Active Health Summary Plan Description
As of July 1, 2022
En Español (PDF)

6.1 Medical Benefits Comparison: Anthem Blue Cross, Kaiser and UnitedHealthcare

This section modified by Amendment 3. View old language.

Comparison of Medical/Prescription Plan Offerings
This is only a summary of the benefits available to you under the Blue Shield PPO Plan Plan and the Kaiser and UnitedHealthcare HMO Plans. For a complete description of the respective PPO or HMO’s benefits, please refer to the carrier’s EVIDENCE OF COVERAGE AND DISCLOSURE DOCUMENT. The EVIDENCE OF COVERAGE AND DISCLOSURE DOCUMENT is the legal document that describes the benefits, exclusions and limitations and other coverage provisions including claims appeals, claims review and adjudication procedures. Additionally, the Summary of Benefits and Coverage (SBC) are available, routinely distributed and appear on the Trust Funds’ website at www.scibew-neca.org.
Vendor	Blue Shield PPO Plan		Kaiser Permanente HMO	UnitedHealthcare
	In Network	Out-of-Network	In Network Only	In Network Only
Member Customer Service Number	(800) 543-3037		(800) 464-4000	(800) 624-8822
Website	www.bluecrossca.com		www.members.kp.org	www.uhcwest.com
General Features
Calendar Year Deductible	$1,000 per individual, $3,000 per Family		None	None
Maximum Benefits	Unlimited		Unlimited	Unlimited
Annual Co-payment Maximum	$2,500 per individual, $5,000 per family		$1500 per Individual, $3,000 per family	$2,500 per Individual. $5,000 per family
Hospital Benefits	10% co-payment. Hospital Pre-Certification Required.	30% co-payment. Additional $200 deductible for non-Blue Shield PPO Plan Hospital or Residential Treatment Center and $500 no-preauthorization penalty (waived for emergency services) Hospital Precertification Required. ²	No Charge	$250 co-payment
Emergency Services	10% co-payment ¹	10% co-payment. ²	$5 co-payment. Co-payment waived if admitted.	$250 co-payment. Co-payment waived if admitted.
Preexisting Conditions	Not Applicable. All conditions are covered provided they are a covered benefit.
Benefits Available While Hospitalized as an Inpatient
Alcohol, Drug or Other Substance Abuse Detoxification	10% co-payment ¹	30% co-payment ²	No Charge	No Charge
Mental Health Services (As required by law, coverage includes treatment for Severe Mental Illness (SMI) of adults and children and the treatment of Serious Emotional Disturbance (SED).	10% co-payment ¹	30% co-payment ²	No Charge	No Charge
Newborn Care	10% co-payment ¹	30% co-payment ²	No Charge	No Charge
Physician Care	10% co-payment 1¹	30% co-payment ²	No Charge	No Charge
Reconstructive Surgery	10% co-payment ¹	30%co-payment ²	No Charge	No Charge
Rehabilitative Care (including physical, occupational and speech therapy)	10% co-payment. Must obtain prior approval. ¹	30% co-payment. Up to $35 max benefit per visit. Must obtain prior approval. ²	No Charge	No Charge
Skilled Nursing	10% co-payment. ¹	30% co-payment. ²	No Charge	No Charge
Voluntary Termination of Pregnancy (Medical, Medication and surgical)	10% co-payment. ¹	30% co-payment. ²	$5 Co-payment	$75 co-payment
Benefits Available on an Outpatient Basis
Ambulance	10% co-payment ¹	10% co-payment ²	No Charge	No Charge
Durable Medical Equipment	10% co-payment. ¹	30% co-payment. ²	No Charge	No Charge
Durable Medical Equipment for the Treatment of Pediatric Asthma (includes nebulizer, peak flow meters, face masks and tubing for Medically Necessary Treatment of Pediatric Asthma of dependent children under the age of 19)	10% co-payment. ¹	30% co-payment. ²	No Charge	No Charge
Immunizations (For Children Under two (2) years of age, refer to well-baby care)	No Charge	30% co-payment ²	$5 Office Visit Co-payment	No Charge
Laboratory Services (When available through or authorized by PCP)	10% co-payment. ¹	30% co-payment. ²	No Charge	No Charge
Mental Health Services (As required by law, coverage includes treatment for Severe Mental Illness (SMI) of adults and children and the treatment of Serious Emotional Disturbance (SED).	10% co-payment ¹	30% co-payment ²	$5 Office Visit Co-payment	$25 Office Visit Co-payment
Oral Surgery Services	10% co-payment ¹	10% co-payment ²	No Charge	No Charge
Outpatient Medical Rehabilitation Therapy at Participating Free Standing or Outpatient Surgery Facility	10% co-payment ¹	30% co-payment ²	$5 Office Visit Co-payment	$25 Office Visit Co-payment
Outpatient Surgery at Participating Free Standing or Outpatient Surgery Facility	10% co-payment. ¹	30% co-payment. ²	No Charge	No Charge
Physician Office Visits (Physician, laboratory, radiology and related services as recommended by the American Academy of Pediatrics (AAP). Advisory Committee on Immunization Practices (ACIP) and U.S. Preventive Services Task Force and authorized through PCP for children).	10% co-payment ¹	30% co-payment ²	$5 Office Visit Co-payment	$5 Office Visit Co-payment
Well-Baby Care (Preventive health service, including immunizations as recommended by the American Academy of Pediatrics (AA), Advisory Committee on Immunization Practices (ACIP) and U.S. Preventive Care Task Force and authorized through PCP for children).	0% co-payment ¹	30% co-payment ²	No Charge	No Charge
Well-Woman Care (includes PAP smear (By PCP or an OB/GYN in PMG and a referral by the PMG for screening mammography as recommended by the U.S. Preventive Services Task Force).	0% co-payment ¹	30% co-payment ²	No Charge	No Charge
Subject to the annual deductible. Subject to the annual deductible and balance billing.
Prescription Drugs Available on an Outpatient Basis: The Mandatory Generic Prescription Drug Plan is designed to help you meet the cost of prescription drugs prescribed by your doctor, for you or your eligible dependents, for the treatment of illness or injury. You must use a generic drug substitute whenever it is available. If you or your doctor requests a brand-name drug instead of a generic equivalent, you will be charged the difference in cost between the brand-name drug and the generic, in addition to the co-payment applicable to the quantity and type of drug prescribed. The co-payments, which vary depending on the type of drug prescribed and the quantity dispensed, are detailed below:
Generic	$10 up to a 30-day supply	$10* up to a 30-day supply ¹	$0 up to a 100-day supply	$10 up to a 30-day supply
Brand-Name	$20 up to a 30-day supply	$20* up to a 30-day supply ¹	$10 up to a 30-day supply	$20 up to a 30-day supply
Mail Order (Maintenance Drugs) – up to a 90-day supply
Generic	$20 up to a 90-day supply	N/A	$0 up to a 100-day supply	$20 up to a 90-day supply
Brand-Name	$40 up to a 90-day supply	N/A	$20 up to a 100-day supply	$40 up to a 90-day supply
Anthem Blue Cross non-network pharmacy claims -You must file a claim to be reimbursed for your drugs within 15 months of the purchase. This option is intended for emergencies or when travelling only. Reimbursement is limited by the Plan's average costs for prescriptions; you will pay for amounts over the limits in addition to the copay.

