Administrative District Council 1 Welfare Fund

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Health and Welfare Plans of Benefits

Summary Plan Description Plan Document

June 1, 2016

LIED PRINTIN AL G UNION ® TRADES LABEL COUNCIL 458 CHICAGO, IL Administrative District Council 1 Welfare Fund 660 North Industrial Drive, Suite 100 Elmhurst, Illinois 60126

IMPORTANT TELEPHONE NUMBERS

ADC 1 Welfare Fund Customer Service 1-800-617-8666 ADC 1 Welfare Fund Claim Fax Number 1-630-279-3377 ADC 1 Fringe Benefit Funds Website www.bacadcfunds.org

Blue Cross Blue Shield 1-800-810-2583 PPO provider finder www.bcbsil.com

OptumRx/Catamaran 1-855-577-6319 Website www.mycatamaranrx.com

ERS – Member Assistance Program (MAP) 1-800-292-2780 Username: adc1 Password: member www.ers-eap.com

Med-Care Management Utilization Review Program 1-800-367-1934 Living Well Program 1-866-844-4222

VSP 1-800-877-7195 Website www.vsp.com

Health Dynamics 414-443-0200 Username: hdhelpsu Password: hdhelpsu

Administrative District Council 1 Welfare Fund 660 North Industrial Drive, Suite 100 Elmhurst, Illinois 60126

(630) 617-8666

www.BACADCFUNDS.org

Union Trustees Employer Trustees

James F. Allen Richard Hill Lauber Administrative District Council 1 J & E Duff, Inc. 660 North Industrial Drive P.O. Box 368 Elmhurst, Illinois 60126 West Chicago, Illinois 60186

Michael Lowery Richard Lauber, Jr. Administrative District Council 1 J & E Duff, Inc. 660 North Industrial Drive P.O. Box 368 Elmhurst, Illinois 60126 West Chicago, Illinois 60186

Timothy Aikens Bernard Van Etten III Administrative District Council 1 Murphy Marble Company 660 North Industrial Drive 11756 South Halsted Street Elmhurst, Illinois 60126 Chicago, Illinois 60628

Tim Rossborough James Zuidema Administrative District Council 1 Jimmy’Z Masonry 660 North Industrial Drive 8550 Ridgefield Road, Suite B Elmhurst, Illinois 60126 Crystal Lake, Illinois 60012

Greg Posch Michael Pilolla Administrative District Council 1 JP Phillips Inc. 660 North Industrial Drive 3220 Wolf Road Elmhurst, Illinois 60126 Franklin Park, Illinois 60131

Ruben Collazo Frank Dziadus Administrative District Council 1 Midwest Masonry 660 North Industrial Drive 1335 Wilhelm Rd, #A Elmhurst, Illinois 60126 Mundelein, Illinois 60060

Dear Employee,

The Board of Trustees of the Administrative District Council 1 Welfare Fund is pleased to provide you with this Summary Plan Description/Plan Document booklet that describes the health and welfare benefits provided to eligible Employees, Retirees and their Dependents. The benefits described in this booklet, except as otherwise noted, are provided directly by the Administrative District Council 1 Welfare Fund.

This booklet has been designed to offer you an understandable and easily-referenced summary of the Health and Welfare Plans of Benefits of the Administrative District Council 1 Welfare Fund. It describes the benefits under the Plan as of June 1, 2016 and supersedes all prior versions. The Life and Accidental Death and Dismemberment benefits are provided through insurance contracts obtained by the Administrative District Council 1 Welfare Fund from a major insurance carrier. We have made every effort to ensure that this booklet is accurate and complete. This booklet (and any future amendments to it) also serves as the official Plan document.

Sincerely,

BOARD OF TRUSTEES

This booklet contains a summary in English of your rights under the Plans of Benefits of the Administrative District Council 1 Welfare Fund. If you have difficulty understanding any part of this booklet, contact the Administrative District Council 1 Welfare Fund at: (630) 617-8666 or by writing to the Fund at 660 North Industrial Drive, Suite 100, Elmhurst, Illinois, 60126. Office hours are from 8:00 a.m. to 4:00 p.m., Monday through Friday.

Este folleto incluye un resumen en ingles de sus derechos bajo el Plan de Beneficios de Administrative District Council 1 Welfare Fund. Si tiene dificultad para entender alguna seccion de este folleto, comuniquese con el Administrative District Council 1 Welfare Fund por tel (630) 617-8666. Las horas de oficina son de 8:00 a.m. a 4:00 p.m., de lunes a viernes. Por favor llame a la Oficina del Fondo para obtener una copia de este folleto en espanol.

Niemniejsza broszura zawiera streszczenie w jezyku angielskim wszystkich uprawnien przyslugujacych Pani/Panu na mocy Planu Swiadczen zatwierdzonych przez Administrative District Council 1 Welfare Fund. W razie trudnosce ze zrozumieniem tresci broszury prosimy zwracac sie do Administrative District Council 1 Welfare Fund, tel. (630) 617-8666 w godzinach pracy, tj. Od 8:00 do 4:00 od poniedzialku do piatku.

TABLE OF CONTENTS

Schedules of Benefits ...... 1 Active Employee Schedule of Benefits – Plan A ...... 1 Active Employee Schedule of Benefits – Plan B ...... 5 Retiree Schedule of Benefits - Plan 7 ...... 9 Retiree Schedule of Benefits – Plan 6 ...... 12 Life Events...... 13 If You Are Adding Coverage ...... 13 If Your Coverage Is Terminating ...... 14 If You Change Employers...... 15 If You Enter Military Service ...... 15 In the Event of Disability ...... 15 When You Retire ...... 15 In the Event of Your Death ...... 15 Eligibility ...... 16 Eligibility for Active Employees and Their Dependents (Plans A and B) ...... 16 Eligibility - Retirees and Their Dependents (Plans 6 and 7) ...... 24 Medical Benefits ...... 32 Health Reimbursement Arrangement (HRA) ...... 32 Physical Exam and Well Child Benefit (Plans A, B and 7) ...... 34 Comprehensive Major Medical Expense Benefit ...... 37 Covered Medical Expenses Plans A, B and 7 ...... 41 General Plan Limitations and Exclusions (Plans A, B and 7) ...... 44 Prescription Drug Benefits (Plans A, B and 7) ...... 47 How to Fill Prescriptions ...... 47 Types of Prescription Drugs ...... 48 The Plan’s Formulary ...... 49 Optum Rx/Catamaran Online ...... 49 Retail and Mail-Order Prescription Drug Card Expenses ...... 49 Benefit Limitations and Exclusions ...... 49 Dental Care Expense Benefit (Plans A and B) ...... 51 Covered Dental Charges ...... 51 Dental Benefit Exclusions ...... 53 Vision Benefit (Plans A and B) ...... 54 About the Vision Benefit ...... 54 Vision Benefit Exclusions ...... 54

Hearing Aid Benefit (Plans A, B, 6 and 7) ...... 55 About the Hearing Aid Benefit ...... 55 Limitations and Exclusions ...... 55 Life Insurance and Accidental Death & Dismemberment (AD&D) Benefits (Plans A and B) ...... 56 Life insurance ...... 56 Accidental Death and Dismemberment (“AD&D”) ...... 57 Claim Payment – Life and AD&D Benefits ...... 58 Weekly Disability Benefit (Plans A and B) ...... 60 About the Weekly Disability Benefit ...... 60 Weekly Disability Benefit Limitations and Exclusions ...... 61 Member Assistance Program (MAP) ...... 62 COBRA Continuation Coverage ...... 64 Coordination of Benefits Rules ...... 69 Subrogation ...... 71 Claim and Appeal Procedures ...... 73 How to File a Claim for Benefits ...... 73 Appealing the Denial of a Claim ...... 76 Medical Child Support Order Determination Procedures ...... 79 Important Plan Information ...... 81 Your Rights under ERISA ...... 84 Protecting Your Privacy ...... 86 Definitions...... 93

Grandfathered Status of the Plan The Board of Trustees of the Administrative District Council 1 Welfare Fund believes that the Plan is a “grandfathered health plan” under the Patient Protection and Affordable Care Act (the “Affordable Care Act”). As permitted by the Affordable Care Act, a grandfathered health plan can preserve certain basic health coverage that was already in effect when the Affordable Care Act was enacted. Being a grandfathered health plan means that your Plan may not include certain consumer protections of the Affordable Care Act that apply to other plans, for example, the requirement to cover certain preventative health services without any cost sharing. However, the grandfathered health plans must comply with certain other consumer protections in the Affordable Care Act, for example, the elimination of lifetime limits on benefits.

Questions regarding which protections apply and which protections do not apply to a grandfathered health plan and what might cause a plan to change from grandfathered health plan status can be directed to the Fund Office at (630) 617-8666 or in writing to 660 North Industrial Drive, Suite 100, Elmhurst, Illinois, 60126. You may also contact the Employee Benefits Security Administration, U.S. Department of Labor at 1-866-444-3272 or www.dol.gov/ebsa/healthreform. This website has a table summarizing which protections do and do not apply to grandfathered health plans.

The Board of Trustees of the Administrative District Council 1 Welfare Fund reserves the right to amend, modify, or terminate the Plan at any time and from time to time. Receipt of this SPD does not confer or guarantee eligibility for benefits.

iii

Schedules of Benefits

Active Employee Schedule of Benefits – Plan A

Life Insurance Benefit Amount

Employee Only ...... $30,000 AD&D Benefit Amount Principal Sum ...... $30,000 Weekly Disability Benefit Benefits begin as of the first day of disability due to accident or Hospital Confinement (including outpatient surgery), or the eighth day of continuous disability due to sickness. Weekly Benefit ...... $400 There is a maximum Weekly Disability Benefit of 26 weeks for each period of qualified disability. Major Medical Benefits Maximum Lifetime Benefits ...... Unlimited Individual Deductible per Calendar Year ...... $250 Maximum Family Deductible per Calendar Year ...... $500 Individual Annual Out-of-Pocket Maximum PPO Network Services...... $1,500 Non-PPO Network Services ...... $2,500 Family Annual Out-of-Pocket Maximum ...... Two Individuals Each Incur $10,000 If two or more Covered Persons in the same family are injured in a common accident, or contract the same contagious disease within a 30-day period, only one Deductible shall be applied to claims related to the common accident or disease. NOTE: The out-of-pocket maximums listed above do not include the deductible. NOTE: Before a Covered Person reaches $10,000 (or two Covered Persons in the same family each incur $10,000), the Coinsurance Percentage is as set forth in this schedule. Once a Covered Person reaches $10,000 in Covered Medical Expenses in a Calendar Year, the Coinsurance Percentage is 100%. Once two Covered Persons who are in the same family each incur $10,000, the Coinsurance Percentage for all eligible family members will be 100% of Covered Medical Expenses. Preventive Care (Annually) Regular Coinsurance After: For Child up to Age 2 ...... 100% up to $700 All Covered Persons Age 2 and Older ...... 100% up to $350 Disease Management/Education Maximum Annual Benefit ...... $200 Chiropractic/Naprapath Care Maximum Annual Benefit ...... $2,500 Nursing Care Maximum Benefit ...... $100 per day Hypnosis and Laser Treatment for Smoking Cessation ...... Up to $1,000 per Calendar Year Physiotherapy/Occupational Therapy Maximum Annual Benefit ...... 50 treatments Note: Physiotherapy ordered by a Chiropractor will be limited to Chiropractic benefits and limitations. Maximum Daily Hospital Benefit for Room and Board ...... Semi-Private Rate

Maximum Daily Intensive Care Benefit ...... Full Hospital Charge Pre-Admission Testing ...... 100% This benefit applies to Covered Medical Expenses incurred for pre-admission testing, performed on an outpatient basis, within 72 hours prior to a Hospital admission. (Deductible Waived.) Outpatient Diagnostic Imaging Services ...... 100% This benefit only applies to prescheduled CT Scans, PET Scans and MRI’s received from in- network PPO providers. Coinsurance Percentage for PPO Outpatient Surgery ...... 85% This benefit applies to Covered Medical Expenses for the following items pertaining to eligible outpatient surgeries that are incurred on the day of the surgery in a PPO facility:  Hospital outpatient department charges or other facility charges (Physician’s office, surgical center, clinic)  Surgeon’s and anesthetist’s fees and  Lab tests, X-rays and supplies Any medical treatment received at a non-PPO outpatient surgical facility is not covered by the Plan. This exclusion applies to the surgical facility’s fee and to any other expenses incurred at the surgical facility. For all Other Covered Medical Expenses, except as noted in this Schedule of Benefits, the Coinsurance Percentage is 85% for all Covered charges and for services provided at a PPO facility, and 75% for facility charges (other than an outpatient surgicenter) that are not part of the PPO network. NOTE: If an individual or a Dependent, while confined in a PPO Hospital, incurs Covered Medical Expenses for charges made by a Physician who is a radiologist, pathologist and/or anesthesiologist and who is not part of the PPO, these Covered Medical Expenses will be paid at the PPO Coinsurance Percentage. If you incur Covered non-PPO hospital expenses as a result of an “emergency” as defined in the Plan, benefits will be paid as if you had used a PPO hospital. If transportation to the nearest Hospital is by police, fire department or ambulance, and such transportation is made under circumstances over which the person has no control, the situation will be considered an “emergency” except in cases of transportation to a hospital for reasons related to the use of alcohol or non-legal use of controlled substances. NOTE: An Additional Deductible of $250 applies if the requirements of the Hospital Utilization Review Program are not followed. NOTE: Except as provided in this Schedule of Benefits, all services from non-PPO providers are covered at the reasonable and customary rate.

Prescription Drug Benefits*

The prescription drug benefit is administered by Optum Rx/Catamaran.

In-Network Retail Pharmacies Generic ...... 10% of drug cost (minimum payment $7) Brand-name (preferred) ...... 25% of drug cost Brand-name (non-preferred) ...... 40% of drug cost

Optum Rx/Catamaran Home Delivery (Mail-Order Program) (up to 90-day supply): Generic ...... $20

Brand-name (preferred) ...... $60 Brand-name (non-preferred) ...... $90

Briova Rx (specialty drugs) - (up to 30-day supply): Specialty drugs ...... $15 * Amounts you pay for prescription drugs, including copays and coinsurance, do not apply to the major medical benefits deductible, out-of-pocket maximum, or annual or lifetime maximum.

Dental Care Expense Benefits The dental benefit is administered by the Fund Office. Services must be provided by a licensed Dentist, Dental Assistant or Physician. Charges are based on the Reasonable and Customary rate at the time of service. Annual Maximum Benefit per Calendar Year...... $2,500 Unlimited for pediatric dental care (not including orthodontia) Orthodontia Lifetime Maximum (under age 19 only) ...... $3,500 Coinsurance Percentage of the Covered Dental Charges Part 1 – Preventive Dental Benefits ...... 100% Part 2 – Basic Dental Benefits ...... 80% Part 3 – Restorative Dental Benefits ...... 80% Orthodontia Benefits ...... 70%

Vision Benefits The vision benefit is administered by VSP.

VSP Benefits To get these benefits, you must visit a provider in the VSP Choice network. For more specific information regarding your VSP benefits please visit www.vsp.com or call 1-800-877-7195. You can receive VSP benefits once every calendar year. WellVision Exam©...... 100% Frames** ...... $250 allowance, then 20% for the remaining amount Lenses** ...... 100% Single vision Lined bifocal Lined trifocal Polycarbonate lenses for Dependent children Other lens options ...... 20% – 25% off total price (select lenses) Contact lenses** ...... $250 allowance for contacts and exam (fitting and evaluation) Contact lens exam ...... 15% discount (in addition to $250 allowance) Additional glasses and sunglasses ...... 20% off total price

Laser Vision Correction*** ...... 15% off regular price (average) or 5% off promotion price **Coverage for either glasses or contact lenses (but not both) is available once every calendar year. ***Laser Vision Correction discount available from contracted facilities only. Contact VSP to find a facility near you.

Non-VSP Vision Benefits You receive these benefits if you go to a non-VSP provider. You can receive these benefits once every calendar year. Annual Maximum ...... $400 Adult eye exam ...... 100%, up to Annual Maximum Frames (includes safety goggles) ...... 100%, up to Annual Maximum Lenses and contact lenses...... 100%, up to Annual Maximum Pediatric eye exam ...... 100%, not subject to Annual Maximum Pediatric prescription lenses and frame ...... 100%, up to Annual Maximum Laser Vision Correction Surgery ...... $1,000 lifetime maximum benefit (per eye)

Hearing Aid Expense Benefit The hearing aid expense benefit is administered by the Fund Office. Maximum Benefit per ear (every 4 consecutive Calendar Years) ...... $1,500 Benefit Deductible ...... $100 Coinsurance ...... 90%

Active Employee Schedule of Benefits – Plan B Life Insurance Benefit Amount Employee Only ...... $30,000 AD&D Benefit Amount Principal Sum ...... $30,000

Weekly Disability Benefit Benefits begin as of the first day of disability due to accident or Hospital Confinement (including outpatient surgery), or the eighth day of continuous disability due to sickness. Weekly Benefit ...... $300 There is a maximum Weekly Disability Benefit of 26 weeks for each period of qualified disability.

Major Medical Benefits Maximum Lifetime Benefit ...... Unlimited Individual Deductible per Calendar Year ...... $300 Maximum Family Deductible per Calendar Year ...... $600 Individual Annual Out-of-Pocket Maximum PPO Network Services...... $3,000 Non-PPO Network Services ...... $4,000 Family Annual Out-of-Pocket Maximum ...... Two Individuals Each Incur $10,000 If two or more Covered Persons in the same family are injured in a common accident or contract the same contagious disease within a 30-day period, only one Deductible shall be applied to claims related to the common accident or disease. NOTE: The out-of-pocket maximums do not include the deductible. NOTE: Before an individual reaches $10,000 (or two Covered Persons in the same family each incur $10,000), the Coinsurance Percentage is as set forth in this schedule. Once a Covered Person reaches $10,000 in Covered Medical Expenses in a Calendar Year, the Coinsurance Percentage is 100%. Once two Covered Persons each incur $10,000, the Coinsurance Percentage for all eligible family members will be 100% of Covered Medical Expenses. Preventive Care (Annually) Regular Coinsurance After: For Child up to Age 2 ...... 100% up to $700 All Covered Persons Age 2 and Older ...... 100% up to $350 Disease Management/Education Maximum Annual Benefit ...... $200 Chiropractic/Naprapath Care Maximum Annual Benefit ...... $2,500 Nursing Care Maximum Benefit ...... $100 per day Hypnosis and Laser Treatment for Smoking Cessation ...... Up to $1,000 per Calendar Year Physiotherapy/Occupational Therapy Maximum Annual Benefit ...... 50 treatments Note: Physiotherapy ordered by a Chiropractor will be limited to Chiropractic benefits and limitations. Maximum Daily Hospital Benefit for Room and Board ...... Semi-Private Rate

Maximum Daily Intensive Care Benefit ...... Full Hospital Charge Pre-Admission Testing ...... 100% This benefit applies to Covered Medical Expenses incurred for pre-admission testing, performed on an outpatient basis, within 72 hours prior to a Hospital admission. (Deductible Waived.) Outpatient Diagnostic Imaging Services ...... 100% This benefit only applies to prescheduled CT Scans, PET Scans and MRI’s received from in- network PPO providers. Coinsurance Percentage for PPO Outpatient Surgery ...... 70% This benefit applies to Covered Medical Expenses for the following items pertaining to eligible outpatient surgeries that are incurred on the day of the surgery in a PPO facility:  Hospital outpatient department charges or other facility charges (Physician’s office, surgical center, clinic)  Surgeon’s and anesthetist’s fees  Lab tests, X-rays and supplies Any medical treatment received at a non-PPO outpatient surgical facility is not covered by the Plan. This exclusion applies to the surgical facility’s fee and to any other expenses incurred at the surgical facility. For all Other Covered Medical Expenses, except as noted in this Schedule of Benefits, the Coinsurance Percentage is 70% for all Covered charges and services provided at a PPO facility, and 60% for facility charges (other than an outpatient surgicenter) that are not part of the PPO network. NOTE: If an individual or a Dependent, while confined in a PPO Hospital, incurs Covered Medical Expenses for charges made by a Physician who is a radiologist, pathologist, and/or anesthesiologist who is not part of the PPO, these Covered Medical Expenses will be paid at the PPO Coinsurance Percentage. If you incur Covered non-PPO hospital expenses as a result of “emergency” as defined in the Plan, benefits will be paid as if you had used a PPO hospital. If transportation to the nearest Hospital is by police, fire department or ambulance, and such transportation is made under circumstances over which the person has no control, the situation will be considered an “emergency” except in cases of transportation to a hospital for reasons related to the use of alcohol or non-legal use of controlled substances. NOTE: An Additional Deductible of $250 applies if the requirements of the Hospital Utilization Review Program are not followed. NOTE: Except as provided in this Schedule of Benefits, all services from non-PPO providers are covered at the reasonable and customary rate.

Prescription Drug Benefits* The prescription drug benefit is administered by Optum Rx/Catamaran. In-Network Retail Pharmacies Generic ...... 10% of drug cost (minimum payment $7) Brand-name (preferred) ...... 25% of drug cost Brand-name (non-preferred) ...... 40% of drug cost Optum Rx/Catamaran Home Delivery (Mail-Order Program) (up to 90-day supply): Generic ...... $20 Brand-name (preferred) ...... $60 Brand-name (non-preferred) ...... $90 6

6 Briova Rx (specialty drugs) - (up to 30-day supply): Specialty drugs ...... $15 * Amounts you pay for prescription drugs, including copays and coinsurance, do not apply to the major medical benefits deductible, out-of-pocket maximum, or annual or lifetime maximum.

Vision Benefits The vision benefit is administered by VSP. VSP Benefits To get these benefits, you must visit a provider in the VSP Choice network. For more specific information regarding your VSP benefits please visit www.vsp.com or call 1-800-877-7195. You can receive VSP benefits once every calendar year. WellVision Exam© ...... 100% Frames** ...... $250 allowance, then 20% for the remaining amount Lenses** ...... 100% Single vision Lined bifocal Lined trifocal Polycarbonate lenses for Dependent children Other lens options ...... 20% – 25% off total price (select lenses) Contact lenses** ...... $250 allowance for contacts and exam (fitting and evaluation) Contact lens exam ...... 15% discount (in addition to $250 allowance) Additional glasses and sunglasses ...... 20% off total price Laser Vision Correction*** ...... 15% off regular price (average) or 5% off promotion price

**Coverage for either glasses or contact lenses (but not both) is available once every calendar year. ***Laser Vision Correction discount available from contracted facilities only. Contact VSP to find a facility near you.

Retiree Schedule of Benefits - Plan 7

Not Medicare Eligible Medical Maximum Lifetime Benefit ...... Unlimited Individual Deductible per Calendar Year ...... $325.00 Maximum Family Deductible per Calendar Year ...... $650.00 Individual Annual Out-of-Pocket Maximum PPO Network Services...... $7,500 Non-PPO Network Services ...... $10,000 Family Annual Out-of-Pocket Maximum ...... Two Individuals Each Incur $25,000 If two or more Covered Persons in the same family are injured in a common accident, or contract the same contagious disease within a 30-day period, only one Deductible shall be applied to claims related to the common accident or disease. NOTE: The out-of-pocket maximums do not include the deductible. NOTE: Before an individual reaches $25,000 (or two Covered Persons in the same family each incur $25,000), the Coinsurance Percentage is as set forth in this schedule. Once a Covered Person reaches $25,000 in Covered Medical Expenses in a Calendar Year, the Coinsurance Percentage is 100%. Once two Covered Persons each incur $25,000, the Coinsurance Percentage for all eligible family members will be 100% of Covered Medical Expenses. Preventive Care (Annually) Regular Coinsurance After: For Child up to Age 2 ...... 100% up to $700 All Covered Persons Age 2 and Older ...... 100% up to $350 Disease Management/Education Maximum Annual Benefit ...... $200 Chiropractic/Naprapath Care Maximum Annual Benefit ...... $2,500 Nursing Care Maximum Benefit ...... $100 per day Hypnosis and Laser Treatment for Smoking Cessation ...... Up to $1,000 per Calendar Year Physiotherapy/Occupational Therapy Maximum Annual Benefit ...... 50 treatments Note: Physiotherapy ordered by a Chiropractor will be limited to Chiropractic benefits and limitations. Maximum Daily Hospital Benefit for Room and Board ...... Semi-Private Rate Maximum Daily Intensive Care Benefit ...... Full Hospital Charge Pre-Admission Testing ...... 100% This benefit applies to Covered Medical Expenses incurred for pre-admission testing, performed on an outpatient basis, within 72 hours prior to a Hospital admission. (Deductible Waived.) Outpatient Diagnostic Imaging Services ...... 100% This benefit only applies to prescheduled CT Scans, PET Scans and MRI’s received from in- network PPO providers.

9 Coinsurance Percentage for PPO Outpatient Surgery ...... 70% This Benefit applies to Covered Medical Expenses for the following items pertaining to eligible outpatient surgeries that are incurred on the day of the surgery in a PPO facility:  Hospital outpatient department charges or other facility charges (Physician’s office, surgical center, clinic)  Surgeon’s and anesthetist’s fees  Lab tests, X-rays and supplies

Any medical treatment received at a non-PPO outpatient surgical facility is not covered by the Plan. This exclusion applies to the surgical facility’s fee and to any other expenses incurred at the su rgical facility. For all Other Covered Medical Expenses, except as noted in this Schedule of Benefits, the Coinsurance Percentage is 70% for all covered charges and for services provided at a PPO facility, and 60% for facility charges (other than an outpatient surgicenter) that are not part of the PPO network. NOTE: If an individual or a Dependent, while confined in a PPO Hospital, incurs Covered Medical Expenses for charges made by a Physician who is a radiologist, pathologist and/or anesthesiologist who is not part of the PPO, these Covered Medical Expenses will be paid at the PPO Coinsurance Percentage. If you incur Covered non-PPO hospital expenses as a result of an “emergency” as defined in the Plan, benefits will be paid as if you had used a PPO hospital. If transportation to the nearest Hospital is by police, fire department or ambulance, and such transportation is made under circumstances over which the person has no control, the situation will be considered an “emergency” except in cases of transportation to a hospital for reasons related to the use of alcohol or non-legal use of controlled substances. NOTE: An Additional Deductible of $250 applies if the requirements of the Hospital Utilization Review Program are not followed. NOTE: Except as provided in this Schedule of Benefits, all services from non-PPO providers are covered at the reasonable and customary rate.

Prescription Drug Benefits* The prescription drug benefit is administered by Optum Rx/Catamaran.

In-Network Retail Pharmacies Generic ...... 10% of drug cost (minimum payment $7) Brand-name (preferred) ...... 25% of drug cost Brand-name (non-preferred) ...... 40% of drug cost

Optum Rx/Catamaran Home Delivery (Mail-Order Program) (up to 90-day supply): Generic ...... $20 Brand-name (preferred) ...... $60 Brand-name (non-preferred) ...... $90

NOTE: Dental, Vision, Weekly Disability Benefits, and Life Insurance coverages are not available under Plan 7.

