MEDICAL BENEFITS - Healthx
Transcript of MEDICAL BENEFITS - Healthx
This is not a guarantee of Benefits. This is a general summary of benefits available under this plan and is not intended to be used as an authorization for services to be provided. We are providing this summary without knowledge of the diagnosis or type of treatment you plan to provide. All specific plan exclusions and limitations will be applied at the time the claim is processed. Participant's eligibility and benefits are based upon the information currently
available to us. Both are subject to change without notice to you. All covered charges will be limited to reasonable and customary charges. Benefits will be coordinated with another carrier, if other coverage is involved.
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MEDICAL BENEFITS Fund Name: Teamsters and Food Employers Security Trust Fund SPD Version: January 1, 2015 Fund ID: L500 Revised: 9/9/21 RG Who is Covered: Active Members, Retirees & Dependents
Trust Fund Contact Information To access eligibility, claim status, summary of benefits for medical, dental and/or vision as well as to contact
the Trust Fund Office for general questions, please visit out Provider Portal or send us an email:
www.memberbenefitsonline.com [email protected]
Correspondence and Appeals:
PO Box 2340 West Covina, CA 91793
Mail Medicare Claims to:
Teamsters and Food Employers Security Trust Fund PO Box 1618
San Ramon, CA 94583 Medicare claims also crossover through a Medicare
clearinghouse.
PPO Medical Network: Anthem Blue Cross
Pre-certification: (800)274-7767
Pricing: (800)688-3828
Find a PPO Provider: www.anthem.com/ca
Mail medical claims to: Anthem Blue Cross
PO Box 60007 Los Angeles, CA 90060
EDI Payor ID: 47198
Group#: 277537
Alpha Prefix: GBU
HMO Medical Option: (Not administered by BeneSys)
Kaiser
(800) 464-4000
*Kaiser Members use BMR Rx unless drug is on the Kaiser Base list.
HMO Medical Option: (Not administered by BeneSys)
Aetna
Active: (877) 647-3776 Retirees: (888) 267-2637
www.aetna.com Plan Name: Aetna Value Network HMO
Active Grp: 0866084, Early-Retiree Grp: 459257, Medicare Retiree Grp: 459260
Mental Health & Substance Abuse Network (E-MAP):
HMC Health Works
Member: (800)431-5036 Provider: (855)487-8914
Mail claims to: PO Box 981605
El Paso, TX 79998-1605 Electronic Payor ID: 75318
(Aetna & PPO members utilize HMC)
Podiatry Network: Podiatry Plan of CA (PPOC)
Find a PPO Provider:
(800)367-7762, or www.podiatryplan.com
Mail all podiatry claims to:
4304 18th Street, PO Box 14671
San Francisco, CA 94114-9991
or fax: (415)928-0228
Chiropractic Network: American Specialty Health Network (ASHN)
Members: (800)678-9133 Providers: (800)972-4226 www.ashcompanies.com
Mail ASHN claims to:
PO Box 509001 San Diego, CA 92150
Mail out-of-network claims to local Blue Cross.
Prescription Benefit Management: Broadreach Medical (BMR)
(Not administered by BeneSys)
Retail: ProCare Rx (877)718-2379 Ext. 4 Mail Order: OptumRx 855-577-6328
Our System is ICD-10 Compliant for Claims after 10/1/15
This is not a guarantee of Benefits. This is a general summary of benefits available under this plan and is not intended to be used as an authorization for services to be provided. We are providing this summary without knowledge of the diagnosis or type of treatment you plan to provide. All specific plan exclusions and limitations will be applied at the time the claim is processed. Participant's eligibility and benefits are based upon the information currently
available to us. Both are subject to change without notice to you. All covered charges will be limited to reasonable and customary charges. Benefits will be coordinated with another carrier, if other coverage is involved.
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PPO Medical Summary of Benefits:
Benefit Comment
Appeals Timely Filing Claimant will have 180 days from the date of denial.
Claims Timely Filing 1 year from the date of the service.
