Skip to main content

Active Health Summary Plan Description
As of September 1, 2017
En Español (PDF)

Amendment No. 10
To the Summary Plan Description of the Southern California IBEW-NECA Health Trust Fund Restated As Of September 1, 2017

This Amendment to the Southern California IBEW-NECA Health Trust Fund, Active Health Plan Summary Plan Description ("SPD”) (restated as of September 1, 2017, as amended), is made by the Board of Trustees of the Southern California IBEW-NECA Health Trust Fund ("Board of Trustees”) with reference to the following facts and circumstances:

  1. The Board of Trustees wishes to amend the SPD to reflect the termination of the self-funded mandatory generic prescription drug program managed by Citizens Rx and implement the insured prescription drug programs under the Anthem Blue Cross PPO Plan, and the Kaiser Permanente and United HealthCare HMO Plans effective for all claims incurred on and after January 1, 2022.
  2. The Board of Trustees has reserved to themselves the ability to amend the SPD from time to time.

NOW THEREFORE, effective January 1, 2022, the SPD is amended as follows:

  1. All references in the SPD appearing at Article 1, General Information, Article 8, Mandatory Generic Prescription Drug Plan, and Article 18, Disclosure Information, and elsewhere in the SPDare amended by removing "Citizens Rx”.
  2. Article 1, Section 1.2 Subsection C, Appeals, is amended by providing clarification of the language in the following paragraph to refer to claims and appeals for claims incurred prior to January 1, 2022.

    "Citizens Rx is a claims fiduciary and handles Prescription Drug claims and appeals under its claims and appeal rules for claims and appeals for claims incurred prior to January 1, 2022. Citizens Rx will decide appeals and obtain independent medical reviews requested by Participants. Citizens Rx will use an IMR company licensed in the State of California. Participants will be notified in writing of any adverse determinations within the time required by federal law and regulations.”
  3. Article 2, Plan Benefits Available to You, and all subsections are amended by deleting Prescription Drug Benefit Options -"Citizens Rx” and replacing the references to "Hospital/Medical Benefit” with "Health/Medical/Prescription Benefit Options”.
  4. Article 6 of this SPD, Comparison of Anthem Blue Cross PPO, Kaiser HMO and UnitedHealthcare HMO Medical Plans, Section 6.1 Medical Benefits Comparison: Anthem Blue Cross, Kaiser and UnitedHealthcare is amended by replacing the existing table with the following table:

    Comparison of Medical Plan Offerings

    This is only a summary of the benefits available to you under the Anthem Blue Cross PPO 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 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-Anthem Blue Cross PPO 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

    Prescription Drugs

    Retail – up to a 30-day supply

    Generic

    $0 up to a 30 day supply

    $5* up to a 30 day supply

    $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

    $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

    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

    1 Subject to the annual deductible.


    * 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.
  5. Article 8, Mandatory Generic Prescription Drug Plan, is deleted in its entirety. All references in the SPD appearing at Article 8 and elsewhere in the SPD to "Citizens Rx” shall be removed.

All other terms and conditions of the Plan shall remain in full force and effect.

BY: Signature on File
Chairman

BY: Signature on File
Secretary