HomeMy WebLinkAboutAgreement A-15-644 with SJVIA.pdfAgreement No. 15-644
SJVIA PARTICIPATION AGREEMENT
THIS AGREEMENT ("Agreement") is made and entered into this 7'h day of December, 2015, by and
between COUNTY OF FRESNO, a political subdivision of the State of California, hereinafter referred to as
"CO~NTY OF FRESNO", and the SAN JOAQUIN VALLEY INSURANCE AUTHORITY, a joint powers agency,
heremafter referred to as "SJVIA".
W I T N E S S E T H:
WHEREAS, the purpose of the SJVIA is to develop and provide various health insurance programs, for
health, pharmacy, vision, dental, mental health, and life insurance, including related administrative services for
such programs to be provided by the insurance provider(s) and the SJVIA and its agents and consultants
(collectively, "Various Benefits"), for the benefit of participating entities; and
WHEREAS, the COUNTY OF FRESNO wishes to participate in the SJVIA Various Benefits for the
purpose of purchasing health insurance programs, and/or other benefits in a cost-effective manner for its
participating employees; and
WHEREAS, the COUNTY OF FRESNO elects to participate in the selected SJVIA health insurance
program as referenced in Exhibit "A" (collectively, "SELECTED PROGRAMS"); and
WHEREAS, the COUNTY OF FRESNO and the SJVIA now desire to enter into this Agreement to secure
the COUNTY OF FRESNO's commitment to remit premium payments to the SJVIA for the Various Benefits to
be provided under the Insurance Contract and by the SJVIA and its agents and consultants, as provided herein.
WHEREAS, a true and correct copy of a summary of applicable SJVIA health insurance programs is
attached hereto and incorporated herein by reference as Exhibit "A"; and
WHEREAS, the SJVIA represents that it will contract with Insurance Providers which will provide its
Various Benefits under the terms and conditions of a written contract between the SJVIA and the Insurance
Provider (the "Insurance Contract") for each of the COUNTY OF FRESNO's participating employees; and
WHEREAS, the SJVIA represents that the rates for the Various Benefits under the SELECTED
PROGRAMS to be provided under the Insurance Contract and by the SJVIA, including the costs of its agents
and consultants, are set forth in Exhibit "B" which is attached hereto and incorporated herein by reference; and
WHEREAS, the COUNTY OF FRESNO and the SJVIA now desire to enter into this Agreement to secure
the COUNTY OF FRESNO's commitment to remit premium payments to the SJVIA for the Various Benefits to
be provided under the Insurance Contract, and the COUNTY OF FRESNO's portion of the costs of the SJVIA's
agents and consultants, as provided herein.
NOW THEREFORE, in consideration of their mutual promises, covenants and conditions, the Parties
agree as follows:
1. COUNTY OF FRESNO's OBLIGATIONS: The COUNTY OF FRESNO acknowledges that this
agreement requires a commitment to participate in SJVIA Various Benefits effective December 7, 2015 through.
December 18, 2016 for employees and January 1, 2016 through December 31, 2016 for retirees. Within ten
business days of the date that SJVIA is required under the Insurance Contract to pay any insurance premium
and/or similar charge to the Insurance Provider, the COUNTY OF FRESNO shall remit to SJVIA the amount
necessary to pay the required premium payment based on the intervals of such payments under the Insurance
Contract.
The COUNTY OF FRESNO may also participate in SELECTED PROGRAMS as referenced in Exhibit "A" and
shall comply with all applicable terms and provisions of the Insurance Contract and this Agreement, effective
December 7, 2015. The attached rates in Exhibit "B" reference only the SELECTED PROGRAMS the COUNTY
OF FRESNO is electing . Exhibit "B" also references the effective term such rates apply to the COUNTY OF
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FRESNO which are effective December 7, 2015 for employees and January 1, 2016 for retirees. The COUNTY
OF FRESNO agrees that it may only elect to participate in additional health insurance programs, or elect to
make changes to the SELECTED PROGRAMS, through subsequent amendment to this agreement or separate
agreement. Subsequent renewals are based on the SJVIA underwriting guidelines. The SJVIA is underwritten
and renewed as a single risk pool using actuarially based underwriting standards.
2. SJVIA'S OBLIGATIONS: The SJVIA shall approve and execute related Insurance Contracts.
Following execution of the Insurance Contracts, (i) SJVIA shall make available the fully-executed copy of the
Insurance Contract to COUNTY OF FRESNO, (ii) SJVIA shall enforce SJVIA's rights under the Insurance
Contract for the benefit of COUNTY OF FRESNO, and (iii) SJVIA shall perform SJVIA's obligations under the
terms and conditions of the Insurance Contracts. including making timely payment of premium payments ,
and/or any similar charges, necessary to keep the Insurance Contracts in full force and effect.
3. MODIFICATION: Any matters of this Agreement may be modified from time to time but only by
the written consent of all the parties hereto without, in any way, affecting the remainder hereof.
4. NON-ASSIGNMENT: Neither party hereto shall assign, transfer, or subcontract this Agreement
nor their rights or duties under this Agreement without the prior written consent of the other party hereto.
5. AUDITS AND INSPECTIONS: The SJVIA shall at any time during usual SJVIA business hours,
upon request by the COUNTY OF FRESNO, and as often as the COUNTY OF FRESNO may deem necessary,
make available to the COUNTY OF FRESNO for examination all SJVIA records and data for inspection ,
examination, and audit by the COUNTY OF FRESNO with respect to the matters covered by this Agreement.
SJVIA shall be subject to the examination and audit of the State Auditor General for a period of three (3) years
after final payment under contract (Government Code section 8546.7).
6. NOTICES: The persons having authority to give and receive notices under this Agreement and
their addresses include the following:
COUNTY OF FRESNO
Paul Nerland
Director of Human Resources
2220 Tulare St, 161
h Floor
Fresno, CA 93721
PNerland@co . fresno . ca. us
SJVIA
Rhonda Sjostrom
SJVIA Manager
2900 West Burrel
Visalia, CA 93291
rsjostro@co.tulare .ca.us
Any and all notices between the COUNTY OF FRESNO and the SJVIA provided for or permitted under
this Agreement shall be in writing and shall be deemed duly served when personally delivered to one of the
parties, or in lieu of such personal service, when deposited in the United States Mail, postage prepaid,
addressed to such party.
7. GOVERNING LAW: The parties agree that for the purposes of venue, performance under this
Agreement is to be in Fresno County, California. The rights and obligations of the parties and all interpretation
and performance of this Agreement shall be governed in all respects by the laws of the State of California .
8. TERM: This Agreement shall become effective beginning at 12:01 a .m . on December 7, 2015
and shall terminate on December 31, 2016.
9. TERMINATION:
a . The terms of this Agreement, and the Various Benefits, Administrative Services, and/or
SJVIA Staff Costs to be provided hereunder, are contingent on the approval of funds by the
COUNTY O F FRESNO . Should sufficient funds not be a llocat e d, th e services provided may
be modified, or this Agreement terminated at any time by giving SJVIA 120 days advance
written notice.
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b. Notwithstanding any other provision of this Article, if the COUNTY OF FRESNO fails to
make in full any payment when due pursuant to Article 1, the SJVIA shall have the right , in
its sole discretion, to terminate this Agreement, without notice, effective at the expiration of
the last period for which full premium payment was made. Notwithstanding such termination
or suspension, the SJVIA, in its sole discretion, may accept late payment or delinquent
amounts and, upon acceptance, this Agreement may be reinstated retroactively to the last
date for which full premium payment was made. Any such acceptance of a delinquent
payment by the SJVIA shall not be deemed a waiver of this provision for termination of this
Agreement in the event of any future failure of the COUNTY OF FRESNO to make timely
payments of any amounts due under this Agreement.
10. SEVERABILITY: In the event any provisions of this Agreement are held by a court of
competent jurisdiction to be invalid, void, or unenforceable, the Parties will use thei r best efforts to meet and
confer to determine how to mutually amend such provisions with valid and enforceable provisions, and the
remaining provisions of this Agreement will nevertheless continue in full force and effect without being impaired
or invalidated in any way.
11. DISPUTE RESOLUTION: Any controversy or dispute between the parties arising out of this
agreement shall be submitted to mediation. The mediator will be selected by mutual agreement. If the matter
cannot be resolved through mediation or if the parties cannot agree upon a mediator the matter shall be
submitted to arbitration and such arbitration shall comply with and be governed by the provisions of the
Californ ia Arbitration Act, of the California Code of Civil Procedure.
12. ENTIRE AGREEMENT: This Agreement constitutes the entire agreement between the SJVIA
and COUNTY OF FRESNO w ith respect to the subject matter hereof and supersedes all previous agreement
negotiations, proposals, commitments, writings, advertisements, publ ications, and understandings of any nature
whatsoever unless expressly included in this Agreement.
13. COUNTERPARTS: This Agreement may be executed in one or more original counterparts , all of
which together will constitute one and the same agreement.
Ill
Ill
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(Go to next page for signatures)
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AGREEMENT BETWEEN COUNTY OF FRESNO AND THE
SAN JOAQUIN VALLEY INSURANCE AUTHORITY
SAN JOAQUIN VALLEY INSURANCE
AUTHORITY:
By __ ~~~~~~----------Pete Vander Poel
SJVIA Board President
Date:
REVIEWED & RECOMMENDED FOR APPROVAL
By ________________________ _
Rhonda Sjostrom
SJVIA Manager
COUNTY OF FRESNO
By ~~
Buddy endes
Chairman, Board of Supervisors
Date: ::fcv-ne. .30 1 dOl L.o
BERNICE E. SEIDEL, CLERK
BOARD OF SUPERVISORS
APPROVED AS TO LEGAL FORM :
DANIEL C . CEDERBORG , COUNTY COUNSEL
PPROVED AS TO ACCOUN T ING FORM :
VICKI CROW
::DIJ~E 7r;; TAX COLLECTOR
REVIEWED & RECOMMENDED FOR
~ ~ (') By \~
Paul Nerland
Director of Human Resources
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Exhibit A
Your Summary of Benefits
County of Fresno
Custom Premier HMO 15
January 1, 2016
Anthem.+.
Blue Cross
This Summary of Benefits is a brief overview ofyour_plan's benefits only. For more detailed information
about the benefits in your plan, please refer to your Certificate of Insurance or Evidence of Coverage (EOC),
which explains the full range of covered services, as well as any exclusions and limitations for your plan.
Anthem Blue Cross HMO benefits are covered only when services are provided or coordinated bx the primary care
physician and authorized by the participating medical group or independent practice association tiP A), except
services provided under the "Ready Access" program, OB/GYN services received within the member's medical
group/IPA, and services for all mental and nervous disorders and substance abuse. Benefits are subject to all terms,
conditions, limitations, and exclusions of the Policy.
Calendar Year copay maximum: Individual $1 ,000; Family $2,000
The following COJ>ay does not apply to the annual copay maximum: for infertility treatment. After an annual COP.aY
maximum is met for medical and prescription drugs <luring a calendar year, the mdividual member or family Will no
longer be required to pay a copay or coinsurance for medical and prescription drug covered expenses for the
remainder of that year. The member remains responsible for non-covered expenses infertility treatment.
Co' ered Sen ices Per i\lember Copay
Preventive Care Services
Preventive Care Services including*, physical exams, No copay
preventive screenings (including screeni':f/ for
cancer, HP V, diabetes, cholesterol, bloo pressure,
hearing and vision, immunizations, health education,
intervention services, HIV testing)., and additional
preventive care for women provided for in the
feidelines supported by the Health Resources and
ervices Admmistration.
*This list is not exhaustive. This benefit includes all
Preventive Care Services required by federal and state
law.
Smoking Cessation Program Nocopay
Physician Medical Services
o Office & home visits $15/visit
o Specialists $15/visit
o Skilled nursing facility visits Nocopay
o Hospital visits Nocopay
o Injectable medications in physician's office
(excluding allergy serum and immunization)
Nocopay
o Surgeon & Surgical assistant No copay
o Anesthesiologist or anesthetist Nocopay
Acupuncture $15/visit
Covered Services Per Member Copay
Outpatient Medical Services (Services received in a
hospital, other than emergency room services, or in
anyfaci/ity that is affiliated with a hospital)
o Outpatient surgery & supplies Nocopay
o Advanced Imaging Nocopay
o All other X-ra~ & laboratory tests (including
genetic testing
Nocopay
o Radiation th=1 chemotherapy & hemodialysis
treatment & 1on therapy
Nocopay
o Other Outpatient Medical Services including: No copay
Rehabilitation Thera~y f:thysica/, Occupational, or
Speech Therapy, limzte to a 60-day period of care)
General Medical Services (when performed in non-
hospital-based facility)
o Advanced Imaging Nocopay
o All other X-ra~ & laboratory tests (including
genetic testing
Nocopay
o Allergy testing & treatment (including serums) Nocopay
o Radiation th=1 chemotherapy & hemodialysis
treatment & 10n therapy
Nocopay
o Rehabilitation Thera!.l (Physical, Ochational, or $15/visit
~eech Ther~~ or iropractic Care, imited to
0-days perio of care)
Emergency Care
o Physician & medical services Nocopay
o Outpatient hospital emergency room services $1 00/visit (waived if admitted inpatient)
Inpatient Medical Services
Semi-private room or private room, medically
necessary services & supplies
Nocopay
Urgent Care
(out of service area) $15/visit (EJR.ay waived if admitted inpatient or
outp_atient For in area, contact your PCP or
meaica/ group)
Skilled Nursin~ Facility
(limited to 100 ays/ca/endar year)
o All necessary services & supplies (excluding take-
home drugs)
Nocopay
Ambulance Services
o Transportation when medically necessary Nocopay
Ambulatory Surgical Center
o Outpatient surgery & supplies Nocopay
Covered Services Per Member ( opa~
Pregnancy and Maternity Care
Prenatal & /nostnatal Professional (physician) services No copay
~or your npatient copay, see Inpatient Medical
rvices. F~our Outpatient Services copay, see
Outpatient edical Services)
Abortions (including prescription drug for abortion,
mifepristone)
No copay
Prosthetic devices (including Orthotics) No copay .
Durable medical equipment Nocopay
o Rental and Purchase ofDME (hearing aids benefit
available for one hearing aid ~er ear every three
years; breast pump and supp 1es are covered under
preventive care at no charge)
Family Planning and Infertility Services
o Infertility studies & tests $15/visit
o Female Sterilization (including tuba/ligation and
counselin?/ consultation)
No copay
o Male Sterilization $15/visit
o Counseling & consultation $15/visit
Mental or Nervous Disorders and Substance Abuse
o Inpatient facility care (subject to utilization review;
waived for emergency adinissions)
Nocopay
o Inpatient physician visits No copay
o Outpatient facility care Nocopay
o Physician office visits (Behavioral Health treatment $15/visit
for Autism or Pervasive Development disorders
require pre-service review)
Home Health Care
~imited to 100 visits/calendar lear; one visit by a $15/visit
ome health aide equals four ours or less)
Hospice Care (Inpatient or outpatient services; family
bereavement serv1ces)
Nocopay
Organ and Tissue Transplant
o Inpatient Care Nocopay
o Physician office visits $15/visit
o Specialist office visits $15/visit I
This Summary of Benefits has been updated to comply with federal and state requirements, including applicable
provisions of the recently enacted :federal health care reform laws. As we receive additional guidance and
clarification on the new health care reform laws from the U.S. Department of Health and Human Services,
Department of Labor and Internal Revenue Service, we may be required to make additional changes to this
Summary of Benefits. This Summary of Benefits, as updatedl is subject to the apP-roval of the California Department
of Insurance and the California Department of Managed Heruth Care (as applicaole).
Premier HMO· Exclusions and limitations
Care Not Approved. care from a health care provider without the OK of primary care doctor, except for
emergency services or urgent care.
Care Not Covered. Services beforE the member was on the plan, or after coverage ended.
Care Not listed. Services not listed as being covered by this plan.
CareNot Needed. Any servicas or supplies that are not medically necessary.
Crime Cl' Nuclear Energy. Any health problem caused: (11 while committing or trying to commit a felony,
as long as any injuries are not a rEsult of a medical condition or an act of domestic violence; or (21 by
nuclear energy, when t he government can pay for treatment.
Experimental or Investigative. Any experimental or investigative procedure or medication.
Bu~ if member is denied ben efrts because it is determined that the requested trEatment is experimental
or investigative, the member may ask that the denial be reviewed by an external independent medical
revi!!W organization, as described in the Evidence of coverage (EOCJ.
Cowrnmerrt Treatment Any services the member actual ly received that were given by a local, state or
federal government agency. except when this plan's benefits, must be provided by law.
We will not cover payment fur these services if the member is not required to pay for them or th ey arE
gi'len to the member fur rree.
Services Given by Providers Wl!o Are Not Willi Anthem Blue cross HMO. We will not cover these
services unless primary care doctor refers the member, except fur emergencies or urgent care.
Services Not Needing Payment Services the member is not required to pay for or are given to the
member at no charge, except services the member got at a charitable research hospital (not with the
government}. This hospital must:l. Be kllown throughout the world as devoted to medical research.2.
Have at least 10% of its yearty budget spent on research not directly related t o patient care .J. Have 113
of its income from donations or grants (not gifts or payments for patient care).4. Accept patients who arE
not able to pay.S. Serve patients with conditions directly related to the hospital's research (at least 2/3
of their patientsl.
Wor!I·Related. Care for health problems that are work-re lated if such health problems are or can be
covered by worllers' compensation, an employer's liability law, or a similar law. We will provide care for a
work-related health problem, but, we have the right robe paid back for that care. see 'Third Party
Uability" below.
Aoopressure. Acupressure, or massage to help pain, treat illn ess or promote health by putting pressure
tv one or more areas of the body.Air condl~ners. Air pu rtfiers. a~ conditioners. or humidifiers .
Birth COntrol Devices. Any deices needed for birth control which can be obtained without a doctor 's
prescription such as condoms.
Blotid. Benefits are not provided for the collection. processing and storage of self-donated blood unless it
is specifically collected for a planned and covs-ed surgical procedure.
Bracas or Clther Ap~iances or Services for straightening the teeth (orthodontic services).
Cli~ical Trials. Services and supplies in connection with dinicaltrials, excep t as specified
as covered in the Evidence of Coverage (EOC).
Commercial WEight loss progranl!l. Weight loss programs, whether or not they are pursued und er
medical or OO!:tor supervision, except as sp ecified as coverEd in the EOC. This exclusion includes, but Is
not limited to, commercial weight loss program s (Weight Watchers. Jenny craig, LA Weight Loss) and
fasting programs. This exclusion does not apply t o med ically necessary trEatmerrts for morbid obesity or
for treatment of anorexia nervosa or bulimia nervosa.
Consultations given by telephone or fax.
Cosmetic Surgery. Surgery or other services done only to make the member: look beautiful;
to improve appearance; or to change or reshape normal parts or tissues of the body. This does not apply
to rEconstructive surg ery the member might need to: get back the use of a body part; have for breast
reconstruction afte r a mastectomy; correct or repa ir a deformity caused by birth defects, abnormal
developme nt, injury or illness in order to improve function, symptomatology or create a nonmal
ap)'!arence . Cosmetic surgery does not become reconstructive because of psycholog ical or psychiatric
reasons.
Custodial Care or Rest Cures. Room and board charges for a hospital stay mostly for a ch ange
of scene or to make the member feel good. Services given by a rest home , a home for the aged,
or any place like that.
Dental Services or supplies. oenwres. bridges, crowns , caps, or dental prostheses. dental implants,
dental services, tooth extraction. or treatment to the teeth or gums. Cosmetic dental surgery or other
dental services for beauty purposeR
Oiabe~c Supplies. Prescription and nof1i!rescription diabetic supplies, except as specifie d as covered in
theEOG.
Eye En!rcises or Services and Supplies for conrectlng VIsion. Dptometry servi ces. eye exerc ises. and
orthoptics, except fur eye exams to find out if the member's vision needs to be corrected , Ey eglasses or
contact lenses are not covered. Contact lens fitting is not coverEd.
Eye Surgery for Refractive Defects. Any eye surgery just fur ccnrecting vision (like nearsightedness
and/or astigmatism). contact lenses and eyeglasses need ed after this surgery.
Food or Dietary Supplements. Nutritional and/or dietary supplements. except as specified as covered in
the EOC or as required by law . This exclusion includes , but is not limited to , those nutritional form ulas and
dietary supplements that can be purchased over the counter, which by law do not requirE either a written
prescription or dispensing by a licensed pharmacist
Health Club Membership. Hea~h club memberships. exercise equipmen~ charges from a physical fitness
instructor or personal trainer, or any other charges fur activities, equipmen~ or faci lities use d for
developing or maintaining physical frtness, even if ordered by a doctor. This exclusion also app li es to
health spas.
Immunizations . Immuniza ti ons needed to travel outside the USA.
Infertility Treatment Any infertility treatment including artificial insemination or in vitro ferti lization &
spenm bank.
lifestyle Programs. Programs to help member change how one lives, like fitness clubs. or dieting
programs. This does not app ly to canlia c rehabilitation programs approved by the medical group.
Mental or nervous disorders. Academic or educational testing, counseling. Remedying an aca demic or
education problem, except as stated as covered in the EOC.
Noll-Prescription-Drugs. NoniJrescrip tion, over-thHounter drugs or medicines.
Orthopedic shoes and shoe inserts. This exclusion does not apply to orthopedic footwear used as an
integral part of a brace , shoe inserts that are custom molded to the patien~ ortherapeutlc shoes and
inserts designed to treat foot complications due to diabetes, as specifically stated in t he we .
Outpatient Drugs. Outpa tient prescription drugs or medications including insulin.
Personal Care and Supplies. Services for personal care. such as: help in walking, bathing, dressing,
feeding, or preparing food. Any supplies for comfort, hygiene or beauty purposes.
Private Contracts. Services or supplies provided purs uant to a priVate co ntract between the member and
a provider. for which reimbursement under the MedicarE program is prohibited. as specified in Section
1002 (42 U.S.C. 1395a) of nile XVIII of the Social Security Act
Routine Exams. Routine physical or psychologi cal exams or tests asked for by a job or othe r group, such
as a schoOl, camp, or sports program.
scalp hair prostheses. Scalp hair prostheses, including wigs or any fonm of hair replacemen t.
Sexual Problems. Treatment of any sexual problems unless due to a medical problem, physic al defect, or
disease.
Sterilizatlon Reversal. Surgery done to reverse a sterilization.
Surrogate Mother Services. For any services or supplies provided to a person not covered under the plan
In connection with a surrogate pregnancy (including , but not limited to, the bearing of a child by another
woman for an infertile couple!.
Third Party Uability-Anthem Blue Cross Is entitled to reimbursement of benefits paid if the membe r
recovers damages from a legally liable third party.
Varicose Vein Treatment. Treatment of varicose veins or telangiectatic dermal veins (spider veinsl by
any method (including sclerotherapy or other surgeries! when servil:es are rendered for cosme tic
purposes.
Coordination of Benefits-The benefits of this plan may be rEduced if the member has any other group
health or dental coverage so that the services received from all group coverages do not exceed lOO'~ of
the covered e~pense.
Antllem Blue Cross is tile tnlJJe name of Bills Cross of Califrlmia. Independent //unsee of tile Bille
Crt!S$ AssD&fstilln. "ANTHEM is a registBred trad8marlr Of Anthem fllSU/3/lCe CompaniBs, Inc. T7J8
Blue Cross nams and symbol iKI1 registered marks of the Bille Cross Association.
Anthem Blue Cross ·1s the trade name of Blue c ros s of California. Independent Licensee of the Blue Cross Association. ®ANTHEM is a registered lrademarl< of Anthem Ins urance
Companies, Inc. The Blue Cross name and symbol are registered marks of the Blue Cross Association.
~nthPm ~n ml~-" An1hAm RlnA C:rn« IP-NPl REV 011201 6 Printed 0912015 Countv of Fresno Premier HMO 15 -C
Blue Cross
SJVIA
Modified Chiropractic Care and Acupuncture
Rider Plan 10/40
The benefits described in this Rider are provided through an agreement between Anthem Blue Cross and American Specialty Health
Plans of California (ASH Plans). The services listed below are covered only if provided by an ASH Plans Chiropractor and/or ASH
Plans Acupuncturist. These benefits are provided in addition to the benefits described in the Anthem Blue Cross HMO Evidence of
Coverage (EOC) document. However, when expenses are incurred for treatment received from an ASH Plans Chiropractor or ASH
Plans Acupuncturist, no other benefits other than the benefits described in this Rider will be paid.
Covered Services
Office Visit to a Chiropractor or Acupuncturist
Maximum Benefits
Office visits to a Chiropractor or Acupuncturist
Chiropractic appliances
Covered Services
Member's Copayment
$10/visit
40 visits per calendar year (chiropractic and
acupuncture visits combined)
$50 per calendar year
Chiropractor Services: Member has up to 40 visits, combined with visits for acupuncture services, in a calendar year for chiropractor care
services that are determined by ASH PLANS to be medically/clinically necessary. All visits to an ASH Plans chiropractor or ASH Plans
acupuncturist will be applied towards the maximum number of visits in a calendar year. The ASH Plans chiropractor is responsible for
submitting a treatment plan to ASH Plans for prior approval.
Covered services include:
> An initial new patient exam by an ASH Plans chiropractor to determine the appropriateness of chiropractic services.
> Follow-up office visits as set forth in a treatment plan approved by ASH Plans and provided by an ASH Plans chiropractor
> An established patient exam performed by an ASH Plans chiropractor to assess the need to continue, extend or change a treatment
plan approved by ASH Plans.
> Adjunctive physiotherapy modalities and procedures as set forth in a treatment plan approved by ASH Plans and provided by ASH
Plans chiropractor.
> Radiological x-rays and laboratory tests when prescribed by an ASH Plans chiropractor and approved by ASH Plans. Covered services
include radiological consultations when determined by ASH Plans to be medically/clinically necessary and provided by a licensed
chiropractic radiologist, medical radiologist, radiology group or hospital which has contracted with ASH Plans to provide those services.
> Chiropractic Appliances: Up to $50 per calendar year when prescribed by an ASH Plans chiropractor and approved by ASH Plans.
Covered chiropractic appliances are limited to:
-elbow supports, back supports (thoracic), lumbar braces and supports, rib supports, or wrist supports;
-cervical collars or cervical pillows;
-ankle braces, knee braces, or wrist braces;
-heel lifts;
-hot or cold packs;
-lumbar cushions;
-rib belts or orthotics; and
-home traction units for treatment of the cervical or lumbar regions.
Acupuncture Services. Member has up to 40 visits, combined with visits for chiropractic care, in a calendar year for acupuncture services
that are determined by ASH Plans to be medically/clinically necessary. All visits to an ASH Plans chiropractor or ASH Plans acupuncturist
will be applied towards the maximum number of visits in a calendar year. The ASH Plans acupuncturist is responsible for submitting a
treatment plan to ASH Plans for prior approval.
Covered services include: > An initial new patient exam by an ASH Plans acupuncturist to determine the appropriateness of acupuncture services.
> Follow-up office visits as set forth in a treatment plan approved by ASH Plans and provided by an ASH Plans acupuncturist
> An established patient exam performed by an ASH Plans acupuncturist to assess the need to continue, extend or change
a treatment plan approved by ASH Plans.
> Adjunctive physiotherapy modalities and procedures as set forth in a treatment plan approved by ASH Plans and provided by ASH
Plans acupuncturist.
anthem.com/ca Anthem Blue Cross NGF cc: OQ2J Effective 01/2016 Printed 2/4/2016
Chiropractic Care and Acupuncture Rider Exclusions & Limitations
Care Not Approved: Any services provided by an ASH Plans chiropractor or an ASH Plans
acupuncturist th at are not approved by ASH Plans except as specified as covered in the Evidence
of Coverage (EOC). An ASH Plans chiropra:tor or ASH Plans acupuncturist is responsible for
submitting a treatment plan to ASH Plans for prior approval.
Care Not Covered: In addition to any service or supply specifically excluded in the EOC, no
benefits will be provided for chiropractic or acupuncture services or supplies in connection with:
)> Diagnostic scanning, such as magnetic resonance imaging (MRI} or computerized axial
tomography (CA 'D scans. Diagnostic services for acupuncture.
)> Thermography.
> Hypnotherapy.
> Behavior training.
) Sleep therapy.
> Weight programs.
> Any oon-medical program or service.
> Pre-employment examinations, any chiropractic or acupuncture services required by an
employer that are not medically/clinically necessa~y, or vocational rehabilitation.
) Services and/or treatments which are not documented as medically/clinically necessary.
) Massage therapy.
) Acupuncture performed with reusable needles.
) Acupuncture services benefits are not provided for magnets used for diagnostic or therapeutic
use, ion cord devices, manipulation or adjustments of the joints, physical therapy services,
iridology, hormone replacement products, acupuncture point or trigger-point injections (including
injectable substances), laserAaser biostim, colorpuncture, NAET diagnosis and/or treatment.
and direct moxibustion.
) Any service or supply for the exam and/or treatment by an ASH chiropractor for conditions other
than those related to neuromusculoskeletal disorders.
) Services from an ASH Plans acupuncturist for exam and/or treatment for conditions not related
to neuromusculoskeletal disorders, nausea or pain, incluing, without limitation, asthma or
addictions such as nicotine addiction.
) Transportation costs including local ambulance charges.
) Education programs, non-medical self-care or self-help, or any self-help physical exercise
training or any related diagnostic testing.
) Hospitalization, surgical procedures, anesthesia, manipulation under anesthesia, proctology,
colonic irrigation, injections and injection services, or other related services;
> All auxiliary aids and services, including, but not limited to, interpreters, transcription se rvices,
written materials, telecommunications devices, telephone handset amplifiers, television
decoders and telephone compatible with hearin g aids;
> Adjunctive therapy not associated with spinal, muscle or joint manipulation.
)> Laboratory and diagnostic x-ray studies, except as specified as covered in the EOC.
Non-ASH Plans Chiropractors or non-ASH Plans Acupuncturists: Services and supplies
provided by a chiropractor or an acupuncturists who does not have an agreement with ASH Plans
to provide covered services under this plan.
Woril Related: Care for health problems that are work-related if such health problems are covered
by 'Mlrkers' compensation, an employer's liability law or similar law. We will provide care for a
work-related health problem, but we have the right to be paid back for that care as described
in theEOC.
Government Treatment: Any services actually given to the member by a local, state or federal
government agency, except when this plan's benefits, must be provided by law. We will not cover
payment for these services if the member is not required to pay for them or they are given to the
member for free.
Drugs: Prescription drugs or medicines, including a non-legend or proprietary medicine or
medication not requiring a prescription.
Supplement Vitamins, minerals, dietary and nutritional supplements or other similar products
and any herbal supplements.
Air Conditioners: Air purifiers, air conditioners, humidifiers, supplies or any other similar devices
or appliances. All appliances or durable medical equipment, except as specified as covered
in the EOC ..
Personal Items: Any supplies for comfort, hygiene or beauty purposes, including therapeutic
mattresses.
Out-Of-Area and Emergency Care: Out-of-area care is not covered under this Chiropractic
and Acupuncture Care benefit, except for emergency services. The member should follow
the procedures specified by their Anthem Blue Cross HMO plan to obtain emergency or
out-<lf-area care.
Third Party Liability
Anthem Blue Cross is entiUed to reimbursement of benefits paid if the member recovers damages
from a legally liable third party.
Anthem Blue Cross is the trade name of Blue Cross of California. Independent Licensee of
the Blue Cross Association.® ANTHEM Is a registered trademark. ® The Blue Cross name
and symbol are registered marlrs of the Slue Cross Association.
Anthein.+.
Blue Cross
SJVIA County of Fresno
Modified BC Lumenos®
Health Savings Account {HSA)
LBHSA266 {1500/80/60) ETSM
Retirees Under 65
This summary of benefits has been updated to comply with federal and state requirements, including applicable provisions of the
recently enacted federal health care reform laws. As we receive additional guidance and clarification on the new health care reform
laws from the U.S. Department of Health and Human Services, Department of Labor and Internal Revenue Service, we may be
required to make additional changes to this summary of benefits. This proposed benefit summary is subject to the approval of the
California Department of Insurance and the California Department of Managed Health Care.
This Lumenos plan is an innovative type of coverage that allows an insured person to use a Health Savings Account to pay for
routine medical care. The program also includes traditional health coverage, similar to a typical health plan, that protects the insured
person against large medical expenses.
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The insured person can spend the money in the HSA account the way the insured person wants on routine medical care, prescription drugs
and other qualified medical expenses. There are no copays or deductibles to satisfy first. Unused dollars can be saved from year to year to
reduce the amount the insured person may have to pay in the future. If covered expenses exceed the insured person's available HSA
dollars, the traditional health coverage is available after a limited out-of-pocket amount is paid by the insured person. Certain Covered
Services have maximum visit and/or day limits per year. The number of visits and/or days allowed for these services will begin accumulating
on the first visit and/or day, regardless of whether your Deductible has been met. The insured person is responsible for all costs over the
plan maximums. Plan maximums and other important information appear in italics. Benefits are subject to all terms, conditions, limitations,
and exdusions of the Policy.
Explanation of Maximum Allowed Amount
Maximum Allowed Amount is the total reimbursement payable under the plan for covered services received from Participating and Non-
Participating Providers. It is the payment towards the services billed by a provider combined with any applicable deductible, copayment or
coinsurance. Participating Providers-The rate the provider has agreed to accept as reimbursement for covered services. Members are not
responsible for the difference between the provider's usual charges & the maximum allowed amount.
