DC 37 Health & Security Plan Trust

1 1 of 6 DC 37 Health & Security plan Trust Coverage Period: 07/01/2018 06/30/2019 Summary of Benefits and Coverage: What this plan Covers & What it Costs Coverage for: Individual + Dependents plan Type: Supplemental Questions: Call 212-815-1234 (or 1- 877-323-7738 for out of state retirees) or visit us at If you aren t clear about any of the bolded terms used in this form, see the Glossary. You can view the Glossary at or call 212-815-1234 (or 1- 877-323-7738 for out of state retirees) to request a copy. This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at or by calling 212-815-1234 (or 1- 877-323-7738 for out of state retirees). This document only describes your supplemental benefits (including prescription drug, dental and optical coverage) provided by the DC37 Health & Security plan Trust .

2 You may be receiving medical or other Health coverage from an alternate source. Important Questions Answers Why this Matters: What is the overall deductible? $ 0 See the chart starting on page 2 for your costs for services this plan covers. Are there other deductibles for specific services? No You don t have to meet deductibles for specific services, but see the chart starting on page 2 for other costs for services this plan covers. Is there an out of pocket limit on my expenses? No There s no limit on how much you could pay during a coverage period for your share of the cost of covered services What is not included in the out of pocket limit? This plan has no out-of-pocket limit. Not applicable because there s no out-of-pocket limit on your expenses. Is there an overall annual limit on what the plan pays? No The chart starting on page 2 describes any limits on what the plan will pay for specific covered services, such as office visits.

3 Does this plan use a network of providers? Yes. For a list of participating providers see http://www. or call 212-815-1234 or 1- 877-323-7738 for out of state retirees. If you use an in-network doctor or other Health care provider, this plan will pay some or all of the costs of covered services. Be aware, your in-network doctor or hospital may use an out-of-network provider for some services. Plans use the term in-network, preferred, or participating providers in their network. See the chart starting on page 2 for how this plan pays different kinds of providers. Do I need a referral to see a specialist? No You can see the specialist you choose without permission from this plan . Are there services this plan doesn t cover? Yes Some of the services this plan doesn t cover are listed on page 4. See your policy or plan document for additional information about excluded services.

4 OMB Control Numbers 1545-2229, 1210-0147, and 0938-1146 2 of 6 Questions: Call 212-815-1234 (or 1- 877-323-7738 for out of state retirees) or visit us at If you aren t clear about any of the bolded terms used in this form, see the Glossary. You can view the Glossary at or call 212-815-1234 (or 1- 877-323-7738 for out of state retirees) to request a copy. Co-payments are fixed dollar amounts (for example, $15 you pay for covered Health care, usually when you receive the service. Co-insurance is your share of the costs of a covered service, calculated as a percent of the allowed amount for the service. For example, if the plan s allowed amount for an overnight hospital stay is $1,000, your co-insurance payment of 20% would be $200. This may change if you haven t met your deductible. The amount the plan pays for covered services is based on the allowed amount.)

5 If an out-of-network provider charges more than the allowed amount, you may have to pay the difference. For example, if an out-of-network hospital charges $1,500 for an overnight stay and the allowed amount is $1,000, you may have to pay the $500 difference. (This is called balance billing.) This plan may encourage you to use participating providers by charging you lower deductibles, co-payments and co-insurance amounts. Common Medical Event Services You May Need Your cost if you use an Limitations & Exceptions In-network Provider Out-of-network Provider If you visit a Health care provider s office or clinic Primary care visit to treat an injury or illness Not Covered Not Covered See your employer s SBC for a description of what medical coverage is provided. Specialist visit Other practitioner office visit Preventive care/screening/immunization If you have a test Primary care visit to treat an injury or illness Not Covered Not Covered See your employer s SBC for a description of what medical coverage is provided.