Coordination of Benefits
Active Employee / Early Retiree
(Non-Medicare Primary)
If the primary plan has a PPO negotiated rate, this Plan (as secondary) will pay the difference between what is paid by the primary plan up to the maximum amount negotiated in the PPO contract.
This Plan will not coordinate with any HMO coverage.
Medicare Primary Retirees
This Plan as a secondary will pay 20% of Medicare’s allowable.
Participant will need to satisfy this Plan’s deductible.
This Plan will deny any services Medicare denies and deems not medical necessary.
Any services that is typically covered under this Plan and is not a covered service under Medicare, will be covered under this Plan. Prior authorization is not required when Medicare is primary, unless it is a service that is not covered by Medicare, and this Plan has a
prior authorization requirement for that service (e.g. home infusion therapy will require prior authorization by this Plan).
With respect to a Retiree and/or Spouse age 65 years or older and a Retiree and/or Spouse entitled to Medicare as a result of a disability, the benefits payable will be reduced by the
benefits payable under Medicare Part A and B, regardless whether the Retiree and/or Spouse actually enrolls for Medicare.
Except for copayments and deductibles which result in out-of-pocket expenses for the Participant, this Plan will not pay benefits for
expenses covered by HMO coverage.
Dependent Age Limit Up to age 26.
Disabling Conditions Only
Should you or your Dependent be disabled on the date your coverage terminates, Hospital, medical and surgical benefits will be continued for you or your Dependent, with respect to such Disability only, provided that:
1. The Plan is in effect when the expense is incurred. 2. the disability continues until treatment is received.
3. Hospital confinement commences within 3 months of the termination of coverage. 4. the surgical procedure is performed within 3 months of the termination of coverage.
5. The medical treatment is covered within any part of the 3 month period immediately following the termination date. In no event will the benefit provided under this section extend beyond the 3 months following the Participant's loss of coverage.
Grandfathered Status This Plan is not grandfathered.
Plan Year January 1 through December 31.
This is not a guarantee of Benefits. This is a general summary of benefits available under this plan and is not intended to be used as an authorization for services to be provided. We are providing this summary without knowledge of the diagnosis or type of treatment you plan to provide. All specific plan exclusions and limitations will be applied at the time the claim is processed. Participant's eligibility and benefits are based upon the information currently
available to us. Both are subject to change without notice to you. All covered charges will be limited to reasonable and customary charges. Benefits will be coordinated with another carrier, if other coverage is involved.
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Traveling Outside of the United States
Non-emergency and elective services outside of the United States are not covered.
Participants cannot assign benefits to a Provider for services rendered outside the United States or its territories.
Situations Where Non-PPO Providers Claims Process at PPO Provider Benefit Level
The benefit reduction to 60% of Covered Expenses will not apply in the following situations: 1. The patient receives services from an anesthetist who is a Non-Contract Provider during the course of a surgery performed
in a Contract Hospital. 2. The patient receives medical services during the course of surgery in a Contract Hospital from an assistant surgeon who is a
Non-Contract Provider. 3. The patient receives services in a Contract Hospital from an emergency physician or emergency physicians group who are
Non-Contract Providers. 4. The patient receives services from a laboratory that is a Non-Contract Provider when medical tests taken by Contract
Provider are sent to that provider to a Non-Contract Provider laboratory. This exception is a onetime exception per Employee or Dependent.
5. The patient receives services from a specialist physician who is a Non-Contract Provider when there are no physicians of that specialty who are Contract Providers in the county in which the Employee or Dependent resides.
Situations Where Non-PPO Claims Process at PPO Benefit
Level
There are 3 situations when a Non-PPO Hospital can be reimbursed at the PPO rate. Those situations are: 1. When there is no PPO Hospital in the County where services are received; or 2. When specialized services are needed and not available at a PPO Hospital (a rare occurrence which requires prior approval
from Anthem Blue Cross); or Emergency Services. However, if admission is required, the Plan may require that the patient be transferred to a PPO Hospital as soon as it is medically safe for the patient to be transported. If the patient decides to remain in the Non-PPO Hospital after the
acute emergency period, the Plan’s Non-PPO Hospital Benefit will apply.
