we can point you in the right direction.€¦ · guidance from registered nurses to help them have...

This guide is information only. You must enroll to be covered. 03429CAMENABC 01/16 37083MUMENMUB REV 01/14

We can point you in the right direction.

Anthem Blue Cross HMO / PPO Benef ts iIBEW Local 18 - www.anthem.com/ca/ibewlocal18 Effective July 1, 2017

In this guide, you'll f nd: i

How most health plans work

Plan comparison information

Frequently Asked Questions (FAQ)

Plan details

Your privacy and rights

You're ready to enroll. Let's take a look at your options.

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Choose a health plan that works for you Visit anthem.com/ca/basics to learn more.

PPO This plan covers services from almost any doctor or hospital, but you get a discount if you use a doctor from the Preferred Provider Organization (PPO) plan. You pay more if you go to a doctor who’s not in the PPO plan. You don’t usually need a referral from your main doctor, also called a primary care doctor, to see a specialist.

Some PPO plans may have different rules. So be sure to check your plan details.

HMO This plan covers services from doctors in your plan. You’ll need to choose a main doctor, also called a primary care doctor, from the Health Maintenance Organization (HMO) plan. If you need a specialist, you’ll most likely have to go through your primary care doctor to get a referral.

Some HMO plans may have different rules. So be sure to check your plan details.

The doctors, hospitals and other health care providers in your plan have agreed to charge lower rates for our members.

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Your costs if you need care You'll get the most out of your benef ts when you understand how youri plan pays for your care.1

2 Blue Cross and Blue Shield Association: bcbs.com/about-the-association.

1 This information is a general description of your benef ts; it is not a contract and does not replace your Summary of Benef ts.ii For a full disclosure of all benef ts, exclusions and limitations, refer to your Summary of Benef ts. ii

IBEW Local 18

HMO IBEW Local 18

PPO Doctors

in the plan Doctors out of the plan

Doctors in the plan

Doctors out of the plan

Deductible

Single N/A N/A $250 $1,000

Family N/A N/A $750 $3,000

Off ce visits iDoctor/specialist

No Copay N/A No Copay / $35 Copay

40%

Out-of-pocket limit

Single $500 N/A $2,000 $6,000

Family $1,500 N/A $4,000 $12,000

Pharmacy

Retail $5 / $10 $5 / $10 + Additional $5 / $10 $5 / $10 + Additional

Frequently asked questions (FAQ)

How do I use my health plan when I need care?

After you enroll, your member ID card will come in the mail. Be sure to bring it with you to the doctor. You can also show a copy of your ID card from the Anthem mobile app.

Is preventive care covered?

Yes, preventive care from a doctor in the plan is covered at 100%. It’s very important to take care of your health with regular checkups even when you feel f ne. So talk to youri doctor about screenings and immunizations that you may need to protect your health.

Can I manage my plan and health care on anthem.com/ca?

Yes. As soon as you become a member, you’ll be able to register at anthem.com/ca or on the Anthem mobile app. It’s designed to help you manage your health care and your benef ts simply and conveniently. Many of our members f ndii these self-service tools helpful:

Check on your claims.

Find a doctor.

Track your health care spending.

Compare quality and costs at hospitals and other facilities.

Visit anthem.com/ca/guidedtour to watch a video explaining how our website can help you.

Do I have health and wellness benef ts with my plan? i

Yes. In fact, we have a set of tools and resources that can help you reach your health goals. They can also save you money on products and services for your health.

Check out these health and wellness programs your employer is providing in addition to your health benef ts: i

24/7 NurseLine — Our registered nurses can answer your health questions wherever you are — any time, day or night.

Future Moms — Moms-to-be get personalized support and guidance from registered nurses to help them have a healthy pregnancy, a safe delivery and a healthy baby.

Healthy Lifestyles — Take charge of your total wellness through a personalized Well-Being Plan and custom trackers that help you manage your physical and mental health.

Staying Healthy Reminders — An annual reminder sent to your home will recommend important preventive health screenings or treatments based on age and gender.

How can Anthem help me save money?

You'll save money every time you go to a doctor in your plan -- they've agreed to charge lower rates for Anthem members. But we'll also help save you money before you go to the doctor.

At anthem.com/ca, you can compare how much a medical procedure will cost at different locations. Plus, all members get discounts on health-related products. You can even print your own coupons for healthier groceries. Check out these cost saving programs your employer is also offering.

Home Delivery Pharmacy — You can save money and time by having your prescriptions delivered to your home.

Anthem Health Rewards — We want to help you get healthier every day. So we’re rewarding you for doing just that! All you have to do is take part in health and wellness programs or activities, and you’ll start earning rewards right away.

LiveHealth Online — Using LiveHealth Online, you can have a video visit with a board-certif ed doctor or therapist on youri smartphone, tablet or computer with a webcam. It’s easy to use and there when you need it. All you have to do is sign up to use it at livehealthonline.com or download the app.

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You can register at anthem.com/ca or on the Anthem BC Anywhere mobile app — your simple and convenient solution to managing your health.

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Anthem Blue Cross

IBEW Local 18 - HMO

Your Plan: Custom Premier HMO 0/100% (RX $5/$10)

Your Network: California Care HMO This summary of benefits is a brief outline of coverage, designed to help you with the selection process. This summary does not reflect each and every benefit, exclusion and limitation which may apply to the coverage. For more details, important limitations and exclusions, please review the formal Evidence of Coverage (EOC). If there is a difference between this summary and the Evidence of Coverage (EOC), the Evidence of Coverage (EOC), will prevail.

Anthem Blue Cross HMO benefits are covered only when services are provided or coordinated by the primary care physician and authorized by the participating medical group or independent practice association (IPA); except OB/GYN services received within the member's medical group/IPA, and services for mental and nervous disorders and substance abuse. Benefits are subject to all terms, conditions, limitations, and exclusions of the EOC.

Covered Medical Benefits

Cost if you use an In-Network Provider

Overall Deductible $0

Out-of-Pocket Limit When you meet your out-of-pocket limit, you will no longer have to pay cost-shares during the remainder of the calendar year. See notes section for additional information regarding your out of pocket maximum.

Individual $500; Two- Party; $1,000; Family $1,500

Doctor Home and Office Services

Preventive care/screening/immunization In-network preventive care is not subject to deductible, if your plan has a deductible.

No copay

Primary care visit to treat an injury or illness No copay

Specialist care visit No copay

Prenatal and Post-natal Care In network preventive pre natal and post natal services covered at 100%.

No copay

Other practitioner visits:

Live Health Online visit No copay

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Chiropractor services (Self referred) An initial examination by an ASHP chiropractor and/or acupuncturist of disorders is required. Up to 30 visits combined during a calendar year if authorized as medically necessary by ASHP.

$10 copay per visit

Acupuncture Chiropractic Appliances

$10 copay per visit $50 per calendar year

Other services in an office:

Allergy testing No copay

Chemo/radiation therapy No copay

Hemodialysis No copay

Prescription drugs For the drugs itself dispensed in the office thru infusion/injection

No copay

Diagnostic Services

Lab:

Office No copay

Freestanding Lab No copay

Outpatient Hospital No copay

X-ray:

Office No copay

Freestanding Radiology Center No copay

Outpatient Hospital No copay

Advanced diagnostic imaging (for example, MRI/PET/CAT scans):

Office Costs may vary by site of service.

No copay

Freestanding Radiology Center Costs may vary by site of service.

No copay

Outpatient Hospital Costs may vary by site of service.

No copay

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Emergency and Urgent Care

Emergency room facility services This is for the hospital/facility charge only. The ER physician charge may be separate. Copay waived if admitted.

No copay

Emergency room doctor and other services No copay

Ambulance (air and ground) No copay

Urgent Care (office setting) No copay

Outpatient Mental/Behavioral Health and Substance Abuse

Doctor office visit No copay

Facility visit:

Facility fees No copay

Outpatient Surgery

Facility fees:

Hospital No copay

Freestanding Surgical Center No copay

Doctor and other services No copay

Hospital Stay (all inpatient stays including maternity, mental / behavioral health, and substance abuse)

Facility fees (for example, room & board) No copay

Doctor and other services No copay

Recovery & Rehabilitation

Home health care Coverage for In-Network Provider is limited to 100 visit limit per benefit period.

