ITPE Health & Welfare Plan

• Death Benefits
• Accidental Death and Dismemberment Benefits
• Survivor Income
• Medical Care
• Dental Care
• Vision Care
• Scholarship Program
• Sickness and Accident Benefits
• Prescription Drug Coverage

1. 100% to any surviving spouse.
2. If there is no surviving spouse, the benefits will be divided equally by any surviving children.
3. If there is no surviving spouse or children, the benefits will be divided equally among the surviving parents.
4. If there are no surviving spouses, children or parents, benefits will be divided equally among surviving brothers and sisters.
5. If there are no surviving spouse, children, parents or brothers and sisters, the benefits will be paid to the executor or administrator of your estate.
6. If your beneficiary is a minor or incompetent, any benefits due as a result of your death shall be paid to the legally appointed guardian of your beneficiary.

• Surgical reconstruction of the breast on which the mastectomy has been performed;
• Surgical reconstruction of the other breast to produce a symmetrical appearance;
• Prostheses and treatment of physical complications, including lymphedemas, associated with all stages of the mastectomy procedure. Your benefit will be determined by your Class of Coverage and the type of benefits which are provided by your Schedule of Benefits.

• Both Feet
• Both Hands
• One Hand and One Foot
• One Hand and Sight of One Eye
• One Foot and Sight of One Eye
• Sight of Both Eyes

• One Hand
• One Foot
• Sight of One Eye

1. Intentionally self-inflicted injuries while sane
2. Declared or undeclared war or act of war
3. Commission of a crime by you
4. Travel or flight (including getting in or out, on or off) any aircraft or device which can fly above the earth's surface, except as a passenger on a regular commercial airliner
5. Sickness, disease or bodily infirmity
6. Injury or death for which the employee is entitled to benefits under any worker's compensation or occupational disease law.
7. Voluntary self-administration of any drug or chemical substance not prescribed by and taken according to the directions of a licensed physician. (Accidental ingestion of a poisonous substance is not excluded)
8. Riding or driving in any kind of a race

1. Other plans which cover people as a group;
2. A self-insured or non-insured plan or other plan which is arranged through an employer, trustee or union;
3. A pre-payment plan which provides medical, vision, dental or health service;
4. Government plans which are in effect on the date the ITPE Health and Welfare Plan becomes effective;
5. Group auto insurance;
6. Single or family subscribed plans issued under a group, blanket or franchise type plan.

1. If two or more plans cover a husband or wife, benefits shall be paid in this order:
   1. Plan of spouse for whom the claim is incurred;
   2. Plan of the other spouse.

2. If two or more plans cover a dependent child, benefits shall be paid in this order:
   1. Plan of parent with earlier birthdate in a calendar year;
   2. The plan of the parent with the later birthdate in a calendar year.

3. If two or more plans cover a dependent child of divorced or separated parents, benefits shall be paid in this order:
   1. The plan of the parent who is obligated to pay medical benefits to the child under a Qualified Medical Support Order;
   2. The plan of the parent with custody of the child;
   3. The plan of the spouse of the parent having custody of the child
   4. The plan of the parent not having custody of the child.

1. Any person to whom, or for whom, the benefits were paid; and/or
2. The other companies or organizations liable for the benefit payments.

