WISCONSIN PIPE TRADES HEALTH FUND BENEFIT HIGHLIGHTS SUMMARY

Transcription

1 WISCONSIN PIPE TRADES HEALTH FUND BENEFIT HIGHLIGHTS SUMMARY Prepared by: Lee Jost and Associates April, 2007

2 WISCONSIN PIPE TRADES HEALTH FUND Eligibility Requirements 1 Employee Class Initial Eligibility Continued Eligibility Class A (active employees) & Class JD (full-time preapprentices, first and second year apprentices, maintenance tradesmen, and warehousemen) First day of the Coverage Month following the corresponding Work Month during which contributions are credited on the employee's behalf for 140 hours of work for a contributing employer for coverage under Plan A and 120 hours for Plan B. Eligibility is maintained by being credited with employer contributions for at least 140 hours per month to continue coverage under Plan A and 120 hours per month to continue coverage under Plan B. 2 The corresponding Work Months and Coverage Months are as follows: Hours Worked During the Month of January February March April May June July August September Provide Coverage for the Month of April May June July August September October November December 1 If employer contributions have not been made on your behalf and you believe you have worked enough hours to become initially eligible, please contact the Fund Office for verification. 2 If you become sick, disabled, retire or die, self-payments may be made to maintain eligibility. If you worked for another fund that has a reciprocity agreement with this Fund, it may reduce or cancel a selfpayment you otherwise would be required to make. i

3 WISCONSIN PIPE TRADES HEALTH FUND Benefit Highlights 3 Benefit Description Class A Class JD Death Benefit (Employee only) $5,000 $2,000 Accidental Death and Dismemberment Benefit (Employee only) $5,000 $2,000 Loss-of-Time Weekly Benefit (Employee only)-- Maximum 26 weeks per period of disability $ 300 $ 140 Comprehensive Major Medical Benefits for hospital services, physicians services, certain prescription drugs, x-ray and lab services, and other covered items and services when medically necessary, subject to the following: Classes A and JD Comprehensive Plan (Plan A) Lifetime maximum per person $1,000,000 Basic Plan (Plan B) Calendar year deductible 4,5 Per person $ 500 $3,000 Per family $1,500 $6,000 Out-of-pocket maximum Per calendar year for covered expenses, NOT including deductible amount or specific dollar amount copayments for emergency room visits and Physicians office visits (including outpatient Physician visits at a hospital and home visits by a Physician) Per person $2,500 $4,000 Per family $4,000 $8,000 3 All benefits and eligibility rules outlined in this summary are subject to review and changes by the Board of Trustees. 4 If an employee and/or dependent spouse participate in the Preferred Provider Preventive Care Program, the individual deductible of the person(s) who participates will be reduced by $125 each for the following calendar year. 5 If both a husband and wife are eligible under the Plan as employees, the Comprehensive Major Medical Benefits deductible amount will be waived for the entire family. ii

4 Benefit Description Classes A and JD Comprehensive Plan (Plan A) Basic Plan (Plan B) Plan s copayment of covered inpatient expenses (except treatment of nervous and mental disorders, substance abuse, and alcoholism) In-network and precertified by the utilization review 90% 80% (UR) manager In-network and not precertified by the UR manager 85% 75% Out-of-network and precertified by the UR manager 85% 70% Out-of-network and not precertified by the UR 80% 60% manager Plan s copayment of covered outpatient expenses (except treatment of nervous and mental disorders, substance abuse, and alcoholism) In-network 85% 65% Out-of-network 80% 60% Routine physical exam for employee and spouse only (subject to Comprehensive Major Medical Benefits deductible and copayment) Pre-admission testing, second surgical opinions, routine immunizations, well child care (80% at non- PPO; birth to age two-no maximum/age 2 to 12-$60 per child per calendar year at both PPO and non-ppo), hospice care, home health care (up to 10 visits per period of disability), and skilled nursing home care (up to 30 days of confinement per period of disability) Hospital emergency room Separate dollar copayment per visit after deductible and before applicable copayment percentage (waived if admitted) Physician office visits (including outpatient Physician visits at a hospital and home visits by a Physician) Eligible person s copayment per visit (deductible and other copayments do not apply) $400 maximum per person per calendar year - or - 100% of actual fee through Health Dynamics 6 100% of reasonable expenses; not subject to deductible $100 $25 6 If Health Dynamics exam is obtained, a credit toward next year s deductible is given (see footnote 2 on page 2). iii

5 Benefit Description Classes A and JD Treatment of nervous and mental disorders Hospital confinement: Plan s copayment For eligible persons using the FSP 90% For eligible persons not using the FSP Maximum per eligible person per calendar year For eligible persons using the FSP only, potential additional days per eligible person per calendar year at FSP recommendation 80% of the FSP allowable rate 31 days 15 days Partial hospitalization (including residential treatment and intensive outpatient treatment): For eligible persons using the FSP only, maximum per eligible person per calendar year, payable at 90% 15 days Outpatient treatment: For eligible persons using the FSP (not subject to deductible), Plan s copayment 100% Combined maximum per eligible person per calendar year 20 visits Potential additional benefit per eligible person per calendar year at FSP recommendation 10 visits OR For eligible persons not using the FSP (subject to deductible), Plan s copayment of the FSP-authorized rate 50% 7 Combined maximum per eligible person per calendar year 20 visits 7 50% copayment for outpatient treatment of nervous and mental disorders, substance abuse, or alcoholism when not using the FSP will not apply to the out-of-pocket maximum. iv

6 Benefit Description Treatment of substance abuse and alcoholism Classes A and JD Hospital confinement: Plan s copayment For eligible persons using the FSP 90% For eligible persons not using the FSP Maximum per eligible person per lifetime For eligible persons using the FSP only, potential additional days per eligible person per lifetime at FSP recommendation 80% of the FSP allowable rate 30 days 15 days Partial hospitalization (including residential treatment and intensive outpatient treatment): For eligible persons using the FSP only, maximum per eligible person per lifetime, payable at 90% $5,000 Potential additional benefit per eligible person per lifetime at FSP recommendation, payable at 90% $2,500 Outpatient treatment: Plan s copayment For eligible persons using the FSP (not subject to deductible) 100% For eligible persons not using the FSP 50% 8 to $35 maximum per visit Combined maximum per eligible person per lifetime $3, % copayment for outpatient treatment of nervous and mental disorders, substance abuse, or alcoholism when not using the FSP will not apply to the out-of-pocket maximum. v

7 Benefit Description Classes A and JD Preferred Provider Pharmacy Prescription Drug Benefits Deductible per eligible person per calendar year $100 Eligible person s copayment 9 Retail network pharmacy per prescription for up to a 30-day supply Generic: $10 Brand Name: 20% of the cost of the prescription, with a minimum copayment of $20 and a maximum of $40 Mail-order per prescription for up to a 90-day supply, or maximum 34-day supply of a controlled substance Generic: $10 Brand Name: $25 Delta Dental Plan Dental Benefits PPO Non-PPO Care-Plus Exams and cleanings (maximum 2 per calendar year), basic dental benefits, and full denture replacement benefits (every 5 years) Deductible None None None Plan s copayment 90% 80% 100% (including lab fees) Maximum benefit per calendar year $1,000 $1, Orthodontic Deductible None None $750 Plan s copayment 100% 100% 100% Maximum lifetime benefit $1,500 Unlimited Class A Only Vision Care Benefits, per person Exam (maximum 1 per calendar year) $40 Lenses, including contact lenses, and frames (maximum each 2 calendar years) $300 Safety glasses (maximum 1 set per Class A employee per calendar year) $60 9 Use of generics is a mandatory requirement. 10 This maximum applies to your first year of coverage; your second and subsequent years of coverage are up to $2,000 per calendar year. vi

8 Wisconsin Pipe Trades Health Fund To All Active Employees and Retirees: We are happy to provide you with this new Summary Plan Description (SPD or Summary) incorporating all Plan changes adopted through June 1, In easy-to-understand language, it tells you how to become and remain eligible for benefits, explains the benefits available, and gives you instructions on how to apply for benefits. If there should be any inconsistencies between this simplified Summary and the more technical legal Plan Document and Trust Agreement, the legal documents will govern. The Trustees have the right to change, add, or to delete benefits, self-payment rates, eligibility rules, or any other provisions relating to the operation of the Plan in an effort to best serve all Plan participants. The benefits described in this Summary Plan Description are self-funded with the exceptions of one alternative dental program and organ transplant insurance. Self-funded benefits payable are limited to Fund assets available for such purposes. The Eligibility Rules and benefits are maintained at levels in line with Trust Fund income and assets and they are reviewed regularly to provide the best protection possible within the Fund's financial means. The Eligibility Rules and other Plan provisions have been updated as necessary to comply with legal requirements, such as the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and its Privacy Rules and Security Regulations and Claims Procedure Regulations. This updated SPD incorporates Plan changes, most of which you were informed of previously in Participant Notices, including: newly revised Eligibility Rules; new two-tier benefit options; new aggregate maximum payable for vision benefits; ChoiceCare as the new Preferred Provider Network; APS Healthcare as the new utilization review manager; elimination of the First Commonwealth dental option; revised COBRA provisions; and updated claims filing and review procedures. x

9 We suggest you familiarize yourself with the information in this Summary and keep it handy for reference. If you have any questions at any time regarding the Plan, please contact the Fund Office. Yours sincerely, The Board of Trustees Ken Bastian James Colwell Jim Cox David Karlsen Kevin LaMere Todd Morris E. Larry Vance Ed Tonn, Jr. Joel Zielke The addresses of the Trustees are found on page 74. Fund Office Wisconsin Pipe Trades Health Fund One Park Plaza West Park Place, Suite 950 Milwaukee, WI Telephone: (414) locally, or call toll-free at: Office Hours: Monday-Friday 8:00 a.m. to 4:30 p.m. xi

10 TABLE OF CONTENTS Page SCHEDULE OF BENEFITS... i ELIGIBILITY RULES How an Employee Becomes Eligible for Benefits How Eligibility Is Continued How Eligibility Is Continued With Self-Payments... 2 (a) Self-Payment Option (1) If Employed Less Than the Minimum Hourly Requirements... 2 (2) If Sick or Injured... 3 (3) If Permanently and Totally Disabled... 3 (4) If a Surviving Dependent... 4 (5) If a Participant in the Senior Program (For Retirees)... 4 (b) Self-Payment Option 2 (COBRA) Reinstatement of Eligibility Employer Contributions for Work Performed Outside the Jurisdiction Coverage for Employees and Their Dependents When Employee Enters Military Service Coverage While on Family and Medical Leave Reciprocity of Welfare Contributions With Other Funds Termination of Individual Coverage Certificate of Creditable Coverage Time for Filing Claims Compliance With Claim Rules Change of Eligibility Rules Conformity With Law DEATH BENEFITS ACCIDENTAL DEATH AND DISMEMBERMENT BENEFITS LOSS OF TIME BENEFITS FICA TAX BENEFITS JURY DUTY BENEFITS COMPREHENSIVE MAJOR MEDICAL BENEFITS Deductible Copayment Lifetime Maximum Covered Expenses Hospital Services Physicians' Services Diagnostic X-Ray and Laboratory Services Prescription Drugs and Medicines Routine Physical Examinations Preferred Provider Preventive Care Program Option Routine Colonoscopies Other Covered Charges Organ Transplant Surgery xii

11 TABLE OF CONTENTS (continued) Page Alternative Ways of Obtaining Care Second Surgical Opinions Pre-Admission Testing Well Child Care Routine Immunizations Skilled Nursing Home Care Hospice Care Home Health Care Comprehensive Major Medical Benefits Exceptions and Limitations OTHER PREFERRED PROVIDERS Preferred Provider Hospital and Physician Network Preferred Provider Pharmacy FAMILY SERVICES PROGRAM UTILIZATION REVIEW VISION CARE BENEFITS DENTAL CARE BENEFITS Dental Plan 1 Care Plus Dental Plans, Inc Dental Plan 2 Delta Dental Plan of Wisconsin TRICARE STANDARD-SUPPLEMENT BENEFITS SUPPLEMENTAL DOLLAR BANK REIMBURSEMENT PROGRAM GENERAL PROVISIONS Coordination of Benefits Medicare Provisions Subrogation Right of Recoupment Physical Examinations General Exclusions Termination of Plan Interpretation by Trustees Prohibition Against Assignment to Providers Privacy Policy HIPAA Security Regulations GENERAL DEFINITIONS HOW TO APPLY FOR BENEFITS YOUR RESPONSIBILITIES AS A PARTICIPANT UNDER THE PLAN YOUR RIGHTS UNDER THE FAMILY AND MEDICAL LEAVE ACT OF INFORMATION REQUIRED BY THE EMPLOYEE RETIREMENT INCOME SECURITY ACT OF 1974 (ERISA) Benefit Appeals Procedure Statement of Participants' Rights Under ERISA Other ERISA Information...74 xiii

12 ELIGIBILITY RULES The following Rules set forth the terms and conditions which govern how you as an employee and your dependents become and remain eligible for most benefits. The Trustees, in their discretion, are empowered to change or amend the Eligibility Rules at any time. You will be notified of any change. There are additional terms and conditions governing eligibility for specific benefits and they are described within the applicable benefit section of this booklet. Your (or your dependent's) action or inaction regarding the release or exchange of information between this Plan and any insurance company, other organization or person, when such information is necessary to determine eligibility and pay benefits may cause your eligibility to be suspended and benefits will not be paid when it results in withholding consent for such release or exchange of information. 1. How an Employee Becomes Eligible for Benefits If you work for an employer obligated by a collective bargaining agreement or participation agreement to pay contributions to this Health Fund, you and your dependents will become and remain eligible for benefits, subject to the following Rules, and any amendments to the Rules which the Trustees may adopt from time to time. (a) Initial Eligibility For bargaining unit employees, you and your dependents become initially eligible for benefits under Class A on the first day of the Coverage Month following the corresponding Work Month during which contributions are credited on your behalf for 140 hours of work for a contributing employer for coverage under Plan A and 120 hours for Plan B. The corresponding Work Months and Coverage Months are as follows: Hours Worked During the Month of January February March April May June July August September Provide Coverage for the Month of April May June July August September October November December October November December January February March For example, if you work 140 hours under Plan A or 120 hours under Plan B during January, you will become initially eligible April 1 st. For alumni, you and your dependents become initially eligible for benefits under Class A on the first day of the month following receipt of two months of contributions. You and your dependents become eligible for benefits under Class JD on the first day of the Coverage Month following the Work Month during which the Fund has received contributions on your behalf for 140 hours of work for a contributing employer for coverage under Plan A and 120 hours for Plan B. (b) Excess Contributions Employer contributions for hours worked in excess of the minimum requirement (140 or 120 hours) will be credited to your Supplemental Dollar Bank, minus a designated portion of the hourly contribution rate which is allocated by the Trustees from time to time to go to Fund assets to build Fund reserves. All deposits are tax-exempt. You may accumulate funds year-to-year and use this money according to the provisions stated on page 48. 1

13 (c) Dependent Special Enrollment Period When you acquire a new dependent through marriage, birth, or adoption, you may request a special enrollment period. Upon such a request, the Fund Office will mail you an enrollment card which must be completed with information pertaining to the newly acquired dependent. If the special enrollment period is requested and the new enrollment card is completed and submitted to the Fund Office, the new dependent s coverage will be effective as of the date of the marriage, birth, or adoption. 2. How Eligibility Is Continued (a) Bargaining Unit Employees To remain eligible, you must be credited with employer contributions for at least 140 hours per month to continue coverage under Plan A and 120 hours per month to continue coverage under Plan B. If you voluntarily leave the Fund's jurisdiction and are not immediately available for work in the industry, you will not be allowed to maintain eligibility under the Plan through self-payments. In addition, if you leave the trade, your Supplemental Dollar Bank balance at the time will be frozen for three years. At the end of the three-year period if your account balance is under $2,000 and you have not returned to the trade, the amount in your account will be forfeited. At the end of the three-year period, if your account balance is over $2,000, the balance will remain frozen until you reach age 55 and if you have not returned to the trade, the amount will be forfeited. (b) Alumni To continue your coverage on a monthly basis, your employer must contribute on all hours paid, with a minimum of 40 hours each week on your behalf. 3. How Eligibility Is Continued With Self- Payments If employer contributions have not been received for you for the required number of hours of work to maintain eligibility, you may make selfpayments to maintain your and your dependents' eligibility with either Self-Payment Option 1 or Self-Payment Option 2. (a) Self-Payment Option 1 You may use Self-Payment Option 1 to continue eligibility under the following circumstances. (1) If Employed Less Than the Minimum Hourly Requirements If your work hours are insufficient and your Supplemental Dollar Bank has sufficient funds, any shortfall automatically will be withdrawn from your Supplemental Dollar Bank. If your Supplemental Dollar Bank does not have sufficient funds, you will receive a selfpayment notice for the balance. This amount must be paid within 10 days after receiving the notice from the Fund Office or you will lose eligibility for the applicable Coverage Month. During the time when you are ineligible for coverage, you will not have access to your Supplemental Dollar Bank. Subsequent self-payments are equal to the difference between the applicable minimum hour requirement and the contribution hours with which you were credited for that month (by employer contributions), multiplied by the employer contribution rate specified in the applicable collective bargaining agreement. If you are immediately available for work in the jurisdiction of this Fund, selfpayments may be made for as long as 18 consecutive months while you are unemployed, or while you are employed outside the work jurisdiction of the Union and outside the geographical jurisdiction of the Fund. However, self-payments will 2

14 be accepted only from individuals residing in the jurisdiction of the Fund. The first self-payment is due within 10 days after you receive written notice from the Fund Office. If you remain unemployed in subsequent months, selfpayments must be made monthly, to be received by the 10th of each month. Failure to make self-payments in the amount and by the due date required will cause you to lose eligibility. (2) If Sick or Injured If contributions from employers are not sufficient to continue your eligibility because you are sick or sustained an injury, your eligibility is continued up to 12 months (unless extended further by a Board of Trustee action, for up to a maximum of 24 months) without selfpayments as long as all of the following conditions are satisfied: (i) The sickness or injury prevents your employment. However, the following provisions apply when you receive a physician's release to perform light-duty work: (A) If light-duty work is available and you elect not to perform such work, you will be required to make the necessary self-payments to continue your coverage under the Plan. (B) If you are available for light-duty work, but light-duty work is not available or there is not sufficient light-duty work for sufficient hours to maintain eligibility, your selfpayment will be waived as specified in this subsection (2). (ii) You are continuously under the care of a physician for the sickness or injury. (iii) You are not covered under any other group health care plan or group insurance program as a result of other employment or as a spouse. (iv) The sickness or injury has not caused you permanent and total disability. (v) You do not elect to retire. While you are receiving Worker's Compensation, your eligibility under the Plan may be continued without selfpayments indefinitely. However, extensions of eligibility for more than 24 months will require Trustee approval. You can receive credits toward eligibility of 35 hours weekly if you notify the Fund, in writing, that you are receiving benefits under Worker's Compensation or Occupational Disease Laws, or if you are receiving Loss of Time Benefits from this Fund. These credits no longer will be given when benefits are terminated, or when your account is credited with 420 hours, whichever occurs first. The Trustees may require a statement from your physician as evidence that you are temporarily unable to work due to the sickness or injury. When you are no longer eligible under this provision, eligibility may be continued by making self-payments as provided under paragraphs (1) and (3). (3) If Permanently and Totally Disabled Permanent and total disability is defined as any sickness or injury which permanently prevents you from performing any employment for remuneration or profit. In the event a sickness or injury causes you to become permanently and totally disabled, you no longer will be eligible under paragraph (2), but you may continue your eligibility under Class B according to this paragraph (3) by: (i) notifying the Trustees that you are eligible for permanent and total disability benefits from Social Security or the Building Trades United Pension 3

15 Trust Fund within 15 days of receiving notice from the Social Security Administration or the Pension Fund; (ii) making the first self-payment, if applicable, no later than the first day of the month following receipt of notice that you are eligible for permanent and total disability benefits; and (iii) making subsequent self-payments, if applicable, no later than the 10th calendar day of each month thereafter. Self-payments also may be paid quarterly in advance. Coverage is provided by making the appropriate self-payment to obtain benefits under Class B for Comprehensive Major Medical Benefits. No benefits are provided for Loss of Time. The benefits and amounts of selfpayments may be changed by the Trustees from time to time. Please note that permanently and totally disabled employees participating in Social Security are covered under Medicare when disabled for 24 or more consecutive months. Once eligible for Medicare, coverage is provided under Class C. (4) If a Surviving Dependent In the event of your death while an eligible employee, your surviving dependents' coverage is continued to the last day of the calendar month for which you would have been eligible as a result of employer contributions. Eligibility may be maintained indefinitely after that date, provided self-payments are made on time and in an amount determined by the Trustees. Failure to make self-payments in the amount and by the due date required will cause loss of eligibility. The right to make self-payments under this paragraph (4) ceases in the event: (ii) other group health coverage is effective as a result of employment. This paragraph (4) does not authorize coverage for children who no longer meet the definition of dependent. (5) If a Participant in the Senior Program (For Retirees) Except when otherwise prevented by law, retiree coverage is subject to change or discontinuation based on Trustee review. The Trustees retain the right in their sole discretion to modify or discontinue, in part or in whole, retiree eligibility rules, types and amount of benefits, terms and conditions under which benefits are payable, and self-payment rates. These provisions are subject to modification as may be required by law. If you retire on or after January 1, 2005: Whether you retire at age 55 or 65, the level of retiree subsidy is based on your years of service in the industry as follows: Years of Percent Subsidy Service 30 50% 25 45% 20 40% 15 35% 10 25% Under 10 0% If you retire before age 55, you won t receive a subsidy until the month after your 55 th birthday. If you make nonsubsidized self-payments from retirement to age 55, that period will qualify as years of service in the industry, and will be credited toward your level of subsidy after age 55. If you were eligible in another health fund prior to such fund merging into this Fund, you will be given credit for those prior years of service when determining your subsidy level. (i) your surviving spouse remarries; or 4

16 AT AGE 55 As a retiree, you may continue coverage for yourself and your dependents. All dependents eligible at the time of your retirement may be covered at the appropriate subsidized self-payment amount. All dependents acquired after the date of your retirement may be covered at the appropriate nonsubsidized self-payment amount. As a retiree, you may continue your coverage under Class B with subsidized self-payments under the following conditions. You must: (i) be at least 55 years of age and less than 65 years of age; (ii) be retired from any active employment; (iii) have been eligible and had contributions or self-payments made in your behalf during each of the 10 consecutive years immediately preceding retirement and be eligible under this Fund at the time of your retirement; or (iv) have been eligible and had contributions or self-payments made in your behalf during each of the 10 consecutive years immediately preceding normal retirement age (as defined by the Building Trades United Pension Trust Fund), have had coverage elsewhere after reaching normal retirement age, and then applied for coverage under the Senior Program within 10 years of the date of reaching normal retirement age; (v) notify the Fund Office of your retirement plans, in writing, at least 30 days in advance of your retirement date; and (vi) make your monthly self-payment in an amount and by the due date required by the Trustees. unless you are eligible according to the prior paragraph (iv). You may make the appropriate selfpayments to provide coverage under Class B for Comprehensive Major Medical Benefits (Plan A), Vision Care, Dental Care, and a Death Benefit of $5,000. No benefits are provided for Loss of Time. AT AGE 65 As a retiree, you may continue coverage for yourself and your dependents. All dependents eligible at the time of your retirement may be covered at the appropriate subsidized self-payment amount. All dependents acquired after the date of your retirement may be covered at the appropriate nonsubsidized self-payment amount. As a retiree, you may continue your coverage under Class C with subsidized selfpayments under the following conditions. You must: (i) be at least 65 years of age; (ii) be retired from any active employment; (iii) have been eligible and had contributions or self-payments made in your behalf during each of the 10 consecutive years immediately preceding retirement; (iv) be eligible under this Fund at the time of your retirement; (v) notify the Fund Office of your retirement plans, in writing, at least 30 days in advance of your retirement date; and (vi) make your monthly self-payment in an amount and by the due date required by the Trustees, if applicable. Your eligibility as an active employee and then as a retiree must be continuous, 5

