BRICKLAYERS AND ALLIED CRAFTWORKERS INTERNATIONAL … Silver Plan Document.pdf · bricklayers and...

BRICKLAYERS AND ALLIED CRAFTWORKERS

INTERNATIONAL HEALTH FUND

SUMMARY PLAN DESCRIPTION

SILVER PLAN

EFFECTIVE OCTOBER 1, 2015

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TABLE OF CONTENTS

PLAN IDENTIFYING INFORMATION ......................................................................................... 2 SUMMARY PLAN DESCRIPTION ............................................................................................... 5

WHAT THIS SPD TELLS YOU ................................................................................................................ 5 WHOM TO CALL FOR HELP OR INFORMATION ............................................................................ 6

Who can be eligible to participate in the plan ...................................................................... 8 Active Participants ......................................................................................................................... 9

How do I Become Eligible to Receive Coverage ............................................................................ 9 When is My Coverage in Effect .......................................................................................................... 11 When Does My Eligibility for Coverage End? ............................................................................... 12

Retiree coverage ........................................................................................................................... 14 How do I Become Eligible to Receive Retiree Coverage ........................................................... 14 When Does My eligibility for Coverage End? ................................................................................ 14

Officer/employee of local union............................................................................................... 16 How do I Become Eligible to Receive Retiree Coverage ........................................................... 16 When Does My eligibility for Coverage End? ................................................................................ 16

Owner/Manager of a Contributing Employer ...................................................................... 18 How do I Become Eligible to Receive Owner/Manager Coverage .......................................... 18 When Does My eligibility for Coverage End? ................................................................................ 18

Employee of a Contributing Employer .................................................................................. 20 How do I Become Eligible to Receive Retiree Coverage ........................................................... 20 When Does my Eligibility for Coverage End? ............................................................................... 20

WHO ARE YOUR ELIGIBLE DEPENDENTS? ....................................................................... 22 When Does Their Coverage Start? .................................................................................................... 23 When Does Their Coverage End? ..................................................................................................... 23 Change in Coverage ............................................................................................................................... 23 Special Enrollment.................................................................................................................................. 26 Qualified Medical Child Support Orders (“QMCSOs”). .............................................................. 27 Continuing Eligibility during Family and Medical Leave ........................................................... 28 Continued Eligibility During Qualified Military Service.............................................................. 29

COBRA Continuation Coverage .............................................................................................. 31 When Is COBRA Coverage Available?............................................................................................. 31 What is a Qualifying Event ................................................................................................................... 31 How long does my coverage last ...................................................................................................... 32 COBRA Continuation Coverage and Medicare ............................................................................. 35 Notifying the Plan .................................................................................................................................... 36

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Election of COBRA Continuation Coverage .................................................................................. 37 Termination of COBRA Continuation Coverage ........................................................................... 38 Where to Send Notices and Information ......................................................................................... 38 Keep Your Plan Informed of Address Changes ............................................................................ 38

Compliance with other laws ...................................................................................................... 39 General Types of Benefits Offered by the Plan .................................................................. 39

MEDICAL COVERAGE: .......................................................................................................................... 39 PRESCRIPTION DRUG: ......................................................................................................................... 39 DENTAL BENEFITS: ............................................................................................................................... 39 VISION BENEFITS: .................................................................................................................................. 40 HEALTH REIMBURSEMENT ACCOUNT: ......................................................................................... 40 LIFE INSURANCE .................................................................................................................................... 40 ACCIDENTAL DEATH AND DISMEMBERMENT BENEFIT ......................................................... 41 SHORT TERM DISABILITY BENEFITS ............................................................................................. 41

HOW THE MEDICAL PLAN WORKS ....................................................................................... 42 Network and Non-Network Benefits ................................................................................................. 42 Copayment ................................................................................................................................................ 44 Coinsurance .............................................................................................................................................. 44 Out-of-Pocket Maximum ....................................................................................................................... 45 Personal Health Support ...................................................................................................................... 46

SCHEDULE OF BENEFITS - MEDICAL .................................................................................. 49 Additional Coverage Details ..................................................................................................... 62

Acupuncture Services ........................................................................................................................... 62 Ambulance Services - Emergency only .......................................................................................... 62 Ambulance Services - Non-Emergency ........................................................................................... 62 Bariatric Procedures .............................................................................................................................. 63 Cancer Resource Services (CRS) ...................................................................................................... 63 Clinical Trials ............................................................................................................................................ 64 Dental Services - Accident Only ........................................................................................................ 66 Diabetes Services ................................................................................................................................... 67 Durable Medical Equipment (DME) ................................................................................................... 68 Emergency Health Services - Outpatient ........................................................................................ 69 Eye Examinations ................................................................................................................................... 69 Healthy Back ............................................................................................................................................. 69 Hearing Aids ............................................................................................................................................. 70 Home Health Care ................................................................................................................................... 70 Hospice Care ............................................................................................................................................ 71 Hospital - Inpatient Stay ........................................................................................................................ 71 Injections received in a Physician's Office .................................................................................... 72 Kidney Resource Services (KRS) ...................................................................................................... 72

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Maternity Services .................................................................................................................................. 73 Massage therapy ..................................................................................................................................... 74 Mental Health Services .......................................................................................................................... 74 Neonatal Resource Services (NRS) .................................................................................................. 75 Neurobiological Disorders - Autism Spectrum Disorders Services ...................................... 76 Nutritional Counseling .......................................................................................................................... 77 Ostomy Supplies ..................................................................................................................................... 78 Outpatient Surgery, Diagnostic and Therapeutic Services ...................................................... 78 Physician Fees for Surgical and Medical Services ..................................................................... 79 Physician's Office Services - Sickness and Injury ...................................................................... 80 Preventive Care Services ..................................................................................................................... 81 Prosthetic Devices .................................................................................................................................. 85 Reconstructive Procedures ................................................................................................................. 85 Rehabilitation Services - Outpatient Therapy ............................................................................... 86 Skilled Nursing Facility/Inpatient Rehabilitation Facility Services ........................................ 87 Spinal Treatment ..................................................................................................................................... 87 Substance Use Disorder Services ..................................................................................................... 87 Transplantation Services...................................................................................................................... 88 Urgent Care Center Services ............................................................................................................... 90

Health and Wellness Resources.............................................................................................. 91 Consumer Solutions and Self-Service Tools................................................................................. 91 Health Assessment ................................................................................................................................. 91 Health Improvement Plan ..................................................................................................................... 92 NurseLineSM ............................................................................................................................................... 92 Treatment Decision Support ............................................................................................................... 93 UnitedHealth Premium® Program ...................................................................................................... 94 www.myuhc.com ..................................................................................................................................... 94 Disease and Condition Management Services ............................................................................. 95 Diabetes Prevention and Control....................................................................................................... 95 Disease Management Services .......................................................................................................... 96 HealtheNotesSM ........................................................................................................................................ 97

Limitations and Exclusions ....................................................................................................... 98 How to file a Medical Benefits claim ................................................................................... 107

In-Network Benefits ..............................................................................................................................107 Non-Network Benefits..........................................................................................................................107 If your non-Network Provider Does Not File Your Claim .........................................................108 Health Statements .................................................................................................................................109 Explanation of Benefits (EOB) ..........................................................................................................110 Types of Claims - Definitions ............................................................................................................110

PRESCRIPTION DRUG BENEFIT .......................................................................................... 115

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DENTAL BENEFIT ...................................................................................................................... 123 Benefit Summary Chart .......................................................................................................................123 How Claims Are Paid ...........................................................................................................................128 How to Submit a Claim ........................................................................................................................130 Other Health Insurance .......................................................................................................................132 Complaints, Grievances and Appeals ............................................................................................133 General Program Information ...........................................................................................................137 Limitations and Exclusions ...............................................................................................................140

VISION BENEFITS ...................................................................................................................... 143 Procedures for Using the Plan .........................................................................................................143 Benefits and Coverages ......................................................................................................................144 Exclusions and Limitations of Benefits ........................................................................................146 Complaints and Grievances ..............................................................................................................147

HEALTH REIMBURSEMENT ARRANGEMENT ................................................................. 150 Eligibility...................................................................................................................................................150 Contributions to your HRA ................................................................................................................151 Using your HRA Balance ....................................................................................................................151 HRA Administration..............................................................................................................................152 Claims Procedure ..................................................................................................................................152

ULLICO LIFE AND ACCIDENTAL DEATH & Dismemberment .................................... 153 SHORT TERM DISABILITY ...................................................................................................... 154 Notice of Denial of Claim ........................................................................................................ 156 APPEALS ...................................................................................................................................... 157

Medical/Presctiption Drug/HRA Claims .........................................................................................158 Life Insurance/AD&D Appeals ..........................................................................................................161

REIMBURSEMENT AND SUBROGATION .......................................................................... 162 Cases Involving a Third Party ...........................................................................................................162 Reimbursement ......................................................................................................................................162 Subrogation.............................................................................................................................................164 Cases Involving Work-Related Claims...........................................................................................164 Fraudulent and Erroneous Claims ..................................................................................................165 Payment to Third Parties ....................................................................................................................166

Coordination of Benefits with Other Plans ....................................................................... 167 How Coordination Works With Another Group Health Plan ..................................................167 How Coordination Works with Medicare .......................................................................................169

Overpayment and Underpayment of Benefits ................................................................. 173 Miscellaneous ............................................................................................................................. 173

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SOURCES OF CONTRIBUTIONS TO THE PLAN .........................................................................174 BAC INTERNATIONAL HEALTH FUND PRIVACY NOTICE .......................................... 174

Your Choices ..........................................................................................................................................175 Our Uses and Disclosures .................................................................................................................175 Your Rights .............................................................................................................................................176 Your Choices ..........................................................................................................................................177 Our Uses and Disclosures .................................................................................................................178 Our Responsibilities.............................................................................................................................180 Changes to the Terms of this Notice ..............................................................................................180 Other Instructions for Notice ............................................................................................................180

STATEMENT OF PARTICIPANTS RIGHTS UNDER ERISA .......................................... 180 DEFINITIONS ............................................................................................................................... 184

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Dear Participant:

The Board of Trustees of the Bricklayers and Allied Craftworkers International Health Fund (IHF) is pleased to provide you with this booklet describing certain features of the Fund. The Trustees of the Fund have established this Plan to provide you and your eligible Dependents with valuable health care and other benefits.

This booklet describes how you and your Dependents become eligible and continue to remain eligible to receive benefits. It also describes in general the types of benefits provided by the Plan. You may not be eligible for all of the benefits described in the booklet. The specific benefits and levels of benefits you are entitled to will be listed on a Schedule of Benefits herein. Limitations and Exclusions are described and instructions are given on how to apply for benefits. Finally, the booklet describes the procedures by which you can appeal a benefit decision and the rights you and other participants are given by the Employee Retirement Income Security Act of 1974, as amended (ERISA).

This booklet has been written in simple, straightforward language. We encourage you to read it and become familiar with the plan of benefits available to you. Please share this information with your family members. If you have any questions about your benefits after reading this booklet, please contact the Fund Office.

Some of the terms used in this SPD begin with a capital letter. These terms have special meaning under the Plan and are defined in the Glossary, which is located at the end of this SPD. Other capitalized terms used within this SPD may be defined within their relevant Article. When reading the provisions of the Plan, you can refer to the Glossary at the end of this SPD. Becoming familiar with the terms defined therein will give you a better understanding of the procedures and benefits described herein.

Fraternally,

BOARD OF TRUSTEES

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PLAN IDENTIFYING INFORMATION

Name of the Plan Bricklayers and Allied Craftworkers International Health Fund

Type of Plan Welfare Plan providing the following benefits:

(a) Death/Life Insurance, (b) Accidental death and

dismemberment, (c) Hospital expense, (d) Major medical, (e) Dental, (f) Vision, (g) Prescription drug, (h) Health reimbursement

account (i) Short term disability.

Funding Medium and Type of Plan Administration This Plan is funded by participating employer contributions pursuant to collective bargaining agreements between the Union and employers participating in the IHF. A copy of any such agreement may be obtained by participants and/or their beneficiaries upon written request to the Welfare Fund office and is available for examination at the Welfare fund office by Participants and/or their Beneficiaries.

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Contributions by non-bargaining unit employees, owner-operators and retired members are made by monthly contributions to the Plan pursuant to a Collective Bargaining Agreement or a separate agreement with the fund in amounts set by the Board of Trustees.

Address of Plan Bricklayers and Allied

Craftworkers International Health Fund.

620 F Street NW, Washington DC 20004

Agent for Service of Legal Process Robin Donovick

Executive Director, IHF 620 F St., NW Washington DC 20004 202-383-3976 [email protected]

Plan Number 501

Plan Sponsor The Board of Trustees of the Bricklayers and Allied Craftworkers International Health Fund.

Employer Identification Number (EIN) 52-6397805

Plan Effective Date July 5, 1988

mailto:[email protected]

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Restatement Effective Date October 1, 2015

Plan Year January 1-December 31

Plan Administrator Robin Donovick

Executive Director, IHF 620 F St., NW Washington DC 20004 202-383-3976 [email protected]

Board of Trustees Union Trustees James Boland (Labor Chair) Henry Kramer Gerard Scarano

Timothy Driscoll Ted Champ

Employer Trustees

Gregory Hess (Management Chair) Matt Aquiline

Robert Hoover Anthony Marra Paul Nysewander

mailto:[email protected]

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SUMMARY PLAN DESCRIPTION

The Bricklayers and Allied Craftworkers International Health Fund (“IHF”) was established in 1988 by the International Union of Bricklayers and Allied Craftworkers and various Contractor Associations. It is financed by: employer contributions established in collective bargaining agreements between the Union and employers participating in the IHF; employer contributions pursuant to Participation Agreements with the IHF; and self-pay contributions made by Participants.

The Bricklayers and Allied Craftworkers International Health Fund is administered by a Board of Trustees consisting of an equal number of representatives of the Union and an equal number of representatives of the employers. They serve without compensation. The Trust Fund is separate from, and not a part of, the International Union or any employers’ association. The U.S. Treasury has advised that the Fund is exempt from Federal income taxes under provisions of Section 501(c)(9). When this booklet refers to “you”, it assumes that you are a Participant covered by this Plan.

WHAT THIS SPD TELLS YOU

This booklet serves as both the Plan Document and the Summary Plan Description (“SPD” or “Plan”) of the IHF. It supersedes all prior SPDs, Plan rules and other notices. This document describes your Coverage under the IHF as well as important information on accessing your Coverage. You should review it and show them to those members of your family who are or will be covered by the Plan. It will give you an understanding of:

• the coverages provided; • the procedures to follow in submitting claims; • your rights under the law; and • your responsibilities to provide necessary information to the Plan.

Remember not every expense you incur for health care is covered by the Plan.

Additionally, the Board of Trustees has full discretionary authority to interpret the Plan and decide all issues pertaining to the terms of this document and coverages available to participants. The Board of Trustees may also, in its sole discretion, modify, amend or terminate the Plan and any of its provisions, including, but not limited to, classes of coverage, eligibility and requirements for coverage, availability, nature and extent of benefits and conditions and methods of payment. No benefits are guaranteed. As the Plan is amended from time to time, the IHF Plan Administrator will send you information explaining the changes. If those later notices describe a benefit or procedure that is

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different from what is described here, you should rely on the later information. Please be sure to read all Plan communications and keep them with this booklet.

Be sure to keep this document, along with notices of any Plan changes, in a safe and convenient place where you and your family can find and refer to them. If you lose this document, please contact the IHF Fund Office at 620 F Street, N.W., Washington, DC 20004, (888) 880-8222 to receive another copy.

WHOM TO CALL FOR HELP OR INFORMATION

When you need information, please check this document first or call the IHF at (888) 880-8222. If you need further help, please do not hesitate to call the following:

WHAT WHO WHERE

MEDICAL BENEFITS UNITED HEALTHCARE 1-866-633-2474

8:30 a.m. to 8:00 p.m. Monday – Friday

PRESCRIPTION DRUG BENEFITS

SAV-RX 1-866-912-7425-

24 hours a day, 7 days a week

VISION CARE VSP 1-800-877-7195 8:00 a.m. to 8:00 p.m. Monday – Friday 9:00 a.m. to 4:00 p.m. Saturday

DENTAL CARE DELTA DENTAL 1-800-932-0783

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OR CONTACT THE IHF IN WRITING AT: Bricklayers and Allied Craftworkers International Health Fund 620 F Street, N.W. Washington, DC 20004

HEALTH REIMBURSEMENT ACCOUNT

AMERIFLEX 1-888-868-3539

ELIGIBILITY INTERNATIONAL HEALTH FUND

1-888-880-8222

LIFE INSURANCE INTERNATIONAL HEALTH FUND

1-888-880-8222

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WHO CAN BE ELIGIBLE TO PARTICIPATE IN THE PLAN

You and your Eligible Dependents may be eligible for benefits from the Plan if you meet two different conditions under the Plan; the first related to your affiliation with the Plan and the second related to contributions made by you or on your behalf to the Plan.

Generally, you may participate in the Plan if you are one of the following five types of individual:

• You are an Eligible Employee working for a Contributing Employer pursuant to a Collective Bargaining Agreement obligating the Contributing Employer to report and pay contributions to this Plan on your behalf.

• You are a Retired Participant who was a Participant in the Plan on the date of your retirement.

• You are an officer or employee of a Local Union that has entered into a Collective Bargaining Agreement providing for contributions to be made to the Plan on behalf of its members

• You are an owner or manager of a Contributing Employer • You are an employee of a Contributing Employer and you do not perform work

under a collective bargaining agreement between the Contributing Employer and the Union or Local

Each of these types has their own section in this booklet that describes, in detail, how you may be eligible for coverage, how to obtain coverage and when your coverage ends. Please note that the participation requirements for each of the five types of individuals listed above may vary so please read the requirements carefully.

Additionally, this booklet uses different terms to refer to categories of Participants who are affected by Plan rules. These terms and some other related terms are explained below and in the “Definitions” section.

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ACTIVE PARTICIPANTS

HOW DO I BECOME ELIGIBLE TO RECEIVE COVERAGE

If you are currently employed by a Contributing Employer, you and your Eligible Dependents become Participants in the Plan and are eligible to receive Coverage for a quarter if you:

i. are a member of the Union and perform work pursuant to a collective bargaining agreement between a Contributing Employer and the Union or a Local; and

ii. meet the minimum hours requirement for Coverage as described below.

In order to qualify for Coverage during each of these quarters (“Coverage Period”), you must meet one of three minimum hours requirements, as shown in the following table:

Coverage Period Eligibility Requirement

February through April • 200 hours during the prior October through December; or

• 500 hours during the prior July through December; or

• 1200 hours during the prior January through December.

May through July • 200 hours during the prior January through March; or

• 500 during the prior October through March; or

• 1200 during the prior April through March.

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August through October • 200 hours during the prior April through June; or

• 500 during the prior January through June; or

• 1200 during the prior July through June.

November through January • 200 hours during the prior July through September; or

• 500 during the prior April through September; or

• 1200 during the prior October through September.

Examples:

A. Joe worked 100 hours in October, 100 hours in November and 120 hours in December, for a total of 320 hours in the quarter. Joe is eligible to receive coverage beginning February 1st for the period February through April because he exceeded 200 hours in the quarter.

B. Continuing with example A, Joe continues to work 50 hours in January, 40 hours in February and 100 hours in March, for a total of 190 hours in the quarter. Joe would not qualify for coverage from May through July because he failed to exceed 200 hours in the quarter. However, because Joe worked 510 hours from October through March, he would satisfy the six-month test and receive coverage beginning May 1st for the period May through July.

C. Assume in example B that Joe only worked 490 hours from October through March, thus failing to exceed 500 hours over the prior six-months. If Joe worked 710 hours from April through October, for a total of 1200 hours for the prior 12 months, Joe will receive coverage beginning May 1st for the period May through July.

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WHEN IS MY COVERAGE IN EFFECT

The IHF evaluates hours worked and contributions received each quarter to determine Eligibility for the following quarter. For initial Eligibility, benefits are effective on the first day of the first month for which the member becomes eligible providing the member completes and submits accurate enrollment information, in accordance with the Plan’s enrollment form, within 60 days of becoming eligible. If the participant’s enrollment information is received later than 60 days of becoming eligible, the participant will begin receiving benefits as of the date of the submission of his enrollment form.

Example: Jason is hired in October by DEF construction. He works 200 hours for the period of July, August and September. He is eligible for benefits effective November 1st for the period November, December and January and must return his enrollment form by December 30th. If he submits his information on January 8th, he will begin receive benefits from January 8th through the remainder of the period.

Notwithstanding the above, your Eligibility for Coverage is contingent upon your employer making sufficient contributions to the IHF on your behalf and in accordance with the collective bargaining agreement and the terms of the IHF. If you work the required hours to qualify for Coverage but your employer fails to make sufficient contributions to meet the tests described above, you will not receive Coverage.

Example: Peter worked for ABC Masonry, Inc. for 150 hours during the quarter October through December. As of January 31st, ABC Masonry contributed only 120 hours to the IHF on Peter’s behalf. Peter will not be eligible to receive Coverage starting February 1st and will be offered the opportunity to purchase Coverage through COBRA.

If, during the Coverage period, your employer makes sufficient contributions to meet the Eligibility tests above, you will receive coverage retroactive to the first day of that Coverage period and will retain Coverage for the quarter. Additionally if you purchased Coverage through COBRA for that Coverage period or part thereof, the IHF will reimburse you for your COBRA payment.

Example: Same as above except ABC Masonry contributes an additional 50 hours’ worth of contributions to the IHF on February 15th. Peter will receive coverage for the period of February through April. If Peter purchased Coverage through COBRA for the month of February, the IHF will reimburse Peter the amount of that COBRA payment.

Notwithstanding any other provision, when you are working out of your home jurisdiction, hours will be reciprocated from the Local Fund who is collecting your

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contributions at the local hourly rate. If the local hourly rate is different than your home jurisdiction rate, you will receive a prorated amount of hours.

Example #1: Jerry worked 200 hours during the period October through December for XYZ Tile Setters in a jurisdiction outside of his home jurisdiction. XYZ Tile Setters has a $3.00/hour health and welfare contribution rate. The IHF rate in his home jurisdiction is $6.00/hour. [(200 x $3.00)/$6.00 = 100]. Because the local fund’s contribution rate is lower, the hours are prorated based on the difference in contribution rate. Therefore, Jerry would receive credit for 100 hours towards IHF Coverage. If Jerry has no additional hours, he does not meet the Eligibility requirements for IHF Coverage.

Example #2: Sam works for TLC Marble in a jurisdiction outside of his home local that has an $8.00 health and welfare contribution rate; the IHF rate is $6.00. Sam works 225 hours during the period October through December. At the end of the quarter the funds reciprocated equate to 300 hours [(225 x 8.00)/6.00 = 300]. He will be eligible because the higher rate buys 300 hours which is more than the 200 hours required.

WHEN DOES MY ELIGIBILITY FOR COVERAGE END?

Your Eligibility for coverage ends on the last day of the third Eligibility month that you do not meet the quarterly Eligibility rules of the next calendar quarter. At that time, certain COBRA provisions may apply as described below.

Example: Ed receives coverage under the IHF for the period August through October. During that period the IHF will review the hours Ed worked and for which his employer made contributions to the IHF over the previous three months (July-September), six months (April-September) and twelve months (October-September). If Ed’s hours do not meet the Eligibility requirement set forth above to obtain coverage for November through January, Ed’s coverage will end as of October 31st. Ed will then be eligible for COBRA coverage.

Your coverage will end immediately in the following events.

i. If you become employed in the Masonry Industry and such employment is not covered by a collective bargaining agreement between the employer and the Union (“Non-Covered Masonry Employment”), coverage for both you and your Eligible Dependents under the IHF will be terminated as of the date of that employment.

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ii. If this plan is terminated, your coverage will end immediately.

If you fail to notify the IHF of your work in Non-Covered Masonry Employment or that you became eligible under another employment-related group health plan and you receive benefits from the IHF after your Eligibility for coverage should have terminated, you shall reimburse the IHF the actual costs of all benefits received. The IHF may, among other steps, withhold future benefits should you fail to do so or seek reimbursement through all legal means.

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RETIREE COVERAGE

Generally, continued coverage is available to participants and their Dependents on a self-payment basis after they retire. Retiree coverage includes Medical, Prescription Drugs, Life and AD&D insurance benefits. Dental and vision are optional benefits available for an additional fee and must be specifically elected by the participant. HRA benefits are not available. Please call the IHF at (888) 880-8222 for current rates.

HOW DO I BECOME ELIGIBLE TO RECEIVE RETIREE COVERAGE

You and your Dependents are eligible to receive monthly Retiree Coverage if you meet all of the following:

i. The Local Union in which you were a member immediately preceding your retirement must be participating in the International Health Fund; and

ii. You participated as a Participant in the IHF the quarter prior to your retirement; and

iii. You are receiving a pension from the Bricklayers and Trowel Trades International Pension Fund or a pension fund maintained by the Union;

iv. You make timely enrollment and Self-Payments to the IHF at rates to be determined by the Board of Trustees from time to time.

The self-payment must be made on or before the 15th day of each month prior to the Eligibility month.


If you stop making self-payments, or fail to make the entire payment required on or before the date due, your Coverage will end as of the last day of the month in which you are receiving Coverage and you will not thereafter be entitled to further Retiree Coverage under the IHF, unless you reestablish Eligibility as a Participant and subsequently retire.

Your coverage will also end in the following events:

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i. If you become reemployed by a Participating Employer of the Union and become eligible for coverage under the IHF active plan, your retiree coverage will end at the first of the month in which you begin receiving those benefits

ii. If you become eligible as an employee for coverage under another employment-related group health plan, your coverage ends immediately. You will not thereafter be entitled to further self-payment Coverage under the IHF, unless you reestablish Eligibility as a Participant and subsequently retire.

iii. If you become employed in Non-Covered Masonry Employment, your coverage under the IHF will be terminated as of the date of that employment. You will not thereafter be entitled to further self-payment Coverage under the IHF, unless you reestablish Eligibility as a Participant and subsequently retire.; or

iv. If this plan is terminated, your coverage will end immediately.

If you fail to notify the IHF of your work in Non-Covered Masonry Employment or that you became eligible under another employment-related group health plan and you receive benefits from the IHF after your Eligibility for coverage should have terminated, you shall reimburse the IHF the actual costs of all benefits received. The IHF may, among other steps, withhold future benefits should you fail to do so or seek reimbursement through all legal means.

Once you are 65 years old and eligible for Medicare Parts A and B, your benefits will be coordinated with Medicare. Medicare will be your primary provider as soon as permitted under applicable law. If you only elect Part A Medicare, all covered health expenses will be paid to you as though you had enrolled in Part B. In other words, reimbursement will be reduced by the Medicare benefits available to you as if you had enrolled. You will be paid the difference between what Medicare pays (or would have paid) and the Medicare allowance for all covered Plan benefits. You should apply for Medicare at your local Social Security office at least three months before you reach age 65. Prescription Drug coverage is also coordinated with Medicare Part D through an AARP plan with a prescription drug wrap.

SURVIVING SPOUSE

A spouse of a deceased retiree is eligible to continue coverage for life providing timely enrollment (within 30 days of the death of the retiree) and self pay premiums are made at the respective retiree rate on or before the due date. Coverage can be continued for eligible Dependents provided they were covered at the time of the retiree’s death.

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OFFICER/EMPLOYEE OF LOCAL UNION


If you are currently employed as an officer or employee of a Local Union, you and your Dependents are eligible to receive Coverage under the IHF, if you meet all of the following:

i. Your Local Union has entered into a collective bargaining agreement providing for contributions to be made to the IHF on behalf of its members; and

ii. The Local Union makes contributions to the IHF on your behalf on the same terms and conditions as provided for in the collective bargaining agreement and in accordance with the eligibility provisions above.

The IHF evaluates hours worked and contributions received each quarter to determine Eligibility for the following quarter. For initial Eligibility, benefits are effective on the first day of the first month for which the member becomes eligible providing the member completes and submits accurate enrollment information, in accordance with the Plan’s enrollment form, within 60 days of becoming eligible. If the participant’s enrollment information is received later than 60 days of becoming eligible, the participant will begin receiving benefits as of the date of the submission of his enrollment form.

Example: Jason is hired in October by DEF Construction. He works 200 hours for the period of July, August, and September. He is eligible for benefits effective November 1st for the period November, December and January and must return his enrollment form by December 30th. If he submits his information on January 8th, he will begin receive benefits from January 8th through the remainder of the period.


Notwithstanding the above, your Eligibility for Coverage is contingent upon the Local Union making sufficient contributions to the IHF on your behalf and in accordance with the collective bargaining agreement and the terms of the IHF. If you work the required hours to qualify for Coverage but the Local Union fails to make sufficient contributions to meet the tests described above, you will not receive Coverage.

Your Eligibility for coverage ends on the last day of the third Eligibility month that you do not meet the quarterly Eligibility rules of the next calendar quarter.

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Example: Ed receives coverage under the IHF for the period August through October. During that period the IHF will review the hours Ed worked and for which his employer (Local Union) made contributions to the IHF over the previous three months (July-September), six months (April-September) and twelve months (October-September). If Ed’s hours do not meet the Eligibility requirement set forth above to obtain coverage for November through January, Ed’s coverage will end as of October 31st. Ed will then be eligible for COBRA coverage.

Your coverage will also end in the following events.

i. If you become eligible as an employee for coverage under another employment-related group health plan, your coverage ends immediately

ii. Your Local Union ceases to represent members who are participants in the IHF.

iii. If this plan is terminated, your coverage will end immediately.

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OWNER/MANAGER OF A CONTRIBUTING EMPLOYER

HOW DO I BECOME ELIGIBLE TO RECEIVE OWNER/MANAGER COVERAGE

If you are an owner or individual who exercises control over the management of a Contributing Employer with at least one Participant in the Plan covered under a Collective Bargaining Agreement, you and your Dependents are eligible for Coverage in the IHF if you contribute a minimum of 480 hours to the IHF per quarter at the rate set forth by the IHF Board of Trustees. This will entitle you to full benefits in the following Coverage period quarter, in accordance with the chart set forth in the eligibility table above.

Example: Joe owns ABC Masonry, Inc which has a collective bargaining agreement with BAC Local 1 covering all of its BAC employees. ABC Masonry contributes 480 hours to the IHF in December. Joe is eligible to receive Coverage beginning February 1st for the period February through April.

The IHF evaluates hours worked and contributions received each quarter to determine Eligibility for the following quarter. For initial eligibility, benefits are effective on the first day of the first month for which the member becomes eligible providing the member completes and submits accurate enrollment information, in accordance with the Plan’s enrollment form, within 60 days of becoming eligible. If the participant’s enrollment information is received later than 60 days of becoming eligible, the participant will begin receiving benefits as of the date of the submission of his enrollment form.

Example: Same as above except that Joe has not previously participated in the IHF and he submits his information on February 20th. Even though Joe is eligible to receive benefits from February 1st, his Coverage does not begin until April 20th. Joe would be responsible for any charges incurred prior to April 20th.


Notwithstanding the above, your Eligibility for Coverage is contingent upon the Contributing Employer making sufficient contributions to the IHF on your behalf and in accordance with the collective bargaining agreement and the terms of the IHF. If you work the required hours to qualify for Coverage but you fail to make sufficient contributions to meet the tests described above, you will not receive Coverage.

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Your Coverage ends on the last day of the third Eligibility month that you do not meet the quarterly Eligibility rules of the next calendar quarter.

Example: Ed receives coverage under the IHF for the period August through October. During that period if the Contributing Employer Ed owns/manages fails to make sufficient contributions on his behalf to qualify for Coverage for the period November through January, Ed will not receive Coverage for that quarter. Ed will then be eligible for COBRA coverage.

Your coverage will also end in the following events:

i. The Contributing Employer is no longer signatory to a collective bargaining agreement with the Union or a Local, your coverage will end immediately;

ii. If your Contributing Employer becomes delinquent in any of its contributions on behalf of any of its Bricklayers employees, your coverage will end immediately;

iii. If your Contributing Employer terminates IHF coverage for any of its Bricklayer employees, your coverage will end immediately;

iv. If your Contributing Employer employs no Active Participants in the Plan;

v. If this plan is terminated your coverage will end immediately.

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EMPLOYEE OF A CONTRIBUTING EMPLOYER


If you are an employee of a Contributing Employer and you do not perform work under a collective bargaining agreement between the Contributing Employer and the Union (“Non Job-Site Participants”), you and your Dependents are eligible to receive monthly Coverage under the IHF if your Contributing Employer make timely contributions to the IHF at a premium set periodically by the IHF Board of Trustees. The IHF Board of Trustees reserves the right to modify the premium rate upon written notice to the Contributing Employer.

All contributions must be reported on the monthly remittance form provided by the IHF and must be received by the IHF, including full payment, on or before the 15th day of each month to receive Coverage for the following month. Any checks received at the IHF on behalf of Non Job-Site Participants without the monthly remittance form for covered employees will be returned, which may result in a delay in Coverage.


Your eligibility for Coverage ends immediately when any of the following events occur:

i. Your Contributing Employer is delinquent in its contributions to the IHF for any of its employees.

ii. The Contributing Employer’s payment to the Fund on behalf of Non-Job Site Participants is not made by the 15th day of the month;

iii. The Contributing Employer is no longer signatory to a collective bargaining agreement with the Union or a Local.

iv. The Contributing Employer remains signatory to a collective bargaining agreement but employs no Active Participants in the Plan.

v. When the Non-Job Site Participant becomes eligible for coverage under another employment-related group health plan

vi. The Non Job-Site Participant’s employer terminates IHF coverage for any of its Bricklayer employees

vii. If this plan is terminated.

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SPECIAL NOTES FOR ALL ELIGIBILITY TYPES:

Please check with the Fund office periodically to confirm that the correct hours have been reported and credited to your account in a timely manner. Unreported hours may cause you to no longer meet the Eligibility requirements. This may cause you to receive a COBRA Continuation self-pay notice. If you are working for an employer who is delinquent, please submit proof of employment to the Fund office (in the form of paystubs) and contact your local Business Representative. This will initiate collection procedures against your employer.

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WHO ARE YOUR ELIGIBLE DEPENDENTS?

Upon becoming eligible for benefits, certain of your Dependent(s) may also become eligible for benefits from this Plan. To be eligible for coverage under the Plan, an Eligible Dependent must reside within the United States. “”Eligible Dependent(s)” (sometimes referred to also as “Dependents”) are:

• Your “Spouse” to whom you is legally married. The Plan does not cover your spouse after your divorce or legal separation, except for purposes of COBRA continuation coverage.. See below for notification requirements upon change of marital status.

• Your “Dependent Children” from enrollment until the end of the calendar month

in which such children attain age 26. Your Dependent Children will qualify as Eligible Dependent(s) even if they are eligible for other employment-based coverage other than the plan of a parent or step-parent. o “Dependent Children” are your biological, legally adopted children (including

children placed with you for adoption); legally placed foster children, children of your current Spouse, or any children for whom you are legally obligated to provide medical coverage under a qualified medical child support order (QMCSO),. Your Grandchildren are not covered by the Plan unless that child is placed for adoption with you or has been adopted by you.

o Your “Disabled Dependent Child” is your Dependent Child over age 26 who is incapable of self-support due to a physical or mental disability. The child must remain continuously disabled, unmarried and incapable of self-support, must have been receiving benefits from the IHF when they turned age 26 and must either (a) be permanently and totally disabled, live with you for more than one- half of the year and not provide more than one-half of his or her own support or (b) depend on you for more than one-half of his or her financial support. You must submit proof of their disability to the Fund Office in the form of a certification of disability benefit (SSDI) award from the Social Security Administration and provide periodic verification of disability upon request of the IHF. If your Dependent Child’s disability subsequently ceases or he or she becomes capable of self-sustaining employment or is no longer Dependent chiefly on you or your Spouse for support or maintenance, their coverage will end immediately. Additionally, your Dependent Child’s coverage ends when your coverage ends. If you again become eligible for

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coverage, your Disabled Dependent Child shall automatically become reenrolled.

WHEN DOES THEIR COVERAGE START?

Your Eligible Dependents may become covered under this Plan at the time your coverage begins only upon submission of a completed written enrollment form which may be obtained from the Fund Office (and any required certificates for spousal or Dependent Children coverage). A person who fails to submit a completed written enrollment form (and any required certificates for Dependent coverage) has no right to any coverage or services under this Plan.

If your Eligible Defendant has a completed written enrollment form on file with the Plan, he or she is eligible to participate in the Plan on the date your coverage begins. If you begin coverage and your Eligible Dependent does not have a completed written enrollment form on file with the Plan, his or her coverage will start the first day of the following calendar month, or as otherwise provide for in the “How to Change your Coverage” section below.

WHEN DOES THEIR COVERAGE END?

Coverage for your Dependents ends the earlier of when your coverage ends, when they no longer meet the definition of a Dependent as described above, or as otherwise noted herein.

Note: Your Dependents may not enroll in the Plan unless you are also enrolled. Additionally if you and your Spouse separately meet the Eligibility requirements to be covered under the IHF, you may each be enrolled as a Participant or be covered as a Dependent of the other person, but not both. In addition, if you and your Spouse are both covered under the IHF, only one parent may enroll your child as a Dependent.

CHANGE IN COVERAGE

Initially, when you become eligible for benefits with the IHF you must complete an enrollment form indicating the type of coverage, i.e., Single, Family or Parent and Child(ren) and listing the Name, Date of Birth and Social Security Number of each Dependent. Circumstances may change during your Coverage Period whereby you need to change your account information. The following procedures must be completed regarding a change to your coverage for the following events:

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ADDING ELIGIBLE DEPENDENT BY VIRTUE OF BIRTH, ADOPTION OR PLACEMENT:

You may add a Dependent Child or your Spouse upon the Birth, Adoption of Placement of a Dependent Child. You must complete a change form and submit a birth certificate, adoption or placement certificate or other proof of his or her status as your Dependent Child, to be determined at the discretion of the Trustees, within 31 days after their birth, adoption or placement. If the form is submitted within the 31 day time period, coverage for your Dependent Child and Spouse (if you are also adding your Spouse) will be effective on the date the child became an Eligible Dependent. If the change form is received later than the 31st day, coverage will begin the later of 15 days after receipt of the form or the first day of the next Coverage Period month.

