Milwaukee Carpenters' District Council Health Fund. Summary Plan Description

Transcription

1 Milwaukee Carpenters' District Council Health Fund Summary Plan Description Effective June 1, 2014

2 Milwaukee Carpenters District Council Health Fund To All Active Employees and Retirees: We are happy to provide you with this new Summary Plan Description (SPD), effective June 1, In easy-tounderstand 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 SPD and the more technical legal Plan Document and Trust Agreement, the legal documents will govern. The Trustees reserve the right in their sole discretion to change, interpret, withdraw, or add benefits, self-payment rates, eligibility rules, or any other provisions relating to the operation of the Plan or terminate the Plan at any time by written amendment in an effort to best serve all Plan participants. All Plan benefits described in this SPD are self-funded, except for certain organ transplant benefits which are insured. 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 you with the best protection possible within the Fund's financial means. The Eligibility Rules and other Plan provisions are updated as necessary to comply with legal requirements, including the Patient Protection and Affordable Care Act and Mental Health Parity Addiction and Equity Act. We suggest you familiarize yourself with the information in this SPD carefully to have a clear understanding of your Plan, and then keep it handy for reference. If you have questions at any time regarding the Plan, please contact the Fund Office. Yours sincerely, The Board of Trustees Peter DiRaffaele Arcadio Perez Mark Scott Tom DuFour Larry Rocole John Topp The addresses of the Trustees are found on page 80. Fund Office N25 W23055 Paul Road, Suite 2 Pewaukee, WI Telephone: (262) locally, or call toll-free in Wisconsin at: FAX: (262) Office Hours: Monday - Friday 8:00 a.m. to 4:30 p.m. i

3 DISCLOSURE LANGUAGE FOR GRANDFATHERED PLANS This group health plan believes it is a grandfathered health plan under the Patient Protection and Affordable Care Act (the Affordable Care Act). As permitted by the Affordable Care Act, a grandfathered health plan can preserve certain basic health coverage that was already in effect when that law was enacted. Being a grandfathered health plan means that your Plan may not include certain consumer protections of the Affordable Care Act that apply to other plans, for example, the requirement for the provision of preventive health services without any cost sharing. However, grandfathered health plans must comply with certain other consumer protections in the Affordable Care Act, for example, the elimination of lifetime limits on benefits. Questions regarding which protections apply and which protections do not apply to a grandfathered health plan and what might cause a plan to change from grandfathered health plan status can be directed to the Plan Administrative Manager at: Milwaukee Carpenters District Council Health Fund, N25 W23055 Paul Road, Suite 2, Pewaukee, WI ; (262) or You also may contact the Employee Benefits Security Administration, U.S. Department of Labor at: or This website has a table summarizing which protections do and do not apply to grandfathered health plans. ii

4 TABLE OF CONTENTS Page ELIGIBILITY RULES How an Employee Becomes Eligible for Benefits Class A Active Employees How Eligibility Is Continued Class A Active Employees How Eligibility Is Continued With Self-Payments All Classes... 5 (a) Self-Payment Option (b) Self-Payment Option 2 (COBRA) Reinstatement of Eligibility for Active Employees Use of Transfers Under Reciprocity Agreement Dependents Coverage for Employees and Their Dependents When Employee Enters Military Service Coverage While on Family and Medical Leave Retiree Benefits and Self-Payments are Subject to Change by the Trustees Termination of Individual Coverage Certificate of Creditable Coverage DEATH BENEFITS ACCIDENTAL DEATH AND DISMEMBERMENT BENEFITS LOSS OF TIME BENEFITS COMPREHENSIVE MAJOR MEDICAL BENEFITS Deductible Coinsurance Covered Expenses Hospital Services Skilled Nursing Home Care Services Physicians' Services Diagnostic X-Ray and Laboratory Services Prescription Drugs and Medicines Other Covered Charges Organ Transplant Surgery Genetic Testing and Counseling Alternative Ways of Obtaining Care Pre-Admission Testing Routine Physical Examinations Preferred Provider Preventive Care Program Option Hospice Care Home Care Treatment for Hemophilia Routine Mammograms Routine Immunizations Exceptions and Limitations iii

5 TABLE OF CONTENTS (continued) Page FAMILY SERVICES PROGRAM CASE MANAGEMENT OTHER PREFERRED PROVIDERS Preferred Provider Network Preferred Provider Pharmacy DENTAL CARE BENEFITS VISION CARE BENEFITS MEDICARE-PLUS BENEFITS GENERAL PROVISIONS Coordination of Benefits Medicare Provisions Subrogation/Reimbursement Right of Recoupment Physical Examinations General Exclusions Amendment and Termination of Plan Prohibition Against Assignment to Providers Genetic Information Nondiscrimination Act HIPAA Security Regulations Discretionary Authority Applicable Governing Law Release of Responsibility for Tax Consequences PRIVACY POLICY 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) Claims Review and Appeal Procedures Statement of Participants' Rights Under ERISA Other ERISA Information iv

6 ELIGIBILITY RULES The following Eligibility 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 such change. There are additional terms and conditions governing eligibility for specific benefits and they are described within the applicable benefit section of this booklet. Participants may include: The Plan generally uses a quarterly eligibility system. WORK QUARTER For work you perform during... January February March CONTRIBUTION QUARTER Employer contributions we receive during... February March April COVERAGE QUARTER With the required hours, you and your dependents are eligible for benefits during... June July August employees working for a contributing employer(s) under a collective bargaining agreement requiring contributions to this Fund; or non-bargaining unit employees and alumni (including certain owners) who are part of a classification specified in a Trustee-approved participation agreement. April May June July August September October November December May June July August September October November December January September October November December January February March April May Although sole proprietors, partners, and 100% owners may perform work covered by a labor contract or are alumni or non-bargaining unit employees, such persons will not be eligible to participate in this Plan. Participation in and eligibility under the Plan is conditional upon you or your dependent not objecting by your action or inaction to 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. Though Eligibility Rule requirements may have been satisfied, eligibility will be suspended and benefits will not be paid when you withhold consent for such release or exchange of information. You and your dependents will be eligible to receive benefits under the Plan provided the following eligibility requirements are satisfied. Eligibility for benefits from this Plan is based on an employee having the required hours from employer contributions, self-payments, or credits. Coverage quarters follow contribution quarters with one month in between for necessary bookkeeping. If insufficient employer contributions or other credits are received during a contribution quarter because you are not fully employed, or are sick or injured and unable to work, the bookkeeping month allows the Trustees time to notify you in advance that a self-payment is due to continue eligibility of you and your dependents for the next coverage quarter. In these Rules, the terms covered work and employment mean work for which an employer is obligated to pay contributions to this Fund under the terms of a collective bargaining agreement with the Chicago Regional Council of Carpenters Northern Region or under an approved participation agreement with the Trustees. Generally under these Rules, credits for eligibility are based on employer contributions being received by the Trustees. However, a bargaining unit employee also will receive credit for selfpayments and disability hours, and apprentices will receive credit for training hours as specified on 1

7 page 5. Non-bargaining unit employees and alumni will not receive credit for disability hours. Further, for up to three months out of every twelve months, Trustees may waive the requirement for bargaining unit employees that contributions be received, provided evidence acceptable to them is furnished which proves you performed covered employment for which the required contributions were not paid. Trustees will not waive the contribution requirement for non-bargaining unit employees or alumni. You will receive a quarterly notice summarizing hours for which employer contributions were received and disability hours for which you have been credited. 1. How an Employee Becomes Eligible for Benefits Class A Active Employees (a) Initial Eligibility You, as a new employee, will become initially eligible for Class A benefits on the first day of the month following the month in which you are credited with employer contributions for at least 400 hours of covered employment within two consecutive work quarters. You and your dependents will remain eligible for three consecutive months. In the event your initial eligibility date is other than the first day of the first month of a coverage quarter, your eligibility will be continued for a part of the next coverage quarter. You will remain eligible for the next coverage quarter, or remainder of the next coverage quarter, subject to Rule 2, How Eligibility Is Continued, which begins on this page. The credit apprentices receive for training hours will be used toward establishing initial eligibility requirements. (b) Dependent Special Enrollment Period When you acquire a new dependent through marriage, birth, adoption, or placement for 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 within 45 days of the marriage, birth, adoption, or placement for adoption, the new dependent s coverage will be effective as of the date of the marriage, birth, adoption, or placement for adoption. If the request is not made within 45 days, the dependent s coverage will be effective on the first day of the month following receipt by the Fund Office of the completed enrollment card. (c) Other Special Enrollment Rights You or your dependent also will be entitled to special enrollment rights if: (1) you or your dependent had other coverage under Medicaid or the State Children s Health Insurance Program ( CHIP ) and lose eligibility for that coverage; or (2) you or your dependent becomes eligible for financial assistance with respect to coverage under the Plan through Medicaid or CHIP. You also may request a special enrollment period upon a child s loss of other health coverage. The effective date of coverage for any of these qualifying events will be the first day of the month following receipt of the request for enrollment. Special enrollment must be requested within 30 days of the qualifying event except for a CHIP event as previously described which must be requested within 60 days of such event. 2. How Eligibility Is Continued Class A Active Employees Eligibility under the Plan is continued subject to the following provisions, provided you are available for full-time covered work. If you work for a non-contributing employer in the construction industry, coverage under the Plan for you and your dependents will 2

8 terminate effective the first day of the month following notice from the Fund Administrative Manager, but not earlier than 20 days after the date of such notice. You will not be allowed to make self-payments under Self-Payment Option 1 as of such termination date; you only will be allowed to make self-payments under Self-Payment Option 2 (COBRA), according to the provisions on pages 13 through 17. The termination of benefits and privileges under this provision does not apply if full-time covered work is not available. However, if you are offered covered work by a contributing employer and you refuse such offer, these termination provisions will apply as of the date of your refusal. If your eligibility for coverage was terminated according to these provisions and then you return to covered work, you will become eligible for benefits effective the day you return, provided you had sufficient accumulated banked hours remaining on the date your eligibility was terminated. If the banked hours remaining to your credit are insufficient for eligibility, you will be required to meet the requirements for initial eligibility in order for you and your dependents to once again become eligible under the Plan. (a) When Credited With Sufficient Hours (1) Bargaining Unit Employees Once you become eligible, you and your dependents will continue to be eligible for Class A benefits as long as you are credited with at least 345 hours for each work quarter. You do not have to receive credit each month of the work quarter to remain eligible, provided you earn the total number of required credits within the quarter. (2) Non-Bargaining Unit Employees and Alumni You must be credited with a minimum of 160 hours in each month of a work quarter in order to remain eligible. If you are not credited with 160 hours in each month of a work quarter, your eligibility will end on the last day of the work month for which at least 160 hours are credited. (b) When Credited With Less Than Required Hours (1) When a bargaining unit employee is credited with less than 345 hours for a work quarter, the hours credited in that quarter and the prior three quarters will be considered. You and your dependents will maintain eligibility for Class A benefits if you are credited with employer contributions or other credits for at least 1,380 hours during the four immediately preceding consecutive work quarters. (2) If an alumni is totally unemployed or totally and permanently disabled and is credited with less than 160 hours in each month of a work quarter, the hours credited in that quarter and each of the preceding three quarters will be considered. You and your dependents will maintain eligibility for Class A benefits if you are credited with employer contributions or other credits for at least 1,920 hours during the four immediately preceding consecutive work quarters. (3) When a bargaining unit employee or an alumni is credited with less than the required number of hours, eligibility for you and your dependents will end, as specified in the following table, unless you continue eligibility with selfpayments as provided in Rule 3, How Eligibility Is Continued With Self- Payments, which begins on page 5. (4) If a non-bargaining unit employee is credited with less than the required number of hours, eligibility for you and your dependents will end as of the last day of the work month for which contributions were last received unless you continue eligibility with selfpayments as provided in Rule 3(b), Self-Payment Option 2 (COBRA), which begins on page 13. 3

9 There are four possible dates on which your continued eligibility terminates, depending on when you fail to meet the credit requirements (does not apply to nonbargaining unit employees). If you do not meet any of the credit requirements by the work quarter ending in: March May 31 Your continued eligibility ends: June August 31 September November 30 December February 28/29 (c) When Receiving Worker's Compensation Benefits [This subsection will apply only to bargaining unit employees and will not apply to non-bargaining unit employees and alumni.] (1) When a disability prevents you from working after becoming eligible, you will be given credit for 27 hours per week, up to 115 hours per month for up to eight work quarters in order to help maintain eligibility for Class A benefits. (2) You receive the disability hours credit provided: (i) you receive temporary total or permanent total disability weekly Worker's Compensation Benefits as a result of injury or sickness; (ii) your disability was incurred because of employment by an employer and for which employer contributions are payable to this Fund; (iii) you submit proof to the Fund Office that you are receiving temporary total or permanent total disability weekly Worker's Compensation Benefits; and (iv) you furnish medical evidence satisfactory to the Trustees, upon request. In addition, you will receive the disability hours credit if you are receiving temporary partial disability weekly Worker s Compensation Benefits as a result of injury or sickness and you have returned to light-duty work. Such credit will be based on the difference between the number of hours you work and 115 hours per month for up to 24 months. You will not receive the credit if you are receiving total partial disability Worker's Compensation Benefits. If an injury or sickness for which Worker's Compensation Benefits are paid allows you to return to work but later requires additional treatment, disability hours can be credited while receiving the additional treatment, up to a total of eight work quarters. You also receive the disability hours credit when receiving Loss of Time Benefits from this Plan as stated in the following subsection (d), When Receiving Loss of Time Benefits. (d) When Receiving Loss of Time Benefits [This subsection will apply only to bargaining unit employees and will not apply to non-bargaining unit employees and alumni.] (1) When you receive Loss of Time Benefits from this Plan, you are credited with 27 hours per week, up to 115 hours per month, for such injury or sickness in order to help maintain eligibility for Class A benefits. (2) If you receive Loss of Time Benefits from this Plan as a result of light-duty work, no disability hours credit will be given for the month once your light-duty work equals 115 hours per month. 4

10 However, you will be given full credit toward eligibility for all light-duty hours worked for which employer contributions were paid. (3) You will receive the disability hours credit for up to 26 weeks. (e) When Apprentices Are Being Trained Apprentices will be credited with 40 hours each quarter while attending training school. These hours will be granted to establish or maintain eligibility. (f) When You Die or Divorce [This subsection will apply only to bargaining unit employees and will not apply to non-bargaining unit employees and alumni.] Your dependents who, at the time of your death or divorce, were eligible because of employer contributions or payments under Self-Payment Option 1, will remain eligible for health care, dental, and vision benefits to the end of the coverage quarter in which you died or the divorce judgment was granted, plus two additional coverage quarters. If you are a retiree, your dependents will remain eligible to the end of the month in which you died or the divorce judgment was granted, plus six additional months. Near the end of the additional coverage period, your dependents will receive an initial notice describing how and when to make self-payments to continue coverage. 3. How Eligibility Is Continued With Self- Payments All Classes Under certain circumstances, you and your dependents may continue eligibility by making self-payments under one of two options. If you are eligible to do so, you will receive a notice. Self-Payment Option 1 is the Fund's traditional self-payment provisions and Self-Payment Option 2 is the COBRA continuation provisions required by law. You must elect one option or the other. If you elect Option 1, you cannot subsequently elect Option 2 unless you experience a second Qualifying Event as defined on page 13. (a) Self-Payment Option 1 [Self-Payment Option 1 will apply to bargaining unit employees. It also will apply to alumni, except for the following subsection (a)(3), If a Bargaining Unit Employee Is Partially Employed. Nonbargaining unit employees will not be eligible for Self-Payment Option 1 except as a retiree in limited circumstances as described in subsection (a)(7), If a Retiree, which begins on page 9.] (1) The following may use Option 1 to continue eligibility for applicable benefits: (i) an employee or former employee who is: (A) available for full-time covered work; or who is (B) totally and permanently disabled; or (ii) a retired employee; or (iii) a surviving spouse who, at the time of your death, was eligible because of employer contributions or selfpayments under Self-Payment Option 1. You will be considered not available for work and, therefore, not eligible to make self-payments to this Fund when: (i) you work for a non-contributing employer in the construction industry (The term non-contributing employer means an employer in the construction industry who does not contribute to a multi-employer health benefit plan anywhere); or (ii) you are not registered on the out-of-work list of the Northern Region of the Chicago Regional Council of Carpenters for the 5

