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Summary Plan Description

BOOKLET2 OF 2

Active Plan Benefit Booklet | General Information and Plan Provisions

January 2017

TeamCare Participant Services

Benefits Specialists are available

Monday through Friday

800-TEAMCARE (832-6227)

MyTeamCare.org

TeamCare Partners

BlueCross BlueShield

bcbsil.com

Private HealthCare Systems

(MO Zip Codes 65400 – 65899)

phcs.com

Medical Mutual

(OH Zip Codes)

medmutual.com

Caremark

caremark.com

888-483-2650

TeamCare Lab Benefit

(Quest Lab Card)

labcard.com

800-646-7788

TeamCare Imaging Benefit

(US Imaging)

usimagingnetwork.com

877-674-0674

Humana Dental

humanadental.com

800-592-3112

EyeMed Vision Care

eyemedvisioncare.com

866-393-3401

Mayo Clinic and AskMayo

mayoclinic.com

800-700-MAYO

My Reminders� Register online at MyTeamCare.org.

� Make sure that TeamCare has my current mailing and email address.

� Notify TeamCare of any life events which may affect my coverage.

� Carry both my PPO medical ID card, and TeamCare Benefit Card and remind my covered dependents to do the same.

� Call 800-TEAMCARE or email TeamCare with any benefit questions.

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My InformationTeamCare ID Number ______________________________________

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Please read these Benefits Booklets in conjunction with one another as together they form the Summary Plan Description for your benefit plan. “Benefits Booklet (1 of 2)” contains your Plan Benefit Profile, a summary of any provisions unique to your Plan, and your Plan’s government mandated Summary of Benefits and Coverage form. “Benefits Booklet (2 of 2)” contains general benefits information and provisions applicable to all plans.

The information in this Benefits Booklet reflects all Health Plan amendments enacted through January 1, 2017. Amendments enacted after this date may impact the information in this Benefits Booklet.

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TTAABBLLEE OOFF CCOONNTTEENNTTSS MEDICAL BENEFITS

TeamCare ...................................................... 4 TeamCare Family Protection Benefit ............. 4 Plan Benefit Limit .......................................... 5 Plan Deductible ............................................. 5 Plan Out-Of-Pocket Limit ............................... 5 TeamCare Office Visit Co-Payment ............... 5 TeamCare Wellness ...................................... 6 CVS/Caremark’s Broader Vaccine Network .. 7 MinuteClinic® Program ................................. 7 TeamCare Prescription Drug Benefit ............. 8 Hospital Expense Benefit ............................. 10 Surgical and Obstetrical Benefit ................... 11 Organ Transplant Benefit .............................. 12 Organ Donor Benefit ..................................... 12 Outpatient Accidental Bodily Injury Benefit .... 13 Outpatient Cancer Treatment Benefit ........... 13 Ambulance Service Benefit ........................... 13 Major Medical Benefit .................................... 14 TeamCare Lab Benefit ................................... 15 TeamCare Imaging Benefit ............................ 15 Chiropractic Benefit ...................................... 16 Hearing Aid Benefit ....................................... 16 Behavioral Health Benefit ............................. 17 Non-Covered Medical Benefits ...................... 18 Mayo Clinic .................................................... 19 Ask Mayo Clinic Program .............................. 19

DENTAL BENEFITS

Dental Benefits ............................................. 21 Orthodontic Benefits ...................................... 22 Dental Exclusions and Limitations ................. 23

VISON BENEFITS

Vision Benefits .............................................. 25

SHORT-TERM DISABILITY AND LIFE INSURANCE BENEFITS

Short-Term Disability Benefits ........................... 28 Life Insurance Benefits ..................................... 29 Accidental Death & Dismemberment Benefits .. 29 Total and Permanent Disability Benefits .......... 31

ELIGIBILITY Participant Eligibility .......................................... 34 Spouse Eligibility .............................................. 35 Qualified Same-Sex Domestic Partners ........... 35 Child Eligibility ................................................... 35 QMCSO ............................................................ 36 Multi-Tiered Plans ............................................. 36 Extension of Benefits ...................................... 38 Notice of Continuation Rights under COBRA ... 39 Other Self-Payments ......................................... 41

GENERAL INFORMATION

Coordination of Benefits ................................... 43 Subrogation and Reimbursement .................... 44 Workers’ Compensation ................................... 44 Assignment of Benefits ..................................... 44 Appeals Process .............................................. 45 Plan Administration .......................................... 47 Statement of ERISA Rights ............................... 47 Legislated Benefits Coverage .......................... 49 Notice of Privacy Practices ............................... 50 Retiree Benefit Information .............................. 54

TERMS AND DEFINITIONS ............................. 56

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MMEEDDIICCAALL BBEENNEEFFIITTSS TeamCare allows you the choice to manage your care. Whether you're trying to get healthy, stay healthy or live with a chronic illness, TeamCare provides you the access to an extensive network of the best doctors, providers, facilities, and hospitals in your area that allows you to improve your overall health and well-being. With TeamCare, you get the dedicated support to help you get more for your health care dollars. The providers in TeamCare have agreed to accept negotiated rates for the services they provide to you or your covered family members. This lowers your co-insurance, if any, and also protects you against charges above those considered Reasonable and Customary.

TeamCare ................................................................................................................... 4 TeamCare Family Protection Benefit .......................................................................... 4 Plan Benefit Limit ........................................................................................................ 5 Plan Deductible ........................................................................................................... 5 Plan Out-Of-Pocket Limit ............................................................................................ 5 TeamCare Office Visit Co-Payment ............................................................................ 5 TeamCare Wellness .................................................................................................... 6 CVS/Caremark’s Broader Vaccine Network ................................................................ 7 MinuteClinic® Program ............................................................................................... 7 TeamCare Prescription Drug Benefit .......................................................................... 8 Hospital Expense Benefit ........................................................................................... 10 Surgical and Obstetrical Benefit ................................................................................ 11 Organ Transplant Benefit ............................................................................................ 12 Organ Donor Benefit ................................................................................................... 12 Outpatient Accidental Bodily Injury Benefit ................................................................. 13 Outpatient Cancer Treatment Benefit ........................................................................ 13 Ambulance Service Benefit ......................................................................................... 13 Major Medical Benefit ................................................................................................. 14 TeamCare Lab Benefit ................................................................................................ 15 TeamCare Imaging Benefit ......................................................................................... 15 Chiropractic Benefit ................................................................................................... 16 Hearing Aid Benefit .................................................................................................... 16 Behavioral Health Benefit .......................................................................................... 17 Non-Covered Medical Benefits ................................................................................... 18 Mayo Clinic ................................................................................................................. 19 Ask Mayo Clinic Program ........................................................................................... 19

TEAMCARE HMO (Health Maintenance Organization) In addition to the TeamCare Preferred Provider Organization (PPO), TeamCare also offers an HMO option in certain geographical areas. If you are in a geographical area under a collective bargaining agreement that offers HMO benefits, information will be included in your enrollment packet. If you choose to participate in the HMO option, you and your family will receive all medical and prescription benefits from the HMO while maintaining TeamCare Dental, Vision, Life Insurance and Short-Term Disability coverage (if available under your plan of benefits). In some HMOs, you may be required to select a Primary Care Physician to coordinate your care. Should you choose the HMO option, a Summary Plan Description, Summary of Benefits and Coverage, and Medical ID cards will be provided to you by the HMO.

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TeamCare is a Preferred Provider organization (PPO), where you and your family enjoy the benefits of network-based health care. Through TeamCare, you and your family may seek care from any physician or hospital in the network. By seeking care from a network provider, you receive higher, in-network benefits, and you are not responsible for pre-certifying procedures or filing claim forms. In most cases, you may seek care from an out-of-network provider and still receive benefits. However, there is an out-of-network penalty that you will be responsible for and you will also have to file all claims. TeamCare offers you and your family the finest quality providers and facilities in your area through your local PPO network. Are You Required To Participate In TeamCare? As a TeamCare member, you are required to use participating network doctors and hospitals for all non-emergency medical care. Failure to use network doctors and hospitals for non-emergency medical care may result in an out of network penalty in the benefits payable by TeamCare. Please refer to your Plan Benefit Profile to determine whether your Plan has this requirement. To locate a TeamCare provider, please refer to the phone number on your TeamCare Medical ID card. In addition, through our website, you can link to the TeamCare network in your area to get an updated listing of your providers. You are free to choose any provider within the TeamCare network. Is Precertification Required? Your in-network TeamCare doctor may be required to pre-certify any inpatient hospital admission, surgical procedure or other medical procedure/test. This is your doctor’s responsibility, and there is no reduction in benefits to you if your doctor fails to pre-certify. Precertification does not determine whether you are eligible for benefits or whether the proposed treatment is actually covered by TeamCare.

Under most other health plans, all of your family’s TeamCare health care benefits will come to an end when you die unless they choose to make self-payments. However, your exclusive use of TeamCare providers can ensure continued coverage for your family members after your death. If, during the two years prior to your death, you and your covered dependents used in-network TeamCare providers exclusively for all your non-emergency medical care, your covered spouse* and dependents will be eligible for up to five years of continued health coverage at no cost. If qualified, your spouse and children will remain covered under the same plan of benefits as you were prior to your death, for care provided by participating TeamCare doctors and hospitals. Your spouse will receive benefits for a maximum of five years until eligible for other insurance (including Medicare) or until remarriage. Even if your spouse remarries, TeamCare will continue to cover your children in certain circumstances. Your children will remain covered for up to five years (provided they meet eligibility for coverage requirements) until, if earlier, (1) the date of their 26th birthday; (2) the date of acquisition of other health coverage; or (3) the date they become a Participant in this Plan.

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* Spouse as used in this document refers to both Spouses and Qualified Same-Sex Domestic Partners effective January 1, 2014. Please refer to the Terms and Definitions section of this Benefits Booklet.

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Your Plan does not have an annual Plan Benefit Limit.

The Plan Deductible is the amount of covered medical expenses that you or your covered dependents must pay each calendar year before the Plan begins paying for certain benefits. Once the deductible is satisfied, by either an individual or family, the Plan pays benefits on the remaining covered expenses. What Is Your Deductible Amount?

Please refer to your Plan Benefit Profile for the Individual and Family Deductible amounts. Please note that the Family Deductible (if applicable) means that if two or more covered family members satisfy the Family Deductible in covered medical expenses in a year, the Plan pays benefits on the remaining covered expenses for all covered family members for that year.

The Out-of-Pocket Expense Limit is your portion of eligible covered medical expenses that you must pay after the Plan has paid its required percentage. Please refer to your Plan Benefit Profile for Out-of-Pocket Expense Limit information for your Plan and the Plan specific information regarding what applies to your Out-of-Pocket Expense Limit in Book 1 of this Summary plan Description.

There are no Plan Deductibles to meet for a TeamCare physician’s covered office visit charge. You only need to make a co-payment, as indicated in your Plan Benefit Profile, at the time of service for the office visit. Unless the TeamCare Lab Benefit or TeamCare Advanced Imaging Benefit is used, related services performed in conjunction with an office visit, such as x-ray and laboratory work, will be subject to the Plan Deductible and will be paid according to the Plan benefit.

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You can view your accumulated Annual Deductible and Out-of-Pocket Expense Limit by visiting our website at: MyTeamCare.org.

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Preventive health coverage is one of the most important benefits of your health plan. Getting the right preventive services at the right time can help you stay healthy by preventing diseases or by detecting a health problem at a stage that may be easier to treat. However, because certain services can be done for preventive or diagnostic reasons, it’s also important you understand exactly what preventive care is and which services your health plan covers as preventive services so you don’t end up with unexpected out-of-pocket costs. The Plan pays 100%, subject to age and frequency plan limits, for preventive care and routine physicals when using in-network providers.

Covered expenses include charges made by your physician for routine physical exams, including routine vision and hearing screenings given as part of the routine physical exam. A routine exam is a medical exam given by a physician for a reason other than to diagnose or treat a suspected or identified illness or injury, and also includes:

• Evidence-based items or services that have in effect a rating of "A" or "B" in the current recommendations of the United States Preventive Services Task Force;

• Immunizations that have in effect a recommendation from the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention;

• With respect to infants, children and adolescents, evidence-informed preventive care and screenings provided for in the comprehensive guidelines supported by the Health Resources and Services Administration;

• With respect to women and Women’s Preventive Services, such additional preventive care and screenings as provided for in comprehensive guidelines supported by the Health Resources and Services Administration. Preventive services include but not limited to well-woman exams, including pap smears, and prenatal care; and

• Preventive care benefits defined under the Health Resources and Services Administration (HRSA) requirement include the cost of renting one breast pump per pregnancy in conjunction with childbirth. Benefits for breast pumps also include the cost of purchasing one breast pump per pregnancy in conjunction with childbirth. These benefits are only available if breast pumps are obtained from an in-network provider or Physician.

What Is Not Covered By This Benefit?

• Examinations, procedures or tests performed by a non-TeamCare provider, • Any test, examination, procedure, service or product which is not uniformly and professionally

endorsed by the general medical community as Standard Medical Care, Treatment, Services or Supplies; • Body scanning procedures; • Department of Transportation (DOT) Physicals; • Executive exams including Mayo Clinic; • Weight loss or exercise programs; • Non-covered prescription drugs and vitamins – unless required under the Affordable Care Act; • Routine dental services (payable under Dental Benefit); and • Routine vision services (payable under Vision Benefit).

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Medical Claims must be filed within one year of date of service. Claims filed more than one year from date of service will be denied.

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As part of TeamCare Wellness, vaccines are an important part of protecting you and your family against disease. TeamCare had partnered with CVS/Caremark’s Broader Vaccination Network to offer immunizations covered at 100% with no deductible or co-insurance at participating retail pharmacies.

Common vaccinations for disease prevention including seasonal flu shots, shingles, pneumonia, tetanus, hepatitis A and B, measles, and other ACA-preventative care vaccines, are conveniently available at the pharmacy counter without an appointment. State laws, clinical considerations, and age restrictions may vary so call ahead to check which vaccines are available and can be administered locally.

You can call 888-483-2650 to locate one of CVS/Caremark’s 62,000 Broader Vaccination Network pharmacies, or look up a location by zip code, distance, or pharmacy name on caremark.com.

Convenient, no-cost treatment for minor medical problems is available to you and your family when you visit MinuteClinic® at your local CVS pharmacy. Certified nurse practitioners and physician assistants can diagnose, treat, and write prescriptions when medically appropriate. No appointment is necessary. MinuteClinics are staffed by certified family nurse practitioners and are open seven days a week, including evenings. You can even view current wait times and secure a place in line before leaving your house when you use the Clinic Locator on the minuteclinic.com website. For your nearest MinuteClinic® location, call 866-389-2727 or visit minuteclinic.com. Hours vary by location.

What Does the Plan Pay Under This Program?

Covered procedures include treatment for minor illnesses and injuries, skin conditions, and vaccinations. You will have no co-payment when you present your TeamCare Medical ID Card. Lab fees and screenings may be billed separately and co-insurance may apply.

Examples of covered services include:

• Allergy symptoms • Bronchitis and coughs • Earaches and infections • Flu-like symptoms • Sinus infections and congestion • Sore and strep throats • Minor burns

• Minor cuts, blisters & wounds • Sprains, strains & joint pain • Vaccinations and injections

o Age restrictions vary by state for vaccinations

o Call ahead for vaccine availability

What Services Are Not Provided by MinuteClinic?

• Department of Transportation physicals • Sports and camp physicals • Routine physicals • Tuberculosis testing

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TeamCare has joined with CVS Caremark, the nation’s leading pharmacy benefit manager, to manage your pharmacy benefit program. Whether you get your medications from one of the 64,000 participating retail pharmacies (Walmart is not a participating pharmacy) or through the CVS Caremark Mail Service Pharmacy, you can confidently rely upon the clinical expertise of CVS Caremark pharmacists and their state-of-the-art technology to provide you the best care and service. By using the TeamCare Prescription Drug Benefit you will:

• Receive up to a 30-day supply of covered medications at participating retail pharmacies; or • Receive up to a 90-day supply of covered medications through Maintenance Choice or the CVS

Caremark Mail Service pharmacy.

