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Home My WebLink AboutAgreement No. A-15-644-4 with SJVIA.pdfAGREEMENT NO. 15-644-4 AMENDMENT 4 TO SJVIA PARTICIPATION AGREEMENT This Amendment 4 to the SJVIA Participation Agreement (Amendment 4) is dated January 1, 2018, and is between the County of Fresno, a political subdivision of the State of California (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" (Ag_reement), to allow COUNTY OF FRESNO to participate in certain insurance programs through SJVIA. The parties have previously amended the Agreement several times, most recently on July 1, 2017, to extend the term of the Agreement through December 31, 2017. The parties now desire to amend the Agreement to further extend the term of the Agreement, and to revise the in~urance programs available to COUNTY OF FRESNO through SJVIA and the rates for benefits under those programs. The parties therefore agree as follows: 1. The Agreement is amended, effe9tive January 1, 2018, as follows: a. The term of the Agreement is extended through December 31, 2018. b. The Exhibit A that is attached to this Amendment 4 replaces and supersedes all documents previously identified as Exhibit A to the Agreement. c: The Exhibit B that is attached to this Amendment 4 replaces and supersedes all documents previously identifie~ as Exhibit B to the Agreement. 2. Except as modified by this Amendment 4, the Agreement remains in full force and effect. IN WITNESS WHEREOF, the parties hereto have executed this Agreement as of the day and year first hereinabove written. SA~J mNV r?NSURANCE A OR:l By ✓ Date: Pete Vander Poel SJVIA Board President 4/b/o01 'l REVIEWED & RECOMMENDED FOR APP~ By_Jneil~ Rhonda Sjostrom' SJVIA Assistant Manager 1 COUNTY OF FRESNO Date: __ S" ..... /_,__;;~'---'('-, ..:.t" ___ _ BERNICE E. SEIDEL, CLERK BOARD OF SUPERVISORS By ~~~~,~ Anthem Blue Cross Your Plan: SJVIA Custom EPO 0/15/0 Your Network: EPO Anthem, BlucCross This mmmary ef bmefits ir a brief 0111/im of co11cmge, deJ'igned to help you 1vith the .relection process. This s11111111ary does not rejlect eqch a11d every benefit, exclusion and limitation 1vhich mqy appfy to the covemgc .. For 111ore details, i111portant li111itations at1d exc/11sio11s, please rr:11ic1v the formal Certificate of Insumnce or Evidence of Coverage (BOC). If there i.r a difference betJveen this sm111nary a11d the Ce11ijicate of Insurance or Evidence of Covera,.ge (EOC), the Certifit:atc of Insurance or Evidence of Coverage (BOC), ivill prevaiL Other practitioner visits: Retail health clinic On-line Visit with LiveIIealth Online Includes behavioral health visits. Chiropractor services Coverage for J,1-Nehvork Pro1,idcr iJ limited lo 40 visit lifllit per benefit period. Chiropractic appliances are limited to $SO per /ienejitJJeriod. J\cupunct.ure $15 copay per visit $15 copay per visit $10 copay per visit $15 copay per visit Not covered Not covered Not covered Not covered Page 1 of 5 Diagnostic Services Lab: Office Freestanding Lab Outpatient Hospital Ad\"'nc.:.d di'\')'nn,,t;,. ''TI""l.'1'" ff,,,, />'l•••nnJ.-,. 11.fJH /PL'.'T'/f'AT .;,..., "'-· " ... ., ~ ~.....,v.., ........• ,.,. , .. S ~ b ,.,,,,. ....... ~ ... o, ..... t"' ..,,, 1Y _. ...... , _ J.:. ....... 1 ~<;,~ ..... - SCHflS); Office Freestanding Radiology Center Out pa ti en t Hospital Arnbul.mcc (air and gnnind) No charge No charge No charge No chat:ge No charge No chaxgc: No c:h:uge Not cove,:cd Not covered Not covered Not covered Not covered Not covered Covncc: as l n, Nct,vo,k ·l Outpatient Mental/Behavioral Health and Substance Abuse Doctor office visit or LiveHealth Online visit Facility visit: Facility fees Hospital Stay (all inpatient stays i11cluding maternity, mental/ behavioral health, and substance abuse) Facility fees (for example, room & board) Doctor and other services Rehabilitation services (for example, physical/ speech/ occupational therapy): Office Costs may vary !!JI site of scmice. Limited to a 60-day period of care. Outpatient hospital Limited to a 60-day period of care. Habilitatioo services Office Outpatient hospital $15 copay per visit No charge No charge No charge $15 copay per visit No charge $15 copay per visit No charge Not covered Not covered Not covered Not covered Not covered Not covered Not covered Not covered Durabl.e Medical Equipmellllt Hearing aid.r benefit (Wai/able for one heari11g aid per ear every three years. Breast p11mp and supplies are co21cred under P~ventiw Care at no charge. Prosthetic Devices Home Infuskm Therapy rrl!ir1u1; Family Planning and Infortillity Senr.i.ces 0 Infertility studies and tests Female Sterilization (including tubal ligation and counseling/ consultation) 0 Male Sterilization Counseling and consultation '-' California Fetal Genetic Testing Smoking Cessation lP'rngll"am ,_,,,~-----,-·--·--,.,_,_, ___ . _____ ,., , ".,,,,,,, .. ,.,.,.,,,,, $15 copay per visit No charge No charge No charge No charge visit $15 copay per visit No charge $15 copay $15 copay per visit No charge No charge Not covered Not covered Not covered Not covered Notes: 0 • • .. • • • .. • • This Summ::i.ry of Benefits has been updated to comply with federal and state require~ents, including applicable provisions o fthc rccentl}: enacted federltfhealth citrc reform laws. As we receive additional guidance and clarification on the new health c:ai;ii refo1an la\vs from th.e: U.S. I:iep_artmcut 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 Sutnm;at)' of Benefits, as updated, is subject to the approval of the California Department of Insurance and the California Department of Managed Health Care (as applicable). In addition to the benefits described in this summary, coverage may include additional benefits, depending upon the mcmbcis hom:c st:ite, U1<: be1i~fit~ pl'.(:)vttl<td in tHls sun11J11u:y are subject to federnl and California laws. Thfu:¢ rue some ,states that require tnore ~cnerous benefits ,be providetl t~ theu: residents, even if the master policy was not iss1.iecl in their ~tate. ff the mernher's stateJH1.s sm::h r.~q1.1it:¢ments, W¢ wUl adjust the benefits to meet the requirements. The fiunily dethi<:tinle anq out-e>t;'.-j>m::kct maxlmµm. nre ~bedded mi~a1ting the cost sbares of o'rie •family i.ueh'il.icr j.vlll be ippli'cdto the individual <,\eclli1ctible and j11divipu:1L out-()f-pock¢t .ri:iax:imuro; in.1tddition, nmo11ri1:s for :1,ll family tl1¢mqcts apply fo:.the ffonily dcduc.tible imd fatuily eut:.9,t0 pock,,et l,1Ja:1d.1n1.n:n. No 9n~ member will pay m:ore th:tn,the individual ·deductibfo and iudividm1l out-of-pocket 1naximu,tl'i. · · All medical services subject to a coinsurance are also subject to the annual medical deductible. Annual Out-of-Pocket Maximums includes deductible,'copays, coinsurance and prescription drug. l,>r~vi;ntive Care Se1,vkes inchu1cs }?hysi~.il e:kl\ttt; prev:eutive scre~i't;gs (i111::lµdi9g S()r<;<.?nings fon::ancer, HPV, diabetes, ehol~ti;rpl, bloodpre~s.ui:e; hearlng itrtdvision,,1mmuiili:ation; b:eal1;hed'11c,1ti~~1,. iu~c:t.VcQ.Jiqn services, HIV testing) and ad<;litiopi(lptev~~tlvecate f.qrwome.i provided fofin.thcguidance supported by Health Resources and Service Administration. For plans wi'tli, an offo;eyisitcOp!yy; the wparapplies to the acliialql;ftce visit and additlpnal r.:e>st,shares may apply for any other scr',!lce performed ih the office (i.e., X-ray, lab, iltttgcry~, attC':.r; any applicable µ~ductible. If your plan includes an emergency room facility copay and you are directly admitted to a hospital, your emergency room facility cqpay is waived. Ccm1u1 services are subject to the util&atio11'r.<!Vie\V°fli:t1gi;11m. Befoxe sd1eduling services, the member.mus.t make sure utilization review is obtained. If 1za.uc,n-.r~r1e,,v not:obtaine.d, b·enefits may be reduced or not paid, .according to the pk~ . Additional visits maybe authorized if medically necessary. Pre-service review must be obtained prior to receiving the additional services. Transplants covered only when performed at Centers of Medical Excellence or Blue Distinction Centers. Bariatric Surgery covered only when performed at Blue Distinction Center for Specialty Care for Bariatric Surgery. Skilled Nursing Facility day limit does not apply to mental health and substance abuse. Respite Care limited to 5 days per admission. Freestanding Lab and Radiology Center is defined as services received in a non-hospital based facility . Coordination of Benefits: Toe benefits of this plan may be reduced if the member has any other group health or dental coverage so that the servjccs received from all group coverage do not exceed 100% of the covered expense. For additional information on limitations and exclusions and other disclosure items that apply to this plan, go to For additional information on this plan, please visit sbc.anthem.com to obtain a Summary of Benefit Coverage . v1su us at '-'·'"·'"==•··-:.:,.,.:.,,,"'~-·A1...,,,.1 Ci\/L/J:/EP<J /C .LF2CJ l .S/01-18 (C\ r:.PO) Page S of 5 SJViA County of Fresno Modified Prem~er PPO (250/20/i 00/50) w Act~ve 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, Deparlment of Labor and Internal Revenue Service, we may be required to make additional changes to this summary of benefits. This proposed benefit summary is subject to the approval of the California Department of Insurance and the California Department of Managed Health Care. In addition to dollar and percentage copays, members are responsible for deductibles, as described below. Please review the deductible information to know if a deductible applies lo a specific covered service. Certain Covered Services have maximum visit and/or day limits per year. The number of visits and/ordays alloweel for these services will begin accum~lating on the first visit and/or day, regardless of whether your deductible has pee/) met. Members are also r1;1si)m1sible for all CQ!!ls:(,v~r lhe pl~ll maximums. Plan maximums and other important inforn1atidn_.appear in ilJ;J,!i£l;, Benefits are subjl).ct lo all terms'. conditions. limilalions, and exclusions or the Policy. Explanation of Maximum Allowed Amount · · Maximum Allowed Amount is the total reimbursement payable under the plan for covered services received from Participating and Non- Participating Providers. It is the payment towards the services billed by a provider combined with any ~pplicable 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)-Reimbursernent 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 -m~y be. responsible for 9rtY, amount in. excess of the reasonable and custC>_mary value. -. ' ,_,_,-,, . . . . .. . ' ~' ' '" When using Non-PPO and Other Health Care Providers, members are responsible for any difference between the covered expense & actual charges, as well as any deductible & percentage copay. Benefit year cfoducHblefor all pr:o\tlders · Deductible for non-Anthem Blue Cross PPO hospital or resJdenthll treatment ce!lter .. Deductible for ~non-Anthem Blue Cross PPOliospltal or res_idential !refil!llent canter if utilization review not obtained $500/admission (waived for emergency admission) 5$t00fvisjt (waived if admitted directly from ER) Annual Out-of-Pocket Maximums (no-cioss accumiilatio11) PPO Providers & other Health Care Providers $3,000/member/year; $5,000/family/year Non-PPO Providers $10,000/memberlyear; $15,000/family/year The following do not apply to the medical out-of-pocket maximums: 'non-covered expenses and prescriptiol) drugs. After an annual·out-of- pocket maximum Is met for medical during a calendar year, the individual member or family will no longer be required to pay a copay or coinsurance for medical. The member remains re~pc:insllile for non-covered expenses and prescription drugs Lifetime Maximum Unlimited Covered Services PPO: Per Ho I Medical Servi(;;os (sul~ocf lo u//Jiz,ation review for j/ . . . service§_; waived/or emer eM admissions) . • Sern!,priiiale r.dom, meals' . & ancillary services • Oulpatif.)ntmedic_al;care, Sllfc(:lipal & supplies (hospitef GiJIP 0({1orll1~n emeiyency mom c:aro) Ambulatory Surgical Centers Member Copay No copay No copay • Outpatient surgery, services & supplies No copay --- Skilled Nursing Facility {subject to utilization review)··--------------··~··-····· • Semi-private room, services & supplies (limited to 100 days/benefit year) Hospice Care • Inpatient or oulpatient services ; family bereavement services Home Health Care (subject to utilization review) • Services & supplies from a home health agency (limited to 100 visils/beneT,i year, one visit by a home health aide equals four hours or less; No copay No copay 2 No copay Non-PPO: Per Member Copay 50%1 50%1 50% (benefit limited lo $350/day) 50% 50% ~-~ot covered while member receives hospice care) ···-----···•· -· --... ·-·••--··· . 'ic·c, CaFforn:~ i~ciiifes, 2 discount will be applied r1 Hie facility has a contract with Anthem B'ur, Cross ror ff:2·ro,-service busin,,ss f0: C:iicfc;rr,,;, f3d 1i!ic,-w-itr;-o:.-,t "-., c-0,-:m-sc-l,- ,:~~verwJ t!.\jJEflSt! Im 11on"cn1ernency 110.spi!.::11 smvlct?S and supplies is it!dttcmJ by ?5%, res:1/Un[l in highr,r costs for members (,!h1?,<w pnv1rJ1:,r~ '~!1: noi 1ep1e.s,!nl~d in lt1(? Anl!H!m f,'ita:: Cross PPO n~l'.-inr~. -~---, ··~~• ··----·----···--- i.l'r' 12.18-11 Covered Services Home Infusion Therapy (subject lo utilization review) • Includes medication, ancillary services & supplies; caregiv~r tr~111tn9-~,visits by proyid~r to monitor lhe(epy;: dun:,ib!erijedical;6ql)fpmebt; lab services Physician Medical Services ' • Office & home visits • Hospital & skilled nursing facility visits • Surgeon & surgical assistant; anesthesiologist or anesthetist • Drugs administered by a medical provider :(certain drUfJS are subject to utilization review Diagnostic X-ray & Lab • MRI, CT scan, PET scan & nuclear cardiac scan (subject to utilization review) • Other cllagnQstic,X':r9y·& lab Preventive Care services Preventive Care Services including•, physical exams, preventive screenings (including screenings for cancer, HPV, diabetes, cholesterol blood pressure, hearing and vision, immunizations, health education, intervention services, HIV testing), and additional preventive care for women provided for in the guidelines supported by the Health Resources and Services Administration. *This list is not exhaustive. This benefit includes all Preventive Care Services required by federal and state law. Physical Th~rapy, P:h.Y$ical Medicine & Occupational Therapy, intfµdlng",Cblt<mractlc Services (limited to 24. visits/benefit year; ~cliJil(~~t:1l visits·it/a}"be authorized) S~~eg,b Therapy PPO: Per Member Copay No copay $20/visit1 (deductible waived) No copay No copay No copay No copay No copay No copay (deductible waiv_ed) No copay Non-PPO: Per Member Copav. 50% (benefit limited to $600/day) 50% 50% 50% 50% 50% ,50% 50% 50% ~• __ o_u_tp_at_ie_nt ___ s_p,....ee=c ..... h_th_e_ra"""py_fi_o'-llo_w_.in=g_l11"'"'j~_ry;_o_r_o_rg_a_ni_c_di_se_a_se_...,.-...,....,_No_c_q_p ___ ay..__. ______ 50_o/c_o ______ ,~ Acupuncture • Services for the treatment of disease, illness or injury (limited to 12 v{sitslbenefit year) Temporomandibular Joint Disorders • Splint therapy & surgical treatment Pregnancy & Maternity Care • Physician office visits • Prescription drug for elective abortion (mifepristone) Normal delivery, cesarean section, complications of pregnancy & abortion • Inpatient physician services • Hospital & ancillary services Org<1n & Tis~ue Tran§p:larits (subject ta. rJUfiz:ation review; specified o,tganfransplanls i:ov!:lred only when.petfortifed at Center of Expertise {COE]) ' • Inpatient services provid.ed h;i•09nnection with 11on~investigative 9rga,n qr tissue transplants • Transplant travel expense for an authorized, specified transplant at a COE (recipient & companion transportation limited to 6tripslepisode & $250/personllrip foii:ound~tifp coath'iiitfat'¢., U clays/trip. o,thet(JXp(fn~es ' No copay 2 No copay No copay No copay No copay No copay No copay 50%2 50% 50% 50% 50% 50%3 No copay (deductible waived) lln1iip~ i<~'f ,frip/qf)1so:cR1 &. $25~for m.tm(Milp r.mm/i ~[rf ~1re, /Jmel l1m1fe.1 fo $·!Q'()ld:rr1:.fo1; 7 d;1ys, ulnar l':XJJem;es,//mifM to $25/day for ( days) ___________________ _..,. 1 The dollar copay applies only lo lhe visit ilsell. An additional No copay applies for any services performed in office (Le., X-ray, lab, surgery), after any applicable deductible, 2 Acupuncture services can be performed by a certified acupuncturist (C.A.), a doctor of medicine (M.D.}, a doctor ol osteopathy (D,0.), a podiatrist (D.P.M.), or a dentisl (D.D.S.). 3 For California facilities, a discount will be applied ii the facility has a conlracl with Anthem Blue Cross for fee-for-service business, For California f«ci!itles withoul a contraGt, covered expense for non-emergency hospital services and supplies is reduced by 25%. resulling in higher costs for members, Covered Services Bariatric Surgery (subject to ulili2atio11 revi1Jw; 111odic:a/ly necessary surgery for weiq//I loss. only for morbid o/Jesity, coverf;!(/ only when perfo1mod at a Center of Expe,tise {COE)) • Inpatient services provided in connection with medically necessary surgery for weight loss, only for morbid obesity No copay • Bariatric travel expense when member's home No copay (ciociuctibio waived) is 50 miles or more from the nearest bariatric COE (member's trat1sporta/io11 lo & from COE limited lo $130/personlltip for 3 trips (pre-surgical visit, initial surgery & one follow-up visit]; one companion's transportation lo & from COE limited to $130/perso11/trip for 2 trips [initial surge1y & one follow-up visit]; hotel for member & one companion limited to one room double occupancy & $100/day for 2 days/trip, or as medically necessary, forpre-surgicol & follow-up visit; hotel for one companion limiled lo one mom double occupancy & $1 OD/day for duration of member's initial ;1;i1fger£ stay for lf dciyt: othat reasonable expenses lftnil<:1d lo lW!_day/prJrson fer ,1_ day&lfrip) Diabetes Educatio!l Programs (reqq1ieri pliysiciansupervision) • Teach members & their families about the disease process, the daily management of diabetic therapy & self-111an~gement training . Prosthetic 0ivitg1, · $20/vislt (deductible waived) • Coverage for breast prostheses: prosthetic devices to No copay restore a method of speaking; s0tijfo~li iniplants; artificial limbs or eyes: the first pair of contact lenses or·ey~g!,1 __ when required as a r, eye-s_ufgJ:J_iii & 1 ·--. • shoes & inserts for.me ,wm1 di~h~u~·s Durable Medical Equipment • Rental or purchase of DME including heari119 aids, No copay dialysis equipment & supplies (lleariHg 11ids benefil 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 MedicalServices & Supplies • Ground or air ambulance transportation, services & disposable supplies • Blood transfusions, blo_od processing & the cost of unreplaced blood & blopd products • Autologous blood (self-donated blood collection, testing, processing & storage for planned surgery) 1 These providers are not represented in the Anthem Blue Cross PPO netwoik. No copay 1 No copay-1 No copay 1 50% 50% 50% Emergency Care • Emergency room services & supplies ($100 deductible waived if admitted) • Inpatient hospital services • Physician services Mental or Nervous Disorders and Substance Abuse Inpatient Care • Facility-based care (subject to ut,1ization review; waived for emergency admissions) • Inpatient physidan visits Outpatient Care • Facility-based care (stibjectto utilization review; waived.for emergency tid.missions) • • :Ou!palli~ntphysJciarrv.lsits (B,ef:/a.viora/Fl~a_lth Treatment for Autism & Pervasive Disorder will be ,sql)J9ct to pre~s~rviC§I review)' Pt'O: Per Member Cooay No copay No copay No copay 100% 100% 100% $20/visit2 (deductible waived) Non-15"Ptr: Per . Member Copay No copay No copay No copay 50%1 50% 50%1 50% 1 For Callfornla facilities, a discount applies If the laclllty has a contract with Anthem Blue Cross for lee-for-service business. For Calilornia lacllities without a contract, covered expense for non-emergency hospital services and supplies Is reduced by 25%, resulting In higher out-of-pocket costs for members. This Summary of Benefits Is a brief review of benefits. Once enrolled, members will receive a Combined Evidence of Coverage and Disclosure Form, which explains the exclusions and limitations, as well as the full range of covered services of the plan, in detail. Premier Plan Exclusions and Limitations Nol Medically Nec.es:sarJ, Se:r-1ir.n:. or ~;oµpi1P~~ lf!,-i:l :;m no! flllliiH::Jllf 1:eo!:i:;¥y, 11-; ,i,:;[Jn,~d bperimen{al or ln•icsiigatlv~~ Any i~Xptv,mcmla! c,; ,;1•✓t?S!i~1-(.1\i•1t1 p:,JGt)dtJ1e 01 rrmd:c.3tlori Btil, if mernhr:r is !te1;1ed benefit-.; l=tcaw,e 1l i~, deler1n;!1ed 1n.11 !~1~ ri::qu':'slt"d l1r.-r1tn-,t:l'l\ is r:xpf;rim('nlal or inv(:st\gal!ve, lhc rrc"!nbr~: m~y f!;QUC>! .ln ii1d~~~)ndunt rnudicai 1evie.,.\1• .:r; dcscri!.).(!d tn !ho E:·1k!ence: ,:,! Coverage (COC} Outside th~ Uni1 ed s,ates. Ser\li~es or s~1ppii&s f1;fnished amJ t:iiled by ;l proviGDr outs\fo 1fu:1 Unlled Sialer,, unless .such servtcr:!> rn ~uµplie::. ~He fnH1i.si1;.:)d in r.(l.!anec.:!ion with 11rget1\ r.::~ru er an C:;1r1cr9enc:,i~ Crime or Nuclear Energ,i. Conrtitiom~ \ha\ resuil from {11 tho inem~m 1s comn1issicr1 (•f oi tJUcmp! !o r:ommi! a felon~•, as kmg a-s any injuries :-,re ncl a rnsul\ cf a mtitl1i:::;tl co,1:Ji!ir;n r;r an J:L~t of dOH'!CSlic viotem.:e; or (2) criy r<:!ease or nuclearet1r!lgy, whel!H::r N nol ih~ m~ui! ol W<!r, 1.vl1~~n govctnment fund!.; are cw2ila:blc for ihc t,oatrncnl of illne:Js or irju;y a1isi119 Item t!1e role;JsC of r.uc!ear ene:gy. Not Ctwernd. Services received before !hf.i mrymbB1's eficctive daie. SeNi.;ci~ recciv€d after !he member'$ cov~rago C;m1s, OXCtWt ~:, spei;ifit1d as e;overEJd in ltie t:OC Excess Amounts. Any jmourl5 ia \:r.cesc of covered expet1~c or l!ie lircUme lni.i:tin:orit · Work-Related. Work~reliile-d comiilK'lns ir benefits arc recovered or car, be recovered~ oilher by adjudication, srJUlomon! or olheN.is-e, und~r any wo1i-:0rs' compensation. emptoycr's ~c"sbi1ity Jaw or t~cupaltonal dise.aso law, Wh(:!ncr (Jl'flOl the membr~r claims those be11eHs_ it there is a dis1mi,;: • of sullslanliol ,1ncorl;;ioly as lo whether benefits may be recovered for lhose. wnd:l.r,ns pursuant !O workers' compei1salion, we will provide the benefit;; of lhis pltin for such com:tilions, subject lo a righl or recovery and rein\bursemenl under California Labnr Codr~ SecHon 48fB, tB :;pecified as covered in the EOC, Government Treatment. Any rnr/ces lhe rnernber actuaily received ltiat were provided by a luc31, stale or federal ~ovemmenl agency, except when payment uodc1 this plan b oxprnssiy required by fMera! or slate law. We wi\l not co~er paymenl 1or theso se1\>ices if tile :nemhor is not required to pay for lhern or lhey are given lo !he insured pernon for bee.., Servlecs of Relatives. Professional se,vit.1>.s receivf:<l from a person living in the member's home or who is reiaied lo lhe memb-er hy blood er maffiage, exce-pt a~ spccif1ei1 :~s covonyJ in lhe EOC Voluntary Paymenl. Services for which lt1e member has no legal ob!ig31ion lo µ;iy, or lo, whic!i no t.harge would be. made in the abser.c~ of insuraot.i: cov~!aga orolher ht':~llh p:ot1 coverny~, exoepl services recei'lteii at a nC>n-govi:,rnmcntal charilablo rnsoarch tiot,pi!aL Sllch a h~,pital rnusl rnoel !he following guidelines: 1 il must ba inlemalionally ~ncwn as being de·,oted mainly lo medical resea1d1; 2, ~I leas! 10% of i!.s yearly budget rnusl bo spent on rnsoarch no\ dirf!Ciiy related lo patient care; 3, al !east one-lhird of i!s gross income must come from donations or grnn(s 0th.er lh,in gifts or paymen(s far patient care; 4, It must accep! pali&nL~ who are unable lo pay; and !i, two-lhirds-01 its paiil',nls mus1 have condlf:ons a1roctly related to the hosp,\al's research, Not Specifically listed, Services not ~pecif1eally listec in tho plan as covert'<i services. Private CQntracls. Services()( supplfes provided pursuant !o a p1ivale conlrad bd,•1ee11 lho mP.mber r.nd tl prnvider, fnrwhich reimb11rssrnen\ umir:r Medir:rm-, prng,am is prohibiled, as spccilie<l h Scclion 1802 [42 U.S.C. 1395a) ofiillo XVII! of ihe Social Security Act Inpatient Diagnostic Tests, inpalien\ room and bo~rd charges in ,;0~11eclion wilh l1 hospital slay prima,ily lcrdiagnos\ic l9sls which could have been performed s;iiely en an o,1tpati&nt basis. Mental or flervous Disorders. Acodemic or educational testing, counse,ing, and remedialh~n, Mental or ne,vous disorders arid alcohol or drug dependenr,a, lnc!uding rehabilitaUve cam in rela1lon lo lhese r,onditinns, except as ·,pt,cif;erJ as CO'lered in !Im EOC, Ortl1adonlla, Gr,ice,, o:!ie1 orthodonlic appliances or orll1odo1\lic services. Dental Services or Supplies, Dental plates, brid~r,s, crowns, cap, or olh,)r ctenlvl pmstheocs, dentl31 irnp!ants, denial s1Jrvir.e~.' extraction cf leelh, lre.tlmnnl to tho ter1th or gvins, ur llealmp.ni to or fa; any diaorders lorlhe lemporomandtular Gaw) join!. except as spccifed a~ ccve:ed in the EOC, Cosmetic denial surgery or olhor d,inta: ser,ices for bem1uficalion. Hearing Aidli or Tests. Ht1aring aids and routine hearing ies!