Docstoc

HAWAII LABORERS HEALTH _ WELFARE TRUST FUND

Document Sample
HAWAII LABORERS HEALTH _ WELFARE TRUST FUND Powered By Docstoc
					 HAWAII LABORERS
HEALTH & WELFARE
   TRUST FUND




     RETIREES-
   CONSTRUCTION
     April 2009
                      THIS PLAN IS ADMINISTERED BY
                          PACIFIC ADMINISTRATORS, INC.
                           1440 Kapiolani Boulevard, Suite 800
                                Honolulu, Hawaii 96814

                                      Oahu: (808) 441-8700
                            Neighbor Islands: 1 (888) 520-8078

                        DIRECT LINE ALSO LOCATED AT THE
                    LABORERS UNION LOCAL 368 HEADQUARTERS


                               IMPORTANT NOTICE

  IF YOU HAVE ANY QUESTIONS CONCERNING THIS PLAN, SUCH AS ELIGIBILITY OR BENEFITS,
PLEASE CONTACT THE HAWAII LABORERS HEALTH AND WELFARE TRUST FUND OFFICE AT
1440 KAPIOLANI BOULEVARD, SUITE 800, HONOLULU, HAWAII 96814, PHONE: (808) 441-8700
(NEIGHBOR ISLANDS DIAL DIRECT TOLL FREE 1 (888) 520-8078), 8:00 A.M. - 4:30 P.M., MONDAY
THROUGH FRIDAY.
  RETIREE BENEFITS ARE NEITHER GUARANTEED NOR VESTED AND WILL BE PROVIDED ONLY
AS LONG AS FUNDS ARE AVAILABLE. THE BOARD OF TRUSTEES RESERVES THE RIGHT, AT ITS
SOLE DISCRETION, TO MODIFY THE PLAN WITH REGARD TO ELIGIBILITY REQUIREMENTS AND
BENEFITS AVAILABLE, TO REQUIRE A CONTRIBUTION FOR THE COST OF BENEFITS, OR TO
TERMINATE BENEFITS AT ANY TIME.
  CHANGES THAT ARE MADE MAY AFFECT YOU AND YOUR DEPENDENTS. PLEASE READ THIS
BOOKLET AND SUBSEQUENT NOTICES THAT ARE MAILED TO YOU CAREFULLY.
  THIS BOOKLET SUMMARIZES THE ELIGIBILITY RULES AND BENEFITS FOR RETIRED
EMPLOYEES ONLY.




                                            1
                           HAWAII LABORERS HEALTH AND
                              WELFARE TRUST FUND
   Several important benefit changes have been made in your Health and Welfare benefits over the past
few years. You have been previously notified of these changes and their effective dates. However, as part
of our ongoing process to familiarize you with the benefit programs and to comply with Federal law, the
changes have been incorporated in this booklet revision.

                                       BENEFIT CHANGES
  The items which have been changed, along with the page number where the complete text of the
change is located, are as follows:
      1.   Effective April 14, 2003,
           a.   the Use and Disclosure of Your Health Information Statement was added (page 109)
           b.   the “Pension and Welfare Benefits Administration” changed it’s name to “Employee
                Benefits Security Administration” (page 111)
      2.   Effective January 1, 2006, the Fund will reimburse eligible Medicare retirees and spouses who
           reside in the continental United States for the Medicare Part D premium, up to the standard
           Medicare Part D premium adopted by the Trustees for retirees residing in the State of Hawaii
           (page 22)
      3.   Effective September 1, 2006, the retiree monthly co-payment for Medicare retirees was
           reduced from $90.00 per month to $85.00 per month (page 20)
      4.   Effective August 1, 2007, the language relating to “Eligible Dependents” was revised (page 13)
      5.   Effective September 1, 2008,
           a.   The language pertaining to “Qualified Medical Child Support Orders” was revised (page
                14)
           b.   In accordance with the Health Insurance Portability and Accountability Act of 1996, the
                section entitled, “If Hospitalized On the Effective Date”, has been revised (page 58)
           c.   The language pertaining to “Appeal of a Post-Service Claims” was revised (page 106)

      6.   INDEMNITY (SELF-FUNDED) COMPREHENSIVE MEDICAL PLAN
           a.   Effective November 1, 2005, services provided by anesthesia assistants, certified
                registered nurse anesthetists, certified registered nurse practitioners, clinical nurse
                specialists and physician assistants will be covered
           b.   Effective July 1, 2006, women age 40 and older may have one (1) mammogram
                screening every 12 months (page 37)
           c.   Effective August 1, 2007,
                i)    The Human Papilloma Virus (HPV) vaccine was added as a covered immunization
                      under the plan (page 33)
                ii)   The Meningococcal vaccine was added as a covered immunization under the plan
                      (page 33)
                iii) The Rotavirus vaccine was added as a covered immunization under the plan (page
                     33)
                iv) The Haemophilus influenzae type B vaccine was added as a covered immunization
                    under the plan (page 33)




                                                    2
     d.   Effective September 1, 2007, physician service benefits will include services provided by
          a Doctor of Optometry (O.D.) (page 26)
     e.   Effective February 1, 2008, the “Screening by Low Dose Mammography” benefit was
          revised (page 37)
     f.   Effective April 1, 2008, Medical Surveillance Service (LifeBed) electronic monitoring
          technology (Inpatient Hospital) was added as a covered benefit under the plan subject to
          prior authorization (page 36)
     g.   Effective July 1, 2008, reimbursement of non-emergency off island travel was added as a
          covered benefit under the plan (page 32)
     h.   Effective November 1, 2008,
          i)     Marriage and Family Therapists and Licensed Mental Health Counselors were added
                 as eligible providers for Mental Health and Substance Abuse services (page 46)
          ii)    The number of outpatient visits to a Psychiatrist, Psychologist, Clinical Social Worker,
                 Marriage and Family Therapist or Licensed Mental Health Counselor was increased
                 to 24 outpatient visits per calendar year (page 46)
     i)   Effective January 1, 2009, the annual deductible for “Other Medical Benefits” services
          rendered by participating providers was eliminated (page 49)

7.   INDEMNITY (SELF-FUNDED) PRESCRIPTION DRUG PLAN
     a.   Effective October 1, 2004,
          i)       A Central Fill Program through Times Pharmacies (for Island of Oahu only) was
                   added (page 55)
          ii)      The day supply limit for the Point of Service Program (for Island of Oahu only) was
                   revised (page 54)
          iii)     Mail order prescriptions will be filled through RESTAT.
     b.   Effective July 1, 2006, generic oral contraceptives and generic contraceptive patches will
          be covered under the Point of Service program or Direct Member Reimbursement
          program (page 57)
     c.   Effective May 1, 2008,
          i)       Smoking cessation drugs, agents and devices were added as a benefit under the
                   plan (page 57).
          ii)      Express Scripts, Inc. replaced RESTAT as the Pharmacy Benefit Manager (page
                   53)

8.   KAISER MEDICAL AND PRESCRIPTION DRUG PLAN
     a.   Effective September 1, 2003,
          i)       The office visit copayment increased to $10.00 per visit (formerly $8.00)
          ii)      The 12-month waiting period for heart-lung, lung, and simultaneous kidney-
                   pancreas transplants has been eliminated
          iii)     Coverage for small bowel and small bowel-liver transplants has been added
                   (formerly not covered)
          iv)      Coverage for donor’s medical expenses which are directly related to a member’s
                   covered transplant is subject to certain limitations (page 75)
          v)       Hospital, skilled nursing and obstetrical care will not be covered after termination of
                   the group’s contract with Kaiser




                                                  3
      vi)     Kaiser may terminate the membership of a member who resides outside the Hawaii
              service area for a period of 90 days or longer (page 69)
      vii)    Emergency services at a non-Kaiser facility will be covered only for services
              necessary to stabilize a member for transfer to a Kaiser facility (page 67)
      viii)   Health education support groups are not covered (page 70)
      ix)     The prescription drug copayment increased to $8.00 per prescription (formerly
              $7.00)
      x)      The prescription drug copayment for a 90-day supply refilled by mail order
              decreased from 3 copayments to 2 copayments.
      xi)     Drugs to shorten the duration of the common cold are not covered (page 79)
b.    Effective September 1, 2004,
      i)      The office visit copayment increased to $12.00 per visit (formerly $10.00)
      ii)     Administered chemotherapy drugs will be covered at no charge and self-
              administered chemotherapy drugs will be covered at $9.00 per prescription
      iii)    The supplemental charge maximum increased to $1,500 per member and $4,500
              per family (formerly $1,000 per member and $3,000 per family)
      iv)     If you receive payment from a third party for surrogate pregnancy services, you
              must reimburse Kaiser for care provided or paid for by Kaiser
      v)      Coverage for physical, occupational, and speech therapy is limited to conditions
              which are subject to significant improvement in physical function within 2 months
              as determined by a Kaiser physician
      vi)     Coverage for urgent out-of-area care is limited to services that cannot be delayed
              until you are medically able to return to the Hawaii service area or transfer to a
              Kaiser facility in another service area (page 69)
      vii)    Air Ambulance coverage is limited to transporting a member to the nearest medical
              facility designated by Kaiser
      viii)   The prescription drug copayment increased to $9.00 per prescription (formerly
              $8.00) and $18.00 per prescription (formerly $16.00) for mail order prescriptions
 c.   Effective January 1, 2005, the Kaiser plan is no longer available on the island of Kauai
 d.   Effective September 1, 2005,
      i)      The outpatient lab and x-ray copayment is $12.00 per department per day (formerly
              no charge)
      ii)     The lab and x-ray copayment will not be applicable to certain screening services,
              such as mammography or routine pap tests, however, the office visit copayment
              will still apply
      iii)    Internal/External prosthetic devices and durable medical equipment will be covered
              at 20% of applicable plan charges (formerly not covered)
      iv)     The billing charge for not paying for services on the same day that services are
              received will increase from $15.00 to $20.00
      v)      If you have a past due amount that you owe Kaiser, Kaiser may charge a 12%
              simple interest on the amounts that are 60 days past due and/or reschedule future
              non-urgent appointments until the past due payment is paid or other payment
              arrangements have been made (page 77)




                                            4
     vi)     Copayments and limitations for inpatient and outpatient chemical dependency
             benefits will be the same as for any other physical disease or illness. Residential
             chemical dependency benefits will remain the same at 60 days per calendar year
             with a 20% copayment and a limitation of two treatment episodes per lifetime
     vii)    The obstetrical care benefit covers only routine obstetrical care (page 75)
     viii)   Certain exams and services and related reports in connection with third party
             requests and requirements are not covered (page 71)
     ix)     Written prior authorization from Kaiser is required for referrals to outside providers,
             durable medical equipment and external prosthetics (page 75)
     x)      The prescription drug copayment increased to $10.00 per prescription (formerly
             $9.00) and $20.00 per mail order for up to a 90-day supply (page 78)
     xi)     Contraceptive drugs and injections will be covered under the medical plan instead
             of the drug plan at a 50% copayment (formerly $9.00 per 30-day supply) (page 63)
     xii)    Injectable drugs will be covered per 30-day supply instead of per dose
     xiii)   Prescription drugs and their associated dose, dosage strengths, or dosage forms
             which are in the same therapeutic category and are used for the same purpose as
             a non-prescription (over the counter) drug as determined by Kaiser are not covered
             (page 79)
e.   Effective January 1, 2006, the Kaiser Senior Advantage Plan will include Medicare Part D
     prescription drug benefits
f.   Effective September 1, 2006,
     i)      The office visit copayment increased to $14.00 per visit (formerly $12.00)
     ii)     The laboratory and x-ray copayment (inpatient and outpatient) increased to $14.00
             per department per day (formerly no charge for inpatient and $12.00 for outpatient)
     iii)    The two-month limit on physical, occupational, and speech therapy will no longer
             apply, however, only short term therapy is covered (page 75)
     iv)     The serious mental illness benefit has been expanded to include obsessive
             compulsive disorder, dissociative disorder, delusional disorder and major
             depression
     v)      A subscriber may live or work in the Hawaii service area and enroll (or continue to
             be enrolled) in a Kaiser Permanente plan as long as he/she lives in the State of
             Hawaii (page 61)
     vi)     After exhausting Kaiser Permanente’s internal appeals process, members whose
             plan is governed by ERISA have the option of choosing binding arbitration or filing
             a lawsuit (page 76)
g.   Effective September 1, 2007,
     i)      The office visit copayment increased to $15.00 per visit (formerly $14.00) (page 62)
     ii)     The laboratory and x-ray copayment (inpatient and outpatient) increased to $15.00
             per department per day (formerly $14.00) (page 62)
h.   Effective September 1, 2008,
     i)      There will be an inpatient hospital copayment of $50.00 per day (formerly no
             charge) (page 62)
     ii)     The copayment for emergency services received within the Hawaii service area
             increased to $50.00 per visit (formerly $25.00 per visit) (page 62)




                                            5
          iii)    The supplemental charges maximum increased to $2,000 per member and $6,000
                  per family (formerly $1,500 per member and $4,500 per family) (page 66)
          iv)     Immunizations will now be covered at no charge for members under 19 years of
                  age and $10.00 per dose for members 19 years of age and older. Flu and
                  pneumococcal immunizations are covered at no charge (page 62)
          v)      Copayments for medical services provided to transplant donors will be the
                  responsibility of the transplant-recipient Kaiser Permanente member and will count
                  toward the member’s Supplemental Charges maximum (page 66)
          vi)     The $20.00 billing fee will no longer be charged to Members who do not pay their
                  copayments at the time medical services are received
          vii)    Drugs and devices that are not approved by the U.S. Food and Drug Administration
                  (FDA) are not covered (page 79)

9.   WELLNESS PROGRAM
     a.   Effective April 1, 2008, wellness program benefits were added (page 82)

10. SELF-FUNDED VISION CARE PROGRAM
     a.   Effective September 1, 2007, the vision care allowances were increased (page 84)

11. HEARING AID PROGRAM
     a.   Effective December 1, 2003, the self-funded hearing aid program was added as a new
          benefit (page 86)

12. HAWAII DENTAL SERVICE
     a.   Effective September 1, 2003, the time frames for dental services were revised:
          i)     Examinations will be changed to once per calendar year (formerly once every 12
                 months)
          ii)    Bitewing x-rays will be changed to twice per calendar year (formerly once every 6
                 months)
          iii) Prophylaxis (cleanings) will be changed to twice per calendar year (formerly once
               every 6 months)
          iv) Stannous Fluoride will be covered at once per calendar year (formerly once every 12
              months)
     b.   Effective September 1, 2006, a patient’s share for services from out-of-sate participating
          dentists will be calculated up to the Delta Dental National Provider Fee
     c.   Effective September 1, 2007, the dental benefits were converted to Evidence Based Plan
          benefits (page 91)

13. GENTLE DENTAL (FORMERLY DENTAL CARE CENTERS OF HAWAII)
     a.   Effective September 1, 2003, the office visit copayment increased to $9.00 per visit
          (formerly $8.00)
     b.   Effective September 1, 2004, a discounted orthodontic program, which covers 24 months
          of usual and customary treatment, is available at predetermined fees (page 95)
     c.   Effective September 1, 2006, Dental Care Centers of Hawaii (DCCH) will now be known
          as Gentle Dental (page 94)
     d.   Effective September 1, 2007, the office copayment increased to $10.00 per visit (formerly
          $9.00) (page 94)



                                               6
      14. UNUM LONG TERM CARE
           a.   Effective April 1, 2005, the voluntary Long Term Care plan was added (page 99)




   If you have any questions about the plan or need additional information, please contact the Trust Fund
Office at (808) 441-8700 (neighbor islands dial direct 1 (888) 520-8078), or write to the Trust Fund Office
at 1440 Kapiolani Boulevard, Suite 800, Honolulu, Hawaii 96814.

                                                 Sincerely,


                                                 BOARD OF TRUSTEES




YOU ARE URGED TO READ THIS BOOKLET CAREFULLY AND BECOME FAMILIAR WITH THE
BENEFITS THAT YOU AND YOUR DEPENDENTS ARE ENTITLED TO RECEIVE.

THIS BOOKLET PROVIDES A SUMMARY OF BENEFITS FOR INFORMATIONAL PURPOSES ONLY.
THE TRUST AGREEMENT, POLICIES, CONTRACTS, AND RULES AND REGULATIONS ADOPTED
BY THE TRUSTEES, AS REFLECTED IN PARTICIPANT NOTICES, ARE THE FINAL AUTHORITIES IN
ALL MATTERS RELATED TO THE HAWAII LABORERS HEALTH AND WELFARE TRUST FUND.
COPIES OF THESE DOCUMENTS ARE AVAILABLE FOR INSPECTION AT THE TRUST FUND
OFFICE DURING REGULAR BUSINESS HOURS.