What Does The Prescription Drug Benefit Cover? The Prescription Drug Benefit covers charges for eligible drugs prescribed by a physician, dispensed by a pharmacist and available over-the-counter with a prescription. CVS Caremark operates both a Retail Pharmacy Service and a Mail Service Pharmacy.

The Retail Pharmacy Service is most convenient when filling your short-term prescription needs. For example, if you need an antibiotic to treat an infection, under the TeamCare Retail Pharmacy Program, you can receive a 30-day supply of covered medication at any one of the 64,000 pharmacies that participate in the network. The Maintenance Choice Program or the CVS Caremark Mail Service Pharmacy provides service for your long-term prescription needs (prescriptions taken for more than 60 days). Under the Maintenance Choice Program or the CVS Caremark Mail Service Pharmacy Program, you can receive up to a 90-day supply of covered medication.

Is there a Generic Requirement? Yes. If a generic equivalent is available for your prescription, you must take the generic equivalent or be responsible for the cost difference between the price of the brand name drug and the generic drug plus any co-payment or co-insurance.

Is there a limit to my cost when I fill a prescription? Your maximum cost per prescription will apply if you use the TeamCare Prescription Retail or Mail Service program, but it does not apply when a brand name drug is selected and the generic equivalent is available. If you use a brand-name drug when a generic equivalent is available, there is no limit on the amount that you may be required to pay. See your Plan Benefit Profile for amounts you may owe and any limits that apply to your Plan. How do I fill my Prescription? Filling your short-term prescription or refills is easy. Simply show your TeamCare Benefits ID card at any participating pharmacy, pay your share of the cost, and pick-up your prescription – it is that easy. Any prescription drug that is considered a maintenance medication (prescriptions taken for more than 60 days) may initially be filled under the Retail Pharmacy Service, however after the second fill of the same prescription, it must be filled either through the convenient CVS Caremark Mail Service Pharmacy or through the Maintenance Choice Program at a local CVS retail pharmacy. For maintenance prescriptions:

• You may obtain up to a 90-day supply at any local CVS retail pharmacy through the Maintenance Choice

Program; or • The CVS Caremark Mail Service Pharmacy is safe and easy and allows you to have your maintenance

medications delivered directly to your home. • Ordering your prescription through the CVS Caremark Mail Service Pharmacy can be done by mail, fax,

online at caremark.com, or by telephone at 1-888-483-2650. Your medication will be delivered to you within 7 to 10 days after your order has been received and there is no charge for standard delivery.

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Is There a Prescription Formulary? To help contain the increasing cost of prescription drug coverage and continue TeamCare’s commitment to quality care, your prescription drug benefit has a formulary. A formulary is simply a list of commonly prescribed medications that have been selected because of their combination of effectiveness and cost. The fformulary operates in conjunction with CVS Caremark mail-order programs. All participating pharmacies in the CVS Caremark prescription program will be aware of drugs currently on the formulary. Your doctor should call CVS Caremark or visit their website to learn which drugs are formulary drugs. You should always encourage your physician to prescribe formulary drugs whenever possible, because their cost is less and their effectiveness has been established. Is There an Annual Maximum Out-of-Pocket on Injectable Medications? Yes. There is a separate annual out-of-pocket maximum that applies only to injectable medications. Once your out-of-pocket for prescription medications costs reach the annual limit, all future injectable medication costs will be paid by the Plan at 100%. Please refer to your Plan Benefit Profile for specific information for your Plan. What Is Not Covered By This Benefit?

• Therapeutic devices or appliances (hypodermic needles, support garments and other non-medicinal items);

• Medications supplied to covered individuals in a hospital or other treatment facility. These charges may be covered under the Hospital Benefit or the Major Medical Benefit;

• Drugs or medications dispensed directly by a physician or dentist; • Cosmetic or beauty aids; • Immunizing agents, blood or blood plasma, or medication prescribed for parenteral administration,

except insulin; • Medications for which the cost is recoverable under any Workers’ Compensation or Occupational

Disease Law or any state or federal governmental agency; • Any medication furnished by any other drug or medical service for which no charge is made to the

covered individual; • Any drug labeled, “Caution – Limited by Federal Law to Investigational Use” or any experimental drug; • Any drug, dietary supplements or vitamins available over-the-counter – unless required under the

Affordable Care Act; • Any drug used for enhancing sexual function; • Any drug or medication primarily intended for cosmetic or lifestyle enhancement; • Any drug or medication ordered from outside the United States; • Drugs or supplies on a formulary exclusion list compiled by the Plan’s pharmacy benefits manager

(available on our website or by contacting CVS Caremark); • Food and/or specialized nutritional products unless approved by the Plan; and • Drugs or medications filled at Walmart.

How Do You File A Prescription Drug Benefit Claim?

If you do not use the CVS Caremark program, you must submit a prescription drug claim form, which can be obtained from the TeamCare website. Full instructions for using this form are included on the claim form. When filing for this benefit, be sure:

• You have a receipt for each prescription drug. Complete the top portion of the claim form, attach the receipts and submit the claim; and

• Do not submit the claim forms until you have 10 or more prescriptions or six months has elapsed since your first prescription drug expense.

NOTE: If you elect to fill your maintenance medication prescription more than twice through the Retail Pharmacy Service, your cost for that prescription will increase to 50% of the medication’s cost.

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What Does This Benefit Cover? If you are hospitalized because of an illness, injury or pregnancy, the Hospital Expense Benefit covers the hospital bill for your room and board and for miscellaneous expenses related to treatment for covered services you receive while you are inpatient in the hospital. This benefit also covers the charges for miscellaneous expenses related to surgery you have on an outpatient basis. Covered expenses include:

• Room and board in a semi-private room, intensive care unit, coronary care unit, burn unit or isolation room, if medically required. If no rate for a semi-private room is available at the hospital where you are confined, the Plan will pay a rate based on the average charge for a semi-private room in the surrounding area.

• Miscellaneous expenses such as medicines, laboratory tests, x-rays, oxygen, anesthesia and other

similar services provided for you in the hospital. What Does The Plan Pay Under This Benefit? After your Plan Deductible is met, the Plan pays as indicated in your Plan Benefit Profile for all covered charges for the duration of the hospital confinement, subject to Reasonable and Customary limitations. What Is Not Covered by This Benefit?

• Hospital charges related to surgeries or other medical treatment that are excluded from coverage under the Plan;

• Personal comfort items, such as hair appointments, magazines, or a telephone or TV in your room; • State taxes and surcharges; • Difference between private and semi-private room rate; • Maintenance Care; • Charges related to organ transplants that have not been pre-approved by the Plan (see “Organ

Transplant Benefit”); and • Inpatient doctor visits (payable under the Major Medical Benefit).

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Medical Claims must be filed within one year of the date of service. Claims filed more than one year from the date of service will be denied.

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What Does This Benefit Cover? The Surgical and Obstetrical Benefit covers the doctor’s bill for surgery and obstetrics performed in a hospital, qualified outpatient surgical facility or doctor’s office. All bariatric procedures (including, but not limited to, gastric bypass, gastric stapling and intestinal bypass) must have prior Plan approval. A Predetermination of Benefits, along with medical documentation, must be submitted through your TeamCare network for review. In addition, bariatric procedures must be performed at a TeamCare approved facility for bariatric procedures. What Does The Plan Pay Under This Benefit? After your Plan Deductible is met, the Plan pays as indicated in your Plan Benefit Profile for the doctor’s fee for a covered surgery, subject to Reasonable and Customary limitations. What Is Not Covered by This Benefit?

• Surgery for obesity, including lipectomy, suction lipectomy, abdominoplasty, panniculectomy or any other surgical procedure for which the primary purpose is to remove fat tissue;

• Bariatric surgeries (including gastric bypass, gastric stapling or intestinal bypass) unless the procedure is preapproved by your TeamCare network and performed at a TeamCare approved facility for bariatric procedures;

• Outpatient x-ray and laboratory charges – these are payable under the Major Medical Benefit; • Assistant surgeon’s charges – these are payable under the Major Medical Benefit; • Any balance over the Reasonable and Customary allowance established by TeamCare; • Charges for medical services that are not considered Standard Medical Care, Treatment, Services or

Supplies; • Reversal of sterilization procedures; • Services related to artificial insemination and/or in-vitro fertilization; • Charges for stand-by surgeons; and • Surgical procedures that are considered Cosmetic unless they are a result of an accidental injury.

Examples of cosmetic surgery include but are not limited to: o Augmentation mammoplasty (breast enlargement surgery), unless it is part of

reconstruction following breast surgery due to cancer; o Rhinoplasty (plastic surgery on the nose), unless surgery is the result of an accident or

chronic nasal obstruction; o Otoplasty (plastic surgery on ears), sometimes referred to as “lop ears” or “cauliflower

ears;” o Blepharoplasty (repair of drooping eyelids), unless the droop restricts the field of vision

as verified by an ophthalmologist. o Keratectomy or keratotomy–for diagnosis of myopia (nearsightedness) when the myopia

is correctable by lenses; and o Rhytidectomy (face lift), Dyschromia (tattoo removal), Genioplasty (chin augmentation).

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The Organ Transplant Benefit applies to all medical expenses relating to the transplant of the following organs:

• Heart • Lung • Liver • Pancreas • Kidney

• Bone Marrow o Autologous o Allogeneic Related o Allogeneic Unrelated

What Does The Plan Pay Under This Benefit? After Plan Deductible, the transplant surgery and related hospital charges are payable under your Plan’s Surgical and Obstetrical Benefit and the Hospital Benefit as indicated in your Plan Benefit Profile. All organ transplant procedures must have prior Plan approval. A Predetermination of Benefits, along with medical documentation, must be submitted through your TeamCare network for review. The Organ Transplant Benefit includes hospital and related facility charges, physician’s fees, ancillary charges and all related expenses associated with the surgical transplant procedure. Organ procurement expenses are also covered and are considered part of the transplant procedure.


• Charges for medical services that are not considered Standard Medical Care, Treatment, Services or Supplies;

• Charges covered by any other group plan or individual health insurance policy; • Charges for a transplant that was not pre-certified through the TeamCare network; • Expenses for any transplants other than those specified; • Expenses related to a transplant of an animal organ or a mechanical device to replace a human organ;

and • Any charges over the Reasonable and Customary amounts paid by TeamCare.

What Does The Plan Pay Under This Benefit? This benefit covers charges for medical treatment the donor receives for the donation of an organ. The Plan covers these charges only when the donor does not have a group or individual health insurance policy that covers these charges. The donor’s medical treatment will be covered under the applicable benefit. Expenses are payable while the donor is in the hospital for the surgery and will continue for 90 days after the donor is released from the hospital.



• Charges covered by any other group plan or individual health insurance policy; • Charges for a transplant that was not pre-certified through the TeamCare network; • Expenses for any transplants other than those specified; • Expenses related to a transplant of an animal organ or a mechanical device to replace a human organ;


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The Outpatient Accidental Bodily Injury Benefit covers the first day of treatment you receive, provided treatment is performed within five days of the accident, in an emergency room or a doctor’s office due to an Accidental Bodily Injury. What Does The Plan Pay Under This Benefit? Please refer to your Plan Benefit Profile to determine whether your Plan provides this benefit and, if so, how the benefit will be paid. Charges after the first day of treatment are paid under the appropriate benefit. If your Plan does not offer the Outpatient Accidental Bodily Injury Benefit, all charges are processed under the appropriate Basic Benefit or the Major Medical Benefit.

What Is Not Covered By This Benefit? Charges for the emergency treatment of an illness – such as a sore throat, a high fever or the flu – are not covered under this benefit.

The Outpatient Cancer Treatment Benefit covers charges for outpatient nuclear therapy, radiation therapy, chemotherapy, x-ray and laboratory procedures and related doctor visits for the treatment of cancer. These treatments can be given at a doctor’s office or a hospital as an outpatient. What Does The Plan Pay Under This Benefit? Please refer to your Plan Benefit Profile to determine whether your Plan provides this benefit and, if so, how the benefit will be paid. If your Plan does not offer the Outpatient Cancer Treatment Benefit, all charges are processed under the appropriate benefit.

What Is Not Covered By This Benefit? The Plan does not cover charges for medical services that are not considered Standard Medical Care, Treatment, Services or Supplies.

The Ambulance Service Benefit covers transportation charges for professional, licensed ambulance service that are incurred for required medical treatment. This includes charges for licensed air ambulance service, but only when air transportation is required to receive urgent needed medical attention and only to the nearest facility where the required medical treatment can be administered. What Does The Plan Pay Under This Benefit? After your Plan Deductible is met, the Plan pays as indicated in your Plan Benefit Profile for professional, licensed ambulance service.


• Transportation in any privately owned vehicle; • Services and supplies for which the covered individual is not legally required to pay; • Transportation for reasons other than receiving needed medical treatment; • Transportation to any location when the required medical treatment is available at the present location;


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The Major Medical Benefit covers certain medical expenses for illness, injury or pregnancy that are not covered by benefits previously described. How Much Does The Plan Pay Under This Benefit? Under the Major Medical Benefit, after your Plan Deductible is met, the Plan pays at the percentage indicated in your Plan Benefit Profile of all covered Major Medical expenses. Once you reach the Out-of-Pocket Limit (not applicable in some Plans, please refer to your Plan Benefit Profile), which is explained below, the Plan pays 100% of all covered Major Medical expenses. What Is The Out-Of-Pocket Expense Limit? The Out-of-Pocket Expense Limit is your portion of eligible covered medical expenses that you must pay after the Plan has paid its required percentage. Please refer to your Plan Benefit Profile for Out-of-Pocket Expense Limit information for your Plan and the Plan specific information regarding what applies to your Out-of-Pocket Expense Limit in Booklet 1 of this SPD. What Major Medical Expenses Are Covered Under The Major Medical Benefit? Charges for the following medically necessary items and services, if performed or prescribed by your doctor, are covered under the Major Medical Benefit:

• Outpatient diagnostic x-rays and laboratory services (see TeamCare Lab Benefit section); • Doctor’s professional services, including charges for office visits if the Doctor is not a TeamCare

provider; • Services of physiotherapists, registered nurses and other licensed health professionals, provided such

services are not provided by a member of your family; • Prescription drugs and medicines when not covered by a Hospital or Surgical Expense Benefits,

including the Prescription Drug Benefit; • Rental of braces, crutches, wheelchairs and hospital-type beds necessary for the temporary treatment of

an illness or injury; however, purchase will be allowed only if deemed more economical than rental; • Prosthetic devices; • Assistant surgeon’s fees; • Contact lenses and/or glasses prescribed to treat glaucoma, keratoconus or resulting from cataract

surgery, once per lifetime; • Repair of natural teeth when the damage is the result of an accident; and • Charges for outpatient cardiac rehabilitation programs that began less than six months after onset of

heart attack or other invasive cardiac procedure, are performed at a qualified hospital, and do not exceed three months in duration.

• What Major Medical Expenses Are Not Covered Under The Major Medical Benefit?

• Any portion of a covered expense that is above the Reasonable and Customary limitation; • Services, treatment, or supplies payable under another benefit described in this booklet; • Treatment, supplies or services excluded from coverage elsewhere in this booklet; • Charges for medical services that are not considered Standard Medical Care, Treatment, Services or

Supplies; • Any costs for transportation or lodging; • Specialized furniture or equipment unless approved by TeamCare; and • Charges for educational programs or materials, unless covered under the Wellness Benefit.

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The Quest Lab Card program offers you and your covered dependents outpatient laboratory testing at no cost when your testing is performed through Quest Diagnostics. Provider collection and handling fees may apply and are subject to your Plan provisions. The Quest Lab Card program is completely voluntary and easy to use.

What Does The Plan Pay Under This Benefit? If you use this voluntary program for covered lab work, you owe nothing toward lab work performed through Quest Lab Card; in other words, you receive a 100% lab testing benefit. If you choose not to participate in the program, your covered lab work will be paid under your Major Medical Benefit on your Plan Benefit Profile.

The Quest Lab Card program applies to diagnostic outpatient laboratory testing, which includes blood testing, urine testing, cytology and pathology, and cultures. If you should have any questions concerning this program, please call Quest Lab Card Client Services at 800-646-7788.

