Summary of Coverage Plan I

SUMMARY OF COVERAGE PLAN I

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   SUMMARY OF COVERAGE—PLAN I

This brochure is a summary of Teamsters Benefit Trust (TBT) benefits and is intended only to highlight benefits. For a more complete description of Plan benefits and eligibility rules, refer to the enclosed Guide to Your Benefits . This brochure is not a guarantee of eligibility or employment.

Enrollment When you are treated by non-PPO PPO Network for You can enroll if you are covered under providers, claims are paid based on a Non-California Residents a Union Contract that provides for percentage of Usual, Customary and If you live outside California, the TBT Plan I participation as long as Reasonable (UCR) charges—which Indemnity Medical option participates you satisfy the eligibility requirements usually means you will pay more in another network of preferred described in the enclosed Guide to Your out-of-pocket costs when you do providers outside of California. For Benefits and your Employer makes not use PPO providers. Pre-admission Certification, except for the required contributions. All alcoholism or chemical dependency, required enrollment forms (including It’s your responsibility to make phone Anthem Blue Cross (the Plan’s an HMO application if you choose an sure that you are treated by PPO Utilization Review Organization) at HMO) must be received by the TBT providers if you want benefits to (800) 274-7767. To locate the nearest Plan Administration Office before be paid at the PPO rates. The PPO Hospital, you must call the coverage begins. chart inside shows the difference Anthem Blue Cross Blue Shield between PPO and non-PPO benefits Nationwide Network toll-free at Medical Options under the Indemnity Medical option. (800) 810-2583. You may choose the Indemnity Medical option or one of the Health To locate the nearest PPO hospitals, Out-of-State Providers Maintenance Organizations (HMOs) surgery centers, doctors, medical labs California residents can verify that available where you live by completing and clinics, contact Anthem Blue Cross their provider is in the PPO by a Medical Option Form (see the at (888) 887-3725. Since participating calling (888) 887-3725 toll-free. Enrollment Materials folder). The providers change often, always confirm Non-California residents can verify Comparison of Medical Benefits folder that a doctor or hospital is a PPO that their provider is in the PPO by highlights coverage under the provider before receiving services. calling (800) 810-2583 toll-free. Indemnity Medical option and HMOs. Each HMO option provides a separate Note: If your TBT coverage is Pre-admission Certification Evidence of Coverage available through secondary and your primary plan and Utilization Review the TBT Plan Administration Office. denies your claim for benefits because The Indemnity Medical option pays Note: To choose an HMO option, you you have elected to receive treatment for medically necessary services and must live within the HMO’s service area. from a provider or facility outside of supplies authorized by a licensed To determine whether you qualify for your primary plan’s preferred provide r doctor for treatment of illness or HMO coverage, call the HMO’s customer network, TBT will coordinate benefits injury. Pre-admission Certification service number printed on the last page. as though you received benefits from and Utilization Review procedures the primary plan under the primary are required to determine medical Preferred Provider Organization plan’s ordinary level of payment for necessity for all non-emergency (PPO) Network p referred network hospitals or doctors . hospital stays and within 72 hours of If you choose the Indemnity Medical See the Guide to Your Benefits for more an emergency admission. California option, amounts paid on your claims are details about Coordination of Benefits . and non-California participants must higher when you take advantage of the call Blue Cross at (800) 274-7767. (For Anthem Blue Cross PPO network of alcoholism or chemical dependency preferred providers. PPO hospitals, treatment, see the next page). doctors, clinics and medical labs agree by contract to accept reduced Failure to obtain Pre-admission rates and fee ceilings (which means Certification may result in a important savings to TBT and you). reduction of benefits. Charges Note: The PPO coverage rates only for non-certified hospital days apply when you are treated by PPO are not covered under the Plan. providers who have agreed to accept Utilization Review is also required lower contracted rates. See the Guide by Anthem Blue Cross to monitor to Your Benefits for more information. in-hospital services and related charges even if you were admitted in an emergency. 2 TEAMSTERS BENEFIT TRUST (TBT)

