SOUTHERN CALIFORNIA DRUG BENEFIT FUND Plus...SOUTHERN CALIFORNIA DRUG BENEFIT FUND PLATINUM PLUS...

SOUTHERN CALIFORNIA DRUG BENEFIT FUND PLATINUM PLUS PLAN SUMMARY

AS OF JANUARY 1, 2018

This group health plan believes this plan is a "grandfathered health plan" under the Patient Protection and Affordable Care Act (the Affordable Care Act). As permitted by the Affordable Care Act, a grandfathered health plan can preserve certain basic health coverage that was already in effect when that law was enacted. Being a grandfathered health plan means that your plan may not include certain consumer protections of the Affordable Care Act that apply to other plans, for example, the requirement for the provision of preventive health services without any cost sharing. However, grandfathered health plans must comply with certain other consumer protections in the Affordable Care Act, for example, the elimination of lifetime limits on benefits.

Questions regarding which protections apply and which protections do not apply to a grandfathered health plan and what might cause a plan to change from grandfathered health plan status can be directed to the plan administrator by phone or in writing at So. California Drug Benefit Fund, 2220 Hyperion Avenue, Los Angeles, CA 90027, (323) 666-8910. You may also contact the Employee Benefits Security Administration, U.S. Department of Labor at 1-866-444-3272 or www.dol.gov/ebsa/healthreform. This Web site has a table summarizing which protections do and do not apply to grandfathered health plans.

SOUTHERN CALIFORNIA DRUG BENEFIT FUND PLATINUMPLUSPLANSUMMARYASOFJANUARY1,2018

OE 2018 - Platinum Plus Plan L

SECTION PAGE

CONTACT INFORMATION ....................................................................................................................................................................................... 1

ELIGIBILITY RULES .................................................................................................................................................................................................. 2

ESTABLISHING ELIGIBILITY & COVERAGE COMMENCEMENT ......................................................................................................... 2

WORKING SPOUSE RULE AND COORDINATION OF BENEFITS ........................................................................................................ 2

DEATH BENEFITS ..................................................................................................................................................................................................... 2

MEDICAL BENEFITS ................................................................................................................................................................................................. 3

HOSPITAL BENEFITS .................................................................................................................................................................................. 4

PROFESSIONAL SERVICES ....................................................................................................................................................................... 5

MENTAL HEALTH AND SUBSTANCE ABUSE BENEFITS ...................................................................................................................... 8

MEDICAL SUPPLIES AND EQUIPMENT ................................................................................................................................................... 9

OTHER SERVICES AND BENEFITS .......................................................................................................................................................... 9

PRESCRIPTION DRUG BENEFITS ....................................................................................................................................................................... 10

DENTAL BENEFITS ................................................................................................................................................................................................. 11

ORTHODONTIC BENEFITS .................................................................................................................................................................................... 11

PLAN EXCLUSIONS ................................................................................................................................................................................................ 12


Page 1 of 13

CONTACT INFORMATION

TrustFundOffice 877-999-8329 www.ufcwdrugtrust.org

AnthemBlueCrossPrudentBuyer 800-227-3641 www.anthem.com/ca/home.html

BlueCard 800-810-BLUE(800-810-2583) www.bcbs.com

DeltaDental 800-765-6003 www.deltadentalins.com

Kaiser 800-464-4000 www.kp.org

HMCHealthWorks 866-268-2510 https://hmc.personaladvantage.com(AccessCode:SCDBF)

PodiatryPlanofCalifornia(PPOC) 800-367-7762 www.podiatryplan.com

OptumRx 800-788-7871 www.optumrx.com

UnitedHealthcare(UHC) 800-624-8822 www.MyUHC.com

UnitedConcordia 800-937-6432 www.unitedconcordia.com

This document is intended merely as a summary of the Platinum Plus health care plan offered by the Southern California Drug Benefit Fund. For exclusions and restrictions, you should read the Summary Plan Description and the evidence of coverage booklets provided by

Kaiser, UnitedHealthcare, and United Concordia.


ThisdocumentisintendedmerelyasasummaryofthePlatinumPlushealthcareplanofferedbytheSouthernCaliforniaDrugBenefitFund.Forexclusionsandrestrictions,youshouldreadtheSummaryPlanDescriptionandtheevidenceofcoveragebookletsprovidedbyKaiser,UnitedHealthcare(formerlyPacifiCare),andUnitedConcordia.

