INDIANA STATE COUNCIL OF PLASTERERS AND CEMENT MASONS

HEALTH AND WELFARE FUND

Plan Document andSummary Plan Description

Amended and Restated

Effective January 2010

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TABLE OF CONTENTS

Letter of Introduction.................................................................................................................. 1

Summary Plan Description......................................................................................................... 2

Contact Information ................................................................................................................... 3

Schedule of Benefits .................................................................................................................. 4

Preferred Provider Organizations............................................................................................... 6

Exceptions to Out-of-Network Level Of Benefits ........................................................................ 7

Benefits Bank Reimbursement Program .................................................................................... 8

Hospital Pre-Certification Program............................................................................................10

Weekly Benefit for Accident and Sickness................................................................................12

Medical Expense Coverage ......................................................................................................13

Covered Medical Charges .....................................................................................................13

Limitations On Covered Medical Charges .................................................................................17

Cosmetic Surgery ..................................................................................................................17Pre-existing Conditions..........................................................................................................17Charges in Connection with Transplants................................................................................18Mental and Nervous Disorders...............................................................................................19Spinal Treatment ...................................................................................................................19Home Health Care Expense Benefits ....................................................................................19Hospice Care Benefits ...........................................................................................................21Wellness Benefits ..................................................................................................................22

Benefits Payable.......................................................................................................................23

Calendar Year Deductible......................................................................................................23Annual Coinsurance Limit ......................................................................................................23

Exclusions.................................................................................................................................24

Prescription Card Service Program...........................................................................................27

Covered Prescription Charges...............................................................................................27Charges Not Covered ............................................................................................................27Charges Not Covered ............................................................................................................27Retail Card Program..............................................................................................................28Mail Order Program ...............................................................................................................28

Preferred Formulary Medications ..............................................................................................29

Termination Of Coverage..........................................................................................................30

Subrogation And Reimbursement .............................................................................................31

Special Medicare Provisions For Large Group Health Plan.......................................................33

Coordination Of Benefits ...........................................................................................................34

Definitions.................................................................................................................................36

Eligibility....................................................................................................................................41

Continuation Of Coverage (COBRA).........................................................................................50

Family And Medical Leave Act ..................................................................................................53

Qualified Medical Child Support Order ......................................................................................53

General Provisions....................................................................................................................54

Procedure For Filing Claims......................................................................................................56

Claim Review Procedures.........................................................................................................58

Claim Denials And Appeals....................................................................................................58Pre-Service Claims Involving Urgent Care.............................................................................58Pre-Service Claims NOT Involving Urgent Care ....................................................................58Concurrent Claims.................................................................................................................58Post Service Claims...............................................................................................................58

Additional Information ...............................................................................................................61

Employee Contributions And Hourly Contribution Rates ........................................................61Plan Funding .........................................................................................................................61Limits Of Liability....................................................................................................................61

HIPAA Privacy And Security Policy ...........................................................................................62

Statement Of ERISA Rights......................................................................................................64

Receive Information About Your Plan and Benefits ...............................................................64Continue Group Health Plan Coverage..................................................................................64Actions By Plan Fiduciaries....................................................................................................64Enforce Your Rights...............................................................................................................65Assistance With Your Questions............................................................................................65

Names Of The Trustees............................................................................................................67

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INDIANA STATE COUNCIL OF PLASTERERS AND CEMENT MASONSHEALTH AND WELFARE FUND

P.O. Box 50440Indianapolis, Indiana 46250-0440

TO ALL OUR MEMBERS:

In serving your interests, we realize that we have a responsibility to provide you and your family with the greatest measure of security. Therefore, it is with a great deal of pleasure that we inform you of the benefits under your Welfare Fund.

Your Trustees, after careful examination of all available benefits, have selected a program that provides Life Insurance, Accidental Death and Dismemberment Insurance, Weekly Disability Income and Medical Benefits as described in this booklet. All Members and Dependents of Members will participate in this program subject to the eligibility provisions as set forth in this booklet.

Only the full Board of Trustees is authorized to administer and interpret the Plan described in this booklet. The Board has the sole discretion to decide all questions about this Plan, including questions about your eligibility for benefits and the benefit payments. The Trustees’ exercise of this discretion shall be afforded the greatest deference afforded under applicable law. No individual Trustee, employer or union representative has authority to interpret this Plan on behalf of the Board or to act as an agent of the Board.

The Board of Trustees has authorized HealthSCOPE Benefits to respond, in writing, to your written questions. If you have an important question about your benefits, you should write to the HealthSCOPE Benefits for a definitive answer.

As a courtesy to you, HealthSCOPE Benefits may also respond informally to oral questions. However, oral information and answers are not binding upon the Board of Trustees and cannot be relied on in any dispute concerning your benefits.

Sincerely,

EMPLOYER TRUSTEES EMPLOYEE TRUSTEES

Fred H. Lusk Pat HansenThomas P. Eulitt Kevin WildesRonald W. Hook John DavisJeff Swan Tom Kleban Rebecca Underwood Mark McCleskeyRuss VanOverberghe Russell RedmonRobert Webster Tom Webster

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SUMMARY PLAN DESCRIPTION

The Employee Retirement Income Security Act of 1974 requires that a welfare benefit plan is established and maintained pursuant to a written Plan document (herein referred to as the “Plan”), and that certain information be furnished to each Plan Participant (herein referred to as a “Participant” or “Member”) in Summary Plan Description. This document serves as the Plan document and your Summary Plan Description. Contributions to this Plan are made by contributing Participating Employers and under certain circumstances by Participants.

1. Name of the Plan. Indiana State Council of Plasterers and Cement Masons Health and Welfare Fund

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

3. Plan Identification Numbers. The Plan Number assigned to this Trust by the Board of Trustees pursuant to instructions of the Internal Revenue Service is 501. The Identification Number assigned to the Board of Trustees by the Internal Revenue Service is 35-6073275.

4. This Plan is Administered by—HealthSCOPE Benefits.5. Agent for Service for Legal Process. Trustees of Indiana State Council of Plasterers and Cement

Masons Health and Welfare Fund, 9045 East 59th Street, Indianapolis, Indiana 46216.6. Statement of Name, Street Address of Location Where the Plan may be Reviewed.

HealthSCOPE Benefits, 9045 East 59th Street, Indianapolis, Indiana 46216.7. The Plan Year. The records of the Plan are kept separately for each Plan year. The Plan year

begins on November 1 and ends on October 31. 8. Name, Street Address, and Telephone Number of Claims Paying Offices. HealthSCOPE

Benefits, 9045 East 59th Street, Indianapolis, Indiana 46216, (317)554-9000.9. Name and Street Address of Parties Responsible for Review of Denied or Compromised

Claims. Trustees of the Indiana State Council of Plasterers and Cement Masons Health and Welfare Fund, 9045 East 59th Street, Indianapolis, Indiana 46216.

10. Collective Bargaining Agreement. This Plan is maintained pursuant to Collective Bargaining Agreements between the Employers and Local Union. Information as to whether a particular Employer is signatory to a Collective Bargaining Agreement which requires contributions to the Fund can be obtained by a Participant upon written request.

11. Source of Contributions. The benefits described in this Booklet are provided through Employer Contributions. The amount of Employer Contributions and the Employees on whose behalf Contributions are made are determined by the provisions of the Collective Bargaining Agreements.

12. Fund’s Assets and Reserves. All assets are held in trust by the Board of Trustees for the purpose of providing benefits to eligible Participants and defraying reasonable administrative expenses. The Trust’s assets and reserves are invested as directed by the Board of Trustees.

13. Type of Plan. This is a Welfare Plan maintained for the purpose of providing benefits to eligible Participants as described herein.

14. Eligibility and Benefits. The type of benefits provided and the Plan’s requirements with respect to eligibility as well as circumstances that may result in the disqualification, ineligibility, or denial or loss of any benefits are fully described in this summary.

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Indiana State Council of Plasterers and Cement Masons Health & Welfare Fund

Contact Information

If You Have A Question About… Contact…

Medical Benefits For claims:

Plan Administratorc/o HealthSCOPE Benefits.P.O. Box 50440Indianapolis, IN 46250-0440(800) 403-0423(317) 554-9000www.healthscopebenefits.com

For In-Network provider information:

Anthem (IN, KY, MO)www.anthem.com

BC/BS of Illinois (IL)www.bcbsil.com

For Utilization Review:

HealthSCOPE Benefits1-800-403-0423

Prescription Drug Benefits For Retail Card and Mail Order Programs:Caremark

2211 Sanders Road, NBT5 Northbrook, IL (888) 784-6333 www.caremark.com

Short Term Disability Benefit ClaimsDeath and Accidental Death &

Dismemberment (AD&D) Benefit Claims

Third Party Administrator c/o HealthSCOPE Benefits P.O. Box 50440 Indianapolis, IN 46250-0440 (800) 403-0423 (317) 554-9000

MRI, MRA, PET and CT Scans Benefit Claims Call Diagnostic Benefit

Management to schedule your MRI, MRA, or CT Scan for maximum benefits.

Diagnostic Benefit Management (DBM) (800) 331-5720 www.diatri.net

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Indiana State Council of Plasterers and Cement Masons Health & Welfare Fund

Schedule of Benefits

Life Insurance And Accidental Death and Dismemberment Benefits

Class Description Life Insurance Benefit Amount

Covered Active Members and Retirees less than 65 years of age:

Member - $12,500 (Life & Accidental Death/Dismemberment)Spouse - $4,000 Child - $100 (Dependent Child 15 days to 6 months) $2,000 (Dependent Child 6 months or older)

Covered Retirees 65 years or older:

Member - $7,500 (Life Insurance Only)

Active Employees OnlyShort Term Disability Income Benefit Benefit/Special Limits

Benefit Amount Maximum Number of WeeksBenefits Begin – Accident - Sickness

$250 Weekly Benefit261st Day (Daily benefit is 1/7 of Weekly Benefit)8th Day

All ParticipantsComprehensive Major Medical Expense Benefits

COVERED SERVICE OR PLAN CATEGORY

IN NETWORK OUT OF NETWORK

Maximum Lifetime Benefit $1,500,000 per person for all benefits

Individual Deductible: $ 500 Family Deductible: $1,000

Calendar Year Deductible Co-pays do not count toward the Deductibles. Co-pays apply even after the Deductible is met.

Additional Hospital Deductible

$ 250Applies only if covered member does not comply with the Hospital Pre-Admission Certification Program

Non-Emergency Use of Emergency Room Additional Deductible

$ 200Additional deductible applies to each Non-Emergency use of an Emergency Room

Coinsurance 80% of Eligible Expenses 60% of Eligible Expenses

Per Member: $12,500Per Family: $25,000

Coinsurance Limits **(Covered Charges subject to Coinsurance)

Co-pays and Deductibles do not count toward the Coinsurance Limits. Co-pays apply even after the Coinsurance Limit is met. Eligible expenses in excess of the coinsurance limits are paid at 100%

Wellness Benefit 100% to $500 calendar year maximum. Charges in excess of $500, deductible and coinsurance applies.

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IN NETWORK OUT OF NETWORK

MRI, MRA, PET and CT Scans

If Diagnostic Benefit Management (DBM) is used, covered at 100%. Non-DBM charges subject to deductible and coinsurance.

Plan pays 80% of Covered Medical Charges after Deductible

Plan pays 60% of Covered Medical Charges after Deductible

Temporomandibular Joint Disorder (TMJ) treatment

$2,500 Lifetime maximum per person

Spinal Treatment**Plan pays 100% of Covered Medical Charges up to $30 per Visit, and no more than 26 Visits per year.

Plan pays 80% of Covered Medical Charges after Deductible up to $40 per visit

Plan pays 60% of Covered Medical Charges after Deductible up to $40 per visit Home Health Care Services

Limited to 100 visits per calendar year

Plan pays 50% of Covered Medical Charges, after Deductible

Outpatient Mental/Nervous Treatment** Outpatient 50 visits per calendar year,

100 visits maximum per lifetime.

Retail Card Program: (30 days supply or 100 units) Copays: $15 - Generic Drugs $40 - Preferred Brand Drugs $75 - Non-Preferred Brand Drugs

Prescription Drug Benefit**Mail Order Program: (90 days supply) Copays: $30 – Generic Drugs $80 – Preferred Brand Drugs $150 – Non-Preferred Drugs

Diabetic Insulin, Needles, Syringes and Supplies**

Deductible Waived, paid at 80% of Covered Medical Charges

Organ Transplants

Organ Transplants and associated expenses will be limited to a lifetime maximum benefit of $250,000, if a Centers of Excellence is not used. If you or a Dependent need services for an organ transplant, YOU MUST CONTACT HEALTHSCOPE for pre-authorization of the services, and to determine maximum benefits available.

Maximum Hospital Daily Room Allowance: Avg. Semi-Private Daily Hospital Room Allowance Maximum Intensive Care Facility Daily Room Allowance:

3 times Average Semi-Private

** These charges do not count toward your coinsurance limit, and will not be paid at 100%

Dependent children are covered from birth for medically diagnosed congenital defects, birth defects, birth abnormalities, and hereditary complications. Routine charges are covered.

Maternity benefits are available only for Covered Members and their Spouses.

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PREFERRED PROVIDER ORGANIZATIONS

To help control medical costs, the Health and Welfare Plan has an agreement with a Preferred Provider Organization regarding In-Network Providers (In-Network Providers). In-Network Providers refer to a group of Hospitals and providers that agree to provide services at fees that are generally lower than those normally charged by other Hospitals or providers.

To minimize your out-of-pocket costs, contact the Preferred Provider Organization for information on which Hospitals and providers belong to the Network. When you use In-Network Hospitals and providers rather than Out-of-Network Hospitals and providers, you can reduce costs for both you and the Plan. You may use any provider you wish, but the Plan pays a higher percentage of your Covered Charges when you use a provider in the Network. As referred to in this section, an “Out-of-Network” provider does not have an agreement in effect with the Preferred Provider Organization. When you use In-Network Providers, you do not need to file claims. The In-Network Provider Organization files the claims for you. It is the Participant’s responsibility to call the Preferred Provider Organization prior to each hospitalization or doctor visit to determine whether the facility and/or provider is a member of the Network. If you need a listing of In-Network Providers, contact the In-Network Provider Organization. If you have a question about In-Network Providers, see “Contact Information” in this summary.

Diagnostic Benefit Management Network (DBM) a DiaTri company

The Plan has an agreement with Diagnostic Benefit Management (DBM) to assist you in reducing your costs for MRI, MRA, PET, and CT Scan procedures prescribed by your Physician and considered Medically Necessary under the Covered Charges section of this Plan.

If your doctor prescribes an MRI, MRA, PET, or CT Scan, you and your doctor should call DBM at the number listed in the Contact Information page, to schedule the exam. When contacting DBM, it must be stated that you are a Participant in the Indiana Plasterers and Cement Masons Health & Welfare Fund in order to receive proper benefits. If you use the facility to which DBM refers you, then the Plan will pay 100% of the cost of the MRI, MRA, PET, or CT Scan, and you will not be required to pay any deductible or co-payment, provided you are eligible for coverage under this Plan at the time of service.

On the day of your appointment, as you are registering for your exam, remind the facility that you were scheduled through DBM as a Participant in the Indiana State Council of Plasterers and Cement Masons Health and Welfare Plan and give them DBM’s toll free telephone number(see Contact Information in this summary). DBM will handle the rest. You will not have to complete claim forms or pay for the MRI, MRA, PET, or CT Scan, if the service is covered under the DBM agreement.

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EXCEPTIONS TO OUT-OF-NETWORK LEVEL OF BENEFITS

The following listing of exceptions represents services and supplies rendered by a non-preferred provider where eligible expenses shall be payable at the preferred provider level of benefits:

1. Emergency treatment rendered at a non-preferred facility;2. Non-preferred anesthesiologist if the operating surgeon is a preferred provider;3. Radiologist or pathologist services for interpretation of x-rays and laboratory tests rendered by a non-

preferred provider when the facility rendering such service is a preferred provider;4. Emergency room physician services rendered by a non-preferred provider when the facility rendering

such services is a preferred provider;5. Diagnostic laboratory and pathology tests performed by a non-preferred provider when referred by a

preferred provider;6. While confined to a preferred provider hospital, a consultation from a non-preferred provider

requested by the preferred provider physician;7. The service is not available from a preferred provider;8. Eligible expenses incurred by a covered Dependent when residing outside the service area of the

preferred provider organization; and9. Ambulance charges.

ORGAN TRANSPLANTS AND ASSOCIATED EXPENSES

Organ Transplants and associated expenses will be limited to a lifetime maximum benefit of $250,000, if a Centers of Excellence is not used for the services. If you or an eligible Dependent need services for an organ transplant, you must contact HealthSCOPE Benefits for pre-authorization of the services, and to determine maximum benefits available for the services.

