Invest In Your Future Teamsters Local 1932 Health & Wefare Trust · Invest In Your Future......

Invest In Your Future...Teamsters Local 1932Health & Wefare Trust

https://teamsters1932.zenith-american.com(909) 494-2916 or (866) 484-1337

Post Office Box 571San Bernardino, CA 92410-4831

June 1 June 21START END

2020-21 OPEN ENROLLMENT

https://teamsters1932.zenith-american.com

2020-21 EMPLOYEE BENEFIT GUIDE

INTRODUCTIONTeamsters Local 1932 Health and Welfare Trust

Welcome Teamsters Local 1932 Members!

The Board of Trustees is excited to be the first to welcome you to the Teamsters Local 1932 Health and Welfare Trust. For the first time ever, you have the opportunity to enroll in a plan created specifically for Teamsters Local 1932 Union Members. This is where affordable healthcare comes first, and benefit improvements become possible going forward. You voted for this and your leaders fought to create a health plan that protects and empowers your future. The first step was lowering premium costs, now we have established your new Health and Welfare Trust that will enable Teamsters Local 1932 to work toward building future benefits utilizing the savings a Trust Fund creates.


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ContentsINTRODUCTION ....................................................................................................................1

AS YOU ENROLL ...................................................................................................................4

PLAN HIGHLIGHTS FOR PLAN YEAR 2020-2021 ..................................................................5

2020 OPEN ENROLLMENT MASTER SCHEDULE ...................................................................7

TEAMSTERS LOCAL 1932 HEALTH and WELFARE PLAN ...................................................18

SUMMARY OF BENEFITS AND COVERAGE .......................................................................18

County Sponsored Benefits ..............................................................................................51

SUMMARY PLAN DESCRIPTION: ........................................................................................52

An Important Message to Participants ...........................................................................58

Eligibility Rules for Employees and Dependents ............................................................60

Enrollment for Benefits ......................................................................................................62

Termination of Coverage .................................................................................................68

Extensions of Coverage During Leaves of Absence .....................................................70

Legislation Affecting Health Care Benefits ....................................................................80

Claims Procedures ............................................................................................................90

Definitions ...........................................................................................................................93

Summary of Trust Benefits .................................................................................................95

Insurers and Providers of Service to the Trust .................................................................97

SUMMARY OF BENEFITS AND COVERAGE .......................................................................98

Teamsters Local 1932 Health and Welfare Trust 1st Annual Open EnrollmentüVisit https://teamsters1932.zenith-american.com to learn more

about your benefit options or view a recorded open enrollment meeting.

üReview What’s New & Different For Plan Year 2020-21 page 5.

üCheck important dates page 7

üEnroll or make changes using the Teamsters Local 1932 Health and Welfare Trust online enrollment module at:

Î https://teamsters1932.zenith-american.com

Î Step-by-step instructions begin on page 10 of this booklet.

üSelect the right coverage level. Review the medical, dental and vision plan highlights and comparison charts pages 40-50

üReview additional benefits that may be available to you on page 51.

üDo not delay — enroll or make your changes before midnight, Sunday, June 21, 2020.

üSubmit any additional required documentation to the Trust Administration Office by Thursday, July 2, 2020.

Detailed benefit plan information and more can be found in this guide or online at: https://teamsters1932.zenith-american.com | 909.494.2916 | 866.484.1337.

OPEN ENROLLMENT IS JUNE 1 – JUNE 21, 2020.

You are encouraged to reference this guide throughout the year.





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PLAN HIGHLIGHTS FOR PLAN YEAR 2020-2021

NEW LOWER COST MEDICAL PLAN OPTIONS AVAILABLE:

The Teamsters Local 1932 Health and Welfare Trust is excited to introduce a new lower premium cost medical plan option now available in addition to the same plans that have been available.

This year we have some EXCITING changes!

Teamsters members have a new medical plan to choose from, and lower premium cost options offered alongside existing plans:

NEW PLAN OPTION AVAILABLE TO TEAMSTERS MEMBERS ONLY - BLUE SHIELD HMO GOLD TRIO - $20 PLAN

Copayment: For most routine care under the HMO Gold Trio plan, you pay a $20 copayment. For other services, copayments range from $20 to 40% of actual charges. For Trio+ Specialist visits, copayments for covered benefits are $20.

Deductible: Under the HMO Gold Trio plan, you pay no deductible and your out-of-pocket annual expenses are limited to $3,500 per person or $7,000 per family.

Trio HMO is powered by a specially selected network of local doctors, specialists, and hospitals all committed to working more closely together. This ensures all aspects of your care are more connected and efficient – keeping your premiums as low as possible in the process.

Like our other HMO plans, with Trio you have a primary care physician (PCP). Your PCP can coordinate your care, treat common illnesses and injuries, and provide a referral if you need to see a specialist.

You can check if your current PCP or other doctors are in the Trio network by visiting https://blueshieldca.com/NetworkTrioHMO. If you do not see them, don’t worry – we can help you find new healthcare providers from within our quality Trio network.

AS YOU ENROLL

This guide is designed to help you understand your benefit enrollment options for plan year 2020-21. Benefit elections will become effective July 18, 2020. Included are summaries of your plan choices, for benefits such as medical, dental and vision. Benefits vary depending on the bargaining unit that you belong to, please check your applicable benefit summary for details at https://teamsters1932.zenith-american.com or your memorandum of understanding (MOU), exempt compensation plan, salary ordinance, or employment contract. You will also find in this benefits guide, comparison charts for convenient at-a-glance referencing and plan contact information. Please read your materials carefully, and chooses the plans that best meet your needs.

We encourage you to use this guide as a reference throughout the year. If you have questions, contact the Trust Fund’s Administrative Office at (909) 494-2916 or the plan providers directly. Plan provider phone numbers and web sites are listed in the Contact Information section on page 16 of this guide.

Disclaimer: This guide is intended as a summary reference; however, the Summary Plan Description and contract documents prevail in all circumstances.

Dependent Election Proof

If your open enrollment

election includes the addition

of new dependents not

currently or previously enrolled

in a County benefit plan, the

deadline to submit proof of

dependency is Thursday, July 2,

2020. If the Administrative Office

does not receive dependent

documentation by 5:00 p.m. on

July 2, 2020, your dependent(s)

will not be added to your plan

for the 2020-21 plan year.

More information

on dependent

documentation can be

found on page 36

https://blueshieldca.com/NetworkTrioHMO


http://cms.sbcounty.gov/hr/Benefits/BenefitCampaigns/OpenEnrollment/ModifiedBenefitOption.aspx


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2020 OPEN ENROLLMENT MASTER SCHEDULEBenefits are an important part of your total compensation package. Take advantage of this opportunity to review your benefit plan options through online educational information and webinars.

JUN 1 MON

Open enrollment begins! Informational webinars, virtual meetings and instructional videos are available.

Open Enrollment is June 1–21, 2020.

Open Enrollment Web Meeting Schedule:

• June 1st at 2:00 p.m. PDT- CLICK HERE TO REGISTER

• June 3rd at 10:00 a.m. PDT - CLICK HERE TO REGISTER

• June 5th at 1:00 p.m. PDT - CLICK HERE TO REGISTER

• June 9th at 2:00 p.m. PDT - CLICK HERE TO REGISTER

• June 11 at 3:00 p.m. PDT - CLICK HERE TO REGISTER

• June 15 at 1:00 p.m. PDT - CLICK HERE TO REGISTER

This year we have some changes to existing benefits. Including:

✓ Employees have new lower premium cost medical plan options to choose from alongside existing plans.

This means that it is very important for employees to review, update, and/or submit their enrollment for their benefits through the Online Enrollment application process, which can be found at https://teamsters1932.zenith-american.com . You may also make the following changes as needed:

• Enroll in a medical, dental, and/or vision plan in either the Teamsters Local 1932 Health and Welfare Trust or in the County’s plan.

• Change medical, dental, and/or vision plans

• Add dependents to or remove them from your medical, dental, and/or vision plans

• Opt-out of a Teamsters sponsored or County sponsored medical plan and/or dental plan (other comparable group coverage required)

Should you need help with completing your online open enrollment, one-on-one assistance is available 8:00 a.m. to 5:00 p.m. Monday through Friday at the Fund’s Administrative Office, 433 N. Sierra Way, San Bernardino, CA. No appointment necessary—walk-ins are welcome.

THE SAME PLAN OPTIONS YOU HAD AVAILABLE FROM THE COUNTY ARE STILL AVAILABLE TO TEAMSTERS MEMBERS, SOME AT A LOWER COST!

Teamster 1932 Plan Name County Plan NameBlue Shield – HMO Platinum POS Plan Blue Shield Signature HMO

Blue Shield – HMO Gold Access+ Plan ($40 copay)

Blue Shield Access+ HMO

Blue Shield – HMO Gold Trio Plan ($20 copay)

{PLAN NOT AVAILABLE THROUGH COUNTY]

Blue Shield – PPO Non-Needles Plan Blue Shield PPO

Blue shield – PPO Needles Plan Blue Shield PPO

Kaiser – HMO Platinum Kaiser Traditional HMO

Kaiser – HMO Gold ($40 copay) Kaiser Choice HMO

Open Enrollment begins June 1st and runs through June 21st, 2020

This means that it is very important for members to review the Plan options available to you, along with informational videos and other posted Open Enrollment material, which can be found at https://teamsters1932.zenith-american.com. Zenith American Solutions has a dedicat-ed Customer Service team available to members of Teamsters Local 1932. They can help you navigate through the system, assist with your enrollment application and answer any questions you may have. They can be reached at (909) 494-2916, or toll free at (866) 484-1337.

MODIFIED BENEFIT OPTION

The Modified Benefit Option (MBO) provides full-time regular employees in eligible classifica-tions the opportunity to convert from a regular position with traditional benefits to a regular position with modified benefits, so they can receive additional compensation above their base rate of pay. For more information, please visit the MBO web page at https://teamsters1932.ze-nith-american.com or (MOU) to see if you qualify!

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JUN 20 SAT SBCERA rates change. Please view the ‘Retirement Plan Highlights’ section to review your rate.

JUN 21 SUN Open enrollment ends at midnight! This is the deadline to submit your 2020–21 benefit elections using the Teamsters Local 1932 Health and Welfare Trust through its online enrollment portal, http:Teamsters1932.zenith-american.com.

JUL 2 THU 5:00 p.m. Deadline to submit proof of dependency for newly added dependents and opt-out verification for new opt-outs need to be delivered to the Trust Fund Office. Failure to provide documentation will result in denial of elections.

JUL 18 SAT Effective date of coverage for changes made to Teamsters Local 1932 Health and Welfare Trust’s medical, dental & vision, and the County/Employer FSA, supplemental life and AD&D plans.

JUL 29 WED Pay check deductions reflect open enrollment rate changes, except FSA deduction.

AUG 12 WED Pay check deductions reflect FSA contribution changes

Open Enrollment – Questions and Answers:

1. How will the plan options work with the addition of the Trust?You will be able to choose between the Teamsters Local 1932 Health and Welfare Trust or the County’s Plan for medical, dental and vision.

2. What are the plan differences between the Trust and the County?

You will have the same plan options under the Teamsters Trust as available under the County, only better! Medical plan options include: Blue Shield HMO Platinum POS, Blue Shield Gold Access+, Blue Shield Non Needles PPO, Blue Shield Needles PPO, Kaiser HMO Gold, and Kaiser HMO Platinum. In addition, the Teamsters Local 1932 Health and Welfare Trust has a new Plan offering, HMO Gold Trio with lower out of pocket costs and lower co-payments for Office Visits, available under the Teamsters Trust. Your dental and vision carriers continue to be Delta Dental and EyeMed.

3. What if I want to move to the Teamsters Trust but would like to keep the same plan?Great news! If you want to move to the Teamsters Plan and would like to remain on the Plan you were enrolled in with the County, and have no changes to your dependent coverage, you will be able to use the short enrollment option during this enrollment pe-riod. On the website, simply click on the box marked:

; No Plan Changes, and your enrollment is complete.

You will be enrolled in the Teamsters Plan, maintaining the same plan options you had under the County.

4. What if I want to move to the Trust and make plan changes?

You can complete the online enrollment form via the website: https://teamsters1932.zenith-american.com or you can request paper enrollment forms by calling the Trust Administration Office at (909) 494-2916. There is an easy to use online self-serve en-rollment module to make your Plan selections. In addition, there will be dedicated Customer Service Representatives available at (909) 494-2916 to assist you in complet-ing your enrollment form, and answer any questions you may have.

5. Can I add or delete dependents during the Open Enrollment Period?

You will be able to make changes to dependents during Open Enrollment. You can add or delete dependents while using the Online Enrollment application. If your open enrollment election includes the addition of new dependents not currently or previ-ously enrolled in a County benefit plan, the deadline to submit proof of dependency is Thursday, July 2, 2020. If the Trust Administration Office does not receive dependent documentation by 5:00 p.m. on July 2, 2020, your dependent(s) will not be added to your plan for the 2020-21 plan year. You can upload the required documents as part of the online enrollment process.

http://Teamsters1932.zenith-american.com





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Additionally, if you are adding a dependent who is mentally or physically disabled and is 26 years or over, this will be allowed in the 2020-2021 Open Enrollment only. Your de-pendent must have had continuous coverage by the County, and the enrollment must be accompanied by documentation of their disabled and dependent status. Please contact the Trust Administration Office if you have any questions. During the enrollment process, you can tell us that they are disabled by checking the disabled box in the Dependent Beneficiary screen of the Online Enrollment application. An upload process is available for supplying the required documentation that supports your dependent’s disabled status.

If you are adding a dependent who is mentally or physically disabled who is under age 26, then the documentation of that condition is not required at this time. However, it will be necessary to submit that information prior to that dependent attaining age 26, to avoid any lapse in coverage.

More information on dependent documentation can be found on page 35.

6. Will I still need to contact the County for my benefit needs?Some of your available benefit options will continue to be managed by the County. The Trust Administration Office can help guide you. Please contact the Customer Service department at (909) 494-2916 for assistance.

Questions Completing Your Enrollment:Should you need help with completing your online open enrollment, one-on-one assistance is available 8:00 a.m. to 5:00 p.m. Monday through Friday at the Trust Administration Office, Zenith American Solutions, 433 North Sierra Way, San Bernardino, California. During the normal course of business, no appointment is necessary - walk-ins are welcome! However, during the social distancing requirement due to COVID-19, walk-in assistance may not be available or limited. Please contact the Customer Service department at (909) 494-2916. The Customer Service Specialists will be able to view the same screens as you while you are enrolling, should you need assistance.

Open enrollment ends at midnight on June 21st! This is the deadline to submit your 2020–21 benefit elections using the Teamsters Local 1932 Health and Welfare Trust through its online en-rollment portal https://teamsters1932.zenith-american.com portal.

The deadline to submit proof of dependency for newly added dependents and opt-out verifi-cation for new opt-outs is 5:00 p.m. on July 2, 2020. Failure to provide documentation will result in denial of elections.

The future belongs to those who prepare for it today



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2020-21 PREMIUM COMPARISON COUNTY AND TEAMSTERS LOCAL 1932Medical Plans – Employee Cost Comparison

Rates Effective July 6, 2020 Coverage Effective July 18, 2020

Plan Coverage Type

Medical Premium

Subsidy (MPS)

County Plan 2020-21

Bi-Weekly Rates*

County Plan Employee

Out-of-Pocket

Teamsters Plan 2020-21

Bi-Weekly Rates*

Teamsters Plan Employee

Out-of-Pocket

BLUE SHIELD OF CALIFORNIA HMO Platinum Plan EE $240.72 $274.09 $33.37 $269.72 $29.00$10 copay EE+1 $452.80 $546.19 $93.39 $541.80 $89.00$0/admit; no charge EE+2 $640.14 $772.03 $131.89 $768.14 $128.00Network: Access+HMO Gold Access+ Plan EE $240.72 $238.13 $0.00 $240.72 $0.00$40 copay EE+1 $452.80 $474.28 $21.48 $474.28 $21.48$100/admit; plus 20% EE+2 $640.14 $670.28 $30.14 $670.28 $30.14$3,500 copay max Cal-yrNetwork: Access+HMO Gold Trio Plan EE $240.72 $240.72 $0.00$20 copay EE+1 $452.80 $472.75 $19.95$100/admit; plus 20% EE+2 $640.14 $664.88 $24.74$3,500 copay max Cal-yrNetwork: TrioPPO Non-Needles Plan EE $240.72 $509.02 $268.30 $509.02 $268.30$10 OV - $250 Ded. EE+1 $452.80 $1,035.30 $582.50 $1,035.30 $582.5080/70% Co-ins. EE+2 $640.14 $1,605.82 $965.68 $1,605.82 $965.68PPO Needles Plan EE $300.39 $574.48 $274.09 $574.48 $274.09$10 OV - $0/$250 Ded. EE+1 $621.89 $1,168.08 $546.19 $1,168.08 $546.19100/70% Co-ins. EE+2 $1,036.83 $1,808.86 $772.03 $1,808.86 $772.03PPO Bronze Plan (with HSA) EE $147.51 $147.51 $0.00 $147.51 $0.00$20 OV - $4,000 Ded. EE+1 $293.01 $293.01 $0.00 $293.01 $0.0080/50% Co-ins., $100 Ded. EE+2 $413.77 $413.77 $0.00 $413.77 $0.00KAISER PERMANENTE - SOUTHERN CALIFORNIAHMO Platinum Plan EE $240.72 $313.40 $72.68 $313.40 $72.68$10 copay EE+1 $452.80 $624.78 $171.98 $624.78 $171.98$0/admit; no charge EE+2 $640.14 $883.21 $243.07 $883.21 $243.07Network: Access+HMO Gold Plan EE $240.72 $272.16 $31.44 $272.16 $31.44$40 copay EE+1 $452.80 $542.31 $89.51 $542.31 $89.51$100/admit; plus 20% EE+2 $640.14 $766.53 $126.39 $766.53 $126.39$3,500 copay max Cal-yr*Note: Includes County, Medical Plan management fee of $2.01

Teamsters 1932 Exclusive Plan●●●●● 2020 - NEW PLAN ●●●●●

2020-21 BI WEEKLY PREMIUM RATE TABLE*Active Employees and Eligible Dependents

Rates Effective July 6, 2020 Coverage Effective July 18, 2020

HMO Platinum Plan Employee Only $2.53 $2.53 0.00 0.00%

***Note: Includes County, Vision Plan management fee of $0.23

EyeMed Vision

Plan Coverage Type

County Plan 2019-20

Bi-Weekly Rates*

Teamsters 2020-21

Bi-Weekly Rates*

Dollar Change

Percentage (%)

Change

HMO Platinum Plan Employee Only $259.42 $269.72 $10.30 3.97%$10 copay Employee + 1 $516.84 $541.80 $24.96 4.83%$0/admit; no charge Employee + 2 $730.51 $768.14 $37.63 5.15%Network: Access+HMO Gold Access+ Plan Employee Only $225.40 $240.72 $15.32 6.80%$40 copay Employee + 1 $448.81 $474.28 $25.47 5.68%$100/admit; plus 20% Employee + 2 $634.24 $670.28 $36.04 5.68%$3,500 copay max Cal-yrNetwork: Access+HMO Gold Trio Plan Employee Only $225.40 $240.72 $15.32 6.80%$20 copay Employee + 1 $448.81 $472.75 $23.94 5.33%$100/admit; plus 20% Employee + 2 $634.24 $664.88 $30.64 4.83%$3,500 copay max Cal-yrNetwork: TrioPPO Non-Needles Plan Employee Only $481.68 $509.02 $27.34 5.68%$10 OV - $250 Ded. Employee + 1 $979.58 $1,035.30 $55.72 5.69%80/70% Co-ins. Employee + 2 $1,519.33 $1,605.82 $86.49 5.69%PPO Needles Plan Employee Only $543.61 $574.48 $30.87 5.68%$10 OV - $0/$250 Ded. Employee + 1 $1,105.20 $1,168.08 $62.88 5.69%100/70% Co-ins. Employee + 2 $1,711.42 $1,808.86 $97.44 5.69%PPO Bronze Plan (with HSA) Employee Only $147.51 $147.51 $0.00 0.00%$20 OV - $4,000 Ded. Employee + 1 $293.01 $293.01 $0.00 0.00%80/50% Co-ins., $100 Ded. Employee + 2 $413.77 $413.77 $0.00 0.00%

HMO Platinum Plan Employee Only $298.85 $313.40 $14.55 4.87%$10 copay Employee + 1 $595.69 $624.78 $29.09 4.88%$0/admit; no charge Employee + 2 $842.05 $883.21 $41.16 4.89%Network: Access+HMO Gold Plan Employee Only $259.54 $272.16 $12.62 4.86%$40 copay Employee + 1 $517.07 $542.31 $25.24 4.88%$100/admit; plus 20% Employee + 2 $730.82 $766.53 $35.71 4.89%$3,500 copay max Cal-yr*Note: Includes County, Blue Shield and Kaiser Medical Plan management fee of $2.01

DeltaCare USA - DHMO Employee Only $9.88 $9.88 0.00 0.00%Employee + 1 $15.94 $15.94 0.00 0.00%Employee + 2 $20.77 $20.77 0.00 0.00%

Delta Dental - PPO Employee Only $25.09 $25.09 0.00 0.00%Employee + 1 $46.80 $46.80 0.00 0.00%Employee + 2 $80.11 $80.11 0.00 0.00%

**Note: Includes County, Dental management fee of $1.44 and Delta Dental PPO, ASO Fee of $1.02

Delta Dental**

KAISER PERMANENTE - SOUTHERN CALIFORNIA

BLUE SHIELD OF CALIFORNIA

* Premiums do not include any medical/dental premium subsidies you may be eligible for. Please refer to the County Contribution section on page 12.

The best is yet to come


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NOTE: For employees assigned to work in the Needles, Trona, and Baker work locations, the County has established a “Needles subsidy.” The Needles subsidy is paid by the employee’s department and is equal to the amount of the premium difference between the indemnity (i.e. PPO) health plan offered in these specific work locations and the lowest cost health plan pro-vided by the County.

County contribution towards the cost of coverage Through Collective Bargaining, Teamsters Local 1932 negotiated a higher Medical Premium Subsidy (MPS) to be contributed by the County to go toward your medical and dental insurance. The amounts the County pays towards the cost of your cover-age varies by bargaining unit, family size, hire date, plan selection, and the number of hours you work. For specific amounts, refer to the appropriate MOU, exempt compen-sation plan, salary ordinance, or employment contract.

Needles Subsidy DisclosureEmployees who are assigned to work locations in Needles, Trona, and Baker are eligible for the Needles subsidy subject to County/Employer approval.

It is the responsibility of the employee to notify the County’s Employee Benefits and the Trust Administration Office if assigned to a Needles subsidy eligible work location. Conversely, if an employee is receiving the Needles subsidy and their work location changes to a non-eligible location, the employee must notify the County’s Employee Benefits and the Trust Administration Office as soon as they are no longer assigned to a qualifying location.

To designate or change an election for the Needles Subsidy, employees must complete and submit the Premium Deduction Election Form to County’s Employee Benefits and the Trust Administration Office.

If it is discovered that an employee has been receiving the Needles subsidy in error, the County will collect, through payroll deduction, any amount of the subsidy the employee received, but was not eligible.

For specific amounts, refer to the appropriate MOU, exempt compensation plan, salary ordinance, or employment contract at https://teamsters1932.zenith-american.com or http://cms.sbcounty.gov/hr/EmployeeRelat ions/ MemorandasofUnderstanding.aspx

CONTACT INFORMATION

Address Phone Website

Teamsters Local 1932 Health and Welfare Trust Administration Office:

Zenith American Solutions

P.O. Box 571

San Bernardino, CA 92402-0571

433 N. Sierra Way

San Bernardino, CA 92410

(909) 494-2916 (866) 484-1337

Fax:

(909) 789-1311


Board of Retirement (SBCERA)

348 W. Hospitality Lane

Third Floor


(909) 885-7980

(877) 722-3721

www.sbcera.org

San Bernardino County Employee Benefits Office

157 West Fifth Street

First Floor

San Bernardino, CA 92415

Interoffice Mail Code: 0440

Email: [email protected]

(909) 387-5787 www.sbcounty.gov/benefits

Additional Benefits Offered to all County Employees

� AD&D

� Life

� Combined Giving Campaign

� Dependent Care Assistance Program (DCAP)

� Leave Cash-Out/Conversion

� Life Events

� Long-Term Disability

� Medical Emergency Leave

� Modified Benefit Option

� Protected Leaves

� Retirement Medical Trust Salary Savings

� Short-Term Disability

Commuter Services [email protected]

(909) 387-9640 http://www.sbcounty.gov/ rideshare

www.sbcounty.gov/rideshare



http://cms.sbcounty.gov/hr/EmployeeRelations/MemorandasofUnderstanding.aspx





http://www.sbcera.org/

mailto:[email protected]

http://www.sbcounty.gov/benefits

http://www.sbcounty.gov/benefits



http://www.sbcounty.gov/rideshare





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Address Phone WebsiteFlexible Spending Account (FSA)

[email protected] (909) 387-5648 http://cms.sbcoun-ty.gov/hr/ Benefits/TaxSavings(DCAP,FSA, Section125)/MedicalExpense ReimbursementPlan.aspx

Wellness Program

My Health Matters!

Steps to Success (ac-tivity tracking portal)

Employee Discount Program

[email protected] (909) 387-5787 http://cms.sbcoun-ty.gov/hr/ Benefits/WellnessProgram.aspx

https://www.healthycom-munity. ca/sbhr/default.aspx

https://sbcounty.perkspot.com

CONTACT INFORMATION – PROVIDERS

Address Phone Website

Providers:

Blue Shield of California

(HMO, PPO and Needles PPO)

P.O. Box 272540 Chico, CA 95927-2540

(855) 599-2657 www.blueshieldca.com/teamsters1932.com

Blue Shield Mental Health Service Administration (MHSA), includes substance abuse services (HMO, PPO and Needles PPO)

Blue Shield of California MHSA

P.O. Box 719002

San Diego, CA 92171-9002

(877) 263-9952 www.blueshieldca.com

Address Phone WebsiteBlueShield of California (HMO, PPO and Needles PPO) Telemedicine

Telephone and Video appointments are available 24/7 for non-emergency conditions such as allergies, colds, coughs and upper respiratory infections

(800) Teladoc

(800) 835-2362

Register online at: www.teladoc.com/bsc

DeltaCare USA (DHMO)

Delta Dental Insurance Company

P. O. Box 1803 Alpharetta, GA 30023

(800) 422-4234 www.deltadentalins.com

Delta Dental PPO Delta Dental of California 560 Mission Street

San Francisco, CA 94105

(855) 244-7323 www.deltadentalins.com

EyeMed Vision P.O. Box 8504

Mason, OH 45040-7111

(877) 406-4146 www.eyemed.com

Kaiser Permanente P.O. Box 7004

Downey, CA 90242-7004 (Claims Administration)

(800) 464-4000 www.kp.org

Kaiser Permanente Mental Health Offices and Services

(866) 205-3595 Appointments

(800) 900-3277 Member help line, after hours, weekends & holidays

www.kp.org

Kaiser Permanente Release of Information (for disability and protected

leaves certification paperwork)

17284 Slover Ave., Palm Court II, Suite 202

Fontana, CA 92337

(909) 609-3200

Kaiser Permanente Telemedicine

Telephone Appointments are available Monday – Friday 7am to 7pm for non-emergency condi-tions such as allergies, colds, coughs and upper respiratory infections

(888) 750-0036 – Fontana and Ontario

MedicalCenter

(866) 984-7483 – Riverside and Moreno Valley

Medical Center

(800) 780-1277 – Baldwin Park Medical Center

*Out of area – Call number on back of your

card.


http://cms.sbcounty.gov/hr/Benefits/TaxSavings(DCAP%2CFSA%2C%20Section125)/MedicalExpenseReimbursementPlan.aspx








http://cms.sbcounty.gov/hr/Benefits/WellnessProgram.aspx




https://www.healthycommunity.ca/sbhr/default.aspx






http://www.blueshieldca.com/teamsters1932.com

http://www.blueshieldca.com/teamsters1932.com

http://www.blueshieldca.com/

http://www.teladoc.com/bsc


http://www.deltadentalins.com/

http://www.deltadentalins.com/

http://www.eyemed.com/

http://www.kp.org/

http://www.kp.org/


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TEAMSTERS LOCAL 1932 HEALTH and WELFARE PLANSUMMARY OF BENEFITS AND COVERAGEYou may view Summary of Benefits and Coverage (SBC) information for the Teamsters Local 1932 Health and Welfare Trust Fund’s medical plans online at https://teamsters1932.zenith-american.com.

