SHEET METAL WORKERS LOCAL 22 WELFARE FUND

SUMMARY PLAN DESCRIPTION

September 2020

IMPORTANT NOTE

This Document, together with the Certificate of Insurance constitute

Your Summary Plan Description (SPD).

SHEET METAL WORKERS

LOCAL UNION NO. 22 WELFARE FUND

P.O. Box 308 106 South Avenue West

Cranford, New Jersey 07016 (908) 276-2320

UNION TRUSTEES

JAMES O’REILLYDAVID CASTNERJASON ROONEY

EMPLOYER TRUSTEES

MARIO CAVALLONEANDREW NOVAK

GREGG WHEATLEY

FUND MANAGER

THOMAS GALLAGHER

COUNSEL

NORMAN ALBERT

AUDITOR

MOORE STEPHENS, P.C.

ACTUARY

BOLTON PARTNERS NORTHEAST, INC.

TABLE OF CONTENTS

INTRODUCTION........................................................................................................................................................... 8WHAT THIS DOCUMENT TELLS YOU.................................................................................................................. 8IMPORTANT NOTICE............................................................................................................................................... 8FOR HELP OR INFORMATION................................................................................................................................ 9PLAN INFORMATION CHART................................................................................................................................ 9

ELIGIBILITY.................................................................................................................................................................11DEFINITION OF TERMS USED IN THIS ELIGIBILITY SECTION......................................................................11INITIAL EMPLOYEE ELIGIBILITY........................................................................................................................12WHEN COVERAGE BEGINS....................................................................................................................................12MAINTAINING ELIGIBILITY..................................................................................................................................12REINSTATEMENT.....................................................................................................................................................14DEPENDENT ELIGIBILITY......................................................................................................................................14COVERAGE FOR ELIGIBLE DEPENDENTS..........................................................................................................15PROOF OF DEPENDENT STATUS..........................................................................................................................15QUALIFIED MEDICAL CHILD SUPPORT ORDER (QMSCO).............................................................................16RETIREE ELIGIBILITY.............................................................................................................................................16

ENROLLMENT..............................................................................................................................................................17HOW TO ENROLL FOR BENEFITS.........................................................................................................................17SPECIAL ENROLLMENT FOR YOU.......................................................................................................................17SPECIAL ENROLLMENT FOR ELIGIBLE DEPENDENTS...................................................................................17STATE CHILDREN’S HEALTH INSURANCE PROGRAM REAUTHORIZATION ACT OF 2009 (SCHIP).....17ENROLLMENT RULES PERTAINING TO HOSPITAL, MAJOR MEDICAL, AND PRESCRIPTION DRUG COVERAGE....................................................................................................................................................17START OF COVERAGE FOLLOWING SPECIAL ENROLLMENT......................................................................18LOSS OF OTHER HEALTH COVERAGE................................................................................................................18FAILURE TO ENROLL..............................................................................................................................................18

WHEN COVERAGE ENDS..........................................................................................................................................19YOUR COVERAGE....................................................................................................................................................19COVERAGE FOR YOUR SPOUSE ENDS WHEN...................................................................................................19COVERAGE FOR YOUR DEPENDENT CHILD(REN) ENDS THE EARLIEST OF............................................19CONTINUATION OF COVERAGE FOR DEPENDENT CHILDREN UNDER NEW JERSEY LAW..................19REINSTATEMENT OF COVERAGE DUE TO LACK OF WORK.........................................................................19EXTENSION OF MEDICAL COVERAGE DURING TOTAL DISABILITY.........................................................19NOTICE TO THE PLAN.............................................................................................................................................20CONTINUATION OF COVERAGE...........................................................................................................................20CERTIFICATION OF COVERAGE WHEN COVERAGE ENDS............................................................................20PROCEDURE FOR REQUESTING AND RECEIVING A CERTIFICATE OF CREDITABLE COVERAGE......20

LEAVE OF ABSENCE FOR ELIGIBLE EMPLOYEES..........................................................................................21FAMILY AND MEDICAL LEAVE ACT (FMLA)....................................................................................................21MILITARY LEAVE....................................................................................................................................................21

Duty to Notify the Plan............................................................................................................................................22Plan Offers Continuation Coverage........................................................................................................................22Paying for USERRA Coverage................................................................................................................................22After Discharge from the Armed Forces.................................................................................................................23

REINSTATEMENT OF COVERAGE AFTER LEAVES..........................................................................................23

LIFE INSURANCE BENEFIT (ACTIVES ONLY)....................................................................................................24YOUR BENEFICIARY...............................................................................................................................................24AMOUNT OF YOUR LIFE INSURANCE BENEFIT...............................................................................................24TOTAL DISABILITY OR TOTALLY DISABLED...................................................................................................24

Benefits will continue under this extension until the earliest of:.............................................................................25Death of Person While the Disability Extension is in Effect...................................................................................25

DUAL POLICIES........................................................................................................................................................25

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CONVERSION PRIVILEGE......................................................................................................................................25Conversion Rights Upon Individual Termination...................................................................................................25Conversion Rights Upon Individual Reduction Due to Age or Retirement.............................................................25Conversion Rights Upon Contract or Class Termination.......................................................................................26Notice of Conversion Privilege................................................................................................................................26Death within Conversion Period.............................................................................................................................26Limitation on Amount Converted............................................................................................................................26Lifetime Limit on Amounts Converted.....................................................................................................................26

ASSIGNMENT OF BENEFITS..................................................................................................................................26

ACCIDENTAL DEATH AND DISMEMBERMENT BENEFITS............................................................................28WHO WILL RECEIVE YOUR AD&D BENEFIT?...................................................................................................28YOUR BENEFICIARY...............................................................................................................................................28THE AMOUNT OF YOUR AD&D BENEFIT..........................................................................................................28LOSSES THAT ARE NOT COVERED.....................................................................................................................29EXAMINATION AND AUTOPSY............................................................................................................................29HOW DO I FILE A CLAIM FOR AN AD&D BENEFIT?........................................................................................29PAYMENTS TO ESTATE, MINOR, OR PERSON LACKING CAPACITY..........................................................29WHEN WILL MY BENEFITS BE PAID?.................................................................................................................29

WEEKLY LOSS OF TIME BENEFITS (ACTIVES ONLY)....................................................................................31THE AMOUNT OF YOUR WEEKLY LOSS OF TIME BENEFIT..........................................................................31FILING A CLAIM FOR WEEKLY LOSS OF TIME BENEFITS............................................................................31

IMPORTANT INFORMATION...................................................................................................................................32MATERNITY CARE BENEFIT.................................................................................................................................32POST-MASTECTOMY BREAST RECONSTRUCTIVE SURGERY BENEFITS...................................................32PRIVACY OF YOUR HEALTH INFORMATION....................................................................................................32

MEDICAL, HOSPITAL, AND MENTAL HEALTH AND SUBSTANCE ABUSE BENEFITS...........................33

TELEMEDICINE…………………………………………………………………………………………………….33 LOWER HUDSON VALLEY E.A.P............................................................................................................................33

DENTAL BENEFIT.......................................................................................................................................................34HOW YOUR DENTAL BENEFIT WORKS..............................................................................................................34COVERED DENTAL CHARGES..............................................................................................................................34NON-ELIGIBLE DENTAL EXPENSES EXPLAINED.............................................................................................34SCHEDULE OF DENTAL BENEFITS......................................................................................................................34COVERED DENTAL CHARGES..............................................................................................................................35Diagnostic and Preventative Procedures.....................................................................................................................35Restorative Procedures................................................................................................................................................35Major Restorative Procedures.....................................................................................................................................35Periodontics.................................................................................................................................................................35Prosthodontics..............................................................................................................................................................36Prosthodontic Repairs..................................................................................................................................................37Orthodontics.................................................................................................................................................................37

GENERAL LIMITATIONS.............................................................................................................................................37

PRESCRIPTION DRUG BENEFITS...........................................................................................................................38WHEN YOU GO TO A PARTICIPATING PHARMACY........................................................................................38WHEN YOU GO TO A NON-PARTICIPATING PHARMACY..............................................................................38MAIL-ORDER PHARMACY.....................................................................................................................................38PRESCRIPTION DRUG BENEFITS FOR ACTIVE MEMBERS AND DEPENDENTS WHO ARE MEDICARE ELIGIBLE..............................................................................................................................................39

OPTICAL BENEFITS....................................................................................................................................................41

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THE NVA NETWORK………………………………………………………………………………………………41 NON-CONTRACTED PROVIDER............................................................................................................................41LOCATING A NETWORK PROVIDER....................................................................................................................41SCHEDULE OF OPTICAL BENEFITS.....................................................................................................................42PRESCRIPTION SAFETY GLASSES.......................................................................................................................43

RETIREE BENEFITS....................................................................................................................................................43BENEFITS FOR RETIREES UNDER AGE 65..........................................................................................................43BENEFITS FOR RETIREES AGE 65 AND OVER (MEDICARE PART B SUPPLEMENTAL BENEFITS)........43YOUR LIFE INSURANCE, PRESCRIPTION DRUG AND OPTICAL BENEFITS................................................44

Life Insurance..........................................................................................................................................................44Prescription Drug Benefits......................................................................................................................................44Optical Benefits.......................................................................................................................................................44Dental Benefits........................................................................................................................................................44

IF YOU RETURN TO WORK....................................................................................................................................44

VACATION BENEFITS................................................................................................................................................45

PLAN EXCLUSIONS.....................................................................................................................................................46GENERAL EXCLUSIONS.........................................................................................................................................46EXCLUSIONS APPLICABLE TO SPECIFIC MEDICAL SERVICES AND SUPPLIES........................................49

Behavioral Health/Mental Health Care and Substance Abuse Exclusions............................................................49Dental Care Exclusions:........................................................................................................................................49Vision Care Exclusions:.........................................................................................................................................51

HEALTH REIMBURSEMENT ACCOUNT (HRA)...................................................................................................52

DEFINITIONS................................................................................................................................................................54

CLAIMS AND APPEALS..............................................................................................................................................59CLAIMS PROCEDURES............................................................................................................................................59AUTHORIZED REPRESENTATIVES......................................................................................................................59TYPES OF CLAIMS...................................................................................................................................................59PROCEDURES REGARDING MEDICAL NECESSITY DETERMINATIONS.....................................................59DEFINITION OF CLAIMS &TIMING OF CLAIMS NOTIFICATION...................................................................60

Pre-Service and Urgent Care Claims......................................................................................................................60Concurrent Claims..................................................................................................................................................61Post-Service Claim..................................................................................................................................................61Life Insurance Claims and Accidental Death and Dismemberment (AD&D) Claims............................................62Weekly Loss of Time................................................................................................................................................62

WHERE, WHEN AND TO HOW TO FILE CLAIMS...............................................................................................63NOTICE OF DECISION.............................................................................................................................................67REQUEST FOR REVIEW OF DENIED CLAIM.......................................................................................................67

Review Process........................................................................................................................................................68Timing of Notice of Decision on Appeal..................................................................................................................68Notice of Decision on Review..................................................................................................................................69

LIMITATION ON WHEN A LAWSUIT MAY BE STARTED................................................................................69

COORDINATION OF BENEFITS...............................................................................................................................70HOW DUPLICATE COVERAGE OCCURS.............................................................................................................70COVERAGE UNDER MORE THAN ONE GROUP HEALTH PLAN....................................................................70

When and How Coordination of Benefits (COB) Applies.......................................................................................70WHICH PLAN PAYS FIRST: ORDER OF BENEFIT DETERMINATION RULES...............................................71THE OVERRIDING RULES.......................................................................................................................................71

Rule 1: Non-Dependent/Dependent.........................................................................................................................71Rule 2: Dependent Child Covered Under More Than One Plan............................................................................71Rule 3: Active/Laid-Off or Retired Employee.........................................................................................................72Rule 4: Continuation Coverage...............................................................................................................................72Rule 5: Longer/Shorter Length of Coverage...........................................................................................................72

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HOW MUCH THIS PLAN PAYS WHEN IT IS SECONDARY...............................................................................73ADMINISTRATION OF COB....................................................................................................................................73COORDINATION WITH MEDICARE......................................................................................................................73

Entitlement to Medicare Coverage..........................................................................................................................73Medicare Participants May Retain or Cancel Coverage Under This Plan............................................................73Coverage Under Medicare and This Plan When You Are Totally Disabled...........................................................74Coverage Under Medicare and This Plan When You Have End-Stage Renal Disease..........................................74How Much This Plan Pays When It Is Secondary to Medicare..............................................................................74

COORDINATION WITH OTHER GOVERNMENT PROGRAMS.........................................................................75Medicaid..................................................................................................................................................................75TRICARE.................................................................................................................................................................75Veterans Affairs Facility Services...........................................................................................................................75Other Coverage Provided by State or Federal Law................................................................................................75

WORKERS’ COMPENSATION.................................................................................................................................75ADVANCE ON ACCOUNT OF PLAN BENEFITS..................................................................................................75REIMBURSEMENT AGREEMENT..........................................................................................................................76COOPERATION WITH THE PLAN BY ALL COVERED INDIVIDUALS............................................................76SUBROGATION.........................................................................................................................................................76REMEDIES AVAILABLE TO THE PLAN...............................................................................................................77

CONTINUATION OF COVERAGE............................................................................................................................78CONTINUATION THROUGH COBRA....................................................................................................................78COBRA ELIGIBILITY (COBRA QUALIFYING EVENTS)....................................................................................78

For You....................................................................................................................................................................78For Your Dependents..............................................................................................................................................78

HOW COBRA COVERAGE WORKS.......................................................................................................................79Providing Notice of Qualifying Events....................................................................................................................79Manner in Which You Must Provide Notice............................................................................................................80When the Notice Should Be Sent.............................................................................................................................80Who May Provide a Notice......................................................................................................................................80How to Elect COBRA Continuation Coverage........................................................................................................80The COBRA Continuation Coverage that will be Provided....................................................................................81Cost of COBRA Coverage.......................................................................................................................................81Paying for COBRA Coverage..................................................................................................................................81COBRA AT-A-GLANCE..........................................................................................................................................82Duration of COBRA Coverage................................................................................................................................83

COBRA COVERAGE IN CASES OF SOCIAL SECURITY DISABILITY.............................................................83Cost of COBRA Coverage in Cases of Social Security Disability...........................................................................83

ACQUIRING A NEW DEPENDENT(S) WHILE COVERED BY COBRA.............................................................83LOSS OF OTHER GROUP HEALTH PLAN COVERAGE OR OTHER HEALTH INSURANCE COVERAGE. 84MULTIPLE QUALIFYING EVENTS WHILE COVERED BY COBRA.................................................................84TERMINATION OF EMPLOYMENT/REDUCTION OF HOURS FOLLOWING MEDICARE ENTITLEMENT..........................................................................................................................................................84WHEN COBRA COVERAGE WILL BE CUT SHORT............................................................................................85WHEN COBRA COVERAGE ENDS.........................................................................................................................85ENTITLEMENT TO CONVERT TO AN INDIVIDUAL HEALTH PLAN AFTER COBRA ENDS......................85KEEP THE FUND INFORMED OF ADDRESS CHANGES....................................................................................85FMLA AND COBRA..................................................................................................................................................86ADDITIONAL COBRA ELECTION PERIOD AND TAX CREDIT IN CASES OF ELIGIBILITY FOR BENEFITS UNDER THE TRADE ACT OF 1974-92...............................................................................................86CERTIFICATE OF CREDITABLE COVERAGE WHEN COVERAGE ENDS......................................................86IF YOU HAVE QUESTIONS.....................................................................................................................................87

GENERAL PROVISIONS.............................................................................................................................................88OFFICIAL NAME OF THE PLAN.............................................................................................................................88NAME AND ADDRESS OF PLAN SPONSOR MAINTAINING THE PLAN........................................................88EMPLOYER IDENTIFICATION NUMBER.............................................................................................................88PLAN NUMBER.........................................................................................................................................................88TYPE OF PLAN..........................................................................................................................................................88

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TYPE OF FUNDING AND ADMINISTRATION.....................................................................................................88INCOME AND RESERVES.......................................................................................................................................89PLAN ADMINISTRATOR.........................................................................................................................................89AGENT FOR SERVICE OF LEGAL PROCESS.......................................................................................................89PLAN TRUSTEES.......................................................................................................................................................89PLAN YEAR................................................................................................................................................................90INFORMATION YOU OR YOUR DEPENDENTS MUST FURNISH TO THE PLAN..........................................90PLAN CONTRACTS GOVERN.................................................................................................................................90RIGHT TO AMEND TO TERMINATE THE PLAN.................................................................................................91DISCRETIONARY AUTHORITY OF THE TRUSTEES AND DESIGNEES.........................................................91NO LIABILITY FOR PRACTICE OF MEDICINE OR DENTISTRY......................................................................91PRIVACY, CONFIDENTIALITY, RELEASE OF RECORDS OR INFORMATION..............................................91PLAN’S PRIVACY AMENDMENT...........................................................................................................................92

STATEMENT OF ERISA RIGHTS.............................................................................................................................95

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INTRODUCTION

WHAT THIS DOCUMENT TELLS YOU

This Summary Plan Description describes the medical, dental, vision, prescription drug, life insurance, accidental death and dismemberment, weekly accident and sickness, retiree, and vacation benefits of Sheet Metal Workers Local 22 Welfare Fund. The Plan described in this document is effective January 1, 2020 and replaces and supersedes all other summary plan descriptions previously provided to you.

This document will help you understand and use the benefits provided by the Sheet Metal Workers Local 22 Welfare Fund. You should review it and also show it to those members of your family who are or will be covered by the Plan. It will give all of you an understanding of the coverage provided; the procedures to follow when submitting claims; and your responsibilities to provide necessary information to the Plan. Be sure to read the Exclusions and Definitions sections. Certain terms that are bold and/or capitalized are defined in this Plan under the Definitions section. Remember not every expense you incur for health care is covered by the Plan.

All provisions of this document contain important information. If you have any questions about your coverage or your obligations under the terms of the Plan, be sure to seek help or information. A “Plan Information Chart” providing sources of help or information about the Plan appears on the following page.

As the Plan is amended from time to time, you will be sent information explaining the changes. If those later notices describe a benefit or procedure that is different from what is described here, you should rely on the later information. Be sure to keep this document, along with notices of any Plan changes, in a safe and convenient place where you and your family can find and refer to them. This Plan is established under and subject to the federal law, Employee Retirement Income Security Act of 1974, as amended, commonly known as ERISA.

IMPORTANT NOTICE

You or your Dependents must promptly furnish to the Fund Office information regarding change of name, address, marriage, divorce or legal separation, death of any covered family member, change in status of a Dependent Child, Medicare enrollment or disenrollment or the existence of other coverage. Failure to do so may cause you or your Dependents to lose certain rights under the Plan. See the “Eligibility” section for more details regarding this requirement.

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FOR HELP OR INFORMATION

When you need information, please check this document first. If you need further help, call the people listed in the following chart.

PLAN INFORMATION CHARTInformation Needed Whom to Contact

General Plan Information and Eligibility

Eligibility Enrollment Information about HIPAA Certificate of Information about USERRA, FMLA, QMCSOs and your Rights under the Plan Request documents or other Plan related information Replacement ID Cards Claim Forms General questions about Plan coverage COBRA Administrator Information About Coverage Adding or Dropping Dependents Cost of COBRA Continuation Coverage Premium payment and notices. HIPAA Privacy and Security Officer

Fund Office Sheet Metal Workers Local 22 Welfare Fund

PO Box 308 106 South Avenue West Cranford, New Jersey 07016

(908) 276-2320

Life Insurance and Accidental Death and Dismemberment Benefits

The Union Labor Life Insurance Company 8403 Colesville Road

Silver spring, MD 20916 Claims Should Be Sent to the Fund Office: Sheet Metal Workers Local 22 Welfare Fund

PO Box 308 106 South Avenue West

Cranford, New Jersey 07016 (908) 276-2320

Loss of Time Benefits Claim forms Claims & Appeals

Fund Office Sheet Metal Workers Local 22 Welfare Fund

PO Box 308 106 South Avenue West

Cranford, New Jersey 07016 (908) 276-2320

Medical and Hospital Benefits Precertification Claim Forms (Medical) Medical Claims and Appeals Plan Benefit Information Medical PPO Providers

Horizon Healthcare of New JerseyPO Box 820

Newark, NJ 071011-800-355-BLUE (2583)www.HorizonBlue.com

. Prescription Drug Program ID Cards Listing of Retail Network Pharmacies Mail Order (Home Delivery) Pharmacy Prescription Drug Information Formulary Preauthorization of Certain Drugs Direct Member Reimbursement (for Non-network retail pharmacy use)

OptumRxP.O. Box 2975

Mission, KS 662011 (800) 788-4863

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PLAN INFORMATION CHARTInformation Needed Whom to Contact

Dental Benefits Dental Claims and appeals

Claims for dental benefits and questions should be directed to ALICARE or Eastern Dental at:

ALICARE P.O. Box 62467

King of Prussia, PA 19406 (800) 220-5261

Eastern Dentalhttp://www.dentalservicesorganization.com/PlanE.htm

(800) 982-5529

Thru ALICARE access is provided to the Guardian Network, their providers can be found at

www.guardianlife.com. Vision Benefits Vision Provider Directory Claims and Appeals

National Vision Administrators1200 US-46

Clifton, NJ 07013800-672-7723

Claims and Request for Vouchers should Be Sent to the Fund Office:

Sheet Metal Workers Local 22 Welfare Fund PO Box 308

106 South Avenue West Cranford, New Jersey 07016

(908) 276-2320 Retiree Benefits Prescription Drug Reimbursement

Send Prescription information to the Fund Office Sheet Metal Workers Local 22 Welfare Fund

PO Box 308 106 South Avenue West

Cranford, New Jersey 07016 (908) 276-2320

Mental Health and Substance Abuse: Mental Health and Substance Abuse Services In-Network Providers and Referral Claims and Appeals

Horizon Healthcare of New JerseyPO Box 820

Newark, NJ 071011-800-355-BLUE (2583)

Mental Health and Substance Abuse: (800) 626-2212Pre-Admission Review/Individual Case Management:

(800)664-2583www.HorizonBlue.com

Employee Assistance Program Lower Hudson Valley EAP 3505 Hill Blvd A

Yorktown Heights, NY 10598(800) EAP-2799

HRA Sheet Metal Workers Local 22 Welfare Fund PO Box 308

106 South Avenue West Cranford, New Jersey 07016

(908) 276-2320

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ELIGIBILITY

Eligibility for benefits under the Plan is determined by your classification, the number of hours you have worked during a consecutive six (6) month period during which you have worked 4 of the 6 months and, if applicable, the Employer Contributions requirement of your classification.

Definition of Terms Used in this Eligibility Section: • Employee Classifications: See the chart below for a description of the classes and benefits

provided.

Class Required Hours & Employer Contributions

Eligible for Welfare Fund Benefits

Benefits

Class A Less than 480 hours during a consecutive six (6) month period.

This is your probation period.

No None

Class 1

a salaried employee of the Welfare Fund; or

you are an appointed salaried business representative of the Union

350 hours during a consecutive three (3) months

Yes Medical Hospital Prescription DrugDentalVisionLife InsuranceAccidental Death & Dismemberment Loss of Time*Mental Health & Substance Abuse

Apprentice 700 hours during a consecutive six (6) month period and 2 months of Employer Contributions.

Yes MedicalHospitalPrescription Drug

Classified Worker 700 hours during a consecutive six (6) month period and 2 months of Employer Contributions.

Yes MedicalHospitalPrescription Drug Discount Card

Residential Worker 700 hours during a consecutive six (6) month period and 2 months of Employer Contributions.