Non-Participating Providers & Other Health Care Providers-(includes those not represented in the PPO provider network)-Reimbursement
amount is based on: an Anthem Blue Cross rate or fee schedule, a rate negotiated with the provider, information from a third party vendor,
or billed charges. For Medical Emergency care rendered by a Non-Participating Provider or Non-Contracting Hospital, reimbursement may
be based on the reasonable and customary value. Members may be responsible for any amount in excess of the reasonable and customary
value. Participating Pharmacies & Mail Service Program-members are not responsible for any amount in excess of the prescription drug
maximum allowed amount. Non-Participating Pharmacies-members are responsible for any expense not covered under this plan & any
amount in excess of the prescription drug maximum allowed amount.
When using non-participating providers, the insured person is responsible for any difference between the covered expense &
actual charges, as well as any deductible & percentage copay. When using the outpatient prescription drug benefits, the insured
person is always responsible for drug expenses which are not covered under this plan, as well as any deductible, percentage or
dollar copay.
Calendar year deductible for all providers
(applicable to medical care & prescription drug benefits}
~ Individual insured person (only 1 person on the plan)
~ Insured family (includes insured employee & one or more
members of the employee's family;
Annual Out-of-Pocket Maximums (in-network/out-of-network
out-of-pocket maximums are exclusive of each other; includes
calendar year deductible & prescription drug covered expense)
~ Participating Providers, Participating Pharmacy
& Other Health Care Providers
$1 ,500/individual insured person
$3.000/insured family
$3,000/individual insured person; $5,000/insured family/year
~ Non-Participating Providers & Non-Participating Pharmacy $10,000/individual insured person; $15,000/insured family/year
The following do not apply to out-of-pocket maximums: costs in excess of the covered expense & non-cover~d expense. After an individual
insured person or insured family (includes insured employee & one or more members of the employee's family) reaches ~e out-of-pocket
maximum for all medical and prescription drug covered expense the individual insured person or insured f~mily incurs dunng that. ca!e.ndar
year, the individual insured person or insured family will no longer be required to pay a copay for the remarn~er of that year. ~e l~d1v1dual
insured person or insured family remains responsible for costs in excess of the covered expense when provided by non-partiapatrng
providers and other health care providers; non-covered expense.
Lifetime Maximum Unlimited
anthem.com/ca Anthem Blue Cross Life and Health Insurance Company (NP) -NGF M-LB2081 Effective 01/2016 Printed 2/4/2016
Covered Services
H~pita! Medica.l Servic.es (subject to utilization review
for mpatient &e/VIC9S; wawed for emergency admissions)
)> Semi-private room, meals & special diets, & ancillary services
)> Outpatient medical care, surgical services & supplies
(hospital care other than emergency room care)
Ambulatory Surgical Centers
)> Outpatient surgery, services & supplies
Skilled Nursing Facility (subject to utilization review)
)> Semi-private room, services & supplies
{limited to 100 dayslcalendar yearj
Holplce Cant
)> Inpatient or outpatient services for insured persons with up
to one year life expectancy; family bereavement services
Home Health Care
)> Services & supplies from a home health agency
{limited to combined maximum of 100 visits/calendar year,
one visit by home health aide equals four hours or less;
not covered while insuted person receives hospice care)
Home Infusion Therapy
)> Includes medication, andllary services & supplies;
caregiver training & visits by provider to monitor therapy;
durable medical equipment, rab services
Physician Medical Services
)> Office & home visits
)> Hospital & skilled nursing facility visits
)> Surgeon & surgical assistant; anesthesiologist or anesthetist
Diagnostic X-ray & Lab
)> MRI, CT scan, PET scan & nuclear cardiac scan
(subject to utilization review)
)> Other diagnostic x-ray & lab
Preventive Care Services
Preventive Care Services including*, physical exams, preventive
saeenings (including screenings for cancer, HPV, diabetes, cholesterol,
blood pressure, hearing and vision, immunizations, health education,
intervention services, HIV testing}, and additional preventive care for
women provided for in the guidelines supported by the Health
Resources and Services Administration.
*This list is not exhaustive. This benefit includes all Preventive Care
Services required by federal and state law.
Physical Therapy, Physical Medicine & Occupational
Therapy, including Chiropractic Services
(limited to 24 visits/calendar year)
Speech Therapy
)> Outpatient speech therapy following injury or organic disease
Acupuncture
)> Services for the treatment of disease, illness or injury
(limited to visits/calendar year)
Temporomandibular Joint Disorders
)> Splint therapy & surgical treatment
Traditional Health Coverage
Insured Person Copay
In-Network Out-of-Network
20%
20%
20%1
20%1
20%1
20%1
20%
20%
20%
20%
20%
No copay
20%
20%
20%2
20%
20%1
(Insured is also responsible
for charges in excess of
covered expense.)
40%
40%
40%1 (benefit limited to $35a'day)
40%1
40%1
40%1
(benefit limited to $6001day)
40%
40%
40%
40%
40%
40%
40%
40%2
40%
1 These provide!S may not be represented in the PPO network in the state where the insured person receives services. If such provider is not available In the service area,
the insured person's copay is 20%. If such provider is avanable in the service area and the insured person receives services from a PPO provider, the insured person's
mpay is 20%. Ha«ever, if the insured person chooses to receive services from a non.PPO provider when such provider is available in the service area, the insured person's
copay is 40%. All copays are in addition to apprK:able deductibles.
2 Aalpunclure services can be performed by a certified acupuncturist (CA.), a doctor of medicine (M.D.), a doclor of osteopathy (D.O.), a podiabist (D.P.M.),
or a dentist (D.D.S.).
Covered Services
Pregnancy & Maternity Care
> Physician office visits
> Prescription drug for elective abortion (mifepristone)
Nonnal delivery, cesarean section, complications of pregnancy
& abortion
> Inpatient physician services
> Hospital & ancillary services
Organ & Tissue Transplants (subject to utilization review)
> Inpatient services provided in connection with
non-investigative organ or tissue transplants
Diabetes Education Programs (requires physician supervision)
> Teach insured persons & their families about the disease
process, the daily management of diabetic therapy &
self-management training
Prosthetic Devices
> Coverage for breast prostheses; prosthetic devices
to restore a method of speaking; surgical implants; artificial limbs
or eyes; the first pair of contact lenses or eyeglasses when
required as a result of eye surgery; wigs for alopecia resulting
from chemotherapy or radiation therapy; & therapeutic shoes
& inserts for insured persons with diabetes
Durable Medical Equipment
Rental or purchase ofDME including hearing aids,
dialysis equipment & supplies (hearing aids benefit is
available for one hearing aid per ear every three years;
breast pump and supplies are covered under preventive
C8l9 at no charge for in-network)
Related Outpatient Medical Services & Supplies
> Ground or air ambulance transportation, services
& disposable supplies
> Blood transfusions, blood processing & the cost
of unreplaced blood & blood products
> Autologous blood (self-donated blood collection,
testing, processing & storage for planned surgery)
Emergency Care
> Emergency room services & supplies
> Inpatient hospital services & supplies
> Physician services
Mental or Nervous Disorders and Substance Abuse
> Facility-based care (subject to utilization review;
waived for emergency admissions)
> Inpatient physician visits
> Outpatient physician visits
(Behavioral Health treatment for Autism & Pervasive
Disorder will be subjBct to pre-service review)
Traditional Health Coverage
Insured Person Copay
In-Network Out-of-Network
20%
20%
20%
20%
20%
20%
20%
20%1
20%
20%
20%
20%
200k
20%
20%1
20%1
20%1
(Insured is also responsible
for charges in excess of
covered upense.J
40%
40%
40%
40%
40%
40%
40%
40%1
20%
20%
20%
40%
40%
40%
1 These providers may not be represented in the PPO network in the state where the insured person receives services. If such provider is not available in the service area,
the insured person's copay Is 20%. If such provider is available in the service area and the insured person receives services from a PPO provider, the insured person's
copay is 20%. However, if the insured person chooses to receive services from a non-PPO provider when such provider is available in the service area, the insured person's
copay is 40%. All co pays are in addition to applicable deductibles.
Covered Services
maximum
Outpatient Prescription Drug Benefits
~ ~reventive imm~izations administered bv a retail oharmacv emale oral CQJ1 aceotJves Qen
1
enc ana stngle source brancl lu, Lostavax IX nellmococca vaccmes
~ Retail pharmacy prescription drug maximum allowed amount
~ Home Delivery prescription drug maximum allowed amount
~ Specialty pharmacy drugs (obtained through specialty
pharmacy program)
Supply Limits2
~ Retail Pharmacy (participating and non-participating)
& Specialty Pharmacy (participating)
~ Home Delivery
Traditional Health Coverage
Insured Person Copay
In-Network Out-of-Network
~o co~a~ (gedductibl1e walvedJ o co a ue uctib e watvecJ) o co a
(Insured is also responsible
for charges in excess of
the prescription drug
allowed amount.)
20% 40%1
20%
20%
Not applicable
Not applicable
30-day supply; 60-day supply for federally classified
Schedule II attention deficit disorder drugs that require
a triplicate prescription form, but require a double copay;
6 tablets or units/30-day period for impotence and/or
sexual dysfunction drugs (available only at retail pharmacies)
90-day supply
1 1nsured person remains responsible for the costs in excess of the prescription drug maximum allowed amount 2
Please refer to the Certificate of Insurance for complete information.
Supply limits for certain drugs may be different
The Outpatient Prescription Drug Benefit covers the following:
~ Outpatient prescription drugs and medications which the law restricts to sale by prescription. Formulas prescribed by a physician
for the treatment of phenylketonuria.
~ Insulin
~ Syringes when dispensed for use with insulin and other self-injectable drugs or medications
~ Prescription oral contraceptives; contraceptive diaphragms. Contraceptive diaphragms are limited to one per year.
~ Injectable drugs which are self-administered by the subcutaneous route (under the skin) by the patient or insured person.
Drugs that have Food and Drug Administration (FDA) labeling for self-administration
~ All compound prescription drugs that contain at least one covered prescription ingredient
~ Diabetic supplies (i.e., test strips and lancets)
~ Prescription drugs for treatment of impotence and/or sexual dysfunction are limited to organic (non-psychological) causes.
~ Inhaler spacers and peak flow meters for the treatment of pediatric asthma.
~ Smoking cessation products requiring a physician's prescription.
~ Certain over-the-counter drugs approved by the Pharmacy and Therapeutics Committee to be included in the prescription drug
formulary.
~ Flu, Zostavax & Pneumococcal vaccines obtained at a local network pharmacy must be administered by a pharmacist
In addition to the benefits described above, coverage may include additional benefits, depending upon the insured person's home
state. The benefits provided in this summary are subject to federal and California laws. There are some states that require more
generous benefits be provided to their residents, even if the master policy was not issued in their state. If the insured person's
state has such requirements, we will adjust the benefits to meet the requirements.
This Summary of Benefits is a brief review of benefits. Once enrolled, insured persons will receive a Certificate of Insurance,
which explains the exclusions and limitations, as well as the full range of covered services of the plan, in detail.
BC Lumenos Health Savings Account Plan-Exclusions and Limitations
Benefll.s are not provided for expenses incurred for or in connection with the
following items:
Not Medically Necessill)'. Services or supplies that are not medically necessary, as defined.
Experimental or Jnve!ltigalive. Any experimental or investigative ~ccedure or medication.
But, if insured persoo is denied benefits because it is determined that the requested treatment
is ellp81imental or investigative, the insured person may request an independent medical review,
as desclil:ed in the Certificate.
Outside the United Slates. Services or supplies furnished and billed by a provider outside
the Uniled States. unless such services or supplies ~e furnished in connection with urgent care
or an emergency.
Crime or Nuclear Energy. Conditions that result from (1) the insured person's commission
of or atlempt to commit a felony, as long as any inju ries are not a result of a medical cond~ion
or an act of domesoc violenoe; or (2) EllY release of nuclear energy, whether oc not the result
of war. when government funds are available for the treatment of illness or injury arising from
the release of nuclear energy.
Uninsured. Services received before the insured person's effective date. Services received
after the insured person 's cover~e ends, except as spocified as covered in the Certificate.
Excess Amounts. Any amounls in excess of covered expense or the lifetime maximum .
Wori!·Related. Woo-related condifuns if benefits are recovered or can be recovered, erther by
adjudication , settlement or otherwise, under any workers' compensation, employer's liabil ity law
or occupational disease law, whether or not the insured person claims those benefits.
Government Treatment. Any services the insured person acwally received that were provided
by a local, state or fEderal government ~ency, except v.tlen payment under this plan is expressly
required by federal or state law. We will not cover payment for these services if the insured person
is not requi red lo pay for them or they are given to the insured person for tree.
Services of Relatives. Profess io nal services received from a person liv ing in the insured person's
home or who is re lated to the insured person by blood or marriage. except as specified as covered
in the Certificalll.
Voluntary Payment Services for v.tlich the ins ured person is not legally obligaled to pay. Services
for wh ich the insu red person is not charged. Services for which no charge is made in the absence of
insurance coverage. except services received at a non-govemm811tal charitable research hospital.
Such a hospital must meet the following guidelines:
1. it must be internationally kn own as being devoled mainly to medical research;
2. at least 10% of i1s yearly budget must be spent on research not directly re lated to patient care;
3. at least one-third of its gross income must come from donations or grants other than gifts
or payme nts for patient care;
4. ij must aocept paijents who are unable to pay; and
5. Jwo.th irds of its patients must have conditions directly rela ted ID the hospital's research.
Not Specifically Listed. Services not spedfkally listed in the plan as coverad services.
Private Contracts. Services or supplies provided pursuant lo a private conlract belv.oon ihe
insured person and a prov ider, for v.tlich reimbursement under Medicare program is prohibited,
as specified in Section 1802 (42 U.S.C. 1395a) of Title XVIII of the Social Security Pd..
Inpatient Diagnostic Tests. Inpatient room and board charges in connection with a hospital stay
~imarily for diagnostic tests v.tl ich could have been perfomned safely on an oulpatient basis.
Mental or Nervous Disorders. Academic or educatiooallesting, counse ling, and remadiatian .
Mental or nervous disorders or substance abuse, including rehabilitative care in relation to these
cooditions. except as specified as covered in the Certificate.
Orthodontia. Braces and other orthodontic appliances or services.
Dental Services or Sup plies. Dental plates, bridges, crowns, caps or other dental prostheses,
dental implants, dental services, extraction of teeth, or trealment to the teeth or gums, or trealment
1o or fo r any diso rders for the jaw joint, except as specified as covered in the Certificate Ccsmetic
dental surgery or other dental services for beauUfication.
Hearing Aids or Tests. Hearing aids and routine hearing Jests, excep t as specified as covered
in the CertifiCate.
Optometric Services or Supplies. Oplometric services, eye exercises including orthoptics.
Routine eye exams and routine eye refractions , except rouline eye screenings provided as specified
as covered in the Certificate. Eyeg lasses or contact lenses, except as specified as covered in
the Certificate.
Outpatient Occupational Therapy. Outpatient oo::upational therapy, except by a home health
~ency, hospice, or home infusion therapy provider, as specified as covered in the Certificate.
Outpatient Speech Therapy. Outpatient speech therapy, except as specified as ca;ered
in tile Certificate.
Cosmetic Surgery. Ccsmetic surgery or other services pertormed solely for beautification
or to alter or reshape normal {including ~ed) slrucfures or tissues of the body lo improve
a~arance. This exclusion does not apply to reconstructive surgery (that is, surgery performed
ID correct deformities caused by congen ffal or developmental abnormalities, illness , or injury for the
puf)Xlse of improving bodily wnction or symptomalology or to create a normal appearance),
including surgery performed to resiDre symmeli)' fo llo~ng mastectomy. Cosmetic surgery does no t
b€come reconstructive surgery because of psychological or psychiatric reasons.
Scalp Hair Prostheses. Scalp hair prostheses, including wigs or any form of hair replacement,
except as specified as covered in !he Certificate.
Commercial Weight Loss Programs. Weight loss programs, v.tlelher or not they are pursued
under medical or physician supervisioo. unless specifically lisled as covered in this plan.
This exclusio n includes. but is not limited to, commerc ial weight loss programs (Weight Watchers,
Jenny Craig, IJ\ Weight Loss) and fasti ng programs.
This exclusion does not app ly to medically necessary treatmenls for morbid obesity or dietary
evaluations and counse ling, and behavioral modification programs fa' lhe treatment of anorexia
nefllosa or bu lim ia nervosa. Surgical treatment for morbid obesity is covered as descril:ed in the
Certificate.
Sterilization Reversal. Reversal of sterilization.
Infertility T rea!menl Any services or supplies furnished in connection with the dia:Jnosis and
treatment of in fe rtility, including, but nat limited to diagnostic tests, medication, sul1)ery, artificial
insemina tion, in vitro fertilization, sterilization reversal and garneill intrilfallapian transfer.
Surrogate Mother Services. For <rlY services or supplies pfO\Iided to a person not covered under
the plan in connection with a surrogate pregnancy (including, but not limited to, the bearing at a
ch ild by another woman for an infertile couple).
Orthopedic shoes and shoe inserts. This exclusion does not apply fo orthopedic footwear used
as an integral part of a brace, shoe inserts that are custom molded to th e patient, or therapeutic
shoes and inserts designed to treat foot complications due to diabetes, as specifically stated in the
Dlrtiticate.
Air Conditioners. Air purif~r s, air conditioners or humid ifi ers .
Custodial Care or Rest Cum. In patient room and board cha11Jes in connection with a hospital
stay pr imari ly for environmental change or physical therapy. Custodial care or rest cures, except as
specified as covered in the Certificate. Services provided by a rest home, a hoone for the aged,
a nursing home or any similar facility. Services provided by a skilled nurs ing facil ity, except as
specified as covered in the Certificate.
Health Club Memberships. Health club membe rships, exercise equipment charges from a
physical ftness instructor or persona l trainer, or any other charges for activities , equipment or
facil ities used for developing or maintaining physical fitness, even if ordered by a physician. This
exclusion also applies to health spas.
Personal Items. Any supplies for comfort, hyg iene or beautification .
Education or Counseling. Educational services or nutritional counseling, except as spocified as
covered in the Dlrtificate. This exclusion does not app~ to counseling for the treatment of anorexia
nervosa or bulimia nervosa.
Food or Dietary Supplements. Nutritiona l and/or dietary supplements, except as provided in this
plan or as req uired by law. This exclusion includes, but is not lim ited ID, !hose nutritiooal formulas
and dietary supplements that can be purchased over the counter, wh ich by law do not nequi remen t
either a written prescription or dispensing by a licensed pharmacist.
Telephone and Facsimile Machine Consultations. Consultations provided by Jelephone,
except as specified as covered in the Certificate, or fa::simile machine.
Routine Exams or Tests. Routine physica exams or tesls which do not directly treat an acwal
illness , injury or condition, inc luding those required by employment or government authority,
except as spocified as covered in the Certificate.
Acupuncture. Acupuncture treatment. except as spocified as covered in the Certificate.
Acupressure or massage to control pain, treat illness or promote health by applying pressure
to one or more specific areas of the body based an dermatomes or acupuncture points.
Eye Surgery for Refractive Defects. Any eye surgery solely or primarily tor the purpose of
correcting refractive defecls of the eye such as nearsightedness (myopia) and/or astigmatism.
Contact le nses and eyeglasses required as a result of this surgery.
Physical Therapy or Physical Medicine. Services of a physician for physic~ therapy or physical
medicine, except when prov ided during a covered inpatient confmement or as specified as covered
in the Certificale.
Outpatient Prescription Drugs and Medications. Outpatient prescri ption drugs, med ications and
ins ul in, except as spec ifi ed as covered in the Certificate. Nan-prescription, over-the-counter patent
or proprietary drugs or medicines, except as specified as covered in !he Certificate. Ccsmetics.
hea lth or beauty aids.
Contraceptive Devices. Conlraceptive devices prescribed for birth control except as specified
as covered in the Certificate.
Diabetic Supplies. Prescription and non -presc ription diabetic supplies except as specified
as covered in the Certificate.
Prtvate Duty Nursing. Inpat ient or outpatient services at a private duty nurse.
Ufestyle Programs. Programs to alter one 's lifesty le which may include but are not limited to diet,
exercise, imagery or nutrition, except as specified as covered in the Cert ificate. This exclusion will
not apply to ca-diac rehabilitation programs appra;ed by us.
BC Lumenos Health Savings Account Plan-Exclusions and Limitations (Continued)
Outpatient prescription drug services and supplies are not provided for or in connection
with the following:
Immunizing agents, biological sera, blood, blood products or blood plasma
Hypodermic syringes &/or needles, except when dispensed for use with insulin & other
se~-injectable drugs or medications
Drugs & medications used to induce spontaneous & non-spontaneous abortions
Drugs & medications dispensed or administered in an outpatient setting, including outpatient
hospital facilities and physicians' offices
Professional charges in connection wnh administering, injecting or dispensing drugs
Drugs & medications that may be obtained without a physician's written prescription,
except insulin or niacin for cholesterol lowering and certain over-the-counter drugs approved
by the Pharmacy and Therapeutics Committee to be included in the prescription drug formulary.
Drugs & medications dispensed by or while confined in a hospital, skilled nursing faciley,
rest home, sanatorium, convalescent hospital or similar facility
Durable medical equipmenL devices, appliances & supplies, even if prescribed by a physician,
except contraceptive diaphragms, as specified as covered in the Certificate
Services or supplies for which the insured person is not charged
Oxygen
Cosmetics & health or beauty aids.
Drugs labeled 'Caution, Umited by Federal law to Investigational Use," or Non-FDA approved
investigational drugs. Any drugs or medications prescribed for experimental indications
Any expense for a drug or medication incurred in excess of the prescription drug maximum allowed
amount
Drugs which have not been approved for general use by the Food and Drug Administration.
This does not apply to drugs that are medically necessary for a covered condition.
Over-the-counter smoking cessation drugs. This does not apply to medically necessary drugs
that the insured person can only get with a prescription under state and federal law.
Drugs used primarily for cosmetic purposes (e.g., Retin-A for wrinkles). However, this will not apply
to the use of this type of drug for medically necessary treatment of a medical condition other than
one that is cosmetic.
Drugs used primarily to treat infertility (including, but not limited to, Clomid, Pergonal and Metrodin),
unless medically necessary for another covered condition.
Anorexiants and drugs used for weight loss, except when used to treat morbid obesity
(e.g., diet pills & appetite suppressants)
Drugs obtained outside the U.S. unless they are furnished in connection with urgent care
or an emergency.
Allergy desensitization products or allergy serum
Infusion drugs, except drugs that are self-administered subcutaneously
Herbal supplements, nutritional and dietary supplements except for formulas for the treatment
of phenylketonuria.
Prescription drugs with a non-prescription (over-the-rounter) chemical and dose equivalent
except insulin. This does not apply if an over-the-rounter equivalent was tried and was in effective.
Compound medications obtained from other than a participating pharmacy. Insured person will
have to pay the full cost of the compound drugs if insured person obtains drug at a
non-participating phannacy.
Specialty pharmacy drugs that must be obtained from the specialty pharmacy program, but which
are obtained from a retail pharmacy are not covered by this plan. Insured person will have to pay
the full cost of the specialty phannacy drugs obtained from a retail phannacy that insured
person should have obtained from the specialty phannacy program.
Third Party Liability-Anthem Blue Cross Life and Health Insurance Company is entiHed
to reimbursement of benefits paid if the insured person recovers damages from a legally liable
third party.
Coordination of Benefits-The benefrts of this plan may be reduced if the insured person has
any other group health or dental coverage so that the services received from all group coverages do
not exceed 1 00% of the covered expense.
Lumenos plans provided by Anthem Blue Cross Life and Health Insurance Company.
Independent licensees of the Blue Cross Association. ®ANTHEM and LUMENOS are
registered trademarlls of Anthem Insurance Companies, Inc. The Blue Cross name and
symbol are regislered marks of the Blue Cross Association.
AntheiD.+.
Blue Cross
SJVIA
Modified Chiropractic Care and Acupuncture
Rider Plan 1 0/40
The benefits described in this Rider are provided through an agreement between Anthem Blue Cross and American Specialty Health
Plans of California (ASH Plans). The services listed below are covered only if provided by an ASH Plans Chiropractor and/or ASH
Plans Acupuncturist. These benefits are provided in addition to the benefits described in the Anthem Blue Cross HMO Evidence of
Coverage (EOC) document. However, when expenses are incurred for treatment received from an ASH Plans Chiropractor or ASH
Plans Acupuncturist, no other benefits other than the benefits described in this Rider will be paid.
Covered Services Member's Copayment
Office Visit to a Chiropractor or Acupuncturist $10/visit
Maximum Benefits
Office visits to a Chiropractor or Acupuncturist
Chiropractic appliances
Covered Services
40 visits per calendar year (chiropractic and
acupuncture visits combined)
$50 per calendar year
Chiropractor Services: Member has up to 40 visits, combined with visits for acupuncture services, in a calendar year for chiropractor care
services that are determined by ASH PlANS to be medically/clinically necessary. All visits to an ASH Plans chiropractor or ASH Plans
acupuncturist will be applied towards the maximum number of visits in a calendar year. The ASH Plans chiropractor is responsible for
submitting a treatment plan to ASH Plans for prior approval.
Covered services include:
};> An initial new patient exam by an ASH Plans chiropractor to determine the appropriateness of chiropractic services.
};> Follow-up office visits as set forth in a treatment plan approved by ASH Plans and provided by an ASH Plans chiropractor
};> An established patient exam performed by an ASH Plans chiropractor to assess the need to continue, extend or change a treatment
plan approved by ASH Plans.
};> Adjunctive physiotherapy modalities and procedures as set forth in a treatment plan approved by ASH Plans and provided by ASH
Plans chiropractor.
};> Radiological x-rays and laboratory tests when prescribed by an ASH Plans chiropractor and approved by ASH Plans. Covered services
include radiological consultations when determined by ASH Plans to be medically/clinically necessary and provided by a licensed
chiropractic radiologist, medical radiologist, radiology group or hospital which has contracted with ASH Plans to provide those services.
};> Chiropractic Appliances: Up to $50 per calendar year when prescribed by an ASH Plans chiropractor and approved by ASH Plans.
Covered chiropractic appliances are limited to:
-elbow supports, back supports (thoracic), lumbar braces and supports, rib supports, or wrist supports;
-cervical collars or cervical pillows;
-ankle braces, knee braces, or wrist braces;
-heel lifts;
-hot or cold packs;
-lumbar cushions;
-rib belts or orthotics; and
-home traction units for treatment of the cervical or lumbar regions.
Acupuncture Services. Member has up to 40 visits, combined with visits for chiropractic care, in a calendar year for acupuncture services
that are determined by ASH Plans to be medically/clinically necessary. All visits to an ASH Plans chiropractor or ASH Plans acupuncturist
will be applied towards the maximum number of visits in a calendar year. The ASH Plans acupuncturist is responsible for submitting a
treatment plan to ASH Plans for prior approval.
Covered services include:
};> An initial new patient exam by an ASH Plans acupuncturist to determine the appropriateness of acupuncture services.
};> Follow-up office visits as set forth in a treatment plan approved by ASH Plans and provided by an ASH Plans acupuncturist
};> An established patient exam performed by an ASH Plans acupuncturist to assess the need to continue, extend or change
a treatment plan approved by ASH Plans.
};> Adjunctive physiotherapy modalities and procedures as set forth in a treatment plan approved by ASH Plans and provided by ASH
Plans acupuncturist.
anthem.com/ca Anthem Blue Cross NGF cc: OQ2J Effective 01/2016 Printed 2/4/2016
Chiropractic Care and Acupuncture Rider Exclusions & Limitations
Care Not Approved: Any services provided by an ASH Plans chiropractor or an ASH Plans
acupuncturist that are not approved by ASH Plans except as specified as covered in the Evidence
of Coverage (EOC). An ASH Plans chiropractor or ASH Plans acupuncturist is responsible for
submitting a treatment pl<11lo ASH Plans for prior approval.
Care Not Covered: In addition to any service or supply specifically excluded in the EOC, no
benefits will be provided for chiropractic or acupuncture services or supplies in connection with:
~ Diagnostic scanning, such as magnetic resonance imaging (MRI) or computerized axial
tomography (CAD scans. Diagnostic services for acupuncture.
~ Thennography.
~ Hypnotherapy.
~ Behavior training.
~ Sleep therapy.
~ Weight programs.
~ Any non-medical program or service.
~ Pre-employment examinations, any chiropractic or acupuncture services required by an
employer that are not medically/clinically necessary, or vocational rehabilitation.
~ Services and/or treatrnen1s which are not documented as medically/clinically necessary.
~ Massage therapy.
~ Acupuncture performed with reusable needles.
~ Acupuncture services benefits are not provided for magnets used for diagnostic or therapeutic
use, ion cord devices, manipulation or adjustments of the joints, physical therapy services,
iridology, hormone replacement products, acupuncture point or trigger-point injections (including
injectable substances},lasernaser biostim, colorpuncture, NAET diagnosis and/or treatment
and direct moxibustion.
~ Any service or supply for the exam and/or treatment by an ASH chiropractor for conditions other
than those related to neuromusculoskeletal disorders.
~ Services from an ASH Plans acupuncturist for exam and/or treatment for conditions not related
to neuromusculoskeletal disorders, nausea or pain, incluing, without limitation, asthma or
addictions such as nicotine addiction.
~ Transportation cos1s including local ambulance charges.
~ Education programs, non-medical seW-care or self-help, or any self-help physical exercise
training or any related diagnostic testing.
~ Hospitalization, surgical procedures, anesthesia, manipulation under anesthesia, proctology,
colonic inigation, injections and injection services, or other related services;
~ All auxiliary aids <11d services, including, but not limited to, interpreters, transcription services,
written materials, telecommunications devices, telephone handset amplifiers, television
decoders and telephone compatible with hearing aids;
~ Adjunctive therapy not associated with spinal, muscle or joint manipulation.
~ Laboratory and diagnostic x-ray studies, except as specified as covered in the EOC.
Non-ASH Plans Chiropractors or non-ASH Plans Acupuncturists: Services <11d supplies
provided by a chiropractor or an acupuncturists who does not have an agreement with ASH Plans
to provide covered services under this plan.
Wor11 Related: Cane for health problems that are work-related if such health problems are covered
by workers' compensation, an employe~s liability law or similar law. We will provide care for a
work-related health problem, but we have the right to be paid back for that care as described
in theEOC.
Government Treatment: Any services actually given to the member by a local, state or federal
government agency, except when this plan's benefits, must be provided by law. We will not cover
payment for these services if the member is not required to pay for them or they are given to the
member for free.
Drugs: Prescription drugs or medicines, including a non-legend or proprietary medicine or
medication not requiring a prescription.
Supplement Vitamins, minerals, dietary and nutritional supplemen1s or other similar products
and any herbal supplements.
Air Conditioners: Air purifiers, air conditioners, humidifiers, supplies or any other similar devices
or appliances. All appliances or durable medical equipment except as specified as covered
in the EOC ..
Personal Items: Any supplies for comfort, hygiene or beauty purposes, including therapeutic
mattresses.
Out-Of-Area and Emergency Care: OUt-of-area care is not covered under this Chiropractic
and Acupuncture Care benefit except for emergency services. The member should follow
the procedures specified by their Anthem Blue Cross HMO plan to obtain emergency or
out-of-area care.
Third Party Liability
Anthem Blue Cross is entiUed to reimbursement of benefits paid if the member recovers damages
from a legally liable third party.
Anthem Blue Cross is the trade name of Blue Cross of California. Independent Licensee of
the Blue Cross Association. ®ANTHEM is a registered trademark. ® The Blue Cross name
and symbol are registered marks of the Blue Cross Association.
AntheiD. +.
Blue Cross
SJVIA County of Fresno
Modified BC Premier PPO 250/20/100/50
ETSM -Active
This summary of benefits has been updated to comply with federal and state requirements, including applicable provisions of the
recently enacted federal health care reform laws. As we receive additional guidance and clarification on the new health care reform
laws from the U.S. Department of Health and Human Services, Department of Labor and Internal Revenue Service we may be
required to make additional changes to this summary of benefits. This proposed benefit summary is subject to the approval of the
Califomi? Department of Insurance and the Calif9rnia Department of Managed Health Care. In addition to dollar and percentage
copays, rnsured persons are responsible for deductibles, as described below. Please review the deductible information to know if a
deductible applies to a specific covered service. Certain Covered Services have maximum visit and/or day limits per year. The
number of visits and/or days allowed for these services will begin accumulating on the first visit and/or day, regardless of whether
your Deductible has been met. Insured persons are also responsible for all costs over the plan maximums. Plan maximums and
other important information appear in italics. Benefits are subject to all terms, conditions, limitations, and exclusions of the Policy.