BENEFIT ELIGIBILITYTo be eligible for the benefits listed in this guide you must meet ALL of the following criteria:

1. Be offered benefits through a MOU, exempt compensation plan, salary ordinance, or employment contract

2. Be an employee in a regular position scheduled to work a minimum of 40 hours per pay period

3. Have received pay for at least one half of your scheduled hours, plus one hour (or be on an approved leave pursuant to applicable law).

DEPENDENT ELIGIBILITYIf you are eligible to participate in the Teamsters sponsored medical and dental plans, your eligible dependents may also participate. Your eligible dependents are:

üYour legal spouseüState registered domestic partnerüYour children up to age 26

� Naturally born child, legally adopted child, a step-child, registered domestic partner’s child or a child that is under your permanent legal guardianship

� Your children over age 26 who are permanently mentally or physically disabled and rely on you for support, subject to carrier approval

üQualifying relativeGrandchildren (in limited circumstances, for Kaiser Permanente members only).

The following documents may be used as proof of relationship:

üQualifying Child/Relative: � Photocopy of birth certificate (legal or hospital) or verification of birth (e.g., Kaiser hospital

printout of birth) — not keepsake or handwritten � Photocopy of a certificate of baptism (must include date of birth and show employee as

parent) � Photocopy of marriage certificate (legal or church — not keepsake or handwritten) � Photocopy of court documents for: � Adoption � Placement � Custody � Legal guardianship � Other court order stating dependent status � Other court order stating benefit coverage must be provided � Disabled dependent certification completed by physician for dependent age 26 or older.

Contact Zenith American Solutions at (909) 494-2916 for detailed information.

üDomestic Partner: � — Photocopy of the certificate of state registered domestic partnership or equivalent out-

of- state certificate (for more information on domestic partnership information in the State of California https://www.sos.ca.gov/registries/domestic-partners-registry/

Required documentation must be sent to Teamsters Local 1932 Health and Welfare Trust. The Trust Administration Office may refer you to Employee Benefits for items not administered through the Trust.

Submit required documentation to: Teamsters Local 1932 Trust Administration OfficeP.O. Box 571


County of San BernardinoEmployee Benefits157 West Fifth Street, 1st FloorInteroffice Mail Code: 0440 Fax: (909) 387-5566Email: [email protected]

If you are directed to submit items to Employee Benefits, be sure to write your employee ID number on the top right corner of each page you submit.

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https://www.sos.ca.gov/registries/domestic-partners-registry/



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ENROLLMENT

As a condition of County employment, if you are an eligible employee, you must enroll in the Teamsters Local 1932 Health and Welfare Trust, or a County-sponsored medical and dental plan unless you have other employer-sponsored group medical and/or dental insurance. Premiums for the Teamsters Local 1932 Health and Welfare Trust or County- sponsored medical and dental insurance will be deducted from your paycheck.

If you are an active employee, enrolled in the Teamsters Local 1932 Health and Welfare Trust or a County-sponsored medical plan, and reach age 65, you will be given the option of remaining on the County-sponsored plan or electing coverage under Medicare Parts A and B. You will be notified of this option just prior to turning 65.

Benefits Calculator Available OnlineThe benefits calculator can help you determine how much bi-weekly out-of-pocket expense you will have and is available for use on the Employee Benefits at web page. You can access this calculator through the Internet at https://teamsters1932.zenith-american.com.

Opt-Outs and Waives of Coverage to County EmployeesIf you have other employer-sponsored group medical and/or dental insurance that offers coverage comparable to the Teamsters Local 1932 Health and Welfare Trust or County-sponsored plan, or are covered by another County employee, you may elect to opt-out of the Teamsters Local 1932 Health and Welfare Trust or County- sponsored medical and/or dental insurance or waive coverage to the subscribing employee.

If you are newly opting-out during this annual open enrollment, you must provide proof of other employer-sponsored group insurance that includes the effective date of the coverage. If you fail to provide the required documentation by 5:00 p.m., July 2, 2020, your previous County-sponsored medical and/or dental plan coverage will be reinstated. If you are newly waiving to another County employee during this annual open enrollment, you will be required to provide their name and employee identification number.

If you are currently opted-out/waived from the medical and/or dental plans and have no changes to the coverage on file, no further action is needed.

New employees and employees making mid-year changes must complete the Change Form and submit it to Teamsters Trust Administration office.

Medical and Dental Plan ID CardsWithin a month of the effective date of your coverage, you should receive identification (ID) cards from your medical and dental plans. You may, however, begin using your medical and dental benefits before receiving your ID cards by contacting the insurance carriers to request your member identification information over the phone. If you do not receive your ID cards, or if you need replacement cards, please refer to plan contact information on page 6 of

this guide. You can also request or print out your ID cards online at the plan website(s). If you have a problem accessing care, call Zenith American Solutions at (909) 494-2916 or email [email protected].

Life EventsAt times in your life, you will have changes in your family that may affect your benefits. When this occurs, you have 60 days to make benefit elections when you experience any of the following life events:

New Hire: New employees have an opportunity to make their initial before or after tax election within the first pay period following their hire date. Failure to make an initial election will result in an automatic enrollment into the lowest cost health and dental plans available on an after-tax basis. If you are automatically enrolled in a plan, you have sixty (60) days from your date of hire to change your election. This is considered a mid-year qualifying life event. Please see below for more information regarding mid-year changes.

Open Enrollment: During open enrollment, you have an opportunity to change your current before-tax or after-tax elections through EMACS. If you do not wish to make changes to your current elections, they will automatically continue with the exception of FSA.

Mid-Year Change: Plan elections are irrevocable for the plan year, unless a qualifying mid-year life event is experienced. Mid-year benefit plan changes must:

1. Be consistent with the qualifying event

2. Meet the guidelines of County contracts/agreements, plan documents and IRC Section 125

3. Be received by Employee Benefits within 60 days of the qualifying life event*

*Submit your mid-year change paperwork within the 60-day timeframe even if you are waiting to receive official documents (e.g., birth certificates, marriage certificates).

To view a summary of the most common life events, please refer to the Life Event Chart on the following pages 37-40

Effective Date of Mid-Year Changes: All mid-year changes have a deadline of 60 days from when they occur, however, elections made within 30 days of hire or a HIPAA special enrollment change-in-status event (e.g., gain of a dependent through birth, marriage, or adoption) will be processed retroactively. All other elections shall become effective on a prospective basis. Elections will be effective the first pay period that follows the date the completed Premium Deduction Election form and applicable enrollment forms and supporting documentation are received by the Fund’s Administrative Office.

If your coverage ended while on leave, upon your return from leave and gain of eligibility for benefits, you will be automatically re-enrolled in the medical and dental plans you had prior to




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going on leave with employee-only coverage. You will be billed for any premiums owed on an after-tax basis.

You will be responsible for re-enrolling any dependents whose coverage was terminated within 60 days of your return from leave. You will be billed for any premiums owed as a result of the addition of eligible dependents. If the life event results in a decrease in premiums, you will receive a refund on a subsequent pay warrant for the premium overpayment. To reduce the amount of premiums owed or to avoid incurring an overpayment of premiums, you are encouraged to submit your paperwork as soon as possible.

FOR NEWBORN CHILDREN: Newborn children must be enrolled in plan coverage to receive benefits under the plan. Failure to enroll your newborn in a plan will result in your newborn not having coverage from date/time of birth forward. Please note, should this occur you will be liable for any services and/or expenses incurred.

To enroll your newborn, submit completed mid-year change paperwork to the Fund’s Administrative Office or your payroll specialist within 60 days of the newborn’s date of birth. Please note, pursuant to IRS regulations and the Teamsters plan document, newborn coverage is made effective the first pay period following the newborn’s date of birth. You are encouraged to submit paperwork as soon as possible to avoid incurring multiple premiums as a result of retroactive coverage. Remember to submit your mid-year change paperwork within the 60-day timeframe even if you are waiting to receive the newborn’s official birth certificate.

Blue Shield Members: The newborn will be assigned under the medical group to which the mother (parent) is assigned for the first 30 days following birth; after 30 days they will be assigned to the physician/group designated on the enrollment form.

Kaiser Members: The newborn will automatically be covered for 31 days from the date of birth.

If you need assistance or have questions regarding mid-year change paperwork to enroll a newborn, please contact the Trust Administrative Office at (909) 494-2916.

TEAMSTERS LOCAL 1932 HEALTH AND WELFARE TRUST ONLINE ENROLLMENT INSTRUCTIONSJune 1 – 21, 2020

As a Teamsters Local 1932 member, you now have the choice of selecting the Teamsters Health Plan, which is the same or better than what you can select from the County’s Plan. You have the same carrier options under the Teamsters Trust as available under the County. The carriers are BlueShield, Kaiser, Delta Dental and EyeMed.

Visit our secure website at Teamsters1932.zenith-american.com to read more about your benefit options or to view a recorded open enrollment meeting.

Whether you are enrolling during the Trust’s First Annual Open Enrollment, between June 1 – June 21, 2020, or if you have a Qualifying Life Event at a later date, enroll using our convenient online portal at Teamsters1932.zenith-american.com.

IMPORTANT NOTE: You must be a dues paying member to enroll in the Teamsters Local 1932 Health and Welfare Trust. If you are not currently a dues paying member, more information is available from your Union Local at www.Teamsters1932.org.

It Is Simple!If you want to move to the Teamsters Plan and have no changes in the Plan you are enrolled in and no changes to your dependent coverage, for the initial June 2020 Open Enrollment you will be able to use the short enrollment option created by Zenith American Solutions. Just one checkbox and minimal information from you, and you will be moved to the Teamsters Plan, maintaining the same plan options you had under the County.

If you want to move to the Teamsters Plan, but you have an update to your coverage choice or covered dependents, don’t hesitate. There is a distinction in the look and feel from the County’s EMACS site, so that you know you are enrolling in the Teamsters Trust. However, the process is similar to what the County has in place. The online enrollment module is also used to make your Plan selections. It is an easy to use self-serve model.

When you add dependents, proof of dependency is required. The website allows you upload the certified birth or marriage certificate or other documentation easily and securely, which is much faster than mailing them in and significantly safer too.

When logging on to the public page, you will be able to view all of the Plan choices, review resource materials from the carriers, and view benefit comparisons and cost comparisons. Please read the Plan choices carefully.

http://www.Teamsters1932.zenith-american.com

http://www.Teamsters1932.org


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Important note:

To improve your first experience, you should have the names, date of birth and social security number for each person you are enrolling. When logging on to the public page, you will be able to view all of the Plan choices, review resource materials from the carriers, and view benefit comparisons and cost comparisons. Please read the Plan choices carefully.

Login to Enroll for BenefitsTeamsters1932.zenith-american.com

INSTRUCTIONS SCREEN

The website is secure.

1. The first time you log on, you must register for an Account.

• Click on the Create Account button at the top of the screen,

or

• Register for Account button, found on the left side menu

You will register by verifying your identity, create account details, and complete an email based activation procedure. There are three easy steps to create your account.

ü Verify your identity by completing the required fields: o Enter your social security

number or your Employee ID number;

o Enter your first name, last name and date of birth.

ü Create your account: o Enter a valid email address;

re-enter your email address; o Enter your password; re-

enter your password; o Click on the drop down box

to select your security question;

o Enter your answer to the security question.

ü Click on the Register for Access button.

INSTRUCTIONS SCREEN

ü A pop up will display showing you have successfully registered and an email has been sent to you with activation instructions

ü Check your email, and the next step is to activate the account you just created. You should be routed to the Account Activation screen. Key in your user name, password and activation code retrieved from the email account you provided while creating your account.



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INSTRUCTIONS SCREEN

ü You will receive a pop-up that shows Activation Successful

ü Click OK.

YOUR ACCOUNT IS ACTIVATED YOU ARE READY TO ENROLL

¨ Once you have activated your account, you are ready to log into the Participant Portal on the main page

¨ Key in your user name and password and click on the button, Log Into Your Account.

¨ It is recommended to have the names, date of birth and social security number for each person you are enrolling when you begin the enrollment process.

Important note:

The online session will expire after 30 minutes of inactivity. Any changes you have made will be lost if you have not completed the enrollment process.


The first time (only) you log into your account, you will see the Terms of Use language.

o continue with the enrollment process, check the box to agree with the terms and use, and click continue.

Click on the Enroll Now button, or Enrollment Form. You will be directed to the Online Enrollment page.

To


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The Online Enrollment page displays your current Plan choices with the County. There are two buttons to choose from:

1) No Plan Changes;

-OR -

2) Change Plan or Make Plan Changes.

ü If you would like to enroll in the Teamsters Local 1932 Plan and want to stay on the same Plan you had with the County, and you have no dependent changes to make, click the short enrollment form option:

ü xx No Plan Changes.

Your enrollment is complete! You are enrolled in the same coverage and Plans you had with the County.

ü If you would like to enroll in the Teamsters Plan and would like to change medical and/or dental benefit plans, or have a change in dependent coverage, click on the button: xx Change Plan or Make Plan Changes.


a. Review the Participant Information page for accuracy. This is the information the County has on file for you. If any portion is inaccurate, please contact the Human Resources department at the County of San Bernardino to update, once your enrollment has been completed.

b. Click continue. c. All dependents who were

covered under the County’s Plan will pre-populate.

d. Click on the button, Enroll or Remove, for each dependent you would like to enroll in the Teamsters Plan. When clicking Enroll, the background color will turn green. When clicking Remove, the background color will turn red.

e. Click on the edit icon (pencil) button to edit your dependent’s information. Important Note: You must key in the social security number for each of your dependents.

f. If you have new dependents to add to your Plan, click the Add New button located at the bottom of the page. Click the Save button.

i. If the dependent you are adding has a different address than you, scroll down using the gray bar on the right side of the text box and key in their address.

ii. Click the save


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button. g. The new dependent will

now display on your dependent screen. Click the Enroll button.

h. You can continue to add dependents. Once completed, click Continue.

2. Medical Plan Selection – You have a new option to choose from, in addition to the Plans you had under the County. When selecting the Medical Plan option of your choice, you must select Before Tax (BTX) or After Tax (ATX). When selecting Before Tax or After Tax for your medical plan, the same choice must be made for your dental plan.

a. Blue Shield HMO Gold Trio ($20 co-payment) – New Option

b. Blue Shield HMO Platinum POS ($10 co-payment)

c. Blue Shield HMO Gold Access+ ($40 co-payment)

d. Blue Shield PPO (Non Needles)

e. Blue Shield PPO Needles f. Kaiser Gold Choice g. Kaiser Platinum Plus


3. Select the medical plan option that best suits you and your family’s needs and click the button, Choose This Plan.

a. Once selecting your plan, you will need to click on the box next to each family member to be enrolled under your plan.

b. If you are selecting a Blue Shield HMO or POS Plan, you will need to enter the Primary Care Provider (PCP) Identification Number, or click on the option for Blue Shield to pick a PCP for you and/or your dependents.

c. If you request Blue Shield to select a PCP for you, one will be chosen in your geographical area.

d. Scroll to the bottom of the page and click Continue.

4. If you want to Waive/Opt Out of medical coverage, scroll to the bottom of the page and click on the Waive/Opt Out button.

a. You will be required to provide the Fund’s Administrative office proof of other coverage on or before July 2nd at 5:00 p.m. You can submit the documentation via secure email to [email protected]; or mail to Teamsters Local 1932 Health and Welfare Trust, P.O. Box 571, San Bernardino, CA, 92402-0571.


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5. Select the Dental option that best suits your family’s needs.

a. Once you’ve selected your Plan, click on each family member you are enrolling in your Dental Plan.

b. Click Continue.

6. Vision Plan a. Employee only coverage is

paid for by the County. Click Continue.


7. Review your enrollment information.

a. Review the Plan selections for you and each of your family members.

b. Review your bi-weekly benefits cost, based upon your Plan selections.

c. If there are no changes, click the Authorize box at the bottom of the screen verifying you have reviewed all information.

d. An Authorization box will display; scroll down using the gray bar on the right side of the text box. Click the Accept button.

e. Click the Submit button. f. You will receive a message

noting that your enrollment is complete. The message will include a reference number.

8. There is a dashboard on the left side of the screen that will appear each time you log into your account.


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9. You can upload supporting documents, such as marriage certificates or birth certificates when adding new dependents, and have them attached to your electronic file.

There are Customer Service Representatives to assist you in completing your enrollment form, and answer any questions you may have. Contact us at 909-494-2916 or (866) 484-1337 Monday through Friday from 8:00 a.m. – 5:00 p.m. PST.

Other benefits are available to you through your employer. Make sure you also review your other benefit enrollment opportunities on the Employee Benefits section of the County’s portal.


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Eligibility for Your Dependent Requires Proof of Dependency

Forms should be the certified versions that reflect that they have been filed with the appropriate State or County records office. For example, there is often a ceremonial marriage certificate produced. The Trust requires a copy of the marriage certificate that was filed and recorded with State.

Provide the full Social Security Number of each dependent you enroll. Federal regulations require health plans to report the names and Social Security Numbers of every covered individual to the IRS.

Dependent Acceptable DocumentationDependent Child Birth Certificate

Certificate of Baptism showing member as parent

Custody Agreement

Guardianship papers

Legal adoption or placement papers

Dependent added after loss of prior insurance

Also submit a Statement of prior insurance company in-cluding the date coverage ended

Overage Dependent Child

(Age 26+ with Disability)

Also submit a Disabled Dependent Certification completed by physician

Divorce Divorce Decree.

Domestic Partnership Domestic Partnership Registered by the State

Marriage Marriage Certificate

Contact the Fund Administration office at 909-494-2916 with questions

OVER AGE DEPENDENT:

Over Age Dependent (OAD)*Dependent Relationship to Subscriber

Blue Shield Kaiser Delta Dental HMO and PPO

Disabled Dependent over the age of 26 Defined as Unmarried, dependent child who is primarily dependent upon the insured for support due to mental incapacity or physical handicap and if a Physician’s written certification is submitted annually for as long as disability continues.

New Hires: May enroll a disabled dependent within 60 days of hire.

Subject to receipt and approval of Physician’s certification.





Continued Enrollment: Disabled dependents must be enrolled in the plan upon attaining the age of 26 in order to continue enrollment. If the disabled dependent discontinues enrollment at any time after attaining age 26, they will not be allowed to re-enroll for coverage (e.g. there must be no break in coverage).

Continued Enrollment:

No prior enrollment requirement.


Continued Enrollment: Disabled dependents must be enrolled in the plan upon attaining the age of 26 in order to continue enrollment. If the disabled dependent discontinues enrollment at any time after attaining age 26, they will not be allowed to re-enroll for coverage (e.g. there must be no break in coverage).

*Subject to carrier approval

LIFE EVENTS CHART, MID-YEAR CHANGE:

QUALIFYING LIFE EVENT MEDICAL/DENTAL/ VISION DOCUMENTATION REQUIRED

Gain of dependent(s)

• marriage

• domestic partnership

• birth/adoption/ placement for adoption

Employee may enroll newly eligible dependent(s)

To enroll dependent(s) in health benefits, you must submit the following within 60-days of event:

• marriage certificate, state registered domestic partner certificate and/or birth certificate(s) or hospital printout of birth

• Adoption or Placement for Adoption court order

Loss of dependent(s)

• divorce or annulment

• domestic partnership termination

• death

Employee must remove dependent; may enroll self and eligible dependent(s)

To remove or enroll self/dependent(s) in health you must submit the following within 60-days of event:

• Medical/Dental/ Vision Plan Enrollment-Change Form

• divorce, legal separation, annulment, or termination of domestic partnership decree

• death certificate• marriage/birth certificate(s)


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Judgment, decree, or order resulting from divorce, annulment or change in legal custody that requires medical/ dental coverage for your dependent child(ren)

Employee may enroll dependent(s)

To enroll dependent(s) in health benefits, you must submit the following within 60-days of event:


• judgment, decree or order• birth certificate(s)

Gain of coverage through spouse/domestic partner’s employer or other change-in-status that results in eligibility under spouse/domestic partner’s plan

Employee may opt-out (self) and/or remove dependent(s)

To remove self/dependent(s) from health benefits, you must submit the following within 60-days of event:


• proof of spouse/domestic partner’s employer-sponsored coverage that includes the effective date

Dependent gain of coverage through a federal or state healthcare exchange

Employee may remove dependent(s). Note that dependents that drop Teamsters sponsored coverage as a result of gaining federal or state healthcare exchange coverage will not be allowed to re-enroll in a Teamsters plan until the next open enrollment period.

To remove dependent(s) from medical benefits, you must submit the following within 60-days of event:

• Medical Plan Enrollment Form• proof of other coverage and effective date

Loss of spouse’s/domestic partner’s employment

Employee must enroll self if coverage is lost and may enroll dependent(s)

To enroll self/dependent(s) in health coverage, you must submit the following within 60-days of event:


• proof of spouse’s employment and benefit plan loss that includes loss of coverage effective date

• marriage/birth certificate(s)

Change in employment status (e.g., part time to full time status)

Employee may elect to enroll self and dependent(s) if change caused employee to gain eligibility

To enroll self/dependent(s) in health, you must submit the following within 60-days of event:


• proof of employment status change


Dependent ceases to satisfy plan eligibility requirements (i.e. overage disabled dependent)

Employee must remove dependent(s)

To remove dependent(s) from health benefits or to decrease annual election amount, you must submit the following within 60-days of event:



Dependent reaches age 26 (OAD) and relies on you for support and is permanently mentally or physically disabled

Employee may elect to keep dependent enrolled

To keep dependent enrolled in health benefits, you must submit the following within 60-days of event:

• Disabled Dependent Certification

Over Age Dependent (OAD) loses coverage under other parent’s employer sponsored plan

Employee may elect to enroll over age dependent

To enroll over age dependent in health benefits, you must complete the following within 60-days of event:


• Disabled Dependent Certification

• proof of loss of coverage

• birth certificate

Commencement of unpaid leave of absence

Contributions for health benefits will automatically cease and employee will be responsible for premium payments; failure to pay premiums will result in termination of coverage

No paperwork required for health benefits cessation.

Return from unpaid leave of absence

If coverage terminated, employee may enroll dependent(s)

To enroll or reinstate dependent(s), you must submit the following within 60-days of event:



Residence change results in gain or loss of eligibility

Employee may enroll or remove dependent(s)

To remove dependent(s) from health benefits, you must submit the following within 60 days of event:

• Medical/Dental/Vision Plan Enrollment-Change Form

• proof of residence change

• marriage/birth certificate(s) (enroll only)Self or dependent(s) be-comes entitled or loses eligibility for Medicare or Medicaid

Employee may enroll or opt- out yourself or enroll or remove dependent(s)

To enroll or opt-out yourself or enroll/remove depen-dent(s) from health benefits you must submit the following within 60 days of event:

• Medical/Dental/Vision Plan Enrollment-Change Form

• Opt-Out/Waiver Agreement

• proof of gain/loss of Medicare or Medicaid



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BLUE SHIELD

HMO PLATINUM POS PLAN

($10-$30 COPAY)

BLUE SHIELD

HMO GOLD ACCESS+ PLAN

($40 COPAY)

BLUE SHIELD

HMO GOLD TRIO PLAN

($20 COPAY)

BLUE SHIELD

PPO NON-NEEDLES PLAN

KAISER

HMO PLATINUM PLAN

($10 COPAY)

KAISER

HMO GOLD PLAN

($40 COPAY)

LEVEL I - HMO LEVEL II - PPO ACCESS+HMO TRIO HMO PARTICIPATING PROVIDER NON-PARTICIPATING PROVIDER KAISER KAISER

Plan Network Blue Shield Access+ HMO Network

Blue Shield

PPO NetworkBlue Shield Access+ HMO Network

Blue ShieldTrio HMO Network

Shield PPO Network(includes Blue Card Program access)

Out-of-Network Kaiser physicians and facilities only

Kaiser physicians and facilities only

Calendar year (CY)Deductible com-bined PPO/OON

None None None None$250 per individual$500 per family

$250 per individual$500 per family

None None

Hospital or Ambulatory Surgical Center deductible

None Not covered None None None None None None

Lifetime benefits maximum None None None None None None None None

Out-of-Pocket annual maximum

$1,500 per individual

$3,000 per family$8,00 per individual$16,000 per family


$7,000 per family


$7,000 per family


$3,000 per family


$4,500per family


$3,000 per family


$7,000 per family

Preexisting condition Fully covered Fully covered Fully covered Fully covered Fully covered Fully covered Fully covered Fully covered

Office/Outpatient Care

Office Visits – Primary Care Physician (PCP) $10 copay $30 copay $40 copay $20 copay

$10 copay(deductible does not apply)

You pay 30% after CY deductible $10 copay $40 copay

Office Visits – Specialist (self-referral within assigned PCP’s medical group)

N/A N/A $50 copay $20 copay N/A N/A N/A N/A

Office Visits -Specialist $10 copay $30 copay$40 copay(referred by PCP)

$20 copay(referred by PCP)

$10 copay(deductible does not apply)


Tele-MedicineCovered through Teladoc 24/7 – No charge

Covered through Teladoc 24/7 – No charge

Covered through Teladoc 24/7 – No charge

Covered through Teladoc 24/7 - No charge

Covered through Teladoc 24/7 – No charge Not covered No charge No charge

Preventive Services No charge $30 copay No charge No chargeNo charge(CY deductible waived)

You pay 30% after CY deductible No charge No charge

Hearing screenings No charge $30 copay No charge No chargeNo charge(deductible does not apply)


Immunizations No charge $30 copay No charge No chargeNo charge(deductible does not apply)


Tubal ligation No charge Not covered No charge No chargeNo charge(deductible does not apply)


Vasectomy $10 copay/surgery Not covered $10 copay/surgery $20 copay/surgery You pay 20% after CY deductible


Well baby/Well child care No charge $30 copay No charge No chargeNo charge(deductible does not apply)


Well woman exam (annual) No charge $30 copay No charge No charge

No charge(deductible does not apply)


Emergency Medical Care

AmbulanceNo charge(for emergency or authorized transport)

No charge(for emergency or authorized transport)

No charge (for emergency or authorized transport)

No charge(for emergency or authorized transport)

You pay 20% after CYDeductible (for emergency or authorized transport)

You pay 20% after CY deductible (for emergency or authorized transport)

No charge when medically necessary

$150 copay when medically necessary


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BLUE SHIELD


($10-$30 COPAY)

BLUE SHIELD


($40 COPAY)

BLUE SHIELD

HMO GOLD TRIO PLAN

($20 COPAY)

BLUE SHIELD


KAISER

HMO PLATINUM PLAN

($10 COPAY)

KAISER

HMO GOLD PLAN

($40 COPAY)

Emergency room(if admitted to the Hospital, see Hospitalization Services for cost share)

$50 copay/visit (does not apply if admitted)

$50 copay/visit(does not apply if admitted)



$50 copay/visit plus 20% after CY deductible; copay does not apply if admitted

Physician: 20% after CY deductible

$50 copay/visit plus 20% after CY deductible; copay does not apply if admitted

Physician: 20% after CY deductible

$50 copay (does not apply if admitted)

$150 copay (does not apply if admitted)

Urgent care $10 copay $10 copay $40 copay $20 copay $10 copay (deductible does not apply) 30% after CY deductible $10 copay $40 copay

Diagnostic Services

Laboratory and Pathology Tests No charge No charge

Outpatient department of Hospital – No chargeOther – You pay 40%


You pay 20% after CY deductible

You pay 30% after CY deductible No charge $10 copay.