OE 2018 - Platinum Plus Plan Page 2 of 13

ELIGIBILITY RULES

ESTABLISHINGELIGIBILITY&COVERAGECOMMENCEMENTAllEmployees Ifyouworkanaverageof23ormorehoursperweek(“QualifyingHours”)for3consecutivemonths,youandyourdependentswillbecome

eligibleforallbenefits,exceptorthodonticbenefits,onthefirstdayofthemonthafter2skipmonths.Forexample,ifyouworkQualifyingHoursinJanuary,FebruaryandMarch,youandyourdependentswillbeeligibleforbenefits,exceptOrthodontic,onJune1.Newlyeligibleparticipants,exceptforKaiserEmployees,arerequiredtoenrollintheIndemnityMedicalPlanandwillbeeligibletoenrollinanHMOplanonthe2ndannualopenenrollmentaftertheirdateofhire.Orthodonticcoveragewillbeavailabletoyouandyourdependentsafteryouhave9consecutivemonthsofeligibilityinthePlatinumPlusPlan.

MaintainingEligibility Onceyoubecomeeligible,youmustcontinuetoworktheQualifyingHoursduringeachmonthtomaintaineligibilityforyourselfandyoureligibledependents.

WORKINGSPOUSERULEANDCOORDINATIONOFBENEFITSWorkingSpouseRule(alsoapplicabletoDomesticPartners)

FormarriedEmployeesandEmployeeswithDomesticPartners(theuseoftheterm“spouse”inthissectionincludesDomesticPartners):Ifyourspouse’semployeroffershealthcarecoverage,yourspousemustenrollinthatemployer’scoveragethatiscomparabletoyourcoverageunderthisFund,evenifheorsheisrequiredtopaysomeorallofthecostofthatcoverage.Ifyourspouse’semployerdoesnotoffercoveragethatiscomparabletoyourcoveragefromtheFund,yourspousemustenrollinthebestcoverageavailablethroughhisorheremployer.Ifyourspouseiseligibleformedical,prescriptiondrug,dental,and/orvisionbenefitsthroughhisorheremployerbutfailstoenroll,thisPlanwillpayonly40%ofitsnormalbenefits(i.e.itwillreduceitspaymentamountby60%)undertheIndemnityMedicalPlan,IndemnityPrescriptionDrugPlan,IndemnityDentalPlan,andIndemnityVisionPlan.ThisruledoesnotapplyifbothspousesareeligibleforcoverageasEmployeesofcontributingEmployersandonespousehaselectedcoveragefor“EmployeeplusspouseorDomesticPartner”.PleasecontacttheFundOfficeformoreinformation.

DEATH BENEFITS Employee Greaterof$15,000ortheamountofsalaryreceivedduringthemostrecent12months.

Dependent $2,000




MEDICAL BENEFITS

INDEMNITYPLAN UNITEDHEALTHCARE(UHC)

KAISER PPO (In Network) Non-PPO (Out of Network)

HowthePlanWorks Formostofficevisits,youmustpaya$10copaypervisit.ThenthePlanpays100%ofContractRates1.WhenyouuseaPPOproviderforpreventiveandwellnessservices,thePlanwillpay100%ofContractRatesforallofthepreventivecareandimmunizationserviceslistedinthePlan’scurrentPreventiveCareGuidelines,whichisavailablefromtheFundOffice.ThereisnocopaymentaslongasservicesarereceivedfromPPOproviders.

Formostservices,thePlanpaysbothBasicandMajorMedicalbenefits.BasicMedicalBenefitsarepaidfirst.AfterBasicMedicalbenefitshavebeenexhausted,youmustsatisfytherequiredCalendarYearDeductible(“Deductible”),thenthePlanpaysapercentageoftheremainingAllowedAmount2asaMajorMedicalBenefit.Forsomeservicesandsupplies,specificdollarlimitsareimposed.YouareresponsibleforanyremainingbalanceaftertheallowedBasicandMajorMedicalbenefitsarepaid.

HospitalandprofessionalservicesaregenerallyprovidedatnochargeifreceivedatHMOcontractedfacilitiesandprovidedbyHMOproviders.Refertoeachbenefitbelowforexceptions.

HospitalandprofessionalservicesaregenerallyprovidedatnochargeifreceivedatHMOcontractedfacilitiesandprovidedbyHMOproviders.Refertoeachbenefitbelowforexceptions.

Refertoeachbenefitbelowforexceptions.

