Summary Plan Description

Schedule of Benefits Summary

This is a summary of benefits available under the Carpenters Health and Security Plan of Western Washington. For benefit details and other plan provisions, including eligibility requirements and enrollment requirements, please refer to the participant, dependent or retiree sections of this Summary Plan Description, as well as the general exclusions and limitations.

Eligibility

Monthly Dollar Bank Deduction
The current monthly dollar bank deduction is $850 for the Western and Central Washington benefit package. The current monthly dollar bank deduction is $750 for the Eastern Washington, Idaho, Montana, and Wyoming benefit package.

Initial Eligibility
You must accumulate a minimum amount equal to three months of eligibility in your dollar bank account in a three consecutive month period to start the eligibility system. The current minimum amount is $2,550 for the Western and Central Washington benefit package and $2,250 for the Eastern Washington, Idaho, Montana, and Wyoming benefit package. At least $1 of contributions must be earned in the first month of the three consecutive month period. The fourth month is the "lag month." You are then eligible for benefits on the first day of the fifth month for a three-month period.

Continuing Eligibility
After your initial eligibility, you must continue to accumulate sufficient contributions in you dollar bank account to fund each monthly dollar bank deduction. When the amount in your dollar bank equals or exceeds the monthly dollar bank deduction, you will be eligible on the first day of the second month after your dollar bank balance exceeds the monthly deduction amount.

Self-Contribution, COBRA and Retiree Coverage
Continuation coverage is available to qualifying participants, retirees and dependents. A monthly contribution must be made to the plan. The monthly amount is reviewed each year by the Board of Trustees in consultation with the plan's consultant.

Out-of-Pocket Medical Expenses and Maximums

Annual Deductible $200/person/calendar year
$400/family/calendar year
Coinsurance 10 percent for most services and supplies from a network provider. Paid at 100 percent for the remainder of the calendar year when a person's coinsurance reaches $2,300 or a family's coinsurance reaches $4,600.

20 percent for most services and supplies from a non-network provider. These services always require 20 percent coinsurance and the 20 percent coinsurance does not apply toward the $2,300 or $4,600 annual coinsurance maximums. This includes chiropractic care.

50 percent for TMJ/MPDS. These services always require 50 percent coinsurance and the 50 percent coinsurance does not apply toward the $2,300 or $4,600 annual coinsurance maximums.
Copayments $10 copayment when a network provider bills an office visit
$20 copayment when a non-network provider bills an office visit
$200 copayment when admitted to a non-network facility
$50 copayment for an emergency room visit. Waived if admitted as an inpatient directly following treatment in the emergency room.
See also Prescriptions Drugs
Copayments do not apply to Medicare-eligible retirees
Out-of-Pocket Maximums $4,000/person/calendar year
$8,000/family/calendar year
Includes the annual deductible, coinsurance, and office visit and emergency room copayments. These out-of-pocket maximums apply to network services only.

Preventive Health Services

Physical Examinations Paid at 100 percent at network providers with no annual deductible or office visit copayment when recommended by the Affordable Care Act. Paid at 80 percent at non-network providers after the annual deductible and office visit copayment.

Routine Immunizations

Routine Immunizations Paid at 100 percent at network providers with no annual deductible or office visit copayment when recommended by the Affordable Care Act. Paid at 80 percent at non-network providers after the annual deductible and office visit copayment.

Physician Services

Physician Services Paid at 90 percent (network) and at 80 percent (non-network)

Hospital Services

Inpatient Hospital Paid at 90 percent (network) and at 80 percent (non-network)
Outpatient Hospital Paid at 90 percent (network) and at 80 percent (non-network)
Emergency Room Paid at 90 percent (network and non-network)

Hospital Alternatives

Skilled Nursing Facility Paid at 90 percent (network) and at 80 percent (non-network). Calendar year maximum of 25 days. Medicare-eligible retirees are eligible for 80 coinsurance days.
Home Health Care Paid at 100 percent (network and non-network). Calendar year maximum of 30 visits.
Hospice Care Paid at 100 percent (network and non-network). Maximum of 14 inpatient days during six-month period. Skilled care in the home is limited to 60 visits. Respite care is limited to 120 hours per three-month period.