Diagnostic Tests and X-Ray No charge

Covered only when performed in physician’s office

Not covered for CT, MRI, MUGA, PET, and SPECT




You pay 30% after CY deductible No charge

$10 copay

MRI, most CT and PET: $100 copay

Diabetes Care

Covered Diabetic drugs and testing supplies

See “Prescription Drugs”

See “Prescription Drugs”

See “Prescription Drugs” See “Prescription Drugs” See “Prescription Drugs” See “Prescription Drugs” See “Prescription Drugs” See “Prescription Drugs”

Diabetes Self-Management Training & Education

No charge $30 copay Office Visit: $40 copay Office Visit: $20 copay $10 copay (deductible does

not apply)You pay 30% after CY deductible No charge No charge

Devices, Equipment,

and Non-Testing SuppliesNo charge Not covered You pay 40% You pay 40% You pay 20% after CY

deductibleYou pay 30% after CY deductible

See Durable Medical Equipment

See Durable Medical Equipment

Maternity Care

Prenatal and Postnatal office visits No charge You pay 20%

coinsurance No charge No charge $10 copay after CY deductible


Delivery (Professional Services) No charge Not covered No charge No charge You pay 20% after CY

deductibleYou pay 30% after CY deductible No charge No charge

Newborn Care

Newborn covered 30 days; must enroll through the Teamsters 1932 Health Trust within 60 days of birth

Covered under HMO, Level I Benefit

No charge. Newborn covered 30 days; must enroll through the Teamsters 1932 Health Trust within 60 days of birth

No charge. Newborn covered 30 days; must enroll through the Teamsters 1932 Health Trust within 60 days of birth

Newborn covered 30 days; must enroll through the Teamsters 1932 Trust within 60 days of birth

Newborn covered 30 days; must enroll through the Teamsters 1932 Trust within 60 days of birth

Newborn covered 30 days; must enroll through the County within 60 days of birth

Newborn covered 30 days;must enroll through the County within 60 days of birth

Hospital Services

Hospital care

(Hospital and Physician charges)

No charge Not coveredHospital: $100/admission plus 20%

Physician: No charge

Hospital: $100/admission plus 20% Physician: No charge


You pay 30% after CY deductible No charge $500 copay per day


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BLUE SHIELD


($10-$30 COPAY)

BLUE SHIELD


($40 COPAY)

BLUE SHIELD

HMO GOLD TRIO PLAN

($20 COPAY)

BLUE SHIELD


KAISER

HMO PLATINUM PLAN

($10 COPAY)

KAISER

HMO GOLD PLAN

($40 COPAY)

Surgical Services

Hospital – In-Patient Surgical Services

No charge

(Facility and Physician)

Not covered

Facility: $100 admission plus 20%Physician: No charge

Facility: $100 admission plus 20%Physician: No charge

Facility: You pay 20% after CY deductible

Physician: You pay 20% after CY deductible



No charge


Facility: $500 copay per day


Outpatient / Ambulatory Surgery Center

No charge


Not coveredFacility: You pay 40% Physician: No charge

Facility: You pay 40% Physician: No charge





Facility: $10 copay per procedure


Facility: $250 copay per procedure


Alternatives to Hospital Care

Home health servicesNo charge up to 100 visits per calendar year

Not coveredNo charge up to 100 visits per calendar year

No charge up to 100 visits per calendar year

You pay 20% after CY deductible up to 100 visits per calendar year

Not covered No charge up to 100 visits per accumulation period

No charge up to 100 visits per accumulation period

Hospice

No charge; includes routine home care, 24-hour continuous home care, short-term IP care for pain/ symptom management

Not covered

No charge; includes routine home care, 24- hour continuous home care, short-term IP care for pain/symptom management

No charge; includes routine home care, 24- hour continuous home care, short-term IP care for pain/symptom management

No charge (deductible does not apply)

24-hr continuous home care/Short-term inpatient care for pain and symptom mgmt.: You pay 20% after CY deductible

Not covered No charge No charge

Skilled nursing facilities (SNF) No charge Not coveredNo charge up to 100 days per Benefit Period

No charge up to 100 days per Benefit Period

You pay 20% after CY deductible up 100 days per Benefit period - combined PPO/Non-PPO maximum

You pay 20% after CY deductible up 100 days per Benefit period - combined PPO/Non-PPO maximum

Hospital based SNF: You pay 30% after CY deductible

No charge up to 100 days per benefit period

No charge up to 100 days per benefit period

Mental Health Care and Substance Abuse Treatment

MHSA

Participating Provider

MHSA

Non-Participating Provider

MHSA


MHSA


MHSAParticipating Provider

MHSANon-Participating Provider

Outpatient services $10 copay $10 copay$40 copay All other services are no charge

$20 copay All other services are no charge

Outpatient: $10 copay (deductible does not apply)

All other services: You pay 20% after CY deductible


$10 copay per individual$5 copay per group

$40 copay individual;$20 copay groupSubstance abuse: $5 copay group

Inpatient services No charge Not covered

Physician: No chargeHospital services and residential care: $100/ admission plus 20%

Physician: No chargeHospital services and residential care: $100/ admission plus 20%


You pay 30% after CY deductible No charge $500 copay per day


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BLUE SHIELD


($10-$30 COPAY)

BLUE SHIELD


($40 COPAY)

BLUE SHIELD

HMO GOLD TRIO PLAN

($20 COPAY)

BLUE SHIELD


KAISER

HMO PLATINUM PLAN

($10 COPAY)

KAISER

HMO GOLD PLAN

($40 COPAY)

Prescription Drugs

Prescription drugs (per fill)

Includes Diabetic drugs and testing supplies

Retail Pharmacy (30-day supply):Tier 1- $5 copayTier 2 - $10 copayTier 3 - $25 copayTier 4 - $10 copay (excluding specialty drugs)

Specialty Pharmacy:Tier 4 - $10 copay (Specialty Drugs 30- day supply)

Mail order(90-day supply):Tier 1- $10 copayTier 2 - $20 copayTier 3 - $50 copayTier 4 - $20 copay (excluding specialty drugs)

Not covered Retail Pharmacy (30-day supply):Tier 1- $5 copayTier 2 - $10 copayTier 3 - $25 copayTier 4 – 20% up to $200/Rx (excluding specialty drugs)

Specialty Pharmacy:Tier 4 – 20% up to $200/Rx (Specialty Drugs 30- day supply)

Mail order(90-day supply):Tier 1- $10 copayTier 2 - $20 copayTier 3 - $50 copayTier 4 – 20% up to $400/Rx (excluding specialty drugs)

Retail Pharmacy (30-day supply):Tier 1- $5 copayTier 2 - $10 copayTier 3 - $25 copayTier 4 – 20% up to $200/Rx (excluding specialty drugs)

Specialty Pharmacy:Tier 4 – 20% up to $200/Rx (Specialty Drugs 30- day supply)

Mail order(90-day supply):Tier 1- $10 copayTier 2 - $20 copayTier 3 - $50 copayTier 4 – 20% up to $400/Rx (excluding specialty drugs)

PARTICIPATING PHARMACY

Retail Pharmacy (30-day supply):

Tier 1- $15 copay

Tier 2 - $30 copay

Tier 3 - $30 copay

Tier 4 - $15 copay (excluding specialty drugs)

Specialty Pharmacy:

Tier 4 - $15 copay (Specialty Drugs 30- day supply)

Mail order

(90-day supply):

Tier 1- $30 copay

Tier 2 - $60 copay

Tier 3 - $60 copay


NON-PARTICIPATING PHARMACY

Retail Pharmacy (30-day supply):

(Member pays 25% of billed amount plus copay)

Tier 1- $15 copay

Tier 2 - $30 copay

Tier 3 - $30 copay


Specialty Pharmacy:

Not covered

Mail order:Not covered

Pharmacy (up to a 100-day supply): Generic – $10 copayBrand – $15 copay

Most specialty items - $15 copay (up to a 30-day supply)

Mail order (up to a 100-day supply): Generic – $10 copayBrand – $15 copay

Pharmacy (up to a 30-day supply): Generic – $15 copay Brand – $35 copay

Most specialty items: 30%, not to exceed $200 (up to a 30-day supply)

Mail order (up to 100-day supply):Generic – $30 copay

Brand – $70 copay

Pharmacy (retail and mail order) copays do not apply toward the out-of- pocket maximum.

Pharmacy (retail and mail order) copays do not apply toward the out-of- pocket maximum

Pharmacy (retail and mail order) copays do not apply toward the out-of- pocket maximum

Other Services

Allergy testing$10 copayAllergy Serum: No charge

$30 copayAllergy Serum: No charge

$40 copayAllergy Serum: You pay 40% copay

$20 copay Allergy Serum: You pay 40% copay

You pay 20%

You pay 30% after CY deductible Allergy serum: $10 copay Allergy serum: $5 copay

Chiropractic careNot covered Discount program available

Not covered Discount program available

Not coveredDiscount program available

Not coveredDiscount program available

20% after CY deductible up to 30 visits per calendar year combined PPO/Non-PPO maximum

30% after CY deductible up to 30 visits per calendar year combined PPO/Non-PPO maximum

Not coveredNot covered

Durable medical equipment (DME)Breast PumpOrthotic Equipment/devicesProsthetic Equipment

No charge Not covered

DME: You pay 40%No chargeNo chargeNo charge

DME: You pay 40%No chargeNo chargeNo charge

You pay 20% after CY deductibleBreast Pump: No charge

You pay 30% after CY deductibleBreast Pump: Not covered

No charge You pay 50%

Physical and Occupational Therapy

Office Location: $10 copay

Outpatient Dept. of a Hospital: No charge

Office Location: $30 copay (up to 12 visits per calendar year

Outpatient Dept. of a Hospital: Not covered

$40 copay $20 copay You pay 20% (deductible does not apply)



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BLUE SHIELD


($10-$30 COPAY)

BLUE SHIELD


($40 COPAY)

BLUE SHIELD

HMO GOLD TRIO PLAN

($20 COPAY)

BLUE SHIELD


KAISER

HMO PLATINUM PLAN

($10 COPAY)

KAISER

HMO GOLD PLAN

($40 COPAY)

Speech Therapy

Office Location: $10 copay

Outpatient Dept. of a Hospital: No charge

Office Location: $30 copay Outpatient Dept. of a Hospital: Not covered

$40 copay $20 copayYou pay 20% (deductible does not apply)


$10 copay $40 copay

Vision (exam only)

$10 copay(one exam in a con-secutive 12-month period provided through contracted VPA)

$0 up to $60/year plus 100% of addi-tional charges (one exam in a consecu-tive 12-month period provided through contracted VPA)

(Not covered) (Not covered)

You pay 20% self-referred exam per 12 consecutive months, no age limit (Vision plan adminis-trator’s providers only)

You pay 20% self-referred exam per 12 consecutive months, no age limit (Vision plan administrator’s providers only)

No charge No charge

Travel

Network(For urgent care services)

Inside of US: Blue Card Program Outside of US: Blue Shield Global Core ProgramRefer to your EOC






Kaiser facilities in the US.Claim forms required for Out of Area Urgent and ER care

Kaiser facilities in the US.Claim forms required for Out of Area Urgent and ER care

Immunizations for purposes of Foreign Travel $10 copay/injection $30 copay/injection $10 copay/injection $10 copay/injection You pay 20% after CY

deductibleYou pay 30% after CY deductible No charge No charge

Additional Travel Information

provider.bcbs.combcbsglobalcore.com






kp.org (search for “Travel Health”)

kp.org (search for “Travel Health”)

Note! This is a Brief Comparison. Please refer to the Healthplan’s Evidence of Coverage or Summary of Benefits for a detailed description of coverage, limitations and exclusions.

http://provider.bcbs.com

http://bcbsglobalcore.com












http://www.kp.org/

http://www.kp.org/


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DENTAL PLAN COMPARISON CHART

DENTAL PLAN COMPARISONDELTA DENTAL

DHMO

*DELTA DENTAL

DPPO

DeltaCare USA^DELTA DENTAL

PPO DENTISTS**NON-DELTA DENTAL

PPO DENTIST**

Plan Network DHMO Network PPO Network Out-of-Network

Calendar Year (CY)Deductible None None None

Calendar Year Maximums(combined PPO/Non-PPO)

None $1,700 per person $1,700 per person

Does Diagnostic & Preventive apply toward Maximum, No No No

Diagnostic & Preventive Services

Exams, Cleaning, X-rays No charge No charge No charge

Sealant per tooth Copays apply You pay 10% You pay 10%

Basic Services

Fillings, Denture repairs/relining No charge – copays apply No charge You pay 10%

Endodontics

Root canals No charge – copays apply No charge You pay 10%

Periodontics

Gum treatment No charge - copays apply You pay 10% You pay 10%

Oral Surgery

Oral Surgery No charge - copays apply No charge You pay 10%

Major Services

Crowns, Inlays, Onlays, Cast restorations

No charge – copays apply You pay 25% You pay 30%

Prosthodontics

Bridges, Dentures, Implants No charge - copays apply You pay 25% You pay 30%

Orthodontics

Adult/Child No charge – copays apply You pay 50% You pay 50%

Orthodontic Maximums Covers up to 24 months of active treatment, beyond 24, additional fees may apply

$1,7000 Lifetime(combined PPO/Non-PPO)

$1,700 Lifetime(combined PPO/Non-PPO)

^Delta Care USA HMO – Refer to the carrier summary of benefits for a complete description of coverage, exclusions and limitations* Limitations or waiting periods may apply for some benefits, some services may be excluded from your plan. Reimbursement is based on Delta Dental maximum contract allowances and not necessarily each dentist’s submitted fees.**Reimbursement is based on PPO contracted fees for PPO dentists, Premier contracted fees for Premier dentists and program allowances for non-Delta Dental dentists.


CO

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RED BEN

EFITS

County Sponsored BenefitsAs a County employee, you are entitled to or may be eligible for additional benefits. You can contact HR-Employee Benefits and Services for more information by calling 909-387-5787 or emailing [email protected]. These benefits include:

ü Flexible Spending Account (FSA)

ü Dependent Care Assistance Program (DCAP)

ü Short Term Disability (STD)

ü Long Term Disability (LTD)

ü Medical Emergency Leave (MEL)

ü Life Insurance

ü Accidental Death & Dismemberment (AD&D)

ü Retirement Plan Highlights

ü 457(b) Deferred Compensation Plan

ü 401(k) Defined Contribution Plan

ü Retirement Medical Trust Fund

ü 529 Education Savings Plan

ü Commuter Services

ü Sick Leave Conversion

ü Leave Cash Outs

ü Unemployment Insurance

ü Medical and Dental Benefits Upon Retirement

SUMMARY PLAN DESCRIPTION:

TEAMSTERS LOCAL 1932 HEALTH AND WELFARE TRUST

SUMMARY PLAN DESCRIPTIONOF

ELIGIBILITY AND BENEFITS

Effective May 1, 2020

THIS IS A GOVERNING PLAN DOCUMENT

FOR THE BENEFITS OUTLINED HEREIN

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SUMMARY OF BENEFITS AND COVERAGE – ONLINE ACCESSYou may view Summary of Benefits and Coverage (SBC) information for the Teamsters Local 1932 Health and Welfare Trust Fund’s medical plans online at https://teamsters1932.zenith-american.com or on page 91.

TEAMSTERS LOCAL 1932 HEALTH AND WELFARE TRUST 433 North Sierra Way

San Bernardino, California 92410

BOARD OF TRUSTEES

PROFESSIONALS AND CONSULTANTS

TRUSTEESRandel Korgan

Kathleen BrennanLouis Fiorino

Carlos Gonzales (Alternate)Creg Quiroz (Alternate)

CONSULTANTSean Silva, FSA, MAAA, CEBS

Milliman2175 North California Blvd., Suite 810

Walnut Creek, CA 94596

LEGAL COUNSELJoe Kaplon, Esq. and Michael Odoca, Esq.Wohlner Kaplon Cutler Halford & Rosenfeld

16501 Ventura Blvd., Suite 304Encino, CA 91436

TRUST ADMINISTRATION OFFICEZenith American Solutions

P.O. Box 571San Bernardino, CA, 92402-0571

433 N. Sierra WaySan Bernardino, CA 92410

“ This is what unions are all about: when we

come together as workers, we improve

our ability to win fair compensation for

our work. In the immediate and over the

long-run, this dynamic is what creates

financial stability at home and in our

communities. ”

- RANDY KORGAN

SECRETARY-TREASURER/PRINCIPAL OFFICER




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TABLE OF CONTENTS Page

An Important Message to Participants ...........................................................................58

Eligibility Rules for Employees and Dependents ............................................................60

Employee Eligibility ...............................................................................................................60

Continuing Eligibility ..............................................................................................................60

Dependent Eligibility .............................................................................................................61

Enrollment for Benefits ......................................................................................................62

Employee Enrollment ............................................................................................................62

Default Enrollment Policy .....................................................................................................63

Dependent Enrollment .........................................................................................................65

Enrollment of Domestic Partners .........................................................................................65

Special Enrollment - Health Information Portability and Accountability Act.................67

Special Enrollment Rights Under “SCHIP” ...........................................................................67

Special Enrollment Under a Qualified Medical Child Support Order ............................. 68

Termination of Coverage .................................................................................................68

Extensions of Coverage During Leaves of Absence .....................................................70

Military Leave ........................................................................................................................70

Family and Medical Leave Act ...........................................................................................71

Continuation Coverage Under COBRA ............................................................................. 73

Individual Conversion Privilege Option .............................................................................. 80

Legislation Affecting Health Care Benefits ....................................................................80

Medi-Cal Health Insurance Premium Program (HIPP) ...................................................... 80

Certificate of Group Health Coverage .............................................................................. 80

Health Insurance Portability and Accountability Act (HIPAA) ......................................... 81

Notice of Privacy Practices – General Information .......................................................... 81

The Women’s Health and Cancer Rights Act .................................................................... 87

Newborns’ and Mothers’ Health Protection Act of 1996 ................................................. 88

Other HIPAA Information ......................................................................................................88

California Mental Health Parity Law ...................................................................................88

Notice of Loss of Grandfathered Status ............................................................................. 89

Claims Procedures ............................................................................................................90

Healthcare Claims Procedures ...........................................................................................90

Important Appeal Deadlines ...............................................................................................90

Acts of Third Parties - Third Party Liability ............................................................................ 91

Eligibility Claims Procedures .................................................................................................91

Definitions ...........................................................................................................................93

Summary of Trust Benefits .................................................................................................95

Medical Plans ........................................................................................................................95

Dental Plans ...........................................................................................................................96

Vision Benefits ........................................................................................................................96

Insurers and Providers of Service to the Trust .................................................................97

Participate, be healthy, retire!


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An Important Message to Participants

We are pleased to welcome you as a Participant in the Teamsters Local 1932 Health and Welfare Trust also known as Teamsters Local 1932 Health and Welfare Plan (“Trust” and “Plan”). This booklet, together with the Evidence of Coverage (“EOC”) booklets prepared by each of the providers describes the benefits available under the Trust and is intended to serve as your Plan Document and your Summary Plan Description (“SPD”). This SPD includes important information to help you understand and appropriately access your benefits. The information in this booklet is effective May 1, 2020, and supersedes and replaces any Trust related information previously provided to you.

There are a number of benefit options referenced in this booklet. You must consult the terms of your Memorandum of Understanding (“MOU”) to determine which of these benefits is available to you and to your Dependents. Your eligibility is determined by the terms of your MOU and the rules of the Teamsters Local 1932 Health and Welfare Trust, and by the Trust Acceptance and Contract Data Agreement (“Trust Acceptance Agreement”).

Depending upon the terms of the MOU between your Employer and your Union, the following benefit programs are available to you and your eligible Dependents under group insurance contracts entered into by the Trust:

• Medical, Hospital and Prescription Drug

• Dental

• Vision

This SPD booklet should be read in conjunction with the EOC booklets. EOCs can be obtained can be obtained free of charge from the Trust Administration Office or directly from the insur-ance carrier. EOCs may also be obtained online at https://teamsters1932.zenith-american.com.

This SPD booklet is accompanied by Schedules of Benefits of the benefits available to you. This booklet and the accompanying Schedules of Benefits are being given general distribution to be certain everyone who is entitled to receive a copy does so. Because of this, you may receive a SPD booklet whether or not you are currently eligible for benefits.

The Board of Trustees has contracted with Zenith American Solutions (“Zenith”) to perform rou-tine administration for the Plan as the contract administrator. If you have any questions regard-ing any benefit program or the administration of the Trust which are not fully answered in this SPD and the EOC booklets for each provider, please contact Zenith American Solutions at the address and numbers listed below:

Trust Administration OfficeZenith American Solutions

P.O. Box 571San Bernardino, CA, 92402-0571

433 N. Sierra WaySan Bernardino, California 92410

Telephone: (866) 484-1337 or (909) 494-2916

Please be aware that the information and answers given over the phone or orally in person are not binding upon the Board of Trustees or any health, dental or other insurer and cannot be relied upon in any dispute concerning your benefits.

IT IS IMPORTANT that you inform the Trust Administration Office promptly of any change in your name or address, so you can receive timely notice of any Plan changes and other infor-mation required by law. If you marry, divorce, legally separate, acquire a new Dependent, change a beneficiary, enter military service, terminate employment, or become disabled, or if a Dependent no longer qualifies as a Dependent under the Plan, be sure to contact the Trust Administration Office to find out how these events may affect your rights or your Dependent’s rights to benefits.

The Board of Trustees reserves the right to amend the types of benefits provided by the Plan and eligibility rules of the Plan. From time to time the Board of Trustees may find it necessary to change the provisions of the Plan or Plan providers. If this occurs, you will be advised of any changes. If there are major changes to the Plan, you will receive updated information which should be kept as part of this booklet.

Benefits are not vested. The Trustees have full authority to modify, limit or terminate health cov-erage at any time as they deem appropriate. Plan benefits shall be provided only so long as sufficient assets are available.

Board of Trustees of the

Teamsters Local 1932 Health and Welfare Trust



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Eligibility Rules for Employees and Dependents

Employee Eligibility

Who Is Eligible for Benefits?

Eligibility for individual Participants shall be determined according to the provisions of the MOU between the various Unions and Employers participating in the Trust. Following any waiting or probationary period stated in the MOU, coverage will become effective on the first day of the pay period following the first pay period in which the employee is scheduled to work for forty (40) hours or more and received pay for at least one-half plus one hour of scheduled hours (your “initial eligibility date”).

Please refer to your MOU to determine the eligibility rules that apply to you. In the absence of any defined initial eligibility date in the MOU, eligibility will be determined based on the Trust Acceptance Agreement between your Employer, your Union, and the Trust.

Under certain circumstances, the Trust may allow for coverage of Non Bargaining Unit (NBU) employees, subject to approval by the Trustees. NBU employees receive the same coverage and eligibility as Union Members covered under a MOU.

What if I am an Employee of a Newly Participating Employer in the Trust?

If you are an Employee of an Employer on the first date the Employer becomes obligated to contribute to the Trust, you will become eligible on the effective date of coverage of your Employer.

What if I Go to Work for an Employer Who Is Already Participating in the Trust?

If you are a newly hired Employee who goes to work for an Employer who is already participat-ing in the Trust, you will become eligible for benefits in accordance with the terms of the MOU requiring Contributions to the Trust on your behalf. There may be a waiting period, which is described in your MOU before Contributions are required to be made on your behalf.

Continuing EligibilityOnce you initially become eligible for benefits, you will remain eligible so long as you continue to satisfy the eligibility rules required to maintain coverage as provided in your MOU. Please refer to your MOU to determine these eligibility rules or contact the Trust Administration Office. Generally, this means that once you become eligible for benefits you will remain eligible so long as you are employed with a Participating Employer and the required Contributions are made on your behalf to the Trust.

Dependent Eligibility

How Do My Dependents Become Eligible for Benefits?

Your Dependents who meet the definition of “Dependent” (see below) under the Plan become eligible for benefits on the date you become eligible.

Who Are My Eligible Dependents?

Your eligible Dependents are:

1. Same or opposite sex spouse;

2. Same sex or opposite sex Domestic Partner having registered with the California Secretary of State pursuant to a Declaration of Domestic Partnership (Form NP/SF DP-1 or DP-1A);

3. Same sex or opposite sex Domestic Partner having completed, signed and filed an official Affidavit of Domestic Partnership with the appropriate city or county of the State of California in which they reside;

4. Same sex or opposite sex Domestic Partner with whom you reside in a California city or county which does not provide official Affidavits of Domestic Partnership, having completed and signed the Affidavit of Domestic Partnership obtainable from the Trust Administration Office;

5. Natural born children, adopted children or children placed for adoption, stepchildren, wards for whom the Employee or Employee’s spouse or Domestic Partner is the court-appointed guardian, and children of Domestic Partners under 26 years of age;

6. Natural born children, adopted children or children placed for adoption, stepchildren, wards for whom the Employee or Employee’s spouse or Domestic Partner is the court-appointed guardian, and children of Domestic Partners regardless of age, who are incapable of self-sustaining employment by reason of a physically or mentally disabling injury, illness, or condition that existed prior to reaching age 26 who is chiefly dependent on you for support and maintenance. Proof of such incapacity must be presented to the Trust Administration Office within sixty (60) days of the date coverage would otherwise end due to age and periodically thereafter at the request of the Board of Trustees, but not more frequently than annually. You must also provide proof to the fully insured carrier in accordance with their applicable requirements.