11 work quarter that corresponds with the coverage quarter to which the self-payment is applicable. Remember: At the time of your first self-payment notice, you are given the opportunity to elect Self-Payment Option 1 or Self-Payment Option 2 (COBRA Continuation). If at that time you elect or have already elected Self-Payment Option 1 and you subsequently become ineligible to make a self-payment under Self- Payment Option 1 because you have not registered on the out-of-work list, you will not be offered another opportunity to elect Self-Payment Option 2. (2) Types of Notices and Self-Payment Due Dates If you are an active employee, a quarterly notice will be sent to you summarizing hours reported and selfpayments received. This notice will tell you if you and your dependents are eligible for the next coverage quarter and the amount due if a self-payment is needed to continue eligibility. The selfpayment must be received at the Fund Office by the 15th day of the month prior to the month for which coverage is applicable. If the self-payment is not received by the 15th day of the month prior to the coverage month, you will lose eligibility as of the last day of the month for which a timely self-payment was made. If the amount due for the quarter exceeds one-third of the full selfpayment amount, the self-payment amount may be made in three equal monthly installments. Coverage will be extended for each applicable month once the monthly installment is received. Self-payments must be received by the 15th day of the month prior to the month for which coverage is applicable. If the self-payment is not received by the 15th day of the month prior to the coverage month, you will lose eligibility as of the last day of the month for which a timely self-payment was made and must reinstate using hours worked in the next work quarter after termination (no previous work hours can be used toward reinstatement). Those who retire or become totally and permanently disabled or those who become surviving spouses entitled to make self-payments will receive an initial notice that the first self-payment is due, provided the Trustees have been notified. This notice names the coverage month (or quarter) for which a self-payment is needed and the amount due to continue eligibility. Selfpayments must be received prior to the first day of the coverage month. Failure to make self-payments when due causes a loss of eligibility. (3) If a Bargaining Unit Employee Is Partially Employed Duration of Self-Payments: If hours credited are insufficient, you can make self-payments to keep yourself and your dependents eligible for all applicable Class A benefits, subject to the following conditions, provided you remain available for full-time covered employment. You will be allowed to make up to an aggregate maximum of six consecutive quarters of self-payments, whether you are partially employed, fully unemployed, or any combination of the two. If you are making self-payments and have not reached the six-quarter maximum, and you, as a bargaining unit employee, are credited with 345 hours in one work quarter, or as alumni are credited with 160 hours in each month of a work quarter, you become eligible to make self-payments for an additional six consecutive quarters. Once you have made six consecutive quarters of any combination of partial and full self-payments, you will not be eligible to make further self-payments. If you lose eligibility, you must satisfy the 6

12 reinstatement rules on page 17 to again have coverage in the Fund. Self-Payment Amount: The initial and subsequent self-payment amount will be shown on the notices. The self-payment required is the difference between the hours credited and the minimum hours needed per quarter to maintain eligibility, multiplied by the employer hourly contribution rate specified in the current collective bargaining agreement. (4) If Unemployed Duration of Self-Payments: As an unemployed person available for fulltime covered work, you can make full self-payments to keep yourself and your dependents eligible for applicable Class A benefits, subject to the following conditions, provided you remain available for full-time covered employment. You will be allowed to make up to an aggregate maximum of six consecutive quarters of self-payments, whether you are partially employed, fully unemployed, or any combination of the two. If you are making self-payments and have not reached the six-quarter maximum, and you, as a bargaining unit employee, are credited with 345 hours in one work quarter, or as alumni are credited with 160 hours in each month of a work quarter, you become eligible to make self-payments for an additional six consecutive quarters. Once you have made six consecutive quarters of any combination of partial and full selfpayments, you will not be eligible to make further self-payments. If you lose eligibility, you must satisfy the reinstatement rules on page 17 to again have coverage in the Fund. Self-Payment Amount: The initial and subsequent self-payment amount will be shown on the notices. The full selfpayment is based on the minimum requirement of 345 hours for a bargaining unit employee or 480 hours for an alumni, per quarter, multiplied by the employer hourly contribution rate specified in the current collective bargaining agreement. Low Cost Option - Class A Bargaining Unit Employees: To qualify for the Low Cost Option in a coverage quarter, you must be: completely unemployed in the work quarter preceding the coverage quarter; available for full-time covered employment in the Fund s jurisdiction; and registered on the out-of-work list of the Northern Region of the Chicago Regional Council of Carpenters for such work quarter. You will be given the opportunity to enroll in the Low Cost Option at the time you receive your first full self-payment notice. If you do not elect the Low Cost Option at that time, you will not be eligible to elect the Low Cost Option in a subsequent coverage quarter. To elect this option, you must complete the election form included with your quarterly self-payment notice and return it to the Fund Office by the 15th of the month prior to the month for which coverage is applicable. Eligibility may be continued under the Low Cost Option: for up to six consecutive coverage quarters; or until you satisfy the Plan s reinstatement rules by being credited with employer contributions for 400 hours of covered employment within two consecutive work quarters, whichever is earlier. Benefits under the Low Cost Option include Comprehensive Major Medical Benefits and Preferred Provider Pharmacy Prescription Drug Benefits only, at different benefit levels than Class A as stated in the Schedule of Benefits. Death Benefits, Loss of Time Benefits, Vision Care Benefits, and Dental Care Benefits are not available under the Low Cost Option. Although out-of-pocket expenses are increased under the Low Cost Option, self-payments are lower than for full Class A benefits. The quarterly selfpayment amount for the Low Cost Option is reviewed at least annually and is subject to change. You can make 7

13 monthly versus quarterly self-payments, provided the payment is received by the 15th of the month prior to the month for which coverage is applicable. Coverage will be provided for the applicable month. Once you elect the Low Cost Option, you will not be eligible for full Plan benefits again until you satisfy the Plan s initial eligibility or reinstatement of Eligibility Rules. (5) If Totally and Permanently Disabled When the Trustees determine that the requirements of total and permanent disability as defined on page 67 have been met, you will receive an initial notice describing the self-payment amount and due dates. If you are disabled and receiving benefits from the Building Trades United Pension Trust Fund, your first selfpayment is due after your bank of hours, if any, is exhausted. Duration of Self-Payments: If totally and permanently disabled, you will be able to make self-payments to keep yourself and your dependents eligible for all applicable Class RA, RAO, RAM, RB, RBO, and RBM benefits. Selfpayments under this section may continue as long as you continue to furnish medical and other information when requested and the Trustees continue to determine total and permanent disability. Self-Payment Amount: The selfpayment amount is set by the Trustees and may be changed at their discretion. Return to Work: If you are eligible under Class RA, RAO, RAM, RB, RBO, or RBM and no longer are totally and permanently disabled and you are released to return to covered work, you will become reinstated under Class A as of the first day of the month following your return to covered employment. You and your dependents will remain eligible for the remainder of the coverage quarter in which you are reinstated. You will remain eligible for subsequent coverage quarters subject to Rule 2, How Eligibility Is Continued, which begins on page 2. Such automatic reinstatement, without having to satisfy the requirements for initial eligibility, will apply only if you are totally and permanently disabled and you have not retired due to age. Evidence of retirement will be your receipt of retirement benefits from a pension trust fund covering Carpenters or Social Security. (6) If a Surviving Spouse of a Deceased Employee Your surviving spouse may continue eligibility for benefits for herself and your eligible dependents by making selfpayments with the consent of the Trustees. The Class of benefits for which eligibility may be continued is the one under which your surviving spouse was covered at the time of your death or, if covered under Class A, your surviving spouse may choose Class RA, RAO, RAM, RB, RBO, RBM, RC, or RD. Duration of Self-Payments: The right to maintain coverage by making selfpayments under this provision ends on the day: (i) your surviving spouse remarries; or (ii) your surviving spouse and/or dependent children become eligible to participate in any other group health care plan as a result of employment and elect not to participate in such plan; or (iii) your surviving spouse and/or dependent children establish residency outside the United States. Self-Payment Amount: The selfpayment amount is set by the Trustees and may be changed at their discretion. The amount and dates due will 8

14 be specified in the self-payments. initial notice of continue eligibility for yourself and your eligible dependents provided you: For Surviving Spouses Who Work for Wage or Profit: Effective January 1, 2015, surviving spouses who are employed and do not have medical coverage available through their employer will be subject to the following earnings rules. If a surviving spouse works for wage or profit, her eligibility to make subsidized self-payments will cease as of April 1 of any year following a calendar year in which her annual earnings from such employment exceed 710 hours multiplied by the hourly base rate for journeymen carpenters specified in the current collective bargaining agreement requiring contributions to the Fund, rounded to the nearest hundred dollars. Such surviving spouses who continue to work may make non-subsidized selfpayments under Self-Payment Option 1 at a rate to be determined by the Trustees from time to time to continue coverage under the Plan. Surviving spouses who continuously make nonsubsidized self-payments under this provision once again will be eligible for a subsidy when they are enrolled in Part A and Part B of Medicare. If a surviving spouse chooses not to make non-subsidized self-payments, her eligibility under the Plan will terminate and she will not be eligible for reinstatement in the Retiree Program. All non-medicare-eligible surviving spouses will be required to complete a form annually certifying the extent of their business and employment-related earnings. Surviving spouses may be asked to furnish information verifying the extent of such earnings, including copies of income tax returns and Form W-2. (7) If a Retiree If eligible for Class A or COBRA benefits at the time of retirement, you may (i) retire because you have reached at least the age of 55 or you are disabled from the kind of work for which employer contributions are payable to this Fund; and (ii) were credited with hours worked (and/or COBRA self-payments made) just prior to retirement (the year in which retirement occurs may be included if it is to your advantage) or prior to becoming a non-bargaining unit employee or alumni as follows: (A) 4,800 hours in five consecutive calendar years; or (B) 5,760 hours in six consecutive calendar years; or (C) 6,720 hours in seven consecutive calendar years; or (D) 7,680 hours in eight consecutive calendar years; or (E) 8,640 hours in nine consecutive calendar years; or (F) 9,600 hours in 10 consecutive calendar years; and (iii) remain a member in good standing of a Local Union participating in this Fund or make non-subsidized selfpayments. Retirees who satisfy the prior requirements may be eligible for a subsidized self-payment based on the work hours credited to the Health Fund over their working career. Please contact the Fund Office to determine your level of subsidy, if any, and the applicable rate. These retiree eligibility requirements may be satisfied, in whole or in part, with coverage as a non-bargaining unit 9

15 employee or alumni. Such retirees may make non-subsidized self-payments under Self-Payment Option 1 at a rate determined by the Trustees from time to time. Duration of Self-Payments: Starting with receipt of the first retirement benefit from the Building Trades United Pension Trust Fund, Milwaukee and Vicinity (BTUPTF), you may continue coverage by making self-payments. You will receive an initial notice of the amount of and due dates for self-payments. A non-bargaining unit employee or alumni not eligible for a retirement benefit from BTUPTF will receive an initial self-payment notice following: written statement from his employer of his retirement date; or proof of the sale of his company, if the employee is an owner. Your first self-payment is due after your bank of hours, if any, is exhausted. Non-bargaining unit employees do not accumulate a bank of hours and therefore may not extend eligibility beyond their date of retirement, except with non-subsidized self-payments. Classes of Benefits (see definitions on pages 60 and 61): (i) When Employee and Dependents Are Eligible for Medicare You may continue eligibility under Class RAM or RBM benefits for yourself and your eligible dependents. (On or before March 20, 2014, you also had the option of electing Class RC.) (ii) When Either the Employee or Dependent Spouse Is Eligible for Medicare and the Other Is Not Eligible for Medicare You may continue eligibility under either Class RAO or RBO. [On or before March 20, 2014, you also had the option of electing Class RD. Class RD provides coverage for you under Class RC and for your dependent child(ren) and spouse under Class RB.] (iii) When Employee and Dependents Are Not Yet Eligible for Medicare You may continue eligibility under Class RA or RB for yourself and your eligible dependents. If you are eligible for Medicare, you must enroll in Part A and Part B of Medicare. Please refer to the Medicare Provisions on pages 47 and 48. Retired employees are not eligible for Loss of Time Benefits. You will have the opportunity to choose under which Class of benefits you want coverage. You may choose a lower Class of benefits at any time, but you will not be permitted to change your election to obtain a higher Class of benefits. Retired employees or their dependents continuing coverage under Class RA, RAO, RAM, RB, RBO, or RBM who become initially entitled to Medicare due to End Stage Renal Disease will not be eligible for Class RC until the expiration of the full 30-month coordination period specified in the Medicare Provisions on pages 47 and 48. If a Medicare-eligible person continuing coverage under Class RAO, RAM, RBO, RBM, RC, or RD enrolls in Medicare Prescription Drug Benefits, he will become ineligible for the Plan s prescription drug benefits upon the effective date of his Medicare Prescription Drug Benefits. (He will have a one-time option to drop Medicare Prescription Drug Benefits and become covered under the Plan s prescription drug benefits again.) If such person does not enroll in Medicare Prescription Drug Benefits, he will continue eligibility for the Plan s prescription drug benefits, 10

16 provided he is otherwise eligible under the Plan. The Amount of Self-Payment Is Set by the Trustees: A retiree who does not maintain Union membership may make non-subsidized self-payments under Self-Payment Option 1 at a rate to be determined by the Trustees from time to time, or the retiree may continue coverage under Self-Payment Option 2. When a retired employee fails to make self-payments on the due date and thereby becomes ineligible for benefits, he can be reinstated as provided under Rule 4, Reinstatement of Eligibility for Active Employees, on page 17 or by consent of the Trustees. Retirees Returning to Work: (i) When a Retiree Returns to Covered Employment: For Retirees in Classes RA, RAO, RAM, RB, RBO, and RBM: If a retiree accepts temporary covered employment and contributions for any work month are equal to or in excess of the required monthly selfpayment, the employee will not be required to make any payment for the related coverage month. If the employer contribution for any contribution month is less than the required monthly self-payment, the employee will be required to make payment for the difference between the contributions received and the retiree self-payment rate. For All Classes of Retirees: A retiree will be reinstated to the status of an active employee and become entitled to all Class A benefits on the first day of the month following the month in which he is credited with employer contributions for at least 400 hours of covered employment within two consecutive work quarters. (ii) When a Non-Medicare-Eligible Retiree Returns to Non-Covered Employment: If a retiree works for wage or profit for a non-contributing employer in the construction industry or in an industrial trade he learned through covered employment, his eligibility to make subsidized self-payments will cease as of the last day of the month in which he begins such employment. If, within 60 days of the date his eligibility for a subsidy ends, he submits proof that his noncovered employment is terminated, his eligibility for a subsidy will be reinstated on a one-time basis. If a retiree works for wage or profit at non-covered employment other than the type specified in the prior paragraph, his eligibility to make subsidized self-payments will cease as of April 1 of any year following a calendar year in which his annual earnings from such employment exceed 710 hours multiplied by the hourly base rate for journeymen carpenters specified in the current collective bargaining agreement requiring contributions to the Fund, rounded to the nearest hundred dollars. Retirees who continue to work at non-covered employment may make non-subsidized self-payments under Self-Payment Option 1 at a rate to be determined by the Trustees from time to time to continue coverage under the Plan. Retirees who continuously make non-subsidized self-payments under this provision once again will be eligible for a subsidy when they are enrolled in Part A and Part B of Medicare. If a retiree chooses not to make non-subsidized self-payments, his eligibility under the Plan will terminate and he will not be 11

17 eligible for reinstatement in the Retiree Program unless he once again satisfies the Eligibility Rules described on page 2. All non-medicare-eligible retirees will be required to complete a form annually certifying the extent of their business and employment-related earnings. Retirees may be asked to furnish information verifying the extent of such earnings, including copies of income tax returns and Form W-2. Retiree Waiver/Reinstatement Provisions: If you are eligible to continue Plan benefits as a retiree, you may elect to waive or terminate your eligibility for all Plan benefits if you are eligible for and enrolled in another employer-sponsored group health care plan. You and your spouse, if applicable, will be required to sign a waiver form certifying that you are covered by another group health care plan and submit proof of such coverage. If you subsequently terminate or become ineligible for the other group health care coverage, you will be given a one-time option to be reinstated into the Milwaukee Carpenters District Council Health Fund. To be eligible for such reinstatement, you must submit proof that you and your eligible dependents were continuously covered under another employersponsored group health care plan within 60 days of the date your other coverage terminates. Your coverage will be reinstated on the first day of the month following termination of your other coverage assuming receipt of your proof of other coverage and receipt of your applicable self-payment. There can be no lapse in coverage. Coverage will be reinstated under the retiree Class of benefits for which you were eligible at the time you waived your eligibility or, if you are eligible for a lesser Class of benefits, you may elect a lesser Class of benefits upon your reinstatement. Your self-payment amount will be based on the then current rate for your applicable Class of coverage. Your eligibility for a subsidy, if any, is frozen at the time of your termination. Upon your reinstatement, you will be eligible for the subsidy applicable to your years of service and hours credited prior to your termination based on the rules in effect on the date of your reinstatement. Reinstatement will follow the Health Insurance Portability and Accountability Act (HIPAA) rules governing pre-existing condition limitations. (8) Information in Support of Self-Payments When an active or retired employee returns a self-payment notice or application to the Fund Office, his signature attests that all of the information furnished is correct and complete and that no facts have been omitted with respect to eligibility for making self-payments to, or receiving benefits from, the Fund. Failure to disclose relevant information or stating of misleading facts will be cause for termination and recovery of any benefits paid by this Fund to the employee or his dependents, retroactive to the date of receipt of such self-payment notice or application. Self-payments improperly made to the Fund may, in the Trustees' discretion, be declared forfeited to the Fund and will be used as an offset against any benefits improperly paid. Any improperly paid benefits must be repaid to the Fund. 12