1. Care, supplies, or equipment not Medically Necessary, as determined by the Plan, for the treatment of an Injury or illness. The determination whether care, supplies or equipment are Medically Necessary shall be made by the Trustees, or their designee, in their absolute discretion and in accordance with the provisions of Section 19 of the Plan Document which is contained at page 112 of the plan booklet and on the website as Section 19.
2. Services rendered or supplies provided before coverage begins, i.e., before a Participant's Effective Date, or after coverage ends. Such services and supplies shall include, but not be limited to Inpatient Hospital admissions which begin before a Participant's Effective Date, continue after the Participant's Effective Date, and are covered by a prior carrier.
3. Any services rendered or supplies provided while you are confined in a facility which does not meet the definition of "hospital" as set forth at Section 1.12 of the Plan booklet and on the website as Definitions.
4. Any services rendered or supplies provided while you are a patient or receive services at or from a person or entity which does not meet the definition of "health care provider" set forth at Section 1.11 of the Plan booklet and on the website as Definitions.
5. Any portion of a provider's fee or charge which is ordinarily due from a Participant, but which has been waived. If a provider routinely waives (does not require the Participant to pay) a Deductible or an Out-of-Pocket amount, the Claims Administrator will calculate the actual provider fee or charge by reducing the fee or charge by the amount waived.
6. Care for any condition or Injury recognized or allowed as a compensable loss through any Workers' Compensation, occupational disease or similar law.
7. Any disease or Injury resulting from a war, declared or not, or any military duty or any release of nuclear energy. Also excluded are charges for services directly related to military service provided or available from the Veterans' Administration or military medical facilities as required by law.
8. Any item, service, supply or care not specifically listed as a Covered Service in this Plan Document.
9. Care given by a medical department or clinic run by your Employer.
10. Admission or continued Hospital or Skilled Nursing Facility stay for medical care or diagnostic studies not medically required on an Inpatient basis.
11. Care of corns, bunions (except capsular or related surgery), calluses, toenail (except surgical removal or care rendered as treatment of the diabetic foot or ingrown toenails), flat feet, fallen arches, weak feet, chronic foot strain, or asymptomatic complaints related to the feet.
12. Daily room charges while this Plan is paying for an Intensive Care, cardiac care, or other special care unit.
13. Vision therapy unless needed due to intraocular surgery.
14. Hearing aids, hearing devices and related or routine examinations and services.
15. Routine physical examinations, screening procedures, and immunizations necessitated by employment, foreign travel or participation in school athletic programs, recreational camps or retreats, which are not called for by known symptoms, illness or injury except those which may be specifically listed herein.
16. The following items related to Durable Medical Equipment are specifically excluded:
    • Bed related items: bed trays, over the bed tables, bed wedges, custom bedroom equipment, nonpower mattresses, pillows, posturepedic mattresses, low air mattresses (powered), alternating pressure mattresses;
    • Bath related items: bath lifts, nonportable whirlpool, bathtub rails, toilet rails, raised toilet seats, bath benches, bath stools, hand held showers, paraffin baths, bath mats, spas;
    • Chairs, Lifts and Standing Devices: computerized or gyroscopic mobility systems, roll about chairs, geri chairs, hip chairs, seat lifts (mechanical or motorized), patient lifts (mechanical or motorized - manual hydraulic lifts are covered if the patient is two-person transfer), vitrectomy chairs, auto tilt chairs and fixtures to real property (ceiling lifts, wheelchair ramps, automobile lift customizations);
    • Air quality items: room humidifiers, vaporizers, air purifiers, electrostatic machines;
    • Blood/injection related items: blood pressure cuffs, centrifuges, nova pens, needle-less injectors;
    • Pumps: back packs for portable pumps;
    • Dialysis Machines;
    • Other equipment: heat lamps, heating pads, cryounits, ultraviolet cabinets, sheepskin pads and boots, postural drainage board, AC/DC adapters, Enuresis alarms, magnetic equipment, scales (baby and adult), stair gliders, elevators, saunas, exercise equipment, diathermy machines.
17. Custodial Care, domiciliary care, rest cures, or travel expenses even if recommended for health reasons by a Physician. Inpatient room and board charges in connection with a Hospital or Skilled Nursing Facility stay primarily for environmental change, Physical Therapy or treatment of chronic pain, except as specifically stated as Covered Medical Expenses. Transportation to another area for medical care is excluded except when Medically Necessary for a Participant to be moved by ambulance from one Hospital to another Hospital. Ambulance transportation from the Hospital to the home is not covered.
18. Services provided by a rest home, a home for the aged, a nursing home or any similar facility.
19. Services provided by a Skilled Nursing Facility.
20. Cosmetic Surgery, reconstructive surgery, pharmacological services, nutritional regimens or other services for beautification, or treatment relating to the consequences of, or as a result of, Cosmetic Surgery, unless treatment relating to such consequences is medically necessary. This exclusion includes, but is not limited to, surgery to correct gynecomastia and breast augmentation procedures, and otoplasties. Reduction mammoplasty and services for the correction of asymmetry, except when determined to be medically necessary, are not covered.
    • This exclusion does not apply to surgery to restore function if any body area has been altered by disease, trauma, congenital/developmental anomalies, or previous therapeutic processes. This exclusion does not apply to surgery to correct the results of injuries when performed within 2 years of the event causing the impairment, or as a continuation of a staged reconstruction procedure, or congenital defects necessary to restore normal bodily functions, including but not limited to, cleft lip and cleft palate.
    • This exclusion does not apply to Breast Reconstructive Surgery.
21. Complications of non-covered procedures are not covered.