Benefit In-Network Out-of-Network (UCR) Comment/Limitation
Annual Maximum None
Deductible $300 individual / $900 family In-network and out-of-network deductibles satisfy each other.
Applicable to primary Medicare members.
Deductible Carry Over Last 3 months (October, November, December).
Lifetime Maximum None
Out-of-Pocket Maximum
$900 per person
Effective 1/1/17: $14,300
Effective 1/1/16:
$13,700 per family
None
Per person out-of-pocket maximum includes deductible, mental health & substance abuse.
Effective 1/1/16, family out-of-pocket maximum includes medical and
prescription drugs.
Prior to 1/16: family out-of-pocket maximum includes medical, mental health & substance abuse, and prescription drugs.
Abortion (Voluntary) Not Covered
This is not a guarantee of Benefits. This is a general summary of benefits available under this plan and is not intended to be used as an authorization for services to be provided. We are providing this summary without knowledge of the diagnosis or type of treatment you plan to provide. All specific plan exclusions and limitations will be applied at the time the claim is processed. Participant's eligibility and benefits are based upon the information currently
available to us. Both are subject to change without notice to you. All covered charges will be limited to reasonable and customary charges. Benefits will be coordinated with another carrier, if other coverage is involved.
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Accident
Plan requires a signed lien and TPL in order to review claims for possible payment but it does not require the auto dec page or police report.
If 2 or more eligible members are injured in the same accident, the covered expenses which result from the accident will be combined and only one deductible will be charged regardless of the number of family members injured. If the same accident results in covered expenses
in the next calendar year, another single deductible only will be applied for these expenses.
Work Related Not Covered
MVA 80% 60%
Fight 80% 60%
Accidental Dental 80% 60%
Acupuncture Not Covered
Allergy Services
Injections 80% 60%
Testing 80% 60%
Ambulance
Must be medically necessary.
Effective 3/1/17, all covered ambulance services accumulate to the out-of-pocket maximum.
Air 80% 80%
Ground 80% 80%
Birth Control See the Routine/Preventive Section under Contraceptives.
Biofeedback 80% 60% EEG Biofeedback for Mental Health Disorders is not covered.
Chiropractic
This Plan uses a Closed Panel of Chiropractors through the American Specialty Health Network (ASHN).
Members: (800)678-9133 Providers: (800)972-4226
ashcompanies.com
The ASHN Network is limited to: Arizona, California, New Mexico, Nevada, Oregon, Utah
& Washington.
In-network claims do not apply to the deductible and out-of-pocket.
Mail ASHN claims to:
ASHN PO Box 509001
San Diego, CA 92150-9001
Medicare Primary members do not need to use ASHN network. Medicare pricing is used as well as the Plan’s guidelines. Example: Medicare doesn’t
cover chiropractic x-rays but the Plan will.
If a non-ASHN provider is used, where a ASHN provider is available, the service is not covered.
If there is no ASHN Provider in the county where services are received, benefits
will be paid at 80% UCR after the deductible and the visit limits below apply: 12 visits 1st Month
8 visits 2nd & 3rd month 4 visits 4th month (Further treatment subject to review)
Blue Cross providers are out of network and receive out-of-network benefits.
Mail out-of-network claims to local Blue Cross.
Office Services 90% Not Covered
This is not a guarantee of Benefits. This is a general summary of benefits available under this plan and is not intended to be used as an authorization for services to be provided. We are providing this summary without knowledge of the diagnosis or type of treatment you plan to provide. All specific plan exclusions and limitations will be applied at the time the claim is processed. Participant's eligibility and benefits are based upon the information currently
available to us. Both are subject to change without notice to you. All covered charges will be limited to reasonable and customary charges. Benefits will be coordinated with another carrier, if other coverage is involved.
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Massage Therapy Not Covered
Modalities 90% Not Covered
X-Ray 90% Not Covered
Clinical Trials The Plan covers Clinical Trials. Please see applicable benefit section for cost share information.
Court Ordered Treatment Not Covered
Dental 80% 60% Accidental injury to natural teeth only.
