How the MSP Works
After you satisfy a $100 annual individual deductible, the Plan pays 80 percent of Eligible Expenses that are not paid by Medicare. The remaining 20 percent of expenses, called the "co-insurance," is your share.
The Plan also covers 80 percent of certain other health care expenses that are excluded under Medicare.
Payments by the MSP are calculated as if you signed up for both Part A and Part B of Medicare, even if you have not. Therefore, you must sign up for both Parts A and B of Medicare when eligible in order to obtain maximum benefits from the Plan. Any other benefits payable through an employer, trustee, union, employee benefit association or government program are applied before this Plan's benefits become payable.
NOTE: Members enrolled in the MSP will receive the benefit of Medicare Part D through this employer plan without enrolling in Medicare Part D. If you enroll in Medicare Part D outside of PG&E enrollment process, you will lose eligibility for all Company-sponsored medical plans.
$100 Deductible
There are two separate $100 deductibles — a medical deductible and a prescription drug deductible. Both deductibles of $100 a year apply to each covered individual. See the Prescription Drug Coverage section for additional information.
The Plan also lets you "carry over" expenses that count toward your deductible in October, November or December of one year and apply them to the next year's deductible.
$10,000 Lifetime Maximum
There are two separate $10,000 lifetime maximums — a medical maximum and a prescription drug maximum. See the Prescription Drug Coverage section for additional information.
The medical maximum lifetime benefit for each member is $10,000. However, the MSP is currently designed to "restore" amounts charged against your maximum during the previous calendar year. Every January 1, the Plan automatically restores up to $1,000 toward your lifetime maximum. These are called "restoral funds."
Customary and Reasonable (C&R) Charges
Customary and Reasonable Charges are those covered charges for services rendered by or on behalf of a non-network physician, for an amount not to exceed the amount determined by Anthem Blue Cross in accordance with the applicable fee schedule.
A Customary and Reasonable Charge is a charge which falls within the common range of fees billed by a majority of physicians for a procedure in a given geographic region. If it exceeds that range, the expense must be justified based on the complexity or severity of treatment for a specific case.
Eligible Expenses
The amount Anthem Blue Cross will pay for Covered Health Services incurred while the Plan is in effect, or Eligible Expenses, are based on Medicare's allowed amount.
Covered Health Services
Covered Health Services are those health services, supplies or equipment provided for the purpose of preventing, diagnosing or treating a sickness, injury, covered medical condition, or their symptoms.
A Covered Health Service is a Medically Necessary health care service or supply described under "What the MSP Covers" as a Covered Health Service and which is not excluded under "What the MSP Does Not Cover", including experimental or investigational services or unproven services.
Covered Health Services must be provided:
  • when the Plan is in effect;
  • prior to the effective date that any of the individual termination conditions set forth in this Summary Plan Description; and
  • only when the person who receives services is a covered person and meets all eligibility requirements specified in the Plan.
Medically Necessary Services
Medically necessary services are those procedures, supplies, equipment or services which the Claims Administrator, Anthem Blue Cross on behalf of Anthem Blue Cross Life and Health, determines to be:
  • Appropriate and necessary for the diagnosis or treatment of the medical condition;
  • Provided for the diagnosis or direct care and treatment of the medical condition;
  • Within standards of good medical practice within the organized medical community;
  • Not primarily for your convenience, or for the convenience of your physician or another provider; and
  • The most appropriate procedure, supply, equipment or service which can safely be provided. The most appropriate procedure, supply, equipment or service must satisfy the following requirements:
    • There must be valid scientific evidence demonstrating that the expected health benefits from the procedure, supply, equipment or service are clinically significant and produce a greater likelihood of benefit, without a disproportionately greater risk of harm or complications, for you with the particular medical condition being treated than other possible alternatives; and
    • Generally accepted forms of treatment that are less invasive have been tried and found to be ineffective or are otherwise unsuitable; and
    • For hospital stays, acute care as an inpatient is necessary due to the kind of services you are receiving or the severity of your condition, and safe and adequate care cannot be received by you as an outpatient or in a less intensified medical setting.
The fact that a physician, licensed professional or other provider may prescribe, order, recommend, or approve a service or supply does not, in itself, make it Medically Necessary, even though it is not specifically listed as an exclusion or limitation. The services or supplies must be ordered by the attending physician or licensed professional for the direct care and treatment of a covered illness, injury or condition. Services must be standard medical practice where received for the illness, injury or condition being treated and must be legal in the United States.