Milwaukee Carpenters' District Council Health Fund · PDF filei Milwaukee Carpenters’...

MilwaukeeCarpenters'District CouncilHealth Fund

Summary Plan Description

Effective June 1, 2014

i

MilwaukeeCarpenters’

DistrictCouncil

Health Fund

To All Active Employees and Retirees:

We are happy to provide you with this new Summary PlanDescription (SPD), effective June 1, 2014. In easy-to-understand language, it tells you how to become and remaineligible for benefits, explains the benefits available, and givesyou instructions on how to apply for benefits. If there shouldbe any inconsistencies between this simplified SPD and themore technical legal Plan Document and Trust Agreement, thelegal documents will govern. The Trustees reserve the right intheir sole discretion to change, interpret, withdraw, or addbenefits, self-payment rates, eligibility rules, or any otherprovisions relating to the operation of the Plan or terminate thePlan at any time by written amendment in an effort to bestserve all Plan participants.

All Plan benefits described in this SPD are self-funded,except for certain organ transplant benefits which are insured.Self-funded benefits payable are limited to Fund assetsavailable for such purposes.

The Eligibility Rules and benefits are maintained at levelsin line with Trust Fund income and assets and they arereviewed regularly to provide you with the best protectionpossible within the Fund's financial means. The EligibilityRules and other Plan provisions are updated as necessary tocomply with legal requirements, including the PatientProtection and Affordable Care Act and Mental Health ParityAddiction and Equity Act.

We suggest you familiarize yourself with the information inthis SPD carefully to have a clear understanding of your Plan,and then keep it handy for reference. If you have questions atany time regarding the Plan, please contact the Fund Office.

The addresses of the Trustees are found on page 80.

Fund OfficeN25 W23055 Paul Road, Suite 2Pewaukee, WI 53072-0670Telephone: (262) 970-5790 locally, or call toll-free in Wisconsinat: 1-800-448-8208FAX: (262) 970-5798Office Hours: Monday - Friday 8:00 a.m. to 4:30 p.m.www.milwaukeecarpenterfunds.org

Yours sincerely,The Board of TrusteesPeter DiRaffaele Tom DuFourArcadio Perez Larry RocoleMark Scott John Topp

ii

DISCLOSURE LANGUAGE FOR GRANDFATHERED PLANS

This group health plan believes it is a “grandfathered health plan” under the Patient Protection andAffordable Care Act (the Affordable Care Act). As permitted by the Affordable Care Act, agrandfathered health plan can preserve certain basic health coverage that was already in effect whenthat law was enacted. Being a grandfathered health plan means that your Plan may not include certainconsumer protections of the Affordable Care Act that apply to other plans, for example, the requirementfor the provision of preventive health services without any cost sharing. However, grandfathered healthplans must comply with certain other consumer protections in the Affordable Care Act, for example, theelimination of lifetime limits on benefits.

Questions regarding which protections apply and which protections do not apply to a grandfatheredhealth plan and what might cause a plan to change from grandfathered health plan status can bedirected to the Plan Administrative Manager at: Milwaukee Carpenters’ District Council Health Fund,N25 W23055 Paul Road, Suite 2, Pewaukee, WI 53072-0670; (262) 970-5790 or 1-800-448-8208. Youalso may 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 whichprotections do and do not apply to grandfathered health plans.

iii

TABLE OF CONTENTSPage

ELIGIBILITY RULES ................................................................................................................. 1

1. How an Employee Becomes Eligible for Benefits – Class A Active Employees ................. 2

2. How Eligibility Is Continued – Class A Active Employees .................................................. 2

3. How Eligibility Is Continued With Self-Payments – All Classes .......................................... 5

(a) Self-Payment Option 1 ................................................................................................. 5

(b) Self-Payment Option 2 (COBRA) ............................................................................... 13

4. Reinstatement of Eligibility for Active Employees............................................................. 17

5. Use of Transfers Under Reciprocity Agreement............................................................... 18

6. Dependents ..................................................................................................................... 18

7. Coverage for Employees and Their Dependents When Employee Enters

Military Service............................................................................................................. 18

8. Coverage While on Family and Medical Leave ................................................................ 20

9. Retiree Benefits and Self-Payments are Subject to Change by the Trustees................... 21

10. Termination of Individual Coverage ................................................................................. 21

Certificate of Creditable Coverage ............................................................................... 21

DEATH BENEFITS .................................................................................................................. 22

ACCIDENTAL DEATH AND DISMEMBERMENT BENEFITS ................................................. 22

LOSS OF TIME BENEFITS ..................................................................................................... 23

COMPREHENSIVE MAJOR MEDICAL BENEFITS ................................................................ 24

Deductible ............................................................................................................................ 24

Coinsurance......................................................................................................................... 24

Covered Expenses .............................................................................................................. 24

Hospital Services .............................................................................................................. 24

Skilled Nursing Home Care Services ................................................................................ 25

Physicians' Services.......................................................................................................... 26

Diagnostic X-Ray and Laboratory Services ....................................................................... 27

Prescription Drugs and Medicines..................................................................................... 27

Other Covered Charges .................................................................................................... 27

Organ Transplant Surgery................................................................................................. 29

Genetic Testing and Counseling ....................................................................................... 30

Alternative Ways of Obtaining Care................................................................................... 31

Pre-Admission Testing ...................................................................................................... 31

Routine Physical Examinations ......................................................................................... 31

Preferred Provider Preventive Care Program Option...................................................... 31

Hospice Care .................................................................................................................... 32

Home Care Treatment for Hemophilia............................................................................... 32

Routine Mammograms...................................................................................................... 32

Routine Immunizations...................................................................................................... 33

Exceptions and Limitations ................................................................................................ 33

iv

TABLE OF CONTENTS (continued)

Page

FAMILY SERVICES PROGRAM ............................................................................................. 34

CASE MANAGEMENT ............................................................................................................ 36

OTHER PREFERRED PROVIDERS........................................................................................ 37

Preferred Provider Network ................................................................................................... 37

Preferred Provider Pharmacy ................................................................................................ 37

DENTAL CARE BENEFITS ..................................................................................................... 41

VISION CARE BENEFITS ....................................................................................................... 43

MEDICARE-PLUS BENEFITS ................................................................................................. 44

GENERAL PROVISIONS ........................................................................................................ 45

Coordination of Benefits ........................................................................................................ 45

Medicare Provisions .............................................................................................................. 47

Subrogation/Reimbursement................................................................................................. 48

Right of Recoupment............................................................................................................. 49

Physical Examinations........................................................................................................... 49

General Exclusions ............................................................................................................... 49

Amendment and Termination of Plan .................................................................................... 52

Prohibition Against Assignment to Providers ......................................................................... 53

Genetic Information Nondiscrimination Act............................................................................ 53

HIPAA Security Regulations.................................................................................................. 53

Discretionary Authority .......................................................................................................... 53

Applicable Governing Law..................................................................................................... 54

Release of Responsibility for Tax Consequences ................................................................. 54

PRIVACY POLICY ................................................................................................................... 55

GENERAL DEFINITIONS ........................................................................................................ 60

HOW TO APPLY FOR BENEFITS .......................................................................................... 68

YOUR RESPONSIBILITIES AS A PARTICIPANT UNDER THE PLAN .................................. 70

YOUR RIGHTS UNDER THE FAMILY AND MEDICAL LEAVE ACT OF 1993....................... 71

INFORMATION REQUIRED BY THE EMPLOYEE RETIREMENT INCOME

SECURITY ACT OF 1974 (ERISA)....................................................................................... 73

Claims Review and Appeal Procedures................................................................................. 73

Statement of Participants' Rights Under ERISA .................................................................... 76

Other ERISA Information....................................................................................................... 80

1

ELIGIBILITY RULES

The following Eligibility Rules set forth the termsand conditions which govern how you, as anemployee, and your dependents become andremain eligible for most benefits. The Trustees, intheir discretion, are empowered to change oramend the Eligibility Rules at any time. You willbe notified of any such change. There areadditional terms and conditions governingeligibility for specific benefits and they aredescribed within the applicable benefit sectionof this booklet.

Participants may include:

· employees working for a contributingemployer(s) under a collective bargainingagreement requiring contributions to this Fund;or

· non-bargaining unit employees and alumni(including certain owners) who are part of aclassification specified in a Trustee-approvedparticipation agreement.

Although sole proprietors, partners, and 100%owners may perform work covered by a laborcontract or are alumni or non-bargaining unitemployees, such persons will not be eligible toparticipate in this Plan.

Participation in and eligibility under the Plan isconditional upon you or your dependent notobjecting by your action or inaction to the release orexchange of information between this Plan and anyinsurance company, other organization or person,when such information is necessary to determineeligibility and pay benefits. Though Eligibility Rulerequirements may have been satisfied, eligibility willbe suspended and benefits will not be paid whenyou withhold consent for such release or exchangeof information.

You and your dependents will be eligible to receivebenefits under the Plan provided the followingeligibility requirements are satisfied.

Eligibility for benefits from this Plan is based on anemployee having the required hours from employercontributions, self-payments, or credits.

The Plan generally uses a quarterly eligibilitysystem.

WORKQUARTERFor workyou performduring . . .

CONTRIBUTIONQUARTEREmployercontributionswe receiveduring . . .

COVERAGEQUARTERWith the requiredhours, you andyour dependentsare eligiblefor benefitsduring . . .

JanuaryFebruaryMarch

FebruaryMarchApril

JuneJulyAugust

AprilMayJune

MayJuneJuly

SeptemberOctoberNovember

JulyAugustSeptember

AugustSeptemberOctober

DecemberJanuaryFebruary

OctoberNovemberDecember

NovemberDecemberJanuary

MarchAprilMay

Coverage quarters follow contribution quarters withone month in between for necessary bookkeeping.If insufficient employer contributions or other creditsare received during a contribution quarter becauseyou are not fully employed, or are sick or injuredand unable to work, the bookkeeping month allowsthe Trustees time to notify you in advance that aself-payment is due to continue eligibility of you andyour dependents for the next coverage quarter.

In these Rules, the terms “covered work” and“employment” mean work for which an employer isobligated to pay contributions to this Fund underthe terms of a collective bargaining agreement withthe Chicago Regional Council of Carpenters –Northern Region or under an approved participationagreement with the Trustees.

Generally under these Rules, credits for eligibilityare based on employer contributions beingreceived by the Trustees. However, a bargainingunit employee also will receive credit for self-payments and “disability hours,” and apprenticeswill receive credit for training hours as specified on

2

page 5. Non-bargaining unit employees and alumniwill not receive credit for “disability hours.” Further,for up to three months out of every twelve months,Trustees may waive the requirement for bargainingunit employees that contributions be received,provided evidence acceptable to them is furnishedwhich proves you performed covered employmentfor which the required contributions were not paid.Trustees will not waive the contribution requirementfor non-bargaining unit employees or alumni.

You will receive a quarterly notice summarizinghours for which employer contributions werereceived and disability hours for which you havebeen credited.

1. How an Employee Becomes Eligible forBenefits – Class A Active Employees

(a) Initial Eligibility

You, as a new employee, will becomeinitially eligible for Class A benefits on thefirst day of the month following the month inwhich you are credited with employercontributions for at least 400 hours ofcovered employment within two consecutivework quarters. You and your dependentswill remain eligible for three consecutivemonths.

In the event your initial eligibility date isother than the first day of the first month of acoverage quarter, your eligibility will becontinued for a part of the next coveragequarter.

You will remain eligible for the nextcoverage quarter, or remainder of the nextcoverage quarter, subject to Rule 2, “HowEligibility Is Continued,” which begins onthis page.

The credit apprentices receive for traininghours will be used toward establishing initialeligibility requirements.

(b) Dependent Special Enrollment Period

When you acquire a new dependentthrough marriage, birth, adoption, orplacement for adoption, you may request aspecial enrollment period. Upon such a

request, the Fund Office will mail you anenrollment card which must be completedwith information pertaining to the newlyacquired dependent. If the specialenrollment period is requested and the newenrollment card is completed and submittedto the Fund Office within 45 days of themarriage, birth, adoption, or placement foradoption, the new dependent’s coveragewill be effective as of the date of themarriage, birth, adoption, or placement foradoption. If the request is not made within45 days, the dependent’s coverage will beeffective on the first day of the monthfollowing receipt by the Fund Office of thecompleted enrollment card.

(c) Other Special Enrollment Rights

You or your dependent also will be entitledto special enrollment rights if:

(1) you or your dependent had othercoverage under Medicaid or the StateChildren’s Health Insurance Program(“CHIP”) and lose eligibility for thatcoverage; or

(2) you or your dependent becomes eligiblefor financial assistance with respect tocoverage under the Plan throughMedicaid or CHIP.

You also may request a special enrollmentperiod upon a child’s loss of other healthcoverage. The effective date of coveragefor any of these qualifying events will be thefirst day of the month following receipt of therequest for enrollment. Special enrollmentmust be requested within 30 days of thequalifying event except for a CHIP event aspreviously described which must berequested within 60 days of such event.

2. How Eligibility Is Continued – Class AActive Employees

Eligibility under the Plan is continued subjectto the following provisions, provided you areavailable for full-time covered work. If youwork for a non-contributing employer in theconstruction industry, coverage under thePlan for you and your dependents will

3

terminate effective the first day of the monthfollowing notice from the Fund AdministrativeManager, but not earlier than 20 days after thedate of such notice. You will not be allowed tomake self-payments under Self-PaymentOption 1 as of such termination date; you onlywill be allowed to make self-payments underSelf-Payment Option 2 (COBRA), according tothe provisions on pages 13 through 17.

The termination of benefits and privileges underthis provision does not apply if full-time coveredwork is not available. However, if you areoffered covered work by a contributingemployer and you refuse such offer, thesetermination provisions will apply as of the dateof your refusal.

If your eligibility for coverage was terminatedaccording to these provisions and then youreturn to covered work, you will become eligiblefor benefits effective the day you return,provided you had sufficient accumulatedbanked hours remaining on the date youreligibility was terminated. If the banked hoursremaining to your credit are insufficient foreligibility, you will be required to meet therequirements for initial eligibility in order for youand your dependents to once again becomeeligible under the Plan.

(a) When Credited With Sufficient Hours

(1) Bargaining Unit Employees

Once you become eligible, you and yourdependents will continue to be eligiblefor Class A benefits as long as you arecredited with at least 345 hours for eachwork quarter. You do not have toreceive credit each month of the workquarter to remain eligible, provided youearn the total number of required creditswithin the quarter.

(2) Non-Bargaining Unit Employees andAlumni

You must be credited with a minimum of160 hours in each month of a workquarter in order to remain eligible. If youare not credited with 160 hours in eachmonth of a work quarter, your eligibility

will end on the last day of the workmonth for which at least 160 hours arecredited.

(b) When Credited With Less Than RequiredHours

(1) When a bargaining unit employee iscredited with less than 345 hours fora work quarter, the hours credited inthat quarter and the prior three quarterswill be considered. You and yourdependents will maintain eligibility forClass A benefits if you are credited withemployer contributions or other creditsfor at least 1,380 hours during the fourimmediately preceding consecutive workquarters.

(2) If an alumni is totally unemployed ortotally and permanently disabled and iscredited with less than 160 hours ineach month of a work quarter, the hourscredited in that quarter and each of thepreceding three quarters will beconsidered. You and your dependentswill maintain eligibility for Class Abenefits if you are credited withemployer contributions or other creditsfor at least 1,920 hours during the fourimmediately preceding consecutive workquarters.

(3) When a bargaining unit employee or analumni is credited with less than therequired number of hours, eligibility foryou and your dependents will end, asspecified in the following table, unlessyou continue eligibility with self-payments as provided in Rule 3, “HowEligibility Is Continued With Self-Payments,” which begins on page 5.

(4) If a non-bargaining unit employee iscredited with less than the requirednumber of hours, eligibility for you andyour dependents will end as of the lastday of the work month for whichcontributions were last received unlessyou continue eligibility with self-payments as provided in Rule 3(b),“Self-Payment Option 2 (COBRA),”which begins on page 13.

4

There are four possible dates on which yourcontinued eligibility terminates, dependingon when you fail to meet the creditrequirements (does not apply to non-bargaining unit employees).

If you do not meetany of the creditrequirements bythe work quarterending in:

Your continuedeligibility ends:

March May 31

June August 31

September November 30

December February 28/29

(c) When Receiving Worker's CompensationBenefits

[This subsection will apply only tobargaining unit employees and will not applyto non-bargaining unit employees andalumni.]

(1) When a disability prevents you fromworking after becoming eligible, you willbe given credit for 27 hours per week,up to 115 hours per month for up toeight work quarters in order to helpmaintain eligibility for Class A benefits.

(2) You receive the “disability hours credit”provided:

(i) you receive temporary total orpermanent total disability weeklyWorker's Compensation Benefits asa result of injury or sickness;

(ii) your disability was incurred becauseof employment by an employer andfor which employer contributions arepayable to this Fund;

(iii) you submit proof to the Fund Officethat you are receiving temporarytotal or permanent total disabilityweekly Worker's CompensationBenefits; and

(iv) you furnish medical evidencesatisfactory to the Trustees, uponrequest.

In addition, you will receive the“disability hours credit” if you arereceiving temporary partial disabilityweekly Worker’s Compensation Benefitsas a result of injury or sickness and youhave returned to light-duty work. Suchcredit will be based on the differencebetween the number of hours you workand 115 hours per month for up to24 months.

You will not receive the credit if you arereceiving total partial disability Worker'sCompensation Benefits. If an injury orsickness for which Worker's Compen-sation Benefits are paid allows youto return to work but later requiresadditional treatment, “disability hours”can be credited while receiving theadditional treatment, up to a total ofeight work quarters.

You also receive the “disability hourscredit” when receiving Loss of TimeBenefits from this Plan as statedin the following subsection (d), “WhenReceiving Loss of Time Benefits.”

(d) When Receiving Loss of Time Benefits

[This subsection will apply only tobargaining unit employees and will notapply to non-bargaining unit employeesand alumni.]

(1) When you receive Loss of Time Benefitsfrom this Plan, you are credited with27 hours per week, up to 115 hours permonth, for such injury or sickness inorder to help maintain eligibility forClass A benefits.

(2) If you receive Loss of Time Benefitsfrom this Plan as a result of light-dutywork, no “disability hours credit” will begiven for the month once your light-dutywork equals 115 hours per month.

5

However, you will be given full credittoward eligibility for all light-duty hoursworked for which employer contributionswere paid.

(3) You will receive the “disability hourscredit” for up to 26 weeks.

(e) When Apprentices Are Being Trained

Apprentices will be credited with 40 hourseach quarter while attending training school.These hours will be granted to establish ormaintain eligibility.

(f) When You Die or Divorce

[This subsection will apply only tobargaining unit employees and will notapply to non-bargaining unit employeesand alumni.]

Your dependents who, at the time of yourdeath or divorce, were eligible because ofemployer contributions or payments underSelf-Payment Option 1, will remain eligiblefor health care, dental, and vision benefits tothe end of the coverage quarter in whichyou died or the divorce judgment wasgranted, plus two additional coveragequarters. If you are a retiree, yourdependents will remain eligible to the end ofthe month in which you died or the divorcejudgment was granted, plus six additionalmonths. Near the end of the additionalcoverage period, your dependents willreceive an initial notice describing how andwhen to make self-payments to continuecoverage.

3. How Eligibility Is Continued With Self-Payments – All Classes

Under certain circumstances, you and yourdependents may continue eligibility by makingself-payments under one of two options. If youare eligible to do so, you will receive a notice.

Self-Payment Option 1 is the Fund's traditionalself-payment provisions and Self-PaymentOption 2 is the COBRA continuation provisionsrequired by law. You must elect one option orthe other. If you elect Option 1, you cannotsubsequently elect Option 2 unless you

experience a second Qualifying Event asdefined on page 13.

(a) Self-Payment Option 1

[Self-Payment Option 1 will apply tobargaining unit employees. It also will applyto alumni, except for the followingsubsection (a)(3), “If a Bargaining UnitEmployee Is Partially Employed.” Non-bargaining unit employees will not beeligible for Self-Payment Option 1 except asa retiree in limited circumstances asdescribed in subsection (a)(7), “If a Retiree,”which begins on page 9.]

(1) The following may use Option 1 tocontinue eligibility for applicablebenefits:

(i) an employee or former employeewho is:

(A) available for full-time coveredwork; or who is

(B) totally and permanently disabled;or

(ii) a retired employee; or

(iii) a surviving spouse who, at the timeof your death, was eligible becauseof employer contributions or self-payments under Self-PaymentOption 1.

You will be considered not “availablefor work” and, therefore, not eligibleto make self-payments to this Fundwhen:

(i) you work for a non-contributingemployer in the constructionindustry (The term “non-contributingemployer” means an employer in theconstruction industry who does notcontribute to a multi-employer healthbenefit plan anywhere); or

(ii) you are not registered on the“out-of-work list” of the NorthernRegion of the Chicago RegionalCouncil of Carpenters for the

6

work quarter that correspondswith the coverage quarter towhich the self-payment isapplicable.

Remember: At the time of your firstself-payment notice, you are giventhe opportunity to elect Self-PaymentOption 1 or Self-Payment Option 2(COBRA Continuation). If at that timeyou elect or have already electedSelf-Payment Option 1 and yousubsequently become ineligible tomake a self-payment under Self-Payment Option 1 because you havenot registered on the out-of-work list,you will not be offered anotheropportunity to elect Self-PaymentOption 2.

(2) Types of Notices and Self-Payment DueDates

If you are an active employee, aquarterly notice will be sent to yousummarizing hours reported and self-payments received. This notice will tellyou if you and your dependents areeligible for the next coverage quarterand the amount due if a self-payment isneeded to continue eligibility. The self-payment must be received at the FundOffice by the 15th day of the month priorto the month for which coverage isapplicable. If the self-payment is notreceived by the 15th day of the monthprior to the coverage month, you willlose eligibility as of the last day of themonth for which a timely self-paymentwas made.

If the amount due for the quarterexceeds one-third of the full self-payment amount, the self-paymentamount may be made in three equalmonthly installments. Coverage will beextended for each applicable monthonce the monthly installment isreceived. Self-payments must bereceived by the 15th day of the monthprior to the month for which coverage isapplicable. If the self-payment is notreceived by the 15th day of the monthprior to the coverage month, you willlose eligibility as of the last day

of the month for which a timelyself-payment was made and mustreinstate using hours worked in thenext work quarter after termination (noprevious work hours can be used towardreinstatement).

Those who retire or become totally andpermanently disabled or those whobecome surviving spouses entitled tomake self-payments will receive aninitial notice that the first self-paymentis due, provided the Trustees havebeen notified. This notice names thecoverage month (or quarter) for whicha self-payment is needed and theamount due to continue eligibility. Self-payments must be received prior tothe first day of the coverage month.

Failure to make self-payments whendue causes a loss of eligibility.

(3) If a Bargaining Unit Employee IsPartially Employed

Duration of Self-Payments: If hourscredited are insufficient, you can makeself-payments to keep yourself andyour dependents eligible for allapplicable Class A benefits, subject tothe following conditions, provided youremain available for full-time coveredemployment.

You will be allowed to make up to anaggregate maximum of six consecutivequarters of self-payments, whetheryou are partially employed, fullyunemployed, or any combination of thetwo. If you are making self-paymentsand have not reached the six-quartermaximum, and you, as a bargaining unitemployee, are credited with 345 hoursin one work quarter, or as alumni arecredited with 160 hours in each monthof a work quarter, you become eligibleto make self-payments for an additionalsix consecutive quarters. Once youhave made six consecutive quartersof any combination of partial and fullself-payments, you will not be eligibleto make further self-payments. If youlose eligibility, you must satisfy the

7

reinstatement rules on page 17 to againhave coverage in the Fund.

Self-Payment Amount: The initial andsubsequent self-payment amount will beshown on the notices. The self-paymentrequired is the difference between thehours credited and the minimum hoursneeded per quarter to maintaineligibility, multiplied by the employerhourly contribution rate specified in thecurrent collective bargaining agreement.

(4) If Unemployed

Duration of Self-Payments: As anunemployed person available for full-time covered work, you can makefull self-payments to keep yourselfand your dependents eligible forapplicable Class A benefits, subject tothe following conditions, provided youremain available for full-time coveredemployment.

You will be allowed to make upto an aggregate maximum of sixconsecutive quarters of self-payments,whether you are partially employed, fullyunemployed, or any combination of thetwo. If you are making self-paymentsand have not reached the six-quartermaximum, and you, as a bargaining unitemployee, are credited with 345 hoursin one work quarter, or as alumni arecredited with 160 hours in each monthof a work quarter, you become eligibleto make self-payments for an additionalsix consecutive quarters. Once youhave made six consecutive quarters ofany combination of partial and full self-payments, you will not be eligible tomake further self-payments. If youlose eligibility, you must satisfy thereinstatement rules on page 17 to againhave coverage in the Fund.

Self-Payment Amount: The initial andsubsequent self-payment amount will beshown on the notices. The full self-payment is based on the minimumrequirement of 345 hours for abargaining unit employee or 480 hoursfor an alumni, per quarter, multiplied bythe employer hourly contribution rate

specified in the current collectivebargaining agreement.

Low Cost Option - Class ABargaining Unit Employees: Toqualify for the Low Cost Option in acoverage quarter, you must be:completely unemployed in the workquarter preceding the coveragequarter; available for full-time coveredemployment in the Fund’s jurisdiction;and registered on the “out-of-work list”of the Northern Region of the ChicagoRegional Council of Carpenters for suchwork quarter. You will be given theopportunity to enroll in the Low CostOption at the time you receive your firstfull self-payment notice. If you do notelect the Low Cost Option at that time,you will not be eligible to elect the LowCost Option in a subsequent coveragequarter. To elect this option, you mustcomplete the election form included withyour quarterly self-payment notice andreturn it to the Fund Office by the 15th ofthe month prior to the month for whichcoverage is applicable.

Eligibility may be continued under theLow Cost Option: for up to six consec-utive coverage quarters; or until yousatisfy the Plan’s reinstatement rulesby being credited with employercontributions for 400 hours of coveredemployment within two consecutivework quarters, whichever is earlier.

Benefits under the Low Cost Optioninclude Comprehensive Major MedicalBenefits and Preferred ProviderPharmacy Prescription Drug Benefitsonly, at different benefit levels thanClass A as stated in the Schedule ofBenefits. Death Benefits, Loss of TimeBenefits, Vision Care Benefits, andDental Care Benefits are not availableunder the Low Cost Option.

Although out-of-pocket expenses areincreased under the Low Cost Option,self-payments are lower than for fullClass A benefits. The quarterly self-payment amount for the Low CostOption is reviewed at least annually andis subject to change. You can make

8

monthly versus quarterly self-payments,provided the payment is received bythe 15th of the month prior to themonth for which coverage is applicable.Coverage will be provided for theapplicable month.

Once you elect the Low Cost Option,you will not be eligible for full Planbenefits again until you satisfy thePlan’s initial eligibility or reinstatement ofEligibility Rules.

(5) If Totally and Permanently Disabled

When the Trustees determine that therequirements of total and permanentdisability as defined on page 67 havebeen met, you will receive an initialnotice describing the self-paymentamount and due dates.

