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CEMENT MASONS SOUTHERN CALIFORNIA

HEALTH & WELFARE PLAN

Summary Plan Description

For Eligible Active Cement Masons

and their Eligible Dependents

Caution: This document, together with the Evidence of Coverage booklet issued by Kaiser, Health Net, Delta

Dental, VSP and the Certificate of Coverage issued by The Union Labor Life Insurance Company, is your Summary

Plan Description. Please attach this Summary Plan Description to those Evidence of Coverage booklets and that

Certificate of Coverage. If the Evidence of Coverage booklets and Certificate of Coverage are not attached, then

this Summary Plan Description is not complete and you should contact the Administrative Office or Kaiser, Health

Net, Delta Dental, VSP or The Union Labor Life Insurance Company for another copy of those Evidence of

Coverage booklets and that Certificate of Coverage.

Effective January 1, 2014

To All Cement Mason Employees and Their Eligible Dependents:

This booklet contains a general description of all benefits to which eligible active Cement Masons and their

eligible dependents are entitled under the Cement Masons Southern California Health & Welfare Plan. You

may be eligible for medical, dental, prescription drug, vision and life insurance coverages if you work the

required hours. Alternatively, you may be eligible for medical, prescription drug and life insurance

coverages only, if you work reduced hours. Refer to the Eligibility section beginning on page 15 for more

detailed information,.

The benefit coverages described in this booklet are as follows:

► Medical Benefits (you may choose one)

Health Net Coverage (HMO)

Kaiser Permanente Coverage (HMO)

PPO Medical Coverage

► Prescription Drug Benefits

OptumRx (walk-in and mail order)

► Dental Benefits

Delta Dental Coverage (PPO)

► Vision Benefits

VSP

► Life Insurance/AD&D Benefits

The Union Labor Life Insurance Company

The Health Plan was established for you as a result of a collective bargaining agreement between your

union and the employer associations. Your employer has agreed under a provision of the collective

bargaining agreement to make contributions to the Plan which are used to pay for the costs of the benefit

coverages described above.

The power to administer the Plan and adopt rules and regulations governing the payment of benefits is

vested in the Board of Trustees. The payment of any benefit is subject to all terms and conditions of this

Cement Masons Southern California Health & Welfare Summary Plan Description; the Agreement and

Declaration of Trust establishing the Cement Masons Southern California Health & Welfare Plan; contracts

issued to the Plan by Health Net, Kaiser Permanente, Delta Dental, VSP, OptumRx, and The Union Labor

Life Insurance Company, as well as the rules and regulations adopted by the Trustees from time to time.

Benefits for the Cement Masons’ Southern California Health and Welfare Plan are financed through

employer contributions that are specifically designated to provide health benefits for active

employees. There is no vested right to receive Plan benefits and the Board of Trustees may amend or

terminate the Plan and your benefits at any time.

The Trustees may periodically review Plan benefit assumptions based on such factors as total hours

worked and projected costs and make any benefit enhancements, eliminations, or modifications they

determine is best for the Plan and its participants and dependents.

Any verbal or written representations made by any employer, union, or Administrative Office

employee or representative will not be binding on the Board of Trustees or the Plan.

The Board of Trustees’ procedures for changing, enhancing, reducing, or eliminating benefits are

enumerated in the Plan Amendment Procedures section beginning on page 87.

To assist you in obtaining Plan benefits, the Trustees have established an Administrative Office. However;

any final decision concerning an individual’s qualification for benefits under this Plan is made exclusively

by the Board of Trustees. Again, any representations, either oral or written, made by employees of the

Administrative Office, or by employer or union employees or representatives, will not be binding upon the

Board of Trustees or the Plan.

This booklet was prepared for your assistance. Take time to read it and become familiar with its contents. If

you have any questions concerning your benefits or need assistance, please call or write the Administrative

Office. The address, phone number and office hours are shown on the following page.

Sincerely,

Board of Trustees

Board of Trustees July 1, 2014

Labor Trustees

Scott Brain, Co-Chairman

Jaime Barton

Marcos Enriquez.

Jesse Mendez, Jr.

Management Trustees Michael Rodriquez, Co-Chairman

Scott Berg

Enrico Prieto

Marc Tarrosa

Administrative Office

Zenith American Solutions

5417 Peck Rd.

Arcadia, California 91006-5847

Telephone: (626) 444-4600

Fax (626) 258-4090

Office Hours: Monday through Friday (excluding holidays)

8:00 a.m. to 4:00 p.m.

Mailing Address:

P.O. Box 968

Monrovia, California 91017-0968

Notice To Spanish-Speaking Participants

Noticia A Los Participantes De Habla Hispana Este folleto contiene un sumario en ingles describiendo sus derechos y beneficios bajo el

Plan de Cuenta de Cement Masons del Sur de California.

Si usted tiene dificultad en entender alguna parte de este folleto, o necesita mayor

información, contacte al Administrador del Plan a la siguiente dirección:


5417 Peck Rd.


Teléfono: (626) 444-4600

Fax (626) 258-4090

Las Horas de oficina son:

8:00 a.m. a las 4:00 p.m.

de Lunes a Viernes

Direccionamiento que envia

P.O. Box 968


10

Assistance

This booklet contains a summary of your Plan rights and benefits under the Cement Masons Southern

California Health & Welfare Plan.

If you have difficulty understanding any part of this Summary Plan Description (SPD), or if you have

any questions, please contact the Administrative Office for assistance. They are here to help you obtain

all of the benefits to which you are entitled. Below is the necessary information to contact them.

Cement Masons Southern California Health & Welfare Plan


5417 Peck Rd.


Telephone: (626) 444-4600

Fax (626) 258-4090

Office Hours: Monday through Friday

8:00 a.m. to 4:00 p.m.

Mailing Address:

P.O. Box 968


Keep Your Records Current

Notify the Administrative Office immediately in writing of any change of address or if you have a

change in dependents. For example:

You get married

You have a baby

You get divorced

You adopt or become a legal guardian of a child

11

Table of Contents

Eligibility ___________________________________________________________________ 15

Active Employees Eligibility _________________________________________________________ 15

Building an Eligibility Reserve _______________________________________________________ 15

Hours Self-Payment Program ________________________________________________________ 16

Reciprocal Contributions ___________________________________________________________ 16

Delinquent Employer Contributions __________________________________________________ 17

Non-bargaining Full-Time Office Employees of Employer _________________________________ 17

Working Employers _______________________________________________________________ 17

Enrollment ______________________________________________________________________ 17

Eligible Dependents _______________________________________________________________ 18

Extended Eligibility for Dependents ___________________________________________________ 19

Termination of Coverage ___________________________________________________________ 19

Disabled Employees and Workers Compensation ________________________________________ 20

Coverage During an FMLA Leave of Absence ___________________________________________ 20

COBRA Continuation Coverage ______________________________________________________ 21

Self-Pay _________________________________________________________________________ 26

California Insurance Marketplace (California Exchange) __________________________________ 26

Military Service (USERRA) __________________________________________________________ 26

Certificate of Group Health Plan Coverage _____________________________________________ 28

Choosing Medical Coverage____________________________________________________ 29

General Discussion ________________________________________________________________ 29

HMO Medical Coverages – Health Net & Kaiser _________________________________________ 29

PPO Medical Coverage _____________________________________________________________ 29

A Brief Synopsis of the Five Medical Coverages _________________________________________ 30

Questions and Answers About the Five Medical Coverages ________________________________ 31

Enrollment Procedures _____________________________________________________________ 32

Annual Open-Enrollment Period _____________________________________________________ 33

Health Net HMO Medical Coverage _____________________________________________ 34

Basic Information _________________________________________________________________ 34

Newborn Dependent Children _______________________________________________________ 34

12

Health Net Website _______________________________________________________________ 35

Complaint Procedure, Claims Appeal and Arbitration ____________________________________ 35

Kaiser Permanente HMO Medical and Prescription Drug Coverage ____________________ 36

Basic Information _________________________________________________________________ 36

Newborn Dependent Children _______________________________________________________ 36

Kaiser Website ___________________________________________________________________ 36

Complaint Procedure, Claims Appeal and Arbitration ____________________________________ 37

PPO Medical Coverage ________________________________________________________ 38

Introduction _____________________________________________________________________ 39

Prudent Buyer vs. Non-Preferred Providers ____________________________________________ 40

Benefits for Out-of-Network (non-PPO) Providers _______________________________________ 40

Summary of Prudent Buyer Plan Provisions ____________________________________________ 41

Summary of Plan Benefits When Using a Prudent Buyer Preferred Provider __________________ 41

Summary of Plan Benefits When Using a Non-Preferred Provider___________________________ 42

Commonly Asked Questions and Answers _____________________________________________ 42

Online Internet Website – Anthem Blue Cross __________________________________________ 44

Summary of Medical Benefits _______________________________________________________ 45

Deductible _______________________________________________________________________ 45

Annual Medical Benefit Maximum ___________________________________________________ 46

Co-payments _____________________________________________________________________ 46

Prior Authorization Review and Approval ______________________________________________ 46

Covered Expenses _________________________________________________________________ 47

Extension of Coverage - Total Disability _______________________________________________ 53

PPO Medical Coverage Exclusions ____________________________________________________ 54

General Provisions Relating to the PPO Medical Coverage ________________________________ 58

Definitions Applicable to the PPO Medical Coverage _____________________________________ 58

Subrogation ______________________________________________________________________ 63

When Do I Report Claims? __________________________________________________________ 66

Payment to Providers ______________________________________________________________ 66

Keeping Records of Medical Expenses _________________________________________________ 66

Coordination of Benefits ___________________________________________________________ 66

Health Care Fraud Information ______________________________________________________ 69

Prescription Drug Coverage ____________________________________________________ 70

13

Walk-In Pharmacy Coverage ________________________________________________________ 70

Mail Order Pharmacy Coverage (for Maintenance Prescriptions) ___________________________ 71

Covered Drugs and Products ________________________________________________________ 72

Exclusions and Limitations __________________________________________________________ 73

Specialty Pharmacy Mail Order Program _______________________________________________ 73

OptumRx Website_________________________________________________________________ 75

Delta Dental PPO Coverage ____________________________________________________ 76

A Brief Overview __________________________________________________________________ 76

Delta Dental PPO Coverage _________________________________________________________ 76

Delta Dental PPO Covered Services ___________________________________________________ 77

How to Use the Delta Dental PPO Program _____________________________________________ 77

Timely Submission of Claims ________________________________________________________ 78

Complaint Procedure and Claims Appeal and Arbitration _________________________________ 78

Vision Care _________________________________________________________________ 79

A Brief Overview __________________________________________________________________ 79

What are the Benefits? _____________________________________________________________ 79

Complaints ______________________________________________________________________ 80

Life Insurance & Accidental Death & Dismemberment Benefits _______________________ 81

Eligibility ________________________________________________________________________ 81

Certificate of Coverage _____________________________________________________________ 81

Schedule of Benefits _______________________________________________________________ 81

Designation of Beneficiary __________________________________________________________ 82

Claim Forms _____________________________________________________________________ 82

Appeals To Union Labor Life _________________________________________________________ 82

Accidental Death & Dismemberment (AD&D) Benefits (24 Hour Coverage) ___________________ 83

General Plan Information _____________________________________________________ 84

Definitions _______________________________________________________________________ 84

Overpayments ___________________________________________________________________ 86

Financing of the Plan ______________________________________________________________ 86

No Guarantee of Tax Consequences __________________________________________________ 86

Governing Benefit Documents _______________________________________________________ 86

Plan Amendment Procedures _______________________________________________________ 87

Disclosure Information ________________________________________________________ 88

14

Claims and Appeals Rules _____________________________________________________ 91

Introduction _____________________________________________________________________ 91

Pre-Service Claims ________________________________________________________________ 91 PPO Medical Coverage _____________________________________________________________________ 92 Prescription Drug Program __________________________________________________________________ 92 Independent Medical Opinions ______________________________________________________________ 92

Concurrent Claims ________________________________________________________________ 93

Post-Service Claims ________________________________________________________________ 93

Eligibility Issues ___________________________________________________________________ 94

Exhaustion of the Appeals Process ___________________________________________________ 95

Appeals Information Pertaining to Pre-Service Claims, Concurrent Claims and Post-Service Claims 95

Some Questions Common to All Claims and Appeals _____________________________________ 97

Notice to Participants ______________________________________________________________ 98

Your ERISA Rights ____________________________________________________________ 99

Notice of Privacy Practices (HIPAA) _____________________________________________ 101

15

Eligibility

Eligibility for coverage for active employees is based on your working a certain minimum number of

hours with one or more employers who contribute to the Plan based on your hours of employment, as

explained below.

Active Employees Eligibility

Employees working for employers contributing to the Plan are eligible for benefits as follows:

TIER 2

If you are an active employee, you and your eligible dependents are eligible for medical, prescription

drug, dental, vision, and life insurance Plan benefits if you work at least 375 hours in a specified three-

month period for one or more employers who contribute to the Plan based on your hours of

employment.

If you work at least 375 hours during:

You and your dependents are covered for

medical, prescription drug, dental, vision, and

life insurance benefits from:

March through May August 1 through October 31

June through August November 1 through January 31

September through November February 1 through April 30

December through February May 1 through July 31

TIER 1

If you work 275 - 374 hours in a specified three-month period, or if your combined work hours during

that period and the hours in your eligibility reserve equal 275 - 374, you and your eligible dependents

are eligible to participate in the medical, prescription drug and life insurance Plan benefits.

If you work at least 275 hours but less than

375 hours during:

You and your dependents are covered for

medical, prescription drug and life insurance

benefits (no dental or vision) from:

March through May August 1 through October 31

June through August November 1 through January 31

September through November February 1 through April 30

December through February May 1 through July 31

IMPORTANT: If you do not have the required hours to maintain your medical/prescription

drug/life insurance eligibility (375 hours), all hours in your reserve account will be canceled.

Building an Eligibility Reserve

If you work more than 375 hours in a specific quarter, the hours you work over 375 are credited to a

reserve account until you accumulate 150 hours from all periods. You can use these reserve hours as

credit toward the next eligibility quarter unless your combined credited hours (hour worked and

reserve hours) are less than 275, in which case your credit reserve is canceled. See the following

examples in the box below.

16

Eligible

Work Hours

and

Contributions

Paid

+ Reserve

Account

= Total

Hours

Eligibility

Hours

Requirement

375 or 275

Reserve

Account

Eligible?

500

400

250

250

0

0

125

25

500

400

375

275

375

375

375

275

125

150

25

0

Yes, All Benefits

Yes, All Benefits

Yes, All Benefits

Yes, Medical, Drug,

Life Only

Hours Self-Payment Program

If an employee is within 25 hours or less of working the required minimum quarterly hours for either

Tier 1 or Tier 2 coverage, the employee may self-pay for up to a maximum of 25 hours based on the

current employer contribution rate. The employer contribution rate is currently $7.27 per hour but is

subject to change. Any quarter in which an employee uses a self-payment to maintain eligibility will

run concurrently with COBRA continuation coverage and will reduce the maximum COBRA coverage

period.

Reciprocal Contributions

The Cement Masons Southern California Health & Welfare Plan participates in the International

(OP&CMIA) Reciprocity Agreement. The International Reciprocity Agreement allows employees to

travel outside the geographic area covered by this Plan and work for employers with collective

bargaining agreements with other OP&CMIA unions, and have their Health & Welfare contributions

sent to the Cement Masons Southern California Health & Welfare Plan.

The reason for this Agreement is that it is recognized that some employees may fail to qualify for

health coverage because they travel out of the geographic area covered by the Plan in which their home

union participates. Therefore, in accordance with the International Reciprocity Agreement,

contributions received from another health plan that participates in the International Agreement will be

credited to the employee as hours worked. This is called “money follows the employee.”

Action on your part is required to have out-of-area contributions paid on your behalf sent to the

Cement Masons Southern California Health & Welfare Plan. This is called “Travelers’ Duties” and

these duties are detailed in the International Reciprocity Agreement, a copy of which can be obtained,

on request, from the Administrative Office.

In short, when working outside the jurisdiction of your home local, you need to report to the Business

Manager or Business Agent of the Visited Local each time you work in the jurisdiction of the Visited

Local. Submit a written request to the Business Manager or Business Agent requesting to have

employer contributions forwarded to your home Plan. For members of Local 500 and 600, the home

Plan is the Cement Masons Southern California Health and Welfare Plan.

The Administrative Office, Zenith American Solutions, can assist you in making arrangements to have

employer contributions transferred from the plan sponsored by the Visited Local to this Plan, or from

this Plan to another plan.

The International Reciprocity Agreement limits reciprocated employer contributions to 12 consecutive

months. There may be exceptions to this limit if approved by both the Visited and the home Plan.

Recognizing that health & welfare plans usually have different employer contribution rates, the

Trustees of this Plan have devised a formula for the crediting of hours to this Plan. As of the effective

date of this Summary Plan Description, the employer contribution rate is $7.27 per hour.

17

By way of example, if an employee works 150 hours in a reciprocal area where the hourly health

contribution rate is $6.10 per hour, and the employee’s home local is either Local 500 or Local 600,

with a current hourly Plan contribution rate of $7.27, the hours credited would be pro-rated as follows:

Participating local rate of $6.10 = 83.9%

Home local rate of $7.27

150 hours x 83.9% = 126 (rounded) credited hours under this Plan.

If you elect to reciprocate contributions to another plan, this Plan will reciprocate to the other plan the

current contribution rate in effect under the Local 500 and 600 collective bargaining agreements.

Delinquent Employer Contributions

If your employer fails to either submit a contribution report and/or pay all or a portion of the

contributions reported to the Plan for hours you worked, you will be granted hours up to a maximum of

five consecutive months only. Further, if your employer has not submitted an employer report of hours

to the Plan, but if you provide proof through employer check stubs of having worked with the

employer, you will be given credit in the same manner as above.

Non-bargaining Full-Time Office Employees of Employer

All full time non-bargaining office employees of any employer signatory to a collective bargaining

agreement are eligible to participate in this Plan, provided that all such employees of the employer

must be covered (unless such employee is covered under another group health plan.) “Full time

employee” means an employee working a minimum of 30 hours per week. Full time employees

covered under this provision are offered coverage through the HMOs only. The employer shall select

either HMO plus prescription drug coverage or HMO plus prescription drug, vision and dental

coverage. Those employees will not be eligible for life insurance or accidental death and

dismemberment coverage. An employer must sign a non-bargaining participation agreement with the

Board and the employer must remit timely payments to the Plan in order for those employees to be

covered under this provision.

Working Employers

All working employers signatory to a collective bargaining agreement are eligible to participate in this

Plan. The employer shall select either; medical plus prescription drug coverage or medical plus

prescription drug, vision and dental coverage. The employer shall remain in the same coverage

selection for at least 12 months or until the next open enrollment period. An employer must sign a

participation agreement with the Board and the employer must remit timely monthly payments to the

Plan in order for the employer to be covered under this provision. If the employer elects to discontinue

coverage or fails to pay the monthly premium, then the employer shall be ineligible to participate in the

Plan for a minimum of 12 months.

Enrollment

In order to avoid delay in processing your claims, an enrollment form must be on file at the

Administrative Office.

As an employee, your enrollment in the Plan is automatic once you have accumulated the required

number of hours to be eligible for Plan benefits. Upon initial eligibility, you must select the medical

coverage under which you want to be covered (Health Net HMO, Kaiser Permanente HMO or the PPO

18

Medical Coverage). If you do not select a medical coverage, you will be covered under the PPO

Medical Coverage. If you elect coverage under either Health Net or Kaiser, their separate enrollment

forms must be completed in addition to the Plan’s enrollment form.

If you wish to cover your dependents, you must submit an enrollment form listing all of your

dependents to be covered. You must also submit proof of dependent status such as a marriage

certificate, birth certificate, adoption papers, court decrees of financial responsibility, etc.

Newly acquired dependents must be enrolled within 30 days of the date acquired in order to be covered

as of the date acquired. If not enrolled within 30 days, these dependents will be eligible on the first

day of the month following the date the enrollment form is received at the Administrative Office.

The Plan does not limit enrollment to an annual open enrollment period or require special enrollment.

However, to ensure proper claims service, a new enrollment form should be filed for each additional

dependent as soon as the additional dependent becomes eligible. The Plan will not process your claims

until a complete enrollment form and all required documentation has been received.

It is also in your best interests to file a new enrollment form if you change your address or wish to

make a change in your beneficiary designation.

Eligible Dependents

Dependents are defined as:

Your legal spouse

Children under age 26, including your natural children, legally adopted children or children placed

for adoption, step-children and foster children. In addition, children placed by an authorized

placement agency, judgment, decree or court order, who reside with you or your spouse and for

who you or your spouse is the legal guardian, are also covered.

Children age 26 and over, if the child is chiefly dependent upon you for support and maintenance

and your child is incapable of self-sustaining employment because of total and permanent

disability. The disability of the child must have commenced prior to attaining age 26. Coverage is

not automatic; you must submit proof to the Administrative Office at least 31 days prior to the

child’s attainment of age 26.

In accordance with federal law, the Plan also provides coverage to certain dependent children (called

alternate recipients) if directed to do so by a Qualified Medical Child Support Order (QMCSO) issued

by a court or state agency of competent jurisdiction. Contact the Administrative Office for details.

You and your dependents may obtain, without charge, a copy of the procedures governing medical

child support orders and determinations from the Administrative Office.

Domestic partners, either same sex or opposite sex, who are registered with the State of California are

also eligible dependents under the Kaiser, Health Net and Delta Dental Coverages only. You must

submit proof of registration of your domestic partner with the State of California to the Administrative

Office. The cost of providing coverage to the domestic partner is taxable income to the employee if

the domestic partner does not qualify as the employee’s dependent as defined in Section 152 of the

Internal Revenue Code.

Upon dissolution, divorce, or annulment, a spouse ceases to be an eligible dependent. In order to avoid

payment of claims for ineligible dependents, which you will have to repay to the Plan, you should

notify the Administrative Office of a dissolution, divorce, legal separation or annulment as soon as it

occurs.

19

The Plan requires that you submit proof of your dependents (i.e., a copy of a marriage certificate for a

spouse, a copy of a birth certificate for a child and a copy of a decree of adoption for an adopted child).

You must also fill out an enrollment/beneficiary card listing dependents and it must be on file with the


Extended Eligibility for Dependents

Dependents, under some circumstances, may continue medical and prescription drug coverage after the

death of the employee.

For eligible dependents to qualify for the following benefits, the deceased employee must have been

eligible for health and welfare benefits for six eligibility quarters during the five years immediately

preceding death. Dependents of active employees who had ten years of pension eligibility credit under

the Cement Masons Southern California Pension Trust and who received either a Spouse’s Pension or

the 36-month Pension Benefit from the Cement Masons Southern California Pension Trust may be

eligible for this extended eligibility. Medical and prescription drug benefits can be extended subject to

the following requirements and limitations:

1. The dependent must authorize a self-payment deduction from the monthly check payable by the

Cement Masons Southern California Pension Trust. The amount of this self-payment is

periodically reviewed by the Trustees for adequacy and may be modified. If increased, the

dependent can elect to continue coverage by paying the higher self-payment amount or discontinue

coverage; and

2. Dependents must select an HMO (Health Net or Kaiser) when they first become eligible provided

they live within an HMO service area. Service areas are specific to the HMO and are explained in

the descriptive literature and Evidence of Coverage Certificate provided by each HMO; and

3. Dependents will receive medical benefits for a maximum of 12 months. Medical benefits will

terminate upon the spouse’s remarriage or at the end of 12 months, whichever occurs first. If a

dependent becomes eligible for Medicare during this 12 month period, he or she must enroll in

Parts A and B of Medicare to continue to be eligible for benefits under this Plan; and

4. Dependents will receive prescription drug benefits for the duration of the Spouse’s Pension or 36-

month Pension Benefit from the Cement Masons Southern California Pension Trust. On cessation

of these pension benefits, the prescription drug benefit will terminate. Prescription drug benefits

will terminate on remarriage for spouses. Marriage by dependent children will also terminate

benefits; and

5. Extended eligibility as herein provided will end on the first of the month for which the monthly

self-payment is discontinued by the Pension Trust as a result of a dependent’s request for

revocation.

Termination of Coverage

An employee’s coverage will terminate on the earliest date of any of the following.

You enter military service.

On the date you lose eligibility.

Termination of any coverage or specific benefit on the effective date established by the Board of

Trustees. For example, a Plan or specific benefit is terminated.

You work in non-covered service, which is defined as employment or self-employment in the

same industry, craft or trade covered by the collective bargaining agreement, including such work

in the geographic jurisdiction of any collective bargaining agreement requiring contributions to the

Cement Masons Southern California Health and Welfare Plan or any other health and welfare plan

sponsored by the Operative Plasters’ and Cement Masons International Association of the United

States and Canada, AFL-CIO (“Related Plan”), if such employment or self-employment is not

subject to a collective bargaining agreement requiring contributions to this Plan or a related plan.

Employment or self-employment in a non-bargaining position for a signatory employer to a

20

collective bargaining agreement requiring contributions to this Plan or a related plan is not

included within the definition of non-covered service. In the event you engage in non-covered

service, you and your dependents will lose eligibility for coverage under this Plan as of the first

day of the calendar month following the month in which you first engaged in the non-covered

service and any remaining hours in your eligibility reserve will also be immediately canceled and

terminated.

The benefits for a dependent will terminate on the earliest date of any of the following.

When the employee’s eligibility terminates.

When the dependent no longer meets the definition of an eligible dependent as provided on

page 18.

When the dependent enters military service.

Disabled Employees and Workers Compensation

If you (an eligible employee) are unable to work in covered employment as a result of a non-

occupational or occupational injury, you may be entitled to extend eligibility up to four eligibility

periods (12 months) for Tier 1 coverage (medical/prescription drug and life/AD&D benefits). In order

to be eligible for this benefit, you must meet all of the following requirements.

You must give written notice of your disability to the Administrative Office within 30 days from

the date you cease to be eligible for Plan benefits. For example, if you lose eligibility on

November 1, you must apply for extended eligibility before December 1 to be considered for this

benefit.

You must provide proof, satisfactory to the Board of Trustees, certifying your disability and the

time period of disability. You will be entitled to a maximum of 92 credited hours per month for

each month of satisfactory evidence of disability you provide up to a maximum of four eligibility

periods (12 months).

After the first disability extension, you will not be eligible for a further extension until you have been

eligible for eight continuous eligibility periods (24 months) as explained under the previous section

entitled “Active Employees Eligibility.” This applies to all disability extensions granted after the first

extension. COBRA periods are excluded for the purpose of determining eligibility under this

provision.

To determine eligibility for this benefit, you may be required to undergo a physical examination by a

medical doctor chosen by the Plan. For more information, contact the Plan’s Administrative Office.

Coverage During an FMLA Leave of Absence

If your employer approves you taking a leave under the terms of the Family and Medical Leave Act of

1993 (FMLA), you and your eligible dependents will continue to be covered under this Plan provided

you were eligible when the leave began and your employer makes the required contributions during

your leave. Coverage will be continued while you are absent from work on an FMLA leave as if there

were no interruption of active employment and as if you were continuing to work the number of hours

required for coverage.

Coverage will continue until the earlier of the expiration of the FMLA leave or the date you give notice

to your employer that you do not intend to return to work at the end of the FMLA leave or the date

your employer stops making the required contributions. If you do not return to work after the end of

the FMLA leave, your employer may require you to reimburse it for the contributions it made to the

Plan on your behalf during the leave.