18 (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; the Health Insurance Portability and Accountability Act of 1996; and the American Recovery and Reinvestment Act of Any future regulatory 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 (described as follows), continue eligibility under Self-Payment Option 2 for: health care benefits only; or health care, dental, and vision 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) voluntary or involuntary termination of covered employment for any reason (except gross misconduct on your part), including disability, sickness, or retirement; or (ii) reduction in the amount of covered employment. Such Qualifying Events occur for your eligible spouse and dependent children upon any of the following events occurring while you are eligible because of employer contributions: (i) termination or reduction of your covered employment for any reason (except gross misconduct on your part), including disability, sickness, or retirement; (ii) your death; (iii) divorce or legal separation from you; (iv) a dependent child ceases to meet the definition of dependent; or (v) your entitlement to Medicare (under Part A, Part B, or both). You or your dependent become 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 you during your period of COBRA continuation coverage also will be treated as a Qualified Beneficiary. As a Qualified Beneficiary, you may continue eligibility for certain benefits through self-payments under the following provisions. (2) Notification and Due Dates (i) Qualified Beneficiary's Responsibility to Notify the Trustees of a Qualifying Event When the Qualifying Event relates to your death, divorce or legal separation, or to a dependent child ceasing to meet the definition of dependent under the Plan, the Qualified Beneficiary must notify the Fund Office within 60 days of the event so the Fund Office may provide proper notices and explanations to a Qualified Beneficiary 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 Fund Office is not notified within 60 days of the Qualifying Event, the person is no longer a Qualified Beneficiary and loses the opportunity to continue coverage. 13

19 (ii) The Trustees' Responsibility to Notify a Qualified Beneficiary When the Qualifying Event is Loss of Coverage Due to the Employee's Death, Divorce or Legal Separation, or to a Dependent Child Ceasing to Meet the 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, selfpayment 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, selfpayment due dates, and duration of self-payment privileges. (iv) Due Dates 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 the Election Form provided. 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. A parent or legal guardian may elect to continue coverage on behalf of a minor child. Failure to provide the written 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 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. Claims for reimbursement will not be processed and paid until you have elected COBRA and made your first COBRA self-payment. (vi) Due Date for Subsequent Self- Payments Subsequent monthly self-payments 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 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 14

20 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 selfpayment last was made and will cause loss of all rights to continuation coverage under the Plan. (3) Coverage 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 dental and vision 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 or to enroll dependents who gain eligibility through Medicaid or CHIP. 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 evidence of 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 dental and vision benefits. The costs are determined annually by the Trustees. There is an additional cost for continued coverage from the 19th through the 29th month for those individuals eligible for such disability extension. The cost may be increased up to 150% of the applicable selfpayment. 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. 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 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. 15

21 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 Social Security Disability 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. When the Qualifying Event is the end of employment or reduction of the employee s hours of employment, and the employee is entitled to Medicare benefits at the time of the Qualifying Event, COBRA continuation coverage for Qualified Beneficiaries other than the employee lasts until the later of 36 months after the date of Medicare entitlement, or 18 months following the employee s termination of employment or reduction in hours. (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 not longer than 36 months from the date of the original Qualifying Event. This Rule will not apply in the case of a reduction in work hours followed by a termination of employment. (7) Termination of Self-Payment Provisions for Qualified Beneficiaries Self-payments no longer are accepted and continued eligibility under this section terminates on behalf of all Qualified Beneficiaries (unless specifically stated otherwise) when: (i) the Fund no longer provides 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 written election for continuation is not made within 60 days following the date of coverage termination or 16

22 receipt of the COBRA Notice, whichever is later; (iv) the initial self-payment is not paid by the due date explained on page 14; (v) the subsequent self-payments are not paid as explained on page 14; (vi) the 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), continuation 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 30 months from the date of ESRD-based 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 expires, the Fund becomes secondary to Medicare for the balance of the continuation coverage. Continuation coverage also may be terminated for any reason the Plan would terminate coverage of a participant or beneficiary not receiving continuation coverage (such as fraud). You will receive a notice if COBRA is terminated early before the maximum period is exhausted. When an employee becomes ineligible for benefits hereunder, he can be reinstated as provided under the following Rule 4, Reinstatement of Eligibility for Active Employees. Additionally, there may be other coverage options for you and your family. When key parts of the health care law take effect in 2014, you will be able to buy coverage through the Health Insurance Marketplace (also known as the Exchanges ). In the Marketplace, depending on your household income, you may be eligible for a new kind of tax credit that lowers your monthly premiums right away. Being eligible for COBRA coverage does not limit your eligibility for coverage or for a tax credit through the Marketplace. You also can see what your premium, deductibles, and out-of-pocket costs will be before you make a decision to enroll in the Marketplace, and you may have multiple coverage options in the Marketplace. Finally, you may qualify for a special enrollment opportunity for another group health plan for which you are eligible (such as a spouse s plan), even if a plan generally does not accept late enrollees, if you request enrollment within 30 days. 4. Reinstatement of Eligibility for Active Employees If eligibility ends, you can become eligible for benefits again provided you are credited with employer contributions for 400 hours of covered employment within two consecutive work quarters. Renewed eligibility becomes effective 17

23 on the first day of the second month during which you worked your 400th hour. 5. Use of Transfers Under Reciprocity Agreement Transfer of contributions and related information about employment from another carpenter's health care plan can be used to satisfy requirements for initial eligibility, continuation of eligibility, and reinstatement of eligibility, provided you are not eligible in another plan after such transfer takes place. If the contribution rate from the transferring fund is less or more than this Fund's contribution rate, your hours will be prorated as follows. The money received on your behalf will be divided by this Fund's contribution rate to determine the number of hours for which you will receive credit. 6. Dependents Dependent coverage is available to your spouse and children, as defined on pages 61 and Coverage for Employees and Their Dependents When Employee Enters Military Service (a) Eligibility Status (1) You, or an appropriate officer, must submit advance 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, or an appropriate officer, do not submit such notice, your accumulated banked hours, if any, will be used until exhausted to further extend your eligibility and the eligibility of your dependents. Your coverage will terminate on the date your accumulated banked hours have been exhausted. If you subsequently submit notice in a reasonable time period, the use of your accumulated banked hours will cease. (3) For military leaves which are less than 31 days in duration and for which you, an appropriate officer, or an employer submit the required notice and otherwise satisfy the reemployment requirements described as follows, 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, an appropriate officer, or an employer submit the required notice, your and your eligible dependents' coverage will cease and your eligibility status will be frozen as of the date you leave employment for the purposes of performing military service with the uniformed services of the United States, unless you elect to continue coverage as described in the following subsection (b), Continuation of Coverage. (5) Your eligibility will be reinstated on the date you return to work for a contributing employer (or upon making yourself available for work if no such work is available) within the applicable time limits stated in the following subsection (c), Status Upon Return from Military Service, provided you otherwise satisfy the reemployment requirements necessary to qualify for reemployment rights under USERRA (e.g., provide evidence of honorable discharge, cumulative military service of no longer than five years). If your accumulated banked hours have been exhausted, you will be allowed to make self-payments under Self-Payment Option 1 to be immediately reinstated in the Plan until you earn sufficient accumulated hours of eligibility to sustain Plan coverage. You also have the option of delaying the reinstatement of your eligibility until you have exhausted any extension of medical benefits provided by the federal 18

24 government upon completion of your military service. (b) Continuation of Coverage (1) If you fail to provide advance notice of your military service, your coverage will terminate on the date your accumulated banked hours has been exhausted and you will not be eligible to continue coverage under this section unless your failure to provide advance notice is excused. The Trustees will, in their sole discretion, determine if your failure to provide advance notice is excusable under the circumstances and may require that you provide documentation to support the excuse. If the Trustees determine that your failure to provide advance notice is excused, you may elect to continue coverage, in accordance with this subsection (b), retroactive to the date you left employment for the purpose of performing services with the uniformed services of the United States, provided that you elect such coverage and pay all amounts required for the continuation coverage. (2) When the Fund Office has been notified that you are entering the military service, you will be given the option of continuing your same Class of coverage under the Plan. Continuation coverage under this subsection (b) is very similar to the continuation coverage described under Self-Payment Option 2, COBRA continuation coverage. The rules for election of and payment for continuation coverage are the same as the COBRA election and payment rules, provided the COBRA rules do not conflict with USERRA. If you do not elect continuation coverage and do not submit payment for all amounts required to continue coverage within the applicable COBRA timeframe, you will lose your right to continue coverage under this section and such right will not be reinstated. (3) You will have the option of using your accumulated banked hours, if available, to continue coverage. If you do not have any accumulated banked hours available or you choose not to use them, you are required to make timely selfpayments at the COBRA rate to be determined by the Trustees from time to time to purchase COBRA continuation coverage. If you elect to use your accumulated banked hours to pay for continuation coverage and you exhaust your accumulated banked hours prior to the end of themaximum coverage period described in the following paragraph (5), you may make self-payments to continue coverage through the end of your maximum coverage period. (4) The COBRA continuation coverage rules apply to payment for continuation coverage under this subsection (b) provided that the COBRA payment rules do not conflict with USERRA. You must make all required self-payments within the COBRA time-frame described under Self-Payment Option 2 in this SPD to continue coverage under this subsection (b) unless the COBRA payment rules conflict with USERRA. (5) You and your eligible dependents may continue coverage for a period ending the earlier of: (i) the date that the Plan no longer provides group health care coverage to any employees; (ii) the day after the date you fail to elect continuation coverage as required by the COBRA continuation coverage election rules; (iii) the first day of the month for which a timely self-payment has not been received and your accumulated banked hours have been exhausted; (iv) 24 months from the first date of absence due to military service; or 19

25 (v) the day after the date you fail to apply for reemployment with a contributing employer within the applicable time period allowed under the following subsection (c), Status Upon Return from Military Service or otherwise cease to have USERRA reemployment rights. The right to freeze eligibility and make self-payments under this provision ceases when you provide 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 have sufficient accumulated banked hours or make timely self-payments to maintain coverage upon your return to work, 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, provided you satisfy the other reemployment requirements of USERRA: (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 service of more than 30 days but less than 181 days, you must apply for reemployment 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 up to two years 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 banked hours prior to your return from military service and you do not have USERRA reemployment rights, you will be treated as a new employee. If you exhaust your accumulated banked hours prior to your return from military service and satisfy USERRA reemployment requirements, you will be eligible for benefits on the date of your return to work within the required time periods, provided you make self-payments required to continue eligibility under Self-Payment Option 1. If you fail to make self-payments as required upon reinstatement in the Plan, your eligibility for coverage will terminate as of the last date of the period for which a timely payment was received and you then will be treated as a new employee. These rules are intended to comply with the requirements of USERRA. The USERRA provisions will control in the event there are any inconsistencies between the Act and the Plan. The Plan will provide continuation coverage and reinstatement rights to the extent required by USERRA. You also may have continuation coverage rights under COBRA. Although the COBRA and USERRA provisions are similar, COBRA continuation coverage and USERRA continuation coverage are not identical. As long as you remain eligible simultaneously for both COBRA and USERRA continuation coverage, you will receive the more generous benefit rights that apply under these statutes. COBRA and USERRA continuation periods will run concurrently. 8. 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 20

26 continued for the number of weeks mandated by law, provided your employer: (a) is subject to the FMLA; (b) makes the required contribution (or you do so); and (c) files the appropriate notification 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 Retiree Benefits and Self-Payments are Subject to Change by the Trustees The Trustees retain the right, in their sole discretion, to change, modify, or discontinue, in whole or in part, the retirees' eligibility for benefits, the types and amounts of benefits, the conditions for payment as well as the retirees' self-payment rates. 10.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 61 and 62. 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 on or before December 31, The certificate provides information on the period of your coverage under the Milwaukee Carpenters' District Council Health Fund that may be credited on your behalf to satisfy any applicable pre-existing condition limitations of a new health plan in which you enroll. If you require a certificate of creditable coverage after December 31, 2014, please contact the Fund Office. 21

27 DEATH BENEFITS Classes A (Bargaining Unit Employees Only), RA, RAO, RAM, RB, RBO, RBM, RC, and RD Employees Only Please Note: Death Benefits are not payable for any non-bargaining unit employee or alumni covered under Class A or COBRA participant. Immediately upon receipt of acceptable proof of your death, 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 an enrollment card provided by the Trustees. 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 in a lump sum to your estate, or at the Trustees' option, to one or more of the following surviving relatives: spouse, child or children, parents, brothers, or sisters. If no relatives survive you, benefits will be paid to the executor or administrator of your estate. ACCIDENTAL DEATH AND DISMEMBERMENT BENEFITS Classes A (Bargaining Unit Employees Only), RA, RAO, RAM, RB, RBO, RBM, RC, and RD Employees Only Please Note: Accidental Death and Dismemberment Benefits are not payable for any non-bargaining unit employee or alumni covered under Class A or COBRA participant. 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, as specified in the Plan Document, and based on the Principal Sum stated in the Schedule of Benefits. All claims must be filed within one year of the date of death or dismemberment. These payments will be made directly to you, if living, otherwise to your beneficiary. 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. 22

28 LOSS OF TIME BENEFITS Class A Bargaining Unit Employees and Certain Alumni Only Please Note: Loss of Time Benefits are not payable for any non-bargaining unit employee covered under Class A or COBRA participant. Loss of Time Benefits are payable to alumni, provided the employee is not an owner, has no financial interest in the company, is not eligible for any other employer-sponsored disability program, and is not receiving or eligible to receive any compensation from an employer while disabled. Alumni are not eligible for disability credits. 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, Loss of Time Benefits will not be payable for any disability that prevents you from active work on the date of your initial or reinstated eligibility until you return to your regular occupation for 160 hours. Loss of Time Benefits also will be paid while you are performing light-duty work (as defined on page 64) provided your disability is not work-related and provided you are not an officer, director, or stockholder of an employer contributing to this Fund. Loss of Time Benefits are not payable in the event you receive disability or retirement benefit payments from the Building Trades United Pension Trust Fund, Milwaukee and Vicinity, or any other pension fund. However, if your disability or retirement benefits are suspended for any reason, you will become entitled to Loss of Time Benefits subject to the reinstatement provisions of the Eligibility Rules. 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; treatment of nervous and mental disorders (including eating disorders), alcoholism, or substance abuse; (d) eighth day of disability due to nervous and mental disorders (including eating disorders), alcoholism, or substance abuse when hospitalconfined; or (e) first day of disability when a surgical procedure is performed on an outpatient basis, if you are disabled for at least three work days. Benefits will continue for a maximum of 26 weeks for any one period of disability for bargaining unit employees and 13 weeks for certain alumni, except for disabilities related to nervous and mental disorders (including eating 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. All claims must be filed within one year of the date of the injury or sickness. Reminder. The Fund Office will deduct the required FICA taxes from your gross benefit. Limitations. Two or more periods of disability are considered as one unless between periods of disability you have returned to your regular occupation for 160 hours. Loss of Time Benefits cease on the date you lose eligibility. Loss of Time Benefits are not payable when you are receiving wages or compensation from any source (unless from an individual policy for which you pay the premium), including Worker s Compensation. (c) first day of disability due to sickness when hospital-confined, except when confined for 23

