THE PIPE TRADES PPO PLUS SELF-FUNDED MEDICAL PROGRAM

Preferred Providers

Under this plan you are free to use any hospital or doctor. However, the Trustees have negotiated lower charges with certain hospitals, physicians, and other health professionals, called "preferred providers" or "Network providers." The Network of preferred providers is called the "Preferred Provider Organization" or "PPO." Because the Plan saves money when you use a preferred provider, your out-of-pocket costs are less when you use preferred providers.

For your free copy of the listing of preferred providers, call the Administrative Office or visit the Plan’s website which links to providers: www.pipetradesbenefits.org.

Obtaining services from a preferred provider does not necessarily mean the services will be covered. Services that are not covered by the Plan are excluded regardless of where or by whom services are provided.

Lifetime Maximum

The Plan pays a maximum of $2,000,000 for all covered medical benefits during the lifetime of any one eligible person.

Annual Deductible

Each covered person must satisfy an annual deductible as shown on the Schedule of Benefits, before the Plan begins to pay benefits. Non-covered charges do not count towards the deductible. The deductible does not apply to the preventive services as defined by the Plan.

Charges applied toward the deductible in the last 90 days of a calendar year will be carried over and combined with subsequent covered charges to satisfy the deductible for the following calendar year. Neither charges payable by the Plan nor the percentage of covered charges that you are required to pay may be used to satisfy the deductible.

If two or more eligible members of your family are injured in the same accident, only one deductible will be charged against all covered expenses resulting from the accident, regardless of the number of family members injured.

Annual Coinsurance Maximum

Benefits provided under the Pipe Trades PPO Plus Self-Funded Indemnity Medical Plan, with some exceptions (see below), will be paid at 100% of covered charges after you have incurred $5,000 in covered expenses in a calendar year, when you use Network providers.

The following do not count towards the $5,000 coinsurance maximum and will not be paid at 100%:

1. Charges because a non-Network provider was used. Benefit reimbursement will not exceed 70% of usual and customary charges when non-Network providers are used;
2. Charges for services that are not covered under the Pipe Trades PPO Plus Self-Funded Indemnity Medical Plan (e.g., the Plan’s EAP, LASIK services);
3. Charges for failure to use a Plan-designated Tertiary Care Network provider for organ transplants; and
4. Outpatient prescription drug copays (except for copays associated with specialty medications/injectables costing more than $500, when Pre-Certified by the Plan).

Physician Services

To receive maximum benefits, you should use Interplan Network providers. If your physician is not an Interplan Network provider, a higher deductible (see page 1) applies and the reimbursement is made at the Out-of-Network rate described in the Schedule of Benefits.

Pre-Certification

Pre-Certification is required for certain services. In some cases, the Plan may require a second opinion before services can be Pre-Certified. In such cases the Plan will refer you to a network provider and pay the provider's fees associated with the second opinion. Benefits will not be paid if Pre-Certification is not obtained for the services listed below. Certification is requested by calling the Plan at (800) 515-2073 .

Services that Require Pre-Certification

1. All types of non-obstetrical diagnostic scans including ultrasound; CT scans, MRIs and PET scans;
2. Genetic testing (other than amniocentesis) and metabolic pharmacologic testing;
3. All hospitalizations and all outpatient surgery, regardless of the location, except for mastectomies and lymph node dissections and other procedures that may be exempt under applicable law;
4. All emergency hospital admissions must receive certification from the Plan within the first working day after admission;
5. All home health care and hospice care, and related medical equipment used in the home;
6. DME (durable medical equipment) costing $1,000 or more;
7. Chemotherapy/radiation and wigs;
8. Hearing aids must be Pre-Certified by Sacramento Ear, Nose and Throat (see page 27);
9. Specialty medications/injectables costing $500 or more for a supply of 31 days or less;
10. Pain management medication costing more than $500 in a twelve month period, unless the patient is in a Hospice program (see page 32);
11. Inpatient mental/nervous/psychiatric care or counseling (Pre-Certification requirements for substance abuse treatment are described on page 34)
12. Sleep studies;
13. Speech and occupational therapies;
14. Acute inpatient rehabilitation;
15. Maternity stays in excess of 48 hours for a vaginal delivery or 96 hours for a Cesarean section.