$, er:ct~pt as sp~cificd tl'.l covered in lhe EOG. Optometric Services or Supplles. Optometric service:--., eye t~xr:rc;se~ including 01th8pti•:.s- Rou\ine eye t'Jirnrns and rnuline eyo (eirnclions 1 eyegia~ses 0, t:Dnl$Cl !en~.es, excBpl ar; t,p€dfled as: C•vere,j in :no EOC~ Outpatient Occupalional Therapy, Ou\palic.n! accup;;uonal therapy, ~xcepl tl 1 ,, home h;,~!,h ag~rcy, hcspice, or idusi1Jn Hierapy provider, e.>:r.epl as spr,~ifiP.d as c0vofc;,i in !Mc COG. Outpatient Speech Therapy. Oulp3!ienl speech lhernpy, e....:cept 3S ~,>r:,._;ifi!~d ;y, u,v(1n~ in lh~ EOC- Cosoietic Surgery. Cosmelir; sJrgery ur 0H1t1( scivil:Cs porlomit~ri sole!y for tv~;;u1'tk13tion or kl aHcr or re$l1;ipp, normal (ird11ding agud) slrucluri,s or lissue5 ol 1/Je body lo imprc·,e appea,ar,ce. This exclusion does ncl apply to 1cconslrucliYo sur9cry (liial is, sugery r,erformed lo correct d0formilios caused b>· co~g€nital or dei:e1opm,;rnl~I abnormalilies, iHnr:35, or injury for the purp0s1:; or irnpmt:ing bodJy funclion r,r symplornalology or lo creat::: a rH;m;,31 appf.:H.)rane<)}, !nclurJing :;urgo;-y perfowt!:d :o ret,fl:re syrnrnel.ry 1t,!l()!l.1ing mastu;;iomyt Ct)$rct:Hc ,,:;1J1gety d0es not be~o1n~ recons.1n1crive f:urguty becau.% L•t psycbd.:.,gil'al or psychiahic rea~1,;ns Commercial Weight loss Programs. Wf:itjht irJst pro~r~rns. ;,,,he!h~: ,Jr !iO{ 111..;y .?ri purw>r,J undGr medi:-.:cl oi physician ~.:,1pt1vb,'.1..;n, ;.ml.:.:s~ ~per.!iicJl!; iislF,ti a:-c:ovsrdi Hi !h'.s fj[un~ 1 his ux::lu::,ioi~ 1r:dude.s, t,~tl is nt1: knitr:..i lo C1}H1{)'.i.m.•i:-1l ,•ir~zjH k1S1i fl!DJ~41'i'r2 (W,~if;t1I Vi,~t•)V:ts, Jenny Cr,1!g, LA V,fotght Lriss) .ind fd5lin9 plL\.l!Zl!ff~ :'his r;1.c!1hi<:-r; r!ve£ ntti ;Jppiy to met.Jica!iy tJt:J~t:ssary t11:a\rr,;~fll~ ftY r:•t:r~,id i;t~:,:iry r;r (Ji'!;~rj· t~v~.lu:JUons £!nd cour;~eling, Gt:r: r)?h:w:orai mod:flct-;1!ir;in ptr;grt~rr", l;.1~ Ui;;.1 tro;3[ni;r1\ of ~ir101ox:,1 r:f:fV:.1~~ er ~JLJ.rnla ner-.:r,:;;.1, (•;1119;c~) lrr.::rmertl for :nt~rh;J ot:;sil;' i;:: ~:..:<:-:;re:J iJ'.: (F:~,,~1ii';s-,:: ;n U:~ f~vidr;r,:('. oi C"---:.1,~ru1~ {[G,1,:;1 i~;,1~i~:,;ill~~~~~~::i.~:~i~~:j:it;~~~'.1::'.t\:~;\~:;G~~:i:'.:r:~,}~;;~~,!i:.'~:~:i;;;'.~,~::0~::~!:i.xi;~i~;:ii, Sllrrouate Mother Se,vicns, t=w any se1v1::es c-r $l,ppli&s. prn·.:iCed to a pnr~r;n not t:O\ir.!r~;d ondi:, the plun in r.nr.~P.cifon with a :;urrogalv µreg1tanty (!ncludiny, but rlol fanl\e(i lo, tftc bo1.!rint1 d., CJ~ild Oy unolt,of w<Hnu.n !or a1, m1urwe c0uplc) Orthopedic shoes ~1\d shoe inserls. fhi:; ~~;(du:Acn dncs not apply \1) l>ilhopt;rJic f1y_-itwC;;1 i;!,td a:. an inlegr;;I p;1i l of a brae •, s,ht)r.: lnwrl.s th3i :31t~ Cll.o;;Jom melded to lht~ paH:11t or thc-rapt~uti,: ~;hoes a1id in'.>ert~ de!~ign(;'t1 !f; lte3l fiY-ll v.;inp:!Jc[jtlr;ns duF..: lo diab,jl~5, as sp•:ci!ictfl!y st.3lcd in the EOG Air Conditioners.. ;\\i pu;if:ers, ;:;1r condiliom;rs c,r humidirier!;, Custodial Care or Rest Cures. lnpafenl ream Gi-d board charges in co:m~dion with;; ho!:pit,1} ~:idy pii,nr-::1i!y f<J1 t::llViH)f1111enl<1l thuhJCJ ~r i;hy:.'..lG<il lltcrnpy~ :3!~fvfw:s r!r<.ivided by <J rnsl hon1--.:, \1 ho:ne fer !he aged,~ 1,u1sin9 horne er ariy sirnilQr ,fa6tity, Services providt.'<l tfy n skilled nur!">hg fadl!ly or GU!:tudia! cam oi rest cures. oxcept as :Jp8ciiled ar, covered 1n lhe EOC. H~allh Cl~b Membnrshtps. Health clut> m,;mhe.rsr.ip,. exercise equipmenl, charges fmrn a ohysica/ fiiness ins\1 uGlm or person;i! lralner, or ariy other charges for activllies. equ!pmeni 01 f~r::!f!Ee.5 userl for rl0vP.k:f)int1 or mt1inlAining phytk:al lilnt1!;!';, ,w~n if orr!?.mrl by rt physici;in. rnis r,xt,iusion also appllos lo he.~llh !ipas. Personal lte111s, Any su.,plics ior corniort, hygiene or beaulilicatio11 Education or Counseling, Ecvcationai ser,ices or nutritional co1111s~!ing. oxcepl as specili!'.d a5 co·:cred in tho EOC Thls exclu!jion does nol aµpty lo counseling lor !he treat,ne!lt of arHXP.Xiil rJi:~rvosa or buliniia i1t)tvosa Food or Dietary Supplements, Nutriliona! amJ/ordiel~r, ~upplemc~ls. oxcepl as provided in !hi, plan or as r0quirerJ by law, 1 hb oxclusicn includes, but is not limited to, ihose nulrilicnal formula, rmd diel~1y supp!eme1;ls th~l can be purchased over lhe counter, which by law do nol. U?Piuirr,menl eit~er a wri:ten prescrip!ion or dispensing by a iicensed pharm~ci~l Tnlephone and facsimile Machine Consultations. Consul!alions provided by lelepilone or facsimi!e machine~, Routine Exams or Test$, Houline physical e,ams or tests wi1ich do ool directly treat an actual illness, injur/ orcondihon, Including those 1equ1red by ornploy1mml or governrnenl t1milorlty, ~xcep! as spGcifled as cove1ed in lhe EOC, Acupuncture, 1\cue'!lncluro tm3tmenl, as specified as cove1ed in the EOC Acupressure or massa;;e 10 conlrol pain, keal i11ness or promoie heallh by applying pressurn to one or m_orc, specilic areas of llrn body based or. ctrn malornes or acupuncture points, Eye Surgery for Refractive Defects. Any eye surgwy solely or primarily for l~e purpose of cwecling refractive defects of lhe eye ~uch as nearsightedness (myopia) and/or asligmalism. Contacl ltinses and eyeglasses required as a result of this surgery, P!lyslca! Therapy or Physf~;;Hfo1!lelne. $iiivii;iis of aJ!lysit~ f;n:physical lhn,·a.w"cr.,,1111,1!!:::1! !iiedl~ine, e,capl when p1cvlJ;!ll!f.o,i~n,;, a cr,-,)\J(i,Hnpatiur;I co,1fir;,'11rJ?nl 01 as ;n the EOC. Outpatient Pre~cripllon Drugs and Mcdlcallons, Ou!palienl prescription dregs or medicaUons and insulin, ~icept as spoci!ied as covered in lhe EOC. Any non-prescripficn, cvor-lhe-counler patenl or propri<1tarf d1ug rn medicine, C-Osmelir.s, heaiL~ or ooauly aids. Specialty Pharmacy Drugs. Sreciaity pnarmaa:y drugs !hal mus! be oblairw<i from Lliu specially phi,nn;i.:;y program, but, which ;;re obtained lrom a 11,lai!-p!illtti\!,t;i', o<e no( toVlil!lil ht lhis pt/lh. . Mai1_\lier will have to pay (he full co~t of the specially,plia•m~ev. drugs obh!ln:Cri from H\;la1I pharmacy that should h:ive been obtained from the specially pharmacy program. Contraceptlve Devices. Co11tra,;eplive devlces prescriblld for birth coij{JOI except as spucifi•x1 ~s <..-ovef(~d i11 the t:OC. Diabetic Supplies. Pros0rip,,1)!1 and ncc-oreoscripiicn dlabet'c supp!ies except w; r.pecinr,d ~is covered in lhu E OC. Pri~atc Duty Nllrslng, lnpa!ient O' outpalienl services al a pliva:e duty ruirsc,, Lifo${ylc P,ogr~n1s. Progrc.ifh$ lo ~io;; enc:/;; Hiesty!t: wt-,h:J, mliy include lfot .1n; n~,t :iff1l:1;.J tti i:li.:-L ex;orc1so, lm<>9c:y or nutriiiO!l Thi~ exc!usion wii\ nol apply to cardiac rehahilil3!ion pronrams apµro1erl by 1Js~ · Wigs. Third Party Liability-" 11nl1iern Bluo Grc,ss is enlille-i to reimhu1semenl of b,1r,oiilr; p:;id ii lil9 rn<~mbe1 recovers a:::mdgcs from a legally li;Jt,le third part1~ Coordination Of Bcncfits--Tlle ue.nefi\s of lhi, r,ia1, 1n~y 1,u 1?d1,,Pd if lho rnernt.rH lrns any,o!he,- g,oup health or dental cover~R: so Iha! lhe s~~rvir;cs rc-r.nived from all gmup covorii~Jes do rv;l exceed l 00% of [1K, <;ovcrcd t.:XfX~n.<;r,~, Anthem Blue Cross is f/,e lrade tr~me of Blue Cross of California. /nde11eJ1den/ L/conseo of tho 8/ue Cross Assccia/ion. r,> ANTHEM Is a registered irademark of Anthom lnsuw,ce Companies, Inc. The Blue Cross namo ,nd symbol 8r'e registered mar,s ol 1/Je Blue Crass Assucla!ion, SJVIA County of Fresno < . PPO 1000 Custom Classic PPO ~ (1000/45/80/50) ~ BluaCross Anthem believes this plan is a "grandfathered health plan" under the Patient Protection and Affordable Care Act (the Affordable Care Act). As permiUed 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 grand(athered he~tth plan means that this plan may no! include certain consumer protections of the Affordable Care Act that apply to other plans, for examplo)he reqtllrement for the provision of preventive heallh se-f\lices wilhout 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. OutJstions regarding which-prolecllons of the Affordable C?re.Act'apply atitl which prolec])ons do not apply to a grandfathered health plan and what m!gt~ Ci}U$(M3iplan to ch~i1g~ffQITT'9H:lndfa\hered health pli;)JTS!atuscan.b.~oirected tOs'AniMrn.a\ the telephone number printed on !he back of your merrtbeddenlilicaliohJ:a(d, or contact.your group benefits,adrtiii:iislrcalorif'Jou do not have an identification card .. For ERISA plans, you may also con tad the· Employee B~nefits Security Adrriinlstralion, U.S. Department of labor.i!J-"86,6;-444-<3272:or .11;ww.dol.gov/eosalhealthrerorrn. This Web site has a tal:lle.sµmmari~lng which protections do and do notapplY to grandfathered lwallhplans, fijfJ:lon!edertil govemrnen_tal plans, you may also coniai::t theJJ.$,{fopartmenfolHeatth and Huma.rJ • ··· · · ,lh addition lo!J.o\la,rart!]pQrljlentagecppays: rnem . . , .. ··· .. .. .. . . . c les;as ribed.below •. Pfi:las.esevJeWlhededlicUblednfonnafipn lcfknow: if a;de<luct,lble applil:lS lo-aspedlic cdvered ser.ilre, :ceilain E:'overM Services have maximum visit and/or day limits per year. The number of visits antilordays all<J11ie0for !li~e se1\il¢~~ WUIJ:i~Jin accurriula!ing 1;1n the first visit and/or day, regardless of whether your deductible has been r)'let MenJbers?realsq.r!l'!lPQl!§ible for.alf cosls overih~.plan mailmums. Plan maximums andotlierlmporlahl informat!(l{l appeanln ila!l.cs. Bory!!Ji!s a(e subject to all terms, conditions, limitations, and exclusions of the Pplii::t, . •. Expl~nation of M·axlmum Allow!fdAn1ount tv1ax1mu111;AllowectAmoµnt'ji,,the.JrilaLrelrnl:lurserm;nt p£!yable.unilef:the.pttlnfor coverect·setvtces received from Patticipalin~ and Non;Parllcipatlng Pro1ti~ers. ll is.lhe..pi:!ymenttmvards· ihi'i'iservi&es·.bllled·by a prov1Qetcon:i.l:line,o w\lh.~rW•applical:!1¢de#uoll~I~, C;Op13yrrient· qr1cplhsu,ram;e; Parlicipallog; PtiMdefs, me .rl:lfe IO:t!:P:rqvii:ler ha$ a,g(e.~d=t2:accepl a:. reimbyrsem(;lnl for covered.tervices. Members are, not resrionsibkl:for lhe 9llfert5,n.ce b~lwe.C!nJ.~e provider's t1sual char~es & the maximum allowed amount. . . . . . . . .. Non.Parlftipallrig .Providers &:OtherHcam1:ei'lte Prov\ders-(jnc!,uae!!Jlig~e·i:i9Lrf!Rf\'l.S1;n\edin the PPO prpvii:lt!r QO!;h'ork):Re)mbursamenl!liuounl hlli1ised ojl:}:i~·/(i'ith~rn;al!,le ¢10,~.f~le: or f~s9hedulQ,.a.rate.11egOUated viith (heprovider,.inforrri"afion from aUiiro:party venllor, or.billed cKarg~~. F.or Ivledlcal Er:ne~gencycareienoered bya NonaParticipniiotrPcoYider, . gHQ~plt<1l, reirnb.tiraement·~ay b9b<1;;~ on.the . reasonable i:ind;cil$!ofoili:~ value: Metnbers .may bl:l re~ponsiblefor,anyamo s. of the reasbnab!eaiid.custorriar,y valt.le· . . . ·'wh~tl using· Non-PP() and Other Health Care Providers, members are responsible forany d!'ffer~nce:between the covered· expense , & actu_al ch.arges;,as welt as ariy~dedt1ctil>le & perc~.ll1t;,ige: .. ~,jeny., . Galendaryeaf deductible for all providers · Deductible for non-Anthem Blue Cross PPO hospital or resideritial treatment center o·edt.ictible for non-Anthem Blue Cross PPO hospital or residential treatment center if utl.Uzation review not()b,,d'.ned None $250/admission (waived for emergency admission) $100/IJisit:(waive<lif admitted d/re(;t/2. {/Qtr1[2i~) .. Ani'iii~tb~f•.<>f•~9pl<ef.Maxtti1um.s ·(no·c111!3sappllbatltm} pP~Pr~yii:!~rs§~lherH~a\fu.~~re:1?roVcldJ:1t'.S $4,0QOhnMitiert11emr; $.8 · /ye'tlr Non.f?JllQ :P.rQv~dercs . . . . $ 'H).Q00/rn~mberlyf.!or;. . ·.· . . . i!y/y~ar The:fol!owili~do hol'~pp1y to o.ti.hof:p<:ii:.~~I m.a:<,imtlfi'.l~: non:c~vetJ}P:expense. After a m~mberreaclu::s:lbt'H:Jut,6J0pqcketmaximum, the m.~mbJ1rr~l(J.i\ii(lsr~p_el\qiolelor n~n~PP{'.lprovider~:&o!lttir'hi:ialth care providers, costs in excess oflhe·cpver:ed'tix1,e1)~e. Lifetime Maximum Unlimited Covered Services PPO, Per Member Copay Hospital Medl.ca!Servici'ls (st1bjectto utilization review far inpatient s(fiViees; waived! qr emergencypclrriissfo111;;j • Semi-priva!eroom, meals.·& ~peciaJ diets., .&a!Jcillary:services .. • Outpal[~ntrneqJcah::are, SllJgipal ser:vlces &.supplie~ (l1ospitf1/ca.re ol/1erthanemergency ro(ml care} $1,000/year 2 + 20% 20% Ambl;!,l~tory S,urg,cal c~n,ters • ©tltpaUr.,nt surgery, services & supplies ·skilled Nursing Facility (subjec( to ufitizalion review) • Semi-private room, services & supplies (limited to 100 days/calendar year) J,lospic~ ,~a.rt (sub}~pf t.<). ail1i~c1Urm review} • lrfpal1ent or•.outpalienl services: for mom.hers With .up lo ont~.y.b.ar Uf,f ex(Jectatic;y: lan1Jly Se.reavtlm{;:)11l eyer.vices. $250/surgery + 20% 20% No copay -c-----------··--· .. ·····-•----· Non-PPO: Per Member Copay1 50% (benefit limited to $600/day) 50% (benefit limited to $600/day) 50% (benefit limited to $350/visit) 20% ~The ptrcenlagr:: copay for nun.unr;:g(,r.CJ ~;c:vic.c~ irnrn n0n-1\nttrnm Blue Cross. PPG proi!idur:i is tnseti 0;1 tho s~h1~dti!Bc.! arncunt 2 Apo!icable to the Annual Oul,o/.rockcl 111>.ximurns anlhem.comlca Anthem Blue Cross (P•NP) Effective 12/18/17 Printeo 113/2018 Oovered Services, PPO: Per Non-PPQ: Per Meniber Copay Me111ber Copay 1 -------~---Horne Health Care (subject lo ulilizarion revitiW) ;;, Services & supplies from a home liealth agericy (hiniled lo 100 prior authorized visi(slc:a/endar year, one vi.,i/ hy a /Jome health aide equals four hours or less; nor covomd _. while member receives hospice care) Home Infusion Therapy (subject to utilization review) • Includes medication, anciUar.y seNices & supplies;) caregiver training & visits by provl~!('!f!O m011Jtor therapy: durable medical eqt1lpn1Eint lab set:)JiC(!S Physician Medical Services • Office & home visits • Hospital & skilled nursing facility visits • Surgeon & surgical assistant; anesthesiologist or anesthetist • Drugs administered by a medical provider (ce,tain drugs are subject to lllilization review) Diagnostic X-ray & Lab • MRI, CT scan, PET scan & nuclear cardiac scan (subject to utilization review) 20% 20% $45/visit 2 (deductible waived) 20% 20¾ 20% 20% ,•. . 0th.er gic1gn_Q~tic x-ray & lab No copay ~~-'--'-------.....:.,c.=;;"-----'-------~--,-...'-_,.... ______ ,,_ ?-,.,~·~,,.·1.,:.-:"-" · Preventive Care Services Preventive Care Services including*, physical exams, preventive screenings (including screenings for cancer, HPV, diabetes, cholesterol, blood pressure, hearing and vision immunizations, health education, Intervention services, HIV testing}, and additional preventive care for women provided for in the guidelines supported by the Health Resources and Services Administration. *This list is not exhaustive. This benefit includes all Preventive Care Serviceue.quired by federal and state law, PhysicalTfior:apyif.lnysical Madicfn·e & occupation al TIJe.r.aPY: . . . eti iropractlc Services (up. (o;12visils/6alendat.Ye;;,r, addilien'al . l{isi1s;r,ptit/:l:e.approved;,if1ne,dfcaQyne.1ui.$sary) Speech Therapy • Outpatient speech therapy following injury or organic disease Acupuncture • Services for the treatment of disease, illness or injury (limited to 20 visits/calendar year) T emporomandibular Joint Disorders • Splint therapy & surgiqal treatment Pregnancy & Maternity Care • Physician office visits • Prescription drug for elective abortion (mifeprislone) Normal delivery, cesarean section, complications of pregnancy & abortion • Inpatient physician services • Hospital & ancillary services . No c;oµay (deductible waived) . $25/vislf · ( de[l,m/i6l11, WiliVed). ·swvisit Mfl.d.L/Q([1:i.Je·waived) $45/visit (dedu<;tible waived) 20%3 20% $45/visil2 (deductible waived) 20% 20% $1,000/year4 + 20% • Female Sterilization(inc/uding tubal ligation and counseling/consultation) No copay • Male Sterilization 20% • Family planning counseling $45/visit (deductible waived) 20% with m1tt1ori1.ation 20% 50% 50% 50% 50% 50% 50% 5.0% 50% 50% 50%3 50% 50% Not covered 50% 50% (benefit /irm1ed to $600/day) Not covered Not Covered Not covered 1The percentage copay for non-emergency services from non-Anthem 8!:Je Cross PPO providers is basc,J on the scheduied amO\Jnl 2Thc dollar copay applies only to the visit ;1sel[, An addit,onal 20% copay applies for any services performed in office (i.e., X-ray, lah, surgery), after any app!,cab:e ded1Jctible. 3Acupuncture services can be performed by a cet1ified ;;cupuncturis: (CA), a dodo: of rnedicine (ivto.), a doctor of osteopathy (D.O.), a p1Jdiatrist (D.P.M.), or a dertist (D.D.S.), 4 /:.pp,icable to the Annual Out•ol-Pocket n'a:<imunis Covered Services Orga.n & 'r!§.~ucr'Tr:ar1spl~nts (subject to i1tiilwtion review; specified organ ti:affsplat,/s.:covered only ,when per(o,rmeii at a Genter' of Expertise [COE]) • Inpatient services proyided.in connection with non-investigative'organ or tissue transplants • trailsplanf travel expense for an authorized, ;s1te1;;iffi'l~flransptanta1 ~ (i;fj~ (r9~i!Jie,tl~·cp1i1pni1~nlraiispqf!atfon:11mitertla.6,tr/t>sloptsoJJi:t ·. &::$25()/persorr!lri{lf orr.metrd,JiiYµ,.scopGJr qfrf,ir~ .limH~a t.0 .. 1 ,:o.om df;Libfe ocr; . .. &· $10O/day for 2J da : other expens~sJimftedto ,$ . .. . . . ·· · · aonpr :tr,a11sp/1tJ<?tlqi,1rfi1nlted,lo1 trf .. .. . ..... rroumMrip cJ1figb t:J[rft:Jte, hoteJ:rifnited:ta · /day for:raayi:,~ •other e)(pens_?s limited to $25/day for 7 days) . · Bariatric:·S4rge!y,(::;µbj?c(!<J.llfilizaticm_ r,ev,iew; 1r,e,aio/alfy t1e<,e$S9cy::surgh,Y'fdr;:Weig/if.Jbss,• only,for rirorbld Qbl§sity, covorfrif:anly when f}.()r:forrn,e(j ar1:1;(}Ji(l(OI' of Expertise . [COE]) • • · Jservic~~mrg.ltitl~d in connection with rneai~~lly ary surger;y'rohi.reight loss, only for morbid obesity Bariatric travel eipeqse when membet's home is 50. miles or rnote:Jrom the ne,arest El,,ui~tric COE (mempe,rs,tran~porlaJioptq,&.ftom 0oefln1iled to:$1';30lpifrsonlttip.fof3,ttips.]ptl'fsurgipalv_islt, ... itiil/alsqrg~ry, & one follow-up v[$it);.;ooe poinpqniqn's trohi{p6rlation :10 & from 'C,0E:fimited toi$13(l/ptirsoN/tfp (CiatriT1s.linifi<1l:s.umep,r ~,one loll(}W·t!P visif); potelf o,r, nif>!JIP?t ,& one·coriipahitirrli1hiled:to. one toon1 cf ·, · · ccupahcy &'$ r OD/dayfot?·rl.ilJ~(tffl,(gr a~ n . . .f!f;C8S~l'!W, . /,'&''{6/l6wi.t'Jp Visit;. hotel.fotlinec;~fopli ·· . on~ .. rao,11 dr;,tJbfe pCt;Up€Jn9Y.~ ;lQDtf.j?,y{orduratit:Jp.XJf me111ber:'sinitfal siligery·stayfar4 days; other reasomiblo expemms Jimiledfci:$2!5/cf,fJy/pers6f!.fqr4W~slltif}); Diabetes Education Programs (requires physician supervision) PPC>: Per Member Copay Non-PPO: Per Member Copay 1 $1,000/year3 + 20% No copay (deductible waived) $1,000/year3 + 20% No copay (deductible waived) • Teach members & their families about the disease process, the dailY. management of diabetic therapy & self-manage01ent training. $45/visit (deductible waived) 50% Prostlietic Davie.Eis • Col.ief:age for br:east:prosUiesos;;prosu1etkH.ievic:es lo . 50% 1:estor,ra metQo_a.~t'~peaJdng; surgi~at i11;1plants: artlCT.cial .111,nps ·gr ey,es; the flrstpa1r. of contaet loose£Miir, ayegl~ss-es. V1!1eh reqaifed'asti· re.suit' ef 1}9,~ S.Urfler:y; &dherapet!!lc shoes & inserts Durable Medical Equipment • :°R!:ln,tal or purGhai;e ofDME includi1J9 50% dialysls equ1pmehl'&.st1pplles, fiorhe medlcal ~qqiproent, pto~th~Jf(l[Qtlb9tlcs ·0!.11r1ri1,1p't1lqs ~enent, ·. . . •· . . . :avwllI.b(rtfQr. iWe. l!r:flm1gi<11(f per e(!r evet;1·/hrer1 yearn; breast-pump. · atld,suppli6.s cir~ r.ovf,ftetl. tJndl;i,f.J!(r.'Nrsm(iv;d t;t~re a:t 1,l'O,C/l~tgff(Otiff'IJ,e/work) Related Outpatient Medical Services & Supplies • Ground or air ambulance transportation, services & disposable supplies • Blood transfusions, blood processing & the cost of unreplaced blood & blood products • Autologous blood (self-donated blood collection, testing, processing & storage for planned surgery) 20%2 20%2 20%2 50% 50% ·, The percentage copay for non-emergency services from non-Anthem Blue Cross PPO providers is based on the scheduled amount 2 These providers are 1101 represented in the Anthem Blue Cross PPO netwcr~, 3 Applicable to the Annual Out-of-Pocket maximums / ·covered Services Emergency Care • Emergency room services & supplies ($100 deductible waived if admitted) • Inpatient hospital services & supplies • Physician services PPO: Per . ".~Non-PPO: Per Member Copay ---·--·-Memb~r Copay 1 20% $1,000/year3 + 20% 20% 20% 20% 20% . ·-·--~-------'-------Mental or Nervous Disorders and Substance Abuse Inpatient Care • :Fcip1~ty,based care (sut,ject to utilization review; waiveitfor emergency ,idmissions) • Inpatient physician visits Outpatient Care • Facility-based care (subject to utilization review; waived for emergency admissions) • Outpal!ent,phy~ician visits ($ehavioral Health treatment for Autism & Pervasive Disorder $1,000/year3 + 20% 20% 20% (fJenefil limited to $600/day) 50% 50% (benefit limited·to $600/day) 50% Wiflibesubje:ct topre~iv-',I~_· ._re_v_ie~wJ..,,._ _____ -,,. _______ ...,,;...--~"-"------ 1 The p~rcenlage copay for non-emergency servi~es from non-Anthem Blue Cross PPO providers is based on the scheduled amount. 2 The dollar copay applies only to the visit itseW. An additional 20% copay applies for any services penom,ed In office (i.e., X-ray, lab, surgery), alter any applicable deductible. 3 Applicable to the Annual 0Ut-0f-Pocket maximums This Summary of Benefits Is a brief review of benefits. Once enrolled, members will receive a Combln~d Evidence of Co11srage and Disclosure Form, which explains the eitc:iusions and limitations, as well as the fuil range of covered services of the pi.m, in detail. Classic PPO Plan Exclusions and Limitations Not Medically Necessary. Services or supplies lhat are nol medically necessary, as dcfinert Expcriiiln"tal or l~vnsUgatlV<!, · dpl,jl1tllil1!;;l ti/· 111\'l!tiigativa,~1!1\Sll!Jittu .ui 1n!l!fl~11l1~n. Hui. II 1pi;l1h.0t. is dl11l!i.J lk,l . i~ 1M\otrl111itl'd lhal lh4 i1::.1mi;,!l!d.iru;,Jmlilll' 1£ n,!l{it,inimlal • · . m1ty/l'\1u1J,1 "" ·,n<fo!)llnrl<?hl rrt_c(l;c(i rnvi:I.·,. a,.,1u/i;~h!'td iri thl?E\lrJJ,,n,eu f,:ivt!lll!)!!:IF.()!)). Outside the United States. Seivices or supplies furnishell and billed by a provider oulside the Uniled Stales, unless such services or supplies are furnished in conneclion wilh urgent care or an omergency. c,Jtimo.r Nui:l~arEli~1uy,,C,on!li1i~Jl1DI ICblllll'll'l'l!ll•I to.c!lilim,1 ati:tOlll', .. , .. · · · iJO!ntliil.1cvilll~:.or{ilJ· a,ivoo\f\1li~r:,ooti~ li(I) .i•,,,1~oii:r1!'lr 111ij'1, efl 'nuclear enorgy, Not Covered, Seivices received before !ho member's elfecUve dale, Services received alter the membe(s coverage ends, except as specified as covered in lho EOC. · Excess Amounts. Any amounls in excess or covered expense or any Medical Benefil Maximum. Work-Related. Work-related conditions l(benenls are reeo11ered or can be i11ustmant 1. II mu~l ba in~mallonally known as being devoted mainly lo medical reseanch: 2. alleasl 10% oflls yearly budget must be spent on research nol dlreclly relaled to patient care: 3, al least one-third of ils gross Income must come from donalions or grants other than gins or payments for patienl care: 4, II must accept pall en ts who are unable lo pay: and . 5, two-thirds of Us palients must have condilions dlreclly related to the hospital's research_ Not Speclflcally Listed. Services not specifically listed in the plan as covered seivices, Prlvilli! Coi1lt'l!Ct~:~Sii/'liclliot-tlll .. th •. ·- lntintl,~ qt ipiimirlli . tlentaf ~r.lfolVOUil. DTturdm, /i&adilrirli! or oduua!!QM! li)s!lnv, co\i°il$!lilng; Miinliil or iiefiiobat1l101dc1s'!it ili)~11:;@0alYJso, !:icll1dlil!