IBEW-NECA Sound & Communications
Benefits Web site
IBEW-NECA Sound & Communications
Benefits Web site
| ANNUAL COPAYMENT MAXIMUM (1) | |
|---|---|
| 3 individual maximum per family | $2,000/individual |
| OUTPATIENT CARE | |
| Alcohol, Drug or Other Substance Abuse - Detoxification | No charge |
| Allergy Testing/Treatment (serum is not covered unless an allergy serum rider was purchased by your employer) | $10 Copayment |
| Cancer Clinical Trials (2,3) | You pay balance, if any, after payment at contracting rate |
| Dental Treatment Anesthesia (additional charges for outpatient and inpatient surgery may apply) | $10 Copayment |
| Hearing Screening | $10 Copayment |
| Hemodialysis (Physician office visit Copayment may apply) | $10 per treatment |
| Immunizations (for children under two years of age, refer to Well-Baby Care) | No charge |
| Infertility Serviced | 50% Copayment |
| Laboratory and Radiology (when available through and authorized by the Member's Participating Medical Group) | No charge |
| Maternity Care, Tests and Procedures | No charge |
| Office Visits | $10 Copayment |
| Oral Surgery Services | No charge |
| Outpatient Rehabilitation Therapy at a Participating Free-Standing or Outpatient Facility (including physical, occupational and speech therapy) | $10 Copayment |
| Outpatient Surgery | No charge |
| Periodic Health Evaluations (Physician, laboratory, radiology and related services as recommended by the American Academy of Pediatrics (AAP) and U.S. Preventive Services Task Force and authorized through your Primary Care Physician in your Participating Medical Group to determine your health status; for children under two years of age refer to Well-Baby Care.) | $10 Copayment |
| Physician Care (for children under two years of age, refer to Well-Baby Care) | No charge |
| Vision Refractions | $10 Copayment |
| Vision Screening | $10 Copayment |
| Well-Baby Care (Preventative health service, including immunizations recommended by the American Academy of Pediatrics (AAP) and U.S. Preventive Services Task Force and authorized through your Primary Care Physician in your Participating Medical Group for children under two years of age. The applicable office visit Copayment applies to infants that are ill at time of services.) | No charge |
| Well-Woman Care (Includes Pap smear by your Primary Care Physician or an OB/GYN in your Participating Medical Group for screening mammography as recommended by the U.S. Preventive Services Task Force.) | $10 Copayment |
| HOSPITAL INPATIENT CARE | |
| Alcohol, Drug or Other Substance Abuse - Detoxification | No charge |
| Bone Marrow Transplants (donor searches limited to $15,000 per procedure) | No charge |
| Cancer Clinical Trials | You pay balance, if any, after payment at contracting rate |
| Hospice Care (autologous (self-donated) blood up to $120.00 per unit) | No charge |
| Hospitalization | No charge |
| Mastectomy/Breast Reconstruction (after mastectomy and complications from mastectomy) | No charge |
| Maternity Care | No charge |
| Newborn Care (4) | No charge |
| Physician Care | No charge |
| Reconstructive Surgery | No charge |
| Rehabilitation Care (including physical, occupational and speech therapy) | No charge |
| Skilled Nursing Care (up to one hundred (100) consecutive calendar days from the first treatment per disability) | No charge |
| PRESCRIPTION DRUGS | |
| Retail Pharmacy (per Prescription Unit or up to 30 days) | |
| Generic | $10 |
| Brand Name | $25 |
| Mail-Service Pharmacy (up to 3 Prescription Units or up to 90 days) | |
| Generic | $20 |
| Brand Name | $50 |
| FAMILY PLANNING | |
| Vasectomy | $50 Copayment |
| Tubal ligation (5) | $100 Copayment |
| Insertion/removal of Intra-Uterine Device (IUD) | $10 Copayment |
| Intra-Uterine Device (IUD) | 50% Copayment (6) |
| Removal of Norplant | $10 Copayment |
| Depo-Provera injection | $10 Copayment |
| Depo-Provera medication (Limited to one Depo-Provera injection every 90 days) | $35 Copayment |
| Voluntary interruption of pregnancy (medical/medication and surgical) | |
| -1st trimester | $75 Copayment |
| -2nd trimester (12-20 weeks) | $150 Copayment |
| -After 20 weeks | Not covered unless mother's life is in jeopardy or fetus not viable |
| MENTAL HEALTH SERVICES (7) | |
| Mental Health Services (As required by state law, coverage includes treatment for Severe Mental Illnesses (SMI) of adults and children and for children the treatment of Serious Emotional Disturbance of Children (SED).) | $10 Copayment per visit |
| Inpatient, Residential and Day Treatment. Up to 30 days per Calendar Year based on the following levels of care: | No charge |
| Inpatient Treatment = 1 day | |
| Residential Treatment = 70% of 1 day | |
| Day Treatment = 60% of 1 day | |
| Outpatient Treatment (Up to 30 visits per Calendar Year) | $10 Copayment |