PreferredProviderNetwork(PPO)

IfyouliveinCalifornia,yourpreferredprovidernetwork(“PPO”)istheAnthemBlueCrossPrudentBuyernetwork.IfyouoryourdependentsliveoutsideofCalifornia,orifyouaretravelingoutsideCalifornia,yourPPOnetworkofhospitalsanddoctorsistheNationalBlueCardnetwork.TheBlueCardnetworkisavailableinall50states.YouarestronglyencouragedtouseaPPOprovider.ThePlanpaysahigherlevelofbenefitswhenyouuseaPPOphysicianorhospital.YoumaychoosetousehospitalsandphysicianswhodonotbelongtothePPOnetworks.However,thePlanpaysalowerlevelofbenefitsfornon-PPOproviders,andyouwillhavehigherout-of-pocketexpenses.TofindaPPOprovidernearestyou,callAnthemBlueCrossPrudentBuyerat800-227-3641orBlueCardAccessat800-810-BLUE.

YoumustuseanUHCHMOprovider.Servicesrenderedbynon-UHCprovidersarenotcovered.IfanemergencyoccursoutsideofUHC’sserviceareas,emergencyproceduresandbenefitsapply.

YoumustuseaKaiserprovider.Servicesrenderedbynon-Kaiserprovidersarenotcovered.IfanemergencyoccursoutsideoftheHMOs’serviceareas,emergencyproceduresandbenefitsapply.

1TheamountthatthePPOProvider(PrudentBuyerNetworkortheBlueCardProgram)hasagreedbycontracttoacceptfortheservicesprovided.2Inmostcases,theAllowedAmountistheallowancethattheFundhasdeterminedisanappropriatepaymentfortheMedicallyNecessaryservice(s)renderedtotheparticipantintheprovider'sgeographicarea.Wheretheprovider'schargeislessthantheFund'sallowancefortheservice(s)provided,theAllowedAmountistheprovider'sbilledamount.TheBoardofTrustees,oritsdesignee,hasdiscretiontodeterminetheAllowedAmount.




MEDICAL BENEFITS



Pre-AuthorizationandUtilizationReview

WhenPre-authorizationorUtilizationReviewisrequired,yourdoctororhospitalmustcontactPrudentBuyer/BlueCardat800-274-7767.PPOhospitalswilldothisautomatically.Youshouldconfirmthatyourotherproviders,includingnon-PPOhospitals,havedonethis.

SeeUHC’sEvidenceofCoverage.

SeeKaiser’sEvidenceofCoverage

CalendarYearDeductible(“Deductible”)

None $50perpersonpercalendaryearbeforeMajorMedicalpaymentsapply.

Notapplicable Notapplicable

Annual/LifetimeMaximum

None

HOSPITALBENEFITSHospitalInpatientServices(includingRoomandBoard,andAncillaryServices)

Planpays100%ofContractRatesupto120daysperdisability,includingICUandchildbirth.After120days,80%ofContractRatesPrudentBuyer/BlueCardprovidersareresponsibleforobtainingallPre-authorizationandUtilizationReview.

Planpays50%oftheAllowedAmountupto120daysperdisability,includingICUonly(excludeschildbirth).After120days,Planpays80%oftheAllowedAmount.Allhospitaladmissions,exceptforchildbirthoremergencyconfinements,mustbepreauthorizedbyPrudentBuyer/BlueCard.Call800-274-7767forPreauthorization.BenefitswillbereducedifyoufailtoobtainrequiredPreauthorization.Unauthorizeddaysarenotcovered.

100%covered 100%covered

HospitalEmergencyRoom(Facilityonly,PhysicianchargesarepayableunderPhysicianHospitalVisits)

Planpays100%ofContractRates

Foraccident,Planpays85%oftheAllowedAmount.Forillness,68%oftheAllowedAmount.

$35copay,waivedifadmittedasinpatient.ReasonablechargesforemergencyservicesreceivedoutsideUHCserviceareasarecoveredsubjecttocopayments.

100%covered

HospitalOutpatientFacilityCharges

Planpays100%ofContractRates Planpays85%oftheAllowedAmount. 100%covered 100%covered




MEDICAL BENEFITS



PhysicianHospitalVisits Planpays100%ofContractRates BasicMedicalpaysupto$25.50perday.MajorMedicalpays80%oftheremainingAllowedAmountafterDeductible.


SkilledNursingFacility(Medicareapproved)

Maximumbenefitof42.5%ofthesemiprivateroomrateoftheprevioushospitalstay,forupto2timestheunusednumberofalloweddaysperdisability.Thenumberofalloweddaysis120daysminusthenumberofdaysspentinthehospital.PatientmustbetransferredintotheSkilledNursingFacilitywithin14daysofacutecarehospitalstaylastingatleast3days.MustbeapprovedbyPrudentBuyer/BlueCard.

