Joint Council #28 - Teamsters Medical Benefits--Plan B

WASHINGTON TEAMSTERS WELFARE TRUST BENEFIT HIGHLIGHTS — MEDICAL PLAN B
The following comparative data is for illustrative purposes only. It is NOT intended to be an all-inclusive description of the Plan benefits or any limitations/exclusions that may apply. It is not to be used for general distribution purposes or in lieu of a Plan booklet. Every effort has been made to insure that the following information is accurate as of the date of issue, however, in all cases the applicable Plan booklet (inclusive of all revisions or modifications made subsequent to the latest printed editions) shall govern the eligibility for the benefits payable under all Washington Teamsters Welfare Trust programs. The Board of Trustees retains the right of final determination in questions of interpretation. BENEFITS CONTACT INFORMATION AND PHONE NUMBERS
	PLAN B
CONTRIBUTION RATE	$658.10
Employer contribution rates as of January 2006 based on December 2005 hours. Plans and rates may change periodically, so check with the Trust Administrative Office for the most current plan information and rates.

COPAYS	PLAN B
•Physician	$20 co-pay per office visit.
•Hospitalization	None
•Emergency Room Care	$75 per visit at PPO and Non-PPO hospitals. Waived if admitted.
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	PLAN B
DEDUCTIBLES	$250 per person, $750 maximum per family, per calendar year, 3-month carryover.
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OUT-OF-POCKET MAX	$1,500 per person; $3,000 maximum per family, per calendar year
	Excludes all co-pays and deductible.
	"Out-of-Pocket maximum" is the point each year most covered services will be paid at 100%. 80%/100% in this summary means that benefits are paid at 80% respectively until you are out-of-pocket the maximum above and 100% thereafter for the rest of the year. Note: Also excludes mental health and chemical dependency, prescription drugs, non-covered expenses, charges over usual and customary charges (UCR), and any penalty for not precertifying inpatient hospitalization.
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	PLAN B
MEDICAL BENEFITS •Trust Lifetime Maximum	$2,000,000 per person.

	PLAN B
MANAGED CARE AND PPO NETWORKS	All of the plans have access to the nationwide Beech Street hospital and physician PPO network.In Washington State, Beech Street uses the First Choice Health Network. Utilization of the PPO network is voluntary but will reduce out-of-pocket costs. The pharmacy network is NBN/Rx. The mental health and chemical dependency network is HMC. Hospital Utilization Review and Case Management is performed by Qualis Health, or--for mental health and chemical dependency--by HMC
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MATERNITY MANAGEMENT PROGRAM	The Trust will pay a $100 incentive benefit if you call Evergreen Healthcare within 60 days of confirmation of a pregnancy of you or your spouse and participate in the program with the Evergreen Healthcare nurses throughout the pregnancy.

	PLAN B
HOSPITAL PRECERTIFICATION	Hospital precertification by Qualis Health required. $200 penalty when admission not preauthorized. No coverage for days not certified as medically necessary at a Non-PPO hospital or when admission not preauthorized at a PPO hospital.
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	PLAN B
HOSPITAL	80%/100% of charges in excess of deductible (and emergency room co-pay if any) for days certified by Qualis Health.
•Preadmission Testing	Testing within four days of hospitalization and related to the condition requiring hospitalization will be paid at 80%/100%. No deductible.
•2nd Surgical Opinions	If required by Qualis Health paid at 100%. No deductible.
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	PLAN B
ALTERNATE TREATMENT SETTINGS	80%/100% of charges. In lieu of hospitalization. Care must be certified by Qualis Health. See limits below.
•Skilled Nursing Facility	Up to $100 per day for 180 days.
•Home Health Care	Maximum 130 visits per calendar year.
•Hospice Care	$10,000 lifetime limit.
•Alternate Housing Facility	$60 per day, maximum 70 days.
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	PLAN B
ORGAN TRANSPLANTS	Special rules and limits. $200,000 maximum per confinement.

REHABILITATION	PLAN B
•Inpatient	80%/100% of charges in excess of deductible.
•Outpatient Physical Therapy, Occupational Therapy and Speech Therapy	100% after $20 co-pay per visit. No deductible. Maximum of 24 visits each for physical and occupational therapy per person per calendar year. Maximum of 60 visits for speech therapy per person per lifetime.

DURABLE MEDICAL EQUIPMENT	80%/100% of charges in excess of deductible.
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	PLAN B
PHYSICIAN SERVICES
•Inpatient, including 1st 72 hours well baby care	80%/100% of charges in excess of deductible.
•Outpatient	100% after $20 co-pay per office visit. No deductible.
•Surgery	80%/100% of charges in excess of deductible.
•Preventative Care Outpatient: physical exams, well baby care, immunizations	100% after $20 co-pay per office visit. No deductible. $500 maximum per person per calendar year. Immunizations during newborn's 1st year are not subject to or applied to the maximum.
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	PLAN B
DIAGNOSTIC X-RAY/LAB	80%/100% of charges in excess of deductible.