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BENEFITS BANK REIMBURSEMENT PROGRAM

Covered Members may be reimbursed, from their Benefits Bank, monies they have paid “out of pocket” for certain eligible expenses on themselves and their eligible Dependents as described below. In order to be eligible for this benefit, the Member must have the prescribed amount in his Benefits Bank and have a signed authorization form on file with HealthSCOPE Benefits. Authorization forms are available from HealthSCOPE Benefits.

Rules of the Reimbursement Program:

A. A Covered Member will be eligible for reimbursement of any amounts that have been applied to the calendar year deductible and/or co-insurance, provided the Covered Member has more than two (2) quarters of eligibility at the then current cost of program in his Benefits Bank when the reimbursement is calculated. No reimbursement will be made unless the Covered Member has written certification from the Local in which the Covered Member last qualified that: (1) the Covered Member is disabled from work; or (2) the Covered Member is available for work.

B. HealthSCOPE Benefits must have an active authorization form on file at their office at the time such claim is reimbursed.

C. The authorization will allow the member to elect reimbursement at either 100%, 80%, or 50% and will remain in effect until rescinded in writing by the Member.

D. Under no circumstances will the member’s Benefits Bank be allowed through such reimbursement to fall to an amount less than the cost of providing two (2) quarters of coverage.

E. Reimbursement will be made quarterly, following the determination of eligibility for coverage and calculation of the Benefits Bank balance.

F. If after this calculation funds are available, reimbursement will be made up to any amounts available in the Benefits Bank which exceeds the minimum of two (2) quarters of coverage. Under no circumstances will reimbursement be made for periods prior to HealthSCOPE Benefits receiving a signed authorization form.

Reimbursement Schedule

Covers Claims Processed Authorization mustReimbursement Date during these months be on file prior to:February 10 November, December, January January 25May 10 February, March, April April 25August 10 May, June, July July 25November 10 August, September, October October 25

G. The claim must be paid within 6 months after December 31 of the year in which the claim was incurred.

H. In no event will a payment of less than $5 be issued.

I. An administrative fee of $10.00 is charged for each check that is issued.

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BENEFITS BANK REIMBURSEMENT PROGRAM

Expenses eligible for reimbursement:

A. Eligible medical deductible and coinsurance expenses will be determined by the Plan Administrator. The Plan Administrator will review all eligible claims paid by the Plan in the previous 3 calendar months and will reimburse the applicable percentage.

B. In most cases, if prescription drugs are purchased through the Prescription Card Service Program, eligible prescription drug copays will be determined by the Plan Administrator. Otherwise, eligible prescription drug copays would be those prescription drug copays for which the Member provides a receipt showing the patient name, drug name, date of fill, and the amount of the copay.

C. Eligible dental expenses would be those dental expenses rendered by properly licensed providers for which the member provides a bill showing the Member, the claimant, an itemization of the services rendered, the date the services were rendered, and an amount for each service.

D. Eligible vision expenses would include services rendered by properly licensed providers and include exams, lenses, frames, and contact lenses. Charges for refractive eye surgery are also eligible under the Reimbursement Program. The member would have to file a bill showing the Member, claimant, an itemization of the services rendered, and an amount for each service.

E. Charges for hearing aids are eligible under the Reimbursement Program. The member would have to file a bill showing the Member, claimant, an itemization of the services rendered, and an amount for each service.

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HOSPITAL PRE-CERTIFICATION PROGRAM

The Hospital Pre-Certification Program requires that any in-patient hospital admission, for you or a Dependent, must be pre-certified in order for you to receive the maximum benefits of this Plan. The toll-free number shown on your benefit identification card must be called to request certification and supply needed information. IT IS YOUR RESPONSIBILITY TO ENSURE THAT CERTIFICATION IS OBTAINED FOR ANY IN-PATIENT HOSPITAL CONFINEMENT.

All elective admissions must be pre-certified at least 24 hours prior to actual hospitalization. Non-elective (urgent and emergency) admissions do not require pre-admission certification; however, certification is required and must be initiated within 48 hours (two working days) of the admission.

Certification Guidelines

Type of Admission Definition Request Review

Elective The patient’s condition permits Up to 30 days in advance.(non-emergency) adequate time to schedule a Review must be completed and

suitable accommodation. case certified at least 24 hours prior to actual hospital admission.

Non-Elective The patient requires immediate Within 48 hours(Urgent) attention for the care and (2 working days)

treatment of a physical or following admission. mental disorder.

(Emergency) The patient requires immediate Within 48 hours medical intervention as a result (2 working days) of a severe, life threatening or following admission. disabling condition. Patient is usually admitted through the Emergency Room.

Urgent or Emergency Admissions include admissions for childbirth.

Certification is valid only for the specific hospitalization for which it is obtained.

ADDITIONAL HOSPITAL DEDUCTIBLE

If your hospital admission has not been certified as indicated above, you will be required to satisfy an additional deductible for each confinement. The additional deductible is $250 for each hospital confinement that is not properly certified. This Additional Hospital Deductible does not count toward satisfying the Medical Deductible or any out-of-pocket maximum specified in the Plan.

Also, the member runs the risk that all or part of the hospitalization will not be deemed Medically Necessary, and, therefore, not covered at all.

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CONTINUED STAY REVIEW PROGRAM

If your doctor determines it is Medically Necessary or appropriate for you or your Dependent to stay in the hospital for a greater length of time than initially certified, you may call the toll-free number on your benefit identification card to report the additional information for the longer hospital confinement. However, this is not essential as the Utilization Review Coordinator will contact your health care provider to conduct additional reviews during your hospitalization to assure Medically Necessary care is provided.

Precertification does not guarantee either payment of benefits under this plan or the amount of benefits. Eligibility for and payment of benefits are subject to all of the terms of the Plan.

Precertification is intended solely for the purpose of reviewing proposed services and is not to be construed as medical opinion or advice.

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ACCIDENT AND SICKNESSWEEKLY BENEFITS

For Active Members Only

If, while covered, you become wholly and continuously disabled by accidental injury or sickness so that you cannot work, benefits will be paid to you provided:

1. you are under the direct care of a physician, and2. after the Elimination Period (See Schedule of Benefits).

BENEFITS PAYABLE

Weekly Benefits are payable up to the Maximum Number of Weeks as shown in the Schedule of Benefits. One-seventh of the Weekly Benefit is payable for each full day you are disabled. No benefit will be paid for part of a day.

PERIODS OF DISABILITY

Periods of disability will be treated as separate periods when:1. separated by at least two consecutive weeks of work as a Full-time Active Member; or2. due to unrelated causes and begins after the termination of the current period of disability.

In any other case, they will be treated as one period.

Periods of disability as a result of pregnancy will be payable as any other illness.

EXCLUSION

Your Weekly Benefits will not be paid when your disability is connected with your employment and you are entitled to benefits under any Worker’s Compensation Law or Occupational Disease Law.

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MEDICAL EXPENSE COVERAGE

COVERED MEDICAL CHARGESCovered Medical Charges means charges which are:1. for Medically Necessary services, supplies, care or treatment; and2. due to Sickness or Injury; and3. prescribed, performed, or ordered by a Physician; and4. Reasonable and Customary Charges; and5. incurred while you and your Dependents are covered under this Plan; and6. if they are not excluded; and7. charges are deemed to be incurred on the date the service is performed or the supply is purchased;

and8. up to any maximums shown in the Schedule of Benefits, including only these charges:

a. HOSPITAL CHARGES FOR:i. Room and Board; andii. other Inpatient and Outpatient services and supplies; andiii. therapeutic supplies and drugs, including but not limited to non-legend vitamins and

minerals, over the counter medications, oral swabs and toothettes, and smoking cessation medications (including gum, pills, patches and inhalers); and

iv. confinement in an Intensive Care Unit. Such confinement must be:a) ordered by a Physician; andb) due to a condition that requires special medical and nursing treatment not generally

provided to other Inpatients of the Hospital.

b. CONVALESCENT OR SKILLED NURSING FACILITY CHARGES FOR:i. Room and board; andii. other services and supplies.

These charges must be incurred while:a) confined as an Inpatient; andb) under the continuous care of a Physician. The Physician must certify that confinement in

a Convalescent or Skilled Nursing Facility is in lieu of a Hospital confinement.

c. AMBULANCE CHARGES for transportation of a Covered Member by a professional ambulance service to the nearest:i. Hospital or Convalescent or Skilled Nursing Facility for Inpatient care; orii. Hospital for emergency accident care.

d. TRANSPORTATION CHARGES for regularly scheduled commercial transportation by train or plane within the continental United States and Canada to the nearest Hospital that can provide Inpatient treatment not available locally.

e. AMBULATORY SURGICAL CHARGES for necessary services and supplies if:i. these charges are due to surgery; andii. benefits for these charges would have been payable if the surgery had been done in a

Hospital.

f. SURGEON’S CHARGES by a Physician for the performance of surgical procedures.

g. PHYSICIAN’S CHARGES for medical care and treatment, other than:i. surgical procedures; andii. related post-operative care.

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h. ANESTHESIA CHARGES and its administration when these are not covered as Hospital charges.

i. NURSING, PHYSIOTHERAPY, AND OCCUPATIONAL THERAPY CHARGES FOR:i. private duty nursing care by a Nurse; andii. treatment by a licensed physiotherapist; andiii. treatment by a licensed occupational therapist.

The person providing the care must not live with or be related to the Covered Member or to his or her spouse.

j. RADIOLOGICAL AND LABORATORY CHARGES FOR:i. x-rays; andii. radiological treatment; andiii. diagnostic laboratory tests.

k. MEDICAL SUPPLY CHARGES FOR:i. oxygen, blood, plasma; andii. casts, splints, trusses, braces, crutches, and surgical dressings; andiii. purchase of needles and syringes; andiv. artificial eyes and limbs for:

a) the initial replacement of natural eyes and limbs; andb) replacement of such artificial limbs only if the replacement is due to body growth of a

covered child; andv. purchase of a breast prosthesis for the initial replacement of a breast surgically removed; andvi. the initial purchase of eyeglasses or contact lenses due to cataract surgery performed; andvii. rental of manually operated wheelchairs and hospital beds, oxygen equipment and other

durable medical equipment that is used solely by the Covered Member for the treatment of his or her Sickness or Injury. The Plan may, at its discretion, approve purchase of such items.

l. PRESCRIPTION DRUG CHARGES for drugs and medicines that:i. one may get only on a Physician’s written prescription;ii. are dispensed only by a licensed pharmacist;iii. are charges for injectable insulin;iv. are not covered under the Prescription Drug Card Benefit.

m. OUTPATIENT SURGERYCharges that are incurred in connection with surgery which results from an illness or injury, and which is performed other than while the individual is confined as a registered bed patient in a hospital:i. Eligible charges by a legally qualified physician for such surgery; andii. Facility charges and hospital-type charges.

n. SECOND SURGICAL OPINION FOR:Charges for a second surgical opinion consultation.“Second surgical opinion” means an evaluation of the need for surgery by a second doctor (or third doctor if the opinions of the doctor recommending surgery and the second doctor are in conflict), including the doctor’s exam of the patient and diagnostic testing.

o. Charges for wellness benefits in excess of the $500 maximum benefit.

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p. OrthoticsEligible charges include the initial purchase, fitting and repair of braces, splints and other appliances used to support or restrain a weak or deformed body part.

Charges for orthopedic braces (including corrective shoes if attached to the brace), crutches and prosthetic devices and appliances, including the initial purchase, fitting, repair and initial placement of fitted devices which replace body parts or perform body functions necessary for the alleviation of or correction of conditions arising out of accidental injury or illness shall be considered an eligible expense. Appliances for palliative treatment of the foot such as, but not limited to: heel lifts, footpads and arch supports are not covered. Custom molded orthotics are not covered unless specifically included as an eligible expense under Podiatry Services in this section. Corrective or orthopedic shoes not attached to a brace are not covered.

Replacement of any of the above following five (5) years from the date of original placement, unless growth and development of the participant necessitates earlier replacement.

Replacement of any of the above will only be covered if Medically Necessary and not as the result of loss, theft or damage.

q. Podiatry ServicesCharges made by a physician for visits, surgery or treatment of medical conditions of the feet. Eligible expenses shall include:i. capsular or bone surgery for treatment of bunions;ii. complete or partial removal of the nail or nail matrix affected by disease, infection, or

fungus;iii. surgical procedures or injections involving the bones, nerves, muscles or tendons of the foot

or ankle;iv. custom molded orthotics for acquired deformities of the foot such as claw toe, hallux rigidus,

hallux valgus, hallux flexus, hallux malleus and hallux varus; orv. cutting or removal of corns, calluses or toenails if done in connection with an underlying

medical condition such as diabetes or peripheral vascular disease.

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NOTICE TO PARTICIPANTS

WOMEN’S HEALTH AND CANCER ACT OF 1998

On October 21, 1998, Congress enacted the Women’s Health and Cancer Act of 1998 (“the Act”). The Act applies specifically to treatment that may be sought by Plan participants related to a mastectomy. Because your Plan provides medical and surgical benefits for a Medically Necessary mastectomy, after the Act takes affect it will be required to provide coverage for the following:

i. Treatment for reconstruction of the breast on which the mastectomy has been performed;

ii. Surgery for reconstruction of the other breast to produce a symmetrical appearance; and,

iii. Prostheses and physical complications at all stages of the mastectomy, including lymphedemas.

Such coverage may be subject to the Plan’s annual deductibles and coinsurance provisions as may be deemed appropriate, consistent with those established for other benefits under your Plan.

If you have any questions about the Act, its effective date, or its application to your Plan, please contact your Plan Administrator.

NEWBORN’S AND MOTHER’S HEALTH PROTECTION ACT

Statement of Rights Under the Newborns’ and Mothers’ Health Protection ActUnder federal law this Plan 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 (e.g. your physician, nurse midwife, or physician assistant), after consultation with the mother, discharges the mother or newborn earlier.

Also, under federal law, this Plan 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, this Plan may not, under federal law, 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). However, to use certain providers or facilities, or to reduce your out-of-pocket costs, you may be required to obtain precertification. For information on precertification, contact HealthSCOPE Benefits.

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LIMITATIONS ON COVERED MEDICAL CHARGES

Certain Covered Medical Charges are limited. These Covered Medical Charges and their limitations are:

1. Charges in connection with TEETH, GUMS, OR ALVEOLAR PROCESS are covered only for:a. Hospital charges for necessary Inpatient care; andb. treatment of tumors; andc. repair to natural teeth or other body tissue due to an Injury. These benefits are payable only for

charges incurred within 24 months from the date of the Injury.

2. Charges in connection with COSMETIC SURGERY are covered only:a. for the correction of a congenital defect of your Dependent child; andb. for replacement of diseased tissue; andc. for services as required by the Women’s Health and Cancer Act of 1998.

3. Charges in connection with any PRE-EXISTING CONDITION are covered only after an Initial Period of Coverage.Pre-Existing Conditions are conditions for which medical advice, diagnosis, care, or treatment was recommended or received during the six (6) months prior to the Enrollment Date.

An Initial Period of Coverage is a period of twelve (12) consecutive months from the Enrollment Date during which he or she has been continuously covered under this Plan.

Enrollment date means the first day of the month for which hours are worked and employer contributions are received by the Plan.

Benefits for Pre-Existing Conditions during an Initial Period of Coverage are limited to a maximum for all benefits of $2,500. Benefits following the Initial Period of Coverage for Pre-Existing Conditions will be considered at the Plan’s normal coverage limits.

For the purpose of determining whether the Pre-Existing Condition provision shall apply to claims for any Covered Person, the Plan Administrator will look not only to the period of time the Covered Person has been covered under this Plan, but also to any period of previous Creditable Coverage the Covered Person may have earned. However, Creditable Coverage will only be applied to this Plan’s Pre-Existing Condition provision if there has been no break in coverage of sixty-three (63) days or more. If there has been a break in coverage of sixty-three (63) days or more, the Plan Administrator will not apply previous coverage towards this Plan’s Pre-Existing Condition limitation. The period between the Enrollment Date and the date of initial eligibility does not count as a break in coverage unless there is a period of 63 days or more during which no employer contributions are due the Fund.

Example: John worked and had hours/contributions continuously reported on his behalf for the months of January through June of 2009, and became covered by the Plan on August 1, 2009. The Enrollment Date would be January 1, 2009, and the Initial Period of Coverage would be Jan 1 to Dec 31, 2009 (12 months from the Enrollment Date). Any condition for which medical advice, diagnosis, care, or treatment was recommended or received during the period from Jul 1 to Dec 31, 2008 (6 months prior to enrollment) may be considered Pre-Existing.

