thePlanpays80%ofHMCContractRates.


MentalHealthOutpatient

$20copayperofficevisit,notsubjecttotheDeductible;otherservicesat80%ofHMCContractRates.


$20copaypervisit,notsubjecttotheDeductible. $20copayperindividualvisitor$10copaypergroupvisit,notsubjecttotheDeductible.

SubstanceAbuseInpatient


AftertheDeductible,thePlanpays50%ofAllowedAmount.


Detoxification:AftertheDeductible,Kaiserpays80%ofCoveredCharges.

SubstanceAbuseOutpatient

$20copayperofficevisit,notsubjecttotheDeductible;otherservicesat80%ofHMCContractRates.


$20copaypervisit,notsubjecttotheDeductible $20copayperindividualvisitor$5copaypergroupvisit,notsubjecttotheDeductible.

MEDICALSUPPLIESANDEQUIPMENT OutpatientMedical&SurgicalSupplies


AftertheDeductible,thePlanpays50%oftheAllowedAmountupto$21.25maximum.

UHCpays100%ofCoveredCharges. AftertheDeductible,Kaiserpays80%ofCoveredCharges

OrthopedicAppliances

Reimbursementof100%ofContractRatesorAllowedAmountforpurchaseorrentalprescribedbyaphysician,uptoonceeachcalendaryear.

HearingAids Forpatientswhosephysicianhascertifiedahearinglossthatmaybelessenedbytheuseofahearingaid. ThePlanpays80%ofAllowedAmountforphysicianexaminationandinstrumentupto$750maximumforeachear,notmoreoftenthanonceduringany12-monthperiod.

DurableMedicalEquipment

ThePlanpays80%ofContractRates.

ThePlanpays80%oftheAllowedAmount.

UHCpays100%ofCoveredCharges,upto$5,000maximumpercalendaryear.

Kaiserpays80%ofCoveredCharges(notsubjecttotheDeductible).DurablemedicalequipmentforhomeuseisgenerallycoveredinaccordancewithKaiser'sformularyguidelines.





KAISER

PPO (In Network) Non-PPO (Out of Network) OTHERSERVICESANDBENEFITS PediatricVisionCare(uptoage19)

RoutineEyeexamsarecoveredat100%upto$135perexam. However,amountspaidforroutineeyeexamswillreducetheannualframeandlensbenefit.

A$135maximumbenefitforframesandlenseseachcalendaryear.

UHCpays100%ofCoveredChargesforRoutineEyeExams.

Kaiserpays100%ofCoveredChargesforRoutineEyeExams.

TheFundprovidesa$135maximumbenefitforframesandlenseseachcalendaryear.IfyougooutsideyourHMOforroutineeyeexams,theFundwillpay100%upto$135perexam.However,amountspaidbytheFundforeyeexamswillreducethe$135annualframeandlensbenefit.

AdultsVisionCare(age19andover)

A$135maximumbenefitforroutineeyeexamsand/orframesandlenseseachcalendaryear. ForKaiserandUHC,ifeyeexamisobtainedthroughyourHMO,the$135Fundbenefitcanbeusedforframesandlenses. ForKaiserEnrollees:routineeyeexamsobtainedthroughKaiserarecoveredat100%(notsubjecttoDeductibleorcopay). ForUHCEnrollees:routineeyeexamsthroughUHCaresubjecttocopays.Note: Youarepermittedtoopt-outofvisioncoverageforyourselfandyourDependents.However,optingoutofvisionbenefitswillnotchangetheamountofyourEmployeecontribution/premiums.

AdditionalAccidentalInjuryBenefit

InadditiontootherPlanbenefits,amaximumof$300ispayableforContractRates/AllowedAmountsforMedicallyNecessaryservicesandsuppliesincurredwithin90daysofanaccidentasaresultoftheaccident.

None.

PRESCRIPTION DRUG BENEFITS

ParticipatingPharmacy AllParticipantsmustuseSoCADrugFundParticipatingPharmacies.(SeeseparateDirectoryatwww.ufcwdrugtrust.orgunder“Downloads”) CalendarYearDeductible None. Out-of-PocketMaximum IndemnityMedicalPlanEnrollees:$5,400individual;$8,800familyperyearforprescriptionsfilledatparticipatingpharmacies

Kaiser/UHCEnrollees: $5,900individual;$11,800familyperyearforprescriptionsfilledatparticipatingpharmacies

MaximumDaysSupply Maximum30dayssupplyperprescription. Formaintenancedrugsincertaintherapeuticclassifications,a90-daysupplymaybeobtained. GenericPreventiveCareDrugs(includingFDAapprovedcontraceptives)

Planpays100%foraspirin,fluoridesupplement,folicacid,statinpreventivemedication,tobaccocessationproducts,breastcancerpreventivemedication,preparationproducts for colon cancer screening test, and female contraceptives;prescription required for OTC available drugs. Brand namewill becoveredwhenagenericisunavailableormedicallyinappropriate,butmustbeauthorizedbyOptumRx. Ageandfrequencylimitsapply.

Generic PlatinumPlan:$8copayperprescription;GoldPlan:$12copayperprescription.


SOUTHERN CALIFORNIA DRUG BENEFIT SUMMARYOFTHEPLATINUMANDGOLDPLANSASOFJANUARY1,

PRESCRIPTION DRUG BENEFITS

FormularyBrand PlatinumPlan:$25copayperprescription;GoldPlan:$30copayperprescription.Thesecopaysareonlyapplicablewhennogenericequivalentisavailableorifyourdoctorindicates“dispenseaswritten.”

