• SPD Table of Contents
  1. Important Contact Information
  2. Introduction
  3. Table of Contents
  4. Plan A Schedule of Benefits
  5. Plan B Schedule of Benefits
  6. Plan C Schedule of Benefits
  7. Plan 11 Schedule of Benefits
  8. Plan 11-C Schedule of Benefits
  9. Eligibility for Active Participants
  10. Eligibility for Retiree Coverage
  11. Insurance Coverage
  12. Weekly Loss of Time Benefit
  13. Medical Benefits
  14. Prescription Drug Program
  15. Medicare Part D Prescription Drug Plan (PDP) for Retirees
  16. Members Assistance Program (MAP)
  17. Dental Benefit
  18. Vision Benefit
  19. Hearing Benefit
  20. Special Fund Program
  21. General Plan Exclusions and Limitations
  22. Other Limitations on Your Benefits
  23. Definitions
  24. Claim and Appeal Procedures
  25. General Plan Provisions
  26. Information About the Plan
  27. Board of Trustees

Medical Benefits

Your medical benefits cover most reasonable health care expenses (with certain deductibles, co-payments and limitations) that you and your family may have, whether treatment, services and supplies are received in or out of the hospital. The following sections describe these benefits and explain how they work.

MAJOR MEDICAL BENEFIT

The Major Medical Benefit pays the majority of medical expenses that you or your dependent may have for a non-occupational illness or injury up to the reasonable and customary charge.

Preferred Provider Organization (PPO)

The Plan’s hospital and physician preferred provider organization (PPO) is the Blue Cross Blue Shield of Illinois Labor Account. The national Blue Card network is for out-of-state services. If you use an in-network (PPO) provider you can save significant out-of-pocket expenses. You can obtain up-to-date information about PPO providers by either calling Blue Cross Blue Shield of Illinois at 1 800-810-BLUE or going to www.bcbsil.com and clicking on “Labor Accounts.”

Pre-Certification and Utilization Review (UR)

• Inpatient Hospitalization - If your physician recommends an inpatient hospital stay, you must call the Plan’s utilization review (UR) organization for pre-certification before hospitalization begins.

Maternity stays do not require pre-authorization unless they exceed 48 hours following a normal delivery and 96 hours following a Cesarean section.

In the case of an emergency admission, the Plan’s UR organization must be contacted within 2 business days. The pre-certification requirement also applies to residential treatment facility and skilled nursing facility care.

If you do not call the Plan’s utilization review (UR) organization at 1-800-367-1934 for precertification of inpatient care, residential treatment facility care, skilled nursing facility care, or inpatient or outpatient surgery, the benefits normally payable on your claim will be reduced by $100. The facility or provider will usually make the call for you, but it is ultimately your responsibility to see that the UR organization is contacted for pre-certification.

• Surgery - Any time you have any surgery, whether inpatient or outpatient, and whether provided in or out of the PPO network, you must call the Plan’s UR organization for pre-certification. If you do not, the benefits normally payable on your claim will be reduced by $100. You do not have to pre-certify a routine (screening) colonoscopy.

Note: The Plan does not cover charges for outpatient surgery performed in surgical centers that are not in the PPO network.

• Physical and Occupational Therapy - Physical or occupational therapies which exceed 12 visits (for all related conditions) require pre-authorization through the Plan’s UR organization.
• Mental Health/Substance Abuse - Partial hospitalization and intensive outpatient programs that exceed 12 visits (for all related conditions) also require pre-authorization through the Plan’s UR organization.
• Other Medical Services - The Fund Office may submit other types of claims to the UR organization in order to obtain qualified professional medical opinions concerning the medical necessity or appropriateness of the treatment.

If you are unsure about whether a proposed service will be covered, ask your provider to have it pre-certified. You can also call the Fund Office and ask for more information.

Wellness Program

The Fund wants to promote wellness and healthy lifestyles, and to encourage participants to obtain regular medical exams and screenings. Therefore, each year you and your spouse will be asked to submit written verification from your doctor that you had comprehensive lab screenings. If you and your spouse do not submit timely verification of your lab screenings, your family’s medical benefits will be subject to the lower level of benefits shown in the Plan C Schedule of Benefits. (Persons normally covered under Plan 11 will be covered under Plan 11-C if the participant and spouse fail to comply.)

All participants will receive a notice outlining the types of lab tests required and the due date for submitting their doctor’s verification. The Fund does not need your lab results!

