Summary Plan Description and Plan Document 2005 Edition

TABLE OF CONTENTS

SECTION 1: LIFE EVENTS
	1.01 Life Events in General
	1.02 Getting Married
	1.03 Adding a Child by Birth or Adoption
	1.04 Divorce or Legal Separation
	1.05 Child Loses Eligibility
	1.06 Your Spouse Loses a Job or Takes a New Job
	1.07 Leave of Absence.
	1.08 In the Event of Your Disability
	1.09 In the Event of Your Death
	1.10 When You Stop Working.
	1.11 When You Retire

SECTION 2: SCHEDULES OF BENEFITS
	2.01 Schedule of Benefits for Active Employees
	2.02 Schedule of Benefits for Retired Employees Not Yet Eligible for Medicare
	2.03 Schedule of Benefits for Retired Employees Eligible for Medicare
	2.04 Schedules for Prescription and Specialty Drug Benefits for Active and Retired Employees

SECTION 3: ELIGIBILITY
	3.01 Eligibility for Active Employee Benefits
	3.02 Retired Employee Eligibility
	3.03 COBRA Continuation Coverage

SECTION 4: DEATH BENEFIT
	4.01 Death Benefit for Active Employees
	4.02 Death Benefit for Retired Employees
	4.03 Designating Your Beneficiary

SECTION 5: ACCIDENTAL DEATH AND DISMEMBERMENT (AD&D) BENEFITS
	5.01 AD&D Benefits for Active Employees Only.
	5.02 Limitations on AD&D Benefits

SECTION 6: WEEKLY ACCIDENT AND SICKNESS DISABILITY BENEFITS
	6.01 Weekly Accident and Sickness Disability Benefits for Active Employees Only
	6.02 When Your Weekly Accident and Sickness Disability Benefits Begin
	6.03 Limitations on Your Weekly Accident and Sickness Disability Benefits

SECTION 7: COMPREHENSIVE MAJOR MEDICAL EXPENSE BENEFIT FOR ACTIVE EMPLOYEES AND RETIRED EMPLOYEES NOT YET ELIGIBLE FOR MEDICARE
	7.01 Eligibility
	7.02 The Deductible
	7.03 Percentage of Benefits Payable
	7.04 Out-of-Pocket Maximum
	7.05 Maximum Benefit Payable
	7.06 Preferred Provider Organization (PPO)
	7.07 Case Management
	7.08 Covered Expenses and Exclusions
	7.09 Extension of Medical Benefits.

SECTION 8: SUPPLEMENTAL MEDICAL BENEFITS FOR RETIRED EMPLOYEES ELIGIBLE FOR MEDICARE
	8.01 Eligibility for Supplemental Medical Benefits
	8.02 Covered Supplemental Medical Benefit Expenses
	8.03 Expenses Not Covered

SECTION 9: PRESCRIPTION DRUG BENEFITS
	9.01 Eligibility of Active Employees and Retired Employees
	9.02 Covered Drugs
	9.03 Drugs Not Covered
	9.04 The Retail Card Program
	9.05 The Mail Order Program
	9.06 Specialty Drug Benefits

SECTION 10: DENTAL EXPENSE BENEFIT FOR ACTIVE EMPLOYEES
	10.01 Eligibility for Dental Expense Benefits
	10.02 Predertermination of Dental Benefits
	10.03 Alternate Course of Dental Treatment
	10.04 Percentage of Dental Benefits Payable
	10.05 Covered Dental Expenses.
	10.06 Orthodontia Care Coverage
	10.07 TMJ Coverage
	10.08 Extension of Dental Benefits
	10.09 Limitations and Exclusions on Payment of Dental Benefits

SECTION 11: VISION CARE EXPENSE BENEFIT FOR ACTIVE EMPLOYEES
	11.01 Eligibility for Vision Care Expense Benefits
	11.02 Covered Vision Care Expenses
	11.03 Limitations and Exclusions on Vision Care Benefits

SECTION 12: THE EMPLOYEE ASSISTANCE PROGRAM BENEFIT
	12.01 Eligibility

SECTION 13: HEARING AID BENEFIT (FOR ELIGIBLE EMPLOYEES AND DEPENDENTS)
	13.01 Eligibility

SECTION 14: HOSPICE BENEFIT
	14.01 Eligibility

SECTION 15: GENERAL PLAN EXCLUSIONS
	15.01 Exclusions from Coverage

SECTION 16: COORDINATION OF BENEFITS
	16.01 Benefits Are Coordinated
	16.02 Another Group Plan Defined
	16.03 How Benefits are Paid
	16.04 Order of Benefit Payment
	16.05 Coordination of Benefits Implementation Rules
	16.06 Coordination of Benefits with Medicare