Explanation of Maximum Allowed Amount
Maximum Allowed Amount is the total reimbursement payable under the plan for covered services received from Participating and Non-
Participating Providers. It is the payment towards the services billed by a provider combined with any applicable deductible, copayment or
coinsurance. Participating Providers-The rate the provider has agreed to accept as reimbursement for covered services. Members are not
responsible for the difference between the provider's usual charges & the maximum allowed amount. Non-Participating Providers & Other
Health Care Providers-(includes those not represented in the PPO provider network)-Reimbursement amount is based on: an Anthem Blue
Cross rate or fee schedule, a rate negotiated with the provider, information from a third party vendor, or billed charges. For Medical
Emergency care rendered by a Non-Participating Provider or Non-Contracting Hospital, reimbursement may be based on the reasonable
and customary value. Members may be responsible for any amount in excess of the reasonable and customary value.
When using Non-PPO and Other Health Care Providers, insured persons are responsible for any difference between
the covered expense & actual charges, as well as any deductible & percentage copay.
Benefit year deductible for all providers (embedded) $250/insured person
maximum of two separate deductibles/family
Deductible for non-PPO hospital $500/admission (waived for emergency admission)
Deductible for hospital if utilization review not obtained $500/admission (waived for emergency admission)
Deductible for emergency room services $1 00/visit (waived ff admitted directly from ER)
Annual Out-of-Pocket Maximums (no cross application)
PPO & Other Health Care Providers $3,000/insured person/year; $5,000/family/year
Non-PPO Providers $10,000/insured person/year; $15,000/family/year
The following do not apply to the medical out-of-pocket maximums: non-covered expenses and prescription drugs. After an annual out-of-
pocket maximum is met for medical during a calendar year, the individual member or family will no longer be required to pay a copay or
coinsurance for medical. The member remains responsible for non-covered expenses and prescription drugs
Lifetime Maximum Unlimited
Covered Services PPO: Per Insured
Person Copay
Hospital Medical Services (subject to utilization review
for inpatient services; waived for emergency admission)
~ Semi-private room, meals & special diets, & ancillary services
~ Outpatient medical care, surgical services & supplies
(hospital care other than emergency room care)
Ambulatory Surgical Centers
~ OUtpatient surgery, services & supplies
Skilled Nursing Facility (subject to utilization review)
~ Semi-private room, services & supplies
(limited to 100 days/benefit year)
Hospice Care
No copay
No copay
Nocopay 1
Nocopay 1
~ Inpatient or outpatient services for insured persons; family bereavement services No copay 2
Home Health Care
Non-PPO: Per Insured
Person Copay
50%
50%
50%1 (benefit limited to $350/day)
50%1
~ Services & supplies from a home health agency No copay1 50%1
(limited to 100 visits/benefit year, one visit by a
home health aide equals four hours or less;
not covered while insured person receives hospice care)
1 These providers may not be represented in the PPO network in the state where the insured person receives services. If such provider is not availa~le in the service are?,
the insured person's copay is the same as for PPO. All copays are in addition to applicable deductibles. 2rhese providers may n~ be represented 1n the ~PO .netw~rk 1n ~e
state where an insured person receives services. If such provider is not available in the service area, the ins.ured person's copay rs .No ~pay. If such provider IS avarlabl~ 1n
the service area and the insured person receives services from a PPO provider, the insured person's copay 1s No copay. However, if the Insured person chooses to receNe
services from a non-PPO provider when such provider is available in the service area, the insured person's copay is 50%. All copays are in addition to applicable
deductibles.
anthem.com/ca Anthem Blue Cross Life and Health Insurance Company (P-NP) -NGF M-LB2105 Effective 01/2016 Printed 2/4/2016
Covered Services
Home Infusion Therapy (subject to utilization review)
> Includes medication, ancillary services & supplies;
caregiver training & visits by provider to monitor therapy;
durable medical equipmen~ lab services (limited to $600/day)
Physician Medical Services
> Office & home visits
> Hospital & skilled nursing facility visits
> Surgeon & surgical assistan~ anesthesiologist or anesthetist
Diagnostic X-ray & Lab
> MRI, Ci scan, PET scan & nuclear cardiac scan
(subject to utilization review)
> Other diagnostic x-ray & lab
Preventive Care Services
Preventive Care Services including*, physical exams, preventive
screenings (including screenings for cancer, HPV, diabetes, cholesterol
blood pressure, hearing and vision, immunizations, health education,
intervention services, HIV testing), and additional preventive care for
women provided for in the guidelines supported by the Health
Resources and Services Administration.
*This list is not exhaustive. This benefit includes all Preventive Care
Services required by federal and state law
Physical Therapy, Physical Medicine & Occupational
Therapy, including Chiropractic Services (limited to
24 visits/benefit year; additional visits may be authorized)
Speech Therapy
> Outpatient speech therapy following injury or organic disease
Acupuncture
> Services for the treabnent of disease, illness or injury
(limited to 12 visitslbeneftf year)
Temporomandibular Joint Disorders
> Splint therapy & surgical treatment
Pregnancy & Maternity Care
> Physician office visits
> Prescription drug for elective abortion (mifepristone)
Normal delivery, cesarean section, complications of pregnancy
& abortion
> Inpatient physician services
> Hospital & ancillary services
Organ & Tissue Transplants (subject to utilization review)
> Inpatient services provided in connection with
non-investigative organ or tissue transplants
PPO: Per Insured
Person Copay
No copay1
$20/visit2
(deductible waived)
No copay
No copay
No copay1
No copay1
No copay
(deductible waived)
No copay
No copay
No copay3
No copay
No copay
No copay
Nocopay
No copay
No copay
Non-PPO: Per Insured
Person Copay
50%1
50%
50%
50%
50%1
50%1
50%
50%
50%
501}'o3
50%
50%
50%
50%
50%
No copay
1 These providers may not be represented in the PPO networ1< in the state where the insured person receives services. If such provider is not available in the service area,
the insured person's copay is the same as for PPO. All copays are in addition to applicable deductibles.
2The dollar copay applies only to the visit itself. An additional No copay applies for any services perfonned in office (i.e., x-ray, lab, surgery), after any applicable deductible.
3 Acupuncture services can be perfonned by a certified acupuncturist (C.A.), a doctor of medicine (M.D.), a doctor of osteopathy (D.O.), a podiabist (D.P .M.),
or a dentist (D.D.S.).
Covered Services
Diabetes Education Programs (requires physician supervision)
~ Teach insured persons & their families about the disease
process, the daily management of diabetic therapy &
self-management training
Prosthetic Devices
PPO: Per Insured
Person Copay
$20/visit
(deductible waived)
~ Coverage for breast prostheses; prosthetic devices to No copay
restore a method of speaking; surgical implants; artificial
limbs or eyes; the first pair of contact lenses or
eyeglasses when required as a result of eye surgery;
& therapeutic shoes & inserts for insured persons with diabetes
Durable Medical Equipment
~ Rental or purchase of DME including hearing aids, No copay1
dialysis equipment & supplies (hearing aids benefit
available for one hearing aid per ear every three years; breast pump
and supplies are covered under preventive care at no charge for in-network)
Related Outpatient Medical Services & Supplies
~ Ground or air ambulance transportation, services
& disposable supplies
~ Blood transfusions, blood processing & the cost of
unreplaced blood & blood products
~ Autologous blood (self-donated blood collection,
testing, processing & storage for planned surgery)
Emergency Care
~ Emergency room services & supplies
($100 deductible waived if admitted)
~ Inpatient hospital services & supplies
~ Physician services
Mental or Nervous Disorders and Substance Abuse
Inpatient Care
~ Facility-based care (subject to utilization review;
waived for emergency admissions)
~ Inpatient physician visits
Outpatient Care
~ Facility-based care (subject to utilization review;
waived for emergency admissions)
~ Outpatient physician visits
(Behavioral Health Treatment for Autism & Pervasive Disorder
wiN be subject to pre-service review)
No copay
No copay
No copay
No copay
No copay
No copay
No copay2
No copay2
No copay2
$201visit3
(deductible waived)
Non-PPO: Per Insured
Person Copay
50%
50%
50%1
No copay
No copay
Nocopay
50%1
50%
50%1
50%
1 These providers may not be represented in the PPO networll in the state where the insured person receives services . If such provider is not available in the service area,
the insured person's copay is the same as for PPO . All copays are in addition to applicable deductibles.
2 These providers may not be represented in the PPO networll in the state where an insured person receives services. If such provider Is not available in the service area,
the insured person's copay is No copay. If such provider is available in the service area and the insured person receives services from a PPO provider, the insured person's
copay is No copay. However, if the insured person chooses to receive services from a non-PPO provider when such provider is available in the service area, the insured
person's copay is 50%. All copays are in addition to applicable deductibles.
In addition to the benefits described above, coverage may include additional benefits, depending upon the insured person's home
state. The benefits provided in this summary are subject to federal and California laws. There are some states that require more
generous benefits be provided to their residents, even if the master policy was not issued in their state. If the insured person's
state has such requirements, we will adjust the benefrts to meet the requirements.
This Summary of Benefits is a brief review of benefits. Once enrolled, insured persons will receive a Certificate of Insurance,
which explains the exclusions and limitations, as well as the full range of covered services of the plan, in detail.
BC Premier ET Plan-Exclusions and Limitations
Not Medically Necessary. Services or supplies that are not medically necessary, as defined.
Experimental or Investigative. Any experimental or investigative procedure or medication.
But, if insured person is denied benefits because ~ is determined that the requested treatment
is experimental or investigative, the insured person may request an independent medical review,
as described in the Certificate.
Outside the United States. Services or supplies furnished and billed by a provider outside the
Un~ Slates, unless such services or supplies are furnished in connection with an emergency.
Crime or Nuclear Energy. Conditions that resutt from (1) the insured person's commission of
or attempt to comm~ a felony, as long as any injuries are not a resutt of a medical condition or an
act of domestic violence; or (2) any release of nuclear energy, whether or not the result of war,
when government funds are available for the treatment of illness or injury arising from the release of
nuclear energy.
Excess Amounts. Any amounts in excess of covered expense or the lifetime maximum.
Worlt·Related. Worlt-related conditions if benefits are recovered or can be recovered, e~er by
adjudication, settlement or otherwise, under any workers' compensation, employer's liability law
or occupational disease law, whether or not the insured person claims those benefits. If there is
a dispute of substantial uncertinty as to whether benefits may be recovered for those conditions
pursuant to workers' compensation, we will provide the benefits of this plan for such conditions,
subject to our right of recovery, as specified as covered in the Certificate.
Government Treatment Any services the insured person actually received that were provided
by a local, state or federal government agency, except when payment under this plan is expressly
required by federal or state law. We will not cover payment for these services if the insured person
is not required to pay for them or they are given to the insured person for free.
Services of Relatives. Professional services received from a person living in the insured person's
horne or who is related to the insured person by blood or manage, except as specified as covered
in the Certificate.
Voluntary Payment Services for which the insured person is not legally obligated to pay.
Services for which the insured person is not ch<rged. Services for which no charge is made
in the absence of insurance coverage, except services received at a non-governmental charitable
research hospital. Such a hospital must· meet the following guidelines:
1. ij must be internationally known as being devoted mainly to medical research;
2. at least 10% of n& yearly budget must be spent on research not directly related to
patient care;
3. at least one-third of n& gross income must come from donations or grants other than gifts
or payments for patient care;
4. ~ must accept patients who are unable to pay; and
5. two-thirds of its patients must have conditions direcUy related to the hospital's research.
Not Specifically Usled. Services not specifically listed in the plan as covered services.
Private Contracts. Services or supplies provided pursuant to a private contract between the
insured person and a provider, for which reimbursement under Medicare program is prohibiled,
as specified in Section 1802 (42 U.S.C. 1395a) ofTiUe XVIII of the Social Security Act.
Inpatient Diagnostic Tests. Inpatient room and board charges in connection with a hospital stay
primarily for diagnostic tests which could have been performed safely on an outpatient basis.
Mental or Nervous Disorders. Academic or educational testing, counseling, and remediation.
Mental or nervous disorders or substance abuse, including rehabilitative care in relation to these
conditions, except as specified as covered in the Certificate.
Dental Services or Supplies. Dental plates, bridges, crowns, caps or other dental prostheses,
dental implants, dental services, extraction of teeth, or treatment to the teeth or gums, or treatment
to or for any disorders for the jaw joint, except as specified as covered in the Certificate. Cosmetic
dental surgery or other dental services for beautification.
Hearing Aids or Tests. Hearing aids, except as specified as covered in the Certificate.
Routine hearing tests.
Optometric Services or Supplies. Optometric services, eye exercises including orthoptics, routine
eye exams and routine eye refractions. Eyeglasses or contact lenses, except as specified as
covered in the Certificate.
Outpatient Occupational Therapy. Outpatient occupational therapy, except by a home health
agency, hospice, or home infusion therapy provider, as specified as covered in the Certificate.
Outpatient Speech Therapy. Outpatient speech therapy, except as specified as covered
in the Certificate.
Cosmetic Surgery. Cosmetic surgery or other services performed solely for beautification or to
atter or reshape normal (including aged) structures or tissues of the body to improve appearance.
This exclusion does not apply to reconstructive surgery (that is, surgery performed to correct
deformities caused by congenital or developmental abnormalities, illness, or injury for the purpose
of improving bodily function or symptomatology or to create a normal appearance), including
surgery performed to restore symmetry following mastectomy. Cosmetic surgery does not become
reconstructive surgery because of psychological or psychiatric reasons.
Commercial Weight Loss Programs. Weight loss programs, whether or not they are pursued
under medical or physician supervision, unless specifically listed as covered in this plan.
This exclusion includes, but is not limited to, commercial weight loss programs (Weight Watchers,
Jenny Craig, LA Weight loss) and fasting programs.
This exclusion does not apply to medically necessary treatments for morbid obesity or dietary
evaluations and counseling, and behavioral modification programs for the treatment of anorexia
nervosa or bulimia nervosa. Surgical treatment for morbid obesity will be covered only when criteria
is met as recommended by our Medical Policy.
Sterilization Reversal.
Infertility Treatment Any services or supplies furnished in connection with the diagnosis and
treatment of infertility, including, but not limited to, diagnostic tests, medication, surgery, artificial
insemination, in vitro fertilization, sterilization reversal, and gamete intrafallopian transfer.
Surrogate Mother Services. For any services or supplies provided to a person not covered under
the plan in connection with a surrogate pregnancy (including, but not limited to, the bearing of a
child by another woman for an infertile couple).
Orthopedic shoes and shoe inserts. This exclusion does not apply to orthopedic footwear used
as an integral part of a brace, shoe inserts that are custom molded to the patient or therapeutic
shoes and inserts designed to treat fool complications due to diabetes, as specifically stated in the
Certificate.
Air Conditioners. Air purifiers, air conditioners or humidifiers.
Custodial Care or Rest Cures. Inpatient room and board charges in connection with a hospital
stay primarily for environmental change or physical therapy. Services provided by a rest home,
a home for the aged, a nursing home or any similar facilijy. Services provided by a skilled nursing
facllijy or custodial care or rest cures, except as specified as covered in the Certificate.
Health Club Memberships. Health club memberships, exercise equipment charges from a
physical fitness instructor or personal trainer, or any other charges for activities, equipment or
facilities used for developing or maintaining physical fitness, even if ordered by a physician. This
exclusion also applies to health spas.
Personal Items. Any supplies for comfort, hygiene or beautification.
Education or Counseling. Educational services or nutritional counseling, excepl as specified
as covered in the Certificate. This exclusion does not apply to counseling for the treatment of
anorexia nervosa or bulimia nervosa.
Food or Dietary Supplements. Nutritional and/or dietary supplements, except as provided in this
plan or as required by law. This exclusion includes, but is not limited to, those nutritional formulas
and dietary supplements that can be purchased over the counter, which by law do not requirement
e~er a written prescription or dispensing by a licensed pharmacist
Telephone and Facsimile Machine Consultations. Consuttations provided by telephone
or facsimile machine.
Routine Exams or Tests. Routine physical exams or tests which do not direcUy treat an actual
illness, injury or condition, including those required by employment or government authorijy,
except as specified as covered in the Certificate.
Acupuncture. Acupuncture treabnent, except as specified as covered in the Certificate.
Acupressure or massage to control pain, treat illness or promote health by applying pressure
to one or more specific areas of the body based on dermatonnes or acupuncture points.
Eye Surgery for Refractive Defects. Any eye surgery solely or primarily for the purpose of
correcting refractive defects of the eye such as nearsightedness (myopia) and/or astigmatism.
Contacllenses and eyeglasses required as a result of this surgery.
Physical Therapy or Physical Medicine. Services of a physician for physical therapy or physical
medicine, except when provided during a covered inpatient confinement or as specified as covered
in the Certificate.
Outpatient Prescription Drugs and Medications. Outpatient prescription drugs, medications and
insulin excepl as specified as covered in the certificate. Non-prescription, over-the-counter patent or
proprietary drugs or medicines. Cosmetics, health or beauty aids.
Contraceptive Devices. Contraceptive devices prescribed for birth control excepl as specified
as covered in the Certificate.
Diabetic Supplies. Prescription and non-prescription diabetic supplies except as specified
as covered in the Certificate.
Private Duty Nursing. Inpatient or outpatient services of a private duty nurse.
Ufestyle Programs. Programs to alter one's lifestyle which may include but are not limited to diet,
exercise, imagery or nutrition. This exclusion will not apply to cardiac rehabilitation programs
approved by us.
Wigs.
Third Party Uability-Anthem Blue Cross Ufe and Health Insurance Company is entiUed to
reimbursement of benefits paid if the insured person recovers damages from a legally liable
third pa1y.
Coordination Of Benefits-The benefits of this plan may be reduced if the insured person has
any other group health or dental coverage so that the services received from all group coverages do
not exceed 100% of the covered expense.
Anthem Blue Cross life and Health Insurance Company is an independent licensee
of the Blue Cross Association. ®ANTHEM is a registered trademarlr of Anthem Insurance
Companies, Inc. The Blue Cross name and symbol are registered marlrs of the
Blue Cross Association.
Anthein.+.
Blue Cross
SJVIA County of Fresno
Modified BC Lumenos®
Health Savings Account (HSA)
LBHSA263 (3000/1 00/50) ETSM (EPID: CGHSA1605)
This summary of benefits has been updated to comply with federal and state requirements, including applicable provisions of the
recently enacted federal health care reform laws. As we receive additional guidance and clarification on the new health care reform
laws from the U.S. Department of Health and Human Services, Department of Labor and Internal Revenue Service, we may be
required to make additional changes to this summary of benefits. This proposed benefit summary is subject to the approval of the
California Department of Insurance and the California Department of Managed Health Care.
This Lumenos plan is an innovative type of coverage that allows an insured person to use a Health Savings Account to pay for
routine medical care. The program also includes traditional health coverage, similar to a typical health plan that protects the insured
person against large medical expenses. The insured person can spend the money in the HSA account the way the insured person
wants on routine medical care, prescription drugs and other qualified medical expenses. There are no copays or deductibles to
satisfy first. Unused dollars can be saved from year to year to reduce the amount the insured person may have to pay in the future. If
covered expenses exceed the insured person's available HSA dollars, the traditional health coverage is available after a limited out-
of-pocket amount is paid by the insured person. Certain Covered Services have maximum visit and/or day limits per year. The
number of visits and/or days allowed for these services will begin accumulating on the first visit and/or day, regardless of whether
your Deductible has been met. The insured person is responsible for all costs over the plan maximums. Plan maximums and other
important information appear in italics. Benefits are subject to all terms, conditions, limitations, and exclusions of the Policy.
Explanation of Maximum Allowed Amount
Maximum Allowed Amount is the total reimbursement payable under the plan for covered services received from Participating and Non-
Participating Providers. It is the payment towards the services billed by a provider combined with any applicable deductible, copayment or
coinsurance.
Participating Providers-The rate the provider has agreed to accept as reimbursement for covered services. Members are not responsible for
the difference between the provider's usual charges & the maximum allowed amount.
Non-Participating Providers & other Health Care Providers-(includes those not represented in the PPO provider network)-Reimbursement
amount is based on: an Anthem Blue Cross rate or fee schedule, a rate negotiated with the provider, information from a third party vendor,
or billed charges. For Medical Emergency care rendered by a Non-Participating Provider or Non-Contracting Hospital, reimbursement may
be based on the reasonable and customary value. Members may be responsible for any amount in excess of the reasonable and customary
value. Participating Pharmacies & Mail Service Program-members are not responsible for any amount in excess of the prescription drug
maximum allowed amount. Non-Participating Pharmacies-members are responsible for any expense not covered under this plan & any
amount in excess of the prescription drug maximum allowed amount.
When using non-participating providers, the insured person is responsible for any difference between
the covered expense & actual charges, as well as any deductible & percentage copay.
When using the outpatient prescription drug benefits, the insured person is always responsible for drug expenses which are not
covered under this plan, as well as any deductible, percentage or dollar copay.
Calendar year deductible for all providers
(applicable to medical care & prescription drug benefits)
~ Individual insured person (only 1 person on the plan)
~ Insured family (includes insured employee & one or more
members of the employee's family
Annual Out-of-Pocket Maximums (in-network/out-of-network
out-of-pocket maximums are exclusive of each other; includes
calendar year deductible & prescription drug covered expense)
$3,000flndividual insured person
$6,000flnsured family
~ Participating Providers, Participating Pharmacy $3,000flndividual insured person; $6,000flnsured family/year
& Other Health Care Providers
~ Non-Participating Providers & Non-Participating Pharmacy $5,000flndividual insured person; $10,000flnsured family/year
The following do not apply to out-of-pocket maximums: costs in excess of the covered expense & non-cover~d expense. After an individual
insured person or insured family (includes insured employee & one Of m_ore m~mbers of the emp~oyee's fam1!Y) _reaches t~e out-of-pocket
maximum for all medical and prescription drug covered expense the md1v1dual msured person or msured f~m1ly mcurs dunng that. ca!~ndar
year, the individual insured person or insured family will no longer be required to pay a copay for the remam~er of that year. ~e 1~d1V1dual
insured person or insured family remains responsible for costs in excess of the covered expense when provided by non-participating
providers and other health care providers; non-covered expense.
Lifetime Maximum Unlimited
anthem.cornlca Anthem Blue Cross Life and Health Insurance Company (NP) -NGF M-LB20n 01/2016 Printed 2/4/2016
Covered Services
Hospital Medical Services (subject to utilization review
for inpatient services; waived for emergency admissions) > Semi-private room, meals & special diets, & ancillary services
> Outpatient medical care, surgical services & supplies
(hospital care other than emergency room care)
Ambulatory Surgical Centers
> Outpatient surgery, services & supplies
Skilled Nursing Facility (subject to utilization review) > Semi-private room, services & supplies
(limited to 100 days/calendar year}
Hospice Care
> Inpatient or outpatient services for insured persons with up
to one year life expectancy; family bereavement services
Home Health Care
> Services & supplies from a home health agency
(limited to combined maximum of 100 visits/calendar year,
one visit by home health aide equals four hours or less;
not covered while insured person receives hospice care)
Home Infusion Therapy > Includes medication, ancillary services & supplies;
caregiver training & visits by provider to monitor therapy;
durable medical equipment lab services
Physician Medical Services
> Office & home visits
> Hospital & skilled nursing facility visits
> Surgeon & surgical assistant anesthesiologist or anesthetist
Diagnostic X-ray & Lab
> MRI, CT scan, PET scan & nuclear cardiac scan
(subject to utilization review)
> Other diagnostic x-ray & lab
Preventive Care Services
Preventive Care Services including*, physical exams, preventive
screenings (including screenings for cancer, HPV, diabetes, cholesterol,
blood pressure, hearing and vision, immunizations, health education,
intervention services, HIV testing), and additional preventive care for
women provided for in the guidelines supported by the Health
Resources and Services Administration.
*This list is not exhaustive. This benefit includes all Preventive Care
Services required by federal and state law.
Physical Therapy, Physical Medicine & Occupational
Therapy, including Chiropractic Services
(limited to 24 visits/calendar year)
Speech Therapy
> Outpatient speech therapy following injury or organic disease
Acupuncture > Services for the treatment of disease, illness or injury
(limited to 12 visits/calendar year)
Traditional Health Coverage
Insured Person Copay
In-Network Out-of-Network
No copay
No copay
No copay1
Nocopay1
No copay 1
Nocopay1
No copay
No copay
Nocopay
Nocopay1
Nocopay1
No copay
Nocopay
Nocopay
No copay 2
No copay 1
(Insured is also responsible
for charges in excess of
covered expense.)
50%
50%
50%1 (benefd limited to $350/day)
50%1
50%1
50%1
(benefit limited to $600/day)
50%
50%
50%
50%1
50%1
50%
50%
50%
50%2
1 These providers may not be represented in the PPO network in the state where the insured person receives services. If such provider is not available in the service area, the
insured person's copay is the same as for PPO. If such provider is available in the service area and the insured person receives services from a PPO provid~r. there is no
copay. However, if the insured person chooses to receive services from a non-PPO provider when such provider is available in the service area, the insured person's copay
is 50%. All copays are in addition to applicable deductibles.
2 Arupuncture services can be perfonned by a certified acupuncb.Jrist (C.A.), a doctor of medicine (M.D.), a doctor of osteopathy (D.O.), a podiatrist (D.P.M.),
or a dentist (D.D.S.).
Covered Services
Temporomandibular Joint Disorders
~ Splint therapy & surgical treatment
Pregnancy & Maternity Care
~ Physician office visits
~ Prescription drug for elective abortion (mifepristone)
Normal delivery, cesarean section, complications of pregnancy
& abortion
~ Inpatient physician services
~ Hospital & ancillary services
Organ & Tissue Transplants (subject to utilization review)
~ Inpatient services provided in connection with
non-investigative organ or tissue transplants
Diabetes Education Programs (requires physician supervision)
~ Teach insured persons & their families about the disease
process, the daily management of diabetic therapy &
self-management training
Prosthetic Devices
~ Coverage for breast prostheses; prosthetic devices
to restore a method of speaking; surgical implants; artificial
limbs or eyes; the first pair of contact lenses or eyeglasses
when required as a result of eye surgery; wigs for alopecia
resulting from chemotherapy or radiation therapy; & therapeutic
shoes & inserts for insured persons with diabetes
Durable Medical Equipment
Rental or purchase of DME including hearing aids,
dialysis equipment & supplies (hearing aids beneftf is
available for one hearing aid per ear every three years;
breast pump and supplies are covered under preventive care
at no charge for in-network)
Related Outpatient Medical Services & Supplies
~ Ground or air ambulance transportation, services
& disposable supplies
~ Blood transfusions, blood processing & the cost
of unreplaced blood & blood products
~ Autologous blood (self-donated blood collection,
testing, processing & storage for planned surgery)
Emergency Care
~ Emergency room services & supplies
~ Inpatient hospital services & supplies
~ Physician services
Mental or Nervous Disorders and Substance Abuse
~ Facility-based care (subject to utilization review;
waived for emergency admissions)
~ Inpatient physician visits
~ Outpatient physician visits
(Behavioral Health treatment for Autism & Pervasive
Disorder will be subject to pre-service review)
Traditional Health Coverage
Insured Person Copay
In-Network Out-of-Network
No copay
No copay
No copay
No copay
No copay
No copay
No copay
No copay
No copay1
No copay
No copay
No copay
No copay
No copay
No copay
No copay1
No copay1
No copay 1
(Insured is also responsible
for charges in excess of
covered expense.)
50%
50%
50%
50%
50%
50%
50%
50%
50%1
No copay
No copay
No copay
50%
50%
50%
1 These providers may not be represented in the PPO network in the state where the insured person receives services. If such provider is not available in the service area, the
insured person's copay is the same as for PPO. If such provider is available in the service area and the insured person receives services from a PPO provider, there is no
copay. However, if the insured person chooses to receive services from a non-PPO provider when such provider is available in the service area, the insured person's co pay
is 50%. All copays are in addition to applicable deductibles.
Covered Services
Outpatient Prescription Drug Benefits
~ Preventive immunizations administered by a retail pharmacy-
~ Female oral contraceptives generic and single source brand,
~ Flu, Zostavax & Pneumococcal vaccines
~ Retail pharmacy prescription drug maximum allowed amount
~ Home Delivery prescription drug maximum allowed amount
~ Specialty pharmacy drugs (obtained through specialty
pharmacy program)
Supply Limits2
~ Retail Pharmacy (participating and non-participating)
& Specialty Pharmacy (participating)
~ Home Delivery
Traditional Health Coverage
Insured Person Copay
In-Network Out-of-Network
No capay (deductible waived)
No co pay (deductible waived)
No capay
No capay
No capay
No capay
(Insured is also responsible
for charges in excess of
the prescription drug maximum
allowed amount.)
50%1
Not applicable
Not applicable
30-day supply; 60-day supply for federally classified
Schedule II attention deficit disorder drugs that require
a triplicate prescription form, but require a double capay;
6 tablets or units/30-day period for impotence and/or
sexual dysfunction drugs (available only at retail pharmacies)
90-day supply
11nsured person remains responsible for the costs in excess of the prescription dnug maximum allowed amount.
2 Supply limits for certain dnugs may be different. Please refer to the Certificate of Insurance for complete information.
The Outpatient Prescription Drug Benefit covers the following:
~ Outpatient prescription drugs and medications which the law restricts to sale by prescription. Formulas prescribed by a physician
for the treatment of phenylketonuria.
~ Insulin
~ Syringes when dispensed for use with insulin and other self-injectable drugs or medications
~ Prescription oral contraceptives; contraceptive diaphragms. Contraceptive diaphragms are limited to one per year .
~ Injectable drugs which are self-administered by the subcutaneous route (under the skin) by the patient or insured person.
Drugs that have Food and Drug Administration (FDA) labeling for self-administration
~ All compound prescription drugs that contain at least one covered prescription ingredient
~ Diabetic supplies (i.e., test strips and lancets)
~ Prescription drugs for treatment of impotence and/or sexual dysfunction are limited to organic (non-psychological) causes.
~ Inhaler spacers and peak flow meters for the treatment of pediatric asthma.
~ Smoking cessation products requiring a physician's prescription.
~ Certain over-the-counter drugs approved by the Pharmacy and Therapeutics Committee to be included in the prescription drug
formulary.
~ Flu, Zostavax & Pneumococcal vaccines obtained at a local network pharmacy must be administered by a pharmacist
In addition to the benefits described above, coverage may include additional benefits, depending upon the insured person's home
state. The benefits provided in this summary are subject to federal and California laws. There are some states that require more
generous benefits be provided to their residents, even if the master policy was not issued in their state. If the insured person's
state has such requirements, we will adjust the benefits to meet the requirements.
This Summary of Benefits is a brief review of benefits. Once enrolled, insured persons will receive a Certificate of Insurance,
which explains the exclusions and limitations, as well as the full range of covered services of the plan, in detail.
BC Lumenos Health Savings Account Plan-Exclusions and Limitations
Benefits 11'8 not provided for expenses ina~md for or in connection with the following
items:
Not Medically Necessary. Services or supplies that are not medically necessary, as defined.
Experimental or Investigative. Ally experimental or investigative pnx:edure or medication.
But, if insured person is denied benefits becaJSe n is detennined that the requested treatment
is experimental or investigmve, the insured person may request an independent medical review,
as described in the Certificale.
Outside the United States. Services or supplies furnished and billed by a provider outside
the United States, unless such services or supplies are furnished in connection with urgent ca-e
or an emergency.
Crime or Nuclear Energy. Conditions that result from (1) the insured person's commission
at or aiiBrr.,t to conunit a felony, as loog as any injuries are not a result of a medical condition
or an 11:1 at domestic violence; or (2) any release of nuctea-enetgy, whether or not the result
ol ww, when government funds are available for the treatment ol illness or injury <rising from
the release ol nuctea-energy.
Uninsured. Services received before the insured person's effective date. Services received
after the insured person's coverage ends, except as specified as covered in the Certificate.
Exce&l Amounts. Ally amounts in excess of covered expense or the lifetime maximum.
Wori!-Related. WOik-related conditions if benefits are recovered or can be recovered, either by
adjldicalion, selllemenl or otherwise, under any WOikers' compensation, emplo~s liabilijy law
or occupalklnal disease law, whether or not the insured person clcims those benefits.
Government Treatment Ally services the insured person actually received that were provided
by a local, state or federal government agency, except when payment under this plants expressly
required by federal or state law. We will not cover payment for these services if the insured person
is not required to pay for them or IIley 118 given to the insured person for free.
Services of Relatives. Professiooal services received from a person living in the insured person's
home or who is related to the insured person by blood or marriage, except as specified as covered
in the Certificate.
Voluntary Payment Services for which the insured person is not legally obligated to pay. Services
for which the Insured person is not cha-ged. Services for which no charge is made in the absence of
insurance coverage, except services received at a llOiliiOYemmental charitable research hospital.
Such a hospital roost meet the following guidelines:
1. n roost be internationally known as being devoted mainly to medical reseach;
2. at least10% o1 ns yea1y budget rrut be spent on research not directly related to patient care;
3. at least om~·third at its gross income must come from donations or grants other than gifts
or payments for patient care;
4. n must accept patients who are unable to pay; and
5. two-thirds of ns piD!nts must have conditions directly related to the hospital's res&IICh.
Not Specifically Usted. Services not specifically listed in the plan as covered servi:es.
Private Contracts. Services or supplies provided pursuant to a private conlrll:t be'-t the
insured person and a provider, for which reimbursement under Medicare program is prohibited,
as specified In Section 1802 (42 U.S.C. 1395a) of TiHe XVIII of the Social Security Ar!..