6 Specialist visit If you need drugs to treat your illness or condition. [More information about prescription drug coverage is available at ] Generic drugs $10- $30 Reimbursement is according to the plan s fee schedule. Some drugs are subject to prior authorization (no coverage if not obtained), step therapy, or quantity limits. Preferred brand drugs $20 - $60 Non-preferred brand drugs $ - $ If you have outpatient surgery Facility fee ( , ambulatory surgery center) Not Covered Not Covered See your employer s SBC for a description of what medical coverage is provided. Physician/surgeon fees If you need immediate medical attention Emergency room services Not Covered Not Covered See your employer s SBC for a description of what medical coverage is provided. Emergency medical transportation Urgent care 3 of 6 Questions: Call 212-815-1234 (or 1- 877-323-7738 for out of state retirees) or visit us at If you aren t clear about any of the bolded terms used in this form, see the Glossary.

7 You can view the Glossary at or call 212-815-1234 (or 1- 877-323-7738 for out of state retirees) to request a copy. Common Medical Event Services You May Need Your Cost If You Use an In-network Provider Your Cost If You Use an Out-of-network Provider Limitations & Exceptions If you have a hospital stay Facility fee ( , hospital room) Not Covered Not Covered See your employer s SBC for a description of what medical coverage is provided. Physician/surgeon fee If you have mental Health , behavioral Health , or substance abuse needs Mental/Behavioral Health outpatient services Not Covered Not Covered See your employer s SBC for a description of what medical coverage is provided. Mental/Behavioral Health inpatient services Substance use disorder outpatient services Substance use disorder inpatient services If you are pregnant Prenatal and postnatal care Not Covered Not Covered See your employer s SBC for a description of what medical coverage is provided.

8 Delivery and all inpatient services If you need help recovering or have other special Health needs Home Health care Not Covered Not Covered See your employer s SBC for a description of what medical coverage is provided. Rehabilitation services Habilitation services Skilled nursing care Durable medical equipment Hospice service If your child needs dental or eye care Eye exam $0 Maximum reimbursement is $6. The Vision Benefit may be used once every two years for each covered individual. Glasses $0 Maximum reimbursement is $9 for lenses and $5 for frames. Dental check-up $0 Maximum Reimbursement available is based on the services provided. A maximum of $1,700 will be paid as dental benefits for each covered person in a single calendar year. 4 of 6 Questions: Call 212-815-1234 (or 1- 877-323-7738 for out of state retirees) or visit us at If you aren t clear about any of the bolded terms used in this form, see the Glossary.

9 You can view the Glossary at or call 212-815-1234 (or 1- 877-323-7738 for out of state retirees) to request a copy. Excluded Services & Other Covered Services: Services Your plan Does NOT Cover (This isn t a complete list. Check your policy or plan document for other excluded services.) Acupuncture Bariatric surgery Chiropractic care Cosmetic surgery Drugs, dental, optical outside US Weight loss programs Infertility Treatment Long-term care Private-duty nursing Other Covered Services (This isn t a complete list. Check your policy or plan document for other covered services and your costs for these services.) Dental Care (Adult) Hearing Aids Routine Eye Care (Adult) Your Rights to Continue Coverage: If you lose coverage under the plan , then, depending upon the circumstances, Federal and State laws may provide protections that allow you to keep Health coverage.

10 Any such rights may be limited in duration and will require you to pay a premium, which may be significantly higher than the premium you pay while covered under the plan . Other limitations on your rights to continue coverage may also apply. For more information on your rights to continue coverage, contact the plan at 212-815-1234 (or 1- 877-323-7738 for out of state retirees). You may also contact your state insurance department, the Department of Labor, Employee Benefits Security Administration at 1-866-444-3272 or , or the Department of Health and Human Services at 1-877-267-2323 x61565 or Your Grievance and Appeals Rights: If you have a complaint or are dissatisfied with a denial of coverage for claims under your plan , you may be able to appeal or file a grievance. For questions about your rights, this notice, or assistance, you can contact: The Inquiry Unit at 212-815-1234 (or 1- 877-323-7738 for out of state retirees) or by visiting Room 300 at 125 Barclay Street, New York, NY 10007.