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1 Plumbers Local Union No 1 Medicare-Eligible Retirees Coverage Period: 01/01/ /31/2015 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual + Dependents Plan Type: Medicare Supplemental This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the Summary Plan Description at or by calling Important Questions Answers Why this Matters: What is the overall deductible? Are there other deductibles for specific? Is there an out of pocket limit on my expenses? What is not included in the out of pocket limit? Is there an overall annual limit on what the plan pays? Does this plan use a network of providers? Do I need a referral to see a specialist? Are there this plan doesn t cover? None. This Plan does not have a deductible but Medicare does apply an annual deductible. No. No. This Plan has no out-of-pocket limit. No. Yes. For information on Medicare Doctors, providers and hospitals, visit For a list of participating pharmacies, dentists or optical providers, visit No. Yes. For out-of-network, you must pay all the costs up to the deductible amount before this plan begins to pay for covered out-of-network you use. Check your plan document to see when the deductible starts over (usually, but not always, January 1st). See the chart on page 2 for how much you pay for covered after you meet the deductible. You don t have to meet deductibles for specific, but see the chart starting on page 2 for other costs for this plan covers. The out-of-pocket limit is the most you could pay during a coverage period (usually one year) for your share of the cost of covered. However, this limit is not applicable here. Not applicable because this Plan does not have an out-of-pocket limit. The chart starting on page 2 describes any limits on what the plan will pay for specific covered, such as office visits. If you use an in-network doctor or other health care provider, this plan will pay some or all of the costs of covered. Be aware, your in-network doctor or hospital may use an out-of-network provider for some. Plans use the term in-network, preferred, or participating for providers in their network. See the chart starting on page 2 for how this plan pays different kinds of providers. You can see the specialist you choose without permission from this plan. Some of the this plan doesn t cover are listed on page 5. See your plan document for additional information about excluded. Questions: Call or visit us at If you aren t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary at or call to request a copy. 1 of 8

2 Common Medical Event If you visit a health care provider s office If you have a test If you have outpatient surgery Copayments are fixed dollar amounts (for example, $10) you pay for covered health care, usually when you receive the service. Coinsurance is your share of the costs of a covered service, calculated as a percent of the allowed amount for the service. For example, if the plan s allowed amount for an overnight hospital stay is $1,000, your coinsurance payment of 20% would be $200. This may change if you haven t met your deductible. The amount the plan pays for covered is based on the allowed amount. If an out-of-network provider charges more than the allowed amount, you may have to pay the difference. For example, if an out-of-network hospital charges $1,500 for an overnight stay and the allowed amount is $1,000, you may have to pay the $500 difference. (This is called balance billing.) This plan may encourage you to use in-network providers by charging you lower deductibles, copayments and coinsurance amounts. Services You May Need Primary care visit to treat an injury or illness Specialist visit Other practitioner office visit Preventive care/ screening/ immunization Diagnostic test (xray, blood work) Imaging (CT/PET scans, MRIs) Facility fee (e.g., ambulatory surgery center) Physician/surgeon fees Your Cost If You Use a Medicare Provider Your Cost If You Use a Non- Medicare Provider Limitations & Exceptions charges associated with out of Medicare. 2 of 8

3 Common Medical Event If you need immediate medical attention If you have a hospital stay If you have mental health, behavioral health, or substance abuse needs If you are pregnant Services You May Need Emergency room Emergency medical transportation Urgent care Facility fee (e.g., hospital room) Physician/surgeon fee Mental/Behavioral health outpatient Mental/Behavioral health inpatient Substance use disorder outpatient Substance use disorder inpatient Prenatal and postnatal care Delivery and all inpatient Your Cost If You Use a Medicare Provider Your Cost If You Use a Non- Medicare Provider Limitations & Exceptions charges associated with out of Medicare. Facility fee not covered after you reach Medicare day/lifetime limits. charges associated with out of Medicare. Inpatient not covered after you reach Medicare day/lifetime limits. charges associated with out of Medicare. 3 of 8