Inpatient Diagnostic Tests. Inpatient room and board charges in connection with a hospital stay
prim<rily for diagnostic tests which could have been performed safely on an outpatient basis.
llentsJ or Nervous Disorder1. Academic or educational testing, counseling, and remediation.
Mental or nervous disorders or subs1ance abuse, including rehabilitative care in relation to these
conditions, except as specified as covered in the Certificate.
Orthodontia. Braces and other orthodontic appliances or services.
Dental Services or Supplies. Dental plates, bridges, crowns, caps or other dental prostheses,
dental implants, dental services, extraction ol teeth, or lrealment to the teeth or gums. or treatment
to or for any disorders for the jaw joint, except as specified as covered in the Certificafe. Cosmetic
dental surgery or other dental services for beartification.
Hearing Aldl or Tests. He<ring aids and routine hearing tests, except as specified as covered
in the Certificate.
Optometric Services or Supplies. Optometric services, eye exercises including orthoptics.
Routine • exams and routine eye refractions, except routine eye screenings provided as specified
as covered in the Certificate. Eyeglasses or conlacllenses, except as specified as covered in
the Certificale.
Outpatient Occupational Therapy. Outpatient occupational therapy, except by a home health
agency, hospice, or home infusion therapy provider, as specified as covered in the Certificate.
Outpatient Speech Therapy. Outpatient speech therapy, except as specified as covered
in the Certificate.
Cosmetic Surgery. Cosmetic surgery or other services performed solely for beautification
or to after or reshape normal (Including aged) sbuclures or tissues of the body to in..,rove
appe!lanCe. This exclusioo 00es not apply to reconslructive surgery (that is, surgery perfonned
to correct deformities caused by congenital or developmental abnorrnarrties, mness, or injury for the
purpose of Improving bodily function or symptomatology or to create a normal appell"ance),
including surgery performed to restore symmetry following mastectomy. Cosmetic surgery does not
become reconstructive surgery because of psychological or psychiatric reasons.
Scalp Hllr Prostheses. Scalp hair prostheses, including wigs or any fonn of hair replacernen~
except as specified as covered in the Certificale.
Commercial Weight Loa Programt. Weight loss programs, whether or not they 118 pursued
under medical or physician supervision, unless specifically listed as covered in this plan.
This exclusioo includes, but is not limited to, commercial weight loss prognms (Weight Watchers,
Jenny Cnig, LA Weight Loss) and fasting prognms.
This exclusion does not apply to medically necessat:y trealments for morbid obesity or dieay
evaluations and counseling, and behavioral modification programs for the treatment at anorexia
nervosa or bulimia nervosa. Surgical treatment for morbid obesity is covered as described in the
Certificate.
Sterilization Reversal. Reversal of sterilization.
Infertility Treabnenl Ally services or supp1"1es furnished in connection with the diagnosis and
treatment ol infertilijy, including, but not lirriled to diagnostic tests, medication, surgery, artificial
insemination, in vttro fertilization, sterilization reYiliSal and ganJete intrafatlopian transfer.
Surrogate Mother Services. For any services or supplies provided to a person not covered under
the plan In connection with a surrogate pregnancy Oncluding, but not limited to, the be<ring of a
child by another woman for an Infertile couple}.
Orthopedic shoes and shoe Inserts. This exclusion 00es not apply to orthopedic foolwecY used
as an integral part of a brace, shoe inserts that 118 custom molded to the patient. or therapeutic
shoes and inserts designed to treat foot COf11llicalions due 1D diabeles, as specifically staled in the
Certificate.
Air Conditioners. Air purifiers, air conditioners or humidifiers.
Custodial Care or Rest Cures. Inpatient room and board charges in connection with a hospnat
stay prim<rily for environmental ch!llg8 or physical therapy. Cuslodial care or rest cures, except as
specified as covered in the Cerlilicate. Services provided by a rest home, a home for the aged,
a nursing home or any sin~lw facilijy. Services provided by a skilled nursing facilijy, except as
specified as covered in the Certificate.
Health Club Mernberahlps. Health club memberships, exercise equipmen~ charges from a
physical fitness instructor or personal trainer, or any other charges for activities, equipment or
facilities used for developing or maintaining physical fitness, even if ordered by a physician. This
exclusion also applies to health spas.
Personal Items. Any supplies for comtilll. hygiene or beautification.
Education or Counseling. Educational services or nutritional counseling, except as specified as
covered In the Certifiicate. This exclusioo does not apply to counseling for the tJeatment ol anorexia
nervosa or bulimia nervosa.
Food or Dietary Supplements. Nutritional and/or dietary supplements, except as provided in this
plan or as required by law. This exclusion includes, but is not limned to, those nutritional formulas
and diellly supplements that can be purchased over the counter, which by law do not requirement
either a wriHen prescription or dispensing by a licensed phannacist.
Telephone and Facsi11111e Machine Consultations. Consultations provided by telephone,
except as specified as covered in the Certificate, or facsimile machine.
Routine Exams or Tests. Routine physical exams or tests which do not directly treat an actual
illness, injury or condition, including those required by employment or government authority,
except as specified as covered in the Certificate.
Al:upuncture. Acupuncture trealmen~ except as specified as covered in the Certificale.
Acupressure or massage to control pain, treat iHness or pranote health by applying pressure
kl one or roore specific areas ol the body based on dermatornes or acupuncture points.
Eye Surgery for Refractive Defects. Any eye surgery solely or prim<rily for the purpose ol
correcting refractive defects ol the eye such as nearsightedness (myopia) and/or astigmatism.
Contact lenses and eyeglasses required as a result of this surgery.
Physical Therapy or Physical Medicine. Services ol a physician for physical therapy or physical
medicine, except when provided during a covered inpatient confinement or as specified as covered
in the Certificate.
Outpatient Prescription Druga and Medications. Outpatient prescription drugs, medications and
insulin, except as specified as covered in the Certificate. Non-prescription, over-the-counter palent
or proprietary drugs or medicines, except as specified as covered in the Certifiicate. Cosmetics,
health or beauty aids.
Contracepllve Devices. Contra::eptive devices prescribed b" birth control except as specified
as covered in the Certificate.
Dllbetic Supplies. Prescription and noniJrescription diabetic supp1"1es except as specified
as covered in the Certificate.
Private Duty Nursing. Inpatient or outpatient services of a private duty nurse.
Ufestyte Programs. Progrwns to alter one's lifestyle which may include but are not limited to die~
exercise, imagery or nubition, except as specified as covered in the Certificate. This exclusion will
not apply to cardiac rehabilitation programs approved by us.
BC Lumenos Health Savings Account Plan-Exclusions and Limitations (Continued)
Outpatient prescription drug services and supplies are not provided for or in connection
with the following:
Immunizing agents, biological sera, blood, blood products or blood plasma
Hypodermic syringes &lor needles, except when dispensed for use with insulin & other
se~-injectable drugs or medications
Drugs & medications used to induce spontaneous & non-spontaneous abortions
Drugs & medications dispensed or administered in an outpatient setting, including outpatient
hospital facilities and physicians' offices
Professional charges in connection with administering, injecting or dispensing drugs
Drugs & medications that may be obtained without a physician's written prescription,
except insulin or niacin for cholesterol lowering and certain over-the-counter drugs approved
by the Pharmacy and Therapeutics Committee to be included in the prescription drug formulary.
Drugs & medications dispensed by or while confined in a hospital, skilled nursing facility,
rest home, sanatorium, convalescent hospital or similar facility
Durable medical equipment, devices, appliances & supplies, even if prescribed by a physician,
except contraceptive diaphragms, as specified as covered in the Certificate
Services or supplies for which the insured person is not charged
Oxygen
Cosmetics & health or beauty aids.
Drugs labeled "Caution, Umited by Federal Law 1o Investigational Use," or Non-FDA approved
investigational drugs. Any drugs or medications prescribed for experimental indications
Any expense for a drug or medication incurred in excess of the prescription drug maximum allowed
amount
Drugs which have not been approved for general use by the Food and Drug Administration.
This does not apply 1o drugs that are medically necessary for a covered condition.
Over-the-counter smoking cessation drugs. This does not apply to medically necessary drugs
that the insured person can only get with a prescription under state and federal law.
Drugs used primarily for cosmetic purposes (e.g., Retin-A for wrinkles). However, this will not apply
to the use of this type of drug for medically necessary treatment of a medical condition other than
one that is cosmetic.
Drugs used primarily to treat infertility (including, but not limijed 1o, Clomid, Pergonal and Metrodin),
unless medically necessary for another covered condition.
Anorexiants and drugs used for weight loss, except when used to treat morbid obesity
(e.g., diet pills & appetite suppressants)
Drugs obtained outside the U.S. unless they are furnished in connection with urgent care
or an emergency.
Allergy desensitization products or allergy serum
Infusion drugs, except drugs that are self-administered subcutaneously
Herbal supplements, nutritional and dietary supplements except for formulas for the treatment
of phenylketonuria.
Prescription drugs with a non-prescription (over-the-counter) chemical and dose equivalent
except insulin. This does not apply if an over-the-counter equivalent was tried and was in effective.
Compound medications obtained from other than a participating pharmacy. Insured person will
have to pay the full cost of the compound drugs if insured person obtains drug at a
non-participating pharmacy.
Specialty phannacy drugs that must be obtained from the specialty pharmacy program, but, which
are obtained from a retail pharmocy are not covered by this plan. Insured person will have to pay
the full cost of the specialty pharmacy drugs obtained from a retail pharmacy that insured
person should have obtained from the specialty pharmacy program.
Third Party Liability-Anthem Blue Cross Ufe and Health Insurance Company is entiUed
to reimbursement of benefits paid if the insured person recovers damages from a legally liable
third party.
Coordination of Benefits-The benefits of this plan may be reduced if the insured person has
any other group health or dental coverage so that the services received from all group coverages do
not exceed 100% of the covered expense.
Lumenos plans provided by Anthem Blue Cross Life and Health Insurance Company.
Independent licensees of the 8/ue Cross Association. ®ANTHEM and LUMENOS are
registered trademarlrs of Anthem Insurance Companies, Inc. The Blue Cross name and
symbolatt registered marlrs of the Blue Cross Association.
Anthein.+.
Blue Cross
SJVIA County of Fresno
Modified Lumenos®
Health Savings Account (HSA)
LHSA 263 (3000/1 00/50) (EPID: CGHSA1605)
This summary of benefits has been updated to comply with federal and state requirements, including applicable provisions of the
recently enacted federal health care reform laws. As we receive additional guidance and clarification on the new health care reform
laws from the U.S. Department of Health and Human Services, Department of Labor and Internal Revenue Service, we may be
required to make additional changes to this summary of benefits. This proposed benefit summary is subject to the approval of the
California Department of Insurance and the California Department of Managed Health Care.
This Lumenos plan is an innovative type of coverage that allows an insured person to use a Health Savings Account to pay for routine
medical care. The program also includes traditional health coverage, similar to a typical health plan, that protects the insured person against
large medical expenses.
The insured person can spend the money in the HSA account the way the insured person wants on routine medical care, prescription drugs
and other qualified medical expenses. There are no copays or deductibles to satisfy first. Unused dollars can be saved from year to year to
reduce the amount the insured person may have to pay in the future. If covered expenses exceed the insured person's available HSA
dollars, the traditional health coverage is available after a limited out-of-pocket amount is paid by the insured person.
Certain Covered Services have maximum visit and/or day limits per year. The number of visits and/or days allowed for these services will
begin accumulating on the first visit and/or day, regardless of whether your Deductible has been met. The insured person is responsible for
all costs over the plan maximums. Plan maximums and other important information appear in italics. Benefits are subject to all terms,
conditions, limitations, and exclusions of the Policy.
Explanation of Maximum Allowed Amount
Maximum Allowed Amount is the total reimbursement payable under the plan for covered services received from Participating and Non-
Participating Providers. It is the payment towards the services billed by a provider combined with any applicable deductible, copayment or
coinsurance.
Participating Providers-The rate the provider has agreed to accept as reimbursement for covered services. Members are not responsible for
the difference between the provider's usual charges & the maximum allowed amount.
Non-Participating Providers & Other Health Care Providers-( includes those not represented in the PPO provider network)-Reimbursement
amount is based on: an Anthem Blue Cross rate or fee schedule, a rate negotiated with the provider, information from a third party vendor,
or billed charges. For Medical Emergency care rendered by a Non-Participating Provider or Non-Contracting Hospital, reimbursement may
be based on the reasonable and customary value. Members may be responsible for any amount in excess of the reasonable and customary
value.
Participating Pharmacies & Mail Service Program-members are not responsible for any amount in excess of the prescription drug maximum
allowed amount. Non-Participating Pharmacies-members are responsible for any expense not covered under this plan & any amount in
excess of the prescription drug maximum allowed amount. When using non-participating providers, the insured person is responsible for any
difference between the covered expense & actual charges, as well as any deductible & percentage capay.
When using the outpatient prescription drug benefits, the insured person is always responsible for drug expenses which are not
covered under this plan, as well as any deductible, percentage or dollar capay.
Calendar year deductible for all providers
(applicable to medical care & prescription drug benefits)
~ Individual insured person (only 1 person on the plan)
~ Insured family (includes insured employee & one or more
members of the employee's family
Annual Out-of-Pocket Maximums (in-network/out-of-network
out-of-pocket maximums are exclusive of each other; includes
calendar year deductible & prescription drug covered expense)
$3,000/individual insured person
$6,000/insured family
~ Participating Providers, Participating Pharmacy $3,000/individual insured person; $6,000/insured family/year
& Other Health Care Providers
~ Non-Participating Providers & Non-Participating Phannacy $5,000/individual insured person; $10,000/insured family/year
The following do not apply to out-of-pocket maximums: costs in excess of the covered expense & non-cover~d expense. After an individual
insured person or insured family (includes insured employee & one or more members of the employee's family) reaches the out-of-pocket
maximum for all medical and prescription drug covered expense the individual insured person or insured f~mily incurs during that. ca!e.ndar
year, the individual insured person or insured family will no longer be required to pay a capay for the rema1n~er of that year. _T~e 1~d1V1dual
insured person or insured family remains responsible for costs in excess of the covered expense when prov1ded by non-part1c1patmg
providers and other health care providers; non-covered expense.
Lifetime Maximum Unlimited
anthem.com/ca Anthem Blue Cross Life and Health Insurance Company (NP) -NGF M-LL2041 Effective 01/2016 Printed 2/4/2016
Covered Services
Hospital Medical Services (subject to utilization review
for inpatient services; waived for emergency admissions)
);> Semi-private room, meals & special diets, & ancillary services
);> Outpatient medical care, surgical services & supplies
(hospital care other than emergency room care)
Ambulatory Surgical Centers
);> Outpatient surgery, services & supplies
Skilled Nursing Facility (subject to utilization review)
);> Semi-private room, services & supplies
(limited to 100 days/calendar year)
Hospice Care
);> Inpatient or outpatient services for insured persons with up
to one year life expectancy; family bereavement services
Home Health Care
);> Services & supplies from a home health agency
(limited to 100 visits/calendar year, one visit by a
home health aide equals four hours or less; not covered
while insured person receives hospice care)
Home Infusion Therapy
);> Includes medication, ancillary services & supplies;
caregiver training & visits by provider to monitor
therapy; durable medical equipment; lab services
Physician Medical Services
);> Office & home visits
);> Hospital & skilled nursing facility visits
);> Surgeon & surgical assistant; anesthesiologist or anesthetist
);> Drugs administered by a medical provider
{certain drugs are subject to utilization review)
Diagnostic X-ray & Lab
);> MRI, CT scan, PET scan & nuclear cardiac scan
(subject to utilization review)
);> Other diagnostic x-ray & lab
Preventive Care Services
Preventive Care Services including*, physical exams, preventive
screenings {including screenings for cancer, HPV, diabetes, cholesterol,
blood pressure, hearing and vision, immunizations, health education,
intervention services, HIV testing), and additional preventive care for
women provided for in the guidelines supported by the Health
Resources and Services Administration.
*This list is not exhaustive. This benefit includes all Preventive Care
Services required by federal and state law.
Physical Therapy, Physical Medicine & Occupational Therapy,
including Chiropractic Services (limited to 24 visits/calendar year)
Speech Therapy
);> Outpatient speech therapy following injury or organic disease
Acupuncture
);> Services for the treatment of disease, illness or injury
(limited to 12 visits/calendar year)
Temporomandibular Joint Disorders
);> Splint therapy & surgical treatment
Traditional Health Coverage
Insured Person Copay
In-Network Out-of-Network
No copay
No copay
No copay
Nocopay
No copay
No copay
No copay
No copay
No copay
No copay
No copay
No copay
No copay
Nocopay
Nocopay
Nocopay
Nocopay 1
Nocopay
(Insured is also responsible
for charges in excess of
covered expense.)
50%
50%
50% (benefit limited to $350/day)
50%
50%
50%
50%
(benefit limited to $600/day)
50%
50%
50%
50%
50%
50%
50%
50%
50%
50%1
50%
1 Acupuncture services can be perfonned by a certified acupuncturist (C.A.), a doctor of medicine (M.D.), a doctor of osteopathy (D.O.), a podiatrist (D.P.M.),
or a dentist (D.D.S.).
Covered Services
Pregnancy & Maternity Care
~ Physician office visits
~ Prescription drug for elective abortion (mifepristone)
Normal delivery, cesarean section, complications
of pregnancy & abortion
~ Inpatient physician services
~ Hospital & ancillary services
Organ & Tissue Transplants (subject to utilization review;
specified organ transplants covered only when performed
at Centers of Medical Excellence [CME])
~ Inpatient services provided in connection with
non-investigative organ or tissue transplants
~ Transplant travel expense for an authorized, specified
transplant at aCME (recipient & companion transportation
limited to 6 tn"pslepisode & $250/personltrip for round-trip
coach airfare hotel limited to 1 room double occupancy &
$100/day for 21 dayslfn"p, other expenses limited to
$25/day/person for 21 days/trip; donor transportation
limited to 1 trip/episode & $250 for round-tnp coach airfare,
hotel limited to $1 00/day for 7 days, other expenses limited to
$25/day for 7 days)
Bariatric Surgery (subject to utilization review; medically
necessary surgery for weight loss, only for morbid obesity,
covered only when performed at Centers of Medical Excellence [CME])
~ Inpatient services provided in connection with medically
necessary surgery for weight loss, only for morbid obesity
~ Bariatric travel expense when insured person's home
is 50 miles or more from the nearest bariatric CME
(insured person's transportation to & from CME limited
to $130/personltrip for 3 tnps [pre-surgical visit,
initial surgery & one follow-up visit]; one companion's
transportation to & from CME limited to $130/personltrip
for 2 trips [initial surgery & one follow-up visit];
hotel for insured person & one companion limited to
one room double occupancy & $100/day for 2 days/trip,
or as medically necessary, for pre-surgical & follow-up visit;
hotel for one companion limited to one room double
occupancy & $100/day for duration of insured person's
initial surgery stay for 4 days; other reasonable expenses
limited to $25/daylperson for 4 days/trip)
Diabetes Education Programs (requires physician supeNision)
~ Teach insured persons & their families about the disease
process, the daily management of diabetic therapy &
self-management training
Prosthetic Devices
~ Coverage for breast prostheses; prosthetic devices
to restore a method of speaking; surgical implants;
artificial limbs or eyes; the first pair of contact
lenses or eyeglasses when required as a result of
eye surgery; wigs for alopecia resulting from
chemotherapy or radiation therapy; & therapeutic shoes
& inserts for insured persons with diabetes
Durable Medical Equipment
Rental or purchase of DME including hearing aids,
dialysis equipment & supplies (hearing aids benefit
available for one hearing aid per ear every three years;
breast pump and supplies are covered under preventive care
at no charge for in-network)
Traditional Health Coverage
Insured Person Copay
In-Network Out-of-Network
No capay
No capay
No capay
No capay
No capay
No capay
No capay
No capay
No capay
No capay
No capay
(Insured is a/so responsible
for charges in excess of
covered expense.)
50%
50%
50%
50%
50%
50%
50%
Covered Services
Related Outpatient Medical Services & Supplies
~ Ground or air ambulance transportation, services
& disposable supplies
~ Blood transfusions, blood processing & the cost
of unreplaced blood & blood products
~ Autologous blood (self-donated blood collection,
testing, processing & storage for planned surgery)
Emergency Care
~ Emergency room services & supplies
~ Inpatient hospital services & supplies
~ Physician services
Mental or Nervous Disorders and Substance Abuse
Inpatient Care
~ Facility-based care (subjectto utilization review;
waived for emergency admissions)
~ Inpatient physician visits
Outpatient Care
~ Facility-based care (subject to utilization review;
waived for emergency admissions)
~ Outpatient physician visits
(Behavioral Health treatment for Autism & Pervasive
Disorder will be subject to pre-service review)
1 These providers are not represented in the PPO network.
Traditional Health Coverage
Insured Person Copay
In-Network Out-of-Network
No capay,
No copay1
No copay1
No capay
No capay
No capay
No capay
No capay
No capay
No capay
(Insured is also responsible
for charges in excess of
covered expense.)
No capay
No capay
No capay
50%
50%
50%
50%
Covered Services
Outpatient Prescription Drug Benefits
~ Preventive immunizations administered by a retail pharmacy
~ Female oral contraceptives generic and single source brand,
~ Flu, Zostavax & Pneumococcal vaccines
~ Retail pharmacy prescription drug maximum allowed amount
~ Home Delivery prescription drug maximum allowed amount
~ Specialty pharmacy drugs (obtained through specialty
pharmacy program)
Supply Limits2
~ Retail Pharmacy (participating and non-participating)
~ Home Delivery
~ Specialty Pharmacy
Traditional Health Coverage
Insured Person Copay
In-Network Out-of-Network
No copay (deductible waived)
No copay (deductible waived)
No copay
(Insured is also responsible
for charges in excess of
the prescription drug
maximum allowed amount)
No copay 50%1
No copay Not applicable
No copay Not applicable
30-day supply; 60-day supply for federally classified
Schedule II attention deficit disorder drugs that require
a triplicate prescription form, but require a double copay;
6 tablets or units/30-day period for impotence and/or
sexual dysfunction drugs (available only at retail pharmacies)
90-day supply
30-day supply
1 1nsured person remains responsible for the costs in excess of the prescription drug maximum amount allowed.
2 Supply limits for certain drugs may be different. Please refer to the Certificate of Insurance for complete information.
The Outpatient Prescription Drug Benefit covers the following:
~ Outpatient prescription drugs and medications which the law restricts to sale by prescription. Formulas prescribed by a physician
for the treatment of phenylketonuria.
~ Insulin
~ Syringes when dispensed for use with insulin and other self-injectable drugs or medications
~ Prescription oral contraceptives; contraceptive diaphragms. Contraceptive diaphragms are limited to one per year.
~ Injectable drugs which are self-administered by the subcutaneous route (under the skin) by the patient or insured person.
Drugs that have Food and Drug Administration (FDA) labeling for self-administration
~ All compound prescription drugs that contain at least one covered prescription ingredient
~ Diabetic suppl ies (i.e., test strips and lancets)
~ Prescription drugs for treatment of impotence and/or sexual dysfunction are limited to organic (non-psychological) causes.
~ Inhaler spacers and peak flow meters for the treatment of pediatric asthma.
~ Smoking cessation products requiring a physician's prescription.
~ Certain over-the-counter drugs approved by the Pharmacy and Therapeutics Committee to be included in the prescription drug
formulary.
)> Flu, Zostavax & Pneumococcal vaccines obtained at a local network pharmacy must be administered by a pharmacist
This Summary of Benefits is a brief review of benefits. Once enrolled, insured persons will receive a Certificate of Insurance,
which explains the exclusions and limitations, as well as the full range of covered services of the plan in detail.
Lumenos Health Savings Account Plan -Exclusions and Limitations
Benefits are not provided for expenses incurred for or in connection with the
following items:
Not Medically Necessary. Services or supplies that are not medically necessary, as defined.
Experimental or Investigative. Ally experimental or investigative procedure or medication.
But, ~ insured person is denied benefits because n is detennined that the requested treatment
is experimental or investigative, the insured person may request an independent medical review,
as described in the Certificate.
Outside the United States. Services or supplies furnished and billed by a provider outside
the United States, unless such services or supplies are furnished in connection with urgent care
or an emergency.
Crime or Nuclear Energy. Conditions that result from {1) the insured person's commission of
or attempt to comrn a felony, as long as any injuries are not a result of a medical condition
or an act of domestic violence; or {2) any release of nuclear energy, whether or not the result
cl war, when government funds are available for the treatment of illness or injury arising from the
release cl nuclear energy.
Not Covered. Services received before the insured person's effective date. Services received
after the insured person's coverage ends, except as specified as covered in the Certificate.
Excess Amounts. Ally amounts in excess of covered expense or the lifetime maximum.
Work-Related. Wert-related conditions ~ benefits are recovered or can be recovered, either by
a:ljudication, settlement or otherwise, under any workers' compensation, employe~s liabilijy law
or occupational disease law, whether or not the insured person claims those benefits. If there
is a dispute cl substantial uncertainty as to whether benefits may be recovered for those conditions
pursuant to workers' compensation, we will provide the benefits of this plan for such conditions,
subject to a right of recovery and reimbursement under California Labor Code Section 4903,
as specified as covered in the Certificate.
Government Treabnent Ally services the insured person actually received that were provided
by a local, state or federal government agency, except when payment under this plan is expressly
required by federal or state law. We will not cover payment for these services ~ the insured person
is not required to pay for them or they are given to the insured person for free.
Services of Relatives. Professional services received from a person living in the insured person's
home or who is related to the insured person by blood or marriage, except as specified as covered
in the Certificate.
Voluntary Payment Services for which the insured person has no legal obligation to pay,
or for which no chage would be made in the absence of insurance coverage or other health plan
coverage, except services received at a non-governmental charitable research hospital.
Such a hospijal must meet the following guidelines:
1. n must be internationally known as being devoted mainly to medical research;
2 at least 10% of ns yearly budget must be spent on research not directiy related to patient care;
3. at least one-third of ns gross income must come from donations or grants other than gifts
or payments for patient care;
4. ij must accept patients who are unable to pay; and
5. !wl>-thirds of its patients must have conditions direcHy related to the hospital's research.
Not Specifically Usted. Services not specifically listed in the plan as covered services.
Private Contracts. Services or supplies provided pursuant to a private contract between the
insured person and a provider, for which reimbursement under Medicare program is prohibited,
as specified in Section 1802 {42 U.S.C. 1395a) ctnHe XVIII of the Social Security Act.
Inpatient Diagnostic Test&. Inpatient room and board charges in connection with a hospital stay
primarily for diagnostic tests which could have been perfonned safely on an outpatient basis.
Mental or Nervous Disorders. Academic or educational testing, counseling, and remediation.
Mental or nervous disorders or substance abuse, including rehabilitative care in relation to these
conditions, except as specified as covered in the Certificate.
Orthodontia. Braces, other orthodontic appliances or orthodontic services.
Dental Services or Supplies. Dental plates, bridges, crowns, caps or other dental prostheses,
dental implants, dental services, extraction of teeth, treatment to the teeth or gums, or treatment to
or for any disorders for the temporomandibular Oaw) joint except as specified as covered in the
Certificate. Cosmetic dental surgery or other dental services for beautification.
Hearing Aids or Tests. Hearing aids, except as specified as covered in the Certificate.
Routine hearing tests, except as specified as covered in the Certificate.
Optometric Services or Supplies. Optometric services, eye exercises including orthoptics.
Routine eye exams and routine eye refractions, as specified as covered in the Certificate.
Eyeglasses or contact lenses, except as specified as covered in the Certificate.
Outpatient Occupational Therapy. Outpatient occupational therapy, except by a home health
agency, hospice, or home infusion therapy provider, as specified as covered in the Certificate.
Outpatient Speech Therapy. Outpatient speech therapy, except as specified as covered
in the Certificate.
Cosmetic Surgery. Cosmetic surgery or other services perfonned solely for beautification
or to alter or reshape nonnal Oncluding aged) structures or tissues of the body to improve
appearance. This exclusion does not apply to reconstructive surgery {that is, surgery perfonned /
to correct deformities caused by congenttal or developmental abnonnalities, illness, or injury
for the purpose of improving bodily function or symptomatology or to create a nonnal appearance),
including surgery perfonned to restore symmetry following mastectomy. Cosmetic surgery does not
become reconstructive surgery because of psychological or psychiatric reasons.
Scalp Hair Prostheses. Scalp hair prostheses, including wigs or any form of har replacement
except as specified as covered in the Certificate.
Commercial Weight Loss Programs. Weight loss programs, whether or not they are pursued
under medical or physician supervision, unless s~ally listed as covered in this plan.
This exclusion includes, but is not limited to, commercial weight loss programs {Weight Watchers,
Jenny Craig, LA Weight loss) and fasting progranns.
This exclusion does not apply to medically necessary treatments for morbid obesijy or dietary
evaluations and counseling, and behavioral modification programs for the treatment of anorexia
nervosa or bulimia nervosa. Surgical treatment for morbid obesity is covered as described in the
Certificate.
Sterilization Reversal.
Infertility Treatment Ally services or supplies furnished in connection with the diagnosis and
treatment of infertility, including, but not limijed to diagnostic tests, medication, surgery, artificial
insemination, in vitro fertilization, sterilization reversal and gamete intrafallopian transfer.
Sunrogate Mother Services. For any services or supplies provided to a person not covered under
the plan in connection with a surrogate pregnancy {including, but not limijed to, the bearing of a
child by another woman for an infertile couple).
Orthopedic shoes and shoe inserts. This exclusion does not apply to orthopedic footwear used
as an integral part of a brace, shoe inserts that are custom molded to the patient or therapeutic
shoes and inserts designed to treat foot complications due to diabetes, as specifically stated in the
EOC.
Air Conditioners. Air purifiers, air conditioners or humidifiers.
Custodial Care or Rest Cures. Inpatient room and board charges in connection with a hospital
stay primarily for environmental change or physical therapy. Custodial care or rest cures, except
as specified as covered in the Certificate. Services provided by a rest home, a horne for the aged,
a nursing home or any similar facilijy. Services provided by a skilled nursing facilijy, except
as specified as covered in the Certificate.
Health Club Memberships. Health club memberships, exercise equipment charges from a
physical fitness instructor or personal trainer, or any other charges for activities, equipment or
facilities used for developing or maintaining physical fitness, even if ordered by a physician. This
exclusion also applies to health spas.
Personal Items. Any supplies for comfort, hygiene or beautification.
Education or Counseling. Educational services or nutritional counseling, except as specified as
covered in the Certificate. This exclusion does not apply to counseling for the treatment of anorexia
nervosa or bulimia nervosa.
Food or Dietary Supplements. Nutritional and/or dietary supplements, except as provided in this
plan or as required by law. This exclusion includes, but is not limited to, those nutritional fonnulas
and dietary supplements that can be purchased over the counter, which by law do not requirement
either a written prescription or dispensing by a licensed pharmacist
Telephone and Facsimile Machine Consultations. Consultations provided by telephone,
except as specified as covered in the Certificate, or facsimile machine.
Routine Exams or Tests. Routine physical exanns or tests which do not directiy treat an actual
illness, injury or condition, including those required by employment or government authority,
except as specified as covered in the Certificate.
Acupuncture. Acupuncture treatment except as specified as covered in the Certificate.
Acupressure or massage to control pan, treat illness or promote health by applying pressure
to one or more specific areas of the body based on dennatomes or acupuncture points.
Eye Surgery for Refractive Defects. Ally eye surgery solely or primarily for the purpose of
correcting refractive defects of the eye such as nearsightedness {myopia) and/or astigmatism.
Contact lenses and eyeglasses required as a result of this surgery.
Ph~ical Therapy or Physical Medicine. Services cl a physician for physical therapy or physical
medicine, except when provided during a covered inpatient confinement or as specified as covered
in the Certificate.
Outpatient Prescription Drugs and Medications. Outpatient prescription drugs or medications
and insulin, except as specified as covered in the Certificate. Non-presaiption, over-the-counter
patent or proprietary drug or medicines. except as specified as covered in the Certificate.
Cosmetics, health or beauty aids.
Specialty Phannacy Drugs. Specialty pharmacy drugs that must be obtained from the specialty
pharmacy program, but which are obtained from a retail pharmacy, are not covered by this plan.
Insured person will have to pay the full cost of the specialty phannacy drugs obtained from
a retail phannacy that should have been obtained from the specialty phannacy program.
Contraceptive Devices. Contraceptive devices prescribed for birth control except as specified
as covered in the Certificate.
Diabetic Supplies. Prescription and non-prescription diabetic supplies except as specified
as covered in the Certificate.
Private Duty Nursing. Inpatient or outpatient services of a private duty nurse.
Ufestyle Programs. Progranns to alter one's lifestyle which may include but are not limijed to diet
exercise, imagery or nutrition, except as specified as covered in the Certificate. This exclusion will
not apply to cardiac rehabilitation programs approved by us.
Clinical Trials. Services and supplies in connection with clinical trials, except as specified
as covered in the Certificate.
Lumenos Health Savings Account Plan -Exclusions and Limitations (Continued}
Outpatient prescription drug services and supplies are not provided for or in connection
with the following:
Immunizing agents, biological sera, blood, blood products or blood plasma
Hypodenmic syringes &/or needles, except when dispensed for use with insulin & other
self-injectable drugs or medications
Drugs & medicalions used to induce spontaneous & non-spontaneous abortions
Drugs & medications dispensed or administered in an outpatient setting, including outpatient
hospital facilities and physicians' offices
Professional charges in connection with administering, injecting or dispensing drugs
Drugs & medications that may be obtained without a physician's written prescription,
except insulin or niacin for cholesterol lowering and certain over-the-counter drugs approved
by the Phanmacy and Therapeutics Committee to be included in the prescription drug formulary.