(.tllli.blk1a!lw. cQto 1n condilions, excepl as specified as covered in the EOC. Orthodontia. Braces, olher orthodonlic appliances or 01thodon~c services. Hearing Aids or Tests., Optometdc S0111lcD• orSupplies, Opl!lri1e\ric ser,iCfl$, oye exorci~s including orthoplics. Roulinoi;ro'ji~_tllid(huline eye relioolili11s, as if)(lCifl!ld as covorc<l in lhe EOC. Eyeg!r,,-sioi;;or::t<!oliicno~~s. except:~ s~\lied as COilorn<I in lhli E()C Ou\pi\lJilll! Otcupalional Tnurnpy, Ou!flll!iMI tx;r;uf)l!liw1nl ,o,,.,,,,.,v.._,,.,.,, by a home heallh li;J'iine:t,:li1.1sp)i;e, or home IIJltjsl{ln \11era/iy11rnvlde1, 11;.~r,-eeified as in lhe EOG. Outpatient Speech Therapy. Oulpalioni· ;pcech iherapy, excepl as specified as covered in lhe EOG. Commiircla!Wti!lhl Lo,s ['.toginri~. Weight loss prcfr,ms, wl1eU1orQtr-01 lh~Yllll! pursued under mrurn:all"r·pli,i\-J'ifian s\Jp;,lr,iliion. unless spccifica!ly ,isled as tGonred in !h,s,p!.:in. This exclusion includes: bul is r.ol lirnilcd lo, comrnorcial weigh! loss programs (VVoight VVaichcrs, Jenny Craig, LA Weigh! Loss) and fasting pro<Jrams, f~vl 1jence o[ Cn•,eragc· {EGC) Sterilization Reversal, S11m19i11eMother S~rvlces, FtJr'My·~•?lVri:~~ or s11{ip!les provided lo a person rillWWered under !h'J.pi\.ln ln®nmi,:\Joo v'lillr a sunllll __ · iil_11_1,re51ilrn,cy (u\i.;l~ding. bul nol limiled 10, l!i~:t,.,llling of a cl!1&i!Jy.anoil1er woman for an iiifo(li!~:.:llup!~). Air Conditioners. Air purifiers, air conditioners or humidifiers, Personal Items, Any supplies for comfort, hygiene or beaulincalion. Edu~ll,fin; or Counsellng\!llli!iiiil~I _JSJV!i;u;; or~~bli!o~f~•~m\:;oung, as. ~Jin Iha EOC. Ttils'e.r.dtislon dPe.,1I<,t aPtllY, l!l'!lll\lnS1Jli119(or the nervosa or'bulimia nervosa. ..• . • . ·' · .• Telephone and Facsimile Machine Consultations, ConsullaUons provided by lelephone or facsimile machine, Qr-Tc_Sl!i. herapy or Phyil!caf r.ic}lit!ri.c except when pro'iii!!llf dutfl)ljj in the EOC. r medi<:0~61\S r-lhe-w,mter l!Ji'.1£~· mo not i:tl'mtilll l!r U\tll iJllln,. [3qu1im 1vl!(b~~l! to p~ytlja(ull i:~sliot\ij~ ~if~l1~lly:jill!iri1i~cy driJgs .obm!nad (tom • ril!J1II·· pharmacy that should have been obtained from the specialty pharmac;y program. ConlracepUve Devices. Conllacepllve devices prescribed for birth control except as specified as covered in lhe EOC. Diabetic Supplies. Prescriplion and non-prescriplion diabeUc supplies except as specilicd as covered in the EOC, Prlvale Duty Nursing. lnpalienl or outpatient services of a private duly nurse, ·Lll!is~yle Programs.f,1~rams lo allar one's life$lylUJ~hich:.rni1y include bulw.;; 1ml.limited lo diel, O:C(•itii:a, imagery or.nlll.ri~!Jn. This exclusion will llill'oppl)'.!n·et1\diac rehabili!~tl'mt 1uograms approved by us. · Wigs. 1'111t.d !'arty Llablll\y ~-Anlhem Blue Cross is en lilied to reirnbursemenl of ilenefils paid ii lhe member recovers damages,from a legally liab!e lhird party. Goo;illnallon ofllcai:!lln-ilmfo11!.!fllS of DIis plan r.norh!,lroouced ii lhe ll\i.'11lber has any Olher gnl'u~!!enllh 01.di:Jnl~ ciwero;j<:IQ lh~t lhe seryices lt:C_1:!~Jmm a!I group~rages do not exceed 100% of lhe covered expense. A11the111B/11a Cr-0u Is th• lr;it:fo11amn.ol.Ill1ie.Cms;; ofi::iillfomill, IIJdJp~jii!cril IJ!ionw!Vi! ~i lh• !llila 'cro.s-A,$to~larior,,'~) ANT/'IEM Is uitgisht~il /tudon!f;1/1uf~t1rhciri /(15Uf_i)!We Cun1P,~1ilos,ft1~.Tl1ii B(tie C(oss 11anto anli:symbat aro ,ogislfirnil mmks f/.f !he Blue Cross Association. SJVIA County of Fresno A ir 1·t· 11l) 't::,,,·1r1·1 , .I.. ,,. . _¥.,..,,,._;Jl .. ' .. ; Modified Lumenos® Health Savings Account (HSA) LHSA266 (1500/2700/80/60) This summary of benefits has been updated to comply with federal and state requirements, including applicable provisions of the recently enacted federal health care reform laws. As we receive'additional guidance and clarification on the new health care reform laws from the U.S. Department of Health and Human Services, Department of Labor and Internal Revenue Service, we may be required to make additional changes to this summary of benefits, This proposed benefit summary is subject to the approval of the California Department of Insurance and the California Department of Managed Health Care. This Lumenos plan is an innovative type of coverage that allows an insured person to use a Health Savings Account to pay for routine medical care. The program also includes traditional health coverage, similar to a typical health plan that protects lhe insured person against large medical expenses. The insured person can spend the money in the HSA account the way lhe insured person wants on routine medical care, prescription drugs and other qualified medical expenses. There are no copays or deductibles lo satisfy first. Unused dollars can be saved from year to year lo 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 me!. The insured person is responsible for all costs over the plan maximums. Plan maximums and other important information appear in itali.cs: Benefi\s.ilre subject lo all terms, conditions, limitations, and exclusions of the Pelicy: Explanatfon of Maximum Allowed Amount - Maximum Allowed Amount is the total reimbursement payable under the plan for covered services received from Participating and Non- Participating Providers. It is the payment towards the services billed by a provider combined with any applicable deductible, copayment or coinsurance. Participating Providers-The rate the provider has agreed to accept as reimbursement for covered services. Members are not responsible for the difference between the provider's usual charges & the maximum allowed amount. Non-Participating Providers & Other Health Care Providers-(includes those not represented rn the PPO provider network)-Reimbursement amount is based on: an Anthem Blue Cross rate or fee schedule, a rate negotiated with the provider, information from a third party vendor, or billed charges. For Medical Emergency care rendered by a Non-Participating Provider or Non-Contracting Hospital, reimbursement may be based on the rea~onable and customary value. Members may be responsible for any amount in excess of the reasonable and customary" value. Participating Pharmacies & Mail Service Program-members are not responsible for any amount in excess of the prescription drug maximum allowed amount. Non-Participating Pharmacies-members are responsible for any expense not covered under this plan & any amount in excess of the prescription drug maximum allowed amount. When using non-participating providers, the insured person is responsible for any difference between the covered expense & actual charges, as well as any deductible & perceniag.e copay. When using th~ o~tj>alient prescription drug benefits, the insured person is always responsible for drug-expenses which are ~ot covered under this plan, as well as any deductible, percetitage or dollar copay. ------------· ····---· Calendar year deductible (applicable lo medical care & prescription drug benefits; The single deductible is applicable to a r_nember that is enrolled as the only covered person on the plan (no dependents), Two or more people can accumulate towards the family deductible. No one member will pay more than the per member deductible of $2, 700. The deductibles accumulate (embedded) individuals on a family plan) • For all Providers $1,500 single/ $2,700 per member/ $3,000 family Individual can receive benefits once individual deductible has been met t\nm1al Qut~p!•Pocket Maximums (in~neMbrhlm1t~rif-nelwork o!ll•of-por;/,:el nu:r:<frm1ms am oxclusive of 1i:,;1cl1 otht::r; includes calendar year deductible & prescription dmg covered expense) • Particip;;1_llng Provl1Jers, Patlicipaling Pharmacy $3,000 single/ $5,000 family & Othe:wl'lealth Care Providers • Non-Participating Providers & Non-Participating Pharmacy $10,000 single/ $15,000 family The following do not apply to out-of-pocket maximums: costs in excess of the covered expense & non-covered expense. After an individual h1sr.i:ed person or h1s4rr:1d,fal)'1ilf{inrtllidt1sin.s1ired ev1ployee & one ~r more m~ml1ers of//Jfi emp!oyee'.s family) teaches-tl_rn o~it,oi-pi.lckel maxmimn for all ruedli--al and pmscnptkm dtug@vere<l expense lhc, mdlvrdual.msur:ed 1;1r mst1,r0d farm!y 111c11rn dUf!ll!'.J lm1tt:lttl1:.nd;:1r 1t1e !ndivti'Jua!insCired par,son ,kinsmod lal:nif9 ~,!II no longer be 1eqnlrnd ~ for the remainder ol lhat.y,,nr. T)mindlvidual or Insured famjly remµl1i11> .responsl)Jlii for cos.is 11i. t1:~tess wt11;:1i bt ti1:m•part1c1fi<1111)rJ providers and other health care providers: non-covered expense. Lifetime Maximum Unlirniteci M-U)(W:\ l:l!e,Jivr 01i2018 Covered Services Traditional Health Coverage Insured Person Copay In-Network Out-of-Network {lil~ured is also responsible for charges in excess of .,..._-,-..,,.,.......,_,..,.....,._._..,_ ___________________ c.o_v._.e_r~JL'!!."'"P'""'P~f!~·~."""a;c...) ___ _ H osplfal Ma.t1"'"iri,....J1.1'""'s=-e-rv...,.i c-e.,...s (st1l)}tit.tl'l6..tlt{f{~Jil1t1n review for inpatient services; waived for Qfl1atge11cy,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 • Outpali~nt surgery; services & supplies Skilled Nursing Facility (subject to utilization review) • $~rt:1!ipri · oorn, se,r~ices & supplies (lfroii{#( to d<Jy!;/o{il011di'Jr year; limit does not App/y to mental health and substance abuse) Hospice Care . • Inpatient or Q.UJp.~tl~otsElrvlee9 f9r insured persons with up to one .year.Ufe ~xpElGlar:igy;'family bereavement services Home Health Care • ~ ; s froma,hbme,he~[t!1t~M1~9y (.f[JiJ .. • . !}teii:,iiif)¢Vli11i.bY::&: tro,me 1l,l.dt!il(h"aillft¢.gi1~l~1ottr :110L(rs,ot lq~; flQl:e1overod while insured person receives hospice 6aie) · · . · Home.fnfuslon Therapy • rnci: Physician Medical Services • Office & home visits • Hospitar & skilled nurslngJa<::llity visits • Surgeon & surgical assistant; anesthesiologist or anesthetist • Drugs administered by a medical provfder JCertalh.drug$ are subject to utilization review) Qiagnostic X-ray & Lab )> MRI, CT sc~n. P~T scan & nuclear cardiac scan ( subject lo utilization review) · • Other diagnostic x-ray & lab Preventive Care Services Preventive Care Services including., physical exams, preventive Screenings (including screenings for cancer, HPV, diabetes, cholesterol, Blood pressure,-hearing and vision, irnmonization's, health educ.a.lion, Intervention services, HIV testing), and additional preventive oare 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 T.herapy, Phy~ical ,Medicine & Occupational Therapy, ~ncluding Chiropractl.c _Services (ltrriifed to 24 vtsilslcalendaryear} Speech Therapy • Outpatient speech therapy following injury or organic disease Acupuncture • Services for the treatment of disease, illness or injury (limited lo 12 visi.(slcalendar year) Temporomandibular Joint Disorders • Splint therapy & surgical treatment 20% 20% 20% 20% 20% 20% 20% 20% 20% 20% 20% 20% 20% No copay (deductible waived) 20% 20% 20%1 20% 40% 40% 40% (benefit limited lo $350/day) 40% 40% 40% 40% (benefit limited to $600/day) 40% 40% 40% 40% 40% 40% 40% 40% 40% 40%1 40% --------------------------------- ;..,1.,UPtJf ~ \,1rt:: SCf\llff'S -<3n bP pe11,::~rf1Pd Qy <l C';rllf12d dU~CU1tCll1f1r::.t (Ct,), 8 Jodor ;/ n·0dir, l~l ttJlJ}.) a iit'C1 :,r ,,' r)Slt'O~•;ilfiy (D.0} ;, r,.1d1atr 1S~ ([)PM), or a dentist (D.D,S.). Covered Services Pregiiahcy & Maternity Care • Physician office visits · • Prescription drug for elective abortion (mifepristone) Normal delivery, cesarean section, complications of pregnancy & abortion • Inpatient physician services • Hospital & ancillary services Organ & Tissue Transplants (subject lo utiliwtion roview; specified organ transplants covered only whe11 performed fll Centers of Medical Excellence [CME]) • Inpatient services provided in connection with non-investigative organ or tissue transplants • Transplant travel expense for an authorized, specified transplant at a CME {recipie11t & companion transporlafion limited to 6 tripslepisode & $250/personltrip for round-trip coach airfare ho/el 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 lo $25/day for 7 days) Bariatric Surgery (subject to uil/iiation review;tn~dlcaW~· ·. 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 • Bari~Jric travel expense when insured person's home is 50 miles or more from the nearest bariatric CME (insured person's transportation to & from CME limited to $130/personltrip for 3 trips [pre-surgical visit, initial surgery & one follow-up visit}; one companion's lransporlation to & from CME limited to $130/personl/rip for 2 trips [initial surgery & one follow-up visit]; hole/for insured per.ion & _one c6mpa11ionlimiled to .. qne rcpmdol!bl&:?Jccupancy & . $1PQlday for 2 rlays.l(~ip, ,,----~~-·ll~"-~ -~•'> '"' ~ ---··~·rraditional Ht!a'itfrcoverage Insured Person Copay In-Network Out-of-Network 20% 20% 20% 20% 20% 20% 20% 20% (Insured is also responsible for charges in excess of cove~~-d .. expense.) 40% 40% 40% 40% or as medically necessary, for pre-surgical & follow-up visit; hole/ for one companion limited lo one room double occupancy & $100/day for duration of insured person's initial surgery stay for 4 days; other reasonable expenses limited to $25/daylpcrson (or 4 days/trip) -----""-':-------=--------'-'-'------'-'-----------· ••.-•··---·-----Diabetes Education Programs (requires physician supervision) • Teach insured persons & their families about the disease process, !he daily management of diabetic therapy & self-management training Prosthetic Devices • Coverage for breast prostheses; prosthetic devices to restore a method of speaking; surgical implants: artificial limbs or eyes; the first pair of contact lenses or eyeglasses when required as a result of eye surgery; wigs for alopecia resulting from chemotherapy or radiation therapy; & therapeutic shoes & inserts for insured persons with diabetes 20% 40% 20% 40% Covered Services Durable Mec!ical Equipment Rental or purchase of DME including hearing aids, dialysis equipment & supplies (hearing aids benefit available for one hearing aid per ear every three years; Breast pump and supplies are covered under · Preventive care at no chame for in-network) Related Outpatient Medical Services & Supplies • Ground or air ambulance transportation, services & disposable supplies • Blood transfusions, blood processing & the cost of unreplaced blood &. blood products • /1:UtQlogous blqqp (seif:.donated bloqd col/eptfon, .testing, proce}i'sing & sf6tage for planned sargery) Emergency Care • Emergency room services & supplies • Inpatient hospital services & supplies • Physician services Mental or Nervous Disorders and Substance Abuse Inpatient Care • • Fa9ility~based care ( s~l)jesf I? ttiifization review; ~tved for emergency:ad1mss1011s) • Inpatient physician visits Outpatient Care • Facmty-based care(subjecl to.utilization review,· . WafJJ13d for emetgency i:idinissions) • '.~utpatient physician visits · ((lehavioral Health treatment for Autism & Pervasive Disorder Will be subJect to:me,s,er:vlce revl~WJ . 1 These providers are not represented in the PPO network. Traditional Health Coverage Insured Person Copay In-Network Out-of-Network 20% 20% 20% 20% 20% 20% 20% 20% (Insured is also responsible for charges in excess of ~--c°"'~ered expense;) 40% 20%1 20%1 20%1 20% 20% 20% 40% 40% 40% 40% Covered Services Outpatient Prescription Drug Benefits • Preventive immunizations administered by a retail pharmacy - • Female oral contraceptives generic and single source brand, • Flu, Zoslavax & Pneumococcal vaccines • Retail pharmacy prescription drug maximum allowed amount • Mail service prescription drug maximum allowed amount • Specialty pharmacy drugs (obtained through specially pharmacy program) Supply Limits2 • Retail Pharmacy (parlicipating and non-parlicipating) • Home Delivery • Specialty Pharmacy "fraditional HealthCove-r-ag_e __ ~·--· ··--·---- Insured Person Copay In-Network Out-of-Network No copay (deduclible waivec!) No copay (deductible warved) No copay (lmmredis also responsible for dhat11es iii excess of the pres-cription drug maximum. allowed !'1mo1mt) . 20% 40%1 20% 20% Not applicable Not applicable 30-day supply; 60-day supply for federally classified Schedule II attention deficit disorder drugs that require a triplicate prescription forrn, but require a double copay: 6 tablets or units/30-day period for impotence and/or sexual dysfunction drugs (available only at retail pharmacies) 90-day supply 30-day supply 1 Insured person remains responsible for the costs In excess of the prescription drug maximum amount allowed. 2 Supply limlls for certain drugs may be different. Please refer lo the Certificate of Insurance for complete Information. The Outpatient Prescription Drug Benefit covers the following: • Outpatient prescription drugs and medications which the law restricts tci'sale by prescription. Formulas prescribed by a physician for the treatment of phenylketonuria. • Insulin • Syringes when dispensed for use with insulin ar:id other self-Jnjectable drugs or medications • Prescr.iption oral contraceptive~; contraceptive diaphragms. qontr~ceptive dif!phragms are limited lo one p~r year. • • Injectable drugs which are self-administered by the subcutaneous route (under the skini by the patient or tnsurecfperson; Drugs that have Food and Drug Administration (FDA) labeling for self-administration • All compound prescription drugs that contain at least one covered prescription ingredient • Diahelic supplies (i.e., test strips and lancets) • Prescription drugs for treatment of impotence and/or sexual dysfunction are limited to organic (non-psychological) causes. • Inhaler spacers and peak flow meters for the treatment of pediatric asthma. • Smoking cessation products requiring a physician's prescription. • Certain over-the-counter dnigs approved by the Pharmacy and Therapeutics Committee to be included in the prescription drug formulary. • Flu, Zostavax & Pneumococcal vaccines obtained al a local network pharmacy must be administered by a pharmacist This Summary of Benefits is a brief review of benefits. Once enrolled, insured persons will receive a Certificate of Insurance, which explains the exclusions and limitations, as well as the full range of covered services of the plan in detail. Lumenos Health Savings Account Plan -Exclusions and Limitations Benefits are not provided for expenses incurred for or in connection with the following items: Not Medically Necessary, Services or supplies thal are nol medically necessary, as defined. Ei~erimonltl flt lnllntig~Ul/li, Any C-iptl11menlal or irwesilgalive p1occdure or. fl\<\diCalion. But. l!.•~~~mll ~ii:6n lsif0nied bcne1ils liecoo~n )[ 15 dnlcrmined llilll il>u l!!l'iuo.i.11:-J;!l\!a~oonl is cx~imonlill i;iflit?ilttl\jli~iin, lhe insu1cd.pnrso11 !ll,t{l~~11esl anin,~1den1 rnr,l)Jc;i! rovlew, as described in the Certificate. Outside the United States. Services or supplies furnished and billed by a provider outside lhc United Slates, unless such services or supplies are furnished In connection wilh urgenl care or an emergency. Crime ar flu~ledr'Ener,gy,Q:it,J~ii11\!> !iii!! · · or .ali!lf11pl 1uroriim!l,1i'ltil0!lY .i,;t ol tlonmsfic,1·kllmim,,()r whoo govermn;;nt lunds =ivallalllid~11tll!J;W;il,!J.1'![1l or nuclear energy, Not Covered, Services received before lhe insured person's effective dale. Services received after !he insured person's coverage ends, except as specified as covered In !he Certificate, Eicess Amounts, Any amounts in excess of covered expense or !he lifetime maximum. Work-Related. Work-related com!!lionsif benefits are ll?l»l'Cled OH.Jtfbe,re 'll'J . . . ' .. , S:iirvlces o[,~dntiVe$. Professlonal tior•ic•m~"llived1'rom a person livltig Jo lheilisUred poiso.ri's h_oine ei ville is mlille,1po the inS!!fetl p!l!Son by'blood onnarriage, excijp\ us spc.clfi!id as cii'ili,rod in lhe Certificate. · ·Vk!Junt~!l'-;Pay111~11t1 Servl,;,e:sfoi,,\;\\ltl¾li,lfw1i ~i!~1;1.:,liiijfo~tllll/1J1J.,woo\dbl;l rnntltr! plan ~l>~~~pJ'.t!J!!~Ctri~illvall ;ltanon'!J\l>rornniental .c a. S~ch'a hosp!l11finust rrieril ll)efollowinggu!il/Jlln~, 1, it must be internationally known as being devoled mainly to medical research; 2 al least 10% or ils yea~y budget must be sponl on research not dlrecUy related to patient care; 3. al leas! one-third ofits gross income must come from donations or grants olher than gifts.·· or payments for patient care; 4. It mus! accept patients who are unable lo pay; and 5. two-thirds of ils patients must have conditions direcUy related to lhe hospillll's research. Not Specllically Listed. Services not specifically listed in lhe plan as covered services. Private Cootr~CI$, insured IJ{ltllllllllfi as .. lnpailiin spit/ii slay primarily , . 01Jlp11!i(.!1\l basis. Mental or Nervous Disorders. Academic or educational testing, counseflng, and remedialion. Mer.tat or nervous disorders or substance abuse, including rehabililalive care in relation to these conditions, except as specified as covered in lhe Certificate. Orthodontia. Braces, olher orthodontic appllarices or orthodontic services. Oe~tal l;ervit~a ar Sllllitll~s:, 0ml dllfltru iniplnnts. .J,,,i\nl ~ · · · "'''"'·'"""'"' to or IOI ~IIY di&Olderr, f Cettifical<¼. Cmineticlllnnt~l surg Hearing Alilt or Tests. Hearing ;;fd.~,;exccpt ~.fp/!cified ii; t;OV!:fllil In lhe Certificale. Rouli11Chtmrlr1g tests, except as npi,1ified as t11;~1ml in tho'.~tlllt5;ib,. Opiornclrlu Sorifo<>s.or S11pplfes:Q Roufino,..iyo erwi\s $\1 IOOline'. . ',. Ejle\J!/w~os.rirr,o,1ll,lij\ l>Ui'\:tis, e Ol.ll11;iU0ri!;;,Jccupa!l!'!1i:it.Tl11ir.1py. Outnooeni occupr;lloonl lherapy1 i,1c,1pt by ahoo!lt!ioil!ll, !l\!M,:Y, ho:;;,lce, or llillllil i1_1ft1s!M therapf[lli;vider, i!Stpt'tlfied as ll/,1\tcrod in tho 0Jrlll:;:.a!a. Outpatient Speech Therapy, Oulpalient speech therapy, except as specified as covered in lhe Cerlificale, Scalp Hair Proslheses. Scalp hair proslhcses., inclurJiog 1,ig~ or any form of hair replaccrnenl, except as 5p~cilied as co•Jered in thr! Cenificaie Coo,mercinl'W,:,ight Loss Ptontorns. Weight loss pt"9rams nol lhO)I ,lie pursued under medielllm physician s,J!!,iolsion, unless spci;iflc;:t!!y !isled ii., lhis p/;111. This exclusion includes, bul is nol limiled lo, commercial woighl loss programs (Weigh! Watchers, Jenny Craig, I A Weigh! l.oss) and las\ing programs Sterilization Reversal. . . . . ~·t!l!'ttllllil!,'lllJOr exclusion r.!Sll'aiirlles !rl lir.ailli spas. Personal Items. Any supplies for comfort. hygiene or beauliffcation, E~l!C~Hon or CO\llia.illing. Educational J1i!l~-0es or nulrilional counseling, except ns specified as , ~oted In lhe Certi_f~le, This exclusioif~,not apply lo counseling for Iha lreal/~1.ol anorexia nervosa or bulimia nervosa. · Food or ,M1i,,11:it'RMi!ltlr1f<!ltitv ,• .. ·:~m!f1ii' ~p,tq •· .. " ·,Ac plan or as lril!oolll;l!i{lilui~:; o nohanulr&mool Te!epho~~ and Facshnilc Machine Consuft~lloriil: Cornii11lalion,:provided by telephone, e;ti:uj!! as spl!cllied as eov~ro<I fn .the Certificate; w faGlllml!e minliine. -~QU!Jno,tii3tm orTest~/t«,11~l\t1 or l.e%.fu. \'.ticfi do not tftt{~ly,!ru!l! llJ1 ~ctual . . byi:mt•ill or g~v~1'i11,1\jrif 1™llm~fy. ~y~'$irrj:p.!iy f9!lle.f91J:ll,!/o,Defects. Any eye i;ifilJo'ry solely or prim!Hilyfoi:lho pUrf'lll?e or .,;mli)J;!lr,t) tefrr,1llveifltfc;;!s of !he eye such as r,caitighledness (myppla)·aiKf/or.asligmaUsm. Conlact lenses and eyeglasses required as a result of this surgery. Physical Therapy or Physical t,1.i•llcll!?; $crv'r.as of a pl1ysicillil'!n, physical ilw.ru;iy.01 phytltJ;'ll medicine, except when inpalient corJir,c-01en! or as s~{it¾! as co11,fm,d' in !he 0,rtif,cale, · Contraceptive Devices. ConlraceplivB devices prescribed as rnvered in lhe Certificate. Diabetic Supplies. Ptescriptio,1 and non prnscripllcn diabolic supplies oxcepl as specified as covered in lhe Ccrtificale. Private Duty Nursing. lnpa!ienl or oulpalienl sel\/ices of a private duly nurse. Programs. P1oarnnls io aJ1c1 ;irm's liieslylo which mai ioduda bu! me pol limited le diet. i1riagor1 01 r.llfifi(!,f!,' except::<; sr,1'!:ilio,J as covered in \lie Ceruficat\i. This exclusion will nol to cardiac r()he:t>Hilalion programs approved by LIS Clinical Trials~ Services ar.ct suppfier, in coi,oec!ion wilh clinical !rial~. cicept ?.S spedficd as coJered in !he Ct1rti0cdle Lumenos Health Savings Account Pian -Exclusions and limitations (Continued) Outpatient pre;scriptiOt\ d(Ug $ervic.c:i and sup~tlics ~ire no~ provide!! fot or in conrn'!dion wi1h the following: Hypodrnrrnr. ~.yringe:, e/,;r reedit::~. (.',:(!