Comparison of Medical/Prescription Plan Offerings
This is only a summary of the benefits available to you under the Blue Shield PPO Plan Plan and the Kaiser and UnitedHealthcare HMO Plans. For a complete description of the respective PPO or HMO’s benefits, please refer to the carrier’s EVIDENCE OF COVERAGE AND DISCLOSURE DOCUMENT. The EVIDENCE OF COVERAGE AND DISCLOSURE DOCUMENT is the legal document that describes the benefits, exclusions and limitations and other coverage provisions including claims appeals, claims review and adjudication procedures. Additionally, the Summary of Benefits and Coverage (SBC) are available, routinely distributed and appear on the Trust Funds’ website at www.scibew-neca.org.
Vendor	Anthem Blue Cross PPO		Kaiser Permanente HMO	UnitedHealthcare
	In Network	Out-of-Network	In Network Only	In Network Only
Member Customer Service Number	(800) 543-3037		(800) 464-4000	(800) 624-8822
Website	www.bluecrossca.com		www.members.kp.org	www.uhcwest.com
General Features
Calendar Year Deductible	$200 per individual, $600 per Family		None	None
Maximum Benefits	Unlimited		Unlimited	Unlimited
Annual Co-payment Maximum	$1,000 per individual, $2,000 per family		$1500 per Individual, $3,000 per family	$1000 per Individual. $3,000 per family
Hospital Benefits	10% co-payment. Hospital Pre-Certification Required.	20% co-payment. Additional $200 deductible for non-Blue Shield PPO Plan Hospital or Residential Treatment Center and $500 no-preauthorization penalty (waived for emergency services) Hospital Precertification Required. ²	No Charge	No Charge
Emergency Services	10% co-payment ¹	10% co-payment. ²	$5 co-payment. Co-payment waived if admitted.	$50 co-payment. Co-payment waived if admitted.
Preexisting Conditions	Not Applicable. All conditions are covered provided they are a covered benefit.
Benefits Available While Hospitalized as an Inpatient
Alcohol, Drug or Other Substance Abuse Detoxification	10% co-payment ¹	20% co-payment ²	No Charge	No Charge
Mental Health Services (As required by law, coverage includes treatment for Severe Mental Illness (SMI) of adults and children and the treatment of Serious Emotional Disturbance (SED).	10% co-payment ¹	20% co-payment ²	No Charge	No Charge
Newborn Care	10% co-payment ¹	20% co-payment ²	No Charge	No Charge
Physician Care	10% co-payment ¹	20% co-payment ²	No Charge	No Charge
Reconstructive Surgery	10% co-payment ¹	20% co-payment ²	No Charge	No Charge
Rehabilitative Care (including physical, occupational and speech therapy)	10% co-payment. Must obtain prior approval. ¹	20% co-payment. Up to $35 max benefit per visit. Must obtain prior approval. ²	No Charge	No Charge
Skilled Nursing	10% co-payment. ¹	20% co-payment. ²	No Charge	No Charge
Voluntary Termination of Pregnancy (Medical, Medication and surgical)	10% co-payment. ¹	20% co-payment. ²	$5 Co-payment	$75 co-payment
Benefits Available on an Outpatient Basis
Ambulance	10% co-payment ¹	10% co-payment ²	No Charge	No Charge
Durable Medical Equipment	10% co-payment. ¹	20% co-payment. ²	No Charge	No Charge
Durable Medical Equipment for the Treatment of Pediatric Asthma (includes nebulizer, peak flow meters, face masks and tubing for Medically Necessary Treatment of Pediatric Asthma of dependent children under the age of 19)	10% co-payment. ¹	20% co-payment. ²	No Charge	No Charge
Immunizations (For Children Under two (2) years of age, refer to well-baby care)	No Charge	20% co-payment ²	$5 Office Visit Co-payment	No Charge
Laboratory Services (When available through or authorized by PCP)	10% co-payment. ¹	20% co-payment.2	No Charge	No Charge
Mental Health Services (As required by law, coverage includes treatment for Severe Mental Illness (SMI) of adults and children and the treatment of Serious Emotional Disturbance (SED).	10% co-payment ¹	20% co-payment ²	$5 Office Visit Co-payment	$5 Office Visit Co-payment
Oral Surgery Services	10% co-payment ¹	10% co-payment ²	No Charge	No Charge
Outpatient Medical Rehabilitation Therapy at Participating Free Standing or Outpatient Surgery Facility	10% co-payment ¹	20% co-payment ²	$5 Office Visit Co-payment	$5 Office Visit Co-payment
Outpatient Surgery at Participating Free Standing or Outpatient Surgery Facility	10% co-payment. ¹	20% co-payment.2	No Charge	No Charge
Physician Office Visits (Physician, laboratory, radiology and related services as recommended by the American Academy of Pediatrics (AAP). Advisory Committee on Immunization Practices (ACIP) and U.S. Preventive Services Task Force and authorized through PCP for children).	10% co-payment ¹	20% co-payment ²	$5 Office Visit Co-payment	$5 Office Visit Co-payment
Well-Baby Care (Preventive health service, including immunizations as recommended by the American Academy of Pediatrics (AA), Advisory Committee on Immunization Practices (ACIP) and U.S. Preventive Care Task Force and authorized through PCP for children).	0% co-payment ¹	20% co-payment ²	No Charge	No Charge
Well-Woman Care (includes PAP smear (By PCP or an OB/GYN in PMG and a referral by the PMG for screening mammography as recommended by the U.S. Preventive Services Task Force).	0% co-payment ¹	20% co-payment ²	No Charge	No Charge
Subject to the annual deductible. Subject to the annual deductible and balance billing.

