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Home > Active Health SPD > Schedule of Benefits
SCHEDULE OF BENEFITS
FOR PARTICIPANTS WHO HAVE SELECTED THE PIPE TRADES PPO PLUS SELF-FUNDED INDEMNITY MEDICAL PLAN
Deductible Information
|
| Deductible |
In-Network |
Out-of-Network |
| Maximum of two deductibles
per family per year |
$100 per person1,2 |
$200 per person1 |
| Coinsurance Maximum3 |
$5,000 |
Does Not Apply4 |
| Lifetime Maximum |
$2,000,000 |
1 In-Network deductible does not count towards Out-of-Network deductible. Out-of-Network deductible counts toward
the In-Network deductible.
2Does not apply to the preventive care as defined by the Plan.
3Not all out-of-pocket expenses count towards the $5,000 maximum. See page 21.
4Only In-Network benefits count toward the $5,000 coinsurance maximum. Charges incurred Out-of-Network will
never be paid at 100%.
Schedule of Medical Benefits |
| Physician Care & Outpatient
Services |
In-Network |
Out-of-Network1 |
|
Physician Visits |
90% of contract rate, after
deductible. |
70% of usual, customary &
reasonable, after deductible. |
| Pre-Certification not required |
| Diagnostics, X-Ray, Lab |
90% of contract rate, after
deductible. |
70% of usual, customary &
reasonable, after deductible. |
| CT Scans, MRI’s, PET Scans and non-obstetrical ultrasound tests
require Pre-Certification regardless of who orders the tests. |
| Chiropractor |
90% of contract rate, after
deductible. |
70% of usual, customary &
reasonable, after deductible. |
Pre-Certification not required
$1,500 maximum benefit per calendar year |
| Physical Therapy |
90% of contract rate, after
deductible. |
70% of usual, customary &
reasonable, after deductible. |
Pre-Certification not required.
$3,000 maximum benefit per calendar year, for physical therapy and
acupuncture combined. |
| Durable Medical Equipment (DME) |
90% of contract rate, after
deductible. |
70% of usual, customary &
reasonable, after deductible. |
| DME costing over $1,000 not covered unless Pre-Certified |
|
Outpatient Specialty
Medications/Injectables over $500 2
(see page 22) |
90% of contract rate, after
deductible, when obtained through
the PBM Specialty Pharmacy |
Not covered unless obtained through
the PBM Specialty Pharmacy. |
|
Not covered unless Pre-Certified 2 |
1
Only In-Network benefits count toward the $5,000 coinsurance maximum. Charges incurred Out-of-Network will
never be paid at 100%.
2Drugs costing $500 or less are covered through the outpatient prescription benefit. See page 31.
Schedule of Medical Benefits |
| Physician Care & Outpatient
Services |
In-Network |
Out-of-Network
1 |
| Audiologists |
90% of contract rate at Sacramento
Ear, Nose and Throat, after
deductible. |
70% of usual, customary &
reasonable, after deductible. |
| Hearing Aids |
90% of contract amount, when
provided through Sacramento Ear,
Nose and Throat, after deductible. |
70% if Pre-Certified by Sacramento
Ear, Nose and Throat, after
deductible. Not covered unless Pre-
Certified by Sacramento Ear, Nose
and Throat.
2 |
$4,000 ($2,000 per ear) maximum payment.
Annual hearing aid maintenance check is required.
3
Adults (18 & over): one aid per ear every 3 years, if necessary as determined
by the Plan.
Children (under the age of 18): one aid per ear every calendar year, if
necessary as determined by the Plan. |
|
Annual Maintenance Check
3 |
90% of contract amount, after
deductible, up to $30. |
70% of usual, customary and
reasonable, after deductible, up to
$30. |
1 Only In-Network benefits count toward the $5,000 coinsurance maximum. Charges incurred Out-of-Network will
never be paid at 100%.