                                                    7
                                                 TABLE OF CONTENTS

                                                                                                                                             Page


Information Required by the Employee Retirement
  Income Security Act of 1974 (ERISA)......................................................................................... 10

General Information
 Enrollment Forms........................................................................................................................ 13
 Eligible Dependents ..................................................................................................................... 13
 Special Enrollment Periods .......................................................................................................... 14
 Qualified Medical Child Support Orders (QMSCO) ..................................................................... 14
 Surviving Dependents .................................................................................................................. 15
 Self Payment Program ................................................................................................................. 15
 COBRA Program.......................................................................................................................... 15
 Health Insurance Portability and Accountability Act
  Of 1996 (HIPAA) - Creditable Coverage.................................................................................... 17

Benefits for Retired Employees....................................................................................................... 18

Medical Benefits .............................................................................................................................. 23
 Indemnity Medical & Prescription Drug Plan................................................................................ 25
 Kaiser Foundation Health Plan, Inc. Medical
   & Prescription Drug Plan........................................................................................................... 61

Wellness Program Benefits............................................................................................................. 82

Vision Care Benefits........................................................................................................................ 84

Hearing Aid Program....................................................................................................................... 86

Dental Benefits ................................................................................................................................ 87
 Hawaii Dental Service .................................................................................................................. 88
 Gentle Dental ............................................................................................................................... 94

Life Insurance................................................................................................................................. 97

Long Term Care Insurance ............................................................................................................. 99

Claims and Appeals Procedures................................................................................................... 104

Use and Disclosure of Your Health Information............................................................................ 109

Statement of ERISA Rights........................................................................................................... 111




                                                                          8
      HAWAII LABORERS HEALTH AND
         WELFARE TRUST FUND
               1440 Kapiolani Boulevard, Suite 800
                    Honolulu, Hawaii 96814
                     Telephone: 441-8600


                BOARD OF TRUSTEES
EMPLOYER TRUSTEES                         LABOR TRUSTEES
   Anacleto Alcantra                           Toni Figueroa
   Albert Hamamoto                            Donna Kekauoha
      Larry Lum                                Al Lardizabal
   Daniel Nakamura                            Mark Matsumoto
    Harry Ushijima                             Alfonso Oliver


                        CONSULTANT
                  Benefit Plan Solutions, Inc.


            CONTRACT ADMINISTRATOR
                  Pacific Administrators, Inc.


                       LEGAL COUNSEL
                        Pablo Quiban, Esq.


               COLLECTION ATTORNEY
                        Pablo Quiban, Esq.


                         CUSTODIAN
                       Central Pacific Bank


                           AUDITOR
                       Hemming Morse, Inc.


               INVESTMENT MANAGERS
                     Oppenheimer Capital
                   Bishop Street Investment
                        Bank of Hawaii




                                9
                   INFORMATION REQUIRED BY THE
                       EMPLOYEE RETIREMENT
                INCOME SECURITY ACT OF 1974 (ERISA)
PLAN SPONSOR AND ADMINISTRATOR
    Board of Trustees
    Hawaii Laborers Health and Welfare Trust Fund
    1440 Kapiolani Boulevard, Suite 800
    Honolulu, Hawaii 96814
    Telephone: (808) 441-8700
               (888) 520-8078 (toll free from neighbor islands)
  Upon written request, participants and beneficiaries may receive information from the plan
administrator as to whether a particular employer is a sponsor of the plan and, if so, the sponsor’s
address.


IDENTIFICATION NUMBERS
    Assigned by Internal Revenue Service - 99-6014749
    Assigned by Plan Sponsor - Plan Number 501

TYPE OF PLAN
  Welfare - medical, prescription drug, vision care, wellness program, chiropractic care1, acupuncture
care2, dental3, life insurance, disability insurance, long term care insurance5 and hearing aid benefits6.


TYPE OF ADMINISTRATION
  The Board of Trustees has engaged Pacific Administrators, Inc. at 1440 Kapiolani Boulevard, Suite
800, Honolulu, Hawaii 96814 to serve as Contract Administrator for the Health and Welfare Trust Fund.


AGENT FOR SERVICE OF LEGAL PROCESS
    Wayne C.K. Chun
    Pacific Administrators, Inc.
    1440 Kapiolani Boulevard, Suite 800
    Honolulu, Hawaii 96814
    Service of legal process may also be made upon a Plan Trustee.




1
    Available to active construction employees and spouse only.
2
    Available to active construction employees and dependents only.
3
    Available to active construction and active non-construction employees and dependents and retired construction
    and retired non-construction employees and spouse only.
4
    Available to active construction and active non-construction employees only.
5
    Available to active construction and active non-construction employees. Available to dependents of active
    construction and active non-construction employees and retired construction and retired non-construction
    employees and dependents on a voluntary basis.
6
    Available to retired construction and retired non-construction employees and spouses only.




                                                         10
             NAME, TITLE, AND ADDRESS OF PRINCIPAL PLACE
                     OF BUSINESS OF EACH TRUSTEE
     MANAGEMENT                                         LABOR
     Anacleto Alcantra                                  Toni Figueroa
     President                                          Laborers Union Local #368
     Group Builders, Inc.                               1617 Palama Street
     2020 Democrat Street                               Honolulu, Hawaii 96817
     Honolulu, Hawaii 96819

     Albert Hamamoto                                    Donna Kekauoha
     2831 Awaawaloa Street                              Laborers Union Local #368
     Honolulu, Hawaii 96819                             1617 Palama Street
                                                        Honolulu, Hawaii 96817

     Larry Lum                                          Al Lardizabal
     98-1979 Hapaki Street                              Laborers Union Local #368
     Aiea, Hawaii 96701                                 1617 Palama Street
                                                        Honolulu, Hawaii 96817

     Daniel Nakamura                                    Mark Matsumoto
     President                                          Laborers Union Local #368
     Takano Nakamura Landscaping Co.                    1617 Palama Street
     1221 Kapiolani Boulevard, Suite 600                Honolulu, Hawaii 96817
     Honolulu, Hawaii 96814

     Harry Ushijima                                     Alfonso Oliver
     President                                          Laborers Union Local #368
     B&C Masonry                                        1617 Palama Street
     2621 Wai Wai Loop                                  Honolulu, Hawaii 96817
     Honolulu, Hawaii 96819


APPLICABLE COLLECTIVE BARGAINING AGREEMENT
  The current Collective Bargaining Agreement between the Laborers’ International Union of North
America, Local #368, AFL-CIO and the Building Industry Labor Association, General Contractors Labor
Association, Hawaii Collective Bargaining Council of Landscape & Irrigation Contractors, Hawaii Wall and
Ceiling Industry Association, Mason Contractors Association, and certain other employers, provides for
participation by all signatory Contractors in the Hawaii Laborers Health and Welfare Trust Fund.
  A copy of the Collective Bargaining Agreement may be obtained by participants and beneficiaries from
the Contract Administrator upon written request, and is available for examination by participants and
beneficiaries at the Trust Fund Office.

SOURCE OF CONTRIBUTIONS
   The funds to pay for plan benefits and expenses are contributed by 1) employers who are parties to a
Collective Bargaining Agreement which requires contributions to the Hawaii Laborers Health and Welfare
Trust Fund, 2) the Union on behalf of its staff employees, and 3) active and retired participants (i.e.,
COBRA payments, self-payments, and retiree copayments). The amount of employer contribution is
calculated by multiplying the contribution rate specified in the Collective Bargaining Agreement by either
1) the number of hours worked during the month by each covered employee (for hourly contributions) or
2) the number of covered employees (for flat monthly contributions). The COBRA payments, self-
payments, and retiree copayments are set by the Trustees, from time to time.




                                                   11
FUNDING MEDIUM
   All contributions to the Health and Welfare Trust Fund are transmitted to the Trust Department of
Central Pacific Bank in Honolulu, which serves as Custodian for the Trust Fund. Contributions are held in
a custody account out of which premium payments are made to the insurance carriers that provide
benefits, as directed by the Contract Administrator, and benefits are paid to participants. Funds in excess
of those needed for immediate requirements are invested by the investment managers in accordance with
general investment guidelines, as determined and reviewed by the Trustees.

FISCAL YEAR
  September 1st through the following August 31st.

AMENDMENT AND ELIMINATION OF BENEFITS AND TERMINATION OF TRUST
FUND

  The Trust Agreement for the Hawaii Laborers Health and Welfare Trust Fund gives the Board of
Trustees the authority to terminate the plan or to amend or eliminate the eligibility requirements and
benefits available under the plan at any time.

  For example, benefits may be amended or eliminated if the Trustees determine that the Trust Fund
does not have sufficient funds to pay for the benefits being provided.

  The Trust Fund may be terminated by the Union(s) and Association(s) or by termination of the Labor
Agreements.

  If benefits under the Hawaii Laborers Health and Welfare Trust Fund are amended or eliminated,
participants and beneficiaries are eligible for only those benefits which are available after the amendment
or elimination of benefits. Participants and beneficiaries have the obligation to read all participant and
beneficiary notices issued pertaining to the amendment or elimination of benefits.

   If the Hawaii Laborers Health and Welfare Trust Fund is terminated, benefits will be provided to
participants and beneficiaries who have satisfied the eligibility requirements established by the Board of
Trustees only as long as funds are available. Benefits under the Trust Fund are not vested or guaranteed.
Participants and beneficiaries have the obligation to read the Summary Plan Description (SPD) and all
participant and beneficiary notices issued pertaining to the termination of the Trust Fund and once notified
by the insurance carriers of the termination of the plan, should contact the various insurance carriers for
information on conversion to an individual plan offered by the respective insurance carriers.

  Upon the termination of the Hawaii Laborers Health and Welfare Trust Fund, any assets remaining
shall be used solely to pay for benefits and for expenses of administration incident to providing said
benefits. Participants and beneficiaries shall have no right to any remaining assets of the Trust Fund.




                                                    12
                                   GENERAL INFORMATION
ENROLLMENT FORMS
  In order to be eligible for benefits, you and your eligible dependents must have a current Trust Fund
enrollment form and all other applicable insurance carrier enrollment forms on file at the Hawaii Laborers
Health and Welfare Trust Fund Office. If you have not done so already, you should complete the
enrollment forms, listing your choice of medical and dental plans, your beneficiary or beneficiaries, and all
your eligible dependents. If you are married, you must submit a copy of your marriage certificate. If you
have dependent children, you must submit a copy of their birth certificates or adoption papers.
   Return the completed enrollment forms to the Trust Fund Office. The Trust Fund Office will process the
insurance carrier enrollment forms and retain the Trust Fund enrollment form.
   No premiums will be paid until the required Trust Fund enrollment forms have been completed and filed
with the Trust Fund Office.
   It is important to keep the Trust Fund Office informed of any change in your personal or family
situation or mailing address. Let the Trust Fund Office know:
         If you change your mailing address or telephone number,
         If you get married, divorced, or widowed,
         If you wish to add an additional dependent child (such as a new baby or an adopted child).

ELIGIBLE DEPENDENTS
   Eligible dependents include your legal spouse and all unmarried children under 19 years of age. The
term “children” includes natural children, stepchildren, and legally adopted children who are dependent
upon you for support as attested by income tax information and live with you in a regular parent-child
relationship. The Board of Trustees may require any information necessary to determine the eligibility of a
dependent.

  To add a spouse, you must submit a copy of your marriage certificate and a completed
enrollment form to the Trust Fund Office within 45 days from the date of marriage. If you do not
notify the Trust Fund Office within this 45-day period, retroactive coverage will not be made. Instead,
coverage for your spouse will be effective on the first day of the month following the date that a copy of
your marriage certificate and the completed enrollment form are received by the Trust Fund Office.
  To add a dependent child, you must submit proper documentation, in writing, to the Trust Fund Office
within 45 days of birth, adoption or placement for adoption. If you do not notify and submit the proper
documentation to the Trust Fund Office within this 45-day period, retroactive coverage will not be made.
Instead, coverage for your dependent child will be effective on the first day of the month following the date
that the birth certificate, adoption, or guardianship papers and your completed enrollment form are
received by the Trust Fund Office. NOTE: To add a newborn child as a dependent, you may call the
Trust Fund Office to give notification of the birth. Your telephone call will be documented as initial
notification to the Trust Fund Office and coverage will become effective on the newborn’s date of birth
provided that you submit a completed enrollment form and a copy of the birth certificate to the Trust Fund
Office within 45 days from the date of birth.
  Foster children placed through a Government agency are not covered by the Plan.
   A dependent child who, upon attaining age 19 has a mental or physical disability which renders him or
her incapable of self-support, will continue to be covered for benefits as long as such child remains
unmarried, disabled, and incapable of self-support, provided that the child was disabled and covered
under the plan prior to age 19. You must, however, submit satisfactory proof to the Trust Fund of the
child’s incapacity upon attaining age 19, and upon request thereafter. Coverage for such child shall
terminate upon the earliest of the following: 1) his or her marriage, 2) he or she becoming capable of self-
support, 3) failure to provide proof of continued disability, or 4) termination of your eligibility.




                                                     13
   A former spouse, upon divorce, or a child who attains age 19 or who marries, may call or write to
Kaiser Foundation Health Plan, Inc. for information on conversion to an Individual or Family Plan offered
directly by Kaiser within 30 days of the change in eligibility status

SPECIAL ENROLLMENT PERIODS
  In compliance with the Health Insurance Portability and Accountability Act of 1996 (HIPAA), the Hawaii
Laborers Health and Welfare Trust Fund allows enrollment during a special enrollment period if you
qualify under one (1) of the following two (2) requirements:
      1. If you declined coverage for yourself and/or your dependent(s) because of other health
         insurance or coverage under another group health plan, you may enroll yourself and/or your
         dependents in this plan provided you request enrollment within 30 days after coverage under
         the other health plan ends.
      2. If you obtain a new dependent through marriage, birth, adoption, or placement for adoption, you
         may enroll your new dependent provided you request enrollment within 30 days after the date
         of marriage, birth, adoption, or placement for adoption.
  If you fail to request enrollment during this special 30-day period, you must wait until the next open
enrollment period. To request special enrollment, contact the Trust Fund Office.

QUALIFIED MEDICAL CHILD SUPPORT ORDERS (QMCSO)
   The Hawaii Laborers Health and Welfare Trust Fund is required to provide benefits in accordance with
the requirements of a “qualified medical child support order”. A “qualified medical child support order” is a
certified copy of a judgment, decree, or order (including a court’s approval of a domestic relations
settlement agreement) issued by a court of competent jurisdiction that requires a group health plan to
provide coverage to the child(ren) of a plan participant pursuant to state domestic relations law. In order
to be “qualified”, the order must clearly specify:
    1. The name and last known address of the participant and each alternate recipient;
    2. A reasonable description of the type of coverage to be provided by the group health plan, or the
       manner in which the coverage is to be determined;
    3. The period for which coverage must be provided; and
    4. Each plan to which the order applies.

  In addition, the medical child support order cannot require the Trust Fund to provide any type or form of
benefit, or benefit option, that the Trust Fund does not already offer (except to the extent required by law).
   All medical child support orders shall be delivered to the Administrator of the Hawaii Laborers Health
and Welfare Trust Fund. The Trust Fund will determine whether or not an order meets the criteria to be
considered a qualified medical child support order and will notify the participant and alternate recipient(s)
of such determination. An alternate recipient is any child of a participant who is recognized as being
entitled to coverage under the participant’s group health plan.

  For further information, contact the Trust Fund Office.




                                                     14
SURVIVING DEPENDENTS
  Effective August 1, 1979, if you are eligible for benefits at the time of your death, your surviving spouse
and dependent children may continue coverage for medical, vision care, and dental (spouse only)
benefits as follows:
      1. One (1) year coverage without payment of contributions from the date of your death, provided
         your spouse does not remarry, or
      2. Continuation of coverage as provided for under the Self-Payment or COBRA Programs (see
         sections below).
  Once your spouse and dependent children have exhausted coverage under the option selected, their
benefits will cease. They may not extend their coverage under the other option.

HOW TO CONTINUE YOUR COVERAGE IF YOU LOSE YOUR ELIGIBILITY
   When your eligibility for benefits terminates, you may continue your coverage by electing one (1) of the
following two (2) options:
      1. Self-Payment Program, or
      2. COBRA Program.

Self-Payment Program
  Since September 1, 2000, the Hawaii Laborers Health and Welfare Trust Fund has been offering the
Self-Payment Program as an option to the COBRA Program for you to continue your benefits when you
become ineligible for benefits.
  Under the Self-Payment Program, you may continue medical and prescription drug benefits only for
twelve (12) consecutive months. If you choose to continue your benefits under the Self-Payment
Program, you give up your right to choose the COBRA option described in the following section.
  To continue coverage under the Self-Payment Program, you and/or your dependents must pay an
amount equal to 102% of the actual cost of the benefits, as determined by the Board of Trustees.
  If you wish to continue your benefits under the Self-Payment Program, contact the Hawaii Laborers
Health and Welfare Trust Fund Office.

