Benefits

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 Company Healthcare Plan
Policy Number:	Insured’s Social Security Number or Insured’s Employee ID #
PPO Networks HealthSmart PPO: MultiPlan PPO:	Discount applied when bill is paid Discount applied when bill is paid
Calendar Year Deductible:	$100 per person; $300 per family (for families with 3 or more people)
Preventative Care & Wellness Visits
Children:	Immunizations & well-checks payable at 100% of allowable amount
Adults:	Well-woman gynecological examinations, mammogram screenings (age 40 & over), colorectal cancer screening (age 50 to 75), immunizations payable at 100% of allowable amount All other covered preventative services paid at 80%
Hospitalization Basic Benefit:	Covers first $3,000 at 100% for inpatient hospitalizations (including inpatient stays for mental health and alcohol and drug rehabilitation) and outpatient surgeries, then Major Medical benefits apply. All other outpatient hospitalizations, including emergency room visits, are covered under Major Medical.
Major Medical (Physician visits, surgical prof fees, lab & x-ray, physical therapy):	80% of the balance after satisfying annual deductible, up to $3,000 out of pocket then account goes to 100% coverage for medical.
Prenotification of Inpatient Hospitalization:	Call HealthSmart: 877-202-6379.
Out-Patient Mental Health & Drug/Alcohol Rehab:	Payable under Major Medical
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:	Paid at 80%
Generic:	Paid at 90%
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
Accidents Basic Benefits:	First $300 covered at 100%, no deductible. Must seek medical attention within 48 hours of accident. Accident details need to be submitted with each claim.
Chiropractic, Acupuncture, & Acupressure:	Limit of 46 visits per calendar year. 1st visit paid at 80% after deductible has been met to a maximum of $150.00. 2nd through the 46th visit are paid at 80% to a maximum of $30.00 each visit.

Dental

Plan Administrator: Delta Dental of California

Group Number: 16001

Effective Date: 01/01/2015

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

Plan Administrator: VSP® Vision Care.

Website: vsp.com

Effective Date: 02/01/2015

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	$130 allowance for a wide selection of frames $150 allowance for featured frame brands 20% savings on the amount over your allowance $70 allowance at Costco Every other calendar year	Lenses
WellVision Exam	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 Premium progressive lenses Custom progressive lenses Average savings of 20-25% on other lens enhancements Every calendar year	$55 $95 – $105 $150 – $175
Contacts (instead of glasses)	$130 allowance for contacts; copay does not apply Contact lens exam (fitting and evaluation) Every calendar year	Up to $60
Additional Coverage	Primary Eyecare