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The Pre-Existing Condition provision does not apply to reinstated participants for conditions which arose while the participant was covered if such coverage took place within the last year. However, any condition that arose for a reinstated participant during a period while the participant was not covered would be considered a Pre-Existing Condition. Any participant who has a break in coverage of four (4) quarters or more and subsequently regains eligibility is considered a new participant, and will experience another Initial Period of Coverage.

The following conditions are not considered Pre-Existing: Pregnancy; Conditions of newborn children, provided the newborn is otherwise eligible under the Plan; or Conditions of children who are adopted by, or placed for adoption with you:

a) While you are covered by this Plan or other Creditable Coverage; andb) Before they turn eighteen (18).

4. Charges in connection with only the following TRANSPLANTS or replacements of tissue or organs, but only to the extent they are NOT experimental or investigational.a) cornea transplants;b) artery or vein transplants;c) kidney transplants;d) bone marrow transplants;e) heart transplants;f) heart and lung transplants;g) liver transplants;h) heart valve replacements;i) implantable prosthetic lenses in connection with cataracts;j) prosthetic by-pass or replacement vessels;k) bone transplants;l) skin transplants;m) lung transplants;n) stem cell transplants;o) pancreas transplants.

Charges in connection with transplants are subject to the Lifetime Maximum Benefit under this Plan. If a Centers of Excellence is not used, Covered Medical Charges will be limited to a lifetime maximum of $250,000. If services are needed for an organ transplant, you must contact HealthSCOPE for pre-authorization of the services, and to determine the maximum benefits available.

Benefits are payable whether natural or artificial replacement materials or devices are used, so long as the procedure or device is not considered Experimental.

If both the donor and the donee are covered under this Plan, the donor’s and donee’s charges are covered. The total of the donor’s and donee’s charges will not be more than any maximums under this Plan applicable to the donee. If the donor is not covered under this Plan and the donee is covered under this Plan, the donor’s charges will be covered only to the extent that the donor’s charges are not covered under any other coverage or Plan. The total of the donor’s and donee’s

Example: Ed was covered by the Plan through July 31, 2008, at which time he lost coverage due to insufficient contributions, and he chose not to make a self-payment. Ed became covered by the Plan again on August 1, 2009. Because has not been covered by the Plan for at least four (4) quarters, the Pre-Existing Condition provision will apply.

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charges will not be more than any maximums under this Plan applicable to the donee.

If the donor is covered under this Plan and the donee is not covered under this Plan, the donor’s charges and the donee’s charges are not covered.

5. MENTAL AND NERVOUS DISORDERSIf you or your Dependent, while covered under this provision, are treated for mental and nervous disorders, benefits will be payable as follows:

Outpatient BenefitsIf you or your Dependent enters a hospital or a treatment center for outpatient treatment or completes an outpatient program, benefits will be paid up to the maximum Outpatient Benefit as shown in the Schedule of Benefits.

Outpatient Treatment means counseling and therapy given in or through a hospital, a treatment center or an outpatient program certified to give the care. The treatment must:a. be upon the referral of a physician; orb. be under the supervision of a physician or psychotherapist.

6. SPINAL TREATMENTIf a Covered Member or eligible Dependent incurs expense for visits to a physician or surgeon as a result of spinal treatment, the Plan will pay benefits as specified in the Schedule of Benefits.

Definition“Spinal Treatment” means detection or correction (by manual or mechanical means) of:a. structural imbalance;b. distortion; orc. subluxation in the body to remove nerve interference or its effects. The interference must be the

result of or related to distortion, misalignment or subluxation of or in the vertebral column.

ExceptionsBenefits will not be payable for:i. more than one visit to a physician or surgeon each day; orii. any X-ray not performed by or under the supervision of a physician or surgeon.

7. Charges in connection with TEMPOROMANDIBULAR JOINT DISEASE OR SYNDROME are covered only as provided in the SCHEDULE OF BENEFITS.

8. HOME HEALTH CARE EXPENSE BENEFITSHome Health Care Expense Benefits provide payment of eligible health care charges up to the maximum payment for a single visit shown in the Schedule of Benefits. These benefits are payable up to the maximum shown in the Schedule of Benefits, during any one calendar year.

Each visit by a representative of a home health care agency shall be considered as one home health care visit; each four hours of home health care service by a representative shall be considered as one home health care visit.

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9. THE FOLLOWING HOME HEALTH CARE CHARGES (IF NECESSARY, REGULAR AND CUSTOMARY) ARE COVERED:

Charges for any accidental bodily injury: (a) which does not arise out of or in the course of any employment and (b) for which he is adjudicated to be not entitled to benefits under any Worker’s Compensation law; and

Charges for any sickness not entitling him to benefits under any Worker’s Compensation or Occupational Disease law;

Provided such charges:a. are medically necessary for the treatment of a Covered Person who is totally disabled and who, in

the opinion of the attending physician, would otherwise be confined as a registered bed patient in a hospital or skilled nursing facility provided:i. the Covered Person is under the direct care of a legally qualified physician,ii. the plan of treatment covering the Home Health Care is established in writing by the

attending physician prior to commencement of such treatment,iii. the plan of treatment covering Home Health Care is certified by the attending physician at

least once every month, andiv. the Covered Person is examined by the attending physician once every 60 days.

b. are for services which are provided by a home health agency which is an agency or organization meeting the following requirements:i. it is primarily engaged in and is federally certified as a Home Health Agency and is duly

licensed, if such licensing is required, by the appropriate licensing authority to provide nursing and other therapeutic services (as listed in c. below).

ii. its professional service policies are established by a professional group associated with such agency or organization, including at least one legally qualified physician and at least one registered nurse (R.N.), to govern the services provided,

iii. it provides for full-time supervision of such services by a legally qualified physician or by a registered nurse (R.N.),

iv. it maintains a complete medical record of each patient, andv. it has an administrator.

c. are incurred for one or more of the following, unless such charges are otherwise covered under another part of this Plan:i. part-time or intermittent nursing care, by a licensed practical nurse (L.P.N.),ii. part-time or intermittent Home Health Aide services,iii. occupational therapy, provided such therapy is performed by a licensed therapist if licensing

is required by the state in which the therapy is performed,iv. social work, performed by a licensed social worker if licensing is required by the state in

which the social work is performed (if licensing is not required by the state the social worker must have at least a Masters degree in social work with one or more years of clinical social work experience),

v. nutrition services performed by a licensed nutritionist, if licensing is required by the state in which the nutrition services are performed, and

vi. special meals.d. are not excluded charges and are not otherwise excluded from coverage by the terms hereof.

THE FOLLOWING HOME HEALTH CARE CHARGES ARE NOT COVERED

All charges not specifically listed as Covered Medical Charges; andi. Charges for services for which the Covered Person is not, in the absence of this coverage,

legally required to pay;

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ii. Charges for services performed by the Covered Person’s immediate family or any person residing with the Covered Person;

iii. Charges for general housekeeping services, or;iv. Charges for services for custodial care.

10. HOSPICE BENEFITSMedical Benefits will be paid if a Covered Person has Covered Medical Charges for services and supplies furnished directly by a Hospice.

Covered Chargesa. Room and board for confinement in a hospice. b. Services and supplies furnished by the hospice while the patient is confined therein.c. Part-time nursing care by or under the supervision of a registered nurse (R.N.).d. Home Health aide services.e. Nutrition services.f. Special meals.g. Counseling services by a licensed social worker or a licensed pastoral counselor.h. Bereavement counseling by a licensed social worker or a licensed pastoral counselor for the

patient’s immediate family as follows:i. the benefit percentage will be 50% of such services; andii. no more than a maximum of 15 visits will be covered for the patient’s immediate family; andiii. such services will only be covered during the six-month period following the patient’s death.

LimitationsHospice Benefits will only be paid if the Covered Person’s attending physician certifies that:

a. the Covered Person is terminally ill; andb. the Covered Person is expected to die within six months or less.

ANY COVERED CHARGES PAID UNDER HOSPICE BENEFITS WILL NOT BE CONSIDERED A COVERED CHARGE UNDER ANY OTHER BENEFIT IN THIS PLAN.

Definitions“Hospice“ means an agency that provides counseling and medical services and may provide room and board to a terminally ill individual and which meets all of the following tests:

a. It has obtained any required state or governmental Certificate of Need approval.b. It provides services 24 hours a day, 7 days a week.c. It is under the direct supervision of a doctor.d. It has a nurse coordinator who is a registered nurse (R.N.).e. It has a social service coordinator who is licensed.f. It is an agency that has as its primary purpose the provision of hospice services.g. It has a full-time administrator.h. It maintains written records of services provided to the patient.i. It is licensed, if licensing is required.

“Patient’s immediate family“ means the patient’s spouse and children who are covered under this plan.

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11. WELLNESS BENEFITEligible charges for routine physicals will be payable at 100% (Deductible and out-of-pocket waived) up to the maximum listed in the “Schedule of Benefits“ per calendar year; charges in excess of the calendar year maximum will be considered under Major Medical (subject to Deductible and Coinsurance).

Eligible charges include, but are not limited to: the Physician’s office visit charges and related tests, x-rays, lab work, immunizations, inoculations, routine cancer screenings, sports physicals, school physicals, and well baby care. Eligible charges also include one (1) routine eye exam, to include the refraction, per calendar year.

12. Training, education instruction, and educational materials must:a. be prescribed by a physician;b. be for a specific injury or illness, including but not limited to:

i. post cardiac episodeii. immediate post diagnosis of diabetesiii. gait trainingiv. self-administration of medication

c. be limited to one (1) course of training per diagnosis

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BENEFITS PAYABLE

Benefits are payable for Covered Medical Charges as follows:1. For charges that are subject to a Deductible, benefits are payable for such charges that are more than

the Deductible in each calendar year. The amount payable after the Deductible will equal the Covered Percentage times the amount of such charges in excess of the Deductible.

2. For such charges that are not subject to a Deductible, the amount payable is equal to the Covered Percentage times the amount of Covered Medical Charges.

3. The total amount payable will not be more than the Maximum Benefit.

The SCHEDULE OF BENEFITS shows the Deductibles, Accumulation Period, Covered Percentages, Daily Maximum, and the Maximum Benefits that apply to this Coverage.

DEDUCTIBLE

The deductible is the amount of covered medical charges that you and each of your eligible Dependents must pay each calendar year before the Plan begins to pay benefits. Deductible amounts are listed in the Schedule of Benefits.

The Individual Deductible applies to each member in your family every calendar year. However, once your family satisfies the Family Deductible amount, no additional deductible will be required for the remainder of the calendar year.

ANNUAL CO-INSURANCE LIMIT

After a Covered Member has incurred a specified amount of Covered Medical Charges or the members of a family have incurred their specified amounts of Covered Medical Charges, during a calendar year, which are payable at 80% In-Network (60% Out-of-Network), (other than those for spinal treatment), the Plan pays 100% of Covered Medical Charges (other than those for (1) mental and nervous conditions, (2) dental conditions, (3) spinal treatment, (4) home health care, and (5) diabetic insulin, needles, syringes, and supplies) subsequently incurred within that calendar year which are not required to satisfy a deductible. Annual Co-insurance limits are stated in the Schedule of Benefits.

MAXIMUM LIFETIME BENEFIT

The Plan will pay up to the Maximum Lifetime Benefit, as specified in the Schedule of Benefits, for any one person during their lifetime for all Medical, Wellness, and Prescription Drug services.

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EXCLUSIONS

No benefits will be paid for charges in connection with:

1. Services or supplies for which a Covered Member is not required to pay or charges made only because coverage exists (subject to the right, if any, of the United States government to recover Reasonable and Customary Charges for care provided in a military or veterans’ hospital).

2. Sickness or Injury:a. For which benefits are paid or payable under Workers’ Compensation or any Occupational Disease

or similar law whether such benefits are insured or self-insured.b. That is caused by, or connected in any way to, employment of the Covered Member. This includes

self-employment or employment by others. It applies whether or not Workers’ Compensation or any Occupational Disease or similar law covers the charges incurred. It applies whether the charges are covered on an insured or uninsured basis.

3. Health exams that are not required for treatment of Sickness or Injury except as identified as Covered Medical Charges.

4. Any act due to war, if declared or not, or other military service.

5. Confinement, treatment or service that results from or is made worse by the intentional commission or attempted commission by the Participant of any criminal act during which that individual uses a firearm, explosive or other weapon likely to cause serious physical harm or death, if the Participant is the aggressor, except for conditions resulting from being a victim of an act of domestic violence.

6. Eye refractions, except as specifically provided herein; eye glasses or the fitting of eye glasses; radial keratotomy; hearing aids or the fitting of hearing aids.

7. Shoes unless specifically stated herein (see “Orthotics“ under the section entitled “Medical Expense Coverage“).

8. Routine, cosmetic or palliative (lessening or controlling pain) unless specifically stated herein (see “Podiatry Services“ under the section entitled “Medical Expense Coverage“).

9. Charges for non-medical expenses such as training, educational instruction or educational materials, unless prescribed by the attending physician for a specific injury or illness, including but not limited to: post cardiac episode, immediate post diagnosis of diabetes, gait training, self-administered medication classes (training shall be limited to one (1) course of training per diagnosis).

10. Custodial Care.

11. Charges incurred as a donor of an organ when the donee is not covered under this Plan.

12. Charges that are more than the Reasonable and Customary charges for the services and supplies furnished.

13. Care, treatment, services or supplies:a. not prescribed by a Physicianb. not Medically Necessaryc. which are experimental as recognized in the United States or provided mainly for the purpose of

medical or other researchd. received from a Nurse which do not require the skill and training of a Nurse

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e. to the extent that benefits are payable under other provisions of this Planf. for which benefits are not paid due to the Deductible or Coinsurance provisions of this Plang. received in a Hospital or Institution owned or operated by the United States government or any of

its agencies (subject to the right, if any, of the United States government to recover Reasonable and Customary Charges for care provided in a military or veterans’ hospital)

h. provided or paid for by any governmental plan or law not restricted to the government’s civilian employees and their Dependents. (This will not apply to Medicaid.)

14. Mental illness, alcohol and/or drug addiction (except as provided in Schedule of Benefits)

15. Temporomandibular joint disease or syndrome (except as provided in Schedule of Benefits)

16. Non-diagnostic services and supplies related to sleep disorders unless deemed Medically Necessary

17. Services and supplies for homeopathic services or medications

18. Services and supplies for holistic medicine

19. Services, supplies or treatment primarily for weight reduction or treatment of obesity such as exercise programs or use of exercise equipment; special diet supplies and diet supplements; appetite suppressants; and hospital confinements for weight reduction programs; however, medically necessary surgical procedures for the treatment of morbid obesity provided the participant has a documented six (6) month physician supervised weight loss treatment and a BMI of 50 or higher. Benefits will be limited to one surgical procedure per lifetime.

20. Services and supplies related to artificial reproductive procedures for the purpose of achieving conception and/or pregnancy including, but not limited to: artificial insemination; ovulation induction procedures; in vitro fertilization; surrogate mother; embryo implantation; gamete intrafallopian transfer (GIFT) or similar procedures which augment or enhance the Covered Member’s reproductive ability; however, if through laboratory testing, x-rays, sonograms and other such diagnostic measures a medical condition is diagnosed, treatment of the medical condition will be covered to the extent that such treatment would be necessary for a similarly situated person who does not desire conception or pregnancy.

21. Care and treatment for hair loss including hair transplants or any drug that promises hair growth, whether or not prescribed by a physician.

22. An elective abortion, except in the case of incest or rape or unless the life of the mother is threatened by the continued pregnancy; however, complications arising from an abortion, whether eligible or not, will be considered as eligible expenses.

23. Acupuncture, anesthesia by hypnosis or anesthesia for non-eligible services.

24. Personal convenience items, such as, but not limited to: air conditioners, air-purification units, allergy-free pillows, blanket or mattress covers, blood pressure instruments, electric heating units,exercising equipment, hot tubs, humidifiers, orthopedic mattresses, physical exercise equipment, stair lifts, swimming pools, and whirlpools, even if prescribed by a physician.

25. Chemical face peels or abrasion of the skin, even if prescribed by a physician.

26. Services and supplies obtained outside of the United States if the Covered Member traveled to such a location for the sole purpose of obtaining medical services, drugs or supplies.

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27. Claims not received within the Plan’s filing limit deadlines.

28. Pregnancy of a Dependent child

29. Cosmetic surgery, except as identified as a Covered Medical Charge

30. Charges related to dental, orthodontic or oral surgical procedures involving the teeth, gums or alveolar process, except as identified as a Covered Medical Charge.

31. Oral contraceptives, contraceptive devices, implants and/or injectables, even if prescribed for a medical condition.

32. Smoking cessation medications/supplies (including gum, pills, patches and inhalers).

33. Reversal of an elective surgical sterilization.

No benefit payment shall be made for charges incurred after the date this Plan is terminated.

