Active Health Summary Plan Description
As of September 1, 2017
En Español (PDF)

6.1 Medical Benefits Comparison: Anthem Blue Cross, Kaiser and UnitedHealthcare

Comparison of Medical Plan Offerings 
This is only a summary of the benefits available to you under the Anthem Blue Cross PPO Plan and the Kaiser and UnitedHealthcare HMO Plans. For a complete description of the respective PPO or HMO's benefits, please refer to the carrier's EVIDENCE OF COVERAGE AND DISCLOSURE DOCUMENT. The EVIDENCE OF COVERAGE AND DISCLOSURE DOCUMENT is the legal document that describes the benefits, exclusions and limitations and other coverage provisions including claims appeals, claims review and adjudication procedures. Additionally, the Summary of Benefits and Coverage (SBC) are available, routinely distributed and appear on the Trust Funds' website at www.scibew-neca.org.
Vendor Anthem Blue Cross PPO Kaiser HMO UnitedHealthcare
  In Network Out-of-Network In Network Only In Network Only
Member Customer Service Number (800) 543-3037 (800) 464-4000 (800) 624-8822
Website www.bluecrossca.com www.members.kp.org www.uhcwest.com
General Features
Calendar Year Deductible $200 per individual, $600 per Family None None
Maximum Benefits Unlimited Unlimited Unlimited
Annual Co-payment Maximum $1,000 per individual, $2,000 per family $1500 per Individual, $3,000 per family $1000 per Individual. $3,000 per family
Hospital Benefits 10% co-payment. Hospital Pre-Certification Required. 20% co-payment. Additional $200 deductible for non-Anthem Blue Cross PPO Hospital or Residential Treatment Center and $500 no-preauthorization penalty (waived for emergency services) Hospital Precertification Required. 2 No Charge No Charge
Emergency Services 10% co-payment 1 10% co-payment. 2 $5 co-payment. Co-payment waived if admitted. $50 co-payment. Co-payment waived if admitted.
Preexisting Conditions Not Applicable. All conditions are covered provided they are a covered benefit.
Benefits Available While Hospitalized as an Inpatient
Alcohol, Drug or Other Substance Abuse Detoxification 10% co-payment 1 20% co-payment 2 No Charge No Charge
Mental Health Services (As required by law, coverage includes treatment for Severe Mental Illness (SMI) of adults and children and the treatment of Serious Emotional Disturbance (SED). 10% co-payment 1 20% co-payment 2 No Charge No Charge
Newborn Care 10% co-payment 1 20% co-payment 2 No Charge No Charge
Physician Care 10% co-payment 1 20% co-payment 2 No Charge No Charge
Reconstructive Surgery 10% co-payment 1 20% co-payment 2 No Charge No Charge
Rehabilitative Care (including physical, occupational and speech therapy) 10% co-payment. Must obtain prior approval. 1 20% co-payment. Up to $35 max benefit per visit. Must obtain prior approval. 2 No Charge No Charge
Skilled Nursing 10% co-payment. 1 20% co-payment. 2 No Charge No Charge
Voluntary Termination of Pregnancy (Medical, Medication and surgical) 10% co-payment. 1 20% co-payment. 2 $5 Co-payment $75 co-payment
Benefits Available on an Outpatient Basis
Ambulance 10% co-payment 1 10% co-payment 2 No Charge No Charge
Durable Medical Equipment 10% co-payment. 1 20% co-payment. 2 No Charge No Charge
Durable Medical Equipment for the Treatment of Pediatric Asthma (includes nebulizer, peak flow meters, face masks and tubing for Medically Necessary Treatment of Pediatric Asthma of dependent children under the age of 19) 10% co-payment. 1 20% co-payment. 2 No Charge No Charge
Immunizations (For Children Under two (2) years of age, refer to well-baby care) No Charge 20% co-payment 2 $5 Office Visit Co-payment No Charge
Laboratory Services (When available through or authorized by PCP) 10% co-payment. 1 20% co-payment. 2 No Charge No Charge
Mental Health Services (As required by law, coverage includes treatment for Severe Mental Illness (SMI) of adults and children and the treatment of Serious Emotional Disturbance (SED). 10% co-payment 1 20% co-payment 2 $5 Office Visit Co-payment $5 Office Visit Co-payment
Oral Surgery Services 10% co-payment 1 10% co-payment 2 No Charge No Charge
Outpatient Medical Rehabilitation Therapy at Participating Free Standing or Outpatient Surgery Facility 10% co-payment 1 20% co-payment 2 $5 Office Visit Co-payment $5 Office Visit Co-payment
Outpatient Surgery at Participating Free Standing or Outpatient Surgery Facility 10% co-payment. 1 20% co-payment. 2 No Charge No Charge
Physician Office Visits (Physician, laboratory, radiology and related services as recommended by the American Academy of Pediatrics (AAP). Advisory Committee on Immunization Practices (ACIP) and U.S. Preventive Services Task Force and authorized through PCP for children). 10% co-payment 1 20% co-payment 2 $5 Office Visit Co-payment $5 Office Visit Co-payment
Well-Baby Care (Preventive health service, including immunizations as recommended by the American Academy of Pediatrics (AA), Advisory Committee on Immunization Practices (ACIP) and U.S. Preventive Care Task Force and authorized through PCP for children). 0% co-payment 1 20% co-payment 2 No Charge No Charge
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). 0% co-payment 1 20% co-payment 2 No Charge No Charge
1 Subject to the annual deductible.
2 Subject to the annual deductible and balance billing.