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Who Is Not an Eligible “Dependent” Under the Plan?

Those not eligible as Dependents are as follows:1. A Dependent who is serving in the Uniformed Services of the United States is not

eligible as a Dependent under this Plan.2. An Employee’s spouse shall cease to be a Dependent under this Plan on the date

set forth for termination of marriage in the Judgment of Dissolution or Nullity.3. An Employee’s Domestic Partner shall cease to be a Dependent under this Plan

on the date of termination of the Domestic Partnership.

Enrollment for BenefitsEmployee Enrollment

Am I Required to Enroll in the Plan?

Eligible Employees must complete an Enrollment Form either online or available from the Trust Administration Office to enroll themselves and/or their eligible Dependents. Neither you nor your Dependents will have coverage until you have submitted a completed Enrollment Form to the Trust Administration Office and have been notified that your enrollment is complete and your participation has been approved, or you have been enrolled pursuant to the Plan’s Default Enrollment Policy. Please see page 63 for a complete description of the Plan’s Default Enrollment Policy. Once you are enrolled, you won’t be able to change your enrollment until the next Annual Open Enrollment Period unless you or your Dependents are eligible for Special Enrollment under HIPAA. If you have questions regarding enrollment, you may contact the Trust Administration Office at (866) 484-1337 or (909) 494-2916.

Can I Waive Participation in the Plan?

Waivers are permitted in accordance with the MOU and the Trust Acceptance Agreement when consistent with the Trust’s HIPAA policies. When a waiver is permitted, Employees may elect to waive coverage only within sixty (60) days of initial eligibility or during the Employer’s Annual Open Enrollment Period. Employees that fail to complete the Trust’s Waiver of Coverage Form and to provide the Trust Administration Office with all required documents within the designated time will not be permitted to waive coverage until the next Annual Open Enrollment Period as set forth in the Trust Acceptance Agreement.

In order to waive coverage, you must meet all of the following conditions:

You are covered by another employer sponsored group plan, or you are listed as the Dependent of a spouse or Domestic Partner covered by the same MOU requiring Contributions to the Trust who is already enrolled in the Plan.

You must provide proof in writing to the Trust Administration Office of other cov-erage or your spouse’s or Domestic Partner’s coverage in the Plan, along with a signed Waiver of Coverage Form provided by the Trust Administration Office with-in sixty (60) days of your employment.

Upon termination of the alternative coverage, the Employee, if eligible, must enroll in a group health plan offered by the Trust Fund. In order to enroll, the Employee who has waived coverage must provide a completed Enrollment Form and proof of termination of coverage to the Trust Administration Office within sixty (60) days of termination of the other coverage. There must be no break in the employee’s medical and dental plan coverage between the termination date of the other employer group coverage and enrollment in a medical and dental plan. The retroactive enrollment period and premiums required to implement coverage are subject to the terms and conditions of the applicable plan. Failure to notify the Trust Administration Office of loss of group coverage within sixty (60) days will require the employee to pay his/her insurance premiums retroactively on an after-tax basis.

Default Enrollment PolicyThe initial coverage for an eligible Employee whose Contributing Employer reported without a completed Enrollment Form will be processed in the following manner:

1. When the Employee is reported to the Trust by the Contributing Employer and the Employee Enrollment Form is not submitted:

a) The Employee will be enrolled in the lowest cost health and dental plans available on an after-tax basis, and provided individual only coverage effective as of the initial eligibility date.

2. When the Employee Enrollment Form is received within sixty (60) days of the initial eligibility date:

a) The Employee will be enrolled in the coverage as selected on the Enrollment Form. The coverage selected will be effective as of the date of the Employee’s initial eligibility.

b) Dependent Enrollment

(1) If Dependent verification documentation is received within sixty (60) days of the Employee’s initial eligibility date, Dependents will be enrolled as of the date of the Employee’s initial eligibility date;

(2) If Dependent verification documentation is not received within sixty (60)


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days of the Employee’s date of eligibility, Dependents will be enrolled as of the first day of the pay period following receipt of the Dependent verification documentation;

(3) If Dependent verification documentation is not received within ninety (90) days of the Employee’s initial eligibility date, Dependents will be eligible to enroll at the Contributing Employer’s next Annual Open Enrollment Period.

3. If the Employee Enrollment Form is received within ninety (90) days of the date of eligibility:

a) The Member will be enrolled in the coverage as selected on the Enrollment Form with coverage effective as of the date of the Employee’s initial eligibility, but only to the extent permitted by the selected carrier. If not received within ninety (90) days, the Member will be eligible to make a plan change at the Contributing Employer’s next Annual Open Enrollment Period.

b) Dependent Enrollment:

(1) Dependents will be enrolled as of the first day of the pay period following receipt of the Dependent verification documentation;

(2) If Dependent verification documentation is not received within ninety (90) days of the Employee’s initial eligibility date, Dependents will be eligible to enroll at the Contributing Employer’s next Annual Open Enrollment Period.

The only exception to this Default Enrollment Policy is if the new enrollee does not reside in the default enrollment plan service area. Under this exception, the new enrollee will be enrolled in a health plan that is similar to the default enrollment plan and offered in the service area, and if one is not available, in another health maintenance organiza-tion offered in the service area.

This Default Enrollment Policy is subject to Special Enrollment Rights which may allow ret-roactive coverage of Dependents in certain circumstances. See page 67 regarding the Special Enrollment Rights.

Dependent Enrollment

Dependents must be enrolled to receive coverage. This includes newly-acquired Dependents and newborn children. Services and reimbursement can be delayed, or denied to Dependents who are not properly enrolled. You may obtain the necessary forms to enroll newly-acquired Dependents from your Employer or the Trust Administration Office. Verification of Dependent status (e.g. marriage certificate, state-issued birth certificate, Affidavit of Domestic Partnership, California State Declaration of Domestic Partnership, certificate of adoption or filed agreement for placement for adoption, or court-issued guardian papers) is required to complete the enrollment process. Coverage may be denied if the necessary forms are not received by the Trust Administration Office within sixty (60) days from the date your Dependent becomes eligible.

In order to enroll a Dependent spouse, a copy of the state-issued marriage certificate is required. To add a Domestic Partner of either the same or opposite sex, please contact the Trust Administration Office for the necessary documentation.

In order to add a Dependent child, a copy of the state-issued birth certificate or other court-ordered documentation proving the child’s Dependent status will be required.

Enrollment of Domestic Partners

Same Sex or oppoSite Sex DomeStic partnerS regiStering With california Secretary of State

Same sex Domestic Partners or opposite sex Domestic Partners may register with the California Secretary of State by filing a state-issued Declaration of Domestic Partnership. To enroll for Dependent coverage as of the Employee’s initial eligibility date, the Declaration of Domestic Partnership must have been registered with the Secretary of State of California prior to the Employee’s initial eligibility date. A copy must be provided to the Trust Administration Office, accompanied by a completed Enrollment Form, within sixty (60) days of initial eligibility.

To enroll for coverage under the HIPAA Special Enrollment provision, a copy of the filed California Declaration of Domestic Partnership must be provided to the Trust Administration Office, accompanied by a completed Change Form, within sixty (60) days of registration with the Secretary of State of California. Coverage will be effective as of the first day of the pay period following receipt of the documentation. If the Employee fails to submit the Declaration of Domestic Partnership and a completed Change Form within sixty (60) days of registering with the Secretary of State of California, the Domestic Partner will not be eligible for enrollment until the Employer’s next Annual Open Enrollment Period.


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Same Sex or oppoSite Sex DomeStic partnerS filing With a california city or county

Same sex or opposite sex Domestic Partners may file an official California city or county Affidavit of Domestic Partnership form with the city or county in which they reside. However, enrollment is restricted to initial enrollment or Annual Open Enrollment only.

To enroll for Dependent coverage as of the Employee’s initial eligibility date, the Affidavit of Domestic Partnership must have been filed with the city or county prior to the Employee’s initial eligibility date; a copy of the Affidavit must be provided to the Trust Administration Office, accompanied by a completed Enrollment Form, within sixty (60) days of initial eligibility.

To enroll for Dependent coverage as of the effective date of coverage following Annual Open Enrollment, the Affidavit of Domestic Partnership must have been filed with the appropriate city or county prior to the end of the Annual Open Enrollment Period; a copy of the Affidavit must be provided to the Trust Administration Office, accompanied by a completed Change Form.

If the Employee fails to submit the filed Affidavit of Domestic Partnership form and a completed Enrollment Form or Change Form within time periods specified above, the Domestic Partner will not be eligible for enrollment until the Employer’s next Annual Open Enrollment Period.

Same Sex or oppoSite Sex DomeStic partnerS completing truSt’S affiDavit of DomeStic partnerShip

Same sex Domestic Partners or opposite sex Domestic Partners may also enroll for Dependent coverage by submitting a completed and notarized Teamsters Local 1932 Health and Welfare Trust Affidavit of Domestic Partnership. However, enrollment is restricted to initial enrollment or Annual Open Enrollment only.

To enroll for Dependent coverage as of the Employee’s initial eligibility date, the notarized Affidavit of Domestic Partnership must be accompanied by at least two of the required documents listed on the Affidavit, together with a completed Enrollment Form, and submitted to the Trust Administration Office within sixty (60) days of initial eligibility.

To enroll for Dependent coverage as of the effective date of coverage following Annual Open Enrollment, the Affidavit of Domestic Partnership must be accompanied by at least two of the required documents listed on the Affidavit, together with a completed Change Form, and submitted to the Trust Administration Office during the Employer’s Annual Open Enrollment Period.

If the Employee fails to submit the notarized Affidavit of Domestic Partnership form and

required documentation within those deadlines, the Domestic Partner will not be eligible for enrollment until the Employer’s next Annual Open Enrollment Period, provided that the proper documentation and Change Form is submitted to the Trust Administration Office during the Annual Open Enrollment Period.

Special Enrollment - Health Information Portability and Accountability Act (HIPAA) of 1996If you acquire a new Dependent because of marriage, birth, adoption or placement for adoption, you may be able to enroll yourself and your Dependents outside of your Employer’s Annual Open Enrollment. Coverage for your new Dependent will be effective retroactively, back to the date of marriage, birth, adoption or placement for adoption. However, you must request enrollment within sixty (60) days after the marriage, birth, adoption, or placement for adoption.

To request special enrollment or obtain more information, contact the Trust Administration Office at:

Zenith American SolutionsP.O. Box 571

San Bernardino, CA, 92402-0571

433 N. Sierra WaySan Bernardino, California 92410

Telephone (866) 484-1337 or (909) 494-2916

If you are declining enrollment for yourself or your Dependents (including your spouse) because of other health insurance or group health plan coverage, you may be able to enroll yourself and your Dependents in this Plan if you or your Dependents lose eligi-bility for that other coverage (or if your Employer stops contributing toward your or your Dependents’ other coverage). However, you must request enrollment within sixty (60) days after your or your Dependent’s other coverage ends (or after the Employer stops contributing toward the other coverage).

Special Enrollment Rights Under “SCHIP” If you decline enrollment for yourself or your Dependents (including your spouse) be-cause of coverage under a state Medicaid Plan such as Medi-Cal in California or a State Children Health Insurance Plan “SCHIP,” you may be able to enroll yourself and your eligible Dependents in this Plan if you or your Dependent loses eligibility for that oth-er coverage or if you become eligible for state premium assistance after April 1, 2009. However, you must request this special enrollment options within sixty (60) days after you and your Dependent’s coverage terminates under the Medicaid Plan or State Plan, or within sixty (60) days after you or your Dependent is determined to be eligible for state


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premium assistance.

Special Enrollment Under a Qualified Medical Child Support OrderSpecial Rules apply to Dependents added to the Plan under a Qualified Medical Child Support Order (QMCSO). A QMCSO is a court order requiring the Plan to provide health coverage for a child of a Participant. Copies of the Trust’s QMCSO procedures are available from the Trust Administration Office, without charge. Please contact the Trust Administration Office if you need further information regarding QMCSOs.

Termination of Coverage

When Does My Eligibility for Benefits End?

Your coverage will terminate on the earliest of the following dates:

The date you fail to satisfy the eligibility rules required to maintain your coverage as pro-vided in your MOU;

The date coverage for which you are eligible is eliminated from the Plan;

The date the Plan terminates;

The date on which you enter full-time military service in the Uniformed Services of the United States which exceeds thirty-one (31) days;

Please refer to the EOC booklets for the particular coverage for a complete description of other circumstances which may cause your eligibility for benefits or a particular benefit to terminate.

Termination of Eligibility for Dependents

In the event of an Employee’s loss of employment, coverage for the Employee’s Dependents will terminate on the same day as the Employee’s. Otherwise, Dependent coverage will terminate on the earliest of the following dates:

1. The date the Dependent, as defined by the Trust, no longer qualifies as an eligible Dependent;

2. The date the Dependent enters into full-time Military Service that lasts longer than thirty (30) days;

3. For your legal spouse, the date of entry of a court judgement that dissolves the marriage or grants a legal separation of the parties.

4. For your same sex or opposite sex Domestic Partner with whom you have regis-tered with the California Secretary of State, the last day of the month which is six months from the date of filing of a Notice of Termination of Domestic Partnership with the State or the date of entry of a court judgement that dissolves, nullifies or legally separates the Domestic Partners.

5. For Domestic Partners who filed an Affidavit of Domestic Partnership with a California municipality, the last day of the month which is six months from the date a Notice of Termination of Domestic Partnership is filed in the same California municipality.

6. For Domestic Partners who submitted the Trust’s Affidavit of Domestic Partnership to the Trust Administration Office, the last day of the month which is six months from the date a Statement of Termination of Domestic Partnership is submitted to the Trust Administration Office; or

7. The date the Trustees terminate coverage for Dependents.

Termination of Eligibility for Domestic Partners

If the Employee would like to terminate coverage for their Domestic Partner, then a notarized Notice of Termination of Domestic Partnership must be filed with the Secretary of State of California or a court judgment terminating the Domestic Partnership must be obtained (in cases where the Declaration of Domestic Partnership was filed with the State); or a Notice of Termination of Domestic Partnership is filed with the California municipality (in cases where the Affidavit of Domestic Partnership was filed with a California municipality); or a notarized Statement of Termination of Domestic Partnership is submitted to the Trust Fund (in cases where the Trust’s Affidavit of Domestic Partnership was submitted).

Employees may not enroll another Domestic Partner within six (6) months of filing a Notice or Statement of Termination of the termination of a Domestic Partnership with the appropriate entity named above.

However, when the Dependent’s eligibility terminates, the Dependent may have the right to elect COBRA coverage under the Trust. See the section on COBRA rights.

Please review Termination of Coverage provisions contained in EOC booklets for each cover-age for a full description of events which may lead to termination of coverage. You may also have individual conversion rights explained in your EOC booklets.


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Extensions of Coverage During Leaves of Absence

Military LeaveContinuation of coverage may be available to you under the Uniformed Services Employment and Reemployment Rights Act of 1994 (USERRA). USERRA was enacted by Congress to provide protections to individuals who are members of the “Uniformed Services.” “Uniformed Services” is defined as the Armed Forces, the Army National Guard and the Air National Guard when engaged in active duty for training, inactive duty training, or full-time National Guard duty, the commissioned corps of the Public Health Services, and any other category of persons designat-ed by the President in time of war or national emergency.

If you take a military leave for thirty (30) days or less, you will continue to receive benefits for up to thirty (30) days. If you take a military leave for more than thirty (30) days, USERRA permits you to continue coverage for you and your Dependents at your own expense, at a cost of 102% of the cost of coverage for up to twenty-four (24) months. The maximum period of continuation coverage for health care under USERRA is the lesser of: (1) twenty-four (24) months (beginning from the date you leave work due to your military leave) or (2) the day after the date you fail to timely apply for or return to a position of employment with an Employer participating in the Plan.

If you make this election, you will be required to submit any required self-payment, which may include administrative costs, to your Employer. If you do not elect to continue your coverage during a period of service in the Uniformed Services of the United States, upon your return to work, your coverage will be reinstated at the same benefit level immediately preceding your service, if you are eligible for reemployment under the criteria established under USERRA.

Your rights to self-pay under USERRA are governed by the same conditions described in the COBRA section of this booklet. If you elect continuation coverage under USERRA, the COBRA and USERRA coverage periods will run concurrently.

For more information regarding your rights under the Uniformed Services Employment and Reemployment Rights Act (USERRA), contact the Trust Administration Office.

Family and Medical Leave ActYour Employer may be required to comply with the Family and Medical Leave Act of 1993 (“FMLA”). FMLA eligible Employees will receive up to twelve (12) weeks of unpaid leave within any rolling twelve-month period for the birth or placement of a child for adoption or foster care,

to care for your child, spouse or your parent with a serious health condition, your own serious health condition or Qualifying Exigency Leave, which is leave to handle exigencies related to a family member’s active duty military service or call to active duty.

In addition, qualified Employees are entitled to twenty-six (26) weeks of covered Service Member family leave during a twelve-month period to care for a spouse, son, daughter, parent or next of kin who has a serious injury or illness incurred in the line of active duty.

Requests for FMLA leave must be directed to your Employer. The Trust Administration Office cannot determine whether or not you qualify for FMLA leave. If you qualify for leave under the FMLA, your Employer must continue to pay the required Contributions during any approved FMLA leave. You and your eligible Dependents will continue to be covered under this Plan provided you and your Dependents were eligible when the leave began. Coverage will be continued while you are absent from work on an FMLA leave as if there were no interruption of active employment. Coverage will continue until the earlier of the expiration of the FMLA leave or the date you give notice to your Employer that you do not intend to return to work at the end of the leave.

Continuation Coverage Under COBRACOBRA Continuation Coverage is a temporary extension of coverage under the Plan. The right to continuing coverage was created by a federal law, the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA). If you qualify for COBRA Continuation Coverage you and your Dependents have the option of continuing their health care coverage on a limited basis after coverage would otherwise terminate. You and each of your Dependents should read this entire section carefully so that you understand the options available to you.

If you or your Dependent lose coverage under the Plan as a result of a Qualifying Event de-scribed below, coverage may be continued for a limited period under COBRA Continuation Coverage by making monthly payments to the Trust. If you do not take advantage of COBRA coverage, you may have limited coverage under a new insurance plan if you have a break in coverage of more than sixty-three (63) days.

COBRA Continuation Coverage is not available to Domestic Partners; however, the Plan recog-nizes Domestic Partners as eligible Dependents and will extend continuation coverage under the Plan for the period during which your coverage is extended under COBRA. Your Domestic Partner has no independent rights to elect or extend COBRA Continuation Coverage. Please contact the Trust Administration Office for more information including the cost of extending coverage for your Domestic Partner.

What Benefits Are Available Under COBRA Continuation Coverage?

You, your Legal spouse or your Dependent children have the option of electing COBRA cov-erage to continue the coverages provided through the Trust described in this booklet. If you choose COBRA Continuation Coverage, you will be entitled to the same coverage that you had on the day before the event that caused your coverage to end.

COBRA Eligibility (COBRA Qualifying Events)

A life event that causes a loss of coverage is called a “Qualifying Event.” COBRA Continuation Coverage is available to you if coverage would otherwise end because of the following Qualifying Events:


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Qualifying Events for the Employee:

1. Your hours are reduced so that you are no longer eligible to participate in the Plan;

2. Your employment ends for any reason other than gross misconduct.

Qualifying Events for your Dependent Spouse are:

1. The Employee’s death;2. The Employee’s hours of employment are reduced; the Employee’s employment

ends for any reason other than the Employee’s gross misconduct; or3. The Employee’s divorce or legal separation.

Qualifying Events for Your Dependent Child Are:

1. Parent-Employee dies;2. Parent-Employee’s hours of employment are reduced;3. Parent-Employee’s employment ends for any reason other than his or her gross

misconduct;4. Parents’ divorce or legally separate; or5. Your child is no longer eligible for coverage under the Plan as a “Dependent

child.”

Who Is Eligible for COBRA Continuation Coverage?

COBRA Continuation Coverage must be offered to each person who is a “Qualified Beneficiary.” A Qualified Beneficiary is someone who will lose coverage under the Plan because of a “Qualifying Event.” Depending on the type of Qualifying Event, Employees and their spouses or Dependent children may be Qualified Beneficiaries. Under the Plan, Qualified Beneficiaries who elect COBRA Continuation Coverage must pay for COBRA Continuation Coverage. Please note that Domestic Partners are not Qualified Beneficiaries.

In the event the Trust Administration Office receives timely notice of a Qualifying Event, but the individual is not entitled to COBRA Continuation Coverage, the Trust Administration Office will advise the individual of the unavailability of COBRA coverage and the reason or reasons why coverage is unavailable within fourteen (14) days of receipt of notice. It is your responsibility to keep the Trust Administration Office informed of your correct mailing address so as to prevent any delay in communications regarding Your COBRA Continuation Coverage.

Who Can Elect COBRA Coverage?

If there has been a Qualifying Event, you, your spouse or your Dependent child can individually elect to continue benefits under COBRA, as provided in this section. If you elect to continue coverage under COBRA, coverage benefits will automatically be extended to all other eligible Qualified Beneficiaries in the family who lost coverage as a result of the same Qualifying Event.

How Do I Obtain COBRA Continuation Coverage?

The Trust Administration Office administers COBRA Continuation Coverage for the Plan. Your Employer has the responsibility for notifying the Trust Administration Office within thirty (30) days of the Qualifying Event or loss of coverage, whichever is later, if the Qualifying Event is your death, reduction of your hours, termination of employment or your entitlement to Medicare.

You as the Employee, your spouse, your Dependent children or any representative acting on behalf of you or your Dependents, have the responsibility of informing the Administrative Office of a divorce, legal separation, or of a child losing Dependent status in writing within the sixty-day period following the Qualifying Event, or the date coverage terminates, whichever is later.

If you do not provide written notice to the Trust Administration Office of the Qualifying Event within the sixty (60) day period after the Qualifying Event, you and your Dependents will lose the right to continue your coverage through self-payments under COBRA. Notice should be sent to Teamsters Local 1932 Health and Welfare Trust at the address listed on page 53 of this booklet. Please contact the Trust Administration Office at (866) 484-1337 or (909) 494-2916 regarding the required information for the written notice.

The Trust Administration Office will promptly send you, your spouse, and/or your Dependent children notice of the date on which coverage ends, together with the information and forms which must be submitted to the Trust Administration Office to elect COBRA coverage. The information from the Trust Administration Office will describe the Plan’s procedures for electing COBRA and will indicate the cost of coverage, if elected.

COBRA Continuation Coverage will be offered to each eligible Qualified Beneficiary. Each Qualified Beneficiary will have an independent right to elect COBRA Continuation Coverage. For example, your spouse may elect coverage even if you do not, you may elect COBRA Continuation Coverage on behalf of your spouse and Dependents, and parents may elect COBRA Continuation Coverage on behalf of any Dependent child who is a Qualified Beneficiary.

Is There a Time Limit for Applying for COBRA Continuation Coverage?

You, your spouse, and/or your Dependents will have only sixty (60) days from the date you lose coverage or the date of the election notice sent by the Trust Administration Office, whichever is later, to apply for COBRA coverage. If you, your spouse and/or Dependent do not elect COBRA coverage within this sixty-day period, you and/or their right to continue coverage under COBRA will be lost and neither you, your spouse and/or your Dependents will have any group coverage through Plan after the date specified in the notice from the Trust Administration Office that coverage ends.

What is the Cost of COBRA Continuation Coverage?

Your cost for COBRA Continuation Coverage is calculated in accordance with Federal law. You may be charged 102% of the cost of coverage as allowed by federal legislation. COBRA rates will be increased during the 19th month through 29th month of continuation coverage for disabled Employees with a Social Security Disability determination as permitted by Federal legislation. You and your Dependents may be charged up to 150% of the cost of coverage during this additional period as allowed by federal legislation.


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COBRA premiums must be paid on a monthly basis. To ensure that you receive both continuous coverage and the exact length of coverage as provided for by law, a daily rate will be used to determine premiums for any partial months of coverage. This daily rate will typically be used to determine the premium for your first and last months of coverage. For example, if due to your qualifying event, your health and welfare plan coverage ended on July 21, your COBRA coverage would begin on July 22. The premium for your first month of COBRA coverage would be for 10 days of coverage and would be calculated by multiplying the daily rate by 10.

When Do COBRA Coverage and Self-Payments Begin?

Although you have up to sixty (60) days to make an election, COBRA coverage must begin the first day of the month in which full coverage would otherwise terminate. Payment of the first Contribution must be received by the Trust Administration Office within forty-five (45) days of the date that the Trust Administration Office receives notification from a Qualified Beneficiary that the Qualified Beneficiary chooses COBRA Continuation Coverage. If a Qualified Beneficiary waits until the end of the election and the payment period, payment for each full month which has passed since the date the Plan coverage terminated must be included with the first pay-ment. Subsequent payments will be due the first day of each month. If payment is not received within thirty (30) days of the due date, COBRA Continuation Coverage will be terminated and all rights to continue coverage will cease.

For How Long Will COBRA Coverage Continue?

COBRA Continuation Coverage can continue for up to 18, 29 or 36 months depending on the COBRA Qualifying Event, as described below:

18 Months – (You and Your Dependents)

If you lose coverage as a result of (1) a reduction in work hours or leave of absence (other than approved FMLA leave); (2) work stoppage; (3) termination of employment through resignation, layoff, discharge, or retirement, you can choose continuation coverage for up to eighteen (18) months; however, if your employment ends due to gross misconduct, you will not qualify for COBRA Continuation Coverage.

29 Months – (You and Your Dependents)

COBRA Continuation Coverage continues for an additional eleven (11) months (up to a total of twenty-nine (29) months) if within the first sixty (60) days of COBRA coverage you or an eligible Dependent is or becomes permanently disabled (as determined by the Social Security Administration). In this event, you or your Dependent must notify the Administration Office of the Social Security determination no later than sixty (60) days after it is received and before the end of the initial eighteen-month COBRA continuation period to be eligible for this COBRA extension.

36 Months – (Your Dependents Only)

COBRA Continuation Coverage continues for up to thirty-six (36) months for your Dependents (spouse and Dependent children) from the date any of the following COBRA Qualifying Events occurs: 1) your death; 2) your divorce or legal separation; 3) your be-coming entitled to Medicare; 4) your Dependent ceases to be a Dependent under the terms of the Plan.

If a spouse or Dependent child becomes eligible for and chooses COBRA coverage due to the Employee’s reduction of hours or termination of employment, and thereafter experiences a second Qualifying Event (such as the death of the Employee, divorce, or the Employee’s enti-tlement to Medicare), a spouse or Dependent child may continue COBRA coverage for up to thirty-six (36) months from the original eligibility date.

If you lose coverage under the Plan due to the termination of your employment or the reduction in your hours within eighteen (18) months after becoming entitled to Medicare benefits, your spouse and Dependents may continue COBRA coverage for up to thirty-six (36) months from the date of your Medicare entitlement.

