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IBEW Local 11-LA NECA Active Health Plan
Summary Plan Description (SPD)

Summary Of Hospital And Medical Benefits For Eligible IBEW-NECA Participants And Their Eligible Dependents

Call or write Anthem Blue Cross if you need further information or have questions regarding the Self-Funded Indemnity Plan, including specific exclusions, limitations, or reductions in benefits. PO Box 60007, Los Angeles, CA 90060-0007 OR 1 (800) 543-3037 – Nationwide Toll Free

Self-Funded Indemnity Plan – with Anthem Blue Cross Prudent Buyer Plan

Maximum Benefit Limit
Note: Refer to subsection titled "Lifetime Maximum" for explanation of how benefit maximum can be restored.

Overall Lifetime Maximum Benefit Payable by Plan $1,000,000 Increased from $400,000 by Amendment 14.

Calendar Year Deductible

$200 per Individual
Maximum 3 ($600)/Family
Hospital Deductible:
In Network PPO – None
Out of Network - $200

Hospital Care – Inpatient Services

Semi-private room and board; nursing care
Intensive Care and Ancillary Services

(90% of PPO-No hospital deductible), ($200.00 deductible 80% non PPO) of First $12,500 Covered Charges After Deductible, 100% of Covered Charges Thereafter. Per Calendar Year.

Hospital – Outpatient Services

Surgery
Emergency

(90% of PPO) (80% non PPO) of First $12,500 Covered Charges After Deductible, 100% of Covered Charges Thereafter. Per Calendar Year.

Skilled Nursing Care

(90% of PPO) (80% non PPO) of First $12,500 Covered Charges After Deductible, 100% of Covered Charges Thereafter. Per Calendar Year.

Ambulatory Surgical Center

(90% of PPO) (80% non PPO) of First $12,500 Covered Charges After Deductible, 100% of Covered Charges Thereafter. Per Calendar Year.

Hospice

Refer to section "Limited and Reduced Benefits" subtitled "Hospice Care" included in this booklet.

Home Health Care

(90% of PPO) (80% non PPO) of First $12,500 Covered Charges After Deductible, 100% of Covered Charges Thereafter. Per Calendar Year.

This section modified by: Amendment 44. View Previous Language

Self-Funded Indemnity Plan — with Blue Cross Prudent Buyer Plan
Physician Services Office Visits Specialist Visits Inpatient Surgery Outpatient Surgery Hospital Visits Home Visits Administration of Anesthesia	(90% of PPO) (80% non PPO) of First $12,500 Covered Charges After Deductible, 100% of Covered Charges Thereafter. Per Calendar Year.
Emergency Care Physician & Medical Services Emergency Room Inpatient Hospital Services	(90% of PPO) (80% non PPO) of First $12,500 Covered Charges After Deductible, 100% of Covered Charges Thereafter. Per Calendar Year.
Diagnostic Studies & Laboratory Procedures	(90% of PPO) (80% non PPO) of First $12,500 Covered Charges After Deductible, 100% of Covered Charges Thereafter. Per Calendar Year.
Pregnancy & Maternity Care Physician & Medical Services Normal Delivery, Cesarean Section, Complications of Pregnancy, Physician Services Inpatient Hospital Ancillary Services Elective Abortions	(90% of PPO) (80% non PPO) of First $12,500 Covered Charges After Deductible, 100% of Covered Charges Thereafter. Per Calendar Year. $150 Doctor
Family Planning Infertility Services Family Planning Only Tubal Ligation Vasectomy Counseling/Consultation	Infertility Treatment to $5,000 Maximum Per Couple Covered Benefit, After Deductible Covered Benefit, After Deductible Not Covered
Preventive/Maintenance Care Physical Exam Well Baby/Well Child Care Preventive Care Immunizations Hearing Exams Allergy Testing/Treatment	Not Covered Covered through Age 6 Covered from Age 7 to Age 16 Covered per Recommendations of the Centers for Disease Control 80% Out-of-Network (90% PPO) of Covered Charges After Deductible
Mental or Nervous Disorders Inpatient Hospital Physician Hospital Visits Outpatient Care	Refer to separate Summary Plan Description in the table of contents titled "Integrated Employee Assistance & Managed Mental Health & Chemical Dependency Program".
Alcoholism & Drug Addiction Inpatient Detoxification Outpatient	Refer to separate Summary Plan Description in the table of contents titled "Integrated Employee Assistance & Managed Mental Health & Chemical Dependency Program".
Durable Medical Equipment, Orthotics, Prosthetics	(90% of PPO) (80% non PPO) of First $12,500 Covered Charges After Deductible, 100% of Covered Charges Thereafter. Per Calendar Year.
Chiropractic Services/Physical Therapy-Outpatient	Combined Total of 50 visits, After Deductible

Speech Therapy – Outpatient

Refer to Section "Indemnity Plan Medical Care That Is A Covered Expense" subtitled "Other Medical Care That Is a Covered Expense"

Occupational Therapy

Obtain prior approval. (90% of PPO) (80% non PPO) of First $12,500 Covered Charges After Deductible, 100% of Covered Charges Thereafter, per calendar year.

Organ & Tissue Transplants

Obtain prior approval. (90% of PPO) (80% non PPO) of First $12,500 Covered Charges After Deductible, 100% of Covered Charges Thereafter, per calendar year.

Infusion Therapy

Obtain prior approval. (90% of PPO) (80% non PPO) of First $12,500 Covered Charges After Deductible, 100% of Covered Charges Thereafter, per calendar year.

Autologous Bone Marrow Transplants

Obtain prior approval. (90% of PPO) (80% non PPO) of First $12,500 Covered Charges After Deductible, 100% of Covered Charges Thereafter, per calendar year.

Acupuncture

Covered Benefit, after deductible, up to $40.00 per Visit.

Student Coverage Through Age:

Limitation of Number of Days or Visits Per Benefit Period Inpatient Hospital Days For:

Skilled Nursing Facility
Home Health Care Visits
Chiropractic Visits (Rider)
Physical Therapy Visits
Speech Therapy Visits

Limited to Negotiated Rate
Limited to UCR
25 Visits
25 Visits
Limited to UCR

Supplemental Accident Benefit

100% of 1st $300 per Accident if within 90 Days, no deductible. After 90 days subject to deductible and co-insurance.