29 COMPREHENSIVE MAJOR MEDICAL BENEFITS Classes A, RA, RAO, RAM, RB, RBO, and RBM Employees and Dependents and Class RD Dependents 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 49 through 52. Deductible The deductible is the amount of covered charges which you pay before you are entitled to benefits. The deductible for both PPO providers and non- PPO providers per person per calendar year and maximum per family each calendar year is stated in the Schedule of Benefits. If you use cost-effective alternative ways of obtaining care that the Trustees approved, the deductible is waived. See pages 31 through 33. Any covered expenses incurred and 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. Coinsurance After you satisfy the required deductible amount for the calendar year, the Plan pays covered expenses at the applicable coinsurance percentage stated in the Schedule of Benefits. The percentage depends upon use of a preferred provider (except eligible persons whose primary coverage is Medicare are not eligible for the preferred provider level of benefits) 1. The balance of charges is payable by you. If you use the cost-effective alternatives Trustees approved, the coinsurance is waived. See pages 31 through 33. When the out-of-pocket covered expenses in a calendar year NOT including the deductible amount reach the amount stated in the Schedule of Benefits, the Plan pays 100% of the balance of covered expenses for that 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. 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. (a) Hospital Services recommended by the attending physician for the following. (1) Room and board expense, up to the hospital's average semi-private room rate. (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 1 See the Schedule of Benefits for the applicable coinsurance, depending on where services are obtained. 24

30 hospital), if used while confined in the hospital as a resident patient. See page 31 for coverage of pre-admission testing. (4) Outpatient services in connection with a surgical procedure or other emergency firstaid treatment resulting from injury or sickness. There is a separate copayment stated in the Schedule of Benefits for each hospital emergency room visit (whether admitted or not) which does not apply to the deductible or out-of-pocket maximum. (5) For hospital confinements related to treatment of nervous and mental disorders (including eating disorders), substance abuse, and alcoholism, hospital charges are payable the same as for any other disability. Benefits also are payable for partial hospitalization at an approved hospital, clinic, and/or non-medical residential treatment facility for treatment of such conditions. Benefits are payable for charges for the ambulance transfer from an out-of-network hospital to an in-network hospital which are authorized by the FSP manager. [See page 34 for details of the Family Services Program (FSP) and page 83 for the name and address of the FSP manager.] (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) Skilled Nursing Home Care Services in a licensed skilled nursing home 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 for at least three days immediately before transfer to the nursing home; (3) skilled nursing home care is needed for care of the same condition treated in the hospital; (4) the attending physician certifies this care is medically necessary and recertification is made every seven days; and (5) 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 for 160 hours or, in the case of a retiree or dependent, return to normal activities, will be considered as one period of disability unless the subsequent 25

31 period of disability is due to injury or sickness entirely unrelated to the causes of the previous disability. (c) Physicians' Services include charges for: (1) Surgery by a physician, including: charges for outpatient surgery; home deliveries by a physician or a certified nurse/midwife under the supervision of a physician; 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 an impacted tooth, alveolectomy, gingivectomy, apicoectomy, torus palatinus (removal), torus mandibularis, frenectomy, excision of cyst(s), osteoplasty, stomatoplasty, and reconstruction of alveolar process with titanium anchors. Titanium anchors (implant) when used to anchor a bridge or a denture are covered under Comprehensive Major Medical Benefits only. The Plan will cover medically necessary surgery for the treatment of temporomandibular joint disease (TMJ) when more conservative forms of treatment have been unsuccessful. When more than one procedure is performed during the same operative session, the primary procedure will be considered for payment at the full usual and customary allowance and any other secondary procedures will be considered for payment at 50% of the usual and customary allowance. If there is an assistant at the surgery, the Plan will consider 20% of the surgical fee allowed for a physician (M.D.) to assist or 10% for a physician's assistant (P.A.). The Plan will not allow for a P.A. if there was a surgical resident on staff at the hospital who was qualified and available to assist with the surgery. The Plan will not cover an R.N. to assist. For individuals receiving mastectomyrelated benefits, coverage will be provided on the same basis as other medical and surgical procedures covered by the Plan and in a manner determined in consultation with the attending physician and the patient for: all stages of reconstruction of the breast and nipple of the breast on which the mastectomy has been performed; surgery and reconstruction of the other breast to produce symmetrical appearance; prostheses; and treatment of physical complications in all stages of the mastectomy, including lymphedemas. For organ transplant surgery and related items, see pages 29 and 30. (2) Anesthetic and its administration by a professional anesthetist when the charge for those services is not included in the hospital's charges. The maximum allowable for the services of a physician and certified registered nurse anesthetist (CRNA) jointly providing anesthesia service may not exceed the Plan s usual and customary allowance or, if a preferred provider, the PPO fee schedule. (3) Medical services rendered during inhospital, outpatient, office, and home visits by a physician, including examination of an eligible newborn dependent child. Chiropractors' visits will be covered up to the maximum per calendar year stated in the Schedule of Benefits. (4) Outpatient treatment for nervous and mental disorders (including eating disorders), substance abuse, and alcoholism is payable as stated in the Schedule of Benefits. Outpatient treatment includes collateral interviews with the eligible person's family. (See page 34 for details of the FSP and page 83 for the name and address of the FSP manager.) (5) Services of a physician for your or your spouse's routine physical examination. See page 31 for details. 26

32 (d) Diagnostic X-Ray and Laboratory Services, including amniocentesis when medically necessary. Any expense incurred for dental x-rays is excluded (unless rendered for dental treatment of a fractured jaw or injury to sound natural teeth within six months after an accident). (e) Prescription Drugs and Medicines for which a written prescription is legally required and when obtained from a licensed pharmacist upon the prescription of a physician will be payable under Comprehensive Major Medical Benefits only under the following circumstances: (1) Implantable contraceptives when determined to be medically necessary for a non-contraceptive use. (2) When the Fund is the secondary payor to another group health plan. Under such circumstances, the Plan will cover the remaining balance after the primary plan has paid at 90% for a generic prescription and at 85% for a brand name prescription. No deductible will apply and the remaining coinsurance will not apply to the out-ofpocket maximum. The Plan s coinsurance will continue to apply once the out-of-pocket maximum is reached. (3) When an eligible person who is a Medicaid recipient fails to use his PPRx drug card at the time of purchase. Under such circumstances, the Plan will reimburse Medicaid for such prescriptions at the outof-network level of benefits. Benefits are not payable for take-home drugs from the hospital that are included on your hospital bill, prescriptions purchased through a VA facility (including any copayment for which you are responsible), and copayments you incur with the Wisconsin SeniorCare Prescription Drug Assistance Program. For all other prescription drug coverage, see the preferred provider pharmacy described on page 37. If a Medicare-eligible person continuing coverage under Class RAO, RAM, RBO, RBM, RC, or RD enrolls in Medicare Prescription Drug Benefits, he will become ineligible for prescription drug benefits under the Plan and no benefits will be paid for any charges incurred for prescription drugs. (f) Other Covered Charges include the following: (1) Other hospital charges incurred as an outpatient. (2) Charges of a licensed physical therapist, occupational therapist, speech therapist, 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). Benefits are payable for physical, occupational, and speech therapy only when medically necessary to restore a function lost due to injury or sickness. Charges of a physical therapy assistant (PTA) will be considered for payment at 50% of the usual and customary allowance. (3) Charges for hospice care. See page 32 for details. (4) Charges for local professional ambulance service between hospitals as well as to and from a hospital if the attending physician 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 helicopter ambulance service to the nearest hospital within the contiguous United States equipped to furnish the treatment. Ground ambulance charges resulting from a 911 emergency call will be payable subject to the in-network deductible, coinsurance, and out-of-pocket maximum. 27

33 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. (5) 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 durable medical equipment (DME), such as a hospital-type bed, wheelchair, or iron lung (or the purchase of such device in lieu of rental if the rental would exceed the purchase price); repair of DME when the damage is not due to abuse or neglect, the cost of repair is projected to be less than the cost of replacement, the equipment has been maintained according to the manufacturer s recommended maintenance schedule, and the Administrative Manager has authorized the repair in advance; initial artificial limbs and eyes to replace natural limbs and eyes that have been amputated or severed; medically necessary replacement or repair of artificial limbs and eyes when authorized in advance by the Administrative Manager; initial breast prosthesis following a mastectomy; replacement prostheses as needed due to material deterioration; hearing aid examinations and hearing aids when prescribed by a physician; repairs to hearing aids; one pair of physician-prescribed custom made orthopedic shoes, custom-molded inserts, or orthotics until worn out and another pair is prescribed by a physician; dental services rendered by a physician, dentist, or dental surgeon for treatment of a fractured jaw or injury to sound natural teeth, including replacement of such teeth within six months after the date of the accident or if the injury is due to domestic violence or a medical condition; diagnosis and nonsurgical treatment of temporomandibular joint disease (TMJ), up to the maximum stated in the Schedule of Benefits per eligible person's lifetime (see page 26 for coverage of surgical treatment of TMJ); essential costs of home care treatment for hemophilia (see page 32 for details); and DME supplies (including CPAP supplies), but excluding batteries, up to the maximum stated in the Schedule of Benefits. (6) Charges related to provision of artificial life support systems for the first five days after a medical determination that death had 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. (7) Diabetic self-management education programs, including dietary counseling, provided the program is medically necessary and prescribed by a physician. Nutritional counseling for the management of other medical conditions also is covered subject to the same requirements. (8) Routine colonoscopies for eligible persons age 50 and over and for eligible persons who have a family history of colon cancer. 28

34 (9) Dental prostheses (such as maxillary or mandibular prosthesis) when the loss of natural teeth is the result of cancer that required radiation to the head and/or neck. (10) Acupuncture when medically necessary. (g) Organ Transplant Surgery and related covered costs for human organ or tissue transplants are provided according to the terms and conditions set forth in a separate Organ & Tissue Transplant Policy (Transplant Policy) that has been issued to the Plan and also in the Organ & Tissue Transplant Certificate enclosed with this SPD booklet. Transplant-related benefits will be provided to each eligible person during the transplant benefit period specified in the Transplant Policy. Once the insured transplant benefit period has elapsed, all transplant-related benefits will revert back to the Plan, subject to its terms and conditions. Insured transplant-related benefits only are available to you if you: are eligible for medical benefits under the Plan; meet all the terms and conditions outlined in the Transplant Policy; and have fulfilled the pre-existing condition waiting period (if applicable) as defined in the Transplant Policy. The pre-existing condition waiting period only applies to certain kidney transplants that are performed from September 1, 2013, through August 31, Eligible persons that are subject to this preexisting condition waiting period under the Transplant Policy will receive transplant benefits according to the terms and conditions of the Plan until the pre-existing condition waiting period has elapsed. Coverage for cornea transplants is provided directly through your self-funded Plan of benefits 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 self-funded procedures. Cornea transplants are covered under the Plan as stated in this section provided they are medically necessary. In addition, the following transplants are covered under your self-funded Plan of benefits for Medicare-eligible retirees and are coordinated with benefits payable by Medicare: cornea, kidney, bone marrow (except bone marrow transplants caused by T-cell leukemia), liver, heart, heart/lung (single or double), lung (single or double), pancreas, pancreas/kidney, and small bowel. Organ transplant benefits are payable provided each of the following conditions is satisfied: (1) You or your dependent receives two written opinions by Board-certified specialists in the involved field of surgery on the necessity for transplant surgery. (2) The specialists certify in writing that alternative procedures, services, or courses of treatment would not be effective in the treatment of your condition. (3) All decisions related to the transplant surgery satisfy applicable state requirements. (4) You must contact the Fund Office for prior approval of all self-funded organ and tissue transplants. Covered expenses for self-funded transplants include reasonable expenses incurred for the following services and supplies: (1) Donor-related services 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 29

35 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. 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 (according to IRS guidelines) 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 companions, up to the maximums stated in the Schedule of Benefits. Mileage will be reimbursed at the IRS standard mileage rate for medical purposes. For these benefits to be payable, itemized receipts for charges are required. (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) Mechanical assist devices when medically necessary for all covered transplants. (5) Postoperative followup expenses, including immunosuppressant drug therapy. (6) All other covered services for the recipient will be payable under the Plan the same as for any other injury or sickness. 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 charges incurred during the duration of the delay for the organ and tissue procurement, transportation, lodging, and meals, as stated in this section. 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 49 through 52; (6) purchase of the organ or tissue; or (7) the temporary use of experimental mechanical equipment. (h) Genetic Testing and Counseling, when such services are rendered for one or more of the following reasons, will be subject to the separate lifetime maximum per eligible person stated in the Schedule of Benefits: (1) You and/or your dependents suffer from a hereditary disease; or (2) A strong family history of a hereditary disease is present even though neither you or your dependents have the disease; a strong family history means at least one first-degree relative (parent, sibling) or at least two second-degree relatives (grandparent, aunt/uncle) of you or your dependent spouse has been diagnosed with a hereditary disease; or (3) You and/or your dependent spouse has produced a child with mental retardation, a hereditary disease, or a birth defect; or (4) You and/or your dependent spouse has had two or more miscarriages, a stillborn child, or a child who died in infancy from a cause that is believed to be genetic in nature. 30

36 Genetic counseling and testing will not be subject to the separate lifetime maximum when deemed medically necessary to determine the course of treatment of a sickness of an eligible person. Alternative Ways of Obtaining Care Deductibles and coinsurance are waived for the following benefits available under Comprehensive Major Medical Benefits to encourage you and your physician to consider their use. In some cases, benefits payable at 100% are limited to a specified maximum after which the Comprehensive Major Medical Benefits provisions do apply. 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) Pre-Admission Testing Laboratory tests and x-rays are sometimes ordered 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 the reasonable expenses actually 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. (b) Routine Physical Examinations If you or your dependent incur expense for an examination, x-rays, and laboratory tests for a routine physical examination performed by a physician in a hospital, clinic, or physician's office, the Plan will pay the reasonable expenses actually incurred, not to exceed the maximum stated in the Schedule of Benefits for all such examinations made during each calendar year. Amounts over such maximum are payable subject to the Comprehensive Major Medical Benefits deductible, coinsurance, and out-of-pocket maximum and, for well child care, also are subject to guidelines of the American Academy of Pediatrics. The Plan will apply reasonable medical management techniques to determine coverage limitations, including the frequency and medical appropriateness of routine services. 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, 31

37 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 benefit for the calendar year will be considered exhausted. 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. 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 will not be covered under your Health Care Plan. 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 Glendale 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 well-being. To schedule an appointment, call Health Dynamics located in the Columbia St. Mary s Urgent Care facility in Glendale at (414) during office hours, Monday through Friday, 8 a.m. - 5 p.m. There are additional hospital-based locations where the physical now is available. Contact Health Dynamics for the current listing of those other locations to find the one nearest you. You also may visit their website at: (username is: hdhelpsu and 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. (c) 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. Benefits are payable for the full reasonable amount of covered hospice services during the period in which the eligible person otherwise would, upon recommendation of his physician, 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 room and board when an inpatient of a hospice unit of a hospital or a separate hospice facility; physicians' visits; care provided by registered nurses 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. (d) Home Care Treatment for Hemophilia When you or your dependent incur expense for the essential costs of home care treatment for hemophilia, the Plan will pay the reasonable expenses actually incurred. Eligible expenses include blood products and related peripheral materials such as tourniquets, needles, and syringes. Benefits will not be paid for a freezer for storage of supplies or for personal service fees for selfinfusion. (e) Routine Mammograms When expenses are incurred by an eligible female for a routine mammogram, the Plan will pay the reasonable expenses actually incurred, subject to the following frequency schedule: For Age Group: Plan Covers: 35 to 39 One every five calendar years 40 and over One every calendar year 32

38 (f) Routine Immunizations When you or your dependent incur expense for routine immunizations, the Plan will pay the reasonable expenses actually incurred. Adult immunizations will be payable according to recommendations of the Advisory Committee on Immunization Practices (ACIP), the American Academy of Family Physicians, the American College of Physicians, and the American College of Obstetricians and Gynecologists. Immunizations for children and adolescents will be payable according to recommendations of the American Academy of Pediatrics, the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention, and the American Academy of Family Physicians. Immunizations for travel are not payable. 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. Exceptions and Limitations In addition to the Plan's General Exclusions on pages 49 through 52, and other limits that apply to specific benefit provisions as described in those sections, Comprehensive Major Medical Benefits do not cover: (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; (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, or any treatment for learning disabilities; (g) 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; (h) a dependent child s pregnancy; (i) DME repair that would be covered by warranty, maintenance of DME, duplicate DME rental, or DME batteries and ancillary supplies; (j) genetic testing and genetic counseling, except as specifically provided; (k) habilitation services; (l) long-term care; (m)weight loss programs; or (n) routine foot care. (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; 33

