ENROLLMENT AND ELIGIBILITY

is a non-profit health fund established in 1966 to provide healthcare for participating Teamster Union members and their families throughout New England. The Board of Trustees is charged by law with fiduciary responsibility to manage the Trust and oversee all the activities of the Trust. This legal responsibility is set forth in the rules established by the Federal Employee Retirement Income Security Act (ERISA) and enforced by the United States Department of Labor. The Trust is committed to partnering with its members and their employers to provide high quality, comprehensive, and cost-effective healthcare benefits for those members and their families to improve and maintain their quality of life. The following information is intended for summary purposes only, and is not a guarantee of coverage. A Summary Plan Description will be provided upon gaining eligibility with the Trust. Prepared for: True Value November, 2015

ENROLLMENT AND ELIGIBILITY All members are required to complete a Election form prior to gaining eligibility. The NNEBT plan includes: CIGNA Medical Teamsters Rx/Express Scripts Prescription NNEBT Dental Davis Vision Life Insurance Family status choices are binding until the next Open Enrollment period, except in the case of a Qualifying Event (change of family status, gain or loss of other insurance, etc.). Dependent Eligibility: A member who wishes to enroll dependents must provide certain documentation prior to eligibility being granted. A checklist of required documents is provided at the end of this packet. The member will have a 60-day grace period in which to provide the documents to NNEBT for dependent coverage to be retroactive to the member s effective date. If the documentation is provided after the 60- day period, dependent coverage will be prospective only. Contact NNEBT: (800) 258-9732 P a g e 1

CIGNA OPEN ACCESS PLUS What does Open Access mean? The Open Access Plus plan works best within a network of providers from which you choose services. You may see any licensed doctor inside or outside the network, but you will have richer benefits and it is more cost-effective if you stay inside the network. How does this differ from an HMO Plan? In an HMO Plan, all care must be coordinated through the member s Primary Care Physician (PCP). A member referral is required to see any type of specialist, care is generally limited to a specific geographic area (such as New England) and there is generally no out-of-network care except for emergencies. In the Open Access Plan, members may receive services from providers nationwide, referrals are not required for specialist care and out-of-network care is available (deductible and co-insurance may apply). Primary Care Physician Members are encouraged (but not required) to select a Primary Care Physician (PCP). It is recommended to have a PCP to be the keeper of all of your medical records, to coordinate your care and to provide: Routine checkups Follow-up care Information and guidance If a network PCP is selected, he/she will take care of obtaining in-network certification for services that require it. Specialist Care Without a Referral The CIGNA Open Access Plus (OAP) plan provides referral-free access to specialists for members covered by CIGNA OAP plans. If you choose an out-of-network health care professional, services are covered at a reduced benefit level. Emergency Care The CIGNA OAP plan allows for out-of-network care at the in-network cost when it is medically necessary. Care Away From the New England Area The CIGNA Open Access Plus (OAP) plan provides a nation-wide network of providers, so care can be obtained anywhere in the country. For example, if you have a college student or adult dependent who resides in another state, they may use network providers in their immediate area, rather than waiting until they are back in New England to schedule an appointment. Out-of-Network Care In the event you choose to see an out-of-network provider, the care will still be covered by CIGNA. However, you will be responsible for meeting the annual deductible plus paying the coinsurance and balance-billed amount, rather than the flat copayment amount. Contact NNEBT: (800) 258-9732 P a g e 2

Summary of CIGNA Medical Coverage This document is for summary purposes only. Complete details will be provided in the Summary Plan Description which will be mailed to members upon initial eligibility. Preventive Care Type of Care PCP Visit (other than preventive) Specialist Visit Chiropractor Prenatal Care Outpatient Surgical Procedure CAT/PET/MRI scans at outpatient facility Routine Lab/X-ray Hospital Stay Skilled Nursing Facility Emergency Room Ambulance Transportation Urgent Care Outpatient Therapy (Physical, Occupational, Cardiac, Speech) Home Health Care Hospice Care Durable Medical Equipment Annual Deductible (Network Provider) Annual Deductible (Out-of-Network Provider) Out of Network Coinsurance Medical Out-of-Pocket Maximum (Network) Medical Out-of-Pocket Maximum (Out-of-Network) Pre-Authorization Required for services including (but not limited to): Office Visits $0 copay $20 copay/visit $25 copay/visit Cost to Member (Network Providers) $25 copay/visit (Limit 34 visits per calendar year) PCP or Specialist copay to confirm pregnancy; no copay for subsequent visits Outpatient Care $150 copay/visit $100 copay/scan No charge Inpatient Care $500 copay/admission No charge Emergency Care $100 copay/visit (waived if admitted to hospital) No charge if medically necessary $25 copay/visit Continuing Care $25 copay/visit (Limit 60 visits per calendar year) No Charge No charge No charge Plan Information $0 Individual/$0 Family $250 Individual/$500 Family 30% after deductible $2,000 Individual/$4,000 Family $4,000 Individual/$8,000 Family Imaging, Inpatient, Behavioral Health, Substance Abuse, Outpatient Therapy, Skilled nursing care, Home/Hospice care, Durable Medical Equipment Contact NNEBT: (800) 258-9732 P a g e 3

