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Please note: This summary is a brief description of Carpenters Health and Plan Rules and Regulations, including any amendments, will be the basis

BENEFITs

KaIsER

Plan Selections

A Health Maintenance Organization

(HMO) that provides prepaid medical, drug, vision and hearing aid benefits to Participants enrolled in this Plan with a guaranteed payment of these benefits. Participants must live within the Service Area.

Phantom COB (Coordination of Benefits)

Phantom COB does not apply

Annual Deductible

None

Annual out of Pocket Limits

Limit on co-payments Per person - $1,500 Per family - $3,000

Co-Payments

Shown for each service

Plan Lifetime Maximum

None

Choice of Physicians

Members choose a Physician on staff at a Kaiser Permanente facility located in their service area. Routine, preventive, and specialist care are provided at Kaiser Permanente facilities or by Kaiser con- tract providers.

Hospital Services

No Charge

2

Plan A & R Comparison

Welfare Plan benefits. In all cases, the for the payment of any benefits.

INdEmNITy

The Indemnity Plan is a comprehensive benefit plan with an annual deductible and a limit on your annual out of pocket for covered expenses. After the out of pocket limit is reached each year, the Plan will pay 100% of covered expenses for the remainder of the calendar year.

Phantom COB: If the participant’s spouse is employed and the employer offers in- surance, the spouse must elect coverage. If he or she declines coverage, the Indem- nity Plan will pay up to 20% of covered medical bills. The Fund will estimate the benefits of the other group plan at 80% of expenses incurred and will coordinate its benefits with the estimated benefits.

Per person: PPO: $100, Non-PPO: $200 Maximum deductible Per family: PPO: $200, Non-PPO: $400

For Contract Providers, $1,000 per per- son, not to exceed $2,000 per family. There is no Out of Pocket Maximum for Non-Contract Provider charges.

Once annual deductible is satisfied and until the out of pocket limit is met, the Plan pays PPO at 90% of contract rates and Non-PPO at 70% of Allowed Charg- es for all benefits unless otherwise indi- cated.

$2,000,000

Members may use the providers of their choice; however to receive maximum benefits, members must use PPO/contract providers.

Inpatient: Subject to deductibles and out of pocket limits. Benefits reduced by 25% if utilization review is not obtained. Outpatient: Subject to deductibles and out of pocket limits. PPO - 90% Non-PPO

  • -

    70%; however, if there was no choice

in the hospital used due to an Emergency and patient was admitted from the Emer- gency Room, the benefit is 90% of Al- lowed Charges.

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