Spouses who have their own health care coverage through their employers do not have to comply with the wellness requirements. Persons for whom Medicare is the primary plan are also exempt.

Your Out-of-Pocket Costs

Annual Deductible

• Individual Deductible - The individual deductible is the amount of covered charges that you or your dependents must pay each calendar year before the Plan pays its percentage share. The amount of the deductible is stated in your Schedule of Benefits.

Any expenses applied against your individual deductible in the last three months of a calendar year will also be carried over and applied against your deductible for the next calendar year. Carryover only applies to individual deductibles – there is no carryover for the family deductible.

• Family Deductible - The Plan provides a maximum family limit on deductibles as stated in your Schedule of Benefits. After amounts totaling the maximum family deductible have been deducted from covered charges of two or more members of the same family toward satisfaction of their individual deductibles during a year, no further amounts will be deducted from any of that family’s covered charges for the rest of that year.

Emergency Room Deductible

A $200 emergency room (ER) deductible will apply to each incident of emergency room treatment at an innetwork or out-of-network hospital. The ER deductible will be waived if the patient is admitted to the hospital as an inpatient directly from the emergency room, or if the condition treated meets the Plan’s definition of an emergency (see page 75). ER deductibles apply in addition to the calendar year deductibles.

The emergency room deductible is not a penalty – it is a cost-sharing provision. Participants are required to share an additional portion of the cost of ER treatment because it is much more costly than an office visit.

PPO Office Visit Co-Payments

The Plan pays 100% for the cost of office visits with in-network (PPO) physicians after you pay a $25 copayment per visit. The annual deductible does not apply. The same $25 co-pay applies to visits with primary care doctors and specialists. The co-pay applies only to the charge for the office visit itself, not to any additional services or procedures. All additional services are subject to the deductible and in-network coinsurance percentage.

Coinsurance

For most other medical expenses, the Plan pays a percentage after your deductible is satisfied. You pay the remaining percentage (called your “coinsurance”) until your out-of-pocket limit is met. The payment percentages and out-of-pocket limits that apply to you are listed in the Schedule of Benefits for your benefit class.

Out-of-Pocket Limits

If the amounts of your deductible, co-pays (PPO office visits and prescription drugs) and coinsurance together total the amount of your out-of-pocket limit for a calendar year, the Plan will pay 100% of the covered charges you incur during the remainder of that calendar year. There are separate out-of-pocket limits for in-network and out-of-network charges. The amounts of your out-of-pocket limits are listed in your Schedule of Benefits. Amounts that are applied to the in-network out-of-pocket limit do NOT apply to the out-of-network limit, or vice versa. The following charges do NOT apply toward your out-of-pocket limits:

• Charges over the allowable or reasonable and customary charge, or, in the case of out-of-network professional providers, charges in excess of 120% of Medicare’s allowable amount;
• Non-covered charges, including amounts in excess of a Plan limit or dollar maximum;
• Penalty amounts for not obtaining the required pre-authorization; or
• With respect to prescription drugs, the difference in cost between the brand and generic drug when the mandatory-generic rule applies.

Once you reach the in-network out-of-pocket limit in a calendar year, the Plan will pay 100% of covered innetwork medical and prescription expenses you incur during the rest of the year. Similarly, covered out-ofnetwork medical expenses will be paid at 100% if you reach your out-of-network out-of-pocket limit in a calendar year. Note that charges in excess of the allowable or reasonable and customary charge will NOT be paid at 100% if your out-of-pocket limit is met.

Benefit Maximums and Limitations

Some types of medical services are subject to limitations and maximum benefits. These limitations are shown in your Schedule of Benefits.

Balance Billed Out-of-Network Charges

Because out-of-network providers do not have fee arrangements with the Fund or Blue Cross Blue Shield, they may bill you for amounts in excess of the Plan’s allowable charge limit. For out-of-network professional fees, the Plan’s allowable charge is 120% of Medicare’s allowable charge. Billing the patient for charges over the allowable charge is called “balance billing.”

Covered Medical Expenses

Covered charges under the Major Medical Benefit are the reasonable and customary charges for the following medically necessary services and supplies received for the treatment of a non-occupational illness or injury:

1. Ambulance services as follows:
   1. Local ambulance transportation to a hospital, including medically necessary inter-facility transfers.
   2. Air ambulance by a licensed air ambulance from the location of a sudden illness or injury to the nearest hospital where emergency treatment can be provided, but only if the following requirements are satisfied:
      • The patient requires immediate medical attention; and
      • The patient’s condition is such that no other mode of transportation could be used without endangering the patient’s life or seriously endangering the patient’s health.

