(For Eligible Employees and Dependents)

The Fund helps you and your family pay for healthcare expenses as described in this section. If you or your Dependents incur covered expenses during any calendar year, the Plan will pay the percentages of such covered expenses as listed in the Schedule of Benefits in Section 3. Covered expenses do not include expenses for work-related accidents, Injuries or Sickness.

Preferred Provider Organization (PPO)
Calendar Year Deductible
Coinsurance
Out-of-Pocket Maximum
Pre-Admission Authorization
Covered Expenses
Hospice Benefit
Common Disaster
Extension of Benefits

10.1 Preferred Provider Organization (PPO)

The Fund provides comprehensive medical coverage through Blue Cross Blue Shield of Illinois, a Preferred Provider Organization (PPO) that has agreed to provide medical services to you and your Dependents at pre-negotiated rates.

You are encouraged to use PPO Hospitals and Physicians whenever possible. You will receive the maximum benefits available under the Fund when you use PPO providers because the Fund will be paying a greater percentage of your covered expenses. Your share will also be less because those covered expenses will be billed at a discount by the PPO.

Preferred Provider Organization (PPO) PPO network Providers are healthcare Providers who participate in the PPO network and have agreed to charge negoitiated rates. The Plan generally pays a higher percentage of covered expenses when you use a network Provider.

To select a PPO provider in your area or to find out whether your Provider is the PPO network, you may contact Blue Cross Blue Shield of Illinois, free of charge, at 1-800-810-BLUE (2583), visit the Blue Cross Blue Shield of Illinois website at www.bcbsil.com, or call the Fund Office at 1-708-449-7373. Have your medical ID card handy so that you can provide any information required about your Fund.

10.2 Calendar Year Deductible

Each calendar year, before the Fund begins to pay benefits, you must pay the individual deductible listed in your Schedule of Benefits in Section 3. Your family meets the deductible when three family members have paid their individual deductibles during the calendar year. After that, no other covered family members will have to meet the individual deductible.

The deductible applies only once in a calendar year even though you may have several different Sicknesses or Injuries during that period. So that your medical claims will not be subject to a deductible late in one calendar year and soon again in the following year, any expenses applied against the deductible in the last three months of a calendar year may also be applied against the deductible for the next calendar year.

When you use a Blue Cross Blue Shield Center of Excellence facility to receive transplant benefits, you are not required to pay the deductible for these expenses. You also do not need to satisfy the deductible before being eligible for Hospice benefits.

Common Accident

If two or more eligible family members are injured in the same accident, only one deductible will apply in the current and next succeeding calendar year for all their covered expenses directly resulting from the accident.

10.3 Coinsurance

You and the Fund share your heathcare expenses. Coinsurance is:

• The amount that the Plan pays of your eligible expenses after you have paid your deductible, and
  
• Listed in the Schedule of Benefits in Section 3 as a percentage of your eligible expenses, after the deductible.

When you use a Blue Cross Blue Shield Center of Excellence facility to receive transplant benefits, the Plan's coinsurance provisions do not apply to your transplant expenses. The coinsurance provisions also do not apply to Hospice benefits.

10.4 Out-of-Pocket Maximum

Each calendar year, after you reach the out-of-pocket maximum per person listed in the Schedule of Benefits in Section 3, the Plan generally pays 100% of your remaining covered expenses during that calendar year, except for the following expenses.

• Treatment for infertility,
  
• Treatment received at a non-PPO hospital or non-PPO Ambulatory Surgicial Facility, or treatment received from a non-PPO Physician, and
  
• Treatment for mental health and/or Substance Abuse.
  
  The following expenses are not counted toward the out-of-pocket maximum:
  
• Deductibles,
  
• Treatment received at a non-PPO Hospital or non-PPO Ambulatory Surgical Facility,
  
• Treatment for mental health and/or Substance Abuse, and
  
• Services performed by non-PPO Physicians.
  
  10.5 Pre-Admission Authorization
  
  When your Physician recommends elective or non-emergency hospitalization or Inpatient surgery, you must call the Blue Cross Blue Shield Medical Service Advisory (MSA) for prior approval of the admission at least one business day before you go into the Hospital. Contact the Blue Cross Blue Shield MSA at 1-800-255-5192.
  
  If you have an emergency admission, you, your Physician, the Hospital or a family member must calll the Blue Cross Blue Shield MSA within two business days of the date of your admission. This provision does not apply to maternity admissions.
  