For Example, if you become entitled to Medicare eight (8) months before the date on which your employment terminates, COBRA Continuation Coverage for your spouse and Dependent children can continue up to thirty-six (36) months after the date of Medicare entitlement, which in this example is twenty-eight (28) months after the date of the Qualifying Event (36 months less 8 months).

Can COBRA Coverage Be Extended Because of Disability?

If you, your spouse or Dependent are entitled to the COBRA Continuation Coverage for the eighteen-month period, that period can be extended for the person who is determined to be entitled to Social Security Disability Income benefits, and/or any other covered family members for up to 11 additional months so long as all the following conditions are met:

1. You are entitled to the eighteen (18) months of COBRA Continuation Coverage;2. You are determined to be disabled under the terms of the Social Security Act as

of the date of the original Qualifying Event or become disabled anytime during the first sixty (60) days of COBRA Continuation Coverage; and

3. You report the disability determination to the Trust Administration Office within six-ty (60) days of the date you received the Social Security disability determination or within sixty (60) days of the date you received this SPD, whichever is later, and prior to the end of the 18-month continuation period.

To qualify for this additional period of coverage, you must provide the Trust Administration Office at the address listed on page 53 of this booklet with written notice of the disability determination within the sixty-day period. The written notice must be accompanied with a photocopy of the entire Social Security Administration determination. If you do not submit written notice to the Plan Administrator within the sixty-day period, you will not be eligible for this extension under COBRA.

When Does an Extension of COBRA Coverage Due to Disability End?

The extension of COBRA Continuation Coverage up to twenty-nine (29) months will end the earlier of:

1. The last day of the month during which the Social Security Administration has de-termined that you and/or your Dependent is no longer disabled.

2. The end of the twenty-nine -month period after the Qualifying Event.


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3. The date the disabled individual first becomes entitled to Medicare after electing COBRA.

If at a subsequent date, the Social Security Administration determines that you are no longer dis-abled, you must provide the Trust Administration Office with written notice of the Social Security Administration’s final determination that you are no longer disabled within thirty (30) days of the final determination or within thirty (30) days of the date you received this SPD, whichever is later. This written notice must be addressed to the Trust Administration Office at the address listed on page 53 of this booklet. The Notice must contain the following information: The Plan name, the Employer’s name, the names and social security numbers of the Employee and Dependents and the date the Social Security Administration determined that the individual is no longer dis-abled. The written notice must be accompanied with a photocopy of the entire Social Security Administration determination and submitted to the Trust Administration Office.

What Happens in Cases Where There Are Multiple Qualifying Events?

If you lose coverage because your employment terminates or your hours are reduced within eighteen (18) months after becoming entitled to Medicare, your spouse and eligible Dependents may continue coverage for up to thirty-six (36) months from the date of your Medicare entitlement.

If you die, divorce or legally separate or become entitled to Medicare, or if your Dependent child ceases to be a Dependent under this Plan during the eighteen-month period of COBRA coverage, your family has experienced a second Qualifying Event which may allow them to continue COBRA coverage for up to a maximum of thirty (36) months from the date of the first Qualifying Event. To be eligible for this extension of coverage under COBRA either you, your spouse and/or Dependent or any representative acting on their behalf must provide written no-tice to the Trust Administration Office listed on page 53 of this booklet of the second Qualifying Event within sixty (60) days after the date of the second Qualifying Event.

Can COBRA Coverage End Early? (Before the 18, 29, or 36 Month Periods)

1. Even though you may have elected COBRA Continuation Coverage and have been advised that it is available for a certain period, your coverage may be ter-minated if any of the following happens:

2. The first day of the month for which a timely payment is not received by the Trust Administration Office;

3. The day on which this Plan is terminated;4. The first date, after the date of the COBRA election on which either you or your

eligible Dependents first become covered by another group health plan (includ-ing a retiree health plan), and that Plan does not contain any legally applicable exclusion or limitation with respect to pre-existing conditions that the Qualified Beneficiary may have. If such a limitation or exclusion for such pre-existing condi-tion exists, coverage will not terminate until the date the condition is covered un-der the new plan, or the maximum time allowed under COBRA has been reached, whichever occurs first;

5. The first date, after the date of the COBRA election, on which you or your eligible Dependents (the Qualified Beneficiary) first become entitled to Medicare benefits under Title XVIII of the Social Security Act;

6. The date the Employee’s Employer stops making Contributions to the Plan on

behalf of its active Employees, and provides alternative coverage to those Employees under another plan; or

7. You or your Dependents have continued coverage for additional months due to a disability, and there has been a final determination by Social Security that you or your Dependents are no longer disabled. In this case, coverage ends on the first of the month that begins more than thirty (30) days after the Social Security Administration makes a final determination that you or your Dependent are no longer disabled or at the end of the applicable eighteen-month maximum cov-erage period described above, whichever occurs last.

Will I Receive Notice of the Early Termination of COBRA Continuation Coverage?

In the event COBRA coverage will terminate before the end of the maximum coverage period, the Trust Administration Office, as soon as practicable after a determination that coverage will terminate, will give notice to each Qualified Beneficiary of the reason or reasons for the early termination of coverage, the date of termination of coverage, and any rights to alternate group or individual coverage which may be available to the Qualified Beneficiary.

When Does COBRA Coverage End?

COBRA Continuation Coverage will automatically terminate upon the earlier of the following:

1. The occurrence of any of the events described above; or2. At the end of the last day of the maximum coverage period (18, 29, 36 months)

applicable to the Qualified Beneficiary under COBRA.

What If I Acquire a New Dependent While I am Receiving COBRA Continuation Coverage?

If you acquire a new Dependent through marriage, birth, adoption or placement for adoption while your coverage has been extended because you are self-paying for COBRA Continuation Coverage, you may add the Dependent to your coverage for the balance of your COBRA coverage period.

For Example, if you have a baby three months prior to the end of your COBRA coverage period, you may enroll the new baby for the last three months of your COBRA coverage period.

If new Dependents are acquired through marriage, birth, or placement for adoption after COBRA Continuation of Coverage has begun, they may be added by contacting the Trust Administration Office at the address and telephone numbers listed page 53 of this booklet. Newborn and adopted children or children placed for adoption may have separate COBRA rights.

To enroll a new Dependent (newborn, child placed for adoption, etc.) for COBRA coverage, you must notify the Trust Administration Office within thirty-one (31) days of acquiring the new Dependent. There may be a change in the COBRA premium as a result of the addition of a new Dependent.

What if My Spouse or Dependent Is Covered Under Another Plan and Loses Coverage While I Am Making Self Payments for COBRA Continuation Coverage?

If, while you are enrolled in COBRA Continuation Coverage, your spouse or Dependent child loses coverage under another group health plan, you may enroll the spouse or Dependent child


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in this Plan for coverage for the balance of the period of your COBRA Continuation Coverage so long as the following conditions are met:

1. Your spouse or Dependent child must have been eligible for COBRA Continuation Coverage at the time of your Qualifying Event, but not enrolled;

2. When COBRA Coverage enrollment under this Plan was offered and declined, the spouse or Dependent child must have been covered under another group health plan or had other health insurance coverage;

3. The loss of coverage must be due to: exhaustion of COBRA Continuation Coverage under another plan; termination as a result of loss of eligibility for coverage; or the termination of the Employer’s Contributions toward the other coverage;

4. Loss of eligibility cannot be due to the failure of your spouse to pay premiums on a timely basis or termination of coverage for cause.

To add a spouse or Dependent child after loss of other coverage, they must be enrolled no later than thirty (30) days after the termination of the other coverage. Adding a spouse or Dependent child may result in an increase in the amount paid for COBRA Continuation Coverage.

What If I Have Questions Regarding Coverage Under COBRA?

If you have any questions regarding COBRA Continuation Coverage under this Plan or need information regarding notices required to be given, you should contact the Trust Administration Office at the telephone numbers and address listed at page 53 of this booklet.

The Centers for Medicare and Medicaid Services (CMS) has advisory jurisdiction over the continuation coverage requirements of COBRA as they apply to group health plans which are sponsored by state, county, municipal, or public school districts (“Public Sector COBRA”). For further information, contact the CMS at the following website: https:// www.cms.gov/CCIIO/Programs-and-Initiatives/Other-Insurance-Protections/ COBRA.

Individual Conversion Privilege Option Once your continuation coverage under COBRA terminates, you or your Dependents may have the right to convert your medical coverage to conversion coverage as detailed in the Right to Convert Health Insurance provisions contained in the EOC booklets which can be obtained free of charge from the Administrative or directly from your insurance carrier. Generally, you must submit your conversion application and initial premium to the insurance carrier within thirty-one (31) days from your loss of eligibility. The individual plan coverage may not be identical to your current coverage and the monthly cost for the individual policy is determined by the insurance carrier.

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Legislation Affecting Health Care BenefitsAll coverages will be made available under the Trust for Employees and their covered Dependents in full compliance with all state and federal laws and regulations including Internal Revenue Code section 4980H, the Uniformed Services Employment and Reemployment Rights Act of 1994 (USERRA), the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA), the Health Insurance Portability and Accountability Act of 1996 (HIPAA), the Newborns’ and Mothers’ Health Protection Act of 1996 (NMHPA), the Women’s Health and Cancer Act of 1998 (WHCRA), and the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA), Genetic Information Nondiscrimination Act of 2008 (GINA) and the Patient Protection Affordable Care Act and Health Care and Education Reconciliation Act (PPACA).

Medi-Cal Health Insurance Premium Program (HIPP) You may qualify for the Health Insurance Premium Payment Program (HIPP) offered by the State of California. Under HIPP, the California Department of Health Care Services will pay your COBRA premium if you meet certain eligibility requirements. To enroll in HIPP, or to find out more information, you should visit the California Department of Health Care Services’ HIPP website at https://www.dhcs.ca.gov/services/Pages/ HIPPOnlineForms.aspx.

Certificate of Group Health CoverageWhen you lose eligibility under the Trust, you will be furnished with a Certificate of Group Health Plan Coverage. This Certificate provides you with evidence of your prior health coverage under the Teamsters Local 1932 Health and Welfare Trust.

Health Insurance Portability and Accountability Act (HIPAA) As a Participant in the Plan you have certain rights under HIPAA with respect to your health information. HIPAA requires that Employee welfare plans such as the Teamster Local 1932 Health and Welfare Trust protect the privacy of your personal health information (“PHI”). A complete description of your rights under HIPAA can be found in the Plan’s Notice of Privacy Practices which is included in your enrollment materials. You may also obtain a copy free of charge by contacting Zenith American Solutions at the numbers listed on page 53 of this booklet.

Notice of Privacy Practices – General InformationTHIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

The Teamsters Local 1932 Health and Welfare Trust (the “Plan”) is committed to maintaining the confidentiality of your private medical information. This Notice describes our efforts to safeguard your health information from improper or unnecessary use or disclosure. This Notice only applies to health-related information created or received by or on behalf of the Plan. We are providing this Notice to you because privacy regulations issued under federal law, the Health Insurance Portability and Accountability Act of 1996, 45 CFR Parts 160 and 164 (“HIPAA”), require us to provide you with a summary of the Plan’s privacy practices and related legal duties, and your rights in connection with the use and disclosure of your Plan information. Please note: If you are enrolled in a HMO, you will also receive a separate notice from your HMO provider that describes the HMO provider’s specific use and disclosure of your health information. Your rights with respect to their use and disclosure of your health information are set forth in that separate notice.

In this Notice, the terms “Plan,” “we,” “us,” and “our” refer to the Trust and third parties to the extent they perform administrative services for the Trust. When third party service providers perform administrative functions for the Plan, we require them to appropriately safeguard the privacy of your information.

What is Protected?

Federal law requires the Plan to have a special policy for safeguarding a category of medical information called “protected health information,” or “PHI,” received or created in the course of administering the Plan. PHI is health information that can be used to identify you and that relates to:

your physical or mental health condition,the provision of health care to you, orpayment for your health care.

Your medical and dental records, your claims for medical and dental benefits and the

CONTACT INFORMATION

If you have any questions regarding this Notice, please

contact:

Patricia Kuchenreuther Privacy Officer

Phone: (702) 347-5812

https://www.dhcs.ca.gov/services/Pages/


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Explanation of Benefits (“EOB’s”) sent in connection with payment of your claims are all examples of PHI.The remainder of this Notice generally describes our rules with respect to your PHI received or created by the Plan.

Uses and Disclosures of Your PHI

To protect the privacy of your PHI, the Plan not only guards the physical security of your PHI, but we also limit the way your PHI is used or disclosed to others. We may use or disclose your PHI in certain permissible ways described below. To the extent required under federal health information privacy law, we use the minimum amount of your PHI necessary to perform these tasks.To determine proper payment of your Health Plan benefit claims. The Plan uses

and discloses your PHI to reimburse you or your doctors or health care providers for covered treatments and services. For example, your diagnosis information may be used to determine whether a specific procedure is medically necessary or to reimburse your doctor for your medical care.

For the administration and operation of the Plan. We may use and disclose your PHI for numerous administrative and quality control functions necessary for the Plan’s proper operation. For example, we may use your claims information for fraud and abuse detection activities or to conduct data analyses for cost-control or planning-related purposes.

To inform you or your health care provider about treatment alternatives or other health-related benefits that may be offered under the Plan. For example, we may use your claims data to alert you to an available case management program if you are diagnosed with certain diseases or illnesses, such as diabetes.

To a health care provider if needed for your treatment. To a health care provider or to another health plan to determine proper payment

of your claim under the other plan. For example, we may exchange your PHI with your spouse’s health plan for Coordination of Benefits purposes.

To another health plan for certain administration and operations purposes. We may share your PHI with another health plan or health care provider who has a relationship with you for quality assessment and improvement activities, to review the qualifications of health care professionals who provide care to you, or for fraud and abuse detection and prevention purposes.

To a family member, friend, or other person involved in your health care if you are present and you do not object to the sharing of your PHI, or it can reasonably be inferred that you do not object, or in the event of an emergency.

For Plan design activities or to collect Plan Contributions. The Plan may use summary or de-identified health information for Plan design activities. In addition, Plan Employees may use information about your enrollment or disenrollment in a Plan in order to collect Contributions that pay for your Plan participation.

To the Plan Sponsor. The Plan may disclose PHI to the Plan sponsor, the Board of

Trustees, to the extent provided by a rule of the Plan, provided that the sponsor protects the privacy of the PHI and it is only used for the permitted purposes described in this Notice.

To Business Associates. The Plan may disclose PHI to other people or businesses that provide services to the Plan and which need the PHI to perform those services. These people or businesses are called business associates, and the Plan will have a written agreement with each of them requiring each of them to protect the privacy of your PHI. For example, the Plan may have hired a consultant to evaluate claims or suggest changes to the Plan, for which he needs to see PHI.

To comply with an applicable federal, state, or local law, including workers’ compensation or similar programs.

For public health reasons, including (1) to a public health authority for the prevention or control of disease, injury or disability; (2) to a proper government or health authority to report child abuse or neglect; (3) to report reactions to medications or problems with products regulated by the Food and Drug Administration; (4) to notify individuals of recalls of medication or products they may be using; or (5) to notify a person who may have been exposed to a communicable disease or who may be at risk for contracting or spreading a disease or condition.

To report a suspected case of abuse, neglect or domestic violence, as permitted or required by applicable law.

To comply with health oversight activities, such as audits, investigations, inspections, licensure actions, and other government monitoring and activities related to health care provision or public benefits or services.

To the U.S. Department of Health and Human Services to demonstrate our compliance with federal health information privacy law.

To respond to an order of a court or administrative tribunal.To respond to a subpoena, warrant, summons or other legal request if sufficient

safeguards, such as a protective order, are in place to maintain your PHI privacy.To a law enforcement official for a law enforcement purpose.For purposes of public safety or national security.To allow a coroner or medical examiner to make an identification or determine

cause of death or to allow a funeral director to carry out his or her duties.To respond to a request by military command authorities if you are or were a

member of the armed forces.For cadaveric organ, eye or tissue donation. The Plan may use and disclose

protected health information to organ procurement organizations or other entities engaged in the procurement, banking, or transplantation of cadaveric organs, eyes, or tissue for the purpose of facilitating organ, eye or tissue donation and transplantation.

For research. The Plan may use and disclose protected health information to assist in research activities, regardless of the source of the funding for the re-search, where a privacy board or an Institutional Review Board has approved an


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alteration to or waived entirely the authorization requirements of the law and the Plan receives certain specific representations and documentation.

To avert serious threat to health or safety. The Plan may use and disclose protect-ed health information to prevent or lessen a serious threat to health or safety of any one person or the general public and the use or disclosure is (1) to a person or persons reasonably able to prevent or lessen the threat to health or safety or (2) necessary for law enforcement authorities to identify or apprehend an individual.

Incident to a permitted use or disclosure. The Plan may use and disclose protect-ed health information incident to any use or disclosure permitted or authorized by law.

As part of a limited data set. The Plan may use and disclose a limited data set that meets the technical requirements of 45 Code of Federal Regulations, Section 164.514(e), if the Plan has entered into a data use agreement with the recipient of the limited data set.

For fundraising. The Plan may use and disclose certain types of protected health information to a business or to an institutionally related foundation for the pur-pose of raising funds. The types of information that may be disclosed under this exception to the authorization requirement are (1) demographic information re-lating to an individual and (2) dates of health care provided to an individual. The fundraising materials must also inform you of how you may elect to opt out of receiving further fundraising communications that are healthcare operations. The entity that sends you such communications must treat your request to opt out as a revocation of your authorization to receive any such communications.

Absent your written permission, Plan Employees will only use or disclose your PHI as de-scribed in this Notice. Plan Employees will not access your PHI for reasons unrelated to Plan administration without your express written authorization.

If an applicable state law provides greater health information privacy protections than the federal law, we will comply with the stricter state law.

Other Uses and Disclosures of Your PHI

Before we use or disclose your PHI for any purpose other than those listed above, we must obtain your written authorization. You may revoke your authorization, in writing, at any time. If you revoke your authorization, the Plan will no longer use or disclose your PHI except as described above (or as permitted by any other authorizations that have not been revoked). However, please understand that we cannot retrieve any PHI dis-closed to a third party in reliance on your prior authorization. Additionally, the Plan must obtain your authorization for most uses or disclosures of psychotherapy notes, uses or disclosures of PHI for marketing purposes, and disclosures that constitute the sale of PHI.

In no event will the Plan use or disclose your PHI that is “genetic information” for “underwrit-ing” purposes, as such terms are defined by the Genetic Information Nondiscrimination Act of 2008.

Your Rights

Federal law provides you with certain rights regarding your PHI. Parents of minor children and other individuals with legal authority to make health decisions for a Plan Participant may exer-cise these rights on behalf of the Participant, consistent with state law.

Right to request restrictions: You have the right to request a restriction or limitation on the Plan’s use or disclosure of your PHI. For example, you may ask us to limit the scope of your PHI disclosures to a case manager who is assigned to you for monitoring a chronic condition. Because we use your PHI to the extent necessary to pay Plan benefits, to administer the Plan, and to comply with the law, it may not be possible to agree to your request. Except in the limited circumstances described below, the law does not require the Plan to agree to your request for restriction. Except as otherwise required by law (and excluding disclosures for treatment purposes), the Plan is obligated, upon your re-quest, to refrain from sharing your PHI with another health plan for purposes of payment or carrying out health care operations if the PHI pertains solely to a health care item or service for which the health care provider involved has been paid out of pocket in full. The Plan will not agree to any restriction, which will cause it to violate or be noncompli-ant with any legal requirement. If we do agree to your requested restriction or limitation, we will honor the restriction until you agree to terminate the restriction or until we notify you that we are terminating the restriction with respect to PHI created or received by the Plan in the future.

You may make a request for restriction on the use and disclosure of your PHI by complet-ing the appropriate request form available from the Plan.

Right to receive confidential communications: You have the right to request that the Plan communicate with you about your PHI at an alternative address or by alternative means if you believe that communication through normal business practices could en-danger you. For example, you may request that the Plan contact you only at work and not at home.

You may request confidential communication of your PHI by completing an appropri-ate form available from the Plan. We will accommodate all reasonable requests if you clearly state that you are requesting the confidential communication because you feel that disclosure in another way could endanger your safety.

Right to inspect and obtain a copy of your PHI: You have the right to inspect and obtain a copy of your PHI that is contained in records that the Plan maintains for enrollment, payment, claims determination, or case or medical management activities. If the Plan uses or maintains an electronic health record with respect to your PHI, you may request such PHI in an electronic format, and direct that such PHI be sent to another person or entity.

However, this right does not extend to (1) psychotherapy notes, (2) information compiled in reasonable anticipation of, or for use in, a civil, criminal, or administrative action or proceeding, and (3) any information, including PHI, as to which the law does not permit access. We will also deny your request to inspect and obtain a copy of your PHI if a licensed health care professional hired by the Plan has determined that giving you the


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requested access is reasonably likely to endanger the life or physical safety of you or another individual or to cause substantial harm to you or another individual, or that the record makes references to another person (other than a health care provider), and that the requested access would likely cause substantial harm to the other person.

In the event that your request to inspect or obtain a copy of your PHI is denied, you may have that decision reviewed. A different licensed health care professional chosen by the Plan will review the request and denial, and we will comply with the health care professional’s decision.

You may make a request to inspect or obtain a copy of your PHI by completing the appropriate form available from the Plan. We may charge you a fee to cover the costs of copying, mailing or other supplies directly associated with your request. You will be notified of any costs before you incur any expenses.

Right to amend your PHI: You have the right to request an amendment of your PHI if you believe the information the Plan has about you is incorrect or incomplete. You have this right as long as your PHI is maintained by the Plan in a designated record set. We will correct any mistakes if we created the PHI or if the person or entity that originally created the PHI is no longer available to make the amendment. However, we cannot amend PHI that we believe to be accurate and complete.

You may request amendments of your PHI by completing the appropriate form available from the Plan.

Right to receive an accounting of disclosures of PHI: You have the right to request a list of certain disclosures of your PHI by the Plan. The accounting will not include disclosures (1) to carry out treatment, payment and health care operations, (2) to you, (3) incident to a use or disclosure permitted or required by law, (4) pursuant to an authorization provided by you, (5) for directories or to people involved in your care or other notification purposes as permitted by law, (6) for national security or intelligence purposes, (7) to correctional institutions or law enforcement officials, (8) that are part of a limited data set, (9) that occurred prior to April 14, 2003, or more than six years before your request. Your first request for an accounting within a 12-month period will be free. We may charge you for costs associated with providing you additional accountings. We will notify you in advance of any costs, and you may choose to withdraw or modify your request before you incur any expenses.

You may make a request for an accounting by completing the appropriate request form available from the Plan.

Right to Receive Breach Notice: An individual has a right to receive notifications of breaches of his or her unsecured protected health information.

Right to file a complaint: If you believe your rights have been violated, you should let us know immediately. We will take steps to remedy any violations of the Plan’s privacy policy or of this Notice.

You may file a formal complaint with our Privacy Officer and/or with the United States

Department of Health and Human Services at the addresses below. You should attach any evidence or documents that support your belief that your privacy rights have been violated. We take your complaints very seriously. The Plan prohibits retaliation against any person for filing such a complaint.

Complaints should be sent to:

Patricia Kuchenreuther

Privacy Officer

Zenith American Solutions

9121 W. Russell Rd., Suite 219

Las Vegas, NV 89148

Phone: (702) 347-5812

Email: [email protected]

Region IX, Office for Civil Rights

U.S. Department of Health and Human Services

90 7th Street, Suite 4-100

San Francisco, CA 94103

Phone: (415) 437-8310

FAX: (415) 437-8329

TDD: (415) 437-8311

https://www.hhs.gov/hipaa/filing-a-complaint/ what-to-expect/index.html

Additional Information About This Notice

Changes to this Notice: We reserve the right to change the Plan’s privacy practices as described in this Notice. Any change may affect the use and disclosure of your PHI already maintained by the Plan, as well as any of your PHI that the Plan may receive or create in the future. If there is a material change to the terms of this Notice, you will receive a revised Notice.

How to obtain a copy of this Notice: You can obtain a copy of the current Notice by contacting the Privacy Officer at the address listed above.

No change to Plan benefits: This Notice explains your privacy rights as a current or former Participant in the Plan. The Plan is bound by the terms of this Notice as they relate to the privacy of your protected health information. However, this Notice does not change any other rights or obligations you may have under the Plan. You should refer to the Plan documents for additional information regarding your Plan benefits.

The Women’s Health and Cancer Rights ActIf you have had or are going to have a mastectomy, you may be entitled to certain benefits under the Women’s Health and Cancer Rights Act of 1998 (WHCRA). For individuals receiving mastectomy-related benefits, coverage will be provided in a manner determined in consultation with the attending physician and the patient, for

All stages of reconstruction of the breast on which the mastectomy was performed;

Surgery and reconstruction of the other breast to produce a symmetrical appearance;

Prosthesis;



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Treatment of physical complications of the mastectomy, including lymphedemas.

These benefits will be provided subject to the same deductibles and coinsurance applicable to other medical and surgical benefits provided by your medical health plan. If you have any questions about Plan coverage of mastectomies or reconstructive surgery or if you would like more information on WHCRA benefits, please call the Trust Administration Office at: (866) 484-1337 or (909) 494-2916.

Newborns’ and Mothers’ Health Protection Act of 1996Group health plans and health insurance issuers generally may not, under Federal law, restrict benefits for any hospital length of stay in connection with childbirth for the mother or newborn child to less than 48 hours following a normal vaginal delivery, or less than 96 hours following a cesarean section. However, Federal law generally does not prohibit the mother’s or newborn’s attending provider, after consulting with the mother, from discharging the mother or her newborn earlier than 48 hours (or 96 hours as applicable). In any case, plans and issuers may not, under Federal law, require that a provider obtain authorization from the Plan or the issuer for prescribing a length of stay not in excess of 48 hours (or 96 hours).

Other HIPAA InformationCertain Plan benefits are guaranteed under a contract or policy of insurance between the Board of Trustees and the benefit provider. Each of these providers maintains an appeals procedure. This appeals procedure is explained in the EOC document provided by each benefit provider. An example of an appeal under an HMO may be where you received emergency care outside of the HMO and the HMO denied the claim because they did not deem it an emergency. You can contact the benefit provider directly for information on appeals procedure. Of course, the Trust Administration Office will assist you if you have questions or need information.

If you think your rights are being denied or your health information is not being protected, you have the right to file a complaint with your provider, health insurer, or the U.S. Department of Health and Human Services. To learn more, visit www.hhs.gov/ocr/privacy/. If you have any questions or need help filing a health information privacy complaint, you may email OCR at [email protected] or call the U.S. Department of Health and Human Services, Office for Civil Rights toll-free at: 1-800-368-1019, TDD: 1-800-537-7697.

California Mental Health Parity LawThe Trust’s HMO programs cover two different categories of mental health care at different levels: Crisis intervention and serious mental disorders. Crisis intervention is short-term, medically necessary acute treatment for a medical condition you are unable to recover from without assistance. To be covered, there must be a good chance you will get better. Care is provided at the lowest level of care that is consistent with safe medical practice.

