Comprehensive Medical Benefits        

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TABLE OF CONTENTS

  Covered Medical Expenses
  Prescription Drug Benefits
  Dental Benefits
  Vision Benefits
  Disability and Death Benefits
  General Plan Exclusions
 

Comprehensive Medical Benefits (for Active Employees, Retirees and Eligible Dependents)

How the Plan Works

Preferred Provider Organization (PPO)

To help manage certain health care expenses, the Plan contains a cost management feature - the Preferred Provider Organization (PPO) network. A PPO is a network of Physicians and Hospitals that have agreed to charge negotiated rates. When you use a PPO provider, you save money for yourself and the Plan because the PPO provider has agreed to charge a negotiated dollar amount.

It's your decision whether or not to use a PPO provider. You always have the final say about the Physicians and Hospitals you and your family use. To encourage you to use PPO providers whenever possible, the Plan pays a higher percentage of Covered Expenses when you use a PPO provider. Also, there are lower deductibles and out-of-pocket maximums if you use PPO providers. If you have questions about, or need a listing of Physicians and Hospitals that participate in the PPO network, contact the Fund Office.

The Plan pays different levels based on whether you use a PPO or non-PPO provider as listed in the Schedule of Benefits. Once your co-payment amounts for Covered Expenses (excluding the deductible) reach the out-of-pocket maximum during the calendar year, the Plan pays 100% of remaining Reasonable and Customary Charges for the rest of that year, up to the annual maximum.

Note: Some expenses may be covered differently or be subject to different benefit maximums. See Schedule of Benefits for more information.

Annual Deductible

Out-of-pocket expenses for covered medical services are limited. The out-of-pocket maximum does not include your annual deductible.

The annual deductible is the amount of Covered Expenses that you pay each calendar year before the Plan begins to pay benefits for PPO and non-PPO provider services.

The deductible applies to each Covered Person each calendar year. The family deductible is met once two or more covered members of a family meet the amount as shown in the Schedule of Benefits for family maximum. Once the individual and/or family deductible is met, no further deductibles are required for that year. Deductibles cannot be carried over from one calendar year to the next.

Common Accident Deductible

Normally, the individual deductible is applied to each member of the family. However, if two or more covered members of a family are Injured in the same accident, the medical expenses that result from the accident will be combined and only one deductible will apply to all expenses incurred as a result of that accident (regardless of the number of family members Injured).

Co-payment

Once you or your family has met the annual deductible, the Plan pays a percentage of Covered Expenses, called a "co-payment." The amount the Plan pays depends on the type of Covered Expense as listed in the Schedule of Benefits. Your payment is the remaining percentage of Covered Expenses.

Out-Of-Pocket Maximum

The out-of-pocket maximum limits the amount you pay out-of-pocket in a calendar year for Covered Expenses. If your co-payments toward Covered Expenses reach the out-of-pocket maximum (excluding the deductible), the Plan pays 100% for most additional Covered Expenses for the rest of the calendar year, up to the annual maximum shown in the Schedule of Benefits. There are separate out-of-pocket maximums for PPO and non-PPO provider Covered Expenses. Your co-payment amounts toward the out-of-pocket maximum do not include amounts you pay toward meeting your annual deductible.

Annual and Lifetime Maximums

You and each eligible Dependent can receive medical benefits up to the annual and lifetime maximums specified in the Schedule of Benefits. Certain services have separate annual and/or lifetime maximums.

Reasonable and Customary Charges

The Plan pays benefits only to the extent that they are Reasonable and Customary." In general, this is the amount providers most frequently charge for the same service or procedure in a geographic area. Reasonable and Customary Charges are determined by the Trustees, who may rely on the advice of medical professionals.

The discounted rates charged by PPO providers are considered Reasonable and Customary by the Plan. For charges incurred by a non-PPO provider, the Plan Administrator determines Reasonable and Customary Charges.

Medically Necessary

The Plan pays benefits only for services and supplies that are Medically Necessary. In general, "Medically Necessary" means a service or supply ordered by a Physician that the Fund or a party or entity selected by the Fund, determines is:

• Provided for the diagnosis or direct treatment of an Injury or Illness;
• Appropriate and consistent with the symptoms and findings or diagnosis and treatment of the person's Injury or Illness;
• Provided according to generally accepted medical practices on a national basis; and
• The appropriate supply or level of service that can be provided on a cost-efficient basis (including, but not limited to, inpatient versus outpatient care, electric vs. manual wheelchair, surgical vs. medical and other types of care).

The fact that a Physician prescribes services or supplies does not automatically mean the services or supplies are Medically Necessary and covered by the Plan.

Your Responsibility

It is important to remember that the medical Plan is not designed to cover every health care expense. The Plan pays charges for Covered Expenses, up to the limits and under the conditions established under the rules of the Plan. The decisions about how and when you receive medical care are up to you and your Physician - not the Plan. The Plan determines how much it will pay; you and your Physician must decide what medical care is best for you.

Extension of Benefits

If your eligibility for coverage ends while you or your Dependent is Totally Disabled, your Comprehensive Medical Benefits may continue for up to 13 weeks, provided:

• The Expenses Incurred are related to that Total Disability; and
• You or your Dependent remains Totally Disabled.

You or your Dependent will be eligible for benefits through the end of the period for which you were already eligible. Then, if you or your Dependent qualify for an extension, the extension will begin when you or your Dependents' eligibility otherwise would end.

An extension of benefits will end for you or your Dependent when the first of the following dates occur:

• The date you or your Dependent are no longer Totally Disabled;
• The end of the 13-week extension of benefits period;
• The date you or your Dependent become covered under another welfare fund, group plan or any plan sponsored by an employer

Payments made under the extension of benefits provision after the calendar year in which your eligibility ends will be subject to a new deductible.

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Covered Medical Expenses

The Reasonable and Customary Charge is determined by comparing the charge with charges made by other Physicians and providers of medical services and supplies for similar services and supplies in your geographic area.

Covered medical expenses are the Reasonable and Customary Charges actually incurred by a Covered Person in connection with the treatment of a Non-Occupational Injury or Disease. If a charge is more than the Reasonable and Customary Charge, only the Reasonable and Customary Charge will be considered a Covered Expense. Please keep in mind that charges relating to Covered Expenses will be paid according to the Plan's benefit maximums and limitations as shown in the Schedule of Benefits.

