International Brotherhood of Electrical Workers Local 234 10300 Merritt Street
Castroville, CA 95012
(831) 633-2311
All questions regarding elegibility, payments, reserve accounts, or C.O.B.R.A. please contact:

United Administrative Services (UAS)
1120 S. Bascom Ave.
San Jose, CA 95128

(800) 748-6417
x4455 (Inside)

x4452 (Res/S&C)

All claims or claim questions should be directed to:

Pacific Health Alliance (PHA)
1350 Old Bayshore Hwy #560
Burlingame, CA 94010

Allison
(800) 533-4742

Summary Schedule of Benefits

NETWORK PROVIDERS NON-NETWORK PROVIDERS
(1) Annual Deductible
(Applies to all expenses unless noted)
Note: Does not include co-payments 		MEDICAL DEDUCTIBLE AMOUNT

You pay $100 per person per calendar year.

(2) Maximum Out of Pocket $15,000 per person, effective from each person's initial coverage elegibility date.  
(3) Lifetime Maximum $1 Million per person, effective from each person's initial coverage eligibility date.
BENEFIT THE PLAN PAYS THE PLAN PAYS
(4) Hospital Benefits (Calendar Year Deductible Applies)
  • Inpatient Services
  • Intensive Care unit
  • Convalescent hospital
  • Extras
  • Outpatient Services
  • 80%, at semi-private room rate.
  • 80% up to 300% of semi-private room rate.
  • $20 per day plus 50% of semi-private room rate up to 365 days.
  • 80%, except payment not to exceed $50 for physiotherapy in a convalescent hospital during a continuous period of disability.
  • 80% of Network Allowance.
  • 80% of Network Allowance, patient pays the excess.
  • "
  • "
  • "
  • "
  • CHOMP and Salinas Valley Memorial 75%. Natividad Medical Center 100%.
(5) Ambulance (Calendar Year Deductible Applies)
  • Maximum
 80% for a surface ambulance. Air ambulance subject to medical review. Same
(6) Physician Services (Calendar Year Deductible Applies)
  • Surgery
  • Anesthesia
  • Hospital Visits
  • Office Visits
  • Home Visits
  • Radiotherapy
  • Speech Therapy
  • Chemotherapy
  • Injectable Medication
  • Referred Specialist
  • Physical Therapy
  • 80% of Network Allowance.
  • 80% of Network Allowance.
  • 80% of Network Allowance.
  • 80% of Network Allowance after $25 co-pay.
  • 80% of Network Allowance after $25 co-pay.
  • 80% of Network Allowance.
  • 80% of Network Allowance.
  • 80% of Network Allowance.
  • 80% of Network Allowance.
  • 80% of Network Allowance, 1st $25 co-pay waived.
  • 80% of Network Allowance, 12 visits max. per Cal. Yr. Authorization required before 4th visit.
  • 80% of Network Allowance, patient pays the excess.
  • "
  • 80% of Network Allowance, patient pays the excess + co-pay.
  • "
  • 80% of Network Allowance, patient pays the excess.
  • 80% of Network Allowance, patient pays the excess.
  • 80% of Network Allowance, patient pays the excess.
  • 80% of Network Allowance, patient pays the excess.
  • 80% of Network Allowance 1st $25 co-pay waived, patient pays the excess.
  • Same - patient pays excess.
(7) Diagnostic Coverage (Calendar Year Deductible Applies)
  • X-ray Procedures
  • Laboratory Procedures
  • 80% of Network Allowance.
  • 80% of Network Allowance.
  • Same - patient pays excess over Network Allowance.
  • Same - patient pays excess over Network Allowance.
(8) Mental Health Care (Calendar Year Deductible Applies)
  • Inpatient
  • Outpatient
  • Same basis as benefit provided for any other illness, up to 60 days per 24 months (Network Allowance).
  • 50% of Network Allowance not to exceed 12 visits per calendar year.
  • Same - patient pays excess over Network Allowance.
  • Same - patient pays excess over Network Allowance.
(9) Chiropractic Benefit (Calendar Year Deductible Applies)
  • Coverage
 80% of Network Allowance after $25 co-pay. 12 visits maximum per calendar year. Authorization required before 4th visit. Same - patient pays the excess over Network Allowance and the 12 visits per calendar year.
(10) Maternity Benefits (Calendar Year Deductible Applies)
  • Coverage
    (For employee or spouse only)
 Treatment of pregnancy shall be on the same basis as the treatment for any other illness.