21

It is not the role of the Plan to determine whether or not an employee is entitled to leave with

continuing medical coverage under the Act. Any disputes regarding entitlement to FMLA leave must

be resolved between you and your employer.

COBRA Continuation Coverage

Introduction

The Consolidated Omnibus Budget Reconciliation Act of 1985, as amended (COBRA), requires that

this Plan offer you and your eligible dependents the opportunity for a temporary extension of health

care coverage at group rates in certain instances (called “qualifying event”), when coverage under the

Plan would otherwise end. Continued coverage under COBRA applies to the health care benefits

described in this booklet.

The benefits under COBRA are the same as those covering people who are not on continuation

coverage. You should also keep in mind that each individual entitled to coverage as the result of a

qualifying event has a right to make his or her own election of coverage. For example, your spouse or

other covered dependent may elect COBRA coverage even if you do not.

IMPORTANT, the continuation of health care coverage as explained below requires that you

must make a timely payment each month to the Administrative Office within the prescribed time

frame explained below. Whether or not the Administrative Office bills for COBRA coverage, it

is your responsibility to make monthly COBRA payments on time. If you don’t make your

payment on time, your coverage will end.

Under the law, the election of COBRA rights must be made in writing within 60 days of the later of:

(1) the date the COBRA notice is sent to you or (2) the date your regular Plan coverage terminates.

You must make your first payment to the Plan for COBRA continuation coverage within 45 days after

you first elect COBRA coverage.

When you make your first COBRA payment, you must pay for all months which are then due.

Payment for subsequent months are due on the first of each month, and your COBRA coverage will

terminate for non-payment if payment is not received in the Administrative Office within 30 days. For

example, a payment for the coverage month of January is due January 1st, and if payment is not

received in the Administrative Office by January 30th

, your COBRA continuation coverage will end

effective January 1. Thus, there is no coverage for January.

You, your spouse and dependents should read this section carefully. The following information

explains both your rights and your obligations under the COBRA continuation coverage provisions. If

you have any questions, contact the Administrative Office. The phone number and address are printed

in the front of this booklet.

At a Glance - Qualifying Events That Entitle You To COBRA Coverage

The following table may be of assistance:

22

If you Lose Coverage Because

of This Reason (a “qualifying

event”)

These People Would Be Eligible

for COBRA Coverage

COBRA Coverage Maximum

Length (measured from the

date normal Plan coverage is

lost)

Your employment terminates* You, your covered spouse and

covered dependents

18 months**

Your working hours are reduced You and your covered spouse and

covered dependents

18 months**

You die Your covered spouse and covered

dependents

36 months

You divorce Your covered spouse and covered

dependents

36 months

Your dependent child(ren) no

longer qualifies as an eligible

dependent

That covered dependent 36 months

You become entitled to Medicare Your covered spouse and covered

dependents

36 months

* For any reason other than gross misconduct (and including military leave and approved leaves granted

according to the Family and Medical Leave Act).

** Continued coverage for up to 29 months from the date of the initial event may be available to those who,

during the first 60 days of continuation coverage, become totally disabled within the meaning of Title II, or

Title VXI of the Social Security Act. This additional 11 months is available to employees and enrolled

dependents if notice of disability is provided within 60 days after the Social Security determination of

disability is issued and before the 18-month continuation period expires. The cost of the additional 11

months of coverage will increase to 150% of the full cost of coverage. Additionally, coverage can be

extended for eligible dependents to a maximum of 36 months in the event of death or Medicare entitlement

of the employee, or divorce or legal separation.

If you are enrolled in an HMO, you can elect Cal-COBRA from your HMO for an additional 18 months. In

no event will Federal COBRA and Cal-COBRA exceed 36 months total.

Employees

If you have established eligibility under the Plan, you have the right to choose this continuation

coverage if you lose health coverage under this Plan for any of the following reasons:

You lose your Cement Masons Southern California Health & Welfare Plan coverage because

of a reduction in your number of hours of covered employment;

Your employer has filed for bankruptcy reorganization under Chapter 11 of the United States

Bankruptcy Code; or

Your employment is voluntarily or involuntarily terminated (for reasons other than gross

misconduct on your part) with a contributing employer. For employees on a Family Medical

Leave Act (FMLA) leave of absence, the qualifying event occurs when the employee fails to

return to work at the end of the FMLA leave, or if earlier, when the employee gives notice to

the employer that the employee will not be returning to work. The period of COBRA

coverage begins on the date that coverage is lost due to the employee’s failure to return to

work from the leave granted under FMLA.

Spouses

If you are the legal spouse of an employee covered for health care benefits under this Plan, you have

the right to choose continuation coverage for yourself if you lose health coverage under this Plan for

any of the following reasons:

23

18-month maximum continuation coverage period:

Termination of your spouse's employment (for reasons other than gross misconduct) or

reduction in your spouse's hours of employment; or

If you are enrolled in an HMO, you can elect Cal-COBRA from your HMO for an additional

18 months. In no event will Federal COBRA and Cal-COBRA exceed 36 months total.


Covered employee's death;

Divorce from your spouse;

Your spouse becomes eligible for Medicare; or

Your spouse's employer files for Chapter 11 reorganization.

If you are enrolled in an HMO, you can elect Cal-COBRA from your HMO for an additional

18 months. In no event will Federal COBRA and Cal-COBRA exceed 36 months total.

Children/Dependent

If you are a dependent child of an employee covered for health care benefits under this Plan on the day

before the qualifying event for that employee, you have the right to choose continuation coverage for

yourself if you lose health coverage for any of the following reasons:


Termination of your parent's employment (for reasons other than gross misconduct) or

reduction in your parent's hours of employment;


Parent's divorce;

Covered parent's death;

The parent covered under the Cement Masons Southern California Health & Welfare Plan

becomes eligible for Medicare;

The dependent ceases to meet the definition of an eligible dependent under the Plan rules (for

example, a child reaches age 26); or

The parent's employer files for Chapter 11 reorganization.

Notification

An employer must notify the Administrative Office of your death, termination of employment,

reduction in hours of employment or Medicare entitlement no later than 60 days after your loss of

coverage due to one of these events. However, you or your family should also notify the

Administrative Office of any of these events, in order to avoid confusion on your status. You or your

eligible dependents are responsible for informing the Administrative Office of a divorce, or a child

losing dependent status under the Plan within 60 days of the date of the event. If the Administrative

Office is not notified within the 60-day time limit, your dependents will lose the right to elect COBRA.

A qualifying event means the reason you are losing eligibility under one of the situations described

above, such as termination of an employee's employment. Another example of a qualifying event for a

spouse would be divorce. For a dependent, he or she may attain age 26 and no longer be an eligible

dependent under Plan rules. If you do not notify the Administrative Office by the end of that 60-day

period, your dependents will not be entitled to continuation coverage.

When the Administrative Office is notified that one of these events has happened, within 14 days the

Administrative Office will notify you that you have the right to choose continuation coverage. This

notice will also explain the monthly payment you must make to continue your health coverage. Under

the law, the election of COBRA rights must be made in writing within 60 days of the later of: (1) the

date the COBRA notice is sent to you or (2) the date your regular Plan coverage terminates.

24

Children born or adopted during the period of COBRA continuation coverage are considered

dependents, the same as those of active eligible employees. Remember, you must enroll your newborn

or adopted child by notifying the Administrative Office within 60 days of acquiring the new

dependent. Contact the Administrative Office for the necessary forms to enroll this new dependent.

If you do not choose COBRA continuation coverage by making the election and self-payment,

coverage under this Plan will end. You will not be able to elect COBRA Continuation Coverage at a

later date.

Length of Coverage

A qualified beneficiary is entitled to 18 months of continued coverage if the qualifying event is

termination of employment or a reduction of employment hours. This may be extended 11 months, for

a total of 29 months if at the time of the qualifying event, an employee or his dependent(s) are

determined to be disabled under the Social Security Administration. To be eligible for the special 11-

month extension, the disabled individual must notify the Administrative Office within 60 days

following the later of the date on which the individual receives the initial COBRA notice following a

qualifying event or the date Social Security determines that the individual is disabled before the end of

the initial 18-month period of COBRA continuation coverage. Any other qualifying event increases the

coverage term for qualified beneficiaries to 36 months (maximum).

If another qualifying event occurs during the 18-month period of continued coverage (29 months in

case of a disability extension), the spouse or dependent children may be entitled to an additional 18-

month extension for up to 36 months (maximum). In no case may the total amount of continued

coverage be more than 36 months.

If you are enrolled in an HMO, you can elect Cal-COBRA from your HMO for an additional 18

months. In no event will Federal COBRA and Cal-COBRA exceed 36 months total

Cancellation of Your COBRA Coverage

Your COBRA coverage may be terminated prior to the end of the 18 or 36 months for any of the

following reasons:

The signatory employers to the Plan no longer provide group health coverage benefits to any of its

employees;

Payment for COBRA continuation coverage is not made in a timely manner when due;

You become covered for benefits under another group health plan provided that plan does not

contain any exclusions or limitations with respect to any pre-existing conditions;

Coverage has continued for the maximum 18, 29 or 36 month period, measured from the date

coverage is lost;

The Board of Trustees terminates a particular coverage for all participants in the Plan. If coverage

is changed or eliminated, persons on COBRA have the right to choose among the options offered

to similarly situated non-COBRA beneficiaries;

You request that your COBRA coverage be canceled. If you request termination, the coverage will

generally end on the first day of the month following completion of a 30-day period beginning on

the date the Administrative Office receives your written notice. For example, if the notice is

received on May 15, the 30-day period would end on June 15, and the coverage would end July 1;

You become entitled to Medicare benefits after COBRA coverage has been elected;

You are no longer disabled. If a qualified beneficiary is determined to no longer be disabled under

the Social Security Act before the end of the 29-month maximum coverage period, COBRA

coverage may be terminated in the month that is more than 30 days after that determination is

made; or

This Plan is terminated.

25

You do not have to show that you are in good health to choose continuation coverage. COBRA

continuation coverage does not apply to life insurance benefits.

Benefits and Cost of Coverage

The cost of COBRA continuation coverage is based on the medical coverage (Health Net, Kaiser or

PPO Medical Coverage) in which you are enrolled as of the date of the qualifying event. You also have

the opportunity to choose between core-only coverage or the whole array of Plan benefits (core-plus)

with the exception of life insurance.

The premium (what you pay) for disabled, qualified participants may be 150% of the Plan cost during

the 19th through 29th months of coverage. You also have the opportunity to choose between core-only

coverage or the whole array of Plan benefits (core-plus).

Core only coverage provides medical and prescription drug benefits (under the coverage selected).

This is the least expensive continuation coverage. Alternately, you can choose core-plus coverage

which adds benefits for dental and vision care. The benefits provided on all COBRA continuation

coverages are as explained in this booklet.

During COBRA continuation coverage, you can change your choice of medical coverages during the

annual open enrollment period.

You should write or phone the Administrative Office to receive a copy of the cost sheet which

provides the continuation coverage rates that apply to you. The phone number and address are shown

in the front of this booklet.

Paying for COBRA Coverage

The cost of COBRA continuation coverage which you must pay is the cost of that coverage for the

Plan, for the period of the continuation coverage, for similarly situated participants who have not had a

qualifying event, plus a 2% administrative fee. (If you are eligible for 29 months of continued

coverage due to disability, the Plan charges 150% of the cost of that coverage during the 19th

to 29th

months of coverage). The following rules apply in making your COBRA payments.

It is easiest to make your first payment when you file your COBRA election form, that is, within

60 days from the date your Plan coverage would otherwise end. In no event may your initial

payment be made later than 45 days from the date you mail your signed election form to the

Administrative Office. By that time, you must have paid for the period from the date your group

coverage ended (and COBRA coverage began) through the current month.

All subsequent payments after that first payment will be due on the first day of each month for that

month’s coverage. For example, a payment for the coverage month of January is due January 1st,

and if payment is not received in the Administrative Office by January 30, your COBRA

continuation coverage will end back on January 1. Thus there is no coverage for January.

Whether or not the Administrative Office sends monthly bills for COBRA coverage, it is your

responsibility to see that your payment is received by the Administrative Office on or before the

due date.

There is a 30-day grace period for all subsequent payments (for example, the end of the grace

period for payment for coverage in the month of January is January 30). However, if you have a

claim during a month for which you have not paid your premium. The claim will not be paid until

the Administrative Office receives your payment for the month.

The Plan allows a third party to pay your premium, such as a family member, hospital, or your

employer.

26

The amount charged for COBRA premiums is generally reviewed at least once a year and is subject to

change. You will be notified by the Administrative Office if the amount of your monthly COBRA

payment changes. In addition, if the benefits change for active employees, your coverage will change

as well.

Dependent/Spouse Change or Address Change

Contact the Administrative Office if you have a change in marital status or if you or your spouse

change addresses.

COBRA and USERRA

If an employee loses eligibility under the Plan because the employee enters the Uniformed Services,

under the Uniformed Services Employment and Reemployment Rights Act (USERRA), the employee

and the employee’s eligible dependents may be eligible for continuing health coverage under the Plan

for up to 24 months (or, if ending earlier, the period beginning on the day that the uniformed service

leave begins and ending on the day after the employee fails to return to employment within the time

allowed by USERRA) upon timely election and payment of the applicable premium cost (the same

premium cost that applies to COBRA continuation coverage). This right is in addition to the right to

COBRA continuation coverage. Employees and dependents eligible for this USERRA mandated

continuation coverage may elect continuation coverage within 60 days of the date coverage is

otherwise lost under the Plan due to departure, in which case the employee and the employee’s eligible

dependents who so elect will be allowed retroactive reinstatement of uninterrupted coverage to the date

coverage is otherwise lost under the Plan if the employee and the employee’s eligible dependents

timely elect continuation coverage and pay all unpaid premium amounts due within the 45-day period

following the date of the election.

Self-Pay

If a participant loses eligibility and the loss of eligibility does not qualify as a COBRA qualifying event,

then the participant shall be allowed to self-pay for continued coverage for a maximum of 18 months.

Notwithstanding anything in this summary plan description to the contrary, this Self-Pay option shall not be

available for a participant who works for a non-signatory Employer or for a participant who has had his

employment terminated due to gross misconduct.

California Insurance Marketplace (California Exchange)

In addition to COBRA continuation coverage, there may be other options for you and your family. The

California Insurance Marketplace (California Exchange) offers many health plans to choose from. Open

enrollments will be held generally from October 15 through December 7 for coverage effective the

following year. After open enrollment ends, you may have special enrollment rights under certain

circumstances. More information is available from the California Exchange website at

www.coveredca.com. Also, you might be eligible for a tax credit that lowers your monthly premium if you

are not eligible for coverage through the Plan.

Note: If you decide to enroll in COBRA coverage and then drop your COBRA coverage, you can only

enroll in Exchange coverage during the Exchange open enrollment period, effective January 1.

Military Service (USERRA)

The Uniformed Services Employment and Reemployment Rights Act of 1994 (USERRA) provides

protections to individuals who are eligible individuals of the Uniformed Services. Uniformed Services is

defined as the Armed Forces, the Army National Guard and the Air National Guard when engaged in active

27

duty for training, inactive duty training, or full-time National Guard duty, and the commissioned corps of

the Public Health Services.

Military Leaves of Absence for a Period Less Than 31 Days.

USERRA provides that if an employee is on a military leave of absence from his employment, and the

period of military leave is less than 31 days, he will continue to be eligible for health care coverage

under this Plan during the leave with no self-payment required, provided he is eligible for benefits

under this Plan at the time his military leave begins.

Military Leaves of Absence for Periods More Than 30 days.

a. If an employee is on a military leave of absence from his employment, or if the employee’s

covered dependent enters the military (thereby otherwise losing overage under this Plan), and

the period of military leave is for more than 30 days, USERRA permits the employee or the

employee’s dependent who entered the military to continue coverage for himself and (in the

case of the employee) his dependents at his own expense. The cost is 102% of the Plan’s cost

of benefits, for up to 24 months, so long as he gives the Administrative Office advance notice

(with certain exceptions) of the leave, and so long as his total leave when added to any prior

periods of leave, does not exceed 5 years.

b. The maximum period of continuation coverage for health care under USERRA is the lesser

of: (1) 24 months (beginning from the date the employee leaves work due to military leave or

the dependent loses coverage due to military service) or (2) the day after the date the

employee fails to timely apply for or return to a position of employment with an employer

participating in the Plan or (3) when the employee or dependent fails to timely pay for health

care under USERRA.

Upon release from active service, the employee’s coverage will be reinstated on the day he returns to

work as if he had not taken leave or as of the date of registration for employment through the union,

provided he is eligible for re-employment under the terms of USERRA and provided he returns to

work:

a. Within 90 days from the date of discharge if the period of service was 31 days or more; or

b. By the beginning of the first full regularly scheduled working period on the first calendar day

following discharge (plus travel time and an additional eight hours) if the period of service

was less than 31 days.

If the employee is hospitalized or convalescing from an injury caused by active duty, these time limits

are extended for up to two years.

A copy of the employee’s separation papers must be submitted to the Administrative Office to

establish his period of service.

If the employee does not elect to continue coverage during his military leave, upon his return to work

his benefit coverage will be reinstated at the same benefit level afforded to active, eligible employees if

he/she is eligible for re-employment under the criteria established under USERRA.

If the employee does not return to work at the end of his military leave, he may be entitled to purchase

COBRA continuation coverage (see page 21) provided he gives timely notice to the Administrative

Office. Coverage will not be offered for any illness or injury determined by the Secretary of Veterans

Affairs to have been incurred in, or aggravated during, performance of service in the uniformed

services. The uniformed services and the Department of Veterans Affairs will provide care for service-

connected injuries or illnesses.

28

The rights to self-pay are governed by the same conditions described in the COBRA section of this SPD.

If election is made for continuation coverage under USERRA, the COBRA and USERRA coverage

periods will run concurrently.

Certificate of Group Health Plan Coverage

When you lose eligibility under this Plan, you will be furnished with a Certificate of Group Health Plan

Coverage. This certificate provides you with evidence of your health coverage with the Plan. You may

need to furnish this certificate if you become eligible under another group health plan that excludes

coverage for certain medical conditions before you enroll. This certificate may need to be provided if

medical advice, diagnosis, care, or treatment was recommended or received for one or more of those

conditions within the six month period prior to your enrollment in the new plan.

If you become covered under another group health plan, check with the Administrative Office to see if you

need to provide this certificate. You may also need this certificate to buy, for yourself or your family, an

insurance policy that does not exclude coverage for medical conditions that are present before you enroll.

29

Choosing Medical Coverage

General Discussion

As a participant in the Cement Masons Southern California Health & Welfare Plan, you are given a choice

of two Health Maintenance Organizations (HMOs, for short) and the PPO Medical Coverage. You can

select from among the five coverages offered, which are “Health Net HMO Elect Open Access (EOA),”

“Health Net HMO Salud y Mas,” “Health Net Exclusive Provider Organization (EPO),” “Kaiser HMO”

and the “PPO Medical Coverage” through Anthem Blue Cross. As explained under the Annual Open

Enrollment Period section (see page 33) you are allowed to change your choice of Coverage once each

year.

This section is intended to help you become acquainted and familiar with the medical coverages being

offered to you.

HMO Medical Coverages – Health Net & Kaiser

A Health Maintenance Organization consists of a network of health care providers who have contracted

with Health Net or Kaiser Permanente (Kaiser Coverage) to provide medical services to eligible

participants. Each HMO has descriptive literature, which explains the services and benefits provided, as

well as the coverage limitations and exclusions.

The HMO you select (Health Net or Kaiser) will provide you with complete descriptive literature after you

enroll, including an identification card. Importantly, you must use the doctors and hospitals associated with

the HMO you select. The HMO will not pay for doctors, hospitals, services and supplies outside the HMO.

In order to enroll in an HMO, you must live or work within that HMO's service area. For Kaiser, you must

live or work within Kaiser's zip code listing. For Health Net, you must live or work within 30 miles of the

medical group elected.

Under the HMO Coverages, covered services are generally provided without charge, or for a fixed

copayment. For complete information on any of the HMO Coverages, you should contact the HMO

directly or the Administrative Office and request that they send you complete descriptive literature for the

specific HMO in which you are enrolled or in which you are considering enrolling.


The PPO Medical Coverage provides you with freedom of choice in selecting a doctor. In order to

maximize benefits, you must seek services from doctors and hospitals which are part of the Anthem Blue

Cross Prudent Buyer Network. The Prudent Buyer Network, called PPO for short, consists of all health care

providers and facilities who are under contract with the Anthem Blue Cross Prudent Buyer Network and

have agreed to reduced charges. This means lower out-of-pocket costs to you. When you use providers

that are not in the PPO network, you may incur substantial out-of-pocket costs.

You should carefully review the benefits of the PPO Medical Coverage (see pages 38 through 69) to make

certain it fits your needs, and that you understand what will be your financial obligation (out-of-pocket

costs) under the PPO Medical Coverage Plan.

30

A Brief Synopsis of the Five Medical Coverages

Health Net, an HMO

Under the Health Net Coverage, you and each member of your family may select a Participating Medical

Group (PMG) or Independent Physician Association (IPA) where each of you will receive care. You and

your family members may choose different PMGs or IPAs. Each medical group has a staff of physicians

from which you will select a Primary Care Physician who will provide basic health care. Each medical

group also has a Health Net Coordinator who will assist you and answer questions you might have. You

must live or work close enough to allow reasonable access to medical care to be eligible to enroll in the

Health Net Coverage. Covered benefits are generally provided to you at no cost or for a fixed co-payment.

Health Net provides the following three options to choose from:

Health Net Elect Open Access (EOA) allows you to self-refer to any physician contracted with Health

Net. However, your coverage and benefits are different when you visit Open Access providers.

Health Net Salud Y Mas is specifically designed to serve the needs of employees and their dependents

on either side of the California-Mexico border. It is Latino – focused health care where you live and

work. Participants who live or work within 50 miles of either side of the California-Mexico border can

access medical care through:

1. Their selected Salud Network physician group in California, or

2. Participating Sistemas Medicos Nacionales, S.A. de C.V. (SIMNSA) providers in Tijuana,

Rosarito, Mexicali and Tecate.

California participants must live in the Health Net Salud service area where they have adequate access

to medical care from Salud network providers.

Family members living in Mexico may only receive covered services from a SIMNSA provider, except

in the case of emergency or urgently needed care. Family members must live or work within the

approved Health Net Salud service area in Mexico.

Health Net Exclusive Provider Organization (EPO) is available for employees who live outside of the

Health Net service area, primarily San Luis Obispo county.

Kaiser Permanente, an HMO

In many instances, Kaiser owns its own medical clinics and hospitals, and employs its own doctors. Kaiser

may also contract with designated hospitals and medical groups. Under the Kaiser Coverage, you can

choose your own physician, and are encouraged to do so. You must live or work within the list of Kaiser

zip codes to be eligible to enroll in the Kaiser Coverage. You can use any Kaiser facility at any time and

are not restricted to a particular medical group. There are specialist doctors within Kaiser and covered

benefits are generally provided to you at no cost or for a fixed co-payment.


The PPO Medical Coverage provides you freedom of choice in selecting a doctor. The Plan has contracted

with Anthem Blue Cross for the purpose of making their Prudent Buyer Network available to employees

and their eligible dependents who are covered for benefits under the PPO Medical Coverage.

The PPO providers for the area where you live and the most current listing of PPO providers is available

online at www.anthem.com/ca.

31

When you use Prudent Buyer PPO doctors and hospitals, you receive greater benefits than if you were to go

to a provider who is not a PPO provider. The difference in benefits between using a PPO provider and a

non-participating provider can be substantial, which affects your out-of-pocket costs.

The PPO providers under contract with the Anthem Blue Cross Prudent Buyer Network agree to provide

services at a reduced fee, and the savings are passed along to you in the form of a higher coinsurance

factor, and less out-of-pocket cost to you. After meeting your $200 deductible, when you use a PPO doctor

(In-Network), the coinsurance factor is 90% of reduced pre-negotiated rates versus 70% of “usual,

customary and reasonable charges” when you receive care from a non-PPO provider (Out-of-Network).

IMPORTANT: The reimbursement from out-of-network providers is based on 70% of usual, customary

and reasonable (UCR) charges for the services you receive. For example, if the Plan determines that a non-

PPO doctor charges a higher amount for the care provided than is permitted applying UCR, you will be

reimbursed based on only 70% of usual, customary and reasonable (UCR) charges and not 70% of the

higher amount charged by the non-PPO provider.

Under the PPO Medical Coverage, you are responsible for the difference between what the Plan pays and

what the doctor charges.

Questions and Answers About the Five Medical Coverages

The following questions and answers may assist you in making a Coverage selection; which is appropriate

for your needs and your eligible family members.

Q. What are the advantages of an HMO?

A. Under HMO Coverage, covered benefits are provided for no charge or for a fixed co-payment.

Your out-of-pocket costs will generally be much lower under HMO Coverage than under PPO

Medical Coverage. There are no claim forms to complete.

Q. Under an HMO, can I select my own doctor?

A. Yes, provided the doctor is an HMO doctor under the Coverage you select. Each family member is

encouraged to select a personal physician.

Q. Can I change my choice of doctors with the HMO?

A. Yes, under any of the HMO Coverages you are allowed to change to another doctor at any time.

However, when you choose another PMG or IPA while under Health Net, you must have approval

from Health Net.

Q. What if I go to a doctor outside of my HMO?

A. Unless the HMO you selected referred you to a specialist, there are no benefits available if you use

doctors outside of the HMO.

Q. What are the advantages of HMOs for families?

A. In view of the affordability factor, parents can seek medical attention for their children as concerns

arise without regard to deductibles and coinsurance. In addition, each HMO has established a

limit to the total amount of co-payments that you would have to pay in any one year. The exact

amount of this maximum co-payment liability is shown in the HMO's Evidence of Coverage

brochure.

Q. Can I convert to an individual HMO policy if I lose eligibility under this Plan?

A. Yes, provided you make written application to the HMO within the prescribed time period.

Q. Are services for medical emergencies a covered benefit under an HMO?

A. Generally yes, subject to the established rules of the HMO. Each HMO has specific benefits for

emergency services, within or outside the HMO enrollment/service area. Refer to the Evidence of

Coverage brochure from your HMO for specific details.

32

Q. What are the advantages of the PPO Medical Coverage?

A. You can go to any licensed doctor of your choice and be eligible for PPO Medical Coverage

benefits, and you are not restricted to a specific service area. That is why the PPO Medical

Coverage is also referred to as the freedom of choice plan. Under the PPO Medical Coverage, you

will have less out-of-pocket costs when using the Anthem Blue Cross Prudent Buyer Network.

Q. Can I receive medical care at any hospital under the PPO Medical Coverage?

A. Yes, provided the following two conditions are met:

1. You are admitted to the hospital, by a licensed doctor of medicine, and

2. The hospital meets the Coverage's definition of a hospital.

Q. Under the PPO Medical Coverage, do I need to receive advance approval for non-emergency

hospitalizations?

A. Yes. The Coverage requires that all non-emergency inpatient stays be approved in advance. Refer

to the Prior Authorization Review and Approval section beginning on page 46 for more

information. There are penalties for not obtaining approval for non-emergency hospitalizations.

Q. If I am enrolled in the PPO Medical Coverage and my doctor recommends surgery, will charges

for a second opinion be a covered benefit?

A. Yes. In fact, for all non-emergency surgeries, the Coverage encourages you to obtain a voluntary

second opinion.

