Table Of Contents Letter to Participants Contact Reference Table Frequently Asked Questions Summary Of Benefits Life Insurance And Ad&d Benefits – see section 12 Medical Plan Benefit – see sections 5.1 through 5.18 Prescription Drug Benefit – see section 8 Dental Care Benefit – see section 9 Vision Care Benefit – see section 10 Section 1 Eligibility Rules For Employees 1.1 Eligibility For Employees 1.2 Hour Bank Account For Employees 1.3 Certificate Of Creditable Coverage For Health Benefits 1.4 Special Late Enrollment Rules For Medical, Dental, Vision, And Prescription Drug Benefits 1.5 Termination Of Eligibility For Employees 1.6 Reinstatement Of Eligibility For Employee 1.7 Continued Coverage While In Uniformed Service 1.8 Family And Medical Leave Act Section 2 Eligibility Rules For Retired Participants 2.1 Eligibility For Retired Participant 2.2 Payments For Retired Participants 2.3 When Coverage Must Begin 2.4 Working While Retired 2.5 When Coverage Ends For Retired Participants And Their Dependents Section 3 Eligibility Rules For Dependents 3.1 Termination Of Eligibility For Dependents 3.2 Qualified Medical Child Support Orders Section 4 Notification Of Status Change Requirements For Participants 4.1 Notices Regarding Cobra Qualifying Events 4.2 Notices Regarding Disability During Cobra Coverage Section 5 Medical Plan Benefit 5.1 Calendar Year Deductible 5.2 Percentage Payable 5.3 Annual Out-of-pocket Limit 5.4 Lifetime Maximum Benefit 5.5 Preferred Provider Program 5.6 Hospital Emergency Room 5.7 Inpatient Hospital Services 5.8 Outpatient Hospital Services 5.9 Surgical Services 5.10 Skilled Nursing Facility Or Extended Care Facility 5.11 Preadmission Testing 5.12 Air Transportation 5.13 Hospice Care 5.14 Preventive Health Care 5.15 Professional Services And Supplies 5.16 Hearing Loss Benefit 5.17 Home Health Care Benefit 5.18 Treatment For Mental Illness/substance Abuse Section 6 Utilization Management Programs 6.1 Elements Of The Utilization Management Programs 6.2 Administration Of The Utilization Management Programs 6.3 Restrictions And Limitations Of The Utilization Management Programs 6.4 Failure To Follow Required Utilization Management Procedures 6.5 Precertification Review 6.5.1 What Services And Procedures Require Precertification Or Pre-surgical Review 6.5.2 Exceptions To Precertification Review 6.5.3 Second Medical Opinion For Pre-surgical Review 6.5.4 Request For Review Of Denial Of Benefits Based On Precertification Review 6.5.5 Concurrent (continued Stay) Review 6.5.6 Request For Review Of A Denial Of Benefits Based On Concurrent Review 6.6 Retrospective Review 6.7 Case Management Section 7 Exclusions And General Limitations Section 8 Prescription Drug Benefit Provided By The Trust For Eligible Employees, Retired Participants And Dependents 8.1 Definitions 8.2 Participating Pharmacy Network 8.3 Retail Pharmacy Program 8.4 Mail Order Pharmacy Program 8.5 Prescription Drugs That Are Not Covered 8.6 Prescription Drugs That Are Limited Section 9 Dental Care Benefit For Eligible Employees And Their Dependents And For Retired Participants Age 65 And Over And Their Dependents Age 65 And Over 9.1 Covered Dental Expenses 9.2 Calendar Year Deductible And Maximum Benefit Payable 9.3 Percentages Payable 9.4 Pre-treatment Estimates 9.5 Covered Dental Services 9.6 Alternate Benefit Provision 9.7 Exclusions And Limitations Section 10 Vision Care Benefit Provided By The Trust For Eligible Employees And Their Eligible Dependents Section 11 Time Loss Benefit Provided By The Trust For Eligible Employees Section 12 Life Insurance And Accidental Death & Dismemberment Benefits Provided By Standard Insurance Company 12.1 Life Insurance Beneficiary Designation 12.2 Review Of Life Insurance And Accidental Death & Dismemberment Claims Section 13 Vacation Plan Benefits Section 14 Continuing Coverage 14.1 Extended Benefits For Total Disability 14.2 Coverage In The Event Of A Strike, Lockout Or Labor Dispute 14.3 Cobra Continuation Coverage 14.4 Qualified Beneficiary 14.5 Qualifying Events 14.6 How To Elect Cobra Continuation Coverage 14.7 Type Of Benefits 14.8 Termination Of Cobra Continuation Coverage 14.9 Cobra Quick Reference Chart Section 15 Payment Of Claims 15.1 Enrollment Procedure 15.2 Subrogation And Reimbursement 15.3 Coordination Of Benefits (cob) And Duplicate Coverage 15.4 When And How Coordination Of Benefits (cob) Applies 15.5 How Much This Plan Pays When It Is Secondary Payor 15.6 Administration Of Cob 15.7 Cob With Medicaid, Champus, Or Veterans Affairs Facility Services 15.8 Cob With Motor Vehicle No-fault Coverage Required By Law 15.9 Cob With Other Coverage Provided By State Or Federal Law 15.10 Coordination With Medicare 15.11 Coordination With Medicare Coverage – Who Pays First 15.12 How Much The Plan Pays When It Is Secondary To Medicare 15.13 How To File Your Claims 15.14 Time Limit For Filing Claims 15.15 Payment Of Benefits 15.16 Claims Review Process 15.16.1 Medical Benefit Claim Determinations And Appeals 15.16.2 Disability Benefit Claim Determinations And Appeals 15.16.3 Non-medical Welfare Benefit Claim Determinations And Appeals Section 16 Important Provisions And Information Regarding Your Plan Benefits 16.1 Authority To Make Changes. 16.2 Administration And Operation Of Plan 16.3 Reciprocity And Transfer Of Assets And Liabilities Section 17 Protection Of Privacy And Security 17.1 Uses And Disclosure Of Summary Health Information 17.2 Permitted And Required Uses And Disclosures Of Protected Health Information For Plan Administration Purposes 17.3 Conditions Of Disclosure For Plan Administration Purposes 17.4 Certification Of Board Of Trustees 17.5 Personnel With Access To Protected Health Information Section 18 General Plan Definitions Statement Of Rights Under Employee Retirement Income Security Act Of 1974