SCHEDULE OF BENEFITS
For Medicare Retirees and Dependents who have Selected the Union Labor Life Insurance Co. Plan

Deductible Information
Deductible	In Network	Out of Network1
Maximum of two deductibles per family per year	$200 per person	$200 per person
Lifetime Maximum	$1,000,000	$1,000,000
Coinsurance Maximum	$10,000	Does Not Apply

1

Only in-network benefits count toward the $10,000 coinsurance maximum. Whether or not you live within the network service area, charges incurred out-of-network will never be paid at 100%. Out of area benefits: if you live more than 30 miles away from the nearest network provider, benefits will be paid at 80% of usual and customary charges2, and benefits will be reduced by 20% if you do not receive prior authorization.

2

For retirees eligible for Medicare, this plan’s benefits will be coordinated with Medicare. Whether or not the provider accepts Medicare assignment, benefits are based upon Medicare’s explanation of benefits and payable up to usual, customary and reasonable or Medicare’s allowance, whichever is less.

SCHEDULE OF BENEFITS
For Medicare Retirees and Dependents who have Selected the Union Labor Life Insurance Co. Plan

Schedule of Medical Benefits
Physician Care & Outpatient Services	In Network	Out of Network1
Visits to Primary Care Physician (PCP)	90% of contract rate2, after deductible.	70% of usual, customary & reasonable3, after deductible.
Visits to Dr. Other than PCP	90% of contract rate2, after deductible.	70% of usual, customary & reasonable3, after deductible.
Diagnostics, X-Ray, Lab	90% of contract rate2, after deductible.	70% of usual, customary & reasonable3, after deductible.
Gynecological Visits	90% of contract rate2, after deductible.	70% of usual, customary & reasonable3, after deductible.
Chiropractor	90% of contract rate2, after deductible.	70% of usual, customary & reasonable3, after deductible.
	$1,500 maximum benefit per calendar year
Physical Therapy	90% of contract rate2, after deductible.	70% of usual, customary & reasonable3, after deductible.
	$3,000 maximum benefit per calendar year
Durable Medical Equipment	90% of contract rate2, after deductible.	80% of usual, customary & reasonable3, after deductible.

1	Only in-network benefits count toward the $10,000 coinsurance maximum. Whether or not you live within the network service area, charges incurred out-of-network will never be paid at 100%. Out of area benefits: if you live more than 30 miles away from the nearest network provider, benefits will be paid at 80% of usual and customary charges.3
2	For retirees eligible for Medicare, this Plan’s benefits will be coordinated with Medicare. Benefits are based upon Medicare’s explanation of benefits and payable up to the contract rate or Medicare’s allowance, whichever is less.
3	For retirees eligible for Medicare, this plan’s benefits will be coordinated with Medicare. Whether or not the provider accepts Medicare assignment, benefits are based upon Medicare’s explanation of benefits and payable up to usual, customary and reasonable or Medicare’s allowance, whichever is less.

SCHEDULE OF BENEFITS
For Medicare Retirees and Dependents who have Selected the Union Labor Life Insurance Co. Plan

Schedule of Medical Benefits
Hospital Inpatient & Outpatient	In Network	Out of Network1
Room & Board	90% of contract rate2, after deductible.	70% of semi-private rate3 after deductible.
Misc. Hosp. Charges, Surgery, Anesthesia	90% of contract rate2, after deductible.	70% of usual, customary & reasonable3, after deductible.
Intensive Care	90% of contract rate2, after deductible.	70% up to 2.5 times semi-private rate3, after deductible.
Emergency Room	90% of contract rate2, after deductible, if emergency. 50% of contract rate2, after deductible, if non-emergency.	70% of usual, customary & reasonable3, after deductible, if emergency. 50% of usual, customary & reasonable3, after deductible, if non-emergency.
Home Health	90% of contract rate2, after deductible.	80% of usual, customary & reasonable3, after deductible.
	100 Visit Maximum Per Year
Hospice Inpatient or Outpatient	80% of contract rate2, after deductible.	80% of usual, customary & reasonable3, after deductible.

