Sacramento Area Electrical Workers
Trust Funds
PPO |
Non-PPO |
|
|---|---|---|
| Initial Eligibility Effective Date | 1st of the 2nd month following reserve dollar bank accumulation of $2,000 |
|
| Continuing Eligibility | $1,000 in reserves for one month coverage |
|
| Pre-Existing Conditions New Members and Dependents |
None |
|
| Resident Requirement | Must reside or work outside HealthNet HMO and Kaiser HMO geographical services areas |
|
| Dependent Coverage | Up to age 19 or 25, if full-time student |
|
| Plan Charges | ||
| Office Visit Copayment | $20/visit |
40% after deductible |
| Deductible | $1,500/Single $4,500/Family Up to $1,000 reimbursed by the Trust Fund after first $500 paid by member |
|
| Annual Out-of-Pocket Limit | $3,000/Single |
$6,000/Single |
| Lifetime Maximum | $5,000,000 General Charges |
|
| Hospital Services - Inpatient | 20% after deductible |
$500 copayment, then 40% after deductible |
Requires prior certification. Uncertified services: 50% after $500 deductible per admission |
||
| Hospital Services - Outpatient | 20% after deductible |
$500 copayment, then 40% after deductible |
Requires prior certification. Uncertified services: 50% after $100 deductible per admission |
||
| Outpatient Surgery | 20% after deductible |
$500 copayment, then 40% after deductible |
Requires prior certification. Uncertified services: 50% after $100 deductible per admission |
||
| Emergency Care | 20% plus $100 deductible (deductible waived if admissted as inpatient) |
40% plus deductible (deductible waived if admitted as inpatient) |
| Ambulance | 20% plus $50 deductible per incident |
40% plus $50 per incident |
| Maternity - Inpatient | 20% after deductible |
$500 copayment, then 40% after deductible |
Requires prior certification. Uncertified services: 50% after $500 deductible per visit |
||
| Maternity - Outpatient | 20% after deductible |
40% after deductible |
Requires prior certification. Uncertified services: 50% after $100 deductible per visit |
||
| Well-Child Care | $20 copayment (includes immunizations) |
not covered |
| Immunizations | not covered |
not covered |
| Mental Health - Inpatient | 20% after deductible |
40% after deductible |
Requires prior certification. Uncertified services: 50% after $500 deductible per admission |
||
| Mental Health - Outpatient | $20 copayment |
40% after deductible |
| Prescription Drugs | ||
| Generic | $10 Copayment |
100% at counter, reimbursed for 50% of in-network PPO cost minus $10 copayment |
| Formulary Brand | $25 Copayment |
100% at counter, reimbursed for 50% of in-network PPO cost minus $25 copayment |
| Non-Formulary Brand | 50% Copayment |
50% Copayment |
Non-PPO percentages apply to Usual, Customary and Reasonable ("UCR") amounts as defined by the Plan. Participant is responsible for charges In excess of the UCR amounts.
This comparison chart is merely an overview of the benefits, which are effective January 1, 2009, and
does not anemptto cover all the benefit features, limitations, and exclusions In these programs. For details you should consult the materials prepared by Health Net or contact Health Net Member Services at 1-800-522-0088.