Asprescribedatdesignatedfacilities.100%covered,limitedto100dayspercalendaryearfromthefirsttreatmentperdisability.

Asprescribedatdesignatedfacilities.100%covered,limitedto100daysperbenefitperiod.

Ambulance Planpays100%ofContractRates/AllowedAmount. 100%covered 100%covered

OutpatientSurgicalCenters

Planpays100%ofContractRates

Planpaysamaximumof$350persurgery.Youareresponsibleforanychargesthatexceed$350.Anychargesinexcessofthe$350donotcounttowardtheDeductible.


MustbePre-authorizedbyPrudentBuyer/BlueCard.

PROFESSIONALSERVICESPreventiveCare Planpays100%ofContractRates,no

copaymentisrequired.AfterDeductible,Planpays85%oftheAllowedAmount.


CoverageisprovidedforthePreventiveandWellnessserviceslistedin,andsubjecttothefrequencydescribedin,theDrugBenefitFund’sPreventiveCareGuidelines.Breastfeedingdevices(e.g.breastpumps)arecoveredat100%onlyifpurchasedandobtainedthroughanAnthemPrudentBuyerapprovedDurableMedicalEquipmentvendor.




MEDICAL BENEFITS



PhysicianOfficeVisits $10copaypervisit BasicMedicalpaysupto$25.50pervisituptoa$300maximumpercalendaryear.Benefitsbeginonthe1stvisitforeachaccidentand2ndvisitforeachillness.AfterBasicMedicalandDeductiblehavebeensatisfied,MajorMedicalpays80%oftheremainingAllowedAmount.


Specialist $10copaypervisit BasicMedicalpaysupto$60pervisitforeachaccidentandeachillnesswhenreferredbyattendingphysician.NoMajorMedicalispayable.


Surgeon,AssistantSurgeon

100%ofContractRates BasicMedicalbenefitsarepaidaccordingtoascheduleofcharges.Excesscharges,afterBasicMedicalandDeductible,arecoveredunderMajorMedicalat80%oftheAllowedAmount


Anesthesiologist 100%ofContractRates Ifprovidedinahospitaloroutpatientsurgicalfacility,85%oftheAllowedAmount.Ifprovidedinaphysician’soffice,BasicMedicalpays$21.25pervisitandnoMajorMedicalispayable.


OutpatientX-rayandLaboratory

100%ofContractRates BasicMedicalpays85%oftheAllowedAmountupto$750maximumperaccidentorpercalendaryearforallillnesses.MajorMedicalpays75%oftheremainingAllowedAmountafterDeductible.


Injections 100%ofContractRates InjectionsarepayableasanOfficeVisitandcounttowardOfficeVisitmaximum.


MustbesuppliedandadministeredbyPhysician’soffice.Self-injectablesarecoveredunderPrescriptionDrugbenefits.




MEDICAL BENEFITS



PhysicalTherapy 100%ofContractRates BasicMedicalpaysupto$25.50pervisit,upto$300maximumpercalendaryear.MajorMedicalpays80%oftheremainingAllowedAmountafterDeductible.


SubjecttoUtilizationReviewbyPrudentBuyer/BlueCardforMedicalNecessity.

SpeechTherapy $10copaypervisit.Preauthorizationrequired.

Notcovered. 100%covered 100%covered

ChiropracticCareandAcupuncture

Planpays$25.50pervisit,nomorethanonevisitperday,uptoacombinedmaximumof$500percalendaryearforofficevisitsand$150percalendaryearforx-rayandlaboratory.

Notcovered. Notcovered.

Podiatry YoumustuseapodiatristonthePodiatryPlanOrganizationofCalifornia(PPOC)panel.Youpay$65forthefirstofficevisitunlessvisitisforemergency,trauma,oradiabeticcondition.ThereafterthePlanpays100%ofContractRates.Uptoamaximumof8visitspercalendaryear.Nobenefitsarepaidfornon-PPOCpodiatrists.OutsideCalifornia,usetheBlueCardnetwork.

Notcovered. 100%coveredifreferredbyyourprimarycarephysiciantoapodiatristinyourHMO.

100%coveredifreferredbyyourprimarycarephysiciantoapodiatristinyourHMO.

SpecialPodiatryBenefit NotApplicable Aseparate$120calendaryearbenefitisavailableregardlessofwhetheryouareenrolledinanHMOMedicalPlanortheIndemnityMedicalPlan.Thebenefitisforofficecallsandcharges(includingx-rays)bynon-networkprovidersincurredforthenon-surgicaltreatmentofchronicfootconditionssuchasweakorfallenarches,flatorpronatedfeet,halluxvalgus,metatarsalgia,orfootstrainandtoenailtrimmingandsurgicaltreatmentinvolvingdebridementofpainfulclavi.

