Self-funded Medical Plan
Prescription drug benefits are provided Optum Rx. Information concerning prescription drug benefits, including a list of the pharmacies in the Optum Rx retail pharmacy network, can be obtained by calling Optum Rx toll-free at 1-800-248-1062.
Additional information concerning prescription drug benefits can be obtained at the Optum Rx website, www.optumrx.com.
The Trust Administrative Office is responsible for reviewing claims concerning eligibility and the Plan.
- Time Requirements
- Written notice of a claim must be given to the Trust Administrative Office as soon as reasonably possible.
- Proof of claim for Hospital confinement must be given to the Trust Administrative Office within ninety (90) days after release from the Hospital.
- Proof of claim for any other service, supply or treatment must be given to the Trust Administrative Office within ninety (90) days after the service or treatment.
- If proof of any claim is not given within ninety (90) days, the claim will not be denied or reduced if the proof of the claim was given as soon as reasonably possible. However, no claim will be paid if submitted to the Trust Administrative Office for more than one year after the date of service or treatment. “Proof” means proof satisfactory to the Board of Trustees.
- The Board of Trustees, at the expense of the Trust, has the right to have You examined by a Provider, as often as it may require, whenever Your Illness or Injury is the basis of a claim.
- The Board of Trustees has the right to require an autopsy, if not prohibited by law. A disputed Illness is a basis for this requirement.
Vision claims are processed and paid by:
P.O. Box 997100 Sacramento CA 95899-7100
TDD/Hearing Impaired 1-800-735-2922
If You are using Postal Prescription Services (PPS) mail-order prescription drug program, You must submit claim forms directly to Postal Prescription Services. Claim forms are available from the Trust Administrative Office or on the web at www.soundcommbenefits.com. Mail Your claim form to:
P.O. Box 2718
Portland, OR 97208-2718
Hospital And Medical
Deductible: a cash deductible of $50
(Out-of-pocket expenses – Family Maximum $150)
A maximum of three times the individual cash deductible, no more than $50 of which may be satisfied by only one person, will be applied to the covered charges incurred by a family unit during any benefit period.
If two or more eligible members of your family are injured in the same accident, only one deductible has to be met during the calendar year in which the accident occurs and the following calendar year for covered charges incurred as a result of the accident. Separate deductibles will still apply to charges not related to the common accident.
PPO Contracted Hospitals
If you use a Blue Cross Preferred Provider Organization (PPO) Contract Hospital, your deductible is waived and the Plan will pay ninety percent (90%) (instead of eighty percent (80%)) of covered charges of the first $2,500 ($7,500 per family unit) of eligible expenses and will pay one hundred percent (100%) (instead of eighty percent (80%)) of covered charges for the remainder of the calendar year. A list of Contract Hospitals is provided to you automatically, free of charge, as a separate document. The ten percent (10%) coinsurance of covered charges will apply to the out-of-pocket expense maximum of $500 for the individual and $1,500 per family.
The $2,500 stop-loss threshold does not apply to services rendered by a non-PPO hospital provider. Therefore, the Plan will pay 80% of all Usual, Customary and Reasonable Charges each calendar year in excess of the $50 deductible for services rendered by a non-PPO hospital provider even for expenses that exceed $2,500.
Benefit Percentage 80%
The self-funded medical plan pays eighty percent (80%) of covered charges incurred by covered individuals during a calendar year in excess of the $50 individual deductible amount ($150 maximum per family unit). The twenty percent (20%) coinsurance of covered charges will apply to the out-of-pocket expense maximum of $500 for the individual and $1,500 per family.
Maximum Lifetime Benefit
The maximum lifetime benefit per individual is One Million Dollars ($1,000,000).
- Semi-private room and board and routine nursing for confinement in a hospital.
- Semi-private room and board and routine nursing for confinement in a skilled nursing facility (not to exceed the average semi-private room rate). Services must commence within 14 days after discharge from a stay of three (3) or more days in an acute care hospital.
- Intensive Nursing Care for each day of confinement in a hospital as follows:
- For those hospitals which make a separate charge for Intensive Nursing Care, the hospital’s specific charge for Intensive Nursing Care is covered;
- For those hospitals which make a combined charge for Room and Board and Intensive Nursing Care, that part of the combined charge that is in excess of the hospital’s prevailing semi-private Room and Board rate will be the covered charge for Intensive Nursing Care.
- Anesthetics and their administration.
- The medical treatment is given by or at the direction of a physician if such treatment is within the scope of the provider.
- Usual, Customary and Reasonable Charges of a physician or surgeon for the performance of an operation, the repair of a dislocation or fracture, and for medical services. Charges of an assistant surgeon are also covered.
- Services of a Licensed Registered Nurse (R.N.) for private duty nursing services in a hospital.
- Services of a Licensed Practical Nurse (L.P.N.) for private duty nursing services in a hospital.
