ENROLLMENT AND ELIGIBILITY

Northern New England Benefit Trust is a non-profit health fund established in 1966

to provide healthcare for participating Teamster Union members and their families

throughout New England.

The Board of Trustees is charged by law with fiduciary responsibility to manage the

Trust and oversee all the activities of the Trust. This legal responsibility is set forth

in the rules established by the Federal Employee Retirement Income Security Act

(ERISA) and enforced by the United States Department of Labor.

The Trust is committed to partnering with its members and their employers to

provide high quality, comprehensive, and cost-effective healthcare benefits for

those members and their families to improve and maintain their quality of life.

The following information is intended for summary purposes only, and is not a

guarantee of coverage. A Summary Plan Description will be provided upon gaining

eligibility with the Trust.

ENROLLMENT AND ELIGIBILITY

 All members are required to complete a Northern New England Benefit Trust Election form prior to gaining eligibility.

 The NNEBT plan includes:  CIGNA Medical

 Teamsters Rx/Express Scripts Prescription

 NNEBT Dental

 Davis Vision

 Life Insurance

 Family status choices are binding until the next Open Enrollment period, except in the case of a Qualifying Event (change of family status, gain or loss of other insurance, etc.).

CIGNA OPEN ACCESS PLUS

The Open Access Plus plan works best within a network of providers from which you choose services. You may see any licensed doctor inside or outside the network, but you will have richer benefits and it is more cost-effective if you stay inside the network.

How does this differ from an HMO Plan?

In an HMO Plan, all care must be coordinated through the member’s Primary Care Physician (PCP). A member referral is required to see any type of specialist, care is generally limited to a specific geographic area (such as New England) and there is generally no out-of-network care except for emergencies.

In the Open Access Plan, members may receive services from providers nationwide, referrals are not required for specialist care and out-of-network care is available (deductible and co-insurance may apply).

Primary Care Physician

Members are encouraged (but not required) to select a Primary Care Physician (PCP). It is recommended to have a PCP to be the “keeper” of all of your medical records, to coordinate your care and to provide:

 Routine checkups  Follow-up care

 Information and guidance

If a network PCP is selected, he/she will take care of obtaining in-network certification for services that require it. Specialist Care Without a Referral

The CIGNA Open Access Plus (OAP) plan provides referral-free access to specialists for members covered by CIGNA OAP plans. If you choose an out-of-network health care professional, services are covered at a reduced benefit level.

Emergency Care

The CIGNA OAP plan allows for out-of-network care at the in-network cost when it is medically necessary. Care Away From the New England Area

The CIGNA Open Access Plus (OAP) plan provides a nation-wide network of providers, so care can be obtained anywhere in the country. For example, if you have a college student or adult dependent who resides in another state, they may use network providers in their immediate area, rather than waiting until they are back in New England to schedule an appointment.

Out-of-Network Care

Summary of CIGNA Medical Coverage

This document is for summary purposes only. Complete details will be provided in the Summary Plan Description which will be mailed to members upon initial eligibility.

Type of Care Cost to Member (Network Providers)

Office Visits

Preventive Care $0 copay

PCP Visit (other than preventive) $20 copay/visit

Specialist Visit $25 copay/visit

Chiropractor $25 copay/visit (Limit 34 visits per calendar year)

Prenatal Care PCP or Specialist copay to confirm pregnancy; no copay

for subsequent visits

Outpatient Care

Outpatient Surgical Procedure $150 copay/visit CAT/PET/MRI scans at outpatient facility $100 copay/scan

Routine Lab/X-ray No charge

Inpatient Care

Hospital Stay $500 copay/admission

Skilled Nursing Facility No charge

Emergency Care

Emergency Room $100 copay/visit (waived if admitted to hospital)

Ambulance Transportation No charge if medically necessary

Urgent Care $25 copay/visit

Continuing Care

Outpatient Therapy (Physical, Occupational, Cardiac, Speech)