22. Any services or supplies for the treatment of obesity, including but not limited to, weight reduction, medical care or Prescription Drugs, nutritional counseling or dietary control. Nutritional supplements; services, supplies and/or nutritional sustenance products (food) related to enteral feeding except when it's the sole means of nutrition. Food supplements. Services of Inpatient treatment of bulimia, anorexia or other eating disorders which consist primarily of behavior modification, diet and weight monitoring and education. Any services or supplies that involve weight reduction as the main method of treatment, including medical or psychiatric care or counseling. Weight loss programs, nutritional supplements, appetite suppressants, and supplies of a similar nature. Procedures including but not limited to liposuction, gastric balloons, jejunal bypasses, and wiring of the jaw.
23. Surgical or medical treatment or study related to the modification of sex (transsexualism) or medical or surgical services or supplies for treatment of sexual dysfunctions or inadequacies, including treatment for impotency (except male organic erectile dysfunction).
24. Transportation provided by other than a state licensed professional ambulance service, and ambulance services other than in a medical emergency.
25. Hair transplants, hair pieces or wigs (except when necessitated by disease), wig maintenance, or prescriptions or medications related to hair growth.
26. Advice or consultation given by any form of telecommunication.
27. Services and supplies for which you have no legal obligation to pay, or for which no charge has been made or would be made if you had no health insurance coverage.
28. Charges for failure to keep a scheduled visit or for completion of claim forms; for Physician or Hospital's stand-by services; for holiday or overtime rates.
29. The following forms of therapy: vestibular rehabilitation, primal therapy, chelation therapy, rolfing, psychodrama, megavitamin therapy, purging, bioenergetic therapy, cognitive therapy, electromagnetic therapy, vision perception training (orthoptics), salabrasion, chemosurgery and other such skin abrasion procedures associated with the removal of scars, tattoos, actinic changes and/or which are performed as a treatment for acne, services and supplies for smoking cessation programs and treatment for nicotine addiction, and carbon dioxide.
30. Radial keratotomy; and surgery, services or supplies for the surgical correction of nearsightedness and/or astigmatism or any other correction of vision due to a refractive problem.
31. Treatment where payment is made by any local, state, or federal government (except Medicaid), or for which payment would be made if the Participant had applied for such benefits. Services that can be provided through a government program for which you as a member of the community are eligible for participation. Such programs include, but are not limited to, school speech and reading programs.
32. Services paid under Medicare or which would have been paid if the Participant had applied for Medicare and claimed Medicare benefits. With respect to end-stage renal disease (ESRD), Medicare shall be treated as the primary payor whether or not the Participant has enrolled in Medicare Part B.
33. Those charges in excess of the usual, customary and reasonable amount for the area. A determination as to whether charges are excessive shall be made by the Trustees, or their designee, in their absolute discretion in accordance with the provisions of Section 19 of this Plan.
34. Services related to or performed in conjunction with artificial insemination, in-vitro fertilization or a combination thereof.
35. Biofeedback, recreational, educational or sleep therapy or other forms of self-care or self-help training and any related diagnostic testing.
36. Personal comfort items such as those that are furnished primarily for your personal comfort or convenience, including those services and supplies not directly related to medical care, such as guests' meals and accommodations, barber services, telephone charges, radio and television rentals, homemaker services, travel expenses, and take-home supplies.
37. Educational services and treatment of behavioral disorders, together with services for remedial education including evaluation or treatment of learning disabilities, minimal brain dysfunction, developmental and learning disorders, behavioral training, and cognitive rehabilitation.
38. Injuries received while committing a crime.
39. Biomicroscopy, field charting or aniseikonic investigation.
40. Orthoptics (a technique of eye exercises designed to correct the visual axes of eyes not properly coordinated for binocular vision) or visual training.
41. Non-emergency treatment of chronic illnesses received outside the United States performed without authorization.
42. Any drug or other item which does not require a prescription.
43. Court-ordered services, or those required by court order as a condition of parole or probation.
44. Hypnotherapy.
45. Religious, marital and sex counseling, including services and treatment related to religious counseling, marital/relationship counseling and sex therapy.
46. Specific non-standard allergy services and supplies, including but not limited to, skin titration (Rinkle method), cytotoxicity testing (Bryan's Test), treatment of non-specific candida sensitivity, and urine autoinjections.
47. Specific medical reports, including those not directly related to treatment of the Participant, e.g., employment or insurance physicals, and reports prepared in connection with litigation.
48. Thermograms and thermography.
49. Elective abortions.
50. Substance Abuse Treatment.
51. Skilled Nursing Facilities.
52. Private Duty Nursing.
53. Injuries incurred as a result of a suicide attempt, or intentionally self-inflicted injury while sane.
54. Custodial Care, domiciliary care, rest cures or travel expenses even if recommended for health reasons by a Physician.
55. Any item, service, supply or care not specifically listed as a covered service in this Plan.
56. Services or supplies not prescribed or directed by a Physician.
57. Court ordered examinations or care.
58. Stop smoking aids, or services of stop-smoking clinics.
59. Physical therapy to maintain motor functions unless there is a chance of improvement or reversal.
60. Conditions related to autistic disease of childhood, hyper-kinetic syndromes, learning disabilities, behavioral problems, mental retardation or hospitalization for environment changes.
61. Services provided by a family member or by a provider's employee to a co- worker.
62. Experimental or investigative procedures
63. Those charges for examination or tests for check-up purposes which are not incidental to and necessary for the treatment of illness or injury.
64. Charges for cosmetic corrective eye surgery.