What Is Not Covered By This Benefit? The program does not apply to:

• Lab work ordered during inpatient hospitalization;

• Lab work needed on an emergency basis; • Time-sensitive, specialized out-patient

laboratory testing such as fertility testing, bone marrow studies and spinal fluid tests;

• Non-laboratory work such as mammography, x-ray imaging and dental work;

• Lab work performed by another lab; and • Testing that is not covered by your Plan

provisions. As a reminder, your physician must mark the lab requisition submitted with the specimen as Lab Card or you will not be eligible for the 100% lab testing benefit. If your physician does not take specimens, simply visit a Quest Diagnostics collection site to have your specimen taken. In either situation, be sure to show your TeamCare Medical ID card and your TeamCare Benefits ID card which lists your Quest Lab Card information, or your tests may not be eligible for the 100% lab testing benefit.

TeamCare Imaging is a voluntary program for outpatient advanced radiology procedures. What Does The Plan Pay Under This Benefit? When you schedule your procedure through US Imaging, you owe nothing and have a 100% benefit towards advanced radiology services (MRI, CT and PET scans only) performed at an outpatient imaging center in the US Imaging network. In other words, you pay no co-insurance for your advanced radiology benefit. If you choose not to participate in the program, your covered advanced radiology procedures will be paid under the Major Medical Benefit shown on your Plan Benefit Profile. The US Imaging program is a premier network with over 2,200 radiology facilities serving many areas across the country. You must call US Imaging to schedule your MRI, CT and PET scans at a network facility that is convenient to you. All facilities are credentialed to ensure that US Imaging facilities meet or exceed the highest quality standards in the industry. When your doctor prescribes an MRI, CT or PET scan, you or your doctor must call US Imaging at 877-674-0674 to schedule an appointment. What Is Not Covered By This Benefit? The program does not apply to:

• Advanced radiology ordered during inpatient hospitalization; • X-rays, mammograms, sonograms, ultrasounds, bone scans, or testing that is not covered by your Plan

provisions. As a reminder, you or your doctor must call US Imaging to schedule your MRI, CT or PET scans or you will not be eligible for the 100% advanced radiology benefit.

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The Chiropractic Benefit covers charges for all services provided, directed, or supervised by a chiropractor, subject to the Plan exclusions and limitations summarized below. This includes x-rays, laboratory charges, therapy, hospitalization, office visits and all other covered services. What Does The Plan Pay Under This Benefit? After your Plan Deductible is met, the Plan pays a percentage of all Reasonable and Customary covered charges up to the maximum per person, per calendar year limit shown on your Plan Benefit Profile.


• Any treatment that is not required due to an illness or injury; • Any remaining balance that is more than the amount allowed under the Plan; • Any treatment for children under the age of 12; • Any treatment that is not medically necessary or not considered to be Standard Medical Care, Treatment,

Services or Supplies; and • Maintenance Care.

The Hearing Aid Benefit covers charges for fittings, approved hearing correction devices (hearing aids) and the first set of batteries. All services must be provided by an audiologist or certified hearing aid specialist and recommended or prescribed by a doctor.

What Does The Plan Pay Under This Benefit? Please refer to your Plan Benefit Profile to determine whether your Plan provides the Hearing Aid Benefit and, if so, how the benefit will be paid.


• Replacement of lost, missing or stolen appliances; • Repair or replacement of broken appliances; • Replacement batteries; • Hearing aids purchased without a prescription or recommendation from a physician or without a waiver

approved by the Food and Drug Administration; and • Services and supplies for which the covered individual would not legally be required to pay.

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The Behavioral Health Benefit covers treatment of all mental health disorders, including the treatment of psychiatric, alcoholism and drug abuse related conditions. Pre-certification is required by the appropriate TeamCare network for all inpatient, residential, intensive outpatient (IOP) and partial hospitalization (PHP) treatment to qualify for payment under the Behavioral Health Benefit. What Does The Plan Pay Under This Benefit For Inpatient Treatment? If you are being treated as an inpatient in an approved psychiatric, alcoholism or drug abuse treatment facility or a qualified hospital, after your Plan Deductible or hospital admission co payment (if applicable), the Plan pays the percentage indicated in your Plan Benefit Profile of Reasonable and Customary covered charges. Once you reach the Medical Out-of-pocket Limit (not applicable in some Plans, please refer to your Plan Benefit Profile), the Plan pays 100% of all covered expenses. What Does The Plan Pay Under This Benefit For Outpatient Treatment? If you are being treated as an outpatient in an approved psychiatric, alcoholism or drug abuse treatment facility and your treatment program is prescribed and performed by a psychiatrist, physician, psychologist, or a state-licensed or registered social worker or counselor:

• If covered services are provided during a physician office visit, you will be responsible for the TeamCare office visit co payment as indicated on your Plan Benefit Profile;

• If covered services are provided in an outpatient hospital setting, the Plan pays the percentage indicated in your Plan Benefit Profile of Reasonable and Customary covered charges. Once you reach the Medical Out-of-pocket Limit (not applicable in some Plans, please refer to your Plan Benefit Profile) the Plan pays 100% of all covered expenses.

What Is Not Covered By The Behavioral Health Benefit?

• Treatment in a half-way house or similar facility; • Inpatient, residential, intensive outpatient (IOP) and partial hospitalization (PHP) treatment not pre-certified

by the appropriate TeamCare network; • Legal services and recreational, vocational, financial or educational counseling, except as part of a chemical

dependency treatment program; • Charges that the Participant is not legally required to pay; • Detoxification or drug withdrawal programs not rendered by an approved hospital or as part of an approved

program; • Personal comfort items; • Marriage or family counseling, except as part of a psychiatric treatment program; • Services rendered by a social worker or counselor who is not licensed or registered in the state in which

services are performed; • Court-ordered treatment, unless assessed and certified to be in accordance with medically necessary

standards; • Services and treatment for the purpose of maintaining employment or insurance, unless assessed and

certified to be in accordance with medically necessary standards services and treatments that are: o Educational or vocational in nature, o Required by law to be provided by a school system for a child (such as evaluation for attention

deficit disorder), o For personal growth and development, o For adjudication of marital, child support and custody cases;

• Services and treatment that are experimental, investigational, mainly for research or not in keeping with national standards of practice as determined in accordance with guidelines adopted by the Plan, for example, treatment of sexual addiction, codependency, or any other behavior that does not have a psychiatric diagnosis;

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• Regressive therapy, megavitamin therapy, nutritionally based-therapies for chemical dependency treatment, and non-abstinence based chemical dependency treatment;

• Custodial care, including, but not limited to, treatment not expected to reduce the disability to the extent necessary to enable the patient to function outside a protected, monitored or controlled environment;

• Services and treatment for intellectual disability (except initial diagnosis), autism (which may be covered by the Plan), pervasive developmental disorders, chronic organic brain syndrome, learning disability;

• Treatment for stammering or stuttering; or • Treatment for chronic pain except for psychotherapy, biofeedback or hypnotherapy provided in connection

with a psychiatric disorder.

The following charges are not covered by the Plan:


• Any costs for transportation or lodging; • Specialized furniture or equipment unless approved by the Plan; • Charges for educational programs or materials; • Cosmetic care or treatment (except to the extent it is required due to an accidental bodily injury); • Any fees over the in-network scheduled fee or Reasonable and Customary limitation; • Personal comfort items, state taxes or surcharges; • Routine dental x-rays and laboratory work (see Dental and Orthodontic Benefit); • Eye examinations for the correction of vision and fitting of glasses or contact lenses, except contact lenses

or glasses for treatment of glaucoma, keratoconus or resulting from cataract surgery (see Vision Benefit); • Injury or illness that is work-related or covered by Workers’ Compensation or an Occupational Disease Law; • Hospital confinements that are longer than accepted standards of medical practice; • Maintenance Care; • Charges for medical services and prescription drugs related to in-vitro fertilization, artificial insemination and

reversal of prior sterilization; • Charges covered by any other group plan or individual health insurance policy; • Charges for a transplant that was not pre-certified through the TeamCare network; • Expenses for any transplants other than those specified; • Expenses related to a transplant of an animal organ or a mechanical device to replace a human organ; • Treatment or services that are covered or provided by the Social Security Act; • Treatment or services for complications of medical, dental or vision procedures not covered by TeamCare; • Treatment or services (unless five years have passed since the original occurrence of the illness or injury)

for illness or injury or for complications of illness or injury that: o Is work-related or covered by a Workers’ Compensation Act or similar law (see “Workers’

Compensation”); o Is received while in the armed services; o Arises out of declared or undeclared war or any act of war or civil disturbance; o Is sustained while participating in an illegal act that is in violation of a state or federal statute;

• Treatment outside the United States shall be limited to treatment, services or supplies that are uniformly and professionally endorsed by the general medical community in the United States. Benefits will be paid in U.S. dollar amounts under Plan limitations not to exceed maximum amounts allowed for similar treatment, care or services in the United States; and

• Services or supplies related to any eye surgery performed mainly to correct refractive errors (for example, radial keratotomy) unless vision acuity cannot be corrected to 20/50 with corrective lenses.

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Under TeamCare, you have complete and direct access to Mayo Clinic for any medical care. Whether it is for information, a second opinion, or the actual treatment - the Mayo Clinic stands ready to provide you the best care. Mayo Clinic is based on the idea of "cooperative medicine" – teams of experts combine their skills and experience to help solve people's medical problems. In simple terms, Mayo Clinic believes that two heads are better than one, and five are even better. For most illnesses and injuries, your care at a local facility or hospital is appropriate; however, for more highly specialized cases, access to the Mayo Clinic can be crucial. Whether confirming the original diagnosis and treatment, or providing treatment, Mayo Clinic has experience in dealing with all types of cases - making the best care available to you and your family. With locations in Rochester, MN, Jacksonville, FL and Scottsdale, AZ - arranging for services at the Mayo Clinic is easy. All you have to do is call Ask Mayo at 800-700-MAYO (6296) and schedule an appointment at one of their three locations. If you decide to go to the Mayo Clinic, you are still responsible for your Plan Deductible, the TeamCare office visit co-payment, and any co-insurance. Also note that services not covered by the Plan and travel and lodging expenses are your responsibility.

You also have access to the Mayo Clinic’s expertise for all of your health care questions through the Ask Mayo Clinic Program. By calling 800-700-MAYO (6296), anytime day or night, you can get answers to health-related questions important to you. You can also request health information packets, self-care and education materials. Every call is answered by experienced registered nurses. In addition, if you want to speak to a physician directly, you will receive a call back, usually within 24 hours. The Ask Mayo Clinic nurses draw on the extensive health information resources of Mayo Clinic’s award-winning online and print reference information to provide up-to-date, reliable information on any of your health concerns. In complex cases, nurses have the option of consulting with Mayo Clinic physicians. NOTE: Ask Mayo Clinic is not a substitute for 911. In the event of a true medical emergency, dial 911 immediately or go to your local hospital emergency room.

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It is important to refer to your Plan Benefit Profile for your specific Dental and Orthodontic Benefits. Dental and Orthodontic Benefits are not available under all plans.

Dental Benefits .......................................................................................................... 21 Orthodontic Benefits ................................................................................................... 22 Dental Exclusions and Limitations .............................................................................. 23

The Plan has joined with Humana Dental Preferred, one of the nation’s largest dental preferred provider networks, to offer TeamCare Dental, which allows you and your family members to maximize your dental benefits. TeamCare Dental is a voluntary program. You may choose to continue your dental care with a non-participating dentist and your benefits will be paid according to your Plan. However, if you choose to use one of the 175,000 dental providers in the network, you will receive the following additional benefits:

• Using an in-network Humana provider allows you to receive your dental care at a lower cost. Through TeamCare Dental, your co-insurance is based on the negotiated discounted dental fee.

• You and your family members benefit directly from the negotiated discounts, and by using an in-network dentist, you are not billable for the charges above the negotiated discounted fee.

• Since the program is completely voluntary, you get to choose your dentist. With over 175,000 dental providers, you may find that your dentist is already a participating dentist. If you elect to use an in-network provider, you will enjoy all the benefits offered under TeamCare Dental.

To find a participating dentist in your area, or for further information, please access the Humana website at humanadentalnetwork.com, or call 800-592-3112 to speak with a Humana representative.

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TeamCare Dental is a voluntary program which allows you to save money and maximize your dental benefits. There is no mandatory network for dental services.

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The Dental Benefit covers treatment usually provided by dentists (including specialists) to prevent or correct dental problems. Covered dental procedures include, but are not limited to, the listed services. All procedures are subject to the limitations listed. All time limitations are determined by the last date of service of each applicable treatment.

Diagnostic and Preventive Dental Care

• Oral exams once every six months; • Full-mouth or panorex x-rays once every two

years; • Bite-wing x-rays once every six months; • Prophylaxis (cleaning) once every six months; • Fluoride treatments for covered children once

every six months; and • Sealants for covered children through age 13

once every 18 months.

Restorative Dental Treatments and Extractions • Fillings and routine extractions, and • Root canal treatments and similar services.

Oral Surgery and Anesthesia • Removal of impacted teeth; • Alveoplasties; and • General anesthesia when used in conjunction

with oral surgical procedures.

Periodontal Surgery • Full mouth debridement, periodontal scaling

and/or root planing once every 12 months; • Gingivectomies or gingivoplasty; • Mucogingival surgery; • Osseous surgery; • Osseous graft; • Gingival curettage; • Periodontal prophylaxis once every six

months; and • General anesthesia when used in conjunction

with periodontal procedures.

Fixed and Removable Prosthetic Devices and Related Services

• Full or partial dentures (including overdentures) once every three years;

• Fixed bridgework, crowns, inlays and onlays once every three years; and

• Repair of dentures, partials, bridges and crowns.

What Does The Plan Pay Under This Benefit? For covered dental treatments, TeamCare pays a percentage of the charge, subject to Reasonable and Customary limitations. The percentage payable depends on the type of dental treatment you or your dependents receive and is indicated in your Plan Benefit Profile. TeamCare will pay a maximum Dental Benefit every calendar year for each covered individual as indicated in your Plan Benefit Profile.

Does This Benefit Cover Any Treatment After Your Plan Coverage Ends? Yes. Certain dental treatments that typically require a longer time to complete will be payable after your Plan coverage ends if they are started while you or your dependents are covered. Following are those procedures that are covered based on the date that work was begun:

• The completion of dentures (full or partial) is payable if you or your dependents were covered on the date the impression was made.

• The completion of fixed bridgework, gold restorations and crowns is payable if you or your dependents were covered on the date any affected teeth were prepared.

• The completion of root canal therapy (endodontics) is payable if you or your dependents were covered on the date the affected teeth were opened for treatment.

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In order for the above procedures to be covered, they must be fully completed within one year of the date that treatment was started.

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For covered children through age 25, the Plan provides part of the cost of straightening teeth (braces, including interceptive or retention orthodontic appliances). To be covered under Orthodontic Benefits, charges must be incurred while your child is covered under the Plan. The dental exclusions and limitations listed in this chapter also apply to orthodontic treatment. Orthodontic Benefits are only payable for covered children under age 26. What Does The Plan Pay Under This Benefit? For covered orthodontic benefits, the Plan pays a percentage of the charge, subject to Reasonable and Customary limitations. The percentage payable is indicated in your Plan Benefit Profile. The Plan will pay a maximum Orthodontic Benefit (if applicable) for each covered child as indicated in your Plan Benefit Profile. Does The Plan Have Predetermination Of Benefits For Dental And Orthodontic Benefits? Yes, for charges of $500 or more, an advance Predetermination of Benefits is available. After your dental examination, your dentist will recommend dental treatment and tell you what the charge will be. If the estimated charge is $500 or more, a Predetermination of Benefits lets you and your dentist know what amount will be payable for the proposed treatment. Many dentists require that you agree to the proposed treatment and charges before treatment begins. Therefore, it is valuable for you to know what the Dental Benefit will pay before you make a financial commitment to the dentist. Follow these steps to have the proposed dental treatment reviewed in advance:

• Ask the dentist to complete a “Predetermination of Benefits Request” showing the proposed treatment and charges, and

• Submit your request to the address on the back of your TeamCare Benefits identification card.