Drugs & medications dispensed by or while confined in a hospital, skilled nursing facility,
rest home, sanatorium, convalescent hospital or similar facility
Durable medical equipment, devices, appliances & supplies, even if prescribed by a physician,
except contraceptive diaphragms, as specified as covered in the Certificate
Services or supplies for which the insured person is not charged
Oxygen
Cosmetics & health or beauty aids.
Drugs labeled "Caution, Limited by Federal Law to Investigational Use," or Non-FDA approved
investigational drugs. Any drugs or medications prescribed for experimental indications
Any expense for a drug or medication incurred in excess of (a) the Drug Limited Fee Schedule
for drugs dispensed by non-participating phanmacies; or (b) the outpatient prescription drug
negotiated rate for drugs dispensed by participating phanmacies or through the mail
service program
Drugs which have not been approved for general use by the State of California Department of
Health Services or the Food and Drug Administration. This does not apply to drugs that are
medically necessary for a covered condition.
Over-the-counter smoking cessation drugs. This does not apply to medically necessary drugs
that the insured person can only get with a prescription under state and federal law.
Drugs used primarily for cosmetic purposes (e.g., Retin-A for wrinkles). However, this will not apply
to the use of this type of drug for medically necessary treatment of a medical condition other than
one that is cosmetic.
Drugs used primarily to treat infertility (including, but not limited to, Clomid, Pergonal and Metrodin),
unless medically necessary for another covered condition.
Anorexiants and drugs used for weight loss, except when used to treat morbid obesity
(e.g., diet pills & appetite suppressants)
Drugs obtained outside the U.S. unless they are furnished in connection with urgent care
or an emergency.
Allergy desensitization products or allergy serum
Infusion drugs, except drugs that are self-administered subcutaneously
Herbal supplements, nutritional and dietary supplements except for formulas for the treatment
of phenylketonuria.
Prescription drugs with a non-prescription (over-the-counter) chemical and dose equivalent
except insulin. This does not apply if an over-the-{;ounter equivalent was tried and was in effective.
Compound medications obtained from other than a participating phanmacy. Insured person
will have to pay the full cost of the compound drugs if insured person obtains drug
at a non-participating phannacy.
Specialty phanmacy drugs that must be obtained from the specialty phanmacy program, but, which
are obtained from a retail pharmacy are not covered by this plan. Insured person will have to pay
the full cost of the specialty phannacy drugs obtained from a retail phannacy that insured
person should have obtained from the specialty phannacy program.
Third Party Liability-Anthem Blue Cross Life and Health Insurance Company is entitled
to reimbursement of benefits paid if the insured person recovers damages from a legally liable
third party.
Coordination of Benefits-The benefits of this plan may be reduced if the insured person has any
other group health or dental coverage so that the services received from all group coverages do not
exceed 100% of the covered expense.
Lumenos plans provided by Anthem Blue Cross Life and Health Insurance Company.
Independent licensees of the Blue Cross Association.® ANTHEM and LUMENOS are
registered trademarks of Anthem Insurance Companies, Inc. The Blue Cross name and
symbol are registered marks of the Blue Cross Association.
AntheiD.+.
Slue Cross
SJVIA County of Fresno
Modified Lumenos®
Health Savings Account (HSA)
LHSA266 (1500/80/60)
Retirees Under 65
This summary of benefits has been updated to comply with federal and state requirements, including applicable provisions of the
recently enacted federal health care reform laws. As we receive additional guidance and clarification on the new health care reform
laws from the U.S. Department of Health and Human Services, Department of Labor and Internal Revenue Service, we may be
required to make additional changes to this summary of benefits. This proposed benefit summary is subject to the approval of the
California Department of Insurance and the California Department of Managed Health Care. This Lumenos plan is an innovative type
of coverage that allows an insured person to use a Health Savings Account to pay for routine medical care. The program also
includes traditional health coverage, similar to a typical health plan that protects the insured person against large medical expenses.
The insured person can spend the money in the HSA account the way the insured person wants on routine medical care,
prescription drugs and other qualified medical expenses. There are no copays or deductibles to satisfy first. Unused dollars can be
saved from year to year to reduce the amount the insured person may have to pay in the future. If covered expenses exceed the
insured person's available HSA dollars, the traditional health coverage is available after a limited out-of-pocket amount is paid by the
insured person. Certain Covered Services have maximum visit and/or day limits per year. The number of visits and/or days allowed
for these services will begin accumulating on the first visit and/or day, regardless of whether your Deductible has been met. The
insured person is responsible for all costs over the plan maximums. Plan maximums and other important information appear in
italics. Benefits are subject to all terms, conditions, limitations, and exclusions of the Policy.
Explanation of Maximum Allowed Amount
Maximum Allowed Amount is the total reimbursement payable under the plan for covered services received from Participating and Non-
Participating Providers. It is the payment towards the services billed by a provider combined with any applicable deductible, copayment or
coinsurance. Participating Providers-The rate the provider has agreed to accept as reimbursement for covered services. Members are not
responsible for the difference between the provider's usual charges & the maximum allowed amount.
Non-Participating Providers & Other Health Care Providers-(includes those not represented in the PPO provider network)-Reimbursement
amount is based on: an Anthem Blue Cross rate or fee schedule, a rate negotiated with the provider, information from a third party vendor,
or billed charges. For Medical Emergency care rendered by a Non-Participating Provider or Non-Contracting Hospital, reimbursement may
be based on the reasonable and customary value. Members may be responsible for any amount in excess of the reasonable and customary
value. Participating Pharmacies & Mail Service Program-members are not responsible for any amount in excess of the prescription drug
maximum allowed amount. Non-Participating Pharmacies-members are responsible for any expense not covered under this plan & any
amount in excess of the prescription drug maximum allowed amount.
Dhen using non-participating providers, the insured person is responsible for any difference between the covered expense &
actual charges, as well as any deductible & percentage copay.
When using the outpatient prescription drug benefits, the insured person is always responsible for drug expenses which are not
covered under this plan, as well as any deductible, percentage or dollar copay.
Calendar year deductible for all providers
(applicable to medical care & prescription drug benefits)
);;> Individual insured person (only 1 person on the plan)
);;> Insured family (includes insured employee & one or more
members ofthe employee's family
Annual Out-of-Pocket Maximums (in-network/out-of-network
out-of-pocket maximums are exclusive of each other; includes
calendar year deductible & prescription drug covered expense)
);;> Participating Providers, Participating Pharmacy
& Other Health Care Providers
);;> Non-Participating Providers & Non-Participating Pharmacy
$1 ,500/individual insured person
$3,000/insured family
$3,000/individual insured person; $5,000/insured family/year
$10,000/individual insured person; $15,000/insured family/year
The following do not apply to out-of-pocket maximums: costs in excess of the covered expense & non-covered expense. After an individual
insured person or insured family (includes insured employee & one or more members of the employee's family) reaches the out-of-pocket
maximum for all medical and prescription drug covered expense the individual insured person or insured family incurs during that. caJ~ndar
year, the individual insured person or insured family will no longer be required to pay a copay for the remainder of that year. T~e 1~d1v1dual
insured person or insured family remains responsible for costs in excess of the covered expense when provided by non-partic1pat1ng
providers and other health care providers; non-covered expense.
Lifetime Maximum Unlimited
anthem.com/ca Anthem Blue Cross Life and Health Insurance Company {NP)-NGF M-LL2045 Effective 01/2016 Printed 2/4/2016
Covered Services
Hospitallledlcal Services (subject to utilization review
for inpatient seM:es; waived for etl'l8lf1fiiiCI admissions)
) Semi-private room, meals & special diets, & ancillary services
) Outpatient medical care, surgical services & supplies
(hospital care other than emergency room care)
Ambulatory Surgical Centers
) Outpatient surgery, services & supplies
Skilled Nursing Facility (subject to utilization review)
) Semi-private room, services & supplies
(limil9d to 100 days/calendar yearj
Hospice Care
) Inpatient or outpatient services for insured persons with up
to one year life expectancy; family bereavement services
Home Health Care
) Services & supplies from a home health agency
(limited to 100 visits/calendar year, one visit by a
home health aide equals four hours or less; not coveted
while insured person TeC8ives hospice care)
Home Infusion Therapy
) Includes medication, ancillary services & supplies;
caregiver training & visits by provider to monitor
therapy; durable medical equipment lab services
Physician Medical Services
) Office & home visits
) Hospital & skilled nursing facility visits
) Surgeon & surgical assistant anesthesiologist or anesthetist
) Drugs administered by a medical provider
(cerlain drugs are subject to util;zation mview)
Diagnostic X-ray & Lab
) MRI, CT scan, PET scan & nuclear cardiac scan
(subject to utilization review)
) Other dagnostic x-ray & lab
Preventive Care Services
Preventive Care Services including•, physical exams, preventive
screenings (including screenings for cancer, HPV, diabetes, cholesterol,
blood pressure, hearing and vision, immunizations, health education,
intervention services, HIV testing), and additional preventive care for
women provided for in the guidelines supported by the Health
Resources and Services Administration.
*This list is not exhaustive. This benefit includes all Preventive Care
Services required by federal and state law.
Physical Therapy, Physical Medicine & Occupational Therapy,
(including Chiropractic Services (limited to 24 visits/calendar yearj
Speech Therapy
) Outpatient speech therapy following injury or organic disease
Acupuncture
) Services for the treatment of disease, illness or injury
(Hmiled to 12 visilslca/endar yeBij
Temporomandibular Joint Disorders
) Splint therapy & surgical treatment
Traditional Health Coverage
Insured Person Copay
In-Network Out-of-Network
20%
20%
20%
20%
20%
20%
20%
20%
20%
20%
20%
20%
20%
Nocopay
20%
20%
20%1
20%
(Insured is also responsible
for charges in excess of
covered expense.)
40%
40%
40% (benefit limited to $35lVday)
40%
40%
40%
40%
(benefit limited to $600/day)
40%
40%
40%
40%
40%
40%
40%
40%
40%
40%1
40%
1 Acupunclure 5eiVices can be perfonned by a certified acupuncturist (CA.), a docfDr of medicine (M.D.), a doctor of osteopathy (D.O.), a podiatrist (D.P .M.),
or a dentist (D.D.S.).
Covered Services
Durable Medical Equipment
Rental or purchase of DME including hearing aids,
dialysis equipment & supplies (hearing aids benefit
available for one hearing aid per ear every three years;
breast pump and supplies are covered under
preventive care at no charge for in-network)
Related Outpatient Medical Services & Supplies
~ Ground or air ambulance transportation, services
& disposable supplies
~ Blood transfusions, blood processing & the cost
of unreplaced blood & blood products
~ Autologous blood (self-donated blood collection,
testing, processing & storage for planned surgery)
Emergency Care
~ Emergency room services & supplies
~ Inpatient hospital services & supplies
~ Physician services
Mental or Nervous Disorders and Substance Abuse
Inpatient Care
~ Facility-based care (subject to utilization review;
waived for emergency admissions)
~ Inpatient physician visits
Outpatient Care
~ Facility-based care (subject to utilization review;
waived for emergency admissions)
~ Outpatient physician visits
(Behavioral Health treatment for Autism & Pervasive Disorder
will be subject to pre-service review)
1 These providers are not represented in the PPO network.
Traditional Health Coverage
Insured Person Copay
In-Network Out-of-Network
20%
20%1
20%1
20%1
20%
20%
20%
20%
20%
20%
20%
(Insured is also responsible
for charges in excess of
covered expense.)
40%
20%
20%
20%
40%
40%
40%
40%
Covered Services
Outpatient Prescription Drug Benefits
~ Preventive immunizations administered by a retail pharmacy-
~ Female oral contraceptives generic and single source brand,
~ Flu, Zostavax & Pneumococcal vaccines
~ Retail pharmacy prescription drug maximum allowed amount
~ Mail service prescription drug maximum allowed amount
~ Specialty pharmacy drugs (obtained through specialty
pharmacy program)
Supply Limits2
~ Retail Pharmacy (participating and non-participating)
~ Home Delivery
~ Specialty Pharmacy
Traditional Health Coverage
Insured Person Copay
In-Network Out-of-Network
No capay (deductible waived)
No capay (deductible waived)
No capay
(Insured is also responsible
for charges in excess of
the prescription drug
maximum allowed amount)
20% 40%1
20% Not applicable
20% Not applicable
30-day supply; 60-day supply for federally classified
Schedule II attention deficit disorder drugs that require
a triplicate prescription form, but require a double capay;
6 tablets or units/30-day period for impotence and/or
sexual dysfunction drugs (available only at retail pharmacies)
90-day supply
30-day supply
11nsured person remains responsible for the costs in excess of the prescription drug maximum amount allowed.
2 Supply limits for certain drugs may be different. Please refer to the Certificate of Insurance for complete information.
The Outpatient Prescription Drug Benefit covers the following:
~ Outpatient prescription drugs and medications which the law restricts to sale by prescription. Formulas prescribed by a physician
for the treatment of phenylketonuria.
~ Insulin
~ Syringes when dispensed for use with insulin and other self-injectable drugs or medications
~ Prescription oral contraceptives; contraceptive diaphragms. Contraceptive diaphragms are limited to one per year.
~ Injectable drugs which are self-administered by the subcutaneous route (under the skin) by the patient or insured person.
Drugs that have Food and Drug Administration (FDA) labeling for self-administration
~ All compound prescription drugs that contain at least one covered prescription ingredient
~ Diabetic supplies (i.e., test strips and lancets)
~ Prescription drugs for treatment of impotence and/or sexual dysfunction are limited to organic (non-psychological) causes.
~ Inhaler spacers and peak ftow meters for the treatment of pediatric asthma.
~ Smoking cessation products requiring a physician's prescription.
~ Certain over-the-counter drugs approved by the Pharmacy and Therapeutics Committee to be included in the prescription drug
formulary.
~ Flu, Zostavax & Pneumococcal vaccines obtained at a local network pharmacy must be administered by a pharmacist
This Summary of Benefits is a brief review of benefits. Once enrolled, insured persons will receive a Certificate of Insurance,
which explains the exclusions and limitations, as well as the full range of covered services of the plan in detail.
Lumenos Health Savings Account Plan -Exclusions and Limitations
Benefits are not provided for expenses incurred for or in connection
with the following items:
Not Medically Neceaary. Services or supplies that are not medically necessary, as defined.
Experimental or Investigative. My experimental or investigative procedure or medication.
But, if insured person is denied benefits because it is detennined that the requested treatment
is experimental or investigative, the insured person may request an independent medical review,
as described in the Certificale.
Outside the United Sbtes. Services or supplies furnished and billed by a provider outside
the United Slales, unless such services or suppi"IBS are furnished in connection with urgent care
or an emergency.
Clime or Nuclear Energy. Conditions that resu~ from (1) the insured person's commission of
or attempt to cornm~ a felony, as long as any injuries are not a result of a medical condition or an
a:t cl domestic violence; or (2) any release of nuclear energy, whether or not the result at Wf!l,
when government ftiiCis are available for the treatment of ilness or ir111Y arising from the release
cl nucleBI energy.
Not Covered. Services received before the insured person's ellective date. Services received
alter the insured person's coverage ends, exoapt as specified as covered in the Certificate.
Excess Amounts. My amounts in excess of covered expense or the lifetime maximum.
Work-Related. Work-filiated conditions if benefits are recovered or can be recovered, either
by aljucfll3im, settlement or othelwise, under lilY workers' compensation, employer's liability
lal or occupational d'IS98S9Ial, whether or not the insured person claims those benefits. If there
is a dispule at subslaltial uncertainty as to whether benefits may be recovered for those conditions
PIJSUanl Ill workers' compensation, we will provide the benefits at this plan for such conditions,
subject to a right of recov91)' and reimbursement under California Labor Code Section 4903,
as specified as covered in the Certificate.
Government T1811ment. My services the insured person actually received that were provided
by a local, state or federal government C91DCY, exoapt when payment under this plan is expressly
recped by federal or state I•. We wiU not cover payment for these services if the insured person
is not requied Ill pay tr them or they are given to the insured person for free.
Services of Relatives. Professional services received from a person &ving in the insured person's
home or who is related to the insured person by blood or mf!lriage, except as specified as covered
in the Certificate.
Voluntary Payment. Services for which the insured person has no legal obligation to pay,
or for which no ch11g9 would be made in the absence of insurance coverage or other health plan
coverage, except services received at a 11011-i10V911lmental ctailable reseach hosP!fal.
Such a hospitalllliSt meal the following guidelines:
1. n 1111St be iltemationally known as being devoted mainly ID medical reseach;
2. at least! 0% cl ns yearly budget must be spent on research not directly related to patient care;
3. at least one-third of ns gross income must come from donations or grants other than gifts
or payments for patient care;
4. itllliSt aooept patients who are unable 1o pay; and
5. lwo-lhinls of its patients 1111SI have conditions direcUy related 1D the hospillts rese81ch.
Not Specifically Usted. Services not specifically listed in the plan as covered services.
Private ContnctJ. Services or supplies provided pursuant 1o a private contra:! between the
insured person and a provider, for which reimbursement under Medicare program is prohibited,
as specified in Section 1802 (42 U.S.C. 1395a) offrtle XVIII of the Social Security Act.
Inpatient Diagnottk: Teats. Inpatient room and boa'd ch81Qes in connection with a hospital stay
primarily for diagnostic tests which could have been perfooned safely on an oulpalient basis.
Mental or Nervous Dlsorden. Academic or educational Jesting, counseling, and remediation.
Mental or nervous disorders or substn:e abuse, including rehabilijalive care in relation 1D these
conditions, except as specified as covered in the Certificate.
Orthodontia. Braoas, other orthodontic !Wiianoas or orthodontic services.
Dental Services or Supplies. Dental plates, bridges, crowns, caps or other dental prostheses,
dental implants, dental services, extraction of teeth, trealmentto the 1eeth or gums, or treatment to
or for lilY cfiSOidels for the temporomandibulf!l Oaw) joint, eliCepl as specified as covered in the
Certificale. Cosrnatic dental surgery or olher dental services for beautification.
Helring Aids or Tests. Helmg aids, except as specified as covered in the Certilicce.
Routine hearing tests, exoapt as specified as covered in the Certificate.
Optometric Services or Supplies. Optometric services, eye exercises including orthoptics.
Routine eye ex8lnS and routine eye refractions, as specified as covered in the Certificate.
Eyeglasses or contact lenses, except as specified as covered in the Certificate.
Outpatient Occupltlonal Therapy. Oulpalient occupational therapy, except by a home health
agency, hospice, or home infusion therapy provider, as specified as covered in the Certificate.
0utp1t1ent Speech Thenpy. Outpatient speech therapy, except as specified as covered
in the CerlificaiB.
Cosmetic Surgery. Cosmetic surgery or other services performed solely for beautification
or to alter or reshape normal Qncluding aged) structures or tissues of the body to improve
appearance. This eliCiusion does not apply to neoonslructive surgery (that is, surgery performed
to conect debmitles caused by congennal or developmental abnormalities, illniBSS, or injury
for the purpose of irrpoving bodily function or symptomalology or Ill create a noonal appearance),
including swgery peOOnned ID restore symmetry following mastectorny. Cosmetic surgery does noJ
become reconstructive surg91)' because of psychological or psychiatric reasons.
Scalp Hair Prostheses. Scalp hair prostheses, including wigs or lilY bm of hair replacement,
except as specified as covered in the Certificate.
Commercial Weight Loss Progl'llllll. Weight loss programs, whether or not they ane pursued
under medical or physician supervision, unless specifically listed as covered in this plan.
This exclusion includes, but is not limited to, commercial weight loss programs (Weight Watchers,
Jenny Craig, LA Weight Loss) and fasting programs.
This exclusion does not apply ID medically necess8l}' treaments for rnorilid obesity or diel8ly
evaluations and counseling, and behavioral modilicalion programs for the treatment of anorexia
nervosa or bulimia nervosa. Surgical trealment for morbid obesity is covered as desaibed in the
Certificate.
Sterilization Reversal.
Infertility Treatment. My services or supplies furnished in connection with the diagnosis and
treatment of infertility, including, but not limited to diagnostic tests, medication, surgery, artificial
insemination, in vitro fertilization, sterilization reversal and gamete intraallopian Jransfer.
Surrogate llolher Services. For lilY services or supplies provided Ill a person not covered under
the plan in connection with a surrogaiB pregn111ey Oncluding, but not limited ID, the baaing cl a
child by another woman for an infertile ccqlle).
Orthopedic shoes and shoe inserts. This exclusion does not apply to orthopedic footwear used
as an integral part of a brace, shoe inserts that are custom molded to the patient, or therapeutic
shoes and inserts designed to treat foot complications due to diabetes, as specifically stated in the
Certificate
Jijr Conditioners. PJr purifiers, air conditioners or humidifiers.
Custodial C.. or Rest Cures. Inpatient room and board ch8lges in connection with a hospital
stay primarily for environmental change or physical therapy. Cus1odial care or rest cures,
except as specified as covered In the Certificate. Services provided by a rest home, a home
for the aged, a nursing home or any similf!lfacility. Services provided by a skilled nursing fa::ll~.
except as specified as covered i n the Certificate.
Health Club Membenhips. Health club membelslips, exercise equipment, ch8IQes from a
Jilysical fitness instructor or personal trainer, or any other chages for activities, equipment or
f<l:ilities used for developing or maintaining physa fitness, even if ordered by a physician. This
exclusion also !Wiles Ill health spas.
Personal Items. My supplies for comfort, hygiene or beautification.
Education or Counseling. Educational services or nutritional counseling, except as specified as
covered in the Certificate. This exclusion does not apply to counseling for the treatment of lllOreXia
nervosa or bulimia nervosa.
Food or Diatlly Supplements. Nutritional and/or dielary supplements, except as provided in this
plan or as required by law. This exclusion includes, but is not limited Ill, those nutritional formllas
and dieiBiy supplemenls that can be purchased over the counler, which by law do not requirement
either a writlen prescription or dispensing by a licensed pharmacist
Telephone and Facsimile Machine Consultations. Consu~ns provided by telephone,
except as specified as covered in the Certificate, or facsimile machine.
Routine Ex11111 or Tests. Routine physa exams or lasts which do not direcUy treat an actual
illness, injury or condition, including those required by employment or government au!IQity,
except as specified as covered in the Certificate.
Acupuncture. Acupuncture treatment, ex~:ept as specified as covered in the Certificate.
Acupressure or massage to control pain, treat illness or promote health by !Wiying pressure
to one or more specific areas of the body based on dermatomes or acupuncture points.
Eye Surgery for Refractive Defects. My eye surgery solely or primarily for the purpose of
conecting refractive defects af the eye such as 11981Sightedness (myopia) 8l'dlor astigmatism.
Contact lenses and eyeglasses required as a result of this SUI'QBIY.
Physical Thenpy or Phy&icallledldne. Services of a physician for physical therapy or Jilysical
med'tcine, except when provided during a covered inpatient confinement or as specified as covered
in the Certificate.
Outpatient PrescripUon Drugs and Medications. Outpatient prescription drugs or medications
and insulin, exoapt as specified as covered In the Certificate. NoniJrescription, over-th&-COUnter
patent or proprielay drug or medicines. except as specified as covered in the Certificate.
Cosmetics, health or beauty aids.
Specialty Pharmacy Drugs. Specia~ pharmacy drugs that must be obtained from the speci~
pharmacy program, but which are otmned from a retail phannacy, are not covered by this plan.
Insured person will have to pay the full coet of the speclaJty pharmacy drugs obtained from
a retail pharmacy thet should have been obtained fro m the specialty pharmacy program.
Contraceptive Devices. Contraceptive devices prescribed for birth control except as specified
as covered in the Certilicale.
Diabetic Supplies. Prescription and non-prescription diabetic supplies except as specified
as covered in the Certificate.
Private Duty Nun~lng.lnpalient or outpatient services of a private duty nurse.
Ufestyle Program1. Programs to alter one's lifestyle which may include but are not limited to diel.
exercise, imagery or nutrition, exoapt as specified as covered in the Certificate. This exclusion will
not apply to cardiac rehabilitation progl'llllS approved by us.
Clinical Trialt. Services and supplies in connection with clinical trials, except as specified
as covered in the Ce!tilicale.
Lumenos Health Savings Account Plan -Exclusions and Limitations (Continued)
Outpatient prescription drug services and supplies are not provided for or in connection
with the following:
Immunizing agents, biological sera, blood, blood products or blood plasma
Hypodermic syringes &lor needles, except when dispensed for use with insulin & other
self-injectable drugs or medications
Drugs & medications used to induce spontaneous & non-spontaneous abortions
Drugs & medications dispensed or administered in an outpatient setting, including outpatient
hospital facilities and physicia1s' offices
Professional charges in connection with administering, injecting or dispensing drugs
Drugs & medications that may be obtained without a physician's written prescription, except insulin
or niacin for cholesterol lowering 111d certain over-the-counter drugs approved by the Pharmacy and
Therapeutics Committee to be included in the prescription drug formulary.
Drugs & medications dispensed by or while confined in a hospital, skilled nursing facility,
rest home, s111atorium, convalescent hospilal or similar facility
Durable medical equipmen~ devices, appliances & supplies, even if prescribed by a physician,
except contraceptive diaphragms, as specified as covered in the Certificate
Services or supplies for which the insured person is not charged
Oxygen
Cosmetics & health or beauty aids.
Drugs labeled "Caution, Umited by Federal law to Investigational Use,' or Non-FDA approved
investigational drugs. Any drugs or medications prescribed for experimental indications
Any expense for a drug or medication incurred in excess of (a) the Drug Umited Fee Schedule
for drugs dispensed by non-pa'ticipating pharmacies; or (b) the outpatient prescription drug
negotiated rate for drugs dispensed by participating ph111macies or through the mail
service program
Drugs which have not been approved for general use by the State of California Department of
Health Services or the Food 111d Drug Administration. This does not apply to drugs that are
medically necessary for a covered condition.
Over-the-counter smoking cessation drugs. This does not apply to medically necessary drugs
that the insured person can only get with a prescription under state and federal law.
Drugs used primarily for cosmetic purposes (e.g., Retin-A for wrinkles). However, this will not apply
to the use of this type of drug for medically necessary treatment of a medical condition other than
one that is cosmetic.
Drugs used primarily to treat infertility (including, but not limited to, Clomid, Pergonal and Metrodin),
unless medically necessary for another covered condition.
Anorexiants and drugs used for weight loss, except when used to treat morbid obesity
(e.g., diet pills & appetite suppressants)
Drugs obtained outside the U.S. unless they ane furnished in connection with urgent care
or an emergency.
Allergy desensitization products or allergy serum
Infusion drugs, except drugs that are self-administered subcutaneously
Herbal supplements, nutritional and dietary supplements except for formulas for the treatment
of phenylketonuria.
Prescription drugs with a non-prescription (over-the-counter) chemical and dose equivalent
except insulin. This does not apply if an over-the-counter equivalent was tried 111d was in effective.
Compound medications obtained from other than a participating pharrnacy.lnsured person
will have to pay the full cost of the compound drugs if insured person obtains drug
at a non-participating pharmacy.
Specialty pharmacy drugs that must be obtained from the specialty pharmacy program, but, which
are obtained from a retail pharmacy are not covered by this plan. Insured person will have to pay
the full cost of the specialty pharmacy drugs obtained from a retail pharmacy that insured
person should have obtained from the specialty pharmacy program
Third Party Uabllily -Anthem Blue Cross Ute and Health Insurance Company is entitied
to reimbursement of benefits paid if the insured person recovers damages from a legally liable
third party.
Coordination of Benefits -The benefits of this plan may be reduced if the insured person has any
other group health or dental coverage so that the services received from all group coverages do not
exceed 100% of the covered expense.
lumenos plans provided by Anthem Blue Cross Life and Health Insurance Company.
Independent licensees of the Blue Cross Association.® ANmEM and LUMENOS aru
registered tradem;wks of Anthem Insurance Companies, Inc. The Blue Cross name and
symbol ;we registered marks of the Blue Cross Association.
AntheiD.+
Blue cross
SJVIA County of Fresno
Modified Premier PPO
(250/20/1 00/50) • Active
This summary of benefits has been updated to comply with federal and state requirements, including applicable provisions of the
recently enacted federal health care reform laws. As we receive additional guidance and clarification on the new health care reform
laws from the U.S. Department of Health and Human Services, Department of Labor and Internal Revenue Service, we may be
required to make additional changes to this summary of benefits. This proposed benefit summary is subject to the approval of the
California Department of Insurance and the California Department of Managed Health Care. In addition to dollar and percentage
copays, members are responsible for deductibles, as described below. Please review the deductible information to know if a
deductible applies to a specific covered service. Certain Covered Services have maximum visit and/or day limits per year. The
number of visits and/or days allowed for these services will begin accumulating on the first visit and/or day, regardless of whether
your Deductible has been met. Members are also responsible for all costs over the plan maximums. Plan maximums and other
important information appear in italics. Benefits are subject to all terms, conditions, limitations, and exclusions of the Policy.
Explanation of Maximum Allowed Amount
Maximum Allowed Amount is the total reimbursement payable under the plan for covered services received from Participating and Non-
Participating Providers. It is the payment towards the services billed by a provider combined with any applicable deductible, copayment or
coinsurance. Participating Providers-The rate the provider has agreed to accept as reimbursement for covered services. Members are not
responsible for the difference between the provider's usual charges & the maximum allowed amount. Non-Participating Providers & Other
Health Care Providers-(includes those not represented in the PPO provider network)-Reimbursement amount is based on: an Anthem Blue
Cross rate or fee schedule, a rate negotiated with the provider, information from a third party vendor, or billed charges. For Medical
Emergency care rendered by a Non-Participating Provider or Non-Contracting Hospital, reimbursement may be based on the reasonable
and customary value. Members may be responsible for any amount in excess of the reasonable and customary value.
When using Non-PPO and Other Health Care Providers, members are responsible for any difference between the
covered expense & actual charges, as well as any deductible & percentage copay.
Benefit year deductible for all providers $250/member ·
Deductible for non-Anthem Blue Cross PPO hospital or
residential treatment center
Deductible for non-Anthem Blue Cross PPO hospital or
residential treatment center if utilization review not obtained
Deductible for emergency room services
Annual Out-of-Pocket Maximums (no ClOSS accumulation)
$500/family (combined/aggregate)
$500/admission (waived for emergency admission)
$500/admission (waived for emergency admission)
$100Msit (waived if admitted directly from ER)
PPO Providers & Other Health Care Providers $3,000/member/year; $5,000/family/year
Non-PPO Providers $10,000/member/year; $15,000/family/year
The following do not apply to the medical out-of-pocket maximums: non-covered expenses and prescription drugs. After an annual out-of-
pocket maximum is met for medical during a calendar year, the individual member or family will no longer be required to pay a copay or
coinsurance for medical. The member remains responsible for non-covered expenses and prescription drugs
Lifetime Maximum Unlimited
Covered Services PPO: Per
Member Copay
Hospital Medical Services (subject to utilization review
for inpatient services; waived for emergency admissions)
~ Semi-private room, meals & special diets, & ancillary services
~ Outpatient medical care, surgical services & supplies
(hospital care other than emergency room care)
Ambulatory Surgical Centers
~ Outpatient surgery, services & supplies
Skilled Nursing Facility (subject to utilization review)
~ Semi-private room, services & supplies
(limited to 100 days/benefit year)
Hospice Care
~ Inpatient or outpatient services ; family bereavement services
Home Health Care (subject to utilization review)
~ Services & supplies from a home health agency
(limited to 100 visits/benefit year, one visit by a
home health aide equals four hours or less;
not covered while member receives hospice care)
Nocopay
Nocopay
No copay
Nocopay
Nocopay
Nocopay2
Non-PPO: Per
Member Copay
50%1
50%1
50% (benefit limited to $350/day)
50%
50%
1 For Callfomla facilities, a discount will be applied if the facility has a contract with Anthem Blue Cross for fee-for-service business. For California facilities without a contract.
covered expense for l'lOIHill8rgency hospital services and supplies is reduced by 25%, resulting in higher costs tlr members.
2These providefs are not represented in the Anthem Blue Cross PPO networ1t
anthem.comlca Anthem Blue Cross (P-NP) -NGF M-LP2039 Effective 01/2016 Printed 214/2016
Covered Services
Home Infusion Therapy (subject to utilization review}
~ Includes medication, ancillary services & supplies;
caregiver training & visits by provider to monitor
therapy; durable medical equipment lab services
Physician Medical Services
~ Office & home visits
~ Hospital & skilled nursing facility visits
~ Surgeon & surgical assistant; anesthesiologist or anesthetist
~ Drugs administered by a medical provider
(certain drugs BIB subject to utilization review
Diagnostic X-ray & Lab
~ MRI, CT scan, PET scan & nuclear cardiac scan
(subject to utilization review}
~ Other diagnostic x-ray & lab
Preventive Care services
Preventive Care Services including*, physical exams, preventive
screenings (including screenings for cancer, HPV, diabetes, cholesterol
blood pressure, hearing and vision, immunizations, health education,
intervention services, HIV testing), and additional preventive care for
women provided for in the guidelines supported by the Health
Resources and Services Administration.