  If you do not notify the Blue Cross Blue Shield MSA within the required periods of time, you will have to pay an additional $250 copayment before the Fund will pay any benefits.
  
  

  You will be required to pay an additional $250 copayment if you do not receive a pre-admission authorization from the Blue Cross Blue Shield MSA.

  
  
  Services received at the following facilities will be subject to an additional $250 copayment unless approved by Blue Cross Blue Shield MSA:

1. Hospital,
   
2. Dialysis facility, or
   
3. Skilled nursing facility.

10.6 Covered Expenses

The Plan provides a wide variety of services and supplies that are Medically Necessary for treatment of non-work related Sickness and Injuries, unless they are excluded or limited by another Plan provision. These include medical care by Hospitals, Doctors and other healthcare Providers, as well as diagnostic tests and procedures used in your treatment.

The following expenses are covered under the Comprehensive Major Medical Benefit if they are Reasonable and Customary charges and are Medically Necessary (see Section 18, Definitions) and are services and supplies provided for the treatment of non-occupational Sicknesses or Injuries:

1. Hospital charges for daily board and bed or room, up to the Hospital’s regular daily rate for semi-private accommodations. The Plan will cover the expense of a private room if semi-private accommodations are no available.
   
2. Hospital speciality care unit charges (intensive care unit or cardiac care unit).
   
3. Charges, other than charges for regular daily services, made by a Hospital for medical care and treatment, exclusive of charges for professional services, including Medically Necessary ancillary services (e.g. prescriptions, supplies).
   
4. Ambulatory Surgical Facilities expenses.
   
5. Professional local ambulance service charges for transportation to a Hospital Transportation by air ambulance is covered if Medically Necessary..
   
6. Charges made by a licensed Physician for medical care and treatment and for performing a surgical procedure or a laparoscopic procedure.
   
7. Charges made by a Registered Nurse (R.N.) during hospital confinement for private nursing service, provided the attending Physician prescribes in writing the need for services of a registered nurse. In addition, only a coordinated home care program provided by an R.N. that is Medically Necessary (not custodial-type care) and that replaces or reduces confinement in a Hospital or Skilled Nursing Facility will be covered.
   
8. Charges made by a person who is legally licensed as a Licensed Practical Nurse (LPN) during hospital confinement, provided a registered nurse is not available and the attending Physician prescribes the services of an LPN. In addition, services of an LPN for home care will be covered if the services are Medically Necessary and are rendered under the direction of a Physician or RN.
   
9. Charges made for the cost and personal administration of an anesthetic by a Physician who remains in constant attendance during a surgical procedure for the sole purpose of rendering an anesthetic.
   
10. Charges made for the cost and personal administration of an anesthetic by a person legally licensed as a Certified Registered Nurse Anesthetist (CRNA) under the supervision of a Physician who remains in constant attendance during a surgical procedure for the sole purpose of rendering an anesthetic. A Certified Registered Nurse Anesthetist includes a person legally licensed as a Certified Registered Nurse Anesthetist, Registered Nurse Anesthetist, or Nurse Anesthetist, who is authorized to administer anesthesia in collaboration with a Physician, and bill and be paid in the Nurse Anesthetist's own name, or any equivalent designation, under the laws of the state of jurisdiction where teh services are rendered, who acts within the scope of the Nurse Anesthetist's license and who is not the patient or the parent, spouse, sibling (by birth or marriage) or child of the patient.
    
11. Charges made for radium therapy, x-ray treatments and examinations, microscopic tests or any laboratory tests or analyses made for diagnostic or treatment purposes. No benefits will be payable for dental x-rays or x-rays for eye refractions, except in cases of bodily Injury.
    
12. Charges made for treatment by a person legally licensed as a professional physical, occupational, or speech therapist who acts within the scope of his/her license. Physical, occupational, and speech therapy are benefits that can be subject to medical review. This means that your Physician or you must contact the Fund Office regarding physical, occupational, and/or speech therapy. The Fund Office requires that your Physician provide a letter indicating that the therapy is Medically Necessary, and proposing your treatment plan. The Fund Office will then have the therapy and the length of treatment approved by one of its Contracted Medical Claim Review Providers. Ongoing therapy may also be sent for review by the Plan's Cotracted Medical Claim Review Provider.
    