Alcohol or Chemical You must complete the Dental Option Extension of Benefits Dependency Benefit Review Form (mailed with your TBT Requirements The Teamsters Assistance Program enrollment materials) to apply You must become totally disabled while (TAP) is the Plan’s review organization for dental coverage. Note: New eligible under your TBT Employer- to oversee all alcohol and chemical employees may only choose Option 2 paid Plan. Proof of disability must dependency treatment. TAP must (Bright Now! Dental) or Option 3 be provided by your doctor before pre-authorize and review such (Pacific Union Dental) until a waiting benefits begin. Periods of disability treatment or it will not be covered. period is satisfied. Option 1 (the from the same condition that are not Before seeking treatment, call the Indemnity Dental option) is not separated by two weeks of full-time Teamsters Assistance Program (TAP) available until one year following covered work, or from two or more at (510) 562-3600 or (800) 253-TEAM. your initial hire date (unless you conditions not separated by return to meet an exception listed on the back full-time covered work, are considered When to Call of your Dental Option Form ). to be one period of disability . Notify Anthem Blue Cross (or TAP if applicable) when your doctor Limitations and Exclusions Benefits are not paid for any injury schedules an inpatient stay. You, your Each TBT medical and dental option or illness while you are not under doctor and the hospital will receive a has unique limitations and exclusions a doctor’s care or for any period of written follow-up notice from Anthem and claim review and denial procedures disability that began before you were Blue Cross by mail. If you have not that are described in the Guide to Your eligible for coverage. received a notice, you should verify Benefits . HMO limitations are described that Pre-admission Certification has in the Evidence of Coverage brochures In all cases, benefits are not paid been conducted before going to the provided by each HMO. Copies of for a disability that begins in a hospital. Check with Anthem Blue these materials are available through month when you were not eligible Cross (or TAP if applicable) in advance . the TBT Plan Administration Office. under your Plan. Remember, if Anthem Blue Cross If you have questions about your Filing a Claim determines that hospitalization is not eligibility or benefits, contact the necessary—or that hospital services TBT Plan Administration Office at 1. Request a Proof of Disability are not medically necessary—you, (510) 796-4676 or (800) 533-0119. Claim Form by calling the TBT your doctor and the hospital will be Plan Administration Office at informed by Anthem Blue Cross. Extension of Benefits While 800-533-0119. Totally Disabled 2. Fill out your portion of the form Anthem Blue Cross will contact If you are eligible but rendered and have your doctor complete your doctor to confirm the need for unable to work because you become the bottom portion. hospitalization and write to tell you totally disabled as a result of an illness whether your hospital stay has been or injury (see What is Total Disability? 3. Send the completed form to the certified and, if so, for how long. The in the Guide to Your Benefits ), coverage TBT Plan Administration Office Plan does not cover charges for for you and your covered dependents at the address printed on the form . days in a hospital that have not will continue for up to three months. been pre-certified by Blue Cross. Coverage is not automatic. You Plan Change or Termination must apply for the extension of TBT reserves the right to change Dental Options benefits by filling out and submitting or terminate the Plan at any time. Your TBT Plan offers a choice of dental the required forms to the TBT Plan options. The Indemnity Dental option Administration Office. Contact the If benefit changes are made, you (Delta Dental) is explained in this Administration office at (800) 533-0119 will be notified at the home mailing summary. See the Comparison of and ask for the disability department as address you have listed with the TBT Dental Benefits for highlights of all soon as your physician has determined Plan Administration Office. If your your dental options. you will be out on disability. covered spouse or dependents do not live with you, let them know that all TBT mail will be sent to your address.