The following services and supplies are considered Covered Expenses under the Plan:

1. Hospital expenses for semi-private room and board charges while Hospital confined. If a hospital has only private rooms, the Plan will cover 90% of the most common private room rate charged by the Hospital, unless a Physician determines that a private room is required for isolation due to a diagnosis or is required by the Hospital's public health regulations.

2. Hospital miscellaneous charges for necessary services and supplies furnished by the Hospital, and not included in the room and board charges, while Hospital confined. These charges include:

   a.  Meals and special diet;
   b.  General nursing services;
   c.  Use of operating room, including cystoscopic room and cast room;
   d.  Complete anesthetic charges, whether administered by an authorized outside anesthetist or an employee of the hospital.
   e.  Blood transfusions, including administration and blood typing;
   f.   Oxygen;
   g.  Medicines;
   h.  Laboratory services;
   i.   X-rays and the use of radium and radioactive substances;
   j.   Basal metabolism test;
   k.  Electrocardiograms and electroencephalograms;
   l.   Physical therapy;
   m. Dressings and casts, including preparations or use of gauze, cotton fabrics, solutions, plasters and other material in dressings or casts;
   n.  X-rays and radiation treatment; and
   o.  Ambulance service to and from the Hospital

3. When Hospital confinement is not required, benefits are payable for Hospital Expenses Incurred in connection with:

   a.  A surgical procedure resulting from accidental bodily Injury or Sickness; or
   b.  Emergency first-aid treatment resulting from Injury.

4. Charges for the diagnosis, treatment and inpatient or outpatient surgical procedure performed as a result of an accidental bodily Injury or Sickness. The operation must be recommended and performed by a legally qualified Physician, Surgeon or assistant Surgeon.

5. Charges for organ transplant surgery. Organ transplants are subject to the annual and lifetime maximum shown in the Schedule of Benefits, as well as the co-payments and other maximums shown in the Schedule of Benefits. The Plan pays a higher percentage of charges if the procedure takes place at a Center of Excellence network facility.

6. Charges for x-ray or laboratory examinations, including basal metabolism determination or an electrocardiogram performed by, or under the supervision of, a legally qualified Physician.

7. Charges for chiropractic care for Non-Occupational Injuries or Diseases. These charges are not subject to the deductible and out-of-pocket maximum. Covered Expenses include office visits and chiropractic x-rays.

8. Charges for private duty nursing services of a registered graduate nurse, other than one who ordinarily resides with you or is a member of your immediate family (including your spouse, your or your spouse's children, brothers, sisters or parents or any other person related to the person).

9. Charges for treatment by a physical therapist, other than one who ordinarily resides with you or who is a member of your immediate family (including your spouse, your or your spouse's children, brothers, sisters or parents or any other person related to the person).

10. Charges for dental work or treatment or dental x-rays, as required as the direct result of the extraction of impacted third molars or of an Injury to the jaw or sound natural teeth incurred within one year of such accident, except as provided for active Employees and their Dependents under the Dental Benefit.

11. Charges for self-injectable drugs (other than insulin) requiring a Physician's prescription and charges for syringes do not apply toward the out-of-pocket maximum.

12. Charges for durable medical equipment including: surgical dressing, casts, splints, trusses, braces, crutches, artificial limbs, artificial eyes, rental of a wheelchair or Hospital-type bed and oxygen (including rental of equipment for its administration ) or artificial respirator.

13. Charges for anesthesia (including administration) in a Hospital by a Physician.

14. Charges for blood and plasma.

15. Charges for radiation therapy treatments including treatment with x-ray, radium, cobalt or other radio active material.

16. Charges for local ambulance service.

17. Charges for Hospital confinement for treatment of alcoholism and chemical dependency, subject to the limitations stated in the Schedule of Benefits.

18. Charges incurred for pregnancy and pregnancy-related conditions by you or a Dependent spouse. Under the Newborns' and Mothers' Health Protection Act of 1996 (NMHPA), the Plan may not, under federal law, restrict benefits for any Hospital length of stay in connection with childbirth for the mother of a newborn or a newborn child to less than 48 hours following a normal vaginal delivery, or less than 96 hours following a cesarean section. However, federal law generally does not prohibit the mother's or newborn's attending provider, after consulting with the mother, from discharging the mother or her newborn earlier than 48 hours (or 96 hours as applicable). In any case, plans and issuers may not, under federal law, require that a provider obtain authorization from the Plan or the issuer for prescribing a length of stay not in excess of 48 hours (or 96 hours if applicable).

19. Charges for the following will be Covered Expenses for a person to whom the Plan is providing benefits in connection with a mastectomy:
    a.  Reconstruction of the breast on which the mastectomy has been performed;
    b.  Surgery and reconstruction of the other breast to produce a symmetrical appearance; and
    c.  Prostheses and physical complications of all stages of mastectomy, including lymph edemas.

20. Charges due to an elective abortion only if the life or physical condition of the mother would be endangered if the child were carried to term.

21. Charges for the treatment of mental and nervous disorders, subject to the limitations stated in the Schedule of Benefits.

22. Charges for second and/or third surgical opinions. These charges will be considered Covered Expenses when:
    a.  The second and/or third opinion is rendered by a board certified specialist;
    b.  The specialist makes a personal examination of you or your eligible Dependent; and
    c.  A written report is sent to the Fund Office by the specialist on a form designed for this purpose.

23. Charges for hospice care are payable up to the amount listed in the Schedule of Benefits for the following services and supplies (after the annual deductible) when provided to a Terminally Ill Person under a Hospice Care Program through a Hospice Care Agency:
    
    a.  Care in the Terminally Ill Person's or family member's home, including the following services and equipment:
        1.  Physician services;
        2.  Physical, respiratory and occupational therapies;
        3.  Drugs, medications, and medical supplies;
        4.  Private duty nursing services by a registered nurse (RN) or licensed practical nurse(LPN) when certified by a Physician;
        5.  Rental of Durable Medical Equipment (DME); and
        6.  Oxygen and rental of related equipment.
    b.  Outpatient care in a licensed medical facility:
        1.  Physician services;
        2.  Laboratory, X-ray and diagnostic testing; and
        3.  Ambulance service or alternative types of transportation.
    c.   Inpatient care in a Hospital or hospice facility for:
        1.   Room and board, which may include overnight visits by family;
        2.   Nursing services;
        3.   All other related Hospital expenses;
        4.   Physician services; and
        5.   Ambulance service or alternative types of transportation.
    d.       The following additional services provided to the Terminally Ill Person and family members:
        1.   Visits by a licensed social worker to evaluate the social, psychological and family problems related to the terminal Illness and the development of a plan to assist in resolving these problems;
        2.   Emotional support services to assist in relieving stress, coping with the anticipated loss, helping families to complete unfinished business and maintaining the Terminally Ill Person in the most appropriate environment;
        3.    Special incidental services for the Terminally Ill Person, such as special dietary requirements, transportation between home and other sites of care; and
        4.    Bereavement counseling for the immediate family following the death of the Terminally Ill Person. (Coverage is limited to the maximum listed in the Schedule of Benefits.)

