Health & Welfare SPD

A. SELF-FUNDED INDEMNITY PLAN

The Indemnity Plan provides you with freedom of choice in selecting your Physician. To maximize Plan benefits, you are urged to use Physicians and Hospitals that are Preferred Providers. When you use health care providers that are not Preferred Providers, you may incur more out-of-pocket costs.

You should carefully review the benefits of the Indemnity Plan to make certain it fits your needs, and that you understand what will be your financial obligation (out-of-pocket costs) under this option.

1. General Provisions.

Summary of Benefits.
1. Deductible. There is a $50 per person, $100 per family per calendar year deductible. (Exception: Non-Medicare-Eligible Retirees: ($100.00 per person, $200.00 per family))
2. Hospital Benefit. The Plan pays the first $5,000 of covered Hospital charges in a calendar year at 100% (not subject to the deductible).
3. Other Medical and Hospital Benefits. The Plan will pay 80% of Covered Charges after the deductible is met.
4. Out-of-Pocket Maximum. There is an out-of-pocket maximum of $1,000 per person per calendar year. (Prior to 1, 2007, the out of pocket maximum was to $1,000.) The Plan will pay 100% of Covered Charges in excess of $5,000 per person in a calendar year.
5. Annual Maximum. There is an annual maximum of $500,000 per person
  
  This section modified by a Benefit Change
  Effective 8/1/2008: the calendar year maximum benefit of $500,000 will increase to $750,000.
6. Maximum Lifetime Benefits. There is a lifetime maximum of $2,000,000 per person (including benefits for both Actives and Retirees).
If you or your Dependent incurs Covered Charges during a calendar year as a result of a non-occupational Illness or Injury sustained while eligible, benefits will be paid at the appropriate percentage of Covered Charges, subject to the limitations and provisions in this booklet.

You and your Dependents are encouraged to review the Plan Comparison Worksheets that are available in the Plan Office when deciding which Plan would most meet your needs, either at the time of initial enrollment or during open enrollment.

This section modified by a Benefit Change
Effective 11/1/2008: the PPO Network will change from First Health to Blue Shield Shared Advantage Program. This change will improve the operation of the indemnity plan with no disruption to Plan participants.

Preferred Provider Network. The Plan has contracted with First Health Group Corp., a Delaware corporation, (“First Health”), to access the First Health Preferred Provider Organization (“PPO”) Network, to cover Hospital and medical services rendered by participating Hospitals and practitioners at predetermined fees. Neither you nor the Plan is responsible for any charges in excess of the contracted amount. The Plan adopted this PPO Network as a cost containment measure and the result is a saving to both the Plan and the members who use participating providers and facilities. Additionally, some services that are not normally covered under the Plan may be included at no charge at a PPO Network facility. Information regarding this program, as well as a schedule of providers, is available by phoning First Health at 1-800-226-5116 at no cost or you may access this information directly through First Health's web-site at www.myfirsthealth.com.

Medically Necessary Requirement. Charges must be Medically Necessary in order for the charge to be covered under the Plan. NOTE: The Plan may rely on its medical review department and/or an independent medical reviewer to determine if treatment is Medically Necessary. The fact that a Physician may order treatment does not, of itself, make it Medically Necessary, or make the expense a Covered Expense. (See Section XIV, Definitions.)

2. Benefits for Active and Early Retiree Members and Their Dependents.

This section modified by a Benefit Change

Effective 11/1/2008: the Blue Shield Shared Advantage transplant and case management programs will replace the programs currently provided through First Health.

The Plan has contracted with First Health Group Corp. to provide Clinical Management Services including utilization review and case management.

Early Medical Assessment. Medical providers are requested to contact First Health prior to any non-emergency hospitalizations and outpatient procedures at (800) 572-5508. Pre-notification ensures early identification of high-risk patients that would benefit from case management through a detailed data collection process. This procedure is not designed to interfere with medical decisions made between patients and their providers.