Both you and your dentist will receive a statement of the amount the Plan will pay for the proposed services. This Predetermination of Benefits is not a guarantee of payment. The projected benefits will be paid only if you are still covered at the time you receive the treatment.

How Do I File A Dental Or Orthodontic Claim? In most cases, claim forms are not required since most health care providers (particularly dentists, doctors and hospitals) send your bills directly to TeamCare. In addition, if you use a TeamCare Dental provider, no claim forms will be required. If you do need to file a claim yourself, send the itemized bill from the dental provider directly to the location indicated on back of either your TeamCare Medical or TeamCare Benefits ID card.

Does This Plan Have Coordination Of Benefits? Yes. If you or your dependents are covered by another group plan that provides dental benefits, this Plan will coordinate with your other plan. This Plan pays a percentage of the dentist’s charges subject to the limitations noted in this chapter. In no case will the total combined payment from this Plan and any other insurance exceed the dentist’s charges.

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Dental and Orthodontic Claims must be filed within one year of date of service. Claims filed more than one year from date of service will be denied.

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The following are not covered by the Dental and Orthodontic Benefit: • Any amount over the Reasonable and Customary allowance established by the Plan with a non-TeamCare

Dental provider; • Treatment by someone other than a dentist, except for cleaning and scaling of teeth and application of fluoride

and/or sealants by a licensed dental hygienist when such services are rendered under the supervision and guidance of a dentist;

• Services and/or supplies that are not necessary according to generally recognized dental guidelines; • Services and/or supplies for cosmetic purposes; • Orthodontic services and/or supplies for participant or spouse, including orthodontia in conjunction with

temporomandibular joint disease (TMJ) and/or other medical/dental conditions; • Services and/or supplies for which you or your dependent is not legally required to pay; • Educational programs such as plaque control, oral hygiene instruction or nutrition counseling; • Charges for failure to keep appointments or charges for completion of claim forms; • Local anesthesia or analgesia; • Prescriptions written by dentists (may be covered under the Prescription Drug Benefit); • Fluoride application performed on a participant or spouse; • In connection with restorative dentistry: temporary restorations or sedative fillings, on the same day; • In connection with restorative dentistry: bases; • Replacement of lost, missing or stolen dental/orthodontic appliances; • Crowns without sufficient breakdown or sufficient decay; • Crowns and/or bridgework without sufficient bone support; • Crowns and/or bridgework supported by implants; • Permanent crowns and/or bridgework on deciduous (baby) teeth; • Any procedure not completed; • Expenses for any prosthetic appliance, if the appliance is not actually inserted; • Expenses for home medicaments, such as oral rinses; • Expenses for multiple periodontal procedures performed on the same day; • Expenses for periodontal procedures performed on children; • Expenses for a space maintainer for a participant or spouse; • Precision attachments, specialized techniques and personalization of dental prosthesis; • Procedures, restorations and/or appliances to increase vertical dimension (the distance between the nose and

chin); • Implantology (except for endosseous staple implants and subperiosteal to support full dentures); • No more than two consecutive abutments on any fixed bridgework (crowns splinted and extended beyond this

will be payable as individual crowns); and • Expenses for extension of bridges or prosthetic devices previously paid for by this Plan, except for expenses for

new extended areas.

The following covered procedures are subject to time limitations • Expenses for replacement made less than three years after placement or replacement of inlays, onlays, crowns,

bridgework, dentures or prosthetic devices are not covered by the Plan (your Plan does, however, cover newly extended areas);

• Expenses for adjustments, tissue conditioning, relining and/or rebasing less than six months after insertion of dentures;

• Expenses for labial veneers/laminate unless due to accident, fracture or birth defect, or within three years of previous payment for labial veneers;

• Expenses for dental laboratory relining made less than three years after the previous payment for relining covered by the Plan;

• Expenses for rebasing of dentures made less than three years after previous payment for rebasing; • Panorex or full-mouth x-rays more than once in any two-year period; • Bite-wing x-rays, fluoride application, oral examination or prophylaxis or periodontal prophylaxis (cleaning) more

than once in any six month period; and • Root canal therapy, apicoectomy and hemisection more than once in a lifetime per tooth (root).

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VVIISSIIOONN BBEENNEEFFIITTSS It is important to refer to your Plan Benefit Profile for your specific Vision Benefits. Vision Benefits are not available under all plans.

Vision Benefits ........................................................................................................... 25

The Plan has joined with EyeMed Vision Care, one of the nation’s largest preferred provider networks, to offer TeamCare Vision. For a small co-payment, TeamCare Vision will cover your eye exam, along with frames and lenses or contact lenses up to the maximum allowances. If you choose to use an out-of-network vision provider who is not a member of the TeamCare Vision network, TeamCare will pay benefits only up to the maximum reimbursement limits.

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The Vision Benefit covers charges for routine eye examinations, lenses, frames, contact lenses and service for lenses and frames for you and your dependents as follows:

• One eye examination per person is covered every 12 months. • One pair of eyeglass lenses per person is covered every 12 months. • One set of frames or one repair to frames per person is covered every 12 months. • One pair of contact lenses instead of glasses is covered every 12 months.

The vision services must be performed by an optician, optometrist or ophthalmologist. In compliance with the Affordable Care Act, the eye exam benefit for glasses for covered children under the age of 19 from out-of-network providers will be subject to reasonable and customary limitations or subject to the Plan’s PPO office visit copay. VISION BENEFITS IN-NETWORK TeamCare has developed a partnership with EyeMed Vision Care using their Advantage Network. EyeMed has more than 28,000 network providers. The network includes LensCrafters, Pearle Vision Centers, and the optical departments at Sears, JC Penney, Target, and numerous independent practices. For the co-payment specified on your Plan Benefit Profile, you and your covered dependents can receive an eye examination and glasses or contact lenses every 12 months. Your co-payment allows you the following:

• Routine Eye Exam and prescription for eyeglass lenses are covered. If receiving a contact lens exam, you are responsible to pay any additional fee associated with the exam, fitting and follow-up.

• Standard Eyeglass Lenses with uncoated plastic lenses, regardless of size or power, are covered. • Lens options such as progressive, polycarbonate, ultraviolet coating, scratch resistant coating,

tints, etc. are available at reduced costs through your EyeMed Vision provider.

• Frames are covered up to the allowance specified on your Plan Benefit Profile. If you choose a frame retailing for more than the covered allowance, you will be responsible to pay the difference in price, less 10%.

or

• Contact Lenses are covered up to the allowance specified on your Plan Benefit Profile. If you choose

contact lenses retailing for more than the covered allowance, you will be responsible to pay the difference in price.

• Contact lenses can be obtained from a participating provider or through the mail by using the Contacts Direct Program. The Contacts Direct Program offers an economical alternative for purchasing contact lenses. For pricing and ordering information, please call 800-987-5367.

To use your Vision benefits, simply call for an appointment or visit any one of the many optical providers and show your TeamCare Benefits ID card that has your EyeMed Vision Care information. The EyeMed Vision Care provider will verify your eligibility, benefits and co-payment. For the location nearest you or if you have questions concerning participating provider locations, call the EyeMed Customer Care Center at 1-866-393-3401, or visit: eyemedvisioncare.com.

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VISION BENEFITS OUT-OF-NETWORK If you choose to go to a vision provider who is not a member of the TeamCare Vision network, TeamCare will provide reimbursement to the limits specified on your Plan Benefit Profile.

How Do You File An Out-of-Network Vision Benefit Claim? In most cases, claim forms are not required since most vision providers send your bills directly to TeamCare. If you do need to file a claim, send the itemized bill directly to TeamCare as indicated on the back of your TeamCare Medical ID card. When submitting these bills, be sure to indicate the participant’s name along with the participant’s identification number that appears on your TeamCare Medical ID card. VISION EXCLUSIONS The following are not covered by the Vision Benefit:

• Procedures requiring hospitalization, surgery, x-rays or laboratory work are not covered under the Vision Benefit but may be covered under Medical Benefits;

• Vision care services or supplies that are paid for or furnished by any other group policy or prepayment plan (individual policies or plans are not affected by this limitation);

• Vision care services or supplies you receive from a medical department maintained by your employer, a mutual benefit association, a labor union, trustee or similar group;

• Vision care services or supplies furnished by or at the direction of the United States Government or any government agency;

• Medical or surgical treatment of the eye. Coverage may be provided under Medical Benefits; • Sunglasses, prescription or non-prescription; • Safety glasses; • Vision training; • Orthoptics (Orthoptics is a technique of eye exercises designed to correct a visual defect); • Treatment of aniseikonia (aniseikonia is a vision defect in which the image of an object as seen by one

eye differs in size and shape from that seen by the other eye); and • Replacement of glasses due to loss or theft, if less than one year has elapsed since purchase date.

Out-of-Network Vision Claims must be filed within one year of the date of service. Claims filed more than one year from the date of service will be denied.

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In this Chapter, we will explain the Short-Term Disability Benefit and Life Insurance Benefits. The Short-Term Disability Benefit is intended to help you if you become disabled and cannot work by providing you with some income and maintaining health insurance for your family. The Short-Term Disability benefit provides you with a weekly payment when you’re disabled as a result of a non-work-related injury or illness or unable to work due to pregnancy. Life Insurance is primarily a benefit for your family or anyone who depends on you for support. Its purpose is to help provide your beneficiary with some measure of financial security in the event of your death. It is important to refer to your Plan Benefit Profile for your specific Short-Term Disability and Life Insurance Benefits. Short-term Disability and Life Insurance Benefits are not available under all plans.

Short-Term Disability Benefits ..................................................................................... 28 Life Insurance Benefits ............................................................................................... 29 Accidental Death & Dismemberment Benefits ............................................................ 29 Total and Permanent Disability Benefits .................................................................... 31

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What Benefits Are Provided? This benefit provides you with a weekly payment for a maximum number of weeks as indicated in the Plan Benefit Profile. In addition, depending on your specific Plan, you and your covered dependents may have full Plan coverage if you are eligible to receive Short-Term Disability Benefits. Please refer to your Plan Benefit Profile. To receive these benefits, you must be disabled as a result of a non-work-related injury or illness or unable to work due to pregnancy, and you must be receiving regular care from your doctor. Additionally, you must be actively employed and covered by the Plan when you become disabled. Short-Term Disability Benefits are not payable for illnesses or injuries that are work related or are the result of surgical procedures not covered under the Plan. When Do Benefits Start? If you are injured, Short-Term Disability Benefits are payable from the date the doctor first determines that you are disabled, provided you receive medical treatment within one day before or three days after you become disabled. Otherwise, the first date of medical treatment after that date would be used to start your Short-Term Disability Benefits. If you are ill or pregnant, Short-Term Disability Benefits are payable from the eighth day after you become disabled, provided you have received medical treatment within one day before or three days after your disability date. Otherwise, Short-Term Disability Benefits will begin eight days after you first receive medical treatment. The chart below illustrates when benefits start:

When Do Benefits Stop? Short-Term Disability Benefits stop when you cease being disabled or after the maximum number of weeks of benefits your Plan provides (whichever is earlier). If you decide to retire during your Short-Term Disability period, your Short-Term Disability Benefits will stop on your retirement date, even if you are still disabled and haven’t received the maximum number of weeks of benefits. Please refer to your Plan Benefit Profile for the maximum number of weeks of benefits. What Happens If You Are Disabled Again After Your Short-Term Disability Benefit Stops? If your second disability is related to your first disability, you must return to active employment and work for 30 consecutive calendar days before you can begin a new Short-Term Disability period (unless your Plan Benefit Profile indicates a different time frame). Note: Active employment cannot be interrupted for vacation days, sick days, paid time off, etc. If your second disability is not related to your first disability, you must return to active employment and work at least one day to qualify for a new Short-Term Disability period. How Do You File For Short-Term Disability Benefits? To file for Short-Term Disability Benefits, you must complete a Short-Term Disability claim form. Have your doctor and employer complete the necessary information on the form to ensure timely processing.

SSHHOORRTT--TTEERRMM DDIISSAABBIILLIITTYY BBEENNEEFFIITTSS ((PPAARRTTIICCIIPPAANNTT--OONNLLYY BBEENNEEFFIITT))

Short-Term Disability Benefit Table

When Did You Receive Medical Attention?

When Does Your Short-Term Disability Benefit Start?

Are You Injured in a Non-Work Related

Accident?

One day before or 3 days after you became disabled On the date you became disabled

Two or more days before, or 4 or more days after you became disabled

On the date you first received medical attention after you became disabled

Are You Ill or Pregnant?

One day before or 3 days after you became disabled On the 8th day after you became disabled

Two or more days before, or 4 or more days after you became disabled

On the 8th day after the date you first received medical attention after you became disabled

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For additional Short-Term Disability Benefits, the Plan will send you a “Continued Disability” form to fill out to verify that you are still off work because of injury, illness or pregnancy. There are special forms to complete when applying for a 13-week Extended Basic Benefit or 24-month Extended Major Medical Benefit or Total and Permanent Disability Benefit. You can obtain these forms from your Local Union, TeamCare or MyTeamCare.org. Please refer to your Plan Benefit Profile to determine if your Plan offers these benefits.

The Life Insurance Benefit is the amount of life insurance payable to your beneficiary upon your death. For benefits to be payable, you must be covered by the Plan on your date of death or die within a 31 day grace period following your last day of coverage. In the case of the death of your enrolled spouse or child, you receive the Life Insurance Benefit. What Does The Plan Pay For This Benefit? The Plan pays Life Insurance Benefits on the Participant, the Spouse, and any Child (through Age 25) as indicated on your Plan Benefit Profile. Are Your Children Covered? Your enrolled children are covered from birth through age 25. The Life Insurance Benefit on all children terminates when they reach age 26.

An Accidental Death & Dismemberment (AD&D) Benefit is payable if you suffer a bodily injury or die because of an accident that occurs while you are covered under the Plan. However, for benefits to be paid, the loss must occur within 120 days of the accident. Benefit amounts vary according to the loss suffered, as shown in the table below. Your spouse and dependents are not covered under this benefit. Accidental Death Benefit For purposes of this benefit, an accidental death is any death directly and solely resulting from external means or an external cause. A death caused or contributed to by an illness or disease is not an accidental death and would not be covered under this benefit. The Accidental Death Benefit is payable in addition to the Life Insurance Benefit for covered participants. The Accidental Death Benefit will be paid to your named beneficiary, or if none, in the beneficiary order specified by the Plan. Accidental Dismemberment Benefit In all cases, for an Accidental Dismemberment Benefit to be payable, the loss must be due to an accidental bodily injury, which is an injury resulting from a sudden and unexpected external event. This benefit is not payable for loss due to an illness or disease. You will receive all benefits for accidental dismemberment or loss of sight immediately after the Plan receives satisfactory proof of loss. Loss of hands or feet means severance at or above the wrist or ankle joints. A loss with regard to the eyes means total and irrecoverable loss of sight. The Plan has the right to require a medical examination in connection with a claim for accidental dismemberment.

Short-Term Disability forms must be filed within one year of the non-work-related accident or illness. Claims filed after more than one year will be denied.

LLIIFFEE IINNSSUURRAANNCCEE BBEENNEEFFIITTSS

AACCCCIIDDEENNTTAALL DDEEAATTHH && DDIISSMMEEMMBBEERRMMEENNTT BBEENNEEFFIITTSS ((PPAARRTTIICCIIPPAANNTT--OONNLLYY BBEENNEEFFIITT))

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In the event of an Accidental Dismemberment, the benefits will be paid to you after the Plan receives satisfactory proof of loss. Benefit amounts vary according to the loss suffered, as shown in the table:

What Is Not Covered By The Accidental Death & Dismemberment Benefit? No benefit is paid for death or dismemberment caused by any of the following:

• Disease, including mental illness, or medical or surgical treatment for disease; • Infections except from an accidental cut or wound; • Suicide or attempted suicide, whether sane or insane; • War or international armed conflict; • The intentional act of another person during a fight that you started; • Ingestion or injection of non-prescribed drugs or intentional overdose of any drug; or • Participation in an illegal act that is in violation of a federal or state criminal statute.

How Are Life Insurance, Accidental Death, And Accidental Dismemberment Claims Paid?