• When you use Blue Cross Blue Shield Network hospitals and physicians your ITPE Health and Welfare Plan benefits last longer, as the charges you incur are discounted. This means you have more benefits when you need them, as the benefits limits that apply to your contribution rate and hours will stretch further,
• Network physicians and hospitals may not bill you beyond the discounted fees which are billed for the services provided. However, non-Network Health Care Providers who charge more than reasonable and customary amounts as determined by Blue Cross Blue Shield, may bill you for charges above the amounts which are paid by the Fund.

• Hospital In-Patient Service for Treatment for Conditions Other than Mental Health Disorders-Charges made by a Hospital, on its own behalf, for room and board at semi-private room rate, for ICU/CCU charges, general nursing care and other necessary services and supplies, provided, that if the Hospital only has private rooms, the covered charges shall be based on the Hospital's prevailing room rate;
• Ambulance Services-Charges for licensed ambulance service to or from the nearest Hospital where the needed medical treatment can be provided. Air ambulance is covered subject to Medical Necessity;
• Hospital Out-Patient Services-Charges made by a Hospital, on its own behalf, for medical care and treatment received as an outpatient;
• Free-Standing Surgical Facility Services-Charges made by a free-standing surgical facility, on its own behalf, for medical care and treatment;
• Rehabilitation hospital and Subacute Facility Services-Charges made by a Rehabilitation Hospital or a subacute facility, on its own behalf, for medical care and treatment, provided that such medical care and treatment is associated with a prior hospitalization and, provided further, that the Fund shall pay for no more than ten (10) days of such medical care and treatment at a Rehabilitation Hospital or subacute facility;
• Physician Services-Charges made by a Physician for professional services;
• Anesthetics Chemo Therapy Services, Etc.-Charges made for anesthetics and their administration; chemotherapy; blood transfusions and blood not donated or replaced; oxygen and other gasses and their administration; prosthetic appliances; and dressings;
• TMJ-Charges made for surgical and non-surgical care of Temporomandibular Joint Dysfunction (TMJ), up to a lifetime maximum of $15,000.00;
• Laboratory Radiation Services, Etc.-Charges made for laboratory services, radiation therapy and other diagnostic and therapeutic and radiological procedures;
• Dependent Child Screening and Care-Charges, as prescribed or ordered by a Physician, for a Dependent child up to age 18 for (a) hereditary and metabolic screening at birth, (b) immunizations, (c) urinalysis, (d) tuberculin tests, and (e) blood tests including hematocrit, hemoglobin, and for screening for sickle hemoglobinpathy;
• Mammogram and PAP Tests-Charges made for and in connection with a baseline mammogram, an annual screening mammogram, or pap tests on an annual basis or more frequently if certified as medically necessary by the attending Physician;
• Mental Health Services-Charges made by a hospital for in-patient treatment of a Mental Health Disorder up to a maximum of 7 days per calendar year, subject to the requirements governing hospital in-patient service, and
  Charges made by a Physician for out-patient treatment of a Mental Health Disorder up to a maximum of 20 calendar visits per year.
• External Prosthetic Appliances-Charges made for the purchase and fitting of external prosthetic devices ordered or prescribed by a Physician which are to be used as replacements or substitutes for missing body parts and are necessary for the alleviation or correction of sickness, injury or congenital defect. The following items shall not be considered Prosthetic Appliances: Corrective shoes, dentures, replacing teeth or structures directly supporting teeth (except to correct traumatic injuries), electric or magnetic continence aids (either anal or urethral), hearing aids or hearing devices, implants for cosmetic purposes (except for reconstruction following a mastectomy).
• Short Term Rehabilitative Therapy and Chiropractic Care Services- Charges made for Short-Term Rehabilitative Therapy that is part of a rehabilitation program, including physical, speech, occupational, cognitive, cardiac rehabilitation and pulmonary rehabilitation therapy, when provided in the most medically appropriate setting. Also included are services that are provided by a Participating Chiropractic Physician when provided in an outpatient setting pursuant to a written treatment plan which is in accordance with the generally accepted chiropractic standard of care. Services of a Chiropractic Physician include the management of neuromusculoskeletal conditions through manipulation and ancillary physiological treatment that is rendered to restore motion, reduce pain and improve function.

Limitations on Short-Term Rehabilitative Therapy and Chiropractic Care Services

The following limitations apply to Short-Term Rehabilitative Therapy and Chiropractic Care services:

• Services which are considered custodial or educational in nature are not covered;
• Occupational therapy is provided only for purposes of enabling you to perform the activities of daily living;
• Speech therapy is not covered when (a) used to improve speech skills that have not fully developed except when speech is not fully developed in children due to underlying disease or malformation that prevented speech development; (b) intended to maintain speech communication; or (c) not restorative in nature.
• If multiple out-patient services are provided on the same day they constitute one visit, but a separate payment will apply to the services provided by each provider.

Limitations on Number of Visits per Calendar Year for Therapy Services

• The Fund shall not pay for speech therapy, physical or occupational therapy, or respiratory therapy visits in excess of the following number per calendar year:
• Speech Therapy-20 visit calendar year maximum;
• Physical or Occupational Therapy-30 visit calendar year maximum;
• Respiratory Therapy-30 visit calendar year maximum

Organ Transplant Services:

The detailed rules governing the circumstances under which the Plan will pay for organ transplant services are set forth at Section 9.03(b)(15) of the Plan Document contained at page 85 of this booklet.