Medical Case Management. This service is designed to assist you or your Dependent in obtaining needed medical care from the most appropriate source available. The care manager will have the option of scheduling services or suggesting methods and providers of care, which may not be specifically covered by this Plan. The costs of these special care facilities and treatments will be treated as “Covered Charges” and reimbursed as outlined below. Referrals into case management will come from First Health’s early medical assessment program and the Plan Office.

Medical & Hospital Benefits. After the deductible has been satisfied, benefits will be paid at 80% of the first $5,000 of incurred Reasonable and Customary charges in a calendar year as defined in the Section XIV of this booklet. The 20% balance (member’s coinsurance) is an out-of-pocket expense for which you are responsible. Once you or your Dependent has incurred $5,000 in Covered Medical and Hospital Charges in a calendar year, the Plan will pay the balance of Covered Charges incurred during the remainder of the calendar year at 100%. (Prior to January 1, 2007, While the Plan paid 80% of the first $7,500 and 100% after $7,500 in incurred Reasonable and Customary charges in a Calendar Year.)
Effective, January 1, 2007, the Plan pays the first $5,000 of covered Hospital charges in a calendar year at 100% (not subject to the deductible) when a member or Dependent:
1. is a registered bed patient, (including room and board charges up to the semiprivate rate); or
2. receives emergency outpatient treatment at a Hospital within 24 hours from the occurrence of an accident; or
3. receives emergency outpatient treatment for a condition characterized by acute symptoms that are of sufficient severity to cause a reasonable expectation, in the absence of immediate medical attention, that the health of the individual is in serious jeopardy; or
4. requires Hospital facilities as an outpatient for a surgical operation.
Successive Hospital confinements shall be considered one confinement unless (1) they are separated by 30 days or (2) readmission is required as a result of accidental bodily injury during the 30 days.

The Trustees have the authority and discretion to interpret, construe and apply the terms of the Plan and to decide any and all other issues arising under the Plan, including the amount of benefits (if any) that may have become payable.
Exception. The following benefits are paid at 100% of the Reasonable and Customary charges and are not subject to deductible or maximum amounts payable.
1. Second Surgical Opinion. You may consult a legally qualified Physician on the need of a non-emergency surgical procedure which is otherwise covered under the Plan, including necessary x-ray and laboratory examinations. If the second opinion does not confirm the need for the surgery you may consult a third Physician. Charges incurred for the second and/or third consultation for surgery will be payable at 100% of the first $100 per consultation. For any Reasonable and Customary charges incurred in excess of $100 for the second or third consultation, reimbursement shall be subject to the deductible amount, percentages payable, and maximum amount payable.
2. Convalescent Hospital and Skilled Nursing Facility expenses are reimbursable after an in-patient Hospital confinement of at least 3 days, up to a maximum of $75.00 per day. The maximum number of Convalescent Hospital days during any one period of confinement is 100, reduced by the number of days of Hospital confinement. Successive Hospital confinements (including Convalescent Hospital confinements) will be considered a single confinement unless they are separated by a period of 30 days or the second confinement is due to a new accidental injury. The Plan will not reimburse expenses in excess of $75.00 per day.

Deductible Amount. The deductible is $50 per person up to a maximum
of $100 per family for each calendar year. This is the out-of-pocket expense for which you are responsible. Non-Covered Charges and your coinsurance percentage may not be used to satisfy the deductible amount.

The deductible amount is subtracted from the Covered Charges and the remaining amount is multiplied by the coinsurance percentage to determine the amount payable.

If charges in the last three months of a calendar year are applied toward the deductible, these charges will also be applied toward the deductible for the next calendar year.

After two or more individuals in an eligible family have satisfied the family deductible in a calendar year, no further deductible is required of that family unit for charges incurred in the remainder of that calendar year. “Eligible family” means a covered member and all Dependents.