• In the event of the death of Spouse or Children, the benefit is payable to you in one lump sum. • In the event of your death and if you have not named a beneficiary or if the beneficiary you named is no

longer living - the benefit amount will be paid in full to the first surviving class as follows: o Your surviving spouse; o Equal shares to your surviving children; o Equal shares to your surviving parents; o Equal shares to your surviving brothers and sisters; or o Your estate.

• In the event of an Accidental Dismemberment, the benefits will be paid to you after the Plan receives satisfactory proof of loss.

How Do You Name A Beneficiary? You can name anyone you want as beneficiary to receive the Life Insurance and Accidental Death Benefits. You may also split the benefits among multiple beneficiaries if you prefer. To change your beneficiary, you must submit a Life Insurance Beneficiary Designation Form to the Plan. What If You Get Divorced? In the event your marriage is terminated due to a final decree of divorce, any previously filed beneficiary designations naming your ex-spouse as your beneficiary will become null and void.

If you do not name a beneficiary, Life Insurance and Accidental Death or Dismemberment Benefits will be paid in accordance with the beneficiary order established by the Plan.

LOSS PAID TO AMOUNT PAYABLE

Accidental Death Your Beneficiary

100% of Member Death Life Insurance Benefit amount per your Plan Benefit Profile

Loss of Both Hands or Both Feet or Sight in Both Eyes

You

Loss of Any Combination of Foot, Hand, or Sight in One Eye

You

Loss of One Hand, One Foot, or Sight in One Eye

You 50% of Member Death Life Insurance Benefit amount per your Plan Benefit Profile

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Who Is Covered By This Benefit? The Total and Permanent Disability Benefit covers you (the participant) if you suffer a total and permanent disability before reaching age 60 and while you are a covered participant. The type of benefit you are eligible to receive is determined by your age at the time you become totally disabled. This benefit does not cover your spouse or dependents. Please refer to your Plan Benefit Profile to determine if your Plan offers this benefit. What Is A Total And Permanent Disability? To receive a Total and Permanent Disability Benefit, you must have become totally disabled by bodily injury or disease while covered under the Plan and before reaching age 60. Your disability must prevent you from ever again working at any gainful occupation. A Social Security Award Certificate for Disability is generally accepted as proof of eligibility for this benefit. What Does This Benefit Cover? The Total and Permanent Disability Benefit takes the place of your Life Insurance Benefit and is payable if you become totally and permanently disabled. Therefore, if you receive the Total and Permanent Disability Benefit, you forfeit your Life Insurance Benefit. How Much Does The Plan Pay Under This Benefit? The Total and Permanent Disability Benefit is provided for covered participants in the following manner:

• If you become disabled before age 50: The Total and Permanent Disability Benefit will be issued to you as indicated in the Plan Benefit Profile once proof that your disability is total and permanent has been accepted by the Plan. The first installment of the benefit will be paid on the later of:

o Six months after your total disability began; or o The month your Social Security award is dated if it is dated before the 15th of the month

or the following month if the Social Security award is dated on or after the 15th of the month.

o All payments end after 60 monthly installments have been paid, even if you are still totally disabled. If you would otherwise be eligible for installment payments because of your total and permanent disability but you die before any or all payments are made, the remaining value of this benefit will be payable in one lump sum to your beneficiary, or if none, in accordance with the Plan.

• If you become disabled from ages 50 to 59: You will be eligible for the Waiver of Premium Benefit. The Waiver of Premium provides you with a Life Insurance Benefit without further contributions on your behalf. Upon your death, a benefit payment as indicated in your Plan Benefit Profile will be paid to your named beneficiary, or if none, in accordance with the Plan.

• If you become disabled at or after age 60: No benefit is payable.

TTOOTTAALL AANNDD PPEERRMMAANNEENNTT DDIISSAABBIILLIITTYY BBEENNEEFFIITTSS ((PPAARRTTIICCIIPPAANNTT--OONNLLYY BBEENNEEFFIITT))

To remain eligible for this benefit, you must continue to be totally and permanently disabled. You will be contacted on a regular basis for updated medical information verifying your condition. If you do not provide this information, your benefits may be terminated.

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When Will You No Longer Be Eligible For This Benefit? If you become disabled before age 50 and you recover from your disability, monthly payments will end. In addition, if you return to covered employment and become eligible for a Life Insurance Benefit again, the amount of your Life Insurance Benefit will be reduced by the amount of the Total and Permanent Disability Benefit already paid to you. After five years of covered employment, your full Life Insurance Benefit will be restored. If you become disabled from ages 50 to 59 and you recover from your disability, you will no longer be eligible for the Waiver of Premium Benefit. In addition, if you return to covered employment and become eligible for a Life Insurance Benefit again, you will be entitled to the full Life Insurance Benefit. How Do You File a Claim? All claims should be filed as soon as possible. You should not wait to receive your Social Security Disability Award to file a claim for the Total and Permanent Disability Benefit. Claim forms are required to apply for these benefits. You can obtain the necessary claim forms through your Local Union, TeamCare or MyTeamCare.org. Other required documentation, such as a death certificate, will be indicated on the claim form. Life Insurance, AD&D and Total and Permanent Disability Benefit claims must be filed within three years of the date of loss.

It is important that you keep your beneficiary designations current to ensure benefits are distributed in accordance with your wishes when you die. The Plan must pay Life Insurance and Accidental Death or Dismemberment Benefits in accordance with valid beneficiary notices filed with the Plan.

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EELLIIGGIIBBIILLIITTYY You may confirm your eligibility for coverage under the Plan by logging into MyTeamCare.org and sending a secure message (question) through the Message Center or by calling Participant Services at 800-TEAMCARE (832-6227).

Participant Eligibility .................................................................................................... 34 Spouse Eligibility ........................................................................................................ 35 Qualified Same-Sex Domestic Partners ..................................................................... 35 Child Eligibility............................................................................................................. 35 QMCSO ...................................................................................................................... 36 Multi-Tiered Plans ....................................................................................................... 36 Extension of Benefits ................................................................................................ 38 Notice of Continuation Rights Under COBRA ............................................................. 39 Other Self-Payments .................................................................................................. 41

Spouse as used in this document refers to both Spouses and Qualified Same-Sex Domestic Partners effective January 1, 2014. Please refer to the Terms and Definitions section of this booklet.

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When Are You Eligible For Benefits? You are eligible for the benefits as described in this booklet after the Initial Contribution Period. Generally, your eligibility for benefits is established as follows:

When eight weeks of contributions on your behalf have been received by the Plan within a

52-week period; or

Immediately, if you meet one of the conditions described under “When Can You Receive Immediate Coverage?”.

You are covered for benefits under this Plan only during periods when you have contributions reported to the Plan. To be eligible for benefits, you must have a contribution reported for the date of service that the services are received. Who Can Receive Immediate Coverage? It may be possible for you to receive immediate coverage. If you meet any of the following conditions, you will not need to meet the Initial Contribution Period requirement and receive immediate coverage:

You come into the Plan as part of a new group that has been accepted for immediate

coverage; or

You leave your employer as a covered participant and return to covered employment with any Plan employer within 52 weeks after your previous coverage ended.

If you are uncertain when your coverage begins, contact TeamCare.

When Does Your Coverage End? Generally, your coverage ends when your employer is not required or is no longer making Health Plan contributions on your behalf. You do not have coverage during any period for which your employer is not obligated to make contributions (for example, if you are on layoff or you quit employment). When your employer is not obligated to make contributions on your behalf, you may be able to extend coverage by making COBRA self-payments.

Can You Continue Coverage? Your coverage may continue after employer contributions end if you choose to make self-payments as explained in the COBRA (“Self-Payments”) section. If employer contributions end due to a disability from an injury or illness, you may be eligible for extended medical coverage. See “Extension of Benefits.”

What If You Have Short-Term Disability Continued Coverage? Under some Plans, you and your covered dependents may have full Plan coverage if you are receiving the Short-Term Disability Benefit. Please refer to your Plan Benefit Profile to see if your Plan offers continued coverage while on Short-Term Disability.

What About Strike Coverage? You and your covered dependents may have full Plan coverage if your Local Union has verified that you are involved in a sanctioned strike. Check with your Local Union and TeamCare for further information regarding this benefit if you are involved in a strike. Plan Coverage related to a strike is subject to Trustee approval.

How Do You Reestablish Eligibility? If you lose coverage after having been an active participant and return to work within 52 weeks of your last eligibility date, you do not need to reestablish eligibility. Your coverage will begin with your first Employer Contribution. If you do not return to work within 52 weeks of your last eligibility date, you must reestablish eligibility. Your coverage will begin after eight weeks of contributions are received within a 52-week period.

In reestablishing eligibility, the first contribution must be a required contribution made by your employer. If needed, you can make COBRA Self-Payments for the remaining Initial Contribution Period as needed to reestablish eligibility.

PPAARRTTIICCIIPPAANNTT EELLIIGGIIBBIILLIITTYY

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When Does Spouse Coverage Start? Generally, coverage for your enrolled spouse begins when your coverage begins. If you marry while covered under this Plan, you must notify the Plan within 60 days to add your spouse to your coverage. Coverage will then begin for your spouse on the day you were married. When Does Coverage End? Coverage for your spouse ends on the date when any of the following occurs:

• Your coverage ends; • You get divorced; or • You elect a tier not providing Spouse coverage (Multi-Tier plans only).

When Does Qualified Same-Sex Domestic Partner Coverage Start?

Effective June 26, 2015, all states are required to recognize same-sex marriages and Spouse Eligibility rules apply to coverage commencing on or after that date. Effective December 31, 2016, TeamCare will no longer recognize qualified same-sex domestic partner relationships unless an exception was granted in conjunction with a new group joining TeamCare on or after January 1, 2014. When Does Coverage End? Coverage for your same-sex domestic partner ends on the date when any of the following occurs:

• Your coverage ends; • December 31, 2016, unless an exception was granted in conjunction with a new group joining

TeamCare January 1, 2014, or later; • You no longer meet the Plan’s requirements of a qualified same-sex domestic partnership; or • You have a legally recognized termination of the relationship.

When Does Coverage Start? Generally, coverage for your enrolled children begins when your coverage begins. If you have a child while covered under this Plan, coverage begins at birth, provided the Plan is notified within 60 days and the dependent is enrolled in your Plan. Covered children are eligible for all benefits (except participant-only benefits) through age 25, except as otherwise provided by the Plan. When Does Coverage End?

• When your coverage ends; • When your child reaches the age of 26, if not mentally or physically disabled; or • You elect a tier not providing Child coverage (Multi-Tier plans only).

SSPPOOUUSSEE EELLIIGGIIBBIILLIITTYY

It is extremely important that you inform TeamCare immediately should you divorce your spouse. Failure to do so could result in claims being paid for your ex-spouse after your divorce date. You will be responsible for reimbursing TeamCare for any claims paid when a spouse is no longer eligible.

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CCHHIILLDD EELLIIGGIIBBIILLIITTYY

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What About Mentally Or Permanently Physically Disabled Children? If you have a mentally or permanently physically disabled child, this child is eligible for Medical, Dental and Vision Benefits (but not the Life Insurance Benefit) if he or she meets all of the following conditions:

• Child is incapable of independent self-support; • Child is unmarried; • Child is not covered under any Other Plan as a result of their employment; • Child was covered under the Plan as your dependent before reaching age 26; and • Child was mentally or permanently physically disabled before reaching age 26.

Medical, dental and vision coverage will comply with the terms of a Qualified Medical Child Support Order (QMCSO) to the extent that a QMCSO does not require the Plan to provide coverage it does not otherwise provide. A medical child support order is a judgment, decree or order (including approval of settlement agreement) issued by a court of competent jurisdiction or an administrative process established under state law that has the force and effect of law or a judgment from a state court directing a plan administrator to cover a child by a company’s group health care plans. Federal law requires that a medical child support order must meet certain form and content requirements in order to be a QMCSO. When an order is received, each affected participant and each child covered by the order will be notified of the implementation procedure to determine whether the order is valid.

Participants in some Plans are covered by a collective bargaining agreement (CBA) that provides coverage under a Multi-tier Plan. Depending on the CBA, these Plans allow you to elect your tier of coverage (Participant, Participant and Spouse, Participant and Child/Children, or Family). These tiers vary by CBA. Generally, at the time of your initial enrollment, you will elect a coverage tier that cannot be changed until your annual Open Enrollment period. If coverage is provided under a Multi-tier Plan, on an annual basis the Plan allows you to choose the benefit coverage tier that best meets your family’s needs. You make your choices during the annual Open Enrollment period that begins each year in November for the Plan year that follows (January 1 through December 31). Your tier choice remains in effect for the full Plan year and may only be changed if you have a qualifying life event, as described below in Special Enrollment Rights. SPECIAL ENROLLMENT RIGHTS You are allowed to change your benefit coverage during the year if a change in your family status occurs. As a general rule, you will only be allowed to make benefit coverage changes if the life event results in you, your Spouse, or your dependents either gaining or losing coverage eligibility under an employer-sponsored plan. For example, if you have a baby, you can change your benefit coverage to add dependent coverage. In addition to qualifying life events, benefit coverage changes can also occur during the Open Enrollment period.

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Participants and beneficiaries can obtain, without charge, a copy of the Plan’s procedures for a Qualified Medical Child Support Order by logging into MyTeamCare.org, sending a secure message (question) through the Message Center found on our website or by contacting the Participant Services Department at: 800-TEAMCARE (832-6227).

MMUULLTTII--TTIIEERREEDD PPLLAANNSS

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How Do I Change My Enrollment During The Year? Changes outside of the Open Enrollment period must be made within 60 days of a qualifying life event. Notify TeamCare immediately if a family member loses eligibility for coverage under TeamCare. Otherwise, you may be required to repay any benefits TeamCare provides for that family member from the date they are no longer eligible for coverage, even if you provided notice within the 60 day period. Qualifying life events include:

• Marriage, divorce or legal separation when allowed under state law in the state in which you reside, including Qualified Same-Sex Domestic Partner;

• Death of your spouse, including Qualified Same-Sex Domestic Partner; • Birth or adoption of a child or placement of a child for adoption, gaining a step-child, becoming legal

guardian of a child; • Death of your child; • A child's change in status due to age; • Involuntary Loss of Coverage under another plan; • Qualification of a Medical Child Support Order; and • Eligibility for Other Group Coverage.

To change your coverage election due to one of these events, submit an Enrollment Form following the instructions accompanying the form within 60 days of the date of the qualifying life event. You will be required to submit the appropriate legal documents related to the change. Revised coverage is effective retroactive to the date of the event with timely notice.

You will not be allowed to change your coverage election after the 60 day period, until the next Annual Open Enrollment period.

What Happens If I Do Not Want To Change My Enrollment? If you are enrolled and do not make a change during the Open Enrollment period or within 60 days of a qualifying life event, your elected coverage will remain at the same coverage level in which you were enrolled for the prior Plan year. When Is Open Enrollment During The Year? The Open Enrollment period, which allows you to change your coverage level, is typically during November with benefits going into effect on the first Sunday of the new calendar year. You will receive notification from TeamCare and during this time you can elect to change your coverage level for any person. This is the only time that you can change your coverage level unless you have a qualifying life event. If you elect to change your coverage level during Open Enrollment, you must complete the required Enrollment information and submit as directed in the Open Enrollment packet. Submissions after the completion of the Open Enrollment period will not be accepted by TeamCare.

It is very important that you notify the Plan within 60 days of a qualifying life event.

A qualifying life event is marriage, divorce, death of a spouse/child, birth, adoption, eligibility for other insurance, loss of coverage, etc. It is your responsibility to notify TeamCare in a timely manner.

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Can You Or Your Dependents Receive Benefits After Your Coverage Ends? You or your dependents can receive some Medical Benefits after your Plan coverage ends under the Extended Benefit and Extended Major Medical Benefit, if you meet certain conditions. You or your dependents may receive Extended Benefits at the same plan of benefits you had with your employer for up to 13 weeks after your Plan coverage ends, if all of the following conditions are met:

• Your coverage under the Plan must end for a reason other than your becoming eligible for other coverage;

• The injury, illness or pregnancy being treated exists on the date that your Plan coverage ends; • You or your dependents must incur an expense covered by the Plan and related to an illness, injury or

pregnancy commencing before the day your coverage ends; • You or your dependents are, on the date your coverage ended, so disabled by the illness, injury or

pregnancy that you are severely restricted from engaging in your normal activities; • The expenses are covered by the Plan and are directly related to the illness, injury or pregnancy that

disabled you; and • You are not eligible for coverage under another plan.

