Summary of Benefits

Annual Deductible

$150 (per individual)

$300 (per family)

Annual Out-of-Pocket Maximum

$10,000 (per family, after meeting your annual deductible)

Annual Limits on Essential Health Benefits

NOTE: Different maximums apply to H Plan participants. See below and here for more information.

Lifetime Benefit Formula (for all covered expenses excluding prescription drugs other than immunosuppressant drugs prescribed in connection with organ transplants)

Once the Fund has provided $1 million in total benefits (essential and non-essential health benefits) on behalf of an individual, expenses that are considered essential health benefits are covered at 50% and non-essential health benefits are not covered

Dental Maximum

Dependent Children Under Age 18: No Limit

Members, Spouses, and Dependent Children Age 18 and Older: $2,000 per calendar year

Annual Limit on Essential Health Benefits for H Plan Participants

Maximum Lifetime Benefit of Non-Essential Health Benefits for H Plan Participants

Once the Fund has provided $100,000 in total benefits (essential and non-essential health benefits) on behalf of an individual, non-essential health benefits are not covered

Doctor’s Office Visits

80% of allowance, after annual deductible

Chiropractic Care (limited to 26 visits per calendar year, prior authorization required)

Emergency Medical Care expenses

Diagnostic Laboratory Pathology Tests and X-Ray Examination (outpatient)

Emergency Room treatment, if not hospitalized

Charges by physicians and surgeons in or out of the hospital

Durable Medical Equipment

Expenses up to $7,000 for each spell of illness

100% of allowance, no deductible applies

Expenses in excess of $7,000

80% of allowance, no deductible applies

Covered home health care visits by a registered or licensed practical nurse

80% of allowance, after annual deductible

Covered home health care visits by a home health care aide

100% of allowance, after annual deductible

Semi-private accommodations rate charged by discharging hospital

50% of actual charges, no deductible applies

Maximum days per spell of illness

60 days

Maximum benefit when combined with covered charges made by discharging hospital

$7,000

Covered Charges that exceed the maximum

80% of allowance, no deductible applies

Hospice Care (approved facility)

100% of actual charges, no deductible applies

Charges by physicians and surgeons in or out of the hospital

80% of allowance, after annual deductible

Assistant or co-surgeon

25% of allowance for surgeon, at 80%, after annual deductible

Anesthesiologist’s charges

80% of allowance

Second Surgical Opinion

$100% of allowance, no deductible applies

Facility fee charged by an approved facility for outpatient surgery (up to first $7,000 per spell of illness)

Expenses after $7,000

80% of allowance, no deductible applies

Child Wellness Visits and Examinations of eligible dependent children by a physician including required immunizations according to the following maximum number of visits:

• „ Birth through age 23 months; maximum of five visits

80% of allowance, after annual deductible

• „ Age 2 through age 18; one visit per year

Physical Exams for participants and spouses

80% of allowance, after annual deductible (including tests and immunizations)

Well-woman office visit

80% of allowance, after annual deductible

Bariatric Surgery — Only one surgical procedure is covered and prior authorization is required by Bariatric Resource Services. (See Wellness
here.)

80% up to maximum lifetime benefit of $100,000. After maximum reached, eligible expenses covered at 50%.

Mammogram

One per year for women age 35 or over

Zostavax (vaccine to prevent herpes zoster) - Physical Examination includes coverage (including administration) for Zostavax, a vaccine for the prevention of herpes zoster (shingles). NOTE: The Zostavax vaccine benefit is also available to Medicare-eligible retirees and their spouse, provided such retirees or spouse are not enrolled in a separate Medicare Part “D” prescription plan, and is not subject to the annual deductible

80% of allowance

Gardasil – for all eligible members through age 26 and dependents through the end of the month they reach age 26

Hospital bills, including maternity and nursery expenses up to $7,000 per spell of illness.