*This list is not exhaustive. This benefit includes all Preventive Care
Services required by federal and state law.
Physical Therapy, Physical Medicine & Occupational
Therapy, including Chiropractic Services (limited to
24 vf3i~Btf)enetf )lear; addlional visits may be authorized)
Speech Therapy
~ Outpatient speech therapy following injury or organic disease
Acupuncture
~ Services for the treatment of disease, illness or injury
(limiled to 12 visilslbenefit year)
Temporomandibular Joint Disorders
~ Splint therapy & surgical treatment
Pregnancy & Maternity Care
~ Physician office visits
~ Prescription drug for elective abortion (mifepristone}
Normal delivery, cesarean section, complications of pregnancy
& abortion
~ Inpatient physician services
~ Hospital & ancillary services
Organ & Tissue Transplants (subject to utilization review;
specified organ transplants covered only when performed
at Center of Expertise [COE]}
~ Inpatient services provided in connection with
non-investigative organ or tissue transplants
~ Transplant travel expense for an authorized,
specified transplant at a COE
(recipient & companion transportation limited to
6tripslepisode & $250/personlfrip
PPO: Per
Member Copay
Nocopay ·
$201visit1
(deductible waived}
Nocopay
Nocopay
Nocopay
Nocopay
Nocopay
Non-PPO: Per
Member Copay
50%
(benefit limited to $60(Vday)
50%
50%
50%
50%
50%
50%
Nocopay 50%
(deductible waNed)
Nocopay 50%
Nocopay 50%
Nocopay2 50%2
Nocopay 50%
Nocopay 50%
Nocopay 50%
Nocopay 50%
Nocopay 50%3
No co pay
No copay (deductible waived}
for IDUnd-#rip coach ailfare, 21 days/trip, other expenses
limited to 1 trifN'episode & $250 for round-trip coach airfare,
hotel Omited to $100/day for 7 days, other expenses limited to $25/day for 7 days}
1 The dollar copay applies only to the visit ilself. An additional No copay applies for any setVices pelfonned in office (I.e., X-ray, lab, surgery), after any applicable deductible.
2 Arupunclure setVices can be pedormed by a certified arupuncturist (C.A.), a doctor of medicine (M.D.), a doctor of osteopathy (D.O.), a podiabist (D.P.M.),
or a dentist (D.D.S.). 3 For California facirrties, a discount wiH be applied if the facility has a conlmct with Anthem Blue Cross for fee.for-5el'lice business. For California
facilities without a conlmct, covered expense for non-emergency hospilal services and supplies is reduced by 25%, resulting in higher cosls for members.
Covered Services
Bariatric Surgery (subject to utilization review; medically
necessary surgery for weight loss, only for morbid obesity,
covered only when performed at a Center of Expertise [COE])
~ Inpatient services provided in connection with medically
necessary surgery for weight loss, only for morbid obesity
PPO: Per
Member Co pay
No copay
Non·PPO: Per
Member Copay
~ Bariatric travel expense when member's home
is 50 miles or more from the nearest bariatric COE
(member's transportation to & from COE limited to
$130/personltrip for 3 trips [pre-surgical visit, initial
surgery & one follow-up visit]; one companion's
transportation to & from COE limited to $130/personltrip
for 2 trips [initial surgery & one follow-up visit];
No copay (deductible waived)
hotel for member & one companion limited to one room
double occupancy & $100/day for 2 days/trip, or as
medically necessary, for pre-surgical & follow-up visit;
hotel for one companion limited to one room double
occupancy & $1 00/day for duration of member's initial
surgery stay for 4 days; other reasonable expenses
limited to $2E/daylperson for 4 days/trip)
Diabetes Education Programs (requires physician supervision)
~ Teach members & their families about the disease
process, the daily management of diabetic therapy &
self-management training
Prosthetic Devices
$20/visit
(deductible waived)
~ Coverage for breast prostheses; prosthetic devices to No copay
restore a method of speaking; surgical implants;
artificial limbs or eyes; the first pair of contact lenses
or eyeglasses when required as a result of eye surgery;
& therapeutic shoes & inserts for members with diabetes
Durable Medical Equipment
~ Rental or purchase of DME including hearing aids, No copay
dialysis equipment & supplies (hearing aids benefit
is available for one hearing aid per ear every three years; breast pump
and supplies are covered under preventive care at no charge for in-network)
Related Outpatient Medical Services & Supplies
~ Ground or air ambulance transportation, services
& disposable supplies
~ Blood transfusions, blood processing & the cost of
unreplaced blood & blood products
~ Autologous blood (self-donated blood collection,
testing, processing & storage for planned surgery)
1 These providers are not represented in the Anthem Blue Cross PPO network.
No copay1
No copay1
No copay 1
50%
50%
50%
Covered Services
Emergency Care
) Emergency room services & supplies
($1 00 deductible waived if admitted)
) Inpatient hospital services
) Physician services
Mental or Nervous Disorders and Substance Abuse
Inpatient Care
) Facility-based care (subject to utilization review;
waived for emergency admissions)
) Inpatient physician visits
Outpatient Care
) Facility-based care (subject to utilization review;
waived for emergency admissions)
) Outpatient physician visits
(Behavioral Health Treatment for Autism & Pervasive Disorder
will be subject to pre-service review)
PPO: Per Non·PPO: Per
Member Copay Member Copay
Nocopay No copay
Nocopay No copay
Nocopay No copay
100% 50%1
100% 50%
100% 50%1
$20/visit2 50%
(deductible waived)
1 For California facilities, a discount applies if the facility has a contract with Anthem Blue Cross for fee-for-service business. For California facilities without
a contract, covered expense for non-emergency hospital services and supplies is reduced by 25%, resulting in higher out-of-pocket costs for members.
This Summary of Benefits is a brief review of benefits. Once enrolled, members will receive a Combined Evidence of Coverage and
Disclosure Form, which explains the exclusions and limitations, as well as the full range of covered services of the plan, in detail.
Premier Plan Exclusions and Limitations
Not Medically Necessary. Services or supplies that are not medically necessary, as defined.
Experimental or Investigative. Arly experimental or investigative procedure or medication.
But, if member is denied benefits because it is determined that the requested lreatment is
experimental or investigative, the member may request an independent medical review,
as described in the Evidence of Coverage (EOC).
Outside the United States. Services or supplies furnished and billed by a provider outside
the United States, unless such services or supplies are furnished in connection with urgent care
or an emergency.
Crime or Nuclear Energy. Conditions that resu~ from (1) the member's commission of or attempt
to commn a felony, as long as any injuries are not a resuH of a medical condition or an act of
domestic violence; or (2) any release of nuclear energy, whether or not the result of war, when
government funds are available for the lreatmenl of illness or injury arising from the release
of nuclear energy.
Not Covered. Services received before the member's effective date. Services received
after the member's coverage ends, except as specified as covered in the EOC.
Excess Amounts. Arly amounts in excess of covered expense or the lifetime maximum.
Worit-Related. Work-related conditions if benefi1s are recovered or can be recovered, either by
adjudication, settlement or otherwise, under any workers' compensation, employer's liability law
or occupational disease law, whether or not the member claims those benefits. If there is a dispute
of substantial uncertainty as to whether benefits may be recovered for those conditions pursuant to
workers' compensation, we will provide the benefits of this plan for such conditions, subject to a
right of recovery and reimbursement under California Labor Code Section 4903, as specified as
covered in the EOC.
Government Treabnent Arly services the member actually received that 'Mlre provided by a local,
state or federal government agency, except wihen payment under this plan is expressly required by
federal or state law. We will not cover payment for these services if the member is not required to
pay for them or they are given to the insured person for free.
Services of Relatives. Professional services received from a person living in the member's home
or who is related to the member by blood or marriage, except as specified as covered in the EOC.
Voluntary Payment Services for which the member has no legal obligation to pay, or for which
no charge would be made in the absence of insurance coverage or other health plan coverage,
except services received at a non'9(lvemmental charitable research hospital. Such a hospital
must meel the following guidelines:
1. it must be internationally known as being devoted mainly to medical research;
2. at least 10% of its yearly budget must be spent on research not directly related to
patient CCI'e;
3. at least one-third of its gross income must come from donations or grants other than gifts
or payments for patient care;
4. it must accept patients who are unable to pay; and
5. two-thirds of its patients must have conditions directly related to the hospital's research.
Not Specifically Usted. Services not specifically listed in the plan as covered services.
Private Contracts. Services or supplies provided pursuant to a private contract between
the member and a provider, for which reimbursement under Medicare program is prohibited,
as specified in Section 1802 (42 U.S.C. 1395a) of Title XVIII of the Social Security Act.
Inpatient Diagnostic Tests. Inpatient room and board charges in connection with a hospital stay
primarily for diagnostic tests which could have been performed safely on an outpatient basis.
Mental or Nervous Disorders. Academic or educational testing, counseling, and remediation.
Mental or nervous disorders and alcohol or drug dependence, including rehabilitative care in
relation to these conditions, except as specified as covered in the E OC.
Orthodontia. Braces, other orthodontic appliances or orthodontic services.
Dental Services or Supplies. Dental plates, bridges, crowns, caps or other dental prostheses,
dental implants, dental services, extraction of teeth, treabnenl to the teeth or gums, or treatment to
or for any disorders for the temporomandibular Oaw) joint except as specified as covered in the
EOC. Cosmetic dental surgery or other dental services for beautification.
Hearing Aids or Tests. Hearing aids and routine hearing tests, except as specified as covered
in the EOC.
Optometric Services or Supplies. Optomebic services, eye exercises including orthoptics.
Routine eye exams and routine eye refractions, eyeglasses or contact lenses, except as specified
as covered in the EOC.
Outpatient Occupational Therapy. Outpatient occupational therapy, except by a horne health
agency, hospice, or infusion therapy provider, except as specified as covered in the EOC.
Outpatient Speech Therapy. Outpatient speech therapy, except as specified as covered
in the EOC.
Cosmetic Surgery. Cosmetic surgery or other services performed solely for beautification or to
liter or reshape normal (including aged) structures or tissues of the body to improve appearance.
This exclusion does not apply to reconstructive surgery (that is, surgery performed to conrect
deformities caused by congenital or developmental abnormalities, illness, or injury for the purpose
of improving bodily function or symptomatology or to create a normal appearance), including
surgery performed to restore symmetry following mastectomy. Cosmetic surgery dces not become
reconstructive surgery because of psychological or psychiatric reasons.
Conunerclal Weight Loss Programs. Weight loss programs, whether or not they are pursued
under medical or physician supervision, unless specifically listed as covered in this plan.
This exclusion indudes, but is not limited to, commercial weight loss programs (Weight Watchers,
Jenny Craig, LA Weight Loss) and fasting programs.
This exclusion does not apply to med'tcally necessary lreatments for morbid obesity or dietary
evaluations and counseling, and behavioral modification programs for the treatment of anorexia
nervosa or bulimia nervosa Surgicallreatment for morbid obesijy is covered as described in the
Evidence of Coverage (E OC).
Sterilization Reversal.
Infertility Treatment Arly services or supplies furnished in connection with the diagnosis and
lreatment of infertilijy, including, but not limited to diagnostic tests, medication, surgery, artificial
insemination, in vitro fertilization, sterilization reversal and gamete intrafallopian transfer.
Surrogate Mother Services. For any services or supplies provided to a person not covered under
the plan in connection with a sunrogate pregnancy (including, but not limited to, the bearing of a
child by another woman for an infertile couple).
Orthopedic shoes and shoe inserts. This exclusion dces not apply to orthopedic footwear used
as an integral part of a brace, shoe inserts that are custom molded to the patient or therapeutic
shoes and inserts designed to treat fool complications due to diabetes, as specifically slated in the
EOC
Air Conditioners. Air purifiers, air conditioners or humidifiers.
Custodial Care or Rest Cures. Inpatient room and board charges in connection with a hospital
stay primarily for environmental change or physical therapy. Services provided by a rest home,
a horne for the aged, a nursing home or any similar facilijy. Services provided by a skilled nursing
facility or custodial care or rest cures, except as specified as covered in the EOC.
HeaHh Club Memberships. Health club memberships, exercise equipment charges from a
physical fitness instructor or personal trainer, or any other charges for activijies, equipment or
facilities used for developing or maintaining physical fitness, even if ordered by a physician. This
exclusion also applies to health spas.
Personal Items. Arly supplies for comfort, hygiene or beautification.
Education or Counseling. Educational services or nutritional counseling, except as specified
as covered in the EOC. This exclusion does not apply to counseling for the treabnenl of anorexia
nervosa or bulimia nervosa.
Food or Dietary Supplements. Nubitional and/or dietary supplements, except as provided in this
plan or as required by law. This exclusion includes, but is not limited to, those nutritional formulas
and dietary supplements that can be purchased over the counter, which by law do not requirement
either a written prescription or dispensing by a licensed phanmacist
Telephone and Facsimile Machine Consultations. Consuliations provided by telephone
or facsimile machine.
Routine Exams or Tests. Routine physical exams or tests which do not directly treat an actual
illness, injury or condition, including those required by employment or government authority,
except as specified as covered in the EOC.
Acupuncture. Acupuncture lreatment as specified as covered in the E OC. Acupressure or
massage to control pain, treat illness or promote health by applying pressure to one or more
specific areas of the body based on dermalomes or acupuncture points.
Eye Surgery for Refractive Defects. Arly eye surgery solely or primarily for the purpose of
conrecting refractive defects of the eye such as neasightedness (myopia) and/or astigmatism.
Contact lenses and eyeglasses required as a result of this surgery.
Physical Therapy or Physical Medicine. Services of a physician for physical therapy or physical
medicine, except when provided during a covered inpatient confinement or as specified as covered
in the EOC.
Outpatient Prescription Drugs and Medications. Outpatient prescription drugs or medications
and insulin, except as specified as covered in the EOC. Arly non-prescription, over-tfle.counter
patent or proprietary drug or medicine. Cosmetics, health or beauty aids.
Specialty Pharmacy Drugs. Specialty phanmacy drugs that must be obtained from the specialty
phanmacy program, bu~ which are obtained from a retail phanmacy, are not covered by this plan.
Member will have to pay the full cost of the specialty pharmacy drugs obtained from a retail
pharmacy that should have been obtained from the specialty pharmacy program.
Contraceptive Devices. Contraceptive devices prescribed for birth control except as specified
as covered in the EOC.
Diabetic Supplies. Prescription and non-prescription diabetic supplies except as specified
as covered in the EOC.
Private Duty Nursing. Inpatient or outpatient services of a private duty nurse.
Ufestyle Programs. Programs to alter one's lifestyle which may include but are not limited to diet,
exercise, imagery or nutrition. This exclusion will not apply to cardiac rehabilnation programs
approved by us.
Wigs.
Third Party Liability-Anthem Blue Cross is entitled to reimbursement of benefits paid if the
member recovers damages from a legally liable third party.
Coordination Of Benefits -The benefits of this plan may be reduced if the member has any other
group health or dental coverage so that the services received from all group coverages do not
exceed 100% of the covered expense.
Anthem Blue Cross is the trade name of Blue Cross of Calffomia. Independent Ucenses
of the Blue Cross Association. ®ANTHEM Is a registered trademarlr of Anthem Insurance
Companies, Inc. The Blue Cross name and symbol are registered msrlrs of the
Blue Cross Association.
604334 COUNTY OF FRESNO,
RETIREE
Summary of Benefits for
Kaiser Permanente Senior Advantage (HMO) with Part D (1/1/16-12/31/16)
The Services described below are covered only if all of the following conditions are satisfied:
• The Services are Medically Necessary and in accord with Medicare guidelines
• The Services are provided, prescribed, authorized, or directed by a Plan Physician and you receive
the Services from Plan Providers inside our Northern California Region Service Area, except where
specifically noted to the contrary in the Evidence of Coverage (EOC)
Accumulation Period
The Accumulation Period for this plan is 1/1/16 through 12/31/16 (calendar year).
-
Plan Out-of-Pocket Maximum
For Services subject to the maximum, you will not pay any more Cost Share for the rest of the calendar
year if the Copayments and Coinsurance you pay for those Services add up to one of the following
amounts:
For self-only enrollment (a Family of one Member) ...................... $1,500 per calendar year
For any one Member in a Family of two or more Members .......... $1,500 per calendar year
For an entire Family of two or more Members .............................. $3,000 per calendar year
Plan Deductible None
Professional Services Plan Provider office visits You Pa
Most Primary Care Visits for evaluations and treatment ................. $15 per visit
Most Specialty Care Visits for consultations, evaluations, and
treatment........................................................................................ $15 per visit
Annual Wellness visit and the "Welcome to Medicare" preventive
visit................................................................................................. No charge
Routine physical exams . .. . .. . . . . .. .. .. .. . . . . .. .. . . . .. . . . . . . . .. . .. .. .. . . . . .. .. . . . . .. . .. .. No charge
Routine eye exams with a Plan Optometrist ................................... $15 per visit
Hearing exams ................................................................................ $15 per visit
Urgent care consultations, evaluations, and treatment.. ................. $15 per visit
Physical, occupational, and speech therapy................................... $15 per visit
Outpatient Services You Pay
Outpatient surgery and certain other outpatient procedures........... $50 per procedure
Allergy injections (including allergy serum) ..................................... $3 per visit
Most immunizations (including the vaccine) .................................... No charge
Most X-rays, annual mammograms, and laboratory tests............... No charge
Manual manipulation of the spine................................................... $15 per visit
Hos italization Services You Pa
Room and board, surgery, anesthesia, X-rays, laboratory tests,
and drugs....................................................................................... No charge
Emergency Health Covera e You Pay
Emergency Department visits . .. .. .. .. .. . .. .. .. . .... .. .. .. .. .. .. .. .. .. .. .. . .. .. .. .. . .. $50 per visit
Ambulance Services You Pa
Ambulance Services . .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. . . .. .. .. .. . . .. ..... .. .. ...... .. .. .. .. .. . $1 00 per trip
Kaiser Foundation Health Plan, Inc., Northern California Region continues
continued
Prescription Drug Coverage You Pay
Covered outpatieni iiems in accord with our drug formulary
guidelines:
Most generic items ....................................................................... $5 for up to a 1 00-day supply
Most brand-name items ................................................................ $20 for up to a 100-day supply
Durable Medical Equipment (DME) You Pay
Covered durable medical equipment for home use ........................ 20 percent Coinsurance
Mental Health Services You Pay
Inpatient psychiatric care .... ........... ........ ............ ... ...... ......... ..... .. .... No charge
Individual outpatient mental health evaluation and treatment.. ....... $15 per visit
Group outpatient mental health treatment ...................................... $7 per visit
Chemical Dependency Services You Pay
Inpatient detoxification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . No charge
Individual outpatient chemical dependency evaluation and
treatment. ....................................................................................... $15 per visit
Group outpatient chemical dependency treatment......................... $5 per visit
------
Home Health Services _ You Pa}'
Home health care (part-time, intermittent) . ....... .... ..... ......... ..... ... .. .. No charge
-
Other You Pay
Eyeglasses or contact lenses every 24 months .............................. Amount in excess of $175 Allowance
Hearing aid(s) every 36 months ...................................................... Amount in excess of $1,000 Allowance
per aid
Skilled nursing facility care (up to 100 days per benefit period) ...... No charge
External prosthetic and orthotic devices ..... ...... ... ............ ............... 20 percent Coinsurance
Ostomy and urological supplies...................................................... 20 percent Coinsurance
This is a summary of the most frequently asked-about benefits. This chart does not explain benefits,
Cost Share, out-of-pocket maximums, exclusions, or limitations, nor does it list all benefits and Cost
Share amounts. For a complete explanation, please refer to the EOC. Please note that we provide all
benefits required by law (for example, diabetes testing supplies).
KAiser FoundAtion Health Plan. Inc .. Northern California Reaion 4196308. 8. 1. S000430720
604334 COUNTY OF FRESNO,
RETIREE
Summary of Benefits for
Kaiser Permanente Senior Advantage (HMO) with Part D (1/1/16-12/31/16)
The Services described below are covered only if all of the following conditions are satisfied:
• The Services are Medically Necessary and in accord with Medicare guidelines
• The Services are provided, prescribed, authorized, or directed by a Plan Physician and you receive
the Services from Plan Providers inside our Northern California Region Service Area, except where
specifically noted to the contrary in the Evidence of Coverage (EOC)
Accumulatmon Period
The Accumulation Period for this plan is 1/1/16 through 12/31/16 (calendar year).
Plan Out-of-Pocket Maximum
For Services subject to the maximum , you will not pay any more Cost Share for the rest of the calendar
year if the Copayments and Coinsurance you pay for those Services add up to one of the following
amounts:
For self-only enrollment (a Family of one Member) ...................... $1,500 per calendar year
For any one Member in a Family of two or more Members .......... $1,500 per calendar year
For an entire Family of two or more Members.............................. $3,000 per calendar year
Plan Deductible None
Professional Services Plan Provider office visits You Pay
Most Primary Care Visits for evaluations and treatment................. $15 per visit
Most Specialty Care Visits for consultations, evaluations, and
treatment........................................................................................ $15 per visit
Annual Wellness visit and the "Welcome to Medicare" preventive
visit ................................................................................................. No charge
Routine physical exams .. . .. .. .. .. .. .. .. .. .. .. .. . .. .. .. .. .. . .. .. .. .. .. .. .. .. .. .. .. .. . .. .. No charge
Routine eye exams with a Plan Optometrist................................... $15 per visit
Hearing exams ................................................................................ $15 per visit
Urgent care consultations, evaluations, and treatment................... $15 per visit
Physical, occupational, and speech therapy................................... $15 per visit
Outpatient Services You Pay
Outpatient surgery and certain other outpatient procedures........... $50 per procedUire
Allergy injections (including allergy serum) ..................................... $3 per visit
Most immunizations (including the vaccine) .................................... No charge
Most X-rays, annual mammograms, and laboratory tests ............... No charge
Manual manipulation of the spine . .. .. .... ................................ .......... $15 per visit
Hospitalization Services You Pa
Room and board, surgery, anesthesia, X-rays, laboratory tests,
and drugs ....................................................................................... No charge
Emergency Health Coverage You Pay
Emergency Department visits .. . . .. .. .. .. .. .. .. .. .. .. .. . .. . .. .. . .. .... .. .. .. .. .. .. .. .. $50 per visit
Ambulance Services You Pa
Ambulance Services ....................................................................... $100 p er trip
Kaiser Foundation Health Plan, Inc., Northern California Region continues
continued
Prescription Dru Coverage You Pa
Covered outpatient items in accord with our drug formulary
guidelines:
Most generic items at a Plan Pharmacy ....................................... $10 for up to a 30-day supply, $20 for
a 31-to 60-day supply, or $30 for a
61-to 1 00-day supply
Most generic refills through our mail-order service ....................... $10 for up to a 30-day supply or $20
for a 31-to 100-day supply
Most brand-name items at a Plan Pharmacy ................................ $25 for up to a 30-day supply, $50 for
a 31-to 60-day supply, or $75 for a
61-to 1 00-day supply
Most brand-name refills through our mail-order service . ........ ...... $25 for up to a 30-day supply or $50
for a 31-to 100-day supply
Dura ble Medical Equipment DME You Pay
Covered durable medical equipment for home use ........................ 20 percent Coinsurance
Men tal Health Services You Pay
Inpatient psychiatric care ................................................................ No charge
Individual outpatient mental health evaluation and treatment......... $15 per visit
Group outpatient mental health treatment ... . . . . ....... .......... ...... ... .... . $7 per visit
-----
Chemical Depenoencv Services You Pa~1
Inpatient detoxification . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . No charge
Individual outpatient chemical dependency evaluation and
treatment........................................................................................ $15 per visit
Group outpatient chemical dependency treatment......................... $5 per visit
-------------------
Home Health Services You Pa\~ _ _
Home health care (part-time, intermittent) ................. .......... ..... .... .. No charge
-
Other You Pay
Eyeglasses or contact lenses every 24 months .............................. Amount in excess of $175 Allowance
Hearing aid(s) every 36 months ...................................................... Amount in excess of $1,000 Allowance
per aid
Skilled nursing facility care (up to 100 days per benefit period) ...... No charge
External prosthetic and orthotic devices ......................................... 20 percent Coinsurance
Ostomy and urological supplies ...................................................... 20 percent Coinsurance
This is a summary of the most frequently asked-about benefits. This chart does not explain benefits,
Cost Share, out-of-pocket maximums, exclusions, or limitations, nor does it list all benefits and Cost
Share amounts. For a complete explanation, please refer to the EOC. Please note that we provide all
benefits required by law (for example, diabetes testing supplies).
Kaiser Foundation Health Plan, Inc., Northern California Region 4196308.8. 2.$000430721
Disclosure Form
580 SJVIA-CO OF FRESNO (SAN JOAQUIN VALLEY IN
Principal benefits for
Kaiser Permanente Traditional Plan (1/1/1 5-12/31/16)
The Services described below are covered only if all of the following conditions are satisfied:
• The Services are Medically Necessary
• The Services are provided, prescribed, authorized, or directed by a Plan Physician and you receive the Services from Plan
Providers inside our Northern California Region Service Area (your Home Region), except where specifically noted to the contrary
in the Evidence of Coverage (EOC) for authorized referrals, hospice care, Emergency Services, Post-Stabilization Care, Out-of-
Area Urgent Care, and emergency ambulance Services
Accumulation Period
The Accumulation Period for this plan is 1/1/16 through 12/31116 (calendar year).
Plan Out-of.Pocket Maximum
For Services subject to the maximum, you will not pay any more Cost Share for the rest of the calendar year if the Copayments and
Coinsurance you pay for those Services add up to one of the following amounts:
For self-only enrollment (a Family of one Member)................................................ $1,500 per calendar year
For any one Member in a Family of two or more Members.................................... $1,500 per calendar year
For an entire Family of two or more Members ....................................................... $3,000 per calendar year
Plan Deductible None
Professional Services (Plan Provider office visits) You Pay
Most Primary Care Visits and most Non-Physician Specialty Visits.......................... $15 per visit
Most Physician Specialist Visits ................................................................................ $15 per visit
Routine physical maintenance exams, including well-woman exams .................... ... No charge
Well-child preventive exams (through age 23 months)............................................. No charge
Family planning counseling and consultations .......................................................... No charge
Scheduled prenatal care exams ................................................................................ No charge
Routine eye exams with a Plan Optometrist.............................................................. No charge
Hearing exams ..................... ..•.•.... .......... ........ ..... .•..•. ..................... ...... .. ............... .. . No charge
Urgent care consultations, evaluations, and treatment ............................................. $15 per visit
Most physical, occupational, and speech therapy ..................................................... $15 per visit
Outpatient Services You Pay
Outpatient surgery and certain other outpatient procedures ..................................... $15 per procedure
Allergy injections (including allergy serum)............................................................... $3 per visit
Most immunizations (including the va ccine) .............................................................. No charge
Most X-rays and laboratory tests............................................................................... No charge
Covered individual health education counseling ....................................................... No charge
Covered health education programs ......................................................................... No charge
Hospitalization Services You Pay
Room and board, surgery, anesthesia, X-rays, laboratory tests, and drugs ............. No charge
Emergency Health Coverage You Pay
Emergency Department visits ................................................................................... $100 per visit
Note: This Cost Share does not apply if admitted directl y to the hospital as an inpatient for covered Services (see •Hospitalization
Services• for inpatient Cost Share).
Ambulance Services You Pay
Ambulance Services.................................................................................................. $50 per trip
Prescription Drug Coverage You Pay
Covered outpatient items in accord with our drug formulary guidelines:
Most generic items at a Plan Pharmacy ................................................................. $10 for up to a 3~ay supply
Most generic refills through our mail-order service ........ .......... .... .......................... $20 for up to a 1 00-day supply
Most brand-name items at a Plan Pharmacy ......................................................... $20 for up to a 30-day supply
Most brand-name refills through our mail-order service ......................................... $40 for up to a 100-day supply
Durable Medical Equipment (DME) You Pay
DME items in accord with our DME formulary guidelines .......................................... 20% Coinsurance
Mental Health Services You Pay
Inpatient psychiatric hospitalization........................................................................... No charge
(continues)
Disclosure Form (continued)
Individual outpatient mental health evaluation and treatment ................................... $15 per visit
Group outpatient mental health treatment................................................................. $7 per visit
Chemical Dependency Services You Pay
Inpatient detoxification ............................................................................................... No charge
Individual outpatient chemical dependency evaluation and treatment.. .................... $15 per visit
Group outpatient chemical dependency treatment.................................................... $5 per visit
Home Health Services You Pay
Home health care (up to 100 visits per calendar year) .............................................. No charge
Other You Pay
Eyeglasses or contact lenses every 24 months ........................................................ Amount in excess of $175 Allowance
Hearing aid(s) every 36 months ................................................................................ Amount in excess of $1,000 Allowance per aid
Skilled nursing facility care (up to 100 days per benefit period)................................ No charge
Prosthetic and orthotic devices ............ .......................... ........ ...... .. ........................... No charge
Hospice care . ........ ..... .. ............. ... .... .. ...... .. .... .. .. .. .... ...... . ...... ...... ...... .. ... ... .......... ... . .. No charge
This is a summary of the most frequently asked-about benefits. This chart does not explain benefits, Cost Share, out-of-pocket
maximums, exclusions, or limitations, nor does it list all benefits and Cost Share amounts. For a complete explanation, please refer to
the EOC. Please note that we provide all benefits required by law (for example, diabetes testing supplies).
8974.42.1.5000436049
YOUR KAISER PERMANENTE
CHIROPRACTIC BENEFIT
Kaiser Foundation Health Plan, Inc., contracts with American Specialty Health Plans of California, Inc. (ASH Plans), to make the
ASH Plans network of Participating Chiropractors available to you. When you need chiropractic care, you have direct access to
more than 3,100 licensed chiropractors in California. Just follow these simple steps:
1. Find an ASH Plans Participating Chiropractor near you.
• Call1-800-678-9133 (TTY users call 711 ), weekdays from 5 a.m. to 6 p.m. (Pacific time)
2. Schedule an appointment.
3. Pay for your office visit when you arrive for your appointment.
Services
Chiropractic Services are covered
when a Participating Chiropractor
finds that the services are medically
necessary to treat or diagnose
Neuromusculoskeletal Disorders. You
can obtain services from any ASH Plans
Participating Chiropractor without a
referral from a Plan physician.
Cost Sharing and Office Visit Maximums
Office visit cost share: $10 copay per visit
Office visit limit: 30 visits per year
Chiropractic appliance benefit: If the amount of the appliance in the ASH Plans fee
schedule exceeds $50, you will pay the amount in excess of $50, and that payment will not
apply toward any applicable deductible or out-of-pocket maximum.
Covered chiropractic appliances are limited to: elbow supports, back supports, cervical
collars, cervical pillows, heel lifts, hot or cold packs, lumbar braces and supports, lumbar
cushions, orthotics, wrist supports, rib belts, home traction units, ankle braces, knee
braces, rib supports, and wrist braces.
Office visits: Each office visit counts toward the year visit limit even if an adjustment is not provided during the visit.
X-rays and laboratory tests: Medically necessary X-rays and laboratory tests are covered at no charge when prescribed as part of
covered chiropractic care when a Participating Chiropractor provides the Services or refers you to a Participating Provider for the Services.
Participating Chiropractors
ASH Plans contracts with Participating Chiropractors and other Participating Providers to provide covered Chiropractic Services,
including laboratory tests, X-rays, and chiropractic appliances. You must receive covered services from a Participating Provider,
except for Emergency Chiropractic Services, Urgent Chiropractic Services, and services that are not available from Participating
Providers that are authorized in advance by ASH Plans. The list of Participating Chiropractors is available from the ASH Plans Member
Services Department toll free at 1-800-678-9133 (TTY users call 711), weekdays from 5 a.m. to 6 p.m. The list of Participating
Chiropractors is subject to change at any time without notice.
How to obtain services: To obtain covered services, call a Participating Chiropractor to schedule an initial examination. If additional
services are required, verification that the Services are Medically Necessary may be required. An ASH Plans clinician in the same or
similar specialty as the provider of Chiropractic Services under review will decide whether the Chiropractic Services are Medically
Necessary Services. ASH Plans will disclose to you, upon request, the process that it uses to authorize a Treatment Plan. For more
information about how to obtain covered Chiropractic Services, please refer to the Chiropractic Services Amendment of your Health
Plan Evidence of Coverage.
CHIRO 142 NCAL_453 SCAL (8-14)
• J lA
San Joaquin Valley
Insurance Authority
Prescription Drug Copays
usscript.
30 Day Supply:
Generic $10
Formulary $20
Non-Formulary $35
DAW 1-No Cost Differential
DAW 2-Non-Formulary+ Cost Difference
90 Day Supply:
Generic $20
Formulary $40
Non-Formulary $60
DAW 1-No Cost Differential
DAW 2-Non-Formulary+ Cost Difference
Annual Out-of-Pocket Maximum
Individual $2,000
Family $4,000
Exclusions
Hair Treatments
Pigmenting/Depigmenting
Anti-wrinkle
Fluoride Preps
Misc. Medical Supplies
OTC Medications
Miscellaneous lnjectables
Toradol (excluded at mail)
Zyvox (excluded at mail)
Mail
Generic $20
Formulary $40
Non-Formulary $60
DAW 1-No Cost Differential
DAW 2-Non-Formulary+ Cost Difference
Specialty Medication Copay:
30% ($100.00 max.)