Yes MedicalHospitalPrescription Drug Discount Card

* If you are not actively at work on the date on which you become covered, you will not be eligible for Loss of Time benefits until the day you return to active full-time work.

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• Collective Bargaining Agreement is an agreement by and between an employer and Sheet Metal Workers Local 22 that requires the employer to make contributions to this Sheet Metal Workers Local 22 Welfare Fund.

• Contributing Employer is an employer who is required to make contributions to the Welfare Fund under a collective bargaining agreement, a participation agreement, contract or other written agreement with the Sheet Metal Workers Local 22 Welfare Fund.

• Probation Period is the period of time until you become a Class 1 employee.

• Participant is an Active Employee who is eligible and enrolled for coverage under the plan.

Initial Employee Eligibility

You will be eligible for Welfare Fund benefits if you:

• Are an active full-time employee who is covered by a collective bargaining agreement, and meet the required hours and, if applicable, the Employer Contributions requirement of your class (Class 1, Apprentice, Classified Worker or Residential Worker).

When Coverage Begins

Provided you properly enroll for coverage (as described in the next section entitled “Enrollment”), your benefits under the Plan begin the first day of the month after you meet the Initial Employee Eligibility requirements described above.

Rules for Continuing Eligibility

Once a participant becomes eligible, working 300 hours in a working quarter establishes eligibility for benefits in the corresponding benefit quarter. There is a two 2-month lag between the Work Quarter and the Benefit Quarter to allow time for your employer and the Fund Office to receive and credit your work hours as follows:

Working Quarter Benefit QuarterJanuary, February, March June, July, August

April, May, June September, October, NovemberJuly, August, September December, January, February

October, November, December March, April, May

Rules for Continuing Eligibility “Look Back” Provision

If you do not meet the general rule for continuing eligibility, you may maintain eligibility for benefits in a benefit quarter if you meet any of the following conditions:

a. Working 600 hours in the preceding two working quarters.

b. Working 900 hours in the preceding three working quarters.

c. Working 1,200 hours in the preceding four working quarters.

The rules, as listed above, do not apply to members upon retirement.

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Look Back Example:

The look back provision provides you with four opportunities to maintain your coverage before self-payments are required. In the example below, you would maintain coverage based on working over 1,200 hours in the last 4 Working Quarters:

Working Quarter Hours Worked Coverage

1. January – March 350 Yes, exceeds the 300-hour requirement

2. April – June 280 Yes, (280+350=630) exceeds 600-hour requirement

3. July – September 340 Yes, exceeds the 300-hour requirement

4. October – December 250 Yes, (250+340+280+350=1,220) exceeds the 1,200requirement

Layoff Provision to Continue Eligibility Due to Lack of Work

If you worked at least 1,200 hours in the preceding 12-month period and are ready, able and willing to work then you are eligible for a 9-month extension provided you are a member in good standing and have not accumulated any work hours. After your 9-month extension, you will be required to requalify based on the Plan’s continuing eligibility rules.

Rules for Continuing Eligibility for Light Commercial Participants

The initial eligibility requirement for participants in the Light Commercial classification is 280 hours in two consecutive months. Once eligible, you must work at least 120 hours a month to maintain coverage. The Plan also allows for a look back provision to continue coverage provided you worked at least 120 hours a month over a consecutive 6-month period (720 hours on a rolling 6-month basis).

Self-Payment to the Fund to Maintain Eligibility

Participants who are unable to maintain eligibility due to not working three-hundred (300) hours in a quarter may make a self-payment of up to 150 hours to maintain eligibility. Participants can make a self-payment for the hours short (300 less number of hours worked in the quarter up to 150 hours) times the contribution rate in effect at the start of the benefit period. In order for self-payments to be accepted, the self-payments must be received by the Fund by the end of the first month of the Benefit period (i.e. the benefit period beginning June 1, the Fund office must receive the payment by June 30). Before making a decision, participants should compare the cost of continuing coverage through the self-payment provision to the cost of continuing coverage through COBRA. Note, you can only buy hours to maintain coverage (buying hours is not an option for reinstatement for a break in service).

Self-Payment Example:

You worked less than 300 hours in the last work quarter and do not meet the Fund’s continuing eligibility provisions. The hours worked in the last 4 Working Quarters is as follows:

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Working Quarter Hours Worked Coverage

1. January – March 325 Yes, exceeded the 300-hour requirement

2. April – June 285 Yes, (285+325=610) exceeds 600-hour requirement

3. July – September 320 Yes, exceeded the 300-hour requirement

4. October – December 250 No, Self-Payment Required

Using the continuing eligibility “look back” provisions, your self-payment is based on the hours in the last four Working Quarters that results in the lowest number of hours short, as follows:

Most Recent Quarter: Worked 250 hours and is 50 hours short of 300

Last Two Quarters: Worked 570 hours (320+250=570) and is 30 hours short of 600

Last Three Quarters: Worked 855 hours (250+320+285=855) and is 45 hours short of 900

Last Four Quarters: Worked 1,180 hours (250+320+285+325=1,180) and is 20 hours short of 1,200

In this example, the 12-month look back provision provides the lowest number of hours short. Your self-payment would be: 20 x the current contribution rate and would provide continuing eligibility for the next Benefit Quarter.

Reinstatement

If a Participant whose eligibility for benefits has been terminated receives credit for at least three hundred (300) hours in any one of the four (4) consecutive calendar quarters immediately following his date of termination, the benefits in effect at date of termination will be reinstated in full as of the first day of the month following the calendar quarter he had at least three hundred (300) hours of credit.

Any participant whose eligibility for benefits has been terminated and who is not reinstated as provided above shall be considered as a new Participant and shall be eligible for benefits upon fulfillment of the Initial Eligibility Requirements.

Dependent Eligibility

Your Eligible Dependents are covered under the Plan and include:

(1) your lawful Spouse (regardless of sex); and

(2) For purposes of this Plan, a Dependent child is any of the employee’s/participant’s children listed below who are under the age of 26 (whether married or unmarried). These include:

• a natural child;

• a stepchild;

• a foster child, lawfully placed with the employee/participant by an authorized placement agency or by judgment, decree, or other order of any court of competent jurisdiction;

• a legally adopted child or child placed for adoption (a child is “placed for adoption” with you on the

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date you first become legally obligated to provide full or partial support of the child whom you plan to adopt). The child’s placed for adoption terminates upon the termination of such legal obligation;

• a child for whom the participant or the participant’s spouse have been appointed as legal guardian (proof of guardianship and marriage license is required) who is fully dependent upon you for support. Such coverage will result in income being imputed to you unless the child is your “qualifying child” or “qualifying relative” under the applicable requirements of Internal Revenue Code Section 152(c) or 152(d), respectively; and

• a child named as an “alternate recipient” under a QMCSO (see the end of this Eligibility section for details on QMCSO).

Coverage for your Dependent Child may continue after the child has reached his or her 26th birthday (as that term is defined by the insurance company and described in the Certificate of Insurance and subsequent Rider(s)) provided that the child is primarily supported by you and incapable of self-sustaining employment by reason of mental or physical handicap. Proof of the child’s condition and dependence date must be submitted to the insurance company (listed in the Plan Information Chart at the front of this document) for medical and hospital benefits within 31 days after child ceases to qualify as stated above. The Insurance Company may, from time to time, require proof of the continuation of such condition and dependence. After that, the Insurance Company may require proof no more than once a year. Details on this provision are detailed in the Certificate of Insurance and any applicable Rider(s) provided by the Insurance Company.

Anyone who does not qualify as a Dependent Child or Spouse as those terms are defined by this Plan has no right to any coverage for Plan benefits or services under this Plan.

Coverage for Eligible Dependents

Provided you properly enroll your eligible Dependents for coverage (as described in the next section entitled “Enrollment”) and provide proof of Dependent status as described below, benefits for your dependents begin on the same day that your coverage begins. If you later add a Dependent, that Dependent’s coverage will be effective as described in the following section entitled “Enrollment.”

Proof of Dependent Status

You are required to provide the Fund Office with proof of Dependent status as follows:

• Spouse/Marriage: copy of the certified marriage certificate. • Child/Birth: copy of the certified birth certificate. • Adopted Child or a Child who is Placed for Adoption: court order paper signed by the judge. • Legal Guardianship: a copy of your legal guardianship documents and a copy of the certified birth

certificate. • Temporary Guardianship: A written document signed by both parents that must include the

child’s name, date of birth, date of guardianship placement and an expiration date within 6 months of placement and a copy of the certified birth certificate. Additional documents may be required depending on the parental circumstances.

• Disabled Dependent Child: Current written statement from the child’s physician indicating the child’s diagnosis that is the basis for the physician’s assessment that the child is currently mentally or physically Handicapped (as that term is defined in this document) and is incapable of self-sustaining employment as a result of that handicap; and is dependent chiefly on you and/or your spouse for support and maintenance. Proof of continued disability may be required, but not more frequently than once a year after 2 years from the date the child attained the limiting age stated on

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the previous page. • Qualified Medical Child Support Order (QMCSO), if applicable along with any other required

proof.

Qualified Medical Child Support Order (QMSCO)

According to Federal law, you might be required to enroll your children in the Plan due to a Qualified Medical Child Support Order (QMCSO) or a National Medical Support Order (NMSO) – a support order of a court or state administrative agency that usually results from a divorce or legal separation. The Fund Office can provide more details about enrolling your children in such cases. A statement that describes procedures with respect to these orders is available upon written request, free of charge, from the Fund Office.

Retiree Eligibility

In order to be eligible for Welfare Fund benefits as a Retiree, you must retire from active status with five consecutive years of service/benefits provided by the Sheet Metal Workers Local 22 Welfare Fund, and

A. Be a Class 1 employee and eligible for Welfare Fund benefits as described on the prior page on the day before your Early or Disability retirement (as defined by the Sheet Metal Workers Local Union 22 Pension Fund);

B. Be in Class 2A and eligible for Retiree Benefits from the effective date of retirement for the one year following such early or disability retirement or until you become Medicare eligible, whichever is earlier. In no event, will benefits last for more than nine months; or

C. Retire on a Normal Pension (as defined by the Sheet Metal Workers Local Union 22 Pension Fund) on or after June 1, 1977, you are in Class 2A and eligible for Retiree benefits for two years following such retirement or until you become eligible for Medicare, whichever is earlier.

Once your coverage under the Plan ends, you and/or your spouse will be offered COBRA coverage.

Once you turn age 65, Medicare Part B Supplemental benefits are available for Participants that have five consecutive years of coverage (in the Welfare Fund) and retire from active status (i.e., are eligible for Welfare Fund benefits on the day before retirement). The Fund Office will notify you when you reach age 65 if you are eligible for this coverage and explain the enrollment process.

See the section, “Retiree Benefits” for more details on your coverage.

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ENROLLMENT

How to Enroll for Benefits

You must enroll for coverage when you become eligible for benefits by completing an enrollment form within 31 days of becoming eligible for the Plan. At the same time, you should also enroll your eligible Dependents and provide proof of dependent status. If you properly enroll yourself and your Dependents when you first become eligible for benefits, their coverage will be effective on the same date as yours.

Special Enrollment For You

If you did not enroll yourself for coverage when you first became eligible, and you subsequently acquire a dependent by marriage, birth, adoption, or placement for adoption, you may enroll yourself with your newly acquired dependent.

Special Enrollment For Eligible Dependents

After you become eligible for coverage under this Plan, and you marry, or have an eligible dependent stepchild or child by birth, adoption, placement for adoption, you may request and enroll your new spouse and/or any dependent children within 31 days of the marriage, birth, adoption or placement for adoption. Any dependent child born while you are covered by the Plan will become insured for hospital, medical and prescription drug benefits on the date of his birth if you elect Dependent Medical Insurance no later than 31 days after his or her birth. If you do not elect to insure your newborn child within such 31 days, coverage for that child will end on the 31st day. No benefits for expenses incurred beyond the 31st day will be payable.

If you acquire a new Dependent through marriage, birth, adoption or placement for adoption, you may enroll your eligible Dependents and yourself, if you are not already enrolled, within 31 days of such event. Coverage will be effective, on the date of marriage, birth, adoption, or placement for adoption. If you did not enroll your spouse for coverage when he or she first became eligible for coverage, and if you later acquire a dependent child by birth, adoption or placement for adoption, you may enroll your spouse together with your newly acquired dependent children.

State Children’s Health Insurance Program Reauthorization Act of 2009 (SCHIP)

You and your eligible dependents may also enroll in this plan if you (or your eligible dependents):

• Have coverage through Medicaid or a State Children’s Health Insurance Program (SCHIP) and you (or your dependents) lose eligibility for that coverage. However, you must request enrollment in this plan within 60 days after the date the Medicaid or SCHIP coverage ends; or

• Become eligible for a premium assistance program through Medicaid or SCHIP. However, you must request enrollment in this plan no later than 60 days after you (or your dependents) are determined to be eligible for such premium assistance.

Enrollment Rules Pertaining to Hospital, Major Medical, and Prescription Drug Coverage

Please refer to the Plan Information Chart and the insurance company’s certificate of coverage at the end of this booklet for detailed information on eligibility, enrollment, benefits, exclusions, limitations, coordination of benefit rules, and claims and appeals procedures.

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Start of Coverage Following Special Enrollment

Provided you properly enroll them, your newborn biological child and adopted newborns will be covered from the date of birth. Your adopted Dependent Child will be covered from the date that child is adopted or “placed for adoption” with you, whichever is earlier. A child is “placed for adoption” with you on the date you first become legally obligated to provide full or partial support of the child whom you plan to adopt. A child who is placed for adoption with you within 31 days after the child was born will be covered from birth if you comply with the Plan’s requirements for obtaining coverage for a newborn dependent child. However, if a child is placed for adoption with you, and if the adoption does not become final, coverage of that child will terminate as of the date you no longer have a legal obligation to support that child. Coverage for a stepchild begins on the day you enroll them. Coverage for your new Spouse begins on the day you marry, provided you properly enroll your spouse.

If you do not enroll your new dependents within 31 days you may enroll them late but coverage will not begin until the first of the month following the month in which the Fund Office receives your completed enrollment for and necessary documentation.

Loss of Other Health Coverage

If you did not enroll yourself and your Dependents (including your spouse) when you first became eligible for coverage because of other health insurance coverage, you may enroll yourself and any eligible dependents, when you or your Dependents lose that other health insurance coverage to the extent required by federal law.

Failure to Enroll

If you do not enroll as described earlier in this section, your claims will be denied until the Fund Office receives your enrollment material.

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WHEN COVERAGE ENDS

Your Coverage:

Employee coverage ends on the earliest of the last day of the month in which: • the Plan terminates; • you are no longer eligible to participate in the Plan; • you enter full-time, active duty within the Armed Forces of any country (See the “Military Leave”

section of this document); • the last day of any consecutive six-month period during which you fail to work at least 300 hours

for Participating Employers, provided you are available for work. If a job is available and you refuse it, coverage will end on the last day of the month;

• with respect to Classified Workers, the last day of the month during which he/she ceases to be employed by a Participating Employer;

• the date of your death; or • the date the Plan is discontinued.

A month of disability for which Workers’ Compensation benefits are paid will not be counted as part of the consecutive six-month period for purposes of determining continued eligibility. For this purpose, a month of disability will be a month in which an employee has been disabled for at least 20 days.

Coverage for your Spouse ends when:

• your coverage ends, as above; or • you and your spouse legally divorce.

Coverage for your Dependent Child(ren) ends the earliest of:

• the date your coverage ends, as described above; or • the last day of the calendar year in which he/she attains his or her 26th birthday.

Continuation of Coverage for Dependent Children under New Jersey Law

A Dependent Child of a Covered Person who meets the limiting age for coverage of a Dependent, is eligible to continue coverage until his 30th birthday, provided the child meets all of the “Special Eligibility Criteria” described in the Insurance Company’s Certificate of Insurance.

Reinstatement of Coverage Due to Lack of Work

If you cease to be an Employee because of lack of work with Participating Employers and then return to work, coverage will be reinstated on the first day of the calendar month immediately following a period of two (2) consecutive calendar months in which you worked a minimum of 120 hours per month with Participating Employers.

Extension of Medical Coverage During Total Disability

If your medical coverage ends because your employment terminates, and if on that date you or a covered Spouse or Dependent Child is Totally Disabled (as defined in the Definitions section of this document), and you or that covered Spouse or Dependent Child is not otherwise covered by Medicare or by any other group or individual health insurance policy or health care plan, benefits for the medical

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condition causing the Total Disability benefits will be extended for the disabled person only, subject to the terms and provisions of this Plan, for up to 12 months after your medical coverage ends, provided the disabled person continues to be Totally Disabled. If the covered Spouse and/or Dependent Child are covered by any other group or individual health care insurance policy or health care plan or by Medicare, the extension of medical coverage will not apply. After 12 months, you (or the Disabled Dependent) will be entitled to COBRA coverage. See the section entitled, “COBRA Continuation Coverage” for more information on COBRA.

Notice to the Plan

You, your Spouse, or any of your Dependent Children must notify the Plan preferably within 30 days but no later than 60 days after the date a:

(a) Spouse ceases to meet the Plan’s definition of Spouse (such as in a divorce); or (b) Dependent Child ceases to meet the Plan’s definition of Dependent (such as the Dependent Child

reaches the Plan’s limiting age or the Dependent Child ceases to have any physical or mental Handicap).

Failure to give this Plan a timely notice will cause your Spouse and/or Dependent Child(ren) to lose their right to obtain COBRA Continuation Coverage or will cause the coverage of a Dependent Child to end when it otherwise might continue because of a physical or mental handicap. For information regarding other notices you must furnish to the Plan, see the Information You or Your Dependents Must Furnish to the Plan section of this document.

Continuation of Coverage

See the COBRA section for information on continuing your health care coverage.

Certification of Coverage When Coverage Ends

When your coverage ends, you and/or your covered Dependents are entitled by law to and will automatically be provided (free of charge) with a Certificate of Coverage that indicates the period of time you and/or they were covered under the Plan. Such a certificate will be provided to you shortly after the insurance company knows or has reason to know that coverage for you and/or your covered Dependent(s) has ended. You can present this certificate to your new employer/health plan to offset a pre-existing condition limitation that may apply under that new plan or use this certificate when obtaining an individual health insurance policy to offset a similar limitation.

Procedure for Requesting and Receiving a Certificate of Creditable Coverage

A certificate will be provided upon receipt of a written request for such a certificate that is received by the Plan Administrator within two years after the date coverage ended under this Plan. The written request must be mailed to the Fund Office and should include the names of the individuals for whom a certificate is requested (including spouse and dependent children) and the address where the certificate should be mailed.

See the end of the COBRA section for an explanation of when and how certificates of coverage will be provided after COBRA coverage ends.

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LEAVE OF ABSENCE FOR ELIGIBLE EMPLOYEES

Family and Medical Leave Act (FMLA)

The Family and Medical Leave Act (FMLA) allows you to take up to 12 weeks of unpaid leave during any 12-month period for:

• the birth, adoption, or placement with you for adoption of a child; • providing care for a spouse, child, or parent who is seriously ill; • your own serious illness; or • qualifying exigencies arising out of the fact that the active participant’s spouse, son, daughter, or

parent is on active duty, or has been notified of an impending call or order to active duty, in support of a contingency operation.

The Family and Medical Leave Act (FMLA) allows you to take up to 26 weeks of unpaid leave during any 12-month period to provide care for a covered service member. If you are the spouse, son, daughter, parent or next of kin (i.e., nearest blood relative) of a service member, you are now entitled to a total of 26 weeks of leave during a 12-month period to care for the service member. A covered service member is a member of the Armed Forces (including National Guard or Reserves) who is undergoing medical treatment, recuperation, or therapy (including on an outpatient basis) for a serious injury or illness. The injury or illness must have been incurred in the line of duty while on active duty, and it must be an injury or illness that may render the service member unfit to perform the duties of his/her office, grade, rank or rating. If you are taking this type of leave, along with FMLA for any other purpose (e.g., birth of a child), the combined total leave required during one 12-month period is 26 weeks.

During your leave, you can continue all of your medical coverage and other benefits offered through the Fund. You are generally eligible for a leave under the FMLA if you:

• have worked for a covered Employer for at least 12 months; • have worked at least 1,250 hours over the previous 12 months; and • work at a location where at least 50 employees are employed by the Employer within 75 miles.

The Fund will maintain your eligibility status until the end of the leave, provided the contributing Employer properly grants the leave under the FMLA and the contributing Employer makes the required contributions to the Fund. Of course, any changes in this Plan’s terms, rules or practices that go into effect while you are away on leave apply to you and your covered dependents, the same as to active employees and their covered dependents. If you do not return to covered employment after your leave ends, you are entitled to COBRA continuation coverage when your leave ends. Call your Employer to determine whether you are eligible for FMLA leave. Call the Fund Office for more information about coverage during FMLA leave.

Military Leave

A participant who enters military service will be provided continuation and reinstatement rights in accordance with the Uniformed Services Employment and Reemployment Rights Act of 1994 (USERRA), as amended from time to time. This section contains important information about your rights to continuation coverage and reinstatement of coverage under USERRA.

USERRA Continuation Coverage is a temporary continuation of coverage when it would otherwise end because the employee has been called to active duty in the uniformed services. USERRA protects

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employees who leave for and return from any type of uniformed service in the United States armed forces, including the Army, Navy, Air Force, Marines, Coast Guard, National Guard, National Disaster Medical Service, the reserves of the armed forces, and the commissioned corps of the Public Health Service.

An employee’s coverage under this Plan will terminate when the employee enters active duty in the uniformed services.

If the employee elects USERRA temporary continuation coverage, the employee (and any eligible dependents covered under the Plan on the day the leave started) may continue Plan coverage for up to 24 months measured from [the date the employee stopped working] [the last day of the month in which the employee stopped working]. • If the employee goes into active military service for up to 31 days, the employee (and any eligible

dependents covered under the Plan on the day the leave started) can continue health care coverage under this Plan during that leave period if the employee continues to pay the appropriate contributions for that coverage during the period of that leave.

Duty to Notify the Plan

The Plan will offer the employee USERRA continuation coverage only after the Plan Administrator has been notified by the employee in writing that they have been called to active duty in the uniformed services. The employee must notify the Plan Administrator (contact information is contained in the Plan Information Chart in the front of this document) as soon as possible but no later than 60 days after the date on which the employee will lose coverage due to the call to active duty, unless it is impossible or unreasonable to give such notice.

Plan Offers Continuation Coverage

Once the Plan Administrator receives notice that the employee has been called to active duty, the Plan will offer the right to elect USERRA coverage for the employee (and any eligible dependents covered under the Plan on the day the leave started). Unlike COBRA Continuation Coverage, if the employee does not elect USERRA for the dependents, those dependents cannot elect USERRA separately. Additionally, the employee (and any eligible dependents covered under the Plan on the day the leave started) may also be eligible to elect COBRA temporary continuation coverage. Note that USERRA is an alternative to COBRA. Therefore, either COBRA or USERRA continuation coverage can be elected and that coverage will run simultaneously, not consecutively. Contact the Fund Office to obtain a copy of the COBRA or USERRA election forms. Completed USERRA election forms must be submitted to the Plan in the same timeframes as is permitted under COBRA.

Paying for USERRA Coverage:

• If the employee goes into active military service for up to 31 days, the employee (and any eligible dependents covered under the Plan on the day the leave started) can continue health care coverage under this Plan during that leave period.

