HomeMy WebLinkAboutAgreement A-15-644-1 with SJVIA.pdfAgreement No. 15-644-1
AMENDMENT 1 TO SJVIA PARTICIPATION AGREEMENT
This Amendment 1 to the SJVIA Participation Agreement (Amendment 1) is dated December
19, 2016 , and is between the County of Fresno, a municipal corporation (COUNTY OF
FRESNO), and the San Joaquin Valley Insurance Authority , a joint powers agency (SJVIA).
The parties previously entered into an agreement dated December 7 , 2015 , and titled "SJVIA
PARTICIPATION AGR E EMENT" (Agreement), to a ll ow COUNTY OF FRESNO to participate in
certain insurance programs through SJVIA.
The parties now desire to amend the Agreement to extend the term of the Agreement, and to
revise th e insurance p rograms availab le to COUNTY OF FRESNO through SJVIA, and the rates
for benef its under thos e programs .
The parties therefore agree as follows :
1. T he Agreement is amended , effective December 19, 2016 , as follows:
a . The term of th e Agreement is extended through March 31 , 2017 .
b . The Exhibit A that is attached to this Amendment 1 replaces and supersedes all
documents pr eviously identified as Exhibit A to the Agreement.
c . The Exhibit B that is attached to this Amendment 1 replaces and supersedes all
documents previously identified as Exhibit B to the Agreement.
2 . Except as modified by this Amendment 1, the Agreement remains in full force and effect .
This agreement is effective on the date first written above .
SAN JOAQUIN VALLEY INSURANCE
AUTHORITY
By---------------------------~~-----------
Pete Vander Poe l
SJVIA Board President
Date:
REVIEWE D & RECOMMENDED FOR
APPROVAL
By __________________________________________________ __
Rhonda Sjostrom
SJVIA Assistant Manager
1
COUNTY OF FRESNO
vtiL-By __________________________________________________ ___
Brian Pacheco
Chairman , Board of Supervisors
Date : __ ...:.\...L( ~=:...._S'....:..I ...!...\1_:___ ______ _
BERNICE E . SEIDEL, CLERK
BOARD OF SUPERVISORS
2
APPROVED AS TO LEGAL FORM :
DANIEL C . CEDERBORG , COUNTY COUNSEL
s f~£'!f;
APPROVED AS TO ACCOUNTING FORM :
Oscar Garcia
AUDITOR-CONTROLLERfTREASURER-TAX COLLECTOR
By C)~,~~
RE V IEWED & RE COMMENDED FOR
APPROVAL I ~ ~ ) s~\~~
Paul Nerland
Director of Human Resources
Agreement No. 15-644-1
AMENDMEN T 1 TO SJVIA PARTIC IPA TION AGR EEMENT
This Amendment 1 to the SJVIA Participation Agreement (Amendment 1) is dated December
19, 2016 , and is between the County of Fresno , a mun icipal corporation (COUNTY OF
FRESNO), and the San Joaquin Valley Insurance Authority , a joint powers agency (SJVIA).
The parties previously entered into an agreement dated December 7, 2015 , and titled "SJVIA
PARTICIPATION AGREEMENT" (Agreement), to allow COUNTY OF FRESNO to participate in
certain insurance programs through SJVIA.
The parties now desire to amend the Agreement to extend the term of the Agreement, and to
revise the insurance programs ava ilable to COUNTY OF FRESNO through SJVIA, and the rates
for benefits under those programs .
The parties therefore agree as foll ow s:
1 . The Agreement is amended , effective December 1 9, 2016 , as follows :
a . The term of the Agreement is extended through March 3 1, 20 17.
b . The Exhibit A that is attached to this Amendment 1 replaces and supersedes all
documents previously identified as Exhibit A to the Agreement.
c . The Exhibit B that is attached to th is A mendment 1 replaces and supersedes all
documents previously identified as Ex hibit B to the Agreement.
2. Exc e pt as modified by this Amendment 1, the Agreement remains in full force and effect.
This agreement is effective on the date first written above .
SAN JOAQUIN VALLEY INSURANC E
AU T HORITY
By __________________________________________________ _
Date :
Pete Vander Poel
SJVIA Board President
REVIEWED & RECOMMENDED FOR
APPROVAL
By _____ ~----------~--------------------------Rhonda Sjostrom
SJVIA Assistant Manager
1
COUNTY OF FRESNO
ll~~ By ______________________ ~-----------------------
Brian Pacheco
Chairman , Board of Supervisors
Date : _______ \ _-_'J._s-_-_,_1 ____________________ _____
BERNICE E . SEIDEL, CLERK
BOARD OF SUPERVI SORS
2
APPROVED AS TO LEGAL FORM :
DA NIEL C . CE DERBORG , CO U NTY COU NSEL
By ~iKifr
APPROVED AS TO ACCOUNTING FORM :
Oscar Garcia
AUD ITO R-CONT ROLL ERrfR EASURER-TAX CO LLEC TOR
By ~~~
REVIEWED & RECO~MMENDED FOR
APPROVAL . ~
By l ~
Paul Nerland
Director of Human Resources
Anthem .+.
SlueCrm
SJVIA County of Fresno
Modified Premier PPO
(250/20/1 00/50) -Active
EXHIBIT A
Th is summary of benefits has been updated to comply with federa l and state requirements , includ ing applicable provisio ns of the
recently enacted fede ral health care reform laws . As we receive add itional guidan ce and clarification on the new health ca re reform
laws from the U.S. Department of Hea lth and Human Services , Department of Labor and Internal Revenue Service, we may be
required to make additiona l changes to th is summary of benefits . This proposed benefit summary is subject to the approval of the
Californ ia Department of Insurance and the Ca lifornia Departmen t of Managed Health Care . In addition to dollar and percentage
copays, membe rs are responsib le for deduct ibles , as described belo w. Plea se review the deductib le information to know if a
deductible appl ies to a speci fic cove red serv ice. Certa in Covered Service s have ma xi mum visit and /or day limits per year . The
number of vis its and /or days allowed for these service s wi ll beg in accumulating on the first visit and /or day , regard less of whether
you r Deductib le has been met. Members are also resp onsible for all costs over the plan ma ximums . Plan ma ximums and other
important information appear in it alics . Benefits are subject to all te rms, condi tions, lim itations, and exclu sions of the Policy .
Explanation of Maximum Allowed Amount
Maximum Allo wed Am ount is the total reimbursement pa yab le under the plan fo r co vered serv ic es re ceived from Partici pating and Non -
Part icipating Prov iders . It is the payment towards the services billed by a provide r combined with any appl icable deductible , copayment or
coinsurance . Participating Providers -The rate the prov ider has ag reed to accept as reimbursement for covered services . Members are not
responsib le for the difference between the pro vi der's usua l charges & the maximum allowed amount. Non-Particip ating Providers & Other
Health Care Providers-(i ncludes those not represented in the PPO pr ovider network)-Reimbursement am ount is based on : an An them Blue
Cross rate or fee schedule , a rate negotiated with the provide r, information from a th ird party vendor , or billed charges . For Medica l
Emergency care rende red by a Non-Participating Provi der or Non-Contracting Hospita l, reimbursement may be based on the reasonable
and customary value . Membe rs may be res ponsib le for any amount in excess of the reasonable and customary va lue .
When using Non-PPO and Other Health Ca re Providers , members are respons ible for any difference between the
covered expense & actual charges , as well as any deductib le & percentage copay.
Benefit year ded uct ible for all providers
Deductible for non-Anthem Blue Cross PPO hospital or
residential treatment center
Deductible for non-Anthem Blue Cross PPO hosp ital or
residential treatment center if utilization rev ie w not obtained
Deductib le for emergency room services
Annual Out-of-Pocket Ma xi mums (no cross accum ulatio n)
$250/member
$500/fami ly (c ombined /aggregate )
$500/adm iss ion (waived for emergency admission)
$500/admission (waived for emergency admissio n)
$1 00/visit (waived if admitted directly fro m ER)
PPO Providers & Other Hea lth Ca re Providers $3 ,000 /member/yea r; $5 ,000 /family /year
Non-PPO Providers $1 0,000/member/year ; $15 ,000/family /year
The following do not apply to the med ic al out-of-po ck et ma ximu ms: non-covered expenses and prescription drugs . After an annual out-of-
po cket maximum is met for med ica l during a ca lendar year, the individual member or fami ly will no longer be required to pay a capay or
coinsurance for medi cal. The member remains respons ible for non-co vered expenses and prescription drugs
Lifetime Maximum Un lim ited
Covered Services PPO : Per
Membe r Copay
Hospital Medical Services (s ubject to utilization review
for inpatien t services; waived fo r emergency admiss ions)
);> Semi-private room , mea ls & spec ial diets , & anc illary services
);> Outp atient med ica l care , surg ica l serv ices & supplies
(hospital care other than emergency roo m care)
Ambulatory Surgical Centers
);> Outpatient su rgery , serv ices & supp lies
Skilled Nursing Facility (su bject to utiliza tion review)
);> Sem i-p rivate room , services & suppl ies
(limit ed to 100 days/b enefi t year)
No capa y
No capay
No capay
No capa y
Hosp ice Care
~ Inpatient or outpat ient serv ices ; family bereaveme nt se rv ices No copay 2
Non-PPO : Per
Member Co pay
50 %1
50%1
50% (b ene fit limited to $350/da y)
50%
Home Health Care (su bj ec t to utilization revie w)
);> Services & supplies from a home hea lth agency No capay 50%
(limited to 100 visits/benefit year, one visit by a
home hea lth aide equals fo ur hours or less;
not cove red while memb er receives hospice ca re)
1 For Californ ia facilitie s, a discount will be app lied if the faci lity has a contract with Anth em Blue Cross for fee-for-service bu si ness. For Cali forni a fac ilities with out a contract,
cove red ex pense for no n-eme rgency hospita l servic es and su pplies is re duced by 25 %, resulting in higher costs for members.
2 These provi ders are not represented in the An them Blue Cross PPO network.
anthem.com/ca Anthem Blue Cross (P-NP)-NGF M-LP2039 Effective 12-19-16 Printed 11 /23/20 16
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
Phys ician Medical Services
~ Office & home visits
~ Hospital & skilled nursing facil ity visits
~ Surgeon & surg ical assistant; anesthesiolog is t or anesthetist
~ Drugs administered by a med ical 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 includ ing *, phys ical exams, preventive
screen ings (including screenings for cancer , HPV, diabetes , cholesterol
blood pressure , hearing and vision, immunizations , health education ,
intervention services , HIV testing ), and additiona l preventive care for
women provided for in the guidelines supported by the Health
Resources and Services Administration.
*Th is list is not exhaustive. Th is benefit includes all Preventive Care
Services requ ired by federa l and state law.
Physical Therapy , Physical Medicine & Occupational
Therapy , includ ing 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 treatment of disease , illness or injury
(limited to 12 visits/benefit year)
Temporomandibular Jo int Disorders
~ Spl int therapy & surgical treatment
Pregnancy & Matern ity Care
~ Physician office visits
)> Prescr iption drug for elective abortion (m ifepristone)
Normal delivery , cesarean section , complications of pregnancy
& abortion
)> Inp atien t physician services
)> Hospital & ancillary services
Organ & Tissue Transplants (subject to utilization revie w;
specified organ transplants covere d only when performed
at Center of Experlise {COEJ)
~ Inpatient services provided in connection with
non -investigative organ or tissue transplants
)> Transp lant travel expense fo r an auth orized ,
specified transplant at a COE
(recipient & companion transportation limited to
6tripslepisode & $250/personltrip
for round-trip coach airfare, 21 days/trip , other expenses
limited to 1 trip/episode & $250 for round-trip coach airfare,
PPO : Per
Member Copa y
No capay
$20/visitt
(deductible waived)
No capay
No capay
No capay
No capay
No capay
No capay
(deductible waived)
No capay
No capay
No cop ay2
No capay
No capay
No cap ay
No capay
No capay
No capay
No n-PPO : Per
Member Co pay
50%
(benefit limited to $600/day)
50%
50%
50%
50%
50%
50%
50%
50%
50%
50 %2
50 %
50%
50%
50%
50%3
No capay (deductible waived)
hotel limited to $100/day for 7 days , other expenses limited to $25/day for 7 days)
1 The dollar copay applies only to the visit itself. An additional No copay applies for any services performed in office (i.e., X-ray , lab, surgery), after any applicable deductible.
2 Acupuncture services can be performed by a certified acupuncturist (CA.), a doctor of medicine (M.D.), a doctor of osteopathy (D.O.), a podiatrist (D.P.M.),
or a dentist (D.D.S.). 3 For California facilities, a discount will be applied if the facility has a contract with Anthem Blue Cross for fee-for-service business . For California
facil ities without a contract , covered expense for non~mergency hospital services and supplies is reduced by 25%, resulting in hig her costs for members .
Covered Serv ices
Bariat ric 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])
);> Inpatie nt se rvic es provided in co nnection with medically
necessary su rgery for weight loss, on ly for morbi d obe sity
PPO : Per
Member Copa y
No ca pay
Non-PPO : Per
Member Co pay
);> Bariatric travel expense when memb er's hom e
is 50 miles or more from the nea rest bari atric COE
(membe r's transportation to & from COE limited to
$130/person/trip for 3 trips [pre-surgical visit, initial
surgery & one follo w-up visit]; one companion 's
transportation to & from COE limited to $130/personltrip
for 2 trips [initial surgery & one follo w-up visit];
No ca pay (deductible waived)
hotel for member & one companion limited to one room
double occupancy & $1 00/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 member's initial
surgery stay for 4 days; other reasonable expenses
limited to $25/day/person fo r 4 daystfrip)
Diabetes Education Programs (requires physician supervision)
);> Teach members & their fami lies about the disea se
process, the daily management of diabe tic therap y &
se lf-ma nagement tra ini ng
$2 0/vi si t
(deductible waived)
Prosthetic Devices
);> Coverage for breas t prostheses ; pros the tic devices to No capay
re store a method of speakin g; surgical imp lants;
artifici al limbs or eyes ; the first pa ir of contact lenses
or eyeg lasses when re quired as a res ult of eye surg ery ;
& therapeu tic sh oes & inserts for members with dia bete s
Durable Medical Equipment
);> Rental or purchase of DME includ ing hearing aids, No co pa y
dialys is eq ui pment & supplie s (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 Med ical Services & Supplies
);> Ground or air ambulance trans port ation , services
& dispos ab le su pp lies
);> Blood tra nsfu sion s, blood processing & th e cost of
unrepl aced blood & blood pro ducts
);> Autolo gous bloo d (self-donated blood collection,
testing, processing & storage for planned surgery)
1 These providers are not represented in the Anthem Blue Cross PPO network.
No co pay1
No co pay1
No cop ay1
50%
50%
50%
Covered Serv1ces
Emergency Care
~ Emergency room services & suppl ies
($100 dedu ctible waived if admitted)
~ In patient hospital services
~ Physician services
Mental or Nervous Disorders and Substance Abuse
Inpatient Ca re
~ Faci li ty-based care (subject to utilization review;
waived for emergency admissions)
~ Inpatient phys ici an visits
Outpa tien t Ca re
~ Facility-based care (subject to utilization rev ie w;
wa ived for emergency admissions)
~ Outpatient physici an visits
(Behavioral Health Treatment for Autism & Pervasive Disorder
will be subject to pre-service review)
PPO : Per Non-PPO : Per
Member Copay Membe r Co pay
No capay No capay
No copay No capay
No copay No ca pay
100% 50%1
100% 50%
100% 50%1
$20/visi t2 50%
(dedu ctible waived)
1 For California facilities , a discount applies if the fa cility 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 Ev idence 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 Limitat ions
Not Medically Necessary. Services or supplies that are not medically necessary, as defined.
Experimental or Investigative. Any experime ntal or investigative procedure or medication.
But d member is denied benefits because it is determined that the requested treatment 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 sup pl ies furnished and bi lled by a provider outside
the United States, unless such services or supplies are furnished in connection with urgent care
or an emergency.
Cri me or Nuclear Energy. Conditions that result from (1) the member's commission of or attempt
to commit 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 of war, when
government funds are available for the treatment 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. Any amounts In excess of covered expense or the lifetime maximum.
Worli·Related. Wo!X-re lated conditions if benefits are recovered or can be recovered , either by
adjudication, settlement or otherwise, under any wo!Xers ' compensation, employer's liability law
or occ upational disease law, whether or not the member claims those benefits. If there is a dispute
of substantial uncertainty as to whether benefi ts may be recovered for those conditions pursuant to
wo!Xers' compensation, we will provide the benefits of this plan for suc h conditions, subject to a
right of recovery and reimbursement under Calrtornia Labor Code Section 4903, as spec ified as
covered in the EOC.
Governmen t Treatment. Any services the member actually received that were provided by a local,
state or federal government agency, except when payment under this plan is expressly requ ired by
fecleral or state law. We will not cover payment for these services rt the member Is not required to
pay for them or they are given to the insured person for free .
Services of Rel atives . Professiona l 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 .
Vo luntary Payment. Services for wh ich the member has no legal obligation to pay, or lor which
no charge 'Mlllld be made in the absence or insurance coverage or other health plan coverage,
except services rece ived at a non-governmental charitable research hospital. Such a hospital
must meet the following guidelines:
1. it must be internationally known as being devoted mainly to medical research;
2. at least 10% or its yea~y budget must be spent on research not direcHy related to
patient care;
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 or its patients must have conditions directly related to the hosp ital's research.
Not Specifica ll y Listed. Services not specifiCally listed in the plan as covered services.
Private Contract s. 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) or Tltie XVIII or 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.
Men tal or Nervous Disorders. Academic or educational testing, counseling , and remediati on.
Mental or nervous disorders and alcOhol or drug dependence, including rehab ili tative care in
rel ation to these cond itions , except as specified as covered in the EOC.
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 Uaw) join~ except as specified as covered In the
EOC. Cosmetic dental surgery or other dental services for beautification .
Hea ri ng Aids or Tests. Hearing aids and routine hearing tests, except as specified as covered
in the EOC .
Optometri c Services or Suppl ies. Optometric services, eye exercises including ortho ptics.
Routine eye exams and routine eye refractions, eyeglasses or contact lenses, except as specified
as covered in the EOC .
Outpatient Occupat ional Therapy. Outpatient occupational therapy , except by a home 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 tor beautification or to
alter or reshape normal (including aged) structures or tissues of the body to improve appearne.
This exclusion does not apply to reconstructive surgery (that is, surgery performed to correct
deformities caused by congenital or developmental abnormalities, ill ness , 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 th is plan.
This exclus io n includes, but is not limited to, commerc ial weigh t loss programs (Weig ht Watchers ,
Jenny Craig, LA Weight Loss) and fasting programs.
Th is 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
nervos a or bulim ia nervosa. Surgical treatment for morbid obesity is covered as described in the
Evidence of Coverage (EOC).
Sterilization Reversal.
Infertility Treatment. Any services or sup plies furnished In connection with the diagnosis and
treatment or Infertility, including, but not limited to diagnostic tests, medication , surgery , artificial
insemination , in vitro fertiliz ation, sterilization reversal and gamete intrafallopian transfer.
Surrogate Mother Servi ces. For any services or su pplies provided to a person not covered under
the plan in connection with a surrogate preg nancy (including , but no11imited to, the bearing or a
child by another wom an tor an infertile couple).
Orthopedic shoes and shoe inserts . This excluskln does not apply to orthopedic footwear used
as an integ ral part of a brace, shoe inserts that are custom molded to the patien~ or therapeutic
shoes and inserts designed to treat foot complications due to diabetes, as specifically stated in the
EOC
Air Cond itioners . Air purifiers , ai r cond itioners 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 nurs ing home or any similar facility. Services provided by a skilled nursing
facility or custodial care or rest cures, exce pt as specified as covered In the EOC.
Hea~h Club Membershi ps. Health club membershi ps , exercise equipment, charges from a
physical fitness instructor or personal trai ner, or any other charges for activities, equipment or
facili ties used for developing or maintaining physical fitness, even n ordered by a physician . This
exclusion also applies to health spas.
Persona l ~ems. Any su pplies for comfort, hygiene or beautifiCation.
Education or Counseling. Educational services or nu tritional counseling , except as specified
as cove red in the EOC . This excl usion 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 requi red by law. This exclusion Includes. but is not limited to, those nutr1tional formulas
and dietary supplements that can be purchased over the counter, which by law do not requirement
either a written presc ription or dispensing by a licensed pharmacist
Telephone and Facsim ile Machine Consu~ations . Consultations 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 specdled as covered in the EOC.
Acupuncture . Acupunctu re treatmen~ as specified as covered in the EOC. Acupressure or
massage to control pain , tre at illness or promote health by applying pressure to one or more
specific areas of the body based on dermatomes or acupunctu re points.
Eye Surgery for Refractive Defects. Any eye surgery solely or primarily for the purpose of
correcting refractive defects of the eye such as nearsig htedness (myopia) and/or astigmatism .
Contact lenses and eyeglasses required as a result of this surgery.
Phys ica l Therapy or Phy sical Medicine. Services of a ph ysician for physical therapy or physical
medicine, except whe n provided during a covered inpatient confinement or as spec ified as covered
in theEOC.
Outpatien t Presc ri ption Drugs and Medications . Outpatient prescription drugs or medications
and insul in, except as specified as covered in the EOC . Any non-prescription , over-the-cou nter
patent or proprietary drug or medicine. Cosmetics, heal th or beauty aids .
Specialty Pharmacy Drugs. Specialty pharmacy drugs that must be obtained from the spec ialty
pharmacy program , but. which are obtained from a retail pharmacy, are not covered by this plan.
Member will have to pay the full cost of th e speci any pharmacy drugs obta ined from a retail
pharmacy that should have been obta ined from the specialty pharmacy program .
Contraceptive Devices. Contraceptive devices prescribed for birth control except as specified
as covered in the EOC.
Diabetic Supplies. Presc ri ption and non-prescription diabetic supplies except as specified
as covered in the EOC.
Private Duty Nursing. Inpa tient or outpatient services of a private duty nurse.
Lifestyle Programs . Programs to alter one's lifestyle which may Include but are not limi ted to die~
exercise, Imagery or nutrition . This exclusion will not apply to cardiac rehabi litation programs
approved by us.
Wigs.
Th ird Party Liability-Anthem Blue Cross is entitled to reimb ursemen t of benefits paid rt the
member recovers damages from a legally liable lhird party.
Coord ination 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% or the covered expense .
Anthem Blue Cross is the trade name of Blue Cross of Californ ia. Independent Licensee
of the Blue Cross Association.® ANTHEM is a reg istered trademark of Anthem Insurance
Companies, Inc. The Blue Cross name and symbol are reg istered marks of the
Blue Cross Association.
Anthem .+. 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 requ irements , incl ud ing applic able provisions of the
recently enacted federa l health care reform laws . As we rece iv e addit io na l guidance and clarification on the new health ca re reform
laws from the U.S. Department of Health and Human Servic es , Department of Labor and Interna l Reve nu e Service, we may be
required to make add itiona l changes to this summary of benefits . Th is proposed be nefi t summary is su bj ect to the approval of the
California Department of Insurance and the California Department of Managed Health Care . In add ition to doll ar and percentage
copays , insured persons are responsible for deductibles , as described below . Please review the deductible informatio n to know if a
deductible applies to a specific covered service . Certain Covered Services have maximum vis it and /or day limits per year. The
number of visits and/or days allowed for these services will begin accumulating on the first vis it and /or day, regard less of whethe r
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 ita lics. Benefits are subject to all terms , conditions , limitations , and exclusions of the Policy .
Explanation of Maximum Allowed Amount
Maximum Allowed Amount is the total re imbursement payable under the plan for covered serv ices received fro m Pa rticipati ng and Non -
Participating Providers. It is the payment towards the servi ces billed by a provider comb ined with any applicab le dedu ctible , co pay ment or
co insurance . Participating Providers-The rate the provider has agreed to accept as reimbursemen t fo r covered serv ices . Mem bers are not
responsible for the difference between the provider's usual charges & the max imum allowed amoun t. Non-Participating Providers & Oth er
Health Care Providers-(i ncludes those not represented in the PPO provider network)-Re imburse ment amou nt is based on: an Anthe m Blue
Cross rate or fee schedule , a rate negotiated with the provider, informat ion from a th ird party vend or , or billed cha rges . For Medica l
Emergency care rendered by a Non-Participating Provider or Non-Contracting Hosp ital , reimburseme nt ma y be based on the reaso nab le
and customary value . Members may be respons ible for any amount in excess of the reasonab le and cus tomary value .
When using Non-PPO and Other Health Care Providers , insured persons are respons ible for any difference between
the covered expense & actual charges , as well as any deductible & percentage copay .
Benefit year deductible for all prov iders (emb edded) $250(J nsured pers on
maximum of two sepa rate deduct ibles/fam ily
Deductible for non -PPO hospital $500/adm issi on (waived for emergency admission)
Deductible for hospital if utilization review not obtained $500/adm ission (waived for emergency admission)
Deductible for emergency room services $1 00/visi t (waived if admitte d directly from ER)
Annual Out -of-Po cket Maximums (no cross application)
PPO & Other Health Care Providers $3 ,000(J nsured person /year; $5,000/fa mily/yea r
Non-PPO Providers $10 ,000(J nsu red pers on/yea r; $1 5,000/fami ly/yea r
The following do not apply to the medical out-of-pocket maximums : non-covered expenses and presc ription drugs. After an annual out-of-
pocket maximum is met for medical during a calendar year, the individual member or family wi ll no longer be req uired to pay a copay or
coinsurance for med ical. The member rema ins respons ible for non -covered expenses and prescripti on drug s
Lifetime Maximum Unlimited
Covered Servi ces PPO : Per Ins ured
Person Co pay
Hospital Medical Serv ic es (subjec t to utilization re vie w
fo r inpatient services; waived for eme rgency admission)
);> Semi-private room , meals & spec ial diets , & an ci llary serv ices
);> Outpatient med ical care , surg ical services & suppl ies
{hospital care other than eme rgency room care)
Ambulatory Surg ical Centers
);> Outpatient surgery, services & supplies
Skilled Nursing Facility (subj ect to utilization review)
);> Semi-private room , services & supplies
(limited to 100 dayslbenefrl year)
Hospice Care
No co pay
No copay
No co pay1
No cop ay1
);> Inpatient or outpatient services for insured persons ; family be reavemen t services
Home Health Care
);> Service s & supplies from a home health agen cy No co pay 1
{limited to 100 visits/benefit year, one visit by a
home health aide equals four hours or less;
not co vered while insured person receives hospice care)
No copa y2
Non-PPO : Per Insured
Perso n Copay
50%
50%
50%1 {benefit limited to $350/day)
50%1
50%1
1 The.se providers may not b~ represen ted in the PPO ne twork in the sta te where the insured person receives services. If such provider is not available in the service area ,
the 1nsured person's copay 1s the same as for PPO. All copays are in addition to applicable dedudibles. 2These provide rs may not be represented in the PPO ne twork in the
sta te ~ere an insured person receives servi~s . 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 ~Mce area and the 1nsured person receiVes serv~ces from a PPO provider, the insured person 's copay is No copay. However, if the insured person chooses to receive
seMces from a non-PPO provider when such provider is available in th e service area, th e insu red 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-LB 2105 Effective 12-19-16 Printed 11 /23/20 16
Covered Services
Home Infusion Therapy (subj ect to utilization re view)
~ Includes medication , ancillary services & suppl ies ;
caregiver train ing & visits by provider to monitor therapy ;
durab le medical equ ipment ; lab services {lim ited to $60 0/day)
Phys ician Medical Services
~ Office & home visits
~ Hosp ital & skilled nursing facil ity vis its
~ Surgeon & surgical ass istant; anesthesio logist or anesthetis t
Diagnostic X-ray & Lab
~ MRI , CT scan , PET scan & nuclear card iac scan
(subject to utilization revie w)
~ Other diagnost ic x-ray & lab
Preventive Care Services
Preventive Care Services including*, physical exams , preventi ve
screenings (including screen ings for cancer , HPV, diabetes , cho lestero l
blood pressure , hearing and vis ion , immunizatio ns, health educat ion ,
intervention services , HIV test ing ), and addit iona l preven ti ve care for
women prov ided for in the guide lines supported by the Health
Resources and Serv ices Adm inistration .
*Th is list is not exhaustive . Th is benefit include s all Preventive Care
Serv ic es required by fede ral and state law
Physical Therapy , Physical Medicine & Occupational
Therapy, including Chiropractic Services (limited to
24 visits/b enefit year; additional visits may be authorized)
Speech Therapy
~ Outpat ient speech the rapy following inj ury or organi c di sease
Acupuncture
~ Servi ces for the treatment of disease , illness or inju ry
{limited to 12 visits/benefit ye ar)
Temporomandibu lar Joint Disorders
~ Spl int the rapy & surg ical treatment
Pregnancy & Maternity Ca re
~ Ph ysician offi ce vi sits
~ Prescr iption drug for elective abort ion (mifep ristone)
No rmal del ivery , cesarean section , comp licat ions of pregnan cy
& abortion
~ Inpatien t phys ician services
~ Hosp ital & ancillary services
Organ & Tissue Transplants (subje ct to utilization review)
~ Inpatient serv ices provided in connection with
non-investigative organ or tissue transp lants
PPO : Per Insured
Person Copay
No copay 1
$20 /vis it2
{deductible waived)
No copay
No copay
No copay 1
No copay 1
No copa y
(deductible waived)
No copay
No copay
No cop ay3
No copa y
No copay
No copa y
No co pay
No copay
No copay
Non-PPO : Per Insured
Person Copay
50 %1
50%
50%
50%
50%1
50%1
50 %
50 %
50 %
50%3
50 %
50%
50%
50%
50%
No co pay
1 These providers may not be represented in th e PPO network in the sta te where the insured person receives services . If such provid er is not avail able in the service area ,
th e in sured person's copay is the sa me as for PP O. All co pays are in addition to appl icab le deducti bles.
2 The dollar copay ap plies only to the visit itself. An add itio nal No copay applies fo r an y services performed in office (i.e., x-ray , lab, surgery), after any applicable deductible .
3 Acup un cture services can be perform ed by a certi fied acupu nctu rist (C.A.), a doctor of medici ne (M.D.), a doctor of osteopathy (D.O.), a podia trist (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 devic es to No copay
restore a method of speaking ; surgic al implants; artificial
limbs or eyes ; the first pair of contact le nses or
eyeglasses when required as a result of eye surgery ;
& therapeutic shoes & inserts for insured persons with diabetes
Durable Medical Equipment
)> Rental or purch ase of DM E including hearing aids , No copay1
dialysis equ ipment & suppl ies {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 Med ical Services & Supplies
:;. Ground or air ambulance transportat ion, services
& disposable supplies
)> Blood transfusions, blood processing & the cost of
unreplaced blood & bloo d products
)> Autologous blood (self-donated blood collection ,
testing, processing & storage for planned surgery)
Emergency Care
)> Emergency room services & suppl ies
($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 utiliza tion review;
wa ived for emergency admissions)
)> Inpatient physician visits
Outpatient Care
)> Facility-based care (subject to utilization review;
wa ived for emergency admissions)
)> Outpa tient physician visits
(Behavioral Health Treatment for Autism & Pervasive Disorder
will be subject to pre-service review)
No copay
No copay
No co pay
No copay
No copay
Nocopay
No copay2
No copay2
No copay2
$20 /visiP
(deductible waived)
Non-PPO : Per Insu red
Person Copay
50%
50%
50%1
No copay
No copay
No copay
50%1
50%
50%1
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 availab le 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 network in the state where an insured person receives services. If su ch provider is no t ava ilable 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 availab le in the service area, the insured
perso n's copay is 50%. All copays are in addition to applicable deductibles.
In addition to the benefits described above , coverage may include additional benefits , depend ing upon the insured person 's home
state. The benefits provided in this summary are subject to federal and Californ ia laws . There are some states that require more
generous benef its be provided to their residents , even if the master pol icy was not issued in their state . If the insured person 's
state has such requirements , we wi ll adjust the benefits to meet the requ irements .
This Summary of Benef its is a brief review of benefits. Once en rolled , insured persons will rece ive a Cert if icate of Insurance ,
which expla ins the exc l us ions and limitations , as well as the full range of covered serv ices of the plan , in deta il.
BC Premier ET Plan-Exclusions and Lim itations
Not Medically Necessary. Services or supplies that are not medically necessary, as defined.
Experimental or Investigative. Any experimental or investigative procedure or med ication.
But ff insured person is de nied benefits because it 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
United States, unless such services or supplies are furnished In connection with an emergency.
Crime or Nuclear Energy . Conditions that result from (1) the insured person 's commission of
or attempt to commit 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, 'Mlether or not the result of war ,
'Mien government funds are avail able 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.
Worii ·Related. Wor'll·related conditions ff benefits are recove red or can be recovered , either by
adjudication, settlement or otherwise, unde r any wor'llers ' compensation, employer's liabili ty liM'
or occupational disease liM', whether or not the Insured person claims those benefits . If the re is
a dispute of substantial uncenalnty as to 'Mlether benefits may be recovered for those conditions
pursuant to wor'llers' compensation , we will provide the benefits of this plan for such conditions,
subject to our right of recovery, as specffi ed as covered In the CertifiCate.
Government Treatment. Any services the Insured person actually received that were provided
by a local, state or federa l governme nt agency, except when paymen t under this plan is ex pressly
required by federal or state liM'. 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 Re latives. Professional services received from a person living in the Insured person's
horne or who is related to the insured pe rson by blood or marri age, except as specified as covered
in the CertifiCate .
Voluntary Payment. Services for whic h the insured person is not legally obligated to pay.
Services for which the insured person Is not charged. Services for which no charge Is made
in the absence of insurance coverage , exce pt services received at a nor~-governmental charitable
research hospital. Suc h a hospital must meet the following guidelines :
1. it must be internationally known as being devoted mainly to medical researc h;
2. at least 10% of its yeariy budiget must be spent on research not directly related to
patient care;
3. at least one-th ird 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 Listed . Se rvices 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 whic h 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 perfonmied safe ly on an outpatient basis.
Mental or Nervous Disorders. Academic or educ ational testing, counsel ing, and remediation .
Mental or nervous disorders or substance abus e, including rehabilitative care in relation to these
conditions, except as specified as covered in the Certificate.
Denta l Services or Supplies. Dental plates, bridges, crowns, caps or other dental prostheses ,
dental implants, de ntal services, extraction of tee th , or treatment to the teeth or gums, or treatment
to or for any disorders for the jiM' joi nt except as specffied as covered in the Certificate. Cosmetic
dental surgery or other dental services for beautifiCation.
Hearing Aids or Tests . Hearing aids, except as spec ified as covered In the Certificate.
Routine hearing tests.
Optometric Services or Supplies. Optometric services , eye exerc ises includi ng ortho ptics, routine
eye exams and routine eye refractions . Eyeglasses or contact lenses, except as specified as
covered in the CertifiCate .
Outpatient Occupational Therapy. Outpa tie nt occ upational the rapy, except by a horne health
agency, hospice, or horne infusion therapy provider, as specified as covered in the Certificate .
Outpatient Speech Therapy. Outpatient speech thera py, exce pt as specified as covered
In the CertifiCate.
Cosmetic Surgery. Cosmetic surgery or other services perfonmed solely for beautification or to
alter or reshape normal (includ ing ag ed) structures or tissues of the bCICy to Improve appeara nce.
