Article 6: Comparison of Blue Shield PPO Plan, Kaiser HMO and UnitedHealthcare >>

6.5 45% and 50% Sound Apprentice – Kaiser Permanente

Southern California IBEW-NECA Health Trust Fund
CID# 101155 Apprentices
Principal Benefits for Kaiser Permanente Traditional Plan

The Services described in this section are covered only if all of the following conditions are satisfied:

1. The Services are Medically Necessary
2. The Services are provided, prescribed, authorized, or directed by a Plan Physician and you receive the Services from Plan Providers inside our Southern California Region Service Area (your Home Region), except where specifically noted to the contrary in the Evidence of Coverage (EOC) for authorized referrals, hospice care, Emergency Services, Post-Stabilization Care, Out-of-Area Urgent Care, and emergency ambulance Services

A. Annual Out-of-Pocket Maximum for Certain Services

For Services subject to the maximum, you will not pay any more Cost Sharing during a calendar year if the Co-payments and Coinsurance you pay for those Services add up to one of the following amounts:

B. Deductible or Lifetime Maximum

None

C. Professional Services (Plan Provider office visits)

D. Outpatient Services

E. Hospitalization Services

F. Emergency Health Coverage

Note: This Cost Sharing does not apply if admitted directly to the hospital as an inpatient for covered services (see "Hospitalization Services" for inpatient Cost Sharing).

G. Ambulance Services

H. Prescription Drug Coverage

I. Durable Medical Equipment

J. Mental Health Services

K. Chemical Dependency Services

L. Home Health Services

M. Other

NOTE:

The benefits chart for 45% and 50% Sound Apprentices is only a representative summary of the coverage and benefits available under the Alternate Kaiser Permanente Plan for the Sound Unit 45%-50% Apprentices. It does not fully describe the coverage and benefits.

For details on your coverage and benefits, please refer to the Evidence of Coverage document. The Evidence of Coverage document is the legal document that describes the benefits, limitations, exclusions, and other coverage provisions provided by the HMO to its members. The current Evidence of Coverage document is available directly from Kaiser Permanente, as well as from the Administrative Office, upon request.

A Kaiser Permanente physician must determine that the services and supplies are medically necessary to prevent, diagnose, or treat a medical condition. The services and supplies must be provided, prescribed, authorized, or directed by a Kaiser Permanente physician. You must receive the services and supplies at a Kaiser Permanente facility, except where specifically noted to the contrary in the respective HMO’s Evidence of Coverage document.

For details on the benefit and claim review and adjudication procedures, please refer to the Evidence of Coverage document or contact Kaiser Permanente’s Membership Services Department at (800) 464-4000.