• If the employee elects USERRA temporary continuation coverage, the employee (and any eligible dependents covered under the Plan on the day the leave started) may continue Plan coverage for up to 24 months measured from the last day of the month in which the employee stopped working. USERRA continuation coverage operates in the same way as COBRA coverage and premiums for USERRA coverage will be 102% of the cost of coverage. Payment of USERRA and termination of coverage for non-payment of USERRA works just like with COBRA coverage. See the COBRA chapter for more details.

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In addition to USERRA or COBRA coverage, an employee’s eligible dependents may be eligible for health care coverage under TRICARE (the Department of Defense health care program for uniformed service members and their families). This plan coordinates benefits with TRICARE. You should carefully review the benefits, costs, provider networks and restrictions of the TRICARE plan as compared to USERRA or COBRA to determine whether TRICARE coverage alone is sufficient or if temporarily continuing this plan’s benefits under USERRA or COBRA is the better choice.

After Discharge from the Armed Forces

When the employee is discharged from military service (not less than honorably), eligibility will be reinstated on the day the employee returns to work provided the employee returns to employment within:

• 90 days from the date of discharge from the military if the period of service was more than 180 days; or

• 14 days from the date of discharge if the period of service was 31 days or more but less than 180 days; or

• at the beginning of the first full regularly scheduled working period on the first calendar day following discharge (plus travel time and an additional 8 hours), if the period of service was less than 31 days.

If the employee is hospitalized or convalescing from an injury caused by active duty, these time limits are extended up to 2 years.

The employee must notify the Plan Administrator in writing within the time periods listed above. Upon reinstatement, the employee’s coverage will not be subject to any exclusions or waiting periods other than those that would have been imposed had the coverage not terminated.

USERRA allows you to apply your accumulated eligibility under this Plan toward the cost of continuation coverage in lieu of paying for the USERRA continuation coverage. When your accumulated eligibility is exhausted, you may pay for USERRA coverage under the self-pay rules of this Plan. If you do not want to use your accumulated eligibility to pay for USERRA coverage, you can choose to freeze your accumulated eligibility and instead proceed to pay for the USERRA coverage under the self-pay rules (out-of pocket) of this Plan.

If the employee does not want to use their accumulated eligibility to pay for USERRA coverage, the employee can choose to freeze their accumulated eligibility and instead proceed to pay for the USERRA coverage under the self-pay rules (out-of-pocket) of this plan. The Trustees would then have to decide how to handle reinstatement.

Call your Employer if you have questions regarding your entitlement to USERRA military service leave. Call the Fund Office if you have questions regarding health coverage during such leave.

Reinstatement of Coverage After Leaves

If your coverage ends while you are on an approved FMLA leave or USERRA military leave, your coverage will be reinstated on the day you return to active employment, subject to all maximums that were incurred prior to the leave of absence.

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LIFE INSURANCE BENEFIT (Actives Only)

The Life Insurance benefit is provided through the Union Labor Life Insurance Company (Union Labor Life). If you die from any cause while you are insured, the proceeds of your Life Insurance benefit will be paid to your beneficiary after the receipt of proof of death by the Fund Office. The Life Insurance Benefit will be paid as a lump sum (unless your beneficiary requests otherwise).

Your Beneficiary

You may name anyone you wish as your beneficiary. Simply enter that person’s name in the appropriate space on your enrollment form when you first enroll in the Plan. You may name more than one beneficiary to receive the Life Insurance benefit. You can change your beneficiary or beneficiaries at any time. Contact the Fund Office for an enrollment card if you wish to change your beneficiary. The beneficiary(ies) on file at the Fund Office at the time of your death is/are the person(s) who will receive the proceeds of your Life Insurance benefit.

If you have not designated a beneficiary or if your beneficiary dies before you, your life insurance benefit will be paid to the first surviving person or persons, as follows:

• your spouse; • if you have no spouse or your spouse has died, payment will go to your children in equal shares; • if there are no children, payment will be made to your parents in equal shares; • if your parents have not survived you, to your brothers and sisters in equal shares; and • if payment cannot be made to any of the indicated individuals, your life insurance benefit will be

paid to your estate.

If any beneficiary is a minor, or someone who is not able to give a valid release for payment, payment will be made to his or her legal guardian. If there is no legal guardian, payment will be made to a person(s) or institution that has, in Union Labor Life’s opinion, custody and principal support of that beneficiary.

Amount of Your Life Insurance Benefit

If you are an active employee, your beneficiary will receive $25,000 payable in a lump sum. If you name more than one beneficiary, the payment will be divided evenly between them unless you indicate otherwise.

Total Disability or Totally Disabled

If you are under the age of 60 and are unable to work because of total disability, and such disability has been in effect for at least 9 consecutive months, your life insurance will be continued without payment of premium while your Total Disability continues. The initial continuation of your insurance under this provision will be for 12 months from the date the premium payments for you have ceased. For purposes of this section, “total disability” and “totally disabled” mean your complete inability, due to injury or illness, to engage in any business, occupation or employment, for which you are qualified or become qualified by reason of education, training or experience for pay, profit or compensation.

You will remain covered for this benefit for 12 months beginning on the date you terminate employment due to Total Disability. You must submit proof of your total disability to Union Labor Life within 12 months after the date you became totally disabled. It must show that the total disability

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occurred while you were covered under this Plan, began before you attained age 60, and rendered you totally disabled for at least 9 consecutive months. You must submit proof of your total disability each year thereafter, if you are still disabled, within three months of the anniversary of the date Union Labor Life received the initial proof of total disability.

Benefits will continue under this extension until the earliest of:

• the date you are no longer totally disabled; • the date you fail to furnish the Union Labor Life proof of your continued disability; • the date you fail to be examined by a physician chosen by Union Labor Life (at Union Labor Life’s

expense), if so requested by Union Labor Life. Such an examination may be requested at any reasonable time during the course of your Total Disability, but it will not be required more than once a year after this benefit has been continued for you under this provision for two full years; or

• the date that is 2 years and 5 months (29 months) from the date you left employment due to disability.

Death of Person While the Disability Extension is in Effect

If you die while the disability extension is in effect, your beneficiary must submit written proof that your Total Disability continued without interruption from the last anniversary of Union Labor Life’s receipt of initial proof to the date of your death.

Dual Policies

In no event will payment be made under this disability extension and under an individual policy of Life Insurance that you obtained through the Conversion Privilege (see below).

Conversion Privilege

If you are no longer eligible for this benefit, you may convert all or any portion of the amount of your benefit to an individual life insurance policy. The individual policy may be any individual policy offered by Union Labor Life at the time you are no longer eligible for this benefit, except for term insurance, or insurance which provides disability or other supplemental benefits. Premium rates for the conversion policy will be Union Labor Life’s premium rates in effect for the amount and type of policy elected based on your class of risk and attained age on the conversion policy’s effective date.

You will not need to submit proof of good health in order to convert. However, you must complete the application form and send it with the first premium payment to Union Labor Life no later than 31 days after your eligibility for this benefit terminates.

Conversion Rights Upon Individual Termination

If you are no longer eligible for this benefit because you terminated employment, you may convert the amount you had under this Plan, minus any amount you become eligible for under this benefit and any amount for which you become eligible under any other group policy within 31 days after your eligibility for this benefit terminates.

Conversion Rights Upon Individual Reduction Due to Age or Retirement

If you are no longer eligible for this benefit because of age or retirement, you may convert up to the amount of the reduction.

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Conversion Rights Upon Contract or Class Termination

If you are no longer eligible for this benefit because this Plan terminates or is amended to terminate coverage for a Class of Eligible Persons under which you were insured, you may convert an amount that does not exceed the lesser of the following, as long as you had been covered under the Plan for at least 5 years:

1. the amount you had under this Plan as of the date of the policy termination, minus any amount you become eligible for under this benefit and any amount for which you become eligible under any other group policy (which replaces this policy) within 31 days after the date of this policy termination; or

2. $2,000.

Notice of Conversion Privilege

The Plan must notify you or your dependent of the right to convert. If the notice is not given by the 16th day of the 31-day Conversion Period, you will have an additional period in which to convert. The additional period will expire 15 days from the date you are notified, but in no event will the right to convert be extended more than 91 days beyond the date insurance terminated under this Plan. Written notice presented to you, or mailed to your last known address, shall constitute notice for the purpose of this provision.

In no event are your Life Insurance benefits extended beyond the end of the 31-day Conversion Period, whether or not notice is given.

Death within Conversion Period

If you should die during the 31-day period after your eligibility for this benefit terminates, your beneficiary will receive from this Plan the amount you would otherwise have been entitled to convert, whether or not you applied for a conversion to an individual life insurance policy.

If a Conversion Policy was applied for, such Conversion Policy will be null and void even if the Conversion Policy had been issued; and no death claim will be payable under the Conversion Policy. The Company will return any premium paid for the Conversion Policy.

Limitation on Amount Converted

If you hold an individual policy of life insurance obtained through the Conversion Privilege of this Plan, you will not be entitled to exercise the conversion privilege again, even if you are otherwise eligible, as long as any such individual life insurance policy remains in force, unless you provide evidence of insurability which is satisfactory to Union Labor Life. The effective date of such individual policy shall be designated by Union Labor Life.

Lifetime Limit on Amounts Converted

The maximum amount of Life Insurance you can convert under this Plan can never exceed the maximum amount of Life Insurance for which you were insured under this Plan.

Assignment of Benefits

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You may not assign your Life Insurance benefit to any individual or entity.

NOTE: This is not a complete benefit comparison or a contract, and should only be viewed as a brief summary to assist you in understanding your Life Insurance benefits. A detailed benefits description, including coordination of benefits, limitations and exclusions, and claims and appeals is contained within the Certificate of Insurance. The terms, conditions, limits and exclusions shown in the Certificate of Insurance shall govern.

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ACCIDENTAL DEATH AND DISMEMBERMENT BENEFITS

An accidental dismemberment benefit is paid to you, or an accidental death benefit is paid to your beneficiary, if you have a covered loss due solely to an accident. Covered losses are outlined in the chart in this section. The loss must occur within 90 days from the date of the accident, the loss must be listed in the Schedule of Losses, and the loss must be the result of the injuries, directly and independently of all other causes. These benefits are in addition to any other benefits you may receive. The accidental death and dismemberment benefit is provided through the Union Labor Life Insurance Company (Union Labor Life).

Who Will Receive Your AD&D Benefit?

If you have an accident that results in dismemberment to you, you will receive an accidental dismemberment benefit. If you have an accident that results in your death, your beneficiary will receive an accidental death benefit. Your beneficiary will receive this benefit in addition to any other life insurance benefit payable under the Plan.

Your Beneficiary

You may name anyone you wish as your beneficiary for this benefit by filing the appropriate form with the Fund Office. You may name more than one beneficiary to receive the accidental death benefit. You can change your beneficiary at any time by filing a new form. The beneficiary(ies) on file at the Fund Office at the time of your death is/are the person(s) who will receive the proceeds of your accidental death benefit.

If you have not designated a beneficiary or if your beneficiary dies before you, your Accidental Death and Dismemberment benefit will be paid to the first surviving person or persons, as follows:

• your spouse; • if you have no spouse or your spouse has died, payment will go to your children in equal shares; • if there are no children, payment will be made to your parents in equal shares, • if your parents have not survived you, to your brothers and sisters in equal shares; and • if payment cannot be made to any of the indicated individuals, your life insurance benefit will be

paid to your estate.

You may designate a separate beneficiary for your Accidental Death and Dismemberment Benefit.

The Amount of Your AD&D Benefit

The amount of benefit to be paid for a covered loss is as follows:

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If you suffer more than one loss in any one accident, payment will be made only for that loss for which the largest amount is payable.

Losses that are not Covered

No benefit is payable under this provision for any loss caused directly or indirectly, wholly or partly, by:

• bodily or mental illness, or disease or illness of any kind; • medical or surgical treatment if an illness or disease; • ptomaine or bacterial infections (except infections caused by pyogenic organisms which occur with

and through an accidental cut or wound); • intentional self-inflicted Injury; • suicide or attempted suicide while sane or insane; • participation in, or the result of participation in, the committing of a felony, or a riot, or a civil

commotion; • war or act of war, declared or undeclared or any act related to war, or insurrection; or • service in any military, naval or air force of any country while such country is engaged in war.

Examination and Autopsy

Union Labor Life, at its expense, has the right to require that you be examined by a physician of its choosing, or, if applicable, an autopsy performed, if not prohibited by law.

How Do I File a Claim For an AD&D Benefit?

You or your beneficiary should file a completed claim form with the Fund Office, provide written proof of your loss, which includes all information needed to determine the nature and date of the loss, and provide any other requested documentation. You must file the form and proof within 90 days after the date of the loss with the Fund Office at the following address:

Sheet Metal Workers Local 22 Welfare Fund 106 South Avenue West

Cranford, NJ 07016

Payments to Estate, Minor, or Person Lacking Capacity

If payment is to be made to your estate, or to a minor or someone not able to give a valid release for payment due to incapacity, Union Labor Life may reimburse any relative by blood or connection by marriage expenses incurred on your behalf (such as final expenses). This reimbursement will be in an amount up to $1,000, and will be made only if Union Labor Life deems this relative is entitled to reimbursement. The benefit payable to your estate will be reduced by such reimbursement, and Union Labor Life will be fully discharged of its liability for any amount of benefit paid in good faith.

When Will My Benefits Be Paid?

These benefits will be paid in accordance with the terms of the Certificate of Insurance upon receipt of complete proof of such loss by the Fund Office.

All provisions of this benefit are subject to the contract and Certificate of Group Insurance issued by

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Union Labor Life. If there are any discrepancies between this booklet and the Certificate or Contract, the Certificate and/or Contract will govern. Please refer to the Union Labor Life certificate for more details on this benefit.

NOTE: This is not a complete benefit comparison or a contract, and should only be viewed as a brief summary to assist you in understanding your Union Labor Life Accidental Death and Dismemberment Insurance benefits. A detailed benefits description, including coordination of benefits, limitations and exclusions, and claims and appeals is contained within the Certificate of Insurance. The terms, conditions, limits and exclusions shown in the Certificate of Insurance shall govern.

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WEEKLY LOSS OF TIME BENEFITS (Actives Only)

This weekly benefit will be payable to you if, while covered under the Plan, you become totally disabled as a result of an accident or sickness and are prevented from performing any or every duty pertaining to your employment. This benefit is payable in addition to any benefits you receive under statutory disability benefits law. You must be under the care of a physician and he or she must complete and sign the physician sections of the claim form in order for you to be eligible for benefits. Benefits will begin as of the 8th day of disability due to an accident or sickness. Benefits may continue for any one period of disability up to a maximum of 26 weeks.

Successive periods of disability separated by fewer than 14 days of continuous active employment shall be considered as one continuous period of disability unless they arise from different and unrelated causes, provided you have earned wages during such 14 day period with the employer who was your employer immediately preceding the first period of disability. You do not have to be confined to your home to collect benefits, but you must be under the care of a physician.

For disabilities arising out of pregnancy or resulting in childbirth, abortion or miscarriage, weekly benefits will be provided in accordance with statutory provisions.

The Amount of Your Weekly Loss of Time Benefit

The amount of your Weekly Loss of Time Benefit is $100. The amount of benefits for each day of disability for which benefits are payable shall be one-seventh of the corresponding weekly benefit amount, rounded to the next higher multiple of one dollar ($1.00).

Filing a Claim for Weekly Loss of Time Benefits

In the event that you become disabled, it should be reported to the Fund Office within 30 days from the commencement of disability.

The claim form must be fully completed by all respective parties and submitted to the Fund Office as promptly as possible, but in no event more than 90 days after the start of disability. Improperly completed forms may cause a delay in the payment of your claim. To claim a Weekly Loss of Time Benefit, contact the Fund Office for a claim form, complete the employee section of the form and have your doctor complete the physician’s section of the form. Submit the completed form to the Fund Office at:

Sheet Metal Workers Local 22 Welfare Fund 106 South Avenue West

Cranford, NJ 07016

Benefits will be paid for the period covered by the first claim form for up to two weeks. If disability continues beyond two weeks, intermediate claim forms must be filed every other week.

No benefits are payable for a period of disability during which you are not under the direct care of a Physician. A period of Disability will not be considered as having started more than three days before the date you first see a Physician for the condition which caused the Disability; or during which you are engaged in any work for remuneration of profit.

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IMPORTANT INFORMATION

Maternity Care Benefit

This Plan generally may not, under federal law, 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 normal vaginal delivery, or less than 96 hours following a cesarean section. However, federal law generally does not prohibit the mother’s or newborn’s attending provider, after consulting with the mother, from discharging the mother or her newborn earlier than 48 hours (or 96 hours, as applicable). In any case, plans and health insurance issuers may not, under federal law, require that a provider or health care practitioner obtain authorization from the Plan or insurance company for prescribing a length of stay not in excess of the above periods.

Post-Mastectomy Breast Reconstructive Surgery Benefits

Under the Women’s Health and Cancer Rights Act of 1998, if you or your covered dependent is receiving benefits in connection with a mastectomy, and you elect breast reconstruction in connection with the mastectomy, you are entitled to coverage for the following:

• reconstruction of the breast on which the mastectomy has been performed; • surgery and reconstruction of the other breast to produce a symmetrical appearance; and • prostheses and treatment of physical complications at all stages of the mastectomy, including

lymphedemas.

If you are a covered member or covered dependent under this Plan, and are currently receiving, or in the future receive, benefits under the Plan in connection with a mastectomy, you are entitled to coverage for the benefits and services described above in the event that you elect breast reconstruction. Your covered dependents are also entitled to coverage for those benefits or services on the same terms.

Coverage for the mastectomy-related services or benefits required under the Women’s Health and Cancer Rights Act of 1998 will be subject to the same copayment or coinsurance provisions that apply with respect to other medical or surgical benefits provided under this Plan.

If you have any questions about whether your plan covers mastectomies or reconstructive surgery, please contact the insurance company. (See the Plan Information chart for its telephone number and/or address.)

Privacy of Your Health Information

A federal law, the Health Insurance Portability and Accountability Act of 1996 (HIPAA), requires that health plans like the Sheet Metal Workers Local 22 Welfare Fund protect the confidentiality of your private health information. A complete description of your rights under HIPAA can be found in the Plan’s Notice of Privacy Practices, which was distributed to you upon enrollment and is available, upon written request. This statement is not intended and cannot be construed as the Plan’s Notice of Privacy Practices.

Under federal law, you have certain rights with respect to your protected health information, including certain rights to see and copy the information, receive an accounting of certain disclosures of the information, and under certain circumstances amend the information. You have the right to request reasonable restrictions on disclosure of information about you, and to request confidential

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communications. You also have the right to file a complaint with the Plan or with the Secretary of the Department of Health and Human Services if you believe your rights have been violated.

MEDICAL, HOSPITAL AND MENTAL HEALTH AND SUBSTANCE ABUSE BENEFITS

The Sheet Metal Workers Local 22 Welfare Fund is a self-funded and provides you and your covered dependents with hospital, medical and mental health and substance abuse coverage.

The details about these benefits, including coverage exclusions and limitations, are included in the coverage description prepared by Horizon BCBS and should be kept with this document. If there is a difference between the information contained in this booklet and the actual contract issued by Horizon BCBS, the terms of the contract will govern. You may obtain a copy of the Fund’s contract with Horizon BCBS upon written request to the Fund Administrator. Your certificate of coverage (Certificate) gives you the most detail about your health care coverage. It is the legal description of your coverage. Some of the language that specifically details your benefit coverage levels that is included in your Certificate is included in this booklet. However, you should rely on the Certificate for the most detail about your benefit levels.

Telemedicine

You and your dependents have access to board-certified physicians through your smartphone or personal computer. Services are available 24/7/365 by licensed physicians. Each physician consultation is offered at no cost. This includes treatments for the flu, eye and sinus infections, allergies, rash, bronchitis and more. Please visit www.horizoncareolnline.com for more information.

Lower Hudson Valley E.A.P.

Lower Hudson Valley is an Employee Assisted Program otherwise known as an E.A.P. They are a proven resource to help members and their families deal with critical issues. As a union sponsored program, they offer voluntary and CONFIDENTIAL help from licensed counselors who have vast experience in dealing with all types of issues.

Assistance is available by calling 1-800-EAP-2799 for the following issues:

Elder Care Substance Abuse Marriage Problems Financial Pressures Drinking Problems Anxiety/Depression

During regular business hours, you will reach an E.A.P. counselor. After hours, your call will be answered by a trained operator and immediately referred to counselors who will promptly return the call. After discussing the problem and evaluating the member’s needs, the counselor will arrange an appointment at the E.A.P. or make a referral to an appropriate resource.

There is no charge to when calling the E.A.P. and no charge to come in and talk with someone for an initial assessment session.

If the participant decides to seek further help, charges of the health professionals or counselors

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whom they are referred to in most cases, will be covered by the Fund’s Health Insurance.

DENTAL BENEFIT

Sheet Metal Workers Local 22 Welfare Fund provides you and your eligible dependents a choice of coverage for dental benefits, which are self-insured and administered by ALICARE or insured through a Dental Health Maintenance Organization (DHMO) with Eastern Dental. Apprentices can only be enrolled in the Eastern Dental option.

How Your Dental Benefit Works

You and your dependents are free to select any dentist or dental specialist you wish. Benefits will be paid upon receipt of proof that you or your Dependent, while covered under the Plan, has incurred Covered Dental Charges. Payment will be made for the Covered Dental Charges incurred, multiplied by the benefit percentage payable, up to the Maximum Amount shown in the Schedule of Benefits below. In no event will the benefit exceed the Maximum Amount per individual, per calendar year or, for Orthodontia, the Maximum Benefit amount shown in the Schedule of Benefits below.

Covered Dental Charges

You are covered for expenses you incur for most, but not all, dental services and supplies provided by a Dental Care Provider, as defined in the Definitions section of this document, that are determined by the Plan Administrator or its designee to be “Medically Necessary,” but only to the extent that:

• the Plan Administrator or its designee determines that the services are the most cost effective ones that meet acceptable standards of dental practice and would produce a satisfactory result; and

• the charges for them are “Usual and Customary.”

Non-Eligible Dental Expenses Explained

The Plan will not reimburse you for any expenses that are not Covered Dental Charges. That means you must pay the full cost for all expenses that are not covered by the Plan, as well as any charges for Covered Dental Charges that exceed the amount determined by the Plan to be Usual and Customary.

Schedule of Dental Benefits

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Covered Dental Charges

Benefits payable for Covered Dental Charges as listed in the following:

Diagnostic and Preventative Procedures

• Initial Oral Examination; • Periodic Examination; • Emergency (Palliative) Examination; and • Prophylaxis and Scaling;

Restorative Procedures

• Amalgam one surface filling; • Amalgam two surface filling; • Amalgam three surface filling; • Amalgam four surface filling; • Silicate cement filling; • Composite Resin one surface; • Composite Resin two surfaces; and • Composite Resin three surfaces.

Major Restorative Procedures

(including Crowns and Inlays, Periodontics and Prosthodontics)

• Three-Quarter Cast Gold Crown; • Full Cast Gold Crown; • Plastic or Acrylic Veneer Crown; • Porcelain Crown; • Porcelain Veneer Crown; • Stainless Steel Crown; and • Gold Post and Core or Dowel.

When a crown is used in restorations, it must be demonstrated by X-rays that a tooth could not be restored by conventional methods.

All bridgework must be submitted for pre-certification before work commences or no payment will be considered.

Abutments and Pontics are considered to be crowns for the purposes of this provision.

Periodontics

Type I -Gingivitis -shallow pockets, no bone loss treatment:

• All necessary diagnostic procedures;

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• Training in personal preventive dental care; • Mouth preparation procedures; • Routine finishing procedures; and • Post-treatment evaluation.