A Dependent Child is “placed for adoption” with you on the date you first become legally obligated to provide full or partial support of the Dependent Child whom you plan to adopt. A Dependent Child who is placed for adoption with you within 31 days after the Dependent Child was born will be covered from birth if you comply with the Plan’s requirements for obtaining coverage for a newborn Dependent Child. However, if a Dependent Child is placed for adoption with you, and if the adoption does not become final, coverage of that Child will terminate as of the date you no longer have a legal obligation to support that Child.

ADD ELIGIBLE DEPENDENTS BY VIRTUE OF MARRIAGE:

If you become an Eligible Dependent by virtue of marriage (Spouse or Stepchild), you may be added as an Eligible Dependent by completing a change form and submitting a marriage certificate within 60 days after the date of marriage. If you submit it within the time period, Coverage will be retroactively effective the first day of the current Coverage Period. If you submit the form after the 60 day period, coverage for your spouse or

Effect of Change in Marital Status on Eligibility If there is a change in your marital status, such as a divorce or legal separation, you are responsible for notifying the Fund Office immediately. Any benefits paid by the Plan on behalf of a divorced Spouse or stepchild after the date of divorce is the responsibility of the Participant or the former spouse. You and your former spouse will be jointly and severally liable for any amounts paid on behalf of your former spouse or stepchild following a divorce. In addition to having to repay the Plan the costs of any benefits provided on behalf of such former spouse or stepchild, the Trustees have sole discretion to terminate your eligibility and the eligibility of your Eligible Dependent(s) if you fail to notify the Fund Office of your divorce.

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stepchild will begin on first day of the next Coverage Period.

INFORMATION YOU OR YOUR DEPENDENTS MUST FURNISH TO THE PLAN

You or your Covered Dependents are responsible for furnishing any information you or they may have that may affect Eligibility for coverage under the Plan. This includes, but is not limited to:

1. Change of name.

2. Change of address.

3. Birth, adoption, marriage, divorce, legal separation, or death of you or any covered Spouse or Dependent Child.

4. Any information regarding the status of a Dependent Child, including, but not limited to:

• The Dependent Child reaching the Plan’s limiting age;

• The existence (or cessation) of any physical or mental Handicap.

5. Medicare enrollment or disenrollment.

6. The existence of other medical coverage.

Notices of the foregoing information should be sent, in writing, to the Fund Office at the address shown above.

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SPECIAL ENROLLMENT

If you are declining enrollment for yourself or your Dependent(s) (including your Spouse) because you currently participate in other health insurance or group health plan coverage, you may be able to enroll yourself and your Dependent(s) in this

VERY IMPORTANT INFORMATION: If you or a Dependent fail to submit any requested information or proof, make a false statement, or furnish fraudulent or incorrect information, your or your Dependent’s benefits under the Plan (and participation in the Plan – even if you or your Dependent would otherwise meet the Eligibility requirements) may be denied, suspended or discontinued at any time and for any length of time (including permanently) by duly authorized representatives of the Fund office, the Trustees or any of their designees in their sole and absolute discretion. In addition, if you or your Dependent commits fraud or makes an intentional misrepresentation or otherwise provides false information to the Plan (including, for example, in an application for coverage under the Plan, in connection with a benefit claim or appeal, or in response to any request for information by the Executive Director or Fund Office staff), the Trustees may terminate your coverage retroactively upon 30 days notice. Failure to notify the Plan of life events (such as divorce) that render a person ineligible for coverage, or providing false information or making false statements in order to obtain coverage for an ineligible Dependent are examples of actions that constitute fraud under the Plan. Coverage may also be terminated retroactively and without notice (unless required by law) if the Trustees determine that a Spouse or Dependent Child is ineligible for coverage under the Plan and such retroactive termination would not be considered a rescission or is a permissible rescission under the Affordable Care Act. If the Fund makes payment for benefits that are in excess of expenses actually incurred or in excess of allowable amounts, due to error (including for example, a clerical error) or fraud or in Eligibility for coverage or for any other reason (including for example, your failure to notify the Fund office regarding a change in family status), the Fund reserves the right to recover such overpayment (plus processing fees, administrative charges, interest, any attorneys’ fees and all other costs incurred by the Fund to collect such amounts) through whatever means are necessary, including, without limitation, deduction of the amounts from future claims and/or by legal action.

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Plan if you or your Dependent(s) lose eligibility from that other coverage because the coverage was provided under COBRA, and the entire COBRA coverage period was exhausted; because the coverage was non-COBRA coverage and the coverage terminated because of loss of eligibility for coverage; or because the coverage was non-COBRA coverage and employer contributions for the coverage were terminated. However, you must request enrollment within 30 days after termination of your or your Dependent’s other coverage (or after the employer stops contributing towards the other coverage). If you submit your request for special enrollment and meet the circumstances described above, your coverage will begin on the first day of the first calendar month beginning after the date the plan or issuer receives the request for special enrollment

You and your Dependent(s) may also enroll in this Plan if you (or your Dependent(s)) have coverage through Medicaid or a State Children’s Health Insurance Program (SCHIP) and you (or your Dependent(s)) lose eligibility for that coverage. You must request enrollment within 60 days after the Medicaid or SCHIP coverage ends. If you submit your request for special enrollment and meet the circumstances described above, your coverage will begin on the first day of the first calendar month beginning after the date the plan or issuer receives the request for special enrollment

You and your Dependent(s) may also enroll in this Plan if you (or your Dependent(s)) become eligible for a premium assistance program through Medicaid or SCHIP. You must request enrollment within 60 days after you (or your Dependent(s)) are determined to be eligible for assistance. If you submit your request for special enrollment and meet the circumstances described above, your coverage will begin on the first day of the first calendar month beginning after the date the plan or issuer receives the request for special enrollment

Please note that your special enrollment rights only apply if you have other met the substantive eligibility provisions above (and are eligible during the Coverage Period in which the triggering event took place). To request special enrollment or obtain more information, contact the Fund Office.

QUALIFIED MEDICAL CHILD SUPPORT ORDERS (“QMCSOS”).

The Plan is required to recognize Qualified Medical Child Support Orders (“QMCSOs”). QMCSOs require health plans to recognize State court orders, which the Plan determines to be a QMCSO as defined by federal law. A QMCSO requires the Plan to provide coverage to a Participant’s child even if the Participant does not have custody of the child.

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A QMCSO is a judgment, decree or order issued by a court of competent jurisdiction or by a state administrative body that has the force of a court judgment, decree or order. To be a QMCSO, a judgment, decree or order must require the child to be enrolled in the Plan as a form of child support or health benefit coverage pursuant to state domestic relations law or enforce a state law relating to medical child support. The order must include:

• the name and last known mailing address (if any) of the Participant and the name(s) and mailing address of each child covered by the order,

• a reasonable description of the type of coverage to be provided by the Plan,

• the period of coverage to which the order pertains, and

• the name of the Plan.

Such an order is not qualified if it requires the Plan to provide any type or form of benefit not otherwise provided under the Plan except to the extent necessary to comply with a state law relating to medical child support orders. Upon receipt of an order, the Plan will notify, in writing, the Participant and each child covered by the order of the Plan’s procedures for determining whether the order is qualified. The Plan will also notify the Participant and each affected child in writing of its determination as to whether an order is a Qualified Medical Child Support Order. Participants and their Dependent(s) can obtain a copy of the procedures, without charge, from the Fund Office.

CONTINUING ELIGIBILITY DURING FAMILY AND MEDICAL LEAVE

If you are employed by an Employer who is covered under the Family and Medical Leave Act of 1993 (the “FMLA”), you may be entitled to take up to 12 weeks of unpaid job- protected leave each year due to your illness, or to care for your seriously ill child, Spouse or parent; the birth of your child or placement of a child with you in the case of adoption or foster care or a “qualifying exigency” as defined in applicable regulations arising out of the fact that a covered family member is on active duty or called to active duty status in the National Guard or Reserves in support of a federal contingency operation. In addition, if you are a qualifying family member or next to kin of a covered military service member, you may be able to take up to 26 work weeks of leave in a single 12 month period to care for the covered service member with a serious illness or injury incurred in the line of duty.

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In order to be eligible for FMLA leave, you must have been employed at least 12 months by an Employer and provided at least 1,250 hours of service to the Employer. If your Employer employs fewer than 50 employees, you will not be eligible for FMLA leave unless the Employer’s total number of employees within a 75 mile radius equals or is greater than 50.

Employers covered by the FMLA are required to maintain medical coverage for Participants on FMLA leave whenever such coverage was provided before the leave was taken and on the same terms as if the employee had continued to work. This means that an Employer is required to continue making contributions to the Plan on your behalf while you are on FMLA leave. Please contact the Fund Office if you are planning to take FMLA leave so that the Plan is aware of the Employer’s responsibility to report and contribute during the FMLA leave. If you do not return to work after your FMLA leave ends, you may be required to repay your Employer the amount that it contributed to the Plan during your FMLA leave. However, if your failure to return to work is due to the serious health condition of you or a family member or other circumstances beyond your control, the repayment rule will not apply.

Any dispute between you and your Employer concerning the application of FMLA to your leave or the obligation of the Employer must be resolved between you and your Employer. If you have questions about the FMLA, you should contact your Employer or the nearest office of Wage and Hours Division, listed in most telephone directories under U.S. Government, Department of Labor and Employment Standards Administration.

CONTINUED ELIGIBILITY DURING QUALIFIED MILITARY SERVICE

Generally, if you terminate employment with a Contributing Employer, your coverage under the Plan continues through the end of the quarter in which you’ve achieved eligibility as set forth above. (Defined previously as your “Coverage Period”). However, if you enter the “Uniformed Services” as defined in the Uniformed Services Employment and Reemployment Rights Act (“USERRA”) and you otherwise meet the requirements of USERRA (see below), your eligibility will be extended for the period described below, both upon your departure from and return to Covered Employment.

When you leave: If you leave Covered Employment to enter the Uniformed Services as defined in USERRA, your eligibility and that of your Dependent(s) will continue through the end of the Coverage Period. You may then self-pay for continuation coverage for the lesser of 24 months or the remaining period of qualified military service under the procedures set forth below for COBRA Continuation Coverage.

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When you return: If you return to Covered Employment and you otherwise meet the requirements of USERRA (see below), your coverage will be reinstated on the day you return to work in Covered Employment. Your eligibility (and that of your Eligible Dependent(s)) will continue through the end of the Eligibility Period as it existed on the date that you departed Covered Employment to enter the Uniformed Services as if the period of qualified military service had not occurred. At the end of that period of extended eligibility, if you have not yet worked sufficient hours in Covered Employment to again meet the requirements for Continuing Eligibility, you may then self-pay for continuation coverage under the procedures set forth below for COBRA Continuation Coverage until you again meet the requirements for Continuing Eligibility or until the maximum period of COBRA Continuation Coverage is reached, whichever first occurs.

Your coverage under this Plan will be secondary to any coverage provided as a result of your service in the military. The Plan coverage will be primary for your Eligible Dependent(s).

Requirements of USERRA: The requirements of USERRA that you must meet to be covered by this section include:

• You (or an appropriate military officer) must give advance written or verbal notice to your Employer that you are entering uniformed service (unless such advance notice is impossible, unreasonable or precluded by military necessity);

• You must not be dishonorably discharged upon the conclusion of the uniformed service;

• The cumulative length of all of your absences with the Employer due to uniformed service must generally be no longer than five (5) years;

• Upon leaving the uniformed service, you must report back to your pre-service Employer for reemployment and/or report to the Local Union hiring hall for a referral to Covered Employment within the following specified periods of time:

o Uniformed service of less than 31 days or for any length for a fitness for duty examination – you must generally report for work on the first regularly- scheduled workday at least 8 hours after you arrive home from service.

o Uniformed service of more than 30 days, but less than 181 days – you must generally report for work within 14 days after completion of service.

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o Uniformed service of more than 180 days – you must report for work within 90 days after completion of the service.

COBRA CONTINUATION COVERAGE

If you or your Eligible Dependents lose coverage under the Plan, you or your Eligible Dependents may have the right to extend coverage under the Consolidated Budget Reconciliation Act of 1985 (COBRA). Much of the language in this section comes from the federal law that governs continuation coverage. You should call your Plan Administrator if you have questions about your right to continue coverage.

You are responsible for meeting the notice requirements and paying the full cost of this coverage in order to maintain coverage. The COBRA rates are established by the Trustees and can change from time to time. You will have the choice to elect Core Coverage, which includes Medical, Prescription Drug, Life and AD&D coverage only, or Core Coverage plus Dental and Vision.

WHEN IS COBRA COVERAGE AVAILABLE?

In certain circumstances in which coverage for benefits from this Plan would otherwise end due to certain events called “Qualifying Events,” you or your Eligible Dependent can pay to continue benefits for a limited period. This extended coverage is called COBRA Continuation Coverage and is available to both you and your Eligible Dependent(s) who were covered by this Plan on the day before the Qualifying Event -- for example, the termination of employment – that causes the loss of Plan coverage.

WHAT IS A QUALIFYING EVENT

QUALIFYING EVENTS FOR THE COVERED PARTICIPANT.

If you are a Participant, you will be entitled to elect COBRA Continuation Coverage if you lose your coverage under the Plan because of one of the following qualifying events:

• You fail to meet the required amount of hours to attain eligibility for the following Coverage Period; or

• Your employment ends for any reason other than your gross misconduct.

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QUALIFYING EVENTS FOR THE COVERED SPOUSE.

If you are the spouse of a Participant, you will be entitled to elect COBRA Continuation Coverage if you lose your coverage under the Plan because of any of the following qualifying events:

• Your Participant spouse dies; • You lose coverage because your Participant spouse’s hours of employment are

reduced; • Your Participant spouse’s employment ends for any reason other than his or her

gross misconduct; or • You become divorced or legally separated from your Participant spouse.

QUALIFYING EVENTS FOR A DEPENDENT CHILD

If you are a Dependent Child, you will be entitled to elect COBRA Continuation Coverage if you lose coverage because of any of the following qualifying events:

• Your Participating parent dies; • You lose coverage because your Participant parent’s hours of employment are

reduced; • Your Participant parent’s employment ends for any reason other than his or her

gross misconduct; or • You no longer meet the definition of “Dependent Child’

Note that there is no Qualifying Event where a Contributing Employer or Local terminates a Collective Bargaining Agreement or Participation Agreement or otherwise ceases to make contributions to the Plan. Additionally there is no Qualifying Event where you have worked sufficient hours to meet the eligibility requirement but your Contributing Employer failed to make its contributions to the Plan on your behalf.

HOW LONG DOES MY COVERAGE LAST

The following chart summarizes your or your Eligible Dependents’ COBRA Continuation Coverage periods for each event (subject to certain notice requirements), which is discussed further below:

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If Coverage Ends Because of the Following Qualifying Events:

You May Elect COBRA:

For Yourself For Your Spouse

For Your Children

Your work hours are reduced 18 months 18 months 18 months

Your employment terminates for any reason (other than gross misconduct)

18 months 18 months 18 months

You or your family member become disabled, as determined by the Social Security Administration, within the first 60 days of Continuation Coverage

29 months 29 months 29 months

You die N/A 36 months 36 months

You divorce (or legally separate) N/A 36 months 36

months

Your child is no longer an eligible family member (e.g., reaches the maximum age limit)

N/A N/A 36 months

You become entitled to Medicare

N/A See below See below

Note that if you have multiple Qualifying Events that overlap (e.g. you are terminated, triggering an 18-month coverage period and then divorce within the 18 months, triggering a 36 coverage period), your Spouse and Dependents may extend their continuation coverage to 36 months from the date of the initial Qualifying Event (e.g. termination).

Note that you will not experience a Qualifying Event solely due to your Employer terminating its participation in the Plan and/or its collective bargaining agreement with the Union or your employer’s failure to pay sufficient contributions on your behalf.

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You may choose COBRA Continuation Coverage for yourself, your Spouse and/or your Dependent Child(ren), assuming your Spouse and/or Dependent Children were covered under the Plan at the time of your Qualifying Event. Coverage, because of the termination of your employment (for reasons other than gross misconduct) or because you do not have sufficient hours of Covered Employment for which contributions are received by the Plan to continue eligibility, can be continued for up to 18 months from the date of the Qualifying Event

Under certain circumstances, coverage may be extended for a total of 29 months following termination of your employment or a reduction in hours of employment at an additional premium. To qualify for the additional 11 months of coverage, you or your Eligible Dependent must have become eligible for Social Security disability benefits before the 60th day of COBRA Continuation Coverage and must last at least until the end of the 18-month period of coverage for this extension to apply. You must notify the Plan of the eligibility for disability in accordance with the notification provisions below. Failure to do so within the time period required may result in a denial of your extension. You or your Eligible Dependent must also agree to pay any increase in the required premium for the additional 11 months over the original 18 months. The extended COBRA Continuation Coverage applies to the disabled individual and all covered non-disabled family members.

If COBRA Continuation Coverage is extended because of a disability and the disability ends, you must notify the Plan within 30 days of a final determination by the Social Security Administration that the disabled individual is no longer disabled, or, if later, within 30 days of the date you are informed of this notice requirement and procedure. COBRA Continuation Coverage ends if Medicare Coverage begins before the 29-month period expires or if the disabled person recovers from the disability and have already received 18 months of COBRA Continuation Coverage.

If you choose not to purchase COBRA Continuation Coverage, your Spouse and/or Dependent child(ren) can separately purchase COBRA Continuation Coverage for themselves by making the election and the required monthly premium payments. The COBRA Continuation Coverage for Dependent(s) can be continued for up to 18 months (29 months if there is a disabled person electing coverage) if coverage would otherwise end because of your termination of Covered Employment or a reduction in your hours of Covered Employment.

If your family experiences another Qualifying Event while receiving COBRA Continuation Coverage, your Spouse and Dependent Child(ren) may receive additional months of COBRA Continuation Coverage, up to a maximum of 36 months. This extension is available to your Spouse and Dependent Child(ren) if you die or become entitled to Medicare (Part A, Part B or both), or if you and your Spouse get divorced or legally separated or if your Dependent Child stops being eligible under the Plan as a

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Dependent Child, but ONLY if the event would have caused the Spouse or Dependent Child to lose coverage under the Plan if the first Qualifying Event had not occurred.

COBRA CONTINUATION COVERAGE AND MEDICARE

If you are age 65 or over OR are disabled and covered by Medicare before you elect COBRA continuation coverage, and subsequently elect COBRA continuation coverage from this Plan, Medicare will pay first and your COBRA continuation coverage under this Plan will pay second.

The following chart describes your coverage periods:

If Dependent Coverage Ends When: You May Elect

COBRA Dependent Coverage For Up

To:

You become entitled to Medicare and don't experience any additional qualifying events 18 months

You become entitled to Medicare, after which you experience a second qualifying event* before the initial 18-month period expires

36 months

You experience a qualifying event*, after which you become entitled to Medicare before the initial 18-month period expires; and, if absent this initial qualifying event, your Medicare entitlement would have resulted in loss of Dependent coverage under the Plan

36 months

* Your work hours are reduced or your employment is terminated for reasons other than gross misconduct.

If you have End-Stage Renal Disease (ESRD) and are covered by Medicare (as a result of ESRD) and are, or become covered by COBRA continuation coverage from this Plan, this Plan will pay first during the first 30 months of eligibility/entitlement to Medicare and Medicare will pay second. After the 31st month after the start of Medicare coverage, if you are, or become covered under COBRA Continuation Coverage, Medicare pays first and your COBRA continuation coverage under this Plan pays second. Note that this provision does not extend the maximum periods of COBRA Continuation Coverage and that once you exhaust the maximum COBRA

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period, your coverage under this Plan will end. See the Coordination of Benefits section for more detail on how this Plan coordinates with Medicare.

NOTIFYING THE PLAN

TERMINATION OR LOSS OF HOURS

Your Contributing Employer or Local Union must notify the Plan if you have experienced a Qualifying Event by virtue of your employment ending within 30 days of the effective date of your employment ending. If your Employer fails to notify the Plan of your termination, the plan is not obligated to notify you of your eligibility for continued coverage. To ensure COBRA Continuation Coverage in the event of termination, please notify the Plan as soon as you are informed of your termination.

The Plan will determine whether you have a Qualifying Event due to a failure to meet the required amount of hours to attain eligibility for the following Coverage Period.

You will be notified by mail if you become eligible for COBRA coverage as a result of these events. The notification will give you instructions for electing COBRA coverage, and advise you of the monthly cost. The IHF Board of Trustees sets your monthly cost. You will have up to 60 days from the date you receive notification or 60 days from the date your coverage ends to elect COBRA coverage, whichever is later. You will then have an additional 45 days to pay the cost of your COBRA coverage, retroactive to the date your Plan coverage ended. If you fail to pay either the initial cost of your COBRA coverage or any ongoing cost of COBRA coverage, you will lose your eligibility for COBRA Continuation Coverage.

OTHER QUALIFYING EVENTS

DIVORCE, LEGAL SEPARATION OR LOSS OF DEPENDENT STATUS

If your Dependents lose coverage due to divorce, legal separation, or loss of Dependent status, you or your Dependents must notify the Plan Administrator within 60 days of the latest of:

• the date of the divorce, legal separation or an enrolled Dependent's loss of Eligibility as a Dependent;

• the date your enrolled Dependent would lose coverage under the Plan; or

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If you or your Dependents fail to notify the Plan Administrator of these events within the 60 day period, the Plan is not obligated to provide continued coverage to the affected Beneficiary.

DISABILITY EXTENSION

You or your Dependents must also notify the Plan Administrator when a qualifying event occurs that will extend continuation coverage such as eligibility for Social Security Disability. You must provide the Plan with notice of the Social Security Administration’s determination within 60 days after the date of that determination, and before the end of your initial 18-month continuation period. The notice requirements will be satisfied by providing written notice to the Plan Administrator. The contents of the notice must be such that the Plan Administrator is able to determine the covered Participant and qualified beneficiary(ies), the qualifying event or disability, and the date on which the qualifying event occurred. If you or your Dependents fail to notify the Plan of these events within the 60 day period, the Plan Administrator is not obligated to provide continued coverage to the affected Beneficiary.

If COBRA Continuation Coverage is extended because of a disability and the disability ends, you must notify the Plan within 30 days of a final determination by the Social Security Administration that the disabled individual is no longer disabled, or, if later, within 30 days of the date you are informed of this notice requirement and procedure.

MEDICARE ELIGIBLITY

If you are age 65 or over OR are disabled and covered by Medicare before you elect COBRA continuation coverage, and subsequently elect COBRA continuation coverage from this Plan, Medicare will pay first and your COBRA continuation coverage under this Plan will pay second.

If you are receiving COBRA Continuation Coverage and become eligible for Medicare coverage, you must notify the Plan within 60 days of your eligibility for Medicare coverage. If you fail to do so, the Plan may retroactively cancel your benefits under the Plan to the 60th day after you are entitled to Medicare coverage.

ELECTION OF COBRA CONTINUATION COVERAGE

Receipt of COBRA Continuation Coverage is NOT automatic; you must actively elect COBRA Continuation Coverage and notify the Plan in accordance with its notice procedures.

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You and each of your Dependent(s) have an independent right to elect COBRA Continuation Coverage. To elect COBRA Continuation Coverage, you and/or your Spouse and/or Dependent Child must complete an election form provided by the Fund Office and submit it to the Fund Office within 60 days after the later of (i) the date coverage would otherwise end or (ii) the date the Participant, Spouse or Dependent child receives the notice of the right to elect COBRA Continuation Coverage.

TERMINATION OF COBRA CONTINUATION COVERAGE

COBRA Continuation Coverage may terminate earlier than the maximum period (18, 29 or 36 months) if:

• All health benefits provided by the Plan terminate; • An Participant, Spouse or Dependent Child who has elected COBRA

Continuation Coverage does not make the required payments to the Plan on time;

• An Participant becomes covered under Medicare after the date of the Qualifying Event; or

• An Participant, Spouse or Dependent Child becomes covered by another group health plan after the date of the Qualifying Event, unless that replacement plan limits coverage due to pre-existing conditions and the pre-existing condition limitation actually applies to the Participant, Spouse or Dependent after coverage under this Plan is taken into account.

WHERE TO SEND NOTICES AND INFORMATION

Notices and information concerning COBRA Continuation Coverage or questions concerning COBRA Continuation Coverage should be sent to: Bricklayers and Allied Craftworkers International Health Fund 620 F Street, NW Washington, DC 20004

KEEP YOUR PLAN INFORMED OF ADDRESS CHANGES

You must keep the Plan informed of any changes in the addresses of you or your family members. Keep a copy for your records of any notices you send to the Fund Office.

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COMPLIANCE WITH OTHER LAWS

The Plan will comply to the extent applicable with the requirements of all applicable state and federal laws, including but not limited to USERRA, COBRA, HIPAA, NMHPA, WHCRA, FMLA, MHPA, MHPAEA, HITECH, Michelle's Law, GINA, and PPACA.

GENERAL TYPES OF BENEFITS OFFERED BY THE PLAN

Please note that you may not be eligible for all of these benefits. Please refer to your Schedule of Benefits below or contact the IHF at (888) 880-8222 for assistance.

MEDICAL COVERAGE:

The IHF offers different types of comprehensive medical insurance plans, each administered through United HealthCare. The collective bargaining agreement (or other agreement) between the union and your employer dictates which plan applies to you. A Schedule of Benefits detailing your coverage as well as costs and other important are set forth herein under the section entitled Medical Coverage. Please refer to this section for any specific questions regarding your Medical coverage.

PRESCRIPTION DRUG:

The IHF offers a prescription drug program through a prescription benefits manager (“PBM” or “Savrx”) to complement your medical coverage under the Plan. If you are eligible to receive medical benefits, you are eligible to participate in the prescription drug program. You do not need a separate prescription drug enrollment.

Please refer to your Schedule of Benefits under the section entitled Prescription Drug Coverage for specifics regarding your Prescription Drug Benefit.

DENTAL BENEFITS:

The IHF offers a dental benefit, currently through Delta Dental, to complement your medical coverage under the Plan. If you are eligible to receive medical benefits, you are eligible to participate in the dental benefit program (if you are a COBRA participant, you must have elected Dental Benefits to participate). You do not need a separate dental enrollment form.

Under the Plan, you have in or out of network Dental benefits. By utilizing an in network provider, you will not be subject to balance billing as the in network providers have agreed to accept Delta Dental’s Usual and Customary fee schedule. Please refer to

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your Schedule of Benefits under the section entitled Dental Coverage for specifics regarding your Dental Benefit.

VISION BENEFITS:

The IHF offers a Vision benefit, currently through VSP, to complement your medical coverage under the Plan. If you are eligible to receive medical benefits, you are eligible to participate in the vision benefit program (if you are a COBRA participant, you must have elected Vision Benefits to participate). You do not need a separate vision enrollment form.

Please refer to your Schedule of Benefits under the section entitle Vision Coverage for specifics regarding your Vision Benefit.

HEALTH REIMBURSEMENT ACCOUNT:

The IHF offers eligible participants a fully integrated Health Reimbursement Account (“HRA”) from which the Participant or their Eligible Dependents may pay Qualified Medical Expenses, as defined in Section 213(d) of the Internal Revenue Code and IRS Publication Section 502, incurred under the IHF. Please see the HRA section of this SPD for details of your benefit.

LIFE INSURANCE

If you die from any cause while you are eligible, the amount of your life insurance benefit will be paid to your beneficiary. The amount of life insurance benefits are as follows:

$10,000 Life for an Active Participant

$2,000 for a Retired Participant

$5,000 for a Grandfathered Retiree Participant

Additional information regarding the Life Insurance Benefit may be found in the Life Insurance section in this SPD.

Total and Permanent Disability

If you become totally and permanently disabled while insured and before age sixty, your Life Insurance will remain in force as long as you remain disabled, subject to continued proof of disability. Please contact the International Health Fund Office if you become permanently and totally disabled.

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Conversion

If your life insurance coverage ends for any of the reasons described herein, you can convert to an individual policy. You must apply for the individual coverage within 15 days after you are notified.

The amount of your individual policy cannot be more than the amount of your group coverage. You can choose any type of individual policy except term insurance. The premium will be based on your age and class of risk at the time you convert.

If you die within the 31-day conversion period, your beneficiary will receive the full amount of your coverage.Your Beneficiary

You may name anyone you wish as you beneficiary. You may change your beneficiary at any time by contacting the Fund Office and completing the correct form.

ACCIDENTAL DEATH AND DISMEMBERMENT BENEFIT

If you die or lose one or more limbs or eyes because of an accidental injury, you or your beneficiary will receive a benefit from this coverage. Your AD&D benefit is worth $10,000. For additional information please see the AD&D Benefit section of this SPD.

SHORT TERM DISABILITY BENEFITS

Based on your Local’s participation in this Plan, you may be eligible for short-term disability benefits in the event of a non-occupational injury or illness. For additional information please see the Short Term Disability Benefit section of this SPD.

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HOW THE MEDICAL PLAN WORKS

NETWORK AND NON-NETWORK BENEFITS

As a participant in this Plan, you have the freedom to choose the Physician or health care professional you prefer each time you need to receive Covered Health Services. The choices you make affect the amounts you pay, as well as the level of Benefits you receive and any benefit limitations that may apply.

You are eligible for the Network level of Benefits under this Plan when you receive Covered Health Services from Physicians and other health care professionals who have contracted with the IHF’s provider, UnitedHealthcare, to provide those services

Network Benefits apply to Covered Health Services that are provided by a Network Physician or other Network provider. Emergency Health Services are always paid as Network Benefits. For facility charges, these are Benefits for Covered Health Services that are billed by a Network facility and provided under the direction of either a Network or non-Network Physician or other provider. Network Benefits include Physician services provided in a Network facility by a Network or a non-Network radiologist, anesthesiologist, pathologist and Emergency room Physician. Non-network providers will be treated as In-Network if seen in an In-Network facility.

Non-Network Benefits apply to Covered Health Services that are provided by a non-Network Physician or other non-Network provider, or Covered Health Services that are provided at a non-Network facility.

If you choose to seek care outside the Network, any money you spend towards the Non-Network benefit does not apply to the In-Network deductible or Out-of-Pocket Maximum. Note that certain limits apply for Non-Network care. A limit of 30 days of inpatient hospital care per calendar year applies per individual. Also, a limit of up to 30 treatments for chemotherapy per individual per year and a limit of up to 30 treatments for renal dialysis per individual per year. Any Non-Network care in excess of these limits is not covered under the Plan.

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HEALTH SERVICES FROM NON-NETWORK PROVIDERS PAID AS NETWORK BENEFITS

In certain situations, if a specific Covered Health Services are not available from a Network provider, you may be eligible to receive Network Benefits from a non-Network provider. In these situations, your Network Physician will notify the Plan or its claims processor, and if they confirm that care is not available from a Network provider, they will work with you and your Network Physician to coordinate care through a non-Network provider.

Network Providers

UnitedHealthcare or its affiliates arrange for health care providers to participate in a Network. At your request, UnitedHealthcare will send you a directory of Network providers free of charge. Keep in mind, a provider's Network status may change.

To verify a provider's status or request a provider directory, you can call UnitedHealthcare at 1-866-405-0797or log onto www.myuhc.com.

Network providers are independent practitioners and are not employees of IHF or UnitedHealthcare.

Medical Eligible Expenses

Eligible Expenses are charges for Covered Health Services that are provided while the Plan is in effect, determined according to the definition in this SPD. For certain Covered Health Services, the Plan will not pay these expenses until you have met your Annual Deductible. The IHF has delegated to UnitedHealthcare the initial discretion and authority to decide whether a treatment or supply is a Covered Health Service and how the Eligible Expenses will be determined and otherwise covered under the Plan.

Looking for a Network Provider?

In addition to other helpful information about the IHF, www.myuhc.com, UnitedHealthcare's consumer website, contains a directory of health care professionals and facilities in UnitedHealthcare's Network. While Network status may change from time to time, www.myuhc.com has the most current source of Network information. Use www.myuhc.com to search for Physicians available in your Plan.

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Don't Forget Your ID Card

Remember to show your UnitedHealthcare/IHF ID card every time you receive health care services from a provider. If you do not show your ID card, a provider has no way of knowing that you are enrolled under the Plan. If you need a new ID card, call the IHF Benefits department at 1-888-880-8222.

Annual Medical Deductible

The Annual Deductible is the amount of Eligible Expenses you must pay each calendar year for Covered Health Services before the Plan will begin paying for these Services. The amounts you pay toward your Annual Deductible accumulate over the course of the Plan year. In certain cases the Plan will pay for Covered Health Services, such as physician visits and preventive care, prior to your exhaustion of the Annual Deductible. Please refer to your Schedule of Benefits below for details.

Amounts paid toward the Annual Deductible for Covered Health Services that are subject to a visit or day limit will also be calculated against that maximum benefit limit. As a result, the limited benefit will be reduced by the number of days or visits you used toward meeting the Annual Deductible.

COPAYMENT

A Copayment (Copay) is the amount you pay each time you receive certain Covered Health Services. The Copay is a flat dollar amount and is paid at the time of service or when billed by the provider. Copays do not count toward the Annual Deductible. If the Eligible Expense is less than the Copay, you are only responsible for paying the Eligible Expense and not the Copay.

COINSURANCE

Coinsurance is the percentage of Eligible Expenses that you are responsible for paying. Coinsurance is a fixed percentage that applies to certain Covered Health Services after you meet the Annual Deductible.

Coinsurance Example

Let's assume that you receive Plan Benefits for outpatient surgery from a Network provider. Since the Plan pays 80% after you meet the Annual Deductible, you are responsible for paying the other 20%. This 20% is your Coinsurance.

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OUT-OF-POCKET MAXIMUM

The annual Out-of-Pocket Maximum is the most you pay each calendar year for Covered Health Services. Please see your Schedule of Benefits below for your Out-of-Pocket Maximum. The plan has an Out-of-Pocket Maximum for Network services and a separate Out-of-Pocket Maximum for Non-Network services. If your eligible out-of-pocket expenses in a calendar year exceed the annual maximum, the Plan pays 100% of Eligible Expenses for Covered Health Services until the end of the calendar year.

The following table identifies what does and does not apply toward your Network Out-of-Pocket Maximums. For Non-Network services, your copays, coinsurance and payments to the Non-Network services accumulate towards the Non-Network Out-of-Pocket Maximum. However, please note that in the case of an emergency that requires use of Non-Network providers, such Non-Network services are adjudicated in accordance with the Network plan features below.

Please note that whether Network or Non-Network, any charges not covered under the plan or charges that exceed the agreed discounts or reasonable & customary charges as applicable are not counted to your Out-of-Pocket Maximum under the plan.

Plan Features requiring you to pay out-of-pocket

Applies to the Network Out-of-Pocket Maximum?

Applies to the Non-Network Out-of-Pocket Maximum?

Copays for Network Services Yes No

Copays for Non-Network Services No Yes

Payments toward the Annual Network Deductible Yes No

Payments toward the Annual Non-Network Deductible No Yes

Coinsurance Payments for Network Services Yes No

Coinsurance Payments for Non-Network Services No Yes

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Plan Features requiring you to pay out-of-pocket

Applies to the Network Out-of-Pocket Maximum?

Applies to the Non-Network Out-of-Pocket Maximum?

Charges for non-Covered Health Services No No

The amounts of any reductions in Benefits you incur by not notifying Personal Health Support

No No

Charges that exceed Eligible Expenses and/or Plan Limits No No

Non-Network Covered Expenses that you pay No Yes

PERSONAL HEALTH SUPPORT

UnitedHealthcare provides a program called Personal Health Support designed to encourage personalized, efficient care for you and your covered Dependents.

Personal Health Support Nurses center their efforts on prevention, education, and closing any gaps in your care. The goal of the program is to ensure you receive the most appropriate and cost-effective services available. A Personal Health Support Nurse is notified when you or your provider calls the number on your ID card regarding an upcoming treatment or service.

If you are living with a chronic condition or dealing with complex health care needs, UnitedHealthcare may assign to you a primary nurse, referred to as a Personal Health Support Nurse to guide you through your treatment. This assigned nurse will answer questions, explain options, identify your needs, and may refer you to specialized care programs. The Personal Health Support Nurse will provide you with their telephone number so you can call them with questions about your conditions, or your overall health and well-being.

Personal Health Support Nurses will provide a variety of different services to help you and your covered family members receive appropriate medical care. Program components are subject to change without notice. As of the publication of this SPD, the Personal Health Support program includes:

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• Admission counseling - Nurse Advocates are available to help you prepare for a successful surgical admission and recovery. Call the number on the back of your ID card for support.

• Inpatient care management - If you are hospitalized, a nurse will work with your Physician to make sure you are getting the care you need and that your Physician's treatment plan is being carried out effectively.

• Readmission Management - This program serves as a bridge between the Hospital and your home if you are at high risk of being readmitted. After leaving the Hospital, if you have a certain chronic or complex condition, you may receive a phone call from a Personal Health Support Nurse to confirm that medications, needed equipment, or follow-up services are in place. The Personal Health Support Nurse will also share important health care information, reiterate and reinforce discharge instructions, and support a safe transition home.

• Risk Management - Designed for participants with certain chronic or complex conditions, this program addresses such health care needs as access to medical specialists, medication information, and coordination of equipment and supplies. Participants may receive a phone call from a Personal Health Support Nurse to discuss and share important health care information related to the participant's specific chronic or complex condition.

If you do not receive a call from a Personal Health Support Nurse but feel you could benefit from any of these programs, please call 1-866-405-0797.