ReconstructiveSurgeryFollowingMastectomy

100%coveredforreconstructionofthebreastonwhichamastectomyisperformed,surgeryontheotherbreasttoprovideasymmetricalappearance,andprosthesesandservicesinconnectionwithphysicalcomplicationsofallstagesofmastectomy,includinglymphedemas.

ObesityBypassSurgery CoveredundertheHospitalandSurgicalbenefitsifpre-authorizedasMedicallyNecessary

CoveredifdeterminedMedicallyNecessaryandauthorized.




MEDICAL BENEFITS



OrganandTissueTransplants

CoveredonlyiftransplantisperformedatanAnthemBlueCrossapprovedCenterofExpertise,thetransplantrecipientisaplanparticipant,andthetransplantispreauthorized.Undercertaincircumstances,donorsearch,organortissueprocurement,anddonorexpensesarecovereduptoacombinedlifetimemaximumof$30,000.

Notcovered. Musthavereferraltotransplantfacility.Subjecttoplancopaymentsandcoverage.

HomeHealthCare RegisterednurseexpensesorlicensedvocationalnursewhenprescribedbyaphysicianasbeingMedicallyNecessaryarecoveredat80%.Pre-AuthorizationbyPrudentBuyer/BlueCardisrequired.ServicesandsuppliesprovidedinlieuoftheservicesthatwouldhavebeencoveredundertheplanifconfinementhadbeeninahospitalorSkilledNursingFacilityarecovered.Homemakerservicesarenotcovered.

100%covered,upto100visitspercalendaryear.

100%covered,upto100visitspercalendaryear.

MENTALHEALTHANDSUBSTANCEABUSEBENEFITSProviderNetwork CoverageisadministeredbyHMCHealthWorks(“HMC”).Youarestrongly

encouragedtocontactHMCat866-268-2510beforereceivingservices.Allinpatienttreatment,exceptemergencyhospitalization,mustbepreauthorizedbyHMC.Preauthorizationisalsorequiredforintensiveoutpatientprograms,ECT,psychologicaltestingneuropsychologicaltestingandpartialhospitalization.

CoverageisadministeredbyHMCHealthWorks(“HMC”).Allservicesandtreatmentsmustbepre-approvedbyHMC(866-268-2510)andprovidedbyHMCnetworkproviders.Nocoverageforservicesandtreatmentsbynon-HMCproviders.

CoverageisprovidedthroughKaiser.ParticipantsmustuseKaiserfacilitiesandproviders.

MentalHealthInpatient

100%ofContractRates Planpays50%ofAllowedAmountforfirst120days;after120days,Planpays80%oftheAllowedAmount


MentalHealthOutpatient

First5visits:100%coveredAfter5thvisit:$10copaypervisit

Planpays$25.50pervisitthen80%oftheremainingAllowedAmount





MEDICAL BENEFITS



SubstanceAbuseInpatient

Detoxification,InpatientRehabilitation,Day/EveningHospital,andIntensiveOutpatientProgram:100%ofContractRates

Detoxification,InpatientRehabilitation,Day/EveningHospital,andIntensiveOutpatientProgram:Planpays50%ofAllowedAmountforfirst120days;after120days,Planpays80%oftheAllowedAmount

100%covered InpatientDetoxification:100%coveredTransitionalResidentialRecoveryServices:$100copayperadmission

SubstanceAbuseOutpatient

100%covered Planpays$25.50pervisitthen80%oftheremainingAllowedAmount.


MEDICALSUPPLIESANDEQUIPMENTOutpatientSurgicalSupplies

100%ofContractRates BasicMedicalpaysupto$21.25pervisitforsupplies,splintsanddressingsforsurgeryinaphysician’soffice.NoMajorMedicalispayable.

100%covered

OrthopedicAppliances Reimbursementof100%ofContractRatesorAllowedAmountforpurchaseorrentalprescribedbyaphysician,uptoonceeverycalendaryear.

HearingAids Forpatientswhosephysicianhascertifiedahearinglossthatmaybelessenedbytheuseofahearingaid.ThePlanpays80%oftheAllowedAmountforphysicianexaminationandinstrumentupto$750maximumforeachear,notmoreoftenthanonceduringany12-monthperiod.

DurableMedicalEquipment

ThePlanpays80%ofContractRates ThePlanpays80%oftheAllowedAmount.

100%coveredduringastayinahospitalorSkilledNursingFacility.

