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Retiree Health Plan Benefit Tabs™

This is a summary of benefits and not a substitute for the Southern California IBEW-NECA Retiree Health Plan Summary Plan Description, and to the extent it differs from the SPD, the terms of the SPD will govern.

Plans

Medicare Eligible Retirees (Enrolled in Medicare Parts A and B) | Early Retirees (Under Age 62 and not eligible or enrolled in Medicare)

Early Retirees (Under Age 62 and not eligible or enrolled in Medicare) - General Features

Calendar Year Deductible	$500 per Individual $1,000 per Family
Maximum Benefits	Unlimited
Annual Co-Payment Maximum	$4,500 per Individual $9,000 per Family
Hospital Benefits	80% after deductible has been met
Emergency Services Co-payment waived if admitted	$100 co-payment; deductible does not apply
Urgently Needed Services Medically Necessary services required outside geographic area service by Primary Medical Group	$50 co-payment; deductible does not apply
Pre-existing Conditions	All Medically Necessary conditions are covered provided they are a covered benefit.

Inpatient Hospital Benefits

Alcohol, Drug or Other Substance Abuse Detoxification	80% after deductible
Mental Health Services As required by law, coverage includes treatment for Severe Mental Illness of adults and the treatment of Serious Emotional Disturbance.	80% after deductible
Physician Care	No charge
Reconstructive Surgery	80% after deductible
Rehabilitative Care Including physical, occupational and speech therapy	$20 co-payment
Skilled Nursing Facility Up to 100 Consecutive Days from the first treatment per disability	80% after deductible

Outpatient Benefits

Alcohol, Drug or Other Substance Abuse Detoxification	$20 co-payment
Ambulance	80% after deductible
Durable Medical Equipment	80% after deductible
Voluntary Termination of Pregnancy (medical, medication, surgical): 1st Trimester	The amount you pay is based on where the covered service is provided.
Laboratory Services When available through or authorized by PCP	No charge
Maternity Care, Tests Procedures	The amount you pay is based on where the covered service is provided.
Mental Health Services As required by law, coverage includes treatment for Severe Mental Illness (SMI) of adults and the treatment of Serious Emotional Disturbance (SED)	$20 co-payment
Oral Surgery Services No dental	$40 co-payment
Outpatient Medical Rehabilitation Therapy at a Participating Free-Standing or Outpatient Surgery Facility	$20 co-payment
Outpatient Surgery at a Participating Free-Standing or Outpatient Surgery Facility	80% after deductible
Preventative Care Physician, laboratory, radiology and related services as recommended by the American Academy of Pediatrics, Advisory Committee on Immunization Practices and U.S. Preventive Services Task Force and authorized through the patient's primary care provider	No charge
Physician Office Visit	$20 co-payment for Primary Care Physician; $40 co-payment for Specialist
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	No charge

Additional Information

Member Customer Service Number	Northern California (800) 624-8822 Out-of-state (866) 633-2446
Website	www.myuhc.com
Evidence of Coverage (EOC)	Out of Area Plan – UnitedHealthcare Choice Plan Group #902027 – Early Retirees