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PRESCRIPTION CARD SERVICE PROGRAMFor Active Members, Retired Members and Dependents

The Prescription Drug Benefit is administered by the provider listed in the “Contact Information“ section of this summary. Two programs are available under the Prescription Drug Benefit – the Retail Card and Mail Order Programs.

Covered Charges

Both parts of the program cover prescriptions for the following:

All federal legend drugs; Compound medications; Insulin on prescription; Insulin needles, syringes and lancets on prescription; and Federal legend oral contraceptives (birth control pills).

In addition, the following drugs are covered when accompanied by a statement from the Physician indicating that the drug is prescribed for the Medically Necessary treatment of a diagnosed condition:

Retin-A (Tretinoin) for severe acne; Amphetamines and anorexiants not for weight loss purposes; and Smoking cessation drugs, two (2) treatment plans per lifetime, maximum eligible charge of $16 for

each 30 day supply. Viagra with a maximum of 6 pills per month.

To find out if a drug is covered, contact HealthSCOPE Benefits.

Charges Not Covered

The following are excluded from coverage under this Prescription Drug Benefit, unless specifically listed under Covered Charges above:

Fertility drugs or agents; Growth hormones; Over-the-counter (OTC) items; Amphetamines and/or anorexiants for weight loss; Retin-A (Tretinoin) for cosmetic purposes; Smoking cessation drugs after two (2) treatment plans per lifetime; Vitamins (prescribed or over-the-counter), including pre-natal vitamins; Devices or appliances (such items may be available under the Comprehensive Major Medical

Expense Benefit); Drugs labeled “Caution – limited by federal law to investigational use“ or Experimental drugs even

though a charge is made to the individual; Medications for which the cost is recoverable under Workers’ Compensation or occupational law, or

any state or governmental agency, or any other drug or medical service for which no charge is made; and

Medications for sexual dysfunction, inadequacies or enhancements.

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Retail Card Program

The Retail Card Program offers benefits for short-term prescriptions. When you become eligible for benefits under the Prescription Drug Benefit, you will receive a prescription drug card. You and any of your Dependents who are covered by the Prescription Drug Benefit will be listed on the card. You may obtain up to two refills through the Retail Card Program.

All drugs must be obtained through a network pharmacy. Participating pharmacies include most nationwide pharmacy chains, as well as many inDependent pharmacies. You may obtain a listing of participating pharmacies, at no charge, by calling the telephone number listed in the “Contact Information“ section of this summary. If you obtain a prescription outside the network, you must file a claim with the prescription drug provider listed in this summary.

Present your prescription drug card and your prescription to your pharmacist. If the cost of the medication is more than the copayment listed in the “Schedule of Benefits“, you will be responsible for the copayment amount. In no event will you have to pay more than the cost of the medication.

The pharmacist will fill your prescription with a brand name drug only if your Doctor specified “May Not Substitute“ or “Dispense as Written (DAW)“ on the prescription form or otherwise specifically indicates that the brand name drug is Medically Necessary. In all other instances, your prescription will be filled with a generic drug, if available in that form.

Note: If you request a brand name drug for your own personal reasons, you must pay the cost difference between the generic equivalent and the charge of the brand name drug, plus the higher copayment.

You will receive the quantity prescribed by your Physician, up to the greater of a 30-day supply or 100-unit dose. No forms, receipts or submission of claims are necessary. The pharmacist will submit the claim. You simply pay the necessary copayment when you fill your prescription. The copayment is not reimbursable under the Comprehensive Major Medical Expense Benefit and does not count toward your individual coinsurance explained in this summary. If you obtain a prescription outside the prescription drug network, you must file a claim with the prescription drug provider listed in this summary.

Mail Order Program

You may order through the mail up to a 90-day supply of any covered medication that your Physician prescribes for you or your eligible Dependent. This service is required for maintenance medications and for the third refill under the Retail Card Program. Maintenance medications are medications you or your Dependent takes for long periods of time for such chronic conditions as high blood pressure, heart condition, diabetes, asthma and arthritis.

If your Physician prescribes a long-term medication that you need right away, ask the Physician to write two prescriptions – one prescription to be filled at a participating pharmacy using the Retail Card Program, and one prescription for the remainder of the medication to be submitted to the Mail Order Program.

The pharmacist will fill your prescription with a brand name drug only if your Doctor specified “May Not Substitute“ or “Dispense as Written (DAW)“ on the prescription form. In all other instances, your prescription will be filled with a generic drug, if available in that form.

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Note: If you request a brand name drug for your own personal reasons, you must pay the cost difference between the generic equivalent and the charge of the brand name drug, plus the higher copayment.

Follow these steps to obtain prescriptions through the mail:

Request a form from the HealthSCOPE Benefits. Fill out all required information on the patient profile/registration form. Enclose the Physician’s prescription for a 90-day supply of medication. Enclose your original prescription and copayment and mail to the address listed in this summary.

To find out the amount of payment to send with your order, call the telephone number listed in the “Contact Information“ section of this summary.

For refills, a new order form and envelope will be included with each delivery, or call the telephone number in the “Contact Information“ section listed in this summary..

The Prescription Card Service Program is a benefit where a Covered Member and/or his covered Dependents’ prescription drugs are subject to a co-payment payable at the time of purchase of covered prescription drugs. It allows a non-hospitalized participant and covered Dependents to receive prescription drugs upon payment of a co-payment, if applicable, for eligible prescription drugs.

DISPENSING LIMITATIONS

The amount normally prescribed by a physician, not to exceed a 30-day supply for Retail prescriptions, a 90-day supply for Mail Order prescriptions.

QUANTUM ALERT PROGRAMThe Trustees have elected to adopt, as a part of the Prescription Drug Program, a procedure which screens for the following items:1. Drug to drug interaction2. Therapeutic duplication3. Excessive daily dose4. Excessive utilization

Your pharmacist may alert you to any problems in these areas, so that you can consult with your doctor.

While this screening has been included to improve the quality of services provided to you, it is not intended to replace the advice of your physician.

PREFERRED (FORMULARY) MEDICATIONSA formulary is a list of preferred medications that includes drugs that are safe, clinically effective, and economical. The formulary was developed by a committee of pharmacists and physicians. This committee meets regularly to discuss new drugs and trends in therapy. These medications have been demonstrated to be clinically effective and are also cost-effective to help manage prescription costs while continuing to maintain the quality of care.

For questions regarding your prescription drug card program, including participating Retail pharmacies and Mail Order prescriptions, please refer to the Prescription Drug Benefits section of the “Contact Information“ section of this summary.

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TERMINATION OF COVERAGE

Your Coverage will automatically terminate on the earliest of:

1. the date this Plan terminates; or2. the last day for which your cost of program has been paid; or3. the date you enter into full-time military, naval, or air service; or4. the date you are no longer in an eligible class; or5. at any time you cease to qualify as a Member as defined (herein) in the Trust Agreement.

Dependent Coverage for each of your Dependents will automatically terminate on the earliest of:

1. the last day for which your Dependent’s cost of program has been paid; or2. the date he or she is no longer a Dependent as defined in this Plan (See DEFINITIONS.); or3. the date your Member Coverage terminates.

No benefit payment shall be made for charges incurred after the date this Plan is terminated.

If you work for an employer who is not required to pay contributions to this Plan, and you do covered work, as defined by the Collective Bargaining Agreement, your Coverage can be terminated. If the Local Union or the Plan becomes aware you are doing covered work for an employer who is not required to pay contributions to this Plan, a written notice will be sent to you by means of a trackable delivery service, to your last known address. If you do not stop working for the employer within 10 days of the date of the written notice, the Plan Administrator will conclude that you voluntarily resigned from the Union and that you are no longer a Covered Person under the terms of the Collective Bargaining Agreement. As a result, your and your Dependents’ Coverage will terminate as of midnight on the 10th day after the date of the notice. If Coverage is terminated under this provision, you will nothave a right to self-pay contributions, or to retiree coverage, or to buy your Coverage under COBRA, because your loss of coverage is based on the fact that you do not meet the definition of a Member eligible for coverage, and not a COBRA Qualifying Event. If at the time notice is sent to you under this provision you are being covered by COBRA Coverage due to a prior qualifying event, you will continue COBRA Coverage subject to the provisions for COBRA found in this summary.

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SUBROGATION & REIMBURSEMENT

In the event the Fund pays or is obligated to pay benefits on behalf of a Covered Member or his Dependents for illness or injury to the Covered Member or Dependents and the Covered Member or Dependent have the right to recover the amounts of such benefits from any other person, corporation, insurance carrier, or governmental agency, including uninsured or underinsured insurance coverage, or any other first-party or third-party contract or claim, the Trustees of the Fund and the Fund shall be subrogated to all of the Covered Member’s or Dependents’ right of recovery against such person, corporation, insurance carrier, governmental agency or uninsured or underinsured insurance coverage or any other first-party or third-party contract or claim and shall have a right of reimbursement from the Covered Member or Dependent to the full extent of payments made by the Fund and for the costs of collection of these amounts, including attorney’s fees. The full amount of benefits paid shall include any Preferred Provider Organization Charge or other payment to a medical discount provider paid with respect to the involved benefits which shall be considered part of the amount of benefits paid. The Trustees and the Fund shall have an equitable lien by agreement in the amount set forth in this paragraph and this equitable lien by agreement shall be enforceable as part of an action to enforce Plan terms under ERISA Section 502(a)(3), including injunctive action to ensure that these amounts are preserved and not disbursed. The Trustees’ and the Fund’s equitable lien agreement imposes a constructive trust upon the assets received as a result of a recovery by the Covered Member or Dependents, as opposed to the general assets of the Covered Member or Dependents, and enforcement of the equitable lien by agreement does not require that any of these particular assets received be “traced“ to a specific account or other destination after they are received by the Covered Member or Dependents. The Trustees’ and the Fund’s equitable lien by agreement is from the first dollar received and its enforcement does not require that the Covered Member or Dependents be “made whole“ or that the entire debt be paid to the Covered Member or Dependents prior to the lien’s payment. The Trustees’ and the Fund’s equitable lien by agreement is also not reduced by the legal fees incurred by the Covered Member or Dependents in recovering the amounts or by any state law doctrine, such as the “common fund“ doctrine, which would purport to impose such a reduction.

The Covered Member or his or her Dependents or the Covered Member acting on behalf of a minor Dependent shall execute and deliver such documents and papers including but not limited to an assignment of the claim against the other party or parties, assignment to the minor child or any parental claim to recover medical expenses of the minor child, and/or a Subrogation or Reimbursement Agreement to the Fund, as the Trustees may require. The Covered Member or Dependents shall do whatever else is necessary to secure the rights of the Trustees and the Fund including allowing the intervention by the Trustees or the Fund or the joinder of the Trustees or the Fund in any claim or action against the responsible party or parties or any uninsured or underinsured insurance coverage or any other first-party or third-party contract or claim.

If the Covered Member or Dependents do not attempt a recovery of the benefits paid by the Fund or for which the Fund may be obligated, the Trustees or the Fund shall, if in the Fund’s best interest and at the Trustees’ sole discretion, be entitled to institute legal action or claim against the responsible party or parties, against any uninsured or underinsured insurance coverage, or against any other first-party or third-party contract or claim in the name of the Fund or Trustees in order that the Fund may recover all benefit amounts paid to the Covered Member or Dependents or paid on their behalf, together with the costs of collection, including attorney’s fees.

In the event of any recovery by judgment or settlement against the responsible party or parties or by payment by any uninsured or underinsured insurance coverage or any other first-party or third-party contract or claim, payment of the lien from the proceeds of the recovery shall take place in the following fashion. Initially, the reasonable costs of collection of the equitable lien by agreement, including the Fund’s attorney’s fees, shall be distributed to the Fund. Next, the amount of benefits paid from the Fund

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to and on behalf of the Covered Member or Dependents, to the full extent of benefits paid or due as a result of the occurrence causing the injury or illness, shall be distributed to the Fund. The remainder or balance of any recovery shall then be paid to the Covered Member or Dependents and their attorneys if applicable.

In the event of any failure or refusal by the Covered Member or Dependents to execute any document requested by the Trustees or the Fund or to take other action requested by the Trustees or the Fund to protect the interests of the Trustees or the Fund, the Trustees may withhold payment of benefits from the Fund or deduct the amount of any payments from amounts otherwise payable from the Fund for future claims of the Covered Member or Dependents. After making claim for benefits from the Fund, the Covered Member or Dependents shall take no action which might or could prejudice the rights of the Trustee or the Fund.

In the event the Covered Member or Dependents recovers any amount by settlement or judgment from or against another party or by payment from any uninsured or underinsured insurance coverage or any other first-party or third-party contract or claim the Fund will request repayment of the amount of its equitable lien for the full amount of benefits paid by the Fund. If the Covered Member and/or Dependents refuses or fails to repay such amount, then, in that event, the Fund shall be entitled to recover such amounts from the Covered Member and/or Dependents by instituting legal action against the Covered Member and/or Dependents and/or by deducting such amounts as may be due on future claims submitted by the Covered Member and Dependents. Once a settlement or judgment is reached on the claim additional bills cannot be submitted with respect to the same injury.

The Covered Member or Dependents shall be required to pay his own legal fees and costs and to hire only attorneys who agree to waive the common fund doctrine, and to remit the gross rather than the net proceeds from litigation. The Trustees shall pay no legal costs or fees from the Fund without receiving a recovery and then only, in their sole discretion, within terms of this provision. In the event that an attorney is hired by or on behalf of the Covered Member or his Dependents and the Fund is given notice and an opportunity to pursue its own subrogation recovery, the Fund shall not be required to hire such attorney. If the attorney representing the eligible individual nevertheless wishes to proceed, and creates a common fund from which the Trustees can recover pursuant to their equitable lien by agreement for subrogation and reimbursement, the Trustees, on behalf of the Fund, may agree to pay up to 10% of its recovery to include the attorney’s legal fees. This 10% shall also include any prorated portion of the cost of recovery. If the attorney agrees to proceed, he will be considered to have waived the common fund doctrine.

These provisions shall apply to any case in which the Fund or Trustees have not been repaid the full amount of benefits made for and on behalf of a Covered Member or beneficiary, together with costs of collection, as of the date of this provision, and any subrogation and reimbursement claim or lien presented by the Fund or Trustees, where the Fund or Trustees have not been repaid the full amount of benefits made for and on behalf of a Covered Member or beneficiary, together with the costs of collection, as of the date of these provisions, shall be construed to involve an equitable lien by agreement under these provisions.

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SPECIAL MEDICARE PROVISION FOR A LARGE GROUP HEALTH PLAN

For any Totally Disabled Dependent (of an active Covered Member) who is under age 65, the benefits payable under this Plan will be primary to any benefits payable under Medicare.

For all Disabled or Retired Covered Members who are eligible to enroll under Part A or Part B of Medicare, the benefits otherwise payable under this Plan will be reduced by the amount of any similar benefits payable under Medicare, whether such person has or has not enrolled.

A Large Group Health Plan means a plan of Health Coverage which covers Members of a Participating Employer that normally employed at least 100 Members on a typical business day during the preceding calendar year.

PERSONS ELIGIBLE FOR MEDICARE

Six months before he or she reaches age 65, a Covered Member or spouse should enroll in Medicare. However, as long as the person continues to be covered under the Plan as an active Member or the spouse of an active Member, the Plan pays its benefits without regard to payments made under Medicare. If a Covered Member qualifies for Medicare for any other reason or in other circumstances, payments made under the Plan may be reduced. Notification of Medicare eligibility by any person is required within 31 days.

Once you notify the Fund of your intent to retire as an Active Member, and you are eligible for Medicare coverage, Medicare will become the primary payor of your claims. That means that all claims should first be filed with Medicare. Upon receipt of your Medicare “Explanation of Benefits“ you should file that “Explanation of Benefits“ along with a copy of the bill to HealthSCOPE Benefits. We will then take into account the amount paid by Medicare and process your claim according to the rules established by the Plan. For items not covered by Medicare, such as prescription drugs, you simply need to file those claims, as you have in the past, with HealthSCOPE Benefits.

The Indiana State Council of Plasterers and Cement Masons Health and Welfare Fund elects treatment under clause (iii) of 42 U.S.C. §1395(b) (1) (A), and consistent with this election, HealthSCOPE Benefits is hereby authorized and directed to pay claims secondary to Medicare benefits in those cases where such secondary payment is permitted.

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COORDINATION OF BENEFITS

The benefits that are payable under this Plan for medical charges will be coordinated with any other plans that provide benefits for the same charges. The total amount payable under both plans will not be more than 100% of the Allowable Expenses that are incurred.