If you are disabled and receivingbenefits from the Building Trades UnitedPension Trust Fund, your first self-payment is due after your bank of hours,if any, is exhausted.

Duration of Self-Payments: If totallyand permanently disabled, you will beable to make self-payments to keepyourself and your dependents eligiblefor all applicable Class RA, RAO, RAM,RB, RBO, and RBM benefits. Self-payments under this section maycontinue as long as you continue tofurnish medical and other informationwhen requested and the Trusteescontinue to determine total andpermanent disability.

Self-Payment Amount: The self-payment amount is set by the Trusteesand may be changed at their discretion.

Return to Work: If you are eligibleunder Class RA, RAO, RAM, RB, RBO,or RBM and no longer are totally andpermanently disabled and you arereleased to return to covered work, youwill become reinstated under Class A asof the first day of the month followingyour return to covered employment.You and your dependents will remain

eligible for the remainder of thecoverage quarter in which you arereinstated. You will remain eligible forsubsequent coverage quarters subjectto Rule 2, “How Eligibility Is Continued,”which begins on page 2.

Such automatic reinstatement, withouthaving to satisfy the requirements forinitial eligibility, will apply only if you aretotally and permanently disabled andyou have not retired due to age.Evidence of retirement will be yourreceipt of retirement benefits from apension trust fund covering Carpentersor Social Security.

(6) If a Surviving Spouse of a DeceasedEmployee

Your surviving spouse may continueeligibility for benefits for herself and youreligible dependents by making self-payments with the consent of theTrustees. The Class of benefits forwhich eligibility may be continued is theone under which your surviving spousewas covered at the time of your deathor, if covered under Class A, yoursurviving spouse may choose Class RA,RAO, RAM, RB, RBO, RBM, RC, or RD.

Duration of Self-Payments: The rightto maintain coverage by making self-payments under this provision ends onthe day:

(i) your surviving spouse remarries; or

(ii) your surviving spouse and/ordependent children become eligibleto participate in any other grouphealth care plan as a result ofemployment and elect not toparticipate in such plan; or

(iii) your surviving spouse and/ordependent children establishresidency outside the United States.

Self-Payment Amount: The self-payment amount is set by the Trusteesand may be changed at their discretion.The amount and dates due will

9

be specified in the initial notice ofself-payments.

For Surviving Spouses Who Work forWage or Profit: Effective January 1,2015, surviving spouses who areemployed and do not have medicalcoverage available through theiremployer will be subject to the followingearnings rules. If a surviving spouseworks for wage or profit, her eligibility tomake subsidized self-payments willcease as of April 1 of any year followinga calendar year in which her annualearnings from such employment exceed710 hours multiplied by the hourly baserate for journeymen carpenters specifiedin the current collective bargainingagreement requiring contributions to theFund, rounded to the nearest hundreddollars.

Such surviving spouses who continueto work may make non-subsidized self-payments under Self-Payment Option 1at a rate to be determined by theTrustees from time to time to continuecoverage under the Plan. Survivingspouses who continuously make non-subsidized self-payments under thisprovision once again will be eligiblefor a subsidy when they are enrolledin Part A and Part B of Medicare. If asurviving spouse chooses not tomake non-subsidized self-payments, hereligibility under the Plan will terminateand she will not be eligible forreinstatement in the Retiree Program.

All non-Medicare-eligible survivingspouses will be required to complete aform annually certifying the extent oftheir business and employment-relatedearnings. Surviving spouses may beasked to furnish information verifying theextent of such earnings, includingcopies of income tax returns and FormW-2.

(7) If a Retiree

If eligible for Class A or COBRA benefitsat the time of retirement, you may

continue eligibility for yourself and youreligible dependents provided you:

(i) retire because you have reached atleast the age of 55 or you aredisabled from the kind of work forwhich employer contributions arepayable to this Fund; and

(ii) were credited with hours worked(and/or COBRA self-paymentsmade) just prior to retirement (theyear in which retirement occursmay be included if it is to youradvantage) or prior to becoming anon-bargaining unit employee oralumni as follows:

(A) 4,800 hours in five consecutivecalendar years; or

(B) 5,760 hours in six consecutivecalendar years; or

(C) 6,720 hours in seven consecutivecalendar years; or

(D) 7,680 hours in eight consecutivecalendar years; or

(E) 8,640 hours in nine consecutivecalendar years; or

(F) 9,600 hours in 10 consecutivecalendar years; and

(iii) remain a member in good standingof a Local Union participating in thisFund or make non-subsidized self-payments.

Retirees who satisfy the priorrequirements may be eligible for asubsidized self-payment based on thework hours credited to the HealthFund over their working career. Pleasecontact the Fund Office to determineyour level of subsidy, if any, and theapplicable rate.

These retiree eligibility requirementsmay be satisfied, in whole or in part,with coverage as a non-bargaining unit

10

employee or alumni. Such retirees maymake non-subsidized self-paymentsunder Self-Payment Option 1 at a ratedetermined by the Trustees from time totime.

Duration of Self-Payments: Startingwith receipt of the first retirement benefitfrom the Building Trades United PensionTrust Fund, Milwaukee and Vicinity(BTUPTF), you may continue coverageby making self-payments. You willreceive an initial notice of the amount ofand due dates for self-payments.

A non-bargaining unit employee oralumni not eligible for a retirementbenefit from BTUPTF will receive aninitial self-payment notice following:written statement from his employer ofhis retirement date; or proof of the saleof his company, if the employee is anowner.

Your first self-payment is due after yourbank of hours, if any, is exhausted.Non-bargaining unit employees do notaccumulate a bank of hours andtherefore may not extend eligibilitybeyond their date of retirement, exceptwith non-subsidized self-payments.

Classes of Benefits (see definitions onpages 60 and 61):

(i) When Employee and DependentsAre Eligible for Medicare

You may continue eligibility underClass RAM or RBM benefitsfor yourself and your eligibledependents. (On or beforeMarch 20, 2014, you also had theoption of electing Class RC.)

(ii) When Either the Employee orDependent Spouse Is Eligible forMedicare and the Other Is NotEligible for Medicare

You may continue eligibility undereither Class RAO or RBO. [On orbefore March 20, 2014, you also hadthe option of electing Class RD.

Class RD provides coverage foryou under Class RC and for yourdependent child(ren) and spouseunder Class RB.]

(iii) When Employee and DependentsAre Not Yet Eligible for Medicare

You may continue eligibility underClass RA or RB for yourself andyour eligible dependents.

If you are eligible for Medicare, youmust enroll in Part A and Part B ofMedicare. Please refer to theMedicare Provisions on pages 47and 48.

Retired employees are not eligible forLoss of Time Benefits.

You will have the opportunity to chooseunder which Class of benefits you wantcoverage. You may choose a lowerClass of benefits at any time, but youwill not be permitted to change yourelection to obtain a higher Class ofbenefits.

Retired employees or their dependentscontinuing coverage under Class RA,RAO, RAM, RB, RBO, or RBM whobecome initially entitled to Medicare dueto End Stage Renal Disease will not beeligible for Class RC until the expirationof the full 30-month coordination periodspecified in the Medicare Provisions onpages 47 and 48.

If a Medicare-eligible person continuingcoverage under Class RAO, RAM,RBO, RBM, RC, or RD enrolls inMedicare Prescription Drug Benefits,he will become ineligible for thePlan’s prescription drug benefits uponthe effective date of his MedicarePrescription Drug Benefits. (He willhave a one-time option to drop MedicarePrescription Drug Benefits and becomecovered under the Plan’s prescriptiondrug benefits again.) If such persondoes not enroll in Medicare PrescriptionDrug Benefits, he will continue eligibilityfor the Plan’s prescription drug benefits,

11

provided he is otherwise eligible underthe Plan.

The Amount of Self-Payment Is Setby the Trustees: A retiree who doesnot maintain Union membership maymake non-subsidized self-paymentsunder Self-Payment Option 1 at a rate tobe determined by the Trustees fromtime to time, or the retiree may continuecoverage under Self-Payment Option 2.

When a retired employee fails to makeself-payments on the due date andthereby becomes ineligible for benefits,he can be reinstated as provided underRule 4, “Reinstatement of Eligibility forActive Employees,” on page 17 or byconsent of the Trustees.

Retirees Returning to Work:

(i) When a Retiree Returns to CoveredEmployment:

For Retirees in Classes RA, RAO,RAM, RB, RBO, and RBM: If aretiree accepts temporary coveredemployment and contributions forany work month are equal to or inexcess of the required monthly self-payment, the employee will not berequired to make any payment forthe related coverage month. If theemployer contribution for anycontribution month is less than therequired monthly self-payment, theemployee will be required to makepayment for the difference betweenthe contributions received and theretiree self-payment rate.

For All Classes of Retirees: Aretiree will be reinstated to the statusof an active employee and becomeentitled to all Class A benefits on thefirst day of the month following themonth in which he is credited withemployer contributions for at least400 hours of covered employmentwithin two consecutive workquarters.

(ii) When a Non-Medicare-EligibleRetiree Returns to Non-CoveredEmployment:

If a retiree works for wage or profitfor a non-contributing employer inthe construction industry or in anindustrial trade he learned throughcovered employment, his eligibility tomake subsidized self-payments willcease as of the last day of themonth in which he begins suchemployment. If, within 60 days ofthe date his eligibility for a subsidyends, he submits proof that his non-covered employment is terminated,his eligibility for a subsidy will bereinstated on a one-time basis.

If a retiree works for wage or profit atnon-covered employment other thanthe type specified in the priorparagraph, his eligibility to makesubsidized self-payments will ceaseas of April 1 of any year following acalendar year in which his annualearnings from such employmentexceed 710 hours multiplied by thehourly base rate for journeymencarpenters specified in the currentcollective bargaining agreementrequiring contributions to the Fund,rounded to the nearest hundreddollars.

Retirees who continue to work atnon-covered employment may makenon-subsidized self-payments underSelf-Payment Option 1 at a rate tobe determined by the Trustees fromtime to time to continue coverageunder the Plan. Retirees whocontinuously make non-subsidizedself-payments under this provisiononce again will be eligible for asubsidy when they are enrolled inPart A and Part B of Medicare.If a retiree chooses not to makenon-subsidized self-payments, hiseligibility under the Plan willterminate and he will not be

12

eligible for reinstatement in theRetiree Program unless he onceagain satisfies the Eligibility Rulesdescribed on page 2.

All non-Medicare-eligible retirees willbe required to complete a formannually certifying the extent of theirbusiness and employment-relatedearnings. Retirees may be asked tofurnish information verifying theextent of such earnings, includingcopies of income tax returns andForm W-2.

Retiree Waiver/ReinstatementProvisions:

If you are eligible to continue Planbenefits as a retiree, you mayelect to waive or terminate youreligibility for all Plan benefits if youare eligible for and enrolled inanother employer-sponsored grouphealth care plan.

You and your spouse, if applicable,will be required to sign a waiver formcertifying that you are covered byanother group health care plan andsubmit proof of such coverage. Ifyou subsequently terminate orbecome ineligible for the other grouphealth care coverage, you will begiven a “one-time” option to bereinstated into the MilwaukeeCarpenters’ District Council HealthFund. To be eligible for suchreinstatement, you must submitproof that you and your eligibledependents were continuouslycovered under another employer-sponsored group health care planwithin 60 days of the date your othercoverage terminates.

Your coverage will be reinstated onthe first day of the month followingtermination of your other coverageassuming receipt of your proof ofother coverage and receipt of yourapplicable self-payment. There canbe no lapse in coverage.

Coverage will be reinstated underthe retiree Class of benefits forwhich you were eligible at the timeyou waived your eligibility or, ifyou are eligible for a lesser Classof benefits, you may elect alesser Class of benefits upon yourreinstatement. Your self-paymentamount will be based on the thencurrent rate for your applicable Classof coverage.

Your eligibility for a subsidy, if any, isfrozen at the time of your termination.Upon your reinstatement, you will beeligible for the subsidy applicable toyour years of service and hourscredited prior to your terminationbased on the rules in effect on thedate of your reinstatement.

Reinstatement will follow theHealth Insurance Portability andAccountability Act (HIPAA) rulesgoverning pre-existing conditionlimitations.

(8) Information in Support of Self-Payments

When an active or retired employeereturns a self-payment notice orapplication to the Fund Office, hissignature attests that all of theinformation furnished is correct andcomplete and that no facts have beenomitted with respect to eligibility formaking self-payments to, or receivingbenefits from, the Fund. Failure todisclose relevant information or statingof misleading facts will be cause fortermination and recovery of any benefitspaid by this Fund to the employee or hisdependents, retroactive to the date ofreceipt of such self-payment notice orapplication. Self-payments improperlymade to the Fund may, in the Trustees'discretion, be declared forfeited to theFund and will be used as an offsetagainst any benefits improperly paid.Any improperly paid benefits must berepaid to the Fund.

13

(b) Self-Payment Option 2 (COBRA)

The intent of these Rules is to complywith the Consolidated Omnibus BudgetReconciliation Act of 1985 (COBRA) asamended in all respects, including thosechanges required by subsequent legislationincluding, but not limited to, the OmnibusBudget Reconciliation Acts of 1989, 1990,and 1993; the Health Insurance Portabilityand Accountability Act of 1996; and theAmerican Recovery and Reinvestment Actof 2009. Any future regulatory guidance willbe incorporated, even if it conflicts withexisting Plan provisions.

Employees and dependents who do notqualify for, or do not use, Self-PaymentOption 1 may, while they are QualifiedBeneficiaries (described as follows),continue eligibility under Self-PaymentOption 2 for: health care benefits only; orhealth care, dental, and vision benefits,subject to the following conditions.

(1) Qualifying Events

Certain events which cause you or yourdependent to lose eligibility under thePlan are Qualifying Events. SuchQualifying Events occur for you, as anemployee eligible because of employercontributions, upon:

(i) voluntary or involuntary terminationof covered employment for anyreason (except gross misconduct onyour part), including disability,sickness, or retirement; or

(ii) reduction in the amount of coveredemployment.

Such Qualifying Events occur for youreligible spouse and dependent childrenupon any of the following eventsoccurring while you are eligible becauseof employer contributions:

(i) termination or reduction of yourcovered employment for any reason(except gross misconduct on yourpart), including disability, sickness,or retirement;

(ii) your death;

(iii) divorce or legal separation from you;

(iv) a dependent child ceases to meetthe definition of dependent; or

(v) your entitlement to Medicare (underPart A, Part B, or both).

You or your dependent become aQualified Beneficiary for a specificperiod of time when a Qualifying Eventoccurs. A dependent child who isborn to or placed for adoption withyou during your period of COBRAcontinuation coverage also will betreated as a Qualified Beneficiary. As aQualified Beneficiary, you may continueeligibility for certain benefits throughself-payments under the followingprovisions.

(2) Notification and Due Dates

(i) Qualified Beneficiary's Responsibilityto Notify the Trustees of a QualifyingEvent

When the Qualifying Event relatesto your death, divorce or legalseparation, or to a dependent childceasing to meet the definition ofdependent under the Plan, theQualified Beneficiary must notifythe Fund Office within 60 daysof the event so the Fund Officemay provide proper notices andexplanations to a Qualified Benefi-ciary about continued eligibility. Thisnotice can be provided to the FundOffice by telephone, facsimile, or inwriting by mail. The Fund Office willadvise the Qualified Beneficiary ifadditional supporting documentationis required. If the Fund Office is notnotified within 60 days of theQualifying Event, the person is nolonger a Qualified Beneficiary andloses the opportunity to continuecoverage.

14

(ii) The Trustees' Responsibility toNotify a Qualified Beneficiary Whenthe Qualifying Event is Loss ofCoverage Due to the Employee'sDeath, Divorce or Legal Separation,or to a Dependent Child Ceasing toMeet the Definition of Dependent

The Fund Office, not later than30 days after receipt of notice, willadvise the Qualified Beneficiary ofthe coverages, options, costs, self-payment due dates, and duration ofthe self-payment privileges.

(iii) The Trustees' Responsibility toNotify a Qualified Beneficiary WhenOther Qualifying Events Occur

Based on monthly employer reports,Trustees are aware of someQualifying Events, such as loss ofeligibility for coverage based oncontributions received from contrib-uting employers because of areduction in your hours and yourceasing active work.

The Fund Office, not later than30 days after receipt of notice ofan employee's loss of coveragefrom the employer or by examiningmonthly contribution reports, willadvise the Qualified Beneficiary ofthe coverages, options, costs, self-payment due dates, and duration ofself-payment privileges.

(iv) Due Dates for Qualified Beneficiary'sResponse

A Qualified Beneficiary has 60 daysfrom the date of coverage termina-tion or receipt of the COBRA Notice,whichever is later, to elect whetherto continue coverage. The electionshould be communicated to theFund Office in writing on the ElectionForm provided. Each employee,spouse, and dependent child has theright to make an individual election.However, covered employees mayelect to continue coverage on behalfof their spouses, and parents may

elect to continue coverage on behalfof their children. A parent or legalguardian may elect to continuecoverage on behalf of a minor child.Failure to provide the written electionto the Fund Office within 60 daysterminates rights to continuedcoverage under this provision.

(v) Due Date for Initial Self-Payment

The required initial self-paymentmust be made to the Fund Office notlater than 45 days following theelection to continue coverage (whichis the post-mark date, if mailed).Failure to do so will causeeligibility and coverage to terminateretroactively to the date of theQualifying Event and will cause lossof all continuation rights under thePlan. The amount of the first self-payment is for the time periodbeginning with the date of theQualifying Event and extendingthrough the month in which paymentis made. Claims for reimbursementwill not be processed and paid untilyou have elected COBRA and madeyour first COBRA self-payment.

(vi) Due Date for Subsequent Self-Payments

Subsequent monthly self-paymentsmust be made to the Fund Office bythe first day of the month for thatmonth of coverage.

The Plan allows a 30-day graceperiod for making self-payments.Continuation coverage will beprovided for each coverage periodas long as payment for thatcoverage period is made before theend of the grace period for thatpayment. However, if a periodicpayment is made later than the firstday of the coverage period to whichit applies, but before the end of thegrace period for the coverageperiod, coverage under the Plan willbe suspended as of the first day ofthe coverage period and then

15

retroactively reinstated (going backto the first day of the coverageperiod) when the periodic paymentis received. Any claim submittedfor benefits while coverage issuspended may be denied and mayhave to be resubmitted oncecoverage is reinstated.

Failure to make subsequent self-payments before the end of thegrace period will cause coverageand eligibility to terminate at the endof the month for which a timely self-payment last was made and willcause loss of all rights tocontinuation coverage under thePlan.

(3) Coverage and Options

If a Qualified Beneficiary elects tocontinue coverage, the followingbenefits are available:

(i) health care benefits only; or

(ii) health care benefits plus dental andvision benefits.

The coverage selected may not bechanged, except to add coverage for anew spouse or to add a new dependentchild as a Qualified Beneficiary uponthe child's birth or placement foradoption with the employee during theemployee’s period of COBRAcontinuation coverage or to enrolldependents who gain eligibility throughMedicaid or CHIP.

The Plan is required to offer continuedcoverage which, as of the day beforecoverage terminated, is identical tosimilarly situated employees or familymembers who have not experienced aQualifying Event. If coverage under thePlan is modified for similarly situatedemployees, the Qualified Beneficiary'scoverage also will be modified.

A Qualified Beneficiary does not have toshow evidence of insurability to choosecontinuation coverage.

(4) Cost of Continuation Coverage

The self-payment amount depends onwhether you choose to continue healthcare benefits only or health care plusdental and vision benefits. The costsare determined annually by theTrustees. There is an additional cost forcontinued coverage from the 19ththrough the 29th month for thoseindividuals eligible for such disabilityextension. The cost may be increasedup to 150% of the applicable self-payment. The Fund Office initially willnotify the Qualified Beneficiary of theself-payment amount and due dates.

(5) Duration of Continuation Coverage(Maximum Continuation CoveragePeriod)

When eligibility is lost due to terminationof employment or reduction in hours, aQualified Beneficiary may continueeligibility for up to 18 consecutivemonths from the date employmentterminated or hours were reduced. This18-month period may be extendedto 36 months for the spouse anddependent children if a secondQualifying Event [e.g., employee’sdeath, divorce or legal separation fromthe employee, employee’s coverage byMedicare (under Part A, Part B, or both),or a dependent child ceasing to meetthe definition of dependent under thePlan] occurs during the 18-monthperiod. These events can be a secondQualifying Event only if they would havecaused the Qualified Beneficiary to losecoverage under the Plan if the firstQualifying Event had not occurred. AQualified Beneficiary must notify theFund Office within 60 days after asecond Qualifying Event occurs if hewants to extend his continuationcoverage and must provide anysupporting documentation the Fundmay request. This provision does notapply in the case of a reduction inwork hours followed by a termination ofemployment.

16

This 18-month period may be extendedup to a total of 29 months for allQualified Beneficiaries during thedisability of the employee, spouse, ordependent child, provided:

(i) the Social Security Administration(SSA) determines that any of theQualified Beneficiaries are disabledunder the Social Security Act either:at the time employment terminatedor hours were reduced; or at anytime within 60 days of suchQualifying Event and the disabilitylasts at least until the end of the18-month period of continuationcoverage; and

(ii) the Qualified Beneficiary notifies theFund Office in writing within 60 daysof the SSA determination and beforethe end of the first 18 months ofcontinuation coverage and providesa copy of the Social SecurityDisability Determination to the FundOffice.

Each Qualified Beneficiary who haselected continuation coverage will beentitled to the 11-month disabilityextension if one of them qualifies. If theQualified Beneficiary is determined bySSA to no longer be disabled, theQualified Beneficiary must notify theFund Office within 30 days after theSSA determination.

Failure to provide notice of a disability orsecond Qualifying Event may affect theright to extend the period of continuationcoverage.

When eligibility is lost due to theemployee’s death, divorce or legalseparation from the employee,employee’s coverage by Medicare(under Part A, Part B, or both), or adependent child ceasing to meet thedefinition of dependent under the Plan,the spouse and eligible dependents maycontinue coverage for up to 36 monthsfrom the date of the Qualifying Event.When the Qualifying Event is the endof employment or reduction of the

employee’s hours of employment, andthe employee is entitled to Medicarebenefits at the time of the QualifyingEvent, COBRA continuation coveragefor Qualified Beneficiaries other than theemployee lasts until the later of36 months after the date of Medicareentitlement, or 18 months following theemployee’s termination of employmentor reduction in hours.

(6) Multiple Qualifying Events

Your spouse or dependent child,as a Qualified Beneficiary, mayexperience more than one QualifyingEvent. However, the combinedcontinuation coverage period for all suchevents may not exceed 36 consecutivemonths from the date of the originalQualifying Event. The second or laterevents, provided they occur within thecontinuation period provided as a resultof the original Qualifying Event, entitlea Qualified Beneficiary to continuecoverage for an additional period notlonger than 36 months from the date ofthe original Qualifying Event. This Rulewill not apply in the case of a reductionin work hours followed by a terminationof employment.

(7) Termination of Self-Payment Provisionsfor Qualified Beneficiaries

Self-payments no longer are acceptedand continued eligibility under thissection terminates on behalf ofall Qualified Beneficiaries (unlessspecifically stated otherwise) when:

(i) the Fund no longer provides healthcare coverage to any eligibleemployee;

(ii) the required notice of a QualifyingEvent is not provided by theQualified Beneficiary within 60 daysof its occurrence;

(iii) the written election for continuationis not made within 60 days followingthe date of coverage termination or

17

receipt of the COBRA Notice,whichever is later;

(iv) the initial self-payment is not paid bythe due date explained on page 14;

(v) the subsequent self-payments arenot paid as explained on page 14;

(vi) the Qualified Beneficiary becomescovered, after electing continuationcoverage, under another grouphealth care plan that does notimpose any pre-existing conditionexclusion for pre-existing conditionsof the Qualified Beneficiary;

(vii)the maximum continuation coverageperiod is reached;

(viii)for a Qualified Beneficiary who wasentitled to the additional 11 monthscontinuation coverage based ona disability extension--eligibility forcontinuing the disability extensionwill terminate when there has been afinal determination that the disabilityno longer exists; or

(ix) the Qualified Beneficiary becomesentitled to Medicare (under Part A,Part B, or both) after such person'sCOBRA election date (althoughother family members not entitled toMedicare will continue to be eligiblefor COBRA continuation). However,if a Qualified Beneficiary becomesentitled to Medicare due to EndStage Renal Disease (ESRD),continuation coverage under Self-Payment Option 2 will not terminateautomatically because of eligibilityfor Medicare. In the case of ESRD,the Fund is the primary source ofcoverage for 30 months from thedate of ESRD-based Medicareentitlement, provided the person isan active eligible employee ordependent or is covered under theFund with COBRA continuationcoverage. In the event the Fund'sliability as the primary source ofcoverage for ESRD ends before theCOBRA continuation period expires,

the Fund becomes secondary toMedicare for the balance of thecontinuation coverage.

Continuation coverage also may beterminated for any reason the Planwould terminate coverage of aparticipant or beneficiary not receivingcontinuation coverage (such as fraud).

You will receive a notice if COBRA isterminated early before the maximumperiod is exhausted.

When an employee becomes ineligiblefor benefits hereunder, he can bereinstated as provided under thefollowing Rule 4, “Reinstatement ofEligibility for Active Employees.”

Additionally, there may be othercoverage options for you and yourfamily. When key parts of the healthcare law take effect in 2014, you will beable to buy coverage through the HealthInsurance Marketplace (also known asthe “Exchanges”). In the Marketplace,depending on your household income,you may be eligible for a new kind of taxcredit that lowers your monthlypremiums right away. Being eligible forCOBRA coverage does not limit youreligibility for coverage or for a tax creditthrough the Marketplace. You also cansee what your premium, deductibles,and out-of-pocket costs will be beforeyou make a decision to enroll in theMarketplace, and you may have multiplecoverage options in the Marketplace.Finally, you may qualify for a specialenrollment opportunity for another grouphealth plan for which you are eligible(such as a spouse’s plan), even if a plangenerally does not accept late enrollees,if you request enrollment within 30 days.

4. Reinstatement of Eligibility for ActiveEmployees

If eligibility ends, you can become eligible forbenefits again provided you are credited withemployer contributions for 400 hours of coveredemployment within two consecutive workquarters. Renewed eligibility becomes effective

18

on the first day of the second month duringwhich you worked your 400th hour.

5. Use of Transfers Under ReciprocityAgreement

Transfer of contributions and relatedinformation about employment from anothercarpenter's health care plan can be used tosatisfy requirements for initial eligibility,continuation of eligibility, and reinstatement ofeligibility, provided you are not eligible inanother plan after such transfer takes place. Ifthe contribution rate from the transferring fundis less or more than this Fund's contributionrate, your hours will be prorated as follows.The money received on your behalf will bedivided by this Fund's contribution rate todetermine the number of hours for which youwill receive credit.

6. Dependents

Dependent coverage is available to yourspouse and children, as defined on pages 61and 62.