~iA wh.::-,11fo~~t-:n:-;..;d fl}f u;.1-;; wilh im·,l,:in & nlh~r .s,"\i~inier.{;::ibl,c iiru;.J!', or rr-ecii(.Jlion~; [ltuHS & med1cQhms os.od to irwuc.e spon1ar1co1i:; & non~sPJHlt1nel,us abnni,ms Drug~, & mP.•Jicidions dispuM,e,; or a~iminitlutt'd in an (HJlpni1e11t t,olhnJ. inch,;dinq (iJJtpJlient hospii;ti faciliiic!~ ~nd physldall$' 61f'ices P,dns~ion,;~; ch:1rge5 in cormcciion with administering, injcC!i!1g 1-;r ,ii$pe11sin9 drug~. [Jrugs &: medicat1ans !hat may be oht3ined withoul a physician\~ wrilitr1 piascripUort excopl insulir t)! 1°1i?(ir1 !or choleslmol 1cwe(in9 and cerl11ln ovef·•lhu..counler dwgs apprnv1~ by ihe Phi:!rmf£j,' .anli Th!::rapF:?ulict. CcmrniUce lo bt induded in !he pm'.\Ciif1lion dtHfl fom:uiary, Drugs-~ med;cdhons di.5µt?nsc-d by 01 wh1le conftnud fn a hospi!al. ;,killed 1w1s\ng foci!i!y, rest home., r;cnalorbm, ~:un·,alesc;enl hospiiol er similar facility Durablo m:.::db:11 equiprncnl, dovicet, appliancet & su~lpfic5, even ir prescdbcd by B phy~idan, excopl t:t'!1/!'acep1f•.,e di.'.lpt,r39rns, as s~'ledficd {!S covered m Um C.crlilicale Sorvlc:cs or suppfies for whtt:h ihe b~urnd pf:!r!;cr. i~ not ch:1rgc(1 0:-iygen Co:c.rJ1e{ic~ & heaith N hr:~uly t;1irj1;_ .. Gaulion. Limited rirugs. Any drugs Any expense for a dwg or rn~,l!ca!ion inc:111eo in otcess or (a) !he Drug Urniled Ft'~ Schoctuh, iDr drugs dispe,,sed by ,1cr.-pJrlidµaling pharmacici: or (b) lhe o:i!palienl p1escripliM drug negolialed ra!e !or drugs diopcnsed by pa,ticipR!ing rharrnac,e.1 or through the mail !iU~ii..;e progrs111 I); nus which h~·,e ml b\,cn approved !or gene12I uso by ih8 SlalB of Cai1tornia Dep.irlmont ol Health Services or the Food and Drug Adminislralian. fhis does not apply ta drngs !hat 3re medK:ally nece;sa,y for a co,•ered ccndii:cn. Over-!he-coun lcr m.oking cessation drugs. Thi, does no! apply to me,.l!cally necessary drugs Iha! the insured person can only gel wiU1 a proscripli<lr. unde, slate and imleral law. Drugs used primari:y for cosmetic pur.,'Qscs (e.g., Relin,A for wlinkles). However, lhis wili not apply !o lhe use or this type ol drug for me:lically necessarr lreatm~nl of a medical cun<lilicn other than ono that Is cosrno!k:, : '."!rut~·:, '.1:,t.d ;:ii:rurTiy t(; ;it<!l '.nful!li\ (!m...:lid1r19. h11l nn! fr·,,;7;.i to, i):/Tild, f._)u1c;,-::,r,:J! .d,J i/.rJro:3;:1) •J:<1{;1:'i rtv:"r::c::t!iv 1;,:ccss,1rv '.c1 ~}ri:,.tb:r cr::,,e1r~,, (i.•ndi!i'.'i.1 i\1orn,-:i;in\i ;1r1,i ,l!u~::; ~,~,1;d fo: ·,.VJ(Jlit lu::-:J, r;x,~,~p[ v.'hc,n i,;.,:,::d :~~ [!QC( mcihld obcsily \cg, <!'ii:~l pH!:·; f, ;)fWU!it(• ~uppit~ssanl~} [;rn~1s Ghlalnod. t~1.1!:1l•Jr. tt11: \ I ~;. 1idr:: .• ~. ih:..!y c.w, lumfsl1•::d in r,onnr;,::Liun with lii'jl'.:'.1! e;1,e c1 <..rn em'.;fg(~flr:y ,~.Iii'.(']/ r:e:::t-!fli1itiz:~1jvn p:cthict::i r.,, :.::11t~rgy s1.~r;1rn tr1fu::;ior ,]ru~s. oxcl~p! dru~J:~ lh:il ;-m: ::l,if,ad~/ni.s!1xr;Q ~;ubcu!ar.:::c,usly H~rhdl .1;opt1lenk:(1t'.~, n~irriilrmJ! ;.m:i cft:lary :~\1pptonwnb: r1o~p1 !or fmniu!a.:; lt1! 1t,1:. lre::1!m~~nt of phr.nyJk{tl0!'1U!ia rrns ... ~riplfan uruus w!th a r:,,.in-prnscrip:icn (0v{~r~tt10-coimle1} ch(:)1nit:1I anti dos~ eq1;iv.atenl {;XU.~J! i11~ulin, This: dot·l nol ;:~poly lf Jn O'!cr-lhe,rm..n!t:r t=-1t1iv;:d?ni :.•.r\1.s: 1rie11 ruHl WG.~ In cf!1:t:\•t1!: C.omcound modfcatio11~ ohldi~ed frcrn c-tt1ci lh.lfl a WJrhr;1pGhng pti;wn-:<:y, Insured person will ,;av~ to pay the f\111 cos! of the compound drugs if insured person obtains drug at a f\OO•participating pharmacy. }lp~<;i;~lly rhrmn~cy d111u:. lhril mll!>I bu ob~;.imed from lhe ~pt.;':i::tty pl1,1rrncr.y pmg,arn, but, Wlil(:h «~ ootrunnrl lrom a retail ph;,rmacy (l:o 111)\ WJ~red by ~;is Insured pQrion will hav~ lo pay Ille fu!J't(IS[tif.!l1e sp~da!~• ptmmacy d(uys oblainnd retail µ1ili111)Jr.y I hat insured r<.n.011 should have ttlitain~d from the spetialty plmrmH::y 111ogram. Third Party Liability-Anthem f11ue ()o:;s Ufr. i!rid I 1eallh lnsurc1nce Comµ2ny i~ entil!ed to reimbursement oi bencfi!i, paid if the insurerj poison rc'Covers dam;;ges fiom a legally liable lhird party. Ccordinntion of Bcnefih~ , TJ:e benefit~ of l.hb pizn li\<lf tr. rtduced if l~-e Tnsure.j r-e1son ha;; any oUier group heallh or denial cvve,a;c ::.;c: !h3l [he services re-~eivGd from aU grcup covcmgcs do n~l exceed 1 OD% of tho C<Nmcd o:-:.pense. tumenos plans provided by AHll1em Blue Crass Lit. and Health Insurance Company. lndopendetl/ lic•nsees af th& Bluo Cross Association.(~ ANTHEM and LUMENOS are roglslored fradomarks of Anthem lns11ra11~• Companies, Inc, The Blue Cross name and symbol are reg/s/ernd,marks o/ rho Blue Cross Association. OlueCross SJVIA County of Fresno Modified Lumenos® Health Savings Account (HSA) LHSA 263 (3000/100/50) (EPID: CGHSA1605) This SJJmfttary:ofb.~n't~fi!~ J'l~s .been Uf)da!ed lc,oomply wlt!fl~e:!et~l and sla.te re~tilmmeots . .ln~lui!ling; anpli0able;provlsitiii~ i;iflhe recenUyt.\:;Jla~tedJetleral 1,t~llli r~{oiro.·l,i11"!l'l,·A?. We.1(€!,'el l guiilamzi1,·ancl:blariftc:ijl)QltOll'llJ!i!"flt;J\N,he1J\llf,.t:a.rl;!:roform, laws fn5f an "Se1vioo lpf, Rr,i,venll~:ServJJ':l:l;·Vfl)} m'E!Y; Be , ~ll1~n('l , , ~{l . , • , , , ,, arrist.SUDJP,6t to (UJ~ ~l?f!tOV~J.{of'.fhi~ Jte~rl,rit~nl.'of . HeallhCl'l'rf.i. li1.Jtallows.anm1:1u ealltl $t,,\(ingsJ\qtpt111Ho pa1,,1forro,1Itine eallh ~overag~; sin1 plan Iha[ proteij{iNl1~Jhsurql:j:1~ct}o.n against ·a1 c;o11:<:litl~ns.i:11rriill'lligQs1Ji9~ . -· . - EJtplanation of Maximum Allowed Amount · Maximum Allowed Amount is the total reimbursement payable under the plan for covered services received from Participating and Non- Participating Providers. It is the payment towards the services billed by a provider combined with any applicable deductible, copayment or coinsurance. Paitl~tiaJ1r19,P(C{VJ<.t~rs-The rn!t\tle provi~e(lja;s agreed to accept as teifnb.llrsemen~for covered ~i3J-\lices. Memb:e~:;are not ~~s.g9n~lble for the .cJnfet.~TIJ'.lflJQa.lWl-le.n the pro~l~r's usuafl.'!h~rges & the maximum GtlldW:Cd amount. Non-P~):tihiR,,t!ing l?r.Qviders & Other Health cite Provlderss(inctudes lliose 11ol·rapres~nte:din,l~e,f>.l'ij prgyider n~tw9rk)-Rei01~u~em~nt arna,QnFis ba~ed ·om an Anthem Blue Cross rate or fee schedule 1 a rate neg:Ollaled l,i/ith lllEl provider,, information from ·a U1ird·party vendor, or bfllerl charges. For Medical :~01~fQQV,9y1care rendered by a Nofl'..Pa):tlc!j)allng;Pto:i)idet or Non~Conlf~'cting Hosp[1a,1! reimpl!iS~l'Sl!iJJ\liW~Y· be.based on the reasonable and;G;t.lsiC:!rri~ry value. Members mat ~e respohsibie'fofaii~ arwJunt in ~~~ss ofll\e.reas9hable 1:1!li:l~qt!.S:!9n1qcy value.. · - Participating Pharmacies & Mail Service Program-members are not responsible for any amount in excess of the prescription drug maximum allowed amount. Non-Participating Pharmacies-members are responsible for any expense not covered under this plan & any amo!-]nt 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 & actu.al charges, 1;1s well as any .deductible & percen_tage copay.. . .. When using the outpatient prescription drug benefits, the insured person ·is always responsible for drug expenses which are not covered under this plan, as well as any deductible, percentage or dollar copay. ' Calendar year dodi1ctible for all providers (appffcabJe to 1n'!Jditiil care & prese,rfp/ion drug benefits) • Individual insured person • Insured family Individual can receive benefits once individual deductible has been met Ann.l,la!O.ut-of-Rocltet Mmdmums (111'11etwoi'l<lout-ol-nef~i@rk m1t-fif,po.ckel mf1x(n111/ns .ire exbl11sive 6fei1(Jfl 1Jlh~r;}nd11des . oalendt:ir yiJilttfedf!olib!e ·e, p,ws~1in~onJJtugcavered e~pm1se) • Par.ticipa\ingRr..oviciers; PnrUci'pating Pharrnacy &:Other Health.Dare,Provioers . $3,000/individual insured person $6,000/insured family $3, 00Q/inqividu.al insure(! pE?rson;· $6 ,OOOlirrsured.family(year • f\h::Jh:c-J't'lrllcipal!ng Provid~rs & Nqn•fDarlicipaUngJ?harmal;ly $5,000flndfvidu·a1 ins.lire(! pi:iHmn; $10;00Qllri,suredfa1nily/year T,he f(llte,wing donpt apply lo ou(~or-pockel ma:dmuh1ste6st$ !ii ex~:ass of lho 0011eted expense,& mln,covered e:q:ler\se. Aftefari• lhdivfoual Insured person or insurecl fiimlly (inolt/des. it1sated, employee: i:I::oue or more membi:m:> of /lie en1pk.i}'l3e '.s rnacl)e.e ll1e p,11J~f,-po~keJ maximtihi fqr 911 111edlr.al ~otj pri:aspription drug coven:!d expense the lndi11ich11!1 lri!'l1JJ0d persqn orinimred . .. incurs<durlrm lh'atcarai,dar .1dMduil! · · or Insured famlly-Will.oP,kmgei: .barequlm~i to pay a eopay for the rnni..tir'ldett'.if lhar year, Tl1<fir:t91vkluar 1rnd ,p,en1.oh or i . )ly rernainsr.esponsil:.ll~fpr oosl':l in exc,iss ofllm r:overl'!d e;,:pemm when pr.ovlded:by 11on-pafticip1:1ting '1tn:ivlders· and other health Ct1re pr0vii:Jers;,not1-<:overerl,,expe1tse. Lifetime Maximum Unlimited Covered Services ·-·-···•···-··---Trncfftional Health Coverag~ .•.. ··-···,·"•"•·· --- Insured Person Copay }losplial '.Meoitol Smvlrirui:(subp,it:l ti, t1!/llkflftei:i,'re11lew for inpatient sef\1/~s; W{IJ\ili'!ti fcir cm(;)rgcmcy admissions) • Senii•private room, meals & special diets, & ancillary services :.-Outpatient medical care. surgical services & supplies (hospital care ot/Jer than emergency room care) ----Ambulatory Surgical Centers • Outpatient surgery, services & supplies Skilled Nursing Facility (subject to utilization review) • Semi;private ramt1, s.~r:vlces & si1pplies {/ijn1led to 1'09diifilcal~11daryea1f Hospice Care • Inpatient or outpatient services for insured persons will, up to one year life expectancy: family bereavement services Home BealthCare • · .& supptl~:frQm a home haal!h•:ag~n<~y • to 1'00 iiisftslq,;1/endar year; .. 1,:me visit lly e tmme.heail/J aide equals four hours or fess; not ,cpvered while insured person receives hospice care) Home lnf(tslob l'herapy • Jq:alur)es 'q1~dl!~Won, ar1cillary1s~eeyice:r&,.3 ~a,r,.91Yex:<J!Biflll),Q'.·& VI~i.!:r:tiy P,f!>\li,d~r:,~,i)l tnerapJ; durable med.lea! eqmpmen!; lab Physician ·Mecllcal 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·r:ay & Lab· • MRI, CT scan, PET scan & nuclear cardiac scan (subject to u/ilizatfon review) • other diagnostic x-ray & lab ' Preventive Care Services Preventive Care Services including•, physical exams, preventive screenings (including screenings for cancer, HPV, diabetes, cholesterol, blood pressure, hearing and vision, immunizations, health education, intervention services, HIV testing), and additional preventive care for women provided for in the guidelines supported by the Health Resources and Services Administration, *This list is not exhaustive. This benefit includes all Preventive Care Services required by federal and state law. Physical Therapy, Physical Medicine & Occupational Therapy, . including Chiropractic Services (limited to 24 visits/calendar year) Speech Therapy • Outpatient speech therapy following injury or organic disease Acupuncture • Sef'.li(:;:lS for the tr.e.11n,l:lnl of disease, illness or injury (liinilei1 to 12 visitsloeli:mdar year) Temporomandibular Joint Disorders • Splint therapy & surgical treatment 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 Nq copay No copay No copay No copay No copay 1 No copay (Insured is also responsible for c/Jarges in excess of covered expense.) ·--· .. 50% 50% 50% (benefit limited to $J5Q(d?,,'i/) -~---· -·='"~-~-~ 50% 50% 50% 50% (benefit limited to $600/day) 50% 50% 50% 50% 50% 50% 50% 50% 50% 50%1 50% ~ Ac:11punc[ure services can be pertonned by a certiHed acu-;incturist (C ;\,}. a d~)clo; d mediclnt; {l1,(0.,), a doctor of osl8opalhy {D.OJ, 0 podiMrisl (O.P J:/.), or a rJentist (D D.S.), Covered Services Traditional Health Coverage Insured Person Copay In-Network Out-of-Network Pregnancy & Maternity Care (fnsured is a/so responsible for charges in excess of covered expense,) ~------~·. '~·-·-·---------~---,......:..---'---~ • Physician office visits • Prescription drug for elective abortion (mifepristone) Normal delivery, cesarean section, complications of pregnancy & abortion • Inpatient physician services • Hospital & ancillary services · Organ & Tissue Transplants (subject to utilization review; specified organ transplants covered onfy when performed at Centers of Medical Exceffence [CME]) • Inpatient services provided in connection with non-investigative organ or tissue transplants • Transplant travel expense for an authorized, specified transplant at a CME (recipient & companion transportation fimited to 6 trips/episode & $250/personltrip for round-trip coach airfare hotel limited to 1 room double occupancy & $100/day for 21 cfay$!frip, other expenses limited to $25/daylperson for 21 days/trip; donor transpo1talion limited to 1 trip/episode & $250 for round-trip coach airfare, hotef fimiled to $100/day for 7 days, other expenses fimited to $25/day for 7 days) ·sariatric Surgery (subject to utilization review; medically necessa,y 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 • ~ariatrl~ tralief;:ex~etlse when insuret:tperson's home 1s 50 mtles pfrn~fe:·f(om the nearest l:i.!:lrl~trl~ 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 companio1i!s transportation to & from CME limited to $130/petsoiJl{ri,o for 2 trips [initial surgery & one}qllq111-gp v1)it]; · hQtel for insuri:q person _& one · nion limited to one ro"/Jtriff:l.tXIJP.lQ!JJJW.liRSh."jjY:& )jfj1/]ys/l,rlp; · or as roG.q!~i!llf ritCfJ;~S~o/., (O/\fJ[o--s1,1rgic_al & fdllr.A'l"VR visit; hotel for one compamoh'/1mifed lo one room double occupancy & '$10Q!dtiy for duration of insured person's initial surgery stay for 4 days; other reasonable expenses limited lo $25/day/person for 4 daysllr/p) Diabetes Education Programs (requires physician supervision) • Teach insurEld persons & their families about the disease process, the daily management of diabetic therapy & self-management training Prosthetic Devices • Coverage for breast prostheses; prosthetic devices to restore a method of speaking; surgical implants; artificial limbs or eyes; the first pair of contact lenses or eyeglasses when required as a result of _ eye surgery; wigs for alopecia resulling 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 avaifable for one hearing aid per ear every three years; breast pump and supplies are covered under preventive care al no charge for in-network) No copay No ~opay No copay No copay No copay No copay No copay No copay No copay No copay No copay 50% 50% 50% 50% 50% 50% 50% "covered Services Related Outpatient Medic"aTservfces • Ground or air ambulance transportation, services & disposable supplies • Blood transfusions, blood processing & the cost of unreplaced blood & blood products • Autologous:b!ood (self0 donaled bhq,;l ooJ!ectlon, testing, priicie&1ing & stbrt!Yt:ffor pl~nm!i<Jsu.rge,zy} Emergency Care • Emergency room services & supplies • Inpatient hospital services & supplies • Pl}ysiciaff flervices Mental or Nervous Disorders and Substance Abuse lnpatlentCar~ • Fa~Jllx~based care (s11iJj11,ci to 11tll/zation review; r-1ai11ed fo.r emergency,atlfiiiflsforiti) • Inpatient physician visits Outpatient Care • Facility-based pare :(subje,cf to 1)/i/lzation review; waived for emergency ai:Jmissio11s) • Qiu,at!enl,physfclaii visits ,(B:i:iflliv!eral Health treatment for Autism & Pervasive Disorder wtll be subieet to ,pre:sel\lice review J 1 These providers are not represented in lhe PPO network. "' __ , ___ Tr.iditional Health Covernge Insured Pierson Copay In-Network Out-of-Ne~work No copay No copay Nocopay No copay No copay No copay No copay No copay 1 No copay 1 (1Hs11rod i:, also responr,ible fol' r:irnrgfJs In excess of COVfs(f,)(1 exp(![1$(1;) No copay No copay No cop:ay 50% 50% 50% 50% Covered Services Outpatient Prescription Drug Benefits • Preventive immunizations administered by a retail pharmacy • Female oral contraceptives generic and single source brand, • Flu, Zostavax & Pneumococcal vaccines • Retail pharmacy prescription drug maximum allowed amount • Home Delivery prescription drug maximum allowed amount • Specialty pharmacy drugs (obtained through specialty pharmacy program) Supply Limits2 • Retail Pharmacy (participating and non-participating) • Home Delivery • Specialty Pharmacy Traditional Health Coverage Insured Person Copay In-Network Out-of-Network No copay (deductible waived) No copay (deductible waived) No copay (lnsuro.cf:is ;J,lso respon~ible forcliargesJn excess of the piescription drug maximum allowed amoµnt)' No copay 50% 1 No copay Not applicable No copay Not applicable 30-day supply; 60-day supply for federally classified Schedule II attention deficit disorder drugs that require a triplicate prescription form, but require a double copay; 6 tablets or units/30-day period for impotence and/or sexual dysfunction drugs (available only at retail pharmacies) 90-day supply 30-dtlY•!iUPRIY 1 Insured person remains responsible for the costs in excess of lhe prescripUon drug maximum amount allowed. 2 Supply limits for certain drugs may be different. Please refer to the Certificate of Insurance for complete information. The Outpatient Prescription Drug Benefit covers the following: • Outpatient prescription drugs and medications which ~he law restricts to sale by prescription. Formulas prescribed_by,a physician for the treatment of phenylketonuria. · • Insulin • Syringes when dispensed for use with insulin and other self-injectable drugs or medications • Prescription oral contraceptives; contraceptive diaphragms. Contraceptive diaphragms are limited lo one per year. · • .. lnj~ctable. dr.ugswhfoh are self-agminls!er13,g by .the sullcUtaneous foute (~rodcer the skin) by _the patient or insured person. Drugs that have Fol'ld and Drug Adminls,r~tion (FDA) labeling for sel_f-admi11isli"allon . . • All compound prescription drugs that contain at least one covered prescription ingredient • Diabetic supplies (i.e,, test strips and lancets) • Prescription drugs for treatment of impotence and/or sexual dysfunction are limited to organic (non-psychological) causes. • Inhaler spacers and peak flow meters for the treatment of pediatric asthma. • Smoking cessation products requiring a physician's prescription. • Certain over-the-counter drugs approved by the Pharmacy and Therapeutics Committee to be included in the prescription drug formulary. • Flu, Zostavax & Pneumococcal vaccines obtained at a local network pharmacy must be administered by a pharmacist This Summary of Benefits is a brief review of benefits. Once enrolled, insured persons will receive a Certificate of Insurance, which explains the exclusions and limitations, as well as the full range of covered services of the plan in detail. Lumenos Health Savings Account Plan Exclusions and Limitations Benefits n:n: no! provided for ('.XJH!ll!WS inluircd tor or in cnrnwclion with lhc., iolt0•·1in!1 items: NoU,lc.dicdliy N4:!ces~ai_-y~ Ser-.•in:~ rn tupl,!i1(Ji ih:•l\ ,w~ r,,:,: n:F.:(1,::;1/iy n-::cos~·;:''r', ~s. r_1er11,fd .Exper'itnC>ntal or lnvesUgativt. l~n; e;..rerimen!ai or !t'\\i(;~llf:).~hv-J ;;r('::":edtH(~ or nw1jicdl1ri!· thJ(* ii 1n::-:,m.'O pt~r~on 1:s i1enicd bt.H\Cf:i!.; tJ1;.•ca1;~,\' i: is rJeh!rminrnJ lt\;Ji !ho requr:~,led \!(:r.!t/!11:;nt i•.i r;:r.pe1i1t1e;:/3I ot inw~:lil]aUv~\_lhe in~;111r.1i •-(.!1st1n H)i;!i rcqm.r:il a, ii:dr.pen•ie.:n: irt.::(11c;~! 1~:t•i(:w, a~~ df~s\~tlbcd in ltl~ Cer!ificale. Oulside the United St.1t~s~ .Servi~e!; L'f sopphc~; ii;111i:it.ed and t.ii!bd bi,"'.] P,(Nkk,r td:,id,; Jhr, Uniled St8le.s, t.mle.~.:; such ~;cr,r,cet orsu~pl!o:; arP i'.irni·;he-d in r;\;m,,:~c!ion wilt,, ;H~ll~nlcrire or an emF:tgcncy, Crime or Nuclear Energy, CtmrUio11s /hc;Lmsull !10111 (i} U:e iw,u,eri p<:r~~on·:; cnmmis::ion ol or aUf;mp\ lo CtlWmit a !ekmy,.. a!; bng Js ~m, injuric!; urc rial w re:~uH DI ~ meriir::11 condilmn 01 ,1n :lCl of •fomesl!c vic!unco; or (2} : .. my r<.~ir:a~o of nur.tear-enc1;.:y, whe:hor or not lhe re&u!t o!war, wi1i:~n govo:rnn8nl luuh r~,c 3v<lil<llfo ioi U;u lH:ahrn::it ,1fi!hv:ss 01 in_jJry arising !1,1m ihc r~le~iso or nudt;m enr.rgyj Not Covered. Smvic~s rece\1e..1 hefme !he insured pHr:-.on's eff1;;divc dale Sc1vicr.:::; r!:ceiv.:.'d i-.lf:ei lhe in!iurod pc1son'r,. covt)r~g(1 end5, except ~6 sr~cified ;;s r,ov~red 1,1 H1e Ce1iificm<;~ [,;ce.ss Amounts, t\ny amoLJnts ir. excess o! cc•!ercU e-xpi-~nY} rJr \ht life!ime max1m.u1n W0tk•Relalcd, \'Vrnk-reidled co11dit\011s if benetti:; <.1m rccovor11n Or c:~n be recovcied. eittler !Jy r,dJ;tdicaHon, seWcrnenl Oi oihEm\'iso. \mder any worker:>' torn~nsalinn, ernploytir's liability i3w or occup.a~:.::nal dise2se l11w 1 whu!her e; no! Hie 1n5urnd pe(son cl,3;1 ns t!H):ie hfJnch!s. \I \here ls a dispute of suh.stanlial ur.ce,t~inlf as to whelh,~r benc•f;!s rnay b& 1frl:)·w0r~d 1~x !hose cc-ndllrnn.s pursuant t(: workers' comper.satkin, we will provide \he honcfils of ihis pic:n for suet, condilions, subjuct l<! .:1 righl of recovety and roimb;1rrnrnenf undN CaHforni::J Latloi Code Sec!inn 4:,0.j 1 as ~;r,.ecifinrj a;; covered in Ille Cer1ilicale. Go1J-ernrnent Treatment Any s.ervicr:s !hu insured p{m;c1n aclua!I/ 1ec(l;ii,red lhal we-in pr,)YiL1ed by a local, sl;ile or ledera! governmenl agency, <1xccpl wt,en payment under ,his 1ian is P.Xptess!y requited Dt !cdern! or sfa1e 1aw~ VVe wiil ncl cover paymunl for lhe$e &t::rvices H lhe insured pcr5c,n ls nol required to pay for lh~m or they ere gii.ien to the intur.ed (>1;1~on ftlf fie(}, Services of Relatives. Professiorrnl services 1ci:ci'1cd frtim a pt?r:;on liv!n:1 in lhe insurnd pr;;1tc,,·!j home m who i~ ,eialeti lo the insured prm,on b; blood or111ar;fage 1 t~.xcepl ;_:i~ ;;~;~it;ili1::d .-1:: c.::vvcuc,J in the Cortilioale. Voluntary Payment. Berv'ic-es tor which !ht; !ns:ure::d pe,~on has :10 li:!9al obiigalion In pay, or fer whicl1 no charge woukl he made in !ho absence of icsurance wveta!Jo 01 olher health p,an coverage, except services received al a non.governmenla: charilable research ho,;pital. Such~ t1o;pilal mi.st meet the following guidelines: ' it mus! be interna!ional~ known as being devoted ma'nly lo medico! 10,earch; 2. at least 10% of its yearly budget 111usl be spent on research no! directly re,aled lo palionl c;;rc; at !~as! one-lhird of its gross income must come Imm don3t1cns or gropir: ot:1er ltmn gi/1:i or payments far p2Uent1:a10: 4. it n1\IS\ accept palienls who me unati~' to pay; ord 5. tN<rlt.irds al its patients must ~ave condifons direciiy related lo i11tl hospil.<!'s research tlot Specillcally listed. Ser,ices not spec'!f,cally listnd in lilt' 1i1an as cove,ed services .. P(htate-Contracts. Ser\'it.es or supplies ~ro·vidc:j pursua11l to a privalR corlrac! between the hGurcd person and a provider, for which reimbur~em~mt ur,der Medi(:are progriim is prol1ibitPd, a_s sP,ecifled in Section 1802 (42 U.S.C. 1395a) o11itle >.'V!II ol lhc Sc,cial Sec4rit1 Acl. Inpatient Dla(jnosUc Testg'. inpaUen( room ,md board charges· in conneciion with a hospllal slay· orimarily fer diagnosi!c lasts which could have i)P,er. performed safely on an 01Jtpalien1 ha,1~, Mental or Nervou, ()isord~r~. Acarfomic er edu:::~(wr:al :~~ticQ, r;our1svllng, and ramedlllliof: Mental or n~r;ous di:;ord-;r~ or wb5to11c:c a:.n.ise, indudin1 ii::hvt::l1iativ0 cart: ln rd~lian lo lhP,5~ condilicns, e:(::epl a$ ~pecifieri as covi~rad in thr~ C:;;r!i((~\t"; Orthodontia. Brnt:t!S, o[h~r o1h:.:dontic apptiu:~c~J 01 Llflh::,(frni1G s;;:n:ir;,11; Dental S~n,ices or Supplies. Oen1,3\ p!a!c:,;, h;idgl'~. ur;wns, caps rA o!ht'.r der,\;JI pm:;lhc~:es, dcm~11 impl:'lnls, denla'. scrvt'ces, e.x(!!.iclion of l.-30!!1, t!P1Hmcni re tht1 tr:elh er gums, Of 1rec:itrn:::nt io r;r for anJ llisorde1s for ttm ic1nporcmarF.iib;Jla1 Oat1r) jc,i1\I, ~1.c~1 pt f.l!