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.

UnitedHealthcare Retiree Programs
 

Early Retirees who elect the UnitedHealthcare Plan have the same hospital and medical benefits as active participants. See the Active Health BenefitTab for UnitedHealthcare.

Participants on Medicare Parts A & B who elect the UnitedHealthcare® Group Medicare Advantage Plan for Retirees have benefits as described below.

General Features
 
Calendar Year Deductible None
Maximum Benefits Unlimited
Annual Co-Payment Maximum $6,700
Hospital Benefits No charge
Emergency Services
Co-payment waived if admitted
$20 co-payment
Urgently Needed Services
Medically Necessary services required outside geographic area service by Primary Medical Group
$15 co-payment
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 No charge
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)
No charge
Physician Care No charge
Reconstructive Surgery No charge
Rehabilitative Care
Including physical, occupational and speech therapy
No charge
Skilled Nursing Facility
Up to 100 Consecutive Days from the first treatment per disability
No charge up to 100 days
Outpatient Benefits
 
Alcohol, Drug or Other Substance Abuse Detoxification $5 co-payment
Ambulance No charge
Durable Medical Equipment No charge
Mental Health Services
As required by law, coverage includes treatment for Severe Mental Illness of adults and the treatment of Serious Emotional Disturbance
$5 co-payment
Oral Surgery Services
No dental
No charge
Outpatient Medical Rehabilitation Therapy at a Participating Free-Standing or Outpatient Surgery Facility No charge
Outpatient Surgery at a Participating Free-Standing or Outpatient Surgery Facility No charge
Periodic Health Evaluations
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 physician
No charge
Physician Office Visit $5 co-payment
Well-Woman Care Office Visit
Includes PAP smear by PCP or an OB/GYN in Primary Medical Group and a referral by the Primary Medical Group for screening mammography as recommended by the U.S. Preventive Services Task Force
No charge
Prescription Drugs
 
Retail Pharmacy: Generic Drugs $5 co-payment
Up to a 30-day supply
Retail Pharmacy: Brand Retail Drugs $15 co-payment
Up to a 30-day supply
Mail Order: Generic Drugs $10 co-payment
Up to a 30-day supply
Mail Order: Brand Name Drugs $30 co-payment
Up to a 30-day supply
Self-Pay Rates - 2020
(1/1/20-12/31/20)
 
Plan Early Retiree Medicare Eligible One Early Retiree & One Medicare
UnitedHealthcare HMOTraditional
Retiree Only
Retiree and Spouse

$224
$462
Not Applicable Not Applicable
UnitedHealthcare Medicare Advantage HMO
Retiree Only
Retiree and Spouse
Not Applicable
 
$125
$250
Not Applicable
Retiree & Spouse Not Applicable Not Applicable $363

UnitedHealthcare HMOHarmony
Retiree Only
Retiree and Spouse

$199
$409
Not Applicable Not Applicable
UnitedHealthcare Medicare Advantage HMO
Retiree Only
Retiree and Spouse
Not Applicable
 
$125
$250
Not Applicable
Retiree & Spouse Not Applicable Not Applicable $323
Additional Information