Requirements for Notifying Personal Health Support

In most cases, Network providers are responsible for notifying Personal Health Support before they provide these services to you. However, you are responsible for notifying Personal Health Support prior to receiving a service for:

• Ambulance Services - Non-Emergency • Bariatric Procedures • Clinical Trials • Dental Services - Accident Only • Rehabilitation Services - Outpatient Therapy - for Benefits after the 20th

visit • Transplants

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Notification is required within one business day of admission or on the same day of admission if reasonably possible after you are admitted to a non-Network Hospital as a result of an Emergency.

For notification timeframes see Additional coverage details. For timeframes and any reductions in Benefits if you do not notify the Mental Health/Substance Use Disorder Administrator, see Additional coverage details.

Contacting the Claims Administrator or Personal Health Support is easy. Simply call 1-866-405-0797.

Special Note Regarding Medicare

If you are enrolled in Medicare on a primary basis (Medicare pays before the Plan pays Benefits) the notification requirements do not apply to you. Since Medicare is the primary payer, the Plan will pay as secondary payer. You are not required to provide notification before receiving Covered Health Services.

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SCHEDULE OF BENEFITS - MEDICAL

The table below provides an overview of Copays that apply when you receive certain Covered Health Services, and outlines the Plan's Annual Deductible and Out-of-Pocket Maximum.

Plan Features Network Out of Network

Copays1

• Emergency Health Services $200 $200

• Physician's Office Services - Primary Physician $20 50% after you meet the

Annual Deductible

• Physician's Office Services – Specialist Physician $35 50% after you meet the

Annual Deductible

• Rehabilitation Services $20 50% after you meet the Annual Deductible

• Urgent Care Center Services $35 50% after you meet the Annual Deductible

• Virtual Visit through United Healthcare program (effective January 1, 2016)

$20 50% after you meet the Annual Deductible

Annual Deductible2

• Individual $600 $10,000

• Family (not to exceed the applicable Individual amount per Participant)

$1,200 $20,000

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Plan Features Network Out of Network

Annual Out-of-Pocket Maximum2

• Individual $5,600 $25,000

• Family (not to exceed the applicable Individual amount per Participant)

$11,200 $50,000

Lifetime Maximum Benefit3

There is no dollar limit to the amount the Plan will pay for essential Benefits during the entire period you are enrolled in this Plan.

Unlimited

Certain limits apply to out of network services. A limit

of 30 days for inpatient hospital care per individual covered per calendar year applies. A limit of up to 30

treatments for chemotherapy applies per

individual per calendar year and a limit of 30 treatments for renal dialysis applies per

individual per calendar year. Any care in excess

of these limits is not covered under the Plan

1In addition to these Copays, you may be responsible for meeting the Annual Deductible for the Covered Health Services described in the chart on the following pages.

2Copays apply toward the Annual Deductible and Out-of-Pocket Maximum. The Annual Deductible applies toward the Out-of-Pocket Maximum for any Covered Health Services.

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3Generally the following are considered to be essential benefits under the Patient Protection and Affordable Care Act: Ambulatory patient services; emergency services, hospitalization; maternity and newborn care, mental health and substance use disorder services (including behavioral health treatment); prescription drugs; rehabilitative and habilitative services and devices; laboratory services; preventive and wellness services and chronic disease management; and pediatric services, including oral and vision care.

This table provides an overview of the Plan’s coverage levels.

Covered Health Services1 Percentage of Eligible Expenses Payable by the Plan:

Network Out of Network

Acupuncture Services

See Additional Coverage Details, for limits.

100% after you pay a $20 Copay 50% after you meet the Annual Deductible

Ambulance Services - Emergency Only Ground and/or Air Transportation

80% after you meet the Annual Deductible

Ground and/or Air Transportation


Ambulance Services - Non-Emergency Ground and/or Air Transportation


Ground and/or Air Transportation


Bariatric Procedures After you pay $5,000 per surgical procedure, the Plan pays



• Physician's Office Services (Copay is per visit)


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Network Out of Network • Physician Fees for

Surgical and Medical Services



• Hospital - Inpatient Stay

80% after you pay a $250 copay and meet the Annual Deductible


• Outpatient Surgery 80% after you pay a $250 copay and meet the Annual Deductible


• Outpatient Diagnostic Services



• Outpatient Diagnostic/Therapeutic Services – CT Scans, PET Scans, MRI and Nuclear Medicine



• Outpatient Therapeutic Treatments



Cancer Resource Services (CRS)2

• Hospital Inpatient Stay 80% after you pay a $250 copay

and meet the Annual Deductible 50% after you meet the

Annual Deductible

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Clinical Trials - Routine Patient Care Costs

Depending upon the Covered Health Service, Benefit limits are the same as those stated under the specific Benefit category in this section.

Depending upon where the Covered Health Service is

provided, Benefits for Clinical Trials will be the same as those

stated under each Covered Health Service category in this

section.

Depending upon where the Covered Health Service is provided, Benefits for Clinical

Trials will be the same as those stated under each Covered Health Service category in this section.

Dental Services - Accident Only 100% after you pay a $35 Copay 50% after you meet the

Annual Deductible

Diabetes Services

• Diabetes Self-Management and Training/ Diabetic Eye Examinations/Foot Care


provided, Benefits for diabetes self-management and training/diabetic eye

examinations/foot care will be paid the same as those stated

under each Covered Health Service category in this section.

Depending upon where the Covered Health Service is provided,

Benefits for diabetes self-management and

training/diabetic eye examinations/foot care

will be paid the same as those stated under each Covered Health Service category in this section.

Diabetes Self-Management Items

• diabetes equipment

• diabetes supplies

Benefits for diabetes equipment will be the same as those stated

under Durable Medical Equipment in this section.

Benefits for diabetes equipment will be the same as those stated

under Durable Medical Equipment in this

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Network Out of Network section.

Durable Medical Equipment (DME) 80% after you meet the Annual

Deductible 50% after you meet the

Annual Deductible

Emergency Health Services - Outpatient (Copay is per visit) Emergency services received at a non-Network Hospital are covered at the Network level.

100% after you pay a $200 Copay (waived if admitted)

100% after you pay a $200 Copay (waived if

admitted)

If you are admitted as an inpatient to a Hospital directly from the Emergency room, you will not have to pay this Copay. The Benefits for an Inpatient Stay in a Hospital will apply instead.

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Eye Examinations (Copay is per visit)



• Specialist Physician's Office Services (Copay is per visit)


Hearing Aids See Additional coverage details, for limits.



Home Health Care Benefits for Home Health Agency services include private duty nursing. See Additional coverage details, for limits.



Hospice Care 80% after you meet the Annual Deductible


Hospital - Inpatient Stay See Additional coverage details, for limits.

80%90% after you pay a $250 copay and meet the Annual

Deductible


Injections received in a Physician’s Office



Kidney Resource Services (KRS)

(These Benefits are for Covered Health Services provided through KRS only)



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Maternity Services Benefits will be the same as those stated under each Covered

Health Service category in this section.


Mental Health Services





100% after you pay a $35 Copay 50% after you meet the

Annual Deductible

Neonatal Resource Services (NRS) (These Benefits are for Covered Health Services provided through NRS only)



Neurobiological Disorders - Autism Spectrum Disorders Services




• Physician's Office Services


Nutritional Counseling 100% after you pay a $35 Copay 50% after you meet the

Annual Deductible

Ostomy Supplies 80% after you meet the Annual Deductible


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Outpatient Surgery, Diagnostic and Therapeutic Services

• Outpatient Surgery 80% after you pay a $250 copay and meet the Annual Deductible


• Outpatient Diagnostic Services 80% after you meet the Annual


Annual Deductible

• Preventive Lab and radiology/X-ray

100% 50% after you meet the Annual Deductible

• Preventive mammography testing

100% 50% after you meet the

Annual Deductible

• Sickness and Injury related diagnostic services



• Outpatient Diagnostic/Therapeutic Services - CT Scans, PET Scans, MRI and Nuclear Medicine



• Outpatient Therapeutic Treatments



Physician Fees for Surgical and Medical Services 80% after you meet the Annual


Annual Deductible

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Physician's Office Services

• Covered Health Services for preventive medical care.

• Primary Physician 100% 50% after you meet the

Annual Deductible

• Specialist Physician 100% 50% after you meet the

Annual Deductible

• Covered Health Services for the diagnosis and treatment of a Sickness or Injury received in a Physician's office

• Primary Physician 100% after you pay a $20 Copay 50% after you meet the

Annual Deductible

• Specialist Physician 100% after you pay a $35 Copay 50% after you meet the

Annual Deductible

Prosthetic Devices 80% after you meet the Annual Deductible


Reconstructive Procedures Depending upon where the Covered Health Service is

provided, Benefits will be the same as those stated under each Covered Health Service category

in this section.

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Rehabilitation Services - Outpatient Therapy (Copay is per visit) See Additional coverage details, for limits.


Skilled Nursing Facility/Inpatient Rehabilitation Facility Services See Additional coverage details, for limits.


If you are transferred to a Skilled Nursing Facility or Inpatient

Rehabilitation Facility directly from an acute facility, any

combination of Copayments required for the Inpatient Stay in a Hospital and the Inpatient Stay

in a Skilled Nursing Facility or Inpatient Rehabilitation Facility

will apply to the stated maximum Copayment per Inpatient Stay.


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Spinal Treatment (Copay is per visit)

See Additional Coverage Details, for limits.


Substance Use Disorder Services






Transplantation Services

Transplantation services must be received at a Designated Facility. The Plan does not require that cornea transplants be performed at a Designated Facility in order for you to receive Network Benefits.


provided, Benefits will be the same as those stated under each

Covered Health Services category in this section.

Depending upon where the Covered Health Service is provided,

Benefits will be the same as those stated under each Covered Health

Services category in this section.

Urgent Care Center Services (Copay is per visit) 100% after you pay a $35 Copay 50% after you meet the

Annual Deductible

1In general, your Network provider must notify Personal Health Support, as described in that section, before you receive certain Covered Health Services. There are some Network Benefits, however, for which you should notify Personal Health Support. See Additional coverage details for further information.

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2These Benefits are for Covered Health Services provided through CRS at a Designated Facility. For oncology services not provided through CRS, the Plan pays Benefits as set forth below.

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ADDITIONAL COVERAGE DETAILS

What this section includes: ■ Covered Health Services for which the Plan pays Benefits; and ■ Covered Health Services for which you should notify Personal Health

Support before you receive them.

This section supplements the second table in Schedule of Benefits-Medical.

While the table provides you with Benefit limitations along with Copayment, Coinsurance and Annual Deductible information for each Covered Health Service, this section includes descriptions of the Benefits. These descriptions include any additional limitations that may apply, as well as Covered Health Services for which you must call Personal Health Support. The Covered Health Services in this section appear in the same order as they do in the table for easy reference. Services that are not covered are described in the Section titled Exclusions.

ACUPUNCTURE SERVICES

Acupuncture services when the service is performed by a Network provider in the provider's office.

Benefits are limited to 45 visits per calendar year.

AMBULANCE SERVICES - EMERGENCY ONLY

Emergency ambulance transportation by a licensed ambulance service to the nearest Hospital where Emergency health services can be performed.

AMBULANCE SERVICES - NON-EMERGENCY

Transportation by professional ambulance (not including air ambulance) between medical facilities.

Transportation by regularly-scheduled airline, railroad or air ambulance, to the nearest medical facility qualified to give the required treatment.

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In most cases, the Claims Administrator will initiate and direct non-Emergency ambulance transportation. If you are requesting non-Emergency ambulance services, please remember that you must notify Personal Health Support as soon as possible prior to the transport.

BARIATRIC PROCEDURES

The Plan covers surgical treatment of morbid obesity provided by or under the direction of a Physician provided all of the criteria are met:

• you have a minimum Body Mass Index (BMI) of 35 with documentation of treatment for cardiac disease, diabetes, lung disease or peripheral vascular disease;

• you must have documentation of a diagnosis of morbid obesity for a minimum of three (3) years from a Physician;

• you must be over the age of 21.

Benefits are available for obesity surgery services that meet the definition of a Covered Health Service, as defined SPD and are not Experimental or Investigational or Unproven Services.

Any combination of Benefits is limited to $5,000 per procedure.

CANCER RESOURCE SERVICES (CRS)

The Plan pays Benefits for oncology services provided by Designated Facilities participating in the Cancer Resource Services (CRS) program.

For oncology services and supplies to be considered Covered Health Services, they must be provided to treat a condition that has a primary or suspected diagnosis relating to cancer. If you or a covered Dependent has cancer, you may:

• be referred to CRS by a Personal Health Support Nurse;

• call CRS toll-free at (866) 936-6002; or

• visit www.myoptumhealthcomplexmedical.com.

To receive Benefits for a cancer-related treatment, you are not required to visit a Designated Facility. If you receive oncology services from a facility that is not a Designated Facility, the Plan pays Benefits as described under:

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• Physician's Office Services - Sickness and Injury;

• Physician Fees for Surgical and Medical Services;

• Outpatient Surgery, Diagnostic and Therapeutic Services; and

• Hospital - Inpatient Stay.

To receive Benefits under the CRS program, you must contact CRS prior to obtaining Covered Health Services. The Plan will only pay Benefits under the CRS program if CRS provides the proper notification to the Designated Facility provider performing the services (even if you self-refer to a provider in that Network).

CLINICAL TRIALS

Benefits are available for routine patient care costs incurred during participation in a qualifying Clinical Trial for the treatment of:

• cancer or other life-threatening disease or condition. For purposes of this benefit, a life-threatening disease or condition is one from which the likelihood of death is probable unless the course of the disease or condition is interrupted;

• cardiovascular disease (cardiac/stroke) which is not life threatening, for which, as UnitedHealthcare determines, a Clinical Trial meets the qualifying Clinical Trial criteria stated below;

• surgical musculoskeletal disorders of the spine, hip and knees, which are not life threatening, for which, as UnitedHealthcare determines, a Clinical Trial meets the qualifying Clinical Trial criteria stated below; and

• other diseases or disorders which are not life threatening for which, as UnitedHealthcare determines, a Clinical Trial meets the qualifying Clinical Trial criteria stated below.

Benefits include the reasonable and necessary items and services used to prevent, diagnose and treat complications arising from participation in a qualifying Clinical Trial.

Benefits are available only when the Participant is clinically eligible for participation in the qualifying Clinical Trial as defined by the researcher.

Routine patient care costs for qualifying Clinical Trials include:

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• Covered Health Services for which Benefits are typically provided absent a Clinical Trial;

• Covered Health Services required solely for the provision of the Experimental or Investigational Service(s) or item, the clinically appropriate monitoring of the effects of the service or item, or the prevention of complications; and

• Covered Health Services needed for reasonable and necessary care arising from the provision of an Experimental or Investigational Service(s) or item.

Routine costs for Clinical Trials do not include:

• the Experimental or Investigational Service(s) or item. The only exceptions to this are:

• certain CATEGORY B devices; • certain promising interventions for patients with terminal illnesses; and • other items and services that meet specified criteria in accordance with the

Claims Administrator's medical and drug policies; • items and services provided solely to satisfy data collection and analysis needs

and that are not used in the direct clinical management of the patient; • a service that is clearly inconsistent with widely accepted and established

standards of care for a particular diagnosis; and • items and services provided by the research sponsors free of charge for any

person enrolled in the trial. With respect to cancer or other life-threatening diseases or conditions, a qualifying Clinical Trial is a Phase I, Phase II, Phase III, or Phase IV Clinical Trial that is conducted in relation to the prevention, detection or treatment of cancer or other life-threatening disease or condition and which meets any of the following criteria in the bulleted list below.

With respect to cardiovascular disease or musculoskeletal disorders of the spine, hip and knees and other diseases or disorders which are not life-threatening, a qualifying Clinical Trial is a Phase I, Phase II, or Phase III Clinical Trial that is conducted in relation to the detection or treatment of such non-life-threatening disease or disorder and which meets any of the following criteria in the bulleted list below.

• Federally funded trials. The study or investigation is approved or funded (which may include funding through in-kind contributions) by one or more of the following:

• NATIONAL INSTITUTES OF HEALTH (NIH). (Includes NATIONAL CANCER INSTITUTE (NCI));

• CENTERS FOR DISEASE CONTROL AND PREVENTION (CDC);

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• AGENCY FOR HEALTHCARE RESEARCH AND QUALITY (AHRQ); • CENTERS FOR MEDICARE AND MEDICAID SERVICES (CMS); • a cooperative group or center of any of the entities described above or the

DEPARTMENT OF DEFENSE (DOD) or the VETERANS ADMINISTRATION (VA);

• a qualified non-governmental research entity identified in the guidelines issued by the NATIONAL INSTITUTES OF HEALTH for center support grants; or

• The DEPARTMENT OF VETERANS AFFAIRS, the DEPARTMENT OF DEFENSE or the DEPARTMENT OF ENERGY as long as the study or investigation has been reviewed and approved through a system of peer review that is determined by the SECRETARY OF HEALTH AND HUMAN SERVICES to meet both of the following criteria:

• comparable to the system of peer review of studies and investigations used by the NATIONAL INSTITUTES OF HEALTH; and

• ensures unbiased review of the highest scientific standards by qualified individuals who have no interest in the outcome of the review

• the study or investigation is conducted under an investigational new drug application reviewed by the U.S. FOOD AND DRUG ADMINISTRATION;

• the study or investigation is a drug trial that is exempt from having such an investigational new drug application;

• the Clinical Trial must have a written protocol that describes a scientifically sound study and have been approved by all relevant institutional review boards (IRBS) before participants are enrolled in the trial. UnitedHealthcare may, at any time, request documentation about the trial; or

• the subject or purpose of the trial must be the evaluation of an item or service that meets the definition of a Covered Health Service and is not otherwise excluded under the Plan

Please remember that you must notify Personal Health Support as soon as the possibility of participation in a Clinical Trial arises.

DENTAL SERVICES - ACCIDENT ONLY

Dental services when all of the following are true:

• treatment is necessary because of accidental damage;

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• dental services are received from a Doctor of Dental Surgery, "D.D.S." or Doctor of Medical Dentistry, "D.M.D.";

• the dental damage is severe enough that initial contact with a Physician or dentist occurred within 72 hours of the accident.

Benefits are available only for treatment of a sound, natural tooth. The Physician or dentist must certify that the injured tooth was:

• a virgin or unrestored tooth; or

• a tooth that has no decay, no filling on more than two surfaces, no gum disease associated with bone loss, no root canal therapy, is not a dental implant and functions normally in chewing and speech.

Dental services for final treatment to repair the damage must be both of the following:

• started within three months of the accident;

• completed within 12 months of the accident. Please note that dental damage that occurs as a result of normal activities of daily living or extraordinary use of the teeth is not considered an "accident". Benefits are not available for repairs to teeth that are injured as a result of such activities.

Please remember that you must notify Personal Health Support as soon as possible, but at least five business days before follow-up (post-Emergency) treatment begins. You do not have to provide notification before the initial Emergency treatment. When you provide notification, Personal Health Support can determine whether the service is a Covered Health Service.

DIABETES SERVICES

DIABETES SELF-MANAGEMENT AND TRAINING/DIABETIC EYE EXAMINATIONS/FOOT CARE

Outpatient self-management training for the treatment of diabetes, education and medical nutrition therapy services. Diabetes outpatient self-management training, education and medical nutrition therapy services must be ordered by a Physician and provided by appropriately licensed or registered healthcare professionals.

Benefits under this section also include medical eye examinations (dilated retinal examinations) and preventive foot care for Participants with diabetes.

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DIABETIC SELF-MANAGEMENT ITEMS

Insulin pumps and supplies for the management and treatment of diabetes, based upon the medical needs of the Participant including:

• Insulin pumps are subject to all the conditions of coverage stated under Durable Medical Equipment.

• Blood glucose monitors.

• Insulin syringes with needles.

• Blood glucose and urine test strips.

• Ketone test strips and tablets.

• Lancets and lancet devices.

DURABLE MEDICAL EQUIPMENT (DME)

The Plan pays for Durable Medical Equipment (DME) that meets each of the following:

• ordered or provided by a Physician for outpatient use;

• used for medical purposes;

• not consumable or disposable; and

• not of use to a person in the absence of a disease or disability. If more than one piece of DME can meet your functional needs, Benefits are available only for the most Cost-Effective piece of equipment.

Examples of DME include but are not limited to:

• equipment to assist mobility, such as a standard wheelchair;

• a standard Hospital-type bed;

• oxygen concentrator units and the rental of equipment to administer oxygen;

• delivery pumps for tube feedings;

• braces, including necessary adjustments to shoes to accommodate braces; (Braces that stabilize an Injured body part and braces to treat curvature of the spine are considered Durable Medical Equipment and are a Covered Health Service. Braces that straighten or change the shape of a body part are orthotic devices, and are excluded from coverage. Dental braces are also excluded from coverage.)

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• mechanical equipment necessary for the treatment of chronic or acute respiratory failure (except that air-conditioners, humidifiers, dehumidifiers, air purifiers and filters, and personal comfort items are excluded from coverage).

• lymphedema compression sleeve when diagnosis of lymphedema is present. UnitedHealthcare provides Benefits only for a single purchase (including repair/ replacement) of a type of Durable Medical Equipment once every three calendar years.

EMERGENCY HEALTH SERVICES - OUTPATIENT

The Plan pays for services that are required to stabilize or initiate treatment in an Emergency. Emergency health services must be received on an outpatient basis at a Hospital or Alternate Facility.

If you are admitted as an inpatient to a Network Hospital directly from the Emergency room, you will not have to pay the Copay for Emergency Health Services. The Benefits for an Inpatient Stay in a Network Hospital will apply instead.

Network Benefits will be paid for an Emergency admission to a non-Network Hospital as long as Personal Health Support is notified within one business day of the admission or on the same day of admission if reasonably possible after you are admitted to a non-Network Hospital. If you continue your stay in a non-Network Hospital after the date your Physician determines that it is medically appropriate to transfer you to a Network Hospital, no Benefits will be paid.

Benefits under this section are not available for services to treat a condition that does not meet the definition of an Emergency.

EYE EXAMINATIONS

The Plan pays Benefits for testing & treatment due to illness or injury only for eye examinations received from a health care provider in the provider's office.

Please note that Benefits are not available for charges connected to the purchase or fitting of eyeglasses or contact lenses.

HEALTHY BACK

The Healthy Back Program is here to help. When you enroll in the Healthy Back Program, you’ll be paired with a personal Health Coach who specializes in low

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back pain. Your coach will work with you to:

• Understand your treatment options

• Make sure you have access to the right care

• Provide tools on how to manage low back pain

You’ll also have access to a website that has information on low back pain. It’s all at no additional cost to you as a partof your benefits. Enroll in Healthy Back by calling 1-800-846-4678.

HEARING AIDS

The Plan pays Benefits for hearing aids required for the correction of a hearing impairment (a reduction in the ability to perceive sound which may range from slight to complete deafness). Hearing aids are electronic amplifying devices designed to bring sound more effectively into the ear. A hearing aid consists of a microphone, amplifier and receiver.

Benefits are available for a hearing aid that is purchased as a result of a written recommendation by a Physician. Benefits are provided for the hearing aid and for charges for associated fitting and testing.

Benefits do not include bone anchored hearing aids. Bone anchored hearing aids are a Covered Health Service for which Benefits are available under the applicable medical/surgical Covered Health Services categories in this section only for Participants who have either of the following:

• craniofacial anomalies whose abnormal or absent ear canals preclude the use of a wearable hearing aid; or

• hearing loss of sufficient severity that it would not be adequately remedied by a wearable hearing aid.

Benefits are limited to one single purchase every 3 years. HOME HEALTH CARE

Covered Health Services are services received from a Home Health Agency that are both of the following:

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• ordered by a Physician; and

• provided by or supervised by a registered nurse in your home. Benefits are available only when the Home Health Agency services are provided on a part-time, intermittent schedule and when skilled home health care is required.

Benefits for Home Health Agency services include private duty nursing.

Skilled home health care is skilled nursing, skilled teaching, and skilled rehabilitation services when all of the following are true:

• it must be delivered or supervised by licensed technical or professional medical personnel in order to obtain the specified medical outcome, and provide for the safety of the patient;

• it is ordered by a Physician;

• it is not delivered for the purpose of assisting with activities of daily living, including but not limited to dressing, feeding, bathing or transferring from a bed to a chair;

• it requires clinical training in order to be delivered safely and effectively; and

• it is not Custodial Care. Benefits are limited to 40 visits per calendar year. One visit equals four hours of Skilled Care services.

HOSPICE CARE

The Plan pays Benefits for hospice care that is recommended by a Physician. Hospice care is an integrated program that provides comfort and support services for the terminally ill. Hospice care includes physical, psychological, social, respite and spiritual care for the terminally ill person, and short-term grief counseling for immediate family members. Benefits are available only when hospice care is received from a licensed hospice agency, which can include a Hospital.

HOSPITAL - INPATIENT STAY

Hospital Benefits are available for:

• non-Physician services and supplies received during the Inpatient Stay; and

• room and board in a Semi-private Room (a room with two or more beds).

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Benefits for other Hospital-based Physician services are described in this section under Physician Fees for Surgical and Medical Services.

Benefits for Emergency admissions and admissions of less than 24 hours are described under Emergency Health Services and OUTPATIENT Surgery, Diagnostic and Therapeutic SERVICES, respectively.

Benefits for Inpatient Rehabilitative Services are limited to 30 days per calendar year

INJECTIONS RECEIVED IN A PHYSICIAN'S OFFICE

The Plan pays for Benefits for injections received in a Physician's office when no other health service is received, for example allergy immunotherapy.

KIDNEY RESOURCE SERVICES (KRS)

The Plan pays Benefits for Comprehensive Kidney Solution (CKS) that covers both chronic kidney disease and End Stage Renal Disease (ESRD) disease provided by Designated Facilities participating in the Kidney Resource Services (KRS) program. Designated Facility is defined in Glossary.

In order to receive Benefits under this program, KRS must provide the proper notification to the Network provider performing the services. This is true even if you self-refer to a Network provider participating in the program. Notification is required:

• prior to vascular access placement for dialysis; and

• prior to any ESRD services. You or a covered Dependent may:

• be referred to KRS by the Claims Administrator or Personal Health Support; or

• call KRS toll-free at (866) 561-7518. To receive Benefits related to ESRD and chronic kidney disease, you are not required to visit a Designated Facility. If you receive services from a facility that is not a Designated Facility, the Plan pays Benefits as described under:

• PHYSICIAN'S OFFICE SERVICES - SICKNESS AND INJURY;

• PHYSICIAN FEES FOR SURGICAL AND MEDICAL SERVICES;

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• OUTPATIENT SURGERY, DIAGNOSTIC AND THERAPEUTIC SERVICES; and

• HOSPITAL - INPATIENT STAY.

To receive Benefits under the KRS program, you must contact KRS prior to obtaining Covered Health Services. The Plan will only pay Benefits under the KRS program if KRS provides the proper notification to the Designated Facility provider performing the services (even if you self-refer to a provider in that Network).

MATERNITY SERVICES

Benefits for Pregnancy will be paid at the same level as Benefits for any other condition, Sickness or Injury. This includes all maternity-related medical services for prenatal care, postnatal care, delivery, and any related complications.

There is a special prenatal program to help during Pregnancy. It is completely voluntary and there is no extra cost for participating in the program. To sign up, you should notify the Claims Administrator during the first trimester, but no later than one month prior to the anticipated childbirth.

UnitedHealthcare will pay Benefits for an Inpatient Stay of at least:

• 48 hours for the mother and newborn child following a vaginal delivery; and

• 96 hours for the mother and newborn child following a cesarean section delivery.

These are federally mandated requirements under the Newborns' and Mothers' Health Protection Act of 1996 which apply to this Plan. The Hospital or other provider is not required to get authorization for the time periods stated above. Authorizations are required for longer lengths of stay. If the mother agrees, the attending Physician may discharge the mother and/or the newborn child earlier than these minimum timeframes.

For Dependent Children Only

Pregnancy Benefits for Dependent children are limited to Covered Health Services for Complications of Pregnancy. For a complete definition of Complications of Pregnancy, see Glossary.

Benefits are payable for Covered Health Services for the treatment of Complications of Pregnancy given to a Dependent child while covered under this Plan.

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Benefits for Complications of Pregnancy are paid in the same way as benefits are paid for Sickness.

Benefits for Complications of Pregnancy which result in the delivery of a child are payable for at least:

• 48 hours of inpatient care for the mother and newborn child following a normal vaginal delivery; and

• 96 hours of inpatient care for the mother and newborn child following a cesarean section.

These are federally mandated requirements under the Newborns' and Mothers' Health Protection Act of 1996 which apply to this Plan. The Hospital or other provider is not required to get authorization for the time periods stated above. Authorizations are required for longer lengths of stay. If the mother agrees, the attending Physician may discharge the mother and/or the newborn child earlier than these minimum timeframes.

The following are not considered Complications of Pregnancy:

• false labor;

• occasional spotting;

• rest prescribed by a Physician;

• morning sickness; and

• other conditions that may be connected with a difficult pregnancy but are not a classifiably distinct complication.

MASSAGE THERAPY The plan covers six visits per year for services provided by an approved provider such as a licensed massage therapist, chiropractor or physical therapist if the therapy is performed in provider’s office.

MENTAL HEALTH SERVICES

Mental Health Services include those received on an inpatient or outpatient basis in a Hospital and an Alternate Facility or in a provider’s office.

Benefits include the following services:

• diagnostic evaluations and assessment;

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• treatment planning;

• treatment and/or procedures;

• referral services;

• medication management;

• individual, family, therapeutic group and provider-based case management services;

• crisis intervention;

• Partial Hospitalization/Day Treatment;

• services at a Residential Treatment Facility; and

• Intensive Outpatient Treatment. The Mental Health/Substance Use Disorder Administrator determines coverage for all levels of care. If an Inpatient Stay is required, it is covered on a Semi-private Room basis.

You are encouraged to contact the Mental Health/Substance Use Disorder Administrator for referrals to providers and coordination of care.

Special Mental Health Programs and Services

Special programs and services that are contracted under the Mental Health/Substance Use Disorder Administrator may become available to you as part of your Mental Health Services Benefit. The Mental Health Services Benefits and financial requirements assigned to these programs or services are based on the designation of the program or service to inpatient, Partial Hospitalization/Day Treatment, Intensive Outpatient Treatment, outpatient or a Transitional Care category of Benefit use. Special programs or services provide access to services that are beneficial for the treatment of your Mental Illness which may not otherwise be covered under this Plan. You must be referred to such programs through the Mental Health/Substance Use Disorder Administrator, who is responsible for coordinating your care or through other pathways as described in the program introductions. Any decision to participate in such program or service is at the discretion of the Participant and is not mandatory.

NEONATAL RESOURCE SERVICES (NRS)

The Plan pays Benefits for neonatal intensive care unit (NICU) services provided by Designated Facilities participating in the Neonatal Resource Services (NRS) program.

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NRS provides guided access to a network of credentialed NICU providers and specialized nurse consulting services to manage NICU admissions. Designated Facility is defined in Section 14, GLOSSARY.

In order to receive Benefits under this program, the Network provider must notify NRS or the Claims Administrator if the newborn's NICU stay is longer than the mother's hospital stay.

You or a covered Dependent may also:

• call Personal Health Support; or

• call NRS toll-free at (888) 936-7246 and select the NRS prompt.

To receive NICU Benefits, you are not required to visit a Designated Facility. If you receive services from a facility that is not a Designated Facility, the Plan pays Benefits as described under:

• PHYSICIAN'S OFFICE SERVICES - SICKNESS AND INJURY; • PHYSICIAN FEES FOR SURGICAL AND MEDICAL SERVICES; • HOSPITAL - INPATIENT STAY; and • OUTPATIENT SURGERY, DIAGNOSTIC AND THERAPEUTIC SERVICES.

NEUROBIOLOGICAL DISORDERS - AUTISM SPECTRUM DISORDERS SERVICES

The Plan pays Benefits for psychiatric services for Autism Spectrum Disorder (otherwise known as neurodevelopmental disorders) that are both of the following:

• provided by or under the direction of an experienced psychiatrist and/or an experienced licensed psychiatric provider; and

• focused on treating maladaptive/stereotypic behaviors that are posing danger to self, others and property and impairment in daily functioning.

These Benefits describe only the psychiatric component of treatment for Autism Spectrum Disorder. Medical treatment of Autism Spectrum Disorder is a Covered Health Service for which Benefits are available under the applicable medical Covered Health Services categories as described in this section.

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Benefits include the following services provided on either an outpatient or inpatient basis:










• Intensive Outpatient Treatment.

The Mental Health/Substance Use Disorder Administrator determines coverage for all levels of care. If an Inpatient Stay is required, it is covered on a Semi-private Room basis.


NUTRITIONAL COUNSELING

The Plan will pay for Covered Health Services provided by a registered dietician in an individual session for Participants with medical conditions that require a special diet. Some examples of such medical conditions include, but are not limited to:

• diabetes mellitus;

• coronary artery disease;

• congestive heart failure;

• severe obstructive airway disease;

• gout (a form of arthritis);

• renal failure;

• phenylketonuria (a genetic disorder diagnosed at infancy); and

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• hyperlipidemia (excess of fatty substances in the blood).

When nutritional counseling services are billed as a preventive care service, these services will be paid as described under PREVENTIVE CARE SERVICES in this section.

OSTOMY SUPPLIES

Benefits for ostomy supplies are limited to:

• Pouches, face plates and belts.

• Irrigation sleeves, bags and ostomy irrigation catheters.

• Skin barriers.

Benefits are not available for gauze, adhesive, adhesive remover, deodorant, pouch covers, or other items not listed above.

OUTPATIENT SURGERY, DIAGNOSTIC AND THERAPEUTIC SERVICES

OUTPATIENT SURGERY

The Plan pays for Covered Health Services for surgery and related services received on an outpatient basis at a Hospital or Alternate Facility.

Benefits under this section include only the facility charge and the charge for required Hospital-based professional services, supplies and equipment. Benefits for the surgeon fees related to outpatient surgery are described under Physician Fees for Surgical and Medical Services.

When these services are performed in a Physician's office, Benefits are described under Physician's Office Services below.

OUTPATIENT DIAGNOSTIC SERVICES

The Plan pays for Covered Health Services received on an outpatient basis at a Hospital or Alternate Facility including:

• Lab and radiology/X-ray.

• Mammography testing.

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Benefits under this section include the facility charge, the charge for required services, supplies and equipment, and all related Physician Fees.


This section does not include Benefits for CT scans, PET scans, MRIs, or nuclear medicine, which are described immediately below.

OUTPATIENT DIAGNOSTIC/THERAPEUTIC SERVICES - CT SCANS, PET SCANS, MRI AND NUCLEAR MEDICINE

The Play pays for Covered Health Services for CT scans, PET scans, MRI, and nuclear medicine received on an outpatient basis at a Hospital or Alternate Facility.


OUTPATIENT THERAPEUTIC TREATMENTS

The Plan pays for Covered Health Services for therapeutic treatments received on an outpatient basis at a Hospital or Alternate Facility, including dialysis, intravenous chemotherapy or other intravenous infusion therapy, and other treatments not listed above.



PHYSICIAN FEES FOR SURGICAL AND MEDICAL SERVICES

The Plan pays for Physician Fees for surgical procedures and other medical care received in a Hospital, Skilled Nursing Facility, Inpatient Rehabilitation Facility or Alternate Facility or Physician house calls.

When these services are performed in a Physician's office, Benefits are described under PHYSICIAN'S OFFICE SERVICES below.

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PHYSICIAN'S OFFICE SERVICES - SICKNESS AND INJURY

Benefits are paid by the Plan for Covered Health Services received in a Physician's office for the evaluation and treatment of a Sickness or Injury. Benefits are provided under this section regardless of whether the Physician's office is free-standing, located in a clinic or located in a Hospital. Benefits under this section include allergy injections. Benefits are also paid for In-Network Virtual Visits. A virtual visit lets you see and talk to a doctor from your mobile device or computer without an appointment. Most visits take about 10-15 minutes and doctors can write a prescription, if needed, that you can pick up at your local pharmacy. Physicians can diagnose and treat a wide range of non-emergency medical conditions, including:

• Bladder infection/ • Urinary tract infection • Bronchitis • Cold/flu • Diarrhea • Fever • Migraine/headaches • Pink eye • Rash • Sinus problems • Sore throat • Stomach ache

To access virtual visits Log in to myuhc.com and choose from provider sites where you can register for a virtual visit. After registering and requesting a visit you will pay your portion of primary care Physcian Copayment. Benefits for preventive services are described under Preventive Care Services in this section.

Please Note

Your Physician does not have a copy of your SPD, and is not responsible for knowing or communicating your Benefits.

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PREVENTIVE CARE SERVICES

As required by federal law, the Plan pays Preventive Care benefits as recommended by the U.S. Preventive Services Task Force (USPSTF) (although other preventive care services may be covered as well). These Preventive Care benefits are provided without the application of the Deductible and at 100% coverage where provided by or obtained In-Network. Preventive Care services provided by an Out-of-Network provider are subject to the Out-of-Network deductible and co-insurance without regard to whether the service otherwise would be considered a Preventive Care benefit.

Covered childhood and adult immunizations include those recommended by the Center for Disease Control and Prevention's Advisory Committee on Immunization Practices (ACIP) and published in the Center for Disease Control and Prevention's Mortality and Morbidity Weekly Report (MMWR).

The chart below lists examples of the preventive care services recommended by the USPSTF and provides a guide to the Preventive Care benefits that are Covered Health Services under the Plan.

