7/01/2013 - 6/30/2014 Plan Year7/01/2013 - 6/30/2014 Plan Year

Benefit Guide Benefit Guide

Visit the Employee Benefit Center

at www.sbmedbenefits.com

 

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WELCOME TO YOUR 2013-14 EMPLOYEE BENEFITS GUIDE

We are committed to providing employees with a benefits program that is both comprehensive and competitive. Our program offers a range of plan options to meet the needs of our diverse workforce. We know that your benefits are important to you and your family. This program is designed to assist you in providing for the health, well-being, and financial security of your family. Helping you understand the benefits San Bernardino Medical Group offers is important to us. That is why we have created this Benefits Guide.

BENEFITS GUIDE OVERVIEW

This guide provides a general overview of your benefits choices to help you select the coverage that is right for you. Be sure to make choices that work to your best advantage. Of course with choice comes responsibility and planning. Please take time to read about and understand the benefits, plan thoughtfully, and enroll on time. Included in this guide are summary explanations of the benefits and costs as well as contact information for each insurance provider. It is important to remember that only those benefit programs for which you are eligible and have enrolled in apply to you. We encourage you to review each section and to discuss your benefits with your family members. Be sure to pay close attention to applicable co-payments and deductibles, how to file claims, preauthorization requirements, networks and services that may be limited or not covered (exclusions). This guide is not an employee/employer contract. It is not intended to cover all provisions of all plans but

rather is a quick reference to help answer most of your questions. Please see your Evidence of Coverage

(EOC) for complete details. We hope this guide will give you a clear explanation of your benefits and help

you be better prepared for the enrollment process.

CONTENTS

Eligibility 2 Section 125 POP 9

Your Responsibility 2 Medical Insurance 10

Qualifying Status Change 2 Dental Insurance 14

Benefits Contacts 3 Vision Insurance 17

How to Find a Provider 4 Basic Life Insurance 17

Employee Benefit Center 5 Voluntary Life 18

Enrollment Directions 6 Work Life Assistance (EAP) 19

What to Expect Next 7 Employee Advocacy Services 20

Rates and Contributions 8

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ELIGIBILITY If you are an active employee working 32 hours or more per week you are eligible to enroll in coverage the first of the month following ninety (90) days of continuous employment. If you enroll, you may also cover eligible dependents. Eligible dependents are:

Your spouse or registered domestic partner

Your dependent children To be eligible, a dependent child must be:

Less than 26 years of age

The natural child, step child, or adopted child of the employee (subscriber) NOTE: A child does not have to live with the parent, be financially dependent upon the parent, or be a student. If you are a full time employee and have already met your waiting period, you can enroll at Open Enrollment effective 7/1/2013 or following a qualifying status change. During Open Enrollment you can change plans, add dependents, or delete dependents. You cannot make any of these changes during the plan year unless you have a Qualifying Status Change.

YOUR RESPONSIBILITY While we provide resources for learning about your benefits, it is up to you to review the information, share it with your family and make your elections. Your efforts to better understand your benefits and health care resources should help you manage what you spend for benefits coverage.

QUALIFYING STATUS CHANGE Below is a list of Qualifying Status Changes. You must notify Human Resources and complete the necessary paperwork for changes within 30 days of the qualifying event.

Marriage, death of spouse, divorce, legal separation, or annulment

Birth, Adoption, or assumption of legal guardianship of a child

Termination or commencement of employment by the Employee, Spouse, or Dependent

Involuntary loss of other employer or government coverage by the Employee, Spouse, or Dependent

A reduction in hours of employment by the Employee, Spouse, or Dependent, including a switch between part-time and full-time status, strike or lockout, or commencement or return from an unpaid leave of absence

An event that causes the Employee’s Dependent to satisfy or cease to satisfy the requirements for coverage due to attainment of age, student status, or any similar circumstance as provided in the health plan in with the Employee participates

A change in the place of residence or work of the Employee, Spouse, or Dependent that affects eligibility

A Court Order to add the Employee’s Dependent to add or remove coverage

Eligibility or loss of eligibility for government coverage by the Employee, Spouse, or Dependent

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BENEFITS CONTACTS

Group # H55497

Member Services (800) 424-6521

NurseHelp 24/7 Line (877) 304-0504

Pharmacy Mail Order Program (866) 346-7200 www.myprimemail.com

www.blueshieldca.com

Group # 902253

DHMO Member Services (866) 357-3304

PPO Member Services (800) 332-0366

www.ucci.com

Member Service (800) 877-6372

www.mesvision.com

Basic Life and AD&D Group # 91988

Voluntary Life and AD&D Group # 201467

Member Service (800) 421-0344

www.unum.com

EAP Service (800) 854-1446

EAP Service Spanish (877) 858-2147

EAP Service TTY/TTD (800) 999-3004

www.lifebalance.net User ID and Password: lifebalance

Human Resources (909) 883-8611

Online Employee Benefits Center o www.sbmedbenefits.com o User Name: sbmed o Password: benefits

Online Enrollment Center o https://www.benefitsconnect.net/sbmg o User Name: first six letters of your last name, your first initial

and the last four of your social security # o First Time Password: your social security #

