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U.A. PLUMBERSLOCAL UNION No. 68GROUPPROTECTION PL ANSummary ofBenefitsand Coverage7/1/2015 – 6/30/2016

U. A. Plumbers Local 68: Group Protection PlanSummary of Benefits and Coverage: What this Plan Covers & What it CostsCoverage Period: 07/01/2015 - 06/30/2016Coverage for: Individual Family Plan Type: PPOThis is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plandocument at www.plu68.com or by calling 713-869-2592 or 1-800-833-2980.Important Questions Answers 500 per person/ 1,000 perfamily. Doesn't apply to mostWhat is the overallpreventive care or hearing aids.deductible?Balance billing and excludedservices do not count toward thedeductible.Yes. 100 per person for dental;Are there otherdeductibles for specific 50 per person for vision. Thereare no other specificservices?deductibles.Yes. In-Network: 6,000 perIs there an out–of–pocket limit on myperson; Out-of-Network:expenses? 20,000 per person.What is not included in Premiums, balance billing, healththe out–of–pocketcare this plan does not cover andlimit?deductibles.Is there an overallannual limit on what the No.plan pays?Does this plan use anetwork of providers?Why this Matters:You must pay all the costs up to the deductible amount before this plan begins to pay forcovered services you use. Check your policy or plan document to see when the deductiblestarts over (usually, but not always, January 1st). See the chart starting on page 2 for how muchyou pay for covered services after you meet the deductible.You must pay all of the costs for these services up to the specific deductible amount beforethis plan begins to pay for these services.The out-of-pocket limit is the most you could pay during a coverage period (usually one year)for your share of the cost of covered services. This limit helps you plan for health careexpenses.Even though you pay these expenses, they don’t count toward the out-of-pocket limit.The chart starting on page 2 describes specific coverage limits, such as limits on the number ofoffice visits.If you use an in-network doctor or other health care provider, this plan will pay some or all ofthe costs of covered services. Be aware, your in-network doctor or hospital may use an out-ofYes. For a list of in-networkproviders, see www.bcbsil.com, network provider for some services. Plans use the term in-network, preferred, or participatingfor providers in their network. See the chart starting on page 2 for how this plan payscall 1-800-810-2583.different kinds of providers.Questions: Call 713-869-2592 or 1-800-833-2980 or visit us at www.plu68.com.If you aren’t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossaryat www.dol.gov/ebsa/healthreform or call 713-869-2592 or 1-800-833-2980 to request a copy.1 of 9

Important QuestionsAnswersDo I need a referral to seeNo.a specialist?Are there services thisYes.plan doesn’t cover?Why this Matters:You can see the specialist you choose without permission from this plan.Some of the services this plan doesn’t cover are listed on page 7. See your policy or plan documentfor additional information about excluded services. Copayments are fixed dollar amounts (for example, 15) you pay for covered health care, usually when you receive the service. Coinsurance is your share of the costs of a covered service, calculated as a percent of the allowed amount for the service. For example, if theplan’s allowed amount for an overnight hospital stay is 1,000, your coinsurance payment of 20% would be 200. This may change if youhaven’t met your deductible. The amount the plan pays for covered services is based on the allowed amount. If an out-of-network provider charges more than the allowedamount, you may have to pay the difference. For example, if an out-of-network hospital charges 1,500 for an overnight stay andthe allowed amount is 1,000, you may have to pay the 500 difference. (This is called balance billing.) This plan may encourage you to use in-network providers by charging you lower deductibles, copayments and coinsurance amounts.CommonMedical EventService You MayNeedYour Cost if You Use anIn-Network ProviderPrimary care visit to treat20% coinsurancean injury or illnessSpecialist visit20% coinsuranceYour Cost if You Use anLimitations & ExceptionsOut-of-Network Provider40% coinsurance40% coinsuranceIf you visit a healthcare provider's officeChiropractic services andChiropractic services andor clinicOther practitioner office acupuncture: 20% coinsuranceacupuncture: 40% coinsurancevisit(coinsurance based on lesser of(coinsurance based on 50) 50 or PPO allowed amount)-- None --- None -Limited to combined in- and out-ofnetwork maximum of 24 chiropracticvisits and 24 acupuncture visits2 of 9

CommonMedical EventService You MayNeedYour Cost if You Use anIn-Network ProviderNo charge for sigmoidoscopies,mammograms, pap smears,prostate exams and thefollowing vaccines: tetanus,pneumonia, flu, hepatitis A&Band meningitis. No charge up toIf you visit a health 400 for routine physicals thenPreventive care/20% coinsurance. No charge upcare provider's officescreening/immunizationto 400/lifetime then 20%or cliniccoinsurance for HPV vaccines.No charge up to 200/lifetimethen 20% coinsurance forshingles vaccines. 20%coinsurance for childimmunizations.If you have a testDiagnostic test (x-ray,20% coinsuranceblood work)Imaging (CT/PET scans,20% coinsuranceMRIs)Your Cost if You Use anLimitations & ExceptionsOut-of-Network ProviderNo charge for sigmoidoscopiesand the following vaccines:tetanus, pneumonia and flu. Nocharge up to 400 for routinephysicals then 40% coinsurance.No charge up to 400/lifetimethen 40% coinsurance for HPVvaccines. No charge up to 200/lifetime then 40%coinsurance for shinglesvaccines. 40% coinsurance forhepatitis A&B and meningitisvaccines. 40% coinsurance formammograms, pap smears,prostate exams and childimmunizations.Routine physicals limited to one per yearfor individuals over 40 and one per every5 years for individuals under 40.Sigmoidoscopies limited to 250 perexam. Tetanus, pneumonia and fluvaccines limited to 30 per vaccine. Inaddition, age and frequency limitationsapply.40% coinsurance-- None --40% coinsurance-- None --3 of 9