3 SUMMARY OF COVERAGE—PLAN I

Disability Income Benefit for Filing a Claim When Coverage Ends Plan I Employees 1. Request a Statement of Claim for Dependent life insurance coverage You may be eligible for a weekly Accident and Sickness Weekly Benefit ends when your dependent no longer income benefit if you become totally form by calling the TBT Plan meets the definition of an eligible disabled while eligible under your TBT Administration Office. dependent in the Guide to Your Benefits . Plan (see definition on this page). 2. Fill out your portion of the form Conversion Privileges The Plan pays you a disability income and have your doctor complete Dependents may convert their of $40 per week for up to 26 weeks as the bottom portion. d e p e n d e n t l i f e i n s u r a n c e c o v e r a g e t o long as you were eligible for benefits 3. Send the completed form to the an individual policy within 31 days at the time you became disabled. TBT Plan Administration Office after their TBT coverage ends. See The daily rate is one-seventh of the at the address printed on the form. the Guide to Your Benefits , for more weekly rate. information about conversion and TOTAL DISABILITY filing life insurance claims. Proof of disability must be A physical or mental condition for which provided by your doctor before you need a doctor’s care and which Open Enrollment benefits may begin. prevents you from performing your You can change your TBT medical regular duties as an employee or any and dental options once a year. Open Periods of disability from the same employment for wages or profit. Enrollment takes place from January 1 condition that are not separated by Disabilities caused by self-inflicted through December 31. After your two weeks of full-time covered work, injuries, commission of a felony or an initial election of medical and dental or from two or more conditions not il lness or injury related to military service options, you may change them once separated by return to full-time do not qualify as total disabilities. every 12 months. See the Guide to covered work, are considered to be Your Benefits or contact the TBT Plan one period of disability . Dependent Life Insurance Administration Office for details. Your Plan provides dependent life If you return to full-time covered insurance benefits. Enrollment is Eligibility and Benefit Questions work after a period of disability of automatic for your covered dependents. Contact the TBT Plan Administration two years or longer, another disability Office at (510) 796-4676 or will be considered a new period of Payment of Benefits (8 00) 533-0119. Note: Only the TBT disability, but only if it begins after You are automatically the beneficiary for Plan Administration Office can verify at least six months of continuous a covered dependent’s life insurance eligibility and coverage. Statements full-time active employment. benefit. If you are not living, benefits or documents provided by other will be paid as follows: sources such as your Employer or Benefits begin on the first day of Local Union are not binding on TBT. 1. To your spouse if living, otherwise, disability for an accident or on the first day you are hospitalized. Benefits 2. To your children (including legally begin on the eighth consecutive day adopted children), otherwise, of disability for an illness that does 3. To your estate. not result from an accident or require hospitalization. Two or more persons entitled to benefits will be paid in equal shares. Benefits are not paid for any injury or sickness while you are not under To file a claim for dependent life a doctor’s care or for any period insurance, contact the TBT Plan of disability that began before you Administration Office. The application were eligible for coverage. must contain a certified copy of the death certificate with an embossed seal . In all cases, benefits are not paid for a disability that begins in a month when you were not eligible under TBT Plan I.