Office (909) 792-1070

Toll Free (866) 792-1070

CSR@fredericksbenefits.com

1700 N. Waterman Ave.

San Bernardino, CA 92404 (909) 883-8611

www.sbmed.com

1200 Nevada Street, Suite 102

Redlands, CA 92374 www.fredericksbenefitsc.com

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HOW TO FIND A PROVIDER

The Member Services Departments for all the carriers are always available for assistance

UNITED CONCORDIA DENTAL

1. Go to www.ucci.com 2. On the right hand side of the screen click on “Find a dentist” 3. Select “General Dentistry” under specialty 4. Enter a starting address or zip code 5. Select distance from location 6. Select a Network

1. For DHMO: DHMO Concordia Plus General Dentistry 2. For PPO: Alliance

7. Click “Show dentists in my area” 8. Click on the provider name for more information 9. If you are enrolling in DHMO, you must enter the dentist’s ID#

into Benefits Connect. If you do not select a dentist, United Concordia will automatically assign you to a provider.

MES VISION

1. Go to www.mesvision.com 2. On the home page enter your zip code and click “find a doctor”

or click “Advanced search” 3. You can change the distance of the search, sort by distance or

name, or pick provider type (ophthalmologist, optician, or optometrist).

4. The advanced search lets you search my provider name and more specific location information.

BLUE SHIELD MEDICAL

1. Go to www.blueshieldca.com 2. On the home page, click on “find a provider” 3. Select plan “Access+ HMO” 4. Enter a zip code and click “find now” or click “Advanced

Search” 5. Advanced Search gives you the ability to look for a provider by

name, language, gender, and medical group 6. You can narrow down the search results using the filter items

on the left of the screen. You can also sort the list by distance or name.

7. You must enter your doctor’s ID# into Benefits Connect when you enroll. If you do not select a doctor, Blue Shield will automatically assign you to a provider.

You can now access everything you need to know about your

benefits, anytime you need it, with the Employee Benefit

Center®. This online portal contains information and forms

for all your benefits provided by sbmedbenefits.com as well

as personal finance, wellness and lifestyle resources, tools,

and calculators that can enrich your life at work and home.

The Employee Benefit Center makes it easy for you to

understand and use the generous benefit package that is

available to you as a valued employee. Get the most out of

your benefits provided and log on to the Employee Benefit

Center today.

Visit: www.sbmedbenefits.com

Username: sbmg

Password: benefits

The Employee Benefit Center is your gateway to your employee benefits and other work-related information. Log on today to learn more!

If you need assistance please contact:

(909)792-1070

csr@fredericksbenefits.com

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ENROLLMENT DIRECTIONS

Before you log in to the San Bernardino Medical Group Enrollment Center, you will need to have the following

information on hand:

Your social security number and the social security numbers of your eligible dependents

Your date of birth and the dates of birth of your eligible dependents

Your date of Marriage if you are enrolling your spouse

Beneficiary information for your Life and AD&D plans

Enrollment Steps:

1. Log into Employee Benefit Center

Go to www.sbmedbenefits.com (username sbmed, password benefits). Go to the Enrollments

tab and click on the link to Benefits Connect.

2. Access and Log on

Username: This will be the first six letters of your last name, your first initial, and the last four of

your social security number combined.

Example: John Smith – Social Security 123-45-6789

User name would be smithj6789

Password: The first time you log in, your password will be your social security number (no dashes,

spaces or separations; Example:. 123456789)

When you enter the system, you will be required to choose a password of your own.

3. Employee Usage Agreement

The first screen you will see is the Employee Usage Agreement. When you have reviewed this information,

click on Continue. Note: you may choose to turn this screen off for future use by clicking “Do not show this

page again” at the bottom of the screen.

4. Completion of Employee Data Screens

You will be prompted to complete the requested information on several screens. Please disregard information

that is not applicable to you.

Complete each of the fields in these screens to the best of your ability. Note: Fields in bold are required. After

completing each screen, click on save & continue at the bottom of each page.

5. Enrollment Process

Once all your personal and dependent data is entered, you will have access to enroll online in the benefits for

which you are eligible.

Plan Outline: If you would like to view an outline of benefits for each plan, simply click on the icon next to the

coverage.

Cost of the coverage: To quickly view a particular benefit plan’s cost per pay period, you may click on the

circle to the left of the benefit name. Then click on the box next to each eligible family member or choose the

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ENROLLMENT DIRECTIONS CONTINUED

coverage level that you are considering. Your per-pay-period cost will automatically show up in the box to the

right of the members’ names and will be updated with each member you add or remove from coverage.

Enrollment: You will have the opportunity to enroll in all the benefit plans you and your dependents are

eligible for by following these steps.

Click on the circle next to the appropriate plan

Click on the box next to each family member to be covered

Or click next to “I waive enrollment” if you wish to waive the coverage entirely.

After selecting coverage, click “Save & Continue.”

6. Selecting Beneficiaries The Group Term Life and the Voluntary Life plans require you to name a beneficiary; you will be prompted to

complete the fields on the Beneficiary screen. Please complete all information for both primary and contingent

(if necessary) beneficiaries.

To begin, click on “click here” (mouse over the text for link) to add a new beneficiary record.

Complete the information requested in the beneficiary record.

Finally, designate a percentage for each primary and contingent beneficiary

When you have completed this information, click “Save & Continue” at the bottom of the screen.

