ST. PAUL ELECTRICAL WORKERS HEALTH PLAN SUMMARY PLAN DESCRIPTION

Transcription

1 ST. PAUL ELECTRICAL WORKERS HEALTH PLAN SUMMARY PLAN DESCRIPTION January 1, 2017 St. Paul Electrical Wrkers Health Plan Summary Plan Descriptin

2 St. Paul Electrical Wrkers Health Plan Plan Administratr and Fund Office Administrative Service Crpratin 1330 Cnway Street, Suite 130 St. Paul, MN Phne: , Optin 4 Fax: mybenefits@speiasc.rg Bard f Trustees Unin Trustees Mr. James C. Schult Mr. Jamie M. McNamara Mr. Edward P. Nelsn Emplyer Trustees Mr. Luke M. Kuhl Mr. J.T. Pedersen Mr. Peter B. Burland Schedule f Benefits are fund at Exhibit A. Translatin Rights and Ntice f Nndiscriminatin Practices are Described at Exhibit D.

3 Intrductin As a Participant in the St. Paul Electrical Wrkers Health Plan, Yu may be eligible fr the fllwing benefits: Main Benefits Ancillary Benefits Medical Benefits Medical Benefits, including prescriptin drug benefits Dental Care Benefits Visin Care Service Plan Other Nn-Medical Benefits Disability Benefits Hearing Aid Benefits Medical Eligibility Bank Prgram Supplemental Unemplyment/Medical Expenses (SUB/ME) Benefits Retiree Supplemental Medicare Cverage Jury Duty Benefits Life Insurance Emplyee Assistance Plan thrugh TEAM Nurtur Health Inc., a wellness prgram that includes a Nurse Advice Line available 24/7/365 Chrnic Back Pain Prgram thrugh Physician s Neck & Back Clinic Health Dynamics EPIC Hearing, a discunt prgram fr hearing devices Heart Savers This Summary Plan Descriptin (SPD) bklet is designed t help Yu understand the benefits available t Yu. We urge Yu t read the bklet and share it with Yur family. In additin, we recmmend that Yu keep this bklet with Yur imprtant papers s Yu can refer t it when needed. Abut This Bklet In this bklet, we have tried t describe Yur benefits in everyday language and rganize it in a way that will be useful t Yu. This bklet includes: A listing f imprtant cntact infrmatin (page 1); A listing f the Benefit Prgram prvided by the Plan (page 2); Infrmatin abut when Yu and/r Yur Dependents may participate in the Plan (page 4); An explanatin f Yur cverage under each benefit prgram (pages 7-Medical Eligibility Bank; 9- SUB/ME Plan; 16-Medical; 31-Dental Care; 37-Visin Care; 39-Hearing Aid; 39-Supplemental Retiree Medical Cverage; 44-Disability; 49-Life Insurance; 50-Jury Duty); Infrmatin abut hw t file claims and appeals (pages 22-Medical Claims; 26-Medical Appeals; 51-Other Claims); Plan administrative infrmatin (page 61); and A glssary f imprtant definitins (page 67). i

4 This bklet describes the benefits in effect as f January 1, 2017 r later. This editin replaces and supersedes any previus Summary Plan Descriptin. The Trustees reserve the right and have the authrity t amend, mdify, r eliminate benefits, r t terminate the Plan at any time. Oral representatins r interpretatins are nt permitted. In additin, the Trustees, r such ther persns as delegated by the Trustees, have the discretin t interpret and cnstrue the rules f the Plan. The Trustees r their agents exercise f discretinary authrity is binding and will nt be verturned r set aside by any curt f law unless fund t be arbitrary and capricius. ANY MEDICAL TREATMENT CONSIDERED INVESTIGATIONAL OR EXPERIMENTAL OR IS NOT CONSIDERED TO BE AN ACCEPTABLE PRACTICE BY THE AMERICAN MEDICAL ASSOCIATION IS NOT COVERED BY THIS PLAN, UNLESS REQUIRED BY LAW. Rescissin r Terminatin f Cverage fr Fraud r Abuse The Plan prhibits Yu frm perfrming an act, practice, r missin that cnstitutes fraud r frm making an intentinal misrepresentatin f material fact, that in any respect relates t Yur enrllment in the Plan, Yur eligibility fr cverage by the Plan, the cverage Yu seek under the Plan r t the treatment fr which Yu seek cverage under the Plan. If Yu engage in such fraud r make such a misrepresentatin, the Plan may rescind Yur cverage retractive t the date f the fraud r misrepresentatin. The Plan will prvide at least thirty (30) days advance written ntice t each Participant wh wuld be affected befre cverage is rescinded pursuant t this prvisin. Restrictins fr Prescriptin Medicatins t Prevent Misuse and Abuse Plan Trustees reserve the right t prtect the Plan frm the ptential misuse and abuse f prescriptin cntrlled substance medicatins by restricting plan Participants t ne Physician fr all basic medical care and/r ne pharmacy fr the filling f all prescriptins. The Plan may impse this restrictin when recrds shw a Participant is btaining prescriptins frm mre than ne Dctr fr the same r similar cntrlled substance medicatins and/r filling the same r similar prescriptins at mre than ne pharmacy. Restrictins shall be twelve (12) mnths in length, subject t renewal at the Plan Trustees discretin. The Plan will prvide ntice t Participants indicating: (1) the effective dates f the restrictin(s); (2) the name, address and phne number fr the assigned Physician and/r pharmacy; r as an alternative, the Participant may chse ne Physician and ne pharmacy t be used. The Participant s chice is subject t apprval by the Plan; and (3) a prcedure by which t file a request fr recnsideratin. A Participant wh fails t adhere t the restrictins will be ne hundred percent (100%) respnsible fr the csts f all cntrlled substance medicatins. ii