17 For retirees age 65 and over, coverage is provided by making the appropriate self-payments to obtain benefits under Class C for Comprehensive Major Medical Benefits (Plan A), Vision Care, Dental Care, and a Death Benefit of $5,000. No benefits are provided for Loss of Time. ELIGIBILITY FOR SENIOR PROGRAM NONSUBSIDIZED SELF-PAYMENTS Retirees who satisfy all other requirements for participation as a retiree but who do not maintain Union membership will be eligible to make nonsubsidized self-payments under the Senior Program at a rate to be determined by the Trustees from time to time. NONSUBSIDIZED RETIREE PARTICIPATION REQUIREMENTS A retiree who does not satisfy the normal retiree participation requirements will be eligible to make nonsubsidized selfpayments to continue coverage for himself and his dependents under the Senior Program, provided the following conditions are satisfied. You must: (i) be at least 55 years of age; (ii) be retired from active employment in the trade; (iii) have been eligible and had contributions or self-payments made in your behalf during each of the three consecutive years immediately preceding retirement; (iv) be eligible under this Fund at the time of retirement; (v) notify the Fund Office of your retirement plans, in writing, at least 30 days in advance of your retirement date; and (vi) make the monthly nonsubsidized selfpayment in an amount and by the due date required by the Trustees. Once you have a combination of 10 years of employer contributions and nonsubsidized self-payments, you will be eligible to make subsidized self-payments. SPECIAL PROVISIONS FOR ELIGIBLE EMPLOYEES WORKING FOR EMPLOYERS UNDER CONTRACT WITH THE UNION The Plan will waive the 10-year eligibility requirement, provided the following conditions are satisfied. You must: (i) be at least 55 years of age and less than 65 years of age; (ii) be retired from any active employment; (iii) have worked for one of the Local Unions as defined in the Trust Agreement and lost retiree coverage through such employer; (iv) make a formal written request to participate in this Fund's Senior Program at least 30 days before your requested effective date of coverage and have such request reviewed and approved by the Trustees; and (v) make the monthly, nonsubsidized selfpayment in an amount and by the due date required by the Trustees. Failure to make a required payment when due cancels your coverage and you may not become reinstated in the Senior Program. AUTOMATIC WITHDRAWAL OF MONTHLY RETIREE SELF-PAYMENTS Effective July 1, 2005, your monthly selfpayments may be deducted automatically from your personal checking or savings account on the 10 th of each month for that month of coverage. For example, your July self-payment will be deducted on July 10 th. If the 10 th falls on a weekend or holiday, your self-payment will be deducted on the next business day. 6

18 This is a voluntary arrangement which you can start or stop at any time by written authorization to the Fund Office. Your request must be received by the 15 th of any month to be effective for the payment due on the 10 th of the following month. There is no fee for this service. OPT-OUT PROVISION Once you have satisfied the requirements for participation in the Senior Program, you may elect not to participate as a retiree in the Wisconsin Pipe Trades Health Fund, provided: (i) You attest that you, or you and your spouse, have primary coverage elsewhere and you show proof of creditable coverage upon reinstatement. (ii) You, or both you and your spouse, sign an Election Form. (iii) In signing the Election Form, you, or both you and your spouse, understand you will be given a onetime option to be reinstated into the Plan at any time prior to your death. After your death, your spouse only (no other dependents) may be reinstated upon showing proof of creditable coverage. (iv) You, or you and your spouse, will be reinstated into the Plan on the first day of the month following receipt of the appropriate monthly self-payment and you show proof of creditable coverage upon reinstatement. (v) You maintain Union membership. (vi) Reinstatement will follow the Health Insurance Portability and Accountability Act (HIPAA) rules governing pre-existing condition limitations. If you wish to take advantage of this option to opt out of the Senior Program, please request an Election Form from the Fund Office. TERMINATION OF YOUR ELIGIBILITY UNDER THE SENIOR PROGRAM Your coverage under the Senior Program remains in force as long as you continue to make the necessary self-payments by the 10th day of each month. Failure to make a required selfpayment cancels your coverage and you may not become reinstated in the Senior Program. IF YOU RETURN TO WORK FOR AN EMPLOYER AFTER BECOMING ELIGIBLE UNDER A SENIOR PROGRAM You may not become eligible again for active employee benefits once you retire. Employer contributions received by the Fund on your behalf will NOT serve to reduce the amount of the selfpayment otherwise payable by you. FOR YOUR SURVIVING SPOUSE If you die while you are participating in the Senior Program, your spouse may continue dependents' coverage until: (i) the end of the period for which the last self-payment was made; (ii) coverage is provided to your spouse under another group health care plan as an employee or dependent; (iii) the date your surviving spouse remarries; or (iv) the date your surviving spouse establishes residence outside the United States. If your surviving spouse fails to make a required self-payment, the coverage terminates on the last day of the sixth calendar month following the month for which the self-payment was made. Coverage may not be reinstated in the Senior Program. Monthly contributions under this Self- Payment Option 1 will not be accepted 7

19 on behalf of surviving dependent children when both parents are deceased. (b) Self-Payment Option 2 (COBRA) The intent of these Rules is to comply with the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA) as amended in all respects, including those changes required by subsequent legislation including, but not limited to, the Omnibus Budget Reconciliation Acts of 1989, 1990, and 1993, and the Health Insurance Portability and Accountability Act of Any future IRS guidance will be incorporated even if it conflicts with existing Plan provisions. Employees and dependents who do not qualify for, or do not use, Self-Payment Option 1 may, while they are Qualified Beneficiaries, continue eligibility under Self- Payment Option 2 for: health care benefits only; or health care, vision care, and dental care benefits, subject to the following conditions. (1) Qualifying Events Certain events which cause you or your dependent to lose eligibility under the Plan are Qualifying Events. Such Qualifying Events occur for you as an employee eligible because of employer contributions upon: (i) a reduction in hours of covered employment for any reason, including disability, sickness, or retirement; or (ii) voluntary or involuntary termination of covered employment for any reason, including disability, sickness, or retirement, unless for gross misconduct on your part. Such Qualifying Events occur for spouses and dependent children upon any of the following events occurring while you are an employee eligible because of employer contributions: (i) termination or reduction of your employment for any reason including disability, sickness, or retirement, unless for gross misconduct on your part; (ii) your death; (iii) divorce or legal separation from you; (iv) your entitlement to Medicare (under Part A, Part B, or both); or (v) a dependent ceasing to meet the definition of dependent under the Plan. You or your dependent becomes a Qualified Beneficiary for a specific period of time when a Qualifying Event occurs. A dependent child who is born to or placed for adoption with an employee during the employee's period of COBRA continuation coverage will be treated as a Qualified Beneficiary. As a Qualified Beneficiary, eligibility may be continued for certain benefits through self-payments under the following provisions. (2) Notifications and Due Dates (i) Qualified Beneficiary s Responsibility to Notify the Trustees When the Qualifying Event relates to your death, divorce or legal separation, or a dependent ceasing to meet the definition of dependent under the Plan, the Qualified Beneficiary must notify the Fund Office directly within 60 days of the Qualifying Event so the Fund Office may provide proper notices and explanations to Qualified Beneficiaries about continued eligibility. This notice can be provided to the Fund Office by telephone, facsimile, or in writing by mail. The Fund Office will advise the Qualified Beneficiary if additional supporting documentation is required. If the 8

20 Fund Office is not notified in writing within 60 days of the Qualifying Event, the person is no longer a Qualified Beneficiary and loses the opportunity to continue coverage. (ii) The Trustees Responsibility to Notify a Qualified Beneficiary When the Qualifying Event is Loss of Coverage Due to the Employee s Death, Divorce, Legal Separation, or to a Dependent Child Ceasing to Meet the Plan s Definition of Dependent The Fund Office, not later than 30 days after receipt of notice, will advise the Qualified Beneficiary of the coverages, options, costs, self-payment due dates, and duration of the self-payment privileges. (iii) The Trustees Responsibility to Notify a Qualified Beneficiary When Other Qualifying Events Occur Based on monthly employer reports, Trustees are aware of some Qualifying Events, such as loss of eligibility for coverage based on contributions received from contributing employers because of a reduction in your hours and your ceasing active work. The Fund Office, not later than 30 days after receipt of notice of an employee's loss of coverage from the employer or by examining monthly contribution reports, will advise the Qualified Beneficiary of the coverages, options, costs, self-payment due dates, and duration of the selfpayment privileges. (iv) Due Date for Qualified Beneficiary s Response A Qualified Beneficiary has 60 days from the date of coverage termination or receipt of the COBRA Notice, whichever is later, to elect whether to continue coverage. The election should be communicated to the Fund Office in writing on an Election Form. Each employee, spouse, and dependent child has the right to make an individual election. However, covered employees may elect to continue coverage on behalf of their spouses, and parents may elect to continue coverage on behalf of their children. Failure to state the election to the Fund Office within 60 days terminates rights to continued coverage under this provision. (v) Due Date for Initial Self-Payment The required initial self-payment must be made to the Fund Office not later than 45 days following the election to continue coverage (which is the post-mark date, if mailed). Failure to do so will cause eligibility and coverage to terminate retroactively to the date of the Qualifying Event and will cause loss of all continuation coverage rights under the Plan. The amount of the first selfpayment is for the time period beginning with the date of the Qualifying Event and extending through the month in which payment is made. (vi) Due Date for Subsequent Self- Payments Subsequent monthly selfpayments must be made to the Fund Office by the first day of the month for that month of coverage. The Plan allows a 30-day grace period for making self-payments. Continuation coverage will be provided for each coverage period as long as payment for that coverage period is made before the end of the grace period for that payment. However, if a periodic payment is made later than the 9

21 first day of the coverage period to which it applies, but before the end of the grace period for the coverage period, coverage under the Plan will be suspended as of the first day of the coverage period and then retroactively reinstated (going back to the first day of the coverage period) when the periodic payment is received. Any claim submitted for benefits while coverage is suspended may be denied and may have to be resubmitted once coverage is reinstated. Failure to make subsequent selfpayments before the end of the grace period will cause coverage and eligibility to terminate at the end of the month for which a timely self-payment was last made and will cause loss of all rights to continuation coverage under the Plan. (3) Coverages and Options If a Qualified Beneficiary elects to continue coverage, the following benefits are available: (i) health care benefits only; or (ii) health care benefits plus vision care and dental care benefits. The coverage selected may not be changed, except to add coverage for a new spouse or to add a new dependent child as a Qualified Beneficiary upon the child's birth or placement for adoption with the employee during the employee's period of COBRA continuation coverage. The Plan is required to offer continued coverage which, as of the day before coverage terminated, is identical to similarly situated employees or family members who have not experienced a Qualifying Event. If coverage under the Plan is modified for similarly situated employees, the Qualified Beneficiary's coverage also will be modified. A Qualified Beneficiary does not have to show insurability to choose continuation coverage. (4) Cost of Continuation Coverage The self-payment amount depends on whether you choose to continue health care benefits only or health care plus vision care and dental care benefits. The costs are determined annually by the Trustees. There is a separate cost for continued coverage from the 19th through the 29th month for those individuals eligible for such disability extension. The Fund Office initially will notify the Qualified Beneficiary of the self-payment amount and due dates. (5) Duration of Continuation Coverage (Maximum Continuation Coverage Period) When eligibility is lost due to termination of employment or reduction in hours, a Qualified Beneficiary may continue eligibility for up to 18 consecutive months from the date employment terminated or hours were reduced, less the number of months eligibility was continued without employer contributions or selfpayments. This 18-month period may be extended to 36 months for the spouse and dependent children if a second Qualifying Event [e.g. employee s death, divorce or legal separation from the employee, employee s coverage by Medicare (under Part A, Part B, or both), or a dependent child ceasing to meet the definition of dependent under the Plan] occurs during the 18-month period. These Events can be a second Qualifying Event only if they would have caused the Qualified Beneficiary to lose coverage under the Plan if the first Qualifying Event 10

22 had not occurred. A Qualified Beneficiary must notify the Fund Office within 60 days after a second Qualifying Event occurs if he wants to extend his continuation coverage and must provide any supporting documentation the Fund may request. This provision does not apply in the case of a reduction in work hours followed by a termination of employment. This 18-month period may be extended up to a total of 29 months for all Qualified Beneficiaries during the disability of the employee, spouse, or dependent child, provided: (i) the Social Security Administration (SSA) determines that any of the Qualified Beneficiaries are disabled under the Social Security Act either: at the time employment terminated or hours were reduced; or at any time within 60 days of such Qualifying Event, and the disability lasts at least until the end of the 18-month period of continuation coverage; and (ii) the Qualified Beneficiary notifies the Fund Office in writing within 60 days of the SSA determination and before the end of the first 18 months of continuation coverage and provides a copy of the SSA determination to the Fund Office. Each Qualified Beneficiary who has elected continuation coverage will be entitled to the 11-month disability extension if one of them qualifies. If the Qualified Beneficiary is determined by SSA to no longer be disabled, the Qualified Beneficiary must notify the Fund Office within 30 days after the SSA determination. Failure to provide notice of a disability or second Qualifying Event may affect the right to extend the period of continuation coverage. When eligibility is lost due to the employee s death, divorce or legal separation from the employee, employee s coverage by Medicare (under Part A, Part B, or both), or a dependent child ceasing to meet the definition of dependent under the Plan, the spouse and eligible dependents may continue coverage for up to 36 months from the date of the Qualifying Event less the number of months eligibility was continued without employer contributions or selfpayments. When the Qualifying Event is the end of employment or reduction of the employee s hours of employment, and the employee became entitled to Medicare benefits less than 18 months before the Qualifying Event, COBRA continuation coverage for Qualified Beneficiaries other than the employee lasts until 36 months after the date of Medicare entitlement. (6) Multiple Qualifying Events Your spouse or dependent child, as a Qualified Beneficiary, may experience more than one Qualifying Event. However, the combined continuation coverage period for all such events may not exceed 36 consecutive months from the date of the original Qualifying Event. The second or later events, provided they occur within the continuation period provided as a result of the original Qualifying Event, entitle a Qualified Beneficiary to continue coverage for an additional period, but not longer than 36 months from the date of the original Qualifying Event. For example, where a widow, as a Qualified Beneficiary, continued coverage for herself and children for 20 months and a child loses dependent status, that child may continue coverage for the remainder of the time the mother is entitled to continue coverage by making his own separate self-payments. This Rule does not apply in the case of a reduction in work hours followed by a termination of employment. 11

23 (7) Termination of Self-Payment Provisions for Qualified Beneficiaries Self-payments no longer are accepted and continued eligibility under this provision terminates on behalf of all Qualified Beneficiaries (unless specifically stated otherwise) when: (i) the Plan no longer provides group health care coverage to any eligible employee; (ii) the required notice of a Qualifying Event is not provided by the Qualified Beneficiary within 60 days of its occurrence; (iii) the election for continuation is not made within 60 days following the date of coverage termination or receipt of the COBRA Notice, whichever is later; (iv) the initial self-payment is not paid by the due date explained in subparagraph (v) of paragraph (2); (v) the subsequent self-payments are not paid as explained in subparagraph (vi) of paragraph (2); (vi) a Qualified Beneficiary becomes covered, after electing continuation coverage, under another group health care plan that does not impose any pre-existing condition exclusion for pre-existing conditions of the Qualified Beneficiary; (vii) the maximum continuation coverage period is reached; (viii) for a Qualified Beneficiary who was entitled to the additional 11 months continuation coverage based on a disability extension -- eligibility for continuing the disability extension will terminate when there has been a final determination that the disability no longer exists; or (ix) the Qualified Beneficiary becomes entitled to Medicare (under Part A, Part B, or both) after such person's COBRA election date (although other family members not entitled to Medicare will continue to be eligible for COBRA continuation). However, if a Qualified Beneficiary becomes entitled to Medicare due to End Stage Renal Disease (ESRD), his coverage under Self-Payment Option 2 will not terminate automatically because of eligibility for Medicare. In the case of ESRD, the Fund is the primary source of coverage for up to 30 months from the date of ESRDbased Medicare entitlement, provided the person is an active eligible employee or dependent or is covered under the Fund with COBRA continuation coverage. In the event the Fund's liability as the primary source of coverage for ESRD ends before the COBRA continuation period ends, the Fund becomes secondary to Medicare for the balance of the continuation coverage for such person. Continuation coverage also may be terminated for any reason the Plan would terminate coverage of a participant or beneficiary not receiving continuation (such as fraud). When you become ineligible for benefits under Self-Payment Option 2, you can be reinstated as provided in Eligibility Rule Reinstatement of Eligibility If you lose eligibility for coverage because you did not work the required number of hours or make the required self-payment, your coverage can be reinstated when you work the required number of hours for the Plan you previously were covered under (i.e., 140 hours in a Work Month for the Comprehensive Plan or 120 hours for the Basic Plan). Eligibility cannot be reinstated 12

24 retroactively and coverage for the months lost can never be regained. See page 1 for corresponding Work and Coverage Months. 5. Employer Contributions for Work Performed Outside the Jurisdiction With the approval of the Trustees, a contributing employer may continue to make contributions for his employees though the employees perform work outside the territorial jurisdiction of the Fund, provided such payments are made pursuant to a written agreement between such employer and the union having jurisdiction over the job site. 6. Coverage for Employees and Their Dependents When Employee Enters Military Service (a) Eligibility Status (1) You must submit advance written notice of military service to the Fund Office (unless circumstances of military necessity as determined by the Defense Department make it impossible or unreasonable to give such advance notice). (2) If you do not submit notice, your accumulated hours of eligibility, if any, will be applied until exhausted to further extend your eligibility. Your coverage will terminate on the date your accumulated hours of eligibility have been exhausted. If you subsequently submit notice in a reasonable time period, the use of your accumulated hours of eligibility will cease. (3) For military leaves which are less than 31 days in duration and for which you submit the required notice, your and your eligible dependents' coverage will be continued as though you are actively at work for the duration of such leave. (4) For military leaves which are 31 or more days in duration and for which you submit the required notice, your and your eligible dependents' coverage will cease and your eligibility status will be frozen as of the date you enter military service with the uniformed services of the United States, unless you elect to continue coverage as described in the following subsection (b). (5) Your eligibility will be reinstated on the date you return to work for a contributing employer (or you are available for work if no such work is available) within the applicable time limits stated in the following subsection (c), provided you have sufficient accumulated hours of eligibility to reinstate eligibility. If your accumulated hours of eligibility have been exhausted, you will be allowed to make self-payments under Self-Payment Option 1. (b) Continuation of Coverage (1) When the Fund Office has been notified that you are entering the military service, you and your eligible dependents will be given the option of continuing your same class of coverage under the Plan. (2) You will have the option of using your accumulated hours of eligibility, if available, to continue coverage. If you do not have any accumulated hours of eligibility available or you choose not to use them, you are required to make timely self-payments at a rate to be determined by the Trustees from time to time to purchase such coverage. (3) Your self-payments must be made by the last day of each month in which eligibility and coverage terminate, or within a 30-day grace period. (4) Failure to make self-payments before the end of the grace period will cause eligibility and coverage to terminate at the end of the month for which you last made a timely self-payment. (5) You and your eligible dependents may continue coverage for a period ending the earlier of: (i) the first day of the month for which a timely self-payment has not been received and your accumulated hours of eligibility have been exhausted; 13

25 (ii) 24 months from the first date of absence due to military service; or (iii) the day after the date you fail to apply for re-employment with a contributing employer within the applicable time period allowed under the following subsection (c). The right to freeze eligibility and make selfpayments under this provision ceases when you provide written notice that you do not intend to return to work for a contributing employer after uniformed service. (c) Status Upon Return from Military Service If you are eligible for benefits when you enter the military service and you do not exhaust employer-provided coverage by using your accumulated hours of eligibility, you and your eligible dependents again will be eligible for benefits on the date of your return to work for a contributing employer within the following time periods: (1) For periods of military service of less than 31 days, you must report to the employer not later than the beginning of the first full regularly scheduled work period on the first full calendar day following completion of the period of military service plus eight hours, after a period allowing for safe transportation from place of military service to place of your residence. (2) For periods of military of more than 30 days but less than 181 days, you must apply for re-employment not later than 14 days after military service is completed. (3) For periods of military service of more than 180 days, you must apply for reemployment not later than 90 days after military service is completed. Such time periods may be extended for injuries or sicknesses, as determined by the Secretary of Veteran Affairs, to have been incurred or aggravated during your service in the uniformed services. If you exhaust your accumulated hours of eligibility prior to your return from military service, you will be eligible for benefits on the date of your return to work within the required time periods, provided you make selfpayments required to continue eligibility under Self-Payment Option 1. (d) Class D TRICARE Standard-Supplement Coverage In lieu of continuing your same class of coverage as described in the prior subsection (b), your dependents will be allowed to make self-payments to continue coverage under Class D, TRICARE Standard-Supplement Benefits, while you are called to active military service. See page 47 for a description of these benefits. Class D coverage terminates as follows: (1) Upon your discharge or release from active duty and return to covered employment, Class D coverage ends on the earliest of the date your eligibility for another class under the Plan is reinstated or TRICARE Standard coverage ceases. (2) In the event you do not return to covered employment, Class D coverage no longer is available on the date your TRICARE Standard coverage ends. (3) When you are scheduled to be released from active duty or discharged and you extend your length of active service voluntarily or are: (i) ordered to continue or extend your active service; (ii) disabled; (iii) deceased; or (iv) named as missing in action or as a prisoner of war; your Class D coverage terminates the earlier of the date TRICARE Standard coverage terminates or six months after you are scheduled to be released from active duty or discharged. However, the Plan may extend such deadline if 14

26 evidence is submitted to prove the service extension was due to government orders. 7. Coverage While on Family and Medical Leave If you become eligible for leave according to the Family and Medical Leave Act of 1993 (FMLA), your coverage under the Plan may be continued for up to 12 weeks, provided your employer: (a) is subject to the Act; (b) makes the required contribution (or you do so); and (c) files the appropriate notification and certification forms with the Fund Office. If your leave is eligible under the FMLA, and you do not return to work after the leave, then for COBRA continuation coverage purposes, the date of the Qualifying Event will be the last day of your FMLA leave. This provision will apply whether or not you elect to continue coverage under the Plan during the leave. To be subject to the Act, an employer must have at least 50 employees within 75 miles. For additional information regarding your rights under the Family and Medical Leave Act, see page Reciprocity of Welfare Contributions With Other Funds (a) Transfer of Contributions FROM this Fund This Fund will transfer contributions to an employee's home fund when the two funds are parties to a reciprocity agreement. (b) Transfer of Contributions TO this Fund If contributions are transferred to this Fund, the dollar amount received is divided by the employer contribution rate required for this Fund to determine the number of hours for which you will be credited. To gain initial eligibility by reciprocity while working outside the jurisdiction of this Fund, you must be credited with 140 hours in a Work Month for Plan A or 120 hours for Plan B. You will be allowed to make a selfpayment for the difference between the required hours and the prorated equivalent of such hours in order to become initially eligible. To maintain eligibility by reciprocity while working outside the jurisdiction of this Fund, you must be credited with at least 140 hours each Work Month for Plan A and 120 hours for Plan B. For example, if the contribution rate where you work is $6.00 per hour and the contribution rate required to be paid to this Fund is $7.50 per hour, you must work, and transfer must be made for, approximately 1.3 hours for each hour of credit in this Fund. If the contribution rate where you work is $8.50 per hour and the contribution rate in this Fund's jurisdiction is $7.50 per hour, you must work, and transfer must be made for, only approximately 9/10 of an hour for each hour of credit in this Fund. 9. Termination of Individual Coverage Coverage will terminate under this Plan on the earliest of the following dates: (a) the date the Trust is terminated; (b) the date you cease to be eligible for coverage according to the Eligibility Rules adopted by the Trustees; or (c) the date your dependent ceases to be an eligible dependent as defined on pages 57 and 58. Certificate of Creditable Coverage: In accordance with the Health Insurance Portability and Accountability Act of 1996 (HIPAA), the Plan will issue a certificate of creditable coverage to you and your dependents when your regular health care benefits coverage or COBRA continuation coverage terminates (and also upon request, within 24 months thereafter). The certificate provides information on the period of your coverage under the Wisconsin Pipe Trades Health Fund that may be credited on your behalf to satisfy any applicable pre-existing condition 15