No copay

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Rehabilitation services (for example, physical/speech/occupational therapy):

Office Coverage for In-Network Provider is limited to 60 day limit per benefit period for Physical, Occupational and Speech Therapy combined. Costs may vary by site of service. Chiropractor visits count towards your physical and occupational therapy limit.

No copay

Outpatient hospital Coverage for In-Network Provider is limited to 60 day limit per benefit period for Physical, Occupational and Speech Therapy combined.

No copay

Habilitation services Habilitation and Rehabilitation visits count towards your Rehabilitation limit.

No copay

Cardiac rehabilitation

Office Coverage for In-Network Provider is limited to 60 day limit per benefit period for Physical, Occupational and Speech Therapy combined.

No copay

Outpatient hospital Coverage for In-Network Provider is limited to 60 day limit per benefit period for Physical, Occupational and Speech Therapy combined.

No copay

Skilled nursing care (in a facility) Coverage for In-Network Provider is limited to 100 day limit per benefit period.

No copay

Hospice No copay

Durable Medical Equipment No copay

Prosthetic Devices No copay

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Covered Prescription Drug Benefits


Cost if you use a Non-Network Provider

Pharmacy Deductible $0 $0

Prescription Drug Coverage

Preventive Pharmacy Preventive Immunization

No copay

50% coinsurance (retail only)

Female oral contraceptive Generic and Single Source brand

No copay 50% coinsurance (retail only)

Tier1 - Typically Generic Member pays the retail pharmacy copay plus 50% for out of network. Covers up to a 30 day supply (retail pharmacy) Covers up to a 90 day supply (home delivery program)

$5 copay per prescription (retail only) and $10 copay per prescription (home delivery only)

Member pays the retail participating pharmacies copay plus 50% coinsurance (retail only)

Tier2 - Typically Preferred / Brand Member pays the retail pharmacy copay plus 50% for out of network. Covers up to a 30 day supply (retail pharmacy) Covers up to a 90 day supply (home delivery program)



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Notes: This Summary of Benefits has been updated to comply with federal and state requirements, including

applicable provisions of the recently enacted federal health care reform laws. As we receive additional guidance and clarification on the new health care reform laws from the U.S. Department of Health and Human Services, Department of Labor and Internal Revenue Service, we may be required to make additional changes to this Summary of Benefits. This Summary of Benefits, as updated, is subject to the approval of the California Department of Insurance and the California Department of Managed Health Care (as applicable).

In addition to the benefits described in this summary, coverage may include additional benefits, depending upon the member's home state. The benefits provided in this summary are subject to federal and California laws. There are some states that require more generous benefits be provided to their residents, even if the master policy was not issued in their state. If the member's state has such requirements, we will adjust the benefits to meet the requirements.

Your plan requires a selection of a Primary Care Physician. Your plan requires a referral from your Primary Care Physician for select covered services.

Preventive Care Services includes physical exam, preventive screenings (including screenings for cancer, HPV, diabetes, cholesterol, blood pressure, hearing and vision, immunization, health education, intervention services, HIV testing) and additional preventive care for women provided for in the guidance supported by Health Resources and Service Administration.

If your plan includes an emergency room facility copay and you are directly admitted to a hospital, your emergency room facility copay is waived.

Certain services are subject to the utilization review program. Before scheduling services, the member must make sure utilization review is obtained. If utilization review is not obtained, benefits may be reduced or not paid, according to the plan.

Additional visits maybe authorized if medically necessary. Pre-service review must be obtained prior to receiving the additional services.

Skilled Nursing Facility day limit does not apply to mental health and substance abuse. Respite Care limited to a maximum of 5 consecutive days per admission. Freestanding Lab and Radiology Center is defined as services received in a non-hospital based facility. Infertility services are not included in the out of pocket amount. Coordination of Benefits: The benefits of this plan may be reduced if the member has any other group health

or dental coverage so that the services received from all group coverage do not exceed 100% of the covered expense

When using non-network pharmacy; members are responsible for in-network pharmacy copay plus 50% of the remaining prescription drug maximum allowed amount & costs in excess of the prescription drug maximum allowed amount. Members will pay upfront and submit a claim form.

Preferred Generic Program: If a member requests a brand name drug when a generic drug version exists, the member pays the generic drug copay plus the difference in cost between the prescription drug maximum allowed amount for the generic drug and the brand name drug dispensed, but not more than 50% of our average cost of that type of prescription drug. The Preferred Generic Program does not apply when the physician has specified "dispense as written" (DAW) or when it has been determined that the brand name drug is medically necessary for the member. In such case, the applicable copay for the dispensed drug will apply.

Certain drugs require pre-authorization approval to obtain coverage. Supply limits for certain drugs may be different, go to Anthem website or call customer service. For additional information on limitations and exclusions and other disclosure items that apply to this plan, go

to https://le.anthem.com/pdf?x=CA_LG_HMO For additional information on this plan, please visit sbc.anthem.com to obtain a Summary of Benefit Coverage. 12

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Exclusions and Limitations

Care Not Approved. Care from a health care provider w ithout the OK of primary care doctor, except for emergency services or urgent care. Care Not Covered. Services before the member w as on the plan, or after coverage ended. Care Not Listed. Services not listed as being covered by this plan. Care Not Needed. Any services or supplies that are not medically necessary. Crime or Nuclear Energy. Any health problem caused: (1) w hile committing or trying to commit a felony, as long as any injuries are not a result of a medical condition or an act of domestic violence; or (2) by nuclear energy, w hen the government can pay for treatment. Experimental or Investigative. Any experimental or investigative procedure or medication. But, if member is denied benefits because it is determined that the requested treatment is experimental or investigative, the member may ask that the denial be review ed by an external independent medical review organization, as described in the Evidence of Coverage (EOC). Government Treatment. Any services the member actually received that w ere given by a local, state or federal government agency, except w hen this plan's benefits, must be provided by law . We w ill not cover payment for these services if the member is not required to pay for them or they are given to the member for free. Services Given by Providers Who Are Not With Anthem Blue Cross HMO. We w ill not cover these services unless primary care doctor refers the member, except for emergencies or urgent care. Services Not Needing Payment. Services the member is not required to pay for or are given to the member at no charge, except services the member got at a charitable research hospital (not w ith the government). This hospital must:1. Be know n throughout the w orld as devoted to medical research.2. Have at least 10% of its yearly budget spent on research not directly related to patient care.3. Have 1/3 of its income from donations or grants (not gifts or payments for patient care).4. Accept patients w ho are not able to pay.5. Serve patients w ith conditions directly related to the hospital's research (at least 2/3 of their patients). Work-Related. Care for health problems that are w ork-related if such health problems are or can be covered by w orkers' compensation, an employer's liability law , or a similar law . We w ill provide care for a w ork-related health problem, but, w e have the right to be paid back for that care. See "Third Party Liability" below . Acupressure. Acupressure, or massage to help pain, treat illness or promote health by putting pressure to one or more areas of the body. Air Conditioners. Air purifiers, air conditioners, or humidifiers. Birth Control Devices. Any devices needed for birth control w hich can be obtained w ithout a doctor's prescription such as condoms. Blood. Benefits are not provided for the collection, processing and storage of self-donated blood unless it is specifically collected for a planned and covered surgical procedure. Braces or Other Appliances or Services for straightening the teeth (orthodontic services). Clinical Trials. Services and supplies in connection w ith clinical trials, except as specified as covered in the Evidence of Coverage (EOC). Commercial weight loss programs. Weight loss programs, w hether or not they are pursued under medical or doctor supervision, except as specified as covered in the EOC. This exclusion includes, but is not limited to, commercial w eight loss programs (Weight Watchers, Jenny Craig, LA Weight Loss) and fasting programs. This exclusion does not apply to medically necessary treatments for morbid obesity or for treatment of anorexia nervosa or bulimia nervosa. Consultations given by telephone or fax. Cosmetic Surgery. Surgery or other services done only to make the member: look beautiful; to improve appearance; or to change or reshape normal parts or tissues of the body. This does not apply to reconstructive surgery the member might need to: get back the use of a body part; have for breast reconstruction after a mastectomy; correct or repair a deformity caused by birth defects, abnormal development, injury or illness in order to improve function, symptomatology or create a normal appearance. Cosmetic surgery does not become reconstructive because of psychological or psychiatric reasons. Custodial Care or Rest Cures. Room and board charges for a hospital stay mostly for a change of scene or to make the member feel good. Services given by a rest home, a home for the aged, or any place like that. Dental Services or Supplies. Dentures, bridges, crow ns, caps, or dental prostheses, dental implants, dental services, tooth extraction, or treatment to the teeth or gums. Cosmetic dental surgery or other dental services for beauty purposes. Diabetic Supplies. Prescription and non-prescription diabetic supplies, except as specified as covered in the EOC. Eye Exercises or Services and Supplies for Correcting Vision. Optometry services, eye exercises, and orthoptics, except for eye exams to find out if the member's vision needs to be corrected. Eyeglasses or contact lenses are not covered. Contact lens fitting is not covered. Eye Surgery for Refractive Defects. Any eye surgery just for correcting vision (like nearsightedness and/or astigmatism). Contact lenses and eyeglasses needed after this surgery. Food or Dietary Supplements. Nutritional and/or dietary supplements, except as specified as covered in the EOC or as required by law . This exclusion includes, but is not limited to, those nutritional formulas and dietary supplements that can be purchased over the counter, w hich by law do not require either a w ritten prescription or dispensing by a licensed pharmacist. Health Club Membership. Health club memberships, exercise equipment, charges from a physical fitness instructor or personal trainer, or any other charges for activities, equipment, or facilities used for developing or maintaining physical fitness, even if ordered by a doctor. This exclusion also applies to health spas. Hearing Aids. Hearing aids or services for fitting or making a hearing aid, except as specified as covered in the EOC. Immunizations. Immunizations needed to travel outside the USA. Infertility Treatment. Any infertility treatment including artificial insemination or in vitro fertilization & sperm bank. Lifestyle Programs. Programs to help member change how one lives, like fitness clubs, or dieting programs. This does not apply to cardiac rehabilitation programs approved by the medical group. Mental or nervous disorders. Academic or educational testing, counseling. Remedying an academic or education problem, except as stated as covered in the EOC. Nicotine Use. Programs to stop smoking or the treatment of nicotine or tobacco use if the program is not affiliated w ith Anthem. Non-Prescription Drugs. Non-prescription, over-the-counter drugs or medicines, except as specified as covered in the Evidence of Coverage (EOC). Orthopedic shoes and shoe inserts. This exclusion does not apply to orthopedic footw ear used as an integral part of a brace, shoe inserts that are custom molded to the patient, or therapeutic shoes and inserts designed to treat foot complications due to diabetes, as specifically stated in the EOC. Outpatient Drugs. Outpatient prescription drugs or medications including insulin. Personal Care and Supplies. Services for personal care, such as: help in w alking, bathing, dressing, feeding, or preparing food. Any supplies for comfort, hygiene or beauty purposes. Private Contracts. Services or supplies provided pursuant to a private contract betw een the member and a provider, for w hich reimbursement under the Medicare program is prohibited, as specified in Section 1802 (42 U.S.C. 1395a) of Title XVIII of the Social Security Act. Routine Exams. Routine physical or psychological exams or tests asked for by a job or other group, such as a school, camp, or sports program. Sexual Problems. Treatment of any sexual problems unless due to a medical problem, physical defect, or disease. Sterilization Reversal. Surgery done to reverse sterilization. Surrogate Mother Services. For any services or supplies provided to a person not covered under the plan in connection w ith a surrogate pregnancy (including, but not limited to, the bearing of a child by another w oman for an infertile couple). Third Party Liability – Anthem Blue Cross is entitled to reimbursement of benefits paid if the member recovers damages from a legally liable third party.