1	Only in-network benefits count toward the $10,000 coinsurance maximum. Whether or not you live within the network service area, charges incurred out-of-network will never be paid at 100%. Out of area benefits: if you live more than 30 miles away from the nearest network provider, benefits will be paid at 80% of usual and customary charges.3
2	For retirees eligible for Medicare, this Plan’s benefits will be coordinated with Medicare. Benefits are based upon Medicare’s explanation of benefits and payable up to the contract rate or Medicare’s allowance, whichever is less.
3	For retirees eligible for Medicare, this plan’s benefits will be coordinated with Medicare. Whether or not the provider accepts Medicare assignment, benefits are based upon Medicare’s explanation of benefits and payable up to usual, customary and reasonable or Medicare’s allowance, whichever is less.

SCHEDULE OF BENEFITS
For Medicare Retirees and Dependents who have Selected the Union Labor Life Insurance Co. Plan

Schedule of Medical Benefits
Preventive Health Services	Network	Non-Network1
Well Baby Care 8 visits from birth to second birthday	90% of contract rate2, after deductible for office visit.	Not covered1 (Out of Area paid at 80% of usual, customary & reasonable3).
	$850 maximum including medically necessary immunizations.
Routine Exam One exam per year ages 2-19 and over 65. One exam every two years ages 20-64.	90% of contract rate2, after deductible.	Not covered1 (Out of Area paid at 80% of usual, customary & reasonable3).
	$100 maximum not including medically necessary immunizations.
Immunizations	100% of contract rate2.	Not covered1 (Out of Area paid at 80% of usual, customary & reasonable3).

1	Out of area preventive health services: if you live more than 30 miles away from the nearest network provider, services still must be provided by your primary care physician. The visit is covered at 80% of usual, customary & reasonable3, after the deductible. Only in-network benefits count toward the $10,000 coinsurance maximum. Whether or not you live within the network service area, charges incurred out-of-network will never be paid at 100%.
2	For retirees eligible for Medicare, this Plan’s benefits will be coordinated with Medicare. Benefits are based upon Medicare’s explanation of benefits and payable up to the contract rate or Medicare’s allowance, whichever is less.
3	For retirees eligible for Medicare, this plan’s benefits will be coordinated with Medicare. Whether or not the provider accepts Medicare assignment, benefits are based upon Medicare’s explanation of benefits and payable up to usual, customary and reasonable or Medicare’s allowance, whichever is less.

SCHEDULE OF BENEFITS
Self-Funded for Medicare Retirees and Dependents who have Selected the Union Labor Life Insurance Co. Plan

Schedule of Medical Benefits
Hearing Aids, Audiology	Network	Non-Network1
Audiology Visits	90% of contract2 after deductible, if provided through Sacramento Ear, Nose and Throat and pre-authorized.	Not covered1 (Out of Area 80% of usual, customary & reasonable3, after deductible, if pre-authorized)
Hearing Aids	100% of contract amount2, when provided through Sacramento Ear, Nose and Throat and pre-authorized.	Not covered1 (Out of Area 80% of usual, customary & reasonable3,after deductible, if pre-authorized and approved by Sacramento Ear, Nose and Throat)
	Pre-Authorization is Required $2,000 ($1,000 per ear) maximum payment. Annual hearing aid maintenance check is required.4 Children (under the age of 18): one aid per ear every calendar year Adults (18 & over): one aid per ear every 3 years.
Maintenance Check	75% of contract amount2, after deductible.	Not covered1 (Out of Area 80% of usual, customary & reasonable3, after deductible).
	$30 maximum per year