Maximum Payment. The maximum amount payable in a calendar year for all illnesses or injuries for any one eligible member or Dependent shall not exceed $500,000 per calendar year and $2,000,000 per lifetime. Each January 1st, the amount of major medical benefits which was used in the preceding calendar year will automatically be reinstated up to a maximum of $1,000. This reinstatement is made without any action required on your part. However, in no event will the total cumulative benefits, including the amount reinstated, exceed the original lifetime maximum. There will be no automatic reinstatement when benefits are being continued under the Non-COBRA Continuation of Coverage provisions. (See III)

3. Benefits for Retirees and Their Dependents.

All benefits described in II.A.1, Benefits for Active and Early Retiree Members and their Dependents also apply to Retirees and Dependents.

If you are a Retiree member but are not yet eligible to enroll in Medicare, the annual deductible is $100.00 for you and $200.00 per family.

If you are a Medicare-eligible Retiree or Dependents, the Plan shall offset Covered Charges by the amount payable by Medicare. Payments made pursuant to Medicare are subject to the satisfaction of any deductibles and the application of any Plan benefit maximums or coinsurance.

If you are a Retiree member or Retiree Dependent covered under the Indemnity Plan, once you or your Dependent becomes eligible to enroll in parts A & B of Medicare, the Plan will process eligible claims incurred on or after that date as though you or your Dependent has Medicare coverage, even if you or your Dependent fails to enroll or is treated by a non-Medicare certified provider.

If you are a Retiree member, and you or your Dependent selects and assigns your (or your Dependent’s) Medicare Parts A & B to a plan outside the Plan, no benefits will be payable unless the supplemental benefits described in Section VII are selected.

4. Covered Charges.

Benefits are payable for the Reasonable and Customary charges for services ordered by a Physician or other Licensed or Certified Health Care Provider that are Medically Necessary and are for services, treatment, and supplies for the care and treatment of an Illness or Injury.

The Plan will pay benefits as outlined in III.A.1 and III.A.2 for the following charges:

Treatment. Made by a duly constituted and lawfully operated Hospital for outpatient and inpatient treatment. Covered Charges for inpatient treatment are limited to the Hospital’s regular rate for semiprivate accommodations. If the Hospital does not have semiprivate accommodations, the Plan will pay 75% of the minimum daily charges for room and board.

Pre-admission and X-Rays. Made by a Hospital for pre-admission testing for diagnostic tests performed and x-rays taken, in the Hospital’s outpatient department in connection with a scheduled Hospital admission for treatment of Injury or Illness covered by the Plan, provided tests are:
1. made within 7 days prior to admission;
2. ordered by the same Physician who ordered the admission; and
3. the same tests that would have been ordered during the hospital confinement.
If the scheduled admission is cancelled or delayed, the benefit will still be paid if:
1. the tests reveal a condition that requires treatment prior to the admission;
2. a medical condition develops that delays the admission;
3. a hospital bed is not available on the scheduled date of admission; or
4. the tests indicate that the admission is not necessary.

Intensive Care or Coronary Care. For accommodations in an Intensive Care Unit or Coronary Care Unit which are in excess of the semiprivate rate, when required for the treatment of a critically ill or injured person.

Licensed Convalescent Hospital or Skilled Nursing Facility. Made by a Licensed Convalescent Hospital or Skilled Nursing Facility as defined in Section XIV, Definitions and subject to the limitations described above in A.1(a)(ii).

Professional Medical Services. For professional medical services of a Physician (including surgeon, anesthesiologist, radiologist, pathologist) or Other Licensed or Certified Health Care Provider as defined in Section XIV, Definitions.

Chiropractor. For Reasonable and Customary charges by generally accepted chiropractic standards when treated by a licensed chiropractor. You should contact the Plan Office for an evaluation before starting treatment because the number of visits is limited depending upon the nature of Illness or Injury. Claims will be referred to the Plan’s medical review department or an independent medical reviewer to determine Medical Necessity and appropriate frequency of treatment based on information provided by the caregiver in most instances.