To coordinate benefits, it is necessary to determine in what order the benefits of various plans are payable. This is determined as follows:1. If a plan does not have a provision for the coordination of benefits, its benefits are payable before

those of a plan that does have one.2. If a plan covers a person other than as a dependent, its benefits are payable before those of a plan that

covers this person as a dependent.3. If a plan covers a current employee, then that plan will pay benefits before a plan that covers that

person as a former employee.4. If a plan covers a person as a dependent, the benefits of the plan of the parent whose birthday,

excluding the year of birth, is earlier in the calendar year, are payable before those of a plan of the Member whose birthday, excluding the year of birth, is later in the calendar year. If both parents have the same birthday, the benefits of the plan which has covered the parent the longest are determined before those of the plan which has covered the shorter period of time. However, if the plan that does not have a provision which is based on the birthday of the Member results in each plan determining its benefits before the other, the plan which does not have a provision which is based on a birthday will provide coverage before the plan that does have such a provision.

EXAMPLE: John, a Covered Member, has a birthday of January 31. His wife, Betty, who is covered by a group plan at her place of employment, has a birthday of June 1. Their dependent son, Danny, has a claim which both John and Betty’s plans would cover. John’s coverage pays first because his birthday is earlier in the year. Betty’s plan generally will pick up the unpaid portion, up to the lesser of its coverage limits or 100% of the claim.

5. If a dependent is a child whose parents are separated or divorced, the order in which benefits are payable will be determined as follows:a. If a plan covers the child as a dependent of the parent with custody and the parent has not

remarried, its benefits are payable before those of a plan that covers the child as a dependent of the parent without custody.

b. If a plan covers the child as a dependent of the parent with custody and the parent has remarried, its benefits are payable before those of a plan that covers the child as a dependent of the stepparent. The benefits of the stepparent’s plan will be payable before those of a plan that covers the child as a dependent of the parent without custody.

6. Benefits under Medicare for the 31st and subsequent months of End Stage Renal Disease will be payable before this Plan’s benefits are payable.

7. If items 1 or 2 do not apply, the benefits of a plan that has covered the person for the longest period of time will be payable before those of the other plan. However, if a plan covers a person as an active employee or as the dependent of such a person, its benefits are payable before those of a plan that covers the person as other than an active employee or as the dependent of such a person.

If the benefits of this plan are payable before those of the other plan, the regular benefits of this plan will be payable. If the benefits of the other plan are payable before those of this plan, the benefits of this plan will be reduced. They will be reduced so that the combined benefits of both plans will not be more than the Allowable Expenses that are incurred.

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COORDINATION OF BENEFITS

SPECIFIC DEFINITIONS

As used in this coordination of benefits provision:

Allowable Expenses means covered medical charges, at least part of which must be covered by one or more of the plans covering the person for whom the claim is made. When a plan provides benefits in the form of services, rather than cash payments, the reasonable and customary value of each service will be treated as both an Allowable Expense and a benefit paid.

Plan means any plan that provides medical benefits or services by or under the following methods:1. group insurance, or any other method of coverage for persons in a group (whether or not the plan is

insured); or2. Medicare; or3. any coverage required or provided by any governmental program or law, other than Medicaid; or4. any coverage required or provided by statute except no-fault automobile coverage or general liability

coverage. In states where the statutes require or allow coordination of benefits with No-fault Motor Vehicle Plan, it will be defined as a plan, for purpose of this coordination of benefits provision.

No-fault Motor Vehicle Plan means motor vehicle insurance required by law that provides benefits for medical care and treatment that are payable, in whole or in part, without regard to fault.

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DEFINITIONS

Throughout this booklet, several words and/or terms are used. In order to help you better understand your Plan of Benefits, we have defined the following:

Ambulatory Surgical Center and like terms means an institution that: (1) is equipped mainly to do surgery; (2) has the services of a Physician and a Nurse (R.N.) at all times when a patient is present; and (3) is not an office maintained by a Physician for the general practice of medicine or dentistry.

Available for Work means performing every duty of the job available in the Member’s usual place of business.

Complications of Pregnancy means: (1) conditions that require Hospital confinement (when the pregnancy is not terminated) whose diagnoses are distinct from pregnancy, such as acute nephritis, nephrosis, cardiac decompensation, missed abortion, and similar medical and surgical conditions of comparable severity, but shall not include false labor, occasional spotting, Physician prescribed rest during the period of pregnancy, morning sickness, hyperemesis gravidarum, pre-eclampsia, and similar conditions associated with the management of a difficult pregnancy not constituting a nosologically distinct Complication of Pregnancy; and (2) non-elective cesarean section, ectopic pregnancy which is terminated, and spontaneous termination of pregnancy, which occurs during a period of gestation in which a viable birth is not possible.

Convalescent or Skilled Nursing Facility means an institution constituted, licensed, and operated as set forth in the laws that apply, which: (1) mainly provides inpatient care and treatment for Covered Persons who are convalescing from a Sickness or Injury; (2) provides care supervised by a Physician; (3) provides 24 hour per day nursing care by Nurses, that are supervised by a full-time Nurse (R.N.); (4) keeps a daily clinical record of each patient; (5) is not a place primarily for the aged, drug addicts, or alcoholics; and (6) is not a rest, educational, or custodial institution or similar place.

Cosmetic Surgery means surgery that is intended to: (1) improve the appearance of the patient; or (2) preserve or restore a pleasing appearance. It does not mean surgery that is intended to correct normal functions of the body.

Covered Person means a Member and/or a Dependent of a Member who is eligible for and enrolled in coverage under this Plan.

Creditable Coverage shall include, but is not limited to: coverage the employee and/or Dependent may have had under a prior employer’s benefit plan or COBRA, individual or group insurance, Part A or Part B of Title XVIII of the Social Security Act (Medicare), Title XIX of the Social Security Act (Medicaid), a state health risk pool, Uniformed Services, Federal Employees Health Benefits Program, a health benefit plan under the Peace Corps Act §5(e) or medical care program of the Indian Health Service or tribal organizations. It does not include coverage consisting solely (not an integral part of the plan) of dental, vision, long term care benefits, or supplemental benefits. Benefits are an integral part of a plan unless a participant has the right to elect not to receive coverage for the benefits and has to pay an additional premium or contribution for that coverage. Benefits which are not coordinated are exempted from the creditable coverage requirements such as a cancer-only policy or prescription drug card. It is the employee’s responsibility to provide the Plan Administrator with the evidence of creditable coverage, but the Plan will assist the employee in obtaining the Certificate of Coverage from the previous plan or insurer, if necessary. Such evidence may be in the form of a Certificate of Coverage or in any other form acceptable to the Plan Administrator.

If creditable coverage is applied and it is later learned that the Certificate of Coverage included false information, the Plan Administrator will adjust the creditable coverage accordingly. The employee

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and/or Dependent will be responsible for any claims which may be pre-existing and not eligible under the provisions of the Plan.

Custodial Care means care: (1) provided primarily for the maintenance of the Covered Person; (2) which is essentially designed to assist the Covered Person in the activities of daily living. It does not include care primarily provided for its therapeutic value in the treatment of Sickness or Injury.

Dependent means: The spouse you are legally married to under the laws of the state in which you reside, but does not

include same-sex domestic partners; or Your unmarried child or stepchild under 19 years of age who permanently resides in your

household and who is Dependent on you for more than 50% of his or her support; or Your unmarried child who is 19 years old until his or her 23rd birthday if that child is enrolled and

physically attends classes at an accredited junior college, college or university or nurses training center, vocational or trade school approved by the Department of Education or Labor which has a regular teaching staff, curriculum, and student body, and who takes the number of credit hours required by the school to be a full-time student (generally 12 credit hours) and who is Dependent on you for more than 50% of his or her support and who is reported to the Plan Administrator with supporting proof of student status. The Plan Administrator may require proof of payment of tuition, and other proof which would establish the child’s eligibility to participate in the Plan; or

A child who is adopted or placed for adoption prior to the age of 18; or Your child or stepchild who reaches the limiting age for Dependents while a Covered Person but

who is incapable of earning his own living due to mental or physical handicap. All other requirements for Dependents must be met. The Plan will require proof of incapacity and dependency. Such proof may be given at any time within 120 days after the date the limiting age is reached, and will not be required earlier than sixty days before the limiting age is reached. The Plan may also require proof of continuing incapacity and dependency. It may require such proof no more than once each year after initial proof is given. If proof is not given within sixty days of a request, coverage for the Dependent will end sixty days after the request is made.

You are responsible for notifying the Plan in the event of a divorce, legal separation or a child ceasing to be a Dependent as defined above.

Dependent children are covered from birth for medically diagnosed congenital defects, birth defects, birth abnormalities and hereditary complications.

A child of divorced or legally separated parents will be considered an eligible Dependent if the Employee is supporting such child pursuant to a Court Order Decree and is current in making the required support payments.

Dependents will not include (1) a foster child; (2) a child or spouse who permanently resides outside of the United States of America; or (3) any person eligible for coverage as a covered employee.

A Dependent Child who is eligible for coverage in the Plan as a full-time student in an accredited school, as described herein, immediately before the first day of a Medically Necessary Leave of Absence from such accredited school, shall be treated as a full-time student for one (1) year after the first day of the Medically Necessary Leave of Absence or until the date on which such coverage would otherwise terminate under the terms of the Plan (such as attaining a maximum age for full-time student coverage).

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Dependent Coverage means the coverage for the Dependents of all of the Members who are eligible to be covered.

Enrollment date means the first day of the month for which hours are worked and employer contributions are received by the Plan.

Family Unit means you, your spouse and children; or in the case of Dependent children, the parents and any sisters or brothers.

Health Coverage means Coverage under this Plan that provides benefits for Hospital, surgical and medical charges that are incurred by a Covered Person.

Hospital means an Institution constituted, licensed, and operated as set forth in the laws that apply to Hospitals, which: (1) provides Room and Board and nursing care for its patients; (2) has a staff with one or more Physicians available at all times; (3) provides 24 hour nursing service; (4) maintains on its premises all the facilities needed for the diagnosis, medical care and treatment of Sickness or Injury; and (5) has organized facilities on its premises for major surgery. No claim for treatment, care or services rendered in a Hospital will be denied solely because the Hospital lacks major surgical facilities. The term Hospital does not include an Institution, or that part of an institution, used mainly for: (1) nursing care; (2) rest care; (3) convalescent care; (4) care of the aged; (5) Custodial Care; (6) educational care; or (7) treatment of alcoholism or drug dependency.

Injury means an Injury to the body that is sustained accidentally.

Inpatient means a Covered Person who is confined in a Hospital or a Convalescent or Skilled Nursing Facility and is charged for Room and Board.

Institution means a facility, operating within the scope of its license, whose purpose is to provide organized health care and treatment to a Covered Person, such as a Hospital, Convalescent or Skilled Nursing Facility, Ambulatory Surgical Center, Psychiatric Hospital, Community Mental Health Center, Residential Treatment Facility, Psychiatric Treatment Facility, Alcohol or Drug Dependency Treatment Center, Alternative Birthing Center, Home Health Center, Hospice, or any other such facility that the Plan approves.

Intensive Care Unit means a separate part of a Hospital that is reserved for critically and seriously ill patients who require highly skilled nursing care and constant or close and frequent audio-visual nursing observation. The Intensive Care Unit must provide its patients with: (1) Room and Board; (2) nursing care by Nurses who work only in the unit; and (3) special equipment and supplies that are primarily for use within the unit.

Medically Necessary or Medical Necessity means services or supplies received, while covered, which are determined by the Plan to be: (1) appropriate and necessary for the symptoms, diagnosis or direct care and treatment of the medical condition; (2) provided for the diagnosis or direct care and treatment of the medical condition; (3) within standards of good medical practice within the organized medical community; (4) not primarily for the convenience of the Covered Person, the Covered Person’s Physician or another provider; and (5) most appropriate supply or level of service which can safely be provided. For Hospital stays, this means that acute care as an Inpatient is necessary due to the kind of services the Covered Person is receiving or the severity of the Covered Person’s condition, and that safe and adequate care cannot be received as an Outpatient or in a less intensified medical setting.

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Medically Necessary Leave of Absence occurs when a Dependent, whose coverage is contingent upon maintaining a full-time student status, starts a leave of absence from school that (i) commences while the Dependent is suffering from a serious illness or injury; (ii) is Medically Necessary; and (iii) would otherwise cause the Dependent to lose full-time student status for purposes of coverage under the terms of this Plan. Such leave of absence applies only when the Plan is provided with a certification by the treating physician that verifies that (i) the Dependent is suffering from a serious illness or injury, and (ii) the leave of absence is Medically Necessary to treat the illness or injury.

Medicare means any coverage under Title XVIII of the Federal Social Security Act. If this Act is amended, this term will mean any coverage provided under the amended Act.

Member means a Covered Person under the terms of a Collective Bargaining Agreement with a Participating Employer which requires participation in this Fund. Member shall include: (1) business agents, financial secretaries and other paid Members of Local and International Unions connected with this Fund; (2) supervisory and other Members of Participating Employers; (3) administrative personnel of this Health and Welfare Fund; and (4) Employees of any Participating Employer who has signed or may sign an assent of participation agreement with the Fund and whose participation has been approved and accepted by the Trustees.

Member Coverage means the coverage for all of the Members who are eligible to be covered.

Nurse means: (1) Registered Nurse (R.N.); (2) Licensed Practical Nurse (L.P.N.); or (3) Licensed Vocational Nurse (L.V.N.) licensed by the appropriate State agency.

Outpatient means a Covered Person who receives care in a Hospital or other Institution but who is not confined and is not charged for Room and Board.

Participating Employer means any Employer who has signed a Collective Bargaining Agreement or other written agreement requiring contributions to be made to the Indiana State Council of Plasterers and Cement Masons Health and Welfare Fund on behalf of a Member and who hires employees to perform work as defined in the Agreement.

Physician means: (1) legally licensed Doctor of Medicine or Doctor of Osteopathy; or (2) any other legally licensed practitioner of the healing arts rendering services: (a) which are covered under this Plan; and (b) which are within the scope of his or her license. This term does not include: (1) you; or (2) your Dependent; or (3) your spouse, parent, child, sister or brother; or (4) your Dependent’s spouse, parent, child, sister or brother.

Plan means the legal document establishing the eligibility requirements for and benefits paid through Indiana State Council of Plasterers and Cement Masons Health and Welfare Fund.

Pre-existing Condition means a Sickness or Injury that existed and for which diagnosis, treatment, and/or medication was received within the 6 months immediately preceding the person’s enrollment date.

Psychiatric Hospital means an Institution constituted, licensed, and operated as set forth in the laws that apply to Hospitals, which: (1) is primarily engaged in providing psychiatric services for the diagnosis and treatment of mentally ill persons, either by or under the supervision of a Physician; (2) maintains clinical records on all patients and keeps records as needed to determine the degree and intensity of treatment provided; (3) is licensed as a Psychiatric Hospital; (4) requires that every patient be under the care of a Physician; and (5) provides 24 hour nursing service. The term Psychiatric Hospital does not include an Institution, or that part of an Institution, used mainly for: (1) nursing care; (2) rest care; (3) convalescent care; (4) care of the aged; (5) Custodial Care; (6) educational care; or (7) treatment of alcoholism or drug dependency.

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Reasonable and Customary Charge(s) means charges made for medical services and supplies that are required for the care of the Covered Person that: (1) are normally charged by the provider for these services and supplies; (2) but not to exceed the amount normally charged within the same locale by most providers of similar services and supplies. Consideration will be given to: (1) the nature and severity of the condition for which the Covered Person needs care; and (2) any circumstances for which additional time, skill, or experience is required. In any case where a provider of services accepts as full payment an amount less than the Reasonable and Customary Charge that would have been accepted in the absence of Coverage, that reduced amount will be the maximum Reasonable and Customary Charge.

Retired Member or Retiree means a former active Member who maintains their eligibility for benefits under the Rules of Eligibility of the Plan.

Room and Board means: (1) room and meals; and (2) all general nursing services which are required for the care of Inpatients in a Hospital or other Institution. Charges for Room and Board must: (1) be billed by the Hospital or other Institution on its own behalf; and (2) be made at a daily or weekly rate that is based on the type of room required.

Sickness means illness or disease. It includes pregnancy and the resulting childbirth, or miscarriage.

Total Disability or Totally Disabled as used in connection with all other Coverage, except Life, means that due to Sickness or Injury a Covered Person is: (1) under a Physician’s care; and (2) not able to perform any and every duty of his occupation; and (3) not engaged in any occupation or business for income or profit. (This applies only if the Covered Person was actively employed immediately before he or she became Totally Disabled.)

You and your mean a Covered Person who is in a class eligible for Member Coverage.

Whenever a term is expressed in the masculine, it is implied to be expressed in the feminine where applicable. Also, when terms are expressed in the singular form, they are implied to be in the plural form where applicable.

