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IBEW Local 11-LA NECA Active Health Plan
Summary Plan Description (SPD)

Southern California IBEW-NECA Active Health Plan

Amendment # 35
To the HMO Plans Available to Participants
As Set Forth in the
Summary Plan Description
for Eligible Active Participants
and their Eligible Dependents

Dated June 1, 2004

Effective for services received on or after July 1, 2008 the office visit copayments for the Kaiser HMO Medical Plan and for the PacifiCare HMO Medical Plan are reduced from $15 per office visit to $5 per office visit. Accordingly pages 37-40 and 47-49 of the Southern California IBEW-NECA Active Health Plan Summary Plan Description dated June 1, 2004 are deleted in their entirety and replaced with the respective pages bearing the same page numbers following this page.

APPROVED AND ADOPTED at the Board of Trustees’ meeting held on June 17, 2008.

BY: Signature on File
Chairman

BY: Signature on File
Secretary

If you have any questions regarding this procedural change, please contact the Administrative Office at (323) 221-5861 or the nationwide toll free-number (800) 824-6935. Please state that you are calling about the open enrollment change so that your call can be directed promptly. Office hours are 9-5, Monday-Friday.

Kaiser HMO Medical Plan

This benefit chart is a summary only. It does not fully describe your benefit coverage. For details on your benefit coverage, please refer to Kaiser Foundation Health Plan, Inc., Evidence of Coverage. The Evidence of Coverage is the binding document between Health Plan and its members.
A Health Plan physician must determine that the services and supplies are medically necessary to prevent, diagnose, or treat your medical condition. The services and supplies must be provided, prescribed, authorized, or directed by a Health Plan physician. You must receive the services and supplies at a Health Plan facility or skilled nursing facility inside our Service area, except where specifically noted to the contrary in the Evidence of Coverage.
For details on the benefit and claims review and adjudication procedures, please refer to Kaiser Health Plan’s Evidence of Coverage or contact Kaiser Membership Services at 1(800) 464-4000.

Kaiser Summary of Benefits

Service	Copayment
Outpatient Care
Primary care visits	$5 per visit
Well-child preventive care visits (23 months or younger)	$5 per visit
Pediatric visits	$5 per visit
Specialty care visits	$5 per visit
Same-day outpatient surgery	$5 per procedure
Chiropractic visits (30 visits per year)	$5 per visit
Allergy testing	$5 per visit
Allergy injections	No Charge
Respiratory therapy visits	$5 per visit
Routine physical exams	$5 per visit
Gynecological visits	$5 per visit
Scheduled prenatal care and first postpartum visit	$5 per visit
Emergency Department visits	$5 per visit (waived if admitted directly to the hospital)
Blood, blood products, and their administration 2	$5 per visit
Hospital Inpatient Care
Room and board and critical care units	No charge
Obstetrical care and delivery, including cesarean section	No charge
Physician, surgeon, and surgical services	No charge
General and special nursing care	No charge
Anesthesia, prescribed drugs, and medical supplies	No charge
Blood, blood products, and their administration	No charge
Respiratory therapy	No charge


Ambulance Copayment
Ambulance services and supplies	No charge
Chemical Dependency Services
Inpatient detoxification	No charge
Outpatient individual therapy visits	$5 per visit
Outpatient group therapy visits	$2 per visit
Transitional residential recovery services (up to 60 days per calendar year, not to exceed 120 days in any five year period)	$100 per admission
Dialysis Care
Inpatient care	No charge
Physician office visits	$5 per visit
Dialysis treatment visits	$5 per visit
Durable Medical Equipment
Durable medical equipment	No charge
Family Planning
All services related to family planning	$5 per visit
Health Education
Education for specific conditions: Individual visits Group visits	$5 per visit No charge
Education not addressed to a specific condition	Charges vary
Health education publications	No charge
Hearing
Hearing tests	$5 per visit
Home Health Care
Covered home health care, including physical, occupational, and speech therapy	No charge
Hospice Care
Covered hospice care	No charge
Imaging, Lab Tests, and Special Procedures
Imaging, lab tests, special procedures, and ultraviolet light treatment visits	No charge
Infertility Services
Office visits and outpatient surgery	$5 per visit
Outpatient surgery	$5 per procedure
Outpatient lab tests, imaging, and special procedures	No charge
Hospital inpatient care	No charge
Inpatient lab tests, imaging, and special procedures	No charge
Mental Health Services
Inpatient psychiatric care and hospital alternative services	No charge
Outpatient visit	$5 per visit
Individual visit	$5 per visit
Group visit	$2 per visit
Ostomy and Urological Supplies
Ostomy and urological supplies	No charge