27 limitations of a new health plan in which you enroll. 10. Time for Filing Claims Notice of claim must be filed within 90 days of the occurrence of the sickness or injury, or as soon as reasonably possible. Notice received later will not disqualify a claim if it still is possible to document the nature and extent of the loss which is the basis of the claim. However, claims received more than one year after the end of the year in which the claim was incurred are disqualified and will not be accepted. 11. Compliance With Claim Rules To obtain benefits, all claimants must comply with every applicable claim rule. The Trustees reserve the right to deny benefits to any claimant who, in their opinion, is attempting to subvert the purpose of the Fund or who does not present a bona fide claim. 12. Change of Eligibility Rules 13. Conformity With Law Any provisions of these Eligibility Rules held to be unlawful or inconsistent with the requirements for tax-exempt status of this Fund under Section 501(c)(9) of the Internal Revenue Code will be void. A Note of Explanation The Eligibility Rules present the requirements which must be satisfied to become and remain eligible for benefits. In the event the requirements are not satisfied, eligibility is lost and benefits are not payable. You also should be aware of the effect which a change in employment may have on employer contributions paid on your behalf. For example, employer contributions stop in the event you: (a) change job classifications from covered to noncovered employment; or (b) change employment from a participating to a nonparticipating employer. The Trustees, in their discretion, are empowered to change, amend, or abolish the foregoing Eligibility Rules at any time. 16

28 DEATH BENEFITS Classes A, B, C, and JD Employees Only Immediately upon receipt of acceptable proof of your death on forms provided by the Trustees, the Plan will pay to your beneficiary of record the Death Benefit stated in the Schedule of Benefits in a lump sum amount. You are requested to designate a beneficiary on a form provided by the Trustees. 1 You may change your beneficiary at any time by filing written notice with the Fund Office. The beneficiary's consent is not required. If your designated beneficiary does not outlive you, the designation of that beneficiary will be void, subject to the provisions of the Plan. If, at the time of your death, there is no surviving designated beneficiary, the amount of the Death Benefit will be paid to one or more of the following surviving relatives: spouse, child or children, parents, brothers and sisters. If no relatives survive you, benefits will be paid to the executor or administrator of your estate. If the beneficiary is a minor and no legal guardian has been appointed, the minor's share may be paid at a rate up to $50 a month to the adult(s) who, in the Trustees' opinion, have assumed custody and principal support of the minor. ACCIDENTAL DEATH AND DISMEMBERMENT BENEFITS Classes A, B, C, and JD Employees Only If, while your coverage is in force under the Plan, you suffer bodily injury caused solely by accidental means and occurring within 90 days of the date of the accident, various benefit amounts are payable depending on the extent of the loss and based on the Principal Sum stated in the Schedule of Benefits, as specified in the Plan Document. Loss with reference to hand or foot means complete severance through or above the wrist or ankle joint and with reference to eye means the irrecoverable loss of its entire sight. If you suffer more than one loss in an accident, benefits will be paid only for the one loss for which the larger amount is payable. These payments will be made directly to you, if living, otherwise to your beneficiary. 1 If you are married and intend to designate someone other than your spouse as your beneficiary, you may want to consult your lawyer. 17

29 LOSS OF TIME BENEFITS Classes A and JD Employees Only When you are disabled due to an injury or sickness that prevents you from working and while under the care of a physician, Loss of Time Benefits will be paid to you at the weekly rate specified in the Schedule of Benefits. However, if you are disabled due to injury or sickness on the date of your initial eligibility for benefits, you will not be eligible for Loss of Time Benefits until the date the disability ends and you resume your regular occupation. Claims for Loss of Time Benefits are monitored for appropriateness of length for all kinds of disabilities and, in questionable cases, will be sent for a second opinion. Benefits begin with the: (a) first day of disability due to an injury; (b) eighth day of disability due to sickness when not hospital-confined (however, if the sickness extends past the seventh day, benefits will be paid retroactively to the first day); (c) first day of disability due to sickness when hospital-confined, except when confined for treatment of nervous or mental disorders, alcoholism, or substance abuse; (d) eighth day of disability due to alcoholism or substance abuse for a hospital confinement or for partial hospitalization at an approved hospital, clinic, and/or non-medical residential treatment facility on the recommendation of the FSP manager and upon written certification by the treating physician that you are disabled and unable to work because of such treatment program; (e) first day of disability due to nervous or mental disorders for a hospital confinement or for partial hospitalization at an approved hospital, clinic, and/or non-medical residential treatment facility on the recommendation of the FSP manager and upon written certification by the treating physician that you are disabled and unable to work because of such treatment program; or (f) first day of disability when any of the following surgical procedures are performed on an outpatient basis: (1) breast surgery; (2) cataract surgery; (3) foot surgery involving removal of bone or tendon revision; (4) hemorrhoidectomy; (5) hernia repair; (6) ligation and excision of varicose veins; (7) open knee surgery, including therapeutic arthroscopy; (8) release of carpel tunnel; (9) removal of pilonidal cyst; (10) septal defect procedures; (11) tonsillectomy and adenoidectomy; or (12) tympanotomy. Benefits will continue for a maximum of 26 weeks for any one period of disability, except for disabilities related to nervous or mental disorders, alcoholism, and substance abuse for which benefits are limited to 24 days each calendar year while you are hospital-confined. Loss of Time Benefits for these specified disabilities stop on the date of hospital discharge. Reminder. This benefit is subject to federal Social Security (FICA) taxes. 18

30 Limitations. Two or more periods of disability are considered as one unless you have returned to your regular occupation for at least two weeks between periods of disability or unless the disabilities are due to entirely unrelated causes. Loss of Time Benefits are not provided for any loss: (a) caused by injury which arises out of or occurs in the course of any occupation or employment for wage or profit; (b) caused by sickness for which you are entitled to benefits under any Worker's Compensation or Occupational Disease Law; (c) during any period for which you are entitled to Unemployment Compensation; or (d) caused by aesthetic cosmetic surgery. Loss of Time Benefits cease as of the date eligibility is lost. FICA TAX BENEFITS Classes A and JD Employees Only FICA Tax Benefits are payable for certain eligible employees in Class A or JD. Benefits are payable in an amount equal to your, the employee's, portion of FICA taxes on Loss of Time Benefits as required by the Social Security Amendments of These benefits are payable for all such disability benefit payments made within six months after you stop working at covered employment. JURY DUTY BENEFITS Classes A and JD Employees Only Jury Duty Benefits are payable only if you are an employee eligible in Class A or JD at the time of jury duty in a court located within the jurisdiction of this Fund. Benefits payable are based on the difference between the hours you worked and the straighttime hours which you could have worked if you were not on jury duty, up to a maximum of eight hours per day. The amount payable is equal to the basic taxable Journeymen or Apprentice hourly wage rate payable to you under the current labor contract under which you work, multiplied by the difference in hours, less the amount paid by the court as jury fee. To apply for Jury Duty Benefits, you are required to contact the Fund Office upon completion of jury duty service and furnish the following documentation: (a) court certificate of service which lists the date of service and the daily amounts paid to you; and (b) Trustees may require a signed and dated statement from your employer to certify the dates and hours of employment lost due to jury duty. 19

31 COMPREHENSIVE MAJOR MEDICAL BENEFITS Classes A, B, C, and JD Employees and Dependents For Classes A and JD, the Fund has an enrollment period each Fall during which you must choose your health care Plan selection for the following calendar year. You and any eligible dependents must be in the same Plan. You may choose from the Comprehensive Plan (Plan A), which has lower out-of-pocket costs and a minimum work requirement of 140 hours per month; or you may choose the Basic Plan (Plan B), which has higher deductibles and out-of-pocket costs, but has a minimum work requirement of only 120 hours per month. See the Schedule of Benefits for the specifics of each Plan. Your election will be for the entire calendar year. However, if you elect Plan A, you will be allowed to switch to Plan B outside of the open enrollment period, but you then must stay in Plan B for the remainder of that calendar year. If you do not make an election during the enrollment period, you automatically are covered under Plan A. For Classes B and C, you automatically are covered under Plan A. When you or your dependent require covered services or supplies which are medically necessary because of injury or sickness, benefits are payable as stated in the Schedule of Benefits, provided you have satisfied any required deductible. If there are limitations for a particular benefit, they are explained with each benefit. General Exclusions for the Plan are on pages 53 through 55. Deductible The deductible is the amount of covered charges which you pay before you are entitled to benefits. The deductible is stated in the Schedule of Benefits. If you use cost-effective alternatives Trustees approved, the deductible is waived. See pages 28 through 31. Also, there is no deductible required when you obtain prescription drugs at a preferred provider pharmacy as described on pages 33 through 35. The deductible amount will be reduced if you and/or your dependent spouse participate in the Preferred Provider Preventive Care Program as stated in the Schedule of Benefits. If both a husband and a wife are eligible under the Plan as employees, the deductible is waived for the entire family. The deductible applies only once in any calendar year even though you may have several different disabilities. Any expenses applied against the deductible in the last three months of a calendar year also may be applied against the deductible in the next calendar year. Normally, the deductible is applied separately to each eligible person in a family. But, if two or more eligible members of a family are injured in the same accident, only one deductible will be charged against all resulting covered charges, regardless of the number of family members injured. A combined deductible also will apply to covered charges related to such common accident which are incurred in subsequent calendar years when new deductible amounts otherwise would apply. Copayment After you satisfy the required deductible amount, the Plan pays covered expenses at the applicable copayment percentage stated in the Schedule of Benefits, up to the lifetime maximum. The percentage depends upon use of a preferred provider 1 ; precertification by the utilization review manager; and/or recommendation of the Family Services Program manager. The balance of 1 See page 33 for benefits payable at a preferred provider. 20

32 charges is payable by you. If you use the costeffective alternatives Trustees approved, the copayment is waived. See pages 28 through 31. When the out-of-pocket covered expenses in a calendar year (NOT including the deductible amount or specific dollar amount copayments for emergency room visits and physicians office/hospital visits) reach the maximum stated in the Schedule of Benefits, the Plan pays 100% of the balance of covered expenses for that eligible person or family for the remainder of that calendar year. Family means one or more eligible persons within a family unit, consisting of you and your dependents. If you receive outpatient treatment for nervous and mental disorders, substance abuse, or alcoholism and do not use the Family Services Program, your copayment will not apply toward the out-of-pocket maximum. Lifetime Maximum The maximum amount payable with respect to all sicknesses and injuries of any one eligible person during such individual's entire lifetime is stated in the Schedule of Benefits. All Comprehensive Major Medical Benefits will terminate as to an eligible person on the date the lifetime maximum is paid or becomes payable for all losses due to all injuries and sicknesses covered by the Comprehensive Major Medical Benefits section. Covered Expenses Benefits are payable for reasonable expenses for the following services and supplies which are medically necessary for treatment of an injury or sickness, including tuberculosis, voluntary sterilization (and its reversal), elective abortion, and pregnancy and childbirth and any related conditions. (a) Hospital Services recommended by the attending physician for the following. 1 (1) Room and board expense, up to the hospital's semi-private room rate (or up to the private room rate, when medically 1 See the Schedule of Benefits for the applicable copayment, depending on where services are obtained. necessary). The Plan will not pay the hospital room and board charge when the utilization review manager and attending physician both determine that days of hospital stay are not medically necessary. (2) Intensive care unit expense, including confinement of 24 or more consecutive hours duration in a recovery room of a hospital if you receive the same care and services as those normally provided in the intensive care unit of the hospital. (3) Drugs, medicines, diagnostic x-rays and laboratory tests, and other hospital miscellaneous services and supplies not included in room charges (including the anesthetist's fee when charged by the hospital), if used while confined in the hospital as a resident patient. (See page 29 for coverage of preadmission testing). (4) Outpatient services in connection with emergency first-aid treatment resulting from injury or sickness. The separate dollar copayment for each hospital emergency room visit is stated in the Schedule of Benefits. Such separate dollar copayment is payable after the eligible person s deductible has been satisfied and before the applicable copayment percentage is payable under Comprehensive Major Medical Benefits. The separate dollar copayment will be waived if the eligible person is admitted to the hospital. (5) Hospital charges for confinements related to treatment of nervous and mental disorders are payable at the copayment stated in the Schedule of Benefits, up to a maximum of 31 days per eligible person per calendar year. Under the Family Services Program (FSP), the Trustees may extend this maximum an additional 15 days per eligible person per calendar year as they deem appropriate on a case-by-case basis upon the recommendation of the FSP manager. For eligible persons using the FSP only, benefits are payable at the applicable copayment for up to a maximum of 15 days per eligible person per calendar year for 21

33 partial hospitalization and intensive outpatient treatment at an approved hospital, clinic, and/or non-medical residential treatment facility at the recommendation of the FSP manager. Hospital charges for confinements related to treatment of substance abuse and alcoholism are payable at the copayment stated in the Schedule of Benefits, up to a maximum of 30 days per eligible person per lifetime. Under the FSP, the Trustees may extend this maximum an additional 15 days per eligible person per lifetime as they deem appropriate on a case-by-case basis upon the recommendation of the FSP manager. For eligible persons using the FSP only, benefits are payable at the applicable copayment for up to a maximum of $5,000 per eligible person per lifetime for partial hospitalization and intensive outpatient treatment at an approved hospital, clinic, and/or non-medical residential treatment facility. At the recommendation of the FSP manager, benefits may be extended an additional $2,500 per eligible person per lifetime. You can contact the FSP manager at (414) locally or at the toll-free number for Wisconsin and Minnesota: (6) A newborn dependent child during the period its mother is hospital-confined as the result of giving birth to the child and after the mother's discharge if the newborn has a condition which necessitates further hospital confinement. (7) An eligible person, undergoing inpatient treatment for a nervous or mental condition, when temporarily released for therapeutic reasons. Under these circumstances, benefits are payable for a maximum of two consecutive days and up to a total of six days during one period of disability. In-hospital benefits are not payable for hospitalizations starting on weekends for treatment or surgery scheduled to begin the following Monday or later, unless scheduled to begin early Monday morning. The Plan generally may not, under federal law, restrict benefits for any hospital length of stay in connection with childbirth for the mother or newborn child to less than 48 hours following a vaginal delivery, or less than 96 hours following a cesarean section, or require that a provider obtain authorization from the Plan for prescribing a hospital length of stay not in excess of these periods. However, federal law generally does not prohibit the mother s or newborn s attending provider, after consulting with the mother, from discharging the mother or her newborn earlier than 48 or 96 hours, as applicable. (b) Physicians' Services include charges for: (1) Surgery by a physician, including charges for outpatient surgery, home deliveries, circumcision of an eligible newborn dependent child, and the following oral surgical procedures: surgical removal of tooth or multiple extractions requiring hospital confinement, removal of impacted tooth, alveolectomy, gingivectomy, apicoectomy, torus palatinus (removal), torus mandibularis, frenectomy, excision of cyst(s), osteoplasty, stomatoplasty, osseous surgery; and treatment of temporomandibular joint disorder (TMJ). Benefits are payable for a penile implant, provided the eligible person's impotence is determined to be organic in nature. Following a mastectomy, surgical benefits are payable for the following in a manner determined in consultation with the attending physician and the patient: reconstruction of the breast and nipple of the breast on which the mastectomy has been performed and of the contralateral breast to produce symmetrical appearance; and for physical complications of all stages of mastectomy, including lymphedemas. (For organ transplant surgery and related items, see pages 26 through 28. See page 28 for coverage of second surgical opinions.) (2) Anesthetic and its administration by a professional anesthetist when the charge for those services is not included in the hospital's charges. (3) Medical services rendered during inhospital, outpatient, office, and home visits by a physician, including examination of an 22

34 eligible newborn dependent child. The dollar amount copayment per visit is stated in the Schedule of Benefits. The deductible and any other copayment percentage requirements do not apply. Chiropractic fees for manipulation are limited to $1,200 per eligible person per calendar year. (4) Outpatient treatment for nervous and mental disorders, substance abuse, and alcoholism, provided such outpatient treatment is rendered by, under the supervision of, or on referral from a physician in a hospital or approved outpatient psychiatric facility, except that a physician can render such treatment at any location. Outpatient treatment does include collateral interviews with the eligible person's family. If you utilize the Family Services Program (FSP), benefits are payable for outpatient treatment of nervous and mental disorders at 100% up to a combined maximum of 20 visits per eligible person per calendar year. The Trustees may extend benefits an additional 10 visits per eligible person per calendar year as they deem appropriate on a case-by-case basis upon the recommendation of the FSP manager. If you do not utilize the FSP, benefits are payable at 50% of the FSP-authorized rate, up to a combined maximum of 20 visits per eligible person per calendar year. Benefits are payable for outpatient treatment of substance abuse and alcoholism at 100% if you utilize the FSP and at 50% up to a maximum of $35 per visit if you do not utilize the FSP, up to a combined maximum of $3,000 per eligible person per lifetime. You can contact the FSP manager at (414) locally or at the toll-free number for Wisconsin and Minnesota: (See page 36 for details of the FSP and page 77 for the name and address of the FSP manager.) (See pages 23 and 24 for coverage of services of a physician for your or your spouse's routine physical examination and page 29 for coverage of physicians' services for well child care.) (c) Diagnostic X-Ray and Laboratory Services, including: (1) the pap test, regardless of the purpose for which it is performed; (2) either amniocentesis or Chorionic Villus Sampling (CVS) for each pregnancy, up to the amount determined to be the reasonable expense for amniocentesis; and (3) mammograms when there is a family history of breast cancer. Dental x-rays are excluded, unless rendered for dental treatment of a fractured jaw or injury to natural teeth within six months after an accident. X-rays and other diagnostic tests that do not require a physician's order, including, but not limited to, heart scans, life scans, and saliva and hair analysis, are excluded under this section and all other sections of Comprehensive Major Medical Benefits. (See page 29 for coverage of diagnostic x-ray and laboratory charges related to well child care.) (d) Prescription Drugs and Medicines covered under Comprehensive Major Medical Benefits include charges for: (1) prescription drugs purchased at the hospital pharmacy at the time of discharge if you have been hospital-confined and issued prescriptions to use upon arrival home; (2) growth hormones; and (3) for eligible persons covered by Medicare: insulin syringes/needles and other diabetic supplies, such as lancets, lancet pens, blood sugar and acetone test strips, and tes-tape. See the Preferred Provider Pharmacy Benefits on pages 33 through 35 for coverage of these items for eligible persons who are not covered by Medicare. (See the Preferred Provider Pharmacy benefits on pages 33 through 35 for coverage for all other prescription drugs.) (e) Routine Physical Examinations for eligible employees and dependent spouses. Benefits are payable for an examination, x-rays, and 23

35 laboratory tests for a routine physical examination performed by a physician in a hospital, clinic, or physician s office while the coverage of such person is in force under this Plan. Payment will not exceed the routine physical examination benefit stated in the Schedule of Benefits for all such examinations made during each calendar year. You are not eligible for this benefit if you use the Health Dynamics option which follows. Preferred Provider Preventive Care Program Option: You or your dependent spouse may choose instead to take advantage of the Preferred Provider Preventive Care Program offered through Health Dynamics. If you use this Program for your routine physical exam, covered services are payable in full, up to the maximum amount approved by the Trustees for that particular preferred provider. If you do use this option, your routine physical examination benefits for the calendar year will be considered exhausted. If you or your dependent spouse participate by obtaining your routine physical examination through the Program, the Comprehensive Major Medical Benefits deductible will be reduced as stated in the Schedule of Benefits. The Program includes a physician-directed physical examination which may be conducted by an M.D. or a physician's extender, such as a physician's assistant or nurse practitioner, and comprehensive preventive care testing. Women may have both a breast screen and pap test performed by Health Dynamics. If you choose to go to Health Dynamics and you intend to have the pap test and/or breast screen performed by your personal physician, please be aware that these procedures may or may not be covered under your Health Care Plan. You should consult with the Fund Office to verify your benefits. You may request to have the bone density screening (heel bone ultrasound) done as part of your complete exam. This screening is offered at the Wauwatosa location only. After the testing, you will have a personal and confidential consultation session which will provide you not only with a medical evaluation but also a personal fitness report and recommendations that focus on your total wellbeing. To schedule an appointment, call Health Dynamics at the St. Joseph Outpatient Center in Wauwatosa at (414) during office hours, Monday through Friday, 7 a.m. - 5 p.m. There are additional hospital-based locations where the physical now is available. Contact the Fund Office for the current listing of those other locations to find the one nearest you. You also may visit their website at (password is: hdhelpsu). Once your appointment has been scheduled, a packet will be sent to you explaining fasting requirements, check-in procedures, and other pertinent information. (f) Routine Colonoscopies for eligible persons over age 50 and for eligible persons who have a family history of colon cancer. This coverage is in addition to the routine physical examination benefit. (g) Other Covered Charges include the following: (1) Other hospital charges incurred as an outpatient. (See page 22 for such charges related to outpatient surgery.) (2) Charges of a qualified physical therapist, occupational therapist, speech therapist (provided such services are medically necessary because of physical impairment caused by injury or sickness), registered nurse (R.N.) or licensed practical nurse (L.P.N.), except for services provided by a person who ordinarily resides in your home or is a member of your immediate family (comprised of your spouse and your and your spouse's children, brothers, sisters, and parents). All therapy treatment will be covered up to a maximum of $3,500 per eligible person per calendar year; benefits can be extended at $3,500 increments with substantiation of medical necessity as determined by an independent medical review. (3) Charges for local professional ambulance service between hospitals as well as to and from a hospital if the attending physician 24