When you call the Plan for Pre-Certification you will need to provide them with the following information:

1. Patient’s name, address, phone number and date of birth;
2. Participant’s Social Security number;
3. The name of the patient’s doctor;
4. Basic medical information about the need for the Pre-Certification.

After you call, the Plan may need to talk with your doctors to get more detailed information.

If services are Pre-Certified, remember that you get maximum Plan benefits when you use preferred providers, and Plan benefits are reduced for services of non-preferred providers. An exception may be made by the Plan if the care needed is not available in the preferred provider Network or the non-Network provider agrees to a contract rate. In addition, in certain cases where you use a Network facility and the treating physician is a Network doctor, some Out-of-Network provider charges may be paid at the In-Network benefit level (examples could include anesthesiologists and emergency room physicians).

Services Not Requiring Pre-Certification by the Plan

1. Outpatient physician office visits;
2. Routine laboratory tests and obstetrical ultrasounds;
3. Diagnostics other than scans (CT scans, MRIs and PET scans require Pre-Certification);
4. Outpatient visits to specialists other than those listed above as requiring Pre-Certification;
5. Outpatient dental care. These services are covered by the dental plan, not by the medical plan, but may require certi- fication from the Plan’s dental consultant. The dental plan is described starting on page 36;
6. Outpatient prescription drugs other than specialty medication/injectables and drugs costing more than $500 per prescription for a supply of 31 days or less. Your prescription drug benefits are described starting on page 31;
7. Chiropractic care;
8. Emergency services as defined by the Plan (emergency admissions must be Certified by the Plan on the first working day following the admission);
9. Mastectomy, lymph node dissection and other procedures as may be exempt from precertification requirements per applicable law; and
10. Hospital stay of less than 48 hours for a vaginal delivery or less than 96 hours for a cesarean section.

Specialty Medications/Injectable Drugs over $500

Specialty medications (including injectable drugs) costing over $500 per prescription for a supply of 31 days or less are covered by the medical Plan, not the prescription drug plan. Even though the Plan’s specialty drug contract is with a separate provider, the PBM still administers the specialty medications and injectable drug process in accordance with Plan guidelines. Just like high dollar medical services, specialty medications and injectable medications costing over $500 (high dollar medications) will require Pre-Certification for medical necessity from the Plan.

Without Pre-Certification from the Plan, high dollar medications also known as specialty drugs (including injectable drugs) costing over $500 for a supply of 31 days or less will not be covered by the Plan.

• Patients should be advised that this process could take up to five business days and should plan accordingly.
• In the case of specialty medications or injectable drugs costing over $500, the patient or the provider should fax the new prescription to the Fund’s Prescription Benefit Manager (PBM) urgent review or standard review. The PBM will determine whether or not the prescription needs pre-certification from the Plan and fax the prescriptions to the Plan for determination of medical necessity and Pre-Certification.
• Based upon review and determination of medical necessity, the Plan will issue the certification to the Fund’s Prescription Benefit Manager (PBM) who will forward the prescription to the Fund’s specialty pharmacy to be filled.
• The Fund’s specialty pharmacy can send the specialty medication to the participant’s home, doctor’s office, or infusion center. In some cases, special arrangements can be made in advance for the patient to pick up the medication at a local pharmacy.
• The Plan will process the claims based upon NDC codes and the Fund’s specialty drug contract in accordance with Plan guidelines and schedule of benefits.
• When all of the above guidelines are met, the Plan will pay for specialty drugs using the same benefit structure as used on In-Network provider claims up to Plan maximums.

