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

6.2 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:

For self-only enrollment (a Family of one Member). $1,500 per calendar year
For any one Member in a Family of two or more Members $1,500 per calendar year
For an entire Family of two or more Members $3,000 per calendar year

B. Deductible or Lifetime Maximum

None

C. Professional Services (Plan Provider office visits)

  You Pay
Most primary and specialty care consultations, exams, and treatment $25 per visit
Routine physical maintenance exams No charge
Well-child preventive exams (through age 23 months) No charge
Family planning counseling No charge
Scheduled prenatal care exams and first postpartum follow-up consultation and exam No charge
Eye exams for refraction No charge
Hearing exams No charge
Urgent care consultations, exams, and treatment $25 per visit
Physical, occupational, and speech therapy $25 per visit

D. Outpatient Services

  You Pay
Outpatient surgery and certain other outpatient procedures $250 per procedure
Allergy injections (including allergy serum) No charge
Most immunizations (including the vaccine) No charge
Most X-rays and laboratory tests No charge
Health education  
Covered individual health education counseling
No charge
Covered health education programs
No charge

E. Hospitalization Services

  You Pay
Room and board, surgery, anesthesia, X-rays, laboratory tests, and drugs $500 per admission

F. Emergency Health Coverage

  You Pay
Emergency Department visits $100 per visit

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

  You Pay
Ambulance Services $50 per trip

H. Prescription Drug Coverage

  You Pay
The outpatient prescription drugs listed in the EOC in accord with our drug formulary guidelines at Plan Pharmacies or through our mail-order service (most outpatient prescription drugs are not covered) $15 for up to a 30-day supply,
$30 for a 31- to 60-day supply,
$45 for a 61- to 100-day supply
for base drugs only

I. Durable Medical Equipment

  You Pay
Covered durable medical equipment for home use in accord with our durable medical equipment formulary guidelines No charge

J. Mental Health Services

  You Pay
Inpatient psychiatric hospitalization $500 per admission
Individual outpatient mental health evaluation and treatment $25 per visit
Group outpatient mental health treatment $12 per visit

K. Chemical Dependency Services

  You Pay
Inpatient detoxification $500 per admission
Individual outpatient chemical dependency evaluation and treatment $25 per visit
Group outpatient chemical dependency treatment $5 per visit

L. Home Health Services

  You Pay
Home health care (up to 100 visits per calendar year) No charge

M. Other

  You Pay
Skilled nursing facility care (up to 100 days per benefit period) No charge
Covered external prosthetic devices, orthotic devices, and ostomy and urological supplies No charge
Hospice care No charge

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 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, as well as from the Administrative Office, upon request.

A Kaiser 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 physician. You must receive the services and supplies at a Kaiser 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's Membership Services Department at (800) 464-4000.