Ifagenericequivalentisavailableandyourdoctordoesnotindicate“dispenseaswritten,”youmustpaythecostdifferencebetweenthegenericdrugandthebrand-namedrugplustheapplicablecopay($25or$30).

Non-formularyBrand PlatinumPlan:$45copayperprescription;GoldPlan:$50copayperprescription. Injectables ThePlanpays80%ofOptumRx’sContractRate. AuthorizationrequiredthroughOptumRx.

ForUHCenrollees,injectablesthatareprescribedbyUHCphysiciansandprovidedbyUHCarecoveredat100%bytheUHCplanandarenotcoveredunderthePrescriptionDrugPlan.

DENTAL BENEFITS

INDEMNITYDENTALPLAN UNITEDCONCORDIA ChoiceofProvider Youmayselectanydentistofyourchoice. UsingaDeltaDentalPPOdentistwillloweryourout-of-pocket

expenses. YoumustusetheUnitedConcordiadentalofficeinwhichyouareenrolled.

CalendarYearDeductible $75perperson;$225perfamily. Notapplicabletoroutinepreventativeanddiagnosticprocedures. None. CoveredCharges ForDeltaPPOdentists,thePlanpaysthelesseroftheDeltaPPOContractRatesortheamountlistedinthe

ScheduleofAllowances.ForDeltaPremierdentists,thePlanpaysthelesseroftheDeltaPremierFiledFeesortheamountlistedintheScheduleofAllowances.Fornon-DeltaDentaldentists,thePlanpaysthelesseroftheamountbilledbythedentistortheamountlistedintheScheduleofAllowances.ScheduleofAllowancesisestablishedbytheTrusteesandadjustedannually(seeseparatescheduleatwww.ufcwdrugtrust.orgunder”Downloads”).

Note: Youarepermittedtoopt-outofdentalcoverageforyourselfandyourDependents.ContacttheFundOfficeformoreinformation.

SeeUnitedConcordia’sScheduleofBenefits.

MaximumBenefit $1,800perpersonpercalendaryearforadultsage19andolder. Nomaximum.


PLAN EXCLUSIONS


INDEMNITYPLAN KAISER&UNITEDHEALTHCARE ExcludedServices 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;§ Anyservicesorsuppliesnotrecommendedandapprovedbyalegallyqualifiedphysicianorsurgeon,

dentist,mentalhealthprofessional,podiatristonthePodiatryPlanpanel,orchiropractorperformingserviceswithinthelegalscopeoftheirpractices;

§ ConditionscoveredbyWorkers’Compensationorincurredinthecourseofemployment,includingself-employment;

§ PenileprosthesisunlesspreauthorizedbyAnthemBlueCross;§ Pregnancyexpensesofdependentchildrenorexpensesforconditionsarisingfrompregnancyof

dependentchildren,exceptpreventivecareexpenses;

§ Surgicalcorrectionofrefractiveproblemsincludingradialkeratotomyunlessvisioncannotbecorrectedthrougheyeglassesorcontactlenses;

PleaserefertotheEvidenceofCoveragebookletsprovidedbyKaiserandUnitedHealthcare.


PLAN EXCLUSIONS


INDEMNITYPLAN KAISER&UNITEDHEALTHCARE ExcludedServices(cont’d) § Expensesincurredforanyconditionwherethereexistsnoinjuryorsickness,exceptthatthisexclusion

doesnotapplytobenefitsspecificallyprovided,suchashospicecare,sterilizationprocedures,andpreventivecarebenefits;

§ Speechtherapy,exceptfromaPPOprovider;§ Takehomedrugswhendischargedfromthehospital;§ ExpensesincurredbyatransplantdonorwhoisnoteligibleunderthePlan(exceptforbenefits

specificallyprovided);§ OrganortissuetransplantsperformedatafacilitythatisnotanAnthemBlueCrossCenterof

Expertise;§ ExpensesincurredbyanorganortissuedonorwhenthetransplantrecipientisnotaPlanparticipant.§ Vocationaltesting,evaluationandcounseling;§ Injuriesresultingfromanyformofwarfareorinvasion;§ Nobenefitswillbeprovidedforpodiatriccarereceivedfromanon-PodiatryPlan,Inc.podiatrist(ifyou

liveoutsideofCalifornianopodiatrybenefitswillbeprovidedunlessyouuseaBlueCardnetworkpodiatrist),exceptforthespecialpodiatrybenefit. Inaddition,benefitsforpodiatriccarearelimitedtothosespecificallydescribed;

§ Claimsfiledmorethanoneyearafterthedateonwhichserviceswereincurred;§ ServicesorsuppliesthatarenotNecessaryTreatment.


ThirdPartyLiability IfaParticipantobtainsarecoveryfromathirdpartythatisinanymannerrelatedtoclaimspaidbytheFund,theParticipantwillreimbursetheFundfromsuchrecoveryinanamountnotinexcessofthepaymentsmadeortobemadebytheFund.


DentalExclusions FortheIndemnityDentalPlan,pleasereadtheIndemnityScheduleofAllowancesforDentalProcedures(updatedeachJanuary).FortheUnitedConcordiaPlan,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

1

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 athttp://www.hhs.gov/ocr/office/file/index.html.

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.دیيریي

October 15, 2016

توجھ : اگر بھ زبان فارسی گفتگو می کنید، تسھیلات زبانی بصورت رایگان برای شما فراھم می باشد . با 8910-666-323-1 تماس بگیرید.

October 15, 2016 Revised: October 11, 2018

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Documents

SOUTHERN CALIFORNIA DRUG BENEFIT FUND Gold and Platinum...OE 2020 – Platinum/Gold Plan Description and the evidence of coverage booklets provided by Kaiser, UnitedHealthcare (formerly