If air ambulance charges do not meet all of the above criteria, benefits will be limited to what the Plan would have paid for transportation by ground ambulance.

2. Anesthesia and its administration, blood, blood plasma, oxygen and rental of equipment for its administration.
3. Chiropractic services billed by a chiropractic practitioner, including physical therapy, x-rays and diagnostic imaging, up to the annual maximum shown in your Schedule of Benefits.
4. Clinical trials - The patient costs for a covered person enrolled in an approved clinical trial. An “approved clinical trial” is defined as a Phase I, II, III or IV clinical trial for the prevention, detection or treatment of cancer or other life-threatening condition that is federally funded or approved; or conducted under an investigational new drug application reviewed by the Food and Drug Administration; or a drug trial that is exempt from having such an investigational new drug application.

A “life-threatening condition” is any disease from which the likelihood of death is probable unless the course of the disease is interrupted.

“Routine patient costs” include all services and supplies that are typically covered by the Plan for persons not enrolled in clinical trials. Routine patient costs do NOT include the investigational item, device or service itself; services that are provided solely to satisfy data collection and analysis needs, or services that are clearly inconsistent with the widely accepted and established standards of care.

5. Corrective refractive surgery, such as Lasik and other procedures to correct refraction (vision) up to the maximum shown in your Schedule of Benefits. (These procedures are not covered under the Plan 11 and 11-C Schedules of Benefits.)
6. Dental-related services - Services of a dentist or dental surgeon for:
   1. The repair of damage to the jaw and sound natural teeth, including replacement of such teeth, that is the direct result of an accident, provided such treatment is rendered within twelve months of the accident;
   2. Surgical removal of partially or completely bony impacted teeth; or
   3. Treatment and/or replacement of congenitally missing teeth, including dental implants, up to the perperson lifetime maximum for all such services specified in your Schedule of Benefits.
7. Diagnostic tests, including x-rays, laboratory examinations and diagnostic scans. Note that covered expenses for MRIs, CT scans and PET scans are paid at 100% if you use Absolute Solutions, the Plan’s preferred imaging provider. See the inside front cover of this booklet for contact information.
8. Durable medical equipment - Rental up to purchase price, or purchase if the purchase cost is expected to be less than the cost of renting, of physician-prescribed equipment that meets the Plan’s definition of durable medical equipment (page 75). The equipment must be prescribed and used to improve the functions of a malformed part of the body or to prevent or slow further decline of the patient’s medical condition. The physician must certify in writing the medical necessity for the equipment, and state the length of time the equipment will be required. The Plan may require proof at any time of the continuing medical necessity of any item. You should pre-certify durable medical equipment with the utilization review organization to ensure that the equipment and duration of use meets the Plan’s medical necessity criteria.
9. Foot orthotics that are custom-made and prescribed by a physician or podiatrist, up to two pairs every three calendar years if medically necessary. You should pre-certify orthotics with the utilization review organization to ensure that they meet the Plan’s medical necessity criteria.
10. Home health care services when ordered by the patient’s physician and provided by a home health agency in lieu of an inpatient hospitalization, up to the maximum number of visits shown in your Schedule of Benefits. The Plan covers the following services:
    1. Part-time or intermittent home nursing care from or supervised by a registered nurse;
    2. Part-time or intermittent home health aide services;
    3. Physical therapy and occupational therapy, subject to Plan limitations for these services;
    4. Speech therapy, if necessary as result of a stroke or traumatic brain injury, subject to Plan limitations; and
    5. Medical supplies, drugs and medications prescribed by a physician, and laboratory services, but only to the extent that they would have been covered in a hospital or skilled nursing facility.

Each visit of four hours or less from a member of a home health agency team is considered one visit.

You should pre-certify home health care with the utilization review organization to ensure that it meets the Plan’s medical necessity criteria.

11. Hospice care furnished by a hospice agency to a terminally ill patient for a maximum period of 180 days. A terminally ill patient is a patient who has been diagnosed by a physician as having a life expectancy of six months or less. Hospice care will only be covered if the care is being case managed by the Plan’s review organization.
12. Hospital services and supplies as follows:
    1. Room and board charges up to the hospital’s regular daily semi-private rate, or for confinement in an intensive care unit, up to the hospital’s average charge for daily intensive care. Private rooms are covered if the hospital is a private-room-only facility, or if a private room is certified as medically necessary by the attending physician for isolation of a communicable disease.
    2. Ancillary inpatient hospital services and supplies, including drugs and medicines that are required for treatment of the covered person.
    3. Newborn nursery room and board, miscellaneous services and supplies, and doctors’ services for healthy newborn infants during the initial hospital confinement after birth.
    4. Emergency treatment provided in a hospital outpatient or emergency department.
    5. Outpatient services and treatment.