Type II - Early periodontitis -moderate pockets, minor to moderate bone loss:

• All necessary diagnostic procedures; • Training in personal preventive dental care; • Mouth preparation procedures; • Occlusal adjustment (if necessary); • Surgical procedures usually involving curettage and/or gingivectomy; • Routine finishing procedures; and • •Post-treatment evaluation.

Type III - Moderate periodontitis -moderate to deep pockets, moderate to severe bone loss:

• All necessary diagnostic procedures; • Training in personal preventive dental care; • Mouth preparation procedures; • Occlusal adjustment; • Surgical procedures usually involving flap entry and osseous procedures; • Routine finishing procedures; and • Post-treatment evaluation.

Type IV - Advanced periodontitis -deep pockets, severe bone loss, advanced mobility pattern (usually cases involving missing teeth and reconstruction):

• All necessary diagnostic procedures; • Training in personal preventive dental care; • Mouth preparation procedures; • Occlusal adjustment; • Surgical procedures usually involving complex techniques; • Routine finishing procedures; and • Post-treatment evaluation.

Services must be performed by a certified Periodontist or qualified Dentist who must forward the dental charts and X-rays. All Periodontic work must also be submitted for precertification before work is to commence or no payment will be considered.

Prosthodontics

Replacement of Dentures is restricted to once every three years.

• Complete or immediate -upper or lower; • Partial acrylic without clasp – upper or lower; • Partial acrylic with gold or chrome clasps with rests -upper or lower; • Partial cast with gold or chrome lingual or palatal bar and two clasps, acrylic or cast base upper or

lower; • Full cast partial -upper or lower; • Unilateral partial, one place casting, gold or chrome cobalt clasp attachment per unit including

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pontics; • Each additional clasp with rests; and • Semi-precision attachment -each.

Prosthodontic Repairs

(Fixed or Removable)

• Repair broken complete or partial with or without teeth damaged; • Replace broken tooth on a complete or partial with or without any other repairs -each; • Adding tooth to partial to replace extracted teeth -each; • Replacing or reattaching clasp; • Replacing broken facing on a crown; and • Replacing broken tru-pontic. • Relining or Rebasing on a partial or complete denture is restricted to one every twelve months.• Relining or rebasing complete or partial -office; and • Relining or rebasing complete or partial -laboratory.

Orthodontics

Covered Dental Charges will be the Usual and Customary charges for the necessary care and treatment of malocclusion (including diagnosis and appliances).

Twenty-five percent (25%) of such Usual and Customary charges will be deemed to have been incurred at the time of the initial visit when the appliances are first inserted, with a limit of onehalf the total Lifetime Maximum. The remaining balance of the charge will be divided by the number of months of treatment, and benefits will be paid on a quarterly basis thereafter up to the Lifetime Maximum.

General Limitations

No payment in excess of the $2,000 annual maximum will be made for expenses incurred for you or any one of your dependents, unless the dependent is under age 19.

No payment in excess of the $2,000 lifetime maximum for orthodontics will be made for expenses incurred for you or your eligible dependents, regardless of age.

Specific exclusions which pertain to this benefit are described in the Exclusion section.

Eastern Dental Option

In lieu of the Dental Benefit described above, a Participant may elect DSO Dental Plan E (100% coverage of diagnostic, preventive, basic and major services with no maximum at participating Eastern Dental providers, only). The current schedule of Benefits as well as a list of Participating Providers can be obtained online at:

http://www.dentalservicesorganization.com/PlanE.htm or by contacting the fund office.

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PRESCRIPTION DRUG BENEFITS

The Sheet Metal Workers Local 22 Welfare Fund provides you with prescription drug coverage, which is self-insured and administered by OptumRx. The prescription drug benefit helps you pay for prescription drugs for you and your covered Dependents. The Fund has contracted with the Insurance Company listed in the Plan Information Chart to provide a nationwide network of retail pharmacies that will fill your prescriptions at a participating pharmacy (a list of participating pharmacies can be furnished to you upon your request, free of charge, as a separate document). You can find a nearby participating pharmacy by contacting the Insurance Company listed in the Plan Information Chart at the front of this document.

When You Go to a Participating Pharmacy

Eligible Participants will be issued a plastic identification card authorizing OptumRx participating pharmacies to fill prescriptions, which come within the scope of the Welfare Plan. Such Participant need only to:

1) Present the Optumcard to any OptumRx pharmacy with the prescription each time he needs to have a prescription filled or refilled;

2) Then, sign the pharmacy claim voucher, and 3) Pay the applicable coinsurance. The portion of the drug cost that you are responsible to pay, is listed

in the table below.

Classification 30-Day Retail

Regular Journeymen You pay 20% with a minimum $5 copay

Apprentices You pay 40% with a minimum $5 copay

Light Commercial You pay 40% with a minimum $5 copay

When You Go to a Non-Participating Pharmacy

If it is not possible to use a Optum member Pharmacy you will receive prescription drug coverage when you go to a pharmacy that is not participating in the Insurance Company’s network, but you will have to pay a higher payment then if you use a participating pharmacy. If you wish to obtain prescription drugs at a non-participating pharmacy, you will be charged the full cost of the drug., A special Prescription Drug Claim Form must be obtained from the Welfare Fund Office. This Claim Form must be completed by the Participant and the dispensing pharmacist, and then forwarded to Optum along with your receipt for reimbursement of the Fund’s portion of the claim. You will be reimbursed you 80% (60% if an apprentice or light commercial) of the cost of the drug that you paid at the point of sale.

Mail-Order Pharmacy

If you or a Dependent takes a Maintenance Drug or other prescription medication for chronic conditions, you must have certain prescriptions filled through Envisions mail-order pharmacy listed in the Plan Information Chart at the front of this document. The mail-order service provides you with the convenience of having prescription Maintenance Drugs delivered right to your home.

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The portion of the drug cost that you are responsible to pay, is listed in the table below.

Classification 90-Day Orchard Mail Order

Regular Journeymen You pay 20%

Apprentices You pay 40%

Light Commercial You pay 40%

All mail order prescriptions should be submitted to you may mail the original 90 day supply prescription(s) with the mail order form which can be obtained from the Fund Office or your physician can fax your prescription(s) to Orchard at 1-866-909-5171. Please be sure that your prescriber includes your date of birth and contact information on the fax. Only faxes sent from a physician’s office will be valid.Your mail order service covers all medications which require a prescription by either state or federal law and are prescribed by a licensed practitioner. This service may be used to purchase any prescription drug but its primary aim is to offer Maintenance Drugs used for chronic ailments such as high blood pressure, heart conditions, diabetes, asthma or arthritis.

The following prescriptions require a letter of Medical Necessity to be submitted to the Fund Office prior to being covered: Tretinoin agents used in the treatment of acne (Retin-A) over age 25 • Tazorac • Regraniex • Growth Hormones (injection) • Aranesp (injection) • Epogen/Procrit injection • Botox injection • Prolastin injection • Diflucan (excluding 150 mg tablets) • Sporanox capsules • Lamisil tablets • Wellburtrin SR/XL • Penlac Topical Solution • Forteo injection • Amevive injection • Remicade injection

Specific exclusions which pertain to this benefit are described in the Exclusion section.

Prescription Drug Benefits for Active Members and Dependents who are Medicare Eligible

If you and/or your Eligible Dependent(s) are enrolled in either Part A or B of Medicare, you are eligible for Medicare Part D (Medicare’s Prescription Drug program). For Active Employees and their Eligible Dependents who are Medicare-eligible, this Plan offers “Creditable Coverage.” This means that the Plan’s prescription drug coverage is expected to pay out, on average, as much or more as the standard Medicare prescription drug benefit will pay. Since this Plan’s coverage is as good as Medicare, you do not need to enroll in a Medicare Prescription Drug Plan while you have the Plan’s Active prescription drug coverage in order to avoid a late penalty under Medicare. When you lose this coverage, you may

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enroll in a Medicare Prescription Drug Plan either during a special enrollment period or during Medicare’s annual enrollment period (of October 15 -December 7 each year). For more information about creditable coverage see the Plan’s Notice of Creditable Coverage that will be mailed to you from the Plan once a year. You may request another copy of this Notice by calling the Fund Office.

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Schedule of Optical Benefits

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Prescription Safety Glasses

Effective November 1, 2019, prescription safety glasses will be covered in house up to $150. The frequency will be one pair of prescription safety glass every calendar year. Member must bring receipt to the Fund office for reimbursement.

RETIREE BENEFITS

Benefits For Retirees Under Age 65

If you retire on an Early or Disability Pension and are eligible (as described in the Eligibility Section) for Retiree benefits (Class 2A), you and your Spouse will receive the same Medical benefits as Active Participants for nine months from your date of retirement lessened by the number of months you may have been out of work immediately prior to retirement. In no event will benefits be provided beyond the date you become eligible for Medicare. Participants must also retire from active status with five consecutive years of service/benefits provided by the Sheet Metal Workers Local 22 Welfare Fund.

Your Life Insurance, Prescription Drug and Optical benefits are described below.

If you retire on a Normal Pension and are eligible (as described in the Eligibility section) for Retiree benefits (Class 2A), you and your Spouse will receive the same Medical benefits as Active Participants for two (2) years from your date of retirement. Your Life Insurance, Prescription Drug and Optical benefits are described below.

If you retire on or after February 1, 2013 and are younger than age 65, you must pay a premium of $150 per month for a single retiree and $150 per month for each additional dependent. This premium applies to under age 65 retirees who are eligible for Welfare Fund benefits following retirement. This premium must be paid by the first of each month you are eligible for coverage, with a grace period of 30 days to make the payment. If payment of the amount due is not made by the end of the grace period, your coverage will terminate and you will lose eligibility for further under age 65 retiree coverage.

Notwithstanding the foregoing, you will not be subject to paying a premium for the first nine-months of coverage, lessened by the number of months you may have been out of work immediately prior to retirement. In no event will benefits be provided beyond the date you become eligible for Medicare.

Benefits For Retirees Age 65 and Over (Medicare Part B Supplemental Benefits)

If you retire on a Normal Pension and are eligible (as described in the Eligibility Section) for Retiree benefits (Class 2A), and are 65 and over, you and your Spouse will receive benefits that supplement Medicare Part B up to a maximum of $4,000 per calendar year. The Plan does not pay any benefits for hospitalization covered under Part A of Medicare. The Plan will reimburse the 20% Coinsurance for which you are responsible and which Medicare does not pay. You must submit the Medicare Explanation of Benefits (EOB) with your claim in order for benefits to be payable. The Plan will then reimburse the Coinsurance amounts up to $4,000 per calendar year for expenses that are: (1) Medically Necessary; (2) recognized and paid by Medicare; and (3) not excluded by Medicare. The Plan will reimburse expenses based on what Medicare allows, not the Usual and Customary amount. See the section on Medicare coordination of benefits for further details on how the Plan coordinates with Medicare.

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Please note that since the Plan pays benefits that supplement Medicare, you should enroll in Medicare Part B and pay the applicable premium. If you do not have a Medicare EOB, the Plan will process your claim as if the claim had been payable by Medicare first according to what Medicare would have paid.

Your Life Insurance, Prescription Drug and Optical Benefits

Life Insurance

If you die from any cause while eligible for Retiree benefits, a Life Insurance Benefit of $3,500 will be paid to your beneficiary, subject to the terms, exclusions and limitations stated in the Life Insurance Benefits and Exclusions sections.

Prescription Drug Benefits

While you are eligible for Retiree benefits, you and your Spouse are each eligible for $600 in prescription drug benefits per calendar year, subject to the terms, exclusions and limitations stated in the Prescription Drug Benefits and Exclusions sections, including the discount provided at the participating Insurance Company’s pharmacies. The Fund will reimburse you 80% of the discounted cost of the drug that you paid at the point of sale.

Please note that for Retirees and their Eligible Dependents, the coverage offered by this plan is NOT “Creditable.” This means that this Plan is not expected to pay out as much in drug benefits as the standard Medicare prescription drug plan will pay out. This is important, because, for most people, failure to enroll in Medicare prescription drug coverage when they are first eligible or when they lose creditable coverage means that they will have to pay a penalty in the form of a higher premium for Medicare prescription drug coverage if they decide to enroll in the coverage later. For more information about non-creditable coverage see the Plan’s Notice of Non-Creditable Coverage that will be/has been mailed to you from Plan. You may request another copy of this Notice by contacting the Fund Office.

Optical Benefits

While you are eligible for Retiree benefits, you and your Spouse are eligible for Optical benefits in the same manner as active Participants, subject to the terms, exclusions and limitations stated in the Optical Benefits and Exclusions sections.

Dental Benefits

No Dental benefits are available under the Retiree benefits.

If You Return to Work

If you return to work after retirement to a category of employment which enables you to participate in the Plan, you will not be eligible for Retiree Benefits from the Plan.

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VACATION BENEFITS

You, as an Employee working for a Contributing Employer, are eligible for Vacation benefits as of the first day you work for a Contributing Employer and contributions are made on your behalf. Contributions are made on your behalf for each hour you work based on the terms of the Collective Bargaining Agreement for your job classification.

Each hour you work which requires contributions to the Vacation benefit will be reported on your pay stub as taxable income. In general, contributions accumulate in the Vacation account during the fiscal year (June 1st to May 31st). You may withdraw the amount in your Vacation account by completing the required withdrawal card, noting the dates of your vacation and signing it.

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PLAN EXCLUSIONS

The following is a list of services and supplies or expenses not covered by the Plan. The Plan Administrator, and other Plan fiduciaries and individuals to whom responsibility for the administration of the Medical program has been delegated, will have discretionary authority to determine the applicability of these exclusions and the other terms of the Plan and to determine eligibility and entitlement to Plan benefits in accordance with the terms of the Plan. General Exclusions are listed first followed by specific plan exclusions. Please note that specific exclusions that pertain to Hospital and Medical and Mental Health and Substance Abuse benefits are described in the “Sheet Metal Workers Local 22 Welfare Fund, Insurance Company’s Certificate of Coverage.”

General Exclusions (applicable to all Plan benefits)

1. Expenses Exceeding Maximum Plan Benefits: Expenses that exceed any Plan Benefit Limitation, Annual Maximum Plan Benefits, or Overall (“Lifetime”) Maximum Plan Benefits as described in the Medical Expense Coverage section of this document.

2. Expenses Exceeding Usual and Customary or Scheduled Charges: Any portion of the expenses

for covered medical services or supplies that are determined by the Plan Administrator or its designee to exceed the Usual and Customary Charge, as defined in the Definitions section of this document.

3. Medically Unnecessary Services: Services or supplies determined by the Plan Administrator or its designee not to be Medically Necessary, as defined in the Definitions section of this document.

4. Occupational Illness, Injury or Conditions Subject to Workers’ Compensation: All expenses incurred by you or any of your covered Dependents arising out of or in the course of employment (including self-employment) if the injury, illness or condition is subject to coverage, in whole or in part, under any workers’ compensation or occupational disease or similar law.

5. Expenses Not Legally Obligated to Pay: All expenses the Covered Individual is not legally obligated to pay.

6. War or Similar Event: Expenses incurred as a result of an injury or illness due to any of war, either declared or undeclared, war-like act, riot, insurrection, rebellion, or invasion, except as required by law.

7. Illegal Act: Expenses incurred by any Covered Individual for injuries resulting from or sustained as a result of commission, or attempted commission by the Covered Individual, of an illegal act that the Plan Administrator determines in his or her sole discretion, involves violence or the threat of violence to another person or in which a firearm, explosive or other weapon likely to cause physical harm or death is used by the Covered Individual. The Plan Administrator’s discretionary determination that this exclusion applies will not be affected by any subsequent official action or determination with respect to prosecution of the Covered Individual (including, without limitation, acquittal or failure to prosecute) in connection with the acts involved.

8. Experimental and/or Investigational Services: Expenses for any medical services, supplies, drugs or medicines that are determined by the Plan Administrator or its designee to be Experimental and/or Investigational, as defined in the Definitions section of this document.

9. Government-Provided Services (TRICARE, VA, etc.): Expenses for services when benefits for

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them are provided to the Covered Individual under any plan or program (including, without limitation, TRICARE and Veterans programs) established under the laws or regulations of any government, including the federal, state, or local government or the government of any other political subdivision of the United States, or of any other country or any political subdivision of any other country; or under any plan or program in which any government participates other than as an employer, unless the governmental program provides otherwise. This will include charges provided or paid for by the federal government at a Veteran’s Administration facility for:

• an Injury or Illness related to military service; or you, or your Dependent, if you are retired from the armed services.

10. Relatives Providing Services: Expenses for services provided by any Physician or other Health Care Practitioner who is the parent, spouse, sibling (by birth or marriage) or child of the patient or covered Employee.

11. Motor Vehicle: Expenses related to any injury sustained as a result of a motor vehicle, including but not limited to, a motorcycle.

12. Costs of Reports, Bills, etc.: Expenses for preparing medical reports, bills or claim forms; mailing, shipping or handling expenses; and charges for broken/missed appointments, telephone calls and/or photocopying fees.

13. Educational Services: Expenses for educational services, supplies or equipment, including, but not limited to computers, software, printers, books, tutoring, visual aides, auditory aides, speech aids, programs to assist with auditory perception or listening/learning skills, programs/services to remedy or enhance concentration, memory, motivation or self-esteem, etc., even if they are required because of an injury, illness or disability of a Covered Individual.

14. Employer-Provided Services: Expenses for services rendered through a medical department, clinic or similar facility provided or maintained by the Fund, or if benefits are otherwise provided under this Plan or any other plan that the Fund contributes to or otherwise sponsors, such as HMOs.

15. Expenses for Which a Third Party Is Responsible: Expenses for services or supplies for which a third party is required to pay. See the provisions relating to Third Party Liability in the section on Coordination of Benefits in this document for an explanation of the circumstances under which the Plan will advance the payment of benefits until it is determined that the third party is required to pay for those services or supplies.

16. Expenses Incurred Before or After Coverage: Expenses for services rendered or supplies provided before the patient became covered under the medical and/or dental program; or after the date the patient’s coverage ends, except under those conditions described in the COBRA section of this document.

17. Modifications of Homes or Vehicles: Expenses for construction or modification to a home, residence or vehicle required as a result of an injury, illness or disability of a Covered Individual, including, without limitation, construction or modification of ramps, elevators, chair lifts, swimming pools, spas, air conditioning, asbestos removal, air filtration, hand rails, emergency alert system, etc.

18. No-Cost Services: Expenses for services rendered or supplies provided for which a Covered Individual is not required to pay or which are obtained without cost, or for which there would be no charge if the person receiving the treatment were not covered under this Plan.

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19. No Physician Prescription: Expenses for services rendered or supplies provided that are not recommended or prescribed by a Physician, except for covered services provided by a Behavioral Health Practitioner, Midwife or Nurse Midwife, Nurse Practitioner, Physician Assistant, Chiropractor, Dentist, or Podiatrist.

20. Non-Emergency Travel and Related Expenses: Expenses for and related to non-emergency travel or transportation (including lodging, meals and related expenses) of a Health Care Provider, Covered Individual or family member of a Covered Individual.

21. Personal Comfort Items: Expenses for patient convenience, including, but not limited to, care of family members while the Covered Individual is confined to a Hospital or other Health Care Facility or to bed at home, guest meals, television, VCR/DVD, telephone, barber or beautician services, house cleaning or maintenance, shopping, birth announcements, photographs of new babies, etc.

22. Physical Examinations, Tests for Employment, School, etc.: Expenses for physical examinations and testing required for employment, government or regulatory purposes, insurance, school, camp, recreation, sports, or by any third party.

23. Private Room in a Hospital or Health Care Facility: The use of a private room in a Hospital or other Health Care Facility, unless the facility has only private room accommodations or unless the use of a private room is certified as Medically Necessary by the Plan Administrator or its designee. See the “Schedule of Medical Benefits” for more information.

24. Medical Students, Interns or Residents: Expenses for the services of a medical student, intern or resident.

25. Stand-By Physicians or Health Care Practitioners: Expenses for any Physician or other Health Care Provider who did not directly provide or supervise medical services to the patient, even if the Physician or Health Care Practitioner was available to do so on a stand-by basis.

26. Services Provided Outside the United States: Expenses for medical services or supplies rendered or provided outside the United States, except for treatment for a medical Emergency as defined in the Definitions section of this document.

27. Appropriate Treatment: Expenses incurred by any Covered Individual as a result of failure to comply with medically appropriate treatment, as determined by the Plan Administrator or its designee.

28. Leaving a Hospital Contrary to Medical Advice: Hospital or other Health Care Facility expenses if you leave the facility against the medical advice of the attending Physician within 72 hours after admission.

29. Travel Contrary to Medical Advice: Expenses incurred by any Covered Individual during travel if a Physician or other Health Care Provider has specifically advised against such travel because of the health condition of the Covered Individual.

30. Telephone Calls: Expenses for any and all telephone calls between a Physician or other Health Care Provider and any patient or other Health Care Provider, Utilization Management Company, or any representative of the Plan for any purpose whatsoever, including, without limitation: Communication with any representative of the Plan or its Utilization Management Company for any

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purpose related to the care or treatment of a Covered Individual; consultation with any Health Care Provider regarding medical management or care of a patient; coordinating medical management of a new or established patient; coordinating services of several different health professionals working on different aspects of a patient’s care; discussing test results; initiating therapy or a plan of care that can be handled by telephone; providing advice to a new or established patient; and providing counseling to anxious or distraught patients or family members.

31. Internet/Virtual Office Visit: Expenses related to an online internet consultation with a Physician or other Health Care Practitioner, also called a virtual office visit/consultation, physician-patient web service or physician-patient e-mail service, including receipt of advice, treatment plan, prescription drugs or medical supplies obtained from an online internet provider.

32. Self-Inflicted Injury or Attempted Suicide: Expenses incurred by any Covered Individual arising from an attempt at suicide or from a self-inflicted injury or illness, including complications thereof, unless the attempt arises as a result of a physical or mental health condition.

EXCLUSIONS APPLICABLE TO SPECIFIC MEDICAL SERVICES AND SUPPLIES

Behavioral Health/Mental Health Care and Substance Abuse Exclusions

1. Expenses for Court ordered chemical dependency admissions are not payable unless Medically Necessary and appropriate and only to the extent benefits would otherwise be payable under the Plan.

[2.] Repeat detoxification for chronic Substance Abuse will not be covered unless it is determined Medically Necessary by Horizon.

2.[3.] Expenses for diagnosis, treatment and prevention of Behavioral Health Disorders, including substance abuse, except as provided under Behavioral Health in the Schedule of Medical Benefits.

3.[4.] Expenses for residential care services for Behavioral Health Care, except as provided under Behavioral Health in the Schedule of Medical Benefits.

4.[5.] Expenses for hypnosis, hypnotherapy and/or biofeedback.

5.[6.] Expenses for Behavioral Health Care services related to: Adoption counseling; attention deficit disorders (with or without hyperactivity), except when the services are for diagnosis and/or the prescription of medication as prescribed by a Physician or other Health Care Practitioner; court-ordered Behavioral Health Care services; custody counseling; developmental disabilities; dyslexia, learning disorders; family planning counseling; genetic testing and counseling (see also the exclusion regarding Genetic Testing and Counseling later in this section), marriage, couples, and/or sex counseling; mental retardation; pregnancy counseling; transsexual counseling; and vocational disabilities; expenses for tests to determine the presence of or degree of a person’s attention deficit disorder, dyslexia or learning disorder; except as provided in the Schedule of Benefits.

Dental Care Exclusions:

1. Expenses for dental care or treatment, or dental X-rays, unless specifically provided by the Dental Plan.

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2. Expenses for Dental Prosthetics or Dental services or supplies of any kind, even if they are necessary because of symptoms, congenital anomaly, illness or injury affecting the mouth or another part of the body.

