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.


Overview
 

UnitedHealthcare is a network model Health Maintenance Organization (HMO). It contracts with doctors who are in private practice or are part of established Medical Groups. You choose a participating Medical Group and from that Medical Group you must select a primary care physician (PCP). Your PCP will be responsible for all of your healthcare needs, and will refer you to a specialist when necessary. Note that certain providers allow for annual enrollments only.

Lifetime Maximum
 

No plan maximum

Annual Copayment Maximums
 

$1,000/individual
3 individual maximum per family

Inpatient Hospital Charges
 

Paid in Full

Outpatient Office Visits and Most Outpatient Services
 

Your copayment is: $5

Other Outpatient Services
 
  • Ambulance - Paid in Full
  • Cochlear Implants - Paid in Full
  • Health Education Services - Paid in Full
  • Home Health Care Visits (Up to 100 per calendar year) - Paid in Full
  • Hospice Care (Prognosis of life expectancy of one year or less) - Paid in Full
  • Laboratory and Radiology - Paid in Full
  • Maternity Care, Tests and Procedures - Paid in Full
  • Outpatient Surgery at a participating Free-Standing or Outpatient Facility - Paid in Full
  • Well-Baby Care - Paid in Full
Emergency Services and Urgently Needed Services when Out of Service Area
 

$50 Copayment unless admitted to hospital.

Chiropractic
 

The Chiropractic benefits covers the services described in this section when performed by a Participating ACN Group, Inc. Chiropractor and authorized when necessary by ACN Group, up to the Annual maximum Benefit listed.

  • Copayments for Each Visit - $5.00
  • Annual Maximum Benefit - 30 Visits
  • Annual Maximum Benefit for Chiropractic Appliances - $50.00
Prescriptions
 

Not covered through UnitedHealthcare. See the Prescription BenefitTab.

Additional Info
 

Phone: 1-800-624-8822
Web Site: https://www.myuhc.com

Summary Schedule of Benefits
Group #:
Active - 144786
Early Retiree - 144787
Non-medicare - 144788
Medicare - 4257

Virtual Visits
Evidence of Coverage
Summary of Benefits and Coverage (SBC)