Self-Funded Medical

Under the medical plan certain hospitals, doctors, and laboratories have agreed to accept negotiated rates for services provided to participants and dependents insured under this Plan. To receive the maximum available benefits, use a Anthem Blue Cross Prudent Buyer Hospital or Doctor for your covered services. If you need a listing of Participating Providers, you may obtain one from the Administrator’s Office. This listing may contain providers that have discontinued their relationship with Anthem Blue Cross or may not include providers who have recently joined the network. For most current information, please check the Anthem Blue Cross website at www.bluecrossca.com. Read the cost containment section of your booklet for other cost containment measures the Board of Trustees has implemented to save YOU and YOUR TRUST FUND money.

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COVERED EXPENSES

Any expense will be considered a covered expense if it satisfies the following conditions:
1. Is Necessary Treatment (as defined on pages 72 and 73) of a Sickness or Injury (as defined on page 72);
2. To the extent that it does not exceed Usual and Customary Charges (as defined on page 73);
3. Is received while covered for this benefit; and
4. Is covered under the Plan.

The following is a listing of covered expenses under Major Medical:
1. Hospital room and board (including intensive and cardiac care units);
2. Hospital extras such as recovery room and operating room charges, medications, anesthesia, etc.;
3. Charges made by a Physician;
4. Charges made for diagnostic testing;
5. Charges made for radiation and chemotherapy treatment;
6. Charges made for private duty nursing;
7. Charges made for prescription drugs from any licensed pharmacy or through the Plan’s mail order prescription service (see pages 25, 26 and 27 for complete details);
8. Charges made for rental (or if cheaper, purchase) of wheelchairs, Hospital type beds, oxygen and equipment for its administration, and mechanical equipment for the treatment of respiratory paralysis;
9. Charges for physical therapy;
10. Charge made for artificial limbs, eyes, casts, splints, crutches and braces (not including dental braces);
11. Charges for ambulance service will be paid as any other medical benefit;
12. Charges for blood and blood plasma except when replaced;
13. Charges incurred at a Skilled Nursing Facility as defined on page 72. Confinement therein must start within 14 days of a Hospital stay. It must also be for continued treatment of the condition causing the Hospital stay or any subsequent condition or complication related to the condition that caused the Hospital stay or that arose as a result of the Hospital stay;
14. Charges made by a licensed home health care agency for home health care services, subject to a maximum of 100 visits in 12 consecutive months. Each visit by an Retiree of a licensed home health care agency will be considered one home health care visit. A visit of more than 4 hours in a day will be considered as 2 visits. Multiple visits a day by one or more persons shall be considered as one visit if they total less than 4 person hours; Coverage includes:

part-time or intermittent nursing care by or under the supervision of a registered nurse;
part-time or intermittent home health aide services which consist primarily of caring for the individual;
physical therapy provided by a home health care agency; and
medical supplies, drugs and medications prescribed by a Physician and laboratory services provided by or on
behalf of a licensed home health care agency, but only to the extent that such charges would have been
payable had the insured been confined in a Hospital.

15. Charges for routine mammographic examinations as diagnostic screening procedures, as specified:

A baseline mammogram for covered females age 35 through 39;
For covered females age 40 through 49 a mammogram every 2 years unless recommended more frequently by her attending Physician; and
For covered females age 50 or over a mammogram annually.

16. Charges for:

the cost of fitting of external breast prostheses (but not more than two in any calendar year for each breast); and inpatient or outpatient chemotherapy; after a mastectomy for which benefits are paid under this Plan.
Reconstruction of the breast on which the mastectomy was performed.
Surgery and reconstruction of the other breast to produce a symmetrical appearance; or prostheses and physical complications of all states of mastectomy, including lymphedemas.

Plan Summary

DEDUCTIBLES & MAXIMUMS
Lifetime Maximum	$2,000,000
Outpatient and Mental and Nervous Disorders	60 Office visits per calendar year paid at 50% of Usual and Customary Charges per person.
Inpatient Hospital Mental and Nervous Disorders	30 days per any 12-month period
Alcohol & Drug Abuse Treatment	$25,000 lifetime maximum per person
Maximum Payable for Outpatient Alcohol & Drug Abuse	40 hours of therapy $500.00
Deductible Amount	$300.00 per person per calendar year, limited to $600 per family per calendar year
Deductible Carryover	Deductible is reapplied on January 1 of each year, and expenses incured in the last 90 days are applied to the deductible for the next calendar year
Coinsurance Percentage	100% for Second Surgical Opinion (deductible waived) 100% of contract rate at preferred provider laboratory after a $10.00 deductible. For Individuals residing WITHIN the Preferred Provider Service Area: 90% of contract rate if by a preferred provider Hospital. For Office Visits to a Preferred Provider Physician the co-pay will be $20.00. This co-payment will be paid directly to the Physician at the time of your visit. These co-payments do not apply to the deductible amounts. 70% of Usual and Customary Charges by non-preferred provider. 80% of Usual and Customary Charges for prescription drugs and other covered supplies and services 50% of Usual and Customary Charges for outpatient mental and nervous disorders and alcohol and drug abuse benefits. For Individuals residing OUTSIDE the Preferred Provider Service Area: 80% of Usual and Customary Charges by a Hospital or Physician. 80% of Usual and Customary Charges for prescription drugs and other covered supplies and services. 50% of Usual and Customary Charges for outpatient mental and nervous disorders and alcohol and drug abuse benefits.
PRESCRIPTIONS (No deductible applied)
Caremark Mail Order (90-day supply)	$10 co-pay for generic, $25 co-pay for preferred brands, $40 for all other brands
Caremark Prescription Card	$10 co-pay for generic, $25 co-pay for preferred brands, $40 for all other brands
ROUTINE CARE
Physical	100% up to $200 per employee and $200 per spouse, depending on age
Preventative Care for Children	19 periodic physical examinations: maximum allowance is $250 per examination
OTHER SERVICES
Skilled Nursing Facility	50% of a Hospital average semi-private room rate, if confined within 14 days after a Hospital confinement for which benefits were payable
Supplemental Accident	100% of Usual and Customary Charges up to $500 benefit per injury (no deductible applied); regular benefit schedule applies thereafter

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