3. Expenses for Dental services may be covered under the Medical Plan if they are incurred for the repair or replacement of injury to sound and natural teeth or restoration of the jaw if damaged by an external object in an accident. For the purposes of this coverage by the Plan, an accident does not include any injury caused by biting or chewing.

4. Expenses for orthognathic services/surgery for treatment of prognathism, retrognathism and TMJ and other cosmetic reasons.

5. Expenses for oral surgery to remove teeth including wisdom teeth, gingivectomies, treatment of dental abscesses, root canal (endodontic) therapy.

6. Expenses for any professional fees whatsoever other than the fees of the Dentist or Physician performing the treatment.

7. Expenses for treatment due to an Injury or illness that is employment-related or that is covered under the Workers’ compensation Law, Occupational Disease Law or similar laws.

8. Expenses for disability due to an accidental bodily injury arising out of and in the course of your or your Dependent’s employment.

9. Expenses for services which you or your Dependent obtains, or is entitled to obtain, under any plan or program without charge, except Medicaid. This will include charges provided or paid for by the federal government at a Veteran’s Administration facility for:

an injury or illness related to military service; or you, or your Dependent, if you are retired from the armed services.

10. Expenses for services which you or your Dependent obtains, or is entitled to obtain, under any plan or dental expenses incurred after termination of coverage.

11. Expenses for prosthetic devices and the fitting thereof which were ordered while the individual was not covered under this Plan.

12. Expenses incurred for lost or stolen appliances (bridgework and dentures).

13. Expenses for replacement of covered dentures more often than once every three years.

14. Expenses for replacement of existing dentures or bridgework installed less than three years, prior to its replacement unless it is satisfactorily shown that the existing denture or bridgework cannot be made serviceable.

15. Charges which are not necessary or are not recommended and approved by the attending Dentist or Physician, or for care or treatment that is deemed inappropriate.

16. Expenses for services rendered solely for cosmetic purposes unless such services are required because of an accidental bodily injury sustained while covered under this Benefit.

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17. Expenses for any services that are paid or payable under any other Benefit of this Plan.

18. Expenses for services paid for or furnished by any employer’s medical or dental department, mutual benefit association, labor union, or similar organization, but only to the extent so paid or furnished.

Vision Care Exclusions:

1. Professional services and/or materials in connection with:

• Plano (non-prescription) lenses

• Aniseikonic Lenses

• Subnormal visual aids

• Orthoptics, vision training, developmental vision procedures, and any associated supplementaltesting

2. Broken, lost or stolen lenses, contact lenses, or frames. NVA network providers may offer additionalwarranties to cover materials.

3. Services or materials, which are payable under any workers’ compensation act, similar law or any public program, other than Medicaid.

4. Services or materials rendered by a provider other than ophthalmologists, optometrists, or opticians acting within the scope of their licensure.

5. Any additional service required outside basic vision analysis for contact lenses, including but not limited to fitting fees, unless otherwise specified in the Proposed Schedule of Benefits.

6. Services rendered after the date a person ceases to be covered under this agreement, except when vision materials ordered before coverage ended are delivered and the services rendered to the person within 31 days from the date of such order.

7. Corrective eyewear required by an employer as a condition of employment unless specifically covered under plan.

8. Medical and/or surgical treatment of the eye, eyes or supporting structures.

9. Two pairs of glasses in lieu of bifocals.

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HEALTH REIMBURSEMENT ACCOUNT (HRA)

A. General

The Health Reimbursement Account (HRA) is an individual account that is maintained for each participant who is working for an employer that is required by Collective Bargaining Agreements and/or Participation Agreements to contribute to the Plan.

You become a participant as soon as contributions are submitted to your account and you remain a participant as long as there is a balance in your account.

However, if the Collective Bargaining Agreement which governs your employment is subsequently modified to eliminate or reduce to a minimum amount of future contributions to the Welfare Fund, the balance in your individual account will be forfeited and you will no longer be eligible for benefits under the Health Reimbursement Account (HRA) so long as that Collective Bargaining Agreement governs your employment.

B. Claim Procedures

Claims for benefits must be made on Health Reimbursement Account (HRA) forms which are available at the Fund Office. You can obtain claim forms by mail or in person. To keep administrative costs low, all claims must be for a minimum of $100.00 in total or whatever you have accumulated in a calendar year.

C. Benefits Eligible for Reimbursement

If you, your spouse or your eligible dependent children incur any medical, dental or optical expenses that are not covered by the Welfare Fund, or any other health insurance plan, you may withdraw the unreimbursed amount from your HRA account. Reimbursable amounts include, but are not limited to, deductibles and co-payments, including prescription drug co-payment.

In addition, you may withdraw from your account to pay for the premium incurred to maintain coverage should you not meet the Plan’s hours eligibility requirement, or for COBRA premiums (Member, Spouse and dependent Children only), upon your written request.

You have 3 months after the close of the calendar year to submit your claims for reimbursement. The Health Reimbursement Account (HRA) will not reimburse any claims incurred in the calendar year after March 31st.

If you qualify for health coverage form the Welfare Fund and/or any other health insurance plan (either group or individual), you MUST first submit your medical claims to all insurance carriers. This establishes what the insurance carriers have paid towards your medical claims and the amount that has not been reimbursed to you, which you may submit to the Fund Office for reimbursement from the Health Reimbursement Account (HRA).

When you are applying for reimbursement from your Health Reimbursement Account (HRA), you MUST furnish the Fund Office with the following:

1. A copy of the Explanation of Benefits form from your other insurance carrier(s), if applicable, showing the amount the other insurance carrier(s) paid or rejected.

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2. An itemization of the co-pay amounts paid from your other insurance carrier(s).

3. An itemized list showing your prescription drug co-pay amounts paid.

4. A copy of paid bills in which you are seeking reimbursement when a Explanation of of Benefits form is not available.

5. A properly completed Health Reimbursement Account (HRA) claim form.

All reimbursements from the Health Reimbursement Account (HRA) will be paid directly to the eligible participant. No reimbursement from the Health Reimbursement Account (HRA) will be paid or reimbursed to any other entity.

D. Forfeiture of Accounts

Because of the expense of administering the individual accounts, any account which does not accumulate any contributions or claims over a period of 12 consecutive calendar months will be forfeited and used to pay health care and other benefits provided by the Welfare Fund. The forfeiture provision does not apply to participants who have met the age and service requirements of the Pension Fund.

E. Administration

If investment return exceeds administrative expenses, the Board of Trustees may declare a distribution that would be applied pro rata to each individual account.

F. Miscellaneous

The benefits under the Health Reimbursement Arrangement are subject to the overall rules and requirements of this Fund, including but not limited to these benefits not being vested, and the Board of Trustees may alter, amend, or do away with such benefits.

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DEFINITIONS

The following are definitions of specific terms and words used in this document or that would be helpful in understanding covered or excluded health care services. These definitions do not, and should not be interpreted to, extend coverage under the Plan.

Accident: A sudden and unforeseen event as a result of an external or extrinsic source, that is not work-related, and that occurred while the Plan Participant was covered under the Plan.

Active Course of Orthodontia Treatment (Dental): The period beginning when the first orthodontic appliance is installed and ending when the last active appliance is removed.

Allowable Expense: A health care service or expense, including deductibles, coinsurance or copayments, that is covered in full or in part by any of the plans covering a Plan Participant (see also the COB section of this document), except as otherwise provided by the terms of this Plan or where a statute applicable to this Plan requires a different definition. This means that an expense or service (or any portion of an expense or service) that is not covered by any of the plans is not an Allowable Expense.

Covered Dental Charges: The Usual and Customary charges for services rendered or supplies furnished by a Dentist, in the area where such services or supplies are so recommended or approved, in connection with the procedures listed in the Covered Dental Charges located in the Dental section of this document.

Date of the Incurred Dental Charge: Except for the Orthodontic Benefit, means the date the applicable service or care is rendered. The insert date of an appliance is considered the date the charge is incurred.

Dental Care Provider: A Dentist, Dental Hygienist or other Health Care Practitioner or Nurse as those terms are specifically defined in this section of the document, who is legally licensed and who is a Dentist or performs services under the direction of a licensed Dentist; and acts within the scope of his or her license; and is not the patient or the parent, spouse, sibling (by birth or marriage) or child of the patient.

Dental Hygienist: A person who is trained and legally licensed and authorized to perform dental hygiene services, such as prophylaxis (cleaning of teeth), under the direction of a licensed Dentist, and who acts within the scope of his or her license; and is not the patient or the parent, spouse, sibling (by birth or marriage) or child of the patient.

Dentist: A person holding the degree of Doctor of Dental Surgery (DDS) or Doctor of Dental Medicine (DMD) who is legally licensed and authorized to practice all branches of dentistry under the laws of the state or jurisdiction where the services are rendered; and acts within the scope of his or her license; and is not the patient or the parent, spouse, sibling (by birth or marriage) or child of the patient.

Denture: A device replacing missing teeth.

Dependent: Any of the following individuals: Dependent Child(ren) or Spouse, as those terms are defined in this document.

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Disability (Total Disability, or Totally Disabled): See the Life Insurance Benefit Section of this plan.

Emergency Care: Medical or dental care and treatment provided after the sudden unexpected onset of a medical or dental condition manifesting itself by acute symptoms, including severe pain, which are severe enough that the lack of immediate medical or dental attention could reasonably be expected to result in any of the following:

• The patient’s life or health would be placed in serious jeopardy. • There would be a serious dysfunction or impairment of a bodily organ or part. • In the event of a Behavioral Health Disorder, the lack of the treatment could reasonably be expected

to result in the patient harming himself or herself and/or other persons.

Experimental and/or Investigational: The Plan Administrator or its designee has the discretion and authority to determine if a service or supply is or should be classified as Experimental and/or Investigational. A service or supply will be deemed to be Experimental and/or Investigational which, in the opinion of the Plan Administrator or its designee, based on the information and resources available at the time the service was performed or the supply was provided, or the service or supply was considered for Pre-certification under the Plan’s Utilization Management program:

1. is not accepted as standard medical treatment for the illness, disease or injury being treated by physicians practicing the suitable medical specialty;

2. is the subject of scientific or medical research or study to determine the item's effectiveness and safety;

3. has not been granted, at the time services were rendered, any required approval by a federal or state government agency, including without limitation, the Federal Department of Health and Human Services, Food & Drug Administration, or any comparable state government agency, and the Federal Health Care Finance Administration as approved for reimbursement under Medicare Title XVIII; or

4. is performed subject to the Covered Person's informed consent under a treatment protocol that explains the treatment or procedure as being conducted under a human subject study or experiment.

Health Care Practitioner: A Physician, Behavioral Health Practitioner, Chiropractor, Dental Hygienist, Dentist, Nurse, Nurse Practitioner, Physician Assistant, Podiatrist, or Occupational, Physical, Respiratory or Speech Therapist or Speech Pathologist, Master’s prepared Audiologist, optometrist, optician for vision plan benefits, who is legally licensed and/or legally authorized to practice or provide certain health care services under the laws of the state or jurisdiction where the services are rendered: and acts within the scope of his or her license and/or scope of practice; and is not the patient or the parent, spouse, sibling (by birth or marriage) or child of the patient.

Illness: Any bodily sickness or disease, including any congenital abnormality of a newborn child, as diagnosed by a Physician and as compared to the person’s previous condition. Pregnancy of a covered employee or covered Spouse will be considered to be an Illness only for the purpose of coverage under this Plan.

Medically Necessary:

A. A medical or dental service or supply will be determined to be “Medically Necessary” by the Plan Administrator or its designee if it: 1. is provided by or under the direction of a Physician or other duly licensed Health Care

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Practitioner who is authorized to provide or prescribe it (or Dentist if a dental service or supply is involved); and

2. is determined by the Plan Administrator or its designee to be necessary in terms of generally accepted American medical or dental standards; and

3. is determined by the Plan Administrator or its designee to meet all of the following requirements: • It is consistent with the symptoms or diagnosis and treatment of the illness or injury; and • It is not provided solely for the convenience of the patient, Physician, Dentist, Hospital,

Health Care Provider, or Health Care Facility; and • It is an “Appropriate” service or supply given the patient’s circumstances and condition; and • It is a “Cost-Efficient” supply or level of service that can be safely provided to the patient;

and • It is safe and effective for the illness or injury for which it is used.

B. A medical or dental service or supply will be considered to be “Appropriate” if: 1. It is a diagnostic procedure that is called for by the health status of the patient, and is as likely to

result in information that could affect the course of treatment asand no more likely to produce a negative outcome than any alternative service or supply, both with respect to the illness or injury involved and the patient’s overall health condition.

2. It is care or treatment that is likely to produce a significant positive outcome and no more likely to produce a negative outcome than any alternative service or supply, both with respect to the illness or injury involved and the patient’s overall health condition.

C. A medical or dental service or supply will be considered to be “Cost-Efficient” if it is not more costly than any alternative Appropriate service or supply when considered in relation to all health care expenses incurred in connection with the service or supply.

D. The fact that your Physician or Dentist may provide, order, recommend or approve a service or supply does not mean that the service or supply will be considered to be Medically Necessary for the medical or dental coverage provided by the Plan.

E. A Hospitalization or confinement to a Health Care Facility will not be considered to be Medically Necessary if the patient’s illness or injury could safely and appropriately be diagnosed or treated while not confined.

F. A medical or dental service or supply that can safely and appropriately be furnished in a Physician’s or Dentist’s office or other less costly facility will not be considered to be Medically Necessary if it is furnished in a Hospital or Health Care Facility or other more costly facility.

G. The non-availability of a bed in another Health Care Facility, or the non-availability of a Health Care Practitioner to provide medical services will not result in a determination that continued confinement in a Hospital or other Health Care Facility is Medically Necessary.

H. A medical or dental service or supply will not be considered to be Medically Necessary if it does not require the technical skills of a Dental or Health Care Practitioner or if it is furnished mainly for the personal comfort or convenience of the patient, the patient’s family, any person who cares for the patient, any Dental or Health Care Practitioner, Hospital or Health Care Facility.

Medicare: The Health Insurance for the Aged and Disabled provisions in Title XVIII of theU.S. Social Security Act as it is now amended and as it may be amended in the future.

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Onlay: An Inlay Restoration that is extended to cover the biting surface of the tooth, but not the entire tooth. It is often used to restore lost and weakened tooth structure.

Orthodontics, Orthodontia: The science of the movement of teeth in order to correct a malocclusion or “crooked teeth.”

Orthognathic Services: Services dealing with the cause and treatment of malposition of the bones of the jaw, such as Prognathism, Retrognathism or TMJ syndrome. See the definitions of Prognathism, Retrognathism and TMJ.

Orthotic (Appliance or Device): A type of Corrective Appliance or device, either customized or available “over-the-counter,” designed to support a weakened body part, including, but not limited to, crutches, specially designed corsets, leg braces, extremity splints, and walkers. For the purposes of the Medical Plan, this definition does not include Dental Orthotics. See also the definitions of Corrective Appliance, Durable Medical Equipment, Nondurable Supplies and Prosthetic appliance (or Device).

Plan, This Plan: The programs, benefits and provisions described in this document.

Plan Administrator: The person who has the fiduciary responsibility for the overall administration of the Plan.

Plan Participant: The employee or individual who has enrolled for coverage under the Plan. As used in this document, this term does not include the Spouse or Dependent Child(ren) of the Plan Participant.

Retiree: See section entitled “Eligibility.”

Spouse: The employee’s lawful spouse or civil union partner as determined by the laws of the state where the covered employee or retiree resides. The Plan will require proof of the legal marital or civil union relationship. A legally separated spouse, former civil union partner or divorced former spouse of an employee or retiree is not an eligible spouse under this plan.

Substance Abuse: A psychological and/or physiological dependence or addiction to alcohol or drugs or medications, regardless of any underlying physical or organic cause, and/or other drug dependency as defined by the current edition of the ICD manual or identified in the current edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM). See the definitions of Behavioral Health Disorders and Chemical Dependency.

Usual and Customary Charge (U&C): The charge for medically necessary services or supplies will be determined by the Plan Administrator or its designee to be the lowest of:

1. For medical benefits, no more than the a national schedule of prevailing health care charges; 2. With respect to a PPO or Participating Health Care or Dental Care Provider, the fee set forth in the

agreement between the PPO or Participating Health Care or Dental Care Provider and the PPO or the Plan;

3. The Health Care or Dental Care Provider’s actual charge; or 4. The usual charge by the Health Care or Dental Care Provider for the same or similar service or

supply.

The “Prevailing Charge” of most other Health Care or Dental Care Providers in the same or similar geographic area for the same or similar health care service or supply will be determined by the Claims Administrator using proprietary data that is provided by a reputable company or entity and is updated

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no less frequently than annually. The Plan will not always pay benefits equal to or based on the Health Care or Dental Care Provider’s actual charge for health care services or supplies, even after you have paid the applicable Deductible and Coinsurance. This is because the Plan covers only the Usual and Customary charge for health care services or supplies. Any amount in excess of the Usual and Customary Charge does not count toward the Plan’s annual Out-of-Pocket Maximums. The Usual and Customary Charge is sometimes referred to as the U & C Charge, the Usual and customary charge, the R & C charge, the usual, customary and usual charge, or the UCR charge.

Visit: See the definition of Office Visit.

You, Your: When used in this document, these words refer to the employee who is covered by the Plan. They do not refer to any Dependent of the employee.

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CLAIMS AND APPEALS

This section describes the procedures for filing claims for benefits from the Sheet Metal Workers Local Union No. 22 Welfare Plan (the “Plan”). It also describes the procedure for you to follow if your claim is denied in whole or in part, or if any adverse determination is made with respect to your claim, and you wish to appeal the decision.

It also provides definitions of types of claims and requirements under ERISA pertaining to claims and appeals. The insurance company (listed in the Plan Information Chart at the front of this document) for hospital and medical benefits maintains procedures for filing claims (including precertification and preauthorization procedures) and appeals as well as timeframes for which decisions must be rendered. These procedures are described in detail in the Insurance Company’s Certificate of Coverage. You should refer to that booklet for a detailed description.

Claims Procedures

In order to file a claim for benefits offered under this Plan, you must follow the procedures outlined in this section which may include submitting a completed claim form (where required). Simple inquiries about the Plan’s provisions that are unrelated to any specific benefit claim or are exclusively about eligibility will not be treated as a claim for benefits. A request for prior approval of a benefit that does not require prior approval by the Plan is not a claim for benefits. In addition, the presentation of a prescription to a pharmacy which exercises no discretion on behalf of the Plan is not considered a claim. Benefits received from in-network providers are not considered a “claim” under these procedures. However, if your request for any of these benefits are denied, in whole or in part, you may file a claim and appeal regarding the denial by using these procedures. In general, health services must be medically necessary to be covered under the Plan.

Authorized Representatives

An authorized representative, such as your spouse, may complete the claim form for you if you are unable to complete the form yourself and have previously designated the individual to act on your behalf. A form can be obtained from the Fund Office to designate an authorized representative. The Plan may request additional information to verify that this person is authorized to act on your behalf. A health care professional with knowledge of your medical condition may act as an authorized representative in connection with an Urgent Care Claim (defined below) without you having to complete the special authorization form.

Types of Claims

The claims procedures for hospital, medical, dental, and prescription, benefits will vary depending on whether your claim is for a Pre-Service Claim, an Urgent Care Claim, a Concurrent Care Claim, or a Post-Service Claim. In addition, claims procedures vary if your claim is for Life Insurance, AD&D or Weekly Loss of Time benefits. Please read each section carefully to determine which procedure is applicable to your request for benefits. This information about the types of claims is provided as general guidance in accordance with the DOL regulations.

Procedures Regarding Medical Necessity Determinations

In general, all health services and benefits must be Medically Necessary and some also require prior

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authorization to be covered under the Plan. The procedures for determining Medical Necessity and Precertification vary, according to the type of service or benefit requested, and the type of health plan. Determinations are made on either a pre-service, concurrent, or post-service basis by the Applicable Insurance Company.

Definition of Claims &Timing of Claims Notification

Pre-Service and Urgent Care Claims

A Pre-Service Claim is a claim for a benefit for which the Plan requires approval of the benefit (in whole or in part) before medical care is obtained. There are pre-service requirements described in the insurance company’s Certificate of Coverage. You should refer to the information provided in the attached booklet for guidelines on pre-service claims. The information contained below is a general outline of the different types of claims. The specific requirements for each Benefit are outlined in the insurance company’s Certificate of Coverage (health care organization responsible for processing the claim).

If a Pre-Service Claim is improperly filed, a health care organization must notify you as soon as possible but not later than 5 days after receipt of the claim, of the proper procedures to be followed in filing a claim. This notification may be oral, unless you (or your representative) request written notification. You will only receive notification of a procedural failure if your claim is received by the Health Organization and it includes (i) your name, (ii) your specific medical condition or symptom, and (iii) a specific treatment, service or product for which approval is requested. Unless the claim is refiled properly, it will not constitute a claim.

For properly filed Pre-Service Claims, you and your health care provider must be notified of a decision within 15 days from receipt of the claim unless additional time is needed. The time for response may be extended up to 15 days if necessary due to matters beyond the control of the Health Organization, and you are notified of the circumstances requiring the extension of time and the date by which a decision is expected to be rendered.

If an extension is needed because the Health Organization needs additional information from you, the extension notice must specify the information needed. In that case you and/or your doctor will have at least 45 days from receipt of the notification to supply the additional information. The normal period for making a decision on the claim will be suspended until the date you respond to the request. The Health Organization then has 15 days to make a decision on a Pre-Service Claim and notify you of the determination.

An Urgent Care Claim is any pre-service claim for medical, dental or prescription care or treatment with respect to which the application of the time periods for making pre-service claim determinations:

1. could seriously jeopardize your life or health or your ability to regain maximum function, or 2. in the opinion of a physician with knowledge of your medical condition, would subject you to

severe pain that cannot be adequately managed without the care or treatment that is the subject of your claim.

Whether a claim is an Urgent Care Claim is determined by the Health Organization applying the judgment of a prudent layperson who possesses an average knowledge of health and medicine. Alternatively, any claim that a physician with knowledge of a medical condition determines is an Urgent Care Claim within the meaning described above, shall be treated as an Urgent Care Claim.

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For an improperly filed Urgent Care Claim, the Health Organization will notify you as soon as possible but must notify you not later than 24 hours after receipt of the claim, of the proper procedures to be followed in filing a claim. This notification may be oral, unless you (or your representative) request written notification. You will only receive notification of a procedural failure if your claim is received by the Health Organization and it includes (i) your name, (ii) your specific medical condition or symptom, and (iii) a specific treatment, service or product for which approval is requested. Unless the claim is refiled properly, it will not constitute a claim.

For properly filed Urgent Care Claims, the Health Organization will respond to you and/or your doctor with a determination by telephone as soon as possible taking into account the medical exigencies, but not later than 72 hours after receipt of the claim by the Health Organization. The determination will also be confirmed in writing.

If an Urgent Care Claim is received without sufficient information to determine whether or to what extent benefits are covered or payable, the Health Organization must notify you and/or your doctor as soon as possible, but not later than 24 hours after receipt of the claim, of the specific information necessary to complete the claim. You will then have a period of no less than 48 hours, taking into account the circumstances, to provide the specified information to the Health Organization. The Health Organization must then notify you of the benefit determination no later than 48 hours after the earlier of (i) the Health Organization’s receipt of the specified information, or (ii) the end of the period afforded to you to provide the specified additional information.