7. Coverage for Employees and TheirDependents When Employee EntersMilitary Service

(a) Eligibility Status

(1) You, or an appropriate officer, mustsubmit advance notice of military serviceto the Fund Office (unless circum-stances of military necessity asdetermined by the Defense Departmentmake it impossible or unreasonable togive such advance notice.)

(2) If you, or an appropriate officer, do notsubmit such notice, your accumulatedbanked hours, if any, will be used untilexhausted to further extend youreligibility and the eligibility of yourdependents. Your coverage willterminate on the date your accumulatedbanked hours have been exhausted. Ifyou subsequently submit notice in areasonable time period, the use of youraccumulated banked hours will cease.

(3) For military leaves which are less than31 days in duration and for which you,an appropriate officer, or an employersubmit the required notice andotherwise satisfy the reemploymentrequirements described as follows, yourand your eligible dependents' coveragewill be continued as though you areactively at work for the duration of suchleave.

(4) For military leaves which are 31 or moredays in duration and for which you, anappropriate officer, or an employersubmit the required notice, your andyour eligible dependents' coverage willcease and your eligibility status will befrozen as of the date you leaveemployment for the purposes ofperforming military service with theuniformed services of the UnitedStates, unless you elect to continuecoverage as described in thefollowing subsection (b), “Continuationof Coverage.”

(5) Your eligibility will be reinstated on thedate you return to work for a contributingemployer (or upon making yourselfavailable for work if no such work isavailable) within the applicable timelimits stated in the followingsubsection (c), “Status Upon Returnfrom Military Service,” provided youotherwise satisfy the reemploymentrequirements necessary to qualify forreemployment rights under USERRA(e.g., provide evidence of honorabledischarge, cumulative military service ofno longer than five years). If youraccumulated banked hours have beenexhausted, you will be allowed to makeself-payments under Self-PaymentOption 1 to be immediately reinstated inthe Plan until you earn sufficientaccumulated hours of eligibility tosustain Plan coverage. You also havethe option of delaying the reinstatementof your eligibility until you haveexhausted any extension of medicalbenefits provided by the federal

19

government upon completion of yourmilitary service.

(b) Continuation of Coverage

(1) If you fail to provide advance notice ofyour military service, your coverage willterminate on the date your accumulatedbanked hours has been exhausted andyou will not be eligible to continuecoverage under this section unless yourfailure to provide advance notice isexcused. The Trustees will, in their solediscretion, determine if your failure toprovide advance notice is excusableunder the circumstances and mayrequire that you provide documentationto support the excuse. If the Trusteesdetermine that your failure to provideadvance notice is excused, you mayelect to continue coverage, inaccordance with this subsection (b),retroactive to the date you leftemployment for the purpose ofperforming services with the uniformedservices of the United States, providedthat you elect such coverage and pay allamounts required for the continuationcoverage.

(2) When the Fund Office has been notifiedthat you are entering the militaryservice, you will be given the option ofcontinuing your same Class of coverageunder the Plan.

Continuation coverage under thissubsection (b) is very similar to thecontinuation coverage described underSelf-Payment Option 2, COBRAcontinuation coverage. The rules forelection of and payment for continuationcoverage are the same as the COBRAelection and payment rules, providedthe COBRA rules do not conflictwith USERRA. If you do not electcontinuation coverage and do notsubmit payment for all amounts requiredto continue coverage within theapplicable COBRA timeframe, you willlose your right to continue coverageunder this section and such right will notbe reinstated.

(3) You will have the option of using youraccumulated banked hours, if available,to continue coverage. If you do nothave any accumulated banked hoursavailable or you choose not to use them,you are required to make timely self-payments at the COBRA rate to bedetermined by the Trustees from time totime to purchase COBRA continuationcoverage. If you elect to use youraccumulated banked hours to pay forcontinuation coverage and you exhaustyour accumulated banked hours prior tothe end of themaximum coverage perioddescribed in the following paragraph (5),you may make self-payments tocontinue coverage through the end ofyour maximum coverage period.

(4) The COBRA continuation coveragerules apply to payment for continuationcoverage under this subsection (b)provided that the COBRA payment rulesdo not conflict with USERRA. You mustmake all required self-payments withinthe COBRA time-frame describedunder Self-Payment Option 2 in thisSPD to continue coverage under thissubsection (b) unless the COBRApayment rules conflict with USERRA.

(5) You and your eligible dependents maycontinue coverage for a period endingthe earlier of:

(i) the date that the Plan no longerprovides group health care coverageto any employees;

(ii) the day after the date you fail toelect continuation coverage asrequired by the COBRA continuationcoverage election rules;

(iii) the first day of the month for which atimely self-payment has not beenreceived and your accumulatedbanked hours have been exhausted;

(iv) 24 months from the first date ofabsence due to military service; or

20

(v) the day after the date you fail toapply for reemployment with acontributing employer within theapplicable time period allowed underthe following subsection (c), “StatusUpon Return from Military Service”or otherwise cease to haveUSERRA reemployment rights.

The right to freeze eligibility and makeself-payments under this provisionceases when you provide notice thatyou do not intend to return to work for acontributing employer after uniformedservice.

(c) Status Upon Return from Military Service

If you are eligible for benefits when youenter the military service and you havesufficient accumulated banked hours ormake timely self-payments to maintaincoverage upon your return to work, you andyour eligible dependents again will beeligible for benefits on the date of yourreturn to work for a contributing employerwithin the following time periods, providedyou satisfy the other reemploymentrequirements of USERRA:

(1) For periods of military service of lessthan 31 days, you must report to theemployer not later than the beginning ofthe first full regularly scheduled workperiod on the first full calendar dayfollowing completion of the period ofmilitary service plus eight hours, after aperiod allowing for safe transportationfrom place of military service to place ofyour residence.

(2) For periods of military service of morethan 30 days but less than 181 days,you must apply for reemployment notlater than 14 days after military serviceis completed.

(3) For periods of military service of morethan 180 days, you must apply for re-employment not later than 90 days aftermilitary service is completed.

Such time periods may be extended upto two years for injuries or sicknesses,

as determined by the Secretary ofVeteran Affairs, to have been incurredor aggravated during your service in theuniformed services. If you exhaust youraccumulated banked hours prior to yourreturn from military service and you donot have USERRA reemployment rights,you will be treated as a new employee.

If you exhaust your accumulated bankedhours prior to your return from militaryservice and satisfy USERRA reemploy-ment requirements, you will be eligiblefor benefits on the date of your return towork within the required time periods,provided you make self-paymentsrequired to continue eligibility underSelf-Payment Option 1. If you fail tomake self-payments as required uponreinstatement in the Plan, your eligibilityfor coverage will terminate as of the lastdate of the period for which a timelypayment was received and you then willbe treated as a new employee.

These rules are intended to comply withthe requirements of USERRA. TheUSERRA provisions will control in theevent there are any inconsistenciesbetween the Act and the Plan.

The Plan will provide continuationcoverage and reinstatement rights to theextent required by USERRA. You alsomay have continuation coverage rightsunder COBRA. Although the COBRAand USERRA provisions are similar,COBRA continuation coverage andUSERRA continuation coverage are notidentical. As long as you remain eligiblesimultaneously for both COBRA andUSERRA continuation coverage, youwill receive the more generous benefitrights that apply under these statutes.COBRA and USERRA continuationperiods will run concurrently.

8. Coverage While on Family and MedicalLeave

If you become eligible for leave according to theFamily and Medical Leave Act of 1993 (FMLA),your coverage under the Plan may be

21

continued for the number of weeks mandatedby law, provided your employer:

(a) is subject to the FMLA;

(b) makes the required contribution (or you doso); and

(c) files the appropriate notification with theFund Office.

If your leave is eligible under the FMLA, andyou do not return to work after the leave, thenfor COBRA continuation coverage purposes,the date of the Qualifying Event will be the lastday of your FMLA leave. This provision willapply whether or not you elect to continuecoverage under the Plan during the leave.

To be subject to the Act, an employer musthave at least 50 employees within 75 miles.For additional information regarding your rightsunder the Family and Medical Leave Act, seepage 71.

9. Retiree Benefits and Self-Payments areSubject to Change by the Trustees

The Trustees retain the right, in their solediscretion, to change, modify, or discontinue, inwhole or in part, the retirees' eligibility forbenefits, the types and amounts of benefits, theconditions for payment as well as the retirees'self-payment rates.

10.Termination of Individual Coverage

Coverage will terminate under this Plan on theearliest of the following dates:

(a) the date the Trust is terminated;

(b) the date you cease to be eligible forcoverage according to the Eligibility Rulesadopted by the Trustees; or

(c) the date your dependent ceases to be aneligible dependent as defined on pages 61and 62.

Certificate of Creditable Coverage: Inaccordance with the Health InsurancePortability and Accountability Act of 1996(HIPAA), the Plan will issue a certificate ofcreditable coverage to you and yourdependents when your regular health carebenefits coverage or COBRA contin-uation coverage terminates on or beforeDecember 31, 2014. The certificate providesinformation on the period of your coverageunder the Milwaukee Carpenters' DistrictCouncil Health Fund that may be creditedon your behalf to satisfy any applicablepre-existing condition limitations of a newhealth plan in which you enroll. If yourequire a certificate of creditable coverageafter December 31, 2014, please contact theFund Office.

22

DEATH BENEFITS

Classes A (Bargaining Unit Employees Only), RA, RAO,RAM, RB, RBO, RBM, RC, and RD

Employees Only

Please Note: Death Benefits are not payable forany non-bargaining unit employee or alumnicovered under Class A or COBRA participant.

Immediately upon receipt of acceptable proof ofyour death, the Plan will pay to your beneficiary ofrecord the Death Benefit stated in the Schedule ofBenefits in a lump sum amount.

You are requested to designate a beneficiary on anenrollment card provided by the Trustees.You may change your beneficiary at any time byfiling written notice with the Fund Office. The

beneficiary's consent is not required. If yourdesignated beneficiary does not outlive you, thedesignation of that beneficiary will be void, subjectto the provisions of the Plan.

If, at the time of your death, there is no survivingdesignated beneficiary, the amount of the DeathBenefit will be paid in a lump sum to your estate, orat the Trustees' option, to one or more of thefollowing surviving relatives: spouse, child orchildren, parents, brothers, or sisters. If norelatives survive you, benefits will be paid to theexecutor or administrator of your estate.

ACCIDENTAL DEATHAND DISMEMBERMENT BENEFITS

Classes A (Bargaining Unit Employees Only), RA, RAO,RAM, RB, RBO, RBM, RC, and RD

Employees Only

Please Note: Accidental Death and Dismem-berment Benefits are not payable for anynon-bargaining unit employee or alumnicovered under Class A or COBRA participant.

If, while your coverage is in force under the Plan,you suffer bodily injury caused solely by accidentalmeans and occurring within 90 days of the date ofthe accident, various benefit amounts are payabledepending on the extent of the loss, as specified inthe Plan Document, and based on the PrincipalSum stated in the Schedule of Benefits. All claimsmust be filed within one year of the date of death ordismemberment.

These payments will be made directly to you, ifliving, otherwise to your beneficiary.

“Loss” with reference to hand or foot meanscomplete severance through or above the wrist orankle joint and with reference to eye means theirrecoverable loss of its entire sight. If you suffermore than one loss in an accident, benefits will bepaid only for the one loss for which the largeramount is payable.

23

LOSS OF TIME BENEFITS

Class A Bargaining Unit Employees and Certain Alumni Only

Please Note: Loss of Time Benefits are notpayable for any non-bargaining unit employeecovered under Class A or COBRA participant.Loss of Time Benefits are payable to alumni,provided the employee is not an owner, has nofinancial interest in the company, is not eligiblefor any other employer-sponsored disabilityprogram, and is not receiving or eligible toreceive any compensation from an employerwhile disabled. Alumni are not eligible fordisability credits.

When you are disabled due to an injury or sicknessthat prevents you from working and while under thecare of a physician, Loss of Time Benefits will bepaid to you at the weekly rate specified in theSchedule of Benefits. However, Loss of TimeBenefits will not be payable for any disability thatprevents you from active work on the date of yourinitial or reinstated eligibility until you return to yourregular occupation for 160 hours.

Loss of Time Benefits also will be paid while youare performing “light-duty work” (as defined onpage 64) provided your disability is not work-relatedand provided you are not an officer, director, orstockholder of an employer contributing to thisFund.

Loss of Time Benefits are not payable in the eventyou receive disability or retirement benefitpayments from the Building Trades United PensionTrust Fund, Milwaukee and Vicinity, or any otherpension fund. However, if your disability orretirement benefits are suspended for any reason,you will become entitled to Loss of Time Benefitssubject to the reinstatement provisions of theEligibility Rules.

Benefits begin with the:

(a) first day of disability due to an injury;

(b) eighth day of disability due to sickness whennot hospital-confined;

(c) first day of disability due to sickness whenhospital-confined, except when confined for

treatment of nervous and mental disorders(including eating disorders), alcoholism, orsubstance abuse;

(d) eighth day of disability due to nervous andmental disorders (including eating disorders),alcoholism, or substance abuse when hospital-confined; or

(e) first day of disability when a surgical procedureis performed on an outpatient basis, if you aredisabled for at least three work days.

Benefits will continue for a maximum of 26 weeksfor any one period of disability for bargaining unitemployees and 13 weeks for certain alumni, exceptfor disabilities related to nervous and mentaldisorders (including eating disorders), alcoholism,and substance abuse for which benefits are limitedto 24 days each calendar year while you arehospital-confined. Loss of Time Benefits for thesespecified disabilities stop on the date of hospitaldischarge.

All claims must be filed within one year of the dateof the injury or sickness.

Reminder. The Fund Office will deduct therequired FICA taxes from your gross benefit.

Limitations. Two or more periods of disability areconsidered as one unless between periods ofdisability you have returned to your regularoccupation for 160 hours.

Loss of Time Benefits cease on the date you loseeligibility.

Loss of Time Benefits are not payable when youare receiving wages or compensation from anysource (unless from an individual policy for whichyou pay the premium), including Worker’sCompensation.

24

COMPREHENSIVE MAJOR MEDICAL BENEFITS

Classes A, RA, RAO, RAM, RB, RBO, and RBM Employees andDependents and Class RD Dependents

When you or your dependent require coveredservices or supplies which are medically necessarybecause of injury or sickness, benefits are payableas stated in the Schedule of Benefits, provided youhave satisfied any required deductible. If there arelimitations for a particular benefit, they areexplained with each benefit. General Exclusionsfor the Plan are on pages 49 through 52.

Deductible

The deductible is the amount of covered chargeswhich you pay before you are entitled to benefits.The deductible for both PPO providers and non-PPO providers per person per calendar year andmaximum per family each calendar year is stated inthe Schedule of Benefits. If you use cost-effectivealternative ways of obtaining care that the Trusteesapproved, the deductible is waived. See pages 31through 33.

Any covered expenses incurred and appliedagainst the deductible in the last three months ofa calendar year also may be applied against thedeductible in the next calendar year.

Normally, the deductible is applied separately toeach eligible person in a family. But, if two or moreeligible members of a family are injured in the sameaccident, only one deductible will be chargedagainst all resulting covered charges, regardless ofthe number of family members injured. A combineddeductible also will apply to covered chargesrelated to such common accident which areincurred in subsequent calendar years when newdeductible amounts otherwise would apply.

Coinsurance

After you satisfy the required deductible amount forthe calendar year, the Plan pays covered expensesat the applicable coinsurance percentage stated in

the Schedule of Benefits. The percentage dependsupon use of a preferred provider (except eligiblepersons whose primary coverage is Medicare arenot eligible for the preferred provider level ofbenefits)1. The balance of charges is payable byyou. If you use the cost-effective alternativesTrustees approved, the coinsurance is waived.See pages 31 through 33. When the out-of-pocketcovered expenses in a calendar year NOTincluding the deductible amount reach the amountstated in the Schedule of Benefits, the Plan pays100% of the balance of covered expenses for thatperson or family for the remainder of that calendaryear. “Family” means one or more eligible personswithin a family unit, consisting of you and yourdependents.

Covered Expenses

Benefits are payable for reasonable expenses forthe following services and supplies which aremedically necessary for treatment of an injury orsickness.

(a) Hospital Services recommended by theattending physician for the following.

(1) Room and board expense, up to thehospital's average semi-private room rate.

(2) Intensive care unit expense, includingconfinement of 24 or more consecutivehours duration in a recovery room of ahospital if you receive the same care andservices as those normally provided in theintensive care unit of the hospital.

(3) Drugs, medicines, diagnostic x-rays andlaboratory tests, and other hospitalmiscellaneous services and supplies notincluded in room charges (including theanesthetist's fee when charged by the

1See the Schedule of Benefits for the applicablecoinsurance, depending on where services areobtained.

25

hospital), if used while confined in thehospital as a resident patient. See page 31for coverage of pre-admission testing.

(4) Outpatient services in connection with asurgical procedure or other emergency first-aid treatment resulting from injury orsickness. There is a separate copaymentstated in the Schedule of Benefits for eachhospital emergency room visit (whetheradmitted or not) which does not apply to thedeductible or out-of-pocket maximum.

(5) For hospital confinements related totreatment of nervous and mental disorders(including eating disorders), substanceabuse, and alcoholism, hospital charges arepayable the same as for any other disability.

Benefits also are payable for partialhospitalization at an approved hospital,clinic, and/or non-medical residentialtreatment facility for treatment of suchconditions.

Benefits are payable for charges for theambulance transfer from an out-of-networkhospital to an in-network hospital which areauthorized by the FSP manager.

[See page 34 for details of the FamilyServices Program (FSP) and page 83 forthe name and address of the FSPmanager.]

(6) A newborn dependent child during theperiod its mother is hospital-confined as theresult of giving birth to the child and afterthe mother's discharge, if the newborn hasa condition which necessitates furtherhospital confinement.

(7) An eligible person, undergoing inpatienttreatment for a nervous or mental condition,when temporarily released for therapeuticreasons. Under these circumstances,benefits are payable for a maximum of twoconsecutive days and up to a total of sixdays during one period of disability.

In-hospital benefits are not payable forhospitalizations starting on weekends fortreatment or surgery scheduled to begin thefollowing Monday or later, unless scheduled tobegin early Monday morning.

The Plan generally may not, under federallaw, restrict benefits for any hospital lengthof stay in connection with childbirth forthe mother or newborn child to less than48 hours following a vaginal delivery, or lessthan 96 hours following a cesarean section,or require that a provider obtain author-ization from the Plan for prescribing ahospital length of stay not in excess ofthese periods. However, federal lawgenerally does not prohibit the mother’sor newborn’s attending provider, afterconsulting with the mother, fromdischarging the mother or her newbornearlier than 48 or 96 hours, as applicable.

(b) Skilled Nursing Home Care Services in alicensed skilled nursing home for up to 30 daysof confinement per period of disability, provided:

(1) you are transferred to the nursing homewithin 24 hours of hospital discharge;

(2) you were hospitalized for at least three daysimmediately before transfer to the nursinghome;

(3) skilled nursing home care is needed for careof the same condition treated in the hospital;

(4) the attending physician certifies this care ismedically necessary and recertification ismade every seven days; and

(5) further hospitalization would be necessary ifnot for skilled nursing home confinement.

Successive periods of disability, due to thesame or related causes, not separated byreturn to full-time active work for 160 hours or,in the case of a retiree or dependent, return tonormal activities, will be considered as oneperiod of disability unless the subsequent

26

period of disability is due to injury or sicknessentirely unrelated to the causes of the previousdisability.

(c) Physicians' Services include charges for:

(1) Surgery by a physician, including:

· charges for outpatient surgery;

· home deliveries by a physician or acertified nurse/midwife under thesupervision of a physician;

· circumcision of an eligible newborndependent child; and

· the following oral surgical procedures:surgical removal of tooth or multipleextractions requiring hospitalconfinement, removal of an impactedtooth, alveolectomy, gingivectomy,apicoectomy, torus palatinus (removal),torus mandibularis, frenectomy, excisionof cyst(s), osteoplasty, stomatoplasty,and reconstruction of alveolar processwith titanium anchors. Titanium anchors(implant) when used to anchor a bridgeor a denture are covered underComprehensive Major Medical Benefitsonly. The Plan will cover medicallynecessary surgery for the treatment oftemporomandibular joint disease (TMJ)when more conservative forms oftreatment have been unsuccessful.

When more than one procedure isperformed during the same operativesession, the primary procedure will beconsidered for payment at the full usual andcustomary allowance and any othersecondary procedures will be considered forpayment at 50% of the usual and customaryallowance. If there is an assistant at thesurgery, the Plan will consider 20% of thesurgical fee allowed for a physician (M.D.)to assist or 10% for a physician's assistant(P.A.). The Plan will not allow for a P.A. ifthere was a surgical resident on staff at thehospital who was qualified and available toassist with the surgery. The Plan will notcover an R.N. to assist.

For individuals receiving mastectomy-related benefits, coverage will be providedon the same basis as other medical and

surgical procedures covered by the Planand in a manner determined in consultationwith the attending physician and the patientfor: all stages of reconstruction of thebreast and nipple of the breast on which themastectomy has been performed; surgeryand reconstruction of the other breastto produce symmetrical appearance;prostheses; and treatment of physicalcomplications in all stages of themastectomy, including lymphedemas.

For organ transplant surgery and relateditems, see pages 29 and 30.

(2) Anesthetic and its administration by aprofessional anesthetist when the charge forthose services is not included in thehospital's charges.

The maximum allowable for the services ofa physician and certified registered nurseanesthetist (CRNA) jointly providinganesthesia service may not exceed thePlan’s usual and customary allowance or, ifa preferred provider, the PPO fee schedule.

(3) Medical services rendered during in-hospital, outpatient, office, and home visitsby a physician, including examination of aneligible newborn dependent child.

Chiropractors' visits will be covered up tothe maximum per calendar year stated inthe Schedule of Benefits.

(4) Outpatient treatment for nervous and mentaldisorders (including eating disorders),substance abuse, and alcoholism ispayable as stated in the Schedule ofBenefits.

Outpatient treatment includes collateralinterviews with the eligible person's family.

(See page 34 for details of the FSP andpage 83 for the name and address of theFSP manager.)

(5) Services of a physician for your or yourspouse's routine physical examination. Seepage 31 for details.

27

(d) Diagnostic X-Ray and Laboratory Services,including amniocentesis when medicallynecessary.

Any expense incurred for dental x-rays isexcluded (unless rendered for dental treat-ment of a fractured jaw or injury to soundnatural teeth within six months after anaccident).

(e) Prescription Drugs and Medicines for whicha written prescription is legally required andwhen obtained from a licensed pharmacist uponthe prescription of a physician will be payableunder Comprehensive Major Medical Benefitsonly under the following circumstances:

(1) Implantable contraceptives when deter-mined to be medically necessary for anon-contraceptive use.

(2) When the Fund is the secondary payor toanother group health plan. Under suchcircumstances, the Plan will cover theremaining balance after the primary planhas paid at 90% for a generic prescriptionand at 85% for a brand name prescription.No deductible will apply and the remainingcoinsurance will not apply to the out-of-pocket maximum. The Plan’s coinsurancewill continue to apply once the out-of-pocketmaximum is reached.

(3) When an eligible person who is a Medicaidrecipient fails to use his PPRx drug cardat the time of purchase. Under suchcircumstances, the Plan will reimburseMedicaid for such prescriptions at the out-of-network level of benefits.

Benefits are not payable for take-home drugsfrom the hospital that are included on yourhospital bill, prescriptions purchased througha VA facility (including any copayment forwhich you are responsible), and copaymentsyou incur with the Wisconsin SeniorCarePrescription Drug Assistance Program.

For all other prescription drug coverage, seethe preferred provider pharmacy describedon page 37.

If a Medicare-eligible person continuingcoverage under Class RAO, RAM, RBO,RBM, RC, or RD enrolls in MedicarePrescription Drug Benefits, he will becomeineligible for prescription drug benefitsunder the Plan and no benefits will be paidfor any charges incurred for prescriptiondrugs.

(f) Other Covered Charges include the following:

(1) Other hospital charges incurred as anoutpatient.

(2) Charges of a licensed physical therapist,occupational therapist, speech therapist,registered nurse (R.N.), or licensed practicalnurse (L.P.N.), except for services providedby a person who ordinarily resides in yourhome or is a member of your immediatefamily (comprised of your spouse and yourand your spouse's children, brothers,sisters, and parents).

Benefits are payable for physical,occupational, and speech therapy onlywhen medically necessary to restore afunction lost due to injury or sickness.

Charges of a physical therapy assistant(PTA) will be considered for payment at50% of the usual and customary allowance.

(3) Charges for hospice care. See page 32 fordetails.

(4) Charges for local professional ambulanceservice between hospitals as well as to andfrom a hospital if the attending physicianconsiders it medically necessary for propertreatment. If an injury or sickness requiresspecial and unique medically necessaryhospital treatment that is not available in alocal hospital, the Plan covers professionalambulance service, air ambulance service,or helicopter ambulance service to thenearest hospital within the contiguousUnited States equipped to furnish thetreatment.

Ground ambulance charges resulting from a911 emergency call will be payable subjectto the in-network deductible, coinsurance,and out-of-pocket maximum.

28

Charges for ambulance service by railroad,ship, bus, or other common carrier are notpayable except as specifically stated.

Benefits are not payable for transpor-tation or transfer based solely on yourconvenience, personal preference, or anyreason other than medical necessity.

(5) Charges for the following additional servicesand supplies:

· oxygen and the rental of equipment forits administration;

· x-ray, radium, or cobalt treatment,including the services of a radiologistand the rental (but not purchase) ofsuch radioactive materials, provided thattreatment is rendered in the radiologist'soffice or in the outpatient department ofthe hospital making the charge;

· blood or blood plasma (if not replaced)and its administration;

· surgical dressings, casts, splints,braces, trusses, and crutches;

· rental of durable medical equipment(DME), such as a hospital-type bed,wheelchair, or iron lung (or the purchaseof such device in lieu of rental if therental would exceed the purchaseprice);

· repair of DME when the damage is notdue to abuse or neglect, the cost ofrepair is projected to be less thanthe cost of replacement, the equipmenthas been maintained according to themanufacturer’s recommended mainte-nance schedule, and the AdministrativeManager has authorized the repair inadvance;

· initial artificial limbs and eyes to replacenatural limbs and eyes that have beenamputated or severed;

· medically necessary replacement orrepair of artificial limbs and eyeswhen authorized in advance by theAdministrative Manager;

· initial breast prosthesis following amastectomy;

· replacement prostheses as needed dueto material deterioration;

· hearing aid examinations and hearingaids when prescribed by a physician;

· repairs to hearing aids;· one pair of physician-prescribed custom

made orthopedic shoes, custom-moldedinserts, or orthotics until worn outand another pair is prescribed by aphysician;

· dental services rendered by a physician,dentist, or dental surgeon for treatmentof a fractured jaw or injury to soundnatural teeth, including replacement ofsuch teeth within six months after thedate of the accident or if the injury is dueto domestic violence or a medicalcondition;

· diagnosis and nonsurgical treatment oftemporomandibular joint disease (TMJ),up to the maximum stated in theSchedule of Benefits per eligibleperson's lifetime (see page 26 forcoverage of surgical treatment of TMJ);

· essential costs of home care treatmentfor hemophilia (see page 32 for details);and

· DME supplies (including CPAPsupplies), but excluding batteries, upto the maximum stated in theSchedule of Benefits.