California law also requires medical benefit programs to cover the diagnosis and treatments of the following serious mental illnesses and emotional disturbances at the same rates they cover other health care: schizophrenia, schizo-affective disorder, bipolar disorder, major depressive disorder, panic disorder, obsessive-compulsive disorder, pervasive developmental disorders (autism), anorexia nervosa, bulimia nervosa. Serious mental disorders also include serious emotional disturbances of a child, as indicated by the presence of one or more mental disorders from the Diagnostic and Statistical Manual (DSM) of Mental Health (other than chemical dependency or developmental disorders) as a result of the mental disorder, the child must behave inappropriately for his or her age and must also meet one of the following criteria:

The child has a substantial impairment in at least two of the following areas: self-care, school functioning, family relationships, or ability to function in the community and is at risk of being removed from the home or has already been removed, or the mental disorder has been present for more than six (6) months and is likely to continue for more than one year without treatment.

The child is psychotic, suicidal or potentially violent.

The child meets the special education eligibility requirements under California law.

The medical benefit program will pay for medically necessary services. If you need more information about covered services, call your HMO.

Notice of Loss of Grandfathered StatusUnder the Affordable Care Act, the medical plans offered through the Teamsters Local 1932 Health and Welfare Trust are not considered “grandfathered plans”.

Since the medical plans are not considered grandfathered, the medical plans must comply with additional requirements under the Affordable Care Act. For specific information about any of these requirements, please contact your medical plan directly.

Our dreams can now become our future

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Claims ProceduresHealthcare Claims Procedures Most of your Health and Welfare Benefits are fully insured by various companies. Generally, you will not be required to submit a claim. If you need to file a claim or if you have received an adverse benefit determination you will be required to follow the claims procedures detailed in your EOC booklet issued by the insurance company that provides your insured benefits.

Please see the EOC booklets issued by the insurers for information about how to file a claim and for details regarding the particular insurance company’s claims procedures.

If your claim is denied in whole or in part, you may appeal to the insurance company for a review of the denied claim. Your insurance company will decide your appeal in accordance with the reasonable claims procedures required by law.

Important Appeal DeadlinesYou should refer to the EOC booklets issued by your health insurance carrier to determine the time limits for filing an appeal. If you fail to file an appeal within the required period, you will lose the right to challenge the denial of your claim in court because you will have failed to exhaust your internal administrative appeal rights.

Please refer to your EOC booklet issued by your health insurance carrier for information about how to appeal a denied claim and for details regarding a particular provider’s claims procedures. A copy can be obtained free of charge from the Trust Administration Office.

Acts of Third Parties - Third Party LiabilityYour EOC booklet contains information about your insurance provider’s right to subrogation or reimbursement of benefits paid on your behalf when either you or your Dependent is injured or becomes ill as the result of the actions of a third-party. Although your insurance carrier will pay your medical expenses you may be obligated to reimburse the insurance carrier from the monies you receive from the third-party up to the amount of benefits the carrier paid on your behalf. If you are injured or become ill, it is very important that you review the EOC – Acts of Third Parties provisions to determine your rights and obligations with respect to your insurance carrier.

Eligibility Claims Procedures No Participant, Dependent or other beneficiary shall have any right or claim to benefits under the Trust, unless eligible pursuant to the MOU, this SPD and the Trust Agreement. Any dispute as to eligibility must be approved or denied by the Trust Administration office within thirty (30) days of receipt of such claim. If determination of the claim cannot be made within the time period, you will be notified prior to the end of the original thirty (30) days and the Trust Administration Office may take up to an additional thirty (30) days to make a decision on the claim. If your claim is denied, the Trust Administration Office will notify you in writing. The notice will explain in detail the reasons for denial with specific reference to the Trust provisions upon which the denial is based, a description of any information or material necessary to perfect the claim and an explanation of the right to appeal.

1) To file an appeal, you must file a request for review by the Board of Trustees with the Trust Administration Office within thirty (30) days of your receipt of the denial notice. Failure to file a request within the thirty (30) period will constitute a waiver of your right to appeal the denial or to take any other action with respect to it, although the Board of Trustees may consider an appeal submitted up to sixty (60) days from the date of the denial notice provided that good cause is shown for the delay. An appeal shall be in writing, shall state in clear and concise terms the reason or reasons for disputing the denial, and shall be accompanied by any pertinent documentary material not already furnished to the Trust.

2) You shall be advised of the Trustees’ decision in writing as soon as practicable but generally no later than ninety (90) days after receipt of your request for review. Should there be special circumstances, the time may be extended for the processing of such request for review for a period not to exceed one hundred twenty (120) days after receipt of a request for review. You will be notified of the extension prior to the end of the original ninety (90) day period, the decision on review shall be in writing and shall include a specific reason for the decision with specific references to the pertinent provisions of the Plan Documents on which the decision is based.

The Trustees have complete and sole discretion to interpret the Trust documents and to determine eligibility. Such determinations shall be conclusive and binding on all persons.

Civil ActionsIn order to file a civil action against the Plan, you must first exhaust the claims and appeals procedure described above. The Board of Trustees have sole discretionary authority to make final determinations regarding your application for benefits and Plan interpretation. If you file a civil action against the Plan, determinations of the Board of Trustees will be subject to judicial

Success is never accidental


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review only for abuse of discretion.

No action may be filed by any person against the Plan, the Board of Trustees, or any of the Board of Trustees’ agents more than one hundred and eighty (180) days after a claimant is given written notice of the denial of an appeal by the Board of Trustees. This one hundred and eighty (180) day limitation period will apply to all legal and equitable actions arising out of or relating to the provision of benefits or rights under the Plan.

Insurance Contracts ControlBenefits hereunder are provided solely pursuant to contracts of insurance entered into between the Teamsters Local 1932 Health and Welfare Trust and the respective insurance companies and health and dental maintenance organizations. If the terms of this document conflict with the terms of the such contracts, the terms of the insurance contracts, group health, vision and dental agreements will control, unless superseded by applicable law.

Amendment and TerminationThe benefits described in this booklet, while intended to remain in effect indefinitely, can be guaranteed only so long as the parties to the Memoranda of Understanding continue to require Contributions into the Plan sufficient to underwrite the cost of the benefits. Should Contributions cease and their reserves be expended, the Trustees would no longer be obligated to furnish coverage. These are not guaranteed lifetime benefits. The Board of Trustees shall, in their sole discretion and without notice to eligible Persons or Employers or Union, but on a nondiscriminatory basis, reserve the right to:

1. Terminate or amend either the amount or conditions with respect to any benefits or provisions of the Plan even though such termination or amendment affects claims in process and/or expenses already incurred; and

2. Alter or postpone the method of payment of any benefit; and3. Amend any provisions of these rules and regulations.

Definitions

Administration Office or Trust Administration Office means the offices maintained by the third party administrator for the administration of the Trust which is Zenith American Solutions.

Annual Open Enrollment Period is the period of time in which you may make changes to your selected benefits and add or remove Dependents. The Annual Open Enrollment Period occurs once in any 12-month period.

COBRA or COBRA Continuation Coverage means the federal legislation Consolidated Omnibus Reconciliation Act of 1986, as amended, requiring the right to continue health coverage upon loss of eligibility.

Contribution or Contributions or Employer Contributions means the dollar amount specified in a MOU to be made by Employers to the Trust for each Employee.

Covered Employment means employment or work covered by the terms of a MOU or other agreement pursuant to which Contributions are required to be made to the Trust.

Day means a calendar Day, not a business Day.

Default Enrollment Policy refer to page 63 for a description of this policy.

Dependent refer to page 65 for more information.

Domestic Partner refer to pages 65-66 for more information.

Employee and Member will be interchangeable and will mean any person covered by a MOU and employed by an Employer. The term Employee will also include Members in good standing and officers and Employees of the Union which make Contributions to the Trust on behalf of such Employees, officers and Members in good standing, provided the inclusion of such persons is not a violation of any existing law or statute.

Employer means for purposes of the Plan, any Employer or any successor in interest of said Employer who has signed or who is bound by a MOU or other agreement, requiring that Contributions be made to the Teamsters Local 1932 Health and Welfare Trust, and shall include the Union which makes Contributions on behalf of its Members in good standing and its officers and Employees, provided the inclusion of said Union as an Employer is not a violation of any existing law or statute.

Enrollment Form is the form made available by the Trust Administration Office or Employer for new Employees to designate the various coverages available to them and their Dependents.

Evidence of Coverage (EOC) is a comprehensive resource guide to your health care coverage. It explains your benefits, premiums and cost-sharing; conditions and limitations of coverage; and plan rules.

Health and Welfare Benefits shall mean any and all benefit payments to Employees or their Dependents as required by a MOU, and provided through a Plan developed and established by the Trustees pursuant to the Restated Declarations of Trust. Said Health and Welfare Benefits may include medical, dental, surgical, hospital, prescription drug, mental health and substance abuse and vision care benefits.


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Medicare means the insurance program established by Title XVIII, United States Social Security Act of 1965, as originally enacted or as subsequently amended.

Memorandum of Understanding (MOU) shall mean a written contract by and between any Employer and Union which provides for Contributions to be made to this Trust. It shall also include any and all extensions, renewals or any new MOU entered into by the Union and the Employer which provides for Contributions to be made to this Trust.

Participant means each eligible Employee or Dependent.

Participating Employer means (a) an Employer who is obligated to make Contributions to the Trust pursuant to a MOU; or (b) an Employer who has agreed to contribute to the Trust to provide coverage under the Plan.

Patient Protection and Affordable Care Act commonly called the Affordable Care Act is a United States federal statute signed into law on March 23, 2010.

Plan or Plan Document means the plan or program of benefits provided for in the Summary Plan Description, as amended from time to time (including the Evidence of Coverage booklets for insured benefits), which is adopted by the Board of Trustees pursuant to the Amended Agreement and Declaration of Trust providing for the Teamsters Local 1932 Health and Welfare Trust.

Qualified Beneficiary refer to COBRA section, commencing on page 72.

Qualifying Event refer to COBRA section, commencing on page 71.

Trust Agreement or Declaration of Trust means the Agreement and Declaration of Trust providing for Teamsters Local 1932 Health and Welfare Trust, effective January 14, 2020, and any modification, amendment, extension or renewal thereof.

Trust means the entire trust estate under “Teamsters Local 1932 Health and Welfare Trust,” and shall include all monies, assets of every kind and nature and Contributions which belong to or are part of the trust estate.

Trust Acceptance and Contract Data Agreement refers to the agreement that binds Employers to the terms of the Trust Agreement (also referred to as the Trust Acceptance Agreement).

Trustees and/or Board of Trustees means the named fiduciaries of the Trust who have the joint authority to control and manage the operation and administration of the Trust and Plan in accordance with the provisions of the Trust Agreement.

Union means those labor organizations that are parties to the Restated Trust Agreement and any other labor organization participating in the Trust which has an agreement with an Employer providing for payments into the Trust and which agreement and parties have been accepted by the Trustees.

USERRA means the Uniformed Services Employment and Reemployment Rights Act of 1994, as amended.

Waiver of Coverage Form refer to page 5 for more information.

Summary of Trust BenefitsMedical PlansAs a new Employee, when you become eligible for coverage for the first time, you must complete an Enrollment Form designating the Health Maintenance Organization (HMO) or Preferred Provider Organization (PPO) of your choice. These medical plans are described in the separate EOC booklets, and are outlined in the Schedules of Benefits included in this SPD. Please refer to the Schedules of Benefits provided with this SPD for the plans that apply to you. It is important you understand the benefits provided under the medical plans before you make your selection and complete the necessary Enrollment Form. You MUST complete the appropriate Enrollment Form in full. You must also select a participating medical group or independent physician association for the HMO plans offered.

The EOC booklets and the medical plan provider directories can be obtained, free of charge, by contacting the Trust Administration Office.

It is important you send the completed Enrollment Form to the Trust Administration Office. Your eligible Dependents will be covered under the same medical plan you select for yourself. Services can be delayed or denied unless you have made your selection in writing, and all the required information has been correctly filled in. The EOC booklet for each plan contains the benefit provisions, including applicable limitations and exclusions for each program. If you have any questions regarding your medical plan coverage, please contact the Trust Administration Office.


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HMO Plans

A health maintenance organization (HMO) offers comprehensive medical care from a group of providers under contract to the HMO. In an HMO, you must select a physician from among those employed by or under contract to the HMO. However, covered services and supplies are provided by the HMO facilities either at no cost to you or with minimal copays. Further, there are no claim forms to file.

Except for certain medical emergencies or authorized referrals, you must use physicians or hospitals affiliated with the HMO. If you do not use physicians or hospitals authorized by your HMO, neither the Trust nor the HMO will be responsible for the charges you incur.

To enroll in an HMO plan, you must live within the service area of the HMO. If you do not reside within any of the HMO service areas, please contact the Trust Administration Office.

PPO Plans

A preferred provider organization (PPO) plan allows you access to both network and out-of-network providers, however, covered services and supplies provided by out-of-network providers require higher out-of-pocket costs. In addition, you may be required to submit a claim form for reimbursement when using an out-of-network provider. Please refer to the Schedules of Benefits provided with this SPD for the plans that apply to you.

Dental PlansThe Trust offers two dental plans, an HMO plan and a PPO plan. Please refer to the Schedules of Benefits provided with this SPD for the plans that apply to you. These dental plans are described in separate EOC booklets, and are outlined in the Schedules of Benefits included with this SPD. Under the dental HMO plan, you must receive services from a network or contracted provider in order to receive coverage. For the PPO dental plan, you can receive services from a network or out-of-network provider, but you may experience higher out-of-pocket costs using an out-of-network provider. Many of the services offered by these dental plans require no copay. In addition, there is no annual deductible to satisfy if enrolled in a dental HMO plan.

Enrolling in one of these dental plans is similar to enrolling in the medical plans previously described. You must complete the appropriate Enrollment Form and select the appropriate dental plan available to you.

Vision BenefitsThe Trust offers a vision plan through EyeMed Vision Care. Please refer to the Schedule of Benefits attached for a general description of benefits offered through EyeMed Vision Care.

Insurers and Providers of Service to the Trust

Hospital, Medical, Surgical andPrescription Drug Benefits

Blue Shield of CaliforniaP.O. Box 272540Chico, CA 95927-2540(855) 599-2657www.blueshieldca.com

Blue Shield Mental Health Service Administration (MHSA)P.O. Box 719002San Diego, CA 92171-9002(877) 263-9952

BlueShield of CaliforniaTelemedicine(800) Teladoc /(800) 835-2362Register at: www.teladoc.com/bsc

Kaiser Permanente P.O. Box 7004Downey, CA 90242-7004 (800) 390-3510 (Claims)(800) 464-4000 (Member Services)www.kp.org

Kaiser Permanente Mental Health Offices and ServicesFor mental health advice, call 24/7 at 1-800-900-3277

(TTY 711).

To schedule an appointment, call:Antelope Valley: 661-951-0070Baldwin Park and surrounding areas:

626-960-4844Downey and surrounding areas: 562-807-6200Fontana, Ontario, and surrounding areas:

1-866-205-3595Kern County: 1-855-323-2700Metro Los Angeles: 323-783-2600Orange County: 714-644-6480Panorama City and surroundings: 1-800-700-8705

(Santa Clarita), 1-800-700-8705 (Reseda)Riverside and Coachella: 951-248-4000 (Canyon

Crest), 951-898-7010 (Corona)San Diego: 1-877-496-0450South Bay: 310-325-6542West Los Angeles: 323-298-3100 Woodland Hills

and surrounding areas (including western Ventura): 855-701-7955

Dental Benefits

DeltaCare USA (DHMO)Delta Dental Insurance CompanyP.O. Box 1803 Alpharetta, GA 30023(800) 422-4234www.deltadentalins.com

Delta Dental PPO Delta Dental of California560 Mission Street, Suite 1300San Francisco, CA 94105 (855) 244-7323www.deltadentalins.com

Claims/Customer Service/GrievancesP.O. Box 997330Sacramento, CA 95899-7330(888) 335-8227

Vision Benefits

EyeMed VisionP.O. Med VisionMason, OH 45040(877) 406-4146www.eyemed.com

http://www.blueshieldca.com


http://www.kp.org

http://www.deltadentalins.com

http://www.deltadentalins.com

http://www.eyemed.com

REGULATORY FILING IN PROCESS A16406 (1/20) 1

Summary of Benefits Teamsters Local 1932 Health and Welfare Trust

Effective July 18, 2020Shield Signature Benefit Plan

HMO Platinum POS Plan

This Summary of Benefits shows the amount you will pay for Covered Services under this Blue Shield of California benefit Plan. It is only a summary and it is part of the contract for health care coverage, called the Evidence of Coverage (EOC). 1 Please read both documents carefully for details.

Medical Provider Network: Shield Signature Network

This benefit Plan uses a specific network of Health Care Providers, called the Shield Signature provider network. This Plan provides benefits at two different levels:

• Shield Signature Level I (HMO Participating Providers): Services must be provided or prior authorized by yourPrimary Care Physician or Medical Group/IPA, except in an Emergency or otherwise specified. Please reviewyour EOC for details about how to access care under this level.

• Shield Signature Level II (PPO Participating Providers): Services are provided by Participating Providers foroutpatient professional services provided in an office setting. Any Copayment or Coinsurance is calculatedfrom the Allowable Amount.

You are responsible for any Copayment or Coinsurance and any charges over the Allowable Amount. You can find Participating Providers in this network at blueshieldca.com.

Calendar Year Deductibles (CYD) 2

A Calendar Year Deductible (CYD) is the amount a Member pays each Calendar Year before Blue Shield pays for Covered Services under the benefit Plan. Blue Shield pays for some Covered Services before the Calendar Year Deductible is met, as noted in the Benefits chart below.

Shield Signature LevelI HMO Plan providers3

Shield Signature Level IIParticipating Providers3

Calendar Year medical Deductible Individual coverage

Family coverage

$0

$0: individual$0: Family

$0

$0: individual$0: Family

Calendar Year Out-of-Pocket Maximum 4

An Out-of-Pocket Maximum is the most a Member will pay for Covered Services each Calendar Year. Any exceptions are listed in the Notes section at the end of this Summary of Benefits.

Shield Signature Level I HMO Plan providers3

Shield Signature Level II Participating Providers3

Individual coverage

Family coverage

$1,500

$1,500: individual$3,000: Family

$8,000

$8,000: individual$16,000: Family

No Annual or Lifetime Dollar Limit

Under this benefit Plan there is no dollar limit on the total amount Blue Shield will pay for Covered Services in a Member’s lifetime.

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Benefits 5 Your payment

Shield Signature Level I HMO Plan

providers3 CYD2

applies

Shield Signature Level II Participating

Providers3 CYD2

applies

Preventive Health Services 6

Preventive Health Services $0 $30/visit

California Prenatal Screening Program $0 $0

Physician services

Primary care office visit $10/visit $30/visit

Specialist care office visit $10/visit $30/visit

Physician home visit $10/visit $30/visit

Physician or surgeon services in an outpatient facility

$0 Not covered

Physician or surgeon services in an inpatient facility

$0 Not covered

Other professional services

Other practitioner office visit

Includes nurse practitioners, physician assistants, and therapists.

$10/visit $30/visit

Acupuncture services Not covered Not covered

Chiropractic services Not covered Not covered

Teladoc consultation $0/consult Not covered

Family planning

• Counseling, consulting, and education $0 Not covered

• Diaphragm fitting, intrauterine device (IUD),implantable contraceptive, and relatedprocedure.

$0 Not covered

• Injectable contraceptive

Under Level II, services are only covered if received in a Physician’s office.

$0 $30/visit

• Tubal ligation $0 Not covered

• Vasectomy $10/surgery Not covered

Podiatric services $10/visit $30/visit

Pregnancy and maternity care6

Physician office visits: prenatal and postnatal $0 20%

Physician services for pregnancy termination $0 20%

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providers3 CYD2

applies


Providers3 CYD2

applies

Emergency services Emergency room services

If admitted to the Hospital, this payment for emergency room services does not apply. Instead, you pay the participating providerpayment under Inpatient facility services/Hospital services and stay.

$50/visit $50/visit

Emergency room Physician services $0 $0

Urgent care center services $10/visit $10/visit

Ambulance services $0 $0

This payment is for emergency or authorized transport.

Outpatient facility services

Ambulatory Surgery Center $0 Not covered

Outpatient Department of a Hospital: surgery $0 Not covered

Outpatient Department of a Hospital: treatment of illness or injury, radiation therapy, chemotherapy, and necessary supplies

$0 Not covered

Inpatient facility services

Hospital services and stay $0 Not covered

Transplant services

This payment is for all covered transplants except tissue and kidney. For tissue and kidney transplant services, the payment for Inpatient facility services/ Hospital services and stay applies.

• Special transplant facility inpatient services $0 Not covered

• Physician inpatient services $0 Not covered

Bariatric surgery services, designated California counties

This payment is for bariatric surgery services for residents of designated California counties. For bariatric surgery services for residents of non-designated California counties, the payments for Inpatient facility services and Inpatient Physician services apply for inpatient services; or, if provided on an outpatient basis, the Outpatient facility services and Outpatient Physician services payments apply.

Inpatient facility services $0 Not covered




providers3 CYD2

applies


Providers3 CYD2

appliesOutpatient facility services $0 Not covered

Physician services $0 Not covered

Diagnostic x-ray, imaging, pathology, and laboratory services

This payment is for Covered Services that are diagnostic, non-Preventive Health Services, and diagnostic radiological procedures, such as CT scans, MRIs, MRAs, and PET scans. For the payments for Covered Services that are considered Preventive Health Services, see Preventive Health Services.

Laboratory services

Includes diagnostic Papanicolaou (Pap) test.

• Laboratory center


$0 $0

• Outpatient Department of a Hospital $0 Not covered

X-ray and imaging services

Includes diagnostic mammography.

• Outpatient radiology center


$0 $0

• Outpatient Department of a Hospital

$0 Not covered

Other outpatient diagnostic testing

Testing to diagnose illness or injury such as vestibular function tests, EKG, ECG, cardiac monitoring, non-invasive vascular studies, sleep medicine testing, muscle and range of motion tests, EEG, and EMG.

• Office location

Under Level II, services are only covered ifreceived in a Physician’s office.

$0 $0


Radiological and nuclear imaging services

• Outpatient radiology center $0 Not covered


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Providers3 CYD2

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Rehabilitative and Habilitative Services

Includes Physical Therapy, Occupational Therapy,and Respiratory Therapy services. Under Level II, up to 12 visits per Member, per Calendar Year.

Office location $10/visit $30/visit

Outpatient Department of a Hospital $0 Not covered

Speech therapy services

Office location $10/visit $30/visit

Outpatient Department of a Hospital $0 Not covered

Durable medical equipment (DME)

DME $0 Not covered

Breast pump $0 Not covered

Orthotic equipment and devices $0 Not covered

Prosthetic equipment and devices $0 Not covered

Home health care services

. Includes home visits by a nurse, Home Health Aide, medical social worker, physical therapist, speech therapist, or occupational therapist.

$0 Not covered

Home infusion and home injectable therapy services

Home infusion agency services

Includes home infusion drugs and medical supplies.

$0 Not covered

Home visits by an infusion nurse $0 Not covered

Hemophilia home infusion services

Includes blood factor products.

$0 Not covered

Skilled Nursing Facility (SNF) services

Freestanding SNF $0 Not covered

Hospital-based SNF $0 Not covered

Hospice program services

Includes pre-Hospice consultation, routine home care, 24-hour continuous home care, short-term inpatient care for pain and symptom management, and inpatient respite care.

$0 Not covered




providers3 CYD2

applies


Providers3 CYD2

applies

Other services and supplies

Diabetes care services

• Devices, equipment, and supplies $0 Not covered

• Self-management training $0 $30/visit

Dialysis services $0 Not covered

PKU product formulas and Special Food Products

$0 Not covered

Allergy serum billed separately from an office visit

$0 $0

Travel immunizations and vaccinations $10/injection $30/injection

Eye examination

One comprehensive eye examination in a consecutive 12-month period provided through the contracted VPA.

• Ophthalmologic exam $10/visit $0 up to $60/year plus 100% of

additional charges• Optometric exam $10/visit $0 up to $50/year

plus 100% of additional charges

Mental Health and Substance Use Disorder Benefits Your payment

Mental health and substance use disorder Benefits are provided through Blue Shield’s Mental Health Service Administrator (MHSA).

Shield Signature Level I MHSA Participating

Providers3 CYD2

applies

Shield Signature Level II MHSA Non-Participating

Providers3 CYD2

applies

Outpatient services

Office visit, including Physician office visit $10/visit $10/visit

Intensive outpatient care $0 Not covered

Behavioral Health Treatment in an office setting $0 $0

Behavioral Health Treatment in home or other non-institutional facility setting

$0 $0

Office-based opioid treatment $0 $0

Partial Hospitalization Program $0 Not covered

Psychological Testing $0 Not covered

Inpatient services

Physician inpatient services $0 Not covered

Hospital services $0 Not covered

Residential Care $0 Not covered

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1 Evidence of Coverage (EOC):

The Evidence of Coverage (EOC) describes the benefits, limitations, and exclusions that apply to coverage under this benefit plan. Please review the EOC for more details of coverage outlined in this Summary of Benefits. You can request a copy of the EOC at any time.

Capitalized terms are defined in the EOC. Refer to the EOC for an explanation of the terms used in this Summary of Benefits.

2 Calendar Year Deductible (CYD):

Calendar Year Deductible explained. A Calendar Year Deductible is the amount you pay each Calendar Year before Blue Shield pays for Covered Services under the benefit Plan.

If this benefit Plan has any Calendar Year Deductible(s), Covered Services subject to that Deductible are identified with a check mark () in the Benefits chart above.

3 Using Shield Signature Level I and Shield Signature Level II Participating Providers:

Shield Signature Level I and Shield Signature Level II Participating Providers have a contract to provide health care services to Members.

When you receive Covered Services from a Participting Provider, you are only responsible for the Copayment or Coinsurance, once any Calendar Year Deductible has been met.

4 Calendar Year Out-of-Pocket Maximum (OOPM):

Your payment after you reach the Calendar Year OOPM. You will continue to pay all charges above a Benefit maximum.

Essential health benefits count towards the OOPM.

This Plan has a separate level I HMO Plan Provider and level II Participating Provider OOPM.

Family coverage has an individual OOPM within the Family OOPM. This means that the OOPM will be met for an individual with Family coverage who meets the individual OOPM prior to the Family meeting the Family OOPM within a Calendar Year.

5 Separate Member Payments When Multiple Covered Services are Received:

Each time you receive multiple Covered Services, you might have separate payments (Copayment or Coinsurance) for each service. When this happens, you may be responsible for multiple Copayments or Coinsurance. For example, you may owe an office visit Copayment in addition to an allergy serum Copayment when you visit the doctor for an allergy shot.

6 Preventive Health Services:

If you only receive Preventive Health Services during a Physician office visit, there is no Copayment or Coinsurance for the visit under the Shield Signature Level 1 provider network. If you receive both Preventive Health Services and other Covered Services during the Physician office visit, you may have a Copayment or Coinsurance for the visit.