24. General administration of anesthesia and Hospital charges for dental care for eligible Dependent children under age five.

25. Charges for a colonoscopy.

26. Charges for PSA testing.

27. Charges for vasectomies.

28. Charges for birth control devices (except oral contraceptives).

29. Charges related to Work Hardening.

30. Charges for adult restorative speech therapy, up to the maximum shown in the Schedule of Benefits to restore speech that was lost or impaired due to an Illness or Injury. Covered Expenses will include treatment prescribed by a legally qualified Physician Covered Expenses will include treatment prescribed by a legally qualified Physician or speech therapist and rendered on an inpatient or out patient basis.

31. Charges for your Dependent child's speech therapy while not Hospital confined, up to the maximum shown in the Schedule of Benefits. Covered Expenses will include treatment prescribed by a legally qualified physician or speech therapist and rendered on an outpatient basis by a:
    a.  Duly constituted and lawfully operate Hospital;
    b.  Licensed speech therapy institute or center; or
    c.  Licensed Physician or speech therapist, other than one who ordinarily resides with the person or is a member of the person's immediate family.

32. Charges for a hearing exam or hearing aid needed because of hearing loss due to an accident, up to the maximums shown in the Schedule of Benefits.

33. Charges for corrective appliances (prosthetic and orthotic devices, other than dental) for:
    a.  Rental up to the allowed purchase price of the device;
    b.  Purchase of standard models at the option of the Plan;
    c.  Medically Necessary repair, adjustment or servicing of the device; and
    d.  Medically Necessary replacement of the device due to change in the Covered Person's physical condition or if the device cannot be satisfactorily repaired.
    
    Corrective appliances are covered only when ordered by a Physician. The Overall Plan maximum listed in the Schedule of Benefits is per person per limb or device for the appliance including necessary supplies, repair and servicing over any three consecutive calendar years. The definition of Durable Medical Equipment is on the Definitions page.
    
    Purchase of Durable Medical Equipment and the cost of maintenance agreements are covered only when the Plan determines that it is cost effective for the Plan. The amount of Plan benefits payable for the purchase of Durable Medical Equipment will be reduced by any benefits paid by the Plan for the rental of the equipment.

Medical Expenses Not Covered

You should be aware that not every medical expense is covered by the Plan. For a list of expenses not covered by the Plan, see General Plan Exclusions.

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Prescription Drug Benefits (for Active Employees, Retirees and Eligible Dependents)

Prescription drug coverage can play an important role in your overall health. Recognizing the importance of this coverage, the Plan has contracted with a network of preferred pharmacies through the prescription drug provider listed in Contact Information. When you have your prescriptions filled at a preferred pharmacy, you save money for yourself and the Plan.

The Plan offers coverage for your short-term prescription needs as well as your long-term prescription needs. When you have prescriptions filled at a preferred retail pharmacy, benefits are payable for up to a 34-day supply. If you are taking a prescription on a long-term basis, you should have your prescription filled through the mail order program. When you use the mail order program, you can have prescriptions filled for up to a 90-day supply. You do not need to meet a deductible before your prescription drugs are covered.

Prescriptions Filled at Preferred Pharmacies

You should present your ID card when you have prescriptions filled at a preferred pharmacy. When you present your ID card at a preferred pharmacy, all you need to do is pay the applicable co-payment. The amount of the co-payment varies depending on whether your prescription is for a Generic or Brand Name Medication, as shown in the Schedule of Benefits. You do not have to complete any claim forms.

Prescriptions Filled at Non-Preferred Pharmacies

If you have a prescription filled at a non-preferred pharmacy or you do not have your ID card with you when purchasing a prescription, you must pay the full cost of the prescription when you have it filled. You will then need to submit a claim form to the prescription drug provider listed in Contact Information. You will be reimbursed only the amount the Plan would pay for the drug at a preferred pharmacy, minus the applicable co-payment.

Generic Equivalents and Brand Name Medications

Almost all prescription drugs have two names: the generic name and the brand name. By law, both Generic and Brand Name Medications must meet the same standards for safety, purity and effectiveness.

When you receive a Brand Name Medication, you pay a higher co-payment. When you or your Dependent need a prescription, you may want to ask your Doctor whether a Generic Medication can be substituted for a Brand name Medication.

In general, using Generic Medications will help control the cost of health care while providing quality medication - and can be a significant source of savings for you and the Plan. Your Doctor or pharmacist can assist you in substituting Generic Medications when appropriate.

Prescriptions Filled Through the Mail Order Program

You should use the mail order program when you need to have prescriptions filled for maintenance medications. When you order by mail, you can get up to a 90-day supply at one time. The mail order program co-payments are listed in the Schedule of Benefits. You can call for a price and send in a check or you can use your credit card (see Contact Information). Because the price of prescription drugs changes frequently, the price of your prescription may change from the time you mail in your co-payment until the time your prescription is dispensed. If the price of your prescription changes, the mail order program provider will send you a bill for any balance due.

Maintenance medications are prescription drugs that are used on a long-term or on-going basis. These prescriptions can be used to treat chronic Illnesses such as:

• Arthritis;
• Diabetes;
• Emotional distress;
• Heart disorders;
• High blood pressure; or
• Ulcers.

Covered Prescription Drug Expenses

The Plan covers certain medications that require a written prescription from a Physician or dentist. A licensed pharmacist must dispense these prescriptions.

The following are considered covered prescription drug expenses under the Plan:

1. Federal legend drugs. Legend drugs are drugs with the following wording on the container: "Federal Law Prohibits Dispensing without a prescription."
2. Up to six Viagra pills per month for you or a covered spouse with medical diagnosis of impotence.
3. Drugs that require a prescription under state law but not under federal law.
4. Compound drugs.
5. Injectable insulin.