39 FAMILY SERVICES PROGRAM Classes A, RA, RAO, RB, and RBO Non-Medicare Eligible Employees and Dependents and Class RD 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 free and strictly confidential benefit that provides assessment, short-term 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 ComPsych Corporation, an organization of medical doctors, social workers, counselors, and psychologists to 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) divorce; (c) family difficulties; (d) child or adolescent concerns; (e) empty nesting; (f) elder issues, such as caregiving; (g) death or illness of a loved one; (h) alcohol or substance abuse; (i) eating disorders; (j) job stress; (k) depression or anxiety; (l) financial difficulties; and If you think you need help with a problem, call toll-free at: for confidential access 24 hours a day. Trained professionals are there to help you and your family evaluate and identify problems. Very often, they can help you to resolve those problems. Up to three visits with a ComPsych licensed therapist are covered in full per person per calendar year for each diagnosis. In some circumstances, ComPsych 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. Other services offered through your FSP include: (a) Work life and convenience services through FamilySource. These services can help with a wide variety of things such as emergency shelter, travel assistance, finding support groups for caregivers and patients, as well as helping you find appropriate resources and support for your particular needs. (b) Legal consultation services, including telephone access to licensed attorneys for information on legal concerns, a free half-hour in-person consultation with a ComPsych attorney, and a 25% discount if you retain an attorney. Legal assistance is available for issues such as divorce, landlord problems, estate planning, small claims court, and child support payments. (c) Financial consultation services by telephone for such issues as budgeting, how to improve your credit score in order to qualify for a mortgage, credit card debt, foreclosure, tax issues, saving for retirement, and financial aid sources to pay for college. (m)legal referrals. 34

40 You also can access these resources online by visiting the website at: First-time users will be prompted for the Company/Organization ID: T15453C, to register and create your own username and password. The site is complete with articles, help sheets, calculators, self-assessment tools, child and elder care resources, and much, much more. In addition, ComPsych will provide case management services to determine the medical necessity of in- and outpatient treatment of nervous and mental disorders (including eating disorders), substance abuse, and alcoholism since all services must be medically necessary to be eligible for Plan benefits. If you have questions concerning the appropriateness or medical necessity of treatment that is recommended for you, you may call ComPsych at Using a ComPsych network provider could save you money; therefore, we recommend you call ComPsych for help in locating a network provider in your community. 35

41 CASE MANAGEMENT The Plan will send large claims to a firm they have selected to provide case management services. Catastrophic or other suitable cases are reviewed by the case manager for medical necessity. The case manager will contact you, your physician, and the Fund Office to discuss treatment options and to identify available community resources. If you and your physician approve, they will coordinate the necessary services. It is often hard to make decisions about ongoing care. Case management allows you to discuss your concerns openly and makes you aware of all your options. Also, both you and the Fund may save money if a less costly setting is appropriate. 36

42 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 31. A description of the Fund's other preferred providers follows. Preferred Provider Network Through the Anthem Blue Cross and Blue Shield 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. You also have access to the BlueCard program which provides a broad national network. In addition to hospitals and physicians, Anthem offers reduced rates for outpatient surgery centers, chiropractors, home infusion therapy, home health care, durable medical equipment, radiology and laboratory facilities, physical therapists, skilled nursing facilities, and urgent care centers. 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 coinsurance is increased for covered expenses incurred at an Anthem preferred provider except for eligible persons who are Medicare primary. The list of preferred providers in the network is subject to change based on the contractual agreement between the agent and the participating providers. It is recommended that you contact Anthem prior to incurring covered expenses to make sure the hospital, physician, or other health care provider you choose is a preferred provider. Call Anthem at BLUE (2583) or visit their website: Preferred Provider Pharmacy CVS Caremark provides full management of the Plan s prescription drug card program. It offers a network of pharmacies where you can use your Plan identification card to purchase your prescription drugs at reduced rates. The network includes all national and regional chains and most independent pharmacies--over 56,000 throughout the United States. To locate a participating pharmacy in the retail network, call: When you purchase prescription drugs at a preferred provider pharmacy (PPRx), benefits are payable subject to the following terms and conditions. However, if a Medicare-eligible person continuing coverage under Class RAO, RAM, RBO, RBM, RC, or RD enrolls in Medicare Prescription Drug Benefits, he will become ineligible for prescription drug benefits under the Plan and no benefits will be paid under the Plan for any charges incurred for prescription drugs. Benefits are payable for the following upon a written prescription executed by a physician and dispensed by a licensed pharmacist: (a) federal legend drugs (meaning drugs requiring, under the Federal Food, Drug and Cosmetic Act, a label that reads, Caution: Federal law prohibits dispensing without a prescription ); (b) compounded medications of which at least one ingredient is a prescription legend drug; (c) insulin; (d) insulin syringes/needles on prescription; (e) prescription prenatal vitamins; (f) AIDS-related drugs; (g) immunosuppressants (anti-rejection drugs); (h) legend Meclizine on prescription; (i) Tretinoin (Retin-A) preparations up to age 23; (j) covered injectable medications filled through the Specialty Pharmacy; 37

43 (k) diabetic test strips and lancets (Classes A, RA, and RB only), subject to the coinsurance stated in the Schedule of Benefits; and (l) EpiPens, up to a maximum of two per eligible person per calendar year, subject to a 10% coinsurance at both a retail PPRx and through the mail service. For prescription claims that you fill at retail pharmacies, you MUST present your eligibility card with the CVS Caremark logo at the point-of-service in order for the claim to be eligible for payment. There is no provision for reimbursement of paper claims in the Fund. If coverage is denied at the point-of-service and you believe the denial is in error, you should contact the Fund Office the next business day for assistance in resolving the problem. There may be instances in which there is a lag in processing your eligibility through the CVS Caremark Preferred Provider Pharmacy Program. For example, if you are working out-of-area, the transfer of contributions for hours worked takes longer than if you are working for a contributing employer in the jurisdiction of the Fund. If your coverage is denied at the point-of-service, and you pay the full cost of the prescription in order to pick it up, you should contact the Fund Office immediately to correct your eligibility. Once your eligibility is updated, you then must ask your pharmacist to resubmit the claim to CVS Caremark in order to be reimbursed your out-of-pocket expenses minus any applicable copays. You have seven days from the date you first filled the prescription to get your eligibility corrected and the claim resubmitted to CVS Caremark. If the claim is not resubmitted within seven days, it will remain denied and there will be no opportunity for you to obtain reimbursement on that claim. For persons age 14 and over, medications to treat Attention Deficit Hyperactivity Disorder (ADHD) need to be initially precertified by the Fund Office. They also need to be recertified by the treating physician annually. Also, prescriptions that have a cosmetic use, such as Accutane and Retin A, may need to be precertified. Check with the Fund Office before filling the prescription. Reminder: If you are filling a prescription and the pharmacy is charging more than the normal copay amount, you should question whether you are being charged for the full cost. If so, call the Fund Office to determine the reason. The prescription may be ineligible because it was not precertified or recertified, so the pharmacy is charging you the full amount. If you get the pre/recertification, you only would be responsible for the copay amount. You have seven days from the date you first filled the prescription to get pre/recertification and the claim resubmitted to CVS Caremark. 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 mail service in a 90-day supply and pay the copayment per prescription as stated in the Schedule of Benefits. You can refill your prescription: online by visiting by phone by calling ; or by mail by completing and mailing a mail service order form. Under the generic incentive program, Caremark will contact you directly by mail if you are taking a targeted brand name drug for which there is a generic equivalent or generic alternative and explain the details of the program. If you are eligible for this program, the first fill for the generic form of targeted medications will be filled for FREE ($0 copayment) at either a retail network pharmacy or through the Caremark mail service pharmacy. You must use CVS Caremark Specialty Pharmacy to obtain your specialty medications. All specialty medications require prior authorization by CVS Caremark. Specialty medications are high-cost, bio-tech medications that generally have special administration requirements, require special handling, and require special clinical support. In many cases, they are injectable medications and usually have complex dosing regimens. They include medications used to treat conditions such as multiple sclerosis, rheumatoid arthritis, Hepatitis C, cancer, cystic fibrosis, organ rejection, and Crohn s disease, to name just a few. The CVS Caremark Specialty Guideline Management Program supports safe, clinically appropriate, and cost-effective use of specialty medications. Specialty oral medications are payable subject to the retail copayment stated in the Schedule of Benefits. Self-administered injectable medications are subject to the coinsurance stated in the Schedule of Benefits and, for the Low Cost Option, you first must satisfy the Comprehensive Major Medical Benefits deductible. Your coinsurance for 38

44 self-administered injectable medications applies to the Comprehensive Major Medical Benefits out-ofpocket maximum. CVS Caremark Specialty Pharmacy provides not only your specialty medications, but also personalized pharmacy care management services: Access to an on-call pharmacist 24 hours a day, seven days a week. Coordination of care with you and your physician. Convenient delivery directly to you or your physician s office. Medicine- and disease-specific education and counseling. Online support, including disease-specific information and interactive areas to submit questions to pharmacists and nurses, through If you have any questions, you can either visit their website as previously stated or call Caremark Connect toll-free at: from 6:30 a.m. to 8 p.m. (CT) Monday through Friday. Please note that these Specialty Pharmacy requirements do not apply to infused medications or other specialty medications that are administered by a health care professional. They apply only to oral medications and selfadministered injectable medications. CVS Caremark develops and maintains standard formularies and drug lists to support and guide clients in the management of the pharmacy benefit. CVS Caremark Drug formularies are developed and maintained according to guidelines and recommended by the Formulary Review Committee (FRC) and approved by the CVS Caremark National P&T Committee. Under your prescription plan design, certain drugs are not covered without a prior authorization for medical necessity. You will be notified in advance by CVS Caremark if you are taking one of these drugs, or if a new prescription, at the time you submit a claim for one of these drugs. If your physician believes you have a specific clinical need for one of these excluded products, he should contact the Prior Authorization Department for medical necessity review. If you continue using one of these drugs without prior approval, you may be required to pay the full cost. 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 49. 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. 39

45 Benefits are not payable under the Preferred Provider Pharmacy Program for the following: (a) non-legend drugs (over-the-counter drugs which do not require a prescription) other than insulin or any prescription with an OTC equivalent; (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 non-contraceptive 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) charges for the administration or injection of any drug; (i) 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; (k) prescriptions deemed not medically necessary for the diagnosis or treatment of an injury or sickness; (l) prescription medicines to treat sexual dysfunction, unless organic in nature (such medications are limited to 10 pills/month); (m) smoking deterrents (except Zyban and Chantix are covered); (n) topical Minoxidil (Rogaine) preparations, whether commercially prepared or compounded; (o) diabetic supplies, such as test tape and alcohol swabs; test strips and lancets are excluded for Medicare-eligible retirees; (p) immunization agents; (q) fertility agents, including Pergonal (Menotropins) and Metrodin (Urofollitropins); (r) prescription and OTC vitamin preparations (except prenatal vitamins are covered); (s) prescription fluoride preparations; (t) drugs purchased outside the United States; (u) infertility medication; and (v) drugs and vitamins prescribed for any dietary purpose. (j) refills of covered drugs which exceed the number of refills the prescription order calls for, or refills after one year from the original date; 40

46 DENTAL CARE BENEFITS Classes A, RA, RAO, and RAM Employees and Dependents Benefits are payable at the percentage and up to the maximum amount stated in the Schedule of Benefits for reasonable expenses related to preventing dental disease, restoring teeth, furnishing dentures, and straightening teeth (orthodontia). Services and supplies must be furnished by a dentist acting within the usual scope of such practice or by a dental hygienist, provided the hygienist works under the supervision of a dentist. The date of service for fixed bridgework and full or partial dentures will be the date the first impressions are taken and/or abutment teeth fully prepared while covered under Dental Care Benefits. The date of service for a crown, inlay, or onlay will be the date the tooth is prepared while covered under Dental Care Benefits. Routine Oral Examination A routine oral examination includes services performed by a dentist for one or any combination of the following: (a) prophylaxis, which also may be performed by a dental hygienist under the direction and supervision of a dentist; (b) oral examination, including dental x-rays if professionally indicated; and (c) diagnosis. You and each of your dependents are entitled to two routine oral examinations, including prophylaxis, each calendar year. Benefits also are payable for dependent children under age 19 for topical fluoride applications (two per person per calendar year) and dental sealants. 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; (j) replacement of a partial denture; (k) examination and treatment by a dentist in connection with an actual or suspected dental disease, defect, or injury; and (l) implants not used to anchor a bridge or a denture. 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 and one lower denture or one full set of dentures is available to you and each of your dependents during any one calendar year. 41

47 Orthodontic Benefits Benefits are payable for reasonable expenses incurred during an entire period of orthodontic treatment while coverage under this section is in effect for such person. If a period of orthodontic treatment has begun before coverage under this Plan takes effect, benefits payable will be prorated based on the remaining length of treatment when such person becomes eligible under this Plan. Benefits payable for orthodontic treatment are subject to the lifetime maximum orthodontic benefit stated in the Schedule of Benefits, which means the amount payable for all orthodontia expenses incurred during each eligible person's lifetime. However, medically necessary orthodontic services for dependent children under age 19 are not subject to the orthodontic lifetime maximum. Medically necessary orthodontic services are defined as orthodontic treatment that is directly related to and an integral part of the medical and surgical correction of a functional impairment resulting from a congenital defect or anomaly. Written guidelines for determining the medical necessity of orthodontics will be maintained at the Fund Office. Medically necessary orthodontic services require predetermination of benefits. Contact the Fund Office prior to initiating such services. 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. Orthodontic benefits are payable on an itemized basis. When the orthodontist submits itemized statements during a period of orthodontic treatment, benefits are paid as expenses are incurred and submitted for payment. Keep in mind that payment for orthodontic treatment cannot exceed the maximum orthodontic benefit. Limitations In addition to the General Exclusions on pages 49 through 52, Dental 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, or commonwealth government or political subdivision thereof, or a foreign government or agency thereof; (b) services, treatment, or supplies received from a dental 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) services or treatment rendered or supplies furnished primarily for cosmetic purposes; (e) expenses incurred for services performed or supplies furnished by other than a dentist, except for prophylaxis which may be performed by a dental hygienist under the direction and supervision of a dentist; (f) expenses incurred for treatment of temporomandibular joint disease (TMJ); or (g) 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. 42

48 VISION CARE BENEFITS Classes A, RA, RAO, and RAM Employees and Dependents Benefits are payable up to the aggregate maximum amount per calendar year stated in the Schedule of Benefits for reasonable expenses related to vision exams, lenses, frames, and contact lenses. For dependent children under age 19, one vision exam per calendar year is payable and will not be subject to the maximum amount. Services and supplies must be furnished by an optician, optometrist, or ophthalmologist acting within the usual scope of such practice. The date of service for any supply payable under Vision Care Benefits is the date the supply is ordered. Limitations In addition to the General Exclusions on pages 49 through 52, 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, or 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) safety lenses or goggles without a prescription; (e) sunglasses without a prescription; (f) orthoptics, vision training, vision therapy, or aniseikonia; (g) expenses incurred for services performed or supplies furnished by other than an optician, optometrist, or ophthalmologist; or (h) 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. 43

49 MEDICARE-PLUS BENEFITS 1,2 Class RC Employees and Dependents and Class RD Employees There are two parts to the Federal Medicare Program. The first is the basic insurance program generally referred to as Part A. The second is the medical insurance program generally referred to as Part B or Supplementary Medicare. The Trustees require that you and your dependents enroll in Part B when first eligible to do so. Medicare-Plus Benefits cover you, your spouse, and any of your dependent children who are eligible for Medicare. Under Medicare, there are certain expenses a person continues to pay for. The Trustees felt that to provide retired employees with the best coverage possible, the Health Fund should offer a Medicare- Plus Benefit which pays benefits in addition to Medicare and further reduces costs when injured or sick. In this way, retired employees who are eligible for Medicare are provided with supplementary coverage. Only expenses eligible under Medicare Part A and Part B are eligible for coverage under these Medicare-Plus Benefits, except emergency care obtained outside the United States as follows. Emergency Care Obtained Outside the United States When you require emergency medical care while traveling in a foreign country, the Plan will provide coverage to the same extent as the services would have been covered had they been rendered in the United States and eligible for Medicare benefits. In order for the Medicare deductible and/or copayments to be payable, the services rendered must be the type of services covered by Medicare and must be rendered by a hospital or physician as they are defined in Medicare. Definitions for Medicare-Plus Benefits The terms extended care facility, home health care agency, home health services, hospital, lifetime reserve, prescription, and reasonable expense have the same meaning in this Medicare- Plus Benefits section as they are defined in Medicare. Expenses eligible under Medicare include, but are not limited to, hospital expenses, post-hospital extended care, medical and other health services, home health services, and hospice care. 1 Classes RC and RD only are available to persons who elected such Classes on or before March 20, See pages 37 through 40 for a description of the Preferred Provider Pharmacy Prescription Drug Benefits for eligible persons covered under Medicare-Plus Benefits. 44