• Breast Reconstruction and Breast Prostheses-Charges made for reconstructive surgery following a mastectomy; benefits include: (a) surgical services for reconstruction of the breast on which surgery was performed; (b) surgical services for reconstruction of the nondiseased breast to produce symmetrical appearance; (c) postoperative breast prostheses; and (d) mastectomy bras and external prosthetics, limited to the lowest cost alternative available that meets external prosthetic placement needs. During all stages of mastectomy, treatment of physical complication, including lymphedema therapy, are covered.
• Durable Medical Equipment- Except for the exclusions set forth below, charges for the rental of Durable Medical Equipment (up to the purchase price of the equipment) that is ordered or prescribed by a physician and is appropriate for in home use, provided that such equipment is used to improve the functions of a malformed part of the body or to prevent or slow further decline of the patient's medical condition. Charges for repair, replacement or duplicative equipment shall be paid only when required due to anatomical change and/or reasonable wear and tear. All maintenance and repairs that result from a Participant's misuse shall be the responsibility of the Participant.


Definition of "Durable Medical Equipment":
The term "Durable Medical Equipment" is defined as equipment which meets the following criteria:
• It can stand repeated use;
• It is manufactured solely to serve a medical purpose;
• It is not merely for comfort or convenience;
• It is normally not useful to a person not ill or injured;
• It is ordered by a physician;
• The physician certifies in writing the medical necessity for the equipment;
• The physician also states the length of time the equipment will be required;
• It is related to the patient's physical disorder.


Durable Medical Equipment Items Excluded from Coverage:
Expenses for the following Durable Medical Equipment items shall not be considered "covered medical expenses":
• Bed related items: bed trays, over the bed tables, bed wedges, custom bedroom equipment, non-power mattresses, pillows, posturepedic mattresses, low air mattresses (powered), alternating pressure mattresses;
• Bath related items: bath lifts, non-portable whirlpool, bathtub rails, toilet rails, raised toilet seats, bath benches, bath stools, hand held showers, paraffin baths, bath mats, spas;
• Chairs, Lifts and Standing Devices: computerized or gyroscopic mobility systems, roll about chairs, geri chairs, hip chairs, seat lifts (mechanical or motorized), patient lifts (mechanical or motorized - manual hydraulic lifts are covered if the patient is two-person transfer), vitrectomy chairs, auto tilt chairs and fixtures to real property (ceiling lifts, wheelchair ramps, automobile lift customizations);
• Air quality items: room humidifiers, vaporizers, air purifiers, electrostatic machines;
• Blood/injection related items: blood pressure cuffs, centrifuges, nova pens, needle-less injectors;
• Pumps: back packs for portable pumps;
• Dialysis Machines;
• Other equipment: heat lamps, heating pads, cryounits, ultraviolet cabinets, sheepskin pads and boots, postural drainage board, AC/DC adapters, Enuresis alarms, magnetic equipment, scales (baby and adult), stair gliders, elevators, saunas, exercise equipment, diathermy machines.
• Hospital Emergency Room Services: Charges for hospital emergency room care in connection with a "Medical Emergency". For purposes of this Section 9.03(b)(18) the term "Medical Emergency" shall mean "a condition of recent onset and sufficient severity including, but not limited to severe pain, that would lead a prudent lay person, possessing an average knowledge of medicine and health, to believe that his or her condition, sickness or injury is of such a nature that failure to obtain immediate medical care could place his or her life in danger or cause serious harm".

• Birth to 1 year: 6 office visits per year and immunizations for hepatitis b, diphtheria, polio, measles, mumps, red measles, and influenza
• 1 year to age 3: 2 office visits per year and necessary immunizations as stated above
• 3 years through age 5: 1 office visit per year and necessary immunizations as stated above
• 2 blood and urine tests and 3 TB tests are covered from birth to age 5
• Immunizations for dependent children under age 19 are covered

• Once as a base-line mammogram for any female between 35 and 40 years of age;
• Once every year for every female age 40 or above; and
• When recommended by a Physician for a female considered at risk:
• who has a personal history of breast cancer;
• who has a personal history of biopsy-proven benign breast disease;
• whose grandmother, mother, sister, or daughter has had breast cancer; or
• who has not given birth prior to age 30.

• 1 Pap smear tissue examination per year or more often when ordered by a physician.

• 1 annual Chlamydia screening test for female Participants who are not more than 29 years old;
• or covered females who are more than 29 years of age if ordered by a physician.

• Annual prostate specific antigen test for covered males who are 45 years of age or older;
• Or covered males who are 40 years of age or older, if ordered by a physician.

• Is licensed as a birthing center in the jurisdiction in which it is located.
• Is set up, equipped and run to provide prenatal care, delivery and immediate postpartum care.
• Charges for services and supplies it provides.
• Is directed by at least one physician who is a specialist in obstetrics and gynecology.
• Has a physician or certified nurse midwife present at all births and during the immediate postpartum period.
• Extends staff privileges to physicians who practice obstetrics and gynecology in an area hospital.
• Has at least 2 beds or 2 birthing rooms for use by patients while in labor and during delivery.
• Provides, in the delivery and recovery rooms, full time skilled nursing services directed by an R.N. or certified nurse midwife.
• Provides, or arranges with a facility in the area for, diagnostic x-ray and lab services for the mother and child.
• Has the capacity to administer a local anesthetic and to perform minor surgery. This includes measures to sustain life.
• Is equipped and has a trained staff to handle medical emergencies and provide immediate support measures to sustain life: If complications arise during labor, and if a child is born with an abnormality which impairs function or threatens life.
• Accepts only patients with low risk pregnancies.
• Has a written agreement with a hospital in the area for emergency transfer of a patient or a child. Written procedures for such a transfer must be displayed and the staff must be aware of them.
• Provides an ongoing quality assurance program. The program must include reviews by M.D.'s or D.O.'s who do not own or direct the facility.
• Keeps a medical record on each patient and child.