Covered Preventive Care Services Recommended by the USPSTF

Preventive care benefits for adults

• Abdominal aortic aneurysm one-time screening for men of specified ages who have ever smoked

• Alcohol misuse screening and counseling • Aspirin use to prevent cardiovascular disease for men

and women of certain ages • Blood pressure screening • Cholesterol screening for adults of certain ages or at

higher risk • Colorectal cancer screening for adults over 50 • Depression screening • Diabetes (Type 2) screening for adults with high blood

pressure • Diet counseling for adults at higher risk for chronic

disease • Hepatitis B screening for people at high risk, including

people from countries with 2% or more Hepatitis B prevalence, and U.S.-born people not vaccinated as infants and with at least one parent born in a region with 8% or more Hepatitis B prevalence.

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Covered Preventive Care Services Recommended by the USPSTF • Hepatitis C screening for adults at increased risk, and

one time for everyone born 1945 – 1965 • HIV screening for everyone ages 15 to 65, and other

ages at increased risk • Immunization vaccines for adults1 Lung cancer screening

for adults 55 - 80 at high risk for lung cancer because they’re heavy smokers or have quit in the past 15 years

• Obesity screening and counseling • Sexually transmitted infection (STI) prevention

counseling for adults at higher risk • Syphilis screening for adults at higher risk • Tobacco Use screening for all adults and cessation

interventions for tobacco users Services for pregnant women or women who may become pregnant

• Anemia screening on a routine basis • Breastfeeding comprehensive support and counseling

from trained providers, and access to breastfeeding supplies, for pregnant and nursing women

• Contraception: Food and Drug Administration-approved contraceptive methods, sterilization procedures, and patient education and counseling, as prescribed by a health care provider for women with reproductive capacity (not including abortifacient drugs). This does not apply to health plans sponsored by certain exempt “religious employers.” Learn more about contraceptive coverage.

• Folic acid supplements for women who may become pregnant

• Gestational diabetes screening for women 24 to 28 weeks pregnant and those at high risk of developing gestational diabetes

• Gonorrhea screening for all women at higher risk • Hepatitis B screening for pregnant women at their first

prenatal visit • Rh Incompatibility screening for all pregnant women and

follow-up testing for women at higher risk • Syphilis screening

1 Covered Adult immunizations include immunizations for Diphtheria, Hepatitis A, Hepatitis B, Herpes Zoster, Human Papillomavirus (HPV) Influenza (flu shot), Measles, Meningococcal, Mumps, Pertussis, Pneumococcal, Rubella, Tetanus, and Varicella (Chickenpox).

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Covered Preventive Care Services Recommended by the USPSTF • Expanded tobacco intervention and counseling for

pregnant tobacco users • Urinary tract or other infection screening

Other covered preventive services for women

• Breast cancer genetic test counseling (BRCA) for women at higher risk

• Breast cancer mammography screenings every 1 to 2 years for women over 40

• Breast cancer chemoprevention counseling for women at higher risk

• Cervical cancer screening for sexually active women • Chlamydia infection screening for younger women and

other women at higher risk • Domestic and interpersonal violence screening and

counseling for all women • Gonorrhea screening for all women at higher risk • HIV screening and counseling for sexually active women • Human Papillomavirus (HPV) DNA test every 3 years for

women with normal cytology results who are 30 or older • Osteoporosis screening for women over age 60

depending on risk factors • Rh incompatibility screening follow-up testing for women

at higher risk • Sexually transmitted infections counseling for sexually

active women • Syphilis screening for women at increased risk • Tobacco use screening and interventions • Well-woman visits to get recommended services for

women under 65 Coverage for children’s preventive health services

• Alcohol and drug use assessments for adolescents • Autism screening for children at 18 and 24 months • Behavioral assessments for children ages: 0 to 11

months, 1 to 4 years, 5 to 10 years, 11 to 14 years, 15 to 17 years

• Blood pressure screening for children ages: 0 to 11 months, 1 to 4 years , 5 to 10 years, 11 to 14 years, 15 to 17 years

• Cervical dysplasia screening for sexually active females • Depression screening for adolescents • Developmental screening for children under age 3

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Covered Preventive Care Services Recommended by the USPSTF • Dyslipidemia screening for children at higher risk of lipid

disorders ages: 1 to 4 years, 5 to 10 years, 11 to 14 years, 15 to 17 years

• Fluoride chemoprevention supplements for children without fluoride in their water source

• Gonorrhea preventive medication for the eyes of all newborns

• Hearing screening for all newborns • Height, weight and body mass index (BMI)

measurements for children ages: 0 to 11 months, 1 to 4 years, 5 to 10 years, 11 to 14 years, 15 to 17 years

• Hematocrit or hemoglobin screening for all children • Hemoglobinopathies or sickle cell screening for

newborns • Hepatitis B screening for adolescents at high risk,

including adolescents from countries with 2% or more Hepatitis B prevalence, and U.S.-born adolescents not vaccinated as infants and with at least one parent born in a region with 8% or more Hepatitis B prevalence: 11 – 17 years.

• HIV screening for adolescents at higher risk • Hypothyroidism screening for newborns • Immunization vaccines for children from birth to age 182 • Iron supplements for children ages 6 to 12 months at risk

for anemia • Lead screening for children at risk of exposure • Medical history for all children throughout development

ages: 0 to 11 months, 1 to 4 years , 5 to 10 years , 11 to 14 years , 15 to 17 years

• Obesity screening and counseling • Oral health risk assessment for young children ages: 0 to

11 months, 1 to 4 years, 5 to 10 years • Phenylketonuria (PKU) screening for newborns • Sexually transmitted infection (STI) prevention

counseling and screening for adolescents at higher risk • Tuberculin testing for children at higher risk of

2 Covered child immunizations include immunizations for ◦Diphtheria, Tetanus, Pertussis (Whooping Cough), Haemophilus influenzae type b, Hepatitis A, Hepatitis B, Human Papillomavirus (PVU), Inactivated Poliovirus, Influenza (flu shot), Measles, Meningococcal, Pneumococcal, Rotavirus, and Varicella (Chickenpox).

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Covered Preventive Care Services Recommended by the USPSTF tuberculosis ages: 0 to 11 months, 1 to 4 years, 5 to 10 years, 11 to 14 years, 15 to 17 years

• Vision screening for all children

Your Physician may recommend additional services based on your family or medical history. For questions about your preventive care Benefits under this Plan call the number on the back of your ID card.

PROSTHETIC DEVICES

External prosthetic devices that replace a limb or an external body part, limited to:

• Artificial arms, legs, feet and hands.

• Artificial eyes, ears and noses.

• Breast prosthesis as required by the WOMEN'S HEALTH AND CANCER RIGHTS ACT OF 1998. Benefits include mastectomy bras and lymphedema stockings for the arm.

If more than one prosthetic device can meet your functional needs, Benefits are available only for the most cost-effective prosthetic device.

The prosthetic device must be ordered or provided by, or under the direction of a Physician. Except for items required by the Women's Health and Cancer Rights Act of 1998, Benefits for prosthetic devices are limited to a single purchase of each type of prosthetic device every three calendar years.

Note: Prosthetic devices are different from DME - see Durable Medical Equipment (DME) in this section.

RECONSTRUCTIVE PROCEDURES

Reconstructive Procedures are services performed when a physical impairment exists and the primary purpose of the procedure is to improve or restore physiologic function. Reconstructive procedures include surgery or other procedures which are associated with an Injury, Sickness or Congenital Anomaly. The fact that physical appearance may change or improve as a result of a reconstructive procedure does not classify such surgery as a Cosmetic Procedure when a physical impairment exists, and the surgery restores or improves function.

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Cosmetic Procedures are excluded from coverage. Procedures that correct an anatomical Congenital Anomaly without improving or restoring physiologic function are considered Cosmetic Procedures. The fact that a Participant may suffer psychological consequences or socially avoidant behavior as a result of an Injury, Sickness or Congenital Anomaly does not classify surgery or other procedures done to relieve such consequences or behavior as a reconstructive procedure.

Please note that Benefits for reconstructive procedures include breast reconstruction following a mastectomy and reconstruction of the non-affected breast to achieve symmetry. Other services mandated by the Women's Health and Cancer Rights Act of 1998, including breast prostheses and treatment of complications, are provided in the same manner and at the same level as those for any Covered Health Service. You can contact UnitedHealthcare at the number on your ID card for more information about Benefits for mastectomy-related services.

Please remember that you should notify Personal Health Support five business days before undergoing a Reconstructive Procedure. When you provide notification, Personal Health Support can determine whether the service is considered reconstructive or cosmetic. Cosmetic Procedures are always excluded from coverage.

REHABILITATION SERVICES - OUTPATIENT THERAPY

The Plan provides short-term outpatient rehabilitation services for:

• physical therapy;

• occupational therapy;

• speech therapy;

• pulmonary rehabilitation therapy; and

• cardiac rehabilitation therapy. For all rehabilitation services, a licensed therapy provider, under the direction of a Physician (when required by state law), must perform the services. Benefits under this section include rehabilitation services provided in a Physician's office or on an outpatient basis at a Hospital or Alternate Facility. Benefits are available only for rehabilitation services that are expected to result in significant physical improvement in your condition within two months of the start of treatment.

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Please note that the Plan will pay Benefits for speech therapy only when the speech impediment or speech dysfunction results from Injury, stroke or a Congenital Anomaly.

Any combination of outpatient rehabilitation services is limited to 45 visits per calendar year. The annual visit limit is a joint limit with Spinal Treatment.

SKILLED NURSING FACILITY/INPATIENT REHABILITATION FACILITY SERVICES

The Plan pays for Covered Health Services for an Inpatient Stay in a Skilled Nursing Facility or Inpatient Rehabilitation Facility. Benefits are available for:

• services and supplies received during the Inpatient Stay; and

• room and board in a Semi-private Room (a room with two or more beds). Benefits are limited to 120 days per calendar year.

Please note that Benefits are available only for the care and treatment of an Injury or Sickness that would have otherwise required an Inpatient Stay in a Hospital.

SPINAL TREATMENT

Benefits for Spinal Treatment when provided by a Network Spinal Treatment provider in the provider's office.

Benefits include diagnosis and related services and are limited to one visit and treatment per day.

Benefits for Spinal Treatment are limited to 45 visits per calendar year. The annual visit limit is a joint limit with Rehabilitation Therapy – Outpatient Services.

SUBSTANCE USE DISORDER SERVICES

Substance Use Disorder Services (also known as substance-related and addictive disorders services) include those received on an inpatient or outpatient basis in a Hospital, an Alternate Facility, or in a provider’s office.

Benefits include the following services:



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• Intensive Outpatient Treatment. The Mental Health/Substance Use Disorder Administrator determines coverage for all levels of care. If an Inpatient Stay is required, it is covered on a Semi-private Room basis.


Special Substance Use Disorder Programs and Services

Special programs and services that are contracted under the Mental Health/Substance Use Disorder Administrator may become available to you as part of your Substance Use Disorder Services Benefit. The Substance Use Disorder Services Benefits and financial requirements assigned to these programs or services are based on the designation of the program or service to inpatient, Partial Hospitalization/Day Treatment, Intensive Outpatient Treatment, outpatient or a Transitional Care category of Benefit use. Special programs or services provide access to services that are beneficial for the treatment of your substance use disorder which may not otherwise be covered under this Plan. You must be referred to such programs through the Mental Health/Substance Use Disorder Administrator, who is responsible for coordinating your care or through other pathways as described in the program introductions. Any decision to participate in such program or service is at the discretion of the Participant and is not mandatory.

TRANSPLANTATION SERVICES

Covered Health Services for organ and tissue transplants when ordered by a Physician. Transplantation services must be received at a Designated Facility. Benefits are

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available when the transplant meets the definition of a Covered Health Service, and is not an Experimental, Investigational or Unproven Service:

Notification is required for all transplant services.

Examples of transplants for which Benefits are available include but are not limited to:

• bone marrow transplants (either from you or from a compatible donor) and peripheral stem cell transplants, with or without high dose chemotherapy. Not all bone marrow transplants meet the definition of a Covered Health Service. The search for bone marrow/stem cell from a donor who is not biologically related to the patient is a Covered Health Service only for a transplant received at a Designated Facility.

• heart transplants;

• heart/lung transplants;

• lung transplants;

• kidney transplants;

• kidney/pancreas transplants;

• liver transplants;

• liver/small bowel transplants;

• pancreas transplants; and

• small bowel transplants. Organ or tissue transplants or multiple organ transplants other than those listed above are excluded from coverage, unless determined by the Claims Administrator to be a proven procedure for the involved diagnoses.

Under the Plan there are specific guidelines regarding Benefits for transplant services. Contact the Claims Administrator at the telephone number on your ID card for information about these guidelines.

Transportation and Lodging

The Claims Administrator will assist the patient and family with travel and lodging arrangements. Expenses for travel and lodging for the transplant recipient and a companion are available under this Plan as follows:

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• Transportation of the patient and one companion who is traveling on the same day(s) to and/or from the site of the transplant for the purposes of an evaluation, the transplant procedure or necessary post-discharge follow-up.

• Eligible Expenses for lodging for the patient (while not confined) and one companion. Benefits are paid at a per diem rate of up to $50 for one person or up to $100 for two people.

• Travel and lodging expenses are only available if the transplant recipient resides more than 50 miles from the Designated Facility.

• If the patient is an Enrolled Dependent minor child, the transportation expenses of two companions will be covered and lodging expenses will be reimbursed up to the $100 per diem rate.

There is a combined overall lifetime maximum Benefit of $10,000 per Participant for all transportation and lodging expenses incurred by the transplant recipient and companion(s) and reimbursed under this Plan in connection with all transplant procedures.

URGENT CARE CENTER SERVICES

The Plan pays for Covered Health Services received at an Urgent Care Center. When services to treat urgent health care needs are provided in a Physician's office, Benefits are available as described under PHYSICIAN'S OFFICE SERVICES earlier in this section.

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HEALTH AND WELLNESS RESOURCES

What this section includes:

Health and well-being resources available to you, including: ■ Consumer Solutions and Self-Service Tools.

■ Disease and Condition Management Services.

IHF believes in giving you the tools you need to be an educated health care consumer. To that end, IHF has made available several convenient educational and support services, accessible by phone and the Internet, which can help you to:

• take care of yourself and your family members;

• manage a chronic health condition; and

• navigate the complexities of the health care system.

NOTE:

Information obtained through the services identified in this section is based on current medical literature and on Physician review. It is not intended to replace the advice of a doctor. The information is intended to help you make better health care decisions and take a greater responsibility for your own health. UnitedHealthcare and IHF are not responsible for the results of your decisions from the use of the information, including, but not limited to, your choosing to seek or not to seek professional medical care, or your choosing or not choosing specific treatment based on the text.

Consumer Solutions and Self-Service Tools

HEALTH ASSESSMENT

You are invited to learn more about your health and wellness at www.myuhc.com and are encouraged to participate in the online health assessment. The health assessment is an interactive questionnaire designed to help you identify your healthy habits as well as potential health risks.

Your health assessment is kept confidential. Completing the assessment will not impact your Benefits or eligibility for Benefits in any way.

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To find the health assessment, log in to www.myuhc.com. After logging in, access your personalized Health & Wellness page and click the Health Assessment link. If you need any assistance with the online assessment, please call the number on the back of your ID card.

HEALTH IMPROVEMENT PLAN

You can start a Health Improvement Plan at any time. This plan is created just for you and includes information and interactive tools, plus online health coaching recommendations based on your profile.

Online coaching is available for:

• nutrition;

• exercise;

• weight management;

• stress;

• smoking cessation;

• diabetes; and

• heart health. To help keep you on track with your Health Improvement Plan and online coaching, you'll also receive personalized messages and reminders - IHF’s way of helping you meet your health and wellness goals.

NURSELINESM

NurseLineSM is a telephone service that puts you in immediate contact with an experienced registered nurse any time, 24 hours a day, seven days a week. Nurses can provide health information for routine or urgent health concerns. When you call, a registered nurse may refer you to any additional resources that IHF has available to help you improve your health and well-being or manage a chronic condition. Call any time when you want to learn more about:

• a recent diagnosis;

• a minor Sickness or Injury;

• men's, women's, and children's wellness;

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• how to take prescription drug products safely;

• self-care tips and treatment options;

• healthy living habits; or

• any other health related topic. NurseLineSM gives you another convenient way to access health information. By calling the same number, you can listen to one of the Health Information Library's over 1,100 recorded messages, with over half in Spanish.

NurseLineSM is available to you at no cost. To use this convenient service, simply call the number on the back of your ID card.

Note: If you have a medical emergency, call 911 instead of calling NurseLineSM.

Your child is running a fever and it's 1:00 AM. What do you do?

Call NurseLineSM any time, 24 hours a day, seven days a week. You can count on NurseLineSM to help answer your health questions.

With NurseLineSM, you also have access to nurses online. To use this service, log onto www.myuhc.com and click "Live Nurse Chat" in the top menu bar. You'll instantly be connected with a registered nurse who can answer your general health questions any time, 24 hours a day, seven days a week. You can also request an e-mailed transcript of the conversation to use as a reference.

Note: If you have a medical emergency, call 911 instead of logging onto www.myuhc.com.

TREATMENT DECISION SUPPORT

In order to help you make informed decisions about your health care, UnitedHealthcare has a program called Treatment Decision Support. This program targets specific conditions as well as the treatments and procedures for those conditions.

This program offers:

• access to accurate, objective and relevant health care information;

• coaching by a nurse through decisions in your treatment and care;

• expectations of treatment; and

• information on high quality providers and programs.

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Conditions for which this program is available include:

• back pain;

• knee & hip replacement;

• prostate disease;

• prostate cancer;

• benign uterine conditions;

• breast cancer; and

• coronary disease. Participation is completely voluntary and without extra charge. If you think you may be eligible to participate or would like additional information regarding the program, please contact the number on the back of your ID card.

UNITEDHEALTH PREMIUM® PROGRAM

To help people make more informed choices about their health care, the UnitedHealth Premium® program recognizes Network Physicians who meet standards for quality and cost efficiency. UnitedHealthcare uses evidence-based medicine and national industry guidelines to evaluate quality. The cost efficiency standards rely on local market benchmarks for the efficient use of resources in providing care.

For details on the UnitedHealth Premium® Program including how to locate a UnitedHealth Premium Physician, log onto www.myuhc.com or call the number on your ID card.

WWW.MYUHC.COM

UnitedHealthcare's member website, www.myuhc.com, provides information at your fingertips anywhere and anytime you have access to the Internet. www.myuhc.com opens the door to a wealth of health information and convenient self-service tools to meet your needs.

With www.myuhc.com you can:

• receive personalized messages that are posted to your own website;

• research a health condition and treatment options to get ready for a discussion with your Physician;

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• search for Network providers available in your Plan through the online provider directory;

• access all of the content and wellness topics from NurseLineSM including Live Nurse Chat 24 hours a day, seven days a week;

• complete a health risk assessment to identify health habits you can improve, learn about healthy lifestyle techniques and access health improvement resources;

• use the treatment cost estimator to obtain an estimate of the costs of various procedures in your area; and

• use the Hospital comparison tool to compare Hospitals in your area on various patient safety and quality measures.

Registering on www.myuhc.com

If you have not already registered as a www.myuhc.com subscriber, simply go to www.myuhc.com and click on "Register Now." Have your ID card handy. The enrollment process is quick and easy.

Visit www.myuhc.com and:

• make real-time inquiries into the status and history of your claims;

• view eligibility and Plan Benefit information, including Copays and Annual Deductibles;

• view and print all of your Explanation of Benefits (EOBs) online; and

• order a new or replacement ID card or print a temporary ID card.

Want to learn more about a condition or treatment?

Log on to www.myuhc.com and research health topics that are of interest to you. Learn about a specific condition, what the symptoms are, how it is diagnosed, how common it is, and what to ask your Physician.

Disease and Condition Management Services

DIABETES PREVENTION AND CONTROL

http://www.myuhc.com/

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UnitedHealthcare provides two programs that identify, assess, and support members over the age of 18 living with diabetes or pre-diabetes. The program is designed to support members in preventing pre-diabetics from progressing to diabetes and assist members living with diabetes in controlling their condition and from developing complications.

The Diabetes Prevention Program (DPP) is available for members living with pre-diabetes and offers a 16 session lifestyle intervention that addresses diet, activity and behavior modification. The goal of this program is to slow and/or prevent the development of Type 2 diabetes through lifestyle management and weight loss and is available at local YMCAs.

The Diabetes Control Program (DCP) is available to members living with diabetes and offers face-to-face consultations with trained local pharmacists who will review diabetes history and medication, provide diabetes management education materials and assist individuals living with diabetes with managing their condition. The goal of this program is to reduce the risk of serious health complications through medication management and ongoing monitoring for complications.

Participation is completely voluntary and without extra charge. There are no Copays, Coinsurance or Deductibles that need to be met when services are received as part of the DPP or DCP programs. If you think you may be eligible to participate or would like additional information regarding the programs, please call the DPCA call center directly at 1-888-688-4019.

DISEASE MANAGEMENT SERVICES

If you have been diagnosed with or are at risk for developing certain chronic medical conditions you may be eligible to participate in a disease management program at no cost to you. The heart failure, coronary artery disease, diabetes and asthma programs are designed to support you. This means that you will receive free educational information through the mail, and may even be called by a registered nurse who is a specialist in your specific medical condition. This nurse will be a resource to advise and help you manage your condition.

These programs offer:

• educational materials mailed to your home that provide guidance on managing your specific chronic medical condition. This may include information on symptoms, warning signs, self-management techniques, recommended exams and medications;

• access to educational and self-management resources on a consumer website;

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• an opportunity for the disease management nurse to work with your Physician to ensure that you are receiving the appropriate care; and

• access to and one-on-one support from a registered nurse who specializes in your condition. Examples of support topics include:

• education about the specific disease and condition; • medication management and compliance; • reinforcement of on-line behavior modification program goals; • preparation and support for upcoming Physician visits; • review of psychosocial services and community resources; • caregiver status and in-home safety; • use of mail-order pharmacy and Network providers.

Participation is completely voluntary and without extra charge. If you think you may be eligible to participate or would like additional information regarding the program, please contact the number on the back of your ID card.

HEALTHENOTESSM

UnitedHealthcare provides a service called HealtheNotesSM to help educate members and make suggestions regarding your medical care. HealtheNotesSM provides you and your Physician with suggestions regarding preventive care, testing or medications, potential interactions with medications you have been prescribed, and certain treatments. In addition, your HealtheNotesSM report may include health tips and other wellness information.

UnitedHealthcare makes these suggestions through a software program that provides retrospective, claims-based identification of medical care. Through this process patients are identified whose care may benefit from suggestions using the established standards of evidence based medicine as described in Section 14, Glossary under the definition of Covered Health Services.

If your Physician identifies any concerns after reviewing his or her HealtheNotesSM report, he or she may contact you if he or she believes it to be appropriate. In addition, you may use the information in your report to engage your Physician in discussions regarding your health and the identified suggestions. Any decisions regarding your care, though, are always between you and your Physician.

If you have questions or would like additional information about this service, please call the number on the back of your ID card.

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LIMITATIONS AND EXCLUSIONS

What this section includes:

Services, supplies and treatments that are not Covered Health Services, except as may be specifically provided for in Additional coverage details.

The Plan does not pay Benefits for any of the following services, treatments or supplies even if they are recommended or prescribed by a provider or are the only available treatment for your condition.

When Benefits are limited within any of the Covered Health Service categories described in Additional Coverage Details, those limits are stated in the corresponding Covered Health Services category. When this occurs, those limits are also stated in Plan Highlights. Please review all limits carefully, as the Plan will not pay Benefits for any of the services, treatments, items or supplies that exceed these benefit limits.

Please note that in listing services or examples, when the SPD says "this includes," or "including but not limiting to", it is not UnitedHealthcare's intent to limit the description to that specific list. When the Plan does intend to limit a list of services or examples, the SPD specifically states that the list "is limited to."

Alternative Treatments

1. Acupressure; 2. Aromatherapy; 3. Hypnotism; 4. Massage therapy provided by a non-licensed massage therapist or for services

beyond plan limitations; 5. Rolfing; and 6. Other forms of alternative treatment as defined by the National Center for

Complementary and Alternative Medicine (NCCAM) of the National Institutes of Health.

Comfort or Convenience

1. Television; 2. Telephone; 3. Beauty/barber service; 4. Guest service; 5. Supplies, equipment and similar incidental services and supplies for personal

comfort.

Examples include:

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1. Air conditioners; 2. Air purifiers and filter; 3. Batteries and battery chargers; 4. Dehumidifiers; 5. Humidifiers; 6. Devices and computers to assist in communication and speech.

Dental

1. Dental care except as described in Additional Coverage Details under the heading Dental Services- Accident Only This exclusion does not apply to dental care (oral examination, X-rays, extractions and non-surgical elimination of oral infection) required for the direct treatment of a medical condition for which Benefits are available under the Plan as identified in Additional Covered Services

2. Preventive care, diagnosis, treatment of or related to the teeth, jawbones or gums. Examples include all of the following:

a. extraction, restoration and replacement of teeth; b. medical or surgical treatments of dental conditions; and c. services to improve dental clinical outcomes.

3. Dental implants; 4. Dental braces; 5. Dental X-rays, supplies and appliances and all associated expenses, including

hospitalizations and anesthesia. The only exceptions to this are for any of the following:

a. transplant preparation; b. initiation of immunosuppressives; and c. the direct treatment of acute traumatic Injury, cancer or cleft palate;

6. Treatment of congenitally missing, malpositioned or super numerary teeth, even

if part of a Congenital Anomaly.

Prescription Drugs (See Sav RX for Covered Expenses)

1. Prescription drug products for outpatient use that are filled by a prescription order or refill;

2. Self-injectable medications; 3. Non-injectable medications given in a Physician's office except as required in an

Emergency; 4. over the counter drugs and treatments.

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Experimental or Investigational Services or Unproven Services

Experimental or Investigational Services and Unproven Services and all services related to Experimental or Investigational and Unproven Services are excluded. The fact that an Experimental or Investigational Service or an Unproven Service, treatment, device or pharmacological regimen is the only available treatment for a particular condition will not result in Benefits if the procedure is considered to be Experimental or Investigational or Unproven in the treatment of that particular condition.

This exclusion does not apply to Covered Health Services provided during a Clinical Trial for which Benefits are provides as described under Clinical Trials in Additional Coverage Details.

Foot Care

1. Routine foot care, except when needed for severe systemic disease or preventive foot care for Participants with diabetes. Routine foot care services that are not covered include:

a. Cutting or removal of corns or calluses; b. Nail trimming or cutting; and c. Debriding (removal of dead skin or underlying tissue);

2. Hygienic and preventive maintenance foot care. Examples include the following: a. cleaning and soaking the feet; b. applying skin creams in order to maintain skin tone; c. other services that are performed when there is not a localized illness,

Injury or symptom involving the foot; 3. Treatment of flat feet; 4. Treatment of subluxation of the foot; 5. Shoe orthotics.

Medical Supplies and Appliances

1. Devices used specifically as safety items or to affect performance in sports-related activities;

2. Prescribed or non-prescribed medical supplies and disposable supplies. Examples include: a. ace bandages; b. gauze and dressings; c. syringes; d. diabetic test strips;

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3. Orthotic appliances that straighten or re-shape a body part, except as described under Durable Medical Equipment (DME) in Additional Covered Services.

4. Examples of excluded orthotic appliances and devices include but are not limited to, foot orthotics or any orthotic braces available over-the-counter.

5. Cranial banding; 6. Tubings and masks are not covered except when used with Durable Medical

Equipment as described under the heading Durable Medical Equipment in Additional Covered Services.

Mental Health/Substance Use Disorder

Exclusions listed directly below apply to services described under Mental Health Services, Neurobiological Disorders - Mental Health Services for Autism Spectrum Disorders and/or Substance Use Disorder Services in Additional Coverage Details

1. Services performed in connection with conditions not classified in the current edition of the Diagnostic and Statistical Manual of the American Psychiatric Association;

2. Services or supplies for the diagnosis or treatment of Mental Illness, alcoholism or substance-related and addictive disorders that, in the reasonable judgment of the Mental Health/Substance Use Disorder Administrator, are any of the following: a. not consistent with generally accepted standards of medical practice for the

treatment of such conditions; b. not consistent with services backed by credible research soundly

demonstrating that the services or supplies will have a measurable and beneficial health outcome, and therefore considered experimental;

c. not consistent with the Mental Health/Substance Use Disorder Administrator's level of care guidelines or best practices as modified from time to time; or

d. not clinically appropriate for the patient's Mental Illness, Substance Use Disorder or condition based on generally accepted standards of medical practice and benchmarks.

3. Mental Health Services as treatments for R and T code conditions as listed within the current edition of the Diagnostic and Statistical Manual of the American Psychiatric Association;

4. Mental Health Services as treatment for a primary diagnosis of insomnia and other sleep disorders, sexual dysfunction disorders, binge eating disorders, neurological disorders and other disorders with a known physical basis;

5. Treatments for the primary diagnoses of learning disabilities, conduct and impulse control disorders, personality disorders and paraphilic disorder

6. Educational/behavioral services that are focused on primarily building skills and capabilities in communication, social interaction and learning;

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7. Tuition for or services that are school-based for children and adolescents under the Individuals with Disabilities Education Act;

8. Learning, motor skills and primary communication disorders as defined in the current edition of the Diagnostic and Statistical Manual of the American Psychiatric Association;

9. intellectual disabilities as a primary diagnosis defined in the current edition of the Diagnostic and Statistical Manual of the American Psychiatric Association;

10. Mental Health Services as a treatment for other conditions that may be a focus of clinical attention as listed in the current edition of the Diagnostic and Statistical Manual of the American Psychiatric Association;

11. All unspecified disorders in the current edition of the Diagnostic and Statistical Manual of the American Psychiatric Association;

12. methadone treatment as maintenance, L.A.A.M. (1-Alpha-Acetyl-Methadol), Cyclazocine, or their equivalents for drug addiction;

13. Intensive behavioral therapies such as applied behavioral analysis for Autism Spectrum Disorders; and

14. Any treatments or other specialized services designed for Autism Spectrum Disorder that are not backed by credible research demonstrating that the services or supplies have a measurable and beneficial health outcome and therefore considered Experimental or Investigational or Unproven Services.

Nutrition

1. Megavitamin and nutrition based therapy; 2. Nutritional counseling for either individuals or groups, except as specifically

described in Additional Covered Details; 3. Enteral feedings and other nutritional and electrolyte formulas, including infant

formula and donor breast milk, even if they are the only source of nutrition and even if they are specifically created to treat inborn errors of metabolism such as phenylketonuria (PKU). Infant formula available over the counter is always excluded;

4. Health education classes unless offered by UnitedHealthcare or its affiliates, including but not limited to asthma, smoking cessation, and weight control classes.

Physical Appearance

1. Cosmetic Procedures. See the definition in, Glossary. Examples include: a. pharmacological regimens, nutritional procedures or treatments; b. scar or tattoo removal or revision procedures (such as salabrasion,

chemosurgery and other such skin abrasion procedures); c. skin abrasion procedures performed as a treatment for acne;

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2. Replacement of an existing breast implant if the earlier breast implant was performed as a Cosmetic Procedure. Note: Replacement of an existing breast implant is considered reconstructive if the initial breast implant followed mastectomy. See Reconstructive Procedures in, Additional Coverage Details;

3. Physical conditioning programs such as athletic training, body-building, exercise, fitness, flexibility and diversion or general motivation;

4. Weight loss programs whether or not they are under medical supervision. Weight loss programs for medical reasons are also excluded;

5. Wigs, except for loss of hair resulting from treatment of a malignancy or permanent loss of hair from an accidental injury.

Providers

1. Services performed by a provider who is a family member by birth or marriage, including spouse, brother, sister, parent or child. This includes any service the provider may perform on himself or herself;

2. Services performed by a provider with your same legal residence; 3. Services provided at a free-standing or Hospital-based diagnostic facility without

an order written by a Physician or other provider. 4. Services that are self-directed to a free-standing or Hospital-based diagnostic

facility. 5. Services ordered by a Physician or other provider who is an employee or

representative of a free-standing or Hospital-based diagnostic facility, when that Physician or other provider:

a. has not been actively involved in your medical care prior to ordering the service; or

b. is not actively involved in your medical care after the service is received. c. This exclusion does not apply to mammography testing.

Reproduction

1. Health services and associated expenses for infertility treatments including assisted reproductive technology, regardless of the reason for the treatment;

This exclusion does not apply to services required to treat or correct underlying causes of infertility.

2. Storage and retrieval of all reproductive materials (examples include egg, sperm, testicular tissue and ovarian tissue)

3. In-vitro fertilization regardless of the reason for treatment 4. Surrogate parenting; donor eggs, donor sperm and host uterus; 5. the reversal of voluntary sterilization; 6. artificial reproductive treatments done for genetic or eugenic (selective breeding)

purposes;

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7. services provide by a doula (labor aid); and 8. parenting, pre-natal or birthing classes.

Services Provided under Another Plan

1. Health services for which other coverage is required by federal, state or local law to be purchased or provided through other arrangements. This includes, but is not limited to, coverage required by workers' compensation, no-fault auto insurance, or similar legislation.

2. If coverage under workers' compensation or similar legislation is optional for you because you could elect it, or could have it elected for you, Benefits will not be paid for any Injury, Sickness or Mental Illness that would have been covered under workers' compensation or similar legislation had that coverage been elected.

3. Health services for treatment of military service-related disabilities, when you are legally entitled to other coverage and facilities are reasonably available to you;

4. Health services while on active military duty.

Transplants

1. Health services for organ, multiple organ and tissue transplants, except as described in Transplantation Services in Additional Coverage Details unless UnitedHealthcare determines the transplant to be appropriate according to UnitedHealthcare's transplant guidelines;

2. Health services connected with the removal of an organ or tissue from you for purposes of a transplant to another person. (Donor costs for removal are payable for a transplant through the organ recipient's Benefits under the Plan.);

3. Health services for transplants involving mechanical or animal organs; 4. Transplant services that are not performed at a Designated Facility;

This exclusion does not apply to cornea transplants; and

5. Any solid organ transplant that is performed as a treatment for cancer.

Travel

1. Health services provided in a foreign country, unless required as Emergency Health Services;

2. Travel or transportation expenses, even though prescribed by a Physician. Some travel expenses related to covered transplantation services may be reimbursed at our discretion identified under Travel and Lodging in Additional Covered Services.

This exclusion does not apply to ambulance transportation for which Benefits are provided as described under Ambulance Services in Additional Covered Services.

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Vision

1. Purchase cost of eye glasses or contact lenses; 2. Fitting charge for eye glasses or contact lenses; 3. Eye exercise or vision therapy; 4. Surgery that is intended to allow you to see better without glasses or other vision

correction including radial keratotomy, laser, and other refractive eye surgery.

All Other Exclusions

1. Health services and supplies that do not meet the definition of a Covered Health Service;

2. Physical, psychiatric or psychological exams, testing, vaccinations, immunizations or treatments that are otherwise covered under the Plan when;

• Required solely for purposes of career, education, sports or camp, travel, employment, insurance, marriage or adoption;

• Related to judicial or administrative proceedings or orders; • Conducted for purposes of medical research;

This exclusion does not apply to Covered Health Services provided during a Clincial Trial for which Benefits are provided as described under Clinical Trials in Additional Coverage Details.

• Required to obtain or maintain a license of any type;

3. Health services received as a result of war or any act of war, whether declared or undeclared or caused during service in the armed forces of any country;

4. Health services received after the date your coverage under the Plan ends, including health services for medical conditions arising before the date your coverage under the Plan ends;

5. Health services for which you have no legal responsibility to pay, or for which a charge would not ordinarily be made in the absence of coverage under the Plan;

6. In the event that a non-Network provider waives Copayments and/or the Annual Deductible for a particular health service, no Benefits are provided for the health service for which the Copayments and/or the Annual Deductible are waived;

7. Any and all services performed at the Cancer Centers of America as a Non-Network provider;

8. Charges in excess of Eligible Expenses or in excess of any specified limitation; 9. Services for the evaluation and treatment of temporomandibular joint syndrome

(TMJ), whether the services are considered to be medical or dental in nature;

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10. Upper and lower jawbone surgery except as required for direct treatment of acute traumatic Injury or cancer. Orthognathic surgery, jaw alignment and treatment for the temporomandibular joint, except as a treatment of obstructive sleep apnea;

11. Non-surgical treatment of obesity, including severe morbid obesity (with a BMI greater than 35);

12. Surgical treatment of obesity, including severe morbid obesity (with a BMI greater than 35);

13. Growth hormone therapy; 14. Sex transformation operations; 15. Custodial Care; 16. Domiciliary care; 17. Private duty nursing received on an inpatient basis; 18. Respite care; 19. Rest cures; 20. Psychosurgery; 21. Treatment of benign gynecomastia (abnormal breast enlargement in males); 22. Medical and surgical treatment of excessive sweating (hyperhidrosis); 23. Panniculectomy, abdominoplasty, thighplasty, brachioplasty, mastopexy, and

breast reduction. This exclusion does not apply to breast reconstruction following a mastectomy as described under Reconstructive Procedures in Additional Coverage Details;

24. Medical and surgical treatment for snoring, except when provided as a part of treatment for documented obstructive sleep apnea;

25. Oral appliances for snoring; 26. Speech therapy except as required for treatment of a speech impediment or

speech dysfunction that results from Injury, stroke, or a Congenital Anomaly; 27. Any charges for missed appointments, room or facility reservations, completion

of claim forms or record processing; 28. Any charge for services, supplies or equipment advertised by the provider as

free; 29. Any charges prohibited by federal anti-kickback or self-referral statutes

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HOW TO FILE A MEDICAL BENEFITS CLAIM

IN-NETWORK BENEFITS

Generally, you must first meet your Deductible before the IHF will provide coverage. However, you may be eligible to receive coverage for certain Benefits, such as preventive care, prior to meeting your Deductible. Please see your Schedule of Benefits below or contact the IHF at (888) 880-8222.

