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Blue Shield PPO and HMO plans benefit summary For Northern California Pipe Trades Health and Welfare Plan members Effective July 2016

We’re here to help If you have any questions, simply contact your dedicated Blue Shield Member Services team at (855) 256-9404 for personal assistance. They are available from 7 a.m. to 7 p.m., Monday through Friday. To find Blue Shield network providers, visit blueshieldca.com/findaprovider.

blueshieldca.com

             

 

When you go with the Preferred Provider Organization (PPO) or Health Maintenance Organization (HMO), administered by Blue Shield of California, you’re on your way to quality health coverage, large provider networks, and a wide range of programs and services that help provide the most value from your coverage. This booklet offers the information you need to choose the right health plan for you and your family.    

   

Plan choices Northern California Pipe Trades Health and Welfare Plan is offering the following plans, administered by Blue Shield: • Shield Spectrum PPO plan • Access+ HMO plan

 

NEW for 2016: Hearing aid benefits - provides a $2,000 allowance every 24 months. See inside for more information about this benefit.

Blue Shield of California’s Shield Spectrum PPO Plan If keeping your relationship with your current doctors is important, our Shield Spectrum PPOSM Plan may be a good choice for you. You can continue to see your doctors, even if they aren’t in the plan’s network.

How the plan works You can receive care from any of the physicians and hospitals within the plan’s network, as well as outside of the network for covered services.

Find a network provider

Within the provider network

2. Select the type of provider you need.

Preventive care services such as a flu shot are fully covered. You pay 100% for all other services until you meet your plan-year deductible. After your deductible is met, you pay a copayment or coinsurance for covered services. PPO network providers submit their claims directly to Blue Shield, so it’s convenient for you. Outside the provider network When you see a non-network provider, what you ultimately pay depends on fees above Blue Shield’s allowable amounts. Those fees vary and can be costly.

1. Go to blueshieldca.com/networkppo. 3. Click Advanced Search to filter your search by name, specialty or facility type. 4. Enter your city and state or ZIP code, then click Find now. If you’re looking for a network provider outside of California, go to provider.bcbs.com. Enter the first three letters of your Blue Shield member ID card or PZF. Search by keyword or by specialty, enter a location and how far you want to travel, and then click Go.

For covered services:

To search for a network provider outside the United States, go to bluecardworldwide.com and accept the terms and conditions. Enter the first three letters of your Blue Shield ID card or PZF and click Go.

• You pay 100% of the amount billed until you meet your plan-year deductible.

Get cost-saving pharmacy benefits

• Only the amount allowed by Blue Shield applies to your deductible.

Our website’s Pharmacy section has helpful information including:

• After you meet your deductible, you pay a copayment or coinsurance based on Blue Shield’s allowable amount, plus any charges above the allowable amount.

• Plus Drug Formulary – Our list includes brand and generic drugs. You may save money if your current medication is a preferred prescription drug.

Non-network providers usually require you to pay the full amount at the time you receive care. You then submit a claim with an itemized doctor’s bill to Blue Shield.

• Prescriptions by mail – If you take stabilized doses of covered medications for chronic conditions such as diabetes, you can have a 90-day supply delivered by mail. Shipping is free, and you may save on your copay.

Estimate your medical costs Blue Shield’s Treatment Cost Estimator lets PPO plan members see approximate total costs, including out-ofpocket expenses, for common medical treatments and services. These estimates provide clear information to help you budget and plan for future healthcare expenses. To begin, log in to blueshieldca.com and then click on Help & Support, then Tools, and then Treatment Cost Estimator.

Have questions? Get answers. Call the Blue Shield Member Services team at (855) 256-9404. Visit blueshieldca.com to find providers, review medical benefits and more. Download the Blue Shield mobile app for iPhone or AndroidTM at blueshieldca.com/mobile.

blueshieldca.com

Blue Shield of California’s Access+ HMO plan If you go to the doctor often, our Access+ HMO plan may be the most cost-effective one for you. It’s affordable and predictable – fixed copays for most services, no deductibles and almost no claim forms.

How the plan works Choose your Personal Physician

Find a network provider

When you enroll in this plan, you’ll choose a Personal Physician (Primary Care Physician) and medical group/ Independent Practice Association (IPA).

You have access to providers in the Blue Shield HMO network, one of the largest HMO provider networks in the state.

Personal Physicians perform preventive care and treat medical conditions. They can also coordinate other health care, including referrals to specialists and hospitals within their medical group/IPA. Each member of your family can choose a different physician and medical group/IPA.

1. Go to blueshieldca.com/networkhmo.

To find a Personal Physician, use Find a Provider at blueshieldca.com. Clicking on a doctor’s name will give you the provider number and medical group/IPA number. Give Blue Shield the name, provider number and medical group/IPA number for each Personal Physician you choose. If the Personal Physician is one you’ve already seen, tell Blue Shield that you’re a current patient. If you don’t choose a Personal Physician during enrollment, we will automatically assign one to you. If you ever need to change your Personal Physician, call Blue Shield Member Services.

Get cost-saving pharmacy benefits Our website’s Pharmacy section has helpful information, including: • Plus Drug Formulary – Our list includes brand and generic drugs. You may save money if your current medication is a preferred prescription drug. • Prescriptions by mail – If you take stabilized doses of covered medications for chronic conditions such as diabetes, you can have a 90-day supply delivered by mail. Shipping is free, and you may save on your copay.

2. Select the type of provider you need. Hint: To find a Personal Physician, select “HMO Personal Physicians.” 3. Enter your city and state or ZIP code, then click Find now.

Stay covered while you travel HMO members using the BlueCard Program can get emergency and urgent care services across the United States and around the world. Getting urgent care with the BlueCard Program can be more cost-effective. It may also eliminate the need to pay for the services at the time you receive them.

Away From Home Care program Designed for students, long-term travelers, workers on long-distance assignments and families living apart, the Away From Home Care program offers flexible coverage across most of the country for extended periods of time.1 Call Blue Shield Member Services to find out if your family is eligible.

Have questions? Get answers. Call the Blue Shield Member Services team at (855) 256-9404. Visit blueshieldca.com to find providers, review medical benefits and more. Download the Blue Shield mobile app for iPhone or AndroidTM at blueshieldca.com/mobile.

blueshieldca.com

Programs and services Condition management programs

Behavioral health benefits

Get nurse support, education and self-management tools to help treat chronic conditions. Programs are available for members with asthma, diabetes, coronary artery disease, heart failure and chronic obstructive pulmonary disease.

Your behavioral health benefits include inpatient and outpatient mental health, residential treatment, and substance abuse care for issues such as: • Depression

• Mental illness

LifeReferrals 24/7

• Alcohol/drug abuse

• Marriage and family counseling

Registered nurses are available day or night to answer your health questions. Call or go online to have a one-on-one personal chat with a registered nurse anytime. The NurseHelp 24/7SM phone number can be found on the back of your Blue Shield ID card.

Prenatal Program

Whenever you need non-emergency mental health or substance abuse care, you can call the MHSA at (877) 263-9952, between 8 a.m. and 5 p.m. PST, Monday through Friday. Press 1 if you need immediate assistance.

Expectant parents get 24/7 phone access to experienced maternity nurses. The program also offers prenatal information, including a choice of a free pregnancy or parenting book. Some materials are also available in Spanish.