Retiree Schedule of Benefits – Plan 6

Medicare Supplemental Benefits Maximum Lifetime Benefit ...... Unlimited Part A: Supplemental Hospital or Skilled Nursing Facility Benefit Initial Expense Benefit ...... Initial Medicare Deductible (1st thru 60th day in Calendar Year) Supplemental Expense Benefit, Daily Rate ...... 25% of Initial Medicare Deductible (61st through 90th day in Calendar Year) Lifetime Reserve Benefit of 60 days, Daily Rate ...... 50% of Initial Medicare Deductible Part B: Medical, Home and Other Health Services Initial Expenses ...... Medicare Calendar Year Deductible Thereafter ...... Balance of the Medicare Approved Expenses

NOTE: Prescription Drug (Medicare Part D), Dental, Vision, Weekly Disability Benefits, and Life Insurance coverages are not available under Plan 6.

Life Events

When you or your Dependents experience a change or major event in your life, your benefits may be affected. Here is a guide of what to do when you experience any of the life events listed on the next few pages.

For all life events, notify the Fund Office right away.

For example, contact the Fund Office whenever any of the following occur: • You get a new Dependent • When a Dependent is no longer eligible for coverage (you may want to continue their coverage through COBRA) • Beneficiary information changes • When you move

You can notify the Fund Office by calling (630) 617-8666 or in writing to 660 North Industrial Drive, Suite 100, Elmhurst, Illinois 60126.

If You Are Adding Coverage You may add coverage for yourself and/or your eligible Dependent(s) as described below.

Active Employees Plans A & B: Acquiring an Eligible Dependent You must meet the Plan’s initial and continuing eligibility requirements in order to have coverage for yourself and your Dependents. If you acquire a Dependent, you must submit documentation as to the relationship. Your Dependent, if eligible, will be covered on the date you acquire the Dependent; however, no claims will be processed until you provide the required documentation. Some ways to acquire eligible Dependents include through: • Marriage • Birth • Adoption • Placement for adoption

Since there is no enrollment for Plans A and B, there is no need for Special Enrollment as required under Federal law.

Retirees Plans 6 & 7: Enrolling Yourself or Acquiring an Eligible Dependent

If you have coverage under another employer-sponsored group health plan (for example, under your spouse’s health plan), you may enroll yourself when you are no longer covered under the other group health plan. You must enroll within 30 days of losing the other coverage.

You can add your Dependents when you enroll or when you acquire a Dependent child. You must be eligible for coverage in order for your Dependents to be covered. The eligibility rules for a Dependent child of an active participant apply to Dependents of retirees as well. A Dependent spouse cannot be

13 added as an eligible Dependent unless the retiree was married to that spouse as of the effective date of the retiree’s pension.

Your surviving spouse may continue retiree coverage if he/she meets the requirements (see page 27). Your Dependent child may continue retiree coverage if he/she meets the requirements (see page 27).

Effective Date of Coverage If you and your Dependents are eligible to enroll, the effective date of coverage will be, as applicable: • The date of the birth • The date of the adoption or placement for adoption • The date of the loss of coverage • No later than the first day of the first calendar month beginning after receipt of a completed request for enrollment in the event of loss of Medicaid or SCHIP coverage or eligibility for financial assistance under Medicaid or SCHIP

Otherwise, coverage will start on the first of the month following your completed application.

If Your Coverage Is Terminating Termination of Retiree Eligibility

Your eligibility under the Retiree Plan terminates on the earliest to occur of the following dates: 1. On the date of your death 2. On the date you fail to make a timely payment for Retiree coverage 3. On the date the Plan terminates

Termination of Dependent’s Retiree Eligibility

Your Dependent’s Retiree Plan eligibility terminates on the earliest to occur of the following dates: 1. On the date he/she ceases to be a Dependent 2. On the date a Dependent fails to make a timely payment for Retiree coverage 3. On the date the Plan terminates

In addition, the eligibility of a Dependent child will terminate on the last day of the month following the date of your death, but the child can elect COBRA Continuation Coverage.

Continuation of Dependent Spouse’s Eligibility after Death of Retiree

Upon your death, your spouse can remain in Plan 6 or Plan 7 (as applicable) so long as the required self- contribution continues to be paid.

NOTE: After you or a dependent loses coverage, if you need a certificate showing the period of time you or your dependent was covered under a Plan, please contact the Fund Office to receive a Certificate of Creditable Coverage.

If You Change Employers If you change Employers, and your new Employer contributes to the Administrative District Council 1 Welfare Fund on your behalf, you may continue your coverage under the Plan.

If you change Employers and your new Employer does not contribute to the Administrative District Council 1 Welfare Fund on your behalf, you are no longer eligible for coverage under the Plan.

If You Enter Military Service If you enter military service (active duty or inactive duty training) for less than 31 days, your health care coverage will continue. If you enter military service for more than 31 days, you may continue your coverage by making self-payments for up to 24 months under the Uniformed Services Employment and Reemployment Rights Act of 1994 (USERRA).

To continue coverage under the Plan for 24 months under USERRA, you must provide advance notice of your military service. If advance notice is not provided, coverage may continue if the Board of Trustees determines it was not possible to provide advance notice.

Following your discharge from service, you may be eligible to apply for reemployment with your former Employer in accordance with USERRA. This reemployment includes your right to elect reinstatement in the Plan under which you were previously covered.

For more information on USERRA and how entering military service affects your benefits, see page 23.

In the Event of Disability You may be eligible to continue coverage for up to six months if you meet all of the following conditions: • Become physically disabled so that you are unable to work

• Submit a certificate from an M.D., D.O., D.P.M., or, in the case of a pregnancy-related disability, a Certified Nurse Midwife, certifying the disability and its existence for at least seven consecutive days

• Would otherwise lose eligibility due to the disability

This continuation of coverage is not automatic. See page 60 for more information on disability benefits.

When You Retire At retirement, you may be able to continue coverage as a Retiree. To avoid a gap in coverage, you should contact the Fund Office a few months before your retirement date. This is especially important if either you or your spouse is age 65 or older. The Fund Office will guide you through the retirement process and answer any questions you may have about your benefits.

Retiree coverage is described in more detail on page 24.

In the Event of Your Death In the event of your death, your surviving Dependents should contact the Fund Office. Your surviving Dependents may be eligible to continue coverage under the Plan (see page 20). Your designated representative or beneficiary should contact the Fund Office regarding Life Insurance benefits.

Eligibility

Eligibility for Active Employees and Their Dependents (Plans A and B)

Initial Eligibility If you are a participant in the Administrative District Council 1 Welfare Fund (“Welfare Fund”) and a new employee, or you have been ineligible for coverage in the past, you must first meet initial eligibility requirements to join the Plan.

Eligibility Requirements Collectively Bargained Employees

To become eligible for benefits in the Administrative District Council 1 Welfare Fund Plan, you must be working for an Employer that contributes to the Welfare Fund under a Collective Bargaining Agreement with a Local Union.

To become initially eligible, you must meet both of the following conditions: • Work the required number of Credited Hours in Covered Employment • Have had contributions for those hours paid to the Welfare Fund on your behalf

Eligibility Date

If you meet the requirements above, you become eligible on the 1st day of the second month following a period of three (or fewer) consecutive months.

The Credited Hours required are:

For Plan A: 300 hours in three (or fewer) consecutive months

For example: You start work in February. You work 300 hours in February, March and April. You are initially eligible for Plan A on June 1.

For Plan B: 240 hours in three (or fewer) consecutive months.

For example: You start work in August. You work 240 hours in August, September and October. You are initially eligible for Plan B on December 1.

If you work the required number of hours in fewer than three months, you will become initially eligible on the first day of the second month following a period of consecutive months in which you worked the required number of hours.

For example: You start work in August. You work 240 hours in August and September. You are initially eligible for Plan B on November 1.

It is also possible to earn Plan B eligibility first and Plan A eligibility a month later.

For example: You start work in August. You work 240 hours in August and September and you are initially eligible for Plan B on November 1. You also work 120 hours in October (still within the first three months of employment) so you have over 300 hours in the August-September-October period. You were eligible for Plan B on November 1 and, as of December 1, you become eligible for Plan A.

Fund Staff

The Fund Office Staff has the same eligibility requirements as Collectively Bargained Employees with the following two exceptions:

• If you were hired between the first and fifteen of the month, coverage starts on the first day of the month hired. If you are hired after the fifteen of a month, coverage will start on the first of the month following.

• If you are terminated for cause, your hour bank will be eliminated on the last day of the month in which you last worked.

Dependent Eligibility Your Dependents include your lawfully married Spouse and your Child(ren) until they reach age 26.

If you have a civil union partner (as defined by the State of Illinois), he or she is not a Dependent under the Welfare Fund Plan. However, he or she is a Dependent under the Life Insurance Benefit and the Accidental and Death and Dismemberment (AD&D) Benefit only. See page 95 for more information.

Eligibility Date for Dependents Your Dependents’ eligibility date is the date you become an eligible Employee or on the date you acquire a Dependent, whichever is later.

Proof of Dependent Eligibility When enrolling a Dependent, you must give proof of Dependent status. That means you must give the Fund Office information and copies of documents that proves the person you are enrolling is your Dependent. You must submit your Dependent’s Social Security number and proof of Dependent status to the Fund Office as soon as it is available.

Proof of Dependent status includes any of the following: • Marriage certificates • Birth certificates • Legal adoption placement papers • Court orders of adoption • Guardianship orders • Other legal documents governing your relationship to the Dependent

Continuing Eligibility To continue to be eligible for benefits after gaining initial eligibility, you must continue to work in Covered Employment and your Employer must make contributions to the Welfare Fund on your behalf for those hours worked.

Eligibility Requirements You must accumulate enough Credited Hours in the specific Work Quarters to be eligible in the corresponding Eligibility Quarter. • Plan A requires 300 hours per Work Quarter • Plan B requires 240 hours per Work Quarter

The Work Quarters and their corresponding Eligibility Quarters are listed below.

Work Quarter Eligibility Quarter January, February, March June, July, August April, May, June September, October, November July, August, September December, January, February October, November, December March, April, May

Unlike the Initial Eligibility rule, which looks at any three consecutive months, the Continuing Eligibility rule looks only at Work Quarters.

The Look Back Rule There is also a “look back” rule, which means that if you do not have enough hours in a Work Quarter, the Welfare Fund will look back at the four consecutive Work Quarters (essentially, the prior twelve months), ending with the Work Quarter that corresponds to the applicable Eligibility Quarter.

Under the look back rule, you need to have worked the required Credited Hours in the previous four consecutive Work Quarters to be eligible for benefits in the applicable Eligibility Quarter. • Plan A requires 1,200 hours in four consecutive Work Quarters • Plan B requires 960 hours in four consecutive Work Quarters

For example, you are in Plan B and you work 200 hours in January, February and March (a Work Quarter). Because you worked fewer than the required 240 hours, you would not be eligible for benefits in June, July and August (the corresponding Eligibility Quarter).

Under the look back rule, the Fund will look back at your previous four consecutive Work Quarters to see your total hours worked. For this example, you worked 1,000 hours in the previous four consecutive Work Quarters. You are therefore eligible for Plan B benefits in June, July and August.

Note that the months that make up a “Work Quarter” are work months, not calendar months. “Work months” are explained in the definition of “Credited Hours” on page 94.

Dependent’s Continuing Eligibility Your Dependent spouse and child remain eligible for coverage as long as you remain eligible or until you or your Dependents meet certain criteria for losing coverage (see below).

Termination of Eligibility You will lose eligibility for benefits under the Plan if both of the following conditions are satisfied: • You earn fewer than 960 Credited Hours in four consecutive Work Quarters • You earn fewer than 240 Credited Hours in the last of these Work Quarters

You lose eligibility at the end of the last Eligibility Quarter for which you satisfied the Continuing Eligibility rules described above.

For example, you work 900 hours in four consecutive Work Quarters (essentially twelve months), from October 1, 2014 through September 30, 2015. In the last of these Work Quarters (or July, August and September), you work 200 hours. Because you did not work the required hours, you would lose eligibility on December 1, 2015.

Any loss of eligibility is subject to the Hour Bank rules (see page 22), the Quarterly Self-Pay rules (see page 20), and the COBRA Continuation Coverage rules (see page 64). Termination of Your Dependents’ Coverage Your Dependent’s coverage terminates at the end of the month following the date he or she ceases to be eligible for Dependent status, or on the date your coverage as an Employee terminates, whichever occurs first. You must notify the Fund Office of your Dependent’s loss of Dependent status (such as by a divorce or death) or a child reaching age 26. If you fail to notify the Fund Office of such an event, you will be required to reimburse the Plan for any expenses covered by the Plan that should not have been covered.

Dependent eligibility also ends in any of the following situations: • You drop a Dependent from coverage (due to divorce or death) • A Dependent is in active military service • The Dependent is an employee and a participant in this Plan

For more information, see the definition of Dependent (spouse and child) in the Definitions section, which starts on page 95.

Extending a Dependent Child’s Coverage Due to Disability You may be able to extend coverage for a disabled child beyond the usual age limits. The rule below applies to a child who becomes permanently disabled before reaching age 26.

Any unmarried child of the Employee, who, at age 26 or older, is disabled due to mental or physical handicap, shall have his or her coverage under the Plan continued. The coverage will be continued only if all of the following conditions are met: 1. The Employee is eligible for benefits under the Plan 2. The child meets all of the requirements of the definition of a child, except for age 3. The child became disabled prior to reaching age 26 4. The child remains disabled due to mental or physical handicap 5. The child is incapable of self-sustaining employment by reason of such mental or physical handicap and is chiefly dependent upon the Employee for support and maintenance (except to the extent that the child is supported by another parent, is receiving governmental aid or assistance, or is the beneficiary of another trust)

You will be required to provide proof of the child’s disability and dependency at least two months before your child turns 26, and every year thereafter. If you do not provide the required proof, your disabled child may lose eligibility when he or she reaches age 26. If no proof is requested, the child’s coverage will continue as long as the Employee remains eligible under the Plan.

Working in Non-Covered Industry Employment If you work in Non-Covered Industry Employment, you will lose your accumulated eligibility. “Non- Covered Industry Employment” means any employment in an industry covered by the Plan, if that employment is not covered by a Collective Bargaining Agreement or by a Participation Agreement with the Welfare Fund.

If you work in Non-Covered Industry Employment at a time when you are eligible for benefits under the Plan, your benefit eligibility will end as of the last day of the month in which you begin Non-Covered Industry Employment.

Also, any accumulated eligibility and any hours in your Hour Bank will be cancelled. The “look back” rule will no longer apply. In addition, you will not be eligible to make self-payments under the Quarterly Self- Payment Program.

Your right to elect COBRA Continuation Coverage is not affected by Non-Covered Industry Employment.

If you die while you are eligible for benefits If you die while eligible for benefits under Plan A or Plan B, your Dependents’ coverage will continue through the date that you would have remained eligible had you survived. The date is based on hours worked in Covered Employment through the date of your death.

For example, you worked 280 hours in April, May and June. You would be eligible for coverage in September, October and November. You die in July, having worked 40 hours. Because you do not have enough hours in the July, August and September Work Quarter, you would not be eligible for benefits starting in December. Your Dependents’ coverage will then continue until November 30.

If you were covered under Plan A at the time of your death, your Dependents’ eligibility will be in Plan A for as long as you would have remained eligible. When your Dependents have exhausted your accumulated eligibility, they may elect COBRA Continuation Coverage (see page 64).

Quarterly Self-Payment Program If you do not have enough Credited Hours to maintain eligibility under the Plan, The self-payment you may self-pay the difference between the Credited Hours you earned and the amount is the hourly Credited Hours required for eligibility under Plan B. This payment, which you contribution rate make quarterly to the Plan, provides you with Plan B coverage for the Eligibility your Employer Quarter that corresponds to the Work Quarter for which you are making the self- pays, minus the payment (see the table on the next page). You cannot self-pay for Plan A HRA amount. coverage.

You can continue self-payments under the Quarterly Self-Payment Program as long as you continue to earn at least 200 Credited Hours in the corresponding Work Quarter. When counting your Credited Hours to determine your eligibility, the Fund takes into account: • First, your hours of work (if any) • Then, the hours in your Hour Bank (if any)

If the combined hours of work and your Hour Bank do not equal at least 240 in a Work Quarter, you will be able to self-pay for coverage. You can only self-pay for the number of hours it would take you to reach the 240 minimum (up to 40 hours can be self-paid). Also, you are ineligible to self-pay if you have self-paid under the Quarterly Self-Payment Program for two of the four most recent Work Quarters.

For example, in 2015 you work 180 hours in the Work Quarter of April, May and June. You also have 40 hours in your Hour Bank.

Because you have only 220 hours, you would not be eligible for Plan B coverage during September, October and November of 2015. The self-payment is due the first day of the month following the notification date of your self-payment by the Fund Office. For example, if the Fund Office notifies you that you are eligible to make self-payments on May 15 (for coverage beginning June 1) the self-payment is due June 1.

Work Quarters and Their Corresponding Eligibility Quarters

 Hours accumulated in the Work Quarter (through work or with hours in your Hour Bank) determine your eligibility for the corresponding Eligibility Quarter For example, if you work 200 hours in January, February and March, those 200 hours are counted when determining your eligibility for June, July and August

NOTE: Until November 30, 2016, the requirement to have at least 200 Credited Hours in the corresponding Work Quarter is waived, and there is no limit to the number of Work Quarters for which you can make a partial self-payment. After that date, you are ineligible for self-pay if you have self-paid under the Quarterly Self-Payment Program for two of the four most recent W ork Quarters. Reinstatement of Eligibility If you lose eligibility under the Plan for fewer than 24 months (if, for example, you do not work the required number of hours), you can be reinstated in the applicable Plan (A or B) without re-establishing Initial Eligibility. To be reinstated, you must meet the requirements described in the Continuing Eligibility rules.

To be reinstated if you lose eligibility under the Plan for 24 or more months, you must work the following required number of Credited Hours in two consecutive Work Quarters.

For Plan A: You must accumulate 600 Credited Hours in two consecutive Work Quarters.

For example, you start work in April. In that Work Quarter (April – June), you work for 250 hours. You still need 350 hours to get to the 600 needed to be eligible. In the next Work Quarter (July – September), you work at least 350 hours. Because you totaled at least 600 hours in two consecutive Work Quarters (250 + 350 = 600), your eligibility starts in the corresponding Eligibility Quarter. See the table below for another explanation of this example. See the table above for the Work Quarters and their corresponding Eligibility Quarters.

21 Work Quarter Hours Accumulated First Available Eligibility Quarter April, May, June 250 hours (N/A: not yet eligible) July, August, September 350 hours December, January, February

For Plan B: You must accumulate 480 Credited Hours in two consecutive Work Quarters. For example, you start work in April. In that Work Quarter (April – June), you work for 275 hours. You still need 205 hours to get to the 480 needed to be eligible. In the next Work Quarter (July – September), you work at least 205 hours.

Because you totaled at least 480 hours in two consecutive Work Quarters (275 + 205 = 480), your eligibility starts in the corresponding Eligibility Quarter. See the table below for another explanation of this example. See page 21 for the Work Quarters and their corresponding Eligibility Quarters.

Work Quarter Hours Accumulated First Available Eligibility Quarter April, May, June 275 hours (N/A: not yet eligible) July, August, September 205 hours December, January, February

NOTE: Until November 30, 2016, the requirements to reestablish eligibility when your period of ineligibility is 24 months or more have been waived so that eligibility can be regained under the Plan (regardless of whether the period of ineligibility was more or less than 24 months) according to the Continuing Eligibility rules. Hour Bank System An individual Hour Bank will be established for you if you work more than 350 Credited Hours in a Work Quarter.

If you work more than 350 hours in a Work Quarter, the extra hours go into your Hour Bank. That is, once you reach 350 hours, each additional hour will be credited to your Hour Bank. The maximum number of hours that you can have in your Hour Bank is 1,200.

For example, you work 400 hours in a Work Quarter. You will get 50 hours put in your Hour Bank (400 – 350 = 50).

Each Work Quarter, hours will be withdrawn as needed to maintain your eligibility. Your hours will be used to maintain eligibility under the highest Plan possible, until your Hour Bank is empty.

For example, you have 100 hours in your Hour Bank. In a Work Quarter, you work 220 hours. To become eligible in the highest plan (Plan A), you need 80 hours. The Fund will deduct 80 hours from your Hour Bank so you can meet eligibility.

When you have used any Credited Hours to establish eligibility, the Credited Hours may be replaced in your Hour Bank, up to the maximum of 1,200 Credited Hours.

Contractor participants are not eligible for an Hour Bank. Apprentices Receive Credited Hours for Full-time Training Sessions If you are an apprentice in the Bricklayers’ Apprentice Training Program, and are required to attend training classes during the work week (Monday through Friday), you will receive eight Credited Hours for each day of full-time training during that week. These Credited Hours will be applied in the same way as hours of work for a contributing Employer. These Credited Hours apply for purposes of eligibility under the Welfare Fund.

22 22

Credited Hours for Period of Disability If you are receiving Weekly Disability Benefits, you will be credited with 40 Credited Hours for each full week (seven days) of disability, up to a maximum of 1,040 Credited Hours. These disability hours will be credited automatically by the Fund Office.

If you are receiving Temporary Disability Benefits (TTD) under Workers’ Compensation, you will be credited with 40 Credited Hours for each full week of disability, up to a maximum of 1,040 Credited Hours. You must provide proof of the TTD benefits to the Fund Office to receive the Credited Hours.

Special Enrollment Federal law (Section 701(f) of ERISA) requires that group health plans offer “special enrollment” in certain circumstances.

This Plan has no “special enrollment” rule for Plans A and B because you and your Dependents do not need to “enroll” or otherwise elect coverage in Plans A and B. If you and/or your Dependents meet the eligibility rules in this section, you are covered by the Plan. There is no need to “enroll” although, as explained on page 17, you must submit to the Fund Office proof of your Dependents’ relationship to you.

Military Service Provisions If you enter military service or other service as described in the Uniformed Services Employment and Reemployment Rights Act of 1994 (“USERRA”), your eligibility for benefits under the Plan will terminate at the end of the month in which you are inducted unless you elect to continue coverage, as provided under USERRA. Your continuation coverage under USERRA will run at the same time with any continuous coverage to which you are entitled under COBRA.

Election and payment procedures for continuation coverage under USERRA will be administered in the same way and at the same contribution rate as COBRA Continuation Coverage, except that your coverage under USERRA may extend for up to 24 months. Only you may elect continuation coverage under USERRA for yourself and your Dependents. If you do not elect to continue coverage under USERRA, your eligible Dependents may continue coverage under the Plan by electing and making self- payments for COBRA Continuation Coverage.

Credited Hours under USERRA Your Credited Hours under the Plan on the day you are inducted will be credited to you when you return to work for a contributing Employer. To reinstate your Credited Hours, you must return to Covered Employment within the time period provided by Federal law and meet other requirements as set forth in USERRA.

You may, however, direct the Plan to use your Credited Hours while you are performing military service to maintain coverage for you and your Dependents, in which case only the unused portion of the Credited Hours will be available when you return to work.

Terminating USERRA Coverage Your coverage under USERRA will continue until the earliest of the following to occur: 1. The date you or your Dependents do not make the required self-payments, within 30 days of the due date 2. The date you reinstate your eligibility for coverage under the Plan 3. The date you lose your rights under USERRA (for example, for a dishonorable discharge) 4. The end of the period during which you are eligible to apply for reemployment in accordance with USERRA

5. The last day of the month after 24 consecutive months 6. The date the Fund no longer provides any group health benefits

Family and Medical Leave Act (FMLA) The FMLA may require your Employer to grant unpaid leave of up to twelve (12) weeks during a twelve (12) month period for specific reasons. Reasons include: • The birth of a child • A serious illness affecting you, your spouse, your Dependent or parents • You have an urgent need for leave because your spouse, son, daughter or parent is on active duty or has been notified of an impending call or order to active duty in the armed services in support of a military operation

In addition, under the FMLA, you may take up to 26 weeks of unpaid leave during any 12-month period to care for a service member. The service member must meet all of the following conditions: • Be your spouse, son, daughter, parent or next of kin • Be undergoing medical treatment, recuperation, or therapy, for a serious illness or injury incurred in the line of duty while in military service • Be an outpatient, or on the temporary disability retired list of the armed services

Eligibility for this unpaid leave is determined by your Employer (not by the Plan or Board of Trustees) in accordance with the requirements of the FMLA. If you have been granted FMLA leave by your Employer, your Employer must notify the Plan and must continue to make contributions on your behalf to prevent you from losing eligibility.

If you and your Employer disagree over your eligibility or coverage under the FMLA, your benefits will be suspended until the disagreement is resolved. The Fund will not intervene in any employer-employee disputes.

The FMLA requires the Employer to inform you of your rights and obligations under the FMLA. You should contact your Employer if you have any questions about FMLA leave.

Self-Employment No contributions will be accepted from a self-employed person who is not covered under a Collective Bargaining Agreement or other Agreement with the Welfare Fund.

Eligibility - Retirees and Their Dependents (Plans 6 and 7) Initial Eligibility You are eligible for retiree coverage as described in this booklet if you meet all three of the following requirements: 1. You are receiving any type of pension (other than a deferred vested pension) from the Administrative District Council 1 Pension Fund or the Fox Valley & Vicinity Construction Workers Pension Fund.

2. You were eligible under the Welfare Fund or a Predecessor Plan based on the following criteria within the five years immediately prior to the effective date of your pension: Number of Number of Eligible Quarters Service Credits (in past 20 quarters) Up to 10 20 11 to 19 16 20 to 29 12 30 to 39 10 40 or more 8

The “Number of Eligible Quarters” refers to the number of quarters you were eligible for coverage as an Active participant in the Welfare Fund’s Plan. You may have been eligible for more than 20 quarters during your time in covered employment, but the Fund Office only looks at the last 20 quarters immediately preceding the effective date of your pension.

For example, you have been eligible for coverage in the Plan for the past three years, or the past 12 quarters.

You have been working continuously in covered employment for the past 25 years with 1200 hours each year. That means you have 25 Service Credits.

Because you have 25 Service Credits and you were eligible for the past 12 quarters, you are eligible for retiree coverage (if you meet the other requirements).

For another example, you have 15 Service Credits and you were eligible for coverage for the past 18 quarters. (Remember, the Eligible Quarters are only counted out of the last 20 quarters.)

You are required to have at least 11 Service Credits and have been eligible for at least 16 quarters to be eligible for retiree coverage. Because you have more than the required minimum, you are eligible for retiree coverage (if you meet the other requirements).

For another example, you have 35 Service Credits but were only eligible for coverage for the past 9 quarters.

Because you fall in the 30-39 range of required Service Credits, you need at least 10 Eligible Quarters to be eligible for retiree coverage.

Because you only have 9 Eligible Quarters, you are not eligible for retiree coverage.

3. You waive COBRA Continuation Coverage, if offered, at the effective date of your retiree coverage.

However, if you are covered under another employer-sponsored group health plan (for example, you are covered under your spouse’s health plan), you may enroll in Plan 6 or Plan 7 when you are no longer covered under the other group health plan, assuming you meet the other requirements for eligibility. You must apply within 30 days of the date your other health plan coverage ends.

Grace Period Employment Eligibility The Grace Period only applies to employment with a municipality within the Fund’s jurisdiction or to Job Corps Instructors in the International Masonry Institute (IMI).

Typically, after you retire you can enroll for retiree coverage. To enroll, you must meet the eligibility requirements listed above. For example, you must receive a pension from the Administrative District Council 1 Pension Fund.