1	Out of area Hearing Aids, Audiology: if you live more than 30 miles away from Sacramento Ear, Nose and Throat, pre-authorization is required for the initial audiology visit. If authorized, the visit is covered at 80% of usual, customary, and reasonable, after the deductible. If hearing aids are needed, your audiology report must be sent to Sacramento Ear, Nose and Throat so the hearing aids can be authorized. Hearing aids are covered at 80% of usual, customary, and reasonable, after deductible, up to $1,000 per ear. Only in-network benefits count toward the $10,000 coinsurance maximum. Whether or not you live within the network service area, charges incurred out-of-network will never be paid at 100%.
2	For retirees eligible for Medicare, this Plan’s benefits will be coordinated with Medicare. Benefits are based upon Medicare’s explanation of benefits and payable up to the contract rate or Medicare’s allowance, whichever is less.
3	For retirees eligible for Medicare, this plan’s benefits will be coordinated with Medicare. Whether or not the provider accepts Medicare assignment, benefits are based upon Medicare’s explanation of benefits and payable up to usual, customary and reasonable or Medicare’s allowance, whichever is less.
4	Annual hearing aid maintenance check is required. If you fail to obtain this annual maintenance check, the Fund will not pay for replacement of hearing aids.

SCHEDULE OF BENEFITS
Mental/Nervous Benefits for Medicare Retirees and Dependents who have Selected the Union Labor Life Insurance Co. Plan

Counseling Benefits For All Medicare Retirees And Dependents
Mental/Nervous Conditions4 For only Medicare retirees and dependents who have selected the Union Labor Life Insurance Co. Plan	Network	Out of Network1
Inpatient	50% of contract rate2, no deductible.	50% of usual, customary & reasonable3, no deductible.
	30 Day Yearly Maximum
Outpatient	50% of contract rate2, no deductible.	50% of usual, customary & reasonable3, no deductible.
	20 Visit Yearly Maximum5
Counseling Benefit4 For all Medicare retirees and dependents
Family counseling, grief counseling, outpatient counseling, etc.	50% of contract rate2, no deductible.	50% of usual, customary & reasonable3, no deductible.
	20 Visit Yearly Maximum5

1	Only in-network benefits count toward the $10,000 coinsurance maximum. Whether or not you live within the network service area, charges incurred out-of-network will never be paid at 100%. Out of area benefits: if you live more than 30 miles away from the nearest network provider, benefits will be paid at 80% of usual and customary charges, and will be reduced by 20% if you do not receive prior authorization.
2	For retirees eligible for Medicare, this plan’s benefits will be coordinated with Medicare. Benefits are based upon Medicare’s explanation of benefits and payable up to the contract rate or Medicare’s allowance, whichever is less.
3	For retirees eligible for Medicare, this plan’s benefits will be coordinated with Medicare. Whether or not the provider accepts Medicare assignment, benefits are based upon Medicare’s explanation of benefits and payable up to usual, customary and reasonable or Medicare’s allowance, whichever is less.
4	Mental/nervous and counseling claims do not count towards the out-of-pocket maximum. Mental/nervous and counseling claims do not go towards, and are never eligible for, 100% coverage.
5	Annual 20 visit limit applies to mental/nervous and counseling benefits combined.

SCHEDULE OF BENEFITS
For Non-Medicare Retirees and Dependents who have Selected the Union Labor Life Insurance Co. Plan

Deductible Information
Deductible	In Network	Out of Network
Maximum of two deductibles per family per year	$200 per person	$200 per person
Lifetime Maximum	$1,000,000	$1,000,000
Coinsurance Maximum	$10,000	Does Not Apply1

1

Only in-network benefits count toward the $10,000 coinsurance max. Whether or not you live within the network service area, charges incurred out-of-network will never be paid at 100%. Out of area benefits: if you live more than 30 miles away from the nearest network provider, benefits will be paid at 80% of usual, customary & reasonable charges, and benefits will be reduced by 20% if you do not receive prior authorization.