You should pre-certify inpatient care and outpatient surgery with the review organization.

13. Infertility - Tests and examinations to identify the cause or causes of infertility, and infertility treatments, up to the maximum benefit shown in your Schedule of Benefits. (Donor, storage and surrogacy services are excluded, as is pre-implantation testing of embryos for in vitro fertilization.) Infertility-related expenses are not covered for children of any age.
14. Intensive outpatient or partial inpatient therapy performed by licensed mental health or substance abuse clinicians with Masters’ degrees or higher. Pre-certification is required after 12 combined visits or days (for all related medical conditions).
15. Medical supplies including surgical dressings, casts, splints, braces and crutches when provided or prescribed by a physician. Prescription back braces are covered up to a maximum of two every twelve months. You should pre-certify back braces with the utilization review organization to ensure that they meet the Plan’s medical necessity criteria.
16. Nutrition counseling - Three individual (one-on-one) visits with a licensed nutritionist who is in the PPO network, when recommended by a physician for a person with diabetes, Crohn’s Disease or celiac disease. (Note that one diet counseling visits for an adult at risk for cardiovascular disease is covered under the Preventive Benefit.)

17. Obesity treatment as follows:
    1. Physician-supervised medical treatment for obesity, including office visits, related laboratory tests, nutritional counseling by a licensed nutritionist, and FDA-approved prescription weight loss medications, up to the maximum benefit shown in your Schedule of Benefits. Exercise and/or diet programs, and food products and nutritional supplements of any kind are not covered. (Note: The Plan also provides benefits for certain obesity management programs under the Preventive Benefit.)
    2. Surgical treatment of obesity if the following criteria are met:
       • The patient has a Body Mass Index (BMI) of at least 40;
       • The obesity is a threat to the patient’s life due to the existence of complicating health factors such as diabetes, heart trouble, hypertension, etc.;
       • During the 24-month period prior to the proposed surgery, the patient must have a documented history of at least six continuous months of physician-assisted attempts to reduce weight by more conservative measures;
       • The surgery is performed in a Blue Cross PPO facility; and
       • Before surgery is performed, the utilization review organization approves the surgery based on a review of the medical history and treatment plan.

Obesity surgery will be covered only once in a patient’s lifetime. No benefits are payable for obesity surgery performed on dependent children. The Plan will not cover any post-operative procedures to remove excess tissue or improve the person’s appearance.

18. Outpatient surgery performed at an in-network (PPO) surgical center. You should pre-certify outpatient surgery with the review organization.

19. Physical therapy performed by a licensed physical therapist (P.T.), physical therapy assistant (P.T.A.), and occupational therapy performed by a licensed occupational therapist (O.T.) or occupational therapy assistant (O.T.A.). Pre-certification for physical and/or occupational therapy is required after 12 combined visits (for all related medical conditions).
20. Professional services of a physician or surgeon.

Professional services of an assistant surgeon are covered when required due to the complexity of the procedure.

The Plan may also cover services and supplies of other licensed, qualified medical professionals who are performing the same types of clinical services that would be covered if rendered by a physician, provided those services are performed within the scope of the practitioner’s license, certification and training. See page 77 for more information.

21. Podiatry.
22. Pregnancy expenses, including medically appropriate prenatal screening tests, and charges made by an attending physician during a birth or delivery of a newborn if the charge is required by the hospital.

Prenatal genetic testing as follows, provided the tests are medically necessary and within the Level A recommendations established by the American College of Obstetrics and Gynecology (ACOG):

1. First or second trimester screening tests for fetal aneuploidy disorders (e.g., Down Syndrome), or specific inherited disorders such as cystic fibrosis and sickle cell disease; and
2. Follow-up diagnostic tests for the same conditions if an initial screening indicates a likelihood of a genetic defect.

The Plan excludes screening and testing: a) of family members, b) by multiple methods for the same disorder(s), c) multigene panels for diseases such as cancer, d) tests to determine the child’s gender or hereditary predispositions (predictive tests), and e) home testing kits. Pre-certification by the Plan’s utilization review organization is recommended.