Concurrent Claims

A Concurrent Claim is a claim that is reconsidered after an initial approval was made and results in a reduction, termination or extension of a benefit. (An example of this type of claim would be an inpatient hospital stay originally certified for five days that is reviewed at three days to determine if the full five days is appropriate.) In this situation, a decision to reduce, terminate or extend treatment is made concurrently with the provision of treatment.

If you are receiving concurrent care benefits and the Health Organization decides to reduce or terminate the course of treatment before the end of the previously approved treatment period (other than by plan amendment or termination), you will be notified of the adverse benefit determination sufficiently in advance of the reduction or termination to allow you ample time to request a review of the decision and obtain a determination upon review before the benefit is reduced or terminated.

If you make a claim to extend a course of treatment beyond the approved period of time or number of treatments, and the claim involves urgent care, the Health Organization will make a determination on your claim as soon as possible, taking into account medical exigencies, and will notify you of the decision within 24 hours after receipt of your claim, provided that your claim was filed at least 24 hours before expiration of the previously approved period of time or number of treatments.

Post-Service Claim

A Post-Service Claim is a claim that is not a Pre-Service Claim (for example, a claim submitted for payment after health services and treatment have been obtained). In order to file a Post-service claim you must:

1. Obtain a claim form. 2. Complete the employee’s portion of the claim form and sign the form. 3. Have your Physician do one of the following: complete the Attending Physician’s Statement section

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of the claim form, complete a CMS Universal health insurance claim form, or submit a HIPAA-compliant electronic claims.

4. Attach all itemized Hospital bills or doctor’s statements that describe the services rendered.

Check the claim form to be certain that all applicable portions of the form are completed and that you have submitted required documentation. By doing so, you will speed the processing of your claim. If the claim forms have to be returned to you for information, delays in payment will result.

Ordinarily, you will be notified of the decision on your Post-Service claim within 30 days from receipt of the claim. This period may be extended one time for up to 15 days if the extension is necessary due to matters beyond the control of the Health Care Organization. If an extension is necessary, you will be notified before the end of the initial 30-day period, of the circumstances requiring the extension of time and the date by which the Health Care Organization expects to render a decision.

If an extension is needed because additional information is needed from you, the extension notice will specify the information needed. In that case, you will have at least 45 days from receipt of the notification to supply the additional information. The normal period for making a decision on the claim will be suspended until the date you respond to the request. The Health Care Organization then has 15 days to make a decision on a Post-Service Claim and notify you of the determination.

Life Insurance Claims and Accidental Death and Dismemberment (AD&D) Claims

A Life Insurance Claim is a claim made by your beneficiary on the occasion of your death. An Accidental Death and Dismemberment claim is a claim for loss of life, limb(s), or sight of eye(s) due to accidental means.

For Life Insurance and AD&D Claims, the Union Labor Life Insurance Company will make a decision on the claim and notify you or your beneficiary within 90 days. If the Union Labor Life Insurance Company requires an extension of time due to matters beyond its control, it will notify you of the reason for the delay and when the decision will be made. This notification will occur before the expiration of the 90-day period. A decision will be made within 90 days of the time the Union Labor Life Insurance Company notifies you of the delay. If an extension is needed because additional information is needed from you, the extension notice will specify the information needed. Until you supply this additional information, the normal period for making a decision on the claim will be suspended.

Weekly Loss of Time

A Weekly Loss of Time Claim is any claim that satisfies the requirements described in the “Weekly Loss of Time” section of this document.

For a Weekly Loss of Time Claim, the Plan will make a decision on the claim and notify you of the decision within 45 days. If the Plan requires an extension of time due to matters beyond the control of the Plan, the Plan will notify you of the reason for the delay and when the decision will be made. This notification will occur before the expiration of the 45-day period. A decision will be made within 30 days of the time the Plan notifies you of the delay. The period for making a decision may be delayed an additional 30 days, provided the Plan Administrator notifies you, prior to the expiration of the first 30-day extension period, of the circumstances requiring the extension and the date as of which the Plan expects to render a decision.

If an extension is needed because the Plan needs additional information from you, the extension notice

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will specify the information needed. In that case you will have 45 days from receipt of the notification to supply the additional information. If the information is not provided within that time, your claim will be denied. During the period in which you are allowed to supply additional information, the normal period for making a decision on the claim will be suspended. The deadline is suspended from the date of the extension notice until either 45 days or until the date you respond to the request (whichever is earlier). Once you respond to the Plan’s request for the information, you will be notified of the Plan’s decision on the claim within 30 days.

Where, When and to How To File Claims

Claims must be filed within the time frames described in each section below. Your claim will be considered to have been filed as soon as it is received at the address below by the appropriate organization that is responsible for determining the initial determination of the claim. These are as follows:

Where to File Claims Quick ChartBenefit Address Claim Filing Deadline and

Important InformationHospital and Medical

Post-Service

Pre-Service Claims

Obtain a claim form from the Fund Office and send the claim to the address on the form.

See your Certificate of Coverage for details on how to file a claim and timing of claims.

See your Certificate of Coverage for details on how to file a claim and timing of claims

You are generally not required to file a claim in order to be reimbursed for hospital and medical benefits because most claims are submitted directly to the Insurance Company by the PPO or hospital participating providers.

If you use an out-of-network or nonparticipating providers, you must submit a completed claim form. Make sure to use your member ID and account number when you file a claim.

Retail Prescription Drugs

Post-Service Claims only

Submit Retail Prescription Drug claims to:

Using a Participating Pharmacy When you use a participating pharmacy, you will receive a discounted rate on prescribed drugs. Your cost will be the discounted rate charged under the insurance company’s program. After you pay for your prescription, you must submit a claim along

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with your receipt to Envision for reimbursement of the Fund’s portion of the claim. You will be reimbursed 80% (after you satisfy the deductible) of the discounted cost of the drug that you paid at the point of sale.

Using a Non-Participating Pharmacy If you use a non-participating pharmacy, you will be charged the full retail price for the drug. After you pay for your prescription, you must submit a claim along with your receipt to the Envision for reimbursement of the Fund’s portion of the claim.

Dental

Post-Service Claims only

Submit claims to the Fund Office at: Sheet Metal Workers Local Union No. 22 Welfare Fund 106 South Avenue West Cranford, NJ 07016 ALICARE is responsible for processing the claim. They can be reached at: ALICARE Attn: Dental Claims P.O. Box 62467 King of Prussia, PA 19406-0093 Phone No. 1-800-220-526

When you assign dental benefits, you do not have to submit a claim because the provider will submit the claim to ALICARE and they will reimburse the provider directly.

Otherwise, you must submit a claim to the Fund Office.

Optical Post-Service only

If you use a non-participating provider, submit the claim directly to the Fund Office at: Sheet Metal Workers Local Union No. 22 Welfare Fund 106 South Avenue West Cranford, NJ 07016

You do not need to file a claim form for in-network vision care benefits. You simply present your NVAID card at an NVA in-network provider.

Members do have the option of visiting an out-of-network provider for their vision care services. If you choosethis option, you will be

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National Vision Administrators

1200 US-46Clifton, NJ 07013

800-672-7723www.e-nva.com

responsible for all charges payable to the provider at time of service. You mustthen submit a copy of the itemized receipt to NVA for reimbursement according to the proposed reimbursement schedule.

Mail Order Prescription Drugs

Post-Service onlyOptumRx

P.O. Box 2975Mission, KS 66201

On the Web www. optumrx.com

Mail Order Service When you use the mail order service, you will receive up to a 90-day supply of maintenance medication (i.e., medications that you use on an ongoing basis). Please note that all prescriptions for maintenance drugs should be submitted to the mail order program along with payment.

Alcohol and Substance Abuse and Inpatient Mental Health Benefits Pre-Service Claims Mental Health and Substance Abuse Benefits. Post-Service

See your Certificate of Coverage for details on how to file a claim and timing of claims.

Horizon manages all treatment programs relating to alcohol abuse and rehabilitation, substance abuse and mental health treatment. You are required to obtain services from Horizon providers in order to obtain benefits for alcohol, substance abuse and mental health benefits. You must contact Horizon at 1-800-664-2583 to obtain prior authorization for these benefits. Claims should be submitted to the Fund Office for reimbursement. Mental Health and Substance Abuse benefits need to be reviewed by Horizon to determine Medical Necessity and to assure you use an In-Network provider because no Out-of-Network benefits are payable by the Plan for Mental Health and Substance Abuse expenses. Following the procedures will assure that you obtain benefits from an In-Network provider and that

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benefits are payable. There is no dollar penalty for failing to obtain pre-certification. However, if you do not precertify, benefits may be reduced or denied if and when you submit a claim due to a lack of Medical Necessity or because you did not use an In-Network provider (for Mental Health and Substance Abuse Benefits). In addition, in order to obtain Mental Health and Alcohol and Substance Abuse benefits, you must contact Horizon at 1-800-664-2583. No benefits are payable if you fail to contact Horizon and/or do not use an In-Network provider.

Life Insurance and AD&D Contact the Fund Office for information and/or to submit a claim at:

Sheet Metal Workers Local Union No. 22 Welfare Fund 106 South Avenue West Cranford, NJ 07016

Please note that the Union Labor Life Insurance Company is responsible for paying claims. They can be contacted at:

The Union Labor Life Insurance Company 8403 Colesville Road Silver Springs, MD 20910

In order to file a claim for Life and/or AD&D benefits offered under this Plan, you or your beneficiary must submit a completed claim form to the Fund Office.

The Union Labor Life Insurance Company is responsible for paying Life and AD&D claims. However, to claim life insurance or accidental death and dismemberment benefits, you should submit proof of loss (e.g. death certificate) and any other requested documentation to the Fund Office.

Weekly Loss of Time Benefit Contact the Fund Office for information and/or to submit a claim at:

Sheet Metal Workers Local Union No. 22 Welfare Fund 106 South Avenue West Cranford, NJ 07016

To claim a Weekly Loss of Time benefit, contact the Fund Office for a claim form.

Complete the employee section of the form and have your doctor complete the physician section of the form.

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Submit the completed claim form to the Fund Office.

You must be under the care of a physician in order to be eligible for this benefit.

Vacation Benefit Submit the completed form to: Sheet Metal Workers Local Union No. 22 Welfare Fund106 South Avenue West Cranford, NJ 07016

To claim a Vacation benefit, contact the Fund Office for a withdrawal form.

Complete the form and sign it and return it to the Fund Office.

Notice of Decision

You will be provided with written notice of a denial of a claim (whether denied in whole or in part) or any other adverse benefit determination. This notice will state:

• The specific reason(s) for the determination • Reference to the specific Plan provision(s) on which the determination is based • A description of any additional material or information necessary to perfect the claim, and an

explanation of why the material or information is necessary • A description of the appeal procedures and applicable time limits • A statement of your right to bring a civil action under ERISA Section 502(a) following an adverse

benefit determination on review. • If an internal rule, guideline or protocol was relied upon in deciding your claim, you will receive

either a copy of the rule or a statement that it is available upon request at no charge. • If the determination was based on the absence of medical necessity, or because the treatment was

experimental or investigational, or other similar exclusion, you will receive an explanation of the scientific or clinical judgment for the determination applying the terms of the Plan to your claim, or a statement that it is available upon request at no charge.

• For Urgent Care Claims, the notice would describe the expedited review process applicable to Urgent Care Claims. For Urgent Care Claims, the required determination may be provided orally and followed with written notification.

Request For Review of Denied Claim

If your claim is denied in whole or in part, or if any adverse benefit determination is made with respect to your claim, you may ask for a review by contacting one of the following:

Appeals for Medical and Hospital Claims including Pre-service, Urgent and Concurrent claims should be made to:

Insurance Company’s Customer Service Toll-Free number or address that appears on your Benefit Identification card, explanation of benefits or claim form.

See the Insurer’s Certificate of Coverage for the details on the insurer’s procedures for filing appeals. Appeals for all Prescription Drug, Optical, Post-Service Mental Health and Substance Abuse Claims,

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Weekly Loss of Time benefits and Vacation benefit claims should be made to:

Board of Trustees/Appeals SubcommitteeSheet Metal Workers Local Union No. 22 Welfare Fund106 South Avenue West Cranford, NJ 07016

Appeals for Life and AD&D benefits should be made to:

The Union Labor Life Insurance Company8403 Colesville Road Silver Springs, MD 20910

Appeals for Post-Service Dental claims should be made to:

Union Labor Life P.O. Box 62467King of Prussia, PA 19406 1-800-220-5261

Your request for review must be made in writing to the organization responsible for making the claims determination within 180 days after you receive notice of the denial. You may have more time under for medical and Hospital claims. Refer to the organization’s certificate for information.

Review Process

You have the right to review, free of charge, documents relevant to your claim. A document, record or other information is relevant if:

• it was relied upon by the organization responsible for making the claims determination in making the decision;

• it was submitted, considered or generated (regardless of whether it was relied upon); • it demonstrates compliance with the organization’s administrative processes for ensuring consistent

decision making; or • it constitutes a statement of plan policy regarding the denied treatment or service.

Upon request, you will be provided with the identification of medical or vocational experts, if any, that gave advice to the organization on your claim, without regard to whether their advice was relied upon in deciding your claim.

Your claim will be reviewed by a person who is not subordinate to (and shall not afford any deference to) the one who originally made the adverse benefit determination. The decision will be made on the basis of the record, including such additional documents and comments that may be submitted by you.

If your claim was denied on the basis of a medical judgment (such as a determination that the treatment or service was not medically necessary, or was investigational or experimental), a health care professional who has appropriate training and experience in a relevant field of medicine will be consulted.

Timing of Notice of Decision on Appeal

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• All Medical, Hospital and Mental Health and Substance Abuse Claims including Pre-Service (including Urgent and Concurrent) and Post-Service Claims: See the Insurance Company’s Certificate for details about when and how appeals are handled. This Certificate also details the rights you have for “External Appeals for Utilization Management” under New Jersey State law.

• Post-Service Dental: You will receive notice of decision on review within 60 days of receipt of the appeal by ALICARE.

• Post-Service Mental Health and Substance Abuse Benefits, Prescription Drug, Optical and Weekly Loss of Time Weekly Benefits and Vacation benefits: You will receive notice of decision on review within 60 days of receipt of the appeal by the Board of Trustees Appeals Subcommittee.

• Pre-Service Mental Health and Substance Abuse Benefits: You will receive notice of decision

on review within 30 days of receipt of the appeal by Horizon.

• AD&D and Life Insurance Claims: The decision will be made within 60 days of your request for review. An extension of 60 days may be granted for reasons beyond the control of the Union Labor Life Insurance Company. You will be advised in writing within the 60 days after receipt of your request for review if an additional period of time will be necessary to reach a final decision on your AD&D or life insurance claims.

Notice of Decision on Review The decision on any review of your claim will be given to you in writing. The notice of a denial of a claim on review will state:

• The specific reason(s) for the determination • Reference to the specific plan provision(s) on which the determination is based • A statement that you are entitled to receive reasonable access to and copies of all documents

relevant to your claim, upon request and free of charge • A statement of your right to bring a civil action under ERISA Section 502(a) following an adverse

benefit determination on review. • If an internal rule, guideline or protocol was relied upon by the Plan, you will receive either a copy

of the rule or a statement that it is available upon request at no charge. • If the determination was based on medical necessity, or because the treatment was experimental or

investigational, or other similar exclusion, you will receive an explanation of the scientific or clinical judgment for the determination applying the terms of the Plan to your claim, or a statement that it is available upon request at no charge.

Limitation on When a Lawsuit may be Started

You may not start a lawsuit to obtain benefits until after you have requested a review and a final decision has been reached on review, or until the appropriate time frame described above has elapsed since you filed a request for review and you have not received a final decision or notice that an extension will be necessary to reach a final decision. The law also permits you to pursue your remedies under section 502(a) of the Employee Retirement Income Security Act without exhausting these appeal procedures if the Plan has failed to follow them. No lawsuit may be started more than 3 years after the end of the year in which medical or dental services were provided, or, if the claim is for short term disability benefits, more than 3 years after the start of the disability.

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COORDINATION OF BENEFITS

How Duplicate Coverage Occurs

This section describes the circumstances when you or your eligible dependents may be entitled to benefits under this Plan and may also be entitled to recover all or part of your medical and/or dental expenses from some other source. The insurance companies listed in the Plan Information chart maintain their own procedures. See the Insurance Company’s Certificate for details. In many of those cases, either this Plan or the other source (the primary plan or program) pays benefits or provides services first, and the other (the secondary plan or program) pays some or all of the difference between the total cost of those services and payment by the primary plan or program. In other cases, only one plan pays benefits. This can occur if you or a covered Dependent is also covered by:

1. Another group health care plan; 2. Medicare; 3. Other government program, such as Medicaid, TRICARE, or a program of the U.S. Department of

Veterans Affairs, motor vehicle including but not limited to no-fault, uninsured motorist or underinsured motorist coverage for medical expenses or loss of earnings that is required by law, or any coverage provided by a federal, state or local government or agency; or

4. Workers’ compensation.

Duplicate recovery of medical expenses can also occur if there is any other coverage for your medical expenses including third party liability.

This section describes the rules that determine which plan pays first (is primary) and which pays second (is secondary), or when one of the plans is responsible for benefits and the other is not. This Plan operates under rules that prevent it from paying benefits which, together with the benefits from another source you possess (as described above), would allow you to recover more than 100% of expenses you incur. In many instances, you may recover less than 100% of those expenses from the duplicate sources of coverage or recovery.

In some instances, this Plan will not provide coverage if you can recover from some other resource. In other instances, this Plan will advance its benefits, but only subject to its right to recover them if and when you or your covered Dependent actually recover some or all of your losses from a third party (see also the subrogation provisions in this section). Duplicate recovery of medical and/or dental expenses may also occur if a third party caused the injury or illness.

Coverage Under More Than One Group Health Plan

When and How Coordination of Benefits (COB) Applies

1. For the purposes of this Coordination of Benefits section, the word “plan” refers to any group medical or dental policy, contract or plan, whether insured or self-insured, that provides benefits payable on account of medical or dental services incurred by the Covered Individual or that provides medical or dental services to the Covered Individual. A “group plan” provides its benefits or services to employees, retirees or members of a group who are eligible for and have elected coverage.

2. Many families that have more than one family member working outside the home are covered by more than one medical or dental plan. If this is the case with your family, you must let the Fund Office know about all your coverages when you submit a claim.

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3. Coordination of Benefits (or COB, as it is usually called) operates so that one of the plans (called the primary plan) will pay its benefits first. The other plan, (called the secondary plan) may then pay additional benefits. In no event will the combined benefits of the primary and secondary plans exceed 100% of the medical or dental expenses incurred. Sometimes, the combined benefits that are paid will be less than the total expenses.

WHICH PLAN PAYS FIRST: ORDER OF BENEFIT DETERMINATION RULES

The Overriding Rules

Group plans determine the sequence in which they pay benefits, or which plan pays first, by applying a uniform order of benefit determination rules in a specific sequence. This Plan uses the order of benefit determination rules established by the National Association of Insurance Commissioners (NAIC) and which are commonly used by insured and self-insured plans. Any group plan that does not use these same rules always pays its benefits first.

When two group plans cover the same person, the following order of benefit determination rules establish which plan is the primary plan that pays first and which is the secondary plan that pays second. If the first of the following rules does not establish a sequence or order of benefits, the next rule is applied, and so on, until an order of benefits is established. These rules are:

Rule 1: Non-Dependent/Dependent

A. The plan that covers a person as an employee, retiree, member or subscriber (that is, other than as a dependent) pays first; and the plan that covers the same person as a dependent pays second.

B. There is one exception to this rule. If the person is also a Medicare beneficiary, and as a result of the provisions of Title XVIII of the Social Security Act and implementing regulations (the Medicare rules), Medicare is secondary to the plan covering the person as a dependent; and primary to the plan covering the person as other than a dependent (that is, the plan covering the person as a retired employee); then the order of benefits is reversed, so that the plan covering the person as a dependent pays first; and the plan covering the person other than as a dependent (that is, as a retired employee) pays second.

Rule 2: Dependent Child Covered Under More Than One Plan

A. The plan that covers the parent whose Birthday falls earlier in the calendar year pays first; and the plan that covers the parent whose Birthday falls later in the calendar year pays second.

B. If both parents have the same Birthday, the plan that has covered one of the parents for a longer period of time pays first; and the plan that has covered the other parent for the shorter period of time pays second.

C. The word “Birthday” refers only to the month and day in a calendar year; not the year in which the person was born.

D. If the specific terms of a court decree state that one parent is responsible for the child’s health care expenses or health care coverage, and the plan of that parent has actual knowledge of the terms of that court decree, that plan pays first. If the parent with financial responsibility has no coverage for

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the child’s health care services or expenses, but that parent’s current spouse does, the plan of the spouse of the parent with financial responsibility pays first. However, this provision does not apply during any Plan Year during which any benefits were actually paid or provided before the plan had actual knowledge of the specific terms of that court decree.

Rule 3: Active/Laid-Off or Retired Employee

A. The plan that covers a person either as an active employee (that is, an employee who is neither laid-off nor retired), or as that active employee’s dependent, pays first; and the plan that covers the same person as a laid-off or retired employee, or as that laid-off or retired employee’s dependent, pays second.

B. If the other plan does not have this rule, and if, as a result, the plans do not agree on the order of benefits, this rule is ignored.

C. If a person is covered as a laid-off or retired employee under one plan and as a dependent of an active employee under another plan, the order of benefits is determined by Rule 1 rather than by this rule.

Rule 4: Continuation Coverage

A. If a person whose coverage is provided under a right of continuation under federal or state law is also covered under another plan, the plan that covers the person as an employee, retiree, member or subscriber (or as that person’s dependent) pays first, and the plan providing continuation coverage to that same person pays second.

B. If the other plan does not have this rule, and if, as a result, the plans do not agree on the order of benefits, this rule is ignored.

C. If a person is covered other than as a dependent (that is, as an employee, former employee, retiree, member or subscriber) under a right of continuation coverage under federal or state law under one plan and as a dependent of an active employee under another plan, the order of benefits is determined by Rule 1 rather than by this rule.

Rule 5: Longer/Shorter Length of Coverage

A. If none of the four previous rules determines the order of benefits, the plan that covered the person for the longer period of time pays first; and the plan that covered the person for the shorter period of time pays second.

B. To determine how long a person was covered by a plan, two plans are treated as one if the person was eligible for coverage under the second plan within 24 hours after the first plan ended.

C. The start of a new plan does not include a change: 1. in the amount or scope of a plan’s benefits; 2. in the entity that pays, provides or administers the plan; or 3. from one type of plan to another (such as from a single employer plan to a multiple employer

plan).

D. The length of time a person is covered under a plan is measured from the date the person was first covered under that plan. If that date is not readily available, the date the person first became a member of the group will be used to determine the length of time that person was covered under the

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plan presently in force.

How Much This Plan Pays When It Is Secondary

When this Plan pays second, it will pay the same benefits that it would have paid had it paid first, less whatever payments were actually made by the plan (or plans) that paid first. In addition, when this Plan pays second, it will never pay more in benefits than it would have paid for each claim, as it is processed, had it been the Plan that paid first. This has the effect of maintaining this Plan’s Deductibles, Coinsurance, network schedules and exclusions. As a result, when this Plan pays second, you may not receive the equivalent of 100% of the total cost of the covered health care services.

Administration of COB

1. To administer COB, the Plan reserves the right to: exchange information with other plans involved in paying claims; require that you or your Health Care Provider furnish any necessary information; reimburse any plan that made payments this Plan should have made; or recover any overpayment from your Hospital, Physician, Dentist, other Health Care

Provider, other insurance company, you or your Dependent. 2. If this Plan should have paid benefits that were paid by any other plan, this Plan may pay the party

that made the other payments in the amount the Fund Office determines to be proper under this provision. Any amounts so paid will be considered to be benefits under this Plan, and this Plan will be fully discharged from any liability it may have to the extent of such payment.