(6) Charges related to provision of artificial lifesupport systems for the first five days after amedical determination that death hadoccurred, not to exceed $5,000; suchdetermination of death to be within themeaning of Section 146.71, WisconsinStatutes (1989-90), or is determined to beclinically dead.

(7) Diabetic self-management educationprograms, including dietary counseling,provided the program is medicallynecessary and prescribed by a physician.Nutritional counseling for the managementof other medical conditions also is coveredsubject to the same requirements.

(8) Routine colonoscopies for eligible personsage 50 and over and for eligible personswho have a family history of colon cancer.

29

(9) Dental prostheses (such as maxillary ormandibular prosthesis) when the loss ofnatural teeth is the result of cancer thatrequired radiation to the head and/or neck.

(10) Acupuncture when medically necessary.

(g) Organ Transplant Surgery and relatedcovered costs for human organ or tissuetransplants are provided according to the termsand conditions set forth in a separate Organ &Tissue Transplant Policy (Transplant Policy)that has been issued to the Plan and also in theOrgan & Tissue Transplant Certificate enclosedwith this SPD booklet. Transplant-relatedbenefits will be provided to each eligible personduring the transplant benefit period specified inthe Transplant Policy. Once the insuredtransplant benefit period has elapsed, alltransplant-related benefits will revert back to thePlan, subject to its terms and conditions.Insured transplant-related benefits only areavailable to you if you: are eligible for medicalbenefits under the Plan; meet all the terms andconditions outlined in the Transplant Policy; andhave fulfilled the pre-existing condition waitingperiod (if applicable) as defined in theTransplant Policy. The pre-existing conditionwaiting period only applies to certain kidneytransplants that are performed fromSeptember 1, 2013, through August 31, 2014.Eligible persons that are subject to this pre-existing condition waiting period under theTransplant Policy will receive transplantbenefits according to the terms and conditionsof the Plan until the pre-existing conditionwaiting period has elapsed.

Coverage for cornea transplants is provideddirectly through your self-funded Plan ofbenefits during the transplant benefit period to arecipient who is an eligible person, not toexceed the amounts stated in the Schedule ofBenefits. A transplant benefit period consists offive days before and eighteen months after thedate of a transplant for self-funded procedures.Cornea transplants are covered under the Planas stated in this section provided they aremedically necessary.

In addition, the following transplants arecovered under your self-funded Plan ofbenefits for Medicare-eligible retirees and arecoordinated with benefits payable by Medicare:

cornea, kidney, bone marrow (except bonemarrow transplants caused by T-cell leukemia),liver, heart, heart/lung (single or double), lung(single or double), pancreas, pancreas/kidney,and small bowel.

Organ transplant benefits are payable providedeach of the following conditions is satisfied:

(1) You or your dependent receives two writtenopinions by Board-certified specialists in theinvolved field of surgery on the necessity fortransplant surgery.

(2) The specialists certify in writing thatalternative procedures, services, or coursesof treatment would not be effective in thetreatment of your condition.

(3) All decisions related to the transplantsurgery satisfy applicable staterequirements.

(4) You must contact the Fund Office for priorapproval of all self-funded organ and tissuetransplants.

Covered expenses for self-funded transplantsinclude reasonable expenses incurred for thefollowing services and supplies:

(1) Donor-related services include:

(i) testing to identify suitable donor(s);

(ii) life support of a donor pending theremoval of a usable organ(s);

(iii) transportation for a living donor or adonor on life support;

(iv) human organ and tissue procurement,including removing, preserving, andtransporting the donated organ ortissue; and

(v) expenses related to the treatment of acondition resulting from the donation ofan organ or tissue.

Benefits for donor-related services alsowill be payable to compensate an organor tissue bank for the procurement,preservation, and transportation of an

30

organ. However, benefits will not bepayable for any financial consideration to adonor other than for payment of a coveredexpense which is incurred in theperformance of, or in relation to, transplantsurgery of an eligible person.

Payment for donor(s)’ services for eacheligible transplant procedure will not exceedthe applicable maximum amount stated inthe Schedule of Benefits. Benefits arepayable under this section only if thetransplant recipient is an eligible person.

(2) Transportation, lodging, and meals(according to IRS guidelines) for therecipient and an immediate family memberor significant other person to and from thetransplant site, as well as lodging and mealcosts incurred during the recipient’s hospitalstay by the companions, up to themaximums stated in the Schedule ofBenefits. Mileage will be reimbursed at theIRS standard mileage rate for medicalpurposes. For these benefits to be payable,itemized receipts for charges are required.

(3) Private nursing care for the recipient by aregistered nurse (R.N.) or a licensedpractical nurse (L.P.N.), up to the maximumstated in the Schedule of Benefits.

(4) Mechanical assist devices when medicallynecessary for all covered transplants.

(5) Postoperative followup expenses, includingimmunosuppressant drug therapy.

(6) All other covered services for the recipientwill be payable under the Plan the same asfor any other injury or sickness.

Benefits are payable for the temporary use ofmechanical equipment which is no longerexperimental pending the acquisition of“matched” human organ(s).

If a covered organ transplant procedure is notperformed as scheduled due to the intendedrecipient’s medical condition or death, benefitswill be payable for charges incurred during theduration of the delay for the organ and tissueprocurement, transportation, lodging, andmeals, as stated in this section.

No organ transplant benefits are payable for:

(1) services not ordered by a physician;

(2) any expenses for a transplant whenapproved alternative courses of treatmentare available or when other specifiedconditions are not satisfied;

(3) animal or mechanical organs fortransplantation;

(4) investigational drugs;

(5) any items specified in the Plan’s GeneralExclusions on pages 49 through 52;

(6) purchase of the organ or tissue; or

(7) the temporary use of experimentalmechanical equipment.

(h) Genetic Testing and Counseling, when suchservices are rendered for one or more of thefollowing reasons, will be subject to theseparate lifetime maximum per eligible personstated in the Schedule of Benefits:

(1) You and/or your dependents suffer from ahereditary disease; or

(2) A strong family history of a hereditarydisease is present even though neither youor your dependents have the disease; astrong family history means at least onefirst-degree relative (parent, sibling) orat least two second-degree relatives(grandparent, aunt/uncle) of you or yourdependent spouse has been diagnosed witha hereditary disease; or

(3) You and/or your dependent spouse hasproduced a child with mental retardation, ahereditary disease, or a birth defect; or

(4) You and/or your dependent spouse has hadtwo or more miscarriages, a stillborn child,or a child who died in infancy from a causethat is believed to be genetic in nature.

31

Genetic counseling and testing will not besubject to the separate lifetime maximum whendeemed medically necessary to determine thecourse of treatment of a sickness of an eligibleperson.

Alternative Ways of Obtaining Care

Deductibles and coinsurance are waived for thefollowing benefits available under ComprehensiveMajor Medical Benefits to encourage you and yourphysician to consider their use. In some cases,benefits payable at 100% are limited to a specifiedmaximum after which the Comprehensive MajorMedical Benefits provisions do apply. If you andyour physician use these less costly systems andfacilities for appropriate treatment, you will helpkeep your own and Plan costs under control.These benefits are subject to all other provisions ofthe Plan.

(a) Pre-Admission Testing

Laboratory tests and x-rays are sometimesordered by your physician before treatmentbegins or surgery takes place. Sometimes theadded tests and x-rays may be performedwithout being hospital-confined. Whether theyare performed before or after hospitalizationbegins is a judgment for you and your physicianto make.

When you or your dependent incur expensesfor pre-admission testing, the Plan will pay thereasonable expenses actually incurred fordiagnostic laboratory tests and x-raysperformed in a hospital outpatient department,physician's office, or clinic which are requiredfor medically necessary treatment you arescheduled to receive upon hospital admission,provided:

(1) you are scheduled for hospital admissionand the scheduled admission occurs;

(2) the treatment is initiated or the surgery isperformed within seven days of the testing;and

(3) hospital benefits are payable for thetreatment or surgery.

If you are not admitted to the hospital followingthe testing, such benefits still are availableprovided:

(1) the tests showed a medical condition whichrequired treatment prior to hospitaladmission;

(2) a hospital bed is not available; or

(3) the tests showed that admission is notnecessary or that treatment or surgery isrequired to be deferred beyond seven daysof the testing.

Pre-admission testing covers diagnosticlaboratory tests and x-rays only.

Physicians' and facility charges are not coveredunder this section.

(b) Routine Physical Examinations

If you or your dependent incur expense for anexamination, x-rays, and laboratory tests for aroutine physical examination performed by aphysician in a hospital, clinic, or physician'soffice, the Plan will pay the reasonableexpenses actually incurred, not to exceed themaximum stated in the Schedule of Benefits forall such examinations made during eachcalendar year. Amounts over such maximumare payable subject to the ComprehensiveMajor Medical Benefits deductible, coinsurance,and out-of-pocket maximum and, for well childcare, also are subject to guidelines of theAmerican Academy of Pediatrics.

The Plan will apply reasonable medicalmanagement techniques to determinecoverage limitations, including thefrequency and medical appropriateness ofroutine services.

Preferred Provider Preventive Care ProgramOption: You or your dependent spouse maychoose instead to take advantage of thePreferred Provider Preventive Care Programoffered through Health Dynamics. If you usethis Program for your routine physical exam,

32

covered services are payable in full, up to themaximum amount approved by the Trustees forthat particular preferred provider. If you douse this option, your routine physicalexamination benefit for the calendar yearwill be considered exhausted.

The Program includes a physician-directedphysical examination which may be conductedby an M.D. or a physician's extender, such as aphysician's assistant or nurse practitioner, andcomprehensive preventive care testing. Womenmay have both a breast screen and pap testperformed. If you choose to go to HealthDynamics and you intend to have the paptest and/or breast screen performed by yourpersonal physician, please be aware thatthese procedures will not be covered underyour Health Care Plan.

You may request to have the bone densityscreening (heel bone ultrasound) done as partof your complete exam. This screening isoffered at the Glendale location only. After thetesting, you will have a personal andconfidential consultation session which willprovide you not only with a medical evaluationbut also a personal fitness report andrecommendations that focus on your totalwell-being.

To schedule an appointment, call HealthDynamics located in the Columbia St.Mary’s Urgent Care facility in Glendale at(414) 443-0200 during office hours, Mondaythrough Friday, 8 a.m. - 5 p.m. There areadditional hospital-based locations where thephysical now is available. Contact HealthDynamics for the current listing of those otherlocations to find the one nearest you. You alsomay visit their website at: www.hdhelpsu.com(username is: hdhelpsu and password is:hdhelpsu).

Once your appointment has been scheduled, apacket will be sent to you explaining fastingrequirements, check-in procedures, and otherpertinent information.

(c) Hospice Care

When it is medically determined that an eligibleperson is terminally ill, the eligible person (orhis authorized representative, such as a family

member) and the physician may prefer hospicecare as opposed to hospital confinement.Benefits are payable for the full reasonableamount of covered hospice services during theperiod in which the eligible person otherwisewould, upon recommendation of his physician,have to be hospital-confined. Such benefits arepayable for home care administered under anapproved hospice program or home health careagency at the patient's home, or for care in ahospice unit of a hospital or a separate hospicefacility. Covered hospice services include roomand board when an inpatient of a hospice unitof a hospital or a separate hospice facility;physicians' visits; care provided by registerednurses and home health care aides;assessment visit by a hospice program staffmember; physical, occupational, speech, andrespiratory therapy; and drugs and suppliesprescribed by a physician.

In the event the medical determination is madethat the terminal condition is reversed, benefitsare payable as provided under other sections ofthe Plan.

(d) Home Care Treatment for Hemophilia

When you or your dependent incur expense forthe essential costs of home care treatment forhemophilia, the Plan will pay the reasonableexpenses actually incurred. Eligible expensesinclude blood products and related peripheralmaterials such as tourniquets, needles, andsyringes.

Benefits will not be paid for a freezer for storageof supplies or for personal service fees for self-infusion.

(e) Routine Mammograms

When expenses are incurred by an eligiblefemale for a routine mammogram, the Plan willpay the reasonable expenses actually incurred,subject to the following frequency schedule:

For Age Group: Plan Covers:

35 to 39 One every five calendaryears

40 and over One every calendar year

33

(f) Routine Immunizations

When you or your dependent incur expense forroutine immunizations, the Plan will pay thereasonable expenses actually incurred. Adultimmunizations will be payable according torecommendations of the Advisory Committeeon Immunization Practices (ACIP), theAmerican Academy of Family Physicians, theAmerican College of Physicians, and theAmerican College of Obstetricians andGynecologists. Immunizations for children andadolescents will be payable according torecommendations of the American Academy ofPediatrics, the Advisory Committee onImmunization Practices of the Centers forDisease Control and Prevention, and theAmerican Academy of Family Physicians.Immunizations for travel are not payable.

Benefits are not payable for: services renderedor supplies dispensed before you or yourdependent is an eligible person, whether or not aseries of treatments for immunization continuesafter you are an eligible person; treatment relatedto allergy; or medications not normally prescribedor administered by a physician or paramedicalpersonnel, such as vitamins.

Exceptions and Limitations

In addition to the Plan's General Exclusions onpages 49 through 52, and other limits that apply tospecific benefit provisions as described in thosesections, Comprehensive Major Medical Benefitsdo not cover:

(a) ambulance service by railroad, ship, bus, orother common carrier, except as specificallyprovided;

(b) dental treatment or dental x-rays, except asspecifically provided;

(c) purchase of radioactive materials for x-ray,radium, or cobalt treatment;

(d) examination for correction of vision or fitting ofglasses or contact lenses;

(e) care in a rest home other than in a hospital;

(f) any loss caused by or resulting from mentaldeficiency, mental retardation, developmentaldeficiencies, or any treatment for learningdisabilities;

(g) counseling or treatment for conditions notsupported by a bona fide medical diagnosis,such as aptitude testing and marriagecounseling, unless covered through the FamilyServices Program;

(h) a dependent child’s pregnancy;

(i) DME repair that would be covered by warranty,maintenance of DME, duplicate DME rental, orDME batteries and ancillary supplies;

(j) genetic testing and genetic counseling, exceptas specifically provided;

(k) habilitation services;

(l) long-term care;

(m)weight loss programs; or

(n) routine foot care.

34

FAMILY SERVICES PROGRAM

Classes A, RA, RAO, RB, and RBO Non-Medicare Eligible Employeesand Dependents and Class RD Dependents

From time to time, we all face personal difficultiesor stress. Sometimes, we need help to resolve ourproblems. Your Family Services Program (FSP) isa free and strictly confidential benefit that providesassessment, short-term counseling, and referralservice for you and your family to help resolvepersonal problems which may be affecting your lifeat work and at home.

The Trustees have contracted with ComPsychCorporation, an organization of medical doctors,social workers, counselors, and psychologists toprovide you and your family with the confidential,professional assistance necessary to deal withpersonal problems and stress.

Skilled counselors are available to talk with you inconfidence about your problems. Your counselorcan help you with:

(a) marital problems;

(b) divorce;

(c) family difficulties;

(d) child or adolescent concerns;

(e) empty nesting;

(f) elder issues, such as caregiving;

(g) death or illness of a loved one;

(h) alcohol or substance abuse;

(i) eating disorders;

(j) job stress;

(k) depression or anxiety;

(l) financial difficulties; and

(m) legal referrals.

If you think you need help with a problem, calltoll-free at: 1-866-379-0895 for confidential access24 hours a day.

Trained professionals are there to help you andyour family evaluate and identify problems. Veryoften, they can help you to resolve those problems.

Up to three visits with a ComPsych licensedtherapist are covered in full per person per calendaryear for each diagnosis.

In some circumstances, ComPsych can refer you tothe most appropriate resource available to assistyou. The earlier you seek help, the easier it is tosolve your problems.

Other services offered through your FSP include:

(a) Work life and convenience services throughFamilySource. These services can help with awide variety of things such as emergencyshelter, travel assistance, finding supportgroups for caregivers and patients, as well ashelping you find appropriate resources andsupport for your particular needs.

(b) Legal consultation services, including telephoneaccess to licensed attorneys for information onlegal concerns, a free half-hour in-personconsultation with a ComPsych attorney, and a25% discount if you retain an attorney. Legalassistance is available for issues such asdivorce, landlord problems, estate planning,small claims court, and child support payments.

(c) Financial consultation services by telephone forsuch issues as budgeting, how to improve yourcredit score in order to qualify for a mortgage,credit card debt, foreclosure, tax issues, savingfor retirement, and financial aid sources to payfor college.

35

You also can access these resourcesonline by visiting the website at:www.guidanceresources.com. First-time users willbe prompted for the Company/Organization ID:T15453C, to register and create your ownusername and password. The site is complete witharticles, help sheets, calculators, self-assessmenttools, child and elder care resources, and much,much more.

In addition, ComPsych will provide casemanagement services to determine the medicalnecessity of in- and outpatient treatment of

nervous and mental disorders (including eatingdisorders), substance abuse, and alcoholism sinceall services must be medically necessary to beeligible for Plan benefits. If you have questionsconcerning the appropriateness or medicalnecessity of treatment that is recommended foryou, you may call ComPsych at 1-866-379-0895.Using a ComPsych network provider could saveyou money; therefore, we recommend you callComPsych for help in locating a network provider inyour community.

36

CASE MANAGEMENT

The Plan will send large claims to a firm they haveselected to provide case management services.Catastrophic or other suitable cases are reviewedby the case manager for medical necessity. Thecase manager will contact you, your physician, andthe Fund Office to discuss treatment options and toidentify available community resources.

If you and your physician approve, they willcoordinate the necessary services. It is often hardto make decisions about ongoing care. Casemanagement allows you to discuss your concernsopenly and makes you aware of all your options.Also, both you and the Fund may save money if aless costly setting is appropriate.

37

OTHER PREFERRED PROVIDERS

As part of the Trustees' ongoing effort to managehealth care costs, the Fund participates in anumber of preferred arrangements which offer costsavings to both you and the Fund. The PreferredProvider Preventive Care Program is described onpage 31. A description of the Fund's otherpreferred providers follows.

Preferred Provider Network

Through the Anthem Blue Cross and Blue Shieldpreferred provider organization, the Fund hasaccess to a network of hospitals, physicians, andother health care providers that have contracted toprovide all necessary covered services atsignificantly reduced rates. You also have accessto the BlueCard program which provides a broadnational network. In addition to hospitals andphysicians, Anthem offers reduced rates foroutpatient surgery centers, chiropractors, homeinfusion therapy, home health care, durablemedical equipment, radiology and laboratoryfacilities, physical therapists, skilled nursingfacilities, and urgent care centers.

Benefits are payable for covered expenses at theapplicable percentage of the preferred provider'snegotiated charge according to the contract ineffect at the time charges are incurred as stated inthe Schedule of Benefits. The Plan's coinsuranceis increased for covered expenses incurred at anAnthem preferred provider except for eligiblepersons who are Medicare primary.

The list of preferred providers in the network issubject to change based on the contractualagreement between the agent and the participatingproviders. It is recommended that you contactAnthem prior to incurring covered expenses tomake sure the hospital, physician, or other healthcare provider you choose is a preferred provider.Call Anthem at 1-800-810-BLUE (2583) or visit theirwebsite: www.anthem.com.

Preferred Provider Pharmacy

CVS Caremark provides full management of thePlan’s prescription drug card program. It offers anetwork of pharmacies where you can use your

Plan identification card to purchase your pre-scription drugs at reduced rates. The networkincludes all national and regional chains and mostindependent pharmacies--over 56,000 throughoutthe United States. To locate a participatingpharmacy in the retail network, call:1-800-966-5772.

When you purchase prescription drugs at apreferred provider pharmacy (PPRx), benefits arepayable subject to the following terms andconditions.

However, if a Medicare-eligible person continuingcoverage under Class RAO, RAM, RBO, RBM, RC,or RD enrolls in Medicare Prescription DrugBenefits, he will become ineligible for prescriptiondrug benefits under the Plan and no benefits will bepaid under the Plan for any charges incurred forprescription drugs.

Benefits are payable for the following upon awritten prescription executed by a physician anddispensed by a licensed pharmacist:

(a) federal legend drugs (meaning drugs requiring,under the Federal Food, Drug and CosmeticAct, a label that reads, “Caution: Federal lawprohibits dispensing without a prescription”);

(b) compounded medications of which at least oneingredient is a prescription legend drug;

(c) insulin;

(d) insulin syringes/needles on prescription;

(e) prescription prenatal vitamins;

(f) AIDS-related drugs;

(g) immunosuppressants (anti-rejection drugs);

(h) legend Meclizine on prescription;

(i) Tretinoin (Retin-A) preparations up to age 23;

(j) covered injectable medications filled throughthe Specialty Pharmacy;

38

(k) diabetic test strips and lancets (Classes A, RA,and RB only), subject to the coinsurance statedin the Schedule of Benefits; and

(l) EpiPens, up to a maximum of two per eligibleperson per calendar year, subject to a 10%coinsurance at both a retail PPRx and throughthe mail service.

For prescription claims that you fill at retailpharmacies, you MUST present your eligibility cardwith the CVS Caremark logo at the point-of-servicein order for the claim to be eligible for payment.There is no provision for reimbursement of paperclaims in the Fund. If coverage is denied at thepoint-of-service and you believe the denial is inerror, you should contact the Fund Office the nextbusiness day for assistance in resolving theproblem. There may be instances in which there isa lag in processing your eligibility through the CVSCaremark Preferred Provider Pharmacy Program.For example, if you are working out-of-area, thetransfer of contributions for hours worked takeslonger than if you are working for a contributingemployer in the jurisdiction of the Fund.

If your coverage is denied at the point-of-service,and you pay the full cost of the prescription in orderto pick it up, you should contact the Fund Officeimmediately to correct your eligibility. Once youreligibility is updated, you then must ask yourpharmacist to resubmit the claim to CVS Caremarkin order to be reimbursed your out-of-pocketexpenses minus any applicable copays. You haveseven days from the date you first filled theprescription to get your eligibility corrected andthe claim resubmitted to CVS Caremark. If theclaim is not resubmitted within seven days, it willremain denied and there will be no opportunity foryou to obtain reimbursement on that claim.

For persons age 14 and over, medications to treatAttention Deficit Hyperactivity Disorder (ADHD)need to be initially precertified by the Fund Office.They also need to be recertified by the treatingphysician annually.

Also, prescriptions that have a cosmetic use, suchas Accutane and Retin A, may need to beprecertified. Check with the Fund Office beforefilling the prescription.

Reminder: If you are filling a prescription and thepharmacy is charging more than the normal copayamount, you should question whether you are

being charged for the full cost. If so, call the FundOffice to determine the reason. The prescriptionmay be ineligible because it was not precertified orrecertified, so the pharmacy is charging you the fullamount. If you get the pre/recertification, you onlywould be responsible for the copay amount. Youhave seven days from the date you first filledthe prescription to get pre/recertification andthe claim resubmitted to CVS Caremark.

For each prescription purchased at a PPRx, youwill pay the copayment per prescription as stated inthe Schedule of Benefits for either generic drugs orbrand name, up to a 30-day supply. You canorder maintenance prescriptions through mailservice in a 90-day supply and pay the copaymentper prescription as stated in the Schedule ofBenefits. You can refill your prescription: online byvisiting www.caremark.com; by phone by calling1-800-966-5772; or by mail by completing andmailing a mail service order form.

Under the generic incentive program, Caremark willcontact you directly by mail if you are taking atargeted brand name drug for which there is ageneric equivalent or generic alternative andexplain the details of the program. If you areeligible for this program, the first fill for the genericform of targeted medications will be filled for FREE($0 copayment) at either a retail network pharmacyor through the Caremark mail service pharmacy.

You must use CVS Caremark Specialty Pharmacyto obtain your specialty medications. All specialtymedications require prior authorization by CVSCaremark. Specialty medications are high-cost,bio-tech medications that generally have specialadministration requirements, require specialhandling, and require special clinical support. Inmany cases, they are injectable medications andusually have complex dosing regimens. Theyinclude medications used to treat conditionssuch as multiple sclerosis, rheumatoid arthritis,Hepatitis C, cancer, cystic fibrosis, organ rejection,and Crohn’s disease, to name just a few. The CVSCaremark Specialty Guideline ManagementProgram supports safe, clinically appropriate, andcost-effective use of specialty medications.Specialty oral medications are payable subject tothe retail copayment stated in the Schedule ofBenefits. Self-administered injectable medicationsare subject to the coinsurance stated in theSchedule of Benefits and, for the Low Cost Option,you first must satisfy the Comprehensive MajorMedical Benefits deductible. Your coinsurance for

39

self-administered injectable medications applies tothe Comprehensive Major Medical Benefits out-of-pocket maximum.

CVS Caremark Specialty Pharmacy provides notonly your specialty medications, but alsopersonalized pharmacy care management services:

· Access to an on-call pharmacist 24 hours aday, seven days a week.

· Coordination of care with you and yourphysician.

· Convenient delivery directly to you or yourphysician’s office.

· Medicine- and disease-specific education andcounseling.

· Online support, including disease-specificinformation and interactive areas to submitquestions to pharmacists and nurses, throughwww.CVSCaremarkSpecialtyRx.com.

If you have any questions, you can either visit theirwebsite as previously stated or call CaremarkConnect toll-free at: 1-800-237-2767 from 6:30 a.m.to 8 p.m. (CT) Monday through Friday.

Please note that these Specialty Pharmacyrequirements do not apply to infusedmedications or other specialty medications thatare administered by a health care professional.They apply only to oral medications and self-administered injectable medications.

CVS Caremark develops and maintains standardformularies and drug lists to support and guideclients in the management of the pharmacy benefit.CVS Caremark Drug formularies are developedand maintained according to guidelines andrecommended by the Formulary Review Committee(FRC) and approved by the CVS CaremarkNational P&T Committee. Under your prescriptionplan design, certain drugs are not covered withouta prior authorization for medical necessity. You willbe notified in advance by CVS Caremark if you aretaking one of these drugs, or if a new prescription,at the time you submit a claim for one of thesedrugs. If your physician believes you have aspecific clinical need for one of these excludedproducts, he should contact the Prior AuthorizationDepartment for medical necessity review. If youcontinue using one of these drugs without priorapproval, you may be required to pay the full cost.

If you use the PPRx while ineligible according tothe Plan's Eligibility Rules, the Plan will recover theineligible payments from you according to the rightof recoupment provisions stated on page 49.

Claims related to prescription drug expensesshould be filed with the patient's primary source ofcoverage and then submitted to the Fund forcoordination of benefits. If this Plan makespayments and later determines it is not the primarysource of coverage, overpayments will be recoupedfrom you.