CommonMedical EventService You MayNeedRetail: 15% coinsurance for upto a 90-day supply; mail order:10% coinsurance for a 90-daysupplyRetail: 20% coinsurance for upto a 30-day supply, 15%coinsurance for a 90-day supply;mail order: 10% coinsurance fora 90-day supplyRetail: 20% coinsurance for upto a 30-day supply, 15%coinsurance for a 90-day supply; Limited to 5,000 per calendar year unlessmail order: 10% coinsurance for a letter of medical necessity is provideda 90-day supplyNon-preferred branddrugsRetail: 20% coinsurance for upto a 90-day supply; mail order:20% coinsurance for a 90-daysupplyRetail: 20% coinsurance for upto a 90-day supply; mail order:20% coinsurance for a 90-daysupplyFacility fee (e.g.,ambulatory surgerycenter)20% coinsuranceNot covered-- None --Physician/surgeon fees20% coinsurance40% coinsurance-- None --Additional 100 emergencyroom deductible plus 100penalty copay, then 40%coinsuranceAdditional deductible waived fortreatment of accidental injury or ifadmitted to hospital directly fromemergency room20% coinsurance40% coinsurance-- None --20% coinsurance40% coinsurance-- None --If you need drugs totreat your illness orconditionMore informationPreferred brand drugsabout prescriptiondrug coverage isavailable atwww.mycatamaranrx.com.If you needimmediate medicalattentionYour Cost if You Use anLimitations & ExceptionsOut-of-Network ProviderRetail: 15% coinsurance for upto a 90-day supply; mail order:10% coinsurance for a 90-daysupplyGeneric drugsIf you haveoutpatient surgeryYour Cost if You Use anIn-Network ProviderAdditional 100 emergencyEmergency room services room deductible, then 20%coinsuranceEmergency medicaltransportationUrgent care4 of 9

CommonMedical EventService You MayNeedYour Cost if You Use anIn-Network ProviderFacility fee (e.g., hospital20% coinsuranceroom)If you have a hospitalstayPhysician/surgeon fee20% coinsuranceYour Cost if You Use anLimitations & ExceptionsOut-of-Network Provider40% coinsurance if admitteddirectly through hospital'sMust pre-certify non-emergency hospitalemergency room; otherwise not confinements and certify emergencycoveredhospital confinements, otherwise, benefitsreduced to 50% co-insurance and limited40% coinsurance if admittedto maximum of 1,000 for entiredirectly through hospital'semergency room; otherwise not confinement.coveredMental/Behavioral health20% coinsuranceoutpatient servicesIf you have mental Mental/Behavioral healthinpatient serviceshealth, behavioralhealth, or substanceabuse needsSubstance use disorderoutpatient servicesSubstance use disorderinpatient servicesPrenatal and postnatalcareIf you are pregnantDelivery and all inpatientservices40% coinsurance-- None --20% coinsurance40% coinsuranceMust pre-certify non-emergency hospitalconfinements and certify emergencyhospital confinements, otherwise, benefitsreduced to 50% co-insurance and limitedto maximum of 1,000 for entireconfinement.Not coveredNot coveredNot coveredNot coveredNot coveredNot covered20% coinsurance40% coinsuranceNot covered for dependent children20% coinsurance40% coinsuranceNot covered for dependent children5 of 9

CommonMedical EventService You MayNeedHome health careIf you need helprecovering or haveother special healthneedsYour Cost if You Use anIn-Network Provider20% coinsuranceYour Cost if You Use anLimitations & ExceptionsOut-of-Network Provider40% coinsurance-- None -Outpatient physical therapy not followingsurgery limited to combined in- and outof-network maximum of 24 visits.Rehabilitation services20% coinsurance40% coinsuranceHabilitation servicesSkilled nursing careNot covered20% coinsuranceNot covered40% coinsuranceDurable medicalequipment20% coinsurance40% coinsurance20% coinsuranceIndividuals age 19 and older:20% coinsurance after visiondeductible. Individuals underage 19: no charge for oneroutine eye exam per calendaryear40% coinsuranceIndividuals age 19 and older:20% coinsurance after visiondeductible. Individuals underage 19: no charge for oneroutine eye exam per calendaryearIndividuals age 19 and older:20% coinsurance after visiondeductible. Individuals underage 19: No charge for"standard" lenses ("standard"lenses do not include extrassuch as scratch proofing, tint,etc.) and no charge for framesup to 150 (costs for frames inexcess of 150 are subject to20% coinsurance after visiondeductible and 500 per personper 3-year benefit period)Individuals age 19 and older:20% coinsurance after visiondeductible. Individuals underage 19: No charge for"standard" lenses ("standard"lenses do not include extrassuch as scratch proofing, tint,etc.) and no charge for framesup to 150 (costs for frames inexcess of 150 are subject to20% coinsurance after visiondeductible and 500 per personper 3-year benefit period)All vision services subject to maximumbenefit payment of 500 per person per 3calendar year benefit period (notapplicable to glasses for individuals underage 19 except when frames cost in excessof 150). Glasses for individuals underage 19 are limited to one pair per calendaryear.No chargeCheck-up includes the exam, prophylaxis(cleaning), x-rays, and fluoride; limited toindividuals under age 19Hospice serviceEye examIf your child needsdental or eye careGlassesDental check-upNo chargeNot covered-- None -Durable medical equipment in excess of 200 not covered without pre-determination of benefits through Fund Office-- None -Maximum vision care benefit payment of 500 per person per 3-calendar yearbenefit period (not applicable to visionexams for individuals under age 19 unlessexam is non-routine)6 of 9