Notes

Benefit Plans may be modified to ensure compliance with State and Federal requirements.MS050820

A16149-a (1/20) Plan ID: 12984 1

Outpatient Prescription Drug Rider


Effective July 18, 2020 HMO/POS

HMO Platinum POS, HMO Platinum Trio Enhanced Rx $5/10/25 Summary of BenefitsThis Summary of Benefits shows the amount you will pay for covered Drugs under this prescription Drug Benefit.

Pharmacy Network: Rx Ultra

Drug Formulary: Plus Formulary

Calendar Year Pharmacy Deductible (CYPD)1

A Calendar Year Pharmacy Deductible (CYPD) is the amount a Member pays each Calendar Year before Blue Shield pays for covered Drugs under the outpatient prescription Drug Benefit. Blue Shield pays for some prescription Drugs before the Calendar Year Pharmacy Deductible is met, as noted in the Prescription Drug Benefits chart below.

When using a Participating2 Pharmacy

Calendar Year Pharmacy Deductible Per Member $0

Prescription Drug Benefits3,4 Your payment

When using a Participating Pharmacy2

CYPD1 applies

Retail pharmacy prescription Drugs

Per prescription, up to a 30-day supply.

Contraceptive Drugs and devices $0

Tier 1 Drugs $5/prescription



Tier 4 Drugs (excluding Specialty Drugs) $10/prescription

Mail service pharmacy prescription Drugs






Tier 4 Drugs (excluding Specialty Drugs) $20/prescription

Network Specialty Pharmacy Drugs


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2



CYPD1 applies

Tier 4 Specialty Drugs $10/prescription

Oral anticancer Drugs $10/prescription


1 Calendar Year Pharmacy Deductible (CYPD):

Calendar Year Pharmacy Deductible explained. A Calendar Year Pharmacy Deductible is the amount you pay each Calendar Year before Blue Shield pays for outpatient prescription Drugs under this Benefit.

If this Benefit has a Calendar Year Pharmacy Deductible, outpatient prescription Drugs subject to the Deductible are identified with a check mark () in the Benefits chart above.

Outpatient prescription Drugs not subject to the Calendar Year Pharmacy Deductible. Some outpatient prescription Drugs received from Participating Pharmacies are paid by Blue Shield before you meet any Calendar Year Pharmacy Deductible. These outpatient prescription Drugs do not have a check mark () next to them in the "CYPD applies” column in the Prescription Drug Benefits chart above.

2 Using Participating Pharmacies:

Participating Pharmacies have a contract to provide outpatient prescription Drugs to Members. When you obtain covered prescription Drugs from a Participating Pharmacy, you are only responsible for the Copayment or Coinsurance, once any Calendar Year Pharmacy Deductible has been met.

Participating Pharmacies and Drug Formulary. You can find a Participating Pharmacy and the Drug Formulary by visiting www.blueshieldca.com/wellness/drugs/formulary#heading2.

Non-Participating Pharmacies. Drugs from Non-Participating Pharmacies are not covered except in emergency situations.

3 Outpatient Prescription Drug Coverage:

Medicare Part D-creditable coverage-

This prescription Drug coverage is on average equivalent to or better than the standard benefit set by the federal government for Medicare Part D (also called creditable coverage). Because this prescription Drug coverage is creditable, you do not have to enroll in Medicare Part D while you maintain this coverage; however, you should be aware that if you do not enroll in Medicare Part D within 63 days following termination of this coverage, you could be subject to Medicare Part D premium penalties.


Brand Drug coverage when a Generic Drug is available. If you select a Brand Drug when a Generic Drug equivalent is available, you are responsible for the difference between the cost to Blue Shield for the Brand Drug and its Generic Drug equivalent plus the Tier 1 Copayment or Coinsurance. This difference in cost will not count towards any Calendar Year Pharmacy Deductible, medical Deductible, or the Calendar Year Out-of-Pocket Maximum. If your Physician or Health Care Provider prescribes a Brand Drug and indicates that a Generic Drug equivalent should not be substituted, you pay your applicable tier Copayment or Coinsurance. If your Physician or Health Care Provider does not indicate

Notes

3

Notes

that a Generic Drug equivalent should not be substituted, you may request a Medical Necessity Review. If approved, the Brand Drug will be covered at the applicable Drug tier Copayment or Coinsurance.

Short-Cycle Specialty Drug program. This program allows initial prescriptions for select Specialty Drugs to be filled for a 15-day supply with your approval. When this occurs, the Copayment or Coinsurance will be pro-rated.

Benefit designs may be modified to ensure compliance with State and Federal requirements.

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A17257 (1/20) Plan ID: 11310 1

Summary of Benefits


Effective July 18, 2020HMO Plan

HMO Gold Access+ Plan ($40 copay)This Summary of Benefits shows the amount you will pay for Covered Services under this Blue Shield of California Plan. It is only a summary and it is included as part of the Evidence of Coverage (EOC).1 Please read both documents carefully for details.

Medical Provider Network: Access+ HMO NetworkThis Plan uses a specific network of Health Care Providers, called the Access+ HMO provider network. Medical Groups, Independent Practice Associations (IPAs), and Physicians in this network are called Participating Providers. You must select a Primary Care Physician from this network to provide your primary care and help you access services, but there are some exceptions. Please review your Evidence of Coverage for details about how to access care under this Plan. You can find Participating Providers in this network at blueshieldca.com.

Calendar Year Deductibles (CYD)2

A Calendar Year Deductible (CYD) is the amount a Member pays each Calendar Year before Blue Shield pays for Covered Services under the Plan.

When using a Participating Provider3

Calendar Year medical Deductible Individual coverage $0

Family coverage $0: individual

$0: Family

Calendar Year Out-of-Pocket Maximum4

An Out-of-Pocket Maximum is the most a Member will pay for Covered Services each Calendar Year. Any exceptions are listed in the EOC. No Annual or Lifetime Dollar Limit

When using a Participating Provider3 Under this Plan there is no annual or lifetime dollar limit on the amount Blue Shield will pay for Covered Services. Individual coverage $3,500

Family coverage $3,500: individual

$7,000: Family

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Benefits5 Your payment

When using aParticipating Provider3

CYD2

applies

Preventive Health Services6

Preventive Health Services $0

California Prenatal Screening Program $0

Physician services

Primary care office visit $40/visit

Access+ specialist care office visit (self-referral) $50/visit

Other specialist care office visit (referred by PCP) $40/visit

Physician home visit $40/visit

Physician or surgeon services in an outpatient facility $0

Physician or surgeon services in an inpatient facility $0


Other practitioner office visit $40/visit


Teladoc consultation $0

Family planning

• Counseling, consulting, and education $0

• Injectable contraceptive; diaphragm fitting, intrauterine device (IUD), implantable contraceptive, and related procedure.

$0

• Tubal ligation $0

• Vasectomy $10/surgery

Podiatric services $40/visit


Physician office visits: prenatal and postnatal $0

Physician services for pregnancy termination $0

Emergency services

Emergency room services $50/visit

If admitted to the Hospital, this payment for emergency room services does not apply. Instead, you pay the Participating Provider payment under Inpatient facility services/ Hospital services and stay.

Emergency room Physician services $0

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CYD2

applies

Urgent care center services $40/visit

Ambulance services $0



Ambulatory Surgery Center 40%

Outpatient Department of a Hospital: surgery 40%

Outpatient Department of a Hospital: treatment of illness or injury, radiation therapy, chemotherapy, and necessary supplies $0


Hospital services and stay $100/admission plus 20%

Transplant services


• Special transplant facility inpatient services $100/admission plus 20%

• Physician inpatient services $0



Laboratory services


• Laboratory center 40%

• Outpatient Department of a Hospital $0



• Outpatient radiology center 40%




• Office location 40%


4



CYD2

applies



• Outpatient Department of a Hospital 40%


Includes Physical Therapy, Occupational Therapy, Respiratory Therapy, and Speech Therapy services.

Office location $40/visit

Outpatient Department of a Hospital $40/visit


DME 40%

Breast pump $0

Orthotic equipment and devices $0

Prosthetic equipment and devices $0

Home health care services $0

Up to 100 visits per Member, per Calendar Year, by a home health care agency. All visits count towards the limit, including visits during any applicable Deductible period. Includes home visits by a nurse, Home Health Aide, medical social worker, physical therapist, speech therapist, or occupational therapist, and medical supplies.


Home infusion agency services $0


Home visits by an infusion nurse $0

Hemophilia home infusion services $0



Up to 100 days per Member, per Benefit Period, except when provided as part of a Hospice program. All days count towards the limit, including days during any applicable Deductible period and days in different SNFs during the Calendar Year.

Freestanding SNF $0

Hospital-based SNF $0

Hospice program services $0


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CYD2

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• Devices, equipment, and supplies 40%

• Self-management training $40/visit

Dialysis services $0

PKU product formulas and Special Food Products $0

Allergy serum billed separately from an office visit 40%

Travel immunizations and vaccinations $10/visit


Mental health and substance use disorder Benefits are provided through Blue Shield's Mental Health Service Administrator (MHSA).

When using a MHSAParticipating Provider3

CYD2

applies

Outpatient services

Office visit, including Physician office visit $40/visit

Other outpatient services, including intensive outpatient care, electroconvulsive therapy, transcranial magnetic stimulation, Behavioral Health Treatment for pervasive developmental disorder or autism in an office setting, home, or other non-institutional facility setting, and office-based opioid treatment

$0

Partial Hospitalization Program $0

Psychological Testing $0

Inpatient services

Physician inpatient services $0

Hospital services $100/admission plus 20%

Residential Care $100/admission plus 20%


The Evidence of Coverage (EOC) describes the Benefits, limitations, and exclusions that apply to coverage under this Plan. Please review the EOC for more details of coverage outlined in this Summary of Benefits. You can request a copy of the EOC at any time.


Notes

6

Notes


Calendar Year Deductible explained. A Deductible is the amount you pay each Calendar Year before Blue Shield pays for Covered Services under the Plan.

If this Plan has any Calendar Year Deductible(s), Covered Services subject to that Deductible are identified with a check mark () in the Benefits chart above.

3 Using Participating Providers:

Participating Providers have a contract to provide health care services to Members. When you receive Covered Services from a Participating Provider, you are only responsible for the Copayment or Coinsurance, once any Calendar Year Deductible has been met.








If you only receive Preventive Health Services during a Physician office visit, there is no Copayment or Coinsurance for the visit. If you receive both Preventive Health Services and other Covered Services during the Physician office visit, you may have a Copayment or Coinsurance for the visit.

Plans may be modified to ensure compliance with State and Federal requirements.

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A16149-a (1/20) 1

Outpatient Prescription Drug Rider Teamsters Local 1932 Health and Welfare Trust

Effective July 18, 2020HMO/POS

HMO Gold, HMO Gold Trio Enhanced Rx $5/10/25Summary of BenefitsThis Summary of Benefits shows the amount you will pay for covered Drugs under this prescription Drug Benefit.

Pharmacy Network: Rx UltraDrug Formulary: Plus Formulary






When using a Participating Pharmacy2CYPD1

applies







Tier 4 Drugs (excluding Specialty Drugs) 20% up to $200/prescription










Tier 4 Specialty Drugs 20% up to $200/prescription

Oral anticancer Drugs

Per prescription, up to a 30-day supply. 20% up to $200/prescription

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Brand Drug coverage when a Generic Drug is available. If you select a Brand Drug when a Generic Drug equivalent is available, you are responsible for the difference between the cost to Blue Shield for the Brand Drug and its Generic Drug equivalent plus the Tier 1 Copayment or Coinsurance. This difference in cost will not count towards any Calendar Year Pharmacy Deductible, medical Deductible, or the Calendar Year Out-of-Pocket Maximum. If your Physician or Health Care Provider prescribes a Brand Drug and indicates that a Generic Drug equivalent should not be substituted, you pay your applicable tier Copayment or Coinsurance. If your Physician or Health Care Provider does not indicate that a Generic Drug equivalent should not be substituted, you may request a Medical Necessity Review. If approved, the Brand Drug will be covered at the applicable Drug tier Copayment or Coinsurance.

Short-Cycle Specialty Drug program. This program allows initial prescriptions for select Specialty Drugs to be filled for a15-day supply with your approval. When this occurs, the Copayment or Coinsurance will be pro-rated.

Notes

Benefit designs may be modified to ensure compliance with State and Federal requirements.MS050620;050720_portfolio

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A47055 (1/20) Plan ID: 11317 1

Summary of Benefits


Effective July 18, 2020HMO Plan

HMO Gold Trio Plan ($20 copay)This Summary of Benefits shows the amount you will pay for Covered Services under this Blue Shield of California Plan. It is only a summary and it is included as part of the Evidence of Coverage (EOC).1 Please read both documents carefully for details.

Medical Provider Network: Trio ACO HMO NetworkThis Plan uses a specific network of Health Care Providers, called the Trio ACO HMO provider network. Medical Groups, Independent Practice Associations (IPAs), and Physicians in this network are called Participating Providers. You must select a Primary Care Physician from this network to provide your primary care and help you access services, but there are some exceptions. Please review your Evidence of Coverage for details about how to access care under this Plan. You can find Participating Providers in this network at blueshieldca.com.


A Calendar Year Deductible (CYD) is the amount a Member pays each Calendar Year before Blue Shield pays for Covered Services under the Plan.




$0: Family


An Out-of-Pocket Maximum is the most a Member will pay for Covered Services each Calendar Year. Any exceptions are listed in the EOC. No Annual or Lifetime Dollar Limit

When using a Participating Provider3 Under this Plan there is no annual or lifetime dollar limit on the amount Blue Shield will pay for Covered Services. Individual coverage $3,500


$7,000: Family

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CYD2

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Preventive Health Services $0

California Prenatal Screening Program $0

Physician services

Primary care office visit $20/visit

Trio+ specialist care office visit (self-referral) $20/visit

Other specialist care office visit (referred by PCP) $20/visit

Physician home visit $20/visit

Physician or surgeon services in an outpatient facility $0

Physician or surgeon services in an inpatient facility $0


Other practitioner office visit $20/visit


Teladoc consultation $0

Family planning

• Counseling, consulting, and education $0


$0

• Tubal ligation $0

• Vasectomy $20/surgery

Podiatric services $20/visit


Physician office visits: prenatal and postnatal $0

Physician services for pregnancy termination $0

Emergency services

Emergency room services $50/visit


Emergency room Physician services $0

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CYD2

applies

Urgent care center services $20/visit

Ambulance services $0





Outpatient Department of a Hospital: treatment of illness or injury, radiation therapy, chemotherapy, and necessary supplies $0



Transplant services



• Physician inpatient services $0



Laboratory services


• Laboratory center 40%








• Office location 40%


4



CYD2

applies



• Outpatient Department of a Hospital 40%



Office location $20/visit

Outpatient Department of a Hospital $20/visit


DME 40%

Breast pump $0

Orthotic equipment and devices $0

Prosthetic equipment and devices $0

Home health care services $0



Home infusion agency services $0


Home visits by an infusion nurse $0

Hemophilia home infusion services $0




Freestanding SNF $0

Hospital-based SNF $0

Hospice program services $0


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CYD2

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• Devices, equipment, and supplies 40%

• Self-management training $20/visit

Dialysis services $0

PKU product formulas and Special Food Products $0

Allergy serum billed separately from an office visit 40%

Travel immunizations and vaccinations $10/visit



When using a MHSAParticipating Provider3

CYD2

applies

Outpatient services

Office visit, including Physician office visit $20/visit


$0

Partial Hospitalization Program $0

Psychological Testing $0

Inpatient services

Physician inpatient services $0






Notes

6

Notes















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A16149-a (1/20) 1

Outpatient Prescription Drug Rider Teamsters Local 1932 Health and Welfare Trust

Effective July 18, 2020HMO/POS

HMO Gold, HMO Gold Trio Enhanced Rx $5/10/25Summary of BenefitsThis Summary of Benefits shows the amount you will pay for covered Drugs under this prescription Drug Benefit.







When using a Participating Pharmacy2CYPD1

applies


















Oral anticancer Drugs

Per prescription, up to a 30-day supply. 20% up to $200/prescription

Blue

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Short-Cycle Specialty Drug program. This program allows initial prescriptions for select Specialty Drugs to be filled for a15-day supply with your approval. When this occurs, the Copayment or Coinsurance will be pro-rated.

Notes

Benefit designs may be modified to ensure compliance with State and Federal requirements.MS050620;050720_portfolio

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A18125 (1/20) Plan ID: 11309 1

Summary of Benefits


Effective July 18, 2020PPO Plan

PPO Non-Needles PlanThis Summary of Benefits shows the amount you will pay for Covered Services under this Blue Shield of California Plan. It is only a summary and it is included as part of the Evidence of Coverage (EOC).1 Please read both documents carefully for details.

Medical Provider Network: Full PPO NetworkThis Plan uses a specific network of Health Care Providers, called the Full PPO provider network. Providers in this network are called Participating Providers. You pay less for Covered Services when you use a Participating Provider than when you use a Non-Participating Provider. You can find Participating Providers in this network at blueshieldca.com.


A Calendar Year Deductible (CYD) is the amount a Member pays each Calendar Year before Blue Shield pays for Covered Services under the Plan. Blue Shield pays for some Covered Services before the Calendar Year Deductible is met, as noted in the Benefits chart below.

When using a Participating3 or Non-Participating4 Provider



$500: Family





When using any combination of Participating3 or Non-Participating4 Providers

Under this Plan there is no annual or lifetime dollar limit on the amount Blue Shield will pay for Covered Services. Individual coverage $1,750 $2,250


$3,000: Family

$2,250: individual

$4,500: Family

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When using aParticipating

Provider3CYD2

applies

When using aNon-Participating

Provider4CYD2

applies


Preventive Health Services $0 30%


Physician services

Primary care office visit $10/visit 30%

Specialist care office visit $10/visit 30%

Office visit for allergy injection 20% 30%

Physician home visit $10/visit 30%

Physician or surgeon services in an outpatient facility 20% 30%

Physician or surgeon services in an inpatient facility 20% 30%


Other practitioner office visit $10/visit 30%


Acupuncture services 20% 30%

Up to 20 visits per Member, per Calendar Year.

Chiropractic services 20% 30%


Teladoc consultation $0 Not covered

Family planning

• Counseling, consulting, and education $0 30%


$0 30%

• Tubal ligation $0 30%

• Vasectomy 20% 30%

Podiatric services $10/visit 30%


Physician office visits: prenatal and postnatal $10/visit 30%

Physician services for pregnancy termination 20% 30%

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Provider3CYD2

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Provider4CYD2

applies

Emergency services

Emergency room services $50/visit plus 20% $50/visit plus 20%


Emergency room Physician services 20% 20%

Urgent care center services $10/visit 30%

Ambulance services 20% 20%



Ambulatory Surgery Center 20% 30%

Outpatient Department of a Hospital: surgery 20% 30%


20% 30%


Hospital services and stay 20% 30%

Transplant services


• Special transplant facility inpatient services 20% Not covered

• Physician inpatient services 20% Not covered


This payment is for bariatric surgery services for residents of designated California counties. For bariatric surgery services for residents of non-designated California counties, the payments for Inpatient facility services/ Hospital services and stay and Physician inpatient and surgery services apply forinpatient services; or, if provided on an outpatient basis, the outpatient facility services and Outpatient Physician services payments apply.

Inpatient facility services 20% Not covered

Outpatient facility services 20% Not covered

4



Provider3CYD2

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Provider4CYD2

applies

Physician services 20% Not covered



Laboratory services


• Laboratory center 20% 30%

• Outpatient Department of a Hospital 20% 30%



• Outpatient radiology center 20% 30%




• Office location 20% 30%







Office location 20% 30%

Outpatient Department of a Hospital 20% 30%


DME 20% 30%


Orthotic equipment and devices 20% 30%

Prosthetic equipment and devices 20% 30%

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Provider4CYD2

applies

Home health care services 20% Not covered



Home infusion agency services 20% Not covered


Home visits by an infusion nurse 20% Not covered

Hemophilia home infusion services 20% Not covered




Freestanding SNF 20% 20%

Hospital-based SNF 20% 30%

Hospice program services

Pre-Hospice consultation $0 Not covered

Routine home care $0 Not covered

24-hour continuous home care 20% Not covered

Short-term inpatient care for pain and symptom management 20% Not covered

Inpatient respite care $0 Not covered



• Devices, equipment, and supplies 20% 30%

• Self-management training $10/visit 30%

Dialysis services 20% 30%

PKU product formulas and Special Food Products 20% 20%

Allergy serum billed separately from an office visit 20% 30%

6



When using a MHSA

Participating Provider3

CYD2

applies

When using a MHSA Non-


CYD2

applies

Outpatient services

Office visit, including Physician office visit $10/visit 30%


20% 30%

Partial Hospitalization Program 20% 30%

Psychological Testing 20% 30%

Inpatient services

Physician inpatient services 20% 30%

Hospital services 20% 30%

Residential Care 20% 30%

Prior Authorization

The following are some frequently-utilized Benefits that require prior authorization:

• Radiological and nuclear imaging services • Hospice program services

• Outpatient mental health services, except office visits

• Inpatient facility services

Please review the Evidence of Coverage for more about Benefits that require prior authorization.




Notes

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Covered Services not subject to the Calendar Year medical Deductible. Some Covered Services received from Participating Providers are paid by Blue Shield before you meet any Calendar Year medical Deductible. These Covered Services do not have a check mark () next to them in the “CYD applies” column in the Benefits chart above.

Family coverage has an individual Deductible within the Family Deductible. This means that the Deductible will be met for an individual with Family coverage who meets the individual Deductible prior to the Family meeting the Family Deductible within a Calendar Year.



"Allowable Amount" is defined in the EOC. In addition:

• Coinsurance is calculated from the Allowable Amount or Benefit maximum, whichever is less.

4 Using Non-Participating Providers:

Non-Participating Providers do not have a contract to provide health care services to Members. When you receive Covered Services from a Non-Participating Provider, you are responsible for:

• the Copayment or Coinsurance (once any Calendar Year Deductible has been met), and

• any charges above the Allowable Amount, or

• any charges above the stated dollar amount, which is the Benefit maximum.

“Allowable Amount” is defined in the EOC. In addition:


• Charges above the Allowable Amount or Benefit maximum do not count towards the Out-of-Pocket Maximum, and are your responsibility for payment to the provider. This out-of-pocket expense can be significant.




Any Deductibles count towards the OOPM. Any amounts you pay that count towards the medical Calendar Year Deductible also count towards the Calendar Year Out-of-Pocket Maximum.

This Plan has a Participating Provider OOPM as well as a combined Participating Provider and Non-Participating Provider OOPM. This means that any amounts you pay towards your Participating Provider OOPM also count towards your combined Participating and Non-Participating Provider OOPM.


8

Notes




If you only receive Preventive Health Services during a Physician office visit, there is no Copayment or Coinsurance for the visit by a Participating Provider. If you receive both Preventive Health Services and other Covered Services during the Physician office visit, you may have a Copayment or Coinsurance for the visit.


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A20046 (1/20) Plan ID: 13000

1



Effective July 18, 2020 PPO

PPO Non-Needles Rx $15/30/30 Summary of Benefits

This Summary of Benefits shows the amount you will pay for covered Drugs under this prescription Drug Benefit.



Calendar Year Pharmacy Deductible (CYPD)1 A Calendar Year Pharmacy Deductible (CYPD) is the amount a Member pays each Calendar Year before Blue Shield pays for covered Drugs under the outpatient prescription Drug Benefit. Blue Shield pays for some prescription Drugs before the Calendar Year Pharmacy Deductible is met, as noted in the Prescription Drug Benefits chart below.

When using a Participating2 or Non-

Participating3 Pharmacy




CYPD1 applies

When using a Non-Participating

Pharmacy3 CYPD1 applies



Contraceptive Drugs and devices $0 Applicable Tier 1,

Tier 2, or Tier 3 Copayment

Tier 1 Drugs $15/prescription 25% plus $15/prescription



Tier 4 Drugs (excluding Specialty Drugs) $15/prescription 25% plus $15/prescription



Contraceptive Drugs and devices $0 Not covered Blue

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CYPD1 applies



Tier 1 Drugs $30/prescription Not covered



Tier 4 Drugs (excluding Specialty Drugs) $30/prescription Not covered



Tier 4 Specialty Drugs $15/prescription Not covered

Oral anticancer Drugs $15/prescription Not covered









3 Using Non-Participating Pharmacies:

Non-Participating Pharmacies do not have a contract to provide outpatient prescription Drugs to Members. When you obtain prescription Drugs from a Non-Participating Pharmacy, you must pay all charges for the prescription, then submit a completed claim form for reimbursement. You will be reimbursed based on the price you paid for the Drug.

Notes

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A20303 (1/20) Plan ID: 11312 1

Summary of Benefits


Effective July 18, 2020PPO Plan

PPO Needles PlanThis Summary of Benefits shows the amount you will pay for Covered Services under this Blue Shield of California Plan. It is only a summary and it is included as part of the Evidence of Coverage (EOC).1 Please read both documents carefully for details.




When using a Participating

Provider3


Provider4

Calendar Year medical Deductible Individual coverage $0 $250


$0: Family

$250: individual

$750: Family





When using any combination of Participating3 or Non-Participating4 Providers

Under this Plan there is no annual or lifetime dollar limit on the amount Blue Shield will pay for Covered Services. Individual coverage $1,500 $2,250


$3,000: Family

$2,250: individual

$4,750: Family

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Provider3CYD2

applies


Provider4CYD2

applies


Preventive Health Services $0 30%


Physician services

Primary care office visit $10/visit 30%

Specialist care office visit $10/visit 30%

Physician home visit $10/visit 30%

Physician or surgeon services in an outpatient facility $0 30%

Physician or surgeon services in an inpatient facility $0 30%


Other practitioner office visit $10/visit 30%


Acupuncture services $0 30%


Chiropractic services $10/visit 30%


Teladoc consultation $0 Not covered

Family planning

• Counseling, consulting, and education $0 30%


$0 30%

• Tubal ligation $0 30%

• Vasectomy $75/surgery 30%

Podiatric services $10/visit 30%


Physician office visits: prenatal and postnatal $10/visit 30%

Physician services for pregnancy termination $150/surgery 30%

3



Provider3CYD2

applies


Provider4CYD2

applies

Emergency services

Emergency room services $50/visit $50/visit


Emergency room Physician services $0 $0

Urgent care center services $10/visit 30%

Ambulance services $0 $0



Ambulatory Surgery Center $0 30%

Outpatient Department of a Hospital: surgery $0 30%


$0 30%


Hospital services and stay $0 30%

Transplant services


• Special transplant facility inpatient services $0 Not covered

• Physician inpatient services $0 Not covered


This payment is for bariatric surgery services for residents of designated California counties. For bariatric surgery services for residents of non-designated California counties, the payments for Inpatient facility services/ Hospital services and stay and Physician inpatient and surgery services apply for inpatient services; or, if provided on an outpatient basis, the outpatient facility services and Outpatient Physician services payments apply.