If, after meeting your deductible, you receive Covered Health Services from a Network Provider, you will not have to file a claim as IHF pays the Physician or facility directly. If a Network provider bills you for any Covered Health Service other than your Copay or Coinsurance, please contact the provider or call IHF at (888) 880-8222.

Keep in mind, you are responsible for paying any deductible, copay or coinsurance owed to a Network provider at the time of service, or when you receive a bill from the provider.

NON-NETWORK BENEFITS

The plan provides coverage under the plan terms for Non-Network benefits provided by a Non-Network provider that the plan covers. If you choose to receive benefits from a covered Non-Network provider, you will be responsible for the deductible, coinsurance, copayments for Non-Network providers as defined in the plan, subject to plan limits as they apply.

If you are treated by a Non-Network provider in an In-Network facility, your claims will be processed as In-Network. If you are treated by a Non-Network provider when you have been admitted for in-patient services through the Emergency Room for Emergency Care, the claim will be processed as In-Network. If you receive a bill for Covered Services from a Non-Network provider as result of an Emergency, you (or the provider if they prefer) must send the bill to United Healthcare for processing. To make sure the claim is processed promptly and accurately, a completed claim for must be attached and mailed to UnitedHealthcare at the address on the back of your ID Card.

If a Non-Network provider (in the situation described above) submits a claim on your behalf, you will be responsible for the timeliness of the submission. If you don’t provide this information to us within one year of the date of service, benefits for that health service will be denied or reduced, in the Trustees’ discretion. This time limit does not apply if you are legally incapacitated. If your claim relates to an Inpatient Stay, the date of service is the date your Inpatient Stay ends.

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IF YOUR NON-NETWORK PROVIDER DOES NOT FILE YOUR CLAIM

If you receive services from a Non-Network provider that is an In-Network claim under this Plan, you may be required to file the claim yourself. The procedure is simple, just take the following steps:

1. Know Your Benefits and review this information to see if the services You received are eligible under the Plan

2. Get an Itemized Bill which must include: a. The Name and address of the service provider b. The patient’s full name c. The date of service or supply

d. the Current Procedural Terminology (CPT) codes; e. a description of, and the charge for, each service; f. the date the Sickness or Injury began; and

g. The diagnosis or nature of the Illness

h. a statement indicating either that you are, or you are not, enrolled for coverage under any other health insurance plan or program. If you are enrolled for other coverage you must include the name and address of the other carrier(s).

3. Complete a Claim Form - You can either obtain a claim form by visiting the

www.myuhc.com, by calling the IHF at (888) 880-8222.

Failure to provide all the information listed above may delay any reimbursement due to you.

After United Healthcare has processed your claim, you will receive payment for Benefits that the Plan allows. In the case of an emergency room visit, it is not your responsibility to pay the provider the charges you incurred, including any difference between what you were billed and what the Plan paid.

You may not assign your Benefits under the plan to a provider without United Healthcare’s consent. When you assign your Benefits under the Plan to a Non-Network provider with United Healthcare’s consent, and the non-Network provider submits a

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claim for payment, you and the provider represent and warrant that the Covered Health Services were actually provided and were medically appropriate.

When UnitedHealthcare has not consented to an assignment, UnitedHealthcare will send the reimbursement directly to you (the Participant) for you to reimburse the provider upon receipt of their bill. However, UnitedHealthcare reserves the right, in its discretion, to pay the provider directly for services rendered to you. When exercising its discretion with respect to payment, UnitedHealthcare may consider whether you have requested that payment of your Benefits be made directly to the provider. Under no circumstances will UnitedHealthcare pay Benefits to anyone other than you or, in its discretion, your Provider. Direct payment to a provider shall not be deemed to constitute consent by UnitedHealthcare to an assignment or to waive the consent requirement. When UnitedHealthcare in its discretion directs payment to a provider, you remain the sole beneficiary of the payment, and the provider does not thereby become a beneficiary. Accordingly, legally required notices concerning your Benefits will be directed to you, although UnitedHealthcare may in its discretion send information concerning the Benefits to the provider as well. If payment to a provider is made, the Plan reserves the right to offset Benefits to be paid to the provider by any amounts that the provider owes the Plan, pursuant to Refund of Overpayments in Coordination of Benefits.

Important - Timely Filing of Non-Network Claims

All claim forms for non-Network services must be submitted within 12 months after the date of service. Otherwise, the Plan will not pay any Benefits for that Eligible Expense, or Benefits will be reduced, as determined by IHF. This 12-month requirement does not apply if you are legally incapacitated. If your claim relates to an Inpatient Stay, the date of service is the date your Inpatient Stay ends.

HEALTH STATEMENTS

Each month in which UnitedHealthcare processes at least one claim for you or a covered Dependent, you will receive a Health Statement in the mail. Health Statements make it easy for you to manage your family's medical costs by providing claims information in easy-to-understand terms.

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If you would rather track claims for yourself and your covered Dependents online, you may do so at www.myuhc.com. You may also elect to discontinue receipt of paper Health Statements by making the appropriate selection on this site.

EXPLANATION OF BENEFITS (EOB)

Once your claim is processed, you will receive a paper copy Explanation of Benefits (EOB) statement upon request. This statement lists: The provider’s charge; the allowable amount; the Co-payment, Deductible, and Coinsurance amounts, if any, you are required to pay; The total benefits payable; and the total amount you owe.

The EOB will let you know if there is any portion of the claim you need to pay. If any claims are denied in whole or in part, the EOB will include the reason for the denial or partial payment. If you would like paper copies of the EOBs, you may call the toll-free number on your ID card to request them. You can also view and print all of your EOBs online at www.myuhc.com.

TYPES OF CLAIMS - DEFINITIONS

Claims procedures differ depending on whether your claim involves “urgent care,” is a “pre-service claim” or is a “post-service claim.” These and other important terms are defined in this subsection.

“Urgent Care Claim” - A pre-service claim that (1) involves emergency medical care needed immediately in order to avoid serious jeopardy to your life, health or ability to regain maximum function; or (2) in the opinion of a Physician, with knowledge of your medical condition, would subject you to severe pain if your claim were not decided within the “urgent care” time frame described below. Whether your claim is one involving urgent care will be determined by an individual acting on behalf of the Plan, applying an average layperson’s knowledge of health and medicine. If a Physician with knowledge of your medical condition determines that your claim is one involving urgent care, the Plan will treat your claim as an urgent care claim. Post-service claims are not urgent care claims because pre-approval is not required before you can receive treatment.

“Pre-service Claim” - Any claim for which the terms of the Plan condition receipt of the benefit, in whole or part, is on approval of the benefit in advance of obtaining medical care.

“Post-service Claim” - Any claim for a benefit that is not a pre-service claim and in which you request reimbursement after medical care has already been provided.

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“Concurrent Care Claim” - Any claim to extend a course of treatment beyond the period of time or number of treatments that the Plan has already approved as an ongoing course of treatment to be provided. A concurrent care claim can be an urgent care claim, a pre-service claim or a post-service claim.

“Incomplete Claim” - A claim is incomplete if you do not provide enough information for the Plan to determine whether and to what extent your claim is covered by the Plan. This includes your failure to communicate to a person who ordinarily handles benefit matters for the Plan, your name, your specific medical conditions or symptom, and the specific treatment or service for which you request payment of benefits.

Notice of Initial Benefit Determination Urgent Care Claims – An Urgent Care Claim is a special type of Pre-Service Claim. A Claim involving Urgent Care is any Pre-Service Claim for Medical Care or treatment with respect to which the application of the time periods that otherwise apply to Pre-Service Claims could seriously jeopardize the Claimant’s life or health or ability to regain maximum function or would, in the opinion of a Physician with knowledge of the Claimant’s medical condition, subject the Claimant to severe pain that cannot be adequately managed without the care or treatment that is the subject of the Claim. The prudent layperson standard applies to these determinations. If a Treating Physician determines the Claim involves Urgent Care, the Claim shall be treated as an Urgent Care Claim. However, in order to file an Urgent Care Claim, you must request to have a procedure which is a Covered Benefit as defined in this Plan Document. The procedure must not be a procedure that is a Limitation or Exclusion as defined in this Plan Document. On receipt of a Pre-Service Claim, the Plan or its claims processor will make a determination of whether it involves Urgent Care; provided, however, that if a Physician with knowledge of the Claimant’s medical condition determines that a Claim involves Urgent Care, the Claim shall be treated as an Urgent Care Claim.

The Plan or its claims processor will decide your claim and notify you of the decision as soon as possible consistent with the medical exigencies involved but in no event later than 72 hours but no later than 72 hours after your claim is received at the proper address, unless your claim is incomplete. The Plan or its claims processor will notify you as soon as possible if your claim is incomplete but no more than 24 hours after receiving your claim. The Plan may notify you verbally, unless you request written notification. You will then have 48 hours to provide the specified information. Upon receiving this additional information, the Plan or its claims processor will notify you of its determination as soon as possible, within the earlier of 48 hours after receiving the information, or the end of the period within which you must provide the information.

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Urgent Pre-certification Requests for Hospital and Medical Claims - If the need for the service is urgent, the Plan or its claims processor will render a decision as soon as possible consistent with the medical exigencies involved but in no event later than 72 hours after your claim is received at the proper address, unless your request is incomplete. If the request is urgent and requires further information to make our decisions, the Plan or its claims processor will notify you within 24 hours of receipt of the request and you and your provider will have 48 hours to respond. The Plan or its claims processor will make a decision within 48 hours of receipt of the requested information or if no response is received, within 48 hours after the deadline for a response.

Pre-service Claims – A Claim is a Pre-Service Claim if the Plan Document specifically conditions receipt of the Benefit, in whole or in part, on receiving approval in advance of obtaining the Medical Care unless the Claim involves Urgent Care, as defined above. Benefits under this Plan that require approval in advance are specifically noted in this Plan Document as being subject to Precertification.

The Plan or its claims processor will decide your claim and notify you of the decision within a reasonable time but no later than 15 days after receipt of your claim at the proper address. This period may be extended by one 15 day period, if circumstances beyond the control of the Plan require that additional time is needed to process your claim. If an extension is needed, the Plan or its claims processor will notify you prior to the expiration of the initial 15-day period of the circumstances requiring an extension and the date by which the Plan or its claims processor expects to reach a decision. If the Plan or its claims processor needs an extension because you have submitted an incomplete claim, the Plan will notify you of this within 5 days of receipt of your claim. The notice will describe the information needed to make a decision. The Plan or its claims processor may notify you verbally, unless you request written notification. You will have 45 days after receiving this notice to provide the specified information. If you fail to submit information necessary for the Plan or its claims processor to decide a claim, the period for making the benefit determination will be tolled or frozen from the date on which the Plan or its claims processor sends you the notification of the extension until the date you respond to the request for additional information.

Pre-certification Requests for Hospital and Medical Claims Administered by UHC - Pre-certification means that you must contact UHC’s for approval before you receive certain health care services. The Plan or its claims processor will review all requests for pre-certification within three (3) business days of receipt of the necessary information but not to exceed 15 calendar days from the receipt of the request. If the Plan or its claims processor does not have enough information to make a decision within three (3) business days, they will notify you in writing of the additional information they need, and you and your provider will have 45 calendar days to respond. the Plan or its claims processor will make a decision within three (3) business days of our receipt of the

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requested information or if no response is received, within three (3) business days after the deadline for a response.

Post-service Claims - The Plan or its claims processor will decide your claim and notify you of the decision within a reasonable time but no later than 30 days after receipt of your claim at the proper address. This period may be extended by one 15-day period, if circumstances beyond the control of the Plan or its claims processor require that additional time is needed to process your claim. If an extension is needed, the Plan or its claims processor will notify you prior to the expiration of the initial 30-day period of the circumstances requiring an extension and the date by which the Plan or its claims processor expects to reach a decision. If the Plan or its claims processor needs an extension because you have not submitted information necessary to decide the claim, the notice will also describe the information it needs to make a decision. You will have 45 days after receiving this notice to provide the specified information. If you fail to submit information necessary for the Plan or its claims processor to decide a claim, the period for making the benefit determination will be tolled or frozen from the date on which the Plan or its claims processor sends you the notification of the extension until the date you respond to the request for additional information.

Retrospective (Post-Service) Requests for Hospital and Medical Claims Administered by the Plan or its claims processor - Retrospective review is conducted after you receive medical services. We will complete all retrospective reviews of services already provided within 30 calendar days of our receipt of the claim. If the Plan or its claims processor does not have enough information to make a decision within 30 calendar days, they will notify you in writing of the additional information we need and you and your provider will have 45 calendar days to respond. The Plan or its claims processor will make a decision within 15 calendar days of our receipt of the requested information or if no response is received, within 15 calendar days after the deadline for a response.

Concurrent Care Claims - If the Plan or its claims processor has approved an ongoing course of treatment to be provided over a period of time, it will notify you in advance of any reduction in or termination of this course of treatment. If you submit a claim to extend a course of treatment and that claim involves urgent care, the Plan or its claims processor will notify you of its determination within 24 hours after receiving your claim, provided that the Plan or its claims processor receives your claim at least 24 hours prior to the expiration of the course of treatment. If the claim does not involve urgent care, the request will be decided in the appropriate time frame, depending on whether it is a pre- service or post-service claim.

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Concurrent Requests for Hospital and Medical Claims Administered by the Plan or its claims processor - Concurrent review means that the Plan or its claims processor reviews your care during your treatment to be sure you get the right care in the right setting and for the right length of time. The Plan or its claims processor will complete all concurrent reviews of services within 24 hours of our receipt of the request.

For Life Insurance Claims, the Plan will make a decision on the claim and notify you and or your beneficiary of the decision within 90 days. If the Plan requires an extension of time due to matters beyond their control, the Plan will notify you of the reason for the delay and when the decision will be made. This notification will occur before the expiration of the 90-day period. A decision will be made within 90 days of the time that the Plan notifies you of the delay.

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PRESCRIPTION DRUG BENEFIT

The following section provides information regarding your prescription drug benefit and how to file claims and appeals. Please read carefully. If you have any questions please contact SavRx at 1-866-91-BRICK (1-866-912-7425) or the Fund office at 1-888-880-8222.

Sav-Rx Prescription Services

Sav-Rx provides you with both retail and mail services. You may get a 90 supply of your medicine from either a retail pharmacy or the mail service. You can access the Sav-Rx mail order forms as well formulary by logging onto www.savrx.com.

Sav-Rx encourages you to use generic drugs whenever they are available and to recommend that you ask their physicians to order generic drugs whenever appropriate. Using generic drugs is an important way that you can help to save money for yourself and your plan.

What is a generic drug?

Generic drugs have been approved by the Food and Drug Administration (FDA) as safe and effective. Generic drugs contain the same active ingredients in the same amounts as the brand-name product. The generic version works like the brand-name drug in dosage, strength, performance and use. Generics may differ in color, shape, size or flavoring from the brand-name product; however, these differences do not affect the performance, safety or effectiveness of the generic drug. They look different because trademark laws in the U.S. do not allow a generic drug to look exactly like other drugs already on the market. When rated by the FDA as equivalent and where permitted by law, a generic drug can be substituted for a brand-name drug.

What are the differences between brand-name and generic drugs?

When a company develops a new drug, the FDA provides a period of time where no other company may sell the drug to allow the original company to recover the investment in the research and development of the medication. This eliminates competition and causes the price to remain high. After this time has lapsed, other companies can manufacture generic versions of the brand medication. In about 50% of the cases, the brand-name firm begins to manufacture the generic themselves. Since the production of generic medications does not require the large investments in research, development and advertising, the cost of the generics are significantly less than that of the brand-name medication. Generally, the cost of generic medications is about half the cost of the brand products.

How does the FDA ensure that my generic drug is as safe and effective as the brand-name drug?

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Regardless of whether drugs are brand-name or generic, all medications must meet the same FDA standards of quality. All generic drugs are put through a rigorous, multi-step process that includes review of the scientific data on the generic drug's ingredients and performance. The FDA also conducts periodic inspections of the manufacturing plant and monitors drug quality even after the generic drug has been approved. All drug manufacturing facilities must meet FDA's standards of good manufacturing practices. The FDA will not permit drugs to be made in substandard facilities. The FDA conducts about 3,500 inspections each year to ensure these standards are met.

Why do I automatically receive a generic drug when my physician prescribes a brand-name drug?

State laws vary, but most allow the pharmacist to automatically substitute a generic equivalent for the prescribed brand-name drug (if a U.S. FDA-approved generic is available and safely interchangeable). Unless your doctor specifically writes your prescription “Dispense As Written” or “Substitution Not Permitted”, Sav-Rx will automatically fill with the generic equivalent when available. These laws are actually in place to protect you, the consumer from unnecessarily paying for the more expensive drug. Although plans vary, if it is necessary for you to have the brand-name medication, you will be responsible to pay the difference in cost between the generic drug and the brand-name version, plus your co-pay.

What if I don't want to take a generic drug?

If it is important to you to have the brand-name drug, you should be aware that many plans require that you pay a higher copayment or the brand copayment plus the difference in price between the brand-name drug and the generic version.

Sav-Rx's Customer Service department responds to calls from customers concerning general information, specific questions concerning the preferred provider networks, the mail service pharmacies, general benefit information and inquiries regarding member- submitted claims. This department offers toll-free assistance 24 hours a day 7 days a week 365 days year. You can reach Sav-Rx at 1-866-91-BRICK (1-866-912-7425).

All Customer Service Representatives have access to Sav-Rx's on-line system, which enables them to immediately respond to member questions or problems. Members also have access to a pharmacist.

Spanish-speaking staff members are always on duty. In addition, Customer Service utilizes a translation service if a customer needs support in his or her native language and it is not represented among the staff. The service provides a translator for 150 languages.

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Prescription Drug Cost Sharing

CO-PAY: GENERIC PREFFERED BRAND NON-FORM BRAND w/GENERIC

RETAIL $5 $25 $50 $50 + Diff in Cost

MAIL $10 $60 $120 $120 + Diff in Cost

WALK IN MAIL $10 $60 $120 $120 + Diff in cost

SPECIALTY MEDICATIONS FOR RETAIL & MAIL ORDER: 25% Co-Pay

Maximum Out of Pocket: $1,000 Per Individual $2,000 Per Family Annual Rollover: January 1st

Covered Medication/Drug Class

INSULIN

INSULIN SYRINGES

DIABETIC SUPPLIES

DIABETIC MACHINES Prior Authorization Required

OTHER SYRINGES

INJECTABLES Prior Authorization Required

GLUCAGON INJECTION

EPINEPHRINE INJECTION

SUMATRIPTAN INJECTION

PRESCRIPTION VITAMIN

PRESCRIPTION PRENATAL VITAMIN

ORAL CONTRACEPTIVE

3 MONTH (91 DAY) ORAL CONTRACEPTIVE PAK Available Mail Order Only

CONTRACEPTIVE IMPLANT

CONTRACEPTIVE RING

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CONTRACEPTIVE DIAPHRAGM

CONTRACEPTIVE PATCH

CONTRACEPTIVE INJECTION

ATTENTION DEFICIT Requires Prior Authorization After Age 18

PRESCRIPTION PPI’s Brand Name PPI’s Subject to Step Therapy

TRANSPLANT Requires Prior Authorization

TRETINOIN Requires Prior Authorization

GROWTH HORMONE Requires Prior Authorization

IMMUNIZATIONS Subject to Prior Authorization

FLU VACCINATIONS Covered at $0.00 Co-Pay

ANTIDEPRESSANTS

PRESCRIPTION NON-SEDATING ANTIHISTAMINE

PRESCRIPTION SMOKING CESSATION*

OTC SMOKING CESSATION*

*Smoking Cessation Products are covered for all groups at 90 days lifetime supply.

Sav-Rx Step Therapy

Certain classes of drugs require that you try a Generic Drug before getting a Brand Name Drug. The following classes of drugs are subject to Step Therapy:

PROTON PUMP INHIBITORS (PPI’s)

STATINS

ANGIOTENSIN-2 RECEPTOR BLOCKERS (ARBs)

ARB/HCTZ COMBINATION

SELECTIVE SEROTONIN REUPTAKE INHIBITORS (SSRI)

SELECTIVE NOREPINEPHRINE REUPTAKE INHIBITORS (SNRI)

SLEEP MEDICATIONS/HYPNOTICS

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BISPHOSPHONATES FOR OSTEOPOROSIS

COX-2 ANTI-INFLAMMATORIES (CELEBREX)

NASAL SPRAYS

TRIPTANS FOR MIGRAINES

GLAUCOMA EYE DROPS

OVERACTIVE BLADDER

LYRICA

BETA BLOCKERS

NON-STEROIDAL ANTI-INFLAMMATORIES (NSAIDs)

CALCIUM CHANNEL BLOCKERS (CCB)

ACE INHIBITORS AND COMBINATIONS

COMBINATION ANTIHYPERTENSIVES (i.e. AZOR, EXFORGE)

TEKTURNA/TEKTURNA HCT

PRESCRIPTION NON SEDATING ANTIHISTAMINE

LEUKOTRIENE PATHWAY INHIBITORS (i.e. ACCOLATE, SINGULAIR)

Exclusions include:

DEVICES / APPLIANCES

OTC VITAMIN

3 MONTH (91 DAY) ORAL CONTRACEPTIVE PAK RETAIL

ABORTIFACIENT

WEIGHT LOSS

ERECTILE DYSFUNCTION ON DEMAND

ERECTILE DYSFUNCTION DAILY DOSE

OTC NON SEDATING ANTIHISTAMINE

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OTC PROTON PUMP INHIBITOR

FERTILITY

COSMETIC

Sav-Rx Drug Utilization Review

The Sav-Rx utilization review service allows on-line monitoring of every prescription purchased with the Sav-Rx card, even if prescriptions are purchased at different pharmacies. The drug interaction service checks for the following:

Drug to Drug Interactions

Potential drug-to-drug interactions are identified and reported to the dispensing pharmacy on-line as the prescription is filled. Drugs in new prescriptions are compared to previously prescribed drugs the member may be taking, regardless of which pharmacy in the network filled the prescription. If an interaction is detected, a message is sent to the pharmacy alerting them to potential problem. This allows the pharmacist at the dispensing pharmacy to further explore the potential problem with the member and/or physician.

Duplicate Drug Therapy

Sav-Rx reviews new prescriptions, which may duplicate or have similar pharmacological actions to prescriptions already being taken. Duplicate therapy is reported on-line to the dispensing pharmacy.

Drug/Age

Sav-Rx identifies drug or drug dosage forms which may be inappropriate for patients in a particular age group.

Early Refill/Overutilization

Sav-Rx checks for an improper frequency on refill prescriptions. Early refills are identified for members who may have used multiple network pharmacies, whether brand or generic drugs were dispensed. The parameters for determining the early window may be set by plan sponsors.

Inadequate or Excessive Dosage

Sav-Rx checks the strength and dosage as reported by the dispensing pharmacy against standard dose parameters.

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Drug-Inferred Disease

Sav-Rx compares the apparent disease state of the patient based upon their drug therapy against the drug and dosage form being prescribed.

Prior Authorization/Therapeutic Review Process

The Sav-Rx Prior Authorization Program is designed on the premise that certain medications require a clinical review for determination of coverage. This requirement helps to ensure that you are receiving the appropriate drugs for the treatment of specific conditions and in quantities as approved by the U.S. Food and Drug Administration (FDA). In these cases, clinical criteria based on the most current medical information must be met. The approval criteria are developed by the Sav-Rx Pharmacy and Therapeutics (P&T) Committee which is an established group of medical professionals including physicians and pharmacists whose primary concern is providing patients with the highest quality of care while supporting the integrity of the doctor-patient relationship.

The following steps are involved in the Sav-Rx Prior Authorization Review Process:

(1.) Sav-Rx will receive a request from you, your physician or pharmacy for a prior authorization on a particular medication for a specified participating member.

(2.) Sav-Rx will contact the prescribing physician to obtain the necessary documentation of the patient’s medical history and diagnosis.

(3.) Sav-Rx will conduct a therapeutic review of the clinical indications and dosage criteria for the medication as approved by the FDA.

(4.) Sav-Rx will either approve or deny the request for prior authorization for the medication based on the combined clinical information.

If approved, Sav-Rx will allow coverage of the medication at either a local pharmacy or the Sav-Rx Mail Order Pharmacy according to plan parameters. The pharmacy, you and/or physician will be notified if appropriate or requested.

If denied, then you will be notified in writing of the denial.

Sav-Rx will maintain complete records of all requests and research documentation utilized in the decision for each individual prior authorization claim.

If Sav-Rx receives a request for appeal from you or your prescribing physician following the initial denial from Sav-Rx, the information provided will be forwarded for an independent, external peer review by a consulting physician.

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If the denial stands, you (and your prescribing physician if applicable) is mailed a denial notification. If you request further consideration of a denied claim following the secondary clinical review, they will be referred to the Plan Sponsor benefit office for the second and third level of appeal. Please see the Section on Appeals for further information.

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DENTAL BENEFIT

The following section provides information regarding your Dental benefit and how to file claims and appeals. Please read carefully. If you have any questions please contact Delta Dental at (800) 932-0783 or the Fund office at 1-888-880-8222.

The services provided through the plan include all the benefits described in the Benefit Summary Charts on the following pages, depending on the participation status of the dentist providing the services, with the exception of those items presented in the Limitations and Exclusions section. The plan covers several categories of benefits when a licensed dentist provides the services and when they are within the standards of generally accepted dental practice. To help you understand the types of procedures that are included in each of the categories of services, examples and descriptions are provided in the charts. The enrollee’s share may be higher than the percentages listed in the charts, depending on the applicability of deductibles, maximums, the difference between the Non-Participating Dentist’s fee and the PPO Maximum Plan Allowance or charges for non-covered services.

BENEFIT SUMMARY CHART

The information in the following chart applies to services provided by Delta Dental PPO Dentists only.

Paid by Paid By Category of Service Delta Dental Enrollee Diagnostic 80%* 20%

Periodic exams (once per 5-month period) Bitewing x-rays (once per 5-month period) Full-mouth x-ray (once per 3-year period) See note on additional benefits during pregnancy

Preventive 80%* 20% Routine prophylaxis (cleaning) (once per 5-month period) Fluoride treatments (once per 5-month period to age 16) Sealants (to age 17) Space maintainers (to age 14) See note on additional benefits during pregnancy

Basic Restorative 80%* 20% Fillings (amalgam “silver” and composite “white” non-molar)

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Major Restorative 50%* 50% Single crowns, inlays, onlays

Oral Surgery 80%* 20% Extraction and other oral surgery procedures, incl. pre- and post-operative care

Endodontics 80%* 20% Root canal, pulpal therapy

Surgical Periodontics 50%* 50% Surgical treatment of the gums and supporting structures of the teeth

Non-Surgical Periodontics 80%* 20% Non-surgical treatment of the gums and supporting structures of the teeth See note on additional benefits during pregnancy

Prosthodontics 50%* 50% Procedures for replacement of missing teeth by construction or repair of bridges and partial or complete dentures

General Anesthesia and IV Sedation 80%* 20% Covered when used in conjunction with covered oral surgical procedures and other selected endodontic and periodontal procedures

Periodontal Maintenance 80%* 20% Periodontal prophylaxis (twice per calendar year)

Bridge and Crown/Inlay/Onlay Recementation 80%* 20% Bridge and Denture Repair (1 in 2 years) 80%* 20% Injectable Antibiotics 80%* 20% Occlusal Adjustments 80%* 20% Periodontal Appliances (1 in 5 years) 50%* 50% Periodontal Splinting 50%* 50% Stainless Steel Crowns 80%* 20% Deductibles Maximums

Individual (Calendar year) $50.00 $1,500.00 Family (Calendar year) $n/a $n/a

* For Delta Dental PPO Dentists, percentages are based on the PPO Allowed Amount,

which is the lesser of the dentist’s submitted fee or the PPO Maximum Plan Allowance.

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The information in the following chart applies to services provided by Delta Dental Premier Dentists and Non-Participating Dentists only.

Benefit Summary Chart

Paid by Paid By Category of Service Delta Dental Enrollee Diagnostic 80%* 20%

Periodic exams (once per 5-month period) Bitewing x-rays (once per 5-month period) Full-mouth x-ray (once per 3-year period) See note on additional benefits during pregnancy

Preventive 80%* 20% Routine prophylaxis (cleaning) (once per 5-month period) Fluoride treatments (once per 5-month period to age 16) Sealants (to age 17) Space maintainers (to age 14) See note on additional benefits during pregnancy

Basic Restorative 80%* 20% Fillings (amalgam “silver” and composite “white” non-molar)

Major Restorative 50%* 50% Single crowns, inlays, onlays

Oral Surgery 80%* 20% Extraction and other oral surgery procedures, incl. pre- and post-operative care

Endodontics 80%* 20% Root canal, pulpal therapy

Surgical Periodontics 50%* 50% Surgical treatment of the gums and supporting structures of the teeth

Non-Surgical Periodontics 80%* 20% Non-surgical treatment of the gums and supporting structures of the teeth See note on additional benefits during pregnancy

Prosthodontics 50%* 50%

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Procedures for replacement of missing teeth by construction or repair of bridges and partial or complete dentures

General Anesthesia and IV Sedation 80%* 20% Covered when used in conjunction with covered oral surgical procedures and other selected endodontic and periodontal procedures

Periodontal Maintenance 80%* 20% Periodontal prophylaxis (twice per calendar year)

Bridge and Crown/Inlay/Onlay Recementation 80%* 20% Bridge and Denture Repair (1 in 2 years) 80%* 20% Injectable Antibiotics 80%* 20% Occlusal Adjustments 80%* 20% Periodontal Appliances (1 in 5 years) 50%* 50% Periodontal Splinting 50%* 50% Stainless Steel Crowns 80%* 20% Deductibles Maximums

Individual (Calendar year) $50.00 $1,500.00 Family (Calendar year) $n/a $n/a

* For Delta Dental Premier Dentists and Non-Participating Dentists, percentages are

based on the Premier Allowed Amount, which is the lesser of the dentist’s submitted fee or the Premier Maximum Plan Allowance.

Copayments

The plan will pay a percentage of the applicable allowed amount (PPO Allowed Amount for PPO Dentists and Premier Allowed Amount for Premier Dentists and Non-Participating Dentists) for each covered service, subject to certain limitations, and you are responsible for paying the balance. What you pay is called the copayment and is part of your out-of-pocket cost. You pay this even after a deductible has been met.

The amount of your copayment will depend on the type of service provided and the dentist providing the service (see section titled “Selecting Your Dentist”). Dentists are required to collect your copayment for covered services.

It is to your advantage to select PPO Dentists because they have agreed to accept the PPO Allowed Amount as payment, which typically results in lower copayments charged

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to you. Please read the sections titled “Selecting Your Dentist” and “How Claims Are Paid” for more information.

Deductible

Most dental plans have a specific dollar deductible. The Benefit Summary Charts show the individual and family deductibles that apply, depending on the participation status of the dentist providing the services. Deductibles apply to all benefits unless otherwise noted. Each enrolled family member must pay the individual deductible amount each calendar year to satisfy the plan deductible. You pay this directly to your dentist for completed services. The total deductible amount paid will not exceed the family deductible for all family members.

Maximum Benefit

Most dental programs have a maximum benefit. This is the maximum dollar amount a dental plan will pay toward the cost of dental care. The enrollee is personally responsible for paying costs above the maximum benefit. The Benefit Summary Charts show the maximum benefit amount that applies, depending on the participation status of the dentist providing the services. This is the maximum benefit amount that Delta Dental will pay for covered services per enrollee in a calendar year.

Note on Additional Benefits During Pregnancy

When an Enrollee is pregnant, Delta Dental will pay for additional services to help improve the oral health of the Enrollee during the pregnancy. The additional services while the Enrollee is covered under the Contract include: one (1) additional oral exam and either one (1) additional routine cleaning or one (1) additional periodontal scaling and root planing per quadrant. Written confirmation of the pregnancy must be provided by the Enrollee or her dentist when the claim is submitted.

Limitations and Exclusions

Dental plans are designed to help with part of your dental expenses and may not always cover every dental need. The typical program includes limitations and exclusions, meaning the program does not cover every aspect of dental care. This can relate to the type of procedures or the number of visits. These limitations and exclusions are carefully detailed in this booklet and you should make yourself familiar with them. Please read the Limitations and Exclusions section to help you understand the limitations and exclusions of this dental plan.

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HOW CLAIMS ARE PAID

Payment by Delta Dental for any single procedure that is a covered service will be made upon completion of the procedure. Payment for care is applied to the calendar year deductible and maximum benefit based on the date of service. After you have satisfied your deductible requirement, Delta Dental will provide payment for covered services at the percentage indicated in the Benefit Summary Chart, up to a maximum for each enrollee in a calendar year.

Payment for Services — Delta Dental PPO Dentist

Payment for covered services performed for you by a PPO Dentist is calculated based on the PPO Allowed Amount. PPO Dentists have agreed to accept a PPO Allowed Amount as the full charge for covered services.

Delta Dental calculates its share of the PPO Allowed Amount (“Delta Dental Payment”) using the applicable percentage from the Benefit Summary Chart and sends it directly to the PPO Dentist who has submitted the claim. Delta Dental advises you of any charges not payable by Delta Dental for which you are responsible (“Enrollee Payment”). These charges are generally your share of the allowed amount (“Co-payment”), the deductible, charges where the maximum benefit has been exceeded, and/or charges for non-covered services.

Example (assuming this is a procedure that is covered at a 50%/50% copayment level, the maximum benefit has not been exceeded and the deductible has been met):

Submitted Amount (Dentist Fee) = $100

PPO Maximum Plan Allowance = $70

PPO Allowed Amount = $70

Co-payment (50% of PPO Allowed Amount) = $35

Delta Dental Payment = $35

Enrollee Payment = $35

Payment for Services — Delta Dental Premier Dentist

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A Delta Dental Premier Dentist is a Participating Dentist, but is not a Delta Dental PPO Dentist. Premier Dentists have not agreed to accept a PPO Allowed Amount as full payment for services, but instead have agreed to accept a Premier Allowed Amount. Payment for covered services performed for you by a Premier Dentist is calculated based on the Premier Allowed Amount, which is the lesser of the dentist’s submitted fee or the Premier Maximum Plan Allowance.

The portion of the Premier Allowed Amount payable by Delta Dental (“Delta Dental Payment”) is limited to the applicable percentage shown in the Benefit Summary Chart. Delta Dental’s Payment is sent directly to the Premier Dentist who submitted the claim. Delta Dental advises you of any charges not payable by Delta Dental for which you are responsible (“Enrollee Payment”). These charges are generally your share of the Premier Allowed Amount, as well as any deductibles, charges where the maximum benefit has been exceeded, and/or charges for non-covered services.



Premier Maximum Plan Allowance = $80

Premier Allowed Amount = $80

Co-payment (50% of Premier Allowed Amount) = $40

Delta Dental Payment = $40


Payment for Services — Non-Participating Dentist

Non-Participating Dentists have not agreed to accept the PPO Allowed Amount as full payment for services. Payment for services performed for you by a Non-Participating Dentist is also calculated by Delta Dental based on the Premier Allowed Amount, which is the lesser of the dentist’s submitted fee or the Premier Maximum Plan Allowance. The portion of the Premier Allowed Amount payable by Delta Dental (“Delta Dental Payment”) is limited to the applicable percentage shown in the Benefit Summary Chart.

However, when dental services are received from a Non-Participating Dentist, Delta Dental’s payment is sent directly to the primary enrollee. You are responsible for

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payment of the Non-Participating Dentist’s total fee. Non-Participating Dentists will bill you for their normal charges, which may be higher than the Premier Allowed Amount for the service. You may be required to pay the dentist yourself and then submit a claim to Delta Dental for reimbursement. Since the Delta Dental payment for services you receive may be less than the Non-Participating Dentist’s actual charges, your out-of-pocket cost may be significantly higher.



Premier Maximum Plan Allowance= $80

Premier Allowed Amount = $80

Co-payment

(50% of Premier Allowed Amount)= $40

Delta Dental Payment to Enrollee = $40


HOW TO SUBMIT A CLAIM

Delta Dental does not require any special claim forms. Most dental offices have standard claim forms available. Participating Dentists will fill out and submit your claims paperwork for you. Some Non-Participating Dentists may also provide this service upon your request. If you receive services from a Non-Participating Dentist who does not provide this service, you can submit your own claim directly to Delta Dental. For your convenience, you can print a claim form from our web site: www.deltadentalins.com.

Your dental office should be able to assist you in filling out the claim form. Fill out the claim form completely and mail it to:

Delta Dental One Delta Drive Mechanicsburg, PA 17055

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Payment Guidelines

Delta Dental does not pay Participating Dentists any incentive as an inducement to deny, reduce, limit or delay any appropriate service.

If you or your dentist files a claim for services more than twelve (12) months after the date you received the services, payment may be denied. If the services were received from a Non-Participating Dentist, you are still responsible for the full cost. If the payment is denied because your Participating Dentist failed to submit the claim on time, you may not be responsible for that payment. However, if you did not tell your Participating Dentist that you were an enrollee of the plan at the time you received the service, you may be responsible for the cost of that service.

We explain to all Participating Dentists how we determine or deny payment for services. We describe in detail the dental procedures covered as benefits, the conditions under which coverage is provided and the program’s limitations and exclusions. If any claims are not covered, or if limitations or exclusions apply to services you have received, you may be responsible for the full payment.

If you have any questions about any dental charges, processing policies and/or how your claim is paid, contact Delta Dental.

Optional Treatment and Non-Covered Services

You must pay for any non-covered or optional dental benefits that you choose to have done. Refer to the Limitations and Exclusions section for information about excluded services and limitations.

Often there are several approaches or different methods that a dentist may use to treat dental needs. This program is designed to cover dental treatment using standards of care consistent with the delivery of quality, affordable dental treatment to the enrollee. If you request a treatment that is more costly than standard practice, you must pay for the charges in excess of the covered dental benefit.