40

Benefits are not payable under the PreferredProvider Pharmacy Program for the following:

(a) non-legend drugs (over-the-counter drugswhich do not require a prescription) other thaninsulin or any prescription with an OTCequivalent;

(b) drugs purchased at the hospital pharmacy foryou at the time of discharge;

(c) covered prescription medications which are notself-administered or are administered in ahospital, long-term care facility, or otherinpatient setting;

(d) contraceptives, oral or other, except ifdetermined to be medically necessary for anon-contraceptive use;

(e) implantable contraceptives, regardless ofintended use;

(f) therapeutic supplies, devices, or appliances,including support garments, and other non-medicinal substances, except those specificallystated;

(g) experimental or investigational drugs;

(h) charges for the administration or injection ofany drug;

(i) prescription drugs or medicines covered underany Worker's Compensation Law or similar lawsor any municipal, state, or federal program,even if the patient chooses not to claim suchbenefits;

(j) refills of covered drugs which exceed thenumber of refills the prescription order calls for,or refills after one year from the original date;

(k) prescriptions deemed not medically necessaryfor the diagnosis or treatment of an injury orsickness;

(l) prescription medicines to treat sexualdysfunction, unless organic in nature (suchmedications are limited to 10 pills/month);

(m)smoking deterrents (except Zyban and Chantixare covered);

(n) topical Minoxidil (Rogaine) preparations,whether commercially prepared orcompounded;

(o) diabetic supplies, such as test tape and alcoholswabs; test strips and lancets are excluded forMedicare-eligible retirees;

(p) immunization agents;

(q) fertility agents, including Pergonal(Menotropins) and Metrodin (Urofollitropins);

(r) prescription and OTC vitamin preparations(except prenatal vitamins are covered);

(s) prescription fluoride preparations;

(t) drugs purchased outside the United States;

(u) infertility medication; and

(v) drugs and vitamins prescribed for any dietarypurpose.

41

DENTAL CARE BENEFITS

Classes A, RA, RAO, and RAMEmployees and Dependents

Benefits are payable at the percentage and up tothe maximum amount stated in the Schedule ofBenefits for reasonable expenses related topreventing dental disease, restoring teeth,furnishing dentures, and straightening teeth(orthodontia). Services and supplies must befurnished by a dentist acting within the usual scopeof such practice or by a dental hygienist, providedthe hygienist works under the supervision of adentist.

The date of service for fixed bridgework and fullor partial dentures will be the date the firstimpressions are taken and/or abutment teeth fullyprepared while covered under Dental CareBenefits.

The date of service for a crown, inlay, or onlay willbe the date the tooth is prepared while coveredunder Dental Care Benefits.

Routine Oral Examination

A routine oral examination includes servicesperformed by a dentist for one or any combinationof the following:

(a) prophylaxis, which also may be performed bya dental hygienist under the direction andsupervision of a dentist;

(b) oral examination, including dental x-rays ifprofessionally indicated; and

(c) diagnosis.

You and each of your dependents are entitledto two routine oral examinations, includingprophylaxis, each calendar year.

Benefits also are payable for dependent childrenunder age 19 for topical fluoride applications (twoper person per calendar year) and dental sealants.

Basic Dental Care

Basic dental care includes services performed by adentist for an actual or suspected dental disease,defect, or injury. These benefits include, but arenot necessarily limited to:

(a) x-rays;

(b) emergency treatment;

(c) treatment of periodontal disease;

(d) extractions, including removal of multipleunimpacted teeth;

(e) root canal therapy;

(f) crowns, fillings, and inlays;

(g) bridgework and repair of bridgework;

(h) space maintainers and related services;

(i) initial installation or repair of a full or partialdenture;

(j) replacement of a partial denture;

(k) examination and treatment by a dentist inconnection with an actual or suspected dentaldisease, defect, or injury; and

(l) implants not used to anchor a bridge or adenture.

Full Denture Replacement

A full denture replacement includes services of adentist for replacement of an existing full upper orlower denture or full dentures. One replacement ofone upper denture and one lower denture or onefull set of dentures is available to you and each ofyour dependents during any one calendar year.

42

Orthodontic Benefits

Benefits are payable for reasonable expensesincurred during an entire period of orthodontictreatment while coverage under this section is ineffect for such person. If a period of orthodontictreatment has begun before coverage under thisPlan takes effect, benefits payable will be proratedbased on the remaining length of treatment whensuch person becomes eligible under this Plan.Benefits payable for orthodontic treatment aresubject to the lifetime maximum orthodontic benefitstated in the Schedule of Benefits, which meansthe amount payable for all orthodontia expensesincurred during each eligible person's lifetime.

However, “medically necessary orthodonticservices” for dependent children under age 19 arenot subject to the orthodontic lifetime maximum.“Medically necessary orthodontic services” aredefined as orthodontic treatment that is directlyrelated to and an integral part of the medical andsurgical correction of a functional impairmentresulting from a congenital defect or anomaly.Written guidelines for determining the medicalnecessity of orthodontics will be maintainedat the Fund Office. Medically necessaryorthodontic services require predetermination ofbenefits. Contact the Fund Office prior to initiatingsuch services.

Eligible dental expense for this provision is expenseincurred as the result of the initial and subsequentinstallation of orthodontic appliances, including allorthodontic treatment rendered by an orthodontistpreceding and subsequent to the installation.

Orthodontic benefits are payable on an itemizedbasis. When the orthodontist submits itemizedstatements during a period of orthodontictreatment, benefits are paid as expenses areincurred and submitted for payment.

Keep in mind that payment for orthodontictreatment cannot exceed the maximum orthodonticbenefit.

Limitations

In addition to the General Exclusions on pages 49through 52, Dental Care Benefits do not cover thefollowing:

(a) services, treatment, or supplies furnished by orat the direction of the United StatesGovernment or any agency thereof, any state,territorial, or commonwealth government orpolitical subdivision thereof, or a foreigngovernment or agency thereof;

(b) services, treatment, or supplies received from adental or medical department maintained by theTrustees, a mutual benefit association, or laborunion;

(c) services, treatment, or supplies which arepayable or furnished under any other coveragewith this Fund or any insurance company, orany other medical benefit plan or service planfor which the Trustees, directly or indirectly,have paid for all or a portion of the cost;

(d) services or treatment rendered or suppliesfurnished primarily for cosmetic purposes;

(e) expenses incurred for services performed orsupplies furnished by other than a dentist,except for prophylaxis which may be performedby a dental hygienist under the direction andsupervision of a dentist;

(f) expenses incurred for treatment oftemporomandibular joint disease (TMJ); or

(g) services, treatment, or supplies rendered orfurnished:

(1) before you or your dependent became aneligible person; or

(2) after termination of your or yourdependent’s eligibility.

43

VISION CARE BENEFITS

Classes A, RA, RAO, and RAMEmployees and Dependents

Benefits are payable up to the aggregate maximumamount per calendar year stated in the Schedule ofBenefits for reasonable expenses related to visionexams, lenses, frames, and contact lenses. Fordependent children under age 19, one vision examper calendar year is payable and will not be subjectto the maximum amount. Services and suppliesmust be furnished by an optician, optometrist, orophthalmologist acting within the usual scope ofsuch practice. The date of service for any supplypayable under Vision Care Benefits is the date thesupply is ordered.

Limitations

In addition to the General Exclusions on pages 49through 52, Vision Care Benefits do not cover thefollowing:

(a) services, treatment, or supplies furnishedby or at the direction of the United StatesGovernment or any agency thereof, any state,territorial, or commonwealth government orpolitical subdivision thereof, or a foreigngovernment or agency thereof;

(b) services, treatment, or supplies received from avision care or medical department maintainedby the Trustees, a mutual benefit association,or labor union;

(c) services, treatment, or supplies which arepayable or furnished under any other coveragewith this Fund or any insurance company, orany other medical benefit plan or service planfor which the Trustees, directly or indirectly,have paid for all or a portion of the cost;

(d) safety lenses or goggles without a prescription;

(e) sunglasses without a prescription;

(f) orthoptics, vision training, vision therapy, oraniseikonia;

(g) expenses incurred for services performed orsupplies furnished by other than an optician,optometrist, or ophthalmologist; or

(h) services, treatment, or supplies rendered orfurnished:

(1) before you or your dependent became aneligible person; or

(2) after termination of your or yourdependent’s eligibility.

44

MEDICARE-PLUS BENEFITS1,2

Class RC Employees and Dependents andClass RD Employees

There are two parts to the Federal MedicareProgram. The first is the basic insurance programgenerally referred to as “Part A.” The second is themedical insurance program generally referred toas “Part B” or “Supplementary Medicare.” TheTrustees require that you and your dependentsenroll in Part B when first eligible to do so.Medicare-Plus Benefits cover you, your spouse,and any of your dependent children who are eligiblefor Medicare.

Under Medicare, there are certain expenses aperson continues to pay for. The Trustees felt thatto provide retired employees with the best coveragepossible, the Health Fund should offer a Medicare-Plus Benefit which pays benefits in addition toMedicare and further reduces costs when injured orsick. In this way, retired employees who areeligible for Medicare are provided with supple-mentary coverage. Only expenses eligible underMedicare Part A and Part B are eligible forcoverage under these Medicare-Plus Benefits,except emergency care obtained outside the UnitedStates as follows.

Expenses eligible under Medicare include, but arenot limited to, hospital expenses, post-hospitalextended care, medical and other health services,home health services, and hospice care.

Emergency Care Obtained Outside theUnited States

When you require emergency medical care whiletraveling in a foreign country, the Plan will providecoverage to the same extent as the services wouldhave been covered had they been rendered in theUnited States and eligible for Medicare benefits.In order for the Medicare deductible and/orcopayments to be payable, the services renderedmust be the type of services covered by Medicareand must be rendered by a hospital or physician asthey are defined in Medicare.

Definitions for Medicare-Plus Benefits

The terms “extended care facility,” “home healthcare agency,” “home health services,” “hospital,”“lifetime reserve,” “prescription,” and “reasonableexpense” have the same meaning in this Medicare-Plus Benefits section as they are defined inMedicare.

1Classes RC and RD only are available to persons who elected such Classes on or before March 20, 2014.

2See pages 37 through 40 for a description of the Preferred Provider Pharmacy Prescription Drug Benefits for eligiblepersons covered under Medicare-Plus Benefits.

45

GENERAL PROVISIONS

Coordination of Benefits(Classes A, RA, RAO, RAM, RB, RBO, andRBM Employees and Dependents andClass RD Dependents)

If you or your eligible dependents are entitled tobenefits under any other group health care plan,the amount of benefits payable by this Plan will becoordinated so that the total amount paid will notexceed 100% of the medical expenses incurred. Inno event will this Plan’s payment exceed theamount which would have been paid if there wereno other plan involved. Benefits payable underanother plan include the benefits that would havebeen payable even if no claim actually was filedwith the other plan.

Definitions for Coordination of BenefitProvisions. The term “other group plan” meansany plan that provides benefits or services for, or byresult of, medical, prescription drugs, dental, orvision care or treatment under:

(a) group insurance;

(b) group practice, Blue Cross/Blue Shield, or otherprepayment coverage provided on a groupbasis;

(c) labor-management trusteed plans, employerorganization plans, or any other arrangementfor individuals of a group; or

(d) governmental employees group programs,including Medicare or coverage required orprovided by law other than no fault insurance.

The term “other group plan” will be construedseparately as to each policy, contract, or otherarrangement for benefits or services based on thefacts and circumstances of each such arrangement.

An individual may have other health plan coveragecontaining a provision commonly known as a “wraparound” provision, “sub-plan” provision, or somesimilar provision whose purpose is to provideprimary coverage only for a small amount ofexpenses, well below the maximum benefitavailable under the plan if no other coverage isavailable (collectively, a “Sub-Plan Provision”).

The effect or intent of a plan with a Sub-PlanProvision is to transfer the much larger secondarycoverage to the other health plan with which suchplan is coordinating benefits. In the event this planis coordinating benefits with a plan containing aSub-Plan Provision, the Sub-Plan Provision will betreated as arbitrary and capricious and a subterfugeand will be ignored, resulting in coordination ofbenefits with the plan, sub-plan, or similar provisionthat would apply if the eligible person did not havecoverage under this Plan.

If the other group plan, which is sponsored,maintained, or contributed to by an eligible person’semployer, contains a provision which: (a) excludesthe eligible person from eligibility under the othergroup plan due to coverage under another plan; or(b) has the effect of either: shifting coverage liabilityto this Plan in a manner designed to avoid anyliability under the other group plan; or avoiding thecustomary operation of this Plan’s COB rules; thisPlan will consider such provision to have no forceor effect. This Plan will coordinate benefits payableunder this Plan with benefits which would havebeen payable under the other group plan if suchprovision had not existed.

Order of Benefit Calculation. If the other groupplan does not contain a coordination of benefits orsimilar provision, then that plan always willcalculate and pay its benefits first. When duplicatecoverage arises and both plans contain acoordination of benefits or similar provision, theeligible person must report such duplicate grouphealth care coverage on the claim form which issubmitted to secure reimbursement of allowableexpenses incurred. This Plan has established thefollowing rules to decide which group plan willcalculate and pay its benefits first.

(a) If a patient is eligible as an employee in oneplan and as a dependent in another, the plancovering the patient as an employee willdetermine its benefits first.

(b) If a patient is eligible as a dependent child intwo plans, the plan covering the patient as thedependent of that parent whose date of birth,excluding year of birth, occurs earlier in acalendar year will determine its benefits first.

46

(c) When parents are divorced or separated, theorder of benefit determination is:

(1) The plan of the parent having custody paysfirst.

(2) If the parent having custody has remarried,the order is:

(i) the plan of the parent having custody;

(ii) the plan of the spouse of the parenthaving custody;

(iii) the plan of the parent not havingcustody; then

(iv) the plan of the spouse of the parent nothaving custody.

Also, if the specific terms of a court decreestate that the parents have joint custody of thechild and do not specify that one parent hasresponsibility for the child’s health careexpenses OR if the court decree states thatboth parents will be responsible for the healthcare needs of the child but gives physicalcustody of the child to one parent (and theentities obligated to pay or provide the benefitsof the respective parent’s plans have actualknowledge of those terms), benefits for thedependent child will be determined according tothe prior subsection (b).

(d) If rules (a), (b), and (c) do not determine whichplan will calculate and pay its benefits first, thenthe plan that has covered the patient for thelonger period of time will determine its benefitsbefore a plan that has covered the patient for ashorter time. There is one exception to thisrule: A plan that covers a person other than asa laid-off person or retiree, or a dependent ofsuch person, will determine its benefits first,even if it has covered the eligible person for theshorter time.

(e) In addition, if a person whose coverage isprovided under a right of continuation pursuantto federal (COBRA) or state law also is coveredunder another plan, the benefits of the planwhich covers the person as an employee will bedetermined before the benefits under thecontinuation coverage.

Benefits of this Plan will be reduced to the extentnecessary to prevent the other group plan fromrefusing to pay benefits available under its policy.

Additionally, if: (a) a Sub-Plan exists; (b) the Sub-Plan is not or cannot be ignored pursuant to thepreviously stated provisions; (c) the Sub-Plan isfound by the Board or a court of competentjurisdiction to apply, then this Plan expressly limitsits secondary coverage available to the eligibleperson to the same dollar amount contained in, orcalculated under, the Sub-Plan Provision.

If an employee and spouse both are coveredemployees under this Plan, benefits payable foreither of them and their dependents will becoordinated the same as they would be with anyother group plan.

See page 27 for coordination of benefits provisionsfor specified drugs covered under ComprehensiveMajor Medical Benefits.

Credits. Whenever this Plan is considered thesecondary plan and a medical claim payment isreduced because of this provision, the amount ofreduction will be carried for the balance of thecalendar year as a credit for the person for whomthe claim was made. This amount may be used forother medical claims due to any cause in the samecalendar year, provided the person has an out-of-pocket allowable expense after the normal benefitsunder both plans have been provided or paid. Aclaim record with credit is maintained only for onecalendar year. Each January 1st, a new recordbegins for each eligible person. This “Credits”provision will not apply if any other group planwhich is primary with respect to this Plan isdetermined by the Board of Trustees to be aSub-Plan.

Exception. This coordination of benefits sectionis not applicable to Class RC employees anddependents and Class RD employees.

The Board and its designees have discretion tointerpret the Plan and determine whether benefitsare payable under the Plan. This discretion willinclude, but not be limited to, discretion to interpretthe language of other plans and also to determinewhether other plans consist of a single plan or

47

multiple plans. The discretion also will include, butnot be limited to, discretion to determine whethera Sub-Plan provision exists. The Board’sdetermination in this regard will be binding and finalfor all purposes, including but not limited to allcoordination of benefit purposes, and only will bereversed if a court of competent jurisdictiondetermines that the Board’s determination isarbitrary and capricious.

Medicare Provisions

Eligible persons who are retired or disabled arerequired to enroll in Part A and Part B of Title XVIIIof the Social Security Amendments of 1965 (morecommonly known and described as “Medicare”) inthe event they become entitled for such coverageby reason of attained age, qualifying disability, orEnd Stage Renal Disease (ESRD). Such personsalso will become eligible for Medicare PrescriptionDrug Benefits. However, such persons are notrequired to enroll in Medicare Prescription DrugBenefits. If such eligible person does not enroll inMedicare Prescription Drug Benefits, he willcontinue eligibility for the Plan’s prescription drugbenefits, provided he is otherwise eligible under thePlan. If such eligible person is continuing coverageunder Class RAO, RAM, RBO, RBM, RC, or RD,and does enroll in Medicare Prescription DrugBenefits, the Plan will provide no prescription drugbenefits for such person.

In no event will benefits paid by the Plan exceedthe applicable amounts stated in the Schedule ofBenefits, nor will the combined amounts payableunder Part A and Part B of Medicare and the Planexceed the eligible expenses incurred by theeligible person as the result of any one injury orsickness. Benefits payable by Part A or Part B ofMedicare include those which would have beenpayable if the eligible person had properly enrolledwhen eligible to do so.

To facilitate Plan payments in the absence ofMedicare payments, it may be necessary for theTrustees to estimate Medicare payments.

Neither you nor the Plan will be responsible forpaying any charges which exceed legal limits set bythe Medicare Physician Payment Reform Act whichlimits the amount that physicians can bill Medicarepatients above the Medicare allowance for aparticular procedure or service, unless services areprivately contracted.

(a) Persons Initially Entitled to Medicare byReason of Attained Age or QualifyingDisability (other than ESRD) and EligibleUnder the Plan Through Self-Payments. Inthe event a person eligible in Class RA, RAM,RB, or RBM solely because of self-paymentsbecomes initially entitled to Part A or Part B ofMedicare due to attained age or a qualifyingdisability (other than ESRD), benefits payableunder this Plan will be reduced by the amountof benefits paid or payable under Part A orPart B of Medicare.

If such person subsequently becomes entitledto Medicare due to ESRD, Medicare willcontinue to be the primary source of coverage.

(b) Persons Initially Entitled to Medicare byReason of Attained Age or QualifyingDisability (other than ESRD) and EligibleUnder the Plan Through EmployerContributions. Plan benefits are not reducedfor persons eligible in Class A through employercontributions even though they also maybecome initially entitled to Part A or Part B ofMedicare due to attained age or a qualifyingdisability (other than ESRD). In the event suchperson subsequently becomes entitled toMedicare due to ESRD, the Plan will continueto be the primary source of coverage for the full30-month coordination period specified in thefollowing subsection.

However, an active employee or dependentspouse eligible under the Plan throughemployer contributions who becomes initiallyentitled to Medicare due to attained age willhave the right to reject the Plan and retainMedicare as their primary source of coverage.In such case, the Plan is legally prohibited fromsupplementing Medicare coverage.

(c) Persons Initially Entitled to Medicare byReason of ESRD and Eligible Under the PlanThrough Either Self-Payments or EmployerContributions. In the event an eligible personbecomes initially entitled to Part A or Part B ofMedicare because of ESRD (or when ESRD-based Medicare entitlement occurs simul-taneously with attained age or other qualifyingdisability-based entitlement), benefits will beprovided subject to the following terms. Thesame terms will apply in the event an eligibleperson becomes initially entitled to Medicare

48

due to ESRD and subsequently becomesentitled to Medicare due to attained age oranother qualifying disability.

(1) The Plan will be the primary source ofcoverage for covered charges incurred forup to 30 consecutive months from the dateof ESRD-based Medicare entitlement.

(2) Benefits payable under the Plan beginningwith the 31st month of ESRD-basedMedicare entitlement will be reduced by theamount of benefits paid or payable underPart A or Part B of Medicare.

(d) Special Provisions for Classes RA, RAO,RAM, RB, RBO, and RBM.

For eligible persons for whom Medicare isthe primary source of coverage: Thebenefits payable under this Plan for servicesincurred at a Veterans Administration (VA)facility for non-service-connected disabilities willbe reduced by the amount that would havebeen payable by Medicare had the servicesbeen rendered by a Medicare-approved facility.

For eligible persons for whom Medicare isthe primary source of coverage: Thebenefits payable under this Plan for servicesotherwise covered by Medicare, but which areprivately contracted with a provider, will belimited to the amount that would have beenpayable by the Plan had the services beenpayable by Medicare.

For eligible persons for whom Medicare isthe primary source of coverage and whohave enrolled in a Medicare Advantage plan:The benefits payable under this Plan forservices otherwise covered by Medicare, butwhich are not covered under the MedicareAdvantage plan because the eligible person didnot obtain services at a network provider and/ordid not comply with that plan’s managed carerequirements, will be limited to the amount thatwould have been payable by the Plan had theservices been payable by Medicare.

(e) Medicaid Provisions

The Plan will not take into account the fact thatany eligible person is eligible for or is providedwith medical assistance by Medicaid for

purposes of determining eligibility for benefitsunder the Plan. In payment of benefits, thePlan will honor any Medicaid assignment ofrights made by or on behalf of an eligibleperson. The Plan will honor any reimbursementor subrogation rights that a state may have byvirtue of payment of Medicaid benefits forexpenses covered by the Plan.

Subrogation/Reimbursement

Whenever the Milwaukee Carpenters’ DistrictCouncil Health Fund has been or is providinghospital, medical, dental, vision, or disabilitybenefits (“Benefits”), as a result of the occurrenceof any injury, sickness, or death which results in apossible recovery of indemnity from any party,including an insurer, including uninsurance andunderinsurance coverage, the Fund may make aclaim or maintain an action against such party.

By virtue of accepting such Benefits resulting froman injury, sickness, or death which results in apossible recovery from any party, including aninsurer, including uninsurance and underinsurancecoverage, the eligible person assigns to the Fundthe right to make a claim against such party to theextent of the amount of such benefits. As acondition of providing Benefits, the Fund mayrequire that the eligible person and his attorneyexecute an agreement that acknowledges theFund’s rights under this provision.

An eligible person must not do anything after theloss for which Benefits were provided to prejudicethe Fund’s right of recovery. An eligible personmust promptly advise the Administrative Managerof this Fund in writing whenever a claim against anyparty is made by or on behalf of the eligible personwith respect to any loss for which Benefits were, orare being, received from the Fund.

The recipient of Benefits has an obligation toprovide the Fund or its designee with the namesand addresses of all potential parties and theirinsurers, adjusters, and claim numbers, as well asaccident reports and any other information theFund requests. If the information requested is notprovided, the Fund in its discretion may withholdfuture benefit obligations pending receipt of therequested information.

The eligible person or the Fund may make a claimagainst a party or commence an action against a

49

party and join the other as provided underSection 803.3 of the Wisconsin Statutes orapplicable state or federal law. Each will have anequal voice in the pursuit of such claim or action.

The proceeds from any settlement or judgment inany claim made against any party will be allocatedas follows:

(a) First, a sum sufficient to fully reimburse theFund for all Benefits advanced will be paid tothe Fund. No court costs nor attorneys’ feesmay be deducted from the Fund’s recoverywithout prior expressed written consent of theFund. This right will not be defeated by any so-called “Fund Doctrine” or “Common FundDoctrine” or “Attorneys’ Fund Doctrine” or anyother similar doctrine or theory.

(b) Any remainder will be paid to the eligible personon whose behalf claim is made.

(c) The Fund will receive a credit, up to the fullamount of any remainder paid to the recipient ofBenefits pursuant to the prior subsection (b), toapply against any future Benefit obligationsarising out of the injury, sickness, or deathwhich was the subject of the claim whichresulted in the settlement or judgment.

The aforesaid allocation of proceeds will be paidfrom the first dollar of any proceeds received andwill have a priority over competing claimsregardless of whether the total amount of therecovery of the eligible person, or those claimingunder him, is less than the actual loss suffered, orless than the amount necessary to make theeligible person, or those claiming under him, whole.The Fund’s rights will not be defeated or reducedby the application of any so-called “Made-WholeDoctrine,” “Garrity Doctrine,” “Rimes Doctrine,” orany doctrine purporting to defeat the Fund’s rightsby allocating the proceeds exclusively, or in part, tonon-medical expense damages.

Furthermore, such allocation will apply to claims ofdependents of employees covered by the Fund,regardless of whether such recipient was legallyresponsible for expenses of treatment.

If an eligible person makes a recovery in a claimfrom any party and the proceeds are not allocatedaccording to the prior paragraphs, the Trustees willhave the right to make a claim for reimbursement,

including but not limited to, claims for restitution,unjust enrichment, or a constructive trust over anyrecovery by the eligible person, to the extent of theFund’s expenditures, whether the recovery is paidto, or in the possession of, the eligible person, theeligible person’s attorney, or any other individual orentity, or to take a credit on future Fund obligationsto the eligible person to the extent of such Benefits.This credit will not be limited to future obligations ofthe Fund to the actual recipient of such Benefits butalso may be taken against any future obligations tothe eligible employee or any of his dependents.

Right of Recoupment

Whenever the Plan has made unauthorizedpayments or overpayments, the Plan has the rightto recover such unauthorized payments oroverpayments from one or more of the followingsources:

(a) any person to whom or on whose behalf suchpayments were made, including by makingdeductions from benefits which may be payableto them or any other eligible person in theirfamily or on their behalf to third parties, in thefuture; or

(b) any service provider, insurance company, orother entity to whom such unauthorizedpayment or overpayment was made.

Physical Examinations

The Trustees, through a physician they maydesignate, have the right and opportunity to havemedically examined any individual whose injury orsickness is the basis for a claim when and as oftenas they reasonably may require during thependency of a claim under the Plan.

General Exclusions

The following General Exclusions apply to allbenefits provided under the Plan. In addition,specific limitations apply to certain benefits. Suchlimitations are stated within each applicable benefitsection. General Exclusions for all Plan benefitsinclude the following. The Plan does not cover:

50

(a) Injury which arises out of or occurs in thecourse of any occupation or employment forwage or profit (except for Death Benefits andAccidental Death and DismembermentBenefits).

(b) Sickness for which the eligible person is entitledto benefits under any Worker's Compensationor Occupational Disease Law. However, ineither the previously-referenced (a) or (b), if:

(1) The eligible person has been deniedWorker’s Compensation or OccupationalDisease Benefits; and

(2) The eligible person and his attorney executean agreement provided by the Fund statingand agreeing to repay and reimburse theFund for all benefits paid by the Fund onbehalf of the eligible person for said injuryout of any recovery proceeds, whether bysettlement or otherwise,

then the Fund will cover such expense, subjectto the terms and conditions of the Plan.