7. Enrollment Forms

After all screens have been completed, you will arrive at a consolidated enrollment form. This form will

confirm all your personal, dependent, and enrollment information. You will have the option to print this form if

you choose.

****Click the “Finish” button to execute the benefit elections! ****

Failure to do so will delete all the benefit elections that have been made

WHAT TO EXPECT NEXT

Once you have completed the enrollment process, you can expect the following:

You will receive dental ID cards within 3-4 weeks of your enrollment deadline. You can go on to the

Employee Benefit Center to print out generic ID cards. You should verify that the carrier has you assigned

to your selected Primary Care Physician and dentist, if applicable.

Your Summary Plan Description (SPD) is available online at the Employee Benefits Center. If you need a

hard copy, please contact Human Resources.

You can access plan documents and forms, and other helpful tools, online at the Employee Benefits Center.

If you have any questions contact Human Resources

For assistance, contact Fredericks Benefits:

Phone: 1.866.792.1070

E-Mail: CSR@fredericksbenefits.com

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RATES AND CONTRIBUTIONS

San Bernardino Medical Group shares in the cost of your employee benefits. San Bernardino Medical Group

contributes all but $25 of the employee only monthly premium for health. San Bernardino Medical Group

contributes 100% of employee only premium for dental DHMO and vision. The employee contributes $25 per

month for employee only health coverage; the employee can “buy up” to the dental PPO employee coverage; and

the employee contributes 100% of dependent costs for health, dental, and vision. San Bernardino Medical Group

provides Basic Life and AD&D and the Employee Assistance Program to you at no cost. Voluntary Life and

AD&D is a voluntary benefit; the employee pays 100% of the premium for employee and dependents. Contributions

listed below are on a semi-monthly basis (24 pay periods per year).

COVERAGE CARRIER CATEGORY EMPLOYEE COST

(semi-monthly)

Medical – Access+ HMO

Blue

Shield of

California

Employee Only $12.50

Employee + 1 Dependent $311.85

Employee + 2 Dependents $474.01

Dental – HMO United

Concordia

Employee Only $0

Employee + Spouse/Dom.Ptnr $5.95

Employee + Child(ren) $6.10

Employee + Family $12.05

Dental – PPO United

Concordia

Employee Only $16.33

Employee + Spouse/Dom.Ptnr $36.85

Employee + Child(ren) $32.93

Employee + Family $59.05

Vision – PPO MES

Vision

Employee Only $0

Employee + Spouse/Dom.Ptnr $2.74

Employee + Child(ren) $2.61

Employee + Family $5.41

Basic Life and AD&D Unum

Provident Employee Only

Paid for by San

Bernardino Medical

Group

Voluntary Life and AD&D Unum

Provident Employee / Spouse / Child(ren)

Paid for by the

Employee

(Age Rated)

Employee Assistance Program Unum

Provident Employee / Spouse / Child(ren)

Paid for by San

Bernardino Medical

Group

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SECTION 125 PREMIUM ONLY PLAN (POP)

WHAT IS A PREMIUM ONLY PLAN (POP)?

This plan allows employees to make their contributions to group health, dental and vision insurance with pre-tax

dollars. A Premium Only Plan creates no new benefits. San Bernardino Medical Group simply is offering a way to

obtain favorable tax treatment on benefits already offered. Here's how it works:

Employees' premium contributions are automatically deducted from their salaries before taxes are taken

out.

Taxable income is reduced by the amount contributed, so employees pay less in taxes and have more take-

home pay.

Section 125 POP lowers your income that is taxed and therefore may minimally affect your Social Security

benefits.

EXAMPLE OF EMPLOYEE SAVINGS

Without Section 125 With Section 125

Employee Gross Pay $1,000 $1,000

Health Premiums $0 $100

Taxable Income $1,000 $900

Taxes Withheld* $250 $225

Employee Net Pay $750 $675

Medical Premium $100 $0

Take Home Pay $650 $675

*Illustration is based on employee paying 25% Federal, State, and FICA taxes; the employee in the

example above paid less in taxes and brought home more pay.

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MEDICAL INSURANCE GROUP NUMBER H55497

ACCESS+ HMO 15-500/DAY

The Blue Shield of California HMO (Health Maintenance Organization) plan offers comprehensive medical

coverage at a low out-of-pocket cost to you and your family. The primary objective of an HMO is to have one

physician coordinate a patient’s care through a network of participating physicians, medical groups and hospitals.

You and your dependents must each choose a Primary Care Physician (PCP). This PCP can be changed

once a month by calling member services, however, you must also update Benefits Connect.

Keep in mind that your PCP will admit you only to hospitals where he or she has admitting privileges.

Therefore, you should confirm that your PCP has admitting privileges to your preferred hospital.

You and your dependents do not have to select the same PCP.

Women may go to an OB/GYN within their medical group to seek services without a referral or

authorization from their PCP for the annual well-woman checkup only.

Additional Member Benefits (these benefits are available to members enrolled on the Blue Shield of California

HMO):

Healthy Living – Helps keep you well by identifying health risks early, and providing support on adopting

healthier habits. You can choose from a variety of programs to help reach your own goals: Prevention

program, Wellness Discount programs, Healthy Lifestyle Rewards, and Prenatal Education Program. Visit

www.blueshieldca.com

Living Better – Gives members who need extra attention the information and support they need to help

them be as healthy and active as possible. Personalized coaching and support is available through Disease

management, Surgery support available through LifeMap and Guided Imagery Program. Personalized

patient care is available through CareTips and Case management.