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ELIGIBILITY

Contribution Periods (Work Months) The Contribution Periods will be the work months of (1) January 1 to March 31; (2) April 1 to June 30; (3) July 1 to September 30; and (4) October 1 to December 31.

Benefit Periods or Eligibility PeriodsA full Benefit Period will be a period of three months. The Benefit Year will have the following Benefit Periods: (1) May 1 to July 31; (2) August 1 to October 31; (3) November 1 to January 31; and (4) February 1 to April 30. Each Benefit Period starts one month after the end of the last month of any Contribution Period.

Eligibility for BenefitsAll Members who are covered by a Collective Bargaining Agreement (CBA) which requires contributions to be remitted to the Indiana State Council of Plasterers and Cement Masons Health and Welfare Fund on their behalf are eligible to participate in the Fund upon satisfying the Rules of Eligibility described in this summary. Other individuals who may be eligible for benefits from this Fund include: (1) employees of Local Unions; (2) other paid employees of Local and International Unions connected with the Indiana State Council of Plasterers and Cement Masons and Local Unions not affiliated with the Indiana State Council of Plasterers and Cement Masons or Operative Plasterers and Cement Masons International Association of the United States and Canada; (3) supervisory and other employees of Participating Employers; (4) retired members of Participating Employers in good standing; (5) eligible surviving Dependents; and (6) administrative employees of the Fund.

Benefits BankHours reported to the Plan and money contributed to the Plan for you are used to establish an individual Benefits Bank balance within the Plan. The individual balance is carried forward until used for benefits provided by the Plan. In the event of the death of a participant, any Benefits Bank balance can remain in the Plan for use by the surviving spouse and/or Dependents of the participant for the purchase of future benefits through the Plan. In the event the Survivor benefits terminate as outlined in Rule 11, any remaining Benefits Bank balance will be forfeited.

Once an individual Benefits Bank is established, the Member can forfeit the Benefits Bank balance by: Failure to have any Employer Contributions or Employee self-payments in the four most recently

completed Contribution Periods. Once a Benefits Bank is forfeited, to again qualify for benefits in the Plan, the Member must meet requirements under Rule 1(a). The Benefits Bank may not be utilized by a Member unless the Member has written certification from the Local in which the member last qualified that: (1) the member is disabled from work; or (2) the member is available for work; or

Doing covered work for an employer who is not required to pay contributions to this Plan, as defined by the CBA. If the Local Union or the Plan becomes aware you are doing covered work for an employer who is not required to pay contributions to this Plan, a written notice will be sent to you by means of a trackable delivery service, to your last known address. If you do not stop working for the employer within 10 days of the date of the written notice, then your Benefits Bank will be forfeited, and Coverage terminated as of midnight on the 10th day after the date of the notice, the Plan Administrator will conclude that you voluntarily resigned from the Union and that you are no longer a Covered Person under the terms of the Collective Bargaining Agreement, making you ineligible for your Benefits Bank. If your Benefits Bank is forfeited and Coverage terminated under this provision, you will not have a right to self-pay contributions, or to retiree coverage, or to buy your Coverage under COBRA because your loss of coverage is based on the fact that you do not meet the definition of a Member eligible for coverage, and not a COBRA

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Qualifying Event. If at the time your Benefits Bank is forfeited under this provision you are being covered by COBRA Coverage due to a prior Qualifying Event, you will continue COBRA Coverage subject to the provisions for COBRA described in this summary.

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RULES OF ELIGIBILITY

Rule 1 - When Benefits Begin

a. NEW Members shall be eligible for Benefits the first day of the second month following the month they have accumulated, in the twenty-four most recent months, sufficient monthly contributions from Participating Employers.

b. REINSTATED Members shall be eligible for Benefits the first day of the second month following the month they have accumulated sufficient monthly contributions from Participating Employers. Reinstatement may not be provided unless the member is working or written certification is provided from the Local in which the member last qualified that: (1) the member is disabled from work; or (2) the member is available for work.

ExampleThe Fund received sufficient reported Contributions on John’s behalf needed to qualify for benefits. The hours were worked between January 1, 2009 and May 31, 2009 and were credited to John’s Benefits Bank from February through June. He will be covered by the Plan beginning July 1, 2009.

NOTE: The difference between contributions needed to qualify for benefits and the cost of program will remain in your Benefits Bank balance to be used for future benefits.

Monthly Participating Employer Contribution Reports received timely will be applied to the proper work month of the Contribution Period. Contribution Reports not received for a Contribution Period will be credited as if they had been received timely provided the member notifies HealthSCOPE Benefits within two months after the end of that Contribution Period and provides HealthSCOPE Benefits with sufficient evidence of the amount of delinquent contributions due.

When a Member notifies HealthSCOPE Benefits of such nonpayment of contributions by a Participating Employer, future credit for hours worked in a subsequent contribution period for the same Participating Employer will not be given unless current contributions are actually received by HealthSCOPE Benefits.

Monies and hours received from reciprocal transfers and/or Participating Employers which are not timely, but within two years of the last month of the latest Contribution Period, will be applied on the member’s behalf in the following manner:

a. to the proper work month if it will provide continuous benefit coverage through the latest Benefit Period;

b. to the proper work month if such application will not change the member’s status within the Fund;

c. to the earliest work month that will provide continuous benefit coverage through the latest Benefit Period; or

d. to the first work month of the current Contribution Period.

Receipts from reciprocal transfers and/or Participating Employers after more than two years will be applied to the member’s Benefits Bank balance.

The cost of benefits and qualification amounts will be determined by the Board of Trustees and adjusted periodically as determined necessary by the Trustees.

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Rule 2 - How to Continue Benefits:

a. Members, once covered, shall continue their eligibility for three months of benefits, starting on the 1st day of May, August, November, or February, following any Contribution Period during which they have accumulated sufficient contributions to pay for the cost of program.

Contributions toward the cost of program are applied from the following three sources: (1) quarterly Employer Contributions during the Contribution Period; (2) monies available from Benefits Bank; and (3) Employee self-payment of quarterly invoice. In order for contributions to be made from sources (2) or (3) above, the member must have written certification from the Local in which the member last qualified that: (1) the member is disabled from work; or (2) the member is available for work.

b. Members may not make an Employee self-payment unless they have written certification from the Local in which they last qualified that: (1) they are disabled from work; or (2) they are available for work.

c. If you fail to continue benefits by not having sufficient contributions from Employers monies available from your Benefits Bank, Employee self-payment, or because you are not able to utilize your Benefits Bank or make an Employee self-payment due to absence of certification that you are disabled from work or available for work, your coverage will be terminated, but the balance of contributions, if any, will be placed in your Benefits Bank to be applied toward your Reinstatement as allowed in Rule 1(b). However, the Benefits Bank may not be applied toward your Reinstatement if you do not have written certification from the Local in which you last qualified that: (1) you are disabled from work; or (2) you are available for work.

Rule 3 - Time Limit on Self-Payments

a. If the Member makes his self-payment within ten days after the first day of any Benefit Period, he and his Dependents will be covered for all of the benefits provided under the Plan without any break in the coverage.

b. If the Member makes his required self-payment between the 11th and 40th day following the first of the Benefit Period, the payment will be accepted without being pro rated and he will be covered, for all eligible claims, as follows:

Life Insurance: 1st to the 30th day, regardless of the date of his demise.31st to 40th day, the day following the postmark date of the self-payment in HealthSCOPE Benefits.Accident and Sickness Benefits:the day following the postmark date of the self-payment in HealthSCOPE Benefits.Medical Benefits:the day following the postmark date of the self-payment in HealthSCOPE Benefits.

c. Payments after the 40th day CANNOT BE ACCEPTED AND WILL BE RETURNED.

Rule 4 - Time Limit on Monthly Self-Payments:

The following provisions will apply to all Covered Members whose coverage is in danger of being terminated because of insufficient contributions in any Contribution Quarter but who elect to pay the required quarterly invoice amount in monthly installments.

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1. It is the responsibility of the Covered Member to divide the quarterly invoice into three equal installments and see that each monthly payment is made on a timely basis in order to maintain uninterrupted coverage.

2. All monthly self-payments are due the 1st of each month, but must be postmarked no later than the 10th.

3. If the Member makes his monthly self-payment by the 10th day of the month, he and his Dependents will be covered that calendar month for all coverage provided under the Plan without any break in the coverage.

4. A monthly self-payment made after the 10th of any month cannot be accepted and will be returned. Coverage will be terminated as of the last day of the previous month.

Rule 5 - Optional COBRA Continuation Versus Plan Self-Payment Rules

If a Member is not eligible for self-payment or use of the Benefits Bank because the Member does not have written certification from the Local in which the Member last qualified that: (1) the Member is disabled from work; or (2) the Member is available for work, coverage will only be permitted to be continued under COBRA if available under the terms of this Plan and applicable law. The amount required for COBRA coverage required may exceed that of the self-payment provisions or any plan subsidized continuation provisions, but will not exceed the maximums established in the COBRA statute.

If a Member eligible to utilize the self-payment provisions of the Plan is given the choice between COBRA coverage and coverage under the Plan self-payment provisions, and the Member elects to make self-payments under the continuation rules of the Plan, he will not be given another opportunity to continue coverage under the COBRA continuation provisions until he has sufficient employer contributions to again be covered due solely to such contributions. If at a later date self-payment is required to continue coverage, the Member may then once again elect either self-payment under the Plan eligibility rules or the COBRA continuation provisions.

If the Member elects to continue coverage under the COBRA continuation provisions, he must reinstate under Fund rules in order to obtain full plan benefits.

NOTICE IS NOT A FULL DESCRIPTION OF COBRA RIGHTS

Although the terms of the Section Continuation of Coverage (COBRA) provide you with the notice required by law, you should be aware that this notice does not fully describe continuation coverage or other rights under the Plan and that more complete information regarding such rights is available elsewhere in this Summary Plan Description and from the Plan Administrator, the Board of Trustees, by contacting the office listed under Plan Contact Information.

IF YOU HAVE QUESTIONS

Questions concerning your Plan or your COBRA continuation coverage rights should be addressed to the contact or contacts identified below. 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 website at www.dol.gov/ebsa. (Addresses and phone numbers of Regional and District EBSA Offices are available through EBSA’s website.)

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KEEP YOUR PLAN INFORMED OF ADDRESS CHANGES

In order to protect your family’s rights, you should keep the Plan Administrator informed of any changes in the addresses of family members. You should also keep a copy, for your records, of any notices you send to the Plan Administrator.

PLAN CONTACT INFORMATION

The Indiana State Council of Plasterers and Cement Masons Health and Welfare Fund and the Plan Administrator, the Board of Trustees, can be contacted at HealthSCOPE Benefits, 9045 East 59th Street, Indianapolis, Indiana 46216, telephone: (800)950-6789. Information about the Plan and about COBRA continuation coverage can be obtained on request by this contact.

Rule 6 - Individual Proprietors, Partners, or Self-Employed Persons:

Cannot become eligible for any benefits of this Fund.

Rule 7 - Termination of Member’s Coverage

A Member’s benefit coverage can be terminated in the following ways: (1) as of the last day of the Benefit Period for which he has become eligible, if he has failed to meet any of the foregoing requirements as described in Rule 2; (2) at any time he ceases to qualify as a Member as defined in this summary; or (3) at any time the Plan terminates.

Rule 8 - Induction into the Armed Forces

If you enter the uniformed services of the United States, you may elect to continue your health coverage (medical and prescription drug) as required by the Uniformed Services Employment and Reemployment Rights Act of 1994 (USERRA).

Uniformed services include service in the United States Armed Forces, and their Reserves, the Army National Guard and the Air National Guard, the commissioned corps of the Public Health Services and any other category of persons designated by the President in time of war or emergency. “Service“ means the performance of duty on a voluntary or involuntary basis under competent authority and includes active duty, active duty training, initial active duty training, inactive duty training, full-time National Guard duty and a period for which a person is absent from a position of employment for the purpose of an examination to determine the fitness of the person to perform any such duty.

Your regular coverage will continue until the last day of the month that you enter Service. For the first 30 days of Service, you do not have to pay for your USERRA Health Coverage. After the 30th day of Service, you or your Dependent must make the required self-payment contribution for USERRA Health Coverage. You may choose to initially “pay“ this premium using your Benefits Bank, but once you have exhausted your Benefits Bank, you must pay cash to continue USERRA Health Coverage. You may also choose to pay cash immediately, leaving your Benefits Bank to “pay“ for coverage when you apply for reemployment or following termination of employment. The premium for this coverage is the same amount as the COBRA premium.

Your USERRA Health 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 the USERRA Health Coverage began; or The date on which you have had a total of five years of USERRA Health Coverage.

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Your Dependents may continue coverage under the Plan during your Service either through USERRA Health Coverage, if you have elected it, or through COBRA Coverage. If you do not elect USERRA Health Coverage, your Dependents can only continue coverage under the Plan through COBRA Coverage. Regular eligibility for you and your Dependents will be reinstated on the day you return to work, provided you reapply for work in accordance with USERRA, although if you have used up your Benefits Bank, you will have to make cash payments for coverage until you have reestablished eligibility through your Benefits Bank.

You need to notify the Plan Administrator in writing when you enter the uniformed services. For more information about continuing coverage under USERRA, contact the Plan Administrator.

Rule 9 - Early Retirement

Those members over age 55 who elect to cease full time work may continue their eligibility for any of the following benefit programs, provided: (1) they are eligible for benefits prior to early retirement, (2) they are covered for benefits in 10 of the 12 most recently completed insurance quarters, (3) they notify HealthSCOPE Benefits in writing, and (4) they continue to maintain Union membership.

The benefit programs available are:a. Life Insurance and Accidental Death and Dismemberment, Member Only; orb. Life Insurance, Accidental Death and Dismemberment and Medical coverage, Member Only; orc. Life Insurance, Accidental Death and Dismemberment and Medical coverage for Member and

Medical Coverage for Dependent; ord. Life Insurance, Accidental Death and Dismemberment and Medical coverage for Member and

Medicare Supplement for spouse covered by Medicare.

NOTE: If you elect not to cover your spouse at the time of retirement, you may not add him/her at a later date.

NOTE: When a Member or his Covered Dependent(s) becomes eligible for Medicare benefits, he will be eligible to change his class of benefits effective with the month that Medicare benefits become effective. Any savings resulting from such change will be credited to the member’s Benefits Bank balance.

NOTE: If a Retiree wishes to return to active work and be classified as a full-time active Member, he must notify HealthSCOPE Benefits in writing.

Rule 10 - Normal Retirement

Those Members over age 65 who elect to cease full time work may continue their eligibility for any of the following benefit programs, provided: (1) they are eligible for benefits immediately prior to normal retirement, (2) they are covered for benefits in 10 of the 12 most recently completed insurance quarters, (3) they notify HealthSCOPE Benefits in writing, and (4) they continue to maintain Union membership.

The benefit programs available are:a. Life Insurance and Accidental Death and Dismemberment, Member Only; orb. Life Insurance and Accidental Death and Dismemberment, and Medicare Supplement, Member Only

or Member and Spouse; orc. Life Insurance Accidental Death and Dismemberment and Medicare Supplement, Member Only and

Medical Coverage for Dependent; ord. Medicare Supplement, Member Only; ore. Medicare Supplement, Member and Spouse.

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NOTE: If you elect not to cover your spouse at the time of retirement, you may not add him/her at a later date.

NOTE: If a Retiree wishes to return to active work and be classified as a full-time active Member, he must notify HealthSCOPE Benefits in writing.

NOTE: When a Member or his Covered Dependent(s) becomes eligible for Medicare benefits, he will be eligible to change his class of benefits effective with the month that Medicare benefits become effective. Any credit resulting from such change will be added to the member’s Benefits Bank balance.

Rule 11 - Survivor Benefits

At the time of death of a Covered Member who has eligible Dependents, the Dependent(s) may continue the Health Coverage by requesting this coverage and making the necessary invoice payment each Eligibility Period. This benefit will terminate upon the earliest of:1. death of the Dependent2. in the case of a surviving spouse, remarriage3. in the case of surviving children, attainment of a limiting age as described in this summary.

NOTE: When a Covered Dependent becomes eligible for Medicare Benefits, she will be eligible to change her class of benefits effective with the month that Medicare benefits become effective. Any credit resulting from such change will be credited to the Dependent’s Benefits Bank balance.

Rule 12 - Totally and Permanently Disabled Members

Those Members who, before age 60, by reason of Total and Permanent Disability, qualify under the terms of such disability (as specified in the Life Insurance Contract) may continue their eligibility for the Medical Coverage only, by having either monies available from the Benefits Bank or by Employee Self-Payment of the actual cost of program in force. Totally and Permanently Disabled Members may continue their coverage provided 1) they remain totally disabled; and 2) they maintain Union membership.

