(For Eligible Employees and Dependents)

If you or your dependent incur covered expenses during any calendar year, the Fund will pay the percentages of such covered expenses that is 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.

To select a PPO provider in your area, you may contact Blue Cross Blue Shield of Illinois at 1-800-255-5192, call the Fund Office at 1-312-372-3653 or visit the Blue Cross Blue Shield MSA website at Error! Hyperlink reference not valid.l.com. 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 diseases or accidents 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 do not need to satisfy the deductible before being eligible for Hospice benefits.

10.3 Coinsurance

Coinsurance is:

1. The amount that the Fund pays of your eligible expenses after you have paid your deductible, and

2. Is 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 Fund’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 that is listed in the Schedule of Benefits in Section 3, the Fund generally pays 100% of your remaining covered expenses during that calendar year. The deductible does not count toward the out-of-pocket maximum. In addition, the following expenses are not counted toward the out-of-pocket maximum:

• Treatment received at a non-PPO hospital or non-PPO ambulatory surgical facility, and
  
• Treatment for mental health and/or substance abuse.
  
  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 or maternity admission, you, your physician, the hospital or a family member must call the Blue Cross Blue Shield MSA within two business days of the date of your admission.
  
  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 co-payment before the Fund will pay any benefits.
  
  Please keep in mind that services received at the following will not be paid for unless approved by Blue Cross Blue Shield MSA:

1. hospital,
   
   
2. dialysis facility, or
   
   
3. skilled nursing facility.

10.6 Covered Expenses

The Fund provides a wide variety of services and supplies that are medically necessary for treatment of non-work related sickness and accidents. These include your medical care by hospitals, doctors and other health care 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) for the following services and supplies for the treatment of non-occupational sicknesses or accidents:

1. Hospital charges for daily board and bed or room, up to the hospital’s regular daily rate for semi-private accommodations.
   
   
2. Hospital Intensive Care Unit Charges.
   
   
3. Charges, other than charges for regular daily services, made by a hospital for medical care and treatment, exclusive of charges for professional services.
   
   
4. Ambulatory Surgical Facilities expenses.
   
   
5. Professional local ambulance service charges for transportation to a hospital.
   
   
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 (“L.P.N.”) during hospital confinement, provided a registered nurse is not available and the attending physician prescribes the services of an L.P.N. In addition, services of an L.P.N. for home care will be covered if the services are medically necessary and are rendered under the direction of a physician or R.N.
   
   
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 (C.R.N.A.) under the supervision of a physician who remains in constant attendance during a surgical procedure for the sole purpose of rendering an anesthetic.
    
    
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 accidental bodily injury.
    
    
12. Charges made for treatment by a person legally licensed as a professional physical or occupational therapist who acts within the scope of his/her license.
    
    
13. Charges made by a physician or covered behavioral health practitioner for inpatient or outpatient treatment of Mental or Nervous Disorders and/or Substance Abuse not to exceed the maximums shown in the Schedule of Benefits in Section 3. Click on the following Behavioral Health Practitioner for a detailed description.
    
    
14. 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.
    
    
15. Rental or (if approved by the Trustees) the purchase of Durable Medical Equipment which is Medically Necessary for treatment of a sickness or disability is covered. To be eligible for coverage:
    
    
    1. The equipment must meet the Fund’s definition of Durable Medical Equipment (DME).
       
       
    2. The equipment must be ordered by a physician who must certify the necessity of said equipment and indicate how long the equipment will be needed. This written order must include a complete diagnosis.
       
    3. The participant 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 for purposes of this Fund.
       
       The Trustees will determine what shall be 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.
       
       
16. Radiation therapy and chemotherapy treatments.
    
    
17. Shock therapy.
    
    
18. Renal dialysis treatments. These treatments are eligible for benefits 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.
    
    
19. Skilled Nursing Facility Care.
    
    
    1. a) Admission to a Plan 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. b) If you have been hospitalized, you may continue your recovery as an inpatient in a Skilled Nursing Facility. It is strongly suggested that you verify that a Skilled Nursing Facility is a Plan Skilled Nursing Facility before admission. The Fund will not pay benefits for services received in a Non-Plan Skilled Nursing Facility. However, for benefits to be available there are two important things to remember:
       
       
       1. It must be a Plan Skilled Nursing Facility. Benefits are not available for services received in a Non-Plan Skilled Nursing Facility. Call or write the Fund Office before admission to a Skilled Nursing Facility to verify that the facility is a Plan Skilled Nursing Facility (see Section 18, Definitions: “Plan Skilled Nursing Facility”).
          
          
       2. You must be admitted to the Plan Skilled Nursing Facility for the same diagnosis as the hospital admission, within 14 days of leaving the hospital or a coordinated home care program.
          
          
    3. Covered Services in a Plan Skilled Nursing Facility include:
       
       1. Bed, board and general nursing care.
          
       2. Ancillary services (such as drugs and surgical dressings and supplies).
       
       
20. Pre-Admission Testing.
    
    
21. 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.
          
          
22. Maternity Service as follows:
    
    
    1. For the eligible employee and spouse.
       
       
       1. Your benefits for maternity service are the same as your benefits for any other condition.
          
          
       2. 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.), physician office visits and immunizations up until the child’s 16th birthday. Coverage also includes benefits for elective abortions if legal where performed.
          
          
    2. Eligible dependent child: a child born to your eligible dependent child will be covered for prenatal and delivery expenses incurred as a result of the birthing process only. No other charges will be considered covered expenses.
       
       
    3. 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, under Federal law, require that a provider obtain authorization from the Fund or the insurance issuer for prescribing a length of stay not in excess of 48 hours (or 96 hours).
       
       
23. 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.
    
    
24. Administration of blood transfusions.
    
    
25. Surgical sterilization charges.
    
    
26. Routine child and adolescent immunizations and routine physician examinations or check-ups (until the child’s 16th birthday).
    
    
27. 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.
       
       
28. Hospice expenses, in accordance with the Hospice Benefit on this page.
    
29. 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.
    
    
30. 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),
       
    3. Binocular dysfunction,
       
       
       1. Convergence/divergence insufficiency (heterophorias: esophoria and exophoria),
          
       2. Strabismus, accommodative (heterotropias: esotropia and exotropia), and
          
       3. Myopia, functional (excessive convergency).
          

Benefits are limited to medical necessity and approval by the Fund Office.. In the event the service or procedure is not covered by the Schedule, it will be reviewed by the Fund through its designated representatives.

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 of $10,000.

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 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
  
  
• 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
  
  
• 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
  
  
• 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.

Other services covered at 100% include, but are not limited to:

• 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.)
  

10.8 Common Disaster

In the event two or more eligible family members are injured in the same accident, then in the current and next succeeding calendar year, only one deductible will apply for all of that family’s covered expenses that are a direct result of the accident.

10.9 Extension of Benefits

If the coverage of an eligible person 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.