Acupuncturist. For Reasonable and Customary charges of a licensed acupuncturist which may be covered as a standard medical benefit for Reasonable and Customary expenses, depending upon the diagnosis. You should contact the Plan Office prior to scheduling treatment to determine whether or not coverage is applicable to your specific Illness or Injury. Claims will be referred to the Plan’s medical review department or an independent medical reviewer to determine Medical Necessity and appropriate frequency of treatment based on information provided by the caregiver in most instances.

Therapist. For Reasonable and Customary charges of a licensed or registered physical therapist or occupational therapist. You should contact the Plan Office for an evaluation before starting treatment since the number of visits may be limited depending upon the nature of Illness or Injury. Claims will be referred to the Plan’s medical review department or an independent medical reviewer to determine Medical Necessity and appropriate frequency of treatment based on information provided by the caregiver in most instances.

Mental Health. For professional services of a licensed psychologist, psychotherapist or psychiatrist for treatment of mental and nervous disorders and emotional disturbances of a child. These benefits are provided through an insured program with PacifiCare Behavioral Health. This supplemental program is described in Section VII.
A “child” within the meaning of the phrase, “emotional disturbances of a child” means a child who:
1. is under age 18; and
2. has one or more mental conditions as identified in the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders, other than a primary substance use disorder or developmental disorder, that results in behavior that is inappropriate to the childâ€™s age according to expected developmental norms if:
  1. as a result of the mental condition the child has substantial impairment in at least two of the following areas: self-care, school functioning, family relationship or the ability to function in the community; and either of the following:
    1. the child is at risk of removal from home or has already been removed from the home; or
    2. the mental disorder and impairments have been present for more than six months or are likely to continue for more than one year without treatment.
  2. the child displays one of the following: psychotic features, risk of suicide or risk of violence due to a mental disorder; or
  3. the child meets special education eligibility requirements under Chapter 26.5 of Division 7 of Title 1 of the Government Code.

Nursing. Made by a registered nurse (R.N.), a licensed vocational nurse (L.V.N.), or licensed practical nurse (L.P.N.), for private duty nursing service.

Outpatient Facilities. For services rendered for outpatient surgery if the patient undergoes a surgical procedure which would normally be performed in a Hospital but which can be performed in an Ambulatory Outpatient Surgical Facility or a Physician’s office. The patient has the right to choose between having the procedure performed in the Ambulatory Outpatient Surgical Facility, the Physician’s office, or in the Hospital.

Prosthetic Services and Appliances.For initial and subsequent post-mastectomy prosthetic devices and prosthetic appliances such as artificial limbs or eyes.

Support. For initial truss, brace or support, cast splints, and crutches.

Rental of Durable Medical Equipment. For the rental (not to exceed the purchase price) of durable medical equipment such as a wheelchair and hospital-type bed. Durable equipment means equipment or Food and Drug Administration (“FDA”) approved medical devices that are medically necessary to aid in recovery, mobility and/or the support of life. Such durable medical equipment must: (i) be prescribed by the attending Physician; (ii) be designed for prolonged use; (iii) not be primarily used for non-medical purposes; and (iv) not be specifically excluded by the Plan.

Oxygen. For oxygen and purchase or rental of equipment for its administration. The benefit limit for rental will not exceed the purchase cost.

Blood. For blood or blood plasma not replaced, including the storage of the patient’s blood when approved or recommended by the attending Physician or surgeon.

Surgical. For surgical procedures whether or not stored blood is used.

Laboratory Tests and X-Rays. For laboratory tests and x-rays.

Anesthesia. For anesthesia and its administration.

Cancer Treatment. For use of radium and radioactive isotopes and/or cancer chemotherapy treatment.

Ambulance/Transportation. For transporting the patient to the first Hospital where treatment is given and when Medically Necessary, if such transport:
1. is to the nearest facility equipped to provide the required treatment;
2. is provided by a licensed professional ambulance service; and
3. is land transportation except where land transport is too dangerous or is not available.