Press 4 for help finding a provider or to receive authorization for services. Once the MHSA has provided authorization for services, you can make an appointment with the network clinician you have selected.

Wellness discount programs Blue Shield offers a wide range of discount programs2 to help you save money and get healthier. These include discounts for:

During the call, you will be asked for your subscriber ID number, which can be found on your Blue Shield member ID card, and also asked a few questions to help identify your needs.

• Weight Watchers

Note: If you believe you need emergency care, call 911.

• Membership with 24 Hour Fitness, ClubSport and Renaissance ClubSport

Health Advocate

• Acupuncture, chiropractic services and massage therapy • Eye exams, frames, contact lenses and LASIK surgery Visit blueshieldca.com/hw to learn more.

Health Advocates are registered nurses who provide sound clinical advice and support to help you get the most out of your health care. In addition to helping you access care and information, your Health Advocate is your dedicated nurse who can: • Assist you with navigating the healthcare system • Help resolve problems with access to care and benefits • Provide health counseling and answer health and treatmentrelated questions • Work with your physicians and other specialty providers to coordinate your care, including inpatient hospitalizations and preauthorization • Coordinate many of the resources you have with Blue Shield If you are currently a Blue Shield member, you can contact your Health Advocate at (866) 596-7557.

1 The Away From Home Care program is not available in all areas and states. Benefits from the host plan may differ from benefits in the Access+ HMO plan. 2 These discount program services are not a covered benefit of your Blue Shield of California, Blue Shield of California Life & Health Insurance Company or self-insured health plan, and none of the terms or conditions of the Blue Shield, Blue Shield Life or self-insured health plan apply. The networks of practitioners and facilities in the discount programs are managed by external program administrators, including any screening and credentialing of providers. Blue Shield does not review the services provided by discount program providers for medical necessity or efficacy, nor does Blue Shield make any recommendations, presentations, claims or guarantees regarding the practitioners, their availability, fees, services or products. Some services offered through the discount program may already be included as part of the Blue Shield plan covered benefits. Members or self-insured plan participants should access those covered services prior to using the discount program. Members or self-insured plan participants who are not satisfied with products or services received from the discount program may use the grievance process described in their Evidence of Coverage and Disclosure (EOC&D) form, Benefit Booklet or Certificate of Insurance/Policy. Blue Shield reserves the right to terminate this program at any time without notice. iPhone is a trademark of Apple Inc. Android is a trademark of Google Inc. LifeReferrals 24/7 and NurseHelp 24/7 are service marks, and Access+ HMO and Wellvolution are registered trademarks, of Blue Shield of California. Blue Shield and the Shield symbol are registered trademarks of the BlueCross BlueShield Association, an association of independent Blue Cross and Blue Shield plans.

A47369-NORCAL-HMO (5/16)

NurseHelp 24/7

The services are provided by Blue Shield’s mental health service administrator (MHSA) network. HMO members only have access to MHSA network providers. PPO members can access both MHSA network and non-network providers, but will pay less and receive higher benefit coverage when they see a network provider.

Blue Shield of California is an independent member of the Blue Shield Association

Call anytime to talk with experienced professionals ready to help you with personal, family and work issues. Get referrals for three face-to-face or telephone visits in a 6-month period with a licensed therapist at no cost. The LifeReferrals 24/7SM phone number can be found on the back of your Blue Shield member ID card.

Northern California Pipe Trades Trust Fund Custom PPO Group W0051500 Benefit Summary (For groups of 300 and above) (Uniform Health Plan Benefits and Coverage Matrix)

Blue Shield of California Effective July 1, 2016

THIS MATRIX IS INTENDED TO BE USED TO HELP YOU COMPARE COVERAGE BENEFITS AND IS A SUMMARY ONLY. THE EVIDENCE OF COVERAGE AND PLAN CONTRACT SHOULD BE CONSULTED FOR A DETAILED DESCRIPTION OF COVERAGE BENEFITS AND LIMITATIONS. Highlights: A description of the prescription drug coverage is provided separately Participating Providers1

Non-Participating Providers2 $100 per individual / $200 per family

Calendar Year Medical Deductible (all providers combined) Calendar Year Out-of-Pocket Maximum

(Includes the calendar year medical deductible. Copayments or coinsurance for covered services from participating providers accrue to both the participating and non-participating provider calendar year out-of-pocket maximum amount.)

$750 per individual / $1,500 per family

Lifetime Benefit Maximum

$1,500 per individual / $3,000 per family None

Covered Services

Member Copayment Participating Providers1

OUTPATIENT PROFESSIONAL SERVICES Professional (Physician) Benefits Physician and specialist office visits

Outpatient diagnostic x-ray, imaging, pathology, laboratory and other testing services Radiological and nuclear imaging (CT scans, MRIs, MRAs, PET scans and

Non-Participating Providers2

$20 per visit (not subject to the calendar year medical deductible) $20 per visit

30%

No Charge

30%

10%

30%

$10 per visit (not subject to the calendar year medical deductible) $10 per visit (not subject to the calendar year medical deductible) $10 per visit (not subject to the calendar year medical deductible) $10 per visit (not subject to the calendar year medical deductible)

30%

30%

cardiac diagnostic procedures utilizing nuclear medicine)

Allergy Testing and Treatment Benefits Allergy testing, treatment and serum injections

(separate office visit

Preventive Health Benefits11 Annual routine physical examination, vision and hearing screening and immunizations Routine laboratory services, including annual mammography, Papanicolaou test, or cervical cancer and human papillomavirus (HPV) screening (One per calendar year) Well baby care (includes eye/ear screenings, immunizations, vaccinations)

Well baby laboratory

30%

30%

30%

An Anindependent independentmember memberof ofthe theBlue BlueShield ShieldAssociation Association

copayment may apply)

OUTPATIENT FACILITY SERVICES Outpatient surgery performed at a free-standing ambulatory surgery center Outpatient surgery performed in a hospital or a hospital affiliated ambulatory surgery center Outpatient services for treatment of illness or injury and necessary supplies (except as described under "Rehabilitation Benefits" and "Speech

$35 per surgery

30% up to $350 per day 3

$35 per surgery

30% up to $350 per day 3

10%

30% up to $350 per day 3

$20 per visit

30% up to $350 per day 3

No Charge

30% up to $350 per day 3

$35 per surgery

30% up to $350 per day 3

No Charge $150 per admission

30% 30% up to $600 per day 5

$150 per admission

30% up to $600 per day 5

Therapy Benefits")

Outpatient diagnostic x-ray, imaging, pathology, laboratory and other testing services Radiological and nuclear imaging (CT scans, MRIs, MRAs, PET scans and cardiac diagnostic procedures utilizing nuclear medicine)

Bariatric surgery4 (prior authorization is required; medically necessary surgery for weight loss, for morbid obesity only)

HOSPITALIZATION SERVICES Hospital Benefits (Facility Services) Inpatient physician services Inpatient non-emergency facility services (semi-private room and board, and medically necessary services and supplies, including subacute care)

Bariatric surgery4 (prior authorization is required; medically necessary surgery for weight loss, for morbid obesity only)

Inpatient Skilled Nursing Benefits6,7 (Coverage limited to 100 days per member per benefit period combined with hospital/free-standing skilled nursing facility.)