Rehabilitative/Habilitative Care

Inpatient Rehabilitative/
Habilitative
Paid at 90 percent (network) and at 80 percent (non-network). Calendar year maximum of 15 inpatient days.
Outpatient Rehabilitative/
Habilitative
Paid at 90 percent (network) and at 80 percent (non-network). Calendar year maximum of 30 visits.

Chiropractic Care

Chiropractic Care Paid at 80 percent (network and non-network). Calendar year maximum of 24 visits.

Behavioral Health Services

Inpatient Services Paid at 90 percent (network) and at 80 percent (non-network)
Outpatient Services Paid at 90 percent (network) and at 80 percent (non-network)

Other Services

Allergy Testing Paid at 90 percent (network) and at 80 percent (non-network). Calendar year maximum of 12 blood tests and 60 skin tests.
Ambulance Paid at 90 percent (network and non-network)
Diagnostic X-Ray and Laboratory Paid at 90 percent (network) and at 80 percent (non-network)
Durable Medical Equipment and Medical Supplies Paid at 90 percent (network) and at 80 percent (non-network)
Infusion Therapy Paid at 90 percent (network) and at 80 percent (non-network)
Pregnancy Care Paid at 90 percent (network and non-network). For the participant and spouse only.
Transplants Paid at 90 percent (network) and at 80 percent (non-network). Subject to a 12-month waiting period.

Prescription Drugs

Express Scripts Retail Pharmacy Program*

$7 copayment for each generic prescription
$15 copayment for each brand-name prescription listed on the drug program formulary
$30 copayment for each brand-name prescription not listed on the drug program formulary
Limited to a 30-day maximum supply

*Dollar Bank Eligibility and Non-Medicare Retirees

Express Scripts By Mail*

$14 copayment for each generic prescription
$30 copayment for each brand-name prescription listed on the drug program formulary
$60 copayment for each brand-name prescription not listed on the drug program formulary
Up to a 90-day maximum supply

*Dollar Bank Eligibility and Non-Medicare Retirees

Out-of-Pocket Maximums $2,850/person/calendar year
$5,700/family/calendar year

Vision Benefits

Eye Examinations and Hardware Routine vision benefits are provided through VSP Vision Care and are based on the benefits and benefit maximums. Routine vision benefits are not available to participants and dependents covered under the Eastern Washington, Idaho, Montana, and Wyoming benefit package or under Retiree Coverage.

Dental Benefits

Dental
Dental Implants
Orthodontic
Dental benefits are provided through Delta Dental of Washington and are based on a fee schedule with the annual maximums below. Dental and orthodontic benefits are not available under Retiree Coverage.

Paid based on a fee schedule with annual maximum of $2,000 for the Western and Central Washington benefit package and an annual maximum of $1,500 for the Eastern Washington, Idaho, Montana, and Wyoming benefit package

Paid at 50 percent with a lifetime maximum of $1,000 under the Western and Central Washington benefit package only

Paid at 50 percent with a lifetime maximum of $1,500 for participants and dependents under the Western and Central Washington benefit package and with a lifetime maximum of $1,000 for dependent children age 18 and younger under the Eastern Washington, Idaho, Montana, and Wyoming benefit package.

Time Loss Benefits

Time Loss The weekly time loss benefit under the Western and Central Washington benefit package is equal to 33 percent of journeyman pay based on a 40-hour week at the prevailing journeyman's rate specified in the Area Master Agreement signed by your most recent contributing employer. The weekly time loss benefit under the Eastern Washington, Idaho, Montana, and Wyoming benefit package is $100. This benefit is paid for a maximum of 26 weeks. Physician certification is required. Seven-day waiting period when disability is due to an illness. For participants with dollar bank eligibility only.

Life Insurance and Accidental Death and Dismemberment Benefits

Life Insurance Dollar Bank Participant – $30,000
Dollar Bank Dependents – $5,000
Retiree – $2,000
Retiree Dependents – $1,000
Accidental Death and Dismemberment Paid based on schedule amounts. For participants with dollar bank eligibility only.