COBRA Program
  The Hawaii Laborers Health and Welfare Trust Fund, in compliance with the Consolidated Omnibus
Budget Reconciliation Act of 1985 (COBRA), as amended, currently offers qualified employees and/or
dependents of employees who lose coverage as a result of a “qualifying event” the opportunity to
continue coverage for a specified period of time as outlined below:

                                                                        Maximum Period of
                        Qualifying Event                               Continuation Coverage

         Employee’s termination of employment                                 18 months
         (for reasons other than gross misconduct)

         Reduction in hours worked by employee                                18 months

         Death of employee                                                    36 months

         Divorce or legal separation                                          36 months

         Employee becomes entitled to Medicare                                36 months

         Dependent child ceases to be eligible as a                           36 months
         dependent as defined by the Trust Fund


                                                     15
  If the continuation coverage is for a maximum period of 18 months and during that period another
qualifying event occurs which would entitle your spouse or dependent child to coverage for a maximum of
36 months, the coverage for your spouse and/or dependent child will be extended to 36 months from the
date of the first qualifying event.

   If the continuation coverage is for a maximum period of 18 months and you, your spouse, or your
covered dependent child is determined to be disabled under the Social Security Act at any time during the
first 60 days of your COBRA continuation coverage, coverage for all covered family members will be
extended to 29 months. However, in order to be eligible for this extended coverage, the Hawaii Laborers
Health and Welfare Trust Fund Office must be notified of the qualification for Social Security disability
within 60 days after the disabled individual receives the Social Security determination letter and before
the end of the 18-month COBRA continuation period. In addition, the Trust Fund Office must be notified
within 30 days after receipt of any Social Security determination letter indicating that the individual is no
longer disabled.

   The Hawaii Laborers Health and Welfare Trust Fund Office will determine the occurrence of a
qualifying event in the event of your termination or reduction in hours. The qualifying event in these cases
will be the date of your loss of coverage under the plan. Your employer is responsible for notifying the
Trust Fund Office within 30 days in the event of your death, termination of employment, reduction in
hours, or entitlement to Medicare benefits. You, your spouse, or your dependent children are responsible
for notifying the Trust Fund Office within 60 days in the event of divorce, legal separation, entitlement to
Medicare benefits, or if a dependent child ceases to be an eligible dependent.

   When the Hawaii Laborers Health and Welfare Trust Fund Office receives notice or otherwise
determines that a qualifying event has occurred, the Trust Fund Office will notify you regarding COBRA
continuation coverage within 14 days. You, your spouse, and/or dependent children will have 60 days
after the date your coverage under the Trust Fund terminates or the date the Trust Fund Office sends
notice to you, your spouse, and/or dependent children, whichever is later, to elect COBRA continuation
coverage (the “election period”).

  Each qualified beneficiary is entitled to make his or her own independent election to continue coverage
under COBRA. A qualified beneficiary who is the covered employee may elect COBRA on behalf of the
other qualified beneficiaries. However, if the covered employee rejects COBRA continuation coverage,
the covered employee’s spouse and/or dependent children have their own independent right to elect
COBRA continuation coverage. If the qualified beneficiary is a minor child, the child’s parent or legal
guardian may make the election.

  If a qualified beneficiary waives coverage under the COBRA Program, the qualified beneficiary can
revoke the waiver at any time before the end of the election period.

  A qualified beneficiary is any employee, spouse, or dependent child who is covered by the Hawaii
Laborers Health and Welfare Trust Fund on the day before a qualifying event occurs. A qualified
beneficiary also includes a child who is born to or placed for adoption with a covered employee during a
period of COBRA continuation coverage.

   If you are covered under another employer’s group health plan or Medicare prior to your COBRA
election, your prior coverage will not disqualify you from electing COBRA.

  Under the COBRA Program, you will be covered for medical, prescription drug, vision, wellness and
dental benefits. Life insurance and long term care benefits are not available under the COBRA Program.

  To continue coverage under the COBRA Program, you and/or your dependents must pay an amount
equal to 102% of the actual cost of the benefits, as determined by the Board of Trustees. However, if you
or your dependent is determined to be disabled by the Social Security Administration, the payment
amount will increase to 150% of the actual cost of the benefits, as determined by the Board of Trustees,
beginning with the 19th month of coverage.




                                                     16
  The first COBRA payment must be received by the Hawaii Laborers Health and Welfare Trust Fund
Office within 45 days after the COBRA election date and must include payment for the period from the
date that coverage is terminated under the Hawaii Laborers Health and Welfare Trust Fund through the
date that COBRA election is made. The Hawaii Laborers Health and Welfare Trust Fund Office must
receive subsequent payments within 30 days after the first day of the payment period.

  Coverage under the COBRA Program may be terminated if:
   1. The Hawaii Laborers Health and Welfare Trust Fund no longer provides health coverage, or
   2. The required payment is not made on time, or
   3. The qualified beneficiary becomes entitled to Medicare, or
   4. The qualified beneficiary becomes eligible under another employer’s group health plan. (Exception:
      If the group plan contains an exclusion or limitation with respect to any pre-existing condition,
      COBRA may be continued until the end of the exclusion or limitation period.)
  If you have any questions about your COBRA rights and obligations, please contact the Hawaii
Laborers Health and Welfare Trust Fund Office.


HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT OF 1996
(HIPAA) – CREDITABLE COVERAGE
     You will 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, or when your COBRA continuation coverage ceases, or if you request a
certificate within 24 months after losing coverage. Without evidence of creditable coverage, you may be
subject to a pre-existing condition exclusion in your coverage for 12 months (18 months for late enrollees)
after your enrollment date.




                                                    17
                    BENEFITS FOR RETIRED EMPLOYEES
    When you retire on a pension from the Hawaii Laborers Pension Trust Fund or on a pension from the
Laborers International of North American National (Industrial) Union Pension Fund and meet the
requirements of the applicable sections outlined below, you may be eligible for health and welfare
benefits from the Hawaii Laborers Health and Welfare Trust Fund.

RETIREES OF THE HAWAII LABORERS PENSION TRUST FUND
     Eligible retirees, who reside in the United States, will be eligible for medical, prescription drug, vision
care, dental and life insurance benefits. Eligible retirees who reside in the Philippines, will be eligible for
medical and prescription drug benefits, as described in the “Self-Funded Medical and Prescription Drug
Plan for Construction Retirees Residing in the Philippines” plan (effective February 1, 2002), and life
insurance benefits. These benefits will be provided to you only during those months for which you
actually receive pension benefits from the Hawaii Laborers Pension Trust Fund and make the required
retiree copayment to the Trust Fund.

    Retired on or after September 1, 1985 (but prior to November 1, 1986)
    For retirees who retired on or after September 1, 1985, but prior to November 1, 1986, only those
    retirees who meet one (1) of the following eligibility requirements and make the required retiree
    copayment will be eligible for health and welfare benefits from this Trust Fund:

        1. Retire on a pension, other than a Disability Pension, from the Hawaii Laborers Pension Trust
           Fund after having earned at least ten (10) years of Vesting Service or Pension Credit under
           that plan in the State of Hawaii; or

        2. Retire on a Disability Pension from the Hawaii Laborers Pension Trust Fund after having
           earned at least two (2) quarters of Current Service Credit in the two (2) consecutive Plan
           Year period prior to the Plan Year in which the retiree became disabled, as a result of actual
           employment in the State of Hawaii.

EXCEPTION: IF YOU LAST WORKED IN AND RETIRED ON A PENSION FROM A MULTI-EMPLOYER
PENSION FUND (A PENSION FUND TO WHICH MORE THAN ONE (1) EMPLOYER CONTRIBUTES)
IN THE CONSTRUCTION INDUSTRY IN THE STATE OF HAWAII, OTHER THAN THE HAWAII
LABORERS PENSION TRUST FUND, YOU WILL NOT BE ELIGIBLE FOR ANY BENEFITS THROUGH
THE TRUST FUND EVEN THOUGH YOU MEET THE ELIGIBILITY REQUIREMENTS LISTED ABOVE.


    Retired on or after November 1, 1986 (but prior to September 1, 1993)
    For retirees who retired on or after November 1, 1986 but prior to September 1, 1993, only those
    retirees who meet one (1) of the following eligibility requirements and make the required retiree
    copayment will be eligible for health and welfare benefits from this Trust Fund:
        1. Retire on a pension, other than a Disability Pension, from the Hawaii Laborers Pension Trust
           Fund after having earned at least ten (10) years of Vesting Service or Pension Credit under
           that plan in the State of Hawaii; or
        2. Retire on a Disability Pension from the Hawaii Laborers Pension Trust Fund after having
           earned at least two (2) quarters of Current Service Credit in the two (2) consecutive Plan
           Year period prior to the Plan Year in which the retiree became disabled, as a result of actual
           employment in the State of Hawaii.

EXCEPTION: IF YOU LAST WORKED IN AND RETIRED ON A PENSION FROM A MULTI-EMPLOYER
PENSION FUND (A PENSION FUND TO WHICH MORE THAN ONE (1) EMPLOYER CONTRIBUTES)
IN THE CONSTRUCTION INDUSTRY IN THE STATE OF HAWAII, OTHER THAN THE HAWAII
LABORERS PENSION TRUST FUND, YOU WILL NOT BE ELIGIBLE FOR ANY BENEFITS THROUGH
THE TRUST FUND EVEN THOUGH YOU MEET THE ELIGIBILITY REQUIREMENTS LISTED ABOVE.




                                                      18
    Retired on or after September 1, 1993 (but prior to May 1, 2002)
    For those retirees who retired on or after September 1, 1993 but prior to May 1, 2002, only those
    retirees who were covered for health and welfare benefits under the Hawaii Laborers Health and
    Welfare Trust Fund for at least six (6) of the eight (8) Eligibility Quarters immediately preceding his or
    her retirement and who meet one (1) of the following eligibility requirements and make the required
    retiree copayment will be eligible for health and welfare benefits from this Trust Fund:
        1. Retire on a pension, other than a Disability Pension, from the Hawaii Laborers Pension Trust
           Fund after having earned at least ten (10) years of Vesting Service or Pension Credit under
           that plan in the State of Hawaii; or
        2. Retire on a Disability Pension from the Hawaii Laborers Pension Trust Fund after having
           earned at least two (2) quarters of Current Service Credit in the two (2) consecutive Plan
           Year period prior to the Plan Year in which the retiree became disabled, as a result of actual
           employment in the State of Hawaii.

EXCEPTION: IF YOU LAST WORKED IN AND RETIRED ON A PENSION FROM A MULTI-EMPLOYER
PENSION FUND (A PENSION FUND TO WHICH MORE THAN ONE (1) EMPLOYER CONTRIBUTES)
IN THE CONSTRUCTION INDUSTRY IN THE STATE OF HAWAII, OTHER THAN THE HAWAII
LABORERS PENSION TRUST FUND, YOU WILL NOT BE ELIGIBLE FOR ANY BENEFITS THROUGH
THE TRUST FUND EVEN THOUGH YOU MEET THE ELIGIBILITY REQUIREMENTS LISTED ABOVE.

    Retire on or after May 1, 2002
    If you retire on or after May 1, 2002 and are receiving a monthly pension from the Hawaii Laborers
    Pension Trust Fund, you and your eligible dependents will be eligible for health and welfare benefits
    under the Hawaii Laborers Health and Welfare Trust Fund if all of the following eligibility requirements
    are met :
        1. You were covered for health and welfare benefits under the Hawaii Laborers Health and
           Welfare Trust Fund for at least eighteen (18) of the twenty-four (24) months immediately
           preceding your retirement. Coverage includes eligibility due to work hours, hour bank hours,
           or continuation coverage under the COBRA or Self-Payment Programs,
        2. You and your dependents are enrolled in both Medicare Parts A and B, if eligible,
        3. You make the required copayment (described below), and
        4. You continue to reside in the United States of America or the Philippines.

EXCEPTION: IF YOU LAST WORKED IN AND RETIRED ON A PENSION FROM A MULTI-EMPLOYER
PENSION FUND (A PENSION FUND TO WHICH MORE THAN ONE (1) EMPLOYER CONTRIBUTES)
IN THE CONSTRUCTION INDUSTRY IN THE STATE OF HAWAII, OTHER THAN THE HAWAII
LABORERS PENSION TRUST FUND, YOU WILL NOT BE ELIGIBLE FOR ANY BENEFITS THROUGH
THE TRUST FUND EVEN THOUGH YOU MEET THE ELIGIBILITY REQUIREMENTS LISTED ABOVE.

     If you reside in the United States of America, you and your eligible dependents will be covered for
medical, prescription drug, vision care, dental (you and your spouse only), and life insurance (you and
your spouse only) benefits as described in this booklet. If you reside in the Philippines, you and your
eligible dependents will be covered for medical and prescription drug benefits as described in the
separate booklet entitled “MEDICAL AND PRESCRIPTION DRUG BENEFITS FOR CONSTRUCTION
RETIREES RESIDING IN THE PHILIPPINES.”




                                                     19
RETIREES OF THE LABORERS INTERNATIONAL UNION OF NORTH AMERICA
NATIONAL (INDUSTRIAL) PENSION FUND
    If you retire on or after November 1, 1988 and are receiving a monthly pension from the Laborers
International Union of North America National (Industrial) Pension Fund, you and your eligible
dependents will be eligible for health and welfare benefits under the Hawaii Laborers Health and Welfare
Trust Fund . Coverage may be available if all of the following eligibility requirements are met :
    1. You were covered for health and welfare benefits under the Hawaii Laborers Health and Welfare
       Trust Fund for at least five (5) consecutive years immediately preceding your retirement.
       Coverage includes eligibility due to work hours, hour bank hours, or continuation coverage under
       the COBRA or Self-Payment Programs,
    2. You and your dependents are enrolled in both Medicare Parts A and B, if eligible,
    3. You make the required copayment (described below), and
    4. You continue to reside in the United States of America or the Philippines.

EXCEPTION: IF YOU LAST WORKED IN AND RETIRED ON A PENSION FROM A MULTI-EMPLOYER
PENSION FUND (A PENSION FUND TO WHICH MORE THAN ONE (1) EMPLOYER CONTRIBUTES)
IN THE CONSTRUCTION INDUSTRY IN THE STATE OF HAWAII, OTHER THAN THE HAWAII
LABORERS PENSION TRUST FUND, YOU WILL NOT BE ELIGIBLE FOR ANY BENEFITS THROUGH
THE TRUST FUND EVEN THOUGH YOU MEET THE ELIGIBILITY REQUIREMENTS LISTED ABOVE.

RETIREE COPAYMENT
   In order for you to receive retiree health and welfare benefits, you must meet the applicable eligibility
requirements listed in the previous sections and contribute towards the cost of these benefits through
copayments. The retiree copayments are subject to review by the Board of Trustees, from time to time,
and may be changed at any time at the sole discretion of the Trustees.
   The monthly copayment that an eligible retiree must pay is as follows:

                                                                   Monthly Copayment
                Non-Medicare Retirees                           $145.00 (Effective 09/01/01)
                Medicare Retirees                               $ 85.00 (Effective 09/01/06)


   Payment of the retiree copayment must be made by the 5th day of each month in order for you to
receive benefits for that month. Failure to make the required copayment, or such other payment as may
be determined by the Board of Trustees, will result in the permanent cancellation of your health and
welfare benefits.
    All retirees and spouses must enroll in Medicare Parts A and B, if eligible. If you and/or your spouse
are eligible for Medicare but are not enrolled, you must pay an additional amount each month for each
plan beneficiary who is eligible for but not enrolled in Medicare Parts A and B. This amount is in addition
to the monthly retiree copayment.

MEDICAL BENEFITS
Non-Medicare Retirees and Dependents (Under Age 65)
   Retirees and dependents who are not eligible for Medicare who reside in the United States will be
covered under the Indemnity (Self-Funded) Comprehensive Medical Plan described on pages 25 - 52 or
the Kaiser Foundation Health Plan, Inc. Medical Plan described on pages 61 - 64, depending on which
plan is selected.




                                                    20
Medicare Retirees and Dependents (Age 65 and Older)
   Retirees and dependents who are eligible for Medicare Parts A and B and who reside in the State of
Hawaii will be covered under the Hawaii Medical Service Association (HMSA) 65C Plus Plan or the Kaiser
Senior Advantage Plan described on page 65, depending on which plan is selected. For a complete
description of HMSA’s 65C Plus Plan, refer to the separate Description of Benefits brochure and Member
handbook. Medicare benefits must be assigned to either HMSA or Kaiser, depending on which plan is
selected.
   Retirees and dependents eligible for Medicare Parts A and B who reside in the continental United
States will be covered under the Indemnity (Self-Funded) Comprehensive Medical Plan described on
pages 25 - 52. Medicare benefits must be assigned to the Hawaii Laborers Health and Welfare Trust
Fund’s Indemnity (Self-Funded) Comprehensive Medical Plan.
   Retirees and dependents who reside in the Philippines will be covered under the Self-Funded Medical
Plan for Construction Retirees.

Medicaid Retirees
   A Retiree with Medicaid is not eligible for the Trust Fund’s Medicare Supplemental Medical or Drug
coverage while enrolled by Medicaid. However, if you lose your Medicaid coverage, you will be eligible to
re-enroll in this Plan under the Special Enrollment provision on page 14.

