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 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: Name Brand: Generic: Compound:	Express Scripts – Use your Express Scripts card when you go to the pharmacy or enroll in the Mail Order Program for ongoing prescriptions. 20% Coinsurance 10% Coinsurance 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?

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%

Basic Services

Fillings, simple tooth extractions, full mouth and panoramic x-rays

80%

Endodontics (root canals)

Covered under Basic Benefits

80%

Periodontics (gum treatments)

Covered under basic services

80%

Oral Surgery

Covered under Basic Services

80%

Major Services

Crowns, inlays, onlays, and cast restorations

80%

Prosthodontics

Bridges, dentures, and implants

80%

Orthodontic Benefits

Adults and dependent children

50%

Orthodontic Maximums

$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 Premium progressive lenses Custom progressive lenses Average savings of 20-25% on other lens enhancements Every calendar year Anti-Reflective Coating	$55 $95 – $105 $150 – $175 $35
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
Your 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