100%coveredduringastayinahospitalorSkilledNursingFacility.DurablemedicalequipmentforhomeuseiscoveredinaccordancewithKaiser'sdurablemedicalequipmentformularyguidelines.

OTHERSERVICESANDBENEFITSPediatricVisionCare(uptoage19)

RoutineEyeexamsarecoveredat100%upto$135perexam.However,amountspaidforroutineeyeexamswillreducetheannualframeandlensbenefit.

RoutineEyeExamsarecoveredthroughtheHMOat100%.IfyougooutsideyourHMOforroutineeyeexams,theFundwillpay100%upto$135perexam.However,amountspaidbytheFundwillreducethe$135annualframeandlensbenefit.

A$135maximumbenefitforframesandlenseseachcalendaryear.




MEDICAL BENEFITS



AdultVisionCare(forage19andover)

A$135maximumbenefittobeusedforeyeexaminationsand/orframesandlenseseachcalendaryear.ForKaiserandUHC,ifeyeexamisobtainedthroughtheHMO,the$135IndemnityPlanbenefitcanbeappliedtoframesand/orlenses.Note:Youarepermittedtoopt-outofvisioncoverageforyourselfandyourDependents.ContacttheFundOfficeformoreinformation.

AdditionalAccidentalInjuryBenefit

InadditiontootherPlanbenefitsamaximumof$300ispayableforContractRates/AllowedAmountsforMedicallyNecessaryservicesandsuppliesincurredwithin90daysofanaccidentasaresultoftheaccident.

None None

PRESCRIPTION DRUG BENEFITS

INDEMNITYPLANUNITEDHEALTHCARE

(UHC)NON-KAISEREMPLOYEESENROLLEDINKAISER

KAISEREMPLOYEESENROLLEDINKAISER

ParticipatingPharmacy AllParticipantsmustuseSoCADrugFundParticipatingPharmacies.(SeeseparateDirectoryatwww.ufcwdrugtrust.orgunder“Downloads”)

MustuseKaiserpharmacies.

Out-of-PocketMaximum Therewillbenoout-of-pocketlimitontheparticipant’sexpenses.

MaximumDaysSupply Maximum30dayssupplyperprescription.Formaintenancedrugsincertaintherapeuticclassifications,a90-daysupplymaybeobtained.

Maximum100dayssupplyperprescription.

GenericPreventiveCareDrugs(includingFDAapprovedcontraceptives)

Planpays100%foraspirin,fluoridesupplement,folicacid,ironsupplement,andfemalecontraceptives;prescriptionrequiredforOTCavailabledrugs.Brandnameiscoveredwhereagenericisunavailableormedicallyinappropriate,butmustbeauthorizedbyOptumRx.Ageandfrequencylimitsapply.

100%covered,prescriptionrequired.

Generic $5copayperprescription. $5copayperprescription.

Brand $5copayperprescriptionifnogenericequivalentisavailable.$8copayperprescriptionifagenericequivalentisavailablebutyourdoctorindicates“dispenseaswritten.”Ifagenericequivalentisavailableandyourdoctordoesnotindicate“dispenseaswritten,”youmustpaythecostdifferencebetweenthegenericdrugandthebrandnamedrugplusthe$8copay.

$5copayperprescription.

Self-administeredInjectables

ThePlanpays80%ofOptumRx’sContractRate.AuthorizationrequiredthroughOptumRx.ForUHCenrollees,injectablesthatareprescribedbyUHCphysiciansandprovidedbyUHCarecoveredat100%bytheUHCplanandnotcoveredunderthePrescriptionDrugPlan.

$5copayperprescription.




DENTAL BENEFITS

INDEMNITYDENTALPLAN UNITEDCONCORDIAChoiceofProvider Youmayselectanydentistofyourchoice.UsingaDeltaPPOdentistwillloweryourout-of-

pocketexpenses.YoumustusetheUnitedConcordiadentalofficeinwhichyouareenrolled.

CalendarYearDeductible $50perperson;$150perfamily.Notapplicabletoroutinepreventiveanddiagnosticprocedures.

None.

CoveredCharges ForDeltaPPOdentists,thePlanpaysthelesseroftheDeltaPPOContractRatesortheamountlistedintheScheduleofAllowances.ForDeltaPremierdentists,thePlanpaysthelesseroftheDeltaPremierfiledfeesortheamountlistedintheScheduleofAllowances.Fornon-DeltaDentaldentists,thePlanpaysthelesseroftheamountbilledbythedentistortheamountlistedintheScheduleofAllowances.ScheduleofAllowancesisestablishedbytheTrusteesandadjustedannually(seeseparatescheduleatwww.ufcwdrugtrust.orgunder“Downloads”).