Prescriptions Drug Expenses Not Covered

In addition to the General Plan Exclusions, the following expenses are not covered under the Plan's prescription drug benefits:

1. Drugs or medicines lawfully obtainable without a prescription order of a Doctor or dentist, except insulin.
2. Any charge for the administration of prescription legend drugs or injectable insulin.
3. Medication that is taken by or administered to you or your eligible Dependents, in whole or in part, while a patient in a licensed Hospital, rest home, sanitarium, Extended Care Facility, convalescent Hospital, nursing home or similar institution that operates on its premises, or allows to be operated on its premises, a facility for dispensing pharmaceuticals.
4. Refilling of a prescription in excess of the number specified by the Physician or dentist, or any refill dispensed after one year from the order of a Physician or dentist.
5. Prescription drugs that may be properly received without charge under a local, state or federal program, including Workers' Compensation.
6. Anti-rejection drugs required as the result of a covered organ transplant that are provided at a retail pharmacy.
7. Drugs, medicines or devices for:

   a. Antiviral drugs used for influenza 9flu) prevention;
   b. Anabolic steroids;
   c. Therapeutic devices or appliances, support garments and other non-medical substances, regardless of  their intended use;
   d. Fertility and/or infertility  (Fertility drugs are covered under the Comprehensive Medical Benefits);
   e. Diabetic supplies, including lancets, test strips, test tape and alcohol swabs, except as covered under the Comprehensive Medical Benefits;
   f. Dental products such as fluoride preparations and products for periodontal disease, except as provided for active Employees and their Dependents under the Dental Benefit;
   g. Injectable drugs, except insulin;
   h. Foods and nutritional supplements including, but not limited to, home meals, formulas, diet plans or any related products, herbs and minerals (whether they can be purchased over-the-counter or require a prescription), except when provided during Hospitalization and except for prenatal vitamins or minerals requiring a prescription;
   i. Medical Foods (as defined in Definitions);
   j. Hair removal or hair growth products (i.e. Propecia, Rogaine, Minoxidil, Vaniqa);
   k. Sexual dysfunction medications (i.e. Muse, Caverject), except Viagra is covered up to six pills per month
   l. tobacco/smoking cessation;
   m. Vitamin A derivatives (retinoids) for dermatologic use (for example, Retin A);
   n. Weight control or anorexiants (i.e. Meridia, Xenical), except those anorexiants used for  treatment of children with attention deficit disorder (ADHD);
   o. Compounded prescription drugs in which there is not at least one ingredient that is a legend drug requiring a prescription as defined by federal or state law;
   p. Take-home drugs or medicines provided by a Hospital, Emergency Room, Ambulatory Medical-Surgical Facility or other health care facility; and
   q. Vaccinations, immunizations, inoculations or preventative injections.

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Dental Benefits (For Active Employees and Their Eligible Dependents)

Preventive dental care can be important. To help you meet the cost of routine and unexpected dental care, the Fund provides dental benefits.

When you or your family need dental care, you can choose any dentist. The Plan will pay Covered Expenses for the services of a dentist licensed to practice dentistry as shown in the Schedule of Benefits.

Annual Dental Deductible

The annual deductible is the amount of covered dental expenses that you pay each calendar year before the Plan begins to pay benefits. The amount of the deductible is shown in the Schedule of Benefits. The dental deductible is separate from the medical deductible.

The deductible applies to each Covered Person each calendar year. The family deductible is met once three covered members of a family meet the individual deductible. Once the individual and/or family deductible is met, no further deductibles are required for that year.

Co-Payment

Once you or your family has met the annual deductible, the Plan pays a percentage of Covered Expenses, called a co-payment. The amount the Plan pays depends on the type of dental service you receive. Your payment is the remaining percentage of Covered Expenses.

Predetermination Review

Predetermination review lets you and your dentist know how much the Plan will pay before treatment begins. The Plan does not require advance approval of dental treatment plans. It is, however, recommended for major or extensive dental work so you will know, in advance, the amount that will be paid by the Plan.

Covered Dental Expenses

The Plan covers the following dental services and supplies, up to Reasonable and Customary Charges when provided by a dentist.

Preventive Services

• Routine periodic examinations, up to twice in any calendar year.
• Bitewing and periapical x-rays as required.
• Full-mouth x-rays, once in any 36 consecutive months.
• Dental prophylaxis (cleaning, scaling and polishing including periodontal maintenance visits), up to twice in any calendar year.
• Topical fluoride application for Covered Persons under age 19 in any calendar year.
• Emergency palliative treatment as needed (minor procedures to temporarily reduce or eliminate pain).
• Space maintainers that replace prematurely lost teeth of eligible Dependent children under age 16 once in a five-year period.
• Dental sealants for eligible Dependent children up to age 16, subject to the following limitations:
  a. Sealants are limited to the occlusal surface (the fit of the teeth when brought together) of non-carious, non-restored permanent molars;
  b. Sealants are not payable for premolars (premolars are one of the two teeth between the molars and the canines of the upper and lower jaw) and primary molars;
  c. Sealants are only to be applied to teeth that do not have decay or previous restorations; and
  d. Sealants are payable once per lifetime.

Basic Services

• Restorative services using amalgam, synthetic porcelain and plastic filling material.
• Endodontics, which include root canal filling and pulpal therapy (therapy for the soft tissue of a tooth).

Major Services

• Prosthetics, which include bridges and dentures, once in any five-year period.
• Periodontics, which include treatment of diseases of the gums and bone supporting the teeth.
• Crowns, jackets, inlays and onlays required due to gross decay or fracture and when teeth cannot be restored with a filling material under Basic Services.
• Oral Surgery, including extractions.

Orthodontic Services

Orthodontic services are treatments for correction of malposed teeth to establish proper occlusion through movement of teeth or their maintenance in position. The Plan covers orthodontic services only for eligible Dependent children under age 19, up to the annual and lifetime maximum amounts listed in the Schedule of Benefits.

Dental Expenses Not Covered

You should be aware that some expenses are not covered by the Plan. In addition to any General Plan Exclusions, the Plan does not cover dental services that are not considered necessary by the Plan. The fact that a dentist may prescribe, order, recommend or approve a service does not, of itself, make it necessary or make the charge a Covered Expense, even though the service is not specifically listed as an exclusion. The Plan is the final authority for determining whether services are necessary.