SECTION 17: SUBROGATION OR REIMBURSEMENT
	17.01 Reimbursement to the Plan
	17.02 Third Parties Defined
	17.03 Your Responsibilities
	17.04 If You Are Reimbursed by a Third Party

SECTION 18: FILING CLAIMS AND APPEALS
	18.01 How to File a Claim
	18.02 When Claims Must Be Filed
	18.03 Where to File Claims
	18.04. Authorized Representatives
	18.05 Benefit Payment to an Incompetent Person
	18.06 Claim Rules for All Medical and Hospital Claims submitted to local Blue Cross Blue Shield Plan, Supplemental Medical, Dental, and Vision and Hearing Aid Benefits
	18.07 Weekly Sickness and Accident Disability Claims
	18.08 Notice of Denial of Claim or Adverse Benefit Determination
	18.09 Your Right to Request a Review of a Denied Claim
	18.10 Review Process
	18.11 Timing of Notice of Decision on Appeal
	18.12 Notice of Decision on Review
	18.13 Physical Examination
	18.14 Payment of Claims
	18.15 Misstatement by Plan Participant
	18.16 Workers’ Compensation
	18.17 Exhaustion of Your Remedies
	18.18 Authority of the Trustees

SECTION 19: DEFINITIONS
	19.01 Definition of Plan Terms

SECTION 20: ADDITIONAL PLAN INFORMATION
	20.01 Plan Name
	20.02 Board of Trustees
	20.03 Plan Sponsor and Administrator
	20.04 Plan Numbers
	20.05 Agent for Service of Legal Process
	20.06 Source of Contributions
	20.07 Collective Bargaining Agreement
	20.08 Trust Fund
	20.09 Plan Year
	20.10 Type of Plan
	20.11 Gender
	20.12 Assignment
	20.13 Amendment and Termination
	20.14 Privacy Policy
	20.15 The Plan’s Use and Disclosure of Your Protected Health Information (PHI)
	20.16 Statement of ERISA Rights

Section 1: Life Events

1.01 Life Events in General.

At some point in your life, you will experience a life event that impacts health care coverage for you and your Dependents. You may have experienced some of these life events already. Life events such as these can affect your benefit coverage:

· Marriage	· Birth or adoption of a child
· Divorce or legal separation	· Your child reaches the maximum age for coverage
· Your spouse loses a job or starts a new job	· Medical leave
· Military duty	· You become disabled
· Your death	· Retirement
· You stop working

Your benefits are designed to adapt to your needs at different stages of your life. This section describes how your coverage is affected when these different events occur.

Enrollment Form;
Copy of your marriage certificate;
Copy of spouse’s birth certificate;
Name of your spouse’s employer; and
Spouse’s medical insurance information if your spouse is covered under another group health insurance plan.

1.02 Getting Married.

When you get married, your spouse is eligible for medical, dental, prescription drug, and vision care benefits. Once you provide the required information about your spouse, coverage for your spouse begins on the date of your marriage, provided you are eligible for benefits. If your spouse is covered under another group medical plan, you must report that other coverage to the Fund Office so that benefits may be coordinated with your spouse’s other coverage. You may want to consider changing your beneficiary designation for your Death Benefit and Accidental Death and Dismemberment Benefit.

Enrollment Form;
Birth date, effective date of adoption or placement, or marriage date for purposes of adding stepchildren;
Copy of the birth certificate or adoption papers;
Copy of the birth certificate, marriage certificate, legal documents, and tax returns (for stepchildren); and
Copy of your child’s other medical insurance information, if covered under another group health insurance plan.

1.03 Adding a Child by Birth or Adoption.

Your natural born child will be eligible for coverage on the date of birth. If you adopt a child or have a child placed with you for adoption, coverage will become effective on the date of placement as long as you are responsible for health care coverage and your child meets the Plan’s definition of a Dependent child. Stepchildren who live in your home are eligible for coverage on the date of your marriage, provided that you can provide satisfactory proof that: a) they are living in your home and b) they are financially dependent on you for support and c) another party is not responsible for providing health coverage.