Free-standing skilled nursing facility Skilled nursing unit of a hospital

10% $150 per admission

10%7 30% up to $600 per day5

$20 per visit (not subject to the calendar year medical deductible) $150 per admission

$20 per visit (not subject to the calendar year medical deductible) $150 per admission

$100 per visit

$100 per visit

$50 per transport

$50 per transport

EMERGENCY HEALTH COVERAGE Emergency room services not resulting in admission (copayment does not apply if the member is directly admitted to the hospital for inpatient services)

Emergency room services resulting in admission (when the member is admitted directly from the ER)

Emergency room physician services AMBULANCE SERVICES Emergency or authorized transport

(ground or air)

PRESCRIPTION DRUG COVERAGE Outpatient Prescription Drug Benefits A description of your outpatient prescription drug coverage is provided separately. If you do not have the separate drug summary that goes with this benefit summary, please contact your benefits administrator or call the Customer Service number on your identification card. PROSTHETICS/ORTHOTICS Prosthetic equipment and devices (separate office visit copayment may

10%

30%

10%

30%

10%

30%

apply)

Orthotic equipment and devices (separate office visit copayment may apply) DURABLE MEDICAL EQUIPMENT Other durable medical equipment MENTAL HEALTH

SERVICES8

Inpatient hospital services Residential care Inpatient physician services Routine outpatient mental health services (includes professional/physician visits)

Non-routine outpatient mental health services

(includes behavioral health treatment, electroconvulsive therapy, intensive outpatient programs, partial hospitalization programs, and transcranial magnetic stimulation.)

MHSA Participating Providers1 $150 per admission $150 per admission No Charge $10 per visit (not subject to the calendar year medical deductible) No Charge

MHSA Non-Participating Providers2 30% up to $600 per day 5 30% up to $600 per day 5 30% 30%

30%

SUBSTANCE ABUSE SERVICES8,9 Inpatient hospital services Residential care Inpatient physician services Routine outpatient substance abuse services

(includes

professional/physician visits)

Non-routine outpatient substance abuse services

(includes behavioral health treatment, electroconvulsive therapy, intensive outpatient programs, officebased opioid treatment, partial hospitalization programs, and transcranial magnetic stimulation.)

HOME HEALTH SERVICES10 Home health care agency services6 (Coverage limited to 100 visits per

MHSA Participating Providers1 No Charge No Charge No Charge $10 per visit (not subject to the calendar year medical deductible) No Charge

Participating Providers1

MHSA Non-Participating Providers2 30% up to $600 per day 5 30% up to $600 per day 5 30% 30%

30%

Non-Participating Providers2

10%

Not Covered10

10%

Not Covered10

No Charge (not subject to the calendar year medical deductible) No Charge (not subject to the calendar year medical deductible) 10% 10%

Not Covered10

$10 per visit

30%

$10 per visit

$10 per visit

member per calendar year. Non-participating home health care and home infusion are not covered unless pre-authorized. When these services are pre-authorized, you pay the participating provider member cost share.)

Home infusion/home injectable therapy and infusion nursing visits provided by a home infusion agency HOSPICE PROGRAM BENEFITS10 Routine home care

Inpatient respite care

24-hour continuous home care Short-term inpatient care for pain and symptom management CHIROPRACTIC BENEFITS6 Chiropractic spinal manipulation

Not Covered10 Not Covered10 Not Covered10

Coverage for chiropractic services is limited to 24 visits per calendar year.

ACUPUNCTURE BENEFITS 6 Acupuncture services Coverage for acupuncture services is limited to 24 visits per calendar year.

REHABILITATION AND HABILITATION BENEFITS (Physical, Occupational and Respiratory Therapy) Office location (an additional facility copayment may apply when services are $20 per visit

30%

rendered in a hospital or skilled nursing facility)

SPEECH THERAPY BENEFITS Office location (an additional facility copayment may apply when services are

$20 per visit

$20 per visit

No Charge

30%

10%

30%

$10 per visit (not subject to the calendar year medical deductible) 10%

Not Covered

10%

Not Covered

10%

30%

$20 per visit (not subject to the calendar year medical deductible)

30%

rendered in a hospital or skilled nursing facility)

PREGNANCY AND MATERNITY CARE BENEFITS Prenatal and postnatal physician office visits (when billed as part of global maternity fee including hospital inpatient delivery services)

Abortion services (an additional facility copayment may apply when services are rendered in a hospital or outpatient surgery center)

FAMILY PLANNING BENEFITS Counseling and consulting

Tubal ligation (an additional facility copayment may apply when services are rendered in a hospital or outpatient surgery center) Vasectomy (an additional facility copayment may apply when services are rendered in a hospital or outpatient surgery center)

DIABETES CARE BENEFITS Devices, equipment, and non-testing supplies (for testing supplies see

Not Covered

Outpatient Prescription Drug Benefits)

Diabetes self-management training

CARE OUTSIDE OF PLAN SERVICE AREA Benefits provided through the BlueCard® Program are paid at the participating level. Member’s cost share will be either a copayment or coinsurance based on the lower of billed charges or the negotiated allowable amount for participating providers as agreed upon with the local Blue’s Plan.

Within US: BlueCard Program Outside of US: BlueCard Worldwide

See Applicable Benefit See Applicable Benefit

See Applicable Benefit See Applicable Benefit

OPTIONAL BENEFITS Optional dental, vision, infertility and hearing aid benefits are available. If your employer purchased any of these benefits, a description of the benefit is provided separately. 1

2

3

4

5

6 7 8

9

10

11

Unless otherwise specified, copayments/coinsurance are calculated based on allowable amounts. After the calendar year medical deductible is met, the member is responsible for copayments/coinsurance for covered services from participating providers. Participating providers agree to accept Blue Shield's allowable amount plus any applicable member copayment or coinsurance as full payment for covered services. Non-participating providers can charge more than Blue Shield’s allowable amounts. When members use non-participating providers, they must pay the applicable deductibles, copayments or coinsurance plus any amount that exceeds Blue Shield's allowable amount. Charges above the allowable amount do not count toward the calendar year deductible or out-of-pocket maximum. The maximum allowed charges for non-emergency surgery and services performed in a non-participating ambulatory surgery center or outpatient unit of a nonparticipating hospital is $350 per day. Members are responsible for 30% of this $350 per day, and all charges in excess of $350 per day. Amounts that exceed the benefit maximums do not count toward the calendar year out-of-pocket maximum and continue to be the member’s financial responsibility after the calendar year maximums are reached. Bariatric surgery is covered when prior authorized by Blue Shield; however, for members residing in Imperial, Kern, Los Angeles, Orange, Riverside, San Bernardino, San Diego, Santa Barbara and Ventura Counties ("Designated Counties"), bariatric surgery services are covered only when performed at designated contracting bariatric surgery facilities and by designated contracting surgeons; coverage is not available for bariatric services from any other participating provider and there is no coverage for bariatric services from non-participating providers. In addition, if prior authorized by Blue Shield, a member in a Designated County who is required to travel more than 50 miles to a designated bariatric surgery facility will be eligible for limited reimbursement for specified travel expenses for the member and one companion. Refer to the Evidence of Coverage for further details. The maximum allowed charges for non-emergency hospital services received from a non-participating hospital is $600 per day. Members are responsible for 30% of this $600 per day, and all charges in excess of $600 per day. Amounts that exceed the benefit maximum do not count toward the calendar year out-of-pocket maximum and continue to be the member’s responsibility after the calendar year maximums are reached. For plans with a calendar year medical deductible amount, services with a day or visit limit accrue to the calendar year day or visit limit maximum regardless of whether the calendar year medical deductible has been met. Services may require prior authorization. When services are prior authorized, members pay the participating provider amount. Mental health and substance abuse services are accessed through Blue Shield's Mental Health Service Administrator (MHSA) - using MHSA participating and MHSA non-participating providers. Only mental health and substance abuse services rendered by MHSA participating providers are administered by the MHSA. Mental health and substance abuse services rendered by non-MHSA participating providers are administered by Blue Shield. Inpatient services for acute detoxification are covered under the medical benefit; see the Hospital Benefits (Facility Services) section of the Evidence of Coverage for benefit details. Services for acute medical detoxification are accessed through Blue Shield using Blue Shield's participating providers or non-participating providers. Services from non-participating providers for home health care and hospice services are not covered unless prior authorized. When these services are prior authorized, the member’s copayment or coinsurance will be calculated at the participating provider level, based upon the agreed upon rate between Blue Shield and the agency. Participating Preventive Health Services, including an annual preventive care or well-baby care office visit, are not subject to the calendar year medical deductible. Other covered non-preventive services received during, or in connection with, the preventive care or well-baby care office visit are subject to the calendar year medical deductible and applicable member copayment/coinsurance