Q. How can I reduce my out-of-pocket expenses under the PPO Medical Coverage?

A. The Coverage has contracted with select doctors and hospitals, who have agreed to provide

medical care at reduced rates. These doctors and hospitals are referred to as PPO providers under

the Anthem Blue Cross Prudent Buyer Network. For a complete explanation, refer to the section

outlining the PPO Medical Coverage beginning on page 38.

Q. Are experimental or investigational procedures covered under any of the Coverages?

A. All Coverages, HMO and the PPO Coverage, have specific exclusions concerning experimental

and investigational procedures. Contact the Administrative Office, your HMO or PPO if you have

any questions about a specific procedure.

Enrollment Procedures

When you first become eligible for benefits, you will be offered a choice of one of the five Medical

Coverages. Once you select a medical Coverage, you cannot change your choice of Coverage (unless you

move out of the service area of the HMO, or your HMO facility or doctor is canceled) until the Annual

Open Enrollment Period explained in the next section. If you do not make a selection, you will

automatically be enrolled in the PPO Medical Coverage.

You may enroll in an HMO Coverage only if you are within the geographical jurisdiction defined by the

HMO you select. For Health Net, you must live or work within 30 miles of the PMG or IPA selected to be

eligible to enroll in the Health Net Coverage. For Kaiser, you must live or work within the Kaiser zip code

area, which consists of an approved listing of zip codes.

If you enroll in an HMO Coverage, and then move out of the service area, you may request transfer to the

PPO Medical Coverage by addressing a letter to the Administrative Office explaining this occurrence. If

approved, the change will normally be made effective on the first day of the month following the month in

which the written request is received by the Administrative Office. You will get confirmation in writing of

the change-over date.

To determine if you are within either the Health Net or Kaiser service area you have two options for each

HMO, telephone or internet. For Health Net, call Member Services at (800) 522-0088, or log on to the

33

Health Net website at www.healthnet.com. For Kaiser, call Member Services at (800) 464-4000, or log on

to the Kaiser website at www.kaiserpermanente.org.

Annual Open-Enrollment Period

Each year, during the annual open enrollment period, eligible employees are permitted to make a change in

their choice of medical coverage. Normally, information on the open enrollment is mailed out in

September of each year and any change in medical coverages must be made and received in the

Administrative Office by October 1. Coverage changes are effective with the eligibility period starting

November 1.

In the event that your HMO medical group or doctor is canceled by the HMO, you are allowed to change to

another health coverage offered through the Plan. The change will be made on the first day of the month

following notification to the Administrative Office that you want to change coverage. You will need to

complete a new enrollment application before the 20th

of the month for your change to become effective on

the first day of the next month. For example, if you want to change from your HMO to another Coverage

on May 1, you must complete a new enrollment form for the new Coverage and have it in the

Administrative Office by April 20.

34

Health Net HMO Medical Coverage

Basic Information

When you join Health Net, you and each of your eligible dependents must select a Participating Medical

Group (PMG) or Independent Physicians Association (IPA) where each of you will receive medical care.

In a PMG, most of the primary care physicians have their offices at one principal location under the

medical group’s name. An IPA is usually made up of primary care physicians who practice at different

locations, under their own names. You and your eligible dependents may choose different PMGs or IPAs.

Each member must reside or work close enough to allow reasonable access to medical care. Call the

Member Services Department at (800) 522-0088 if you need a provider directory or if you have questions

on reasonable access to care. The provider directory is also available on the Health Net website at

www.healthnet.com under “Provider Search.”

Once you have selected a medical group, choose a primary care physician. Again, each family member

may choose a different primary care physician. This is your personal physician, the doctor who will be

responsible for performing or authorizing all the medical attention and treatment, including hospitalization,

you receive through Health Net.

Should your primary care physician determine that specialist care is necessary (care that he or she cannot

provide personally), your primary care physician will authorize a referral to an appropriate specialist. As a

member of Health Net, you must obtain a referral from your primary care physician to see a specialist.

Referral specialists are not available for selection as your primary care physician.

Health Net has three Coverages available to participants – Elect Open Access (EOA), Salud y Mas and

Exclusive Provider Organization (EPO). A brief explanation of each Coverage is provided on page 30.

Complete benefits and information about the Health Net Coverages is described in their descriptive

literature or call Member Services at (800) 522-0088.

The information contained in this section is a summary outline only. For details on your benefits,

exclusions, etc., refer to Health Net Coverage’s Evidence of Coverage. The Evidence of Coverage is

the binding document between Health Net and its members.

Details on benefit and claims review and adjudication procedures can be obtained by referring to

Health Net Coverage’s Evidence of Coverage or by contacting the Health Net Customer Service

Department at (800) 522-0088.

A Health Net physician must determine that the services and supplies are medically necessary to

prevent, diagnose, or treat your medical condition. The services and supplies must be provided,

prescribed, authorized, or directed by a Health Net physician. You must receive the services and

supplies at a Health Net facility or skilled nursing facility inside the Health Net service area, except

where specifically noted to the contrary in the Evidence of Coverage.

If there are any discrepancies between this Summary Plan Description (SPD) and the Evidence of

Coverage, the Evidence of Coverage will prevail.

Newborn Dependent Children

Health Net will not automatically enroll newborn children. To add newborn children, employees must

complete a change form requesting to add their newborn children.

35

Health Net Website

www.healthnet.com

Complaint Procedure, Claims Appeal and Arbitration

Health Net has its own grievance and claims appeal process. If you have a grievance, complaint, or claim

to appeal against Health Net, you should contact Health Net directly and use Health Net’s grievance and

claims appeal process. They may be time-sensitive, so don’t delay.

36

Kaiser Permanente HMO Medical and

Prescription Drug Coverage

Basic Information

If you enroll in Kaiser HMO Coverage, you and your dependents will receive medical as well as

prescription drug benefits from Kaiser.

In most instances, Kaiser owns its own hospitals and medical centers. You may enroll in Kaiser if you live

or work within any of the Kaiser zip code service areas.

Once enrolled, you can use any Kaiser facility. However, it is suggested that you choose a Kaiser facility

closest to your home, or most convenient for you to receive most of your care. Within the Kaiser facility,

you are encouraged to select a primary care physician who will be your own doctor, with whom you make

appointments.

It is important to note that in order to receive covered benefits, you must use a Kaiser facility to provide

care for you and your dependent(s). Referrals to certain specialists may require a referral by your primary

care provider.

Kaiser Coverage benefits apply when your care is provided, prescribed, or directed by a Kaiser physician

except where specifically stated in emergency situations as described in the Kaiser descriptive literature.

Complete benefits and information about Kaiser Coverage are described in their descriptive literature or

call their Customer Service Center at (800) 464-4000.

The information contained in this section is an outline only. For a complete description of your

benefits, exclusions, etc., please refer to Kaiser’s Evidence of Coverage. The Evidence of Coverage is

the binding document between Kaiser and its members.

Details regarding benefit and claims review and adjudication procedures can be obtained by referring

to Kaiser’s Evidence of Coverage or contact Kaiser Membership Services at (800) 464-4000. They

may be time-sensitive, so don’t delay.

If there are any discrepancies between this Summary Plan Description (SPD) and the Evidence of

Coverage, the Evidence of Coverage will prevail.

Newborn Dependent Children

Kaiser will not automatically enroll newborn children. To add newborn children, members must complete

a change form requesting to add their newborn children.

Kaiser Website

www.members.kp.org

Kaiser maintains Kaiser Permanente Online, a confidential interactive Web site offering convenient

services, instant information, and personal advice from health care professionals. Some of the services

available to you online are as follows:

Schedule an appointment

Consult with a pharmacist

37

Join an online discussion

Locate Kaiser facilities

Research health education classes

Get you own customized health assessment

Complaint Procedure, Claims Appeal and Arbitration

Kaiser has its own grievance and claims appeal process. If you have a grievance, complaint, or claim to

appeal against Kaiser, you should contract Kaiser directly and use Kaiser’s grievance and claims appeal

process. They may be time-sensitive, so don’t delay.

38


Claims adjudication for the PPO Medical Coverage is performed by Zenith American Solutions, Inc. (ZAS). Call

ZAS Customer Service at (626) 732-2140 if you need further information or have questions regarding the PPO

Medical Coverage, including specific exclusions, limitations or reductions in benefits.

For details on claims review and adjudication procedures, refer to the section entitled Claims and Appeals Rules,

which can be located beginning on page 91.

Brief Outline of the PPO Medical Coverage – with Anthem Blue Cross Prudent Buyer Network

Annual Benefit Maximum

Claims incurred on/after January 1, 2014

Claims incurred prior January 1, 2014

None

$2,000,000

Calendar Year Deductible $200 per person

$600 per family maximum

Hospital Care – Inpatient Services

Semi-private room and board; nursing care

Intensive care and ancillary services

Admission review required-penalty non-compliance

90% - PPO (70% -Non-PPO)

(Note: Non-PPO charges incurred while an inpatient at a

PPO Hospital will be paid at 90% of reasonable charges)

Non-PPO – room and board limit of $650/day

Hospital – Outpatient Services

Surgery

Emergency

90% - PPO (70% - Non-PPO)

Skilled Nursing Facility 90% - PPO (70% - Non-PPO)

Ambulatory Surgical Center 90% - PPO (70% - Non-PPO)

Hospice 90% - PPO (70% - Non-PPO)

Home Health Care 90% - PPO (70% - Non-PPO)

Physician Services

Office visits

Specialist visits

Inpatient surgery

Outpatient surgery

Hospital visits

Home visits

Administration of anesthesia

90% - PPO (70% - Non-PPO)

Emergency Care – When Meeting the Coverage’s

Definition of Emergency Medical Condition

Physician & medical services

Emergency room

Inpatient hospital services

90% of UCR–PPO & Non-PPO

(Emergency Care obtained at a Non-PPO facility

will be paid at 70% co-insurance if it is determined

that the medical services provided did not meet the

Coverage’s definition of emergency care.)

Diagnostic Studies & Laboratory Procedures 90% - PPO (70% - Non-PPO)

Pregnancy & Maternity Care

Physician & medical services

Normal delivery, cesarean section, complications of pregnancy,

physician services, inpatient

Hospital ancillary services

Elective abortion

90% - PPO (70% - Non-PPO)

Family Planning

39

Brief Outline of the PPO Medical Coverage – with Anthem Blue Cross Prudent Buyer Network

Tubal ligation

Vasectomy

90% - PPO (70% - Non-PPO)

Preventive/Maintenance Care

Well Baby to age 7

Preventive Care beginning at age 7

90% - PPO (70% - Non-PPO)

Mental or Nervous Disorders

Inpatient – admission review required

Physician visits

Outpatient care

90% PPO (70% - Non-PPO)

Alcoholism & Drug Addiction

Inpatient detoxification – admission review required

Outpatient

90% PPO (70% - Non-PPO)

Durable Medical Equipment, Orthotics, Prosthetics 90% - PPO (70% - Non-PPO)

Chiropractic Services

90% - PPO (70% - Non-PPO)

Up to 30 visits per calendar year

Acupuncture 90% - PPO (70% - Non-PPO)


Physical Therapy – Outpatient 90% - PPO (70% - Non-PPO)


Speech Therapy – Outpatient 90% - PPO (70% - Non-PPO)

Occupational Therapy 90% - PPO (70% - Non-PPO)

Organ, Tissue, and Autologous Bone Morrow Transplants

(obtain prior approval)

90% - PPO (70% - Non-PPO)

Supplemental Accident Benefit 100% of 1st $300 per accident if within 90 days

Introduction

Important - Take the time to read this section carefully, so that you and your eligible dependents will

know how to use the PPO Medical Coverage to your full advantage. By learning a few basics, your out-of-

pocket costs will be substantially reduced. Thus, key terms and concepts in this section are highlighted in

bold print.

For additional assistance in understanding how to use the PPO Medical Coverage, there is a separate

Question and Answer section. This section is composed of questions most frequently asked by participants

about the PPO Medical Coverage.

The Board of Trustees has contracted with Anthem Blue Cross of California for the purpose of making

their expansive Prudent Buyer Network of preferred providers available to employees and their eligible

dependents who are covered under the PPO Medical Coverage.

Anthem Blue Cross has established a network of "Preferred Providers." These providers have agreed to

participate in the Anthem Blue Cross preferred provider organization program, called PPO for short.

The Anthem Blue Cross PPO is called the Prudent Buyer Plan. Therefore, whenever you see the term

Prudent Buyer just remember it is the Anthem Blue Cross PPO.

When you think of a PPO, you probably think of doctors and hospitals, which is correct. However, there

are other health care providers, which are neither physicians nor hospitals. The Anthem Blue Cross Prudent

40

Buyer Network includes an expanded list of providers in addition to doctors and hospitals. For example,

ambulatory surgical centers, home health care agencies, home infusion therapy providers, skilled nursing

facilities and medical products and services.

These Prudent Buyer preferred providers have agreed to provide health care for eligible participants and

accept the Plan’s payment for a covered service plus the member’s share of the covered charge (i.e.,

deductible, co-insurance, co-payment, penalty amount [if any]) as payment in full.

It is your responsibility to verify current Prudent Buyer status of the provider before you obtain

services. Remember to ask your doctor if he/she is an Anthem Blue Cross Prudent Buyer Preferred

Provider. You can also locate Prudent Buyer doctors online at www.anthem.com/ca or by calling the


The Administrative Office will supply you with an identification card, which identifies you as being

eligible to use the Anthem Blue Cross Prudent Buyer Plan Network of Preferred Providers. To be eligible

for PPO Medical Coverage you must work the required hours and be eligible for benefits as explained in

the Eligibility section beginning on page 15.

When you use a Prudent Buyer provider you will realize substantial savings and have less out-of-

pocket expense as opposed to going to a non-preferred provider. This, in part, is because Anthem Blue

Cross Prudent Buyer providers have agreed to provide health care at a reduced cost, and these savings are

passed along to you.

Prudent Buyer vs. Non-Preferred Providers

IMPORTANT, the amount of benefits payable under the PPO Medical Coverage will be greater for

preferred providers (Prudent Buyer) than for non-preferred providers. When you use a Prudent Buyer

provider you will be reimbursed (subject to PPO Medical Coverage deductibles and covered charges) 90%

of the Anthem Blue Cross Prudent Buyer preferred rate. Thus, your out-of-pocket expense will be 10% of

the preferred rate. This does not apply to non-preferred providers.

Additional savings may be realized when using a Prudent Buyer provider because they generally refer

only within the Prudent Buyer provider network. For example, should you need to see a specialist your

Prudent Buyer primary care physician will refer you to a doctor who is also a Prudent Buyer preferred

provider. However, it is your responsibility to always verify in advance that a doctor or other health

care provider is a member of the Prudent Buyer network.

Benefits for Out-of-Network (non-PPO) Providers

Non-preferred providers are providers that do not participate in the Prudent Buyer network PPO. They

have not agreed to the negotiated rates and other provisions of the Anthem Blue Cross contract. In other

words, you will have reduced coverage for services rendered by a non-preferred provider.

When you use a non-preferred provider, you will only be reimbursed (subject to PPO Medical Coverage

deductibles, co-insurance, co-payment, penalty amount, if any) 70% of covered charges based on usual,

customary and reasonable charges. In most instances you will be responsible for paying a large part of the

billed charges, called out-of-pocket expenses, when using a non-PPO provider.

Important, the non-preferred provider may bill you for amounts over the covered charges. That

amount does not apply to any deductible or out-of-pocket limit. It is your responsibility to pay the

difference between the providers’ billed charges and the covered charges.

In addition to receiving greater benefits when using a preferred provider there are also other advantages.

The preferred provider (PPO) is responsible for filing claims directly with Anthem Blue Cross. In the

41

reverse, if you use a non-preferred provider you may be required to pay the non-PPO provider in full, and

submit your claims for reimbursement; the decision is up to the provider.

Refer to the Question and Answer section on page 42 for an example of what PPO Medical Coverage will

pay and what your out-of-pocket expenses might be, comparing a preferred provider claim to a non-

preferred provider with the same services.

Summary of Prudent Buyer Plan Provisions

Preferred Providers are the key to reducing your out of pocket costs. The participating hospitals,

physicians, and other facilities have signed Anthem Blue Cross Preferred Provider Agreements. They have

agreed to accept a reduced, pre-negotiated rate for services, which are covered by the PPO Medical

Coverage. They will not bill you for any difference between the pre-negotiated rates for services covered

by the PPO Medical Coverage. You are responsible only for your deductibles and co-payment amounts

which are required by the PPO Medical Coverage as explained above and in the sections that follow.

Do not make any payment to your Anthem Blue Cross doctor, hospital, or other health care

provider, except co-payments and deductible amounts not yet paid, until you receive the Explanation

of Benefits (EOB) from the ZAS Claims Customer Service office. This ensures that you receive the

discounted rate for using a Prudent Buyer provider.

The ZAS Claims Customer Service office will provide you with a copy of the claim (Explanation of

Benefits) showing what PPO Medical Coverage has paid, and the amount which is your responsibility.

Under the PPO Medical Coverage, you have complete freedom of choice in where you obtain health care.

However, it is to your financial advantage to use an Anthem Blue Cross provider, as well as to the financial

advantage of the Plan. In the rare instance where you may be unable to utilize an Anthem Blue Cross

provider, please contact the Administrative Office for assistance.

Summary of Plan Benefits When Using a Prudent Buyer Preferred

Provider

Deductibles (per calendar year)

Per Person $200

Per Family Maximum $600

Annual Benefit Maximum (per calendar year)

Per Person None (for claims incurred on or after January 1, 2014)

$2,000,000 (for claims incurred prior to January 1, 2014)

Co-payments

The PPO Medical Coverage will pay 90% of the negotiated Prudent Buyer rates after the

deductible.

To receive maximum benefits under the PPO Medical Coverage, it is imperative that you make certain you

are using a Prudent Buyer provider for all hospital and doctor services. For example, for doctor visits,

hospitalization, lab work and other services use Prudent Buyer providers and facilities.

42

Summary of Plan Benefits When Using a Non-Preferred Provider

Deductibles (per calendar year)

Per Person $200

Per Family Maximum $600

Note: The regular hospital room and board limit is $650 per day when using a non-participating

hospital. You are responsible for any difference between the $650 limit and what you are billed.

Annual Benefit Maximum (per calendar year)

Per Person None (for claims incurred on or after January 1, 2014)

$2,000,000 (for clams incurred prior to January 1, 2014)

Co-payments

The PPO Medical Coverage will pay 70% of the covered charges after the deductible.

Note: Covered charges are based on usual, customary and reasonable (UCR) charges. The charge

made by a non-participating provider may be more than the amount allowed by the PPO Medical

Coverage. You are responsible for the difference between these charges, in addition to your

co-payment of 30%.

Commonly Asked Questions and Answers

Q. What is the Prudent Buyer Network

A. The Anthem Blue Cross network that is considered an in-network provider under the PPO Medical

Coverage.

Q. Do I have to select a Prudent Buyer doctor?

A. No. You can use any doctor of your choice at any time. If you already have a personal physician, we

suggest you determine if your physician is a Prudent Buyer provider by calling the physician’s office. You

can also locate Prudent Buyer doctors online, at www.anthem.com/ca or by calling the Administrative

Office. Remember, you will save money by using a Prudent Buyer PPO doctor.

Q. How can using the services of a Prudent Buyer provider save me money?

A. Prudent Buyer providers have agreed to give members health care at a reduced cost. Because of these

savings, the PPO Medical Coverage can provide richer benefits when you choose to get your health care

from a Prudent Buyer doctor, hospital or other provider.

Q. What are the differences in Plan benefits when using a Prudent Buyer provider versus a non-preferred

provider?

A. When you use a Prudent Buyer preferred provider, you are responsible for 10% of covered charges (subject

to PPO Medical Coverage deductibles and benefit maximums) of the reduced PPO rate. When you use a

non-preferred provider, you will be responsible for 30% of covered charges plus the difference between the

allowed amount and what is charged by your doctor (subject to PPO Medical Coverage deductibles and

benefit maximums). Importantly, there is a daily $650 room and board limit when you use a non-

preferred provider. Based on current hospital charges, you may incur substantial out-of-pocket costs

if you use a non-preferred hospital.

Q. Can you provide an example of the above?

43

A. Assume after satisfying the $200 calendar year deductible, that you have a combined doctor and hospital

bill for covered charges in the amount of $10,000. By way of illustration, your out-of-pocket expense may

be as follows.

If you use a Prudent Buyer doctors and hospital:

$10,000 of covered charges reduced to special, contract rate of $7,000. Your out-of-pocket cost, after the

deductible, would be 10% of $7,000 or $700.

If you use non-contracting doctors and hospital:

$10,000 of covered charges is reduced to $7,000, which is the amount determined by Anthem Blue Cross to

be usual, customary and reasonable charges. You will be reimbursed by the PPO Medical Coverage, after

the deductible, 70% of $7,000, or $4,900. Your out-of-pocket expense will be $5,100, which is the

difference between total charges of $10,000 and PPO Medical Coverage benefits of $4,900.

Q. Will I have to complete a claim form if I use a Prudent Buyer provider?

A. No. Prudent Buyer providers will submit your bills directly to Anthem Blue Cross of California. However,

if you do not use a Prudent Buyer provider, you are required to submit your claims to Anthem Blue Cross,

directly:

Anthem Blue Cross

PO Box 60007

Los Angeles, CA 90060-0007

Q. If I go to a Prudent Buyer provider, will I need to make a payment at the time of service?

A. Generally, you will not make a payment until you receive a statement of the claim, called an Explanation of

Benefits or EOB for short, from the Claims Administrator, Zenith American Solutions, Inc. To receive

benefits, you must meet the eligibility rules of the Plan and be eligible for benefits.

Q. Is there a mandatory Prior Authorization Review in the PPO Medical Coverage?

A. Yes. The PPO Medical Coverage has a mandatory inpatient utilization review program, including a pre-

service review and concurrent review. All inpatient NON-EMERGENCY admissions must be approved

in advance. Contact Anthem Blue Cross prior to elective surgery or being admitted. There are dollar

penalties for non-compliance. Anthem Blue Cross must be contacted within 48 hours from emergency

surgery and/or inpatient admission.

To receive full benefits, the PPO Medical Coverage requires all non-emergency admissions to be approved

in advance. When you use a Prudent Buyer doctor and hospital, the pre-certification will take place with

no action required on your part. If you choose to go to a non-preferred doctor or hospital, be certain that

your hospital stay is approved before admission. The number for utilization review is shown on your

Prudent Buyer identification card.

Q. Must non-emergency elective surgery be approved in advance?

A. Yes, for inpatient hospital confinement. Benefits are provided only for medically necessary and appropriate

services. For example, many elective surgeries are considered cosmetic, for which no PPO Medical

Coverage benefits are payable. If you have questions as to whether a particular elective surgery is covered

by the PPO Medical Coverage, you or your doctor should contact Zenith American Solutions, Inc. who is

the Claims Administrator for the PPO Medical Coverage.

Q. Will the PPO Medical Coverage cover a second opinion prior to having elective surgery?

A. Yes, subject to PPO Medical Coverage benefits (deductibles and coinsurance) a second doctor's opinion for

elective surgery is a covered benefit.

Q. Why does the PPO Medical Coverage maintain a Prior Authorization Review Program?

A. This program provides you with valuable information, so that unexpected out-of-pocket costs can be

avoided. When the program is properly used, you will know in advance whether the proposed services are

medically necessary and appropriate, and therefore eligible for PPO Medical Coverage benefits.

44

Q. Why would a proposed hospital confinement be questioned?

A. 1. Your doctor may be confining you for a type of surgery which can, in accordance with medical accepted

standards, be performed on an outpatient basis at a surgical center. For example, removal of tonsils and

adenoids and insertion of ear drainage tubes are outpatient surgery.

2. The doctor may be confining you a day earlier than necessary to perform tests that could be just as well

performed on a pre-admission basis.

3. The confinement may be scheduled on a Friday, Saturday, or Sunday with surgery to be performed on

Monday and the need for pre-operative confinement is questionable.

4. The confinement may be proposed for five days when medical review indicates only three days are

necessary unless complications develop.

5. The confinement may be proposed for treatment of an ailment, which does not necessitate acute hospital

care. In such cases, an alternate type of proper care could be recommended.

6. The confinement might be for optional or for cosmetic surgery which is not a covered benefit.

Q. Is there a penalty if my non-emergency hospitalization is not approved in advance?

A. Yes. PPO Medical Coverage benefits otherwise payable will be reduced 50% up to a maximum $500. In

addition, Anthem Blue Cross utilization review will perform a retrospective review of your inpatient stay.

No PPO Medical Coverage benefits will be provided for inpatient days which are not determined to be

medically necessary.

Q. Are there chiropractors that are members of the Prudent Buyer network?

A. Yes. A listing of Prudent Buyer chiropractors can be located online at www.anthem.com/ca

Online Internet Website – Anthem Blue Cross

Participating health care providers in the Prudent Buyer network include hospitals, physicians, and

laboratory and radiology facilities. From time to time providers are added or deleted from the network.

There is a quick and easy way to find participating Prudent Buyer health care providers – including doctors

and hospitals. To find a provider, simply go to the Anthem Blue Cross web site and use the online provider

finder resource.

Follow these easy steps to find a participating California provider:

Go to http://www.anthem.com/ca

Click on continue after each one of these steps

1. Select Visitor Search

2. Plan Information – select Large Group Plans

3. Plan Information – select your coverage: Blue Cross PPO

4. Type of Provider – select a provider type (e.g., health facility, physician, specialist, etc.)

5. Specialty (optional) – you may select a specialty to refine your search. To select multiple

specialties, hold down the Control key and click on each specialty name.

6. Location or Name – enter location or name criteria. Receive your search results via a listing,

map or downloadable directory.

Alternately to the above, you can:

1. Inquire of a physician or other provider if he/she is an Anthem Blue Cross Prudent Buyer

Provider.

2. Contact the Claims Customer Service Office at (626) 732-2140. Remember, it is your

responsibility to make certain that you are receiving medical services from a Prudent Buyer

provider.

45

This PPO Medical Coverage contains many important terms (such as “medically necessary” and “covered

charges” that are defined in the Definitions section beginning on page 58. When reading this section of the

SPD, consult the Definitions section to be sure that you understand the meanings of these terms. If you

have any questions, contact Zenith American Solutions, Inc. who is the Claims Administrator at (626) 732-

2140

Summary of Medical Benefits

Only a non-occupational accident or illness is considered a covered expense under the PPO Medical

Coverage.

For your convenience, this Summary Plan Description provides an outline of your benefits under the PPO

Medical Coverage. If you require additional information concerning the benefits or exclusions of the PPO

Medical Coverage, please call or write the Claims Administrator.

The benefits of the PPO Medical Coverage are subject to reimbursement for acts of third parties. Third

party means that injuries sustained by you were the result of the fault (negligence or carelessness) of a third

party or parties. Under these circumstances, what is called a Subrogation Agreement & Assignment of

Benefits will need to be signed before PPO Medical Coverage benefits are payable. Refer to the

Subrogation section beginning on page 63 for details.

All benefits of the PPO Medical Coverage are subject to coordination of benefits with other plans. Refer to

the Coordination of Benefits section beginning on page 66 for details.

The benefits of PPO Medical Coverage are provided only for those services that the Plan, based on expert

doctor’s opinions, determines to be medically necessary. Contact the ZAS Claims Customer Service Office

at (626) 732-2140 if you have any questions regarding whether services are covered by this coverage.

Deductible

The deductible is the amount of covered medical expenses you are responsible for paying before your

medical benefits are available - $200 per person, but not more than $600 per family per calendar year.

Once your family reaches $600, no further deductible is required for any family member that year.