However, you may decide to work as an International Masonry Institute (IMI) Job Corps Instructor or for a municipality in a job that is within the Fund’s jurisdiction after you retire, before receiving your pension. The Welfare Fund considers this a “Grace Period.” If you are in the Grace Period, you do not have to start Welfare Fund retiree coverage. The Grace Period does not apply unless the effective date of your Administrative District Council 1 Pension is within three months of the end of your Grace Period Employment or three months of the date you were last covered under the Administrative District Council 1 Pension Plan, whichever is later.

Grace Period Eligibility for Job Corps Instructors To be eligible for the Grace Period, you must satisfy all of the following conditions: • You have 15 or more Service Credits with the Welfare Fund’s Plan or a Predecessor Plan on the date the Grace Period begins (most recent service must be within the last five years on the date the Grace Period begins) • You are employed by the International Masonry Institute (IMI) as a Job Corps Instructor and you are covered under a health plan sponsored by IMI while you work for them (this is called Grace Period Employment) • You are receiving a pension from the Administrative District Council 1 Pension Fund • You apply for the Grace Period in writing

Grace Period Eligibility for Municipality Jobs To be eligible for the Grace Period, you must satisfy all of the following conditions: • You have 30 or more Service Credits with the Welfare Fund or a Predecessor Plan (most recent service must be within the last five years on the date the Grace Period begins) • You are employed by a municipality within the Fund’s job and location jurisdiction and you are covered under a health plan sponsored by the municipality while you work for them (this is called “Grace Period Employment”) • You are receiving a pension from the Administrative District Council 1 Pension Fund • You apply for the Grace Period in writing

Retirement Eligibility after Grace Period When you decide to retire and end the Grace Period, you may then be eligible for retiree coverage.

Like regular retiree coverage, your eligibility depends on how long you were covered under the Plan (or a Predecessor Plan), plus how many Service Credits you have. The table showing the required Service Credits and Eligible Quarters follows:

Number of Number of Eligible Quarters Service Credits (in past 20 quarters) Up to 10 20 11 to 19 16 20 to 29 12 30 to 39 10 40 or more 8

The Service Credits and Eligibility Quarters are determined at the beginning of your Grace Period employment.

The same requirements apply after you finish the Grace Period. Your time in the Grace Period does not affect your Service Credits. It does affect the number of Eligible Quarters.

The effective date of your pension must be within three months of: • The end of your Grace Period ending date, or • The date you are last covered under the Plan (if later)

If you don’t apply for your pension within three months, your Grace Period will not apply.

Dependent Eligibility Your Dependent spouse and children are eligible for Retiree coverage, under the same rules that apply to an active Employee’s Dependent(s). You cannot add a Dependent spouse after the effective date of your pension, unless you were married to your spouse as of the effective date of your pension.

Surviving Spouse Eligibility If you die before retiring, your surviving spouse will be eligible for Retiree coverage if he or she meets all of the following requirements: 1. At the date of your death, you had earned the right to a pension from the Administrative District Council 1 Pension Fund or the Fox Valley & Vicinity Construction Workers Pension Fund. 2. In the five years before your death, you had been eligible under the Welfare Fund’s Plan or a Predecessor Plan. Your eligibility was based on whether you had: a. Up to 10 Service Credits and were eligible for 20 of the prior 20 quarters b. 11 to 19 Service Credits and were eligible for 16 of the prior 20 quarters c. 20 to 29 Service Credits and were eligible for 12 of the prior 20 quarters d. 30 to 39 Service Credits and were eligible for 10 of the prior 20 quarters e. 40 or more Service Credits and were eligible for 8 of the prior 20 quarters

Continuation of Dependent’s Eligibility after Death of Retiree Upon your death, your surviving spouse will remain eligible for Plan 6 or Plan 7 (as applicable) so long as the required Retiree self-contributions are paid. Upon your death, your surviving Dependent child(ren) will remain eligible for Plan 6 or Plan 7 (as applicable) only if you also have a surviving spouse who p ays the required Retiree self-contributions. Upon remarriage or death of a surviving spouse, coverage for such surviving Dependent child(ren) terminates.

Termination of Retiree Eligibility Your eligibility for Retiree coverage terminates on the earliest to occur of the following: 1. On the date of your death 2. On the date you fail to make a timely payment of Retiree self-contributions for Retiree coverage 3. On the date the Retiree Plan terminates

Termination of Surviving Spouse’s Retiree Eligibility Your surviving spouse’s eligibility for Plan 6 or 7 will terminate if any required self-contribution payment is not received on a timely basis. Eligibility will also terminate upon the remarriage of the surviving spouse.

Termination of Dependent’s Retiree Eligibility Your Dependent’s eligibility for Retiree coverage terminates on the earliest to occur of the following: 1. On the date he or she ceases to be a Dependent 2. On the date your Dependent fails to make a timely payment for Retiree coverage 3. On the date the Retiree Plan terminates

In addition, the eligibility of a Dependent child will terminate on the last day of the month following the date of your death if you do not have a surviving spouse. Your Dependent child will have opportunity to elect COBRA Continuation Coverage (see page 64).

Retiree Self-Contributions The cost of Retiree self-contributions depends on many factors, including the number and types of claims, the cost of health care, and more. The Board of Trustees works hard to keep self-contribution rates as low as possible. The Board of Trustees may need to change the self-contribution rates for Plan 6 and Plan 7 coverage from time to time.

Amount of Retiree Self-Contributions Currently, there are two methods for determining the amount of your monthly Retiree self-contribution. • The first method applies to participants who first retire on or after January 1, 2003, and to the eligible spouses of those participants • The second method generally applies to Retirees whose pensions from the Bricklayers Local 21 Pension Plan became effective before January 1, 2003, and to the eligible spouses of those Retirees

First Method: Participants retiring on or after January 1, 2003

The cost of coverage is established by the Board of Trustees in its sole and unrestricted discretion and is subject to change at any time and from time to time. The cost of coverage will be offset by the value of your Service Credits. You earn Service Credits for hours you work during active employment. Each Service Credit (or partial Service Credit) helps offset, or lower, the cost of your Retiree self-contributions. For explanation of the value of a Service Credit, see “Service Credit Values” on the next page.

Service Credits are earned as follows: • One (1) Service Credit for each 1,200 hours worked in Covered Employment in a Calendar Year • Partial Service Credits for hours worked between 300 and 1,200. Partial Service Credit is calculated by dividing the hours worked by 1,200

For example, you work 500 hours in a Calendar Year. 500 divided by 1,200 is 0.42. You would earn 0.42 Service Credit, or 5/12 of a Service Credit. • You earn no, or zero, Service Credits for working fewer than 300 hours in a Calendar Year • You can earn additional Service Credits if you work more than 1,200 hours in a Calendar Year. You earn one-tenth (0.10) of a Service Credit for each 120 hours worked (over 1,200). There is no limit to the maximum number of Service Credits you can earn

For example, you work 1,400 hours in a Calendar Year. You receive one Service Credit for the 1,200 hours you worked. You have 200 additional hours that earn you Service Credit, but only 120 of those hours apply to the additional Service Credit. You have an additional one-tenth Service Credit for those 120 hours. For the entire Calendar Year, you earned 1.1 Service Credits.

28 For service on and after January 1, 2010, your hours worked will be determined from the Welfare Fund’s records.

For service prior to January 1, 2010, Service Credits will be determined based on your work history as provided by the Pension Funds affiliated with the Local Unions.

Service Credit Values Each Service Credit has a set dollar value. The amount of each Service Credit is used to help offset the cost of the Retiree coverage premium. The more Service Credits you have, the lower your monthly premium.

As of the time of publication, the Service Credit values are as follows: • Plan 7 - Service Credit value is $19.00 per month • Plan 6 - Service Credit value is $5.00 per month

For example, the monthly premium for Plan 7 Retiree coverage is $900 a month. You are in Plan 7 and have 20 Service Credits at the time you retire. 20 Service Credits equals $380 (20 x $19 = $380). The value of your Service Credits is deducted from the total premium cost. Your total monthly cost for Retiree coverage would be $520 ($900 - $380 = $520).

Service credits have no cash value except as an offset to the cost of Plan 6 or Plan 7 coverage.

If you retire on or after January 1, 2003 and subsequently die, your eligible surviving spouse’s coverage will be determined by the same method your Service Credits were calculated (see “Amount of Retiree Self-Contributions,” page 28). Your surviving spouse can apply your Service Credits to the cost of your surviving spouse’s Retiree coverage.

If you have a child who is eligible for Plan 6 or Plan 7 coverage as your Dependent, the Plan imposes a separate charge for each eligible Dependent child. Service Credits are not applied to reduce the cost of a child’s Retiree coverage.

Second Method: Participants who retired prior to January 1, 2003

The cost of coverage is established by the Board of Trustees in its sole and unrestricted discretion and is subject to change at any time and from time to time.

If you retired under the second method, your surviving spouse, if eligible, will be charged for coverage under the second method.

Minimum Retirement Age Effective January 1, 2016, the minimum age for Retiree coverage is age 55, unless you are receiving a Disability Pension, in which case there is no minimum age. If you retire prior to age 61, your Service Credits are permanently reduced by 6.72% for each Calendar Year (0.56% per month) that you are younger than age 61. (This percentage reduction does not apply if you retire with a Disability Pension.)

For example, you retire at age 60. You have 20 Service Credits. Because you retire one year before reaching age 61, your Service Credits are reduced by 6.72%.

If your pension (other than a Disability Pension) is effective earlier than age 55, you are eligible to self- pay for coverage under the self-pay rules for active employees participating in the Welfare Fund. If this applies to you, you may self-pay until you reach age 55. The self-pay limits under the Quarterly Self- Payment Program do not apply (see page 20).

Paying for Retiree Self-Contributions For all Retirees, self-contributions must be made by deductions from your monthly pension payment.

If your monthly pension payment does not cover the Retiree self-contribution amount, then the Retiree Self-Contributions must be paid quarterly in advance (that is, before the first day of the quarter for which the payment is made). Eligibility for Retiree coverage terminates if the applicable payment is not timely received by the Fund Office. In the event Retiree coverage is terminated for non-payment, you may not re-enroll in Plan 6 or Plan 7.

Applying for Surviving Spouse Coverage Your surviving spouse must apply for Plan 6 or Plan 7 coverage within 90 days of the effective date of the pre-retirement surviving spouse pension. • If your surviving spouse is Medicare-eligible, he or she will be covered under Plan 6 • If your spouse is not Medicare-eligible, he or she will be covered under Plan 7

If your surviving spouse meets the requirements but is covered under another employer-sponsored group health plan at the date of your death, your surviving spouse may enroll in Plan 6 or Plan 7 (as applicable) when he or she is no longer covered under the other group health plan. In this case, your surviving spouse must apply for coverage under this Plan within 30 days of the date the other group health plan coverage ends. Your surviving spouse’s coverage will become effective as of the date the other coverage ends, subject to timely application and payment of the applicable charge.

Amount of Surviving Spouse Coverage The amount of the self-contributions your surviving spouse needs to pay for Retiree coverage will be determined the same way as regular “Retiree Self Contributions.” (see page 28). • Self-contributions will be based on whether your surviving spouse’s pre-retirement surviving spouse pension was effective before, on or after January 1, 2003 • The self-contributions must be made by deduction from your surviving spouse’s monthly pension payment

If the monthly pension payment is insufficient to cover the self-contribution amount, then the self- contributions must be paid quarterly in advance.

50-Year Members 50-Year Members are eligible for Plan 6 or 7 benefits at no charge.

You are eligible as a 50-Year Member if you meet all the following requirements on or after January 1, 2006: 1. You are receiving a pension from the Administrative District Council 1 Pension Fund or the Fox Valley & Vicinity Construction Workers Pension Fund 2. During the last 25 years of your employment before retirement, you were a member of a collective bargaining unit represented by a Local Union or were an eligible participant in the Plan 3. You have been identified as a 50-Year Member by a Local Union 4. You were continuously eligible under the Welfare Fund’s Plan (or a Predecessor Plan) for the five years immediately preceding your satisfaction of the requirements in paragraphs 1, 2, and 3. The five years of continuous eligibility may include periods of self-paid eligibility, COBRA Continuation Coverage or coverage under Plan 6 or Plan 7

5. You waive COBRA Continuation Coverage, if offered, at the effective date of your 50 Year Member coverage for Plan 6

The Dependent spouse of a 50-Year Member is also eligible for no-cost Retiree Plan coverage, provided that the spouse satisfies the five-year requirement of continuous eligibility described in item 4 above.

A spouse of a 50-Year Member who satisfies these requirements, or a child of a 50 -Year Member who satisfies the Plan’s definition of “Dependent,” can be covered under Plan 6 (if the Dependent is covered by Medicare) or Plan 7 (if the Dependent is not covered by Medicare), provided that the Dependent makes a timely application for Dependent coverage and you pay the cost of that coverage. Upon your death, coverage for the surviving spouse or surviving Dependent child(ren) of a 50 -Year Member will be determined in accordance with the eligibility rules for Plan 6 or Plan 7 (as appropriate), as outlined on pages 27-28.

Medical Benefits

The Fund provides you and your eligible Dependents with major medical benefits to help you pay for health care. In addition to helping you pay for services to make you feel better, the Plan also covers certain preventive services. These include certain yearly physicals, immunizations and mental health benefits.

Health Reimbursement Arrangement (HRA)

The Plan includes a Health Reimbursement Account (HRA). An HRA is a record-keeping account that the Fund sets up and maintains on your behalf. There is no individual cash account for each participant. The account is used to keep track of contributions, reimbursements and your available balance. Amounts credited to your HRA can be used to pay for certain health care-related expenses.

Your HRA is funded exclusively through contributions made on your behalf by an Employer that contributes to the Welfare Fund under a Collective Bargaining Agreement or a Participation Agreement. All contributions credited to your HRA are assets of the Fund. You cannot contribute your own money to the HRA. The amount of the contribution is determined by the Board of Trustees and is subject to change or being discontinued at any time. You are not vested in the contributions made on your behalf and you may use your HRA only for the purposes listed below.

Eligibility To participate in the HRA, you must be enrolled in the Plan. This means you must first meet the eligibility requirements of the Plan (see page 16).

Opting Out Each year, you will have the opportunity to opt-out of, or stop participating in, the HRA. Opting out of the HRA is permanent and means you waive any and all future reimbursements and contributions to your HRA. Once you stop participating in the HRA, you cannot re-open your account.

One reason you may wish to opt-out is to sign up for coverage in the Health Insurance Marketplace. The Marketplace, set up under the Affordable Care Act, lets you choose individual coverage from a health insurance company at group rates.

If you meet certain financial requirements, you can get a subsidy (in the form of a tax credit) to help you pay for your coverage in the Marketplace. If you have money in your HRA, that might prevent you from getting the subsidy. That’s because the money in your HRA can count as “minimum essential coverage.” This means that you have health care coverage that meets basic, minimum requirements, so you may not qualify for a subsidy. If you think you would need the subsidy to help pay for Marketplace coverage, you may wish to opt-out of the HRA.

HRA Balance You can roll over your Your HRA balance is the total of employer HRA contributions made on your HRA balance from one behalf, minus any reimbursements you receive from your HRA for you, your year to the next, which spouse and/or Dependents. No earnings are credited to an HRA. Contributions helps you accumulate will not be credited to your HRA until they are received by the Fund. money for your account. There will be a lag between the time in which hours are worked and the time the contributions are received, which is when they will become available for you to use. Any unused balance in your HRA at the end of a Calendar Year is carried over into the next year.

Note: Reciprocated Hours will not receive HRA credit if the reciprocated contribution rate is less than the Administrative District Council 1 Welfare Fund’s current contribution rate.

Quarterly Status Report You will receive a quarterly status report that reflects your work history for the most recent Work Quarters, including the Employer and month reported to the Fund. This report also includes your HRA ending balance.

Covered Reimbursement Expenses Only certain health care expenses are eligible for reimbursement under an HRA. You can use the money in your HRA to pay for your, your spouse’s and/or your eligible Dependents’ expenses. Examples of covered reimbursable expenses include: • Your Calendar Year deductible • Your co-payment amounts • Charges exceeding the Allowable Expense • Costs exceeding the benefit maximum (hearing aids, eyeglasses, etc.) • Quarterly self-payments, COBRA payments, or retiree premiums • Medicare premiums and qualified long-term care insurance premiums (up to certain limits)

The IRS determines eligible covered expenses. For a full list of covered expenses, see IRS Publication 502, as amended.

HRA Benefit Exclusions Expenses that are not eligible for reimbursement from the HRA (as defined by Sections 105 and 213(d) of the Internal Revenue Code) include, but are not limited to: • Gym membership • Cosmetic surgery and procedures • Cosmetics, hygiene products, and similar items • Health programs offered by resort hotels, health clubs, and gyms • Long-term care medical expenses • Premiums for a high deductible health plan (with some exceptions) • Premiums for a Medigap policy • Premiums for life insurance and disability benefits

Claim Payment - HRA Reimbursement Expenses eligible for reimbursement from the HRA may be submitted at any time after you meet the Plan’s initial eligibility requirements. All expenses must be incurred before being considered for reimbursement. A claim is “incurred” on the date you or your Dependents receive goods or services that are eligible for reimbursement from the HRA.

For example, you schedule a doctor’s appointment and know what the cost will be. You cannot submit a claim for the appointment because it has not happened yet and you have not made any type of payment.

Minimum Reimbursement Amount The Plan requires that any request for reimbursement be for a minimum amount of $100. If you submit a claim for an expense that cost less than $100, you will not be reimbursed. You must wait until you have enough expenses in the aggregate that equal or are greater than $100. The only exception to this rule is that, if your Plan coverage terminates, eligible expenses totaling less than $100 may be submitted to close out your HRA. The amount reimbursed for any expense cannot exceed your HRA balance.

HRA Claim Forms Reimbursement requests must be accompanied by a properly completed claim form, which can be obtained from the Fund Office.

The claim form will include a statement that you must sign verifying that the eligible HRA expenses meet both of the following requirements:

• Have not been otherwise reimbursed, nor will they otherwise be reimbursed, through any other source • For premiums paid for other coverage, have not been paid on a pre-tax basis and have not been taken, nor will they be taken as an income tax deduction

Along with the claim form, you must provide verification of your expense, such as the following: 1. An itemized bill from the service provider that includes all of the following: a. Name of the person incurring the charges b. Date of service c. Description of services d. Name of provider e. Amount of charge 2. An Explanation of Benefits (EOB) from any coverage (including any EOB from this Plan), whenever you are requesting reimbursement of the balance of charges for which coverage is available plus original receipts verifying payment (photocopies of receipts are not considered proof of payment) 3. Proof of the amount and date paid when requesting reimbursement for other insurance premiums, such as a spouse’s group health coverage premiums 4. A receipt and proof of purchase for rental of covered items (such as crutches or wheelchairs) 5. Any additional documentation requested by the Fund Office

If you lose eligibility under the Plan, you can continue to submit reimbursement claims, as long as you have a balance in your HRA. Any unused credit in your HRA will be forfeited after a two-year period that you are not covered under the Plan.

Physical Exam and Well Child Benefit (Plans A, B and 7) The Plan provides a Physical Exam Benefit for you and your eligible Dependent spouse. The eligible Employee and Dependent spouse may utilize the Health Dynamics Preventive Care Program in addition to or instead of a routine physical exam (by a Physician of your choice).

The Plan provides the Well Child Benefit for your eligible Dependent child(ren) to help make sure they receive the medical attention they need.

Well Child Benefit The Well Child Benefit is available to eligible Dependent children. Covered expenses under the Well Child benefit include routine office visits and childhood immunizations, as set forth in the guidelines issued by the American Academy of Pediatrics.

Calendar Year Maximum $700 (up to age 2) (per Dependent child) $350 (age 2 – 26)

If a covered expense is more than the Calendar Year Maximum, the remainder of the expense will be covered under the major medical benefits.

For example, required medical exams for an 18-month-old child cost $950.00. The first $700.00 of the eligible expense will be covered at 100%. The remaining $250.00 will be covered under the major medical benefits. If the major medical deductible has already been met, the $250.00 would be reimbursed at a percentage (as coinsurance), the same as any other covered expense.

Physical Exam Benefit A routine physical exam lets you and your doctor get a basic reading of your health. By taking common health measurements, such as weight, blood pressure and cholesterol levels, you and your doctor can better create a health plan that fits your needs. Physical exams are also good ways of detecting any health issues early, helping you prevent more serious problems later on.

The Plan covers the cost of a physical exam up to $350 each year. If the cost of the exam is more than $350, your major medical benefits will help cover the rest of the cost.

For example, you visit a doctor in the Plan’s network for a physical exam, which costs $500. The Plan covers the first $350, leaving $150. If you have already met your deductible (the amount you pay yourself before the Plan helps pay for medical services), then you pay coinsurance. If you are in Plan A, the coinsurance is 85%. This means the Plan covers 85% and you cover 15% of $150.

Preventive Care Some parts of the physical exam are considered preventive care. Many preventive health services are covered at 100%, without having to meet the deductible or pay coinsurance. Some services include:

1. Breast cancer screening beginning at age 40 When going to your doctor to have a physical exam, 2. Cervical cancer screening remind the doctor’s office to 3. Bone density screening beginning at age 50 code your visit as a preventive visit. That will 4. Sigmoidoscopy (covered every 5 years for average risk patients) help ensure that your exam is covered correctly. 5. Prostate cancer screening beginning at age 50 (men with increased risk factors are covered at age 40) 6. Colorectal cancer screening for individuals age 50 years and older, including a. Fecal occult blood test (FOBT) annually b. Sigmoidoscopy (covered every 5 years for average risk patient) c. Double contrast barium exams (DCBE) (covered every 5 years for average risk patients) d. Colonoscopy (covered every 10 years for average risk patients)

Exceptions i. Colorectal cancer screening beginning at age 40 for persons with a single first-degree relative (sibling, parent, or child) with a history of colorectal cancer or an adenomatous polyp

ii. Screening with sigmoidoscopy, DCBS, or colonoscopy covered as frequently as every two years for individuals with one or more of the following high risk factors for colorectal cancer: (A) A first degree-relative (sibling, parent, child) who has had colorectal cancer or an adenomatous polyposis (screening covered beginning at age 40) (B) Family history of familial adenomatous polyposis (screening covered beginning at puberty) (C) Family history of hereditary nonpolyposis colorectal cancer (HNPCC) (screening covered beginning at age 20 years) iii. Colorectal cancer surveillance with colonoscopy, flexible sigmoidoscopy of DCBE covered as frequently as every two years for individuals who meet any of the following criteria: (A) Patient has inflammatory bowel disease (including ulcerative colitis or Crohn’s disease) (B) Personal history of adenomatous polyps (C) Personal history of colorectal cancer Exclusions a. No coverage provided for colorectal cancer screening using molecular genetic techniques, as these tests are considered experimental and investigational 7. Prostate cancer screening beginning at age 50. Men with increased risk factors covered at age 40

Health Dynamics Preventive Care Program For eligible Employees and their Dependent spouses, the Plan has contracted with Health Dynamics to provide a preventive care program. Health Dynamics provides comprehensive physical exams by creating a complete health profile for you. The benefits under this program are covered at 100% under the Physical Exam Benefit. The Welfare Fund offers a $100 prepaid VISA gift card for completing this program.

If you utilize the Health Dynamics Program, the Welfare Fund will reduce the amount of the Calendar Year Deductible for the Covered Person by the amount of $50.00. If you or your Dependent spouse has already satisfied your Calendar Year Deductible, the $50.00 will be refunded directly to you.

The following tests may be included in the Health Dynamics exam. 1. Health history questionnaire (a voluntary and confidential questionnaire; completion is not required to receive the Calendar Year Deductible reduction) 2. Complete blood chemistry analysis, including glucose and cholesterol 3. Urinalysis 4. Body composition measurements 5. Resting blood pressure

6. Height and weight measurements 7. Pulmonary function test 8. Strength evaluation 9. Flexibility testing 10. EKG 11. Cardiovascular fitness test 12. Physician-directed examination, including Pap smear for women upon request 13. Colorectal cancer screening (multi-slide available) 14. Breast screening mammography, according to American Cancer Society guidelines (women) 15. Chest X-ray, according to OSHA guidelines (men only) 16. PSA test for prostate cancer, according to American Cancer Society guidelines (men)

For a full list of tests and other services, contact Health Dynamics.

Call the location below for a list of examination centers or to schedule an appointment:

Health Dynamics 377 W. River Woods Parkway, Ste 225 Milwaukee, WI 53212 (414) 443-0200

You can also visit Health Dynamics Intervention on the web at www.hdhelpsu.com. You will need to register to use the site. Username: hdhelpsu Password: hdhelpsu

Living Well Health Management Programs If you or your spouse has been diagnosed with heart disease or diabetes, you may be eligible to enroll in the Plan’s Living Well Health Management Programs.

The Living Well Health Management Programs, provided through Med-Care Management, help you or your spouse manage your chronic care. After you enroll, the program provides you or your spouse with a registered nurse. The nurse will speak with you on a regular basis to help keep track of doctors' appointments, lab results and medications.

If you and your spouse both have heart disease or diabetes, you may both enroll in the program.

There is no cost to you for the Living Well Health Management Programs. The Welfare Fund pays the full cost of these programs. Participation in these Programs is voluntary and all information is confidential.

Comprehensive Major Medical Expense Benefit

The Plan covers hospital and medical expenses for you and your Dependents.

How the Plan Works When you and your Dependents visit the doctor or if you are admitted to the hospital, you and the Fund split the cost of health care expenses. There are two ways you and the Fund share the costs of your medical bill.

Coinsurance For other medical expenses and services, you and the Fund split the cost by paying different percentages of the bill. This is known as coinsurance. The percentage amount you or your Dependents pay for the medical expense is set by the Plan. Typically, you pay a smaller percentage of the bill while the Plan covers the rest.

Deductible The major medical benefit has a Calendar Year deductible. The deductible is a set amount of money you must pay for medical expenses and services before the Fund starts splitting the cost. You pay the full amount of medical expenses until you reach the deductible. After you reach the deductible, you pay coinsurance.

For example, your deductible for the year is $250. You have a surgery that costs $300. You pay the first $250 yourself. The remaining $50 is split between you and the Fund. You pay a percentage of the $50 and the Fund pays the rest.

In-Network vs. Out-of-Network The Plan uses a network of medical providers. Providers in the network negotiate their rates with the Plan. Negotiated rates are typically less than the full price of a medical expense or service. That means that when you visit a network provider, the network provider will typically charge less for the service.

If you visit a provider not in the network, you pay based on the reasonable and customary charge. This is typically higher than the rate for in-network providers. For the amount covered by the Fund, you also pay a higher percentage of the cost if you visit a provider not in the network. A provider not in the network may also choose to bill you for any difference between the amount charged and the amount covered by the Fund, which is commonly known as “balance billing.” As a result, if you visit an out-of-network provider, you pay the higher coinsurance plus the full balance of the cost between the total charge and the reasonable and customary charge.

Out-of-Network Providers at an In-Network Hospital Sometimes, when you are in a hospital for care, you will be treated by many doctors and specialists. For example, you might interact with some medical providers in a hospital, who include radiologists, pathologists or anesthesiologists. Not all of these medical providers are in the network, even if the hospital is. If this is the case, your share of the cost will be covered at the in-network rates; for example, the in-network coinsurance amount applies, so long as the service is provided in an in-network hospital.