Out-of-Plan Emergency Care
Covered services	Any Copayment that would apply had you received the services from Plan Providers
Physical, Occupational, and Speech Therapy and Multidisciplinary Rehabilitation
Physical, occupational, and speech therapy: Inpatient services Outpatient visits	No charge $5 per visit
Multidisciplinary rehabilitation: Inpatient Outpatient	No charge $5 per day
Prosthetic and Orthotic Devices
Covered devices	No charge
Reconstructive Surgery
Inpatient care	No charge
Office visits	$5 per visit
Same-day outpatient surgery	$5 per procedure
Skilled Nursing Facility Care
Care in a Skilled Nursing Facility (up to 100 days per benefit period)	No charge
Transplants
Inpatient care	No charge
Physician office visits	$5 per visit
Vision
Eye refraction exams to determine the need for vision correction and to provide a prescription for eyeglasses	$5 per visit
Regular plastic eyeglass lenses every 24 months	$100 allowance*
An eyeglass frame every 24 months	$100 allowance*
Medically necessary contact lenses	No charge
*An allowance is the total expense of an item that is covered. If the cost of the item you select exceeds the allowance, you will pay the difference.
Annual Copayment Limit
There are limits to the total amount of Copayments you must pay in a calendar year for certain services covered under this EOC. Those limits are: One Member Subscriber and all his or her Dependents	$1,500 $3,000
Copayments for only the following covered services apply toward these limits: Ambulance services Home health care Hospital care Imaging, lab tests, and special procedures Out-of-Plan emergency care Physical, occupational, and speech therapy and multidisciplinary rehabilitation Professional services

Chiropractic

Chiropractic benefits are offered through American Specialty Health Plans of California. The co-payment for each visit is $5 for up to 30 visits per year. Please call the Member Services department for a Chiropractic Provider Directory to find a Chiropractor near you at (800) 464-4000. If you have questions about your chiropractic benefits, call ASH Plans Member Services at (800) 678-9133.

Basic Information
In most instances, Kaiser owns its own hospitals and medical centers. You may enroll in Kaiser if you live or work within any of the Kaiser zip code service areas.

Once enrolled, you can use any Kaiser facility. However, it is suggested that you choose a Kaiser facility closest to your home, or most convenient for you to receive most of your care.

It is important to note that in order to receive covered benefits, you must use a Kaiser Plan facility to provide care for you and your dependent(s). Referrals to certain specialists may require a referral by your primary care provider.

Kaiser Plan benefits apply when your care is provided, prescribed, or directed by a Kaiser physician except where specifically stated in emergency situations as described in the Kaiser descriptive literature.

Complete benefits and information about the Kaiser Plan are described in their descriptive literature or call the Customer Service Call Center at 1(800) 464-4000.

Definition of Dependents
Kaiser maintains their own definition of dependents. Any questions pertaining to dependent status and entitlement to Plan participation should be directed to the Administrative Office or Kaiser.

For example, in certain instances court-appointed guardians (before the person's 18th birthday) can be considered as dependents.

Kaiser does not automatically enroll newborn children. To add newborn children, members must complete a change form requesting to add their newborn child. The effective date of coverage will be the first of the month following birth.

In Case of an Emergency
Emergency care is provided at nearly all Plan Hospitals 24 hours a day, 7 days a week. If you are not sure whether your situation is an emergency, call the Emergency Department at your local Plan Hospital and we will advise you on the appropriate action to take. Refer to The Guidebook to Kaiser Permanente Services or your local telephone directory for telephone numbers. For life-threatening conditions, call 911 immediately.

For urgent care, call one of Kaiser’s telephone advice nurses who are registered nurses (RNs) specially trained to help assess medical problems and provide medical advice. They can help solve a problem over the phone and instruct you on self-care at home if appropriate. If the problem is more severe and you need an appointment, they will help you get one.

Payment will be made for covered emergency care services received from out-of-plan providers even if you were injured through the fault of someone else. If you collect any money from the other person or from his or her insurance company, you will be required to reimburse Kaiser (or its designee) for those payments Kaiser made for medical care provided to you for that injury or illness, up to the amount you received from the settlement or judgment. Kaiser shall have a lien on the settlement or judgment for the purpose of that reimbursement.

At Kaiser's request, you shall execute lien forms directing your attorney or the other person to make payments directly to Kaiser from the proceeds of the settlement or judgment. If Kaiser institutes legal action to enforce its lien, the party that substantially prevails shall be reimbursed for the reasonable costs of collection, including attorney fees, by the other party(s).

This provision applies even if the total settlement or judgment you receive is less than your action damages. It is your responsibility to notify Kaiser of any actual or potential claim or legal action you anticipate bringing or have brought against the other person within 30 days from the date of filing a claim or legal action against the other person.

PacifiCare HMO Medical Plan

This benefit chart is a summary only. It does not fully describe your benefit coverage. For details on your benefit coverage, please refer to PacifiCare Health Systems, Inc., Evidence of Coverage. The Evidence of Coverage is the binding document between Health Plan and its members.
PacifiCare participants are covered for mental health and substance abuse benefits under a separate “carve out” plan. Refer to the separate Summary Plan Description listed in the Table of Contents under the heading “Integrated Member Assistance Program (MAP) and Managed Mental Health & Chemical Dependency Benefits Program.”
For details on the benefit and claims review and adjudication procedures, please refer to PacifiCare Health Plan’s Evidence of Coverage or contact PacifiCare Customer Service Department at 1(800) 624-8822.