~ '.;pe~1f1ed a~ COV(·rec1 in \ht: Certificate. r;i_,:;moUc dental StJrycry or-olher denl<1\ s;_~rvicts tnr b!:autifr:;1lion Hearinrr Aids or Tests. Hear,ng aids, excBpl a:; ,,r;cciricd as cc,vorea in the Ci'rtlllc,tc. Hou!me hearing it~:its, er.c;Gpt a'> $pecified as covered 1~ ll1t:: Corlificdtt Oplome(rir; Svrvices or Supplies. Opl<J:n&U,c fervicv~, 0y1;; E.Xf;;r;i~e& ir:-c\11-1:n:~ u1t!1op1Ks, RrnHn?. eyo oxams 3!ld ruut:ne eyf: rcfwr;lions, 11s specifieu d5 1.x,w~wd in !hr: Ct:erti(cate Eyr;-ql;;s~)l;~ c, ccnlc1cl let\!Je5, r~xc.cpt as r:p(1~;ficti a$ l~C'Jtred in hr, Ce1~:ficde Outpatient Occopation.1l"Thcrapy~ Ou:ri:~1i011 at~t:!!f:.cth:""Jfl.:~! !hff!ipy, c>:copi by a h:..1mr: 11.:\'":llh r.1~wncy. ho:)µk:c, 01 horn~ infusicm lhc: ur,y ;1r8v:dc 1, u3 ;-.r,:::(firLi as cc;,{;ft:.d 'n [tic Ccrtricah~ Outpatient Speech Therapy. Oulp3!ienl speech therapy, excepl <.iS spe•.::!!e,! a~ t:o._iu0cl 111 Iha Cerlificc1le. Cosmetic Surgery. Cc$m!!ilc surger,' or vfher serv'.ces pf;forrnsd f.oie!y k,; healil1f:cali.:::r tv' le alli:.'f ()! resf',ape normal (lr\c!udfr'1g aiJGd) s!•1-~c'.urr,:, 01 tis:.\;?s-c.f thn l\{Jdy \J lmµ~nvc ,lpp0a1anu.; 1 hf~. ?.>:.dus:,m Jnt!~i i'hJl app\ lo rGl(..'rt;j.lf!Jt:/.i'!!~ :·u~~ff'f {thal i;; .tu:gcry µarbnmd kl :~or rec:! defonr,:t10s ,;r,u~c:J IJy c1;rgt'ri(3, ~;r devc!corr,::,1\zt tflrf,,x:t.,'-!hti"'";~ i!lne.ss. !Y in;uy (er \he rnrpos,:! d inwroviarJ baOl 1y r,1i::·Iic11 r;1 ;";finptorn.;.Hck:;r:r c~ kJ ucJ'.~~ ~ i,-:)rn~;i ,.JPp!ar,.;nr:eL hc! .. Jk\9 si1rge!y pHfc.:-med b i'CSlo:e t:yrr,111e:iry fr),c-.·.ir-J Cn:~1,,d;~ w,:_~!·:11 di;,::~ n;;; Sc~1.lp H,,ir Prosth~se.s., :•.;co!p hair rrn~[tw~c••:,~ ty_h,,:\ln(; \';.9~. z1: r1n~· IDr:11 n! ha:; rr:p\a 1;~1H:n!, l~:..:r.r:pl ::J:; !'.pf:t:divi w,; ccvcrr~J ,n i11e Cr'.iiilir:;;t,~ Commnrci.il Weight Loss: Progran1$-¢ VVt~rghl k1ss pr0:;raI1:s. wheihttr L)r r(j( lli_er• at pur~~ur;•J u;1dl~r rr:edical m p!Jysrfi::t111uper;I~.ion, t.rnlu~~:,:, :~pcr;tfic:ily !i~le,j i.t~; \~•..,liCft'd in lh's plan l hi~ ;,x,~1w,1cr11• ,c!ii(!O~. bul 1:: HL\I ii11nloJ lt, l"G11:1n1-:1~ic.1I "t\·1.,1;-1i1l ;rn~s p10;.·ra:ns {V\1'1~igt1l Wai•;hi~rr .. JL\r,11y Cr dip, U\ '!Jcigh! Lo~;~) ;md fa~;hmJ pr0QF1m::. 1 nls eA-Cltislon fJ\)Ct. flf,;l ,:!ppli IC mod!caify necessary !r,"J;J\monis lu motllid OL'.t~sily or di:-;\;;ry r:vdi!Jdtio1,'.,i and counsa'.ing. end brhavia;;,il rnodific;~[ir;n prnprams tor the t,eatmenl of anmcx:;~ n{1t 11osa L)f bt.:ilmit1 nervvs:L., Sur9x::1l tr~atmet1t ror morbid vb..--.:::;:it)"' i$ coverer.I as dc-sc.;1iti,!d in Um Ccriifl•:ate Sterilization Reversal. Infertility Tre11tmcnt. t\n'I ~crviccJ or :ilipf;)ins furnishvd in corinecfon wilh the diagno~is Gn.j lmalmPr1t of inl~rtllily, lndudin~J. bH! n1Jt lfmiicti io diagno!itic lt~sls, mrX!icalian, surg&rf, artif;c1at in~,,;m1naUon, in vii<() fertilin;ilion, r;le1ilizalic11 wversal and gamC=te intrnf;1Uopian lran;,(er, SurrogDfo Mother s~rvices. For cny se,vices or supplies µ1ovid3d lo a persr;n noi covewd 1.mdc:r ttie pl;.m iii' connccfon wilh a surrogale pregnancy (including, but n.-Jt li1niltm to, !he bo.:iring of a child by another woman for an !flfe11ilr1 c.ouple)_ Orthopedic shoes and shoe instr!s. 111:s il<d!Jsion or;cs nol opply :o orthopedic foalwe;ir tJsed as 3!i in!E1;-:Fal part cl a k3ce, zhr;e incer($ Iha! aro c!J;;lorn moidmt to tho ptticnl, or lhcr()f>-':tltic shoes and 1nsmts deliiyr:1 ... "J to treat fool COl])p]ica!ions due lo diabetes. ss ~Pt~ciftca!Jy slale-0 ir, I.he f.OC~ Air Gondilioners. r\irpurif:frf1, ;_1ir condiUor.er5 01 humid,rie,s.. Custodial Care or Rest Cums. !nµ:,tienl room m~d hoard tharg(:S in connecOon with a hospi{al slay primadiy for environmenl~ d1imge or physical therapy. Custodial care oi rest corns, except o::. specified a:; r.overed in U:c Cortilicate., S2rvice~ provided by a res I home, a horne for lhe J>Jcd, ;J m.irsing i1urne or any similar fadiity. Services provided by a skilled nursing facilir/1 e.Xcept as specWer! as covered in iho Cert.tficate. · Health Club Memberships, Heam, ciub rr.emberships, oxerciso equipment, charges lrom a physical filness instruclcr or pmsooaf trc1i1;cr, or any olher charges for aclivilles, equipment or fadHt!os us1-1d tor developing O! malntaining physical Jilne$S, tven if oaiemd by a phy.sii:;{\1n, This ox.;iusion also aµr,l:cs lo heallh spa~. Personal Items. Any supplies tor comfort, hyg!cno or beauliflcalion. Education or Counseling. Educatictiai scrvir,~s or nulrilion<1i counseling, except as spcci!iud a, cover0d in !he Ccr1ificala This exclusion does not apply lo counseling for !he trnatmenl or anoroxia r1ervosa o, bulimia narvosa. Food or Dietary Supplements. Nulri!klnal and/or die{ary supp!ern~nls, except as provided in lhis p!;;n or as required by law, This exclusion includes, bu! is no\ limited lo, those nu!rilional brmulas and diclary supp!emenls Iha! can he purchased over lhe counter, which by law do not requiremanl ei!her a written ptescrlplion or dispensing by a iicer.sed pharmacist · Telephone and Facsimile M~chtne Consultations. Ccnsulia~ons prov\ded by telephone, uxc~pl as sr,ecified as covered in lhe Cer!irlaate, or locsimile machine. Routine Exams or Tests. Roulir.e physi~al cxMl5 or tesls which do 1101 diraclly lreat an xlJal lilness, iniury or cundition, induding lho,e re;;uirnd by omploymenl or govcrnrcenl auihorl!y, €Xcep( a~ spe~ified as covorcd in ll10 Certmcate. Acupuncture. Acupunctun-1 bea~11enf, e~cer,1 a~ specified 3S col.'eri;d in ltio-C-.:rt1r:catc. Acupressure or massage lo control pain, keat illness or prclllQ(e heallh by applying pressure lo o<>e or more specific areai;,of U,e bpdy based on dermatcrnos or acapu~c!ure points. Eye Surg~ry for,Rairactl'lc Defec_ts, Any eye sprgery S\~ely or primarily for lhe purpo;e of ccrrecling re-fraGlive defec!s of lhrt eye ::;udt as ncaisighle<lntt..ss (mj'Opi:-i) ar.dlor asligrnati:;nl, Contact leiises end oyeglai3nes require.ct as a n~~ull Df ll!is su:gcry. Pilysical Therapy or Physical Medicine. SoNices cf a plty,idan for physical L~r,rapy or physical !"'le,clidr,c, ~xcepl wl;eu prc\/ided durin~ u ccvernd iopal:cnl confincmc1il or a:> specified a~ co-.ic:rr.:i Hl the C'.A:!r11l1i::att~ Outpatient Prescription Orugs and Medic a lions. Olllpalie11I ~,escriplion drugs or medicalbns and insulir,, Hxcept vs spt.-'Cifi,~rl as cov0red in the Certificate, Nor ,prescription, ovN-thc-wun!er patent or pmpri-etarf drug N me<Jrclnes.: except cs ~•pcc:fied as covered in !he Certificate Cm:rrcl1c:::, he81Pl er be.1U!)' aids. Specialty Pharmacy Drugs, Spu;ially phmrn:,q· '.frugs !hat nu;s, be cblaine,j from li1e sp,)ciai'-, pharmacy pr{uJrnm, tr.1t, which are-ob:alned fmm a n~IBil pharmacy, are 11ot covered t,y lhls pl<lil, Insured person will h~ve lo pay !he full cost of lite specialty pharmacy drugs obtaio•d rrom a r eta ii pharmacy that should have been obtained trorn the specialty pharmacy pr'ograrn. Contracopctve Oc'llces. Conl,:iccr1tvn d-2•,-k;er; presolcied f,Jt t.i,lh ccr.lrGl except ::s s.pec·ffiod ::l~ covered ;1: lhe Cerffca!;:;, Diabetic Supplies. Pre:;criptivn ~Yid fH):'l•pro~~tripti:..)~ ci~Cehc ~.upp!ie~J e.:.:.::.:Ep! c~, spcciti,;d as COSO'.GQ in lhe c,:rtific:i!e. Private Duty Nursing. Inpatient or o;,;lpatienl !:.e1vire$ of;) µn\1are d11ty nurse Lifestyle Programs. Pmgram;; Lo aller ones lifestyle which m;iy include t,ut am nQl li;nile~ !o di~,. t~)Gfci!ie, im:;;;H·:;y u nu!dl;o:1, exr:~pt r.15 specHled as r,::r.:errd h tr,c Cerli!k:ale_ Thi~ exdus.bn will n,:,{ r:!pflly k• c;.1rd;,::c rel1t1bili\c1lion ptograms :1pprovcd by u;i, Clinical Trials. ~en:k:es :1n,1 :,uppil::.1~~ Ir1 Ujrmi::c!ion wilh dwi,~~l iu~ls. e).cepl a~ s1>:::cilif:d w; r0v-:-;!r;d J:I !h_~ Ci!r1iftcDl8 Lumenos Health Savings Account Plan -Exclusions and Limitations (Continued) Outpatient prcscriptiun dri1g ".",Cr'i!iccs u1d suppiies arc nol prv'Jided ior or in connr::lion ,..,ilh tl1e Jollowin9: ,lrnmuiuzir1g il•]Cnls, Li\}JDr;ical ;-cr;.J bl::.,od, l1!,:,,0'1 pmr1ucl'.-. 01 tilriod fil,:1~.m;1 Hypodcri1,1r. 5yring,~r> 6.inr ncerUC!~, except whe11 dispcns.cd !or use with tnsul1n & other :.clf,1nif'C!dt:W d11JJJ~ n: 11:edu:21\ivliS Orl1gs. & mz'1ir.twnns r,:~r~d lo 1r.c1ucr: spon!c1neous. t non-:1pcm1,:1r;c,au~ ,1bo,runs Df!lgs & m~t'f!CJ.\ions lii5pcnsed or .:1dmirnst1:-red in ai1 oulp~licn! setling, mc\1t1int1 ouJµ;:i\1enl 110~.•pitnl lar.ihlics and phy!,ic·1ans.' 0Hices Proressi,:,nal char~1e.c; in conrwclton with ,1drnin;$\;_•1ing"" inwc.!in~l c,r rlispcnsir1g drn9s Drugs & mcdir.a!Jons U1al m;iy be obwined v;it~1oul a r,h·;:;!cian's wriltcn pm~;uipl!on, excep! irr:;ulin or niacin for chc!es.\ewl 10.,-.,e,ing and cr.rtain cver~the,coun!f:r drugs approved by the Pharmacy and I ilerapculi(;s CornrniUee lo be inch1dcd in lhe prcscriplion ctrug formulary Drugs & mcdicdtiw15 disµcnscd L:y or whde confined ir. a hosp:lal, skilled nursing f:~cilily, rest ho111e. sanatOi!Um, convale:i.cent hospital or simi!ar racih!~• Our.a!Jle medic a! equi1uncnl, dev1ce::s, app!irmce~~ & supplies~ even if prescribed by a physician, o,cep! co11lraccplive diaphragms. a~ specified a, covered in lhe Ccrli[1cate Services or supplies lur ".•.1lticti ihf! insured person is nol char~ied Oxygen Cosmetics & hcallh or beau!y aids, Drugs labelod "Caufon, Limited by Federal Law to lnvestiaalional Use.' er Mon-FDA approved invcstl9alioniJl drugs Any dn1g~ or medications prescribed fer expe(imontal indicaUons Any expense fa, a drug or med!cGlion inciJcred in excess of (a) the Drug Limiled Fee Scticdulc !or drugs dispensed by non-participating ph,,rmacies; or (h) the outpatient prescnp!ion drug negctialed rair, for dru~s dis,.ensed by pmlicipating pharmacies or lilrough lho mail servfce program Drugs which have nol been apprnve-.l for general use by !he Stale al California Depar!fnenl ol Heallh Services or tho rood and Drug /ldmi11islrn!icn. This does not apply lo drugs lhal are medically necP.ssary for a covered condilio:t Ove1-lhe counter smoking cessation dnJgs, This does not apply to medically necessary drugs lh;al the insured person can only gel with a prescripiion under stalu and federal law. Drugs used primarily for cosmetic purposes (e.g., Rolin-A for wrinkles}. However, this will not apply to Iha use of lhis type or drug for mertically necessary !realmenl of a medical cornlilion other than one lhal is cosmetic. Drugs used primarily to treat infer1ili()' (including, bul not limited to, Ctcmid, Pergonal and Me!rodin), unless medically necessary lor another covered condition. i\norcx1a11!s and dru1:-s used ior we:1~Jht !as$ r.>.tcr,I -.vl1c:1 us!:il la lrcili n;:,:t,1;J oti.;:::;ii·i {(HJ , rfo?I p11i:; & .~ppeh\o s,ipprec;:;an!s) On1gs ohlnined oul5Me !he U,S untess lhr::y arc fum,(.;h!!•j !fl connr:chon wilh lugent r:arn ot an emergency <.\!\ergy desensi!izatioo products Of ;.il[o,gy scrv111 ln(usiori drnrys, excopt drugs !!1al cue scl!,admrni~:ier(:d r.ubr..ut,:inef;u~l•1 lierbal supp!cmenls, nutritional ::nd dlo\;ny sup~l(m1enl~ excc11l for !ormulas for lhe healrnr:111 c,f r.henylke(onuria rrcsc1ip!ion drugs wilh a non-prnscripliori (ovcr-lhc-coun!et) chemical and dose eqt;ivaleni cxcepl insulin. This does n()\ apply ii an OVC!:r-lhe,co!mler equivalent was iried and w;,s in c(foc!iva Compound med!calions oblainr,d from other lhan a partictpa!ing phatmacy: Insured person will have lo pay th• full cost of the compo11n11 drugs ii insured person obtains drug at a non-partidpallng pharmacy. Specially phar11,acy urugs Iha! mus I be obtai11e,1 /rom the specialty pharmacy program. bul, which are obtained ftom a reloil pharrn~cy are nol covered by !his pl(ln. Insured pe.rson will have to pay the full cost of the specialty pharmacy drugs obtained from a retail pharmacy lhal insured person should have obtained from tho specialty pharmacy program. Third Party Liability -Anlhcrn Blue Cmss Life and Heallh lnsu1ance Company is enliUed lo reimbursement ol benefits paid if lhe insured person recovers damages from a legally liable lhird pa~y. CoordinaUon of Benefits -The benefits of lhis plan may be reduced if lhe insured person has any other group health or dental coverage so lhal the services received rrcm all group coverages do nol exceed 100% of lhe covered expense. Lumenos plans /JTovlded by Anthem Blue Cross Lffe and Health Insurance Company. Independent licensees of th• Blue Crass Assoclat/011. ® ANTHEM and LUMENOS ara registered trademarks of Anthem lnsuranco Companias, Inc. The Blue Cross name and symbol are registered marks of the B/ve Cross Association. Ho:t, do I find c participating network pharmacy? You ~an use your EmpiRx Health ID card at over 68,000 pharmacies nationwide including all pharmacy chains. You can find a network pharmacy by logging onto www.empirxhealth.,com or calling 877-262-7435. !Nhc: is o prior authorization and why is it necessary? Certain medications require prior authorization {PA) because of their potential side effects, potentially harmful interactions with other prescription medications, or to confirm they are being prescribed in accordance with Food & Drug Administration (FDA) approved indications. This process is designed to help ensure your-health and safety. If a PA is needed, EmpiRx Health will work directly with your physician to obtain the necessary information prior to fulfillment. How do I find out ifa particular prescription is covered by my benefits? Call 877-262-7435 to speak to a representative who can assist you with drug coverage questions or log onto www.empirxhealth.com for details. How can I find out if generic or lower cost alternatives may be available to me? Log into the member portal at www.empirxhealth.com and select "Drug Pricing." Search your medication and if there is a generic available, you will see the cost for both the brand as well as the generic. You can also call 877-262-7435 to speak to a representative who can assist you, or consult your physician or pharm~cist to determine if generic equivalents are available for your prescription. i:Vh}' does my copay change from month to month? The cost of medications changes regularly and prices are not all the same at each pharmacy. If your copay is based on a percentage rather than a fixed dollar amount then depending on the pharmacy you use and the cost of the medication at the ~ime your prescription is filled, you may see a variation in your copay amount. r his brochure is only a general description of your prescription benefit prograrn and it is npt a contract . . <\Ii benefits described herein are subject to the terms, conditions and limitations of the group· master :or.tract and applicable law. All personal health information is kept strictly confidential, as required by the privacy rules of th.e Health Insurance Portability and Accountability Act. SJV 1I of Fresno Prescri1ption Benefit :Plan San Joaquin Valley Insurance Authority EmpiRx Health Member Services 877-262-7435; TDD: 1~888-907-0020 24 hours a day, 7 days a week four ;,~,:scr:ption Benefit Program 1\nnu;,! Maximum OLlt of Pocket Amount i'<J.l' pl.,;, ;ncic:des ,, ~2,000 !ndividu.il / $4,000 family arrnual rn~ximum out of pocket amount. Retail Pi:;1rmacy Co payment You ere respori!,ible to pay the retail pharmacist the copayment per prescription which is :,,'.ed be'ow: $10.00 f()r a Ge11eric Medic~tion $20.00 for a Generic Me_dicatlo_n $2.0.00 for a Preferred Brand Medication ~35.00 for a Non-Preferred Brand Medication $40.00 for a Preferred Brand Medication $70.00 for a Non-Preferred Brand Medication TreG ,:, ,, i;isoen:;t~ ,\s Wrim,r Plar1 (DAW), meaning your pharmacis: mus: dis;ie'lse the generic ,,q,~:,·;-;lent drug when one is available unless your physician specifically requests the brand be dispensed. ,f you request the brand name rnedic:ation from your pharmacist, you are ccsponsible tor the difference in co.st between ,he ::irand and the generic plus the co payment. Retail quantities will be dispensed according to your physician's instructions written on the :'Jrescr'1pt:on up to a rnaxirnurn of a 90-day si;;:1piy, Please Note: If the cos:: of your medication is less than your calculated copayment, you will only oay the ca,t of the medic.ition. Mail Ord,:r Pharmacy Copayment rvia;nten;1nce r.~edications can be submitted to Benecard Central Fill, the ErnpiRx Health mail order facl,ity. Yo1.1[ pl~n a!lows for up to a 90-day supply with three (o-) refills, according to yo,1r phv,ician's instructions. Your copay amount will be: $20.00 for a Generic Medication $40.00 for a Preferred Brand Medication $70.00 for a Non-Preferred Brand Medication Specialty Medication Copayment Speci;iIty -nedications are high-cost biotechnology drugs requiring special distribution, hJr'diing. ,:ind administration. These medications are typically designed to treat c_hronic di:it:ase~ $10,00 for a Generic Specialty Medication $20.00 for a Preferred Bran!l Specialty Medicatio_n $35.00 for a Non-Preferred Brand SpecialtV. Medication Sp,;ciJl:y n1edica1i:)ns can be fil!ed one (1) time at a retail pharmacy. ,\ii future vescriptions rnust. be obtainel1 at 8enec;ird Central Fill's Specialty Pharmacy. Ple.ise note that specialty rnedicatiJ,s arc lirni:ed to a 30-day ,upply. Online Member Tools Maximize your benefit and find out how you can save on your out-of- pocket costs with our valuable member resource tool.son line at www.empirxhealth.com including: " Plan coverage details and copay information " Network pharmacy finder <> Mail service access to request refills and check order status o Updated preferred medication list Drug comparison pricing tool to identify lower cost alternatives Drug information " Recent personal drug utilizatlon history including the amount you have paid and what the plan has paid on your behal( This is helpful for year-end tax purposes Registration is easy! Along with your EmpiRx Health lD card, you will need basic member information, a phone number and an email address. Refer to our website periodically for the most recent pharmacy network finder ancl preferred medication list. by Preferred Medication List The Preferred Medication List is a guide for selecting clinically and therapeutically appropriate medications. It should not take the pl.lee of a physician's or pharmacist's judgment with regard to a patient's pharmaceutical care. Refer to www.empfrxhealth.com for the most: recent version of the Preferred Medication List. Exclusions Your prescription i:irogram covers most Medically Necessary, Federal Legend, State Restricted and Compounded Medications which, by law, may not be dispensed without a prescription. Be sure to present your EmpiRx Health ID card at a participating network pharmacy to receive a discount off the retail price of medications that may not be covered. V Retail Pharmacy Network Your EmpiRx Health prescription benefit program provides you with access to an extensive national pharmacy network, including all chain pharmacies and most independents. This plan allows for a 90-day supply of maintenance medications. Your ID card provides all the information your pharmacist will need to process your prescription through EmpiRx Health. To locate a participating network pharmacy, fog onto www.empirxhealth.com or call EmpiRx Health Member Services toll-free at 877-262-7435 (TDD: 1-888-907-0020). Mail Order Pharmacy The EmpiRx Health mail service pharmacy, Benecard Central Fill, is an option for you to obtain maintenance medications. Typically, prescriptions filled through mail service include medications used to treat chronic conditions and are written for up to a 90-day supply, plus refills. Prescriptions that you need to use right away should always be taken to your local pharmacy. You do have the option to obtain 90-day supplies through the retail network. For your first order, complete the enclosed Mail Service Order Form and mail it along with your original prescription using the pre-addressed envelope provided to Benecard Central Fill. You can also have your physician submit your prescription electronically to Benecard Central Fill or fax your prescription to 1-888-907-0040. Be sure that your physician includes the cardholder name, ID number, shipping address, and patient's date of birth. Only prescriptions faxed from a doctor's office will be accepted via fax. To order refills you have three options: • Internet: Visit www.empirxhealth.com. If you have not yet registered, click on Register. If you are a registered user, log in and select Mail Order. • Phone: Call Member Services toll-free, 877-262-7435, 24 hours a day, 7 days a week and use the prompts to order your refills. Have your identification number and credit card information ready. 0 Mail: Send the Refill Request Order Form provided with your last shipment back to Benecard Central Fill mail service in the pre-addressed envelope EmpiRx Health does NOT automatically refill your prescriptions. To avoid delays, always include the appropriate copayment (if applicable) when your order is placed. Visa, MasterCard, Discover, or American Express and debit cards are accepted. You may also pay by check or money order made payable to Benecard Central Fill. Please do not send cash. Please allow up to two (2) weeks for delivery. Emergency prescriptions can be expedited at an additional charge. Specialty Pharmacy Specialty pharmaceuticals are typically produced through biotechnology, adrnin1stered by injection, and/or require special handling ;rnd patient monitoring. Through the Specialty Pharmacy, you receive personalized attention to help you manage your· medical condition including one-on-one counseling with our-team of ;1harr:-;sicists and trained medical professionals. Our ciin,ca: te:,m partners with you and your prescribing doctor to ensure you ur,d(;rstand: How to manage your condition What medications you have been prescribed How to take your medication What lower cost options may be available Haw to coordinate delivery of your medication • How to safely handle and store your medication Shinments wil! arrive in senire, temperature-controlled packaging (if necessary) Jnd wi!t include everything you will need to take your medication. D.ue to the sers'tive natun: of specialty medications, some packages may require a signature. Where Can! Ship My Medications? vV,0 offer the convenience you need. Your medication can b,2 shipped directly to: • Your home Your work • Your doctor's office • Or ,1 convenient location of your choice Save with Generic Medications Generic equivalent drugs must meet the same Food & Drug 1\dminisuation (FDA) standards ~or purity, strength, and safety as brand name drugs. They also must have the same active ingredients and identical absorption rate within the body as the brand name version. If you wish to ,ake advantage of this savings opportunity, speak with your physician about the use of generics. You may also consult with your pharmacist regarding generic drug options that may be available to you. ID Cards If your ID card is lost, you may print a temporary card online at www.empirxh!=alth.com. If there is an emergency and you need a prescription filled, call EmpiRx Health Member Services toll-free at 877-262-7435 (TDD: 1-888-907- 0020) and we will provide your pharmacist with the required information to facilitate processing the claim. Direct Member Reimbursement If you must pay out-of-pocket for your medication which is covered by your pla:i, submit a Direct Member Reimbursement Form, which is available online at www.empirxhealth.com. You will need to pro11ide an itemized receipt showing: the amount charged, prescription number, medication dispensed, manufacturer, dosage form, strength, quantity, and date dispensed, Your pharmacist can as,bt you if you do not have a detailed receipt. Direct reimbursement is based upon your plan benefits and the amount reimbursed may be significantly lower than the retail price you paid; therefore, always try to use a participating r1etwork pharmacy and present your ID card to reduce any unnecessary out-of-pocket expenses. Disclosure Form 580 SJVIA • CO OF FRESNO (SAN JOAQUIN VALLEY Principal Benefits for Kaiser Permanente Traditional Plan (12/18/17-12/17/18) Health Plan believes this coverage is a "grandfathered health plan" under the Patient Protection and Affordable Care Act. If you have questions about grandfathered health plans, please call our Member Service Contact Center. Accumulation Period The Accumulation Period for this plan is 1/1/17 through 12/31/17 (calendar year). Out-of.Po,cket Maxhtu,1roj~ and Deduc~lblefs). For Services that apply to the Plan Out-of-Pocket Maximum, you will not pay any more Cost Share for the rest of the Accumulation P~riod or1ct1.vciu· liave:;reacnedJtie amounls•lisledb:~low. Self-Only Coverage Family Coverage Family Coverage Amounts Per Accumulation Period (a Family of one Member) Each Member in a Family of Entire Family of two or more two or more Members Members Plan Out-of-Pocket Maximum : .