NOTE: When a Member or his Covered Dependent(s) becomes eligible for Medicare benefits, he will be eligible to change his class of benefits effective with the month that Medicare benefits become effective. Any credit resulting from such change will be credited to the member’s Benefits Bank balance.

NOTE: If you elect not to cover your spouse at the time of disability determination, you may not add him or her at a later date.

Rule 13 – If you take a leave under the Family and Medical Leave Act (FMLA)

The Family and Medical Leave Act of 1993 (FMLA) enables you to take up to 12 weeks (during any 12-month period) of unpaid leave for the birth or adoption of a child or for your serious illness or to care for a seriously ill spouse, parent or child, if you are eligible. The FMLA requires your Employer to continue making contributions for your Health Coverage for the length of a qualified FMLA leave, as if you were still working. During your FMLA leave, dollars will not be taken from your Benefits Bank to pay for your Health Coverage, nor will dollars be added to your Benefits Bank.

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You are eligible for FMLA benefits if you:

Work for the same Employer for at least 12 months; Have worked at least 1,250 hours for that Employer during the previous 12 months; and Work at a location where at least 50 employees are employed by the Employer within 75 miles.

When taking a leave under FMLA, you and your Employer need to inform the Trustees in writing so that your rights to Health Coverage are protected during the leave.

If you return to work within 12 weeks, you will not lose Health Coverage. If you do not return to work within 12 weeks, you will then qualify to continue your coverage under COBRA Coverage. You may self-pay for COBRA Coverage through your Benefits Bank and then cash for up to 18 additional months, or in some situations 29 months. Contact the Plan Administrator for additional information about FMLA or continuing your coverage under COBRA Coverage.

If you and your Employer disagree over your eligibility for coverage under FMLA, your benefits will be suspended until the disagreement is resolved. Such disputes are between you and your Employer. The Trustees will not become involved in resolving this type of dispute.

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CONTINUATION OF COVERAGE (COBRA)

Under certain circumstances, coverage for you or your eligible Dependents (“Qualified Beneficiaries“) can be temporarily continued, at your expense, after it would normally end due to a “Qualifying Event“. The Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA) provides you with the right to this continuation coverage. This Plan is automatically amended to conform with any changes made to the COBRA regulations.

This section of the booklet serves as your initial notice of your COBRA rights, including when COBRA may be available to you and your qualified Dependents and what you must do to protect your COBRA rights.

COBRA Coverage is identical to the coverage you had under the Plan. You may continue your medical benefit under this Plan, but the Life Insurance and Short Term Disability Benefits cannot be continued.

After a “Qualifying Event“, each person losing Health Coverage will become individually entitled to elect COBRA Coverage. You or your Spouse, if your Spouse is eligible to elect COBRA Coverage, may elect COBRA Coverage for your Dependent Children who are eligible for COBRA Coverage. Each person must pay the full cost of the COBRA Coverage plus a small administrative charge.

If you (the Employee) have a newborn child, adopt a child or have a child placed with you for adoption (for whom you have financial responsibility) while COBRA Coverage is in effect, you may add your child to your COBRA Coverage. You must notify the Plan Administrator, in writing, of the birth or placement to have your child added to your coverage. Alternate recipients receiving benefits under a QMSCO which is received by the Plan Administrator during your Health Coverage are entitled to the same right to elect COBRA Coverage as other eligible Dependent Children.

Children born, adopted or placed for adoption as described above, have the same COBRA rights as a Spouse or Dependent Children who were covered by the Plan before the Qualifying Event that triggered COBRA Continuation Coverage. Like all Qualified Beneficiaries with COBRA Coverage, their continued coverage depends on timely and uninterrupted COBRA premiums on their behalf.

18-Month COBRA Continuation Coverage

If coverage ends for one of the following reasons or “Qualifying Events,“ you may elect to pay for COBRA Coverage for yourself and your qualified Dependents for up to 18 months:

Your coverage ends because your employment ends, including retirement, but not including termination due to gross misconduct; You are no longer eligible for Plan coverage due to your failure to work the required number of hours in the corresponding work period; or Your Employer lays you off.

However, if your qualified Dependents have a second “Qualifying Event“ during the initial 18 months of COBRA Coverage, they may pay for COBRA Coverage for a total of 36 months. Second “Qualifying Events“ include your:

Death; Divorce or legal separation; or Dependent child no longer qualifying for Dependent coverage under the terms of the Plan.

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If the “Qualifying Event“ is the end of employment, layoff or a reduction of hours, and you became entitled to Medicare benefits less than 18 months before the “Qualifying Event“, COBRA Coverage for your Dependents can last until up to 36 months after the date of your Medicare entitlement. So, for example, if you become entitled to Medicare 8 months prior to a termination of employment that results in your losing Health Coverage under the Plan, then your Dependents could receive COBRA Coverage for 28 months (36 months minus 8 months). This COBRA Coverage period is available only if you become entitled to Medicare less than 18 months before your termination, layoff or reduction of hours.

29-Month COBRA Continuation Coverage

If your coverage ends due to one of the above “Qualifying Events“ (termination, layoff or reduction of hours) and, at the time of the event, or within the first 60 days of COBRA Coverage, you or one of your qualified Dependents is totally disabled (as determined by the Social Security Administration), COBRA Coverage for you and all of the family members who are covered under COBRA Coverage is extended for an additional 11 months, for a total of 29 months. This option offers the disabled individual COBRA Coverage until Medicare coverage becomes effective. Coverage for the additional 11 months will be at a higher cost.

If your qualified Dependents have a second “Qualifying Event“ during the initial 29 months of coverage, they may pay for a total of 36 months of COBRA Coverage.

36-Month COBRA Continuation Coverage

Your qualified Dependents may elect to purchase COBRA Coverage for up to 36 months if their Plan coverage ends for any of the following “Qualifying Events“ or reasons:

Your death; Your divorce or legal separation; or Your Dependent Child no longer qualifies for Dependent coverage under the terms of the Plan.

If coverage was terminated in anticipation of a separation or divorce, a later separation or divorce is still a Qualifying Event, even if coverage was reduced or eliminated prior to the divorce or separation.

Notice of Qualifying Events

To be eligible for COBRA Coverage, you, your qualified Dependents, or your Employer must providewritten notice to the Plan Administrator of the Qualifying Event. The notice must be mailed, emailed, faxed or hand-delivered to HealthSCOPE Benefits. Who must provide this notice depends on the nature of the Qualifying Event.

You should notify the Plan Administrator of your entitlement to Medicare. Your Employer will notify the Plan Administrator of your termination of employment, reduction of hours, or death. However, because employers contributing to multiemployer funds may not be aware of these events, HealthSCOPE Benefits will rely on its records for determining when eligibility is lost under these circumstances. To help ensure that you do not suffer a gap in coverage, we urge you or your family to notify HealthSCOPE Benefits of qualifying events as soon as they occur.

To elect COBRA Coverage after a divorce, legal separation or a child ceasing to be a Dependent Child under the Plan, you and/or a family member must inform the Plan Administrator in writing of that event no later than 60 days after that event occurs. That notice should be sent to HealthSCOPE Benefits, whose address is listed in the “Contact Information“ section of this summary.

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To receive an extension of COBRA Coverage due to a second Qualifying Event, you or a family member must inform the Plan Administrator in writing within 60 days of the death, divorce, legal separation or the date a Child ceases to be a Dependent under the Plan. To receive an extension, this notice must also be received before the end of the first 18 months of COBRA Coverage. Otherwise, you will NOT be eligible for the extension of coverage.

If you and/or your qualified Dependents are seeking an extension due to disability, you or a family member must inform the Plan Administrator in writing, providing Social Security Administration’s determination of disability, within 60 days of the latest of:

• the date of the SSA’s disability determination;• the date of termination, layoff or reduction of hours; and • the date of lost coverage of your Dependent due to termination, layoff or reduction of

hours.

If HealthSCOPE Benefits does not receive the notice discussed above within the 60-day period, the Qualified Beneficiary will not be entitled to choose or extend COBRA Coverage.

What is Not a Qualifying Event

If your Employer withdraws from participating in the Plan (for example becomes a non-union contractor) then when your Benefits Bank runs out, you do not have the right to buy COBRA Coverage from this Plan, because your Employer’s withdrawal from this Plan is NOT a Qualifying Event.

If you lose your Retiree Coverage because you do not pay your premium, this is not a Qualifying Event.

When COBRA Coverage Ends

COBRA Coverage may end for any of the following reasons:

You or your Dependent becomes covered under another group medical plan. However, COBRA coverage will continue if you or a qualified Dependent has an existing health problem for which coverage is excluded under the other group plan; The required contribution is not paid on time; The Board of Trustees terminates the Health and Welfare Plan; You or your Dependent reaches the end of the 18-month, 29-month or 36-month COBRA Coverage period;

• If the Qualified Beneficiary who was disabled is later determined by Social Security to no longer be disabled, you must notify the Plan Administrator of that decision within 30 days of the decision, and your COBRA coverage will end as of that date;

You become entitled to Medicare; or Your Dependents become entitled to Medicare.

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

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FAMILY AND MEDICAL LEAVE ACT

You may be eligible for continued coverage through your Employer pursuant to the terms of the Family and Medical Leave Act. Please refer to Rule 13 of the Rules of Eligibility for more information, or contact your Employer for more information.

QUALIFIED MEDICAL CHILD SUPPORT ORDER

The Plan will comply with the terms of a Qualified Medical Child Support Order (QMCSO), as long as it does not require the Plan to provide coverage which it would not provide in the absence of such an Order and otherwise complies with federal law regarding a QMCSO. Upon written request, HealthSCOPE Benefits will provide you with a copy of its procedures for processing a QMCSO.

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GENERAL PROVISIONS(Not Applicable to Life Insurance)

CLAIM FORMS

When the Plan receives the notice of claim, it will send the Covered Member the forms to be used in filing proof of claim. If the Plan does not send these forms within 15 days, the Covered Member can meet the requirements for proof of claim as along as he or she sends written proof satisfactory to the Plan of: (1) the occurrence of the loss; and (2) the nature of the loss; and (3) the extent of the loss. This proof must be given within the time limit stated in Proof of Claim below.

PROOF OF CLAIM

Written proof of claim satisfactory to the Plan must be given to the Plan at HealthSCOPE Benefits within 90 days after the date of the event for which the claim is made. If proof of claim is not sent within the time required, the claim will not be reduced or denied if it was not possible to send proof within this time. However, the proof must be sent as soon as reasonably possible. In any case, the proof required must be sent to the Plan no later than two years following the 90 day period specified, unless the Covered Member was legally incapacitated.

PHYSICAL EXAMINATION AND AUTOPSY

The Plan, at its expense, has the right to have a Physician of its choice examine any Covered Member as often as reasonably necessary while there is a claim pending. The Plan also has the right to have an autopsy performed, unless it is not permitted by law.

LEGAL ACTIONS

No Covered Member may sue for payment of claim: (1) within 60 days after the date proof of claim is sent as required; or (2) more than 3 years after the time proof of claim is required. If any time for giving notice or proof of claim or beginning legal action is less than that permitted by the laws in effect where the Plan is situated, the limit will be extended to the minimum period of time permitted.

PAYMENT OF BENEFITS

Benefits will be paid to you. They will be paid as soon as written proof of claim satisfactory to the Plan is received. For a continuing claim, you may ask the Plan to pay the benefits on a weekly basis. If any benefit has not been paid when you die, if you are minor, or if you are legally incapable of giving a valid release for any benefit, the Plan may pay all or part of the benefit to: (1) your guardian; (2) your estate; (3) any Institution or person (as payment for charges made in connection with the claim these benefits are paid for); or (4) any one or more persons among the following relatives: your spouse, parents, children, brothers, or sisters. Payment of a claim to anyone described above releases the Plan from all further liability for that claim.

ASSIGNMENT

The Fund recognizes the right of a Participant or Beneficiary to enter an agreement with a service provider to have the Fund directly pay the service provider for services rendered by that service provider. However, no agreement executed by a Participant or Beneficiary purporting to assign a right to collection of benefits to a service provider shall provide a service provider with any right to maintain an action in contract, tort or as an ERISA benefit claim by the service provider against the Fund or the Trustees for

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recovery of any amounts from the Plan. Any claim brought against the Plan for payment of benefits must be brought in the name of the Participant or Beneficiary upon whom services were performed.

RIGHT TO RECOVERY

If the Plan pays more on a claim than it should have, the Plan may recover the overpayment. The Plan may seek recovery from one or more of: (1) any Covered Member to or for whom benefits were paid; (2) any other insurers or Plans; (3) any Institution, Physician or other provider of medical care; or (4) any other organization.

The Plan shall be entitled to deduct the amount of any such overpayments from any future claims payable to or on behalf of you or any of your Dependents.

PLAN’S SOLE DISCRETION

The Plan may, at its sole discretion, pay benefits for services and supplies not specifically covered by the Plan. This applies if the Trustees determine such services and supplies are in lieu of more expensive services and supplies which would otherwise be Medically Necessary for the care and treatment of the Covered Member.

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PROCEDURE FOR FILING CLAIMS

The following outline of the claim filing procedure is designed to assist you to receive the best possible claim service from your Health & Welfare Plan. When you need claim forms, contact your Union Office or HealthSCOPE Benefits.

YOU SHOULD ALWAYS KEEP COPIES OF ANY FORMS OR BILLS SENT TO HealthSCOPE Benefits.

1. WEEKLY DISABILITY BENEFIT CLAIMSa. FILING THE INITIAL CLAIM.

i. When a Member suffers an illness or injury requiring regular medical care and the absence from work because of the disability, he may be eligible for benefits under this Plan. Claim forms should be submitted as soon as possible following such illness or disability.

ii. All items under the section headed “To Be Completed By Insured“ on the Claim Form should be answered. The Member’s signature and date that he completes the form should appear in the authorization section of the form.

iii. The Member should take the form to his doctor and ask him to complete the Physician or Supplier portion of the form, accurately answering all questions, dating and signing the appropriate place. You should personally mail the form directly to HealthSCOPE Benefits, P.O. Box 50440, Indianapolis, Indiana 46250-0440.

iv. HealthSCOPE Benefits processes disability claims on the Friday following the day they are received. Properly completed claim forms enable them to prepare a check for benefits and mail it the next business day; incomplete or inaccurate claims obviously require more time to handle.

b. PROOF OF CONTINUING DISABILITYi. If disabilities or illnesses are prolonged, it may be necessary to obtain additional medical

information from your attending physician.ii. If additional information is necessary, HealthSCOPE Benefits will send you a form to be

completed by you and the attending physician. The Member should personally mail this form or have it mailed for him directly to HealthSCOPE Benefits.

NOTE: Under no circumstance will your Weekly Sick Benefits be more than the benefits stated in the Schedule of Benefits.

IMPORTANT--Do not rely on your doctor to mail the form. For prompt claim service, see to it personally that the completed form is placed in the mail.

2. CLAIMS FOR HOSPITAL BENEFITSa. TO RECEIVE BENEFITS

i. Most local hospitals have a standard form in use by all members of the American Hospital Association. Any form that is approved by the American Hospital Association is satisfactory to the Trustees.

ii. The Member should present his identification card to the Admission Desk on entering the hospital. The hospital will provide the proper form for signature and will mail the form, together with an itemized copy of the billing, to HealthSCOPE Benefits, after the member is discharged.

iii. HealthSCOPE Benefits will pay the hospital directly and send a copy of the check to you, if you assign benefits.

iv. If the hospital bill is in excess of the amounts allowed under your Plan, the Member may be required by the hospital to pay the remaining amounts upon his discharge.

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v. If a Member knows in advance that he will be hospitalized outside of Indiana or his immediate vicinity, it is wise for him to present his booklet showing his benefits to the hospital at the time he is admitted.

vi. As this Plan requires Hospital Pre-certification, please refer to the Hospital Pre-Certification Program section of this summary.

3. MEDICAL BENEFITSa. TO RECEIVE BENEFITS

i. Eligible Medical charges should be mailed to HealthSCOPE Benefits, along with a completed Claim Form.

ii. Bills should be mailed on a regular basis, not held to the end of the year.iii. You must keep separate records of medical expenses incurred for yourself and each of your

Dependents, since the Deductible Amount, the maximum, and other provisions apply separately to each individual. Be sure to save all bills for any item of covered expense and in each case a record of the date the expense was incurred (not the date of the bill). A bill or cash receipt for prescription drugs must indicate the date of purchase, the prescription number, and the name of the Doctor who issued the prescription.

4. MEDICARE BENEFITSa. TO RECEIVE BENEFITS

i. Please refer to the Special Medicare Provision Section of this summary for a description of your benefits under this Plan after you become eligible for Medicare.

ii. Always remember, you will need two (2) copies of your bills and itemized receipts--one for this Plan and one for Medicare.

iii. If your doctor or hospital files your Medicare Claim for you, be sure they also give you a copy of their bills.

iv. Medicare will send you a form, “Medicare Explanation of Benefits“ from which they pay their portion of the charges.

v. Send the “Medicare Explanation of Benefits“ with a completed Claim Form to HealthSCOPE Benefits, P.O. Box 50440, Indianapolis, Indiana 46250-0440. Attach your copies of the bills that are covered by the Medicare payment.