4 TEAMSTERS BENEFIT TRUST (TBT)

1. INDEMNITY MEDICAL OPTION I. MENTAL HEALTH SERVICES 3. DENTAL BENEFITS (For You and Your Covered Dependents) —IN-HOSPITAL (For You and Your Covered Dependents) Pays for medically necessary services and supplies Maximum inpatient days per calendar year See the Dental Options section on page 2 for details about authorized by a licensed doctor for treatment of illness 30 days your Plan’s dental options and the waiting period for or injury for you and your covered dependents. PPO 100% new TBT participants. The Comparison of Dental Non-PPO 50% of UCR Benefits folder briefly explains each dental option. Calendar year maximum $2,000,000 Deductible per calendar year Provided through the Indemnity Dental J. MENTAL HEALTH SERVICES Per covered person $50 option—Option 1 —IN MEDICAL OFFICES Family maximum $150 Calendar year maximum per covered person None Carryover Any part of the deductible Per visit covered expense maximum $80 Delta participating dentist 90% of covered satisfied in the last three PPO 100% preventive, basic and major calendar months will also apply to Non-PPO 80% of UCR dental expenses next calendar year deductible K. ALCOHOL OR CHEMICAL Non-Delta dentist 90% of UCR charges A. HOSPITAL BENEFITS DEPENDENCY TREATMENT for covered preventive, basic and major expenses Note: All in-hospital care must be pre-authorized and (Not Subject to Deductible) Orthodontia 70% of covered monitored by the Plan’s Review Organization. In an Must be pre-authorized and monitored by orthodontia expenses per covered emergency, call within 72 hours. Teamsters Assistance Program (TAP) person up to $2,000 lifetime maximum Inpatient (not subject to deductible) Lifetime maximum PPO 100% 2 treatments subject to UCR Note: For temporomandibular joint dysfunction, the Plan Non-PPO 50% of UCR First treatment 100% pays 70% of covered charges up to a lifetime maximum Outpatient (subject to deductible) Second treatment 80% of $1,000. See your Guide to Your Benefits . PPO 80% Note: The 20% copayment for second treatment is not 4. VISION CARE BENEFITS Non-PPO 80% of UCR to $5,000 per a covered expense and will not apply toward your (For You and Your Covered Dependents) calendar year and 100% of UCR thereafter copayment maximum for the calendar year. Exception: Surgery or accident within 24 hours Provided through the Vision Service Plan (VSP) network —with no deductible 100% of PPO or UCR L. CHIROPRACTIC TREATMENT See Vision Care section of the Guide to Your Benefits. (Not Subject to Deductible) VSP eye care professional 100% B. ACCIDENT EXPENSE BENEFIT of covered charges (Not Subject to Deductible) Initial visit and diagnostic x-rays do not count against the maximums below and are subject to the deductible: Frequency of service: Treatment within three months of accident date Calendar year maximum $1,250 Vision exam once in 12 months PPO 100% to $300 Per visit covered expense maximum $25 Lenses once in 12 months Non-PPO 100% of UCR to $300 PPO 100% to $25 Basic frames once in 24 months Non-PPO 100% of UCR to $25 C. AMBULANCE See Vision Care section of Guide to Your Note: There is a separate $300 maximum per covered PPO 100% Benefits for: person per calendar year for treatment of muscle Non-PPO 80% of UCR to $5,000 Non-VSP eye care professional benefits spasms, soft tissue or back strain. per calendar year; 100% of UCR thereafter Contact lens benefits Cosmetic options D. SURGERY (PHYSICIAN SERVICES) 2. PRESCRIPTION DRUGS THROUGH OPTUM R x Note: Non-VSP provider benefits are limited. PPO 100% (For You and Your Covered Dependents) Non-PPO 80% of UCR to $5,000 5. DISABILITY INCOME BENEFIT per calendar year; 100% of UCR thereafter Outpatient prescription drugs using plastic OptumRx (For You Only—See Previous Page) ID card E. DOCTOR VISITS Generic or brand name drugs from Weekly benefit $40 Maximum benefit period 26 Weeks PPO 100% OptumRx pharmacy 100% Non-PPO 80% of UCR to $5,000 Note: If you (or your doctor) order a brand name 6. LIFE INSURANCE BENEFIT per calendar year; 100% of UCR thereafter drug (when a generic equivalent is available), you also pay the difference between generic and (For You Only) F. PREVENTIVE CARE brand name. The Plan pays full price of brand Survivors must file claim within 12 calendar months of name drugs only when there is no generic Routine physical exams and related x-ray and lab work , event equivalent. pap tests, routine mammograms (see Section G. below), Your death $10,000 PSA tests for detection of prostate cancer, flu shots, Specialty Pharmacy Program : Most injectable routine pediatric exams and shots recommended by the medications are only covered through the OptumRx 7. ACCIDENTAL DEATH & U.S. Preventive Services TaskForce . mail order Specialty Pharmacy Program (30-day DISMEMBERMENT supply); unless your injectable medications are (For You Only) Calendar year maximum None covered under your HMO. See Guide to Your Benefits . PPO 100% Survivors must file claim within 12 calendar months of Non-PPO 90% of UCR Mail Service Program : Prescriptions ordered event through the OptumRx Mail Service Program are Your accidental dismemberment: G. DIAGNOSTIC X-RAY AND LAB covered at 100%. If you (or your doctor) order a Your accidental death $10,000 PPO 100% brand name drug when a generic equivalent is Both hands or feet $10,000 Non-PPO 80% of UCR to $5,000 per available, you pay the cost difference between Both eyes $10,000 calendar year; 100% of UCR thereafter generic and brand name. One hand and one foot $10,000 One hand and one eye $10,000 Note: Mammograms follow guidelines of American Outpatient drugs through non-participating pharmacy Cancer Society. Routine mammograms are covered One hand or one foot $5,000 • Direct reimbursement by OptumRx . One eye $5,000 annually beginning at age 40. (Amount reimbursed is usually less than retail charges at a non-participating pharmacy.) H. NURSING HOME CARE 8. DEPENDENT LIFE INSURANCE (See Previous Page) Room and board (within 7 days of inpatient stay of 5 or more days) Survivors must file claim within 12 calendar months of PPO 100% event Non-PPO 80% of UCR to $5,000 per Death of spouse $1,000 calendar year; 100% of UCR thereafter Death of children Per disability maximum 60 days (including legally adopted children): Newborns (14 days to 6 months) $100 Other children (7 months to 21 years) $1,000 each 5 BOARD OF TRUSTEES

