This is a summary of benefits available under the Carpenters Health and Security Plan of Western Washington – For Retired Carpenters. For benefit details and other plan provisions including the eligibility requirements for spouses and dependent children, enrollment requirements, and limitations and exclusions, please refer to the appropriate section of the Retired Plan booklet. If there is a conflict between the “Benefit Summary” and the Retired Plan booklet, the Retired Plan booklet governs.

A retiree is eligible for the Retired Plan if he or she:

• Receives 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 his or her retirement effective date (as determined by the Carpenters Retirement Plan of Western Washington). For disability retirement or, if early retirement was taken because of a disability, the retiree must have worked at least 7,500 hours in the 120 months immediately preceding the date of disability. Reciprocal service hours or participation in Self-Contribution Coverage or COBRA Continuation Coverage cannot be used to help establish eligibility.

Employer contributions to the Carpenters Health and Security Trust of Western Washington (as described in the second bullet above) can be used to satisfy the eligibility requirements of this plan for retirees if pension contributions were not required under a collective bargaining agreement.

Annual Deductible

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

Annual Maximum

$325,000 per individual per calendar year.

Copayments

$50 emergency room copayment. Waived if admitted as an inpatient directly following treatment in the emergency room.
$10 office visit copayment (non-Medicare individuals only) if an office visit is billed by a preferred or nonpreferred physician or mental health care provider.
$10 office visit copayment (non-Medicare individuals only) if an office is billed by a nonpreferred provider. Does not apply to office visits when care is received outside Washington State.
$200 inpatient hospital copayment (non-Medicare individuals only) for inpatient hospital admissions at nonpreferred provider facilities. Does not apply to inpatient hospital admissions when care is received outside Washington State.
See also Prescriptions.

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.

Physician Services

Physician Services

Paid at 90 percent. $10 office visit copayment if an office visit is billed by a preferred or nonpreferred physician (non-Medicare individuals only). $10 office visit copayment if an office visit is billed by a nonpreferred provider (non-Medicare individuals only).

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 (non-Medicare individuals only).

Surgical Services – Surgeon, Assistant Surgeon and Anesthetist

Paid at 90 percent of the usual, customary and reasonable charge as determined by this plan. If a second surgical opinion is required but not obtained, the surgeon is paid at 50 percent for the covered surgery (non-Medicare individuals only).

Preventive Care

Retiree and Spouse

Paid at 90 percent. Includes only routine immunizations for influenza, pneumococcal and hepatitis B, and colorectal cancer and prostate cancer screening for men and women age 50 and older. Routine examinations are not covered.

Children

Paid at 90 percent. $400 maximum during first year of life
(0 months through 11 months), $300 maximum during second year of life (12 months through 23months) and $200 annual maximum during third year through eighteenth year of life (24 months through 18 years).

Pap Smear and Mammogram

Paid at 90 percent. One pap smear per calendar year, one baseline mammogram and its interpretation (women ages 35-39), and one mammogram and its interpretation each calendar year (women age 40 and older).

Hospital Services (Medical, Surgical and Maternity)

Inpatient Hospital

Paid at 90 percent. $200 inpatient hospital copayment for nonpreferred provider facilities (non-Medicare individuals only). Preadmission certification is required (non-Medicare individuals only). If preadmission certification is not obtained, $50 is deducted from the covered room and board expense for each day of inpatient hospital care, up to a maximum of $250.

Outpatient Hospital

Paid at 90 percent. $50 copayment for emergency room.

Hospital Alternatives

Skilled Nursing Facility

Paid at 90 percent. Calendar year maximum of $5,000.

Home Health Care

Paid at 100 percent. Calendar year maximum of $5,000 for non-Medicare individuals and $1,500 for Medicare individuals. 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.

Rehabilitative Care

Inpatient Rehabilitation

Paid at 90 percent. Calendar year maximum of $24,000.
$200 inpatient hospital copayment for nonpreferred provider facilities (non-Medicare individuals only). Preadmission certification is required (non-Medicare individuals only). If preadmission certification is not obtained, $50 is deducted from the covered room and board expense for each day of inpatient hospital care, up to a maximum of $250.

Outpatient Rehabilitation

Paid at 90 percent. Calendar year maximum of $2,000.

Chiropractic Care

Chiropractor

Paid at 80 percent. Calendar year maximum of $750.

Mental Health Care

Inpatient Mental Health

Paid at 80 percent. Calendar year maximum of 15 inpatient days. $200 inpatient hospital copayment for nonpreferred provider facilities (non-Medicare individuals only). Preadmission certification is required (non-Medicare individuals only). If preadmission certification is not obtained, $50 is deducted from the covered room and board expense for each day of inpatient hospital care, up to a maximum of $250.

Outpatient Mental Health

Paid at 80 percent. Calendar year maximum of 30 visits.
$10 office visit copayment if an office visit is billed by a preferred or nonpreferred mental health care provider (non-Medicare individuals only). $10 office visit copayment if an office visit is billed by a nonpreferred provider (non-Medicare individuals only).

Chemical Dependency

Chemical Dependency

Paid at 80 percent. Lifetime maximum of $2,500. $200 inpatient hospital copayment for nonpreferred provider facilities (non-Medicare individuals only). Preadmission certification is required (non-Medicare individuals only). If preadmission certification is not obtained, $50 is deducted from the covered room and board expense for each day of inpatient hospital care, up to a maximum of $250.

Other Services

Allergy Testing

Paid at 90 percent. Calendar year maximum of $600.

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 – Children Age Six and Under

Paid at 90 percent. Calendar year maximum of $1,500. Preauthorization is required.

Neuropsychological Assessments or Tests

Paid at 80 percent. Calendar year maximum of $600. Life-time maximum of $1,200. Preauthorization is required.

Pregnancy Care – Retiree and Spouse Only

Paid at 90 percent.

Transplants

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

Prescriptions

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 Health Home Delivery Pharmacy Service

$10 copayment for each generic prescription purchased through the home delivery pharmacy service.
$20 copayment for each brand-name prescription listed on the drug program formulary and purchased through the home delivery pharmacy service.

Medco Health Home Delivery Pharmacy Service

$35 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.

Life Insurance

Retiree – $2,000.
Spouse – $1,000.
Dependent Children – $1,000.