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Sheet Metal Workers Local 46

Health Fund

The Plan started on July 1, 1950

Summary Plan Description/ Plan Document

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Sheet Metal Workers Local 46 Health Fund244 Paul Road

Rochester, NY 14624Phone: 585-458-0400

Fax: 585-458-5226Website: SMW46benefits.com

January 1, 2012

Board Of Trustees

Union Trustees Employer Trustees

Joseph P. Leone John BeilingDonald Steltz Philip M. SomersBrian Winters Gavin Vogt

Fund Manager Legal CounselJoseph P. Leone Blitman & King LLP585-458-0400 800-724-3190

Fund Office Manager Fund AuditorChristina M. Lucci The Bonadio Group585-458-0400 585-381-1000

Fund Consultant Prescription Benefit ManagerThe Segal Company Envision Rx Options212-251-5000 800-361-4542

Third Party Administrator Dental and Vision RMSCO, Inc. Benefits Administrator315-448-9000 Health Economics Group (HEG) 585-241-7500

This Summary Plan Description/Plan Document has been prepared for active and retired participants of the Sheet Metal Workers Local 46 Health Fund. This Summary Plan Description also serves as official Plan rules and regulations that establish the Plan. The Trustees reserve the right to interpret, amend, or terminate the Plan at any time. The Trustees have not empowered anyone else to speak for them regarding the Health Fund. No employer, union representative, supervisor, or shop steward is in the position to discuss your rights under this Fund with authority. No benefits in this booklet are vested.

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Table of ConTenTsPage

Introduction ....................................................................................5Schedule Of Benefits ........................................................................8Contact Information ...................................................................... 21Eligibility Requirements ................................................................ 22 Initial Eligibility ...............................................................................22 Special Enrollment ...........................................................................29 Pre-Existing Conditions ...................................................................30 When Eligibility Ends .....................................................................32 Self-Pay Program .............................................................................33 Reinstatement Of Eligibility ............................................................35Life Events At-A-Glance ............................................................... 36 Getting Married ...............................................................................36 Adding A Child ...............................................................................36 Getting Divorced .............................................................................37 Entering The Uniformed Services ....................................................39 Losing Eligibility .............................................................................41 Child Losing Eligibility ...................................................................41 When You Are Out Of Work Due To Disability

(For Active Participants) ..................................................................42 In The Event Of Your Death (For Active Participants) ....................43 Keep Plan Informed Of Address Changes .......................................44 Family And Medical Leave Act (For Active Participants) ...............44 When You Retire ..............................................................................46 When You Leave Covered Employment ..........................................47 Returning To Work ..........................................................................52Medical Benefits (For Active Participants And Dependents) ........... 53 How The Plan Works .......................................................................53 Covered Expenses ............................................................................60 Expenses Not Covered .....................................................................60Medical Benefits (For Retirees And Dependents) ............................ 61

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Prescription Drug Benefits (For Active Participants And Dependents) ...................................... 63 Retail Pharmacy Program ................................................................63 Mail Order Program.........................................................................64 Specialty Pharmacy Medication Services .........................................64 Generic And Brand Name Medications ...........................................65 Formulary Versus Non-Formulary Medications ...............................65 Step Therapy Program ......................................................................65 Covered Expenses ............................................................................65 Expenses Not Covered .....................................................................66Dental Benefits Administered By Health Economics Group, Inc. (HEG) – (For Active Participants And Dependents) ........................ 68 Covered Expenses ............................................................................68 Eligible Charges ...............................................................................70 Maximum Annual Benefit ................................................................70 Predetermination Of Benefits ..........................................................70 Annual Deductible ...........................................................................71 Expenses Not Covered .....................................................................72Vision Benefits Administered By Health Economics Group, Inc. (HEG) - (For Active Participants And Dependents) ...... 74 Covered Expenses ............................................................................74 Expenses Not Covered .....................................................................74Hearing Aid Benefits (For Active Participants) ................................ 75 Covered Expenses ............................................................................75 Expenses Not Covered .....................................................................75Employee Assistance Plan (For Active Participants And Dependents) ...................................... 76 What The Program Covers ...............................................................76Health Reimbursement Account (HRA) (For Active Participants And Retirees) ............................................ 77 Health Reimbursement Accounts – In General ...............................77 Minimum Personal Account Balances ..............................................79In The Event Of Your Disability (For Active Participants) ................ 80 Benefits .............................................................................................80

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Life Insurance Benefits (For Active Participants) ............................. 81 Benefit ..............................................................................................81 Life Insurance Conversion ...............................................................81 Naming A Beneficiary ......................................................................81Accidental Death And Dismemberment (AD&D) Insurance Benefit (For Active Participants) ..................................... 83 Benefits .............................................................................................83 Benefit Exclusions ............................................................................84General Plan Exclusions................................................................. 85Claims And Appeals Procedures ..................................................... 90 Filing Claims ....................................................................................90 Types Of Health Care Claims ..........................................................91 Initial Claim Decisions .....................................................................92 Notification Of Initial Adverse Benefit Determinations ..................95 Appealing An Adverse Benefit Determination ................................95 Determinations On Appeal ..............................................................98 Return Of Overpayments ...............................................................100Administrative Information.......................................................... 101 Coordination Of Benefits ...............................................................101 Claims Where A Third Party Is Liable ...........................................104 Confidentiality Of Protected Health Information .........................106Important Information About The Plan ........................................ 110 ERISA Rights ................................................................................114Definitions .................................................................................. 117

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InTRoDUCTIonThe Board of Trustees of the Sheet Metal Workers Local 46 Health Fund is pleased to provide you with this updated Summary Plan Description (SPD)/Plan Document, which contains current health and welfare benefits information. The benefits described in this booklet are effective January 1, 2012. This SPD/Plan Document replaces and supersedes prior versions.For active participants and their dependents, the Plan offers: Medical Benefits administered

by RMSCO, Inc.; Regional Network through

the RMSCO PPN - Preferred Provider Network;

National Network through Private Health Care Systems (PHCS);

Prescription drug benefits administered by Envision Pharmaceuticals;

Dental benefits administered by Health Economics Group;

Vision benefits administered by Health Economics Group;

Hearing aid benefits (self-funded and for active members only);

An Employee Assistance Program (EAP); A Health Reimbursement Account (HRA) to assist with the cost of

medical expenses; Weekly income accident and sickness benefits (for active members

only); Life insurance benefits (for active members only); and Accidental death and dismemberment insurance benefits (for active

members only).For retirees, the Fund provides a supplement to assist with the cost of medical insurance premiums. These plans are community rated health insurance products which require a monthly premium payment. These products may be changed, or the services provided may be altered by the provider, at any time, and without notice to you from this Fund or your union. For all issues relative to these services and products, please contact the provider directly. Please note that the Trustees have determined that the benefits offered to retirees are considered to be a Retiree-Only Plan.

If you have questions about how the Plan works, please call, write or email the Fund Office at:Sheet Metal Workers Local 46 Health Fund244 Paul RoadRochester, NY 14624Phone: 585-458-0400Fax: 585-458-5226Website: www.SMW46benefits.com email: [email protected] SMW Local 46 website is www.smw46.com.

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Currently the Plan offers retirees access to several Excellus BlueCross BlueShield medical programs and Smile Saver Dental programs, the HEG-administered Dental Plan (same as for active participants), as well as a medical program offered by MVP (formerly Preferred Care). As these programs change from time to time, you should contact the Fund Office for the current list of available retiree plan options. Note: The types of coverage provided within the retiree health plans are subject to change by the provider. The premiums, as well as the level of coverage, may change without the consent or knowledge of Sheet Metal Workers Local 46 Health Fund.It is the Trustees’ goal to maintain a financially stable Fund while providing adequate health care coverage to you and your family. The Fund has implemented some cost-saving methods such as medical deductibles and out-of-pocket maximums to ensure that we can meet your current and future health care needs. Here are just a few examples of how you can help us manage health care costs for you, your family and the Fund: Using network providers – Network and participating providers,

which include hospitals, physicians, and other health care providers, charge negotiated, reduced rates. In addition, the Plan pays a higher percentage of the costs to you when you use a network provider.

Examining emergency treatment alternatives – In the event of an emergency, the most important consideration is to seek immediate medical care, especially in a life-threatening situation. However, in some cases, you can obtain the same level of care at a physician’s office or an urgent care facility as in an emergency room. Keep your physician’s telephone number easily accessible and locate the nearest facility so you will be prepared in case of an emergency.

Requesting generic medications – Often medications come in two forms: generic and brand name. Generic medications have to meet the same quality standards for pureness and effectiveness, but can cost much less than their brand name equivalent. Check with your doctor to see if a generic medication is appropriate for you.

Using the mail order program – The mail order program is a convenient way to have maintenance medications delivered to your home. When you use the mail order program, you pay less for a larger supply of medication.

We urge you to read this information and, if you are married, share it with your spouse. Also, please keep this SPD/Plan Document with your important papers so you can refer to it when needed.Sincerely,

Board of Trustees

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Notice of Grandfathered Health Plan

This group health plan believes this Sheet Metal Workers Local 46 Health Fund is a “grandfathered health plan” under the Patient Protection and Affordable Care Act (the Affordable Care Act). As permitted by the Affordable Care Act, a grandfathered health plan can preserve certain basic health coverage that was already in effect when that law was enacted. Being a grandfathered health plan means that your plan may not include certain consumer protections of the Affordable Care Act that apply to other plans, for example, the requirement for the provision of preventive health services without any cost sharing. However, grandfathered health plans must comply with certain other consumer protections in the Affordable Care Act, for example, the elimination of lifetime limits on benefits. Questions regarding which protections apply and which protections do not apply to a grandfathered health plan and what might cause a plan to change from grandfathered health plan status can be directed to the Plan Administrator at 585-458-0400. You may also contact the Employee Benefits Security Administration, U.S. Department of Labor at 866-444-3272 or www.dol.gov/ebsa/healthreform. This website has a table summarizing which protections do and do not apply to grandfathered health plans.

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sCHeDUle of benefITs

For Active Participants And DependentsMedical Benefits Coverage

Lifetime Maximum Unlimited per person

Calendar Year Deductible $100 per person; $300 per family

Calendar Year Out Of Pocket Maximum (does not include the annual deductible)

$1,000 per person; $3,000 per family (3 family members must meet deductible before the family out-of-pocket max can apply)

*Medical Benefits that Require Pre-certification

*Behavioral Health (inpatient facility and/or inpatient hospital)*Durable Medical Equipment (DME)*Home Care by an Agency*Hospice Facility*Hospice Home*Hospice Inpatient*Inpatient Acute Care Hospital*IV Therapy Home, Hospital and/or Office*MRI, MRA, PET, CAT any place of service*Private Duty Nursing (facility, home or as an inpatient in a hospital)*Rehabilitation Inpatient Facility*Substance Abuse (inpatient facility and/or inpatient hospital)*Substance Abuse Detoxification*Skilled Nursing Inpatient Facility

In this Schedule of Benefits, wherever a Specific Benefit begins with the asterisk (*), it means that

prior to receiving the benefit you must call the number below for pre-certification.

For limitations of the specific benefit, see the chart below.

This benefit requires pre-certification by calling 866-397-9768.

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Specific Benefits Network/Participating Provider

Non-Network/Non-Participating Provider

Coinsurance (unless otherwise noted)

You pay 20% You pay 30%

Allergy Network/Participating Provider


Allergy Injection No deductible, you pay no coinsurance

After deductible, you pay 30%

Allergy Serum No deductible, you pay no coinsurance


Allergy Testing No deductible, you pay $10 co-payment


Ambulance Network/Participating Provider


Ambulance No deductible, you pay $50 co-payment

No deductible, you pay $50 co-payment

Anesthesia Network/Participating Provider


Inpatient Anesthesia After deductible, you pay 20%


Outpatient Anesthesia After deductible, you pay 20%


Office Anesthesia After deductible, you pay 20%


Chiropractic Services Network/Participating Provider


Chiropractic Services* No deductible, you pay $10 co-payment


Manipulation by an Osteopath



*Chiropractic services and manipulation by an Osteopath benefits are covered for individuals 15 years of age and over. These benefits have $1,500 limit per year.

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Family Planning Network/Participating Provider


Maternity Prenatal & Postnatal Office Visits



Maternity Hospital Charges For Mother

Physician Charges For Mother while in the

hospital



Family Planning No deductible, you pay $10 co-payment


Infertility Treatment Not covered Not covered

Reversal of Sterilization Not covered Not covered

Elective Abortion After deductible, you pay 20%


Benefits under Family Planning are limited to the Active Participant or their Spouse. This benefit is not covered for dependent child(ren) of the Active Participant.

Home Health Care Network/Participating Provider


*Home Care by an Agency After a $50 deductible, you pay 20%

After a $50 deductible, you pay 30%

The $50 deductible is a separate deductible specific for the home health care benefit that is not included in the Calendar Year Deductible. The home health care benefit has a maximum benefit of 40 visits, where 1 visit = 4 hours.

Hospice Network/Participating Provider


*Hospice Facility No deductible, you pay 20%


*Hospice Home No deductible, you pay 20%


*Hospice Inpatient No deductible, you pay 20%


Bereavement Counseling No deductible, you pay 20%Limit of 5 days

After deductible, you pay 30%Limit of 5 days

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Inpatient Services Network/Participating Provider


Inpatient Consultation After deductible, you pay 20%


Inpatient Newborn Physician Visit

No deductible, you pay 20%


*Inpatient Acute Care Hospital



Inpatient Physician Visit After deductible, you pay 20%


Inpatient Nursery No deductible, you pay 20%


Diagnostic Testing Network/Participating Provider


Diagnostic Test in OP Hospital



Diagnostic Test in Office After deductible, you pay 20%


Diagnostic Professional Component



Diagnostic Test Facility After deductible, you pay 20%


*MRI, MRA, PET, CAT any place of service



Lab Services Network/Participating Provider


Diagnostic Lab Home After deductible, you pay 20%


Diagnostic Lab Facility After deductible, you pay 20%


Diagnostic Lab OP Hospital



Diagnostic Lab Office After deductible, you pay 20%


Diagnostic Lab Prof Component



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X-Ray Services Network/Participating Provider


Diagnostic X-Ray Facility After deductible, you pay 20%


Diagnostic X-Ray OP Hospital



Diagnostic X-Ray Office After deductible, you pay 20%


Diagnostic X-Ray Prof Component



Diagnostic X-Ray Home After deductible, you pay 20%


Durable Medical Equipment (DME)

Network/Participating Provider


*Durable Medical Equipment (DME)



* DME requires pre-certification if the benefit is over $200.

Medical/Surgical Supply After deductible, you pay 20%


Ostomy Supplies After deductible, you pay 20%


Foot Orthotics After deductible, you pay 20%


Orthopedic Shoe and Appliance



Prosthetic external brace, splint, and non-dental prosthetic appliances such as artificial limbs, larynx and eyes. Dental prostheses replacing accidentally injured natural teeth within 12 months of accident.



There is no annual calendar year limit on this benefit.

Prosthetic to replace functioning body part



Oxygen and Supplies After deductible, you pay 20%


Diabetic Supply After deductible, you pay 20%


This Diabetic Supply benefit only covers supplies not covered by the pharmacy.

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Physician Services Network/Participating Provider


Maternity Physician You pay $10 co-payment; no deductible


Coverage is limited to the Active Participant or their Spouse. This benefit is not covered for dependent child(ren) of the Active Participant.

Physician Home Visit (not agency employed)



Podiatrist Office Visit No deductible, you pay $10 co-payment


Osteopath Office Visit No deductible, you pay $10 co-payment


Consult Elsewhere No deductible, you pay $10 co-payment


Office Visit No deductible, you pay $10 co-payment


Physician Visit Elsewhere No deductible, you pay $10 co-payment


Annual Physical Examination

Covered 100%; limited to one per calendar year

Medic Alert Benefit Benefit pays for a stainless steel bracelet or necklace with relevant medical information for covered Participants and their dependents; limited to one per lifetime.

Well Baby/Well Child Benefits for covered dependent children

Well baby and well child examinations covered 100%, up to age 18

Private Duty Nursing Network/Participating Provider


*Private Duty Nursing Facility (not hospital)



*Private Duty Nursing Home



*Private Duty Nursing Inpatient Hospital



The $50 deductible is a separate deductible specific for the Private Duty Nursing benefit that is not included in the Calendar Year Deductible. The Private Duty Nursing benefit has a maximum benefit of 40 visits, where 1 visit = 4 hours.

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Educational Services Network/Participating Provider


Diabetic Education No deductible, you pay $10 co-payment


Nutritional Counseling No deductible, you pay $10 co-payment


Surgical Services Network/Participating Provider


Newborn Circumcision No deductible, you pay 20%


Office Surgery Physician No deductible, you pay $10 co-payment


Outpatient Surgery Physician charge



Free Standing Surgical facility



Inpatient Surgery Physician charge



Outpatient Assistant Surgeon (MD only)



Inpatient Assistant Surgeon (MD only)



Medical Oral Surgery After deductible, you pay 20%


Emergency Services Network/Participating Provider


ER Facility Accident No deductible, you pay $50 co-payment


ER Facility Life Threatening



ER Facility Non-emergency



ER Physician Accident No deductible, you pay no coinsurance

No deductible, you pay no coinsurance

ER Physician Life Threatening



ER Physician Non-emergency



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Therapy Services Network/Participating Provider


Occupational Therapy other place of service



Occupational Therapy Outpatient Hospital



Physical Therapy other place of service



Physical Therapy Outpatient Hospital



Respiratory Therapy Outpatient Hospital



Respiratory Therapy other place of service



Speech Therapy other place of service



Speech Therapy Outpatient Hospital



The above benefits under Therapy Services have a limit of 45 days combined therapy.

*Rehabilitation Inpatient Facility

You pay 0% After deductible, you pay 30%

The Rehabilitation Inpatient Facility benefit has a limit of 60 days per calendar year.

Cardiac Rehabilitation Network/Participating Provider


Cardiac Rehabilitation Outpatient Hospital



Cardiac Rehabilitation other place of service



Chemotherapy Network/Participating Provider


Chemotherapy Outpatient After deductible, you pay 20%


Chemotherapy Office After deductible, you pay 20%


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Radiation Therapy Network/Participating Provider


Radiation Therapy Office After deductible, you pay 20%


Radiation Therapy OP After deductible, you pay 20%


Dialysis Network/Participating Provider


Dialysis Outpatient Hospital



Dialysis other location After deductible, you pay 20%


IV Therapy Network/Participating Provider


*IV Therapy Home After deductible, you pay 20%


*IV Therapy Hospital After deductible, you pay 20%


*IV Therapy Office After deductible, you pay 20%


Routine Services Network/Participating Provider


Routine Exam Adult No deductible, you pay $10 co-payment Limit one per year.


Routine Adult Immunization



Routine Adult Ancillary No deductible, you pay no coinsurance


Routine Child Immunization


$0 deductible; $0 coinsurance

Routine Mammogram No deductible, you pay no coinsurance


Routine Mammogram benefit is covered for individuals age 18 and over.

Routine Exam Child No deductible, you pay no coinsuranceCovered up to age 18.


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Routine Child Ancillary No deductible, you pay no coinsuranceCovered up to age 18.


HPV Vaccine No deductible, you pay $25 co-paymentHPV Vaccine is covered for individuals age 9 to 26.


Routine Gynecological Exam

No deductible, you pay $10 co-paymentBenefit is limited to one per year age 18 and over.


Routine PAP Smear No deductible, you pay no coinsuranceBenefit is limited to one per year age 18 and over.


Routine PSA Test No deductible, you pay no coinsurance


Routine Colonoscopy After deductible, you pay no coinsurance


Must have a physician recommendation.

Behavioral Health Network/Participating Provider


*Inpatient Facility (not a hospital)



*Inpatient Hospital After deductible, you pay 20%


Inpatient Facility (not a hospital) Inpatient Physician Visit



Partial Hospitalization Program or Day Treatment



Outpatient/Office No deductible; $10 copay No deductible; $10 copay

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Alcohol and Substance Abuse

Network/Participating Provider

Out-of-Network

*Substance Abuse treatment received at an Inpatient Facility (not a hospital)



*Substance Abuse treatment received in a hospital



Hospital Inpatient Physician Visit

No deductible; $10 copay No deductible; $10 copay

*Detoxification After deductible, you pay 20%


Outpatient/Office No deductible; $10 copay No deductible; $10 copay

Skilled Nursing Network/Participating Provider


Physician Visit Skilled Nursing Facility


You deductible, you pay 30%

*Skilled Nursing Inpatient Facility


You deductible, you pay 30%

Limit 45 days per year.

Miscellaneous Services Network/Participating Provider


Acupuncture No deductible, you pay 50%


Limit 10 visits per year.

Blood and Blood Products After deductible, you pay 20%


Pre-admission Testing No deductible, you pay no coinsurance


Enteral Formula (including orally administered Neocate® formula)



Must be medically necessary.

Modified Food Product No deductible, you pay 20%


Must be medically necessary.

Hospital Clinic No deductible, you pay $25 co-payment


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Urgent Care Facility No deductible, you pay $25 co-payment


Obesity Surgery After deductible, you pay 20%


Temporomandibular Joint Disorder Surgery Benefit



Prescription Drug Benefit Retail Pharmacy (30-days) Mail Order Program (90-days)

Generic Medications (Tier 1)

$5 $5

Formulary Medications (Tier 2)

$20 $10

Non-Formulary Medications (Tier 3)

$35 $15

Hearing Benefits Coverage (For Active Participants Only)Network/Participating Provider


Hearing Exam No deductible, $25 co-payment

Not covered

Hearing Aid Appliance Deductible

$25 per person Not covered

Hearing Aid Appliance Coinsurance

After hearing aid appliance deductible, Plan pays 80% of the reasonable and customary cost

Not covered

Hearing Aid Appliance Maximum Benefit

Plan pays up to $800 per person every five years

Not covered

Vision Benefits Coverage (For Active Participants and Dependents Only)

Eye Examination, Lenses, And Frames

Plan pays up to $500 per family (participants age 14 and over) per calendar yearPlan pays unlimited amount for Pediatric Vision Benefits (one examination and corrective lenses per calendar year) for children (birth to age 14), and up to $100 per set of frames per child (birth to age 14) per calendar year

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Dental Benefits Coverage (For Active Participants and Dependents Only)

Calendar Year Deductible $50 (does not apply to preventive benefits)

Calendar Year Maximum Plan pays up to $1,500 per person (age 14 and over). Covered dental services are paid according to the Dental Plan Coverage Chart on page 71.

Plan pays unlimited amount for Pediatric Dental Benefits for children (birth to age 14). Orthodontic benefits remain subject to the $2,000 lifetime maximum.