23. Prescription drugs, medicines and supplies that are covered by the Plan but cannot be purchased through the Prescription Drug Program, such as drugs for obesity, infertility, and necessary supplies for diabetics or after any type of ostomy surgery (e.g. colostomy, ileostomy).
24. Prosthetics such as artificial limbs and artificial eyes, and conventional monofocal intraocular lenses following cataract surgery (but not multifocal lenses), including restoration or adjustment to prosthetic devices.

You should pre-certify prosthetics with the utilization review organization.

25. Radiation therapy and chemotherapy.
26. Residential treatment facility - Treatment provided in a facility that meets the Plan’s definition of a covered residential treatment facility and is located in the State of Illinois or in the state in which the patient is a resident or is a full-time college student. The Trustees will only grant an exception to these requirements if evidence is submitted that compliance with these requirements will present a hardship to the participant or patient. Note that not all facilities in Illinois will meet the Plan’s qualifications – you should call the Fund Office before admission. The Plan will cover no more than 45 days for all related confinements. Confinements are considered “related” if they are for the same or related medical condition and are not separated by a twelve-month period during which the person received no treatment for that condition (other than maintenance medications).

Residential treatment must be pre-certified by the review organization.

27. Skilled nursing facility - Treatment provided in a skilled nursing facility, up to a maximum of 45 days for all related confinements, provided that:
    1. The confinement begins within 14 days of a hospital confinement of at least three consecutive days;
    2. The confinement is due to the same or related causes as the hospital confinement;
    3. A hospital confinement would otherwise be needed;
    4. The confinement has been pre-certified by the review organization; and
    5. The facility must be in the State of Illinois or in the state in which the patient is a residence or is a fulltime college student. The Trustees will grant exceptions only if evidence is submitted that compliance with this rule will present a hardship to the participant or patient. Note that not all facilities in Illinois will meet the Plan’s qualifications – you should call the Fund Office before admission.

The maximum room and board rate is limited to 50% of the semi-private room rate at the hospital at which the person had been a patient just prior to the skilled nursing facility confinement.

Confinements are considered “related” if they are for the same or related medical condition and are not separated by a twelve-month period during which the person received no treatment for that condition (other than maintenance medications).

28. Speech therapy for correction of a congenital anatomic defect; or restoration or correction of normal speech that was lost as a result of a disease or injury.

In addition, the Plan will cover up to 40 speech therapy visits per calendar year for a child under age 12 for treatment of autism spectrum disorders, cerebral palsy or another congenital neurological or anatomical disorder, a hearing deficit caused by an illness, or dysphagia. Any visits in excess of 40 in a calendar year will not be covered.

To be covered, speech therapy must meet the following requirements:

1. _It must require one-on-one sessions with a licensed speech-language pathologist;
2. It must be prescribed by a medical doctor (M.D. or D.O.); and
3. If the speech therapy is for a child, periodic progress reports must be submitted to show that the treatment:
   • Continues to have measurable goals and objectives that require the skills of a trained speech-language therapist;
   • Is not for drill and practice that can be performed at home; and
   • Is not, other than incidentally, aimed at improving the child’s school performance.

The Plan will NOT cover speech therapy for developmental and psychosocial delays, learning and educational problems, attention disorders, behavioral problems, verbal apraxia, or stuttering or stammering unless due to a specific disease or injury.

29. TMJ - Services, supplies, or appliances to treat temporomandibular joint syndrome (TMJ).
30. Transplants - Organ and tissue transplants. Organ donor expenses will also be covered if the recipient is covered under the Plan, and the Plan will cover the tests and screenings for up to six potential donors per transplant procedure.
31. Vasectomy - Charges incurred for a voluntary vasectomy. (Female sterilization procedures are covered under the Preventive Benefit.)
32. Urgent or immediate care treatment at a licensed urgent care facility.
33. Wig - One wig for a chemotherapy patient, up to a maximum allowable amount of $500.

PREVENTIVE BENEFIT

The Plan covers a wide range of preventive services for eligible participants and their dependents. Those services are listed below. • All covered preventive services provided by an in-network (PPO) provider will be paid at 100% with no deductible.

• Out-of-network services are subject to the deductible, out-of-network coinsurance, and allowable charge limitations.
• Most of the services in this list are determined by federal agencies. However, this Plan covers many preventive services in addition to the mandated coverages. • All items listed are subject to change.

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