$1,500 $1,500 .· $3,000 Plan Deductible .• None None None Drua Deductible None • .. None .. ·• ·None Pr.ofessional Services (Plan.Pi'.oviderofffoe,visitsl You Pa~ . Most Primary Care Visits and most Non-Physician Specialist Visits ................ ,,.,..,.. $15 per visit Most Physician Specialist Visits ., ......... ,,v .. , ... , .... , ..... ,.,., .. ,,, ..... ., •• , ..•.. ,, .......... ,, •• , .... , ......... ,."., $15 per visit Routine physical maintenance exams, Including well-woman exams .... : ......... ,;.:~.... No charge Well-child preventive exams (through age 23 months)., •. ,, ...... , ............. ,., ... , ....... ,.,, .. ,..,,.~ No charge Family planning counseling and consultatlons ............ ,c.,.·.,:,,." .• ,.,.;, ....... , ........... · ••• '" ..... , No charge Scheduled prenatal care exams ................................... ,.,.,, ,.,,,v.,•,r. .. ,, ............... 1:-,·i•.·~, .,., .• ,•.,, No charge Routine eye exams with a Plan Optometrist ....................... ,.,.;;.:::;; ..... ;, ..... :.,;,., .• ,,., ...... No charge Urgent care consultations, evaluations, and treatment.,.,,.!••:-.. ,,,,, .... , ... , ••.•.•••..• , .. ,, .• , ...... ,.,. $15 per visit Most physical, occupational, and speech therapy .......... ~;;,• .. , .... ;., •• ,.;;,.; ..... ,., .... ~;·s,.-.•. ,. $15 per visit Outpaflent:Seryices You eay Outp~tient surgery and certain other outpatient procedures ........................... ,, •• ,c •••• $15 per procedure Allergy injections (including allergy serum) ... ,,,·.:,.••.,·•"""•":••······"···,···•·"·'''•')•,.• ... ,., ...... $3 per visit Most immunizations (including the vaccine);.".,:; ..•• ~ ....................... ; .... ,.,m ........ ;, .... , ..... No charge Most X-rays and laboratory tests •. , .... ,. .• ,,.,.,,.,,.,:.,: ... ,...," ........ ,.,., •.•. ,,., ..... , ..... , ... , .• ,., ... ,..... No charge Covered individual health education counseling ......................................... ., .... ,........ No charge Covered health education programs.,,., ..................... , ...................... , ........................... No charge Hospltalizati.on Seryices You ray Room and board, surgery, anesthesia, X-rays, laboratory te•sts, and drugs .. , .......... No·charge Emergency Health Coveraae You Pav Emergency Department visits ........ "' .................................. .,,..,"' u. .......... ., .... ,. ........ $100 per visit Note: This 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). Am.bulance Services You Pa)'. Ambulance Services ................. , ...... ., ......................... .,,_, .. ,.: .. ,,.." .............. '° ... , ....... ., .. $50 per trip Prescription Druj:I Coverage You Pay· Covered outpatient items in accord with our drug formulary guidelines: Most generic items al a Plan Pharmacy ................... , ............................................. $10 for up lo a 30-day supply Most generic refills through our mail-order service •.. ,. .. ,,., ........... HH«••·· ..... , .......... $20 for up to a 100-day supply Most brand-name items at a Plan Pharmacy ............... .,., ................................ ., ... $20 for up to a 30-day supply Most brand-name refills through our mail-order service ....... ""·····"•"'·• ................. $40 for up lo a 100-day supply Most specialty items at a Plan Pharmacy .. ,,. .... " .. ··· ....... :., ... ., ........ ," ... "'°''""·····r $20 for up lo a 30-day supply Durable Medical Equipment {DME) You Pav DME items in accord with our DME formulary guidelines., ...... ; .................. ., .. H .... , ..... 20% Coinsurance Mental Health Services Inpatient psychiatric hospitalization .......................... , ......................................... . Individual outpatient mental health evaluation and treatmenL ...... . Group outpatient mental health treatment.. ..... .., .... You Pay No charge $15 per visit $7 per visit (continue~.) Disclosure Form Chemical Deoendeoc .$.er:vlaes Inpatient detoxification ........ _.., .... " ... ,.,..,,. .. ,,.,., .............. , ...... ,, .. , .............................. . Individual outpatient chemical dependency evaluation and treatment... .................. . Group outpatient chemical dependency treatment ................................................. . Home Health Sitrvice, You Pay No charge $15 per visit $5 per visit You Pa Home health care (up to 100 visits per Accumulation Period) ...... ,,,. ... , ..... ,,.., ..... "'" No charge Other You Pa Eyeglasses or contact lenses every 24 months ........ ,, ..... ,, ..... ,, .. ,, ....................... -. ..... Amount in excess of $175 Allowance (continued) Hearing aid(s) every 36 months ........................... , ............... , .............. ,. ............. "' ......... Amount in excess of $1,000 Allowance per aid Skilled nursing facility care (up to 100 days per benefit period) ........... ,., .................. No charge Prosthetic and orthotic devices ............ ,., •. .-... , .. .,., .. , .... ,. ....... ", .... « .......... ,. •• ,.._."'" ........ No charge li9 ic~ care.,. •. ,.,,,.,.,,,,,..,.,,·· ,,,,,,.,,,,.;;,,,,,,, .• "''"""''·, .. ,,, .,,,,,,,.,, ........................ No char e This is a summary of the most frequently asked-about benefits. This chart does not explain benefits, Cost Share, out-of-pocket maximums, exclusions, or limitations, nor does it list all benefits and Cost Share amounts. For a complete explanation, please refer to the EOC. Please note that we provlde all benefits required by law (for example, diabetes testing supplies). Disclosure Form 580 SJVIA • CO OF FRESNO (SAN JOAQUIN VALLEY Principal Benefits for Kaiser Permanente Traditional Plan (12/18/17-12/17/18) Health Plan believes this coverage is a "grandfathered health plan" under the Patient Protection and Affordable Care Act. If you have questions about grandfathered health plans, please call our Member Service Contact Center. Accumulation Period The Accumulation Period for this plan is 1/1/17 through 12/31/17 (calendar year) . . Out,of~P<>/;ke:tMaxini.uJll(s)and Oeductible:(s) .. , For Services that apply to the Plan Out-of-Pocket Maximum, you will not pay any more Cost Share for the rest of the Accumulation F!entJ'd onc;e.vou have'reaofi(t(Hho ..;;II..,..;; ... -;;,,::.J ueilaW; Family Coverage Family Coverage Self-Only Coverage Amounts Per Accumulation Period (a Family of one Member) Each Member in a Family of Entire Family of two or more two or more Members Members Plan Out-of-Pocket MaximuUJ $'1.500 $1.500 $3,000 Plan Deauctlble None None None Druo, Deductible None None None . ...... Most Primary Care Visits and most Non-Physician Specialist Visits ......................... $15 per visit Most Physician Specialist Visits.:,,,., ••.•••. ".1, .. ,..,.,'., .... ,,..,,..,,.,.,, .... :•,•···•·•·••.•.•., .. ··:··• ................ , .•• $15 per visit Routine physical maintenance exams, including well-woman exams ..................... ,. No charge Well-child preventive exams (through age 23 months) ............................................ 0., •• No charge Family planning counseling and consultatlons ......... ,._ ••. , •• , ••••.. , ....................... ;;.;,.:,.: ..... ;,.,. No charge Scheduled prenatal care exams ..... ,.,.,,.,,•,.~··"-'''·'·''···•·~••,.•~.i.••~···•,.".,.., .•••• , •. :'"•''''·~··•,,,, ..• ~,,,.. No charge Routine eye exams with a Plan Optometrist •• ,,, ••.• ,,;,.,,., ... ;~ •• · ......... ~ •• ., .... , ............... ~ .... ,,. No charge Urgent care consultations, evaluations, and treatment. ................................................ $15 per visit Most physical, occupational, and speech therapy ...... :.:·:::: .. :.:;;:,.,;:;;,,.: •. ;;:.,.: .. :-.:.,.:: .... $15 per.visit Outpati.ent s~rvices YouJ~ay Outpatient surgery and certain other outpatient"procedures ......... , ... , .. i ..... , ........ : ... : ... $15 per .. prot:edure Allergy injections (including allergy serum) ..•• ,.,,•·•:t•'·''···•··••., .. ,.,: .... ,., ..... ,, .. ,,.,., ... , •..• , .............. $3 per visit Most immunizations (including the vaccine) .•• a ••• " .... · .. ., ... , .... , ..... , ...................... , .... .-..... No charge Most X-rays and laboratory tests ..... ,,.,., .. ,, ....... ,,, ... , ......... , .... , .......... ,.., .......... , ................. ,. No charge Covered individual health education counseling .................... · ............................. ,..... No charge Covered health education programs .... ,.. ........... " ...................... , ................. , .............. No charge .Hospitalization Servi~!:!S .. Yoµ PaX; . .,, . Room and board, surgery, anesthesia, X-rays; laboratory tests;,;;ind drugs ........... :: No charge Emergency Health Coverage You Pay Emergency Department visits ...... , ................... _.. ................................................. " ... ,. $100 per visit Note: This 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 .. .,. •. , .................... ., ..................... , ............................................ $50 per trip Prescription Drug Coverage Covered outpatient items in accord with our drug formulary guidelines: Most generic items at a Plan Pharmacy., .............. , ........................................... " .. . Most generic refills through our mail-order service .......................... " . ., .. .., Most brand-name items at a Plan Pharmacy .......................... , .... ,. ................... .. Most brand-name refills through our mail-order service ....................... " ...... ,.,,. .. Most specialty items at a Plan Pharmacy ............................................................ .. Durable Medical Eqµipment {DME) You Pay $10 for up to a 30-day supply $20 for up to a 100-day supply $20 for up to a 30-day supply $40 for up to a 100-day supply $20 for up to a 30-day supply You Pay DME items in accord with our DME formulary guidelines ................... , ....... " ...... ., ..... 20% Coinsurance Mental Health Services You Pav Inpatient psychiatric hospitalization ........................... : .............. ,. ....................... : .... No charge Individual outpatient mental health evaluation and treatment $15 per visit Group outpatient mental health treatmenL ................. ., .. .,.,. .• .,. $7 per visit 8%3 L'4 1.S000508966 Tradition.ii HMO ..... (continyes) ------ Disclosure Form Chemical De · ndenc Servicea lnpatienCdetoxification ··········· .... ·'-.. ., •....... :: ....... ., .......... ., .......... ,. ................. , .......... .. Individual outpatient chemical dependency evaluation and treatmenL ............. ,. .• ., Group outpatient chemical dependency treatment ........ ,.,..,,, ..... ,, .......... "•""" . ._ ... .. Home Health Services Home health care {up to 100 visits per Accumulation Period) n-••·""'····----· .. .,·•'····--· Other Eyeglasses or contact lenses every 24 months ............................. : .... : ........ : .. .-: ..... :. Hearing aid(s) every 36 months •(_. ... ., ... , ................ ,, . ., ............. ,w .... , ........................... .. Skilled nursing facility care (up to 100 days per benefit period), .... ""···•""""·"·--· .. .. Prosthetic _and orthotic devices,. .• ...,,." ............. ,., ....... _. ............................................ ,,, .. You Pa. No charge $15 per visit $5 per visit You Pay, No charge YouP Amount in excess of $175 Allowance (continued} Amount in excess of $1,000 Allowance per aid No charge No charge ch This is a summary of the most frequently asked-about benefits. This chart does not explain benefits, Cost Share, out-of-pocket maximums, exclusions, or limitations, nor does it list all benefits and Cost Share amounts. For a complete explanation, please refer to the EOC. Please note that we provide all benefits required by law (for example, diabetes testing supplies). 8'J63 12,U.5000508%6 fr~ditional Hi·/lO " __ _,, .. _,.._.,._ .. _ ··am---- Plan Benefit Highlights for: County of Fresno Group No: 05879 Primary enrollee, spouse (includes domestic partner) and eligible dependent children to the end of the month dependent turns age 26 Deductibles $50 per person/ $150 per family each calendar year Deductibles waived for D & P? PPO-Dentlsts: Yes Non-PPO Dentists: No Maximums D & P ~cunts t9ward maximum? 1 Waiting Period(s) Diagnostic & Preventive Services (D & P) Exams,.cleanin. sand :way~: BasiltServrces Fiillngi:;, simplE! tooth extraotiehs ~·ad ,sealants .· Eododontlcs (root c,aiials) C-pVe{ed Under Ma 'ot Services Peri~dtiiillC:s (gum treatment>. covered .Under Maior Sel'Vines . Orai S"t~rgeiy Covered Under Ma' or Ser.vices Major Services Crowns, inlays, onlays and. cast -,:e.s.toootign_s" ... Prosthodontics Bridqes, dentures and implants . $2,500 per person each calendar year No 100% 50,% 50% 50% . 50% 50 % .~P% 90% 50% 5D% 50% 50% Orthodontic Benefits 100 % 100 % Adults and de endent children After co-payment After co-payment 1--......,,.----=c;...;;.;:..i;...::..:_:___.;.;;...cc.;.~.;;.;...---+---------------+---------'--------- Orthodontic Maximum Adults (age 20 and over) Child(ren) (through age 19) One Orthodontic treatment per lifetime Maximum of 24 months of active orthodontic treatment $ 1,880 per case $ 1,880 per case $ 1,660 ,per case $ 1,660 per case * Limitations or waiting periods may apply for some benefits; some services may be e)(cluded from your plan. Reimbursement is based on Della Dental maximum contract allowances and not necessarily each dentisrs submitted fees. ""' Reimbursement is based on PPO contracted fees for PPO dentists, Premier contracted fees for Premier dentists and program allowance for non-Delta Denta·I dentists. bEilta-Qental of: Californla 100 First St. S~n Frailcisco:C/\ 94105 Customer Servic~ 8•0~76fr-p00~ deltadentali111s.com -c1anms:iXddress , f? .<). Box ~91330 ·Sacramento, CA95899,.:7330 • •• < This benefit info, rnalio11 is 11ol inte111kd or ci<e:,i,Jm,<.I tri repltlU:: or s,:,rvt', as the, plan's Evidence Qf C0•1eril(J(' or Surnrnary PIRn Description. If you trnve specific qucs\iorn; rerprdin9 lhe bunc:iilr,, lirnila1ior1s or c,xclusioi,s for yo1ir pl::rn, pleas,• consul! you1 company's beoelrls ,l'pre.0;;;11l,1live, !11 T f'PO-?COL. rmc (f<G'1.m.1os201 •1) SCHEDULE A Description of Benefits and Copayments Tbs Benefits shown below are performed as deemed apprqpriall:l by the attepd!ng,(fo1'1U·iiictBentistsv ieJ;.t,ta the limitations and exc;!J.Jsions of the Program. Please refer to Schedule B f,o'rfurthefclarifiealiltli1.of8er1efits, ~r,r~l.le · auttl discuss all ,ffeatm~nt options with their Contract Dentist prior to services beina rendered. Te. ~ ... tha.:f·a,.· pp:·e· _a· .. ~ 1n···i·ta· Ucs·ll. e. l.o.1J:1,IS",$p.,ecl·f.l~.all¥:l?ie.t10 .. e.}L ..... , . t.l.,lllde.lty.t,,,~ .. ,0;fB~9 ·~ll? 1qt~ lie•1nt.brpre,t!7,d u1;1 Q.DT-20'1'5 proc~t:1..1,1r;e,cocll;!S; t:l.l;!S. . riomar1 . '... ~m Darj~I l\ss).'lg)a'U~·n. The /\11,ari<t!!l)Den,ul As$'oci~.Ton·mil~Jl~~rtodt~atlx 91>£lated codes,,{!es·ct1ptonn1nd 11omenclalure·ro~y ·betp~e.d .m (!E!~~nllm'if!®"e ucrtte legislation. · ·· eNgoi.:1.EE COl:>E Dl$.iflli~ . ~'at El0100-D0999 I. DIAGNOSTIC D0120 Periodic oral evaluation -established patient .......... .,., ... ,~ ... ~•p.-:••.•·-•··••·•·~·~•·•·~"·•.•·· .. •······•··•··--.. ••u•, .... ~···• ... • .. •• No Cost D0140 Limited oral evaluation -problern focused .•..•.......•.... , .•...•...•.•.•.•••• , ......................... , ..... , .................. No Cost D0145 Oral evaluation for a patient under three years of age and courrsellng With primacy ·caregiver .......................... No Cost D0150 Comprehensive oral e\fal.uatlon -new or established patient ........................... ,., .......... , ........................ No Cost D0160 Detailed and extensive oral evaluation -problem focuseq, by report ........................................... ~.; •••• ; ..... No Cost 00170. Re-evaluatltm-' limited, problem focused (established 'p~ti~lit; not posi-opetl:ltlYe Visit). ...... , ......•. ,, ..•••..•••• , ....... , No Cost 00171 Re--evaluatton -post-operative office visit .......................................................................................... No Cost &:>9180 Comptebensive periodontal evaluatl0n -new or establhihed. patient •.• ,, ........................ , ........... .; ..................... No Cost D0190 Screening of a patient .........•..........•...•.........•••••..•.•••••..••..••...•.•..••. : ............................................ No Gast 0():191 Assessment of a.patient .................•.•••• ,., •. ; ...•.•••••.•. ,.! ........... , .............. ,.·.!•••• .. ··•······•, ................. u· ••• , •. • No Cost Db21:0 lntraoral ~ complete.series of r.adlographtc;imag~s -limited ro 1 series av.ezy'24 months,., •• ;;~,-:~~~·•··•.•,.·······""··· li,!6;0osi IJQ22b ll'l1raoral .,, pf1rl~p,icl:ll 1irti.t radlogr,aphic:image ...... , .•••••• ····~·•····,··,•·•1,.,,:.,,, .• .,..°', ...... ,.,, .•..••..•.... ;.,, ................ Nc;iJ!ost Ddza·o bitraoral -petiapical each additional radiographic linage ............... ~;~·.~••••••·~•;•.••·•···•~••·••••.••~.~:~•:.••· .. ··•·••• .. ····" No Cost Dri246: 'irit.raQral -pcQ.Jus~I r.'idjographic image ................ ,~ ••.•••• .,, ............ , .......... : .•.•••••••• : ••. '. •••.. : ..•• ,. ...... ,., •• ,,:;, .... :No Cost D0250 Extraoral -first radfographic image ...................................................... ~ .•....... ; ........................... ;: •• No C.ost D0260 Extra.oral -each additional rat11o·graphlc image ....... , .. , ................. ; ...• ,., •.. , ... ,. ........ , •.• , .. ,, ..... , ............... No.Cost D0270 Bitewing -single radiographic image .................................... ., .................................................. , ......... No Cost D0272 Bltewings -two radiographic images ........ : •.••. , .. i;,· ... •~··· ................. ~; ..................................... ,• •. ., ............. No Cost 00273· Bitewings three radiographic images ...................................... , ........................................... ,. ............ Na Cost D027.4 ·s1tewings -founadlographic._images -limited to 1. series every B months .......... , •• ;.,., ............... ; ................ No Cost D0277 Vertical bitewings -7 to 8 radiographic images •. .' .............................. :: .......... ; .... :· ... .-........ ; ............ "•···"' No Cost D0330 Panoramic radiographic image ............................................................................ .' ......................... No Cost D0415 Collection of microorganisms for culture and sensitivity .............. , ... , , ..................................................... No Cost D0425 Caries susceptibility tests .................................................................. , ........................................... No Cast D0460 Pulp vitality tests .......... , ........................ : ............... , ................... , .............................. ..,, ••.•..•.•• , .......... No Cost D0470 Diagnostic casts ............ , .......... ., ................................................................................................ No Cost D0472 Accession of tissue, gross examination, preparation and transmission of written report-available only when performed in conjunction ·with a covered biopsy .................. · .............................. ,. ................................ No Cost D0473 Accession oftissue, gross and microscopic examination. preparation and transmission of written report- avai/ab/e only when performed in conjunction with a covered biopsy ............ , .......................................... No Cost 0047 4 Accession of tissue, gross and microscopic examination, including assessment of surgical margins for presence of disease, preparation and transmission of written report -available only when perfonned in conjunction with a covered biopsy ................................. •;.; ..• , .................... · ................... ; ............................. ,.; ..••••• , •••.. No Cost D0601 Caries risk assessment and documentation, with a finding of low risk -limited to children age 3 to 19, 1 eve,y 3 years .......................................................................... , ....................... , ......... + ............................... No Cost D0602 Caries risk assessment and documentation, with a finding of moderate risk -limited to children age 3 to 19, 1 eveIy 3 years ............................................................................... , .................................... _ .. ,, ........ No Cost D0603 Caries risk assessment and documentation, with a finding of high risk-limited to children age 3 to 19, 1 every 3 years .............................. ,. ................. , .......... .., ........... ,.,, ........................ H ... .,-........................... No Cost 00999 Unspecified diagnostic procedure. by report -includes office visit, per visit (in addition to other services) ........... No Cost O1000-D1999 II. PREVENTIVE D1110 Prophylaxis cleaning-adult -1 per 6 month period .................................................. ,.;." ........ , ........... No Cost 01110 Additional prophylaxis cleaning• adult (wit/Jin Che 6 month period) ...................... H.. .. ........ $45.00 01120 Prophylaxis cleaning -child -1 per 6 month period .............................. ., ........... ; .. M ......... ., ................. No Cost D1120 Additional prophylaxis cleaning -child (within the 6 month pen'od) .... ,., ,..,.. .,.,...,.. $35.00 01206 Topical application of fluoride varnish -1 D1206 or D1208 per 6 month period ........................................... No Cost 01208 Topical application of fluoride -excluding varnish -1 D1206 or D1208 per 6 month peIiod ............................. No Cost D1310 Nutritional counseling for control of dental disease ....................... ,. ............... ,. .................................... No,Cost 01320 Tobacco counseling for the control and prevention of or.al disease ...... ,-...................... , ..... ··:··""·'·" .... , ..... No Cost 01330 Oral hygiene instructions .................................. , ....................................... , ................................... No Co,st D1351 Sealant -per tooth -limited to permanent molars through age 15 .............. -............................................ No Cosi D1352 Preventive resin restoration in a moderate to high caries risk patient-permanent tooth -limited to pennan~mt molars through age 15 ................... ,. ..... ., .....•.•• .,, ...... , .......................... , ....................................... No Cost 12)1:3.53 Sealant repair -per tooth -limited to permanent molaIS through age 15 ._ .............. ,. .................................. No Cost ~1'.!~~ Space maintainer -fixed -unilateral ................................................................................................ No Cost ..,,""''', Space maintainer -fixed -bilateral ......................................................... __ .. i ................. , ................. No Cost b 1rn2e, Space maintainer -removable -unilateral ...... ; ............. -... '° •• -................................................... , .... , ..... No Cost 0:[625 Space maintainer -removable -bilateral ................ , ............................ ,.. ........ ........ •• ... .. ......... •. .... •• . No Cost Dtli60 Re-cement or re-bond space maintainer .... ., ....... ,. .............. ., .............. , ............. , ......... i ... -.................. No Cost .ai:iiltt5 Removal of fixed space maintainer ,.. ... ,H.\tlt>U<lr._•~·· .. ""····•"u.lJ"l.~, .. ,..9Jlil'IIA.11<1J .. "f*'l~411Ufl• .. '4a-..4~··-........ .,. .. , •••.••• ~,. •• H ...... #,~UIO, No Cost D2000-D2999 Ill. RESTORATIVE -· ili,~~{li,;11n1t~ · · · ... ·· · . . .. .. Roplacementofor;oiJms, inlnys_end onlays requires the existing restgrniiqn.lp b.e :Ei+ }"(:?l'lCS old. . labs/a! or fn~offica plf.lcf!ltis;ed ~r~Wi1~pt)f!ti~,pj'<,di,lc!id thi-pqgp ,sp~ft:1lfzl';ld.te.qh(1ique or mat{!ria/s <ll'ftc . · r;f?nrgaanci1dditftinalfr.ut:mit ./o excMd/'l32liD(lin additia11 to.the listed Copaymont Rofarto Amalgam -·one surface, primary or-p~linanent ••·•··•••••• ........ , ....................... , •• , .••••. M .......................... No Cost Amalgam -two surfaces, primary or permanent ................. ,. •• ,~ .......... ! ........ "' ..................................... No Cost Amalgam -three surfaces, pnma,:y or permanent ............. , ........ -........ -.......................... : ...................... No Cost D2161 Amalgam -four or more surfaces, primary or permanent .................................. -.. : ............ ; ,.. .. ..... ... .. • .... No Cost 02330 ResJnabased composite -one surface, anterior ............... ,. ... , .. i·•• ....................................................... No Cost D2331 Resin-based composite -two surfaces, ariterior .., ........ ~ ......................................................... , ........... No Cost 02332 Resin-based composite -three surfaces. anterior ....... , ....................................... " ......... : .. ····--"·"·'·"·' No Cost 02335 Resin-based composite -four or more surfaces or involving incisal angle (anterior) .............. , ...... , ............... No Cost 02.~90 :Resin-based composite crown, anteriqr ..... , ••• ~: ....... ; ........ , ... · .......... , ... : .......... .' ..... ,,: .... " ....... ,.,'.., ............ ;. No Cost D2391 Resin-based composite -one surface, posterior ....... · ........... : ............................... , ... "'....................... $25.00 D2392 Resin-based composite -tv.ro surfaces, posterior ...................................................... ., ...... ,................ $30.00 D2393 Resin-based composite -three su1faces, posterior ........................................................ "................... $35.00 02394 Resin-based composite -four or more surfaces, posterior .......... ,.......... ...... $40.00 02510 inlay -metallic -one surface ................................................ •nH• ........ ., .... .,, ... n ................... No Cost 02520 Inlay -metallic -two surfaces ............................... '" .................... -................................... , ............... No Cost 02530 Inlay -. metallic -three or more surfaces ......................... , .• , ., ..................... ,. ................... a ................ No Cost 02542 Onlay -metallic -two surfaces .............. ......................... . ................ -................... No Cost D2543 Onlay-metallic. three surfaces ....................................... ., ............... ., ................ " ...................... ,. No Cost D2544 Onlay -metallic -four or more surfaces ..... -..................................................................................... No Cost D2610 Inlay -porcelain/ceramic -one surface•-..................... -......... ., .......... .,,, ........ ., ... ,,............................. $50.00 02620 Inlay -porcelain/ceramic -two surfaces• ........ "" ............... , .... ,.......................................................... $60,.00 D2630 Inlay -porcelain/ceramic -three or more surfaces• ........ , ................ , ............... , ..... ,., .......... , ................ $65.00 02642 Onlay -porcelain/ceramic -two surfaces• ........................... ,. •... , ....... ,. ., .......................... .,....... ........ $55.00 D2643 Onlay -porcelain/ceramic -three surfaces• ............................................................... , .. , .................... $65.00 D2644 Onlay -porcelain/cemmic -four or more surfaces* ............. ,............. " .......................................... $70.00 02650 Inlay -1·esin-based composite -one surface ....................... .,............... . ...................... •rn• ........ ...... $'15.00 0265·1 Inlay -resin-based composite -two surfaces ...................................................................... .,. .. $20.00 D2652 Inlay -resin-based composite -three or more surfaces ................. "' .......... "............................ $30.00 D2662 Onlay -resin-based composite -t:1,vo surfaces .............. ., ........... · ........................................ d.... .. $25.00 02663 Onlay -resin·based composite -three surfaces .. ... .... .... ........... .... •. ...... .... ... ....... $35.00 02664 Onlay -resin•based composite -four or more surfaces .... .. .......................... ,.. "..... .. .... $50.00 0271 O Crown -resin-based composite (indirect) , ........... ,. .. Crown -¾ resin-based composite (indirect) .......................................... "' .......... ,, ....... . D2720 Crown -resin with high noble metal ............................... ,.i ............ n,., ............................... ·:·•···•.• .. ·•··· $30.00 D2721 Crown -resin with predominantly base metal ................................................................... ,................. $15.00 02722 Crown -resin with noble metal ...................................................... ;.· .. , •••• , ................................. , ... ,._., $20.00 D2740 Crown -porcelain/ceramic substrate* ............... -.... ..-................. , ................... , •. .-,:., ............... , ............... $85.00 D2750 Crown -porcelain fused to high noble metal* ................................................................. ! .... , ....... '....... $70.00 D2751 Crown -porcelain fused to predominantly base metal ................................. ..,... ................... .................. $55.00 D2752 Crown -porcelain fused to noble metal .............................................................................. ,.............. $60.00 D2780 Crown-¾ cast high noble metal ................................... ~ .......... , •• ; ........................... «.,;~ ........................ , ... $70.00 D2781 Crown -¾ cast predominantly base metal .............. ,, ..•••..•..•... » ............................ .-............................. $55.00 D2782 Crown -¾ cast noble metal .......... " ... , ... ~ ... ".,. .. ~.,, ......... -t>i-•••~·"" .. " .. «"• .. '1!••~•A .. ~4-. .. -~.~Jl'·•·• .. •,,t4t.l"''~·,,.,•••••,,••"•••••-"I•~•.--~ ........ ., ............ ~ $60.00 D2783 Crown -¾ porcelain/ceramic* ..................................... ,·.. •• • . . .. . .. • •• . • . .. . .. • . ... . .. .. . . . .. . . . . .. . . ... . •....•.. ... .. .. . $70.00 02790 Crown -full cast high noble metal .... .:.-. ••• ;: ... ;=.~.,,-; ............. ~ ...... ., ...... t, ••• ~.;•.~:••; .................... ; •• ,................. $70.00 D2791 Crown -full cast predominantly base metal ...... : ......................................... , ...................................... $55,00 D2792 Crown -full cast noble metal ........... , ........... '. ... ~ .. ~.,-• .. ··•·•··., .. , .................................................. ; •••••••• $60,00 D2794 Crown,_ titanium ................................. , •. ,., ... , ........ ,., ..... ,, .. , .. , •. _ .. , ..... ,, ................. , ......................... $70.00 D2910 Re-cement or re•bond inlay, onlay, veneer or partial cover~ge restoration ,•)••••ar~•,..•.,..,.,, .... ~ .•. , ........ ~.M••··--No Co~t D4915 Re-cement or re-bond Indirectly.fabricated or prefabricated po.~t and cor~ ., ....... ,,, ..................................... No Cost D2920 Re-cement or re-bond crown .......... f.,.,. ..... : •.••. -..!'·t--u•.•.H:t:~✓-.f'~"'~:•"~ ~,.,~,o•·-... ~•• .. : ... ,:t~·!',.,,:'!.,u;.:•:~i!,•:!(t"(-!':., ... ~~-• .. :..,;u•'<f•H'°'·.~••.'-:~•-····· No Cost 02921 Reatta~hmel'\t of tooth fragment, incisal !:)dge or q1,1sp (~vterlqrJ ........ ,, ... ,.,.,., ......•.•.. ,, •. ,;., ......... , ................. No Cost 02929 Prefabricated p.orcelain/ceramic crown -primaiy tooth -an.tenor ................... "· ............................. , . . ... . . .. No Cost 029'30 Prefabricated stainless steel crown -primary tooth ... , ...... ,. .• , .......... , .• , ...... , ... , ...... ~ ... , ..... , •• , .... , .............. No Cost 02931 Pr.efabricated stalnle.ss steal crown -permanent tooth ................................................................ ,., ...• ;., .• No Co13t D2-932 Prefabricated resin crown -anterior primary.topth ........ ,., .. , • ., ........ , ........ , .............. , ... , ........ , ................. No Co.st D2933 Prefabricated stainless steel crown with r:esln window~ a'(ltetior primary tooth .. .. .. • • . .. . •. ... . .. . • .. .. . .. .. .. . .... • . .. . No Cr;,st D2940 Protective restoration .................................... , ......................... , ........................ , ................................ No Cost 0294,1 Interim therapeutic resti:ir.ation -primary dentition ................... ; .. ;,. .......................................................... No CQst -'· D2949 Restl'lrativ.e foundation for an lhe!lrect resto.r.ei.tibO-..... , .. i-.. , ............... ,i ........................... , ....................... : No Oost D2950 Core buildup, ihcluding any pins when reqaired .......... ~ ..... , ............... , ...... ,.;· ....• :, ...................... , ............... , No Cost D2951 Pin retenticm -per tooth, in addition to restoration ,. •• ; ... !·;~ •.• ,.!:.~; •.•.•••••• ,·:.. ......... ,, ....................... ~ .......... , ....... No Cost 02952 Post al'.ld core in addition to crown, lnoir~ctly fabtfc1;1t~d -indlLJdes eanal'preparatlon ... , ............. · .................. No.Cost D2953 Each additlonal indirectly fabricated post -same tooth -includes canal preparation ••• , ................ , ................ No Cost D2954 Prefabricated post and core in addition to crown -base metal post; includes canal preparation ............ ., ......... No Cost D2995 ,, ,Po~t r:erno~y:~I . •!,-~:,,..•n:-~~-·•"'t•~•~.•-•.".'!-~••1",!'"''._~,;•'"! •~,J.•t•.•},.~-:~.·-.,.~'!··~\--,. ... ~h.!',\~~~~,!,'t:''!:. .. ,r.:~r,.'.,rl'f,.f, ... ~."f.'~.:~r-t~~;,~~---,~,..:"····':.~-!"f'.··· -•. ·-.~.~I ................ ~o ~-«?~t D2957 Ea9ti add\Uonai.prefoibri~atad posf-same tooth -base m'?fill post; includes ¢anal preparation ...... ~ ..... , .......... No Cost D2960 Labial veneer (resin laminate) -chairside -limited to replacement of significant tooth stmcture Joss due ta caries or fracture .................................. ., ............................................................................................ $245.00 D2961 Labial veneer (resin laminate) -laboratory -limited to replacement of significant tooth structure loss due to caries or fracture .............................................................................. , ................ , ................................. $295.00 D2962 Labial veneer (porcelain laminate) • laboratory -limited to replacement of significa·nt tooth structure loss due to caries or fracture ................................................... v·.,.. ............. i .. ,1-.............. , ~-....... , ............... #,.•*'"'·~ ••• , ....... ,.,. •••• , •••••••• $345.00 D2970 Temporary crown (fractured tooth) -palliative treatment only ...... , ................................. ., ....................... No Cost D2971 Additional procedures to construct new crown under e-xisting partial,denture framework............................... $14.00 D2980 Crown repair necessitated by restorative material failure ...................................................................... No Cost D2981 Inlay repair necessitated by restorative material failure .................................. .,.,. ........ ,. ................ , ....... No Cost 02982 Onlay repair necessitated by restorative material failure . . . . . . .. . .. ... . ..................... •• ....... ....... ... .. •. ... . ... ...... No Cost 02983 Veneer repair necessitated by restorative material failure ............................................................ ,..: .•••. No Cost D2990 Resin infiltration of incipient smooth surface lesions -limited to permanent molars through age 15 ................... No Cost 03000-D3999 IV. ENDODONTICS D3110 Pulp cap -direct (excluding final restoration) .................................................................................... No Cost D3120 Pulp cap -indirect (excluding final restoration) ................................................................................... No Cost D3220 Therapeutic pulpotomy (excluding final restoration) -removal of pulp coronal to the dentinocemental junction and application of medicament ............................................................ ,. ............. : .................................. No Cost D3221 Pulpal debridement, primary and permanent teeth .............................................................................. No Cost 03222 Partial pulpotomy for apexogenesis -permanent tooth with incomplete root development ...... ., .. ·., .................. No Cost D3230 Pulpal therapy (resorbable filling) -anterior, primary tooth (excluding final restoration) ......................... _ ......... No Cost D3240 Pulpal therapy (resorbable filling) -posterior, primary loath (excluding final restoration) , .............................. No Cost D3310 Root canal -endodontic therapy, anterior tooth (excluding final restoration) ................. ., ............ ,............... $20.00 D3320 Roof canal-endodontlc therapy. bicuspid tooth (excluding final restoration) ............ " ... ,. ................. ,_........ $40.00 D3330 Root canal -endodontic therapy, molar (excluding final restoration) ........... , ... ". .... ..... ..... .. . .••• ......... ... . .. .. $60.00 03331 Treatment of root canal obstruction; non-surgical access .............. , .•••. h .............................................. , $40.00 03332 Incomplete endodontic therapy; inoperable, unrestorable or fractured tooth ..•.. .............. .... •• . ... •.. ..... •. ........ $40.00 03333 Internal root repair of perforation defects ............................................................... , ......................... ,. $40.00 D3346 Retreatment of previous root canal therapy -anterior ...... , ...................................................... , ........... " $36.00 D3347 Retreatment of pravlous root canal therapy -bicuspid .............. ~ ..................... ,.................................... $60.00 03348 Retreatment of previous root canal therapy,. molar ....... " ..... ,, ....... ; ................ ; ....................... ,............ $95.00 03351 Apexificalion/recalcificalion -initial vis1t (apical closure/calcific repair of perforations, root resorption, etc.) ..•.. .... . $55.00 D3352 Apexification/recalcification -interim medication replacement (apical closure/calclfic repair of perforations, root resorption, pulp space dislntection. etc.) ................. : ••...•..•.. , ...... , ............................................... ,...... $45,00 D3353 Apexification/recalcitication -final visit (includes completed root canal therapy -apical closure/calcific repair of perforations. root resorption, etc.) ....... ,. ... °' .................................................... ;:, ........... / ... ., .......... "··· $4'6;00 03410 Apicoectomy -anterfor .......................... " .................... , ..................................... .-.......................... NoC09t D3421 Apicoectom_y -bicu_spid (first root) ................ ""··•· .. ·•"•·•• ................... ,. ................ · ....... ,. ....................... No Cost D3425 Apicoectomy-molar (firsi root) ...... ~ .... ~ ........ : ....... ; .. ,: ............. ., .... , ... : .................... ,. .......... ,., ......... No Cost D3426 Apicoectomy (each addtlional root) ..................................................... ,. ..... , ........................ , .. : ........ No Cost 03427 Periradicular surgery without apicoectemy ................................ ~ ........... , ....................... , ..................... No Cost 03430 Retrograde filliAg., per toot ......................... ; ......................................... , .. , ..................................... , No Cost D3450 Root amputation" per root ••.•••.. ,, •• ,, ................. " ... , ......................... , .............. .' ..................... ; .. • ......... , .. No Cnst D3920 Hemisection {including any rtltlt removal), not including root canal therapy ................................. , •..•.•••••• 0. No Cost 04000-D4999 V. PERIODONTICS -Includes preoperative and postoperative evaluations and treatment under a local anesthetic. D4210 Gingi11ectomy or glngivoplasty -four or more contiguous teeth or tooth bounded spaces per quadrant .............. N.o CQi>t 04211 Gingivectbmy or gfngivoplasty -one to thf'l;ie contiguous teeth or. tooth bounded spaces per quadrant ............... No Qost, D4212 Glriglvectomy. or giligivoplasty to allow acc~ss for restotati:v~ proced0re, per tooth ........................... , --"·······. No Cost 04240 Gingival flap proced1,1r~. induding root pl~nlng -four or more contlgl!ous teeth or tooth bounded spaces per quadrant ....... ~ ...... "'~~, .... .;, ,4.·,.~,, •• ·•~-...... ":' •• I ••• ""'"'· ............... 1o•• '""'"''" .-,~ ... .,.,. ............... ~ ..... ~,. ...... ~ ~ ................................. ., ....... '-1•• .•• No Cost D4241 Glngival flap procedure, including root. planlng -one te three contiguous teeth or tooth bounded spaces per quadrant ............... , ............. :,, ............................ .:, ............ ,..·, .. ,. ..................................................... No Cost 04245 Apically.positioned flap ••. , .... , ••.. , ...................... _.,, •... , .. ,_.., ..... , ................. 1 ... , ........................ , ............. . 04249 • ,Clinical crown lengthening -hard tissue .. , .. ,.-.... ;;, ............ · .................... , ... : ............................... ·; ..... , ....... : D4260 Osseous surgery (including elevation of a full thickness flap and closure) -four or more contiguous teeth· or tooth bounded spaces per quadrant . ..... .. ... .. . . . . . . ......... .... .. .. . .. . . . . .. . . . . . . . . . . . ... . ... ... . . . . . . . . . . . .. . .. . . . . .. ... .. . ... . . .. . . $75.00 D4261 Osseous surgery (including elevation of a full thickness flap and closure) -one to three contiguous teeth or tooth bounded spaces per quadrant ................................................................................ ,,............ $60.00 04263 Bone replacement graft -first site in quadrant ............................................ , ....................................... $125.00 D4264 Bone replacement graft" each additional site in quadrant ......... ,. ................. ,........................................ $45.00 D4266 Guided tissue regeneration~ resorbable barrier, per site .. ................. ..... ......... ............ ... ... . ............... $100.00 D4267 Guided tissue regeneration -nonresorbable barrier, per site (includes membrane removal) ......... ., ................ $140.00 04270 Pedicle soft tissue graft procedure ... ,........... .... ........... ........ . ................................ ,, ................ $125,00 04273 Subepithelial connective tissue graft procedures, per tooth .............................. ,... . .......... , ......... ".... $75.00 D4274 Distal or proximal wedge procedure (when not performed in conjunction with surgical procedures in the same anatomical area) ............................... , ........... , .... ., ........ .,... ... .. .................. ,. ........ .,"•···----... , ... No Cost D4275 Soft tissue allograft ............... ,. ............................. ., ...... ,,,.., .... ,. ............... " ............................... · •• $115.00 04277 Free soft tissue graft procedure (including donor site surgery), first tooth or edentulous tooth position in graft ...... $·125.00 04278 Free soft tissue graft procedure (including donor site surgery}, each additional contiguous tooth or edentulous tooth position in same graft site " ... ., ................................. ,........... ... ... ,.-m. $125.00 D4341 Periodontal scalinf) and rool planing. four or more teeth per quadrant. limiled lo ;J quaclmn!s c1uring any 12 consecutive months ................ .-. . .. . . . . .. .. .. . . . . . . .. . . . . . . . . . . . .. . . .. . . . . . .. . . . . . . . . . . .. . . . .. . . . . .. . . .. . . . . . . . . . . . . . . . . . . . .• No Cost 04342 Periodontal scaling and root planing • one to three tee1l1 per quadrant• limited to 4 quadrants du~ng any 12 consec11/1ve months . . . .. .. . . .. . . . . ... . . .. . . . . ... . .. . • . . . .. . . . . .. . . .. .. . . .. . . .. . . . . ... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . No Cost D4355 Full mouth debridement to enable comprehensive evaluation and diagnosis -Jimiteri to 1 !mn!rnonl in any -/2 consecutive months ................................. , ......... ., ........................................... , ... " ............... __ ,. ... No Cost 04381 Localized deiivery of antimicrnbtal agents via a controlled release vehicle into diseased crevicular tissue, per tooth -for cDcii oi !ho first iwo /eei/1 /re:clied within a qoao'riJn/ following root planinq or 1w1in1Jonlai n:ainlu, 1a11u, • $all.DO 04381 Localized delivery of antimicrobial agents via a controlled release vehicle Into diseased crevicµlar tissue, per tooth -for an addftlonaf tooth treated In the same quadrant following root planing or periodQntal maintenance ..•.• No Cost 0491 O Periodontal maintenance -limited to 1 treatment each 6 month period ............... ,. ....... ., .......... , .. , ............ Na €6sl 0491 0 Atlt'!itfuinal periodontal maintenance (within the 6 month period) ............................. ,...... ... .. ............ •. .... ... $l'i{i0Q 04921 <3,ingival inigation -per quadrant ......................................................................................... , .. ~ ......... Nb Cost D5000-D5899 VI. PROSTHODONTICS (remo~able) • .;:, fqGJ1ll tfst~d:tf entu1vs and 1J.Eirtili1,de,:i,l~tm_$, ~b . m.enl' it1cfut!.l'Jlr <tff,er B.i six n1,on1.hs·~f(e_r,plii~ement. •rh~ EFjjrotle'e,:li!US . . iif:ftto lje ,iltg/JileJ whore the, deri_~urD o/,as·o.rfgl11p}Jsr er~d; . ·· -Rebas-es:. r.ellnes andtfssrm cg.. !Jlmlt~ate> 1peP(J~ntu.r~ diJriJJCJ, any 12 consecutive months. -Replacement of a denture or a parlfl!I · requfre:Mhl:l eils(fng t:J.Mtu(tJ to be Q"+ years old. D5110. Complete dentll.re -maxJUary •l,,••·· .. ,·.""·' ... ,.•,,••.•···•• ........... •:•,.••.•··"··•'·• ... •···•···· ...... " ••• , •• , ......... ., .•••..•• ,_, ............. .. $75.00 $·75.00 $85.00 $85.00 $80.00 $80,00 05.1:20 Complete denture -man<;libula-r ................................... , ................ , ........................ , ....... " .•.•..• " •••.•••••.. ,£>5130 Immediate denture -maxillary ••••••. , •• , ................ ..,., .•• ,,:,.,, ••• :. ............ , ...... :, ......................................... :, •• , ...... . D.5:'1.40 Immediate del)ture ~ mandibular ......... , .. , ........... , ........................ , ....... ,, .................... , ................... , .. . ·os211 Maxillary partial denture -resin base (including any oenventional clasps, rests and teeth) ....................... , .... . 0511';2 Mandib1,1lar partlal denture -reslh baSf:\ (lflcludli'J9. any conventienal clesf;la. resta 1;1nd teeth) ...................... , .•.. JJe;2j'$. Maxillary partial denture -cast metal framework with resin denture base.s (Including -any conventional clasps, rests and teeth) ................... , ......................................................... : ............................................ $95.00 D5214 Mandibular partial denture -cast metal frameworkwith resin denture bases (Including any conventloAal clasps, D.5225 D5226 D5281 D'5410 D54:11 05421 '0542-2 D5510 D5520 D5610 D5620 05630 D5640 D5650 D5660 05670 05671 D5710 05711 D5720 05721 05730 D5731 D5740 05741 D5750 D5751 05760 05761 05820 05821 05850 D5851 rests and teeth) '"'!,r• >••·"•!'.~-:" ... ~~•~,!•,~--•!' •.•···~·--::"~~~~·· .... , .... ~·~•~ ........ #,•~·••! .. A•1\~'.•~·---"·•:•~·"'••"! ... ,.~ ....... ·······»"'·· .... ., ... ,.,.,. ~--·~~•-•.••>t .. ••·••'"4'.