You or your dependents may continue to be covered by the Major Medical Benefit Extension for up to 24 calendar months from the last day of coverage. Coverage includes periods you receive the Short-Term Disability Benefit and the 13-week Extended Basic Benefit, if applicable. The Major Medical Benefit Extension provides coverage at the same level of Major Medical benefits in your Plan. Note that you must meet your Plan Deductible and there is no out-of-pocket expense limit while under the Major Medical Extension.

For you or your dependents to be eligible for extended Major Medical Benefits, all of the following conditions must be met:

• You or your dependents must be suffering from a disability on the day your coverage ends and remain disabled as long as you receive the Major Medical Benefit Extension. You must also be so disabled by the illness, injury or pregnancy that you are severely restricted from engaging in your normal activities.

• The expenses are covered by the Plan and are directly related to the illness, injury or pregnancy that disabled you.

• You are not eligible for coverage under another plan. • You must meet your Plan Deductible.

EEXXTTEENNSSIIOONN OOFF BBEENNEEFFIITTSS

It is important to note that the Extension of Benefits coverage will only provide benefits for the illness, injury, or pregnancy that disables the applicant and does not cover unrelated illnesses / injuries or other family members. For full coverage, including family coverage, you will need to make COBRA self-payments.

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NOTICE OF CONTINUATION COVERAGE RIGHTS UNDER COBRA COBRA continuation coverage is a temporary extension of coverage under the Plan. The right to COBRA continuation coverage was created by a Federal Law, the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA). COBRA continuation coverage can become available to you when you would otherwise lose your group health coverage. It can also become available to other members of your family who are covered under the Plan when they would otherwise lose their group health coverage. For additional information about your rights and obligations under the Plan and under federal law, you should contact our Participant Services Department at 800-TEAMCARE (832-6227).

You may have other options available to you when you lose group health coverage. For example, you may be eligible to buy an individual plan through the Health Insurance Marketplace. By enrolling in coverage through the Marketplace, you may qualify for lower costs on your monthly premiums and lower out-of-pocket costs. Additionally, you may qualify for a 30-day special enrollment period for another group health plan for which you are eligible (such as a spouse’s plan), even if that plan generally doesn’t accept late enrollees.

What Is COBRA Continuation Coverage? COBRA continuation coverage is a continuation of Plan coverage when coverage would otherwise end because of a life event known as a “qualifying event.” Specific qualifying events are listed later in this notice. After a qualifying event, COBRA continuation coverage must be offered to each person who is a “qualified beneficiary.” You, your spouse, and your dependent children could become qualified beneficiaries if coverage under the Plan is lost because of the qualifying event. Under the Plan, qualified beneficiaries who elect COBRA continuation coverage must pay for COBRA continuation coverage. If you are an employee, you will become a qualified beneficiary if you lose your coverage under the Plan because either one of the following qualifying events happen:

• Your hours of employment are reduced, or • Your employment ends for any reason other than your gross misconduct.

If you are the spouse of an employee, you will become a qualified beneficiary if you lose your coverage under the Plan because either one of the following qualifying events happen:

• Your spouse dies; • Your spouse’s hours of employment are reduced; • Your spouse’s employment ends for any reason other than his or her gross misconduct; • Your spouse becomes entitled to Medicare benefits (Part A, Part B, or both) under Title XVIII of the

Social Security Act (42 U.S.C. Section 1395 et seq.) (“Title XVIII”): or • You become divorced or legally separated from your spouse.

Your dependent children will become qualified beneficiaries if they lose coverage under the Plan because any of the following qualifying events happen:

• The parent-employee dies; • The parent-employee’s hours of employment are reduced; • The parent-employee’s employment ends for any reason other than his or her gross misconduct; • The parent-employee becomes entitled to Medicare benefits (Part A, Part B, or both) under Title XVIII; • The parents become divorced or legally separated; or • The child stops being eligible for coverage.

When Is COBRA Coverage Available? The Plan will offer COBRA continuation coverage to qualified beneficiaries only after TeamCare has been notified that a qualifying event has occurred. The following qualifying events require notification from your employer: end of employment; reduction of hours of employment; unpaid sick leave; layoff; unpaid military leave; and commencement of a proceeding in bankruptcy with respect to the employer.

You Or A Qualified Beneficiary Must Give Notice Of Some Qualifying Events There are qualifying events which require notifications, within 60 days of the qualifying event, from either you or a qualified beneficiary. The following events require such notifications: death of the employee; divorce or legal

NNOOTTIICCEE OOFF CCOONNTTIINNUUAATTIIOONN CCOOVVEERRAAGGEE RRIIGGHHTTSS UUNNDDEERR CCOOBBRRAA

Page | 40

separation of the employee and spouse; employee’s entitlement to Medicare benefits (Part A, Part B, or both) under Title XVIII; and a dependent child losing eligibility for coverage as a dependent child. Please note that proper documentation is required for the above events. The following documents are needed for their applicable event: death certificate; divorce decree; or Medicare card. You must provide this notice to:

TeamCare A Central States Health Plan P.O. Box 5112 Des Plaines, IL 60017-5112

How Is COBRA Coverage Provided? Once TeamCare receives notice that a qualifying event has occurred, COBRA continuation coverage will be offered to each of the qualified beneficiaries for a maximum period of 24 or 36 months, depending on the qualifying event(s). Each qualified beneficiary will have an independent right to elect COBRA continuation coverage. Covered employees may elect COBRA continuation coverage on behalf of their spouses, and parents may elect COBRA continuation coverage on behalf of their children. COBRA continuation coverage is a temporary continuation of coverage. When the qualifying event is the death of the employee, the employee becoming entitled to Medicare benefits (Part A, Part B or both) under Title XVIII, your divorce or legal separation, or a dependent child losing eligibility as a dependent child, COBRA continuation coverage lasts for up to a total of 36 months. When the qualifying event is the end of employment or reduction of the employee’s hours of employment, and the employee became entitled to Medicare benefits less than 24 months before the qualifying event, COBRA continuation coverage for qualified beneficiaries other than the employee lasts until 36 months after the date of Medicare entitlement. For example, if a covered employee becomes entitled to Medicare 8 months before the date on which his/her employment terminates, COBRA continuation coverage for his/her spouse and children can last up to 36 months after the date of Medicare entitlement, which is equal to 28 months after the date of the qualifying event (36 months minus 8 months). Otherwise, when the qualifying event is the end of employment or reduction of the employee’s hours of employment, COBRA continuation coverage generally lasts for only up to a total of 24 months. There are two ways in which this 24-month period of COBRA continuation coverage can be extended.

Disability Extension of 24-Month Period of Continuation Coverage If you or anyone in your family covered under the Plan is determined by the Social Security Administration to be disabled and you notify TeamCare within 60 days of the determination, you and your entire family may be entitled to receive up to an additional 5 months of COBRA continuation coverage, for a total maximum of 29 months. The disability must have started at some time before the 60th day of COBRA continuation coverage and must last at least until the end of the 24-month period of continuation coverage. Second Qualifying Event Extension of 24-Month Period of Continuation Coverage If your family experiences another qualifying event while receiving 24 months of COBRA continuation coverage, the spouse and dependent children in your family can get up to 12 additional months of COBRA continuation coverage, for a maximum of 36 months, if notice of the second qualifying event is properly given to TeamCare. This extension may be available to the spouse and any dependent children receiving continuation coverage if the employee or former employee dies, becomes entitled to Medicare benefits (Part A, Part B, or both), or gets divorced or legally separated, or if the dependent child stops being eligible under the Plan as a dependent child, but only if the event would have caused the spouse or dependent child to lose coverage under the Plan had the first qualifying event not occurred. Are there other coverage options besides COBRA Continuation Coverage? Yes. Instead of enrolling in COBRA continuation coverage, there may be other coverage options for you and your family through the Health Insurance Marketplace, Medicaid, or other group health plan coverage options (such as a spouse’s plan) through what is called a “special enrollment period.” Some of these options may cost less than COBRA continuation coverage. You can learn more about many of these options at healthcare.gov. If You Have Questions Questions concerning your Plan or your COBRA continuation coverage rights should be addressed to our Participant Services Department at 800-TEAMCARE (832-6227). For more information about your rights under ERISA, including COBRA, the Health Insurance Portability and Accountability Act (HIPAA), and other laws affecting group health plans, contact the nearest Regional or District Office of the U. S. Department of Labor’s Employee Benefits Security Administration (EBSA) in your area or visit the EBSA website at dol.gov/ebsa. (Addresses and phone numbers of Regional and District EBSA Offices are available through EBSA’s website).

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Your eligibility for benefits is based upon contributions made each month by your employer. If your employer fails to make payments as required by your contract, your benefits may be suspended. Before your benefits are suspended, you’ll receive a written notice indicating that your benefits are about to stop. You may continue coverage during the suspension period by making self-payments in accordance with the rules specified in the written notice. Following the suspension period, if your employer pays the contributions that were owed, all proper claims that occurred during the suspension will be paid. In addition, if your employer pays all owed contributions, any Self-Payments you made during the suspension period will be refunded.

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GGEENNEERRAALL IINNFFOORRMMAATTIIOONN In the General Information Chapter, you will learn about Coordination of Benefits which happens when your spouse or dependents have other insurance coverage. In addition, you will also learn about Subrogation, Workers’ Compensation and Plan Exclusions. Finally, you will find out how to file claim appeals in the event you disagree with the way a claim payment was made by the Plan. Generally, the provider of medical services will require you to assign benefits directly to them. When you assign benefits to the provider, you are authorizing the Plan to issue benefit payment directly to that provider. If we do not issue payment to the provider, we will mail you a benefit check for the amount payable on the submitted claim and it is your responsibility to pay the provider for services rendered. After your claim is processed, you will receive the Explanation of Benefits (EOB), which details what was paid on your claim. The EOB will also indicate a reason if your claim was denied either in full or in part. If, after receiving the EOB, you have questions as to how the claim was processed, you can visit our website, send us a securevmessage or call TeamCare. You can also review your EOB through our website. If the Plan erroneously makes payment on a claim, we are entitled to recover the overpayment. Generally, we will request the monies back from the provider of services. If unsuccessful, we will request the overpayment from you. If necessary, the Plan will deduct amounts overpaid from future claims submitted on you or your dependents. In addition, the Plan aggressively pursues action (including legal action when appropriate) against any fraudulently filed claims.

Coordination of Benefits ............................................................................................ 43 Subrogation and Reimbursement .............................................................................. 44 Workers’ Compensation ............................................................................................. 44 Assignment of Benefits ............................................................................................... 44 Appeals Process ........................................................................................................ 45 Plan Administration .................................................................................................... 47 Statement of ERISA Rights ........................................................................................ 47 Legislated Benefits Coverage .................................................................................... 49 Notice of Privacy Practices ......................................................................................... 50 Retiree Benefit Plan .................................................................................................... 54

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Coordination of Benefits takes place when you and your dependents are covered by this Plan and by another plan that provides group health benefits. This is especially common when both you and your spouse work, with each of you covered as a dependent under the other person’s group health insurance plan. Coordination of Benefits also takes place when your injuries or your covered dependent’s injuries result from a motor vehicle accident and motor vehicle no-fault or P.I.P. insurance benefits are available. Coordination of Benefits provides complete payment of your allowable expenses while preventing duplicate payment for the same service. Coordination of Benefits can be a complex issue and you should always refer to the terms of your Plan for complete details of the Coordination of Benefits process. The following summary only describes the basic principles which will be applied. When there is coverage under more than one group plan, primary responsibility is decided by these rules in the following order:

1) The other plan has primary responsibility if it has no Coordination of Benefits provision.

2) Whichever plan provides benefits for the ill, injured or pregnant person as a participant (employee) has primary responsibility before the plan covering the person as a dependent.

3) If the claim is for a child whose parents are married or are living together, the plan that covers the parent with the earlier birthday (month and day) has primary responsibility.

4) In the case of a child whose parents are divorced or separated and a court decree states that one of the parents is responsible for the child’s health care expenses, that plan is primary. If a court decree states that both parents are responsible for the child’s health care expenses or states that the parents have joint custody without specifying that one parent has responsibility for the health care expenses, the plan that covers the parent with the earlier birthday (month and day) has primary responsibility. If there is no court decree, allocating responsibility for the child’s health care expenses, the order of benefits for the child are as follows: (1) the plan covering the custodial parent; (2) the plan covering the spouse of the custodial parent; (3) the plan covering the non-custodial parent; and then (4) the plan covering the spouse of the non-custodial parent. For a child covered under more than one plan of individuals who are not the parents of the child, the plan of the individual with the earlier birthday (month and day) has primary responsibility as if those individuals were the parents of the child .

5) If a participant or a dependent is covered under more than one plan, the plan providing coverage through active employment has primary responsibility.

6) If the order of responsibility cannot be determined by the preceding rules (such as when the same individual is covered through active employment by two group plans), whichever plan has covered the ill, injured or pregnant person for the longer period of time has primary responsibility.

7) If there is coverage by a governmental program, the governmental program will have primary responsibility unless prohibited by federal law.

8) If the preceding rules do not determine the order of benefits, the allowable expenses shall be shared equally between the plans.

How Does Coordination Of Benefits Work With An HMO? In the case of coverage through an HMO, this Plan will coordinate benefits as previously described, provided that the HMO rules and procedures are followed. If charges are denied by the HMO for failure to follow its rules or to use an HMO provider, this Plan will also deny benefits. What About Coordination With No-Fault Or P.I.P. Motor Vehicle Insurance Coverage? When the injury or illness results from a motor vehicle accident and motor vehicle no-fault or P.I.P. insurance is available, that insurance has primary responsibility for the payment of benefits to you or your covered dependent. What If This Plan Has Primary Responsibility? When this Plan has primary responsibility, you or your covered dependents will receive full Plan benefits without regard to any coverage that you or your dependents have under another plan. What If The Other Plan Has Primary Responsibility? When the other plan has primary responsibility, it must first pay its full benefit. This Plan will then pay any remaining covered expenses up to the amount that this Plan would have paid if it had primary responsibility, unless payment is excluded by a provision of the Plan.

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The Plan has a full right of subrogation and/or reimbursement each time you and/or one or more of your covered dependents receive benefit payments by the Plan for any physical or mental condition or injury that was or may have been caused by any person. The Plan’s subrogation right to 100% reimbursement applies to all sources of recovery for all such injuries. What Must You And Your Covered Dependents Do? You and your covered dependents must fully cooperate with the Plan and keep the Plan fully and promptly informed of all facts about all causes of the injuries and all potential sources of recovery. In any injury caused by a third party, you must provide all details to the Plan as soon as possible. This includes the date, time and place of the accident or injury; names, addresses and telephone numbers of all parties and witnesses, hospitals and medical providers; description of all motor vehicles (in vehicle accidents); source of the police report if any; and full particulars of all liability insurance of all parties to the accident, as well as all other potential sources of recovery. You and your covered dependents have a continuing obligation to comply with all subrogation-related requests by the Plan. Failure to cooperate with the Plan may place your rights to benefit payments in jeopardy – after an accident, the Plan may postpone benefit payments until there is cooperation; after you receive a monetary recovery without the Plan’s prior approval, the Plan may decline future benefit payments for you until the Plan’s subrogation share is reimbursed.

How Much Is the Plan Entitled To Receive From Your Settlement Or Other Recovery? The Plan is entitled to full reimbursement, from your settlement or other recovery, of all of its benefit payments for care and treatment of injuries. That full reimbursement is not reduced by any attorneys’ fees or other costs you incur in obtaining your settlement or other recovery. That full reimbursement is also not reduced by the fact you may not have been “made whole” by your monetary recovery (because of permanent injuries, loss of future earnings, hardship, etc.). The Plan’s right to a 100% reimbursement, prior to any amount you may recover, is an essential funding provision of your benefit plan. However, the Plan will consider settlement and compromise on the amount owed in appropriate cases. Your Plan pays benefits for illnesses and injuries that are not work-related. You are not entitled to payment on a claim for any charge incurred for any treatment or service of an illness or injury which is sustained as a result of any occupation or enterprise for wage or profit, or any illness or injury of any type covered under any applicable Workers’ Compensation Act or similar law.