Inpatient facility services $0 Not covered

Outpatient facility services $0 Not covered

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Provider3CYD2

applies


Provider4CYD2

applies

Physician services $0 Not covered



Laboratory services


• Laboratory center $0 30%

• Outpatient Department of a Hospital $0 30%



• Outpatient radiology center $0 30%




• Office location $0 30%



• Outpatient radiology center $0 30%




Office location $10/visit 30%

Outpatient Department of a Hospital $10/visit 30%


DME $0 30%


Orthotic equipment and devices $0 30%

Prosthetic equipment and devices $0 30%

5



Provider3CYD2

applies


Provider4CYD2

applies

Home health care services $0 Not covered



Home infusion agency services $0 Not covered


Home visits by an infusion nurse $0 Not covered

Hemophilia home infusion services $0 Not covered




Freestanding SNF $0 $0

Hospital-based SNF $0 30%

Hospice program services $0 Not covered




• Devices, equipment, and supplies $0 30%

• Self-management training $10/visit 30%

Dialysis services $0 30%

PKU product formulas and Special Food Products $0 $0

Allergy serum billed separately from an office visit $0 30%

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When using a MHSA


CYD2

applies



CYD2

applies

Outpatient services

Office visit, including Physician office visit $10/visit 30%


$0 30%

Partial Hospitalization Program $0 30%

Psychological Testing $0 30%

Inpatient services

Physician inpatient services $0 30%

Hospital services $0 30%

Residential Care $0 30%

Prior Authorization









Notes

7

Notes




Covered Services not subject to the Calendar Year medical Deductible. Some Covered Services received from Participating Providers are paid by Blue Shield before you meet any Calendar Year medical Deductible. These Covered Services do not have a check mark () next to them in the “CYD applies” column in the Benefits chart above.

This Plan has a separate Participating Provider Deductible and Non-Participating Provider Deductible.


















This Plan has a Participating Provider OOPM as well as a combined Participating Provider and Non-Participating Provider OOPM. This means that any amounts you pay towards your Participating Provider OOPM also count towards your combined Participating and Non-Participating Provider OOPM.

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If you only receive Preventive Health Services during a Physician office visit, there is no Copayment or Coinsurance for the visit by a Participating Provider. If you receive both Preventive Health Services and other Covered Services during the Physician office visit, you may have a Copayment or Coinsurance for the visit.


A16154-b (1/20) Plan ID: 13001

1



Effective July 18, 2020 PPO

PPO Needles Enhanced Rx $10/15/15 Summary of Benefits

This Summary of Benefits shows the amount you will pay for covered Drugs under this prescription Drug Benefit.



Calendar Year Pharmacy Deductible (CYPD)1 A Calendar Year Pharmacy Deductible (CYPD) is the amount a Member pays each Calendar Year before Blue Shield pays for covered Drugs under the outpatient prescription Drug Benefit. Blue Shield pays for some prescription Drugs before the Calendar Year Pharmacy Deductible is met, as noted in the Prescription Drug Benefits chart below.

When using a Participating2 or Non-

Participating3 Pharmacy




CYPD1 applies





Contraceptive Drugs and devices $0 Applicable Tier 1,





Tier 4 Drugs (excluding Specialty Drugs) $10/prescription 25% plus $10/prescription



Contraceptive Drugs and devices $0 Not covered Blue

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CYPD1 applies






Tier 4 Drugs (excluding Specialty Drugs) $10/prescription Not covered



Tier 4 Specialty Drugs $10/prescription Not covered

Oral anticancer Drugs $10/prescription Not covered









3 Using Non-Participating Pharmacies:

Non-Participating Pharmacies do not have a contract to provide outpatient prescription Drugs to Members. When you obtain prescription Drugs from a Non-Participating Pharmacy, you must pay all charges for the prescription, then submit a completed claim form for reimbursement. You will be reimbursed based on the price you paid for the Drug.

Notes

3

Notes








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A44636 (1/20) Plan ID: 11341 1

Summary of Benefits


Effective July 18, 2020PPO Savings Plan

PPO Bronze/Full Savings Plan with HSAThis Summary of Benefits shows the amount you will pay for Covered Services under this Blue Shield of California Plan. It is only a summary and it is included as part of the Evidence of Coverage (EOC).1 Please read both documents carefully for details.





When using a Participating3 or Non-Participating4 Provider

Calendar Year medical and pharmacy Deductible

Individual coverage $4,000

This Plan combines medical and pharmacy Deductibles into one Calendar Year Deductible

Family Coverage $4,000: individual

$8,000: Family


An Out-of-Pocket Maximum is the most a Member will pay for Covered Services each Calendar Year. Any exceptions are listed in the Notes section at the end of this Summary of Benefits. No Annual or Lifetime Dollar Limit


When using a Non-Participating Provider4

Under this Plan there is no annual orlifetime dollar limit on the amount Blue Shield will pay for Covered Services. Individual coverage $5,500 $10,000

Family Coverage $5,500: individual

$11,000: Family

$10,000: individual

$20,000: Family

Blue

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Provider3CYD2

applies


Provider4CYD2

applies


Preventive Health Services $0 Not covered


Physician services

Primary care office visit 20% 50%

Specialist care office visit 20% 50%

Physician home visit 20% 50%

Physician or surgeon services in an outpatient facility 20% 50%

Physician or surgeon services in an inpatient facility 20% 50%


Other practitioner office visit 20% 50%


Acupuncture services 20% 50%


Chiropractic services 20% 50%


Teladoc consultation $5/consult Not covered

Family planning

• Counseling, consulting, and education $0 Not covered


$0 Not covered

• Tubal ligation $0 Not covered

• Vasectomy 20% Not covered

Podiatric services 20% 50%


Physician office visits: prenatal and postnatal 20% 50%

Physician services for pregnancy termination 20% 50%

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Provider3CYD2

applies


Provider4CYD2

applies

Emergency services

Emergency room services $100/visit plus 20% $100/visit plus 20%


Emergency room Physician services 20% 20%

Urgent care center services 20% 50%

Ambulance services 20% 20%




50% of up to $350/day






20%







Transplant services



Not covered

• Physician inpatient services 20% Not covered

4



Provider3CYD2

applies


Provider4CYD2

applies


This payment is for bariatric surgery services for residents of designated California counties. For bariatric surgery services for residents of non-designated California counties, the payments for Inpatient facility services/ Hospital services and stay and Physician inpatient and surgery services apply for inpatient services; or, if provided on an outpatient basis, the outpatient facility services and Outpatient Physician services payments apply.

Inpatient facility services $100/admission plus 20%

Not covered

Outpatient facility services 20% Not covered

Physician services 20% Not covered



Laboratory services


• Laboratory center 20% 50%

• Outpatient Department of a Hospital $25/visit plus 20%









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Provider3CYD2

applies


Provider4CYD2

applies



• Office location 20% 50%











Office location 20% 50%

Outpatient Department of a Hospital 20%




DME 20% 50%


Orthotic equipment and devices 20% 50%

Prosthetic equipment and devices 20% 50%

6



Provider3CYD2

applies


Provider4CYD2

applies

Home health care services 20% Not covered



Home infusion agency services 20% Not covered


Home visits by an infusion nurse 20% Not covered

Hemophilia home infusion services 20% Not covered




Freestanding SNF 20% 20%

Hospital-based SNF 20%



Hospice program services $0 Not covered




• Devices, equipment, and supplies 20% 50%

• Self-management training 20% 50%

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Provider3CYD2

applies


Provider4CYD2

applies

Dialysis services 20%



PKU product formulas and Special Food Products 20% 20%

Allergy serum billed separately from an office visit 20% 50%



When using a MHSA


CYD2

applies



CYD2

applies

Outpatient services

Office visit, including Physician office visit 20% 50%


20% 50%

Partial Hospitalization Program 20%



Psychological Testing 20% 50%

Inpatient services

Physician inpatient services $0 50%







8



CYD2

applies


Pharmacy4CYD2

applies



Contraceptive Drugs and devices $0Applicable Tier 1,


Tier 1 Drugs $10/prescription 25% plus

$10/prescription


$25/prescription


$40/prescription


30% up to $200/prescription

plus 25% of purchase price



Contraceptive Drugs and devices $0 Not covered





Not covered




Not covered

Oral Anticancer Drugs 30% up to $200/prescription

Not covered


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Prior Authorization




• Some prescription Drugs (see blueshieldca.com/pharmacy)









Covered Services not subject to the Calendar Year combined medical and pharmacy Deductible. Some Covered Services received from Participating Providers are paid by Blue Shield before you meet any Calendar Year combined medical and pharmacy Deductible. These Covered Services do not have a check mark () next to them in the “CYD applies” column in the Benefits chart above.










Notes

10

Notes









This Plan has a separate Participating Provider OOPM and Non-Participating Provider OOPM.

Covered Drugs obtained at Non-Participating Pharmacies. Any amounts you pay for Covered Drugs at Non-Participating Pharmacies count towards the Participating Provider OOPM.








This Plan’s prescription drug coverage is on average equivalent to or better than the standard benefit set by the federal government for Medicare Part D (also called creditable coverage). Because this plan’s prescription drug coverage is creditable, you do not have to enroll in Medicare Part D while you maintain this coverage; however, you should be aware that if you do not enroll in Medicare Part D within 63 days following termination of this coverage, you could be subject to Medicare Part D premium penalties.


Brand Drug coverage when a Generic Drug is available. If you select a Brand Drug when a Generic Drug equivalent is available, you are responsible for the difference between the cost to Blue Shield for the Brand Drug and its Generic Drug equivalent plus the tier 1 Copayment or Coinsurance. This difference in cost will not count towards any Calendar Year pharmacy Deductible, medical Deductible, or the Calendar Year Out-of-Pocket Maximum. If your Physician or Health Care Provider prescribes a Brand Drug and indicates that a Generic Drug equivalent should not be substituted, you pay your applicable tier Copayment or Coinsurance. If your Physician or Health Care Provider does not indicate

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Notes

that a Generic Drug equivalent should not be substituted, you may request a Medical Necessity Review. If approved, the Brand Drug will be covered at the applicable Drug tier Copayment or Coinsurance.



4209119.2.1.S000591241 - Traditional Plan $10 HMO (continues)

TEAMSTERS LOCAL 1932 PID 234855 $10 HMO

Principal Benefits for Kaiser Permanente Traditional HMO Plan (7/18/20—7/30/21)

Health Plan believes this coverage is a "grandfathered health plan" under the Patient Protection and Affordable Care Act. If you have questions about grandfathered health plans, please call our Member Service Contact Center. Accumulation Period

The Accumulation Period for this plan is January 1 through December 31.

Out-of-Pocket Maximum(s) and Deductible(s)

For Services that apply to the Plan Out-of-Pocket Maximum, you will not pay any more Cost Share for the rest of the Accumulation Period once you have reached the amounts listed below.

Amounts Per Accumulation Period Self-Only Coverage

(a Family of one Member)

Family Coverage Each Member in a Family of two

or more Members

Family Coverage Entire Family of two or more

Members

Plan Out-of-Pocket Maximum $1,500 $1,500 $3,000

Plan Deductible None None None

Drug Deductible None None None

Professional Services (Plan Provider office visits) You Pay

Most Primary Care Visits and most Non-Physician Specialist Visits ........................................ $10 per visit Most Physician Specialist Visits .............................................................................................. $10 per visit Routine physical maintenance exams, including well-woman exams .................................... No charge Well-child preventive exams (through age 23 months).......................................................... No charge Family planning counseling and consultations ....................................................................... No charge Scheduled prenatal care exams .............................................................................................. No charge Routine eye exams with a Plan Optometrist .......................................................................... No charge Urgent care consultations, evaluations, and treatment ......................................................... $10 per visit Most physical, occupational, and speech therapy .................................................................. $10 per visit

Outpatient Services You Pay

Outpatient surgery and certain other outpatient procedures ................................................ $10 per procedure Allergy injections (including allergy serum) ............................................................................ No charge Most immunizations (including the vaccine) .......................................................................... No charge Most X-rays and laboratory tests ........................................................................................... No charge

Hospitalization Services You Pay

Room and board, surgery, anesthesia, X-rays, laboratory tests, and drugs ........................... No charge

Emergency Health Coverage You Pay

Emergency Department visits ................................................................................................. $50 per visit Note: This Cost Share does not apply if you are admitted directly to the hospital as an inpatient for covered Services (see "Hospitalization Services" for inpatient Cost Share).

Ambulance Services You Pay

Ambulance Services ................................................................................................................ No charge

Prescription Drug Coverage You Pay

Covered outpatient items in accord with our drug formulary guidelines: Most generic items at a Plan Pharmacy or through our mail-order service ....................... $10 for up to a 100-day supply Most brand-name items at a Plan Pharmacy or through our mail-order service................ $15 for up to a 100-day supply Most specialty items at a Plan Pharmacy ............................................................................ $15 for up to a 30-day supply

Durable Medical Equipment (DME) You Pay

DME items as described in the EOC ........................................................................................ No charge

Mental Health Services You Pay

Inpatient psychiatric hospitalization ....................................................................................... No charge Individual outpatient mental health evaluation and treatment ............................................. $10 per visit Group outpatient mental health treatment ........................................................................... $5 per visit

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(continued)

4209119.2.1.S000591241 - Traditional Plan $10 HMO 4209119.2.1.S000591241

Substance Use Disorder Treatment You Pay

Inpatient detoxification .......................................................................................................... No charge Individual outpatient substance use disorder evaluation and treatment .............................. $10 per visit Group outpatient substance use disorder treatment ............................................................. $5 per visit

Home Health Services You Pay

Home health care (up to 100 visits per Accumulation Period) ............................................... No charge

Other You Pay

Skilled nursing facility care (up to 100 days per benefit period) ............................................ No charge Prosthetic and orthotic devices as described in the EOC........................................................ No charge Diagnosis and treatment of infertility and artificial insemination (such as outpatient procedures or laboratory tests) as described in the EOC...................................................... 50% Coinsurance

Assisted reproductive technology ("ART") Services................................................................ Not covered Hospice care ........................................................................................................................... No charge

This is a summary of the most frequently asked-about benefits. This chart does not explain benefits, Cost Share, out-of-pocket maximums, exclusions, or limitations, nor does it list all benefits and Cost Share amounts. For a complete explanation, please refer to the EOC. Please note that we provide all benefits required by law (for example, diabetes testing supplies).

4209324.2.1.S000591242 - High Copay - $40 HMO (continues)

TEAMSTERS LOCAL 1932 PID 234855 $40 HMO

Principal Benefits for Kaiser Permanente Traditional HMO Plan (7/18/20—7/30/21) Accumulation Period

The Accumulation Period for this plan is January 1 through December 31.

Out-of-Pocket Maximum(s) and Deductible(s)

For Services that apply to the Plan Out-of-Pocket Maximum, you will not pay any more Cost Share for the rest of the Accumulation Period once you have reached the amounts listed below.

Amounts Per Accumulation Period Self-Only Coverage

(a Family of one Member)

Family Coverage Each Member in a Family of two

or more Members

Family Coverage Entire Family of two or more

Members

Plan Out-of-Pocket Maximum $3,500 $3,500 $7,000

Plan Deductible None None None

Drug Deductible None None None

Professional Services (Plan Provider office visits) You Pay

Most Primary Care Visits and most Non-Physician Specialist Visits ........................................ $40 per visit Most Physician Specialist Visits .............................................................................................. $50 per visit Routine physical maintenance exams, including well-woman exams .................................... No charge Well-child preventive exams (through age 23 months).......................................................... No charge Family planning counseling and consultations ....................................................................... No charge Scheduled prenatal care exams .............................................................................................. No charge Routine eye exams with a Plan Optometrist .......................................................................... No charge Urgent care consultations, evaluations, and treatment ......................................................... $40 per visit Most physical, occupational, and speech therapy .................................................................. $40 per visit

Outpatient Services You Pay

Outpatient surgery and certain other outpatient procedures ................................................ $250 per procedure Allergy injections (including allergy serum) ............................................................................ $5 per visit Most immunizations (including the vaccine) .......................................................................... No charge Most X-rays and laboratory tests ........................................................................................... $10 per encounter Preventive X-rays, screenings, and laboratory tests as described in the EOC ........................ No charge MRI, most CT, and PET scans .................................................................................................. $100 per procedure

Hospitalization Services You Pay

Room and board, surgery, anesthesia, X-rays, laboratory tests, and drugs ........................... $500 per day

Emergency Health Coverage You Pay

Emergency Department visits ................................................................................................. $150 per visit Note: This Cost Share does not apply if you are admitted directly to the hospital as an inpatient for covered Services (see "Hospitalization Services" for inpatient Cost Share).

Ambulance Services You Pay

Ambulance Services ................................................................................................................ $150 per trip

Prescription Drug Coverage You Pay

Covered outpatient items in accord with our drug formulary guidelines: Most generic items at a Plan Pharmacy .............................................................................. $15 for up to a 30-day supply Most generic refills through our mail-order service ........................................................... $30 for up to a 100-day supply Most brand-name items at a Plan Pharmacy ...................................................................... $35 for up to a 30-day supply Most brand-name refills through our mail-order service ................................................... $70 for up to a 100-day supply Most specialty items at a Plan Pharmacy ............................................................................ 30% Coinsurance (not to exceed $200) for up to a 30-

day supply

Durable Medical Equipment (DME) You Pay

DME items as described in the EOC ........................................................................................ 50% Coinsurance


Inpatient psychiatric hospitalization ....................................................................................... $500 per day Individual outpatient mental health evaluation and treatment ............................................. $40 per visit

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(continued)

4209324.2.1.S000591242 - High Copay - $40 HMO 4209324.2.1.S000591242


Group outpatient mental health treatment ........................................................................... $20 per visit

Substance Use Disorder Treatment You Pay

Inpatient detoxification .......................................................................................................... $500 per day Individual outpatient substance use disorder evaluation and treatment .............................. $40 per visit Group outpatient substance use disorder treatment ............................................................. $5 per visit

Home Health Services You Pay

Home health care (up to 100 visits per Accumulation Period) ............................................... No charge

Other You Pay

Skilled nursing facility care (up to 100 days per benefit period) ............................................ No charge Prosthetic and orthotic devices as described in the EOC........................................................ No charge Diagnosis and treatment of infertility and artificial insemination (such as outpatient procedures or laboratory tests) as described in the EOC...................................................... 50% Coinsurance

Assisted reproductive technology ("ART") Services................................................................ Not covered Hospice care ........................................................................................................................... No charge

This is a summary of the most frequently asked-about benefits. This chart does not explain benefits, Cost Share, out-of-pocket maximums, exclusions, or limitations, nor does it list all benefits and Cost Share amounts. For a complete explanation, please refer to the EOC. Please note that we provide all benefits required by law (for example, diabetes testing supplies).

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Copyright © 2019 Delta Dental. All rights reserved. HL_PPO #121175AE (rev. 5/19)

1 In Texas, Delta Dental Insurance Company provides a dental provider organization (DPO) plan.

2 You can still visit any licensed dentist, but your out-of-pocket costs may be higher if you choose a non-PPO dentist. Network dentists are paid contracted fees.

3 You are responsible for any applicable deductibles, coinsurance, amounts over annual or lifetime maximums and charges for non-covered services. Out-of-network dentists may bill the difference between their usual fee and Delta Dental’s maximum contract allowance.

4 Applies only to procedures covered under your plan. If you began treatment prior to your effective date of coverage, you or your prior carrier is responsible for any costs. Group- and state-specific exceptions may apply. If you are currently undergoing active orthodontic treatment, you may be eligible to continue treatment under Delta Dental PPO. Review your Evidence of Coverage, Summary Plan Description or Group Dental Service Contract for specific details about your plan.

Save with PPOVisit a dentist in the PPO1 network to maximize your savings.2 These dentists have agreed to reduced fees, and you won’t get charged more than your expected share of the bill.3 Find a PPO dentist at deltadentalins.com.

Set up an online accountGet information about your plan anytime, anywhere by signing up for an online account at deltadentalins.com. This useful service, available once your coverage kicks in, lets you check benefits and eligibility information, find a network dentist and more.

Check in without an ID cardYou don’t need a Delta Dental ID card when you visit the dentist. Just provide your name, birth date and enrollee ID or Social Security number. If your family members are covered under your

plan, they will need your information. Prefer to take a paper or electronic ID card with you? Simply log in to your account, where you can view or print your card with the click of a button.

Coordinate dual coverage If you’re covered under two plans, ask your dental office to include information about both plans with your claim, and we’ll handle the rest.

Understand transition of careDid you start on a dental treatment plan before your PPO coverage kicked in? Generally, multi-stage procedures are only covered under your current plan if treatment began after your plan’s effective date of coverage.4 You can find this date by logging in to your online account.

Newly covered?Visit deltadentalins.com/welcome.

Save with a PPO dentist

PPO NON–PPO

Keep Smiling Delta Dental PPO™

Teamsters Local 1932 Health and Welfare Trust21017 Effective Date: 7/18/2020

Basic Benefits Major Benefits Prosthodontics Orthodontics None None None None

Plan Benefit Highlights for: Group No:

Eligibility Primary enrollee, spouse (includes domestic partner) and eligible dependent children to age 26

Deductibles NoneMaximums $1,700 per person each calendar year

D & P counts toward maximum? NoWaiting Period(s)

Benefits and Covered Services*

Delta Dental PPO Non-Delta Dental PPO dentists** dentists**

Endodontics (root canals) Periodontics (gum treatment)

Diagnostic & Preventive Services (D & P) 100% 100%

Exams, cleanings and x-rays

Basic Services 100% 90%Fillings and denture repairs/relining

100% 90%90% 90%

90%90%

Oral Surgery Major Services

75% 70%Crowns, inlays, onlays and cast restorations

100% 90%

Claims Address

Prosthodontics 75% 70%Bridges, dentures and implants

Orthodontic Benefits 50% 50%Adults and dependent children

Sealants

deltadentalins.com

This benefit information is not intended or designed to replace or serve as the plan’s Evidence of Coverage or Summary Plan Description. If you have specific questions regarding the benefits, limitations or exclusions for your plan, please consult your company’s benefits representative.

560 Mission St., Suite 1300 888-335-8227 P.O. Box 997330San Francisco, CA 94105 Sacramento, CA 95899-7330

Orthodontic Maximums $1,700 Lifetime $1,700 Lifetime

* Limitations or waiting periods may apply for some benefits; some services may be excluded from your plan. Reimbursement is based on Delta Dental maximum contract allowances and not necessarily each dentist’s submitted fees.

** Reimbursement is based on PPO contracted fees for PPO dentists, Premier contracted fees for Premier dentists and program allowance for non-Delta Dental dentists.

Delta Dental of California Customer Service

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Version 7

Vision Care Services Out-of-Network Reimbursement*

Exam with Dilation as Necessary $48

Retinal Imaging Benefit N/A

Exam Options:

Standard Contact Lens Fit and Follow-Up: N/A

Premium Contact Lens Fit and Follow-Up: N/A

Frames:

Any available frame at provider location

Standard Plastic Lenses Single Vision $40 Bifocal $55 Trifocal $75 Lenticular $125 Standard Progressive Lens $70 Premium Progressive Lens $70

Lens Options: UV Treatment N/A Tint (Solid and Gradient) N/A Standard Plastic Scratch Coating N/A Standard Polycarbonate - Adults $14 Standard Polycarbonate - Kids under 19 $14 Standard Anti-Reflective Coating N/A Polarized N/A

Other Add-Ons N/AContact Lenses(Contact lens allowance includes materials only)

Conventional $85Disposable $85Medically Necessary $250Laser Vision CorrectionLasik or PRK from U.S. Laser Network N/A

Frequency:ExaminationLenses or Contact LensesFrame

* Member Reimbursement Out-of-Network will be the lesser of the listed amount or the member’s actual cost from the out-of-network provider. In certain states members may be required to pay the full retail rate and not the negotiated discount rate with certain participating providers. Please see EyeMed’s online provider locator to determine which participating providers have agreed to the discounted rate

Plan Exclusions:1) Orthoptic or vision training, subnormal vision aids and any associated supplemental testing; Aniseikonic lenses; 2) Medical and/or surgical treatment of the eye, eyes or supporting structures;3) Any eye or Vision Examination, or any corrective eyewear required by a Policyholder as a condition of employment; Safety eyewear4) Services provided as a result of any Workers’ Compensation law, or similar legislation, or required by any governmental agency or program whether federal, state or subdivisions thereof;5) Plano (non-prescription) lenses and/or contact lenses; 6) Non-prescription sunglasses; 7) Two pair of glasses in lieu of bifocals; 8) Services rendered after the date an Insured Person ceases to be covered under the Policy, except when Vision Materials ordered before coverage ended are delivered, and the services rendered to the Insured Person are within 31 days from the date of such order; 9) Services or materials provided by any other group benefit plan providing vision care;10) Lost or broken lenses, frames, glasses, or contact lenses will not be replaced except in the next Benefit Frequency when Vision Materials would next become available.

TC0

$0 Copay

$0 Copay$0 Copay

Up to $39

Members also receive a 40% discount off complete pair eyeglass purchases and a 15% discount off conventional contact lenses once the funded benefit has been used.

Up to $40

$15

$45

Once every 12 monthsOnce every 12 months

$47

$0 Copay, Paid-in-Full

20% off Retail Price

$20 Copay

Teamsters 1932EyeMed Select Plan H, Fixed FeeVoluntaryOption as is Employee only coverage

Member Cost In-Network

$15

EyeMed Vision Care in conjunction with Fidelity Security Life Insurance Company


15% off Retail Price or 5% off promotional price

$65 Copay

$0 Copay

Once every 12 months


$15

$0 Copay

$0 Copay; $120 allowance, plus balance over $120

$0 Copay; $120 Allowance, 20% off balance over $120

$65 Copay, 80% of Charge less $120 Allowance

$20 Copay

$0 Copay; $120 allowance, 15% off balance over $120

Amplifon Hearing Health CareHearing Health Care from Amplifon Hearing Health Care Network

Members receive a 40% discount off hearing exams and a low price guarantee on discounted hearing aids.

N/A

Additional Discounts:Member receives a 20% discount on items not covered by the plan at network Providers. Discount does not apply to EyeMed Provider's professional services, or contact lenses. Plan discounts cannot be combined with any other discounts or promotional offers. Services or materials provided by any other group benefit plan providing vision care may not be covered.Members also receive 15% off retail price or 5% off promotional price for Lasik or PRK from the US Laser Network, owned and operated by LCA Vision.After initial purchase, replacement contact lenses may be obtained via the Internet at substantial savings and mailed directly to the member. Details are available at www.eyemedvisioncare.com.The contact lens benefit allowance is not applicable to this service.Benefit Allowances provide no remaining balance for future use within the same Benefit Frequency.Certain brand name Vision Materials in which the manufacturer imposes a no-discount practice.

Insured Plans are underwritten by Fidelity Security Life Insurance Company of Kansas City, Missouri, except in New YorkPolicy number VC-19/VC-20, form number M-9083

Additional Pairs Benefit: N/A

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Bright future ahead.

Check YES to the

Teamsters Local 1932 Health & Welfare Trust

This year, for the first time ever, you have the opportunity to enroll in a new health

plan, a plan that’s investing in your future...

Invest In Your Future Teamsters Local 1932 Health & Wefare Trust · Invest In Your Future......

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