5. LIFE INSURANCE TOTAL AND PERMANENT DISABILITY BENEFITIf you feel you may be eligible for this benefit, contact HealthSCOPE Benefits or the life insurance carrier. They will send forms for your and your doctor’s completion.

6. CLAIMS REVIEWIf you believe payment of a claim (or denial of a claim) is not according to the terms of the Plan, contact HealthSCOPE Benefits. Your claim will be reviewed.

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CLAIM REVIEW PROCEDURES

CLAIM PRESENTATION

Claim Presentation Procedures are included in the General Provisions section of this summary.

CLAIM FORMS

May be obtained from HealthSCOPE Benefits. See Contact Information section of this summary.

CLAIM DENIALS AND APPEALS

Medical Claims

Pre-Service Claims Involving Urgent CareIn the event the Plan requires that a determination be made prior to the receipt of care in order for a service to be covered (including utilization review) the Plan must respond within 72 hours of receipt of the claim as to the Plan’s determination with respect to that claim. If additional information is necessary to make the determination, the claimant must be notified within 24 hours of receipt of the claim and must be given a minimum of 48 hours to provide the additional information. The Plan Administrator must then notify the claimant of the determination no later than 48 hours after the earlier of: 1) the Plan’s receipt of the specified additional information, or 2) the end of the period given the claimant to provide the information.

Pre-Service Claims Not Involving Urgent CareIf the Plan requires that a service or treatment be approved prior to the receipt of the treatment or service that does not include urgent care, the Plan must respond to the claim within 15 days of receipt of the claim. One extension of 15 days is allowed as long as the participant is notified during the initial 15-day period. If such an extension is necessary due to a failure of the claimant to submit the information necessary to decide the claim, the notice of extension shall specifically describe the required information, and the claimant shall be afforded at least forty-five (45) days from receipt of the Notice within which to provide the specified information.

Concurrent ClaimsIn the event that the Plan makes a determination that an ongoing claim (concurrent claim) that has been covered by the Plan is or will no longer be covered by the Plan, the Plan must provide a response within 24 hours of receipt of the claim.

Post-Service ClaimsThe Plan Administrator shall notify the claimant of the Plan’s adverse benefit determination (defined as the denial, in whole or in part, of a claim for benefits) within a reasonable period of time, but not later than thirty (30) days after receipt of the claim. This period may be extended one time by the Plan for up to fifteen (15) days, provided that the Plan Administrator both determines that such an extension is necessary due to matters beyond the control of the Plan and notifies the claimant, prior to the expiration of the initial thirty (30) day period, of the circumstances requiring the extension of time and the date by which the Plan expects to render a decision. If such an extension is necessary due to a failure of the claimant to submit the information necessary to decide the claim, the notice of extension shall specifically describe the required information, and the claimant shall be afforded at least forty-five (45) days from receipt of the Notice within which to provide the specified information.

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Disability, Accidental Death and Dismemberment and Death Benefit Claims.

In the case of a claim for disability, AD&D or death benefits, the Plan Administrator shall notify the claimant of the Plan’s Procedures for Appeals of adverse benefit determinations within a reasonable period of time, but not later than forty-five (45) days after receipt of the claim by the Plan. This period may be extended by the Plan for up to thirty (30) days, provided that the Plan Administrator both determines that such an extension is necessary due to matters beyond the control of the Plan and notifies the claimant, prior to the expiration of the initial forty-five (45) day period, of the circumstances requiring the extension of time and the date by which the Plan expects to render a decision. If, prior to the end of the first thirty (30) day extension period, the Plan Administrator determines that, due to matters beyond the control of the Plan, a decision cannot be rendered within that extension period, the period for making the determination may be extended for up to an additional thirty (30) days, provided that the Plan Administrator notifies the claimant, prior to the expiration of the first thirty (30) day extension period, of the circumstances requiring the extension and the date as of which the Plan expects to render a decision. In the case of any extension under this paragraph, the notice of extension shall 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, and the claimant shall be afforded at least forty-five (45) days within which to provide the specified information.

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APPEAL OF ADVERSE BENEFIT DETERMINATIONS

As part of the claimant’s rights of appeal:a. Claimants shall have at least one hundred eighty (180) days following receipt of a notification of

an adverse benefit determination within which to appeal the determination;b. The review on appeal shall not afford deference to the initial adverse benefit determination and

shall be conducted by the Board of Trustees or a designated committee thereof.c. In deciding an appeal of any adverse benefit determination that is based in whole or in part on a

medical judgment, including determinations with regard to whether a particular treatment, drug, or other item is experimental, investigational, or not medically necessary or appropriate, the Trustees shall consult with a health care professional who has appropriate training and experience in the field of medicine involved in the medical judgment;

d. The Plan shall provide to claimant the identification of any medical or vocational experts whose advice was obtained on behalf of the Plan in connection with a claimant’s adverse benefit determination, without regard to whether the advice was relied upon in making the benefit determination;

e. The appeal review process shall provide that the health care professional engaged for purposes of a consultation under paragraph “c“ of this Section shall be an individual who is neither an individual who was consulted in connection with the adverse benefit determination that is the subject of the appeal, nor the subordinate of any such individual; and

The appeals process of a claim for disability, AD&D or death benefits shall be as set forth above, except that such appeals must be filed within sixty (60) days of receipt of the adverse determination.

TIMING OF NOTIFICATION OF BENEFIT DETERMINATION ON REVIEW.

The Trustees shall make a benefit determination no later than the date of the meeting of the committee or board that immediately follows the Plan’s receipt of a request for review, unless the request for review is filed within thirty (30) days preceding the date of such meeting. In such case, a benefit determination may be made by no later than the date of the second meeting following the Plan’s receipt of the request for review. If special circumstances require a further extension of time for processing, a benefit determination shall be rendered not later than the third meeting of the committee or board following the Plan’s receipt of the request for review. If such an extension of time for review is required because of special circumstances, the Plan Administrator shall notify the claimant in writing of the extension. The Plan Administrator shall notify the claimant of the benefit determination as soon as possible, but not later than five (5) days after the benefit determination is made.

Furnishing Documents.

In the case of an adverse benefit determination on review, the Plan Administrator shall provide the claimant such access to, and copies of, documents, records, and other information as is appropriate and required by law.

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ADDITIONAL INFORMATION

CHANGES TO/DISCONTINUATION OF YOUR PLAN

The Trustees reserve the right to change all or any portion of the Plan from time to time or to discontinue all or any portion of the Plan. The Trustees have sole authority and responsibility to review and make final decisions on all claims to benefits according to the provisions of the Plan and to use the fullest amount of discretion afforded by law in making these decisions. Benefits under this Plan will be paid only if the Plan Administrator decides in his discretion that the participant is entitled to them.

The Plan is maintained for the exclusive benefit of the Plan’s Participants and their eligible Dependents. All rights and benefits granted you under the Plan are legally enforceable.

EMPLOYEE CONTRIBUTIONS AND HOURLY CONTRIBUTION RATES

The Trustees may determine the amount of the required contributions from time to time at their discretion, and will advise Covered Members of any changes in the contribution amount.

PLAN FUNDING

From time to time and at their discretion, the Trustees may determine the funding method for benefits under this Plan which may include, without limitation, insurance policies of Health Coverage, self-funding and partial self-funding. Currently, the Plan is funded by Employer and Employee contributions to the Trust, and it pays all benefits due under this Plan out of the Trust.

LIMITS OF LIABILITY

No Participant shall have any claim arising under this Plan against the Trustees, the Plan, the Plan Administrator, the Plan’s service providers or any other person except for the amount of regular Plan benefits due under this Plan.

This Plan’s use of any preferred provider network does not constitute a recommendation or endorsement of any Hospital, Physician or other provider. No person shall have any claim against the Trustees, the Plan, the Plan Administrator or their service providers, appointees or agents arising out of injuries caused by any provider.

This Plan does not create a contract of employment between any Employer and any Employee, nor does it affect the status of any person as an Employee-at-will.

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HIPAA PRIVACY AND SECURITY POLICY

Protected health information (“PHI“) means individually identifiable health information that: 1) relates to the past, present or future physical or mental health or condition of an individual, the provision of health care to the individual, or to the past, present, or future payment for the provision of health care to the individual; 2) identifies the individual or reasonably could identify the individual; and 3) is created or received by the Plan.

Plan means the Indiana State Council of Plasterers and Cement Masons Health & Welfare Fund

HIPAA refers to the Health Insurance Portability and Accountability Act’s (HIPAA) Privacy of Individually Identifiable Health Information standards (45 CFR Parts 160 and 164).

Plan Sponsor means the Trustees of the Indiana State Council of Plasterers and Cement Masons Health & Welfare Fund

A. Plan Certification

The Plan will disclose PHI to the Plan Sponsor only upon receipt of a certification by the Plan Sponsor that the Plan documents include the assurances set out in Paragraphs B and C below.

B. Assurances of Plan Sponsor

With respect to PHI about Plan participants, the Plan Sponsor agrees to:1. Use and disclose PHI as permitted by HIPAA, including but not limited to purposes

related to health care treatment, payment for health care, and health care operations;

2. Not use or further disclose PHI other than as permitted or required by the Plan documents or as permitted or required by law;

3. Ensure that any agents, including a subcontractor, to whom it provides PHI received from the Plan agree to the same restrictions and conditions that apply to the Plan Sponsor with respect to such information, including implementing reasonable and appropriate security measures to protect electronic PHI;

4. Not use or disclose PHI for employment-related actions and decisions or in connection with any other benefit or employee benefit plan of the Plan Sponsor;

5. Report to the Plan any use or disclosure of PHI by the Plan Sponsor that is not permitted of which it becomes aware;

6. Make available PHI to Participants in accordance with HIPAA;

7. Amend PHI as requested by a Plan Participant or provide an explanation for the denial of the request in accordance with HIPAA;

8. Make PHI available as required, to provide an accounting of disclosures in accordance with HIPAA;

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

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10. If feasible, return or destroy all PHI received from the 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 disclosure was made, and 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 infeasible;

11. Ensure that the adequate separation between the Plan and the Plan Sponsor is established, as described in Section C, including ensuring reasonable and appropriate security measures;

12. Implement administrative, physical and technical safeguards that reasonably and appropriately protect the confidentiality, integrity and availability of electronic PHI that the Plan Sponsor creates, receives, maintains or transmits on behalf of the Plan; and

13. Promptly report to the Plan any security incident relating to electronic PHI of which it becomes aware. (A security incident is the attempted or successful unauthorized access, use, disclosure, modification, or destruction of information or interference with system operations in an information system).

C. Separation Between Group Health Plan and Plan Sponsor.

The Plan Sponsor agrees that the confidentiality of PHI will be protected by adoption of the following measures:

1. The administration of the Plan is outsourced to third parties who have signed Business Associate agreements limiting their use of PHI and requiring them to maintain the confidentiality of PHI. The only representatives of participating employers and unions who will have access to PHI claims information disclosed by the Plan are those representatives who serve as Trustees of the Plan.

2. Access to and use of PHI by the Trustees is limited and restricted to Plan administration functions that they perform for the Plan.

3. In the event that a third party contractor or sub-contractor described above does not comply with the limitations on uses and disclosures of PHI as described in their Business Associate agreement, the Trustees shall consider such actions a breach of the agreement. Unless the breach can be promptly corrected and the Trustees can obtain reasonable assurance that a breach will not recur, the third party will be required to return all PHI, will no longer be allowed access to PHI, and the underlying agreement with the Plan may be immediately terminated.

4. The Plan may disclose PHI to the Plan Sponsor to carry out administrative functions that the Plan Sponsor performs on behalf of the Plan.

5. The Plan will not use or disclose PHI for employment-related actions and decisions or in connection with any other benefit or employee benefit plan of the Plan Sponsor.

6. Policies and procedures are in place for the resolution of any non-compliance with the Plan documents by a Trustee.

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STATEMENT OF ERISA RIGHTS

As 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 the following rights.

Receive Information About Your Plan And Benefits

You have the right to:

Examine, without charge, at the Plan Administrator’s office and at other specified locations, such as worksites and Union halls, all documents governing the Plan. These include insurance contracts and 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 and collective bargaining agreements and copies of the latest annual report (Form 5500 Series) and updated Plan document/Summary Plan Description. 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 Eligible Employee 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 and the documents governing the Plan on the rules governing your COBRA Coverage rights.

Reduce or eliminate exclusionary periods of coverage for preexisting 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 Coverage; or• Your COBRA Coverage ceases.

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 a pre-existing condition exclusion for 12 months (18 months for late enrollees) after your enrollment date in your coverage.

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.

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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. For instance, if you request a copy of the Plan documents 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, which 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.

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 nearest office of the Employee Benefits Security Administration (EBSA), U.S. Department of Labor, listed in your telephone directory or:

Division of Technical Assistance and InquiriesEmployee Benefits Security Administration

U.S. Department of Labor200 Constitution Avenue N.W.

Washington, D.C. 20210

For more information about your rights and responsibilities under ERISA: Call 1-866-444-3272; Visit www.dol.gov/ebsa; or Send electronic inquiries to www.askebsa.gov.

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All of the benefits of this Plan are made available to you and your eligible Dependents by the Trustees as a privilege and not as a right. You and your eligible Dependents do not acquire any vested right to Plan benefits either before or after your retirement.

The Trustees reserve the right to amend, modify or discontinue all or part of the Plan whenever, in their judgment, conditions so warrant. Participants will be notified in writing of any Plan changes.

Subject to the stated purposes of the Plan and the provisions of the Trust Agreement, the Trustees have full and exclusive authority to determine all questions of coverage and eligibility, methods of providing or arranging for benefits and all other related matters. They have full power to construe the provisions of this Summary Plan Description, the terms used herein and the bylaws and regulations issued thereunder. Any such determination and any such construction adopted by the Trustees in good faith will be binding upon all of the parties hereto and beneficiaries hereof. No matters respecting the foregoing or any difference arising thereunder or any matter involved in or arising under the Trust Agreement or this Summary Plan Description will be subject to the grievance or arbitration procedure established in any collective bargaining agreement between the Employers.

It is the intent of the drafters of this Summary Plan Description that the Trustees possess the maximum discretion to determine eligibility for benefits and to construe the terms of the Trust Agreement and/or Plan document and Summary Plan Description governing benefits. It is also the intent of the drafters of the Trust Agreement and Plan document and Summary Plan Description, by adopting the discretionary power specified above, that the decisions of the Trustees as to determinations of eligibility and the granting or denial of benefits and the construing of terms of the Trust Agreement and Plan, be given judicial deference and be reviewed pursuant to an “arbitrary and capricious“ standard of review, as enunciated by the United States Supreme Court in Firestone Tire and Rubber Company et al. V. Richard Bruch, 57 W L 4194 (Feb 21, 1989).

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Trustees of theIndiana State Council of Plasterers and Cement Masons

Health and Welfare Fund

Employer Trustees

Fred H. LuskVerkler, Inc.7240 Georgetown RoadIndianapolis, IN 46268Chairman

Thomas P. EulittThomas P. Eulitt, Inc.8501 West Redbud LaneMuncie, IN 47304

Ronald W. HookPeyronnin Construction Co.1901 North KentuckyEvansville, IN 47711

Jeff SwanWalsh & Kelly, Inc.1700 East Main StreetGriffith, IN 46319

Rebecca UnderwoodIndy Walls & Ceilings1901 North Sherman DriveIndianapolis, IN 46218Vice-Chairman

Russ VanOverbergheVanOverberghe Builders53922 Olive RoadSouth Bend, IN 46628

Robert WebsterBouma-Betten of IndianaP.O. Box 5554Lafayette, IN 47903

Employee Trustees

Pat HansenOPCMIA Local 692, Area 46220 North Fulton StreetIndianapolis, IN 46202Secretary

Kevin WildesOPCMIA Local 692, Area 1011001 N Michigan StreetLakeville, IN 46536

John DavisOPCMIA Local Union No. 34656 Baumgartner RoadSt. Louis, MO 63129

Tom KlebanOPCMIA Local Union 406610 East Main StreetGriffith, IN 46319

Mark McCleskeyOPCMIA Local 692220 North Fulton StreetIndianapolis, IN 46202Assistant Secretary

Russell RedmonOPCMIA Local Union 692, Area 566210 North Fulton, Room 106Evansville, IN 47710

Tom WebsterOPCMIA Local 692, Area 7531½ South 13th StreetTerre Haute, IN 47807

KD_2396632_3.DOC