Limitations

Dental expenses covered by the Plan are limited for the following services:

• The Fund will pay for fixed bridgework and partial or removable dentures only if the replacement or addition of teeth is needed to replace one or more teeth extracted after the existing denture or bridgework was installed and while you or your eligible Dependent is covered under the Plan. Also, the dental work must be done within 12 months after the tooth was extracted.
• Replacements of dentures or bridgework will be covered for newly eligible participants at 50% of Reasonable and Customary Charges (after the deductible), provided you have already had the dentures or bridgework in place at least five years and they cannot be repaired or made serviceable.

Exclusions

The Plan does not cover the following expenses:

• Expenses for dental implants.
• Expenses for the treatment of temporomandibular joint (TMJ) dysfunction or syndrome.
• Expenses for orthognathic services/surgery for treatment of prognathism, retrognathism and other cosmetic reasons.
• Mouth guards or night guards.
• Bleaching, bonding or any other cosmetic procedures (with the exception of orthodontia for Dependent children under 19 only).
• Replacement of lost or stolen appliances.
• Appliances, restorations or procedures for the purpose of altering vertical dimension, restoring or maintaining occlusion, splinting or replacing tooth structure lost as a result of abrasion.
• A service not reasonably necessary or not customarily performed for the dental care of the Covered Person.
• A service not furnished by a dentist, unless the service is performed by a licensed dental hygienist under the supervision of a dentist or is an x-ray ordered by a dentist.
• Charges made for the cost and administration of a general anesthetic made by a dentist for a procedure performed in his or her office.
• Nutritional guidance, hygiene instructions, periodontal splinting and implants.
• Temporary appliances.

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Vision Benefits (For Active Employees and Their Eligible Dependents)

The Plan provides two separate coverages for vision expenses for you and your eligible Dependents - Vision Care and Vision Surgical Correction Services.

Vision Care Services

Vision Care Services provide you and your eligible Dependents with coverage for routine vision-care related expenses, up to the amount listed in the Schedule of Benefits during a two-consecutive calendar-year period.

Vision services must be provided by and supplies received from an optician, optometrist or ophthalmologist acting within the usual scope of his or her practice to be considered Covered Expenses under this benefit.

When you need vision care:

• Schedule an appointment with the optician, optometrist or ophthalmologist of your choice.
• File a completed claim form with the Fund Office.

Covered Vision Care Services Expenses

These vision care services are considered Covered Expenses under the Plan.

• Eye examinations
• Lenses and frames (including tinted lenses).
• Contact lenses (including colored contacted lenses).

Vision Care Service Expenses Not Covered

In addition to the General Plan Exclusions, the following expenses are not covered under the Plan's vision care services:

• Vision therapy (orthoptics) and supplies.
• Orthokeratology lenses for reshaping the cornea of the eye to improve vision.

Vision Surgical Correction Services

Vision Surgical Correction Services cover surgical procedures for you or your eligible spouse to correct nearsightedness or farsightedness, limited to Radial Keratotomy (RK) or LASIK surgery only.

You must pay a Vision Surgical Correction Services deductible before the procedure is covered up to the maximum listed in the Schedule of Benefits. If, after the procedure, your vision changes in one (or both) eyes and you need further surgery, it will not be covered under the Plan.

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In the Event of Your Disability or Death

Weekly Accident and Sickness, Death and Accidental Death and Dismemberment (AD&D) Benefits help provide financial protection to you and/or your family in the event you become Injured, die or become terminally Ill. This section describes these benefits. Retirees are eligible for Death Benefits only.

Weekly Accident and Sickness Benefits (For Active Employees Only)

If you become Totally Disabled while you are covered under this Plan and while you are employed by a Contributing Employer, you may be eligible for Weekly Accident and Sickness Benefits.

If you can't work because of a non-work related Injury or Sickness:

• Call your Employer and the Fund Office.

  Fund Office
  Carpenters' District Council of Kansas City and Vicinity Health Plan
    3100 Broadway, Suite 805
    Kansas City, MO  64111
    (816) 756-3313
    Toll-Free (866) 756-3313

• See a Physician as soon as possible.
• File a claim with the Fund Office.

Eligibility

You must be an eligible, active Employee under the Plan to receive Weekly Accident and Sickness Benefits and the disability must:

• Be an accidental bodily Injury or a Sickness that prevents you from working at your occupation;
• Require the regular care and attendance of a legally qualified Physician or Surgeon; and
• Be the result of an accidental Non-Occupational Injury or Sickness.

Benefits

The amount of Weekly Accident and Sickness Benefits is listed in the Schedule of Benefits. Benefits are payable for up to 26 weeks. If you are disabled for part of the week, you will receive 1/5 of your weekly benefit for each day of disability.

Weekly Accident and Sickness Benefits are subject to Social Security, federal income and unemployment taxes and may be included in your gross income for tax purposes. At year end, you will receive a W-2 Form from the Fund that shows the amounts paid and withheld. If you have questions about including your benefits in your gross income or about exclusions in the law, you should consult your tax advisor or legal counsel.

If you are receiving Weekly Accident and Sickness Benefits under the Plan or Worker's Compensation benefits, you will receive 20 hours of work credit for each week, or four hours for each day you are entitled to receive these benefits. These credited hours may be used to continue your eligibility for benefits. No further hours will be credited after your benefits end. No more than 520 hours can be credited for one period of disability.

When Benefits Begin

Benefits begin on the first day of an accidental bodily Injury or the eighth day of disability due to a sickness. A period of disability will not begin until the first day you are actually examined or treated by a Physician.

If you have successive periods of disability, they will be considered one period of disability unless they are separated by a return to active full-time employment for at least two full weeks. If the disabilities are due to entirely unrelated causes and begin after a return to active full-time employment, they will be treated as separate periods of disability.

If you are disabled as the result of a maternity or pregnancy-related condition, the disability will be treated the same as a disability caused by a Sickness.

Benefit Exclusions and Limitations

Weekly Accident and Sickness Benefits are not payable for any accidental Injury or Sickness that is work-related.

Death Benefit (For Active Employees and Retirees Only)

The Death Benefit is paid if you die while eligible for benefits as an active or retiree, even if the cause of death is work-related.