36 considers it medically necessary for proper treatment. If an injury or sickness requires special and unique medically necessary hospital treatment that is not available in a local hospital, the Plan covers professional ambulance service, air ambulance service, or a regularly scheduled commercial airline flight to the nearest hospital within the contiguous United States equipped to furnish the treatment. Charges for ambulance service by railroad, ship, bus, or other common carrier are not payable except as specifically stated. Benefits are not payable for transportation or transfer based solely on your convenience, personal preference, or any reason other than medical necessity. (4) Charges for the following additional services and supplies: oxygen and the rental of equipment for its administration; x-ray, radium, or cobalt treatment, including the services of a radiologist and the rental (but not purchase) of such radioactive materials, provided that treatment is rendered in the radiologist's office or in the outpatient department of the hospital making the charge; blood or blood plasma (if not replaced) and its administration; surgical dressings, casts, splints, braces, trusses, and crutches; rental of hospital-type bed, wheelchair, or iron lung (or the purchase of such device if the rental would exceed the purchase price); batteries for motorized wheelchairs are limited to one battery when the wheelchair is purchased and up to $250 for replacement batteries, as needed; rental and installation of chair lifts; artificial limbs and eyes; hearing aid examinations and hearing aids when prescribed by a physician, payable up to a maximum of $1,000 per aid once every two calendar years; orthopedic shoes, custom-molded inserts, and orthotics one pair only until worn out and another pair is prescribed by a physician; breast prostheses following a mastectomy and up to four mastectomy bras per eligible person per calendar year; dental services rendered by a physician, dentist, or dental surgeon for treatment of a fractured jaw or injury to natural teeth, including replacement of such teeth within six months after the date of the accident (this time period may be extended for a period of up to five years following the date of the accident, provided the eligible person submits a treatment plan from his attending physician with substantiation that the corrective treatment could not be completed within six months); purchase of glucometers when prescribed by a physician; needles, syringes, and Medi-Jectors used by diabetics for insulin injection when prescribed by a physician; dietary counseling for diabetics; speechviewers, covered at 50% of the purchase price, up to a maximum of $500 per eligible person's lifetime; the first set of lenses following cataract surgery; wigs when hair loss is the result of a disease or medical treatment; and Jobst stockings, up to four pair per eligible person per calendar year. (5) Back care instruction at a back school, upon a physician's referral, up to a maximum of $40 per visit and a maximum of five visits per eligible person per calendar year. (6) Acupuncture, provided such services are rendered by a person licensed to perform acupuncture, up to a maximum of $500 per eligible person per calendar year. Payment of benefits also is subject to medical guidelines which specify certain conditions and diagnoses for which acupuncture is recognized to be effective, including but not limited to: post-operative- or chemotherapyrelated nausea or vomiting; nausea associated with pregnancy; anesthesia for surgery; and chronic pain for certain conditions such as migraine headaches, tennis elbow, and arthritis. (7) Covered charges for temporomandibular joint disorder (TMJ), payable as follows: Non-surgical treatment (including, but not limited to, splints, related physical and splint therapy) is covered up to a maximum of $1,000 per eligible person per calendar year. Surgical treatment and covered expenses related to the surgical procedure are covered subject to the lifetime maximum of the Plan, but are 25

37 not subject to the $1,000 calendar year maximum. (8) Non-cosmetic sclerotherapy for the treatment of varicose veins, in lieu of surgery, up to the amount otherwise payable for such surgery, but not to exceed $5,000 per leg per eligible person s lifetime. (9) Charges related to provision of artificial life support systems for the first five days after a medical determination that death has occurred, not to exceed $5,000, such determination of death to be within the meaning of Section , Wisconsin Statutes ( ), or is determined to be clinically dead. (10)Voluntary sterilization (and its reversal). (See page 29 for coverage of skilled nursing home care, page 30 for coverage of hospice care, and page 30 for coverage of home health care.) (h) Organ Transplant Surgery and related covered costs for a human organ or tissue transplant during the transplant benefit period to a recipient who is an eligible person, not to exceed the amounts stated in the Schedule of Benefits. A transplant benefit period consists of five days before and eighteen months after the date of a transplant for those procedures that are self-funded. For procedures that are insured, the transplant benefit period is a period of 370 continuous days beginning five days before the date of a transplant or, in the case of a bone marrow transplant, a period of 395 continuous days beginning 30 days before the date of a transplant. If the transplant decision has been approved as specified later in this section, but the eligible transplant procedure has to be delayed for reasons such as the recipient's medical condition or an organ not being available, the transplant benefit period may be extended to include more than the stated five (or 30) days prior to the transplant. In addition, the costs for stem cell collection will be payable up to one year preceding the benefit period for insured bone marrow transplants. Insured procedures include a spell of illness benefit which covers costs incurred during the transplant benefit period which are related to the underlying disease that caused the transplant in addition to the costs related to the transplant itself, up to the insurance policy's lifetime maximum. Organ transplant benefits are payable provided each of the following conditions is satisfied: (1) You or your dependent must have been eligible under the Plan for at least 12 consecutive months immediately prior to incurring covered expenses for those transplants that are self-funded and for those transplants that are insured. However, this eligibility requirement does not apply to newborn dependent children. Organ transplant benefits are payable for all newborn dependent children, regardless of any prior eligibility requirements. (2) You or your dependent receives two written opinions by Board-certified specialists in the involved field of surgery on the necessity for transplant surgery. (3) The specialists certify in writing that alternative procedures, services, or courses of treatment would not be effective in the treatment of your condition. (4) All decisions related to the transplant surgery satisfy applicable state requirements. (5) You must contact the Fund Office for prior approval for all organ transplants. Transplants of the following human organs or tissues are covered when transplanted to an eligible person: cornea; heart; kidney; heart/lung (single or bone marrow double); (except bone lung (single or marrow double); transplants pancreas; caused by T-cell pancreas/kidney; leukemia); and liver; small bowel. Coverage for cornea and kidney transplants for Classes A, B, and JD is provided directly through your self-funded Plan of benefits. 26

38 Coverage for all other procedures for Classes A, B, and JD is provided under the insurance policy issued by a carrier Trustees select. Coverage for all covered transplant procedures is self-funded for Class C and is coordinated with those benefits payable by Medicare, as specified in the Schedule of Benefits. Covered expenses include reasonable expenses incurred for the following services and supplies: (1) Donor-related services for self-funded transplants include: (i) testing to identify suitable donor(s); (ii) life support of a donor pending the removal of a usable organ(s); (iii) transportation for a living donor or a donor on life support; (iv) human organ and tissue procurement, including removing, preserving, and transporting the donated organ or tissue; and (v) expenses related to the treatment of a condition resulting from the donation of an organ or tissue. Benefits for donor-related services also will be payable to compensate an organ or tissue bank for the procurement, preservation, and transportation of an organ. However, benefits will not be payable for any financial consideration to a donor other than for payment of a covered expense which is incurred in the performance of, or in relation to, transplant surgery of an eligible person. Donor-related services for insured transplants include procurement only. Payment for donor(s)' services for each eligible transplant procedure will not exceed the applicable maximum amount stated in the Schedule of Benefits. Benefits are payable under this section only if the transplant recipient is an eligible person. (2) Transportation, lodging, and meals for the recipient and an immediate family member or significant other person to and from the transplant site, as well as lodging and meal costs incurred during the recipient's hospital stay by the companion, up to the maximums stated in the Schedule of Benefits. For these benefits to be payable, itemized receipts for charges are required. If the recipient is a minor, charges for two other companions will be covered. (3) Private nursing care for the recipient by a registered nurse (R.N.) or a licensed practical nurse (L.P.N.), up to the maximum stated in the Schedule of Benefits. (4) Postoperative followup expenses, including immunosuppressant drug therapy. For insured procedures, immunosuppressant drugs are covered under the insurance policy only during the transplant benefit period. After the transplant benefit period, the Plan will cover expenses for such drugs, subject to applicable requirements. (5) For insured procedures: Coverage is provided for the use of circulatory assist devices, such as Left Ventricular Assist Devices (LVADs) and hepatic assist devices, to sustain an eligible person while waiting for a transplant. (6) All other covered services for the recipient will be payable under the Plan the same as for any other injury or sickness, up to the lifetime maximum payment stated in the Schedule of Benefits (or under the insurance policy up to its lifetime maximum). For procedures covered under the insurance policy: You have the option of either using any facility for your transplant or of using a facility that is part of the carrier's transplant network for inpatient care. You do not have to use a network facility, but if you choose NOT to do so, benefits payable are limited to the amount which would be allowable at the nearest network facility which performs that procedure. You will be responsible for all costs which exceed the network facility's negotiated allowance. A current list of the network facilities is available at the Fund Office. As soon as your 27

39 physician tells you that you or one of your dependents may require a transplant, contact the Fund Office immediately for all necessary information. Multiple transplants during one operative session are payable in the same manner as are other multiple procedures during the same anesthesia period. Benefits for replacement transplant(s) if the first organ fails or is rejected are payable in the same manner as the first organ, unless failure or rejection is due to physician or hospital error in which case no benefits are payable. Benefits are payable for the temporary use of mechanical equipment which is no longer experimental pending the acquisition of "matched" human organ(s). If a covered organ transplant procedure is not performed as scheduled due to the intended recipient s medical condition or death, benefits will be payable for the following. For self-funded procedures: Charges incurred during the duration of the delay because of a medical condition or up to the date of death for the organ and tissue procurement, transportation, lodging, and meals will be payable as stated in this section. For insured procedures: All covered medical expenses directly related to the transplant, except procurement expenses, will be reimbursed if they occur within five days of the date of the scheduled transplant. If the transplant would have made use of an organ from a living related donor, procurement expenses will be reimbursed if they occur within five days of the date of the scheduled transplant. If a covered bone marrow or stem cell transplant is not performed after the high dose portion of the therapy has begun, procurement expenses will be reimbursed. Covered medical expenses for the eligible person that are incurred 30 days before the scheduled date of the bone marrow or stem cell transplant also will be reimbursed. A transplant is deemed to be scheduled if: an eligible donor has been located; and a date has been assigned as the date that the transplant will take place. All expenses to be reimbursed are subject to the organ transplant maximums in the Schedule of Benefits. All expenses incurred according to this paragraph as a result of one or more failed transplant(s) will be used in calculating the maximums. No organ transplant benefits are payable for: (1) services not ordered by a physician; (2) any expenses for a transplant when approved alternative courses of treatment are available or when other specified conditions are not satisfied; (3) animal or mechanical organs for transplantation; (4) investigational drugs; (5) any items specified in the Plan's General Exclusions on pages 53 through 55; (6) purchase of the organ or tissue; or (7) the temporary use of experimental mechanical equipment. Please Note: The prior description of the insured Organ Transplant Benefits is only a summary of the provisions of the organ transplant insurance policy. In cases of conflict, the insurance policy certificate will govern. Alternative Ways of Obtaining Care Deductibles and copayments are waived for the following benefits available under Comprehensive Major Medical Benefits to encourage you and your physician to consider their use. If you and your physician use these less costly systems and facilities for appropriate treatment, you will help keep your own and Plan costs under control. These benefits are subject to all other provisions of the Plan. (a) Second Surgical Opinions If your or your dependent's physician recommends surgery, you may wish to obtain another opinion from a Board-certified surgeon to confirm the medical need for the surgery. The Plan will pay 100% of the reasonable expenses incurred to obtain a second or third opinion before the surgery is performed, including consultation fees and necessary 28

40 laboratory tests and x-rays related to the second or third opinion. If you choose to have the surgery performed despite conflicting opinions from physicians, Plan benefits still will be payable. The consulting physician must be in a medical practice independent of your physician and not be recommended by your treating physician, and must agree not to perform the surgery if in agreement with the original recommendation. No Plan benefits are payable if the consulting physician performs the surgery. (b) Pre-Admission Testing Laboratory tests and x-rays are sometimes needed by your physician before treatment begins or surgery takes place. Sometimes the added tests and x-rays may be performed without being hospital-confined. Whether they are performed before or after hospitalization begins is a judgment for you and your physician to make. When you or your dependent incur expenses for pre-admission testing, the Plan will pay 100% of the reasonable expenses incurred for diagnostic laboratory tests and x-rays performed in a hospital outpatient department, physician's office, or clinic which are required for medically necessary treatment you are scheduled to receive upon hospital admission, provided: (1) you are scheduled for hospital admission and the scheduled admission occurs; (2) the treatment is initiated or the surgery is performed within seven days of the testing; and (3) hospital benefits are payable for the treatment or surgery. If you are not admitted to the hospital following the testing, such benefits still are available provided: (1) the tests showed a medical condition which required treatment prior to hospital admission; (2) a hospital bed is not available; or (3) the tests showed that admission is not necessary or that treatment or surgery is required to be deferred beyond seven days of the testing. Pre-admission testing covers diagnostic laboratory tests and x-rays only; physicians' and facility charges are not covered under this section. (c) Well Child Care If your eligible dependent child from birth through age 11 incurs expenses for routine examinations, including related laboratory and x-ray charges, the Plan will pay 100% of the reasonable expenses incurred, provided expenses are incurred at a preferred provider. The Plan's copayment will be reduced to 80% for such expenses incurred at a nonparticipating provider. Payment will not exceed the applicable maximum stated in the Schedule of Benefits for all such examinations made during each calendar year. (d) Routine Immunizations The Plan will pay 100% of the reasonable expenses incurred when you or your dependent incurs expense for routine immunizations, including professional services and supplies to prevent diphtheria, pertussis, tetanus, polio, measles, mumps, rubella, influenza, pneumonia, and Hepatitis B. With respect to childhood immunizations, the Plan will cover those recommended by the American Academy of Pediatrics. Benefits are not payable for: services rendered or supplies dispensed before you or your dependent is an eligible person, whether or not a series of treatments for immunization continues after you are an eligible person; treatment related to allergy; or medications not normally prescribed or administered by a physician or paramedical personnel, such as vitamins. (e) Skilled Nursing Home Care If you or one of your dependents is confined in a licensed skilled nursing home, the Plan will pay 100% of the reasonable expenses incurred 29

41 for up to 30 days of confinement per period of disability, provided: (1) you are transferred to the nursing home within 24 hours of hospital discharge; (2) you were hospitalized immediately before transfer to the nursing home; (3) the attending physician certifies this care is medically necessary and recertification is made every seven days; and (4) further hospitalization would be necessary if not for skilled nursing home confinement. Successive periods of disability, due to the same or related causes, not separated by return to full-time active work or, in the case of a dependent, return to normal activities, will be considered as one period of disability unless the subsequent period of disability is due to injury or sickness entirely unrelated to the causes of the previous disability. (f) Hospice Care When it is medically determined that an eligible person is terminally ill, the eligible person (or his authorized representative, such as a family member) and the physician may prefer hospice care as opposed to hospital confinement. The Plan will pay 100% of the reasonable expenses incurred for covered hospice services during the period in which the eligible person otherwise, upon recommendation of his physician, would have to be hospital-confined. Such benefits are payable for home care administered under an approved hospice program or home health care agency at the patient's home, or for care in a hospice unit of a hospital or a separate hospice facility. Covered hospice services include physicians' visits; care provided by registered nurses (R.N.) and home health care aides; assessment visit by a hospice program staff member; physical, occupational, speech, and respiratory therapy; and drugs and supplies prescribed by a physician. In the event the medical determination is made that the terminal condition is reversed, benefits are payable as provided under other sections of the Plan. (g) Home Health Care The Plan will pay 100% of the reasonable expenses incurred by you or your dependent for home health care services provided in the patient's home, subject to your attending physician certifying that: (1) hospitalization or confinement in a skilled nursing home would be required in the absence of home health care; (2) the patient's family or persons residing with the patient cannot provide necessary care and treatment without causing an undue hardship; and (3) home health care services are coordinated by a state-licensed or Medicare-certified home health care agency or certified rehabilitation agency. Reasonable expenses are payable for up to 10 visits per period of disability. Up to each four consecutive hours of home health aide service, evaluation, or planning in 24 hours is considered one home health care visit. Successive periods of disability due to the same or related causes, not separated by return to regular occupation and/or normal activity, will be considered as one period of disability. Home health care services available include: (1) part-time or intermittent nursing care under the supervision of a registered nurse (R.N.); (2) medically necessary home health aide services (part-time or intermittently) solely for the care of the patient and under the supervision of a R.N. or a medical social worker; (3) physical, respiratory, occupational, or speech therapy; (4) medical supplies, drugs, and medications prescribed by a physician and necessary laboratory services to the extent they would have been covered during a hospital confinement; (5) nutritional counseling by a registered dietitian when medically necessary; and 30

42 (6) evaluation of the need for development of a plan for home health care by a R.N., physician extender, or medical social worker when requested or approved by the attending physician. Limitations. Home health care benefits are not provided for: (1) food, housing, homemaker services, or home-delivered meals; (2) custodial care; (3) services or supplies not included in the home health care plan established for the patient; (4) services provided by the patient's family or anyone residing with the patient; or (5) any services not specifically listed in this section. Comprehensive Major Medical Benefits Exceptions and Limitations In addition to the Plan's General Exclusions on pages 53 through 55 and other limits that apply to specific benefit provisions as described in those sections, Comprehensive Major Medical Benefits do not cover: (a) ambulance service by railroad, ship, bus, or other common carrier, except as specifically provided; (b) dental treatment or dental x-rays, except as specifically provided; (c) purchase of radioactive materials for x-ray, radium, or cobalt treatment; (d) examination for correction of vision or fitting of glasses or contact lenses, except as specifically provided; (e) care in a rest home other than in a hospital; (f) any loss caused by or resulting from mental deficiency, mental retardation, developmental deficiencies, genetics, or any treatment for learning disabilities, except as specifically provided; (g) genetic testing, except as specifically provided; (h) counseling or treatment for conditions not supported by a bona fide medical diagnosis, such as aptitude testing and marriage counseling, unless covered through the Family Services Program; (i) charges incurred for any special education rendered to any eligible person, regardless of the type of education, except as specifically provided; (j) charges for telephone conversations and/or telephone consultations; (k) charges for special home construction to accommodate a disabled eligible person; (l) charges incurred for services, treatment, or surgical procedures rendered in connection with an overweight condition or condition of obesity including diet plans, surgical procedures for the treatment of morbid obesity (under no circumstances is gastric bypass surgery covered under the Plan), and related visits to a physician (except medically necessary physician visits for the treatment of morbid obesity); (m) complications resulting from obesity surgery; (n) charges incurred for any services or supplies which are not recommended or approved by the attending physician; (o) charges incurred for any of the following list of items, regardless of intended use, including but not limited to: air conditioners; air purifiers; whirlpools; swimming pools; humidifiers; dehumidifiers; allergy-free pillows, blankets, or mattress covers; electric heating units; orthopedic mattresses; exercise equipment; gravity lumbar reduction chairs; vibratory equipment; elevators or stair lifts; stethoscopes; clinical thermometers; scales; blood pressure monitors; or magnetic devices; (p) routine care (except pap smear) for dependent children age 12 and older; (q) services and supplies which are not medically necessary as defined by the Plan; 31

43 (r) all liquid nutrition used for tube feedings and other nutritional and electrolyte supplements or formula whether or not prescribed by a physician; (s) charges incurred for any items such as telephones, televisions, cosmetics, barber or beauty services, magazines, newspapers, laundry, guest trays, beds or cots for guests, or any other personal comfort or convenience items (in- or out-of-hospital) that are not medically necessary; (t) court-ordered treatment/confinement unless there is substantiation of medical necessity; (u) all expenses associated with personal blood storage; or (v) services of a massage therapist.. 32

44 OTHER PREFERRED PROVIDERS As part of the Trustees' ongoing effort to manage health care costs, the Fund participates in a number of preferred arrangements which offer cost savings to both you and the Fund. The Preferred Provider Preventive Care Program is described on page 24. The Preferred Provider Dental Program alternatives are described on pages 40 through 46. A description of the Fund's other preferred providers follows. The preferred provider provisions do not apply to persons eligible for Medicare. Preferred Provider Hospital and Physician Network Through the ChoiceCare preferred provider organization, the Fund has access to a network of hospitals, physicians, and other health care providers that have contracted to provide all necessary covered services at significantly reduced rates. In addition to hospitals and physicians, ChoiceCare offers reduced rates for outpatient surgery centers, chiropractors, home infusion therapy, reference laboratories, home health care, and durable medical equipment. Benefits are payable for covered expenses at the applicable percentage of the preferred provider's negotiated charge according to the contract in effect at the time charges are incurred as stated in the Schedule of Benefits. The Plan's copayment is higher for covered expenses incurred at a ChoiceCare preferred provider. The list of preferred providers in the network is subject to change based on the contractual agreements between the agent and the participating providers. A current listing will be maintained at the Fund Office and you will be notified of updates periodically. You can receive a current listing of participating providers from ChoiceCare upon request at no charge. It is recommended that you contact ChoiceCare prior to incurring covered expenses to make sure the hospital, physician, or other health care provider you choose is a preferred provider. Call ChoiceCare at , ext or visit their website at Preferred Provider Pharmacy Serve You Custom Prescription Management provides full management of the Plan s prescription drug card program. It offers a nationwide network of pharmacies where you can use your identification card to purchase your prescription drugs at reduced rates. The network includes all of the major chain stores (such as Walgreens) and most independent pharmacies. When you purchase prescription drugs at a preferred provider pharmacy (PPRx), benefits are payable subject to the following terms and conditions. Benefits are payable for the following upon a written prescription executed by a physician and dispensed by a licensed pharmacist: (a) federal legend drugs; (b) compounded medications of which at least one ingredient is a prescription legend drug; (c) insulin; (d) insulin syringes/needles and other diabetic supplies, such as lancets, lancet pens, blood sugar and acetone test strips, and tes-tape for eligible persons who are not covered by Medicare (see Comprehensive Major Medical Benefits on page 23 for coverage of these items for eligible persons who are covered by Medicare); (e) injectable medications; (f) Tretinoin (Retin-A) preparations (if you obtain prior authorization); (g) AIDS-related drugs; (h) fertility agents, including Pergonal (Menotropins) and Metrodin (Urofollitropins); (i) prenatal prescription vitamin preparations; (j) immunosuppressants (anti-rejection drugs); (k) appetite suppressants (if you obtain prior authorization); 33

45 (l) anti-narcolepsy/anti-hyperkinesis drugs (treatment for ADD); (m) oral contraceptives (if you obtain prior authorization); (n) Betaseron and other Multiple Sclerosis medications; and (o) impotence medications (if you obtain prior authorization). For each prescription purchased at a PPRx, you will pay the copayment per prescription as stated in the Schedule of Benefits for either generic drugs or brand name, up to a 30-day supply. You can order maintenance prescriptions through Serve You's DirectRx Mail Service Pharmacy in a 90-day supply, and pay the copayment per prescription as stated in the Schedule of Benefits. There is no calendar year benefit maximum. Serve You has a formulary program through which the manufacturer offers rebates on certain drugs. You will be sent a list of these prescriptions periodically which you may show to your physician. If he prescribes any of the medications on the list, the Fund will receive the rebate and, ultimately, the savings are passed on to you by way of reduced costs to the Fund. Participation in this program is strictly voluntary. It is a mandatory requirement for you to use generic equivalents for all prescriptions. If a generic equivalent is available on a prescription and you elect to purchase the brand name drug, you must pay the difference between the cost of the generic and the brand name drug in addition to the brand name copayment. If a generic equivalent is not available, you will pay the brand name copayment. You will be allowed to purchase a brand name drug without penalty, only upon a physician s written authorization that the brand name drug is medically necessary. If you use the PPRx while ineligible according to the Plan's Eligibility Rules, the Plan will recover the ineligible payments from you according to the right of recoupment provisions stated on page 53. Claims related to prescription drug expenses should be filed with the patient's primary source of coverage and then submitted to the Fund for coordination of benefits. If this Plan makes payments and later determines it is not the primary source of coverage, overpayments will be recouped from you. Benefits are not payable under the Preferred Provider Pharmacy Program for the following: (a) non-legend (OTC) drugs other than insulin and diabetic supplies; (b) drugs purchased at the hospital pharmacy for you at the time of discharge; (c) covered prescription medications which are not self-administered or are administered in a hospital, long-term care facility, or other inpatient setting; (d) contraceptives, oral or other, except if determined to be medically necessary for a noncontraceptive use; (e) implantable contraceptives, regardless of intended use; (f) therapeutic supplies, devices, or appliances, including support garments, and other nonmedicinal substances, except those specifically stated; (g) experimental or investigational drugs; (h) human growth hormone; (i) immunization agents; (j) charges for the administration or injection of any drug; (k) prescription drugs or medicines covered under any Worker's Compensation Law or similar laws or any municipal, state, or federal program, even if the patient chooses not to claim such benefits; (l) refills of covered drugs which exceed the number of refills the prescription order calls for, or refills after one year from the original date; (m) prescriptions deemed not medically necessary for the diagnosis or treatment of an injury or sickness; (n) prescription medicines to treat sexual dysfunction, unless organic in nature; 34