50 GENERAL PROVISIONS Coordination of Benefits (Classes A, RA, RAO, RAM, RB, RBO, and RBM Employees and Dependents and Class RD Dependents) 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 with the other plan. Definitions for Coordination of Benefit Provisions. The term other group plan means any plan that provides benefits or services for, or by result of, medical, prescription drugs, dental, or vision care or treatment under: (a) group insurance; (b) group practice, Blue Cross/Blue Shield, or other prepayment coverage provided on a group basis; (c) labor-management trusteed plans, employer organization plans, or any other arrangement for individuals of a group; or (d) governmental employees group programs, including Medicare or coverage required or provided by law other than no fault insurance. The term other group plan will be construed separately as to each policy, contract, or other arrangement for benefits or services based on the facts and circumstances of each such arrangement. An individual may have other health plan coverage containing a provision commonly known as a wrap around provision, sub-plan provision, or some similar provision whose purpose is to provide primary coverage only for a small amount of expenses, well below the maximum benefit available under the plan if no other coverage is available (collectively, a Sub-Plan Provision ). The effect or intent of a plan with a Sub-Plan Provision is to transfer the much larger secondary coverage to the other health plan with which such plan is coordinating benefits. In the event this plan is coordinating benefits with a plan containing a Sub-Plan Provision, the Sub-Plan Provision will be treated as arbitrary and capricious and a subterfuge and will be ignored, resulting in coordination of benefits with the plan, sub-plan, or similar provision that would apply if the eligible person did not have coverage under this Plan. If the other group plan, which is sponsored, maintained, or contributed to by an eligible person s employer, contains a provision which: (a) excludes the eligible person from eligibility under the other group plan due to coverage under another plan; or (b) has the effect of either: shifting coverage liability to this Plan in a manner designed to avoid any liability under the other group plan; or avoiding the customary operation of this Plan s COB rules; this Plan will consider such provision to have no force or effect. This Plan will coordinate benefits payable under this Plan with benefits which would have been payable under the other group plan if such provision had not existed. 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 person 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. 45

51 (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. 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 person or retiree, or a dependent of such person, will determine its benefits first, even if it has covered the eligible person for the shorter time. (e) In addition, if a person whose coverage is provided under a right of continuation pursuant to federal (COBRA) 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. Additionally, if: (a) a Sub-Plan exists; (b) the Sub- Plan is not or cannot be ignored pursuant to the previously stated provisions; (c) the Sub-Plan is found by the Board or a court of competent jurisdiction to apply, then this Plan expressly limits its secondary coverage available to the eligible person to the same dollar amount contained in, or calculated under, the Sub-Plan Provision. If an employee and spouse both are covered employees under this Plan, benefits payable for either of them and their dependents will be coordinated the same as they would be with any other group plan. See page 27 for coordination of benefits provisions for specified drugs covered under Comprehensive Major Medical Benefits. 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 1 st, a new record begins for each eligible person. This Credits provision will not apply if any other group plan which is primary with respect to this Plan is determined by the Board of Trustees to be a Sub-Plan. Exception. This coordination of benefits section is not applicable to Class RC employees and dependents and Class RD employees. The Board and its designees have discretion to interpret the Plan and determine whether benefits are payable under the Plan. This discretion will include, but not be limited to, discretion to interpret the language of other plans and also to determine whether other plans consist of a single plan or 46

52 multiple plans. The discretion also will include, but not be limited to, discretion to determine whether a Sub-Plan provision exists. The Board s determination in this regard will be binding and final for all purposes, including but not limited to all coordination of benefit purposes, and only will be reversed if a court of competent jurisdiction determines that the Board s determination is arbitrary and capricious. 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 for such coverage by reason of attained age, qualifying disability, or End Stage Renal Disease (ESRD). Such persons also will become eligible for Medicare Prescription Drug Benefits. However, such persons are not required to enroll in Medicare Prescription Drug Benefits. If such eligible person does not enroll in Medicare Prescription Drug Benefits, he will continue eligibility for the Plan s prescription drug benefits, provided he is otherwise eligible under the Plan. If such eligible person is continuing coverage under Class RAO, RAM, RBO, RBM, RC, or RD, and does enroll in Medicare Prescription Drug Benefits, the Plan will provide no prescription drug benefits for such person. 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. 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 RA, RAM, RB, or RBM 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. 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 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. However, an active employee or dependent spouse eligible under the Plan 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 ESRDbased 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 47

53 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 31 st 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. (d) Special Provisions for Classes RA, RAO, RAM, RB, RBO, and RBM. 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-service-connected disabilities will be reduced by the amount that would have been payable by Medicare had the services been rendered by a Medicare-approved 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 eligible persons for whom Medicare is the primary source of coverage and who have enrolled in a Medicare Advantage plan: The benefits payable under this Plan for services otherwise covered by Medicare, but which are not covered under the Medicare Advantage 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. (e) Medicaid Provisions The Plan will not take into account the fact that any eligible person is eligible for or is provided with medical assistance by Medicaid for purposes of determining eligibility for benefits under the Plan. In payment of benefits, the Plan will honor any Medicaid assignment of rights made by or on behalf of an eligible person. The Plan will honor any reimbursement or subrogation rights that a state may have by virtue of payment of Medicaid benefits for expenses covered by the Plan. Subrogation/Reimbursement Whenever the Milwaukee Carpenters District Council 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. As a condition of providing Benefits, the Fund may require that the eligible person and his attorney execute an agreement that acknowledges the Fund s rights under this provision. 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 48

54 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: (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 expense 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 payments or overpayments, the Plan has the right to recover such unauthorized 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 them or any other eligible person in their family or on their behalf to third parties, in the future; or (b) any service provider, insurance company, or other entity to whom such unauthorized 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 following General Exclusions apply to all benefits provided under the Plan. In addition, specific limitations apply to certain benefits. Such limitations are stated within each applicable benefit section. General Exclusions for all Plan benefits include the following. The Plan does not cover: 49

55 (a) Injury which arises out of or occurs in the course of any occupation or employment for wage or profit (except for Death Benefits and Accidental Death and Dismemberment Benefits). (b) Sickness for which the eligible person 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 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 Agreement allows the Fund, at its discretion, to either: (1) Take 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) 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 Covered Expenses" on page 28 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. (i) 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. (j) 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. (k) Any expenses, wage loss, or benefits under the Plan (except Death and Accidental Death and Dismemberment Benefits) that are payable (or required under law to be payable) under an automobile insurance policy issued in conformity with no-fault insurance laws or otherwise covered under no-fault laws. (l) Expenses incurred by an eligible person for abortions, or reversal of sterilizations, except: 50

56 (1) when such procedures are determined to be medically necessary by a physician in the treatment of an injury or sickness; or (2) in the case of an abortion, when the pregnancy is caused by rape or incest. (m) Services, supplies, or equipment that are not medically necessary. (n) Cosmetic treatment, surgery, and any related services intended solely for cosmetic purposes or to improve appearance, but not intended to restore normal bodily function or correct deformity resulting from disease, trauma, or a previous therapeutic process that is eligible for Plan benefits. This exclusion does not apply to breast reconstruction of the affected tissue following mastectomy, as described on page 26, or to repair of congenital malformations. Examples of treatment, surgery, and related services subject to this exclusion include, but are not limited to, the following: (1) cosmetic reconstruction of the nose; (2) electrolysis; (3) keloids; (4) removal of wrinkles or excess skin; (5) revision of previous elective procedures; (6) treatment of male pattern baldness; and (7) wigs. (o) Medical supplies and durable medical equipment used primarily for an eligible person s comfort, personal hygiene, or convenience including, but not limited to: air conditioners; air cleaners; humidifiers; dehumidifiers; purifiers; allergy-free pillows, blankets, or mattress covers; physical fitness equipment; physician s equipment; elevators or stair lifts; disposable supplies other than colostomy supplies, including but not limited to, urinary catheters, lubricants, and wipes; selfhelp devices not medical in nature; and all similar equipment. (p) All liquid nutrition used for tube feedings and other nutritional and electrolyte supplements or formula whether or not prescribed by a physician. (q) Food received on an outpatient basis, food supplements, and vitamins. (r) Any treatment, care, surgical procedures, services or supplies, including prescription medications that are experimental or investigative in nature or not generally accepted by the medical community as standard therapy at the time service is rendered for the indicated diagnosis. (s) Services, supplies, or equipment for: (1) invitro-fertilization, artificial insemination, and all other insemination or fertilization services intended to induce ovulation and/or promote spermatogenesis and/or to achieve conception; (2) transsexual surgery or any treatment leading to or connected with transsexual surgery; or (3) treatment of sexual dysfunction which is not related to organic disease. (t) Therapy services such as recreational or educational therapy or physical fitness or exercise programs. (u) The following charges: (1) telephone consultation charges; (2) charges for failure to keep a scheduled visit; (3) charges for completion of a claim form or return to school/work form; (4) additional charges beyond the charges for basic and primary services requested after normal provider service hours or on holidays; 51

57 (5) charges which are not documented in provider records; or (6) interest charges, federal, state or local tax, and shipping and handling charges. (v) Any services, supplies, or equipment which are required to be provided by a public school district or state or local educational agency pursuant to the requirements of the federal Individuals with Disabilities Education Act, 20 U.S.C et. seq., as amended, or any state or local law(s) and regulation(s) which implement such Act. This exclusion applies whether or not the service actually is provided by the public school district or educational agency. (w) Refractive eye surgery. (x) Orthoptics, vision training, vision therapy, or aniseikonia. (y) Charges in excess of the usual and customary allowance or, if a PPO provider, the provider s negotiated fee. (z) Personal convenience items while hospitalconfined. (aa)alternate therapies except as specifically provided. (bb)services or charges not covered by the Plan whether or not prescribed by a health care provider. (cc)services which are not provided. (dd)expenses incurred while not an eligible person. Amendment and Termination of Plan The Trustees will have the power and authority to amend or terminate the Plan to increase, decrease, or change benefits, or change Eligibility Rules or other provisions of the Plan of Benefits, including retiree benefits, as may in their discretion be proper or necessary for the sound and efficient administration of the Trust Fund, provided that such changes are not inconsistent with law or with the provisions of the Trust Agreement. Any amendment made by the Trustees will be reduced to writing and may be effective prospectively or retrospectively, provided, however, no amendment to the Plan will retroactively reduce benefit entitlement or benefit levels for claims incurred under the Plan then in effect. All amendments are subject to the limitation of the Trust Agreement and the applicable law and administrative regulations. Written notice of amendment to, or termination of the Plan will be provided to participants within the time required by law. This Plan also may be terminated: (a) in its entirety--by Trustee action and 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; (b) 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 (c) for a particular employer and his non-bargaining unit persons--the Trustees determine that an employer, signatory to a participation agreement to cover non-bargaining unit persons, no longer meets the requirements of such participation agreement and related policies. 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 52

58 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. 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. 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 protected health information be maintained. Any disclosures of electronic protected health information to the Trustees are supported by reasonable and appropriate security measures. Discretionary Authority The Trustees and other Plan fiduciaries and individuals to whom responsibility for the administration of the Plan has been delegated, have the full discretionary authority available under applicable law to construe the Trust Agreement, the regulations, the Plan, the Plan documents and the procedures of this Fund, to interpret any facts relevant to such construction. This authority extends to every aspect of their administration of the Plan including benefit determinations, eligibility determinations, and entitlement to Plan benefits. Any interpretation or determination made under this discretionary authority will give full force and effect and will be accorded judicial deference, unless it can be shown that the interpretation or determination was arbitrary and capricious, In addition, any interpretation or determination made pursuant to this discretionary authority is binding on all involved parties hereto, including but not limited to, eligible persons and their beneficiaries. Benefits under the Plan are payable only if the Trustees decide in their discretion that the applicant is entitled to the benefit. Genetic Information Nondiscrimination Act Notwithstanding anything in the Plan to the contrary, the Plan will comply with the Genetic Information Nondiscrimination Act. 53

59 Applicable Governing Law All questions pertaining to the validity and construction of the Trust Agreement, the Plan, and the acts and transactions of the Trustees or of any matter affecting the Plan will be determined under federal law where applicable federal law exists, including the Employee Retirement Income Security Act of 1974, as amended. Release of Responsibility for Tax Consequences Payment of benefits by the Plan to you or your representative, or to the service provider, releases and discharges the Plan from any liability for the tax consequences of such payment. 54

60 PRIVACY POLICY Summary of Privacy Practices The Health Insurance Portability and Accountability Act of 1996 (HIPAA) and Health Information Technology for Economic and Clinical Health Act ( HITECH ) and their Privacy Rules grant certain rights to participants and beneficiaries of the Milwaukee Carpenters District Council Health Fund (the Plan) in relation to their protected health information (called medical information ). The Plan may use and disclose your medical information without your permission for treatment, payment, and health care operations activities and, when required or authorized by law, for public health activities, law enforcement, judicial and administrative proceedings, research, and certain other public benefit functions. The Plan may disclose your medical information to your family members, friends, and others involved in your health care or payment for health care, and to appropriate public and private agencies in disaster relief situations. The Plan may disclose to the sponsor of the Plan, the Board of Trustees of the Milwaukee Carpenters District Council Health Fund (the Board of Trustees ) whether you are enrolled or disenrolled in the Plan, summary health information for certain limited purposes, and your medical information for the Board of Trustees to administer the Plan if the Board of Trustees explains the limitations on its use and disclosure of your medical information in the Plan Document. Except for certain legally-approved uses and disclosures, the Plan otherwise will not use or disclose your medical information without your written authorization. You have the right to examine and receive a copy of your medical information, to receive an accounting of certain disclosures the Plan may make of your medical information, and to request that the Plan amend, further restrict use and disclosure of, or communicate in confidence with you about your medical information. You have the right to receive notice of breaches of your unsecured medical information in accordance with HITECH. IMPORTANT NOTE: The Plan reserves the right to provide your medical information to any person identified by you (such as a business agent), or whom the Plan in good faith believes was identified by you, or to a family member, other relative, or close personal friend. For example, the Plan may disclose your medical information to your spouse if the spouse contacts the Plan to help resolve a payment issue on your behalf. The Plan only will provide medical information in such a situation if it is directly relevant to such person's involvement with your care or payment related to your health care. If you object to such disclosures, please express your written objection to the contact listed on page 59. The Plan s Legal Duties The Plan is required by applicable federal and state law to maintain the privacy of your medical information. The Plan also is required to give you this notice about its privacy practices, its legal duties, and your rights concerning your medical information. The Plan reserves the right to change its privacy practices and the terms of its Privacy Practices Notice at any time, provided such changes are permitted by applicable law. The Plan reserves the right to make any change in its privacy practices and the new terms of its notice applicable to all medical information that the Plan maintains, including medical information the Plan created or received before the Plan made the change. Before the Plan makes a significant change in its privacy practices, the Plan will send a new notice to its then-current participants as required by law. You may request a copy of the Plan s Privacy Practices Notice at any time from the contact listed on page