HOW TO SECURE MEDICARE COVERAGE
    All retirees and dependents eligible for Medicare must enroll in Medicare Parts A and B. In addition, all
retirees and dependents who retire with a Social Security disability must also enroll in Medicare Parts A
and B.
   When you become eligible for Medicare benefits provided under the Social Security law, you should
contact the local Social Security Office and arrange for both Part A and Part B coverage. Part A covers
hospital care while Part B covers physician services. You will be covered by Medicare as soon as you
reach the age at which you are eligible only if you apply during the three-month period just prior to
reaching your eligible age. If you fail to apply during the ninety (90) days prior to your eligible age, you
may still apply during the first three (3) months of any later calendar year. However, you may lose some
Medicare benefits during the period that you are not enrolled.


PRESCRIPTION DRUG BENEFITS
Non-Medicare Retirees and Dependents (Under Age 65)
   Retirees and dependents under 65 years of age who are not eligible for Medicare will be covered
under the Indemnity (Self-Funded) Prescription Drug Plan described on pages 53 - 57 or the Kaiser
Prescription Drug Plan described on pages 78 - 79 depending on which plan is selected.

Medicare Retirees and Dependents (Age 65 and Older)
    A Retiree (or dependent) cannot be enrolled in the Trust Fund’s Medicare Drug program and enrolled
    in a Medicare subsidized drug plan or another Medicare Part D drug plan; the Retiree must choose
    one plan to be enrolled in.
    Retirees and dependents age 65 and older who are enrolled in HMSA 65 C Plus will be covered
    under HMSA’s Group Medicare Drug Plan. For a complete description of HMSA’s Medicare Part D
    prescription drug benefits, refer to the separate Description of Benefits brochure and Member
    handbook.
    Retirees and dependents age 65 and older who are enrolled in Kaiser Senior Advantage will be
    covered under the Kaiser Prescription Drug Plan described on pages 78 - 80, which includes
    Medicare Part D.




                                                     21
    Retirees and dependents age 65 years and older who are eligible for and enrolled in Medicare Parts
    A and B and reside in the continental United States must enroll in an approved Medicare Part D plan
    in your state of residence. The Trust Fund will reimburse you for the Medicare Part D premium, on a
    quarterly basis, up to the standard Medicare Part D premium adopted by the Trustees for retirees
    residing in the State of Hawaii. You must submit the proper documentation of your enrollment in an
    approved Medicare Part D program in your state of residence and a copy of that program to the Trust
    Fund office.

    A Retiree who qualifies for Medicare Drug Limited Income Subsidy is not eligible for the Trust Fund’s
    Medicare Drug Program; however, the Retiree may be reimbursed by the Trust Fund for any
    unsubsidized drug premium, on a quarterly basis, not to exceed the Medicare Part D monthly
    premium. In order to receive this reimbursement, you must submit the following documentation to
    the Trust Fund office:
       1)   a copy of your Limited Income Subsidy approval letter from the Social Security
            Administration; and
       2)   proof of your payment of the unsubsidized portion of your Medicare Drug Plan premium.
    IMPORTANT NOTE: If you do not submit all of the required documentation to the Trust Fund office,
    no reimbursement will be made.


VISION CARE BENEFITS
   Retirees and their dependents are eligible for the vision care benefits described on page 84 as long as
they reside in the United States.

HEARING AID PROGRAM
   Retirees and spouses covered under the HMSA 65C Plus Plan or the Kaiser Senior Advantage Plan
are covered for the hearing aid program benefits described on page 86 as long as they reside in the
United States. Dependent children are not covered.

DENTAL BENEFITS
   Retirees and their spouses only are eligible for the dental benefits described on page 87 as long as
they reside in the United States. Dependent children are not covered. Retirees residing on Oahu may
select either the Hawaii Dental Service (HDS) dental plan or the Gentle Dental plan. Retirees residing on
the neighbor islands and the continental United States are covered under the HDS dental plan.

LIFE INSURANCE
  Retirees and their spouses only are covered for the life insurance benefits described on page 97.
Dependent children are not covered.
    For the purpose of life insurance, the term retired employee is an employee who is receiving a pension
from the Hawaii Laborers Pension Trust Fund or the Laborers International Union of North America
National (Industrial) Pension Fund and is no longer eligible for benefits as an active employee under the
eligibility rules of the Hawaii Laborers Health and Welfare Trust Fund.

LONG TERM CARE
   Retirees and their family members who reside in the United States have an option to purchase long
term care benefits as described on pages 99 - 103.

RETIREE BENEFITS ARE NEITHER GUARANTEED NOR VESTED FOR THE LIFE OF THE RETIREE
AND WILL BE PROVIDED ONLY AS LONG AS FUNDS ARE AVAILABLE. THE BOARD OF
TRUSTEES RESERVES THE RIGHT, AT ITS SOLE DISCRETION, TO MODIFY THE PLAN WITH
REGARD TO ELIGIBILITY REQUIREMENTS AND BENEFITS AVAILABLE, TO REQUIRE A RETIREE
CONTRIBUTION FOR THE COST OF BENEFITS, OR TO TERMINATE BENEFITS AT ANY TIME.




                                                   22
                                  MEDICAL BENEFITS
CHOICE OF PLANS
You may choose one (1) of the following medical plans:
   Non-Medicare Retirees and Dependents (Under Age 65)
   1. The Indemnity (Self-Funded) Comprehensive Plan available on all islands, or
   2. The Kaiser Foundation Health Plan available on Hawaii, Maui, and Oahu.
       The principal benefit provisions of the Indemnity (Self-Funded) Comprehensive Medical Plan and
       the Kaiser Health Plan are summarized in this booklet. You and your spouse should compare the
       benefits of each plan carefully before choosing a plan.
       If you reside outside the Kaiser Hawaii service area, you are not eligible to enroll in the Kaiser
       Plan. If you enroll in the Kaiser Plan and subsequently move outside of the Kaiser Hawaii service
       area for more than 90 days, you will not be allowed to continue coverage under the Kaiser Plan.
       You must enroll in the Indemnity (Self-Funded) Comprehensive Plan.

   Medicare Retirees and Dependents Who Reside in Hawaii (Age 65 and Older)
   1. The Hawaii Medical Service Association (HMSA) 65C Plus Plan available on all islands, or
   2. The Kaiser Foundation Health Plan Senior Advantage Plan available on Hawaii, Maui, and Oahu.
       The principal benefit provisions of the Kaiser Senior Advantage Plan are summarized in this
       booklet. For a complete description of HMSA’s 65 C Plus Plan, refer to the separate Description
       of Benefits brochure and Member handbook. You and your spouse should compare the benefits
       of each plan carefully before choosing a plan.
            If you enroll in the Kaiser Senior Advantage Plan and subsequently move to a Neighbor
            Island where the Senior Advantage Plan is not available, you will not be allowed to continue
            coverage under the Kaiser Senior Advantage Plan. You must enroll in the HMSA 65 C Plus
            Plan.
            If you enroll in the HMSA 65 C Plan or the Kaiser Senior Advantage Plan and subsequently
            move outside the State of Hawaii for more than 90 days, you will not be allowed to continue
            coverage under these plans. You will be covered under the Trust Fund’s Self-Funded
            Supplemental Medical Plan to Medicare Parts A and B.

   Medicare Retirees and Dependents Who Reside in the Continental United States (Age 65 and
   Older)
   1. The Trust Fund’s Self-Funded Supplemental Medical Plan to Medicare Parts A and B
       The Trust Fund’s Supplemental Medical Plan for retirees and dependents who are eligible for
       Medicare and who reside outside the State of Hawaii will pay benefits that supplement Medicare
       Parts A and B. You must be enrolled in Medicare Parts A and B. Your Medicare benefits will be
       primary and the Supplemental Medical Plan will be secondary to Medicare.

      For specific benefits under your Medicare Parts A and B coverage, please refer to “Medicare &
   You”, the official government handbook which contains important information about your Medicare
   benefits, or visit the Medicare website at “my.medicare.gov”.

   Retirees Who Reside in the Philippines
   1. The Trust Fund’s Self Funded Medical Plan for Construction Retirees Residing in the Philippines.
      Please contact the Trust Fund Office for further information concerning this Plan.




                                                  23
OPEN ENROLLMENT PERIOD
    You may change medical plans during the annual open enrollment period. If you wish to change
plans, contact the Trust Fund Office during the months of December and January of any year. The
change will become effective March 1. No change between medical plans may be made at any other
time, except if:
      1.   You are enrolled in the Kaiser Plan or Kaiser Senior Advantage Plan and subsequently move
           outside of the Kaiser Hawaii service area for more than 90 days or move to an island where
           the plans are not available, or
      2.   You are enrolled in the HMSA 65C Plus Plan and subsequently move outside of Hawaii for
           more than 90 days, or
      3.   You meet one (1) of the requirements specified in the Special Enrollment Period section on
           page 14.

HOW TO SECURE BENEFITS
   The medical plan you select will send you a membership card. Contact the Trust Fund Office if you
have not received, or have lost, your membership card.
    If you are an Indemnity (Self-Funded) Comprehensive Plan member, show the doctor, hospital or
laboratory your membership card. If you do not have your membership card when you are scheduling or
seeking medical care, be sure to tell the provider in advance that you are an Indemnity (Self-Funded)
Comprehensive Plan member and you belong to the Hawaii Laborers Health and Welfare Trust Fund.
    If you are a Kaiser member, show your Kaiser membership card when going to the Kaiser Hospital or
Clinic for services. If you do not have your membership card when you are scheduling medical care, be
sure to tell the appointment clerk that you are a Kaiser member and you belong to the Hawaii Laborers
Health and Welfare Trust Fund.
    If you do not have your membership card available, ask the doctor or facility rendering services to
contact the Trust Fund Office to confirm your eligibility.




                                                  24
                         INDEMNITY (SELF-FUNDED)
                           COMPREHENSIVE PLAN
                                      MEDICAL BENEFITS
  The Hawaii Laborers Health and Welfare Trust Fund has contracted with Pacific Administrators, Inc.
(PAI) to handle the claims administration for the Indemnity Comprehensive Plan. This means that if you
choose the Indemnity Comprehensive Plan, your physician, hospital, or you will file claims directly with
the PAI Claims Office. If you have any questions about payments made by the PAI Claims Office, or any
other aspect of your coverage, you should call the PAI Claims Office.


                                           PAI Claims Office
                                   1440 Kapiolani Boulevard, Suite 800
                                        Honolulu, Hawaii 96814
                                   Phone: 441-8700 or 1 (888) 520-8078
                                            (neighbor islands)



                                      IMPORTANT FACTS

UNDERSTANDING YOUR MEDICAL PLAN
  Your plan pays benefits based on Eligible Charges (see page 27 for an explanation) and by the use of
some copayments. A copayment is a percentage of the Eligible Charge that you owe when you receive
certain medical services covered by this plan.
  Knowing what services your plan covers and using them only as needed are ways of getting the best
protection from your plan. When you need medical services, talk to your physician about different
methods and places of treatment and their cost. Together, you and your physician can make the right
decisions about your health care.


ANNUAL MAXIMUM
  The total amount of benefits available under this plan, on an incurred basis, is $300,000 per person per
calendar year.


LIFETIME MAXIMUM
   This plan will stop paying benefits if the total benefits paid or provided on your behalf under this plan
during your lifetime reaches $500,000 (“lifetime maximum”). Benefits will be counted toward the
maximum whether they were provided to you as a member or as a dependent and regardless of any
interruptions in coverage.
    Once the lifetime maximum is reached, the plan will not pay any further benefits with one exception.
Beginning January 1st of the calendar year following the year in which you reach the lifetime maximum,
and continuing each January 1st thereafter as long as you remain covered by the plan, the plan will make
$25,000 in additional benefits available to you. These benefits will be available only during one (1)
calendar year and any unused benefits may not be carried over into any future year. The $500,000
lifetime maximum previously described is applied separately to you and to each of your covered
dependents.
  This lifetime maximum provision applies to the Indemnity Comprehensive medical plan only. The
benefit payments made under your prescription drug plan do not count toward this lifetime maximum.




                                                    25
DEDUCTIBLES
  For services and supplies received from a non-participating provider, you must pay a deductible before
the plan begins paying benefits. Payments used to satisfy one deductible may not be used to satisfy
another deductible. Payments necessitated by any benefit reduction resulting from any failure to obtain a
required pre-approval may not be counted toward meeting any deductible. Deductibles can be satisfied
by paying Eligible Charges or by incurring liability to pay them.

Annual Deductible
   The Annual Deductible is the first $200 of Eligible Charges that you paid for those services or supplies
that you received from a non-participating provider during a calendar year that are covered under this
plan. However, if you and your dependents are covered as a family under this plan, the Annual
Deductible for the entire family will not exceed $400 for a calendar year.
    The following payments do not count toward the Annual Deductible:
       Your copayments for prescription drug services,
       Your copayments for those covered services not subject to the Annual Deductible,
       Your copayments from a participating provider,
       The Hospital Deductible, and
       Any benefit reduction as a result of not obtaining the required pre-approval under the Managed
       Care Program.
  If you did not meet the Annual Deductible for the previous calendar year, any portion of the deductible
that you paid during the last three (3) months of the previous calendar year (i.e. October, November, and
December) may be carried over to meet the current calendar year’s Annual Deductible. This carry-over
provision does not apply if you had met the Annual Deductible and received plan benefits during the
previous calendar year for services or supplies that were subject to the Annual Deductible.

Hospital Deductible
  When you receive covered services in a nonparticipating hospital, you must pay a Hospital Deductible
before plan benefits will be paid for that hospital stay. The Hospital Deductible is the first $200 of Eligible
Charges not paid by this plan for covered hospital services. A Hospital Deductible will apply to each
admission to a nonparticipating hospital. This Hospital Deductible is separate from the Annual Deductible
and does not count toward the Annual Deductible or Maximum Annual Copayment. There is no Hospital
Deductible for covered services from a Participating Hospital.

CHOICE OF HEALTH CARE PROVIDERS
  You are free to go to any licensed physician* or service provider of your choice and receive coverage
under this plan. The Trust Fund suggests that you choose a physician or service provider who can help
you obtain the health care you need at a reasonable cost. Your choice of physician or other health care
provider can make a difference in how much you will owe after your plan benefit payments have been
made.
Participating Providers
    The Trust Fund, through PAI, has contracted with physicians, hospitals, laboratories, and other health
care providers throughout Hawaii to provide you the medical services covered by this plan. When you go
to one of these participating providers, the PAI Claims Office sends the provider the benefit payment for
the service and you owe only the copayment shown in this booklet (see example on page 27) and the tax,
if any.



*   For the purpose of this plan, a physician is a properly licensed doctor of medicine (M.D.), doctor of osteopathy
    (D.O.), doctor of podiatric medicine (D.P.M.) or doctor of optometry (O.D.). Benefits are available for services
    rendered by other providers as shown in specific sections of this booklet.




                                                         26
  A list of participating providers will be provided to you at no charge. You may obtain a current list of
participating providers by visiting the Hawaii Laborers Health and Welfare Trust Fund website at
www.hilabtrustfunds.com.

Nonparticipating Providers
   When you go to a nonparticipating provider, the Trust Fund, through PAI, has no contract with the
provider to guarantee limited copayments. The PAI Claims Office will base the benefit payment on
Eligible Charges (see below) and sends the payment directly to you. You will then owe the provider the
total charge and any tax for the service (see example on page 27).


ELIGIBLE CHARGES
  Benefit payments are based on the Trust Fund’s determination of an Eligible Charge for a covered
service. Here’s how the Trust Fund determines the Eligible Charge.

Participating Providers
  Eligible Charges for covered services of participating providers are part of the contract that the Trust
Fund’s Claims Administrator has arranged with each participating provider to guarantee you limited
copayments.

Nonparticipating Providers
   The Eligible Charge for physician and most medical services of nonparticipating providers is the lesser
of the following two (2) charges:
     The Eligible Charge established by the Trust Fund, or
     The actual charge to you.

Infrequent Services
   There may be times when a service is performed for the first time in Hawaii or so infrequently that an
Eligible Charge as described above is not available. In these cases, PAI’s Medical Consultants, who are
qualified, practicing physicians, will recommend the Eligible Charge by comparing the complexity of the
infrequent service with similar, frequent services. The Trust Fund will make the final determination.

                                  HOW TO USE THIS PLAN
                This is an example of benefits and copayments for a physician’s office visit.

                  If you go to a                                        If you go to a
             Participating Provider                                Nonparticipating Provider

  Plan pays Provider:                                    Plan pays You:
     90% of the Eligible Charge                             80% of the Eligible Charge



  You owe Provider:                                      You owe Provider:
     10% of the Eligible Charge (copayment)                 The Total Charges which includes the
     You do not owe any amount above the                    Plan payment (80% of the Eligible
     Eligible Charge                                        Charge), your copayment (20% of the
                                                            Eligible Charge) and any amount above
                                                            the Eligible Charge




                                                    27
  The Trust Fund suggests that you discuss charges with your health care provider before receiving
services.

  You should ask your physician or call the PAI Claims Office to find out if your physician is a
participating provider. You will receive a Participating Physicians and Health Care Providers list when
you join this plan. Updated listings are available at no charge upon request.