If you are in the hospital because of an emergency, even if it is an out-of-network hospital, your share of the cost will also be based on the in-network rates (for example, the in-network coinsurance amount).

Keep in mind, however, that although your share of the costs might be at in-network rates, all costs for out-of-network providers are always based on the reasonable and customary charge, and the Plan only covers Medically Necessary Allowable Charges for incurred medical expenses.

Filing Durable Medical Equipment (DME) Claims

Before you incur any expenses for DME, the Fund recommends that you request precertification review from the Hospital Utilization Review provider, Med-Care Management at: (800) 367-1934.

Checking if a Provider is In-Network Before receiving medical services, it is always helpful to ask your physician or the provider if they are a BCBS provider (i.e., in-network provider) because of the potential cost-savings of using an in-network provider, as explained above. If your physician sends your laboratory work out for analysis, or you are

38 contacting a DME supplier in another state, ask the provider if they are in-network, that is, in the BCBS PPO network.

If the answer is no, we suggest you find an in-network (BCBS) provider so that you will receive the in- network discount. You can always find an in-network provider by visiting www.bcbsil.com or by calling BCBS at (800) 810-2583.

Hospital Utilization Review Program The Hospital Utilization Review Program assists with planning for Hospital stays, outpatient surgery, and home health services. The Hospital Utilization Review Program helps ensure that you and your Dependents receive the quality of care you deserve when you need it.

Participating in the program is easy: simply call or have your Physician call the Hospital Utilization Review provider, Med-Care Management, at (800) 367-1934 whenever hospitalization, outpatient surgery, or home health care is recommended. When to Call the Hospitalization Utilization Review Provider Hospital Confinement – non-emergency situations: If your Physician recommends that you or your covered Dependent be admitted to a Hospital, you must contact the Hospitalization Utilization Review provider at least two (2) business days prior to admission. If certification is not obtained prior to admission, the first $250.00 of Covered Medical Expenses per Hospital Confinement is not payable. The $250.00 deductible is in addition to the Cash Deductible for the Calendar Year.

Emergency Admissions: All Emergency Hospital Admissions must be reported within 72 hours after the admission. If not reported, the first $250.00 of Covered Medical Expenses per Hospital Confinement is not payable, in addition to the Cash Deductible for the Calendar Year.

Extended stays: If complications arise and it becomes Medically Necessary for you or your Dependent to stay in the Hospital longer than originally expected, your Physician should call Med-Care Management to coordinate your care.

Outpatient Surgery: When your Physician recommends non-emergency outpatient surgery, your Physician must call the Hospital Utilization Review provider at least two (2) business days prior to the outpatient surgery. Upon completion of the precertification review process, your Physician and the surgical facility will receive written certification. Any surgical procedure performed on an emergency basis does not need to be precertified, unless the procedure results in a Hospital Confinement. In such a case, you must notify the Hospital Utilization Review provider within two (2) business days following the emergency admission.

Note: Medical treatment provided by a Non-PPO Outpatient Surgical Facility is not covered by the Plan. This exclusion applies to the surgical facility’s fee and to any other expenses incurred at the surgical facility.

Considering Options: Surgery does not necessarily require an automatic stay in the Hospital. Due to improvements in medical techniques, many less intrusive surgical procedures can be performed in a Hospital’s outpatient surgery facility and, in some cases, in the Physician’s office. Outpatient surgical facilities are viewed as a viable alternative to inpatient Hospital treatment. Prior to any surgical procedure, discuss with your Physician what alternatives to surgery may be available to you. You may call the Hospital Utilization Review provider, for such information, where trained nurses are available to answer your questions.

Home Care and Durable Medical Equipment: You must contact the Hospital Utilization Review provider when you or your Dependents need Home Health Care services, including Hospice. The Hospital Utilization Review provider will arrange for medically appropriate home care delivered by quality providers. The Fund also recommends that you contact the Hospital Utilization Review provider when you

39 or your Dependents require Durable Medical Equipment. When equipment is ordered by your Physician, the Hospital Utilization Review provider will work with your Physician to determine whether to rent or purchase the necessary equipment and will coordinate the purchase of the equipment at a reduced cost.

Remember: Call or have your Physician call the Hospital Utilization Review provider any time he/she recommends Hospital Confinement, outpatient surgery, or home health care services.

Hospital Utilization Review Provider

Med-Care Management P.O. Box 20564 West Palm Beach, Florida 33416-0564 800-367-1934

Covered Medical Expenses Plans A, B and 7

The term “Covered Medical Expenses” means the Medically Necessary Allowable Charges incurred for treatment of a disease or a bodily injury for the services and supplies specified below. Covered Medical Expenses are ordered by a Physician and are not excluded under the “General Plan Limitations and Exclusions” on page 44. Covered Medical Expenses are considered to have been incurred on the date of the service. 1. Hospital charges as follows: a. For room and board, up to the average semi-private room rate b. For Intensive Care or coronary care unit accommodation, up to an amount equal to such charge, but not in excess of the applicable Maximum Daily Intensive Care Benefit for each day of Intensive Care confinement c. For any other services and supplies during a period of Hospital Confinement d. For emergency treatment e. For treatment in connection with surgery 2. Physician’s services for: a. Hospital, office and home visits and other medical care and treatment b. A surgical operation or a radiotherapy procedure 3. Nursing Care: Professional nursing services by a Registered Nurse, Nurse Practitioner, or Licensed Practical Nurse, up to $100.00 per day, provided such care is not custodial, is authorized by a Physician and is not provided by the Covered Person’s spouse, child, brother, sister or parent. 4. Hospice care, includes expenses for: a. Nursing care, medical social services, Home Health Aide services, medical supplies, medical appliances, drugs, biologicals b. Physician services, short-term inpatient care, respite care and patient counseling Benefits in a Hospice are limited to a period of six months and must be pre-certified by the Hospital Utilization Review provider. Medicare-eligible participants in Plan 6 are covered for Hospice under Medicare Part A; the Fund will supplement Medicare approved expenses. 5. Ambulance service for necessary transportation of a person to the nearest Hospital equipped to furnish treatment for such injury or disease. 6. Charges made by any other person or institution for any of the following services and supplies to the extent such charges do not duplicate charges included under items 1 through 5: a. Drugs and medicines properly identified and ordered in writing by a Physician and dispensed by a licensed pharmacist or Physician b. Anesthesia and its administration c. X-ray and laboratory examinations made for diagnostic purposes in connection with therapeutic treatment d. X-ray, radium, and radioactive isotope therapy e. Oxygen and its administration f. Purchase or rental of durable medical equipment that is used for therapeutic treatment

g. Purchase of durable medical equipment that serves as a prosthetic device for initial replacement of natural limbs or eyes h. Blood and blood plasma i. Casts, splints, trusses, braces and crutches (except dental braces) 7. Maternity expenses for Covered Persons, including Dependent children: a. Childbirth (including home delivery) and related medical conditions The Newborns’ and Mothers’ Health Protection Act provides that coverage for a hospital stay following a normal vaginal delivery may generally not be limited to less than 48 hours for both the mother and newborn child. Health coverage for a hospital stay in connection with childbirth following a cesarean section may generally not be limited to less than 96 hours for both the mother and newborn child. Further, the mother’s Physician may not be required to obtain authorization from the Plan for prescribing a length of stay not in excess of those periods. 8. Nursery charges (Hospital room and board and miscellaneous Allowable Charges) incurred by each eligible newborn Dependent child while the mother is Hospital Confined due to pregnancy. 9. Therapeutic abortion, if the continuation of the pregnancy seriously endangers the life or health of the prospective mother. The procedure must be performed by a Physician upon the recommendation of a Board of Physicians who are members of the staff of the institution in which the procedure is performed. 10. Benefits are provided for the screening, by low-dose mammography, for the presence of occult breast cancer in women, ages 35 and older, once every Calendar Year. Such benefits will be payable to the same extent as for any other radiological examination and subject to the same dollar limits, deductibles and coinsurance factors under the Plan. “Low-dose mammography” means the x-ray examination of the breast using equipment dedicated specifically for mammography, including the x-ray tube, filter, compression device, screens, film and cassettes, with an average radiation exposure delivery of less than one rad mid-breast, with two views for each breast. 11. Federal law (the Women’s Health and Cancer Rights Act) requires health plans that cover mastectomies to follow certain standards in covering breast reconstruction after a mastectomy. If a Covered Person (you or your eligible Dependent) undergoes a mastectomy, the following services and supplies will also be covered under the Plan: (a) reconstruction of the breast on which the mastectomy was performed; (b) surgery and reconstruction of the other breast to produce a symmetrical appearance; and (c) prostheses and treatment of physical complications at all stages of the mastectomy. Coverage will be subject to the same annual deductible, co-payments and limitations that apply to other medical procedures that are covered under the Plan. 12. Fertility and infertility benefits are payable for the diagnosis and treatment of infertility to the same extent as for any other injury or sickness, subject to all general and applicable Plan provisions, provided that these benefits are limited to the Employee and spouse, and subject to a joint lifetime maximum benefit of $25,000. This includes surgical procedures, microtherapy and artificial insemination, including but not limited to in vitro fertilization (IVF), gamete intrafallopian transfer (GIFT), zygote intrafallopian transfer (ZIFT) and intracytoplasmic sperm injection (ICSI). 13. Outpatient Hospital care. 14. Emergency room treatment in a Hospital for non-work-related injury; treatment that is received within the first 24 hours of the Injury is covered at 100%. 15. A Physician’s charges for treatment of an Injury, if the charges are incurred within 90 days of a non- work-related Injury, will be paid at 100% of the Allowable Charge. 16. Spinal manipulation, spinal adjustments and/or adjustments of cervical or vertebral subluxation, acupuncture, and other related services performed by a licensed physician (which includes a chiropractor) or a licensed naprapath, and subject to an annual maximum benefit of $2,500.00.

17. Physiotherapy and/or Occupational Therapy treatment by a licensed physiotherapist (other than a relative listed under nursing care), up to 50 treatments per Calendar Year. 18. Gastric bypass surgery expenses, up to once during a Covered Person’s lifetime, if all of the following conditions are satisfied: a. The Covered Person is at least 100 pounds over his/her medically desirable weight and has a history of unsuccessful attempts to lose weight by more conservative means. A Covered Person with a body mass index (“BMI”) of 45 or higher is presumed to satisfy this requirement b. The Covered Person has been continuously eligible for benefits from the Welfare Fund for a period of five years prior to the gastric bypass surgery c. The Plan’s medical consultant has approved the gastric bypass surgery as a medically appropriate treatment of the Covered Person’s obesity The Plan will cover follow-up treatment after an eligible gastric bypass surgery. The Plan will not cover cosmetic or reconstructive surgery to remove excess skin following weight loss. 19. Disease management/education services by a licensed provider, acting under a Physician’s prescription, up to maximum annual benefit of $200.00. 20. Donor’s expenses in the event of an organ transplant to a Covered Person if such expenses are billed to the Covered Person and if the donor’s expenses, combined with those of the Covered Person, do not exceed the maximum amounts payable under the Plan. Covered Expenses that the Covered Person incurs as a recipient of an organ transplant will be payable as any other Injury or Illness. 21. Payment for dental surgery performed in a Dentist’s office, but only if the surgery is necessary for the treatment of a dental disease. Extractions, orthodontics and restorative surgery performed as a pre- requisite for the replacement of tooth structures are not considered dental surgery and are not covered expenses. Restorative surgery is the substitution of artificial material for lost or lacking tooth structure including fillings, crowns, root canal therapy, bridges, implants, dentures or surgery performed as a pre-requisite for a restorative appliance. 22. Expenses incurred for the repair of injury to natural teeth required as a result of a non-work-related Injury, provided treatment is rendered within six months of the Injury. 23. Hypnosis and laser treatment for smoking cessation, up to a maximum annual benefit of $1,000.00. See also General Plan Limitations and Exclusions, see page 44.

General Plan Limitations and Exclusions (Plans A, B and 7)

No payment will be made under the Plan for a loss sustained or for charges incurred for any of the following: 1. Expenses in connection with cosmetic surgery, unless (a) the surgery is performed to repair injuries sustained in a non-work-related accident, or (b) the surgery corrects a congenital anomaly in a child, or (c) the surgery is reconstructive and is incidental to or following surgery for a mastectomy or any other covered illness. 2. Expenses in connection with dental work, except as specifically covered under the Dental Care Expense Benefit. This exclusion does not apply if one of the following conditions exists: a. A non-dental physical condition which makes hospitalization Medically Necessary to safeguard the health of the patient b. A systemic disease such as brittle diabetes or cardiovascular disease for which the patient is currently under medical management c. Complex oral surgical procedures which carry a high probability of life-threatening complications such as excessive bleeding or airway embarrassment d. Complex or extensive restorative services to a Dependent child under age five, in which case coverage is limited to that which is provided under the dental benefit e. Dental surgery, as provided under item 21 under the Covered Medical Expenses on page 41 3. Expenses in connection with any disease or injury caused by any act of war, whether declared or undeclared. 4. Expenses in connection with treatment rendered outside the United States and Canada to a person during an absence from the United States, except if for non-work-related emergency care. 5. Expenses in connection with Substance Abuse or psychiatric services, except charges made by a Licensed Clinical Psychologist (LCP or PsyD), a Licensed Clinical Social Worker (LCSW), a Licensed Clinical Professional Counselor (LCPC), or by a Physician for treatment (including diagnosis) of Mental and Nervous Conditions. Charges for Substance Abuse are payable as determined under the major medical benefit. 6. Expenses incurred as a result of participation in or attempt to commit a crime that may be punishable as a felony, except that this exclusion shall not apply to incidents of domestic violence. 7. Expenses in connection with any intentionally self-inflicted injury or sickness, including suicide or any attempt thereof, unless the self-inflicted injury or sickness is due to an underlying physical or mental condition. 8. Expenses or supplies which are not rendered or provided in connection with, or as treatment for, a specific injury or illness, unless such services or supplies are specifically covered under the Plan. 9. Expenses, supplies or treatments that are preventive in nature, unless specifically covered under the Plan. 10. Hospital charges, unless the hospitalization is recommended and approved by a Physician. 11. Charges for medicines, drugs or nutritional supplements that can be obtained without a doctor’s prescription, or which have not been legally dispensed by a pharmacist upon a doctor’s prescription. 12. Charges for eyeglasses, contact lenses or hearing aids, except as specifically covered under the Plan (for example, the first pair of glasses or lenses placed following cataract surgery).

13. Charges for failure to keep a scheduled visit, for completion of a claim form and for consultation with a Physician by e-mail. 14. Supplies or equipment for personal hygiene, comfort or convenience such as, but not limited to, air conditioners, humidifiers, and physical fitness equipment. 15. Charges for services rendered by a person who ordinarily resides in your home or is a member of your immediate family. 16. Medical expenses of a person enrolled and covered in an HMO, whether or not that person utilized HMO providers. 17. Services or supplies for which the person is not required to make payment or would have no obligation to pay if he did not have this coverage. 18. Services or supplies that are Experimental or Investigative or do not meet accepted standards of medical practice. 19. Charges for Custodial Care, convalescent care, domiciliary care or rest cures. 20. Charges in excess of Allowable Charges. 21. Sterilization; in no event will correction or reversal of previous sterilization surgeries be covered. 22. Charges for elective abortions, except that the Plan will cover complications arising from abortion. 23. Treatment leading to or in connection with transsexual surgery. 24. Charges in connection with the purchase or fitting of appliances or implants relating to sexual dysfunction or impotence. 25. Expenses for transportation to a place of treatment (except for transportation by ambulance when Medically Necessary) and expenses for room and board incurred in connection with travel for medical treatment. 26. Services and supplies rendered for the treatment of obesity or weight loss, including bariatric surgery, except as specifically provided under the Plan. 27. Expenses for surgical correction of refractive errors of the eye, except as specifically covered under the major medical benefit or the vision benefit. 28. Expenses for which a claim is not received at the Fund Office within one year of the date the claim was incurred. 29. Expenses related to any injury, illness or dental treatment for which an Employee has received or is entitled to receive benefits under a Workers’ Compensation or similar law, or which arises out of or in the course of any occupation or employment. 30. Expenses for education or training of any type, except as otherwise expressly provided in the Plan. 31. Inpatient or outpatient medical expenses, services or supplies provided by a skilled nursing facility, intermediate care facility or personal care facility, except that this exclusion will not apply to Medicare Supplemental Benefits under Plan 6. 32. Services or supplies furnished by or for the U.S. government, or by or for any other government unless payment is legally required, or to the extent provided under any governmental program or law (other than Medicare) under which the individual is, or could be, covered. 33. Expenses for replacement of lost, missing, or stolen, duplicate or personalized Corrective Appliances, Orthotic Devices, Prosthetic Appliances, or Durable Medical Equipment. 34. Expenses for occupational therapy adaptive supplies and devices used to assist a person in performing activities of daily living including self-help devices such as feeding utensils, reaching tools, devices to assist in dressing and undressing, etc. However, the Plan covers shower benches and raised (height-adjustable) toilet seats, if they are pre-approved by Med-Care Management.

35. Expenses for long-term care. 36. Expenses incurred for routine foot care, except as Medically Necessary and as specifically provided under the Plan. 37. Any medical treatment received at a Non-PPO Outpatient Surgical Facility is not covered by the Plan. This exclusion applies to the surgical facility’s fee and to any other expenses incurred at the surgical facility.

Prescription Drug Benefits (Plans A, B and 7)

Medication plays a major role in health care, which is why the Welfare Fund provides coverage for prescription drugs. The Prescription Drug Benefits are administered by Optum Rx/Catamaran. See the Schedules of Benefits for your plan, beginning on page1, for specific copayment amounts.

How to Fill Prescriptions Under the Prescription Drug Benefits program, you have three ways of getting your medication:  At retail pharmacies (for example, Walgreens)  With Optum Rx/Catamaran Home Delivery (Mail-Order program—see below)  With Briova Rx (for specialty drugs—see below)

Retail Pharmacies  Optum Rx/Catamaran has created a network of over 64,000 retail pharmacies across the country. Only prescriptions filled at network retail pharmacies will be covered by the Plan’s benefits. Typically, you can only fill prescriptions for up to 30 days at a retail pharmacy. For prescriptions that are longer than 30 days (such as a 90-day prescription), you can use Optum Rx/Catamaran Home Delivery (see below).

 Maintenance orders can be obtained two times at a Retail Pharmacy on any new prescription.

 When visiting a retail pharmacy, simply take your prescription and your BCBS/Rx ID card (you share a medical and prescription drug ID card). Give your pharmacist the prescription and pay the necessary copay and coinsurance, if applicable.

 To find a network pharmacy near you, contact Optum Rx/Catamaran Member Services at (855) 577- 6319 or visit www.mycatamaranrx.com.

Optum Rx/Catamaran Home Delivery You may fill any prescription using Optum Rx/Catamaran Home Delivery, the mail-order program. Here are some of the features of the Home Delivery program:  After sending in your prescription, your medications are shipped right to your door  Mail-order programs are required for prescriptions longer than 30 days or for maintenance medication (see below)  Using the mail-order program to purchase maintenance medication saves you money because you are “buying in bulk”  You can have your prescription for maintenance medications refilled automatically

To use Optum Rx/Catamaran Home Delivery, use the mail-order form and attach a new prescription from your doctor. Include your payment information and mail the form, prescription and payment to the address listed on the form, which is:

Optum Rx/Catamaran Home Delivery P.O. Box 696054 San Antonio, TX 78269.

Your doctor can also fax the prescription to Optum Rx/Catamaran at (888) 637-5191.

Briova Rx Briova Rx, part of Optum Rx/Catamaran, is used for specialty drugs only. Briova Rx delivers specialty drugs directly to your home. Through Briova Rx, you work closely with a Care Coordinator to help ensure proper delivery, administration and compliance to the medication. If you are taking specialty medication, you are required to use Briova Rx to fill your specialty medication prescriptions.

Contact Briova Rx at (855) 427-4682 before your next refill to place your order. See below for more information on specialty drugs.

Types of Prescription Drugs The amount you pay for prescription drugs depends on where you pick up your prescription and the type of drug. Under the Plan, there are four types of prescription drugs:  Generic  Brand-name  Maintenance  Specialty

Generic Drugs and Brand Name Drugs The generic name of a drug is its chemical name. The brand name is the trade name under which the drug is advertised and sold. Both generic and brand name drugs must meet the same Federal requirements for safety, purity and strength. The main differences are the name of the manufacturer and the price–generic drugs are usually much lower in cost.

The Plan requires the use of generic drugs when available, unless your doctor requires the brand name drug. If your doctor has authorized the use of a generic substitute and you request the brand name drug, the Plan will only cover the prescription as if you had used the generic substitute.

For example, a 30-day prescription for a generic drug costs $100. A 30-day prescription of the same drug, but the brand-name version, costs $400. • If your doctor prescribes the generic version, you pay the generic coinsurance amount (10% of the drug cost, in this case $10). • If your doctor prescribes the brand-name version and if there is no generic available, you pay the brand-name coinsurance amount (25% of the drug cost, in this case $100). • If you choose to take the brand-name version, even though the generic is available, you pay the brand-name coinsurance amount (40% of the drug cost, in this case $160).

Maintenance Drugs A maintenance drug is a prescription drug that helps treat a chronic disease state, or when the treatment for a disease is longer than one year.

Maintenance drugs are generally not covered at retail pharmacies, except for new prescriptions for a maintenance drug, in which case the initial prescription and one refill can be purchased at a retail pharmacy.

Specialty Drugs Specialty drugs are used to treat serious or chronic medical conditions such as, but not limited to, multiple sclerosis, hemophilia, hepatitis and rheumatoid arthritis. These drugs are often administered by injection. Specialty drugs are covered by Briova Rx, part of Optum Rx/Catamaran.

The Plan’s Formulary  The Plan also uses a formulary. A formulary is a list of discounted prescription drugs that is negotiated between the drug manufacturer and the prescription drug benefit administrator, in this case, Optum Rx/Catamaran.

 Purchasing prescription drugs from the Plan’s formulary will save you money. Prescription drugs on Optum Rx/Catamaran’s formulary include generic and brand-name drugs. These are known as “preferred” drugs. Prescription drugs not on the formulary are “non-preferred.”

 To view the Optum Rx/Catamaran formulary, contact Optum Rx/Catamaran Member Services at (855) 577-6319 or visit www.mycatamaranrx.com.

Optum Rx/Catamaran Online

Optum Rx/Catamaran’s website is www.mycatamaranrx.com. To set up your own personal account with a password, visit www.myOptum Rx/Catamaranrx.com. The website offers many beneficial tools to help you with your prescription needs. You can also find nearby pharmacies, refill mail-order prescriptions, view your claims, research your medications, and much more.

Retail and Mail-Order Prescription Drug Card Expenses Covered drugs are any of the following: 1. Legend drugs, that is, those which under Federal law are required to bear the legend, “CAUTION: FEDERAL LAW PROHIBITS DISPENSING WITHOUT A PRESCRIPTION” 2. Insulin and epinephrine on prescription; imitrex (sumatriptan), limited to 6 doses per month 3. Diabetic supplies: disposable insulin needles/syringes, test strips, lancets and lancet devices (Plan pays 100% if obtained through Optum Rx/Catamaran Home Delivery (Mail-Order Program)) 4. Compounded medications of which at least one ingredient is a prescription legend drug

Benefit Limitations and Exclusions 1. Dispensing limitation for prescriptions filled at retail pharmacies is limited to the amount normally prescribed by your doctor, but not to exceed a 30-day supply. The Optum Rx/Catamaran Home Delivery program will cover up to a 90-day supply of your prescribed medication. 2. Refills are limited to doctor’s authorization, and each refill requires an additional coinsurance payment 3. Certain self-injectable drugs require prior authorization after review for medical necessity 4. Contraceptive drugs are covered only under the Optum Rx/Catamaran Home Delivery program 5. Erectile dysfunction oral medications are limited to 6 tablets per month (Cialis, Levitra, and Viagra); Muse limited to 12 units per month, and only if Medically Necessary 6. Smoking deterrent medications are limited to a $1,000.00 Calendar Year maximum

No benefits will be payable for the following: 1. Non-legend drugs other than insulin 2. Charges for the administration of an injectable drug 3. Therapeutic devices or appliances, including needles, syringes (other than for use with insulin), support garments and other non-medicinal substances, regardless of intended use 4. Drugs labeled, “CAUTION: LIMITED BY FEDERAL LAW TO INVESTIGATIONAL USE,” or experimental drugs 5. Immunization agents, biological sera, blood or blood plasma (e.g. Hepatitis Vaccination, Chicken Pox Vaccine) 6. Medication which is to be taken by or administered to an individual, in whole or in part, while he or she is a patient in a licensed Hospital, rest home or similar institution which operates on its premises, or allows to be operated on its premises, a facility for dispensing pharmaceuticals 7. Any prescription refill in excess of the number specified by the Physician, or any other refill dispensed after one year from the Physician’s original order 8. Fertinex, follistim, gonal-f (follitropins), or repronex (menotropin) 9. Cosmetic drugs 10. Services or supplies that are excluded under the “General Plan Limitations and Exclusions” on page 44 11. Charges for medicines, drugs or nutritional supplements that can be obtained without a doctor’s prescription (over-the-counter)

Dental Care Expense Benefit (Plans A and B)

Good dental care also leads to good overall health. In addition to brushing and flossing regularly, a thorough cleaning is necessary every six months to maintain healthy teeth and gums. That’s why the Fund provides you with dental care benefits. See the Schedule of Benefits for your plan, beginning on page 1, for limits and coinsurance amounts.

You and your Dependents can visit any dental provider.