Orthognathic Not Covered
Diabetic Supplies 80% 60%
Diagnostic Labs / X-Rays 80% 60% ONE-TIME exception per employee or dependent: Lab ordered by a PPO
Provider at a Non-PPO laboratory will be covered at 80%.
Durable Medical Equipment (DME)
80% 60%
DME costing $1,000 and over require prior authorization.
Stockings, CPAP & Supplies are covered with review of Medical Necessity.
Corrective shoes are not covered.
See Routine/Preventive section for breast pump benefits.
Compression Stockings 80% 60%
Diabetic Shoes/Inserts 80% 60%
Educational or Training Programs
Not Covered, except as provided under the Routine/Preventive Section.
Emergency Care
Emergency Facility 80% 80%
Services provided in an ER or Urgent care facility which are not due to an Emergency shall be covered as an Office visit with a Physician and the facility
charges shall not be covered.
Emergency Physician 80% 80%
Emergency Misc. 80% 80%
Emergency with Admit. 80% 80%
Urgent Care Facility 80% 80%
Urgent Care Physician 80% 80%
Urgent Care Lab/X-Rays 80% 80%
Urgent Care Misc. 80% 80%
Extended Care Facility See Skilled Nursing Facility. Custodial care is not covered.
Foot Care (Routine)
The Plan requires the use of a Podiatry Plan of California (PPOC) panel provider (including Medicare primary participants).
Find a PPOC provider go to www.podiatryplan.com or call 800-367-7762
If there is no PPOC provider in the area, the out-of-network podiatrists can contact PPOC and sign up under a "special contract" for one patient.
This is not a guarantee of Benefits. This is a general summary of benefits available under this plan and is not intended to be used as an authorization for services to be provided. We are providing this summary without knowledge of the diagnosis or type of treatment you plan to provide. All specific plan exclusions and limitations will be applied at the time the claim is processed. Participant's eligibility and benefits are based upon the information currently
available to us. Both are subject to change without notice to you. All covered charges will be limited to reasonable and customary charges. Benefits will be coordinated with another carrier, if other coverage is involved.
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NOTE: Although there are no specific limitations set forth by the Plan, if denied by PPOC the member will need to appeal to PPOC and then appeal to the BOT if still denied. Guidelines for the foot care benefit are determined medically necessary by PPOC.
Mail podiatry claims to:
PPOC 203 Willow St., #204
San Francisco, CA 94109 OR via fax: 415-928-0228
Medicare claims do not crossover to PPOC. Submit claims and Medicare EOB to PPOC.
Foot Care 100% Not Covered
Routine foot care is not covered.
Must be medically necessary due to an underlining medical condition.
Deductible does not apply.
Orthotics / Supports 100% Not Covered Prior authorization through PPOC is required.
Deductible does not apply.
Genetic Testing Not covered, except as provided under the Routine/Preventive Section.
Hearing Aids
Not Covered through the Plan. However, there is a discount program available to Plan Participants:
EPIC Hearing Healthcare Services 866-956-5400
Office Visits / Testing 80% 60%
Home Health 80% 60% Must be in lieu of hospitalization.
Prior authorization is required.
Home Infusion 80% 60% Prior authorization is required.
Hospice 80% 60%
Must be in lieu of hospitalization.
Must be recommended by the attending physician.
Prior authorization is required.
Bereavement 80% 60%
Hospital Inpatient admission requires prior authorization.
Room & Board 80% 60% Standard semi-private room rate.
Inpatient Physician 80% 60%
ICU/CCU 80% 60%
Ancillary 80% 60%
This is not a guarantee of Benefits. This is a general summary of benefits available under this plan and is not intended to be used as an authorization for services to be provided. We are providing this summary without knowledge of the diagnosis or type of treatment you plan to provide. All specific plan exclusions and limitations will be applied at the time the claim is processed. Participant's eligibility and benefits are based upon the information currently
available to us. Both are subject to change without notice to you. All covered charges will be limited to reasonable and customary charges. Benefits will be coordinated with another carrier, if other coverage is involved.