Plan designs may be modified to ensure compliance with state and Federal requirements.

A17265 (01/16) 16490 RM021616 GF

Blue Shield believes this plan/policy is a “grandfathered health plan” under the Patient Protection and Affordable Care Act (the Affordable Care Act). As permitted by the Affordable Care Act, a grandfathered health plan can preserve certain basic health coverage that was already in effect when that law was enacted. Being a grandfathered health plan means that your plan or policy is not required to include certain consumer protections of the Affordable Care Act that apply to other plans, for example, the requirement for the provision of preventive health services without any cost sharing. However, grandfathered health plans must comply with certain other consumer protections in the Affordable Care Act, for example, the elimination of lifetime limits on benefits. Note, even though they are not required to be included, many of the protections of the Affordable Care Act are included in your current plan/policy. Questions regarding which protections apply and which protections do not apply to a grandfathered health plan and what might cause a plan to change from grandfathered health plan status can be directed to Blue Shield at the telephone number on your identification card. If you obtain this plan/policy through your employer and your plan is subject to ERISA, you may also contact the Employee Benefits Security Administration, U.S. Department of Labor at 1-866-444-3272 or www.dol.gov/ebsa/healthreform. This website has a table summarizing which protections do and do not apply to grandfathered health plans. If you obtain your coverage through a nonfederal governmental employer, you may also contact the U.S. Department of Health and Human Services at www.healthreform.gov.

Northern California Pipe Trades Trust Fund Custom PPO Plan Outpatient Prescription Drug Coverage (For groups of 300 and above)

THIS DRUG COVERAGE SUMMARY IS ADDED TO BE COMBINED WITH PPO PLANS UNIFORM HEALTH PLAN BENEFITS AND COVERAGE MATRIX. THE EVIDENCE OF COVERAGE AND PLAN CONTRACT SHOULD BE CONSULTED FOR A DETAILED DESCRIPTION OF COVERAGE BENEFITS AND LIMITATIONS.

Blue Shield of California Highlight:

3-Tier/Incentive Formulary $0 Calendar year Brand Drug Deductible $10 Formulary Generic/$20 Formulary Brand/$35 Non-Formulary Brand Drug - Retail Pharmacy $20 Formulary Generic/$40 Formulary Brand/$70 Non-Formulary Brand Drug - Mail Service

Covered Services

Member Copayment

DEDUCTIBLES (Prescription drug coverage benefits are not subject to the medical plan deductible.)

Calendar Year Brand Drug Deductible PRESCRIPTION DRUG COVERAGE1

None Participating Pharmacy

Non-Participating Pharmacy7,8

Retail Prescriptions (up to a 30-day supply)  Contraceptive Drugs and Devices2

$0 per prescription



Formulary Generic Drugs

$10 per prescription

Applicable Generic, Brand or Non-Formulary Copayment9 $10 per prescription



Drugs3, 4

$20 per prescription

$20 per prescription

$35 per prescription

$35 per prescription

Mail Service Prescriptions (up to a 90-day supply)  Contraceptive Drugs and Devices2

$0 per prescription

Not Covered



Formulary Generic Drugs

$20 per prescription

Not Covered



Drugs3, 4

$40 per prescription

Not Covered

$70 per prescription

Not Covered

30%

Not Covered





Formulary Brand

Non-Formulary Brand

Formulary Brand

Non-Formulary Brand

Drugs3, 4

Drugs3, 4

Specialty Pharmacies (up to a 30-day supply)5  Specialty Drugs6

(Up to $150 copayment maximum per prescription) 1 Amounts paid through copayments and any applicable brand drug deductible do not accrue to the member's medical calendar year out-of-pocket maximum. Please refer to the Evidence of Coverage and Plan Contract for exact terms and conditions of coverage. Please note that if you switch from another plan, your prescription drug deductible credit, if applicable, from the previous plan during the calendar year will not carry forward to your new plan. 2 Contraceptive Drugs and Devices covered under the outpatient prescription drug benefits will not be subject to the applicable calendar year brand drug deductible when obtained from a participating pharmacy. If a brand contraceptive is requested when a generic equivalent is available, the member will be responsible for paying the difference between the cost to Blue Shield for the brand contraceptive and its generic drug equivalent. In addition, select contraceptives may need prior authorization to be covered without a copayment. 3 Select formulary and non-formulary drugs require prior authorization by Blue Shield for Medical Necessity, or when effective, lower cost alternatives are available. 4 If the member requests a brand drug and a generic drug equivalent is available, the member is responsible for paying the generic drug copayment plus the difference in cost to Blue Shield between the brand drug and its generic drug equivalent. 5 Specialty Drugs are Drugs requiring coordination of care, close monitoring, or extensive patient training for self-administration that generally cannot be met by a retail pharmacy and are available at a Network Specialty Pharmacy. Specialty Drugs may also require special handling or manufacturing processes (such as biotechnology), restriction to certain Physicians or pharmacies, or reporting of certain clinical events to the FDA. Specialty Drugs are generally high cost. 6 Specialty drugs are available from a Network Specialty Pharmacy. A Network Specialty Pharmacy provides specialty drugs by mail or upon member request, at an associated retail store for pickup. 7 To obtain prescription drugs at a non-participating pharmacy, the member must first pay all charges for the prescription and submit a completed Prescription Drug Claim Form for reimbursement. The member will be reimbursed the price paid for the drug less any applicable deductible, copayment or coinsurance (Generic, Formulary Brand, or Non-Formulary Brand) and any applicable out of network charge.

An independent member of the Blue Shield Association

Member pays 25% of billed amount plus a copayment of:

8 Outpatient prescription drug copayments for covered drugs obtained from non-participating pharmacies will accrue to the participating provider maximum calendar year out-of-pocket maximum. 9 To obtain contraceptive drugs and devices at a non-participating pharmacy, the member must first pay all charges for the prescription and submit a completed Prescription Drug Claim Form for reimbursement. The member will be reimbursed the price paid for the drug less any applicable deductible, copayment or coinsurance (Generic, Formulary Brand, or NonFormulary Brand) and any applicable out of network charge.