For example, let us assume there is a family of six is covered under the PPO Medical Coverage. Mom

and dad and two of the children each have covered expenses of $150. In this example, the family

deductible for the calendar year has now been satisfied for all family members because the $600

accumulative ($150 x 4 = $600) deductible has been met.

Additionally, if two or more eligible family members are injured in the same accident, only one deductible

will be applied to that calendar year against expenses related to the accident.

Covered medical expenses applied against the deductible during the last three months of a calendar year

will also be used to reduce the deductible for the next calendar year.

For example, if you are credited with $75 toward your individual deductible during the month of

October and an additional $25 in December, $100 will apply toward your deductible for the following

year.

46

Annual Medical Benefit Maximum

For claims incurred on or after January 1, 2014, there is no annual maximum benefit under the PPO

Medical Coverage.

For claims incurred prior to January 1, 2014, there is an annual maximum benefit of $2,000,000 per person

per calendar year.

Co-payments

Prudent Buyer (PPO) Providers

After you have satisfied any applicable deductible, PPO Medical Coverage will pay 90% of the negotiated

Prudent Buyer rate up to the PPO Medical Coverage maximum.

Your “co-payment” will be 10% of the negotiated Prudent Buyer rate. Participating physicians, hospitals,

and other health care providers have agreed to accept a reduced, pre-negotiated rate for medical expenses

covered by PPO Medical Coverage. Therefore, your co-payment will not exceed 10% of the negotiated rate

for covered medical expenses.

Non-Preferred Providers

After you have satisfied any deductible, the PPO Medical Coverage will pay 70% of covered charges,

based on usual, customary and reasonable charges up to the PPO Medical Coverage maximums. You are

responsible for the difference between what the doctor charges and the allowed amount.

Prior Authorization Review and Approval

Inpatient Admissions All non-emergency in-patient admissions to a hospital, skilled nursing facility or approved treatment

facility must be approved (prior authorization) by Anthem Blue Cross BEFORE you are admitted. In the

event of a medical emergency (requiring surgery or inpatient admission), you must notify Anthem Blue

Cross within 48 hours of being admitted as an inpatient or as soon thereafter as possible.

These approval requirements will provide you with assurance that you are being treated in the most

efficient and appropriate health care setting and can help manage the rising costs of health care.

The prior authorization inpatient admissions program applies to the following:

Pre-service review determines the medical necessity of scheduled non-emergency admission.

Concurrent review determines whether services continue to be medically necessary and appropriate

when pre-service review is not required or has been performed as required.

Retrospective review is performed when Anthem Blue Cross has not been notified and therefore has

been unable to perform the appropriate pre-service or concurrent review.

Failure to obtain prior authorizations will result in PPO Medical Coverage benefits otherwise payable being

reduced 50% up to a maximum of $500. Additionally, Anthem Blue Cross utilization review will perform

a retrospective review of your inpatient stay. No PPO Medical Coverage benefits will be provided for any

inpatient days, which are not determined to be medically necessary.

Prior approval determines only the medical necessity of a specific service and/or an admission and an

allowable length of stay. Prior approval does not guarantee your eligibility for coverage. Eligibility and

benefits are based on the date you receive the services. An approval does not guarantee payment or that

you will receive the highest level of benefits. For example, services not listed as covered, services received

after you lose eligibility under this PPO Medical Coverage and services that are not medically necessary

will be denied.

47

Generally, Anthem Blue Cross Prudent Buyer providers will obtain prior approval in which case prior

approval is not your responsibility. On the other hand, it is your responsibility to make certain than all non-

preferred providers obtain prior approval before services are rendered.

Admission review requirements may affect the amounts that this PPO Medical Coverage pays for inpatient

services, but they do not deny your right to be admitted to any facility and to choose your services.

Other Prior Approvals

In addition to admission review for all inpatient services, prior approval by Anthem Blue Cross is required

for certain other services. If prior approval is not obtained for the following services, benefits may be

denied in whole or in part based on a retrospective medical review giving consideration to medical

necessity and that the charges incurred are for a covered service:

Home health care Home infusion therapy Transplants Chemotherapy – pre-service review is provided for chemotherapy if services are in-patient PPO

Contact Anthem Blue Cross at (800) 274-7767 for all prior approvals and inpatient pre-authorization

review.

Covered Expenses

This section describes the services and supplies covered by the PPO Medical Coverage. All covered

expenses are subject to the deductible, co-payment, co-insurance and out-of-pocket limit provisions of the

PPO Medical Coverage. All payments are based on the covered charge as determined by Anthem Blue

Cross and the Claims Administrator.

Also, please refer to the PPO Medical Coverage Exclusions section, beginning on page 54.

Acupuncture Treatment Acupuncture visits shall be limited to 30 visits per calendar year for necessary care, based on Usual,

Customary & Reasonable (UCR) charges.

Ambulance Services A specially designed and equipped vehicle used only for transporting the sick and injured. It must

have customary safety and lifesaving equipment such as first-aid supplies and oxygen equipment. This

vehicle must be operated by trained personnel and licensed as an ambulance.

Necessary ambulance services in an emergency (e.g., cardiac arrest, stroke) to and from the nearest

hospital providing emergency treatment if you are admitted as an inpatient.

If you are treated as an outpatient for accidental injury or emergency illness, provided within 24 hours

after your accident, the PPO Medical Coverage pays benefits for ambulance service.

Air Ambulance The PPO Medical Coverage only covers air ambulance when terrain, distance or your physical

condition requires the use of air ambulance services.

Ambulatory Surgical Facility Services and supplies provided by an ambulatory surgical center in connection with outpatient surgery.

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Birth Centers Use of a birth center instead of a hospital, provided it has approval by the Joint Commission on

Accreditation of Health Care Organizations.

Blood Blood transfusions, including blood processing and the cost of un-replaced blood and blood products.

Charges for the collection, processing, and storage of self-donated blood are covered, but only when

specifically collected for a planned and covered surgical procedure.

The PPO Medical Coverage does not cover blood replaced through donor credit.

Cancer Screenings Cervical cancer screening services and supplies (every 12 months) provided in connection with a

routine test to detect cervical cancer (i.e., pap smear) including testing for sexually transmitted diseases

(STDs)

Routine colorectal screening after age 50 for one of the following testing schedules:

o Fecal Occult Blood Test (FOBT) or Fecal Immunochemical Test (FIT) once a year

o Flexible sigmoidoscopy once every five years

o Yearly FOBT or FIT, plus flexible sigmoidoscopy every five years

o Barium enema once every five years

o Colonoscopy every ten years

Routine and diagnostic mammogram examinations (every 24 months to age 40 unless medical

necessity requires it more frequently, every 12 months after age 40) to detect breast cancer.

Prostate cancer screening services and supplies (every 12 months) provided in connection with a

routine test to detect prostate cancer.

Cardiac and Pulmonary Rehabilitation Outpatient cardiac rehabilitation programs provided within six months of a cardiac incident and

outpatient pulmonary rehabilitation services.

Chemical Dependency Treatment

Outpatient services are covered the same as any other outpatient physician service under the PPO

Medical Coverage

Inpatient treatment in a hospital or approved treatment facility is covered in the same manner as any

another inpatient hospital stay and is subject to the prior authorization requirements of the PPO

Medical Coverage (see page 46).

Chemotherapy and Radiation Therapy Treatment of malignant disease by standard chemotherapy and treatment of disease by radiation

therapy

Chiropractic Treatment For outpatient and non-hospital chiropractic care by a licensed chiropractor (D.C.) the PPO Medical

Coverage pays up to a maximum of 30 visits per calendar year for necessary care.

Dental Care Expenses for dental work or oral surgery, not to exceed the $300 additional accident benefit, for

prompt repair of natural teeth and other body tissue required as a result of a non-occupational injury

which occurs within 90 days from the date of accident.

Diagnostic Services Outpatient diagnostic procedures such as laboratory and pathology tests, x-ray services, EKGs and

49

EEGs and that are ordered by a physician to determine a condition or disease.

Dialysis Renal (hemodialysis) Continual ambulatory peritoneal dialysis (CAPD) Apheresis and plasma pheresis Cost of equipment, rentals and supplies for home dialysis

Durable Medical Equipment (DME) Rental (not to exceed purchase price) or purchase of durable medical equipment is a covered expense

provided it is:

1) Of no further use when medical needs end;

2) For the exclusive use of the eligible patient;

3) Not primarily for comfort or hygiene;

4) Not for environmental control or for exercise; and

5) Manufactured specifically for medical use.

Note: The Board of Trustees will determine whether the item satisfies the conditions above.

Replacement of equipment that has been lost, abused, or neglected is not a covered benefit.

Rental or purchase of dialysis equipment, dialysis supplies, casts, splints, trusses, braces, crutches,

wheelchair, hospital-type bed, and similar equipment when medically necessary and prescribed by

your doctor.

Maintenance of durable medical equipment is not a covered expense.

Emergency and Urgent Care Hospital Emergency Room Care - medical or surgical procedures, treatments, including x-rays and

laboratory services delivered after the onset of what reasonably appears to be a medical condition with

symptoms of sufficient severity including severe pain, that the absence of immediate medical attention

could reasonably be expected to result in jeopardy to one’s health; serious impairment of bodily

functions; serious dysfunction of any bodily organ or part; or disfigurement.

Urgent Care - Necessary medical or surgical procedures, treatments or services received for an

unforeseen condition that is not life-threatening. The condition does however, require prompt medical

attention to prevent a serious deterioration in your health (e.g., high fever, cuts requiring stitches.)

Use of an emergency facility for non-emergency services is NOT covered; however, services will not

be denied if you, in good faith and possessing average knowledge of health care and medicine seek

care for what reasonably appears to be an emergency – even if your condition is later determined to be

non-emergency.

Home Health Care in Lieu of Hospitalization Home health care services are covered only when pre-approved by Anthem Blue Cross and take the place

of hospital confinement. Home health care provides certain benefits for medical services and supplies

furnished on a visiting basis in a private residence to treat bodily injury or disease. After Anthem Blue

Cross pre-approves home health care, Anthem Blue Cross will monitor this care to determine the

continuing need for these services.

Home health care benefits do not cover custodial care including but not limited to, items such as bathing,

feeding, administering oral medications, and exercising. These benefits are not available to a person who

lives with the eligible individual or is a member of the eligible individual’s family.

Hospice Care Services for hospice care are a covered expense for a terminally ill participant who does not have a

reasonable prospect for cure and who has a life expectancy of 6 months or less, as certified by the attending

physician. A hospice care program means a coordinated plan or inpatient and home health care which treat

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the terminally ill person and family as a unit. Care must be provided by a team made up of medical

personnel, counselor, and other individuals with special training and can include homemakers who work in

conjunction with the hospice care program. Covered services include the following.

a. Inpatient care, including semi-private room and board, doctor's services, inpatient skilled nursing

care, respiratory therapy, life support systems, pain therapy, drugs and medicines, psychological

counseling, and spiritual support. b. Outpatient hospice care including nursing care given at home, visits by hospice staff personnel,

physical and respiratory therapy, oxygen and the rental of medical equipment for the patient's care,

medicine and drugs, and homemaker services.

c. Up to a $1,000 benefit maximum for professional counseling sessions with the patient and/or

family members during the period of hospice care.

d. Up to a $500 benefit maximum for bereavement counseling sessions with the patient's family

members for help in coping with the death of the patient within 90 days following the patient's

death.

Immunizations Charges for immunizations.

Infertility Covered charges for infertility are limited to initial diagnostic tests furnished in connection with

infertility including doctors’ services and all necessary laboratory expense

Inpatient Hospital Benefits Regular room and board (including all medically necessary ancillary services) in an accredited hospital

provided that the includable room and board charges may not exceed the hospital's regular rate for semi-

private accommodations whether or not a semi-private room is available

Intensive care unit charges.

Coronary care unit charges.

Anesthetic supplies furnished by the hospital.

Surgical supplies, dressings, and cast materials.

Drugs and oxygen.

Blood and plasma which are not replaced.

X-rays and laboratory tests directly related to the sickness or injury for which you are hospitalized.

Mastectomy Related Services All stages of reconstruction of the breast on which the mastectomy has been performed;

Surgery and reconstruction of the other breast to produce a symmetrical appearance; and

Prostheses and physical complications in all stages of the mastectomy, including lymphedemas;

in a manner determined in consultation with the attending physician and the patient.

Maternity Related expense, including pregnancy, childbirth, miscarriage, or abortion, are covered like any other

medical condition. In accordance with federal law, the PPO Medical Coverage does not restrict lengths of

hospital stays for a mother or newborn to less than 48 hours following normal vaginal delivery or 96 hours

following cesarean delivery. In consultation with your physician, you may choose not to stay the full 48/96

hours. The length of inpatient care may, however, be extended upon application of the mother’s or

newborn’s attending physician to the Plan provided that the Plan determines that the extended stay is

medically necessary.

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Mental Health Treatment Inpatient treatment in a hospital or approved treatment facility is covered in the same manner as any

other hospital stay and is subject to the prior authorization requirement of the PPO Medical Coverage

(see page 46).

Outpatient services are covered the same as any other outpatient physician service under the PPO

Medical Coverage.

Nursing Care Charges for registered graduate nurse (R.N.) provided the services are usual-customary prescribed by

the attending physician. There is no coverage for a nurse who resides in your home or who is related

to you by blood or marriage.

Organ and Tissue Transplants Prior approval must be obtained from Anthem Blue Cross before a pre-transplant evaluation is

scheduled. A pre-transplant evaluation may not be covered if prior approval to receive the services is

not obtained from Anthem Blue Cross.

Services provided in connection with a non-investigative organ or tissue transplant, if you are the

organ or tissue recipient or donor.

If you are the recipient, the organ or tissue donor who is not an eligible participant is also eligible for

services as described. Benefits are reduced by any amounts paid by that donor's own coverage.

Services must be provided at an approved transplant facility.

Organ acquisition or procurement costs for the surgical removal, storage and transportation of an organ

acquired from a cadaver. If there is a living donor that requires surgery to make an organ available

(kidney or liver), coverage is available only for expenses incurred by the donor for surgery, organ

storage expenses and inpatient follow-up care.

No coverage is available for donor expenses after the donor has been discharged from the transplant

facility.

Outpatient Hospital Service Hospital emergency room services and supplies – refer to the section titled “Emergency and Urgent

Care.” Use of hospital room for outpatient surgery.

Pre-admission diagnostic test within three days of being admitted to the hospital or having outpatient

surgery.

Hemodialysis, cobalt radiation and blood transfusions.

Physical Therapy See Rehabilitative Therapy on page 52.

Physician Services Usual, customary, and reasonable charges made by a licensed physician, as defined by the PPO

Medical Coverage, for treatment of an illness or injury.

Physician charges are covered for visits at the physician's office, hospital, and your home when

medically required.

No physician visits are payable for treatments given by the operating physician on or after the day of a

surgical procedure and within the follow-up days stipulated for the surgery performed.

Limit of one office visit per day unless there is an emergency.

Note: Physician means more than an M.D. Certain other practitioners are included in this term as it is used

throughout the PPO Medical Coverage. This does not mean they can provide every service that a medical

doctor could; it just means that the PPO Medical Coverage will cover expenses you incur from them when

they are practicing within their specialty, provided the service they provide is a covered benefit under the

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PPO Medical Coverage. As with other terms, be sure to read the definition of physician in the Definition

section (beginning on page 58) to determine which providers' services are covered.

Podiatry Treatment – Non-Surgical Treatment of the Feet The PPO Medical Coverage covers doctor services for non-surgical treatment of feet, limited to 30 visits

per calendar year. Covered charges are based on usual, customary and reasonable charges (UCR).

Preventive Care (Dependents under age 7) A physician’s services for routine medical examinations.

Immunizations given as standard medical practice for children.

Radiology and laboratory services in connection with routine physical examinations.

Services and supplies provided in connection with screening for blood lead levels if your dependent

child is at risk for lead poisoning, as determined by your physician, when the screening is prescribed

by your physician.

Preventive Care (Dependents Age 7 through Age 16)

A physician’s services for routine physical examinations, limited to no more frequently than

once every 12 months.

Immunizations given as standard medical practice.

Radiology and laboratory services and tests ordered by the examining physician in

connection with routine physical examinations.

Preventive Care for Employees, Spouses and Eligible Dependents over Age 16

Preventive health exams, health evaluations and diagnostic preventive procedures are covered benefits

limited to no more frequently than once every 12 months. Covered services are based on the

recommendations published by the U.S. Preventive Services Task Force.

Prosthetic Devices When medically necessary and ordered by a physician the PPO Medical Coverage covers the following

items: Breast prostheses following a mastectomy.

Prosthetic devices to restore a method of speaking when required as a result of a medically necessary

laryngectomy.

Other medically necessary prosthetic devices including surgical implants and artificial limbs or eyes.

Replacement of items only when required because of wear (an item cannot be repaired) or because of a

change in your condition.

Functional orthotics only for individuals having a locomotive problem or gait difficulty resulting from

mechanical problems of the foot, ankle or leg.

When alternate prosthetic devices are available, the allowance for a prosthesis will be based upon the

least costly prosthetic device available.

Rehabilitative Therapy Speech therapy when prescribed by a doctor for an illness or injury that first occurs to a person (with

normal speech) while covered by this PPO Medical Coverage and performed by a properly accredited

speech therapist.

Physical therapy limited to 30 visits per year performed by a physician, licensed physical therapist or

other outpatient professional provider licensed as a physical therapist. In-patient physical rehabilitation

and skilled nursing facility services are also covered.

Occupational therapy.

To be eligible for benefits, therapies must meet the following two requirements: there is a documented

condition or delay in recovery that can be expected to measurably improve with therapy within two

months of beginning active therapy; improvement would not normally be expected to occur without

intervention.

53

Screening for Blood Lead Levels Services and supplies provided in connection with screening for blood lead levels if your eligible

dependent child is at risk for lead poisoning, as determined by your physician, when the screening is

prescribed by your physician.

Skilled Nursing Facilities Skilled Nursing facilities or admissions to similar institutions; admissions primarily for the purpose of

receiving therapeutic or rehabilitative treatment, such as for oxygen therapy (for physical rehabilitations

benefits and skilled nursing facilities see Rehabilitative Therapy on page 52).

Supplemental Accident Benefit If, within 90 days after an accidental injury, you have any expenses for the following services, the PPO

Medical Coverage will pay the charges at 100% up to a maximum of $300. This benefit is not payable for

sickness, but applies to hospital and medical bills due to accident only.

Hospital, surgical and medical services

Private duty services or a Registered Nurse

Laboratory and X-ray examinations

Doctor's medical and surgical treatment

Physical therapy

Ambulance service

Well Baby and Well Child Care See Preventive Care benefits.

Extension of Coverage - Total Disability

If you or an eligible dependent is totally disabled when your eligibility terminates under this PPO Medical

Coverage, the disabled participant may be entitled to an extension of benefits for the disabling illness or

injury only, under the PPO Medical Coverage. This Extension of Coverage provision is subject to the

following rules and limitations.

Coverage under this PPO Medical Coverage will continue only for the condition causing disability,

and only for the uninterrupted continuance of the disability. Coverage for the disabling condition will

continue only for the number of months that the family member has been continuously covered under

this PPO Medical Coverage on the date of termination. In all events, coverage under this PPO Medical

Coverage will end twelve months after the initial termination of coverage or eligibility under this PPO

Medical Coverage.

Covered charges will only be applicable to the illness of injury which has caused you to be totally

disabled.

Benefits under the PPO Medical Coverage will only be provided to the disabled family member.

You must be totally disabled on the date of termination of coverage or eligibility under this PPO

Medical Coverage.

You incur an expense resulting directly from the uninterrupted existence of the disabling disability that

would have entitled you to benefits prior to the termination of eligibility under this PPO Medical

Coverage.

You are not entitled to benefits for expenses from the disabling condition under any other group

insurance policy or plan providing similar benefits on the date you incur any medical expense.

Benefits can also be continued under the PPO Medical Coverage by electing COBRA coverage. Refer to

the COBRA section beginning on page 21 for a full explanation of your COBRA rights and obligations.

54

PPO Medical Coverage Exclusions

No payment will be made under this PPO Medical Coverage for expenses incurred for or in

connection with any of the items below.

1. Cosmetic surgery is covered only if it is for the prompt and necessary repair of an injury while

you are eligible for benefits under the PPO Medical Coverage. This exclusion does not apply to

reconstructive surgery as required by the Women’s Health & Cancer Rights Act.

2. Not Medically Necessary

Charges for services or supplies not medically necessary for treatment, or which are not

recommended by the attending physician, not generally accepted medical practice, or are

experimental, are not covered. A service or supply is considered necessary only if it is broadly

accepted professionally as essential to the treatment of the disease or injury.

3. No Legal Payment Obligation

This PPO Medical Coverage does not cover any services or charges incurred for which the

member has no legal obligation to pay or that are free, including:

Charges made only because benefits are available under this PPO Medical Coverage;

Services for which the participant has received a professional courtesy discount;

Volunteer services;

Services provided by the participant for him/herself or a covered family member, or by a

person ordinarily residing in the patient’s household, or by a family member;

Physician charges exceeding the amount specified by CMS when primary benefits are

payable under Medicare.

4. Complications of Non-Covered Services

This PPO Medical Coverage does not cover any services, treatments or procedures required as a

result of complications of a non-covered service, treatment or procedure (e.g., due to a non-

covered sex change operation, cosmetic surgery or experimental procedure).

5. Experimental or Investigative.

The PPO Medical Coverage does not cover any experimental or investigative procedure or

medication. Refer to page 60 for a definition of experimental.

6. Not Covered

Services received before your effective date of coverage under this PPO Medical Coverage.

Services received after your coverage ends, except as specifically stated under the Extension of

Coverage - Total Disability section on page 53.

7. Work Related

Work related conditions if benefits are recovered or can be recovered, either by adjudication,

settlement, or otherwise, under any workers' compensation employer's liability law or occupational

disease law, even if you do not claim those benefits.

55

8. Not Specifically Listed

Services not specifically listed in this PPO Medical Coverage as covered charges or covered

expenses.

9. Services of Relatives

Professional or other services received from a person who lives in your home or who is related to

you by blood or marriage.

10. Inpatient Diagnostic Tests

Inpatient room and board charges in connection with a hospital stay primarily for diagnostic tests

which could have been performed safely on an outpatient basis.

11. Nicotine Uses

The PPO Medical Coverage does not cover smoking cessation programs or treatments of nicotine

or tobacco use.

12. Government Treatment

Any services provided by a local, state, or federal government agency, except when payment

under this PPO Medical Coverage is expressly required by federal law.

13. Government Treatment - Armed Services

Charges for services or supplies provided by reason of past or present service of any person

in the armed forces of a government. This PPO Medical Coverage does not cover services or

supplies furnished by a Veteran’s Administration facility for a service-connected disability

or while a member is in active military service.

This PPO Medical Coverage does not cover any service required as the result of any act of

war, or for any illness or accidental injury sustained during combat or active military service.

14. Custodial Care or Convalescent Care

The PPO Medical Coverage does not cover charges for custodial or convalescent care. Custodial or

convalescent care means care comprised of services and supplies, including room and board and

other institutional services, which are provided to an individual, whether disabled or not, primarily

to assist him in the activities of daily living.

Such services and supplies are custodial without regard to the practitioner or provider by whom or

by which they are prescribed, recommended, or performed.

15. Eye and Hearing

The PPO Medical Coverage does not cover charges for eye refractions or examinations for the

fitting of glasses or hearing aids, as well as expenses for eye glasses and hearing aids. See the

Vision Care section beginning on page 79 for routine vision services.

16. Non-Essential Items

Non-essential items while hospitalized, such as TV, telephone, guest trays and other personal items,

obtaining photocopies of records, etc.

17. Sex Change Operation and Services - Sexual Dysfunction Treatment

All services related to sex change operations, reversals of such procedures or complications

arising from trans-sexual surgery.

Services related to the treatment of sexual dysfunction.

56

18. Dental

Expenses incurred in connection with services performed on or to the teeth, including

orthodontics, nerves of the teeth, gingivae, or alveolar processes, except to tumors or cysts or as

otherwise specifically included herein. Any dental expense covered under the Delta Dental

Coverage as described in this SPD is not a covered expense under this PPO Medical Coverage.

19. Charges for senile deterioration, mental deficiency, mental retardation, attention deficit

disorder and learning disabilities

20. Charges for radial keratotomy

21. Charges for reverse, voluntary, surgically induced infertility and sterility for purposes of

fertility again.

22. Loss caused by accidental bodily injury or illness which arises out of or occurs in the course of

any occupation or employment for wage or profit.

23. Hospital admissions on Friday and Saturday are not payable unless an emergency, or are

approved in advance by Anthem Blue Cross. Avoid Friday and weekend elective procedures

and/or admissions.

24. All surgical and medical procedures for weight loss are generally excluded services under this

PPO Medical Coverage. This includes, but is not limited to, gastric bubble procedures, special

diets and dietary supplements, acupuncture, biofeedback, hypnosis, exercise programs, gastric

bypass, gastric stapling, intestinal bypass and weight management programs. The treatment plan

for morbid obesity as a life threatening illness must be approved, in advance, by Anthem Blue

Cross, for any benefits to be considered as covered charges.

25. Vitamins

This includes vitamins and vitamin injections, except B-12 for pernicious anemia, malabsorption

and following major abdominal surgery.

26. Whole Blood

Whole blood when replaced.

27. Telephone Consultations

28. Excluded Expense for Non-Contracting Doctors and Hospitals

Benefits for non-contracting doctors and hospitals (not part of Anthem Blue Cross) are based on

UCR charges. Charges in excess of the following will not be considered covered expenses:

1) The charge usually made for it by the provider who furnishes it, or

2) The prevailing charge made for it in the same geographic area, by those of similar

professional standing.

29. Air Conditioners

This includes air purifiers, air conditioners, or humidifiers.

30. Exercise Equipment

Exercise equipment, or any charges for activities, instrumentalities, or facilities normally intended

or used for developing or maintaining physical fitness, including but not limited to, charges from a

physical fitness instructor, health club or gym, even if ordered by a physician.

31. Personal Items

This includes any supplies for comfort, hygiene, or beautification.

57

32. Birth Control Pills.

Note: Birth Control pills are a covered benefit under the prescription drug plan; refer to the

separate Prescription Drug Coverage section beginning on page 70. An IUD is a covered benefit

under the PPO Medical Coverage with a doctor’s written prescription.

33. Charges incurred outside the United States except for emergency treatment

Provided that if evidence of permanent residency in a foreign country is demonstrated, the Board

of Trustees will review payment of the benefits.

34. Charges for toenail trimming, shoe inserts, manipulation of the feet, fallen arches or flat feet,

gait analysis and minor foot diseases such as athlete’s foot

35. Duplicate (Double) Coverage

This PPO Medical Coverage does not cover amounts already paid or payable by other valid

coverage.

36. Duplicate Testing

This PPO Medical Coverage does not cover duplicative diagnostic testing or over reads of

laboratory, pathology or radiology tests.

37. Hair Loss Treatments

This PPO Medical Coverage does not cover wigs, artificial hair pieces, hair transplants or

implants, or medication used to promote hair growth or to control hair loss, even if there is a

medical reason for hair loss.

38. Hypnotherapy

This PPO Medical Coverage does not cover hypnosis or services related to hypnosis, whether for

medical or anesthetic purposes.

39. Long Term or Maintenance Therapy

This PPO Medical Coverage does not cover long-term therapy if the participant’s physician

does not believe measurable improvement is possible within two months of beginning active

therapy.