** Specialty medications are covered at a 30-day
Supply only.**
This is not a complete summary of benefits. Additional limitations and exclusions may apply.
Effective Jauary 1, 2016
Plan Benefit H i ghlights for: County of Fresno
Group No: 05879
.E.Iigib-iJlty ---... ~--~
.!"-----~---_----~--
Deductibles
Deductibles waived for D & P?
Maximums
D & P counts toward maximum ?
Waiting Period(s)
f BenefitS.and -~ ~1
~Cgvereg_. Services :~ .II
Diagnostic & Prev entive
Services (D & P)
Fillings, simple tooth extractions and
sealants
Endodontics (root canals}
Covered Under Ma·o r Serv ices
Periodontics (gum treatment)
Cov ered Under Ma·o r Services
Oral Surgery
Covered Under Ma"or Services
Major Services
Crowns, inlays, onlays and cast
restorations
Prosthodonti cs
Brid es, dentures and im !ants
Orthodontic Benefits
Adults and de endent children
Orthodontic Maximum
Adults (age 20 and over}
Child(re n) (th roug h age 19)
One Ort hod ontic treatment per
lifetime
Maximum of 24 months of active
orthodontic treatment
Primary enrollee, spouse (includes domestic partner} and eligible dependent
children to the end of the month dependent turns age 26
$50 per person I $150 per family each calendar year
PPO-Dentists: Yes
Non-PPO Dentists: No
$2,500 per person each calendar year
No
Basic Benefits
None
Major Benefits
None
Delta Dental PPO
dentists**
100%
90%
50%
50%
50%
50%
50%
100%
After co-payment
$ 1,880 per case
$ 1,660 per case
Orthodontics
None
Prosthodontics
None
Non-Delta Dental PPO
dentists**
90%
90%
50%
50%
50%
50%
50%
100%
After co-payment
$ 1,880 per case
$ 1,660 per case
* Limitations or waiting periods may apply for some benefits; some services may be excluded from your plan.
Reimbursement is based on Delta Dental maximum contract allowances and not necessarily each dentist's submitted fees.
** Reimbursement is based on PPO contracted fees for PPO dentists, Premier contracted fees for Premier dentists and
program allowance for non-Delta Dental dentists.
Delta Denta l of Cal ifo rn ia
1 00 First St.
San F ra n cisco, CA 94 1 05
Customer Service
800-765-6 00 3
deltadentalins.com
Claims Address
P.O. Box 9 9733 0
S acramento, CA 95899-7330
This benefit inform atio n is not int ended or designed to replace or serve as the plan's Evidence of Coverage or Summary Plan
Descri ption. If you have specific questions regardi ng the benefits, limitations or exclusions for your plan, please consult your
company's benefits representative. HLT_PP0_2COL_o oc (Rev.OB/052014)
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Plan CA42N DeltaCare USA Description of Benefits and Copayments
SCHEDULE A
Description of Benefits and Copayments
The Benefits shown below are performed as deemed appropriate by the attending Contract Dentist subject to the limitations and
exdusions of the Program. Please refer to Schedule B for further clalification of Benefits. Enrollees should discuss all treatment
options with their Contract Dentist prior to services being rendered.
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-2015 procedure codes, descriptors or nomenclature that are under copyright by the
American Dental Association. The American Dental Association may periodically change COT codes or definitions. Such
updated codes, descriptors and nomenclature may be used to describe these covered procedures in compliance with federal
legislation.
CODE DESCRIPTION
00100-00999 I. DIAGNOSTIC
ENROLLEE
eAYS.
00120 Periodic oral evaluation-established patient .................................................................................... No Cost
00140 limited oral evaluation -problem focused ........................................................................................ No Cost
00145 Oral evaluation for a patient under three years of age and counseling with primary caregiver ......................... No Cost
00150 Comprehensive oral evaluation -new or established patient ................................................................. No Cost
00160 Detailed and extensive oral evaluation-problem focused, by report ....................................................... No Cost
00170 Re-evaluation -limited, problem focused (established patient; not post-operative visit) ................................. No Cost
00171 Re-evaluation -post-operative office visit ......................................................................................... No Cost
00180 Comprehensive periodontal evaluation -new or established patient ........................................................ No Cost
00190 Screening of a patient ................................................................................................................ No Cost
00191 Assessment of a patient .............................................................................................................. No Cost
00210 Intraoral-complete series of radiographic images -limited to 1 series evety 24 months ............................... No Cost
00220 Intraoral -periapical first radiographic image .. .. .. .. .. .. .. .. . .. . • .. .. . .. .. .. . . . . .. .. .. • .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. • . . .. .. No Cost
00230 Intraoral -periapical each additional radiographic image ...................................................................... No Cost
00240 Intraoral -occlusal radiographic image ............................................................................................ No Cost
00250 Extraoral -first radiographic image .. .. .. .. . . . .. . . .. .. .. .. . .. .. . .. .. .. . .. .. . .. . .. .. .. .. .. .. . .. .. .. .. .. .. .. .. .. . .. .. .. . .. .. .. .. .. . .. No Cost
00260 Extra oral -each additional radiographic image .................................................................................. No Cost
00270 Bitewing -single radiographic image .. .. .. .. . .. . .. .. .. .. .. . .. . . .. .. .. .. .. • .. . .. .. . . .. .. .. .. .. . .. .. .. .. • .. .. • .. .. .. .. .. . .. .. .. .. .. . No Cost
00272 Bitewings -two radiographic images .. .. . .. .. . .. .. .. .. .. .. .. .. .. .. .. .. . .. .. .. .. .. .. .. .. • .. .. .. .. .. .. . .. .. .. . .. .. .. .. .. .. .. .. .. .. .. No Cost
00273 Bitewings three radiographic images .. .. . . . .. .. . . .. . . .. . .. . . .. . . .. .. . . . .. .. . . .. .. . . . . . .. .. . . . . .. . . . . .. . .. . . . . . .. .. . .. .. . . .. . . . .. . . No Cost
00274 Bitewings-four radiographic images-limited to 1 series evety 6 months ................................................. No Cost
00277 Vertical bitewings -7 to 8 radiographic images .. .. .. .. .. .. .. .. .. .. .. .. .. .. . .. .. . .. .. .. .. . .. .. .. .. . .. .. .. .. .. .. .. .... .. .. .. .. .. • No Cost
00330 Panoramic radiographic image ...................................................................................................... No Cost
00415 Collection of microorganisms for culture and sensitivity . .. . .. .. .. .. .. .. . .. .. . .. .. .. .. .. .. .. . .. .. . .. .. .. .. .. .. .. .. . .. .. .. • .. • .. No Cost
00425 Caries susceptibility tests . . . . . . . .. . . . . . . .. . . . . ... .. . .. . .. .. . .. .. . . . . . .. . . . . .. .. . . . . .. . . . . . .. . . . . . .. .. . .. .. . . . . . .. . . . .. .. .. . . . .. . . . .. . . No Cost
00460 Pulp vitality tests ....................................................................................................................... No Cost
00470 Diagnostic casts ........................................................................................................................ No Cost
00472 Accession of tissue, gross examination, preparation and transmission of written report-available only when
performed in conjunction with a covered biopsy .. .. . .. . .. .. .. .. .. .. .. .. . .. .. .. .. .. • .. .. .. . .. . .. . .. .. .. .. .. .. . .. . .. .. • .. .. .. .. .. No Cost
004 73 Accession of tissue, gross and microscopic examination, preparation and transmission of written report -
available only when performed in conjunction with a covered biopsy ....................................................... No Cost
00474 Accession of tissue, gross and microscopic examination, including assessment of surgical margins for presence
of disease, preparation and transmission of written report-available only when performed in conjunction with a
covered biopsy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . • . . . . . . . . . . . . . . . • . • • • . . . . . . . . . . . . . . • . • . . . . • • . No Cost
00601 Caries risk assessment and documentation, with a finding of low risk-limited to children age 3 to 19, 1 evety 3
years •.•...........•....•.................................................................................................................. No Cost
00602 Caries risk assessment and documentation, with a finding of moderate risk-limited to children age 3 to 19, 1
evety 3 years ........................................................................................................................... No Cost
00603 Caries risk assessment and documentation, with a finding of high risk-limited to children age 3 to 19, 1 evety
3 years . .. .. . .. . . .. .. .. . .. .. . .. . . . . . . .. . .. .. . . .. . . .. . . . . . . .. .. . .. . .. .. .. . . . . . . . .. . . . . . .. . . .. . . .. . . . . . . .. . . . .. .. . . . .. . . . . . . .. .. . .. .. .. .. .. . No Cost
00999 Unspecified diagnostic procedure, by report-includes office visit, per visit (in addition to other services) ........... No Cost
01000-01999 II. PREVENTIVE
01110 Prophylaxis cleaning-adult-1 per 6 month period ............................................................................ No Cost
01110 Additional prophylaxis cleaning-adult (within the 6 month period) .......................................................... $45.00
-
Plan CA42N DeltaCare USA Description of Benefits and Copayments
01120 Prophylaxis cleaning-child-1 per 6 month period .....................................................................•...... No Cost
01120 Additional prophylaxis cleaning -child (within the 6 month period) . . . . . .. . . . . . ..••.. .. .. . . . ... . . . . .. . . . .. . .. .....•... ••. .••. $35.00
01206 Topical application of fluoride varnish-101206 or01208 per6 month period ........................................... No Cost
01208 Topical application of fluoride-excluding varnish-1 01206 or 01208 per 6 month period ............................. No Cost
01310 Nutritional counseling for control of dental disease ............••.••...•...........•••.............•.....••...........•••.....•. No Cost
01320 Tobacco counseling for the control and prevention of oral disease •.........•.••••.....•...........••••.•........••...•..••. No Cost
01330 Oral hygiene instructions .....................................................•.......•.................•...••.••••.......•.........•. No Cost
01351 Sealant-per tooth-limited to permanent molars through age 15 .......................................................... No Cost
01352 Preventive resin restoration in a moderate to high caries risk patient-permanent tooth -limited to permanent
molars through age 15 ..........•.•••...•.......•...................••......••.........•..•...............•.....•.•........••••.....•. No Cost
01353 Sealant repair-per tooth -limited to permanent molars through age 15 ................................................... No Cost
01510 Space maintainer-fixed-unilateral .........................................................•.........•....•...................... No Cost
01515 Space maintainer-fixed-bilateral .........................................................................•................•...... No Cost
01520 Space maintainer -removable -unilateral ......•...•...................................•......................................... No Cost
01525 Space maintainer -removable -bilateral . . . . . . . . . . . . • • . . . . . . . . . . . . • . • . . • . • . . . • . . . . . . • . . • . . . • . . . . . . . . • . . . . . • . . • . . . . . . . . • • . . . . . . • . . No Cost
01550 Re-cement or re-bond space maintainer .......•.•..............•••......•.........•..•...•................••...........•••.•.•••. No Cost
01555 Removal of fixed space maintainer .................•....................................•.•.••.......•......•••.........•..••••... No Cost
02000-02999 Ill. RESTORATIVE
-Includes polishing, all adhesives and bonding agents, indirect pulp capping, bases, liners and acid etch procedures.
-When there are more than six crowns in the same treatment plan, an Enrollee may be charged an additional $125.00 per crown, beyond
the 6th unit.
-Replacement of crowns, inlays and on/ays requires the existing restoration to be 5+ years old.
* Name brand, laboratory processed or in-office processed crownslpontics produced through specialized technique or materials are
material upgrades. The Contract Dentist may charge an additional fee not to exceed $325.00 in addition to the listed Copayment. Refer to
Umitation of Benefits #4 for additional infonnation.
02140 Amalgam-one surface, primary or permanent .•.•••..................••.........•...•...•.•...........••••.........•.•••....••. No Cost
02150 Amalgam -two surfaces, primary or permanent . . • • • • . . . . . . . . . . . . . • . . •• • . . . . . . . . . . . . • • . • . . . . . . . . . . . . . . . • . . . . . . . . . . . . . . • • . . . . . • • No Cost
02160 Amalgam-three surfaces, primary or permanent .............................................................................. No Cost
02161 Amalgam-four or more surfaces, primary or permanent ..................................................................... No Cost
02330 Resin-based composite -one surface, anterior •...............•••...••.•............•........................................... No Cost
02331 Resin-based composite-two surfaces, anterior ..................•••.•.•.............•..••.............•.•..........•.••......•. No Cost
02332 Resin-based composite -three surfaces, anterior ............................................................................... No Cost
02335 Resin-based composite -four or more surfaces or involving incisal angle {anterior) ..................................... No Cost
02390 Resin-based composite crown, anterior ........................................................................................... No Cost
02391 Resin-based composite -one surface, posterior .. . . . . . . .. . ..... .• . •. .. .• . . .. . . . . . . . . • .. . . . ... . . . . .•. . . . . . . . . . . . . . .. . . . . . . . . . . . . $25.00
02392 Resin-based composite -two surfaces, posterior . . . . . . . . . . . . . • • . . . . . . •• . . . . . . . . . . . . . • . . . . . . . . . . . . . • • . • . . . . • • . . . . . . . . . . • . • • • . • • . $30.00
02393 Resin-based composite-three surfaces, posterior ..............•................•................ :............................ $35.00
02394 Resin-based composite -four or more surfaces, posterior . . . . . . • . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . • . .• .•. .. . . . . . . . . ••. •• . . .•. $40.00
0251 0 Inlay -metallic -one surface ...•.................................................................................................... No Cost
02520 Inlay -metallic -two surfaces .••••...••...........••..............•••..................•...............••......•.................... No Cost
02530 Inlay -metallic -three or more surfaces ............................................•..•...•...............••.............••....•. No Cost
02542 On lay -metallic -two surfaces ......•.•........•...•...•.................•..............•..................................•••..•••. No Cost
02543 On lay -metallic -three surfaces . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . • . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . • . . • • . • . . • • No Cost
02544 On lay -metallic -four or more surfaces . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . • . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . No Cost
02610 Inlay-porcelain/ceramic-one surface* ............•.•..............................•••...•....•....•.....••..•.................. $50.00
02620 Inlay -porcelain/ceramic -two surfaces* . . . . • • . . . . . . . . • . . . . . . . . . • . . . . . . . . • . . . . .. . . . . . • . . . . . . . . . . . . . . . . . . . . . • . . • . . . . . . . • . • • • . . . . • • $60.00
02630 Inlay -porcelain/ceramic -three or more surfaces* . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . • . . . • • . . . . . . . • . . . . . . • . . . . . . . . . . . • . • . . . • • . • . $65.00
02642 On lay -porcelain/ceramic -two surfaces* . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . • . . . . • • $55.00
02643 On lay -porcelain/ceramic -three surfaces* . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . • . . . . . . . . . . . . . . . . . . . . . . . • . . $65.00
02644 Onlay -porcelain/ceramic -four or more surfaces* • .. ...... .. . •. . . . .•..... ... . . . . .• . . •. . . . . . .. . . . . .. . . . . .•. . . . . . . . . . . . . . . . . . . . . $70.00
02650 Inlay-resin-based composite-one surface •.....•.............•......••.........•..•.•..•..............•••••.........••••....•• $15.00
02651 Inlay -resin-based composite -two surfaces . . •.. . . .. . . ...... .•.•... .•. . . ..... .. . . . . . . . . . . ... . . . . . . . . .. . . •. .• . .... .. . ••. •.•.. .•• $20.00
02652 Inlay -resin-based composite -three or more surfaces . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . •. . . . . .. . . $30.00
02662 Onlay -resin-based composite -two surfaces . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . • . . . . . . . . . . . . . . . . . . . . . • . . . . . . . . . . . . . . . . . . . $25.00
02663 On lay -resin-based composite -three surfaces • • . • . . . . . . . . . . . • . • • . • • • • • • . . . . . . . • • • . . . • . • • • . . . . . . . • • • • . . . . . • . • • . . . . . . . . • . • . . . . . . $35.00
02664 Onlay -resin-based composite -four or more surfaces .. ... . .•. . . .•.••. .. . . . .. . . . • .• . . . . .. . . . ...•.... •••...... ... . • .•• . . . .. . . $50.00
02710 Crown -resin-based composite {indirect) ......•...•..............•.....••........•....•............••.......•........•.•••.•••.•. No Cost
02712 Crow n -% resin-based compos ite {indirect) ·--·-"·-····-··-··································-······--··-·······-···-···········No Cost
Plan CA42N DeltaCare USA Description of Benefits and Copayments
02720 Crown -resin with high noble metal . . . . . . . . . . • . • . . . • . • . . . • . .. . . .. . • . • . • . . . . • . . . . . . . . . • • . • . . . . . . . . . . . • . . • • . • • • . . . . . . .. . . • . . . . • • . .. • $30.00
02721 Crown-resin with predominantly base metal ....................................•.•...•............••.••..•.........•.•••..•••.• $15.00
02722 Crown -resin with noble metal . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . $20.00
02740 Crown-porcelain/ceramic substrate* •............•.•.............................................................................. $85.00
02750 Crown -porcelain fused to high noble metal* . ..• .. .. . .. . .. .. . .•. . . . . . .•. . . ... .. . . . . . .. . • .•..... ... . . ••. ••••... ....... ••. .•. .••• $70.00
02751 Crown-porcelain fused to predominantly base metal ..........•..................•••...•........••.•...•••...........•..••... $55.00
02752 Crown -porcelain fused to noble metal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . • . . . . . . . . . .. . . . . •. .. . .. . . . .•• . . . • .. . . . .. . . . .•• . • ••. .. ••.. $60.00
02780 Crown -% cast high noble metal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . • . • . . . . . . . . . . . . . . . . . . . . . . . . •. $70.00
02781 Crown-% cast predominantly base metal ..•....••............•.....•.•.............................•........................... $55.00
02782 Crown -% cast noble metal . . •. . . . . . . .•..... .. .. • . . .•. .. . ..• .. .. . .. . .•. . ••.•... ......... .• . . . . . . ... . •.. • . . . •••....... ... • . •. .•.•• ... $60.00
02783 Crown -% porcelain/ceramic* • . • • . . . . . . . . . . . . . . • . . • • . • . • . . . . . . . . . . . • • • . . . • . . . . . . . . . . . . . . • • • . . • . . . . . . . . • . • . . . • . • . • . . . . . . . . . • • •• • . • . • . $70.00
02790 Crown -full cast high noble metal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . • . . . . . . . . . . • • . . . . . . . . . . . . . . • . • . • • . • • • . $70.00
02791 Crown -full cast predominantly base metal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $55.00
02792 Crown -full cast noble metal • .•••.. .. . .. . . .. ... . . . . ..•.. •....... .. .• .. . . . . .•... ....•• •. . . . . •. . . . . . . . . . .. . . . . . . . . . . . . . .. . . . . . • . . . . .. . $60.00
02794 Crown -titanium . . . . • • . . . . . . . . . . . . . • • . . • . • • . . . . . . . . • • . . • . . . . . . . . . . . . . . . . • . . • • . . . . . . . . . . . . . • • . . . • . . . . . . . . . . • . . . • . . . . . . . . . . .. . . • . • • . . . . • . . $70.00
02910 Re-cement or re-bond inlay, onlay, veneer or partial coverage restoration ................................................. No Cost
02915 Re-cement or re-bond indirectly fabricated or prefabricated post and core ................................................ No Cost
02920 Re-cement or re-bond crown ........................................................................................................ No Cost
02921 Reattachment of tooth fragment, incisal edge or cusp (anterior) ............................................................. No Cost
02929 Prefabricated porcelain/ceramic crown -primary tooth -anterior . . . • . . . . . . . . . . . . . . . • . . . . . . . . . . . . • • . . . . . • • • .. . . . . . • . • . . • • . . • • No Cost
02930 Prefabricated stainless steel crown -primary tooth ............................................................................. No Cost
02931 Prefabricated stainless steel crown -permanent tooth ......................................................................... No Cost
02932 Prefabricated resin crown -anterior primary tooth .............................................................................. No Cost
02933 Prefabricated stainless steel crown with resin window -anterior primary tooth . . . . . . . . . . . . . . . . . . . . . . • .. . . . . . .. . . . . . . . . .. . No Cost
02940 Protective restoration .........•......•...•........•....•.•••..............•..•............•....•..........•.•...•............•••....... No Cost
02941 Interim therapeutic restoration -primary dentition •...................••.............•.•...........••••..............•.••.•...•.. No Cost
02949 Restorative foundation for an indirect restoration . .. . . .. .. . .. . . . . . . . . . . . . . .. . .. . . . . • . . . . . . . . . . .. . .. . . . . • . • . . . . . . . . . .. . • . . • . . . . . . No Cost
02950 Core buildup, including any pins when required ................................................................................. No Cost
02951 Pin retention-per tooth, in addition to restoration .............................................................................. No Cost
02952 Post and core in addition to crown, indirectly fabricated -includes canal prepamtion . . .. .. • . . . . • • • • . . . .. .. . . . •• • • . . • • • . No Cost
02953 Each additional indirectly fabricated post -same tooth -includes canal prepamtion ........••.•.....•.......••.•......•. No Cost
02954 Prefabricated post and core in addition to crown -base metal post; includes canal prepamtion ....................... No Cost
02955 Post removal ............................................................................................................................ No Cost
02957 Each additional prefabricated post -same tooth -base metal post; includes canal prepamtion . • . . . .. . . . . . • . . . • . . . . . . No Cost
02960 Labial veneer (resin laminate) -chairside-limited to replacement of significant tooth structure loss due to caries
or fracture ................................................................................................................................ $245.00
02961 Labial veneer (resin laminate) -laboratory-limited to replacement of significant tooth structure loss due to caries
or fracture ................................................................................................................................ $295.00
02962 Labial veneer (porcelain laminate) -laboratory -limited to replacement of significant tooth structure loss due to
caries or fmcture ....................................................................................................................... $345.00
02970 Temporary crown (fractured tooth) -palliative treatment only ................................................................. No Cost
02971 Additional procedures to construct new crown under existing partial denture framework . . . . . . .••............. .•. ...... $14.00
02980 Crown repair necessitated by restorative material failure ...................................................................... No Cost
02981 Inlay repair necessitated by restorative material failure ........................................................................ No Cost
02982 Onlay repair necessitated by restorative material failure .. . . . . • . . • . . . . . . . . . . .. . • • • • • . • . • . . . . . . . . . . . • • • . • • • • . . . • . . . . • . •• • • . . • . . No Cost
02983 Veneer repair necessitated by restorative material failure ..................................................................... No Cost
02990 Resin infiltration of incipient smooth surface lesions -limited to permanent molars through age 15 ................... No Cost
D3000-D3999 IV. ENDODONTICS
03110 Pulp cap-direct (excluding final restoration) .................................................................................... No Cost
03120 Pulp cap-indirect (excluding final restoration) .................................................................................. No Cost
03220 Therapeutic pulpotomy (excluding final restoration)-removal of pulp coronal to the dentinocemental junction and
application of medicament . . . .. . . . . . . . . . .. . . .. . . . . .. . • . . . . . . . . .. . . .. . . . . . . . . . . . .. . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . • . . . . No Cost
03221 Pulpal debridement, primary and permanent teeth ............................................................................. No Cost
03222 Partial pulpotomy for apexogenesis -permanent tooth with incomplete root development .............................. No Cost
03230 Pulpal therapy (resorbable filling) -anterior, primary tooth (excluding final restoration) .........••.•............•....•... No Cost
03240 Pulpal therapy (resorbable filling) -posterior, primary tooth (excluding final restoration) ................................ No Cost
-----------
--
Plan CA42N DeltaCare USA Description of Benefits and Copayments
03310 Root canal-endodontic therapy, anterior tooth (excluding final restoration) ••.•.•.•..........•....•••••........•••••..•.•. $20.00
03320 Root canal-endodontic therapy, bicuspid tooth (excluding final restoration) ..••.•...••••.....••.....•........•...•...•••. $40.00
03330 Root canal-endodontic therapy, molar (excluding final restoration) . . . . . . . . . .. . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. .. . $60.00
03331 Treatment of root canal obstruction; non-surgical access . . . . . .. . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $40.00
03332 Incomplete endodontic therapy; inoperable, unrestorable or fractured tooth . . ••. . . . ........ .•.••... •.•... ... . . • . •••. •. . . •. $40.00
03333 Internal root repair of perforation defects . . . . . • • . • . . . . . . . .. . . . . . • • . . . . . . . •• . . . . . . . • . • . • • • . . . . . . . . . . . . . . . • • . . . • . . . . . . . . . . • • . • . • . • • . $40.00
03346 Retreatment of previous root canal therapy -anterior . .. . . . . . . . . . . . . . . . . . . . . . . . . . .•• . . . . . . . . . . . ... . ..• . . ..• . . . .. . .. . . .• . . .. •••. $35.00
03347 Retreatment of previous root canal therapy-bicuspid ......................................................................... $50.00
03348 Retreatment of previous root canal therapy -molar •. ... ...... .•..• ............................................................ $95.00
03351 Apexification/recalcification-initial visit (apical closure/calcific repair of perforations, root resorption, etc.) .••••..... $55.00
03352 Apexification/recalcification -interim medication replacement (apical closure/calcific repair of perforations, root
resorption, pulp space disinfection, etc.) .. .. .. . .. .. .. .. .. .. .. .. .. . .. . .. .. .. .. .. .. .. .. .... .. .. .. ... ... .... . .......... .... •• .... ••.. $45.00
03353 Apexification/recalcification -final visit (includes completed root canal therapy -apical closure/calcific repair of
perforations, root resorption, etc.) .................................................................................................. $45.00
03410 Apicoectomy -anterior ................................................................................................................ No Cost
03421 Apicoectomy-bicuspid (first root) .................................................................................................. No Cost
03425 Apicoectomy -molar (first root) ..................................................................................................... No Cost
03426 Apicoectomy (each additional root) . . .. .. . . .. . . . . . .. . . . .. . . .. . . . . .. .. . .. .. . . . .. .. . .. . . . .. . . . . .. .. .. .. .. . . .. . . . . .. . . . .. . . . . .. .. . .. . . No Cost
03427 Periradicular surgery without apicoectomy ........................................................................................ No Cost
03430 Retrograde filling -per root .......................................................................................................... No Cost
03450 Root amputation -per root ........................................................................................................... No Cost
03920 Hemisection (including any root removal), not including root canal therapy ............................................... No Cost
04000-04999 V. PERIODONTICS
-Includes preoperative and postoperative evaluations and treatment under a local anesthetic.
04210 Gingivectomy or gingivoplasty-four or more contiguous teeth or tooth bounded spaces per quadrant .............. No Cost
04211 Gingivectomy or gingivoplasty-one to three contiguous teeth or tooth bounded spaces per quadrant ............... No Cost
04212 Gingivectomy or gingivoplasty to allow access for restorative procedure, per tooth ...................................... No Cost
04240 Gingival flap procedure, including root planing -four or more contiguous teeth or tooth bounded spaces per
quadrant .................................................................................................................................. No Cost
04241 Gingival flap procedure, including root planing -one to three contiguous teeth or tooth bounded spaces per
quadrant .................................................................................................................................. No Cost
04245 Apically positioned flap . . .. . .. . . . . .. . . . .. . . . . . . .. . . .. . . . .. . . . .. .. . . .. . .. . .. . .. . .. . . . .. . . . . . . . . . . . . . . .. . . .. . .. . .. . . . .. .. . . .. • • .. .. .. • . . $45.00
04249 Clinical crown lengthening -hard tissue . .. . .. . . . . .. . . . . . . .. . . . . .. . .. . . . .. . . . . .. .. . . .. . . . . .. . . . . . . . .. .. . . . .. . . . . .. . . . .. . . .. . .. .. . . $45.00
04260 Osseous surgery (including elevation of a full thickness flap and closure)-four or more contiguous teeth or tooth
bounded spaces per quadrant . .•••.. .. . . . . . ........ ....... ... . . . . ... . .. . . ... . . . . .. . .. .. . . . . . . . . . . . . . ........ .• . . . .. . .. . . . • .•••••... $75.00
04261 Osseous surgery (including elevation of a full thickness flap and closure)-one to three contiguous teeth or tooth
bounded spaces per quadrant . . .. • . .. .. . . . . . . .. .. . . . .. . . . .. . . .. . . . .. . . .. .. .. . . .. .. . . . . . . . .. .. .. .. . . .. .. .. .. • .. • • .. • • .. • . • . . .. .. .. .. $60.00
04263 Bone replacement graft-first site in quadrant ................................................................................... $125.00
04264 Bone replacement graft -each additional site in quadrant .. .. . • . . . . . .. .. . .. . .. . . . . . . • . . . • .. .. .. .. . .. .. .. .. .. .. .. . .. . . .. .. .. .. $45.00
04266 Guided tissue regeneration-resorbable barrier, per site ...................................................................... $100.00
04267 Guided tissue regeneration-nonresorbable barrier, per site (includes membrane removal) ........................... $140.00
04270 Pedicle soft tissue graft procedure ................................................................................................. $125.00
04273 Subepithelial connective tissue graft procedures, per tooth .. .. .. .. . .. .. .. .. .. .. . . .. .. .. .. . .. .. .. .. .. .. . . .. .. .. .. .. .. . . .. .. .. . $75.00
04274 Distal or proximal wedge procedure (when not performed in conjunction with surgical procedures in the same
anatomical area) • • • • • .. .. . .. . . • . . . . . . . . . . . . . . . . . .. . . . . . . • • • . . .. . . .. . . . . • . . . .. . • . . . . . . . . . . . . . • • . . . • .. . . .. .. . . . . • . . . • . . . .. . .. . . . . • • • • • •• . No Cost
04275 Soft tissue allograft .................................................................................................................... $115.00
04277 Free soft tissue graft procedure (including donor site surgery), first tooth or edentulous tooth position in graft ...... $125.00
04278 Free soft tissue graft procedure (including donor site surgery), each additional contiguous tooth or edentulous
tooth position in same graft site .................................................................................................... $125.00
04341 Periodontal scaling and root planing-four or more teeth per quadrant -limited to 4 quadrants during any 12
consecutive months . . . . . . . . . . . . . • • . . . . . . . • . . . . . . . . . . . . . . • . . . . . . . . . . . . . • • . . . . • . . . . . . . . . . • . . • • . . . . . . . . . . . . . . • • • . . • • . • . . . . . . . . . • • • • . . . . • • No Cost
04342 Periodontal scaling and root planing -one to three teeth per quadrant-limited to 4 quadrants during any 12
consecutive months . . .. .. . .. . . . . . .. • .. . .. . . . . .. . . .. . . . .. . . . . .. .. . . . . .. . . . . . . .. . . . .. .. . . . . . . . .. .. .. . .. . . . . .. . . . .. . .. .. .. .. .. . . . . .. .. .. . No Cost
04355 Full mouth debridement to enable comprehensive evaluation and diagnosis -limited to 1 treatment in any 12
consecutive months . . . . . . . . . . . . . . . • • . . • . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . • . . . . • . . • . . . . . . . . . . . . • • • . • • • . . . . . . . . . . . • . . . . . • . . . . . . . • . . . . . . • . . . No Cost
04381 Localized delivery of antimicrobial agents via a controlled release vehicle into diseased crevicular tissue, per
tooth-for each of the first two teeth treated within a quadrant following root planing or periodontal maintenance • . $60.00
Plan CA42N Delta Care USA Description of Benefits and Copayments
04381 Localized delivefY of antimicrobial agents via a controlled release vehicle into diseased crevicular tissue, per
tooth -for an additional tooth treated in the same quadrant following root planing or periodontal maintenance . • • . . No Cost
0491 0 Periodontal maintenance -limited to 1 treatment each 6 month period . . . . . .. .. .. .. . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . .. • . . No Cost
04910 Additional periodontal maintenance (within the 6 month period) . • . . . . . . . . . . . . . . . . . . • . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . $55.00
04921 Gingival irrigation-per quadrant •••..•........•...........................•...........••.•....................•.........•..•.....•. No Cost
05000-05899 VI. PROSTHODONTICS (removable) . .
-For all listed dentures and partial dentures, Copayment includes after delivery adjustments and tissue conditioning, if needed, for the first
six months after placement. The Enrollee must continue to be eligible, and the seNice must be provided at the Contract Dentist's facility
where the denture was originally delivered.
-Rebases, relines and tissue conditioning are limited to 1 per denture during any 12 consecutive months.
-Replacement of a denture or a partial denture requires the existing denture to be 5+ years old.