NNEBT/Teamsters RX Prescription Plan The prescription drug benefit program is currently administered through Teamsters Rx for retail and Express Scripts (ESI) for mail order prescriptions. Use of generic medications is preferred whenever possible, as there is a higher cost to the member for brand name medications. For retail prescriptions there is an additional cost if a brand name is prescribed when a generic medication is available. Retail Purchases (up to 30-day supply) Retail benefits are available at all major pharmacies (except Wal-Mart, Walgreens or Sam s Club). Please present your Teamsters Rx/ESI Pharmacy card and ask the pharmacist to confirm their participation before filling your prescription. You may also visit www.teamstersrx.com, sign in and click locate a pharmacy. You are limited on your retail purchase to a 30-day supply or 100 units, whichever is less. Mail Order Purchases (maintenance medications up to 90-day supply) Mail-order service should be used for all maintenance medications (taken on a daily basis). Your provider will write a prescription for 90 days with three refills for one year of medication. Mail-order prescriptions will be processed through Teamsters Rx/Express Scripts (ESI). ESI will dispense up to a 90-day supply of a drug, subject to the prescription written by your physician and to the Teamsters Rx Pharmacy Limitations and Exclusions. ESI will dispense a brand name drug only if no generic drug equivalent is available. Cost to Member (Network Providers) Benefit Retail (Up to 30-day supply) Mail Order (Up to 90-day supply) Annual Deductible $0 Individual/$0 Family $0 Individual / $0 Family Prescription out-of-pocket Maximum $2,500 Individual/$5,000 Family (combined retail and mail order) Types of Prescriptions Generic Lower of Usual/Customary or $15 copay Lower of Usual/Customary or $15 copay Brand Name $25 copay $25 copay (only available when generic is not available) Brand Name if Generic is Available $25 Brand copay + difference Not available between brand and generic Specialty Drugs Limited to 30-day supply Not available through retail $25 copay Available through ESI/Accredo Diabetic Lancets/Test Strips Not available through retail $15 copay Contact NNEBT: (800) 258-9732 P a g e 4

NNEBT Dental Plan (DN1) NNEBT s dental plan is a nation-wide plan with no network restrictions. You may use any provider in the country, and providers have the ability to submit claims electronically to NNEBT for payment. The plan operates on a fee schedule, whereby NNEBT will pay up to a designated amount per diagnosis code. The Plan will pay up to the fee schedule amount with the member being responsible for the remainder of charges. A pre-treatment estimate is required for any care that will result in a claim over the amount of $250.00. The plan offers separate calendar year limits for periodontic procedures (scaling/root planning, adding/removal of bone, adding/removal of soft tissue) and prosthodontic procedures (crowns, bridges, dentures). Preventive Care Type of Care Deductible for Basic/Major Care Basic Care Major Care Orthodontia* Schedule of Benefits Coverage Amounts Plan pays 100% up to fee schedule amount No deductible $25 Individual/$50 Family Plan pays 80% up to fee schedule amount Plan pays 50% up to fee schedule amount Plan pays 75% up to $1,500 lifetime max * Members must be covered for a minimum of six consecutive months under the DN1 Program to be eligible for the Orthodontia benefit. Contact NNEBT: (800) 258-9732 P a g e 5