This exclusion does not ap ply to reconstructive surgery (th at is, su rgery perform ed to correct
deformities caused by congenital or developme ntal abnormalities, illness, or inj ury for the purpose
of improving bCICIIy functio n or symptomatology or to create a normal appearar~te), including
surgery performed to res tore symmetry following mastectomy. Cosmetic surgery does not become
reconstructive surgery because of psychological or psych iatric reasons.
Commercial Weight Loss Programs. Weight loss programs, 'Mlether or not they are pursued
under medical or physic ian supervision, unless spec ffic ally listed as covered in this plan.
This exclusion Includes, but is not limi ted to, commercial weigh t loss programs (Weight Watchers ,
Jenny Craig, LA Weigh t Loss) and fasting programs.
This exc lusion does not apply to medically necessary treatments for morbid obesity or dietary
evaluations and counseling , and be havioral rood ifiCation programs for the treatment of anorexia
nervosa or bulimia nervosa. Surgical treatment for mcrbld 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 wi th the diagnosis and
treatment of infertility , including, but not limi ted to, diagnosti c tests, medication, surgery, artific ial
insem ination, in vitro ferti lization, sterilization reversal , and gamete lntrafallopian transfer .
Surrogate Mother Services . For any services or supplies prov ided to a person not covered under
the pl an In connection wi th a sumogate pregnancy (including, but not limi ted to, the bearing of a
child by another woman for an infertile couple).
Orthopedic shoes and shoe Inserts. This exc lusion does not ap ply to orthopedic footwear used
as an integral part of a brace , shoe inserts th at are custom molded to the patient or therapeutic
shoes and inserts designed to treat foot complications due to diabetes , as spec ffi call y stated in the
CertifiCate.
Air Conditioners . Air purifiers, ai r cond itioners or humldfflers.
Custodial Care or Rest Cures . Inpatient room and board charges in connectio n with a hospital
stay primarily for enviro nmental change or ph ysical the rapy. Se rvices provided by a rest home,
a horne for the aged , a nursing home or any similar facility . Services prov ided by a sk illed nursing
facil ity or custod ial care or res t cures , except as specified as covered in the CertifiC ate.
Health Club Memben;hips . Health club members hi ps , exercise equipment, charges from a
physical fitness instructor or personal trainer, or an y other charge s for activities , equipment or
facilities used for developing or maintaining physical fitness , even ff ordered by a physician. This
excl usion also applies to health spas.
Personal ~ems . Any suppli es for comfort, hygiene or beautification .
Education or Counseling. Educational services or nutritiona l counseling , except as specified
as covered in the CertifiCate. This exc lusion does not apply to counseling for the treatment of
ar~trexia nervosa or bulim ia nervosa.
Food or Dietary Supplements. Nutritional and/or dietary su pplements, except as provided in this
plan or as required by liM'. This exclusion incl ude s, but is not limited to, those nutritional formulas
and dietary su pplements that can be purc hased over the counter , which by liM' do not requirement
either a written prescription or dispensing by a licensed ph armac ist
Telephone and Facsimile Machine Consultations. Consu ltations provided by telephone
or facsimile machine.
Routine Exams or Tests . Routine physical exams or tests whic h do not directly treat an actual
illness, injury or condition , including those requi red by employment or government authority,
except as spec ified as covered in the CertifiCate.
Acupuncture. Acupuncture trea trnen~ except as specified as covered in the Certifica te.
Acupressure or massag e to control pain, treat ill ne ss or promcte health by applying pressure
to one or mone specific areas of the bCIC y based on dermatomes or acupuncture points.
Eye Surgery for Refractive Defects. Any eye surgery solely or pri marily for the purpose of
correcting refractive defects of the eye SUICh as nears ightedness (myopi a) and /or astigmatism.
Contact lenses and eyeglasses required as a result of this surgery.
Physical Therapy or Physical Medicine. Services of a physidarl for physical therapy or physical
medicine, except 'Mien provided during a covered in patient confinement or as specified as covered
in the CertifiCate.
Outpatient Prescription Drugs and Medications. Outpatient presc ri ption drug s, medications and
insulin except as specified as covered In the certifiCate. Non-prescription, over·the-<:ounter patent or
proprietary drugs or medicines. Cosmetics , health or beauty aids .
Contracepti ve Devices . Contracepti ve devices pre sc ri bed for birth control except as specified
as covered in the Certificate.
Diabetic Supplies. Pre scription and nor~-prescription diabetic supplies except as specified
as covered in the Certificate .
Private Duty Nun;ing. Inpatient or outpatient services of a private duly nurse.
Li festyle Programs . Programs to alte r one's lifestyle which may Include but are not li mited to diet
exe rc ise, imagery or nutrition. This exc lusion will not apply to cardiac reha bilitation programs
approved by us.
Wigs.
Third Party Liability -Anthem Bl ue Cross Lffe and Health Insurance Company Is enti tled to
reimbursement of benefits paid n the insured person recovers damages from a legally liable
thi rd party.
Coordination Of Benef~s-The benefits of this pl an may be reduced d the Insured person has
any other group health or dental coverage so that the servi ce s received from all group coverages do
not exceed 100% of the covered expense.
Anthem Blue Cross Life and Health Insurance Company is an indepen dent licensee
of the Bl ue Cross Association .® ANTHEM is a registered trademarlt: of Anthem Insurance
Compan ies, Inc. The Blue Cross name and symbol are registered marks of the
Blue Cross Association.
Anthem .+.
81ueCtou
SJVIA County of Fresno
PPO 1000
Custom Classic PPO
(1 000/45/80/50)
Anthem believes this plan is a "grandfathered health plan" under the Patient Protection and Affordable Care Act (the Affordable Care Act). As permitted by
the Affordable Care Act, a grandfathered health plan can preserve certain basic health coverage that was already in effect when that law was enacted. Being
a grandfathered health plan means that this plan may not include certain consumer protections of the Affordable Care Act that apply to other plans , for
example, the requirement for the provision of preventive health services without any cost sharing . However, grandfathered health plans must comply with
certain other consumer protections in the Affordable Care Act , for example, the elimination of lifetime limits on benefits.
Questions regarding which protections of the Affordable Care Act apply and which protections do not apply to a grandfathered health plan and what
might cause a plan to change from grandfathered health plan status can be directed to Anthem at the telephone number printed on the back of your
member identification card , or contact your group benefits administrator if you do not have an identification card . For ERISA plans, you may also
contact the Employee Benefits Security Administration , U.S. Department of Labor at 1-866-444-3272 or www.dol.gov/ebsa/healthreform. This Web
site has a table summarizing which protections do and do not apply to grandfathered health plans . For nonfederal governmental plans , you may
also contact the U.S . Department of Health and Human Services at www.healthreform .gov.
In addition to dollar and percentage copays , members are responsible for deductibles , as described be low. 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 max imums .
Plan maximums and other important information appear in italics. Benefits are subject to all terms, conditions , limitations, and exclusions of the
Polic .
Explanation of Maximum Allowed Amount
Maximum Allowed Amount is the total reimbursement payable under the plan for covered serv ices 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 , re imbursement may be based on the
reasonab le 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 .
Calendar year deductible for all providers
Deductible for non -Anthem Blue Cross PPO hospital or
residential treatment center
$1 ,000 /member; $2,000/family
None
Deductible for non-Anthem Blue Cross PPO hospital or
residential treatment center if utilization review not obtained
$250/admission (waived for emergency admission)
Deductible for emergency room services $1 00/visit (waived if admitted directly from ER)
Annual Out -of-Pocket Maximums (no cross application )
PP O Providers & Othe r Health Care Providers $4 ,000/member/year; $8,000/family/year
Non-PPO Providers $10,000/member/year; $20 ,000/family/year
Th e following do not apply to out-of-pocket maximums: non-covered expense . After a member reaches the out-of-pocket maximum, the
member remains responsible fo r non-PPO providers & other health care providers , costs in excess of the covered expense.
Lifetime Max imum Unlimited
Covered Services PPO : Per
Member Co pay
Hospital Medical Services (subject to utilization review
for inpatient services; waived for emergency admissions)
~ Semi-private room , meals & special diets ,
& anci llary services
~ Ou tpatient medical care , surgica l 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 & supplie s
(limited to 100 days/calendar year)
Hospice Care (subject to utilization review)
~ Inpatient or outpatient services; for members
with up to one year life expectancy; family
Bereavement services
$1 ,000/year2 + 20%
20%
$250/surgery + 20%
20%
No capay
Non·PPO : Per
Member Copay1
50%
(benefit limited to $600/day)
50%
(benefit limited to $600/day)
50%
(benefit limited to $350/vis it)
20%
1The percentage copay for non-emergency seiVices from non -Anthem Blue Cross PPO providers is based on the scheduled amount.
2 Applicable to the Annual Out-of-Pocket maximums .
anthem .com/ca Anthem Blue Cross (P -NP) Effe ctive 12-19-16 Printed 11/23/2016
Covered Services
Home Health Care (subject to utilization review)
)> Serv ices & supplies from a home health agency
(limited to 100 prior authorized visits/calenda r year, one visit by a
home health aide equals four hours or less ; not covered
while membe r receives hospice care)
Home Infusion Therapy (subject to utilization review)
)> Includes med ic at ion , ancillary services & supplies ;)
careg iver tra ining & vis its by provider to mon itor
therapy ; durable medical equipment ; lab services
Phys ician Med ical Serv ices
)> Office & home visits
)> Hospital & skilled nursing facility visits
)> Surgeon & surgical assistant ; anesthes iologist or anesthetist
)> Drugs admin istered 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 Ca re Serv ices
Prevent ive Care Services includ ing*, physical exams , preventive
screenings (including screenings for cancer, HP V, diabetes , cholesterol ,
blood pressure, hearing and vision immun izat ions , health education,
in tervent ion serv ices , HIV testing), and additio nal preventi ve care
for women provided for in the gu id elines supported by the Health
Resources and Services Adm in istration.
*This list is not exhaustiv e. This benefit includes all Prevent ive Care
Services required by federa l and state law.
Physical Therapy , Physica l Medic ine & Occupat ional
Therapy
Ch iropractic Services (up to 12 visits/calendar year; additional
visits may be approved, if medically necessary)
Speech Therapy
)> Outpatient speech the rapy fo llowing injury or org an ic dise ase
Acupuncture
)> Serv ices for the treatment of disease, ill ness or injury
(limited to 20 visits/calendar year)
Temporomandibular Jo int Disorders
)> Splint therapy & surgical treatment
Pregnancy & Maternity Care
)> Phys ici an office visits
)> Prescr iption drug for elective abortion (m ifepristone )
Normal de livery, cesarean sect ion, complications of pregnan cy
& abort ion
)> Inpatient physician serv ices
)> Hospital & ancillary services
PPO : Per
Me mber Copay
20%
20%
$45 /visit2
(deductible waived)
20%
20%
20%
20%
No capay
No capay
(deductible waived)
$25 /visit
(deductible waived)
$25 /visit
(deductible waived)
$45 /visit
(deductible wa ived)
20%3
20%
$45/visit2
(deductible waived)
20%
20 %
$1 , 000/year' + 20%
)> Female Steri lization(inc/uding tuba/ligation and counseling/consultation) No capay
)> Male Sterilization 20%
)> Family plann ing counseling $45 /visi t
(deductible waived)
Non -PPO: Per
Member Copay1
20% with authorization
20%
50%
50%
50 %
50 %
50 %
50 %
50%
50%
50%
50%
50%3
50%
50 %
Not covered
50 %
50 %
(benefit limited to $600/day)
Not covered
Not Covered
Not covered
1The percentage copay for non-emergency services fro m non-Anthem Blue Cross PPO providers is based on the sched uled amount.
2The dollar copay applies only to the visit itsel f. An additional20% copay applies for any services performed in office (i.e., X-ray , lab , surgery), after any applicable deductible.
3Acupuncture services can be performed by a certified acu puncturist (CA), a docto r of medici ne (M .D.), a doctor of osteopathy (D.O.), a podiatrist (D.P.M.),
or a dentist (D.D.S.).
4 Appl icable to the Annual Out-of-Pocket ma ximums
Covered Services
Organ & Tiss ue Transplants (subject to utilization review;
specified organ transplants covered only when performed
at a Center of Expertise [COE])
};> Inpa tient services provided in connection with
non-investigative organ or tissue transplants
};> Transplan t trave l expense for an authorized ,
specified transplant at a COE
(recipient & companion transportation limited to 6 trips/episode
& $250/personltrip for round-trip coach airfare , hole/limited to 1
room double occupancy & $100/day for 21 days/trip , other
expenses limited to $25/day/perso n for 21 days/trip, donor
transportation limited to 1 trip/episode & $250 for round-trip
coach airfare , hotel limited to $100/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 a Center of Expertise
[COE])
};> Inpatient services provided in connection with medically
necessary surgery for weight loss , only for morbid obesity
};> 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];
hotel for member & one companion limited to one ro om
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 member's initial
surgery stay for 4 days; other reasonab le expenses
limited to $25/day/person for 4 days/trip)
Diabetes Education Programs (requires physician supervision)
PPO : Per
Member Cop ay
Non-PPO : Per
Member Copay ,
$1 ,000/y earJ + 20%
No capay (deductible waived)
$1 ,000/yearJ + 20%
No capay (deductible wa ived)
};> Teach members & their families about the disease
process, the daily management of diabetic therapy &
self-management training
$45/visit
(deductible waived)
50 %
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 su rgery; & therapeutic shoes
& inserts
Durable Medical Equipment
50%
};> Ren tal or purchase of DM E including 50%
dialysis equipment & supp lies , home medical equipment,
prosthetic /o rthotics (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 ai r ambulance transportation, services
& disposable supp lies
};> Bl oo d transfusions, blood processing & the cost of
unreplaced bloo d & blood products
};> Autologous blood (self-donated blood collection,
testing, processing & storage for planned surgery)
50 %
50%
20%2
20%2
20%2
1 The percentage copay for non-emergency ser.tices from non-Anthem Blue Cross PPO providers is based on the scheduled amount.
2 Th ese providers are not repre sented in the Anthem Blue Cross PPO network.
3 Applicable to the Annual Out-of-Pocket maximums
Covered Services
Emergency Care
~ Emergency room services & supplies
($100 deductible waived if admitted)
~ Inpatient hospi tal services & supplies
~ Physician services
Mental or Nervous Disorders and Substance Abuse
Inpatient Care
~ Facility-based care (subject to utilization review;
waived for emergency admissions)
~ In patient physician vis its
Outpatient Care
~ Faci lity-based care (subject to utilization review;
waived for emergency admissions)
~ Outpatient phys ician visits
(Behavioral Health treatm en t for Autism & Pervasive Disorder
will be subject to pre-service review)
PPO : Pe r Non·PPO : Per
Member Copa y Member Copay1
20% 20%
$1 , 000/yearJ + 20% 20%
20% 20%
$1 ,0 00/y earJ + 20% 50%
(benefit limited to $600/day)
20% 50 %
20% 50%
(benefit limited to $600/day)
$45 /visiF 50%
(deductible waived)
1 The percentage ccpay for non-emergency services from non -Anthem Blue Cross PPO providers is based on the scheduled am ou nt.
2 The dollar ccp ay applies only to the visit itself. An additional20% ccpay applies for any services performed in office (i .e., X-ray , lab, su rgery), after any applica ble deductible .
3 Applicable to the Annual Out-of-Pocket maximums
Th is Summary of Benefits is a brief review of benefits . On ce enrolled , members will receive a Combined Evidence of Coverage and
Disclosure Form , wh ich expla ins the exclusions and lim itations , as well as the full range of covered services of the plan ,
in detail.
Classic PPO Plan Exclusions and Limitations
Not Medically Necessary. Services or supplies that are not medically necessary, as defined .
Experimental or Investigative. Any experimental ()(Investigative procedure()( medication.
Bu~ ~ mem ber Is denied benefits because " is determined that the requested treatment
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 Unted States , unless such services or supplies are furnished In connection with urgent care
or an emergency.
Crime ()(Nuclear Energy. Conditions that result from (1) the member's commission ol ()(attempt
to commit a felony, as long as any lrjuries are not a resutt of a medical cond itlion or an act of
d()(OOStic >iolence; ()( (2) any release ot nuclear energy, whether ()( not the resutt ot war, when
government funds are available f()( the treatment of mness ()(Injury arising from the release
of nuclear energy.
Not Covered. Services received bef()(ethe membe~s effectlve date. Services rece ived
atter the membe~s coverage ends, except as specified as covered In the EOC .
Excess Amounts . Any amounts in excess of covered expense or any Medic al Benefit Maximum .
Work·Related. Wori<·relaled conditions ~benefits are recovered()( can be recovered , either by
adjudication, settlement or otherwise, under any wori<ers' compensation, ernploye~s liability law
()(occupational disease law, whether()( not the member cl aims those benefits . If there is a dispute
of substantial oooenainty as to whether benefits may be recovered tor those conditions pur.;uant to
wori<ers' compensation , we will provide the benefits of this plan tor such conditions, subject to a
right of recovery and re imbursement under CatitorrOa Labor Code Section 4903, as specified as
covered In the EOC.
Government Treatment. Any services the member actually received that were provided by
a local, state or federal government agency, except when payment under this plan Is expressly
required by fed eral ()( state law. We wi ll not cover payment tor these services if the member Is not
required to pay f()( them or they are given to the member for tree.
Services of Relatives. Professional services received from a per.;on living in the member's
h()(ne ()(who Is related to the member by blood ()( marriage, excep t as specified as covered
ln the EOC
Voluntary Payment. Services tor which the member has no legal obllgatlion to pay ,()( tor which
no charge waud be made In the absence otlnsurance coverage()( other health plan coverage,
except services received at a non-governmental charitable research hospital . Such a hospital
must meet the following guidelines:
1. "must be internationally known as being de'o'Oted mainly to medical research;
2. at least 10% of Its yearly budget must be spent on research not directly rel ated to
patient care;
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~ patients must have conditions directly related 10 the hospital's research.
Not Specifically Usted. Services not specifiCally Usted In the plan as covered services.
Private Contrads. Services()( supplies provided pur.;uant to a private contract between
the member and a provider, for which relmrusement under Medicare program Is prohibited ,
as specified In Section 1802 (42 U.S.C. 1395a) of Title XV III of the Social Security Act.
Inpatient Diagnostic Tests. Inpatient 10()(0 and board charges In connectlion with a hospital stay
primarily tor diagnostic tests which could have been pertomned safe ly on an outpatient basis.
Mental or Nervous Dlsorden. Academic()( educational testing, counseling , and remediation .
Mental or nervous dlmers or subs tance ab use , Including rehabilitative care in relation to these
conditions , except as specified as covered In the EOC.
Orthodontia. Braces, other ()(thodontic ap pliances or orthodontic services.
Dental Services or Supplies. Oental plates, bridges, crowns, caps()( other dental prostheses ,
dental implants, dental services, extraction of teeth, treatment to the teeth()( gums , or treatment to
or tor any dimers !()(the temporornand ib\.lar ijaw) joi~ except as specified as covered In the
EOC. Cosmetic dental st.Wgery ()(other dental services for beautJflcatlon
Hearing Aids or Tests ..
Optometric Services or Supplies. Opt()(OOtric services, eye exercises Including or1hoptics.
Routine eye exams and routine eye refraction s, as spec ified as covered In the EOC.
Eyeglasses or contact lenses, except as specified as covered In the EOC.
Outpatient Occupational Therapy. Outpatient occupational therapy, except by a h()(ne health
agency, hospice, or h()(ne Infusion therapy provider, as specified as covered in the EOC .
Outpatient Speech Therapy. Outpatient speech therapy, except as specified as covered
intheEOC.
Cosmetic Surgery. Cosmetic surgery()( other services perf()(med solely for beautificatlion or to
al1er ()(reshape normal (lnclud1ng aged) struclires ()(tissues olthe body to Improve appeararce.
This exclusion does not apply to reconstructive surgery (that Is , surgery performed to conrect
deformities caused by congenital()( developmental abnormal ities , Inness, ()( irjla'Y f()( the purpose
of improving bodily function()( symptomatology or to create a normal appearance), includ ing
SlWQery performed to restore symmetry following mastectomy. Cosmetic SlWQery does not become
reconstructive surgery because of psychological()( psychiatric reasons.
Commercial Weight Loss Programs. Weight loss programs, whether()( not they are pur.;ued
under medical()( physician supervision, unless specifiCally listed as covered In this plan .
This exclusion Includes, but is not limited to, commercial weight loss programs (Weight Watcher.;,
Jenny Craig, LA Weight Loss) and fasting programs.
This exclusion does not apply to medicii/y necessB')' treatments tor morbid obesity or dietary
evaluations and counseling, and behavioral modification programs for the treatment of anorexla
nervosa ()(bu limia nervosa SlWQical treatment f()( mocbld obesity Is covered as described In the
Evlldence of Coverage (E OC).
Sterilization Reversal.
lnfertil"r Treatment. Any services or supplies tumshed in connection wi th the diagnosis and
treatment of lnfertil"r, Including, but not limited to diagnostic tests, medication , SlWQery , artificial
Insemination, in vitro fertilizatlion , sterilization rever.;al and gamete lntrafalloplan transfer.
Surrogate Mother Services. For any services()( supplies provided to a per.;on not covered under
the plan in connection -Mth a surrogate pregnancy (including, but not limited to , the bearing of a
child by another v.oo1an f()( an Infertile couple).
Orthopedic shoes and shoe Inserts . This exclusion does not apply 10 ()(thoped ic footwear used
as an integral part of a brace, shoe Inserts that a-e custom molded 10 the patien~ ()( therapeutk
shoes and inserts designed to treat foot complicatlions due to diabetes, as specifically stated In the
EOC
Air Cond ki oners. Air purifier.;, air conditioners ()( hllllldlfiers .
Custodial Care or Rest Cures. Inpatient 10()(0 and board charges In connectlion with a hosp"al
stay primarily tor environmental change or physical therapy . Services provided by a rest home,
a h()(OO f()( the ag ed, a nur.;lng home or any similar facility. Services provided by a skilled nur.;ing
facility or cu stodial care()( rest cures . except as specified as covered In the EOC .
Health Club Membellihlps . Health club membeiShips, exercise eq uipment, charges from a
physical fi tness Instruct()(()( peiSDnal trainer, ()(any other charges for ac tivities, equipment or
facilities used f()( developing()( maintaining physical fitness, even~ ()(dered by a p/Jysician. This
exclusion also applies to health spas.
Penonal ~ems. Any supplies for comf~ hygiene()( beautification
Education or Counseling. Educational services()( ootritional counseling, except as specified
as covered In the EOC. This exclusion does not apply to counseling for the treatment of anorexia
nervosa ()( bulimia nervosa
Food or Dietary Supplements. Nutri tional and/()( dietary supplements, except as provided In this
plan or as required by law. This exclusion Inc ludes, but Is not limited to, those nutritional focmulas
and dietary supplements that can be purchased over the counter , which by law do not requirement
either a written prescription()( dispensing by a licensed pharmacist
Telephone and Facsi mile Machin e Consu Hatlons. ConstJtatlions provided by telephone
()( facsimile machine.
Routine Exams or Tests. Routine pllysical exams or tests which do not d1rectty treat an actual
i lness, Injury()( condition , lnclud1ng those required by employmen t()( govenvnent authority,
except as specified as covered In the EOC .
Acupuncture. Acupoo:ture treatmen~ except as specified as covered In the EOC. Acupressure
or massag e to control pain , treat Illness or promote health by applying pressure to one()( more
specific areas of the body based on dermatomes or acupuncture points.
Eye Surgery for Refractive Defects . Any eye surgery solely()( primarily f()( the purpose of
correcting refractive defects of the eye such as near.;ightedness (myopia) and}()( astigmatism.
Contact lenses and eyeglasses req uired as a resul t of this surgery.
Physical Therapy or Phys ical Medicine. Services of a physician for physical therapy()( physical
medicine, except when provided during a covered inpatient confinemen t()( as specified as covered
lntheEOC.
Outpatient Presc ri ption Dru gs and Medications . Outpatient prescription drugs or medications
and Insulin, except as specified as covered In the EOC. Any non-prescriptlion, over-the-counter
patent or proprietary drug or medicine . Cosmetics , health()( beauty aids.
Specialty Phanmacy Drugs. Specialty pharmacy drugs that must be obtained from the specialty
pharmac y program , but, which are obtained from a retail pharmacy, are not covered by this plan.
Member will have to pay the full cost of th e specla"y phanmacy drugs obtained from a retail
pharmacy that should have been obtained from the speclatty phanmacy program.
Contraceptive Devices . Contraceptlve devlices prescribed f()( birth control ex cept as specified
as covered in the EOC .
Diabetic Suppl ies. Prescription and non-prescrip tion diabetic suppl ies except as specified
as covered in the EOC .
Private Duty Nulliing. Inpatient or outpatient services of a private duty nur.;e
Lifestyle Programs. Prog rams 10 alter one's ~feslyle which may include but are not llm"ed to die~
exercise, imagery or nutrition . This exc lusion will not apply to c<rtfiac reha bili tation programs
approved by us .
Wigs .
Third Party Liab ility -Anthem Blue Cross Is entitled to reimbursemen t of benefits paid~ the
member recover.; damages from a legally liable thi rd party.
Coordination of Benefits -The bene fits ol this plan may be reduced ~the member has any other
group health()( 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 Ca lifornia. Independent Licensee
of the Blue Cross Association.@> ANTHEM Is a registered trMiemark of Anthem Insurance
Compani es, Inc. The Blu e Cross name and symbol are reg istered marks of the
Blue Cross Association.
Anthem .+. SJVIA County of Fresno
PPO 1000
Custom Classic PPO
(1 000/45/80/50)
Anthem believes this plan is a "grandfathered health plan " under the Patient Protection and Affordable Care Act (the Affordable Ca re Act). As permitted by
the Affordable Care Act, a grandfathered health plan can preserve certain basic health coverage that was already in effect when that law was enacted . Being
a grandfathered health plan means that this plan may not include certain consumer protections of the Affordable Care Act that apply to other plans, for
example, the requirement for the provision of preventive health services without any cost sharing. However, grandfathered health plans must comply with
certain other consumer protections in the Affordable Care Act , for example, the elimination of lifetime lim its on benefits .
Questions regarding which protections of the Affordable Care Act app ly and which protections do not apply to a grandfathered hea lth plan and what
might cause a plan to change from grandfathered health plan status can be directed to Anthem at the telephone number printed on the back of your
member identification card , or contact your group benefits administrator if you do not have an identification card. For ER ISA plans , you may also
contact the Employee Benefits Security Administration , U.S. Department of Labor at 1-866-444-3272 or www.dol.gov/ebsa/healthrefo rm. This Web
site has a table summarizing wh ich protections do and do not apply to grandfathered health plans . For nonfederal governmental plans , you may
also contact the U.S. Department of Health and Human Services at www.healthreform .gov.
In addition to dollar and percentage copays , members are responsible for deductibles , as described be low. Please review the deductib le information
to know if a deductible applies to a specific covered serv ice. Certain Covered Services have max imum visit and /or day lim its per yea r. The number
of visits and/or days allowed for these services will beg in accumu lating on the first visit and/or day, regardless of whethe r your Deductible has been
met. Members are also responsible for all costs over the plan maximums .
Plan max imums and other important information appear in ital ics . Benefits are subject to all terms , conditions, limitat ions , and exclus ions of the
Polic .
Explanation of Ma ximum Allowed Amount
Max imum Allowed Amount is the total reimbursement payable under the plan for covered services rece ived from Participating and Non-Participating
Providers . It is the payment towards the services billed by a prov ider co mbined with any applicable deductib le, copayment or co insu rance.
Participating Providers-The rate the prov ider has agreed to accept as re imbursement for covered services . Members are not respo nsible 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 vendo r, or billed cha rges .
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 .
Calendar year deductible for all providers
Deductible for non-Anthem Blue Cross PPO hospital or
residential treatment center
$1 ,000/member; $2 ,000 /family
None
Deduct ible for non-Anthem Blue Cross PPO hospital or
res idential treatment center if utilization review not obta i ned
$250/admission (waived for emergency admission)
Deductible for emergency room services $100/visit (waived if admitted directly from ER)
Annua l Out-of-Pocket Maximums (no cross application)
PPO Providers & Other Health Care Providers $4 ,000/member/year ; $8 ,000/family /year
Non -PPO Providers $10 ,000/member/year ; $20,000/family/year
The following do not apply to out-of-pocket maximums : non-covered expense. Afte r a member reaches the out-of-pocket maximum , the
member remains responsible for non -PPO provide rs & other health care providers , costs in excess of the covered expense.
Lifetime Maximum Unlimited
Covered Services PPO : Per
Member Copay
Hospital Med ica l Services (subject to utilization review
for inpatient services ; waived for emergency admissions)
);:> Semi-pr ivate room , meals & special diets ,
& ancillary services
);:> Outpatient medical care , surgical services & supplies
(hospital care other than emergency room care)
Ambu latory Surg ica l Centers
);:> Outpatient surgery, services & supplies
Skilled Nursing Facility (subject to utilization review)
);> Semi-private room, services & supp lies
(limited to 100 days/calendar year)
Hospice Care (subject to utilization review)
);:> Inpatient or outpatient services ; for members
wi th up to one year life expectancy ; family
Bereavement services
$1 ,000/year2 + 20%
20 %
$250/surgery + 20%
20 %
No capay
Non-PPO : Per
Member Copay1
50%
(benefit lim ited to $600/day)
50 %
(benefit limited to $600/day)
50 %
(be nefit limited to $350Msit)
20%
1The percentage copay for non-emergency services from non-Anthem Blue Cross PPO providers is based on th e sched ul ed amount.
2 Applicable to the Annual Out-of-Pocket max imums.
anthem .com/ca Anthem Bl ue Cross (P-N P) Effective 12-19-16 Printed 11 /23/20 16
Covered Services
Home Health Care (subj ect to utilization review)
}> Services & supplies from a home health agency
(limited to 100 prior authorized visits/calendar year, one visit by a
home health aide equals four hours or less; not covered
while member receives hospice care)
Home Infusion Therapy (subject to utilization re view)
}> Includes medication , ancillary services & supplies ;)
caregiver training & visits by provider to monitor
therapy ; durable medical equipment ; lab services
Physician Medical Serv ices
}> 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 Serv ices
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 , Phys ical Med icine & Occupational
Therapy
Chiropractic Serv ices (up to 12 visits/calendar year; additional
visits may be approved, if medically necessary)
Speech Therapy
}> Out patient speech therapy following injury or organic disease
Acupuncture
}> Services for the treatment of disease , illness or injury
(limited to 20 visits/calendar year)
Temporomandibular Jo int 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
PPO : Per
Member Co pay
20%
20%
$45 /visit2
(deductible waived)
20%
20%
20 %
20%
No capay
No copay
(deductible waived)
$25/visit
(deductible waived)
$25/visit
(deductible wa ived)
$45/visit
(deductible waived)
20 %3
20 %
$45/visit2
(deductible waived)
20%
20%
$1 ,000/year' + 20 %
}> Female Sterilization(including tuba/ligation and counseling/consultation) No copay
}> Male Sterilization 20 %
}> Family planning counseling $45/visit
(deductible waived)
Non-PPO : Per
Membe r Copay 1
20% with authoriza tion
20%
50%
50 %
50 %
50%
50%
50%
50 %
50%
50%
50%
50%3
50%
50%
Not covered
50 %
50 %
(benefit limited to $600/day)
Not covered
Not Covered
No t covered
1The percentage copay for non-eme rgency services from non-Anthem Blue Cross PP O providers is based on the scheduled amoun t.
2The dollar copay ap plies only to the visit itself. An add itional20% co pay applies for any services performed in office (i.e., X-ray , lab, surgery), after any applicable deductible.
3Acu punctu re services can be perform ed by a certified acupuncturist (C .A.), a doctor of medicine (M .D.), a doc tor of ost eopa thy (D.O.), a podiatrist (D.P.M.),
or a dentist (D.D.S.).
4 Applicabl e to the Annual Out-o f-P octet maxim um s
Covered Services
Organ & Tissue Transplants (subject to utilization review;
specified organ transplants covered only when performed
at a Center of Expertise [CO E])
).> Inpatient services provided in connection with
non-investigative organ or tissue transplants
lo-Transplant travel expense for an authorized ,
specified transp lant at a COE
(recipient & companion transportation limited to 6 trips/episode
& $250/person/trip for round-trip coach airfare, hotel limited to 1
room double occupancy & $1 00/day for 21 days/trip, other
expenses limited to $25/day/p erson for 21 days/trip, donor
transportation limited to 1 trip/ep isode & $250 for round-trip
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 revie w; 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 su rgery for weight loss, only fo r morbid obesity
~ Bar iatr ic travel expense when member's home
is 50 miles or more from the nearest Bariatr ic COE
(m ember's transportation to & from COE limited
to $130/personArip fo r 3 trips [pre-s urg ical visit,
initial surgery & one follo w-up visit]; one companion 's
transportation to & from COE limited to $130/person/trip
for 2 trips [initial surgery & one follow-up visit];
hotel for member & one companion limited to one room
double occupancy & $100/da y 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 member's initial
surgery stay for 4 days ; other reasonable expenses
limited to $25/day/person for 4 days/trip)
Diabetes Education Programs (requires physician supervision)
~ Teach members & their fam ili es about the disease
process , the daily management of diabetic th erap y &
self-management training
Prosthetic Devices
PPO : Per
Member Copay
Non-PPO : Per
Member Copay1
$1 ,000/yearJ + 20%
No copay (deductib le waived)
$1 ,000/yearJ + 20%
No copay (deductible waived)
$45/vis it
(deductible waived)
50 %
lo-Coverage for breast prostheses ; pros thetic devices to 50%
resto re a method of speaking ; surg ical impl ants ; artificial
50%
limbs or eyes ; the first pair of contact lenses or eyeglasses
when required as a result of eye surgery ; & therapeutic shoes
& inserts
Durable Medical Equipment
~ Rental or purchase of DM E including 50%
dialysis eq ui pme nt & supplies , home med ical equipment ,
pros thetic/orthotics (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
& dis posable supplies
~ Blood transfus ion s, blood process ing & the cost of
unreplaced blood & blood produ cts
~ Autologous blood (self-donated blood collection,
testing , process ing & storage for planned surgery)
50 %
20%2
20%2
20%2
1 The percentage copay for non-emergency services from non-Anthem Blue Cross PPO providers is based on the scheduled amou nt.
2 These providers are not represented in the Anthem Blu e Cross PPO network .
3 Applicable to the Annual Out-of-Pocket maximums
Covered Services
Emergency Care
:> Emergency room services & supp lies
($100 deductible waived if admitted)
:> Inpat ient ho spital se rvices & su pp li es
:> Physici an se rvices
Mental or Nervous Disorders and Substance Abuse
Inpatient Care
:> Facility-based care (subject to utilization review;
waived for emergency admissions)
:> Inpatient physician visits
Outpat ien t Care
:> Facility-ba sed care (subject to utilization review;
waived for emergency admissions)
:> Outpati ent physician visits
{Behavioral Health treatment for Autism & Pervasive Disorder
will be subject to pre-service review)
PPO : Per
Member Co pay
20%
$1 ,000/year l + 20%
20%
$1 ,000/yearl + 20%
20%
20%
$45/visit2
{deductible waived)
Non-PPO : Pe r
Member Copay1
20%
20%
20%
50%
{benefit limited to $600/day)
50%
50%
{benefit limited to $600/day)
50%
1 The percentage copay for non-emergency services from non -Anthem Blue Cross PPO providers is based on the sched uled am ou nt.
2 The dollar copay applies only to the visit itself. An additional 20% copay app lies for any services performed in office (i.e ., X-ray , lab, surgery), after any applicable dedu ctible.