05110 Complete denture-maxillary •......•.••..................•.......••..•....•.................•..........••...•...•.......•.••••..•••. $75.00
05120 Complete denture-mandibular .............................................................................................••...... $75.00
05130 Immediate denture -maxillary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . • . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. $85.00
05140 Immediate denture-mandibular •••...........•..•.........••......••....•..............•..•••......•..•..••........................ $85.00
05211 Maxillary partial denture-resin base (including any conventional clasps, rests and teeth) .•••••••.•...........•......• $80.00
05212 Mandibular partial denture-resin base (including any conventional clasps, rests and teeth) •••.•••........•••.••..... $80.00
05213 Maxillary partial denture -cast metal framework with resin denture bases (including any conventional clasps,
rests and teeth) ........................................................................... ....•......................................... $95.00
05214 Mandibular partial denture-cast metal framework with resin denture bases (including any conventional clasps,
rests and teeth) . . . . . . • • . . . . . . . . . . • • . . . . . . • • . . . . . . . • • . . . . . • • . . . . . . . . . . • . . . . . . • . . • . . . . . . . . • . . . . • . . . • .. . . . . . . . . . . . . . • . • . . . . . . . . • . • • • . . • • • • . $95.00
05225 Maxillary partial denture-flexible base (including any clasps, rests and teeth) ..•..•............•.•••.......•...•......•. $195.00
05226 Mandibular partial denture-flexible base (including any clasps, rests and teeth) ................................•.•.•.•. $195.00
05281 Removable unilateral partial denture -one piece cast metal (including clasps and teeth) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $80.00
05410 Adjust complete denture-maxillary •••........•...•.•............•.......••.................•..............••...................•.. No Cost
05411 Adjust complete denture-mandibular .............•................•....•.................•.........•.....•............•••.•...•.. No Cost
05421 Adjust partial denture-maxillary .•..•................•................•...••........•.................••....••.•..•......••...••.•• No Cost
05422 Adjust partial denture -mandibular . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. • . . . .. . . . .•• . . . . . .• No Cost
05510 Repair broken complete denture base ............................................................................................ No Cost
05520 Replace missing or broken teeth-complete denture (each tooth) .......................................................... No Cost
05610 Repair resin denture base ........•.•..............••....•...........••...........•.........•...........•••..•....•.........•.•...•.. No Cost
05620 Repair cast framework .....•....•••...•.•............•.•.•...................•.....••..........••.........•...••..•.......•.••....•.•. No Cost
05630 Repair or replace broken clasp .......................•..............•........................................................•..... No Cost
05640 Replace broken teeth -per tooth ................................................................................................... No Cost
05650 Add tooth to existing partial denture .•........••..•..•............•........•........•.•..•..•..............••••............•....... No Cost
05660 Add clasp to existing partial denture ••................•..................•..................••...............••........•••.••...... No Cost
05670 Replace all teeth and acrylic on cast metal framework (maxillary) • . . . . . . . . . . . . . . . . . • • . . . . . . . . . . • • . . • . . . • . . . . . . . . . . . . . . • . . . • $65.00
05671 Replace all teeth and acrylic on cast metal framework (mandibular) . . . . . . . . . . . . . • . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . .. . $65.00
05710 Rebase complete maxillary denture . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $30.00
05711 Rebase complete mandibular denture ........•.....•...........••........•............•....••..........••.••...........•.••....... $30.00
05720 Rebase maxillary partial denture . . • . . • . . . . . . . . . . . . . . • . . . . . . . . . . . . . • • . . . . . • . . . . . . . . . . . . • . • • . . . . • . . . . . . . • . . . • . . . • . . . . . . . . . . . • . • . • • • • • $30.00
05721 Rebase mandibular partial denture . . . ... . . ... . . .. . .. .. .•. . .... .. .•. . . . .. . . .. . ... . .. . . • • .. . . • . ... . . . . . ••. •. • .• .•• . . ...... .. •••• .. . . . $30.00
05730 Reline complete maxillary denture (chairside) ................................................................................... No Cost
05731 Reline complete mandibular denture (chairside) ................................................................................ No Cost
05740 Reline maxillary partial denture (chairside) ....•.................•.........................•...........••...•...........•.•...•... No Cost
05741 Reline mandibular partial denture (chairside) ..•.•..•............••.................................•.•..••..•..........••••..... No Cost
05750 Reline complete maxillary denture (laboratory) . ..•.. .. . .. . .. . .••..... .. .•. . ... ..•... .•. . . . ............... •• . ......... .••••.. •.•• $25.00
05751 Reline complete mandibular denture (laboratory) .........................................................................•..... $25.00
05760 Reline maxillary partial denture (laboratory) . . . . . . . . . . . • . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $25.00
05761 Reline mandibular partial denture (laboratory) . ..•. .. . . . ... . . . . . .• .• . .••... .. . . . . . . . .. . . . . . ... . . . .•. . . . . . . . . •. . . . ... . • • .•• . . . •. . . $25.00
05820 Interim partial denture (maxillary) -limited to 1 in any 12 consecutive months •.............•••••••...................•••. No Cost
05821 Interim partial denture (mandibular) -limited to 1 in any 12 consecutive months •..........•......••..........••..•...•.. No Cost
05850 Tissue conditioning, maxillary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . No Cost
05851 Tissue conditioning, mandibular ..................................................................................................... No Cost
Plan CA42N I DeltaCare USA Description of Benefits and Copayments
05900-05999 VII. MAXILLOFACIAL PROSTHETICS -Not Covered
06000-06199 VIII. IMPLANT SERVICES-Not Covered
06200-06999 IX. PROSTHODONTICS, fixed (each retainer and each pontic constitutes a unit in a fixed partial denture
[bridge])
-When a crown and/or pontic exceeds six units in the same treatment plan, an Enrollee may be charged an additional $125.00 per unit,
beyond the 6th unit.
-Replacement of a crown, pontic, inlay, onlay or stress breaker requires the existing bridge to be 5+ yeam old.
* Name brand, laboratory processed or in-office processed crownslpontics produced through specialized technique or materials are
material upgrades. The Contract Dentist may charge an additional fee not to exceed $325.00 in addition to the listed Copayment. Refer to
Umitation of Benefds #4 for additional information.
06205 Pontic -indirect resin based composite . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . .. . . .. . . .. . .. . . . . . . . . . . . . . . . .. .. . . .. .. . . . . . . . . .. . . . . $30.00
06210 Pontic-cast high noble metal ............ ......................................... ................................................. $70.00
06211 Pontic-cast predominantly base metal ........................................................................................... $55.00
06212 Pontic-cast noble metal ............................................................................................................. $60.00
06214 Pontic-titanium ......... ............................................................................................................... $70.00
06240 Pontic -porcelain fused to high noble metal* .. .. .. .. .. .. .. .. . . .. .. .. .. .. .. . .. . . .. .. .. .. .. .. .. .. . .. .. .... .. .. .. . . .. .. .. .. .. .. .. .. $70.00
06241 Pontic -porcelain fused to predominantly base metal .. .. .. .. .. .. . . .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. . . .. . .. .. .. .. .. .. .. .. .. .. .. .. $55.00
06242 Pontic -porcelain fused to noble metal .. . .. .. .. .. .. .. .. .. .. . .. . . . . .. . .. .. .. .. .. .. . .. .. .. .. .. .. .. . .. .. . .. . .. .. .. . . . . . . .. .. .. . . .. . . $60.00
06245 Pontic -porcelain/ceramic* . . . . . . . . . . . . . . .. .. . . .. . . .. . . . .. . . . . . . . . . . . . . . . . . . . . . . .. . . . . .. .. .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $70.00
06250 Pontic -resin with high noble metal .. .. .. .. .. .. .. .. .. .. .. .. .. . . . . .. .. . .. . .. .. .. . .. . .. .. .. .. .. .. .. . . .. . .. . . .. .. .. .. .. .. .. .. .. .. . .. . $30.00
06251 Pontic -resin with predominantly base metal .. .... .... .. .. . . . .. . . .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. . . . . . .. .. .. .. .. .. .. .. .. .. .. .. .. $15.00
06252 Pontic -resin with noble metal . . .. . . . . . .. .. . .. . . . . .. .. .. . . .. . . . . .. . . . . . . . . . . . . . . . . . .. . . . .. . . . . . . . .. . . . . . . . .. . . . . . . .. .. .. . .. .. . .. . .. . $20.00
06600 Inlay -porcelain/ceramic, two surfaces . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. .. . .. .. . . . . . . . . . . . . . . . .. . . . . .. . .. . .. $60.00
06601 Inlay -porcelain/ceramic, three or more surfaces .. . .. .. .. . . .. . . . . . . . . . . . .. .. .. .. .. .. .. .. .. .. .. . .. . . . . . . . . . . . . . .. .. .. .. .. .. .. .. . $65.00
06602 Inlay -cast high noble metal, two surfaces .. . .. .. .. .. .. .... . ..... . . .. . . . . .... ... .. .. .. .. . .. .. .... .. . . ... . . .. .. . . .. .. .... .. .... .. $70.00
06603 Inlay -cast high noble metal, three or more surfaces .. .. .. .. .. .. . . . . . . . . . . .. . .. . .. .. . .. .. .. .. .. .. .. . . . .. . . .. . . . .. .. .. .. .... .. . $70.00
06604 Inlay -cast predominantly base metal, two surfaces ........................................................................... No Cost
06605 Inlay -cast predominantly base metal, three or more surfaces . .. . . . .. .. . . .. .. .. .. .. .. .. .. .. .. .. .. . .. .. . . . . . . . . .. .. .. .. .. .. . No Cost
06606 Inlay -cast noble metal, two surfaces . . . . . . .. .. .. .. .. .. .. .. .. .. .. .. .. . . . . . . . . . . . .. . . .. .. .. .. .. .. .. .. .. .. . . . . . . . . . . . . . .. .. .. .. .. .. . $60.00
06607 Inlay -cast noble metal, three or more surfaces .. .. .. .. .. . .. .. .. .. . . . . . . . .. . . . .. .. .. .. .. .. .. .. .. .. .. .. . . . . .. . . . . . . . .. .. .. .. . .. . $60.00
06608 Onlay -porcelain/ceramic, two surfaces . . . . .. .. .. .. .. .. .. .. .. .. .. .. .. . . . . . . . . .. . . . .. .. .. .. .. .. .. .. .. .. .. . . .. . .. . . . . . . . . .. .. .. .. .. $55.00
06609 Onlay -porcelain/ceramic, three or more surfaces .. .. .. .. .. .. .. .. .. . . . . . . . . . . . . . .. .. .. .. .. .. .. .. .. .. . .. .. .. .. .. . . . .. .. .. .. .. .. $65.00
06610 Onlay-cast high noble metal, two surfaces .................................... ................................................. $70.00
06611 Onlay-cast high noble metal, three or more surfaces ........................................................................ $70.00
06612 Onlay-cast predominantly base metal, two surfaces .......................................................................... No Cost
06613 On lay -cast predominantly base metal, three or more surfaces ............................................................. No Cost
06614 Onlay-cast noble metal, two surfaces ........................................................................................... $60.00
06615 Onlay-cast noble metal, three or more surfaces ............................................................................... $60.00
0671 0 Crown -indirect resin based composite . .. . . . . . . . . .. .. .. .. .. .. . . .. .. .. .. .. .. .. . . .. .. . . . .. .. .. .. .. .. .. .. .. .. .. .. .. . . . . . . . . .. .. .. .. . $30.00
06720 Crown -resin with high noble metal .. . . .. . . . . .. . . . . . . .. .. .. .. .. .. . .. .. .. . . . . . .. . . . . . . . . . . . .. .. . .. .. . . . . . . . . . . .. . . .. . . . . . . . . . .. . . . . $30.00
06721 Crown -resin with predominantly base metal . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. .. .. . . . . . . . .. . . . . . . . . . . . . . . .... .. $15.00
06722 Crown -resin with noble metal . . . . .. . . . . . .. . . . . . . . . . . .. . . . . . . .. . .. . . . . . .. . .. . . . . . . . . . . . . .. . . . . . . . . . .. .. .. .. . .. .. . .. . .. .. . . . . . .. . .. . $20.00
06740 Crown -porcelain/ceramic* ................ ......................................... ................................................. $70.00
06750 Crown -porcelain fused to high noble metal* . . . . . . . . .. .. .. .. .. . .. . .. .. .. .. .. . . . .. .. .. .. . . .. .. .. . .. .. .. .. . .. .. .. .. . .. .. . . . . . .. .. $70.00
06751 Crown -porcelain fused to predominantly base metal .. . . . .. .. .. .. . .. .. . .. .. .. .. .. .. .. .. .. .. .. .. . .. .. . .. .. . .. .. .. .. . .. .. .. .. .. $55.00
06752 Crown -porcelain fused to noble metal . .. .. . . . . . . . . . .. . .. .. .. . .. .. .. .. .. .. .. .. . . . . . .. .. .. .. . . . . .. .. .. .. .. .. .. .. .. .. .. .. .. .. . . . . . . $60.00
06780 Crown -% cast high noble metal .. .. .. . . . .. .. . .. . . . . . . . .. . .. . . .. .. .. .. .. . .. .. . .. .. . . . . . . . . . . . . . .. .. .. .. . .. .. .. .. .. . .. .. . . . . .. . . . . . . $70.00
06781 Crown -% cast predominantly base metal .. .. ..... .. . . . . .. ............. .... . .. .. . . ... . . ..... .... .. .. .... .. .. .. . . . . . . . . . . . . . . . . . . $55.00
06782 Crown -% cast noble metal .. . .. .. .. .. .. .. .. .. .. . .. . . . . . . . . . .. .. .. .. .. .. .. .. .. . .. . .. . . . . .. . . . . . . .. . . .. . . . . . . . .. . . .. .. . . . . . . . . . . . . . . . $60.00
06783 Crown -% porcelain/ceramic* .. .. .. .. .. .. . . .. .. .. .. . . . . . . . . . .. .. .. .. . . . . . . . . .. . . .. . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . .. . .. . . . . . . . . . . . $70.00
06790 Crown -full cast high noble metal . . . . .. .. .. .. . . . . . . . . . .. . . . . . .. . . . . . . . . . . .. . . . . .. . .. . . .. . . . . . . . . . .. . . .. . .. . . .. .. . . . . . .. .. . . . . . . . . . $70.00
06791 Crown -full cast predominantly base metal .. . . . . . . .. . . . . . . . . . . . .. .. . . .. . .. .. . .. . .. . . . .. . . . . . . . . .. .. .. .. . .. . .. .. .. .. . . .. . . . . . .. . . $50.00
06792 Crown-full cast noble metal ........................................................................................................ $60 .00
06794 Crown -titanium . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . .. . . .. . . .. .. . . ... . . . . . . .. . .. . . .. . . . . . . ..... .. . .... . . . . .. . . . ... . . . . . .... . . .. $70.00
06930 Re-cement or re-bond fixed partial denture . . . . .. .. . . . . . . . .. . . . . . . . . .. . . . . . . . . . . . . . . . .. . . . . .. . . . .. .. . .. . . . . .. . . . . . . .. . .. .. . . . . . . . No Cost
Plan CA42N DeltaCare USA Description of Benefits and Copayments
06940 Stress breaker . . . . . . .. .. . .. . .. .. . . .. .. . . . . .. . . . .. . .. . .. . . . . .. . .. .. .. .. . . . . . . .. . .. . . .. . . .. . . .. . . . . . . . . . . . . .. .. . . . . . . . . . . . . .. . . . . . . . . . . . . . No Cost
06980 Fixed partial denture repair necessitated by restorative material failure .................................................... No Cost
D7000-D7999 X. ORAL AND MAXILLOFACIAL SURGERY
-Includes preoperative and postoperative evaluations and treatment under a local anesthetic.
07111 Extraction, coronal remnants-deciduous tooth ................................................................................. No Cost
07140 Extraction, erupted tooth or exposed root (elevation and/or forceps removal) ............................................. No Cost
07210 Surgical removal of erupted tooth requiring removal of bone and/or sectioning of tooth, and including elevation of
mucoperiosteal flap if indicated ............................... ....................... ............................................... $10.00
07220 Removal of impacted tooth -soft tissue .. .. .. . .. .. .. . .. . . . .. . . . . . . .. .. .. .. .. .. .. .. .. .. .. .. . .. . . . .. . . . . .. .. .. .. .. . .. .. .. .. . .. .. . . . $15.00
07230 Removal of impacted tooth-partially bony ....................................................................................... $25.00
07240 Removal of impacted tooth -completely bony .. .. .. .. .. .. . .. .. .. .. . . . . . . .. .. .. .. .. .. . . .. .. . . . .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. . .. . . $35.00
07241 Removal of impacted tooth-completely bony, with unusual surgical complications ...................................... $50.00
07250 Surgical removal of residual tooth roots (cutting procedure) .................................................................. No Cost
07251 Coronectomy-intentional partial tooth removal .................................................... ............................. $50.00
07270 Tooth reimplantation and/or stabilization of accidentally evulsed or displaced tooth .. .. .. .. .. .. .. .. . .. .. .. .. .. .. .. .. .. .. . $35.00
07280 Surgical access of an unerupted tooth .. .. .. .. .. .. .. .. .. . . .. . . . .. . .. .. .. .. .. . .. .. .. . .. .. .. .. .. . .. .. .. . .. .. .. . .. .. .. .. .. .. .. .. .. .. . $25.00
07282 Mobilization of erupted or malpositioned tooth to aid eruption .. .. .. .. .. .. .. .. .. .. .. .. . . . .. .. . . .. . .. .. .. .. .. .. .. .. .. . .. .. .. .. . $25.00
07283 Placement of device to facilitate eruption of impacted tooth .................................................................. No Cost
07286 lncisional biopsy of oral tissue -soft -does not include pathology laboratory procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . No Cost
07310 Alveoloplasty in conjunction with extractions-four or more teeth or tooth spaces, per quadrant ...................... No Cost
07311 Alveoloplasty in conjunction with extractions-one to three teeth or tooth spaces, per quadrant ...................... No Cost
07320 Alveoloplasty not in conjunction with extractions -four or more teeth or tooth spaces, per quadrant .................. No Cost
07321 Alveoloplasty not in conjunction with extractions -one to three teeth or tooth spaces, per quadrant .................. No Cost
07 450 Removal of benign odontogenic cyst or tumor -lesion diameter up to 1.25 em ........................................... No Cost
07451 Removal of benign odontogenic cyst or tumor -lesion diameter greater than 1.25 em .................................. No Cost
07471 Removal of lateral exostosis (maxilla or mandible) ............................................................................. No Cost
07472 Removal of torus palatinus .......................................................................................................... No Cost
07473 Removal of torus mandibularis ...................................................................................................... No Cost
07510 Incision and drainage of abscess-intraoral soft tissue ........................................................................ No Cost
07960 Frenulectomy-also known as frenectomy or frenotomy-separate procedure not incidental to another procedure No Cost
07970 Excision of hyperplastic tissue -per arch ......................................................................................... No Cost
07971 Excision of pericoronal gingiva ...................................................................................................... No Cost
D8000-D8999 XI. ORTHODONTICS
-The listed Copayment for each phase of orthodontic treatment (limited, interceptive or comprehensive) covers up to 24 months of active
treatment. Beyond 24 months, an additional monthly fee, not to exceed $125.00, may apply.
-The Retention Copayment includes adjustments and/or office visits up to 24 months.
Pre and post orthodontic records include:
The benefit for pre-treatment records and diagnostic services includes: ................................................... $200.00
00210 Intraoral -complete series of radiographic images
00322 Tomographic survey
00330 Panoramic radiographic image
00340 Cephalometric radiographic image
00350 20 oral/facial photographic images obtained intraorally or extraorally
00351 30 photographic image
00470 Diagnostic casts
The benefit for post-treatment records includes: .. . . . . . . . . . . . . . . .. .. . . .. .. .. .. .. . .. .. .. . . . . . . . . . .. . . .. . . . .. .. .. .. .. .. .. .. .. .. .. . $70.00
00210 Intraoral-complete series of radiographic images
00470 Diagnostic casts
08010 Limited orthodontic treatment of the primary dentition ......................................................................... $725.00
08020 Limited orthodontic treatment of the transitional dentition-child or adolescent to age 19 ............................... $725.00
08030 Limited orthodontic treatment of the adolescent dentition-adolescent to age 19 ........................................ $725.00
08040 Limited orthodontic treatment of the adult dentition -adults, including covered dependent adult children ............ $925.00
08050 lnterceptive orthodontic treatment of the primary dentition .................................................................... $725.00
08060 lnterceptive orthodontic treatment of the transitional dentition ................................................................ $725.00
08070 Comprehensive orthodontic treatment of the transitional dentition-child or adolescent to age 19 ................... $1 ,700.00
Plan CA42~ DeltaCare USA Description of Benefits and Copayments
D8080 Comprehensive orthodontic treatment of the adolescent dentition-adolescent to age 19 ............................ .$1 ,700.00
D8090 Comprehensive orthodontic treatment of the adult dentition-adults, including covered dependent adult children .. $1 ,900.00
D8660 Pre-orthodontic treatment examination to monitor growth and development . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $25.00
D8670 Periodic orthodontic treatment visit -included in comprehensive case fee ................................................. No Cost
D8680 Orthodontic retention (removal of appliances, construction and placement of removable retainers} . . . . . . . . . . . . . . . . . . $275.00
D8693 Re-bond or re-cement fixed retainer -limited to 2 per 6 month period .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . No Cost
D8694 Repair of fixed retainers, includes reattachment -limited to 2 per 6 month period ....................................... No Cost
D8999 Unspecified orthodontic procedure, by report -includes treatment planning session .................................... $100.00
09000-09999 XII. ADJUNCTIVE GENERAL SERVICES
D9110 Palliative (emergency} treatment of dental pain-minor procedure .......................................................... No Cost
D9211 Regional block anesthesia ........................................................................................................... No Cost
D9212 Trigeminal division block anesthesia ............................................................................................... No Cost
D9215 Local anesthesia in conjunction with operative or surgical procedures ..................................................... No Cost
D9219 Evaluation for deep sedation or general anesthesia ............................................................................ No Cost
D9220 Deep sedation/general anesthesia-first 30 minutes ........................................................................... $165.00
D9221 Deep sedation/general anesthesia -each additional 15 minutes .. .. ...... .... .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. ... ... $80.00
D9241 Intravenous moderate (conscious} sedation/analgesia -first 30 minutes ................................................... $165.00
D9242 Intravenous moderate (conscious} sedation/analgesia-each additional15 minutes .. .... .......... .... .. .. . .. . ......... $80.00
D9310 Consultation-diagnostic service provided by dentist or physician other than requesting dentist or physician ....... No Cost
D9430 Office visit for observation (during regularly scheduled hours}-no other services performed .......................... No Cost
D9440 Office visit -after regularly scheduled hours .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. . . .. .. .. .. . .. .. .. .. .. .. .. .. .. .. .. .. .. .. . .. .. .. . .. .. $20.00
D9450 Case presentation, detailed and extensive treatment planning ............................................................... No Cost
D9931 Cleaning and inspection of a removable appliance ............................................................................. No Cost
D9940 Occlusal guard, by report-limited to 1 in 3 years ........ ...................................................................... $75.00
D9951 Occlusal adjustment, limited ......................................................................................................... No Cost
D9952 Occlusal adjustment, complete ...................................................................................................... No Cost
D9975 External bleaching for home application, per arch; includes materials and fabrication of custom trays -limited to
one bleaching tray and gel for two weeks of self-treatment ................................................................... $125.00
09986 Missed appointment-without 24 hour notice-per 15 minutes of appointment time-up to an overall maximum
of $40.00 . . . . . . . . . . .. .. . . . . . . . .. . . . .. . . . .. . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . .. . . .. . .. . .. . . . . .. . . . .. .. . . . . .. . . . . . . . . . . . . . . . . . . . . . . .. . . $10.00
D9987 Canceled appointment-without 24 hour notice-per 15 minutes of appointment time-up to an overall maximum
of $40.00 . . . . .. .. . . .. . . . .. . . . . . . . . . . . . . . . . . . . . . .. . . . . . . .. . .. . . .. . . . . . . . . .. .. .. . . .. . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . .. . .. . . .. .. $10.00
If services for a listed procedure are performed by the assigned Contract Dentist, the Enrollee pays the specified Copayment. Listed
procedures which require a Dentist to provide Specialist Services, and are referred by the assigned Contract Dentist, must be authorized
by Delta Dental. The Enrollee pays the Copayment specified for such services.
Procedures not listed above are not covered, however, may be available at the Contract Dentist's "filed fees." "Filed fees" mean the
Contract Dentist's fees on file with Delta Dental. Questions regarding these fees should be directed to the Customer Service department
at 800-422-4234.
SCHEDULE B
Limitations of Benefits
--~
Limitations and Exclusions of Benefits
1. The frequency of certain Benefits is limited. All frequency limitations are listed in Schedule A, Description of Benefits and
Copayments.
2. If the Enrollee accepts a treatment plan from the Contract Dentist that includes any combination of more than six crowns, bridge
pontics and/or bridge retainers, the Enrollee may be charged an additional $100.00 above the listed Copayment for each of these
services after the sixth unit has been provided.
3. General anesthesia and/or intravenous sedation/analgesia is limited to treatment by a contracted oral surgeon and in conjunction
with an approved referral for the removal of one or more partial or full bony impactions, (Procedures D7230, D7240, and D7241 ).
4. Benefits provided by a pediatric Dentist are limited to children through age seven following an attempt by the assigned Contract
Dentist to treat the child and upon prior authorization by Delta Dental, less applicable Copayments. Exceptions for medical
conditions, regardless of age limitation, will be considered on an individual basis.
5. The cost to an Enrollee receiving orthodontic treatment whose coverage is cancelled or terminated for any reason will be based on
the Contract Orthodontist's usual fee for the treatment plan. The Contract Orthodontist will prorate the amount for the number of
months remaining to complete treatment. The Enrollee makes payment directly to the Contract Orthodontist as arranged.
6. Orthodontic treatment in progress is limited to new DeltaCare USA Enrollees who, at the time of their original effective date, are
in active treatment started under their previous employer sponsored dental plan, as long as they continue to be eligible under the
DeltaCare USA program. Active treatment means tooth movement has begun. Enrollees are responsible for all Copayments and fees
subject to the provisions of their prior dental plan. Delta Dental is financially responsible only for amounts unpaid by the prior dental
plan for qualifying orthodontic cases. ·
Exclusions of Benefits
1. Any procedure that is not specifically listed under Schedule A, Description of Benefits and Copayments.
2. Any procedure that in the professional opinion of the Contract Dentist:
a. has poor prognosis for a successful result and reasonable longevity based on the condition of the tooth or teeth and/or
surrounding structures, or
b. is inconsistent with generally accepted standards for dentistry.
3. Services solely for cosmetic purposes, with the exception of procedure D9975 (External bleaching for home application, per arch),
or for conditions that are a result of hereditary or developmental defects, such as cleft palate, upper and lower jaw malformations,
congenitally missing teeth and teeth that are discolored or lacking enamel, except for the treatment of newborn children with
congenital defects or birth abnormalities.
4. Porcelain crowns, porcelain fused to metal, cast metal or resin with metal type crowns and fixed partial dentures (bridges) for children
under 16 years of age.
5. Lost or stolen appliances including, but not limited to, full or partial dentures, space maintainers, crowns and fixed partial dentures
(bridges).
6. Procedures, appliances or restoration if the purpose is to change vertical dimension, or to diagnose or treat abnormal conditions of
the temporomandibular joint (TMJ).
7. Precious metal for removable appliances, metallic or permanent soft bases for complete dentures, porcelain denture teeth,
precision abutments for removable partials or fixed partial dentures (over1ays, implants, and appliances associated therewith) and
personalization and characterization of complete and partial dentures.
a. Implant-supported dental appliances and attachments, implant placement, maintenance, removal and all other services associated
with a dental implant.
9. Consultations for non-covered benefits.
10. Dental services received from any dental facility other than the assigned Contract Dentist, a preauthorized dental specialist, or a
Contract Orthodontist except for Emergency SeNices as described in the Contract and/or Evidence of Coverage.
11. All related fees for admission, use, or stays in a hospital, out-patient surgery center, extended care facility, or other similar care
facility.
12. Prescription drugs.
Limitations and Exclusions of Benefits
13. oe"ntal expenses incurred in connection with any dental or orthodontic procedure started before the Enrollee's eligibility with the
DeltaCare USA program. Examples include: teeth prepared for crowns, root canals in progress, full or partial dentures for which an
impression has been taken and orthodontics unless qualified for the orthodontic treatment in progress provision.
14. Lost, stolen or broken orthodontic appliances.
15. Changes in orthodontic treatment necessitated by accident of any kind.
16. Myofunctional and parafunctional appliances and/or therapies.
17. Composite or ceramic brackets, lingual adaptation of orthodontic bands and other specialized or cosmetic alternatives to standard
fixed and removable orthodontic appliances.
18. Treatment or appliances that are provided by a Dentist whose practice specializes in prosthodontic services.
You r Vision
Benefits Su mma ry
Get the best In eyecare and eyewear with COUNTY OF FRESNO
and vspe Vision Care.
Using your VSP benefit is easy.
• Register at vsp.com Once your plan is effective, review your
benefit information.
• Find an eyecare provider who's right for you. The decision
Is yours to make-choose a VSP doctor, a participating retail
chain, or any out-of-network provider. To find a VSP provider,
visit vsp.com or call800.877.7195.
• At your appointment, tell them you have VSP. There's no ID
card necessary. If you'd like a card as a reference, you can
print one on vsp.com.
That's it! We'll handle the rest-there are no claim forms to
complete when you see a VSP provider.
Primary EyeCare
As a VSP member, you can visit your VSP doctor for medical
and urgent eyecare. Your VSP doctor can diagnose, treat, and
monitor common eye conditions like pink eye, and more serious
conditions like sudden vision loss, glaucoma, diabetic eye
disease, and cataracts. Ask your VSP doctor for details.
Choice in Eyewear
From classic styles to the latest designer frames, you'll find
hundreds of options. Choose from featured frame brands like
Anne Klein, bebe•, Calvin Klein, Flexon•, Lacoste, Nike, Nine
West, and more1
• VIsit vsp.com to find a VSP provider who
carries these brands.
Plan Information
VSP Coverage Effective Date: 01/0112016
VSP Provider Network: VSP Choice
COUNTY OF FRESNO and VSP provide you with an affordable
eyecare plan.
Visitvsp.com or call800.877.7195
for more details on your vision
coverage and exclusive savings
and promotions for VSP members.
'BrandsiPromotloo subjact to change.
"2014 Vision Service Plan. All rlghlll raserved. VSP, VSP Vision cera for life. and WeiMsion Exam
are registered trademarks of Vision Se1Vice Plan. Flexon Is a reglste18d trademark of Marchon
Eyewear, Inc. All other company names and brands ere trademarks or registered trademarks
at their respective owners.
Benefit
WellVision
Exam
• • ~Y.~P·
Description
• Focuses on your eyes and overall
well ness
• Every 12 months
CC?P'}Y
$10
Prescription Glasses $10
Frame
Lenses
r:-$150 allo~-;,ce for a wide selection
of frames or $170 allowance for
featured frame brands (see 'Extra 1
Savings' below)
20% savings on the amount over your I
allowance ! • $100 Costco• frame allowance I
!__~~very_ 24 _!!!On~-_____ _
• Single vision, lined bifocal and lined
trifocal lenses
• Polycarbonate lenses for dependent
children
• Every 12 months
• Standard progressive lenses
• Premium progressive lenses
Included in
Prescription
Glasses
Included in
Prescription
Glasses
Lens • Custom progressive lenses
$55
$95-$105
$150-$175
Enhancements • Average savings of 20-25% on other
lens enhancements
Contacts
(instead of
glasses)
Primary
Eyecare
Extra Savings
• Every 12 months
• $150 allowance for contacts; copay
does not apply
• Contact lens exam (fitting and
evaluation)
• Every 12 months
----------·····-·· -·
• Treatment and diagnosis of eye
conditions like pink eye, vision loss
and monitoring of cataracts,
glaucoma and diabetic retinopathy.
Limitations and coordination with
medical coverage may apply. Ask
your VSP doctor for details.
• As needed
Glasses and Sunglasses
Up to $60
$20
• Extra $20 to spend on featured frame brands. Go to
vsp.comlspecialoffers for details.
• 20"/o savings on additional glasses and sunglasses,
including lens enhancements, from any VSP provider
within 12 months of your last ~eiMsion Exam
Retinal Screening
• No more than a $39 copay on routine retinal screening
as an enhancement to a WeiiVision Exam
Laser VIsion Correction
• Average 15% off the regular price or 5% off the
promotional price; discounts only available from
contracted facilities
VIsit vsp.com for details, if you plan to see a provider other than a VSP network provider.
· Exam---·---·-·---·-up to $45 Lined Trifocal Lenses----up to $65
F~me -------·-UP to $70 Progressive Lenses _up to $50
Srngle VIsion Lenses ---·--UP to $30 Contacts up to $105
Lined Bifocal Lenses ........... up to $50
Coverage with a participating retail chain may be differ~n)..
for details. Coverage ioformallon is su~ to ch!'Jlga.ln the
and your organization's contract with VSP, the terms of the
laws, benefits may val}' by location.
Exhibit B
San Joaquin Valley Insurance Authority
County of Fresno
January 1, 2016 -December 31 , 2016
SJVIA Plan Rates: Jan 2016 ACTIVE
EE ES
Anthem HMO $684.41 $1,210.38
Anthem PPO $895.83 $1,880.52
Anthem HDPPO $492.61 $1,043.45
Anthem HDPPO PRE-65 $689.60 $1,220.82
Kaiser HMO $658.68 $1,165.91
Kaiser HMO PRE-65 $1,215.84 $2,225.44
Delta Dental DHMO $25.04 $42.96
Delta Dental DPPO $50.29 $80.19
VSPVision $7.49 $13.46
EC EF
$1,068.24 $1,592.76
$1,703.72 $2,597.93
$935.49 $1,425.57
$1,077.26 $1,607.16
$1,030.30 $1,536.34
$1,864.88 $2,850.43
$43.26 $62.35
$69.88 $102.58
$13.19 $19.32