| Emergency | $50 Copayment |
| waived if admitted as inpatient | |
| Urgently Needed Services (Medically Necessary services required outside the geographic area served by your Participating Medical Group.) | $50 Copayment |
| Waived if admitted as inpatient | |
| SEVERE MENTAL ILLNESS BENEFIT | |
| Inpatient, Residential and Day Treatment (Unlimited days) | No charge |
| Outpatient Treatment (Unlimited Visits) | $10 Copayment |
| Emergency | $50 Copayment waived if admitted as inpatient |
| Urgently Needed Services (Medically Necessary services required outside the geographic area served by your Participating Medical Group.) | $50 Copayment waived if admitted as inpatient |
| CHEMICAL DEPENDENCY SERVICES | |
| Inpatient and Outpatient treatment (Maximum annual benefit for detoxification and all levels of care limited to $25,000 per Calendar Year; $35,000 Lifetime Maximum Benefit | No charge |
| Emergency | $50 Copayment waived if admitted as inpatient |
| Urgently Needed Services (Medically Necessary services required outside the geographic area served by your Participating Medical Group.) | $50 Copayment waived if admitted as inpatient |
| OTHER SERVICES | |
| Ambulance | No charge |
| Chiropractic Care | $10 Copayment per visit (30 visit annual maximum |
| Cochlear Implants (Outpatient surgery or inpatient hospitalization and outpatient rehabilitation therapy Copayments may apply) | No charge |
| Crisis Intervention (up to twenty (20) visits for Crisis Intervention per calendar year) | $35 Copayment |
| Durable Medical Equipment, Corrective Appliances and Prosthetics | No charge |
| Health Education Services | No charge |
| Home Health Care | No charge |
| Hospice Care (prognosis of life expectancy of one year or less) | No charge |
| EMERGENCY CARE | |
| Emergency Services | $50 Copayment waived if admitted as inpatient |
| Urgently Needed Services (Medically Necessary services required outside the geographic area served by your Participating Medical Group.) | $50 Copayment waived if admitted as inpatient |
(1) Annual Copayment Maximum does not include Copayments for pharmacy and supplemental benefits.
(2) Cancer Trial. Services require preauthorization by PacifiCare.
(3) If you participate in a clinical trial provided by a Non-Participating Provider that does not agree to perform these services at the rate PacifiCare negotiates with Participating Providers, you will be responsible for payment of the difference between the Non-Participating Provider's billed charges and the rate negotiated by PacifiCare with Participating Providers, in addition to any applicable Copayments, Coinsurance or Deductibles.
(4) The newborn care Copayment does not apply when the newborn is discharged with the mother within 48 hours of the normal vaginal delivery or 96 hours of the cesarean delivery. Please see the Combined Evidence of Coverage and Disclosure Form for more details.
(5) Copayment applies regardless of whether this benefit is performed on an inpatient or outpatient basis. If performed on an inpatient basis, additional inpatient Copayment, if any, will apply.
(6) Percentage Copayment amounts are based upon PacifiCare's contracted rate
(7) Preauthorization is required for all Mental Health- Services, Chemical Dependency Services and Severe Mental Illness (SMI) Benefits. You do not need to go through your Primary Care Physician, but you must obtain prior authorization through PacifiCare Behavioral Health of California (PBHC), an affiliate of PacifiCare that specializes in mental health and chemical dependency benefits. PBHC is available to you toll-free, 24 hours a day, 7 days a week, at 1-800-999-9585.
(8) Severe Mental Illness diagnoses include: Anorexia Nervosa, Bipolar Disorder, Bulimia Nervosa, Major Depressive Disorder, Obsessive-Compulsive Disorder, Panic Disorder, Pervasive Developmental Disorder or Autism, Schizoaffective Disorder, and Schizophrenia. In addition, the Severe Mental Illness Benefit includes coverage of Serious Emotional Disturbance of Children (SED).
(9) The Lifetime Dollar Maximum for Severe Mental Illness will be applied to the Medical Plan Lifetime Dollar Maximum Benefit, if applicable.
Except in the case of a Medically Necessary Emergency or an Urgently Needed Service (outside the geographic area served by your Participating Medical Group), each of the above-noted benefits is covered when authorized by your Participating Medical Group or PacifiCare. A utilization review committee may review the request for services.
The above is only a summary of the benefits available under the PacifiCare HMO. You may request a more detailed explanation of the benefits available under the PacifiCare HMO, including definitions of the terms used in the above summary, at no cost from the Fund Administrator.
(800) 624-8822