Benefit Amount

The amount of the benefit is shown in the Schedule of Benefits. For your Death Benefit to be paid to your beneficiary, written notice of your death must be received by the Fund Office within 12 months of your date of death.

After the Fund Office receives proof of your death, the Plan may, at its option, pay a portion of the benefit due, but not exceeding $500, to any person that the Plan determines has incurred expenses on your behalf for your fatal Illness or burial. This payment will satisfy, to the extent of the amount paid, all claims under the Plan. The beneficiary is entitled to receive only the remainder, if any, of the proceeds.

Continuation of Coverage

If you die while an active Employee, coverage for your eligible Dependents will be continued for the period of time that eligibility would be maintained based on your accumulated hours, but not less than 90 days.

If you die while an active Employee and are making self-payments to maintain eligibility, coverage for eligible Dependents will be continued for the month in which you die and for 90 days following the month of your death. no self-payments will be required during the 90-day period.

If you are a retiree and die, coverage ends at the end of the month for which payment was made.

In the event of your death, your beneficiaries should contact the Fund Office.

Accidental Death and Dismemberment (AD&D) Benefit (For Active Employees Only)

The Accidental Death and Dismemberment (AD&D) benefit is payable for the loss of life, the loss of limb(s) or the entire and irrecoverable loss of sight of one or both eyes. Benefits are payable only if the loss results from an accident while you are eligible. The loss must occur within 90 days of the accident.

Benefit Amount

If you suffer any combination of losses as shown below as the result of one accident, only one amount (the largest) is payable for all losses. The amount payable for all losses resulting from one accident will not exceed the principal amount listed in the Schedule of Benefits. Benefits are payable for the following losses:

Benefits are paid directly to you for an injury or to your beneficiary in the event of your death. The AD&D Benefit is in addition to the Death Benefit.

Limitations and Exclusions

The following limitations apply to payment of the AD&D Benefit:

• The loss must occur within 90 days from the day of the accident.
• The loss of limb means dismemberment by severance at or above the wrist or ankle joint.
• The loss of sight means the total and irrecoverable loss of sight.
• If more than one of the losses listed above is suffered as the result of any one accident, only the full principal sum is payable.

No payment will be made for death or any loss resulting from or caused directly by any of the following:

• Bodily or mental infirmity, hernia, ptomaine, bacterial infections (except infections caused by pyogenic organisms that occur with and through an accidental cut or wound), disease or Illness of any kind or medical or surgical treatment.
• Intentional self-destruction or intentional self-inflicted Injury.
• Participation in or as the result of the committing of a felony.
• Insurrection, participation in a riot or police duty as a member of any military, naval or air organization.
• Travel or flight in any aircraft, except as a fare-paying passenger on a licensed passenger aircraft.

Naming a Beneficiary

You may designate anyone you wish as your beneficiary for Death and AD&D Benefits (if you are eligible for AD&D). To change or designate a beneficiary(ies), you need to file a form with the Fund Office. You can change your beneficiary at any time, without the consent of your previous beneficiary. The designation will take effect, after the Fund Office receives your completed and signed form, as of the date you signed the form whether or not you are living at the time the Fund Office receives your form.

If you name more than one beneficiary and you don't identify how much each beneficiary receives, the beneficiaries will share the benefit equally.

It is very important that you designate a beneficiary. If you do not designate a beneficiary, your Death Benefit and AD&D Benefit, if eligible, will be paid as follows:

• To your surviving spouse; or if none,
• To your surviving children in equal shares; or if none,
• To your surviving parent(s) in equal shares; or if none,
• To your estate.

If a beneficiary dies before you, that beneficiary's benefit will automatically terminate. Any amount that the beneficiary would have been eligible to receive will be paid equally to the beneficiary or beneficiaries that survive you, unless you have made a written request otherwise.

If your beneficiary is a minor or in the opinion of the trustees is legally incapacitated, the Trustees reserve the right to make payment of any benefit pursuant to the requirements of state law governing payments to minors and/or incapacitated individuals.

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General Plan Exclusions

The following lists excluded items for which charges may be incurred applies to all such charges unless an exception is stated and applies to all benefits provided under the Plan. In addition to the exclusions listed under each benefit section, no benefits are payable under the Plan for any of the following exclusions:

1. Autopsy: Expenses for an autopsy and any related expenses
2. Costs of Reports, Bills, etc.: Expenses for preparing medical reports, bills or claim forms; mailing, shipping or handling expenses; and charges for missed appointments, telephone calls and/or photocopying fees.
3. Educational Services: Expenses for educational services, supplies or equipment, including, but not limited to computers, software, printers, books, tutoring, visual aides, auditory aides, speech aides, programs to assist with auditory perception or listening/learning skills, programs/services to remedy or enhance concentration, memory, motivation or self-esteem, etc., even if they are required because of an Injury, Illness or disability of a Covered Person. However, education/medical training for diabetics is covered once per lifetime.
4. Employer-Provided Services: Expenses for services rendered through a medical department, clinic or similar facility provided or maintained by a Contributing Employer, or, if benefits are otherwise provided under this Plan or any other plan that a Contributing Employer contributes to or otherwise sponsors, such as an HMO.
5. Expenses Exceeding Maximum Plan Benefits: Expenses that exceed any specific Plan benefit limitation, annual maximum or overall (lifetime) maximum as described in the Summary Plan Description/Plan Document.
6. Expenses Exceeding Reasonable and Customary Charges: Any portion of the expenses for covered medical services or supplies that are determined by the Plan Administrator to exceed the Reasonable and Customary Charge.
7. Expenses for Which a Third Party is Responsible: Expenses for services or supplies for which a third party is required to pay because of the negligence or other tortuous or wrongful act of that third party. See Subrogation for an explanation of the circumstances under which the Plan will advance the payment of benefits until it is determined that the third party is required to pay for those services or supplies.
8. Expenses Incurred Before or After Coverage: Expenses for services rendered or supplies provided before you or your eligible Dependents became covered under the Plan or after the date the Covered Person's coverage ends, except under those conditions described in COBRA Continuation Coverage.
9. Experimental and/or Investigational Services: Expenses for any medical services, supplies or drugs or medicines that are determined by the Plan Administrator to be Experimental and/or Investigative as defined in Definitions.
10. Government-Provided services (CHAMPUS, VA, etc.): Expenses for services when benefits are provided to the Covered Person under any plan or program (including, without limitation, CHAMPUS and VA programs) established under the laws or regulations of any government, including the federal, state or local government, government of any other political subdivision of the United States or of any other country, any political subdivision of any other country or under any plan or program in which any government participates other than as an employer, unless the governmental program provides otherwise.
11. Illegal Act: Expenses Incurred by any Covered Person for Injuries resulting from or sustained as a result of commission, or attempted commission, by the Covered Person of an illegal act that the Plan Administrator determines in his or her sole discretion, on the advice of legal counsel, involves violence or the threat of violence to another person or in which a firearm, explosive or other weapon likely to cause physical harm or death is used by the Covered Person. The Plan Administrator's discretionary determination that this exclusion applies will not be affected by any subsequent official action or determination with respect to prosecution of the Covered Person (including, without limitation, acquittal or failure to prosecute) in connection with the acts involved.
12. Medically Unnecessary Services: Services or supplies determined by the Plan Administrator not to be Medically Necessary as defined in Definitions.
13. Treatment for temporomandibular joint syndrome (TMJ): Expenses for services rendered or supplies provided for the treatment of temporomandibular joint syndrome (TMJ).
14. Modifications of Homes or Vehicles: Expenses for construction or modification to a home, residence or vehicle required as a result of an Injury, Illness or disability of a Covered Person, including, without limitation, construction or modification of ramps, elevators, chair lifts, swimming pools, spas, air conditioning, asbestos removal, air filtration, hand rails, emergency alert system, etc.
15. No-Cost Services: Expenses for services rendered or supplies provided for which a Covered Person is not required to pay or that are obtained without cost, or for which there would be no charge if the person receiving the treatment were not covered under this Plan.
16. No Physician Prescription: Expenses for services rendered or supplies provided that are not prescribed by a Physician.
17. Non-Emergency Travel and Related Expense: Expenses for, and related to, non-Emergency travel or transportation (including lodging, meals and related expenses) of a health care provider, Covered Person or family member of a Covered Person.
18. Occupational Illness or Injury or Conditions Subject to Workers' Compensation: All Expenses Incurred by a Covered Person arising out of or in the course of employment (including self-employment) if the Injury, Illness or condition is subject to coverage, in whole or in part, under any Workers; Compensation, occupational disease or similar law. This applies even if you or your covered Dependent was not covered by Workers' Compensation insurance, or if your rights under Workers' Compensation, occupational disease or similar law has been waived, denied, disputed or challenged.
19. Personal Comfort Items: Expenses for patient convenience, including, but not limited to, care of family members while the Covered Person is confined to a Hospital or other specialized health care facility or to bed at home, guest meals, television, VCR, telephone, barber or beautician services, house cleaning or maintenance, shopping, birth announcements, photographs of new babies, etc.
20. Physical Examinations, Tests for Employment, School, etc.: Expenses for physical examinations and testing required for employment, government or regulatory purposes, insurance, school, camp, recreation, sports or by any third party.
21. Private Room in a Hospital or Specialized health Care Facility: The use of a private room in a Hospital or other specialized health care facility, unless the facility has only private room accommodations or unless the use of a private room is certified as Medically Necessary by the Physician. If a Hospital has only private rooms, the Plan will cover 90% of the most common private room rate charged by the Hospital, unless a Physician determines that a private room is required for isolation due to a diagnosis or is required by the Hospital's public health regulations.
22. Relatives Providing Services: Expenses for services provided by any Physician or other health Care Practitioner who is the parent, spouse, sibling (by birth or marriage) or child of the patient or Employee.
23. Medical Students, Interns or Residents: Expenses for the services of a medical student, intern or resident.
24. Stand-by Physicians or Health Care Practitioners: Expenses for any Physician or other health care provider who did not directly provide or supervise medical services to the patient, even if the Physician or health care practitioner was available to do so on a stand-by basis.
25. Services Provided Outside the United States: Expenses for medical services or supplies rendered or provided outside the United States, except for treatment for a medical Emergency as defined in Definitions or when you are on temporary work assignment for a Contributing Employer at a location outside the United States. Payment will be made to the employee only, once the necessary documentation is received, as an out-of-network claim.
26. Failure to Comply with Medically Appropriate Treatment: Expenses Incurred by any Covered Person who fails to comply with medically appropriate treatment, as determined by the Plan Administrator.
27. Leaving a Hospital Contrary to Medical Advice: Hospital or other specialized health care facility expenses if you leave the facility against the medical advice of the attending Physician.
28. Travel Contrary to Medical Advice: Expenses Incurred by any Covered Person during travel if a Physician or other health care provider has specifically advised against such travel because of the health condition of the Covered Person.
29. Telephone Calls: Any and all telephone calls between a Physician or other health care provider and any patient, other health care provider on any representative of the Plan for any purpose whatsoever, including, without limitation:
    a. Communication with any representative of the Plan for any purpose related to the care or treatment of a  Covered Person;
    b. Consultation with any health care provider regarding medical management or care of a patient;
    c. Coordinating medical management of a new or established patient;
    d. Coordinating services of several different health professionals working on different aspects of a patient's care;
    e. Discussing test results;
    f. Initiating therapy or a plan of care that can be handled by telephone;
    g. Providing advice to a new or established patient; and
    h. Providing counseling to anxious or distraught patients or family members.
30. War or Similar Event: Expenses Incurred as a result of an Injury or Illness due to any act of war, either declared or undeclared, war-like act, riot, insurrection, rebellion or invasion, except as required by law.

Specific Medical Services and Supplies Exclusions

Alternative/Complementary Health Care Services Exclusions

1. Expenses for acupuncture and/or acupressure.
2. Expenses for chelation therapy, except as may be Medically Necessary for treatment of acute arsenic, gold, mercury or lead poisoning, and for diseases due to clearly demonstrated excess of copper or iron.
3. Expenses for prayer, religious healing or spiritual healing.
4. Expenses for naturopathic, naprapathic, and/or homeopathic services, treatments or supplies.

Behavioral Health Care Exclusions

1. Expenses for diagnosis, treatment and prevention of Behavioral Health Disorders, including, but not limited to adoption counseling, custody counseling, developmental disabilities, dyslexia, learning disorders, family planning counseling, genetic testing and counseling, marriage, couples and/or sex counseling, mental retardation, pregnancy counseling, transsexual counseling and vocational disabilities.
2. Expenses for residential care services for Behavioral Health Disorders.
3. Expenses for hypnosis, hypnotherapy and/or biofeedback.
4. Expenses for tests to determine the presence of , or degree of, a person's dyslexia or learning disorder.