NNEBT/Davis Vision Plan The elective vision plan is separate from the health coverage component of your plan, and you must use a Davis Vision Provider. The Davis Vision program has a wide network of providers within New England and in other parts of the country. If there is not a Davis Vision Provider available in your area (or that of a covered dependent), Davis Vision will locate a provider and assign temporary network status in order to accommodate our members. If you choose to use a provider who is not part of the Davis Vision Network, you may file an individual claim and receive up to $45 reimbursement for the examination and up to $55 reimbursement for one pair of eyeglasses or contact lenses. Contact Davis Vision toll-free at 1-800-999-5431 to find a participating provider in your area (Monday-Friday 8:00 AM to 8:00 PM and Saturdays 9:00 AM to 4:00 PM) or visit www.davisvision.com. NOTE: Under either the innetwork or out-of-network benefit, you must claim all parts of the benefit (exam, lenses and frames) at one time and through a single provider. Schedule of Benefits Family Members Service Frequency Member and Spouse Adult Dependents (age 19 through end of the month in which age 26 is attained) Dependent Children (through end of year age 19 is attained) One Free routine eye examination (including dilation as professionally indicated) One Free pair of glasses including frames from the Davis Vision Tower Second pair of glasses available for $25 co-pay + discounted rates for frame/lens optional items. Once every 24 months One Free routine eye examination (including dilation as professionally indicated) Once every 24 months One Free pair of glasses including frames from the Davis Vision Tower One Free routine eye examination (including dilation as professionally indicated) Once every 12 months One Free pair of glasses including frames from the Davis Vision Tower Contact Lenses Plan Contact Lenses: Plan contact lenses (manufactured and or distributed by Davis Vision) may be received in lieu of one pair of glasses. Standard, soft, daily-wear, disposable or planned replacement contact lenses are available. Fitting and follow-up will be included upon obtaining Plan contact lenses. Non- Plan Contact Lenses: A $105 credit will be applied toward non-plan contact lenses from the provider s own supply (fitting and follow-up are not included). Contact NNEBT: (800) 258-9732 P a g e 6

Life Insurance / Accidental Death and Dismemberment Life insurance provides a benefit to you or your family members in the event of a death. Life insurance benefits for an active member will be paid to the beneficiary you select. Life insurance benefits for a spouse or child will be paid automatically to the active member. For actively employed members 70 and older, the benefit is reduced based on age. Amounts are detailed in the Summary Plan Description. Coverage Type Benefit Paid Life Insurance Active Member (through age 69) $25,000 Spouse $5,000 Dependent Child $2,500 Accidental Death/Dismemberment Active Member (through age 69) $25,000 Spouse Dependent Child No benefit No benefit Contact NNEBT: (800) 258-9732 P a g e 7

FREQUENTLY ASKED QUESTIONS How do I enroll my spouse/children? A member may enroll a spouse and/or children with proper eligibility documentation (please see the final page of this booklet for required documents). Dependents will be made eligible after all required documentation is received. Additional documentation may be required for step-children, adopted or foster children, or ex-spouses. My adult dependent lives in another state. Is he/she able to be covered on my plan? According to the guidelines of the Affordable Care Act (ACA) an adult dependent may remain covered under a member until the end of the month in which he/she attains age 26. The spouse or child of an adult dependent will not be covered by NNEBT. If an adult dependent obtains health coverage through an employer or another source, we must receive Coordination of Benefits so that claims are paid properly. How does the CIGNA Open Access plan differ from my current HMO Plan? In an HMO Plan, all care must be coordinated through the member s Primary Care Physician (PCP). A member referral is required to see any type of specialist, care is generally limited to a specific geographic area (such as New England) and there is generally no out-of-network care except for emergencies. In the Open Access Plan, members may receive services from providers nationwide, referrals are not required for specialist care and out-of-network care is available (deductible and co-insurance may apply). Do I need a referral to see a specialist? A referral is not required; however for certain types of specialty care, a review may be conducted to ensure that specialty care is medically necessary. What if I need to have an MRI/Surgery/Colonoscopy/Mammogram, etc.? A paper or electronic referral is not required; however, the test or service must be ordered by your Primary Care Physician and may require pre-certification by CIGNA. Your CIGNA PCP will handle pre-certifications with CIGNA network providers. There is a greater cost to the member if out-of-network facilities are utilized. How does the mail order pharmacy benefit work? Your physician should write a prescription for 90 days with three refills. This will provide one year of medication. The original prescription must be sent to Express Scripts (ESI) either by mail or faxed by a physician. Refills may be obtained by registering online, mail or telephone. For most prescriptions, the mail order pharmacy provides 90 days of medication for the same low copay as 30 days of the same medication from a retail pharmacy. When should I use the mail order pharmacy benefit? The mail order pharmacy benefit is for maintenance medications that are used every day. Maintenance medications include (but are not limited to): blood pressure, cholesterol, birth control, thyroid, glaucoma drops, etc. Certain drugs with dosage limitations will be outlined in your Summary Plan Description (SPD). Diabetic test strips are ONLY covered through the mail order pharmacy. There is no benefit or reimbursement for test strips purchased through a retail source or through media advertisements (television, magazines, etc.). Contact NNEBT: (800) 258-9732 P a g e 8