46 (o) smoking deterrents; (p) prescription vitamins, other than prenatal; (q) prescription fluoride preparations; and (r) drugs purchased outside the United States. The toll-free phone number for contacting Serve You Customer Service is: You can order refills for your mail service prescriptions by calling the same number. You also can access their web site at: to refill your mail service prescriptions, find information on specific drugs, view your prescription history, and locate a participating pharmacy in the retail network. 35

47 FAMILY SERVICES PROGRAM Classes A, B, C, and JD Employees and Dependents From time to time, we all face personal difficulties or stress. Sometimes, we need help to resolve our problems. Your Family Services Program (FSP) is a confidential assessment, counseling, and referral service for you and your family to help resolve personal problems which may be affecting your life at work and at home. The Trustees have contracted with Aurora Employee Assistance Program, an organization of medical doctors, social workers, counselors, and psychologists that will provide you and your family with the confidential, professional assistance necessary to deal with personal problems and stress. Skilled counselors are available to talk with you in confidence about your problems. Your counselor can help you with: (a) marital problems; (b) family difficulties; (c) child or adolescent concerns; (d) death or illness of a loved one; (e) alcohol or substance abuse; (f) eating disorders; (g) job stress; (h) depression or anxiety; (i) financial difficulties; and (j) legal referrals. If you think you need help with a problem, just call the confidential hotline at: locally, or the toll-free number for Wisconsin and Minnesota: Trained professionals are there to help you and your family assess and identify problems. Very often, they can help you to resolve those problems. In some circumstances, they can refer you to the most appropriate resource available to assist you. The earlier you seek help, the easier it is to solve your problems. If you contact the FSP manager and receive authorization, benefits for treatment of nervous and mental disorders, abuse of substances, and alcoholism are payable under Comprehensive Major Medical Benefits as described on pages 21 through

48 UTILIZATION REVIEW Classes A, B, C, and JD Employees and Dependents The purpose of your Plan is to provide you and your dependents with quality health care services when medically necessary. To help determine "medical necessity," the Trustees have selected APS Healthcare, a health benefit management service staffed by physicians and registered nurses, to provide pre-hospitalization review. Outpatient surgery, outpatient laboratory tests and x-rays, as well as emergency room visits which do not require a hospital admission are excluded from this review. To help ensure that high quality medical care is available and affordable, all inpatient hospital treatment and surgery will be reviewed by APS for medical necessity. APS uses defined criteria to do so, including appropriateness of treatment, compliance with generally accepted medical practice and professional standards, and deliverance in the appropriate environment and at the level of service required to provide safe, quality care. Notification Requirements To qualify for the maximum level of benefits at the lowest out-of-pocket expense, it is necessary for you to contact APS at least 48 hours before any non-emergency admission to a hospital. The Plan's copayment will be higher if you do so. Call APS toll-free number at For emergency and maternity admissions, it is necessary to notify APS within two business days following admission. (However, we do encourage you to call during the first trimester of pregnancy for maternity cases.) Consideration will be given in those individual cases where unforeseen circumstances prevent prompt notification to APS. If you do not call before entering the hospital or following an emergency or maternity admission, the Plan's copayment of your expenses will not be higher as specified in the Schedule of Benefits. Review Procedures When calling APS, a Medical Care Coordinator will ask for the following information: (a) patient's name and medical condition; (b) names, addresses, and telephone numbers of the physician and hospital involved; (c) name and Social Security number of the eligible employee; and (d) name of your Health Care Plan. You will receive a case number that indicates APS was properly notified. Keep this number in your records for future reference. Certification of medical necessity by APS is not a guarantee of coverage. Eligibility and coverage verification must be obtained through the Fund Office. After being notified, APS will ask you to notify your physician's office that they will be calling. The Medical Care Coordinator will contact your physician to discuss your medical history and treatment plan and to ensure that the recommended treatment is necessary and within medically acceptable guidelines. If surgery is proposed, the medical treatment to date is reviewed to determine if a second opinion is appropriate. If it is, APS will assist you in arranging the appointment and will provide a second opinion form to take to the consulting physician. APS considers several factors when evaluating the level of medical care necessary for each case, including the diagnosis, patient's current status, and attending physician's treatment plan. In cases where your physician's treatment plan differs from APS' criteria, APS physicians and registered nurses will discuss alternative health care services with your physician. These alternative care options will provide the level of quality medical care necessary without adversely affecting the patient's condition. 37

49 When you are admitted to the hospital, the Coordinator will monitor your stay to make sure that your care is appropriately delivered within your physician's treatment plan. Finally, the Coordinator will work with your physician to arrange a safe, timely discharge from the hospital. In some cases, APS will be able to ease your return home by arranging services such as home health care if your physician feels it is necessary for a safe recuperation. The Trustees may extend benefits beyond existing limits for medically necessary services and supplies as recommended by APS. 38

50 VISION CARE BENEFITS Classes A, B, C, and D Employees and Dependents Benefits are payable up to the maximum amounts and for the time periods stated in the Schedule of Benefits for reasonable expenses related to vision exams, lenses, and frames. Services and supplies must be furnished by an optician, optometrist, or ophthalmologist acting within the usual scope of such practice. Vision Examination You and each of your dependents are entitled to one vision examination each calendar year, up to the amount stated in the Schedule of Benefits. Lenses and Frames Benefits are payable for lenses (including contact lenses) and frames, up to the maximum per eligible person each two calendar years as stated in the Schedule of Benefits. Related professional services for fitting and adjusting are included in such coverage. Safety Glasses Each Class A employee is entitled to one set of safety glasses per calendar year, up to the amount stated in the Schedule of Benefits. Limitations In addition to the General Exclusions on pages 53 through 55, Vision Care Benefits do not cover the following: (a) services, treatment, or supplies furnished by or at the direction of the United States Government or any agency thereof, any state, territorial, commonwealth government or political subdivision thereof, or a foreign government or agency thereof; (b) services, treatment, or supplies received from a vision care or medical department maintained by the Trustees, a mutual benefit association, or labor union; (c) services, treatment, or supplies which are payable or furnished under any other coverage with this Fund or any insurance company, or any other medical benefit plan or service plan for which the Trustees, directly or indirectly, have paid for all or a portion of the cost; (d) orthoptics, vision training, or aniseikonia; (e) expenses incurred for services performed or supplies furnished by other than an optician, optometrist, or ophthalmologist; (f) services, treatment, or supplies rendered or furnished: (1) before you or your dependent became an eligible person; or (2) after termination of your or your dependent's eligibility; or (g) tinting or coating of lenses or insurance contracts for contacts, lenses, and frames. 39

51 DENTAL CARE BENEFITS Classes A, B, C, D, and JD Employees and Dependents Two dental plans currently are provided. You have the option once each year of enrolling yourself and your dependents in the plan of your choice during the open enrollment period in December. Enrollment is for one year, beginning each January 1. To compare benefits available under each alternative, see the Schedule of Benefits. You decide which plan best fits your needs. A current list of participating providers for each option is maintained at the Fund Office and you will be notified of updates. You can receive a copy of this list from the Fund Office upon request at no charge. Dental Plan 1 Care-Plus Dental Plans, Inc. Care-Plus Dental Plans, Inc. has been selected to provide one of your two coverage options. Services are provided by Dental Associates dentists. Under this arrangement, the Fund pays Care-Plus a monthly fee for families who select this alternative. If you choose this program, you and each of your eligible dependents must select a dental office from the listing provided in your enrollment packet. All dental services, from routine examinations to specialty care, are provided through the dental office you choose. Benefits are payable up to the percentage and maximum amount stated in the Schedule of Benefits for reasonable expenses related to preventing dental disease, restoring teeth, furnishing dentures, and straightening teeth (orthodontia). Please be advised that Care-Plus charges a $30 administrative fee if you cancel a dental appointment within four hours of your scheduled time. The Plan will not pay this fee; it will be your responsibility. Make sure to cancel an appointment well in advance if you know you can t make it to avoid this unnecessary expense. Routine Services Routine services performed by a dentist for the following: (a) routine oral examination and diagnosis; (b) dental x-rays, if professionally indicated; and (c) prophylaxis, which also may be performed by a dental hygienist under the direction and supervision of a dentist. You and each of your dependents are entitled to two routine oral examinations, two sets of dental x-rays, and two prophylaxis each calendar year. Basic Dental Care Basic dental care includes services performed by a dentist for an actual or suspected dental disease, defect, or injury. These benefits include, but are not necessarily limited to: (a) x-rays; (b) emergency treatment; (c) treatment of periodontal disease; (d) extractions, including removal of multiple unimpacted teeth; (e) root canal therapy; (f) crowns, fillings, and inlays; (g) bridgework and repair of bridgework; (h) space maintainers and related services; (i) initial installation or repair of a full or partial denture; 40

52 (j) replacement of a partial denture; and (k) examination and treatment by a dentist in connection with an actual or suspected dental disease, defect, or injury. Full Denture Replacement A full denture replacement includes services of a dentist for replacement of an existing full upper or lower denture or full dentures. One replacement of one upper denture or one lower denture or one full set of dentures is provided to you and each of your dependents each five consecutive years, as medically necessary. Orthodontic Benefits Benefits are payable for reasonable expenses incurred during an entire period of orthodontic treatment, provided you or your dependent is eligible when the treatment begins and during the entire course of treatment. Benefits payable for orthodontic treatment are subject to the lifetime maximum orthodontic benefit stated in the Schedule of Benefits, which means the aggregate amount payable for all orthodontia expenses per each eligible person's lifetime. Eligible dental expense for this provision is expense incurred as the result of the initial and subsequent installation of orthodontic appliances, including all orthodontic treatment rendered by an orthodontist preceding and subsequent to the installation. Limitations Benefits available under Dental Plan 1 will not be duplicated if similar benefits are payable by another group plan. Care-Plus reserves the right to recover payments that are the liability of a third party. The Care-Plus Plan does not cover the following: (a) Dental services which are not specified in the Dental Contract. (b) Dental services with respect to congenital malformations or which are primarily for cosmetic purposes, except for congenitally missing teeth. (c) Any duplicate prosthetic device or any other duplicate appliance. (d) Replacement of lost or stolen prosthetic devices or appliances. (e) Replacement of an orthodontic appliance. (f) Any splinting procedure and/or double abutment in connection with fixed bridgework or any service to stabilize periodontally weakened teeth. (g) Appliances, restorations, or procedures necessary to adjust vertical dimension or to restore occlusion. (h) Treatment of temporomandibular joint (TMJ) dysfunction. (i) Gold foil, gold, or other precious metal restorations, except when used as a necessary functional material. (j) Implants or transplants. (k) Dental service or emergency service: (1) That would be furnished without charge to you by any person or entity other than Care- Plus; (2) Which you would be entitled to have furnished or paid for, fully or partially, under any law, regulation, or agency of any government; (3) Which you would be entitled to have furnished or paid for (or would be entitled if you were enrolled) under any voluntary medical or dental insurance plan established by any government if this Contract were not in effect; (4) For which benefits otherwise are provided or available under a surgical, medical, or prescription drug coverage; (5) For, or resulting from injuries, disease, or conditions for which you receive, or are the subject of, any award or settlement under a Worker s Compensation Act or any Employer Liability Law; 41

53 (6) Rendered or furnished after the date you cease to be covered under this Contract, except for: (i) procedures (other than prosthetic services) commenced prior to, and completed in one visit within 31 days following termination of coverage; and (ii) prosthetic devices which were ordered and fitted prior to, and completed within 60 days following termination of coverage. (7) Emergency care provided at a location other than the offices of the primary provider, except as provided in the Schedule of Benefits. (l) Hospital or physician services of any kind, whether or not related to covered dental services. (m) Dental service and emergency service resulting from diseases contracted or injuries sustained as a result of war, declared or undeclared, enemy action, or action of the Armed Forces of the United States, or its allies, or while serving in the Armed Forces of any country; or any injury or sickness occurring after the effective date of this Contract and caused by atomic explosion whether or not the result of war. (n) Reimbursement to you or any dental office for the cost of dental services secured from dentists other than network providers, unless expressly authorized in writing by the network dentist. (o) Dental service and emergency service received from a dental or medical department maintained on behalf of an employer, a mutual benefit association, a labor union, academic institution, trustee or similar person or group. (p) Replacement of an existing removable partial denture, full denture, fixed bridge, or crown by a new removable partial denture, full denture, fixed bridge, or crown will not be provided more often than once in every five-year period. The five-year period will be measured from the date on which the existing appliance was last supplied, whether under this Contract or under any other dental coverage. (q) If a satisfactory result can be achieved by a conventional removable partial denture in the case of bilateral edentulous areas, but you select a more complicated treatment (precision attachments or fixed bridgework), benefits will be limited to the appropriate procedures necessary to eliminate oral disease and restore missing teeth. The balance of the cost for the more elaborate selected procedure will be your responsibility. (r) Services or supplies for personalization or characterization of dentures or bridges. (s) Posterior composite restorations. (t) Crowns to restore diseased or broken teeth when tooth can be restored by a conventional type filling. (u) Any service related to: (1) Replacing tooth structures as a result of abrasion, attrition, or erosion. (2) Bite registration or bite analysis. Please Note: The prior description of the insured Dental Plan 1 is only a summary of the provisions of the Care-Plus dental insurance policy; the insurance policy certificate contains the complete description of benefits and limitations and governs in cases of conflict. 42

54 Dental Plan 2 - Delta Dental Plan of Wisconsin Delta Dental Plan has been selected to provide your second dental coverage option. The Group Dental Contract issued to the Fund is the complete document of coverage and governs all claims processing. You can find a participating network dentist and access benefit information (such as eligibility and claim status) by calling: or visiting: Selecting a Dentist Delta Dental PPO offers a benefit to those patients receiving treatment from a PPO dentist. A PPO Dentist List is provided to you periodically from which you may choose a PPO Dentist. However, you and your eligible dependents may select any dentist on a treatment by treatment basis, whether or not the dentist is included on the PPO Dentist List. IT IS IMPORTANT TO REMEMBER YOUR OUT- OF-POCKET COSTS MAY BE LOWER WHEN YOU SEE A PPO DENTIST. PPO DENTIST: is a licensed dentist who has signed an agreement with Delta Dental to accept payment based on a reduced fee schedule. Delta Dental s payment and the patient's payment, if any, are accepted by the PPO Dentist as payment in full. Delta Dental s payment is sent directly to the PPO Dentist. PARTICIPATING DENTIST: You are free to go to the dentist of your choice. If your dentist has signed a Participating Dentist Agreement with Delta Dental Plan, he has agreed to accept direct payment from Delta Dental on a usual, customary, and reasonable (UCR) fee basis. The Participating Dentist will charge you only for copayments, deductibles, and services not covered by your particular Group Dental Contract. You will receive an Explanation of Benefits form indicating the amount Delta Dental has paid to the Participating Dentist and the amount, if any, you owe the dentist. NONPARTICIPATING DENTIST: If your dentist has not signed a Participating Dentist Agreement with Delta Dental, payment will be calculated on a UCR fee basis and sent directly to you. You are responsible for reimbursing your dentist through his usual billing procedure. If the fee charged is not allowed in full, Delta Dental is not implying that the dentist is overcharging. Dental fees vary and are based on the dentist's overhead, skill, and experience. Therefore, not every dentist will have fees that fall within the allowable UCR fee range. For dental benefits and services provided by an out-of-state dentist, Delta Dental will pay directly to the dentist the applicable percentage of the reduced fee schedule. The difference between Delta Dental s payment and the out-ofstate dentist s full fee is your financial responsibility. Filing Claims To file a claim, simply present your I.D. card to the receptionist at the dental office or give your Social Security number. Delta Dental accepts any standard claim form and will provide claim forms to your dentist on request. Predetermination of Benefits After an examination, your dentist will recommend a treatment plan. If the services involve crowns, fixed bridgework, partial/complete dentures, or orthodontics, ask your dentist to send the treatment plan to Delta Dental, including x-rays. The available benefits will be calculated and printed on a Predetermination of Benefits form, which will be returned to your dentist. Before you schedule dental appointments, you should discuss with your dentist the amount to be paid by Delta Dental and your financial obligation for the proposed treatment. The Predetermination of Benefits is valid for 90 days from the date of issue, provided you maintain your eligibility under the Plan. Optional Treatment In all cases in which a patient selects a more expensive service than is customarily provided, or for which Delta Dental does not believe a valid need is shown, Delta Dental will pay the applicable percentage of the fee for the service which is adequate to restore the tooth or dental arch to contour and function. The patient is responsible for the entire remainder of the dentist's fee. 43

55 Description of Services The following services are covered, subject to the maximums stated in the Schedule of Benefits, the limitations described within each coverage category, and the Limitations on pages 45 and 46. Coverage A - Diagnostic and Preventive Services (a) Examinations, no more frequently than twice in a calendar year. (b) Full mouth x-rays once each three years; either individual films or panoramic film, including bitewings. (c) Bitewing x-rays, no more frequently than twice in a calendar year (limited to a set of four films). (d) Dental prophylaxis (teeth cleaning), no more frequently than twice in a calendar year. (e) Topical fluoride applications, no more frequently than twice in a calendar year. (f) Space maintainers for retaining space when a primary tooth is prematurely lost. Coverage B - Regular Restorative Services (a) Emergency treatment to relieve pain. (b) Extractions and other oral surgery (cutting procedures) including pre-operative and postoperative care, except those procedures covered under Comprehensive Major Medical Benefits. Both scalpel and brush biopsies for the prevention and early detection of oral cancer will be covered. (c) Amalgam (silver) restorations, one placement per tooth surface in a 12-month period. Composite (tooth-colored) restorations in anterior (front) teeth - one placement per tooth surface in a 12-month period. Stainless steel prefabricated crowns - one per tooth surface in a three-year period. (d) Topical application of sealants for dependents to age 14. Application is limited to the occlusal surface of permanent molars which are free of decay and restorations. Benefits are limited to one application per tooth per lifetime. (e) Local anesthetic is covered as a part of a dental procedure. General anesthetics or intravenous sedation is a benefit only when billed with covered oral surgery (cutting procedures). (f) Endodontics includes root canal treatments and root canal fillings, once per tooth in a two-year period. (g) Periodontics includes procedures necessary for the treatment of disease of the gums and bone supporting teeth. Non-surgical treatment is limited to once each 24 months. Surgical treatment is limited to once each three years except those procedures covered under Comprehensive Major Medical Benefits. Periodontal prophylaxis is a benefit four times each calendar year, when medically necessary. (h) Dental implants. Coverage C - Special Restorative Services (a) Crowns, inlays, or onlays are provided when teeth are broken down by dental decay or accidental injury and no longer may be restored adequately with a filling material. (b) Prosthetics includes fixed bridgework, partial dentures, and complete dentures to replace missing permanent teeth. (1) Repairs and adjustments to prosthetic appliances. Denture reline and rebase is a benefit once in any 36-month period. (2) Porcelain veneers on crowns or pontics are covered benefits only on the six front teeth, bicuspids, and upper first molars. (3) Coverage for the purpose of replacing a defective existing crown, inlay, onlay, fixed bridge, or partial/complete denture will be provided only after a five-year period from the date on which it was last supplied, whether or not it was benefited by Delta Dental. 44

56 (4) Fixed bridges and partial/complete dentures are provided where chewing function is impaired due to missing teeth. Complete or partial dentures should be constructed when necessary to replace missing teeth. Fixed bridges will be a benefit only if the use of a removable prosthetic appliance is inadequate. Coverage D - Orthodontic Services Includes orthodontic appliances and treatment, related services for orthodontic purposes to include examinations, x-rays, extractions, photographs, study models, etc., for you, your spouse, and your dependent children. Coverage includes orthodontic treatment in progress. Liability for orthodontic treatment in progress extends only to the unearned portion of the treatment in progress. Delta Dental will be the sole determinant of the unearned amount eligible for coverage. Repair or replacement of orthodontic appliances is not covered. If orthodontic treatment is stopped for any reason before it is complete, Delta Dental will pay only for services and supplies actually received. There are no benefits available for charges made after coverage stops. Delta Dental calculates all orthodontic treatment schedules according to the following formula: 25% of the total case fee is considered the initial payment to be paid by Delta Dental and the patient at the stated copayment percentage. Remainder of the allowed fee is divided by the months of treatment. Monthly payments are made by Delta Dental at the stated copayment percentage, up to the orthodontic maximum benefit. Limitations Coverage is not provided under the Delta Dental Plan for: (a) Services for injuries or conditions compensable under Worker's Compensation or Employer's Liability Laws. (b) Prescription drugs, premedications, and relative analgesia; charges for anesthesia other than charges by a licensed dentist for administering general anesthesia in connection with covered oral surgery (cutting procedures); preventive control programs; charges for failure to keep a scheduled visit with the dentist; charges for completion of forms; charges for consultation. (c) Charges by any hospital or other surgical or treatment facility and any additional fees charged by a dentist for treatment in any such facility. (d) Treatment of or services related to temporomandibular joint dysfunction (TMJ). (e) Services which are determined to be partially or wholly cosmetic in nature. (f) Cast restorations placed on eligibles under age 12; prosthetics placed on eligibles under age 16. (g) Appliances or restorations for increasing vertical dimension; for restoring occlusion; for correcting harmful habits; for replacing tooth structure lost by attrition; for correcting congenital or developmental malformations for temporary dental procedures; or for splints, unless necessary as a result of accidental injury. (h) Treatment by other than a licensed dentist, his employees, or agents. (i) Dental care injuries or disease caused by war or acts of war, riots or any form of civil disobedience; injuries sustained while committing a criminal act; injuries intentionally inflicted; dental care injuries or diseases caused by atomic or thermonuclear explosion or by the resulting radiation. (j) Treatment rendered outside of the United States or Canada. (k) Replacement of lost or stolen dentures or charges for duplicate dentures. (l) Those services and benefits not specifically provided under the Contract and/or excluded by the rules and regulations of Delta Dental, including the processing policies, which may change periodically and are printed on the 45

57 Explanation of Benefits form and Claim Payment Voucher. (m) Services or appliances, including prosthetics (crowns, bridges, and dentures), started prior to the date the patient became eligible under the Wisconsin Pipe Trades Health Fund. Claims not submitted to Delta Dental Plan of Wisconsin within 90 days of the date of service still will be accepted and processed within 15 months of the date of service. Settlement of Disputes In the event of a dispute between Delta Dental Plan of Wisconsin and the dentist with respect to any of the terms, conditions, or benefits of this Plan, the facts will be presented by the Plan or the dentist, with notice given to the other party, to the local Peer Review Committee of the local dental society for adjudication by such Committee. If the Plan or the dentist is not satisfied with the judgment of the local Peer Review Committee, an appeal may be made to the State Peer Review Committee. All disputes will be settled in this manner before any action at law is taken by the Plan. Plan Liability Delta Dental acts only as the intermediary between dentists, the Group, and our subscribers. In no instance will Delta Dental be liable for any conduct including but not limited to tortious conduct, negligence, wrongful acts or omissions of any person including but not limited to subscriber, dentist, dental assistant, dental hygienist, hospital or hospital employee, receiving or providing services. In no instance will Delta Dental be liable for services of facilities which, for any reason, are unavailable to the subscriber. Grievance Procedures A grievance is any dissatisfaction with the administration or claims practices of this Plan submitted to us in writing. Delta Dental will acknowledge a grievance within 10 days of receiving it. All grievances will be resolved within 30 days from the date the grievance is received. Should Delta Dental be unable to resolve the grievance within that time, we will notify you when a resolution may be expected, within 30 additional days, and the reason for the delay. Delta Dental will notify you in writing of the resolution of the grievance. You have the right to appear in person before the Grievance Committee to present written and oral information and ask questions of those people responsible for the determination which resulted in the grievance. Delta Dental will provide written notice of the meeting place and time at least seven days before the meeting. 46