Union Trustees Employer Trustees Rome A. Aloise, Co-Chairman Keith Fleming, Co-Chairman Teamsters Beneﬁt Trust Teamsters Beneﬁt Trust Secretary-Treasurer Chairman of the Board Warehouse, Mail Order, Retail Employees IEDA and Wholesale Liquor Salespersons 2200 Powell Street, Suite 1000 Teamsters Local Union No. 853 Emeryville, CA 94608-1809 2100 Merced Street, Suite B San Leandro, CA 94577-3247

Carlos Borba William Albanese President President Teamsters, Chauffeurs, Warehousemen Central Concrete Supply and Helpers 755 Stockton Avenue Teamsters Local Union No. 315 San Jose, CA 95126-1839 445 Nebraska Street Vallejo, CA 94590-3830

Don E. Garcia Richard Jordan Secretary-Treasurer Trustee, Teamsters Beneﬁt Trust General Truck Drivers, Warehousemen, c/o Lipman Insurance Administrators, Inc. Helpers and Automotive Employees 39420 Liberty Street, Suite 260 Teamsters Local Union No. 315 Fremont, CA 94538-2200 2727 Alhambra Avenue Martinez, CA 94553-3120

Bill Hoyt Richard Murphy Secretary-Treasurer Trustee, Teamsters Beneﬁt Trust Teamsters, Freight, Construction, General c/o Lipman Insurance Administrators, Inc. Drivers, Warehousemen and Helpers 39420 Liberty Street, Suite 260 Teamsters Local Union No. 287 Fremont, CA 94538-2200 1452 North Fourth Street San Jose, CA 95112-4778

Robert Morales Jeanette Paige Secretary-Treasurer Director of Human Resources Sanitary Truck Drivers and Helpers Southern Wine & Spirits of Teamsters Local Union No. 350 Northern California 295 89th Street, Suite 304 33321 Dowe Avenue Cedar Hill Ofﬁce Building Union City, CA 94587-2033 Daly City, CA 94015-1656

Ron Paredes Bill Rossi Trustee, Teamsters Beneﬁt Trust Trustee, Teamsters Beneﬁt Trust c/o Lipman Insurance Administrators, Inc. c/o Lipman Insurance Administrators, Inc. 39420 Liberty Street, Suite 260 39420 Liberty Street, Suite 260 Fremont, CA 94538-2200 Fremont, CA 94538-2200

Sam Rosas Chris Servi Secretary-Treasurer Group Controller General Teamsters United Parcel Service (UPS) Teamsters Local Union No. 439 2222 17th Street, 4th ﬂoor 1531 E. Fremont Street San Francisco, CA 94103-5015 Stockton, CA 95205-4458