UnitedConcordia’sScheduleofBenefits.

Note:Youarepermittedtoopt-outofdentalbenefitsforyourselfandyourDependents.ContacttheFundOfficeformoreinformation.

ORTHODONTIC BENEFITS

CONTRACTEDORTHODONTISTS NON-CONTRACTEDORTHODONTISTSPrecertificationRequired AlltreatmentplansmustbeapprovedbythePlan’sOrthodonticConsultantbeforetreatmentbegins.Iftreatmentbeginsbefore

precertification,nobenefitswillbepaid.ContacttheFundOfficeformoreinformation.

FullTreatment ThePlanallowanceis$3,200.ThePlanpays$3,000ofthecontractrateafteryourcopaymentof$200.

Planpays80%ofchargesupto$3,000maximum.

LimitedTreatment Planpays80%ofthecontractrate.Youareresponsibleforthebalanceofthecontractrate.


PhaseOneTreatment ThePlanallowanceis$1,250.ThePlanpays$1,050ofthecontractrateafteryourcopaymentof$200


DevelopmentSupervision ThePlanallowanceis$270.ThePlanpays$220afteryourcopaymentof$50. Planpays80%ofchargesupto$270maximum.

LifetimeMaximumBenefit $3,000




PLAN EXCLUSIONS

INDEMNITYPLAN KAISER&UNITEDHEALTHCARE

ExcludedMedicalServices ThePlandoesnotpaybenefitsforthefollowing:» ChargesinexcessofContractRates;or,asapplicable,theAllowedAmount;» Replacementofartificialeyes;» Orthognathicsurgery;» Cosmetictreatmentorsurgeryandcomplicationsresultingfromanysuchprocedure,exceptforrepair

ofdamagecausedbyaccidentalbodilyinjury(restorativesurgeryperformedduringorfollowingmutilativesurgerywhichwasrequiredasaresultofillnessorinjuryisnotconsideredcosmetic);

» ChargesmadebyrelativesofanyoneintheParticipant'shousehold,exceptforCoveredChargeswhichconstituteout-of-pocketexpensestosuchproviders;

» Experimentaltreatment,proceduresandtherapiesandanycomplicationsarisingfromsuchtreatment;» Custodialcareregardlessofthetypeoffacilityand/orprovider;» Eyeexaminationsincludingrefractionsandfittingofglasses,hearingaids,healthaids,artificiallimbs,

andorthopedicappliances,exceptasspecificallycovered;» AnysuppliesorservicesfurnishedbyahospitalorfacilityoperatedbytheU.S.Governmentorany

authorizedagencythereof,orfurnishedattheexpenseofsuchGovernmentoragency;» Anyexpensesconnectedwithanyformofartificialinsemination,anynon-surgicaltreatmentfor

infertilityafterdiagnosis,anyexpensesconnectedwithorresultingfromsurrogatemothersorspermbanks,orthereversalofvoluntaryinfertility;

» Servicesandsuppliesforwhichnochargeismade,orforwhichoneisnotrequiredtopay;» Speechtherapy,exceptfromaPPOprovider;» Anyservicesorsuppliesnotrecommendedandapprovedbyalegallyqualifiedphysicianorsurgeon,

dentist,mentalhealthprofessional,podiatristonthePPOCpanel,orchiropractorperformingserviceswithinthelegalscopeoftheirpractices;

» ConditionscoveredbyWorkers’Compensationorincurredinthecourseofemployment,includingself-employment;

» PenileprosthesisunlesspreauthorizedbyAnthemBlueCross;» Pregnancyexpensesofdependentchildrenorexpensesforconditionsarisingfrompregnancyof

dependentchildren,exceptpreventivecareexpenses;

PleaserefertotheEvidenceofCoveragebookletsprovidedbyKaiserandUnitedHealthcare.