Covered Dental Charges Part 1 – Preventive Dental Benefits These benefits are limited to the following: 1. Oral examination performed by a Dentist, limited to two times in a Calendar Year 2. Prophylaxis (cleaning of teeth), scaling, cleaning and polishing, performed by Dentist or Dental Hygienist, limited to two times in a calendar year 3. Bite-wing x-rays, limited to once in a period of 12 consecutive months 4. Full mouth x-rays, limited to once in a period of 36 months 5. Topical application of sodium or stannous fluoride, fluoride limited to Covered Persons under age 19 and limited to not more than once per Calendar Year. Periodontal prophylaxis limited to once every 3 months not to exceed 4 times per Calendar Year 6. Examination in connection with emergency palliative treatment 7. Examination for consultation purposes

Part 2 – Basic Dental Benefits These benefits are limited to the following: 1. Dental x-rays as required for diagnosis of a specific dental condition 2. Application of sealants on bicuspid and posterior teeth (molars), limited to permanent bicuspids and molars, once in a period of 36 consecutive months, for children under age 19 3. Injection of necessary antibiotic drugs by the attending Dentist 4. Tooth extractions 5. Space maintainers for the premature loss of posterior primary teeth, limited to children under age 14 6. Amalgam, silicate, acrylic, synthetic porcelain and composite filling restoration for decayed or broken teeth 7. Treatment of periodontal and other diseases of the gums and supporting structures of the mouth (gingiva and/or alveolar bone) 8. Occlusal adjustment, only in connection with periosurgery 9. Oral surgery, including extractions and surgical procedures, limited to removal of impacted teeth or as necessary for: a. Wisdom teeth b. Teeth covered partially or totally by bone c. Root canal treatment d. Gingivectomy 51

10. Administration of local anesthesia in connection with covered dental services 11. Administration of general anesthesia and/or intravenous sedation (only in connection with covered oral surgery) 12. Endodontic treatment, including root canal therapy 13. Laboratory services, including cultures necessary for diagnosis and/or treatment of a specific dental condition

Part 3 - Restorative Dental Benefits These benefits are limited to the following: 1. Inlays, onlays and crowns (including porcelain for the front teeth)

2. Repair or recementing of crowns, inlays or onlays

3. Initial installation of fixed bridgework (including wing attachments, inlays and crowns as abutments) to replace natural teeth that were extracted. Expenses on account of adjustments to fixed bridgework are covered only for the six-month period following initial installation

4. Installation of fixed bridgework, implants and dentures. Installation of fixed bridgework must be completed within 12 months of the extraction

5. Replacement of an existing partial or full removable denture or fixed bridgework; addition of teeth to an existing partial or removable denture; bridgework to replace teeth that were extracted if evidence, satisfactory to the Plan Administrator or its designee, is presented that the following conditions have been satisfied:

a. The replacement or addition of teeth is necessary to replace one or more teeth extracted after the existing denture or bridgework was installed and the addition of teeth is completed within 12 months of the extraction

b. The existing denture or bridgework cannot be made serviceable and was installed at least five years prior to the replacement date

c. The existing denture is an immediate temporary denture replacing one or more natural teeth extracted. Replacement by a permanent denture is required. The replacement must take place within 12 months from the placement of the temporary denture

d. The replacement is due to injury requiring oral surgery and the replacement takes place within 15 months of the injury

6. Precision or semi-precision attachments for prosthetic devices

Orthodontia Benefits These benefits are limited to the following: 1. Covered Persons under age 19 only 2. A separate lifetime maximum of $3,500 3. Charges for orthodontia care do not become payable under the Plan until the services relating to such charges are actually provided

4. Initial and subsequent installation of orthodontic appliances. The treatment must be within 90 days of the date the treatment plan is submitted; otherwise, a new treatment plan must be submitted to the Fund Office 52

If eligibility terminates while a Covered Person is receiving Dental or Orthodontia benefits, coverage will be provided only for expenses for treatment performed and completed prior to the date the Covered Person lost eligibility. 52 Dental Benefit Exclusions

Charges incurred for the following expenses are not covered: 1. Dental care that is included as a Covered Expense under any medical benefit 2. Dental services or supplies furnished without charge or paid for by a government unit, employer, benefit association, union or similar group, or for which no charge would be made in the absence of dental benefits 3. Illness or Injury that arises out of any occupation or employment for wage or profit, or which is compensable under any Workers’ Compensation Law or similar legislation 4. Services or supplies furnished before the effective date of benefit eligibility of any Covered Person who receives such services or supplies 5. Treatment of any condition caused by war, or by any act of war, declared or undeclared, or by participating in a riot or commission of an offense that may be punishable as a felony, except that this exclusion shall not apply to incidents of domestic violence 6. Charges for failure to keep a scheduled appointment for Dental treatment of any kind 7. Charges for services with respect to congenital or developmental malformations, or dentistry for purely cosmetic reasons, except orthodontia, including but not limited to: cleft palate, maxillary and mandibular malformation, enamel hypoplasia, flourosis and anodontia 8. Charges for completion of claim forms 9. Expenses not eligible because of the application of Coordination of Benefits. Refer to page 69 10. Services or supplies furnished to a person who is covered by a Dental HMO Plan. The Plan does not coordinate benefits with a Dental HMO Plan

Dental Benefit Exclusions

Vision Benefit (Plans A and B)

About the Vision Benefit

The Fund gives you and your Dependents coverage for vision benefits. Vision benefits include coverage for Eye Exams, allowances for prescription eyeglass lenses, fames and contact lenses, and discounted laser vision surgery.

The Plan’s vision benefits provider is VSP. VSP has a nationwide network of licensed Ophthalmologists and Optometrists. By visiting a provider in the VSP network, you can save money on vision care services. VSP benefits include discounts on a selection of designer frames.

If you choose to go to a provider who is not in the VSP network, the Plan will cover you under the Non- VSP Vision benefit.

To find a VSP provider near you, visit www.VSP.com or call (800) 877-7195. There is no ID card required.

See the Schedule of Benefits for your plan, beginning on page 1, for vision copays, limits, and coinsurance.

Vision Benefit Exclusions

The following vision care services, items or care are not covered under the Plan: 1. Training and any associated supplemental testing 2. Plano lenses (non-prescription) 3. Sunglasses with plano lenses (except for the sunglasses discount benefit at VSP providers) 4. Injury or Illness caused by war or by any act of war, declared or undeclared, or by participating in a riot, or as the result of the commission of an offense that may be punishable as a felony, except that this exclusion shall not apply to incidents of domestic violence 5. Corrective vision services, treatments, and materials of an experimental nature 6. Intentionally self-inflicted injury or sickness, including suicide or any attempt thereof, unless the self- inflicted injury or sickness is due to an underlying physical or mental condition 7. Services or supplies furnished by or at the direction of the U.S. Government or any agency thereof, any state, territorial or commonwealth government or political subdivision thereof, or a foreign government or agency thereof 8. Expenses incurred for services performed or supplies furnished by other than an Optician, Optometrist or Ophthalmologist 9. Services or supplies that are excluded under the “General Plan Limitations and Exclusions” on page 44

Hearing Aid Benefit (Plans A, B, 6 and 7)

About the Hearing Aid Benefit

The Fund provides you and your Dependents with hearing aid benefits. For expenses to be covered, a Physician must certify that you or your Dependents have a hearing loss, which a hearing aid device may help. The Plan will pay up to the amount of Allowable Charges shown on the Schedule of Benefits for your plan, beginning on page 1.

Limitations and Exclusions

1. The replacement of a hearing aid device for any reason more than once in a four Calendar Year period 2. Batteries or other equipment, other than those items obtained upon purchase of the hearing aid device necessary for the operation of the device 3. Expenses that you or your Dependent do not have to pay 4. Repairs, servicing or alteration of the hearing aid device 5. Charges for a hearing aid device in excess of the cost of the device prescribed by the examining Physician 6. Charges for expenses incurred after termination of coverage for the Hearing Aid Benefit except for expenses for a hearing aid device, which was prescribed by the examining Physician, ordered prior to termination of coverage and delivered to you or your Dependent within 30 days after the date of termination of coverage under the Plan 7. Any Injury or Illness arising out of or in the course of employment, or which is compensable under any Workers’ Compensation or Occupational Disease Act or Law 8. Charges, which are not certified by the examining Physician to be medically necessary 9. Charges incurred as a result of an Injury or Illness caused by war, or by any act of war, declared or undeclared, or by participating in a riot or commission of an offense that may be punishable as a felony, except that this exclusion shall not apply to incidents of domestic violence 10. Charges for services or supplies which are furnished, paid for or otherwise provided in a U.S. Government Hospital or in any other Hospital operated by a government unit, unless a charge is made that you or your Dependent are legally required to pay without regard to the existence of health coverage 11. Also see “General Plan Limitations and Exclusions” on page 44

Life Insurance and Accidental Death & Dismemberment (AD&D) Benefits (Plans A and B)

Life Insurance

The Plan’s Life Insurance Benefit pays a lump sum benefit to a deceased Employee’s Beneficiary in the event of the death of the eligible Employee (excluding eligibility solely under COBRA Continuation Coverage). Life insurance benefits are not available to eligible Dependents. See the Schedule of Benefits for your plan for the amount of the benefit.

Naming a Beneficiary You can name any person to be your beneficiary. See the “Claim Payment – Life and AD&D Benefits” on page 58 for more details.

Disability Waiver of Premium If you become totally disabled while eligible for benefits (excluding eligibility solely under COBRA Continuation Coverage) and before you reach age 60, your Life Insurance Benefit will remain in effect at no cost to you until the earliest of the following dates: 1. The date you are no longer disabled 2. The date you no longer qualify for a Disability Waiver of Premium 3. The date you attain age 65

In order to qualify for the Disability Waiver of Premium, you must submit proof that you have been disabled for at least nine months. Such proof must be submitted to the Insurance Company no later than 12 months from the date your active employment ends. Contact the Fund Office for the name and address of the Insurance Company. Premiums will not be waived unless the Insurance Company agrees in writing to waive your premiums.

For purposes of the Disability Waiver of Premium, “disabled” means that you are unable, because of injury or illness, to work in any type of employment for which you are qualified by reason of your training, education or experience.

The Disability Waiver of Premium remains in effect for 12 months. The waiver will be renewed for successive 12 month periods if you provide the Insurance Company the required proof of your continuing disability three months before the end of the 12 month period.

It is your sole responsibility to provide the necessary information to the Insurance Company. Neither the Insurance Company nor the Fund Office will request it.

Termination of Eligibility If your eligibility for the Life Insurance Benefit terminates, you may convert such Life Insurance Benefit to an individual policy, called a “conversion policy.” A medical examination is not required for a conversion policy.

To convert your Life Insurance Benefit, you must apply to the Insurance Company within 31 days of the termination of your eligibility. The amount of life insurance available under the conversion policy will not

56 exceed the amount of the Life Insurance Benefit. You must pay the full premium charged for your conversion policy. Contact the Fund Office for more information.

Life Insurance Benefit Exclusions No Life Insurance benefit will be paid if death is caused by any of the following: • Participation in, or the result of participation in, a riot, or a civil commotion or the commission of a crime that may be punishable as a felony, except that this exclusion shall not apply to incidents of domestic violence • War or act of war, declared or undeclared; or any act related to war, or insurrection • Service in the armed forces of any country

Accidental Death and Dismemberment (“AD&D”)

If you suffer an accidental injury and suffer a covered loss within 90 days of the injury, you may be able to receive an AD&D benefit. The Insurance Company must receive proof of your accident or loss within 90 days of your accidental injury.

Benefits for accidental loss of limb or sight will be paid directly to you. The benefit for accidental death will be paid to the same beneficiary who is entitled to receive your Life Insurance Benefit.

AD&D Benefit Amount See the Schedule of Benefits for your plan, beginning on page 1, for the amount of the Principal Sum.

The Principal Sum will be paid for the covered loss of: 1. Life 2. Both hands 3. Both feet 4. One hand and one foot 5. One hand and one eye 6. One foot and one eye 7. Both eyes

One-half the Principal Sum will be paid for the covered loss of: 1. One hand 2. One foot 3. One eye

One-fourth of the Principal Sum will be paid for the covered loss of a thumb and index finger of the same hand.

Loss is defined as follows: • Loss of a hand means the severance at or above the wrist joint • Loss of a foot means the severance at or above the ankle joint

• Loss of thumb and index finger means the severance of two or more phalanges of both the thumb and the index finger • Loss of any eye means the total loss of sight in that eye

If the person suffers more than one covered loss in any one accident, payment shall be made only for that Covered Loss for which the largest amount of AD&D Benefits is payable.

AD&D Exclusions No AD&D benefit will be paid for any covered loss that is caused by any of the following: 1. An injury which arises out of or in the course of any employment with any employer; bodily or mental illness or disease of any kind 2. Ptomaine or bacterial infections (except ptomaine and bacterial infections occurring as a result of accidental ingestion or infections caused by accidental injury) 3. Any intentional self-inflicted injury or sickness, including suicide or any attempt thereof, unless the self-inflicted injury or sickness is due to an underlying physical or mental condition 4. Participation in, or the result of participation in, a riot, or a civil commotion or the commission of a crime that may be punishable as a felony, except that this exclusion shall not apply to incidents of domestic violence 5. War or act of war, declared or undeclared, or any act related to war, or insurrection 6. Medical or surgical treatment of an illness or disease 7. Service in the armed forces of any country 8. Travel or flight as pilot or crew member in any kind of aircraft including, but not limited to a glider, a seaplane, or a hang kite 9. For any covered loss which is not permanent; or for any covered loss which occurs more than 90 days after the Accidental Injury

Claim Payment – Life and AD&D Benefits Claim of Employee Beneficiary Your Beneficiary is the person or persons named by you, as shown in the Welfare Fund’s records, to receive the benefits payable under the Plan upon your death. You may name one or more Beneficiaries to receive the Life Insurance Benefit. When the AD&D Benefit is payable on account of death, it is paid to the same person(s) who is your Beneficiary for the Life Insurance Benefit. Changing Your Beneficiary You may change the Beneficiary at any time, without the consent of the previously named Beneficiary. You must request a change of Beneficiary, in writing, on a form furnished by the Welfare Fund. The change will take effect upon receipt of a completed and signed form by the Fund Office. Contact the Fund Office for the beneficiary change form. Civil Union Partners If you have a civil union partner, as defined by the State of Illinois, he or she is eligible to be a beneficiary for Life and AD&D benefits. Your civil union partner is automatically your beneficiary if you have not named a beneficiary. The same rules about changing your beneficiary also apply to your civil union partner.

Submitting Claims Completed proof of loss claim forms or other written proof of loss detailing how the covered loss occurred must be sent to the Insurance Company within 91 days after the date of the covered loss or as soon as reasonably possible. Upon Receipt of Satisfactory Proof of Claim The Insurance Company will pay the Life Insurance Benefit and, if on account of death, the AD&D Benefit to your named Beneficiary as follows: 1. If you have named more than one Beneficiary, each surviving Beneficiary will share equally, unless otherwise indicated by you when the Beneficiaries were named

2. If there is no Beneficiary, or if no named Beneficiary is surviving at the time of your death, payment will be made to the first surviving class in the following order of preference

a. your surviving spouse or your civil union partner

b. your children, in equal shares

c. your parents, in equal shares

d. your brothers and sisters, in equal shares

e. the executor or administrator of your estate

In order to determine which class of individuals is entitled to the Life Insurance Benefit, the Welfare Fund may rely on an affidavit made by any individual listed above. If payment is made based on such affidavit, the Welfare Fund will be discharged of its liability for the amount so paid, unless written notice of claim by another individual listed above is received before payment is made 3. If the Beneficiary is a minor or someone not able to give a valid release for payment, the Welfare Fund will pay the benefit to his or her legal guardian. The Welfare Fund will be fully discharged of its liability for any amount of benefit so paid in good faith

Proof of Claim Satisfactory Proof of Claim will include a certified copy of the individual’s death certificate and any other information that the Welfare Fund may require to establish the validity of the claim.

Mode of Payment Life Insurance Benefit proceeds will be paid to the Beneficiary in one lump sum. AD&D Benefits, other than for death, are paid to you in a lump sum.

Weekly Disability Benefit (Plans A and B)

About the Weekly Disability Benefit

If you are injured or sick due to disability, you may need to take time off work. To help you get through your time away from work, the Plan offers Weekly Disability Benefits. Weekly Disability Benefits are for the Employee only. Weekly Disability Benefits are not the same as Worker’s Compensation benefits. Eligibility You are eligible to receive a Weekly Disability Benefit if you cannot work due to a qualified disability. You must be eligible for either Plan A or Plan B at the time the disability occurs.

A qualified disability means a non-work-related accident or illness that leaves you unable to work. You must be unable to perform the duties of your occupation and you cannot be engaged in any other occupation for wage or profit. Accidents, injuries or illness due to a Hospital Confinement, including outpatient surgery, can also be considered a qualified disability.

Your Dependents are not eligible for Weekly Disability Benefits. Benefit Amount Benefits begin as of the first day of disability due to accident or Hospital Confinement (including outpatient surgery), or the eighth day of continuous disability due to sickness. See the Schedule of Benefits for your plan for the amount of the benefit.

There is a maximum Weekly Disability Benefit of 26 weeks for each period of qualified disability.

You may have two (or more) cases of disability during the year. If this happens, you can receive benefits for each period of disability if: • The cause of your disabilities are DIFFERENT or • You DO return to active Covered Employment for at least 40 hours between the periods of disability

You hurt your leg and are out on disability for 20 weeks. You then return to active Covered Employment for six weeks. One weekend at home, you injure your arm and cannot work. Because the cause of the second case of disability is different from the previous case, you start a new period of disability.

If you have two (or more) cases of disability, your cases will be considered only ONE period of disability if: • The cause of your disabilities is the SAME or • You do NOT return to active covered employment for at least 40 hours between the periods of disability

You hurt your leg and are out on disability for 20 weeks. You then return to active covered employment for 2 days. One night at home, the same leg you injured before acts up and you cannot move. You have to go on disability again.

Since the cause of the new disability is the same as before, it will be considered part of the first case. That means you can only receive benefits for six more weeks (equaling 26 weeks total of disability—the maximum benefit for one period of disability).

You also will be credited with 40 Credited Hours for each full week (7 days) of qualified disability, up to a maximum of 1,040 Credited Hours. These disability hours will be credited automatically by the Fund Office.

Applying for Weekly Disability Benefits If you need to go on disability due to accident, Hospital Confinement (including outpatient surgery) or sickness, you or someone you know (such as a Dependent or emergency contact) must contact the Fund Office right away. You need to provide proof of disability. Proof includes a statement or report from your doctor confirming the need for disability. See the “Claim and Appeal Procedures” section on page 75 for more information on Disability Claims.

Weekly Disability Benefit Limitations and Exclusions 1. In order to have a qualified disability, you must be wholly and continuously disabled because of an injury or sickness, unable to perform the duties of your occupation, and not engaged in any other occupation for wage or profit

2. Two or more periods of qualified disability due to the same cause, which are not separated by a return to active employment or a medical release, are considered one period of qualified disability

3. The Weekly Disability Benefit payment amount is paid based upon your current eligibility. For example, if you had a qualified disability beginning in February while in Plan A, your Weekly Disability Benefit will be $400.00. For the next Eligibility Quarter beginning March 1, based upon your hours worked, you are eligible in Plan B. Your Weekly Disability Benefit will be $300.00 in that Eligibility Quarter. In the same way, if you had a qualified disability while eligible under Plan B, and based upon hours worked you are eligible in Plan A in the next Eligibility Quarter, your Weekly Disability Benefit will increase to $400.00

4. No Weekly Disability Benefits will be payable for any of the following: a. Any intentional self-inflicted injury or sickness, including suicide or any attempt thereof, unless the self-inflicted injury or sickness is due to an underlying physical or mental condition b. War or any act of war, declared or undeclared c. Travel or flight in any kind of aircraft except as a fare-paying passenger in an aircraft operated on a regular schedule by an incorporated common carrier for passenger service over its established air route d. Accidental bodily injury or disease for which you are not under the care of a licensed doctor or surgeon e. Work-related injury or illness f. Disability of your spouse or Dependent

Member Assistance Program (MAP)

Hotline Number: (800) 292-2780 www.ers-eap.com User name: adc1 Password: member

The Plan provides a Member Assistance Program (MAP) and managed health care services to you and your eligible Dependents. These confidential services were developed to help you and your Eligible Dependents cope with personal difficulties that can affect your lives both at home and at work. MAP services are available Monday through Friday from 8:30 a.m. to 5:30 p.m. Central Standard Time (CST) by calling (800) 292-2780. Calls are always answered directly by clinical professionals who provide immediate service, even after standard business hours. The 800 hotline number can be used anywhere in the United States.

Confidentiality All contact with the MAP is confidential. The MAP counselor will not speak with any supervisor, coworker, or family member without permission from you (or your eligible Dependent using the MAP), subject to the privacy rules of HIPAA (see page 86). Confidentiality is compromised only when a threat exists (e.g., risk of suicide or homicide, stalking or child abuse).

Contacting the MAP can be a first step toward resolution of personal difficulties.

MAP Services You and your Dependents who are eligible to use the MAP have access to up to three counseling sessions per problem, situation or issue, at no cost to you. Services may include a comprehensive evaluation, brief counseling and a referral, if necessary. Some services not covered under the Plan may be provided by the MAP, at no cost to you.

Covered Issues The MAP assists people with a variety of life problems including: alcohol and drug abuse; stress, anxiety and depression; marital, family and relationship discord; child and adolescent behavioral problems; domestic violence; child care; elder care; financial and legal concerns; and education and career-related problems at no cost to you.

Issues Not Covered The MAP does not address difficulties related to wages, job assignments or other work-related issues. Should you or your Dependent require care beyond the MAP, you will be directed to the best and most appropriate in-network provider available.

When you or your Eligible Dependent contacts the MAP, the immediate task of the MAP is to rule out any threat to the life and safety of the caller or the risk caused by the caller. Once safety has been established, the MAP offers an in-person session or provides services over the phone. A thorough assessment of your current situation is conducted.

A variety of issues presented to the MAP can be assessed within the scope of up to three-in-person counseling session models currently in place for the Plan. Short-term counseling through the MAP is appropriate for individuals who are experiencing a variety of stressors including a difficult transition, stress, depression, and relationship and family conflicts.

If, during the assessment, it becomes apparent that brief counseling is either inappropriate or insufficient to address your concern, the MAP counselor will guide you to the appropriate in-network provider and the correct level of care.

Usually, individuals who contact the MAP due to a substance abuse problem or a long-term or severe psychiatric issue will require care beyond the MAP. If you require care beyond the MAP, you will be directed to the best and most appropriate in-network provider available.

There are also cases in which individuals may contact the MAP, not for the purpose of counseling but to receive referrals to in-network providers. In these situations, the MAP will act as an educator, explaining the benefits that are available and reminding the individual about the importance of selecting in-versus out-of-network providers.

COBRA Continuation Coverage

This section provides the General Notice of COBRA Continuation Coverage, as required by COBRA.

Introduction This section contains important information about your right to COBRA Continuation Coverage, which is a temporary extension of coverage under the Plan. This notice generally explains COBRA Continuation Coverage, when it may become available to you and your family, and what you need to do to protect the right to receive it.

The right to COBRA Continuation Coverage was created by a federal law, the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA). COBRA Continuation Coverage can become available to you when you would otherwise lose your group health coverage. It can also become available to other members of your family who are covered under the Plan when they would otherwise lose their group health coverage. If you have any questions about your rights and obligations under the Plan and under federal law, you may contact the Fund Office.

What Is COBRA Continuation Coverage? COBRA Continuation Coverage is a continuation of Plan coverage when coverage would otherwise end because of a life event known as a “qualifying event.” Specific qualifying events are listed below. After a qualifying event, COBRA Continuation Coverage is offered to each person who is a “qualified beneficiary.” You, your spouse, and your Dependent children are qualified beneficiaries if coverage under the Plan is lost because of the qualifying event. Under the Plan, qualified beneficiaries who elect COBRA Continuation Coverage must pay for COBRA Continuation Coverage.

If you are an Employee, you are a qualified beneficiary if you lose your coverage under the Plan because either one of the following qualifying events happens: • Your hours of employment are reduced to the point that you are no longer eligible for Plan coverage • Your employment ends

If you are the spouse of an Employee, you are a qualified beneficiary if you lose your coverage under the Plan because any of the following qualifying events happens: • Your spouse dies • Your spouse’s hours of employment are reduced to the point that you are no longer eligible for Plan coverage • Your spouse’s employment ends • You become divorced from your spouse

Your Dependent children are qualified beneficiaries if they lose coverage under the Plan because any of the following qualifying events happens: • The parent-Employee dies • The parent-Employee’s hours of employment are reduced to the point that the child is no longer eligible for Plan coverage • The parent-Employee’s employment ends • The child no longer satisfies the Plan’s definition of “Dependent” (see page 95)

COBRA Continuation Coverage applies only to group health benefits. It does not apply to the Fund’s Death Benefit, Accidental Death and Dismemberment (AD&D) Benefit or the Weekly Disability Benefit.

COBRA Continuation Coverage is under the same benefit Plan (Plan A, B, 6 or 7) under which the qualified beneficiary was covered at the time of the qualifying event (with the exception of the non-health benefits described in the preceding paragraph). However, if a qualified beneficiary is eligible for COBRA Continuation Coverage under Plan A, the qualified beneficiary may elect to take COBRA Continuation Coverage under Plan B. This is an irrevocable election made at the time of the initial COBRA election.

When Is COBRA Coverage Available? The Plan offers COBRA Continuation Coverage to qualified beneficiaries only after the Plan has been notified that a qualifying event has occurred.

Giving Notice of Qualifying Events For the other qualifying events (divorce of the Employee and spouse, or a child’s losing eligibility for coverage as a Dependent child), you must notify the Plan in writing within 60 days after the qualifying event occurs. You must provide this notice to the Plan at the address in the “Important Plan Information” section on page 81.

How Is COBRA Coverage Provided? Once the Plan determines that a qualifying event has occurred, COBRA Continuation Coverage will be offered to each of the qualified beneficiaries. Each qualified beneficiary will have an independent right to elect COBRA Continuation Coverage. Covered Employees may elect COBRA Continuation Coverage on behalf of their spouses, and parents may elect COBRA Continuation Coverage on behalf of their children.

How Long Will Continuation Coverage Last? COBRA Continuation Coverage is a temporary continuation of coverage. When the qualifying event is the death of the Employee, your divorce or a child’s losing eligibility as a Dependent, COBRA Continuation Coverage lasts for up to a total of 36 months. When the qualifying event is the end of employment or a reduction in the Employee’s hours of employment, COBRA Continuation Coverage lasts for up to a total of 18 months.

However, if the Employee became entitled to Medicare benefits less than 18 months before the qualifying event, COBRA Continuation Coverage for qualified beneficiaries (other than the Employee) lasts until 36 months after the date of Medicare entitlement.

For example, if a covered Employee becomes entitled to Medicare eight months before the date on which his employment terminates, COBRA Continuation Coverage for his spouse and children can last up to 36 months after the date of Medicare entitlement, which is equal to 28 months after the date of the qualifying event (36 months minus 8 months).

There are two ways in which the 18-month period of COBRA Continuation Coverage can be extended.

1. Disability extension of 18-month period of COBRA Continuation Coverage If you or anyone in your family covered under the Plan is determined by the Social Security Administration to be disabled and you notify the Plan in a timely fashion, you and your entire family (all individuals covered by the Plan) may be entitled to receive up to an additional 11 months of COBRA Continuation Coverage, for a total maximum of 29 months. The disability must have started at any time before the 60th day of COBRA Continuation Coverage and must last at least until the end of the 18-month period of COBRA Continuation Coverage.

If this extension applies to you, you must notify the Plan in writing within 60 days of the date of the Social Security Administration’s determination or, if later, within 60 days of the start of your COBRA Continuation Coverage, but in no event later than the end of the 18-month period of COBRA Continuation Coverage. Your written notice should be sent to the address in the “Important Plan Information” section on page 81.

Also, if, during the 11-month extension period, the Social Security Administration finds that the disabled family member is no longer disabled, you are required to notify the Plan in writing within 30 days of that finding. In that case, the extension will end for all covered family members. Finally, the cost of COBRA Continuation Coverage is higher during the 11-month period of the extension than it is in the initial 18 months.

2. Second qualifying event extension of 18-month period of COBRA Continuation Coverage If your family experiences another qualifying event while receiving 18 months of COBRA Continuation Coverage, the spouse and Dependent children in your family can get up to 18 additional months of COBRA Continuation Coverage, for a maximum of 36 months, if notice of the second qualifying event is given to the Plan.