Note: This plan's prescription drug coverage is on average equivalent to or better than the standard benefit set by the Federal government for Medicare Part D (also called creditable coverage). Because this plan's prescription drug coverage is creditable, you do not have to enroll in a Medicare prescription drug plan while you maintain this coverage. However, you should be aware that if you have a subsequent break in this coverage of 63 days or more anytime after you were first eligible to enroll in a Medicare prescription drug plan, you could be subject to a late enrollment penalty in addition to your Part D premium.

Important Prescription Drug Information You can find details about your drug coverage three ways: 1. Check your Evidence of Coverage. 2. Go to https://www.blueshieldca.com/bsca/pharmacy/home.sp and log onto My Health Plan from the home page. 3. Call Member Services at the number listed on your Blue Shield member ID card. At Blue Shield of California, we're dedicated to providing you with valuable resources for managing your drug coverage. Go online to the Pharmacy section of https://www.blueshieldca.com/bsca/pharmacy/home.sp and select the Drug Database and Formulary to access a variety of useful drug information that can affect your out-of-pocket expenses, such as:  Look up non-formulary drugs with formulary or generic equivalents;  Look up drugs that require step therapy or prior authorization;  Find specifics about your prescription copayments;  Find local network pharmacies to fill your prescriptions. TIPS! Using the convenient mail service pharmacy can save you time and money. If you take a consistent dose of a covered maintenance drug for a chronic condition, such as diabetes or high blood pressure, you can receive up to a 90-day supply through the mail service pharmacy with a reduced copayment. Call the mail service pharmacy at (866) 346-7200. Members using TTY equipment can call TTY/TDD 866-346-7197. Plan designs may be modified to ensure compliance with state and Federal requirements.

A16154-c (01/16) 16499 RM021616

Northern California Pipe Trades Trust Fund Additional Blue Shield Infertility Benefits For Active Employees and non-Medicare Retirees How the Plan Works Your health plan includes infertility benefits in addition to those listed in the Benefit Summary (Uniform Benefits and Coverage Matrix1). Coverage includes authorized professional, hospital, ambulatory surgery center, and ancillary services, as well as injectable drugs administered or prescribed to diagnose and treat the cause of infertility including induced fertilization2.

Coverage Details The following procedures are limited, per lifetime as shown. 

Six (6) natural (without ovum/egg [oocyte or ovarian tissue] stimulation) artificial inseminations and;



Three (3) stimulated (with ovum/egg [oocyte or ovarian tissue] stimulation) artificial inseminations and;



One (1) gamete intrafallopian transfer (GIFT)3



Cryopreservation of sperm/ oocyte /embryos when retrieved from a covered subscriber, spouse, or domestic partner. Benefits include cryopreservation services for a condition which the treating physician anticipates will cause infertility in the future (except when the infertile condition is caused by elective chemical or surgical sterilization procedures). Benefits are limited to one retrieval and one year of storage per person per lifetime

Health Plans

Copayment

HMO plan**

50% of the allowable amount

PPO plan**

50% of the allowable amount

1.

If you are an HMO member, services that diagnose and treat the cause of infertility are included in your basic plan benefits. For PPO members, these services are only covered when the group adds “Additional Blue Shield Infertility Benefits” to the plan.

2.

These services are covered only when authorized by Blue Shield, and provided by a Participating Provider (PPO plan) or HMO plan provider (HMO plan). Procedures must be consistent with established medical practice in treatment of infertility and induced fertilization.

3.

This procedure is covered only when performed on a subscriber or covered spouse/ domestic partner.

4.

The lifetime benefit maximums for the above described procedures apply to all services related to or performed in conjunction with such procedures.

* Services provided under this benefit are subject to any applicable calendar year medical deductible and accrue to the calendar year outof-pocket maximum of the health plan. ** Services provided under this benefit are not subject to any applicable calendar year medical deductible and do not accrue to the calendar year out-of-pocket maximum. Services continue to be the member's responsibility after the calendar year out-of-pocket maximum is reached.

This is only a summary for informational purposes. It is not a contract. Please refer to the plan contract and Evidence of Coverage for a detailed description of covered benefits and limitations. 16502

An independent member of the Blue Shield Association

All benefits are subject to a lifetime benefit maximum4 and copayment.

A17275 (01/16) RM021616

EXCLUDED: in-vitro fertilization (IVF), intracytoplasmic sperm injection (ICSI), and zygote intrafallopian transfer (ZIFT).

Northern California Pipe Trades Additional Hearing Aid and Ancillary Equipment Benefit Attachment to Benefit Summary (Uniform Benefits and Coverage Matrix) Additional coverage for PPO Plans

How the Plan Works In addition to the benefits set forth in the Benefit Summary (Uniform Benefits and Coverage Matrix), your group has added hearing aid benefits to your benefit plan. Coverage includes hearing aid services, subject to the conditions and limitations listed below. This rider provides a $2,000 allowance every 24 months towards the purchase of hearing aids and ancillary equipment. The calendar year deductible does not apply to the services provided in this hearing services benefit and hearing aid expenses in excess of the maximum allowance are not included in the calendar year out-of-pocket maximum amount.

Coverage Details A hearing aid instrument, monaural or binaural, including ear mold(s)



Visit for fitting, counseling, and adjustments



The initial battery



Cords



Other ancillary equipment

Benefit Plan Design Plan Options PPO Plans

Benefit Allowance $2,000 allowance every 24 months

The following services and supplies are not covered: 

Purchase of batteries or other ancillary equipment, except those covered under the terms of the initial hearing aid purchase



Charges for a hearing aid which exceed specifications prescribed for correction of a hearing loss



Replacement parts for hearing aids, repair of hearing aid after the covered warranty period and replacement of a hearing aid more than once in any period of 24 months



Surgically implanted hearing devices

All benefits are subject to the general provisions, limitations and exclusions listed in your Evidence of Coverage. 16505

An independent member of the Blue Shield Association



A19528 (01/16) RM021616_portfolio

The hearing aid allowance includes:

Northern California Pipe Trades Trust Fund Custom HMO Group W0051500 Benefit Summary (For groups of 300 and above) (Uniform Health Plan Benefits and Coverage Matrix)

Blue Shield of California Effective July 1, 2016 THIS MATRIX IS INTENDED TO BE USED TO HELP YOU COMPARE COVERAGE BENEFITS AND IS A SUMMARY ONLY. THE EVIDENCE OF COVERAGE AND PLAN CONTRACT SHOULD BE CONSULTED FOR A DETAILED DESCRIPTION OF COVERAGE BENEFITS AND LIMITATIONS.