• Any medications which have been withdrawn from the market by the Food and Drug Administration,
• Any medications which have not been approved for use by the Food and Drug Administration,
• Any medication imported into the United States without the approval of the U.S. Food and Drug Administration,
• Any drug which can legally be bought without a prescription,
• Therapeutic devices or appliances or other non-medical substances, regardless of their intended use,
• Administration or injection of any drug,
• Administration of allergy shots,
• Drugs used to treat obesity or assist weight reduction; anorexiants,
• Immunization agents, biological sera, blood and blood plasma,
• Any drug for cosmetic purposes,
• Rogaine and like drugs,
• Retin-A for a Participant over age 30,
• Any prescription refilled in excess of the number of refills specified in the prescription or any prescription or refill dispensed more than one year after the original prescription,
• Any drug which is dispensed to, administered to, or consumed by a participant in whole or in part, while a patient in a licensed hospital or other institution covered by this plan,
• Any drug which is consumed or administered at the place where it is dispensed,
• Prescriptions filled prior to the effective date or after the termination date of the participant's coverage, regardless of when the prescription was issued,
• Drugs labeled "Caution - Limited by Federal law to Investigational Use"; drugs which are experimental or investigational in nature, or which are in connection with experimental or investigative services or supplies, medications or supplies rendered to a participant.
• Prescription drugs utilized in connection with in vitro fertilization, gamete intrafallopian transfer (GIFT), zygote intrafallopian transfer (ZIFT), or like procedures.

• Any loss or expense caused, incurred for, or resulting from:
1. Procedures or supplies furnished on account of visual defect which arises out of or in the course of your or your Dependent's job;
2. Declared or undeclared war, or any act thereof or military or naval service for any country;
3. Any medical or surgical treatment of the eye;
4. Sunglasses plain or prescription, or safety lenses or goggles;
5. Othoptics, vision training or aniseikonia.

1. Diagnostic service/office visits, consultation, diagnostic procedures;
2. Oral surgery - extractions or other dental surgical procedures including pre and post-operative care;
3. Restorative dentistry - amalgam, synthetic porcelain and plastic restorations; or, in the event it is determined by the dentist that restoration is not practicable by means of a filling material, gold restoration by means of crowns, and jackets;
4. Endodontics - Pulp therapy and root canal filling;
5. Preventative - Sealants coverage is for dependent children only and shall extend only to age 15 years;
6. Periodontics - All necessary procedures for the treatment of diseases of the gums and bones supporting the teeth.

1. After a period of twelve (12) consecutive months during which the employee has been continually eligible for benefits.
2. With respect to one prosthetic appliance in any period of five (5) consecutive years.

1. Any charges whatsoever that were incurred prior to the effective date of your eligibility for benefits under the Fund;
2. Charges incurred in connection with treatment of a congenital malformation except that this exclusion shall not apply to such charges when they are incurred following a period of thirty-six (36) consecutive months during which the person has been continuously eligible for benefits under the Fund;
3. Charges incurred in connection with any treatment to the teeth or gums for tumors;
4. Charges incurred for services purely cosmetic in nature;
5. Charges incurred for services or supplies that are unreasonably priced or not reasonably necessary in light of the dental procedure being treated; for purpose of determining whether a particular charge comes within this exclusion, the Fund will take into consideration the fees and prices generally charged and the services and supplies generally furnished in the area concerned for cases comparable to the case being treated, and in no event shall payment for fees and charges equivalent to those made by the California Medical Assistance (commonly referred to as Medi-Cal) in the area concerned be considered unreasonable; it being the intent of this exclusion that the benefits hereunder shall not cover charges for services or supplies that a reasonable person would consider to be priced unreasonably high or to be of a luxury nature;
6. Charges incurred in connection with any dental injury (a) which arises out of or in the course of any occupation or employment for wage or profit, or (b) for which the Employee or Dependent is entitled to benefits under any worker's compensation or occupational disease law;
7. Services furnished by a hospital or facility operated by any national, state, county or provincial government or political subdivision thereof or by any authorized agency thereof or furnished at the expense of such government or agency, unless a charge is made to the individual imposing an unconditional requirement of payment without regard to the existence of benefits. For example, if you are entitled to services at a facility operated by any agency of the federal government and such services are furnished at the expense of the government or agency involved, the Fund is not obligated to pay for such services;
8. Charges incurred in connection with orthodontic services. (Braces, etc.)