100% of allowance, no deductible applies

Expenses in excess of $7,000

80% of allowance, no deductible applies

Maternity and Gynecological Care expenses including charges by physicians and surgeons in or out of the hospital

80% of allowance, after annual deductible

Initial routine physical examination for newborn

100% of allowance, no deductible applies

Assistant or co-surgeon

25% of allowance for surgeon, at 80% after annual deductible

Pap Test

One routine exam per year

Outpatient treatment

80% of allowance, after annual deductible

Inpatient treatment for the first $7,000 of expenses for each spell of illness

100% of allowance, no deductible applies

Inpatient expenses in excess of $7,000 for each spell of illness

80% of allowance, no deductible applies

• Generic Drugs

• Preferred Brand Name Drugs

• Non-Preferred Brand Name Drugs

$35 co-payment

$35 co-payment plus difference between the allowance and retail price

• Generic Drugs

• Preferred Brand Name Drugs

• Non-Preferred Brand Drugs

Visits and Examinations

100% of the allowance

80% of the allowance

Examinations (limited to once every six months)

• „ Prophylaxis, including scaling and polishing (limited to once every six months)

• „ Topical applications of fluorides limited to one course of treatment per 12-month period

X-rays and pathology

• „ Single films (up to 13)

• „ Panorex (limited to once every year)

• „ Entire denture series (14 or more films; limited to once every year)

• „ Bitewings

• „ Biopsy and examination of oral tissue

• „ Problem visits

80% of the allowance

80% of the allowance

• „ Consultation by specialist when diagnosis has been made by a general dentist

• „ Restoration (fillings)

Oral Surgery (including local anesthesia)

• „ Extractions

• „ Incision and drainage of abscess

• „ Removal of cyst or tumor

• „ Alveoplasty with ridge extension

• „ Suture, soft tissue injury

Periodontics

• „ Subgingival curettage

• „ Root planing

• „ Provisional splinting

• „ Gingivectomy

Endodontics

• „ Pulp capping

• „ Root canals

• „ Apicoectomy

• „ Denture repairs

• „ Space maintainer, fixed (bank type) and removable

Inlays and Crowns (not covered if teeth can be restored with a filling material)

80% of the allowance

50% of the allowance

Pontics (artificial teeth)

Removable bridge (one piece casting clasp attachment)

Dentures (complete upper or lower; specialized techniques not eligible)

Maximum for all covered dental services

Children Under Age 18: No Limit

Members, Spouses and Children Age 18 and Older: $2,000 per calendar year

Vision survey once per every two calendar years, unless prescription changes and meets specified criteria

100% of allowance

You pay the difference between the actual charge and the allowance

Vision analysis, if indicated, once per every two calendar years, unless prescription changes and meets specified criteria

Eyeglass lenses, if necessary, once per every two calendar years, unless prescription changes and meets specified criteria

Frames, once per every two calendar years, unless prescription changes and meets specified criteria

100% of allowance, up to $40 per person

You pay the difference between the actual charge and the allowance

Contact lenses, once per every two calendar years, unless prescription changes and meets specified criteria

100% of allowance, up to $70 per person

You pay the difference between the actual charge and the allowance

Safety Glasses (actively working eligible members only), once per calendar year

100% of allowance for lenses. Safety frames at 100% of allowance up to $65 plus 20% of out of pocket costs

You pay the difference between the actual charge and the allowance

Audiologist Exam

80% of allowance, up to $100 maximum

First Hearing Aid

$3,000

Second Hearing Aid

$1,000

One hand

$5,000

One foot

$5,000

Sight of one eye

$5,000

Two or more of the above

$10,000

Benefit based on a percentage of regular gross compensation and a normally scheduled work week of 40 hours or less

First 13 weeks of disability

50%; $350 per week maximum

Next 13-weeks of disability (after Trustee approval)

40%; $210 maximum per week

Eligible Active Electrical Worker or Non-Bargaining Unit Employee

$25,000

Eligible Retired Employee

$6,000

Loss of life

$100,000 maximum benefit payable

Loss of one hand

$50,000 maximum benefit payable

Loss of one foot

$50,000 maximum benefit payable

Loss of sight in one eye

$50,000 maximum benefit payable

Loss of hearing in one ear

$50,000 maximum benefit payable

Two or more of the above

$100,000 maximum benefit payable

Loss of speech

$100,000 maximum benefit payable

Thumb and index finger of same hand

$25,000 maximum benefit payable

First 52 weeks of disability

$150 per week maximum

Next 52 weeks of disability

$150 per week maximum

The maximum amount payable for Supplemental Occupational Accident Benefits is $100,000 including $50,000 for disability.