3 Applicable to the Annual Out-of-Pocket maximums
Th is Summary of Benefits is a brief rev iew of be nef its . Once enrolled , membe rs will rece ive a Comb ined Evidence of Coverage and
Disclosure Form , wh ich expla ins the exclusions and limitations , as well as the fu ll range of co vered serv ices of the plan,
in detail.
Classic PPO Plan Exclusions and Limita tions
Not Med ically Necessary. Services or supplies that are not medically necessary, as defined .
Experimental or Investigative. Any experimental or investigative procedure or medication.
But, if member is den ied benefits because it is determined that the requested treatment
is experimental or investig ative, the member may request an independent medical review,
as described in the Evidence of Coverage (EOC).
Outside the United States . Services or supplies furn ished and billed by a provider outside
the United States, unless such services or supplies are furnished in connection v.1th urgent care
or an emergency.
Cri me or Nuclear Energy. Conditions that result from (1) the member's commission of or attempt
to commit a felony, as long as any injuries are not a result of a medical cond ition or an act of
domestic violence; or (2) any release of nuclear energy, whe ther or not the result of war , when
government funds are available for the treatment of illness or injury arising from the release
of nuclew energy.
Not Covered. Services received before the member's effective date. Services rece ived
after the membe r's coverage ends, except as specified as covered In the EOC.
Excess Amounts. Any amounts in excess of covered expense or any Medical Benefit Maximum.
Wor1<·Related. Wor1<·related conditions if benefits are recovered or can be recovered, either by
adjudication, settlement or otherwise, under any wor1<ers ' compensation, em ployers liability law
or occ upational disease law, whether or not the member claims those benefits. If there is a dispute
of substantial uncertainty as to whether benefits may be reccvered for those conditions pursuant to
wor1<ers' compensation, we v.111 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 Treatment. Any services the member actually received that were provided by
a iocal, state or federal government agency, except when payment under th is plan is expressly
required by federal or state law. We v.111 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.
Services of Relat ives. Professional services received from a person living in the member's
horne 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 rece ived at a non-9ovemmental charitable research hospital. Such a hospital
must meet the follov.1ng guidelines:
1. it must be Internationally known as being devoted mainly to medical research ;
2. at least 10% of its yea rly budget must be spent on research not directly related to
patient care;
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-th irds of its patients must have cond itions directly related to the hos pital's research .
Not Specifically Listed. Services not specifiCally listed in the pian as covered services.
Private Contracts. Services or supplies provided pursuant to a private contract between
the member and a provider, for wh ich reimbursemen t under Medicare program is prohibi ted,
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 v.ith 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 rehabil itative care in relation to these
conditions, except as specified as covered In the EOC.
Orthodontia. Braces, other orthodontic appliances or orthodontic services.
Dental Services or Supplies. Dental plates, bridges, crowns , caps or other den tal prostheses,
dental impl ants, dental services, extraction of teeth, treatment to the teeth or gums, or treatment to
or for any disorders for the temporomandibular uaw) jolnL except as specified as covered in the
EOC . Cosmetic dental surgery or other dental serv ices for beautifiCation.
Hearing Aids or Tests ..
Optometric Services or Supplies. Optometric services , eye exercises inc luding orthoptics .
Routine eye exams and routine eye refractions, as specified as covered in the EOC .
Eyeglasses or contac t lenses, exc ept as specified as covered In the EOC .
Outpatient Occupational Therapy . Outpatient occu pational therapy , except by a home health
agency, hospice, or horne infusion therapy provider, as spec ified as covered in the EOC.
Outpatient Speech Therapy. Outpatient speech therapy, except as specified as cove red
in the EOC.
Cosmetic Surgery. Cosmetic surgery or other services perfonmed solely for beautification or to
alter or reshape normal (including aged) structures or tissues of the body to improve appearance.
This exc lusion does not apply to reconstructive surgery (that is, surgery periiormed to correct
deformities caused by congenital or developmental abnormalities , illness , or injury for the purpose
of Improving bodi ly function or symptomatology or to create a normal appearance), Includ ing
surgery performed to restore symmetry follov.1ng mastecto my. 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 physldan supervision, unless specifiCal ly listed as covered in this plan.
This exc lusion includes, but is not limited to, commercial weight loss programs (Weight Watchers,
Jenny Craig, LA Weight Loss) and fasting programs .
This exclusion does not ap ply to medically necesslll}' treatments for morbid obesity or dietary
evaluations and counsel ing, and behavioral modification programs for the treatment of anorexia
nervosa or bulimia nervosa. Surgical treatment for morbid obes ity Is covered as described in the
Evidence of Coverage (EOC).
Ste rili zation Reversal.
Infertility Treatment. Any services or supplies furnished in connection v.1th the diagnosis and
treatment of infertility, Including, but not limited to diagnostic tests, medication , surgery , artificial
insemination, in vitro fe rtilizatio n, sterili zation reversal and gamete intrafalloplan transfer.
Surrogate Mother Services. For any services or su pplies provided to a pers on not covered under
the plan in connection v.1th a surroga te pregnancy (including , but not limited to, the bearing of a
child by another woman for an infertile couple).
Orthopedic shoes and shoe inserts . Th is exclusion does not apply to orthopedi c footwear used
as an Integral part of a brace, shoe inserts that are custom molded to the patienL 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 v.1th a hospital
stay pri marily for environmental chang e or physica l therapy . Services provided by a res t home,
a horne for the aged, a nursing home or any similar fac ility. Services provided by a skilled nursing
facility or custodial care or rest cures, except as specified as covered in the EOC .
Hea~h Club Membel'$hlps . Health club memberships, exerc ise equipment. cha rg es from a
physical fitness instructor or persona l trainer, or an y other charges for activities, equipment or
facilities used for developing or maintaining physic al fitness , even ff ordered by a physidan. This
exclusion also applies to health spas.
Personal ~ems. Any supplies for comfort, hygiene or beautification.
Education or Counsel ing. Educational services or nutritional counseling, except as specified
as cove red in the EOC . This excl usion does not appl y 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 requi red by law. This exclusion includes, but Is not limited to, those nutri tional form ulas
and dietary supplements that can be purchased over the coun ter , whic h by law do not requirement
either a written prescriptk>n or dispensing by a licensed pharmacist
Telephone and Facsimile Machi ne Consu~ations . Consultations provided by telephone
or facsimile mach ine .
Routine Exams or Tests. Routine physic al exams or tests which do not directly treat an actua l
illness, Injury or condition, including those required by employment or government authority ,
except as specified as covered in the EOC .
Acupuncture. Acupuncture treatmenL except as specified as covered in the EOC. 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 dermatomes or acupunc ture points.
Eye Surgery for Refractive Defects . An y eye surgery solely or primarily for the purpose of
correcting refractive defects of the eye such as nearsighted ness (myop ia) and/or astigmatism.
Co ntact 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
intheEOC .
Outpatient Prescri ption Drugs and Medications . Outpatient prescription drugs or medic ations
and insulin, except as specified as covered in the EOC . Any non-prescri ption, over-the-counter
patent or proprietary drug or med icine. Cosmetics, health or beauty aids.
Specialty Pharmacy Drugs . Speci alty pharmacy drugs that must be obtained from the specialty
pharmacy program, but, whic h are obtained from a re tail pharmacy, 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 obta ined from the speci a~y pharmacy program.
Contraceptive Devices. Contraceptive devices prescribed for birth control exc ept as specified
as covered in the EOC.
Diabeti c Supplies. Prescription and non-prescription diabetic supplies except as specified
as covered In the EOC.
Pri vate Duty Nurs ing. Inpatient or outpatie nt services of a private duty nurse.
Lifestyle Programs . Programs to al ter one's lifestyle which may include but are not limited to dieL
exercise, imagery or nutrition . This exclusion v.111 not apply to cardiac reh abilitation programs
approved by us.
Wigs .
Third Party Liability -Anthem Blue Cross is entitied to reimbursement of benefits paid ff the
member recovers damages from a leg ally liable third party .
Coordination of Benefits - The benefi ts of thi s pl an may be reduced ff 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 Californ ia. Independent Licensee
of the Blue Cross Assoc iation.® ANTHEM Is a registered trademark of Anthem Insurance
Companies, Inc. The Blue Cross name and symbol are registered marks of the
Blue Cross Association.
Anthem .+. SJVIA County of Fresno
Modified Lumenos ®
Health Savings Account (HSA)
LHSA266 (1500/80/60)
Thi s summary of benefits has been updated to comply with federal and state requi rements , includ ing applicable provisions of the
recently enacted federal health care reform laws . As we receive additional guidance and clarification on the new hea lth care reform
laws from the U.S. Department of Heal th and Human Services , Department of Labor and Internal Revenue Se rvi ce , we may be
required to make additional changes to this summary of benefits . This proposed benefit summary is subject to the approval of the
Cal ifo rn ia Department of Insurance and the Ca liforn ia Department of Managed Hea lth Care . This Lumenos plan is an innovative type
of coverage that allows an insured person to use a Health Sav ings Account to pay for rout ine medical care . The prog ram also
includes traditional health coverage , simi lar to a typica l health plan that protects the insured person against large med ic al expenses .
The insured person can spend the mo ney in the HSA account the way the insured person wants on rout ine med ical care ,
prescription drugs and other qual ified medical expenses . There are no copays or deductibles to satisfy first. Unused do ll ars can be
saved from year to year to reduce the amount the insured person may ha ve to pay in the future . If covered expenses exceed the
insured pe rson's available HSA dollars, the trad itional health co verage is availab le after a limited out-of-pocket amount is pa id by the
insured pe rson . Certa in Covered Services have maxi mum vis it and/or day limits per year . The number of visits and /or days allowed
fo r these services wi ll begin accumulat ing on the first vi sit and/or day, regardless of whether your Dedu ctib le has been met. The
insured person is responsib le for all costs over the plan ma ximums . Plan max imums and other important information appear in
italics. Benefits are subject to all terms , conditions , limitatio ns , and exclusions of the Policy.
Explanation of Ma ximum 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 serv ices billed by a provider combined with any appl ic able deductib le, copayment or
coinsurance . Participating Prov iders-The rate the prov ider has agreed to accept as reimbursement for covered services . Members are not
responsib le for the differen ce between the provider's usual charges & the ma ximum 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 provi der, information from a third party vendor,
or billed charges . Fo r Med ical Emergency care rendered by a Non -Participating Provider or Non-Contracting Hospital , re imbursement may
be based on the reasonab le and customary value. Members may be respons ible 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-Participa ting Pharmacies -members are responsible for any expense not covered under th is plan & any
amount in excess of the prescr iption drug ma ximum allowed amount.
When using non-part icipating prov iders , the insured person is responsible for any difference between the cove red expense &
actual charges , as well as any deductible & perc entage copay .
When us ing the outpatient prescription drug benef its , the insured pers on is always responsible for drug expenses which are not
covered under th is plan , as well as any deductib le, percentage or dolla r co pa y.
Calenda r yea r deductible fo r all providers
(applicable to medical care & pre scription drug benefits)
)> Ind ividual insured person (only 1 person on the plan )
)> Insured family (in cludes insured employe e & one or more
members of the employee's fam ily
Individual can rece ive benefits once ind ividual deductible has been met
Annual Out-of-Pocket Ma ximums (in -network/out-of-network
out-of-pocket maximums are exclusive of ea ch other; includes
calendar year deductible & prescription drug covered expense)
)> Participating Prov iders, Participating Pharmacy
& Other Health Care Providers
)> Non-Participating Providers & Non-Part icipating Pharmacy
$1 ,500ft nd ividual insured person
$3 ,000ft nsured fam ily
$3 ,000ft nd ividual insured person ; $5 ,0 00 /insured fami ly/year
$1 O,OOOft nd ividual insured person ; $15,000 /insured family /year
}he following do n~t apply to ~ut-~f-pocket .maximums : costs in excess of the co vered expense & non-covered expense . After an ind ividua l
1nsu~ed person or 1ns.ured fam1ly (m~lu.des msured employee & one o.r rn_o:e m~mbers of the emp!oyee 's fami!Y) .reaches the out-of-pocket
max1mum fo~ ~II me.d1cal and pres cnp~1on drug coyere~ expense the md1V1?ual1nsured person or 1nsured fam1 ly mcurs during that calendar
year , the 1nd1v1 dua~ msured pe~son or 1.nsured fam!I Y w1ll no lonQer be requ1red to pay a capay for the remainder of that year . The ind ividual
Insured person or 1nsured family remams responsible for costs 1n excess of the covered expense when prov ided by non-participating
providers and other heal th care providers ; non-covered expense .
Lifetime Maximum Unlimited
an the m.co m/ca Anth em Blue Cross Life and Health Insurance Company (NP). NGF M-LL 2045 Effective 01/2017 Pri nted 11123/2016
Covered Serv ices
Hospital Med ical Services (subject to utilization re view
for inpatient services ; wa ived for emergen cy admission s)
~ Sem i-private room , meals & special diets, & ancillary services
~ Outpatient medical care, surgical services & supplies
(hospital care other than emergen cy room care )
Ambulatory Surgical Centers
~ Outpatient surgery , services & supplies
Skilled Nursing Facility (subj ect to utilization review)
~ Semi-private room, services & supplies
(limited to 100 days/calendar year)
Hosp ice Care
~ Inpatient or outpatient services for insured persons with up
to one year life expectancy; family bereavement services
Home Hea lth Care
~ Services & supplies from a home health agency
(limited to 100 vis its/c alendar 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
Physic ian 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
Prevent ive Care Services
Preventive Care Services including•, physical exams , prevent ive
screenings (includ ing screenings for cancer , HPV , diabetes , cholesterol ,
blood pressure , hearing and vis ion , immunizations, health education ,
intervention services , HIV testing), and additional preventive care for
women provided for in the guidelines supported by the Health
Resources and Serv ices Administration .
•This list is not exhaustive . This be nefit includes all Preventive Care
Services requi red by federal and state law.
Physical Therapy , Physical Med icine & Occupat ional Th erapy ,
~ncluding Chiropractic Services (lim ited to 24 visits /calendar year)
Speech Therapy
~ Outpatient speech therapy following injury or organ ic disease
Acupuncture
~ Services fo r the treatment of disease , illness or injury
(limited to 12 visits/calendar year)
Temporomandibular Joint Disorders
~ Splint therapy & surgical treatment
Traditional Health Coverage
In sured Person Cop ay
In-Network Out-of-Network
20%
20%
20%
20%
20 %
20%
20 %
20%
20%
20%
20%
20 %
20 %
No co pay
20%
20%
20%1
20 %
(Insured is also responsible
for charges in excess of
covered expense .)
40 %
40 %
40 % (benefit limited to $350/day)
40 %
40 %
40 %
40%
(benefit limited to $600/day)
40 %
40%
40%
40 %
40%
40%
40%
40%
40%
40%1
40 %
1 Acupuncture services ca n be performed by a ce rtified acupuncturist (C.A .), a doctor of medicin e (M.D.), a doctor of osteopathy (D.O.), a podiatrist (D .P.M.),
or a dentist (D.D.S.).
Covered Services
Pregnancy & Maternity Care
~ Phy sician office visits
~ Prescription drug for elect ive abortion (mifepristone)
Normal delivery, cesarean section , com plications
of pregnancy & abortion
~ In pa tient phys ician services
~ Hospital & ancill ary services
Organ & Tissue Transplants (subject to utilization review;
specified organ transplants covered only when performed
at Centers of Medical Excellence [CME])
~ In patient servi ces prov ided in connection with
non-investigativ e organ or tissue transp lants
~ Transplant travel expense for an au thorized , specified
transplant at a CME (recipient & companion transportation
limited to 6 trips/episode & $250/personltrip for round-trip
coach airfare hole/limited to 1 room double occupancy &
$100/day for 21 daysArip, other expenses limited to
$25/day/person for 21 daysArip; donor transportation
limited to 1 trip/episode & $250 for round-trip coach airfare,
hole/limited to $100/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 connect ion with medically
necessary surgery for weight loss , on ly 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/pe rsonltrip for 3 trips [pre-surgical visit,
initial surgery & one follo w-up visit]; one companion 's
transportation to & from CME limited to $130/person/trip
for 2 trips [initi al surgery & one follow-up visit];
hotel for insured person & one companion limited to
one room double occupancy & $1 00/day for 2 days/trip,
or as medically necessary, for pre-surgical & follow-up visit;
hotel for one compan ion limited to one room double
occupancy & $100/day for duration of insured person 's
initi al surgery stay for 4 days; other reasonable expenses
limited to $25/day/person for 4 daysArip)
Diabetes Education Programs (requires physician supervision)
~ Teach insured persons & the ir fam ilie s about the dise ase
process , the daily management of dia betic therapy &
se lf-management training
Prosthetic Devices
> Coverage for breast prostheses ; prosthetic devices
to restore a method of speaking ; surgical im plants ;
artificial limbs or eyes; the first pa ir of contact
lenses or eyeg lasses when requ ired as a result of
eye surgery ; wigs for alopecia resu lting from
chemotherapy or rad iation therapy; & therapeutic shoes
& inserts for insured persons with diabetes
Trad itiona l Health Coverage
Insured Person Copay
In-Network Out-of-Network
20%
20%
20%
20%
20%
20%
20%
20 %
20%
20%
(Insured is also responsib l e
for charges in excess of
covered expense .)
40%
40%
40%
40%
40%
40%
Covered Services
Durable Med ica l Equipment
Rental or purchase of DM E including hearing aids ,
dialysis equipment & supp lies (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 Outpatie nt Med ical Services & Supplies
);> Ground or air ambu lance transportation , services
& disposable supplies
);> Blood transfusions , blood processing & the cost
of unreplaced blood & blood products
);> Autologous blood (s elf-donated blood colle ction,
te sting, 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 (subj ect to utilization re view;
waived for emergency admissions)
);> Inpatient physician visits
Outpatient Care
);> Faci lity-based care (subj ect to utilization review;
waived for emergency admiss ions)
);> Outpatient physician visits
(Behavio ral Health treatment for Autism & Pervasive Disorder
will be subject to pre-service review)
1 The se providers are not represented in the PPO networll .
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 respons ible
fo r cha rges in excess of
covered expense .)
40 %
20%
20 %
20%
40%
40%
40 %
40%
Covered Services
Outpatient Presc ri ption Drug Benefits
} Preventive immuni zations administered by a retail pharmacy •
} Female oral contraceptives generic and single source brand ,
} Flu , Zostavax & Pneumococcal vaccines
} Retail pharmacy prescription drug maximum allowed am ou nt
} Mail service prescription drug maximum allowed amount
} Specialty pharmacy drugs (obtained through specialty
pharmacy program)
Supply Lim its 2
} Retail Pharmacy (participating and non-participating)
} Home Delivery
} Specialty Pharmacy
Traditional Hea lth Coverage
Insured Person Copay
In -Network Out-of-Network
No capay (deductible wa ived)
No capay (deductible waived)
No capay
20%
20%
20%
(Insured is also respons ible
fo r charges in excess of
the prescription drug
maximum affowed amoun t)
40 %1
Not applicable
Not applicable
30-day supply; 60-day supp ly for federally class ified
Schedule II attention deficit disorder drugs that require
a triplicate prescription form , but requ ire a doub le co pay;
6 tablets or un its/30-day period for impotence and/or
sexual dys fu nction drugs (available only at reta il pharmacies)
90-day supply
30-day supply
11nsure d person remains resp onsible 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 comple te inform ation.
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 med ications
} Prescription oral contraceptives; con traceptive diaphragms. Contra ceptive diap hragms are limited to one per year.
} Injectable drugs which are self-administered by the subcutaneous route (un der 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 ingredien t
} Diabetic supplies (i.e ., test strips and lancets)
} Prescription drugs for treatment of impotence and/or sexual dysfunction are limited to organ ic (non -psycho logical) causes .
} In haler spacers and peak flow meters for the treatment of pediatric asthma.
} Smoking cessa tion products requiring a phys ician 's prescription .
} Certai n over-the-counte r drugs approved by the Pharmacy and Therapeutics Committee to be include d in the prescription drug
formulary .
} Flu , Zos tavax & Pneumococcal vaccines obtained at a local network pharmacy must be administered by a pha rmacist
This Summary of Benefits is a brief review of benefits . Once enrolled , insured persons will re ceive a Certificate of Insurance ,
which expla ins the exclus ions and limitations , as well as the full range of covered serv ices of the plan in deta il.
Lumenos Health Savings Acc ount Plan-Exclusions and Limita tions
Benefits are not pro vided fo r expenses incurred for or in connect ion
with the fo llow ing items :
Not Medically Necessary. Services or supplies that are not med ically necessary, as defined .
Ex perimental or Investigative. Any experimental or investigative procedure or medication.
But ~insured perso n is denied benefits because it is determined that the requested treatment
is experimental or investigative , the insured perso n 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 sup plies are furnished In connection with urgent care
or an emergency.
Cri me or Nuclear Energy. Conditions that result from (I) the insured person's commission of
or attempt to commit a felony, as long as any injuries are not a result of a medical condition or an
act of domestic violence: or (2) any rele ase 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.
Not Covered. Services rereived 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 . Any amounts in excess of covered expense or the lifetime maximum.
Worli ·Re lated. Wor'f(.re lated conditions ~benefits are recovered or can be recovered , either
by adjudication, settlement or otherwise, under any wor11e rs ' compensation , employers liability
law or occupational disease law, whether or not the insured person claims those benefits. If there
is a disp ute of substantial uncertai nty as to whethe r benefits may be recovered for those conditions
pursuant to wor'f(ers' compensation , we will provide the benefits of this plan for such cond itions,
subject to a right of recovery and reimbursement under Calitonnia Labor Code Section 4903,
as specifiec as covered in the CertifiC ate.
Government Treatment. Any services the insu red person actually received that were provided
by a local, state or federal government agency, except when payment unde r 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 rereived from a perso n living In the insured person's
honne or wiho is rel ated to the insured person by blood or marriage , exce pt as specified as covered
in the CertifiCate.
Voluntary Payment. Services for which the insured person has no legal obligation to pay,
or for wh ich no charge woul d 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 hospital must meet the followi ng 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 di rectly related to patient care :
3. at least one-th ird of its gross Income must come from donatio ns or grants other than gifts
or payments for patient care:
4. it must acce pt 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 Listed. Services not specifiCally listed in the pian as covered services .
Private Contracts . Services or supplies provided pursuant to a private co ntract between the
insured person and a provider, for which reimbursement under Medicare prog ram is prohibited,
as specified In Section 1802 (42 U.S.C. 1395a) of Title XVIII of the Social Security Act.
Inpatient Diagnostic Tests. Inpatient roonn and board charges in connection with a hospital stay
primarily for diagnostic tests which could have been performed safe ly on an outpatient bas is.
Mental or Nervous Disorders. Academic or educational testing , counseling, and remediation .
Mental or nervous disorders or substance abuse, includi ng rehabilitative care in relation to these
conditions , except as specified as covered in the Certificate .
Orthodontia. Braces , other orthodonti c appliances or orthodontic services .
Denta l Services or Supplies. Dental plates, bridges, crowns, caps or other dental prostheses,
dental implants, dental services , extraction of teeth , treaunent to the teeth or gums , or treaunent to
or for any disorders for the temporomandibular Qaw) joint excep t as specified as covered in the
CertifiCate. Cosmetic dental surgery or other dental services for beautification
Heari ng Aids or Tests. Heari ng aids , except as specified as covered in the CertifiCate.
Routine hearing tes ts, exce pt as spec ified as covered in the CertifiCate.
Optometric Services or Su pplies . 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 Occu pat ional Therapy. Outpatient occupational therapy , exce pt by a honne health
agency, hospice, or honne infusio n therapy provider, as specified as cove red 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 beautificatio n
or to alter 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 correc t deformities caused by congenital or developmental abnormalities , illness , or injury
for the purpose of improving bodily function or symptomatology or to cre ate a normal appearance),
including surgery performed to restore symmetry following mastectomy. Cosmetic surgery does not
become reconstructive surgery because of psychological or psyc hiatric reasons.
Scalp Hair Prostheses. Scalp hair prostheses , inc lud ing wigs or any form of hair replacement,
exce pt as specified as covered in the CertifiCate.
Commercial Weight Loss Programs. Weight loss programs, whether or no t they are pursued
under medical or physidan supervision , unless specifiCally lis ted as covered In this plan.
This exclusion inc ludes , but is not limited to, commercial weight loss prog rams (Weight Watc hers,
Jenny Craig, LA Weigh t Loss) and fasting programs.
This exclusion does not apply to medically necessary treatments for morbid obes ity or die tary
evaluations and counseling, and behavioral modification programs for the treatme nt of anorexia
nervosa or bulimia nervosa. Surgic al treatment tor morbid obesity is covered as described In the
CertifiCate.
Sterilization Reversal .
Infertility Treatment. Any services or supplies furnished in connection with the diagnosis and
treatment of Infertility , including, but no t limi ted to diagnostic tests, medic ation, surgery , artifiCial
insemination, In vitro fertil ization, sterili zation reversal and gamete intrafallopian transfer.
Surrogate Mother Services . For any services or supplies prov ided to a person not covered under
the plan In connection wi th a surrogate pregnancy (including , but not limited to , the bearing of a
child by another woman for an infertile couple).
Ort hopedic sh oes and shoe Inserts. This exclusion does not apply to orthopedic footwear used
as an integral part of a brace, shoe inserts th at are custom molded to the patien~ or the rapeutic
shoes and inserts designed to treat foot complications due to diabetes, as specifically stated in the
CertifiCate
Air Cond itioners . Air purifiers, air conditioners or humidifters.
Custodial Care or Rest Cu res . Inpatient roonn and board charges in co nnection with a hosp ital
stay primarily for environmental change or physical the rapy . Custodial care or rest cures,
except as specified as covered in the CertifiCate. Services provided by a rest home, a home
tor the aged , a nursing home or any similar facility. Services provided by a skilled nursing facility,
except as specified as covered in the CertifiCate .
Hea~h Club Membersh ips . Health club membershi ps, exercise equipment, charges from a
physical fitness instructor or personal trainer, or any othe r charges for activities, equ ipment or
faci lities used for developing or maintaining physic al fitness, even ij ordered by a physidan. This
exclusion also applies to health spas .
Personal ~ems. Any supplies for comfort, hygiene or beautifiCatio n.
Education or Counseling . Educational services or nutritio nal counseling, except as specified as
covered in the Certificate . This excl usion does not apply to counseling for the treaunent of anorexia
nervosa or bulimia nervosa
Food or Dietary Supplements. Nutritional andlor 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 thai can be purchased over the counter, which by law do not requi rement
either a written prescri ptio n or dispensing by a licensed pharmacist.
Telephone and Facs imile Machine Consult ations . Consultations provided by telephone,
except as specified as covered in the Certificate , or facs imile machine.
Routine Exams or Tests. Routine physical exams or tests which do not directly treat an actual
illness , injury or cond ition, including those requi red by employment or government authority,
except as specified as covered in the Certificate.
Acupuncture. Acupunci\J re treatmen ~ 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 dermatomes or acupuncture points .
Eye Surgery for Refractive Defects. Any eye surgery solely or primarily for the purpose of
correcting refractive detects ot the eye such as nearsigh tedness (myopia) andlor astigmatism.
Contact lenses and eyeglasses required as a result of this surgery .
Physical Therapy or Physica l Medi cine. Services of a physician for physical therapy or physical
medicine , except when provided during a covered inpatient confi nement 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. Nor~-prescri ption, over-the-counter
patent or proprietary drug or medicines. except as spec ified as covered in the CertifiCate .
Cosmetics , health or beauty aids.
Spec ialty Pharmacy Drugs . Specialty pharmacy drugs that must be obtained from the specialty
pharmacy program, but, which are obtained from a re tail pharmacy, are not covered by this pl an.
Insured person will have to pay the full cost of the specialty pharmacy drugs obtained from
a reta il pharmacy that should have been obta ined from the specl atty ph anmacy program.
Contraceptive Devices . Contraceptive devices prescribed tor birth control except as specified
as covered in the CertifiCate.
Diabetic Supp lies . Prescription and non-prescription diabe tic supplies except as specifi ed
as covered in the CertifiCate.
Private Du ty Nursing . Inpatient or outpatient services of a priv ate duty nurse .
Lifestyle Programs. Prog rams to alter one 's lifestyle which may include but are not limited to die~
exerc ise, imagery or nutrition, except as specified as covered in the Certificate. This exclusion will
not apply to cardiac rehab ilitation programs approved by us.
Cli nical Tri als. Services and supplies in connection with clinical trials, except as specifiec
as covered in the CertifiCate .
Lumenos Health Savings Account Plan-Exclusions and Limitations (Continued)
Outpatient prescription drug services and supplies are not provided lor or in connection
with the following :
Immunizing agents, biOlogical sera, blood, blood products or blood plasma
Hypodennic syr1nges &lor needles, except vmen dispensed lor use w\111 insulin & other
self-injectable drugs or medications
Drugs & medications used to Induce spontaneous & non-spontanecus abortions
Drugs & medications dispensed or administered in an outpatient setting, including outpatient
hospital facilities and physicians' offiCes
Professional charges in comection wltll administering , injecting or dispensing drugs
Drugs & medications that may be obtained wltllout a physician's written prescription, except Insulin
or niacin for cholesterol lowering and certain over-tile-counter drugs approved by tile Phannacy and
Ther apeutics Committee to be included In tile prescription drug lonnuiary.
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 1f prescribed by a physician ,
except contraceptive diaphragms, as specified as covered In the Certificate
Services or supplies for ~ tile insured person is not charged
0X)1len
Cosmetics & health or beauty aids.
Drugs labeled 'Caution, Limited by Fecleral 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
lor drugs dispensed by non-pMicipa ting pharmacies; or (b) the outpatient prescription drug
negotiated rate lor drugs dispensed by participating phannacles or through tile mai l
service program
Drugs >Mlith have no1 been approved for general use by the State of California Department of
Health Services or tile Food and Drug Administration. ThiS does not apply to drugs that are
medically necessary lor a covered condition .
Over-tile-counter smoking cessation drugs. This does not apply to medically necessary drugs
that tile Insured person can only get wltll a prescription under state and federal law .
Drugs used primarily for cosmetic purposes (e.g ., Retin-A l or wrinkles). However, this will not apply
to tile 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 Inferti lity ~nciuding, but not limited to, Cfornid , Pergonal and Metrodin),
unless medically necessary lor another covered cond ition .
Anorexiants and drugs used for weight loss, except vmen us ed to treat morbid obesity
(e g., diet pills & appeti te suppressants)
Drugs ob tained outside tile U.S. unless they are furnished in connection wltll urgent care
or an emesgency .
Allergy desensitization products or allergy senrn
Infusion drugs, except drugs that are se~-administered subcutaneously
Herbal supplements, nutritional and dielary supplements except lor formulas for the treatment
of phenylketonllia
Prescription drugs with a non-prescription (over-tile-counter) chemical and dose eq uivalent
excep t Insulin. This does not apply ~an over-tile-counter equivalent was tried and was In effective.
Compound medications obtained from other th an a participating pharmacy. Insured person
will have to pay the full cost of the compound drugs II insured person obtains drug
at a non-participating pharmacy.
Specialty pharmacy drugs that must be obtained from the specialty phanmacy program, bu~ which
are obtained from a reta1 l pharmacy are not covered by this plan . Insu red person will have to pay
the lull cost of the specialty pharmacy drugs obtained from a retail pharmacy that In su red
person should have obtained from the specialty pharmacy program .
Third Party Liability -Antllern Blue Cross Lffe and Health Insurance Company Is enbtied
to reimbursement of benefits paid ff tile Insured person recovers damages from a legally li able
third party.
Coordination of Benefits -The benefits of tills plan may be reduced ff 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 tile covered expense.
Lumanos plans provided by Anthem Slut Cross Life and Health lnsur•nce Company.
lndependentlicansaas of the Slut Cross Association.~ ANTHEM •nd LUMENOS are
registered trademarks of Anthem In surance Companies, Inc. Tht Blue Cross nama and
symbol"' registered marks of the Blue Cross Association.
Anthem .+.
srveerm
SJVIA County of Fresno
Modified BC Lumenos ®
Health Savings Account (HSA)
LBHSA266 (1500/80/60) ETSM
This summary of benefits has bee n 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 hea lth care re form
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 app roval 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 insu red
person against large medical expenses .
The insu red 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 rece ived from Participating and Non-
Participating Providers. It is the payment towards the services billed by a provider combined with any applicable deductible, copayment or
coinsura nce . Participating Providers-The rate the provide r has agreed to accept as reimburseme nt fo r covered services . Members are not
responsible for the difference betwee n the provider's usual charges & the maximum allowed amount.
Non-Participating Providers & Other Health Care Providers-(includes those not represented in the PPO provid er network)-Reimbursement
amount is based on : an Anthem Blue Cross rate or fee schedule , a rate negotiated with the prov ider, information from a third party vendor ,
or billed charges . For Medical Emergency care rendered by a Non-Participating Provider or Non-Cont racting Hospi tal , reimbursement may
be based on the reasona ble and customary value . Members may be responsible for any amount in excess of the reasonable and customary
value . Participating Pharmacies & Ma il 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 us in g non-participating providers , the i nsured person is responsible for any difference between the covered expense &
actual charges , as well as any deductible & percentage copay . When us in g the outpatient presc ri pt ion drug benefits , the in su red
person is always respons ible for drug expenses wh ich are not covered under th is plan , as well as any deductib le, percentage or
dollar copay .
Calendar year deductible for all provid ers
(applicable to medical care & prescription drug benefits)
~ Individual insure d person
~ Insured family
Individual can receive benefits once individual deductible has been met
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 ,000fl ndividual insured person ; $5 ,000fl nsured family /yea r
~ Non-Part icipating Providers & Non-Participating Pharmacy $10 ,000fl ndividual insured person ; $15 ,000fl nsured family /yea r
The following do not apply to out-of-pocket maximums : costs in ex cess of the covered expense & non-cover~d expense . After an individua l
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~mi ly incurs during that. ca.le.ndar
year , the individual insured person or insured family will no longer be required to pay a copay for the rema~n?er of that year .. T~e t~dtvtdual
insured person or insu red family remains responsible for costs in excess of the covered expense when provtded by non-partictpating
providers and other health care providers; non-covered expense .
Lifet ime Maximum Unlimited
anthem .com/ca Anth em Blue Cross Life and Health Insurance Com pany (NP) · NGF M-LB2081 Effective 01/20 17 Prin ted 11 /23/20 16
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
:> Outpatien t surgery , services & supplies
Skilled Nursing Facility (subject to utilization review)
:> Semi-private room , services & supplies
(limited to 100 days/calendar year)
Hospice Care
:> Inpatie nt or outpatient services for insured persons with up
to one year life expectancy; fam ily bereavement services
Home Health Care
:> Services & suppl ies 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 utiliza tion revie w)
:> Othe r diagnostic x-ray & lab
Preventive Care Services
Preventive Care Services including*, phys ic al exams , prevent ive
screenings (i ncludin g screenings for cancer, HPV, diabetes, cholesterol ,
blood pressure , hearing and vision , immunizations , health education ,
in terven tion services , HIV testing), and additional preventive care for
'NOmen provided for in the guidelines supported by the Hea lth
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
(In sured is also responsible
fo r charges in excess of
covered expense.)
40%
40 %
40%1 (benefit limited to $350/day)
40 %1
40 %1
40 %1
(benefit limited to $600/day)
40 %
40 %
40 %
40 %
40 %
40%
40%
40%
40%2
40%
1 These providers may no t be represented in the PPO ne twork 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 provid er 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 in sured person 's
copay is 40%. All co pays are in addition to app licable deductibles.