61 Uses and Disclosures of Your Medical Information Treatment: The Plan may disclose your medical information, without your permission, to a physician or other health care provider to treat you. Payment: The Plan may use and disclose your medical information, without your permission, to pay claims from physicians, hospitals, and other health care providers for services delivered to you that are covered by the Plan, to determine your eligibility for benefits, to coordinate your benefits with other payers, to determine the medical necessity of care delivered to you, to obtain premiums for your health coverage, to issue explanations of benefits to the participant of the Plan in which you participate and the like. The Plan may disclose your medical information to a health care provider or another health plan for that provider or plan to obtain payment or engage in other payment activities. Health Care Operations: The Plan may use and disclose your medical information, without your permission, for health care operations. Health care operations include: health care quality assessment and improvement activities; reviewing and evaluating health care provider and health plan performance, qualifications and competence, health care training programs, health care provider and health plan accreditation, certification, licensing, and credentialing activities; conducting or arranging for medical reviews, audits, and legal services, including fraud and abuse detection and prevention; rating the risk and determining the necessary funding levels for the Plan, and obtaining stoploss and similar reinsurance for the Plan s health coverage obligations; and business planning, development, management, and general administration, including customer service, grievance resolution, claims payment and health coverage improvement activities, de-identifying medical information, and creating limited data sets for health care operations, public health activities, and research. The Plan may disclose your medical information to another health plan or to a health care provider subject to federal privacy protection laws, as long as the plan or provider has or had a relationship with you and the medical information is for that plan s or provider s health care quality assessment and improvement activities, competence and qualification evaluation and review activities, or fraud and abuse detection and prevention. Your Authorization: You may give the Plan written authorization to use your medical information or to disclose it to anyone for any purpose. If you give the Plan an authorization, you may revoke it in writing at any time. Your revocation will not affect any use or disclosure permitted by your authorization while it was in effect. Unless you give the Plan a written authorization, the Plan will not use or disclose your medical information for any purpose other than those described in the Plan s Privacy Practices Notice. The Plan generally may use or disclose any psychotherapy notes it holds only with your authorization. Family, Friends, and Others Involved in Your Care or Payment for Care: The Plan may disclose your medical information to a family member, friend, or any other person you involve in your health care or payment for your health care. The Plan will disclose only the medical information that is relevant to the person s involvement. The Plan may use or disclose your name, location, and general condition to notify, or to assist an appropriate public or private agency to locate and notify, a person responsible for your care in appropriate situations, such as a medical emergency or during disaster relief efforts. The Plan will provide you with an opportunity to object to these disclosures, unless you are not present or are incapacitated or it is an emergency or disaster relief situation. In those situations, the Plan will use its professional judgment to determine whether disclosing medical information related to your care or payment is in your best interest under the circumstances. Your medical information remains protected by the Plan for at least 50 years after you die. After you die, the Plan may disclose to a family member, or other person involved in your health care prior to your death, the medical information that is relevant to that person s involvement, unless doing so is 56

62 inconsistent with your preference and you have told the Plan so. Disclosures to the Board of Trustees: The Plan may disclose to the Board of Trustees whether you are enrolled or disenrolled in the Plan. The Plan may disclose summary health information to the Board of Trustees to obtain premium bids for the health insurance coverage offered under the Plan or to decide whether to modify, amend, or terminate the Plan. Summary health information is aggregated claims history, claims expenses, or types of claims experienced by the enrollees in the Plan. Although summary health information will be stripped of all direct identifiers of these enrollees, it still may be possible to identify medical information contained in the summary health information as yours. The Plan is expressly prohibited from using or disclosing any health information containing your genetic information for underwriting purposes. The Plan may disclose your medical information and the medical information of others enrolled in the Plan to the Board of Trustees to administer the Plan. Before the Plan may do that, the Board of Trustees must amend the Plan Document to establish the limited uses and disclosures the Board of Trustees may make of your medical information. Please see the Plan Document for a full explanation of those limitations. Health-Related Products and Services: The Plan may use your medical information to communicate with you about health-related products, benefits, and services, and payment for those products, benefits, and services that the Plan provides or includes, and about treatment alternatives that may be of interest to you. These communications may include information about the health care providers in the Plan s network, if any, about replacement of or enhancements to the Plan, and about health-related products or services that are available only to the Plan s enrollees that add value to, although they are not part of, the Plan. Public Health and Benefit Activities: The Plan may use and disclose your medical information, without your permission, when required by law, and when authorized by law for the following kinds of public health and public benefit activities: for public health, including to report disease and vital statistics, child abuse, and adult abuse, neglect, or domestic violence; to avert a serious and imminent threat to health or safety; for health care oversight, such as activities of state insurance commissioners, licensing and peer review authorities, and fraud prevention agencies; for research; in response to court and administrative orders and other lawful process; to law enforcement officials with regard to crime victims and criminal activities; to coroners, medical examiners, funeral directors, and organ procurement organizations; to the military, to federal officials for lawful intelligence, counterintelligence, and national security activities, and to correctional institutions and law enforcement regarding persons in lawful custody; and as authorized by state Worker s Compensation laws. Individual Rights Access: You have the right to examine and to receive a copy of your medical information, with limited exceptions. You must make a written request to obtain access to your medical information. You should submit your request to the contact on page 59. You may obtain a form from that contact to make your request. If the information you request is in an electronic health record, you may request that these records be transmitted electronically to you or a designated individual. The Plan may charge you reasonable, cost-based fees (including labor costs) for a copy of your medical information, for mailing the copy to you, and for preparing any summary or explanation of your medical information you request. Contact the Plan using the information on page 59 for information about these fees. Your medical information may be maintained electronically. If so, you can request an electronic copy of your medical information. If you do, the 57

63 Plan will provide you with your medical information in the electronic form and format you requested, if it is readily producible in such form and format. If not, the Plan will produce it in a readable electronic form and format as the Plan and you mutually agree upon. You may request that the Plan transmit your medical information directly to another person you designate. If so, the Plan will provide the copy to the designated person. Your request must be in writing, signed by you, and must clearly identify the designated person and where the Plan should send the copy of your medical information. Disclosure Accounting: You have the right to a list of instances from the prior six years in which the Plan disclosed your medical information for purposes other than treatment, payment, health care operations, as authorized by you, and for certain other activities. You should submit your request to the contact on page 59. The Plan will provide you with information about each accountable disclosure that the Plan made during the period for which you request the accounting, except the Plan is not obligated to account for a disclosure that occurred more than six years before the date of your request and never for a disclosure that occurred before the Plan s effective date (if the Plan was created less than six years ago). Amendment: You have the right to request that the Plan amend your medical information. You should submit your request in writing to the contact on page 59. The Plan may deny your request only for certain reasons. If the Plan denies your request, the Plan will provide you a written explanation. If the Plan accepts your request, the Plan will make your amendment part of your medical information and use reasonable efforts to inform others of the amendment who the Plan knows may have relied on the unamended information to your detriment, as well as persons you want to receive the amendment. Restriction: You have the right to request that the Plan restrict its use or disclosure of your medical information for treatment, payment, or health care operations, or with family, friends, or others you identify. The Plan is not required to agree to your request, except for certain required restrictions described as follows. If the Plan does agree, the Plan will abide by the agreement, except in a medical emergency or as required or authorized by law. You should submit your request to the contact on page 59. Any agreement the Plan may make to a request for restriction must be in writing signed by a person authorized to bind the Plan to such an agreement. The Plan will agree to (and not terminate) a restriction request if: the disclosure is to a health plan for purposes of carrying out payment or health care operations and is not otherwise required by law; and the medical information pertains solely to a health care item or service for which the individual, or person other than the Plan on behalf of the individual, has paid the covered entity in full. Confidential Communication: You have the right to request that the Plan communicate with you about your medical information in confidence by means or to locations that you specify. You must make your request in writing, and your request must represent that the information could endanger you if it is not communicated in confidence as you request. You should submit your request to the contact on page 59. The Plan will accommodate your request if it is reasonable, specifies the means or location for communicating with you, and continues to permit the Plan to collect contributions and pay claims. Please note that an explanation of benefits and other information that the Plan issues to the participant about health care that you received for which you did not request confidential communications, or about health care received by the participant or by others covered by the Plan, may contain sufficient information to reveal that you obtained health care for which the Plan paid, even though you requested that the Plan communicate with you about that health care in confidence. Breach Notification: You have the right to receive notice of a breach of your unsecured medical information. Notification may be delayed or not provided if so required by a law enforcement official. You may request that notice be provided by electronic mail. If you are deceased and there is a breach of your medical information, the notice will be provided to your next of kin or personal 58

64 representatives if the Plan knows the identity and address of such individual(s). Electronic Notice: If you receive a Privacy Practices Notice on the Plan s website or by electronic mail ( ), you are entitled to receive this notice in written form. Please contact the Plan using the information on this page to obtain this notice in written form. State Law: As a condition of Plan participation, the Board of Trustees requires that the privacy rights of you, your spouse, and dependents be governed only by 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, as applicable), without regard to whether HIPAA incorporates privacy rights granted under the laws of other states and without regard to Wisconsin s choice of law provisions. Questions and Complaints For information about the Plan s privacy practices, to discuss questions or concerns, or to get additional copies of this notice, please contact the Plan using the information at the end of this section. If you are concerned that the Plan may have violated your privacy rights, or you disagree with a decision the Plan made about access to your medical information, about amending your medical information, about restricting the Plan s use or disclosure of your medical information, or about how the Plan communicates with you about your medical information (including a breach notice communication), you may complain to the Plan using the contact information at the end of this section. You also may submit a written complaint to the Office for Civil Rights of the United States Department of Health and Human Services, 200 Independence Avenue, SW, Room 509F, HHH Building, Washington, D.C You may contact the Office of Civil Rights Hotline at The Plan supports your right to the privacy of your medical information. The Plan will not retaliate in any way if you choose to file a complaint with the Plan or with the U.S. Department of Health and Human Services. Contact Person: Telephone: Privacy Official (262) , local , toll-free in Wisconsin Fax: (262) Address: Milwaukee Carpenters District Council Health Fund N25 W23055 Paul Road Suite 2 Pewaukee, WI

65 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 because of 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. Bargaining Unit Employee means any employee represented by the Union and working for an employer (as defined in the Trust Agreement) who is required to make contributions to the Trust Fund. 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, RA, RAO, RAM, RB, RBO, RBM, RC, RD, and COBRA as follows: Class A: Eligible active employees and their eligible dependents. The term employees will include bargaining unit employees and, provided the employer is party to an approved participation agreement, the term also will include certain non-bargaining unit employees or alumni. Class RA: Eligible retired employees and their eligible dependents who are not eligible for Medicare and who are making the appropriate self-payments to obtain coverage for Death Benefits, Comprehensive Major Medical Benefits, Vision Care Benefits, and Dental Care Benefits. Class RAO: Class RA and Class RAM eligible retired employees and their eligible dependents when either the retired employee or dependent spouse is eligible for Medicare. Class RAM: Eligible retired employees who are enrolled in Part A and Part B of Medicare and their eligible dependents who are making the appropriate selfpayments to obtain coverage for Death Benefits, Comprehensive Major Medical Benefits, Vision Care Benefits, and Dental Care Benefits. If a Medicare-eligible person enrolls in Medicare Prescription Drug Benefits, he will become ineligible for the Plan s prescription drug benefits. If such person does not enroll in Medicare Prescription Drug benefits, he will continue eligibility for the Plan s prescription drug benefits, provided he is otherwise eligible under the Plan. Class RB: Eligible retired employees and their eligible dependents who are not eligible for Medicare and are making the appropriate self-payments to obtain coverage for Death Benefits and Comprehensive Major Medical Benefits. Class RBO: Class RB and Class RBM eligible retired employees and their eligible dependents when either the retired employee or dependent spouse is eligible for Medicare. 60

66 Class RBM: Eligible retired employees who are enrolled in Part A and Part B of Medicare and their eligible dependents who are making the appropriate selfpayments to obtain coverage for Death Benefits and Comprehensive Major Medical Benefits. If a Medicare-eligible person enrolls in Medicare Prescription Drug Benefits, he will become ineligible for the Plan s prescription drug benefits. If such person does not enroll in Medicare Prescription Drug benefits, he will continue eligibility for the Plan s prescription drug benefits, provided he is otherwise eligible under the Plan. Class RC (Only available for those who elected this Class on or before March 20, 2014): Eligible retired employees who are enrolled in Part A and Part B of Medicare and their eligible dependents who are enrolled in Part A and Part B of Medicare who are making the appropriate selfpayments to obtain coverage for Medicare-Plus Benefits. If a Medicare-eligible person enrolls in Medicare Prescription Drug Benefits, he will become ineligible for the Plan s prescription drug benefits. If such person does not enroll in Medicare Prescription Drug benefits, he will continue eligibility for the Plan s prescription drug benefits, provided he is otherwise eligible under the Plan. Class RD (Only available for those who elected this Class on or before March 20, 2014): Eligible retired employees who are enrolled in Part A and Part B of Medicare (covered under Class RC), and their eligible dependents who are not eligible for Medicare (covered under Class RB), who are making the appropriate self-payments. If a Medicare-eligible person enrolls in Medicare Prescription Drug Benefits, he will become ineligible for the Plan s prescription drug benefits. If such person does not enroll in Medicare Prescription Drug benefits, he will continue eligibility for the Plan s prescription drug benefits, provided he is otherwise eligible under the Plan. COBRA Class: Eligible former employees who are making the appropriate self-payments to continue Comprehensive Major Medical Benefits, or Comprehensive Major Medical Benefits, Vision Care Benefits, and Dental Care Benefits under the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA), as amended in all respects. 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. Dependent means the eligible employee's: (a) spouse of the opposite sex, pursuant to the legal marriage of one man and one woman as husband and wife; and (b) child or children under age 26. The term child or children means: (a) 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 previously stated. 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. (b) Stepchildren who are children of the eligible employee's spouse on the date of marriage to the eligible employee and who meet the specified age restrictions. 61

67 (c) Children under the legal guardianship of an eligible employee who meet the specified age restrictions previously stated and who are younger than the eligible employee, provided the child is living with the eligible employee for the entire calendar year, receives more than half of his or her annual support from the employee, and provided a certified copy of the guardianship court order is filed with the Trustees and that the employee subsequently furnishes tax filings demonstrating the support and residency requirements were satisfied. (d) 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 age 26. After age 26, such child must be unmarried and primarily financially dependent upon the eligible employee. Due proof of the incapacity must be submitted to the Trustees within 31 days of the date the dependent child's coverage otherwise would terminate due to attainment of age 26 or, in the case of a newly eligible employee, within 31 days after the employee first becomes eligible under the Plan. Due proof includes, but will not be limited to, proof of a Social Security disability award. (e) A child who is named as an alternate payee in a Qualified Medical Child Support Order or National Medical Support Notice with which you and the Fund are obligated to comply and who is younger than the eligible employee. Durable Medical Equipment (DME) means equipment that is medically necessary and able to withstand repeated use. It also must be primarily and customarily used to serve a medical purpose, appropriate for use in the home, and not generally be useful to a person except for the treatment of an injury or sickness. Eligible Employee means any employee or former employee of an employer, who is eligible for benefits in accordance with the Eligibility Rules of the Fund. Eligible Person means either the eligible employee or the eligible dependent. Enrollment Date means the eligible person's effective date of coverage, or if a waiting period is applicable, the first day of the waiting period. Please note that the period of covered employment for which contributions are payable and which leads to the attainment of initial eligibility or reinstatement of eligibility is considered a waiting period. Experimental/Investigative means any treatment, service, procedure, facility, equipment, drug, device, or supply 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. A treatment, service, procedure, facility, equipment, drug, device, or supply also will be considered experimental/investigative if any of the following are true: (a) It has failed to obtain final approval by a United States governmental agency at the time the expense is incurred; (b) Reliable evidence does not establish a consensus conclusion among experts recognizing the safety and effectiveness of the treatment, service, procedure, facility, equipment, drug, device, or supply for a specific diagnosis; (c) Reliable evidence shows that the treatment, service, procedure, equipment, drug, device, or supply is the subject of on-going phase I, II, or III clinical trial or is otherwise under study to determine its maximum tolerated dose, its toxicity, its safety, or its efficacy as compared with a standard means of treatment or diagnosis; or (d) Reliable evidence shows that the prevailing opinion among experts regarding the treatment, service, procedure, facility, equipment, drug, device, or supply is that further studies or clinical trials are necessary to determine its maximum tolerated dose, its toxicity, its safety, or its efficacy as compared with a standard means of treatment or diagnosis. 62

68 Reliable evidence includes anything determined to be such by the Trustees and may include published reports and articles in the authoritative medical and scientific literature, the written protocol or protocols used by the treating facility or the protocol(s) of another facility studying substantially the same treatment, service, procedure, facility, equipment, drug, device, or supply. The Trustees will have authority to determine, in their discretion, based on reliable evidence whether a treatment, service, procedure, facility, equipment, drug, device, or supply is experimental/ investigative. The fact that a physician has prescribed, ordered, recommended, or approved the treatment, service, procedure, facility, equipment, drug, device, or supply does not, in itself, make it eligible for payment. Fiscal Year means the 12 months beginning any June 1st and ending the following May 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; (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-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 which requires treatment by a physician and which results 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 63