3. To obtain all the benefits available to you, you should file a claim under each plan that covers the person for the expenses that were incurred. However, any person who claims benefits under this Plan must provide all the information the Plan needs to apply COB.

4. If this Plan is secondary, and if the coordinating primary plan does not cover health care services because they were obtained out-of-network or because the Participant did not follow the rules of the Plan (like obtaining the necessary pre-certification or referrals), benefits for services covered by this Plan will be payable by this Plan to the amount allowable by this Plan less any amount that would have been paid by the primary plan had the Plan Participant obtained the services on an In-Network basis or followed the Primary Plan’s rules. Benefits are only payable to the extent they would have been payable if this Plan were the primary plan and subject to the rules applicable to COB.

5. If this Plan is secondary, and if the coordinating plan is also secondary because it provides by its terms that it is always secondary or excess to any other coverage, or because it does not use the same order of benefit determination rules as this Plan, this Plan will not relinquish its secondary position. However, if this Plan advances an amount equal to the benefits it would have paid had it been the primary plan, this Plan will be subrogated to all rights the Plan Participant may have against the other plan, and the Plan Participant must execute any documents required or requested by this Plan to pursue any claims against the other plan for reimbursement of the amount advanced by this Plan.

Coordination With Medicare

Entitlement to Medicare Coverage

Generally, anyone age 65 or older is entitled to Medicare coverage. Anyone under age 65 who is entitled to Social Security Disability Income Benefits is also entitled to Medicare coverage after a waiting period.

Medicare Participants May Retain or Cancel Coverage Under This Plan

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If you, your covered Spouse or Dependent Child becomes covered by Medicare, whether because of end-stage renal disease (ESRD), disability or age, you may either retain or cancel your coverage under this Plan. If you and/or any of your Dependents are covered by both this Plan and by Medicare, as long as you remain actively employed, your medical expense coverage will continue to provide the same benefits and your contributions for that coverage will remain the same. In that case, this Plan pays first and Medicare pays second.

If you are covered by Medicare and you cancel your coverage under this Plan, coverage of your Spouse and/or your Dependent Child(ren) will terminate, but they may be entitled to COBRA Continuation Coverage. See the COBRA section for further information about COBRA Continuation Coverage. If any of your Dependents are covered by Medicare and you cancel that Dependent’s coverage under this Plan, that Dependent will not be entitled to COBRA Continuation Coverage. The choice of retaining or canceling coverage under this Plan of a Medicare participant is yours, and yours alone. Neither this Plan nor your employer will provide any consideration, incentive or benefits to encourage you to cancel coverage under this Plan.

Coverage Under Medicare and This Plan When You Are Totally Disabled

If you become Totally Disabled and entitled to Medicare because of your disability, you will no longer be considered to remain actively employed. As a result, once you become entitled to Medicare because of your disability, Medicare pays first and this Plan pays second.

Coverage Under Medicare and This Plan When You Have End-Stage Renal Disease

If, while you are actively employed, you or any of your covered Dependents become entitled to Medicare because of end-stage renal disease (ESRD), this Plan pays first and Medicare pays second for 30 months starting the earlier of the month in which Medicare ESRD coverage begins; or the first month in which the individual receives a kidney transplant. Then, starting with the 31st month after the start of Medicare coverage, Medicare pays first and this Plan pays second.

How Much This Plan Pays When It Is Secondary to Medicare

1. When the Plan Participant Is Covered by Medicare Parts A and B: When the Plan participant is covered by Medicare and this Plan is secondary to Medicare, this Plan pays the benefits up to the Plan’s maximums less any amounts paid by Medicare. Benefits payable by this Plan are based on the fees allowed by Medicare and not on the Usual and Customary Charges of the health care provider.

2. When the Plan Participant Is Not Covered by Medicare: If the Plan Participant is eligible for, but is not enrolled in Medicare, this Plan pays benefits less the amounts that would have been paid by Medicare had the Plan Participant been covered by Medicare. Benefits are not based on the Usual and Customary Charges of the provider.

3. When the Plan Participant Enters Into a Medicare Private Contract: Under the law a Medicare participant is entitled to enter into a Medicare private contract with certain Health Care Practitioners under which he or she agrees that no claim will be submitted to or paid by Medicare for health care services and/or supplies furnished by that Health Care Practitioner. If a Medicare participant enters into such a contract. This Plan will NOT pay any benefits for any health care services and/or supplies the Medicare participant receives pursuant to it.

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Coordination with Other Government Programs

Medicaid

If a Covered Individual is covered by both this Plan and Medicaid, this Plan pays first and Medicaid pays second.

TRICARE

If a Covered Dependent is covered by both this Plan and TRICARE, the program that provides health care services to dependents of active armed services personnel, this Plan pays first and TRICARE pays second. For an employee called to active duty for more than 30 days, TRICARE is primary and this plan is secondary.

Veterans Affairs Facility Services

If a Covered Individual receives services in a U.S. Department of Veterans Affairs Hospital or facility on account of a military service-related illness or injury, benefits are not payable by the Plan. If a Covered Individual receives services in a U.S. Department of Veterans Affairs Hospital or facility on account of any other condition that is not a military service-related illness or injury, benefits are payable by the Plan to the extent those services are Medically Necessary and the charges are Usual and Customary.

Other Coverage Provided by State or Federal Law

If you are covered by both this Plan and any other coverage (not already mentioned above) that is provided by any other state or federal law, the coverage provided by any other state or federal law pays first and this Plan pays second.

Workers’ Compensation

This Plan does not provide benefits if the expenses are related to employment, including but not limited to expenses covered by workers’ compensation or occupational disease law. If your employer contests the application of workers’ compensation law for the illness or injury for which expenses are incurred, this Plan will pay benefits, subject to its right to recover those payments if and when it is determined that they are covered under a workers’ compensation or occupational disease law. However, before such payment will be made, you and/or your covered Dependent must execute a subrogation and reimbursement agreement acceptable to the Plan Administrator or its designee.

Advance on Account of Plan Benefits

The Plan does not cover expenses for services or supplies for which a third party is required to pay. (See the exclusion regarding Expenses for Which a Third Party Is Responsible in the Exclusions section), but it will advance payment on account of Plan benefits (hereafter called an “Advance”), subject to its right to be reimbursed to the full extent of any Advance payment from the covered Employee and/or Dependent(s) if and when there is any recovery from any third party. The right of reimbursement will apply:

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1. Even if the recovery is not characterized in a settlement or judgment as being paid on account of the medical or dental expenses for which the Advance was made;

2. Even if the recovery is not sufficient to make the ill or injured employee and/or dependent(s) whole pursuant to state law or otherwise (sometimes referred to as the “make-whole” rule);

3. Without any reduction for legal or other expenses incurred by the employee and/or dependent(s) in connection with the recovery against the third party or that third party’s insurer pursuant to state law or otherwise (sometimes referred to as the “common fund” rule);

4. Regardless of the existence of any state law or common law rule that would bar recovery from a person or entity that caused the illness or injury, or from the insurer of that person or entity (sometimes referred to as the “collateral source” rule).

Reimbursement Agreement

The covered Employee and/or any covered Dependent(s) on whose behalf the Advance is made, must sign and deliver a reimbursement and/or subrogation agreement (hereafter called the “Agreement”) in a form provided by or on behalf of the Plan. If the ill or injured Dependent(s) is a minor or incompetent to execute that Agreement, that person’s parent (in the case of a minor dependent child) or spouse or legal representative (in the case of an incompetent adult) must execute that Agreement upon request by the Plan Administrator or its designee.

If the Agreement is not executed at the Plan Administrator’s request, the Plan may refuse to make any Advance, but if the Plan makes an Advance in the absence of an Agreement, that Advance will not waive, compromise, diminish, release, or otherwise prejudice any of the Plan’s rights.

Cooperation with the Plan by All Covered Individuals

By accepting an Advance, regardless of whether or not an Agreement has been executed, the covered Employee and/or covered Dependent(s) each agree to:

1. Reimburse the Plan for all amounts paid or payable to the covered Employee and/or covered Dependent(s) or that third party’s insurer for the entire amount Advanced; and 2. Do nothing that will waive, compromise, diminish, release, or otherwise prejudice the Plan’s reimbursement and/or subrogation rights; and 3. Notify and consult with the Plan Administrator or designee before starting any legal action or administrative proceeding against a third party based on any alleged negligent or wrongful act that may have caused or contributed to the injury or illness that resulted in the Advance, or entering into any settlement Agreement with that third party or third party’s insurer based on those acts; and 4. Inform the Plan Administrator or its designee of all material developments with respect to all claims, actions, or proceedings they have against the third party.

Subrogation

By accepting an Advance, the covered Employee and/or covered Dependent’s jointly agree that the Plan will be subrogated to the covered employee and/or covered dependent’s right of recovery from a third party or that third party’s insurer for the entire amount Advanced, regardless of any state or common law rule to the contrary, including without limitation, a so-called collateral source rule (that would have the effect of prohibiting the Plan from recovering any amount). This means that, in any legal action against a third party who may have caused the injury or illness that resulted in the Advance, the Plan may be substituted in place of the covered Employee and/or covered Dependent(s), but only to the extent of the amount of the Advance.

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Under its subrogation rights, the Plan may, at its discretion: • start any legal action or administrative proceeding it deems necessary to protect its right to recover

its Advances, and try or settle that action or proceeding in the name of and with the full cooperation of the covered Employee and/or covered Dependent(s), but in doing so, the Plan will not represent, or provide legal representation for the covered Employee and/or covered Dependent(s) with respect to their damages that exceed any Advance; or

• intervene in any claim, legal action, or administrative proceeding started by the covered Employee or covered Dependent(s) against any third party or third party’s insurer on account of any alleged negligent or wrongful action that may have caused or contributed to the injury or illness that resulted in the Advance.

Remedies Available to the Plan

If the covered Employee or covered Dependent(s) does not reimburse the Plan as required by this provision, the Plan may, at its sole discretion:

1. apply any future Plan benefits that may become payable on behalf of the covered Employee and/or covered Dependent(s) to the amount not reimbursed; or

2. obtain a judgment against the covered Employee and/or covered Dependent(s) for the amount Advanced and not reimbursed, and garnish or attach the wages or earnings of the covered Employee and/or covered Dependent(s).

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CONTINUATION OF COVERAGE

Continuation Through COBRA

A federal law, the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA), allows you and your covered dependents to continue health care coverage at your own expense under certain circumstances when health care coverage would otherwise end. Your COBRA rights are subject to change. Coverage will be provided only as required by law. If the law changes, your rights will change accordingly.

Under COBRA, you and your covered dependents may continue the same health coverage that you had before the COBRA-qualifying event, including:

• Medical coverage. • Hospital coverage. • Prescription drug coverage. • Dental coverage • Optical coverage.

COBRA Eligibility (COBRA Qualifying Events)

For You

COBRA coverage is available to you if coverage would otherwise end if:

• You do not work the required number of hours to maintain participation in the Fund’s health insurance benefits program.

• Your employment ends for any reason other than gross misconduct.

For Your Dependents

COBRA coverage is available to your covered dependents if coverage would otherwise end if: • You do not work the required number of hours to maintain participation in the Fund’s health

insurance benefits program. • You (the active member) end employment for any reason other than gross misconduct. • You (the active member) die or get divorced. • Your dependent child ceases to be eligible for Fund coverage, for example, he or she reaches the

maximum age limit for coverage.

Taking leave under the Family and Medical Leave Act (FMLA) does not constitute a qualifying event. However, failure to return to work with your employer at the end of the FMLA leave will constitute a qualifying event to the extent that coverage is lost, prior to the end of what would be your COBRA maximum coverage period, under the Plan.

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How COBRA Coverage Works

The following is the name, address and telephone number of the office responsible for administering COBRA Continuation Coverage:

Sheet Metal Workers Local 22 Welfare Fund PO Box 308 106 South Avenue West

Cranford, New Jersey 07016 (908) 276-2320

In order to protect your family’s rights, you should keep the Fund Manager/Fund Office 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 Fund Manager/Fund Office.

Providing Notice of Qualifying Events

Your employer will usually notify the Fund Office of your death, termination of employment, reduction in hours or retirement. However, you or your family should also notify the Fund Office promptly and in writing if any such event occurs in order to avoid confusion over the status of your or their health care in the event there is a delay or oversight in providing that notification. It is also important that you notify the Fund Office of a COBRA-qualifying event in your life or in the life of your spouse and/or dependent child(ren) so that they can provide you and/or them with a certificate of creditable coverage.

The time period in which your employer must notify the Fund Office of your death, termination of employment, reduction in hours or retirement, will begin to run from the date of your loss of coverage and not the date of the qualifying event.

You and/or a family member are responsible for providing the Fund Office with timely notice of the following qualifying events:

1. The divorce or legal separation of the covered employee from his or her spouse. 2 A child ceasing to be covered under the plan as a dependent child of the covered employee. 3. The occurrence of a second qualifying event after a qualified beneficiary has become entitled to

COBRA with a maximum of 18 (or 29) months. This second qualifying event could include the covered employee’s death, divorce or a child losing dependent status. In addition to these qualifying events, there are two other situations where you and/or a family member must provide the Fund Office with notice within the timeframe noted in this section:

4. When a qualified beneficiary entitled to receive COBRA coverage with a maximum of 18 months has been determined by the Social Security Administration to be disabled. If the determination is made that an individual is disabled at any time during the first 60 days of COBRA coverage, the qualified beneficiary (and each other qualified beneficiary entitled to the 18-month period of COBRA due to the same initial event) may be eligible for an 11-month extension of the 18 months maximum coverage period, for a total of 29 months of COBRA coverage.

5. When the Social Security Administration determines that a qualified beneficiary is no longer disabled.

You must make sure that the Fund Manager is notified of any of these five occurrences listed above. Failure to provide this notice within the form and timeframes described below may prevent you and/or your dependents from obtaining or extending COBRA coverage.

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Manner in Which You Must Provide Notice

The notice of any of the above five situations must be provided in writing. You may use a form that the Fund Office maintains, or you may send a letter to the Fund Office containing the following information: your name, for which of the five events listed on the prior page you are providing notice, the date of the event, and the supporting documentation. Notice should be sent to:

Sheet Metal Workers Local 22 Welfare Fund PO Box 308 106 South Avenue West

Cranford, New Jersey 07016 (908) 276-2320

The notice may be sent first class mail or hand-delivered.

When the Notice Should Be Sent

If you are providing notice due to a divorce or legal separation, a dependent losing eligibility for coverage or a second qualifying event, you must send the notice no later than 60 days after the latest of (1) the date upon which coverage would be lost under the plan as a result of the qualifying event, (2) the date of the qualifying event.

If you are providing notice of a Social Security Administration determination of disability, notice must be sent no later than 60 days after the later of (1) the date of the disability determination by the Social Security Administration or (2) the date on which the qualified beneficiary is informed through the furnishing of a summary plan description or initial COBRA notice of the responsibility to provide the notice and the procedures for providing this notice to the Fund Manager. Notwithstanding the previous sentence, notice must be sent no later than the end of the first 18 months of continuation coverage.

If you are providing notice of a Social Security Administration determination that you are no longer disabled, notice must be sent no later than 30 days after the later of: (1) the date of the determination by the Social Security Administration that you are no longer disabled; or (2) the date on which the qualified beneficiary is informed through the furnishing of a summary plan description or initial COBRA notice of the responsibility to provide the notice and the procedures for providing this notice to the Fund Manager.

If the notice has not been received by the Fund by the end of the applicable period described above, you and/or your spouse and/or dependent will not be entitled to choose/extend COBRA Continuation Coverage.

Who May Provide a Notice

Notice may be provided by the covered employee, qualified beneficiary with respect to the qualifying event, or any representative acting on behalf of the covered employee or qualified beneficiary. Notice from one individual will satisfy the notice requirement for all related qualified beneficiaries affected by the same qualifying event. For example, if you, the employee, your spouse and your child are all covered by the Plan, and you and your spouse decide to legally separate, a single notice sent by your spouse would satisfy this requirement.

Once you have provided notice, the Fund Office will send you information about COBRA coverage.

How to Elect COBRA Continuation Coverage 81

When your employment terminates or you no longer work enough hours to be entitled to coverage under the Plan, or when the Fund Office is notified on a timely basis that you died, divorced, or legally separated, became entitled to Medicare (and voluntarily dropped Fund coverage), or that a dependent child lost dependent status under the Plan, the Fund Office will give you and/or your covered dependents notice of the date on which your coverage ends and the information and forms you need to elect COBRA Continuation Coverage.

Under the law, you and/or your covered dependents will then have only 60 days from the date you or they receive that notice to apply for COBRA Continuation Coverage.

IF YOU AND/OR ANY OF YOUR COVERED DEPENDENTS DO NOT CHOOSE COBRA CONTINUATION COVERAGE WITHIN THIS 60-DAY PERIOD, YOU AND/OR THEY WILL NOT HAVE ANY GROUP HEALTH COVERAGE FROM THIS PLAN AFTER COVERAGE INITIALLY ENDED.

If you notified the Fund Office of a qualifying event and you are not entitled to COBRA coverage, the Fund Office will send you a written notice stating the reason you are not eligible for COBRA. The Fund Office will provide this notice within 14 days after its receipt of your notice of a qualifying event.

Each Qualified Beneficiary has an independent right to elect COBRA Continuation Coverage. One or more covered dependents may elect COBRA even if the employee does not elect it. One member of the family may elect COBRA for other members of the family. COBRA Continuation Coverage may be elected for some members of the family and not others. In order to elect COBRA Continuation Coverage, the persons for whom COBRA is being elected must have been covered by the Plan on the date of the Qualifying Event. A parent or legal guardian may elect or reject COBRA Continuation Coverage on behalf of covered dependent children.

The COBRA Continuation Coverage that will be Provided

If you choose COBRA Continuation Coverage, you will be entitled to the same health coverage that you had when the event occurred that caused your health coverage under the Plan to end, but you must pay for it. See the sections entitled “Cost of COBRA Continuation Coverage” and “Paying for COBRA Coverage” below for information about how much COBRA will cost you and about grace periods for payment of those amounts. If there is a change in the health coverage provided by the Plan to similarly situated active employees and their families, that same change will be made in your COBRA Continuation Coverage.

Cost of COBRA Coverage

Individuals who continue full coverage under COBRA pay 102% of the Plan’s cost, on an aftertax basis, except in cases of extended COBRA coverage due to Social Security disability. See the section entitled “COBRA Coverage in Cases of Social Security Disability” for details.

Paying for COBRA Coverage

The amount you, your covered spouse, and/or your covered dependent child(ren) must pay for COBRA coverage will be payable monthly. The Plan is permitted to charge the full cost of coverage for similarly situated active employees and families, plus an additional 2% (for a total charge of 102%). The COBRA Continuation Coverage charge is different in cases of extended COBRA coverage due to Social Security disability. See the section entitled “Cost of COBRA Coverage in Cases of Social Security Disability”

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below for further information.

The Fund Office will notify you of the cost of the coverage at the time you receive your notice of entitlement to COBRA coverage, and of any monthly COBRA premium amount changes. The cost of COBRA Continuation Coverage may be subject to future increases during the period it remains in effect.

There will be an initial grace period of 45 days to pay the first amounts due starting with the date COBRA coverage was elected. If this payment is not made when due, COBRA Continuation Coverage will not take effect. After that, payments are due on the first day of each month. There will then be a grace period of 30 days to pay these monthly payments. If payment of the amount due is not made by the end of this grace period, your COBRA coverage will terminate.

COBRA AT-A-GLANCE

Medicare entitlement is not a qualifying event under this plan. Such Medicare entitlement following a termination of employment or reduction in hours will not extend a dependent qualified beneficiary’s COBRA coverage to 36 months.

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Duration of COBRA Coverage

Your COBRA coverage can continue for up to 18, 29, or 36 months depending on the COBRA-qualifying event.

The COBRA Continuation Coverage period begins on the date you and/or your covered dependents lose coverage (rather than on the date of the qualifying event).

COBRA Coverage in Cases of Social Security Disability

If you, your spouse, or any of your covered dependent child(ren) are entitled to COBRA coverage for an 18-month period, that period can be extended for the Covered Person who is determined to be entitled to Social Security Disability Income benefits, and for any other covered family members, for up to 11 additional months (for a total of 29 months) if all of the following conditions are satisfied:

• The disability occurred on or before the start of COBRA coverage, or within the first 60 days of COBRA coverage.

• The disabled Covered Person receives a determination of entitlement to Social Security Disability Income benefits from the Social Security Administration.

• The Plan is notified by you or your eligible dependent that the determination was received: -No later than 60 days after it was received; and -Before the 18-month COBRA continuation period ends.

• The last day of the month, 30 days after Social Security has determined that you and/or your eligible dependent(s) are no longer disabled.

• The end of 29 months from the date of loss of coverage due to the COBRA qualifying event. • The date the disabled individual becomes entitled to Medicare.

This extended period of COBRA coverage will end at the earlier of:

Cost of COBRA Coverage in Cases of Social Security Disability

If the 18-month period of COBRA Continuation Coverage is extended because of Social Security disability, the Plan will charge members and their families 150% of the cost of coverage for the COBRA family unit that includes the disabled person for the 11-month Social Security disability extension period. Any family units that do not include the disabled person will be charged 102% of the cost of coverage.

Acquiring a New Dependent(s) While Covered by COBRA

If you, your spouse, or your dependent child elects COBRA and acquires a new dependent through marriage, birth, adoption or placement for adoption while enrolled in COBRA Continuation Coverage, that person may add the dependent to COBRA coverage for the balance of the COBRA coverage period. For example, if you have five months of COBRA left and you get married, you can enroll your new spouse for five months of COBRA coverage.

To enroll your new dependent for COBRA coverage, notify the Fund Office as soon as possible within 31 days after acquiring the new dependent. There may be a change in your COBRA premium amount in order to cover the new dependent.

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If COBRA coverage ceases for you, your spouse or your dependent child before the end of the maximum 18, 29, or 36-month COBRA coverage period, COBRA coverage also will end for the newly added dependent. Check with the Fund for more details on how long COBRA coverage can last.

Loss of Other Group Health Plan Coverage or other Health Insurance Coverage

If, while you are enrolled in COBRA Continuation Coverage, your spouse or dependent child loses coverage under another group health plan, you may enroll the spouse or dependent child for coverage for the balance of the period of COBRA Continuation Coverage. The spouse or dependent must have been eligible but not enrolled for coverage under the terms of the plan and, when enrollment was previously offered under the plan and declined, the spouse or dependent must have been covered under another group health plan or had other health insurance coverage.

You must enroll the spouse or dependent. Adding a spouse or dependent child may cause an increase in the amount you must pay for COBRA Continuation Coverage.

The loss of coverage must be due to exhaustion of COBRA Continuation Coverage under another plan, termination as a result of loss of eligibility for the coverage, or termination as a result of employer contributions toward the other coverage being terminated. Loss of eligibility does not include a loss due to failure of the individual or participant to pay premiums on a timely basis or termination of coverage for cause.

Multiple Qualifying Events While Covered by COBRA

If, during an 18-month period of COBRA Continuation Coverage resulting from loss of coverage because of your termination of employment or reduction in hours, you die, or if a covered child ceases to be a dependent child under the Plan, the maximum COBRA Continuation period for the affected spouse and/or child is extended to up to 36 months from the date of loss of coverage due to the occurrence of your termination of employment or reduction of hours.