6 TEAMSTERS BENEFIT TRUST (TBT)

If You Need Help Language Notice Noticia en Español If you need help understanding your If you need help understanding any Si usted tiene dificultad en entender Plan benefits, the Board of Trustees part of this summary or the other alguna parte de este folleto, o necesita encourages you to call or write the materials in this package, contact the mas información comuniquese con la TBT Plan Administration Office. TBT Plan Administration Office at Oficina de Administracion del Plan the address listed on this page. TBT a el domicilio localisado abajo en Plan Administration Office Office hours are from 8:00 a.m. to esta pagina. Horas de oficina: 8:00 a.m. Teamsters Benefit Trust 5:00 p.m. P.S.T., Monday through a 5:00 p.m. P.S.T., Lunes a Viernes 39420 Liberty Street, Suite 260 Friday (except holidays). Customer (excepto dias festivos). Horas de Servicio Fremont, CA 94538-2200 service hours are from 8:30 a.m. to al Cliente: 8:30 a.m. a 5:00 p.m. P.S.T., Local telephone: (510) 796-4676 5:00 p.m. P.S.T., Monday through Lunes a Viernes (excepto dias festivos). Toll free: (800) 533-0119 Friday (except holidays). El numero de telefono es (510) 796-4676 Internet web site: www.tbtfund.org o (800) 533-0119.

PHONE NUMBERS AND ADDRESSES Organization Phone Numbers Address Reasons To Call

TBT Plan Administration Ofﬁce (510) 796-4676 39420 Liberty Street, #260 TBT eligibility, enrollment (including HMOs), marital status www.tbtfund.org (800) 533-0119 Fremont, CA 94538-2200 an d dependent changes, contributions, Anthem Blue Cross ID cards, prescription drug ID cards, Indemnity Medical option claims, vision, disability, life and accidental death & dismemberment claims and other questions.

Anthem Blue Cross Life & Health (800) 274-7767 P.O. Box 60007 Hospital Pre-admission Certiﬁcation and www.anthem.com/ca Los Angeles, CA 90060 Utilization Review.

Anthem Blue Cross (888) 887-3725 P.O. Box 60007 Preferred Provider hospitals, PPO network physicians PPO Network Los Angeles, CA 90060 and other PPO providers. www.anthem.com/ca

Anthem Blue Cross Blue Shield (800) 810-2583 P.O. Box 60007 Outside California: Preferred Provider hospitals, National Network (Outside CA) Los Angeles, CA 90060 PPO network physicians and other PPO providers.* www.bcbs.com

United HealthCare (800) 624-8822 P.O. Box 30968 HMO beneﬁt questions*; Web site has list of www.uhcwest.com Salt Lake City, UT 84130-0968 network physicians.

Kaiser Member Services (800) 464-4000 1800 Harrison, 9th Floor HMO beneﬁt questions.* www.kaiserpermanente.org Oakland, CA 94612-2998

OptumRx (800) 797-9791 3515 Harbor Boulevard Pharmacy and medication questions.* Contact the TBT www.optumrx.com Costa Mesa, CA 92626 Plan Administration Ofﬁce for all other prescription- Mail Service Program (800) 562-6223 related matters. or (877) 889-2802 Specialty Pharmacy (800) 711-4555

Delta Dental (800) 765-6003 P.O. Box 997330 Dental Option 1 beneﬁt questions.* www.deltadentalca.org or (888) 335-8227 Sacramento, CA 95999-7330 For Delta Dental provider ﬁnder service, call (800) 427-3237.

Bright Now! Dental (800) 497-6453 8105 Irvine Center Dr. Dental Option 2 beneﬁt questions.* Newport Option (714) 668-1300 Irvine, CA 92618

Paciﬁc Union Dental (PUD) (800) 999-3367 P.O. Box 30567 Dental Option 3 beneﬁt questions.* Salt Lake City, UT 84130-0567

Teamsters Assistance Program (510) 562-3600 300 Pendleton Way Substance abuse matters including inpatient programs. (TAP) (800) 253-TEAM Oakland, CA 94621-2109

Western Conference of (650) 570-7300 355 Gellert Blvd., #100 All pension matters. Teamsters Pension Trust Fund (800) 845-4162 Daly City, CA 94015-2666 www.wctpension.org

Prudential Life Insurance (800) 524-0542 P.O. Box 1215 First call the TBT Plan Administration Ofﬁce. Newark, NJ 07101-1215

* Note: For general enrollment information, medical, HMO and dental option elections, address changes and changes in dependent status, contact the TBT Plan Administration Ofﬁce. Any required forms (including HMO change forms) are mailed to you by TBT.

7 Plan I— September 2014 , Form C1-C 9-24-14 8