Highlights: A description of the prescription drug coverage is provided separately

Calendar Year Medical Deductible Calendar Year Out-of-Pocket Maximum Lifetime Benefit Maximum

Covered Services OUTPATIENT PROFESSIONAL SERVICES Professional (Physician) Benefits Physician and specialist office visits

None $750 per individual / $1,500 per family None

Member Copayment

$20 per visit

(note: a woman may self-refer to an OB/GYN or family practice physician in her personal physician's medical group or IPA for OB/GYN services)

Outpatient diagnostic x-ray, imaging, pathology, laboratory and other testing services Radiological and nuclear imaging (CT scans, MRIs, MRAs, PET scans and cardiac diagnostic

No Charge No Charge

procedures utilizing nuclear medicine)

Allergy Testing and Treatment Benefits Allergy testing, treatment and serum injections Access+ SpecialistSM Benefits1 Office visit, examination or other consultation (self-referred office visits and consultations

$20 per visit $30 per visit

only)

Preventive Health Benefits Routine physical exams

$20 per visit

Vision and hearing screening (through the age of 18) Medically necessary immunizations (according to age schedule) Well baby care: office visits and consultations include eye/ear screenings, immunizations, and vaccines (birth through age 2) Well baby laboratory OUTPATIENT FACILITY SERVICES Outpatient surgery performed at a free-standing ambulatory surgery center Outpatient surgery performed in a hospital or a hospital affiliated ambulatory surgery center Outpatient services for treatment of illness or injury and necessary supplies

No Charge No Charge No Charge No Charge No Charge No Charge No Charge

(except as described under "Rehabilitation Benefits" and "Speech Therapy Benefits")

Outpatient diagnostic x-ray, imaging, pathology, laboratory and other testing services Radiological and nuclear imaging (CT scans, MRIs, MRAs, PET scans and cardiac diagnostic procedures utilizing nuclear medicine)

No Charge No Charge

An independent member of the Blue Shield Association

Note: A woman may self-refer to an OB/GYN or family practice physician in her Personal Physician's medical group or IPA for OB/GYN services

HOSPITALIZATION SERVICES Hospital Benefits (Facility Services) Inpatient physician services Inpatient non-emergency facility services (semi-private room and board, and medically

No Charge No Charge

necessary services and supplies, including subacute care)

INPATIENT SKILLED NURSING BENEFITS2,3 (combined maximum of up to 100 days per benefit period; prior authorization is required; semi-private accommodations)

Free-standing skilled nursing facility Skilled nursing unit of a hospital EMERGENCY HEALTH COVERAGE Emergency room services not resulting in admission

No Charge No Charge (copayment does not apply if the

$35 per visit

member is directly admitted to the hospital for inpatient services)

Emergency room physician services AMBULANCE SERVICES Emergency or authorized transport

(ground or air)

No Charge No Charge

PRESCRIPTION DRUG COVERAGE Outpatient Prescription Drug Benefits A description of your outpatient prescription drug coverage is provided separately. If you do not have the separate drug summary that goes with this benefit summary, please contact your benefits administrator or call the Member Services number on your identification card. PROSTHETICS/ORTHOTICS Prosthetic equipment and devices (separate office visit copayment may apply) Orthotic equipment and devices (separate office visit copayment may apply)

No Charge No Charge

DURABLE MEDICAL EQUIPMENT Other durable medical equipment (member share is based upon allowed charges)

No Charge

MENTAL HEALTH AND SUBSTANCE ABUSE SERVICES4, 5 Inpatient hospital services Residential care Inpatient physician services Routine outpatient mental health and substance abuse services (includes

No Charge No Charge No Charge $20 per visit

professional/physician visits)

Non-routine outpatient mental health and substance abuse services (includes

No Charge

behavioral health treatment, electroconvulsive therapy, intensive outpatient programs, office-based opioid treatment, partial hospitalization programs, psychological testing and transcranial magnetic stimulation)

HOME HEALTH SERVICES Home health care agency services2 (Coverage limited to 100 visits per member per calendar

$20 per visit

year.)

Home infusion/home injectable therapy and infusion nursing visits provided by a home infusion agency HOSPICE PROGRAM BENEFITS Routine home care Inpatient respite care 24-hour continuous home care Short-term inpatient care for pain and symptom management PREGNANCY AND MATERNITY CARE BENEFITS Prenatal and postnatal physician office visits

No Charge

No Charge No Charge No Charge No Charge No Charge

(when billed as part of global maternity fee including hospital inpatient delivery services)

Abortion services (an additional facility copayment may apply when services are rendered in a

No Charge

hospital or outpatient surgery center)

FAMILY PLANNING AND INFERTILITY BENEFITS Counseling and consulting Infertility services (member cost share is based upon allowed charges)

$20 per visit 50%

(diagnosis and treatment of cause of infertility. Excludes in vitro fertilization, injectables for infertility, artificial insemination and GIFT)

Tubal ligation6 (an additional facility copayment may apply when services are rendered in a hospital or outpatient surgery center)

$100 per surgery

Vasectomy (an additional facility copayment may apply when services are rendered in a hospital or

$75 per surgery

outpatient surgery center)

Injectable contraceptives REHABILITATION AND HABILITATION BENEFITS (Physical, Occupational and Respiratory Therapy) Office location (an additional facility copayment may apply when services are rendered in a hospital

No Charge $20 per visit

or skilled nursing facility)

SPEECH THERAPY BENEFITS Office location (an additional facility copayment may apply when services are rendered in a hospital

$20 per visit

or skilled nursing facility)

DIABETES CARE BENEFITS Devices, equipment, and non-testing supplies (member share is based upon allowed

No Charge

charges; for testing supplies see Outpatient Prescription Drug Benefits)

Diabetes self-management training $20 per visit URGENT CARE BENEFITS Urgent care services outside your personal physician service area within $20 per visit California Urgent care services outside of California (BlueCard® Program) $20 per visit OPTIONAL BENEFITS Optional dental, vision, hearing aid, infertility, chiropractic or acupuncture benefits are available. If your employer purchased any of these benefits, a description of the benefit is provided separately. 1 2 3

4 5 6

To use this option, members must select a personal physician who is affiliated with a medical group or IPA that is an Access+ provider group, which offers the Access+ Specialist feature. Members should then select a specialist within that medical group or IPA. For Plans with a facility deductible amount, services with a day or visit limit accrue to the calendar year day or visit limit maximum regardless of whether the plan deductible has been met. Inpatient skilled nursing services are limited to 100 preauthorized days during a benefit period except when received through a hospice program provided by a participating hospice agency. This 100 preauthorized day maximum on inpatient skilled nursing services is a combined maximum between skilled nursing services provided in a hospital unit and skilled nursing services provided in a skilled nursing facility (SNF). Mental Health and Substance Abuse services are accessed through Blue Shield's Mental Health Service Administrator (MHSA) using MHSA participating providers. Inpatient services for acute detoxification are covered under the medical benefit; see the Hospital Benefits (Facility Services) section of the Evidence of Coverage for benefit details. Services for acute medical detoxification are accessed through Blue Shield using Blue Shield participating providers. Copayment does not apply when procedure is performed in conjunction with delivery or abdominal surgery.

Plan designs may be modified to ensure compliance with state and federal requirements.

A15814 (01/16) 16493 RM021616 GF

Blue Shield believes this plan/policy is a “grandfathered health plan” under the Patient Protection and Affordable Care Act (the Affordable Care Act). As permitted by the Affordable Care Act, a grandfathered health plan can preserve certain basic health coverage that was already in effect when that law was enacted. Being a grandfathered health plan means that your plan or policy is not required to include certain consumer protections of the Affordable Care Act that apply to other plans, for example, the requirement for the provision of preventive health services without any cost sharing. However, grandfathered health plans must comply with certain other consumer protections in the Affordable Care Act, for example, the elimination of lifetime limits on benefits. Note, even though they are not required to be included, many of the protections of the Affordable Care Act are included in your current plan/policy. Questions regarding which protections apply and which protections do not apply to a grandfathered health plan and what might cause a plan to change from grandfathered health plan status can be directed to Blue Shield at the telephone number on your identification card. If you obtain this plan/policy through your employer and your plan is subject to ERISA, you may also contact the Employee Benefits Security Administration, U.S. Department of Labor at 1-866-444-3272 or www.dol.gov/ebsa/healthreform. This website has a table summarizing which protections do and do not apply to grandfathered health plans. If you obtain your coverage through a nonfederal governmental employer, you may also contact the U.S. Department of Health and Human Services at www.healthreform.gov.