For example, assume you lose your job (the first COBRA-qualifying event), and you enroll yourself and your eligible dependents for COBRA coverage. Three months after your COBRA coverage begins, you divorce and your former spouse is no longer eligible for Plan coverage. Your former spouse can continue COBRA coverage for 33 months, for a total of 36 months of COBRA coverage.

This extended period of COBRA Continuation Coverage is not available to anyone who became your spouse after your loss of coverage due to the termination of employment or reduction of hours. However, this extended period of COBRA Continuation Coverage is available to any child(ren) born to, adopted by, or placed for adoption with you (the active member) during the 18-month period of COBRA Continuation Coverage.

In no case are you entitled to COBRA Continuation Coverage for more than a total of 18 months if your employment is terminated or if you have a reduction in hours (unless you are entitled to an additional COBRA Continuation Coverage period on account of Social Security disability). As a result, if you experience a reduction of hours then have a termination of employment, the termination of employment is not treated as a second qualifying event and COBRA may not be extended beyond 18 months from the date of loss of coverage due to the occurrence of the initial qualifying event.

Termination of Employment/Reduction of Hours Following Medicare Entitlement

If a qualifying event that is a termination of employment or reduction in hours occurs less than 18

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months after the date you become entitled to Medicare (Part A, Part B or both), the period of coverage for your dependents who are qualified beneficiaries will last until 36 months after the date of your Medicare entitlement.

When COBRA Coverage Will Be Cut Short

Once COBRA coverage has been elected, it will be cut short on the occurrence of any of the following events:

• The first day of the time period for which you don’t pay the COBRA premiums within the required time period.

• The date on which the Plan is terminated. • The date, after the date of the COBRA election, on which you or your eligible dependent(s) first

become covered by another group health plan and that plan does not contain any legally applicable exclusion or limitation with respect to a preexisting condition that the Covered Person may have.

• The date, after the date of the COBRA election, on which you or your eligible dependent(s) first become entitled to (enrolled in) Medicare (usually age 65).

• If you and/or your family members have the 11-month extension for Social Security disability and the person is deemed no longer disabled by SSA.

If COBRA coverage is cut short as described above, the Fund Manager will send you a written notice as soon as practicable following his or her determination that COBRA coverage will terminate. The notice will set out why COBRA coverage will terminate early, the date of termination, and your rights, if any, to alternative individual or group coverage.

When COBRA Coverage Ends

Your COBRA coverage ends on the earliest of the date that:

•Any of the above-listed events occurs. •The COBRA period (18, 29, or 36 months) ends.

Entitlement to Convert to an Individual Health Plan after COBRA Ends

At the end of the 18-month or 36-month period of COBRA Continuation Coverage, you will be allowed to enroll in an individual conversion health plan as provided by the Plan, if that right is offered by the Plan at the time your COBRA Continuation Coverage period runs out. However, no conversion rights are available for the dental, vision or prescription drug coverages.

You will be advised if conversion rights are available when your COBRA Continuation Coverage ends by the insurance company.

Keep the Fund Informed of Address Changes

In order to protect your family’s rights, you should keep the Fund 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 Fund Administrator.

In considering whether to elect continuation coverage, you should take into account that a failure to continue your group health coverage will affect your future rights under federal law. First, you can lose

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the right to avoid having pre-existing condition exclusions applied to you by other group health plans if you have more than a 63-day gap in health coverage, and election of continuation coverage may help you not have such a gap. Second, you will lose the guaranteed right to purchase individual health insurance policies that do not impose such pre-existing condition exclusions if you do not get continuation coverage for the maximum time available to you. Finally, you should take into account that you have special enrollment rights under federal law. You have the right to request special enrollment in another group health plan for which you are otherwise eligible (such as a plan sponsored by your spouse’s employer) within 30 days after your group health coverage ends because of the qualifying events listed above. You will also have the same special enrollment right at the end of the continuation coverage if you get continuation coverage for the maximum time available to you.

FMLA and COBRA

Taking a leave under the Family and Medical Leave Act (FMLA) is not a COBRA qualifying event. A qualifying event can occur after the FMLA period expires, if the person does not return to work and thus loses coverage under their group health plan. Then the COBRA period is measured from the date of the qualifying event—in most cases, the last day of the FMLA leave. Note that if the Participant notifies the Employer that they are not returning to employment prior to the expiration of the applicable maximum FMLA 12 or 26 week period, a loss of coverage could occur earlier.

Additional COBRA Election Period & Tax Credit in Cases Of Eligibility for Benefits Under the Trade Act of 1974

The Trade Act of 2002 created a tax credit for certain individuals who become eligible for trade adjustment assistance and for certain retired employees who are receiving pension payments from the Pension Benefit Guaranty Corporation (PBGC). Under the tax provisions, eligible individuals can either take a tax credit or get advance payment of 65% of premiums paid for qualified health insurance, including continuation coverage. ARRA made several amendments to these provisions, including an increase in the amount of the credit to 80% of premiums for coverage before January 1, 2011 and temporary extensions of the maximum period of COBRA continuation coverage for PBGC recipients (covered employees who have a nonforfeitable right to a benefit any portion of which is to be paid by the PBGC) and TAA-eligible individuals. However, electing the ARRA premium reduction disqualifies you from receiving this tax credit.

If you have questions about these provisions, you may call the Health Coverage Tax Credit Customer Contact Center toll-free at 1-866-628-4282. TTD/TTY callers may call toll-free at 1866-626-4282. More information about the Trade Act is also available at www.doleta.gov/tradeact.]

Certificate of Creditable Coverage when Coverage Ends

When your coverage ends you and/or your covered dependents are entitled by law to, and will be provided with, a certificate of creditable coverage. Certificates of creditable coverage indicate the period of time you and/or your dependent(s) were covered under the Plan (including, if applicable, COBRA coverage), as well as certain additional information required by law. This certificate may be necessary if you and/or your dependent(s) become eligible for coverage under another group health plan, or if you buy for yourself and/or your covered dependents a health insurance policy within 63 days after your coverage under this Plan ends (including, if applicable, COBRA coverage). The certificate is necessary because it may reduce any exclusion for pre-existing conditions that may apply to you and/or your covered dependents under the new group health plan or health insurance policy.

This certificate will be provided to you shortly after this Plan knows, or has reason to know, that

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coverage (including COBRA coverage) for you and/or your covered dependent(s) has ended. The Fund Office will send you (or any of your covered dependents) a certificate by first class mail shortly after your or their coverage under this Plan ends. If you (or any of your covered dependents) elect COBRA coverage, another certificate will be sent to you (or them if COBRA coverage is provided only to them) by first class mail shortly after the COBRA coverage ends for any reason.

Please address all requests for certificates of creditable coverage to the Fund Office.

If You Have Questions

Questions concerning the Plan or your COBRA coverage rights should be addressed to the Fund Administrator 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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GENERAL PROVISIONS

The following information will help you properly identify your Plan if you have any questions about your benefits. It also provides other important information about your benefits.

OFFICIAL NAME OF THE PLAN

Sheet Metal Workers Local 22 Welfare Fund

NAME AND ADDRESS OF PLAN SPONSOR MAINTAINING THE PLAN

Board of TrusteesSheet Metal Workers Local Union No. 22 Welfare Fund 106 South Avenue West Cranford, New Jersey, 07016

A complete list of the employers sponsoring the Plan may be obtained by participants upon written request to the Plan Administrator and is available for examination by Plan participants.

EMPLOYER IDENTIFICATION NUMBER 22-1505-211

PLAN NUMBER 501

TYPE OF PLAN

Employee Welfare Benefits Plan including: 1. Medical expense benefits; 2. Dental expense benefits; 3. Vision expense benefits; 4. Prescription Drug expense benefits; 5. Accidental Death and Dismemberment expense benefits; 6. Life Insurance expense benefits; 7. Weekly Loss of Time benefits; and 8. Vacation benefits.

TYPE OF FUNDING AND ADMINISTRATION:

Sheet Metal Workers Local 22 Welfare Fund is liable for Vision, and Prescription Drug, Dental, Weekly Loss of Time Benefits and Vacation benefits under the Plan. The Dental Benefits are administered by ALICARE or Eastern Dental. The Accidental Death and Dismemberment and Life Insurance benefits are insured and administered by Union Labor Life Insurance Company, 8403 Colesville Road Silver Springs, MD 20910.

All contributions to the Plan are made by employers in accordance with their collective bargaining agreements with the Sheet Metal Workers Local 22. The Fund Administrator will provide you, upon written request, information as to whether a particular employer is contributing to this Plan on behalf of participants working under the collective bargaining agreement.

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The collective bargaining agreement requires contributions to the Plan at fixed rates. You may request in writing, a copy of the collective bargaining agreement from the Fund Administrator and a copy is also available for examination by participants and dependents at the Fund Office.

Benefits are provided from the Fund’s assets, which are accumulated under the provisions of the Collective Bargaining Agreement and the Trust Agreement and held in a Trust Fund for the purpose of providing benefits to covered participants and defraying reasonable administrative expenses.

INCOME AND RESERVES:

Contributions made to the Fund are held in a Trust Fund and are used solely for the purpose of providing benefits to eligible members and for reasonable administrative expenses.

PLAN ADMINISTRATOR

Board of Trustees Sheet Metal Workers Local 22 Welfare Fund 106 South Avenue West Cranford, NJ 07016

Medical, hospital, accidental death and dismemberment and life insurance benefits are insured according to chart at front of the booklet

AGENT FOR SERVICE OF LEGAL PROCESS

For disputes arising under the Plan, service of legal process may be made on the Board of Trustees: Board of Trustees Sheet Metal Workers Local 22 106 South Avenue West Cranford, NJ 07016

Service of legal process may be made upon an individual Plan Trustee or the Fund Administrator. With respect to the life insurance and accidental death and dismemberment coverage, service may also be made upon Union Labor Life Insurance Company at its local office. Insured medical/hospital service may be upon the insurer. Service may also be made upon the supervisory official of the Insurance Department in the state in which you reside.

PLAN TRUSTEES

The Trustees of the Plan are:

Union Trustees Employer Trustees

David Castner Mario CavalloneSheet Metal Workers Local 22 Air Side Inc.106 South Avenue West 246 Brighton RoadCranford, NJ 07016 Andover, NJ 07821

James O’Reilley Andrew NovakSheet Metal Workers Local 22 International S/M & Plate106 South Avenue West P.O. Box 506Cranford, NJ 07016 Somerville, NJ 08876

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Jason Rooney Gregg WheatleySheet Metal Workers Local 22 Westfield Sheet Metal106 South Avenue West Monroe Avenue & 8th StreetCranford, NJ 07017 Kenilworth, NJ 07033

PLAN YEAR

The Plan’s fiscal records are kept on a Plan Year that is the twelve-month period beginning each June 1 and ending on the following May 31.

INFORMATION YOU OR YOUR DEPENDENTS MUST FURNISH TO THE PLAN (Very Important Information)

In addition to information you must furnish in support of any claim for Plan benefits under this Plan, you or your covered Dependents must furnish information you or they may have that may affect eligibility for coverage under the Plan. If you fail to do so, you or your covered Dependents may lose the right to obtain COBRA Continuation Coverage or to continue coverage of a Dependent Child who has a physical or mental Handicap.

Submit such information in writing to the Plan Administrator at the address shown in the Quick Reference chart in the Introduction section of this document. The information needed and timeframes for submitting such information are outlined below:

PLAN CONTRACTS GOVERN

The hospital, medical, accidental death and dismemberment, and life insurance benefits described in this booklet are subject to the terms, conditions, exclusions and limitations of the contracts issued to the Fund by the following carriers:

Hospital and Medical Benefits Horizon BCBC Life Insurance Union Labor Life Insurance Accidental Death and Dismemberment Union Labor Life Insurance

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RIGHT TO AMEND TO TERMINATE THE PLAN

The Sheet Metal Workers Local 22 Welfare Fund reserves the right to amend, modify, suspend or terminate this Plan, or any part of it, at any time. Amendments may be made in writing by the Board of Trustees and become effective on the date of adoption or on any other date as may be specified in the document amending the Plan. At any time, the Plan or any coverage under it may be terminated by the Board of Trustees and new coverage may be added by the Board of Trustees. If the Plan terminates, the Trustees will apply the assets of the Fund to provide benefits or otherwise to carry out the purposes of the Fund in an equitable manner until the entire remainder of the Fund has been disbursed. The type and amount of Fund benefits are always subject to the actual terms of the Plan as it exists at the time the claim occurs.

DISCRETIONARY AUTHORITY OF THE TRUSTEES AND DESIGNEES

In carrying out their respective responsibilities under the Plan, the Board of Trustees, and other Plan fiduciaries and individuals to whom responsibility for the administration of the Plan has been delegated, have discretionary authority to interpret the terms of the Plan and to determine eligibility and entitlement to Plan benefits in accordance with the terms of the Plan, and to decide any fact related to eligibility for an entitlement to Plan benefits. Any interpretation or determination under such discretionary authority will be given full force and effect, unless it can be demonstrated that the interpretation or determination was arbitrary and capricious.

NO LIABILITY FOR PRACTICE OF MEDICINE OR DENTISTRY

The Plan, the Board of Trustees, or any of their designees are not engaged in the practice of medicine or dentistry, nor do any of them have any control over any diagnosis, treatment, care or lack thereof, or any health care services provided or delivered to you by any health care provider. Neither the Plan, the Board of Trustees, nor any of their designees, will have any liability whatsoever for any loss or injury caused to you by any health care provider by reason of negligence, by failure to provide care or treatment, or otherwise.

PRIVACY, CONFIDENTIALITY, RELEASE OF RECORDS OR INFORMATION

This Plan operates in compliance with the Health Insurance Portability and Accountability Act (HIPAA) of 1996, which requires group health plans to protect certain individual health information.

A federal law, the Health Insurance Portability and Accountability Act of 1996 (HIPAA), requires that health plans like the Sheet Metal Workers Local 22 Welfare Fund protect the confidentiality of your private health information. A complete description of your rights under HIPAA can be found in the Plan’s Notice of Privacy Practices, which was distributed to you upon enrollment and is available from the Plan Administrator. This statement is not intended and cannot be construed as the Plan’s Notice of Privacy Practices.

This Plan, and the Plan Sponsor, will not use or further disclose information that is protected by HIPAA (“protected health information”) except as necessary for treatment, payment, health Plan operations and Plan administration, or as permitted or required by law. In particular, the Plan will not, without your written authorization, use or disclose protected health information for employment-related actions and decisions or in connection with any other benefit or employee benefit plan of the Plan Sponsor.

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The Plan also hires professionals and other companies to assist it in providing health care benefits. The Plan has required these entities, called “Business Associates,” to observe HIPAA’s privacy rules. In some cases, you may receive a separate notice from one of the Plan’s Business Associates. It will describe your rights with respect to benefits provided by that company.

Under federal law, you have certain rights with respect to your protected health information, including certain rights to see and copy the information, receive an accounting of certain disclosures of the information, and under certain circumstances amend the information. You have the right to request reasonable restrictions on disclosure of information about you, and to request confidential communications. You also have the right to file a complaint with the Plan or with the Secretary of the Department of Health and Human Services if you believe your rights have been violated.

This Plan maintains a Notice of Privacy Practices which provides a complete description of your rights under HIPAA’s privacy rules. For a copy of the Notice, please contact the Plan Administrator. If you have questions about the privacy of your health information please contact the Plan’s Privacy Official. If you wish to file a complaint about a privacy issue, please contact the Plan’s Privacy Official.

PLAN’S PRIVACY AMENDMENT

Use and Disclosure of Protected Health Information

A. Use and disclosure of Protected Health Information (PHI): The Plan will use protected health information to the extent and in accordance with the uses and disclosures permitted by the Health Insurance Portability and Accountability Act of 1996 (HIPAA). Specifically, the Plan will use and disclose protected health information for purposes related to health care treatment, payment for health care, and health care operations.

“Payment” includes activities undertaken by the Plan to obtain premiums or determine or fulfill its responsibility for coverage and provision of Plan benefits that relate to an individual to whom health care is provided. These activities include, but are not limited to, the following:

1. Determination of eligibility, coverage, and cost sharing amounts (e.g. cost of a benefit, Plan maximums, and copayments as determined for an individual’s claim),

2. Coordination of benefits with other health plans, 3. Adjudication of health benefit claims, including appeals and other payment disputes, 4. Subrogation of health benefit claims, 5. Establishing contribution rates for contributing employers, including risk adjusting amounts as

necessary based on enrollee health status and demographic characteristics, 6. Establishing employee contribution rates as necessary, 7. Billing, collection activities and related health care data processing, 8. Claims management and related health care data processing, including auditing payments,

investigating and resolving payment disputes, 9. Responding to participant and beneficiary (and their authorized representatives’) inquiries about

payments, 10. Obtaining payment under a contract for reinsurance, including stop-loss and excess of loss

insurance, 11. Medical necessity reviews, or reviews of appropriateness of care or justification of charges, 12. Utilization review, including precertification, preauthorization, concurrent review and retrospective

review,

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13. Coordination of benefits, 14. Disclosure to consumer reporting agencies related to collection of premiums or reimbursement (the

following PHI may be disclosed for payment purposes: name and address, date of birth, social security number, payment history, account number, and name and address of the provider and/or health Plan), and

15. Reimbursement of individual overpayments to the Plan.

Health Care Operations include, but are not limited to, the following activities:

1. Quality Assessment, 2. Population-based activities relating to improving health or reducing health care costs, protocol

development, case management and care coordination, 3. Disease management, including asthma, diabetes and cardiac disease management, 4. Contacting of health care providers and patients with information about treatment alternatives and

related functions, 5. Rating provider and Plan performance, including accreditation, certification, licensing, or

credentialing activities, 6. Underwriting, premium rating, and other activities relating to the creation, renewal and/or

replacement of a contract of health insurance or health benefits, 7. Ceding, securing, or placing a contract for reinsurance of risk relating to claims for health care

(including stop-loss insurance and excess of loss insurance), and administration of the stop-loss contract (including claims processing),

8. Conducting or arranging for medical review, and legal services, 9. Conducting or arranging for auditing functions, including carrier audits, audits of the self insured

health benefit program, fraud and abuse detection and compliance programs, 10. Business planning and development, such as conducting cost-management and planning-related

analyses related to managing and operating the entity, including formulary development and administration, development or improvement of methods of payment or coverage policies,

11. Business management and administrative activities of the entity, including, but not limited to: a. Management activities relating to implementation of and compliance with the requirements of

HIPAA Administrative Simplification, b. Customer service, including the provision of data analyses for policyholders, Plan sponsors, or

other customers, c. Resolution of internal grievances, and d. Due diligence in connection with the sale or transfer of assets to a potential successor in interest,

if the potential successor in interest is a covered entity or, following completion of the sale or transfer, will become a covered entity.

12. Compliance with and preparation of all documents as required by the Employee Retirement Income Security Act of 1974 (ERISA), including Form 5500’s, SAR’s, and other documents.

B. The Plan will use and disclose PHI as required by law and as permitted by authorization of the participant or beneficiary. With an authorization, the Plan will disclose PHI, as indicated on the authorization.

C. For purposes of this section the Board of Trustees of Sheet Metal Workers Local 22 Health and Welfare Fund is the “Plan Sponsor.” The Plan will disclose PHI to the Plan Sponsor only upon receipt of a certification from the Plan Sponsor that the Plan documents have been amended to incorporate the following provisions.

With respect to PHI, the Plan Sponsor agrees to:

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1. Not use or further disclose the information other than as permitted or required by the Plan Document or as required by law,

2. Ensure that any agents, including a subcontractor, to whom the Plan Sponsor provides PHI received from the Plan agree to the same restrictions and conditions that apply to the Plan Sponsor with respect to such information,

3. Not use or disclose the information for employment-related actions and decisions unless authorized by the individual,

4. Not use or disclose the information in connection with any other benefit or employee benefit Plan of the Plan Sponsor unless authorized by the individual,

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

6. Make PHI available to the individual in accordance with the access requirements of HIPAA, 7. Make PHI available for amendment and incorporate any amendments to PHI in accordance with

HIPAA, 8. Make available the information required to provide an accounting of disclosures, 9. Make internal practices, books, and records relating to the use and disclosure of PHI received from

the group health Plan available to the Secretary of HHS for the purposes of determining compliance by the Plan with HIPAA, and

10. If feasible, return or destroy all PHI received from the Plan that the 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. If return or destruction is not feasible, limit further uses and disclosures to those purposes that make the return or destruction infeasible.

D. Adequate separation between the Plan and the Plan Sponsor must be maintained. Therefore, in accordance with HIPAA, only the following employees or classes of employees may be given access to PHI: 1. The Fund Administrator, 2. The Fund Staff designated by the Fund Administrator. Fund Staff have access to individually

identifiable health information, including claims information in the

3. form of paper claims and in the system. The Fund’s computer system provides for logon ID’s and a password.

E. The persons described in section D may only have access to and use and disclose PHI for Plan administration functions that the Plan Sponsor performs for the Plan.

F. If the persons described in section D do not comply with this Plan Document, the Plan Sponsor shall provide a mechanism for resolving issues of noncompliance, including disciplinary sanctions.

G. For purposes of complying with the HIPAA privacy rules, this Plan is a “Hybrid Entity” because it has both health plan and non-health plan functions. The Plan designates that its health care components that are covered by the privacy rules include only health benefits and no other plan functions or benefits.

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STATEMENT OF ERISA RIGHTS

As a participant in the Sheet Metal Workers Local 22 Welfare Fund, you are entitled to certain rights and protections under the Employee Retirement Income Security Act of 1974 (ERISA). ERISA provides that all Plan participants shall be entitled to:

RECEIVE INFORMATION ABOUT YOUR PLAN AND BENEFITS

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, including insurance contracts and collective bargaining agreements and copies 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 Pension and Welfare Benefits Administration.

Obtain, upon written request to the Plan Administrator, copies of documents governing the operation of the Plan, including insurance contracts and collective bargaining agreements and copies of the latest annual report (Form 5500 Series) and updated summary plan description. The plan administrator's office may make a reasonable charge for the copies.

Receive a summary of the Plan’s annual financial report. The plan administrator is required by law to furnish each participant with a copy of this summary annual report.

CONTINUE GROUP HEALTH PLAN COVERAGE

Continue health care coverage for yourself, spouse or dependent children if there is 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 continuation coverage rights.

Reduction or elimination of 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, when you become entitled to elect COBRA continuation coverage, when your COBRA continuation coverage ceases, if you request it before losing coverage, or if you request it up to 24 months after losing coverage. Without evidence of creditable coverage, you may be subject to a preexisting condition exclusion for 12 months (18 months for late enrollees) after your enrollment date in your coverage.

PRUDENT ACTIONS BY PLAN FIDUCIARIES

In addition to creating rights for Plan participants, ERISA imposes duties upon the people who are responsible for the operation of the employee benefit Plan. The people who operate your Plan, called “fiduciaries” of the Plan, have a duty to do so prudently and in the interest of you and other Plan participants and beneficiaries. No one, including your Employer, your union, or any other person, may fire you or otherwise discriminate against you in any way to prevent you from obtaining welfare Fund 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 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 administrator.

If you have a claim for benefits that is denied or ignored, in whole or in part, you may file suit in 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 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 Area Office of the Employee Benefits Security Administration, U.S. Department of Labor, listed in your telephone directory or the Division of Technical Assistance and Inquiries, Employee Retirement Income Security Administration, U.S. Department of Labor, 200 Constitution Avenue, N.W., Washington D.C, 20210. You may also obtain certain publications about your rights and responsibilities under ERISA by calling the publications hotline of the Employee Benefits Security Administration (EBSA).

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