Orthodontic Deductible $50 – Once per Lifetime

Orthodontic Coinsurance You pay 50%

Orthodontic Lifetime Maximum

Plan pays up to $2,000 per child up to age 19 or per adult with TMJ

Weekly Income Accident And Sickness Benefits

Coverage (For Active Participants Only)

Weekly Benefit $150 per week (subject to FICA tax)

Maximum Benefit Period Up to 39 weeks per each period of disability.

Benefits Begin Covered accident: First day you are unable to workCovered sickness: Eighth day you are unable to work

Life Insurance Benefits Coverage (For Active Participants Only)

Benefit Amount $50,000

AD&D Insurance Benefits

Coverage (For Active Participants Only)

Principal Benefit Amount $50,000

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ConTaCT InfoRMaTIon

If You Need Information About… Contact…

Locating A Network Provider Health and Wellness Programs

Local Network - See RMSCO below.

National Network Private Health Care Systems (PHCS) Phone: 800-950-7040 Website: www.phcs.com

Medical Claims

RMSCO – Group #: SHEMW11

RMSCO Provider inquiry number: 877-300-9969

RMSCO Member service: 866-634-6509 or 315-701-9726

Web MD Payer ID #16117 for Professional Services Pre-Certifications: 866-397-9768

RMSCO, Inc.115 Continuum DriveLiverpool, NY 13088Phone: 315-448-9000Fax: 315-476-8440;Medical Claims Fax: 315-448-9132Website: www.ebsrmsco.com

Prescription Drug Program

Envision Bin #009893 Envision RX PCN #ROIRX

Specialty Pharmacy Provider (administered by Envision Rx)

Mail Order Prescription Drugs

Envision Pharmaceutical Services, Inc.2181 East Aurora Road, Suite 201Twinsburg, OH 44087Phone: 800-361-4542Fax : 330-405-8081Email: [email protected]: http://www.envisionrx.com

Costco Specialty ServicesPhone: 866-443-0060

Orchard Pharmaceutical ServicesP.O. Box 3094North Canton, OH 44720Phone: 866-909-5170 (call center)Fax: 866-909-5171Website: www.orchardrx.com

Dental Benefits Vision Benefits

Health Economics Group, Inc. (HEG)1050 University Avenue, Suite ARochester, NY 14607Phone: 585-241-9500 or 800-666-6690Fax: 585-241-9518Website: www.heginc.com

Hearing Aid Benefits Health Reimbursement Accounts (HRA) Weekly Income Accident and Sickness

Benefits Life Insurance Benefits AD&D Insurance Benefits

Sheet Metal Workers Local #46 Fund Office244 Paul RoadRochester, NY 14624Phone: 585-458-0400Fax: 585-458-5226Website: www.SMW46benefits.comEmail: [email protected]

Employee Assistance Program (EAP) Mental Health And Substance Abuse

Pre-certification

AFL-CIO EAPPhone: 585-426-5710For Pre-certification Call 866-397-9768

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elIGIbIlITY ReQUIReMenTsInitial EligibilityActive Employees

Active employees include: Employees of contributing

employers; Employees of the Health Fund

Office; and Salaried employees of the

union. You become eligible for coverage as a participant in the Plan after the minimum number of hours of contributions are made on your behalf from a contributing employer or employers. The hours requirement per month varies depending on whether you elect single or family coverage (or are an Owner-Member), as described in the table below. Note that on or after January 1, 2011, if you were employed in the Youth to Youth (YTY) or Salting Programs sponsored by SMW Local 46, you were immediately covered and credited with a maximum of 120 hours (single) or 150 hours (family) for each month you participated in either Program. In addition, hours credited under this provision will also be counted toward meeting eligibility when you work in covered employment for a contributing employer, after you stop working in either the YTY Program or the Salting Program.

Active participants are eligible for: Medical Benefits; Prescription Drug Benefits; Dental Benefits; Vision Benefits; Hearing Aid Benefits; Employee Assistance

Program (EAP); Health Reimbursement

Account (HRA); Weekly Income Accident and

Sickness Benefits; Life Insurance; and Accidental Death and

Dismemberment (AD&D) Insurance.

Dependents of active participants are eligible for: Medical Benefits; Prescription Drug Benefits; Dental Benefits; Vision Benefits; and Employee Assistance

Program.

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Initial Eligibility and Maintaining Coverage

Coverage status may change based on when hours are reported to the Fund Office. You should contact the office on a regular basis to check your eligibility status. The Fund Office will notify you when you are no longer eligible, based on contributions to the Plan and the hours in your bank.Hour Bank

If you have more than the required number of hours necessary to continue coverage for an eligibility month (80, 100 or 150), the excess hours will be credited to an hour bank on your behalf. If you are unable to meet the hours requirement to maintain coverage in a given month, you may use the credited hours in your hour bank to continue your eligibility.The hour bank works on a 14-month rolling bank during which you may accrue hours up to the maximum number of hours allowed. You may not use more than the maximum number of allowable bank hours in any 14-month period but you will not forfeit hours that remain in your bank (up to the maximum amount) even if you use the maximum period in your bank during a 14-month period.

Important: Initial Eligibility will begin immediately for individuals reported to the Fund Office as newly organized by Local Union 46 who are working in covered employment (i.e., your Employer is contributing to the Health Fund on your behalf under the terms of a collective bargaining agreement with Local Union 46). After the initial two months of eligibility granted to newly organized individuals, maintaining eligibility will be based on the regular required hours of work in covered employment as noted in the chart above.

Type of Coverage

Minimum Number of Hours Required for Initial Eligibility

When Coverage Begins

Hours Required to Maintain Coverage Each Month

Single Coverage 80 hours Coverage begins on the first day of the second month following the month in which the required contributions have been received on your behalf.

80 hours

Family Coverage(2 or more individuals enrolled for coverage)

100 hours 100 hours

Owner-Member Single or Family Coverage(2 or more individuals enrolled for coverage)

150 hours 150 hours

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1) Single Coverage: All hours in excess of the first 80 hours per month will be credited to an hour bank on your behalf. The maximum number of credited hours allowed to accrue for single coverage is 480 hours. You may use a maximum 480 bank hours in any continuous 14-month period.

2) Family Coverage (2 or more individuals enrolled for coverage): All hours in excess of the first 100 hours per month will be credited to an hour bank on your behalf. The maximum number of credited hours allowed to accrue for family coverage is 600 hours. You may use a maximum of 600 bank hours in any continuous 14-month period.

3) Owner-Member (Family or Single coverage): All hours in excess of the first 150 hours per month will be credited to an hour bank on your behalf. The maximum number of credited hours allowed to accrue for Owner-Member coverage is 900 hours. You may use a maximum of 900 bank hours in any continuous 14-month period.

The maximum amount of hours you are eligible to bank for single coverage is 480 hours or 600 hours for family coverage (900 hours for Owner-Member coverage (single or family)). Therefore, the maximum usable banking hours in any 14-month period is 480 or 600 hours (900 hours for Owner-Member).Any “newly organized” designated individual who was granted immediate eligibility would have any hours accumulated in their hour bank reduced in order to reimburse the Fund for those first two months of immediate eligibility. The “reimbursement” reduction from the hour bank will be at the required number of hours for those two months of initial eligibility (80, 100 or 150). Note: If you were employed in the Youth to Youth (YTY) or Salting Programs sponsored by SMW Local 46 on or after January 1, 2011, you were immediately covered and credited with a maximum of 120 hours (single) or 150 hours (family) for each month you participated in either Program. Hours credited under this provision will also be counted toward meeting eligibility when you work in covered employment for a contributing employer, after you stop working in either the YTY Program or the Salting Program.

If you are an active participant, you should have all of your pay stubs in case you have to verify eligibility for benefits.

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Retirees

You become eligible for retiree medical benefits under the Retiree-Only Plan if you:• Are a participant in the Health

Fund at retirement age (as defined in the Sheet Metal Workers Local 46 Pension Fund Plan Document); and

• Are eligible to receive a Regular, Disability, or Early Retirement Pension from the Sheet Metal Workers Local 46 Pension Fund.

• Maintain the necessary eligibility requirements to qualify for the Sheet Metal Workers National Pension Fund 401(h) Supplemental Medicare Benefit. (While you may not qualify for this benefit until you are eligible for Medicare, you must maintain continuous eligibility status in order to qualify for the benefit when you do become Medicare eligible).

Retirees may choose between the current retiree coverage program and COBRA Continuation Coverage for 18 months after your employment ends. The 18 month COBRA period is reduced by the number of months of free coverage you might elect.

Example

Linda is single and has 150 hours of contributions made on her behalf during the month of June. Therefore, she is eligible for coverage during July. The excess 70 hours (150 - 80) will be credited to her hour bank.

During the month of July, Linda has only 40 hours of contributions made on her behalf. Since 80 hours are required to continue coverage for August, Linda uses 40 hours from her hour bank to meet the 80 hour eligibility requirement to continue coverage leaving her with 30 hours remaining in her bank.

During the month of August, Linda does not have any hours of contributions made on her behalf. Since 80 hours are required to continue coverage for September, Linda uses the 30 hours remaining in her hour bank and must self-pay the remaining 50 hours to meet the 80 hour eligibility requirement in order to continue coverage.

After the six-month period of free coverage ends, retired employees and their dependents may be eligible under the retiree medical benefits program for: Medical Subsidy; and Prescription Drug Benefits. Please note: Retirees currently eligible for and enrolled in the $1,500 prescription drug benefit will continue to have this benefit. However, effective January 1, 2007, this benefit will no longer be available to retirees who have not yet enrolled. For retirees who continue to be eligible for the prescription drug benefit, the premium will be $10/month per person.

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After you retire, you will be covered for the benefits available to active participants who retire on an early, reduced or disability pension, free of charge, for six months from the date of your retirement. After the six-month period of free coverage ends, you may select a qualified community health plan from the current options available. In order to qualify you must live in the geographic limitations as outlined by the HMO or PPO Provider(s). Should you elect this option you will no longer be eligible for dental, vision, weekly income accident and sickness, life insurance, or accidental death and dismemberment insurance benefits. If you are Medicare eligible, you have the option to elect one of the available Group Medicare Advantage plans.If you are a participant in the Health Fund and are eligible to retire on a disability pension, you will be covered as outlined above if you have not received Medicare – see below for how you will be covered if you have received Medicare. Please note that if you have received Medicare, the Health Fund will pay 100% of the Medicare Subsidy premium for the first six months. If you are an active participant, and lose eligibility for active coverage due to retirement but do not meet the eligibility requirements or choose not to elect retiree coverage, you may be eligible for COBRA Continuation Coverage. COBRA Continuation Coverage provides the opportunity to elect the same benefits as active coverage except that no benefits are provided for weekly income accident and sickness, life insurance, or accidental death and dismemberment insurance.Retiree Coverage Subsidy

To assist with the cost of retiree medical coverage, the Fund provides a subsidy for retiree premiums for single and family coverage provided to the retiree by a separate insurance company. To be eligible for this subsidy, you must purchase your coverage through the Fund Office and have the monthly premiums automatically deducted from your Local 46 Pension Payments. You must also be eligible to receive the Sheet Metal Workers National Pension Fund 401(h) Supplemental Medicare benefit (“401(h) benefit”). If you are not eligible to receive or do not maintain the necessary eligibility requirements of the 401(h) benefit, you will not be eligible to receive the Sheet Metal Workers Local 46 retiree subsidy. Because retiree coverage subsidies change from time to time, please contact the Fund Office for information on the current retiree subsidy in effect for both Pre-Medicare-eligible retirees (under age 65) and Medicare-eligible retirees (over age 65).

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Retiree Benefits After a Break-in-Coverage

Retirees are allowed to reestablish eligibility (provided they meet the eligibility rules described above) for coverage after a break in coverage with the exception of the $1,500 prescription drug benefit. Retired individuals who have a break in coverage are ineligible for reestablishment of the prescription drug benefit once they drop the coverage.

Dependents

Eligible dependents include: Your legal spouse (unless legally divorced); Your child(ren), whether married or unmarried, up to age 26. A “child”

may be your: • Son or daughter. Proof of relationship and age will be required. • Legally adopted child, including a child placed with you for

adoption. Proof of adoption or placement for adoption and age will be required. “Placed for adoption” means the assumption and retention by you (the employee or participant) of a legal obligation for total or partial support of such child in anticipation of adoption of such child. The child’s placement for adoption terminates upon the termination of such legal obligation.

• Stepson or stepdaughter (proof of relationship and age will be required).

• Eligible foster child, lawfully placed with the employee or participant by an authorized placement agency or by judgment, decree, or other order of any court of competent jurisdiction. Proof of relationship and age will be required.

• A child named as an “alternate recipient” under a Qualified Medical Child Support Order. Proof of relationship and age will be required.

An unmarried child over age 26 who is permanently and totally disabled. For an unmarried child who is permanently and totally disabled to be covered beyond age 26, the child must:

• be incapable of self-sustaining employment due to a total and permanent mental or physical disability;

• have been so incapacitated while covered under the Plan and before reaching age 18 (if you, the participant, remain covered under the Plan);

• live with you for more than one-half of the calendar year and not provide over one-half of his or her own support for the taxable year.

Important: Please note that the Trustees have determined that the benefits offered to retirees are considered to be a Retiree-Only Plan.

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No coverage will be provided for a child who is permanently and totally disabled after age 18. To cover a permanently and totally disabled child under this provision, you must provide proof of the incapacity to the Fund Office within 30 days after coverage would otherwise end. Additional proof will be required at the Fund’s discretion.

Except as provided for a child who is totally and permanently disabled, coverage will terminate for a Dependent Child on the last day of the month in which the child turns age 26.For Plan years beginning prior to July 1, 2014, an adult Dependent Child is not eligible for coverage under the Plan if such adult child is eligible for coverage under another employer-sponsored health plan other than a group health plan of a parent. Children and spouses of a Dependent Child are NOT covered under the Plan. No one will be eligible as a dependent while covered as a member or while in military service.You must notify the Fund Office promptly when you add a new dependent or when a dependent no longer is considered a dependent under the Plan. Forms are available for reporting changes in family status by contacting the Fund Office. Claims will not be paid for any dependents until you have enrolled them.Note: If at the time of the birth of a child you wish to claim as a dependent, you and your spouse maintain separate and independent domiciles, the Fund Office will assume that the child is not your dependent unless proof of paternity can be established. Until paternity is established, no costs arising from the birth of the child, including any applicable maternity benefits, will be covered under the Plan.

The Fund Office will accept a copy of any of the following documents as proof of dependent status: Marriage: Copy of the certified marriage certificate. Birth: Copy of the certified birth certificate. Adoption or placement for adoption: Court order paper signed by

the judge. Disabled Dependent Child: Current written statement from the

child’s physician indicating the child’s diagnoses that are the basis for the physician’s assessment that the child is currently mentally or physically handicapped (as that term is defined by the Plan) and is incapable of self-sustaining employment as a result of that handicap; and dependent relies on you and/or your spouse for support and maintenance. Proof of support and maintenance (for example, a copy of your income tax return) showing you claim the child as a dependent on IRS tax forms in compliance with the IRS Code 152 (a) may be required.

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When Dependent Coverage Begins

Dependent coverage begins on the same date your eligibility begins, or if a later date, the date you acquire an eligible dependent (and you complete, sign and submit an enrollment form to the Fund Office) or as specified in a Qualified Medical Child Support Order. If you have a dependent child(ren) covered under this Plan, they may be eligible for coverage under any other qualified group health plan or a government-sponsored program such as the Federal State Children’s Health Insurance Program (SCHIP) or the New York Child Health Plus Program. You may disenroll your child(ren) from coverage under this Plan and enroll them in such a program. Contact the Fund Office to request a Disenrollment Form.

Special EnrollmentIf you or your eligible dependent declined coverage under this Plan because you have other health coverage, you may be eligible for a special enrollment if you: Lose the other health coverage; or Acquire a dependent through marriage, birth, adoption, or placement

for adoption.For special enrollments due to loss of other coverage, you or your dependent must: Otherwise be eligible for coverage; and When coverage under this Plan was declined, you or your dependent

must have been covered under another group plan or must have had other health coverage, and enrollment must have been declined on the enrollment form.

If the other health coverage was COBRA Continuation Coverage, a special enrollment is only available after the COBRA Continuation Coverage has been exhausted. If the other coverage is not COBRA Continuation Coverage, a special enrollment is available if you or your dependent is no longer eligible for coverage or employer contributions for the other coverage. If you decline enrollment for yourself or your dependents (including your spouse) because of other health insurance coverage, you may in the future be able to enroll yourself or your dependents in this plan, provided that you request enrollment within 30 days after your other coverage ends. In addition, if you have a new dependent as a result of marriage, birth, adoption or placement for adoption, you may be able to enroll yourself and your dependents, provided that you request enrollment within 30 days after the marriage, birth, adoption or placement for adoption.

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Coverage of a newborn or newly adopted dependent child who is enrolled within 31 days after birth will become effective as of the date of birth. Coverage of a newly adopted dependent child who is enrolled more than 31 days after birth, but within 31 days after the child’s adoption or placement for adoption, will become effective as of the date of the child’s adoption or placement for adoption, whichever occurs first. Coverage of a newly adopted dependent child who is enrolled more than 31 days after birth, and more than 31 days after the child’s adoption or placement for adoption, will become effective on the date of placement as long as you are responsible for health care coverage and the child meets the Plan’s definition of a dependent. Charges for a newborn child’s routine nursery care and an in-hospital physical examination are covered by the Plan. To enroll your new dependent, you will need to complete, sign, and submit an enrollment form to the Fund Office. You will also need to provide proof of dependent status. Special enrollments are not available for loss of coverage due to failure to pay premiums, fraud, or misrepresentation. To be eligible for a special enrollment, you must notify the Fund Office within 31 days of the loss of other coverage or the date of marriage, adoption, or placement for adoption.

Pre-Existing ConditionsA pre-existing condition may affect your medical coverage. A pre-existing condition is any illness or injury (whether physical or mental) regardless of its cause, for which medical advice, diagnosis, care, or treatment was recommended or received within the six-month period that ends on your or your dependent’s enrollment date. If you or your dependent have a pre-existing condition, coverage for medical care or treatment in connection with a condition, injury, or illness that exists when you and your dependents become eligible for coverage is subject to a waiting period of one year (subject to the requirements of the Health Insurance Portability and Accountability Act).The pre-existing condition waiting period is reduced by any coverage (prior creditable coverage) you or your dependent had under a previous health care plan, provided there is no more than 63 days between the last day of coverage under the prior plan and the first day of eligibility for coverage under this Plan. A leave under the Family and Medical Leave Act will not be counted as a break in coverage. You may have to submit a certification of the period of creditable coverage under any other health care plan or insurance policy to reduce or eliminate the one-year period of exclusion of coverage.

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Extended Benefits During Disability

If you become totally disabled while active coverage was in effect and are collecting weekly income accident and sickness benefits under the Plan, or workers’ compensation benefits, your coverage may be extended up to nine months. At the end of that nine-month period, you may be eligible to continue your coverage by applying the credited hours in your hour bank. When this combined extended period ends, you may elect to self-pay or you may elect COBRA Continuation Coverage. Please note that the maximum COBRA period will be reduced by the number of months you were covered under the extended benefits provided by the hour bank and the disability benefit.Retirees

Your eligibility for retiree coverage will continue as long as the required self-payment is received on your behalf. You must also be able to receive (when eligible) the 401(h) Medicare subsidy benefit as administered through the Sheet Metal Workers National Pension Fund. If you are not yet Medicare eligible, you must maintain the necessary requirements as established by that Fund. Once eligible, you must apply for, and the Fund must receive on your behalf, the monthly benefit payment. If you return to work as an active participant and you become eligible for active coverage, you will have the same benefits as an active participant. Once you are no longer eligible as an active participant, you will be reinstated into the retiree medical benefits program, provided you submit the payments in a timely manner.Dependents

Your dependents’ coverage will continue as long as you remain eligible for coverage and your dependent(s) continues to meet the Plan’s definition of a dependent.

IMPORTANT: The pre-existing condition coverage limitation does not apply to:• Pregnancy;• Newborn children who are enrolled for coverage under this Plan

within 31 days of birth; and• Adopted children who are enrolled within 31 days of adoption or

placement for adoption.Also note that the limitation does not apply to children under age 19 (effective July 1, 2011). In addition, the pre-existing condition limitation will be eliminated in its entirety as of July 1, 2014.

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When Eligibility EndsWhen your coverage ends, you will be provided with certification of your length of coverage under the Plan. This may help reduce or eliminate any pre-existing condition limitation under a new group medical plan.Active Participants

When your or your eligible dependents’ coverage ends, you, or your dependent(s) may be eligible to continue coverage by making monthly self-payments or electing COBRA Continuation Coverage (see page 47).Coverage ends on the earliest of the following: The date you die; The end of any coverage month in which the hours you worked (or

banked during previous eligibility months) are not enough to continue eligibility;

The date your employer does not make the required contributions on your behalf;

If you are making self-payments for self-pay continuation coverage, at the end of the calendar month for which you were entitled to make and did not make a correct and timely self-payment; or

If you are making COBRA self-payments, at the end of the last day that you are entitled to COBRA Continuation Coverage or the end of the calendar month during which a correct and on-time COBRA payment was not received; or

The day the Plan ends.To determine whether or not a termination of eligibility has occurred, your entitlement to coverage will not be reduced by a period of leave under the Family Medical and Leave Act. If your eligibility ends because you are no longer working for a contributing employer, you may also continue your eligibility for coverage by making monthly self-payments for yourself and your dependents. You have two options to continue coverage, which include: Making self-payments for self-pay continuation coverage for up

to nine months. Then, if you do not meet the continuing eligibility requirements, you may be entitled to extend coverage by making COBRA Continuation Coverage self-payments, provided that you make a timely election for COBRA Continuation Coverage (see page 33); or

Electing to make COBRA Continuation Coverage self-payments (see page 47).

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If you are eligible for COBRA Continuation Coverage, but are also eligible for extended coverage using your hours bank as described on page 51, COBRA Continuation Coverage (if elected) will not begin until you have used all of your hours bank.