                    KEEPING YOUR COVERAGE AFFORDABLE
   The purpose of this plan is to help you pay your medical expenses. To keep your plan affordable, each
claim is reviewed to make sure that only services that follow standard medical practice and are medically
necessary are covered.

   The fact that a physician may prescribe, order, recommend, or approve a service or supply does not in
itself mean that it follows standard medical practice or is medically necessary.

   Most of the claims received are for services that follow standard medical practice and are medically
necessary. However, there are times when the PAI Claims Office and your physician may not agree.
When this happens, PAI’s Medical Consultants will review the services and decide whether the services
follow standard medical practice, are medically necessary, and therefore, are eligible for benefits.

  PAI’s Medical Consultants are qualified, practicing physicians. They consult with other physicians and
specialists in Hawaii and use the findings of agencies of the Federal government.

  At times, new or complex cases require more information than what is provided by your physician.
PAI’s Medical Consultants will then consult with agencies and specialists outside the State of Hawaii. If
more research is required, the PAI Claims Office will notify you of any delay in their evaluation.

  If you want to know whether a particular service follows standard medical practice or is medically
necessary for an illness or injury, please ask your physician to write or contact PAI for an evaluation
before the service is performed. PAI’s medical consultants will review the service and send their written
evaluation to your physician.

STANDARD MEDICAL PRACTICE
  To be covered by your plan, all services must follow standard medical practice. This means that most
physicians in the U.S.A. regard the service as safe and effective. If a service is in its trial stages (e.g.,
“experimental” because it is used in research or on animals, or “investigative” because it is or has been
used on a limited number of people, or where the long-term effectiveness of the treatment has not been
scientifically proven, and where applicable, has not been approved by the appropriate government
agency), the service is not considered standard medical practice.

MEDICAL NECESSITY
   The plan pays benefits only for services that are medically necessary for the illness or injury being
treated. To be medically necessary, a service or the use of a facility must follow standard medical
practice. And in following standard medical practice, the service must be essential, appropriate, and
economical for the diagnosis or treatment of an injury or illness.
  The following examples will help you understand what is meant by medical necessity.
   Generally, when there are two (2) different treatments and both are equally safe and effective, benefits
   for the more economical treatment will be paid.
  Example: A minor surgery could have been done safely and effectively in the physician’s office at less
  expense, but instead, was done in the hospital. In this case, the surgery is considered medically
  necessary and the physician’s claim will be paid. However, since the surgery could have been done
  safely in the physician’s office, the unnecessary, additional expenses for the hospital services will not
  be paid.



                                                     28
Services or tests that are not generally accepted or appropriate for the diagnosis or treatment of your
illness are usually determined to be not medically necessary.
Example: You visit your physician because of the flu and the physician orders a whole series of tests to
check on diabetes, kidney disease, heart problems, etc. Only those exams and tests for your flu will be
considered medically necessary. The tests for diabetes, kidney disease, and other illnesses that are
not necessary in this situation will not be covered.
Example: You are hospitalized and want to stay an extra day after your physician discharges you. This
extra day will not be covered because you are well enough to go home and no longer need the
continuous skilled medical care provided by the hospital.




                                                 29
                             MANAGED CARE PROGRAM
   Under the Managed Care Program, prior approval must be obtained from the Claims Administrator for
all surgeries, elective outpatient procedures or surgeries, and hospitalizations. If your physician is a
participating physician, he or she must notify PAI at 441-8711 or neighbor islands 1 (888) 520-8078 to
obtain the necessary pre-approval. If your physician is a nonparticipating physician, you are responsible
for notifying PAI at 441-8711 or neighbor islands 1 (888) 520-8078. If you do not obtain the required pre-
approval, your benefit payments may be reduced by 10%.
  PAI must be notified by the following deadlines:
   1. For all non-emergency hospitalizations and elective outpatient procedures, PAI must be notified
      prior to the admission or procedure date or as soon as it has been determined that hospitalization
      or an elective outpatient procedure is necessary.
   2. For all urgent admissions or procedures, PAI must be notified twenty-four (24) hours prior to the
      admission or procedure date.
   3. For all emergency hospitalizations or procedures, PAI must be notified within forty-eight (48) hours
      from the date of the admission or procedure.
   4. For maternity cases, PAI must be notified during the first trimester of the pregnancy.

OUTPATIENT PROCEDURE OR SURGERY
   The following outpatient procedures or surgeries do not require prior approval if they are done on an
elective outpatient basis and are provided by participating providers. For all other elective outpatient
procedures or surgeries not listed below, prior approval must be obtained from PAI.
     Abortion (1st trimester)
     Arthroscopy
     Breast biopsy
     Bronchoscopy
     Cervical node biopsy
     Circumcision
     Closed Reduction (fracture)
     Colonoscopy
     Colostomy, revision
     Culdoscopy
     Cystoscopy
     Dilation and Curettage (D&C)
     Endoscopy
     Endoscopic retrograde cholangiopancreatography (ERCP)
     Esophagoscopy
     Excision of breast mass, cyst
     Excision of foreign body, superficial
     Excision of lipoma
     Excision of mass
     Excision of skin lesion
     Gangliectomy
     Hemorrhoidectomy
     Hymenotomy
     Inguinal hernia repair
     Laparoscopy
     Liver biopsy, percutaneous
     Meatotomy


                                                     30
     Menisectomy
     Muscle biopsy
     Myringoplasty
     Myringotomy
     Neurectomy
     Orchidectomy
     Osteotomy
     Phalangectomy
     Rectal polypectomy
     Sigmoidoscopy
     Tendon sheath repair
     Tenotomy
     Testicular biopsy
     Tubal ligation
     Tympanoplasty
     Umbilical hernia repair
     Urethral dilation
     Vasectomy
 If hospitalization becomes necessary after undergoing one of the above procedures or surgeries, PAI
must be notified within twenty-four (24) hours.

PRE-OPERATIVE DAYS
  If your physician recommends admission to the hospital at least one (1) day prior to the date of your
surgery, pre-approval must be obtained from PAI.

SECOND SURGICAL OPINION
   Under the Managed Care Program, a second surgical opinion may be required for certain surgeries. If
your physician recommends any of the surgeries listed below, you must call PAI at 441-8711 or neighbor
islands 1 (888) 520-8078.
     Back surgery
     Blepharoplasty
     C-Section Delivery (Primary)
     Cataract surgery
     Foot surgery
     Gall bladder surgery
     Gastroplasty/gastric stapling
     Heart surgery
     Hemorrhoidectomy
     Hysterectomy
     Mastectomy
     Nose surgery
     Prostatectomy
     Tonsillectomy
     Total Hip Replacement
     Total Knee Replacement
     Varicose veins ligation and stripping
     Other surgical procedures where medical necessity is not clearly justified (to be specified by PAI)




                                                   31
   Upon obtaining the necessary information from you and your physician, PAI will determine whether or
not a second surgical opinion is required. If a second surgical opinion is required, PAI will provide you
with the names of at least three (3) participating providers to choose from (if available) and the Plan will
cover 100% of the Eligible Charges for you to obtain a second surgical opinion. A third opinion may be
arranged, at your request, if you were required to obtain a second surgical opinion. If you are required to
have a second surgical opinion and you do not obtain one, your benefit payments may be reduced by
10%.

  If you choose to obtain a second surgical opinion when it is not required, regular benefits will apply.


NON-EMERGENCY OFF ISLAND TRAVEL BENEFITS
    For beneficiaries who do not reside on the island of Oahu and who have been preauthorized to
receive medical services that are not available on the island where the beneficiary resides, the following
travel benefit will be provided:

          Round trip air travel reimbursement of up to $200.00 or the actual cost, whichever is less.
          An allowance for round trip travel by ferry of up to $50.00 for beneficiaries residing on the island
          of Lanai, or the actual cost, whichever is less.
          An allowance for taxi fare from the airport to the medical facility and back to the airport, not to
          exceed $50.00.
          An allowance for round-trip travel by the Hawaii Superferry of up to $100.00 or the actual cost,
          whichever is less.
          Travel reimbursement for one (1) parent to accompany a minor child, under the age of 18.

    The off-island travel benefit is subject to review by Care Management for medical necessity and prior
authorization. For this travel benefit to apply, the beneficiary must not be a resident of Oahu and the
medical service being sought must not be available on the island where the beneficiary resides.

    Off-Island travel must be documented and will require copies of the boarding pass and the invoice or
receipt for the transportation service.

     For beneficiaries residing on the island of Lanai who are preauthorized to receive medical services on
Maui, the benefits under this section will be limited to travel by ferry unless the beneficiary’s medical
condition prohibits this mode of travel. In that case, beneficiary’s physician must provide the necessary
information to substantiate the need for alternative transportation at the time the request for prior
authorization is submitted.




                                                     32
                              INDEMNITY (SELF-FUNDED)
                                 MEDICAL BENEFITS
                                  PHYSICIAN SERVICES
PHYSICIAN                          PARTICIPATING              NONPARTICIPATING
SERVICES                           PROVIDER                   PROVIDER

Physician Visits                   You owe a copayment        You owe a copayment of
Home, office,                      of 10% of Eligible         20% of Eligible Charges
hospital emergency                 Charges (You owe no        and any difference
room, or office                    copayment for an           between actual and
consultation visit.                office visit regarding a   Eligible Charges after you
Office visit benefits              second surgical            pay the Annual
will be paid for a second          opinion on the             Deductible.
surgical opinion on the            necessity of surgery if
necessity of surgery.              the second surgical
                                   opinion is arranged by
                                   PAI)

Well-Baby Care Visits              You owe a copayment        You owe a copayment of
Eight visits during the            of 10% of Eligible         20% of Eligible Charges
first two years of a               Charges                    and any difference
child’s life, and one visit                                   between actual and
each year during ages                                         Eligible Charges after you
two, three, four and five.                                    pay the Annual
Well-baby immunizations                                       Deductible.
are covered under
Immunizations below.
Well- baby routine
laboratory tests are
covered under
Outpatient Laboratory
and X-ray Services.

Immunizations                      You owe a copayment        You owe a copayment of
Cholera, diphetheria,              of 20% of Eligible         20% of Eligible Charges
hepatitis, influenza,              Charges (You owe no        and any difference
measles, rubella, mumps,           copayment if for well-     between actual and
whooping cough, polio,             baby care)                 Eligible Charges after you
smallpox, tetanus,                                            pay the Annual Deductible
typhoid, typhus, chicken                                      (You owe a copayment of
pox, and streptococcus                                        20% of Eligible Charges
pneumoniae, haemophilus                                       and any difference
influenzae type B, human                                      between actual and
papilloma virus,                                              Eligible Charges if for
meningococcal, and                                            well-baby care).
rotavirus. All applicable
plan deductibles shall be
waived for immunizations
in connection with well-
baby care.

Hospital Visit                     You owe a copayment        You owe a copayment of
One visit per day to an            of 10% of Eligible         20% of Eligible Charges
inpatient                          Charges                    and any difference
                                                              between actual and
                                                              Eligible Charges after you


                                                33
  PHYSICIAN                            PARTICIPATING                     NONPARTICIPATING
  SERVICES                             PROVIDER                          PROVIDER
                                                                         pay the Annual Deductible

  Skilled Nursing Facility             You owe a copayment               You owe a copayment of
  Visit                                of 10% of Eligible                20% of Eligible Charges
  One visit per day for an             Charges                           and any difference
  inpatient, up to 60 visits per                                         between actual and
  calendar year                                                          Eligible Charges after you
                                                                         pay the Annual Deductible

  Consultation Visit                   You owe a copayment               You owe a copayment of
  Medical or surgical, one             of 10% of Eligible                20% of Eligible Charges
  visit per stay for an inpatient      Charges                           and any difference
  in a hospital or skilled                                               between actual and
  nursing facility as required                                           Eligible Charges after you
  by the attending physician                                             pay the Annual Deductible
  and approved by PAI

  Surgery                              You owe a copayment               You owe a copayment of
  Inpatient or outpatient              of 10% of Eligible                20% of Eligible Charges
                                       Charges                           and any difference
                                                                         between actual and
                                                                         Eligible Charges after you
                                                                         pay the Annual Deductible

  Anesthesiology Services              You owe a copayment               You owe a copayment of
  Services of an                       of 10% of Eligible                20% of Eligible Charges
  anesthesiologist (physician)         Charges                           and any difference
  that are required by a                                                 between actual and
  physician. Hospital                                                    Eligible Charges after you
  anesthesia services (i.e.,                                             pay the Annual Deductible
  nurse anesthetist services)
  will be paid in accordance
  with Hospital Inpatient
  Services.

PHYSICIAN SERVICES SPECIAL NOTES
Immunizations
  The Human Papilloma Virus (HPV) vaccine is a covered benefit under the plan only when the first
  dose is administered to a 9 to 17 year old female, with the second and third dose administered prior to
  18 years of age.
  Under all other circumstances, this immunization is not eligible for coverage under the Plan.
  The Meningococcal vaccine is covered under the plan for those individuals from the age of 11 years
  old. Those younger than 11 years old who are at increased risk due to immune compromise or other
  disorders will require prior authorization.
  The Rotavirus vaccine is covered under the plan when the first dose is administered to an infant by 12
  weeks of age and the remaining two (2) doses of the vaccine are administered by 32 weeks of age.

Well-Baby Visits
  When a well-baby visit cannot be scheduled within the designated benefit period, the visit may be
  covered if rendered within thirty (30) days of the benefit period, as long as the total number of well-
  baby visits allowed is not exceeded.




                                                   34
Surgery
   The preoperative and postoperative care customarily provided in connection with most major surgery
   is included in the Eligible Charge for surgery. If a physician charges separately for the preoperative
   and postoperative care in excess of this single Eligible Charge, the excess will not be paid.
   Postoperative care for most minor surgery is not included in the charge for surgery and will be
   considered a separate physician’s visit payable at 90% of Eligible Charges for a Participating Provider
   and 80% of Eligible Charges after the annual deductible for a nonparticipating provider.
   When the service of another physician may be necessary during a surgery so that the physician must
   “stand-by” at the hospital, the plan will pay benefits for covered services that the physician actually
   provides, but will not pay for the waiting or “stand-by” time.
   The plan will pay benefits for the services of an assistant surgeon only when the assistance is
   medically necessary based on the complexity of the surgery and the hospital had no resident or
   training program in effect so that there was no resident or intern on its staff to assist the surgeon.

Reconstructive Surgery
   The plan will pay benefits for reconstructive surgery only when it is required to restore, reconstruct,
   and correct any bodily function that was lost, impaired, or damaged as a result of an illness or injury.
   In compliance with the Women’s Health and Cancer Rights Act of 1998, the Plan provides coverage
   for services in connection with a mastectomy including reconstruction of the breast on which a
   mastectomy was performed, surgery and reconstruction of the other breast to produce a symmetrical
   appearance, prostheses, and treatment of physical complications in all stages of mastectomy,
   including lymphedemas. Benefits are subject to deductibles, copayments and coinsurance limitations
   consistent with other benefits under this Plan.

Oral Surgery
   For the purposes of this plan, a dentist means a doctor of dentistry (D.M.D.) or dental surgery
   (D.D.S.) who is appropriately licensed to practice by the proper governmental authority and who
   renders services within the lawful scope of such license.
   Physician benefits are available for certain oral surgical services provided by a physician or a dentist.
   Services of a dentist are covered only when: (a) the dentist is performing emergency services or
   surgical services and (b) these services could also be performed by physicians (M.D. or D.O.).
   Hospital benefits are available if you have a medical problem, such as hemophilia, that makes
   hospitalization necessary in order for you to safely receive dental services or when the oral surgery
   itself requires hospitalization.

Transplants
   The following transplants are covered: Kidney, cornea, bone marrow (excluding high dose
   chemotherapy with bone marrow transplants or peripheral stem cell infusion for epithelial ovarian
   cancer, multiple myeloma, primary intrinsic tumors of the brain), liver (excluding liver transplants for
   metastatic malignancies to the liver and Hepatitis B e antigen or core antibody positive), heart, heart-
   lung, and lung. This plan does not pay benefits for any other transplants, including artificial or animal
   organ transplants.
   You must receive prior approval from PAI for transplants and transplant evaluation services. If prior
   approval is not received, no benefits will be payable.