Drugs. For drugs and medicine obtainable only upon the written prescription of a Doctor and dispensed by a licensed pharmacist, including insulin and diabetic supplies (administered through RxAmerica's prescription drug card program - see Supplemental Benefits, Section VII). This section modified by a Benefit Change
Effective 8/1/2008: to enhance prescription drug benefits provided through the Indemnity Plan, the Trustees have adopted the following RxAmerica programs:
- Specialty Pharmacy Program for participants who are being treated with biotech or injectable drugs for chronic medical conditions.
- 3 For Free Program (3 months with a zero copay for certain generic drugs) for participants being treated for high cholesterol, depression, or arthritis.
- TrueTrack Glucometer Program for participants diagnosed with Diabetes.

Injectable Drugs. For injectable drugs, including syringes and needles for the administration thereof.

Substance Abuse. Substance Abuse. For substance abuse, including detoxification. These benefits are provided through an insured program with PacifiCare Behavior. This supplemental program, which is available to all Plan Participants and their Dependents, is described in VII.E and VII.F.

Tempomandibular Joint Dysfunction. For the treatment of Tempomandibular Joint Dysfunction syndrome (“TMJ”), or any other treatment of the face, neck, or head is covered on the basis as any other treatment of the skeletal system, if the procedure is Medically Necessary to treat a condition caused by congenital deformity, Injury or Illness. However, charges for intra-oral prosthetic devices are excluded. Benefits for TMJ may not exceed a lifetime maximum of $1,500.

Maternity Charges. For maternity-related services for a member or spouse or Domestic Partner. Maternity charges incurred by a Dependent child are not covered, except for complications of pregnancy, defined in clause (i) below. Charges due to elective abortion shall not be considered a Covered Expense except for those charges incurred for an abortion where the life or health of the mother would be endangered if the fetus were carried to term, or those charges which directly result from complications of an abortion. Expenses for “well-baby” care are not covered, with the exception of a “well baby Physician’s Hospital visit” at the time of release from the Hospital.
1. Complications of pregnancy means:
  1. conditions that require Hospital confinements (when the pregnancy is not terminated), whose diagnoses are distinct from pregnancy but are adversely affected by pregnancy, or which are caused by pregnancy; and
  2. non-elective Cesarean section; ectopic pregnancy which is terminated; and spontaneous termination of pregnancy which occurs during a period of gestation in which a viable birth is not possible.
2. A female member or Dependent spouse or Domestic Partner who is pregnant on the date of termination of her coverage will be entitled to the applicable benefits for covered expenses due to her pregnancy even though she may not be totally disabled on the date of termination provided:
  1. the pregnancy commenced while such individual was eligible for coverage under the Plan, and
  2. such individual is not eligible for coverage under any other group plan providing similar benefits for the pregnancy.
3. Charges for maternity-related care will be provided on the same basis as any other Illness. However, expenses for inpatient Hospital treatment for childbirth delivery will be provided for the mother’s newborn child for:
  1. 48 hours following normal vaginal delivery; and
  2. 96 hours following delivery by Caesarean section.
4. The mother and newborn child may be discharged earlier than the above indicated time periods if both of the following conditions are met:
  1. the treating Physician or Other Licensed or Certified Health Care Provider in consultation with the mother makes the decision to discharge the mother and child for an earlier time period; and
  2. a post discharge follow-up visit for the mother and newborn child is provided within 48-hours of discharge, when:
    1. prescribed by her treating Physician; and
    2. the visit is provided by a Licensed or Certified Health Care Provider whose scope of practice includes postpartum care and newborn care, and may include parent education, assistance and training in breast or bottle feeding; and the performance of any necessary maternal or neonatal physical assessments.

Gynecological. For annual routine pap smears including a gynecological exam.

Mammography. For mammography screening as follows:
1. a single baseline mammogram for women age 35, but less than 40
2. one mammogram every two years, or more frequently if recommended by a Physician, for a woman age 40, but less than age 50; and
3. one mammogram every year for a woman age 50 or older.