This PPO Medical Coverage does not cover any treatment that does not significantly enhance

or increase the patient’s function or productivity or care provided after the patient has reached

his/her rehabilitative potential.

40. Immunizations required for international travel

41. Charges for Broken or Missed Appointments

42. General Services

Services related to routine physical or screening exams and immunizations given primarily for

insurance, licensing, employment, camp, weight reduction programs, medical research programs,

sports, or for any non-preventive purpose.

43. Biofeedback

This PPO Medical Coverage does not cover services related to biofeedback.

44. Domiciliary Care

This PPO Medical Coverage does not cover domiciliary care or care provided in a residential

institution, treatment center, half-way house or school because a member’s own arrangements are

not available or are unsuitable, and consisting primarily of room and board, even if therapy is

included.

45. Sleep Disorders

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There are no benefits for the treatment of sleep disorders

46. Chemical Dependency Treatment

Psychoactive substance abuse, without dependence.

47. Administrative Services

Services such as expert testimony, medial records review and maintenance, preparation of reports

regarding civil or legal matters (child custody issues), ability to stand trial, consultation with

attorneys or other representations of social control systems.

48. Consultation with a counselor or professional for adjudication of marital, child support and

custody cases.

49. Damage to a hospital or approved treatment facility caused by a participant. The actual cost of

such damage may be billed directly to the participant.

50. Training or education therapy for learning disabilities or other educational services.

51. Court Ordered mental health and substance use disorder testing.

General Provisions Relating to the PPO Medical Coverage

A) Coverage is non-occupational. Only non-job-related accidental bodily injury and non-job-related

diseases are covered.

B) Coverage is provided only for charges, services, and supplies furnished to an individual while

eligible. Also, coverage for hospital confinement begins while eligible.

C) Any coverage provided for charges by a physician will be recognized only if they are made by a

legally licensed physician. No charges for the services of a hospital resident or intern are covered.

D) The PPO Medical Coverage has a complete definition of a hospital. Briefly, the definition of a

hospital includes almost all community general hospitals, but some hospitals are excluded. Any

questions about recognition of a hospital under the definition should be referred to the ZAS

Claims Office before confinement.

E) Charges related to pregnancy are covered as any other illness.

F) Refer to the sections entitled, PPO Medical Coverage Exclusions beginning on page 54, and also

note that certain limitations appear in the various coverage descriptions.

Definitions Applicable to the PPO Medical Coverage

Allowable Expense An expense or charge shall be an Allowable Expense only if Anthem Blue Cross and the Trustees in their

sole discretion determine that:

It is recommended and approved by a physician and is for a valid course of medical treatment,

which is not experimental, which is expected to lead to the cure and/or rehabilitation of the patient

and which is recognized as valid by an established medical society in the United States, provided

that the Plan may obtain and rely upon independent medical advice to determine whether services

or supplies are necessary for such medical treatment, are consistent with professionally recognized

standards of care with regard to quality, frequency, and duration, and are provided in the most

economical and medically appropriate site for treatment.

59

If a Program provides benefits in the form of services rather than cash payment, the reasonable cash value

of each service rendered shall be deemed to be both an Allowable Expense and a benefit paid.

Ambulatory Surgical Facility An appropriately licensed provider with an organized staff of physicians that meets all of the following

criteria:

Has permanent facilities and equipment for the primary purpose of performing surgical procedures

on an outpatient basis; and

Provides treatment by or under the supervision of physicians and nursing services whenever the

patient is in the facility; and

Does not provide inpatient accommodations; and

Is not a facility used primarily as an office or clinic for the private practice of a physician or other

provider.

Anthem Blue Cross of California (Blue Cross)

Anthem Blue Cross of California is a health care service plan regulated by the California Department of

Corporations.

Anthem Blue Cross Prudent Buyer PPO The Board of Trustees has entered into an agreement with Anthem Blue Cross of California to utilize the

Anthem Blue Cross Prudent Buyer PPO. Anthem Blue Cross has contracted with selected hospitals, doctors

and other health care providers (called Prudent Buyer Providers) who have agreed to certain fixed fees and

rates. Anthem Blue Cross Prudent Buyer PPO is organized to assist its members in providing cost-

containment for health care services at reasonable costs.

Approved Treatment Facility An approved treatment facility means a facility that provides treatment for mental health or chronic

alcoholism and/or substance abuse and that is operating under the direction and control of the appropriate

licensing or regulatory agency of the jurisdiction in which the facility is located.

Birth Center An approved facility that meets professionally recognized standards and all of the tests that follow:

It mainly provides an outpatient setting for childbirth following a normal, uncomplicated pregnancy;

It has at least two birthing rooms, all the medical equipment needed to support the services furnished

by the facility, laboratory diagnostic facilities, emergency equipment, trays and supplies for use in life

threatening events;

It has a medical staff that is supervised full time by a physician and includes a registered nurse at all

times when patients are in the facility;

It has written agreements with a local acute care hospital and a local ambulance company for the

immediate transfer of patients who require greater care than can be furnished by the facility;

It admits only patients who:

(a) have undergone an educational program to prepare them for the birth; and

(b) have records of adequate prenatal care;

It schedules stays of not more than 48 hours for a vaginal birth;

It maintains a medical record for each patient;

It complies with all licensing and other legal requirements that apply;

It is not the office or clinic of one or more physicians;

It is not a hospital; and

It is JACHO-approved.

Claims Administrator Claims Administrator refers to Zenith American Solutions, Inc. (ZAS). ZAS shall perform all

administrative services in connection with the processing of claims under the PPO Medical Coverage.

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Claims Determination Period The period January 1 through December 31 of any calendar year, based on the date the service was

provided.

Contracting and Non-Contracting Hospitals Another type of provider is the "contracting hospital." This is different from a hospital which is a preferred

provider. Contracting hospitals have agreed to provide a discount to Anthem Blue Cross, but it is less

favorable than a Prudent Buyer hospital. Non-contracting hospitals have agreed to no discount. When a

Participant uses a non-contracting hospital, he/she will be responsible for all charges incurred after the

application of the benefits of this PPO Medical Coverage, based on Allowable Expense and/or Covered

Charges.

Covered Charges and/or Covered Expenses Charge or expenses incurred and expressly provided for under the various benefits of this PPO Medical

Coverage, incurred while eligible for the benefits of the PPO Medical Coverage and deemed to be

medically necessary by the Board of Trustees based on medical advice provided to the Board of Trustees,

or opinion(s) rendered from an independent medical review.

All covered charges and/or covered expenses are subject to the limitations and exclusions of this summary

plan description. All covered charges and/or covered expenses are subject to the PPO Medical Coverage’s

deductible, co-insurance, co-payment and any out-of-pocket limit provisions.

Durable Medical Equipment (DME) This includes medically recognized standard items of DME that adequately meets the medical needs of the

participant and is provided in accord with Medicare guidelines. In order to be a covered benefit, the DME

must be prescribed by a licensed medical doctor and must be an essential, standard, medical treatment for

non-occupational illness, disease or accidental injury.

"Durable" means that the DME must be able to withstand repeated use without significant deterioration,

customarily serves a medical purpose, generally are not useful in the absence of illness or injury and are not

disposable. The item may be rented, leased, or purchased. If rented or leased, the Plan will only provide

reimbursement up to the usual, customary and reasonable cost of the equipment, not to exceed the purchase

price.

Emergency Care An emergency medical condition is a medical condition manifesting itself by acute symptoms of sufficient

severity (including severe pain) such that the Participant, as a prudent layperson, could reasonably expect

the absence of immediate medical attention to result in any of the following:

Placing the Participant’s health in serious jeopardy,

Serious impairment to his or her bodily functions;

A serious dysfunction of any bodily organ or part; or

Active labor, meaning labor at a time that either of the following would occur:

– There is inadequate time to effect a safe transfer to another hospital prior to delivery;

– Or a transfer poses a threat to the health and safety of the Participant or unborn child.

Hospital emergency care at a non-PPO facility for an Emergency Medical Condition (see above) will be

paid at 90/10% co-insurance provided the facility agrees to lower the charges through negotiations, or

alternately, Anthem Blue Cross, certifies that the charges are usual, customary and reasonable for such

emergency services.

Experimental or Investigative All procedures generally recognized by the national medical community and its societies as experimental or

investigative, including services which are solely and explicitly related to these procedures. A treatment

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procedure will be deemed experimental if scientific evaluation thereof has not been completed and/or

effectiveness thereof has not been established. No benefit will be payable for investigational or

experimental treatment or surgery not covered by Medicare, all of which will be excluded as an Allowable

Expense under the PPO Medical Coverage.

Hospital A health care institution offering facilities, which provides 24-hours a day, seven days a week the

diagnosis, treatment and care of persons who need acute inpatient hospital care under the supervision of

physicians. It must be licensed as a general acute care hospital according to state and local laws. It must

also be registered as a general hospital by the American Hospital Association and meet accreditation

standards of the Joint Commission on Accreditation of Health Care Organizations.

Infertility Infertility is:

1) The presence of a condition recognized by a physician as a cause of infertility; or

2) The inability to conceive a pregnancy or to carry a pregnancy to a live birth after a year or more of

regular sexual relations without contraception.

Medically Necessary The services or supplies provided by a hospital, physician, or other provider of health care, that are required

to identify or treat a participant's illness or injury and which as determined by the Plan, are:

1) Consistent with the symptom(s) or diagnosis and treatment of a participant's condition, disease,

ailment, or injury;

2) Appropriate with regard to standards of good medical practice and could not have been omitted

without adversely affecting the participant's condition or the quality of medical care rendered;

3) Not primarily for the convenience of the participant, physician, hospital or other provider; and

4) The most appropriate supply or level of service which can be safely provided to a participant.

When specifically applied to an inpatient, it further means that the participant's medical symptoms or

condition require that the diagnosis or treatment cannot be safely provided to the participant as an

outpatient.

The fact that a physician, hospital, or other provider may prescribe, order, recommend, or approve a service

or supply does not, of itself, make it medically necessary or make the charge an allowable expense, even

though it is not specifically listed as an exclusion. The Board of Trustees, relying on an expert independent

medical opinion, will determine if a service or supply is an allowance expense.

Mental – Nervous – Chemical Dependency Illness A mental, nervous, or chemical dependency illness is any disorder that involves a clinically-significant

behavioral or psychological syndrome or pattern; is associated with serious symptoms; impairs a

participant’s ability in one or more major life functions or activities; and is not solely a character disorder,

problem of living, or for personal exploration, desire of self-fulfillment, or forensic evaluation as listed or

defined in the latest edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM, American

Psychiatric Association).

Non-Occupational Disease A disease which is not caused or contributed to or by, or as a consequence of any disease which arises out

of or in the course of any employment or occupation for compensation or profit. However, if evidence

satisfactory to the Trustees is furnished that the individual concerned is covered as an employee under any

workers’ compensation law, occupational disease law, or any other legislation of similar purpose, or under

the maritime doctrine of maintenance, wages, and cure, but that the disease involved is one not covered

under the applicable laws or doctrine, then that disease shall for the purposes of this PPO Medical

Coverage, be regarded as a non-occupational disease.

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Non-Occupational Injury An accidental bodily injury which is not caused or contributed to or by, or as a consequence of, any injury

which arises out of or in the course of any employment or occupation for compensation or profit.

Non-Preferred Providers Non-preferred providers are providers, which have not agreed to participate in the Prudent Buyer Coverage

network. They have not agreed to the negotiated rates and other provisions of a Prudent Buyer Coverage

contract.

Participant The term “Participant” applies to all eligible employees and their dependents that are eligible for benefits

under this PPO Medical Coverage.

Physician Physician means:

1) A doctor of medicine (M.D.) or doctor of osteopathy (D.O.) who is licensed to practice medicine or

osteopathy where the care is provided; or

2) One of the following providers, but only when the provider is licensed to practice where the care is

provided, is rendering a service within the scope of that license, is providing a service for which

benefits are specified in this PPO Medical Coverage section and when benefits would be payable if the

services were provided by a physician as defined above:

a) A dentist (D.D.S.)

b) A podiatrist or chiropodist (D.P.M., D.S.P., or D.S.C.)

c) A psychologist

d) A chiropractor (D.C.)

e) An acupuncturist – doctor of oriental medicine (D.O.M .)

f) A clinical social worker (L.C.S.W.)

g) A marriage, family, and child counselor (M.F.C.C.)

h) A physical therapist*

i) A speech pathologist*

j) A registered nurse (R.N.)*

k) A vocational nurse (L.V.N.)*

l) A respiratory care practitioner (R.C.P.)*

m) A physician’s assistant (P.A.)*

n) A licensed midwife**

* The providers indicated by asterisks (*) are covered only by referral and supervision of a physician as

defined in 1 above.

** Services provided by midwives are a covered expense only for deliveries performed at either a birth

center or hospital as defined by the PPO Medical Coverage.

Plan Year This includes period of January 1 of any year to December 31 of that year.

Prior Authorization A requirement that you or your provider must obtain authorization from Anthem Blue Cross before you are

admitted (non-emergency) as an inpatient (admission review approval) or receive certain types of services

(other prior approvals).

Program Any plan providing benefits or services for or by reason of Covered Expenses, which benefits or services

are provided by a) group practice, individual practice or other prepayment coverage, b) any coverage under

labor-management trusted program, union welfare plans, Employer organizations plans, and c) any

coverage under governmental programs and any coverage required or provided by any statute, or Title

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XVIII of the Social Security Act of 1965 (Medicare) Parts A and B, as amended, whether or not the Person

has enrolled for Part B.

Prudent Buyer Providers Anthem Blue Cross has established a network of various types of "Preferred Providers." These providers

are called "preferred" because they have agreed to participate in the Anthem Blue Cross preferred provider

organization (PPO) program, which is called the Prudent Buyer Coverage. These providers have agreed to

provide members with health care at a reduced cost.

Skilled Nursing Service – Room and Board Room and board and skilled nursing services, when provided to an individual in a hospital or skilled

nursing facility that is licensed in accordance with state or local law; and is approved as a Medicare-

participating facility; and is primarily engaged in providing in-patients skilled nursing care under the

supervision of a duly licensed physician; and provides continuous 24-hour nursing service under the

supervision of a registered nurse; and does not include any facility that is primarily a rest home, facility of

the care of the aged or for care and treatment for custodial or educational care.

To be a covered benefit, skilled nursing services must be combined with other necessary therapeutic

services and supplies in accordance with generally accepted medical standards to establish a program of

medical treatment which can reasonably be expected to contribute substantially to the improvement of the

individual’s medical condition.

Totally Disabled and/or Total Disability The employee, due solely to injury or illness, is wholly prevented from performing any work or engaging in

any occupation for remuneration or profit; with respect to dependents, the inability to engage in normal

activities because of bodily injury or sickness.

Transplant Services Transplant – a surgical process that involves the removal of an organ from one person and placement of the

organ into another. Transplant can also mean removal of organs or tissue from a person for the purpose of

treatment and re-implanting the removed organ or tissue into the same person.

Transplant related services – any hospitalizations and medical or surgical services related to a covered

transplant or re-transplant and any subsequent hospitalizations and medical or surgical services related to a

covered transplant or re-transplant and received within one year of the transplant or re-transplant.

Usual, Customary and Reasonable Charges or Charges (UCR) A charge meaning the "Usual, Customary and Reasonable” charge (UCR). A charge is UCR when it

matches the average community charge for a given service by a doctor or other provider of medical

services. The charge is "customary" when it is within the range of the usual charges made by providers of

medical services, with similar training and experience, for the same service within the same specific and

limited area (socio-economic area of a metropolitan area or socio-economic area of a county). Anthem Blue

Cross will determine the allowance for UCR. If Anthem Blue Cross does not establish a UCR allowance,

the UCR allowance will be determined by professional medical review.

You (Your) You (your) refers to the participant (employee and/or dependents) who are eligible for the benefits of the

PPO Medical Coverage.

Subrogation

Benefits provided under the PPO Medical Coverage are subject to reimbursement by the participant when

the medical condition is caused by the acts of a third party. Third party means that injuries sustained by you

were the result of the fault (negligence, carelessness, or intentional act) of a third party or parties. Under

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these circumstances, what is called a “Subrogation Agreement” must be signed by you before Plan benefits

are payable. The following are the PPO Medical Coverage rules pertaining to subrogation.

If a participant receives benefits from this Plan for an injury or illness sustained from the acts or omissions

of any third party, the Plan has the right to be reimbursed in the event the participant recovers all or any

portion of the benefits paid by the Plan by legal action, settlement, or otherwise, regardless of whether the

benefits were paid by this Plan prior to or after the date of recovery. The participant will not be entitled to

receive any benefits for those expenses under this Plan unless the participant executes a Subrogation

Agreement and agrees in writing to the following conditions:

A. Reimbursement to Plan. The participant authorizes reimbursement to the Plan upon

obtaining any monetary recovery from any party or organization for such injury or illness, whether

by action at law, settlement or otherwise by virtue of executing a Subrogation Agreement, with the

understanding that any and all monies recovered as a result of the actions of a third party will be

reimbursed to the Plan in accordance with these provisions.

B. Assignment of Rights. The participant irrevocably assigns to the Plan all rights to

recover monetary compensation from the third party to the extent of all benefits paid by this Plan

and to give notice of this assignment directly to the third parties, their agents, or insurance carriers,

or to any agent or attorney who may represent the participant. The assignment shall also entitle the

Plan to reimbursement from any sums to be held or received by the following third parties which

are due the participant prior to any distribution to the participant, and shall provide that these

parties will specifically direct that any and all monies recovered from any third party are to be

reimbursed to the Plan in accordance with these provisions. The parties who shall be bound by this

assignment are:

(1) Any party or its insurance carriers making payments to or

on behalf of the participant, including pursuant to any

uninsured or under-insured motorist provision of any

insurance policy; and

(2) Any agent or attorney receiving payments for or on behalf

of the participant.

C. Notice. The participant agrees to notify the Plan of any claim or legal action asserted

against any third party or any insurance carrier(s) for such injuries or illnesses, as well as the name

and address of the third parties, insurance carrier(s), any agent or attorney who is representing or

acting on behalf of the participant or the estate of the participant, or any person claiming a right

through the participant, on a form to be supplied by the Plan.

D. Schedule of Reimbursement. The Plan shall be reimbursed in accordance with the

following schedule based on the net recovery received by the participant from all sources, whether

from more than one tortfeasor, under any workers’ compensation law or otherwise:

Net Recovery Trust Reimbursement

2 times or more the benefits paid by the Plan 100% of benefits paid

1½ times or more the benefits paid by the Plan 75% of benefits paid

Equal or more to the benefits paid by the Plan 66 % of benefits paid

½ or more of the benefits paid by the Plan 50 % of benefits paid

Less than ½ of the benefits paid by the Plan 33 % of benefits paid

For the purpose of this Section, "net recovery" means the actual amount to be received by the

participant from all sources after deducting all attorney’s fees and court costs actually incurred.

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In no event will the Plan’s recovery exceed the amount of all proceeds received by the participant

from the third party or its insurers.

E. Subrogation. The Plan shall have the independent right to bring suit in the name of the

participant. The Plan shall also have the right to intervene in any action brought by the participant

against any third party, to and including the insurance carrier of the participant under any

uninsured or under-insured motorist provision or policy. The participant further agrees to take no

action inconsistent with the requirements of this provision.

F. Cooperation with Plan. The participant agrees to cooperate fully with the Plan in the

exercise of any Assignment or right of Subrogation, and not to take any action or refuse to take

any action which would prejudice the rights of the Plan.

G. Withholding Future Benefits. The participant agrees to acknowledge that this Plan has

the Right of Recovery against the participant, should the participant and/or their legal

representative fail to execute an Assignment, Subrogation Agreement or any other documents

required herein, or fail to reimburse the Plan in accordance with these provisions. In addition, in

such event, the Plan may withhold future benefit payments to be made on behalf of the participant

until such time as the Plan is fully reimbursed as provided in this Section.

H. Disclaimer. If there is any reasonable cause to believe that the injuries or illnesses

sustained by a participant were in any way the result of the acts or omissions of a third party or

parties, but the participant disclaims any third party involvement, the Plan shall have the right to

require the participant to sign a declaration, under penalty of perjury, regarding such disclaimer as

a pre-condition to the payment of any benefits.

I. Separate Rights. Each of the provisions set forth above relating to the right of this Plan

to receive reimbursement for eligible expenses paid to or on behalf of a participant because of

injuries sustained relating to or resulting from the acts and omissions of any third party is separate

and any illegality or invalidity of any one provision shall not affect the legality or validity of any

other provision.

J. Medical Expenses Incurred After Settlement or Final Judgment in Third Party

Claim. In the event a participant incurs medical expenses relating to his or her injuries or

disabilities, which are the subject of a Subrogation Agreement following any settlement or final

judgment received from the third party(ies) responsible for the injuries, the Plan shall have no

responsibility to pay for those medical expenses. The participant must agree to release and hold

the Plan harmless from any further obligations under the Subrogation Agreement for any future

medical expenses incurred following any settlement or final judgment received from the third

party(ies) responsible for the injuries. However, provisions can be made by the participant for the

continued payment of such medical expenses by the third party(ies) pursuant to a settlement

agreement which must be approved by the Plan in writing prior to its execution. In that event, the

rights of the participant to the continued payment of medical expenses shall also be assigned to the

Plan under the Subrogation Agreement and the participant shall be required to reimburse the Plan

for 100% of all medical expenses paid by the Plan under this provision following execution and

payment by the responsible third party(ies) under the settlement agreement or final judgment.

K. This Plan does not recognize the Make-Whole Doctrine. This Plan is entitled to obtain

restitution of any amounts owed to it either from third-party plans received by the participant,

regardless of whether the participant has been made whole for losses sustained as a result of the

acts or omissions of a third party.

L. This Plan expressly rejects the Common Plan Doctrine with respect to payment of

attorney’s fees. A Plan representative may commence or intervene in any proceeding or take any

other necessary action to protect or exercise this Plan’s equitable (or other) rights to obtain full

restitution.

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M. Cooperation with The Plan. The participant, as well as the participant’s attorney or

agent, shall cooperate fully with the Trustees in the exercise of any Assignment or right of

Subrogation, and not to take any action or refuse to take any action which would prejudice the

rights of the Plan.

N. Acknowledgment by Agent or Attorney. The agent or attorney for the participant

must acknowledge that no claim for benefits under the Plan will be processed or paid by the Plan

until the Administrative Office receives a duly executed acknowledgment of the terms of the

required Subrogation Agreement from the agent or the attorney of the participant in the form and

content acceptable to the Plan. The participant shall direct that the agent or attorney shall readily

comply with the terms of the Subrogation Agreement to reimburse the Plan in accordance with the

Reimbursement Schedule as outlined above.

When Do I Report Claims?

Report medical expense claims promptly when any individual has incurred expenses in any given calendar

year. The Plan only covers claims that are filed with Anthem Blue Cross within one year of the date

services were provided.

Payment to Providers

The PPO Medical Coverage will pay benefits directly to contracting hospitals, participating providers,

Centers of Excellence (COE) and medical transportation providers. Also, the PPO Medical Coverage will

pay non-contracting hospitals and other providers of service directly when the participant assigns benefits

in writing.

Keeping Records of Medical Expenses

Keep complete records of medical expenses for each covered individual. They will be required when a

claim is made.

Very important information to keep includes:

A) Names of doctors and others who furnished medical services;

B) Dates expenses are incurred; and

C) Copies of bills and receipts.

Coordination of Benefits

When you or your eligible dependents are covered under more than one group plan, health care expenses

are charged first against one plan, up to that plan’s limits. Any remaining expenses are charged to the

second plan. Determination of what plan pays first depends on which of the plans is the “primary plan”

and which is the “secondary plan.” The primary plan pays first.

Coordination of benefits set out rules for the order of payment of covered charges when you are covered by

two or more plans, including Medicare.

If you are eligible to receive benefits from another plan, such as your spouse’s plan, or your children are

covered under two or more plans, the plans will coordinate benefits when a claim is received so that the

total amount you can receive from all plans is not more that 100% of your allowable expenses.

Benefits will be coordinated with any of the following:

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Union-management welfare plans, employer or organization plans, or employee benefit plans,

labor-management trusteed plans, or other plans for members of a group;

Group or blanket benefit plans;

Blue Cross and Blue Shield group plans;

Group practice and other group prepayment plans;

Coverage other than school accident-type coverage;

Federal government plans or programs, including Medicare;

Other plans required by or provided by law. This does not include Medicaid or any benefit

plan like it that, by its terms, does not allow coordination; and

No-Fault auto insurance, by whatever name it is called, when coordination is not prohibited

by law.

Benefit Determination

When two or more plans provide benefits for the same claim, the benefits will be paid according to the

following order:

Plans that do not have a coordination provision will pay first. Plans with such a provision will

be considered after those without one;

Plans with a coordination provision will pay their benefits by the following order up to the

allowable charge:

1) The benefit plan that covers the patient as an employee or participant will be considered

before a benefit plan that covers the patient as a dependent;

2) When a child is covered as a dependent and the parents are not legally separated or

divorced, an order of payment called the “birthday rule” applies. The benefits of the plan

of the parent whose birthday falls earlier in a year are determined before those of the

benefit plan of the parent whose birthday falls later in that year. If both parents have the

same birthday, the benefits of the plan that has covered the parent longer are determined

before those of the plan that covers the other parent. If the other plan does not provide

for this order of payment, but instead has a rule based on gender of the parent, and if, as a

result, the plans do not agree on the order of benefits, the gender rule will determine the

order of benefit;

3) When a child’s parents are divorced or legally separated, the following order of payment

applies: First, the plan of the parent with legal custody of the child; then the plan of the

spouse of the parent with legal custody of the child; finally the plan of the parent not

having custody. However, if the specific terms of a court decree state that one of the

parents is responsible for the health care expenses of the child and the plan of that parent

has been notified of those terms, the benefits of that plan are determined first. This does

not apply with respect to any calendar year during which any benefits are actually paid or

provided before the plan has been notified. If the specific terms of a court decree state

that the parents will share joint custody, without stating that one of the parents is

responsible for the health care expenses of the child, the order of benefit determination

will be the same as for a married couple that is not separated or divorced; and

4) If a person whose coverage is provided under a right of continuation according to a

federal or state law also is covered under another plan, this is the order of benefit

determination: First, the benefits of the plan covering the person as an employee,

member or subscriber (or as that person’s dependent); and second, the benefits under the

continuation coverage. If the other plan does not follow this order of benefit

determination, and if, as a result, the plans do not agree on the order of benefits, this rule

does not apply.

This PPO Medical Coverage will pay as primary coverage except when otherwise permitted

under Federal law or regulation, to be the secondary payor to Medicare. An active employee

or employee’s spouse, age 65 or older, may reject coverage under this PPO Medical

Coverage, in which case Medicare shall be the primary provider of medical expense benefits

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for that person. If Medicare is the primary provider, then benefits from this PPO Medical

Coverage shall be payable, as provided by government regulations.

For situations not covered by the above rules, of for which the above rules conflict, the plan

that has covered the patient longer will be considered first.

Right to Receive and Release Necessary Information

Certain facts are needed to apply these Coordination of Benefits rules. The claim administrator has the

right to decide which facts it needs. The claim administrator may get needed facts from or give them to any

other organization or person. The claim administrator need not tell, or get the consent of, any person to do

this. Each person claiming benefits under this PPO Medical Coverage must give the claim administrator

any facts it needs to pay the claim.

Right of Payment and Recovery

If by mistake, another plan makes a payment which should have been paid under this PPO Medical

Coverage, then this PPO Medical Coverage may reimburse the other plan for the payment. That payment

will then be treated as though it were a benefit paid under this PPO Medical Coverage. This PPO Medical

Coverage will not have to pay that amount again.