                                                    35
                                HOSPITAL INPATIENT SERVICES

  HOSPITAL                           PARTICIPATING                       NONPARTICIPATING
  INPATIENT SERVICES                 PROVIDER                            PROVIDER

  Up to 365 days per                                                     All benefits subject to
  calendar year of hospital                                              Annual and Hospital
  inpatient services                                                     Deductibles

  Room & Care                        You owe a copayment of              You owe a copayment of
  Based on semiprivate               10% of Eligible Charges             20% of Eligible Charges
  room rate                                                              and any difference
                                                                         between actual and
                                                                         Eligible Charges

  Intermediate Care and              You owe a copayment of              You owe a copayment of
  Isolation Unit                     10% of Eligible Charges             20% of Eligible Charges
                                                                         and any difference
                                                                         between actual and
                                                                         Eligible Charges

  Intensive Care or                  You owe a copayment of              You owe a copayment of
  Coronary Care Unit                 10% of Eligible Charges             20% of Eligible Charges
  Operated according to                                                  and any difference
  standards acceptable to                                                between actual and
  the Trust Fund                                                         Eligible Charges

  Ancillary Inpatient                You owe a copayment of              You owe a copayment of
  Services                           10% of Eligible Charges             20% of Eligible Charges
  Operating room, surgical                                               and any difference
  supplies, drugs, dressings,                                            between actual and
  anesthesia services and                                                Eligible Charges
  supplies, oxygen,
  antibiotics, and blood
  transfusion services

  Laboratory and X-Ray               See Outpatient Laboratory           See Outpatient Laboratory
  Services                           and X-Ray services on               and X-Ray services on
                                     page 37                             page 37


HOSPITAL INPATIENT SERVICES SPECIAL NOTES
  If a hospital uses a single, all-inclusive daily charge instead of itemized charges for laboratory, x-ray,
  radiotherapy, and all other allowable hospital inpatient services and supplies, you owe a copayment of
  10% of Eligible Charges for a participating provider and 20% of Eligible Charges and the difference
  between actual and Eligible Charges after you pay the Annual and Hospital Deductibles for a non-
  participating provider. In no event will the plan pay more than if the hospital had charged separately
  for these services.
  If you choose to receive inpatient services in a private room, you may be responsible for additional
  room charges not covered by the plan.
  Inpatient hospital services for a member being treated for mental illness are covered under Mental
  Illness and Alcohol or Drug Dependence Services and are subject to the limitations specified in that
  section.
  Benefits for Medical Surveillance Services (LifeBed) will be available when a hospital provides for
  inpatient care with the new electronic monitoring technology. The eligible charge per day is $18.00.




                                                    36
               OUTPATIENT LABORATORY AND X-RAY SERVICES

 OUTPATIENT
                                     PARTICIPATING                        NONPARTICIPATING
 LABORATORY AND X-RAY
                                     PROVIDER                             PROVIDER
 SERVICES

 Services ordered by a
 physician for the diagnosis
 and treatment of an injury
 or illness

 X-ray films for injuries            You owe no copayment                 You owe a copayment of
 (within 48 hours) and                                                    20% of Eligible Charges
 radiotherapy for malignancy                                              and any difference
                                                                          between actual and
                                                                          Eligible Charges after
                                                                          you pay the Annual
                                                                          Deductible

 Laboratory Services and             You owe a copayment of               You owe a copayment
 Diagnostic Tests, Other             20% of Eligible Charges              of 20% of Eligible
 X-ray films, and                                                         Charges and any
 Radiotherapy for non-                                                    difference between
 malignancy                                                               actual and Eligible
                                                                          Charges after you pay
    Routine Pap Smear
                                                                          the Annual Deductible
    Limited to one per
    calendar year
    Prostate Specific
    Antigen Test
    Limited to one per
    calendar year for men
    age 50 and above.
    Tuberculin Tine Test
    Limited to one per
    calendar year

 Screening by Low-Dose               You owe a copayment of               You owe a copayment
 Mammography                         10% of Eligible Charges              of 20% of Eligible
                                                                          Charges and any
                                                                          difference between
                                                                          actual and Eligible
                                                                          Charges

OUTPATIENT LABORATORY AND X-RAY SERVICES SPECIAL NOTES
   Laboratory tests in connection with well-baby care visits are limited to the following tests through age
   five: two (2) tuberculin tests (tine or skin sensitivity), two (2) blood tests (hemoglobin or hematocrit)
   and one (1) urinalysis. All applicable plan deductibles shall be waived for laboratory tests in
   connection with well-baby care.
   Screening by low-dose mammography is limited to one (1) baseline mammogram for women age 35
   through 39, and one (1) mammogram every 12 months for women age 40 and above. Women of any
   age with a history of breast cancer or whose mother or sister has had a history of breast cancer, or
   women at an increased risk of breast cancer, are eligible for a mammogram upon the
   recommendation of a Physician. All applicable plan deductibles shall be waived for screening by low-
   dose mammography.




                                                    37
                       SKILLED NURSING FACILITY SERVICES

 SKILLED NURSING                     PARTICIPATING                       NONPARTICIPATING
 FACILITY SERVICES                   PROVIDER                            PROVIDER

 Up to 60 days per calendar                                              All benefits subject to
 year of skilled nursing                                                 Annual and Hospital
 facility services                                                       Deductibles, unless
                                                                         otherwise stated

 Room & Care                         You owe a copayment of              You owe a copayment of
 Based on semiprivate room           10% of Eligible Charges             20% of Eligible Charges
 rate                                based on single, all-               and any difference
                                     inclusive amount per day            between actual and
                                                                         Eligible Charges

 Inpatient Services                  You owe a copayment of              You owe a copayment of
 Routine surgical supplies,          10% of Eligible Charges             20% of Eligible Charges
 drugs, dressings,                   based on single, all-               and any difference
 anesthesia services and             inclusive amount per day            between actual and
 supplies, oxygen,                                                       Eligible Charges
 antibiotics, blood
 transfusion services,
 diagnostic and therapy
 services

 Laboratory Services and             For Participating Providers         See Outpatient Laboratory
 X-ray Services                      whose laboratory and x-             and X-ray Services mon
                                     ray services are not                page 37
                                     included in a single, all-
                                     inclusive amount per day,
                                     this plan shall pay
                                     laboratory and x-ray
                                     services in accordance
                                     with Outpatient Laboratory
                                     and X-ray Services (see
                                     page 37)

SKILLED NURSING FACILITY SERVICES SPECIAL NOTES
  To be eligible for benefits, the facility must meet Medicare standards and be approved by the Trust
  Fund’s Claims Administrator.
  A physician must admit you to the facility. You must need skilled nursing services and must be under
  the care of an attending physician while in the facility. No payment will be made for services furnished
  primarily for comfort, convenience, rest cure, or domiciliary or custodial care.
  If you remain in the facility more than 30 days, the attending physician must submit a report showing
  the need for skilled nursing care at the end of each 30-day period.




                                                   38
                    OUTPATIENT SURGICAL CENTER SERVICES

 OUTPATIENT SURGICAL                PARTICIPATING                       NONPARTICIPATING
 CENTER SERVICES                    PROVIDER                            PROVIDER

 Operating room, surgical           You owe no copayment                You owe a copayment of
 supplies, drugs, dressings,                                            20% of Eligible Charges
 anesthesia services and                                                and any difference
 supplies, oxygen,                                                      between actual and
 antibiotics, blood                                                     Eligible Charges after you
 transfusion services;                                                  pay the Annual Deductible
 covered services include
 routine laboratory and x-ray
 services normally
 associated with the surgery

 Other Laboratory and X-ray         See Outpatient Laboratory           See Outpatient Laboratory
 Services                           and X-ray Services on               and X-ray Services on
                                    page 37                             page 37


OUTPATIENT SURGICAL CENTER SERVICES SPECIAL NOTES
  An outpatient surgical center is a facility which provides surgical services without an overnight stay.
  This facility may be in a hospital or it may be a separate, independent facility. To be eligible for
  benefits, the facility must be approved by the Trust Fund’s Claims Administrator.




                                                  39
                               HOME HEALTH CARE SERVICES

 HOME HEALTH CARE                    PARTICIPATING                        NONPARTICIPATING
 SERVICES                            PROVIDER                             PROVIDER

 Up to 150 visits per                You owe a copayment of               You owe a copayment of
 calendar year for part-time         20% of Eligible Charges              20% of Eligible Charges
 skilled medical services                                                 and any difference
                                                                          between actual and
                                                                          Eligible Charges after you
                                                                          pay the Annual Deductible

HOME HEALTH CARE SERVICES SPECIAL NOTES
  To be eligible for benefits, services must be received from a qualified home health agency which
  meets Medicare requirements and is approved by the Trust Fund’s Claims Administrator.
  Your physician must certify that you are homebound due to an injury or illness, require part-time skilled
  health services, and would require inpatient hospital or skilled nursing facility care if there were no
  home health care visits. Homebound standards as defined by the Federal Medicare program apply.
  If you need home health care services for more than 30 days, a physician must certify that there is
  further need for the services and provide a continuing plan of treatment at the end of each 30-day
  period of care.
  No payment will be made for home care services furnished primarily to assist in meeting personal,
  family, and domestic needs such as general household services, meal preparation, shopping, bathing,
  or dressing.




                                                   40
                                HOSPICE CARE SERVICES

 HOSPICE CARE                      PARTICIPATING                       NONPARTICIPATING
 SERVICES                          PROVIDER                            PROVIDER

 Up to 150 days of care for        You owe no copayment                Not a benefit
 a terminal illness, based
 on an all-inclusive daily
 rate (in lieu of other
 covered services for such
 illness)

HOSPICE CARE SERVICES SPECIAL NOTES
  To be eligible for benefits, services must be received from a hospice under contract with the Trust
  Fund’s Claims Administrator to provide hospice benefits and which is operated under generally
  accepted standards for hospices.
  The hospice agency and attending physician must certify, in writing, that you are terminally ill and
  have a life expectancy of six (6) months or less.
  If you elect hospice benefits, you will not be eligible for any other benefits for the treatment of the
  terminal illness, except for physician services. You may continue to receive benefits for all other
  illnesses or injuries.
  You may decide to discontinue hospice care and receive other covered services at any time before
  the end of the 150-day hospice benefit period. However, if you decide to do so, any remaining days
  of the 150 days of hospice benefits will be lost and will not be available for future use.




                                                  41
                                   EMERGENCY SERVICES

 EMERGENCY                           PARTICIPATING                       NONPARTICIPATING
 SERVICES                            PROVIDER                            PROVIDER

 Emergency Room                      You owe a copayment of              You owe a copayment of
                                     10% of Eligible Charges             20% of Eligible Charges
                                                                         and any difference
                                                                         between actual and
                                                                         Eligible Charges after you
                                                                         pay the Annual Deductible

 Automobile Ambulance                You owe a copayment of              You owe a copayment of
                                     10% of Eligible Charges             20% of Eligible Charges
                                                                         and any difference
                                                                         between actual and
                                                                         Eligible Charges after you
                                                                         pay the Annual Deductible

 Air Ambulance                       You owe a copayment of              You owe a copayment of
 Air ambulance services are          20% of Eligible Charges             20% of Eligible Charges
 limited to inter-island                                                 and any difference
 transportation within the                                               between actual and
 State of Hawaii                                                         Eligible Charges after you
                                                                         pay the Annual Deductible


EMERGENCY SERVICES SPECIAL NOTES
  An emergency is the sudden onset of an acute condition requiring immediate treatment. The
  physician’s claim or hospital emergency report must describe the need for immediate treatment.
  Some examples of an emergency are heart attack, poisoning, loss of consciousness, and convulsions.
  Emergency room physician services are covered under physician visits or surgical services.
  No payment will be made for use of emergency room facilities for any treatment which is not an
  emergency.
  No payment will be made for take-home drugs or supplies such as crutches or braces when billed by
  the Emergency Room Facility.
  If the use of an outpatient operating room for surgery is medically necessary, but not an emergency,
  then the benefits under “Outpatient Surgical Center Services” on page 39 apply.

Automobile and Air Ambulance
  Services must be received from a properly licensed or certified automobile or air ambulance service.
  Transportation must be from the place where an injury occurred or first required care to the nearest
  facility equipped to furnish emergency treatment.
  The injury or illness must require emergency medical treatment, surgical treatment, or hospitalization.
  Return or roundtrip ambulance service is not covered.




                                                   42
                                MATERNITY SERVICES

MATERNITY                       PARTICIPATING               NONPARTICIPATING
SERVICES                        PROVIDER                    PROVIDER

Physician Services              See Physician Services on   See Physician Services
For pregnancy, childbirth, or   pages 33 - 35               on pages 33 - 35
other termination of
pregnancy, and related
medical conditions;
caesarean section and
surgery; and routine nursery
visits to newborn child

Surgery for                     See Physician Services on   See Physician Services
Complications of                pages 33 - 35               on pages 33 - 35
Pregnancy
Including ectopic pregnancy

Nurse-Midwife Services          You owe no copayment        You owe a copayment of
                                                            20% of Eligible Charges
                                                            and any difference
                                                            between actual and
                                                            Eligible Charges after you
                                                            pay the Annual Deductible

Hospital Services               See Hospital Inpatient      See Hospital Inpatient
Hospital services shall         Services on page 36         Services on page 36
count against the 365-day
maximum for hospital
benefits

Birthing Center Services        You owe no copayment        You owe a copayment of
                                                            20% of Eligible Charges
                                                            and any difference
                                                            between actual and
                                                            Eligible Charges after you
                                                            pay the Annual Deductible

In Vitro Fertilization
One (1) procedure per
lifetime, whether successful,
or not, up to a maximum of
$5,000 for all covered
services (including
physician services, lab and
x-ray services, and
prescription drugs)

Physician Services              See Physician Services on   See Physician Services on
                                pages 33 - 35               pages 33 - 35

Laboratory and X-ray            See Outpatient Laboratory   See Outpatient Laboratory
Services                        and X-ray Services on       and X-ray Services on
                                page 37                     page 37




                                              43
 MATERNITY                             PARTICIPATING                         NONPARTICIPATING
 SERVICES                              PROVIDER                              PROVIDER

 Prescription Drugs                    See Prescription Drug                 See Prescription Drug
                                       section on pages 53 - 57              section on pages 53 - 57

MATERNITY SERVICES SPECIAL NOTES
    The Eligible Charge for delivery includes prenatal and postnatal care.
    In accordance with the Newborns’ and Mothers’ Health Protection Act of 1996 (NMHPA), hospital
    stays in connection with childbirth for the mother and newborn child will be provided up to 48 hours
    following a normal vaginal delivery or up to 96 hours following a caesarean delivery, unless, after
    consultation with the mother, the attending provider discharges the mother or newborn earlier.
Nurse-Midwife Services
    For normal pregnancy and childbirth, payment may be made in lieu of physician services for services
    of a certified nurse-midwife who is properly licensed, certified by the American College of Nurse-
    Midwives, and is formally associated with a physician for purposes of supervision and consultation.
Birthing Center Services
    When a properly licensed birthing center is used instead of regular hospital facilities, payment for
    birthing center services will be made under Hospital Inpatient Services. The birthing center must be
    approved by the Trust Fund’s Claims Administrator.
Newborn Child
    Hospital and physician benefits are available for in-hospital, routine nursery care of a newborn.
    In order for a newborn child to be eligible for plan benefits from the date of birth for illness, injury,
    circumcision, premature birth care, or birth defect, you must enroll the child as a dependent within 45
    days of birth.
    Diagnostic tests for an unborn child will be paid only when medically necessary.
In Vitro Fertilization
    Only beneficiaries who have been covered under the Indemnity Comprehensive Plan for 12
    consecutive months preceding the in vitro fertilization procedure are eligible for benefits.
    Limitations
     -    One (1) procedure per lifetime, whether successful or not, with a $5,000 maximum for all
          covered services.
     -    Beneficiary’s oocytes are to be fertilized with beneficiary’s spouse’s sperm.
     -    Beneficiary and beneficiary’s spouse have a history of infertility of at least five (5) years duration
          or infertility associated with a) endometriosis, b) exposure in utero to diethylstilbestrol (DES) , c)
          blockage or surgical removal of fallopian tube, or d) abnormal male factors.
     -    Beneficiary has been unable to attain a successful pregnancy through other applicable infertility
          treatments for which coverage is available under this plan.
     -    In vitro fertilization procedures are performed at medical facilities that conform to American
          College of Obstetrics and Gynecology guidelines for in vitro fertilization clinics or to American
          Fertility Society minimal standards for programs of in vitro fertilization.
     -    “Spouse” means the person who is legally married to the eligible beneficiary and is qualified as
          a spouse in accordance with the Internal Revenue Code.




                                                      44
Exclusions
-   Cost of equipment and of collection, storage, and processing of sperm.
-   In vitro fertilization requiring the use of either donor sperm or donor eggs.
-   Artificial insemination requiring the use of donor sperm.
-   Services related to conception by artificial means, other than a) artificial insemination and b) in
    vitro fertilization, as specified above.