Example: If a metal filling would fix the tooth and you choose to have the tooth crowned, you are responsible for paying the difference between the cost of the crown and the cost of the filling. You must pay this money directly to your dentist.

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Pre-Treatment Estimates

If you and your dentist are unsure of your benefits for a specific course of treatment, or if treatment costs are expected to exceed $250, it is recommended that you ask for a pre-treatment estimate. You should ask your dentist to submit the claim form in advance of performing the proposed services. Pre-treatment estimate requests are not required but may be submitted for more complicated and expensive procedures such as crowns, wisdom tooth extractions, bridges, dentures, or periodontal surgery. You’ll receive an estimate of your share of the cost and how much Delta Dental will pay before treatment begins. Delta Dental will act promptly in returning a pre-treatment estimate to you and the attending dentist with non-binding verification of your current availability of benefits and applicable maximums. The pre-treatment estimate is non-binding as the availability of benefits may change subsequent to the date of the estimate due to a change in eligibility status, exhaustion of applicable maximum benefit or application of frequency of procedure limitations.

OTHER HEALTH INSURANCE

Be sure to advise your dentist of all programs under which you have dental coverage and have him or her complete the dual coverage portion of the claim form, so that you will receive all benefits to which you are entitled. When you have coverage under more than one benefit program, the primary and secondary carriers coordinate the two programs, so that the primary carrier pays its portion first and then the secondary carrier pays its portion, not to exceed the dentist’s fees for the covered services.

The following rules will be followed to establish the order of determining the liability of this or any other programs:

1. The program covering the enrollee as an employee will determine its benefits before the program covering the enrollee as a dependent.

2. The program covering the enrollee as a dependent of an employee whose birthday falls earlier in the calendar year will determine it benefits before the program covering the enrollee as a dependent of an employee whose birthday falls later in the calendar year. If both employees have the same birthday, the program covering the employee for the longest period will be primary over the program covering the employee for the shorter period.

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3. The program covering the enrollee having custody of the dependent will determine its benefits first; then the program of the spouse of the parent with custody of the dependent; and finally, the program of the parent not having custody of the dependent. However, if the specific terms of a court order state that one of the parents is responsible for the health care expenses of the dependent, the benefits of that program are considered first. The prior sentence will not apply with respect to any period during which any benefits are actually paid or provided before a program has actual knowledge of the court order.

4. The program covering the enrollee as an employee or as a dependent of an employee will determine its benefits before one that covers the enrollee as a laid-off or retired employee or as the dependent of such person. If the other plan does not have a rule concerning laid-off or retired employees, and as a result each plan determines its benefits after the other, then this paragraph will not apply.

5. If the other program does not have a rule establishing the same order of determining liability for benefits or is one which is “excess” or always “secondary,” Delta Dental will determine its benefits first. If such determination indicates that Delta Dental should not have been the first program to determine its benefits, Delta Dental will be considered as not the first to determine its benefits.

6. In situations not described in items 1 through 5, the program under which the enrollee has been enrolled for the longest period of time will determine its benefits first.

When Delta Dental is the first to determine its benefits, benefits will be paid without regard to coverage under any other program. When Delta Dental is not the first to determine its benefits, and there are remaining expenses of the type allowable under this program, Delta Dental will pay only the amount by which its benefits under this plan exceed the amount of benefits payable under the other program or the amount of such remaining expenses, whichever is less.

COMPLAINTS, GRIEVANCES AND APPEALS

Our commitment to you is to ensure quality throughout the entire treatment process: from the courtesy extended to you by our customer service representatives to the dental services provided by our Participating Dentists. If you have questions about any services received, we recommend that you first discuss the matter with your dentist. However, if you continue to have concerns, please call Delta Dental’s Customer Service Center.

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Delta Dental attempts to process all claims within 30 days. If a claim will be delayed more than 30 days, Delta Dental will notify the enrollee in writing within 30 days stating the reason for delay.

Questions or complaints regarding eligibility, the denial of dental services or claims, the policies, procedures, or operations of Delta Dental, or the quality of dental services performed by the dentist may be directed in writing to Delta Dental or by calling Delta Dental at (717) 766-8500 or toll-free at (800) 932-0783. You can also e-mail questions by accessing the “Contact Us” section of Delta Dental’s web site at www.deltadentalins.com.

A grievance is a written expression of dissatisfaction with the provision of services or claims practices of Delta Dental. When you write, please include the name of the enrollee, the primary enrollee’s name and enrollee ID, and your telephone number on all correspondence. You should also include a copy of the claim form, Benefits Statement, Invoice or other relevant information.

Appeals

Any dissatisfaction with adjustments made or denials of payment should be brought to Delta Dental’s attention, and if unresolved to your satisfaction, to the Plan Sponsor. Please see the Appeals Section in the SPD for further information.

Appeals on claims denied must be submitted in writing. The following section explains the claim review and appeal process and time limits applicable to such process. This information can also be found in your Benefits Statement.

If a post-service claim is denied in whole or in part, Delta Dental will notify you and your attending dentist of the denial in writing within 30 days after the claim is filed, unless special circumstances require an extension of time, not exceeding 14 days, for processing. If there is an extension, you and your attending dentist will be notified of the extension and the reason for the extension within the original 30-day period. If an extension is necessary because either you or your attending dentist did not submit the information necessary to decide the claim, the notice of extension will specifically describe the required information. You or your attending dentist will be afforded at least 45 days from receipt of the notice within which to provide the specific information. The extension period (15 days) – within which a decision must be made by Delta Dental – will begin to run from the date on which the response is received by the plan (without

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regard to whether all of the requested information is provided) or, if earlier, the due date established by the plan for furnishing the requested information (at least 45 days).

The notice of denial shall explain the specific reason or reasons why the claim was denied in whole or in part, including a specific reference to the pertinent contract provisions on which the denial is based, a description of any additional material or information necessary for you to perfect the claim and an explanation as to why such information is necessary. The notice of denial shall also contain an explanation of Delta Dental’s claim review and appeal process and the time limits applicable to such process, including a statement of the enrollee’s right to bring a civil action under ERISA upon completion of Delta Dental’s second level of review. The notice shall refer to any internal rule, guideline, and protocol that was relied upon (and that a copy will be provided free of charge upon request). The notice shall state that if the claim denial is based on lack of dental necessity, experimental treatment or a clinical judgment in applying the terms of the contract, an explanation is available free of charge upon request by you or your attending dentist.

If you or your attending dentist wants the denial of benefits reviewed, you or your attending dentist must write to Delta Dental within 180 days of the date on the denial letter. In the letter, you or your attending dentist should state why the claim should not have been denied. Also any other documents, data, information or comments which are thought to have bearing on the claim including the denial notice should accompany the request for review. You or your attending dentist are entitled to receive upon request and free of charge reasonable access to and copies of all documents, records, and other information relevant to the denied claim. The review will take into account all comments, documents, records, or other information, regardless of whether such information was submitted or considered in the initial benefit determination.

The review shall be conducted on behalf of Delta Dental by a person who is neither the individual who made the claim denial that is the subject of the review, nor the subordinate of such individual. If the review is of a claim denial based in whole or in part on a lack of dental necessity, experimental treatment, or a clinical judgment in applying the terms of the contract, Delta Dental shall consult with a dentist who has appropriate training and experience in the pertinent field of dentistry and who is neither the Delta Dental dental consultant who made the claim denial nor the subordinate of such consultant. The identity of the Delta Dental dental consultant whose advice was obtained in connection with the denial of the claim whether or not the advice was relied upon in making the benefit determination is also available to you or your attending

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dentist on request. In making the review, Delta Dental will not afford deference to the initial adverse benefit determination.

If after review, Delta Dental continues to deny the claim, Delta Dental will notify you and your attending dentist in writing of the decision on the request for review within 30 days of the date the request is received. Delta Dental will send to you or your attending dentist a notice, which contains the specific reason or reasons for the adverse determination and reference to the specific contract provisions on which the benefit determination is based. The notice shall state that you are entitled to receive, upon request and free of charge, reasonable access to, and copies of all documents, records and other information relevant to your claim for benefits. The notice shall refer to any internal rule, guideline, and protocol that was relied upon (and that a copy will be provided free of charge upon request). The notice shall state that if the claim denial is based on lack of dental necessity, experimental treatment or a clinical judgment in applying the terms of the contract, an explanation is available free of charge upon request by either you or your attending dentist. The notice shall also state that you have a right to bring an action under ERISA upon completion of Delta Dental’s second level of review, and shall state: “You and your plan may have other voluntary alternative dispute resolution options, such as mediation. One way to find out what may be available is to contact your local U.S. Department of Labor Office and your State insurance regulatory agency.”

If in the opinion of you or your attending dentist, the matter warrants further consideration, you or your attending dentist should advise Delta Dental in writing as soon as possible. The matter shall then be immediately referred to Delta Dental’s Dental Affairs Committee. This stage can include a clinical examination, if not done previously, and a hearing before Delta Dental’s Dental Affairs Committee if requested by you or your attending dentist. The Dental Affairs Committee will render a decision within 30 days of the request for further consideration. The decision of the Dental Affairs Committee shall be final insofar as Delta Dental is concerned. Recourse thereafter would be to the state regulatory agency, a designated state administrative review board, or to the courts with an ERISA or other civil action.

Send your grievance, appeal, or claims review request to Delta Dental at the address shown below:

Delta Dental One Delta Drive Mechanicsburg, PA 17055

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GENERAL PROGRAM INFORMATION

Proof of Claim

Before approving a claim, Delta Dental will be entitled to receive, to such extent as may be lawful, from any attending or examining dentist, or from hospitals in which a dentist’s care is provided, such information and records relating to attendance to or examination of, or treatment provided to, an enrollee as may be required to administer the claim, or that an enrollee be examined by a dental consultant retained by Delta Dental, in or near the community or residence. Delta Dental will in every case hold such information and records confidential.

Physical Access

Delta Dental has made efforts to ensure that our offices and the offices and facilities of Participating Dentists are accessible to the disabled. If you are not able to locate an accessible dentist, please call our Customer Service Center and a representative will help you find an alternate dentist.

Access for the Hearing Impaired

The hearing impaired may contact the Customer Service Center through our toll-free TTY/TDD number at (888) 373-3582.

Privacy

Delta Dental values its relationship with you. Protecting your personal information is of great importance to us. Delta Dental will obtain from the enrollee only nonpublic information that relates to Delta Dental’s administration of the dental benefits we provide. Information may include, but not be limited to name, address, social security number, enrollee ID, and date of birth. We do not disclose any nonpublic personal information about you to any affiliated or nonaffiliated third parties except as is necessary in order to provide our service to you or as we are required or permitted by law. Delta Dental maintains physical, electronic, and procedural security measures to safeguard your nonpublic personal information in our possession.

Web Site Security

Delta Dental employs security measures to control access to the eligibility and dental benefit information under our control. Delta Dental uses industry standards, such as

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firewalls and Secure Socket Layers, to safeguard the confidentiality of personal enrollee information.

There are areas of our web site that require a specific user ID and password for web site access. In order to receive a user ID and password, Delta Dental requires enrollees to contractually agree to not provide information they may access to other individuals. The user identification and password required for site access is internally validated to ensure this information cannot be viewed without proper authority and security authentication.

ENROLLEE RIGHTS AND RESPONSIBILITIES

We believe that you, as a Delta Dental enrollee, have the right to expect quality, affordable care that protects not only your dental health, but also your privacy and ability to make informed choices. We also believe that you have certain responsibilities to help protect these rights.

The Right to Choose

The Delta Dental system maintains some of the largest dentist networks in the industry — each with a full range of specialists — to give you the widest possible choice of dentists. Dentists are never penalized for referring you to a specialist. You can visit any dentist at any time, without prior notification or authorization from Delta Dental.

The Right to Quality Assurance

While we support the right of enrollees to choose their dentist, we recognize our responsibility to provide some assurances of quality care.

Therefore, each dentist who has contracted with Delta Dental agrees to provide care that meets the standards of the dental profession. Dentist contracts allow Delta Dental to audit dental offices in person — at random and for cause — to help ensure that these standards are met. If you should ever receive substandard care from a Delta Dental dentist, Delta Dental will fully investigate the matter and can arrange for you to be reimbursed and/or retreated as needed.

The Right to Affordability

Delta Dental contracts with dentists to provide fair and reasonable compensation. Those contracts also prohibit dentists from billing you for excess charges, “add-on”

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procedures that should already be included, or for any amount that is Delta Dental’s responsibility.

Delta Dental benefit plans are designed to promote preventive care, avoiding dental disease before more costly treatment becomes necessary.

The Right to Full Disclosure

You have the right to clear and complete information about your dental benefits, including treatment that is subject to limitations or not covered. You are entitled to know what your share of costs will be before you receive treatment (“pre-treatment estimate”), and how your dentist is compensated by Delta Dental. Delta Dental provides materials to explain these features to you.

Delta Dental dentists are not subject to policies sometimes called “gag clauses.” You are entitled to hear about all treatment options your dentist may recommend, whether covered or not, and to obtain a second opinion if you choose.

The Right to Fair Review and Appeal

Delta Dental supports your right, as well as your dentist’s, to a fair and prompt review of any of Delta Dental’s coverage decisions. We maintain effective complaint resolution systems in the event of disagreement over coverage or concern about the quality of care.

The Responsibility to Protect These Rights

Protection of the rights described above is possible only with your cooperation. In order to ensure the continued enjoyment of these rights, you share:

• The responsibility to participate in your own dental health — practicing personal dental hygiene and receiving regular professional care. You should avoid substances and behaviors that could jeopardize your oral health, and should cooperate with your dentist on his or her recommended treatment plans.

• The responsibility to become familiar with your coverage. This includes meeting any financial obligation incurred as a result of treatment (including the appropriate copayments or deductibles required by the program). It means cooperation with Delta Dental policies designed to protect against health care fraud schemes by fellow enrollees or dentists. It also means taking advantage of

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the information available on dental health and your dental program so that you can become a more informed consumer.

LIMITATIONS AND EXCLUSIONS

Excluded Benefits

The plan covers a wide variety of dental care expenses, but there are some services for which we do not provide benefits. It is important for you to know what these services are before you visit your dentist.

The plan does not provide benefits for:

1. Treatment or materials that are benefits to an enrollee under Medicare or Medicaid unless this exclusion is prohibited by law.

2. Treatment or materials to correct congenital or developmental malformations (including treatment of enamel hypoplasia) except for newborn children eligible at birth, so long as such eligible children continue to be enrolled. When services are not excluded under this provision congenital defects or anomalies specifically includes individuals born with cleft lip or cleft palate, and other limitations and exclusions of this section shall specifically apply.

3. Treatment that increases the vertical dimension of an occlusion, replaces tooth structure lost by attrition or erosion, or otherwise unless it is part of a treatment dentally necessary due to accident or injury.

4. Treatment or materials primarily for cosmetic purposes including but not limited to treatment of fluorosis (a type of discoloration of the teeth) and porcelain or other veneers not for restorative purposes, except as part of a treatment dentally necessary due to accident or injury. If services are not excluded as to particular teeth under this provision, cosmetic treatment of teeth adjacent or near the affected teeth are excluded.

5. Treatment or materials for which the enrollee would have no legal obligation to pay.

6. Services provided or materials furnished prior to the effective eligibility date of an enrollee under this plan, unless the treatment was a year in duration and completed after the enrollee became eligible if no other limitations shall apply.

7. Preventive plaque control programs, including oral hygiene instruction programs.

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8. Myofunctional therapy, unless covered by the exception in Item 2, above.

9. Temporomandibular joint dysfunction, unless covered by the exception in Item 2, above.

10. Prescription drugs including topically applied medication for treatment of periodontal disease, pre-medication, analgesias, separate charges for local anesthetics, general anesthesia except as a covered benefit in conjunction with a covered oral surgery procedure.

11. Experimental procedures that have not been accepted by the American Dental Association.

12. Services provided or material furnished after the termination date of coverage for which premium has been paid, as applicable to individual enrollees, except this shall not apply to services commenced while the plan was in effect or the enrollee was eligible.

13. Charges for hospitalization or any other surgical treatment facility, including hospital visits.

14. Dental practice administrative services including but not limited to, preparation of claims, any non-treatment phase of dentistry such as provision of an antiseptic environment, sterilization of equipment or infection control, or any ancillary materials used during the routine course of providing treatment such as cotton swabs, gauze, bibs, masks, or relaxation techniques such as music.

15. Replacement of existing restorations for any purpose other than restoring active carious lesions or demonstrable breakdown of the restoration.

Limitations

Benefits to enrollees are limited as follows:

Limitation on Optional Treatment Plan. In all cases in which there are optional plans of treatment carrying different treatment costs, payment will be made only for the applicable percentage of the least costly course of treatment, so long as such treatment will restore the oral condition in a professionally accepted manner, with the balance of the treatment cost remaining the responsibility of the enrollee. Such optional treatment includes, but is not limited to, specialized techniques involving gold, precision partial attachments, overlays, implants, bridge attachments, precision dentures, personalization or characterization such as jewels or lettering, shoulders on crowns or

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other means of unbundling procedures into individual components not customarily performed alone in generally accepted dental practice.

Limitation on Major Restorative Benefits. If a tooth can be restored with amalgam, synthetic porcelain or plastic, but the enrollee and the dentist select another type of restoration, the obligation of Delta Dental shall be only to pay the applicable percentage of the fee appropriate to the least costly restorative procedure. The balance of the treatment shall be considered a dental treatment excluded from coverage under this plan.

Replacement of crowns, jackets, inlays and onlays shall be provided no more often than once in any five-year period and then only in the event that the existing crown, jacket, inlay or onlay is not satisfactory and cannot be made satisfactory. The five-year period shall be measured from the date on which the restoration was last supplied, whether paid for under the provisions of this plan, under any prior dental care contract, or by the enrollee.

Limitation on Prosthodontic Benefits. Replacement of an existing denture will be made only if it is unsatisfactory and cannot be made satisfactory. Services, including denture repair and relining, which are necessary to make such appliances fit will be provided as outlined in the section “Covered Benefits.” Prosthodontic appliances and abutment crowns will be replaced only after five years has elapsed following any prior provision of such appliances and abutment crowns under any plan procedure.

Limitation on Periodontal Surgery. Benefits for periodontal surgery in the same quadrant are limited to once in any five-year period. The five-year period shall be measured from the date on which the last periodontal surgery was performed in that quadrant, whether paid for under the provisions of this plan, under any prior dental contract, or by the enrollee.

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VISION BENEFITS

Vision Service Plan (VSP)

PROCEDURES FOR USING THE PLAN

1. When you desire to receive Plan Benefits from a Member Doctor, contact VSP or a Member Doctor. A list of names, addresses, and phone numbers of Member Doctors in your geographic location can be obtained from your Group, Plan Administrator, or VSP. If this list does not cover the geographic area in which you desire to seek services, you may call or write the VSP office nearest you to obtain one that does.

2. If you are eligible for Plan Benefits, VSP will provide Benefit Authorization directly to the Member Doctor. If you contact a Member Doctor directly, you must identify yourself as a VSP member so the doctor knows to obtain Benefit Authorization from VSP.

3. When such Benefit Authorization is provided by VSP, and services are performed prior to the expiration date of the Benefit Authorization, this will constitute a claim against the Plan in spite of your termination of coverage or the termination of the Plan. Should you receive services from a Member Doctor without such Benefit Authorization or obtain services from a provider who is not a Member Doctor, you are responsible for payment in full to the provider.

4. You pay only the Copayment (if any) to a Member Doctor for services covered by the Plan. VSP will pay the Member Doctor directly according to its agreement with the doctor.

Note: If you are eligible for and obtain Plan Benefits from a Non-Member Provider, you should pay the provider his/her full fee. You will be reimbursed by VSP in accordance with the Non-Member Provider reimbursement schedule shown on the enclosed insert, less any applicable Copayments.

5. In emergency conditions, when immediate vision care of a medical nature such as for bodily trauma or disease is necessary, Participant can obtain covered services by contacting a Member Doctor (or Out-of-Network Provider if the Schedule of Benefits indicates Participant’s Plan includes such coverage). No prior approval from VSP is required for Participant to obtain vision care for Emergency Conditions of a medical nature. However, services for medical conditions, including emergencies, are covered by VSP only under the Acute EyeCare and Primary EyeCare Plans. If coverage for one of these plans is not

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indicated on the Schedule of Benefits, Participant is not covered by VSP for medical services and should contact a physician under Participant’s medical insurance plan for care. For emergency conditions of a non-medical nature, such as lost, broken or stolen glasses, the Participant should contact VSP’s Customer Service Department for assistance.

6. Emergency vision care is subject to the same benefit frequencies, plan allowances, Copayments and exclusions stated herein. Reimbursement to Member Doctors will be made in accordance with their agreement with VSP.

7. In the event of termination of a Member Doctor’s membership in VSP, VSP will remain liable to the Member Doctor for services rendered to you at the time of termination and permit the Member Doctor to continue to provide you with Plan Benefits until the services are completed or until VSP makes reasonable and appropriate arrangements for the provision of such services by another authorized doctor.

BENEFITS AND COVERAGES

Through its Member Doctors, VSP provides Plan Benefits to Participants, subject to the limitations, exclusions, and Copayment(s) described herein. When you wish to obtain Plan Benefits from a Member Doctor, you should contact the Member Doctor of your choice, identify yourself as a VSP member, and schedule an appointment. If you are eligible for Plan Benefits, VSP will provide Benefit Authorization for you directly to the Member Doctor prior to your appointment. IMPORTANT: The benefits described below are typical services and materials available under most VSP Plans. However, the actual Plan Benefits provided to you by your Group may be different. Refer to the Schedule of Benefits and/or Disclosure to determine your specific Plan Benefits. 1. Eye Examination: A complete initial vision analysis which includes an appropriate examination of visual functions, including the prescription of corrective eyewear where indicated. 2. Lenses: The Member Doctor will order the proper lenses necessary for your visual welfare. The doctor shall verify the accuracy of the finished lenses. 3. Frames: The Member Doctor will assist in the selection of frames, properly fit and adjust the frames, and provide subsequent adjustments to frames to maintain comfort and efficiency.

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4. Contact lenses: Unless otherwise indicated on the enclosed insert, contact lenses are available under this Plan in lieu of all other lens and frame benefits described herein for the current eligibility period. Necessary contact lenses, together with professional services, will be provided as indicated on the enclosed insert. When Elective contact lenses are obtained from a Member Doctor, VSP will provide an allowance toward the cost of professional fees and materials as shown on the enclosed insert. A 15% discount shall also be applied to the Member Doctor’s usual and customary professional fees for contact lens evaluation and fitting. Contact lens materials are provided at the Member Doctor’s usual and customary charges.

1. If you elect to receive vision care services from a Member Doctor, Plan Benefits are provided subject only to your payment of any applicable Copayment. If your Plan includes Non-Member Provider coverage, and you choose to obtain Plan Benefits from a Non-Member Provider, you should pay the Non-Member Provider his/her full fee. VSP will reimburse you in accordance with the reimbursement schedule shown on the enclosed insert, less any applicable Copayment. THERE IS NO ASSURANCE THAT THE SCHEDULE WILL BE SUFFICIENT TO PAY FOR THE EXAMINATION OR THE MATERIALS. Availability of services under the Non-Member Provider reimbursement schedule is subject to the same time limits and Copayments as those described for Member Doctor services. Services obtained from a Non-Member Provider are in lieu of obtaining services from a Member Doctor and count toward plan benefit frequencies.

2. Low Vision Services and Materials (applicable only if included in your Plan Benefits outlined on the enclosed insert): The Low Vision Benefit provides special aid for people who have acuity or visual field loss that cannot be corrected with regular lenses. If a Participant falls within this category, he or she will be entitled to professional services as well as ophthalmic materials, including but not limited to, supplemental testing, evaluations, visual training, low vision prescription services, plus optical and non-optical aids, subject to the frequency and benefit limitations as outlined on the enclosed insert. Consult your Member Doctor for details.

When Plan Benefits are received from Member Doctors, benefits appearing in the Member Doctor benefit column below are applicable subject to any applicable Copayments and other conditions, limitations and/or exclusions as stated below. When

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Plan Benefits are available and received from Non-Member Providers, the Participant is reimbursed for such benefits according to the schedule in the Non-Member Provider benefit column below less any applicable Copayments. The Participant pays the provider’s full fee at the time of service and submits an itemized bill to VSP for reimbursement. Discounts do not apply to vision care benefits obtained from Non-Member Providers. PLAN BENEFITS MEMBER DOCTOR BENEFIT NON-MEMBER PROVIDER

BENEFIT VISION CARE SERVICES Vision Examination Up to $ 50.00 Up to $ 50.00 VISION CARE MATERIALS Lenses and Frames Up to $ 200.00 Up to $200.00 CONTACT LENSES

Elective Professional Fees** and Materials Up to $ 200.00 Up to $200.00 **15% discount applies to Member Doctor's usual and customary professional fees for contact lens evaluation and fitting. COPAYMENT There shall be no Copayment payable by the Participant to the Member Doctor at the time services are rendered.

EXCLUSIONS AND LIMITATIONS OF BENEFITS

This vision service Plan is designed to cover visual needs rather than cosmetic materials. If you select any of the following options, the Plan will pay the basic cost of the allowed lenses, and you will be responsible for the options extra cost, unless it is defined as a Plan Benefit in the Schedule of Benefits.

• Optional cosmetic processes. • Anti-reflective coating. • Color coating.

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• Mirror coating. • Scratch coating. • Blended lenses. • Cosmetic lenses. • Laminated lenses. • Oversize lenses. • Polycarbonate lenses. • Photochromic lenses, tinted lenses except Pink #1 and Pink #2. • Progressive multifocal lenses. • UV (ultraviolet) protected lenses. • Certain limitations on low vision care.

NOT COVERED There is no benefit for professional services or materials connected with: • Orthoptics or vision training and any associated supplemental testing; plano lenses (less than ±.50 diopter power); or two pair of glasses in lieu of bifocals. • Replacement of lenses and frames furnished under this plan which are lost or broken except at the normal intervals when services are otherwise available. • Medical or surgical treatment of the eyes. • Corrective vision treatment of an Experimental Nature. • Costs for services and/or materials above Plan Benefit allowances indicated on the enclosed insert. • Services/materials not indicated as covered Plan Benefits on the enclosed insert. LIABILITY IN EVENT OF NON-PAYMENT IN THE EVENT COMPANY FAILS TO PAY THE PROVIDER, YOU SHALL NOT BE LIABLE TO THE PROVIDER FOR ANY SUMS OWED BY THE VISION PLAN OTHER THAN THOSE NOT COVERED BY THE PLAN.

COMPLAINTS AND GRIEVANCES

If Participant ever has a question or problem, Participant’s first step is to call VSP’s Customer Service Department. The Customer Service Department will make every effort to answer Participant’s question and/or resolve the matter informally. If a matter is

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not initially resolved to the satisfaction of a Participant, the Participant may communicate a complaint or grievance to VSP orally or in writing by using the complaint form that may be obtained upon request from the Customer Service Department. Complaints and grievances include disagreements regarding access to care, or the quality of care, treatment or service. Participants also have the right to submit written comments or supporting documentation concerning a complaint or grievance to assist in VSP’s review. VSP will resolve the complaint or grievance within thirty (30) days after receipt, unless special circumstances require an extension of time. In that case, resolution shall be achieved as soon as possible, but no later than one hundred twenty (120) days after VSP’s receipt of the complaint or grievance. If VSP determines that resolution cannot be achieved within thirty (30) days, a letter will be sent to the Participant to indicate VSP’s expected resolution date. Upon final resolution, the Participant will be notified of the outcome in writing. Claim Payments and Denials A. Initial Determination: VSP will pay or deny claims within thirty (30) calendar days of the receipt of the claim from the Participant or Participant’s authorized representative. In the event that a claim cannot be resolved within the time indicated VSP may, if necessary, extend the time for decision by no more than fifteen (15) calendar days. B. Request for Appeals: If a Participant’s claim for benefits is denied by VSP in whole or in part, VSP will notify the Participant in writing of the reason or reasons for the denial. Within one hundred eighty (180) days after receipt of such notice of denial of a claim, Participant may make a verbal or written request to VSP for a full review of such denial. The request should contain sufficient information to identify the Participant for whom a claim for benefits was denied, including the name of the VSP Enrollee, Member Identification Number of the VSP Enrollee, the Participant’s name and date of birth, the name of the provider of services and the claim number. The Participant may state the reasons the Participant believes that the claim denial was in error. The Participant may also provide any pertinent documents to be reviewed. VSP will review the claim and give the Participant the opportunity to review pertinent documents, submit any statements, documents, or written arguments in support of the claim, and appear personally to present materials or arguments. Participant or Participant’s authorized representative should submit all requests for appeals to:

VSP Member Appeals

3333 Quality Drive Rancho Cordova, CA 95670

(800) 877-7195

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VSP’s determination, including specific reasons for the decision, shall be provided and communicated to the Participant within thirty (30) calendar days after receipt of a request for appeal from the Participant or Participant’s authorized representative. If Participant disagrees with VSP’s determination, he/she may request a second level appeal within sixty (60) calendar days from the date of the determination. VSP shall resolve any second level appeal within thirty (30) calendar days. When Participant has completed all appeals mandated by the Employee Retirement Income Security Act of 1974 (“ERISA”), additional voluntary alternative dispute resolution options may be available, including mediation and arbitration. Participant should contact the U. S. Department of Labor or the State insurance regulatory agency for details. Additionally, under ERISA (Section 502(a)(1)(B)) [29 U.S.C. 1132(a)(1)(B)], Participant has the right to bring a civil (court) action when all available levels of reviews of denied claims, including the appeal process, have been completed, the claims were not approved in whole or in part, and Participant disagrees with the outcome.

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HEALTH REIMBURSEMENT ARRANGEMENT

A Health Reimbursement Account (“HRA”) is an individual account under the Plan that uses pretax dollars in the account to pay for eligible out-of-pocket health care expenses incurred by you and your Dependents. The HRA is intended to qualify as an employer-provided medical reimbursement plan under code §§105 and 106 and regulations issued thereunder, and as a health reimbursement arrangement as defined under Internal Revenue Service (IRS) Notice 2002-45, and shall be interpreted to accomplish that objective. The HRA is also intended to be fully integrated into the IHF in compliance with DOL Technical Release 2013-03 and IRS Notice 2013-54.

You will need to satisfy the eligibility requirements of the Plan to participate in the

HRA. If you have any questions regarding the HRA benefit, please contact the Plan at (888) 880-8222.

ELIGIBILITY

The HRA is available to Participants performing Covered Work under a CBA only. The eligibility requirements for participation in the HRA are the same for participation in the Plan as previously described (i.e. contingent upon you being an “Eligible Employee” and meeting the hours thresholds to become a Participant). Once you reach the hours threshold, you become and remain a Participant for as long as your coverage is continued pursuant to the Eligibility Rules in Section 1 and/or you have a balance in your HRA. If you fail to meet the eligibility requirements in Section 1 (e.g. you do not have enough hours to qualify for the current or following Coverage Period) you will no longer accumulate an account balance in the HRA and your HRA account will be suspended until such time as you regain eligibility. During this suspension period, you may continue to pay for Qualified Medical Expenses incurred under the IHF.

If any balance remains in your HRA Account at the end of a Coverage Period

(e.g. February through April), such balance shall be carried over to be used in future Coverage Periods, subject to any forfeiture discussed herein.

Notwithstanding, if you fail to meet the requirement to obtain coverage for a Coverage Period under the Plan for the greater of 24 consecutive months or the length of your COBRA Coverage, the balance in your HRA will be forfeited.

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CONTRIBUTIONS TO YOUR HRA

Your HRA account will be funded exclusively through Employer Contributions pursuant to a CBA or Participation Agreement. Participant contributions to your HRA are prohibited.

Contributions to your HRA account will be credited quarterly and are contingent

upon your meeting all of the eligibility requirements for the following Coverage Period. If you fail to meet any of the eligibility requirements and are thus not eligible to participate in the Plan for the following coverage period, you will not receive credit for your HRA for work performed in the previous quarter. You have no vested right in any HRA contribution.

Example:

Joe works 50 hours in January, 40 hours in February and 100 hours in March, for a total of 190 hours in the quarter. Joe worked 475 hours in the prior six months and 1000 hours in the prior twelve months. Joe is therefore not eligible for coverage. Joe would not qualify for coverage from May through July because he failed to meet any of the eligibility tests. In this example, Joe would not receive credit to his HRA for worked performed in January through March.

USING YOUR HRA BALANCE

To the extent permitted by law, each HRA Participant may use his or her HRA balance to pay for Qualified Medical Expenses, as defined in Section 213(d) of the Internal Revenue Code and IRS Publication Section 502, incurred under the IHF. This includes copays, coinsurance, deductibles for Qualified Medical Expenses provided under your plan of benefits. The HRA balance can also be used to pay for your or your Eligible Dependents’ COBRA premiums if you or your Eligible Dependents qualify for COBRA Coverage. Lastly, you may use your HRA balance to make self-payments for Retiree Coverage, at rates set by the Plan. Add provision re MSP and HRA.

If you have a balance in your HRA upon your death, your Eligible Dependents who were participating in the IHF on the date of your death may use your remaining HRA balance to pay for COBRA premiums under the Plan. If there is a shortfall between the participant’s HRA balance and the COBRA premium, the participant’s spouse or Dependents may pay the remaining premium due to attain coverage. If the spouse or Dependents fail to pay the remaining premium to attain coverage, the HRA balance shall be forfeited.

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Participants performing Covered Work under a Collective Bargaining Agreement who have a balance in their HRA at retirement may continue to receive reimbursement from the HRA for IHF related Qualified Medical Expenses (including COBRA premiums) until your account reaches zero.

Please note that at no point may your HRA account be converted to cash or used for medical expenses incurred outside of this Plan.

HRA ADMINISTRATION

The administrative cost of operating this HRA program will be paid by IHF and the individual HRA Participant’s account will not be charged for any such administrative costs.

Each participant with an HRA account balance will be issued a MASTERCARD© with access to such HRA monies and will also have the option to file a paper claim in place of using a MASTERCARD©. The amount of contributions you receive towards your HRA is dependent upon the terms of your collective bargaining agreement. Please contact the Plan office for additional information on your contribution level.

CLAIMS PROCEDURE

You should use your MASTERCARD to pay for all of your Qualified Medical Expenses paid through your HRA account. If you have a paper claim, the following procedure shall apply: (a) Timing. Within 30 days after receipt by the IHF or its claims administrator of a reimbursement claim from a Participant, the IHF or its claims administrator will reimburse the Participant for the Participant’s Qualified Medical Expenses (if the IHF approves the claim), or the IHF or its claims administrator will notify the Participant that his or her claim has been denied. The 30-day time period may be extended for an additional 15 days for matters beyond the control of the IHF or its claims administrator, including in cases where a reimbursement claim is incomplete. The IHF or its claims administrator will provide written notice of any extension, including the reasons for the extension, and will allow the Participant 45 days in which to complete an incomplete reimbursement claim. (b) Claims Substantiation. A Participant who seeks Benefits may apply for reimbursement by submitting an application in writing to the IHF or its claims administrator in such form as the Administrator may prescribe, no later than 3 months following the close of the Plan Year in which the Qualified Medical Expense was incurred, setting forth:

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• the individual(s) on whose behalf Qualified Medical Expense have been incurred;

• the nature and date of the Qualified Medical Expense so incurred; • the amount of the requested reimbursement; • other such details about the expenses that may be requested by the IHF or its

claims administrator in the reimbursement request form or otherwise (e.g., a statement from a medical practitioner that the expense is to treat a specific medical condition, or a more detailed certification from the Participant); and

• a statement that such Qualified Medical Expense have not otherwise been reimbursed and are not reimbursable through any other source and that Health FSA coverage, if any, for such Qualified Medical Expense has been exhausted.

The application shall be accompanied by an Explanation of Benefits (EOB) showing that the Qualified Medical Expense have been incurred and the amounts of such Qualified Medical Expense, together with any additional documentation that the IHF or its claims administrator may request.

ULLICO LIFE AND ACCIDENTAL DEATH & DISMEMBERMENT

There are two classes of members covered under the Life and Accidental Death & Dismemberment Policy. All employees of Participating Employers, whose employment is the subject of Collective Bargaining Agreement by and between the Participating Employers and Bricklayers and Allied Craftworkers International Health Fund and classified as follows: Class 1 – Actives of BAC IHF Class 2 – Retirees Class 3 – Grandfathered Retirees THE AMOUNT OF INSURANCE OF ANY PERSON SHALL BE BASED UPON THE FOLLOWING: LIFE INSURANCE BENEFIT Class 1 $10,000.00 Class 2 $ 2,000.00 Class 3 $ 5,000.00

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ACCIDENTAL DEATH AND DISMEMBERMENT BENEFIT (AD&D) (Principal Sum) Class 1 $10,000.00 WORKPLACE ACCIDENTAL DEATH BENEFIT An additional amount equal to one times the standard AD&D amount up to a maximum of $50,000. When you first enroll in benefits, you are asked for beneficiary information. You may change your beneficiary at any time by contacting the IHF Fund office at 1-888-880-8222. The Fund Office will send the necessary form to update your beneficiary. To file a claim, the beneficiary needs to call the IHF Fund Office at 1-888-880-8222 to obtain a claim form. The form should be completed and returned with a certified copy of the death certificate to: 620 F ST NW Washington, DC 20004

SHORT TERM DISABILITY WEEKLY DISABILITY BENEFITS Applicable to covered Members Only WEEKLY DISABILITY SCHEDULE OF BENEFITS Weekly Benefit (Non-Occupational) …………………....................... $200* (Not to exceed 66 2/3% of Weekly Income)

Maximum Number of Weeks** .......................................................... 8 First Benefit Day For Injury .........................................................................................… 1st day For Sickness ..................................................................................….. 8th day**

*Terminates at Retirement. **1st week will be covered for disability lasting 4 weeks or more.