58 TRICARE STANDARD-SUPPLEMENT BENEFITS Class D Dependents TRICARE Standard-Supplement Benefits are payable only for eligible dependents in Class D who are covered under the TRICARE Standard Program (formerly the Civilian Health and Medical Program of the Uniformed Services or CHAMPUS ). The benefits payable under this Plan are limited to: (b) TRICARE Standard-required copayments for TRICARE Standard covered in- and outpatient services. Vision Care and Dental Care Benefits also are available to Class D persons. (a) the deductible required by TRICARE Standard for covered outpatient services; and 47

59 SUPPLEMENTAL DOLLAR BANK REIMBURSEMENT PROGRAM The Supplemental Dollar Bank (SDB) Reimbursement Program is available to all active employees and retirees who have a dollar bank balance. Withdrawals from your SDB are tax-exempt, but are limited to the following eligible expenses: (a) To make monthly self-payments (full or partial payments), in the event you do not work the required number of hours each month; (b) To make retiree self-payments; (c) To make dependents self-payments in the event of your death; or (d) As reimbursement for eligible out-of-pocket health care expenses, such as deductibles and copayments. In order for an expense to be reimbursable from your SDB, the expense must: (a) have been incurred on or after January 1, 2005; (b) be payable by you or your dependent; (c) not have been payable under the regular health care benefits provided by this Plan or any other source of coverage; and (d) not have been subject to any previous tax deduction. The following expenses are examples of the types of healthcare expenses eligible for reimbursement: Acupuncture (excluding remedies and treatment prescribed by acupuncturists) Alcoholism treatment Ambulance Artificial limbs/teeth Chiropractic care Contact lenses and solutions Copayments Costs for physical or mental illness confinement Crutches Deductibles Dental fees Dentures Diagnostic fees Dietary supplements with doctor s letter of medical necessity Drugs and health care supplies (i.e., syringes, needles, etc.) Eyeglasses prescribed by your doctor Eye examination fees Eye surgery (cataracts, LASIK, etc.) Hearing devices and batteries Hospital bills Insulin Laboratory fees Obstetrical fees Oral surgery Orthodontic fees Orthopedic devices if the device is dualpurpose; documentation from health care provider may be required and reimbursement may be limited to extra cost incurred for health care use Over-the-counter drugs that are medically necessary, like allergy medications, aspirin, or antacids Oxygen Physician fees Premiums you pay for health or long-term care coverages Prescribed medications Psychiatric care Psychologist fees Routine physicals and other non-diagnostic services or treatments Smoking-cessation over-the-counter drugs Smoking-cessation programs Surgical fees Vitamins with doctor s letter of medical necessity Weight-loss over-the-counter drugs with doctor s letter of medical necessity Weight-loss programs with doctor s letter of medical necessity Wheelchair X-rays The following types of expenses are not considered eligible for reimbursement: Cosmetic surgery and procedures 48

60 Dental bleaching Marriage and family counseling Over-the-counter items, drugs or medications that are not medically necessary or are not prescribed by your physician Premiums for dental insurance coverage Premiums your spouse pays for his/her employer-sponsored insurance coverage Weight-loss programs for general health or appearance You will be mailed a reimbursement request form twice annually. Instructions for submitting the reimbursement request and the applicable deadline will be included with the form. You must be eligible under the Plan at the time of your request to receive reimbursement. For expenses other than the Plan deductible and copayments, a copy of the itemized bill must be submitted with the request. Upon receipt of a properly completed reimbursement request, the Plan will issue you a reimbursement check and will deduct the amount of the reimbursement from your SDB. 49

61 GENERAL PROVISIONS Classes A, B, C, and JD Employees and Dependents Coordination of Benefits If you or your eligible dependents are entitled to benefits under any other group health care plan, the amount of benefits payable by this Plan will be coordinated so that the total amount paid will not exceed 100% of the medical expenses incurred. In no event will this Plan's payment exceed the amount which would have been paid if there were no other plan involved. Benefits payable under another plan include the benefits that would have been payable even if no claim actually was filed. When another plan provides benefits in the form of services, the reasonable cash value of each service will be considered both an allowable expense and a benefit paid. Order of Benefit Calculation. If the other group plan does not contain a coordination of benefits or similar provision, then that plan always will calculate and pay its benefits first. When duplicate coverage arises and both plans contain a coordination of benefits or similar provision, the eligible employee must report such duplicate group health care coverage on the claim form which is submitted to secure reimbursement of allowable expenses incurred. This Plan has established the following rules to decide which group plan will calculate and pay its benefits first. (a) If a patient is eligible as an employee in one plan and as a dependent in another, the plan covering the patient as an employee will determine its benefits first. (b) If a patient is eligible as a dependent child in two plans, the plan covering the patient as the dependent of that parent whose date of birth, excluding year of birth, occurs earlier in a calendar year will determine its benefits first. (c) When parents are divorced or separated, the order of benefit determination is: (1) The plan of the parent having custody pays first. (2) If the parent having custody has remarried, the order is: (i) the plan of the parent having custody; (ii) the plan of the spouse of the parent having custody; (iii) the plan of the parent not having custody; then (iv) the plan of the spouse of the parent not having custody. However, when a Qualified Medical Child Support Order names and directs one of the parents to be responsible for the child's health care expenses, the plan of that parent will pay first and will supersede any order given here. Also, if the specific terms of a court decree state that the parents have joint custody of the child and do not specify that one parent has responsibility for the child's health care expenses OR if the court decree states that both parents will be responsible for the health care needs of the child but gives physical custody of the child to one parent (and the entities obligated to pay or provide the benefits of the respective parent's plans have actual knowledge of those terms), benefits for the dependent child will be determined according to the prior subsection (b). (d) If rules (a), (b), and (c) do not determine which plan will calculate and pay its benefits first, then the plan that has covered the patient for the longer period of time will determine its benefits before a plan that has covered the patient for a shorter time. There is one exception to this rule: A plan that covers a person other than as a laid-off or retired employee, or a dependent of such person, will determine its benefits first, even if it has covered the eligible person for the shorter time. 50

62 In addition, if a person whose coverage is provided under a right of continuation pursuant to federal or state law also is covered under another plan, the benefits of the plan which covers the person as an employee will be determined before the benefits under the continuation coverage. Benefits of this Plan will be reduced to the extent necessary to prevent the other group plan from refusing to pay benefits available under its policy. Credits. Whenever this Plan is considered the secondary plan and a medical claim payment is reduced because of this provision, the amount of reduction will be carried for the balance of the calendar year as a credit for the person for whom the claim was made. This amount may be used for other medical claims due to any cause in the same calendar year, provided the person has an out-ofpocket allowable expense after the normal benefits under both plans have been provided or paid. A claim record with credit is maintained only for one calendar year. Each January 1st, a new record begins for each eligible person. Medicare Provisions Eligible persons who are retired or disabled are required to enroll in Part A and Part B of Title XVIII of the Social Security Amendments of 1965 (more commonly known and described as "Medicare") in the event they become entitled to such coverage by reason of attained age, qualifying disability, or End Stage Renal Disease (ESRD). In no event will benefits paid by the Plan exceed the applicable amounts stated in the Schedule of Benefits, nor will the combined amounts payable under Part A and Part B of Medicare and the Plan exceed the eligible expenses incurred by the eligible person as the result of any one injury or sickness. Benefits payable by Part A or Part B of Medicare include those which would have been payable if the eligible person had properly enrolled when eligible to do so. For eligible persons for whom Medicare is the primary source of coverage, the benefits payable under this Plan for services incurred at a Veterans Administration (VA) facility for non-serviceconnected disabilities will be reduced by the amount that would have been payable by Medicare had the services been rendered by a Medicareapproved facility. For eligible persons for whom Medicare is the primary source of coverage, the benefits payable under this Plan for services otherwise covered by Medicare, but which are privately contracted with a provider, will be limited to the amount that would have been payable by the Plan had the services been payable by Medicare. For Class C retirees, the benefits payable under this Plan for services otherwise covered by Medicare, but which are obtained outside the United States, will be limited to the amount that would have been payable by the Plan had the services been payable by Medicare. For eligible persons for whom Medicare is the primary source of coverage and who have enrolled in a Medicare+ Choice plan: the benefits payable under this Plan for services otherwise covered by Medicare, but which are not covered under the Medicare+ Choice plan because the eligible person did not obtain services at a network provider and/or did not comply with that plan s managed care requirements, will be limited to the amount that would have been payable by the Plan had the services been payable by Medicare. To facilitate Plan payments in the absence of Medicare payments, it may be necessary for the Trustees to estimate Medicare payments. Neither you nor the Plan will be responsible for paying any charges which exceed legal limits set by the Medicare Physician Payment Reform Act which limits the amount that physicians can bill Medicare patients above the Medicare allowance for a particular procedure or service, unless services are privately contracted. (a) Persons Initially Entitled to Medicare by Reason of Attained Age or Qualifying Disability (other than ESRD) and Eligible Under the Plan Through Self-Payments. In the event a person eligible in Class A, B, C, or JD solely because of self-payments becomes initially entitled to Part A or Part B of Medicare due to attained age or a qualifying disability (other than ESRD), benefits payable under this Plan will be reduced by the amount of benefits paid or payable under Part A or Part B of Medicare. 51

63 If such person subsequently becomes entitled to Medicare due to ESRD, Medicare will continue to be the primary source of coverage. (b) Persons Initially Entitled to Medicare by Reason of Attained Age or Qualifying Disability (other than ESRD) and Eligible Under the Plan Through Employer Contributions. Plan benefits are not reduced for persons eligible in Class A or Class JD through employer contributions even though they also may become initially entitled to Part A or Part B of Medicare due to attained age or a qualifying disability (other than ESRD). In the event such person subsequently becomes entitled to Medicare due to ESRD, the Plan will continue to be the primary source of coverage for the full 30-month coordination period specified in the following subsection (c). However, an active employee or dependent spouse eligible in Class A or Class JD through employer contributions who becomes initially entitled to Medicare due to attained age will have the right to reject the Plan and retain Medicare as their primary source of coverage. In such case, the Plan is legally prohibited from supplementing Medicare coverage. (c) Persons Initially Entitled to Medicare by Reason of ESRD and Eligible Under the Plan Through Either Self-Payments or Employer Contributions. In the event an eligible person becomes initially entitled to Part A or Part B of Medicare because of ESRD (or when ESRD-based Medicare entitlement occurs simultaneously with attained age or other qualifying disability-based entitlement), benefits will be provided subject to the following terms. The same terms will apply in the event an eligible person becomes initially entitled to Medicare due to ESRD and subsequently becomes entitled to Medicare due to attained age or another qualifying disability. (1) The Plan will be the primary source of coverage for covered charges incurred for up to 30 consecutive months from the date of ESRD-based Medicare entitlement. (2) Benefits payable under the Plan beginning with the 31st month of ESRD-based Medicare entitlement will be reduced by the amount of benefits paid or payable under Part A or Part B of Medicare. Subrogation Whenever the Wisconsin Pipe Trades Health Fund has been or is providing hospital, medical, dental, vision, or disability benefits ("Benefits"), as a result of the occurrence of any injury, sickness, or death which results in a possible recovery of indemnity from any party, including an insurer, including uninsurance and underinsurance coverage, the Fund may make a claim or maintain an action against such party. By virtue of accepting such Benefits resulting from an injury, sickness, or death which results in a possible recovery from any party, including an insurer, including uninsurance and underinsurance coverage, the eligible person assigns to the Fund the right to make a claim against such party to the extent of the amount of such Benefits. An eligible person must not do anything after the loss for which Benefits were provided to prejudice the Fund s right of recovery. An eligible person must promptly advise the Administrative Manager of this Fund in writing whenever a claim against any party is made by or on behalf of the eligible person with respect to any loss for which Benefits were, or are being, received from the Fund. The recipient of Benefits has an obligation to provide the Fund or its designee with the names and addresses of all potential parties and their insurers, adjusters, and claim numbers, as well as accident reports and any other information the Fund requests. If the information requested is not provided, the Fund in its discretion may withhold future benefit obligations pending receipt of the requested information. The eligible person or the Fund may make a claim against a party or commence an action against a party and join the other as provided under Section of the Wisconsin Statutes or applicable state or federal law. Each will have an equal voice in the pursuit of such claim or action. The proceeds from any settlement or judgment in any claim made against any party will be allocated as follows: 52

64 (a) First, a sum sufficient to fully reimburse the Fund for all Benefits advanced will be paid to the Fund. No court costs nor attorneys fees may be deducted from the Fund s recovery without prior expressed written consent of the Fund. This right will not be defeated by any socalled Fund Doctrine or Common Fund Doctrine or Attorneys Fund Doctrine or any other similar doctrine or theory. (b) Any remainder will be paid to the eligible person on whose behalf claim is made. (c) The Fund will receive a credit, up to the full amount of any remainder paid to the recipient of Benefits pursuant to the prior subsection (b), to apply against any future Benefit obligations arising out of the injury, sickness, or death which was the subject of the claim which resulted in the settlement or judgment. The aforesaid allocation of proceeds will be paid from the first dollar of any proceeds received and will have a priority over competing claims regardless of whether the total amount of the recovery of the eligible person, or those claiming under him, is less than the actual loss suffered, or less than the amount necessary to make the eligible person, or those claiming under him, whole. The Fund s rights will not be defeated or reduced by the application of any so-called Made-Whole Doctrine, Garrity Doctrine, Rimes Doctrine, or any doctrine purporting to defeat the Fund s rights by allocating the proceeds exclusively, or in part, to non-medical expenses damages. Furthermore, such allocation will apply to claims of dependents of employees covered by the Fund, regardless of whether such recipient was legally responsible for expenses of treatment. If an eligible person makes a recovery in a claim from any party and the proceeds are not allocated according to the prior paragraphs, the Trustees will have the right to make a claim for reimbursement, including but not limited to, claims for restitution, unjust enrichment, or a constructive trust over any recovery by the eligible person, to the extent of the Fund s expenditures, whether the recovery is paid to, or in the possession of, the eligible person, the eligible person s attorney, or any other individual or entity, or to take a credit on future Fund obligations to the eligible person to the extent of such Benefits. This credit will not be limited to future obligations of the Fund to the actual recipient of such Benefits but also may be taken against any future obligations to the eligible employee or any of his dependents. Right of Recoupment Whenever the Plan has made unauthorized or erroneous payments or overpayments, the Trustees have the right to recover such unauthorized or erroneous payments or overpayments from one or more of the following sources: (a) any person to whom or on whose behalf such payments were made, including by making deductions from benefits which may be payable to or on behalf of such person in the future; or (b) any service provider, insurance company, or other entity to whom such unauthorized or erroneous payment or overpayment was made. Physical Examinations The Trustees, through a physician they may designate, have the right and opportunity to have medically examined any individual whose injury or sickness is the basis for a claim when and as often as they reasonably may require during the pendency of a claim under the Plan. General Exclusions The Plan does not cover: (a) injury which arises out of, or occurs in the course of, engaging in any occupation or employment for wage or profit (except for Death and Accidental Death and Dismemberment Benefits); (b) sickness for which the eligible employee is entitled to benefits under any Worker's Compensation or Occupational Disease Law. However, in either the previously-referenced (a) or (b), if: (1) The eligible person has been denied Worker s Compensation or Occupational Disease Benefits; and (2) The eligible person and his attorney execute an agreement provided by the Fund stating and agreeing to repay and reimburse the Fund for all benefits paid by the Fund on 53

65 behalf of the eligible person for said injury out of any recovery proceeds, whether by settlement or otherwise, then the Fund will cover such expense, subject to the terms and conditions of the Plan. Failure by the eligible person to comply with the reimbursement agreement allows the Fund, at its discretion, to either: (1) Take a credit against future claims of the eligible person up to the amount of the Fund s expenditures of such expense; (2) Initiate legal proceedings to recover the Fund s expenditures; or (3) Exercise the Fund s right to reimbursement, including but not limited to, claims for restitution, unjust enrichment, or a constructive trust over any recovery by the eligible person, to the extent of the Fund s expenditures, whether the recovery is paid to, or in the possession of, the eligible person, the eligible person s attorney, or any other individual or entity. (c) care for armed service-connected disabilities furnished within any facility of, or provided by, the United States Department of Veterans Affairs or Department of Defense; (d) care for non-service-connected disabilities furnished within any facility of, or provided by, the United States Department of Veterans Affairs or Department of Defense for which there has not been furnished to the Fund Office required details and supporting papers; (e) expenses which the eligible person would not be required to pay in the absence of these benefits; (f) any loss caused by war or any act of war (declared or undeclared); (g) loss incurred while engaged in military service (including naval or air service) for any country; (h) aesthetic cosmetic surgery, treatment, or supplies, unless: (1) necessary for repair or alleviation of damage resulting from an injury; or (2) to correct a scar, disfigurement to the area above the shoulders which is the result of a sickness, disease, surgery, or previous therapeutic process that is a covered service under this Plan, excluding conditions related to developmental disabilities or congenital deformities, such as by way of example but not limited to, port wine stain, unless such condition has resulted in a functional defect. Such surgery must be performed no later than six months from the date of the injury or surgery that caused the scar or disfigurement; or the date the treatment or therapeutic process that caused the disfigurement ended. (This time period may be extended for a period of up to five years following the date of the injury or surgery, provided the eligible person submits a medical treatment plan from his attending physician with substantiation that the corrective treatment could not be completed within six months and for services and prostheses received for the well-being of cancer patients after radiation, chemotherapy, or surgery such as a mastectomy, or as otherwise may be specifically provided under the Plan); (i) artificial life support systems, including, without limitation, cardiopulmonary resuscitation systems, for any eligible person after such person has been determined to be dead within the meaning of Section , Wisconsin Statutes ( ), or determined to be clinically dead, except as provided in paragraph (g)(9) of "Covered Expenses" (on page 26) with respect to which the Plan's liability is limited to the first five days after death has been so determined, not to exceed $5,000 in the aggregate; (j) the cost of removal of organs from a transplant donor who is a living eligible person or who was an eligible person prior to his death, unless the transplant recipient is an eligible person; (k) experimental surgical procedures or treatments, except as may be specifically provided under the Plan or those that may be authorized by the Board of Trustees pursuant to advice provided by a competent medical authority retained by the Trustees as medical consultant; 54

66 (l) services for or related to invitro-fertilization; (m) sex change operations and non-organic sexual dysfunctions; (n) artificial insemination; (o) care for conditions suffered while engaged in the commission of a felony or while attempting to commit a felony, or while engaged in a riot, other than when engaged in, as part of, or in connection with, a labor dispute; (p) suicide or attempted suicide (except for Death Benefits), unless caused by an underlying medical condition; (q) state and local taxes incurred on covered expenses; (r) services performed by a person who lives with you or is part of your family (comprised of you, your spouse, or your or your spouse's child, brother, sister, or parent). However, dental treatment provided by a dentist who lives with you or is part of your family will be covered; (s) radial keratotomy or Lasik surgery; (t) shipping and handling for charges incurred on covered expenses; (u) drugs or medicines prescribed by a physician which are available as over-the-counter purchases, including but not limited to, aspirin, cough medicine, vitamin supplements, etc.; (v) charges incurred for travel, whether or not recommended by a physician, except if specified as a covered expense under the Plan; (w) charges incurred for the completing of claim forms (or forms required by the Plan for the processing of claims) by a physician or other provider of medical services or supplies; (x) any losses incurred by an eligible person at a time than an eligible person owes payment to the Plan because of benefit payments made in reliance upon incorrect, misleading, or fraudulent statements or representations by an eligible person, or where such person has failed to honor the Plan s right of subrogation or reimbursement or otherwise failed to cooperate with the Plan as specified; or (y) homeopathic providers, services, and supplies. Termination of Plan This Plan may be terminated: (a) as to participants (and their dependents) in a particular collective bargaining unit, by agreement of the union and employer association (or individual employers, where applicable) which negotiate the labor agreements covering such collective bargaining units; or (b) when the Trustees determine that the Trust Fund is inadequate to carry out the intent and purpose of the Trust Agreement or is inadequate to meet the payments due or to become due participants and/or dependents under the Trust Agreement or under the Plan Document. In the event of termination, the Trustees will: (a) make provision out of the Trust Fund for the payment of expenses incurred up to the date of termination of the Trust and the expenses incidental to such termination; (b) arrange for a final audit and report of their transactions and accounts, for the purpose of termination of their Trusteeship; (c) apply the Trust Fund to pay any and all obligations of the Trust and distribute and apply any remaining surplus in such manner as will, in their opinion, best effectuate the purposes of the Trust and the requirements of law; and (d) give any notices and prepare and file any reports which may be required by law. Interpretation by Trustees Benefits under this Plan will be paid only if the Board of Trustees (or its Plan Administrator) decides in its discretion that the applicant is entitled to them. The Plan will be interpreted and applied in the sole discretion of the Board of Trustees (or its delegate, including but not limited to, its Plan Administrator). Such decision will be final and binding on all persons covered by the Plan who are claiming any benefits under the Plan. 55

67 Prohibition Against Assignment to Providers You, as an eligible person, participant, or beneficiary, may not assign any right under the Plan or statutory right under applicable law to a provider of services or supplies. The prohibition against assignment of such rights includes, but is not limited to, the right to: (a) receive benefits; (b) claim benefits in accordance with Plan procedures and/or federal law; (c) commence legal action against the Plan, Trustees, Fund, its agents, or employees; (d) request Plan documents or other instruments under which the Plan is established or operated; (e) request any other information that a participant or beneficiary as defined in Section 102 of ERISA may be entitled to receive upon written request to a Plan Administrator; and (f) any and all other rights afforded an eligible person, participant, or beneficiary under the Plan, Restated Trust Agreement, federal law, and state law. This provision does not have the effect of prohibiting the claims administrator or the Trustees from mailing payment of benefits under the Plan directly to a provider of services or supplies. Privacy Policy Under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), the Plan is required to protect the confidentiality of your protected health information, including electronic protected health information. Generally, health information means any information, whether oral or recorded in any form or medium, that is created or received by a covered entity such as the Plan, and relates to your past, present, or future physical or mental health condition, the provision of health care to you, or your past, present, or future payment for the provision of health care. By law, you have a right to adequate notice of the uses and disclosures of your protected health information that may be made by the Plan, and of your rights and the Plan s legal duties with respect to your protected health information. The Plan s Privacy Notice sets forth your rights under HIPAA s privacy rules and regulations and the Plan s privacy policies and procedures. You may obtain a copy of the Plan s Privacy Notice by contacting the Fund Office. Please be advised that the Plan will provide eligibility and basic claims payment information to members of your family and those who are involved in your health care unless you request otherwise. As a condition of Plan participation, the Board of Trustees require that the privacy rights of you, your spouse, and dependents be governed only by the Health Insurance Portability and Accountability Act of 1996 ( HIPAA ) and the laws of the state of Wisconsin (but only to the extent such laws are not preempted by the Employee Retirement Income Security Act of 1974 or ERISA ), without regard to whether HIPAA or Wisconsin law incorporates privacy rights granted under the laws of other states. HIPAA Security Regulations The Plan has implemented administrative, physical, and technical safeguards that reasonably and appropriately protect the confidentiality, integrity, and availability of protected health information in electronic form that it creates, receives, maintains, or transmits on behalf of the Plan. The Trustees will report to the Plan any security incident of which they become aware. The Plan s agreements with its business associates will require that the electronic, physical, and technical security of electronic protected health information be maintained. Any disclosures of electronic protected health information to the Trustees are supported by reasonable and appropriate security measures. 56