                                                   45
                    MENTAL ILLNESS AND ALCOHOL OR DRUG
                           DEPENDENCE SERVICES
MENTAL ILLNESS AND
                               PARTICIPATING               NONPARTICIPATING
ALCOHOL OR DRUG
                               PROVIDER                    PROVIDER
DEPENDENCE SERVICES

MENTAL ILLNESS
SERVICES
 INPATIENT
  Hospital and Facility        See Hospital Inpatient      See Hospital Inpatient
  Services                     Services on page 36         Services on page 36
  Up to 30 days per
  calendar year which
  shall count against the
  365-day maximum for
  hospital benefits

   Psychiatrist,               See Physician Services on   See Physician Services on
   Psychologist, Clinical      pages 33 - 35               pages 33 - 35
   Social Worker,
   Marriage and Family
   Therapist or Licensed
   Mental Health
   Counselor
   Up to 30 inpatient visits
   per calendar year

 OUTPATIENT
  Psychiatrist,                See Physician Services on   See Physician Services on
  Psychologist, Clinical       pages 33 - 35               pages 33 - 35
  Social Worker,
  Marriage and Family
  Therapist or Licensed
  Mental Health
  Counselor
  Up to 24 outpatient visits
  per calendar year

 PSYCHOLOGICAL
 TESTING
  Each outpatient or
  inpatient psychological
  testing session shall
  count against the 30
  inpatient or 24 outpatient
  visits per calendar year
  maximum, as
  appropriate
     Inpatient Services        You owe a copayment of      You owe a copayment of
                               10% of Eligible Charges     20% of Eligible Charges
                                                           and any difference
                                                           between actual and
                                                           Eligible Charges after you
                                                           pay the Annual Deductible




                                             46
 MENTAL ILLNESS AND
                                        PARTICIPATING                          NONPARTICIPATING
 ALCOHOL OR DRUG
                                        PROVIDER                               PROVIDER
 DEPENDENCE SERVICES


       Outpatient Services              You owe a copayment of                 You owe a copayment of
                                        20% of Eligible Charges                20% of Eligible Charges
                                                                               and any difference
                                                                               between actual and
                                                                               Eligible Charges after you
                                                                               pay the Annual Deductible

ALCOHOL OR DRUG DEPENDENCE SERVICES
  Benefits for Mental Illness Services described are available for alcohol or drug dependence treatment
services, including detoxification. Benefits paid for alcohol or drug dependence services will count
against the plan maximums for mental illness, and will be subject to the clarifications and limitations listed
under Special Notes.

MENTAL ILLNESS AND ALCOHOL OR DRUG DEPENDENCE SERVICES SPECIAL NOTES
Hospital and Facility Services
   Each day of hospital inpatient services may be exchanged for two (2) days of non-hospital residential
   services, two (2) days of partial hospitalization services, or two (2) days of treatment services in a
   Qualified Treatment Facility provided that such exchange services include at least three hours of
   treatment per day. Each day of inpatient services may also be exchanged for two (2) outpatient visits,
   provided that the beneficiary’s condition is such that hospitalization would become imminent if the
   outpatient services were interrupted and the outpatient services would reasonably preclude
   hospitalization. This plan shall not pay more for two (2) days of exchange services than if the services
   had been provided through one (1) day of hospital inpatient services.
   A Qualified Treatment Facility is an inpatient or outpatient facility that has been specifically accredited
   to render mental illness or alcohol or drug dependence services by the Joint Commission on
   Accreditation of Health Care Organizations or the Commission on Accreditation of Rehabilitation
   Facilities and, if the facility is residential, has been licensed as a special treatment facility by the proper
   government authority.

General Limitations
   Benefits for the treatment of mental illness or alcohol or drug dependence, including detoxification and
   emergency services, must be pre-approved by PAI. If you or your psychiatrist, psychologist,
   clinical social worker, marriage and family therapist or licensed mental health counselor do not
   notify PAI’ prior to receiving treatment, no benefit will be payable.
   Any allowance for treatment sessions by a psychiatrist, psychologist, clinical social worker, marriage
   and family therapist or licensed mental health counselor shall be limited to sessions of not more than
   50 minutes per day and the allowance for any session of less than 50 minutes will be a prorated
   portion of the Eligible “50 minute” Charge.
   For inpatient hospital or facility services, benefits will be limited to room and care charges and no
   additional benefits will be payable for intensive or special care psychiatric units.

Mental Illness Limitations
   Mental health services must be for a nervous or mental disorder classified as such in the current
   version of the Diagnostic and Statistical Manual of the American Psychiatric Association and must be
   provided under an individualized treatment plan approved by a psychiatrist, psychologist, clinical social
   worker, marriage and family therapist or licensed mental health counselor.




                                                       47
Alcohol and Drug Dependence Limitations
  Outpatient alcohol or drug dependence treatment services must be provided under an individualized
  treatment plan approved by a psychiatrist, psychologist, clinical social worker, marriage and family
  therapist or licensed mental health counselor who is a certified substance abuse counselor.
  Alcohol or drug dependence treatment benefits shall be limited to two treatment episodes per lifetime.
  A treatment episode means an admission to a hospital or Qualified Treatment Facility, or to a
  psychiatrist, psychologist, clinical social worker, marriage and family therapist or licensed mental
  health counselor’s office for treatment under a plan designed to produce remission in those who
  complete treatment. This limitation shall not apply to detoxification services.
  In the case of alcohol or drug dependence treatment episodes, if a hospital or Qualified Treatment
  Facility charges on an all-inclusive basis, this plan shall pay benefits in accordance with Hospital
  Inpatient Services benefits (see page 36).
  The cost of educational programs to which drinking or drugged drivers are referred by the judicial
  system and any and all services performed by mutual self-help groups shall not be eligible for benefits.




                                                   48
                              OTHER MEDICAL SERVICES

OTHER MEDICAL                   PARTICIPATING             NONPARTICIPATING
SERVICES                        PROVIDER                  PROVIDER

Allergy Testing and             You owe a copayment of    You owe a copayment of
Treatment Materials             20% of Eligible Charges   20% of Eligible Charges
One (1) testing series per                                and any difference
calendar year                                             between actual and
                                                          Eligible Charges after
                                                          you pay the Annual
                                                          Deductible

Appliances and Durable          You owe a copayment of    You owe a copayment of
Medical Equipment               20% of Eligible Charges   20% of Eligible Charges
                                                          and any difference
                                                          between actual and
                                                          Eligible Charges after
                                                          you pay the Annual
                                                          Deductible

Blood, Blood Products,          You owe a copayment of    You owe a copayment of
and Blood Bank                  20% of Eligible Charges   20% of Eligible Charges
Service Charges                                           and any difference
Cost of blood and blood                                   between actual and
products except when                                      Eligible Charges after
donated, and blood bank                                   you pay the Annual
service charges. Any                                      Deductible
additional charges for
autologous blood
(reserved for the person
who donated the blood)
are excluded as a
benefit.

Chemotherapy                    You owe a copayment of    You owe a copayment of
Chemical agents (other          20% of Eligible Charges   20% of Eligible Charges
than oral) for treatment of                               and any difference
malignancy                                                between actual and
                                                          Eligible Charges after
                                                          you pay the Annual
                                                          Deductible

Dialysis and Supplies           You owe a copayment of    You owe a copayment of
                                20% of Eligible Charges   20% of Eligible Charges
                                                          and any difference
                                                          between actual and
                                                          Eligible Charges after
                                                          you pay the Annual
                                                          Deductible

Evaluations for the Use         You owe a copayment of    You owe a copayment of
of Hearing Aids                 20% of Eligible Charges   20% of Eligible Charges
                                                          and any difference
                                                          between actual and
                                                          Eligible Charges after
                                                          you pay the Annual
                                                          Deductible


                                             49
  OTHER MEDICAL                     PARTICIPATING                       NONPARTICIPATING
  SERVICES                          PROVIDER                            PROVIDER

  Outpatient Injections             You owe a copayment of              You owe a copayment of
  Outpatient services and           20% of Eligible Charges             20% of Eligible Charges
  supplies for the injection                                            and any difference
  or intravenous                                                        between actual and
  administration of                                                     Eligible Charges after
  medication or nutrient                                                you pay the Annual
  solutions required for                                                Deductible
  primary diet

  Physical Therapy                  You owe a copayment of              You owe a copayment of
  Physical therapy from a           20% of Eligible Charges             20% of Eligible Charges
  registered physical                                                   and any difference
  therapist (R.P.T.) or                                                 between actual and
  registered occupational                                               Eligible Charges after
  therapist (O.T.R.), up to a                                           you pay the Annual
  maximum of 10 visits per                                              Deductible
  illness or injury

  Speech Therapy                    You owe a copayment of              You owe a copayment of
  Speech therapy from a             20% of Eligible Charges             20% of Eligible Charges
  certified speech therapist                                            and any difference
                                                                        between actual and
                                                                        Eligible Charges after
                                                                        you pay the Annual
                                                                        Deductible

  Transplant Donor                  You owe a copayment of              You owe a copayment of
  Services                          20% of Eligible Charges             20% of Eligible Charges
  Services related to the                                               and any difference
  donor or organ bank                                                   between actual and
                                                                        Eligible Charges after
                                                                        you pay the Annual
                                                                        Deductible

OTHER MEDICAL SERVICES SPECIAL NOTES
Appliances and Durable Medical Equipment
The plan pays benefits for the initial provision and replacement of appliances and durable medical
equipment listed below:
   Hearing aids (one (1) device per ear every five (5) years); cardiac pacemakers; artificial limbs, eyes,
   and hips, and similar nonexperimental appliances;
   Casts, splints, trusses, braces, and crutches; and
   Oxygen and rental of equipment for its administration; rent or purchase of wheelchair and hospital-
   type bed; charges for use of an iron lung, artificial kidney machine, pulmonary resuscitator, and
   similar medical equipment.

   Limitations
   -    The plan will pay only for the appliances and durable medical equipment listed above.
   -    All appliances and durable medical equipment must be for services covered under this plan and
        must be ordered by the attending physician. However, the Trust Fund must agree that the
        ordered item is medically necessary for the treatment of your illness or injury.
   -    The plan will not pay for any convenience items.




                                                   50
Physical and Speech Therapy
   Physical and Speech Therapy services must be ordered by the physician under an individual
   treatment plan.
   Physical therapy services must be for the restoration of a musculoskeletal function that was lost or
   impaired by injury or illness, and must be reasonably expected to improve the patient’s condition
   through short-term care. Long-term maintenance therapy is not covered. Group exercise programs
   are not covered.
   Prior authorization is required for physical therapy visits above the maximum of 10 visits per illness or
   injury. Your physician must certify that the additional visits are required and provide a continuing plan
   of treatment acceptable to the Trust Fund every 30 days.
   Speech therapy services must be for restoration of speech or hearing function that was lost or
   impaired by injury or illness, and must be reasonably expected to improve the patient’s condition
   through short-term care. Long-term maintenance therapy is not covered.
   Speech therapy for children with developmental learning disabilities (developmental delay) is not a
   benefit.

Transplant Donor Services
   Services related to the donor or organ bank are covered only if a beneficiary is the recipient.
   If the donor is covered under another medical plan, that plan will be primary and its benefits will be
   applied before benefits under this plan apply.
   Covered expenses for screening of donors are limited to expenses of the actual donor. Screening
   expenses of other candidates who do not become the actual donor are not eligible for benefits.




                                                    51
                                         EXCLUSIONS
Cosmetic services (services, supplies or drugs that may improve physical appearance but do not
restore or materially improve a bodily function)
Treatment of baldness, including hair transplants and topical medications.
Treatment with non-ionizing radiation
Eye refractions, eyeglasses or contact lenses, and refractive eye surgery to correct visual problems
Dental services done only by dentists and not physicians, including orthodontia, dental splints and
other dental appliances, dental prostheses, osseointegration and all related services, removal of
impacted teeth, and any other procedures involving the teeth, gums, and structures supporting the
teeth. In addition, any services in connection with the diagnosis or treatment of temporomandibular
joint problems or malocclusion (misalignment of the teeth or jaws) are not eligible for benefits under
this plan
Rest cures
Routine physical examinations, screenings or checkups, except for well-baby care and the screening
services provided under Outpatient Laboratory and X-ray Services
Services which are or may be covered by Workers’ Compensation or any other employer’s liability
insurance
Services provided without charge by any federal, state, municipal, territorial, or other government
agency.
Services for which no charge or collection would be made if you or your dependents had no health
plan coverage
Services provided by a member of your immediate family or household
Services or expenses connected with confinement which is primarily for custodial or domiciliary care
Services due to an act of war (whether or not a state of war legally exists) or required during a period
of active duty that exceeds 30 days in any armed force
Reversal of sterilization
Fertilization by artificial means (except for one (1) in vitro fertilization program per qualified married
couple per lifetime)
Services related to the diagnosis or treatment of infertility
Services related to sex transformations or sexual dysfunctions or inadequacies
Biofeedback and other forms of self-care or self-help training and any related diagnostic testing
Human growth hormone therapy, except replacement therapy services due to hypothalamic-pituitary
axis damage caused by primary brain tumors, trauma, infection, or radiation therapy
Weight loss or weight control programs
Physician’s waiting or stand-by time
Private duty nursing
Foot orthotics, expect for specific diabetic conditions
Services that do not follow or are not standard medical practice (i.e., experimental or investigative
services)
Services not described as covered in this booklet or the Comprehensive Medical Plan Document
General excise tax




                                                   52
                            INDEMNITY (SELF-FUNDED)
                          PRESCRIPTION DRUG BENEFITS
    Effective May 1, 2008, the Hawaii Laborers Health and Welfare Trust Fund has contracted Express
Scripts, Inc. (ESI) as the Pharmacy Benefit Manager to administer and process claims for the Indemnity
Prescription Drug benefits. To obtain services through the Point of Service or Central Fill Program, you
must use participating or designated pharmacies and present your Express Scripts identification card. To
obtain prescriptions through the Mail Order Program, you must complete the Express Scripts mail order
brochure. You may obtain claim and mail order forms from Express Scripts or from the PAI Office.
(NOTE: All Direct Member Reimbursement claims shall be submitted to the Trust Fund Office).

   If you have any questions regarding your prescription drug benefits or would like to request a listing of
Express Scripts participating pharmacies in your area, please contact:


                                           Express Scripts, Inc.
                                       Patient Customer Department
                                               (available 24 hours)
                              Call toll free: 1 (866) 274-0887, or visit website at
                                          “www.express-scripts.com”



DRUGS COVERED
    The Plan will cover only medically necessary prescription drugs that have been approved by the
United States Food and Drug Administration (FDA) and prescribed by a physician. The fact that a
physician may prescribe, order, recommend or approve a particular prescription drug does not guarantee
coverage under this Plan.
    You may seek prior approval for a particular drug by asking your physician to submit a request to ESI
prior to dispensing the drug. ESI will determine if a particular drug is medically necessary, and thus,
covered under this Plan. The drug may be considered medically necessary if it meets the following
requirements:
        Is essential and appropriate for the diagnosis or treatment of an illness or injury;
        Is regarded as safe and effective by most Physicians in the United States; and
        Is the most appropriate and economical prescription drug available.

    The following drugs and supplies, although obtainable without a prescription, are covered if your
physician orders them as part of your treatment and provides verification to the Trust Fund Office that
they are necessary for the treatment of an illness or injury:
        Special vitamins for treatment of a severe vitamin deficiency
        Insulin and diabetic supplies limited to syringes, lancets, needles, sugar test tablets and tapes,
        and acetone test tablets prescribed for the treatment of diabetes

Coverage for New Drugs
   Upon the submission of a claim involving a new drug that is approved by the Federal Drug
Administration (FDA), the new drug will be reviewed for approval on a case-by-case basis under the
Managed Care Program.
    The Managed Care Program in conjunction with a medical review board, will review new drugs and
make a determination on the medical appropriateness and necessity of a new drug treatment plan. Once
a decision has been made, you and/or your physician will be notified of the decision and your rights to
appeal the decision. For more information on the appeals process, please refer to the Claims and
Appeals Procedures section on pages 104 - 107.




                                                      53
BENEFIT PAYMENT
    The Indemnity Prescription Drug Plan offers the following options through which you may obtain
prescription drugs:
    1. The Point of Service Program (through participating pharmacies),
    2. The Central Fill Program (through Times Pharmacies for Island of Oahu only),
    3. The Mail Order Program (through Express Scripts Home Delivery), and
    4. The Direct Reimbursement Program.

    A brief description of each program is outlined below.


Short Term Prescriptions
     A short term prescription is a prescription drug that you need to take for an acute or limited illness or
injury, usually for less than fifteen (15) days. For short-term prescriptions, you may use the Point of
Service Program or Direct Member Reimbursement Program.


POINT OF SERVICE PROGRAM (Participating Pharmacies)
    Under the point of service program, you may fill your short term prescriptions through any Express
Scripts participating pharmacy at the following copayments:

                                    (Island of Oahu Only)               (Neighbor Islands)
                                        15-Day Supply             21-Day Supply    30-Day Supply
      Generic Drugs                         $ 4.00                    $ 4.00               $ 5.00

      Brand Name Drugs                      $12.00                    $12.00               $15.00


          For prescription drugs that can only be dispensed in “unbreakable packages” (i.e.,
          creams, ointments, certain inhalers), the days supply limit shall be equal to the package
          size days supply, not to exceed a 30-day supply, with a single copayment charged to the
          member.

          A generic drug is one which is prescribed or dispensed under its commonly used generic
          (chemical) name and is no longer protected under patent laws.

          For brand name oral contraceptives (other than for specific hormonal disorders) and
          brand name contraceptive patches, the member shall be responsible for the $4.00
          copayment and any cost difference between the generic and brand name drug or device.

    How to Use the Point of Service Program:
    Step 1:   Obtain a prescription from your doctor.
    Step 2:   Go to any participating pharmacy and present your Express Scripts identification card. (For
              a current list of participating pharmacies in your area, contact the Trust Fund office or
              Express Scripts).
    Step 3:   Pay the applicable copayment listed above.