PLAN EXCLUSIONS

INDEMNITYPLAN KAISER&UNITEDHEALTHCARE

ExcludedMedicalServices(cont’d)

» Surgicalcorrectionofrefractiveproblemsincludingradialkeratotomyunlessvisioncannotbecorrectedthrougheyeglassesorcontactlenses;

» Expensesincurredforanyconditionwherethereexistsnoinjuryorsickness,exceptthatthisexclusiondoesnotapplytobenefitsspecificallyprovided,suchashospicecare,sterilizationprocedures,andpreventivecarebenefits;

» Takehomedrugswhendischargedfromthehospital;» Expensesincurredbyatransplantdonorwhoisnoteligibleundertheplan(exceptforbenefits

specificallyprovided);» OrganortissuetransplantsperformedatafacilitythatisnotanAnthemBlueCrossCenterof

Expertise;» Expensesincurredbyanorganortissuedonorwhenthetransplantrecipientisnotaplanparticipant.» Vocationaltesting,evaluationandcounseling;» Injuriesresultingfromanyformofwarfareorinvasion;» Nobenefitswillbeprovidedforpodiatriccarereceivedfromanon-PPOCpodiatrist(ifyouliveoutside

ofCalifornianopodiatrybenefitswillbeprovidedunlessyouuseaBlueCardnetworkpodiatrist), exceptforthespecialpodiatrybenefit.Inaddition,benefitsforpodiatriccarearelimitedtothosespecificallydescribed;

» Claimsfiledmorethanoneyearafterthedateonwhichserviceswereincurred;» ServicesorsuppliesthatarenotNecessaryTreatment.


ThirdPartyLiability IfaParticipantobtainsarecoveryfromathirdpartythatisinanymannerrelatedtoclaimspaidbytheTrust,theParticipantwillreimbursetheTrustfromsuchrecoveryinanamountnotinexcessofthepaymentsmadeortobemadebytheFund.


DentalExclusions FortheIndemnityDentalPlan,pleasereadtheIndemnityScheduleofAllowancesforDentalProcedures(updatedeachJanuary).ForUnitedConcordia,pleaserefertheEvidenceofCoveragebookletprovidedbyUnitedConcordia.

PrescriptionDrugExclusions PleasecontacttheFundOffice.

SOUTHERN CALIFORNIA DRUG BENEFIT FUND 2220 HYPERION AVENUE • LOS ANGELES, CALIFORNIA 90027

TEL (323) 666-8910 • FAX (323) 663-9495 • WWW.UFCWDRUGTRUST.ORG

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Nondiscrimination Notice & Language Assistance

The Southern California Drug Benefit Fund (the “Plan”) does not discriminate on the basis of race, color, national origin, age, disability, or sex. The Plan provides free aids and services to people with disabilities, such as qualified sign language interpreters for individuals with disabilities and information in alternative formats (large print, audio), when necessary to ensure equal opportunity to participate.

The Plan also provides free language assistance services, such as qualified interpreters and oral interpretation, when such services are necessary to provide meaningful access to individuals with limited English proficiency. If you need these services, contact the Plan’s Civil Rights Coordinator at:

Southern California Drug Benefit Fund P.O. Box 27920 Los Angeles, CA 90027-0920 Phone: (323) 666-8910, ext. 234 Fax: (323) 663-9495

If you believe that the Plan has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with the Fund’s Civil Rights Coordinator, at the address listed above. You can file a grievance in person, by mail, or by fax. If you need help filing a grievance, the Civil Rights Coordinator can help.

You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services, 200 Independence Avenue, SW, Room 509F, HHH Building, Washington, D.C. 20201, 1-800-368-1019, 800-537-7697 (TDD). Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-323-666-8910

注意：如果您使用繁體中文，您可以免費獲得語言援助服務。請致電 1-323-666-8910。

CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số 1-323-666-8910

PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa 1-323-666-8910

주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수 있습니다. 1-323-666-8910 번으로 전화해 주십시오.

با. باشدی م فرااھھھهم شمایی براا گاننیيرراا بصوررتتی ززبان لاتتیيتسھه د٬،یيکنی م گفتگو فاررسی ززبانن بھه ااگر: توجھه تماسس1-‐323-666-8910 .دیيریيبگ

October 15, 2016

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ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните 1-323-666-8910

注意事項：日本語を話される場合、無料の言語支援をご利用いただけます。1-323-666-8910 まで、お電話にてご連絡ください。

1برقم ملحوظظة: إإذذاا كنت تتحدثث ااذذكر االلغة٬، فإنن خدماتت االمساعدةة االلغویية تتواافر لك بالمجانن. ااتصل -323-666-8910.

LUS CEEV: Yog tias koj hais lus Hmoob, cov kev pab txog lus, muaj kev pab dawb rau koj. Hu rau 1-323-666-8910

1-323-666-8910

1-323-666-8910 । 'ਤੇ ਕਾਲ ਕਰੋ ।

1-323-666-8910

यान द: य द आप हदी बोलते ह तो आपके िलए मु त म भाषा सहायता सेवाएं उपल ध ह।1-323-666-8910 - पर कॉल कर।

1-323-666-8910

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