Health Coverage for Foreign Claims
The Deductible
The Health Plan’s deductible is $325 per individual, with a maximum of $975 per family, per calendar year. So, you will pay the first $325 in covered medical costs for each member of your family each year, up to $975. Then, co-insurance will apply.
Co-Insurance
After you meet the deductible, we will cover benefits for covered services by non-network providers at the following percentages:
| Plan | Non-Network Doctor |
|---|---|
| DGA Choice Plan | Health Plan Pays 60% |
| DGA Premier Choice Plan | Health Plan Pays 70% |
Note: If you are in the United States and use a network provider, the Health Plan will pay 90% of the contract amount charged by the provider.
Out-of-Pocket Limit
Each year, after you meet the deductible, we limit the amount you pay for covered medical costs. This limit is referred to as the out-of-pocket limit. Once you meet the out-of-pocket limit, we will cover 100% of all covered services through the end of the year if it is not covered by your national health plan.
The following are the Health Plan’s out-of-pocket limits:
| Plan | Non-Network Doctor |
|---|---|
| DGA Choice Plan | $8,900 |
| DGA Premier Choice Plan | $3,550 |
There is a separate out-of-pocket limit for each family member.
Covered and Non-Covered Services
The Health Plan’s benefits are applicable when a medical procedure falls under What’s Covered Under Medical Benefits, which starts on page 54 in the March 2020 Health Plan Summary Plan Description. Claims that are not covered under the Health Plan are listed in the What’s Not Covered Under Medical Benefits section that starts on page 63 of the March 2020 Health Plan Summary Plan Description.
Not all services provided by a doctor are covered (cosmetic surgery, for example). You are responsible for 100% of the cost of non-covered services. The best way to determine if a treatment is covered is to call the Plan office.
Reasonable and Customary Charges (R&C)
When you visit a non-network doctor, the Health Plan will only consider charges up to the reasonable and customary (R&C) amount for a covered service. You will be responsible for all charges over the R&C amount. Below is an example of how R&C works for someone who is covered under the Choice Plan after the deductible has been paid.
| Non-Network Doctor | |
|---|---|
| Cost of Procedure A R&C of Procedure A Health Plan Pays Co-Insurance |
$600 $300 60% of the R&C $180 |
| Total cost to Health Plan | $180 |
| Participant Pays Co-Insurance Amount in Excess of R&C |
40% of the R&C $120 $300 |
| Total cost to Participant | $420 |
The R&C amount is calculated based on the average charge for a medical service by a percentage of doctors in a given area. For doctors outside of the United States, the R&C amount is based on provider rates in the New York metropolitan area. Even if you have reached your out-of-pocket limit, you will still be responsible for any cost over the R&C amount.
Prescription benefits are provided through Express Scripts. When you begin coverage, Express Scripts will send you an ID card that contains important information that you will need when you submit a prescription drug claims to our office for reimbursement (see the What You Pay at a Non-Network Pharmacy section below for more information). In addition, if you travel to the United States, you can use your ID card to fill prescriptions at a pharmacy.
Pharmacies Outside of the United States
All pharmacies outside of the United States are considered non-network pharmacies. You will not need your prescription ID card at these pharmacies. Instead you will pay for the prescription and submit the claim for reimbursement to Express Scripts. See the Claims page for instructions on submitting the claim to Express Scripts.
What You Pay at a Non-Network Pharmacy
When you purchase a covered prescription drug outside of the United States, you must pay the full cost of the prescription at the time of purchase. You can then submit your claim to Express Scripts for reimbursement. You will be reimbursed for the amount the Plan would have paid had the drug been purchased at an Express Scripts-participating pharmacy in the United States.
See the Claims page for instructions on submitting the claim to Express Scripts.
What’s Covered
The Health Plan covers generic drugs, brand name drugs, and certain lifestyle drugs.
To be eligible for coverage under the Health Plan’s prescription drug benefit, a medication must be available in the United States and have received FDA approval.