13. Charges made by a person legally licensed as a doctor or chiropractic medicine (DC) who acts within the scope of his/her license, as provided in the Schedule of Benefits in Section 3 and subject to a calendar year maximum shown in the Schedule of Benefits.
    
14. Charges made by a person legally licensed as a doctor of osteopathic medicine (DO) who acts within the scope of his/her license, in accordance with the Schedule of Benefits.
    
15. Charges made by a Physician for Inpatient or Outpatients treatment of Mental or Nervous Disorders and/or Substance Abuse not to exceed the maximums shown in the Schedule of Benefits.
    
16. Charges made by a Dentist for the performance of oral surgery, consisting of cutting procedures for the treatment of diseases or injuries of the jaw or extraction of impacted teeth, provided that such oral surgery is performed during a period of confinement of at least 18 hours in a legally constituted and operating Hospital.
    
17. Gastric By-Pass procedures to treat morbid obesity, provided the following criteria are met:

• The patient's Body Mass Index (BMI) is greater than or equal to 50, or
  
• The patient's Body Mass Index (BMI) is greater than or equal to 45 with two or more co-morbidities that immediately endanger the patient's well-being. Co-morbidities include hypertension, diabetes, dyslipidemia, sleep apnea and coronary heart disease.
  
• the Gastric By-Pass procedure must be performed by a PPO Physician at a PPO surgical facility. The Plan will make no payment for Gastric By-Pass procedures that are performed by a non-PPO Physician or for Gastric By-Pass procedures that are performed at a non-PPO facility.

18. Rental or, if approved by the Fund Office, the purchase of Durable Medical Equipment (DME) which is Medically Necessary for treatment of a Sickness or disability. To be eligible for coverage:

1. The equipment must meet the Plan's definition of (DME).
   
2. The equipment must be ordered by a Physician who must certify the necessity of the equipment and indicate how long the equipment will be needed. This written order must be submitted to the Fund Office and must include a complete diagnosis and treatment plan so the Fund Office can determine whether purchase or rental of the Medically Necessary equipment is more cost-effective..
   
3. You must submit an itemized bill from the company supplying the equipment showing the date the equipment was delivered and the full rental or purchase price.
   
   Only one item of the same or similar DME will be covered during each eligible person’s lifetime.
   
   The items listed in the attachment at the back of this booklet are considered DME or covered supplies for which benefits may be payable, if all other conditions to entitlement
   are satisfied. The items listed as “Non-Covered” are not considered DME or a covered supply.
   
   The Trustees will have the authority and discretion to determine what is considered DME and covered supplies for items not listed, and when to rent, lease or purchase the equipment.
   
   For the purpose of determining the Reasonable and Customary charge for the purchase of DME, the Trustees may ascertain the wholesale cost of the basic model for the same or similar equipment.
   
   The Trustees shall have the authority to authorize additional payment if, in their opinion, such additional payment is reasonable.
   
   Repairs of DME are not considered covered expenses.
   

19. Radiation therapy and chemotherapy treatments.
    
20. Renal dialysis treatments are covered if you receive them in a Hospital, a Plan Approved Dialysis Facility or in your home under the supervision of a Hospital or Plan Approved Dialysis Facility.
    
21. Skilled Nursing Facility Care.
    
    1. Admission to a Plan/PPO Skilled Nursing Facility is considered a continuation of your Inpatient Hospital stay and payment will be the same as that previously described for Inpatient covered services.
       
    2. If you have been hospitalized, you may continue your recovery as an Inpatient in a Skilled Nursing Facility. You must be admitted for the same diagnosis as the Hospital admission within 14 days of leaving the Hospital or a coordinated home care program.
       
       Services must be received in a Plan/PPO Skilled Nursing Facility. Benefits are not available for services received in a Non-Plan Skilled Nursing Facility. Contact the Fund Office before admission to a Skilled Nursing Facility to verify that the facility is a Plan/PPO Skilled Nursing Facility (see the Definations section)Non-Plan Skilled Nursing Facility.
       
    3. Covered Services in a Plan/PPO Skilled Nursing Facility include:
       
       1. Bed, board and general nursing care.
          
       2. Ancillary services (such as drugs and surgical dressings and supplies).
22. Pre-Admission Testing.
    
23. Human Organ Transplants. Benefits will be provided only for cornea, kidney, bone marrow, heart valve, muscular-skeletal, parathyroid, heart, lung, heart/lung, liver, pancreas or pancreas/kidney human organ or tissue transplants. Benefits are available to both the recipient and donor of a covered transplant as follows:
    
    1. The Fund’s deductible and coinsurance provisions do not apply to expenses of covered transplants received at Blue Cross Blue Shield Centers of Excellence facilities.
       