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Varicose Vein Treatment. Treatment of varicose veins or telangiectatic dermal veins (spider veins) by any method (including sclerotherapy or other surgeries) w hen services are rendered for cosmetic purposes. Coordination of Benefits – The benefits of this plan may be reduced if the member has any other group health or dental coverage so that the services received from all group coverages do not exceed 100% of the covered expense.

Prescription Drug Exclusions & Limitations Immunizing agents, biological sera, blood, blood products or blood plasma. Hypodermic syringes &/or needles, except w hen dispensed for use w ith insulin & other self-injectable drugs or medications. Drugs & medications used to induce spontaneous & non-spontaneous abortions. Drugs & medications dispensed or administered in an outpatient setting, including outpatient hospital facilities and physicians' offices. Professional charges in connection w ith administering, injecting or dispensing drugs. Drugs & medications that may be obtained w ithout a physician's w ritten prescription, except insulin or niacin for cholesterol low ering and certain over-the-counter drugs approved by the Pharmacy and Therapeutics Process to be included in the prescription drug formulary. Drugs & medications dispensed by or w hile confined in a hospital, skilled nursing facility, rest home, sanatorium, convalescent hospital or similar facility. Durable medical equipment, devices, appliances & supplies, even if prescribed by a physician, except contraceptive diaphragms, as specified as covered in the EOC/Certificate. Services or supplies for w hich the member is not charged. Oxygen. Cosmetics & health or beauty aids. How ever, health aids that are medically necessary and meet the requirements as specified as covered in the EOC/Certificate. Drugs labeled "Caution, Limited by Federal Law to Investigational Use," or experimental drugs. Drugs or medications prescribed for experimental indications. Any expense for a drug or medication incurred in excess of the prescription drug maximum allow ed amount. Drugs w hich have not been approved for general use by the Food and Drug Administration. This does not apply to drugs that are medically necessary for a covered condition. Drugs to eliminate or reduce dependency on, or addiction to, tobacco and tobacco products. This does not apply to medically necessary drugs that the member can only get w ith a prescription under federal law . Drugs used primarily for cosmetic purposes (e.g., Retin-A for w rinkles). How ever, this w ill not apply to the use of this type of drug for medically necessary treatment of a medical condition other than one that is cosmetic. Anorexiants and drugs used for w eight loss, except w hen used to treat morbid obesity (e.g., diet pills & appetite suppressants). Drugs obtained outside the U.S, unless they are furnished in connection w ith urgent care or an emergency. Allergy desensitization products or allergy serum. Infusion drugs, except drugs that are self-administered subcutaneously. Herbal supplements, nutritional and dietary supplements. Formulas and special foods for the treatment of phenylketonuria (PKU). Prescription drugs w ith a non-prescription (over-the-counter) chemical and dose equivalent except insulin. This does not apply if an over-the-counter equivalent w as tried and w as ineffective. Compound medications unless: a. There is at least one component in it that is a prescription drug; and b. It is obtained from a participating pharmacy. Member w ill have to pay the full cost of the compound medications if member obtains drug at a non-participating pharmacy.

Specialty pharmacy drugs that must be obtained from the specialty pharmacy program, but w hich are obtained from a retail pharmacy are not covered by this plan. Member w ill have to pay the full cost of the specialty pharmacy drugs obtained from a retail pharmacy that member should have obtained from the specialty pharmacy program.

Off label prescription drugs

Third Party Liability

Anthem Blue Cross is entitled to reimbursement of benefits paid if the member recovers damages from a legally liable third party.

Anthem Blue Cross is the trade name of Blue Cross of California. Independent licensee of the Blue Cross Association. ® ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross name and symbol are registered marks of the Blue Cross Association. Questions: (855) 333-5730 or visit us at www.anthem.com/ca CA/L/F/HMO/LH2047/LR2067/01-15

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Anthem Blue Cross

IBEW Local 18-PPO

Your Plan: Custom Incentive PPO 250/35/20 (RX $5/$10)

Your Network: Prudent Buyer PPO

This summary of benefits is a brief outline of coverage, designed to help you with the selection process. This summary does not reflect each and every benefit, exclusion and limitation which may apply to the coverage. For more details, important limitations and exclusions, please review the formal Certificate of Insurance or Evidence of Coverage (EOC). If there is a difference between this summary and the Certificate of Insurance or Evidence of Coverage (EOC), the Certificate of Insurance or Evidence of Coverage (EOC), will prevail.




Overall Deductible See notes section to understand how your deductible works. Your plan may also have a separate Prescription Drug Deductible. See Prescription Drug Coverage section.

$250/member; maximum of three separate deductibles/family

$1,000/member; maximum of three separate deductibles/family

Out-of-Pocket Limit When you meet your out-of-pocket limit, you will no longer have to pay cost-shares during the remainder of the calendar year. See notes section for additional information regarding your out of pocket maximum.

$2,000/member; $4,000/family

$6,000/member; $12,000/family

Doctor Home and Office Services

Preventive care/screening/immunization In-network preventive care is not subject to deductible, if your plan has a deductible.

No copay (deductible waived)

40% coinsurance

Primary care visit to treat an injury or illness Deductible does not apply to In-Network providers.