5 Table f Cntents INTRODUCTION... I TABLE OF CONTENTS... III IMPORTANT CONTACTS... 1 PARTICIPATION IN THE PLAN: ELIGIBILITY, ENROLLMENT AND COVERAGE... 2 General Descriptin f Participants and Available Benefit Prgrams... 2 Eligibility... 3 Yur Initial Eligibility and Initial Date f Cverage... 3 The Eligibility f Yur Dependent... 4 Enrllment... 4 Initial and Cntinuing Enrllment... 4 Adding a Dependent... 5 Enrllment t Reinstate Cverage... 5 Special Enrllment fr Lss f Other Cverage... 5 Cverage... 5 Initial Date f Cverage... 5 When Cverage Ends... 6 Ntificatin f Terminatin f Cverage... 7 Cntinuatin f Cverage Medical Benefits... 7 Cntinuing Cverage Thrugh Medical Plan Eligibility Bank (Regular Emplyees Only)... 7 Cntinuing Cverage Thrugh SUB/ME Plan (Regular Emplyees Only) and SUB/ME Benefits... 9 Cntinuing Cverage In Medical Benefits Thrugh Self-Payments (Nn-COBRA)...11 Cntinuing Cverage While Disabled...12 Cntinuing Cverage Thrugh COBRA Cntinuatin Cverage...13 Cntinuatin f Cverage Due t Military Service (USERRA)...14 Crdinatin f USERRA and COBRA...14 Cverage During A Family and Medical Leave f Absence...14 Reinstating Cverage...15 Keep the Fund Office Infrmed f Changes and Keep Cpies f Ntices...15 MEDICAL BENEFITS The Medical Plan Prescriptin Drug Benefits General Exclusins fr the Medical Plan Ntice f Rights Under the Federal Wmen s Health and Cancer Rights Act f Ntice f Rights Under Newbrns and Mthers Health Prtectin Act Infrmatin Regarding Genetic Infrmatin HOW TO FILE A MEDICAL BENEFITS CLAIM Types f Medical Claims Where t File Claims Urgent Care Claims...22 Pre-Service Claims...22 Pst-Service Claims...22 Deadline fr Filing Claims Ntificatin f Initial Benefit Decisin Explanatin f Medical Benefits Incmplete Claims Right f Examinatin Release f Recrds Legal Actins N Assignment f Claim and/r Appeal and/r Right t Sue UTILIZATION REVIEW OF CERTAIN DENIED MEDICAL BENEFIT CLAIMS APPEALING A DENIED MEDICAL BENEFITS CLAIM TO THE BOARD OF TRUSTEES Appeal Prcedures Time fr Deciding Nn-Urgent Care Appeals...27 Filing Urgent Care Appeals...27 Cnsideratin f Recrd...27 Ntificatin f Appeal Decisin iii

6 EXTERNAL THIRD-PARTY REVIEW OF AN ADVERSE APPEAL DECISION Standard External Review f Nn-Urgent Claim Expedited External Review DENTAL CARE BENEFITS Hw the Plan Wrks Cvered Expenses Preventive Care...31 Basic Dental Care Services...32 Basic Enddntic Services (Nerve r Pulp Treatment)...32 Peridntics (Gum & Bne Treatment)...33 Oral Surgery (Tth, Tissue, r Bne Remval)...33 Cmplex r Majr Restrative Services...34 Prsthetic Services (Dentures, Partials, and Bridges)...34 Orthdntics...34 Exclusins t Dental Care Benefits Cverage is NOT prvided fr:...35 VISION CARE SERVICE PLAN In-Netwrk Benefits Out-Of-Netwrk Benefits HEARING AID BENEFITS Hearing Aid Benefits PHYSICIAN NECK AND SPINE CHRONIC SPINE PAIN PROGRAM SUPPLEMENTAL RETIREE MEDICAL COVERAGE COORDINATION OF BENEFITS Benefits Subject t this Prvisin Effect n Benefits Plans Cnsidered fr COB Order f Benefit Determinatin Operatin f COB Crdinatin f Benefits with Medicare Infrmatin Gathering Privacy Plicy DISABILITY BENEFIT PLAN General Prvisins Weekly Benefit fr Temprary Ttal Disability f the Participant...44 Own Occupatin Temprary Disability f the Participant...46 Permanent Ttal Disability Benefit fr the Participant...46 Medical Cverage While Disabled Regular Emplyee...47 EMPLOYEE ASSISTANCE PROGRAM Hw t Use Yur Emplyee Assistance Prgram LIFE INSURANCE JURY DUTY BENEFIT SUPPLEMENTAL UNEMPLOYMENT BENEFITS (SUB/ME) HOW TO FILE CLAIMS FOR BENEFITS OTHER THAN MEDICAL BENEFITS (DENTAL CARE, HEARING, VISION CARE, MEDICAL ELIGIBILITY BANK, SUB/ME, DISABILITY, LIFE OR JURY DUTY) Where t Submit Dental Care Claims Where t Submit a Disability, Hearing Aid, Life Insurance, Medical Eligibility Bank, SUB/ME Claims Where t Submit Visin Care Claims Benefit Determinatin Payment f Benefits Nn-Assignment f Benefits Appealing a Denied Nn-Medical Benefits Claim Appealing a Denied Claim t The Bard f Trustees...54 Appeal Determinatins...54 Appeal Determinatin Timeframes...54 Medical Judgments...54 Authrized Representatives Trustee Authrity and Interpretatin iv

7 PAYMENT OF CLAIMS Manner f Claims Payment Overpayment f Claims SUBROGATION, REPAYMENT AND EQUITABLE LIEN Plan s Pursuit f Subrgatin Rights Against Third Parties Plan s Right t Reimbursement Subrgatin, Reimbursement and Lien Prcedures ADMINISTRATIVE INFORMATION Plan Spnsr Bard f Trustees is: Administrative Manager Plan Name Plan Numbers Plan Privacy Officer Plan Security Officer Legal Cunsel Cnsultant Parties t the Cllective Bargaining Agreement Agent fr Service f Legal Prcess Plan Funding Plan Year Plan Type Eligibility Requirements Wrkers Cmpensatin and the Plan Plan Amendment and Terminatin Bard f Trustees Discretin and Authrity YOUR ERISA RIGHTS Receive Infrmatin abut Yur Plan and Benefits Cntinue Grup Health Plan Cverage Prudent Actins by Plan Fiduciaries Enfrce Yur Rights Assistance with Yur Questins GLOSSARY RECIPROCITY EXHIBIT A SCHEDULE OF MEDICAL BENEFITS Preventive Health Care Preventive Services fr Adults Preventive Services fr Wmen Preventive Services fr Children Ambulance Chemical Dependency Chirpractic Care Dental Care as a Result f an Accidental Injury Physician Services Durable Medical Equipment and Supplies Emergency Rm and Urgent Care Hme Health Care Hme Infusin Therapy Hspice Inpatient Services Facility Fees Maternity Mental Health Outpatient Services Facility Fees Physician Services Prescriptin Drugs Rehabilitative Services / Habilitative Services Speech, Physical and/r Occupatinal Therapies Skilled Nursing Facilities Transplant Services EXHIBIT B INITIAL NOTICE OF COBRA CONTINUATION COVERAGE RIGHTS v

8 EXHIBIT C NOTICE OF PRIVACY PRACTICES EXHIBIT D ANNUAL NOTICE OF LANGUAGE ACCESS SERVICES Ntice f Nndiscriminatin Practices Cverage f Health Care Services n the Basis f Gender vi