69 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 covered under the Plan. Under no circumstances will "lifetime" mean during the life of an eligible person, even after the person's eligibility ends. Light-Duty Work, for an employee who has been disabled as the result of an injury or sickness that is not work-related, means: (a) the employee has been released for work on a limited or restricted basis by the treating physician; and (b) the available work is within the limitations of the treating physician's release. Light-duty work in regard to the disability hours credit while receiving temporary partial disability weekly Worker s Compensation Benefits refers to an injury or sickness that is work-related and satisfies the prior subsections (a) and (b). The employee may not continue at light-duty for more than six months from the initial return to work on a light-duty basis unless the Trustees agree to a time extension. Medically Necessary means: (a) 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; (b) is not experimental; (c) could not have been omitted without adversely affecting the eligible person s condition or the quality of medical care; (d) is provided by or under the direction of a physician or other duly licensed health care practitioner who is authorized to provide or prescribe it; (e) is not provided solely for the convenience of the eligible person, physician, hospital, health care provider, or health care facility; (f) is a safe and effective supply or level of service given the patient s circumstances and condition; and (g) is safe and effective for the injury or sickness for which it is used. A medical service or supply will not be deemed to be medically necessary solely because a physician orders or approves it. Medicare Prescription Drug Benefits means Medicare Part D, the federal Medicare prescription drug program created by the Medicare Modernization Act of 2003 and effective January 1, Military Service or Military Leave means service or leave to serve in the United States Armed Forces, the Army National Guard, and the Air National Guard when engaged in active duty for training, inactive duty training, or full-time National Guard duty, the commissioned corps, or the Public Heath Service, and any other category of persons designated by the President in time of war or emergency. Non-Bargaining Unit Employee means an employer's full-time employees who perform work which is not covered by a labor contract requiring contributions to this Fund and who are, therefore, not represented by a labor organization and who are not alumni. A full-time employee is one who is regularly employed by an employer 25 or more hours per week. 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. 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. 64

70 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. Plan means the Milwaukee Carpenters' District Council Health Plan 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 June 1st and ending the following May 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 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 Trustees have a contract with Anthem Blue Cross and Blue Shield under which: (1) The Blue Preferred Point-of-Service (POS) Network is the Preferred Provider Network for services obtained in the state of Wisconsin; and (2) The BlueCard PPO Network is the Preferred Provider Network for services obtained outside the state of Wisconsin. (b) Preferred Provider Pharmacy (PPRx) means the pharmacy which participates in the Preferred Provider Pharmacy Program party to a contract with the Trustees, currently CVS Caremark. (c) Family Services Program (FSP) Manager means the organization which contracts with the Trustees to provide specified family assistance services. The current FSP provider is ComPsych Corporation. (d) Preferred Provider Preventive Care Program means the organization which contracts with the Trustees from time to time to provide health promotion and cancer screening services, currently Health Dynamics. Qualified Medical Child Support Order (QMCSO) (including a National Medical Support Notice) 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: (a) provides for child support payments related to health benefits with respect to a child of a participant 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 65

71 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 mailing address (if any) of the participant from whom such child's status as an alternate recipient under this Plan is derived and the name and mailing address of each alternate recipient covered by the order, except that, to the extent provided in the order, the name and mailing address of an official of state or a political subdivision thereof may be substituted for the mailing address of any such alternate recipient, a reasonable description of the type of coverage to be provided by the Plan to each alternate recipient or the manner in which the type of coverage is determined, 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 by the Plan Administrator 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 the covered supplies furnished in the particular geographical area concerned, provided such services and supplies are medically necessary as 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 sources such as the Fair Health schedule for relevant zip code areas at the percentile Trustees adopt (currently the 90th percentile) and, if the charge exceeds by more than $50.00, the annual Physicians Fee Guide or similar publication with a geographic adjustment factor. Charges in excess of reasonable expenses are not covered under the Plan and are the sole responsibility of the eligible person. 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. Expenses related to tubal ligations and vasectomies will be considered a sickness; however, reversals of sterilization procedures or any other contraceptive-related procedure or supply will not be considered a sickness. Skilled Nursing Home means an institution which fully meets each 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; 66

72 (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 and Permanent Disability means being permanently unable, due to disability, to perform: (a) for bargaining unit employees--the work covered by the collective bargaining agreement under which the employee worked; or (b) for non-bargaining unit employees and alumni-- the work pertaining to an employee's occupation; and (c) unable to engage in any regular occupation or employment for reasonable remuneration 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 21, 1975, as amended, which is incorporated by reference. 67

73 HOW TO APPLY FOR BENEFITS Pre-Service Claims: You must contact the Fund Office for prior approval of specified self-funded organ transplants, repair of durable medical equipment, medically necessary replacement or repair of artificial limbs and eyes, certain drugs specified on page 38, and medically necessary orthodontic services for dependent children under age 19. 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 prior authorization must be submitted in writing to the Fund Office. In addition, you must contact the PPRx Prior Authorization Department as specified on page 39 for determination of medical necessity for certain drugs. 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 approval of emergency admissions. Post-Service Claims: Any claim for benefits that is not a pre-service claim is considered a postservice claim. You must submit all 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 one year from the date of service. Insured Transplant Claim Procedures: The preservice and post-service claims procedures for insured transplant claims are included in the enclosed Organ & Tissue Transplant Certificate. Once you become eligible, you will receive an identification card from the Fund which identifies you and contains the name and address of the Milwaukee Carpenters' District Council Health Fund. The Fund's Administrative Manager, named on page 83, certifies eligibility, processes claims, and makes the benefit payments. When you obtain health care services or supplies, make sure you present your ID card to the provider. Your ID 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 for inpatient and outpatient treatment of mental health, substance abuse, and eating disorders to: ComPsych GuidanceResources P.O. Box 8379 Chicago, IL Send all claims for dental, vision, and Medicareeligible retirees to: Fund Office Milwaukee Carpenters' District Council Health Fund P.O. Box 670 Pewaukee, WI Send all other medical claims for services obtained in Wisconsin to: Anthem Blue Cross and Blue Shield P.O. Box Louisville, KY Send all other medical claims for services obtained outside Wisconsin to your local Blue Cross and Blue Shield Plan. For organ transplant insurance claims, see the enclosed Organ & Tissue Transplant Certificate. Claims should be complete. They should contain, at a minimum: (a) Fund name (Milwaukee Carpenters District Council Health Fund); (b) Employee s name and unique identification 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; 68

74 (e) Federal tax identification number of provider; (f) Diagnosis of the condition; (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. 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. Pre-determined 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/ coinsurance (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 73 through 76. 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. 69

75 YOUR RESPONSIBILITIES AS A PARTICIPANT UNDER THE PLAN 1. NOTIFY THE FUND OFFICE IMMEDIATELY REGARDING ANY CHANGE IN ADDRESS. 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. For your convenience, a card is provided by the Fund Office which you may use to notify the Fund Office about an address change. Or, just drop a postcard in the mail to the Fund Office with your new address. 2. MAKE SELF-PAYMENTS ON TIME AND IN THE CORRECT AMOUNTS. However, 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. 3. AVOID UNNECESSARY DELAYS IN PROCESSING 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. 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. Benefits paid by this Plan are financed primarily by employer contributions. 70

76 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 unpaid, job-protected leave to "eligible" employees for certain family and medical reasons up to the number of weeks mandated by law. 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 21 for an explanation of what constitutes a "covered employer. Your employer must approve your FMLA leave. REASONS FOR TAKING LEAVE Unpaid leave must be granted for up to 12 weeks 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; (c) for a serious health condition that makes the employee unable to perform his job; or (d) because of any qualifying exigency arising out of the fact that the spouse, son, daughter, or parent of the employee is on active duty, or has been notified of an impending call to active duty status, in support of a contingency operation. The Secretary of Labor will issue regulations defining any qualifying exigency. Unpaid leave must be granted for up to 26 weeks in a single 12-month period for an eligible employee who is the spouse, son, daughter, parent, or next of kin of a covered service member to care for the service member while recovering from a serious illness or injury sustained in the line of duty on active duty. This military caregiver leave is available during a single 12-month period during which an eligible employee is entitled to a combined total of 26 weeks of all types of FMLA leave. 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." COBRA coverage may apply if the employee does not return from an FMLA leave. (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. 71

77 If an employee and the employer have a dispute over the employee s eligibility and coverage under FMLA, the employee s benefits will be suspended pending resolution of the dispute. The Trustees will have no direct role in resolving such a dispute. 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 your employer or the nearest office of the Wage and Hour Division, listed in most telephone directories under "U.S. Government, Department of Labor." 72

78 INFORMATION REQUIRED BY THE EMPLOYEE RETIREMENT INCOME SECURITY ACT OF 1974 (ERISA) Claims Review and Appeal Procedures When you submit a pre-service claim, if applicable, the Plan (meaning the Fund Office) 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. 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 requiring 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 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. 73

79 For insured transplant claims, the claims review and appeal procedures are included in the enclosed Organ & Tissue Transplant Certificate. If the Plan denies coverage for your claim, the denial is called an adverse benefit determination as defined under the U.S. Department of Labor Regulations. An adverse benefit determination includes a rescission of your coverage under the Plan, except in the case of fraud or intentional misrepresentation of a material fact. An example of fraud or intentional misrepresentation of a material fact includes a fraudulent or intentional misrepresentation about your past medical history. The Regulations define a rescission as a cancellation or discontinuance of coverage that has a retroactive effect. A cancellation or discontinuance of coverage is not a rescission if the cancellation or discontinuance only has a prospective effect. The following retroactive terminations of coverage in the normal course of business are not considered rescissions under the Regulations even though retroactive: (a) retroactive termination to the extent attributable to failure to pay a timely premium (selfpayment) towards coverage; (b) retroactive elimination of coverage back to the date of termination of employment, due to delays in administrative recordkeeping if you do not pay any premiums for coverage after termination of employment; and (c) the Plan s termination of coverage retroactive to the date of a divorce. To clarify, this means that, in general, the Plan cannot terminate your coverage retroactively. However, the Plan may do so under the circumstances described and in other instances as may be prescribed in the Regulations. The Plan is required to provide at least 30 days advance written notice to each eligible person who is affected by a rescinding of coverage before the coverage may be rescinded. 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 claims review and appeal procedures and time limits applicable to such appeal procedures, 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 74

80 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. (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 claims review and appeal procedures. 75

81 (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 two years after the time the claim was required to be filed as specified on page 68. 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 claims review and appeal procedures described here, please contact the Fund Office. Insured transplant benefits under the Plan also are subject to grievance procedures under state insurance law. These appeals and procedures are included in the enclosed Organ & Tissue Transplant Certificate. For the purposes of insured transplant benefits under the Plan, nothing in the claims procedures in the section entitled "How to Apply for Benefits" and "Claims Review and Appeal Procedures" is intended to preempt any provision of state law that regulates insurance, except to the extent that the state law prevents the application of a requirement of the claims procedures. 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 Milwaukee Carpenters' District Council Health Fund want you to be fully aware of your rights, and in accordance with federal law, a statement of your rights follows. As a participant in the Milwaukee Carpenters' District Council 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 76

82 report. A copy of the full report also is available upon written request. (d) You may examine, without charge, all documents relating to 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 the latest annual report (Form 5500 Series) and Plan descriptions. Such documents may be examined at the Fund Office (or at other specified 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. (g) You are entitled to a reduction or elimination of exclusionary periods of coverage for preexisting conditions under your 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 welfare 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 73 through 76 of this booklet. Basically, they provide that: (1) If your claim for a health care benefit is denied or ignored, 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 77

83 claim in accordance with the Plan's claims review and appeal 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 responsible 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 make a written request for a copy of Plan documents or the latest annual report from the Trustees and do not receive them within 30 days of the Plan s receipt, you may file suit in federal court. Of course, before taking such action, you no doubt will 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 still are 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 after you have exhausted the Plan s claims appeal procedures if you 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 claims review and appeal 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 and 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. 78

84 If you have any questions about your Plan, you should contact the Trustees by writing to: The Board of Trustees Milwaukee Carpenters' District Council Health Fund N25 W23055 Paul Road, Suite 2 Pewaukee, WI Or phone: (262) locally, or Call toll-free in Wisconsin: 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, D.C 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 ; sending electronic inquiries to or visiting the website of the EBSA at 79

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: The Board of Trustees Milwaukee Carpenters' District Council Health Fund N25 W23055 Paul Road, Suite 2 Pewaukee, WI Name of Plan The name of the Plan is the Milwaukee Carpenters District Council Health Fund. 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/Fiduciary The Plan Sponsor and Fiduciary is the Board of Trustees of the Milwaukee Carpenters' District Council Health Fund. This Fund is maintained by several employers and one or more employee organizations, and is administered by a Joint Board of Trustees which consists of Labor and Management representatives selected by the employers and unions who have entered into collective bargaining agreements that relate to this Plan. 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. The Administrative Manager maintains the eligibility records, accounts for the employer contributions, answers participant inquiries about the benefit programs, processes claims and benefit payments, files required government reports, and handles other routine administrative functions. The Names and Addresses of the Trustees Labor Trustees Peter DiRaffaele Chicago and Northeast Illinois District Council of Carpenters 12 East Erie Street Chicago, IL Arcadio Perez Chicago Regional Council Northern Region N25 W23055 Paul Road, Suite 1 P.O. Box 790 Pewaukee, WI Mark Scott Chicago Regional Council Northern Region N25 W23055 Paul Road, Suite 1 P.O. Box 790 Pewaukee, WI Management Trustees Tom DuFour J.H. Hassinger, Inc. N60 W16289 Kohler Lane Menomonee Falls, WI Larry Rocole J.P. Cullen & Sons, Inc West Lisbon Road, Suite 900 Brookfield, WI John Topp A.C.E.A West Bluemound Road, Suite 102 Brookfield, WI

86 Parties to the Collective Bargaining Agreement Chicago Regional Council of Carpenters Northern Region N25 W23055 Paul Road, Suite 1 Pewaukee, WI Allied Construction Employers Association, Inc West Bluemound Road, Suite 102 Brookfield, WI Also, those employers who are not members of or represented by such Associations but which execute an individual collective bargaining agreement with the Local Union. 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 Administrative Manager Milwaukee Carpenters' District Council Health Fund N25 W23055 Paul Road, Suite 2 P.O. Box 670 Pewaukee, 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 21. 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: (a) the collective bargaining agreements between the Union and Association; (b) the collective bargaining agreements between those employers who are not members of or represented by an Association but which execute an individual collective bargaining agreement with the Union; and (c) the Trustees' NBUE 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 persons, the Trustees determine the employer contribution amount, due date, and related policies. Method of Funding Benefits All Plan benefits are self-funded from accumulated assets and are provided directly from the Trust Fund except for certain organ transplant benefits which are insured. A portion of Fund assets is maintained in reserve to cover unexpected or 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. JP Morgan Chase Bank, N.A., Chicago, IL, is currently 81

87 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 Morgan Stanley, Milwaukee, WI. Benefits for certain organ transplants as referenced on pages 29 and 30 are provided through an insurance policy with National Union Fire Insurance Company of Pittsburgh, PA, c/o Medical Excess LLC, 7330 Woodland Drive, Suite 250, Indianapolis, IN 46278, Benefits eligible under the organ transplant insurance policy are submitted to and paid by National Union Fire Insurance Company of Pittsburgh, PA. Procedures To Be Followed in Presenting Claims for Benefits Under the Plan The procedures for filing for benefits are described on pages 68 and 69. 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 73 through 76. Effective Date Plan benefits described in this Summary Plan Description booklet are effective June 1, Fiscal Year of the Plan The Plan's fiscal year begins June 1st and ends the following May 31st. 82

88 Fund Administrative Manager Carday Associates, Inc. N25 W23055 Paul Road, Suite 2 Pewaukee, WI Fund Preferred Provider Network Anthem Blue Cross and Blue Shield 120 Monument Circle Indianapolis, IN Fund Legal Counsel Reinhart Boerner Van Deuren S.C North Water Street, Suite 1700 P.O. Box 2965 Milwaukee, WI Fund Family Services Program Provider ComPsych Corporation NBC Tower 455 North Cityfront Plaza Drive Chicago, IL Fund Legal Counsel Whitfield McGann & Ketterman 111 East Wacker Drive, Suite 2600 Chicago, IL Fund Preferred Provider Pharmacy CVS Caremark One CVS Drive Woonsocket, RI Fund Consultant Lee Jost and Associates One Park Plaza West Park Place, Suite 950 Milwaukee, WI Fund Preferred Provider Preventive Care Program Health Dynamics Columbia St. Mary s Urgent Care Facility 377 West River Woods Parkway, Suite 225 Glendale, WI Fund Certified Public Accountant Clifton Larsen Allen LLP West Research Drive, Suite 200 Milwaukee, WI Organ Transplant Benefits Insured by National Union Fire Insurance Company of Pittsburgh, PA c/o Medical Excess LLC 7330 Woodland Drive, Suite 250 Indianapolis, IN

89 NOTES 84

90 SUMMARY PLAN DESCRIPTION Effective June 1, 2014 Milwaukee Carpenters District Council Health Fund N25 W23055 Paul Road, Suite 2 Pewaukee, WI Telephone: (262) locally, or Call toll-free in Wisconsin: