OPERATING ENGINEERS HEALTH & WELFARE FUND BENEFIT PLANS SUMMARY COMPARISON FOR ACTIVE and RETIRED PARTICIPANTS

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1 Employee Premium None None None None None Explanation of Plans and Options Available to You Deductible Annual Out-of-Pocket Calendar Year (Applicable to members who reside in California & Nevada Only.) Pre-Existing Condition Limitations If you choose your own doctor who is not contracted with Anthem Blue Cross the Plan will pay the following benefits according to Plan rules Individual $500 per ; maximum $1,500 per family (Applicable to Most Services) Out of Network $6,000 per individual; $12,000 per family The Plan will pay a maximum of $400,000 per individual per. Once met, you may enroll in an HMO for the remainder of that. January 1 st of the next year you may re-enroll in the F-F-S Plan If you use Anthem Blue Cross PPO providers, the Plan will pay the following benefits according to Plan rules Treatment must be rendered by a PPO contract provider and be a covered service Individual $250 per calendar year; maximum $750 per family (Applicable to Most Services) In-Network $3,000 per individual; $6,000 per family The Plan will pay a maximum of $400,000 per individual per. Once met, you may enroll in an HMO for the remainder of that. January 1 st of the next year you may re-enroll in the F-F-S Plan If you enroll in this plan you must use Kaiser facilities for all of your medical care If you enroll in this plan you must choose a participating medical group where you must go for all your medical care None None None $1,500 per Individual $3,000 for Two or More Family Members $1,500 per Individual $3,000 for Two Family members $4,500 for Three or More Family Members None None None None None None None None If you enroll in this plan, you must choose a participating medical group where you must go for all your medical care $6,500 per Individual

2 Operating Engineers Kaiser Permanente Plan PROFESSIONAL SERVICES: Office Visits Hospital Visits Plan pays $15 per visit. of 50 visits per Plan pays 100% of the contracted after a $20 co-pay per visit of 50 visits per $25 co-pay per visit $25 co-pay per visit $5 co-pay per visit $250 co-pay per admission $250 co-pay per admission Inpatient $100 co-pay per admission Outpatient $50 co-pay per admission Lab and X-Ray Therapy - Acupuncture, Biofeedback, Chiropractic & Physical Therapy (Note: The combined 26 visit limit on the FFS and PPO plans is a combined limit. You do not receive a separate benefit of 26 visits under each plan.) Speech Therapy Routine Physicals Surgeon Assistant Surgeon Anesthetist Urgent Care Services reasonable Plan pays $15 per visit with a combined limit of 26 visits per Plan pays $15 per visit of 52 visits per to a maximum of $150 for one annual routine physical Plan pays 20% of payable to primary surgeon for one or more assistant surgeons. Plan pays 10% of payable to primary surgeon for physician assistant services performed as an assistant surgeon (Only if surgery warrants an Assistant Surgeon) Chiro/PT - Plan pays 50% of the contracted Acupuncture/Biofeedback Plan pays 90% of the contracted after a $20 co-pay per visit All services have a combined limit of 26 visits per calendar year of 52 visits per to a maximum of $175 for one annual routine physical. (Only if surgery warrants an Assistant Surgeon) $10 co-pay per service $25 co-pay per visit (see Kaiser s Summary of Benefits for ) (see Health Net s Summary of Benefits of complete details) $5 co-pay per service $25 co-pay per visit No Charge $10 co-pay per visit $25 co-pay per visit $25 co-pay per visit $10 co-pay per visit $35 per occurrence $10 co-pay per visit. (see s Summary of Benefits for ) N/A $35.00 per occurrence $20 per occurrence within service area $40 per occurrence outside of service area

3 HOSPITAL SERVICES: Inpatient Care Semi-Private Room and Misc. Charges Outpatient Care Emergency Room Care Non Emergency covered Plan pays $15 for Emergency Room Visit, 70% of reasonable for Lab and X-ray services the negotiated contract the hospital s charge $ per admission $ per admission $ per admission $50 co-pay per visit Emergency Room Care Emergency related the hospital s charge $50 co-pay per visit Surgical Facility Inpatient Mental Health Care covered the contract negotiated contract. You are responsible for 10% of the negotiated contract. $250 co-pay per procedure of 45 days per $250 co-pay per occurrence of 30 days per $50 co-pay per occurrence $100 per admission of 30 days per Inpatient Alcohol and Substance Abuse Care covered negotiated contract. You are responsible for 10% of the negotiated contract. $250 per inpatient admission for detoxification. $100 co-pay per admission for transitional residential recovery services Detoxification only of $9,000 per Skilled Nursing Facility Plan pays 80% of reasonable. Limited to a 60 day maximum per Co-pay is 10% of the negotiated contract. 60 day maximum per of 60 days per, not to exceed 120 days in any 5 year period 100 days per benefit period 100 days per 100 days per

4 OTHER SERVICES: Ambulance reasonable Plan pays 80% of the contract $50 per trip $50 per trip $50 per trip Hearing Aids Plan pays 100% to a maximum of $1,000 per aid (x2), once every 3 years See Fee-for-Service Plan option Not covered Not covered Not covered Durable Medical Equipment reasonable not to exceed purchase price Plan pays 90% of the contract not to exceed purchase price In accordance with formulary Covered on a case by case basis Prosthetic Appliances reasonable Plan pays 90% Plan pays $200 per device with a lifetime maximum of $10,000, including repairs