Self-Pay ProgramAs an alternative to COBRA Continuation Coverage, you can elect to participate in the self-pay program. You may elect to contribute at the current hourly contribution rate times the required number of minimum monthly hours. This coverage is available only if you remain available to work in covered employment with a contributing employer and only if you have been continuously covered under this Plan for at least one year. Self-pay coverage may continue for up to nine months. After the nine-month period, you may elect COBRA Continuation Coverage. However, the maximum COBRA period will be reduced by the number of months you were covered under the self-pay program. Regular self-payments will continue all of your benefits, except weekly income accident and sickness benefits and HRA deposits. You must elect to make regular self-payments in writing within 30 days following the date you would otherwise lose your eligibility. The first self-payment is due the first day of each month for which eligibility is continued. If you fail to make a self-payment, it cannot be made up, coverage will end at the end of the month.A self-payment also continues coverage for your eligible dependents who were covered under the Plan on the day your eligibility ended.Self-payment continuation coverage ends on the earlier of: The last day of the month following the month for which you have

made nine months of self-payments; The date you again qualify for coverage under the Plan by working for

a contributing employer; The last day of the month preceding the month you do not make a

required self-payment; or The date the Plan ends.Your dependents’ coverage will also end on the date your coverage ends.After your self-payment continuation coverage ends, you may be able to elect COBRA Continuation Coverage, (see page 47). It is important that you elect COBRA Continuation Coverage in a timely manner; otherwise, your coverage will end.If you are eligible for continued coverage based on the Family and Medical Leave Act (FMLA) or the Uniform Services Employment and Reemployment Rights Act of 1994 (USERRA), you may continue coverage as required by FMLA and USERRA if you agree in writing and make the required payments on a timely basis.

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Retirees

Your eligibility for retiree coverage will end on the earliest of the following: The date you die; The day the Plan ends; The last day of the month in which your self-payment is not received; or The date you no longer meet the eligibility requirements for retiree

coverage.Dependents

Your dependent’s eligibility will end on the earliest of:1. The date your eligibility under the Plan ends;2. The date your dependent dies;3. The date the dependent no longer meets the Plan’s definition of a

dependent (see page 27 for definition of a dependent);4. The date the Plan is modified to end dependent benefits;5. The date the Plan ends;6. For a covered spouse, the day you become legally divorced;7. The date specified in a Qualified Medical Child Support Order; or8. If your dependent has COBRA Continuation Coverage, at the end

of the last day of the period in which your dependent’s COBRA Continuation Coverage period ends.

If your eligible dependent’s coverage ends, your eligible dependent may elect COBRA Continuation Coverage as described on page 48.If a dependent loses eligibility due to your death or your divorce from your spouse, he/she may choose free coverage and COBRA Continuation Coverage. Dependent benefits may continue at no charge for six-consecutive months after the death of an eligible employee provided that the spouse does not remarry during that time, or the dependent may elect to pay the COBRA Continuation Coverage rate and continue coverage for 36 months after the death or divorce (see page 48).

Dependents of Retirees: Please note that in addition to retiree dependents’ eligibility ending on the earliest of the dates listed in 1 through 8 above, eligibility will also end on the date you no longer meet the eligibility requirements for Retiree Coverage.

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Reinstatement Of EligibilityIf your eligibility ends under the active Plan and you return to work for a contributing employer, you must satisfy initial eligibility requirements as described in the Initial Eligibility section on page 22.If you decline or disenroll from retiree coverage, coverage may be reinstated at a later date, provided you are receiving a monthly pension check from which premiums can be deducted and you maintain the eligibility requirements of the Sheet Metal Workers National Pension Fund 401(h) Supplemental Medicare benefit.

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lIfe eVenTs aT-a-GlanCeYour benefits are designed to meet your needs at different stages of your life. This section describes how your Plan benefits are affected when different lifestyle changes occur after you become a participant.

Getting MarriedWhen you get married, your spouse is eligible for medical, prescription drug, dental, vision, and EAP benefits if you are an active participant; or, medical and prescription drug coverage if you are an early retiree; or, the retiree medical subsidy if you are eligible. Once you provide any required information, coverage for your spouse begins on the date of your marriage. At this time, you also may want to update your beneficiary information for your life insurance and AD&D insurance benefits. You must notify the Fund Office within 30 days of the date of your marriage.If your spouse is covered under another group medical plan, you must report the other coverage to the Fund Office. The amount of benefits payable under this Plan will be coordinated with your spouse’s other coverage.

Adding A Child Your natural child will be eligible for coverage on his or her date of birth. If you have guardianship for a child, adopt a child or have a child placed with you for adoption, coverage will be effective on the date of placement as long as the child meets the Plan’s definition of a dependent. For more specific details on adoption, please see the Special Enrollment section on page 29. Stepchild(ren) are eligible for coverage on the date of your marriage to the child(ren)’s natural parent.

When you get married, provide the Fund Office with: A copy of your marriage

certificate. Your spouse’s date of birth. A copy of your spouse’s

medical insurance information, if he or she is covered under another plan.

When you add a child, provide the Fund Office with: The birth date, effective date

of adoption or placement for adoption, or the date of your marriage (for stepchildren).

When you add a stepchild, you must submit a copy of your spouse’s divorce decree to establish if there is other coverage for that child.

A copy of the birth certificate, adoption papers, court order, or marriage certificate (for stepchildren).

A copy of your child’s other medical insurance information, if he or she is covered under another plan.

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Getting DivorcedIf you and your spouse divorce, your spouse will no longer be eligible for coverage as a dependent under the Plan. However, your spouse may elect to continue coverage under COBRA for up to 36 months. You or your spouse must notify the Fund Office within 60 days of the divorce for your spouse to obtain COBRA Continuation Coverage. At this time, you may also want to review your beneficiary designation for your life insurance and AD&D insurance benefits, if eligible.Qualified Medical Child Support Orders (QMCSOs)

The Plan recognizes Qualified Medical Child Support Orders (QMCSOs) and provides benefits for eligible dependents, as determined by the order. A Qualified Medical Child Support Order (QMCSO) is a court order or administrative order, which has the force of law pursuant to the state’s administrative procedure, relating to child support that provides for a child’s coverage under the Plan. A copy of the Plan’s QMCSO qualification procedures and a sample is available, free of charge, at the Fund Office.According to federal law, a Qualified Medical Child Support Order (QMCSO), is a child support order of a court or state administrative agency that usually results from a divorce or legal separation, that has been received by the Plan, and that: Designates one parent to pay for a child’s health plan coverage; Indicates the name and last known address of the parent required to

pay for the coverage and the name and mailing address of each child covered by the QMCSO;

Contains a reasonable description of the type of coverage to be provided under the designated parent’s health care plan or the manner in which such type of coverage is to be determined;

If you divorce, provide the Fund Office with: A copy of your divorce decree. If you have children for whom

you do not have custody, a copy of any QMCSO.

If your spouse wants to continue coverage, he or she must: Contact the Fund Office; and Enroll for COBRA

Continuation Coverage.

The Trustees may require proof of dependent status including birth certificates, guardianship papers, marriage certificates, adoption decrees, paternity decrees, support agreements, divorce decrees, federal tax returns, or financial dependency.

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States the period for which the QMCSO applies; and Identifies each health care plan to which the QMCSO applies.An order is not a QMCSO if it requires the Plan to provide any type or form of benefit or any option that the Plan does not otherwise provide, or if it requires someone who is not covered by the Plan to provide coverage for a dependent child, except as required by a state’s Medicaid-related child support laws. For a state administrative agency order to be a QMCSO, state statutory law must provide that the order will have the force and effect of law, and the order must be issued through an administrative process established by state law.If a court or state administrative agency has issued an order for health care coverage for any of your dependent children, the Plan Administrator or its designee will determine if that order is a QMCSO as defined by federal law, and that determination will be binding on you, the other parent, the child and any other party acting on behalf of the child. If an order is determined to be a QMCSO, and if you are covered by the Plan, the Plan Administrator or its designee will so notify the parents and each child, and advise them of the Plan’s procedures that must be followed to provide coverage of the dependent child(ren).If you are a participant in the Plan, the QMCSO may require the Plan to provide coverage for your dependent child(ren) and to accept contributions for that coverage from a parent who is not a Plan member. The Plan will allow you to enroll the dependent child(ren) specified by the QMCSO from either you or the custodial parent. Coverage of the dependent child(ren) will become effective as of the date the enrollment is received by the Plan, and will be subject to all terms and provisions of the Plan.If you are not a participant in the Plan at the time the QMCSO is received and the QMCSO orders you to provide coverage for your dependent child(ren), the Plan will allow you to enroll yourself and the dependent child(ren) specified by the QMCSO only when you become eligible for benefits by satisfying the eligibility rules. Your coverage and coverage of your dependent child(ren) will become effective as of the date you become eligible for coverage and will be subject to all terms and provisions of the Plan.Coverage of a dependent child under a QMCSO will end when your coverage ends for any reason, subject to the dependent child’s right to elect COBRA Continuation Coverage if that right applies.If the order is determined to be a QMCSO, the Fund Office will treat the child(ren) entitled to benefits from the Fund as provided in the order. Any payment for benefits by the Fund under a QMCSO in reimbursement for expenses paid by the child(ren) or the child’s(ren’s) custodial parent or legal guardian will be made to the child’s(ren’s) custodial parent or legal guardian.

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Neither the Fund, its Administrators, fiduciaries, employees, nor agents will be liable for any loss caused by a delay in determining whether an order is a QMCSO or for any payments made or withheld as a result of the determination.

Entering The Uniformed ServicesIf you are called into the uniformed services (active duty or inactive duty training), you may elect to continue your health coverage, as required by the Uniformed Services Employment and Reemployment Rights Act of 1994 (USERRA). Health coverage includes medical, prescription drug, dental, vision, and hearing aid benefits provided under the Plan.If you are on active duty for 31 days or less, you will continue to receive health care coverage for up to 31 days, in accordance with the Uniformed Services Employment and Reemployment Rights Act of 1994 (USERRA).If you are on active duty for more than 31 days, you can continue coverage for you and your dependents at your own expense for up to 24 months. In addition, your dependent(s) may be eligible for health care coverage under TRICARE. This Plan will coordinate coverage with TRICARE.Service in the uniformed services means the performance of duty on a voluntary or involuntary basis in a uniformed service under competent authority and includes: Active duty; Active duty for training; Initial active duty for training; Inactive duty training; Full-time national guard duty; and A period for which you are absent from a position of employment for an examination to determine your fitness for duty.To continue coverage, you or your dependent must pay the required self-payment.

If you are called to military service: Notify your employer and the

Fund Office. Make self-payments if

you wish to continue your coverage.

Uniformed services means the: United States Armed Forces; Army National Guard; Air National Guard when

engaged in active duty for training, inactive duty training or full-time National Guard duty;

Commissioned corps of the Public Health Service; and

Any other category of persons designated by the President in time of war or emergency.

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Your coverage will continue until the earlier of: The end of the period during

which you are eligible to apply for reemployment in accordance with USERRA; or

24 consecutive months after your coverage would have otherwise ended.

However, your coverage will end the earliest day: Your coverage would

otherwise end as described above;

Your former employer ceases to provide any health plan coverage to any employee;

Your self-payment is due and unpaid; or You again become covered under the Plan.Your coverage ends on the first day of the month following the date you enter uniformed services and elect not to continue coverage. Your eligible dependents may continue coverage under the Plan by electing and making self-payments for COBRA Continuation Coverage.You need to notify the Fund Office when you enter the military and when you return to covered employment. For more information about continuing coverage under USERRA, contact the Fund Office.Reinstating Your Coverage

Following discharge from military service, you may apply for reemployment with your former employer in accordance with USERRA. Reemployment includes the right to elect reinstatement in the existing health coverage provided by your employer. According to USERRA guidelines, reemployment and reinstatement deadlines are based on your length of military service.When you are discharged or released from military service that was: Less than 31 days, you have one day after discharge (allowing eight

hours for travel) to return to work for a contributing employer; More than 30 days but less than 181 days, you have up to 14 days after

discharge to return to work for a contributing employer; or More than 180 days, you have up to 90 days after discharge to return

to work for contributing employer.

Reemployment

Following your discharge from service, you may be eligible to apply for reemployment with your former employer in accordance with USERRA. Such reemployment includes your right to elect reinstatement in health care coverage provided by your employer.

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When you are discharged, if you are hospitalized or recovering from an illness or injury that was incurred during your military service, you have until the end of the period that is necessary for you to recover to return to or make yourself available for work for a contributing employer. The Fund will maintain your prior eligibility status until the end of the leave, provided your employer properly grants the leave under the federal law and makes the required notification and payment to the Fund. If you do not return to work within the required timeframes, you must again meet the initial eligibility requirements to be eligible for coverage.If you have any questions about taking a leave, please speak directly with your employer. If you have any questions about how a leave or absence affects your benefits, please contact the Fund Office.

Losing EligibilityA detailed description of the requirements needed to continue eligibility is shown on page 23. If you are an active participant and your eligibility ends under the active Plan, you can become eligible again by meeting the initial eligibility requirements as described on page 22. When your coverage ends, you may be eligible to continue coverage by using your hour bank, making monthly self-payments for self-pay continuation coverage, or self-paying for COBRA Continuation Coverage (see page 47).

Child Losing EligibilityIn general, your child is no longer eligible for coverage when he or she reaches age 26. Coverage ends for a child age 26 and over who was eligible because of being totally and permanently disabled when the child: (i) is no longer so disabled; (ii) marries; (iii) is no longer dependent on you for more than one-half of his or her support or no longer lives with you for one-half of the year; or (iv) when you fail to submit the necessary documentation to the Fund Office. You must notify the Fund Office within 60 days of when your child is no longer eligible for coverage. Your child may elect to continue coverage by making COBRA self-payments for up to 36 months. See the COBRA Continuation Coverage section for details on how COBRA works.

If your child is no longer eligible for coverage under the Plan, he or she can elect to continue coverage under COBRA Continuation Coverage. Within 60 days of losing eligibility for coverage, he or she must: Contact the Fund Office. Enroll for COBRA

Continuation Coverage if he or she plans to continue coverage under the Plan.

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Coverage for you and/or your dependents may be terminated retroactively (rescinded) due to any of the following: in cases of fraud or intentional misrepresentation (in such cases, you

will be provided with 30-day notice) due to non-payment of premiums (including COBRA premiums)Failure to provide complete, updated and accurate information to the Fund Office on a timely basis regarding your marital status, employment status of a spouse or child, or the existence of other coverage (or, in the case of adult children, eligibility for other employer-sponsored coverage) constitutes intentional misrepresentation of material fact to the Plan.

When You Are Out Of Work Due To Disability (For Active Participants)If you are out of work due to either a work-related disability or a non-work related disability, you may receive weekly income accident and sickness benefits until you recover or receive the maximum number of weeks of benefits for one period of disability, whichever occurs first. See the Eligibility sub-section entitled “Extended Benefits During Disability” for information regarding your coverage under the Plan while you are out due to a disability. The Fund requires proof that you are under the care of a physician to be eligible for weekly income accident and sickness benefits. The Fund also has the right to require you to submit to a medical examination.If you become disabled due to an injury that is covered by AD&D insurance, you may also be eligible for an AD&D insurance benefit.If you are out of work due to a work-related disability, you may be eligible for workers’ compensation benefits. Contact your local or state workers’ compensation office. After your disability ends, you must notify the Fund Office or your Business Agent.

When you are out of work due to a non-work related disability: Notify your employer and the

Fund Office. Provide the Fund Office with

proof of your disability. Apply for weekly income

accident and sickness benefits.When you are out of work due to a work-related disability: Notify your employer and the

Fund Office. Apply for weekly income

accident and sickness benefits. Contact your local workers’

compensation office and apply for workers’ compensation benefits.

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In The Event Of Your Death (For Active Participants)If you are an active participant and eligible for coverage on the date of your death, your beneficiary will receive a life insurance benefit (and an AD&D insurance benefit, for active participants only, if your death is caused by an accident). See pages 81 and 83 for more information about life insurance and AD&D insurance benefits.If your dependent loses eligibility due to your death, he/she may choose free coverage and COBRA Continuation Coverage. Dependent benefits may continue at no charge for six-consecutive months after your death provided that your spouse does not remarry during that time, or your dependent may elect to pay the COBRA Continuation Coverage rate and continue coverage for 36 months after your death (see page 48).Retirees

If you are a retiree and you elected subsidized coverage for your dependent, your dependent’s coverage will continue until the last day of the month in which you die. Your surviving dependent can continue subsidized coverage through self-payments if they are receiving a survivor’s pension from the Sheet Metal Workers Local 46 Pension Plan. If you have elected any other form of pension and you were enrolled in the Plan at the time of your death, your surviving dependent can continue un-subsidized coverage through self-payments. If the self-payments are discontinued for any month, or if your dependent does not elect to make self-payments when first eligible, your dependent will not be eligible to continue coverage by making self-payments. See page 33 for more information.Your dependent may continue health care coverage for up to 36 months by electing COBRA Continuation Coverage and making the necessary self-payments (see page 48).

In the event of your death, your spouse or beneficiary should: Notify the Fund Office. Provide the Fund Office

with a copy of your death certificate.

Apply for your life insurance (and AD&D insurance, if applicable).

If your dependents want to continue coverage under the Plan, enroll for self-pay continuation coverage or COBRA Continuation Coverage.

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Keep Plan Informed Of Address ChangesTo protect your family’s rights, you should keep the Fund Office informed of any changes in the addresses of you and any family members. You should also keep a copy, for your records, of any notices you send to the Fund Office.

Family And Medical Leave Act (For Active Participants)The Family and Medical Leave Act (FMLA) of 1993 allows you to take up to 12 weeks of unpaid leave for your serious illness, to care for a child after the birth, adoption, or placement for adoption of a child, or to care for your seriously ill spouse, parent, or child. The Family and Medical Leave Act requires employers to maintain health coverage under any health plan for the length of a leave as if you were still employed. In addition, the Act states that if you take a family or medical leave, you may not lose any benefits that you had accrued before the leave.To be eligible for FMLA benefits, you must: Work for a contributing employer; Have worked for the employer for at least 12 months; Have worked at least 1,250 hours over the previous 12 months; and Work at a location where at least 50 employees are employed by the

employer within 75 miles.If you and your employer have a dispute over your eligibility and coverage under the Family and Medical Leave Act, your benefits will be suspended pending resolution of the dispute. The Trustees have no direct role in resolving such disputes.Leave Entitlement

An employer covered under FMLA may grant you up to a total of 12 weeks of unpaid leave during any 12-month period for one or more of the following reasons: For the birth or placement of

a child for adoption or foster care;

To care for an immediate family member (spouse, child, or parent) with a serious health condition; or

To take medical leave when you are unable to work because of a serious health condition.

Leave for birth or adoption (including foster care placement) must conclude within 12 months of the birth or placement.

If you and your spouse both work for the same employer, you and your spouse are eligible for a combined total of 12 weeks of leave during a 12-month period.

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Spouses employed by the same employer are entitled to a combined total of 12 weeks of family leave for the birth, placement of a child for adoption, foster care, or to care for a child or parent (but not parent-in-law) who has a serious health condition.Under some circumstances, you may take FMLA leave intermittently – which means taking leave in blocks of time, or by reducing your normal weekly or daily work schedule. Intermittent FMLA leave for birth or adoption or foster care placement requires your employer’s approval. FMLA leave may be taken intermittently whenever it is medically necessary to care for a family member’s serious health condition, or because you have a serious health condition and are unable to work.Maintenance Of Health Benefits

A covered employer is required to maintain the same health coverage for you on FMLA leave as the coverage that was provided before the leave was taken and under the same terms as if you had continued work. Therefore, an employer covered under FMLA must continue to contribute on your behalf while you are on FMLA leave as though you had been continuously employed.Returning To Work

Upon return from FMLA leave, you must be restored to your original job, or to an equivalent job with equivalent pay, benefits, and other employment terms and conditions. In addition, your use of FMLA leave cannot result in the loss of benefits that you earned or were entitled to before using FMLA leave.Termination Of FMLA Health Care Coverage

Health care coverage during FMLA leave ends on the earliest of the following dates: When you return to work; When 12 weeks of leave ends; or Failure of the employer to remit contributions to the Fund.FMLA And Other Benefits

You will not accrue additional benefits during an unpaid FMLA leave, but you cannot lose benefits you had accrued before your leave. Welfare benefits other than health care must be reinstated when you return to work without any new conditions or the need to meet eligibility requirements.How FMLA Works With COBRA

Taking a family or medical leave is not itself considered a COBRA qualifying event. If you return from leave within 12 weeks, there will not be a loss of coverage.

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If you do not return from leave, that is considered a COBRA qualifying event (a reduction in hours causing a loss of coverage). You will have up to 12 weeks of maintained health care coverage during FMLA leave and an additional 18 months (or 36 months, if applicable) of continued coverage under COBRA.Taking An FMLA Leave

If you need to take an FMLA leave, your employer may require you to provide: 30-day advance notice of the need to take the FMLA leave, if the need

is foreseeable; Medical certifications supporting the need for leave due to a serious

health condition affecting you or an immediate family member; Second or third medical opinions and periodic recertifications (at your

employer’s expense); and Periodic reports during FMLA leave regarding your status and intent

to return to work.When leave is needed to care for an immediate family member or your own illness, and is for planned medical treatment, you must schedule treatment so that it will not unnecessarily disrupt your employer’s operation. You and your employer must certify to the Trustees that you have been granted leave under the Family and Medical Leave Act.

When You RetireCoverage for you and your dependents will end under the active Plan when you retire. However, if you meet certain eligibility requirements, you may eligible for six months of free active coverage. When you retire, you may be eligible for coverage under the retiree medical benefits program if you meet the eligibility requirements described on page 25. Please note that the Trustees have determined that the benefits offered to retirees are considered to be a Retiree-Only Plan.There are two programs of medical benefits for retirees – for retirees and dependents not eligible for Medicare and for retirees and dependents eligible for Medicare. Each program has different medical plans to choose from. Currently each program has several medical plan options available.

When you retire: Notify the Fund Office in

advance of your retirement. Apply for retiree benefits if

you are eligible. If you want to continue

coverage under the Plan, enroll for COBRA Continuation Coverage, unless you qualify for retiree coverage.

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In general, benefits under the retiree program may not include hearing aid coverage, weekly income accident and sickness, life insurance, or accidental death and dismemberment insurance benefits. The dental and vision benefits (if available) may be limited. If you are an active participant, and lose eligibility for active coverage due to retirement and do not meet the eligibility requirements for retiree coverage, you may be eligible for COBRA Continuation Coverage.

When You Leave Covered EmploymentCOBRA Continuation Coverage – In General

The right to COBRA Continuation Coverage was created by a federal law, the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA). Under COBRA, you, your spouse and your other dependents are entitled to elect to continue coverage on a self-pay basis under the Plan under certain circumstances if coverage would otherwise end. There are two parts to your coverage under the Plan:• Your insured health benefits; and• Your Health Reimbursement Account (HRA) benefits.You, your spouse and your dependents may elect COBRA Continuation Coverage for the health insurance benefits only; or, for both the health insurance benefits and the Health Reimbursement Account benefits. Employees Who Are Eligible for COBRA Continuation Coverage

If you are covered by the Plan as an employee, you may elect COBRA Continuation Coverage when your coverage would otherwise end as a result of termination of employment (other than for gross misconduct) or because you no longer meet the Plan’s eligibility requirements due to a reduction in hours worked, including a strike, walkout or layoff. You are not required to elect COBRA Continuation Coverage or pay COBRA premiums in order to continue to receive reimbursements from your HRA. You will continue to have access to and receive reimbursements from your HRA as long as the account balance is sufficient to cover your claims and exceeds the minimum required account balance. Note: your HRA can be used to pay the required COBRA premiums for Health Fund benefits.