Enrollment Form;
Copy of your separation or divorce decree; and
Copy of any QMCSO, if applicable.
If your spouse wants to continue coverage, he or she should:
Contact the Fund Office in writing within 60 days of the divorce or legal separation; and
Enroll for COBRA Continuation Coverage.

1.04 Divorce or Legal Separation.

If you and your spouse obtain a legal separation or divorce, your spouse will no longer be eligible for coverage as a Dependent under the Plan. However, your spouse may elect to continue coverage under COBRA for up to 36 months. See Section 3.03 for additional information and the requirements for electing COBRA Continuation Coverage.

You should contact the Fund Office if a Qualified Medical Child Support Order (QMCSO) has been issued as a result of your divorce or legal separation. A QMCSO may affect benefit coverage for your Dependents. Therefore, it is important to notify the Fund Office immediately to avoid unnecessary delays in claim payments or denial of benefits.

Contact the Fund Office in writing within 60 days of losing eligibility; and
Enroll for COBRA Continuation Coverage.

1.05 Child Loses Eligibility.

In general, your child is no longer eligible for coverage when your child is no longer dependent on you for support or reaches age 19 (age 23 if a full-time student). However, if your child is mentally or physically disabled before reaching age 19 and continues to be mentally or physically disabled and dependent on you for more than half of their support and maintenance, that child will continue to be covered as your Dependent. You should notify the Fund Office immediately when your child is no longer eligible for coverage.

Your Dependent child may consider applying for COBRA coverage as your child nears the age of 19 or 23 (if a full-time student). Your Dependent child may, if eligible, elect to continue coverage under COBRA for up to 36 months. However, if you do not notify the Fund Office that your child is no longer a Dependent within 60 days of the time that your child loses Dependent status, your child will not be eligible to elect COBRA Continuation Coverage. See Section 19.01 for a definition of Dependent and full-time student and see Section 3.03 for the rules governing COBRA coverage.

1.06 Your Spouse Loses a Job or Takes a New Job.

When your spouse loses employer-provided insurance due to the loss of employment, you should contact the Fund Office to let them know that this Plan’s coverage will be primary. Please provide a copy of the letter from your spouse’s insurance carrier advising as to the date of termination.

If your spouse takes a new job and enrolls in the coverage offered by your spouse’s employer, then this Plan will cover your spouse’s medical expenses as the secondary plan under the coordination of benefits provisions.

1.07 Leave of Absence.

If you take maternity or paternity leave, a leave of absence under the Family and Medical Leave Act (FMLA) or if you take military leave under the Uniformed Services Employment and Reemployment Rights Act (USERRA), your eligibility under this Plan may be affected. You should refer to the explanation of these types of leave in Section 3.01(I) and Section 3.01(J).

1.08 In the Event of Your Disability.

If you become disabled because of a certified disability, you will be eligible for Weekly Accident and Sickness Disability Benefits for a maximum of 26 weeks. During that time, you will be credited with disability hours to help maintain your eligibility under the Plan. When your coverage ends, you may elect COBRA coverage as explained in Section 3.03.

Provide a copy of your death certificate;
Apply for the Death Benefit, if eligible; and
Enroll and pay for COBRA to continue Plan coverage.

1.09 Enroll and pay for COBRA to continue Plan coverage,
or In the Event of Your Death.

At the time of your death, your spouse or beneficiary should notify the Fund Office and provide a copy of your death certificate. Your spouse or beneficiary should complete a Death Benefit application from the Plan and/or an application for Accidental Death and Dismemberment Benefits, if applicable. If your spouse and Dependents are covered under the Plan on the date of your death, their eligibility will continue for as the hours in your Accumulation Account allow. Then, they may continue health care coverage for up to 36 months by electing COBRA Continuation Coverage and making the necessary self-payments. There is also Enhanced Continuation Coverage for surviving spouses who are age 60 to 65 at the time of the employee’s death as explained in Section 3.03(F).

If you are retired at the time of your death, your surviving spouse and Dependents may be eligible for continuation of your Retiree coverage. To determine if your spouse and/or Dependents are eligible to continue coverage under the Retiree health plan, please review the information in Section 3.02 or contact the Fund Office.

1.10 When You Stop Working.

If you are eligible for Active Employee Benefits, coverage for you and your Dependents will end on the last day of any benefit quarter for which you do not have the required hours of contributions in your Accumulation Account. You may elect COBRA Continuation Coverage when your coverage ends, as explained beginning in Section 3.03.

When you retire, you may continue coverage if you meet the requirements for Retiree coverage. Retiree coverage converts to Supplemental Medical Benefits when you become eligible for Medicare.