This extension may be available to the spouse and any Dependent children receiving COBRA Continuation Coverage if the Employee or former Employee dies or gets divorced, or if the child stops being eligible under the Plan as a Dependent child, but only if the event would have caused the spouse or Dependent child to lose coverage under the Plan had the first qualifying event not occurred.

Here is a chart summarizing the possible durations of COBRA Continuation Coverage:

If You Lose Coverage These People Would Be For up to… Because… Eligible for COBRA Coverage… Your employment terminates You and your eligible 18 months‡ Dependents You become ineligible due to You and your eligible 18 months‡ reduced work hours Dependents You die Your eligible Dependents 36 months You divorce Your eligible Dependents 36 months Your Dependent children no Your eligible Dependent children 36 months longer qualify as Dependents ‡ May be extended to 29 months; see “Disability Extension,” above.

Early Termination of COBRA Continuation Coverage COBRA Continuation Coverage will be terminated before the end of the maximum period (described above) if: • Any required premium is not paid in full on time • A qualified beneficiary becomes covered, after electing COBRA Continuation Coverage, under another group health plan that does not impose a pre-existing condition exclusion for a pre-existing condition of the qualified beneficiary • A qualified beneficiary becomes entitled to Medicare benefits (under Part A, Part B, or both) after electing COBRA Continuation Coverage • The Plan ceases to provide group health coverage to any participants How Can You Elect COBRA Continuation Coverage? When you or an eligible Dependent has had a qualifying event, the Plan will send a notice of the right to COBRA Continuation Coverage, along with an Election Form, which is used to apply for COBRA Continuation Coverage. You must complete and return the Election Form no later than 60 days from the date of the notice or 60 days from your coverage termination date, whichever is later. If you do not choose COBRA Continuation Coverage within the 60-day period, your eligibility will end on the eligibility termination date provided in the Plan and you will have no COBRA Continuation Coverage rights.

Each qualified beneficiary has a separate right to elect COBRA Continuation Coverage. For example, the Employee’s spouse may elect COBRA Continuation Coverage even if the Employee does not. Adding Dependents to COBRA Continuation Coverage Ordinarily, the qualified beneficiaries for COBRA Continuation Coverage are the persons (you and/or your Dependents) who lost coverage as a result of a qualifying event. One exception is that, if a child is born to or adopted by the Employee and his/her spouse while the Employee is receiving COBRA Continuation Coverage, that child is a qualified beneficiary and can be added to the COBRA Continuation Coverage. You must notify the Fund Office within 30 days of the birth or adoption to add a child to your coverage. Payment for COBRA Continuation Coverage In order to maintain COBRA Continuation Coverage, you must pay the cost of that coverage on a timely basis. You must make your first payment for COBRA Continuation Coverage within 45 days after the date of your election of COBRA Continuation Coverage. Your first payment must cover the cost of COBRA Continuation Coverage from the time your coverage under the Plan would have otherwise terminated up to the time you make the first payment.

You are responsible for making sure that the amount of your first payment is enough to cover this entire period. You may contact the Fund Office to confirm the correct amount of your first payment. After you make your first payment for COBRA Continuation Coverage, you will be required to pay for COBRA Continuation Coverage for each subsequent month of coverage.

Under the Plan, these periodic payments for COBRA Continuation Coverage are due on the first day of each month. If you make a periodic payment on or before its due date, your coverage under the Plan will continue for that coverage period without any break. The Plan will not send periodic notices of payments due for these coverage periods.

Although periodic payments are due on the first day of each month, you will be given a grace period of 30 days to make each periodic payment. Your COBRA Continuation Coverage will be provided for each coverage period as long as payment for that coverage period is made before the end of the grace period for that payment.

However, if you pay a periodic payment later than its due date but during its grace period, your coverage under the Plan will be suspended as of the due date and then retroactively reinstated (going back to the due date) when the periodic payment is made. This means that any claim you submit for benefits while your coverage is suspended may be denied and may have to be resubmitted once your coverage is reinstated. If you fail to make a periodic payment before the end of the grace period for that payment, you will lose all rights to COBRA Continuation Coverage under the Plan. Cost of COBRA Continuation Coverage The monthly charge for COBRA Continuation Coverage is set by the Board of Trustees and, subject to legal requirements, the Board of Trustees can increase the charge as the Plan’s cost of providing benefits increases. The monthly charge for COBRA Continuation Coverage provides coverage for one person (the Employee, spouse or a Dependent child). Payments for COBRA Continuation Coverage must be made by check or money order. If You Have Questions Questions concerning the Plan or your COBRA Continuation Coverage rights should be addressed to the Plan’s COBRA Coordinator at the address and telephone number given below. For more information about your rights under ERISA, including COBRA, the Health Insurance Portability and Accountability Act (HIPAA), and other laws affecting group health plans, contact the nearest Regional or District Office of the U.S. Department of Labor’s Employee Benefits Security Administration (EBSA) in your area or visit the EBSA website at www.dol.gov/ebsa. (Addresses and phone numbers of Regional and District EBSA Offices are available through EBSA’s website.) Keep the Plan Informed of Address Changes In order to protect your family’s rights, you should keep the Plan informed of any changes in the addresses of family members. You should also keep a copy, for your records, of any notices you send to the Plan. Plan Contact Information The Plan’s COBRA Coordinator can be reached at (630) 617-8666, and you can mail inquiries or notices to:

Attention: COBRA Coordinator Administrative District Council 1 Welfare Fund 660 North Industrial Drive, Suite 100 Elmhurst, Illinois 60126.

Coordination of Benefits Rules

Coordination of Benefits (“COB”) is applicable to medical benefits and dental benefits. Coordination with Other Health Plans If any person, while covered under the Plan, is also covered under one or more other plans, and the sum of benefits payable under the Plan together with the benefits payable under all other plans exceeds your allowable expenses during any claim determination period, then the benefits otherwise payable to you shall be reduced so that the benefits payable under all of the plans involved shall not exceed your allowable expenses for such period. Benefits payable under another plan include the benefits that would have been payable had a claim been made.

If a person is covered under two or more plans, the order in which benefits shall be determined is as follows: 1. When one of two plans providing benefits for an individual has no non-duplication provision, the plan with the non-duplication provision is secondary. 2. The benefits of a plan covering a person other than as a Dependent shall be determined before the benefits of a plan covering such a person as a Dependent. 3. The benefits of a plan covering the person as a Dependent child of the parent with the earlier birth date (month and day only) shall be determined before the benefits of the plan covering the person as a Dependent child of the parent with the later birth date (month and day only). 4. When (1), (2) or (3) above fail to establish an order of benefit determination, then the benefits of the plan covering the person for the longer period of time shall be determined first. 5. This Plan shall be secondary if the person has COBRA coverage under this Plan and non-COBRA coverage under another plan.

Where this Plan’s coverage is secondary under the foregoing rules, and if the primary plan includes a provision that results in the primary plan paying a lesser benefit when there is secondary coverage, then this Plan’s secondary benefits will be limited to the difference between the amount that the Covered Person’s primary plan would have paid if the primary plan had been the only plan providing coverage, and the total amount of covered charges. In no event will this Plan pay more than the amount it would have paid as a primary payor.

For the purpose of Coordination of Benefits, the Plan: 1. May release to or obtain from any other insurance company or other organization or person any claim information and any person claiming benefits under the self-funded benefits of the Plan must furnish any information that the Plan may require. 2. Has the right, if an overpayment is made, to recover such overpayment from any other person, or any other insurance company or organization. 3. Has the right to pay to any other organization an amount it shall determine to be warranted, if payments, which should have been made by the Plan, have been made by such organization. Coordination with Medicare This Medicare COB provision applies when the eligible person: 1. Has health benefits under the Plan 2. Is eligible under Medicare Part A or Part B (whether or not the eligible person has applied or is enrolled for Medicare benefits)

The Medicare COB provision applies before any other COB provision of the Plan. Effect on Benefits 1. If, in accordance with the rules in this section, this Plan has primary responsibility for the Covered Person’s claims, then this Plan pays benefits first. 2. If, in accordance with the rules in this section, this Plan has secondary responsibility for the Covered Person’s claims. a. First Medicare benefits are determined or paid b. Then Plan benefits are paid, provided that the combined Medicare benefits and Plan benefits will not exceed 100% of the expense incurred Important Note: If the Covered Person is eligible for Medicare and it is determined that this Plan has secondary responsibility for the Covered Person’s claim, benefits will be paid on that basis even if the Covered Person has not enrolled in Medicare Parts A & B. Thus, it is very important to enroll in Medicare Parts A & B when you become eligible for Medicare. When Medicare coverage is based on age For Employees and Dependents enrolled in or eligible for Medicare, this Plan has primary responsibility for your claims if the following conditions are both satisfied: 1. The Covered Person is at least age 65 and is eligible for Medicare Part A solely because of age 2. The Covered Person (or his/her spouse) is actively employed by an ADEA Employer that pays all or part of the required contributions for eligibility

If a Covered Person is eligible for Medicare but does not satisfy clause (2), then this Plan has secondary responsibility for claims. When Medicare coverage is based on end-stage renal disease For the first 30 months of Medicare eligibility, this Plan has primary responsibility for the claims of a Covered Person who is eligible for Medicare benefits because of end-stage renal disease. Thereafter, this Plan’s coverage is secondary. When Medicare coverage is based on disability This Plan has primary responsibility for the claims of a Covered Person who is eligible for Medicare benefits because the Covered Person is receiving Social Security disability benefits.

Subrogation

The Plan’s subrogation rules apply when you or your eligible Dependent is injured and, because of that injury, you or your Dependent become entitled to reimbursement from another source. For purposes of these subrogation rules, “another source” or “other source” means any third party, including an insurance company that is obligated to pay claims on account of the acts of a third party, and an “injury” includes any injury, sickness or condition.

The other source can also be your own insurance carrier, although these subrogation rules do not apply to benefits paid under another employer-sponsored group health plan if that coverage is subject to Coordination of Benefits as described on page 69.

In any case in which you or a Dependent may be able to recover money or benefits from another source, the injured person’s entitlement to benefits from the Plan is conditioned upon compliance with the subrogation rules described in this section and is also conditioned upon the signing of a Reimbursement Agreement. Reimbursement Agreement The Reimbursement Agreement is an agreement by which the injured person (you or your Dependent) agrees to reimburse the Plan from any money recovered from another source. If the injured person is a minor, the Reimbursement Agreement must be signed by a person legally authorized to act on behalf of the minor.

The Reimbursement Agreement must be on a form approved by the Board of Trustees. It will require the injured person to repay the Plan for the amount of all benefits paid on account of the injury, whether or not the recovery was sufficient to reimburse fully the person for his or her losses. However, no person will be required to repay to the Plan more than the amount of benefits the Plan paid on the claim, or more than the gross amount the injured person (or his or her representative) received in recovery.

The Plan is not responsible for legal fees and expenses incurred in obtaining a recovery from another source, unless the Fund has agreed in writing to assume a share of those fees and expenses. The Plan does not recognize the “make whole” doctrine or the “common fund” doctrine.

The Plan is also entitled to a lien on the proceeds of any recovery from another source, to the extent of the full amount of benefits paid for the injury in question. This lien arises under both the Reimbursement Agreement and the Plan itself and the lien applies even if a Reimbursement Agreement is not signed or is invalid for any reason. If you obtain a recovery from any source, you must hold the recovery or an amount equal to the total claims and benefits paid the Plan in trust pending reimbursement to the Plan or pending resolution of the Plan’s lien; such recovery will be considered and deemed to be held in trust for such purpose.

You and the injured person are obligated to do everything that is necessary to enable the Plan to bring about a recovery of the amount of benefits paid. Neither you nor the injured person (or his or her representative) may assign to another person the right to recover money from another source. The injured person (or his or her representative) is not permitted to compromise the Plan’s subrogation claim and lien and is also required to obtain the Fund’s consent before releasing another person from liability for any injury.

If you fail to reimburse the Plan as required by the Reimbursement Agreement, or if you otherwise violate the Plan’s subrogation rules, the Plan has the right, in addition to any other legal rights it may have, to reduce future benefits on claims made by you or any covered Dependent, until the full amount of the repayment has been received by the Plan.

“Subrogation” means that the Plan has the same right as the injured person to make a claim against the other source to recover the amount of benefits paid. For this reason, if you or your injured Dependent (or his or her representative) fail to make a claim against a person or insurer that is liable to you, the Plan is entitled to do so in your name as the injured person and for the purpose of recovering amounts due under these subrogation rules. In that event, the Fund’s expenses, costs and attorney’s fees will also be paid out of any recovery or settlement. Compensated Injuries If an injured person obtains a recovery from another source prior to this Plan’s payment of benefits for treatment of that injury, benefits are not payable under the Plan for any claim related to that injury until the total of covered expenses arising out of or related to the compensated injury equals or exceeds the gross amount of the recovery paid to or on behalf of the injured person. The Plan will then consider only the amount of claims that exceeds the amount of the gross recovery.

This rule applies regardless of who makes the claim against the responsible party and who pays the recovery. The Plan will also have subrogation rights with respect to any benefits paid prior to the time that the injured person recovers money from another source for the injury.

Claim and Appeal Procedures

How to File a Claim for Benefits

In order for the Plan to pay benefits, a claim must be filed with the Plan, under the procedures described below. A claim can be filed by you, your eligible Dependent or by someone authorized to act on behalf of you or your eligible Dependent. In these Claim and Appeal Procedures, “you” means the Claimant.  A claim for a benefit is considered to have been filed on the date it is received at the Fund Office. Even if a claim is incomplete–for example, the Fund Office has received a medical bill but has not received a claim form–the claim is considered to have been filed on the date the Fund Office first receives notice of the claim  You may obtain claim forms by telephoning or writing the Fund Office at 660 North Industrial Drive, Suite 100, Elmhurst, Illinois 60126, telephone (630) 617-8666. You can also visit the Fund Office to obtain claim forms  If you incur a medical expense and ask the Plan to pay benefits, that is considered a claim. However, a request for confirmation of Plan coverage is not a claim if you have not yet incurred the medical expense (except in the case of a Pre-service Claim). The following are examples of situations that do not constitute a claim: an inquiry about general benefit eligibility; a dispute concerning a Plan finding that you or a Dependent is not eligible for benefits, where no medical costs have been incurred; presenting a prescription to a pharmacy, whether or not the pharmacy is a prescription network provider  A claim must be filed within one year of the Date of Expense  Life and AD&D Insurance claims must be filed within 91 days after the loss or as soon as reasonably possible  You may designate another person as your authorized representative for purposes of filing a claim. Except in the case of an Urgent Care Claim, such designations must be in writing on a form provided by the Plan. Please contact the Fund Office if you need a form to designate an authorized representative  When you designate a person as your authorized representative, it allows that person to deal with the Plan on your behalf but it does not mean that the Plan will send your benefit payments to that person. When you designate an authorized representative, all notices regarding your claims will be sent to your authorized representative and not to you. Designating an authorized representative is different from assigning benefits to a Medical Provider. (See “Limitations on Assignments, on page 79.) Where to File Initial Claims All inquiries regarding eligibility should be directed to the Fund Office. Medical benefit claims may be filed at the Fund Office. As explained on your Plan identification card, a medical provider who is in the PPO network must send your claim directly to the PPO network. Dental benefit claims are filed with the Fund Office; Vision claims are filed with VSP at P.O. Box 997105, Sacramento, California, 98599-7105. Prescription drug claims can be made at a retail pharmacy that is in the prescription network, or they can be mailed to the mail-order pharmacy. See your prescription drug card for details. Finally, in the case of any claim that is received at the Fund Office and that should have been sent elsewhere, the Fund Office will forward the claim to the proper location.

Initial benefit claims for vision and prescription drug benefits are processed by the vision or prescription drug benefit provider, as applicable and as indicated in the Schedule of Benefits, beginning on page 1.

Benefit Payment to an Incompetent Person Benefit payments under the Plan may become payable to a person who is adjudicated incompetent. In this event, the Board of Trustees may make such payments for the benefit of the incompetent person as they deem best. The Board of Trustees will have no duty or obligation to see that the funds are used or applied for the purpose or purposes for which paid if they are paid: 1. Directly to the person 2. To the legally appointed guardian or conservator of such person 3. To any spouse, child, parent, brother, or sister of such person for the welfare, support, and maintenance of the person 4. By the Board of Trustees directly for the support, maintenance and welfare of the person

If any question or dispute arises concerning the proper person or persons to whom any payment will be made under the Plan, the Board of Trustees may withhold payment until a binding adjudication of the question or dispute is made. The resolution must be satisfactory to the Board of Trustees in their sole and unrestricted discretion. Alternatively, the Board of Trustees may pay the benefits if it has been adequately indemnified to its satisfaction against any resulting loss. Time Periods for Processing Claims The amount of time that the Plan can take to process a claim depends on the type of claim. Medical or Health Care Claims: • Post-service Claims: Approval or denial of a Post-service Claim will normally be made within 30 days of the date the claim is received by the Plan.

If an Extension is necessary, the Plan can extend the 30-day time period by another 30 days. Before the end of the original 30-day period, you will be notified in writing of the circumstances requiring an Extension and the date by which the Plan expects to make a final decision on the claim.

• Pre-service Claims: Approval or denial of a normal Pre-service Claim (not an Urgent Care or Concurrent Care Claim) will ordinarily be made within 15 days of the date the claim is received by the Plan. If an Extension is necessary, the Plan can extend the 15-day time period by another 15 days. Before the end of the original 15-day period, you will be notified in writing of the circumstances requiring an Extension and the date by which the Plan expects to make a final decision on the claim. • Urgent Care Claims: For Pre-service Claims that are also Urgent Care Claims, the Plan or its representative will advise you whether or not the treatment or service is approved as soon as possible, and not later than 72 hours of the Plan’s receipt of the Urgent Care Claim. This notice may be given by telephone or in writing but, if the notice is by telephone, a written confirmation will follow within 3 days. If the Plan cannot process the claim without additional material or information from you or your medical provider, the Plan may take an Extension and request the necessary material within 24 hours of receipt of the claim. You will be given no less than 48 hours to provide the needed information. Once the Plan has received a response to its request, the Plan will make a determination on your claim within 48 hours of the time the additional information is received or, if no information is provided, within 48 hours of the expiration of the time period within which a response was to be made. For Urgent Care Claims, a medical professional with knowledge of your medical condition can act as your authorized representative. The Plan will not require the medical professional to show that you have designated him/her as your authorized representative.

• Concurrent Care Claims: For Pre-service Claims that are also Concurrent Care Claims, the same time limits that govern normal (non-urgent) Pre-service Claims will apply, unless the Concurrent Care Claim is also an Urgent Care Claim. The following additional rules apply to Concurrent Care Claims. If the Plan has approved coverage for a specified period of treatment and you request an extension of that period, the request for an extension is treated as a new Pre-service Claim. However, if the extension request is an Urgent Care Claim, the Plan will notify you of its decision within 24 hours of the Plan’s receipt of the request, provided that the request for an extension is received more than 72 hours before the end of the originally approved period of treatment. Otherwise, the time periods for processing an Urgent Care Claim will apply. If you have a Concurrent Care Claim and the Plan terminates or reduces a previously approved period of treatment, you will have the right to appeal that termination or reduction. (The rules governing appeals are explained below.) The Plan will give you 10 days’ advance notice of such a termination or reduction. If you appeal the termination or reduction within the 10-day period, the Plan will not implement the termination or reduction before you are given notice of the outcome of the appeal. This rule, allowing the course of treatment to continue pending an appeal, does not apply if your benefits terminate because you have lost eligibility under the Plan or if the termination or reduction of benefits is the result of a Plan amendment. Disability Claims: • Disability Claims: Approval or denial of a Disability Claim will normally be made within 45 days of the date the claim is received by the Plan. If an Extension is necessary, the Plan can extend the 45-day time period by 30 days. If one 30-day Extension is not sufficient, the Plan can apply a second 30-day Extension. Before the end of the original 45-day period (or, for a second extension, before the end of the first 30-day extension), you will be notified in writing of the circumstances requiring an extension of time and of the date by which the Plan expects to make a final decision on the claim. Life Insurance or Accidental Death and Dismemberment Insurance Claims: • Life Insurance or AD&D Claims: Written notice of denial will be furnished by the Insurance Company to the claimant within 90 days after receipt of the claim. An extension of 90 days will be allowed for processing the claim if special circumstances are involved. The claimant will be given notice of any such extension. The notice will state the special circumstances involved and the date a decision is expected. Denial of Claims If your claim is denied, in whole or in part, the Plan will send you a written notice stating the specific reason or reasons for the denial, making reference to pertinent Plan provisions on which the denial was based. A notice of claim denial will also include: • A summary of the Plan’s appeal procedures. • If applicable, a description of any additional material or information necessary to process your claim, along with an explanation of why such material or information is necessary. • If applicable, a statement that, upon written request, you will be furnished with a copy of any internal rule, guideline or policy that the Plan relied on in processing your claim. • If applicable, a statement that, upon written request, you will be furnished with an explanation of any scientific or clinical judgment used by the Plan in denying your claim if the Plan found that the treatment was experimental or not Medically Necessary.

• A statement that Section 502(a) of ERISA provides that a participant or beneficiary of an employee benefit plan may file suit to recover benefits due under the terms of the plan, to enforce the terms of the plan or to clarify the person’s right to future benefits under the plan.

Appealing the Denial of a Claim If your claim has been denied in whole or in part, you may request a full and fair review (referred to in these Procedures as an “appeal”) for all claims, except life insurance or AD&D, by filing a written notice of appeal with the Plan. • A notice of appeal must be received at the Fund Office not more than 180 days after you receive the written notice of denial of a health care or disability claim. Your appeal is considered to have been filed on the date the written notice of appeal is received at the Fund Office. For life insurance or accidental death and dismemberment claims, an appeal must be filed with the Insurance Company during the 60-day period following receipt of the notice of denial of the claim.

• If you wish, another person may represent you in connection with an appeal. If another person claims to be representing you in your appeal, the Board of Trustees has the right to require that you give the Plan a signed statement, advising the Board of Trustees that you have authorized that person to act on your behalf regarding your appeal. Any representation by another person will be at your own expense.

• In connection with your appeal, you or your authorized representative may review pertinent documents and may submit issues and comments in writing. Upon written request, the Plan will provide reasonable access to, and copies of, all documents, records or other information relevant to your claim. If the Plan obtained an opinion from a medical or vocational expert in connection with your claim, the Plan will, on written request, provide you with the name of that expert. The Plan will not charge you for copies of documents you request in connection with an appeal. • Appeals of Post-service Claims and Disability Claims will be decided by the Board of Trustees. Appeals of Pre-service Claims will be decided by a Plan fiduciary selected by the Board of Trustees. The person who decides the appeal will not be the same person, or a subordinate of the person, who made the original claim denial. In the paragraphs that follow, “Review Committee” means the Board or Committee or person who decides an appeal. You (and your authorized representative, if any) are not entitled to appear before the Review Committee and no hearing will be held on the appeal.

• Appeals of Pre-service Claims regarding coverage of prescription drugs will be administered by the Plan’s pharmacy benefit manager.

• In deciding your appeal, the Review Committee will consider all comments and documents that you submit, regardless of whether that information was available at the time of the original claim denial. Also, the Review Committee will not presume that the original denial was correct. • If an appeal involves a medical judgment, such as whether treatment is Medically Necessary, the Review Committee will consult with a medical professional who is qualified to offer an opinion on the issue. If a medical professional was consulted in connection with the original claim denial, the Review Committee will not consult with the same medical professional (or a subordinate of that person) for purposes of the appeal. Denials Based on Missing Information or Documents If your claim was denied because the Plan did not have information or documents necessary to process the claim and if, on appeal, you submit information or documents that respond to the reason for denial, then, in place of the appeal procedures described above, the Plan has the right to simply reopen and

76 reprocess the claim. In this case, you will be sent a new Explanation of Benefits form, advising of the determination of the claim upon reprocessing. If, on reprocessing, your claim is denied in whole or in part, you will have a new right of appeal with respect to the reprocessed claim. Time Periods for Processing Appeals • Post-service Claims and Disability Claims: The Review Committee meets four times per year. If your appeal is filed more than 30 days prior to a regular meeting of the Review Committee, your appeal will be decided at that meeting unless special circumstances require an extension of time for processing, in which case a decision will be made on your appeal at the next following meeting of the Review Committee. If your appeal is filed within the 30-day period immediately preceding a regular meeting of the Review Committee, the appeal will not be decided at that meeting but will be decided at the next following meeting, unless special circumstances require an extension of time for processing. In that case, a decision will be made on your appeal at the third meeting following the date your appeal was filed. Whenever there are special circumstances that require that the decision be delayed until the next following meeting, you will be advised in writing of why the extension of time was needed and when the appeal will be decided. When the Review Committee, in its discretion, determines that it can decide an appeal sooner than the time limits stated above, the Committee will do so. Once the Review Committee has decided your appeal, the Plan will send you a written notice of that decision. The notice will be mailed within five days of the Review Committee’s decision. • Pre-service Claims: For a Pre-service Claim that is not an Urgent Care Claim, the Plan will notify you of the decision on appeal within 30 days of the Plan’s receipt of the appeal. For an Urgent Care Claim, the Plan will notify you of the decision on appeal within 72 hours of the Plan’s receipt of the appeal. Also, for appeals of Urgent Care Claims, the notice of appeal can be oral instead of in writing, and the Plan may notify you of its decision by telephone or facsimile (“fax”). If a Claimant whose Pre-service Claim was denied obtains the service or treatment that had been denied, the claim is no longer a Pre-service Claim and any appeal of the denial of the Pre-service Claim will be handled under the rules that apply to Post-service Claims. Advisory Appeals Ordinarily, in order to have the right to appeal a claim denial, you must have incurred a claim and that claim must have been denied (in whole or in part) by the Plan. An “advisory appeal” is permitted for certain types of requests (described below) where a claim has not yet been incurred but the Plan nevertheless allows you to use a modified appeal process to challenge a Plan decision. Advisory appeals are permitted in two situations: • If you, or a Medical Provider on your behalf, have submitted a written request for a predetermination of benefits payable for a certain procedure, and if the Plan has responded in writing that the procedure is not eligible for reimbursement under the Plan, you can file an advisory appeal. Please note, if pre-approval of a procedure is required by the Plan, then a request for predetermination is a claim and you have the right to appeal an adverse determination under the Plan’s regular (non- advisory) appeal procedures. However, there are few (if any) claims for which preapproval is required by the Plan, so most predetermination requests are advisory and an appeal from such a denial is an advisory appeal. • If you have received a letter from the Plan denying you the right to self-pay, either under COBRA or the Plan’s Quarterly Self-Payment Program, you can file an advisory appeal. If you have already incurred a claim that was denied because you are not eligible to self-pay, that would be a regular (non-advisory) appeal, rather than an appeal of the right to self-pay, which is an advisory appeal.