40% coinsurance

Specialist care visit Deductible does not apply to In-Network providers.

$35/visit (deductible waived)

40% coinsurance

Prenatal and Post-natal Care Deductible does not apply to In-Network providers. In network preventive pre natal and post natal services covered at 100%.


40% coinsurance

Other practitioner visits:

Retail health clinic Deductible does not apply to In-Network providers.


40% coinsurance

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LiveHealth Online Visit Deductible does not apply to In-Network providers.


Not covered

Chiropractor services Coverage for In-Network Provider and Non-Network Provider combined is limited to 30 visit limit per benefit period. Deductible does not apply to In- Network providers.


40% coinsurance

Acupuncture Coverage for In-Network Provider and Non-Network Provider combined is limited to 20 visit limit per benefit period. Deductible does not apply to In- Network providers.


40% coinsurance

Other services in an office:

Allergy testing 20% coinsurance 40% coinsurance

Chemo/radiation therapy 20% coinsurance 40% coinsurance

Hemodialysis 20% coinsurance 40% coinsurance

Prescription drugs For the drugs itself dispensed in the office thru infusion/injection

20% coinsurance 40% coinsurance

Diagnostic Services

Lab:

Office 20% coinsurance 40% coinsurance

Freestanding Lab 20% coinsurance 40% coinsurance

Outpatient Hospital


X-ray:


Freestanding Radiology Center 20% coinsurance 40% coinsurance

Outpatient Hospital


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Advanced diagnostic imaging (for example, MRI/PET/CAT scans):


Freestanding Radiology Center 20% coinsurance 40% coinsurance

Outpatient Hospital 20% coinsurance 40% coinsurance

Emergency and Urgent Care

Emergency room facility services Emergency Room $100 copayment per visit. This is for the hospital facility charge only. The ER physician charge may be separate

20% coinsurance (Copayment waived if admitted)

20% coinsurance (Copayment waived if admitted)

Emergency room doctor and other services 20% coinsurance 20% coinsurance

Ambulance (air and ground) 30% coinsurance 30% coinsurance

Urgent Care (office setting) Deductible does not apply to In-Network providers.

$25/visit (deductible waived)

40% coinsurance

Outpatient Mental/Behavioral Health and Substance Abuse

Doctor office visit Deductible does not apply to In-Network providers.


40% coinsurance

Facility visit:

Facility fees 20% coinsurance 40% coinsurance

Outpatient Surgery

Facility fees:

Hospital


Freestanding Surgical Center Coverage for Out-of-Network Provider is limited to $350 maximum per visit.


Doctor and other services 20% coinsurance 40% coinsurance

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Hospital Stay (all inpatient stays including maternity, mental / behavioral health, and substance abuse)

Facility fees (for example, room & board) Co-pay $500 if you do not receive preauthorization. Apply to Out-of-Network Provider. Apply to non- emergency admission.


Doctor and other services 20% coinsurance 40% coinsurance

Recovery & Rehabilitation

Home health care Coverage for In-Network Provider and Non-Network Provider combined is limited to 100 visit limit per benefit period.


Rehabilitation services (for example, physical/speech/occupational therapy):

Office Costs may vary by site of service.


Outpatient hospital


Habilitation services 20% coinsurance 40% coinsurance

Cardiac rehabilitation


Outpatient hospital


Skilled nursing care (in a facility) Coverage for In-Network Provider and Non-Network Provider combined is limited to 100 day limit per benefit period.


Hospice 20% coinsurance (deductible waived)

30% coinsurance

Durable Medical Equipment 20% coinsurance 40% coinsurance

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Prosthetic Devices 20% coinsurance 40% coinsurance

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Covered Prescription Drug Benefits



Pharmacy Deductible $0 $0

Prescription Drug Coverage

Preventive Pharmacy Preventive Immunization

No copay

50% coinsurance (retail only)

Female oral contraceptive Generic and Single Source brand

No copay 50% coinsurance (retail only)

Tier1 - Typically Generic Member pays the retail pharmacy copay plus 50% for out of network. Covers up to a 30 day supply (retail pharmacy) Covers up to a 90 day supply (home delivery program)



Tier2 - Typically Preferred / Brand Member pays the retail pharmacy copay plus 50% for out of network. Covers up to a 30 day supply (retail pharmacy) Covers up to a 90 day supply (home delivery program)



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Notes: • This Summary of Benefits has been updated to comply with federal and state requirements, including

applicable provisions of the recently enacted federal health care reform laws. As we receive additional guidance and clarification on the new health care reform laws from the U.S. Department of Health and Human Services, Department of Labor and Internal Revenue Service, we may be required to make additional changes to this Summary of Benefits. This Summary of Benefits, as updated, is subject to the approval of the California Department of Insurance and the California Department of Managed Health Care (as applicable).

• In addition to the benefits described in this summary, coverage may include additional benefits, depending upon the member's home state. The benefits provided in this summary are subject to federal and California laws. There are some states that require more generous benefits be provided to their residents, even if the master policy was not issued in their state. If the member's state has such requirements, we will adjust the benefits to meet the requirements.

• The family deductible and out-of-pocket maximum are embedded meaning the cost shares of one family member will be applied to the individual deductible and individual out-of-pocket maximum; in addition, amounts for all family members apply to the family deductible and family out-of-pocket maximum. No one member will pay more than the individual deductible and individual out-of-pocket maximum.

• All medical services subject to a coinsurance are also subject to the annual medical deductible. • Annual Out-of-Pocket Maximums includes deductible, copays, coinsurance and prescription drug. • In network and out of network out of pocket maximum are exclusive of each other. • For plans with an office visit copay, the copay applies to the actual office visit and additional cost shares may

apply for any other service performed in the office (i.e., X-ray, lab, surgery), after any applicable deductible. • Preventive Care Services includes physical exam, preventive screenings (including screenings for cancer, HPV,

diabetes, cholesterol, blood pressure, hearing and vision, immunization, health education, intervention services, HIV testing) and additional preventive care for women provided for in the guidance supported by Health Resources and Service Administration.

• For Medical Emergency care rendered by a Non-Participating Provider or Non-Contracting Hospital, reimbursement is based on the reasonable and customary value. Members may be responsible for any amount in excess of the reasonable and customary value.

• If your plan includes an emergency room facility copay and you are directly admitted to a hospital, your emergency room facility copay is waived.

• If your plan includes out of network benefit and you use a non-network provider, you are responsible for any difference between the covered expense and the actual non-participating providers charge.

• Non-emergency, out-of-network air ambulance services are limited to Anthem maximum payment of $50,000 per trip.

• Certain services are subject to the utilization review program. Before scheduling services, the member must make sure utilization review is obtained. If utilization review is not obtained, benefits may be reduced or not paid, according to the plan.

• Certain types of physicians may not be represented in the PPO network in the state where the member receives services. If such physician is not available in the service area, the member's copay is the same as for PPO (with and without pre-notification, if applicable). Member is responsible for applicable copays, deductibles and charges which exceed covered expense.

• Additional visits maybe authorized if medically necessary. Pre-service review must be obtained prior to receiving the additional services.

• If your plan includes out of network benefits, all services with calendar/plan year limits are combined both in and out of network.

• Transplants covered only when performed at Centers of Medical Excellence or Blue Distinction Centers.

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• Bariatric Surgery covered only when performed at Blue Distinction Center for Specialty Care for Bariatric Surgery.

• Skilled Nursing Facility day limit does not apply to mental health and substance abuse. • Respite Care limited to a maximum of 5 consecutive days per admission. • Freestanding Lab and Radiology Center is defined as services received in a non-hospital based facility. • Coordination of Benefits: The benefits of this plan may be reduced if the member has any other group health

or dental coverage so that the services received from all group coverage do not exceed 100% of the covered expense

• When using non-network pharmacy; members are responsible for in-network pharmacy copay plus 50% of the remaining prescription drug maximum allowed amount & costs in excess of the prescription drug maximum allowed amount. Members will pay upfront and submit a claim form.

• Preferred Generic Program: If a member requests a brand name drug when a generic drug version exists, the member pays the generic drug copay plus the difference in cost between the prescription drug maximum allowed amount for the generic drug and the brand name drug dispensed, but not more than 50% of our average cost of that type of prescription drug. The Preferred Generic Program does not apply when the physician has specified "dispense as written" (DAW) or when it has been determined that the brand name drug is medically necessary for the member. In such case, the applicable copay for the dispensed drug will apply.