68 GENERAL DEFINITIONS Wherever used in this Summary Plan Description, the following terms are understood to have the meanings described as follows. Alumni means persons who once participated in the Plan through work performed under a collective bargaining agreement requiring contributions to this Fund and who currently perform work which is not covered by such agreement for: (a) one or more employers that are parties to the collective bargaining agreement requiring contributions to the Fund; (b) the Plan; or (c) the Union. Calendar Year means that period commencing at 12:01 a.m. standard time on the date the eligible person first becomes eligible and continuing until 12:01 a.m. standard time on the next following January 1st. Each subsequent calendar year will be the period from 12:01 a.m. standard time on January 1st to 12:01 a.m. standard time on the next following January 1st. The time will be that time at the address of the Trustees. Classes of Eligible Persons means Class A, B, C, JD, and D as follows: Class A: Active eligible employees and alumni and their eligible dependents. Class B: (a) Eligible former employees who are permanently and totally disabled but not entitled to Medicare and their eligible dependents; and (b) Eligible retired employees ages 55 to 65 and their eligible dependents; who are making the appropriate self-payments to obtain coverage under Comprehensive Major Medical Benefits. Class C: (a) Eligible former employees who are permanently and totally disabled and entitled to Medicare and their eligible dependents who are entitled to Medicare; and (b) Eligible retired employees age 65 and over who are entitled to Medicare and their eligible dependents who are entitled to Medicare; who are making the appropriate self-payments to obtain coverage under Comprehensive Major Medical Benefits. If a dependent of a Class C employee is not entitled to Medicare, he will be eligible for Class B benefits. Class JD: Steamfitters Local Union No. 601, Local 118 Kenosha, and Local 118 Racine full-time preapprentices, first and second year apprentices, maintenance tradesmen, and warehousemen and their eligible dependents. Class D: Eligible dependents of eligible employees in the reserve components of the military service who have been inducted or called to active duty. Dental Hygienist means any person who is currently licensed (if licensing is required in the state) to practice dental hygiene by the governmental authority having jurisdiction over the licensure and practice of dental hygiene, and who works under the supervision of a dentist. Dentist means any person who is currently licensed to practice dentistry by the governmental authority having jurisdiction over the licensure and practice of dentistry, and who is acting within the usual scope of such practice. Dependent means the eligible employee's spouse and unmarried child or children, including lineal dependents such as a grandchild if the eligible employee submits IRS tax filings to prove financial responsibility for such lineal dependent. 57

69 If both husband and wife are eligible under the Plan as employees, each will be covered under the Plan as an employee and also will be eligible for coverage as a dependent of their respective spouse; and children may be covered as dependents of both the husband and wife, subject to coordination of benefits provisions. The term child or children includes the following: (a) Children under 19 years of age (termination age) who are primarily financially dependent upon the eligible employee. (b) Children under 25 years of age (termination age), as long as their primary activity is that of a full-time student carrying 12 credits per semester in an accredited school, or it is during summer vacation or semester break, and they remain primarily financially dependent upon the eligible employee. (c) Children legally adopted by an eligible employee and children placed for adoption with an eligible employee for the purpose of legal adoption who meet the specified age restrictions. Placement for adoption means the assumption and retention by an eligible employee of a legal obligation for total or partial support of a child in anticipation of the legal adoption of such child by the eligible employee. Placement for adoption will terminate upon the termination of such legal obligation. (d) Stepchildren who are children by a former marriage of the eligible employee's spouse and who are primarily financially dependent on the eligible employee for support, unless evidence is presented to the Fund that the divorce judge obligates the natural parent(s) for medical bills. (e) Children, regardless of age, who are incapable of self-sustaining employment by reason of mental retardation or physical handicap and such incapacity began prior to attainment of the termination age previously stated and who are primarily financially dependent upon the eligible employee. Proof of the incapacity must be submitted to the Trustees within 31 days of the date the dependent child's coverage otherwise would terminate or, in the case of a newly eligible employee, within 31 days after the employee first becomes eligible under the Plan. (f) An unmarried child who is named in a Qualified Medical Child Support Order with which you and the Fund are obligated to comply. Eligible Employee means any employee or former employee of an employer, which employee is eligible for benefits in accordance with the Eligibility Rules of the Fund. Eligible Person means either the eligible employee or the eligible dependent. Experimental means any procedure that is investigative and limited to research rather than applied to accepted, general clinical practice. Experimental also means any technique that is restricted to use at those centers which are capable of carrying out disciplined clinical efforts and scientific studies. Any procedure that has a lack of objective evidence which suggests therapeutic benefit and proven value, or whose efficacy is medically questionable also is considered experimental. Fiscal Year means the 12 months beginning any January 1st and ending the following December 31st. Home Health Care Agency means a public or private organization which is primarily engaged in providing skilled nursing and therapeutic services (but not custodial care) on an at-home basis. A home health agency must be supervised by professional medical personnel and be licensed or approved by the state or locality in which it operates. Hospice Program means a program which has received a certificate of need from the state or locality in which it operates to initiate hospice care in a given area; is eligible to satisfy accreditation requirements as developed by Medicare and/or the Joint Commission on the Accreditation of Health Care Organizations; and meets the following criteria: (a) The patient and family are seen as the unit of care; (b) An integrated, centralized administrative structure ensures continuity for home care and inpatient care; 58

70 (c) There is direct provision of care by an interdisciplinary team consisting of physicians, nurses, social workers, chaplains, and volunteers; (d) Volunteers are used to assist paid staff members; and (e) 24-hour-per-day, 7-seven-day-per-week service is available. Hospital means an establishment which meets all of the following requirements: (a) holds a license as a hospital (if licensing is required in the state); (b) operates primarily for the reception, care, and treatment of sick or injured persons as inpatients; (c) provides 24-hour-per-day nursing service by registered nurses; (d) has a staff of one or more licensed physicians available at all times; (e) provides organized facilities for diagnostic and major surgical procedures; and (f) is not primarily a clinic, nursing, rest, or convalescent home or similar establishment. However, "hospital" also will include an establishment or institution specializing in the care, treatment, and rehabilitation of alcoholics or substance addicts provided such establishment is licensed by the appropriate governmental authority, if licensing is required. Injury means accidental bodily damage including all related conditions and recurrent symptoms which require treatment by a physician and which result in loss independently of sickness and other causes. Intensive Care Unit means a special area of a hospital exclusively reserved for critically ill patients requiring constant observation which, in its normal course of operation, provides: (a) personal care by specialized registered nurses and other nursing care on a 24-hour-per-day basis; (b) special equipment and supplies which are available immediately on a standby basis; and (c) care required but not rendered in the general surgical or medical nursing units of the hospital. The term "intensive care unit" also includes an area of the hospital designated and operated exclusively as a coronary care unit, cardiac care unit, or neonatal intensive care unit. Lifetime, with reference to benefit maximums and limitations, means aggregate covered expenses incurred while an eligible person is both alive and covered under the Plan. Under no circumstances will "lifetime" mean during the life of an eligible person, even after the person's eligibility ends. Medically Necessary means a service or supply which is appropriate and consistent with the diagnosis of an injury or sickness in accordance with accepted standards of community practice and which could not have been omitted without adversely affecting the person's condition or the quality of medical care. Optician, Optometrist, and Ophthalmologist mean any person who is qualified and currently licensed (if licensing is required in the state) to practice each such occupation by the appropriate governmental authority having jurisdiction over the licensure and practice of such occupation, and who is acting within the usual scope of such practice. Outpatient Psychiatric Facility means a hospital, community mental health center, day care center or night care center associated with a hospital and licensed as required by applicable law. It does not include institutions or facilities primarily engaged in providing services which are custodial, recreational, social, or educational in nature. An approved outpatient psychiatric facility will be recognized only if there is either a psychiatric physician or a licensed psychologist present in the facility on a regularly scheduled basis who assumes the overall responsibility for coordinating the care of all patients. Services must be available through the professional staff of the facility, as needed, from a psychiatric physician, licensed psychologist, registered nurse, and psychiatric social worker. Emergency medical care must be accessible through formal agreement with a hospital. 59

71 Permanent and Total Disability means any total disability that has existed continuously for at least six months, or up to the date of death, if death occurs within six months. It also means the entire and irrecoverable loss of sight in both eyes, or the loss of use of both hands or both feet, or of one hand and one foot, if the employee otherwise was eligible for a Disability Benefit. Personal Pronoun Usage. Words used in this SPD in the masculine or feminine gender will be considered as the feminine gender or masculine gender respectively, where appropriate. Words used in the singular or plural will be considered as the plural or singular, respectively, where appropriate. Physician means a person who is licensed to practice medicine by the governmental authority having jurisdiction over such licensure and who is acting within the usual scope of such practice and includes the services of a doctor of medicine, podiatrist, chiropractor, osteopath, optometrist, and doctor of dental surgery, provided such individual is licensed and acting within the usual scope of such practice. Plan means the document adopted by the Trustees, as amended from time to time, which incorporates the provisions, terms, and conditions under which benefits are paid and the schedules of benefits which are in effect. Plan Year means the 12 months beginning any January 1st and ending the following December 31st. Preferred Provider means a: (a) physician, dentist, registered nurse, physical therapist, or other licensed health care provider; (b) hospital; (c) alcohol and substance abuse treatment facility; (d) hospice; (e) laboratory; (f) outpatient surgical facility; (g) pharmacy; (h) business establishment selling or renting durable medical equipment; or (i) any other source for services or supplies covered under this Plan; who/which alone, or as part of a group, enter into a contract with the Trustees and who/which agree to be compensated for their services and supplies as are covered under this Plan according to the terms of the contract. Such parties are preferred providers while such contract is in effect. Current types of preferred providers include the following: (a) "Preferred Provider Network" means any of the hospitals, physicians, or other health care providers which contract with the Trustees directly or through their agents from time to time. The agent is ChoiceCare. A current list of network providers is maintained at the Fund Office. (b) Family Services Program (FSP) Provider means the organization which has contracted with the Trustees to provide specified family assistance services. The current FSP provider is Aurora Employee Assistance Program. (c) Preferred Provider Preventive Care Program means the organization which contracts with the Trustees from time to time to provide preventive care services, currently Health Dynamics. (d) Preferred Provider Pharmacy (PPRx) means the pharmacy which is party to a contract with the Trustees, currently Serve You Custom Prescription Management. (e) Preferred Provider Dental Program means the organization which contracts with the Trustees from time to time to provide dental care services. The current Preferred Provider Dental Program is Delta Dental Plan of Wisconsin. Qualified Medical Child Support Order (QMCSO) means any court judgment, decree, or order, including a court's approval of a domestic relations settlement agreement, or any judgment, decree, or order issued through an administrative process established under state law which has the force and effect of law under applicable state law, that: 60

72 (a) provides for child support payments related to health benefits with respect to a child or requires health benefit coverage for such child by the Plan, and is ordered under state domestic relations law; or (b) enforces a state law relating to medical child support payments with respect to the Plan; and (c) creates or recognizes the right of a child as an alternate recipient who is recognized under the order as having a right to be enrolled under the Plan to receive benefits derived from such child's relationship to an eligible employee who is a participant in the Plan; and (d) includes the name and last known address of the participant from whom such child's status as an alternate recipient under this Plan is derived and of each alternate recipient, a reasonable description of the type of coverage to be provided by the Plan, and the period for which coverage must be provided; and (e) does not require or purport to require the Plan to provide any type or form of benefit, or any option, not otherwise provided under the Plan, except to the extent necessary to meet the requirements of law relating to medical child support described in Section 1908 of the Social Security Act; and (f) has been determined to be a Qualified Medical Child Support Order under reasonable procedures adopted and uniformly applied by the Plan. A copy of the written procedures for determining whether or not an order is qualified is available from the Fund Office upon request at no charge. Reasonable Expense means the usual and customary fee or charge for the covered services rendered and for the covered supplies furnished in the area concerned, provided services and supplies are recommended and approved by a physician or dentist. Reasonableness is determined by comparisons with fees and charges by other providers for similar services and supplies as authorized by the Trustees and may include data obtained from the Medical Data Research (MDR) schedule for relevant zip code areas at the percentile Trustees adopt or from guidelines obtained from other sources as well. Self-Funded Plan means a group health care plan in which the Fund assumes the financial risk for providing health care benefits to its employees. Instead of paying a fixed premium to an insurance company to pay the claims, a self-funded plan directs employer contributions, self-payments, and investment earnings into a Trust Fund that is overseen by strict federal government regulation. The Plan pays claims directly from accumulated Trust Fund assets. Sickness means a disease, disorder, or condition (including pregnancy and childbirth and any related conditions) which requires treatment by a physician. Skilled Nursing Home means an institution which fully meets every one of these requirements: (a) is regularly engaged in providing skilled nursing care for sick and injured persons at the patient's expense; (b) requires that patients be regularly attended by a physician and that medications be given only on the order of the physician; (c) maintains a daily medical record of each patient; (d) continuously provides nursing care under 24- hour-a-day supervision by a registered nurse; (e) is not, except incidentally, a facility for the aged, a rest home, or the like; (f) is not, except incidentally, a place for treatment of substance addiction, alcoholism, or mental illness; (g) is currently licensed as a skilled nursing home, if licensing is required in the area where it is located, and is classified as a skilled nursing home under Medicare; (h) has permanent facilities for the care of six or more resident inpatients; and (i) requires a physician's certification that confinement is medically necessary. Total Disability means any disability commencing while the employee otherwise is eligible and prior to his 60th birthday, which results from bodily injury 61

73 or disease and which wholly and continuously prevents the employee from engaging in any occupation for wage or profit. You means any eligible employee. The terms "Association," "Beneficiary," "Employee," "Employer," "Participant," "Trust Agreement," "Trust Fund," "Trustees," and "Union" have the same meaning in this Summary Plan Description as they do in the Restated Trust Agreement, effective May 19, 1975, as amended, which is incorporated by reference. 62

74 HOW TO APPLY FOR BENEFITS Pre-service claims: You must obtain precertification from the utilization review firm at least 48 hours prior to any non-emergency inpatient hospitalization. In addition, you must obtain precertification from the Family Services Program (FSP) manager for non-emergency inpatient and all outpatient treatment of nervous and mental disorders, substance abuse, and alcoholism. See page 37 for details on how to obtain precertification. Also, you must contact the Fund Office for prior authorization for: all organ transplants and certain prescription drugs, such as Tretinoin (Retin-A), appetite suppressants, oral contraceptives, and impotence medications. Predetermination of benefits is required for certain dental services under the Delta Dental Plan. Claims such as this are called pre-service claims, which means any claim which requires approval of the benefit in advance of obtaining medical care. Claims requiring precertification by the utilization review firm or FSP may be submitted initially by telephone. All other claims requiring prior authorization must be submitted in writing to the Fund Office. Please note that there are special provisions in the Claims Procedure Regulations for urgent care claims (referred to under the Plan as emergencies ), but, by definition, these provisions do not apply to your Plan because the Plan does not require prior authorization of emergency admissions. Post-service claims: Any claim for benefits that is not a pre-service claim is considered a postservice claim. Post-service claims include those for emergency hospital admissions. You must notify the Plan within two business days following an emergency admission. You must submit all other post-service claims in writing within 90 days of the occurrence of the accident or sickness, or as soon thereafter as is reasonably possible. In no event (except in the absence of legal capacity) can you submit a claim later than December 31 of the calendar year following the year in which the claim was incurred. Once you become eligible, you will receive an identification card from the Fund which identifies you and contains the name and address of the Wisconsin Pipe Trades Health Fund. The Fund s Administrative Manager, named on page 77, certifies eligibility, processes claims, and makes the benefit payments. When you obtain health care services or supplies, make sure you present your I.D. card to the provider. Your I.D. card will give the provider all the information necessary to submit the claim for payment. If the provider does not submit the claim, you must do so yourself. Post-service claims must be submitted in writing to the appropriate party as follows: Send all claims to: Fund Office Wisconsin Pipe Trades Health Fund P.O. Box Milwaukee, WI Claims should be complete. They should contain, at a minimum: (a) Fund name (Wisconsin Pipe Trades Health Fund); (b) Employee s name and Social Security number; (c) Full name (including Jr., if applicable) and date of birth of the eligible person who incurred the covered expense; (d) Name and address of the service provider; (e) Federal tax identification number of provider; (f) Diagnosis of the condition (this must be indicated on each claim submitted); (g) Procedure or nature of the treatment; (h) Date of and place where the procedure or treatment has been provided; (i) Amount billed and the amount of the covered expense not paid through coverage other than this Plan, as appropriate; and (j) Evidence that substantiates the nature, amount, and timeliness of each covered expense that is in a reasonably understandable format and is in compliance with all applicable law. 63

75 Claims will not be deemed submitted for purposes of these procedures unless and until received at the correct address. A general request for an interpretation of Plan provisions will not be considered a claim for benefits. Predetermined amounts you must pay, such as a prescription drug copayment or amount required because of use of a network or non-network provider, will not be considered a claim for benefits subject to the claims procedures. However, if you feel you have been charged an improper dollar or percentage copayment (for example through the Preferred Provider Pharmacy Program), you may submit a formal appeal to the Fund Office in writing within 180 days to have your claim reviewed according to the appeal procedures stated on pages 67 through 70. You or an authorized representative can pursue a claim. You may authorize a representative by submitting a written authorization to the Trustees. Benefits are paid directly to you, or to the provider if you assign benefits to the provider on a form acceptable to the Trustees. However, benefits for in- and outpatient treatment of nervous and mental disorders, abuse of substances, and alcoholism are paid directly to the provider of service in all cases. 64

76 YOUR RESPONSIBILITIES AS A PARTICIPANT UNDER THE PLAN 1. NOTIFY THE FUND OFFICE IMMEDIATELY REGARDING ANY CHANGE IN ADDRESS OR DESIRED CHANGE IN BENEFICIARY. Most information about your Plan is sent to you by mail. For you to receive this information, we must have a correct address on file at the Fund Office at all times. If you move, it is up to you to let us know your new address. Failure to do so may jeopardize your eligibility or benefits because we will have no way to contact you about any changes in the Eligibility Rules or improvements in benefits. So don't lose out. Remember: The responsibility for advising the Fund Office of your new address is yours, and you should do so in writing. Also, if your marital status changes or there are other changes in your personal life which might affect the name of the person(s) you wish to designate as your beneficiary, you must notify the Fund Office in writing regarding any change in beneficiary you wish to make. It is necessary that you notify the Fund Office in writing of any change in your marital status because the Wisconsin Marital Property Law may have an effect on your beneficiary for Death Benefits. For your convenience, a card is provided by the Fund Office which you may use to notify the Fund Office about an address or beneficiary change. Or, just drop a postcard in the mail to the Fund Office with the new information. 2. NOTIFY THE FUND OFFICE IMMEDIATELY IF YOU ADD A NEW DEPENDENT CHILD. If you acquire a new dependent child, please call the Fund Office right away to let them know so they can send you the necessary paperwork. Prompt notification will avoid any potential delays in the processing of claims for your new dependent. 3. MAKE SELF-PAYMENTS ON TIME AND IN THE CORRECT AMOUNTS. Benefits paid by this Plan are financed primarily by employer contributions based on the number of hours worked. However, the Plan also provides that if you are not employed or have not worked the required minimum number of hours to maintain eligibility, you may make up the difference with self-payments. You will be notified if self-payments are required to maintain your eligibility. The self-pay notice indicates the amount due and the date due. Failure to pay the required amount on time will lead to a loss of eligibility. Remember: The responsibility for making timely self-payments is yours. 4. AVOID UNNECESSARY DELAYS IN PRO- CESSING YOUR CLAIMS BY PROVIDING ALL NECESSARY INFORMATION. A major reason for delays in processing of benefits is failure on the part of the providers furnishing supplies or services and the person filing for benefits to provide all the necessary information as specified on page 63. You probably would not be aware of the information omitted by your physician; however, a reminder to the receptionist or nurse in the physician's office that such information is important may help to solve the problem. If you are submitting claims yourself, be sure to double check that you have included all the needed information before you send them in. Remember: All claims, whether submitted by you or your provider, should be mailed directly to the Fund Office. 65

77 YOUR RIGHTS UNDER THE FAMILY AND MEDICAL LEAVE ACT OF 1993 The federal Family and Medical Leave Act of 1993 (FMLA) requires certain covered employers to provide up to 12 weeks of unpaid, job-protected leave to "eligible" employees for certain family and medical reasons. Employees are eligible if they have worked for the same covered employer for at least one year, and for 1,250 hours over the previous 12 months. See page 15 for an explanation of what constitutes a "covered" employer. REASONS FOR TAKING LEAVE Unpaid leave must be granted for any of the following reasons: (a) to care for the employee's child after birth, or placement of a child with the employee for adoption or foster care; (b) to care for the employee's spouse, son or daughter, or parent who has a serious health condition; or (c) for a serious health condition that makes the employee unable to perform his job. At the employee's or employer's option, certain kinds of paid leave may be substituted for unpaid leave. ADVANCE NOTICE AND MEDICAL CERTIFICATION The employee ordinarily must provide 30 days advance notice when the leave is "foreseeable." An employer may require medical certification to support a request for leave because of a serious health condition, and may require second or third opinions (at the employer's expense) and a fitness for duty report to return to work. Taking of leave may be denied if these requirements are not met. JOB BENEFITS AND PROTECTION (a) For the duration of FMLA leave, the employer must maintain the employee's health coverage under any "group health plan." (b) Upon return from FMLA leave, most employees must be restored to their original or equivalent positions with equivalent pay, benefits, and other employment terms. (c) The use of FMLA leave cannot result in the loss of any employment benefit that accrued prior to the start of an employee's leave. UNLAWFUL ACTS BY EMPLOYERS FMLA makes it unlawful for any employer to: (a) interfere with, restrain, or deny the exercise of any right provided under FMLA; or (b) discharge or discriminate against any person for opposing any practice made unlawful by FMLA or for involvement in any proceeding under or relating to FMLA. ENFORCEMENT The U.S. Department of Labor is authorized to investigate and resolve complaints of violations. An eligible employee may bring a civil action against an employer for violations. FMLA does not affect any federal or state law prohibiting discrimination, or supersede any state or local law or collective bargaining agreement which provides greater family or medical leave rights. FOR ADDITIONAL INFORMATION: Contact the nearest office of the Wage and Hour Division, listed in most telephone directories under "U.S. Government, Department of Labor." 66