If the amount of payments made by this PPO Medical Coverage is more than it should have paid under the

coordination of benefits provision, it may recover the excess from one or more of the persons it has paid or

for whom it has paid, or insurance companies or other organizations. The amount of payments made

includes the reasonable cash value of any benefits provided in the form of services.

Filing a Claim

You are responsible for following the correct procedures in filing a claim under these COB rules. These

guidelines will help you:

1) First, send your completed claim form and copies of your bills to the primary plan. Wait to

receive payment from the primary plan before proceeding to the next step.

2) Then, send copies of claim forms, bills, EOB, check, etc. to the secondary plan. The secondary

plan will send you (or the provider of services if you direct the plan to pay the provider) a check

for any benefits due on the remaining covered expenses.

How Medicare Affects Coverage If you or your spouse are covered as an active employee under this PPO Medical Coverage and are age 65

or older and are eligible for Medicare, OR you are eligible for Medicare for any other reason, such as Total

and Permanent Disability, this PPO Medical Coverage will remain as the primary coverage for coordination

of benefits purposes.

Therefore, benefits for you or your spouse will remain the same as before. All bills should be presented to

the PPO Medical Coverage first. When the PPO Medical Coverage evaluates and processes the claim(s),

inform the provider of services to submit a copy of the PPO Medical Coverage’s Explanation of Payment

with the corresponding itemized bill to Medicare with their Request for Medicare Payment form. Medicare

will evaluate the payment(s) made by the Plan and may issue payment as secondary carrier. In no event

will the sum of the two payments exceed 100% of your expenses.

Exception to Above This PPO Medical Coverage will be primary unless you elect in writing to drop this PPO Medical

Coverage and to take Medicare as your primary hospital and medical coverage. If you elect Medicare as

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primary coverage, this PPO Medical Coverage is precluded by government regulations from providing

secondary hospital and medical coverage to supplement Medicare. If your spouse becomes eligible for

Medicare before you, the decision to elect either this PPO Medical Coverage or Medicare as primary

hospital and medical coverage must be made at that time, but your coverage under this PPO Medical

Coverage will be unaffected by that decision until you become eligible for Medicare.

Whether or not you elect this PPO Medical Coverage as primary, it is very important that you sign up for

Medicare on or before your eligibility date to avoid late enrollment fees and to be sure your coverage is in

force when your eligibility under this PPO Medical Coverage ends.

Health Care Fraud Information

Health care and insurance fraud results in cost increases for all health plans. You can help prevent health

care fraud by being aware of the following.

Be careful of offers to waive co-payments, deductibles, or co-insurance. These costs may be passed

along to you in other ways.

Be careful of mobile health testing labs. Ask what your health care plan will be charged for the tests

and check with your doctor before submitting to any testing.

Review the bills from your providers and the Explanation of Benefits (EOB) you receive from the

claims administrator. Verify that services for all charges were received, if there are any differences,

contact Zenith American Solutions Claims’ Administrators.

Be very careful about giving information about your health care coverage over the telephone.

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Prescription Drug Coverage

This Prescription Drug Coverage section does not apply to participants in the Kaiser HMO Coverage; those

participants receive their prescription drug benefit from Kaiser.

The Prescription Drug Coverage is designed to help you meet the cost of prescription drugs prescribed by

your doctor for you or your eligible dependents for the treatment of illness or injury.

You must use a generic drug whenever it is available. A generic drug is identified by its official chemical

name rather than a brand name because of existing patent laws. Some medications are supplied only under

their trademarked brand names.

To summarize, below is an outline of the Prescription Drug Coverage benefits.

Generic Drugs Brand Name Drug

with NO generic equivalent

Brand Name Drug

with generic available

Walk-In Pharmacy Coverage – (30-day supply)

$5 co-payment $15 co-payment $15 plus the difference in

cost between generic and brand

name

Mail Order Pharmacy Coverage – (100-day supply)

$5 co-payment $15 co-payment $15 plus the difference in

cost between generic and brand

name

Whether through Walk-In Pharmacy Coverage or Mail Order Pharmacy Coverage, if you or your

doctor request a brand name drug instead of a generic equivalent, you will be charged the difference

in cost between the brand name drug and the generic, in addition to the $15 co-payment instead of

the $5 co-payment. However, if your doctor determines that a brand name drug is medically

necessary, then your doctor must request a prior authorization from OptumRx by calling (800) 711-

4555. If OptumRx approves the request, then you will be charged the co-payment for the brand

name drug only and not the difference between the brand and generic drug cost. If OptumRx denies

the request, you may appeal the denial pursuant to the Claims and Appeal section as described on

page 91.

To fill your prescription, you can use any of the following:

OptumRx Walk-In Pharmacy Coverage (contracted network of national pharmacies)

OptumRx Mail Order Pharmacy Coverage

Each Coverage is described in greater detail in the following sections.

Walk-In Pharmacy Coverage $5 Co-payment for a generic prescription for a 30-day supply,

$15 Co-payment for a brand name prescription for a 30-day supply

To obtain a prescription, you must use a network pharmacy. The OptumRx pharmacy network is extensive

and includes most major chains and many independent pharmacies An up-to-date listing of nationwide

pharmacies can be found online at www.optumrx.com or you can call OptumRx Customer Service toll-free

(800) 797-9791 to find the pharmacy nearest you.

You simply pay directly to the pharmacy a co-payment for each prescription. The Prescription Drug

Coverage allows up to a 30-day supply. For maintenance drugs you can get up to a 100-day supply by

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using the Mail Order Coverage, as explained in the following section. As a cost-containment feature, the

Prescription Drug Coverage requires that you use a generic drug when it is available.

Here's how the Walk-In Pharmacy Coverage works:

When your doctor issues you a prescription, you must have it filled by a participating pharmacy in

the OptumRx network.

Go to a network pharmacy and present your OptumRx Drug Identification Card and your

prescription. Do not give the pharmacist a health coverage identification card, such as Health Net,

Kaiser, or Anthem Blue Cross. Tell the pharmacist you are eligible under the Cement Masons

Southern California Health & Welfare Plan, administered by OptumRx. The pharmacist will then

ask for personal identification and the Social Security number of the employee eligible under the

Plan. With this information the drug benefit can be processed at the pharmacy

You will then pay your $5 co-payment for generic medications, or $15 co-payment for brand

name, to the pharmacist. The Plan pays the rest and there is no need for you to file a claim.

It is important to note, however, that if the prescription calls for a brand name drug, the pharmacist will

dispense the generic drug whenever a generic equivalent is in stock and may legally be substituted for the

prescribed brand name.

Mail Order Pharmacy Coverage (for Maintenance Prescriptions) $5 Co-payment for a generic prescription for a 100-day supply

$15 Co-payment for a brand name prescription for a 100-day supply

Mail Order Pharmacy Coverage is available for maintenance drugs. Maintenance medications are

prescribed for such conditions as high blood pressure, diabetes, heart disease, ulcers, and arthritis. You may

obtain up to a 100-day supply of a maintenance drug for a $5 generic/ $15 brand name co-payment.

Maintenance drugs will be mailed directly to your home by OptumRx. Your prescription should arrive

within seven working days after your order is received at the OptumRx Mail Order Pharmacy. OptumRx

pays all mailing expenses for standard deliveries.

It is important to note, however, that if the prescription calls for a brand name, the pharmacist will dispense

the generic drug whenever a generic equivalent is in stock and may legally be substituted for the prescribed

brand name.

Your co-payment can be paid by check, money order, or credit card. Your prescription can be sent in a pre-

printed envelope supplied by OptumRx and your medication will be delivered to your home within seven

working days after your order is received. You can order refills online at www.optumrx.com or by phone

(800) 797-9791. You may also call this toll free number to ask any questions or raise any concerns you may

have regarding your prescription.

Ordering is simple:

Call OptumRx Customer Service representatives at (800) 797-9791 and they will request your

prescription(s) from your doctor. They will need your prescription information and the name and phone

number of your doctor.

OR

Obtain a written prescription for your medication(s) from your doctor. Your doctor can write the

prescription for up to a 100-day supply with refills. Mail in this prescription, along with a confidential

Patient Profile Form and payment to:

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OptumRx

PO Box 509075

San Diego, CA 92150-9075

Confidential Patient Profile Forms can be downloaded at www.OptumRx.com or you can order from

OptumRx Customer Service at (800) 797-9791. You may also obtain this information from the


OptumRx will normally fill your prescription(s) within 24 to 48 hours, door-to-door delivery is usually

seven days. OptumRx pays all standard mailing expenses. Refill prescriptions should be placed two to

three weeks prior to the time your current supply of medication runs out, to allow for shipping.

Covered Drugs and Products

The Prescription Drug Coverage covers the following services and materials which require a prescription

written by a physician.

Federal Legend Drugs: Any medicinal substance which bears the legend, “Caution: Federal law

prohibits dispensing without a prescription.”

State Restricted Drugs: Any medicinal substance which may be dispensed by prescription only

according to state law.

Insulin and diabetic supplies for syringes (for insulin order), test strips, test tablets and lancets when

prescribed in writing by a doctor.

Compounded dermatological preparations (lotions and ointments) when prepared by a pharmacist in

accordance with a doctor’s written prescription.

Federal legend oral contraceptives/birth control pills, up to a three-month supply .

Contraceptive products, including, but not limited to diaphragms, cervical caps and patches.

Morning after pills & kits (i.e., Preven, Plan B).

Inhaler extender devices and bags.

Anaphylaxis prevention kits.

Compounds with at least one federal legend or state restricted ingredient.

Normal saline for inhalation and irrigation.

Prescription prenatal vitamins.

Retin-A, Azelex, Differin, Avita for non-cosmetic purposes.

Dental related products (i.e., Prescription oral and topical fluoride, Peridex, Atridox and Periostat).

Prescriptions to treat erectile dysfunction (ED).

The following non-prescription items are also covered when prescribed in writing by a physician and

dispensed by a licensed pharmacist:

Insulin, insulin syringes and needles;

Glucose test strips;

Sterile lancets; and

Prefilled Pens, Penneedles; refill cartridges.

Diabetic Supplies - for Participants Enrolled in Health Net

Members enrolled in Health Net should be aware that Health Net Coverage provides benefits for diabetic

supplies and equipment. As a result, you will save money for both yourself and the Cement Masons Health

and Welfare Plan by obtaining your diabetic supplies from Health Net as opposed to obtaining them

through the OptumRx drug coverage. The following diabetic supplies and equipment are a covered benefit under the Prescription Drug Coverage:

Blood glucose monitor and related supplies such as test-strips, lancets and lancet devices,

for diabetes blood testing.

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Insulin pump and related supplies: Also, members can receive training and education on how to use the

insulin pump before receiving one.

Exclusions and Limitations

The following items are not covered under the Walk-In or Mail-Order Coverages.

Drugs must be approved by the Federal Food and Drugs Administration (FDA). Drugs not approved

by the FDA will not be covered under the Prescription Drug Coverage. Experimental drugs or drugs

labeled “Caution – Monitored by Federal Law to Investigational Use.”

Medications available without a prescription (over-the-counter) or prescription medications for which

there is a non-prescription equivalent available, even if ordered by a physician via a prescription,

except as listed under Covered Drugs.

Smoking cessation products (including, but not limited to OTC nicotine patches, nasal and oral

inhalers, Zyban).

Medications used for elective or voluntary enhancement, including hair growth, athletic performance,

cosmetic purposes, anti-aging, and mental performance. Examples of these drugs include, but are not

limited to Renova, Vaniqa, Propeccia, Lustra, and Xenical.

Drugs used in the treatment of infertility.

Medications for the treatment of sexual dysfunction.

Biological sera.

Blood and blood plasma.

Drugs directly dispensed after one year from the original prescription order date.

Drugs taken or administered while confined in a hospital, nursing home, a convalescent home, or any

institution of like character.

Any pharmaceutical services provided under any other sections of the PPO Medical portion of the Plan

and described in this Summary Plan Description.

Drugs for which no charges are made, of which are provided under any workers’ compensation or

similar benefit or for which reimbursement is provided by any federal, state or other governmental

agency.

Medical devices, therapeutic devices or appliances including hypodermic needle syringes, (except

insulin syringes) support garments and other non-medicinal substances (unless listed as covered).

Drugs or medicines purchased and received prior to the member’s effective date or subsequent to the

member’s termination.

Drugs or medicines delivered or administered to the member by a prescriber or prescriber’s staff. For

example, drugs administered, injected, or dispensed by a physician.

Medications prescribed for experimental or non-FDA approved indications unless prescribed in a

manner consistent with a specific indication in Drug Information for the Health Care Professional,

published by the United States Pharmacopoeial Convention, or in the American Hospital Formulary

Services edition of Drug Information; medications limited to investigational use by law.

All homeopathic medications.

Unit dose drugs (unless only available as unit dose).

Vitamins (other than prescription prenatal vitamins).

Injectables, with the exception of insulin, must receive prior authorization and are only a covered

benefit through the Specialty Pharmacy Mail Order Program described in a separate section below.

Oral vaccines.

Insulin pen devices (i.e., Humulin Pen, Novopen).

Schedule II amphetamines/narcotics (i.e., Ritalin, Dexedrine, Adderall – maximum age 18 then prior

authorization required through the Plan).

Specialty Pharmacy Mail Order Program

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Specialty pharmaceuticals, primarily highly complex oral medications and injectable drugs, are a covered

benefit when pre-authorized as medically necessary and obtained through the OptumRx Specialty

Pharmacy.

In order to take advantage of this program, you must comply with all of the Coverage requirements that are

outlined in this Summary Plan Description. Also, your share of the cost of injectable drugs will be 20% of

the overall cost, as determined by OptumRx, of the drug being prescribed for you by your doctor.

Importantly, in order to receive benefits under this Specialty Pharmacy Program, prior authorization is a

coverage requirement. Prior authorization ensures that there is clinically appropriate prescribing of these

oral and injectable medications.

Self-administered injectable medications are covered when preauthorized as medically necessary and

obtained through OptumRx Mail Order Pharmacy.

Self-Injectables

All self-injectables will require prior authorization. Your physician’s office MUST call OptumRx

at (800) 711-4555, Option 1, to receive prior authorization. This service is available from 7 a.m.

to 6 p.m. Pacific time, Monday through Friday.

Your injectable prescriptions will be filled and delivered by express mail by OptumRx Specialty

Pharmacy. Whether you administer your medication yourself, have a caregiver or your doctor

administer it for you, OptumRx will ensure timely delivery to your home or physician’s office via

express mail. Shipping is free.

If OptumRx deems your first time prescription as urgent, then arrangements may be made to have

your prescription filled at a contracted pharmacy.

Office Based Injectables

An injectable given in the physician office will be paid for under this program (subject to co-

insurance) if it is the first time that the injectable has been administered to you.

Subsequent administration of the injectable in the physician office will not be paid for under this

program if prior authorization through OptumRx is not received.

Your physician MUST call OptumRx at (800) 711-4555, Option 1, to receive prior authorization.

This service is available from 7 a.m. to 6 p.m. Pacific time, Monday through Friday.

If you are enrolled in Health Net, all injectables, except insulin, which are included as part of your

HMO medical benefit are excluded from coverage under this program. Generally, those

injectables not covered by Health Net will be covered under this program.

High-Cost/High-Complexity Oral Medications

Certain limited high-cost and high-complexity oral medications will only be dispensed through the

Specialty Pharmacy Mail Order Program. Such oral medications will be filled for up to a 90-day supply.

Other Important Information

Here are some of the ways the Specialty Pharmacy Program will assist you in having your injectable

prescriptions filled and improve the accuracy of your orders.

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A Patient Care Coordinator (PCC) will:

- Help you manage your supplies and deliveries to be sure that you receive refills in a

timely manner and don’t run out of medications;

- Provided you are still eligible for benefits, contact you about a week before your next

scheduled delivery – to verify your remaining supplies and answer any questions you

may have; and

- With advance notice, arrange to deliver your supplies to your vacation destination

within the U.S.

In addition, clinical pharmacists, specialists in injectable therapy, are also available to answer your

questions regarding your medications 24 hours a day, 7 days a week. They will contact your

doctor for authorization as needed.

Educational materials regarding your medications and specific disease information are available

through OptumRx Specialty Pharmacy Disease Therapy Management programs.

If you have any questions, you can call the Administrative Office at (626) 444-4600, or the Specialty

Pharmacy Team at (800) 711-4555, Option #1 or visit www.optumrx.com. Patient Care Coordinators are

available from 6 a.m. to 6 p.m., Monday through Friday.

Weight Loss Medications

For prescriptions filled at network walk-in pharmacies, the Prescription Drug Coverage will cover weight-

loss drugs prescribed by a physician for morbid obesity provided the benefit is pre-authorized. To

receive pre-authorization, your physician’s office must call OptumRx at (800) 711-4555. This services is

available from 7 a.m. to 6 p.m. Pacific time, Monday through Friday.

OptumRx Website

OptumRx maintains a web site which can provide you with valuable assistance, including the most

up-to-date list of nationwide pharmacies. Visit www.OptumRx.com

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Delta Dental PPO Coverage

You and your eligible dependents will be entitled to benefits under the Delta Dental PPO Coverage if you

have worked the required 375 hours within a specific three month work period. Refer to the Eligibility

section beginning on page 15 for more information.

A Brief Overview

The following information is designed as a summary of benefits only. Refer to the Evidence of Coverage

booklet provided to you by Delta Dental for a complete description of your benefits, limitations and

exclusions.

For customer service and eligibility/benefits information:

(800) 765-6003

or

www.deltadentalins.com

For a list of PPO or Delta dentists:

(800) 765-6003

or

www.deltadentalins.com

Delta Dental - Customer and Member Service Department

P.O. Box 997330

Sacramento, CA 95899-7330

Delta Dental PPO Coverage

The PPO coverage provides the maximum benefit when you visit a PPO dentist. PPO dentists are Delta

dentists who have agreed to charge PPO patients reduced fees. Delta endodontists, oral surgeons and

periodontists are not PPO dentists, but you also receive in-network benefits when visiting one of these

Delta specialists.

The Delta PPO program includes the following features.

Save on out-of-pocket expense when you visit a PPO network dental office.

Visit any licensed dentist of your choice – select a different dentist for each member of your family.

Change dentists at any time.

Go to a dental specialist of your choice.

Receive dental care anywhere in the world.

Under the PPO coverage, you may visit any licensed dentist you wish. However, you receive the maximum

benefits available under the program when you choose a PPO dentist.

77

Delta Dental PPO Covered Services

In-Network

PPO Dentist

Out-of-Network

Dentist Deductibles/Maximums

Calendar Year Deductible – per person

Annual Family Deductible – per family

Maximum Benefits – per calendar year

$50

$150

$1,500 per person

$50

$150

$1,500 per person

BENEFIT COVERAGE:

Diagnostic and Preventive Benefits* Oral Examinations

Prophylaxis (cleanings)

X-rays

Examination of Tissue Biopsy

Fluoride Treatment

Space Maintainers

Specialist Consultation

100% of PPO approved fee

(no deductible applies for these

services)

50% of Delta approved fee

(deductible applies for these

services)

Basic Benefits

Oral Surgery (extractions)

Restorative (fillings)

Endodontics (root canal therapy)

Periodontics (treatment of gums and bones

supporting teeth)

Sealants



Crowns, Jackets, and Cast Restorations*

For treatment of carious lesions (visible

destruction of hard tooth structure resulting

from dental decay) which cannot be restored

with amalgam, synthetic or plastic restorations



Prosthodontic Benefits

Bridges (fixed and removable)

Partial Dentures

Full Dentures


(subject to a maximum

allowance)


(subject to a maximum

allowance)

Orthodontic Benefit*

- for adults and eligible dependent children


(subject to a $1,000 lifetime

maximum per person)


(subject to a $1,000 lifetime

maximum per person)

* Please refer to your Evidence of Coverage for limitations on these benefits. Some examples of limitations on

services are the number of cleaning and oral exams covered in a calendar year, and time limitations on filling and

crown replacements.

Note: Delta endodontists, oral surgeons, and periodontists are not PPO dentists, but you receive in-network benefits

when visiting one of these specialists.

How to Use the Delta Dental PPO Program

To use the Delta Dental PPO program, call the dental office of your choice and make an appointment. During

your first appointment, give your dentist the following information:

1. Identify yourself as eligible for benefits under the Cement Masons Southern California

Health and Welfare Plan, Delta group number 182; and

2. The employee’s social security number.

When you call a PPO dentist for an appointment, please confirm that the dentist participates in the Delta Dental

PPO network.

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To locate a Delta Dental PPO dentist in your area or to determine if a particular dentist is a participant in the

Delta Dental PPO program, call toll free (800) 765-6003 or visit Delta’s website at www.deltadentalins.com.

Timely Submission of Claims

Delta is not obligated to pay claims submitted more than 12 months after the date the service was provided.

If a claim is denied because a participating dentist failed to make timely submission, the eligible person

does not owe that dentist the amount which would have been paid by Delta, provided that the eligible

person advised the dentist of his or her eligibility for benefits at the time of treatment.

Complaint Procedure and Claims Appeal and Arbitration

If an eligible employee or eligible dependent has any questions about the services received from a

participating dentist, Delta recommends that he or she first discuss the matter with the dentist. If he or she

continues to have concerns, the eligible person may call or write Delta. Delta will provide notification if

any dental services or claims are denied, in whole or in part, stating the specific reason or reasons for

denial. If an eligible person has any question or complaint regarding eligibility, the denial of dental

services or claims, the policies, procedures, and operations of Delta, or the quality of dental services

performed by a participating dentists, he or she may call Delta at (800) 765-6003, or write to Delta at:

Delta Dental

P.O. Box 997330

Sacramento, CA 95899-7339

Attn: Customer and Member Service Department

An eligible person has 180 days after he or she receives notice to appeal a denial of benefits. If in writing,

the correspondence must include the group name and number (Cement Masons Group Number is 182), the

primary enrollee’s name and social security number, and the inquirer’s telephone number. The

correspondence should also include a copy of the treatment form, Notice of Payment, and any other

relevant information. He or she should clearly explain the complaint. It is recommended that the appeal be

mailed by certified mail.

Delta will review that complaint and will respond to it within 30 days unless more information or time is

needed to resolve the matter. Delta may need more time if the complaint is referred to a dental consultant

or to a peer review committee of the local dental society. If referral is necessary, a reply may take longer,

but in no case will it be more than 120 days after Delta receives the complaint. Delta will respond, within

three days of receipt, to complaints involving imminent and serious threat to a patient’s health.

You may also file a complaint with the California Department of Corporations after you have completed

Delta’s grievance process or after you have been involved in Delta’s grievance process for 30 days.

Complete details are included in the “Evidence of Coverage” booklet. If you do not have this booklet, call

or write the Administrative Office and one will be mailed to you.

79

Vision Care

You and your eligible dependents will also be entitled to benefits under the VSP Vision Care Coverage if you

have worked the required 375 hours within a specific three month work period. Refer to the Eligibility section

beginning on page 15 for more information.

A Brief Overview

VSP has an extensive nationwide network of doctors who provide quality eye care and materials. This

Coverage is designed to provide for regular eye examinations and benefits toward vision care expenses

including glasses and contact lenses.

The information contained in this section is an outline only. For a complete description of your

benefits, exclusions, limitations, etc., please refer to the VSP Evidence of Coverage. The Evidence

of Coverage is the binding document between the VSP and its members.

Details regarding benefit and claims review and adjudication procedures can be obtained by

referring to VSP’s Evidence of Coverage.

For complete benefit description or to locate an eyecare provider, visit www.vsp.com or call (800)

877-7195.

What are the Benefits?

Below is a brief outline of benefits only:

Standard Eye Examination and Glasses:

Benefits Active Members Dependents Eye Examination

Lenses

Frames

Once every 12 months*






Copayment

Examination and

Materials

$20 Copayment

$20 Copayment

*From your last date of service

Second Pair of Glasses – Active Employees Only

Active employees only are eligible for a second pair of glasses under the VSP Coverage once every 24

months. For an additional $20 copayment, an employee can receive a second pair of glasses including

prescription sunglasses. If you prefer, your second pair of glasses can be safety glasses with either plain or

tinted lenses.

Contact Lenses:

Elective or medically necessary contact lenses may be provided instead of glasses.

80

Elective Contact Lenses:

The standard eye examination is covered in full, less any applicable copayment. An allowance will be

provided toward the contact lens evaluation, examination, fitting costs, and materials. Any costs exceeding

the allowance are the patient’s responsibility.

VSP’s additional value is also extended to include a 15% discount off the participating doctor’s

professional services when you purchase prescription contact lenses. Materials are provided at usual and

customary fees. This benefit is available in conjunction with your VSP contact lens allowance, or you can

use it to purchase contacts in addition to glasses.

You may use these discounts for 12 months following the date of the covered eye examination. Also, these

discounts are only offered through the VSP participating doctor who provided the last covered eye

examination.

Medically Necessary Contact Lenses:

Covered in full when prescribed by a participating doctor for one of the following conditions:

following cataract surgery;

to correct extreme vision problems that cannot be corrected with spectacle lenses;

with certain conditions of anisometropia; and

with certain conditions of keratoconus.

The participating doctor must secure prior approval from VSP for medically necessary contact lenses.

Complaints

If a participant has a complaint regarding VSP service or claim payment, he/she may communicate the

complaint to VSP by using the complaint form which is available in all Member Doctor offices, from the

Administrative Office, or by calling VSP Customer Service Department's toll-free number (800) 877-7195

Monday through Friday, 6:00 a.m. to 7:00 p.m., Pacific Standard Time.

81

Life Insurance & Accidental Death & Dismemberment

Benefits

Eligibility

You are insured for benefits upon the date you satisfy the eligibility requirements of the Cement Masons

Southern California Health and Welfare Plan. Refer to the Eligibility section beginning on page 15 for

more information.

Certificate of Coverage

Life insurance benefits and accidental death and dismemberment benefits for active employees and life

insurance benefits for dependents of actives are insured by The Union Labor Life Insurance Company.

Insurance benefits are governed by the terms of the insurance policies issued by The Union Labor Life

Insurance Company to the Cement Masons Southern California Health and Welfare Plan.

For a complete description of your life insurance and accidental death and dismemberment benefits, (for

employees only), refer to the Certificate of Insurance; a Certificate of Insurance can be obtained by

contacting the Administrative Office.

Note: Life and accidental death and dismemberment benefits are not available to participants making a

COBRA self-payment.

Schedule of Benefits

The following is a brief summary of your benefits under this Coverage. For complete information on this

Coverage, including claim forms, beneficiary designations, conversion privileges, total disability death

benefit, etc. refer to your Certificate of Coverage as provided by The Union Labor Life Insurance

Company.

The following indicates the maximum amounts payable.

Employee Only

Life Insurance ........................................................................................................................ $20,000

Accidental Death &

Dismemberment Insurance (Principal Sum) .......................................................................... $20,000

The accidental death or dismemberment insurance of each employee will automatically terminate on the

date eligibility ceases and may not be converted to an individual policy.

Life Insurance for Dependents

Spouse ...................................................................................................................................... $4,500

Dependent Child (age 6 months to age 26) .............................................................................. $4,500

Dependent Child (birth to 6 months age) .................................................................................... $100

The Dependent Effective Date Proviso shall apply if a child is then confined to a hospital.

Any change in the amount of your dependent’s life insurance because of a change in your dependent’s age,

is effective on the date the dependent’s age changes.