• Supply limits for certain drugs may be different, go to Anthem website or call customer service. • Certain drugs require pre-authorization approval to obtain coverage. • For additional information on limitations and exclusions and other disclosure items that apply to this plan, go

to https://le.anthem.com/pdf?x=CA_LG_PPO • For additional information on this plan, please visit sbc.anthem.com to obtain a Summary of Benefit Coverage.

Exclusions and Limitations Not Medically Necessary. Services or supplies that are not medically necessary, as defined. Experimental or Investigative. Any experimental or investigative procedure or medication. But, if member is denied benefits because it is determined that the requested treatment is experimental or investigative, the member may request an independent medical review, as described in the Certificate. Outside the United States. Services or supplies furnished and billed by a provider outside the United States, unless such services or supplies are furnished in connection with urgent care or an emergency. Crime or Nuclear Energy. Conditions that result from (1) the member's commission of or attempt to commit a felony, as long as any injuries are not a result of a medical condition or an act of domestic violence; or (2) any release of nuclear energy, whether or not the result of war, when government funds are available for the treatment of illness or injury arising from the release of nuclear energy. Not Covered. Services received before the member's effective date. Services received after the member's coverage ends, except as specified as covered in the Certificate. Excess Amounts. Any amounts in excess of covered expense or any medical benefit maximum. Work-Related. Work-related conditions if benefits are recovered or can be recovered, either by adjudication, settlement or otherwise, under any workers' compensation, employer's liability law or occupational disease law, whether or not the member claims those benefits. If there is a dispute of substantial uncertainty as to whether benefits may be recovered for those conditions pursuant to workers' compensation, we will provide the benefits of this plan for such conditions, subject to a right of recovery and reimbursement under California Labor Code Section 4903, as specified as covered in the Certificate. Government Treatment. Any services the member actually received that were provided by a local, state or federal government agency, except when payment under this plan is expressly required by federal or state law. We will not cover payment for these services if the member is not required to pay for them or they are given to the member for free. Services of Relatives. Professional services received from a person living in the member's home or who is related to the member by blood or marriage, except as specified as covered in the Certificate. Voluntary Payment. Services for which the member has no legal obligation to pay, or for which no charge would be made in the absence of insurance coverage or other health plan coverage, except services received at a non-governmental charitable research hospital. Such a hospital must meet the following guidelines:1. it must be internationally known as being devoted mainly to medical research;2. at least 10% of its yearly budget must be spent on research not directly related to patient care;3. at least one-third of its gross income must come from donations or grants other than gifts or payments for patient care;4. it must accept patients who are unable to pay; and5. Two-thirds of its patients must have conditions directly related to the hospital's research. Not Specifically Listed. Services not specifically listed in the plan as covered services. Private Contracts. Services or supplies provided pursuant to a private contract between the member and a provider, for which reimbursement under Medicare program is prohibited, as specified in Section 1802 (42 U.S.C. 1395a) of Title XVIII of the Social Security Act. Inpatient Diagnostic Tests. Inpatient room and board charges in connection with a hospital stay primarily for diagnostic tests which could have been performed safely on an outpatient basis. Mental or Nervous Disorders. Academic or educational testing, counseling, and remediation. Mental or nervous disorders or substance abuse, including rehabilitative care in relation to these conditions, except as specified as covered in the Certificate. Nicotine Use. Smoking cessation programs or treatment of nicotine or tobacco use if the program is not affiliated with Anthem. Smoking cessation drugs except as specified as covered in the EOC or Certificate.

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Orthodontia. Braces, other orthodontic appliances or orthodontic services. Dental Services or Supplies. For dental treatment, regardless of origin or cause, except as specified below. "Dental treatment" includes but is not limited to preventative care and fluoride treatments; dental x rays, supplies, appliances, dental implants and all associated expenses; diagnosis and treatment related to the teeth, jawbones or gums, including but not limited to: 1. Extraction, restoration, and replacement of teeth; 2. Services to improve dental clinical outcomes. This exclusion does not apply to the following: 1. Services which we are required by law to cover; 2. Services specified as covered in this booklet; 3. Dental services to prepare the mouth for radiation therapy to treat head and/or neck cancer. Hearing Aids or Tests. Hearing aids and routine hearing tests, except as specified as covered in the Certificate. Optometric Services or Supplies. Optometric services, eye exercises including orthoptics. Routine eye exams and routine eye refractions, as specified as covered in the Certificate. Eyeglasses or contact lenses, except as specified as covered in the Certificate. Outpatient Occupational Therapy. Outpatient occupational therapy, except by a home health agency, hospice, or home infusion therapy provider, as specified as covered in the Certificate. Outpatient Speech Therapy. Outpatient speech therapy, except as specified as covered in the Certificate. Cosmetic Surgery. Cosmetic surgery or other services performed solely for beautification or to alter or reshape normal (including aged) structures or tissues of the body to improve appearance. This exclusion does not apply to reconstructive surgery (that is, surgery performed to correct deformities caused by congenital or developmental abnormalities, illness, or injury for the purpose of improving bodily function or symptomatology or to create a normal appearance), including surgery performed to restore symmetry following mastectomy. Cosmetic surgery does not become reconstructive surgery because of psychological or psychiatric reasons. Commercial Weight Loss Programs. Weight loss programs, whether or not they are pursued under medical or physician supervision, unless specifically listed as covered in this plan. This exclusion includes, but is not limited to, commercial weight loss programs (Weight Watchers, Jenny Craig, LA Weight Loss) and fasting programs. This exclusion does not apply to medically necessary treatments for morbid obesity or dietary evaluations and counseling, and behavioral modification programs for the treatment of anorexia nervosa or bulimia nervosa. Surgical treatment for morbid obesity is covered as described in the Certificate. Sterilization Reversal. Infertility Treatment. Any services or supplies furnished in connection with the diagnosis and treatment of infertility, including, but not limited to diagnostic tests, medication, surgery, artificial insemination, in vitro fertilization, sterilization reversal and gamete intrafallopian transfer. Surrogate Mother Services. For any services or supplies provided to a person not covered under the plan in connection with a surrogate pregnancy (including, but not limited to, the bearing of a child by another woman for an infertile couple). Orthopedic shoes and shoe inserts. This exclusion does not apply to orthopedic footwear used as an integral part of a brace, shoe inserts that are custom molded to the patient, or therapeutic shoes and inserts designed to treat foot complications due to diabetes, as specifically stated in the EOC/Certificate. Air Conditioners. Air purifiers, air conditioners or humidifiers. Custodial Care or Rest Cures. Inpatient room and board charges in connection with a hospital stay primarily for environmental change or physical therapy. Services provided by a rest home, a home for the aged, a nursing home or any similar facility. Services provided by a skilled nursing facility or custodial care or rest cures, except as specified as covered in the Certificate. Clinical Trials - Services and supplies in connection with clinical trials, except as specified as covered in the Certificate or EOC. Health Club Memberships. Health club memberships, exercise equipment, charges from a physical fitness instructor or personal trainer, or any other charges for activities, equipment or facilities used for developing or maintaining physical fitness, even if ordered by a physician. This exclusion also applies to health spas. Personal Items. Any supplies for comfort, hygiene or beautification. Education or Counseling. Educational services or nutritional counseling, except as specified as covered in the Certificate. This exclusion does not apply to counseling for the treatment of anorexia nervosa or bulimia nervosa. Food or Dietary Supplements. Nutritional and/or dietary supplements, except as provided in this plan or as required by law. This exclusion includes, but is not limited to, those nutritional formulas and dietary supplements that can be purchased over the counter, which by law do not requirement either a written prescription or dispensing by a licensed pharmacist. Telephone and Facsimile Machine Consultations. Consultations provided by telephone or facsimile machine. Routine Exams or Tests. Routine physical exams or tests which do not directly treat an actual illness, injury or condition, including those required by employment or government authority, except as specified as covered in the Certificate. Acupuncture. Acupuncture treatment, except as specified as covered in the Certificate. Acupressure or massage to control pain, treat illness or promote health by applying pressure to one or more specific areas of the body based on dermatomes or acupuncture points. Eye Surgery for Refractive Defects. Any eye surgery solely or primarily for the purpose of correcting refractive defects of the eye such as nearsightedness (myopia) and/or astigmatism. Contact lenses and Eye glasses required as a result of this surgery. Physical Therapy or Physical Medicine. Services of a physician for physical therapy or physical medicine, except when provided during a covered inpatient confinement or as specified as covered in the Certificate. Outpatient Prescription Drugs and Medications. Outpatient prescription drugs or medications and insulin, except as specified as covered in the Certificate. Any non- prescription, over-the-counter patent or proprietary drug or medicine. Cosmetics, health or beauty aids. Specialty Pharmacy Drugs. Specialty pharmacy drugs that must be obtained from the specialty pharmacy program, but, which are obtained from a retail pharmacy, are not covered by this plan. Member will have to pay the full cost of the specialty pharmacy drugs obtained from a retail pharmacy that should have been obtained from the specialty pharmacy program. Contraceptive Devices. Contraceptive devices prescribed for birth control except as specified as covered in the Certificate. Diabetic Supplies. Prescription and non-prescription diabetic supplies except as specified as covered in the Certificate. Private Duty Nursing. Private duty nursing services. Lifestyle Programs. Programs to alter one's lifestyle which may include but are not limited to diet, exercise, imagery or nutrition. This exclusion will not apply to cardiac rehabilitation programs approved by us.

