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: |
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| 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:
*Compound topical pain creams are not covered |
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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% |
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| Basic Services
Fillings, simple tooth extractions, full mouth and panoramic x-rays |
80% |
80% | ||
| Endodontics (root canals)
Covered under Basic Benefits |
80% |
80% |
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| Periodontics (gum treatments)
Covered under basic services |
80% |
80% |
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| Oral Surgery
Covered under Basic Services |
80% |
80% |
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| Major Services
Crowns, inlays, onlays, and cast restorations |
80% |
80% |
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| Prosthodontics
Bridges, dentures, and implants |
80% |
80% |
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| Orthodontic Benefits
Adults and dependent children |
50% |
50% |
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| 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 |
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$10 | ||
| Prescription Glasses | $25 | |||
| Frame |
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Included in Prescription Glasses | ||
| Lenses |
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Included in Prescription Glasses | ||
| Lens Enhancements |
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| Contacts (instead of glasses) |
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Up to $60 | ||
| Additional Coverage |
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| Extra Savings |
Glasses & Sunglasses
Retinal Screening
Laser Vision Correction
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Your Coverage with Out-of-Network Providers |
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| 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 |
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