82

Designation of Beneficiary

You may change your designation of beneficiary at any time. You can obtain a Designation of Beneficiary

Form by calling or writing the Administrative Office. The change will be effective when the completed

form is received by the Administrative Office. The Administrative Office is located at 5417 Peck Rd,

Arcadia, California 91006-5847. The Administrative Office telephone number is (626) 444-4600.

Newly covered employees should complete a Designation of Beneficiary Form immediately upon

becoming eligible for Coverage and mail it by secure mail to the Administrative Office at the address

shown above.

The Union Labor Life Insurance Company may pay up to $500 of the proceeds to either your beneficiary,

executor or administrator, or relative, or any other person appearing to be equitably entitled, who has

incurred expenses on your behalf for burial.

Claim Forms

Contact the Administrative Office to arrange the submission of a claim.

Appeals To Union Labor Life

Issues related to rival claimants for proceeds are referred to the Legal Department of Union Labor Life for

handling through interpleader actions in state or federal courts. Otherwise, a claim determination, benefit

denial, or other matters related to the administration of the policy may be appealed if disputed by an insured

or beneficiary or representative of such persons.

The claim examiner shall forward the claim file and an explanation of the dispute to the Assistant

Vice President of Insurance Operations. If the Assistant Vice President is unable to resolve the

matter, the claim will then be reviewed by the Assistant Vice President for Insurance Operations, the

Vice President for Underwriting, the Legal Department, and, if necessary, the Medical Director to

determine appropriate action. The consensus recommendation of those individuals shall be provided

to the Manager of the Life Claims Department for implementation within 10 business days of their

receipt of the claim information.

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Accidental Death & Dismemberment (AD&D) Benefits (24 Hour

Coverage)

Below is only a summary of benefits. Refer to your Certificate of Coverage for a complete description of

benefits.

This benefit will be payable if, while insured, the employee sustains any of the losses listed below as a

direct result of an accident and independent of any other cause. For benefits to be payable, the loss must

take place within 90 days from the date of the accident.

Who Will Receive Benefits?

For loss of life, benefits will be paid to the beneficiary you name. For any other loss, the benefits will be

paid to you as the employee.

Accidental Death and Dismemberment Benefits

The amount and payment of such benefits shall be as follows.

The Benefits for Loss of: The Benefit is:

Life ............................................................................................................ $20,000

Two Feet .................................................................................................... $20,000

Two Hands ................................................................................................ $20,000

Sight of Two Eyes ..................................................................................... $20,000

One Hand and Sight of One Eye ............................................................... $20,000

One Foot and Sight of One Eye ................................................................. $20,000

One Hand or One Foot .............................................................................. $10,000

Sight of One Eye ....................................................................................... $10,000

If you suffer more than one loss in any one accident, payment will be made only for that loss for which the

largest amount is payable.

Loss of a hand or foot means that the limb is severed at or above the wrist or ankle joint, respectively.

Loss of sight means the total and irrecoverable loss of sight.

Exclusions

No benefit will be paid for any loss that is caused directly or indirectly, or in whole or in part, by any of the

following:

1. Bodily or mental illness or disease of any kind;

2. Ptomaine or bacterial infections (except infections caused by pyogenic organisms which occur with

and through an accidental cut or wound);

3. Suicide or attempted suicide while sane or insane;

4. Intentional self-inflicted injury;

5. Participation in, or result of participation in, the commission of an assault, or a felony, or a riot, or a

civil commotion;

6. War or act of war, declared or undeclared; or any act related to war; or insurrection;

7. Medical or surgical treatment of an illness or disease;

8. Service in the armed forces of any country while such country is engaged in war; or

9. Police duty as a member of any military, naval or air organization.

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General Plan Information

Definitions

Active Employee An employee of an Employer (as defined below) who works in Covered Employment.

Cement Mason Includes any employee who works in any classification covered by a Collective Bargaining

Agreement participating in this Plan.

COBRA The continuation of health care coverage when Plan eligibility coverage ends as required by the

Consolidated Omnibus Budget Reconciliation Act (COBRA) and any changes or amendments to

this law which may be enacted by law or regulation.

Collective Bargaining Agreement Any agreement between the employer and the Union which requires contributions to this Plan.

Contribution The payment made or required to be made to the Plan by any individual employer under the

provisions of any of the Collective Bargaining Agreements. The term “Contribution” shall also

include a payment made on behalf of an employee of a Local Union pursuant to regulations

adopted by the Board of Trustees.

Covered Employment Work as a Cement Mason at a job covered by a Collective Bargaining Agreement between the

Union and an employer.

Credited Hour Credited hour means work hours reported and paid to the Plan.

Dependent This is as defined in this SPD booklet under the section entitled, “Eligible Dependents.”

Eligible Employee

An employee of an employer (as defined below) who works in Covered Employment or on whose

behalf contributions are made to the Cement Masons Southern California Health and Welfare Plan

pursuant to the terms of a Participation Agreement between the employer and the Cement Masons

Southern California Health and Welfare Plan and satisfies the rules of eligibility adopted by the

Plan.

Employer Any individual employer signatory to a Collective Bargaining Agreement with the Union which

requires contributions by the employer into this Plan. The term “employer” also includes the local

unions when signed to a Participation Agreement with the Plan. The term ‘employer’ also

includes any corporation engaged by the Board of Trustees to provide administrative services to

this Plan and who has entered into a Participation Agreement with this Plan in which the

corporation has agreed to be bound by all terms and conditions of the Declaration of Trust

establishing the Cement Masons Southern California Health and Welfare Plan.

85

Family Member An employee or a dependent of an employee.

Plan or Health Plan The Cement Masons Southern California Health and Welfare Plan.

HMO Medical Plan (Health Maintenance Organization) The Health Net Coverage and Kaiser Permanente Coverage. Under these coverages, you must use

the doctors and hospitals associated with the HMO you have selected.

Open Enrollment Period The time period established by the Board of Trustees during which you can change your choice of

medical coverage. The following medical coverages are offered: Health Net, Kaiser or the PPO

Medical Coverage. Every year, the Plan will send you a letter that tells you the open enrollment

dates. The open enrollment is usually held during the months of September and October.

Changes in coverages become effective with the eligibility period starting November 1. If your

medical group or physician is canceled at any time, you will be able to select among coverages

then being offered.

Participant The term “participant” includes all employees eligible for benefits under the Plan.

Participation Agreement The term “participation agreement” means an agreement between an individual employer or

employer association and the Cement Masons Southern California Health and Welfare Fund

which requires the making of employer contributions to the Fund.

Plan and/or Plan Document The Cement Masons Southern California Health & Welfare Plan or Plans as described in the

Summary Plan Description.

PPO Medical Coverage Under this coverage, you and your eligible dependents may go to the doctor of your choice and the

Plan will pay for those services, based on a schedule of benefits established by the Plan’s Trustees,

after receipt of a properly completed claim form. Any differences between what the Plan pays and

what is charged is the participant’s responsibility.

Qualifying Event A qualifying event for continuation coverage occurs when a qualified beneficiary loses coverage

under this Plan for any of the reasons provided by COBRA. This entitles the qualified beneficiary

to continuation coverage on a self-payment basis.

Summary Plan Description and/or SPD This document, together with your HMO Evidence of Coverage, Delta Dental and VSP Evidence

of Coverage and The Union Labor Life Insurance Company Certificate of Coverage, distributed to

the participants, which contains all or substantially all of the information the average participant

would deem crucial to have a knowledgeable understanding of Pan benefits and the circumstances

that may disqualify a participant from securing those benefits under the Plan.

Trust Agreement The Agreement and Declaration of Trust establishing the Cement Masons Southern California

Health & Welfare Plan and any modification, amendment, extension, or renewal of it.

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Trustee and/or Board of Trustees Refers to the individual fiduciaries appointed and acting pursuant to the Trust Agreement.

Union and/or Local Union The Operative Plasters’ and Cement Masons’ International Association of the United States and

Canada, AFL-CIO, Locals 500 and 600.

Overpayments

Any and all benefit overpayments made by this Plan to a employee or dependent shall be repaid to the Plan

by the employee within 90 days following notice of overpayment from the Plan to the employee. If the

overpayment or any portion of it is not returned to the Plan within that 90 days, the Plan will deduct that

amount from future claims payments which may be payable to or for the benefit of the employee or

dependent until the full amount of the overpayment is recovered by the Plan. For example, if an employee

is overpaid (overpayment) on a specific claim and fails to repay the Plan within 90 days of demand from

the Plan, then any future claim(s) payable to or for the benefit of the employee or dependent will be

reduced by the amount of the overpayment until the total overpayment is recovered by the Plan.

Any and all benefit overpayments made by the Plan directly to a benefit provider or any other entity for the

benefit of an employee or dependent shall be repaid to the Plan by the benefit provider or other entity

within 90 days following notice of overpayment from the Plan. If the overpayment or any portion of it is

not returned to the Plan within that 90 days, the Plan will deduct that amount from future claim payments

which may be payable to that benefit provider or other entity for the benefit of that employee or dependent

on whose behalf the overpayment(s) was made until the full amount of overpayment(s) has been recovered

by the Plan.

If the Plan does not receive reimbursement of the overpayment within 90 days from the date of the notice

of overpayment, the Plan reserves the right to pursue legal action against the employee, dependent, benefit

provider or other entity that received the overpayment(s) within the discretion of the Board of Trustees.

Financing of the Plan

Employees’ benefits are funded through contributions made by employers pursuant to the collective

bargaining agreements. If employer contributions do not fully fund the benefits provided under the Plan,

the Trustees will consider what actions may be appropriate so that contributions fully fund the benefits,

which may include reducing or eliminating particular benefits as required to prudently manage the Plan.

No Guarantee of Tax Consequences

Neither the Plan, the union, nor any employer make any commitment or guarantee that any amounts paid to

or for the benefit of an employee or dependent will be excludable from the employee’s gross income for

federal or state income tax purposes, or that any other federal or state tax treatment will apply to or be

available to any employee.

Governing Benefit Documents

The extent of each employee’s benefits is governed by the terms of this Cement Masons Southern

California Health & Welfare Summary Plan Description, the Declaration of Trust and the policies,

contracts and agreements entered into between the Plan and Health Net, Kaiser Permanente, Delta Dental,

VSP, OptumRx and The Union Labor Life Insurance Company, and any rules and regulations which the

Trustees adopt from time to time. This booklet describes these benefits in general terms. If there is any

difference between this booklet and any of those documents, the terms and conditions of those documents

will prevail. Those documents are available for inspection at the Administrative Office.

87

If you have any questions about the Plan’s terms or about the proper benefit payments, you may obtain

more information from the Administrative Office.

Plan Amendment Procedures

Changing, Enhancing, Reducing, or Eliminating Benefits

There is no vested right to receive Plan benefits. What this means is that the Board of Trustees may change,

enhance, reduce, or eliminate benefits at any time. The Board of Trustees has a fiduciary responsibility to

prudently manage the Plan. In order to meet this responsibility, the Trustees periodically review the cost

and benefits of the various coverages. As a result, the Trustees may find it necessary to change, reduce, or

eliminate benefits. Nevertheless, once you incur a valid claim under any particular coverage then in effect,

your right to that benefit is fixed and determined by the rules of the Plan and that coverage.

The following examples provide information on situations which may require the Trustees to reduce

benefits. For example, a reduction in total hours worked by all employees reduces employer contributions

to the Plan and alters the projected hours used to establish benefits. As another example, Plan costs for a

specific benefit may increase more than projected, requiring a reduction in the benefit allowance.

Notification of Plan Changes to Participants

The Trustees reserve the right to change or discontinue any Plan benefit, in whole or in part, as the Trustees

deem necessary or desirable.

That action by the Trustees will be accomplished by a Plan Amendment, which details in writing the

changes made.

You will be provided written notice when those changes are made. The notice will describe the changes

and will be provided to you within 210 days after the close of the Plan year in which the change became

effective or no less than 60 days after the date of the adoption of the modification or change for material

reduction of benefits.

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Disclosure Information

The following information is provided as required by the Employee Retirement Income

Security Act of 1974 (ERISA).

1) Name and type of administration of the Plan:

Cement Masons Southern California Health and Welfare Plan, a collectively bargained,

jointly-trusteed, labor-management Trust. This is a welfare benefit plan, providing

Medical, Prescription Drug, Dental, Vision, Life Insurance and Accidental Death &

Dismemberment Insurance benefits to eligible employees and their dependents.

2) Name and address of the person designated as agent for the service of legal process:

William Lee


5417 Peck Rd.


Thomas Reed

Hill, Farrer and Burrill LLP

300 South Grand Ave.

Los Angeles, CA 90071

(Service of legal process may also be made upon the plan administrator or any Trustee)

3) Administrative Office of the Plan Administrator:


5417 Peck Rd.


(626) 444-4600

4) Names, titles and addresses of the Trustees (the Board of Trustees is the “Plan

Administrator” as that term is defined by section 3(16) of ERISA. The Board has delegated

the day-to-day administration functions of the Plan to Zenith American Solutions):

Labor Trustees Scott Brain – Co-Chairman

Cement Masons Local #600

c/o Zenith American Solutions

5417 Peck Rd.


Jaime Barton



5417 Peck Rd.


Marcos Enriquez

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5417 Peck Rd.


Jesse Mendez, Jr.



5417 Peck Rd.


Management Trustees:

Michael Rodriguez – Co-Chairman

Southern California Contractors Assoc.


5417 Peck Rd.


Scott Berg

Hensel Phelps Construction Co.


5417 Peck Rd.


Enrico Prieto

Prieto Construction, Inc.


5417 Peck Rd.


Mac Tarrosa

Associated General Contractors


5417 Peck Rd.


5) Source of financing of the Plan and identity of the organizations through which benefits are

provided:

Contributions are paid to the Plan by employers as required under the provisions of

applicable collective bargaining agreements.

The Trustees provide a choice of medical programs.

The following organizations provide benefits by virtue of a contract with the Plan as

follows:

Health Net

o Medical Benefits

Kaiser Foundation Health Plan, Inc.

o Medical/Prescription Drug Benefits

PPO Medical Coverage with Anthem Blue Cross Prudent Buyer Network and

Zenith American Solutions for payment of claims

o Medical Benefits including the payment of claims

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OptumRx

o Prescription Drug Benefits and drug claim processor

Delta Dental

o Dental Benefits

VSP

o Vision Benefits

The Union Labor Life Insurance Company

o Life Insurance/AD&D Benefits

6) Date of the end of the Plan year:

December 31

7) Internal Revenue Service Plan Identification Number:

95-6042883

8) Description of the relevant provisions of any applicable collective bargaining agreement

This plan is maintained pursuant to many collective bargaining agreements. You may

obtain a copy of the agreement pertaining to you by writing to the Trustees. The

agreements also are available at the Administrative Office, and at local union offices,

with 10 days advance written request. The Trustees may make a reasonable charge to

cover the cost of furnishing a copy of an agreement. You may want to ask the cost up

front.

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Claims and Appeals Rules

Introduction

The Claims & Appeal Rules described in this section do not apply to the following coverages:

1. Kaiser Permanente HMO Medical Coverage

2. Health Net HMO Medical Coverage

3. Delta Dental PPO Coverage

4. VSP Coverage

5. The Union Labor Life Insurance Coverage

Benefits provided by the above Health Maintenance Organizations (HMOs), Delta Dental, VSP and The

Union Labor Life Insurance Company are subject to the claims and appeal rules established by each of

these providers. Contact the provider directly for its claims review or grievance procedure. There are

always timeframes for claims submission, so don’t delay in pursuing any claim you think you may have.

The Administrative Office can provide you with information on where to write.

Unless specifically stated to the contrary, the following rules only cover claims and appeals for participants

enrolled in either of the following coverages:

1. PPO Medical Coverage

2. Prescription Drug Coverage

It is the intent and desire of the Trustees that these rules be consistent and comply with applicable

regulations, including but not limited to 29 CFR §2560. et. seq. The rules below shall be construed in

accord with that intent. Those regulations are incorporated here as though set forth in full. The regulations

shall be construed in accord with Department of Labor guidance issued after issuance of the regulations.

Pre-Service Claims

Pre-service claims are claims for benefits where the Plan requires pre-authorization before you receive

medical care.

For both of the coverages listed above, there are no pre-authorization (prior approval) requirements

for urgent medical care or medical emergencies. If you require urgent medical care, you should seek

immediate medical attention or dial 911 as may be required.

For all other pre-service claims for those coverages you will be notified in writing if your claim has been

denied, either in whole or in part. The notice will contain:

The specific reason(s) for the determination;

Reference to the specific Plan provision(s) on which the determination is based;

A description of any additional material or information necessary to perfect the claim and an

explanation of why the material or information is necessary;

A description of the appeal procedures and applicable time limits;

A statement of your right to bring a civil action under ERISA section 502(a) following an

adverse benefit determination on review;

If an internal rule, guideline, protocol, or other similar criterion was relied upon in deciding

your claim, you will receive either a copy of the rule or a statement that it is available upon

request at no charge; and

If the determination was based on the absence of medical necessity or characterization as an

experimental treatment or similar exclusion or limit, either an explanation of the scientific or

clinical judgment for the determination, applying the terms of the Plan to your medical

circumstances, or a statement that such explanation will be provided free of charge upon

92

request.


The Plan contracts with Zenith American Solutions (herein referred to as ZAS, for short) to process all

claims under the PPO Medical Coverage. Participants enrolled in the PPO Medical Coverage have access

to the Anthem Blue Cross Prudent Buyer Network.

As stated above, in the event of a medical emergency or urgent care, you do not need to get approval from

the Plan to seek medical care. Nevertheless, you must notify Anthem Blue Cross within 48 hours of being

admitted as an inpatient or as soon thereafter as possible. This is so that ZAS can manage your claim to

ensure that you are receiving treatment only for medically necessary care and that your hospital stay is not

excessive. If you do not notify Anthem Blue Cross, you will still be eligible for PPO Medical Coverage

benefits for medically necessary services. To contact Anthem Blue Cross, call toll-free (800) 274-7767.

In order to receive full benefits, the PPO Medical Coverage requires that all non-emergency

hospitalizations be approved (pre-authorization) before you are admitted to the hospital. This is explained

beginning on page 46. If you do not notify Anthem Blue Cross, you will still be eligible for PPO Medical

Coverage benefits for medically necessary services, but you may be subject to a $500 reduction in benefits

as explained under the Prior Authorization Review and Approval section beginning on page 46.

If you are planning a non-emergency hospitalization, you or your doctor must call Anthem Blue Cross at

(800) 274-7767 to receive prior authorization. Again, this requirement is not applicable to any medical

care that is considered “urgent care” by you or your doctor.

For medical claims involving routine pre-certification for non-emergency admissions and elective surgery,

the claim regulations require that you be advised of a decision within a 15-day turn around. The time

period for a response may be extended up to 15 days if necessary due to matters beyond the control of the

Administrator. If an extension is necessary, you will be notified prior to the expiration of the initial 15 day

period of the circumstances requiring the extension of time and the date by which a decision is expected to

be rendered.

If the event that an extension is necessary because you failed to submit information necessary to decide

your claim, the written extension notice will describe the information required of you. The time period for

making a benefit decision will also be suspended until the earlier of the Plan’s receipt of all the requested

information or 45 days from your receipt of the notification to supply additional information. A decision

will be made on your claim within 15 days after you respond to the request for additional information or

within 15 days after the end of the deadline given to provide the additional information, whichever is

earlier.

If your claim for pre-certification is improperly filed, the Administrator will notify you as soon as possible,

but not later than 5 days after receipt of your claim, of the proper procedures to be followed in filing a

claim.

Prescription Drug Program

There are no pre-certification requirements for urgent care under the Prescription Drug Program provided

you use a Prudent Buyer PPO provider for the inpatient stay.

Independent Medical Opinions

These pre-service claims and appeals involve issues predicated upon medical necessity and the

appropriateness of requested medical care. While the Board of Trustees is the named fiduciary responsible

for the final determination of your pre-service appeal, the Board of Trustees does not possess medical

93

expertise. Therefore, the Board has established a policy of adopting as its own opinion the opinion(s)

received from outside independent medical doctors and review organizations retained by the Board.

Concurrent Claims

If the Claims Administrator approves an ongoing course of treatment to be provided over a period of time

or number of treatments and there is a reduction or termination of the course or number of treatments

before the end of the period of time or number of treatments, the Claims Administrator will notify you

sufficiently in advance of the reduction or termination to allow you to appeal the decision before the benefit

is reduced or terminated.

Post-Service Claims

Post-service benefits are claims made after the treatment is received. You or your doctor completing a

claim form and submitting it for reimbursement generate these claims.

For example, under the PPO Medical Coverage, you may have routine doctor office visits. If you use a

Anthem Blue Cross Prudent Buyer Network contracted provider there may be no claim forms for you to

complete. However, your claim will be deemed made when the PPO provider transmits the claim to

Anthem Blue Cross. If you use a medical provider who is not a PPO contracted provider then the non-PPO

provider will need to mail a claim to Anthem Blue Cross, Payor ID 47198, directly:

Anthem Blue Cross

PO Box 60007

Los Angeles, CA 90060-0007

The claim is deemed made when Anthem Blue Cross receives a claim from your doctor.

Prescription drug benefits are administered by OptumRx. Your prescription drug benefit is a card-based

system, and your claim is deemed made when you present the prescription and your OptumRx

identification card to a participating pharmacist.

Within 30 days of filing a post service claim, to the extent that any portion of your claim is denied, you will

receive a notice of denial that identifies the specific Plan provision upon which the denial is based. For

example, a claim or a portion of it may not be payable under the PPO Medical Coverage because the annual

deductible has not been met.

The notice that your claim has been denied, either in whole or in part, will contain the following:

The specific reason(s) for the determination;

Reference to the specific Plan provision(s) on which the determination is based;

A description of any additional material or information necessary to perfect the claim and an

explanation of why the material or information is necessary;

A description of the appeal procedures and applicable time limits;

A statement of your right to bring a civil action under ERISA section 502(a) following an

adverse benefit determination on review;

If an internal rule, guideline, protocol or other similar criterion was relied upon in deciding

your claim, you will receive either a copy of the rule or a statement that it is available upon

request at no charge;

If the determination was based on the absence of medical necessity or characterization as an

experimental treatment or similar exclusion or limit, either an explanation of the scientific or

clinical judgment for the determination, applying the terms of the Plan to your medical

circumstances, or a statement that such explanation will be provided free of charge upon

request.

94

The Plan may extend the 30 day period for making a determination once, for up to 15 days, if the extension

is necessary due to matters beyond the control of the Plan. If an extension is necessary, you will be notified

before the end of the initial 30 day period of the circumstances requiring the extension of time and the date

by which the Plan expects to render a decision.

In the event that an extension is necessary because you failed to submit information necessary to decide

your claim, the written extension notice will described the information required. The time period for

making a benefit decision will also be suspended until the earlier of the Plan’s receipt of all the requested

information or 45 days from your receipt of the notification to supply additional information. A decision

will be made on your claim within 15 days after you respond to the request for additional information or

within 15 days after the end of the deadline given to provide the additional information, whichever is

earlier.

Eligibility Issues

Eligibility for Plan coverage is explained in this Summary Plan Description under the Eligibility section.

On behalf of the Board of Trustees, the Administrative Office oversees eligibility. Each month the

Administrative Office provides all benefit providers to the Plan, such as Kaiser, Health Net, Delta Dental,

and VSP, with a listing of eligible participants.

There may be instances where a Plan participant has a claim denied because he or she has not met the Plan

rules to be eligible for benefits under the Plan. There are many reasons why this can happen.

For illustrative purposes, several examples are cited below.

Example 1: An employee may not work the required hours to be eligible for benefits as explained under

the Eligibility section of this Summary Plan Description.

Example 2: An employee has worked the required hours in covered employment but his or her employer

has not remitted the required health and welfare contributions to the Plan.

Example 3: An employee does not work the required 375 hours during a three-month work period to

maintain eligibility and his or her bank hours have been depleted to zero, or there are not enough hours left

in the hours bank to establish eligibility.

Example 4: An employee is no longer working and has elected COBRA continuation coverage, but has

failed to make the required self-payment to be eligible for continuation coverage.

Most eligibility issues are resolved quickly with a call or a letter to the Administrative Office. The

Administrative Office is there to assist you and provide you with exact information on the status of your

eligibility and entitlement to benefits under the various coverages.

If you have a claim denied because you do not meet the eligibility requirements of the Plan, you have the

right to appeal this denial. Your appeal should be in writing and be sent to the Administrative Office

(ideally by certified mail, although not required as long as the appeal is timely received). You should state

in your appeal why you believe you meet the eligibility requirements and provide any factual information

you believe is important in having your appeal reviewed.

Your appeal will be considered within the time parameters described in the sections above entitled Pre-

Service Claims and Post Service Claims depending on the nature of your claim. Some examples are

provided below.

Example 1: Assume you want pre-certification for non-emergency elective surgery under the PPO Medical

Coverage (Pre-Service Claim), and your claim is denied because you are not eligible for benefits, you then

have the right to appeal this decision. If you appeal the claim denial, the Administrative Office will

95

respond to your appeal within 15 days from the date your appeal is received in writing in the


Example 2: Assume you submit a medical claim (Post-Service Claim) under the PPO Medical Coverage

to ZAI and your claim is denied because you are not eligible for benefits. If you appeal the claim denial,

the Administrative Office will respond to your appeal. If your appeal is received within 30 days prior to a

Board meeting, your appeal will be considered. Otherwise, your appeal will be considered at the next

meeting of the Board or by the Appeals Committee, whichever comes first.

Generally, the Board meets no less frequently than quarterly.

Exhaustion of the Appeals Process

Under a Federal Law known as ERISA an employee or dependent whose claim for benefits has been denied

may file suit against the Plan seeking the denied benefits. However, prior to filing a suit, the appeal process

under the Plan described above must be pursued and exhausted. Thus, following any initial denial of

benefits, if you disagree, it is important you file a timely appeal. In all cases your appeal must be filed no

later than 180 days after the initial denial of your claim as received by you. If you do not file an appeal

within the required time frame you will have failed to exhaust your appeal rights, and you cannot sue. The

Trustees may extend the 180 day limit upon your showing good cause for the delay, but to protect your

rights you must file any appeal promptly after your receipt of the initial denial.

Appeals Information Pertaining to Pre-Service Claims, Concurrent Claims

and Post-Service Claims

If you disagree with the Plan’s determination of your claim, you may appeal the determination to the Board

of Trustees. You may request such a review by sending a letter to the Administrator within 180 days of

receiving the denial notice. As with the decision-making on the initial claim, the time frames for

responding to your appeal will depend on the categorization of your claim as a pre-service claim, a

concurrent claim or a post-service claim. It is strongly suggested that any appeals be filed by certified mail.

1. TIME FRAMES FOR DECISION-MAKING ON APPEAL

Pre-Certification Claims

If you submitted an appeal of a denied pre-admission certification claim, the Plan will notify you of its

decision no later than 30 days after the Plan’s receipt of your appeal.

96

Concurrent Claims

If you submitted an appeal for a concurrent claim that does not involve an urgent care decision, the claim

will be decided according to either the pre-service or post-service claim time frame depending on which

applies.

Post Service Claim

If you submitted an appeal of a denied post-service claim, the Board of Trustees will notify you of its

determination on appeal as soon as possible, but not later than 5 days after the next regularly scheduled

Board of Trustees meeting, unless the appeal is filed less than 30 days before the next meeting. In that

case, the Board of Trustees will notify you no later than 5 days after the second Board of Trustees meeting

following the Plan’s receipt of the appeal. If special circumstances require a further extension of time for

processing, the Board of Trustees will notify you of its determination no later than 5 days after the third

meeting of the Board of Trustees following the Plan’s receipt of the appeal. The Board of Trustees will

provide you with a written notice of the extension, describing the special circumstances and the date as of

which the benefit determination will be made, prior to the commencement of the extension.