$25 copay/visit (Limit 60 visits per calendar year)

Home Health Care No Charge

Hospice Care No charge

Durable Medical Equipment No charge

Plan Information

Annual Deductible (Network Provider) Annual Deductible (Out-of-Network Provider)

$0 Individual/$0 Family $250 Individual/$500 Family

Out of Network Coinsurance 30% after deductible

Medical Out-of-Pocket Maximum (Network) Medical Out-of-Pocket Maximum (Out-of-Network)

$2,000 Individual/$4,000 Family $4,000 Individual/$8,000 Family Pre-Authorization Required for services including

(but not limited to):

NNEBT/Teamsters RX Prescription Plan

The prescription drug benefit program is currently administered through Teamsters Rx for retail and Express Scripts® (ESI) for mail order prescriptions. Use of generic medications is preferred whenever possible, as there is a higher cost to the member for brand name medications. For retail prescriptions there is an additional cost if a brand name is prescribed when a generic medication is available.

Retail Purchases (up to 30-day supply)

Retail benefits are available at all major pharmacies (except Wal-Mart, Walgreens or Sam’s Club). Please

present your Teamsters Rx/ESI Pharmacy card and ask the pharmacist to confirm their participation before filling your prescription. You may also visit www.TeamstersRx.com, sign in and click “locate a pharmacy.”

You are limited on your retail purchase to a 30-day supply or 100 units, whichever is less.

Mail Order Purchases (maintenance medications up to 90-day supply)

Mail-order service should be used for all maintenance medications (taken on a daily basis). Your provider will write a prescription for 90 days with three refills for one year of medication. Mail-order prescriptions will be processed through Teamsters Rx/Express Scripts® (ESI). ESI will dispense up to a 90-day supply of a drug, subject to the prescription written by your physician and to the Teamsters Rx Pharmacy Limitations and Exclusions. ESI will dispense a brand name drug only if no generic drug equivalent is available.

Benefit

Cost to Member (Network Providers) Retail

(Up to 30-day supply)

Mail Order (Up to 90-day supply) Annual Deductible $0 Individual/$0 Family $0 Individual / $0 Family Prescription out-of-pocket

Maximum

$2,500 Individual/$5,000 Family (combined retail and mail order)

Types of Prescriptions

Generic Lower of Usual/Customary or

$15 copay

Lower of Usual/Customary or $15 copay

Brand Name $25 copay $25 copay (only available when

generic is not available) Brand Name if Generic is Available $25 Brand copay + difference

between brand and generic

Not available Specialty Drugs

Limited to 30-day supply

Not available through retail $25 copay

NNEBT Dental Plan (DN1)

NNEBT’s dental plan is a nation-wide plan with no network restrictions. You may use any provider in the country, and providers have the ability to submit claims electronically to NNEBT for payment.

The plan operates on a fee schedule, whereby NNEBT will pay up to a designated amount per diagnosis code. The Plan will pay up to the fee schedule amount with the member being responsible for the remainder of charges. A pre-treatment estimate is required for any care that will result in a claim over the amount of $250.00.

The plan offers separate calendar year limits for periodontic procedures (scaling/root planning, adding/removal of bone, adding/removal of soft tissue) and prosthodontic procedures (crowns, bridges, dentures).

Schedule of Benefits

Type of Care Coverage Amounts

Preventive Care Plan pays 100% up to fee schedule amount

No deductible

Deductible for Basic/Major Care $25 Individual/$50 Family

Basic Care Plan pays 80% up to fee schedule amount

Major Care Plan pays 50% up to fee schedule amount

Orthodontia* Plan pays 75% up to $1,500 lifetime max

NNEBT/Davis Vision Plan

The elective vision plan is separate from the health coverage component of your plan, and you must use a Davis

Vision Provider. The Davis Vision program has a wide network of providers within New England and in other parts

of the country. If there is not a Davis Vision Provider available in your area (or that of a covered dependent), Davis Vision will locate a provider and assign temporary network status in order to accommodate our members. If you choose to use a provider who is not part of the Davis Vision Network, you may file an individual claim and receive up to $45 reimbursement for the examination and up to $55 reimbursement for one pair of eyeglasses or contact lenses.