WEEKLY DISABILITY BENEFITS Weekly Disability benefits are payable if You become Totally Disabled while You are covered under this Plan.

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BENEFITS PAYABLE Weekly Disability benefits are payable for each separate period of disability. Benefits begin on the First Benefit Day. They are payable up to the Maximum Number of Weeks. One-seventh of the Weekly Benefit is payable for each full day you are disabled. No benefit will be paid for part of a day. This benefit is not available to your dependents.

The Short Term Disability Schedule of Benefits shows the Weekly Benefit, Maximum Number of Weeks, and First Benefit Day.

The Coverage may not be assigned. This means benefits will be paid directly to You.

Non-Occupational weekly benefits begin on the 1st day of accident disability, and on the 8th day of sickness disability (1st day of sickness disability if the sickness extends beyond 28 days) and continue for a maximum of 8 weeks during any one continuous period of disability. No reduction or restrictions of benefits because of age.

NOTE: Weekly benefits will be reduced by the amounts, if any, you receive, or are entitled to receive, for the same period of time during which each weekly benefit is payable, as total disability benefits under any Federal Social Security law.

If Social Security Disability Benefits are paid or payable for your disability, the amount payable by the Plan will not exceed 2/3 of your basic weekly earnings minus the total amount paid or payable to Social Security, as of the date Weekly Benefits become payable.

No benefits will be paid for charges in connection with sickness or injury for which benefits are paid or payable under Workers' Compensation or any Occupational Disease or similar law whether such benefits are insured or self-insured; or that is caused by, or connected in any way to, employment of the Covered Member. This includes self-employment or employment by others. It applies whether or not Workers' Compensation or any Occupational Disease or similar law covers the charges incurred. It applies whether the charges are covered on an insured or uninsured basis.10

CONTINUOUS DISABILITY - NEW DISABILITY For this coverage, a continuous period of disability includes all periods of disability due to the same or related cause or causes, separated by less than two weeks of continuous, full-time active work. If you return to continuous, full-time, active work for a period of at least two weeks, any subsequent disability will be considered a new disability irrespective of its cause or causes.

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EXCLUSION No benefit will be paid for disability caused or contributed to by intentionally self-inflicted injury.

NOTICE OF DENIAL OF CLAIM

If a claim for Hospital, Medical, Prescription Drug, Life, accidental death or dismemberment benefits is denied, in whole or in part, the Plan or the applicable PPO or claims processor will provide you with a written notice that provides:

• the specific reasons for the denial,

• references to the specific Plan provisions on which the denial is based,

• a description of any additional material or information that might help the claim and an explanation why this information is necessary,

• an explanation of the Plan’s review procedures and any time limits applicable to such procedures, including a statement of your right to bring a civil action under section 502(a) of the Participant Retirement Income Security Act of 1974 (ERISA) following an adverse determination on review;.

• If an internal rule, guideline, protocol or similar criterion was relied on in making the adverse determination, you will be provided either with the specific rule, guideline, protocol or similar criterion, or will receive a statement that such a rule, guideline, protocol or similar criterion was relied on in making the adverse determination, and a copy of such rule, guideline, protocol or other criterion will be provided to you upon request.

• If the adverse determination is based on a Medical Necessity determination or experimental treatment or similar exclusion or limitation, you will be provided either an explanation of the scientific or clinical judgment for the determination applying the terms of the Plan to your medical circumstances or a statement that such explanation will be provided free of charge upon request; and

• In the case of an adverse benefit determination concerning an urgent care claim, the notice will also describe the shortened time frames for reviewing urgent care claims. In addition, in the case of an urgent care claim, the notice may be

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provided to you verbally, within the time frames described above. You will be provided with a written notice within 3 days of verbal notification.

For Dental and Vision claims, please see the applicable section on either Dental or Vision coverage.

APPEALS

URGENT CARE CLAIMS

If the denials of benefits is rendered with respect to an Urgent Care Claim, you and/or your attending physician may submit an appeal by calling the following:

For Medical or Hospitalization: United Healthcare at 1-866-633-2474

For Prescription Drug: SavRx at 1-800-228-2181

For Dental Claims at 1-800-932-0783

For Vision Claims at 1-800-877-7195

ForHealth Reimbursement Arrangement (HRA) Disability Claims and Life Insurance Claims, contact the Plan at: 1-888-880-8222

The Plan or its claims processor will make a decision on the Urgent Care Claim within 72 hours.

ALL OTHER CLAIMS

An appeal is a request to review and change an adverse determination (i.e., denied authorization for a service) made by the Plan or its claims processor that a service is not medically necessary or is excluded from coverage. All appeals must be in writing and must be received at the appropriate address within 180 days after you receive the claim denial notice from the claims processor. Failure to file a timely written appeal will result in a complete waiver of your right to appeal and the decision of the claims processor will be final and binding.

In presenting an appeal, you have the opportunity to submit written comments, documents, records and other information relating to the claim for benefits. You are also entitled to receive, upon request and free of charge, reasonable access to, and copies of, all documents, records, and other information relevant to the claim for benefits. Personal appearances on appeals are not permitted.

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The review will take into account all comments, documents, records and other information that you submit, without regard to whether such information was submitted to or considered by the claims processor in its determination. The review will also not afford deference to the initial determination by the claims processor.

The following provisions apply to Medical, Hospitalization, Prescription Drugs, Life Insurance and Disability Benefits. For Dental or Vision appeals, please see the appeals provision in each of those sections.

For Medical and Hospitalization Appeals, please submit your appeal in writing to: United Healthcare- Appeals P.O. Box 30432 Salt Lake City, UT 84130-0432 For Prescription Drug Appeals, please submit your appeal in writing to: Sav-Rx 224 N Park Ave Fremont, NE 68025

For appeals ofHealth Reimbursement Arrangement (HRA) AD&D, and/or Life Insurance benefits, please submit your appeal in writing to: Bricklayers and Allied Craftworkers International Health Fund 620 F Street, NW Washington, DC 20004

For claims related to eligibility or other administrative issues, please submit your appeal in writing to: Bricklayers and Allied Craftworkers International Health Fund 620 F Street, NW Washington, DC 20004

MEDICAL/PRESCTIPTION DRUG/HRA CLAIMS

Level 1 Appeals - A Level 1 Appeal is your first request for review of the initial reduction or denial of services. You have 180 calendar days from the date of the notification letter to file an appeal. An appeal submitted beyond the 180-calendar-day limit will not be accepted for review. If the services have already been provided, the Plan or its claims processor will acknowledge receipt of your appeal in writing within 15 calendar days from the initial receipt date. Qualified clinical professionals who did not

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participate in the original decision will review your appeal. The Plan or its claims processor will make a decision within the following timeframes for 1st Level Appeals:

• Pre-certification - We will complete our review of a pre-certification appeal (other than an expedited appeal) within 15 calendar days of receipt of the appeal.

• Concurrent - We will complete our review of a concurrent appeal (other than an expedited appeal) within 15 calendar days of receipt of the appeal.

• Retrospective - We will complete our review of a retrospective appeal within 30 calendar days of receipt of the appeal.

The Plan or its claims processor will provide a written notice of the determination to you or your representative, and your provider, within two (2) business days of reaching a decision. If the Plan or its claims processor does not make a decision within 60 calendar days of receiving all necessary information to review your appeal, the Plan or its claims processor will approve the service. If you are dissatisfied with the outcome of your Level 1 Appeal, you have the right to file a Level 2 Appeal.

Remember - A Level 1 Appeal submitted beyond the 180-calendar-day limit will not be accepted for review. A Level 2 Appeal submitted beyond the 60-business-day limit will not be accepted for review. Level 2 Appeals and Timeframes - If you are dissatisfied with the outcome of your Level 1 Appeal, you may file a Level 2 Appeal with the Plan or its claims processor within 60 business days from the receipt of the notice of the letter denying your Level 1 Appeal. If the appeal is not submitted within that timeframe, the Plan or its claims processor will not review it and its decision on the Level 1 Appeal will stand. Appeals may be filed by telephone and in writing.

The Plan or its claims processor will make a decision within the following timeframes for Level 2 Appeals:

• Pre-certification - the Plan or its claims processor will complete our review of a pre-certification appeal within 15 calendar days of receipt of the appeal.

• Concurrent - the Plan or its claims processor will complete our review of a concurrent appeal within 15 calendar days of receipt of the appeal.

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• Retrospective - the Plan or its claims processor will complete its review of a retrospective appeal within 30 calendar days of receipt of the appeal.

Independent Review Organization

Health Services Claims. If you are not fully satisfied with the decision of the Plan or its claims processor’s level-two appeal decision of a claim that involved Medical Judgment, you may request that your appeal be sent to an Independent Review Organization (IRO) for review. The IRO is composed of persons who are not employed by the Plan or its claims processor, or any of its affiliates. A decision to request an appeal to an IRO will not affect your rights to any other benefits under the Plan. There is no charge for this independent review process. The Plan will abide by the decision of the IRO. In order to request a referral to an IRO, the reason for the denial must be based on a Medical Judgment or clinical appropriateness determination by the Plan or its claims processor. As noted above, medical judgment means a determination based on, but not limited to, the Plan’s requirements for medical necessity, appropriateness, health care setting, level of care, or effectiveness of a covered benefit; or a determination that a treatment is experimental or investigational. Administrative, eligibility, or benefit coverage limits or exclusions are not eligible for review by the IRO. To request a review, you must have exhausted the Fund’s internal appeal process, or are not required to exhaust (for example you are appealing an urgent care claim) and notify the Plan or its claims processor within four months of your receipt of the Plan or its claims processor’s level-two appeal review denial. The Plan or its claims processor will then forward the file to the IRO. The IRO will provide written notice of its decision within 45 days. When requested, and if a delay would be detrimental to your medical condition, as determined by the Plan or its claims processor’s physician reviewer, or if your appeal concerns an admission, availability of care, continued stay, or health care item or service for which you received emergency services, but you have not yet been discharged from a facility, the IRO review shall be completed within 72 hours.

To proceed with an IRO Review, you or your authorized representative must contact the Plan in writing at Bricklayers and Allied Craftworkers International Health Fund, 620 F Street, NW, Washington, DC 20004 and provide at least the following information:

• the identity of the claimant • the date(s) of the medical service • the specific medical condition or symptom; • the provider’s name; • the service or supply for which approval of benefits was sought

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• any reasons why the appeal should be processed on a more expedited basis.

LIFE INSURANCE/AD&D APPEALS The Plan maintains a one level appeal for post-service Life Insurance and AD&D Claims. Appeals must be submitted in writing to the: Appeals Committee of the Bricklayers and Allied Craftworkers International Health Fund 620 F Street, NW Washington, DC 20004 (888) 880-8222 (phone) The Appeals Committee of the Board of Trustees will make a determination on the appeal no later than 90 calendar days from receipt of the appeal. You will receive a notice of decision on review within 5 days of the Appeals Committee making the benefit determination. Content of Notification of Decision on Review You will receive a written or electronic notice of the determination on review. If the appeal is denied in whole or in part, the written notice will include:

• The specific reason(s) for the denial; • Reference to the specific Plan provisions on which the benefit determination is

based; • a statement that you are entitled to receive upon request and free of charge

reasonable access to and copies of all documents, records and other information relevant to your claim for benefits;

• if an internal rule, guideline, protocol or similar criterion was relied on in making the adverse determination, either you will be provided with the specific rule, guideline, protocol or similar criterion, or you will receive a statement that such a rule, guideline, protocol or similar criterion was relied on in making the adverse determination, and a copy of such rule, guideline, protocol or other criterion will be provided to you free of charge upon request; and

• If the adverse determination was based on a Medical Necessity or experimental treatment or similar exclusion or limit, the denial notice will include either an explanation of the scientific or clinical judgment for the determination or a statement that such explanation will be provided free of charge upon request.

Reviewer's Decision on Appeal is Final and Binding

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The decision of each reviewer is final and binding on all parties, including anyone claiming a benefit on behalf of the claimant. Each reviewer has full discretion and authority to determine all matters relating to the benefits provided under the portion of the Plan for which the reviewer has responsibility including, but not limited to, questions of coverage, eligibility, and methods of providing or arranging for benefits. Each reviewer also has full discretion and authority over the standard of proof required for any claim and over the application and interpretation of the portion of the Plan for which the reviewer has responsibility. In the case of reviews conducted by the Trustees of the Plan, the Fund Office will maintain records of determinations on appeal and Plan interpretations so that those determinations and interpretations may be referred to in future cases with similar circumstances. If a reviewer denies an appeal and the claimant decides to seek judicial review, the reviewer’s decision will typically be subject to limited judicial review to determine only whether the decision was arbitrary and capricious. No lawsuit may be brought without first exhausting the above claims and appeals procedure. Nor may any evidence be used in court unless it was first submitted to the appropriate reviewer prior to the decision on appeal.

REIMBURSEMENT AND SUBROGATION

CASES INVOLVING A THIRD PARTY

This Plan is not required to pay benefits for you or your Dependent for an injury (including an illness) for which another party may be liable. The Plan may, however, advance benefits to the injured party (you or your Dependent) while a third party's liability is being determined. You must notify the Plan in writing as soon as the injured party institutes a claim against another person or entity, and the Fund Office will require the injured party to sign a Reimbursement/Subrogation acknowledgement form before any benefits are paid. If you, your Dependent, if applicable, or your attorney refuse to sign a Reimbursement/Subrogation acknowledgement form, the Plan may withhold payment of any benefits as a result of the injury cause by a third-party, and may recoup by offset or lawsuit any amount already paid.

REIMBURSEMENT

If you or your Dependent should recover damages from an insurance company or from the other party (for example, in a lawsuit), then you must reimburse the Plan for the payments it has made or will make in connection with the injury. If you are injured by another party, you are required as a condition of receiving benefits from the Plan to sign a form acknowledging the Plan's right to recover under the terms of the Plan. The

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Plan's right or subrogation/reimbursement is established by the Plan and not by the acknowledgement form. In the event you receive benefits in such a case, the Plan's interest in your recovery is governed by the terms of the Plan irrespective of whether you have signed the acknowledgement form.

Under the terms of the Plan, the acceptance of benefits by a Participant or beneficiary (or someone acting on his or her behalf) who has been injured by another party constitutes an agreement by the injured party to reimburse the Plan for benefits paid up to the full amount of the recovery due to the injury. The Plan has a right to first reimbursement out of any recovery whether or not the amounts recovered are designated to cover medical expenses. By accepting benefits from the Plan, the injured person agrees that any amount recovered by the injured person by judgment, settlement or compromise, will be applied first to reimburse the Plan, without reduction for attorneys’ fees or costs, even if the injured person is not made whole. Amounts recovered by the injured person in excess of benefits paid by the Plan are the separate property of the injured person. In addition, amounts received from an individual health insurance policy for which the injured person or a member of the injured person’s family has paid premiums are also the separate property of the injured person.

By accepting benefits from the Plan, the injured party agrees to notify the Plan promptly of efforts made to recover from a third party, including filing a suit to recover amounts in connection with the injury or illness. Furthermore, in the event the injured party or someone acting on his or her behalf receives payment from any source for claims related to the injury, the injured person agrees to notify the Plan promptly. By accepting benefits from the Plan, the injured person agrees that neither the injured person nor anyone acting on behalf of the injured person will settle any claim relating to the accident or illness without the written consent of the Plan.

In the event an injured party accepts benefits from the Plan and amounts are recovered from claims arising from the injury, the amounts recovered, up to the amount paid on behalf of the injured person by the Plan, are assets of the Plan by virtue of the Plan’s reimbursement interest. Such Plan assets may not be distributed without a release from the Plan. Furthermore, by accepting benefits from the Plan, the injured person specifically agrees that any payments, up to the amount paid on behalf of the injured person by the Plan, must remain in the possession of the injured person or his or her authorized agent and placed in a specifically identifiable segregated account. The injured person also acknowledges that, under the terms of the Plan, any payments so held constitute assets of the Plan until and unless the Trustees waive or release the Plan’s right to reimbursement.

In the event monies are recovered and the Plan is not reimbursed to the extent of its interest in accordance with Plan provisions, the Plan may bring suit against the injured party, insurers and any recipients of the Plan assets improperly distributed

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without the consent of the Plan. The Plan may recover benefits paid on behalf of the injured person by treating such benefits as an advance and deducting such amounts from benefits which become due to the injured person and his or her immediate family until the Plan’s interest is recovered. Such benefits may be deducted from amounts due to third parties who have provided medical services despite any certification of coverage which the Plan may have provided to such providers.

SUBROGATION

The Plan is not required to participate in an injured person's claims to demand reimbursement from an injured person or to invoke its subrogation rights. The Plan may request that the injured person assign or subrogate his or her claim or any other right of recovery to the Plan so that the Plan can enforce its right to recovery. The injured person must cooperate fully with the Plan in connection with any claim brought by the Plan to recover its assigned or subrogated interest. By accepting benefits from the Plan, the injured person authorizes the Plan to elect to pursue any claims arising from the injury in the name of the injured person and/or the Plan's name and to sue, compromise or settle such claims without the approval of the injured person to the extent of benefits paid and/or to be paid. If the injured person does not cooperate or if the injured person or anyone acting on the injured person's behalf takes any action which harms the Plan's subrogated interest, the Plan is entitled to cease payment of any benefits connected to the third-party-caused injury, and recover from the injured person the amount of plan benefits paid. The Plan may bring a lawsuit against the injured person to collect payments already made or may collect these amounts by offset, against any future benefit payments otherwise due to the injured person and their immediate family. If legal proceedings are instituted the Plan may recover the costs and attorney's fees incurred.

CASES INVOLVING WORK-RELATED CLAIMS

In general, the Plan does not cover expenses for an illness or injury that arises out of the course of employment. However, an exception exists if you have a work related injury or illness for which a claim has been filed with a worker’s compensation insurance carrier or with a federal or state court or agency. In the event that the claim has been initially denied, then the Plan, upon request, may pay benefits arising from the work- related injury or illness.

By accepting these benefits from the Plan, you agree to actively pursue your work- related claim and also agree that the Plan has the power to institute, compromise or settle such a claim in your name, to the extent of benefits paid. By accepting these benefits, you also agree that any amounts recovered by award, judgment, settlement or otherwise, and regardless of how the proceeds are characterized, are assets of the Plan and will be applied first to reimburse the Plan, in full and without any reduction for

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attorney’s fees or costs, for benefits paid due to the work related claim. The Plan must be reimbursed first, even if you are not made whole. Once benefits are paid under this provision, you may not settle your work related claim without the written consent of the Plan.

As a condition of receiving benefits from the Plan, you are required to sign a form acknowledging the Plan’s right to reimbursement under the Plan. The Plan’s right to reimbursement is established by the Plan and not by the form. The Plan’s interest in your recovery is governed by the terms of the Plan irrespective of whether you have signed the acknowledgment form. Therefore, the Plan has the rights described in the section even if you have not notified the Plan.

If monies are recovered and the Plan is not reimbursed to the extent of its subrogation interest in accordance with Plan provisions, the Plan may bring suit against you, any insurers and any recipients of the Plan assets improperly distributed without the consent of the Plan. The Plan may recover benefits paid on your behalf by treating such benefits as an advance and deducting such amounts from benefits, which become due to you and your family until the Plan’s interest is recovered. Such benefits may be deducted from amounts due to third parties who have provided medical services despite any certification of coverage which the Plan may have provided to such providers.

FRAUDULENT AND ERRONEOUS CLAIMS

If a fraudulent claim is submitted, benefits will be denied. However, if any benefits are paid on a fraudulent claim, the amounts due to the Plan may be deducted from any benefits due to the Participant and his or her Dependent(s) until the Plan is reimbursed for the benefits improperly paid.

If any claim is paid because of a mistake of law or fact not due to fraud, the Plan Office will make a written demand upon the Participant for repayment. If repayment is not promptly made, the matter will be brought to the attention of the Trustees. If the Trustees so determine, the amounts due the Plan may be deducted from any benefits due to the Participant and his or her Dependent(s) until the Plan is reimbursed for the benefits improperly paid.

You must reimburse the Plan for any claim paid in error by the Fund Office because you have failed to update your enrollment status. Important events that must be reported include your divorce, legal separation, loss of custody, and the marriage or gainful employment of a child. If reimbursement is not promptly made, the amounts due the Plan may be deducted from any benefits due to the Participant and his or her Dependent(s) until the Plan is reimbursed for the benefits improperly paid.

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PAYMENT TO THIRD PARTIES

Generally, benefits payable under the Plan cannot be alienated, transferred, assigned, or otherwise promised to a person or party other than the employee. However, there are some exceptions to this rule. You may direct that benefits payable to you be paid to an institution or provider of medical care that provided medical care for which benefits are payable under this Plan. However, the Plan is not obligated to accept such direction from you, and no payment by the Plan pursuant to your direction shall be considered as recognition by the Plan of a duty or obligation to pay a provider of medical care except to the extent to which the Plan actually chooses to do so.

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COORDINATION OF BENEFITS WITH OTHER PLANS

Family members may be covered under more than one plan of health benefits. In order to avoid duplication of benefits (i.e., two plans paying benefits for the same dollar of medical expense), the Plan has a Coordination of Benefits provision for all covered benefits except Health Reimbursement Arragement,Life Insurance and Accidental Death & Dismemberment.

“Coordination” means that benefits from this Plan plus benefits received from other health plans can total, but not exceed, 100% of the Allowable Expenses for each Participant in each calendar year. This is intended to permit full payment of Allowable Expenses but not duplicate payments.

“Allowable Expenses” are any Medically Necessary charges for Hospital, Medical, Dental and Vision benefits and services covered in whole or in part by this Plan (except as noted above) and any other plan covering the person making the claim. Expenses not covered by any plan to which a person belongs are not Allowable Expenses, for example, charges for personal comfort items, such as television rental in the Hospital.

“Other health plans” include group plans (either insured or self-insured) such as health plans available from your Spouse’s employer and Medicare.

HOW COORDINATION WORKS WITH ANOTHER GROUP HEALTH PLAN

If you are covered by two or more plans, the benefit payment follows the rules below in this order:

• this Plan will always be secondary to medical payment coverage or personal injury protection coverage under any auto liability or no-fault insurance policy;

• when you have coverage under two or more medical plans and only one has COB provisions, the plan without COB provisions will pay benefits first;

• a plan that covers a person as an employee pays benefits before a plan that covers the person as a Dependent;

• if you are receiving COBRA continuation coverage under another employer plan, this Plan will pay Benefits first;

• your Dependent children will receive primary coverage from the parent whose birth date occurs first in a calendar year. If both parents have the same birth

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date, the plan that pays benefits first is the one that has been in effect the longest. This birthday rule applies only if:

o the parents are married or living together whether or not they have ever been married and not legally separated; or

o a court decree awards joint custody without specifying that one party has the responsibility to provide health care coverage;

• if two or more plans cover a Dependent child of divorced or separated parents and if there is no court decree stating that one parent is responsible for health care, the child will be covered under the plan of:

§ the parent with custody of the child; then § the Spouse of the parent with custody of the child; then § the parent not having custody of the child; then § the Spouse of the parent not having custody of the child;

• plans for active employees pay before plans covering laid-off or retired employees;

• the plan that has covered the individual claimant the longest will pay first; and • finally, if none of the above rules determines which plan is primary or secondary,

the allowable expenses shall be shared equally between the plans meeting the definition of Plan. In addition, this Plan will not pay more than it would have paid had it been the primary Plan.

WHEN THIS PLAN IS SECONDARY

If this Plan is secondary, it determines the amount it will pay for a Covered Health Service by following the steps below.

• the Plan determines the amount it would have paid based on the allowable expense.

• the Plan pays the entire difference between the allowable expense and the amount paid by the primary plan – as long as this amount is not more than the Plan would have paid had it been the only plan involved.

You will be responsible for any Coinsurance or Deductible payments as part of the COB payment. The maximum combined payment you may receive from all plans cannot exceed 100% of the total allowable expense.

DETERMINING THE ALLOWABLE EXPENSE IF THIS PLAN IS SECONDARY

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If this Plan is secondary, the allowable expense is the primary plan's Network rate. If the primary plan bases its reimbursement on reasonable and customary charges, the allowable expense is the primary plan's reasonable and customary charge. If both the primary plan and this Plan do not have a contracted rate, the allowable expense will be the greater of the two plans’ reasonable and customary charges.

When the provider is a Network provider for both the primary plan and this Plan, the allowable expense is the primary plan’s network rate. When the provider is a network provider for the primary plan and a non-Network provider for this Plan, the allowable expense is the primary plan’s network rate. When the provider is a non-Network provider for the primary plan and a Network provider for this Plan, the allowable expense is the reasonable and customary charges allowed by the primary plan. When the provider is a non-Network provider for both the primary plan and this Plan, the allowable expense is the greater of the two Plans’ reasonable and customary charges.

HOW COORDINATION WORKS WITH MEDICARE

MEDICARE COORDINATION FOR ACTIVE PARTICIPANTS WHO ARE ELIGIBLE FOR MEDICARE

At age 65, you become eligible for Medicare benefits. In addition, anyone under age 65 who is entitled to Social Security Disability is also entitled to Medicare coverage (usually after a waiting period). If you continue to work and have enough hours to meet the eligibility requirements, you continue to be covered by the Plan’s medical benefits as an Active Participant and the Plan will pay as primary. Medical benefits provided by the Plan will be primary coverage for both you and your Spouse ( even if he or she is also eligible for Medicare), and Medicare benefits will be secondary. You will have the benefit of two coverages. As long as you remain eligible under this Plan, due to hours worked or employee self-payments, you should continue to submit your claims to the Plan. After payment by the Plan, you can submit any remaining expenses to Medicare for possible payment.

Active disabled employees (as defined in Federal Regulations) also receive primary coverage from the Plan and secondary coverage from Medicare as described above.

In deciding whether to enroll in Medicare, the following points should be kept in mind:

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• Having coverage under this Plan and Medicare provides the greatest protection;

• You are responsible for enrolling in Medicare; and

• Consider how long you expect to work and what will happen to your coverage when you stop working. You may not be able to enroll in Medicare at the same time that coverage under this Plan stops.

The Plan requires that all Participants eligible for Medicare enroll in Medicare Parts A and B, and pay the Premium for Parts A and B. The Plan will pay benefits based on the premise that the Participant has elected Parts A and B, regardless of whether the Participant has elected Parts A and B or not.

MEDICARE COORDINATION FOR END-STAGE RENAL DISEASE

If you are an Active Participant and are entitled to Medicare because of End-Stage Renal Disease (ESRD), this Plan pays first and Medicare pays second for 30 months starting the earlier of the month in which Medicare ESRD coverage begins or the first month in which the individual receives a kidney transplant. Then, starting with the 31st month after the start of Medicare coverage, Medicare pays first and this Plan pays second.

MEDICARE COORDINATION FOR COBRA QUALIFIED BENEFICIARIES

If you are age 65 or over OR are disabled and covered by both Medicare and COBRA continuation coverage from this Plan, Medicare will pay first and your COBRA continuation coverage under this Plan will pay second.

If you have End-Stage Renal Disease (ESRD) and are covered by Medicare (as a result of ESRD) and are, or become covered by COBRA continuation coverage from this Plan, this Plan will pay first during the first 30 months of eligibility/entitlement to Medicare and Medicare will pay second. After the 31st month after the start of Medicare coverage, if you are, or become covered under COBRA Continuation Coverage, Medicare pays first and your COBRA continuation coverage under this Plan pays second. Note that this provision does not extend the maximum periods of COBRA Continuation Coverage and that once you exhaust the maximum COBRA period, your coverage under this Plan will end.

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MEDICARE COORDINATION FOR RETIRED PARTICIPANTS

If you are a retiree or an inactive disabled Participant and become eligible for Medicare, Medicare will be your primary coverage. After Medicare has covered the expense, the Plan will pay benefits. You will have to satisfy any applicable Deductible whether or not the medical services are covered by Medicare.

Medicare has two parts, Hospital Insurance (Part A) and Medical Insurance (Part B). Part A covers inpatient Hospital care and generally is available to all individuals age 65 and over at no cost. Part B covers Physician services, outpatient Hospital services and other medical supplies and is optional. You must pay a monthly premium for Part B. To have adequate coverage, you and your Spouse must sign up for both Medicare Part A and Part B when eligible.

All medical claims after your enrollment in Medicare must be submitted to Medicare first. After Medicare pays the claim, submit a copy of the bill along with the Medicare Explanation of Benefits to the Plan.

The Plan’s medical payment will coordinate with Medicare’s payment. For covered expenses, the Plan will determine its benefit based on the Medicare-approved amount and then subtract the Medicare benefit and consider the balance under the provisions of the Plan. For these expenses, the Plan carves out Medicare payments. However, Federal Law limits the amount a provider (Hospital, Physician, etc.) can charge above the Medicare payment. The Plan cannot pay the provider more than that amount and the provider cannot legally bill you more than that amount.

ENROLLING IN MEDICARE

It is important that you or your Eligible Dependent visit an office of the Social

Security Administration during the three-month period prior to your 65th birthday or earlier if you are disabled or have End-Stage Renal Disease (ESRD), to learn all about Medicare. If you have questions about this Plan’s coverage or would like help in comparing benefits offered by this Plan and Medicare, please contact the Fund Office. Keep in mind that the Plan will pay benefits as if you have enrolled both Medicare Part A and Part B benefits irrespective of whether you enroll in Medicare Part A and Part B.

In addition, if an individual who is eligible for benefits under this Plan becomes covered by Medicare, whether because of age, disability or ESRD, that individual may either retain or cancel coverage under this Plan. The choice of retaining or canceling coverage under this Plan of a Medicare participant is the responsibility of the

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Participant. Neither this Plan nor the Participant’s employer will provide any consideration, incentive or benefits to encourage cancellation of coverage under this Plan.

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OVERPAYMENT AND UNDERPAYMENT OF BENEFITS

If you are covered under more than one medical plan, there is a possibility that the other plan will pay a benefit that UnitedHealthcare should have paid. If this occurs, the Plan may pay the other plan the amount owed.

If the Plan pays you more than it owes under this COB provision, you should pay the excess back promptly. Otherwise, the IHF may recover any overpayment by legal action or offset payments on future Eligible Expenses.

If the Plan overpays a health care provider, UnitedHealthcare reserves the right to recover the excess amount, by legal action if necessary.

REFUND OF OVERPAYMENTS

If IHF pays for Benefits for expenses incurred on account of a Participant, that Participant, or any other person or organization that was paid, must make a refund to IHF if:

• all or some of the expenses were not paid by the Participant or did not legally have to be paid by the Participant

• all or some of the payment IHF made exceeded the Benefits under the Plan; or • all or some of the payment was made in error.

The refund equals the amount IHF paid in excess of the amount that should have been paid under the Plan. If the refund is due from another person or organization, the Participant agrees to help IHF get the refund when requested.

If the Participant, or any other person or organization that was paid, does not promptly refund the full amount, IHF may reduce the amount of any future Benefits for the Participant that are payable under the Plan. The reductions will equal the amount of the required refund. IHF may have other rights in addition to the right to reduce future Benefits.

MISCELLANEOUS

Under the Patient Protection and Affordable Care of 2010 (the “Affordable Care Act”), the Plan may not rescind a participant’s coverage retroactively except in the case of fraud or the individual’s intentional misrepresentation of a material fact, as prohibited by the Plan’s terms.

The Plan reserves the right to terminate the health coverage of you and/or your Dependents prospectively without notice for cause (as determined by the Plan Administrator), or if you and/or your Dependents are otherwise determined to be ineligible for coverage under the Plan. In addition, if you or your Dependents commit

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fraud or intentional misrepresentation in an application for health coverage under the Plan, in connection with a benefit claim or appeal, or in response to any request for information by the Plan, the Plan may terminate your coverage retroactively upon thirty (30) days notice.

Additionally, although the Board of Trustees expect to continue the Plan indefinitely, it reserves the right to discontinue, alter or modify the Plan in whole or in part, at any time and for any reason, at its sole determination.

The Trustees’ decision to terminate or amend a Plan may be due to changes in federal or state laws governing employee benefits, the requirements of the Internal Revenue Code or Participant Retirement Income Security Act of 1974 (ERISA), or any other reason. A plan change may transfer plan assets and debts to another plan or split a plan into two or more parts. If the Trustees does change or terminate a plan, it may decide to set up a different plan providing similar or different benefits.

If this Plan is terminated, Participants will not have the right to any other Benefits from the Plan, other than for those claims incurred prior to the date of termination, or as otherwise provided under the Plan. In addition, if the Plan is amended, Participants may be subject to altered coverage and Benefits.

The amount and form of any final benefit you receive will depend on any SPD or contract provisions affecting the Plan and Trustees’ decisions. After all Benefits have been paid and other requirements of the law have been met, certain remaining Plan assets will be turned over to the Trustees and others as may be required by any applicable law.

SOURCES OF CONTRIBUTIONS TO THE PLAN

The Plan is maintained pursuant to a number of Collective Bargaining Agreements. A copy of any such agreement may be obtained by participants and/or their beneficiaries covered under that particular agreement upon written request to the Welfare Fund office and is available for examination at the Welfare Fund office by participants and/or their beneficiaries covered under that particular agreement

Contributions are made to the Welfare Fund by Employers in accordance with the terms of these Collective Bargaining Agreements. Contributions by non-bargaining unit employees, owner-operators and retired members are made by monthly contributions to the Plan in amounts set by the Board of Trustees.

BAC INTERNATIONAL HEALTH FUND PRIVACY NOTICE

This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully.

You have the right to:

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• Get a copy of your health and claims records • Correct your health and claims records • Request confidential communication • Ask us to limit the information we share • Get a list of those with whom we’ve shared your information • Get a copy of this privacy notice • Choose someone to act for you • File a complaint if you believe your privacy rights have been violated

YOUR CHOICES

You have some choices in the way that we use and share information as we: • Answer coverage questions from your family and friends • Provide disaster relief • Market our services and sell your information

OUR USES AND DISCLOSURES

We may use and share your information as we: • Help manage the health care treatment you receive • Run our organization • Pay for your health services • Administer your health plan • Help with public health and safety issues • Do research • Comply with the law • Respond to organ and tissue donation requests and work with a medical

examiner or funeral director • Address workers’ compensation, law enforcement, and other government

requests • Respond to lawsuits and legal actions

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YOUR RIGHTS

When it comes to your health information, you have certain rights. This section explains your rights and some of our responsibilities to help you.

Get a copy of health and claims records

• You can ask to see or get a copy of your health and claims records and other health information we have about you. Ask us how to do this.

• We will provide a copy or a summary of your health and claims records, usually within 30 days of your request. We may charge a reasonable, cost-based fee.

Ask us to correct health and claims records

• You can ask us to correct your health and claims records if you think they are incorrect or incomplete. Ask us how to do this.

• We may say “no” to your request, but we’ll tell you why in writing within 60 days.

Request confidential communications

• You can ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address.

• We will consider all reasonable requests, and must say “yes” if you tell us you would be in danger if we do not.

Ask us to limit what we use or share

• You can ask us not to use or share certain health information for treatment, payment, or our operations.

• We are not required to agree to your request, and we may say “no” if it would affect your care.

Get a list of those with whom we’ve shared information

• You can ask for a list (accounting) of the times we’ve shared your health information for six years prior to the date you ask, who we shared it with, and why.

• We will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked us to make). We’ll provide one accounting a year for free but will charge a reasonable, cost-based fee if you ask for another one within 12 months.

Get a copy of this privacy notice

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You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. We will provide you with a paper copy promptly.

Choose someone to act for you

• If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information.

• We will make sure the person has this authority and can act for you before we take any action.

File a complaint if you feel your rights are violated

• You can complain if you feel we have violated your rights by contacting us using the information on page 1.

• You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775, or visiting www.hhs.gov/ocr/privacy/hipaa/complaints/.

• We will not retaliate against you for filing a complaint.

YOUR CHOICES

For certain health information, you can tell us your choices about what we share. If you have a clear preference for how we share your information in the situations described below, talk to us. Tell us what you want us to do, and we will follow your instructions.

In these cases, you have both the right and choice to tell us to:

• Share information with your family, close friends, or others involved in payment for your care

• Share information in a disaster relief situation

If you are not able to tell us your preference, for example if you are unconscious, we may go ahead and share your information if we believe it is in your best interest. We may also share your information when needed to lessen a serious and imminent threat to health or safety.

In these cases we never share your information unless you give us written permission:

• Marketing purposes

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• Sale of your information

OUR USES AND DISCLOSURES

HOW DO WE TYPICALLY USE OR SHARE YOUR HEALTH INFORMATION?

We typically use or share your health information in the following ways.

Help manage the health care treatment you receive

We can use your health information and share it with professionals who are treating you.

Example: A doctor sends us information about your diagnosis and treatment plan so we can arrange additional services.

Run our organization

• We can use and disclose your information to run our organization and contact you when necessary.

• We are not allowed to use genetic information to decide whether we will give you coverage and the price of that coverage. This does not apply to long term care plans.

Example: We use health information about you to develop better services for you.

Pay for your health services

We can use and disclose your health information as we pay for your health services.

Example: We share information about you with your dental plan to coordinate payment for your dental work.

Administer your plan

We may disclose your health information to your health plan sponsor for plan administration.

Example: Your company contracts with us to provide a health plan, and we provide your company with certain statistics to explain the premiums we charge.

HOW ELSE CAN WE USE OR SHARE YOUR HEALTH INFORMATION?

We are allowed or required to share your information in other ways – usually in ways that contribute to the public good, such as public health and research. We have to meet

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many conditions in the law before we can share your information for these purposes. For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html.

Help with public health and safety issues

We can share health information about you for certain situations such as:

• Preventing disease • Helping with product recalls • Reporting adverse reactions to medications • Reporting suspected abuse, neglect, or domestic violence • Preventing or reducing a serious threat to anyone’s health or safety

Do research

We can use or share your information for health research.