2. ADDITIONAL RIGHTS ON APPEAL

If you choose to pursue an appeal, you will have the following rights:

1. You will have the opportunity to submit written comments, documents, records and other

information relating to your claim to the Board of Trustees;

2. You will have the opportunity to request reasonable access to, and copies of, all

documents, records, and other information relevant to your claim for benefits free of

charge;

3. The appeal will take into account all comments, documents, records and other

information submitted by you, without regard to whether that information was submitted

or considered in the initial benefit determination;

4. The reviewer, i.e., the Board of Trustees, will consider the full record of the claim and

will independently make a determination;

5. The appeal will be conducted by a named fiduciary who is neither the individual who

made the initial adverse determination, nor the subordinate of that individual;

6. If the denial is based in whole or in part on a medical judgment, including determinations

with regard to whether a particular treatment, drug, or other item is experimental,

investigational, not medically necessary or not appropriate, the named fiduciary will

consult with a health care professional who has the appropriate training and experience in

the field of medicine involved in the medical judgment;

7. The health care professional consulted on appeal will not be the individual consulted in

connection with the initial denial nor the subordinate of any such individual;

8. You may request the identification of any medical or vocational experts whose advice

was obtained on behalf of the Plan in connection with the initial denial, without regard to

whether the advice was relied upon in making the benefit determination; and

9. You may request to present your appeal in person to the Board of Trustees. If you wish

to present your appeal in person, you must clearly state so in your appeal request.

Additionally, you may be represented by counsel or any other person designated to speak

97

on your behalf. Upon receipt by the Administrative Office of your request to present

your appeal in person, the Administrative Office shall inform you in writing of the date,

time and place of the Board of Trustee meeting in which your appeal be heard.

3. NOTIFICATION REQUIREMENTS FOR DENIAL ON APPEAL

If the Board of Trustees denies your appeal, the Board of Trustees will provide you with a notice of the

adverse determination that includes the following information:

a. The specific reason or reasons for the adverse determination;

b. Reference to the specific Plan provisions on which the benefit determination is based;

c. Statement regarding your entitlement to request, free of charge, reasonable access to, and

copies of, all documents, records and other information relevant to your claim for

benefits;

d. Statement of your right to bring an action under section 502(a) of ERISA;

e. If an internal rule, guideline, protocol, or other similar criterion was relied upon in

making the denial, either the specific rule, guideline, protocol, or other similar criterion;

or a statement that such a rule, guideline, protocol, or other similar criterion was relied

upon in making the determination and that a copy of the rule, guideline, protocol, or other

criterion will be provided free of charge upon request; and

f. If the denial is based on a medical necessity or experimental treatment or similar

exclusion or limit, either an explanation of the scientific or clinical judgment for the

determination, applying the terms of the Plan to your medical circumstances, or a

statement that the explanation will be provided free of charge upon request.

Some Questions Common to All Claims and Appeals

Question: Who may file an appeal if my claim is denied?

Answer: You may file the appeal yourself or you may authorize a representative (i.e., doctor, spouse, etc.)

to file an appeal on your behalf. Except in pre-service claim appeals where your doctor is acting as your

representative, any representative acting on your behalf must have received written authorization from you

to act on your behalf and that written authorization must be filed immediately with the Administrative

Office as part of your appeal. If you are physically or mentally incapacitated the Trustees will waive this

written authorization requirement. It is extremely important to understand that an assignment of benefits to

the provider of services does not constitute an authorization for the provider to act as your representative.

Question: If my claim is denied will the Plan, upon request, supply me or my representative with all

documents relevant to my claim?

Answer: Yes. The Plan will, upon request, supply copies of all documents and opinions relevant to your

claim in accord with federal regulations.

Question: May I seek prior approval from the Plan for medical care that is not governed by pre-service

provisions of the Plan and appeal any adverse determination under Pre-Service Rules?

Answer: No. Only claims for which pre-authorization is required under the Plan are subject to the

expedited decision and appeal provisions pertaining to pre-service claims.

Question: May the Plan and I mutually agree to extend the time frames contained in the pre-service and

post-service claim rules.

Answer: Yes.

98

Question: Whom should I contact if I have questions about these claims and appeal rules?

Answer: You should call, write, or visit the Administrative Office.


5417 Peck Rd.


Telephone: (626) 444-4600

Fax (626) 258-4090

Office Hours: Monday through Friday (excluding holidays)

8:00 a.m. to 4:00 p.m.

Mailing Address:

P.O. Box 968


Question: Do any provisions of these rules change the deductibles, co-payments, exclusions, or limitations

contained in any of the coverages?

Answer: No.

Notice to Participants

This applies to the following providers under contract with the Cement Masons Plan.

Kaiser

Health Net

Delta Dental

Vision Service Plan

The California Department of Corporations is responsible for regulating health care service plans. The

department has a toll-free telephone number (800) 400-0815 to receive complaints regarding health plans.

If you have a grievance against the coverages or providers listed above, you should contact the Plan and use

the Plan's grievance process. If you need the department's help with a complaint involving an emergency

grievance or with a grievance that has not been satisfactorily resolved by the Plan, you may call the

department's toll-free number.

99

Your ERISA Rights

As a participant in the Cement Masons Southern California Health and Welfare Plan, you are entitled to

certain rights and protections under the Employee Retirement Income Security Act of 1974 (ERISA).

ERISA provides that all plan participants shall be entitled to:

Receive Information about Your Plan and Benefits

Examine, without charge, at the plan administrator's office and at other specified locations, such as

worksites and union halls, all documents governing the plan, including insurance contracts and collective

bargaining agreements, and a copy of the latest annual report (Form 5500 Series) filed by the plan with the

U.S. Department of Labor and available at the Public Disclosure Room of the Employee Benefits Security

Administration of the U.S. Department of Labor.

Obtain, upon written request to the plan administrator, copies of documents governing the operation of the

plan, including insurance contracts and collective bargaining agreements, and copies of the latest annual

report (Form 5500 Series) and updated summary plan description. The administrator may make a

reasonable charge for the copies.

Receive a summary of the plan's annual financial report. The plan administrator is required by law to

furnish each participant with a copy of this summary annual report.

Continue Group Health Plan Coverage

As set forth in detail above, continue health care coverage for yourself, spouse or dependents if there is a

loss of coverage under the plan as a result of a qualifying event. You or your dependents may have to pay

for such coverage. Review this summary plan description and the documents governing the plan on the

rules governing your COBRA continuation coverage rights.

Reduction or elimination of exclusionary periods of coverage for preexisting conditions under your group

health plan, if you have creditable coverage from another plan. You should be provided a certificate of

creditable coverage, free of charge, from your group health plan or health insurance issuer when you lose

coverage under the plan, when you become entitled to elect COBRA continuation coverage, when your

COBRA continuation coverage ceases, if you request it before losing coverage, or if you request it up to 24

months after losing coverage. Without evidence of creditable coverage, you may be subject to a preexisting

condition exclusion for 12 months (18 months for late enrollees) after your enrollment date in your

coverage.

Prudent Actions by Plan Fiduciaries

In addition to creating rights for plan participants, ERISA imposes duties upon the people who are

responsible for the operation of the employee benefit plan. The people who operate your plan, called

fiduciaries of the plan, have a duty to do so prudently and in the interest of you and other plan participants.

No one, including your employer, your union, or any other person, may fire you or otherwise discriminate

against you in any way to prevent you from obtaining a welfare benefit or exercising your rights under

ERISA.

Enforce Your Rights

If your claim for a welfare benefit is denied or ignored, in whole or in part, you have a right to know why

this was done, to obtain copies of documents relating to the decision without charge, and to appeal any

denial, all within certain time schedules.

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Under ERISA, there are steps you can take to enforce the above rights. For instance, if you request a copy

of plan documents or the latest annual report from the plan and do not receive them within 30 days, you

may file suit in a Federal court. In such a case, the court may require the plan administrator to provide the

materials and pay you up to $110 a day until you receive the materials, unless the materials were not sent

because of reasons beyond the control of the administrator. If you have a claim for benefits which is denied

or ignored, in whole or in part, you may file suit in a state or Federal court. In addition, if you disagree with

the plan's decision or lack thereof concerning the qualified status of a domestic relations order or a medical

child support order, you may file suit in Federal court. If it should happen that plan fiduciaries misuse the

plan's money, or if you are discriminated against for asserting your rights, you may seek assistance from the

U.S. Department of Labor, or you may file suit in a Federal court. The court will decide who should pay

court costs and legal fees. If you are successful the court may order the person you have sued to pay these

costs and fees. If you lose, the court may order you to pay these costs and fees, for example, if it finds your

claim is frivolous.

Assistance with Your Questions

If you have any questions about your plan, you should contact the plan administrator. If you have any

questions about this statement or about your rights under ERISA, you should contact the nearest office of

the Employee Benefits Security Administration, U.S. Department of Labor, listed in your telephone

directory or the Division of Technical Assistance and Inquiries, Employee Benefits Security

Administration, U.S. Department of Labor, 200 Constitution Avenue N.W., Washington, D.C. 20210. You

may also obtain certain publications about your rights and responsibilities under ERISA by calling the

publications hotline of the Employee Benefits Security Administration.

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Notice of Privacy Practices (HIPAA)

This notice describes how medical information about you may be used and disclosed and how you can get access to

this information. Please review it carefully.

Use and Disclosure of Health Information

Pursuant to regulations issued by the federal government, the Plan is providing you this Notice about the

possible uses and disclosures of health information about you. Your health information is information that

constitutes protected health information (PHI) as defined in the Privacy Rule of the Administrative

Simplification provision of the Health Insurance Portability and Accountability Act of 1996 and the

regulations thereunder, as amended (HIPAA). The Plan has established a policy to guard against

unnecessary disclosure of your PHI. The following summarizes the circumstances under which and

purposes for which your PHI may be used and disclosed.

To Make or Obtain Payment. The Plan may use or disclose your PHI to make payment to or collect

payment from third parties, such as other health plans or providers, for the care you receive. The Plan

may disclose your PHI to a health care provider if needed for your treatment. For example, the Plan

may provide information regarding your coverage or health care treatment to other health plans to

coordinate payment of benefits. The Plan may use and disclose your PHI to determine eligibility for

benefits; to determine the amount of Plan benefits for the health care services received and to

otherwise manage and process claims; and to conduct utilization review activities. The Plan may also

use and disclose your PHI for other payment purposes as permitted by HIPAA.

To Facilitate Treatment. The Plan may disclose information to facilitate treatment which involves

the provision, coordination or management of health care or related services. For example, the Plan

may disclose the name of your treating dentist to a treating orthodontist so that the orthodontist may

ask for your dental x-rays. The Plan may also use your claims data to alert you to an available case or

disease management program or care coordination program if you are diagnosed with certain diseases

or illnesses. If case management is required, the Plan may use or disclose PHI to health care providers

to coordinate or help manage treatment. If your plan requires precertification for hospitalization or

certain procedures or diagnostic services, the Plan may use or disclose PHI to health care providers to

assist in determining an appropriate course of treatment. The Plan may also disclose your PHI to a

health care provider or to another health plan to coordinate benefit coverage between the Plan and the

other plan, to determine proper payment of your claim, and for other certain administration or

operations purposes (including quality assessment and improvement activities, to review the

qualifications of health care professionals who provide care to you, and fraud and abuse detection and

prevention purposes). For example, the Plan may exchange your PHI with your spouse's health plan

for coordination of benefits purposes, or the Plan may discuss your specific medical history with a

health care provider to determine a particular treatment's medical necessity.

To Conduct Health Care Operations. The Plan may use or disclose PHI for its own operations to

facilitate the administration of the Plan and as necessary to provide coverage and services to all of the

Plan’s participants. Health care operations include such activities as: contacting health care providers

and participants with information about treatment alternatives and other related functions; conducting

data analyses and other activities for planning related purposes, and for clinical guideline and protocol

development; case management and care coordination; conducting data analyses and other activities

designed to improve health or reduce health care costs; fraud and abuse detection activities; reviewing

and evaluating providers; in connection with the merger or consolidation of the Plan and/or its plans

with another plan; creating limited data sets or de-identified health information in accordance with the

requirements of HIPAA; submitting claims for stop-loss (or excess loss) coverage; underwriting,

premium rating or related functions to create, renew or replace health insurance or health benefits

(provided the Plan may not use or disclose "genetic information" for "underwriting purposes" (as such

terms are defined by HIPAA)); business management and general administrative activities of the Plan,

including customer service and resolution of internal grievances, review and auditing, including

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compliance reviews, medical reviews, legal services and compliance programs, quality assessment

and improvement activities, business planning and development including cost management and

planning related analyses and formulary development. For example, the Plan may use your PHI to

conduct case management, quality control, assessment and improvement functions, medical review,

and utilization review or to engage in customer service and the resolution of claim appeals.

For Plan Design Activities or to Collect Plan Contributions. The Plan may use summary or de-

identified health information for plan design activities. In addition, the Plan may use information

about your enrollment or disenrollment in a plan in order to collect contributions that pay for your

plan participation.

In Connection With Judicial and Administrative Proceedings. If required or permitted by law, the

Plan may disclose your PHI in the course of any judicial or administrative proceeding: (1) in response

to an order of a court or administrative tribunal, as expressly authorized by such order, or (2) in

response to a subpoena, discovery request or other lawful process if the Plan (a) receives satisfactory

assurances from the party seeking the information that reasonable efforts have been made by such

party to ensure that you have been given notice of the request or to secure a protective order or (b)

makes reasonable efforts to provide such notice or to secure a protective order.

When Legally Required For Law Enforcement Purposes. The Plan will disclose your PHI when it

is required to do so by any federal, state or local law. Additionally, as permitted or required by law,

the Plan may disclose your PHI to a law enforcement official for certain law enforcement purposes,

including but not limited to: (1 ) about your death if the Plan has a suspicion that your death was the

result of criminal conduct; (2) in an emergency to report a crime; (3) to identify or locate a suspect,

fugitive, material witness, or missing person; (4) about you as a victim of a crime if, under certain

limited circumstances, the Plan is unable to obtain your agreement; and (5) about criminal conduct at

a Plan office or facility.

For Treatment Alternatives. The Plan may use and disclose your PHI to tell you about or

recommend possible treatment options or alternatives that may be of interest to you.

For Distribution of Health-Related Benefits and Services. The Plan may use or disclose your PHI

to provide to you health-related benefits and services that may be of interest to you, including health-

related products or services (or payment for such product or service) that are provided by, or included

in your plan benefits, or other health-related products or services, only available to you, that add value

to, but are not part of, your plan benefits.

For Disclosure to the Plan Trustees. The Plan may disclose your PHI to the Board of Trustees and

necessary advisors for plan administration functions performed by the Board of Trustees on behalf of

the Plan, such as those listed in this summary, or to handle claim appeals, solicit bids for services, or

modify, amend or terminate the Plan.

Business Associates. The Plan may disclose PHI to other people or businesses that provide services

to the Plan and which need the PHI to perform those services. These people or businesses are called

business associates, and the Plan will have a written agreement with each business associate requiring

each of them to protect the privacy of your PHI. For example, the Plan may have hired a consultant to

evaluate claims or suggest changes to the plan, for which the consultant needs to see PHI.

To Report Abuse, Neglect or Domestic Violence. The Plan may report a suspected case of abuse,

neglect or domestic violence to a law enforcement official or other government authority, as permitted

or required by applicable law.

For Public Health Reasons. The Plan disclose your PHI for certain public health reasons, including

(1) to a public health authority for the prevention or control of disease, injury or disability; (2) to a

proper government or health authority to report child abuse or neglect; (3) to report reactions to

medications or problems with products regulated by the Food and Drug Administration; (4) to notify

individuals of recalls of medication or products they may be using; (5) to a proper government or

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health authority to report births and deaths; or (6) to notify a person who may have been exposed to a

communicable disease or who may be at risk for contracting or spreading a disease or condition.

To Conduct Health Oversight Activities. The Plan may disclose your PHI to a health oversight

agency for authorized activities including audits, civil, administrative or criminal investigations,

inspections, licensure or disciplinary action. The Plan, however, may not disclose your PHI if you are

the subject of an investigation and the investigation does not arise out of or is not directly related to

your receipt of health care or public benefits. The Plan may also disclose your PHI to the Secretary of

the Department of Health and Human Services to demonstrate the Plan's compliance with HIPAA.

In The Event of a Serious Threat to Health or Safety. The Plan may, consistent with applicable law

and ethical standards of conduct, disclose your PHI if the Plan, in good faith, believes that such

disclosure is necessary to prevent or lessen a serious and imminent threat to your health or safety or to

the health and safety of the public.

To Your Family Members or Other Persons Involved in Your Health Care. The Plan may

disclose your PHI to your family members, other relatives, your close personal friends, and any other

person you choose to identify if: (1) the information is directly relevant to the family members', other

relatives', close personal friends' or other person's involvement with your care or payment for that care

(including if you are deceased, subject to certain limitations with respect to your prior expressed

preferences which are known to the Plan), or (2) the information is used or disclosed to notify, or

assist in the notification of, a family member, personal representative, or another person responsible

for your care, of your location, general condition, or death (the Plan may also disclose your PHI to

disaster relief agencies or entities for the same purposes). If you are present for, or otherwise available

prior to a use or disclosure permitted above, and you have the capacity to make health care decisions,

the Plan will not use or disclose your PHI to your family and friends unless (a) the Plan obtains your

agreement, or provides you with an opportunity to object to the use and disclosure of your PHI and

you express no objections to such use and disclosure, or (b) the Plan can reasonably infer from the

circumstances that you do not object to such use and disclosure. The Plan may also disclose PHI to

the persons and entities and for the purposes set forth above in emergency circumstances or if you are

incapacitated, and the Plan reasonably believes to be in your best interests and relevant to that person's

involvement in your care.

For Specified Government Functions. In certain circumstances, federal regulations require or permit

the Plan to use or disclose your PHI to facilitate specified government functions related to the military

and veterans, national security and intelligence activities, protective services for the president and

others, and correctional institutions and inmates.

For Workers’ Compensation. The Plan may release your PHI to the extent necessary to comply with

laws related to workers’ compensation or similar programs.

For Fundraising. The Plan may use, and disclose to a business or to an institutionally related

foundation, certain types of PHI for the purpose of raising funds. The type of information that may be

disclosed includes (1) demographic information relating to you, (2) dates of health care provided to

you and (3) your health insurance status. The Plan may also contact you to raise Plans as permitted by

HIPAA and you have a right to opt out of receiving such communications.

To a Coroner, Medical Examiner or Funeral Director. The Plan may disclosure your PHI to allow

a coroner or medical examiner to make an identification or determine cause of death or to allow a

funeral director to carry out his or her duties.

For Cadaveric Organ, Eye, or Tissue Donation Purposes. If you are an organ donor, the Plan may

disclose your PHI as necessary to facilitate organ, eye or tissue donation and transplantation.

For Limited Research Purposes. The Plan may use or disclose your PHI for research purposes if the

Plan obtains one of the following: (1) documented institutional review board or privacy board

approval or waiver; (2) representations from the researcher that the use or disclosure is being used

solely for preparatory research purposes; (3) representations from the researcher that the use or

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disclosure is solely for research on the PHI of decedents; or (4) an agreement to exclude specific

information identifying the individual.

As Part of a Limited Data Set. The Plan may disclose your PHI as part of a limited data set that

meets the technical requirements of 45 Code of Federal Regulations, Section 164.514(e), if the Plan

has entered into a data use agreement with the recipient of the limited data set.

Incident to a Permitted Use or Disclosure. The Plan may use and disclose protected health

information incident to any use or disclosure permitted or authorized by law.

Use or Disclosure of Psychotherapy Notes

It is not the Plan's standard practice to access any psychotherapy notes kept by behavioral health providers.

However, in the event the Plan needs access to these notes, such notes cannot be used or disclosed without

your written authorization (except in certain limited situations permitted by HIPAA addressed below). If

you elect not to provide written authorization, the notes will not be used or disclosed; provided the Plan

may use or disclose psychotherapy notes as required by applicable law or as permitted by applicable law.

For example, the Plan may use or disclose psychotherapy notes as necessary to defend itself in a legal

action or other proceeding brought by you or on your behalf or as necessary to prevent or lessen a serious

and imminent threat to the health or safety of a person or the public, and the Plan may disclose

psychotherapy notes to public health oversight agencies and coroners and medical examiners as permitted

by HIPAA

Disclosure of PHI for Marketing Purposes; Sale of PHI

Except in the limited circumstances permitted by HIPAA or other applicable law, the Plan may not ( l) use

or disclose your PHI to market services or products to you, (2) provide your PHI to anyone else for

marketing purposes, or (3) sell your PHI, without your written authorization. Your authorization is not

required for marketing communications in the form of a face-to-face communication made by the Plan to

you or a promotional gift of nominal value provided by the Plan.

Authorization to Use or Disclose PHI; Revocation of Authorization

Other than as stated above or otherwise provided for herein, the Plan will not disclose your PHI other than

with your written authorization. If you have authorized the Plan to use or disclose your PHI, you may

revoke that authorization in writing at any time.

Additionally, your written authorization will generally be required before the plan will use or disclose

psychotherapy notes. Psychotherapy notes are separately filed notes about your observations with your

mental health professional during a counseling session. They do not include summary information about

your mental health treatment. The plan may use and disclose such notes when needed to defend against

litigation filed by you.

Your Rights With Respect to Your Health Information

You have the following rights regarding your PHI that the Plan maintains:

Right to Request Restrictions. You may request restrictions on certain uses and disclosures of your

PHI. You have the right to request a limit on the Plan’s disclosure of your PHI to someone involved in

the payment of your care. However, except in the limited circumstances described below, the Plan is not

required to agree to your request. Except as otherwise required by law (and excluding disclosures for

treatment purposes), upon your request, the Plan may not share your PHI with another health plan for

purposes of payment or carrying out health care operations if the PHI pertains solely to a health care

item or service for which the health care provider involved has been paid out of pocket in full by you or

by another person (other than the Plan) on your behalf. If you wish to request restrictions, please make

the request in writing to the Plan's Privacy Contact Person listed below.

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Right to Receive Confidential Communications. You have the right to request that the Plan

communicate with you in a certain way if you feel the disclosure of your PHI could endanger you. For

example, you may ask that the Plan only communicate with you at a certain telephone number or by e-

mail. If you wish to receive confidential communications, please make your request in writing to the

individual identified as the Plan’s Privacy Contact Person below. The Plan will attempt to honor your

reasonable requests for confidential communications.

Right to Inspect and Copy Your PHI. You have the right to inspect and copy your PHI which is

maintained in a designated record set (as defined by HIPAA) (e.g., records that the Plan maintains for

enrollment, payment, claims determination, or case or medical management activities). If such PHI is

maintained electronically, you may request such PHI in an electronic format. The Plan will work with

you to provide such PHI in the form and format you request or in a satisfactory alternative if such PHI

is not readily producible in such form and format. You may also direct that such PHI be sent to another

person or entity. However, this right to inspect and copy your PHI does not extend to (1) psychotherapy

notes, (2) information compiled in reasonable anticipation of, or for use in, a civil, criminal, or

administrative action or proceeding, and (3) any information, including PHI, as to which the law does

not permit access. The Plan may also deny your request to inspect and obtain a copy of your PHI if a

licensed health care professional hired by the Plan has determined that giving you the requested access

is reasonably likely to endanger the life or physical safety of you or another individual or to cause

substantial harm to you or another individual, or that the record makes references to another person

(other than a health care provider), and that the requested access would likely cause substantial harm to

the other person. A request to inspect and copy such records containing your PHI must be made in

writing to the Privacy Contact Person listed below. If you request a copy of your PHI, the Plan may

charge a reasonable fee for copying, assembling costs and postage, if applicable, associated with your

request.

Right to Amend Your PHI. If you believe that your PHI records are inaccurate or incomplete, you

may request that the Plan amend the records. That request may be made as long as the information is

maintained by the Plan in a designated record set. A request for an amendment of records must be made

in writing to the Plan’s Privacy Contact Person listed below. The Plan may deny the request if it does

not include a reasonable reason to support the amendment. The request also may be denied if your PHI

records were not created by the Plan, if the PHI you are requesting be amended is not part of the Plan’s

records, if the PHI you wish to amend falls within an exception to the PHI you are permitted to inspect

and copy, or if the Plan determines the records containing your PHI are accurate and complete.

Right to an Accounting. You have the right to request a list of disclosures of your PHI made by the

Plan other than disclosures made (1) for treatment, payment or health operations, (2) to you, (3) incident

to a use or disclosure permitted or required by law, (4) pursuant to an authorization provided by you, (5)

for certain directories or to people involved in your care or other notification purposes as permitted by

law, (6) for national security or intelligence purposes, (7) to correctional institutions or law enforcement

officials, or (8) that are part of a limited data set. The request must be made in writing to the Privacy

Contact Person listed below. The request should specify the time period for which you are requesting

the information, but may not start earlier than April 14, 2003 when the Privacy Rule became effective.

Accounting requests may not be made for periods of time going back more than six years. The Plan will

provide the first accounting you request during any 12-month period without charge. Subsequent

accounting requests may be subject to a reasonable cost-based fee. The Plan will inform you in advance

of the fee, if applicable.

Right to a Paper Copy of this Notice. You have a right to request and receive a paper copy of this

Notice at any time, even if you have received this Notice previously or agreed to receive the Notice

electronically. To obtain a paper copy, please contact the Privacy Contact Person listed below.

Right to Receive Notice. The Plan must notify you following the acquisition, access, use or disclosure

of your unsecured PHI in a manner that is impermissible under the HIPAA privacy rules, unless there is

a low probability that such PHI was compromised (or notification is not otherwise required under

HIPAA).

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Right to File a Complaint. You have the right to express complaints to the Plan and/or to the Secretary

of the Department of Health and Human Services if you believe that your privacy rights have been

violated. Any complaints to the Plan should be made in writing to the Privacy Official identified below.

For information on how to make a complaint to the Secretary of the Department of Health and Human

Services go to http://www.hhs.gov/ocr/privacy/hipaa/complaints/index.html or call (800) 368-1019. The

Plan encourages you to express any concerns you may have regarding the privacy of your PHI. You

will not be retaliated against in any way for filing a complaint.

Privacy Contact Person/Privacy Official

To exercise any of these rights related to your PHI, contact:

Privacy Contact Person

5417 Peck Rd

Arcadia. CA 91006

Phone (626) 444-4600

Fax (626) 258-4090

The Plan has also designated the Client Service Manager as its Privacy Official. This person has the same

address and phone/fax numbers as listed above.

Duties of the Plan

The Plan is required by law to maintain the privacy of your PHI as set forth in this Notice and to provide to

you this Notice of its duties and privacy practices. The Plan is required to abide by the terms of this Notice,

which may be amended from time to time. The Plan reserves the right to change the terms of this Notice

and to make the new Notice provisions effective for all PHI that it maintains. Upon a material change to

this Notice, the Plan will inform you of such change as provided by HIPAA and provide you with

information about how to get a copy of the revised Notice. While the Plan is bound by the terms of this

Notice as they relate to the privacy of your PHI under HIPAA as provided above, this Notice does not

change any other rights or obligations you may have under the plans maintained by the Plan. You should

refer to the plan documents for additional information regarding your plan benefits.

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