Northern California Pipe Trades Trust Fund Custom HMO Plan Outpatient Prescription Drug Coverage (For groups of 300 and above)

THIS DRUG COVERAGE SUMMARY IS ADDED TO BE COMBINED WITH THE HMO OR POS PLANS UNIFORM HEALTH PLAN BENEFITS AND COVERAGE MATRIX. THE EVIDENCE OF COVERAGE AND PLAN CONTRACT SHOULD BE CONSULTED FOR A DETAILED DESCRIPTION OF COVERAGE BENEFITS AND LIMITATIONS.

Blue Shield of California Highlight:

3-Tier/Incentive Formulary $0 Calendar Year Brand Drug Deductible $10 Formulary Generic/$20 Formulary Brand/$35 Non-Formulary Brand Drug - Retail Pharmacy $20 Formulary Generic/$40 Formulary Brand/$70 Non-Formulary Brand Drug - Mail Service

Covered Services

Member Copayment

DEDUCTIBLES (Prescription drug coverage benefits are not subject to the medical plan deductible.) Calendar Year Brand Drug Deductible

None

PRESCRIPTION DRUG COVERAGE1,2

Participating Pharmacy

Retail Prescriptions (up to a 30-day supply)  Contraceptive Drugs and Devices3

$0 per prescription



Formulary Generic Drugs

$10 per prescription



Formulary Brand

Drugs4, 5

$20 per prescription



Non-Formulary Brand Drugs4, 5

$35 per prescription

Mail Service Prescriptions (up to a 90-day supply)  Contraceptive Drugs and Devices3

$0 per prescription



Formulary Generic Drugs

$20 per prescription



Formulary Brand

Drugs4, 5

$40 per prescription



Non-Formulary Brand Drugs4, 5

Specialty Pharmacies (up to a 30-day supply)6  Specialty Drugs7

$70 per prescription

20%

1 Amounts paid through copayments and any applicable brand drug deductible do not accrue to the member's medical calendar year out-of-pocket maximum. Please refer to the Evidence of Coverage and Plan Contract for exact terms and conditions of coverage. Please note that if you switch from another plan, your prescription drug deductible credit, if applicable, from the previous plan during the calendar year will not carry forward to your new plan. 2 Drugs obtained at a non-participating pharmacy are not covered, unless Medically Necessary for a covered emergency. 3 Contraceptive Drugs and Devices covered under the outpatient prescription drug benefits will not be subject to the applicable calendar year brand drug deductible. If a brand contraceptive is requested when a generic equivalent is available, the member will be responsible for paying the difference between the cost to Blue Shield for the brand contraceptive and its generic drug equivalent. In addition, select contraceptives may need prior authorization to be covered without a copayment. 4 Select formulary and non-formulary drugs require prior authorization by Blue Shield for Medical Necessity, or when effective, lower cost alternatives are available. 5 If the member requests a brand drug and a generic drug equivalent is available, the member is responsible for paying the generic drug copayment plus the difference in cost to Blue Shield between the brand drug and its generic drug equivalent. 6 Specialty Drugs are Drugs requiring coordination of care, close monitoring, or extensive patient training for self-administration that generally cannot be met by a retail pharmacy and are available at a Network Specialty Pharmacy. Specialty Drugs may also require special handling or manufacturing processes (such as biotechnology), restriction to certain Physicians or pharmacies, or reporting of certain clinical events to the FDA. Specialty Drugs are generally high cost. 7 Specialty drugs are available from a Network Specialty Pharmacy. A Network Specialty Pharmacy provides specialty drugs by mail or upon member request, at an associated retail store for pickup.

An independent member of the Blue Shield Association

(Up to $100 copayment maximum per prescription)

Note: This plan's prescription drug coverage is on average equivalent to or better than the standard benefit set by the Federal government for Medicare Part D (also called creditable coverage). Because this plan's prescription drug coverage is creditable, you do not have to enroll in a Medicare prescription drug plan while you maintain this coverage. However, you should be aware that if you have a subsequent break in this coverage of 63 days or more anytime after you were first eligible to enroll in a Medicare prescription drug plan, you could be subject to a late enrollment penalty in addition to your Part D premium.

Important Prescription Drug Information You can find details about your drug coverage three ways: 1. Check your Evidence of Coverage. 2. Go to https://www.blueshieldca.com/bsca/pharmacy/home.sp and log onto My Health Plan from the home page. 3. Call Member Services at the number listed on your Blue Shield member ID card. At Blue Shield of California, we're dedicated to providing you with valuable resources for managing your drug coverage. Go online to the Pharmacy section of https://www.blueshieldca.com/bsca/pharmacy/home.sp and select the Drug Database and Formulary to access a variety of useful drug information that can affect your out-of-pocket expenses, such as:  Look up non-formulary drugs with formulary or generic equivalents;  Look up drugs that require step therapy or prior authorization;  Find specifics about your prescription copayments;  Find local network pharmacies to fill your prescriptions. TIPS! Using the convenient mail service pharmacy can save you time and money. If you take a consistent dose of a covered maintenance drug for a chronic condition, such as diabetes or high blood pressure, you can receive up to a 90-day supply through the mail service pharmacy with a reduced copayment. Call the mail service pharmacy at (866) 346-7200. Members using TTY equipment can call TTY/TDD 866-346-7197. Plan designs may be modified to ensure compliance with state and Federal requirements.

A16149-c (01/16) 16498 RM021616

Northern California Pipe Trades Trust Fund Chiropractic Benefits Additional coverage for your HMO Plans Blue Shield Chiropractic Care coverage lets you self-refer to a network of more than 4,000 licensed chiropractors. Benefits are provided through a contract with American Specialty Health Plans of California, Inc. (ASH Plans).

How the Program Works You can visit any participating chiropractor from the ASH Plans network without a referral from your HMO Personal Physician. Simply call a participating provider to schedule an initial exam. At the time of your first visit, you’ll present your Blue Shield identification card and pay only your copayment. Because participating chiropractors bill ASH Plans directly, you’ll never have to file claim forms. If you need further treatment, the participating chiropractor will submit a proposed treatment plan to ASH Plans and obtain the necessary authorization from ASH Plans to continue treatment up to the calendar year maximum of 30 visits.

What’s Covered Initial and subsequent examinations



Office visits and adjustments (subject to annual limits)



Adjunctive therapies



X-rays (chiropractic only)

Benefit Plan Design Calendar year Maximum Calendar year Deductible Calendar year Chiropractic Appliances Benefit1,2

Covered Services Chiropractic Services Out-of-network Coverage

30 Visits None $50

Member Copayment $10 None

1.

Chiropractic appliances are covered up to a maximum of $50 in a calendar year as authorized by ASH Plans.

2.

As authorized by ASH Plans, this allowance is applied toward the purchase of items determined necessary, such as supports, collars, pillows, heel lifts, ice packs, cushions, orthotics, rib belts and home traction units.