When your COBRA Continuation Coverage ends, you will be provided with certification of your length of coverage under the Plan. This may help reduce or eliminate any pre-existing condition limitation under a new group medical plan.

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Spouse Eligibility for COBRA Continuation Coverage

Your spouse may elect COBRA Continuation Coverage in the event:1. You die;2. Your employment ends for any reason, other than gross misconduct; 3. You no longer meet the Plan’s eligibility requirements as a result of a

reduction in hours worked (including a strike, walkout or layoff ); 4. You become entitled to and enroll in Medicare Part A or Part B, or

both; 5. You get divorced or are granted a judicial order of legal separation.If your spouse has a COBRA qualifying event as listed in 1 – 4 above, he or she is not required to elect COBRA Continuation Coverage or pay COBRA premiums to continue to receive reimbursements from your HRA. Your spouse will continue to have access to and receive reimbursements from your HRA as long as the account balance is sufficient to cover claims and is in excess of the minimum account balance. In the event you and your spouse divorce or become legally separated, your spouse must elect COBRA Continuation Coverage and pay COBRA premiums in order to continue to have access to and receive reimbursements from your HRA. Dependent Child(ren) Eligibility for COBRA Continuation Coverage

Your dependent child(ren) can elect COBRA Continuation Coverage in the event:1. You die;2. Your employment ends for any reason, other than gross misconduct;3. You no longer meet the Plan’s eligibility requirements as a result of a

reduction in hours worked (including a strike, walkout or layoff );4. You become entitled to and enroll in Medicare Part A or Part B, or

both; 5. You and your spouse divorce or become legally separated; or6. Your child(ren) no longer qualifies as an “eligible dependent” as

described on page 27.If your dependent child(ren) has a COBRA qualifying event as listed in 1 – 4 above, they are not required to elect COBRA Continuation Coverage or pay COBRA premiums to continue to receive reimbursements from your HRA. Your dependent child(ren) will continue to have access to and receive reimbursements from your HRA as long as the account balance is sufficient to cover claims and is in excess of the minimum account balance.

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In the event you and your spouse divorce or become legally separated (#5) or your dependent child(ren) no longer qualifies as an “eligible dependent” (#6), your dependent child(ren) must elect COBRA Continuation Coverage and pay COBRA premiums in order to continue to have access to and receive reimbursements from your HRA. Note: If you have a newborn child or a child is placed with you for adoption while you are receiving COBRA Continuation Coverage, the child may be added to your coverage. However, you must notify the Fund Office immediately of the change. COBRA Continuation Coverage Eligibility Notification

In the event of your death or your enrollment in Medicare Part A or Part B, it is your employer’s responsibility to notify the Fund Office accordingly. However, employees frequently work for more than one employer contributing to the Plan, which makes it difficult for employers to provide this notice. Therefore, the Trustees have determined that employment will be considered to have terminated and/or the number of hours worked to have been reduced when your regular group health care coverage ends.In cases of divorce, judicial order of legal separation, loss of eligible dependent status for your child(ren), or the birth or adoption of a dependent, you are responsible to notify the Fund Administrator. You must complete the “Participant’s Notice to Fund Administrator” form, which you can get from the Fund Office. This form must be returned within 60 days after the qualifying event has occurred or the date coverage would be lost because of the event, whichever is later. If you do not provide notice to the Fund Administrator within these time limits, you may not be eligible for COBRA Continuation Coverage. After receiving your notice of the qualifying event, the Fund Administrator will notify each eligible individual whether he or she has the right to elect COBRA Continuation Coverage and will send the materials needed to make the proper election. Generally, the Fund Administrator will notify eligible individuals of their COBRA rights within 14 days after receiving notice of the qualifying event or after it has been determined that your regular group health care coverage has ended. When To Make Your COBRA Continuation Coverage Election

You, your spouse and your dependent child(ren) each have independent election rights. Covered employees may elect COBRA Continuation Coverage on behalf of their spouses and parents may elect COBRA Continuation Coverage on behalf of their children. Each individual will have 60 days from the date he or she would lose coverage because of one of the qualifying events previously described or the date on which he or she is advised of the right to elect COBRA

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Continuation Coverage, whichever is later, to notify the Fund Administrator that he or she wants COBRA Continuation Coverage. If no election is made, the individual’s health coverage will end and there will not be another opportunity to elect COBRA Continuation Coverage. Note, however, that you may change your election within the 60-day period described above as long as the completed COBRA Election Form, if mailed, is post-marked no later than the due date. If the COBRA Election Form is hand-delivered, the delivery date must be on or before the due date. If you change your mind after first rejecting COBRA Continuation Coverage, your COBRA Continuation Coverage will begin on the date the completed Election Form is post-marked (if mailed). If hand-delivered, your COBRA Continuation Coverage will begin on the date of delivery.What Benefits Are Available Under COBRA Continuation Coverage?

If you are eligible for COBRA Continuation Coverage, you may elect to receive all the benefits you were entitled to before you experienced one of the qualifying events described previously. However, life insurance, disability benefits, accidental death and dismemberment benefits, or other non-health benefits will not be included. What Happens If You Don’t Elect or Waive COBRA Continuation Coverage?

As you consider whether to elect COBRA Continuation Coverage, remember to take into account that failure to continue your group health coverage will affect your future rights under federal law. Some things to think about as you make your decision: • You can lose the right to avoid having pre-existing condition exclusions

applied to you by other group health plans if you have more than a 63-day gap in health coverage. Electing COBRA Continuation Coverage may help you avoid that gap.

• You will lose the guaranteed right to purchase individual health insurance policies that do not impose such pre-existing condition exclusions if you do not get COBRA Continuation Coverage for the maximum time it is available to you.

• You should take into account that you have special enrollment rights under federal law. For example, you have the right to request special enrollment in another group health plan that you may be eligible for (such as a plan sponsored by your spouse’s employer) within 30 days after your group health coverage ends because of the qualifying event described previously. You will also have the same special enrollment right at the end of COBRA Continuation Coverage if you get it for the maximum time it is available to you.

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Time Frames for COBRA Continuation Coverage

If you elect COBRA Continuation Coverage because your employment ends or your hours worked are reduced, your COBRA Continuation Coverage will end 18 months after the loss of your other coverage. However, if you, your spouse or one of your dependent children is determined to be disabled by the Social Security Administration on the day regular coverage ends or within 60 days after, each of you can receive a total of 29 months of COBRA Continuation Coverage. For all other situations, COBRA Continuation Coverage is available for 36 months. Please note that COBRA Continuation Coverage will end at an earlier date for any of the following reasons:• The employer no longer provides group health coverage; • You fail to pay the monthly premium on time;• The individual becomes covered under another group health plan (other

than the one sponsored by the employer), except for any period the other group health plan limits coverage of your pre-existing conditions;

• The individual enrolls in Medicare Part A or Part B; or• There are circumstances that could result in the individual’s participation

being cancelled if that individual were an active employee.If any of these events occur, the Fund Office will send you a Notice of Termination of Coverage, explaining the reason COBRA Continuation Coverage ended early, the date it ended, and any rights you, your spouse or dependent child(ren) may have under the Plan to elect alternate coverage. Coordination of Other Coverage with COBRA Continuation Coverage

If you become eligible for COBRA Continuation Coverage, but you are also eligible for extended coverage under the “Hours Bank” as described in the Eligibility Requirements section of this Summary Plan Description, you will not begin any period of COBRA Continuation Coverage until your available “Hours Bank” coverage is used up.As an alternative to COBRA Continuation Coverage, you may elect to participate in a separate self-pay program by contributing an hourly contribution rate up to a maximum of 80 hours per month. This coverage is available only for those participants who remain available to work in covered employment with the contributing employer. This alternative coverage may continue for a maximum of nine months, after which you may purchase COBRA Continuation Coverage. However, the maximum COBRA Continuation Coverage period will be reduced by the number of months of alternative coverage.

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What Does COBRA Continuation Coverage Cost?

Any individual who elects COBRA Continuation Coverage will be required to make a monthly payment to the Fund Office to ensure continuation of coverage. This monthly premium will be based on the average cost that the Plan incurs annually per participant, plus a two percent administrative charge. The extra 11 months of COBRA Continuation Coverage available to disabled participants are at a monthly charge based on 1-1/2 times the average annual per participant cost incurred by the Plan. The monthly COBRA premium will usually be more than the monthly premium charged to self-pay participants described previously in this section. If You Have Questions

Questions concerning your Plan or your COBRA Continuation Coverage rights should be addressed to the Fund Office. You should note that COBRA Continuation Coverage is described in greater detail in the letter you will receive from the Fund Office when you become eligible to participate in the Fund or when COBRA first became applicable to the Fund, if later.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’s website at www.dol.gov/ebsa. (Addresses and phone numbers of regional and district EBSA offices are available through EBSA’s website.)

Returning To WorkActive Participants

If your eligibility ended and you start working again for an employer who contributes to the Fund, your coverage will be reinstated as described on page 35.If you return to work following a military leave of absence, your coverage will be reinstated as described on page 40.Retirees

Your retiree coverage under the Plan will end when you return to employment and you become eligible for active coverage (see page 22 for the Plan’s initial eligibility requirements).

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MeDICal benefITs (foR aCTIVe PaRTICIPanTs anD DePenDenTs)

The Plan offers comprehensive health care coverage to help you and your eligible dependents stay healthy and helps provide financial protection against catastrophic health care expenses. This section describes how the Plan works for active participants and eligible dependents. For information on coverage for retirees and dependents, see page 25.

How The Plan WorksPreferred Provider Organization (PPO)

For active participants and dependents, to help manage certain health care expenses, the Plan contains a cost management feature – a Preferred Provider Organization (PPO) network. The Plan’s PPO network is the RMSCO PPN. A PPO is a network of physicians and hospitals that have agreed to charge negotiated rates. When you use a network provider, you save money for yourself and the Plan because the network provider has agreed to charge a discounted dollar amount.It’s your decision whether or not to use a network provider. You always have the final say about the physicians and hospitals you and your family use. To encourage you to use network providers whenever possible, the Plan pays a higher percentage of covered expenses when you use a network provider. If you have questions, or need a listing of physicians and

Preferred Provider Organization (PPO)A PPO is a network of health care providers who have agreed to charge negotiated rates. Since network providers have agreed to these negotiated rates, you help control health care costs for yourself and the Plan when you use network providers.

Please keep in mind that when you visit a PPO network hospital, the physicians and other health care providers in the hospital may not belong to the PPO network, and vice versa.

When you need to see a doctor: Call to make an appointment. Write down any health-

related questions you have before your appointment. This way, you will not forget to ask your doctor important questions during your appointment.

Make a list of any medications you’re taking. Be sure to note how often you take the medication.

Show your ID card when you go to your appointment to ensure your doctor knows where to file your claim.

Consider asking your doctor for samples of any prescription medication you may need.

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hospitals that participate in the PPO network (provided free of charge), see page 21 for PPO contact information.The Plan pays different levels based on whether you use a network or non-network provider, as listed on the Schedule Of Benefits on page 8. For a listing of the services and supplies covered under the Plan, see page 8.Once your co-payment coinsurance amounts for covered expenses reach the out-of-pocket maximum during the calendar year, the Plan pays 100% of remaining maximum allowable amounts for most covered services for the rest of that year up to any specific benefit maximums. You must show your ID card each time you receive medical care, otherwise, your expenses may be paid as non-network expenses, even if you use a network provider. Note that some expenses may be covered differently or subject to different benefit maximums. See the Schedule Of Benefits on page 8 for more information. Here’s an example of how using a network provider can save you money.

Let’s look at what Charles, an active participant, would pay at a network hospital compared to a non-network hospital. This assumes that he has not satisfied his annual deductible. Network Hospital* Non-Network HospitalCovered expenses $1,500 $2,000Deductible - $100 - $100Expenses For Reimbursement $1,400 $1,900Plan Pays x 80% = $1,120 x 70% = $1,330Charles Pays $480 (20% plus $100 deductible) $770 (30% plus $100 deductible)

In the above example, using a PPO hospital saves Charles $290.* This example assumes a PPO savings rate of approximately 25%. The actual savings may vary.

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Deductible

The calendar deductible is the amount of covered expenses that you pay each calendar year before the Plan begins to pay benefits for most covered services. The deductible applies to each covered person each calendar year. The family deductible is no more than $100 per person with a maximum of $300. See the Schedule Of Benefits on page 8 for the family maximum. Once an individual and/or family deductible is met, no further deductibles are required for that year.Normally, the individual deductible is applied to each member of the family. However, if two or more covered members of a family are injured in the same accident, the medical expenses that result from the accident will be combined and only one deductible will apply to all expenses incurred as a result of that accident.Any amounts applied to a deductible for expenses incurred during the last three months of the calendar year will also be applied to meet the next calendar year’s deductible, but not the out-of-pocket maximum.Not all covered services are subject to the deductible. In addition, not all payments apply toward meeting your annual deductible. For example, flat co-payments you pay for doctor’s visits do not apply toward meeting the deductible. Services Not Available Within The Service Area

If you or your dependent require treatment that is not available from a network provider within the service area, the Plan will cover that treatment from a non-network provider subject to the same co-payments that apply for network providers. The Plan will provide assistance with reasonable and necessary travel expenses as determined by RMSCO, when you obtain pre-certification and are required to travel more than 75 miles from your residence as a result of services not being available within the network. The Plan’s assistance with travel expenses includes transportation to and from the nearest network provider facility, lodging, and meals. You must submit itemized receipts for transportation, meals, and lodging expenses that is satisfactory to RMSCO when claims are filed. You will not be required to pay more for medical services than if the services had been received from a network provider within the service area.

Out-of-pocket expenses for covered medical services are limited. The out-of-pocket maximum does not include your annual deductible.

If you need to be hospitalized: Ask your doctor to refer you

to a network hospital. Contact RMSCO for pre-

certification. Inform your supervisor that

you’ll be away from work. Bring your medical ID card

to the hospital.

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Pre-certification And Case Management

Health care management is designed to promote the delivery of cost-effective medical care to all by reviewing the use of appropriate procedures, setting (place of service), and resources through case management and pre-certification. Pre-certification means that you obtain approval before receiving certain procedures or services. Most providers know which services require pre-certification and will obtain any required pre-certification. However, it’s a good idea to check with your provider to ensure he or she has obtained pre-certification when necessary. You may designate an authorized representative to act on your behalf for a specific pre-certification request. The authorized representative can be anyone who is 18 years or older. Inpatient admissions following emergency care do not require pre-certification. However, you must notify RMSCO or verify that your physician has notified RMSCO within 48 hours or as soon as possible within a reasonable period. Please see the Schedule Of Benefits on page 8 for the services that require pre-certification. For childbirth admissions, pre-certification is not required unless there is a complication and/or the mother and baby are not discharged at the same time.

Make The Call: 866-397-9768If your physician recommends hospitalization, you must call RMSCO to get your stay pre-certified. If you do not make this call, benefits may be reduced or denied.If you receive emergency hospitalization, you or a family member must call RMSCO no later than 48 hours after the hospital admission.

Statement of Rights Under the Newborns’ and Mothers’ Health Protection ActUnder Federal law, group health plans generally may not 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 delivery by cesarean section. However, the Plan may pay for a shorter stay if the attending provider, after consulting with the mother, discharges the mother or newborn earlier. Also under Federal law, plans may not set the level of benefits or out-of-pocket costs so that any later portion of the 48-hour (or 96-hour) stay is treated in a manner less favorable to the mother or newborn than any earlier portion of the stay. In addition, a plan may not require that a physician or other health care provider obtain authorization for prescribing a length of stay of up to 48 hours (or 96 hours in the case of a cesarean section).

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Pre-certification does not guarantee coverage for or the payment of the service or procedure reviewed. It is a confirmation of medical necessity only.Coinsurance And Co-payment

Once you or your family meet the deductible, the Plan pays a percentage of covered expenses, called coinsurance. The amount the Plan pays depends on the type of covered expense as listed on the Schedule Of Benefits on page 8. Your payment is the remaining percentage of covered expenses. For certain services, you a pay a flat dollar amount called a co-payment.Out-Of-Pocket Maximum

The out-of-pocket maximum limits the amount you pay out-of-pocket in a calendar year for covered expenses. If your co-payments toward covered expenses reach the out-of-pocket maximum, the Plan pays 100% for most additional covered expenses for the rest of the calendar year, up to the annual maximum shown on the Schedule Of Benefits on page 8. The following expenses do not apply to the out-of-pocket limit: Charges not considered covered medical expenses; Annual deductible; Office visit, Rx and Ambulance co-payments; Charges made after the maximum benefit has been received or paid; Expenses paid at less than 100% after the out-of-pocket maximum is

met (i.e., psychological benefits paid at 50%); and Amounts above the maximum allowable amount.Specific Benefit Maximums

You and each eligible dependent can receive medical benefits up to the specific benefit maximums specified on the Schedule Of Benefits on page 8. Certain services have separate lifetime or benefit maximums.Maximum Allowable Amount

The maximum allowable amount is the PPO’s negotiated rate for covered services with network providers. The Plan pays the same rate to non-network providers as well. When you use a non-network provider, you are responsible for paying the difference between the maximum allowable amount and the non-network provider’s charge, if applicable.

Maximum Allowable AmountThe maximum allowable amount is the PPO’s negotiated rate for covered services with network or participating providers. The PPO pays the rate to non-network providers as well. When you use a non-network provider, you are required to pay any co-payments and deductibles and any amounts that exceed the maximum allowable amount. The maximum allowable amount is reduced by any penalties for which a provider is responsible as a result of its agreement with RMSCO.

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The maximum allowable amount for a covered service is determined using internally developed criteria and industry accepted methods and fee schedules that are based on estimates of resources and costs required to provide a drug, biologic, device, diagnostic, product, equipment, procedure, treatment, service, or supply.For a network provider, the maximum allowable amount is equal to the amount that is payment in full under the network provider’s participation agreement for a service or product. For a non-network provider, even if the provider has a participation agreement, the maximum allowable amount is the lesser of the actual charge or the standard rate under the participation agreement used with network providers. If there is not a negotiated amount, RMSCO has discretionary authority to establish the maximum allowable amount for a non-network provider facility. The maximum allowable amount is the lesser of the non-network provider facility’s charge, or an amount as determined by RMSCO after consideration of industry cost, reimbursement, utilization data, and other factors RMSCO considers appropriate.You are required to pay any co-payments and deductibles and any amounts that exceed the maximum allowable amount. The maximum allowable amount is reduced by any penalties for which a provider is responsible as a result of its agreement with RMSCO.Medically Necessary Or Medical Necessity

The Plan pays benefits only for services and supplies that are medically necessary or based on medical necessity. In general, medically necessary means only those services, treatments, or supplies provided by a hospital, a doctor, or other qualified provider of medical services or supplies that are required, in the Trustees’ judgment (based on the opinion of a medical professional), to identify or treat an injury or sickness. The services, treatment, or supplies must be: Medically appropriate for and consistent with the symptoms and

proper diagnosis or treatment of the patient’s condition, illness, disease or injury;

Obtained from a provider; Provided in accordance with applicable medical and/or professional

standards; Known to be effective, as proven by scientific evidence, in materially

improving health outcomes; The most appropriate supply, setting, or level of service that can safely

be provided to the patient and that cannot be omitted consistent with recognized professional standards of care (which, in the case of hospitalization, also means that safe and adequate care could not be obtained in a less comprehensive setting);

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Cost-effective compared to alternative interventions, including no intervention (cost effective does not mean lowest cost);

Not experimental or investigative; Not primarily for the convenience of the patient, the patient’s family,

or the provider; and Not otherwise listed as an exclusion under the Plan.Your Responsibility

It is important to remember that the Plan is not designed to cover every health care expense. The Plan pays charges for covered expenses, up to the limits and under the conditions established under the rules of the Plan. The decisions about how and when you receive medical care are up to you and your physician — not the Plan. The Plan determines how much it will pay; you and your physician must decide what medical care is best for you.

Choosing A PhysicianYou save money for yourself and the Plan when you use a physician who participates in the Plan’s network. One way to find a physician is to ask around. Ask a family member, friend, or co-worker if they have the name of a physician they would recommend. Before visiting a physician, you should contact RMSCO (www.rmscoinc.com/Provider Search) to ensure your physician is in the network.Here are some questions you may want to ask the physician(s) you’re thinking about making an appointment with: Are you accepting new patients? What’s your treatment style? Are you board certified? If so, in what specialties? (Any physician

with a license can practice in any specialty. Board certification is your assurance that the physician has appropriate training for the specialty.)

At which hospitals do you admit patients for major health care needs? Does the hospital belong to the PPO network? Do the hospital technicians (for example, for laboratory tests and X-rays) belong to the PPO network?

What are your office hours? On average, how long do patients have to wait to make an

appointment? During an appointment, on average, how long is the wait in your

waiting room?

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Covered Expenses See the Schedule of Benefits on page 8.

Expenses Not CoveredYou should be aware that not every medical expense is covered by the Plan. Also, for additional expenses not covered by the Plan, see General Plan Exclusions on page 85.

Women’s Health and Cancer Rights ActFederal law requires that in the case of a participant or beneficiary who receives benefits under the Plan in connection with a mastectomy and who elects breast reconstruction, coverage will be provided in a manner determined in consultation with the attending physician and the patient, for:(1) Reconstruction of the breast on which the mastectomy has been

performed; and(2) Surgery and reconstruction of the other breast to produce a

symmetrical appearance; and(3) Prostheses and treatment of physical complications at all stages of

the mastectomy, including lymphedemas.The above coverages are subject to any co-payments, deductibles and coinsurance limitations consistent with those established for other benefits under the Plan.

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MeDICal benefITs (foR ReTIRees anD DePenDenTs)

The Fund is pleased to be able to provide you and your eligible dependents with a subsidy to help pay for retiree health coverage. The Plan offers you access to comprehensive health care coverage to help you and your eligible dependents stay healthy and have some financial protection against catastrophic health care expenses. The medical coverage you are eligible for varies depending on whether or not you or your dependents are eligible for Medicare. The Plan provides both Pre-Medicare-eligible retirees and Medicare-eligible retirees with access to several medical programs. When you retire, you will be notified about which plans you are eligible for. These plans are described in separate booklets. For more information, contact the Fund Office.