And More! – Go to www.blueshieldca.com to see all of the member tools available for you

MEDICAL BENEFITS AT A GLANCE

The following table shows how the plan pays benefits for most covered expenses. For a more detailed explanation

of coverage, refer to the Evidence of Coverage (EOC).

Annual Out of Pocket Maximum 1

For self-only enrollment $2,500 per calendar year

For an entire Family of two or more Members $5,000 per calendar year

Deductible None

Lifetime Maximum None

Professional Services Physician and Specialist Office Visits (Note: A woman may self-refer to an OB/GYN or

family practice physician in her Personal Physician’s medical group or IPA for OB/GYN

services)

$15 per visit

Preventative Health Services (as required by applicable federal and California law) No Charge

Access+ Specialist SM

1, 2

Office visit, Examination, or Other Consultation (self-referred

office visits and consultations only) $30 per visit

Allergy Testing and Treatment, office visits (includes visits for allergy serum injections $15 per visit

Well-child preventive exams (through age 23 months) No Charge

Prenatal and postnatal physician office visits No Charge

Physical, occupational, respiratory, and speech therapy $15 per visit

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MEDICAL BENEFITS AT A GLANCE CONTINUED

Outpatient Services Outpatient surgery performed at an Ambulatory Surgery Center

3 $200 per procedure

Outpatient surgery in a hospital $400 per procedure

Allergy injections (including allergy serum) No Charge

Most immunizations (including vaccines) No Charge

Outpatient X-ray, pathology, and laboratory No Charge

Preventive X-rays, screenings, and laboratory tests as described in the EOC No Charge

Health education: Covered individual health education counseling No Charge

Covered health educational programs No Charge

Hospitalization Services

Room and board, surgery, anesthesia, X-rays, laboratory tests, and drugs $500 per day

(3 day max per admission)

Inpatient Medically Necessary skilled nursing services including Subacute Care 4 $150 per day

Emergency Services Emergency Room (waived if admitted) $100 per visit

Ambulance Services $100 per trip

Urgent Care Services outside your physician service area (BlueCard® Program) $50 per visit

Diabetes Care Benefits Devices, equipment, and non-testing supplies (member share is based on allowed charges;

for testing supplies see Prescription Drug benefits) 50%

Diabetes self-management training $15 per visit

Family Planning and Infertility Benefits Counseling and Consulting

6 No Charge

Infertility Services (member share is based on allowed charges) (Diagnosis and treatment

of cause of infertility. Excludes in vitro fertilization, injectables for infertility, artificial

insemination and GIFT).

50%

Tubal ligation No Charge

Elective abortion 7 $100 per surgery

Vasectomy 7 $75 per surgery

Durable Medical Equipment Durable Medical Equipment (member share is based on allowed charges)

1 50%

Prosthetics/Orthotics

Prostheic Equipment and devices (separate office copay may apply) No Charge

Orthotic eqipment and devices (separate office copay may apply_ No Charge

Mental Health Services (Psychiatric) 5

Inpatient psychiatric hospitalization $500 per day (3 day max per

admission)

Outpatient mental health evaluation and treatment $15 per visit

Chemical Dependency Services (Substance Abuse)

Inpatient hospitalization $500 per day

(3 day max per admission)

Professional (Physician) services – Inpatient and Outpatient Physician Visit $15 per visit

Partial Hospitalization/Day Treatment $200 per procedure

Home Health Services Home health care agency services (up to 100 visits per calendar year) $15 per visit

Medical supplies and laboratory Services (see Prescription Drug Benefits for specialty

drugs) No Charge

Hospice Program Benefits Routine home care No Charge

Inpatient Respite Care No Charge

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MEDICAL BENEFITS AT A GLANCE CONTINUED

Hospice Program Benefits (continued) 24-hour Continuous Home Care $150 per day

General Inpatient care $150 per day

Prescription Drug Benefits 8, 9

(Participating Pharmacies Only) (includes contraceptives, diaphragms, and covered diabetic drugs and testing supplies)

Retail Prescriptions (up to a 30-day supply)

Formulary Generic Drugs $10 per prescription

Formulary Brand Name Drugs 10, 11

$30 per prescription

Non-Formulary Brand Name Drugs 10, 11

$50 per prescription

Mail Service Prescriptions (up to a 70-day supply)

Formulary Generic Drugs $20 per prescription

Formulary Brand Name Drugs 10, 11

$60 per prescription

Non-Formulary Brand Name Drugs 10, 11

$100 per prescription

Specialty Pharmacies (up to a 30-day supply) 12

Specialty Drugs 13

(up to $100 copayment maximum per prescription) 20%

Notes

1

Copayments marked with a "1" do not accrue to the calendar-year copayment maximum. Copayments and charges for services

not accruing to the member's calendar-year copayment maximum continue to be the member's responsibility after the calendar-

year copayment maximum is reached. Please refer to the Evidence of Coverage and the Plan Contract for exact terms and

conditions of coverage.

2

To use this option, members must select a personal physician who is affiliated with a medical group or IPA that is an Access+

provider group, which offers the Access+ Specialist feature. Members should then select a specialist within that medical group

or IPA. Access+ Specialist visits for mental health services must be provided by a MHSA network participating provider.