9 Imprtant Cntacts If Yu need t: Cntact: At: Check eligibility Fund Office , Optin 4 r Find a Netwrk Prvider Blue Crss & Blue Shield f Minnesta Custmer Service BLUE (2583) r T find a Netwrk Prvider; Inpatient Blue Crss & Blue Shield f Minnesta Custmer Service Ask a questin abut medical benefits Alan Sturm & Assciates r r dental care benefits Ask a questin abut a medical claim Alan Sturm & Assciates r r dental care claims T find a participating pharmacy Prime Therapeutics Member Services T find a participating dentist r ask a questin abut dental care benefits Alan Sturm & Assciates r Or Ask a questin abut nn-medical Fund Office , Optin 4 benefits (disability, ME, SUB, etc.) Change addresses Fund Office , Optin 4 Add/delete a Dependent Fund Office , Optin 4 Ask a questin abut life insurance Fund Office , Optin 4 Nurse Advice Line, Available 24/7/365 Behavir Health Assessment, Shrt Term Cunseling and Referrals Ask a questin abut chrnic spine pain prgram Ask a questin abut visin benefits r lcate a VSP Netwrk Prvider Fr infrmatin n wellness and disease management Ask questins abut hearing care benefits Nurse Advice Line TEAM Emplyee Assistance Prgram Physician s Neck & Back Clinic Health Plan Visin Service Plan Nurtur - Nurse Advice Line 24/7/365 Epic Hearing TTY , and say Yu are in the St. Paul Electrical Wrkers TDD and g t Plugged int Wellness link , hearing impaired call 711 Natinal Relay Service Thrugh Wellness Care Exam Health Dynamics Fr earliest detectin f heart disease Heart Savers Access state-f-the-art tls t help yu reach yur persnal gals Access supprt frm a health cach t bring in resurces as needed t prvide a cntinuum f care Ask questins regarding yur Healthy Rads Prgram Under Members Sectin/Health & Wellness Care Management Prgram BCBS MN Maternity Management Prgram BCBS MN pregnancy Get supprt t Quit Smking Quitting Tbacc Supprt Prgram BCBS MN BLUE (2583) 1

10 Participatin in the Plan: Eligibility, Enrllment and Cverage General Descriptin f Participants and Available Benefit Prgrams Yu r Yur Dependents wh satisfy the eligibility requirements and enrllment requirements may participate in the fllwing benefit prgrams: Type f Emplyee r Dependent Regular Emplyees Regular Emplyee s Dependent (including Spuse) Benefit Prgrams Medical Benefits Dental Care Benefits Hearing Aid Benefits Visin Care Service Plan Disability Benefits Medical Eligibility Bank* SUB/ME* Jury Duty Life Insurance TEAM Emplyee Assistance Prgram Nurse Advice Line Nutur Wellness/Disease Management Chrnic Spine Pain Prgram EPIC Hearing Heart Savers Health Dynamics Retiree Supplemental Medicare cverage ** Medical Benefits Dental Care Benefits Hearing Aid Benefits Visin Care Service Plan Medical Eligibility Bank* SUB/ME* TEAM Emplyee Assistance Prgram Nurse Advice Line Nurtur Wellness/Disease Management (Spuse nly) Chrnic Spine Pain Prgram EPIC Hearing Heart Savers (Spuse nly) Health Dynamics (Spuse nly) Retiree Supplemental Medicare Cverage** * Excludes LEA agreement emplyees and their Dependents. ** Fr a Retiree wh is age 65 r lder and the Retiree s Spuse. 2

11 Type f Emplyee r Dependent Nn-Bargaining Unit Emplyee Nn-Bargaining Unit Emplyee s Dependent (including Spuse) Benefit Prgrams Medical Benefits Dental Care Benefits Hearing Aid Benefits Visin Care Service Plan Disability Benefits Life Insurance Retiree Supplemental Medical Cverage** TEAM Emplyee Assistance Prgram Nurse Advice Line Nurtur Wellness/Disease Management Chrnic Spine Pain Prgram EPIC Hearing Heart Savers Health Dynamics Medical Benefits Dental Care Benefits Hearing Aid Benefits Visin Care Service Plan Retiree Supplemental Medical Cverage** TEAM Emplyee Assistance Prgram Nurse Advice Line Nurtur Wellness/Disease Management (Spuse nly) Chrnic Spine Pain Prgram EPIC Hearing Heart Savers (Spuse nly) Health Dynamics (Spuse nly) Eligibility Yur Initial Eligibility and Initial Date f Cverage Generally, Yu are eligible fr benefits if Yu are: Or A member f IBEW Lcal Unin N. 110 (the Unin) r emplyed thrugh the St. Paul Electrical Jint Apprenticeship Training Cmmittee; and Yur emplyer is bligated by an agreement between the Unin and the St. Paul Chapter f the Natinal Electrical Cntractrs Assciatin (NECA). Yu wrk fr a Related Organizatin. If Yu are a: Regular Emplyee. Yu becme eligible n the first day f the mnth fllwing receipt f emplyer cntributins n Yur behalf fr at least three hundred (300) hurs wrked if Yu are wrking in Cvered Emplyment. If Yu are a Regular Emplyee emplyed in Cvered Emplyment, Yu may self-pay the premium fr cverage in the Plan s Medical Benefits until the three hundred (300)-hur eligibility requirement is satisfied. Cverage will start n the first f the mnth fllwing the 3

12 date f hire r the date f enrllment as determined by the Fund Office, prvided the premium is paid. If Yu are a Regular Emplyee wh has three hundred (300) hurs f cntributins made t the Plan, but are nt wrking in Cvered Emplyment n the first f the mnth fllwing receipt f the three hundred (300) hurs f cntributins, Yu may elect t start cverage n the first f the mnth fllwing receipt f the three hundred (300) hurs f cntributins thrugh self-payment r by using Yur Medical Eligibility Bank. If Yu are a Regular Emplyee wh had satisfied the three hundred (300)hurs wrk requirement, and ceased wrking but cntinued cverage as allwed by COBRA r the Plan prvisins, when Yu return t wrk Yu may self-pay the premium fr cverage in the Plan s Medical Benefits until the three hundred (300) hurs eligibility requirement is satisfied, even if a COBRA perid technically lapses. Cverage will start fr these purpses n the first f the mnth fllwing the date Yu return t wrk, prvided the premium is paid. LEA emplyees are eligible t participate in the Plan as f the date specified in the LEA Agreement entered int between their emplyer and the Unin. Generally, this is the first day f the mnth fllwing the date f hire. If Yu are an wner-peratr, Yu must remit cntributins fr at least three hundred (300) hurs during any six (6)-mnth perid t retain eligibility. Nn-Bargaining Unit Emplyee. if Yu are emplyed by an Emplyer apprved by the Trustees, Yu becme eligible n the first day f the mnth fr which Emplyer cntributins in the amunt determined by the Trustees are received. Yur effective date f cverage is the first day f a mnth as stated abve. In rder t include Dependents in Yur cverage, Yu must prvide a cmpleted applicatin frm with supprting legal dcuments as required by the Trustees, i.e., birth certificates r marriage license. The Eligibility f Yur Dependent Yur Dependent(s) becme eligible fr Plan benefits n the date Yu becme eligible r, if later, n the date the persn satisfies the definitins f Dependent. Yu must ntify the Fund Office f any Dependents and prvide any requested materials befre the Plan will pay benefits fr Yur Dependents. In general, Yur Dependents include Yur Spuse and Yur dependent Children. Fr detailed definitins f Child, Dependent, and Spuse, see pages 67 and 72, respectively. Enrllment Initial and Cntinuing Enrllment In general, Yur Dependents include Yur Spuse and Yur dependent Children. Regular Emplyees are enrlled in the Plan when the Fund Office receives cntributins fr three hundred (300) hurs wrked r, in the case f an LEA emplyee, as prvided in the LEA Agreement. Nn-bargaining Unit Emplyees are enrlled when there is a Participatin Agreement in place t cver thse emplyees and a premium fr cverage has been paid. Cverage is effective the first f the mnth fllwing such enrllment. Regular Emplyees may elect t self-pay t btain cverage in the Plan until the three hundred (300)-hur eligibility requirement is satisfied. A Regular Emplyee will enrll in the Plan when he r she makes that electin. In that instance, cverage will start n the first f the mnth fllwing the date f hire r the date f enrllment as determined by the Fund Office. 4