1.11 When You Retire.

When you retire, if you are not yet eligible for Medicare, you may continue coverage if you meet the Plan’s requirements for Retiree coverage. If you retired and are eligible for Medicare, the Plan provides a Supplemental Medical Benefit that supplements the benefits you receive from Medicare. See the Schedule of Benefits in Section 2 and Section 3.02 regarding Retired Employee Eligibility.

Section 2: Schedules of Benefits

A Schedule of Benefits is a list of benefit amounts and exclusions that apply to the plan of benefits. Each specific benefit is described in more detail in the section concerning that particular benefit. When reading the specific benefit section you should reference the applicable Schedule of Benefits and vice versa. If there is a discrepancy between the Schedule and a specific Plan section, the specific Plan section will usually govern. However, the Board has discretionary decision making authority to interpret the terms of the Plan.

This Section provides information for each type of participant under the Plan. Section 2.01 provides a Schedule for Active Employees. Section 2.02 provides a Schedule for Retired Employees not yet eligible for Medicare. Section 2.03 provides a Schedule for Retired Employees who are eligible for Medicare. Section 2.04 provides Schedules for Prescription and Specialty Drug Benefits for Active and Retired Employees

The following Schedule provides an overview of the benefits that apply to each type of participant.

Benefit	Active Employees	Retired Not Yet Eligible for Medicare*	Retired Eligible for Medicare*
Major Medical; Section 7	x	x
Supplemental Medical; Section 8			x
Prescription Drug; Section 9	x	x	x
Dental; Section 10	x
Vision; Section 11	x
Employee Assistance Plan; Section 12	x	x
Hearing Aid Benefit; Section 13	x	x
Hospice Benefits; Section 14	x	x

* When you retire; if you meet the eligibility requirements for retiree medical benefits, those benefits will commence after eligibility for active Employee benefits ceases due to the exhaustion of your Accumulation Account.

2.01 Schedule of Benefits for Active Employees.

Benefit	Benefit Amount or Limitation

*Death Benefit for Active Employees Only*	$10,000

*Accidental Death and Dismemberment Benefit for Active Employees Only*
For loss of:
Life	$10,000
Both hands, both feet, or sight of both eyes	$10,000
One hand and one foot, one hand and sight of one eye, or one foot and sight of one eye	$10,000
One hand, one foot, or sight of one eye	$5,000
*Weekly Accident and Sickness Disability Benefit for Active Employees Only*
Weekly Benefit Amount	$350
Maximum Number of Weeks of Benefit	26
*Medical Expense Benefits for Active Employees and Dependents*
*Calendar Year Deductible*	$300 per Person Maximum 3 deductibles per Family
*Maximum Benefit*
Maximum per Disability	$1,000,000 per Person
Spinal Manipulation Maximum (including diagnostic tests)	$1,000 per Calendar Year (for covered individuals age 16 and older)
Confinement in a Skilled Nursing Care Facility	60 Days per Confinement
*Covered Expenses Payable by the Fund up to the Usual and Customary Fees*	*PPO Charges*	*Non-PPO Charges*
Physician, Hospital/Facility (inpatient and outpatient)	85%	75%
Skilled Nursing Care	60 days per confinement; See Sec. 7.08 (A) (11)
*Out-of-Pocket Maximum per Calendar Year* Out-of-Pocket Maximum Does Not Include: · Deductible Amount · Prescription Drug Copayments · Dental Expense Payments · Vision Care Expense Payments · Copayments for Outpatient Treatment of Mental and Nervous Disorders, or Chemical Dependency	$1,000 per Person for PPO expenses $2,500 per Person for Non-PPO expenses Once you reach the Out-of-Pocket Maximum, the Plan pays 100% of allowable expenses for the calendar year up to the Maximum Benefit listed above. Expenses that apply towards the Non-PPO out-of-pocket limits apply towards the PPO out-of-pocket limits and vice versa.

Note: Durable Medical Equipment and Local Ambulance Service for which PPO services are not available will be covered the same as PPO charges

*Mental and Nervous Disorders*	*PPO Charges*	*Non-PPO Charges*
Outpatient	50%	50%
Inpatient	85%	75%
*Chemical Dependency*	*PPO Charges*	*Non-PPO Charges*
Outpatient	50%	50%
Inpatient	85%	75%
Inpatient Maximum	$6,000 per Course of Treatment Limited to Two Courses of Treatment per Lifetime