Corrective Appliances, Durable Medical Equipment and Nondurable Supplies Exclusions

Expenses for corrective appliances except those specifically included in the Covered Medical Expenses.

Cosmetic Services Exclusions

Surgery or medical treatment to improve or preserve physical appearance. Cosmetic surgery or treatment includes, but is not limited to removal of tattoos, breast augmentation or other medical or surgical treatment intended to restore or improve physical appearance, as determined by the Plan Administrator.

Fertility and Infertility Services Exclusions

Expenses for the diagnosis and treatment of infertility and complications thereof, including, but not limited to, services, prescription drugs, procedures or devices to achieve fertility, in vitro fertilization, low tubal transfer, artificial insemination, embryo transfer, gamete transfer, zygote transfer, surrogate parenting, donor egg/semen, cryostorage of egg or sperm, adoption, ovarian transplant, infertility donor expenses and reversal of sterilization procedures.

Foot/Hand Care Exclusions

1. Expenses for routine foot care including, but not limited to:
   a. Trimming of toenails;
   b. Removal of corns and calluses;
   c. Treatment of:
       (1) Corns, bunions (except capsular or bone surgery);
       (2) Calluses
       (3) Nails of the feet except surgery for ingrown nails;
       (4) Flat feet;
       (5) Fallen arches;
       (6) Weak feet;
       (7) Chronic foot strain or symptomatic complaints of the feet except when surgery is performed; and
   d. Preventive care with assessment of pulses, skin condition and sensation.
2. Expenses for hand care, including manicure and skin conditioning.

Genetic Testing and Counseling Exclusions

• Expenses for genetic tests such as obtaining a specimen and laboratory analysis, detecting or evaluating chromosomal abnormalities or genetically transmitted characteristics, including:
  a. Pre-parental genetic testing intended to determine if a prospective parent or parents have chromosomal abnormalities that are likely to be transmitted to the child; and
  b. Prenatal genetic testing intended to determine if a fetus has chromosomal abnormalities that indicate the presence of a genetic disease or disorder, except when those tests are performed using fluid or tissue samples obtained through amniocentesis when medically necessary as determined by the Plan Administrator.
• Expenses for genetic counseling.

Hair Exclusions

Expenses for hair removal, hair transplants and other procedures to replace lost hair or to promote the growth of hair, including prescription and non-prescription (or non-legend or over-the-counter) drugs such as Minoxidil, Propecia, Rogaine, Vaniqa; or for hair replacement devices including, but not limited to, wigs, toupees and/or hairpieces or hair analysis.

Hearing Care Exclusions

1. Expenses for and related to the purchase, servicing, fitting and/or repair of hearing aid devices, including implantable hearing devices except when provided as the result of an accident.
2. Special education and associated costs in conjunction with sign language education for a Covered Person or family members.

Home Health Care Exclusions

1. Charges for Home Health Care services, other than for private duty nursing services of a registered graduate nurse who ordinarily does not reside with the person or is not a member of the person's immediate family.
2. Expenses for services that are provided by someone who ordinarily lives in the patient's home or is a parent, spouse, sibling by birth or marriage or child of the patient; or when the patient is not under the continuing care of a Physician.
3. Expenses for a homemaker, Custodial Care, child care, adult care or personal care attendant, except as provided under the Plan's hospice coverage.

Maternity/Family Planning Exclusions

1. Termination of Pregnancy: Elective abortion, except where Medically Necessary.
2. Home Delivery: Expenses for pre-planned home delivery.
3. Services of a Midwife: Expenses for care and services rendered by a midwife.
4. Dependent Pregnancy: Pregnancy, resulting childbirth, abortion or miscarriage or conditions resulting from such condition for Dependent children.
5. Expenses related to cryostorage of umbilical cord blood or other tissue or organs.

Nutrition Exclusions

1. Foods and nutritional supplements including, but not limited to, home meals, formulas, foods, vitamins, weight reduction/control special foods, food supplements, liquid diets, diet plans or any related products, herbs and minerals, whether they can be purchased over-the-counter or require a prescription (except when provided during Hospitalization and except for prenatal vitamins) or minerals requiring a prescription.
2. Medical Foods (see Definitions).

Prophylactic Surgery or Treatment Exclusions

Expenses for all medical or surgical services or procedures, including prescription drugs and the use of prophylactic surgery, when prescribed or performed for the purpose of:

1. Avoiding the possibility or risk of an Illness, disease, physical or mental disorder or condition based on family history and/or genetic test results; or
2. Treating the consequences of chromosomal abnormalities or genetically transmitted characteristics, when there is an absence of objective medical evidence of the presence or disease or physical or mental disorder.

Rehabilitation Therapy Exclusions (Inpatient or Outpatient)

1. Expenses for educational, job training or vocational rehabilitation and/or special education for sign language; excluding approved Work Hardening programs.
2. Expenses for massage therapy, rolfing and related services.
3. Expenses incurred at an inpatient rehabilitation facility for any inpatient Rehabilitation Therapy services provided to an individual who is unconscious, comatose or is otherwise incapable of conscious participation in the therapy services and/or unable to learn and/or remember what is taught, including, but not limited to, coma stimulation programs and services.
4. Expenses for Maintenance rehabilitation as defined in Definitions.
5. Expenses for adult speech therapy (that is not restorative therapy) for functional purposes including, but not limited to, stuttering, stammering and conditions of psychoneurotic origin or for developmental speech delays.

Transplant (Organ and Tissue) Exclusions

1. Expenses for human organ and/or tissue transplants that are Experimental and/or Investigative, including, but not limited to, donor screening, acquisition and selection, organ or tissue removal, transportation, transplants, post operative services and drugs or medicines.
2. Expenses related to non-human (Xenografted) organ and/or tissue transplants or implants, except heart valves.
3. Expenses for insertion and maintenance of an artificial heart or other organ or related device, except heart valves and kidney dialysis and complications thereof.

Weight Management and Physical Fitness Exclusions

1. Medical or surgical treatment for weight-related disorders including, but not limited to, surgical interventions, dietary programs and prescription drugs.
2. Expenses for memberships in, or visits to, health clubs, exercise programs, gymnasiums and/or any facility for physical fitness programs, including exercise equipment.

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