2 Acu pun cture services can be performed by a certified acupuncturist (C .A.), a doctor of medicine (M.D.), a doctor of osteopathy (D.O.), a pod iatris t (D .P.M.),
or a dentist (D.D.S.).
Covered Services
Pregnancy & Maternity Care
~ Physician office visits
~ Prescr iption drug for elective abort ion (mifep ristone)
Normal de livery, cesarean se ction , compli cat ions of pregnan cy
& aborti on
~ Inpatient phys ician services
~ Hosp ital & ancillary services
Organ & Tissue Transplants (s ubject to utilization review)
~ Inpatient services prov ided in connect ion with
non-investigative organ or tissue transplants
Diabetes Education Programs (requires phys ician supervision)
~ Teach insured persons & the ir famil ies about the disease
process , the daily management of diabet ic therap y &
self-management train ing
Prosthetic Devices
~ Co verage for breast prostheses ; pro sthet ic dev ices
to restore a meth od of speaking ; surg ic al im pl ants ; art ific ial li mbs
or eyes ; the first pair of contact lenses or eye gl asses when
required as a result of eye surgery; wigs for alopec ia result ing
from chemotherapy or radiation therap y; & therapeutic shoes
& inserts for insured persons with diabetes
Durable Medical Equipment
Renta l or purchase of DME incl ud ing hearing aids ,
dialysis equ ipment & supp lies (hearing aids benefit is
available for on e hearing aid per ear every three years;
bre ast pu mp and supplies are cove red under preventive
care at no charge for in -network)
Related Outpatient Medical Services & Supplies
~ Ground or air ambulan ce transportation, serv ic es
& disposable supplies
~ Blood tra nsfusions, blood proc essing & the co st
of unrepla ced blood & blood produ cts
~ Aut ol og ous bl ood (se lf-donated blood collection ,
testing , processing & storage for planned surgery)
Emergency Care
~ Emergency room services & suppl ies
~ Inpatient hosp ital services & suppl ies
~ Phys ician services
Mental or Nervous Disorders and Substance Abuse
~ Facility-based care (s ubject to utilization review;
wa ived for emergency admissions)
~ Inpatient physic ian visits
}> Outpatient phys ician visit s
(Behavioral Health treatment for Autis m & Pervasive
Diso rder will be subject to pre-se rvic e 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 %
20 %
20%
20 %1
20 %1
20 %1
(Insured is also responsible
for charges in excess of
covered expense.)
40%
40%
40%
40%
40%
40 %
40 %
40%1
20 %
20 %
20 %
40 %
40 %
40 %
1 These prov iders may not be repre se nted in th e PPO ne twork in the state where the insure d perso n receives services. If such provi der is not available in the service area,
th e insured person 's cop ay is 20%. If such provider is avail able in the service area and th e insured perso n receives services from a PPO provi der , the insu red person 's
copay is 20%. However, if the insured pe rson chooses to receive services from a non-PPO prov ider whe n suc h provider is ava il able in th e servic e area , th e insured pe rson's
cop ay is 40%. All cop ays are in addition to applicable deductibles .
Covered Services
maximum
Outpatient Prescript ion Drug Benefits
~ ~reventive \·mm~izations administered by a
1
retail pharmacy em ale ora CQfl aceohVes oen
1
enc and sing e soutce bran<l lu , Lostavax & nellmococca vaccmes
:> Retail pharmacy prescr iption drug maximum allowed amount
:> Home Delivery prescription drug maximum allowed amount
:> Specialty pharmacy drugs (obtained through specialty
pharmacy program)
Supply Limits 2
:> Retail Pharmacy (participating and non-participating)
& Specialty Pharmacy (participating)
:> Home Delivery
Traditiona l Health Coverage
Insured Person Copay
In-Network Out-of-Network
~o coBa~ {decJuctib~e wa(ved.J o co a (deuu cfib ,e warve(f) o co a
(Insured is also responsible
for charges in excess of
the prescription drug
allowed amount.)
20% 40%1
20%
20%
Not app licable
Not applicab le
30-day supply ; 60-day supply fo r federally class ified
Schedule II attention deficit disorder drugs that requ ire
a triplicate prescription fo rm, but requ ire a double copay ;
6 table ts or uni ts/30-day period for impotence and /or
sexual dysfunction drugs (availab le only at retail pharmacies)
90-day supply
11nsured person rem ains responsible for th e cos ts in excess of the prescription drug maximum allowed amount 2
Please refer to the Certificate of Insu rance fo r com plete information .
Supply limits for certain drugs may be different
The Outpatient Prescription Drug Benefit cov ers the following :
:> Out patient prescription drugs and medications which the law restricts to sale by prescripti on . Formu las presc ri bed by a physician
for the treatment of phenylke tonuria .
:> Insulin
:> Syringes when dispensed for use with insul in and other self-injectable drugs or medications
:> Prescription oral contraceptives ; contraceptive diaphragms. Contraceptive diaphragms are limited to one per year.
:> Injectable drugs wh ich are self-adm inistered by the subcutaneous route (under the sk in) by the pati ent or in sured person .
Drugs that have Food and Drug Adm inistration (FDA) labeling for self-administration
:> All compound prescription drugs that conta in at least one covered prescription ingredient
:> Diab etic 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 ped iatric asthma .
:> Smoking cessation products requiring a phys ician 's prescription .
:> Certain over-the-counter drugs approved by the Pharmacy and Therapeutics Comm ittee to be included in th e prescription drug
formulary .
:> Flu , Zost avax & Pneumococcal vaccines obtained at a local network pharmacy must be administered by a pharmacist
In addition to the benefits described above , coverage may include add itional 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 the ir state . If the insured person 's
state has such requirements , we will adjust the benef its to meet the requirements .
This Summary of Benefits is a brief review of benefits . Once enrolled , insured persons will rece ive a Certificate of Insurance ,
which explains the exclusions and limitations , as well as the full range of covered services of the plan , in deta il.
BC Lumenos Health Savings Acc ount Plan -Exclus ions and Limitations
Benefits are not provided for expenses inc urred for or in con nection with the
following ~ems:
Not Medically Necessary. Services or supplies that are not medically necessary, as defined .
Experimental or Investigative. Any experimental or Investigative procedure or medication.
Bu~ n insured person Is denied benefits because it 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 Un ited States. Services or suppl ies 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 Nucle ar Energy. Conditions that result from (1) the insured person's commission
of or attempt to commit 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 resul t
of war. when government funds are available for the tre atmen t of illness or inj ury arising from
the release of nuclear energy.
Uninsu red . Se rv ices received before the insured person's effective date. Services received
after the insured person's coverage ends , exce pt as specified as covered in the CertifiCate.
Excess Am ounts. Any amounts in excess of covered expense or the lifetime maximum.
Wor1<·Related. Worll-relaled conditions if benefits are recovered or can be recovered. either by
adjudication, settlement or otherwise. under any worllers ' compensation, employe(s liabi lity law
or occupational disease law, whether or not the insured person claims those benefits.
Gove rnment Tre atment. An y services the insured person actually received that were provided
by a local. state or federal government agency, exce pt when payment under th is plan is expressly
required by fede ral or state law. We will not cover payment for these services if the insured person
is not requ ired 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 wllO is related to the insured person by blood or marriage, except as spec ified as covered
in the Certificate.
Vo luntary Payment. Services for which the insured person is not legally obliga ted to pay. Services
for which the Ins ured person is not charged . Services for wh ich no charge is made in the absence of
Insurance coverage , except services rece ived at a noo-govemmental charitable research hospital .
Suc h a hospi tal must meet the following guidelines:
1. it must be interna tionally known as being devoted mainly to medical researth;
2. atleast10'1o of its yeariy budget must be spent on researth not directly related to patient care;
3. at least one-third of its gross income must come from dcnations or grants other than gifts
or payments for patient care;
4. it must accept patients wllO are unable to pay; and
5. two-thirds of its patients must have conditions directl y related to the hOspital's researth.
Not Specifically Listed. Services not specifK:al ly listed in the plan as covered services .
Private Contract s. Services or supplies provided pursuant to a private contract between the
insured person and a provider, for which reimbursement under Medicare prog ram is prohibited ,
as specified in Section 1802 (42 U.S.C. 1395a) of Title XV III of the Social Securi ty 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.
Men tal or Nervous Disorders. Academic or educational testing, counseling, and remediation.
Mental or nervous disorders or su bstance abuse, including rehabilitative care in re lation to these
conditio ns, 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 of tee th, 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 CertifK:ate. Cosmetic
dental surgery or other dental services for beautifK:ation.
Hearing Aids or Tests . Hearing aids and routine hearing tests, except as specified as covered
in the CertifK:ate.
Optometric Services or Supplies. Optometric services. eye exertises including orthOptics.
Routine eye exams and routi ne eye refractions, exc ep t routine eye screenings provided as specified
as covered in the Certificate. Eyeglasses or contact le nses. except as specified as covered in
the CertifK:ate.
Outpatient Occupational Therapy. Outpatient occupatio nal thera py, except by a home health
agency, hospice. or home infusion therapy provider, as specified as covered in the CertifK:ate.
Outpatient Speech Therapy. Outpatient speec h therapy, except as specified as covered
In the CertifK:ate.
Cosmetic Surgery. Cosmetic surgery or other services performed solely for beautification
or to alter or reshape norm al (Including aged) structures or tissues of the body to improve
appearance. This exclusion does not app ly 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 symptoma!Diogy or to create a normal appearance),
Includ ing surgery performed to restore symmetry following mastec tomy. Cosmetic surgery does not
become reconstructive surgery because of psychOlog ical or psyc hiatric reasons.
Scalp Hair Prostheses. Scalp hair prostiheses, including wigs or any form of hair replacement.
except as specified as covered in the CertifK:ate.
Commercial Weight Loss Programs. Weight less programs, whether or not they are pursued
under medical or physician supervis ion, unless specifK:ally listed as covered in this plan.
Th is exclusion includes, but is not lim ited to, commertial weigh t loss programs (Weight Watchers ,
Jenny Cra ig , LA Weight Loss) and fasting programs.
Th is exclusion does not apply to medically necessary treatments for morbid obesity or dietary
evaluations and counseling, and behavioral modification p!"ograms for the treatment of anorexia
nervosa or buli mia nervos a. Surgical treatment for morbid obesity is covered as described in the
Certificate .
Sterilization Reversal. Reversal of sterilization.
In ferti lity Treatment. Any services or supplies furnished in connection with the diagnosis and
treatment of infertility, includi ng, but not li mited to diagnos tic tests , medication, surgery, artificial
insemination , In vitro ferti lization, sterilization reversal and game te lntrafalloplan transfe r.
Surrogate Mot her Services. For any services or supplies provided to a person not covered under
th e plan in connection with a surrogate pregnancy (including, but not limi ted 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 lherapeutc
shOes and Inserts desi gned to trea t foot complications due to diabetes, as specifiCally stated in the
CertifiCate.
Air Conditioners. Air purifiers , air conditioners or humid ifters .
Custodial Care or Rest Cures . Inpatient room and board ch arges In connection with a hospital
stay primarily for environme ntal change or physical therapy. Custodial care or rest cures, except as
specfied as covered in the CertifK:ale. Services p!"OVided by a rest hOme, a hOme for tihe aged ,
a nursing hOme or any similar fac ility. Services provided by a skilled nursing facility , except as
specified as covered in the Certificate.
Health Club Memberships. He alth club memberships, exertise equ ipment, charges from a
physical fitness instructor or personal trainer, or an y other charges for activities . equipment or
facilities used for developing or maintaining physical fitness . even H ordered by a physician. This
exclusion also appl ies to health spas.
Personal items. Any supplies for comfort, hyg iene 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 bulim ia nervosa.
Food or Dietary Supplements. Nutritional and/or dietary supp lements, except as p!"OVided in this
plan or as required by law. This exclusion includes, but Is not limited to, those nutritional form ulas
and dietary suppleme nts that can be purthased over the coun ter , which by law do not requirement
either a written prescription or dispensing by a licensed pharmacist
Telephone and Facsimile Machine Consultations. Consu ltations provided by telephone,
except as specified as covered in the CertifK:ate . 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 aulhort ty,
except as specified as covered in the CertifK:ate.
Acupuncture . Acup unc ture treatment, except as specified as covered in the Certificate.
Acupressure or massage to control pain, treat illness or promote health by applying press ure
to one or more spec ific areas of the body based on dermatornes or acupuncture points.
Eye Surgery for Refractive Defects. Any eye su rgery solely or primarily for the purpose of
correcting refractive defects of the eye such as nearsightedness (myopia) and/or astigmatism .
Contac t lenses and eyeglasses req uired as a res ult of this surgery.
Ph ysical Therapy or Ph ysic al Medicine. Services of a physician for physical therapy or physical
medicine, except when provided du ring a covered inpatient confinement or as specified as covered
in the CertifK:ate.
Outpatient Prescript ion Drugs an d Medications. Outpatient p!"escription drugs , medications and
Insulin, except as specified as covered in the CertifK:ale. Nco-prescription , over-the-counter patent
or proprietary drugs or medic ines , except as specified as covered in the Certificate. Cosmetics,
health or beauty aids .
Contraceptive Devices . Contraceptive devices prescribed for binh control except as specified
as covered in the CertifK:ate.
Diabetic Supplies . Prescription and non-prescription diabetic supplies except as specified
as covered in tihe CertifK:ate.
Private Duty Nursing. Inpatient or outpatient services of a private duty nurse .
Li festyle Programs. Programs to alter one's lifestyle which may include but are not limited to die ~
exercise. Imagery or nutrition, except as specified as covered in tihe Certificate. This exclusion will
not apply to cardiac rehabilitation programs app!"oved by us.
BC Lumenos Health Savings Account Plan-Exclusions and Limitations (Continued)
Outpatient prescription drug servlces and supp lies are not provided for or i n connecti on
w~h the follow ing :
Immunizing agents, biological sera, blood, blood products or blood plasma
Hypodermic syringes &/or needles, e~cept when dispensed for use .,.,;th Insulin & other
self-lnjectllble drugs or medications
Orugs & medications used to induce sponraneous & non-spontaneous abortions
Drugs & medications dispensed or administered in an outpatient setl!ng, Including outpatient
hospital facilities and physicin' offices
Professional ch;vges In connection .,.,;th administering , if1ecting or dispensing drugs
Drugs & medications that may be obtained v.;thout a physician's v.rinen prescription,
except insulin or niacin for cholesterol lowering and certain over-the~nter 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, appl iances & 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 ch<Vged
Oxygen
Cosmetics & health or beauty aids.
Drugs labeled 'C aution, limited by Federal Law to InvestigatiOnal Use," or Non-FDA approved
Investigational drugs . Any drugs or medications prescribed for experimental indications
Any expense tor 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-~nter smoking cessation drugs. This does not apply tl medically necessary drugs
lhat the insured person can only get With a prescription under state and federal law
Drugs used primarily for cosmetic purposes (e.g., Retill-A for wrinkles). However, this .,.,;11 not apply
to the use of this type of drug for medically necessary treatment of a medical condition other than
one th at Is cosmetic.
Drugs used primarily to treat Infertility (lndud1ng , but not limited to, Clomid, Pergonal and Metrodin),
unless medically necessary for another covered conditiOn.
Anore~lants and drugs used for weig ht 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 .,.,;th urgent care
or an emergency.
Allergy desensitization products or allergy serum
Infusion drugs, axcept drugs that are sen-administered slilculaneously
Herbal supplements, nutritional and dietary supplements except for formulas for the treatment
of phenylketonuria
Prescripbon drugs v.;th a noll-prescription (over-~nter) chemical and dose equivalent
e~cept Insulin. This does not apply if an over-the~nter 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 dru gs If In su red person obta ins dru g at a
non -participating pharmacy .
Specialty pharmacy drugs that must be obtained from the specialty pharmacy program, but, which
are obtained from a retaU pharmacy are not covered by this plan. Insu red perso n will have to pay
the full cost of the specialty pharm acy drugs obtain ed from a reta il ph armacy that Insured
person should have obtained from the specialty pharmacy program.
Third Party Liability -Anthem Blue Cross L ~e and Health Insurance Company Is entitled
to reimbursement of benefits paid ~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 al l group coverages do
not axceed 100% of the covered expense.
Lumenos plans provided by Anthem Blue Cro ss Lift ltld Health Insurance Company.
Independent licensees of the Blue Cros s Associati on. e ANTHEM and LUMENOS art
reg istered trademarl!s of Anth em Insurance Companies, Inc. The Blue Cross nwne and
symbo l are reg istered maries of the Blue Cross Assoc iation.
Anthem .+. 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 Labo r and Internal Revenue Service , we may be
required to make additional changes to th is summary of benefits . This proposed benefi t summary is subject to the approval of th e
California Department of Insurance and the California Department of Managed Health Care.
This Lumenos plan is an innovative type of coverage that allows an insu red 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 rout ine medical care, presc ription 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 cove red expenses exceed the insured person's available HSA
dollars , the traditional health coverage is available after a limited out-of-pocket amount is pa id 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 Max i mum Allowed Amou nt
Maximum Allowed Amount is the total reimbursement payable under the plan for cov ered services received from Part icipating and Non-
Participating Providers . It is the payment towards the services billed by a provider combined with any applicable dedu ctible, copayment or
coinsurance.
Part icipating Providers-The rate the provider has agreed to accept as reimbursement for covered services . Members are not responsible fo r
the difference between the provider's usual charges & the maximum allowed amount.
Non -Partici pating Providers & Other Health Care Providers-(includes those no t rep resented in the PPO provider network)-Reimbursement
amount is based on: an An them 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-Participa ting Provider or Non-Contracting Hospital , reimbu rsement may
be based on the reasonable and customary value . Members may be responsible for any amount in excess of the reasonable and customary
value .
Participat ing 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 wh ich 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
)> Insured family
Individual can receive benefits once individual deductible has been met
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, Participa ting Pharmacy
& Other Health Care Providers
$3 ,000flndividual insured person
$6,000/insured family
$3 ,000flndividual insured person ; $6 ,000/insured family/year
)> Non -Participating Providers & Non-Participating Pharmacy $5,000flndividual insured person ; $10 ,000fl nsured fam ily/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 presc ription drug covered expense the individual insured person or insured f~mily incurs during that. ca!e.nda r
year, the individual insured person or insured family will no longer be required to pay a copay for the rematn~er of that year .. T~e t~dtvtdual
insured person or insured family rema ins responsible for costs in excess of the covered expense when provtded by non-parttctpabng
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 /2017 Printed 11 /23 /2016
Cove red Services
Hospital Medical Services (subject to utilization review
for inpatient services; waived for emergency admissions)
~ Semi-private room , meals & special diets, & ancillary services
~ Outp atient medical care , surgical services & supplies
(hospital care other than emergency room care)
Ambulatory Surgical Centers
~ Outpati ent su rgery, services & supplies
Skilled Nursing Facility (subject to utilization review)
~ Semi-priv ate room , services & supplies
(limited to 100 days/calendar year)
Hospice Care
~ Inpati ent or outpatient services for insured persons with up
to one year life expectancy; family bereavement services
Home Health Care
~ Services & supplies fro m 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 Infus ion Therapy
~ Includes medication , ancillary services & supplies ;
caregiver training & visits by provider to monitor
thera py; durab le medical equipment; lab services
Physician Medical Services
~ Office & home visits
~ Hospi ta l & skilled nursing facility visits
~ Surg eon & 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
(s ubject to utilization review)
~ Other diag nostic x-ray & lab
Preventive Care Services
Preventive Care Services including•, physical exams , preventive
screening s (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
Servic es req ui red by feder al 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 th erapy & surgical treatment
Trad itional Hea lth 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 copay
No copay
No copay
No copay
No copay
No copay
No copay
No copay
No copay1
No copay
(Insured is also responsible
for charges in excess of
cove red expense .)
50%
50%
50% (benefit limited to $350/day)
50%
50 %
50 %
50 %
(benefit limite d to $600/day)
50 %
50%
50 %
50%
50%
50%
50 %
50%
50%
50%1
50%
1 Acupuncture services can be performed 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
~ Phys ici an office visi ts
~ Prescr iption drug for elective abortion (mifepristone)
Normal de livery, 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])
~ In patient services provided in connection with
non-investigative organ or tissue transp la nts
~ Transplant travel expense fo r an authorized , specified
transplant at a CM E (recipient & companion transportation
limited to 6 trips/episode & $250/person/trip for round-trip
coach airfare hotel limited to 1 room double occupancy &
$100/day for 21 days/trip, other expenses limited to
$25/day/person for 21 days/trip ; donor transportation
limited to 1 trip/episode & $250 for round -trip coach airfare ,
hotel limited to $100/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
~ Bar iatric tr av el 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 trips {pre-surgical visit,
initial surgery & one follow-up visit]; one companion's
transportation to & from CME limited to $130/person/trip
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/day/person for 4 days/trip)
Diabetes Education Programs (requires physician supervision)
~ Tea ch insured persons & th eir families about the disease
process, the daily mana gement of diabetic therapy &
self-management tra ining
Prosthetic Devices
~ Coverage for breast prostheses ; prosthe tic devices
to restore a method of speaking ; surgical impl ants ;
artificial limbs or eyes ; the first pai r of contact
lenses or eyeglasses when required as a result of
eye surgery; wigs for alopecia re sulting from
chemothe rapy or radiation therapy; & therapeutic shoes
& inse rts for insured persons with diabetes
Durable Medical Equipment
Rental or pu rc hase 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 also responsible
for charges in excess of
covered expense.)
50%
50%
50%
50%
50%
50%
50%
Covered Services
Related Outpat ient Medical Servi ces & 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)
};> Inp ati ent physician visits
Outpatient Care
};> Facility-based care (subject to utilization review;
waived for emergency admissions)
};> Outp atient physician visits
(Beh avioral Health treatment for Autism & Pervasive
Disorder will be subject to pre -service review )
1 These providers are not represented in the PPO networ1t
Traditional Healt h Coverage
Insured Perso n Copay
In-Network Out-of-Network
No copay 1
No copay 1
No copay 1
No capay
No capay
No capay
No capay
No capay
No capay
No capay
(Insured is also responsible
for charges in ex cess of
covered expense .)
No capay
No capay
No capay
50 %
50 %
50 %
50 %
Covered Services
Outpat ient Prescription Drug Benefits
~ Preventive immunizations administered by a reta il pharmacy
~ Female oral contraceptives generic and sing le source brand ,
~ Flu , Zostavax & Pneumococcal vaccines
~ Retail pharmacy prescr iption drug maximum allowed amount
~ Home Delivery prescription drug ma ximum allowed amount
~ Spec ialty pharmacy drugs (obta ined through specialty
pharmacy program)
Supply Limits 2
~ Retail Pharmacy (p articipa ting and non-participating)
~ Home Del ivery
~ Specialty Pharma cy
Traditional Health Coverage
Insured Person Capay
In-Network Out-of-Network
No capay (deductible wa ived)
No capay (deductible waived)
No capay
(Insured is also responsible
for charges in excess of
the prescription drug
maximum allowed amount)
No capay 50%1
No capay
No capay
Not applicable
Not applicable
30-day supply ; 60-day supply for federally classified
Schedu le II attention deficit disorder drugs that require
a tripl ic ate prescription form , but require a double capay;
6 tablets or units/30-day period for impotence and /or
se xual dysfunction drugs (available only at retail pharmacies )
90-day supply
30-day supp ly
1 1nsured person remai ns responsi ble for the costs in excess of the prescription drug maximum amount allowed .
2 Su pply limits for ce rta in drug s may be different. Please refer to the Certificate of Insu rance for complete in formation .
The Outpatient Prescription Drug Benefit covers the following :
~ Outpatient prescript ion drugs and medications which the law restricts to sale by prescr iption . Formulas prescribed by a physician
for the treatment of phenylketonuria .
~ Insulin
~ Syringes when dispensed for use with insu li n and other self-i njectable drugs or medications
~ Prescript ion oral contraceptives ; contracepti ve diaphragms . Contraceptive diaphragms are lim ited to one per year .
~ Injectable drugs wh ich are se lf-adm inistered by the subcutaneous route (under the skin) by the patient or insured person .
Drugs that have Food and Drug Adm inistration (FDA) labe ling 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 se xua l dysfunction are lim ited to organic (non-psychological ) causes .
~ Inhaler spacers and peak flow meters for the treatment of ped iatric asthma .
~ Smok ing cessat ion products requiring a physician 's pres crip tion .
~ Certain over-the -counter drugs approved by the Pharmacy and Therapeutics Committee to be included in the prescription drug
formulary .
)1> Flu , Zostavax & Pneumococca l vaccines obtained at a local networ k pharmacy must be admin istered by a pharmac ist
This Summary of Benefits is a brief review of benef its. Once enrolled , insured persons will receive a Certificate of Insurance,
which explains the exclusions and li mitations , as well as the full range of covered services of the plan in detail.
Lumenos Health Savings Account Plan -Exclusions and Limitations
Benefrts are not provi ded for expenses Incurred for or in connect io n with the
following nems:
Not Medically Necessary. Services or supplies that are not medically necessary, as defined.
Experimental or Investigative. Any experimental or Investigative procedure or medication.
But, ~insured perso n 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 desc ribed in the CertifiCate.
Outside the United States. Services or supplies furn ished and billed by a provider outside
the Uniled States, unless such services or supplies are furnished In connection with urgent care
or an emergency .
Cri me or Nuclear Energy. Conditions that result from (1) the insured person's commission of
or attempt to commit 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, wllether or not the result
of war, wllen government funds are available for the treatment of Illness or Injury arising from the
release of nuclear energy .
Not Cov ered. Services rece ived 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 . Any amounts in excess of covered expense or the lifetime maximum.
Woi'X·Related. Worll-related conditions ij benefits are recovered or can be recovered, either by
adjudication, settlement or othe!wise , under any oorllers' compensation, employefs liability law
or occupational disease law, Whether or not the ins ured person claims those benefits. If there
is a dispute of substantial uncertainty as to whether benefits may be recovered for those conditions
pursuant to oorllers ' compensation, we will provide the benefits of this plan for such conditions,
subject to a right of recovery and re imbursement under California Labor Code Section 4903,
as specified as covered In the Certificate.
Government Treatment. Any services the Insured person actually received that were provided
by a loc al, 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 requ ired 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 marriage , except as specified as covered
In the CertifiCate.
Vo luntary Paymen t. Services for which the insured person has no legal obligation to pay ,
or for which no charge oould be made in the absence of Insurance coverage or other health plan
coverage, except services received at a noniJOvemmental charitable researth hospital.
Such a hospital must meet the following guidelines:
1. it must be Internationally known as being devoted mainly to medical researth ;
2. at least 10% of its yeariy budget must be spent on researth not directly related to patient care:
3. at least one-th ird of its gross income must come from donations or grants other than gifts
or payments for patient care;
4. it must acce pt patients who are unable to pay; and
5. two-thirds of its patients must have conditions directly related to the hospital's researth.
Not Specifically Listed . Services not specifically listed in the plan as covered services .
Pri vate Contracts. Services or supplies provided pursuant to a private contract between the
Insured person and a provider, for wh ich reimbursement under Med icare 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
primari ly fOr diag nostic 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 heari ng tests, except as specified as covered in the CertifiCate.
Optometric Services or Supplies. Optometric services, eye exertises 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 Occupat ional 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 specifi&C as covered
in the CertifiCate.
Cosmetic Surgery. Cosmetic surgery or other services performed solely for beautification
or to alter or reshape no nnal (including aged) structures or tissues of the body to Improve
appea rili'ICe. This exclusion does not apply to reconstructive surgery (that is, surgery pertonned
to correct deformities caused by congenital or developmental abnonnalities, illness, or injury
fo r the purpose of improving bodily function or symptomatology or to create a nonnal appearance),
includ ing surgery performed to restore symmetry following mastectomy. Cosmetic surgery does not
become reconstructive surgery because of psychological or psyc hiatric reasons.
Scalp Hair Prostheses. Scalp hair prostheses, inc luding wigs or any fonn of hair replacement,
except as specified as covered In the CertifiCate.
Commercia l Weight Loss Programs . Weight loss programs, wllether or not they are pursued
under med ical or physidan supervision, unless specifiCally listed as covered In this plan.
This exclus ion incl udes , but is not limited to, commertlal weight loss prog rams (Weight Watchers,
Jenny Craig, LA Weigh t Loss) and fasting programs.
This exclusion does not apply to medically necessary treatments for morbid obesity or dietary
evaluations and counseling , and behavioral mod ification programs for the treatment of anorexia
nervosa or bu limia nervosa Surgical treatment for morbid obesity is covered as described in the
CertifiCate.
Ste ri lization Reversal.
Infert ilit y Treatment. Any services or supplies furnished In connection with the diagnosis and
treatment of infertility , including, but not limiled to diagnostic tests , medic ation, surgery, artifiCial
insemination, in vitro fertilization, steriliz ation reversal and gamete lntrafallopian transfer.
Su rrogate Moth er Servi ces. 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 ooman for an Infertile couple).
Ort ho pedic shoes and shoe Inserts. Th is 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 Cond itioners. Air purifiers, air conditioners or humid ifiers .
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 home for the aged ,
a nursing home or any similar facility. Services provided by a skilled nursing facili ty, except
as specifi&C as covered in the Certificate.
Health Club Memberships. Health club memberships , exercise equipment, charges from a
physical fitness Instructor or perso nal trainer , or any other charges for activities, equipment or
facilities used for developing or maintaining physical fitness, even ij ordered by a physidan. This
exclusion also applies to health spas .
Personal ~ems . Any supplies for comfort, hygiene or beautification.
Education or Counseling. Educational services or nutritional counseling , except as specified as
covered In the Certificate. This exclus ion 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 exclus io n includes, but is not limited to , those nutritional formulas
and die tary supplements that can be purthased over the counter, which by law do not req uirement
either a wri tten prescription or dispensing by a licensed phanmacisl
Tel ephone and Facsimile Machine Cons ultati ons. Consultations provided by telephone .
except as specified as covered in the CertifiCate, or facsimile machine.
Ro utine 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.
Acupuncture . Acupuncture treatment, except as specified as covered in the Certificate .
Acupressure or massage to control pain, treat illness or promo te health by applying pressure
to one or more specifiC areas of the body based on dennatomes or acupuncture points.
Eye Surgery for Refracti ve Defects. Any 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 req uired 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 Prescript ion Drugs and Med ications . Outpatient prescription dru<,lS or medications
and Insulin, except as specifi&C as covered in the Certificate. Non-prescription, over-the-<:ounter
patent or proprietary dru<,l or med icines. except as specified as covered In the CertifiCate.
Cosmetics, health or beauty aids .
Specialty Phanmacy Drugs . Specialty phannacy drugs that must be obtained from the specialty
phannacy program, but, which are obtained from a retai l phannacy, are not covered by this plan.
Insu red person will have to pay the fu ll cost of the specialty pharmacy drugs obtained from
a retail phanmacy that should have been obtained from the specialty phanmacy program .
Contracept ive Devices. Contraceptive devices prescribed fOr birth control except as specified
as covered In the CertifiCate.
Diabetic Suppli es . Prescription and non-prescription diabetic supplies except as specified
as covered In the Certific ate.
Private Duty Nurs ing . Inpatien t or outpatient services of a private duty nurse.
Lifestyle Programs. Programs to alter one 's lifestyle which may Include but are not limited to diet,
exertise, imagery or nutrition , except as specified as covered in the Certificate. This exclusion will
not apply to card iac rehabilitation programs approved by us.
Clin ica l 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 prescriptio n drug services and suppl ies are not provided for or in connect ion
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 fac ilities <r1d physicians' offtees
Professional charges in connection with administering , injecting or dispens ing drugs
Drugs & medications that may be obtained without a physician's written prescriptio n,
except insu lin or niac in for cho lesterol lowering and certain over-thEH:ounter 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 fac lity,
rest home, sanatorium, convalescent hospital or simi lar facility
Durable medical equipme nt, devices, appl iances & suppl ies , even if prescribed by a physician,
excep t contraceptive diaph ragms, as specified as covered in the Certificate
Services or supplies for which the insured person Is not charged
Oxygen
Cosmetics & healtih or beauty aids.
Drugs latbeled "Caution , Limi ted by Federal Law to Investigational Use: or Non-FDA approved
investigational drugs. Any drugs or medications prescribed for experimental ind ications
Any expense for a drug or medication incurred In excess of (a) the Drug Limi ted Fee Schedule
for drugs dispensed by non-participating pharmacies; or (b) the outpatient prescrip tio n drug
negoti ated rate for drugs dispensed by participating pharmacies or tihrough the mail
serv ice program
Drugs which have not bee n approved for general use by the State of CaiHomia 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-thEH:ounter 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 wrink les). However, this will not apply
to the use of th is type of drug for medically necessary treatment of a medical cond ition other than
one that is cosmetic .
Drugs used primarily to treat infertility (includ ing, but not limited to, Clomid , Pergonal and Metrodin),
unless med ically necessary for another covered condition.
Anorexiants and drugs used for weight loss , except when used to treat mort>id obesity
(e.g., diet pill s & appetite suppressants)
Drugs obtained outside the U.S. unless they are fu rnished in connection with urgent care
or an emergency.
Allergy desensitization products or allergy serum
Infusion drugs, except drugs that are self-adm inistered subcutaneously
Herbal supplements , nutritional and dietary supplements except for form ulas for the treatme nt
of phenylketonuMa.
Prescription drugs with a non-prescription (over-thEH:ounter) chemic al and dose equivalent
except insulin. This does not apply if an over-thEH:ounter equivalent was tried and was in effective .
Compound medications obtained from other than a participating pharmacy. Insured person
will ha ve to pay the full cost of the compound drugs if insured person obta ins drug
at a non-participating pharmacy.
Specialty pharmacy drugs that must be obtained from the specially pharmacy prog ram , but which
are obtained from a retail pharmacy are not covered by this plan . Insured person will have to pay
the fu ll cost of the specialty pharmacy drugs obtained from a reta il pharmacy that Insured
person shou ld ha ve obtained from the specialty pharma cy program.
Th ird Party Liabili ty -Anthem Blue Cross LHe 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 H 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 Hea#h 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 reg istered marks of the Blue Cross Association.
Anthem .+.
81ueCI'oss
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 approva l 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 aga inst 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 /o r 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
importan t information appear in italics. Benefits are subject to all terms , conditions, limitations , and exclusions of the Policy.
Explanation of Maximum Allowed Amou nt
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 applicab le deductible , co payment or
coinsurance.
Participating Providers-The rate the provider has agreed to accept as reimbursement for covered services . Members are not respons ible 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)-Re imbursement
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. Part icipating Pharmacies & Mail Service Program-members are not respons ible for any amount in excess of the prescription drug
maximum allowed amount. Non-Participating Pharmac ies-members are responsible for any expense not covered under th is plan & any
amount in excess of the prescription drug maximum allowed amount.
When using non-participating pro vi de rs, the in sured pers on is respons ible for any difference betwee n
the covered expense & act ual cha rges , as well as any deductible & perce ntage copay .
When us ing the outpat ient prescription drug benefit s, the insured person is alw ays respons ible fo r drug expenses wh ich are not
covered under th is plan , as well as any deduct ible , pe rcen tage or dollar copay .