When you file an advisory appeal, the appeal is not about a claim you have actually incurred; it is about a claim you have not yet incurred - either a procedure you plan to have performed, or a claim you might incur and submit if you have the right to extend your eligibility by making self-payments. Advisory appeals are processed exactly like regular (non-advisory) appeals, including the applicable time limits for filing appeals, with two exceptions. First, if, after an advisory appeal is decided, you incur a claim and that claim is denied, in whole or in part, you still have the right to file a regular (non-advisory) appeal. Also, while a Claimant ordinarily has the right to file a lawsuit if an appeal is denied (subject to certain requirements, such as timeliness and exhaustion of administrative remedies), you do not have the right to sue the Plan based on the denial of an advisory appeal because no claim has actually been incurred. Decisions on Appeal A notice that the Review Committee has decided your appeal will state the specific reason or reasons for the decision, making reference to pertinent Plan provisions on which the decision was based. If applicable, the notice will also include: • A statement that, upon written request, you will be furnished with a copy of any internal rule, guideline or policy that the Plan relied on in processing your claim • A statement that, upon written request, you will be furnished with an explanation of any scientific or clinical judgment used by the Plan in denying your claim if the Plan found that the treatment was experimental or not Medically Necessary • If your appeal is denied, you are entitled to receive, upon written request and at no cost, copies of documents and information that the Plan relied on in denying your claim • If the Review Committee upholds the denial of your claim, you will then have the right to file suit, under the authority of ERISA • A Claimant may not file suit against the Plan until the claimant has exhausted all of the procedures described in these Claim and Appeal Procedures. However, this rule is subject to the following: • If the Plan does not issue a decision on a claim within the time limits stated in these Procedures, the claimant shall have the immediate right to file an appeal under these Procedures • If a decision on an appeal is not furnished within the time limits stated in these Procedures, this requirement to exhaust Plan remedies will not apply Limitations Period The Plan provides for a “limitations period,” which is the period of time within which any lawsuit must be filed to challenge an adverse claim determination. The limitations period is three years from the date of the Plan’s notice advising you of the determination of your claim. If you file a timely appeal, the limitations period is three years from the date of the Plan’s notice advising you of the determination of your appeal. Also, if your claim is denied and you fail to file a timely appeal, a lawsuit, even if filed within the limitations period, will be subject to dismissal because, as explained above, the Plan, in accordance with ERISA, requires you to use the appeal process before filing a lawsuit. Finally, if the Plan fails to send a notice advising you of the determination of your claim, the limitations period is three years from the date a determination was due under these Claim and Appeal Procedures. Plan Benefits Payable to Medical Provider When you receive treatment for services that are covered under the Plan, the Plan will pay its benefits directly to the provider of that treatment or service. This rule applies whether or not you have assigned Plan benefits to the Medical Provider (see next paragraph). However, the Plan will make payment directly to the Plan participant if either you or the Medical Provider has advised in writing that Medical Provider has already been paid, or will be paid from another source.

Limitation on Assignments An “assignment of benefits” is a written statement, signed by you, that gives a Medical Provider the right to receive Plan benefits for services provided to you. When benefits have been assigned to a Medical Provider, the Medical Provider will also have certain rights, such as the right to file an appeal.

Please call the Fund Office if you have any questions about these Procedures. When a participant or beneficiary has exhausted the remedies provided in the Claim and Appeal Procedure, he or she has the right to file suit under the ERISA to enforce rights created under the Plan.

Medical Child Support Order Determination Procedures As required by Federal law (ERISA Section 609(a)(5)(B), as enacted by the Omnibus Budget Reconciliation Act of 1993), the Board of Trustees has adopted the following procedures for handling medical child support orders (“MCSO”) received by the Fund. An MCSO that is found “qualified” under these Procedures is referred to as a “QMCSO.” 1. An MCSO is a judgment, decree or order of court that either requires or purports to require the Plan to cover an eligible participant’s child (the “Alternate Recipient”) as an eligible Dependent of the participant, or which recognizes of the existence of an Alternate Recipient’s right to such coverage. 2. When the Fund receives an MCSO, the Fund Office will send an acknowledgment of receipt of the MCSO to the participant and to the Alternate Recipient. The notice acknowledging receipt of the MCSO shall include a copy of the MCSO, except that a copy need not be sent to the party who sent the MCSO to the Fund Office. 3. Any notice that the Fund Office sends to the participant regarding an MCSO shall be sent to the participant’s address as indicated in the MCSO or, if an address is not shown, to the participant’s last known mailing address according to the records of the Fund. Any notice sent to an Alternate Recipient shall be mailed to the Alternate Recipient’s address as shown on the MCSO. 4. The Board of Trustees has delegated to the Fund Manager authority and responsibility to determine the “qualified” status of an MCSO, subject to the conditions and limitations of these Procedures and further subject to the Board’s authority to overrule any such determination made by the Fund Manager and to exercise authority over the determination process in its own right. The Fund Manager, in his or her discretion, may seek an opinion from Fund Counsel on any issue relating to “qualification” of an MCSO. An MCSO shall be deemed “qualified” only if it satisfies all of the following requirements: a. The MCSO must identify the participant by name and last known mailing address, and must specify the name and mailing address of each Alternate Recipient covered by the order. [Sec. 609(a)(3)(A).] b. The MCSO must contain a reasonable description of the type of coverage to be provided to the Alternate Recipient, or provide the Fund with a basis for determining the type of coverage. [Sec.609(a)(3)(B).] c. The MCSO must specify the period of time to which the order applies. [Sec. 609(a)(3)(c).] d. The MCSO must clearly identify the Plan by name. [Sec. 609(a)(3)(D).] e. An MCSO may not require the Plan to provide any type or form of benefit, or any option, not otherwise provided under the Plan and may not require the Plan to cover an Alternate Recipient during any period of time during which the participant himself is not eligible for benefits or during which the participant’s Dependent (in the absence of a QMCSO) would not be eligible for benefits. [Sec. 609(a)(4).] 5. An MCSO that can be interpreted in such a way as to satisfy the requirements of ERISA Sec. 609(a)(3) shall be so interpreted. Accordingly, the Fund shall recognize as “conditionally qualified” an MCSO that is otherwise “qualified” but which fails to satisfy one or more of the requirements set forth

in subparagraphs (a) through (e) of paragraph 4, above, while satisfying the corresponding subparagraph of this paragraph 5. If an MCSO is “conditionally qualified,” it shall be considered as “qualified” only to the extent that it does not require the Fund (a) to pay a claim on behalf of an Alternate Recipient if that claim would not have been paid with respect to a child who is an eligible Dependent of the participant in the absence of a “qualified” MCSO (hereinafter, a “non-QMCSO child”), or (b) to pay a claim incurred prior to the date of entry of the MCSO or, if earlier, the date the Fund had actual notice of a party’s intent to seek a QMCSO. a. An MCSO shall be deemed to satisfy Sec. 609(a)(3)(A) if it clearly identifies the participant and this identification enables the Fund Office to ascertain the participant’s address from the records of the Fund. b. The requirements of Sec. 609(a)(3)(B) shall be deemed satisfied if the MCSO indicates that the Alternate Recipient is to be considered as the participant’s Dependent, in which case the MCSO shall be interpreted as requiring the Alternate Recipient to be covered under the Plan as if he or she were a non-QMCSO child of the participant. c. If an otherwise “qualified” MCSO fails to specify the beginning date for coverage, as required by Sec. 609(a)(3)(c), the beginning date of coverage shall be the first of the month following the date that the MCSO is received by the Fund. If an otherwise “qualified” MCSO fails to specify an ending date for the Alternate Recipient’s coverage, the Alternate Recipient shall lose eligibility as of the date he or she would cease to be eligible as a non-QMCSO child of the participant. d. An MCSO that does not correctly state the full name of the Fund shall be deemed to satisfy Sec. 609(a)(3)(D) if, in context, the Fund is reasonably able to conclude that the Court intended the Order to apply to this Fund, and if a parent of the Alternate Recipient is a participant in this Fund. e. An otherwise “qualified” MCSO which purports to require the Plan to cover an Alternate Recipient during any period of time in which the participant himself is not eligible for benefits or during which a non-QMCSO child of the participant would not be eligible for benefits shall be deemed “qualified” with respect to any period of time following the date of entry of the MCSO during which a non-QMCSO child of the participant would be eligible for benefits under the Plan. 6. After an MCSO has been determined “qualified” or “not qualified” under these Procedures, the Fund Office shall send a notice to the participant and the Alternate Recipient regarding the Plan’s determination. If the MCSO is not “qualified,” the notice shall state the reasons for that determination, with specific reference to the legal requirement, which the MCSO does not satisfy. If the MCSO is found “qualified” or “conditionally qualified,” the letter shall advise the parties of the effective date of the Alternate Recipient’s coverage. 7. Any benefits payable with respect to an Alternate Recipient shall be paid to the Alternate Recipient or to the Alternate Recipient’s custodial parent, or to a medical provider pursuant to a valid assignment of benefits. 8. In the event that a photocopy of a final entered MCSO is received by the Fund, such order will be processed according to these Procedures. However, actual payment of benefits or confirmation of coverage to a medical provider shall be deferred until the Fund receives an original or certified copy of a QMCSO. 9. If a proposed MCSO (that is, an MCSO which has not yet been entered or approved by the court) is received by the Fund Office, it will be processed in the same manner as a final order, except that any coverage of an Alternate Recipient will be contingent upon the Fund’s receipt of an original or certified copy of a final entered order that is found “qualified.”

Important Plan Information

Name and Address of Plan Administrative District Council 1 Welfare Fund 660 North Industrial Drive, Suite 100 Elmhurst, Illinois 60126

Telephone: (630) 617-8666 Fax: (630) 279-3377 www.BACADCFUNDS.org Board of Trustees The Board of Trustees is responsible for the operation of the Plan. The Board of Trustees consists of an equal number of representatives of the Union and Employers who have entered into collective bargaining agreements providing for contributions to the Fund. You may contact the Board of Trustees at the Fund Office address and telephone number given above. The Board of Trustees is both the Plan Sponsor and Plan Administrator. Identification Numbers Plan number: 501 Employer Identification Number (EIN): 36-2150067

Agent for Service of Legal Process The Board of Trustees’ agent for service of legal process is:

C.T. Corporation System 208 South LaSalle Street Chicago, Illinois 60604

Service may also be made upon any Trustee at the Fund Office. Collective Bargaining Agreements The Plan is maintained pursuant to collective bargaining agreements between the Employers and the Union. Upon written request, the Fund Office will provide you with a copy of the collective bargaining agreement under which you are covered. The Fund Office will also provide, upon written request, information as to whether a particular employer is contributing to the Plan and, if so, the name and address of the Employer. Source of Contributions The benefits described in this booklet are provided through Employer contributions, Employee contributions and Retiree contributions. The amount of Employer contributions for Employees on whose behalf contributions are made are determined by the provisions of collective bargaining agreements. Welfare Fund Assets and Reserves This is a multiemployer welfare benefit plan. All assets are held in trust by the Board of Trustees for the purpose of providing benefits to eligible Employees and Dependents and defraying reasonable administrative expenses. The Fund’s reserves are managed by professional investment managers. Type of Administration Medical, dental, vision and hearing aid benefits are provided on a self-funded basis and are paid from assets of the Welfare Fund. Life insurance and Accidental Death and Dismemberment benefits are

81 provided through group insurance policies. As of the date this booklet was printed, the insurance company issuing those group insurance policies is UNUM. The Fund Office processes applications for those benefits. The Board of Trustees maintains a specific “stop loss” insurance policy to reimburse the Fund in the event total claims or an individual’s claims exceed a specified level. Eligibility and Benefits The types of benefits provided and the Plan’s eligibility requirements are fully described in this booklet. There are some circumstances that may result in denial or loss of any benefits that would otherwise be payable, and these are also described in this booklet. For example, when the Plan’s Coordination of Benefits or Subrogation rules apply, benefits may be reduced or eliminated. Also, when you erroneously receive benefits that are not properly payable under the Plan, the Plan may reduce future benefits, to which you would otherwise be entitled, in order to recover a prior overpayment. Cost-sharing Provisions Plan participants pay for Retiree Plan coverage and COBRA Continuation Coverage. The Plan also includes deductibles, coinsurance percentages and co-payment amounts that are described in this booklet. The Plan has several provider networks. At the time this booklet was printed, the Hospital and Physician preferred provider organization (“PPO”) was maintained by Blue Cross Blue Shield of Illinois, and the network of pharmacies providing prescription drug benefits was maintained by Optum Rx/Catamaran.

As explained in this booklet, the Plan provides coverage, at a reduced reimbursement rate, for medical, dental and vision services and prescription drugs from non-network providers. The Plan includes a Hospital Utilization Review Program, maintained by Med-Care Management, which is described in this booklet. If the Hospital Utilization Review Program is not notified of a Hospital admission within the stated time limits, an additional deductible will be applied to the Plan’s benefit payments. Plan Year The Plan’s fiscal year, used for reporting to government agencies, is from June 1 through May 31. Authority of the Board of Trustees; Discretion Regarding Benefits Under the Trust Agreement creating the Welfare Fund and the Plans of Benefits, the Board of Trustees or persons acting for them, such as a claim review committee, has sole authority to make final determinations regarding any application for benefits. The Board of Trustees also has sole authority over the interpretation of the Plan, the Trust Agreement and any other regulations, procedures or administrative rules adopted by the Board of Trustees. Benefits under this Plan will be paid only if the Board of Trustees or persons delegated by them decide, in their discretion, that the Employee or Dependent is entitled to benefits under the terms of the Plan. The Board of Trustees’ decisions in such matters are final and binding on all persons dealing with the Plan or claiming a benefit from the Plan. If a decision of the Board of Trustees is challenged in court, it is the intention of the parties to the trust that the Board of Trustees’ decision is to be upheld unless it is determined to be arbitrary or capricious. Benefit Rights Not Vested No one has a vested (that is, non-forfeitable) right to future coverage under the Plan or to the continuation of any given benefit under the Plan. The Board of Trustees has the right to modify or discontinue any benefit or any component of the Plan, such as coverage for Retirees, at any time and from time to time. The Board of Trustees also has the right to terminate the Plan and the Trust under which the Plan is maintained. If the Trust is terminated, the Trust Agreement provides that any remaining assets of the Fund, after payment of the Fund’s obligations, will be used to provide benefits for Employees who are covered at the time of termination. In their discretion, the Board of Trustees may also transfer remaining funds to another trust fund that covers employees who were covered under this Fund prior to its termination. Under no circumstances will any surplus assets revert to the Employers.

Women’s Health and Cancer Rights Act Of 1998 (WHCRA) You or your Dependents may be entitled to certain benefits under the Women’s Health and Cancer Rights Act of 1998 (WHCRA). For individuals receiving mastectomy-related benefits, coverage will be provided in a manner determined in consultation with the attending physician and the patient for any of the following: • All stages of reconstruction of the breast on which the mastectomy was performed • Surgery and reconstruction of the other breast to produce a symmetrical appearance • Prostheses • Treatment of physical complications of the mastectomy, including lymphedema

Plan limits, deductibles, copayments, and coinsurance apply to these benefits. For more information on WHCRA benefits, contact the Fund Office. Amendment or Termination of Plan Pursuant to the terms of the Trust Agreement governing the Plan, the Board of Trustees reserves the right, in their sole and unrestricted discretion, at any time and from time to time to amend or terminate in whole or in part any of the provisions of the Plan or any document forming a part of the Plan, and such amendment or termination shall be effective as of the date specified by the Board of Trustees. Participants will be notified in writing of any such amendment or termination. To the extent permitted by law, any such amendment or termination may take effect retroactively or otherwise. In the event of a termination or reduction of benefits under the Plan, the Plan shall be liable only for benefit payments due and owing as of the effective date of such termination or reduction and no payments scheduled to be made on or after such effective date shall result in any liability to the Plan, the Board of Trustees, the Employers or the Union, or any agent thereof.

Your Rights under ERISA

As a Participant in the Welfare Fund, you are entitled to certain rights and protections under the Employee Retirement Income Security Act of 1974, as amended (ERISA). ERISA provides that all Plan Participants shall be entitled to: Receive Information About Your Plan and Benefits Examine, without charge, at the Fund Office and at other specified locations, all documents under which the Plan is maintained, 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 Employee Benefits Security Administration.

Obtain, upon written request to the Fund Office, copies of documents under which the Plan is maintained, including insurance contracts and your collective bargaining agreement, and copies of the latest annual report (Form 5500 Series) and updated summary plan description. The administrator may make a reasonable charge for the copies.

Receive a summary of the Plan’s annual financial report. The Plan is required by law to furnish each participant with a copy of this summary annual report. Continue Group Health Plan Coverage Continue health care coverage for yourself, spouse or Dependents if there is a loss of coverage under the Plan as a result of a qualifying event. You or your Dependents may have to pay for such coverage. You should review this summary plan description and the documents governing the Plan on the rules governing your COBRA Continuation Coverage rights. Prudent Actions by Plan Fiduciaries In addition to creating rights for Plan participants, ERISA imposes duties upon the people who are responsible for the operation of the employee benefit plan. The people who operate your Plan, called “fiduciaries” of the Plan, have a duty to do so prudently and in the 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 obtaining a welfare benefit or exercising your rights under ERISA. Enforce Your Rights If your claim for a welfare 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.

Under ERISA, there are steps you can take to enforce the above rights. For instance, if you request a copy of the Plan documents or the latest annual report from the Plan and do not receive them 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 because of reasons beyond the control of the administrator. If you have a claim for benefits, which is denied or ignored, in whole or in part, you may file suit in a state or Federal court. In addition, if you disagree with the Plan’s decision or lack thereof concerning the qualified status of a medical child support order, you may file suit in Federal court. If it should happen that Plan 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 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 the Plan, you should contact the Fund Manager. 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, you should contact the nearest office of the Employee Benefits Security Administration, U.S. Department of Labor, listed in your telephone directory or the Division of Technical Assistance and Inquiries, Employee Benefits Security Administration, U.S. Department of Labor, 200 Constitution Avenue N.W., Washington, D.C. 20210. You may also obtain certain publications about your rights and responsibilities under ERISA by calling the publications hotline of the Employee Benefits Security Administration.

Protecting Your Privacy

This Plan complies with the Health Insurance Portability and Accountability Act of 1996, as amended (HIPAA), a Federal law that requires that health plans protect the confidentiality of private health information. Your privacy rights under HIPAA are described below in the Plan’s Notice of Privacy Practices. If you have questions about your privacy rights, please call the Fund Office. Notice of Privacy Practices This notice describes how medical information about you may be used and disclosed and how you can have access to this information. Please review it carefully.

The Administrative District Council 1 Welfare Fund (“Welfare Fund”) exists for one purpose: to provide health and welfare benefits to participants in the Welfare Fund and to their eligible Dependents. In the course of providing health and welfare benefits, the Welfare Fund receives and maintains information that constitutes “protected health information” as defined in Federal privacy rules. This Notice describes the Welfare Fund’s policies and procedures that protect you from the unnecessary disclosure of your protected health information and give you certain rights regarding your protected health information.

In this Notice, “you” means any person whose protected health information is received by the Welfare Fund. This Notice applies to you whether you are the Plan participant or an eligible Dependent. Privacy rights can be exercised either by you or your Personal Representative (defined below). For a minor child, the parent is the Personal Representative. Your Protected Health Information The term “protected health information” includes all information related to your past or present health condition that individually identifies you or could reasonably be used to identify you and is transferred to another entity or maintained by the Welfare Fund in oral, written, electronic or any other form. Circumstances in Which the Welfare Fund Uses or Discloses Protected Health Information The following categories describe different ways that the Welfare Fund uses and discloses protected health information without your consent or authorization as permitted by law. For Treatment The Welfare Fund may use or disclose protected health information about you to facilitate medical treatment or services by providers. For example, the Welfare Fund may disclose information about your current medical history to the utilization review organization to determine if a proposed treatment of your illness is appropriate. To Process and Pay Your Claims The Welfare Fund may use or disclose your protected health information to process and pay your benefit claims. Claim processing includes all aspects of the process including, for example: • Determining benefit eligibility or Plan coverage • Reviewing health care services for medical necessity and reasonableness of charges and duration of hospital stays • Providing information regarding your coverage or health care treatment to another health plan to coordinate payment of benefits • Processing claim appeals • Telephoning you (or in your absence, a member of your household) to obtain information needed to process your claim

• Answering claim and benefit questions from you, your family members or other relatives or close personal friends, if such person is involved with your health care or the payment of your claim To Collect Contributions for Coverage The Welfare Fund may use or disclose your protected health information in the process of collecting any payments, such as the cost of COBRA coverage. For Administrative Purposes The Welfare Fund may use or disclose protected health information for its own health care operations. Some examples are: • Quality assessment and improvement activities • Activities designed to improve health or reduce health care costs • Underwriting, premium rating or related functions to create, renew or replace Plan benefits • Review and auditing, including compliance reviews, medical reviews, legal services and compliance programs • Business planning and development including cost management and planning related analyses • General administrative activities of the Welfare Fund, including customer service and resolution of internal grievances To Provide You with Health-Related Information The Welfare Fund may use and disclose your protected health information to tell you about or recommend possible treatment options or alternatives, or to advise you of health-related benefits and services that may be of interest to you. When Legally Required The Welfare Fund will disclose your protected health information when it is required to do so by any Federal, state or local law. Examples include: • When the Welfare Fund receives an order, issued by a court or a state agency, to disclose your protected health information. • When the Welfare Fund receives a subpoena or a discovery request in a lawsuit or a workers’ compensation case. In the case of a discovery request that has not been issued under a court order, the party requesting the information is obligated to attempt to notify you of the request so that you will have an opportunity to obtain a court order protecting your protected health information. To Conduct Health Oversight Activities The Welfare Fund may disclose your protected health information to a health oversight agency for authorized activities including audits, civil administrative or criminal investigations, inspections, licensing or disciplinary action. For Law Enforcement Purposes As permitted or required by state law, the Welfare Fund may disclose your protected health information to a law enforcement official for certain law enforcement purposes, including, but not limited to, reporting a crime in an emergency or if the Welfare Fund has reason to believe that your death was the result of criminal conduct. For Specified Government Functions In certain circumstances, Federal regulations require the Welfare Fund to use or disclose your protected health information to facilitate specified government functions, for example those related to the military and veterans, national security and intelligence activities, protective services for the president and others, and correctional institutions and inmates.

In the Event of a Serious Threat to Health or Safety The Welfare Fund may, consistent with applicable law and ethical standards of conduct, disclose your protected health information if the Welfare Fund, in good faith, believes that disclosure is necessary to prevent or lessen a serious and imminent threat to your health or safety or to the health and safety of the public. Persons Who Will Use Your Protected Health Information Claims adjusters and other employees in the Welfare Fund Office will use your protected health information to process your benefit claims. Supervisory personnel may use your protected health information for claim payment, training and administrative purposes, among others. The Board of Trustees, in its capacity as administrator of the Welfare Fund, may have access to your protected health information for appeals or other administrative or supervisory purposes. Releasing Protected Health Information with Your Authorization The categories above (“Circumstances in Which the Welfare Fund Uses or Discloses Protected Health Information”) describe when the Welfare Fund will use or disclose your protected health information without your authorization. Other than as stated above, the Welfare Fund will not disclose your protected health information, except with your written authorization. The following rules apply to authorizations to release protected health information: • Authorizations will be in writing, signed by you or your Personal Representative • You or your Personal Representative will receive a copy of the authorization form • Authorizations have an expiration date that is stated on the authorization form • You or your Personal Representative can revoke the authorization at any time. The revocation must be in writing, and delivered to the Welfare Fund at the address given below before the revocation will be effective Your Rights with Respect to Your Protected Health Information You have the following rights regarding your protected health information that the Welfare Fund maintains: Right to Request Restrictions You may request restrictions on certain uses and disclosures of your protected health information. The Welfare Fund is not required to agree to your request but the Welfare Fund will ordinarily honor any request that the Welfare Fund communicate only with you (that is, refrain from disclosing your claim or benefit information to your relatives, friends or members of your household ). If you wish to make a request for restrictions, please contact the Welfare Fund’s Privacy Coordinator. Right to Receive Confidential Communications You have the right to request that the Welfare Fund communicate with you in a certain way. The Welfare Fund is not required to honor such requests but the Welfare Fund will do so if it can be done without interfering with the normal operations of the Welfare Fund Office, or if you believe that the disclosure of your protected health information could endanger you. If you wish to receive confidential communications, please make your request in writing to the Welfare Fund’s Privacy Coordinator. Here are some examples of requests for confidential communications: • A request that the Welfare Fund communicate only with you (that is, refrain from disclosing your claim or benefit information to your relatives, friends or members of your household). The Welfare Fund will routinely grant this request. • A request that the Welfare Fund only communicate with you at a certain telephone number or send written communications to a P.O. Box instead of your home.

Right to Inspect and Copy Your Protected Health Information You have the right to inspect and copy your protected health information. A request to inspect and copy records containing your protected health information must be made in writing to the Welfare Fund’s Privacy Coordinator. If you request a copy of your protected health information, the Welfare Fund will charge you $0.25 per page for copying, plus actual mailing costs. Right to Amend Your Protected Health Information If you believe that your protected health information records are inaccurate or incomplete, you may request that the Welfare Fund amend those records. That request may be made as long as the information is maintained by the Welfare Fund. A request for an amendment of records must be made in writing to the Welfare Fund’s Privacy Coordinator. The Welfare Fund may deny the request if it does not include a reason to support the amendment. The request also may be denied if your protected health information records were not created by the Welfare Fund, if the protected health information you are requesting to amend is not part of the Welfare Fund’s records, if the protected health information you wish to amend falls within an exception to the protected health information you are permitted to inspect and copy, or if the Welfare Fund determines the records containing your protected health information are accurate and complete. Right to an Accounting You have the right to request a list of certain disclosures of your protected health information that the Welfare Fund is required to keep a record of under the Federal privacy rules, such as disclosures for public purposes, disclosures authorized by law or disclosures that are not in accordance with the Welfare Fund’s privacy policies and procedures or applicable law. The request must be made in writing to the Welfare Fund’s Privacy Coordinator. The request should specify the time period for which you are requesting the information, but may not start earlier than April 14, 2003. Accounting requests may not be made for periods of time in excess of six years. The Welfare Fund will provide the first accounting you request during any 12-month period without charge. Subsequent accounting requests will be subject to a reasonable cost-based fee. The Welfare Fund will inform you in advance of the fee, if applicable. Right to a Copy of this Notice You have a right to request and receive a copy of this Notice at any time, even if you have received this Notice previously. To obtain a copy, please contact the Welfare Fund’s Privacy Coordinator or any employee at the Welfare Fund Office. Your Personal Representative If you are of legal age, you can exercise the privacy rights explained in this Notice. Your rights can also be exercised by your Personal Representative. A Personal Representative is: • The parent of a minor child • The person designated in a Health Care Power of Attorney (limited to the rights stated in the Power of Attorney) • The legal guardian of a mentally incompetent adult • The administrator or executor of your estate, or your next of kin Obligations of the Welfare Fund The Welfare Fund is required by law to maintain the privacy of your protected health information as described in this Notice and to provide to you this Notice of the Welfare Fund’s duties and privacy practices and procedures. The Welfare Fund is required to conform to the terms of this Notice. The Welfare Fund reserves the right to change the terms of this Notice at any time. If that happens, the Welfare Fund will revise the Notice and will provide you with a copy of the revised Notice within 60 days of the change. Any change in the Welfare Fund’s privacy practices and procedures will apply to all protected health information that the Welfare Fund has, regardless of whether the information was obtained before or after the change in privacy practices. You have the right to submit any complaints regarding privacy issues to the Welfare Fund’s Privacy Coordinator. If you believe that your privacy rights

89 have been violated, you have the right to report any violations to the Secretary of the Department of Health and Human Services. The Welfare Fund encourages you to express any concerns you may have regarding the privacy of your information. Neither the Welfare Fund, your employer nor your Union is permitted to retaliate against you in any way for filing a complaint. Contact Person The Welfare Fund has designated the Fund Manager as Privacy Coordinator. The Fund Manager is the contact person for all issues regarding patient privacy and your privacy rights. You may contact the Privacy Coordinator at the Administrative District Council 1 Welfare Fund Office at 660 North Industrial Drive, Suite 100, Elmhurst, Illinois 60126, telephone (630) 617-8666. Use and Disclosure of Protected Health Information The Plan will use protected health information to the extent and in accordance with uses and disclosures permitted by the Health Insurance Portability and Accountability Act of 1996 (HIPAA). Specifically, the Plan will use and disclose protected health information for purposes related to health care treatment, payment for health care, and health care operations.