3

Participating ambulatory surgery centers may not be available in all areas. Regardless of their availability, you can obtain

outpatient surgery services from a hospital or an ambulatory surgery center affiliated with a hospital, with payment according

to your health plan's hospital services benefits.

4

Skilled nursing services are limited to 100 preauthorized days during a calendar year except when received through a hospice

program provided by a participating hospice agency. This 100 preauthorized day maximum on skilled nursing services is a

combined maximum between SNF in a hospital unit and skilled nursing facilities.

5

Mental health services are accessed through Blue Shield's Mental Health Service Administrator (MHSA) using Blue Shield's

MHSA participating providers. For a listing of severe mental illnesses, including serious emotional disturbances of a child, and

other benefit details, please refer to the Evidence of Coverage and Plan Contract.

6 Includes insertion of IUD as well as injectable contraceptives for women

7 Physician services

8

Copayments and charges for these covered services are not included in the calculation of the member's medical calendar-year

copayment maximum and continue to be the member's responsibility after the calendar-year copayment maximum is reached.

Please refer to the Evidence of Coverage and Plan Contract for exact terms and conditions of coverage. Please note that if you

switch from another plan, your prescription drug deductible credit from the previous plan during the calendar year, if

applicable, will not carry forward to your new plan.

9

Select contraceptives, including diaphragms, covered under the outpatient prescription drug benefits will no longer require a

copayment and will not be subject to the calendar year brand name drug deductible. However, if a brand-name contraceptive is

requested when a generic equivalent is available, the member will still be responsible for paying the difference between the

cost to the Plan for the brand-name contraceptive and its generic drug equivalent, as well as the applicable generic drug

copayment. In addition, select contraceptives may need prior authorization.

10 Selected formulary and non-formulary drugs require prior authorization by Blue Shield for Medical Necessity, and when

effective, lower cost alternatives are available.

11

If the member requests a brand-name drug and a generic drug equivalent is available, the member is responsible for paying the

generic drug copayment plus the difference in cost to Blue Shield between the brand-name drug and its generic drug

equivalent.

12

Specialty Drugs are specific Drugs used to treat complex or chronic conditions which usually require close monitoring such as

multiple sclerosis, hepatitis, rheumatoid arthritis, cancers, and other conditions that are difficult to treat with traditional

therapies. Specialty Drugs are listed in the Blue Shield Outpatient Drug Formulary. Specialty Drugs may be self-administered

in the home by injection by the patient or family member (subcutaneously or intramuscularly), by inhalation, orally or

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MEDICAL BENEFITS AT A GLANCE CONTINUED

Notes (continued)

topically. Infused or Intravenous (IV) medications are not included as Specialty Drugs. These Drugs may also require special

handling, special manufacturing processes, and may have limited prescribing or limited pharmacy availability. Specialty Drugs

must be considered safe for self-administration by Blue Shield's Pharmacy & Therapeutics Committee, be obtained from a

Blue Shield Specialty Pharmacy and may require prior authorization for Medical Necessity by Blue Shield.

13 Specialty drugs are covered only when dispensed by select pharmacies in the Specialty Pharmacy Network unless Medically

Necessary for a covered emergency.

Note: This plan's prescription drug coverage is on average equivalent to or better than the standard benefit set by the federal

government for Medicare Part D (also called creditable coverage). Because this plan's prescription drug coverage is creditable, you

do not have to enroll in a Medicare prescription drug plan while you maintain this coverage. However, you should be aware that if

you have a subsequent break in this coverage of 63 days or more anytime after you were first eligible to enroll in a Medicare

prescription drug plan, you could be subject to a late enrollment penalty in addition to your Part D premium.

You can find details about your drug coverage three ways:

1. Check your Evidence of Coverage.

2. Go to blueshieldca.com and log onto My Health Plan from the home page.

3. Call Member Services at the number listed on your Blue Shield member ID card.

At Blue Shield of California, we're dedicated to providing you with valuable resources for managing your drug coverage. Go online

to the Pharmacy section of blueshieldca.com and select the Drug Database and Formulary to access a variety of useful drug

information that can affect your out-of-pocket expenses, such as:

Look up non-formulary drugs with formulary or generic equivalents;

Look up drugs that require step therapy or prior authorization;

Find specifics about your prescription copayments;

Find local network pharmacies to fill your prescriptions.

TIPS! Using the convenient mail service pharmacy can save you time and money. If you take a consistent dose of a covered maintenance

drug for a chronic condition, such as diabetes or high blood pressure, you can receive up to a 90-day supply through the mail

service pharmacy with a reduced copayment. Call the mail service pharmacy at (866) 346-7200. Members using TTY equipment

can call TTY/TDD 866-346-7197.

For a more detailed explanation of coverage, refer to the Evidence of Coverage (EOC).

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DENTAL INSURANCE GROUP NUMBER 902253

San Bernardino Medical Group offers employees two dental plans to choose from - an HMO Dental plan or a PPO

Dental Plan. A brief description of the two plans is listed below to assist you with making a decision.

UNITED CONCORDIA HMO DENTAL PLAN CA 1331 – Concordia Plus Network

The HMO Dental Plan offers a wide variety of services, while emphasizing the benefit of preventive care for

maintaining good health. Your entire family can enjoy dental coverage with a broad range of services, using an

HMO participating dentist. The HMO is designed to lower your out-of-pocket costs and provide savings on your

dental expenses.