Is there a network for dentists? The NNEBT dental plan is not limited to a network or participating dentists. The member may choose his/her dental provider. However, members should be aware that all providers do not charge consistent rates for the same services. NNEBT will pay according to the fee schedule (attached) and the member is responsible for any/all remaining balance. If a member is using the services of an oral surgeon, care should be taken to ensure that surgeon is part of the CIGNA network, as some oral surgery benefits are billable under the medical plan. Contact the NNEBT Dental department for specifics. How does the Vision benefit work? Choose a Davis Vision provider from the directory included with your enrollment materials. When making the appointment, inform the provider that you will be utilizing Davis Vision benefits. The examination and eyeglass or contact lens selection must be completed in one visit. Does Davis Vision cover chain vision providers or providers within a department store? The Davis Vision Network does not accept chain or department store vision providers such as LensCrafters, Pearle, JC Penney, Sears, Wal-Mart, etc.). What if I have a medical condition involving my eyes? Medical conditions should be handled by a CIGNA network Ophthalmologist. However, if you have a routine eye examination or obtain a prescription for eyeglasses from such a provider, the services are not covered under the Davis Vision benefit or the CIGNA benefit. Does NNEBT refund my gym membership? NNEBT provides a $100 reimbursement after every 6 month period of using a gym for an average of 3 times per week. You may join the gym, YMCA or health club of your choice. At the end of each 6-month period, you (or your covered spouse) may submit a printout of your attendance along with the NNEBT Health Club Reimbursement form and the refund check will be mailed to you. This benefit is payable twice per year. The Health Club Reimbursement does not apply to adult dependents or children. How am I reimbursed after a massage? You may obtain services from a licensed massage therapist. Take an NNEBT Massage Claim form with you, as the therapist must complete the bottom portion. You may submit a form for each massage or list up to 5 appointments per form. NNEBT will reimburse up to $30 per appointment (one per calendar day), to a maximum of $1,000 reimbursement per calendar year for you or your covered spouse. The massage benefit does not apply to adult dependents or children. Does NNEBT cover hearing aids? The NNEBT Hearing benefit includes testing/evaluation and hearing aids for members and dependents over the age of 19. The member must pay the provider in full and submit a complete, itemized bill including the provider s name and address. NNEBT will reimburse 75% of the total charge, up to $1,500 per member (or covered dependent) once every 5 years. Batteries are not covered under the NNEBT Hearing benefit. Contact NNEBT: (800) 258-9732 P a g e 9

CHECKLIST FOR DEPENDENT ELIGIBILITY All required items must be provided to NNEBT within 60 days of eligibility to complete the enrollment process. Eligibility for covered dependents is pending until all applicable documentation is received. ALL MEMBERS MUST PROVIDE: NNEBT ENROLLMENT AND ELECTION FORMS SOCIAL SECURITY NUMBERS for member and all covered dependents COORDINATION OF BENEFITS to show additional insurance for member and all covered dependents HIPAA CERTIFICATE showing termination date for previous insurance (as applicable) TO ADD FAMILY MEMBERS DOCUMENTS REQUIRED Spouse Photocopy of State or town-issued Marriage Certificate (we do not accept church or venue certificates) Ex-Spouse Photocopy of Divorce Decree showing responsibility for your exspouse s coverage Natural Child Photocopy of State or town-issued Birth Certificate (we do not accept hospital certificates or birth announcements) Adopted Child Photocopy of State-issued Birth Certificate Photocopy of Adoption Certificate/Court Documents Step-Child Photocopy of State-issued Birth Certificate Photocopy of any applicable Divorce Decree showing responsibility for the child s insurance coverage Child support order, QMSO or NNEBT Step-child affidavit (required if a divorce decree does not exist) Foster Child or Legal Dependent Photocopy of State-issued Birth Certificate Photocopy of Legal Guardianship Court Documents Contact NNEBT: (800) 258-9732 P a g e 10