PacifiCare Summary of Benefits

Benefits and Coverage		Your Cost
General Features
Calendar Year Deductible		$0
Maximum Benefits		Unlimited
Annual Copayment Maximum 3 individual maximum per family		$1000/Individual
Office Visits		$5 Copayment
Hospitalization		Paid in Full
Emergency Services		$50 Copayment waived if admitted as an inpatient
Urgently Needed Services (Medically necessary services required outside your service area. Please consult your brochure for additional details.)		$50 Copayment waived if admitted as an inpatient
Pre-Existing Conditions		All conditions covered, provided they are covered benefits.
Benefits Available While Hospitalized as an Inpatient
Bone Marrow Transplants (Donor searches limited to $15,000 per procedure)		Paid in Full
Cancer Clinical Trials 1		Paid at contracting rate Balance (if any) is the responsibility of the member
Hospice Care (Prognosis of life expectancy of one year or less)		Paid in Full
Hospital Benefits (Autologous (self-donated) blood up to $120.00 per unit)		Paid in Full
Mastectomy/Breast Reconstruction (After mastectomy and complications from mastectomy)		Paid in Full
Maternity Care		Paid in Full
Newborn Care		Paid in Full
Physician Care		Paid in Full
Reconstructive Surgery		Paid in Full
Rehabilitation Care (Including physical, occupational and speech therapy)		Paid in Full
Skilled Nursing Care (Up to one hundred (100) consecutive calendar days from the first treatment per disability)		Paid in Full
Voluntary Interruption of Pregnancy 1 st Trimester 2 nd Trimester (12-20 weeks) After 20 weeks		$75 Copayment $150 Copayment Not covered unless mother’s life is in jeopardy or fetus is not viable
Benefits Available on an Outpatient Basis
Alcohol, Drug, or Other Substance Abuse or Addiction	(see Integrated MAP and MH&CD Benefits Program SPD)
Allergy Testing/Treatment (Serum is covered)	$5 Copayment
Ambulance	Paid in Full
Cancer Clinical Trials 1	Paid at contracting rate Balance (if any) is the responsibility of the Member
Cochlear Implants (Additional Copayment for outpatient surgery or inpatient hospital benefits may apply)	Paid in Full
Durable Medical Equipment, Corrective Appliances and Prosthetics	Paid in Full
Eligible Materials and Supplies	Paid in Full
Family Planning/Voluntary Interruption of Pregnancy Vasectomy Tubal ligation 2 Insertion/removal of intra-uterine device (IUD) Intra-Uterine Device (IUD) Removal of Norplant Depo-Provera injection Depo-Provera medication (Limited to one Depo-Provera injection) (Limited to one Depo-Provera injection every 90 days) Voluntary interruption of pregnancy 1 st trimester 2 nd trimester (12-20 weeks) After 20 weeks	$50 Copayment $100 Copayment $5 Copayment 50% of cost Copayment 3 $5 Copayment $5 Copayment $35 Copayment $75 Copayment $150 Copayment Not Covered unless mother’s life is in jeopardy
Health Education Services	Paid in Full
Hearing Screening	$5 Copayment
Hemodialysis	$5 Copayment per treatment
Home Health Care Visits (up to 100 per calendar year)	Paid in Full
Hospice Care (Prognosis of life expectancy of one year or less)	Paid in Full
Immunizations (For children under two years of age, refer to Well-Baby Care)	$5 Copayment
Infertility Services	50% of cost Copayment 3
Laboratory and Radiology	Paid in Full
Maternity Care, Tests and Procedures	Paid in Full
Mental Health Services (see Integrated MAP and MH&CD Benefits Program SPD)	$10 Copayment per authorized session
Oral Surgery Services	Paid in Full
Outpatient Medical Rehabilitation Therapy at a Participating Free-Standing or Outpatient Facility	$5 Copayment
Outpatient Surgery at a Participating Free-Standing or Outpatient Facility	Paid in Full
Periodic Health Evaluations Physician, laboratory, radiology and related services as recommended by the American Academy of Pediatrics (AAP) and U.S. Preventive Services Task Force and authorized through your Primary Care Physician in your Participating Medical Group to determine your health status. For children under two years of age, refer to Well-Baby Care.	$5 Copayment
Physician Care (For children under two years of age, refer to Well-Baby Care	$5 Copayment
Vision Refractions	$5 Copayment
Vision Screening	$5 Copayment
Well-Baby Care Preventive health service, including immunizations recommended by the American Academy of Pediatrics (AAP) and U.S. Preventive Services Task Force and authorized through your Primary Care Physician in your Participating Medical Group for children under two years of age.	Paid in Full
Well-Woman Care Includes Pap smear (by your Primary Care Physician or an OB-GYN in your Participating Medical Group) and referral by the Participating Medical Group for screening mammography as recommended by the U.S. Preventive Services Task Force.	$5 Copayment

Service requires preauthorization from PacifiCare.
This Copayment applies regardless of whether this service is performed as an inpatient or on an outpatient basis. If this service is performed on an inpatient basis, you will also be required to pay the applicable inpatient Copayment for your benefit plan, if any.
Percentage Copayment amounts are based upon PacifiCare’s contracted rate.

Except in the case of a Medically Necessary Emergency or an Urgently Needed Service (outside your Service Area), each of the above-noted benefits are covered when authorized by your Primary Care Physician in your Participating Medical Group. Where the recommended service involves hospital admission or referrals, your Physician’s recommendation may receive a second opinion review by a utilization review committee. The committee is designed to promote the efficient use of resources while maintaining quality care for a Member.

NOTE: This is not a contract – This Schedule of Benefits and its enclosures constitute only a summary of the health plan.

Basic Information About the Plan

Provider Network
PacifiCare maintains comprehensive contracted provider networks in California. As a PacifiCare member, you and each member of your family can select separate Primary Care Physicians (PCPs) and can change them monthly.

Selection of Participating Medical Group
Each member will receive a directory of participating medical groups. Each member must designate a provider located within a 30-mile radius of the member's primary residence or primary workplace on the enrollment form when applying for enrollment in this health plan.

For up-to-date information, you can access the PacifiCare provider network on-line at www.pacificare.com.