Medicare Supplement Plans

The Fund allows certain family members who are Medicare-eligible the opportunity to enroll in a Medicare Supplement Plan offered by the Fund. These plans may be purchased on a self-pay premium basis for an individual policy. The Fund Office will notify Medicare-eligible family members of the Participant of the initial monthly cost of coverage. Once notified, the Medicare-eligible family members will be responsible for making regular monthly premium payments one month in advance of the covered month (for example, to be covered as ofJune 1st, the premium is due by May 1st), or the coverage may be canceled. The Fund Office will not mail out monthly bills for premiums due.

IMPORTANT: Dental coverage continues to be available through the BCBS Smile Saver Dental Plan. However, effective January 1, 2012, retirees and dependents will also be able to elect the HEG-administered Dental Plan that is available to active participants. See page 68 for a description of this dental plan. You can contact HEG at the number listed on page 21 or the Fund Office for information on individual and family premiums.

If you are eligible for Medicare, you must enroll for Medicare. The Plan coordinates benefits with Medicare, regardless of whether or not you actually enroll.Information about Medicare is available: At any Social Security

Administration Office; By calling the Social Security

Administration at 800-772-1213; or

Online at www.ssa.gov (search for Your Medicare Handbook).

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The Medicare-eligible family members who may participate in a Medicare Supplement plan offered by the Fund on a self-pay basis include: your parents; your grandparents; and your siblings.If you would like more information about enrolling Medicare-eligible family members into one of the Medicare Supplements Plans offered by the Fund, please call the Fund Office.

Required Notice: The Early Retiree Reinsurance Program (ERRP)You are a Plan participant, or are being offered the opportunity to enroll as a Plan participant, in an employment-based health plan that is certified for participation in the Early Retiree Reinsurance Program. The Early Retiree Reinsurance Program is a Federal program that was established under the Affordable Care Act. Under the Early Retiree Reinsurance Program, the Federal government reimburses a plan sponsor of an employment-based health plan for some of the costs of health care benefits paid on behalf of, or by, early retirees and certain family members of early retirees participating in the employment based plan. By law, the program expires on January 1, 2014. Under the Early Retiree Reinsurance Program, your Plan sponsor may choose to use any reimbursements it receives from this program to reduce or offset increases in Plan participants’ premium contributions, co-payments, deductibles, co-insurance, or other out-of-pocket costs. If the Plan sponsor chooses to use the Early Retirement Reinsurance Program reimbursements in this way, you, as a Plan participant, may experience changes that may be advantageous to you, in your health plan coverage terms and conditions, for as long as the reimbursements under this program are available and this Plan sponsor chooses to use the reimbursements for this purpose. A Plan sponsor may also use the Early Retiree Reinsurance Program reimbursements to reduce or offset increases in its own costs for maintaining your health benefits coverage, which may increase the likelihood that it will continue to offer health benefits coverage to its retirees and employees and their families.

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PResCRIPTIon DRUG benefITs (foR aCTIVe PaRTICIPanTs anD DePenDenTs)

Note: The prescription drug benefits apply to active participants and dependents and to Medicare-eligible retirees who elect prescription drug coverage. If you elect retiree medical coverage, this section does not apply to you, unless you are covered under the active plan for a period of free coverage. The retiree medical plans have separate prescription drug coverage. Prescription drug coverage can play an important role in your overall health. Recognizing the importance of this coverage, the Plan provides prescription drug benefits.When you need a short-term medication filled (for example, an antibiotic or cold remedy), it may be best to use the retail pharmacy program. If you take medication on a long-term basis (maintenance medications), it is usually better to use the mail order program. Pre-certification may be required for certain medications. For a list of medications that require pre-certification, see page 21 for contact information.

Retail Pharmacy ProgramThe Plan has contracted with Envision Pharmaceutical Services’ network of participating pharmacies (as listed in Contact Information on page 21). It is always your decision where you have prescriptions filled, but when you use participating pharmacies, you save money for yourself and the Plan because participating pharmacies have agreed to charge discounted rates for prescription drugs. If you use a non-participating pharmacy (non-network), your prescription will not be covered.Through the retail pharmacy program, you may receive up to a 30-day supply. When filling a prescription, simply present your prescription drug ID card and pay the applicable co-payment. The

If you have your prescriptions filled at a pharmacy that is not part of the network or you do not present your ID card to the pharmacist, you will not receive discounted medication prices.

You save money by using network pharmacies because network pharmacies have agreed to charge discounted rates. To find a participating pharmacy, see page 21 for contact information.

Generic Or Brand NameWhile the Plan covers generic and brand name medications, you pay a higher co-payment amount when you receive a brand name medication. You pay the highest co-payment when you have your prescription filled with a non-formulary medication.

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amount you pay depends on the pharmacy you use and whether you have your prescription filled with a generic formulary, brand name formulary, or non-formulary medication. For the Plan’s co-payments, see the Schedule Of Benefits on page 8. If you have any questions, please call the Envision RxOptions Member helpdesk at 800-361-4542.If you visit a non-participating pharmacy, your prescription may not be covered.

Mail Order ProgramThe Plan also offers a mail order program for your long-term, or maintenance, prescription drug needs. Maintenance medications are often prescribed for heart disease, high blood pressure, asthma, etc. Through the mail order program, you receive up to a 90-day supply. With the mail order program, you receive a larger supply of medication at one time and enjoy the convenience of having the medication sent directly to your home.To place an order, complete an Order Form, which is available by contacting Orchard Pharmaceutical Services as listed on page 21. You will need to complete the patient profile information only once. You may mail the written prescription from your physician, have your physician fax the prescription to Orchard Pharmaceutical Services, or your physician may phone in the prescription. You will need to submit the applicable co-payment amounts when you request a prescription or refill. The amount you pay depends on whether you have your prescription filled with a generic formulary, brand name formulary, or non-formulary medication. For the Plan’s co-payments, see the Schedule Of Benefits on page 8. For more information about how to use the mail order program, contact Orchard Pharmaceutical Services Call Center at 866-909-5170. If you call Orchard Pharmaceutical Services, you should identify yourself as a Sheet Metal Workers Local 46 participant as well as part of Envision RxOptions.

Specialty Pharmacy Medication ServicesEnvision RxOptions has designated Costco Specialty Services as the provider for all Specialty Medications (examples include those medications used multiple sclerosis, osteoporosis, osteoarthritis, Crohn’s disease, psoriasis, Hepatitis C, fertility, growth hormone, anticoagulants and more). This change is effective January 1, 2012. Therefore, if you have an existing prescription on or after that date, you must get a new prescription and place a new order with Costco Specialty Services. All Specialty Medications must be filled at a Costco Specialty Pharmacy. Costco Specialty Services is open from 8:00 a.m. to 11:00 p.m., EST, Monday through Friday, and 8:00 a.m. to 4:00 p.m. EST on Saturday, and you can call toll-free at 866-443-0060. Also see page 21 for Contact Information.

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Generic And Brand Name MedicationsAlmost all prescription drugs have two names: the generic name and the brand name. By law, both generic and brand name medications must meet the same standards for safety, purity, and effectiveness.When you receive a brand name medication, you generally pay more because they are more expensive. When you or your dependent needs a prescription, you may want to ask your doctor whether a generic medication can be substituted for a brand name medication.In general, using generic medications will help control the cost of health care while providing quality medications – and can be a significant source of savings for you and the Plan. Your doctor or pharmacist can assist you in substituting generic medications when appropriate.

Formulary Versus Non-Formulary MedicationsThere are often several types of medications that can be used to treat the same condition. To ensure high-quality care and to help manage costs, the prescription drug program has a formulary that lists preferred drugs. The Plan’s formulary includes most generic medications and brand name medications that are either more effective than others in their class or as effective as and less costly than similar medications. You are responsible for a higher co-payment amount for non-formulary medications.When you or your dependent needs a prescription, you may want to ask your doctor whether a formulary medication can be substituted for a non-formulary medication. For information about the drug formulary, see page 21 for Contact Information.

Step Therapy Program Envision Rx has implemented a new Step Therapy program as part of the prescription drug plan. The Step Therapy program requires you to try another drug first to treat your medical condition before the Plan will cover the drug initially prescribed by your doctor. For example, if Drug A and Drug B treat the same medical condition, the Plan may require you to try Drug A first. If Drug A does not work for you, the Plan will then cover Drug B.

Covered ExpensesCovered expenses include:1. Those, which require compounding by a pharmacist of two or more

ingredients, one of which must require a prescription.2. Those drugs that cannot be dispensed, under federal or state law, by

a pharmacist without a prescription from a licensed medical doctor, osteopathic physician, dentist, or podiatrist, when prescribed within the area of their specialty.

3. Insulin on prescription.4. Two prescriptions per year for a maximum of four Epi Pens for allergic

reactions.

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Expenses Not CoveredIn addition to any General Plan Exclusions or limitations (see page 85), benefits are not paid for:1. Drugs dispensed without a prescription (except insulin) or drugs that

can be purchased without a prescription even though a doctor may prescribe it (such as aspirin, vitamins and diet supplements).

2. Any medication that is to be taken by or administered to, in whole or in part, the eligible person while such person is in a licensed hospital, rest home, sanitarium, extended care facility, convalescent hospital, nursing home, or similar institution.

3. Drugs considered experimental or investigational using the following standards:

a. If the drug cannot be lawfully marketed without the approval of the U.S. Food and Drug Administration and approval for marketing has not been given at the time the drug is furnished;

b. If the drug or the patient informed consent document utilized with the drug was reviewed and approved by the treating facility’s institutional review board or other body serving a similar function or, if federal law requires, such review or approval;

c. If reliable evidence shows that the drug is the subject of ongoing phase I or phase II clinical trials, is the subject of research, experimental study, or investigational arm of ongoing phase III clinical trials or is otherwise under study to determine its maximum tolerated dose, toxicity, safety, effectiveness, or effectiveness as compared with a standard means of treatment or diagnosis; or

d. If reliable evidence shows that the prevailing opinion among experts regarding the drug is that further studies or clinical trials are necessary to determine its maximum tolerated dose, toxicity, safety, effectiveness, or effectiveness as compared with a standard means of treatment or diagnosis.

Reliable evidence means only published reports and articles in the authoritative medical and scientific literature, the written protocol or protocols used by the treating facility or the protocol(s) of another facility studying substantially the same drug, device, medical treatment, or procedure, or the written informed consent used by the treating facility or by another facility studying substantially the same drug, device, medical treatment, or procedure.4. Immunizing agents and biological sera.5. Drugs administered to an eligible person by the prescriber in his or her

office.

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6. Prescriptions that an eligible person is entitled to receive without charge under any workers’ compensation program or any municipal, state, or federal program regardless of jurisdiction.

7. Medication reimbursable under any governmental program or employee liability law (including workers’ compensation) regardless of jurisdiction.

8. Administration charges for drugs or insulin.9. Unauthorized refills.10. Any medication taken primarily for cosmetic purposes.11. Appliances, bandages, heat lamps, braces, splints, hypodermic syringes,

needles, etc.12. Therapeutic devices or appliances, support garments, and other non-

medical substances.13. Retin-A, except as medically prescribed for treatment of acne.14. Rogaine, except as medically prescribed for uses other than hair

growth.15. Growth hormones.16. Genetically engineered drugs.17. Anorexiants (appetite suppressants used for weight loss).18. All medication in connection with infertility.19. Contraceptives and contraceptive devices, other than oral

contraceptives and Intra-Uterine Devices (IUDs).20. Weight-loss medications, unless specifically authorized on a case-by-

case basis to treat morbid obesity. The Plan is the final authority for determining what medications are covered. No additional prescription drug benefits will be paid except as otherwise specified as covered by the Plan.

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DenTal benefITs ADMINISTERED BY HEALTH ECONOMICS GROUP, INC. (HEG) – (FOR ACTIVE PARTICIPANTS AND DEPENDENTS)

Preventive dental care can be important. To help meet the cost of routine and unexpected dental care, the Plan provides dental benefits for active participants and their eligible dependents through Health Economics Group, Inc. (HEG), the dental plan administrator.

Covered ExpensesBefore January 1, 2012, the Plan paid according to a schedule of dental allowances, meaning that for all services (except Orthodontics) specific amounts were paid for each dental service, up to the annual maximum of $1,500 per individual. However, in a change effective January 1, 2012, dental benefits will be calculated on a percentage basis. Allowances for Diagnostic and Preventive services (exams, cleanings and X-rays) were approximately 60% to 70% of the average dental fees in the greater Rochester area. The new benefit for Diagnostic and Preventive services will be 100% of what the dentist bills, but payment will be limited to what is called the Usual, Customary and Reasonable (UCR) charge. This limit is the amount billed by approximately 90% of area dentists, so in the vast majority of cases, the UCR limit will not affect benefit payments at all. Fillings, root canal treatment, extractions and gum surgery will be paid on a percentage basis also. Although the allowances were previously set at about 55% of the greater Rochester area averages, as of January 1, 2012, these services will be paid at 60%, up to the UCR limits.In addition, while crowns and bridges were paid at allowances that were about 55% of the greater Rochester area averages, as of January 1, 2012, these services will be paid at 55%, up to the UCR limits.

IMPORTANT: Dental coverage for retirees continues to be available through the BCBS Smile Saver Dental Plan. However, effective January 1, 2012, retirees and dependents will also be able to elect the HEG-administered Dental Plan that is available to active participants. See below for a description of this dental plan. You can contact HEG at the number listed on page 21 for more details or the Fund Office for information on individual and family premiums.

When you need dental care: Schedule an appointment

with the dentist of your choice.

File a completed claim form with HEG.

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The amount the Plan pays depends on the type of dental service you receive and reasonable charges. Once the calendar year maximum is reached, the Plan will not pay dental expenses for the remainder of the calendar year. You must meet a separate dental deductible before the Plan begins to pay benefits. The deductible does not apply to preventive services. If the annual deductible is not met during the calendar year, any amount that is counted toward the deductible in the last three months of a calendar year may be carried over to the following calendar year for satisfaction of that following year’s deductible.The Plan pays a percentage of the eligible charges for a covered child up to and including age 19 or for an eligible adult suffering from a temporomandibular joint (TMJ) condition after the orthodontic deductible is met. This benefit is not included in the dental calendar year maximum. Orthodontic Expense Benefit

Orthodontic treatment will continue to be paid at 50%, up to the lifetime maximum of $2,000. Eligible charges are those made to you for an orthodontic procedure that: Is in an orthodontic treatment

plan that has been been reviewed by HEG before treatment started and returned to the dentist showing estimated benefits; and

Is required by an overbite of at least four millimeters, crossbite, or protrusive, or retrusive relationship of at least one cusp.

The claim will be paid in installments beginning when the orthodontic appliances are first inserted, and quarterly thereafter for the estimated duration of the treatment plan, as long as the patient remains covered. Exclusions Under Orthodontic Expense Benefit

The following charges are not covered:1. Charges for a procedure for which an active appliance was installed

before the patient was insured.2. The charges referred to in items 2, 3 and 10 under Dental Expenses

Not Covered.3. A charge incurred while the patient’s coverage is not in effect.

An orthodontic treatment plan is a report on a form satisfactory to HEG that among other things describes the recommended treatment, gives the estimated charge, and is accompanied by cephalometric X-rays, study models, and other supporting evidence.

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Eligible ChargesAn eligible charge is the charge a dentist makes for a covered preventive, basic, or major dental service furnished to you or a covered dependent, provided the service: Is in the list of dental services. Is part of a treatment plan; and Is not excluded under the Plan’s dental benefits.The amount of the eligible charge for a covered service is equal to the charge made by the dentist, not to exceed the reasonable and customary charge.A charge is considered to be incurred: For an appliance, or

modification of an appliance, on the date the impression is taken.

For a crown, bridge, or gold restoration, on the date the tooth is prepared.

For a root canal therapy, on the date the pulp chamber is opened.

For all other services, on the date the service is received.

Maximum Annual BenefitThe maximum dental benefit shown in the schedule applies separately to you and to each covered dependent (over age 14) for all preventive, basic, and major dental services received in any one calendar year. The Plan pays an unlimited amount for pediatric dental benefits for children (birth to age 14).

Predetermination Of BenefitsPredetermination of benefits permits the review of the proposed treatment in advance and allows for resolution of any questions before, rather than after, the work has been done. Additionally, both you and the dentist will know in advance what is covered and what the estimated benefits are, assuming you or the dependent remains covered.

A treatment plan is the dentist’s report that: Itemizes recommended

services; Shows the charge for each

service; and Is accompanied by

supporting X-Rays or other diagnostic records where required or requested by the HEG.

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Dental Plan Coverage Chart

Class I

DIAGNOSTIC & PREVENTIVE Examinations Cleanings X-rays Sealants Fluoride

Class II

BASIC/MINOR RESTORATIVE Fillings Root Canal Therapy Extractions Gum Surgery Denture Repair

Class III

MAJOR RESTORATIVE Crowns Bridgework Dentures

Annual Maximum: $1500 (Age 14 and Over) for Classes I, II, and III

Class IV

ORTHODONTICS(Dependents to age 19)

*UCR is the Usual, Customary, and Reasonable charge for the service in the geographic area in which it was provided.

Then

Then

Class I

Plan pays 100% UCR*

Plan pays 50% of eligible

charges up to the Lifetime Maximum of

$2000

Class II

Plan pays 60% UCR*

Class III

Plan pays 55% UCR*

There is no Deductible.

$50 lifetime deductible

Annual Deductible

$50.00 per Individual

$150.00 per Family

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Expenses Not Covered You should be aware that some expenses are not covered by the Plan. In addition to any General Plan Exclusions (see page 85), the Plan does not cover dental services that are not considered necessary by the Plan. The fact that a dentist may prescribe, order, recommend, or approve a service does not, of itself, make it necessary or make the charge a covered expense, even though the service is not specifically listed as an exclusion. In addition to any General Plan Exclusions or limitations (see page 85), benefits are not paid for:1. A service or supply not included in the Dental Plan Coverage Schedule

except under the conditions explained on page 85.2. Anything not furnished by a dentist, except X-rays ordered by a

dentist, and services by a licensed dental hygienist under the dentist’s supervision.

3. Anything not necessary or not customarily provided for dental care.4. Services: a. Furnished by or for the U.S. Government, or any other government

unless payment is legally required; or b. To the extent provided under any governmental program or law

under which the individual is, or could be, covered.5. An appliance, or modification of one, where an impression was made

before the patient was covered, such as but not limited to, a crown, bridge, or gold restoration for which the tooth was prepared before the patient was covered, root canal therapy if the pulp chamber was opened before the patient was covered.

6. A crown, gold restoration, or a denture, fixed bridge, or addition of teeth to one, if the work involves a replacement or modification of a crown, gold restoration, denture, or bridge installed less than five years before.

7. A denture or fixed bridge involving replacement of teeth extracted before the individual was covered, unless it also replaces a tooth that is extracted while covered, and such tooth was not an abutment for a denture or fixed bridge installed during the preceding five years.

8. Services due to an accident related to employment or disease covered under workers’ compensation or similar law.

9. Replacement of lost or stolen appliances, appliances or restorations for the purpose of splinting, to increase vertical dimension, or restore occlusion.

10. Orthodontics (a program to straighten teeth) such as, but not limited to, services for cosmetic purposes unless made necessary by an accident. Facings on molar crowns or pontics are always considered cosmetic.

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11. Any portion of a charge for a service in excess of the reasonable and customary charge, which is the charge usually made by the provider when there is no coverage, not to exceed the prevailing charge in the area for dental care of a comparable nature, by a person of similar training and experience.

12. Expenses applied toward satisfaction of a deductible under the Plan’s dental benefits.

If a particular charge is covered under the Plan’s dental benefits and also under another part of the Plan, or any other plans of which the Plan has paid any part of the cost, dental benefit payment will be limited to the excess, if any, of the amount normally paid by that plan over the amount payable by the other plan.

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VIsIon benefITsADMINISTERED BY HEALTH ECONOMICS GROUP, INC. (HEG) – (FOR ACTIVE PARTICIPANTS AND DEPENDENTS)

Vision coverage provides active participants and eligible dependents with coverage for routine vision related expenses. You can obtain vision services from any licensed optical provider.

Covered ExpensesBenefits are paid based on reasonable charges for vision care for you and your family each calendar year, up to the amounts listed on the Schedule Of Benefits on page 8. The Plan will provide vision benefits for: Eye examinations; and Lenses (prescription single,

bi-focal, or tri-focal) and frames; or Contact lenses (lenticular lenses).

Expenses Not Covered In addition to any General Plan Exclusions or limitations (see page 85), benefits are not paid for:1. Eye examinations required by an employer as a condition of

employment that the employer is required to provide by virtue of a labor agreement or by a government body.

2. Services furnished by or for the U.S. Government or any other government unless payment is legally required or to the extent provided under any governmental program or law under which the individual is, or could be, covered.

3. Anything not necessary for vision care, such as but not limited to, charges in excess of those usually made when there is no coverage or in excess of the general level in the area.

4. Special procedures such as orthoptics and visual training, or medical or surgical treatment of the eye.

The Plan is the final authority for determining whether services are covered. No additional vision benefits will be paid except as otherwise specified as covered by the Plan.

Vision services must be provided by a licensed optical provider to be covered.

When you need vision care: Schedule an appointment

with the optician, optometrist, or ophthalmologist of your choice.

File a completed claim form with HEG.

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HeaRInG aID benefITs (foR aCTIVe PaRTICIPanTs)

The Plan provides hearing aid benefits for active participants. Dependents are not eligible for hearing aid benefits.

Covered ExpensesThe Plan covers hearing aid devices and necessary repairs or replacement of batteries once in every five consecutive year period, up to the amounts listed on the Schedule Of Benefits on page 8. To determine whether an expense is included in a particular maximum benefit time period, expenses are considered to be incurred on the date the service is provided. Benefits also include reasonable charges for medical examinations to determine the need for a hearing aid and for hearing aids. The service must be performed by and a prescription provided by a licensed medical doctor operating within the scope of his or her license, including, but not limited to, an otologist or otolaryngologist.

Expenses Not CoveredIn addition to any General Plan Exclusions or limitations (see page 85), hearing aid benefits are not paid for:1. Expenses not recommended or approved by an otologist.2. Expenses for which benefits are payable under any workers’

compensation law.3. Benefits payable under Medicare or any other governmental plan.4. Special procedures or training such as lip reading courses, schooling, or

institutional expenses.5. Medical or surgical treatment of the ear or ears.6. Charges for services or supplies that are covered in whole or in part

under any other portion of the Plan.The Plan is the final authority for determining whether services are covered. No additional hearing aid benefits will be paid except as otherwise specified as covered by the Plan.