••· $95.00 Maxillary PF1rtlal ctentur13 -flexibl~ ba$e .(lnclu~ing any c!E1sp:h rests and teeth) ................ : ............. ., •. ". ,·, .... $195.00 Man.dlbular partia·1 denture -flexible base (including any clasps; rests and teeth) ............. ,.~·•· ....... ., .. ,,., .. ,,, ..... : $1,S:~PQ Removable unilateral p~rtlal denture-. one piece cast mefal «nel!.ldlng,claspi; and teeth) ................................ $80.00 Adjust complete denture -ma)(]llary .................................................................................................. No CQst Adjust complete dentur~ -mandibular .,,., ...................................... ., •.•• :•• .. ·•······ .. ·····•"···"· ................... No C.ost Adjust partial denture -maxillary .............. " .................................................... , .................................... No C.ost Adjust partial denture -ma.n<;l\bul1:1r ............................ ~, .................. ,, .......... ; ..•. ::c ............................... No Cost Repair broken complete c;l~nture baser ............... ; ...................... ; ........................... ; .................... , ...... ; .... No ~ost Replace missin•g or broken t:eeth -complete denture f&aah tooth) .. ~ ....................... , ........... , .... ~ •..•.••.•••••• ;.; No Cost Repair resin denture bi'i$e ...... , .• ,, •.. , ........................................................ · ••. · .. , ................................ No Cost Repair cast framework ....... .,. .. 11••>••9~ .. · ...... ,. ... ,.il<.lo>••"'" .... ,, .................... ~ .......... ,. ..... ,. ..... -~~"'·" ..................... " ............... ,iil .......... ~ ..... " .............. No Cost Repair or replace broken clasp ............................................................. "' • .,.... • .. .. • ....... ... •• . • .. .. . . .. . .. . No Cost Replace broken teeth -per tQoth , .• ·'.~.,,., •. ,'.~·•• .. •,r-, .... ~.•.•·~~,~•.~·''··,'.·•.•--•.«.-••·.~···••.•·· .. ~·•.•.-•:""" ....... , .•. ., ............. ; ...... No Cost Add tooth to existing.partial denture .;.' ....... : ......... ; ...... : ... :· ........ : .. : .... ;; ... '..; ...... :; ..... ; ... .' •• ~ ...... : ....... :: .. No Cost Add clasp to existing partial denture ................................................................................................ No Cost· Replace all teeth and acrylic on cast metal framework (maxillary) :......................................................... $65.00 Replace all teeth and acrylic on cast metal framework (mandibular) ...... 0 ......... , .. ,................................ .... $65.00 Rebase complete maxillary denture ................................................................................................ $30.00 . Rebase complete mandibular denture ...... , ....... ,................................................................................ $30.00 Rebase maxillary partial denture ..................................................................................................... $30.00 Rebase mandibular partial denture ......................................... , ... , .................................................... $30.00 Reline complete maxillary denture (chairside) ................... , ................................................................. No Cost Reline complete mandibular denture (chairside) .................. ; ................. , ............................................ No Cost Reline maxillary partial denture (chairslde) .......... ,., ....................................... ; .................................... No Cost Reline mandibular partial denture (chairside) ............................. ,. ..................................................... No Cost Reline complete maxillary denture (laboratory) .................. , ... ~...... ................... .•...•. ...... .... .................. $25.00 Reline complete mandibular denture (laboratory) ....... , ...................................................................... ;. $25.00 Reline maxillary partial denture {laboratory) ............................ , ........ , ............. " ............... , ... , ................ $25.00 Reline mandibular partial denture (laboratory) ..................................................... , .......................... , •. $25.00 Interim partial denture (maxillary) -limited to 1 in any 12 consecutive months ............. , .............................. No Cost Interim partial denture (mandibular) -limited to 1 in any 12 consecutive months .......... .-.. ,:•··•--·•·· .. •····--·--·--... No Cost Tissue conditioning, maxillary ........................................................................... , ................................ No Cost Tissue conditioning, mandibular ................................................................... , .... , .................. ,. ........... No Cost D5900-D5999 VII. MAXILLOFAC!Al PROSTHETICS • Not. Covered DG000-06199 VIII. IMPLANT SERVICES· Not Covered D6200-D6999 IX. PROSTHODONTICS, fixed (each retainer and each pontlc constitutes a unit In a fixed partial denture [bridge]) -When a crown and/or pontic exceeds six units in the same treatment plan, an Enrollee may be charged an aadll.lonal $125.DO per unit, bey,ond the 6th unit. -Reji(tiaaiffent of a crown, pontic, inlay, cmtay or stress breaker requires the to be ,~iimr1.bninrJ,Jabor:atory,pmbessed?,f1n,bfflcfi.~RiceSMd . .. ftM1pi;,ura.1nw·a 1~''""'"'1111" o.rmnrnnnlsam mclorin/11pg111df.Js. The ContmGLDiilqllst1may0cl)!i11Je an Umilatloi1 of Bane/its 114 for adllilfonal infaititation. D6205 Pantie -indirect resin ·based composite ...... , .................... ,_ ............................................ ,. .............. ,. D6210 Pantie-cast high noble metal ............. , .............. , .......................................................... ; ... ., .......... . D6211 Pontic -cast predominantly base metal ......... , •..•.• ,.,, .... ,. .. .-, .......................... "" •.• , ........... , ........... , ........ . D6212 Pantie -cast noble metal ................. .,, •••.•••• 1 •• , .••• ,., •• , •• ; ................ , ............. , •• ! .............. ., ................... , •• $60.00 06214 Pantle~ titanium ................................................................... , ...................... ., .............................. $70.00 D6240 Pontic -porcelain fused to high noble metal* .,, ........ ,, .............. ,,, ..... , .... n ................................................. , $70.00 D6241 Pantie -porcelain fused to predominantly base metal .......................................................... ,.............. .$55.00 06242 Pantie -porcelain fused to noble metal .••t•Y••·· .... •:•••:••--·,-·; ............ : ......................... ; ..... ;, .......................... , $60 . .00 D624S Pontic -porcelainlceramfc" ......................................................... ._ .......................... , ......................... $70:0o 06250 Pontic -resin with high noble metal .................... v, •..•••• ~ ••. ;; ............ a.· ••.•.• · .......... ,,., ........................... ~......... $3.0JJO 06251 Pantie -res1h With predom!naritly base metal .• ; ........ ;~~, •••••••.•• ; ........ , .. , ................... : ••.• u••···· .. ···--····•·"·• $':tei,PO 06252 Pontlc, -resin with noble metal ··""~,,_.~ ... ~,.. .... ~ .. ,, ....... " ... ";,"'l'••·,.,,.,"~"'·--·~ .. \o•,~*',.,. ... ;,,'1, .... ,..~,.'t-~,.~"")h,•~,•,·•--,.~~11,.-t'"'""*••·•;? ..... , .......... $20.00 06600 Inlay-pCirce.iajl'I/CE)n;!n'IIO, 1'No surfaces ....................... , ••. , .......... , .• , ... p••············ ... ~ ........ , .. , ..... , ............. ieo.Qo 06601 Inlay ~ p.orcelaln/oeramlc, three or more surfaces ....... ,~,: •••••••••••.•• ~ ................... ,..... ... . .. ... . . .. .. ..... . . .. . ... . .. $(5.5.00 D6602 Inlay. -cast high. noble m.etal, two ~urfaces ................. : ................................................................ ,..... ·$71:LOP 06603 l!'llay-.cast high noble metal, thtee or more surfaces ...................................................................... !•~... •:ii'?0 •. 90· - 06604 Inlay-cast predominantly base metal, 't'Wo surfaces ......................................... , ......... , ............ , .......... NqCost D6605 lnl.ay-cast pre!iominantiy base meta!, three or more surfaces ................................................................ No Cost oa·eos Inlay~ cast noble metal, two. surfaces ........................ ,.......................................................................... $60.00 D6607 Inlay -cast noble metal, three or more surfaces .............................................................................. ,. $60.00 D6608 Onlay -porcefain/ceramic. two surfaces ......................................................... ,................................ $55.00 06609 Onlay -porcelain/ceramic; thre.e or more surfaces .......... ,, .. , .•. ~,,,, .... ,., ........ ,. •. , .... ..,., ..... ~ ••• :,.,• .. ,• ... ••··••:•-•:~,.,.... $66.00 0661 O Onlay -: cast high noble metal, ·11-vo surfaces .......... ." .................... : : ............ : ................... : .. . .... • .. . .. .. • . .. . $70.00 06611 Onlay -cast high noble metal, three or more surfaces ................. ,. ; ....... , • ., ..... ,. •. ., ......... ·--·... $70.00 06612 Onlay -cast predominantly base metal, two surfaces ...................... ""'""""' .,.,.._., ........... ,.., ................ No Cost 06613 Onlay -cast predominantly base metal, three or more surfaces ........................ ,., .... ,. ........................... ; No Cost 05614 Onlay -cast noble metal, two suifaces ................................... ., ................................. ,...................... $GO.OD 06615 Onlay -cast noble metal, three or more surfaces ..... , .......................................... · ............................. ,.. $60.00 D6710 Crown -indirect resin based composite .. . .... ... ..... .... . • .... .. .. • .. .. .• .. . .. .. ... . .. ... .... .... ... .. ... .... •• . ..... . . . ........ $30.00 D6720 Crown -resin with high noble metal ........................................... .. .... ......... ............. ....... ........ .•.... ..... $30.00 06721 Crown -resin with predominantly base metal ................ H ................................................................ ,. $15.00 06722 Crown -resin with noble metal ............................... ,. ... ., ............. ,................................................... $20.00 06740 Crown -porcelain/ceramic* ............... "··· .................... ., ...... ,.... . ...................... ,........ $70.00 06750 Crown -porcelain fused to high noble metal* ...................... ,, .... ,. .................. .,,. ............................ $70~00 06751 Crown -porcelain fused ta predominantly base metal ................... ,. ....... m .................. ., ........ « ..... ,...... $55.00 06752 Crown -porcelain fused to noble metal ...................................... ., ...... .,.. ................................... ...... $60.00 06780 Crown -¾ cast high noble metal .......................... " ............... , ............. ,,.., ........... "" ............ ,. ,. . .. .... .. $70.00 06781 Crown -¾ cast predominantly base metal ................. .., .. .,"'.............. ........ .................. $55.00 05782 Crown -¾ cast noble metal ........................ , ........................ ,...... . ................................ "•• .. ···•·"" $60.00 D6783 Crown -¾ porcelain/ceramic" .................................. ,............ . ........................ , ...... " .............. $70.00 06790 Crown -full cast high noble metal .... ,.......................... ............................. . ......... .,.............. $70.00 D6791 Crown -full cast predominantly base metal . ..., ................................... .., ....................... ~···· $50.00 05792 Crown -full cast noble metal ........... ., ...... , ....................... . .............................. $60.00 06794 Crown -titanium . .. . ... . . .. . . . . . .. . . . .. . ... .. . .... . ... ... . ........ $70.00 06930 Re-cement or re-bond fixed partial denture ..... •.. No Cost D6940 Stress breaker ........................................................................................ ., .................... ,., .••• ~,_ ... No Cost D6980 Fixed partial denture repair necessitated by restorative material failure ., .................................. , ................ No Cost D7000-D7999 X. ORAL AND MAXILLOFACIAL SURGERY -Includes preoperative and postoperetive evaluations and treatment under a local anesthetic. D7111 Extraction, coronal remnants -deciduous tooth .................. , ...................... , ............................................. No Cost D7140 Extraction, erupted tooth or exposed root (elevation and/or forceps removal) ............................................. No Cost D721 0 Sur_gica! removal of erupted tooth requiring removal of bone and/or sectioning of tooth, and including elevation of mucoperiosteal flap if indicated .......................................................... , ............ , .. ,........................... $10.00 D7220 Removal of impaqted tooth" soft tissue .................. ,,;;.,.,., ...... : ....... ; ............. ; .......................... ,............... $15 •. 00 D7230 Removal of impacted tooth -partially oony .... , ... ., •.• , ..... , ••. , •• , .............................. , ........ , ......... ,, ... ,, ................ $25.00 D7240 Removal of Impacted tooth"' completely bony •••• ~ ..... i ........... ~••.•·· .. ••.••.• ............... ; ............. , ....... , ........... ,. $35.00 D7241 Removal of impacted tooth -completely bony, with unusual surgical complications ................................ ;,..,,.. $50.00 D7250 Surgical removal of residua! tooth root~ (cutting procedure) .................................................................. No Cost D7251 Coronectomy-lntentlonal partial tooth removal ................................... ,, .................................................. $50.00 D7270 Tooth reimplantatlon and/or stabilization of accidenti:!lly evulsed or displaced tooth ................ .,., ............... ., ... $35.00 D7280 Surgical access of,an unerupted tooth ....... s··•·-'·········•;,. •• " •••• i •• ·, • ..-................................................................. $25.00 D7282 Mobilizatio·n of erupted or malpeisltioned tooth to aid eruption ............................... ,, ............................ ,.. $25.00 D7283 Placement of device to facilitate eruption of impacted tooth .,~., ............................................... "' ....... ,, ... ,., No Cost D7286 lncisional biopsy of oral tis.sue·" s·ott-does not include pathb/ogy laboratory procedures .............................. No Cost D7310 Alveoloplasty in conjunction with extractions -four or more teeth or tooth spaces, per quadrant ........ ~ •• ,,.';• ...••. No Cost lil7:3·J1 Alvei'.>loplasty In .celiJunotlon With extrsctlori$·-1:>ne to,three teeth or fo0th ~paces, per quadrant ...................... No €ost Dt,320 Alveoloplasty. not in conjunction with.extractions -four or more teeth or tooth spaces, p.er quadrant ................... No Cost P1,'3fl1 Alve9lqpl1;1sty notl.n conj!,!actlon Wllh tl.xtraC.tlAns -l'ine .to three le~th ·ottooth spac,es, per quaorant ,. , .......... ,, , .. No Ci;>st Removal of benign o.dontagenlc cyst or tumor ~ lesion diameter up to 1.25 cm ........................ , .................. No Cost •: Removal of benigl'\ pdontog~nlc cyst !:ir.l1.1msr-lesl!m d.l~m~ter greater than 1.25 cm ....... , •..• ; ........ ; ........... ,. Nb Cost O_T4'71 Removal of ..lateral exostosls (maxilla or mandible) ............................................................................. No Cost D74ii2· Re.i:nqval of tofl.J!i-•Palatlt,u~ ...... , ....... , ........ _..,;,~.,,, ... , ....... , .......................... ; •.. , ................... , ..•.•.•. , .•.• · .. ,' No CoE!t D7 413 Removal of torus mandlbularis ............ ~,11:,f•.~;· •. .,.., .. ,.:,.i-..-.,r:~.4""!"•" ... !, ............. ',~". ~ ... •:•!f4t ........ '"'; u "•· ........ •· ......... " .. u ... ,. ), • .: ..... , ............ ,. ...... ~;.:~.-J~-N.Q/~t, D7510 lncisio.n and drainage of abscesE! -lntraortd softti"ssue .,.,, ... , ................................................. : ............ : No Gpst D7960 Frenulectomy-also known as freMctomy orfrenotomy~ separate procedure not lncldental to another procedure No Cost D7970 Excision of hyperplastlc tissue -per arch ·"·······,••m .. ••··· .. ·····,·•·····················,·····•····· ....................... No Cost D7971 Excision of pericorona_l gingiva ................................... ~., ................................................................ No Cost D8000~08999. XI. ORTHODONTICS -The listed Copayment for each phase oforlhodpn/ic treatment (limited, interceptive or comprehensive) covers up to 24 months of active treahnent. Beyond 24 months, an ad_tjif[onal monthly fee, notto exceed $125.00, may apply. -The Retention Copayment includes adjustments and/or offlca visits up to 24 months. Pre and post orthodontic records include: The benefit for pre-treatment records and diagnostic services includes: ............. , ..................................... $200.00 D0210 lntraoral -complete series of radiographic images D0322 Tomographic survey D0330 Panoramic radiographic image D0340 Cephalometric radiographic image D0350 2D oral/facial photographic images obtained lntraorally or extraorally D0351 3D photographic image D0470 Diagnostic casts The benefit for post-treatment records includes: ............................... , ................. .,............................. $70.00 D021 0 lntraoral -complete series of radiographic images D0470 Diagnostic casts D8010 Limited orthodontic treatment of the primary dentition ................................................ ,. ....................... $725.00 08020 Limited orthodontic treatment of the transitional dentition -child or adolescent to age 19 ................................ $725.00 08030 Limited orthodontic treatment of the adolescent dentition -adolescent to age 19 .................................. , . ,. .. $725.00 08040 Limited orthodontic treatment of the adult dentition -adults, including covered dependent adult children ............ $925.00 08050 lnterceptive orthodontic treatment of the primary dentition .................................................................... $725.00 08060 lnterceptive orthodontic treatment of the transitional dentition ....... ,, ................................................... , ... $725.00 08070 Comprehensive orthodontic treatm1:1nt of the transitional dentition -child or adolescent to age 19 ................•.. $1.700.00 D8080 Comprehensive orthodontic treatment of the adolescent dentition -adolescent to age 19 ............. : .............. ,$1 ,700. 00 08090 Comprehensive orthodontic treatment of the adult dentition -adults, including covered dependent adult chl1dren .. $1,900.00 D8660 Pre-orthodontic treatment examination to monitor growth and development .• .. ..... ... . .•. .• .. •• ......... ............. ... $25.00 D8670 Periodic orthodontic treatment visit -included in comprehensive case fee ... ., ............................ ,.. .............. No Cost D8680 Orthodontic retention (removal of appliances, construction and placement of removable retainers) ................ ,. $275.00 08693 Re-bond or re~cement fixed retainer -limited to 2 per 6 month period,. ........ ., .......................................... No Cost 08694 Repair of fl>ced retainers, ihcludes reattachment -Jfm11ed to 2 per 6 month period .... ~····~······· .. ··,·.,.··,···"""'· No Cost D8999 Unspecified orthodontic procedure, by report -includes treatment planning session ............... ., ................ ,.. $100.00 09000-D9999 XII. ADJUNCTIVE GENERAL SERVICES D9110 Palliative (emergency) treatment of dental pain -minor procedure .......................................................... No Cost 09211 Regional block anesthesia •. , ............................................................ , ........................... ., .. ,,., ............. No Cost 09212 Trigemim:il division block anesthesia .................. .,_., ........................................................................... No Cost D9215 Local anesthesia In conjunction wiih operative or surgical procedures ..................................... ;., .............. No Cost 09219 Evaluation for deep sedation or general anesthesia ...................................................... s ..................... No Cost 09220 Deep sedation/genera! anesthesia -first 30 minutes ........................................................................... $165.00 D9221 Deep sedattonlgl:!ne~I anesthesia-~ach additional 15 minutes .................. ,......................................... $80.00 D9241 Intravenous mod~rate (tonscitius) sedation/analgesia -first 30 minutes ..... ,, ................ ,. .......................... $165.00 09-242 Intravenous moderate (conscious) sedation/analge.sJa -ei;ich ElddJtional 15 minutes ..................................... $B0.00 D93W Consultation -di~gnostlc service provided by dentfst or physician other than requesting dentist or physician ....... No Cost D9430 Qf{l~~ ~1$.it fQl'.ob~eJtta.f!!)!J (d!.lrJ.h"Q r~ula,rly scheduled hours) -no oth¢r $ervlces performed , ......................... No Cosi D9440 Office visit -after regularly scheduled hours ....................................... , ................................. , . .. • . .... • • $20.00 •-9450 Case pres~l)~tiQl'.l, det~i.l~d ang ,extensive treatment planning ...................................... , ......................... No Cost 09931 Cleaning and Jn$1)ect!Qn of a removable appllemce ........ .,, ........... , ........................ ,-........... , .... , .............. No Csst 0~940 Occlus;QI gua~~ 'i:,y. repe?rt -limited t9 1 fn 3 years ............... " •. ,, ••••••• ,~ ... ~,., ... r ......... ~••••·• .. •'-•~•·•• ............. $1Sjllo: D995, Oeclusal aajostment, llri'llted ................. , ......................... : .............. ., ..................... , ....................... N~=Cij~t 09952 Occlm~al adjtis}ment; complete ., •• :.~.+.~, ....... , 1._ ............ ,.,,-.., ...... ~ ....... : ........................... ; ......... ;, ............ Nd Coot' 0997.5 ~I.ems! bleaohitig for home applicauan, per arcli; includes materials and fab,ri~~uon of custpm tr1;1ys • liWtedto on~ ble.a~fiing ttajl and ge.l for iwQ weeks of self-treatmtJnt ... ,, ... , .................... , ........................... i••··•--···· D9966 Missed appointment-without 24 how notlr.e-J)er 15 minl1_les of appointment -up to an · maxfrnum of $40.0D .................. ,, ~-"}""""''" ........ 1ro ..... "' .... ,..:.-,11 tci>i,<1,</;«,..it'• ,, •••• ·,-.,, •O ""'" .,,.,. ....•.• , •• lo •• , ......... t. ,..,,.;'t'J.l!e.11"". l ~ .. -. ........... "'"•'"' .. ., •• ~.,,.,,...If~ .• ii.'O«........ -$:1:Qf~o D9987 Canceled appointment-without 24 hour notice -per 15 minutes of appointment t!me -up to an overall maximum of$4CJ;OO ,"'' ' . Procedures not listed above are not covered, however, may be available at the Contract Dentist's "filed fees." "Filed fees" mean the Contract Dentist's fees on file with Delta Dental. Questions regarding these fees shouid be directed to the Customer Service department at 800-422-4234. Ext)lbit B Employee Empfoy_ee-& Empfoyee·& Spouse Child(ren) Family Anthem $250 PPO $1,125.73 $2,363.12 $2,l.40;95 $3,264.65 Anthem $1000 PPO $835,75 $1,754.41 $1,58_9.46 $2,423.70 Anthem $1500 Active $757.61 $1,590.36 $1,440.84 $2,197.07 Anthem $1500 Retirees $866.57 $1,534.13 $1,353.72 $2;019.60 Anthem $3,000 $619.03 $1,311.24 $1,175.57 $1,791.42 Anthem EPO $791.52 $1,399.80 $1,23SA2 $1,842.03 Kaiser HMO $353.45 $625,56 $552.71 $824.15 Delta Dental PPO $50.29 $80.19 $69.88 $102.58 Delta Dental DHMO $26;38 $45.27 $45.58 $65.70 VSPVision $7.64 $13.73 $13.46 $19.71 ~ . t • • ~"