A hospital length of stay is allowed for the mother and newborn child for up to 48 hours following a vaginal delivery and up to 96 hours following a cesarean section delivery. No authorization is required for a hospital length of stay that does not exceed these periods. Benefits for a shorter period will apply if the patient's attending provider, after consultation with the mother, has approved an earlier discharge.

(11) Temporal Mandibular Joint (TMJ) Benefit (Calendar Year Deductible Applies)
  • Coverage
 80% of Network Allowance. Maximum benefit, $1,000 lifetime. Same - patient pays excess over Network Allowance. Maximum benefit, $1,000 lifetime.
(12) Alcoholism Benefit (Calendar Year Deductible Applies)
  • Coverage
 80% of Network Allowance not to exceed a $7,500 lifetime maximum. Same - patient pays 20% plus excess over Network Allowance.
(13) Acupuncture Benefit (Calendar Year Deductible Applies)
  • Coverage
 80% treatment by a physician or acupuncturist licensed by the State. Benefit payable - initial visit, per condition, not to exceed $60. Benefits payable - additional visits not to exceed $30. Maximum calendar year visits (for all conditions) not to exceed 10. Same
(14) Home Health Care Benefit (Calendar Year Deductible Applies)
  • Coverage
 80%, maximum visits 100 per calendar year. Maximum benefit per visit is $35, nutritional counseling maximum benefit is $50 per calendar year, Mental Health Care maximum benefit is $100 per calendar year. Same - patient pays excess over Network Allowance. Maximum visits 100 per calendar year.
(15) Hospice Care Benefit (Calendar Year Deductible Applies)
  • Coverage
 80% - Maximum benefit, $7,500 lifetime. Same
(16) Additional Accident Benefit (Calendar Year Deductible DOES NOT Apply)
  • Coverage
 80% of Network Allowance, for charges incurred within 90 days of accident. Same - patient pays excess over Network Allowance.
(17) Well Child Care Benefit (Calendar Year Deductible Applies)
  • Coverage
  1. The charge of an acute care hospital for routine nursery care furnished to a newborn well baby while the mother is an inpatient.
  2. The charge of a physician for the initial pediatric examination of a newborn performed before the child is released from nursery care.
  3. The charges of a physician for no more than 15 outpatient visits through the age of 5 years.
  • 80% of Network Allowance.
  • 80% of Network Allowance.
  • 80% of Network Allowance after applicable $25.00 co-pay.
  • Same - patient pays excess over Network Allowance.
  • Same - patient pays excess over Network Allowance.
  • Same - patient pays excess over Network Allowance.
(18) Well Adult Care Benefit (Effective 1-1-99) (Calendar Year Deductible Applies)
  • Coverage
  1. Females Age 18 and older, one annual cervical cancer screening examination, including PAP smear, a breast examination and for age 40 and older a mammogram, as recommended by the American Cancer Society.
  2. Males Prostate cancer screening, PSA blood test and digital rectal examination, as recommended by a physician.
  • 80% of Network Allowance.
  • 80% of Network Allowance.
  • Same - patient pays excess over Network Allowance.
  • Same - patient pays excess over Network Allowance.
(19) Vision Care Benefit (Calendar Year Deductible DOES NOT Apply)
  • Coverage
 Payable Allowance
Complete Examination (every 12 months) $60
Lenses - (per pair)(every 12 months):
Single Vision Prescription $55
Bifocal Prescription $75
Trifocal Prescription $90
Lenticular Lenses $150
Contact Lenses
(other than Cosmetic Contact Lenses) $300
Cosmetic Contact Lenses $125
Frames - (every 24 months) $70

Copyright © 2006 IBEW Local 234, Castroville, California.