Benefits – California Water Service Group

California Water Service Group and its subsidiaries offer medical, dental, and vision insurance to employees. General health benefit information is provided below. Additional and/or alternate benefits are available in some locations.

Medical

Plan Name	California Water Service Medical Plan
Plan Administrator	Benefits & Risk Management Services (BRMS) 1-844-886-2400 www.vbas.com
PPO Networks	Anthem (Blue Cross Prudent Buyer): CA only First Health: NM and all other states other than CA and WA First Choice: WA only
	In-Network Benefits	Out-of-Network Benefits
Calendar Year Deductible	$100 per person; $300 per family (for families with 3 or more people)	$200 per person; $600 per family (for families with 3 or more people)
Out-of-Pocket Max	$3,100 per person; $9,300 per family (amount includes deductible)	$6,200 per person; $18,600 per family (amount includes deductible)
Physician Office Visits	Deductible and 20% Coinsurance	Deductible and 30% Coinsurance
Preventative Care & Wellness Visits Covered based on USPTF guidelines and subject to age and gender restrictions	Covered at 100%	Deductible and 30% coinsurance
In-Patient Hospitalization (including Maternity)	Deductible and 20% Coinsurance	Deductible and 30% Coinsurance
Emergency Room	Deductible and 20% Coinsurance	Deductible and 30% Coinsurance
Mental Health In-Patient & Out-Patient	Deductible and 20% Coinsurance	Deductible and 30% Coinsurance
Out-Patient Hospital Surgery (including Surgical Expense)	Deductible and 20% Coinsurance	Deductible and 30% Coinsurance
Diagnostic X-Ray & Labs	Deductible and 20% Coinsurance	Deductible and 30% Coinsurance
Chiropractic & Acupuncture Each benefit has 46 visits max per year, in- and out-of-network combined	First visit: Deductible and 20% Coinsurance (max coverage $150); $30 coverage for each subsequent visit	First visit: Deductible and 30% Coinsurance (max coverage $150); $30 coverage for each subsequent visit
Prescriptions (including birth control)
Managed by	Express Scripts. Use your Express Scripts card when you go to the pharmacy or enroll in the Mail Order Program for ongoing prescriptions.
Name Brand	20% Coinsurance
Generic	10% Coinsurance
Compound	Not covered through Express Scripts. Submit to Cal Water Medical Plan for reimbursement. Coverage is limited to: Hormone replacement therapies; and If there are problems with FDA approved version of a prescription drug (e.g. You are unable to take the FDA approved drug in the form that is available or you are allergic to an ingredient in the FDA approved drug); *Compound topical pain creams are not covered

Dental

Plan Administrator: Delta Dental of California
Group Number: 16001
Effective Date: 01/01/2017
Claims Address: P.O. Box 997330, Sacramento, CA 95899-7330
Customer Service: 1-800-765-6003

Eligibility	Primary enrollee, spouse, and eligible dependent children to age 26
Deductibles	$50 per person/$150 per family each calendar year. Any deductible applied during the last 3 months of the year will carry forward to next year’s deductible.
Deductibles waived for Diagnostic & Preventative?	Yes
Maximums	$1,500 per person each calendar year
Diagnostic & Preventative counts towards maximum?	No
Waiting Period(s)	Basic Benefits: None
	Major Benefits: None
	Prosthodontics: None
	Orthodontics: None
Benefits and Covered Services	Delta Dental PPO Dentists	Non-Delta Dental PPO Dentists
Diagnostic & Preventative Services Exams, cleanings, bitewing x-rays, and sealants	100%	100%
Basic Services Fillings, simple tooth extractions, full mouth and panoramic x-rays	80%	80%
Endodontics (root canals) Covered under Basic Benefits	80%	80%
Periodontics (gum treatments) Covered under basic services	80%	80%
Oral Surgery Covered under Basic Services	80%	80%
Major Services Crowns, inlays, onlays, and cast restorations	80%	80%
Prosthodontics Bridges, dentures, and implants	80%	80%
Orthodontic Benefits Adults and dependent children	50%	50%
Orthodontic Maximums	$2,000 Lifetime	$2,000 Lifetime

Vision

To view vision claim status, details on claims already processed, or more specific information about benefits for you or a covered dependent, visit VSP online.

Plan Administrator: VSP® Vision Care.
Website: vsp.com
Effective Date: 01/01/2017
VSP Provider Network: VSP Choice
Customer Service: 1-800-877-7195

Benefit	Description	Copay
WellVision Exam	Focuses on your eyes and overall wellness Every calendar year	$10
Prescription Glasses		$25
Frame	$150 allowance for a wide selection of frames $170 allowance for featured frame brands 20% savings on the amount over your allowance $80 allowance at Costco Every other calendar year	Included in Prescription Glasses
Lenses	Single vision, lined bifocal, and lined trifocal lenses Polycarbonate lenses for dependent children Every calendar year	Included in Prescription Glasses
Lens Enhancements	Standard progressive lenses	$55
	Premium progressive lenses	$95–$105
	Custom progressive lenses	$150–$175
	Anti-Reflective Coating	$35
	Average savings of 20-25% on other lens enhancements
	Every calendar year
Contacts (instead of glasses)	$150 allowance for contacts; copay does not apply Contact lens exam (fitting and evaluation) Every calendar year	Up to $60
Additional Coverage	Primary Eyecare
Extra Savings
Glasses & Sunglasses	Extra $20 to spend on featured frame brands. Go on www.vsp.com/specialoffers for details 20% savings on additional glasses and sunglasses, including lens enhancements, from any VSP provider within 12 months of your last WellVision Exam
Retinal Screening	No more than a $39 copay on routine retinal screening as an enhancement to a WellVision Exam
Laser Vision Correction	Average 15% off the regular price or 5% off the promotional price; discounts only available from contracted facilities
Coverage with Out-of-Network Providers	Visit www.vsp.com for details, if you plan to see a provider other than a VSP network provider
	Exam	up to $45
	Lined Trifocal Lenses	up to $65
	Frame	up to $70
	Progressive Lenses	up to $50
	Single Vision Lenses	up to $30
	Contacts	up to $105
	Lined Bifocal Lenses	up to $50