    2. If both the donor and recipient have coverage, each will have their benefits paid by their own program.
       
    3. If you are the recipient of the transplant and the donor for the transplant has no coverage from any other source, the benefits described in this benefit booklet will be provided for both you and the donor. In this case, payments made for the donor will be charged against the recipient’s benefits.
       
    4. If you are the donor for the transplant and no coverage is available to you from any other source, the benefits described in this benefit booklet will be provided for you, however, no benefits will be provided for the recipient.
       
    5. In addition to the above provisions, benefits for heart, lung, heart/lung, liver, pancreas or pancreas/kidney transplants will be provided as follows:
       
       1. Benefits under this coverage will begin no earlier than 5 days prior to the transplant surgery and will continue for a period of no longer than 365 days after the transplant surgery. Benefits will be provided for all Inpatient and Outpatient covered services related to the transplant surgery in accordance with the Schedule of Benefits in Section 3.
          
       2. Benefits will also be provided for the transportation of the donor organ to the location of the transplant surgery. Benefits will be limited to the transportation of the donor organ in the United States or Canada.
          
    6. In addition to the other exclusions of this benefit booklet, benefits will not be provided for the following:
       
       1. Cardiac rehabilitation services when not provided to the transplant recipient within 3 days after discharge from a Hospital for transplant surgery.
          
       2. Transportation by air ambulance for the donor or the recipient.
          
       3. Travel time and related expenses required by the Provider.
          
       4. Drugs that are investigational, as determined by Blue Cross Blue Shield of Illinois.
24. Maternity Service as follows:

1. Benefits provided for you and your Dependents including your Dependent Child.
   
2. Benefits for maternity services are the same as benefits for any other condition.
   
3. Benefits will be paid for covered services received in connection with both normal pregnancy and complications of pregnancy. Maternity service benefits will also be provided for the routine Inpatient nursery charges (such as room and board, infant feedings, etc.). Coverage also includes benefits for elective abortions if legal where performed.
   
4. Your Eligible Dependent Child is covered by prenatal and delivery expenses incurred as a result of the birthing process only. No other maternity or newborn charges will be considered covered expenses for your Dependent Child or the newborn Child.
   
5. Group health plans and health insurance issuers generally may not, under Federal law, restrict benefits for any Hospital length of stay in connection with childbirth for the mother or newborn child to less than 48 hours following a vaginal delivery or less than 96 hours following a Cesarean Section. However, Federal law generally does not prohibit the mother's or newborn's attending Physician, after consulting with the mother, from discharging the mother or her newborn earlier than 48 hours (or 96 hours as applicable). In any case, plans and issuers may not require that a Provider obtain aurthorization from the Fund or the insurance issuer for prescribing a length of stay not in excess of 48 hours (or 96 hours).

25. The necessary care and treatment of medically diagnosed congenital defects and birth abnormalities of your newborn Child. In addition, benefits will be payable with respect to expenses incurred as a result of routine nursing care, routine well baby care, immunizations and medical exams or tests.
    
26. Administration of blood transfusions.
    
27. Surgical sterilization charges.
    
28. Routine child and adolescent immunizations and routine Physician examinations or check-ups (until the Child’s 16th birthday) for eligible Dependents.
    
29. Reconstructive breast surgery and breast prosthesis following a mastectomy, including:
    
    1. Reconstruction of the breast on which the mastectomy was performed,
       
    2. Surgery and reconstruction of the other breast to produce a symmetrical appearance, and
       
    3. Prostheses and treatment of physical complications at all stages of the mastectomy, including lymphedemas.
       
30. Hospice expenses, in accordance with the Hospice Benefit on this page.
    
31. Infertility treatment, including in vitro fertilization (IVF), embryo transfer, artificial insemination (AI), interine embryo lavage, gamete intrafallopian tube transfer (GIFT), zygote intrafallopian tube transfer (ZIFT), lower tubal transfer and prescription drugs related to the treatment of infertility, subject to the limits contained in the Schedule of Benefits in Section 3.
    