13 T enrll Dependents, in all cases, Yu must cmplete and return t the Fund Office an enrllment applicatin with the required supprting dcumentatin, such as a marriage license and/r birth certificate. Yu must list all f Yur Dependents n the applicatin. If Yu d nt submit a prperly cmpleted applicatin, benefit payments fr Yur Dependents are delayed until the Fund Office has a cmpleted applicatin fr Yur Dependents. Adding a Dependent T add a Spuse r a Child, Yu must cntact the Fund Office fr an enrllment applicatin. Return the cmpleted applicatin alng with any required supprting dcumentatin t the Fund Office. Cverage is effective n the date the persn became a Dependent, as lng as the cmpleted applicatin is received by the Fund Office within sixty (60) days f the persn becming a Dependent. After sixty (60) days, the Spuse r Child will be cvered beginning n the first f the mnth fllwing receipt f the applicatin. Enrllment t Reinstate Cverage If Yur cverage is terminated and Yu return t wrk and becme eligible again, Yu will need t cmplete a reinstatement applicatin and return it t the Fund Office. Call the Fund Office fr an applicatin. (See page 15 n Reinstating Cverage.) Special Enrllment fr Lss f Other Cverage If Yu are declining enrllment fr Yurself r Yur Dependents (including Yur Spuse) because f ther health insurance r grup health plan cverage, Yu may be able t enrll Yurself and Yur Dependents in this Plan if eligibility is lst fr that ther cverage (r if the emplyer stps cntributing twards the ther cverage). Hwever, Yu must request enrllment within thirty (30) days after Yu r Yur Dependents ther cverage ends (r the emplyer stps cntributing tward the ther cverage). Fr special enrllments due t lss f ther cverage, Yu r Yur Dependent must therwise be eligible fr Plan cverage; and have been cvered under anther grup health plan r ther health insurance, including Medicaid r state Children s Health Insurance Prgram (CHIP), when cverage under this Plan was declined and enrllment must have been declined due t this ther cverage. If the ther health cverage was COBRA cntinuatin cverage in anther plan, a special enrllment is nly available after the COBRA cntinuatin cverage has been exhausted. If the ther cverage is nt COBRA cntinuatin cverage, a special enrllment is available if Yu r Yur Dependents are n lnger eligible fr cverage r emplyer cntributins fr the ther cverage. Special enrllments are nt available fr lss f cverage due t failure t pay premiums, fraud, r misrepresentatin. T be eligible fr a special enrllment, Yu must ntify the Fund Office within thirty (30) days f the lss f ther cverage r the date f marriage, adptin, r placement fr adptin (within sixty (60) days fr special enrllment related t Medicaid r CHIP cverage). T request special enrllment r btain mre infrmatin, cntact the Fund Office. Cverage Initial Date f Cverage Yur initial date f cverage is the first f the mnth fllwing satisfactin f an Eligibility Requirement, as stated n page 3 under Yur Initial Eligibility and Initial Date f Cverage. The effective Date f Cverage fr Dependents is either the first f the mnth fllwing certain criteria, r fr certain New Dependents, it will be the date f birth, date f adptin r date f marriage. 5

14 When Cverage Ends Cverage ends as specified belw. Cverage may be cntinued in sme instances thrugh self-payment; by cntinuing cverage under federal laws knwn as COBRA, USERRA r by using funds in the Medical Plan Eligibility Bank r the SUB/ME. Certain retired emplyees may als cntinue cverage with sme self-payment ptins. Fr Yu Cverage under the Plan will end n the earliest date listed belw: The date the Plan ends; The date Yu enter active military service; At the end f the mnth in which Yu terminate active emplyment r are n lnger wrking in Cvered Emplyment (unless Yu are able t cntinue cverage under the Plan s Medical Eligibility Bank prvisins); The end f the mnth fllwing the mnth in which Yu die; The end f the mnth fr which insufficient cntributins have been made n Yur behalf; The end f the mnth befre any mnth fr which Yu d nt pay the required mnthly charge if sufficient cntributins are nt made n Yur behalf; Fr Regular Emplyees wh are wner-peratrs, at the end f any six (6)-mnth perid where cntributins have nt been remitted fr at least three hundred (300) hurs; Fr Nn-Bargaining Unit Emplyees, at the end f the mnth in which the Emplyer Related Organizatin is n lnger in cmpliance with r emplying at least ne emplyee under the prvisins f any agreement(s) apprved by the Trustees; The end f the mnth befre any mnth in which Yu d nt make the required self-payment fr cverage under the prvisins f the Plan; r The date n which Yu perfrm an act, practice r missin that cnstitutes a fraud n the Plan r make an intentinal misrepresentatin f a material fact r abuse the prvisin f benefits under this plan. Such actins include but are nt limited t submitting fraudulent misstatements r missins abut medical histry r eligibility status; submitting fraudulent, altered r duplicate billings fr persnal gain; allwing anther party nt eligible fr cverage under the Plan t use cverage; and/r repeatedly request cverage fr benefits that are nt Medically Necessary r cumulatively exceed reasnable and custmary expenditures fr a medical issue. Fr Yur Dependent Yur Dependent s cverage will end n the earliest date listed belw: The date he r she becmes an Eligible Emplyee in the Plan, unless he r she is a dependent Child wh elects t remain n his r her parent member s cverage until age twenty-six (26); The date he r she n lnger satisfies the definitin f a Dependent under the Plan; The date the Plan discntinues all Dependent cverage; Immediately when Yur, the member s, cverage ends; The Dependent requests in writing t end cverage; The date f his r her death; r 6