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eMPloYee assIsTanCe Plan (foR aCTIVe PaRTICIPanTs anD DePenDenTs)

The Employee Assistance Program (EAP) helps you and your dependents receive professional counseling and guidance when faced with personal problems. This is a voluntary and completely confidential program. The EAP will coordinate claims payment between RMSCO and the Fund office at an agreed-upon rate for services. If you have an issue or concern, contact AFL-CIO EAP at 585-426-5710 and an interview with a trained counselor will be arranged. At the interview, the counselor will discuss the nature of your problem and work with you to develop an approach to a solution. Following an appraisal of the interview by the counselor, you will be given a recommended course of action. Assistance in arranging for follow up treatment or counseling is provided, if necessary.

What The Program CoversThe EAP covers a variety of concerns, which could include: Stress; Job performance difficulties; Child and elder care problems; Legal referrals; Financial concerns; Marital or family stress; Alcohol or drug abuse; Depression; and Physical fitness and wellness issues.The program is available to all participants and their immediate family members. Most of the treatment services are covered by the Health Plan. If you have questions, contact the Fund Office.The EAP is entirely confidential. No reports are made by the EAP to any personnel records and records held by the EAP will not be released without patient consent.The EAP does handle referrals by supervisors. That is, a supervisor can refer you directly to the EAP if he or she feels that you have a personal or behavioral problem that is affecting your job performance.See the Schedule of Benefits on page 8 for more information on your behavioral health and substance abuse treatment coverage.

If you need to contact the Employee Assistance Program, call AFL-CIO EAP at 585-426-5710.

Important!Before receiving mental health or substance abuse treatment, you must call the AFL-CIO EAP at 585-426-5710 to pre-certify treatment. If you do not make this call, the benefits payable by the Plan will be reduced.

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HealTH ReIMbURseMenT aCCoUnT (HRa)(foR aCTIVe PaRTICIPanTs anD ReTIRees)

Health Reimbursement Accounts – In GeneralThe Health Reimbursement Account (HRA) is designed to help you pay for certain medical costs not covered by this Plan or any other health care or insurance plan. There is an HRA for active participants and an HRA for retirees.Employer contributions will be made to the Sheet Metal Workers Local 46 Health Fund for each hour you work in covered employment and a portion of those contributions will be credited to a personal HRA for you. The Trustees will determine the portion of the contributions that will be credited to your personal HRA. Since these amounts may change based upon the Plan’s financial requirements, you should refer to the collective bargaining agreement or contact the Fund Office for current information. Your HRA will grow through contributions that are made in the future and will decrease whenever there is a benefit distribution. You (or your beneficiary) will not receive any amount greater than what has been contributed into your personal HRA based on your work. Eligible Expenses

Once you have obtained a minimum $500 balance in your HRA, and if you, your spouse or dependents meet the Eligibility Requirements on page 22, you can use your HRA funds to pay for eligible health care expenses that you incurred. These health-related expenses include, but are not limited to, charges by any doctor, dentist, optometrist, ophthalmologist, hospital, long-term care facility or other health facility, pharmacy, optical dispensing service, or hearing aid provider that are not covered by any health care plan under which you are covered. The Board of Trustees or the Administrator, acting on their behalf, may authorize reimbursement to you from your personal HRA after considering the circumstances when you apply for reimbursement. In addition to the benefits described above, after you retire, as part of the Retiree-Only HRA, the Board of Trustees or the Administrator may also authorize reimbursement for any health insurance payments for yourself, your spouse or your dependents. It is important to note, however, that the HRA for retirees has been determined by the Trustees to be a Retiree-Only Plan.You may be reimbursed only for uninsured health-related expenses that you incurred on or after August 1, 2005, the effective date of this Plan. Please note that no health-related expenses may be reimbursed under the Plan unless they qualify as medical expense deductions under Internal Revenue Service rules. (Contact the IRS for its Publication 502 which

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has a comprehensive listing of these expenses; or, visit www.irs.gov.). In addition, you may not receive a reimbursement for any medical expense that you have taken as a deduction on your income tax return.

If you have a remaining balance in your personal HRA when you die, your spouse and/or other dependents may continue to apply for health-related expense reimbursements. In the event you die, but do not have a spouse or any other dependents, any remaining amount in your personal HRA will be forfeited. Contact the Fund Office for more information. Submitting Claims

You must submit HRA claims to the Fund Office on the form that they will provide and include any documentation that the Administrator requires. Each claim for reimbursement must include itemized bills for eligible health-related expenses that have already been paid. In order to be eligible for reimbursement, health-related expenses must have been incurred by you, your spouse or other eligible dependents within 24 months prior to the date on which you submit your claim.Note that if payment for a health-related expense before you are reimbursed under the Plan would cause extreme financial hardship, the Board of Trustees or the Administrator acting on their behalf may also authorize payment directly to the health care provider from your personal account on your behalf – but only after you have submitted an itemized bill for the health-related claim and expense that you incurred. The minimum claim filed must be at least $50 of out-of-pocket expense and you may add several bills together to arrive at the $50 minimum. If you submit multiple claims under this Plan, they will be processed in the order in which they are received. However, upon your written request, the Administrator may authorize processing multiple claims in a different order than they were received. Claims under this benefit must be submitted by the end of each month and payment will be made during the first week of the following month.

IMPORTANT: As a result of the Affordable Care Act, you must have a prescription from your health care provider in order to be reimbursed for over-the-counter (OTC) medications (excluding insulin). These OTC medications include, but are not limited to, cold remedies, cough medicines, etc.

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Minimum Personal Account BalancesThe benefits provided by the Health Reimbursement Account for you, your spouse and other dependents may never exceed the participant’s Minimum Account Balance. As noted on page 77, each participant’s HRA must contain a minimum balance of $500 prior to becoming eligible to receive a distribution and, after, a minimum balance of $100 must be maintained in your account at all times to ensure that reimbursements or other payments made under the Plan do not exceed personal account balances. This $100 minimum balance does not apply to final payment based upon: • retirement and receipt of benefits from the Sheet Metal Workers

Local 46 Pension Fund; or • disability; or • following the death of the participant; or • following one (1) year of having no contributions made to the Sheet

Metal Workers Local 46 Health Fund on your behalf. Accounts that do not reach the $500 minimum balance will be forfeited when no contributions have been received for the account for twenty-four (24) months.

It is important to note that if you retire prior to attaining a $500 account balance, you may begin receiving distributions from your account upon retirement, regardless of the account balance, as part of the Retiree-Only HRA.

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In THe eVenT of YoUR DIsabIlITY (foR aCTIVe PaRTICIPanTs)

Weekly income accident and sickness benefits help provide financial protection in the event you become injured or ill.If you become totally disabled, you may be eligible for weekly income accident and sickness benefits if you: Were eligible for coverage

under the Plan when you become disabled; and

Worked and have hours during the previous month, or were available for work;

Are unable to work because of a covered non occupational accident or sickness; and

Are under the care of a physician.

BenefitsThe amount of weekly income accident and sickness benefits is listed on the Schedule Of Benefits on page 8. The weekly income accident and sickness benefit for a period of total disability of less than seven days will be prorated. Benefits are subject to FICA tax.When Benefits Begin

Weekly income accident and sickness benefits begin on the: First day you are unable to work due to an accident; or Eighth day you are unable to work due to sickness.Successive disabilities separated by less than two weeks of full time work will be considered one disability, unless the subsequent disability is due to a different cause and does not begin before your return to full time work.Maximum Benefits

Benefits are paid for up to 39 weeks for each period of disability for accident- or illness-related disabilities. The aggregate amount of your weekly benefit and the amount received under New York Disability Benefit laws cannot exceed 66% of your weekly earnings.After your disability ends, you must notify the Fund Office that your disability has ended and that you are available for work.Note: Weekly income accident and sickness benefits are paid for workers’ compensation claims or paid sick leave from an employer.

The amount of weekly income accident and sickness benefits is listed on the Schedule Of Benefits on page 8.If you can’t work because of a non-work related injury or sickness: Call your employer and the

Fund Office. See a physician as soon as

possible. File a claim with the Fund

Office.

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lIfe InsURanCe benefITs (foR aCTIVe PaRTICIPanTs)

Life insurance benefits provide financial protection to your beneficiary in the event of your death. The life insurance benefit is paid if you die while eligible for benefits as an active participant, even if the cause of death is work-related. Life insurance benefits are provided through an insurance company. If you would like a copy of the full terms of the policy, please contact the Fund Office for a free copy of the Certificate of Insurance.

Benefit The amount of the benefit is shown on the Schedule Of Benefits on page 20. However, please note that the benefit amount is reduced by 35% when you reach age 70 and by 50% when you reach age 75. For your life insurance benefit to be paid to your beneficiary, written proof of your death must be provided to the insurance company. Benefits are paid in one lump sum.

Life Insurance ConversionWithin 31 days after your coverage ends, you may convert your life insurance, without having to furnish evidence of good health, to one of a number of individual life policies. The policy will be effective at the end of the 31 day period following your loss of group coverage, and the premiums will be the same as you would ordinarily pay if you applied for an individual policy at that time. If you die during this 31 day period, your group term life insurance will be paid whether or not you have applied for an individual policy. Please note there is no life insurance benefit if you have elected COBRA Continuation Coverage.

Naming A BeneficiaryYou may designate anyone you wish as your beneficiary for life insurance and AD&D insurance benefits (see page 83). You can change your beneficiary at any time, without the consent of your previous beneficiary.To designate or change a beneficiary, request a beneficiary form and file it with the Fund Office. Be sure to list your beneficiary’s full name and his or her relationship to you. The change will take effect when the insurance company receives the signed form. Your beneficiary designation will be kept on file with the Fund Office. It is very important that you designate

To designate a beneficiary, request an enrollment form from the Fund Office. Be sure to review your beneficiary designation from time to time to ensure your life insurance benefits are paid as you wish.

A beneficiary is the person or persons shown in the Plan’s records that you designate to receive your life insurance and AD&D insurance benefits.

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a beneficiary. If there is no surviving beneficiary at the time of your death, payment will be made to your estate. If your beneficiary is a minor or in the opinion of the Trustees is legally incapacitated, the Trustees reserve the right to make payment of any benefit pursuant to the requirements of state law governing payments to minors and/or incapacitated individuals.

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aCCIDenTal DeaTH anD DIsMeMbeRMenT (aD&D) InsURanCe benefIT (foR aCTIVe PaRTICIPanTs)

The accidental death and dismemberment (AD&D) insurance benefit provides a benefit to you or your beneficiary in the event you are injured or die as the result of an accident. The AD&D insurance benefit is payable for the loss of life, loss of limb(s), or entire and irrecoverable loss of sight of one or both eyes. Benefits are payable only if the loss results from an accident while you are eligible and within 90 days of the accident.AD&D insurance benefits are provided through an insurance company. If you would like a copy of the full terms of the policy, please contact the Fund Office for a free copy of the Certificate of Insurance.

BenefitsBenefits are paid directly to you for an injury or to your beneficiary in the event of your death. The AD&D insurance benefit is in addition to the life insurance benefit.If you suffer any combination of losses as shown in the following table as the result of one accident, only one amount (the largest) is payable for all losses. The amount paid for all losses resulting from one accident will not exceed the full amount listed on the Schedule Of Benefits on page 8. Benefits are payable for the following losses:

Loss means for hands and feet dismemberment by severance through or above the wrist or ankle joints; for eyes, entire, and irrevocable loss of sight.

Type Of Loss BenefitLife Full amount, paid to your

beneficiaryBoth hands, both feet, loss of sight in both eyes, one hand and one foot, one hand and sight in one eye, one foot and loss of sight in one eye

Full amount, paid to you

One hand, one foot, or loss of sight in one eye

One half of the full amount, paid to you

Thumb and index finger of same hand or movement of one limb (uniplegia)

One quarter of the full amount, paid to you

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Benefit ExclusionsIn addition to any General Plan Exclusions or limitations (see page 85), AD&D insurance benefits are not paid for: 1. Any loss that occurs more than 90 days after the accident.2. Any loss that results from war (including undeclared war and armed

aggression);3. Any loss that results from suicide or attempted suicide.4. Any loss that results from bodily or mental infirmity or disease,

ptomaine, infection other than a pyogenic infection, accidental cut or wound, or voluntary inhalation of poisonous gases.

5. Any loss that results from commission or attempt to commit a criminal act.

6. Any loss that results from use of alcohol, drugs, or intoxicants (except as prescribed by a physician).

7. Any loss that results from contact with nuclear or atomic energy.8. Any loss that results from travel in any moving aircraft aboard which

you are giving or receiving training or have any duties.

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GeneRal Plan eXClUsIonsThe following list of exclusions applies to all such charges, unless an exception is stated, and applies to all benefits provided under the Plan. In addition to the exclusions listed under each benefit section, no benefits are payable under the Plan for: 1. Confinement, treatment, services, or supplies furnished by or in a U.S.

Government hospital or furnished by or for any other government unless payment is legally required or to the extent provided under any governmental program or law under which the individual is or could be covered.

2. Anything not ordered by a doctor or not necessary for medical care. The portion of any charge for service or supply in excess of the reasonable and customary charge, which is the charge usually made by the provider when there is no coverage not to exceed the prevailing charge in the area for a service of the same nature and duration and performed by a person of similar training and experience or for a substantially equivalent supply.

3. Treatment of infertility or impotence, except for certain impotency drugs under the Plan’s prescription drug benefits or treatment of sexual dysfunction related to organic disease.

4. Treatment of weak, strained, flat, unstable, or unbalanced feet, metatarsalgia or bunions, except open cutting operations. Corns, calluses, or toenails, except the removal of nail roots and necessary services in the treatment of metabolic or peripheral-vascular disease.

5. Services that are not medically necessary, as determined by the Trustees, in their sole discretion.

6. Telephone conversations or charges for completion of claim forms or other medical reports.

7. Cosmetic surgery, except to the extent necessary to repair a disfigurement due to an injury or non-occupational accident.

8. Services and/or supplies that are essentially cosmetic in nature.9. Services related to an injury or ailment incurred as a result of war,

declared or undeclared, including armed aggression.10. Sales taxes.11. Expenses for services not prescribed by a licensed physician, unless

explicitly authorized by other provisions of this Plan.12. Services rendered by individuals or entities other than qualified

hospitals, physicians, and other medical providers.13. Services rendered by an individual in your family or in your spouse’s

family unless that individual is licensed by the State of New York to render such services.

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14. Any expense incurred for any drug, device, medical treatment, or procedure that is considered experimental or investigational by the federal government or is not recognized as generally accepted by the American medical community. A drug, device, medical treatment, or procedure is experimental or investigational:

a. If the drug or device cannot be lawfully marketed without approval of the U.S. Food and Drug Administration and approval for marketing has not been given at the time the drug or device is furnished;

b. If the drug, device medical treatment, procedure, or patient informed consent document utilized with the drug, device, treatment, or procedure was reviewed and approved by the treating facility’s institutional review board or other body serving a similar function or if federal law requires such review or approval;

c. If reliable evidence shows that the drug, device, medical treatment, or procedure is the subject of on-going phase I or phase II clinical trials, is the research, experimental study, or investigational arm of on-going phase III clinical trials or is otherwise under study to determine its maximum tolerated dose, toxicity, safety, efficacy, or efficacy as compared with a standard means of treatment or diagnosis; or

d. If reliable evidence shows that the prevailing opinion among experts regarding the drug, device, medical treatment, or procedure is that further studies or clinical trials are necessary to determine its maximum tolerated dose, toxicity, safety, efficacy, or efficacy as compared with a standard means of treatment or diagnosis. Reliable evidence means only published reports and articles in the authoritative medical and scientific literature, the written protocol or protocols used by the treating facility or the protocol(s) of another facility studying substantially the same drug, device, medical treatment, or procedure, or the written informed consent used by the treating facility or by another facility studying substantially the same drug, device, medical treatment, or procedure.

15. Charges for a private hospital room.16. Services for which you have other health coverage or for which some

other third party is responsible, in accordance with other provisions of this Plan.

17. Services for which payment has been made under Medicare or would have been made if you had applied for Medicare and claimed Medicare benefits, to the extent allowed by law.

18. Services or treatment for which you do not incur a charge or for which you would not incur a charge if you were not covered under this Plan.

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19. Long-term convalescent or custodial, domiciliary, or rest care.20. Injuries or sickness developing from or directly attributable to your

employment or ailment or injury arising out of and in the course of your employment for which there is worker’s compensation or occupational disease law coverage.

21. Service not related to the treatment of an illness or injury, or services or supplies not specifically listed as covered medical services or expenses under the Plan.

22. Personal comfort or entertainment items.23. Charges for home reconstruction, including those arising from special

medical treatments in the patient’s home.24. Services for palliative or cosmetic foot care.25. Maternity benefits or services for performing an abortion (unless

medically necessary to protect the health of the mother) for dependent children.

26. Services for artificial insemination, in vitro fertilization, and/or related charges.

27. Services for treatment leading to or in connection with transsexual surgery.

28. Services for treatment of obesity, except for surgical treatment of morbid obesity.

29. Diet supplements or diet or weight loss programs, except for morbid obesity.

30. Transportation, except local ambulance service.31. Air ambulance charges in excess of $10,000 per service.32. Charges related to an injury, condition, or disease resulting from, or

incurred while committing, an unlawful act, or resulting from being engaged in an unlawful act. If you are convicted of committing or engaging in an unlawful act, then such conviction will serve as proof that you committed or engaged in the unlawful act. However, for purposes of this exclusion, you will also be deemed to have committed or engaged in the unlawful act to the extent that the Trustees determine that you committed or engaged in such unlawful act, based upon the facts and circumstances involved, even if a criminal prosecution does not result, or it does result and you are found not guilty.

33. Charges for holistic testing and treatment.34. Charges for counseling or behavior modification guidance for

smoking, weight control, etc.

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35. Hypnosis.36. Except as otherwise indicated, charges for blood, blood plasma

provided by the American Red Cross, except blood given by and stored for the benefit of the covered person.

37. Charges for hearing aids or eye infractions or fitting of glasses or hearing aids, except for benefits under the Plan’s vision and/or hearing aid benefits.

38. Expenses for services or supplies to the extent the person receives payment or reimbursement for such expenses as a result of legal action or settlement.

39. Expenses for genetically engineered treatment or genetic testing.40. Expenses for a medical opinion beyond the first and second medical

opinion.41. Expenses incurred as a result of a self-inflicted injury or disease, except

injuries stemming from mental or medical conditions as required by HIPAA or other regulations.

42. Any service, treatment, or items that you are covered for through no-fault automobile insurance, worker’s compensation, or similar legislation, even if you have failed to claim or apply for such coverage.

43. Paternity blood tests.44. Hospital charges that are in excess of the daily semi-private room and

board rate on an expense-incurred basis.45. Services or supplies received as a result of an act of war.46. Examinations in connection with a hearing aid or in connection

with cosmetic surgery. However, cosmetic surgery does not include reconstructive surgery:

a. Incidental to or following surgery for injury or disease to the involved part; or

b. To correct a functional defect due to a congenital disease or anomaly of a covered child.

47. Nursing, speech therapy, physiotherapy, or home health care rendered by yourself, spouse, or a child, brother, sister, or parent of yourself or spouse.

48. Expenses applied toward satisfaction of the deductible previously described.

49. Out of hospital drugs and medicines dispensed by a licensed pharmacist, except as otherwise covered by the Plan’s prescription drug benefits.

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50. Treatment of periodontal or periapical disease or any condition (other than a malignant tumor) involving teeth, surrounding tissue, or structure. This exclusion does not apply to charges for dental services received within 12 months after an accident, including treatment by a physician, dentist, or dental surgeon of injuries to natural teeth including replacement of such teeth and related X-Rays.

51. Mental Illness treatment must be directly related to a mental illness (as defined). Benefits are not payable for care primarily directed at raising the level of consciousness, social enhancement, retraining, professional training, educational therapy, mental retardation, developmental delays, cognitive training, or counseling limited to everyday problems of living, marriage counseling, family counseling, sex therapy, or support groups. Under no circumstances will benefits be provided for therapy that includes the satisfaction of requirements for professional training.

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ClaIMs anD aPPeals PRoCeDUResFiling ClaimsYou should file any initial claim for Plan benefits within two years after the date you received treatment. If you do not, your claim may be denied. If a claim is denied, in whole or in part, there is a process you can follow to have your claim reviewed by the Trustees.Medical Claims

When you receive medical treatment, you must present your identification (ID) card at the time of your visit. All network providers submit claim forms for you. Benefits are then paid directly to the doctor or hospital providing the services. You will receive an explanation of benefits (EOB) for all claims received. Your ID card provides the group and identification number the provider will need to submit your claim. While it is preferred that all claims be submitted electronically, paper claims may be mailed to the address in the Contact Information section on page 21.Prescription Drug Claims

Each time you need a prescription filled, be sure to present your ID card. Network pharmacies will submit claims electronically for you. If you need to submit a claim, you can submit the claim to the address shown in the Contact Information section on page 21.Dental, Vision, Hearing Aid, EAP, And Weekly Income Accident And Sickness Benefit Claims

Be sure to submit your claim forms as soon as possible. When completing your claim form be sure to: Fill in the front of the claim

form completely and sign it. If the claim is connected to an accident, be sure to fill in all information related to the accident. If someone else is at fault for the accident, you may be required to sign a subrogation agreement (see page 105) before the Plan will pay benefits for your claim.

Claims should be filed within two years of the date services are received or your claim may be denied.

If you or an eligible dependent has coverage under more than one health care plan, benefits are coordinated (see page 101).With each claim be sure to attach an itemized statement that includes: Patient’s name; Date of service; Itemized charges; Procedure codes; Diagnosis; Receipts (if applicable); and Provider’s name, address,

phone number, and tax ID number.

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Have your doctor fill in and sign the physician’s section.

Have your employer complete the employer portion of the claim form if the claim is for you.

Keep a copy of all claim forms and bills for your records.

You can obtain claim forms from the Fund Office. Send claim forms for dental and vision benefits to Health Economics Group, Inc., 1050 University Avenue, Suite A, Rochester, NY 14607. Send claims for hearing aid, and weekly income accident and sickness benefits to the Fund Office at 244 Paul Road, Rochester, NY 14624. Life Insurance And AD&D Insurance Benefit Claims

If you or your beneficiary needs to file a life insurance and/or AD&D insurance benefit claim, you or your beneficiary should contact the Fund Office. Written proof of your dismemberment or death will need to be provided to the insurance company before benefits are paid. Proof of dismemberment must be provided within 90 days of your loss.