Calendar year deductible for all provid ers
(applicable to medical care & prescription drug benefits)
~ Individual insured person
~ Insured family
Individual can receive benefits once individual dedu ctible has been met
Annual Out-of-Pocket Max imums (in-ne twork/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 Prov iders
$3 ,000(1ndividual in sured person
$6,000 /insured family
$3,000 /individual in sured person ; $6 ,000/insured family/year
~ Non-Participating Providers & Non-Participating Pharmacy $5,000 /i ndividual insured person ; $10 ,000(1 nsured fam ily/yea r
!he following do n?l app ly to ~ut-~f-pocket .maximums : costs in exc ess of the covered expense & non-covered expense. After an individual
msured person or msured fam1ly (mcludes msured employee & one or more members of the employee's family) reaches the out-of-pocket
maximum. fo~ ~II me.dical and prescrip~ion drug co~ere~ expense the indivi~ual insured person or in sured family incurs during that calendar
year , the 1nd1v1dualmsured person or 1nsured fam 1ly Will no longer be requ 1red to pay a copay for the remainder of that year . The individual
insured person or insured family remains responsible for costs in excess of the covered expense when provided by non-participating
prov iders and other health care providers; non-covered expense .
Lifetime Max imum Unlimited
anth em .corn/ca Anthem Blue Cross Life and Health Insurance Company (NP)-NGF M-LB2077 01/2017 Prin ted 11 /2 3/2016
Covered Services
Hospital Medical Services (subject to utilization review
for inpatient services; waived for emergency admissio ns)
};> Sem i-private room , meals & spec ial diets , & ancillary services
};> Outpat ient medical care , surg ic al serv ices & suppl ies
(hospital care other than emergency room care)
Ambulatory Surgical Centers
};> Outpat ient surgery , serv ices & supp li es
Sk ill ed Nursing Facil ity (s ubje ct to utilization re vie w)
};> Semi-private room , services & supplie s
(limited to 100 days/c alendar year)
Hospice Care
};> Inpatient or outpatient services for insured per sons wi th 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/c alendar year,
one visit by home health aide equals four hours or less;
not covered while insured pers on re ceives hospice care)
Home Infusion Therapy
};> Includes med ication , anc illary serv ices & supplies;
careg ive r training & visits by prov ider to monitor therap y;
durab le med ica l equipment; lab services
Physician Med ical Serv ic es
};> Office & home visits
};> Hospital & sk illed nursing fa cili ty visits
};> Surgeon & surg ica l ass istant ; anesthesio logist or anesthetist
Diagnostic X-ray & Lab
};> MR I, CT scan , PET scan & nuclear card iac scan
(subj ect to utilization review)
};> Other diagnost ic x-ray & lab
Preventive Care Services
Preventive Care Services including*, phys ic al exa ms, pre venti ve
screenings (i nc luding screenings for cancer , HP V, diabetes, chole sterol,
bl ood pressure , hearing and vision , immunizations , health edu cation,
interve nti on services , HIV testing ), and additiona l pre ve nti ve care for
women provided for in the guidel ines supported by the Health
Resources and Services Administration .
*This li st is not exhaustive . This benefit includes all Prevent ive Care
Services requ ired by federal and state law.
Physical Therapy , Physical Medicine & Occupational
Therapy , including Chiropractic Services
(limited to 24 visits/calendar year)
Speech Therapy
};> Outpat ient speech therapy following injury or organic disease
Acupuncture
};> Services for the treatment of disea se, illness or inj ury
(limited to 12 visits/calendar year)
Trad itional Health Coverage
Insured Person Copay
In-Network Out-of-Network
No copay
No copay
No copa y1
No copay 1
No copay 1
No copay 1
No copay
No copay
No co pay
No co pay1
No copa y1
No copay
No copay
No copa y
No cop ay 2
No copay 1
(Insured is also responsible
for charges in excess of
covered expense.)
50 %
50 %
50%1 (benefit limited to $350/day)
50%1
50 %1
50 %1
(benefit lim ited to $600/day)
50%
50%
50%
50%1
50%1
50 %
50 %
50 %
50 %2
1 These provi ders may not be rep rese nted in the PPO ne tw orlt in the state where the insured person receives services. If such provi der is not av ailable in the se rvice area , the
insured person 's co pay is the same as for PPO. If such provider is availa ble in the service area and th e insured perso n receives services from a PPO provide r, there is no
cop ay . However , if th e insure d person chooses to receive services from a non -PPO provider when such provider is available in the service area, th e ins ured pe rso n's copay
is 50%. All copays are in additio n to applicab le deductib les.
2 Acu puncture services can be perfo rmed by a ce rti fied acupuncturist (C .A.), a docto r of medicine (M.D .). a doctor of osteopathy (D.O.), a podi atrist (D.P.M.),
or a dentist (D.D.S.).
Covered Services
Temporomandibular Joint Disorders
~ Splint therapy & surgical treatment
Pregnancy & Maternity Care
~ Physicia n office visits
)> Prescription drug for elective abortion (mifepristone)
Normal delivery, cesarean section , complications of pregnancy
& abortion
~ Inpatient phys ician 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 famil ies 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 requ ired 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 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 & Supp lies
~ 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 & suppl ies
~ 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 co pay
No copay
No copay
No copay 1
No copay 1
No copay1
(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 networ'K in the state where the insured perso n receives services . tf such provider is not available in the service area , the
insured person's copay is the same as for PPO . tf 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 copay
is 50%. All copays are in addition to applicable deductibles.
Covered Services
Outpatient Prescription Drug Benefits
):> Preventive immunizations adm inistered by a retail pharmacy -
):> Female oral contraceptives generic and single source brand ,
)> Flu , Zostavax & Pneum ococcal vaccines
)> Retail pharmacy prescription drug ma ximum allowed amount
)> Home Delivery prescription drug ma xi mum allowed amount
)> Specialty pharmacy drugs (obtained through specialty
pharmacy program)
Supply Limits 2
)> Retail Pharmacy (participating and non-participating)
& Specialty Pharmacy (participating)
)> Home Delivery
Traditional Health Coverage
Insured Person Copay
In-Network Out-of-Network
No co pay (deductible waived)
No ca pay (deductible waived)
No cap ay
No capay
No cop ay
No copay
(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 fo r federally classified
Schedule II attention deficit diso rder drugs that require
a triplicate prescription fo rm, but require a double copay;
6 tab le ts or units /30-day period for impotence and /or
se xual dysfunc tion drugs (availab le only at retail pharmacies )
90-day supply
1 Insu red person remains responsible for the costs in excess of the prescription drug maximum allowed amount.
2 Supply limits for certain drugs may be di fferen t. Please refer to the Certificate of Insurance for complete information .
The Outpat ient Presc ri pt ion Drug Bene fi t cove rs th e follow ing :
):> Outpatient prescript ion 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 insul in and othe r se lf-in jec table drugs or medicati ons
)> Prescript ion oral contraceptives; contraceptive diaphragms . Contraceptive diaphragms are limited to one per year.
)> Injectable drugs which are sel f-adm inistered by the subcutaneous rou te (under the skin) by the patient or insu red person .
Drugs that have Food and Drug Administrati on (FDA) labeling for self-administration
)> All compound prescription drugs that contain at least one covered prescr ip tio n ingred ient
):> Diabetic supplies (i.e ., test strips and lancets)
)> Prescript ion drugs for treatment of impotence and /or sexual dysfunct ion are lim ited to organic (non-psychological} causes .
)> Inhale r space rs and peak flow meters for the treatme nt of ped iatri c asthma .
)> Smoking cessation products requiring a physician 's prescript ion.
)> Certain over-the-counte r drugs approved by the Pharma cy and Therapeutics Committee to be included in the prescription drug
formulary .
)> Flu , Zostavax & Pneumococcal vaccines obtained at a loc al ne two rk pharma cy must be administered by a pharmacist
In addition to the benefits described above , cove rage may include additional benefits , depending upon the insured person 's home
state . The benefits provided in this summary are subject to federal and Ca li fo rnia laws . There are some states that require more
generous benefits be provided to the ir res idents , even if the maste r policy was not issued in their state . If the insured person 's
state has such requ irements , we will adjust the benefits to meet the requ irements .
Th is Summary of Benefits is a brief review of benefits . On ce en roll ed , insured persons will receive a Certificate of Insurance ,
which explains the exclusions and limitations , as well as the full range of cove red servic es of the plan , in detail.
BC Lumenos Health Savings Account Plan-Exclusions and Limitations
Benefrts are not provi ded 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. Any experimental or investigative procedure or medication.
Bu~ if Insured person is denied benefits because it is determined tha t the requested treatmen t
is experimental or investigative, the insured person may request an independent med ical 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 res ult from ( t) the Insured person's commission
of or attempt to commit a felony, as long as any injuries are not a resull of a medical cond ition
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.
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.
Excess Amounts. Any amounts in excess of covered expense or the lifetime maximum.
Worlt·Related. Wor1<-related conditions n benefits are recovered or can be recovered , either by
adjudication, settlement or otheiWise, unde r any worl<ers' compensation , employe(s liability law
or occupational disease law, whethe r or not the insured person claims those benefits.
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
req uired by federal or state law. We will not cover payment fo r these services if the insured person
is not requ ired to pay for them or they are given to the insured person fo r 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 Paymen t. Services for which the Insured person Is not legally obligated to pay. Services
for whic h the insured person Is not charged . 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 :
t . it must be internationally known as being devoted mainly to medical research ;
2. at least tO% of its yearly budget must be spent on research not directly related to patient care ;
3. at least one-third of its gross income must come from donations or grants other than gifts
or pay ments for patient care;
4. ~must accept patients who are unable to pay; and
5. two-thirds of its patients must have conditions directly related to the hospita l's research.
Not Specifically Listed. 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) of Title XVI II 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 perfomned safely on an outpatient bas is.
Mental or Nervous Disorders. Academ ic or educational testing , counsel ing , and remed iation.
Mental or nervous disorders or substance abuse , including rehabilitative care in relation to these
conditions, except as spec ified 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, extractio n of teeth, or treatment to the teeth or gums, or treatment
to or for any disorders for the jaw joint except as spec ified as covered In the CertifiCate. 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 CertifiCate.
Optometric Services or Supplies . Optometric services, eye exert ises including orthoptics.
Routi ne eye exams and routine eye refractions, except routine eye screenings provided as spec ified
as covered in the Certificate. Eyeglasses or contact lenses, except as specified as covered In
the CertifiCate.
Outpatient Occupational Therapy. Outpatient occupational the rapy, except by a home health
agency, hospice, or home Infusion therapy provide r, 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 sole ly for beautification
or to alter or reshape normal (including aged) structu res or tissues of the body to Improve
appearar~ee . This exclusion does not apply to reconstructive surgery (that is, surgery perfomned
to correct deformities caused by congenital or develo pmental abnormalities, illness, or Injury for the
purpose of Improving bodily function ex symptomatology or to create a normal appearance),
including surgery perfornned to restore symmetry following mastectomy. Cosmetic surgery does not
become reconstructive surgery because of psychological or psychiatric reasons.
Scalp Hair Prostheses. Scalp hair prostheses, Inc lud ing wigs or any form of hair replacemen~
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 specifiCally li sted as covered in this plan .
This exclusion Includes , but Is not limited to, commertial weight loss programs (Weight Watchers,
Jenny Craig , LA Weigh t Loss) and fasting programs .
This exclus ion does not apply to medically necessary treatments for morbid obesity or dietary
evaluations and counsel ing , and behavioral modifiCation programs for the treatment of anorexia
nervosa ex bulimia nervosa. Surgical treatment for morbid obesity is covered as described in the
CertifiCate.
Sterilization Reversal . Reversal of steri li zation.
Inferti lity Treatment. Any services or supplies furn ished in connection with the diagnosis and
treatmen t of infertility , Including, but not limited to diagnostic tests, medication, surgery, artificial
Inseminat ion, 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 patien~ or therapeutic
shoes and inserts designed to treat foot 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 primari ly for environmental change or physical the rapy. Custodial care or rest cures, except as
specified as covered In the CertifiCate . Services provided by a rest home, a home lex the aged,
a nursing home or any similar fac ili ty. Services provided by a skill ed nursing facility, except as
specified as covered in the CertifiCate.
Health Club Membersh ips . Health club memberships, exertise equipment, charges from a
physical fitness instructor or personal traine r, or any other charges lex activities, eq uipment or
facilities used for developing or maintaining physical fitness , even H ordered by a physician. This
exclusion also applies to health spas.
Pe rsonal ~ems . 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 bu limia 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 purthased over the counter, which by law do not requ irement
either a written prescription ex dispensing by a licensed pharmacist
Telephone and Facsimile Mach ine Consu~ations. Consultations provided by telephone,
except as specified as covered In the CertifiCate, or facs imile machine.
Routine Exams or Tests. Routine physical exams or tests which do not d irec~y treat an actual
Illness , injury or condition, including those req uired by employment or government authority,
except as specified as covered in the Certificate .
Acupuncture . Acupuncture treatment, except as specified as covered in the Certifica te.
Acupressure or massage to control pain , treat illness ex promote health by applying pressure
to one or more specific areas of the body based on dermatomes ex 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.
Contact lenses and eyeglasses required as a res ult of this surgery.
Physical Therapy or Phys ical Medicin e. Services of a physician for physical therapy or physical
med icine, excep t when provided during a covered Inpatient confinement or as specified as covered
in the CertifiCate .
Outpatient Prescription Drugs and Medication s. Outpatient prescri ption dnugs, medications and
insulin, except as specified as covered in the CertifiCate . Non-prescription, ove r-the-counter patent
or proprie tary dnugs or medicines , except as specified as covered In the Certificate . Cosmetics ,
health or beauty aids.
Contraceptive Devices. Contraceptive devices prescribed for birth control except as spec ified
as covered in the Certificate.
Diabetic Suppl ies. Prescription and non-prescrip tion diabetic suppl ies except as specified
as covered In the CertifiCate.
Private Duty Nurs ing. Inpatient or outpatient services of a private duty nurse.
Lifestyle Programs. Programs to alter one's li festyle which may include but are not limited to diet,
exert ise, Imagery or nutri tion, except as specified as covered in the CertifiCate. This exclusio n will
not apply to card iac rehalbilitation programs approved by us .
BC Lumenos Health Savings Account Plan-Exclusions and Limitations (Continued)
Outpatient prescription drug services and supp li es are not provi ded for or In connection
w~h the fo llowing :
Immunizing agents, biological sera, blood , blood products or blood plasma
Hypodermic syringes &/or needles , except when dispensed for use witll 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 , includ ing outpatient
hospital facilities and physldans ' offiCes
Professional ch arges in connection with administering , injecting or dispensing drugs
Drugs & medications that may be obtained without a physic ian's written prescription,
except insulin or niacin for cholesterol lowering and certain over-the-counter drugs approved
by the Pharmacy and Therapeutics Co mmittee to be Included in the prescription drug formu lary.
Drugs & medications dispensed by or while confined in a hospital, skilled nursing facility,
rest home, sanatorium , convalescent hospital or similar facility
Durable medical eq uipment, 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 be auty 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 the prescription drug maximum allowed
amount
Drugs wh ich 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 prima11y for cosmetic purposes (e.g., Retin-A for wrink les). However, this will not apply
to the us e of this ty pe of drug for medically necessary treatment of a medical condition other tllan
one that is cosmetic.
Drugs used prim<Vily to treat Infertility (Including, but not limited to, Clomld, Pergonal and Metrodin),
unless medically necessary for another covered cond ition.
Anorex iants 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 wi th a non-prescription (over-the-counter) chemical and dose equivalent
except Insulin. Th is 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 phanmacy.
Specialty pharmacy drugs that must be obtained from the specialty pharmacy program, bUL 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 phanmacy that insu red
person should ha ve obtained from the specialty phanmacy program.
Th ird Party Liability -Anthem Blue Cross L~e and Health Insu rance Company is entitled
to re imbursement of benefits paid ~the Insured person recovers damages from a legally li able
third party.
Coordinat ion 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 rece ived 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
reg istered trademarks of Anthem Insurance Companies, Inc. The Blue Cross name and
symbol are registered marks of the Blue Cross Association.
Your Summary of Benefits
County of Fresno
C ustom P remier H MO 15
12-1 9 -2016
Anthem .+.
Blue Cross
T his S umm a r y of Be n e fits is a brie f overview o f yo u r pla n 's b e n e fits o nly. For m o r e d e t a il ed inform a tio n
a bout the be nefits in your pla n , plea se r e fe r t o yo ur Certificate o f Ins ura n ce o r Eviden ce of Cover a g e (EOC),
whic h expla ins the full r a n ge o f covered services, a s w e ll a s any ex clus io n s a nd limita tio n s fo r y o ur pl a n.
A nthe m B lue Cross HMO benefi ts are covered only when services are provided or coordinated bY. t he primary care
physician and aut ho r ized by the participati ng medical g roup or ind ependent p ractice association (IPA), except
serv ices provid ed under the "Ready Access" p rogram, OB/GYN ser vices received within t he member's medical
g roup/IPA, a nd services fo r a ll mental a nd nervo us disorders a nd substance abuse. Benefits are subject to all terms,
conditions, limitations, and exclusions of the Policy.
C alend a r Yea r cop ay maximum : Individua l $1,000; Family $2,000
T he fo ll owing coJ:>ay does not apply to the annual copay maximum: for infertili ty treatment. After an annual coP.ay
maximum is met for medical a nd prescription d rugs during 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 fo r the
remainder o f t hat yea r. T he member rem ains respo nsible for non-covered expenses infertility treatment.
CO\ ered Sen ires l'er \lemher Cotla~
Preve ntive C a r e Services
Preven tive Care Services including•, physical exams, No copay
preventive screeni ngs (including screeni':l_sfor
cancer, HPV, diabetes, cholesterol, bloo pressure,
hearing and vision, immuni=ations, health education,
intervention services, HI V testin8), and additional
preventive care for women provtded fo r in the
§uid~lines supp9rted .bY the Health Resources and
erv1ces Admm1strat10n.
•This lis t is not exhaustive. Th is benefi t includes all
Preventive Care Services required by federal and state
law.
S mo king Cessa tio n P r ogr a m No copay
Physi c ia n Medica l Serv ices
o Office & home visits $15/visit
o Spec ia lists $15/visit
o Sk ill ed nursin g facility visits No copay
o Hospital v isits No copay
o Injectable medications in physician's office
(excluding allergy serum and immuni=ation)
No copay
o Surgeon & Surgical assistant No copay
o Anesthesiologist or anesthetist No copay
Acupunc ture $15/visit
CO\ en~d Sen kes Per :\I ember Copa\
O utpatie nt Medical Services (Services received in a
hospital, other than emergency room services. or in
any facility that is affiliated with a hospitaf)
o Outpatient s urgery & supplies No copay
o Advanced Im agin g No copay
o All other X-ray & laborator y tests (including
genetic testing)
No copay
o Radiation therafuy , c he motherapy & hemo dial ysis
treatment & In usion therapy
No copay
o Other Outpatient Medical Se rv ices in c luding: No copay
Rehabilitation T herapy JPhysical, Occupational, or
Speech Therapy, limite to a 60-day period of care)
Gen e r a l Med ical Services (when performed in non-
hospital-based facility)
o Advanced Imaging No capa y
o All o ther X-ray & laborato ry tests (including
gene tic testing)
No copay
o Allergy te s ting & tr eatm ent (i ncluding serum s) N o copay
o Rad ia tion the rafuy, c hemotherapy & hemo di a lysis
treatment & In usion therapy
No capay
o Rehabilitatio n Therch; (P hys ical. Occ uff.ati onal. or $1 5/v isit
s;oeech Thera'l or ir oprac tic Care, imited to
0-days perio of care)
Emergen cy Ca r e
o Phys ician & medical serv ice s No capay
o Outpatient hospital emergency room services $1 00/vis it (waived if admilled inpatient)
Inpatie nt Medica l Services
emi-private room or pri vate room, medically
nec e ssa ry service s & supplies
No capay
U r gent Car e
(o ut of service area) $1 5/vis it (copay waived if admitt ed inpatient or
outpatient ER. For in area, contac t your PCP or
medical gro up)
Skille d N ursi n g Facility
(limited to I 00 days/calendar [ear; limit does not
apply to mental health and su stance abuse)
o All necessary services & supplies (excluding take-
home drugs)
o capay
A m b ula n ce Services
o T ransportation w he n medica ll y necessary o capay
Amb ul a t ory S urg ica l Center
o Outpa ti ent s urgery & s upplies No copay
Co\'en•d Sen kes l'er Member Cop:l\'
Preg na ncy and Mat erni ty Care
No copay Prenatal & postnatal Professional (physician) services
(For your Inpatient capay, see Inp atient Medical
Services. For your Outpatient Services capay, see
Outpatient Medical Services)
Ab ortions (including prescription drug for abortion, No copay
mifepris tone)
Prosth eti c devices (i ncluding Orthotics) No copay
Durable medi ca l equ ip me nt No copay
o Rental and Purc hase of D ME (hearing aids benefit
available for one hearing aid t_er ear every thre e
years; breast pump and supp ies are covered under
preventive care at no charge)
Fa mil y Pla nnin g and Infertility Services
o Inferti l ity studies & tests $15/vis it
o Female Steril ization (i n clu ding tuba/ligation and No co pay
counseling/cons ultation)
o Male Steriliz ation $15 /visit
o Counseling & cons ultation $15/visit
Mental or Nervous Disorders and S ubs ta nce A buse
0 Inpatient facility care (subje ct to utili=ation
waived for emergency admissions)
review; No copay
o Inpati ent physic ian v isits No copay
o Outpatient facili ty care No copay
o Physician office v is its (Be havioral Health treatment $15 /v is it (for non-preventive visits)
for Autism or Pervasive Development disorders
require pre-service review)
Ho me Hea lth Ca re
~imited to I 00 visits/calendar kear; one visit by a $15/v isit
ome health aide eq uals four ours or less)
Hospi ce Care (Inpatient or outpatient services; family
bereavement services)
No copay
Org an a nd Tiss u e Transpla nt
o Inpatient Care No copay
o Physician o ffice visits $15/visi t
o Specialist office visits $15 /visi t
This S ummary of Benefits has been updated to comply with federal and s tate requ irements, including appli cable
provis ions of the recently enacted federal health care reform laws. As we receive addi ti onal guidance and
clarifi cation on the new heal th care reform laws from the U.S. Department o f Health and Human Serv ice s,
Department of Labor a nd Internal Revenue Service, we may be required to make addi tio nal changes to this
Summary o f B enefits. T hi s Summary of B enefits, as updated( is s ubject to the approval of th e California Department
o f In s ura nce a nd the California Department of Managed Hea th Care (as applicable).
For a dditio n al in fo rmati o n o n limitati o ns a nd excl us io ns a nd oth er d isclosu re items t ha t a pply to
t hi s p la n , go to https://le .anthem.com/pdf?x=CA LG HMO
This plan inc ludes custom benefits that may su persed e so me of th e inform ation in c luded in the Limitations and Ex clu sio ns
lin k provided here. Please see you r EOC for full details on your covered benefits
Antnem Bl ue Cross is tne trade name of Blue Cross of California. Independent Licensee of tne Blue Cross Assodation. ®ANTHEM i s a rl!gistered trademar1< of Anthem In surance
Companles, Inc. The Blue Cross name and symbol are reg istered marks of the Blue Cross Association
anthem comics Anthem Blue Cross (P·NP) Printed 0912016 County of Fresno Premier HMO 15 .c
SJVIA Anthem .+.
811/eCro~ Modified Chiropractic Care and Acupuncture
Rider Plan 10/40
The benefits described in th is 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 rece ived from an ASH Plans Chiropractor or ASH
Plans Acupuncturist, no other benefits other than the benefits described in this Ride r will be pa id.
Covered Services Member's Copayment
Office Visit to a Chiropractor or Acupuncturist $10/visit
Max imum Benef its
Office visits to a Chiropractor or Acupuncturist
Chiropractic appliances
Covered Services
40 visits pe r calendar year (ch iropract ic and
acupunctu re visits combined )
$50 per calendar year
Ch irop ractor Serv ices : Member has up to 40 visits , comb ined 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
subm itting 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 ch iropractor 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
chiropract ic rad iologist, medical radiologist , radiology group or hospital which has con tracted with ASH Plans to prov ide those services .
~ Chiropract ic Applian ces : Up to $50 per calendar year when prescribed by an ASH Plans chiropractor and approved by ASH Plans .
Cove red chiropractic appliances are limited to :
-elbow supports , back supports (thoracic), lumbar braces and supports, rib supports , or wri st 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 Serv ices . 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 med ically/clin ic ally necessary . All visits to an ASH Plans chi ro practo r or ASH Plans acupuncturist
will be applied towards the maximum number of visits in a calendar year . The ASH Plans acupunctur ist 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 acupunctur is t to determine the approp ri ateness 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.
an them .com/ca Anthem Blue Cross Effective 12-19-16 Printed 11 123120 16
Chiropractic Care and Acupuncture Rider Exclusions & Limitations
Care Not App roved : Any servic es provided by an ASH Plans chlropraciOr 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 plan to ASH Plans for prior approval.
Care Not Covered : In addition to any serv ice or supply specifocally excluded In the EOC , no
benefits .,.;n be provided for chiropractlc or acupuncture services or supplies in comection with:
:;.. Diagnostlc seaming, such as magnetlc resonance imaging (MRI) or computerized axial
k>mOgraphy (CAT] scans. Dlagnosllc services for acupuncture.
, Thermography.
:;.. Hypnotherapy.
:;.. Behavior training.
:;.. Sleep therapy.
). Weight programs.
). Any noll-medical program or service.
, P~mployment examinations, any chlropractlc or acupuncture services required by an
employer that ate not medically.tllnically necessary, or vocational rehabilitation.
,. Services andfor treatments whiCh ate not doct.mented as medicalty/dlnlc ally necessafY .
, Massage therapy.
, Acupoocture performed with reusable needles .
>-Acupuncture services benefits are not provided for magnets used for diagnostic or therapeullC
use, ion cord devices, manipulation or adjustments of the joints, physical therapy services,
lridology, hormone replacement products, acupuncture point or tr1gger-polntlnjections (including
injectable substances), lasernaser blostlm, colorpuncture, NAET diagnosis and/or treatmen~
and di rect moxibustion.
:;.. Any service or supply for the exam and/or treatment by an ASH chiropractor for conditions other
than those related to neurorrusculoskeletal disorders.
, Services from an ASH Plans acupuncturist for exam and/or treatment for cond itions not related
10 neuromuscufoskeletal disorders, nausea or pain, incluing , '.vithout li mitation, asthma or
addictions such as nicotine addiction.
,. Transportation costs including local ambulance charges.
,. Education programs, no!l-medocal self-care or self-help, or any seH-help physical exercise
training or any rel ated diagnostic testing .
). Hospitali zation , su '9ical procedures, anesthesia, manipulation under anesthesia, proctology,
colonic irrigation, injections and Injection services, or other related services;
, All auxiliary cids and services, including, but not li mited to, interpreters, transcription services,
"Mitten materials , telecommun ications devices, telephone handset amplifiers , television
decoders and telephone compati ble '.vith hearing aids ;
l> Adjunctive therapy not associated '.vilh spinal, muscle or )oint manipulation.
). Laboratory and diagnostlc x-ray studies, except as specified as covered In the EOC
Non-ASH Plans Ch iropractors or non· ASH Plans Acupunctu ri sts: Services and supplies
provided by a chiropractor or an acupuncturists 1\00 does not have an agreemen t wnh ASH Plans
to provide covered services under this plan .
Wort Related: Care for health problems that are work-related n such health problems are covered
by workers ' compensation, an employer's llabl~ty law or simil ar law. We >viii provide care tor a
wort-related health problem, but we have the rig ht to be paid back for that care as described
in the EOC .
Government Treatment: Any services actually given to the member by a local , state or federal
government agency , except when lhis plan 's benefits , must be provided by law. We \vi ii not cover
payment lor these services n 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 flOil-legend or proprietary medicine or
medocabon not requiring a prescription.
Supplement. Vitamins , minerals, dietary and nutritional supplements or other simHar products
and any herbal supplements.
Air Conditioners : Air purifiers, air conditioners , humidifiers, suppUes or any other similar devices
or appliances. All appliances or durable medical equipment, except as specified as covered
in the EOC ..
Personal ~ems : Any supplies for comfort, hygiene or beauty purposes, Including therapeutic
mattresses .
Out-Of-Area and Emergency Ca re: Out-of-area care Is not covered lllder this Chiropractlc
and AcupunctLre Care benefl~ except for emergency services . The member should follow
the proced~n~s specified by their Anthem Blue Cross HMO plan " obtain emergency or
OIJI-of-area care .
Th ird Party Liab ility
Anthem Blue Cross is entitled to reimbursement of benefits paid if lhe member recovers damages
from a legally liable third party .
Anthem Blue Cross is the trade name of Blu e Cross of Ca liforn ia. Independent Licensee of
the Blue Cross Association. e ANTHEM Is a reg istered trademark.® The Blue Cross name
and symbol are registered marlls of fhe Blue Cross Association.
•SJVIA
San Joaquin Valley
Insurance Authority
Prescription Drug Copays
usscript.
30 Day Supply:
Generic $10
Formu lary $20
Non -Formulary $35
DAW 1 -No Cost Differential
DAW 2 -Non-Formu lary+ Cost Difference
90 Day Supply:
Generic $20
Formulary $40
No n-Formulary $60
DAW 1 -No Cost Differential
DAW 2-Non -Formulary+ Cost Difference
Annual Out-of-Pocket Maximum
Individual $2,000
Fam ily $4,000
Exclusions
Ha ir Treatments
Pigmen ting/Depigmenting
Anti -wrinkle
Fluoride Preps
M isc. Med ical 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 o complete summary of benefits. Additional/imitations and exclusions may apply.
Effecti ve January 1, 2017
Disclosure Form
SJVIA -County of Fresno
Customer ID 580
Membe r Services 1-800-464-4000
Home Reg ion : North ern Californ ia
Principal benefits for
Kaiser Permanente Traditional Plan (12/19/16-12/18/17)
Health Plan believes this coverage is a "grand fathered health plan" under the Pa t ient Pro tectio n and Affordable Care Act. If you have
questions about grand fathe red health plans , please call our Membe r Service Con t act Center.
Accumulation Period
T he Accumulation Perio d fo r this plan is 1/1/16 through 12/31 /16 (ca lendar yea r).
Out-of-Pocket Maximum(s) and Deductible(s)
For Services that app ly t o the Plan Out-of-Pocket Maximum , you will not pay any more Cost Share fo r the rest of the Accumulation
P . d h h d th t I' t d b I eno once you ave reac e e amoun s IS e eow.
Self-Only Coverage Family Coverage Family Coverage
Amounts Per Accumulation Period (a Family of one Member) Each Member in a Fam ily of Entire Family of two or more
two or more Members Membe rs
Plan Out-of-Pocket Maximum $1 ,500 $1 ,500 $3 000
Plan Deductible None None None
Drug Deductible None None None
Profess ional Services (Plan Provider office visits) You Pay
Most Primary Care V isits and most Non-Physician Specialist V isits ......................... $15 per v isit
Most Physician Specialist Vis its ................................................................................ $15 per vi sit
Routine physical maintenance exams , including we ll -woman exams .... ......... .... ... ... No charge
Well-ch ild preventive exams (through age 23 mon ths)............................................. No cha rge
Family planning counse ling and consultations .......................................................... No charge
Scheduled prenatal care exams ................................................................................ No charge
Routine eye exams with a Plan Optometrist.............................................................. No charge
Hearing exams . . .. .. . .. . .. .. .... . . .. .. .... ...... .... . .. .. . .. . ... ... .. ... .... .. . ...... ..... . . .... .... .. . .... ....... .... . . No cha rge
Urgent care consu ltations , evaluations , and treatment ............................................. $15 per v isit
Most physical , occupational , and speech therapy ..................................................... $15 per vi sit
Outpatient Servi ces You Pay
Outpatient surgery and certain other outpatient procedures ..................................... $15 per procedu re
Allergy injections (i ncluding allergy serum )............................................................... $3 per vis it
Most immun izations (including the vaccine ) .............................................................. No charge
Most X-rays and lab oratory tests ............................................................................... No cha rge
Cove red indiv idua l hea lth education counseling .......................................... ............. No charge
Covered health educa ti on programs .. . .. .. .. .. .. .. . .. .. .. .. .. . ... .. .. .... .. .... .. .. ... . .... .. .. .. . .. .. .. . .. . No cha rge
Hos p it alization Servi ces You Pay
Room and board , surgery , anesthesia , X-rays , lab orat ory tests, and drugs ............. No cha rge
Emergency Hea lth Coverage You Pay
Emergency Department visits .... .. ..... .. .... ... .. ......... .......... ......... .... ....... ..... ... .. .. .... ... ... $100 per visi t
Note : Th is Cost Sha re does not apply if you are admi t ted dire ctly to the hosp ital as an inpatient for covered Services (see
"Hospi talizat ion Services" for inpatient Cost Share ).
Ambulance Services You Pay
Ambulance Services .................................................................................................. $5 0 per t rip
Pres cription Drug Coverage You Pay
Covered outpat ient items in accord with our drug formulary gu idelines:
Most generic items at a Plan Pharmacy ................................................................. $10 fo r up t o a 30 -da y suppl y
Most generic refills through our mail -order service ................................................ $20 for up to a 100-day supply
Most brand-name items at a Plan Pharma cy ......................................................... $20 fo r up to a 30-da y su pply
Most brand -name refills through our mail-order service ......................................... $40 f or up to a 100-da y su pply
Most specialty items at a Plan Pharmacy ............................................................... $20 for up to a 30-day su pply
Durable Medical Equipment (DME) You Pay
DME items in accord with our DME formulary guidelines .......................................... 20% Coi nsuran ce
Mental Health Servi c es You Pay
Inpatient psychiat ric hospitalization ........................................................................... No cha rge
(continue s)
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 e valuatio n and treatment... ................... $15 per visit
Group outpatient chem ical dependency treatment.................................................... $5 per visit
Home Health Services You Pay
Home health care (u p to 100 visits per Accumulat ion Period) ................................ .
Other
No charge
You Pa
Eyeg lasses 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 (u p to 100 days per benefit per io d ) ................................ No charge
Prosthet ic and orthotic device s .. .. .. .. .. .... . .. .. .. .. .... ..... .... .. .. ...... .. .. ....... ...... .. ........ ... .. . .. No charge
Hos pice care .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. . .. .. .. .. .. .. .. .. .. .. .. .. . .. .. .. .. .. .. .. No charge
T his is a summary of the most frequently asked-about benefits . This ch art does not explain benefits , Cost Share, out-of-pocket
ma xi mums , 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 prov ide all benefits requ ired b y law (for examp le, diabetes testing su pplies).
8963.!23.1.5000472339
Disclosure Fo r m
SJVIA -County of Fresno
Customer ID 580
Member Serv ices 1-800-464-4000
Home Reg ion : Northern Californ ia
Principal benefits for
Kaise r Permanente Traditional Plan
Accumulation Pe r iod
The Accumu lation Period for th is plan is 1/1/17 through 12/31 /17 (calendar year).
Out-of-Pocket Maximum(s) and Ded uctible(s)
(1/1/17-12/31/17)
For Services that apply to the Plan Out-of-Pocket Ma xi mum , you will not pay any more Cost Share for the rest of the Accumulation
P · d h h d th t r t d b 1 eno once vou ave reac e e amoun s IS e eow.