Comply with the law

We will share information about you if state or federal laws require it, including with the Department of Health and Human Services if it wants to see that we’re complying with federal privacy law.

Respond to organ and tissue donation requests and work with a medical examiner or funeral director

• We can share health information about you with organ procurement organizations.

• We can share health information with a coroner, medical examiner, or funeral director when an individual dies.

Address workers’ compensation, law enforcement, and other government requests

We can use or share health information about you:

• For workers’ compensation claims • For law enforcement purposes or with a law enforcement official • With health oversight agencies for activities authorized by law • For special government functions such as military, national security, and

presidential protective services

Respond to lawsuits and legal actions

http://www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html

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We can share health information about you in response to a court or administrative order, or in response to a subpoena.

OUR RESPONSIBILITIES • We are required by law to maintain the privacy and security of your protected

health information. • We will let you know promptly if a breach occurs that may have compromised the

privacy or security of your information. • We must follow the duties and privacy practices described in this notice and give

you a copy of it. • We will not use or share your information other than as described here unless

you tell us we can in writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind.

For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html.

CHANGES TO THE TERMS OF THIS NOTICE

We can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available upon request, on our web site, and we will mail a copy to you.

OTHER INSTRUCTIONS FOR NOTICE

• This Notice is effective October 1, 2015 • Robin Donovick is your Privacy Officer and she can be reached at (888) 880-

8222

STATEMENT OF PARTICIPANTS RIGHTS UNDER ERISA

As a plan participant in the IHF, you are entitled to certain rights and protections under the Participant Retirement Income Security Act of 1974 (“ERISA”). ERISA provides that all Plan Participants shall be entitled to:

a. The right to receive information about your plan and benefits including the right to examine, without charge, at the Plan Administrator’s office and at other specified locations, such as work sites and union halls, all documents governing the Plan, including insurance contracts and Collective Bargaining Agreements, and a copy of the latest annual report (Form 5500 Series) filed by the Plan with the U.S. Department of Labor and available at the Public Disclosure Room of the Participant Benefit Security Administration.

http://www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html

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b. The right to obtain, upon written request to the Plan Administrator, copies of

documents 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. The Plan Administrator may make a reasonable charge for the copies.

c. The right to receive a summary of the Plan’s annual financial report. The Plan Administrator is required by law to furnish each participant with a copy of this summary annual report.

d. The right to continue group health coverage under COBRA should you or your Dependent lose coverage as a result of a Qualifying Event

e. The right to prudent action by Plan fiduciaries. In addition to creating rights for Plan participants, ERISA imposes duties on the people who are responsible for the operation of the Plan. The people who operate your Plan, who are called "fiduciaries" of the Plan, have a duty to do so prudently and in the sole interest of you and other Plan participants and beneficiaries. No one, including your Employer, your union, or any other person may fire you or otherwise discriminate against you in any way to prevent you from receiving benefits under the Plan Benefit or exercising your rights under ERISA.

How to Enforce Your Rights

a. If your claim for a Plan Benefit is denied or ignored, in whole or in part, you have a right to know why this was done, to obtain copies of documents relating to the decision without charge, and to appeal any denial, all within certain time schedules.

b. Under ERISA, there are steps you can take to enforce the above rights. For instance, if you request a copy of the SPD from the Plan, and do not receive it within 30 days, you may file suit in a federal court. In such a case, the court may require the Plan Administrator to provide the materials and pay you up to $110 a day until you receive the materials, unless the materials were not sent for reasons beyond the control of the Plan Administrator.

If you have a claim for Benefits, which is denied or ignored, in whole or in part, and if you have exhausted the claims procedure available under the Plan, you may file suit in a state or federal court. In addition, if you disagree with the Plan's decision or lack thereof concerning the qualified status of a domestic relations order, you may file suit in federal court. If it should happen that the Plan's fiduciaries misuse the Plan's money, or if you are discriminated against 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

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order the person you have sued to pay these costs and fees. If you lose, the court may order you to pay these costs and fees; for example, if it finds your claim is frivolous.

Assistance with Your Questions

If you have any questions about your Plan, you should contact the Plan Administrator. If you have any questions about this statement or about your rights under ERISA, or if you need assistance in obtaining documents from the Plan Administrator, you should contact the nearest office of the Participant Benefits Security Administration, U.S. Department of Labor, listed in your telephone directory, or write to the Division of Technical Assistance and Inquiries, Participant Benefits Security Administration, U.S. Department of Labor, 200 Constitution Avenue N.W. Washington, DC 20210. You may also obtain certain publications about your rights and responsibilities under ERISA by calling the publications hotline of the Participant Benefits Security Administration at (866) 444-3272.

The Medical Plan's Benefits are administered by IHF, the Plan Administrator. UnitedHealthcare is the Claims Administrator and processes claims for the Plan and provides appeal services; however, UnitedHealthcare and IHF are not responsible for any decision you or your Dependents make to receive treatment, services or supplies, whether provided by a Network or non-Network provider. UnitedHealthcare and IHF are neither liable nor responsible for the treatment, services or supplies provided by Network or non-Network providers.

PLAN ADMINISTRATOR’S DISCRETIONARY AUTHORITY

Please note that the Plan Administrator shall perform its duties as Plan Administrator and in its sole discretion shall determine appropriate courses of action in light of the reason and purpose for which this Plan is established and maintained. In particular, the Plan Administrator shall have full and sole discretionary authority to interpret this Summary Plan Description, and to resolve and interpret any ambiguities that may exist and to make all necessary factual determinations as to whether any individual is entitled to receive any benefit under the terms of the Plan. Any construction of the terms of this SPD and any determination of fact adopted by the Plan Administrator shall be final and legally binding on all parties.

Any interpretation, determination, or other action of the Plan Administrator shall be subject to review only if it is arbitrary or capricious or otherwise an abuse of discretion. Any review of a final decision or action of the Plan Administrator shall be based only on such evidence presented to or considered by the Plan Administrator at the time it made the decision that is the subject of review. Accepting any benefits or making any claim for benefits under this Plan constitutes an agreement with and consent to any decisions that the Plan Administrator makes, in its sole discretion and, further, constitutes agreement to the limited standard and scope of review described by this section.

Information and Records

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IHF and its Business Associates may use your individually identifiable health information to administer the Plan and pay claims, to identify procedures, products, or services that you may find valuable, and as otherwise permitted or required by law. IHF and its Business Associates may request additional information from you to decide your claim for Benefits. IHF and its Business Associates will keep this information confidential. IHF and its Business Associates may also use your de-identified data for commercial purposes, including research, as permitted by law.

By accepting Benefits under the Plan, you authorize and direct any person or institution that has provided services to you to furnish IHF and its Business Associates with all information or copies of records relating to the services provided to you. IHF and its Business Associates have the right to request this information at any reasonable time. This applies to all Participants, including enrolled Dependents whether or not they have signed the Participant's enrollment form. IHF and its Business Associates agree that such information and records will be considered confidential.

IHF and its Business Associates have the right to release any and all records concerning health care services which are necessary to implement and administer the terms of the Plan, for appropriate medical review or quality assessment, or as IHF is required to do by law or regulation. During and after the term of the Plan, IHF and its Business Associates and their related entities may use and transfer the information gathered under the Plan in a de-identified format for commercial purposes, including research and analytic purposes.

For complete listings of your medical records or billing statements IHF recommends that you contact your health care provider. Providers may charge you reasonable fees to cover their costs for providing records or completing requested forms.

If you request medical forms or records from its Business Associates, they also may charge you reasonable fees to cover costs for completing the forms or providing the records.

In some cases, IHF and its Business Associates will designate other persons or entities to request records or information from or related to you, and to release those records as necessary. Business Associates’ designees have the same rights to this information as does the Plan Administrator.

Rebates and Other Payments

IHF and UnitedHealthcare may receive rebates for certain drugs that are administered to you in a Physician's office, or at a Hospital or Alternate Facility. This includes rebates for those drugs that are administered to you before you meet your Annual Deductible. IHF and UnitedHealthcare do not pass these rebates on to you, nor are they applied to your Annual Deductible or taken into account in determining your Copays or Coinsurance.

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DEFINITIONS

Some terms have special meanings when used in this Plan booklet. Some of these terms are defined in the text of the Plan, generally in the section in which they are first used. Other terms are defined below. All defined terms apply throughout the Plan unless indicated otherwise.

Accident or Accidental is an unexpected event causing injury, dismemberment or death which is not due to any fault or misconduct on the part of the person injured and which does not arise from and is not related in any way to the person’s employment or place of employment.

Allowed Amount is the maximum amount the Plan will pay for covered services.

Allowable Expenses are any Medically Necessary charges for Hospital, Medical, Dental and Vision benefits and services covered in whole or in part by this Plan (except Life Insurance and Accidental Death & Accidental Dismemberment) and any other plan covering the person making the claim.

Alternate Facility - a health care facility that is not a Hospital and that provides one or more of the following services on an outpatient basis, as permitted by law:

• Surgical services.

• Emergency Health Services.

• Rehabilitative, laboratory, diagnostic or therapeutic services. An Alternate Facility may also provide Mental Health Services or Substance Use Disorder Services on an outpatient basis or inpatient basis (for example a Residential Treatment Facility).

Alternate Recipient is an individual who may be authorized to receive notices of the receipt or adjudication of claims or payment of benefits when authorized by the Trustees or pursuant to a valid legal order.

Annual Deductible is the amount of Eligible Expenses you must pay each calendar year for Covered Health Services before the Plan will begin paying for these Services

Autism Spectrum Disorders - a condition marked by enduring problems communicating and interacting with others, along with restricted and repetitive behavior, interests or activities.

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Beneficiary shall mean a person who is Eligible to receive benefits under the Plan. Sometimes “Beneficiary” is used for Eligible Dependents enrolled under the Plan; “Beneficiary” can also be used to mean any person Eligible for Benefits, including Employees, retires, and Eligible Dependents.

Cancer Resource Services (CRS) - The CRS program provides:

• Specialized consulting services, on a limited basis, to Participants and enrolled Dependents with cancer.

• Access to cancer centers with expertise in treating the most rare or complex cancers.

• Education to help patients understand their cancer and make informed decisions about their care and course of treatment.

Claims Administrator – With respect to Medical Benefits only, UnitedHealthcare (also known as United Healthcare Services, Inc.) and its affiliates, who provide certain claim administration services for the Plan.

Clinical Trial - a scientific study designed to identify new health services that improve health outcomes. In a Clinical Trial, two or more treatments are compared to each other and the patient is not allowed to choose which treatment will be received.

COBRA - see Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA).

Coinsurance is the percentage of Eligible Expenses that you are responsible for paying. Coinsurance is a fixed percentage that applies to certain Covered Health Services after you meet the Annual Deductible.

Collective Bargaining Agreement is an agreement between the Union and Contributing Employers that requires the Employer to make contributions to this Plan.

Concurrent Care Claim is any claim to extend a course of treatment beyond the period of time or number of treatments that the Plan has already approved as an ongoing course of treatment to be provided. A concurrent care claim can be an urgent care claim, a pre-service claim or a post-service claim.

Congenital Anomaly - a physical developmental defect that is present at birth and is identified within the first twelve months of birth.

Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA) - a federal law that requires employers to offer continued health insurance coverage to certain employees and their dependents whose group health insurance has been terminated.

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Contributing Employer is an Employer that, subject to the terms of a Collective Bargaining Agreement or Participation Agreement, is required the to make contributions to this Plan.

Coordination means that benefits from this Plan described in this booklet plus benefits received from other health plans can total, but not exceed, 100% of the allowable expenses for each covered person in each calendar year. This is intended to permit full payment of Allowable Expenses but not duplicate payments.

Copayment (Copay) is the amount you pay each time you receive certain Covered Health Services.

Please note that for Covered Health Services, you are responsible for paying the lesser of the following:

• The applicable Copayment.

• The Eligible Expense. Cosmetic Procedures - procedures or services that change or improve appearance without significantly improving physiological function, as determined by the Claims Administrator.

Cost-Effective - the least expensive equipment that performs the necessary function. This term applies to Durable Medical Equipment and prosthetic devices.

Coverage shall mean applicability of Benefits to Plan Participants and their Beneficiaries.

Coverage Period refers to the quarters in which you are eligible for coverage. The coverage periods are: February – April, May – July, August – October, and November – January.

Covered Employment is work under a Collective Bargaining Agreement or Participation Agreement for which contributions must be paid to this Plan.

Covered Health Services - those health services, including services or supplies, which the Claims Administrator determines to be:

• Provided for the purpose of preventing, diagnosing or treating Sickness, Injury, Mental Illness, substance use disorders, or their symptoms.

• Included in various Sections of this SPD, as described therein. The Claims Administrator maintains clinical protocols that describe the scientific evidence, prevailing medical standards and clinical guidelines supporting its determinations regarding specific services. You can access these clinical protocols (as revised from time to time) on www.myuhc.com or by calling the number on the back of

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your ID card. This information is available to Physicians and other health care professionals on www.UnitedHealthcareOnline.com.

Covered Person is either the Participant or an enrolled Dependent, but this term applies only while the person is enrolled and eligible for Benefits under the Plan. References to "you" and "your" throughout this SPD are references to a Covered Person.

Custodial Care - services that do not require special skills or training and that:

• Provide assistance in activities of daily living (including but not limited to feeding, dressing, bathing, ostomy care, incontinence care, checking of routine vital signs, transferring and ambulating).

• Are provided for the primary purpose of meeting the personal needs of the patient or maintaining a level of function (even if the specific services are considered to be skilled services), as opposed to improving that function to an extent that might allow for a more independent existence.

• Do not require continued administration by trained medical personnel in order to be delivered safely and effectively.

CRS - see Cancer Resource Services (CRS).

Deductible is the amount a Participant pays before the Plan pays benefits for Covered Health Services. Designated Facility - a facility that has entered into an agreement with the Claims Administrator or with an organization contracting on behalf of the Plan, to render Covered Health Services for the treatment of specified diseases or conditions. A Designated Facility may or may not be located within your geographic area. The fact that a Hospital is a Network Hospital does not mean that it is a Designated Facility.

Designated Physician - a Physician that the Claims Administrator identified through its designation programs as a Designated provider. A Designated Physician may or may not be located within your geographic area. The fact that a Physician is a Network Physician does not mean that he or she is a Designated Physician.

DME - see Durable Medical Equipment (DME).

Domiciliary Care - living arrangements designed to meet the needs of people who cannot live independently but do not require Skilled Nursing Facility services.

Durable Medical Equipment (DME) - medical equipment that is all of the following:

• Is used to serve a medical purpose with respect to treatment of a Sickness, Injury or their symptoms.

• Is not disposable.

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• Is generally not useful to a person in the absence of a Sickness, Injury or their symptoms.

• Can withstand repeated use.

• Is not implantable within the body.

• Is appropriate for use, and is primarily used, within the home.

• One of the following: • For Covered Health Services other than Pharmaceutical Products, selected data

resources which, in the judgment of the Claims Administrator, represent competitive fees in that geographic area.

• For Covered Health Services that are Pharmaceutical Products, 110% of the amount that the Centers for Medicare and Medicaid Services (CMS) would have paid under the Medicare program for the drug determined by either:

• Reference to available CMS schedules. • Methods similar to those used by CMS;

• Fee(s) that are negotiated with the provider. • 80% of the billed charge. • A fee schedule that the Claims Administrator develops.

These provisions do not apply if you receive Covered Health Services from a non-Network provider in an Emergency or as otherwise arranged by the Claims Administrator. In that case, Eligible Expenses are the amounts billed by the provider, unless the Claims Administrator negotiates lower rates.

Eligible Employee is an individual who is covered by a Collective Bargaining Agreement or a Participation Agreement that requires his or her Employer to make contributions to this Plan on his or her behalf. Contributions on an Eligible Employee’s behalf are made for hours worked in accordance with the applicable Collective Bargaining or Participation Agreement. Eligible Expenses - for Covered Health Services, incurred while the Plan is in effect, Eligible Expenses are determined by UnitedHealthcare as stated below and as detailed in this SPD.

Eligible Expenses are determined solely in accordance with UnitedHealthcare’s reimbursement policy guidelines. UnitedHealthcare develops the reimbursement policy guidelines, in UnitedHealthcare’s discretion, following evaluation and validation of all provider billings in accordance with one or more of the following methodologies:

• as indicated in the most recent edition of the Current Procedural Terminology (CPT), a publication of the American Medical Association, and/or the Centers for Medicare and Medicaid Services (CMS);

• as reported by generally recognized professionals or publications;

• as used for Medicare; or

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• as determined by medical staff and outside medical consultants pursuant to other appropriate source or determination that UnitedHealthcare accepts.

Emergency - a serious medical condition or symptom resulting from Injury, Sickness or Mental Illness, which is both of the following:

• Arises suddenly.

• In the judgment of a reasonable person, requires immediate care and treatment, generally received within 24 hours of onset, to avoid jeopardy to life or health.

Emergency Health Services - health care services and supplies necessary for the treatment of an Emergency.

Employee Retirement Income Security Act of 1974 (ERISA) - the federal legislation that regulates retirement and employee welfare benefit programs maintained by employers and unions.

EOB - see Explanation of Benefits (EOB).

ERISA - see Employee Retirement Income Security Act of 1974 (ERISA).

Experimental or Investigational Services - medical, surgical, diagnostic, psychiatric, mental health, substance-related and addictive disorders or other health care services, technologies, supplies, treatments, procedures, drug therapies, medications or devices that, at the time the Claims Administrator and the Plan make a determination regarding coverage in a particular case, are determined to be any of the fol lowing:

• Not approved by the U.S. Food and Drug Administration (FDA) to be lawfully marketed for the proposed use and not identified in the American Hospital Formulary Service or the United States Pharmacopoeia Dispensing Information as appropriate for the proposed use.

• Subject to review and approval by any institutional review board for the proposed use. (Devices which are FDA approved under the Humanitarian Use Device exemption are not considered to be Experimental or Investigational.)

• The subject of an ongoing Clinical Trial that meets the definition of a Phase I, II or III Clinical Trial set forth in the FDA regulations, regardless of whether the trial is actually subject to FDA oversight.

Exceptions:

• If you are not a participant in a qualifying Clinical Trial as described under Section 6, Additional Coverage Details, and have a Sickness or condition that is likely to cause death within one year of the request for treatment, the Claims Administrator and the Plan may, at their discretion, consider an otherwise Experimental or Investigational Service to be a Covered Health Service for that Sickness or condition. Prior to such consideration, the Claims Administrator and the Plan must determine that, although

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unproven, the service has significant potential as an effective treatment for that Sickness or condition.

Explanation of Benefits (EOB) - a statement provided by UnitedHealthcare to you, your Physician, or another health care professional that explains:

• The Benefits provided (if any).

• The allowable reimbursement amounts.

• Deductibles.

• Coinsurance.

• Any other reductions taken.

• The net amount paid by the Plan.

• The reason(s) why the service or supply was not covered by the Plan.

Health Reimbursement Account (“HRA”) is an account offered by the IHF to eligible participants from which the participant may pay qualified medical expenses.

Health Statement(s) - a single, integrated statement that summarizes EOB information by providing detailed content on account balances and claim activity.

Home Health Agency - a program or organization authorized by law to provide health care services in the home.

Hospital - an institution, operated as required by law and that meets both of the following:

• It is primarily engaged in providing health services, on an inpatient basis, for the acute care and treatment of sick or injured individuals. Care is provided through medical, mental health, substance use disorders, diagnostic and surgical facilities, by or under the supervision of a staff of Physicians.

• It has 24-hour nursing services. A Hospital is not primarily a place for rest, Custodial Care or care of the aged and is not a nursing home, convalescent home or similar institution.

Injury - bodily damage other than Sickness, including all related conditions and recurrent symptoms.

Inpatient Rehabilitation Facility - a long term acute rehabilitation center, a Hospital (or a special unit of a Hospital designated as an Inpatient Rehabilitation Facility) that provides rehabilitation services (including physical therapy, occupational therapy and/or speech therapy) on an inpatient basis, as authorized by law.

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Inpatient Stay - an uninterrupted confinement, following formal admission to a Hospital, Skilled Nursing Facility or Inpatient Rehabilitation Facility.

Intensive Outpatient Treatment - a structured outpatient mental health or substance-related and addictive disorders treatment program that may be free-standing or Hospital-based and provides services for at least three hours per day, two or more days per week.

Intermittent Care - skilled nursing care that is provided or needed either:

• Fewer than seven days each week.

• Fewer than eight hours each day for periods of 21 days or less. Exceptions may be made in special circumstances when the need for additional care is finite and predictable.

Kidney Resource Services (KRS) - a program administered by UnitedHealthcare or its affiliates made available to you by the Plan. The KRS program provides:

• Specialized consulting services to Participants and enrolled Dependents with ESRD or chronic kidney disease.

• Access to dialysis centers with expertise in treating kidney disease.

• Guidance for the patient on the prescribed plan of care.

Masonry Industry shall mean any and all types of work covered by Collective Bargaining agreements to which the Union and/or any Local, District Council or Conference are a party; or under the trade jurisdiction of the Union as that trade jurisdiction is described in the International Union's Constitution; or in a related building trade; or any other work to which a craftsworker has been assigned, referred, or can perform because of his skills and training. The term "Masonry Industry" shall not include employment which is on referral by and authorized by the Union.

Medicaid - a federal program administered and operated individually by participating state and territorial governments that provides medical benefits to eligible low-income people needing health care. The federal and state governments share the program's costs.

Medicare - Parts A, B, C and D of the insurance program established by Title XVIII, United States Social Security Act, as amended by 42 U.S.C. Sections 1394, et seq. and as later amended.

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Mental Health Services - Covered Health Services for the diagnosis and treatment of Mental Illnesses. The fact that a condition is listed in the current Diagnostic and Statistical Manual of the American Psychiatric Association does not mean that treatment for the condition is a Covered Health Service.

Mental Health/Substance Use Disorder (MH/SUD) Administrator - the organization or individual designated by the Plan who provides or arranges Mental Health and Substance Use Disorder Services under the Plan.

Mental Illness - mental health or psychiatric diagnostic categories listed in the current Diagnostic and Statistical Manual of the American Psychiatric Association, unless they are listed in an exclusions section.

Neonatal Resource Services (NRS) - a program administered by UnitedHealthcare or its affiliates made available to you by the Plan. The NRS program provides guided access to a network of credentialed NICU providers and specialized nurse consulting services to help manage NICU admissions.

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Network - when used to describe a provider of health care services, this means a provider that has a participation agreement in effect (either directly or indirectly) with the Claims Administrator or with its affiliate to participate in the Network; however, this does not include those providers who have agreed to discount their charges for Covered Health Services. The Claims Administrator's affiliates are those entities affiliated with the Claims Administrator through common ownership or control with the Claims Administrator or with the Claims Administrator's ultimate corporate parent, including direct and indirect subsidiaries.

A provider may enter into an agreement to provide only certain Covered Health Services, but not all Covered Health Services, or to be a Network provider for only some products. In this case, the provider will be a Network provider for the Covered Health Services and products included in the participation agreement, and a non-Network provider for other Covered Health Services and products. The participation status of providers will change from time to time.

Network Benefits - for Benefit Plans that have a Network Benefit level, this is the description of how Benefits are paid for Covered Health Services provided by Network providers.

Noncovered Masonry Employment means Employment or self-employment in the Masonry Industry on or after June 1, 1988 either for an employer that does not have a collective bargaining agreement between the Union and the employer or which is not otherwise covered by a collective bargaining agreement between the Union and the employer.

Open Enrollment - the period of time, determined by the Plan, during which eligible Participants may enroll themselves and their Dependents under the Plan. The Plan determines the period of time that is the Open Enrollment period.

Out-of-Pocket Maximum - The maximum amount you pay every calendar year for Covered Services.

Partial Hospitalization/Day Treatment - a structured ambulatory program that may be a free-standing or Hospital-based program and that provides services for at least 20 hours per week.

Participant – an individual who meets the eligibility requirements specified in the Plan, as described under Eligibility above. A Participant must live and/or work in the United States.

Participation Agreement is an agreement between the Trustees of this Plan and an Employer that requires the Employer to make contributions to this Plan.

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Patient Protection and Affordable Care Act The comprehensive health care reform law enacted in March 2010. The law was enacted in two parts: The Patient Protection and Affordable Care Act was signed into law on March 23, 2010 and was amended by the Health Care and Education Reconciliation Act on March 30, 2010. The name “Affordable Care Act” is used to refer to the final, amended version of the law.

Personal Health Support - programs provided by the Claims Administrator that focus on prevention, education, and closing the gaps in care designed to encourage an efficient system of care for you and your covered Dependents.

Personal Health Support Nurse - the primary nurse that UnitedHealthcare may assign to you if you have a chronic or complex health condition. If a Personal Health Support Nurse is assigned to you, this nurse will call you to assess your progress and provide you with information and education.

Physician - any Doctor of Medicine or Doctor of Osteopathy who is properly licensed and qualified by law.

Please note: Any podiatrist, dentist, psychologist, chiropractor, optometrist or other provider who acts within the scope of his or her license will be considered on the same basis as a Physician. The fact that a provider is described as a Physician does not mean that Benefits for services from that provider are available to you under the Plan.

Plan - The Bricklayers & Allied Craftworkers International Health Fund

Plan Administrator - The Bricklayers & Allied Craftworkers International Health Fund or its designee.

Plan Sponsor – The Board of Trustees of the The Bricklayers & Allied Craftworkers International Health Fund

Pregnancy - includes all of the following:

• Prenatal care.

• Postnatal care.

• Childbirth.

• Any complications associated with the above.

Primary Physician - a Physician who has a majority of his or her practice in general pediatrics, internal medicine, family practice or general medicine.

Private Duty Nursing - nursing care that is provided to a patient on a one-to-one basis by licensed nurses in a home setting when any of the following are true:

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• No skilled services are identified.

• Skilled nursing resources are available in the facility.

• The skilled care can be provided by a Home Health Agency on a per visit basis for a specific purpose.

• The service is provided to a Covered Person by an independent nurse who is hired directly by the Covered Person or his/her family. This includes nursing services provided on a home-care basis, whether the service is skilled or non-skilled independent nursing.

Reconstructive Procedure - a procedure performed to address a physical impairment where the expected outcome is restored or improved function. The primary purpose of a Reconstructive Procedure is either to treat a medical condition or to improve or restore physiologic function. Reconstructive Procedures include surgery or other procedures which are associated with an Injury, Sickness or Congenital Anomaly. The primary result of the procedure is not changed or improved physical appearance. The fact that a person may suffer psychologically as a result of the impairment does not classify surgery or any other procedure done to relieve the impairment as a Reconstructive Procedure.

Residential Treatment Facility - a facility which provides a program of effective Mental Health Services or Substance Use Disorder Services treatment and which meets all of the following requirements:

• It is established and operated in accordance with applicable state law for residential treatment programs.

• It provides a program of treatment under the active participation and direction of a Physician and approved by the Mental Health/Substance Use Disorder Administrator.

• It has or maintains a written, specific and detailed treatment program requiring full-time residence and full-time participation by the patient.

• It provides at least the following basic services in a 24-hour per day, structured milieu:

• Room and board. • Evaluation and diagnosis. • Counseling. • Referral and orientation to specialized community resources.

A Residential Treatment Facility that qualifies as a Hospital is considered a Hospital.

Retired Participant - an Employee who retires while covered under the Plan.

Semi-private Room - a room with two or more beds. When an Inpatient Stay in a Semi-private Room is a Covered Health Service, the difference in cost between a

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Semi-private Room and a private room is a benefit only when a private room is necessary in terms of generally accepted medical practice, or when a Semi-private Room is not available.

Sickness - physical illness, disease or Pregnancy. The term Sickness as used in this SPD include Mental Illness or substance-related and addictive disorders, regardless of the cause or origin of the Mental Illness or substance-related and addictive disorder.

Skilled Care - skilled nursing, teaching, and rehabilitation services when:

• They are delivered or supervised by licensed technical or professional medical personnel in order to obtain the specified medical outcome and provide for the safety of the patient.

• A Physician orders them.

• They are not delivered for the purpose of assisting with activities of daily living, including dressing, feeding, bathing or transferring from a bed to a chair.

• They require clinical training in order to be delivered safely and effectively.

• They are not Custodial Care, as defined in this section.

Skilled Nursing Facility - a Hospital or nursing facility that is licensed and operated as required by law. A Skilled Nursing Facility that is part of a Hospital is considered a Skilled Nursing Facility for purposes of the Plan.

Spinal Treatment - detection or correction (by manual or mechanical means) of subluxation(s) in the body to remove nerve interference or its effects. The interference must be the result of, or related to, distortion, misalignment or subluxation of, or in, the vertebral column.

Spouse - an individual to whom you are legally married.

Substance Use Disorder Services - Covered Health Services for the diagnosis and treatment of alcoholism and substance-related and addictive disorders that are listed in the current Diagnostic and Statistical Manual of the American Psychiatric Association, unless those services are specifically excluded. The fact that a disorder is listed in the Diagnostic and Statistical Manual of the American Psychiatric Association does not mean that treatment of the disorder is a Covered Health Service.

Total Disability or Totally Disabled - a Participant's inability to perform all of the substantial and material duties of his or her regular employment or occupation; and a Dependent's or retired person's inability to perform the normal activities of a person of like age and gender.

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Transitional Care - Mental Health Services/Substance Use Disorder Services that are provided through transitional living facilities, group homes and supervised apartments that provide 24-hour supervision that are either:

• Sober living arrangements such as drug-free housing, alcohol/drug halfway houses. These are transitional, supervised living arrangements that provide stable and safe housing, an alcohol/drug-free environment and support for recovery. A sober living arrangement may be utilized as an adjunct to ambulatory treatment when treatment doesn't offer the intensity and structure needed to assist the Covered Person with recovery.

• Supervised living arrangement which are residences such as transitional living facilities, group homes and supervised apartments that provide members with stable and safe housing and the opportunity to learn how to manage their activities of daily living. Supervised living arrangements may be utilized as an adjunct to treatment when treatment doesn't offer the intensity and structure needed to assist the Covered Person with recovery.

Unproven Services - health services, including medications that are determined not to be effective for treatment of the medical condition and/or not to have a beneficial effect on health outcomes due to insufficient and inadequate clinical evidence from well-conducted randomized controlled trials or cohort studies in the prevailing published peer-reviewed medical literature.

• Well-conducted randomized controlled trials are two or more treatments compared to each other, with the patient not being allowed to choose which treatment is received.

• Well-conducted cohort studies from more than one institution are studies in which patients who receive study treatment are compared to a group of patients who receive standard therapy. The comparison group must be nearly identical to the study treatment group.

UnitedHealthcare has a process by which it compiles and reviews clinical evidence with respect to certain health services. From time to time, UnitedHealthcare issues medical and drug policies that describe the clinical evidence available with respect to specific health care services. These medical and drug policies are subject to change without prior notice. You can view these policies at www.myuhc.com.

Please note:

• If you have a life threatening Sickness or condition (one that is likely to cause death within one year of the request for treatment), UnitedHealthcare and the Plan may, at their discretion, consider an otherwise Unproven Service to be a Covered Health Service for that Sickness or condition. Prior to such a consideration, UnitedHealthcare and the Plan must first establish that there is

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sufficient evidence to conclude that, albeit unproven, the service has significant potential as an effective treatment for that Sickness or condition.

The decision about whether such a service can be deemed a Covered Health Service is solely at UnitedHealthcare's and the Plan’ discretion. Other apparently similar promising but unproven services may not qualify.

Urgent Care - treatment of an unexpected Sickness or Injury that is not life-threatening but requires outpatient medical care that cannot be postponed. An urgent situation requires prompt medical attention to avoid complications and unnecessary suffering, such as high fever, a skin rash, or an ear infection.

Urgent Care Center - a facility that provides Urgent Care services, as previously defined in this section. In general, Urgent Care Centers:

• Do not require an appointment.

• Are open outside of normal business hours, so you can get medical attention for minor illnesses that occur at night or on weekends.

• Provide an alternative if you need immediate medical attention, but your Physician cannot see you right away.

The following definitions shall apply to the Dental Benefits provided by Delta Dental only. Other capitalized terms in that section not defined below shall be defined under the definitions section above. Where there is a conflict, the terms below shall control. Allowed Amount shall mean the lesser of the charged fee, the Maximum Plan Allowance, or the equivalent amount as stated in the National Provider File for Participating Dentists of other Delta Dental Plans on which program deductibles, maximums and co-payments are based.

Attending Dentist Statement (proof of loss) shall mean the written report of a series of procedures recommended for the Treatment of a specific dental disease, defect or injury, prepared for an Enrollee by a Dentist as a result of an examination made by such Dentist.

Delta Dental PPO shall mean a dental care program for Enrollees under which all fees paid or otherwise discharged by Delta Dental for DDIC for Services provided by a PPO Dentist shall be the PPO Allowed Amount, subject to any applicable co-payments, deductibles and maximums. All fees paid or otherwise discharged by Delta Dental for Services provided by a Participating Dentist who is not a PPO Dentist or a Non-Participating Dentist under this Delta Dental PPO program shall be the Allowed Amount

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as defined in Article I, subject to any applicable copayments, deductibles and maximums.

Delta Dental Premier® shall mean a dental care program for Enrollees under which all fees paid or otherwise discharged by Delta Dental for DDIC for Services shall be the Allowed Amount, subject to any applicable co-payments, deductibles and maximums.

Dental Affairs Committee shall mean a duly appointed committee of the Board of Directors of Delta Dental.

Dentist shall mean any doctor of dental surgery (DDS), doctor of dental medicine (DMD), or other established dental degree, duly licensed by the applicable government authority to practice dentistry in the state of the Delta Dental Plan administering this Contract for DDIC or adjacent states.

Maximum Plan Allowance shall mean the amount payable for Services of Participating and Non- Participating Dentists, calculated by Delta Dental, for use in payment by it and by its Enrollees from claim charges submitted, on a regional basis, for a given Service by Dentists of similar training within the same geographical area blended by Delta Dental with dentist fee information from a number of other sources, including dentist fee filings, using various factors, subject to regulatory limitations and adjustment for extreme difficulty or unusual circumstances.

National Provider File shall mean the file maintained by Delta Dental Plans Association listing maximum allowable amounts or equivalents per procedure, by product and network status used by Delta Dental Plans.

Non-Participating Dentist shall mean a Dentist who has not entered into a Participating Dentist Agreement which is currently in effect with Delta Dental or another Delta Dental Plan.

Participating Dentist shall mean a Dentist, who has entered into a Participating Dentist Agreement which is currently in effect with Delta Dental or another Delta Dental Plan. A Participating Dentist agrees to abide by the terms and conditions of his/her Agreement and published Bylaws which provide that a Participating Dentist shall be subject to Dental Insurance Contracts under which an Enrollee is covered by DDIC insofar as they regulate the Services to be provided to Enrollees, the basis of payment therefore, and any other matter pertaining to the obligation of DDIC to Enrollees.

Participating Dentist Agreement shall mean the contract between Delta Dental and the Participating Dentist who agrees to accept Delta Dental’s Allowed Amount and certain other conditions when treating an Enrollee.

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PPO Allowed Amount shall mean the lesser of the charged fee, the PPO Maximum Plan Allowance or the equivalent amount as stated in the National Provider File for Participating Dentists of other Delta Dental Plans on which program deductibles, maximums and copayments are based.

PPO Dentist shall mean a Participating Dentist as defined in Article I, who agrees to accept payment, as described in Article VI, Paragraph A, as full payment for Services, provided to Enrollees under this Contract.

PPO Maximum Plan Allowance shall mean an amount, determined by Delta Dental, usually less than its Maximum Plan Allowance for Delta Dental Premier programs, from claim charges submitted on a regional basis for a given Service by Dentists of similar training within the same geographical area blended by Delta Dental with dentist fee information from a number of other sources, including dentist fee filings, using various factors, subject to regulatory limitations and adjustment for extreme difficulty or unusual circumstances.

Premium shall mean the Premium or pre-fund payment described in Schedule I, which Schedule is incorporated herein and made a part hereof by reference, as well as the Premium paid by, or on behalf of, an Enrollee for Continuation Coverage. Premiums for Continuation Coverage shall be payable to Company, and by Company to Delta Dental, in amounts allowable by law and based on the amounts provided in Schedule I.

Pre-Treatment Estimate shall mean the pretreatment review by Delta Dental of an Attending Dentist Statement to determine the eligibility of the Enrollee and the benefits available for proposed procedures in accordance with Article IV, Paragraph C.

Primary Enrollee shall mean the Participant

Prospective Rating Method shall mean the rating method where DDIC is at risk for claims cost versus premium.

Services shall mean the Treatments set forth in Schedule II and any appl icable Riders to Schedule II, which Schedule and Riders are incorporated herein and made a part hereof by reference, the provisions, conditions, limitations and exclusions contained in Schedule II, performed by a Dentist or under his/her supervision and direction and when necessary, customary and reasonable, as determined by Delta Dental, using standards of generally accepted dental practice.

Treatment shall mean a caring for or dealing with an oral condition.

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The following definitions shall apply to the Vision Benefits provided by VSP only. Other capitalized terms in that section not defined below shall be defined under the general definitions section above. Where there is a conflict, the terms below shall control:

Benefit Authorization - Authorization issued by VSP identifying the individual named as a Covered Person of VSP, and identifying those Plan Benefits to which a Covered Person is entitled.

Emergency Condition - A condition, with sudden onset and acute symptoms, that requires the Covered Person to obtain immediate medical care, or an unforeseen occurrence requiring immediate, non-medical action.

Member Doctor - An optometrist or ophthalmologist licensed and otherwise qualified to practice vision care and/or provide vision care materials who has contracted with VSP to provide vision care services and/or vision care materials on behalf of Covered Persons of VSP.

Non-Member Provider - Any optometrist, optician, ophthalmologist, or other licensed and qualified vision care provider who has not contracted with VSP to provide vision care services and/or vision care materials to Covered Persons of VSP.

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