- Services of a licensed physiotherapist.
- Charges by a doctor or speech therapist for rehabilitative speech therapy due to an illness (other than a functional nervous disorder), or due to surgery on account of illness. If the speech therapy is due to a congenital anomaly, surgery to correct the anomaly must have been performed prior to the therapy.
- X-ray exams (other than dental), lab tests, and other diagnostic services.
- X-ray and radiation therapy.
- Charges for the repair of sound natural teeth (including their replacement) required as a result of, and within six (6) months of an accidental bodily injury that occurs while the person is covered under the Plan.
- Transportation that is medically necessary and recommended by your attending physician within the United States and Canada of the covered individual by professional ambulance service, railroad, or scheduled airline to, but not returning from a hospital or sanitarium. These charges will be covered only if the covered individual’s
illness cannot be adequately treated in the locale where the illness occurs.
- Medical supplies as follows:
- Drugs which require a written prescription from a doctor and must be dispensed by a licensed pharmacist or doctor;
- Blood and other fluids to be injected into the circulatory system;
- Artificial limbs and eyes for loss of natural limbs and eyes which occurred while coverage is in force;
- Lens, each eye (contact or frames) immediately following and because of cataract surgery only;
- Casts, splints, trusses, braces, crutches, and surgical dressings;
- Purchase or rental of hospital-type equipment for kidney dialysis for your personal and exclusive use. The total purchase price considered will be on a monthly pro-rata basis during the first twenty-four (24) months of ownership, but only so long as a dialysis treatment continues to be medically necessary. Also covered are all charges for supplies, materials, and repairs necessary for the proper operation of such equipment and reasonable and necessary expenses for the training of a person to operate and maintain the equipment for your sole benefit. No benefits are paid on or after the day you are entitled to benefits under Medicare.
- Rental (not to exceed the purchase price) or purchase (if the cost is less than the rental for the period required) of durable medical equipment such as oxygen, a wheelchair, or hospital bed for medically necessary therapeutic treatment of a covered illness or non-industrial injury.
- Medically necessary prosthesis.
- Maternity Expenses and Well Baby Coverage (Employee and spouses Only): Maternity expenses are covered the same as any other illness and cover only female Employees and dependent wives. Coverage must be in effect at the time of delivery. Hospital where baby nursery charges are covered only in BlueCross PPO contract hospitals and only during the mother’s normal maternity stay.
Effective January 1, 1998, group health plans and health insurance issuers offering group health coverage generally may not, under federal law, restrict available benefits for any hospital length of stay in connection with childbirth for the mother or newborn child to less than 48 hours following a normal vaginal delivery, or less than 96 hours following a cesarean section. However, federal law generally does not prohibit the mother’s or newborn’s attending provider, after consulting with the mother, from discharging the mother or her newborn earlier than 48 hours (or 96 hours as applicable). In any case, plans and issuers may not, under federal law, require that a provider obtain authorization from the plan or issuer for prescribing a length of time in excess of 48 hours (or 96 hours).
- Breast reconstruction following a mastectomy. In accordance with the Women’s Health and Cancer Rights Act of 1998 (WHCRA), if you receive mastectomy-related benefits, coverage will be provided for the following mastectomy-related services as determined in consultation between you and your attending physician:
- All stages of reconstruction of the breast on which the mastectomy has been performed.
- Surgery, and reconstruction of the other breast to produce a symmetrical appearance.
- Treatment of physical complications, including lymphedemas, at all stages of mastectomy.
Any exclusion of benefits for cosmetic services does not apply to this benefit. This benefit is subject to the annual deductible and copayments specified above.
- Fees for chiropractic and acupuncture treatments are limited to $25 per call with a maximum of twenty calls per calendar year. Payments are subject to the Plan’s deductible and co-insurance. Maximum X-ray charges for chiropractic services are limited to $100 per calendar year.
To keep Health costs down, your Health & Welfare Board of Trustees have made available to the Self-Funded Plan participants and their eligible dependents conveniently located clinical laboratories at negotiated fees.
Laboratory tests performed at one of the participating Laboratories will be paid by the Health & Welfare Plan at discounted prices. This means less out-of-pocket expenses to you and your eligible dependents.
What to Tell Your Physician
When your physician orders laboratory testing, i.e. blood, cultures, urinalysis – tell the physician that you have a laboratory program. If you have your test performed at one of your participating laboratories it is less out-of-pocket expense to you.
IF THE PHYSICIAN’S OFFICE COLLECTS THE SPECIMEN – ask the office to call a laboratory on your list for a courier pick-up.
At the laboratory – you do not have to pay. Show the Lab attendant your ID Card for billing information. If you get a bill in the mail, do not pay it. Send it to our office: United Administrative Services, P.O. Box 5057, San Jose, CA 95150.