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Varicose Vein Treatment. Treatment of varicose veins or telangiectatic dermal veins (spider veins) by any method (including sclerotherapy or other surgeries) when services are rendered for cosmetic purposes. Wigs. Third Party Liability: Anthem Blue Cross Life and Health Insurance Company is entitled to reimbursement of benefits paid if the member recovers damages from a legally liable third party. Coordination of Benefits. The benefits of this plan may be reduced if the member has any other group health or dental coverage so that the services received from all group coverages do not exceed 100% of the covered expense.

Prescription Drug Exclusions & Limitations

Immunizing agents, biological sera, blood, blood products or blood plasma. Hypodermic syringes &/or needles, except when dispensed for use with insulin & other self-injectable drugs or medications. Drugs & medications used to induce spontaneous & non-spontaneous abortions. Drugs & medications dispensed or administered in an outpatient setting, including outpatient hospital facilities and physicians' offices. Professional charges in connection with administering, injecting or dispensing drugs. Drugs & medications that may be obtained without a physician's written prescription, except insulin or niacin for cholesterol lowering and certain over-the-counter drugs approved by the Pharmacy and Therapeutics Process to be included in the prescription drug formulary. Drugs & medications dispensed by or while confined in a hospital, skilled nursing facility, rest home, sanatorium, convalescent hospital or similar facility. Durable medical equipment, devices, appliances & supplies, even if prescribed by a physician, except contraceptive diaphragms, as specified as covered in the EOC/Certificate. Services or supplies for which the member is not charged. Oxygen. Cosmetics & health or beauty aids. However, health aids that are medically necessary and meet the requirements as specified as covered in the EOC/Certificate. Drugs labeled "Caution, Limited by Federal Law to Investigational Use," or experimental drugs. Drugs or medications prescribed for experimental indications. Any expense for a drug or medication incurred in excess of the prescription drug maximum allowed amount. Drugs which have not been approved for general use by the Food and Drug Administration. This does not apply to drugs that are medically necessary for a covered condition. Drugs to eliminate or reduce dependency on, or addiction to, tobacco and tobacco products. This does not apply to medically necessary drugs that the member can only get with a prescription under federal law. Drugs used primarily for cosmetic purposes (e.g., Retin-A for wrinkles). However, this will not apply to the use of this type of drug for medically necessary treatment of a medical condition other than one that is cosmetic. Anorexiants and drugs used for weight loss, except when used to treat morbid obesity (e.g., diet pills & appetite suppressants). Drugs obtained outside the U.S, unless they are furnished in connection with urgent care or an emergency. Allergy desensitization products or allergy serum. Infusion drugs, except drugs that are self-administered subcutaneously. Herbal supplements, nutritional and dietary supplements. Formulas and special foods for the treatment of phenylketonuria (PKU). Prescription drugs with a non-prescription (over-the-counter) chemical and dose equivalent except insulin. This does not apply if an over-the-counter equivalent was tried and was ineffective. Compound medications unless: a. There is at least one component in it that is a prescription drug; and b. It is obtained from a participating pharmacy. Member will have to pay the full cost of the compound medications if member obtains drug at a non-participating pharmacy.

Specialty pharmacy drugs that must be obtained from the specialty pharmacy program, but which are obtained from a retail pharmacy are not covered by this plan. Member will have to pay the full cost of the specialty pharmacy drugs obtained from a retail pharmacy that member should have obtained from the specialty pharmacy program.

Off label prescription drugs

Third Party Liability

Anthem Blue Cross is entitled to reimbursement of benefits paid if the member recovers damages from a legally liable third party.

Anthem Blue Cross is the trade name of Blue Cross of California. Anthem Blue Cross and Anthem Blue Cross Life and Health Insurance Company are independent licensees of the Blue Cross Association. ® ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross name and symbol are registered marks of the Blue Cross Association.

Questions: (855) 333-5730 or visit us at www.anthem.com/ca CA/L/F/PPO/LP2011/LR2053/01-16

Get the best in eye care and eyewear with IBEW LOCAL 18HEALTH & WELFARE TRUST and VSP® Vision Care.

Using your VSP benefit is easy.Create an account at vsp.com. Once your plan is effective,review your benefit information.

Find an eye care provider who’s right for you. The decisionis yours to make—choose a VSP doctor, a participating retailchain, or any out-of-network provider. To find a VSP provider,visit vsp.com or call 800.877.7195.

At your appointment, tell them you have VSP. There’s no IDcard necessary. If you’d like a card as a reference, you canprint one on vsp.com.

That’s it! We’ll handle the rest—there are no claim forms tocomplete when you see a VSP provider.

Best Eye CareYou’ll get the highest level of care, including a WellVisionExam®– the most comprehensive exam designed to detect eyeand health conditions. Plus, when you see a VSP provider, you'llget the most out of your benefit, have lower out-of-pocket costs,and your satisfaction is guaranteed.

Choice in EyewearFrom classic styles to the latest designer frames, you’ll findhundreds of options. Choose from featured frame brandslike bebe®, Calvin Klein, Cole Haan, Flexon®, Lacoste, Nike, NineWest, and more1. Visit vsp.com to find a Premier Programlocation that carries these brands. Prefer to shop online? Checkout all of the brands at Eyeconic.com, VSP's online eyewearstore.

Plan InformationVSP Coverage Effective Date: 07/01/2017VSP Provider Network: VSP Signature

IBEW LOCAL 18 HEALTH & WELFARE TRUST and VSP provideyou with an affordable eyecare plan.

CopayDescriptionBenefitYour Coverage with a VSP Provider

$0WellVisionExam

Focuses on your eyes and overallwellnessEvery 12 months

Prescription Glasses

$0Frame

$130 allowance for a wide selectionof frames$150 allowance for featured framebrands20% savings on the amount over yourallowance$70 Costco® frame allowanceEvery 12 months

$0LensesSingle vision, lined bifocal, and linedtrifocal lensesEvery 12 months

$0

LensEnhancements

Progressive lenses$0Anti-reflective coating$0Tints/Photochromic adaptive lenses$0Polycarbonate lenses$0Scratch-resistant coating$0UV protection

Average savings of 35-40% on otherlens enhancementsEvery 12 months

Up to $60Contacts(instead ofglasses)

$120 allowance for contacts; copaydoes not applyContact lens exam (fitting andevaluation)Every 12 months

$20DiabeticEyecare PlusProgram

Services related to diabetic eyedisease, glaucoma and age-relatedmacular degeneration (AMD). Retinalscreening for eligible members withdiabetes. Limitations and coordinationwith medical coverage may apply. Askyour VSP doctor for details.As needed

Glasses and Sunglasses

Extra Savings

Extra $20 to spend on featured frame brands. Go tovsp.com/specialoffers for details.30% savings on additional glasses and sunglasses,including lens enhancements, from the same VSP provideron the same day as your WellVision Exam. Or get 20%from any VSP provider within 12 months of your lastWellVision Exam.

Retinal ScreeningNo more than a $39 copay on routine retinal screeningas an enhancement to a WellVision Exam

Laser Vision CorrectionAverage 15% off the regular price or 5% off thepromotional price; discounts only available fromcontracted facilitiesAfter surgery, use your frame allowance (if eligible) forsunglasses from any VSP doctor

Your Coverage with Out-of-Network ProvidersVisit vsp.com for details, if you plan to see a provider other than a VSP network provider.