Failure by the eligible person to comply with theAgreement allows the Fund, at its discretion, toeither:

(1) Take credit against future claims of theeligible person up to the amount of theFund’s expenditures of such expense;

(2) Initiate legal proceedings to recover theFund’s expenditures; or

(3) Exercise the Fund’s right to reimbursement,including but not limited to, claims forrestitution, unjust enrichment, or aconstructive trust over any recovery by theeligible person, to the extent of the Fund’sexpenditures, whether the recovery is paidto, or in the possession of, the eligibleperson, the eligible person’s attorney, orany other individual or entity.

(c) Care for armed service-connected disabilitiesfurnished within any facility of, or provided by,the United States Department of VeteransAffairs or Department of Defense.

(d) Care for non-service-connected disabilitiesfurnished within any facility of, or provided by,the United States Department of VeteransAffairs or Department of Defense for whichthere has not been furnished to the Fund Officerequired details and supporting papers.

(e) Expenses which the eligible person would notbe required to pay in the absence of thesebenefits.

(f) Any loss caused by war or any act of war(declared or undeclared).

(g) Loss incurred while engaged in military service(including naval or air service) for any country.

(h) Artificial life support systems, including, with-out limitation, cardiopulmonary resuscitationsystems, for any eligible person after suchperson has been determined to be dead with-in the meaning of Section 146.71, WisconsinStatutes (1989-90), or determined to beclinically dead, except as provided in “CoveredExpenses" on page 28 with respect to which thePlan's liability is limited to the first five daysafter death has been so determined, not toexceed $5,000.

(i) The cost of removal of organs from a transplantdonor who is a living eligible person or who wasan eligible person prior to his death, unless thetransplant recipient is an eligible person.

(j) Care for conditions suffered while engaged inthe commission of a felony or while attemptingto commit a felony, or while engaged in a riot,other than when engaged in, as part of, or inconnection with, a labor dispute.

(k) Any expenses, wage loss, or benefits under thePlan (except Death and Accidental Death andDismemberment Benefits) that are payable (orrequired under law to be payable) under anautomobile insurance policy issued inconformity with “no-fault” insurance laws orotherwise covered under no-fault laws.

(l) Expenses incurred by an eligible person forabortions, or reversal of sterilizations, except:

51

(1) when such procedures are determined to bemedically necessary by a physician in thetreatment of an injury or sickness; or

(2) in the case of an abortion, when thepregnancy is caused by rape or incest.

(m)Services, supplies, or equipment that are notmedically necessary.

(n) Cosmetic treatment, surgery, and any relatedservices intended solely for cosmetic purposesor to improve appearance, but not intended torestore normal bodily function or correctdeformity resulting from disease, trauma, or aprevious therapeutic process that is eligible forPlan benefits. This exclusion does not apply tobreast reconstruction of the affected tissuefollowing mastectomy, as described onpage 26, or to repair of congenital mal-formations. Examples of treatment, surgery,and related services subject to this exclusioninclude, but are not limited to, the following:

(1) cosmetic reconstruction of the nose;

(2) electrolysis;

(3) keloids;

(4) removal of wrinkles or excess skin;

(5) revision of previous elective procedures;

(6) treatment of male pattern baldness; and

(7) wigs.

(o) Medical supplies and durable medicalequipment used primarily for an eligibleperson’s comfort, personal hygiene, orconvenience including, but not limited to: airconditioners; air cleaners; humidifiers;dehumidifiers; purifiers; allergy-free pillows,blankets, or mattress covers; physical fitnessequipment; physician’s equipment; elevators orstair lifts; disposable supplies other thancolostomy supplies, including but not limited to,urinary catheters, lubricants, and wipes; self-help devices not medical in nature; and allsimilar equipment.

(p) All liquid nutrition used for tube feedings andother nutritional and electrolyte supplementsor formula whether or not prescribed by aphysician.

(q) Food received on an outpatient basis, foodsupplements, and vitamins.

(r) Any treatment, care, surgical procedures,services or supplies, including prescriptionmedications that are experimental or inves-tigative in nature or not generally accepted bythe medical community as standard therapy atthe time service is rendered for the indicateddiagnosis.

(s) Services, supplies, or equipment for:

(1) invitro-fertilization, artificial insemination,and all other insemination or fertilizationservices intended to induce ovulation and/orpromote spermatogenesis and/or to achieveconception;

(2) transsexual surgery or any treatmentleading to or connected with transsexualsurgery; or

(3) treatment of sexual dysfunction which is notrelated to organic disease.

(t) Therapy services such as recreational oreducational therapy or physical fitness orexercise programs.

(u) The following charges:

(1) telephone consultation charges;

(2) charges for failure to keep a scheduled visit;

(3) charges for completion of a claim form orreturn to school/work form;

(4) additional charges beyond the charges forbasic and primary services requested afternormal provider service hours or onholidays;

52

(5) charges which are not documented inprovider records; or

(6) interest charges, federal, state or local tax,and shipping and handling charges.

(v) Any services, supplies, or equipment which arerequired to be provided by a public schooldistrict or state or local educational agencypursuant to the requirements of the federalIndividuals with Disabilities Education Act,20 U.S.C. § 1401 et. seq., as amended, or anystate or local law(s) and regulation(s) whichimplement such Act. This exclusion applieswhether or not the service actually is providedby the public school district or educationalagency.

(w) Refractive eye surgery.

(x) Orthoptics, vision training, vision therapy, oraniseikonia.

(y) Charges in excess of the usual and customaryallowance or, if a PPO provider, the provider’snegotiated fee.

(z) Personal convenience items while hospital-confined.

(aa)Alternate therapies except as specificallyprovided.

(bb)Services or charges not covered by the Planwhether or not prescribed by a health careprovider.

(cc)Services which are not provided.

(dd)Expenses incurred while not an eligible person.

Amendment and Termination of Plan

The Trustees will have the power and authority toamend or terminate the Plan to increase, decrease,or change benefits, or change Eligibility Rules orother provisions of the Plan of Benefits, includingretiree benefits, as may in their discretion be properor necessary for the sound and efficientadministration of the Trust Fund, provided that suchchanges are not inconsistent with law or with theprovisions of the Trust Agreement.

Any amendment made by the Trustees will bereduced to writing and may be effectiveprospectively or retrospectively, provided, however,no amendment to the Plan will retroactively reducebenefit entitlement or benefit levels for claimsincurred under the Plan then in effect. Allamendments are subject to the limitation of theTrust Agreement and the applicable law andadministrative regulations. Written notice ofamendment to, or termination of the Plan will beprovided to participants within the time requiredby law.

This Plan also may be terminated:

(a) in its entirety--by Trustee action and when theTrustees determine that the Trust Fund isinadequate to carry out the intent and purposeof the Trust Agreement or is inadequate to meetthe payments due or to become due partici-pants and/or dependents under the TrustAgreement or under the Plan Document;

(b) as to participants (and their dependents) in aparticular collective bargaining unit--byagreement of the union and employerassociation (or individual employers, whereapplicable) which negotiate the labor agree-ments covering such collective bargaining units;or

(c) for a particular employer and his non-bargainingunit persons--the Trustees determine that anemployer, signatory to a participation agree-ment to cover non-bargaining unit persons, nolonger meets the requirements of suchparticipation agreement and related policies.

In the event of termination, the Trustees will:

(a) make provision out of the Trust Fund for thepayment of expenses incurred up to the date oftermination of the Trust and the expensesincidental to such termination;

(b) arrange for a final audit and report of theirtransactions and accounts, for the purpose oftermination of their Trusteeship;

(c) apply the Trust Fund to pay any and allobligations of the Trust and distribute and applyany remaining surplus in such manner as will, in

53

their opinion, best effectuate the purposes ofthe Trust and the requirements of law; and

(d) give any notices and prepare and file anyreports which may be required by law.

Prohibition Against Assignment toProviders

You, as an eligible person, participant, orbeneficiary, may not assign any right under thePlan or statutory right under applicable law to aprovider of services or supplies. The prohibitionagainst assignment of such rights includes, but isnot limited to, the right to:

(a) receive benefits;

(b) claim benefits in accordance with Planprocedures and/or federal law;

(c) commence legal action against the Plan,Trustees, Fund, its agents, or employees;

(d) request Plan documents or other instrumentsunder which the Plan is established oroperated;

(e) request any other information that a participantor beneficiary as defined in Section 102 ofERISA may be entitled to receive upon writtenrequest to a Plan administrator; and

(f) any and all other rights afforded an eligibleperson, participant, or beneficiary under thePlan, Restated Trust Agreement, federal law,and state law.

This provision does not have the effect of prohib-iting the claims administrator or the Trustees frommailing payment of benefits under the Plan directlyto a provider of services or supplies.

Genetic Information Nondiscrimination Act

Notwithstanding anything in the Plan to thecontrary, the Plan will comply with the GeneticInformation Nondiscrimination Act.

HIPAA Security Regulations

The Plan has implemented administrative, physical,and technical safeguards that reasonably andappropriately protect the confidentiality, integrity,and availability of protected health information inelectronic form that it creates, receives, maintains,or transmits on behalf of the Plan. The Trusteeswill report to the Plan any security incident ofwhich they become aware. The Plan’s agreementswith its business associates will require that theelectronic protected health information be main-tained. Any disclosures of electronic protectedhealth information to the Trustees are supported byreasonable and appropriate security measures.

Discretionary Authority

The Trustees and other Plan fiduciaries andindividuals to whom responsibility for theadministration of the Plan has been delegated,have the full discretionary authority available underapplicable law to construe the Trust Agreement, theregulations, the Plan, the Plan documents and theprocedures of this Fund, to interpret any factsrelevant to such construction. This authorityextends to every aspect of their administration ofthe Plan including benefit determinations, eligibilitydeterminations, and entitlement to Plan benefits.Any interpretation or determination made under thisdiscretionary authority will give full force and effectand will be accorded judicial deference, unlessit can be shown that the interpretation ordetermination was arbitrary and capricious, Inaddition, any interpretation or determination madepursuant to this discretionary authority is binding onall involved parties hereto, including but not limitedto, eligible persons and their beneficiaries. Benefitsunder the Plan are payable only if the Trusteesdecide in their discretion that the applicant isentitled to the benefit.

54

Applicable Governing Law

All questions pertaining to the validity andconstruction of the Trust Agreement, the Plan, andthe acts and transactions of the Trustees or of anymatter affecting the Plan will be determined underfederal law where applicable federal law exists,including the Employee Retirement IncomeSecurity Act of 1974, as amended.

Release of Responsibility for TaxConsequences

Payment of benefits by the Plan to you or yourrepresentative, or to the service provider, releasesand discharges the Plan from any liability for the taxconsequences of such payment.

55

PRIVACY POLICY

Summary of Privacy Practices

The Health Insurance Portability and AccountabilityAct of 1996 (HIPAA) and Health InformationTechnology for Economic and Clinical Health Act(“HITECH”) and their Privacy Rules grant certainrights to participants and beneficiaries of theMilwaukee Carpenters’ District Council Health Fund(the Plan) in relation to their protected healthinformation (called “medical information”).

The Plan may use and disclose your medicalinformation without your permission for treatment,payment, and health care operations activities and,when required or authorized by law, for publichealth activities, law enforcement, judicial andadministrative proceedings, research, and certainother public benefit functions.

The Plan may disclose your medical information toyour family members, friends, and others involvedin your health care or payment for health care, andto appropriate public and private agencies indisaster relief situations.

The Plan may disclose to the sponsor of the Plan,the Board of Trustees of the Milwaukee Carpenters’District Council Health Fund (the “Board ofTrustees”) whether you are enrolled or disenrolledin the Plan, summary health information for certainlimited purposes, and your medical information forthe Board of Trustees to administer the Plan if theBoard of Trustees explains the limitations on its useand disclosure of your medical information in thePlan Document.

Except for certain legally-approved uses anddisclosures, the Plan otherwise will not use ordisclose your medical information without yourwritten authorization.

You have the right to examine and receive a copyof your medical information, to receive anaccounting of certain disclosures the Plan maymake of your medical information, and to requestthat the Plan amend, further restrict use anddisclosure of, or communicate in confidence withyou about your medical information.

You have the right to receive notice of breaches ofyour unsecured medical information in accordancewith HITECH.

IMPORTANT NOTE: The Plan reserves the rightto provide your medical information to anyperson identified by you (such as a businessagent), or whom the Plan in good faith believeswas identified by you, or to a family member,other relative, or close personal friend. Forexample, the Plan may disclose your medicalinformation to your spouse if the spousecontacts the Plan to help resolve a paymentissue on your behalf. The Plan only will providemedical information in such a situation if it isdirectly relevant to such person's involvementwith your care or payment related to your healthcare. If you object to such disclosures, pleaseexpress your written objection to the contactlisted on page 59.

The Plan’s Legal Duties

The Plan is required by applicable federal and statelaw to maintain the privacy of your medicalinformation. The Plan also is required to give youthis notice about its privacy practices, its legalduties, and your rights concerning your medicalinformation.

The Plan reserves the right to change its privacypractices and the terms of its Privacy PracticesNotice at any time, provided such changes arepermitted by applicable law. The Plan reserves theright to make any change in its privacy practices

and the new terms of its notice applicable to allmedical information that the Plan maintains,including medical information the Plan created orreceived before the Plan made the change. Beforethe Plan makes a significant change in its privacypractices, the Plan will send a new notice to itsthen-current participants as required by law.

You may request a copy of the Plan’s PrivacyPractices Notice at any time from the contact listedon page 59.

56

Uses and Disclosures of Your Medical Information

Treatment: The Plan may disclose your medicalinformation, without your permission, to a physicianor other health care provider to treat you.

Payment: The Plan may use and disclose yourmedical information, without your permission, topay claims from physicians, hospitals, and otherhealth care providers for services delivered to youthat are covered by the Plan, to determine youreligibility for benefits, to coordinate your benefitswith other payers, to determine the medicalnecessity of care delivered to you, to obtainpremiums for your health coverage, to issueexplanations of benefits to the participant of thePlan in which you participate and the like. The Planmay disclose your medical information to a healthcare provider or another health plan for thatprovider or plan to obtain payment or engage inother payment activities.

Health Care Operations: The Plan may use anddisclose your medical information, without yourpermission, for health care operations. Health careoperations include:

· health care quality assessment andimprovement activities;

· reviewing and evaluating health care providerand health plan performance, qualifications andcompetence, health care training programs,health care provider and health planaccreditation, certification, licensing, andcredentialing activities;

· conducting or arranging for medical reviews,audits, and legal services, including fraud andabuse detection and prevention;

· rating the risk and determining the necessaryfunding levels for the Plan, and obtaining stop-loss and similar reinsurance for the Plan’shealth coverage obligations; and

· business planning, development, management,and general administration, including customerservice, grievance resolution, claims paymentand health coverage improvement activities,de-identifying medical information, and creatinglimited data sets for health care operations,public health activities, and research.

The Plan may disclose your medical information toanother health plan or to a health care providersubject to federal privacy protection laws, as longas the plan or provider has or had a relationship

with you and the medical information is for thatplan’s or provider’s health care quality assessmentand improvement activities, competence andqualification evaluation and review activities, orfraud and abuse detection and prevention.

Your Authorization: You may give the Planwritten authorization to use your medicalinformation or to disclose it to anyone for anypurpose. If you give the Plan an authorization, youmay revoke it in writing at any time. Yourrevocation will not affect any use or disclosurepermitted by your authorization while it was ineffect. Unless you give the Plan a writtenauthorization, the Plan will not use or disclose yourmedical information for any purpose other thanthose described in the Plan’s Privacy PracticesNotice. The Plan generally may use or discloseany psychotherapy notes it holds only with yourauthorization.

Family, Friends, and Others Involved in YourCare or Payment for Care: The Plan maydisclose your medical information to a familymember, friend, or any other person you involve inyour health care or payment for your health care.The Plan will disclose only the medical informationthat is relevant to the person’s involvement.

The Plan may use or disclose your name, location,and general condition to notify, or to assist anappropriate public or private agency to locate andnotify, a person responsible for your care inappropriate situations, such as a medicalemergency or during disaster relief efforts.

The Plan will provide you with an opportunity toobject to these disclosures, unless you are notpresent or are incapacitated or it is an emergencyor disaster relief situation. In those situations, thePlan will use its professional judgment to determinewhether disclosing medical information related toyour care or payment is in your best interest underthe circumstances.

Your medical information remains protected by thePlan for at least 50 years after you die. After youdie, the Plan may disclose to a family member, orother person involved in your health care prior toyour death, the medical information that is relevantto that person’s involvement, unless doing so is

57

inconsistent with your preference and you have toldthe Plan so.

Disclosures to the Board of Trustees: The Planmay disclose to the Board of Trustees whether youare enrolled or disenrolled in the Plan.

The Plan may disclose summary health informationto the Board of Trustees to obtain premium bids forthe health insurance coverage offered under thePlan or to decide whether to modify, amend, orterminate the Plan. Summary health information isaggregated claims history, claims expenses, ortypes of claims experienced by the enrollees in thePlan. Although summary health information will bestripped of all direct identifiers of these enrollees, itstill may be possible to identify medical informationcontained in the summary health information asyours. The Plan is expressly prohibited from usingor disclosing any health information containing yourgenetic information for underwriting purposes.

The Plan may disclose your medical informationand the medical information of others enrolled inthe Plan to the Board of Trustees to administer thePlan. Before the Plan may do that, the Board ofTrustees must amend the Plan Document toestablish the limited uses and disclosures theBoard of Trustees may make of your medicalinformation. Please see the Plan Document for afull explanation of those limitations.

Health-Related Products and Services: ThePlan may use your medical information tocommunicate with you about health-relatedproducts, benefits, and services, and payment forthose products, benefits, and services that the Planprovides or includes, and about treatment

alternatives that may be of interest to you. Thesecommunications may include information about thehealth care providers in the Plan’s network, if any,about replacement of or enhancements to the Plan,and about health-related products or services thatare available only to the Plan’s enrollees that addvalue to, although they are not part of, the Plan.

Public Health and Benefit Activities: The Planmay use and disclose your medical information,without your permission, when required by law, andwhen authorized by law for the following kinds ofpublic health and public benefit activities:

· for public health, including to report disease andvital statistics, child abuse, and adult abuse,neglect, or domestic violence;

· to avert a serious and imminent threat to healthor safety;

· for health care oversight, such as activities ofstate insurance commissioners, licensing andpeer review authorities, and fraud preventionagencies;

· for research;· in response to court and administrative orders

and other lawful process;· to law enforcement officials with regard to crime

victims and criminal activities;· to coroners, medical examiners, funeral

directors, and organ procurementorganizations;

· to the military, to federal officials for lawfulintelligence, counterintelligence, and nationalsecurity activities, and to correctionalinstitutions and law enforcement regardingpersons in lawful custody; and

· as authorized by state Worker’s Compensationlaws.

Individual Rights

Access: You have the right to examine and toreceive a copy of your medical information, withlimited exceptions. You must make a writtenrequest to obtain access to your medicalinformation. You should submit your request to thecontact on page 59. You may obtain a form fromthat contact to make your request. If theinformation you request is in an electronic healthrecord, you may request that these records betransmitted electronically to you or a designatedindividual.

The Plan may charge you reasonable, cost-basedfees (including labor costs) for a copy of yourmedical information, for mailing the copy to you,and for preparing any summary or explanation ofyour medical information you request. Contact thePlan using the information on page 59 forinformation about these fees.

Your medical information may be maintainedelectronically. If so, you can request an electroniccopy of your medical information. If you do, the

58

Plan will provide you with your medical informationin the electronic form and format you requested, if itis readily producible in such form and format. Ifnot, the Plan will produce it in a readable electronicform and format as the Plan and you mutuallyagree upon.

You may request that the Plan transmit yourmedical information directly to another person youdesignate. If so, the Plan will provide the copy tothe designated person. Your request must be inwriting, signed by you, and must clearly identify thedesignated person and where the Plan should sendthe copy of your medical information.

Disclosure Accounting: You have the right to alist of instances from the prior six years in which thePlan disclosed your medical information forpurposes other than treatment, payment, healthcare operations, as authorized by you, and forcertain other activities.

You should submit your request to the contact onpage 59. The Plan will provide you with informationabout each accountable disclosure that the Planmade during the period for which you request theaccounting, except the Plan is not obligated toaccount for a disclosure that occurred more thansix years before the date of your request and neverfor a disclosure that occurred before the Plan’seffective date (if the Plan was created less than sixyears ago).

Amendment: You have the right to request thatthe Plan amend your medical information. Youshould submit your request in writing to the contacton page 59.

The Plan may deny your request only for certainreasons. If the Plan denies your request, the Planwill provide you a written explanation. If the Planaccepts your request, the Plan will make youramendment part of your medical information anduse reasonable efforts to inform others of theamendment who the Plan knows may have reliedon the unamended information to your detriment,as well as persons you want to receive theamendment.

Restriction: You have the right to request that thePlan restrict its use or disclosure of your medicalinformation for treatment, payment, or health careoperations, or with family, friends, or others youidentify. The Plan is not required to agree to your

request, except for certain required restrictionsdescribed as follows. If the Plan does agree, thePlan will abide by the agreement, except in amedical emergency or as required or authorized bylaw. You should submit your request to the contacton page 59. Any agreement the Plan may make toa request for restriction must be in writing signed bya person authorized to bind the Plan to suchan agreement. The Plan will agree to (and notterminate) a restriction request if:

· the disclosure is to a health plan for purposes ofcarrying out payment or health care operationsand is not otherwise required by law; and

· the medical information pertains solely to ahealth care item or service for which theindividual, or person other than the Plan onbehalf of the individual, has paid the coveredentity in full.

Confidential Communication: You have the rightto request that the Plan communicate with youabout your medical information in confidence bymeans or to locations that you specify. You mustmake your request in writing, and your requestmust represent that the information could endangeryou if it is not communicated in confidence as yourequest. You should submit your request to thecontact on page 59.

The Plan will accommodate your request if it isreasonable, specifies the means or location forcommunicating with you, and continues to permitthe Plan to collect contributions and pay claims.Please note that an explanation of benefits andother information that the Plan issues to theparticipant about health care that you received forwhich you did not request confidential commu-nications, or about health care received by theparticipant or by others covered by the Plan, maycontain sufficient information to reveal that youobtained health care for which the Plan paid, eventhough you requested that the Plan communicatewith you about that health care in confidence.

Breach Notification: You have the right to receivenotice of a breach of your unsecured medicalinformation. Notification may be delayed or notprovided if so required by a law enforcementofficial. You may request that notice be providedby electronic mail. If you are deceased and there isa breach of your medical information, the notice willbe provided to your next of kin or personal

59

representatives if the Plan knows the identity andaddress of such individual(s).

Electronic Notice: If you receive a PrivacyPractices Notice on the Plan’s website or byelectronic mail (e-mail), you are entitled to receivethis notice in written form. Please contact the Planusing the information on this page to obtain thisnotice in written form.

State Law: As a condition of Plan participation, theBoard of Trustees requires that the privacy rights ofyou, your spouse, and dependents be governedonly by HIPAA and the laws of the state ofWisconsin (but only to the extent such laws are notpreempted by the Employee Retirement IncomeSecurity Act of 1974, as applicable), without regardto whether HIPAA incorporates privacy rightsgranted under the laws of other states and withoutregard to Wisconsin’s choice of law provisions.

Questions and Complaints

For information about the Plan’s privacy practices,to discuss questions or concerns, or to getadditional copies of this notice, please contact thePlan using the information at the end of thissection.

If you are concerned that the Plan may haveviolated your privacy rights, or you disagree with adecision the Plan made about access to yourmedical information, about amending your medicalinformation, about restricting the Plan’s use ordisclosure of your medical information, or abouthow the Plan communicates with you about yourmedical information (including a breach noticecommunication), you may complain to the Planusing the contact information at the end of thissection.

Contact Person: Privacy Official

Telephone: (262) 970-5790, local1-800-448-8208, toll-free inWisconsin

Fax: (262) 970-5798

Address: Milwaukee Carpenters’District Council Health FundN25 W23055 Paul RoadSuite 2Pewaukee, WI 53072-0670

You also may submit a written complaint to theOffice for Civil Rights of the United StatesDepartment of Health and Human Services,200 Independence Avenue, SW, Room 509F,HHH Building, Washington, D.C. 20201. You maycontact the Office of Civil Rights’ Hotline at1-800-368-1019.

The Plan supports your right to the privacy of yourmedical information. The Plan will not retaliate inany way if you choose to file a complaint with thePlan or with the U.S. Department of Health andHuman Services.

60

GENERAL DEFINITIONS

Wherever used in this Summary Plan Description,the following terms are understood to have themeanings described as follows.

Alumni means persons who once participated inthe Plan because of work performed under acollective bargaining agreement requiringcontributions to this Fund and who currentlyperform work which is not covered by suchagreement for:

(a) one or more employers that are parties to thecollective bargaining agreement requiringcontributions to the Fund;

(b) the Plan; or

(c) the Union.

Bargaining Unit Employee means any employeerepresented by the Union and working for anemployer (as defined in the Trust Agreement) whois required to make contributions to the Trust Fund.

Calendar Year means that period commencing at12:01 a.m. standard time on the date the eligibleperson first becomes eligible and continuing until12:01 a.m. standard time on the next followingJanuary 1st. Each subsequent calendar year willbe the period from 12:01 a.m. standard time onJanuary 1st to 12:01 a.m. standard time on the nextfollowing January 1st. The time will be that time atthe address of the Trustees.

Classes of Eligible Persons means Class A, RA,RAO, RAM, RB, RBO, RBM, RC, RD, and COBRAas follows:

Class A:

Eligible active employees and their eligibledependents.

The term “employees” will include bargaining unitemployees and, provided the employer is party toan approved participation agreement, the term alsowill include certain non-bargaining unit employeesor alumni.

Class RA:

Eligible retired employees and their eligibledependents who are not eligible for Medicare andwho are making the appropriate self-payments toobtain coverage for Death Benefits,Comprehensive Major Medical Benefits, VisionCare Benefits, and Dental Care Benefits.

Class RAO:

Class RA and Class RAM eligible retiredemployees and their eligible dependents wheneither the retired employee or dependent spouse iseligible for Medicare.

Class RAM:

Eligible retired employees who are enrolled inPart A and Part B of Medicare and their eligibledependents who are making the appropriate self-payments to obtain coverage for Death Benefits,Comprehensive Major Medical Benefits, VisionCare Benefits, and Dental Care Benefits.

If a Medicare-eligible person enrolls in MedicarePrescription Drug Benefits, he will becomeineligible for the Plan’s prescription drug benefits.If such person does not enroll in MedicarePrescription Drug benefits, he will continueeligibility for the Plan’s prescription drug benefits,provided he is otherwise eligible under the Plan.

Class RB:

Eligible retired employees and their eligibledependents who are not eligible for Medicare andare making the appropriate self-payments to obtaincoverage for Death Benefits and ComprehensiveMajor Medical Benefits.

Class RBO:

Class RB and Class RBM eligible retiredemployees and their eligible dependents wheneither the retired employee or dependent spouse iseligible for Medicare.