SCHEDULE OF BENEFITS
For Non-Medicare Retirees and Dependents who have Selected the Union Labor Life Insurance Co. Plan

Schedule of Medical Benefits
Physician Care & Outpatient Services	In Network	Out of Network1
Visits to Primary Care Physician (PCP)	100% of contract rate, after $15 copay.	70% of usual, customary & reasonable, after deductible.
	Prior Authorization Not Required
Visits to Dr. Other than PCP	90% of contract rate, after deductible, if pre-authorized.	70% of usual, customary & reasonable, after deductible, if pre-authorized.
	Not Covered if Not Pre-Authorized
Diagnostics, X-Ray, Lab	90% of contract rate, after deductible.	70% of usual, customary & reasonable, after deductible.
	CT Scans, MRIs, PET Scans and non-obstetrical ultrasound tests require pre-authorization regardless of who orders the tests.
Chiropractor	90% of contract rate, after deductible.	70% of usual, customary & reasonable, after deductible.
	Prior Authorization Not Required $1,500 maximum benefit per calendar year
Physical Therapy	90% of contract rate, after deductible, if pre-authorized.	70% of usual, customary & reasonable3, after deductible, if pre-authorized.
	Not Covered if Not Pre-Authorized $3,000 maximum benefit per calendar year
Durable Medical Equipment	90% of contract rate, after deductible, if pre-authorized.	80% of usual, customary & reasonable, after deductible, if pre-authorized.
	Not Covered if Not Pre-Authorized

1

Out of area benefits: if you live more than 30 miles away from the nearest network provider, benefits will be paid at 80% of usual, customary & reasonable charges, and will be reduced by 20% if you do not receive prior authorization. For emergency admissions, a 20% penalty will apply if authorization is not sought within the first business day after admission. Only in-network benefits count toward the $10,000 coinsurance maximum. Charges incurred out-of-network will never be paid at 100%, whether or not you live in-area or out-of-area.

SCHEDULE OF BENEFITS
For Non-Medicare Retirees and Dependents who have Selected the Union Labor Life Insurance Co. Plan

Schedule of Medical Benefits
Hospital Inpatient & Outpatient	In Network	Out of Network1
Prior Authorization Requirement: Inpatient, Outpatient, and Emergency Admissions	Benefits will be reduced by 10% on inpatient or outpatient hospital services unless prior authorization is obtained. For emergency admissions, 10% benefit reduction applies if authorization not obtained on first working day.
Room & Board	90% of contract rate, after deductible.	70% of semi-private rate after deductible.
Misc. Hosp. Charges, Surgery, Anesthesia	90% of contract rate, after deductible.	70% of usual, customary & reasonable, after deductible.
Intensive Care	90% of contract rate, after deductible.	70% up to 2.5 times semi-private rate, after deductible.
Organ/Tissue Transplants	At Interplan-designated Tertiary Care Network Facility: 90% of contract rate.2	50% of usual, customary & reasonable, after deductible.
Emergency Room, Urgent Care Center	90% of contract rate, after deductible, if emergency. 50% of contract rate, after deductible, if non-emergency.3	70% of usual, customary & reasonable, after deductible, if emergency. 50% of usual, customary & reasonable, after deductible, if non-emergency.3
Home Health	90% of contract rate, after deductible.	80% of usual, customary & reasonable, after deductible.
	Prior Authorization Required 100 Visit Maximum Per Year
Hospice Inpatient or Outpatient	80% of contract rate, after deductible.	80% of usual, customary & reasonable, after deductible.
	Prior Authorization Required $15,000 Lifetime Maximum

1	Only in-network benefits count toward the $10,000 coinsurance maximum. Whether or not you live within the network service area, charges incurred out-of-network will never be paid at 100%. Out of area benefits: if you live more than 30 miles away from the nearest network provider, benefits will be paid at 80% of usual and customary charges, and will be reduced by 20% if you do not receive prior authorization.
2	Or 50% of contract rate if facility is part of the PPO Network but not a designated Tertiary Care Network Facility. Your coinsurance for failure to use a provider which is not part of the Tertiary Care Network will not count towards the $10,000 coinsurance maximum.
3	Benefit reduction waived if you contacted your Primary Care Physician prior to obtaining services, and she/he directed you to use the Urgent Care Center or Emergency Room, and she/he provides the Plan with documentation to that effect.