Self-Only Coverage Fam ily Coverag e Family Coverage
Amounts Per Accumulation Pe riod (a Family of one Member) Each Member in a Fam ily of Entire Fami ly of two or more
two or more Members
Plan Out-of-Pocket Maximum $1 500 $1 500
Plan Deductible None None
Druq Deductible None None
Professional Services (Plan Provide r offic e visits) You Pay
Most Primary Care Visits and most Non-Physician Spec ial ist Visits ......................... $15 per visit
Most Physician Special ist V isi ts ................................................................................ $15 per visit
Routine physical maintenance exams, including well-woman exams ...... .......... .... .. . No charge
Well-chi ld preventive exams (through age 23 months).......................... ... ............... No charge
Fami ly planning counseling and consultations ......................................................... No charge
Scheduled prenatal care exams ................................................................................ No charge
Routine eye exams with a Plan Optometrist.............................................................. No charge
Urgent care consultations , evaluations, and treatment.. ........................................... $15 per visit
Most phys ical , occupat ional , and speech therapy ..................................................... $15 per visit
Outpatient Servic es You Pay
Outpatient su rgery and certain other outpatient procedures ..................................... $15 per procedu re
Allergy injections (i ncl uding allergy serum)............................................................... $3 per visit
Most immu n izations (including the vaccine ) .............................................................. 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 Pa y
Room and board , surgery , anesthesia , X-rays , laboratory tests , and drugs ............. No charge
Emergency Health Coverage You Pay
Emergency Department visits ................................................................................... $100 per visit
Members
$3 000
None
None
Note: Th is Cost Share does not apply if you are admitted directly to the hospital as an inpatient for covered Services (see
"Hospitalization Services" for inpatient Cost Share).
Ambulance Services Y ou Pay
Ambulance Services ................................................................................................ . $50 per trip
Prescription Drug Coverage You Pay
Covered outpatient items in accord wi th our drug formulary gu ide lines:
Most generic items at a Plan Pharmacy ................................................................. $10 for up to a 30-day supply
Most generic re fills through our ma il-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
Mos t brand-name refills through our mail-order service ......................................... $40 for up to a 100-day suppl y
Most specialty items at a Plan Pharmacy ............................................................... $20 for up to a 30-day supply
Durable Medic al 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
Individual outpatient mental health evaluation and treatment ................................... $15 per visit
Group outpa tient mental health treatment................................................................. $7 per visit
(continues)
Disclosure Form
Che mical Dependency Services Yo u Pay
Inpatient detoxification .............................................................................................. No charge
Individual outpatient chemical dependency evaluation and treatment.. .................... $15 per visit
Group outpatient chemical dependency treatment................... .. .. .. . .. .. .. . . . .. . .. . .. . . . . . . .. $5 pe r visit
Home Health Services
Home health care (u p to 100 visits per Accumulation Pe riod) ................................. .
Other
You Pay
No charge
You Pa
(continued)
Eyeglasses or contact lenses e very 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 ch arge
Prosthetic and orthotic devices .. .. .. .. .... .. .... .. .. .. .. .. .. .. .. .. .. .. .... ............ .... .. .. . ................ No charge
Hospice care .. .. .... .... .... .. .. . .... ...... .. .. .. .. ...... .. .. .. .... .. .... .. .. .... .. ...... .. .... .. .... .. .. .. ........... No charge
This is a summary of the most frequently asked-about benefits. Th is 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 ).
8974.46.1 .5000472340
SJVIA -County of Fresno
Customer ID 580
Member Services 1-800-464-4000
Summary of Benefits Chart for
Kaiser Permanente Senior Advantage (HMO) with Part D (1/1/17-12/31/17)
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 Co payments 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 Fam ily 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 and most Non-Physician Specialist Visits
....................................................................................................... $15 per visit
Most Physician Specialist Visits ...................................................... $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
Urgent care consultations , evaluations , and treatment ................... $15 per visit
Physical , occupational , and speech therapy ................................... $15 per visit
Outpatient Services You Pa
Outpatient surgery and certain other outpatient procedures ........... $50 per procedure
Allergy injections (including allergy serum ) .. .. . .. . . . . .. . . .. . . . . .. . . . . . .. . . . . . . . $3 per visit
Most immunizations (i ncluding 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
Emer enc Health Covera e You Pa
Emergency Department visits . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . .. . . . . . . . . . . . . . . . . . . . . . $50 per visit
Ambulance Services You Pa
Ambulance Services ....................................................................... $100 per trip
Prescription Drug Coverage You Pay
Covered outpatient items 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 1 00-day supply
Durable Medical E uipment DME You Pa
Covered durable medical equipment for home use . . . . . .. . . . . . . .. ... .. . . . . 20 percent Coinsurance
Mental Health Services You Pa
Inpatient psychiatric hospitalization ................................................. No charge
Kais er Foundation H ealth Plan, In c., N orthern Californ ia Region continues
continued
Mental Health Services You Pa
Individual outpatient mental health evaluation and treatment.. ....... $15 per visit
Group outpatient mental health treatment . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . .. . . .. . $7 per visit
Chemical De endenc Services You Pa
Inpatient detoxification .................................................................... No charge
Individual outpatient chemical dependency eva luation 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 Pa
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 , e xclusions , or limitations , nor does it list all benefits and Cost
Share amounts . For more information , please refer to the Summary of Benefits booklet enclosed .
Please note that we provide all benefits required by law (for example , diabetes testing supplies).
Ka is er Fo undation Hea lth Plan, In c., Northe rn Ca lifornia Region 8964 .140.1.5000472348
Provi d ed by American Specia lty Health Plans of California, Inc. (ASH Plans)
When you need chiropractic care, follow these simple steps:
1. Find an ASH Plans Participating Pr ovider near yo u:
• Go to ashl i nk.com/ash /kp, or
• Cal l 1 -800-678 -9133 (TTY 711 ), Monday through Fr iday,
from 5 a.m. to 6 p.m. Pacific time
2. Schedu le an appo i ntment.
3 . Pay for your office visit when you arrive for your appointment.
(See the reve rse for more details.)
I Am erican Spec ialty Hea lth.
~ans of California
•• ~Ill~ KAISER PERMANENTE .
YOUR KAISER PERMANENTE
CHIROPRACTIC BENEFIT
Services
Chiropractic Services are covered when provided
by a Part ic i pating Prov ider and medically necessary
to treat or d iagnose Neuromusculoskeletal
Disorders. You can obtain services from any ASH
Plans Parti cipating Provider without a referral from
a Plan Physi cian .
Cost Sharing and Office Visit Maximums
Office visi t cost share : $10 copay per visit
Office v i sit limit: 30 v1sits per year
Ch i ropractic appli an ce 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 l imited to: elbow supports. back supports, cervical
collars, cerv ical pi llows, 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 : Covered Serv ices are limited to Medically Necessary Ch iropractic Services authorized and provided by ASH Plans Partic ipating
Provi ders except for Emergency Ch iropractic Servic es and Servic es that are not ava il able from Participating Providers or other licensed
providers with which ASH contracts to provide covered care. Each office visit counts toward any visit limit, if app li cable, even if an adj ustment
is not provided during the visit.
X-rays and labo ratory tests: Medically necessary X-rays and laboratory tests are covered at no charge when prescribed as part of covered
chiropractic care and a Part icipating Provider provides the Serv ices or refers you to another licensed provider with which ASH contracts for
the Services.
Participating Providers
ASH Plans contracts with Participating Providers and other licensed provi ders to provide covered Chiropractic Servic es, including laboratory
tests, X-rays, and chiropractic appliances. You must receive covered services from a Participating Prov ider or another licensed provider w ith
which ASH contracts, except for Emergency Chiropractic Services, Urgent Chiropractic Services, and services that are not available from
Participating Providers or other licensed providers with which ASH contracts to provide covered Services that are authorized in advance by
ASH Plans . The li st of Partici patin g Prov iders is ava i lable on the ASH Plans website at ashlink.com/ash /kp or from t he ASH Plans Customer
Service Department toll free at 1-800-678-9133 (TTY users ca ll 711 ), weekdays from 5 a.m. to 6 p .m. The list of Participating Providers is
subject to change at any time without notice.
How to obtain services
To obtain covered services, call a Participating Provi der to schedule an initial examination. If additional services are required, verific at ion that
the Services are Medically Necessary may be required. Your Partici pating Provider will request any medica l necessity determinations. An ASH
Plans clinician in the same or similar special ty as the provider of Services under review w ill decide whether t h e Ser vi ces are or were Medic al ly
Necessary Services. ASH Plans will disclose to you, upon request. the process that it uses to authorize, modify. delay, or deny a request for
authorizat ion. If you have questions or concerns, p lease contact the ASH Plans Customer Service Department.
CHI R O 142 NCAL_ 453 SCAL (9/16)
YOUR KAISER PERMANENTE CHIROPRACTIC BENEFIT
Second Opinions
You may request a second opi nion in rega rd to covered Services by contacting another Participating Provider. A Participating Provider may
also request a second opinion in regard to covered Services by referring you to another Participating Provider in the same or similar specialty.
Your Costs
When you receive covered Services, you must pay your Cost Share amount as described in the Ch iropractic Services Amendment of your
Health Plan Evidence of Coverage. The Cost Share does not apply toward the Plan Out-of-Pocket Maxi mum described in the Health Plan
Evidence of Coverage.
Emergency and Urgent Ch iropractic Services
We cover Emergency Chiropractic Services and Urgent Chiropractic Services provided by both Participating Providers and Non-Participating
Providers . We do not cover follow-up or continuing care from a Non-Partic i pati ng Provider un less ASH Plans has authorized the services i n
advance . Also, we do not cover services from a Non-Participati ng Prov ider that ASH Plans determines are not Emergency Chiropractic
Services or Urgent Ch i ropractic Services.
Getting Assistance
If you have a question or concern regarding the services you received from an ASH Plans Participating Provider or another licensed provi der
with which ASH contracts, you may call AS H Plans Customer Service Department toll free at 1-800-678 -9 133 (TTY users ca ll 711 ), weekdays
from 5 a.m. to 6 p.m. Pacific time.
Grievances
You can file a grievance with Kaiser Permanente regarding any issue . Your grievance must expla in your issue, such as the reasons why you
believe a decision was in error or why you are d i ssatisfied with Serv ices you received. You may submit your grievance ora ll y or in writing to
Kaiser Permanente as described i n your Health Plan Evidence of Coverage.
Exclusions and Limitations
• Services for asthma or addiction, such as nicotine addiction
• Hypnotherapy, behavior training, sleep therapy, and weight programs
• Thermography
• Experimental or investigational services
• CT scans, MRis, PET scans, bone scans, nuclear medicine, and any other types of diagnostic imaging or radiology other than X-rays covered
under the "Covered Services" section of your Chiropractic Services Amendment
• Ambulance and other t ransportation
• Education programs, nonmedical self-care or self-help, any self-help physical exercise tra i ning, and any related diagnostic t esting
• Services for p re-employment physicals or vocational rehabi litation
• Air conditioners, air purifiers, therapeutic mattresses, chiropractic appliances, durable medical equipment, su pplies , devices, appliances, and
any other item except those listed as covered in your Chiropractic Services Amendment
• Drugs and medic ines, including non-legend or proprietary drugs and medicines
• Services you rece ive outside the state of California except for Emergency Ch iropractic Services and Urgent Chi ropractic Se rvices
• Hospital services, anesthesia, manipulation under anesthesia, and related services
• For Ch iropractic Services, adjunctive therapy not associated w ith sp inal, muscle, or joint manipulations
• D ietary and nutritional supplements, such as vitam ins, m inerals, herbs, herbal products, injectable supplemen t s, and si milar products
• Massage therapy
• Services provided by a chiropractor that are not w ithin the scope of licensure for a chiropractor licensed in Ca li forn ia
• Maintenance care (services provided to members whose treatment records indicate that they have reached maximum t herapeutic benefit)
CHIRO 14 2 NCAL_453 SCAL (9/16)
YOUR KAISER PERMANENTE CHIROPRACTIC BENEFIT
Definitions
ASH Plans: American Specialty Health Plans of California, Inc., a Ca li fornia corporation .
Chiropractic Services: Services provided or prescribed by a ch iropractor (incl uding laboratory tests, X-rays, and ch iropractic appli ances) for the
treatment of your Neuromusculoskeletal Disorder.
Emergency Chiropractic Service s: Covered Ch iropractic Ser vices provided for the treatment of a Neuromusculoskeletal Disorder wh ich
manifests itself by acute symptoms of sufficien t severity (including seve re pain) such t hat a reasonable person could expect the absence of
immediate Chiropractic Services to result in serious jeopardy to your h ea lth o r body functio ns or organs.
Neuromusculoskeletal D is orders: Condit ions with associated signs and symptoms re lated t o the nervous, muscular, or skeletal systems.
Neuromusculoskeletal Disorders are conditions typically categorized as structural, degenerative, or inflammator y disorders, or b iomechanic al
dysfunction of t h e joints of the body o r re la ted components of the motor un it (muscles, tendons, fasc ia, nerves, ligaments/capsu les, d i scs, and
synovial structures), and rela ted neu ro log ic al mani festat ions o r conditio ns .
Participating Provider: A ch i ropractor who is licensed to provide c hiropractic services in Cali f ornia and who has a contract wi t h ASH Plans to
provide Med ica lly Necessary Chiropractic Services to you.
Urgent Chiropractic Services : Chi ropractic Services tha t meet all of the fo llowing requ irements:
• They are necessary to prevent serious deteriorat ion of your health, resu lting from an unforeseen ill ness, injury, or complication of an existi ng
condition, i nc luding pregnancy.
• They c annot be delayed until you return to the Service Area.
Th is is only a summary and is intended to highlight on ly the mos t frequently asked questions about the benefi t , includi ng cost shares . Please refer
to the Ch iropractic Services Amendment of the Ka is er Foundation Health Plan , Inc., Evidence of Coverage for a detailed descri ption of the
chiropr actic benefits, in cl udi ng exclus ions and l imitations, Emergency Chiropractic Services, and Urgent Ch i ropractic Services.
Kaiser Foundation Health Plan, Inc . (Health Pl an), contracts w ith Americ an Specialty Health Plans of California, Inc. (ASH Plans), to make the ASH
Plans network of Participating Providers ava il able to you. You can obtain covered Serv ices f ro m any Participating Provider without a referral from
a Plan Phys ici an. Your Cost Share is due when you re ceive covered Ser vices . Plea se see t h e defi nit ions section o f your Chiropractic Services
Amendment of the Ka is er Foundation Health Plan, Inc., Evidence o f Coverage for terms you shou ld know.
I American Special~ Health.
~ans ol Calilomia
• •• ~m~ KAISER PERMANENTE.
CHIRO 14 2 NCAL_ 453 SCAL (9 /16)
ATTENTION : If you speak English, language assistance services, free of charge, are available to you. Calli -
800-678 -9133 (fTY: 1-877-257-2746 ).
~~ u.u. ,&J) 800-678-9133-1 ,&..>?J.-.,ll .~.ill _)1_,»..,_,&1 ou.L....ll d....~ J.i ,W\1 fill c.:..~~ llJ :.U.yl.o
.(877 -257-2746-1 :~1_,
nr-cu'1rnr-ra-anr-tJ · tp-tJununLutp hwJtptU, wUJ.watq wutji{wpl.jwflilll tu tnpwU'WI}llt\tL
Ltqtjwl.jwu w2wl.jgmp-Jwu bwnwJnlp-Jnluutp: ~uqwhwptp 1-800-678-9133 (fTY (htnwtnP.u{l · 1-877-
257 -2746):
1-800-678-9133 (fTY: 1-4 .~<.>"Fly U.. (51..>?J.ft1J WJ~ ~j w~ .Jf>S. <.>" .}::i/:. c.s-"'fl ~j ~}.I :~
.~~~ 877-257 -2746)
t:~rrnt: ma-3fN~ ~6c=IT ~rc;rv~~ ~~~~6'1 1-800-678-9133 (fTY: 1-
LUS CEEV : Yog tias koj hais Ius Hmoob, covkev pabtxoglus, muaj kevpab dawb rau koj . Hu rau 1-800-
678-9133 (fTY: 1-877-257 -27 46).
5.i ~*J~ : 8 it88~85~ tl~~.g., ~~0) ~ glf)Zti~ ~'fljffl L' t.:tclt ~9 o 1-800-678-9133 (TTY:l-
877-257-2746) ~ -c·, 3311[851~-r ~-il~< t.:~L '0
(T TY: 1-877-257-2746)~ £.£ ~ £~oH ~~ Al.2 .
Dil bao ako uini zi n: Dii s.1nd bee ro nifti'~o Dlnr Bi7:llld . saa d becoi ka ':i n ida ·nwo ·d ~¢-. t'M
j h k'eh. e i n:\ h6lQ, koj j' h6di illlih 1-800-678-9133 (TTY : 1-877-257-2746).
~~:~~~~-b. 3i"STF.JTres~~~tre\~~ ~11 -8 00-678-9133 (fTY:
1-877-257-2746) '3 ~ aBI
BHHMAHHE: ECJIH BI>I roBopme Ha pyccKOM.113I>IKe , TO BaM,DiOCtyiiHbi 6ecrmaTHI>re ycnyrnnepeBO,Dia .
3BoH!1T e 1-800-678-9133 (re.neraful : 1-877-257-2746).
A TEN CION : si habla espano~ tiene a su dis posicion servicios gratuitos de asistencialingilistica. Uame all-
800-67 8-9133 (TTY: 1-877-257-2746).
CHIRO 142 NCAL_ 453 SCAL (9/16)
PAUN A WA : Kung ~asalita ka ng T ~al.og, maaari k~ ~unamit 11g m;:a se1bisvo ng tulo~ sa wika ~
walang bay ad . Tumawa? sa 1-800-678-9133 (TIT: 1-877-257-2746).
)!:a : ~D~~ffffl9R Rcp )Z • ~DJ J,~9aJt3i~~s~!!t.JRii~ o it~~ 1-800-678-9133 (TIT : 1-$77-
257-2746) 0
CHU Y: N.k b~ n6i TikngV~t. c6 c.ic dich ~ h6 tn;tngenngihni~n phidanhcho b~. GQi s8 1-800-678-
9133(TTY : 1-877-257-2746).
CHIRO 142 NCAL_ 45 3 SCAL (9/16)
County of Fresno
Your Two Delta Dental
Plan Options
The cho ice Is you rs. When it comes
to dental hea lth, you wa nt benefits
that provide you wi t h the best bal ance
of value and coverage. De lta Dental
PP05M* and DeltaCa re® USA both
offer comprehensive dental coverage,
quality care and excellent customer
service. Each plan has its own
advantages .**
The PPO plan gives you the freedom
to choose any dentist, and the
oppo rtunity for meaningful savings o n
your treatment costs when you vis it
a PPO dentist. With a DeltaCare USA
plan , when you recei ve trea tment from
your assigned dentist you have the
convenience of kno wi ng what your
co payment is for covered procedures
before your visit.
Yo u have the option to selec t either
one of these two outstand ing dental
benefits plans, both admini ste re d by
one of the foremost dental benefits
organizat ions In th e Un ite d States .
Se lect either Delta Den tal PPO or
De ltaCare USA. Whichever plan you
choose, we look forward to providing
you with the excellent de ntist access,
great coverage and friendly service
that so many enro llees have come to
expect.
* In Texas, Delta Dental offers a
Denta l Provider Organ i zatio n
(DPO) Pla n.
** See bac k pag e for the
und erwri ters of these p lan s in
you r sta te.
and then some.
This booklet provides high lights about both dental pl ans to he lp you select the coverage option that best fits your needs. It Is no t Intended or desi gned to
serve as an Evid ence of Coverage or benefit booklet. For complete information about your coverage, processing policies, lim itations and exclusion s, ple as e
refe r to your Evidence of Coverage or benefit booklet. If you still have ques tions about your coverage, please conta ct yo ur group's benefits admini strator.
BL_CYP _PPO_USA_DDC_08.04.2011
Plan Features
Copayments/colnsurance
Coverage
Dentist network
Changing your dentist
Transition s from previous plan
Orthodontic treatment
in progress
(when covered under prior plan)
Authorization for specialty
care trea tment
Out-of-area coverage
Deductlbles and maximums
Claims
Compare Program Features
Delta Dental PPO
• Cove red seNices paid at applicab l e
percentage -for example, fillings are
covered at 80% of allowed amount-you
pay the remaining 20%
• Wide range of covered seNices
• No exclus ion s fo r most pre-existing
condi t ions
• Freedom to choose any licensed d entist
• No referral required fo r specia l ty care
• Ch ange dentists any time wi t hout
contac ti ng Delt a Den tal
• Cove rage is provided only for t r eatment
st arted and completed after your effective
date of coverage un d er t he Delta Den t al
p lan
• Plan will pay the remaining amount
of t he t ota l case fee no t pa id by your
former dental p lan (when plan includes
orthodontic coverage)
• Preauthorization is not required
• Visit any licensed dentist
• Deductibles and annual maximums app ly
to most plan designs
• Delta Dental dentists Ale cla i m forms and
acc ept paymen t directly from Delta Dental
• Non-De lta Denta l dentists may require
payment up fron t , and require you t o file a
cl aim fo r reimbursement
DeltaCare USA
• Cove red procedu res have pred etermined
dollar copayments for seNices p rovided by
network dentists (this means out-of-pocket
costs are predic t able)
• Plan cover s nea rl y 300 p rocedures
• No copaymen t s or l ow copayments for
mos t diagnostic and p reventive seNices
• No exclu sions fo r pre -existing con ditions or
mi ssi ng t ee th
• You must select a den ti st from a list of
ne twork denta l facil iti es and you m ust visit
t hi s de ntist t o rec eive b enefi t s
• Easy referrals t o a large specialty ca r e
network
• Ab ility to cha nge select ed o r ass i gned
network denti st s via t el ephone or Internet
• Coverage Is provided only for t rea t ment
started and com p leted after your effecti ve
da t e of coverage under t h e plan
• Covers new enrollees w ho, on the effective
da t e of their coverage, are In active
trea t ment start ed •Jn der their previous
employer-sponsored denta l plan
• Enrollees are respons ible fo r all
copayments and f ees subject to th e
provi sions of t he ir p ri or d en tal p lan
• Preautho rlzatlon Is requi r ed fo r t reatment
provi ded by a sp ecialist
• Yo ur Delta Ca re USA denti st w ill coordinate
your specia l ty ca re t reat men t authorizatio n
• Limited to eme rgency ca re provision
• No a nnual deducti bl e o r ann ua l dollar
maxi mums
• No clai m fo r ms req uired
• Yo u only need to p ay the specified
co payment at th e time of you r visi t
Delta Dental PPO SM -Benefit highlights
Easy
Friendly
Accessible
Greatest potential savings
when you visit a Delta Dental
PPO dentist
OUT-OF -POCKET COSTS
SAVE LESS SAVE MORE
-t----J AMOUNT YOU SAVE
AMOUNT YOU PAY
Illustration showing sample enrolle e
sha re of cost for Information purposes
only. Actual dentist fees and contract
allowances wlll vary by region,
procedure and by group contrac t.
We 're pleased to be yo ur partne r in ma i ntai ning great ora l heal th. The De lta Denta l PPO *
plan makes it ea sy for yo u to find a dentist , an d easy to control your costs when you vis i t a
network dentist. Here are some of t he great thin gs you 'll need to know about enrolling with
De lta Denta l:
• Save money with a Delta Dental PPO
dentist. Our PPO network den ti sts
accept reduce d fees for covered
services they provide you , so yo u'll
usua lly pay the least when you
visit a PPO network dentist. This
al so ensures Delta Denta l dentists
won't ba lance bill yo u th e difference
between the contracted amount an d
thei r usua l fee.
• Visit th e denti st of your choic e.
Want to visit a non-De l ta Denta l
d en t ist? No problem. You can visit
any li cense d den t ist, but yo ur costs
are usually lowest when you see a
PPO dentist.
• Many netwo r k denti sts to choose
from . Since Delta Denta l offers
ac cess to so me of the la rgest de ntist
networks in the U.S., chances are
t here's a wide choice of network
dent ists near your home or office.
Fou r ou t of five denti sts nationwide
are contracted Delta Dental dent ist s,
giving more enro ll ees conven i ent
access to more dentists. Visit us at
deltadentali ns.com to search our
dentist directory by location
or specialty.
• Easy t o use you r benefi ts.
When you visit a Delta Dental dent i st,
pay on l y your portion for services.
Delta Dental dentists will file claim
forms for you and receive payment
di rectly from us. Many non-Delta
Denta l den tists ask tha t you pay
the entire cost up front an d wa it
for reimbursemen t.
• Delta Dental 's Onlin e Servi ces make
getting In formation qu ick and easy.
Access you r benefits an d eli gibi li ty,
pri nt ID cards and get i nformation
about your claims . And check out
Delta Dental's oral health resources
for tips and information that can he l p
keep your sm ile healthy.
*In Texas, Delta Dental Insurance Company offers a Dental Provider Organization (DPO) plan.
DELTA DENTAL PPO
Plan Benefit Highlights for: Cou nty o f Fresno
Group No: 05879
l3.mllillJ1i'1 J "'<I
Primary enrollee, spouse (includes domestic partner) and elig ible dependent
children to the end of the month dependent tu rns age 26
Deductibles $50 per person I $150 per family each calendar year
D e ductibles waived f o r D & P ? PPO-Dentists: Yes
Non-PPO D entists: No
Maxi mums $2 ,500 per person each cal endar y ear
D & P counts toward maximum? No
Waiting Period(s) Basic Benefits I Major Benefit s I Orthodontics I P rosthodontics
None None N one Non e
1 :rnrn'I n ~ ErmJ Delta Dental PPO Non-Delta Dental PPO
.r-o. ... -..no. _..
l.,. tl'l!J ~ ~ •lt!l:IJ\!M I( ;l... "i"' dentists** dentists**
Diagnostic & Preventive
Services (D & P) 100% 90%
Exams, cleanings and x-rays
Basic Services
Fillings, simple tooth extractions and 90% 90%
sealants
Endodontics (root canals) 50% 50%
Covered Under Major Services
Periodontics (gum treatmen t)
Covered Under Major Services 50% 50%
Oral Surgery 50% 50%
Covered Under Major Services
Major Services
Crowns, i nlays , onlays and cast 50% 50%
restorations
Prosthodontics 50 % 50%
Bridges. dentures and implants
Orthodontic Benefits 100% 100%
Adults and dependent children After co-payment After co-payment
Orthodontic Maximum
Adults (age 20 and over) $ 1 ,880 per case $ 1,880 per c a se
Child(ren) (th rough age 19) $ 1 ,660 per case $ 1,660 per c a se
One Orthodontic treatment per
lifetime
Maximum of 24 months of active
orthodontic treatment
• Limitations or waiting periods may apply for some benefits ; some services may be excluded from y our p l an.
Reimbursement is based on Delta Dental maximum contra ct all owances and not necessaril y each dentist's submitted fees .
Re imbursement is based on PPO co ntracted fees for PPO dentists , Prem ier con tracted fees for Prem ier dentists and
program allowance for non-Delta Dental dentists .
Delta Dental of C alifornia
1 00 F i r s t St.
S a n Franc i sco , CA 94 105
Customer Service
800-765-6003
deltadentalins.com
Claims Address
P .O. Box 997330
S a cramento, CA 95899-7330
This benefit information is not intended or designed to repl ace or serve as the plan's Evi dence of Coverage or Su mmary Plan
Description. If you have specific questions regard ing the benefits, limitations or exclusions for your plan, please consult you r
company's benefits representative . HLT_PP0_2CO L_ooc (R ev.OB/0520 14)
(J)
1-
J:
(!)
:J
:X:
(!)
:X:
1-u:: w z w co
Getting the most from your plan
Easy
Friendly
Accessible
With PPO there are no claim
forms to submit.
• Select a CJJ PPO dentist
0 Schedule an
appointment
fl Receive
dental
care
0 Pay only
patient's
share to
dentist
No paperwork.
No hassle.
Save money with a Delta Dental
PP05M dentist
Although you can visit any dentist,
you'll usually pay less when you vis i t
a Delta Denta l PPO dentist.
• PPO dentists agree to accept Delta
Dental contracted fees as full
payment.
• Your share of the bill will likely
be lower than when you visit a
non-Delta Dental dentist.
Find a Delta Dental PPO dentist
Delta Denta l PPO, our preferred
provider organization (PPO) plan,*
provides access to the largest network
of its kind nationwide.
Your out-of-pocket costs are usually
lowest when you vis i t a PPO dentist.
To find the most current listing of our
network dental offices:
• Visit our website and click on
"Find a Dentist" on our home page.
• Select "Delta Dental PPO" as your
plan network.
Is your dentist a Delta Denta l
PPO dentist?
We recommend that you veri fy your
current dentist's participation in the
De lta Dental PPO network. Simply
asking if a dentist "accepts Delta
Dental" does not guarantee he or
she Is a PPO dentist.
• Ask specifically if he or she Is a
contracted Delta Dental PPO dentist.
• You should verify your dentist's
participation before each dental
appointment.
Ma xi mum ch oice
The Delta Dental Premie~ netwo rk-
our larger network consisting of near ly
80 percent of dentists na tionwide -
provides cost-saving features and is
the next best option if you can't find
a PPO dentist. You can find a Premier
dentist us ing our online dentist
d irectory.
• Premie r dentists' contracted fees are
usually somewhat higher t han PPO
dentists' contra ct ed fees.
• Premier dent ists will not bill you
above their contracted fees , so
you still receive cost protections
not avai lable with a non-Delta
Dental dentist.**
Easy to use
• No ID card is requi red to receive
services; simply provide the denta l
office with your name, date of birth
and socia l secu rity or enrollee
ID numbe r.
• No claim forms to file-Delta Dental
dentists file cla i m forms for you
and accept payment directly from
Delta Dental.
• After a claim has been processed,
you wi ll receive a denta l benefits
statement from De lta Dental.
This document lists the services
p rovided, the costs of the dental
t reatment and the amount of any
fees you owe your dentist.
• In Texas, Delta Dental Insurance Company offers a Dent al Provider Organiza ti on (DPO) plan .
**Please review your Evidence of Coverage, Summary Pl an Descript ion or Grou p Dental
Service Contract for specific details about your plan's denti st network.
DELTA DENTAL PPO
Dual covera ge/Coordination
of benefits
If your spouse has coverage with
another dental plan , you or your family
members may be covered by both
den t al plans.*
• The two plans will likely coordinate
bene f its to potentia lly lower your
out-of-pocket costs.
• Ask your dentist to submit the other
plan's Exp lanation of Benefits with
the Delta Dental cla im form and
we'll take it from there.
Orthodontic treatment i n progress
If your Delta Dental plan i ncludes
orthodontic benefits, payment for
orthodont ic t reatment in progress
depends on the specific provisions
of your plan. Typically, treatment in
progress is covered and Delta Dental
begins payi ng duri ng the first eligib le
month. Under some plans, however,
you may not be el igible for work in
progress or you may lose eligibility
if yo ur cove rage has lapse d for more
than 30 or 60 days.
Transit ioning from another plan?
De lta Dental covers treatment started
and comp leted after your plan's
effective date of coverage. If you have
any dental treatment in progress when
your coverage begins -such as root
cana ls, crowns and bridgework-those
expenses are not cov ered by Delta
Dental. Tho se costs may either be your
res ponsibility or that of your previous
denta l carrie r.
Visit our web site :
deltadentalins.com
On our website, you can:
• Find a dentist i n our online directory
• Review benefits
• Check cla i m status
• Print an ID card and much more
To access some services, you'll need
to tog in: simply enter your user name
and password in the designated
boxes and submit. If you are visiting
our website for the first time, you'll
need to complete a quick one-t ime
reg istration process by clicking the
"Register Tod ay " lin k.
Talk to your dentist about your
health and treatment options
When you visit the dent ist, be sure to
share your denta l and medical history
and any prior com pli cations . Dent ists
can identify signs of more serious
health conditions and should be made
aware of health information that may
be cri tica l to your dental care.
Questions about your plan ?
If you have que stions, you can che ck
your benefit s, el ig ibility and claims
i nformation on our website or on our
i nteractive voice response telephone
l ine. For more information, you may
also contact us thro ugh our website
or ca ll one of our he l pful mu ltilingua l
Customer Servi ce r_epresentatives
toll-free during business hours.
*G roup-sp ecific exceptions may apply. Please review your Evidence of Cove rage, Summary Plan
Description or Group Dental Service Con tract for specific detail s about your plan's coordination
of benefits, including rules ror determining primary and secondary coverage.
'§.r:!)J1~~~~y -
Wellness Program
Find all of our dental
hea lth resources ,
including risk
assess ment quizz es,
articles, videos and
a free newslette r
subscription at:
mysmlleway.com .
DELTA DENTAL PPO
Delta Care~ USA-provided by Delta Dental of California
Quality
Convenience
Predictable
Costs
Find a DeltaCare USA dentist
Select from among the
many conveniently located
DeltaCa re USA contracted
general dentists. To find
the mos t current listing of
De ltaCare USA dental offices:
Visit our website and
click on "Find a Dentist"
on ou r home page.
Select "DeltaCare USA"
as yo ur plan ne twork.
OR
Call Customer Service
for help in finding a
Delta Care USA dentist.
We'll do whatever it takes and then some.
Welcome to DeltaCare USA-quality, convenience , predictable costs
DeltaCare USA (administered by Delta Denta l Insu rance Company) provides you
and your fam ily wi t h qua lity denta l benefi t s at an affordable cost. The
Del t aCare USA program is designe d to encourage you and your family to visit the
dentist regularly to maintai n your dental health .
When you enroll, you select a contract dentist to provide services. The
Delt aCare USA network co nsis t s of private practice denta l facilities that have
been carefu lly sc reened for qua li ty.
Enro ll in DeltaCare USA and you'll enjoy these features:
Quality Convenience Predictable costs
• Extensive benefits for • No claim forms to • No deductibles
you and you r family comp lete • Out -of-pocket co sts
• No restrictions • Easy access to are clearly defined
on pre-ex isti ng specia l ty care • Out-of-area denta l con di tions, except for • Expanded business emergency coverage wo rk in progress hours for toll-free up to $100 per
• Large, stab le network customer service, emergency
of dentists, so you from 5 a.m . to 6 p.m., • No annual or lifetime can enjoy a long-term Pacific time dollar ma ximums re l ationship with your
den t ist
OELTACARE USA
Administered by Delta Denta l Insuran ce Company
Pl an CA4 2N DeltaCare USA Description of Benefits and Copayments
SCHEDULE A
D escr iption of Benef its and Cop ayme nts
Th e Benefits shown below are pe rformed as deemed appropriate by the attending Con tract Dentis t subject to the limitations and
excl usions of the Program. Please refer to Schedule B for further clarification of Bene fit s. En rollee s should d iscu ss all treatm e nt
o ptions w i t h their Cont ract Dentist p ri or to se rvi ces being rendered .
Text t hat a ppears In Italics below is specifically Inte n d ed to c lar ify th e d e livery of Benef its und er t he De ltaCa re USA Program
and is n ot to be i nte rpret ed a s CDT-20 16 p rocedure cod es, d es c ri ptor s o r n om enclature t h at are under copyright by the
Ameri can Den tal Associatio n . The Ame ri c an Dent a l Association m ay periodically ch ange COT c odes o r d ef i nitions. Such
updated codes, descripto r s and nome nc l atu re may be u sed t o descr ib e these co ver ed proced ures In compliance w ith f ed eral
le gisla tion.
kQQ& DESCRIPTION
D01 OO -D0999 I . DIAGNOSTIC
ENROLLEE
fAYS.