Friendly Customer Service Helpful ASH Plans Member Services representatives are available at (800) 678-9133 Monday through Friday from 6 a.m. to 5 p.m. to answer questions, assist with problems, or help locate a participating chiropractor. This document is only a summary for informational purposes. It is not a contract. Please refer to the Evidence of Coverage and the Group Health Service Agreement for the exact terms and conditions of coverage. 16501

An independent member of the Blue Shield Association



A17274 (01/16) RM021616_portfolio

The plan covers medically necessary chiropractic services including:

Northern California Pipe Trades Trust Fund Additional Blue Shield Infertility Benefits For Active Employees and non-Medicare Retirees How the Plan Works Your health plan includes infertility benefits in addition to those listed in the Benefit Summary (Uniform Benefits and Coverage Matrix1). Coverage includes authorized professional, hospital, ambulatory surgery center, and ancillary services, as well as injectable drugs administered or prescribed to diagnose and treat the cause of infertility including induced fertilization2.

Coverage Details The following procedures are limited, per lifetime as shown. 

Six (6) natural (without ovum/egg [oocyte or ovarian tissue] stimulation) artificial inseminations and;



Three (3) stimulated (with ovum/egg [oocyte or ovarian tissue] stimulation) artificial inseminations and;



One (1) gamete intrafallopian transfer (GIFT)3



Cryopreservation of sperm/ oocyte /embryos when retrieved from a covered subscriber, spouse, or domestic partner. Benefits include cryopreservation services for a condition which the treating physician anticipates will cause infertility in the future (except when the infertile condition is caused by elective chemical or surgical sterilization procedures). Benefits are limited to one retrieval and one year of storage per person per lifetime

Health Plans

Copayment

HMO plan**

50% of the allowable amount

PPO plan**

50% of the allowable amount

1.

If you are an HMO member, services that diagnose and treat the cause of infertility are included in your basic plan benefits. For PPO members, these services are only covered when the group adds “Additional Blue Shield Infertility Benefits” to the plan.

2.

These services are covered only when authorized by Blue Shield, and provided by a Participating Provider (PPO plan) or HMO plan provider (HMO plan). Procedures must be consistent with established medical practice in treatment of infertility and induced fertilization.

3.

This procedure is covered only when performed on a subscriber or covered spouse/ domestic partner.

4.

The lifetime benefit maximums for the above described procedures apply to all services related to or performed in conjunction with such procedures.

* Services provided under this benefit are subject to any applicable calendar year medical deductible and accrue to the calendar year outof-pocket maximum of the health plan. ** Services provided under this benefit are not subject to any applicable calendar year medical deductible and do not accrue to the calendar year out-of-pocket maximum. Services continue to be the member's responsibility after the calendar year out-of-pocket maximum is reached.

This is only a summary for informational purposes. It is not a contract. Please refer to the plan contract and Evidence of Coverage for a detailed description of covered benefits and limitations. 16502

An independent member of the Blue Shield Association

All benefits are subject to a lifetime benefit maximum4 and copayment.

A17275 (01/16) RM021616

EXCLUDED: in-vitro fertilization (IVF), intracytoplasmic sperm injection (ICSI), and zygote intrafallopian transfer (ZIFT).

Northern California Pipe Trades Trust Fund Additional Hearing Aid and Ancillary Equipment Benefit Attachment to Benefit Summary (Uniform Benefits and Coverage Matrix) Additional coverage for HMO Plans

How the Plan Works In addition to the benefits set forth in the Benefit Summary (Uniform Benefits and Coverage Matrix), your group has added hearing aid benefits to your benefit plan. Coverage includes hearing aid services, subject to the conditions and limitations listed below. This rider provides a $2,000 allowance every 24 months towards the purchase of hearing aids and ancillary equipment. The calendar year deductible does not apply to the services provided in this hearing aid services benefit and hearing aid expenses in excess of the maximum allowance are not included in the calendar year out-of-pocket maximum amount.

The hearing aid allowance includes: 

A hearing aid instrument, monaural or binaural, including ear mold(s)



Visit for fitting, counseling, and adjustments



The initial battery



Cords



Other ancillary equipment

Benefit Plan Design Plan Options HMO Plans

Benefit Allowance $2,000 allowance every 24 months

The following services and supplies are not covered: 

Purchase of batteries or other ancillary equipment, except those covered under the terms of the initial hearing aid purchase



Charges for a hearing aid which exceed specifications prescribed for correction of a hearing loss



Replacement parts for hearing aids, repair of hearing aid after the covered warranty period and replacement of a hearing aid more than once in any period of 24 months



Surgically implanted hearing devices

All benefits are subject to the general provisions, limitations and exclusions listed in your Evidence of Coverage. 16504

An independent member of the Blue Shield Association

A45833 (01/16) RM021616_portfolio

Coverage Details

Notes

20

Blue Shield of California

Language Assistance Notice on the availability of language assistance services to accompany

Notice on the availability of language assistance services vital documents issued in English to accompany vital documents issued in English.

IMPORTANT: Can you read this letter? If not, we can have somebody help you read it. You may also be able to get this letter written in your language. For free help, please call right away at the Member/Customer Service telephone number on the back of your Blue Shield ID card, or (866) 346-7198. IMPORTANTE: ¿Puede leer esta carta? Si no, podemos hacer que alguien le ayude a leerla. También puede recibir esta carta en su idioma. Para ayuda gratuita, por favor llame inmediatamente al teléfono de Servicios al miembro/cliente que se encuentra al reverso de su tarjeta de identificación de Blue Shield o al (866) 346-7198. (Spanish) 重要通知：您能讀懂這封信嗎？ 如果不能，我們可以請人幫您閱讀。 這封信也可以用您所講的語言書寫。 如需幫助，請立即撥打登列在您的Blue Shield ID卡背面上的會員/客戶服務部的電話，或者撥打電話866-346-7198。 (Chinese) QUAN TRỌNG: Quý vị có thể đọc lá thư này không? Nếu không, chúng tôi có thể nhờ người giúp quý vị đọc thư. Quý vị cũng có thể nhận lá thư này được viết bằng ngôn ngữ của quý vị. Để được hỗ trợ miễn phí, vui lòng gọi ngay đến Ban Dịch vụ Hội viên/Khách hàng theo số ở mặt sau thẻ ID Blue Shield của quý vị hoặc theo số 866-346-7198. (Vietnamese)

Go with Blue�Shield for a healthier you. For more information, visit blueshieldca.com, download the Blue�Shield of California Mobile app through the App Store or Google Play, or call your dedicated Blue�Shield Member Services team at (855) 256-9404 from 7 a.m. to 7 p.m., Monday through Friday.

Member confidentiality Blue Shield protects the confidentiality and privacy of your personal and health information, including medical information and individually identifiable information such as your name, address, telephone number, and Social Security number. To ensure this, Blue Shield requires a signed authorization form for you to access health information for your spouse or dependents over the age of 18.

To request an authorization form, log in to blueshieldca.com and select My Health Plan. Click on Download Forms under “Tools” on the right side. Scroll down to “Release of information” and click on Personal and Health Information Release. If you don’t have access to the Internet, or have questions about how Blue Shield protects your privacy and confidentiality, please call our Privacy Office directly at (888) 266-8080.

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