Contact Davis Vision toll-free at 1-800-999-5431 to find a participating provider in your area (Monday-Friday 8:00 AM to 8:00 PM and Saturdays 9:00 AM to 4:00 PM) or visit www.davisvision.com. NOTE: Under either the

in-network or out-of-in-network benefit, you must claim all parts of the benefit (exam, lenses and frames) at one time and through a single provider.

Schedule of Benefits

Family Members Service Frequency

Member and Spouse One Free routine eye examination (including dilation as professionally indicated)

Once every 24 months One Free pair of glasses including frames from the

Davis Vision Tower

Second pair of glasses available for $25 co-pay + discounted rates for frame/lens optional items. Adult Dependents (age 19

through end of the month in which age 26 is attained)

One Free routine eye examination (including dilation

as professionally indicated) Once every 24

months One Free pair of glasses including frames from the

Davis Vision Tower Dependent Children

(through end of year age 19 is attained)

One Free routine eye examination (including dilation

as professionally indicated) Once every 12

months One Free pair of glasses including frames from the

Davis Vision Tower Contact Lenses

“Plan” Contact Lenses: “Plan” contact lenses (manufactured and or distributed by Davis Vision) may be received in lieu of one pair of glasses. Standard, soft, daily-wear, disposable or planned replacement contact lenses are available. Fitting and follow-up will be included upon obtaining Plan contact lenses.

Life Insurance / Accidental Death and Dismemberment

Life insurance provides a benefit to you or your family members in the event of a death. Life insurance

benefits for an active member will be paid to the beneficiary you select. Life insurance benefits for a

spouse or child will be paid automatically to the active member.

For actively employed members 70 and older, the benefit is reduced based on age. Amounts are detailed

in the Summary Plan Description.

Coverage Type Benefit Paid

Life Insurance

Active Member (through age 69) $25,000

Spouse $5,000

Dependent Child $2,500

Accidental Death/Dismemberment

Active Member (through age 69) $25,000

Spouse No benefit

FREQUENTLY ASKED QUESTIONS

A member may enroll a spouse and/or children with proper eligibility documentation (please see the final page of this booklet for required documents). Dependents will be made eligible after all required documentation is received. Additional documentation may be required for step-children, adopted or foster children, or ex-spouses. My adult dependent lives in another state. Is he/she able to be covered on my plan?

According to the guidelines of the Affordable Care Act (ACA) an adult dependent may remain covered under a member until the end of the month in which he/she attains age 26. The spouse or child of an adult dependent will not be covered by NNEBT. If an adult dependent obtains health coverage through an employer or another source, we must receive Coordination of Benefits so that claims are paid properly.

How does the CIGNA Open Access plan differ from my current HMO Plan?

In an HMO Plan, all care must be coordinated through the member’s Primary Care Physician (PCP). A member referral is required to see any type of specialist, care is generally limited to a specific geographic area (such as New England) and there is generally no out-of-network care except for emergencies.

In the Open Access Plan, members may receive services from providers nationwide, referrals are not required for specialist care and out-of-network care is available (deductible and co-insurance may apply).

Do I need a referral to see a specialist?

A referral is not required; however for certain types of specialty care, a review may be conducted to ensure that specialty care is medically necessary.

What if I need to have an MRI/Surgery/Colonoscopy/Mammogram, etc.?

A paper or electronic referral is not required; however, the test or service must be ordered by your Primary Care Physician and may require pre-certification by CIGNA. Your CIGNA PCP will handle pre-certifications with CIGNA network providers. There is a greater cost to the member if out-of-network facilities are utilized.