D0120 Periodi c o ral eva l ua tio n • establi shed patient .................................................................................... No Cost
DO 140 Li m ited oral evaluatio n -problem focused ........................................................................................ No Cost
D01 45 Oral evaluation for a patient under three years of age and counseling w ith primary ca regiver ......................... No Cost
D0150 Compreh ensi ve oral evaluation -new or establi shed pati e nt ................................................................. No Cost
D0160 Deta il ed a nd exten sive o ra l evaluatio n-problem focused, by report ....................................................... No Cost
D0 17 0 Re-eva l uatio n -l imite d , pro bl em focused (e stablished pat ient ; not post-ope rative v isit) ................................. No Co s t
DO 17 1 Re-eva l uation -p ost-opera tive offi ce vi sit ......................................................................................... No Cos t
D0 180 Comprehensive periodonta l evaluation -new or established pa tient ........................................................ No Cost
D01 90 Screeni ng of a patient .. . .. . .. . .. . . .. .. .. . .. . . .. .. .. . . .. . .. . . .. .. . . .. . .. . . . . .. . . .. . . . .. .. . .. .. .. . . . . . .. . . . . . . .. . . .. . . . . . . . .. . . . .. . . .. . N o Cost
D0191 Assessment o f a patient .............................................................................................................. N o Co st
D0210 Intraoral -com pl et e series of radio g raph ic images -limite d to 1 series every 24 months ............................... N o Cos t
D0 220 Intra o ral -peria pica l f irst rad iog raphic image .. .. .. .. .. .. .. .. .. .. .. .. . .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. . .. .. .. . .. . .. .. .. .. . .. .. .. . No Cos t
D0230 Intraoral -periapical each ad d itional radiographic image ...................................................................... No Cos t
D0240 Intraoral -occlusal radiographic image ............................................................................................ No Cos t
D0250 E xtraoral -2 D projection radiographic image created using a stationary radiatio n source, a nd detector .. . .. .. .. .. .. N o Cos t
D0251 E xtra o ra l posterior denta l radiograph ic image ................................................................................... No Cos t
D0270 B itew ing -sin gle radi o graphic image .............................................................................................. N o Cost
D0 272 B itewings -two ra diographic im ages .............................................................................................. N o Cost
D0273 B it ewings three rad iographic images .............................................................................................. No Co st
D027 4 B itewings -fou r ra d iographic images -limited to 1 series every 6 months ................................................. No Cost
D02 77 Ve rtica l bitew ings -7 to 8 radiograph ic images ................................................................................. No Cos t
D0330 P ano ramic radi ogra phic image ...................................................................................................... No Cost
D0415 Collection of microorg an isms for cultu re an d sensitivi ty ....................................................................... No Cost
D0425 Caries su sceptibili ty te sts ............................................................................................................ N o Cos t
D04 60 Pulp vitality tests ....................................................................................................................... N o Cost
D04 70 Di agnostic casts ........................................................................................................................ N o Cost
D04 72 Accession of tissue, gross examination , prepa ratio n and tran sm ission of written report -available only wh en
performe d in conjunctio n with a covered biopsy .. . .. .. .. .. .. . .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. . .. . .. .. .. .. .. .. .. .. .. .. .. .. .. .. No Cost
D047 3 Accession of tissue, g ross an d microscopic examination , preparati on and transmission of w ri tten report ·
availa ble only when performed in conjunction with a covered biopsy ....................................................... No Cos t
00474 Accession of t issu e, g ross and microscopic examin ation, including assessment of surgical m a rgin s for presence
of d isea se, pre pa rati on and t ransmission of w ritten re po rt-available only when pe rformed in conjunction with a
cove red biopsy ......................................................................................................................... N o Co s t
D0601 C aries risk a ss essme nt a nd documentation, wit h a find ing of low risk -limited to children a ge 3 to 19, 1 e ve ry 3
years ...................................................................................................................................... N o Cost
D 0602 Caries risk assessment a nd documentation, w ith a findi ng of moderate ri sk -limited to children age 3 to 19, 1
every 3 years ........................................................................................................................... No Cost
D 0603 C ari es ris k assessment and documentation, w ith a findi ng of high risk-limited to children age 3 to 19, 1 every
3 ye ars . .. . . . .. . .. .. . .. .. . .. .. .. . . . . . . .. . . . .. .. . .. .. . . . .. .. .. .. .. .. . .. .. .. . .. . .. . .. .. .. .. . .. . .. . .. . .. .. .. . . .. . .. .. .. .. . .. . . .. .. .. .. . .. .. .. N o Cost
D 0999 Unspecifie d diagnostic proced u re , b y report -includes office visit, per visit (In addition to o ther services) ........... No Cos t
01000-D1999 II . PREVENTIVE
D1 11 0 P rophylax is cleaning -adul t -1 per 6 month period ............................................................................ No Cost
D1 11 0 Additional prophylaxis cleaning -adult (within the 6 month period) .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. . .. . .. .. $45.00
Plan CA42N DeltaCare USA Description of Benefits and Copayments
01120 Prophylaxis cleaning-chi ld -1 p er 6 month period ............................................................................ No Cost
01120 Additional prophylaxis cleaning-child (within the 6 month period) ........ .......... .... ........... ... .. ..... ...... ......... $35.00
01206 Topical application of fluoride varnish-1 01206 or 01208 per 6 month period ........................................... No Cost
01208 Topi ca l 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 Toba cco counseling for the control and prevention of ora l disease .......................................................... No Cost
0 1330 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 repa ir -per tooth -limited to permanent molars through age 15 ................................................... No Cost
01354 Interim caries arresting medicament application-1 per 6 month period ................................................... 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 -bi lateral ......................................................................................... No Cost
01550 Re-cement or re -bond space mainta iner .......................................................................................... No Cost
01555 Remova l 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 addi tiona l $125.00 per crown, beyond
the 6th unit.
-Replacement of crowns, Inlays and onlays requires the existing restora tion to be 5+ years old.
• Name brand, laboratory processed or in-office processed crowns/pontics produced through specialized technique or materials are
material upgrades. The Contract Dentis t may charge an additional faa not to exceed $325.00 in addition to the listed Copayment. Refer to
Limitation of Benefits #4 for additional information .
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 involvi ng in cisal angle (anterior) ..................................... No Cost
02390 Resin-based composite crown , anterior ........................................................................................... No Cost
02391 Resin-based composite-one surface, posteri or ................... ............................. ......... ............. ...... .... $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
02510 Inlay-metallic-one surface ........................................................................................................ No Cost
02520 Inlay -metallic -two surfaces ....................................................................................................... No Cost
02530 Inla y -metallic -three or more surfa ces .......................................................................................... No Cost
02542 Onla y -meta llic -two surfaces ...................................................................................................... No Cost
02543 On l ay -metallic -three surfaces .. .. .. .. .. .. .. . .. . .. .. .. . .. . . . . . . . . . . . . . . .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. . . .. .. . . . . . .. .. . No Cost
02544 Onlay -metallic -four or more surface s .......................................................................................... No Cost
02610 Inlay -porcela in/ceramic-one surface* .......................................................................................... $50.00
02620 Inlay -porcelain/ceramic -two surfaces* .. .. .. . . . .. . . .. . .. .. .. . . . . . . . . . . . .. ... .. .. .. .. .. .. .. .. .. .. .. .. . .. .. .. .. .. . .. .. .. .. .. . .. .. $60.00
02630 Inlay -porcelain/ce ramic -three or more surfaces* .. .. .. .. .. .. .. .. .. . . .. .. . . .. .. .. .. .. .. . .. .. .. .. . .. .. .. .. .. . . .. . . . . .. .. .. . . . .. $65 .00
02642 On lay -po rcelain/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-ba sed composite -one surface ..................................................................................... $15.00
02651 Inlay -resin-based composite -two su rfaces . .. .. .. .. . . .. . .. .. .. .. .. .. . .. . . . . . .. .. .. .. .. .. .. . . .. .. .. .. .. .. .. .. . . . . .. . .. .. . .. . . . . $20.00
02652 Inlay -resin-based composite -three or more surfaces .. .. .. . . . .. .. .. . .. .. . .. .. .. .. .. . .. . .. .. . . . .. . . . . . .. .. .. .. .. .. . . . . .. . ... $30.00
02662 Onlay -resin-based composite -two surfaces . .. .. .. .. .. .. . . . . .. .. .. . .. .. .. .. . .. .... .. . .... . .. .. .. .. .. . .. .. . . .. .. . .. .. .. . . .. . .. . $25.00
02663 On l ay -resin-ba sed composi te -three surfaces . . .. . . .. .. .. .. .. .. .. . .. . .. .. .. . .. .. .. .. . . . . . . . . . . . .. .. .. .. .. . . . . . . . . .. . .. . . . . . .. . $35.00
02664 O n lay -resin-based composite -four or more surfaces .. .. .. .. . . . .. . . . . . .. .. .. .. .. . .. . .. .. . . .. .. .. . .. . .. .. . . .. .. .. .. .. .. .. . . . $50.00
02710 Crown -resin-based composite (indirect) ......................................................................................... No Cost
Pl an CA42N DeltaCare USA Description of Benefits and Copayments
02712 Crown -o/. resin-based composite (in direct) ...................................................................................... No Cost
02720 Crown -resin with high noble metal . .. .. .. .. . .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .... .. .. ... .. .. .. .. .. .. .. .. .. .. .. .. . . $30.00
02721 Crown-resin with pred ominantly base metal .................................................................................... $15 .00
02722 Crown -resi n wi th noble metal . .. . . . .. . .. .. . . . . .. . .. . . . . .. . . . . . . . .. . . . . . .. . .. . . .. . . . . . . . . . .. . . . .. . . . . . .. . . . . . . . . . .. . . . .. .. . . . . . . . . . $20.00
02740 Crown -porcelain/ceramic subst rate• .............................................................................................. $85.00
02750 Crown -porcelain fused to high noble metal' .. .......... ........ ........................ ...... .. ...... .. .. .... .. .... ........ ... $70.00
02751 Crow n -porcelain fused to predominantly base metal .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. . . .. . .. .. .. .. .. .. .. . .. .. .. .. .. . $55.00
02752 Crown -porcelain fused to noble meta l .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. . .. .. .. .. .. .. .. .. .. .. .. . .. .. .. . $60 .00
02780 Crown -o/. cas t high noble metal . .. .. .. .. .. .. .. .. .. .. .. .. . .. .. . .. .. .. .. .. . .. .. .. .. .. .. .. . .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. $70 .00
02781 Crown -3/. cast predominantly base metal ...... ...... ................ ........ .... .... ........ ................................... $55.00
02782 Crown -o/. cast noble metal .. . .. .. .. . . .. .. .. .. .. . .. .. .. . .. .. .. .. .. . .. . .. . .. .. .. . .. .. . .. .. .. . .. . .. .. . .. .. . .. . .. .. .. . .. .. . .. . .. . .. .. .. $60.00
02783 Crown -o/. porce lain /ceram ic* . . .. . . . . . . .. . . .. . . . .. . . . .. . .. . . . .. . . . . .. . . . . . .. .. . .. .. . . . . . . . . .. . .. . . . . . . . . . .. . . .. . . . .. .. . . .. . . .. . .. . . . $70.00
02790 Crown -full cast high noble metal .. .. . .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. ... .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. . $70.00
02791 Crown -full cast predomina ntl y base meta l .. .. .. .. .. .. .. .. .. .. . .. .. .. . .. .. . . .. .. .. .. .. .. .. . .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. . .. .. .. $55.00
02792 Crown -full cast noble metal . .. .. . .. . .. .. .. . .. .. .. .. .. .. .. .. .. .. .. .. .. . .. . .. .. .. . . .. .. .. . .. . .. .. .. .. . .. .. .. . .. .. .. .. .. .. .. .. .. .. . . .. $60.00
02794 Crown -titanium . .. . . .. . .. . . .. . . . . . .. . . . . .. . . . .. . . . . . . .. . . . .. .. . . . . . . .. . . .. . .. . . .. .. . . . . . . . . . . .. .. . . . .. . . . . .. . . . . .. . . .. . . . .. .. . .. . .. . . .. $70.00
02910 Re-cemen t or re-b on d in lay, onlay, veneer or pa rt ia l cove rage res tora tion ................................................. No Cost
0 2915 Re-cemen t or re-bond indirectly fabricated or prefabricated post and co re ................................................ No Cos t
02920 Re-cemen t o r re-bond crown ........................................................................................................ No Cos t
02921 Re attachmen t of tooth fragment, incisal edge or cusp (anterior) ............................................................. No Cost
0 2929 Pre fabricated porcelain /ceramic crown -primary tooth -anterior ............................................................ No Cost
02930 Prefab ricated sta inless steel crown -primary tooth ............................................................................. No Cost
02931 Pre fabricated stain less steel crown -permanent too th ......................................................................... No Cost
02932 Pref abricated resin crown -anterior primary tooth .............................................................................. No Cost
02933 Prefab rica ted stainless stee l crown with resin window -anterior primafY tooth ........................................... No Cost
02940 Pro tective restoration .................................................................................................................. No Cos t
02941 Interim therapeuti c restoration -primary dentition ............................................................................... No Cost
02949 Restorative foun dation for an Indirect restoration ............................................................................... No C ost
0 2950 Core buildup, including any pins when required ................................................................................. No Cost
02951 Pin rete ntion-per toot h, in addition to restoration .............................................................................. No Cost
02952 Post and core in addition to crown, indirectly fabricated -includes canal preparation ................................... No Cost
0 2953 Each additional indirectly fabricated post -same tooth -includes canal preparation ..................................... No Cost
02954 Prefabricated post and core in ad dition to crown -base metal post; includes canal preparation ....................... No Cost
0 2955 Pos t removal ............................................................................................................................ No Cost
02957 Each additional prefabricated post -same tooth -base me tal post; includes canal preparation ....................... No Cost
02960 Labia l veneer (res in laminate) -cha irslde -limited to replacement of significant tooth structure loss due to caries
or fra cture ................................................................................................................................ $245.00
0 2961 Labia l veneer (resi n laminate) -labora tory -limited to replacement o f significant tooth structure loss due to caries
or fracture ................................................................................................................................ $295.00
0 2962 Labi al veneer (porce la in laminate)-laborato ry-limited to rep la cement o f sig nificant tooth s tructure Joss due to
caries or fracture ....................................................................................................................... $345.00
0 2971 Additiona l procedures to construct new crown under ex isti ng partia l denture framework .. ....... .......... .... .... . ... $1 4.00
02980 Crown repair necessitated by re sto rative material failure ...................................................................... No Cost
0 2981 Inlay rep ai r necessitat ed by restorative material failu re ........................................................................ No Cost
0 2982 On lay repair necess ita ted by restorative material failure ...................................................................... No Cost
02983 Veneer repa ir necessitated by re storative material failure ..................................................................... No Cost
0 2990 Re si n infil tratio n of Incipient smooth surface les ions -limited to permanen t molars through age 15 ................... No Cos t
D3000-D39 99 IV. ENDODONTICS
0 3110 Pulp cap-direct (excluding final restoration) .................................................................................... No Cost
03120 Pulp cap -Indire ct (excluding final restoration) .................................................................................. No Cost
0 3220 T hera peutic pulpotomy (excluding fin al restoration)-rem ova l o f pu lp coronal to the dentinocemental junction and
application of medicament .. . . . . . . .. . . . . . . . . . .. . . . . . . . . .. . . . . .. .. . . .. . . . . .. . . . .. .. . . . .. . . . . . . . . . .. . .. . . . . . . . .. . .. .. . . .. . . . .. . . .. . .. . . No Cost
D3221 Pulpal debridemen t, primary and permanent teeth ............................................................................. No Cost
0 3222 Partia l pulpotomy for apexogenesis -permanent tooth with incomplete root development .............................. No Cost
03230 Pulpa l therapy (resorba ble fi lling)-anterior, primary tooth (excluding fina l restoration) .................................. No Cost
03240 Pulpa l th erapy (resorbable fi lli ng)-posterior, primary tooth (exclu ding final restoration) ................................ No Cos t
Plan CA42N DeltaCare USA Description of Benefits and Copayments
03310 Root canal-endodontic therapy, anterior tooth (excluding final restoration ) ............................................... $20.00
03320 Root canal-endodont ic therapy, b icuspid tooth (excl uding 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 Retreatmen t of previous root canal therapy -anterior .. .. .. .. .. .. .... .. .. .. .. .. .. .. .. .. .. . .. .... .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. . $35.00
03347 Retreatment of previous root canal therapy -bicuspid ......... .......................... ............................. .... ..... $50.0 0
03348 Retreatment of previous root cana l 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 (a pica l closure/ca lcific repair of perforations, roo t
resorption, pulp space disinfection , etc.) .... . ............................. ............ .... ............. .... ..... ......... ..... .... $45.00
03353 Apexification/recalcification -final visit (incl udes completed root canal therapy-apica l 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 Perirad icu lar 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 In cluding 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 Ging iva l flap procedure, including root planing -one to three contiguous teeth or too th bounded spaces per
quadrant .................................................................................................................................. No Cost
04245 Apica ll y positioned flap . . . . . . . . . .. .. . .. .. . . . . . .. . . . .. . .. . .. . . . .. .. . . . . . .. . .. . . .. . . . . .. .. . . . . .. . . .. . . . . . . . . .. .. .. .. . . .. . . . . .. .. .. .. . . . . $45.00
04249 Clinical crown lengthening -hard tissue .. .. .. .. .. .. .... .. .. .. .. .. .. .. .. .. .. .. . .. .. .. .. .. .. .. .. .. . .. ... .. .. .. .. .. .. .. . .. .. .. . .. .. . $45.00
04260 Osseous surgery (including elevation of a full th ickness 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 co ntiguous teeth or tooth
bounded spaces per quadrant . .. . . . .. . .. . . . . .. . . . .. . . . . .. .. . .. . . .. . . .. . . .. . .. . .. . .. .. . . . . . .. . . . . .. . . . .. . . . . . . . . . . . . . .. . . . . . . . . .. . . . $60.00
04263 Bone replacement graft-first site in quadrant ................................................................................... $125.00
04264 Bone replacement graft -each addit ional site in quadrant .. .. .. .. .. .. .. .. .. .. .. . .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. . .. .. .. $45.00
04266 Guided tissue regeneration-resorbable barrier, per site ...................................................................... $100.00
04267 Guided tissue regeneration-non resorbable barrier, per site (includes membrane removal ) ........................... $140.00
04270 Pedicle soft tiss ue graft p rocedure ................................................................................................. $125.00
04273 Autogenous connective tissue graft procedure (including donor and recipient surgical sites) first tooth, Implant, or
edentulous tooth position in graft . . .. .. .. .. .. .. . .. .. .. .. . . . . .. . . .. . .. . . .. .. .. . .. .. .. . . . . . .. .. . . .. .. . . .... . . . .. . .. . . .. . . . .. . . . .. . . . .. $75.00
04274 Distal or proximal wedge procedure (when not performed in conjunction with surgical procedures in the same
anatomical area) ....................................................................................................................... No Cost
04275 Non-autogenou s connective tissue graft (including recipient site and donor material) fi rst tooth, implant , or
edentu lous tooth position in graft ................................................................................................... $115.00
04277 Free soft tissue graft procedure (including recip ient and donor surgical sites) first tooth , implant, or edentulous
tooth position in graft .................................................................................................................. $125.00
04278 Free soft tissue graft procedure (including recipient and donor surgical sites) each additional contiguous tooth ,
imp lant, or edentulous tooth position in same graft site ....................................................................... $125.00
04283 Autogenous connective tissue graft procedure (includ ing donor and recipient surgical sites)-each additional
contiguous tooth, implant or edentulous tooth position in same graft site .. . .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. . .. . .. . .. .. .. $45.00
04285 Non-autogenous connective tissue graft procedure (including recipient surgical site and donor material)-each
additiona l contiguous tooth, implant or edentulous tooth position in same graft site . .. .. .. .. .. . .. . .. .. ... .. .. .. .. .. .. .. . $69.00
04341 Periodontal scaling and root planing -four or more teeth per quadrant -limited to 4 quadrants during any 12
consecutive months . . . . . . .. . . .. .. . . . .. . . . . . . .. . . . . . . .. . .. . . . . .. . .. . . . . . .. .. . . .. . .. .. . . .. . . . . .. . . . .. . . .. .. . .. .. . . . . . . . . . . . . .. . . . .. . . . . . No Cost
Pl an CA42N DeltaCare USA Description of Benefits and Copayments
04342 Periodontal scaling and root planing -one to three teeth per quadrant-limited to 4 quadrants during any 12
consecutive months . . . . . . . .. . . . . . . . . . .. . . . . .. . . .. .. .. . . . . . . . .. . . . . .. .. .. . .. . . . . . .. . . . .. . . . . .. .. . .. . . . .. . . .. .. . . . . . . .. . .. . . . .. . . . . . . . . . No Cost
04355 Fu ll mouth debridement t o enable comprehensive evaluation and diagnosis -limited to 1 treatment in any 12
consecutive months . . . .. .. .. . . . . . .. . . . . . . . . . . . . . .. . . . . . . . . .. . . . .. . . . .. .. . . .. .. . . . .. . . .. . . . . . . . . . . .. . . . . . . . . .. . . .. . . . . . .. . . . .. . .. . .. .. . No Cost
04381 Local ized delivery of antimic robia l 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
04381 Localized delivery of antimicrobial agents via a controlled re lease vehicle into diseased crevicular tissue, per
tooth -for an additional tooth treated in the same quadrant following root p laning or periodontal maintenance ..... No Cost
04910 Periodontal maintenance-limited to 1 treatment each 6 month period .................................................... No Cost
04910 Addi tional 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-mand ibu lar .. .... ..... ..... .. ... .............. ............ .......... ... ...... .. ..... .... .... ........ ... ....... .. $75.00
05130 Immediate dentu re -maxillary ....................................................................................................... $85.00
05140 Immediate denture -mandibular . .. . . .. . . . . . . . . . .. . . . . . . . . . ... . .. . . .. . .. . . . . . . .. .. . . . . . . . . . . .. . . . . . . .. . . .. . . . . . . ... . . . . . .. . . . .. . . .. . $85.00
05211 Maxillary partia l denture -res in base (in clud ing any conventiona l clasps, rests and teeth) ................ ....... .... .. $80.00
05212 Mandibula r partia l denture-resin base (including any conventional clasps, rests and teeth) .... .... .. .... .. ..... ..... $80 .00
0~213 Maxillary partia l denture-cast meta l framework with resin denture bases (including any conventiona l clasps,
res ts and teeth) ......................................................................................................................... $95.00
0 5214 Ma ndibula r partia l denture-cast metal framework with resin denture bases (including any conventional clasps,
res ts and teeth) ......................................................................................................................... $95.00
05221 Immediate maxillary partial denture-resin base (including any conventional clasps, rests and teeth) ...... .. .. .. .. .. $80.00
05222 Immediate mandibular partial denture -res in base (including any conventional clasps, rests and teeth ) .. .. .. .... .. . $80.00
05223 Immediate maxillary partial denture -cast meta l framework with resin denture bases (Including any conventional
clasps, rests and teeth) . .. . . . . . ... . . .. . . . . . . . . . .. . .. . . . . . . . . . . . . . ... . ... . .. . . . . . .. . . .. . . . . . .. . . .. . . . . . . ... . . . . . . .. . . . ... . . . . . . . . . . . . . . $95.00
05224 Immediate mandibular partia l den ture -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 Mand ibular partia l denture -flexible base (including any clasps, rests and teeth) ........................................ $195.00
05281 Removab le unilatera l partial denture-one piece cas t metal (including clasps and teeth ) ............................... $80.00
0 5410 Adjust complete denture-maxillary ................................................................................................ No Cost
05411 Adjust complete denture -mandibular ............................................................................................. No Cost
05421 Adjust partial denture-maxillary ................................................................................................... No Cost
05422 Adjust part ial dentu re -mand ibular .. .. .. .. . .. . .. .. . .. .. .. .. . .. .. . .. .. .. .. .. .. .. .. . .. .. .. . .. .. .. .. .. .. .. .. . .. . .. .. .. . .. .. .. .. .. . .. . No Cost
05510 Repair broken complete dentu re base ............................................................................................ No Cost
05520 Rep lace mis sing or b roken 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 -per tooth ....................................................................................... No Cost
05640 Replace broken teeth -per tooth ................................................................................................... No Cost
05650 Add tooth to existing partia l denture ............................................................................................... No Cost
05660 Add clasp to existing partia l denture -per tooth ................................................................................. 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 comp le te mand ibular denture . ... ...... ...... ............... .... ... ....................... ...... ... .......... .......... ... $30.00
05720 Rebase maxi ll ary partia l denture . . . . . . . . . . . . . . . . . . .. .. . .. . . . . . . . . . . . . . . . . . . . . .. . . . . . . . .. .. .. . . .. . . . . .. . . . . . .. . . .. . .. . . .. . . . . . . . . . .. $30.00
05721 Rebase mandibu lar pa rt ia l denture . . . . . .. . . . . . . . . . . . . .. . .. . . . . .. .. . . . . .. . . . . . . . . . . .. . . . . .. . . . . . . . . . . . .. . . . . . . . . . . . . .. . . . . . . . . . . . . . . $30.00
05730 Re line comp lete maxillary denture (chairside) ................................................................................... No Cost
05731 Reline complete mand ibular denture (chairside) ................................................................................ No Cost
05740 Reline maxillary partial dentu re (chairside) ....................................................................................... No Cost
05741 Re line mandibular partial denture (chairside) .................................................................................... No Cost
Plan CA42N DeltaCare USA Description of Benefits and Copayments
05750 Re line complete maxillary denture (laboratory) . . .. . ... . . . .. .. .. .. . .. . . ... . . . .. .. . . .. . . . . .. . .. . .. . . . .. . .. .. . .. .. . . .. .. . . . . . .. . .. . $25.00
05751 Reline comp lete mandibular denture (l aboratory) ........................ ................................. ..... ... ..... ......... $25 .00
05760 Reline maxillary partia l denture (laboratory) .. . . .. . . .. .. . . . .. . .. .. .. . . .. .. . . . .. .. . .. . .. .. .. . .. . . .. . .. . . .. . .. . . .. . . .. . . . . . . . .. .. . . . $25.00
05761 Reline mandibular partial denture (laboratory) .. . .. .. .. . .. .. ... .. .. .. . . .. ... .. .. . . . . . . . .. .. . . .. . . .. . . . .. . . .. .. . . .. . . . .. . . . .. . .. . . $25.00
05820 Interim partial denture (max illary) -limited to 1 in any 12 consecutive months ............................................ No Cost
0 582 1 Interim partia l denture (mandibular) -limited to 1 in any 12 consecutive months ......................................... No Cost
05850 Tissue cond itioning, ma xillary ....................................................................................................... No Cost
05851 Tissue conditioning, mandibular ..................................................................................................... No Cost
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 f ixed partial denture
[bridge])
-When a crown end/or pontic exceeds six units in the same treatment plan, an Enrollee may be charged a n additional $125.00 per unit,
bey ond the 6th unit.
-Replacement of a crown, po nti c, inlay, onley or stress brea ker require s the existing bridge to be 5+ years o ld .
• Name brand, laboratory proc essed or in-offic e processed crown s/pontics produced through specialized t echnique or ma terials are
material upgrades. The Contract Dentist ma y charge an additional fe e not to exc eed $32 5.00 in addition to the listed Copayment. Refer to
Umitation of Bene fits #4 for additional inform ation.
06205 Pontic -indirect resin based composi te .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .... .. .. .. .. .. .. .. .. . . .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. . $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 -titan ium . . . .. .... .. . .. . . ... . .. .... ... . . . .. . . . .. ..... . . . . .. . .. ... .. .. .. . . .. ... . . .. . . . . . . ..... .. . . . . . . . .. . ... .. . . . . .. . ... ... . . . . . . $70.00
06240 Pontic -porcelain fused to high noble metal* .. .. .. .. .. .. .. .. .. .. .. .. .... .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. . .. .. .. .. .. . $70 .00
06241 Pon tic -porcelain fused to predom inantly base metal .. . .. .. .. .. . .. .. .. .. .. .. .. .. .. . .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. $55.00
06242 Pontic -po rcelain fused to noble me tal .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .... .. .. .. .. .. .. .. .... .. . .. .. .. .. .. . .. .. .. .. .. .. . $60.00
06245 Pontic -porcelain /ceram ic* .. . .. .. .. ... . . .. .... . . .. .. .. .. .. . .. . . .. .. . .. .. . . .. .. .. . . .. .. . . . . . . .. . . .. . .. . . . . . . . . . .. . . .. . .. . .. . . .. .. . .. . . $70.00
06250 Pontic -resin wi th high noble meta l .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .... .. .. .. .. .. .. .. .. .. .... .. .. .. . .. .. .. .. . .. .. .. . .. .. . .. .. .. .. . $30 .00
06251 Pontic-res in with predom inantly base metal .................................................................................... $15.00
06252 Pontic -resin with nobl e met al . . . . .. . . . ... .. . .. .. .. .. . .. .. .. . . .. . .. .. . . . . .. . .. .. .. . . . .. .. . . . . . .. .. .. .. .. . . . . . .. .. .. . .. .. . .. . . . .. . . .. $20 .00
06600 Retainer in lay -porcelain/ceramic, two surface s .. .. .. .. . .. .. .. .. .. .. .. .... .. .. .. .. . .. .... . .. . .. .. .. .. .. .. .. .. . .. .. .. .. .... .. .. . $60.00
0 6601 Retainer Inlay -porcela in/ceram ic , three or more surfaces . .. .. .. . .. .. .. .. .. .. .. . .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. $65.00
06602 Reta iner inlay-cast high noble metal , two surfaces .......................... ........................ ............. ... ......... $70 .00
06603 Reta iner in lay -cast high noble metal, th ree or more surfaces .. . .. .. .. .. .. . .. .. .. .. . .. .. ... .. .. .. .. .. .. .. .. .. .. .. .. .... .. .. $70 .00
06604 Retainer inlay -cast predominantl y base meta l, two surfaces ................................................................ No Cost
06605 Reta iner inlay -cast predominantly base metal, three or more surfaces ................................................... No Cost
06606 Reta iner inlay -cast noble metal, two surfaces .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .... .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. . $60.00
06607 Reta iner inlay • ca st noble metal, th ree or more surface s .. .. . .. .. .. .. .. .. .. .. .. .. . .. .. .. .. .. .. .. .. .. .. .. .. .. .. . .. .. .. .. .. .. .. $60 .00
06608 Retain er on lay -porce lai n/ceramic, two surfaces .. .. .. .. . .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. . .. .. .. .. .. .. .. .. . $55.00
06609 Retainer on lay -porce lain/ceramic, three or more surfaces .... .. .. .. .. .. .. . .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. . .. . .. .. .. .. .. .. .. $65.00
06610 Retainer onlay-cast hig h nob le metal, two surfaces ................................ .......................... ................ $70.00
06611 Reta iner onlay -cast high noble metal , three or more surfaces .............................................................. $70.00
06612 Retainer onlay-ca st predominantly base metal , two surfaces ............................................................... No Cost
06613 Retainer onlay-cast predom inantly base metal, three or more surfaces .................................................. No Cos t
06614 Retaine r onlay-cas t nobl e m etal , two surfaces .. .............. ................... ............................. ...... ...... .... $60 .00
06615 Retainer onlay-ca st nobl e me tal , th re e or more surfaces ......................................... ...... .... ........ .... ..... S60 .00
06710 Retainer crown -Indirect resin based composite .. .. ..... .. .. .... .... .. .... .. .... .... .. .. .. ...... .... .. .. .. ... .. .... .... .. .. .. .. $30.00
06720 Retainer crown -resin with high nobl e meta l .. .. .. .. .. ... .. .. .. .. .. .. .. .. . .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. $30.00
06721 Retainer crown-res in with predominantly base meta l ................ ......................................................... $15 .00
06722 Reta iner crown -resin with noble metal .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. . .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. . $20.00
06740 Retainer crown -porcelain /ceramic* . . ..... . .. .... . . .. .. . . . .... . .. . . ... .. .. . . . .. . . . .. . . . . . . . . . ... . .. .. . . . . . . ... . . . . .. . ... . . . . .. . .. . $70.00
06750 Retainer crown -porcelain fused to high nob le meta l* .. .. .. .. .. .. .. .. . .. .. .. .. .. .. .. .. .. . .. .. .. .. .. .. . .. .. .... .. .. .. .. .. .. . .. . $70.00
06751 Retainer crown-porcelain fused to predominantl y base metal ........................... ................................... $55.00
06752 Retainer crown -porcela in fused to noble metal .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. . .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .... .. .. . $60 .00
06780 Retainer cro wn -o/. cast high noble me tal .. .. .. . .. .. .. .. .. . .. .. .. . .. .. .. .. .. .. .. . .. . .. .. .. .. .. .. .. .. . .. .. .. .. .. .. .. .. .. .. .. .. .. .. $70 .00
06781 Retain er crown -o/. cas t predom inan tl y base metal .. . .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. . $55 .00
Pl an CA42 N DeltaCare USA Description of Benefits and Copayments
06782 Retainer crown -•;. cast noble metal . .. . . . . . . . . . . . . . . . .. . . . .. .. . . . . . .. . . .. . .. . . . . . . . . . . . . . .. . . . . . .. . .. . . .. . .. . . . .. . . . .. . . . . . . . .. . . $60.00
06783 Retainer crown -Y. porcelain/ce ramic* ............................................................. 00 •••• 00 00 •• 00 ...... 00 •• 00 00... $70.00
06790 Retainer crown -full cast high noble meta l 00 00 00 .... 00 ... 00 00 00 ............ 00 .. 00 ...... 00 00 00 00 00 00 00 00 00 00 00 .. 00 00 00 00 00 00 .. 00. $70 .0 0
06791 Retainer crow n -fu ll cas t predom inantly base meta l 00.00 00 00 00 00 00 00 00 00 00 00 ......... 00 00 .. 00 ......... 00 00 00 00 00 00 00 .. 00 00 .. 00 $50.00
06792 Retainer crown -full cast nob le metal ...... 00.00 00 .. 00.00 .. 00 .. 00 •• 00 ...... 00 ..... 00 .... 00 00 00 .. 00 00 .. 00 00 00 00 .. 0000 .. 00 .. 00 .. 00 00 $60 .0 0
06794 Retainer crown -ti tanium .... 00 •• 00 ..... 00 ••••• 00 •••• 00 ........... 00 •••••• 00.00 00 •• 00 ••• 00 ••• 00 •• 00 ••• 00 •••••• 00 •••• 00 •••• 00 •• 00 00 00. $70.00
D6930 Re -cemen t or re-bond fixed partial denture . 00 00 00 00 00 .. 00 00 00 00.00 00 00 00 00 00 00 00 00 00 00 00 00 00 00 00 00 00 .. 00 00 00 00 00 00 00 00 00 00 00 00 00 No Cost
D6940 Stress breake r ......... 00 ••• 00 ••••••• 00 ••• 00 ••••••••• 00. 00 •• 00 •••••• 00 •••••••••••••••••••• 00 ••••• 00 •••••••• 00 ••• 00. 00 •• 00 •••• 00 •• 00 ••• 00 No Cost
D6980 Fixed partial denture repair necessitated by restorative materia l fai lure 00 00 00 00 00 00 00 00 00 00 00 00 00 00 00 00 00 .... 00 00 00 00 .. 00 00 N o Cost
07000-07999 X. ORAL AND MAXILLOFACIAL SURGERY
-Includes preoperative and postoperative evaluations and treatment under a local anesthetic.