You and each of your dependents must select a primary care dentist from the Concordia Plus HMO

directory of participating dentists in your area.

There are no deductibles and no annual or lifetime benefit maximums. Your cost is listed on a copayment

schedule that is based on a reduced fee from your dentist’s usual and customary fee (UCR).

UNITED CONCORDIA PPO DENTAL PLAN – Alliance Network

The United Concordia PPO Dental plan allows you the freedom to see any dentist. The plan covers a broad

spectrum of dental care, from routine checkups and cleanings to major services such as crowns and dentures. Since

this plan does not require dentists to be contracted with United Concordia, fees for dental services may exceed the

usual, customary and reasonable (UCR) fees resulting in higher out-of-pocket costs.

You may select a dentist from the Alliance PPO Network which will provide the employee with less out-of-

pocket expense or

You also have the freedom to select a dentist of your choice out of network. Out-of-pocket costs may be

higher.

PPO DENTAL BENEFITS AT A GLANCE

The following table shows how the plan pays benefits for most covered expenses. For a more detailed explanation

of coverage, refer to the Evidence of Coverage (EOC).

In Network* Out of Network*

Calendar Year Deductible $50 per person (maximum 3 per family)

waived for Type 1

Max Benefit Per Year $2,000 per person

Co

insu

ran

ce

Type 1: Diagnostic/Preventative Services

Exams, X-rays, Cleanings & Fluoride treatments; Sealants; Palliative

Treatment; etc. 0% 0%

Type 2: Basic Services

Basic Restorative (fillings); Simple Extractions; Space Maintainers;

Repairs of Crowns, Inlays, Onlays, Bridges, & Dentures; Endodontics;

Nonsurgical Periodontics; Surgical Periodontics; Complex Oral

Surgery; General Anesthesia; etc.

20% 20%

Type 3: Major Services

Inlays, Onlays, Crowns; Prosthetics (Bridges, Dentures); etc. 50% 50%

Smile for Health® Maternity Benefit Covers 1 additional cleaning during pregnancy

* Network dentists agree to accept our allowances as payment in full for covered services. Non-network dentists may bill the

member for any difference between our 90th

percentile allowance and their fee (also known as balance billing). United Concordia

Dental’s standard exclusions and limitations apply. If you are balance billed by a dentist, please contact Fredericks Benefits.

For a complete list of benefit details and the Limitations and Exclusions for the DHMO and PPO Dental

plans, please refer to the EBC website.

Pre-Authorization: If the charge for any dental treatment is expected to exceed $300, United Concordia

recommends a dental treatment plan be submitted to Claims for review before treatment begins.

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DENTAL INSURANCE

Your Plan Includes UCWellness Enhanced Benefits for People with Diabetes

For people with diabetes, having gum disease (periodontal disease) is fairly common—it’s often called

the “sixth complication of diabetes.” But research shows that those who get treatment for their gum

disease could reduce medical costs, hospital admissions and doctor’s visits.

If you or any of your covered dependents have diabetes, you can get additional benefits that make gum

disease treatment even more affordable. This plan feature is called UCWellness. Available at no

additional cost to you, UCWellness provides:

100% coverage for the services needed to treat and control gum disease

Regular notifications on using the program and tips to help you maintain good oral health

Added Benefits with UCWellness

Service Coverage

Periodontal Maintenance 1 additional added to your plan’s standard

limit per year, all covered at 100%

Scaling & Root Planing 100%

Periodontal Surgery 4 procedures, all covered at 100%

If you or your covered dependents have diabetes, you can sign up as soon as your plan is effective, or

whenever the diagnosis is made throughout the plan year (no need to wait until the next plan year).

Registering for UCWellness is easy. Once your plan is effective:

Sign in to My Dental Benefits on UCWellness.com

Sign up under UCWellness–My Oral Health

After registering, you will receive a confirmation email. Then you can talk to your dentist about what

additional services you may need to keep your mouth healthy.

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DENTAL INSURANCE GROUP NUMBER 902253

DHMO DENTAL BENEFITS AT A GLANCE

The following table shows how the plan pays benefits for most covered expenses. For a more detailed explanation of coverage, refer to the Evidence of Coverage (EOC).

ADA

Code ADA Description

Member

Copay

ADA

Code ADA Description

Member

Copay

Clinical Oral Evaluations Endodontic Therapy

D0120 Periodic oral evaluation – established

patient 0 D3310

Endodontic therapy (root canal), anterior

tooth (excluding final restoration) 40

Radiographs/Diagnostic Imaging D3320

Endodontic therapy (root canal), bicuspid

tooth (excluding final restoration) 60

D0272 Bitewings – two radiographic images 0

D0330 Panoramic radiographic images 0 D3330

Endodontic therapy (root canal), molar

tooth (excluding final restoration) 95

Dental Prophylaxis

D1110 Prophylaxis – adult 0 Surgical Services

D1120 Prophylaxis – child 0

D4210

Gingivectomy or gingioplasty – four or

more contiguous teeth or tooth bounded

spaces per quadrant

20 Other Preventative Services

D1330 Oral hygiene instructions 0

D1351 Sealant – per tooth 0

D4260

Osseous surgery (including flap entry and

closure) – four or more contiguous teeth or

tooth bounded spaces per quadrant

50 Space Maintenance (passive appliances)

D1510 Space maintainer – fixed – unilateral 21

D1515 Space maintainer – fixed – bilateral 32 Non-Surgical Periodontal Services

Amalgam Restorations (including polishing) D4341

Periodontal scaling and root planing – four

or more teeth per quadrant 15

D2140 Amalgam – one surface, primary or

permanent 0

Complete/Partial Dentures (including routine post-delivery care)