Lined Trifocal Lenses ............ up to $100Exam .................................................. up to $50Progressive Lenses .................. up to $85Frame ................................................ up to $70Contacts ........................................ up to $120Single Vision Lenses ............... up to $50Tints ....................................................... up to $5Lined Bifocal Lenses ............... up to $75

Coverage with a participating retail chain may be different. Once your benefit is effective, visit vsp.comfor details. Coverage information is subject to change. In the event of a conflict between this informationand your organization’s contract with VSP, the terms of the contract will prevail. Based on applicablelaws, benefits may vary by location.

Visit vsp.com or call 800.877.7195for more details on your visioncoverage and exclusive savingsand promotions for VSP members.

1Brands/Promotion subject to change.

©2014 Vision Service Plan. All rights reserved. VSP, VSP Vision care for life, and WellVision Examare registered trademarks of Vision Service Plan. Flexon is a registered trademark of MarchonEyewear, Inc. All other company names and brands are trademarks or registered trademarksof their respective owners.

Your VisionBenefits Summary

25

SET YOUR SIGHTS ON SAVINGS.With Exclusive Member Extras, savings never looked so good. We put our members first by providing exclusive special offers from leading industry brands, totaling more than $2,500 in savings.

• Extra $20 to spend on featured frame brands1,3

• Instant savings and satisfaction guarantees on popular lenses2,3

• Savings on LASIK at NVision and TLC eye centers

• Mail-in rebate savings and free trials on popular contact lens brands

• Savings on digital hearing aids and replacement batteries for you and your extended family through TruHearing4

• Savings on EyePromise vitamins for improved visual performance, night driving, and dry eye

• Financing for vision care expenses with the CareCredit credit card

• Discounts and savings for you and your family on medical care, prescription drugs, lab work, and more with VSP® Simple Values5

Visit vsp.com to find Premier Program locations that offer a wide selection of featured frame brands, Bonus Offers, and so much more.

For more great offers, scanor visit vsp.com/specialoffers.

JOB#4648-16-VCCM 5/16

1. Brands/promotions subject to change. 2. Savings based on doctor’s retail price and vary by plan and purchase selection; average savings determined after benefits are applied. 3. Available only to VSP members with applicable plan benefits. 4. Offer not available in WA. 5. Some members may not be eligible for this program; visit vsp.com/simplevalues for terms and conditions.

©2016 Vision Service Plan. All rights reserved.VSP and Eyeconic are registered trademarks of Vision Service Plan. UNITY and sunsync are registered trademarks of Plexus Optix, Inc. Transitions and the swirl are registered trademarks of Transitions Optical, Inc. All other brands or marks are the property of their respective owners.

26

Body Scan International is proud to enter their 14th year of providing service to the IBEW Local 18-sponsored health plans. Since 2004, more than 4,000 Local 18 members and spouses/domestic partners have participated in the BSI Preventive Medicine Body Scan program, with a member satisfaction rating of over 99%.

Body Scan Benefit Enhancement for 2017-18: Cervical Spine Coverage

We are pleased to announce the addition of cervical spine coverage to the Body Scan Program.This portion of the examination integrates seamlessly with the Body Scan, and will allow BSI physicians to evaluate your cervical spine (neck) vertebrae, carotid arteries, and maxillary sinuses for disease while enhancing visualization of the thyroid and parathyroid glands.

The BSI Advantage:Scan appointments are available onsite at the Local 18 Headquarters, or at multiple other locations from Bishop to San Diego

Your appointment includes a comprehensive consultation/scan review with a specially trained board-certified BSI radiologist (physician.) This consultation can take place onboard the BSI Mobile Unit, at the BSI office in Newport Beach, or through the internet into a location of your choosing via computer, tablet or smartphone

The initial study provides you with an anatomic baseline and comprehensive educational experience to help you truly understand the current status of your health

Follow-up examinations include a detailed comparion to your previous examinations, which allows for detailed health tracking and lifestyle assessment

BSI is the most experienced Body Scan company in the world (over 150,000 examinations performed since 1997)

The BSI Preventive Medicine Body Scan ProgramFree to IBEW Local 18-Sponsored Anthem Blue Cross Medical Plan Subscribers and Spouses/Domestic Partners

(a $1495 value)

BODY SCAN INTERNATIONAL 8 7 7 - B S I - 5 5 7 7 www.bodyscan internat ional .comBODY SCAN INTERNATIONAL 8 7 7 - B S I - 5 5 7 7 www.bodyscan internat ional .comBODY SCAN INTERNATIONAL 8 7 7 - B S I - 5 5 7 7 www.bodyscan internat ional .comBODY SCAN INTERNATIONAL 8 7 7 - B S I - 5 5 7 7 www.bodyscan internat ional .comBODY SCAN INTERNATIONAL 8 7 7 - B S I - 5 5 7 7 www.bodyscan internat ional .comBODY SCAN INTERNATIONAL 8 7 7 - B S I - 5 5 7 7 www.bodyscan internat ional .com27

Anthem Blue Cross is the trade name of Blue Cross of California. Independent licensee of the Blue Cross Association. ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross name and symbol are registered marks of the Blue Cross Association. Form no. 04/14

Dear IBEW Local 18 Member, We are about to reward you for getting healthy! Get ready to join an exciting new generation of healthier and happier IBEW Local 18 members! We are happy to bring you a-new program called Health Rewards. All IBEW Local 18 members, their covered spouses, domestic partners and adult children who are currently enrolled in Anthem Blue Cross are eligible for the new Health Rewards program. We think it’s going to be a great opportunity for you to take your health to a whole new level. IBEW Local 18 Health & Welfare Trust wants you to be the best that you can possibly be; and what better way to help you get there then by adding some extra motivation! That’s why we ’re really excited about offering the Health Rewards program. All you will need to do to get rewarded is to take part in certain health and wellness programs. When you enroll in The Future Moms Program or Condition Care Program, you will receive gift cards for your participation. Once you enroll in a program you will get the following:

1) The Future Moms Program : Anthem Blue Cross will send a $25 Babies “R” Us gift card for enrolling in the program, and a $100 Babies “R” Us gift card, for completing the progr am.

2) The Condition Care Program : Anthem Blue Cross will send a $25 gift card for enrolling in the

program, and a $100 gift card for completing the program for those identified . Here’s how your Health Rewards program will work: Future Moms – if you or a covered family member is pregnant you can call 866-664-5404 to enroll. You

will receive coaching from a registered nurse to provide care and support for a healthy pregnancy and healthy child.

Condition Care Program – if you or a covered family member is suffering from diabetes or CAD, you can

call 800-621-2232 to enroll. You will receive counseling and coaching on healthy lifestyles to meet your goals.

Sincerely, Anthem Blue Cross

28

You’re always on the move, juggling responsibilities. You don’t wait for information to fi nd you. You get what you need, when you need it — and appreciate regular reminders to keep you on track. That’s where our Mobile Health app for smartphones and tablets comes in.

Whether you’re looking for a nearby urgent care clinic, pulling up your virtual ID card or connecting with a doctor on your phone, we’re with you every step of the way. And when you need guidance, we can be a few steps ahead, too.

Mobile Health is more than just another health tool. It’s technology that brings together our health plan data with programs, resources and personalized content specifi c to your health.

One app, many applications

With Mobile Health, you can:

See a doctor face-to-face in minutes online.

Record activities to qualify for health incentives.

Track your biometric levels, such as body mass index (BMI), blood pressure and cholesterol levels.

Get reminders about scheduling checkups and important tests.

Receive suggestions and tips for managing health conditions like diabetes or asthma.

Check on the status of your claims.

Keep track of your deductible and out-of-pocket charges.

Estimate your costs for a procedure or treatment.

Find a doctor or facility in your plan.

Ready to get started?

It’s as easy as 1, 2, … there’s not even a third step; it’s that simple.

From your smartphone or other mobile device:

1. Go to the Apple StoreSM or Google PlayTM.

2. Search for Mobile Health Consumer.

From your computer:

1. Go to mobilehealthconsumer.com.

2. Choose the User button in the top-right corner.

3. Select Register Now.

Download and register for Mobile Health today to make managing your health care — and your life — a whole lot simpler.