D7111 Extractio n, coronal remnants-deciduous tooth ooooooooooOOooooooOO 00000000000000000 00 0000 000000 00000000 000 OOOOOOOOOooOOooooOOOO No Cos t
D7140 Extraction , erupted tooth or exposed root (elevation and/or forceps removal) 00000000 000000 ...... ooooooOOoo 00 ooOOOO oo oooo . N o Cos t
D7210 Surgica l removal of erupted tooth requiring remova l of bone and/or sectioning of tooth, and including elevation of
mucoperiosteal fl ap if indicated ......... oo······oo••oooooooooooo •• oo ........ oo ............. oo.oooo•········ .................. oo •• oo. $10.00
07220 Remova l of impacted tooth -soft tissue ... OOOOOOOOoo ....... OOOOOOOOooooooooooooooooooooooooo ......... oooooooooooooooooo oo oo00oo00 $15.00
D7230 Removal of impacted tooth -partia ll y bony .... 00 00 .. 00 00 00 .......... 00 ..... 00 00 00 .. 00 .......... 00 00 .. 00 00 .... 00 ................ 00 $25.00
D7240 Removal of impacted tooth -completely bony 00 00 ...... 00 ..... 00 .. 00 ........ 0000 .. 00 .... 00 00 00 00 00 00 00 .... 00 00 00 00 00 00 00 00 00 .. 00 $35 .00
D7241 Remova l of impacted tooth -compl etely bony, with unusual surgical complications .......... 00 ...... 00 .. 00 00 .... 00 00 00 00 $50 .00
D7250 Surgical remova l of res i dua l tooth roots (cutting procedure) ..... 00 .... 0000000000 00 00 ooooooooooooooooooooooooo ................ No Cost
D7251 Coronectomy-intentional partial tooth removal .. 00 0000 ... 0000 00 00 .... 00 00 .. 00 .... 00 .... 00 0000 0000 00 00 .. 00 .... 00 00 0000 0000 .... .. $50.00
D7270 Tooth reimplanta tion and/or stabilization of accidentally avulsed or displaced tooth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $35.00
D7280 Surgica l access of an unerupted tooth .... 00 00 .. 00 00 00 ........ 00 .. 00 .. 00 00 ...... 00 .. 00 .. 00 .. 00 00 00 00 00 00 00 00 .. 00 .. 00 00 00 .. 00. 00 00. $25.00
07282 Mobil ization of erupted or mal positioned tooth to aid eruption 00 00 00 00 .... 00 00 .. 00 00 00 .... 00 ..... 0000 .. 00 00 00 00 00 00 ........ 00. $25.00
D7283 Pl acement of device to facilita te eruption of Impacted tooth 00 00 00 00 .. 00 00 .... 00 00 .. 00 00 .. 00 .. 00 00 00 .... 00 .. 00.00 .. 00 .. •oo 00 00 No Cost
D7286 lncisional biopsy of oral tissue -soft -does not include pathology laboratory procedures 00 .. 00 00 ...... 00 .......... 00 00 No Cost
D7310 Alveoloplasty in conjunction with extractions-four or more teeth or tooth spaces, per quadrant 000000 ............. oo. No Cost
0731 1 Alveoloplas ty in conjunction with extractions-one to three teeth or tooth spaces, per quadrant OOOO OOooooOOOOOOOOOO OO No Cos t
07320 Alveoloplasty not in conjunction wi th extractions -four or more teeth or tooth spaces, per quadran t .................. No Cos t
D7321 Alveoloplasty not in conjunction with extractions-one to three teeth or tooth spaces, per quadrant 000000 0000000000 00 No Cost
D7450 Removal of benign odontogenic cyst or tumor -lesion diameter up to 1.25 em 00000000000000000000 oooooooooooooooooooooo• No Cost
D7 451 Removal of benign odontogenic cyst or tumor-lesion diameter greater than 1.25 em .................................. No Cost
07471 Remova l of lateral exostosis (maxilla or mandible) 00 000000000000 oooooooooo .... oo 00000000 .. 00 ........ 00 oooooooooo ......... 00 oooo No Cost
D7472 Remova l of torus pala tinus ........... oo•· ..................... •oo········ ........ oo ........ •oo····· ·oooo• •• oo •••• oo ••••••••••••••••• No Cost
D7473 Remova l of torus mand ibula ris ............. ··oooo ••••••• oo •• ooooooooooooo•••oo ••• 00 ............... 00 ......... 00 ..................... No Cost
D75 10 Incision and drainage of abscess-intraoral soft tissue .. 00 0000 00 ....... oo .... 00 00 00 ............ ooooOOooOOooooOO ooOOOO .. ooooooo N o Cos t
D7960 Frenulectomy-also known as frenectomy or frenotomy-separate procedure not incidenta l to another proced ure N o Cos t
D7970 Excision of hyperplastic tissue -per arch 00 .. 0000 .. 00 00 .... 00.00. 00 .... 00 00 00.00 00 00 00 .... 00 00 ...... 00 00 00 .. 00 ...... 00 .. 00 ........ No Cost
D7971 Excision of pericoronal gingiva .. oo ••••• oo •• oo ...... oo •• oo .. oo .......................... oo ..................... oo ......... oo .... 00 ••• No Cost
08000-08999 XI. ORTHODONTIC S
-The listed Copayment for each phase of orthodontic treatment (limited, in terceptlve or comprehensive) covers up to 24 months of active
treatment. Beyond 24 months, en additional monthly fee , not to eKceed $125.00, may apply.
-The Retention Copayment includes adjustments and/or office visits up to 24 months.
Pre and pos t orthodontic recor ds In c lude:
The benefit for pre-treatment records and diagnostic seNices includes: 00 00 00 .... 00 .. 00 ...... 00 .... 00 .. 00 .. 00 00 00 .. 00 00 ... $200.00
D0210 Int raoral-compl ete series of radiographic images
D0322 Tomographic survey
00330 Panoramic radiographic image
00340 2D cepha lometric radiographic Image -acquisition, measurement and ana lysi s
00350 2D oral/facial photographic images obtained intraora ll y or extraorally
D0351 3D photographic image
D0470 Diagnostic casts
The benefit for post-treatment records in cludes : .......................................................................... 00 00.. $70.00
00210 Intraoral -complete series of radiographic Images
004 70 Diagnostic casts
Plan CA42N DeltaCare USA Description of Benefits and Copayments
D801 0 Lim ited orthodontic treatm ent of th e primary d enti tion . . . . . . .. . .. . . . . . . . . . . . . .. .. . .. .. . . . . . . . . .. .. . . . . . . . . . . . . . . .. . . .. . . . . . . . . . $725.00
D8020 Limited orthodontic treatment of the transitional dentition-child or adoles cent to age 19 ............................... $725.00
D8030 Limited orthodontic treatm ent of t he adolesce nt dentition-adolesce nt to age 19 ........................................ $72 5.00
D8040 Lim ite d orthodontic treatment o f the adult dentition -adults, including cove red d epend e nt adult childre n ............ $925.00
D8050 lnterceptlve orthodontic treatment of th e primary dentition .................................................................... $725.00
D80 60 lntercepti ve orth o dontic treatment o f th e t ransitiona l dentition ................................................................ $72 5.00
D8070 Comprehensiv e orth odo ntic treatme nt of the transi tional d entition -child or a dolescent to ag e 19 ................... $1 ,700.00
D8080 Comprehensive orthodontic t reatme nt of the ad olesce nt dent ition -adolescent to age 19 ............................ S1 ,700.00
D8090 Comprehensive orthod on ti c treatme nt of the adu lt dentition-adults, including covere d d ependent adult children .. $1 ,900.00
D8660 Pre-orthodontic treatment examination to monitor g rowth and development .. .. .... .. .. .. .. . .. .. .. .. .. .. .. .. .. .. . .. . .. .. .. $25.00
D8670 Period ic orthod onti c treatment vi si t -Included in comprehensive case fee ................................................. No Cost
D8680 Orthodon tic re ten tion (removal of app liances, construction and placement of re movable retaine rs) .................. $275.00
D8681 Removable orth odontic retainer adju stment ...................................................................................... No Cost
D8693 Re-bond o r re-ce ment fixed retain er -limited to 2 per 6 mo nth period .. .. .. .. .. .. . . . .. . . . . .. . . . . .. . .. .. .. . . . . . . .. .. .. .. .. . No Cost
D8694 Repair of fixed retainers , includes reattachment -limited to 2 per 6 month period . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . No C ost
D8999 Un specified orthodontic procedure, by report-includes tre atment planning se ssion .................................... $100.00
09000·09999 XII . ADJUNCTIVE GENERAL SERVICES
D9110 Pall iative (emergency) tre atment of d ental pain-min o r procedure .......................................................... No Cost
D9211 Reg ional bl ock anesthesia ........................................................................................................... No Cost
D9212 Trigeminal division block anesthe sia ............................................................................................... No Cost
D9215 Local an esthesia in conj uncti on with operative or surgical procedures ..................................................... No Cost
D9219 Eva luation for deep sedation or general anes the sia ............................................................................ No Cost
D9223 Deep sedation/general an e sthesia -each 15 minute i ncrement .. . .. .. .. .. .. .. .. .. .. . . . .. .. . .. .. .. .. .. . . . .. . . .. .. . .. .. .. .. . .. $80.00
D9243 Intravenous moderate (conscious) sedation /ana lgesia-each 15 m i nu te incre ment ...................................... $80.00
D9310 Consultation -diagnostic service provided by dentist or ph ysician o th er than requesting dentist or physician ....... No Cost
D9430 Office vi si t for observation (during regu l arly scheduled hours)-no othe r services pe rformed .......................... No Cost
D9440 Office visit -after regularly schedu led hours .. .. . .. .. .. .. . .. .. .. . .. .. .... .. .. .. .. .. .. .. .. .. .. .. .. . .. .. .. . .. .. . . . . . .. . .. . .. .. .. . . . $20.00
D9450 Case pres entation, detailed and extensive treatment plann ing ............................................................... No Co st
09932 Cleaning and inspec tion of removable co mplete denture , maxillary ......................................................... No Cost
D9933 Cleaning and inspection of removable comp lete denture, mand ibular ...................................................... No Cost
D9934 Cleaning and in spe ction of removab le partia l denture, max ill a ry ............................................................. No Cost
D9935 Cleaning and inspe ction of removab le partia l denture, m an dibular .......................................................... No Cost
D9940 Occlusal guard, by report -limite d to 1 in 3 years .... . .. .. .. .. .. . .. . .. .. .. .. .. . .. .. .. .. .. .. .. .. .. ... .. . .. .. .. .. .. .. . .. . .. .. . .. . $75.00
D9943 Occlusal guard adj ustment ........................................................................................................... $10.00
09951 Occlusal adjustment, limite d ......................................................................................................... No Cost
09952 Occlu sal adjustm ent , compl et e ...................................................................................................... No Cost
D9975 External bleaching for home applicat ion, per arch; includes materia ls and fabrication of custom trays -lim ited to
one bleaching tray and gel for two weeks of self-treatment ................................................................... $125.00
D9986 Missed appointment -without 24 hour notice -per 15 minutes o f app ointment t ime -up to an overall maximum
of$40.00 ................................................................................................................................. $10.00
D9 987 Canceled appointment-with out 24 hour notice -per 15 minutes of appointment time -up to an overall maximum
of $40.00 ....... .......................... .... ...................................................... .... ............... ..... .... ... ....... $10.00
If servi ces for a listed procedure are perfo rmed by the ass igned Co ntrac t Dentist, t he Enroll ee pays the sp eci fi ed Copayme nt. Li sted
procedures which require a Denti st to pro vide Specialist Servi ces , and are referred by the assi gn ed Contra ct Dentist, mu st be autho ri zed
by Delta Dental. The Enrollee pa ys th e Co paym ent spe cified f or su ch se rvices.
Procedure s not listed above are not covered, however, ma y be available at the Con tra ct Dent is t's "fil ed fees." "Filed fees• mean the
Contract Dentist's fees on file with Delta Dental. Que stions reg ard ing th ese fees should be directed to the Customer Service de partm ent
at 800-42 2-4234 .
SC H EDULE B
Limitations of Benefits
Limitations and Exclusions of Benefits
1. The freque ncy of certa in Benefits is limited . All frequency l imitations are listed in Schedule A, Description of Benefits and
Copayments.
2. If th e Enrollee accepts a treatment pl an from the Contract Den ti st that includes any com bina tion of more than six crowns, bridge
pont ics and/or bridge retainers, the Enrollee may be charged an additional $100.00 above the listed Co payment f or each of th ese
services a fter the sixth un it has been provid ed.
3. General anesthesia and/or intravenous sedation/analgesia is limited to treatment by a contracted oral surg eon and in conjunction
with an approved refe rral for the removal of one or more partial or full bony impactions, (Procedures D7230, D7240, and D7241 ).
4. Benefits provid ed by a pediatric Denti st are l imited to chi ldren 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 , regard less of age limitation , wi ll be conside red on an Individual basis.
5. The cos t 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 Co ntract Orthodontist w ill prorate the amoun t for the number o f
months remai ning to complete treatment. The Enrollee makes payment d irectly to the Contract Orthodon tist as arranged.
6. Orthodontic treatment In progress is limited to new DeltaCare USA Enrollees who, at the time of their original effect1ve date, are
in active treatment started under thei r previous employer sponsored dental plan, as long as th ey conti n ue to be eligible under the
De ltaCare USA Program . Active trea tment means tooth movement has begun. Enrollees are responsible for all Copayments and
fees subject to th e provisions of their prior denta l plan. Delta Dental is financially responsible only for amounts unpaid by t he prior
dental plan for qualifying orthodontic cases .
Exclusions of B e n efits
1. Any procedure that Is not specifica lly listed under Schedule A, D escription of Benefits and Copayments.
2. Any procedure that in the professiona l opinion of the Contract Dentist:
a. has poor prognosis for a successful result and rea sonable lo ngevity based on t he condition of the tooth or teeth and/or
surrounding structures, o r
b. is inconsistent with generally accepted standards fo r de ntistry.
3. Services solely for cosmetic purposes, with the exception of procedure 09975 (External bleaching for home application, per arch),
or for condi tions that are a resul t of hereditary or developmental defects, such as cleft pa l ate, upper and lower jaw malformations,
congeni tally missi ng teeth and teeth that are discolored or l acking enamel , except for the treatment of newborn children w ith
congenital defects or birth abnormalities.
4. Porce lain crowns, porcelain fused to metal , cast metal or resin wi th metal type crowns and fixed parti al dentures (bridges) for children
under 16 years of age.
5. Lost or stolen appliances including, but not lim ited to , full or partial dentures, space malntainers , crowns and fixed partial dentures
(bridges).
6. Procedures, appliances o r restoration if the purpose Is to change vertical dimension, or to d iag nose or t reat abnormal conditions of
the temporomand ibular 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 (overlays , implants, and appliances associa ted therewith) and
personalization and ch aracterization of com plete and partial dentures.
8. Implant-supported dental appliances and attachments, implant placement, maintenance, removal and all o th er services associated
with a dental implant.
9. Consul tations for non-covered bene fits.
10. Denta l services received from any dental facility other than the assigned Contract Dentist, a preauthorized dental specialist, or a
Contract Orthodontist except for Emergency Services 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 faci lity, or other similar care
faci lity.
12. Prescription drugs.
Limitations and Exclusions of Benefits
13. Dental expenses incu rred In connection w ith any dental o r ortho dontic proced ure starte d before the Enroll ee's eligi bi lity with the
Delta Car e USA Program . Examples include: teeth prepared for crowns, root canals In progress, f ull or partial dentures for which an
impression has been t aken and orthodontics unle ss qualified for the orthodontic treatment i n progress provision.
14 . Lost , st olen or broken orthodontic appliances.
15 . Changes in orth odontic treatment necessitated by accident of any ki nd.
16 . Myofunctional and parafunctiona l appliances and/o r therapies, with the exception of procedure D9940 (occl usal guard, per report).
17. Co mposite or cer amic br ackets, li ngua l ad apta tio n of orthodontic bands and o ther specialized or cos metic alternatives to standard
fixed and r emovable orthodontic appliances.
18. Treatme nt or applian ces that are provided by a Den tist whose practice specializes in pros thodon tic services.
Getting the most from your plan
Quality
Convenience
Predictable
Costs
With DeltaCa re USA, there
are no cla i m forms to submit.
• Se lect a
fJJ DeltaCare USA
dentist
~ Receive your
welcome kit
0 Schedu le an
appoin tment
9 Receive
dental
care
0 Pay only you r
copayment
dire ctly to
dentist
No paperwork.
No hassle.
Save money with a DeltaCaref! USA
den tist
DeltaCare USA plans fea t ure:
• Set co payments.
• No annua l deduct i bles and no
maximums for covered benefits.
• Low out-of-pocket costs for many
diagnostic and preventive services
(such as professional clean ings
and regular denta l exams).
Choosing your Delta Care USA de ntis t
When you enroll, you choose from
many convenient ly located De ltaCare
USA contracted general dentists to
receive benefits under your plan.
To find the most current list ing of
DeltaCare USA network den ta l offices:
• Visit our website and click on
"Find a Dentist" on our home page.
• Se lect "Delta Care USA" as your
plan network .
You can also call Customer Service
for help i n find ing a dentist.
Visit your Delta Care USA dentist
You must visit you r selecte d DeltaCare
USA dentist to rece ive benefits unde r
your plan.
• If you do not se lect a dentist, we wi ll
se le ct a dentist for you.
• Fam ily members may se lect a
different dentist fo r treatment within
the covered service area. Re fer to
your plan booklet for details.
• You can change your se lected
network dentist by t elephone or
through our website.
• Changes receive d by t he 21st of the
month wi ll be effective the first day
of the foll owing month .
Easy to use
• We will notify your De ltaCa re USA
dentist about yo ur enroll ment
in the plan and other important
details abou t your coverage such
as dependent informat ion , group
number and enro ll ee ID number.
• No ID card is required to rece ive
services; simply provide the dental
office with your name, date of birth
and soc ial security or enrolle e
ID number.
• With DeltaCare USA, there are no
clai m forms to submit. And, sin ce
you are respons i ble on ly for the
co payment at the time of treatment ,
you will no t rece ive a claims
stateme nt.
• Predictable costs: you 'll find a
complete list of covered procedu res ,
copayments, plan limitations and
exclusions in your plan booklet.
Specialty care and authorizations
If you require treatment from a specialist,
your DeltaCa re USA gene ral dentist
will coordinate any re fe rrals for you.
In some sta tes, De lta Dental must
pre-author ize any denta l services,
with the except ion of eme rgency
treatm ent, that are not performed by
you r DeltaCare USA gene ral dentist.
Please refer to yo ur p lan booklet for
spe cific details abo ut your plan.
DELTACARE USA
Dual coverage/Coord ination
of benefit s
If your spo use has coverage with
anothe r dental plan, you or your family
membe rs may be covered by both
dental plans.*
• We do not coordinate benefits with
the other plan when you receive
treatment from your Delta Care USA
general dentis t. However, if you
receive authorized treatment from a
speci al ist (such as an ora l surgeon),
we will coordinate benefits with th e
other ca rrier.
• Ask your specia li st to su bmit the
other plan's explanation of benefits
with the DeltaCare USA cla im form
and we'll take it from there .
Orthodo ntic trea tment in progress
Del taCare USA has an orthodontic
treatmen t-in-progress provis ion that
allows new enrollees to continue
treatment with their current
orthodontist, as long as the enrollee
is in active treatment started under
his or her previous employer-sponsored
dental plan. Enrollees are responsible
for all co paym en ts and fees subject
to the provisions of the ir prior
denta l pla n.**
Trans itl on ing from another plan?
Your De ltaCare USA plan cover s
treatment started and completed
only after your plan's effective date
of coverage. If you have any dental
treatment in progress when your
coverage begins-root cana ls in
progress, teet h prepared for crowns
and dentures fo r which an imp res sion
has been taken -those expenses are
not covered by your DeltaCare USA
plan . However, Delta Care USA plans
have no exclusion for pre -ex isting
dental conditions or missing teeth .
Visit our we bsite:
deltaden talins.com
On our website, you can:
• Find a dentist in our online directory
• Review benefits
• Verify eligibility
• Print an 10 card and much more
To access some services, you'll need
to log in: simp ly enter your username
and password in the designated
boxe s and submit. If you are visiting
our websi te for the first time, you'll
need to complete a quick one-time
reg istrat ion pro cess by clicking
the "Register Today" link.
Ques tions about you r plan ?
If you have questions, you can
check your benefits and eligibility
information on our website or on our
interactive voice response te lephone
line. For more in formation, you may
also contact us through our website
or ca ll one of our helpfu l multilingual
Customer Service repr esentatives
toll-free during business hours.
* Group-specific exceptions may apply. Please re view yo ur plan booklet for specific details
about your plan's coordination of bene fits, Including rules for determinin g primary and
secondary coverage .
**This provision may not apply to all plans . Please refer to you r plan booklet for specific
coverage details.
Wi th DeltaCare USA,
you and your family
will enjoy many new
features Including:
0
Expanded business hours/
toll-free customer service
Out-of-area
emergen cy coverage
Orthodontic treatment
In progress provision
DELTACARE USA
Fi nd a ll of ou r dental he alth
resources, including ris k
asse ssm en t quizzes, a rticles ,
vi deos an d a f ree newsletter
subscripti on, at: mysmlleway.com .
Connect with us!
face book. com Ide I tad ent a li ns
twi t te r.com I delta de ntalins
youtube.co m /del tade ntali ns
Della Dental PPO"' Is underwri tten by
Delt a Dental Insurance Compa ny In AL,
DC, Fl, GA, LA, MS, MT, NV and UTan d by
not·for·proflt dent al service comp anies
In t hese stat es: CA-Delta Dental of
Californ ia, PA, MD-Delta Dental of
Pennsylvania, NY -Della Dental of New
York, Inc., DE-Del t a De nta l of Delaware,
Inc., WV-Delta Denta l of West VIrginia.
In Texas, Delta Denta l Insurance Com pany
provides a Dental Provider Organization
(DPO) plan.
DeltaCare• USA Is un derwritten in these
states by these entities: Al -Alp ha
Dental of Alabama, Inc.; CA-De lta
Dental of Cali fornia; AR, CO , lA, Mt,
OR, Rt, SC, WA, WI, WV-Dentegra
Insurance Company; DE, Fl. GA, KS, TN,
WV and Washington. D.C.-Delta Dental
Insurance Compa ny; HI, ID, IN, KY, MD,
MO. NJ . TX -Al pha Dental Prog rams,
I nc.; UT-Alpha Denta l of Utah, Inc.;
NV-De lta Den tal of New York, In c.; PA -
De lla De ntal of Pennsylva nia; VA-De lta
Denta l of VIrginia. Delta Den t al Insurance
Company acts as th e DeltaCare USA
administrator In all these states. These
companies are flnanclally res ponsible for
thei r ow n prod uct s.
0 DELTA DENTAL
We l(eep Yo u Smiling
Adva ncing d enta l heal th and access t hroug h exceptiona l d ent al b ene fits se rvi ce ,
t ech n ology and professional su ppo rt.
Del t a Dental Custom er Servic e
Delta Dental PPO
Ca ll 800·765-6003
1 00 First Street
San Francisco, CA 94105
De ltaCare USA
CallS00-422-4234
P.O. Box 1 803
Alpharetta , GA 30023
dlltadentallns .com
5879 08.30.20 16 0
Your Vision
Benefits Summary
Get the best in eye c are and eyewear with COUNTY OF FRESN O
and VS~ Vision Care .
Using your VSP benefit is easy.
• Create an account at vsp.com. Once your plan is effective,
review your benefit informat ion.
• Find an eye care provider who's right for you. The decision
is yours to make-choose a VSP d octor, a participating re tail
c ha in , or any out-of-netwo rk provider. To find a VSP provider,
visit vsp.com or call 800.877 .7195 .
• At your appointment, tell them you have VSP . There's no ID
card necessary. If you 'd like a c ard as a reference, you can
print o ne 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 Eye Care
As a VS P member, you can visit your VSP doctor for medical
and urgent eye ca re . Your VSP doctor ca n diagnose, t reat, and
monitor common eye conditions li ke pink eye, and more serious
cond itions like sudden vision loss, glaucoma, d iabetic eye
d isease, and cataracts. Ask your VSP doctor f or deta ils.
Choice in Eyewear
From classi c styles to the la test designer frames, you'll find
hundreds o f options. Choose from featured fr ame brands
like bebe41 , Calvin Klei n, Cole Haan, Flexon•, Lacoste, Nike, Nine
West, and more'. Visit vsp.com to find a Premier Program
locati on th at c arries these brands. Prefer to shop on li ne? Check
out all of the brands at Eyeconic.com, VSP 's online eyewear
store.
Plan Information
VSP Coverage Effective Date: 01/01/2017
VSP Provider Network: VS P Choice
SAN JOAQUIN VALLEY INSURANCE AUTHORITY and VSP provide
you with an affordable e ye care plan.
Visit vsp.com or call 800.877.7195
for more details on your vision
coverage and exclusive savings
and promotions for VSP members.
•erands/Promotion sub ject to change.
~014 Vision Service Plan. All rights reserved. VSP, VSP Vision care for life. and Wei !Vision Exam
are registered t rademarks of Vision Service Plan. Flexon Is a registered trademark of Marchon
Eyewear, Inc. All other company names and brands are trademarks Of registered trademarks
of their respective owners.
WeiiVislon
Exam
• Focuses on your eyes and overall
well ness
• Every 12 months
$10
Prescription Glasses $10
Frame
Lenses
• $150 allowance for a wide selection
of frames
• $170 allowance for featured frame
brands (see 'Extra Savings' below)
• 20% savings on the amount over your
allowance
• $80 Costco• frame allowance
• Every 24 months
• Single vision , lined b ifocal, 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
Contacts
(Instead of
glasses)
Primary
Eyecare
Extra Savings
lens enhancements
• Every 12 months
• $150 a llowance for contacts; copay
does not apply
• Contact lens exam (fitting a nd
evalua t ion)
• Every 12 months
• Treatment and d iagnosis of eye
conditions l ike p ink eye, vision loss
and moni toring of cataracts,
glaucoma and d iabet ic 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 S20 to spend on featured frame brands. Go to
vsp.com/specialoffers for details.
• 20% savings on additional glasses and sunglasses,
includin g lens enhancements, from any VSP pr ovi d er
within 12 months of your last WeiiVision 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 regu lar price o r 5% off the
promotional price; discounts only available from
contracted faci lities
Your Coverage with Out-of-Network Providers
Visit vs p.com for details, if you plan to see a provider other than a VSP network provider.
Exam .................................................. up to $45 L' d T 'f 1 L
Frame ................................................ up to $70 Pme n .oca enses .............. up to $65
Single Vision Lenses ............... up to $30 rogress tve Lenses .................. up to $50
Lined Bifocal Lenses ............... up to $50 Con tacts ........................................ up to $105
Coverage with a partiCipating reta•l chain maY be different Once your benefit 11 effect1ve. VISit vsP com
for details Coverage tnformatlon IS subject to change In the event of a confbct betwe&n th1s informabon
and your orgeruzabon s contract woth VSP, the terms of th .. con1ract Wlli preva•l B<laed on apphcoble
laws. benehta may vary by locabon
' "'';--y' ~ ,J 1: ~ ~ ..
San Joaquin Valley Insurance Authority
County of Fresno
Plan Rates
EXHIBIT B
Effective December 19, 2016 through December 17, 2017 _~-------'
Ao t b~:m 1111.11: ~[Q~~ -M !l otb l ~
Anthem $250 $1,001.54 $2,102.42 $1,904 .76 $2,904.49
Anthem $1000 $743.55 $1,560.86 $1,414.11 $2,156.32
Anthem $1500 Active $674.03 $1,414.91 $1 ,281.89 $1 ,954.69
Anthem $1500 Retiree $770.97 $1 ,364.88 $1,204.38 $1 ,796.80
Anthem $3000 $55 0.74 $1 ,166.58 $1 ,045.88 $1 ,593 .79
Anthem HMO $791.52 $1 ,399.80 $1 ,235.42 $1 ,842.03
Ki.im
Ka iser HMO Active Bi -Weekly $353 .45 $625 .56 $552.71 $824.15
SJVIA D!;l n tal & Vision Rates
Delta Dental DHMO $25.04 $42 .96 $43.26 $62.35
Delta Dental DPPO $50.29 $80.19 $69.88 $102 .58
VSP Vision $7.49 $13 .46 $13 .19 $19 .32
Page 1 2017 Exhibit 8 ·County o f Fresno
Agreement No. 15-644
SJVIA PARTICIPATI O N AGREEME NT
TH IS AGREEMEN T ("Agreement") is made and entered into th is t h day of December, 2015, by and
between COUNTY OF FRESNO , a political subdivision of the State of California, hereinafter referred to as
"CO~N TY O F FRESNO ", and the SAN JOAQUIN VALLEY INSURANCE AUTHORITY, a joint powers agency,
hereinafter 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 insu rance , including related adm inistrative services for
such programs to be provided by the insurance provider(s ) and the SJVIA and its agents and consultants
(collectively, "Va rious Benefits"), for the benefit of participatin g entities; and
WHEREAS , the COUNTY OF FRESNO w ishes 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 ins urance
program as referenced in Exhibit "A " (collectively, "S ELECTED 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 hea lth insurance programs is
attached hereto and incorporated herein by reference as Exhibit "A"; and
WHEREAS , the SJVIA represents that it will contract with In su rance Providers which will provide its
Va rious Benefits under the terms and conditions of a written contract between the SJVIA and the Insurance
Provider (the "Insurance Contra ct") for each of the COUNTY O F 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 co nsultants, are set forth in Exhibit "B" which is attached hereto and incorporated here in 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 the ir mutual promises, covenants and conditions, the Parties
agree as follows :
1. COUNTY OF FR ESNO's OBLIGATI ONS : The COUNTY OF FRESNO acknowledges that th is
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 insu rance premium
and/or sim ilar charge to the Insurance Provider, the COU NTY OF FRESNO shall remit to SJVIA the amount
necessary to pay the required premium payment based on the in tervals of such payments under the Insurance
Contract.
The COUNTY OF FRESNO may also part icipate in SELECTED PROGRAMS as referenced in Exhibit "A" and
sha ll comply with all applicable terms and provis io ns 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
-1 -
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 SJ VI A underwriting guidelines . The SJVI A is underwritten
and renewed as a single risk pool using actuarially based underwriting standards .
2. SJVIA 'S OB LIG ATI ON S: The SJ VIA shall approve and execute related Insurance Contracts .
Following execution of the Insurance Contracts , (i) SJ VIA 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) SJ V IA shall perform SJVIA's obligations under the
term s and conditions of the Insurance Contracts , includ ing making timely payment of premium payments ,
and/or any similar charges , necessary to keep the Insurance Contracts in full force and effect.
3. MODI FI CAT ION : Any matters of this Agreement may be modified from time to time but only by
the written consent of all the parties hereto w ithout, in any way, affecting the remainder hereof.
4 . NON-ASS IGN MENT : Neither party hereto shall assign, transfer, or subcontract th is Agreement
nor their rights or duties under this Agreement without the prior written consent of the other party hereto .
5. AUDITS AND IN SP ECTI O NS : The SJVIA shall at any time during usual SJVIA business hours,
upon request by the COUNTY OF FRESNO , and as often as the COUNT Y OF FRESNO may deem necessary ,
make ava ilable 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 exam ination 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. NOT ICES: The persons having autho rity to give and receive notices under this Ag r eement and
their addresses include the following :
COUNTY OF FRESNO
Paul Nerland
Director of Human Resou rces
2220 Tulare St, 161
h Floor
Fresno , CA 93721
PNerland@co .fresno .ca .us
SJ VIA
Rhonda Sjostrom
SJVIA Manager
2900 West Burrel
Visalia , CA 93291
rsjostro@co .tulare .ca .us
Any and all notices between the COUNT Y OF FRESNO and the SJVIA provided for or perm itted under
this Agreement shall be in writ ing 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. GOV ERNING L AW : The parties agree that for the purposes of venue , performance under th is
Agreement is to be in Fresno County, California . The rights and obligations of the parties and all interpretation
and performance of this Ag reement shall be governed in all respects by the laws of the State of California .
8. TERM : Th is Agreement shall become effective beginning at 12 :01 a .m . on December 7, 2015
and shall terminate on December 31 , 2016 .
9. T ERMINAT ION :
a . The terms of this Agreement , and the Various Benefits , Adm inistrative Services , and /or
SJ VIA Staff Costs to be provided hereunder, are contingent on the approval of funds by the
COUNTY OF FRESNO . Should sufficient funds not be allocated , the services provided may
be modified , or this Agreement terminated at any time by giving SJVIA 120 days advance
written notice .
-2 -
t
b . Notwithstanding any other prov ision of th is A rticle , 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 so le discretion , to term inate this Agreement, without notice , effective at the expiration of
the last period for wh ich fu ll premium payment was made . Notwithstanding such termination
or suspension , the SJ VIA , in its sole d iscretion , may a ccept late payment or delinquent
amounts and , upon acceptance, th is Ag reement may be reinstated retroactive ly to the last
date for which full prem ium payment was made . Any such acceptance of a delinquent
payment by the SJ V IA shall not be deemed a waiver of this provision for termination of this
Agreement in th e event of any futu re fa ilu re of the COUNT Y OF FRESNO to make timely
payments of any amounts due under th is Agreement.
10. SEVERAB I LITY : In the event any prov is ions of this Agreement are held by a court of
competent jurisdiction to be invalid , void , or unenforceable , the Parties will use their best efforts to meet and
confer to determine how to mutually amend such provisions with valid and enforceable provisions , and the
remai n ing provisions of th is Agreement w ill nevertheless continue in full force and effect without being impaired
or inval idated in any way.
11. DISPUTE RESO LUT ION : Any contro versy or dispute between the parties arising out of th is
ag reement shall be submitted to mediation . The med iator will be selected by mutual agreement. If the matter
cannot be resolved through mediation or if the part ies cannot agree upon a mediator the matter shall be
submitted to arbitration and such arbitration shall comply w ith and be governed by the provisions of the
California Arbitrat io n Act , of the Cal ifornia Code of Ci vil Proc edu re .
12. ENT IRE AGREEM ENT : This Agreement constitutes the entire ag reement between the SJVIA
and COUNTY OF FRESNO w ith respect to the subj ect matter hereof and supersedes all previous agreement
negotiations , proposals , comm itments , writings , advertisements , publ ications , and understandings of any nature
w hatsoever unless expressly in c luded in th is Agreement.
13 . COUNTERPART S: This Agreement may be executed in one or more or iginal counterparts, all of
wh ich together will constitute one and the same agreemen t.
Ill
Ill
Ill
(Go to ne xt page for signatures)
-3 -
AGREEM ENT BE TWE EN COUNTY OF FRESNO AND T HE
SAN JOAQUIN VALLEY INSURANCE AUTHORITY
SAN JOAQUIN VALLEY INSURANCE AUTHW
sy!g;(g__ rR
Pe te \Jande r Poel
S JVIA Bo a rd President
Date: --
REV IEW ED & REC O MMENDED FOR A P PROVAL
By --:f?ko::-lh'-olan-da~S-"'jo"""~"""ro~f-bA~~='----
SJVIA M anager
COUNTY OF FRESNO
By~~
Buddy e ndes
Chairman, Boa rd of Supervisors
BERN ICE E. S EI DEL , C L ERK
BOARD OF SUPERVISORS
PPROVED AS T O ACCOU NTING FORM:
VICKI CROW ::OIJ:;:;E"?s:;:TAX CO~ECTOR
REV IEWED & RECOMM ENDED FOR
B;=?~
Paul Ner land
Di rector of Hu man Res ources
- 4 -
..