15 The date n which Yu r Yur Dependent perfrms an act, practice r missin that cnstitutes a fraud n the Plan r make an intentinal misrepresentatin f a material fact r abuse the prvisin f benefits under this plan. Such actins include but are nt limited t submitting fraudulent misstatements r missins abut medical histry r eligibility status; submitting fraudulent, altered r duplicate billings fr persnal gain; allwing anther party nt eligible fr cverage under the Plan t use cverage; and/r repeatedly request cverage fr benefits that are nt Medically Necessary r cumulatively exceed reasnable and custmary expenditures fr a medical issue. Ntificatin f Terminatin f Cverage If Yu r Yur Dependent s cverage in the Plan has been terminated fr any reasn, Yu r Yur Dependent will be ntified in writing f the terminatin by the Fund Office. This ntificatin will be mailed t Yu r Yur Dependent at the address prvided t the Trustees. If Yu r Yur Dependent fails t receive this written ntificatin, it will nt affect the terminatin f Yur cverage r Yur Dependent s cverage. D nt miss imprtant infrmatin frm the Plan. Keep Yur address infrmatin current with the Fund Office. Cntinuatin f Cverage Medical Benefits If Yur cverage ends, Yu r Yur Dependents may cntinue cverage in the medical benefits in the Plan (Medical, Dental Care and Visin Care) as allwed by laws knwn as COBRA r USERRA. There is n cntinuatin f cverage fr nn-medical benefits. Regular Emplyees (r a Dependent f a Regular Emplyee) may have accunt balances available t them thrugh the Medical Plan Eligibility Bank and/r the SUB/ME prgram. If Yu cntinue cverage under COBRA r USERRA, Yu may pay fr such cverage using any ne r mre f the fllwing methds: (1) funds available thrugh the SUB/ME Prgram; r (2) self-payment. If Yu suffer a Temprary Ttal Disability r a Ttal Permanent Disability, Yu may cntinue cverage fr free fr a perid f time and subject t certain limitatins described in detail starting at page 44. If Yur cntinuatin perid under COBRA r USERRA, r self-payment expires, Yu may be able t reinstate cverage as described n page 15. Cntinuing Cverage Thrugh Medical Plan Eligibility Bank (Regular Emplyees Only) The Medical Plan Eligibility Bank (Eligibility Bank r Bank) allws Regular Emplyees wh experience a severance f emplyment r d nt have sufficient hurs t cntinue cverage fr medical benefits (Medical, Dental Care, and Visin Care) t use the accumulated funds in their accunt t help pay fr cverage. If the Bank dllars are used t cntinue cverage fr medical benefits after a severance f emplyment r reductin in hurs, there is n COBRA event until the Bank dllars have been exhausted. Eligibility Regular Emplyees emplyed under Agreements apprved by the Trustees that prvide fr the Medical Plan Eligibility Bank will have Emplyer cntributins made fr this purpse n their behalf. Each eligible emplyee will have a separate accunt. If Yu wrk mre than the required hurs needed t pay fr a mnth f benefits, the excess hurly cntributins made n Yur behalf will be added t Yur accunt. 7

16 Benefits The accunt may be used t pay mnthly health plan premium payments fr medical benefits (Medical, Dental Care, and Visin Care) as fllws: fr Yu, fr premiums fr cverage in either this Health Plan, cntinuatin cverage in this Health Plan, r as reimbursement fr substantiated premium csts t btain health cverage in anther emplyer-spnsred health plan; fr Retirees, fr premiums fr cverage as a Retiree in this Health Plan, the Supplemental Medicare Cverage Plan, r as reimbursement fr substantiated premium csts t btain health cverage in anther emplyer-spnsred health plan; r fr surviving Dependents fr premiums fr cverage in this Health Plan, the Supplemental Medicare Cverage Plan, r as reimbursement fr substantiated premium csts t btain health cverage in anther emplyer-spnsred health plan. All requests fr reimbursement f premiums paid t anther emplyer-spnsred health plan must be substantiated and must include an attestatin that Yu (r Yur surviving Dependents) are cvered by such plan. All such claims must be submitted within twelve (12) mnths f the date the expense was incurred. The amunt reimbursed may nt exceed the Eligibility Bank accunt balance. The Trustees determine, in their discretin, if requested amunts will be reimbursed. Frfeiture f Yur Eligibility Bank Accunt The cntributins in Yur Eligibility Bank accunt will be frfeited back t the Trust, if any f the fllwing events ccurs: The Health Plan is discntinued. Yu are separated frm Yur Emplyer (ther than fr Early Retirement r Nrmal Retirement) and Yu have lst cverage under the Plan, Yur accunt is frfeited n the twenty-furth (24 th ) mnth fllwing the lss f cverage in the Plan. Yu are fund t be in vilatin f the cllective bargaining agreement. Yu die withut a surviving Dependent. Yu die and Yur surviving Dependent declines cverage r dies. Yu d nt elect t self-pay fr cverage r lse cverage in this Plan r anther emplyer-spnsred health plan, Yur accunt will be frfeited twenty-fur (24) mnths frm the date Yu lst cverage. Yu enter int active military service, but nly if Yu return frm active duty, are nt disabled, and d nt return t Cvered Emplyment within ninety (90) days after returning frm active duty. If Yu return frm active duty, but are disabled and cannt return t Cvered Emplyment within ninety (90) days, then Yur accunt balance may be used t pay fr medical benefits cverage in this Plan r anther emplyer-spnsred health plan until the disability ends r the accunt balance is exhausted. If, n r after Early Retirement, Yu elect t pt ut f the Plan, Yu have a ne-time pt-ut pprtunity t return t the Plan. Once Yur pt-ut perid is ver, if Yu have a break in cverage with this Plan fr twenty-fur (24) mnths, Yur accunt in the Bank will be frfeited. See the ptut rules in the bx n page 12. 8