Payment includes activities undertaken by the Plan to obtain premiums or determine or fulfill its responsibility for coverage and provision of Plan benefits that relate to an individual to whom health care is provided. These activities include, but are not limited to, the following: 1. Determination of eligibility, coverage, and cost sharing amounts (e.g. cost of a benefit, Plan maximums, and copayments as determined for an individual’s claim) 2. Coordination of benefits 3. Adjudication of health benefit claims (including appeals and other payment disputes) 4. Subrogation of health benefit claims 5. Establishing employee contributions 6. Risk adjusting amounts due based on enrollee health status and demographic characteristics 7. Billing, collection activities and related health care data processing 8. Claims management and related health care data processing, including auditing payments, investigating and resolving payment disputes and responding to participant inquiries about payments 9. Obtaining payment under a contract for reinsurance (including stop-loss and excess of loss insurance) 10. Medical necessity reviews, or reviews of appropriateness of care or justification of charges 11. Utilization review, including precertification, preauthorization, concurrent review and retrospective review 12. Disclosure to consumer reporting agencies related to collection of premiums or reimbursement (the following protected health information may be disclosed for payment purposes, name and address, date of birth, Social Security Number, payment history, account number, and name and address of the provider and/or health Plan) 13. Reimbursement to the Plan

Health Care Operations include, but are not limited to, the following activities: 1. Quality Assessment 2. Population-based activities relating to improving health or reducing health care costs, protocol development, case management and care coordination, disease management, contacting of health care providers and patients with information about treatment alternatives and related functions

3. Rating provider and Plan performance, including accreditation, certification, licensing, or credentialing activities 4. Underwriting, premium rating, and other activities relating to the creation, renewal or replacement of a contract of health insurance or health benefits, and ceding, securing, or placing a contract for reinsurance of risk relating to claims for health care (including stop-loss insurance and excess of loss insurance) 5. Conducting or arranging for medical review, legal services and auditing functions, including fraud and abuse detection and compliance programs 6. Business planning and development, such as conducting cost-management and planning-related analyses related to managing and operating the entity, including formulary development and administration, development or improvement of methods of payment or coverage policies 7. Business management and general administrative activities of the entity, including, but not limited to: a. Management activities relating to implementation of and compliance with the requirements of HIPAA Administrative Simplification b. Customer service, including the provision of data analyses for policyholders, Plan sponsors, or other customers c. Resolution of internal grievances d. Due diligence in connection with the sale or transfer of assets to a potential successor in interest, if the potential successor in interest is a covered entity, or, following completion of the sale or transfer, will become a covered entity 8. Compliance with and preparation of all documents as required by the Employee Retirement Income Security Act of 1974, as amended (ERISA), including Form 5500's, Summary Annual Reports, and other documents

The Plan will use and disclose protected health information as required by law and as permitted by authorization of the participant or beneficiary. With an authorization, the Plan will disclose protected health information to related plans, workers’ compensation insurers, etc. for purposes related to administration of these plans.

The Board of Trustees is the Plan Sponsor. The Plan will disclose protected health information to the Plan Sponsor only upon receipt of a certification from the Plan Sponsor that the Plan Document has been amended to incorporate the following provisions:

With respect to protected health information, the Plan Sponsor agrees to: 1. Not use or disclose the information other an as permitted or required by the Plan Document or as required by law. 2. Ensure that any agents, including a subcontractor, to whom the Plan Sponsor provides protected health information received from the Plan agree to the same restrictions and conditions that apply to the Plan Sponsor with respect to such information. 3. Not use or disclose the information for employment-related actions and decisions unless authorized by the individual. 4. Not use or disclose the information in connection with any other benefit or employee benefit Plan of the Plan Sponsor unless authorized by the individual. 5. Report to the Plan any use or disclosure of the information that is inconsistent with the uses or disclosures provided, of which it becomes aware. 6. Make protected health information available to the individual in accordance with the access requirements of HIPAA.

7. Make protected health information available for amendment and incorporate any amendments to protected health information in accordance with HIPAA. 8. Make available the information required to provide an accounting of disclosures. 9. Make internal practices, books, and records relating to the use and disclosure of protected health information received from the group health Plan available to the Secretary of Health and Human Services for the purposes of determining compliance by the Plan with HIPAA. 10. If feasible, return or destroy all protected health information received from the Plan that the sponsor still maintains in any form and retain no copies of such information when no longer needed for purposes for which disclosure was made. If return or destruction is not feasible, limit further uses and disclosures to those purposes that make the return or destruction infeasible.

Adequate separation between the Plan and the Plan Sponsor must be maintained. Therefore, in accordance with HIPAA, only the following employees or classes of employees may be given access to protected health information: 1. The Fund Manager 2. Staff designated by the Fund Manager

The persons described in the above paragraph may only have access to and use and disclose protected health information for Plan administration functions that the Plan Sponsor performs for the Plan. If the persons described in the paragraph above do not comply with this Plan Document, the Plan Sponsor shall provide a mechanism for resolving issues of noncompliance, including disciplinary sanctions.

For purposes of complying with the HIPAA privacy rules, this Plan is a Hybrid Entity because it has both health plan and non-health plan functions. The Plan designates that its health care components that are covered by the privacy rules include only health benefits and no other plan functions or benefits.

With respect to electronic Protected Health Information (PHI) the Plan Sponsor agrees to protect the security of such information by: 1. Implementing administrative, physical, and technical safeguards that reasonably and appropriately protect the confidentiality, integrity, and availability of electronic PHI that it creates, receives, maintains, or transmits on behalf of the Plan. 2. Ensuring that an adequate separation between the Plan and Plan Sponsor is maintained, specific to electronic PHI, by supporting reasonable and appropriate security measures. 3. Ensuring that any agent, including a subcontractor, to whom it provides electronic PHI, agrees to implement reasonable and appropriate security measures to protect electronic PHI. 4. Reporting to the Plan any security incident of which it becomes aware concerning electronic PHI.

Definitions

The following terms are used throughout this booklet.

ADEA Employer means an employer that meets both of the following conditions: 1. Is subject to the U.S. Age Discrimination in Employment Act (ADEA)

2. Has 20 or more employees each working day in 20 or more calendar weeks during the current or preceding Calendar Year

Agreement means a written agreement providing for contributions to the Welfare Fund, whether a Collective Bargaining Agreement or a Participation Agreement between the Welfare Fund and an Employer.

Allowable Charge means: 1. With respect to a network provider, the Allowable Charge is the negotiated fee/rate set forth in the Plan’s agreement with the participating network health and/or dental provider, facility, or organization.

2. With respect to an out-of-network provider, the Allowable Charge means the amount as determined by the Board of Trustees for a particular service or supply. Under no circumstances will the Plan pay an Allowable Charge for out-of-network services or supplies that is determined by any provider, facility, or other person or organization, other than the Board of Trustees.

Allowable Expense means any necessary Allowable Charge, at least a portion of which is covered under at least one of the plans covering the person for whom claim is made.

Board of Trustees means the Board of Trustees of the Welfare Fund. The Board of Trustees is both the Plan Sponsor and Plan Administrator.

Calendar Year begins at 12:01 A.M. on January 1 and continues until 12:01 A.M. on the next January 1.

Chiropractic Care means services or supplies which are provided or ordered by a chiropractor or a naprapath.

Claim Determination Period means a Calendar Year or, if shorter, that portion of a Calendar Year during which you are eligible for benefits.

Claimant means the person who has incurred a claim except that, if the claim is incurred by a Dependent child, then the adult who files the claim on behalf of the child is the Claimant.

Collective Bargaining Agreement means a written labor agreement entered into by a Local Union or the International Union, governing wages and working conditions, and providing for contributions to the Fund.

Concurrent Care Claim is a special type of Pre-service Claim. A claim is a Concurrent Care Claim if the Plan reconsiders the claim after pre-approval of an ongoing course of treatment, and the reconsideration results in reduction, extension, or termination of benefits.

Course of Treatment refers to a planned program of one or more services or supplies, whether rendered by one or more Dentists, for the treatment of a dental condition diagnosed by the attending Dentist as a result of an oral examination. The course of treatment commences on the date a Dentist first renders a service to correct or treat such diagnosed condition.

Covered Dental Charges refers to the Allowable Charge, or fee for services or supplies furnished on the recommendation and approval of a Dentist.

Coverage means you have earned eligibility (either Initial Eligibility or Continuing Eligibility), and you are covered under the Plan. Plan coverage for a month runs from the first day of the month to the last day of the month, for example, from March 1 through March 31.

Covered Employment means employment for which your Employer is obligated to contribute on your behalf to the Welfare Fund under a Collective Bargaining Agreement with a Local Union or other labor organization associated with the International Union, or under a Participation Agreement.

Covered Expense is considered to have been incurred on the date the medical service or supply is rendered.

Covered Person means you or your covered Dependent.

Creditable Coverage means a continuous period of time, before a person becomes eligible under this Plan, during which the person is eligible for benefits under another health plan. (This can be another employer-sponsored plan, COBRA coverage, a private health insurance plan or a government-sponsored plan.) However, coverage under another health plan is not Creditable Coverage if there is a gap of 63 or more days between the date the person’s prior coverage ended and the date the waiting period for coverage under this Plan began.

Credited Hours means the hours of work for which contributions are required to be paid and are paid into the Plan. Credited Hours are based on the work week and the work month, not the calendar week (Sunday through Saturday) or the calendar month. Under the Collective Bargaining Agreement, the work week begins on Monday and ends on the following Sunday. Both wages and fringe benefit payments are based on the work week. A “work month” is a period of four or five work weeks, determined by the number of Sundays in the calendar month. The work month consists of the work weeks (Monday through Sunday) that end in a given calendar month. Hours of work are credited only in this manner and will not be moved from one work month to another.

Custodial Care means care comprised of services and supplies which are provided to you or your Dependent primarily to assist in the activities of daily living.

Date of Expense a charge shall be deemed to have been incurred on the date the service is rendered.

Deductible Amount The “Deductible” is the amount of Covered Medical Expenses which must be incurred with respect to a person, while eligible (you or your Dependent), before benefits become payable under the major medical benefit, and such Deductible must be satisfied wholly within a Calendar Year, except that Covered Medical Expenses incurred during the last 31 days of a Calendar Year which are applied to the Deductible for that Calendar Year will also be used to satisfy the Deductible for the next Calendar Year. 1. Common Deductible Provision. If two or more Covered Persons in the same family are injured in a common accident, or contract the same contagious disease within a 30-day period, only one Deductible must be met during the Calendar Year for expenses pertaining to that accident or contagious disease.

2. Maximum Family Deductible. If, during a Calendar Year, Deductibles have been satisfied by persons who are members of the same family, and if the sum of such Deductibles is equal to the Maximum Family Deductible, the Deductible requirement is waived with respect to any remaining members of that family for the remainder of such Calendar Year. For purposes of this provision, a “family” means an Employee and eligible Dependents.

3. Plan Deductible Provision. If your eligibility changes from Plan A to Plan B, you will be subject to the deductible and co-payment percentage of the Plan under which you are eligible during that Eligibility Quarter in which the Covered Expense is incurred.

Dentist refers to a person licensed to practice dentistry by the governmental authority having jurisdiction over the license and practice of dentistry and who is acting within the scope of that license.

Dental Hygienist refers to a person licensed to practice dental hygiene by the governmental authority having jurisdiction over the practice of dentistry and who works under the supervision of a Dentist.

Dependent means your: 1. Spouse - the person who is married to you and is recognized as your spouse by the laws of the state where the marriage took place. (Note: if you have not designated a beneficiary for Life Insurance or AD&D benefits, your civil union partner, if applicable, will be your automatic beneficiary; however, your civil union partner is not your Dependent under the Plan).

2. Biological, adopted, step or foster child who is younger than age 26. Coverage for a child will end the last day of the month of the child’s 26th birthday, unless disabled (see below). A child for whom you are required to provide health care due to a Qualified Medical Child Support Order (QMCSO) will also be considered your Dependent. The definitions of the above terms are: a. Biological child: you are shown as a parent on the child’s birth certificate or paternity order b. Adopted child: legally adopted or child placed with you pending legal adoption c. Step-child: biological (born prior to your marriage) or adopted child of your current spouse d. Foster child: a child placed in your care by a court or child welfare agency, without any compensation to you or any member of your household for the child’s care

3. If your child, as defined above, was mentally or physically disabled prior to reaching age 26 and who:

a. Is not married b. Remains disabled and incapable of self-sustaining employment c. Is mainly financially dependent on you or the other parent, is receiving governmental aid or assistance, or is the beneficiary of a trust and d. You provide proof of your child’s disability, when requested by the Board of Trustees (at least two months prior to age 26)

4. The definition of a Dependent does not include your spouse or child if they are: (a) eligible for benefits under the Plan as an Employee; or (b) a full-time active member of the military service or armed forces of any country or nation.

Disability Claim is any Plan benefit that is conditioned on a finding of disability. A claim for Weekly Disability Benefits is a Disability Claim.

Durable Medical Equipment means equipment that can withstand repeated use and is not a consumable or disposable item, and is exclusively and customarily used to serve a medical purpose. Durable Medical Equipment is not useful to a person in the absence of injury or illness and is appropriate for use in the home. Durable Medical Equipment includes, but is not limited to, apnea monitors, blood sugar monitors, commodes, electric hospital beds with safety rails, electric or manual wheelchairs, nebulizers, oximeters, oxygen and supplies, and ventilators. 1. Corrective Appliances means appliances or devices that support a weakened body part (Orthotic) or replace a missing body part (Prosthetic).

2. Nondurable Supplies means goods or supplies that cannot withstand repeated use and/or that are considered disposable and limited to either use by a single person or one-time use, including, but not limited to, bandages, hypodermic syringes, diapers, and soap or cleaning solutions.

3. Orthotic (Appliance or Device) means a type of Corrective Appliance or device, either customized or available “over-the-counter” designed to support a weakened body part, including, but not limited to, crutches, specially designed corsets, leg braces, extremity splints, and walkers. For the purposes of the Medical Plan, this definition does not include Dental Orthotics.

Emergency means one of the following: 1. A medical condition, which, if immediate medical attention is not provided, can reasonably be, expected to lead to death, serious dysfunction of any bodily organ or part or other serious medical consequences. These conditions must be severe, sudden in onset and involve one or more of the major organ systems of the body, such as the cardiovascular, metabolic, respiratory, nervous, gastrointestinal or urinary system. In no event will a condition be considered an Emergency if the first treatment by a Physician is provided more than 24 hours after the onset of symptoms.

2. If symptoms exist which reasonably may have been interpreted as an Emergency under the above definition, that condition will be considered an Emergency even if the final diagnosis is of another condition. For example, severe chest pain that creates a suspicion of heart attack and for which cardiac tests are done will be considered an Emergency even if a final diagnosis of a heart attack is not made.

3. In addition to medical conditions that are Emergencies as defined above, there are some conditions that result from Injuries, which appear to be serious and so threatening to a body part that emergency room treatment is indicated. These conditions will be considered Emergencies, even though they do not meet the foregoing definition.

4. In addition, transportation to the nearest Hospital or trauma center by police, fire department or ambulance, when such transportation is made under circumstances over which the person has no control, will be considered an Emergency, except in cases of transportation to a Hospital for reasons related to the use of alcohol or non-legal use of controlled substances.

Emergency Hospital Admission means a Hospital Confinement in circumstances that constitute an Emergency as defined above.

Employee means an individual who is working in Covered Employment and is eligible for benefits under the Plan. If your eligibility under a Plan changes and you become eligible under a different Plan, you will be subject to the deductible and co-payment percentage of the Plan under which you are eligible during the Work Quarter in which the Covered Expense is incurred. In connection with benefits under the Retiree Plan, “Employee” also means a Retiree who is eligible for benefits under one of the Retiree Plans (Plans 6 and 7).

Employer means an association, individual, partnership or corporation that has a Collective Bargaining Agreement with the Local Union, if that Agreement requires the employer to pay contributions to the Welfare Fund. The Welfare Fund, the Local Union, and the fringe benefit funds associated with the Local Union are also considered to be Employers with regard to their own Employees.

ERISA means the Employee Retirement Income Security Act of 1974, as amended.

Experimental means services, supplies and procedures, which have not received the required approval by an agency of the U.S. Government. Experimental treatments, services and supplies are also those that largely have been confined to laboratory or research settings. The Board of Trustees has the authority to

96 determine whether a treatment, service or supply is Experimental. The fact that a Physician has prescribed, ordered, recommended or approved the treatment, service or supply does not in itself make it eligible for payment by the Plan.

Extension extends the time period for processing a claim. If there are circumstances beyond the control of the Plan that cause the Plan to need an extension of time to process a claim, the Plan may take an Extension.

Eye Exam includes a check of principal vision functions; a determination of ability and condition of vision; and a complete vision analysis. The Plan covers eye exams only if performed by a licensed Optometrist, Ophthalmologist or Optician.

Fund or Welfare Fund means the Administrative District Council 1 Welfare Fund, which has been established and maintained under a Restated Agreement and Declaration of Trust, as amended from time to time.

Fund Office means the administrative office of the Fund, located at: 660 North Industrial Drive, Suite 100 Elmhurst, Illinois, 60126. (630) 617-8666

Home Health Agency means (a) a Hospital possessing a valid operating certificate authorizing the Hospital to provide home health services, or (b) a public or private health service or agency licensed as a home health agency by the State in which it operates to provide coordinated home care.

Home Health Aide means a health worker other than a Physician, nurse or professional therapist, who is on the staff of a Home Health Agency and performs personal health care services, such as: helping the patient to bathe; helping the patient in and out of bed to exercise; helping the patient with medications which are ordinarily self-administered; and other services which are intimately related to the health care of the patient and have been specifically ordered by a Physician. Home Health Aide does not include a person who ordinarily resides in your home or is your spouse, child, son-in-law, daughter-in-law, brother, brother-in-law, sister, sister-in-law, parent, father-in-law, or mother-in-law.

Hospice means a manner of providing care for terminally ill patients, either in their home or in a special care facility. Hospice care allows terminally ill individuals to live their final days in as natural and comfortable a setting as possible.

Hospital means a facility which has received Joint Commission accreditation, operates lawfully in the jurisdiction where it is located, and (a) maintains permanent and full-time facilities for bed care of five or more resident patients, (b) has a Physician in regular attendance, (c) continuously provides 24 hour a day nursing service by Registered Nurses, and (d) is primarily engaged in providing diagnostic and therapeutic facilities for medical and surgical care (either on the premises or by formal arrangement with an acceptable institution) of injured and sick persons on a basis other than as a rest home, convalescent home, a place for the aged or a sanatorium for substance abusers.

Hospital Confinement means a confinement in a Hospital for which you are charged for room and board by the Hospital. Successive periods of Hospital Confinement will be considered as one confinement unless due to entirely different causes or, with respect to an Employee’s eligibility, unless the later period of confinement commences after the Employee has returned to active work on a full-time basis for two weeks or, with respect to a Dependent’s eligibility, unless the later period of confinement is separated from the previous confinement by a period of at least 3 months.

Illness means a disease causing loss beginning after the effective date of coverage of the Covered Person whose illness is the basis of the claim and resulting in loss covered by the Plan. Pregnancy will be treated on the same basis as an Illness under the Plan.

Injury means a localized abnormal condition of the body, internal or external, induced by trauma, which occurs through an unforeseen event after the effective date of coverage.

Infertility means the inability to conceive after one year of unprotected sexual intercourse or the inability to sustain a successful pregnancy, as certified by the covered individual’s Physician.

Insurance Company(ies) means the insurance company that has issued group insurance policies to the Welfare Fund to provide certain benefits. As of the date this booklet was printed, the life insurance and AD&D benefits are provided through group insurance policies, and the insurance company issuing those group insurance policies is UNUM.

Intensive Care Accommodation means a section, ward, or wing within a Hospital, which is operated exclusively for critically ill patients and provides special supplies, equipment and constant supervision and care by a registered nurse (R.N.) but shall not include any Hospital facility maintained for the purpose of providing normal post-operative recovery, treatment or service.

Laser Vision Correction Surgery is a surgery that corrects poor vision. Types of laser vision correction surgery covered by the Plan include the following procedures: • Radial keratotomy (RK) • Photo refractive keratectomy (PRK) • Laser in situ keratomileusis (Lasik) • Automated keratoplasty (ALK)

Licensed Nurse means a professional nurse who is legally entitled to use the title of Registered Nurse, Nurse Practitioner, or Licensed Practical Nurse.

Lifetime Maximum is not in addition to, but is included in, the overall lifetime maximum for all Plans under which an Employee may be covered while eligible because of hours worked, self-payments, COBRA, and/or Retiree coverage.

Local Union means Local 20, Local 21, Local 27, Local 56 or Local 74 of Illinois of the International Union of Bricklayers and Allied Craftworkers and also means the Administrative District Council 1 of the International Union of Bricklayers and Allied Craftworkers.

Medical Provider includes all providers of treatment or services that are covered under the Plan, whether such treatment or services are medical, dental, vision, or other types of covered health care expenses.

Medically Necessary means any service, supply or treatment which meets all of the following conditions: 1. Is essential for the diagnosis or treatment of the injury or sickness for which it is prescribed or performed

2. Meets generally accepted standards of medical practice

3. Is ordered by a Physician

Medicare means Title XVIII (health insurance for the aged) of the United States Social Security Amendment of 1965 or as later amended.

Mental and Nervous Condition means a neurosis, psychoneurosis, psychopathy of psychosis or a mental or emotional disease or Illness of any kind that is defined within the mental disorders section of

98 the current edition of the International Classification of Diseases (ICD) manual or is identified in the current edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM).

Naprapath means a person who is licensed under the Illinois Naprapathic Practice Act, or a comparable statute in another jurisdiction, to give medical care or treatment for the type of illness or injury for which claim is made and who is acting within the scope of that license.

Naprapathic Care means services or supplies which are provided or ordered by a Naprapath.

Non-Covered Industry Employment means any employment in an industry covered by the Plan, if that employment is not covered by a Collective Bargaining Agreement or by a Participation Agreement with the Welfare Fund.

Ophthalmologist refers to a Physician who restricts his practice to eye care.

Optician means a person who is technically qualified to design or manufacture ophthalmic appliances or optical instruments, or who fills prescriptions and dispenses glasses on prescriptions written by an Ophthalmologist or Optometrist, and who is acting within the scope of his occupation.

Optometrist means a person who is licensed under the Illinois Optometric Practice Act, or a comparable statute in another jurisdiction, to give optometry care or treatment and who is acting within the scope of that license.

Other Plan means the following plans providing benefits or services for or by reason of medical care or treatment: (a) group insurance coverage; (b) any group hospital service prepayment plan, group medical service prepayment plan or other prepayment coverage; (c) any coverage under labor-management trusteed plan, or employee benefit organization plans; and (d) any coverage under governmental programs, including any coverage required or provided by any state, as permitted by law.

PHI means Protected Health Information as defined under HIPAA. This includes all information related to your past and current health conditions and any information that can be used to identify you. Physician means a medical practitioner who is licensed under the Illinois Medical Practice Act, or under a comparable law in another state, and who is acting within the scope of that license.

Plan means the Health and Welfare Plans of Benefits that is provided by the Welfare Fund and is summarized in this booklet. “Plan” also refers to the separate classes of benefits that are maintained under the Health and Welfare Plans of Benefits, including Retiree benefits. If your eligibility under a Plan changes and you become eligible under a different Plan, you will be subject to the Cash Deductibles and co-payment percentages of the Plan under which you are eligible during the Work Quarter in which the Covered Expense is incurred.

Post-service Claim applies if the Claimant has already received the health care treatment or service and the claim consists of asking the Plan for payment. In general, any claim that is not a Concurrent, Pre-service or a Disability Claim is a Post-service Claim.

Pre-admission Review is the evaluation of the number of days of Hospital Confinement to be authorized as reasonably necessary for the treatment of a bodily injury or sickness. In no event shall a Pre-admission Review be considered a guarantee of payment of benefits. Your eligibility for plan benefits, and the payment of such benefits, is subject to all the terms and conditions of the plan.

Pre-service Claim applies only if the Plan specifies that health care benefits will not be paid unless the claim is approved before care is provided. In addition to normal Pre-service Claims, there are two special types of Pre-service Claims, which are Urgent Care Claims and Concurrent Care Claims.

Predecessor Plan means the Masonry Institute Plan of Benefits, the Bricklayers and Stone Masons Local No. 20 of Lake County Welfare Plan, the Fox Valley & Vicinity Construction Workers Welfare Fund, the Bricklayers Local 56 Welfare Fund or the Bricklayers and Allied Craftworkers Local 74 of DuPage County Welfare Plan.

Preferred Provider Organization (“PPO”) means the network of Hospitals, Physicians and other health care providers, which providers have agreed to provide health care services to Employees and Dependents of the Plan for a pre-determined fee or at a discounted rate.

Prosthetic Appliance (or Device) means a type of Corrective Appliance or device designed to replace all or part of a missing body part, including, but not limited to, artificial limbs, heart pacemakers, or corrective lenses needed after cataract surgery. See also the definition of Durable Medical Equipment.

Qualified Medical Child Support Order means a court order that requires the Fund to cover a child under the Plan. The requirements for a Qualified Medical Child Support Order are stated on page 79.

Retiree means an individual who formerly worked in Covered Employment and who is eligible for benefits under one of the Retiree Plans (Plans 6 and 7).

Review Committee is the Board of Trustees or a Committee or person appointed by the Board of Trustees who decides an appeal is the “Review Committee.”

Service Credit is earned based on hours worked in Covered Employment in a Calendar Year, so that 1,200 hours equal one Service Credit, with additional Service Credits earned for work over 1,200 hours at the rate of one-tenth of a Service Credit for each 120 hours of work in Covered Employment. Hours worked between 300 and 1,200 earn a partial Service Credit determined by dividing the actual hours worked in Covered Employment by 1,200. No Service Credit is earned for less than 300 hours worked in Covered Employment in any Calendar Year.

Urgent Care Claim is a special type of Pre-service Claim. A claim is an Urgent Care Claim if applying the claim processing time limits for a non-urgent Pre-service Claim could jeopardize the life or health of the patient or subject the patient to severe pain that could be managed with care or treatment. The Trustees expect that there will be few, if any, Urgent Care Claims because there are few circumstances in which the Plan conditions eligibility for a benefit on prior approval of the treatment.

Weekend means Saturday and Sunday.

Work Quarter means three specific consecutive months.

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