D2150 Amalgam – two surfaces, primary or

permanent 0

D5110 Complete denture – maxillary (upper) 150

D5213 Maxillary (upper) partial denture – cast

metal framework with resin denture bases (including conventional clasps, rests, & teeth)

125 D2160

Amalgam – three surfaces, primary or

permanent 0

Resin-based Composite Restorations – Direct Denture Reline Procedures

D2330 Resin-based composite – one surface,

anterior 0 D5730

Reline complete maxillary (upper) denture

(chairside) 10

D2391 Resin-based composite – one surface,

posterior 85 D5750

Reline complete maxillary (upper) denture

(laboratory) 25

Inlay/Onlay Restorations Fixed Partial Denture Pontics

D2520 Inlay – metallic – two surfaces 70* D6242 Pontic – porcelain fused to noble metal 100*

D2542 Onlay – metallic – two surfaces 80* Surgical Extractions (includes local anesthesia, suturing, if

needed, and routine postoperative care) Crowns – Single Restorations Only

D2752 Crown – porcelain fused to noble metal 110* D7220 Removal of impacted tooth – soft tissue 20

Other Restorative Services D7230 Removal of impacted tooth – partial bony 25

D2930 Prefabricated stainless steel crown –

primary tooth 20 D7240

Removal of impacted tooth – complete

bony 30

D2952 Post and core in addition to crown,

indirectly fabricated 22

Alveoloplasty (surgical preparation of ridge for dentures)

D7310

Alveoloplasty in conjunction with

extractions – four or more teeth or tooth

spaces, per quadrant

0 Pulpotomy

D3220 Therapeutic pulpotomy (excluding final

restoration) 9

Comprehensive Orthodontic Treatment

Unclassified Treatment D8080 Adolescent 1,500

D9110 Emergency treatment of pain (minor) 8 D8090 Adult 2,000

* Charges for the use of precious (high noble) or semi-precious (noble) metal are not included in the copayment for crowns, bridges,

pontics, inlays and onlays. The decision to use these materials is a cooperative effort between the provider and the patient, based on

the professional advice of the provider. Providers are expected to charge no more than an additional $125 for these materials.

For a more detailed explanation of coverage, refer to the Evidence of Coverage (EOC).

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VISION INSURANCE

Our vision program gives you the flexibility to seek services from both network participating providers and

non-network (non-participating) providers. If you seek services from non-participating providers, you are

responsible for the copay applicable to the services rendered based on the allowable charges.

VISION BENEFITS AT A GLANCE

The following table shows how the plan pays benefits for most covered expenses. For a more detailed explanation of coverage, refer to the Evidence of Coverage (EOC).

Vision Care Services In-Network Member Cost Out-of-Network

Allowance/Reimbursement

Co-Pay $10 Exam Co-Pay

$25 Materials Co-Pay

Eye Exam Covered 100% after co-pay Up to $40

Lenses

Single

Covered 100% after co-pay

(additional lens coating extra)

Up to $30

Bifocal Up to $50

Trifocal Up to $65

Lenticular Up to $125

Frames $130 Allowance Up to $75

Contact Lenses Fitting/Evaluation/Lenses

Elective $130 Allowance Up to $130

Medically Necessary Covered 100% after co-pay Up to $250

Frequency

Exams Every 12 months

Lenses Every 12 months

Frames Every 24 months

Contact Lenses (in lieu of glasses) Every 12 months

For a more detailed explanation of coverage, refer to the Evidence of Coverage (EOC).

BASIC LIFE AND AD&D INSURANCE GROUP NUMBER 91988

San Bernardino Medical Group offers a company paid Life & AD&D benefit through UNUM Insurance. In the

event of your death, this coverage will pay a benefit of $15,000 to the beneficiary(ies) you name.

Basic Life and AD&D Benefits

Life Benefit Amount $15,000

Your beneficiary will get the benefit amount if you pass away.

AD&D Benefit Amount

$15,000

Accidental Death and Dismemberment Insurance pays a benefit to your

beneficiary if your death is caused by an accident. You may also get part

of this benefit if an accident results in the loss of sight, a limb, certain

fingers or toes, speech, hearing or certain types of paralysis (not able to

move part of your body).

Age Reduction Age 70: Benefit reduced 35%

Age 75: Benefit reduced 50%

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VOLUNTARY LIFE AND AD&D INSURANCE

GROUP NUMBER 201467

In addition to the $15,000 Basic Life & AD&D benefit paid for by San Bernardino Medical Group, you have the

option of purchasing additional Life/AD&D insurance for yourself and your eligible dependents offered through

UNUMProvident. Rates are based upon your age and your spouse’s age.

VOLUNTARY LIFE AND AD&D BENEFITS AT A GLANCE

The following table shows how the plan pays benefits for most covered expenses. For a more detailed explanation of coverage, refer to the Evidence of Coverage (EOC). Note: In order to purchase life coverage for your dependents, you must buy life coverage for yourself.