17 Cntinuing Cverage Thrugh SUB/ME Plan (Regular Emplyees Only) and SUB/ME Benefits If Yu are a Participant in the SUB/ME Plan, Yu may use Yur accunt balance in the SUB/ME Plan t pay fr premiums fr medical benefits (Medical, Dental Care, and Visin Care) in the Plan. Prir t using SUB/ME funds, Yu must have exhausted any funds available t Yu in the Eligibility Bank, which may trigger a COBRA qualifying event. The SUB/ME Plan prvides benefits, if Yu are eligible, t supplement State Unemplyment Cmpensatin benefits, wrkers cmpensatin payments and/r t help pay medical premiums, Deductibles and C-insurance. Eligibility in SUB/ME Yu are eligible if the Cllective Bargaining Agreement (CBA) requires cntributins n Yur behalf t the Supplemental Pensin Plan and any ne f the fllwing applies t Yu: Yu are a Participant in the Health Plan; Yu are a Participant in the Health Plan and n lnger wrking in Cvered Emplyment; r Yu are retired. The fllwing grups are nt eligible fr the SUB/ME Plan: LEA agreement members and Retirees returning t Cvered Emplyment. Benefits in SUB/ME If Yu are eligible, an accunt is established fr Yu. Yur Emplyer cntributes t the accunt n Yur behalf. Cntributins int Yur accunt will accumulate up t Six Thusand Dllars ($6,000) maximum; hwever, Yur accunt value may exceed that amunt based n earnings (gains/lsses) that the Trustees apply t all accunts frm time t time. Yu may use Yur SUB/ME accunt t pay fr the fllwing benefits: Yu may receive Tw Hundred Fifty Dllars ($250) a week (subject t tax withhlding), if Yu are receiving (and have been receiving fr three weeks) Wrkers Cmpensatin r if yu are receiving disability benefits under Part A f the Plan and if Yu have at least One Thusand Tw Hundred Dllars ($1,200) in Yur accunt; Yu may receive Tw Hundred Fifty Dllars ($250) a week (subject t tax withhlding), if Yu are receiving (and have been receiving fr three weeks) Unemplyment Cmpensatin fr unemplyment and if Yu have at least One Thusand Tw Hundred Dllars ($1,200)in Yur accunt; The accunt may be used t pay mnthly medical premiums fr Yu, Retirees (even with the Retirement Medical Funding Plan), r surviving Dependents; If Yu have nt wrked sufficient hurs t make a full cntributin t the Health Plan and Yu have received a bill frm the Health Plan and have nt respnded within twenty-ne (21) days f the invice date frm the Health Plan, Yu will pay fr cntinued medical cverage frm Yur SUB/ME accunt, after Yur Medical Eligibility Bank accunt is exhausted; r The SUB/ME Plan als reimburses the fllwing tax-deductible medical expenses fr Yu r Yur Dependents; 9

18 Annual Deductibles under this Health Plan, the Supplemental Medicare Cverage Plan r under anther emplyer-spnsred grup health plan, C-insurance (the amunt Yu pay, after the Plan pays benefits) fr medical expenses fr Yurself r Yur Dependent under this Health Plan, the Supplemental Medicare Cverage Plan r under anther emplyer-spnsred grup health plan, r Insurance premiums fr Yu r a Dependent fr this Health Plan, Supplemental Medicare Cverage Plan r under anther emplyer-spnsred grup health plan. All requests fr reimbursement f premiums paid t anther emplyer-spnsred health plan must be substantiated and must include an attestatin that Yu (r Yur surviving Dependents) are cvered by such plan. Filing a claim fr reimbursement frm the SUB/ME fr the abve nted expenses must be dne n a frm apprved by the Trustees (available in the Fund Office) and include dcumentatin that substantiates the expense actually incurred and its specific nature. All claims fr medical expense reimbursement must be submitted within twelve (12) mnths f the date the expense was incurred. The amunt reimbursed frm a Participant s SUB/ME accunt shall nt exceed the balance f the accunt n the date the claim fr reimbursement was filed. The Trustees, in their discretin, shall determine whether a claimed expense will be reimbursed. NOTE: Sme benefits prvided thrugh the SUB/ME may be taxable. Frfeiture f Yur SUB/ME Accunt The cntributins in Yur SUB/ME accunt will be frfeited back t the Trust, if any f the fllwing events ccurs: Yu are separated frm Yur Emplyer (ther than fr Early Retirement r Nrmal Retirement) and Yu have lst cverage under the Plan, Yur accunt is frfeited n the twenty-furth (24 th ) mnth fllwing the lss f cverage in the Plan. Yu are fund t be in vilatin f the Cllective Bargaining Agreement. Yu die withut a surviving Dependent. Yu die and Yur surviving Dependent declines cverage r dies. Yu d nt self-pay fr cverage and lse cverage n the last day f the mnth fr which cverage was paid, then Yur SUB/ME accunt will be frfeited n the twenty-furth (24 th ) mnth after Yu lse cverage. If, n r after Early Retirement, Yu elect t pt ut f the Plan, Yu have a ne-time pt ut allwance. Fr example, if Yur Spuse cntinues emplyment and cvers Yu under his r her emplyer s benefits, then Yu can elect t pt ut f this Plan until Yur Spuse and Yu lse cverage under that plan. Once Yur pt-ut perid is ver, if Yu have a break in cverage with this Plan fr twenty-fur (24) mnths, Yur accunt will be frfeited. Yu enter int active military service, but nly if Yu return frm active duty, are nt disabled, and d nt return t Cvered Emplyment within ninety (90) days after returning frm active duty. If Yu return frm active duty, but are disabled and cannt return t Cvered Emplyment within ninety (90) days, then Yur accunt balance may be used t pay fr cverage until the disability ends r the accunt balance is exhausted. If Yu are an apprentice n an apprved leave f absence frm the JATVC prgram, Yur SUB/ME accunt will nt be frfeited during the apprved leave. 10

19 Cntinuing Cverage In Medical Benefits Thrugh Self-Payments (Nn-COBRA) This sectin describes when Yu r Yur Dependents lse cverage, but may cntinue cverage thrugh regular self-payments. Fr Regular Emplyees If Yu are a Regular Emplyee and Yu are granted a participating withdrawal frm IBEW Lcal Unin 110 r a disability pensin frm the Natinal Electrical Benefit Fund (NEBF), but Yu are nt eligible fr the Disability Benefit, Yu may cntinue cverage by paying the mnthly cst fr cverage befre the mnth fr which cverage is elected. Cverage will end accrding t Plan prvisins (as described n page 6). Cverage cannt be extended beynd the earlier f: The date Yu reach age 65; The effective date f Yur Medicare eligibility if Yu have retired r are SSA disabled; The date the participating withdrawal ends; r The date Yu vilate the Cllective Bargaining Agreement; r The date Yu are n lnger receiving the NEBF disability pensin. Fr a Surviving Dependent Spuse If Yu die, Yur Dependent Spuse s cverage wuld nrmally end at Yur death; hwever, Yur Spuse may cntinue cverage t the first day f the mnth in which he r she reaches age 65 r becmes eligible fr Medicare, r n the date Yur Spuse remarries, if: Yu were a Regular Emplyee r a Nn-Bargaining Unit Emplyee; Yu had at least sixty (60) cnsecutive mnths f cverage under the Plan; and Yur Spuse pays the mnthly cst f cverage n a timely basis. Yur surviving Spuse may use any amunts in Yur Eligibility Bank r Yur SUB/ME t pay these premiums. Fr Yur Divrced Spuse If Yu and Yur Spuse divrce r legally separate and a curt decree requires Yu (the Participant) t pay the COBRA premiums fr Yur Spuse, then Yur Spuse may cntinue cverage at n additinal cst under this Plan. Hwever, this extended cverage will end when either Yu r Yur Spuse dies, if Yur Spuse becmes eligible fr cverage elsewhere including Medicare, r Yu r Yur Spuse remarries. In rder t btain this benefit, Yur frmer Spuse must elect COBRA cverage within the time limits specified fr a divrce. (See Exhibit B t this SPD.) In additin, Yu and Yur frmer Spuse must prvide t the Fund ntice f Yur divrce and the curt rder requiring payment f COBRA premiums as sn as practicable. DELAY IN PROVIDING THE COURT ORDER MAY RESULT IN DENIAL OF THIS BENEFIT. Fr a Retiree If Yu are a Regular, full-time Bargaining Unit Emplyee, r Nn-Bargaining Unit Emplyee, Yu may cntinue cverage in this Plan when Yu retire if Yu: Were a Participant in the Plan at the time f Yur retirement; 11