78 INFORMATION REQUIRED BY THE EMPLOYEE RETIREMENT INCOME SECURITY ACT OF 1974 (ERISA) Benefit Appeals Procedure When you submit a pre-service claim, the Plan (meaning either the utilization review firm, FSP, or Fund Office, as applicable) will notify you whether or not the claim is approved within a reasonable period of time appropriate to the medical circumstances, but not later than 15 days of the Plan s receipt of the claim. If you fail to follow the Plan s procedures for filing a claim, you will be notified of the failure and the proper procedures as soon as possible, but no later than five days following the failure. We will notify you verbally, unless you request us to notify you in writing. If the utilization review firm or FSP denies your pre-service claim, you can contact them directly according to their internal review process which will be stated in the determination letter for reconsideration of your claim. If you are not satisfied with the determination, you can file a formal appeal to the Fund Office in writing, subject to the appeals procedure which follows. For organ transplants that are insured by BCS Insurance Company, BCS will notify you directly of their decision. You must appeal directly to BCS according to their grievance procedures; the Fund Office will be glad to assist you. The decision by BCS will be final and binding. For post-service claims, the Plan will notify you of an adverse benefit determination within a reasonable period of time, but not later than 30 days of the Plan s receipt of a claim. For both pre- and post-service claims, if the Plan needs additional time to determine whether a claim is a covered expense for reasons beyond the Plan s control, the Plan may take one 15-day extension. The Plan will notify you prior to the expiration of the initial 15- or 30-day notification period, as applicable, of the circumstances requireing the extension and the date by which the Plan expects to make a decision. If an extension is needed due to your failure to submit necessary information to decide the claim, the Plan, in the notice of extension, will specifically describe the required information needed. The time period for making the determination is suspended from the date on which the notice of the necessary information is sent to you until the date you respond. You have at least 45 days from receipt of the notice to respond to the request for information. Once you respond, the Plan will decide the claim within the 15-day extension period. Your claim will be denied if you do not respond in a timely manner. The Plan may take only one extension for group health claims and may not further extend the time for making its decision unless you agree to a further extension. A concurrent care claim is a claim that is reconsidered after the Plan has approved an ongoing course of treatment to be provided over a period of time or a number of treatments and the reconsideration results in the reduction or termination of the treatment (other than by Plan amendment or termination) before the scheduled end of the treatment. Although this situation almost never arises, we are required by law to tell you that this provision exists. If the Plan reduces or terminates treatment before the end of the course of the treatment, the Plan will notify you far enough in advance of the termination or reduction of treatment to allow you to appeal the adverse benefit determination and obtain a determination on review before the termination or reduction takes effect. For disability claims, the Plan has a reasonable period of time, not in excess of 45 days, to provide written notice of an adverse benefit determination for any claim for disability benefits under the Plan. The Plan may extend the decision-making period for up to an additional 30 days for reasons beyond the Plan s control but the Plan will notify you in writing before the expiration of the 45-day period of the reason for the delay and when the decision will be made. A second 30-day extension is allowable if the Plan still is unable to make the decision for reasons beyond its control. You will be provided, before the expiration of the first 30-day extension period, a notice that details the reasons for the delay and the date as of which the Plan expects to render a decision. If an extension is needed because the Plan needs additional information from you, the extension notice will specifically 67

79 explain the standards on which entitlement to a benefit is based, the unresolved issues that prevent a decision on the claim, and specify the additional information needed to resolve those issues, in which case you will have 45 days from receipt of the notification to provide the requested information. The Plan will issue its decision within 30 days of the date you submit your information (subject to the 30-day extension previously described). Your claim will be denied if you do not submit the requested information in a timely manner. When you submit a claim for benefits to the Fund Office, the Fund Office will determine if you are eligible and the Fund's claims administrator will calculate the amount of benefit payable, if any. If your claim for benefits is denied in whole or in part, the Plan will provide you, your dependent, beneficiaries, or authorized or legal representatives, as may be appropriate (hereafter referred to as you or your ) with written or electronic notice of adverse benefit determinations within the time frames previously stated. Notices will include the following information stated in an easily understandable manner: (a) The specific reason or reasons for the adverse benefit determination. (b) References to specific Plan provision(s) on which the adverse benefit determination is based. (c) A description of any additional material or information, if any, necessary for you to perfect your claim and an explanation of why the material or information is necessary. (d) A description of the Plan s benefit appeals procedure and time limits applicable to such appeals procedure, including a statement of your right to bring a civil action under Section 502(a) of ERISA following an adverse benefit determination on review. (e) If an internal rule, guideline, protocol, or similar criterion was relied upon in making the adverse benefit determination, a statement that such rule, guideline, protocol, or other similar criterion was relied upon in making the adverse benefit determination and that a copy of such criterion will be provided free of charge to you upon request. (f) If the adverse benefit determination was based on a medical necessity or experimental treatment, or similar exclusion or limit, an explanation of the scientific or clinical judgment of the Plan in applying the terms of the Plan to your medical circumstances will be provided free of charge to you upon request. (g) If a medical or vocational expert's advice was obtained on behalf of the Plan in connection with your claim, you may request the identity of the expert, regardless of whether the advice was relied on. If you feel that the action taken on your eligibility or claim is incorrect, you immediately should ask the Fund Office to review your claim with you. In some cases, the Fund Office may request additional information from you which might enable the Fund Office to reevaluate its decision. If all or part of a claim is denied or if you are otherwise dissatisfied with the determination made by the Plan, or if you have not received the notice of denial of your claim within the applicable time limits after the Plan has received all necessary claim information, you have the right to appeal the decision and request a review of the claim. The Plan will provide for a full and fair review of a claim and adverse benefit determination, pursuant to the following: (a) You will have 180 days after you receive the notice of an adverse benefit determination to file your appeal in writing to the Fund Office and it must include the specific reasons you feel denial was improper. (b) You will be allowed the opportunity to submit written issues and comments, documents, records, and other information relating to the claim for benefits which may have been requested in the notice of denial or which you may consider desirable or necessary. (c) You or your duly authorized representative will be provided, upon request and free of charge, reasonable access to, and copies of, all designated, pertinent documents, records, and other information relevant to your claim for benefits. 68

80 (d) Your review will take into account all comments, documents, records, and other information submitted by you relating to the claim, whether or not such information was submitted or considered in the initial benefit determination. (e) The Board of Trustees, as an appropriate named fiduciary for the Plan, will be the assigned decision maker on appealed claims. (f) The Plan will consult with appropriate health care professionals in deciding appealed claims that are based in whole or in part on medical judgment, including determination of experimental or investigational treatments and medical necessity. Such health care professional will have appropriate training and experience in the field of medicine involved in the medical judgment. The health care professional consulted for the appeal of an adverse benefit determination will be someone who was not consulted in the initial adverse benefit determination nor the subordinate of such individual. (g) If a medical or vocational expert's advice was obtained on behalf of the Plan in connection with your claim, you may request the identity of the expert, regardless of whether the advice was relied on. (h) For appeals of pre-service claims, the Plan will notify you of the decision within a reasonable period of time appropriate to the medical circumstances, but not later than 30 days of receiving the appeal request. (i) The Board of Trustees will review post-service and disability claim appeals at their next regularly scheduled Board of Trustees' meeting (at least quarterly) that follows the receipt of the request for review. However, if the request is filed within 30 days of the date of the meeting, the determination may be made no later than the date of the second meeting following the receipt of the request for review. If special circumstances (such as the need to hold a hearing) require a further extension, the appeal decision can be pushed back to the third meeting following the appeal request, but the Plan must notify you of this extension and of the special circumstances and the date as of which the determination will be made prior to the extension time. The Plan will provide you with written or electronic notice of an adverse benefit determination as soon as possible but within five days of the decision being made. The notice will include the following information stated in an easily understandable manner: (1) The specific reason or reasons for the adverse benefit determination. (2) References to specific Plan provision(s) on which the adverse benefit determination is based. (3) A statement that you will be provided, upon request and free of charge, reasonable access to, and copies of, all documents, records, and other information relevant to your claim for benefits. (4) A statement of your right to bring a civil action under Section 502(a) of ERISA after you have exhausted the Plan s benefit appeals procedure. (5) If an internal rule, guideline, protocol, or similar criterion was relied upon in making the adverse benefit determination, a statement that such rule, guideline, protocol, or other similar criterion was relied upon in making the adverse determination and that a copy of such criterion will be provided free of charge to you upon request. (6) If the adverse benefit determination was based on a medical necessity or experimental treatment, or similar exclusion or limit, an explanation of the scientific or clinical judgment of the Plan in applying the terms of the Plan to your medical circumstances will be provided free of charge to you upon request. The Trustees will make every effort to interpret Plan provisions in a consistent and equitable manner. You will be given maximum opportunity to present your viewpoint on any denied claim. You may not begin any legal action, including proceedings before administrative agencies, until you have followed the procedures and exhausted the review opportunities described here. You may, at your own expense, have legal representation at any stage of these review procedures. No legal action for any benefits under the Plan may begin later than 69

81 three years after the time the claim was required to be filed as specified on page 63. Benefits under this Plan will be paid only if the Board of Trustees (or its Plan Administrator) decides in its discretion that you are entitled to them. The Plan will be interpreted and applied in the sole discretion of the Board of Trustees (or its delegate, including but not limited to, its Plan Administrator). Such decision will be final and binding on all persons covered by the Plan who are claiming any benefits under the Plan. If you have any questions about the benefit appeals procedure described here, please contact the Fund Office. 70

82 Statement of Participants' Rights Under ERISA In 1974, Congress passed and the President signed the Employee Retirement Income Security Act, commonly referred to as ERISA. ERISA sets forth certain minimum standards for the design and operation of privately-sponsored welfare plans. The law also spells out certain rights and protections to which you are entitled as a participant. The Trustees of the Wisconsin Pipe Trades Health Fund want you to be fully aware of your rights, and for this reason, a statement of your rights follows. As a participant in the Wisconsin Pipe Trades Health Fund: (a) You automatically will receive a Summary Plan Description (this booklet). The purpose of this booklet is to describe all pertinent information about the Plan. (b) If any substantial changes are made in the Plan, you will be notified within the time limits required by ERISA. Federal regulations under HIPAA require that participants and beneficiaries receive a summary of material modifications of any modification or change that is a material reduction in covered services or benefits under a group health plan within 60 days after the adoption of the modification or change, unless the Plan sponsor regularly sends out summaries of the modifications or changes at regular intervals of 90 or fewer days. (c) Each year you automatically will receive a summary of the Plan's latest annual financial report. A copy of the full report also is available upon written request. (d) You may examine, without charge, all documents relating to the operation of this Plan. These documents include: the legal Plan Document, insurance contracts, collective bargaining agreements, and copies of all documents filed by the Plan with the Department of Labor or the Internal Revenue Service, such as annual reports (Form 5500 Series) and Plan descriptions. Such documents may be examined at the Fund Office (or at other required locations such as worksites or union halls) during normal business hours. In order to ensure that your request is handled promptly and that you are given the information you want, the Trustees have adopted certain procedures which you should follow: (1) your request should be in writing; (2) it should specify what materials you wish to look at; and (3) it should be received at the Fund Office at least three days before you want to review the materials at the Fund Office. Although all pertinent Plan documents are on file at the Fund Office, arrangements can be made upon written request to make the documents you want available at any worksite or union location at which 50 or more participants report to work. Allow 10 days for delivery. (e) You may obtain copies of any Plan document governing the operation of the Plan, including insurance contracts and collective bargaining agreements, and copies of the latest annual report (Form 5500 Series) and updated Summary Plan Description upon written request to the Trustees, addressed to the Fund Office. ERISA provides that the Trustees may make a reasonable charge for the actual cost of reproducing any document you request. However, you are entitled to know what the charge will be in advance. Just ask the Fund Office. (f) You have the right to continue health care coverage for yourself, your spouse, or dependents if there is a loss of coverage under the Plan as a result of a qualifying event. You or your dependents may have to pay for such coverage. Review this Summary Plan Description and the documents governing the Plan on the rules governing your COBRA continuation coverage rights. 71

83 (g) You are entitled to a reduction or elimination of exclusionary periods of coverage for preexisting conditions under a group health plan, if you have creditable coverage from another plan. You should be provided a certificate of creditable coverage, free of charge, from your group health plan or health insurance issuer when you lose coverage under the plan, when you become entitled to elect COBRA continuation coverage, when your COBRA continuation coverage ceases, if you request it before losing coverage, or if you request it up to 24 months after losing coverage. (h) No one including your employer, your union, or any other person, may fire you or otherwise discriminate against you in any way or take any action which would prevent you from obtaining a benefit to which you may be entitled or from exercising any of your rights under ERISA. (i) In accordance with Section 503 of ERISA and related regulations, the Trustees have adopted certain procedures to protect your rights if you are not satisfied with the action taken on your claim. These procedures appear on pages 67 through 70 of this booklet. Basically, they provide that: (1) If your claim for a health care benefit is denied, in whole or in part, you have a right to know why this was done, you will receive a written explanation of the reason(s) for the denial, and you have a right to obtain copies of documents relating to the decision without charge. (2) Then, if you still are not satisfied with the action on your claim, you have the right to have the Plan review and reconsider your claim in accordance with the Plan's benefit appeals procedures. These procedures are designed to give you a full and fair review and to provide maximum opportunity for all the pertinent facts to be presented in your behalf. (j) In addition to creating rights for Plan participants, ERISA also defines the obligations of people involved in operating employee benefit plans. These persons are known as "fiduciaries." They have the duty to operate your Plan prudently and with reasonable care and to look out for your best interests as a participant under the Plan and the best interests of other Plan participants and beneficiaries under the Plan. The duties of a fiduciary are complex and are constantly changing as new laws and regulations are adopted, applicable to employee benefit plans. Be assured that the Trustees of this Plan will do their best to know what is required of them as fiduciaries and to take whatever actions are necessary to ensure full compliance with all state and federal laws. (k) Under ERISA, you may take certain actions to enforce the rights previously listed. (1) For instance, if you request a copy of Plan documents or the latest annual report from the Plan and do not receive them within 30 days, you may file suit in federal court. Of course, before taking such action, you will no doubt want to check again with the Fund Office to make sure that: the request actually was received; the material was mailed to the right address; or the failure to send the material was not due to circumstances beyond the Trustees control. If you are still not able to get the information you want, you may wish to take legal action. The court may require the Trustees to provide the materials promptly or pay you a fine of up to $110 for each day s delay until you actually receive the materials (unless the delay was caused by reasons beyond the Trustees control). (2) Although the Trustees will make every effort to settle any disputed claims with participants fairly and promptly, there always is the possibility that differences cannot be resolved satisfactorily. If you have a claim for benefits which is denied or ignored in whole or in part, you may file suit in a state or federal court if you 72

84 feel that you have been improperly denied a benefit. In addition, if you disagree with the Plan s decision or lack thereof concerning the qualified status of a medical child support order, you may file suit in federal court. However, before exercising this right, you must take advantage of all the benefit appeals procedures provided under the Plan at no cost. If you still are not satisfied, then you may wish to seek legal advice. (3) If it should happen that Plan fiduciaries misuse the Plan s money or discriminate against you for asserting your rights, you may seek assistance from the U.S. Department of Labor or you may file suit in a federal court. The court will decide who should pay court costs ad legal fees. If you are successful, the court may order the person you have sued to pay these costs and fees. If you are not successful, the court may order you to pay these costs and fees. For example, if the court finds your claim is frivolous, you may be expected to pay legal costs and fees. If you have any questions about your Plan, you should contact the Trustees by writing to: The Board of Trustees Wisconsin Pipe Trades Health Fund One Park Plaza West Park Place, Suite 950 Milwaukee, WI Or phone: (414) Call toll-free: Or, if you have questions about this statement or your rights under ERISA or if you need assistance in obtaining documents from the Trustees, you may contact the nearest office of the Employee Benefits Security Administration (EBSA) at U.S. Department of Labor listed in your telephone directory or at: Division of Technical Assistance and Inquiries, Employee Benefits Security Administration, U.S. Department of Labor, 200 Constitution Avenue, N.W., Washington, DC You also may find answers to your Plan questions, your rights and responsibilities under ERISA, and a list of EBSA field offices by contacting the EBSA by: calling (866) ; sending electronic inquiries to or visiting the website of the EBSA at 73

85 Other ERISA Information The Name and Address of Plan Administrator The Plan is administered and maintained by the Board of Trustees. The Administrative Office of the Fund is located at: Wisconsin Pipe Trades Health Fund One Park Plaza West Park Place, Suite 950 Milwaukee, WI Type of Plan This Plan is a group health plan. It is maintained for the exclusive benefit of the employees and provides Death, Accidental Death and Dismemberment, and Loss of Time Benefits for employees and health care, vision, and dental benefits for employees and dependents. This Plan is subject to the Health Insurance Portability and Accountability Act of 1996 (HIPAA). Plan Sponsor The Plan Sponsor is the Board of Trustees of the Wisconsin Pipe Trades Health Fund. This Fund is maintained by several employers and one or more employee organizations, and is administered by a Joint Board of Trustees. A complete list of the employers and employee organizations sponsoring the Plan may be obtained by participants and beneficiaries upon written request to the Plan Administrator, and is available for examination by participants and beneficiaries at the Fund Office. Type of Plan Administration Although the Trustees are legally designated as the Plan Administrator, they have delegated certain administrative responsibilities to an Administrative Manager and to a claims administrator under an administrative services contract. The claims administrator is primarily responsible for the processing of claims and benefit payments. The Administrative Manager maintains the eligibility records, accounts for the employer contributions, answers participant inquiries about the benefit programs, files required government reports, and handles other routine administrative functions. The Names and Addresses of the Trustees Labor Trustees Ken Bastian Plumbers & Steamfitters Local th Avenue Kenosha, WI Jim Cox Steamfitters Union Local South 103rd Street Milwaukee, WI Kevin LaMere Steamfitters Union Local South 103rd Street Milwaukee, WI E. Larry Vance Plumbers & Steamfitters Local Spring Street Sturtevant, WI Joel Zielke Steamfitters Union Local South 103rd Street Milwaukee, WI Management Trustees James Colwell United Mechanical th Street Racine, WI David Karlsen Karlsen Plumbing 1951 Grove Avenue Racine, WI Todd Morris Total Comfort of Wisconsin W234 N2830 Paul Road Pewaukee, WI Ed Tonn, Jr. Butters-Fetting Company, Inc South 1st Street Milwaukee, WI

86 Parties to the Collective Bargaining Agreement The Plan is maintained pursuant to collective bargaining agreements between: Local Union No. 601 of United Association of Journeymen and Apprentices of the Plumbing and Pipe Fitting Industry of the United States 3300 South 103rd Street Milwaukee, WI Local Union No. 118 of United Association of Journeymen and Apprentices of the Plumbing and Pipe Fitting Industry of the United States and Canada th Avenue 1840 Sycamore Avenue Kenosha, WI Racine, WI Plumbing & Mechanical Contractors Association of Milwaukee and Southeastern Wisconsin West Lincoln Avenue, Suite 1600 Milwaukee, WI Mechanical Contractors Southeast Inc th Street Racine, WI Also, employers who are not members of or represented by the Associations but which execute individual collective bargaining agreements with the Local Union(s). A copy of any such agreement is available for examination by participants and their beneficiaries at the Fund Office during normal business hours. Also, upon written request to the Administrative Manager, participants and their beneficiaries may obtain: (a) a copy of any such agreement; and (b) information as to the address of a particular employer and whether that employer is required to pay contributions to the Plan. Internal Revenue Service Employer and Plan Identification Numbers The Employer Identification Number (EIN) issued to the Board of Trustees is and the Plan Number (PN) is 501. Name and Address of the Person Designated as Agent for Service of Legal Process Fund Administrative Manager Benefit Plan Administration of Wisconsin, Inc. One Park Plaza West Park Place, Suite 950 Milwaukee, WI Service of legal process also may be made upon any Plan Trustee. Eligibility Requirements The Plan's requirements with respect to eligibility for benefits are shown in the Eligibility Rules on pages 1 through 16. Circumstances which may cause the participant to lose eligibility are explained in the Eligibility Rules. Sources of Trust Fund Income Sources of Trust Fund income include employer contributions, self-payments, and investment earnings. All employer contributions are paid to the Trust Fund subject to provisions in: the collective bargaining agreements between the Union and Association; those employers who are not members of or represented by such Association but which execute an individual collective bargaining agreement with the Local Union; and employers signatory to such labor contracts who cover their alumni under an approved participation agreement. For bargaining unit employees, the labor agreements specify the amount of contribution, due date of employer contributions, type of work for which contributions are payable, and the geographic area covered by the labor contract. For non-bargaining unit or alumni employees, the Trustees determine the employer contribution amount, due date, and related policies. Method of Funding Benefits All Plan benefits except organ transplant insurance and one dental option are self-funded from accumulated assets and are provided directly from the Trust Fund. A portion of Fund assets is maintained in reserve to cover unexpected or 75

87 unusually high expenses which the Fund may experience from time to time, such as a catastrophic claim. All assets of the Fund are held by a custodian (bank) selected by the Trustees. Park Bank, Milwaukee, WI, is currently the custodian of Fund assets. Assets not needed for the immediate payment of benefits and other Fund expenses are invested by an investment manager hired by the Trustees in accordance with guidelines established and monitored by the Trustees. The current Investment Manager is Pennant Management, Inc., Milwaukee, WI. Benefits for certain organ transplants as described on pages 26 through 28 are provided through an insurance policy with BCS Insurance Company, 676 North St. Clair Street, Chicago, IL , Benefits eligible under the organ transplant insurance policy are submitted to and paid by BCS. Benefits for one of the alternative dental programs as described on pages 40 through 42 are provided through Care-Plus Dental Plans, Inc., West Burleigh Street, Wauwatosa, WI 53222, Benefits eligible under this program are submitted by the provider directly to Care-Plus and are paid by Care-Plus directly to the participating provider. Fiscal Year of the Plan The Plan's fiscal year begins January 1st and ends the following December 31st. Procedures To Be Followed in Presenting Claims for Benefits Under the Plan The procedures for filing for benefits are described on page 63. If a participant wishes to appeal a denial of a claim in whole or in part, certain procedures for this purpose are found on pages 67 through 70. We hope this booklet has provided you with the most important information about your Plan and your rights under ERISA. 76

88 Fund Administrative Manager Benefit Plan Administration of Wisconsin, Inc. One Park Plaza West Park Place, Suite 950 Milwaukee, WI Fund Legal Counsel Michael, Best & Friedrich 100 East Wisconsin Avenue, Suite 3300 Milwaukee, WI Fund Legal Counsel Previant, Goldberg, Uelmen, Gratz, Miller & Brueggeman, S.C North RiverCenter Drive, Suite 202 Milwaukee, WI Fund Consultant Lee Jost and Associates One Park Plaza West Park Place, Suite 950 Milwaukee, WI Fund Certified Public Accountant Schenck Business Solutions West Park Place, Suite 200 Milwaukee, WI Stop Loss Insurance Insured by ACE American Insurance Company 1601 Chestnut Street P.O. Box Philadelphia, PA Organ Transplant Benefits Insured by BCS Insurance Company 676 North St. Clair Street Chicago, IL Fund Utilization Review Manager APS Healthcare 300 North Executive Drive Brookfield, WI Fund Preferred Provider Network ChoiceCare 500 West Main Street, 9 th Floor Louisville, KY Fund Family Services Program Provider Aurora Employee Assistance Program 2500 North Mayfair Road, Suite 630 Wauwatosa, WI Fund Dental Provider Delta Dental Plan of Wisconsin P.O. Box 828 Stevens Point, WI Fund Dental Provider Care-Plus Dental Plans, Inc West Burleigh Street Wauwatosa, WI Fund Preferred Provider Pharmacy Serve You Custom Prescription Management P.O. Box Milwaukee, WI Fund Preferred Provider Preventive Care Program Health Dynamics St. Joseph Outpatient Center 201 North Mayfair Road, Suite 510 Wauwatosa, WI

89 78 NOTES