Voluntary Life and AD&D Benefits Employee Spouse Children

(15 days to 26 years)

Guaranteed Issue

(must provide Evidence of Insurability

form if you are a late entrant)

$100,000 $50,000 $10,000

Minimum/Increments $10,000 $5,000 $2,000

Maximum

(all amounts over Guaranteed Issue

require Evidence of Insurability form)

Up to 5 times salary

(not to exceed

$500,000)

Up to 50% of

employee amount (not

to exceed $250,000)

$10,000

Benefit Reduction at age 70

(coverage may not be increased

after a reduction)

Lesser of $30,000 or 1

times salary

Lesser of $15,000 or

50% of employee

amount

Not Applicable

Additional Benefits Survivor Financial

Counseling Services

This personalized financial counseling service provides expert, objective financial

counseling to survivors and terminally ill employees at no cost to them. This service is

also extended to employees upon the death or terminal illness of their covered spouse. The

financial counselors, all highly trained attorneys, help develop strategies needed to protect

resources, preserve current lifestyles, and build future security. At no time will the

counselor offer or sell any product or service.

Portability If your employment terminates for any reason other than an injury or sickness, you can

take this coverage with you according to the terms outlined in the contract.

Accelerated Benefit If you become terminally ill and are not expected to live more than twelve months, you

may request up to 50% of your life insurance amount up to $50,000, without fees or

present value adjustments. A doctor must certify your condition in order to qualify for this

benefit. Upon your death, the remaining benefit will be paid to your designated

beneficiary(ies). This feature also applies to your covered dependents.

Waiver of Premium If you become disabled (as defined by your plan) and are no longer able to work, your

Life coverage premium payments – as well as premiums for your spouse and dependents –

will be waived during the period of disability.

Unum Security

Account

Benefits of $10,000 or more are paid through the Unum Security Account. This interest

bearing account will be established in the beneficiary's name. He or she can then withdraw

money at any time for $250 or more, up to the full amount, as needed.

Limitations and Exclusions

For a full list of Limitations and Exclusions, please refer to the plan documents.

NOTE: If you do not elect Voluntary Life & AD&D Insurance when it is first made available to you

and elect to add the coverage at the next annual enrollment period, the entire amount elected will

require satisfactory evidence of insurability.

*Guarantee Issue Amount: If you elect Voluntary Life & AD&D Insurance in excess of the Guarantee Issue Amount, satisfactory evidence of insurability must be approved by medical underwriting by completing a medical history statement and possibly an exam.

- 19 -

WORK LIFE EMPLOYEE ASSISTANCE PROGRAM (EAP)

Your work-life balance Employee Assistance Program (EAP) can help you find solutions for the everyday

challenges of work and home as well as for more serious issues involving emotional and physical well-

being.

Childcare and/or eldercare referrals Financial planning assistance

Personal relationship information Stress management

Health information and online tools Career development

Legal consultations with licensed attorneys

Help Is Easy To Access

Telephone Consultations: Speak confidentially with a master’s level consultant to clarify your

need, evaluate options and create an action plan.

Face-to-face Meeting: Meet with a local consultant up to three times per issue for short-term

problem resolution.*

Educational Materials: Receive information through our online library of downloadable

materials and interactive tools.

Learn more at www.unum.com/worklifebalance

Work-life balance employee assistance program services are provided by Ceridian Corporation and are

available with selected Unum insurance offerings. Exclusions, limitations and prior notice requirements

may apply, and service features, terms and eligibility criteria are subject to change. The services are not

valid after termination of coverage and may be withdrawn at any time. Please contact your plan

administrator for full details.

*You may confer with a local consultant up to three times in a six month time period.

- 20 -

EMPLOYEE ADVOCACY SERVICES

We all need someone in our corner for those stressful situations that can take forever to resolve. San

Bernardino Medical Group’s Insurance Broker is here to help in the event you or your dependents

experience a healthcare or insurance related issue or problem. They will be able to provide a clear

understanding of the benefits that you and your dependents are entitled to, as well as help you navigate

through the system to get your issue corrected.

Types of Services They CAN Assist with:

Difficulty accessing care

Eligibility issues

Claim problems

Complex lab and imaging issues

Scheduling problems

Billing reconciliation Explanation of Benefits

For assistance, contact:

Phone: 1.866.792.1070 E-Mail: CSR@fredericksbenefits.com

 

THESE SUMMARIES ARE FOR INFORMATIONAL PURPOSES ONLY

THE INFORMATION IN THE BOOKLET IS ONLY A BRIEF DESCRIPTION OF THE BENEFITS AND INSURANCE PLANS, AND IS NOT AN EVIDENCE OF COVERAGE

(EOC) FOR THE PLAN.

FOR COMPLETE DETAILS ON ANY BENEFIT, REFER TO YOUR MEMBER HANDBOOK, OR THE PLAN'S BENEFIT BOOKLET. IF THERE ARE ANY INCONSISTENCIES

BETWEEN THE DESCRIPTIONS IN THIS BOOKLET AND THE INSURANCE CONTRACTS, THE INSURANCE CONTRACT AND PLAN AGREEMENTS WILL CONTAIN

LEGAL, BINDING PROVISIONS AND WILL PREVAIL.