Your Medical Benefits do not replace Workers’ Compensation Benefits. The Plan has a full right of subrogation and/or reimbursement for any payment on a claim for the treatment of any work-related illness or injury.

Workers’ Compensation is a state fund to which your employer contributes and which pays for work-related injuries or illnesses. It is important that you understand what kind of protection you have under Workers’ Compensation. Workers’ Compensation laws vary from state to state. You should know about the laws in your state. To obtain information, call your state bureau of Workers’ compensation (each state has one) or a local office. It is their job to see that your claim is handled quickly and efficiently.

The most important thing to remember is … “do not wait”. Often there are time limits on how long you can take to file a claim. If you miss the time limit, you may not be able to file at all.

Usually, the provider of medical services will require you to assign benefits directly to them. When you assign benefits to the provider, you are authorizing the Plan to issue benefit payment directly to that provider. If we do not issue payment to the provider, we will mail you a benefit check for the amount payable on the submitted claim and it is your responsibility to pay the provider for services rendered.

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If your claim is denied in whole or in part and you disagree with its settlement, you can ask to have it reviewed.

The Plan has established a two-step process for appeal when you disagree with the payment of your claim. This process is intended to give you the opportunity for two separate fair and impartial reviews. At all times during the appeal process, you have the right to submit whatever written comments, documents, records and other information you choose. All of your comments, documents, records and other information will be considered and will be included in the record of your appeal. In addition, at any time during your appeal, the Plan, upon your request and free of charge, will send you copies of all documents, records, and other information possessed by the Plan and relevant to your claim and your appeal.

You have the burden of proof in demonstrating any fact essential to the approval of your claim, including your eligibility and the extent to which a claimed benefit is covered or payable.

Any time limit for the Plan’s decision on your Step One Appeal or Step Two Appeal, and notice of the decision, may be waived or modified based on your request or consent or on your failure to submit information necessary to decide your appeal. Depending on your Plan, additional appeals rights may be available to you. Please refer to the Specific Plan Provisions section of Benefits Booklet (1 of 2) of this SPD for additional information.

STEP ONE APPEAL If you are notified that your claim was denied in whole or in part and you disagree with the decision, you may have your claim reviewed as a Step One Appeal. To do this, send a written request for review to:


The Research and Correspondence Department must receive the written request for review within 180 days after you receive the claim settlement.

Your written request for review must contain all of the following:

• Participant’s name and address; • Participant’s identification number; • Claim number, if known; • Patient’s name; • Relationship of patient to participant (husband, wife, son, daughter or self); • The date of loss for which the claim was made; and • Exact reason you are dissatisfied with the handling of your claim.

The Plan will mail you the Step One Appeal decision within 30 days after it receives your request for review. There will be a delay, however, if your request did not contain all of the required information. The Plan will do more than just inform you of its decision. The notice sent to you will contain additional information. If your claim is again denied in whole or in part, the notice will provide:

• The exact reason why your claim was again denied in whole or in part; • A reference to the section of the Plan document on which the denial was based; and • An explanation of the process for the second step of review.

If additional information is required, the notice will provide:

• A listing of additional information needed, if any, that might help approve your claim; and • An explanation of why additional information may be necessary.

What If Additional Information Is Requested? Be sure to send any requested information to the Research and Correspondence Department as soon as possible. When the information is received from the Step One Appeal process, your claim will be reviewed again and a final decision will be mailed to you.

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STEP TWO APPEAL If your first appeal is denied and you disagree with the decision, you have the right to file a second and final appeal. To initiate a second and final review, you need to complete and return the appeal notification form sent to you by the Research and Correspondence Department to:


You must submit this form within 180 days after you receive the decision of the Step One Appeal process from the Research and Correspondence Department.

In addition to the form, you and your authorized representative may submit written issues and comments regarding your case. You have the right to obtain copies of any documents or files that apply to your claim. They will be mailed to you if you request them in writing.

If your second and final appeal is denied, a decision will be mailed to you within 30 days after your appeal notification form was received. This decision will also contain:

• The exact reason your claim was again denied; • A reference to the section of the Plan document on which the refusal was based; and • An explanation of your rights under the Employee Retirement Income Security Act of 1974 (ERISA).

Please note that based on the nature of the appeal, the Step Two Appeal review will be conducted by either the Trustee Appellate Review Committee or the Staff Final Review Committee.

The Plan Document vests the members of the Trustee Appellate Review Committee (and the Staff Final Review Committee, in appeals assigned to it) with discretionary and final authority in deciding your Step Two Appeal, including decisions upon claims for benefits and including Trustee decisions interpreting the Plan Document. What if I still disagree with the payment of my claim? If you are dissatisfied with the Plan’s decision at the conclusion of your Step Two Appeal, you have the right to file suit in state or Federal court pursuant to Section 502 of the Employee Retirement Income Security Act. Before filing suit, however, you must complete your Step Two Appeal and receive the Plan’s final decision.

You must submit any appeal in a timely manner. TeamCare must receive the written request for review within 180 days after the claim has been processed.

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This Plan is administered by the Trustees of the Central States, Southeast and Southwest Areas Health and Welfare Fund. The Plan’s Board of Trustees is the only group with the authority to change or interpret any part of this Plan. No agent or Union representative or employee of TeamCare acting alone has this authority.

Amendments To The Plan And Plan Termination The provisions of this Plan may be amended from time to time as deemed necessary by the Trustees. Amendments may include increases, modifications, reductions or the elimination of certain benefits. Copies of all amendments are included in the records and minutes of the Trustees’ meetings. This Plan may be terminated under circumstances specified in the Plan document. In the event of Plan termination, all benefits will terminate.

Information Required By The Employee Retirement Income Security Act Of 1974 (ERISA)

This booklet describes the comprehensive Health Benefits available to you as a Participant in Central States. The Plan administrator is:

Board of Trustees TeamCare A Central States Health Plan 9377 West Higgins Road Rosemont, IL 60018-4938 Telephone (847) 518-9800

Your participation in Central States is determined by your Collective Bargaining Agreement and by the eligibility rules listed in this booklet. Your Collective Bargaining Agreement is the contract between your employer and your union which requires your employer to contribute to TeamCare for you. The amount of employer contributions is actuarially determined. Within 30 days of receipt of your written inquiry, TeamCare will verify whether any employer or employee organization participates in this Plan. Also, you may either look at or obtain your own copy of the Collective Bargaining Agreement that applies to you by making a written request to your Union. If the Union denies this request for any reason and you notify TeamCare, in writing, of the denial, TeamCare will provide you with a copy of the agreement that applies to you.

To obtain this information from TeamCare, either call 800-TEAMCARE (832-6227) or write to:


As a participant in the Central States, Southeast and Southwest Areas Health and Welfare Plan, you are entitled to certain rights and protections under the Employee Retirement Income Security Act of 1974 (ERISA). ERISA provides that all plan participants shall be entitled to:

Receive Information About Your Plan and Benefits Examine, without charge, at the plan administrator’s office and at other specified locations, such as worksites and union halls, all documents governing the plan, including insurance contracts and collective bargaining agreements, and a copy of the latest annual report (Form 5500 Series) filed by the plan with the U.S. Department of Labor and available at the Public Disclosure Room of the Employee Benefits Security Administration.

Obtain, upon written request to the plan administrator, copies of documents governing the operation of the plan, including insurance contracts and collective bargaining agreements, and copies of the latest annual report (Form 5500 Series) and updated summary plan description. The administrator may make a reasonable charge for the copies.

Receive a summary of the plan’s annual financial report. The plan administrator is required by law to furnish each participant with a copy of this summary annual report.

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Continue Group Health Plan Coverage Continue health care coverage for yourself, spouse or dependents if there is a loss of coverage under the plan as a result of a qualifying event. You or your dependents may have to pay for such coverage. Review this summary plan description and the documents governing the plan on the rules governing your COBRA continuation coverage rights.

Prudent Actions by Plan Fiduciaries In addition to creating rights for plan participants ERISA imposes duties upon the people who are responsible for the operation of the employee benefit plan. The people who operate your plan, called “fiduciaries” of the plan, have a duty to do so prudently and in the interest of you and other plan participants and beneficiaries. No one, including your employer, your union or any other person, may fire you or otherwise discriminate against you in any way to prevent you from obtaining a welfare benefit or exercising your rights under ERISA.

Enforce Your Rights If your claim for a welfare benefit is denied or ignored, in whole or in part, you have a right to know why this was done, to obtain copies of documents relating to the decision without charge, and to appeal any denial, all within certain time schedules.

Under ERISA, there are steps you can take to enforce the above rights. For instance, if you request a copy of plan documents or the latest annual report from the plan and do not receive them within 30 days, you may file suit in a Federal court. In such a case, the court may require the plan administrator to provide the materials and pay you up to $110 a day until you receive the materials, unless the materials were not sent because of reasons beyond the control of the administrator. If you have a claim for benefits which is denied or ignored, in whole or in part, you may file suit in a state or Federal court. In addition, if you disagree with the plan’s decision or lack thereof concerning the qualified status of a domestic relations order or a medical child support order, you may file suit in Federal court. If it should happen that plan fiduciaries misuse the plan’s money, or if you are discriminated against for asserting your rights, you may seek assistance from the U.S. Department of Labor, or you may file suit in a Federal court. The court will decide who should pay court costs and legal fees. If you are successful, the court may order the person you have sued to pay these costs and fees. If you lose, the court may order you to pay these costs and fees, for example, if it finds your claim is frivolous.

Assistance With Your Questions If you have any questions about your plan, you should contact the plan administrator. If you have any questions about this statement or about your rights under ERISA, or if you need assistance in obtaining documents from the plan administrator, you should contact the nearest office of the Employee Benefits Security Administration, U.S. Department of Labor listed in your telephone directory or the Division of Technical Assistance and Inquiries, Employee Benefits Security Administration, U.S. Department of Labor, 200 Constitution Avenue N.W., Washington, DC 20210. You may also obtain certain publications about your rights and responsibilities under ERISA by calling the publications hotline of the Employee Benefits Security Administration.

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Health Insurance Portability And Accountability Act (HIPAA) This law became applicable to TeamCare on July 1, 1997. TeamCare, however, did not need to amend its benefit coverage provisions because it already complied with the HIPAA requirement that plans not apply any preexisting medical condition exclusion or otherwise discriminate against covered individuals as to eligibility and coverage on the basis of any health-status factors. Women’s Health And Cancer Rights Act TeamCare complies with this law’s requirements which can be summarized as follows:

• Every covered individual and beneficiary who, due to cancer, receives coverage for a mastectomy from TeamCare, and who elects breast reconstruction as part of that coverage, shall be provided coverage for such reconstructive surgery in a manner determined in consultation between her and her attending physician.

• This coverage will include reconstruction of the breast on which the mastectomy was performed, surgery and reconstruction of the other breast to produce a symmetrical appearance, and prostheses and treatment of physical complications at all stages of the mastectomy, including lymphedemas.

• The deductible and/or co-payment applicable to reconstructive breast surgery is the same as for other surgeries.

• Annual plan maximum-dollar coverage limits, out-of-pocket limits and Reasonable and Customary limitations, to the extent applicable, are also the same as other plan coverage limitations.

Newborns’ and Mothers’ Health Protection Act 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 provider, 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 plan or the insurance issuer for prescribing a length of stay not in excess of 48 hours (or 96 hours).

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NOTICE OF PRIVACY PRACTICES This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully. Your Information. Your Rights. Our Responsibilities. Your Rights You have the right to:

o Get a copy of your health and claims records. o Correct your health and claims records. o Request confidential communication. o Ask us to limit the information we share. o Get a list of those with whom we’ve shared your information. o Get a copy of this privacy notice. o Choose someone to act for you. o File a complaint if you believe your privacy rights have been violated.

Your Choices You have some choices in the way that we use and share information as we:

o Answer coverage questions from your family and friends. o Provide disaster relief. o Market our services and sell your information.

Our Uses and Disclosures We may use and share your information as we:

o Help manage the health care treatment you receive. o Run our organization. o Pay for your health services. o Administer your health plan. o Help with public health and safety issues. o Do research. o Comply with the law. o Respond to organ and tissue donation requests and work with a medical examiner or funeral

director. o Address workers’ compensation, law enforcement, and other government requests. o Respond to lawsuits and legal actions.

Your Rights

When it comes to your health information, you have certain rights. This section explains your rights and some of our responsibilities to help you. Depending on where you live, there may also be state or other laws that require greater limits on disclosures.

Get a copy of health and claims records

• You can ask to see or get a copy of your health and claims records and other health information we have about you. Ask us how to do this.

• We will provide a copy or a summary of your health and claims records, usually within 30 days of your request. We may charge a reasonable, cost-based fee.

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Ask us to correct health and claims records

• You can ask us to correct your health and claims records if you think they are incorrect or incomplete. Ask us how to do this.

• We may say “no” to your request, but we’ll tell you why in writing within 60 days.

Request confidential communications

• You can ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address.

• We will consider all reasonable requests, and must say “yes” if you tell us you would be in danger if we do not.

Ask us to limit what we use or share

• You can ask us not to use or share certain health information for treatment, payment, or our operations.

• We are not required to agree to your request, and we may say “no” if it would affect your care.

Get a list of those with whom we’ve shared information • You can ask for a list (accounting) of the times we’ve shared your health information for six years prior to the

date you ask, who we shared it with, and why. • We will include all the disclosures except for those about treatment, payment, and health care operations,

and certain other disclosures (such as any you asked us to make). We’ll provide one accounting a year for free but will charge a reasonable, cost based fee if you ask for another one within 12 months.

Get a copy of this privacy notice You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. We will provide you with a paper copy promptly. Choose someone to act for you

• If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information.

• We will make sure the person has this authority and can act for you before we take any action. File a complaint if you feel your rights are violated

• You can complain if you feel we have violated your rights by contacting us using the information at the end of this notice.

• You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775, or visiting hhs.gov/ocr/privacy/hipaa/complaints/.

• We will not retaliate against you for filing a complaint.

Your Choices

For certain health information, you can tell us your choices about what we share. If you have a clear preference for how we share your information in the situations described below, talk to us. Tell us what you want us to do, and we will follow your instructions. In these cases, you have both the right and choice to tell us to:

• Share information with your family, close friends, or others involved in payment for your care. • Share information in a disaster relief situation.

Unless you tell us otherwise, in writing: • We will share information with a spouse or with parents of an adult child if that information is relevant to their

involvement in the health care of the individual or the payment of claims. • We often share limited information about your medical claims (such as the date of service, payment amount,

and payment date) with your union for their use in assisting you with claim payment.

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If you are not able to tell us your preference, for example if you are unconscious, we may go ahead and share your information if we believe it is in your best interest. We may also share your information when needed to lessen a serious and imminent threat to health or safety. We will never share your information for marketing purposes unless you give us written permission. Our Uses and Disclosures How do we typically use or share your health information? We typically use or share your health information in the following ways.

Help manage the health care treatment you receive We can use your health information and share it with professionals who are treating you.

Example: A doctor sends us information about your diagnosis and treatment plan so we can

arrange additional services. Run our organization We can use and disclose your information to run our organization and contact you when necessary. We are not allowed to use genetic information to decide whether we will give you coverage and the price of that coverage. This does not apply to long term care plans.

Example: We use health information about you to develop better services for you.

Pay for your health services We can use and disclose your health information as we pay for your health services.

Example: We share information about you with your dental plan to coordinate payment for your

dental work.

Administer your plan We may disclose your health information to your health plan sponsor for plan administration.

Example: Your company contracts with us to provide a health plan, and we provide your company

with certain statistics to explain the premiums we charge.