Types Of Health Care ClaimsThere are four types of health care claims, each with its own set of rules, for medical benefits (administered by RMSCO), dental and vision benefits (administered by Health Economics Group, Inc. (HEG)), Health Reimbursement Account (HRA) benefits, prescription drug benefits (administered by Envision Pharmaceutical Services), and health-related Employee Assistance Program (EAP) benefits: Pre-Service Claim. A Pre-Service claim is a claim for benefits where

you must obtain approval in advance of obtaining medical care. Urgent Care Claim. An Urgent Care claim is a Pre-Service claim for

medical care or treatment that, if the time periods for making non-urgent care determinations were applied, could:

• seriously jeopardize your life or health, or your ability to regain maximum function; or

• subject you to severe pain that cannot be adequately managed without the care or treatment for which approval is sought, in the opinion of a doctor with knowledge of your condition.

Concurrent Care Claim. A Concurrent Care claim is a claim involving a pre-approved, ongoing course of treatment, including a request for extension of a course of treatment.

In case of an emergency, have the hospital or a relative call the Fund Office as soon as possible. The person who calls should be able to provide your or your dependent’s: Name and address; Social Security number; and Group number or name.

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Post-Service Claim. A Post-Service claim is any claim for benefits that is not a Pre-Service claim, i.e., prior Plan approval is not required to obtain medical care and payment is being requested for medical care you already received.

Note that claims for Health Reimbursement Account (HRA) benefits, Vision Care Expense benefits, and Prescription Drug benefits are Post-Service claims. The only Pre-Service, Urgent Care or Concurrent Care claims are claims for the self-insured Health Insurance benefits administered by RMSCO and dental benefits administered by HEG.

Initial Claim DecisionsWhen you submit a claim for benefits, the Plan will determine if you are eligible for benefits and calculate the amount of benefits payable, if any. All claims are processed promptly, when complete claim information is received. The Plan will make an initial determination within certain timeframes, as follows:Pre-Service Claims

For Pre-Service claims, you will be notified of the benefit determination (whether adverse or not) by RMSCO or HEG, the third-party administrators, within a reasonable period, but not later than 15 days after the claim has been received. The 15-day period may be extended for up to 15 days for matters beyond the Plan’s control if, before the end of the initial 15-day period, you are notified of the reasons for the extension and of the date by which RMSCO or HEG expects to make a decision. If the extension is needed because you did not submit the information necessary to decide the claim, the notice of extension will describe the required information and you will have 45 days from receipt of the notice to provide the specified information. A decision will then be made within 15 days after the date you supply the requested information or the date by which you must provide the additional information, whichever is earlier. In addition, if the claim is improperly filed, RMSCO or HEG will provide notice within 5 days. Urgent Care Claims

The rules are slightly different for Urgent Care claims (i.e., Pre-Service claims that involve urgent care). For Urgent Care claims, you will be notified by RMSCO or HEG regarding the benefit determination (whether adverse or not) as soon as possible, but not later than 72 hours after the claim has been received – unless you fail to provide sufficient information to decide the claim. If you fail to provide sufficient information or to follow filing procedures, you will be notified as soon as possible, but not later than 24 hours after the claim is received, of the specific information needed to complete the claim. Notification of

In this section, the term Plan means the Fund Office or organization designated by the Trustees for handling claims.

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the decision on that claim will then be provided within 48 hours after RMSCO’s or HEG’s receipt of the requested information or the end of the additional period given to you to provide the information. Notification can be made verbally, provided a written or electronic communication is provided within 3 days of the verbal notification.Concurrent Care Claims

If the Plan has approved an ongoing course of treatment to be provided over a period of time or number of treatments, any reduction or termination by the Plan of the course of treatment is an adverse benefit determination. You will receive notice of such an adverse determination sufficiently in advance of the reduction or termination in order to allow you to appeal and obtain a determination on review before the reduction or termination occurs. In addition, for any request to extend an urgent care ongoing course of treatment beyond the initially prescribed period of time, you will be notified of the decision (whether adverse or not) within 24 hours after the claim is received – if the claim is made at least 24 hours before the end of the initially prescribed period of time or number of treatments. Post-Service Claims

For Post-Service claims, you will be notified of any adverse benefit determination within a reasonable period, but not later than 30 days after the claim is received, by:• RMSCO, the third-party administrator for Health Insurance benefits;• HEG, the third-party administrator for the Dental and Vision benefits; • Envision Pharmaceutical Services, the third-party administrator for

Prescription Drug benefits; or• The Plan, for the Health Reimbursement Account benefit.The 30-day period may be extended up to 15 days for matters beyond the Plan’s control if, before the end of the initial 30-day period, the third-party administrator or the Plan (if applicable), notifies you of the reasons for the extension and of the date by which it expects to make a decision. If the extension is needed because you did not submit the information necessary to decide the claim, the notice of extension will describe the required information and give you at least 45 days from receipt of the notice to provide it. A determination will then be made within 15 days after the date you supply the requested information or the date by which you must provide the additional information, whichever is earlier.

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Prescription Drug Benefit Claims

Claim forms are not needed to obtain prescription drug benefits. Simply present your card and prescription to the pharmacist. That request is not considered a “claim” under these procedures. However, if your request is denied in whole or in part, you may file a claim for benefits by submitting your paid receipts for the prescription drug, along with a completed claim form to:Envision RxOptions2181 E. Aurora Road, Ste. 201Twinsburg, OH 44087For help or to find out the status of your claim, you can call the Member Helpdesk at 800-361-4542. Or, you can access the Envision website at www.envisionrx.com (click on Resource Tools and then Direct Member Reimbursement) for additional information and claim forms. If Envision denies your claim, the rules regarding Post-Service claims apply. If you need a claim form, or have any questions regarding these procedures, call the Fund Office at 585-458-0400.Weekly Income Accident and Sickness Benefits

If your claim for Weekly Income Accident and Sickness benefits is denied in whole or in part for any reason, the Plan will send you a written notice of its decision within 45 days after the Plan has received your claim. This period may be extended for up to two 30-day periods due to matters beyond the Plan’s control. For any extensions, the Plan will provide advance written notice indicating the circumstances requiring the extension and the date by which the Plan expects to make a decision. Any notice of extension will specifically explain the standards on which entitlement to a benefit is based, the unresolved issues that prevent a decision on the claim, and the additional information needed to resolve those issues (if any). You will be given at least 45 days to provide the specified information (if applicable). A decision will then be made within 30 days after the date you supply the requested information or the date by which you must supply the additional information, whichever is earlier. Life Insurance and Accidental Death and Dismemberment Insurance and Non-Health Related Employee Assistance Program Benefits

If your claim for a Non-Health Related Employee Assistance Program benefit is denied in whole or in part for any reason, the Plan will send you a written notice of its decision within 90 days after the Plan has received your claim. If special circumstances require an extension, the Plan will send you written notice of its decision no later than 180 days after the Plan has received your claim. If an extension is necessary, you will be given written notice of the extension before the end of the initial 90-day period. This notice will indicate the special circumstances requiring the extension

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and the date by which the Plan expects to make the benefit determination. Life Insurance and Accidental Death and Dismemberment Insurance benefits will be decided by the insurer within the same timeframe.

Notification of Initial Adverse Benefit DeterminationsThe initial notice of an adverse benefit determination will include: The specific reason(s) for the adverse decision; Reference to the specific Plan provision(s) (including any internal

rules, guidelines, protocols, criteria, etc.) on which the decision was based;

A description of any additional information or material needed to properly process your claim and an explanation of why it is needed;

A description of the Plan’s review procedures and the time limits to appeal the adverse benefit determination, including a statement of your right to bring a civil action under Section 502(a) of ERISA following an adverse benefit determination on review;

In the case of an adverse determination involving a claim for urgent care, a description of the expedited review process applicable to these claims;

The specific internal rule, guideline, or protocol that was relied upon in making the adverse determination, and a statement that a copy of the rule, guideline, or protocol will be provided free of charge upon request; If the adverse determination is based on Medical Necessity or Experimental treatment, either an explanation of the scientific judgment for the determination, applying the Plan’s terms to your medical circumstances, or a statement that such an explanation will be provided free of charge upon request.

Appealing An Adverse Benefit DeterminationAn adverse benefit determination is defined as:1. a denial, reduction, or termination of, or a failure to provide or make

payment (in whole or in part) for a benefit, including any such denial, reduction, or failure to provide or make payment that is based on a determination of a participant’s eligibility to participate in this Plan; and

2. a denial, reduction, or termination of, or a failure to make payment (in whole or in part) for a benefit resulting from the application of any utilization review or failure to cover an item or service for which benefits are otherwise provided because it is determined to be experimental or investigational or not medically necessary or appropriate.

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If you are not satisfied with the reason or reasons for your adverse benefit determination, you may appeal. If you have chosen someone to represent you in making your appeal, then your letter (or your representative’s letter) must state that you have authorized him or her to represent you with respect to your appeal, and you must sign the statement. Otherwise, the Trustees (or their third-party administrators) may not be sure that you have actually authorized someone to represent you. The Trustees (or their third-party administrators) do not want to communicate about your situation to someone unless they are sure he or she is your chosen representative.To appeal an adverse determination of a Medical benefit, you must file your appeal with RMSCO within 180 days after you receive the initial adverse benefit determination. For Medical claims other than Urgent Care claims, the Plan employs a two-level appeal process. If you have your first-level appeal of a Medical claim denied, to go to the second level of appeal, you must file your second-level appeal with RMSCO, Inc. within 45 days from the date of the letter of denial of your first-level appeal. The Board of Trustees will then decide your second-level appeal. RMSCO will decide all appeals of Urgent Care claims and the first level of appeals for Pre-Service and Post-Service claims. The Board of Trustees will decide the second level of appeal on any Pre-Service and Post-Service claims. To appeal an adverse determination of a Dental, Vision, Prescription Drug benefit, a Non-Health Related EAP benefit, or a Weekly Income Accident and Sickness benefit, you must write to the Trustees within 180 days after you receive this Plan’s initial adverse benefit determination.To appeal an adverse determination of the Life Insurance and Accidental Death and Dismemberment Insurance Benefit claim, you must follow the procedures included in that insurance policy and must be given at least 60 days to file an appeal. Notwithstanding anything in this paragraph to the contrary, for Concurrent Claims involving a reduction or termination of a pre-approved, ongoing course of treatment, you will have 180 days to appeal.Special Rule Regarding Urgent Care Claims: If Urgent Care claims are involved, you may request an expedited appeal, either verbally or in writing, and all necessary information, including the Plan’s benefit determination on review, will be transmitted between you and the Plan (or the third-party administrator, as applicable) by telephone, facsimile, or other similarly expeditious method. Further, if the appeal involved an Urgent Care claim, a health care professional with knowledge of your medical condition will be permitted to act as your authorized representative.

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For appeals to the Board of Trustees, your correspondence (or your representative’s correspondence) must include the following statement: “I AM WRITING IN ORDER TO APPEAL YOUR DECISION TO DENY ME BENEFITS. YOUR ADVERSE BENEFIT DETERMINATION WAS DATED _________________, 20____.” If this statement is not included, the Trustees may not understand that you are making an appeal, as opposed to a general inquiry. You will have the opportunity to submit written comments, documents, records, and other information related to the claim for benefits. You will also be provided, upon request and free of charge, reasonable access to, and copies of, all documents, records, and other information relevant to your claim for benefits. The review will take into account all comments, documents, records, and other information submitted related to the claim, without regard to whether the information was submitted or considered in the initial benefit determination. In addition, all appeals other than those involving Life Insurance and Accidental Death and Dismemberment benefits or Non-Health Related EAP benefits must adhere to the following criteria: The review will not afford deference to the initial adverse benefit

determination and will be conducted by an appropriate named fiduciary of the Plan who is neither the individual who made the initial determination nor the subordinate of that individual;

If the adverse benefit determination is based on medical judgment, the Board will consult with a health care professional who has appropriate training and experience in the field of medicine involved in the medical judgment;

The health care professional will not be the individual, if any, who was consulted in connection with the adverse benefit determination that is the subject of the appeal, nor the subordinate of such individual; and

Medical or vocational experts whose advice was obtained on behalf of the Plan, without regard to whether the advice relied upon in making the adverse benefit determination, will be identified.

In most cases, disagreements about benefit eligibility or amounts can be handled informally. If a disagreement is not resolved, there is a formal procedure you can follow to have your claim reconsidered.You must follow and exhaust the Plan’s appeals procedure before you file a lawsuit under ERISA, the federal law governing employee benefits, or initiate proceedings before any administrative agency.

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Determinations On Appeal The Plan’s determination of its decision will be made within certain timeframes. The deadlines differ for the different types of claims as follows: Pre-Service Claims for Medical Benefits: These medical claims are

subject to a two-level appeal process as noted previously. At the first level of appeal, RMSCO, Inc., the third-party administrator, will notify you of the decision on appeal within a reasonable time period appropriate to the medical circumstances, but not later than 15 days after receipt of the request for review. If your first-level appeal is denied and you appeal at the second level to the Board of Trustees, the Board of Trustees will notify you of the decision on appeal within a reasonable time period appropriate to the medical circumstances, but not later than 15 days after the request for review is received.

Urgent Care Claim: RMSCO, Inc. will decide and communicate its decision on appeal as soon as possible, taking into account medical emergencies, but no later than 72 hours after the request for review is received.

Post-Service Claims for Medical Benefits: These medical claims are subject to a two-level appeal process as noted previously. At the first level of appeal, RMSCO, Inc. will notify you of its determination on appeal within 30 days of receipt of the appeal. If your first-level appeal is denied and you appeal to the second level to the Board of Trustees, the Board of Trustees will also notify you of its determination on appeal within 30 days of receipt of the appeal.

Pre-Service Dental Claims: You will be notified by HEG of the decision within a reasonable period of time appropriate to the medical circumstances, but not later than 30 days after receipt of the request for review.

Life Insurance and Accidental Death and Dismemberment Insurance Benefit Claims: Appeals of adverse Accidental Death and Dismemberment Insurance benefit determinations must be decided by the insurance company within 60 days (plus a possible 60-day extension, if necessary).

Weekly Income Accident and Sickness Benefit Claims: Appeals of adverse Weekly Accident and Sickness Benefit claims must be decided by the Trustees within 45 days (plus a possible 45-day extension, if necessary).

All Other Claims: The Trustees, at their next regularly scheduled meeting, will make a determination of appeal. However, if the appeal is received less than 30 days before the meeting, the decision may be made at the second meeting following receipt of the request. If special circumstances require an extension of time for processing, then a decision may be made at the third meeting following the

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date the appeal is made. Before an extension of time commences, you will receive written notice of extension, describing the special circumstances requiring the extension and the date by which the determination will be made. The Plan will notify you of the benefit determination not later than five days after the determination is made.

Notice Content of Adverse Benefit Determination on Review

The Plan’s written notice of the Board’s decision will include the following: The specific reasons for the adverse benefit determination; Reference to specific plan provisions on which the determination is

based; A statement that the claimant is entitled to receive, upon request

and free of charge, reasonable access to, and copies of, all documents, records, and other information relevant to your claim for benefits;

A statement of your right to bring a civil action under Section 502(a) of the Employee Retirement Income Security Act;

If an internal rule, guideline, protocol, or other similar criterion was relied upon in making the adverse benefit determination, the notice will provide either the specific rule, guideline, protocol, or other similar criterion, or a statement that such rule, guideline, protocol, or other similar criterion was relied upon in making the adverse benefit determination and that a copy of such rule, guideline, protocol, or other criterion will be provided free of charge upon request; and

If the adverse benefit determination is based on medical necessity or experimental treatment or similar exclusion or limit, the written notice will contain an explanation of the scientific or clinical judgment for the determination, applying the terms of the Plan to the claimant’s medical circumstances, or a statement that such explanation will be provided upon request.

The Trustees’ Decision is Final and Binding

The Trustees’ (or their designee’s) final decision with respect to their review of your appeal will be final and binding upon you because the Trustees have exclusive authority and discretion to determine all questions of eligibility and entitlement under the Plan. Any legal action against this Plan must be started within 90 days from the date the adverse benefit determination denying your appeal is deposited in the mail to your last known address. Please note that filing a lawsuit without exhausting the Fund’s appeals procedures could limit your right to appeal or cause you to lose benefits to which you would otherwise be entitled.

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Return Of OverpaymentsIf you, or a third party, are paid benefits from the Fund in an improper amount or otherwise receive Plan assets not in compliance with the Plan (known as overpayments or mistaken payments), the Fund has the right to pay the correct benefit amount in accordance with the Plan. In addition, the Trustees have the right to recover any overpayment or mistaken payment made to you or to a third party. The person receiving the overpayment or mistaken payment must pay back the overpayment or mistaken payment to the Fund with interest at 2% per month. The Fund may recover those monies by reducing other benefit payments made to you or on your behalf, by commencing a legal action or by any other methods as the Trustees, in their discretion, determine appropriate. The person receiving the overpayment or mistaken payment must reimburse the Fund for attorneys’ fees and paralegal fees, court costs, disbursements, and any expenses incurred by the Fund in attempting to collect and in collecting the overpayment or mistaken payment of benefits. The determination as to these matters is solely made by the Trustees.

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aDMInIsTRaTIVe InfoRMaTIonCoordination Of BenefitsWhen members of a family are covered under more than one benefit plan, there may be instances of duplication of coverage – two plans paying benefits for the same medical expenses. The Plan’s Coordination of Benefits (COB) provision coordinates the benefits payable by this Plan with similar benefits payable under other plans, excluding weekly income accident and sickness, life insurance, and accidental death and dismemberment insurance benefits. All benefits provided under this Plan are subject to Coordination of Benefits.This Plan follows rules established by law to decide which plan pays first and how much the other plan must pay. The objective is to make sure the combined payments of all plans are no more than your actual bills. When you or your family members are covered by another group plan in addition to this one, this Plan will follow Coordination of Benefit rules to determine which plan is primary and which is secondary. You must submit all bills first to the primary plan. The primary plan must pay its full benefits as if you had no other coverage. If the primary plan denies the claim or does not pay the full bill, you may then submit the balance to the secondary plan.This Plan pays for health care only when you follow this Plan’s rules and procedures. The Plan contains a non profit provision coordinating it with other plans under which an individual is covered so that the total benefits available will not exceed 100% of the allowable expenses. An allowable expense is any necessary, reasonable, and customary expense covered, at least in part, by one of the plans. “Plans” mean: Coverage under a governmental program or provided or required by

statute; No fault coverage to the extent required in policies or contracts by a

motor vehicle insurance statute or similar legislation; and Group coverage or other insurance for a group of individuals,

including student coverage obtained through an educational institution above the high school level.

When a claim is made, the primary plan pays the benefits without regard to any other plans. The secondary plans adjust their benefits so that the total benefits available will not exceed the allowable expenses. No plan pays more than it would without the COB provision.

Injuries and diseases covered under any workers’ compensation program are excluded from coverage under this Plan.

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Which Plan Pays Benefits First

A plan without a coordination provision is always the primary plan. If all plans have a coordination provision: The plan covering the patient as an employee rather than as a

dependent is primary and the others secondary. If a child is covered under both parents’ plans, the plan covering the

parent whose birthday falls earlier in the year pays first. The plan covering the parent whose birthday falls later in the year pays second. If both parents have the same birthday, the plan that covered the parent longer pays first. The plan that covered the other parent for a shorter time pays second.

If a child is covered by parents who are divorced, the plan of the parent with custody pays first. The plan of the spouse of the parent with custody (the step parent) pays second. The plan of the parent without custody pays last.

If none of the bullets above apply, the plan covering the patient longest is primary.

The coordination of benefits provisions are subject to any court order that directs one parent to provide health care coverage for a child.When this Plan is the secondary plan and its payment is reduced to consider the primary plan’s benefits, a record is kept of the reduction. This amount will be used to increase Plan payments on the patient’s later claims in the same calendar year to the extent there are allowable expenses that would not otherwise be fully paid by this Plan and the others.Medicare

Medicare is a multi-part program: Hospital Insurance Benefits for the Aged and Disabled (commonly

referred to as Part A of Medicare) covers hospital benefits, although it also provides other benefits.

Supplementary Medical Insurance Benefits for the Aged and Disabled (commonly referred to as Part B of Medicare) primarily covers physician’s services, although it, too, covers a number of other items and services.

Medicare Advantage (Part C of Medicare) is Medicare’s managed care programs.

Medicare Prescription Drug Coverage (Part D of Medicare) covers prescription drug benefits (and is incorporated into the Medicare Advantage Plans that you may purchase through Sheet Metal Workers Local 46 subsidized (Drug Riders) benefit.

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If you do not enroll for Part B coverage within the three months after reaching age 65, and you stop working or lose eligibility for Plan benefits, you may enroll for Part B coverage within seven months of the first day of the first month in which you are no longer covered by the Plan, without any penalty or waiting period. If you are such an individual and you do not enroll for Part B coverage within this seven month period, you may enroll during the general enrollment period. The general enrollment period occurs between January 1 and March 31 of each year and coverage begins the following July 1.The monthly premium will be assessed a 10% increase for each full 12 months (after age 65) you are not enrolled in Part B coverage. However, months during which you were covered by the Plan are not counted.It’s your (and your dependent’s) responsibility to apply for Medicare. If you or your dependent is eligible for Medicare and want information about enrollment, contact your local Social Security Administration Office three months before your 65th birthday or when you are otherwise eligible for Medicare. Contact your local Social Security Administration Office if you have questions concerning Medicare eligibility, enrollment, or coverage.If you, your spouse, and/or your dependent child are covered by this Plan and by Medicare, and you keep your coverage under this Plan, as long as you remain actively employed, your health care coverage will continue to provide the same benefits and your contributions for coverage will remain the same, and this Plan pays first and Medicare pays second.If you cancel your coverage under this Plan, coverage of your spouse and/or your dependent child(ren) will end; however, they may be entitled to elect COBRA Continuation Coverage. See page 47 for more information on COBRA Continuation Coverage.If you become totally disabled and entitled to Medicare because of your disability, you will no longer be considered actively employed. As a result, once you become entitled to Medicare because of your disability, Medicare pays first and this Plan pays second.If, while you are actively employed, you or any of your covered dependents become entitled to Medicare because of end-stage renal disease (ESRD), this Plan pays first and Medicare pays second for 30 months starting the earlier of: The month in which Medicare ESRD coverage begins; or The first month in which the individual receives a kidney transplant.Then, starting with the 31st month after the start of Medicare coverage, Medicare pays first and this Plan pays second.