61

Class RBM:

Eligible retired employees who are enrolled inPart A and Part B of Medicare and their eligibledependents who are making the appropriate self-payments to obtain coverage for Death Benefitsand Comprehensive Major Medical Benefits.


Class RC (Only available for those who electedthis Class on or before March 20, 2014):

Eligible retired employees who are enrolled inPart A and Part B of Medicare and their eligibledependents who are enrolled in Part A and Part Bof Medicare who are making the appropriate self-payments to obtain coverage for Medicare-PlusBenefits.


Class RD (Only available for those who electedthis Class on or before March 20, 2014):

Eligible retired employees who are enrolled inPart A and Part B of Medicare (covered underClass RC), and their eligible dependents who arenot eligible for Medicare (covered under Class RB),who are making the appropriate self-payments.


COBRA Class:

Eligible former employees who are making theappropriate self-payments to continueComprehensive Major Medical Benefits, orComprehensive Major Medical Benefits, VisionCare Benefits, and Dental Care Benefits under theConsolidated Omnibus Budget Reconciliation Act of1985 (COBRA), as amended in all respects.

Dental Hygienist means any person who iscurrently licensed (if licensing is required in thestate) to practice dental hygiene by thegovernmental authority having jurisdiction over thelicensure and practice of dental hygiene, and whoworks under the supervision of a dentist.

Dentist means any person who is currentlylicensed to practice dentistry by the governmentalauthority having jurisdiction over the licensure andpractice of dentistry.

Dependent means the eligible employee's:(a) spouse of the opposite sex, pursuant to thelegal marriage of one man and one woman ashusband and wife; and (b) child or children underage 26.

The term “child” or “children” means:

(a) Children legally adopted by an eligibleemployee and children placed for adoption withan eligible employee for the purpose of legaladoption who meet the specified agerestrictions previously stated. Placement foradoption means the assumption and retentionby an eligible employee of a legal obligation fortotal or partial support of a child in anticipationof the legal adoption of such child by the eligibleemployee. Placement for adoption willterminate upon the termination of such legalobligation.

(b) Stepchildren who are children of the eligibleemployee's spouse on the date of marriage tothe eligible employee and who meet thespecified age restrictions.

62

(c) Children under the legal guardianship of aneligible employee who meet the specified agerestrictions previously stated and who areyounger than the eligible employee, providedthe child is living with the eligible employee forthe entire calendar year, receives more thanhalf of his or her annual support from theemployee, and provided a certified copy of theguardianship court order is filed with theTrustees and that the employee subsequentlyfurnishes tax filings demonstrating the supportand residency requirements were satisfied.

(d) Children, regardless of age, who are incapableof self-sustaining employment by reason ofmental retardation or physical handicap andsuch incapacity began prior to age 26. Afterage 26, such child must be unmarried andprimarily financially dependent upon the eligibleemployee. Due proof of the incapacity must besubmitted to the Trustees within 31 days of thedate the dependent child's coverage otherwisewould terminate due to attainment of age 26 or,in the case of a newly eligible employee, within31 days after the employee first becomeseligible under the Plan. “Due proof” includes,but will not be limited to, proof of a SocialSecurity disability award.

(e) A child who is named as an alternate payee in aQualified Medical Child Support Order orNational Medical Support Notice with which youand the Fund are obligated to comply and whois younger than the eligible employee.

Durable Medical Equipment (DME) meansequipment that is medically necessary and able towithstand repeated use. It also must be primarilyand customarily used to serve a medical purpose,appropriate for use in the home, and not generallybe useful to a person except for the treatment of aninjury or sickness.

Eligible Employee means any employee or formeremployee of an employer, who is eligible forbenefits in accordance with the Eligibility Rules ofthe Fund.

Eligible Person means either the eligibleemployee or the eligible dependent.

Enrollment Date means the eligible person'seffective date of coverage, or if a waiting period is

applicable, the first day of the waiting period.Please note that the period of covered employmentfor which contributions are payable and which leadsto the attainment of initial eligibility or reinstatementof eligibility is considered a waiting period.

Experimental/Investigative means any treatment,service, procedure, facility, equipment, drug,device, or supply that is investigative and limited toresearch rather than applied to accepted, generalclinical practice. Experimental also means anytechnique that is restricted to use at those centerswhich are capable of carrying out disciplined clinicalefforts and scientific studies. Any procedure thathas a lack of objective evidence which suggeststherapeutic benefit and proven value, or whoseefficacy is medically questionable also isconsidered experimental.

A treatment, service, procedure, facility, equipment,drug, device, or supply also will be consideredexperimental/investigative if any of the following aretrue:

(a) It has failed to obtain final approval by a UnitedStates governmental agency at the time theexpense is incurred;

(b) Reliable evidence does not establish aconsensus conclusion among experts recog-nizing the safety and effectiveness of thetreatment, service, procedure, facility,equipment, drug, device, or supply for aspecific diagnosis;

(c) Reliable evidence shows that the treatment,service, procedure, equipment, drug, device, orsupply is the subject of on-going phase I, II, orIII clinical trial or is otherwise under study todetermine its maximum tolerated dose, itstoxicity, its safety, or its efficacy as comparedwith a standard means of treatment ordiagnosis; or

(d) Reliable evidence shows that the prevailingopinion among experts regarding the treatment,service, procedure, facility, equipment, drug,device, or supply is that further studies orclinical trials are necessary to determine itsmaximum tolerated dose, its toxicity, its safety,or its efficacy as compared with a standardmeans of treatment or diagnosis.

63

Reliable evidence includes anything determined tobe such by the Trustees and may include publishedreports and articles in the authoritative medical andscientific literature, the written protocol or protocolsused by the treating facility or the protocol(s) ofanother facility studying substantially the sametreatment, service, procedure, facility, equipment,drug, device, or supply.

The Trustees will have authority to determine, intheir discretion, based on reliable evidence whethera treatment, service, procedure, facility, equipment,drug, device, or supply is experimental/investigative. The fact that a physician hasprescribed, ordered, recommended, or approvedthe treatment, service, procedure, facility,equipment, drug, device, or supply does not, initself, make it eligible for payment.

Fiscal Year means the 12 months beginning anyJune 1st and ending the following May 31st.

Home Health Care Agency means a public orprivate organization which is primarily engaged inproviding skilled nursing and therapeutic services(but not custodial care) on an at-home basis. Ahome health agency must be supervised byprofessional medical personnel and be licensed orapproved by the state or locality in which itoperates.

Hospice Program means a program which hasreceived a certificate of need from the state orlocality in which it operates to initiate hospice carein a given area; is eligible to satisfy accreditationrequirements as developed by Medicare and/or theJoint Commission on the Accreditation of HealthCare Organizations; and meets the followingcriteria:

(a) The patient and family are seen as the unit ofcare;

(b) An integrated, centralized administrativestructure ensures continuity for home care andinpatient care;

(c) There is direct provision of care by aninterdisciplinary team consisting of physicians,nurses, social workers, chaplains, andvolunteers;

(d) Volunteers are used to assist paid staffmembers; and

(e) 24-hour-per-day, 7-day-per-week service isavailable.

Hospital means an establishment which meets allof the following requirements:

(a) holds a license as a hospital (if licensing isrequired in the state);

(b) operates primarily for the reception, care, andtreatment of sick or injured persons asinpatients;

(c) provides 24-hour-per-day nursing service byregistered nurses;

(d) has a staff of one or more licensed physiciansavailable at all times;

(e) provides organized facilities for diagnostic andmajor surgical procedures; and

(f) is not primarily a clinic, nursing, rest, orconvalescent home or similar establishment.

However, "hospital" also will include an estab-lishment or institution specializing in the care,treatment, and rehabilitation of alcoholics orsubstance addicts provided such establishment islicensed by the appropriate governmental authority,if licensing is required.

Injury means accidental bodily damage whichrequires treatment by a physician and which resultsin loss independently of sickness and other causes.

Intensive Care Unit means a special area of ahospital exclusively reserved for critically ill patientsrequiring constant observation which, in its normalcourse of operation, provides:

(a) personal care by specialized registered nursesand other nursing care on a 24-hour-per-daybasis;

(b) special equipment and supplies which areavailable immediately on a standby basis; and

(c) care required but not rendered in the generalsurgical or medical nursing units of the hospital.

The term "intensive care unit" also includes an areaof the hospital designated and operated exclusively

64

as a coronary care unit, cardiac care unit, orneonatal intensive care unit.

Lifetime, with reference to benefit maximums andlimitations, means aggregate covered expensesincurred while an eligible person is covered underthe Plan. Under no circumstances will "lifetime"mean during the life of an eligible person, evenafter the person's eligibility ends.

Light-Duty Work, for an employee who has beendisabled as the result of an injury or sickness that isnot work-related, means:

(a) the employee has been released for work on alimited or restricted basis by the treatingphysician; and

(b) the available work is within the limitations of thetreating physician's release.

“Light-duty work” in regard to the disability hourscredit while receiving temporary partial disabilityweekly Worker’s Compensation Benefits refers toan injury or sickness that is work-related andsatisfies the prior subsections (a) and (b).

The employee may not continue at light-duty formore than six months from the initial return to workon a light-duty basis unless the Trustees agree to atime extension.

Medically Necessary means:

(a) a service or supply which is appropriate andconsistent with the diagnosis of an injury orsickness in accordance with acceptedstandards of community practice;

(b) is not experimental;

(c) could not have been omitted without adverselyaffecting the eligible person’s condition or thequality of medical care;

(d) is provided by or under the direction of aphysician or other duly licensed health carepractitioner who is authorized to provide orprescribe it;

(e) is not provided solely for the convenience of theeligible person, physician, hospital, health careprovider, or health care facility;

(f) is a safe and effective supply or level of servicegiven the patient’s circumstances and condition;and

(g) is safe and effective for the injury or sicknessfor which it is used.

A medical service or supply will not be deemed tobe “medically necessary” solely because aphysician orders or approves it.

Medicare Prescription Drug Benefits meansMedicare Part D, the federal Medicare prescriptiondrug program created by the MedicareModernization Act of 2003 and effectiveJanuary 1, 2006.

Military Service or Military Leave means serviceor leave to serve in the United States ArmedForces, the Army National Guard, and the AirNational Guard when engaged in active duty fortraining, inactive duty training, or full-time NationalGuard duty, the commissioned corps, or the PublicHeath Service, and any other category of personsdesignated by the President in time of war oremergency.

Non-Bargaining Unit Employee means anemployer's full-time employees who perform workwhich is not covered by a labor contract requiringcontributions to this Fund and who are, therefore,not represented by a labor organization and whoare not alumni. A full-time employee is one who isregularly employed by an employer 25 or morehours per week.

Optician, Optometrist, and Ophthalmologistmean any person who is qualified and currentlylicensed (if licensing is required in the state) topractice each such occupation by the appropriategovernmental authority having jurisdiction over thelicensure and practice of such occupation, and whois acting within the usual scope of such practice.

Personal Pronoun Usage. Words used in thisSPD in the masculine or feminine gender will beconsidered as the feminine gender or masculinegender respectively, where appropriate.

Words used in the singular or plural will beconsidered as the plural or singular, respectively,where appropriate.

65

Physician means a person who is licensed topractice medicine by the governmental authorityhaving jurisdiction over such licensure and who isacting within the usual scope of such practice andincludes the services of a doctor of medicine,podiatrist, chiropractor, osteopath, optometrist, anddoctor of dental surgery.

Plan means the Milwaukee Carpenters' DistrictCouncil Health Plan Document adopted by theTrustees, as amended from time to time, whichincorporates the provisions, terms, and conditionsunder which benefits are paid and the schedules ofbenefits which are in effect.

Plan Year means the 12 months beginning anyJune 1st and ending the following May 31st.

Preferred Provider means a:

(a) physician, dentist, registered nurse, physicaltherapist, or other licensed health care provider;

(b) hospital;

(c) alcohol and substance abuse treatment facility;

(d) hospice;

(e) laboratory;

(f) outpatient surgical facility;

(g) pharmacy,

(h) business establishment selling or rentingdurable medical equipment; or

(i) any other source for services or suppliescovered under this Plan;

who/which alone, or as part of a group, enter intoa contract with the Trustees and agree to becompensated for their services and supplies as arecovered under this Plan according to the terms ofthe contract. Such parties are preferred providerswhile such contract is in effect.

Current types of preferred providers include thefollowing:

(a) "Preferred Provider Network" means any of thehospitals, physicians, or other health careproviders which contract with the Trustees

directly or through their agents from time totime.

The Trustees have a contract with Anthem BlueCross and Blue Shield under which:

(1) The Blue Preferred Point-of-Service (POS)Network is the Preferred Provider Networkfor services obtained in the state ofWisconsin; and

(2) The BlueCard PPO Network is the PreferredProvider Network for services obtainedoutside the state of Wisconsin.

(b) “Preferred Provider Pharmacy (PPRx)” meansthe pharmacy which participates in thePreferred Provider Pharmacy Program partyto a contract with the Trustees, currentlyCVS Caremark.

(c) “Family Services Program (FSP) Manager”means the organization which contracts withthe Trustees to provide specified familyassistance services. The current FSP provideris ComPsych Corporation.

(d) “Preferred Provider Preventive Care Program”means the organization which contracts withthe Trustees from time to time to provide healthpromotion and cancer screening services,currently Health Dynamics.

Qualified Medical Child Support Order (QMCSO)(including a National Medical Support Notice)means any court judgment, decree, or order,including a court's approval of a domestic relationssettlement agreement, or any judgment, decree, ororder issued through an administrative processestablished under state law which has the forceand effect of law under applicable state law, that:

(a) provides for child support payments related tohealth benefits with respect to a child of aparticipant or requires health benefit coveragefor such child by the Plan, and is ordered understate domestic relations law; or

(b) enforces a state law relating to medical childsupport payments with respect to the Plan; and

(c) creates or recognizes the right of a child as analternate recipient who is recognized under theorder as having a right to be enrolled under the

66

Plan to receive benefits derived from suchchild's relationship to an eligible employee whois a participant in the Plan; and

(d) includes the name and last known mailingaddress (if any) of the participant from whomsuch child's status as an alternate recipientunder this Plan is derived and the name andmailing address of each alternate recipientcovered by the order, except that, to the extentprovided in the order, the name and mailingaddress of an official of state or a politicalsubdivision thereof may be substituted for themailing address of any such alternate recipient,a reasonable description of the type ofcoverage to be provided by the Plan to eachalternate recipient or the manner in which thetype of coverage is determined, and the periodfor which coverage must be provided; and

(e) does not require or purport to require the Planto provide any type or form of benefit, or anyoption, not otherwise provided under the Plan,except to the extent necessary to meet therequirements of law relating to medical childsupport described in Section 1908 of the SocialSecurity Act; and

(f) has been determined by the Plan Administratorto be a Qualified Medical Child Support Orderunder reasonable procedures adopted anduniformly applied by the Plan. A copy of thewritten procedures for determining whether ornot an order is “qualified” is available from theFund Office upon request at no charge.

Reasonable Expense means the usual andcustomary fee or charge for the covered servicesrendered and the covered supplies furnished in theparticular geographical area concerned, providedsuch services and supplies are medicallynecessary as recommended and approved by aphysician or dentist. Reasonableness isdetermined by comparisons with fees and chargesby other providers for similar services and suppliesas authorized by the Trustees and may includedata obtained from sources such as the Fair Healthschedule for relevant zip code areas at thepercentile Trustees adopt (currently the 90thpercentile) and, if the charge exceeds by more than$50.00, the annual Physicians Fee Guide or similarpublication with a geographic adjustment factor.Charges in excess of reasonable expenses are

not covered under the Plan and are the soleresponsibility of the eligible person.

Self-Funded Plan means a group health care planin which the Fund assumes the financial risk forproviding health care benefits to its employees.Instead of paying a fixed premium to an insurancecompany to pay the claims, a self-funded plandirects employer contributions, self-payments, andinvestment earnings into a Trust Fund that isoverseen by strict federal government regulation.The Plan pays claims directly from accumulatedTrust Fund assets.

Sickness means a disease, disorder, or condition(including pregnancy and childbirth and any relatedconditions) which requires treatment by aphysician. Expenses related to tubal ligations andvasectomies will be considered a “sickness;”however, reversals of sterilization procedures orany other contraceptive-related procedure or supplywill not be considered a sickness.

Skilled Nursing Home means an institution whichfully meets each of these requirements:

(a) is regularly engaged in providing skilled nursingcare for sick and injured persons at the patient'sexpense;

(b) requires that patients be regularly attended by aphysician and that medications be given only onthe order of the physician;

(c) maintains a daily medical record of eachpatient;

(d) continuously provides nursing care under24-hour-a-day supervision by a registerednurse;

(e) is not, except incidentally, a facility for the aged,a rest home, or the like;

(f) is not, except incidentally, a place for treatmentof substance addiction, alcoholism, or mentalillness;

(g) is currently licensed as a skilled nursing home,if licensing is required in the area where it islocated, and is classified as a skilled nursinghome under Medicare;

67

(h) has permanent facilities for the care of six ormore resident inpatients; and

(i) requires a physician's certification thatconfinement is medically necessary.

Total and Permanent Disability means beingpermanently unable, due to disability, to perform:

(a) for bargaining unit employees--the workcovered by the collective bargaining agreementunder which the employee worked; or

(b) for non-bargaining unit employees and alumni--the work pertaining to an employee'soccupation; and

(c) unable to engage in any regular occupation oremployment for reasonable remuneration orprofit.

You means any eligible employee.

The terms "Association," "Beneficiary,""Employee," "Employer," "Participant," "TrustAgreement," "Trust Fund," "Trustees," and"Union" have the same meaning in this SummaryPlan Description as they do in the Restated TrustAgreement, effective May 21, 1975, as amended,which is incorporated by reference.

68

HOW TO APPLY FOR BENEFITS

Pre-Service Claims: You must contact the FundOffice for prior approval of specified self-fundedorgan transplants, repair of durable medicalequipment, medically necessary replacement orrepair of artificial limbs and eyes, certain drugsspecified on page 38, and medically necessaryorthodontic services for dependent children underage 19. Claims such as this are called “pre-serviceclaims,” which means any claim which requiresapproval of the benefit in advance of obtainingmedical care. Claims requiring prior authorizationmust be submitted in writing to the Fund Office. Inaddition, you must contact the PPRx PriorAuthorization Department as specified on page 39for determination of medical necessity for certaindrugs.

Please note that there are special provisions inthe Claims Procedure Regulations for “urgentcare claims” (referred to under the Plan as “emer-gencies”), but, by definition, these provisions do notapply to your Plan because the Plan does notrequire prior approval of emergency admissions.

Post-Service Claims: Any claim for benefits thatis not a pre-service claim is considered a “post-service claim.” You must submit all post-serviceclaims in writing within 90 days of the occurrence ofthe accident or sickness, or as soon thereafter as isreasonably possible. In no event (except in theabsence of legal capacity) can you submit a claimlater than one year from the date of service.

Insured Transplant Claim Procedures: The pre-service and post-service claims procedures forinsured transplant claims are included in theenclosed Organ & Tissue Transplant Certificate.

Once you become eligible, you will receive anidentification card from the Fund which identifiesyou and contains the name and address of theMilwaukee Carpenters' District Council HealthFund. The Fund's Administrative Manager, namedon page 83, certifies eligibility, processes claims,and makes the benefit payments. When you obtainhealth care services or supplies, make sure youpresent your ID card to the provider. Your ID cardwill give the provider all the information necessaryto submit the claim for payment. If the providerdoes not submit the claim, you must do so yourself.

Post-service claims must be submitted in writing tothe appropriate party as follows:

Send all claims for inpatient and outpatienttreatment of mental health, substance abuse,and eating disorders to:

ComPsych GuidanceResourcesP.O. Box 8379Chicago, IL 60680-8379

Send all claims for dental, vision, and Medicare-eligible retirees to:

Fund OfficeMilwaukee Carpenters' DistrictCouncil Health FundP.O. Box 670Pewaukee, WI 53072-0670

Send all other medical claims for servicesobtained in Wisconsin to:

Anthem Blue Cross and Blue ShieldP.O. Box 34210Louisville, KY 40232-4210

Send all other medical claims for servicesobtained outside Wisconsin to your localBlue Cross and Blue Shield Plan.

For organ transplant insurance claims, see theenclosed Organ & Tissue Transplant Certificate.

Claims should be complete. They should contain,at a minimum:

(a) Fund name (Milwaukee Carpenters’ DistrictCouncil Health Fund);

(b) Employee’s name and unique identificationnumber;

(c) Full name (including “Jr.,” if applicable) anddate of birth of the eligible person who incurredthe covered expense;

(d) Name and address of the service provider;

69

(e) Federal tax identification number of provider;

(f) Diagnosis of the condition;

(g) Procedure or nature of the treatment;

(h) Date of and place where the procedure ortreatment has been provided;

(i) Amount billed and the amount of the coveredexpense not paid through coverage other thanthis Plan, as appropriate; and

(j) Evidence that substantiates the nature, amount,and timeliness of each covered expense that isin a reasonably understandable format and is incompliance with all applicable law.

Claims will not be deemed submitted for purposesof these procedures unless and until receivedat the correct address. A general request for aninterpretation of Plan provisions will not be

considered a claim for benefits. Pre-determinedamounts you must pay, such as a prescription drugcopayment or amount required because of use of anetwork or non-network provider, will not beconsidered a claim for benefits subject to the claimsprocedures. However, if you feel you have beencharged an improper dollar or percentagecopayment/ coinsurance (for example through thePreferred Provider Pharmacy Program), you maysubmit a formal appeal to the Fund Office in writingwithin 180 days to have your claim reviewedaccording to the appeal procedures stated onpages 73 through 76.

You or an authorized representative can pursue aclaim. You may authorize a representative bysubmitting a written authorization to the Trustees.

Benefits are paid directly to you or to the provider, ifyou assign benefits to the provider on a formacceptable to the Trustees.

70

YOUR RESPONSIBILITIESAS A PARTICIPANT UNDER THE PLAN

1. NOTIFY THE FUND OFFICEIMMEDIATELY REGARDING ANYCHANGE IN ADDRESS.

Most information about your Plan is sent to youby mail. For you to receive this information, wemust have a correct address on file at the FundOffice at all times.

If you move, it is up to you to let us know yournew address. Failure to do so may jeopardizeyour eligibility or benefits because we will haveno way to contact you about any changes in theEligibility Rules or improvements in benefits.

So don't lose out. Remember: Theresponsibility for advising the Fund Officeof your new address is yours, and youshould do so in writing.

For your convenience, a card is provided by theFund Office which you may use to notify theFund Office about an address change.

Or, just drop a postcard in the mail to the FundOffice with your new address.

2. MAKE SELF-PAYMENTS ON TIME ANDIN THE CORRECT AMOUNTS.

Benefits paid by this Plan are financed primarilyby employer contributions.

However, you will be notified if self-paymentsare required to maintain your eligibility. Theself-pay notice indicates the amount due andthe date due. Failure to pay the requiredamount on time will lead to a loss of eligibility.

Remember: The responsibility for makingtimely self-payments is yours.

3. AVOID UNNECESSARY DELAYS INPROCESSING YOUR CLAIMS BYPROVIDING ALL NECESSARYINFORMATION.

A major reason for delays in processing ofbenefits is failure on the part of the providersfurnishing supplies or services and the personfiling for benefits to provide all the necessaryinformation as specified. You probably wouldnot be aware of the information omitted by yourphysician; however, a reminder to the recep-tionist or nurse in the physician's office thatsuch information is important may help to solvethe problem. If you are submitting claimsyourself, be sure to double check that you haveincluded all the needed information before yousend them in.

71

YOUR RIGHTS UNDER THE FAMILYAND MEDICAL LEAVE ACT OF 1993

The federal Family and Medical Leave Act of 1993(FMLA) requires certain “covered employers” toprovide unpaid, job-protected leave to "eligible"employees for certain family and medical reasonsup to the number of weeks mandated by law.Employees are eligible if they have worked for thesame covered employer for at least one year, andfor 1,250 hours over the previous 12 months. Seepage 21 for an explanation of what constitutes a"covered employer.” Your employer must approveyour FMLA leave.

REASONS FOR TAKING LEAVE

Unpaid leave must be granted for up to 12 weeksfor any of the following reasons:

(a) to care for the employee's child after birth, orplacement of a child with the employee foradoption or foster care;

(b) to care for the employee's spouse, son ordaughter, or parent who has a serious healthcondition;

(c) for a serious health condition that makes theemployee unable to perform his job; or

(d) because of “any qualifying exigency” arising outof the fact that the spouse, son, daughter, orparent of the employee is on active duty, or hasbeen notified of an impending call to active dutystatus, in support of a contingency operation.The Secretary of Labor will issue regulationsdefining “any qualifying exigency.”

Unpaid leave must be granted for up to 26 weeks ina single 12-month period for an eligible employeewho is the spouse, son, daughter, parent, or next ofkin of a covered service member to care for theservice member while recovering from a seriousillness or injury sustained in the line of duty onactive duty. This military caregiver leave isavailable during “a single 12-month period” duringwhich an eligible employee is entitled to acombined total of 26 weeks of all types of FMLAleave.

At the employee’s or employer’s option, certainkinds of paid leave may be substituted for unpaidleave.

ADVANCE NOTICE AND MEDICALCERTIFICATION

The employee ordinarily must provide 30 daysadvance notice when the leave is "foreseeable."An employer may require medical certification tosupport a request for leave because of a serioushealth condition, and may require second or thirdopinions (at the employer's expense) and a fitnessfor duty report to return to work. Taking of leavemay be denied if these requirements are not met.

JOB BENEFITS AND PROTECTION

(a) For the duration of FMLA leave, the employermust maintain the employee's health coverageunder any "group health plan." COBRAcoverage may apply if the employee does notreturn from an FMLA leave.

(b) Upon return from FMLA leave, most employeesmust be restored to their original or equivalentpositions with equivalent pay, benefits, andother employment terms.

(c) The use of FMLA leave cannot result in the lossof any employment benefit that accrued prior tothe start of an employee's leave.

UNLAWFUL ACTS BY EMPLOYERS

FMLA makes it unlawful for any employer to:

(a) interfere with, restrain, or deny the exercise ofany right provided under FMLA; or

(b) discharge or discriminate against any personfor opposing any practice made unlawful byFMLA or for involvement in any proceedingunder or relating to FMLA.

72

If an employee and the employer have a disputeover the employee’s eligibility and coverage underFMLA, the employee’s benefits will be suspendedpending resolution of the dispute. The Trustees willhave no direct role in resolving such a dispute.

ENFORCEMENT

The U.S. Department of Labor is authorized toinvestigate and resolve complaints of violations. Aneligible employee may bring a civil action againstan employer for violations.

FMLA does not affect any federal or state lawprohibiting discrimination, or supersede any state orlocal law or collective bargaining agreement whichprovides greater family or medical leave rights.

FOR ADDITIONAL INFORMATION: Contact youremployer or the nearest office of the Wageand Hour Division, listed in most tele-phone directories under "U.S. Government,Department of Labor."