20 Had a minimum f sixty (60) mnths f participatin (as lng as the mnths are cnsecutive r the perid in cvered emplyment after an interruptin is greater than the interruptin, if any) in the Plan immediately preceding Early Retirement; and Make payments t the Plan fr cverage. When Yu retire, Yu have these three ptins (r, fr Nn-Bargaining Emplyees, tw ptins): 1. If Yu are a Regular Emplyee, Yu may chse t pt ut f the Plan s cverage, because Yu are cvered under Yur Spuse s emplyer s plan and Yur Spuse will cntinue t wrk. 2. Yu may chse t cntinue cverage in this Plan thrugh self-payments, as lng as Yu are nt yet eligible fr Medicare. 3. If Yu are eligible fr Medicare, Yu may chse Supplemental Retiree Medicare Cverage as described n page 39. If Yu have cvered Dependents wh are nt eligible fr Medicare, Yu may cntinue t cver them in the active Plan while Yu are cvered thrugh Supplemental Retiree Medicare Cverage, an insured plan. Yu will have t self-pay fr Yur Dependents and Yurself. Yu may cntinue Dependent cverage until Yur last Dependent either becmes eligible fr Medicare r n lnger meets the definitin f Dependent under the Plan. In the event Yur Dependent n lnger meets the definitin f a Dependent under the Plan, Yur Dependent may be able t cntinue cverage under COBRA (see page 13). Once Yu r Yur Dependent becmes eligible fr Medicare, Medicare cverage will be cnsidered primary fr that individual, as described n page 42. If Yu are receiving a pensin check frm the St. Paul Electrical Cnstructin Pensin Plan and Yu are self-paying t cntinue cverage in this Health Plan, Yu may elect t have Yur premium payments deducted frm Yur pensin check and remitted t this Plan. Fr a Dependent f a Deceased Retiree One-Time Opt Out fr Regular Emplyees Yu may pt ut f cverage under this Plan nly nce. When Yu return t this Plan, Yu must shw that Yu (and any Dependents) were cntinuusly cvered under the ther plan until Yu came back t this Plan. Yu will have t self-pay fr cverage. If Yu are eligible t receive a cntributin allwance frm the Retirement Medical Funding Plan fr St. Paul Electrical Wrkers, Yu can use this allwance t ffset Yur self-payments. Cverage f a Dependent may cntinue even if the cverage wuld nrmally terminate because Yu retire, if Yu: Are eligible fr a pensin frm the St. Paul Electrical Cnstructin Pensin Fund, and Die after retirement. Yur Dependent will have t pay the mnthly cst f cverage. Yur Dependent may use any amunts in Yur Eligibility Bank r Yur SUB/ME accunt t pay fr these premiums. Cntinuing Cverage While Disabled In additin t Yur COBRA and USERRA rights, if Yu suffer a Temprary Ttal Disability r Ttal Permanent Disability, Yu may cntinue medical benefits cverage fr free fr a perid f time. G t pages

21 Cntinuing Cverage Thrugh COBRA Cntinuatin Cverage COBRA Cntinuatin Cverage is a temprary extensin f grup health cverage under the Plan under certain circumstances when cverage wuld therwise end. COBRA (and the descriptin f COBRA Cntinuatin Cverage included here). If Yu experience a COBRA event, the Plan allws Yu t cntinue the medical benefits (Medical, Dental Care, and Visin Care) in the Plan. The right t COBRA Cntinuatin Cverage was created by a federal law called the Cnslidated Omnibus Budget Recnciliatin Act f 1985 (COBRA). COBRA Cntinuatin Cverage becmes available t Yu when Yu wuld therwise lse Yur grup health cverage under the Plan. It als becmes available t Yur Spuse and Children (Yur Dependents) wh are cvered under the Plan when they wuld therwise lse their cverage. Yu r Yur cvered Dependents may cntinue cverage under the grup health benefits in this Plan if current cverage ends because f any f the qualifying events listed n the fllwing page. (Please nte that there may be ther cverage ptins available t Yu and Yur family including being able t purchase cverage thrugh the Health Insurance Marketplace, instead f cntinuing Yur cverage under this Plan.) Yu r Yur Dependent must be cvered under the Plan befre the qualifying event in rder t cntinue cverage. In all cases, cntinuatin ends if the Plan ends r required charges are nt paid when due. The fllwing table generally describes cntinuatin cverage under this Plan. Als, refer t Initial COBRA Ntice attached t this Plan as Exhibit B fr mre infrmatin. Qualifying Event Wh May Cntinue Maximum Cntinuatin Perid Emplyment ends, certain leaves f absence, layff, r reductin in hurs (except grss miscnduct dismissal)** Emplyees and Dependents Earlier f: 1. Enrllment date in ther grup cverage, r 2. eighteen (18) mnths Divrce Death f Emplyee Frmer Spuse and any dependent Children wh lse cverage Nte: A Divrced Spuse may be able t cntinue cverage as allwed n page 11 f this Plan. Surviving Spuse and dependent Children This sectin prvides a general explanatin f COBRA Cntinuatin Cverage, when it may be available t Yu and Yur family, and what Yu need t d t prtect Yur right t receive it. Earlier f: 1. thirty-six (36) mnths frm the date f divrce 2. Enrllment date in ther grup cverage, r 3. Date cverage wuld therwise end Earlier f: 1. thirty-six (36) mnths frm the date f death 2. Enrllment date in ther grup cverage, r 3. Date cverage wuld therwise end 13