Mobile Health moves at your speedGet the answers you need in real time, on the go

Anthem Blue Cross is the trade name of Blue Cross of California. Anthem Blue Cross and Anthem Blue Cross Life and Health Insurance Company are independent licensees of the Blue Cross Association. ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross name and symbol are registered marks of the Blue Cross Association. 60021CAMENABC VPOD 5/16

29

Have you ever been at work and didn’t feel well? Maybe you had a fever or a sore throat but you didn’t have time to leave and see your doctor or go to urgent care. Now, with LiveHealth Online, you can see a board-certified doctor in minutes.

Just use your smartphone, tablet or computer with a webcam. It’s so convenient, almost 90% of people who’ve used it feel they saved two hours or more and would use it again in the future.1 To start using LiveHealth Online, all you need to do is sign up at livehealthonline.com or download the app.

Sign up for free today and get:

1. 24/7 access to doctors. They can assess your condition, provide treatment options and even send a prescription to the pharmacy of your choice, if needed.2 It’s a great way to get care when your doctor isn’t available.

2. Medical care when you need it. For things like the flu, a cold, sinus infection, pink eye, rashes, fever and more.

3. Convenience. Since there are no appointments or long waits. In fact, most people are connected to a doctor in about 10 minutes or less.

Your $0 physician visit copayment will apply to all LiveHealth Online services

LiveHealth Online Psychology An easy, convenient way to see a therapist or psychologist in just a few days

If you’re feeling stressed, worried, or having a tough time, you can talk to a licensed psychologist or therapist through video using LiveHealth Online Psychology. It’s easy to use, private and, in most cases, you can see a therapist within four days or less.3 All you have to do is sign up at livehealthonline.com or download the app to get started. The cost is what you’d pay for an office therapy visit.

Make your first appointment — when it’s easy for you o Use the app or go to livehealthonline.com and log

in. Select LiveHealth Online Psychology and choose the therapist you’d like to see.

o Or, call LiveHealth Online at 1-844-784-8409 from 7 a.m. to 11 p.m.

o You’ll get an email confirming your appointment.

57980CAMENABC VPOD 12/15

LiveHealth Online Quick and easy access to a doctor 24/7

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LiveHealth Online: what you need to know

What kind of doctors can you see on LiveHealth Online?

Doctors on LiveHealth Online are: o Board certified with an average of 15

years of practicing medicine o Mainly primary care physicians o Specially trained for online visits

When can you use LiveHealth Online?

LiveHealth Online is a great option for care when your own doctor isn’t available and more convenient than a trip to the urgent care. With LiveHealth Online, you can receive medical care for things like:

o Cold and flu symptoms, such as a cough, fever and headaches

o Allergies o Sinus infections and more

How do I pay for an online visit using LiveHealth Online? LiveHealth Online requires credit card information and accepts Visa, MasterCard and Discover cards as payment for an online doctor visit, however, you will not be charged as long as your IBEW Local 18 Anthem health plan information is provided at the time you register with LiveHealth Online.

LiveHealth Online Psychology

What conditions can be treated when you have a visit with a psychologist or therapist?

You can get help for these types of conditions: o Stress o Anxiety o Depression o Family or relationship issues o Grief o Panic attacks o Stress from coping with a sickness

LiveHealth Online is the trade name of Health Management Corporation, a separate company providing telehealth services on behalf of Anthem Blue Cross. Online counseling is not appropriate for all kinds of problems. If you are in crisis or have suicidal thoughts, it’s important that you seek help immediately. Please call 1-800-784-2433 (National Suicide Prevention Lifeline) or 911 and ask for help. If your issue is an emergency, call 911 or go to your nearest emergency room. LiveHealth Online does not offer emergency services. 1 LiveHealth Online user feedback survey, May 2015. 2 Prescription availability is defined by physician judgment and state regulations. LiveHealth Online is available in most states and is expected to grow more in the near future.

Please visit the map at livehealthonline.com for more details. 3 Appointments subject to availability of a therapist. Anthem Blue Cross is the trade name of Blue Cross of California. Anthem Blue Cross and Anthem Blue Cross Life and Health Insurance Company are independent licensees of the Blue Cross Association. ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross name and symbol are registered marks of the Blue Cross Association.

How much does a therapist visit cost?

For IBEW Local 18 members, your office visit copayment for a therapist is $0 when your Anthem health plan information is provided at the time you register with LiveHealth Online.

How do I decide which therapist to see?

After you log in at livehealthonline.com or with the app, select LiveHealth Online Psychology. Next, you can read profiles of therapists and psychologists. Once you select the one you would like to see, schedule a visit online or by phone. At the end of the first visit, you can set up future visits with the same therapist if both of you feel it’s needed. You always have the choice of the therapist you want to see.

What else do I need to know about LiveHealth Online Psychology?

o You must be at least 18 years old to see a therapist online and have your own LiveHealth Online account.

o Psychologists and therapists using LiveHealth Online do not prescribe medications.

o Visits usually last about 45 minutes.

Get started today

It’s quick and easy to sign up for LiveHealth Online. Just go to livehealthonline.com or download the mobile app at Google PlayTM or the App StoreSM.

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IBEW Local 18 Members: For questions regarding Local 18's Anthem Blue Cross Medical benefits or for general questions (i.e. enrollment, claims, eligibility or ID cards), please contact:

Local 18 Benefit Service Center

9500 Topanga Canyon Blvd.,

Chatsworth, CA 91311

[email protected]

800-842-6635 (toll-free)

818-678-0040 (main)

818-477-1476 (fax)

Monday - Friday, 8:30am - 5:00pm (closed 12:00pm -12:45pm)

For more information, please visit: www.mybenefitchoices.com/local18

Anthem Blue Cross is the trade name of Blue Cross of California. Independent Licensee of the Blue Cross Association. ®A NTHEM is a registered trademark . ® The Blue Cross name and symbol are registered marks of the Blue Cross Association. anthem.com/ca SC10620 9/08 32

1. Log onto www.anthem.com/ca/ibewlocal18

3. Click on the link that

best describes the type

of provider you need

2. Click on the "Find

a Doctor" link

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City and State or Zip Code

4. Select the type of

provider AND

Enter your Location

THEN

Click “Search”

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5. Once you have

found a provider

Click on the

provider name to

view more

information

You will see a list of available providers based on the selections you chose.

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The HMO medical plan requires you to be assigned to a doctor or medical group. Using

the Anthem BlueCross website to search for providers allows you to identify the 3- or 6-

digit PCP ID Number that you will need for your Online Enrollment.

In this example the provider is

associated with various medical

groups. You can only select one

medical group.

6. Enter PCP ID number for (Paper/Online)

in the Online Enrollment Wizard.

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As a member, you have the right to expect the privacy of your personal health information to be protected, consistent with state and federal laws and our policies. And you also have certain rights and responsibilities when receiving your health care.

To learn more about how we protect your privacy, your rights and responsibilities when receiving health care and your rights under the Women’s Health and Cancer Rights Act, go to www.anthem.com/ca/memberrights. To request a printed copy, please contact your Benef ts Administrator or Humani Resources representative.

How we help manage your care

To decide if we'll cover a treatment, procedure or hospital stay, we use a process called Utilization Management (UM). UM is a program that lets us make sure you’re getting the right care at the right time. Licensed health care professionals review information your doctor has sent us to see if the requested care is medically needed. These reviews can be done before, during or after a member’s treatment. UM also helps us decide if the services will be covered by your health plan.

We also use case managers. They're licensed health care professionals who work with you and your doctor to help you

learn about and manage your health conditions. They also help you better understand your health benef ts. i

To learn more about how we help manage your care, visit www.anthem.com/ca/memberrights. To request a printed copy, please contact your Benef ts Administrator or Humani Resources representative.

Let's talk about your privacy and rights

Life products underwritten by Anthem Blue Cross Life and Health Insurance Company. Disability products underwritten by Anthem Life Insurance Company.

Anthem Blue Cross is the trade name of Blue Cross of California. Anthem Blue Cross, Anthem Life Insurance Company and Anthem Blue Cross Life and Health Insurance Company are independent licensees of the Blue Cross Association. ® ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross name and symbol are registered marks of the Blue Cross Association.

Express Scripts, Inc. is a separate company that provides pharmacy services and pharmacy benef t management services on behalf of health plan members. i

The Healthy Lifestyles programs are administered by Healthways, Inc., an independent company.

You’ve got health goals. We’ve got your back.

Benef t Service Center i

800-842-6635

If you need more information

we can point you in the right direction.€¦ · guidance from registered nurses to help them have...

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