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Inpatient Pathology 80% 60%
Inpatient Radiology 80% 60%
Inpatient Surgery 80% 60%
Pre-Admission Testing 80% 60% (If done within 7 days prior to admission for approved Hospital stay. Duplicate
pre-admit tests done in the hospital not covered)
Infertility Not Covered
Injections 80% 60%
Maternity Care Dependent-child maternity is not covered except as provided under the Routine/Preventive Section.
Pre/Post Natal Care 100% 60% For services that are Routine/Preventive in nature, please see that section.
Delivery 80% 60%
Newborn Nursery 80% Not Covered
Midwife 80% 60%
Birthing Center 80% 60%
Home Birth Not Covered
Mental Health & Substance Abuse
All Retirees and their dependents enrolled in the
Indemnity PPO Plan, and Aetna Medicare retirees and
Medicare dependents of Aetna retirees are NOT eligible for Mental Health & Substance
Abuse.
Kaiser members must use Kaiser’s benefits.
Mental Health & Substance Abuse network (E-MAP):
HMC Health Works To locate a Preferred Provider or to obtain approval/precertification call: (800)431-5036
All inpatient services, non-routine outpatient surgeries such as electric convulsive treatment, psychological testing, neuropsychological
testing require precertification. Other outpatient services may require pre-approval. Providers are required to call HMC to verify if services need approval/precertification.
If approval/precertification is not obtained where it is required, benefits will not be paid.
Eating Disorders are covered under Mental Health.
ABA Therapy is not covered for PPO Plan Participants; however, ABA Therapy is covered for Aetna participants that are qualify for
Mental Health benefits.
Deductible does not apply. PPO out-of-pocket accumulates to the $900 out-of-pocket.
Submit Aetna & PPO Claims:
HMC Health Works PO Box 981605
El Paso, TX 79998-1605
Electronic Payor ID: 75318
This is not a guarantee of Benefits. This is a general summary of benefits available under this plan and is not intended to be used as an authorization for services to be provided. We are providing this summary without knowledge of the diagnosis or type of treatment you plan to provide. All specific plan exclusions and limitations will be applied at the time the claim is processed. Participant's eligibility and benefits are based upon the information currently
available to us. Both are subject to change without notice to you. All covered charges will be limited to reasonable and customary charges. Benefits will be coordinated with another carrier, if other coverage is involved.
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Aetna Plan Participants
Aetna Inpatient $350 per admission copay Not Covered In-network copays are paid to the provider.
Out-of-network charges are not covered, unless of an emergency. Aetna Outpatient $20 copay Not Covered
PPO Plan Participants (Active Plans Only)
Inpatient Physician 90%
$300 out-of-pocket max per year
60%
Inpatient Semi Private Rm 90%
$300 out-of-pocket max per year
60%
Outpatient Physician 90%
$300 out-of-pocket max per year
60%
Residential/Day Treatment 90%
$300 out-of-pocket max per year
60%
Group Therapy/Family/Marriage
90% $300 out-of-pocket max
per year 60%
Emergency Care 90%
$300 out-of-pocket max per year
90% (Emergency room, ambulance, urgent care facility)
HMC must be notified within 1 day of an Emergency inpatient admission.
Anesthesia for Electric Convulsive Treatment
90% $300 out-of-pocket max
per year 60%
Ambulance 90%
$300 out-of-pocket max per year
60% (to hospital for mental health treatment & substance abuse)
Nursing Care 80% 60% Private Duty Nursing is not covered.
Morbid Obesity/ Bariatric Surgery
80% 60%
Precertification is required.
Must be medically necessary.
Pre/Post-Operative office visits for approved surgery are covered, however records may be requested for review of lap-band adjustments to verify that
patient still meets criteria.
(See the Routine/Preventive Section for services covered under ACA.)
This is not a guarantee of Benefits. This is a general summary of benefits available under this plan and is not intended to be used as an authorization for services to be provided. We are providing this summary without knowledge of the diagnosis or type of treatment you plan to provide. All specific plan exclusions and limitations will be applied at the time the claim is processed. Participant's eligibility and benefits are based upon the information currently
available to us. Both are subject to change without notice to you. All covered charges will be limited to reasonable and customary charges. Benefits will be coordinated with another carrier, if other coverage is involved.