SCHEDULE OF BENEFITS
For Non-Medicare Retirees and Dependents who have Selected the Union Labor Life Insurance Co. Plan

Schedule of Medical Benefits
Preventive Health Services All preventive services must be provided by your primary care physician (except for routine annual Gynecological exam)
	Network	Non-Network1
Well Baby Care 8 visits from birth to second birthday	100% after $15 copay for office visit	Not covered1 (Out of Area Primary Care Physician paid at 80% of usual, customary & reasonable).
	$850 maximum including medically necessary immunizations.
Routine Exam One exam per year ages 2-19 and over 65. One exam every two years ages 20-64.	100% after $15 copay	Not covered1 (Out of Area Primary Care Physician paid at 80% of usual, customary & reasonable).
	$100 maximum not including medically necessary immunizations.
Adult Immunizations	100% of contract rate2.	Not covered1 (Out of Area Primary Care Physician paid at 80% of usual, customary & reasonable).
Routine Annual Gynecological Visits (performed by a Gynecologist or your primary care physician)	100% of contract rate, after $15 copay	70% of usual, customary & reasonable, after deductible
	Prior Authorization Not Required for Routine Annual Exam All other Gynecologist visits not covered if not pre-authorized.

1

Out of area preventive health services: if you live more than 30 miles away from the nearest network provider, services still must be provided by your primary care physician. The visit is covered at 80% of usual, customary & reasonable, after the deductible. Only in-network benefits count toward the $10,000 coinsurance maximum. Whether or not you live within the network service area, charges incurred out-of-network will never be paid at 100%.

SCHEDULE OF BENEFITS
Self-Funded for Non-Medicare Retirees and Dependents who have Selected the Union Labor Life Insurance Co. Plan

Schedule of Medical Benefits
Hearing Aids, Audiology	Network	Non-Network1
Audiology Visits	90% after deductible, if provided through Sacramento Ear, Nose and Throat and pre-authorized.	Not covered1 (Out of Area 80% of usual, customary & reasonable, after deductible, if pre-authorized)
Hearing Aids	100% of contract amount, when provided through Sacramento Ear, Nose and Throat and pre-authorized.	Not covered1 (Out of Area 80% of usual, customary & reasonable, after deductible, if pre-authorized and approved by Sacramento Ear, Nose and Throat)
	Pre-Authorization is Required $2,000 ($1,000 per ear) maximum payment. Annual hearing aid maintenance check is required.2 Children (under the age of 18): one aid per ear every calendar year Adults (18 & over): one aid per ear every 3 years.
Maintenance Check	75% of contract amount	Not covered1 (Out of Area 80% of usual, customary & reasonable, after deductible).
	$30 maximum per year

1

Out of area Hearing Aids, Audiology: if you live more than 30 miles away from Sacramento Ear, Nose and Throat, pre-authorization is required for the initial audiology visit. If authorized, the visit is covered at 80% of usual, reasonable and customary, after the deductible. If hearing aids are needed, your audiology report must be sent to Sacramento Ear, Nose and Throat so the hearing aids can be authorized. Hearing aids are covered at 80% of usual, customary & reasonable, after deductible, up to $1,000 per ear. Only in-network benefits count toward the $10,000 coinsurance maximum. Whether or not you live within the network service area, charges incurred out-of-network will never be paid at 100%.

2

Annual hearing aid maintenance check is required. If you fail to obtain this annual maintenance check, the Fund will not pay for replacement of hearing aids.