1. The Fund ceases to provide any medical, vision, dental care or prescription drug benefits to any active Employees; or
2. An Employee or Dependent fails to make timely payment of the premium required of such Employee or Dependent; or
3. The date an individual receiving Continuation of Coverage becomes entitled to Medicare; or
4. The date the Employee or Dependent becomes covered under another group health care plan because of a new job or marriage.

• The reason for the termination;
• The effective date of the termination; and
• Any right to elect alternative coverage.

1. The Fund Office shall send notice to all Employees and Dependents for whom they have received enrollment cards as described at page 10 of this booklet, notifying such Employees and Dependents of their rights to Continuation of Coverage for medical, vision , dental and prescription drug benefits.
2. Within 30 days of receipt of any enrollment card submitted by an Employee on or after October 1, 1987, the Fund Office will send a General Notice in conformity with applicable Federal law to such Employee and his or her Dependents informing them of their rights to Continuation of Coverage for medical, vision, dental and prescription drug benefits.
3. All Employers must notify the Fund Office within 30 days of the date of an Employee's death, termination of employment or reduction in weekly work schedule which results in such Employee being dropped to a lower Benefit Classification Level. In addition, the affected Employee may also give such notice to the Fund Office.
4. Each covered Employee or Dependent is responsible for notifying the Fund Office in the event of a divorce or legal separation of the Employee from his or her spouse, or a Dependent child ceasing to be a Dependent child under the requirements set out at page 68 of this booklet. Such Employee or Dependent must give notice to the Fund Office of such Qualifying Event within 60 days after the date of the Qualifying Event. In the event the Employee or Dependent does not give notice of such Qualifying Event to the Fund office within 60 days after its occurrence, such Employee and his or her Dependent shall lose eligibility for Continuation of Coverage.
5. Within 14 days of the date on which the Fund Office receives notice of a Qualifying Event from either the Employer, Employee or Dependent, the Fund Office shall notify such Employee and his or her Dependents of their rights to Continuation of Coverage for medical, vision, dental care and prescription drug benefits and shall submit appropriate claim forms to the said Employee and his or her Dependents for use in applying for Continuation of Coverage. Notification to the spouse of the Employee shall be considered notice to all other Dependents residing with such spouse at the time such notification is made. Such notification shall be in conformity with applicable Federal law.
6. If the Fund determines that an Employee or Dependent is not entitled to Continuation of Coverage, the Fund office shall so notify such Employee or Dependent within 14 days of the date the Fund office receives notice of a Qualifying Event. Such notice shall be in conformity with Federal law and shall explain why the Employee or Dependent is not entitled to Continuation of Coverage.

1. If an Employee or Dependent elects to receive continuation of Coverage, he or she must so notify the Fund Office, on forms prepared by the Fund Office, within 60 days after the latter of (i) the date that such Employee or Dependent would lose coverage for medical , vision, dental care and prescription drug benefits or have such coverage reduced by reason of a Qualifying Event, or (ii) the date such Employee or Dependent is sent notice by the Fund Office of his or her right to elect Continuation of Coverage. If such Employee or Dependent does not submit such notice to the Fund Office, on forms prepared by the Fund Office, within such 60 day period, the Employee or Dependent will not be eligible for Continuation of Coverage.
   
   Example 1
   An Employee is terminated from employment on October 1 and is sent notice of his or her right to elect Continuation of Coverage from the Fund Office on October 15th. The Employee, or his or her Dependent, must send a notice to the Fund Office on forms prepared by the Fund Office, electing to continue coverage no later than the 60th day following October 15.
   
   Example 2
   An Employee is terminated from employment on October 1 by reason of disability and is sent notice of his or her right to elect Continuation of Coverage from the Fund Office on October 15. Under the provision for Extension of Benefits During A Period of Disability spelled out in this booklet, the Employee and his or her Dependents retain their eligibility for benefits for a period of two months from the date of the Employee's last contribution period. Accordingly, the Employee or Dependent in this situation would be required to send notice of his or her election to continue coverage no later than the 60th day following the period ending two months after the date of his or her last contribution period.



2. In making such election to continue coverage, the Employee, spouse of such Employee or child of such Employee who has lost Dependent status, may separately elect to continue coverage for medical care benefits only or for medical, vision, dental care and prescription drug benefits. As described later in this booklet, the notice sent by the Fund Office to the Employee and his or her Dependents informing them of their rights to Continuation of Coverage shall include a description of the cost to the Employee and his or her Dependents if they elect coverage for medical care only or they elect coverage for medical, vision, dental care and prescription drug benefits. If an Employee makes an election to provide any Dependent with continuation of coverage, that election shall be binding on the Dependent or legal guardian. An election on behalf of an Employee or Dependent who is incapacitated may be made by the legal representative of such Employee or Dependent or by the spouse of such Employee or Dependent.