32. Vision therapy to improve and correct vision problems rendered by an optometrist or orthoptic technician for certain limited conditions. The diagnosis must indicate a structural or physical disorder of the eye or eye muscles, such as:
    
    1. Accommodation inability (non-presbyopic),
       
    2. Amblyopia (resulting from disuse/exanopsia), and
       
    3. Binocular dysfunction, including:
       
    4. Convergence/divergence insufficiency (heterophorias: esophoria and exophoria),
       
    5. Strabismus, accommodative (heterotropias: esotropia and exotropia), and
       
    6. Myopia, functional (excessive convergency).
       
33. Out-of-Network emergency claims of an emergency nature will be processed as follows:

1. The claims will be sent by the Fund Office to its Contracted Medical Claim Review Provider for re-pricing based on Reasonable and Customary charges at the 90th percentile.
   
2. After the claim is re-priced by the Contracted Medical Claim Review Provider, the resulting charges will be processed at the appropriate in-network rate.
   
3. Payment of the claim will be based on Reaasonable and Customary charges at the 90th percentile and paid at the appropriate in-network rate for the initial emergency claim, as well as surgical follow-up care.
   

34. The first pair of eyeglasses purchased after cataract surgery.
    

Benefits are limited to services that are Medically Necessary. Certain benefits must be approved by the Blue Cross Blue Shield MSA or the Fund Office and its Contracted Medical Claim Reveiw Provider. In the event the service or procedure is not covered by the Schedule of Benefits, it will not be covered.

10.7 Hospice Benefit

The Hospice Benefit covers 100% of Reasonable and Customary charges for the services outlined in the following chart up to a lifetime maximum shown in the Schedule of Benefits.

To be eligible for hospice benefits, the hospice care must be rendered as part of a Hospice Care Program by a licensed Hospice Care Agency. Before a covered individual enrolls in a Hospice Care Program, they should contact the Fund Office to verify that services will be covered under this benefit.

SCHEDULE OF BENEFITS FOR HOSPICE SERVICES

HOME HOSPICE CARE -Allows patient to receive care in his or her own home.

Services and equipment covered at 100% include:

• Physician services
  
• Physical, respiratory and occupational therapies,
  
• Drugs, medications and medical supplies when provided under the Hospice Care Program through Hospice Care Agency,
  
• Private duty nursing services by a Registered Nurse or Licensed Practical Nurse, if certified by a Physician,
  
• Rental of Durable Medical Equipment (DME), as described in Appendix A, and
  
• Oxygen and rental of related equipment
  

OUTPATIENT CARE – Care that you receive in a licensed medical facility. After you receive treatment, however, you return to your home.

Services covered at 100% include:

• Physician services,
  
• Laboratory, X-ray and diagnostic testing, and
  
• Ambulance service or alternative types of transportation.

INPATIENT CARE – Care received while you are an admitted patient in a Hospital or Hospice facility.

Services covered at 100% include:

• Room and Board which may include overnight visits by family
  
• Nursing services,
  
• All other related Hospital expenses,
  
• Physician services, and
  
• Ambulance service or alternative types of transportation.

OTHER SERVICES – In addition to the services outlined above, certain other services for you and your family are also covered.

Services covered at 100% include:

• Visits by a licensed social worker to evaluate the social, psychological and family problems related to the terminal illness. In addition, this professional will help develop a plan to assist in resolving these problems;
  
• Emotional support services to help relieve stress, cope with the anticipated loss, complete unfinished family business and maintain the patient in the most appropriate environment;
  
• Special incidental services for the patient, such as special dietary requirements, transportation between home and other sites of care; and
  
• Bereavement counseling for the immediate family following the death of the Hospice patient. (Coverage is limited to six visits at a maximum expense of $50 per visit.)

10.9 Extension of Benefits

If the coverage terminates for any reason while benefits are being paid under the Comprehensive Major Medical Benefit, benefits may be extended if:

1. The eligible person was Totally Disabled on the date coverage terminated,
   
2. Expenses were incurred in connection with the Injury or Sickness causing such Total Disability, and
   
3. The total maximum amount of benefits, if any, have not been paid.

Benefits will continue until the earliest of:

1. The end of the calendar year next following the calendar year in which coverage terminated,
   
2. The date that the total amount of benefits have been paid, or
   
3. The date that the eligible person ceases to be Totally Disabled.

No benefits will be payable after the above date for that disability nor will any benefits be payable with respect to separate disabilities beginning after the day coverage terminated.