To determine if a prescription drug has received FDA approval, you can browse the FDA’s database of approved drug products. You may need both the drug’s brand name (e.g. Lipitor) and the chemical name (e.g. atorvastatin calcium), as some medications are sold under a different brand name outside the United States. If you are unsure if the medication is FDA-approved, you can call the Health Plan Office at (323) 866-2233.
Currently, lifestyle drugs include erectile dysfunction drugs, proton pump inhibitors (like Nexium), non-sedating antihistamines, and sleep aides. There are special rules for coverage of proton pump inhibitors and sleep aides. See the “Lifestyle Drugs” section on pages 70-71 of the March 2020 Health Plan Summary Plan Description for more information.
Contact Information
You can call the Health Plan Office at (323) 866-2233 for more information regarding your prescription benefits or to discuss a claim.
The Health Plan’s dental benefits are provided through Delta Dental.
Dentists Outside of the United States
All dentists outside of the United States are considered non-network dentists. For more information, see page 75 in the March 2020 Health Plan Summary Plan Description.
What You Pay at a Non-Network Dentist
When you visit a non-network dentist, you must pay your dentist at the time of service. Afterward, you can submit the claim to Delta Dental for reimbursement. Your claim will be reimbursed based on the deductibles, co-insurance, and maximum benefit detailed below.
See our Claims page for instructions on submitting a dental claim to Delta Dental.
Deductibles
For non-network dentists, the deductible is $50 per person per calendar year, with a maximum deductible of $100 per family each year. Non-network dental benefits are only payable once you satisfy this deductible.
Co-Insurance
Dental benefits are broken down into four categories: Category 1 (which includes exams and x-rays), Category 2 (which includes fillings and crowns), Category 3 (which includes bridges, dentures and oral surgery) and Orthodontics. The applicable co-insurance for dental benefits is as follows:
| Type of Service | Non-Network Dentist |
|---|---|
| Category 1 | 85% |
| Category 2 | 60% |
| Category 3 | 50% |
| Orthodontic Benefit | 50% |
For non-network dentists, benefits are calculated based on Reasonable and Customary charges. See the section above for more information on Reasonable and Customary charges.
Orthodontic Benefits are only available up to age 19.
Maximum Benefit
There is a maximum dental benefit of $2,500 per person each year.
Contact Information
You can call Delta Dental at (415) 972-8300 for more information regarding your dental benefits or to discuss a claim. If you have any difficulty, please contact the Health Plan office at (323) 866-2233.
The Health Plan’s vision benefits are provided through Vision Service Plan (VSP).
Doctors Outside of the United States
All doctors outside of the United States are considered non-network doctors. See pages 80-81 of the March 2020 Health Plan Summary Plan Description for more information.
What You Pay at a Non-Network Doctor
When you visit a non-network vision services provider, you must pay your provider at the time of service. Afterward, you can submit the claim to us for reimbursement. Your claim will be reimbursed based on the payment schedules detailed below.
See our Claims page for instructions on submitting a vision claim to VSP.
Eye Exams
There is a $30 co-payment for eye exams. You can receive a maximum reimbursement of $45.
The maximum benefit is one exam per year.
Frames
There is a $220 allowance for eyeglass frames. ($240 for featured frame brands.) You can receive a maximum reimbursement of $70.
The maximum benefit is one set of frames every other calendar year.
The vision benefit covers a wide variety of frames, but not all frames are covered in full. You will be responsible for any costs that exceed the vision benefit’s allowance.
Lenses
There is a $200 allowance for eyeglass lenses or contact lenses.
You can receive a maximum reimbursement of:
- Up to $30 on single vision lenses;
- Up to $50 on lined bifocal lenses;
- Up to $65 on lined trifocal lenses;
- Up to $105 per lens for elective contact lenses;
- Up to $210 per lens for medically necessary contact lenses.
The maximum benefit is one set of lenses per calendar year.
Contact Information
You can call VSP at (916) 635-7373 for more information regarding your vision benefits or to discuss a claim. If you have any difficulty, please contact the Health Plan office at (323) 866-2233.