4 Common Medical Event If you need drugs to treat your illness or condition More information about prescription drug coverage is available at: Services You May Need Generic drugs Single source drugs (Brand name drug without a generic equivalent) Multi source drugs (Brand name drug with a generic equivalent) Your Cost If You Use a Medicare Provider Retail: $10 copay/script CVS and Other Network Retail Pharmacy 1 st 3 fills: $10 copay/script 4 th fill and after: $25 copay/script CVS day supply 1 st fill and after: $25 copay/script Non-CVS Pharmacy day supply: Not Covered Mail order (30-day supply): $10 copay/script 60-day supply: $30 copay/script 90-day supply: $50 script Retail: $30 copay/script CVS and Other Network Retail Pharmacy 1 st 3 fills: $35 copay/script 4 th fill and after: $55 copay/script CVS day supply 1 st fill and after: $75 copay/script Non-CVS Pharmacy day supply: Not Covered Mail order (30-day supply): $16.50 copay/script 60-day supply: $50 copay/script 90-day supply: $87.50 script Retail: $30 copay/script CVS and Other Network Retail Pharmacy 1 st 3 fills: $35 copay/script 4 th fill and after: $55 copay/script CVS day supply 1 st fill and after: $75 copay/script Non-CVS Pharmacy day supply: Not Covered Mail order (30-day supply): $16.50 copay/script 60-day supply: $50 copay/script 90-day supply: $87.50 script Your Cost If You Use a Non- Medicare Provider Retail: $10 copay/script plus the difference between In and Outof-Network costs Retail: $30 copay/script plus the difference between In and Outof-Network costs Retail: $30 copay/script plus the difference between In and Outof-Network costs Limitations & Exceptions You have Creditable Coverage under the Plan and you do not have to enroll in Medicare Part D. If you are enrolled in Medicare Part D, you will not have prescription drug coverage under the Plan. CVS Retail up to-30 day supply. Mail order up to 90-day supply. Maintenance drugs at CVS Retail up to day supply. for certain generic preventive prescriptions required under ACA. If a drug is available over-the-counter and covered under this provision, a prescription must be presented at the time of purchase in order for the drug to be covered under the Plan. Specialty drugs are available from Caremark s SpecialtyRx Pharmacy. You can receive up to a 30-day supply of specialty medications at a time. These drugs require preapproval from Caremark. There are no out-of-network providers for mail order or specialty drugs. 4 of 8

5 Common Medical Event If you need help recovering or have other special health needs If your child needs dental or eye care Services You May Need Home health care Rehabilitation Skilled nursing care Durable medical equipment Hospice service Your Cost If You Use a Medicare Provider Your Cost If You Use a Non- Medicare Provider Limitations & Exceptions charges associated with out of Medicare. Home health care and skilled nursing care not covered after you reach Medicare day limits. Eye exam up to Plan allowance up to Plan allowance Offered through PPO, payable to Glasses up to Plan allowance up to Plan allowance $100 once every 24 months. Dental check-up Not covered Not Covered You must pay 100% of these expenses, even In-Network. Excluded Services & Other Covered Services: Services Your Plan Does NOT Cover (This isn t a complete list. Check your plan document for other excluded.) Acupuncture Cosmetic surgery Dental care Infertility treatment Long-term care Non-emergency care when traveling outside the U.S. Private-duty nursing Routine foot care Weight loss programs Other Covered Services (This isn t a complete list. Check your plan document for other covered and your costs for these.) Bariatric surgery (Plan pays secondary to Medicare only to the extent that Medicare covers such service and only up to the Medicare allowance). Chiropractic care (Plan pays secondary to Medicare only to the extent that Medicare covers such service and only up to the Medicare allowance). Hearing aids (Limit - $500 every 3 years) Routine eye care (Exam only) 5 of 8

6 Your Rights to Continue Coverage: If you lose coverage under the plan, then, depending upon the circumstances, Federal and State laws may provide protections that allow you to keep health coverage. Any such rights may be limited in duration and will require you to pay a premium, which may be significantly higher than the premium you pay while covered under the plan. Other limitations on your rights to continue coverage may also apply. For more information on your rights to continue coverage, contact: Plumbers Local Union No. 1 Welfare Fund, George Meany Boulevard, 2nd Floor, Howard Beach, NY the Fund Office Phone: You may also contact the U.S. Department of Labor, Employee Benefits Security Administration at or or the U.S. Department of Health and Human Services at x61565 or Your Grievance and Appeals Rights: If you have a complaint or are dissatisfied with a denial of coverage for claims under your plan, you may be able to appeal or file a grievance. For questions about your rights, this notice, or assistance, you can contact the Plumbers Local 1 Welfare Fund Office at You may also contact Medicare at medicare.gov for information about your Medicare benefits. You may also contract the Department of Labor's Employees Benefits Security Administration at EBSA (3272) or Does this Coverage Provide Minimum Essential Coverage? The Affordable Care Act requires most people to have health care coverage that qualifies as minimum essential coverage. This plan does provide minimum essential coverage. Does this Coverage Meet the Minimum Value Standard? The Affordable Care Act establishes a minimum value standard of benefits of a health plan. The minimum value standard is 60% (actuarial value). However, this standard is not applicable for this benefit. Language Access Services: To see examples of how this plan might cover costs for a sample medical situation, see the next page. 6 of 8