How else can we use or share your health information? We are allowed or required to share your information in other ways – usually in ways that contribute to the public good, such as public health and research. We have to meet many conditions in the law before we can share your information for these purposes. For more information see: hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html. Help with public health and safety issues We can share health information about you for certain situations such as:

• Preventing disease. • Helping with product recalls. • Reporting adverse reactions to medications. • Reporting suspected abuse, neglect, or domestic violence. • Preventing or reducing a serious threat to anyone’s health or safety.

Do research We can use or share your information for health research.

Comply with the law We will share information about you if state or federal laws require it, including with the Department of Health and Human Services if it wants to see that we’re complying with federal privacy law.

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Respond to organ and tissue donation requests and work with a medical examiner or funeral director

• We can share health information about you with organ procurement organizations. • We can share health information with a coroner, medical examiner, or funeral director when an individual

dies. Address workers’ compensation, law enforcement, and other government requests We can use or share health information about you:

• For workers’ compensation claims. • For law enforcement purposes or with a law enforcement official. • With health oversight agencies for activities authorized by law. • For special government functions such as military, national security, and presidential protective services.

Respond to lawsuits and legal actions We can share health information about you in response to a court or administrative order, or in response to a subpoena. Our Responsibilities

• We are required by law to maintain the privacy and security of your protected health information. • We will let you know promptly if a breach occurs that may have compromised the privacy or security of

your information. • We must follow the duties and privacy practices described in this notice and give you a copy of it. • We will not use or share your information other than as described here unless you tell us we can in

writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind.

For more information see: hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html. Changes to the Terms of this Notice We can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available upon request, on our web site, and we will mail a copy to you. Contact us for Further Information Mail: Privacy Officer TeamCare A Central States Health Plan 9377 W. Higgins Road Rosemont, IL 60018 Internet: MyTeamCare.org E-mail: [email protected] Telephone: 847-939-2500

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After a long journey through the working world, retirement should be a time for relaxation and enjoyment. A Retiree Benefit Plan may be available to you if your employer made contributions on your behalf at a level sufficient to provide you coverage under this program. You may confirm your eligibility for coverage under a Retiree Benefit Plan by contacting TeamCare. If your Collective Bargaining Agreement requires your Employer to provide Retiree Benefit Plan coverage, your eligibility after retirement depends on several factors including your age, active Health Plan coverage and, in many cases, your pension eligibility. You should inquire about your eligibility for a Retiree Benefit Plan well before retirement.

RREETTIIRREEEE BBEENNEEFFIITT PPLLAANN

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TTEERRMMSS AANNDD DDEEFFIINNIITTIIOONNSS In the Terms and Definitions Chapter you can familiarize yourself with some of the terms used in describing your benefits. A complete listing of terms and definitions can also be found in the Health and Welfare Plan Document.

Terms and Definitions ............................................................................................... 56

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Accidental Bodily Injury – Physical damage to the body, e.g. a hurt, a wound, a trauma, resulting from a sudden and unexpected event, injury or external force occurring without forewarning.

Accidental Death – Any death directly and solely resulting from external means or an external cause, as opposed to a death caused or contributed to by a disease or infirmity. Benefits are not payable if death occurs in a manner excluded by the Plan Document.

Active Employee – A person who is actively at work as an Employee, after the commencement date of coverage, except that, with respect to periods during which an Employee’s Employer is obligated to make Employer Contributions on his behalf pursuant to a Collective Bargaining Agreement or applicable law, or with respect to periods during which Coverage is otherwise available for the Employee under this Plan, an Employee on vacation, involved in a Temporary Work Stoppage, on Sick Leave, or confined to a hospital shall be considered an Active Employee. An Employee on Leave of Absence is not an Active Employee unless such Leave of Absence is also on Family Medical Leave under federal law. An Employee on Layoff, or otherwise unable to actively work, is not an Active Employee.

Child – A Participant’s natural child, adopted child, step-child; a child placed with a Participant for adoption; or a child for whom the Participant is obligated to provide support pursuant to a Qualified Medical Child Support Order. A child whose legal guardian or custodian is a Participant shall only be considered a “Child” under this definition if the Participant establishes that the guardianship or custodianship is permanent and established pursuant to court order and the Participant (or the Participant and spouse) is the sole support of the child unless that child is a beneficiary under a Qualified Medical Child Support Order under federal law. Temporary designation of guardianship entered into primarily for the purpose of obtaining coverage for a person under this Plan shall not qualify that person as a “Child” eligible for coverage. The term “Child” shall not include the child of a Participant in cases where the Participant or the Participant’s spouse is serving as a Surrogate Mother (even if the Participant or Spouse provides the ovum).

Collective Bargaining Agreement – An agreement reached by bargaining as to wages and conditions of work and to which the Local Union is a party.

Cosmetic – Care, treatment, services or supplies the primary effect of which is to improve the physical appearance of a Covered Individual. The fact that there may be an incidental medical benefit does not prevent a determination that the care, treatment, services or supplies are cosmetic.

Coverage – Full entitlement to all benefits of this Plan by a Participant or Dependent, unless limited or excluded by any provision of this Plan.

Dependent – A Participant’s Spouse or Child.

Discharge – A permanent termination of employment initiated by the Employer.

Employee – All persons who are accepted by the Trustees for participation in the Fund, under the terms and conditions stated by the Trustees for participation, and who are Active Employees of an Employer under the terms and conditions of a Collective Bargaining Agreement which requires Employer contributions be made to the Fund, and such other employees of the Employer as are proposed and accepted by the Trustees for participation, on whose behalf payments are required by the agreement of the Employer or applicable law to be made to the Fund;

TTEERRMMSS AANNDD DDEEFFIINNIITTIIOONNSS

Page | 57

All persons employed by the Union upon being proposed by the Union and accepted by the Trustees; as to such Union personnel, the Union shall be considered an Employer solely for the purpose of contributions within the meaning of the Trust Agreement, as herein defined, and shall, on behalf of such personnel, make payments to the Trust Fund at the same times and at the rate of payment equal to that made by any other Employer who is a party to the Trust Agreement;

All persons employed by Central States, Southeast and Southwest Areas Health and Welfare Fund or Central States, Southeast and Southwest Areas Pension Fund upon acceptance by the Trustees; as to such Trust Fund personnel, the Trustees shall be deemed an Employer solely for the purpose of contributions within the meaning of the Trust Agreement, on behalf of such personnel, make payments to the Trust Fund at the times and at the rate of payment equal to that made by any other Employer who is a party to the Trust Agreement; or

All persons who are Trustees of Central States, Southeast and Southwest Areas Health and Welfare Fund or Central States, Southeast and Southwest Areas Pension Fund upon acceptance by the Trustees; on behalf of such persons who are Trustees, their Employers shall make contributions to the Trust Fund at the times and at the rate of payment equal to that required by any other Employer who is a party to the Trust Agreement.

In all instances the common-law test for, or the applicable statutory definition of, master-servant relationship shall control Employee status. The continuation of employee status shall be subject to such rules as the Trustees may adopt.

Employer – Any Employer (including an Association of Employers) who is or becomes a party to a Collective Bargaining Agreement and who, with the acquiescence of the Trustees, agrees to be bound by the Trust Agreement and this Plan and is accepted for participation in the Plan by the Trustees, subject to such rules as the Trustees may in their discretion adopt. The Union, the Health and Welfare Fund and the Pension Fund shall be deemed to be Employers of those persons employed and proposed by such organizations and accepted by the Trustees.

Employer Contributions – Contributions made by Employers to the Fund; contributions made by the Union or the Fund on behalf of their Employees; and, amounts set aside by the Fund on behalf of its Employees.

Family Medical Leave – A voluntary absence from work taken by an Employee pursuant to the provisions of the federal Family Medical Leave Act.

Fund – The Central States, Southeast and Southwest Areas Health and Welfare Fund.

Hospital Confinement – A hospital stay of at least overnight duration. An emergency room visit is not part of a Hospital Confinement unless it leads directly to a stay in a hospital room.

Lay-Off – An involuntary separation from employment caused by an Employer suspending Employees. Individuals shall not be deemed on Lay-off if they engage in gainful employment for any other employer, nor shall lay-off status continue when an individual retires or otherwise terminates the employment relationship.

Leave of Absence – An Employee’s voluntary temporary absence from employment, approved by the Employer. Individuals on Leave of Absence shall not engage in gainful employment for any other employer, nor shall Leave of Absence status continue when an individual retires.

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Local Union – Those Local Unions affiliated with the International Brotherhood of Teamsters who have executed Collective Bargaining Agreements which require contributions to be made to the Fund on behalf of the covered employees, and such other Unions as the Trustees may agree upon.

Maintenance Care – Maintenance Care is care provided to a person who needs assistance or support for the essence of daily living but who is not under a course of treatment which will improve his condition to the extent necessary to enable him to function without such assistance or support, except for care which is necessary to treat a curable illness. A Maintenance Care determination is not precluded by the fact that a patient is under the care of a Physician and that the services are provided at the Physician’s request.

Other Plan – Any group plan, insurance policy or contract which provides benefits for hospital, surgical, dental, psychiatric, chiropractic or other medical treatment, and any plan or insurance coverage. Other Plan includes a plan providing benefits through:

• Group blanket or franchise insurance coverage;

• Group BlueCross, Group BlueShield, group practice or other prepayment coverage;

• Any coverage under labor-management trusteed plans, union welfare plans, employer organizations or employee benefits organization plans;

• Any coverage under government programs or any coverage required or provided by statute;

• Any other arrangement providing hospital, surgical, dental, psychiatric, chiropractic or other medical treatment for members of a group; and

• No fault, personal injury protection or financial responsibility motor vehicle insurance coverage which provides benefits to or for a Covered Individual for bodily or psychological injury, including but not limited to, benefits for hospital, surgical, dental, psychiatric, chiropractic and other medical treatment.

The term “Other Plan” shall be construed separately with respect to each policy, contract or other arrangement for benefits or services and separately with respect to that portion of any such policy or other provision thereof, sub-plan, contract or other arrangement (whether a separate plan or not) which reserves the right to take the benefits or services of Other Plans into consideration in determining its benefits and that portion which does not.

Participant – An Employee for whom an Employer is obligated to make Employer Contributions or an Employee who is entitled to and who does make Self-Payments to the Fund.

Plan – The Central States, Southeast and Southwest Areas Health and Welfare Plan as set forth herein and as hereafter amended.

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Prescription Drug – A drug or medicine prescribed by a Physician or Dentist, dispensed by a pharmacist, not available over the counter (except for insulin and insulin syringes) and bearing the Federal or State Legend.

Psychiatric Treatment Facility – A facility that is:

• Primarily engaged in providing, under the supervision of a Physician, psychiatric services for the diagnosis and treatment of mentally ill persons; and

• Licensed, certified or approved as a Psychiatric Treatment Facility, and not as a Hospital, by the state or jurisdiction in which it is located.

Qualified Medical Child Support Order – Any order entered by a court of competent jurisdiction that complies with requirements of the federal Qualified Medical Child Support Act and which requires coverage for one or more dependent children.

Qualified Same-Sex Domestic Partner - An individual who shares a stable (but non-Spousal) domestic partner same-sex relationship with a Participant residing:

• In a state or other jurisdiction that does not recognize same-sex marriage, but does recognize same-sex domestic partnerships and affords legal status or recognition to such partnerships, provided that the relationship qualifies for such legal recognition or status under the laws of the state or jurisdiction of the Participant’s residence and a written record or registry documenting the legal qualification of the same-sex domestic partnership is presented to the Fund; or

• In a state or other jurisdiction that recognizes neither same-sex marriage nor same-sex domestic partnerships, provided that the domestic partners have been in an exclusive and committed relationship for at least 12 months in the same principal residence, intend to remain in the relationship permanently, are jointly responsible for each other’s living expenses and welfare, have not entered the relationship solely for the purpose securing benefits coverage and present:

o A deed or other documentation (current within last 12 months) showing that the partners are joint owners of a residence, or

o The partners’ current lease showing they are joint tenants on the lease; or

o If neither item listed above is available or applicable, the partners submit a current copy of two items from the following list:

A joint bank statement or credit card bill of the partners from within the last 12 months.

A loan note or payment coupon showing the partners are joint obligators on a loan.

Utility or telephone bills from within the last 12 months showing the partners have common household and shared household expenses.

Other documents showing the partners have common and shared household expenses.

Executed wills naming each partner as executor and/or beneficiary of the other.

Grants of mutual durable powers of attorney by each partner to the other.

Documentation signed by each partner conferring upon each other authority to make health care decisions under a health care power of attorney.

Documentation designating each partner as a beneficiary under the other’s retirement benefits plan or account.

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Quit – A permanent termination of employment initiated by the Employee.

Reasonable and Customary – The usual, Reasonable and Customary charge for the treatment, supply or service, determined by comparison with the charges customarily made for similar treatments, supplies or services to individuals with similar medical conditions within a given geographical area.

Self-Payments – Contributions to the Fund under this Plan by a Participant on his own behalf.

Sick Leave – A temporary absence from work caused by an Employee’s illness, injury or pregnancy.

Spouse – An individual who is married to a Participant in a legally recognized civil or religious ceremony. A Participant’s common-law Spouse shall be considered a Spouse for purposes of the Plan, if:

• The Participant’s state of domicile recognizes common-law marriage; and

• The Participant furnishes the Fund with appropriate documentation that the couple has fulfilled all conditions which his state of domicile requires for such a marriage.

Standard Medical Care, Treatment, Services or Supplies – Care, treatment, services or supplies which are uniformly and professionally endorsed by the general medical community as Standard Medical Care, Treatment, Services or Supplies.

TeamCare® – A program of preferred providers who agree to negotiated rates for medical services and supplies for the Fund, in exchange for which the Fund provides financial incentives for Participants to use the services of these providers. The Fund publishes a list of TeamCare providers periodically, as well as the benefit modifications which apply and the areas covered by a TeamCare network.

Teamsters – The International Brotherhood of Teamsters, and its affiliated Local Unions.

Temporary Work Stoppage – A strike by Participants which is sanctioned by the Teamsters.

Terminated Employee – An individual who is separated from his employment by reason of Quit or Discharge.

Total and Permanent Disability – A disease or bodily injury which will permanently, continuously and wholly prevent a person from engaging in any occupation or employment for wage or profit for the duration of his life. Additionally, the complete and irrecoverable loss of the sight of both eyes, or the use of both hands, or of both feet, or of one hand and one foot.

Trust Agreement – The Agreement and Declaration of Trust made and entered into on the fourteenth (14th) day of March, 1950, by and between Central Conference of Teamsters, Southern Conference of Teamsters and their affiliated Local Unions, and the Southeastern Area Motor Carriers Labor Relations Association; Southwest Operators Association; and Motor Carriers Employers Conference – Central States, and as amended from time to time thereafter by the Trustees.

CENTRAL STATES, SOUTHEAST

AND SOUTHWEST AREAS HEALTH

AND WELFARE PLAN

is a jointly administered, defined

benefit employee benefit plan.

EXECUTIVE DIRECTOR

Thomas C. Nyhan

ADDRESS OF ADMINISTRATIVE OFFICE

9377 West Higgins Road

Rosemont, IL 60018-4938

ADDRESS FOR CORRESPONDENCE

P.O. Box 5126

Des Plaines, IL 60017-5126

TELEPHONE NUMBER

847-518-9800

PARTICIPANT SERVICES

800-TEAMCARE (800-832-6227)

INTERNET WEBSITE

MyTeamCare.org

EMPLOYER IDENTIFICATION

36-2154936

PLAN NUMBER

501

PLAN YEAR

January 1 through December 31

The agent for service of legal process is

Thomas C. Nyhan, Executive Director, Central States,

Southeast and Southwest Areas Health and Welfare

Fund, at the Administrative Office address.

IMPORTANT

Para obtener asistencia en Español, llame al

800-832-6227

Kung kailangan ninyo ang tulong sa

Tagalog tumawag

800-832-6227

800-832-6227

Dinek’ehgo shika at’ohwol ninisingo,

kwiijigo holne’

800-832-6227

January 2017

9377 West Higgins Road • Rosemont, IL 60018-4938 • 800-TEAMCARE • MyTeamCare.org

Questions? We’re here to help!Call us toll-free at 800-TEAMCARE (800-832-6227) or visit MyTeamCare.org.

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