This is a summary of benefits available under the Carpenters Health and Security Plan of Western Washington—For Retired Carpenters (the Retiree Health Plan). For benefit details and other plan provisions including the eligibility requirements for eligible dependents, enrollment requirements, and limitations and exclusions, please refer to the appropriate section of the Retiree Health Plan booklet. If there is a conflict between the "Benefit Summary" and the Retiree Health Plan booklet, the Retiree Health Plan booklet governs.

You (the retiree) are eligible for the Retiree Health Plan if you:

• Receive a monthly benefit from the Carpenters Retirement Plan of Western Washington or, for retired lathers, from the Cement Masons and Plasterers Retirement Plan; and
• Worked at least 7,500 hours (for which employer contributions were received by the Carpenters Health and Security Trust of Western Washington) during the 120 months immediately preceding your retirement effective date. This is the only requirement if you worked under a collective bargaining agreement that did not require contributions to the Carpenters Retirement Plan of Western Washington or the Cement Masons and Plasterers Retirement Plan.

Annual Deductible

$200 per person per calendar year.
$400 per family per calendar year.

Annual Maximum

$750,000 per person per calendar year.

Copayments

$50 emergency room copayment for individuals without Medicare. Waived if admitted as an inpatient directly following treatment in the emergency room.

$10 office visit copayment for individuals without Medicare if an office visit is billed by a physician or mental health care provider.

Additional $10 office visit copayment for individuals without Medicare if an office visit is billed by a nonpreferred provider. Does not apply to office visits billed outside the preferred provider network.

$200 inpatient hospital copayment for individuals without Medicare for inpatient hospital admissions at nonpreferred provider facilities. Does not apply to hospital admission billed outside the preferred provider network.

See also "Prescriptions" on pages 34-35.

Coinsurance

10 percent for most services and supplies. Paid at 100 percent for the remainder of the calendar year when an individual's coinsurance reaches $2,300.

20 percent depending on the type of service or supply received, and the type of provider used. These services always require 20 percent coinsurance and the 20 percent coinsurance does not apply toward the $2,300 annual coinsurance maximum.

Physical Examinations

Retiree, spouse and domestic partner—
Paid at 90 percent. Subject to the Preventive Health Benefit Schedule.

Children—
Paid at 90 percent. Subject to the Preventive Health Benefit Schedule.

Screening Tests

Paid at 90 percent for retired participants, spouses and domestic partners. Physical examination services are subject to the annual deductible and annual coinsurance for persons with Medicare, as well as office visit copayment(s) for persons without Medicare. Subject to the Preventive Health Benefit Schedule.

Routine Immunizations

Physician Services

Paid at 90 percent. $10 office visit copayment for individuals without Medicare if an office visit is billed. An additional $10 office visit copayment for individuals without Medicare if an office visit is billed by a nonpreferred provider.

Second Surgical Opinion (if required)

Paid at 100 percent. Not subject to the annual deductible. A second opinion must be obtained through the medical review program. Applies to individuals without Medicare.

Surgical Services—Surgeon, Assistant Surgeon and Anesthetist

Paid at 90 percent of the usual, customary and reasonable charge as determined by this plan.

Inpatient Hospital

Paid at 90 percent. $200 inpatient hospital copayment for nonpreferred provider facilities (applies to individuals without Medicare). Preadmission certification is required (applies to individuals without Medicare).

Outpatient Hospital

Paid at 90 percent.

Emergency Room

Paid at 90 percent. $50 copayment for emergency room (applies to individuals without Medicare).

Skilled Nursing Facility

Paid at 90 percent. Calendar year maximum of 25 inpatient days.

Home Health Care

Paid at 100 percent. Calendar year maximum of 30 visits. Preauthorization is required.

Hospice Care

Paid at 100 percent. Maximum of 14 inpatient days during six-month period. Skilled care in the home is limited to 60 visits. Respite care is limited to 120 hours per three-month period. Preauthorization is required.

Inpatient Rehabilitation

Paid at 90 percent. Calendar year maximum of 15 inpatient days. $200 inpatient hospital copayment for nonpreferred provider facilities (applies to individuals without Medicare). Preadmission certification is required (applies to individuals without Medicare).

Outpatient Rehabilitation

Paid at 90 percent. Calendar year maximum of 30 visits.

Chiropractor

Paid at 80 percent. Calendar year maximum of 24 spinal manipulations.

Inpatient Mental Health

Paid at 80 percent. Calendar year maximum of 15 inpatient days. $200 inpatient hospital copayment for nonpreferred provider facilities (applies to individuals without Medicare). Preadmission certification is required (applies to individuals without Medicare).

Outpatient Mental Health

Paid at 80 percent. Calendar year maximum of 30 visits.

Chemical Dependency

Paid at 80 percent. Inpatient treatment not to exceed 28 days in a 24-month period. Outpatient treatment not to exceed 36 visits in a 24-month period. Lifetime maximum of three episodes of treatment. $200 inpatient hospital copayment for nonpreferred provider facilities (applies to individuals without Medicare). Preadmission certification is required (applies to individuals without Medicare).

Allergy Testing

Paid at 90 percent. Calendar year maximum as follows: blood testing for allergies is limited to 12 allergens; skin testing for allergies is limited to 60 allergens.

Ambulance

Paid at 90 percent.

Diagnostic X-Ray and Laboratory

Paid at 90 percent.

Durable Medical Equipment and Medical Supplies

Paid at 90 percent. Preauthorization is required.

Neurodevelopmental Therapy

Paid at 90 percent. Calendar year maximum of 15 visits. Preauthorization is required.

Neuropsychological or Psychological Assessments or Tests

Paid at 80 percent. Lifetime maximum of $1,200. Preauthorization is required.

Pregnancy Care

Paid at 90 percent. For the retiree, spouse and domestic partner only.

Transplants

Paid at 90 percent. Subject to a 12-month waiting period. Donor procurement maximum of $25,000.

Carpenters Health and Security Plan

This benefit is for individuals without Medicare.

Medco Health Retail Pharmacy Program

$7 copayment for each generic prescription purchased from a participating retail pharmacy.

$15 copayment for each brand-name prescription listed on the drug program formulary and purchased from a participating retail pharmacy.

$30 copayment for each brand-name prescription not listed on the drug program formulary and purchased from a participating retail pharmacy.

Up to a 30-day maximum supply.

Medco By Mail

$14 copayment for each generic prescription purchased through the home delivery pharmacy service.

$30 copayment for each brand-name prescription listed on the drug program formulary and purchased through the home delivery pharmacy service.

$60 copayment for each brand-name prescription not listed on the drug program formulary and purchased through the home delivery pharmacy service.

Up to a 90-day maximum supply.

Medco Medicare Prescription Plan

This benefit is for individuals with Medicare.

$7 copayment for each generic prescription.

$15 copayment for each preferred brand-name prescription.

$35 copayment for each non-preferred brand-name prescription.

Up to a 34-day maximum supply.

Medco By Mail

$10 copayment for each generic prescription.

$20 copayment for each preferred brand-name prescription.

$40 copayment for each non-preferred brand-name prescription.

Up to a 90-day maximum supply.

Life Insurance

Retiree—$2,000.
Dependents—$1,000.