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Office Visits Home visits are not covered.
Primary Care Physician 80% 60%
Specialists 80% 60%
Online Office Visit through Live Health Online
80% N/A
Available through www.livehealthonline.com.
Visits are subject to the deductible. Deductible and coinsurance will accumulate towards the out-of-pocket.
Patient pays their coinsurance with a credit card at the time of the visit.
Telehealth 80% 60%
Pain Management 80% 60%
Prosthetics 80% 60%
Prosthetics Bra 80% 60%
Wig Not Covered
Routine/Preventive – Adult & Women
No Coverage for Out of Network Preventive Services (except Pap and Mammogram).
Routine Exam 100% Not Covered
Well-Woman Visits 100% Not Covered (to receive services below for women under 65)
Abdominal Aortic Aneurysm 100% Not Covered (one-time screening for men ages 65-75 who have ever smoked)
Alcohol Misuse Screening/Counseling
100% Not Covered
Anemia Screening 100% Not Covered (on a routine basis for pregnant women)
Aspirin 100%
(Through the Prescription Plan)
Not Covered (To prevent cardiovascular disease for men ages 45 - 79 & women ages 55 - 79)
Blood Pressure Screening 100% Not Covered (for all adults)
Breast Cancer Genetic Test (BRCA) Counseling
100% Not Covered (for women at higher risk of breast cancer)
Breast Cancer Mammography Screening
100% 60% (every 1-2 years for women over 40)
Breast Cancer Chemoprevention Counseling
100% Not Covered (for women at higher risk)
Breastfeeding Comprehensive Support/Counseling
100% Not Covered (from trained provider for pregnant/nursing women)
Breast Pump/Supplies 100% Not Covered (for pregnant and nursing women)
Cervical Cancer Screening (PAP)
100% 60%
(for sexually active women)
Effective 1/1/18 the following limitations are applicable:
• Ages 21-29 covered every 3 years.
This is not a guarantee of Benefits. This is a general summary of benefits available under this plan and is not intended to be used as an authorization for services to be provided. We are providing this summary without knowledge of the diagnosis or type of treatment you plan to provide. All specific plan exclusions and limitations will be applied at the time the claim is processed. Participant's eligibility and benefits are based upon the information currently
available to us. Both are subject to change without notice to you. All covered charges will be limited to reasonable and customary charges. Benefits will be coordinated with another carrier, if other coverage is involved.
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• Ages 30-65, HPV testing with pap smear every 5 years, or a pap smear alone every 3 years.
Chlamydia Infection Screening 100% Not Covered (for younger women, and women at higher risk)
Cholesterol Screening 100% Not Covered (Adults over age 50)
Colorectal Cancer Screening 100% Not Covered Cologuard is covered under the Diagnostic Lab benefit, not the Preventive
Care benefit. Subject to Deductible and Co-insurance.
Contraception
100% (Oral contraceptive
through the Prescription Plan)
Not Covered
(FDA approved contraceptive methods, Sterilization procedures, and patient education and counseling as prescribe by a health care provider for women with reproductive capacity. Not including abortifacient drugs. This does not apply to health plans sponsored by certain exempt "religious employers".)