2 If you use an audiologist other than Sacramento Ear, Nose and Throat your audiology report must be sent to
Sacramento Ear, Nose and Throat so the hearing aids can be pre-Certified for coverage.
3 Annual hearing aid maintenance check is required. If you fail to obtain this annual maintenance check, the Plan
will not pay for replacement of hearing aids.
Schedule of Medical Benefits |
| Hospital Inpatient & Outpatient1 |
In-Network |
Out-of-Network2 |
Pre-Certification Requirement:
Inpatient, Outpatient, and
Emergency Admissions |
Benefits will not be paid unless Pre-Certified. For emergency admissions, benefits will not be paid unless certification is obtained on first working day
following admission. |
| Room & Board, Miscellaneous
Hospital Charges, Surgery,
Anesthesia |
90% of contract rate, after
deductible. |
70% of usual, customary &
reasonable, after deductible. |
| Intensive Care |
90% of contract rate, after
deductible. |
70% of usual, customary &
reasonable, after deductible. |
| Organ/Tissue Transplants |
At designated Tertiary
Care Network Facility; 90% of
contract rate, after deductible.3
|
50% of usual, customary &
reasonable, after deductible. |
| Emergency Services |
90% of contract rate, after
deductible, if emergency. |
70% of usual, customary &
reasonable, after deductible. |
| NO COVERAGE UNLESS AN EMERGENCY AS DEFINED BY THE
PLAN 4 |
| Urgent Care Center |
90% of contract rate after deductible. |
70% of usual, customary &
reasonable, after deductible. |
| Home Health |
90% of contract rate, after
deductible. |
70% of usual, customary &
reasonable, after deductible. |
No coverage unless Pre-Certified.
100 Visit Maximum Per Year |
Hospice
Inpatient or outpatient |
90% of contract rate, after
deductible. |
70% of usual, customary &
reasonable, after deductible. |
No coverage unless Pre-Certified.
$15,000 Lifetime Maximum
|
1 When participants use Network providers and hospitals, sometimes ancillary services such as radiology and
anesthesiology are provided by Out-of-Network providers. When this occurs, these ancillary services will be paid at
90% of usual, reasonable and customary charges. The Plan will make every attempt to negotiate a discounted rate
through the national provider Network.
2 Only In-Network benefits count toward the $5,000 coinsurance maximum. Charges incurred Out-of-Network will
never be paid at 100%.
3 Or 50% of contract rate if facility is part of the Interplan Network but not a designated Tertiary Care Network
Facility. If you use a provider which is not part of the Tertiary Care Network your out-of-pocket coinsurance expense
will not count towards the $5,000 coinsurance maximum.
4 If you require out-of-area services for treatment of an Emergency (as defined by the Plan) these services will be paid under the same guidelines as for In-Network providers. The Plan will make every attempt to negotiate a discounted rate through the National Provider Network.
Schedule of Medical Benefits |
| |
Network |
Non-Network1 |
Preventive Health Services
The In-Network deductible is waived, if you use Network providers for Preventive care as defined by the Plan. Non-
Network preventive care limited to $300 per person per year. |
Well Baby Care
From birth to second birthday. |
90% of contract rate. |
70% of usual, customary &
reasonable after deductible. |
Routine Exam
One exam per year ages 2-19 and
over 65.
One exam every two years ages
20-64. |
90% of contract rate. |
70% of usual, customary &
reasonable after deductible. |
| Immunizations |
90% of contract rate. |
70% of usual, customary &
reasonable after deductible. |
|
Routine Annual Gynecological Visits
and Mammography |
90% of contract rate. |
70% of usual, customary &
reasonable, after deductible. |
Nicotine Replacement Therapy
To assist participants in quitting
smoking |
50% up to a lifetime maximum benefit of $150. |
1 Only In-Network benefits count toward the $5,000 coinsurance maximum. Charges incurred Out-of-Network will
never be paid at 100%.
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