Prescription Drugs Available on an Outpatient Basis
The Mandatory Generic Prescription Drug Plan is designed to help you meet the cost of prescription drugs prescribed by your doctor, for you or your eligible dependents, for the treatment of illness or injury. You must use a generic drug substitute whenever it is available. If you or your doctor requests a brand-name drug instead of a generic equivalent, you will be charged the difference in cost between the brand-name drug and the generic, in addition to the co-payment applicable to the quantity and type of drug prescribed. The co-payments, which vary depending on the type of drug prescribed and the quantity dispensed, are detailed below:
Vendor	Anthem Blue Cross PPO		Kaiser Permanente HMO	UnitedHealthcare
	In Network	Out-of-Network	In Network Only	In Network Only
Generic	$0 up to a 30 day supply	$5* up to a 30 day supply ¹	$0 up to a 100 day supply	$0 up to a 30 day supply
Brand-Name	$10 up to a 30 day supply	$15* up to a 30 day supply ¹	$10 up to a 30 day supply	$10 up to a 30 day supply
Mail Order (Maintenance Drugs) – up to a 90-day supply
Generic	$0 up to a 90 day supply	N/A	$0 up to a 100 day supply	$0 up to a 90 day supply
Brand-Name	$20 up to a 90 day supply	N/A	$20 up to a 100 day supply	$20 up to a 90 day supply
Anthem Blue Cross non-network pharmacy claims -You must file a claim to be reimbursed for your drugs within 15 months of the purchase. This option is intended for emergencies or when travelling only. Reimbursement is limited by the Plan's average costs for prescriptions; you will pay for amounts over the limits in addition to the copay.

New Participant Portal

Active Health Summary Plan Description
As of July 1, 2022
En Español (PDF)

6.1 Medical Benefits Comparison: Anthem Blue Cross, Kaiser and UnitedHealthcare

New Participant Portal

New Participant Portal

Active Health Summary Plan DescriptionAs of July 1, 2022En Español (PDF)

6.1 Medical Benefits Comparison: Anthem Blue Cross, Kaiser and UnitedHealthcare

New Participant Portal

Active Health Summary Plan Description
As of July 1, 2022
En Español (PDF)