Sterilization. Charges for sterilization of the reproductive system, including vasectomy and tubal ligation.

Stand-by Surgeon. For services by a stand-by surgeon when Medically Necessary due to the risk of the surgical procedure.

Annual Physical. For an annual physical up to a maximum of $300.

Preventive Child Care. For preventive child care which will be considered Medically Necessary for the following services:
1. Physician's services for routine physical examinations;
2. immunizations; and
3. laboratory services in connection with routine physical examinations.
4. Benefits will be limited to one Physician's visit, including immunizations and laboratory services in connection with such visit at approximately the following ages:
  1. birth;
  2. 2, 4, 6, 9, 12, 15 and 18 months of age; and
  3. 2, 3, 4, 5, 6, 8, 10, 12, 14 and 16 years of age;

Newborn. For Newborn care, limited to one well baby Hospital visit.

Cataract Surgery. For contact lenses or eyeglasses and frames required immediately following and as a result of cataract surgery.

Osteoporosis. For the treatment of osteoporosis, including all FDA-approved technologies, including bone mass measurement technologies as deemed medically appropriate by a Physician.

Speaking Assistance. For prosthetic devices to restore a method of speaking for the patient incident to a laryngectomy, including the initial and subsequent prosthetic devices or installation accessories, as prescribed by the treating Physician, but will not include electronic voice producing machines.

Adult Immunizations. Charges for immunizations for adults. Benefits are limited to immunizations that are recommended by the American Academy of Family Physicians or the patient’s Physician.

Schedule of Transplant Benefits. This section modified by a Benefit Change

Effective 11/1/2008: Blue Shield Shared Advantage transplant program will replace the First Health National Transplant Program.

The following schedule summarizes coinsurance amounts paid by the Plan, benefit maximums and additional explanations needed for your transplant benefits. Please refer to the other Plan provisions that may affect your benefits.

Benefit Description	First Health National Transplant Program	Non-National Transplant Program	Additional Limitation and Explanations
Plan Pays	100%	Not Covered	Travel, lodging and meals allowance is for the transplant recipient and his or her immediate family travel companion (both parents, if patient under age 19). Transplants performed outside the National Transplant Program will not be covered, including any donor expenses or travel, lodging and meals related to the transplant.
Organ Donor Costs Per Transplant	$100,000	Not Covered
Travel, Lodging and Meals	$10,000	Not Covered
Allowance Per Transplant	$10,000	Not Covered
Individual Lifetime Benefit Maximum	$1,000,000	Not Covered

First Health National Transplant Program/Member Services toll-free number: 1-800-572-5508

This section modified by a Benefit Change

Effective 8/1/2008

Recognizing that early screenings are important steps in promoting good health and controlling costs, the Plan has been amended to provide 100% reimbursement of reasonable and customary charges for the following services based on Medicare guidelines:

Preventative Procedure	Schedule for Routine Normal Risk Participants	Schedule for High Risk Participants
Fecal occult blood test	Once every 12 months	Once every 12 months
Flexible Sigmoidoscopy	Once every 48 months	Once every 48 months
Colonoscopy	Once every 10 years	Once every 48 months
Colonoscopy	Not payable if performed within 48 months of a screening flexible sigmoidoscopy
Pap smears and Pelvic Exams	Once every 24 months	Once every 12 months
Prostate Cancer Screenings	Once every 12 months for men age 50 and older	Once every 12 months for men age 50 and older
Mammogram Screenings	One baseline screening mammogram for women 35 to 39 years of age; once every 12 months for women 40 years and older	Diagnostic mammograms when a screening mammogram shows an abnormality

NOTES: Please refer to the separate flyer regarding the First Health7 National Transplant Program for additional information about the program.

Transplant benefits are subject to the medical plan lifetime benefit maximum on the Schedule of Medical Benefits.