22 Qualifying Event Wh May Cntinue Maximum Cntinuatin Perid Dependent Child lses eligibility dependent Child Earlier f: 1. thirty-six (36) mnths frm the date f lsing eligibility 2. Enrllment date in ther grup cverage, r 3. Date cverage wuld therwise end Ttal Disability Emplyee and Dependents Earliest f: 1. eighteen (18) mnths, r 2. twenty-nine (29) mnths after the qualifying event, r 3. Date Ttal Disability ends, r 4. Date f enrllment in Medicare, r 5. Date cverage wuld therwise end ** Fr Regular Emplyees, if Yu experience a severance f emplyment, leave f absence r layff, if Yu have Eligibility Bank dllars, Yu d nt have a COBRA event until the first f the mnth fllwing the mnth in which Yur Eligibility Bank is exhausted. Cntinuatin f Cverage Due t Military Service (USERRA) If Yu leave wrk fr military service and the military service is fr thirty (30) r fewer days, Yu and Yur Dependents may cntinue health plan cverage at ne hundred percent (100%) f premium cst. If military service lasts mre than thirty (30) days, Yu and/r Yur Dependents may cntinue cverage fr a perid f up t twenty-fur (24) mnths at ne hundred tw percent (102%) f the cverage ( applicable premium ) cst. Crdinatin f USERRA and COBRA When Yu r Yur Dependent lses cverage under the Plan and Yu r Yur Dependent is eligible t cntinue medical benefits cverage thrugh USERRA r COBRA, then Yu r Yur Dependent may elect the type f cntinuatin cverage t use. If Yu elect USERRA, Yur cverage level des nt change and n ptinal levels f cverage are ffered. If instead Yu elect COBRA cverage, then tw ptins are ffered Full (medical, dental care and visin care, n disability) r medical nly. If Yu are eligible fr either USERRA r COBRA cverage, then Yur electin f ne type f cverage will mean that Yu waive the thers. Fr example, if Yu elect the USERRA ptin, Yur electin waives Yur right t COBRA cverage. Cverage During A Family and Medical Leave f Absence Nt all Emplyers are cvered by FMLA, and the benefits f this law d nt extend t emplyees f such Emplyers. If Yu are uncertain as t whether FMLA applies t Yu, ask Yur Emplyer r the Plan Administratr. If Yu cease t wrk due t an Emplyer-apprved family medical leave f absence in accrdance with the requirements f the Federal Family and Medical Leave Act f 1993 (r in accrdance with any state r lcal law which If Yu and Yur Spuse bth wrk fr the same Emplyer, Yu and Yur Spuse are eligible fr a cmbined ttal f twelve (12) weeks f leave during a twelve (12)-mnth perid. prvides a mre generus medical r family leave and requires cntinuatin f cverage during leave), cverage will be cntinued under the same terms and cnditins which wuld have been prvided had Yu cntinued t wrk. 14

23 Reinstating Cverage If Yur eligibility fr cverage under the Plan ends, Yu will need t meet the Plan s initial eligibility requirements t reinstate Yur eligibility fr cverage (see page 3), hwever, there are certain exceptins as nted belw and als as described n page 5. If Yu are a Regular Emplyee and Yu return t wrk in either the Hme Area r a Reciprcal Area, Yu may pay the full premium t btain cverage effective the first day f the mnth fllwing Yur return t wrk, until Yu have established the three hundred (300) hurs f emplyer cntributins. Yu must cmplete a new applicatin fr any Dependents Yu want t cver under the Plan. If Yur cverage ends after Yu entered military service under the Unifrmed Services Emplyment and Reemplyment Rights Act f 1994 ( USERRA ), and Yu return t wrk in the jurisdictin cvered by the Plan, Yu will be immediately eligible fr cverage under the Plan n the first day f such reemplyment. Keep the Fund Office Infrmed f Changes and Keep Cpies f Ntices T prtect Yu and Yur family s rights, Yu shuld keep the Fund Office infrmed f any changes in status r in Yur address and the addresses f Dependents. Yu als shuld keep a cpy, fr Yur recrds, f any ntices Yu send t the Fund Office. Infrm the Fund Office f: Change f Address Adptin f Child Marriage Death f Member Divrce Death f Dependent Birth f Child Receipt f SSA Ttal Disability Determinatin NOTIFICATION MUST BE MADE TO THE FUND OFFICE. Changes f infrmatin that Yu make t the Unin ffice are NOT made r transmitted t the Fund Office. 15

24 Medical Benefits The Medical Plan The Medical Plan prvides cverage fr certain medical expenses fr Eligible Emplyees and their Dependents wh enrll in the Plan. The Plan pays the Allwed Amunt f Cvered Charges after Participant pays applicable C-pays, Deductibles and C-insurance. The actual Medical Benefits prvided under the Plan depend n whether the health care Prvider is In- Netwrk r Out-f-Netwrk. In-Netwrk Prviders are Prviders wh maintain a cntract with Blue Crss r Hst Blue and serve as a participating Prvider in the netwrk established by the Plan thrugh its cntracts with Blue Crss. If Yu d nt use Dctrs and healthcare facilities that are In-Netwrk, Yu will be cvered by lesser benefits. Blue Crss maintains the Prvider directry f the In-Netwrk Prviders at their website, The list f In-Netwrk Prviders may change as Prviders initiate r terminate their netwrk cntracts. DETERMINE WHETHER YOUR PROVIDER IS IN- NETWORK OR OUT-OF-NETWORK PRIOR TO ANY CARE TO AVOID PAYING ADDED COSTS RELATED TO USING AN OUT-OF-NETWORK PROVIDER. Out-f-Netwrk Prviders are NOT bligated t accept the Allwed Amunt as payment in full; they may charge mre. Plus, the Plan may impse a different Allwed Amunt fr an Out-f-Netwrk Prvider that is less than the Allwed Amunt fr the same service by an In-Netwrk Prvider. Fr example, the Plan will nly pay ut fr any Out-f-Netwrk claims the lesser f the amunt the nnparticipating Prvider charges r 175% f the Medicare Like Rates (MLR) fr the particular service r claim. This means that Yu may have substantial Out-f-Pcket expense when Yu use an Out-f- Netwrk Prvider Claims and Benefits. Certain Services, prcedures and medical devices require Preauthrizatin, as listed in the Schedule f Medical Benefits and as subsequently mdified. Pre-authrizatin is a prcess that invlves a benefits review and determinatin f Medical Necessity befre Services, prcedures r devices are prvided and csts are incurred. In-Netwrk Prviders are bligated thrugh their cntracts with Blue Crss t btain Preauthrizatin fr Yu. The Preauthrizatin requirements are mdified by Blue Crss frm time t time, s cntact Alan Sturm and Assciates t determine when Yu need t btain Preauthrizatin r prvide Ntificatin. Prvisins gverning submissin f claims t the Medical Plan are described starting at page 22. All claims must be submitted within twelve (12) mnths f the date service was rendered. If the claim is nt submitted n a timely basis, it will be denied. The Schedule f Medical Benefits fr the Medical Plan is cntained n Exhibit A n page 75. Please nte that there is a separate Dental Care Plan, described at page 31 and a separate Visin Care Service Plan, described at page 37. Prescriptin Drug Benefits The Schedule f Medical Benefits fr the Medical Plan at Exhibit A als cntains infrmatin related t prescriptin drug cverage. N prescriptin drug benefits will be payable fr any charges incurred by an individual wh is enrlled in Medicare Part D. The Plan participates with a pharmacy benefit manager, wh manages a Frmulary fr prescriptin drug purchases. The pharmacy benefit manager uses its drug Frmulary t determine which prescriptin 16