How does the mail order pharmacy benefit work?

Your physician should write a prescription for 90 days with three refills. This will provide one year of medication. The original prescription must be sent to Express Scripts (ESI) either by mail or faxed by a physician. Refills may be obtained by registering online, mail or telephone. For most prescriptions, the mail order pharmacy provides 90 days of medication for the same low copay as 30 days of the same medication from a retail pharmacy.

When should I use the mail order pharmacy benefit?

Is there a network for dentists?

The NNEBT dental plan is not limited to a network or “participating” dentists. The member may choose his/her dental provider. However, members should be aware that all providers do not charge consistent rates for the same services. NNEBT will pay according to the fee schedule (attached) and the member is responsible for any/all remaining balance. If a member is using the services of an oral surgeon, care should be taken to ensure that surgeon is part of the CIGNA network, as some oral surgery benefits are billable under the medical plan. Contact the NNEBT Dental department for specifics.

How does the Vision benefit work?

Choose a Davis Vision provider from the directory included with your enrollment materials. When making the appointment, inform the provider that you will be utilizing Davis Vision benefits. The examination and eyeglass or contact lens selection must be completed in one visit.

Does Davis Vision cover “chain” vision providers or providers within a department store?

The Davis Vision Network does not accept “chain” or department store vision providers such as LensCrafters, Pearle, JC Penney, Sears, Wal-Mart, etc.).

What if I have a medical condition involving my eyes?

Medical conditions should be handled by a CIGNA network Ophthalmologist. However, if you have a routine eye examination or obtain a prescription for eyeglasses from such a provider, the services are not covered under the Davis Vision benefit or the CIGNA benefit.

Does NNEBT refund my gym membership?

NNEBT provides a $100 reimbursement after every 6 month period of using a gym for an average of 3 times per week. You may join the gym, YMCA or health club of your choice. At the end of each 6-month period, you (or your covered spouse) may submit a printout of your attendance along with the NNEBT Health Club Reimbursement form and the refund check will be mailed to you. This benefit is payable twice per year. The Health Club Reimbursement does not apply to adult dependents or children.

How am I reimbursed after a massage?

You may obtain services from a licensed massage therapist. Take an NNEBT Massage Claim form with you, as the therapist must complete the bottom portion. You may submit a form for each massage or list up to 5 appointments per form. NNEBT will reimburse up to $30 per appointment (one per calendar day), to a maximum of $1,000 reimbursement per calendar year for you or your covered spouse. The massage benefit does not apply to adult dependents or children.

Does NNEBT cover hearing aids?

CHECKLIST FOR DEPENDENT ELIGIBILITY

All required items must be provided to NNEBT within 60 days of eligibility to complete the enrollment

process. Eligibility for covered dependents is pending until all applicable documentation is received.

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M

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 NNEBT ENROLLMENT AND ELECTION FORMS

 SOCIAL SECURITY NUMBERS for member and all covered dependents

 COORDINATION OF BENEFITS to show additional insurance for member and all covered dependents  HIPAA CERTIFICATE showing termination date for previous insurance (as applicable)

T

A

F

M

D

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Spouse  Photocopy of State or town-issued Marriage Certificate (we do not accept church or venue certificates)

Ex-Spouse  Photocopy of Divorce Decree showing responsibility for your ex-spouse’s coverage

Natural Child  Photocopy of State or town-issued Birth Certificate (we do not accept hospital certificates or birth announcements)

Adopted Child  Photocopy of State-issued Birth Certificate

 Photocopy of Adoption Certificate/Court Documents Step-Child  Photocopy of State-issued Birth Certificate

 Photocopy of any applicable Divorce Decree showing responsibility for the child’s insurance coverage

 Child support order, QMSO or NNEBT Step-child affidavit (required if a divorce decree does not exist)

Foster Child or Legal Dependent  Photocopy of State-issued Birth Certificate