SCHEDULE OF BENEFITS
Mental/Nervous Benefits for Non-Medicare Retirees and Dependents who have Selected the Union Labor Life Insurance Co. Plan

Counseling Benefits For All Non-Medicare Retirees And Dependents
Mental/Nervous Conditions2 For only Non-Medicare retirees and dependents who have selected the Union Labor Life Insurance Co. Plan	Network	Out of Network1
Inpatient	50% of contract rate, no deductible.	50% of usual, customary & reasonable, no deductible.
	10% benefit reduction if hospitalization not pre-authorized 30 Day Yearly Maximum
Outpatient	50% of contract rate, no deductible.	50% of usual, customary & reasonable, no deductible.
	Prior Authorization Required 20 Visit Yearly Maximum3
Counseling Benefit2 For all Non-Medicare retirees and dependents
Family counseling, grief counseling, outpatient counseling, etc.	50% of contract rate, no deductible.	50% of usual, customary & reasonable, no deductible.
	20 Visit Yearly Maximum5

1	Only in-network benefits count toward the $10,000 coinsurance maximum. Whether or not you live within the network service area, charges incurred out-of-network will never be paid at 100%. Out of area benefits: if you live more than 30 miles away from the nearest network provider, benefits will be paid at 80% of usual, customary & reasonable charges, and will be reduced by 20% if you do not receive prior authorization.
2	Mental/nervous and counseling claims do not count towards the out-of-pocket maximum. Mental/nervous and counseling claims do not go towards, and are never eligible for, 100% coverage.
3	Annual 20 visit limit applies to mental/nervous and counseling benefits combined.

SCHEDULE OF BENEFITS
Self-Funded for all Retirees and Dependents who have Selected the Union Labor Life Insurance Co. Plan

Schedule of Prescription Benefits
Outpatient Prescription Drugs
Self-funded by the Plan through Pharmaceutical Care Network (PCN) network pharmacies and Certifax Mail Service pharmacy.
	Generic Drugs	Brand Name Drugs1
Certifax Mail Order Service2	$3 copay per 90-day supply	$10 copay per 90-day supply
	90-day supply maximum
Medications obtained2 at PCN pharmacies using PCN card	80% of negotiated price	70% of negotiated price
	30-day supply maximum
Medications obtained without using PCN card or obtained at a non-PCN pharmacy.	50% of retail cost

1	Benefit when no generic equivalent exists. If a generic equivalent exists but is not dispensed, the Plan pays only the benefit which would have been paid if generic had been dispensed. The patient will pay the difference between the brand name and the generic drug.
2	Oral contraceptives (birth control pills) are covered for a 30-day supply at retail (walk-in) pharmacies only. They are not available through Certifax Mail Service.
Note: If you are covered under a Medicare HMO plan, your prescriptions must be obtained through that carrier. For copay reimbursement information, please refer to page 33.

SCHEDULE OF BENEFITS
Self-Funded for all Non-Medicare Retirees and Dependents

Schedule of Medical Benefits
Employee Assistance Program (EAP)1 Treatment of Alcohol or Substance Abuse (In/Outpatient) Lifetime Dollar Maximum Lifetime Treatment Maximum	Not covered unless provided through the Plan’s EAP: 24 Hour Phone Number: 916-922-1099 No Deductible $10,000 2 Treatment Courses (not to exceed 6 months each)
Nicotine Replacement Patches To assist participants in quitting smoking	50% up to a lifetime maximum benefit of $150

1	EAP benefits are not applied to deductible, or annual or lifetime maximums.

SCHEDULE OF BENEFITS
For Retirees who have Selected the Delta AdapTable or Delta Care PMI Plan

Summary of Dental Benefits
DELTA ADAPTABLE1
Dental Benefits Under the Delta AdapTable Plan, you may go to any licensed dentist; however, dentists participating with Delta AdapTable may offer you a more competitive rate than a dentist who is not a participating Delta AdapTable provider.
Annual Deductible	Annual Maximum
$50 per person 3 per family	$1,000 per person
DELTA CARE PMI1
Dental Benefits Only services performed by your selected Delta Care PMI panel dentist are covered under this Plan.
Annual Deductible	Annual Maximum
None Co-pays vary by procedure	None

1	If you are covered by Medicare and belong to an HMO, you can select either program at no charge. Your HMO may also have a low- or no-cost dental plan available.