Active Health Plan Benefit Tabs™

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

Anthem BlueCross Prudent Buyer PPO
 
Overview
 

Anthem Blue Cross Prudent Buyer Preferred Provider Network (PPO) covers most forms of medically necessary care subject to various limits.  After you satisfy the annual deductible of $200, the Plan pays 80% of covered charges (or 90% if you use the PPO).

Effective for claims incurred on and after July 1, 2008
 

Bariatric (weight loss) surgical procedures and adult immunizations will be considered a covered medical expense, when the Participant meets the criteria established in the Anthem Blue Cross Evidence of Coverage.

Annual Deductible
 

Before any payments are made by the plan you must satisfy the annual deductible.

Individual - $200 per calendar year

Family - $600 per calendar year.
This is the maximum total deductible for all family members combined.

Hospital Deductible
 

For each hospitalization

PPO - No Deductible

Non-PPO - $200 Deductible

Coinsurance
 

The portion (percentage) of the charges that the plan pays after all deductibles have been satisfied.

For most services the following schedule applies until you reach the maximum amount of charges. Please see the Schedule of Benefits for a complete list of schedules and coinsurance rates.

  Plan Pays You Pay
PPO    90%    10%
Non PPO
   80%
   20%

After the maximum of $12,500 in covered charges has been reached for a family member in a calendar year, subsequent charges for that family member are paid at 100%.

Important: Only charges of PPO Providers are automatically considered "covered" for the purpose of the annual out-of-pocket maximum. Charges from other providers may exceed the amount allowed so you will have to pay the excess out-of-pocket, and these excess charges will not count towards the $12,500 maximum.

Other Out-of-Pocket Expenses
 

Are those which are not covered by the plan and for which you are responsible. These do not count towards your coinsurance maximum.

  • Non-PPO providers may charge amounts in excess of the UCR (usual, customary and reasonable) amounts allowed by the plan.
  • Charges for services that exceed your annual maximum or a specific maximum or limit.
  • Charges which are not medically necessary including care not approved through the medical review process.
Lifetime Maximum
 

No plan maximum

Prudent Buyer
PPO
 

You are encouraged to receive all of your medical care from providers who are members of the plan's PPO network. Some of benefits you receive for using the Prudent Buyer PPO are:

  • Copayments for some types of care are less.
  • Your coinsurance will be lower as shown above.
  • PPO provider must directly bill the Plan, rather than making you pay and then request reimbursement.

Click here to locate PPO providers.

Medical Review
 

The set of programs to help ensure that you receive appropriate care. Penalties will apply if you neglect to use the medical review required by the plan.

  • Preadmission certification is mandatory for all non-emergency admissions.
  • For emergency hospitalization, Anthem BlueCross must be notified within 1 day of admission.
Coinsurance and Limitations for Some Common Types of Coverage
 
Supplemental Accident Benefit
 

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

Additional Info:
 

Phone: 1-800-543-3037
Web Site: www.bluecrossca.com

Summary Schedule of Benefits
Group #: 170001M004

LiveHealth Online – for Medical and Psychological
Evidence of Coverage
Summary of Benefits and Coverage (SBC)