7 About these Coverage Examples: These examples show how this plan might cover medical care in given situations. Use these examples to see, in general, how much financial protection a sample patient might get if they are covered under different plans. This is not a cost estimator. Don t use these examples to estimate your actual costs under this plan. The actual care you receive will be different from these examples, and the cost of that care will also be different. See the next page for important information about these examples. Having a baby (normal delivery) Amount owed to providers: $7,540 Plan and Medicare pays $7,370* Patient pays $170 Sample care costs: Hospital charges (mother) $2,700 Routine obstetric care $2,100 Hospital charges (baby) $900 Anesthesia $900 Laboratory tests $500 Prescriptions $200 Radiology $200 Vaccines, other preventive $40 Total $7,540 Patient pays: Deductibles $0 Copays $20 Coinsurance $0 Limits or exclusions $150 Total $170 Managing type 2 diabetes (routine maintenance of a well-controlled condition) Amount owed to providers: $5,400 Plan and Medicare pays $4,890* Patient pays $510 Sample care costs: Prescriptions $2,900 Medical Equipment and Supplies $1,300 Office Visits and Procedures $700 Education $300 Laboratory tests $100 Vaccines, other preventive $100 Total $5,400 Patient pays: Deductibles $0 Copays $430 Coinsurance $0 Limits or exclusions $80 Total $510 *The coverage examples on this page take into account the amount that the Plan and Medicare pays. Medicare will pay benefits first and the Plan will pay the net of what Medicare pays. *The coverage examples on this page take into account the amount that the Plan and Medicare pays. Medicare will pay benefits first and the Plan will pay the net of what Medicare pays. 7 of 8

8 Questions and answers about the Coverage Examples: What are some of the assumptions behind the Coverage Examples? Costs don t include premiums. Sample care costs are based on national averages supplied by the U.S. Department of Health and Human Services, and aren t specific to a particular geographic area or health plan. The patient s condition was not an excluded or preexisting condition. All and treatments started and ended in the same coverage period. There are no other medical expenses for any member covered under this plan. Out-of-pocket expenses are based only on treating the condition in the example. The patient received all care from innetwork providers. If the patient had received care from out-of-network providers, costs would have been higher. What does a Coverage Example show? For each treatment situation, the Coverage Example helps you see how deductibles, copayments, and coinsurance can add up. It also helps you see what expenses might be left up to you to pay because the service or treatment isn t covered or payment is limited. Does the Coverage Example predict my own care needs? No. Treatments shown are just examples. The care you would receive for this condition could be different based on your doctor s advice, your age, how serious your condition is, and many other factors. Does the Coverage Example predict my future expenses? No. Coverage Examples are not cost estimators. You can t use the examples to estimate costs for an actual condition. They are for comparative purposes only. Your own costs will be different depending on the care you receive, the prices your providers charge, and the reimbursement your health plan allows. Can I use Coverage Examples to compare plans? Yes. When you look at the Summary of Benefits and Coverage for other plans, you ll find the same Coverage Examples. When you compare plans, check the Patient Pays box in each example. The smaller that number, the more coverage the plan provides. Are there other costs I should consider when comparing plans? Yes. An important cost is the premium you pay. Generally, the lower your premium, the more you ll pay in out-ofpocket costs, such as copayments, deductibles, and coinsurance. You should also consider contributions to accounts such as health savings accounts (HSAs), flexible spending arrangements (FSAs) or health reimbursement accounts (HRAs) that help you pay out-of-pocket expenses. Questions: Call or visit us at If you aren t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary at or call to request a copy. 8 of 8

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