73

INFORMATION REQUIRED BY THE EMPLOYEERETIREMENT INCOME SECURITY ACT OF 1974 (ERISA)

Claims Review and Appeal Procedures

When you submit a pre-service claim, ifapplicable, the Plan (meaning the Fund Office) willnotify you whether or not the claim is approvedwithin a reasonable period of time appropriate tothe medical circumstances, but not later than 15days of the Plan’s receipt of the claim. If you fail tofollow the Plan’s procedures for filing a claim, youwill be notified of the failure and the properprocedures as soon as possible, but no later thanfive days following the failure. We will notify youverbally, unless you request us to notify you inwriting.

For post-service claims, the Plan will notify you ofan adverse benefit determination within areasonable period of time, but not later than30 days of the Plan’s receipt of a claim.

For both pre- and post-service claims, if the Planneeds additional time to determine whether a claimis a covered expense for reasons beyond thePlan’s control, the Plan may take one 15-dayextension. The Plan will notify you prior to theexpiration of the initial 15- or 30-day notificationperiod, as applicable, of the circumstancesrequiring the extension and the date by which thePlan expects to make a decision. If an extension isneeded due to your failure to submit necessaryinformation to decide the claim, the Plan, in thenotice of extension, will specifically describe therequired information needed. The time period formaking the determination is suspended from thedate on which the notice of the necessaryinformation is sent to you until the date yourespond. You have at least 45 days from receipt ofthe notice to respond to the request for information.Once you respond, the Plan will decide the claimwithin the 15-day extension period. Your claim willbe denied if you do not respond in a timely manner.The Plan may take only one extension for grouphealth claims and may not further extend the timefor making its decision unless you agree to a furtherextension.

A concurrent care claim is a claim that isreconsidered after the Plan has approved an

ongoing course of treatment to be provided over aperiod of time or a number of treatments and thereconsideration results in the reduction ortermination of the treatment (other than by Planamendment or termination) before the scheduledend of the treatment. Although this situation almostnever arises, we are required by law to tell you thatthis provision exists. If the Plan reduces orterminates treatment before the end of the courseof the treatment, the Plan will notify you far enoughin advance of the termination or reduction oftreatment to allow you to appeal the adversebenefit determination and obtain a determination onreview before the termination or reduction takeseffect.

For disability claims, the Plan has a reasonableperiod of time, not in excess of 45 days, to providewritten notice of an adverse benefit determinationfor any claim for disability benefits under the Plan.The Plan may extend the decision-making periodfor up to an additional 30 days for reasons beyondthe Plan’s control but the Plan will notify you inwriting before the expiration of the 45-day period ofthe reason for the delay and when the decision willbe made. A second 30-day extension is allowableif the Plan still is unable to make the decision forreasons beyond its control. You will be provided,before the expiration of the first 30-day extensionperiod, a notice that details the reasons for thedelay and the date as of which the Plan expects torender a decision. If an extension is neededbecause the Plan needs additional information fromyou, the extension notice will specifically explainthe standards on which entitlement to a benefit isbased, the unresolved issues that prevent adecision on the claim, and specify the additionalinformation needed to resolve those issues, inwhich case you will have 45 days from receipt ofthe notification to provide the requestedinformation. The Plan will issue its decision within30 days of the date you submit your information(subject to the 30-day extension previouslydescribed). Your claim will be denied if you do notsubmit the requested information in a timelymanner.

74

For insured transplant claims, the claims reviewand appeal procedures are included in theenclosed Organ & Tissue Transplant Certificate.

If the Plan denies coverage for your claim, thedenial is called an adverse benefit determination asdefined under the U.S. Department of LaborRegulations. An adverse benefit determinationincludes a rescission of your coverage under thePlan, except in the case of fraud or intentionalmisrepresentation of a material fact. An example offraud or intentional misrepresentation of a materialfact includes a fraudulent or intentional misrepre-sentation about your past medical history. TheRegulations define a rescission as a cancellation ordiscontinuance of coverage that has a retroactiveeffect. A cancellation or discontinuance ofcoverage is not a rescission if the cancellation ordiscontinuance only has a prospective effect. Thefollowing retroactive terminations of coverage in thenormal course of business are not consideredrescissions under the Regulations even thoughretroactive:

(a) retroactive termination to the extent attributableto failure to pay a timely premium (self-payment) towards coverage;

(b) retroactive elimination of coverage back to thedate of termination of employment, due todelays in administrative recordkeeping if you donot pay any premiums for coverage aftertermination of employment; and

(c) the Plan’s termination of coverage retroactive tothe date of a divorce.

To clarify, this means that, in general, the Plancannot terminate your coverage retroactively.However, the Plan may do so under the circum-stances described and in other instances as maybe prescribed in the Regulations. The Plan isrequired to provide at least 30 days advance writtennotice to each eligible person who is affected by arescinding of coverage before the coverage may berescinded.

If your claim for benefits is denied in whole or inpart, the Plan will provide you, your dependent,beneficiaries, or authorized or legal representa-tives, as may be appropriate (hereafter referred toas “you” or “your”) with written or electronic noticeof adverse benefit determinations within the timeframes previously stated. Notices will include the

following information stated in an easilyunderstandable manner:

(a) The specific reason or reasons for the adversebenefit determination.

(b) References to specific Plan provision(s) onwhich the adverse benefit determination isbased.

(c) A description of any additional material orinformation, if any, necessary for you to perfectyour claim and an explanation of why thematerial or information is necessary.

(d) A description of the Plan’s claims review andappeal procedures and time limits applicable tosuch appeal procedures, including a statementof your right to bring a civil action underSection 502(a) of ERISA following an adversebenefit determination on review.

(e) If an internal rule, guideline, protocol, or similarcriterion was relied upon in making the adversebenefit determination, a statement that suchrule, guideline, protocol, or other similarcriterion was relied upon in making the adversebenefit determination and that a copy of suchcriterion will be provided free of charge to youupon request.

(f) If the adverse benefit determination was basedon a medical necessity or experimentaltreatment, or similar exclusion or limit, anexplanation of the scientific or clinical judgmentof the Plan in applying the terms of the Plan toyour medical circumstances will be providedfree of charge to you upon request.

(g) If a medical or vocational expert’s advice wasobtained on behalf of the Plan in connectionwith your claim, you may request the identity ofthe expert, regardless of whether the advicewas relied on.

If you feel that the action taken on your eligibility orclaim is incorrect, you immediately should ask theFund Office to review your claim with you. In somecases, the Fund Office may request additionalinformation from you which might enable the FundOffice to reevaluate its decision.

If all or part of a claim is denied or if you areotherwise dissatisfied with the determination made

75

by the Plan, or if you have not received the noticeof denial of your claim within the applicable timelimits after the Plan has received all necessaryclaim information, you have the right to appeal thedecision and request a review of the claim. ThePlan will provide for a full and fair review of a claimand adverse benefit determination, pursuant to thefollowing:

(a) You will have 180 days after you receive thenotice of an adverse benefit determinationto file your appeal in writing to the FundOffice and it must include the specificreasons you feel denial was improper.

(b) You will be allowed the opportunity to submitwritten issues and comments, documents,records, and other information relating to theclaim for benefits which may have beenrequested in the notice of denial or which youmay consider desirable or necessary.

(c) You or your duly authorized representative willbe provided, upon request and free of charge,reasonable access to, and copies of, alldesignated, pertinent documents, records, andother information relevant to your claim forbenefits.

(d) Your review will take into account all comments,documents, records, and other informationsubmitted by you relating to the claim, whetheror not such information was submitted orconsidered in the initial benefit determination.

(e) The Board of Trustees, as an appropriatenamed fiduciary for the Plan, will be theassigned decision maker on appealed claims.

(f) The Plan will consult with appropriate healthcare professionals in deciding appealed claimsthat are based in whole or in part on medicaljudgment, including determination of experi-mental or investigational treatments andmedical necessity. Such health careprofessional will have appropriate training andexperience in the field of medicine involved inthe medical judgment. The health careprofessional consulted for the appeal of anadverse benefit determination will be someonewho was not consulted in the initial adversebenefit determination nor the subordinate ofsuch individual.

(g) If a medical or vocational expert's advice wasobtained on behalf of the Plan in connectionwith your claim, you may request the identity ofthe expert, regardless of whether the advicewas relied on.

(h) For appeals of pre-service claims, the Plan willnotify you of the decision within a reasonableperiod of time appropriate to the medicalcircumstances, but not later than 30 days ofreceiving the appeal request.

(i) The Board of Trustees will review post-serviceand disability claim appeals at their nextregularly scheduled Board of Trustees' meeting(at least quarterly) that follows the receipt of therequest for review. However, if the request isfiled within 30 days of the date of the meeting,the determination may be made no later thanthe date of the second meeting following thereceipt of the request for review. If specialcircumstances (such as the need to hold ahearing) require a further extension, the appealdecision can be pushed back to the thirdmeeting following the appeal request, but thePlan must notify you of this extension and of thespecial circumstances and the date as of whichthe determination will be made prior to theextension time. The Plan will provide you withwritten or electronic notice of an adverse benefitdetermination as soon as possible but withinfive days of the decision being made. Thenotice will include the following informationstated in an easily understandable manner:

(1) The specific reason or reasons for theadverse benefit determination.

(2) References to specific Plan provision(s) onwhich the adverse benefit determination isbased.

(3) A statement that you will be provided, uponrequest and free of charge, reasonableaccess to, and copies of, all documents,records, and other information relevant toyour claim for benefits.

(4) A statement of your right to bring a civilaction under Section 502(a) of ERISA afteryou have exhausted the Plan’s claimsreview and appeal procedures.

76

(5) If an internal rule, guideline, protocol, orsimilar criterion was relied upon in makingthe adverse benefit determination, astatement that such rule, guideline, protocol,or other similar criterion was relied upon inmaking the adverse determination and thata copy of such criterion will be provided freeof charge to you upon request.

(6) If the adverse benefit determination wasbased on a medical necessity or experi-mental treatment, or similar exclusion orlimit, an explanation of the scientific orclinical judgment of the Plan in applying theterms of the Plan to your medicalcircumstances will be provided free ofcharge to you upon request.

The Trustees will make every effort to interpretPlan provisions in a consistent and equitablemanner. You will be given maximumopportunity to present your viewpoint on anydenied claim. You may not begin any legalaction, including proceedings before adminis-trative agencies, until you have followed theprocedures and exhausted the reviewopportunities described here. You may, at yourown expense, have legal representation at anystage of these review procedures. No legalaction for any benefits under the Plan may

begin later than two years after the time theclaim was required to be filed as specified onpage 68. Benefits under this Plan will be paidonly if the Board of Trustees (or its PlanAdministrator) decides in its discretion that youare entitled to them. The Plan will be inter-preted and applied in the sole discretion of theBoard of Trustees (or its delegate, including butnot limited to, its Plan Administrator). Suchdecision will be final and binding on all personscovered by the Plan who are claiming anybenefits under the Plan.

If you have any questions about the claims reviewand appeal procedures described here, pleasecontact the Fund Office.

Insured transplant benefits under the Plan also aresubject to grievance procedures under stateinsurance law. These appeals and procedures areincluded in the enclosed Organ & TissueTransplant Certificate. For the purposes of insuredtransplant benefits under the Plan, nothing in theclaims procedures in the section entitled "How toApply for Benefits" and "Claims Review and AppealProcedures" is intended to preempt any provisionof state law that regulates insurance, except to theextent that the state law prevents the application ofa requirement of the claims procedures.

Statement of Participants' Rights Under ERISA

In 1974, Congress passed and the Presidentsigned the Employee Retirement Income SecurityAct, commonly referred to as ERISA.

ERISA sets forth certain minimum standards for thedesign and operation of privately-sponsoredwelfare plans. The law also spells out certain rightsand protections to which you are entitled as aparticipant.

The Trustees of the Milwaukee Carpenters' DistrictCouncil Health Fund want you to be fully aware ofyour rights, and in accordance with federal law, astatement of your rights follows.

As a participant in the Milwaukee Carpenters'District Council Health Fund:

(a) You automatically will receive a Summary PlanDescription (this booklet). The purpose of this

booklet is to describe all pertinent informationabout the Plan.

(b) If any substantial changes are made in thePlan, you will be notified within the time limitsrequired by ERISA.

Federal regulations under HIPAA require thatparticipants and beneficiaries receive asummary of material modifications of anymodification or change that is a materialreduction in covered services or benefits undera group health plan within 60 days after theadoption of the modification or change, unlessthe Plan sponsor regularly sends out sum-maries of the modifications or changes atregular intervals of 90 or fewer days.

(c) Each year you automatically will receive asummary of the Plan's latest annual financial

77

report. A copy of the full report also is availableupon written request.

(d) You may examine, without charge, alldocuments relating to this Plan. Thesedocuments include: the legal Plan Document,insurance contracts, collective bargainingagreements, and copies of all documents filedby the Plan with the Department of Labor or theInternal Revenue Service, such as the latestannual report (Form 5500 Series) and Plandescriptions.

Such documents may be examined at the FundOffice (or at other specified locations such asworksites or union halls) during normalbusiness hours.

In order to ensure that your request is handledpromptly and that you are given the informationyou want, the Trustees have adopted certainprocedures which you should follow:

(1) your request should be in writing;

(2) it should specify what materials you wish tolook at; and

(3) it should be received at the Fund Office atleast three days before you want to reviewthe materials at the Fund Office.

Although all pertinent Plan documents are onfile at the Fund Office, arrangements can bemade upon written request to make thedocuments you want available at any worksiteor union location at which 50 or moreparticipants report to work. Allow 10 days fordelivery.

(e) You may obtain copies of any Plan documentgoverning the operation of the Plan, includinginsurance contracts and collective bargainingagreements, and copies of the latest annualreport (Form 5500 Series) and updatedSummary Plan Description upon written requestto the Trustees, addressed to the Fund Office.ERISA provides that the Trustees may make areasonable charge for the actual cost ofreproducing any document you request.However, you are entitled to know what thecharge will be in advance. Just ask the FundOffice.

(f) You have the right to continue health carecoverage for yourself, your spouse, ordependents if there is a loss of coverage underthe Plan as a result of a qualifying event. Youor your dependents may have to pay for suchcoverage. Review this Summary PlanDescription and the documents governing thePlan on the rules governing your COBRAcontinuation coverage rights.

(g) You are entitled to a reduction or elimination ofexclusionary periods of coverage for pre-existing conditions under your group health planif you have creditable coverage from anotherplan. You should be provided a certificate ofcreditable coverage, free of charge, from yourgroup health plan or health insurance issuerwhen you lose coverage under the plan, whenyou become entitled to elect COBRAcontinuation coverage, when your COBRAcontinuation coverage ceases, if you request itbefore losing coverage, or if you request it up to24 months after losing coverage.

(h) No one including your employer, your union, orany other person, may fire you or otherwisediscriminate against you in any way or take anyaction which would prevent you from obtaininga welfare benefit to which you may be entitledor from exercising any of your rights underERISA.

(i) In accordance with Section 503 of ERISA andrelated regulations, the Trustees have adoptedcertain procedures to protect your rights if youare not satisfied with the action taken on yourclaim.

These procedures appear on pages 73 through76 of this booklet. Basically, they provide that:

(1) If your claim for a health care benefit isdenied or ignored, in whole or in part, youhave a right to know why this was done, youwill receive a written explanation of thereason(s) for the denial, and you have aright to obtain copies of documents relatingto the decision without charge.

(2) Then, if you still are not satisfied with theaction on your claim, you have the right tohave the Plan review and reconsider your

78

claim in accordance with the Plan's claimsreview and appeal procedures.

These procedures are designed to give you afull and fair review and to provide maximumopportunity for all the pertinent facts to bepresented in your behalf.

(j) In addition to creating rights for Plan partici-pants, ERISA also defines the obligations ofpeople responsible in operating employeebenefit plans. These persons are known as"fiduciaries." They have the duty to operateyour Plan prudently and with reasonable careand to look out for your best interests as aparticipant under the Plan and the best interestsof other Plan participants and beneficiariesunder the Plan.

The duties of a fiduciary are complex and areconstantly changing as new laws and regula-tions are adopted, applicable to employeebenefit plans. Be assured that the Trustees ofthis Plan will do their best to know what isrequired of them as fiduciaries and to takewhatever actions are necessary to ensure fullcompliance with all state and federal laws.

(k) Under ERISA, you may take certain actions toenforce the rights previously listed.

(1) For instance, if you make a written requestfor a copy of Plan documents or the latestannual report from the Trustees and do notreceive them within 30 days of the Plan’sreceipt, you may file suit in federal court.

Of course, before taking such action, you nodoubt will want to check again with the FundOffice to make sure that:

· the request actually was received;

· the material was mailed to the rightaddress; or

· the failure to send the material was notdue to circumstances beyond theTrustees' control.

If you still are not able to get the informationyou want, you may wish to take legal action.The court may require the Trustees toprovide the materials promptly or pay you afine of up to $110 for each day's delay untilyou actually receive the materials (unlessthe delay was caused by reasons beyondthe Trustees' control).

(2) Although the Trustees will make everyeffort to settle any disputed claims withparticipants fairly and promptly, therealways is the possibility that differencescannot be resolved satisfactorily. If youhave a claim for benefits which is denied orignored, in whole or in part, you may file suitin a state or federal court after you haveexhausted the Plan’s claims appealprocedures if you feel that you have beenimproperly denied a benefit. In addition, ifyou disagree with the Plan’s decision or lackthereof concerning the qualified status of amedical child support order, you may filesuit in federal court.

However, before exercising this right, youmust take advantage of all the claims reviewand appeal procedures provided under thePlan at no cost. If you still are not satisfied,then you may wish to seek legal advice.

(3) If it should happen that Plan fiduciariesmisuse the Plan's money or discriminateagainst you for asserting your rights, youmay seek assistance from the U.S.Department of Labor or you may file suit ina federal court.

· The court will decide who should paycourt costs and legal fees. If you aresuccessful, the court may order theperson you have sued to pay thesecosts and fees.

· If you are not successful, the court mayorder you to pay these costs and fees.For example, if the court finds yourclaim is frivolous, you may be expectedto pay legal costs and fees.

79

If you have any questions about your Plan, youshould contact the Trustees by writing to:

The Board of TrusteesMilwaukee Carpenters' DistrictCouncil Health FundN25 W23055 Paul Road, Suite 2Pewaukee, WI 53072-0670

Or phone: (262) 970-5790 locally, orCall toll-free in Wisconsin: 1-800-448-8208

If you have questions about this statement or yourrights under ERISA or if you need assistance inobtaining documents from the Trustees, you may

contact the nearest office of the Employee BenefitsSecurity Administration (EBSA) at U.S. Departmentof Labor listed in your telephone directory or at:Division of Technical Assistance and Inquiries,Employee Benefits Security Administration,U.S. Department of Labor, 200 Constitution AvenueN.W., Washington, D.C. 20210. You also may findanswers to your Plan questions, your rights andresponsibilities under ERISA, and a list of EBSAfield offices by contacting the EBSA by: calling1-866-444-3272; sending electronic inquiries towww.askebsa.dol.gov; or visiting the website of theEBSA at www.dol.gov/ebsa/.

80

Other ERISA Information

The Name and Address of PlanAdministrator

The Plan is administered and maintained by theBoard of Trustees. The Administrative Office of theFund is located at:

The Board of TrusteesMilwaukee Carpenters' DistrictCouncil Health FundN25 W23055 Paul Road, Suite 2Pewaukee, WI 53072-0670

Name of Plan

The name of the Plan is the Milwaukee Carpenters’District Council Health Fund.

Type of Plan

This Plan is a group health plan. It is maintainedfor the exclusive benefit of the employees andprovides Death, Accidental Death andDismemberment, and Loss of Time Benefits foremployees and health care, vision, and dentalbenefits for employees and dependents. This Planis subject to the Health Insurance Portability andAccountability Act of 1996 (HIPAA).

Plan Sponsor/Fiduciary

The Plan Sponsor and Fiduciary is the Board ofTrustees of the Milwaukee Carpenters' DistrictCouncil Health Fund. This Fund is maintained byseveral employers and one or more employeeorganizations, and is administered by a JointBoard of Trustees which consists of Labor andManagement representatives selected by theemployers and unions who have entered intocollective bargaining agreements that relate tothis Plan. A complete list of the employers andemployee organizations sponsoring the Plan maybe obtained by participants and beneficiaries uponwritten request to the Plan Administrator, and isavailable for examination by participants andbeneficiaries at the Fund Office.

Type of Plan Administration

Although the Trustees are legally designated as thePlan Administrator, they have delegated certainadministrative responsibilities to an AdministrativeManager.

The Administrative Manager maintains the eligibilityrecords, accounts for the employer contributions,answers participant inquiries about the benefitprograms, processes claims and benefit payments,files required government reports, and handlesother routine administrative functions.

The Names and Addresses of the Trustees

Labor Trustees

Peter DiRaffaeleChicago and Northeast Illinois District Councilof Carpenters12 East Erie StreetChicago, IL 60611-2796

Arcadio PerezChicago Regional Council – Northern RegionN25 W23055 Paul Road, Suite 1P.O. Box 790Pewaukee, WI 53072-0790

Mark ScottChicago Regional Council – Northern RegionN25 W23055 Paul Road, Suite 1P.O. Box 790Pewaukee, WI 53072-0790

Management Trustees

Tom DuFourJ.H. Hassinger, Inc.N60 W16289 Kohler LaneMenomonee Falls, WI 53051

Larry RocoleJ.P. Cullen & Sons, Inc.13040 West Lisbon Road, Suite 900Brookfield, WI 53005

John ToppA.C.E.A.17100 West Bluemound Road, Suite 102Brookfield, WI 53005-5950

81

Parties to the Collective BargainingAgreement

Chicago Regional Council of Carpenters –Northern RegionN25 W23055 Paul Road, Suite 1Pewaukee, WI 53072-0790

Allied Construction Employers Association, Inc.17100 West Bluemound Road, Suite 102Brookfield, WI 53005-5950

Also, those employers who are not members ofor represented by such Associations but whichexecute an individual collective bargainingagreement with the Local Union.

A copy of any such agreement is available forexamination by participants and their beneficiariesat the Fund Office during normal business hours.Also, upon written request to the AdministrativeManager, participants and their beneficiaries mayobtain:

(a) a copy of any such agreement; and

(b) information as to the address of a particularemployer and whether that employer is requiredto pay contributions to the Plan.

Internal Revenue Service Employer andPlan Identification Numbers

The Employer Identification Number (EIN) issued tothe Board of Trustees is 39-0851641 and the PlanNumber (PN) is 501.

Name and Address of the PersonDesignated as Agent for Service of LegalProcess

Administrative ManagerMilwaukee Carpenters' District CouncilHealth FundN25 W23055 Paul Road, Suite 2P.O. Box 670Pewaukee, WI 53072-0670

Service of legal process also may be made uponany Plan Trustee.

Eligibility Requirements

The Plan's requirements with respect to eligibilityfor benefits are shown in the Eligibility Rules onpages 1 through 21. Circumstances which maycause the participant to lose eligibility are explainedin the Eligibility Rules.

Sources of Trust Fund Income

Sources of Trust Fund income include employercontributions, self-payments, and investmentearnings.

All employer contributions are paid to the TrustFund subject to provisions in:

(a) the collective bargaining agreements betweenthe Union and Association;

(b) the collective bargaining agreements betweenthose employers who are not members of orrepresented by an Association but whichexecute an individual collective bargainingagreement with the Union; and

(c) the Trustees' NBUE Participation Agreement.

For bargaining unit employees, the labor agree-ments specify the amount of contribution, due dateof employer contributions, type of work for whichcontributions are payable, and the geographic areacovered by the labor contract.

For non-bargaining unit persons, the Trusteesdetermine the employer contribution amount, duedate, and related policies.

Method of Funding Benefits

All Plan benefits are self-funded from accumulatedassets and are provided directly from the TrustFund except for certain organ transplant benefitswhich are insured. A portion of Fund assets ismaintained in reserve to cover unexpected orunusually high expenses which the Fund mayexperience from time to time, such as acatastrophic claim. All assets of the Fund are heldby a custodian (bank) selected by the Trustees. JPMorgan Chase Bank, N.A., Chicago, IL, is currently

82

the custodian of Fund assets. Assets not neededfor the immediate payment of benefits and otherFund expenses are invested by an investmentmanager hired by the Trustees in accordance withguidelines established and monitored by theTrustees. The current Investment Manager isMorgan Stanley, Milwaukee, WI.

Benefits for certain organ transplants as referencedon pages 29 and 30 are provided through aninsurance policy with National Union Fire InsuranceCompany of Pittsburgh, PA, c/o Medical ExcessLLC, 7330 Woodland Drive, Suite 250,Indianapolis, IN 46278, 1-888-449-2377. Benefitseligible under the organ transplant insurance policyare submitted to and paid by National Union FireInsurance Company of Pittsburgh, PA.

Fiscal Year of the Plan

The Plan's fiscal year begins June 1st and ends thefollowing May 31st.

Procedures To Be Followed in PresentingClaims for Benefits Under the Plan

The procedures for filing for benefits are describedon pages 68 and 69.

If a participant wishes to appeal a denial of a claimin whole or in part, certain procedures for thispurpose are found on pages 73 through 76.

Effective Date

Plan benefits described in this Summary PlanDescription booklet are effective June 1, 2014.

83

Fund Administrative ManagerCarday Associates, Inc.

N25 W23055 Paul Road, Suite 2Pewaukee, WI 53072

Fund Legal CounselReinhart Boerner Van Deuren S.C.1000 North Water Street, Suite 1700

P.O. Box 2965Milwaukee, WI 53202

Fund Legal CounselWhitfield McGann & Ketterman

111 East Wacker Drive, Suite 2600Chicago, IL 60601

Fund ConsultantLee Jost and Associates

One Park Plaza11270 West Park Place, Suite 950

Milwaukee, WI 53224

Fund Certified Public AccountantClifton Larsen Allen LLP

10700 West Research Drive, Suite 200Milwaukee, WI 53226

Organ Transplant Benefits Insured byNational Union Fire Insurance Company of

Pittsburgh, PAc/o Medical Excess LLC

7330 Woodland Drive, Suite 250Indianapolis, IN 46278

Fund Preferred Provider NetworkAnthem Blue Cross and Blue Shield

120 Monument CircleIndianapolis, IN 46204

Fund Family Services Program ProviderComPsych Corporation

NBC Tower455 North Cityfront Plaza Drive

Chicago, IL 60611-5322

Fund Preferred Provider PharmacyCVS CaremarkOne CVS Drive

Woonsocket, RI 02895

Fund Preferred Provider PreventiveCare Program

Health DynamicsColumbia St. Mary’s Urgent Care Facility

377 West River Woods Parkway, Suite 225Glendale, WI 53212

84

NOTES

SUMMARY PLAN DESCRIPTIONEffective June 1, 2014

Milwaukee Carpenters’ District Council Health FundN25 W23055 Paul Road, Suite 2Pewaukee, WI 53072-0670

Telephone: (262) 970-5790 locally, orCall toll-free in Wisconsin: 1-800-448-8208

Milwaukee Carpenters' District Council Health Fund · PDF filei Milwaukee Carpenters’...

Documents

Transcript of Milwaukee Carpenters' District Council Health Fund · PDF filei Milwaukee Carpenters’...