Cost to Employee or Dependent for Continuation of Coverage
1. The Trustees, in conjunction with the Fund actuary, shall calculate the cost of providing coverage for an Employee and/or his or her Dependents for medical care benefits only and for medical, vision, dental and prescription drug benefits together. The amount of the premium payable by the Employee and/or his or her Dependents shall be 102% of such cost calculated by the Trustees and Fund actuary. The Employee and his or her Dependents shall be notified of the amount of the applicable premium in the notice sent to the Employee and his or her Dependents by the Fund Office following the happening of the Qualifying Event.
2. Applicable premiums for Continuation of Coverage shall be established by the Trustees for each 12 month period commencing October 1. In the event there is an increase in the cost of the applicable premium which is put into effect by the Trustees on October 1 which falls within any Continuation of Coverage period, the Trustees shall notify the Employee and/or his or her dependents by October 15th. In such event, the Employee and/or his or her Dependents will be required to pay the increased applicable premium in order to continue eligibility for Continuation of Coverage.
3. In order to maintain eligibility for Continuation of Coverage an Employee and/or his or her Dependent must make premium payments no later than 30 days following the month for which they are eligible for such coverage. For example, an Employee or his or her Dependent must submit their payment no later than the end of January in order to insure Continuation of Coverage for the month of December.
4. If an election to obtain Continuation of Coverage is made by an Employee or Dependent after the date of the Qualifying Event, the Fund shall provide Continuation of Coverage for the period following the Qualifying Event and preceding the election date so long as the first premium payment is made within 45 days of the date the Employee and/or Dependent submits a notice of election to the Fund Office on forms prescribed by the Trustees.
5. In the event an Employee or Dependent fails to make timely payment of premiums as specified herein, they shall no longer be eligible for Continuation of Coverage.


Reminder: Remember, in order to be eligible for continuation of coverage you must satisfy the requirements for eligibility for benefits from the Fund as of the date before the "Qualifying Event". In addition, no Participant Employee or Dependant shall be eligible for continuation of coverage in the event he, she or they are covered by another Group Medical Plan.

Continuation of Coverage (Federal Law - USERRA)
Under the Uniformed Services Employment and Reemployment Rights Act of 1994 (USERRA), a Participant may have a right to continuation of benefits subject to the conditions described below.

Under USERRA, if the Employee (or his or her Dependents) is covered under this Plan, and if the Employee becomes absent from employment by reason of military leave, the Employee (or his or her Dependents) may have the right to elect to continue health coverage under the plan. In order to be eligible for coverage during the period that the Employee is gone on military leave, the Employee must give reasonable notice to the Employer of his or her military leave and the Employee will be entitled to COBRA-like rights with respect to his or her medical benefits in that the Employee and his or her Dependents can elect to continue coverage under the plan for a period of 18 months from the date the military leave commences or, if sooner, the period ending on the day after the deadline for the Employee to apply for or return to work with the Employer. During military leave the Employee is required to pay the Employer for the entire cost of such coverage, including any elected Dependents' coverage. However, if the Employee's absence is less than 31 days, the Employer must continue to contribute to the Fund on behalf of the Employee.

Also, when the Employee returns to work, if the Employee meets the requirements specified below, USERRA states that the Fund must waive any exclusions and waiting periods, even if the Employee did not elect COBRA continuation. These requirements are (i) the Employee gave reasonable notice to his or her Employer and the Fund of military leave, (ii) the military leave cannot exceed a prescribed period (which is generally five (5) years, except in unusual or extraordinary circumstances) and the Employee must have received no less than an honorable discharge (or, in the case of an officer, not been sentenced to a correctional institution), and (iii) the Employee must apply for reemployment or return to work in a timely manner upon expiration of the military leave (ranging from a single day up to 90 days, depending upon the period that he or she was gone). The Employee may also have to provide documentation to the Employer and the Fund upon reemployment that would confirm eligibility. This protection applies to the Employee upon reemployment, as well as to any Dependent who has become covered under the Plan by reason of the Employee's reinstatement of coverage.

Top of page

• The birth of a child of the Employee in order to care for such child;
• The placement of a child with the Employee for adoption or foster care;
• Caring for a spouse, child or parent who has a serious health condition;
• A serious health condition of the Employee which renders him or her unable to perform the functions of the position of such Employee.

1. Seriously jeopardize the life or health of the claimant or the ability of the claimant to regain maximum function; or


2. In the opinion of a physician with knowledge of the claimant's medical condition, would subject the claimant to severe pain that cannot be adequately managed without the care or treatment that is the subject of the claim.

1. The specific reason for the determination;
2. Reference to the specific claims provisions on which the determination is based;
3. A description of any additional material or information necessary for you to provide to the Plan and an explanation of why the information is necessary (if applicable);
4. A description of the Plan's Claim Review Procedures and Time Limits to appeal a denial, including a statement of your right to bring a civil action under Section 502 (a) of ERISA following an adverse benefit determination on review;
5. A statement of any specific internal rule, guideline, protocol or other matter that was relied upon in making the benefit denial;
6. If the denial is based on a medical necessity or experimental treatment exclusion, an explanation of the scientific or clinical judgment for the determination, applying the terms of the Plan to your medical circumstances;
7. In the case of a denial involving an urgent care claim, a description of the expedited review process applicable to such claims;
8. The identification of any medical experts whose advice was obtained on behalf of the Plan, whether or not that advice was relied upon in making the denial.