ACUPUNCTURE TREATMENT	100% after $20 co-pay per office visit. No deductible. Maximum of 15 visits per person per calendar year. Only covered if a PPO provider is used.
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	PLAN B
SPINAL TREATMENT BENEFIT	100% after $20 co-pay per office visit. No deductible. Maximum of 15 treatments and $100 for diagnostic X-rays per person per calendar year.

JAW TREATMENT	80% up to $6,000 per lifetime. Regular benefits apply for accidents.
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	PLAN B
HEARING AIDS	80%/100% of charges in excess of deductible up to $500 per person per 3 consecutive calendar years. Cochlear implants covered under regular benefits subject to special medical necessity criteria.
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PRESCRIPTION DRUGS
	Plan deductibles do not apply. Contraceptives are covered.
Retail Network Pharmacies	Recommended Network	Regular Network
•Generic	100% after a co-pay equal to the greater of 10% or $5.	100% after a co-pay equal to the greater of 10% or $10.
•Brand	100% after a co-pay equal to the greater of 30% or $15.	100% after a co-pay equal to the greater of 30% or $20.
	Notes: Participant pays only the co-pay at the pharmacy. Retail prescriptions are limited to a maximum 34-day supply. Prescriptions obtained from non-network pharmacies are not covered except in a medical emergency.	Notes: Participant pays only the co-pay at the pharmacy. Retail prescriptions are limited to a maximum 34-day supply. Prescriptions obtained from non-network pharmacies are not covered except in a medical emergency.
Mail Order Network Pharmacies	100% for up to a 100-day supply. $20 co-pay per brand name prescription when a qualified generic is available.	100% after a $10 co-pay per generic and $35 co-pay per brand name prescription. Limited to a 100-day supply. Participant pays only the co-pay.
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	NON-HMC NETWORK
MENTAL HEALTH	Mental Health and Chemical Dependency administered by Health Management Center (HMC)
•Inpatient	50% of UCR charges for HMC authorized treatment up to 45 combined days per person per calendar year with a combined lifetime maximum of 90 days.
•Outpatient	50% of UCR charges for HMC authorized treatment up to 50 combined days per person per calendar year.

>CHEMICAL DEPENDENCY	50% of HMC authorized network charges up to a combined $10,000 per episode, and a 2-episodes lifetime maximum.
	Maximums are a combination of HMC network and non-network treatment.

ASSISTANCE PROGRAM	None

SUBSTANCE ABUSE PROFESSIONAL (SAP)	None

	PLAN B
LIFE INSURANCE
•Employee	Optional 5)
•Dependents	Optional 5)

AD&D •Employee Only	Optional 5)

TIME LOSS BENEFITS •Employee Only	Optional 4)

LONG TERM DISABILITY •Employee Only	Optional 6)

DISABILITY WAIVERS	3 months 7)

COORDINATION OF BENEFITS	Yes. Standard Coordination of Benefits for Plans A, B and C.
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Plan WT-100 1)Life and AD&D in increments of $2,500 = $.75 (Maximum $30,000) — May be used to increase or decrease amounts. 3)Time Loss (1-8-26) in increments of $25/week = 1.375 (Maximum $400/week) — May be used to increase or decrease amounts. Plans A, B and C 4) Long Term Disability benefit available at an additional $6.25 per person, per month. 5) Life and AD&D options: $5,000 Life and AD&D with $500 Dep. Life=$1.70/wk, $15,000 Life/AD&D with $1,500 Dep. Life=$4.75, and $30,000 Life/AD&D with $3,000 Dep. Life=$9.40 6) Time Loss (1-8-26) options: $100/wk=$5.50, $200/wk=$11.00, $300/wk=$16.50, $400/wk=$22.00 7) Additional 9-months medical disability waiver of contributions=$11.40 ** Time Loss is only available as 1-8-26; i.e., 1st day accident, 8th day illness and 26 weeks maximum. OVERALL SUMMARY NOTE: The hospital/physician PPO network, pharmacy PPO network, and mental health and chemical dependency HMC network in this summary apply to all Plans participants. The co-insurance percentages listed in this spreadsheet refer to: —% of UCR (usual, customary, and reasonable) charges, if using a non-PPO (non-network) provider, and —% of PPO (network) providers' discounted charges, if using a PPO (network) provider. Use of a PPO provider will eliminate the potential for charges over UCR, which are non-covered expenses and, generally speaking, result in less out-of-pocket costs to the participant.
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