Depression Screening 100% Not Covered (for all adults)
Diabetes (Type 2) Screening 100% Not Covered (for adults with high blood pressure)
Diet Counseling 100% Not Covered (for adults at higher risk of chronic disease)
Domestic/Interpersonal Violence Screening/Counseling
100% Not Covered (for all women)
Folic Acid Supplements 100%
(Through the Prescription Plan)
Not Covered (for women who may become pregnant)
Gestational Diabetes Screening 100% Not Covered (for women who are 24-28 weeks pregnant and those at high risk of gestational
diabetes)
Gonorrhea Screening 100% Not Covered (for all women at higher risk)
Hepatitis B Screening 100% Not Covered (for pregnant women at first prenatal visit)
HIV Screening 100% Not Covered (for everyone ages 15-65 and those at high risk)
Human Papillomavirus (HPV) DNA Test
100% Not Covered (every 3 years for women with normal cytology results who are 30 or older)
Immunization Vaccines 100%
(Also through the Prescription Plan)
Not Covered
(For adults. Doses, recommended ages, and recommended populations vary) Hepatitis A & B, Herpes Zoster (shingles), Human Papillomavirus (Gardasil),
Influenza (flu shot), Measles Mumps & Rubella (MMR), Meningococcal, Pneumococcal, Tetanus, Diphtheria, Pertussis, Varicella (chicken pox)
Obesity Screening/Counseling 100% Not Covered (for all adults)
Osteoporosis Screening 100% Not Covered (for women over age 60 depending on risk factors)
Rh Incompatibility Screening 100% Not Covered (for all pregnant women and follow-up testing for women at higher risk)
Sexually Transmitted Infection (STI) Prevention Counseling
100% Not Covered (for adults at higher risk & sexually active women)
Syphilis Screening 100% Not Covered (for adults at higher risk, and sexually active women)
Tobacco Use Screening 100% Not Covered (for all adults, and expanded counseling for pregnant tobacco users)
Tobacco Cessation Interventions
100% (Through the Prescription
Plan) Not Covered (for tobacco users. Also covered at a pharmacy through Rx benefits)
This is not a guarantee of Benefits. This is a general summary of benefits available under this plan and is not intended to be used as an authorization for services to be provided. We are providing this summary without knowledge of the diagnosis or type of treatment you plan to provide. All specific plan exclusions and limitations will be applied at the time the claim is processed. Participant's eligibility and benefits are based upon the information currently
available to us. Both are subject to change without notice to you. All covered charges will be limited to reasonable and customary charges. Benefits will be coordinated with another carrier, if other coverage is involved.
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Urinary Tract/Other Infection Screening
100% Not Covered (for pregnant women)
Routine/Preventive - Children No Coverage for Out of Network Preventive Services.
Alcohol and Drug Use Assessments
100% Not Covered (for adolescents)
Autism Screening 100% Not Covered (for children at 18 and 24 months)
Behavioral Assessment 100% Not Covered (for children at the following ages: 0 to 11 months, 1 to 4 years, 5 to 10 years,
11 to 14 years, 15 to 17 years)
Blood Pressure Screening 100% Not Covered (for children at the following ages: 0 to 11 months, 1 to 4 years, 5 to 10 years,
11 to 14 years, 15 to 17 years)
Depression Screening 100% Not Covered (for adolescents)
Developmental Screening 100% Not Covered (for children under age 3)
Dyslipidemia Screening 100% Not Covered (for children at higher risk of lipid disorders at the following ages: 1 to 4 years,
5 to 10 years, 11 to 14 years, 15 to 17 years)
Fluoride Chemoprevention Supplements
100% (Through the Prescription
Plan) Not Covered (for children without fluoride in water source)
Gonorrhea Preventive Medication
100% Not Covered (for the eyes of all newborns)
Hearing Screening 100% Not Covered (for all newborns)
Height, Weight and Body Mass Index Measurements
100% Not Covered (for children at the following ages: 0 to 11 months, 1 to 4 years, 5 to 10 years,
11 to 14 years, 15 to 17 years)
Hematocrit or Hemoglobin Screening
100% Not Covered (for children)
HIV Screening 100% Not Covered (for adolescents at higher risk)
Hypothyroidism Screening 100% Not Covered (for newborns)
Immunization Vaccines 100%
(Also through the Prescription Plan)
Not Covered
(for children from birth to age 18 —doses, recommended ages, and recommended populations vary)
Diphtheria, Tetanus, Pertussis, Haemophilus influenzae type b, Hepatitis A & B, Human Papillomavirus (Gardasil), Inactivated Poliovirus, Influenza (Flu Shot),
Measles, Meningococcal, Pneumococcal, Rotavirus, Varicella.