5 PRESCRIPTION DRUGS: Contract Prescription Card Walk-in (30 Day Supply) At contracting pharmacies your copay is $10 for a generic drug. For a preferred brand name drug with NO generic equivalent your co-pay is $25. For a non-preferred brand name drug with NO generic equivalent your co-pay is $40. For a brand name drug WITH a generic equivalent you pay the applicable copay $25 or $40 plus 50% of the difference in price between the brand drug and the generic drug At contracting pharmacies your co-pay is $10 for a generic drug. For a preferred brand name drug with NO generic equivalent your co-pay is $25. For a non-preferred brand name drug with NO generic equivalent your co-pay is $40. For a brand name drug WITH a generic equivalent you pay the applicable copay $25 or $40 plus 50% of the difference in price between the brand drug and the generic drug For generic drugs at plan pharmacies you pay $10 for up to a 30 day supply, $20 for a 31 to 60 day supply, or $30 for a 61 to 100 day supply For brand drugs at plan pharmacies you pay $20 for up to a 30 day supply, $40 for a 31 to 60 day supply or $60 for a 61 to 100 day supply At Plan pharmacies you pay $10 for a generic drug on the Health Net recommended drug list (RDL). For a RDL brand name drug you pay $30. For a drug not listed on the RDL you pay 50% of the drug cost At Plan pharmacies you pay $7 for a preferred generic drug. For a preferred brand name drug with NO generic equivalent you pay $30 Non preferred generic or nonpreferred brand $50 per prescription Contract Prescription Card Mail Order (90 Day Supply) Fee-For-Service Prescription Drug Plan (Drug store of your choice) At contracting pharmacies your copay is $25 for a generic drug. For a preferred brand name drug with NO generic equivalent your co-pay is $ For a non-preferred brand name drug with NO generic equivalent your co-pay is $100. For a brand name drug WITH a generic equivalent you pay the applicable copay $62.50 or $100 plus 50% of the difference in price between the brand drug and the generic drug Plan pays 80% of reasonable after satisfaction of deductible. You may obtain a max of 60 days of any one drug, after that you must use the contracting pharmacies for additional refills. Continued purchases at NON contract pharmacies will be denied At contracting pharmacies your co-pay is $25 for a generic drug. For a preferred brand name drug with NO generic equivalent your co-pay is $ For a non-preferred brand name drug with NO generic equivalent your co-pay is $100. For a brand name drug WITH a generic equivalent you pay the applicable copay $62.50 or $100 plus 50% of the difference in price between the brand drug and the generic drug Plan pays 80% of reasonable after satisfaction of deductible. You may obtain a max of 60 days of any one drug, after that you must use the contracting pharmacies for additional refills. Continued purchases at NON contract pharmacies will be denied For generic drugs through mail order you pay $10 for up to a 30 day supply or $20 for a 31 to 100 day supply You pay twice the applicable co-pay as outlined above Not applicable Not applicable Not applicable You pay twice the applicable co-pay as outlined above

6 United Concordia Advantage Plan - DPPO United Concordia Concordia Plus - DHMO Delta Dental PMI DHMO DENTAL/ORTHODONTIA CARE: Deductible Dental Coverage $25 per person, per, $75 per family per (Combined dental/orthodontia deductible) Plan pays 100% of the non contract fee schedule. (approx. 60% of cost) Any balance remaining is patient co-pay Benefit maximum of $6,000 in any two (2) year period, per person $25 per person, per, $75 per family per (Combined dental/orthodontia deductible) Plan pays 100% Benefit maximum of $6,000 in any two (2) year period, per person Dental Services: $25 per person, per, $75 per family per Orthodontic Services: $100 per person, per, $300 per family per Plan pays 100% In- Network Plan pays 50% Out-of- Network Calendar Year Benefit : $3,000 In-Network/Per Person $1,000 Out-of- Network/Per Person No deductible Plan pays 100% on most covered services coverage and copay s No deductible coverage and copay s Orthodontia Coverage Plan pays 50% of up to a lifetime maximum benefit of $2,000 Dependent Children only Plan pays 50% up to $995. Co-pay is also 50% up to $995 Lifetime maximum benefit of $2,000 Dependent Children only Plan pays 50% In and Out-of-Network Lifetime maximum benefit of $2,000 in and Out-of-Network Dependent Children only coverage and copay s Dependent Children and Adults coverage and copay s Dependent Children and Adults

7 VISION CARE: Eye Examination $15 deductible See Fee-For-Service Plan benefits $25 co-pay per visit $25 co-pay per visit Not Covered See Fee for Service Plan benefits Exam covered once every 12 months Eye Lenses / Frames Lenses covered once every Lenses covered once every Lenses covered once every Lenses covered once every Lenses covered once every Frames covered once every Frames covered once every Frames covered once every Frames covered once every Frames covered once every lenses every for a $65 co-pay lenses every for a $65 co-pay lenses every for a $65 co-pay lenses every for a $65 co-pay lenses every for a $65 co-pay SPECIAL NOTES: Limitations and Exclusions. Please refer to your Plan Booklet for

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