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Veterans Affairs Facility Services

If you or your dependent receives services in a U.S. Department of Veterans Affairs hospital or facility for a military service-related illness or injury, benefits are not payable by the Plan.If you or your dependent receives services in a U.S. Department of Veterans Affairs hospital or facility due to any other condition that is not a military service-related illness or injury, benefits are payable by the Plan to the extent those services are medically necessary and the charges are usual and customary.Coordination With Other Coverages

Claims Where A Third Party Is LiableNote: This provision applies to all employees (and pensioners) and their covered spouses and dependents, with respect to the benefits provided under this Plan. For the purposes of this provision, the terms “you” and “your” refer to all employees, pensioners, covered spouses and covered dependents. General

Occasionally, a third party may be liable for your medical expenses. This may occur when a third party is responsible for causing your illness or injury or is otherwise responsible for your medical bills. The rules in this section govern how this Plan pays benefits in such situations.These rules have two purposes. First, the rules ensure that your benefits will be paid promptly. Often, when there is a question of third party liability, many months pass before the third party actually pays. These rules permit this Plan to pay your covered expenses until your dispute with the third party is resolved.

If you or your dependent is covered by this Plan and: Then . . .

Medicaid This Plan pays first and Medicaid pays second.

TRICARE (Civilian Health and Medical Program of the Uniformed Services)

This Plan pays first and TRICARE pays second.

Motor vehicle no-fault coverage required by law

The motor vehicle no-fault coverage pays first, and this Plan pays second.

Any other coverage provided by any other state or federal law

The coverage provided by the other state or federal law pays first and this Plan pays second.

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Second, the rules protect this Plan from bearing the full expense in situations where a third party is liable. Under these rules, once it is determined that a third party is liable in any way for the injuries giving rise to these expenses, this Plan must be reimbursed for the relevant benefits it has advanced to you out of any recovery whatsoever that you receive that is in any way related to the event which caused you to incur the medical expenses.Rights of Subrogation and Reimbursement

If you incur covered expenses for which a third party may be liable, you are required to advise the Plan of that fact. By law, the Plan automatically acquires any and all rights which you may have against the third party.In addition to its subrogation rights, the Plan has the right to be reimbursed for payments made on your behalf under these circumstances. The Plan must be reimbursed from any settlement, judgment, or other payment that you obtain from the liable third party, before any other expenses, including attorneys’ fees, are taken out of the payment. The Plan’s rights of subrogation and reimbursement will not be affected, reduced or eliminated by the make-whole doctrine, comparative fault or the common fund doctrine.The Trustees may, in their sole discretion, require the execution of this Plan’s lien forms by you (or your authorized representative if you are a minor or if you cannot sign) before this Plan pays you any benefits related to such expenses. If the Trustees have required execution of the Plan’s lien forms, no benefits will be provided unless you and your attorney (if any) sign the form. You must also notify the Plan before you retain another attorney or an additional attorney since that attorney must also execute the form. IN NO EVENT SHALL THE FAILURE OF THE TRUSTEES TO REQUIRE EXECUTION OF THE LIEN FORMS DIMINISH OR BE CONSIDERED A WAIVER OF THE PLAN’S RIGHTS OF SUBROGATION AND REIMBURSEMENT.If any disability benefits are paid by the Plan, Section 227 of the New York Workers’ Compensation Law requires that you give notice to the Plan within ninety (90) days of the commencement of any action against a liable third party. You are also required to obtain the written consent of the Plan prior to the compromise of any cause of action.Assignment of Claim

You may not assign any rights or causes of action that you may have against any third-party tort feasor without the express written consent of the Plan. The Trustees, in their sole discretion, may require you to assign your entire claim against the third party to this Plan. If this Plan recovers from the third party any amount in excess of the benefits paid to you, plus the expenses incurred in making the recovery, then the excess will be paid to you.

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Failure to Disclose and/or Cooperate

If you fail to tell this Plan that you have a claim against a third party; if you fail to assign your claim against the third party to this Plan when required to do so (and to cooperate with the Fund’s subsequent recovery efforts); if you fail to require any attorney you subsequently retain to sign the Fund’s lien forms; if you and/or your attorneys fail to reimburse this Plan out of any payment you obtain from the third party; and/or if you fail to fully reimburse the Fund (out of any settlement you receive, or otherwise, even if this Fund reduces the amount of its lien or otherwise limits its rights); then you are personally liable to this Plan for the reimbursement owed to this Plan by the third party as well as for the Plan’s attorney’s fees and costs incurred in recovering that amount from you. This Plan may offset the amount you owe from any future benefit claims, or, if necessary, take legal action against you.

Confidentiality of Protected Health InformationA federal law, the Health Insurance Portability and Accountability Act of 1996 (HIPAA), requires that health plans protect the confidentiality of your Protected Health Information (PHI), effective April 14, 2004. A summary of your rights under HIPAA can be found in the Plan’s privacy notice, which was distributed to you in accordance with HIPAA and which is available from the Plan’s Privacy Official, Joseph Leone.This Plan and the Plan Sponsor (the Plan Sponsor for HIPAA purposes is the Board of Trustees of the Sheet Metal Workers Local 46 Health Fund) will not use or disclose your PHI except as necessary for treatment, payment, health care operations and plan administration, or as permitted or required by law.“Payment” includes activities undertaken by the Plan to determine or fulfill its responsibility for coverage and the provision of Plan benefits that relate to an individual to whom health care is provided. The activities include, but are not limited to: Determination of eligibility, coverage, and cost sharing amounts

(for example, cost of a benefit, Plan maximums, and co-payments as determined for a participant’s claim);

Coordination of benefits; Adjudication of health benefit claims (including appeals and other

payment disputes); Subrogation of health benefit claims;

Protected Health Information (PHI) includes all individually identifiable health information transmitted or maintained by the Plan.

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Establishing contributions to the Plan, including, but not limited to, COBRA Continuation Coverage contributions;

Risk adjusting amounts due based on enrollee health status and demographic characteristics;

Billing, collection activities, and related health care data processing; Claims management and related health care data processing, including

auditing payments, investigating and resolving payment disputes, and responding to participant inquires about payments;

Obtaining payment under a contract for reimbursement (including stop-loss and excess loss insurance);

Medical necessity reviews or reviews of appropriateness of care or justification of charges;

Utilization review, including pre-certification, preauthorization, concurrent review, and retrospective review;

Disclosure to consumer reporting agencies related to reimbursement (the following PHI may be disclosed for payment purposes: name, address, date of birth, Social Security number, payment history, account number, and name and address of the provider and/or health plan); and

Reimbursement to the Plan.“Health care operations” include, but are not limited to, the following activities: Quality assessment; Population-based activities relating to improving health or reducing

health care costs, protocol development, case management and care coordination, disease management, contacting health care providers and patients with information about treatment alternatives, and related functions;

Rating provider and Plan performance, including accreditation, certification, licensing, or credentialing activities;

Underwriting, premium rating, and other activities relating to the creation, renewal or replacement of a contract of health insurance or health benefits, and coding, securing, or placing a contract for reinsurance of risk relating to claims for health care (including stop-loss insurance and excess loss insurance);

Conducting or arranging for medical review, legal services, and auditing functions, including fraud and abuse detection and compliance programs;

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Business planning and development, such as conducting cost-management and planning-related analyses related to managing and operating the Plan, including formulary development and administration, development or improvement of payment methods or coverage policies;

Business management and general administrative activities of the Plan, including, but not limited to:

• Management activities relating to the implementation of and compliance with HIPAA’s administrative simplification requirements; and

• Customer service, including the provision of data analyses for policy holders, Plan sponsors, or other customers.

Only the employees of the Sheet Metal Workers Local 46 Health Fund who assist in the Plan’s administration and the Board of Trustees of the Sheet Metal Workers Local 46 Health Fund will have access to your PHI. These individuals may only have access to use and disclose your PHI for Plan administration functions. This Plan provides a complaint mechanism for resolving non-compliance matters. If these individuals do not comply with the above rules, they will be subject to disciplinary sanctions.By law, the Plan has required all of its business associates to also observe HIPAA’s privacy rules. The Plan will not, without your authorization, use or disclose your PHI for employment-related actions and decisions or in connection with any other benefit or employee benefit plan of the Plan Sponsor.HIPAA provides that this Plan may disclose your PHI to the Plan Sponsor only upon receipt of certification by the Plan Sponsor that it agrees to the following: Not use or further disclose the information other than as permitted or

required by the Plan documents or as required by law; Ensure that any agents, including a subcontractor, to whom its

provides PHI received from this Plan agree to the same restrictions and conditions that apply to the Plan Sponsor with respect to such information;

Not use or disclose the information for employment-related actions and decisions unless authorized by you;

Not use or disclose the information in connection with any other benefit or employee benefit plan of the Plan Sponsor unless authorized by you;

Report to this Plan any use or disclosure of the information that is inconsistent with the uses or disclosures provided for of which it becomes aware;

Make PHI available to you in accordance with HIPAA’s access requirement;

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Make PHI available for amendment and incorporate any amendments to PHI in accordance with HIPAA;

Make available the information required to provide an accounting of disclosures;

Make its internal practices, books, and records relating to the use and disclosure of PHI received from this Plan available to the Secretary of the U.S. Department of Health and Human Services for purposes of determining compliance by this Plan with HIPAA;

If feasible, return or destroy all PHI received from this Plan that the Plan Sponsor still maintains in any form and retain no copies of such information when no longer needed for the purpose for which the disclosure was made, except that, if such return or destruction is not feasible, limit further uses and disclosures to those purposes that make the return or destruction of the information unfeasible; and

Maintain adequate separation between the Plan and the Plan Sponsor. The Plan Sponsor will make such certification to the Plan.

Under HIPAA, you have certain rights with respect to your PHI, including certain rights to see and copy the information and, under certain circumstances, amend the information. You also have the right to file a complaint with this Plan or with the Secretary of the U.S. Department of Health and Human Services, if you believe your rights under HIPAA have been violated.This Plan’s privacy notice provides a summary of your rights under HIPAA’s privacy rules. Please contact Joseph Leone, the Fund’s Privacy Official and Administrator at 585-458-0400 if: You wish to obtain a copy of the notice; You have questions about the privacy of your health information; or You wish to file a complaint under HIPAA.The Plan Sponsor will: Implement administrative, physical and technical safeguards that

reasonably and appropriately protect the confidentiality, integrity, and availability of the electronic protected health information that it creates, receives, maintains or transmits on behalf of the Plan;

Ensure that the adequate separation between the Plan and the Plan Sponsor, as required by HIPAA, with respect to electronic protected health information, is supported by reasonable and appropriate security measures;

Ensure that any agent, including a subcontractor, to whom it provides electronic protected health information agrees to implement reasonable and appropriate security measures to protect the information; and

Appoint Joseph Leone as the HIPAA Security official.

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IMPoRTanT InfoRMaTIon aboUT THe PlanPlan Name

The name of the Plan is the Sheet Metal Workers Local 46 Health Plan.Plan Year

The Plan year is July 1 through June 30. The records of the Plan are kept separately for each Plan year. The Plan was first established on July 1, 1950.Board Of Trustees

A Board of Trustees is responsible for the operation of the Plan. The Board of Trustees consists of employer and union representatives selected by the Sheet Metal and Air Conditioning Contractors’ National Association and the union that have entered into collective bargaining agreements relating to the Plan. If you wish to contact the Board of Trustees, use the address and phone number at the beginning this booklet. The Trustees of this Plan as of January 1, 2012 are:Union Trustees Employer Trustees

Joseph P. Leone John BeilingSheet Metal Workers Local 46 Postler & Jaeckle244 Paul Road 615 South AvenueRochester, NY 14624 Rochester, NY 14620

Donald Steltz Philip M. SomersSheet Metal Workers Local 46 Monroe Piping244 Paul Road P.O. Box 90600Rochester, NY 14624 Rochester, NY 14609 Brian Winters Gavin VogtSheet Metal Workers Local 46 GJV Enterprises Inc.244 Paul Road 201 Murray StreetRochester, NY 14624 Rochester, NY 14606

Plan Sponsor And Plan Administrator

The Board of Trustees is both the Plan Sponsor and Plan Administrator.Identification Numbers

The number assigned to this Plan is 501. The Employer Identification Number (EIN) assigned to the Board of Trustees by the Internal Revenue Service is 16-0760551.

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Agent For Service Of Legal Process

The Plan Administrator is the Plan’s agent for service of legal process. Accordingly, if legal disputes involving the Plan arise, any legal documents may also be served upon any individual Trustee.Source Of Contributions

Employer contributions and employee, dependent, and retiree self-payments are received and held in trust by the Trustees pending payment of benefits and administrative expenses. Employer contributions are determined by the provisions of the collective bargaining agreements in force with the local union affiliated with the Sheet Metal Workers Local 46 Health Fund. The collective bargaining agreements require contributions to the Plan at fixed rates per hour worked.The Fund Office issues each participant a quarterly statement that includes the names of employers and the hours of work reported. Upon written request, you may receive information as to whether a particular employer or organization has entered into a collective bargaining agreement with Sheet Metal Workers Local Union 46 or obtain a copy of the collective bargaining agreement. You are entitled to participate in this Plan if you work under one of the collective bargaining agreements and if your employer makes the required contributions to the Fund on your behalf.Plan Type

This Plan is considered a welfare plan and is maintained for the purpose of providing medical, prescription drug, dental, vision, hearing aid, health reimbursement account, weekly income accident and sickness, life insurance, and accidental death and dismemberment insurance benefits. Plan benefits are shown on the Schedule Of Benefits on page 8.Trust Fund

All assets are held in trust by the Board of Trustees for the purpose of providing benefits to covered participants and defraying reasonable administrative expenses. The Fund’s assets and reserves are managed by professional asset managers selected by the Board of Trustees.

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Insurance Companies/Vendors

Benefit Insurance Companies/Vendors

Medical Benefits

RMSCO, Inc. 115 Continuum DriveLiverpool, NY 13088Phone: 315-448-9000Fax: 315-476-8440

Prescription Drug Benefits

Envision RxOptions (Retail program)2181 East Aurora Road, Suite 201Twinsburg, OH 44087 Phone: 800-361-4542Orchard Pharmaceutical Services (Mail Order) P.O. Box 3094North Canton, OH 44720Phone: 866-909-5170 (call center)Costco Specialty Services (Specialty Medications)Phone: 866-443-0060

Dental BenefitsVision Benefits

Health Economics Group, Inc. (HEG)1050 University Avenue, Suite ARochester, NY 14607Phone: 585-241-9500 or 800-666-6690

Life Insurance and Accidental Death And Dismemberment Insurance Benefits

Aetna Life Insurance Company151 Farmington AveHartford Connecticut 06156Phone: 860-273-2783

Hearing Aid, Health Reimbursement Account, and Weekly Accident and Sickness Benefits

Sheet Metal Workers Local 46 Health Fund244 Paul RoadRochester, NY 14624Phone: 585-458-0400Fax: 585-458-5226Website: www.SMW46benefits.comEmail: [email protected]

Employee Assistance Plan

For pre-certification call:AFL-CIO EAP: 585-426-5710

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Eligibility

The Plan’s requirements with respect to eligibility as well as circumstances that may result in disqualification, ineligibility, or denial or loss of any benefits are described in this booklet, beginning on page 22. The Plan Administrator has broad discretion to determine eligibility for benefits and interpret Plan language. The Plan Administrator’s decisions will receive judicial deference to the extent they do not constitute an abuse of discretion. Participation in the Plan or eligibility for benefits is not a guarantee of employment.Claim Procedures

The procedures to follow for filing a claim for benefits are listed beginning on page 90 of this booklet. If all or any part of a claim is denied, you have the right to request that the Board of Trustees review the matter.Plan Amendment Or Termination

This Plan may be amended, changed, or discontinued at any time without the consent of any covered person by a majority vote of Trustees present and voting at a meeting where a quorum is present. An amendment may be effective prospectively or retroactively and is subject to the limitation of the Trust Agreement and to applicable law and regulations.If the Plan is modified or terminated, you will be notified in writing or as required by law. The Trust may be terminated because of the expiration of all collective bargaining agreements requiring payment of contributions to the Fund, or for any other reason deemed necessary by the Trustees.In the event of a termination, any and all assets remaining after the payment of all obligations and expenses will be used, in accordance with a plan for dissolution adopted by the Trustees, to continue the benefits provided by the existing Plan until such assets have been exhausted or in such manner as will best serve the purposes of the Fund. In no event will assets be paid to or be recoverable by any contributing employer, association, or labor organization.

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ERISA RightsAs a participant in the 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 are entitled to certain rights, as described in this section.Receive Information About Your Plan And Benefits

You have the right to: Examine, without charge, at the Fund Office and at other specified

locations, such as worksites and union halls, all documents governing the Plan. These include insurance contracts, 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. These include insurance contracts, collective bargaining agreements, and copies of the latest annual report (Form 5500 Series) and updated Summary Plan Description/Plan Document. The Plan 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.

Continue Group Health Plan Coverage

You also have the right to: 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/Plan Document and other documents governing the Plan on the rules governing your COBRA Continuation Coverage rights.

Reduce or eliminate exclusionary periods of coverage for pre-existing conditions under your group health plan, if you have creditable coverage from another plan. You should be provided a certificate of creditable coverage, free of charge, from your group health plan or health insurance issuer when:

• You lose coverage under the Plan; • You become entitled to elect COBRA Continuation Coverage; or • Your COBRA Continuation Coverage ends.

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You must request the certificate of creditable coverage before losing coverage or within 24 months after losing coverage. Without evidence of creditable coverage, you may be subject to pre-existing condition exclusion for 12 months (18 months for late enrollees) after your enrollment date in your coverage.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. However, you may not begin any legal action, including proceedings before administrative agencies, until you have followed and exhausted the Plan’s claims and appeals procedures. For instance, if you request a copy of the Summary Plan Description/Plan Document 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 Plan Administrator.If you have a claim for benefits that 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 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.

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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 Employee Benefits Security Administration (EBSA), U.S. Department of Labor at:Nearest Regional Offices:Boston Regional OfficeJ.F.K. Building, Room 575Boston, MA 02203New York Regional Office33 Whitehall Street, Suite 1200New York, NY 10004National Office:Division of Technical Assistance and InquiriesEmployee Benefits Security AdministrationU.S. Department of Labor200 Constitution Avenue N.W.Washington, D.C. 20210866-444-3272For more information on your rights and responsibilities under ERISA or for a list of EBSA offices, contact EBSA by visiting their website at www.dol.gov/ebsa.

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DefInITIonsThese are some of the terms used in this Summary Plan Description. Other terms are described in detail where they are used. Please read the definitions for all terms carefully so you can better understand your benefits. Behavioral Health Partial Hospitalization Program or Day Treatment: This program, which requires pre-authorization, is designed to help individuals with psychiatric illness cope with life circumstances, improve their ability to function and enhance their quality of life. The program may be used as a step-down transition from acute inpatient care or as an alternative to inpatient treatment. It provides clinical diagnostic and treatment services at a level of intensity equal to an inpatient program, but on a less than 24-hour basis. It offers a multi-modal, inter-disciplinary cost-effective alternative to inpatient hospital treatment of certain psychiatric or chemical dependency conditions as determined by the patient’s level of functioning. See the Schedule of Benefits on page 8 for details on coverage levels. Contributing Employer: A Sheet Metal Contractor who is a member of the Sheet Metal and Air Conditioning Contractors’ National Association, and all other contractors employing members of the Sheet Metal Workers International Association, Local 46, entitled to benefits under the Sheet Metal Workers Local 46 Health Fund for the purpose of providing and maintaining group coverage for the benefit of the employees of the employer, provided the employer satisfies the requirements for participation.Durable Medical Equipment: Medical equipment that satisfies all of the following requirements: Generally not useful in the absence of an injury or illness (sickness); Appropriate for use in the home; Can withstand repeated use; Is Medically Necessary; Is not useful or convenient to other household members; and Is not a convenience item or an aid to daily living. Home Health Care Agency: A hospital, agency or organization that meets all of the following requirements: Primarily provides skilled nursing services or other therapeutic services

and is duly licensed by the appropriate licensing authority; Has policies established by a professional group associated with the

agency or organization consisting of at least one physician and at least one registered professional nurse to govern the services provided (it must provide for full-time supervision of such services by a physician or by a registered professional nurse);

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Maintains a complete medical record on each patient; Has a full-time administrator; Is a provider of services under Medicare with respect to covered

members and their families who are entitled to Medicare; and Does not primarily provide custodial care, care or treatment for mental

illness or substance abuse or care for disabled individuals.Hospice Facility: A facility that mainly provides hospice care and nursing services 24 hours a day under the direction of a Registered Nurse (RN) and meets any licensing or certification standards set forth by the jurisdiction in which it operates. It must employ a full-time administrator, physician or RN and maintain complete medical records on each patient. Hospital: A licensed institution that meets all of the following requirements: Primarily provides, for compensation from its patients and on

an inpatient basis, all facilities necessary for medical and surgical treatments, and care of injured and sick persons by or under the supervision of a staff of physicians;

Continuously provides 24 hour a day nursing service by registered professional nurses;

Is not a primary place for rest or for the aged, or a nursing home; Is not primarily a place providing convalescent/skilled nursing care,

rehabilitation care, custodial care, hospice care, treatment of mental illness or substance abuse, a health resort or spa, a sanitarium, or an infirmary at any school, college or camp;

Is a provider of services under Medicare with respect to covered members and their families who are entitled to Medicare; and

Is accredited by the Joint Commission on the Accreditation of Health Care Organizations ( JCAHO).

In addition, a licensed birthing center will qualify under this definition if it: Provides care and treatment during uncomplicated pregnancy, routine

full-term delivery and immediate postpartum care; Provides full-time skilled nursing services; Is staffed and equipped to give Emergency care; Had a written arrangement with a local Hospital for Emergency care; Is a provider of services under Medicare with respect to covered

members and their families who are entitled to Medicare; and Is approved for its stated purpose by the Accreditation Association for

Ambulatory Care.

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Injury: An accidental loss, unforeseen impairment or physical harm inflicted on your body by unexpected, external means.Reasonable and Customary Charge: Generally means the smaller of (a) the charge usually made for the service by the provider who furnishes it; or, (b) the prevailing charge made for the service in the same geographic area by providers of similar professional standing, as determined by the Plan. If the usual and prevailing charge for a service or supply cannot be easily determined because of the unusual nature of the service or supply, the claim administrator will determine to what extent the charge is a reasonable and customary charge, taking into account: (i) the nature and severity of the condition; (ii) the complexity involved; (iii) the degree of professional skill required; and, (iv) any unusual circumstances that require additional time, skills or experience. Sickness (or Illness): An unhealthy condition of the body, a disease, a mental or physical disorder or pregnancy. The term sickness (illness) means all such sicknesses (illnesses) due to the same or related causes, including all complications or recurrences. The term sickness (illness) does not mean an Injury.

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