Iron Supplements 100%
(Through the Prescription Plan)
Not Covered (for children ages 6-12 months at risk of anemia)
Lead Screening 100% Not Covered (for children at risk of exposure)
Medical History 100% Not Covered (for all children throughout development at the following ages: 0 to 11 months,
1 to 4 years, 5 to 10 years, 11 to 14 years, 15 to 17 years)
Obesity Screening/Counseling 100% Not Covered
Oral Health Risk Assessment 100% Not Covered (for young children Ages: 0 to 11 months, 1 to 4 years, 5 to 10 years)
This is not a guarantee of Benefits. This is a general summary of benefits available under this plan and is not intended to be used as an authorization for services to be provided. We are providing this summary without knowledge of the diagnosis or type of treatment you plan to provide. All specific plan exclusions and limitations will be applied at the time the claim is processed. Participant's eligibility and benefits are based upon the information currently
available to us. Both are subject to change without notice to you. All covered charges will be limited to reasonable and customary charges. Benefits will be coordinated with another carrier, if other coverage is involved.
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Phenylketonuria (PKU) Screening
100% Not Covered (for this genetic disorder in newborns)
Sexually Transmitted Infection (STI) Prevention
Counseling/Screening 100% Not Covered (for adolescents at higher risk)
Tuberculin Testing 100% Not Covered (for children at higher risk of tuberculosis at the following ages: 0 to 11 months,
1 to 4 years, 5 to 10 years, 11 to 14 years, 15 to 17 years)
Vision Screening 100% Not Covered (for all children)
Must be billed as a preventive visit.
Respite Care Not Covered
Skilled Nursing Facility 80% 60%
Prior authorization is required.
If Medicare is primary and did not deny, no prior authorization is required under this Plan.
Up to 100 days.
Sleep Apnea
Sleep Study/Titration 80% 60%
Smoking Cessation See Routine/Preventive Section Under "Tobacco Use."
Sterilization Female Only. Not Subject to Deductible.
Tubal Ligation 100% Not Covered
Vasectomy Not Covered
Reversal Not Covered
Surgery If no precertification is obtained, claim will pay at 60%.
Inpatient Facility 80% 60%
Inpatient Physician 80% 60%
Outpatient Facility 80% 60%
Office Procedure 80% 60%
Assistant Surgeon 80% 60%
CRNA 50% 50%
Phys. Assistant 65% 65%
Anesthesiology 80% 60%
TMJ (By an MD only)
80% 60%
ASC 80% 60% up to $1,000/day
Refractive Eye Surgery Not Covered
Therapy/Rehabilitative
This is not a guarantee of Benefits. This is a general summary of benefits available under this plan and is not intended to be used as an authorization for services to be provided. We are providing this summary without knowledge of the diagnosis or type of treatment you plan to provide. All specific plan exclusions and limitations will be applied at the time the claim is processed. Participant's eligibility and benefits are based upon the information currently
available to us. Both are subject to change without notice to you. All covered charges will be limited to reasonable and customary charges. Benefits will be coordinated with another carrier, if other coverage is involved.
Teamsters and Food Employers Security Trust Fund Page 13 of 13
Frequency and Limitations for Physical/Occupational/Speech
only.
Rx required Fax (626)262-4722
Frequency of treatment begins with 1st day of treatment and is per diagnosis. 1st month 3 treatments per week 2nd month 2 treatments per week 3rd month 1 treatment per week
4th month 2 treatments per month
Any treatment exceeding the frequencies listed above will require review of medical necessity. Submit request for additional visits with all progress notes and Rx via fax to: PHT (626)262-4722.
Physical Therapy 80% 60%
Occupational Therapy 80% 60%
Speech Therapy 80% 60% Licensed Speech Therapist only.
Limited to therapy for speech lost or impaired due to sickness or injury.
Cardiac Rehab 80% 60%
Pulmonary 80% 60%
Radiation 80% 60%
Chemo 80% 60%
Developmental Not Covered
Transplants
Transplants R & B 80% 60%
Transplant Organ Procedure 80% 60%
Transplant Fees 80% 60%
Donor Search Not Covered