All current Health Plan provisions and guidelines for medical benefits will apply to specialty medications and injectable drugs costing over $500 for a supply of 31 days or less. If providers refuse to use the Plan’s specialty drug program, specialty medications/injectable drugs will be paid at the appropriate percentage (90% or 100%) of the lowest AWP price of the medication minus 10%. Patients should keep in mind that there are many different AWP prices so failure to use the above guidelines could result in much higher out-of-pocket expense.

These guidelines do not apply to chemotherapy medications. However, chemotherapy still requires precertification from the Plan.

An Important Reminder About Emergency Care

If you are admitted to the hospital in an emergency, the Plan must be notified (by you, your doctor, the hospital, a family member or friend) on the first working day after your admission. Failure to notify the Plan of an emergency admission and obtain certification, benefits will not be paid.

What Is an “Emergency?”

An “emergency” is defined by the Plan as a sudden, serious, and unexpected onset of acute illness or accidental injury for which the patient secures immediate care (within 24 hours of the onset of symptoms) and that, in the absence of immediate emergency treatment, could be reasonably expected to result in:

1. severe jeopardy to the patient’s health;
2. serious impairment to bodily functions; or
3. serious dysfunction of any bodily organ or part.

The Plan will not cover emergency room services if you use an emergency room and it is later determined that you did not have an emergency as defined above.

What to do in an Emergency

If urgent care is needed outside of normal business hours and the situation does not meet the definition of Emergency, use the nearest urgent care/immediate care medical office. Remember that benefits are better if Network providers are used.

If the situation is life threatening, use the nearest emergency room. Remember that benefits are better when Network providers are used, and if an admission results, you must call the Plan for certification within the first working day, at (800) 515-2073. If you require services for treatment of an Emergency (as defined by the Plan) these services will be paid under the same guidelines as for In-Network providers. The Plan will make every attempt to negotiate a discounted rate through the National Provider Network.

Organ/Tissue Transplants

If you need to have a covered* organ or tissue transplant, you must use a facility that is designated by the Plan as part of their Tertiary Care Network, in order to receive maximum benefits. If you fail to use a Plan-designated Tertiary Care Network facility, your benefits will be reduced to 50% of usual and customary (Non-Network hospital) or 50% of the contract rate (Network hospital), and your out-of-pocket coinsurance does not count towards the $5,000 coinsurance maximum.

Facilities in the Tertiary Care Network have been selected on the basis of a number of factors including patient outcomes, length of time the facility has been performing the specific transplant, re-hospitalization rates and re-transplant rates.

* Remember: all organ transplants require Pre-Certification from the Plan. Experimental procedures (see Definitions section) are not covered, and additional exclusions apply (see Exclusions section).

To determine which facilities are part of the Tertiary Care Network, call the Fund office.

Case Management

The Plan also provides participants with a service called case management. Under many circumstances where continuing care or extensive medical services are required, case managers will work with your doctor to help make sure the services you receive are the most appropriate and cost effective available.

If you have questions about the case management program, you should call the Plan at (800) 515-2073, or the Administrative Office.

Extended Case Management Services

The Plan provides a team of case management physicians, nurses, pharmacists and other health professionals to help you coordinate your medical care and provide early intervention and assessment to those who may benefit from these services. The Plan and Trustees hope that you will take advantage of this program and participate to help prevent significant and dangerous medical events. Expanded Case Management services and any referrals made by the Plan are paid at 100%, with no cost to participants. In order to help you manage your health care, you may be contacted by one of the Plan’s nurse case managers or physician consultants.

The Plan’s electronic data systems capture all patient information including prescription drug use, medical claims data, pharmacy consultations and case management information. The Plan’s physician and nurse case management team may contact you to ensure that you are receiving the highest quality of care for your condition and also may recommend specialty services.

Additional information relating to the Plan’s pharmacy consultation program can be found in the Prescription Drug Benefits section of this booklet.