    NOTE:     Claim forms submitted for prescription drugs that are purchased from a participating
              pharmacy will not be accepted or paid under the Direct Reimbursement Program.




                                                     54
Long Term Prescriptions
    A long term prescription is a prescription drug that is taken daily or regularly. For long term
prescriptions, you may use either the Central Fill program (if available in your area) or the Mail Order
Program.


CENTRAL FILL PROGRAM (through Times Pharmacies on Island of Oahu)
   Under the Central Fill Program, you may fill your long term prescriptions for up to a 60 day supply at
any Times Pharmacy on the Island of Oahu. If this is the first time (initial fill) that you are taking this
drug and dosage, the pharmacy will fill your prescription for a 15-day supply at the following
copayments:

                                                                           (Initial Fill)
                                                                         15-Day Supply
              Generic Drugs                                                  $ 4.00
              Brand Name Drugs                                               $12.00

  If you continue to use this drug beyond the 15-day supply, you may obtain a refill for up to a 60-day
supply at the following copayments:

                                                                            (Refills)
                                                                         60-Day Supply
              Generic Drugs                                                 $ 6.00
              Brand Name Drugs                                              $18.00


    How to use the Central Fill Program:
    Step 1:    Obtain a prescription from your doctor
    Step 2:    Go to any Times Pharmacy on Oahu and present your Express Scripts identification card.
               If this is the first time you are taking this drug and dosage, the pharmacy will fill your
               prescription for up to a 15-day supply at the applicable copayment listed above.
    Step 3:    If your doctor prescribes continued use of this drug and dosage, contact Times Pharmacy
               and request a refill. You may obtain up to a 60-day supply at the applicable copayment.


MAIL ORDER PROGRAM (through Express Scripts Home Delivery)
   Under the Mail Order Program, you may fill your long term prescriptions through the Express Scripts
Home Delivery program, for up to a 60-day supply, at the following copayments:

                                                                   60-day Supply Limit *

              Generic Drugs                                                 $ 6.00
              Brand Name Drugs                                              $18.00
           * Requires 15-day initial fill for members residing on Oahu




                                                     55
   How to use the Mail Order Program:
   Step 1:    Obtain a new prescription from your doctor.
   Step 2:    Fill out an Express Scripts Home Delivery mail order form. (Mail Order forms are available
              from the Trust Fund Office)
   Step 3:    Complete the credit card billing section or enclose a check for the applicable copayment. If
              you are not sure whether your prescription is a generic or brand name drug, contact Express
              Scripts.
   Step 4:    Mail your prescription, completed order form and applicable copayment in the pre-addressed
              envelope directly to Express Scripts, Inc. or send it to: Express Scripts Home Delivery
              Service, P.O. Box 66773, Saint Louis, MO 63166-6773.

              Your prescription will be mailed to you within 2-3 business days after receiving your order
              and copayment.


DIRECT REIMBURSEMENT PROGRAM
     Under the Direct Reimbursement Program, you may obtain your prescription drugs from any
pharmacy of your choice. When prescriptions are dispensed by a legally licensed provider, the Trust Fund
will pay as follows:

For Generic Drugs, Insulin, and Diabetic Supplies:
    100% of Eligible Charges for original prescription or refills, or
    the cost of the prescription, whichever is less

For All Other Covered Drugs:
    80% of Eligible Charges for original prescriptions, or
    the cost of the prescription, whichever is less
    90% of Eligible Charges for refills, or
    the cost of the prescription, whichever is less
    Refills will be paid for up to one (1) year from the date the original prescription was written.

Limitation:
    All prescription drugs are limited to a 30-day supply or a standard size package of 100 units for solid
oral drugs or 240 units for liquid oral drugs when 100 units or 240 units, as applicable, would be charged
even through it is more than a 30-day supply.

    How to Use the Direct Reimbursement Program
    Step 1:   Go to any licensed pharmacy of your choice to fill your prescription and present your
              membership card. (NOTE: The membership card is for identification only and does not
              guarantee eligibility.)
    Step 2:   You pay for the entire cost of the prescription and file a claim for reimbursement from the
              Trust Fund. (Claim forms are available from pharmacies and the PAI Office).
    Step 3:   Fill out your portion of the claim form and have the pharmacy complete the remaining
              portion of the claim form.
    Step 4:   Mail the completed claim form, together with your receipt, to the Trust Fund Office.
    Step 5:   Reimbursement will be made directly to you.

                    All claims must be filed within 180 days after the date of purchase.




                                                       56
LIMITATIONS
  Smoking Cessation Drug Agents and Devices
  Coverage shall be limited to:
     -     Nicotine transdermal patches; one treatment cycle (12 weeks) per calendar year; limit of two
           treatment cycles per lifetime.
     -     Prescription Non-Nicotine Medications: Zyban (bubpropion hydrochloride) and Chantix
           (varenicline) only. No other prescription smoking cessation drugs are covered.
     -     Prescription Nicotine Gum.
     -     Prescription Nicotine Inhalers and Nasal Spray.


DRUGS NOT COVERED
  Agents used in skin tests to determine sensitivity.
  Appliances and other non-drug items.
  Compounded preparations, except compounds which contain at least one (1) prescription drug.
  Drugs dispensed to members confined as a registered bed patient.
  Drugs to treat infertility.
  Drugs to treat sexual dysfunction.
  Immunization agents.
  Injectable drugs.
  Drugs that may be purchased without a prescription, except as specified above.
  Contraceptives (other than generic oral contraceptives and generic contraceptive patches under the
  Direct Member Reimbursement Program or the Point-of-Service Prescription Drug Program or oral
  contraceptives prescribed for specific hormonal disorders).
  Drugs for the treatment of acne (example Retin-A) for any participant age 24 and over.




                                                   57
                             INDEMNITY (SELF-FUNDED) PLAN
                               ADDITIONAL INFORMATION

IF HOSPITALIZED ON THE EFFECTIVE DATE
    If you are confined in a hospital or other inpatient facility on your effective date (i.e., the day on which
your coverage under this Plan begins) and you had no other insurance or coverage prior to this coverage,
the Plan will cover the confinement from your effective date of eligibility under this Plan. However, if you
had other insurance or coverage immediately prior to your effective date under this Plan, which extends
coverage for any services, to include hospitalization or other inpatient facility services, the Plan will
provide coordination of benefits with your existing coverage until the termination of your existing
coverage. Thereafter, the Plan will provide coverage in accordance with the plan document and plan of
benefits.

INCORRECT OR FALSE INFORMATION
     The plan will not pay any benefits to the extent that such benefits are payable by reason of any false
statement made on the enrollment form or in any claim for benefits. If the plan pays such benefits before
learning of any false statement, you agree to reimburse the plan for 100% of such payment, without any
deduction for legal fees and costs which you incurred or paid. In addition, you agree to reimburse the plan
for any legal fees and costs incurred or paid by the plan to secure reimbursement. If reimbursement is not
made as specified, the plan, at its sole option, may:
    1. Take legal action to collect 100% of any payments made, including any legal fees and costs
       incurred or paid by the plan to secure reimbursement, or
    2. Offset future benefit payments by the amount of such reimbursement, including any legal fees or
       costs incurred or paid by the plan to secure reimbursement.

COORDINATION OF BENEFITS (DUAL COVERAGE)
    If you are covered under this plan and another group medical plan, Medicare, or motor vehicle
insurance, the benefits of this plan and those of the other plan will be coordinated and adjusted so that
the total payments by all programs or polices will not be greater than the Eligible Charge for the covered
service. However, in no event will the payment from this plan exceed what the plan would have paid had
there been no other program or policy creating dual coverage.
    In order to coordinate benefits, it is necessary to determine which plan is primary (pays first) and
which plan is secondary (pays second) for each family member. The following is a chart to assist in the
determination for different family members.

                  Patient                        Employee’s Plan                   Spouse’s Plan
      Employee                                        Primary                        Secondary

      Employee’s Spouse                              Secondary                         Primary

      Dependent Children*
       Employee’s birthday is                         Primary                        Secondary
       earlier in calendar year

        Spouse’s birthday is earlier                 Secondary                         Primary
        in calendar year

    * For children, the plan uses the “birthday rule” to determine which plan pays first. Under the
      birthday rule, the plan of the parent whose birthday is earlier in the calendar year is the
      primary plan.




                                                      58
    For motor vehicle insurance cases, motor vehicle insurance will be considered primary for payment
and those benefits will be applied first before any benefits of this plan apply. You must provide the plan
with a list of the medical expenses that the motor vehicle insurance covered. The list of expenses will be
reviewed and upon verification that the benefit maximums were met, this plan will begin paying benefits. If
another person caused the motor vehicle accident, refer to the “Third Party Liability” section below.

   Claims for services must be paid by the primary plan first. Once payment is made, a copy of the
Explanation of Benefits (EOB) must be sent to the secondary plan, along with a claim for payment. THE
SECONDARY PLAN CANNOT PROCESS YOUR CLAIM WITHOUT AN EOB.

Note:   If both you and your spouse are covered as either an active employee or retired employee under
        the Hawaii Laborers Health and Welfare Trust Fund and covered under the Indemnity (Self-
        Funded) Comprehensive Plan, benefits will not be coordinated.

SPECIAL PROVISIONS RELATING TO MEDICAID
    In determining or making any payment for you under this plan, eligibility for, or provision of state-
provided medical assistance shall not be taken into account.

WORKERS’ COMPENSATION
    If you are entitled to receive disability benefits or compensation under any Workers’ Compensation or
Employer’s Liability Law for an injury or illness, the plan will not pay benefits for any services rendered in
connection with such injury or illness. If you formally appeal the denial of a Workers’ Compensation claim,
you must notify the Trust Fund of such appeal. Upon the execution and delivery to the Trust Fund of all
documents it requires to secure its rights of reimbursement, the plan may pay such benefits. However,
such payment shall be considered only as an advance or loan to you.

    If your claim is declared eligible for benefits under Workers’ Compensation or Employer’s Liability
Law or if you reach a compromise settlement of the Workers’ Compensation claim, you agree to repay
100% of the advance or loan, without any deduction for legal fees or costs which you incurred or paid,
within 10 calendar days of receiving payment. If reimbursement is not made as specified, the plan, at its
sole option, may:
    1. Take legal action to collect 100% of any payments made plus any legal fees and costs incurred or
       paid by the plan to secure reimbursement, or
    2. Offset future benefit payments by the amount of such reimbursement plus any legal fees or costs
       incurred or paid by the plan to secure reimbursement.

THIRD PARTY LIABILITY
     If your injury or illness is or may have been caused by a third party and you have a right or assert a
right to recover damages from that third party or your own insurance company, the plan is not liable for
benefits in connection with services rendered for such injury or illness. However, upon the execution and
delivery to the Trust Fund of all documents it requires to secure its rights of reimbursement, the plan may
pay such benefits. Such payments shall be considered only as an advance or loan to you and you agree
to repay 100% of this advance or loan, without any deduction for legal fees and costs which you incurred
or paid, from any recovery received, however classified or allocated, and you promise not to waive or
impair any rights of the Trust Fund without its written consent.
    If the plan makes payments for such injury or illness, the Trust Fund shall have reimbursement rights
and shall have a lien against any recovery you or a covered dependent obtain from the third party or your
insurance company to the extent of the plan payments. Such lien may be filed with the third party, his or
her agent or insurance company, your insurance company, or the court. If you do not repay the loan from
the recovery, the Trust Fund has the right to either:
    1. Take legal action to collect 100% of any payments made plus any legal fees and costs incurred or
       paid by the plan to secure reimbursement, or
    2. Offset future benefit payments by the amount of such reimbursement plus any legal fees or costs
       incurred or paid by the plan to secure reimbursement.


                                                     59
                        INDEMNITY (SELF-FUNDED) PLAN
                          CLAIMS FILING AND PAYMENT
HOW TO FILE A MEDICAL CLAIM
   When you obtain the services of a physician or hospital,
   Step 1:   Present your membership card. (NOTE: The membership card is for identification only
             and does not guarantee eligibility.)
   Step 2:   Be sure that the physician, hospital, and PAI Claims Office has your correct mailing
             address; and
   Step 3:   Ask your physician or the hospital to file a claim directly on your behalf.
                  All claims must be filed within one (1) year after the date of service.
NOTE: For a claim submitted in a timely manner for which additional information is required for
processing, the late claims deadline shall be one (1) year from the date of request for such additional
information.

PAYMENTS FOR MEDICAL BENEFITS
   If you go to a participating provider, payment will be made directly to the provider.
   If you go to a nonparticipating provider, payment will be made directly to you. You will be responsible
   for paying the nonparticipating provider.
   The PAI Claims Office will mail you an Explanation of Benefits (EOB) after your claim has been
   processed showing the services preformed, the amount charged, the amount allowed, and the
   amount paid by the PAI Claims Office.
   Retain your Explanation of Benefits and receipts for tax purposes.
NOTE: A stale dated check for payment under this Plan may be re-issued by the PAI Claims Office within
one (1) year from the original check date subject to confirmation that the original check has not been
cashed or negotiated and upon receipt of a written request for re-issuance of the check from the
Beneficiary or provider.

OUT-OF-STATE MEDICAL SERVICES
   When you receive covered services outside the State of Hawaii:
   Send a completed claim form signed by the provider together with a copy of the itemized bill or
   receipt to the PAI Claims Office. Claim forms are available from the PAI Claims Office to take on your
   trip. For covered services outside the State of Hawaii, the Plan’s reimbursement is based on Eligible
   Charges for similar services in Hawaii. Please see the section on Eligible Charges on page 27.

            FOR INFORMATION ON THE CLAIMS AND APPEALS PROCEDURES FOR
     MEDICAL AND PRESCRIPTION DRUG BENEFITS, SEE PAGES 104 - 107 OF THIS BOOKLET.




    The Indemnity Comprehensive Plan benefits are self-insured. The preceding is a summary of
coverage for informational purposes only. Its content is subject to the provisions of the Comprehensive
Medical Plan Document (Self-Funded), Prescription Drug Plan (Self-Funded) documents, and all
amendments thereto. These documents are on file with Hawaii Laborers Health and Welfare Trust Fund
Office. Please refer to these documents for specific questions about coverage.




                                                    60
             KAISER FOUNDATION HEALTH PLAN INC.




                               KAISER PERMANENTE
    The Kaiser Permanente Plan is designed to provide quality medical care at a reasonable cost. The
Kaiser Permanente Plan provides prepaid medical and hospital services for members, as well as
preventive health benefits like health evaluations.
    When you join, you and other enrolled members of your family are encouraged to follow a health
maintenance program with covered benefits such as periodic health evaluations, eye examinations for
glasses, and pediatric checkups. When an illness does occur, your benefit coverage enables your
personal Kaiser Permanente physician to provide the necessary services.


                HOW TO USE THE KAISER PERMANENTE PLAN
PERSONAL DOCTOR
    You obtain your medical care directly from Kaiser Permanente facilities and physicians. You may
choose your personal doctor from a staff of over 350 highly qualified physicians representing all major
specialties. Your personal Kaiser Permanente physician is responsible for your medical care and
arranges consultations with other specialists, as necessary. All care and services need to be coordinated
by a Kaiser Permanente physician.
    A list of providers is included in the Kaiser Permanente Member Handbook which is provided to you
at no charge.

LIVE OR WORK
    Members may live or work in the Hawaii service area and enroll (or continue to be enrolled) in a
Kaiser Permanente plan as long as they live in the State of Hawaii. Family dependents must live in the
Hawaii service area to enroll (or continue to be enrolled) in a Kaiser Permanente plan.

LOCATIONS
    For your convenience, Kaiser Permanente operates multiple outpatient facilities for Oahu, Maui, and
the Big Island. You can obtain care at the facility or facilities of your choice. Members on Oahu receive
hospital care in semiprivate rooms at the Moanalua Medical Center. Members on the Big Island receive
hospital care at the Kona Community Hospital, Hilo Medical Center, or North Hawaii Community Hospital.
Members on Maui receive hospital care at Maui Memorial Medical Center.

   For detailed information on the Kaiser Permanente locations, please contact the Customer Service
Center at 432-5955 (Oahu), or 1 (800) 966-5955 (neighbor islands), or visit the website at
www.kaiserpermanente.org.

MEDICAL OFFICE VISITS
    You may schedule routine visits to physicians or other health professionals by calling in advance to
arrange appointments. In case of sudden illness, you can be seen by a physician that same day by calling
one of Kaiser Permanente’s conveniently located facilities and describing your condition. Referrals to
non-Kaiser Permanente physicians and hospitals may be made for very specialized care.




                                                   61
                                             BASIC MEDICAL BENEFITS
SERVICES                                                                                                             MEMBER CHARGES
OUTPATIENT SERVICES
Office Visits (doctors and other health professionals) ............................................................$15.00 per visit
Pediatric checkups ..................................................................................................................$15.00 per visit
Health evaluations...................................................................................................................$15.00 per visit
Eye exams for eyeglasses ......................................................................................................$15.00 per visit
Short Term physical, speech and occupational therapy .........................................................$15.00 per visit
Radiation therapy ....................................................................................................................$15.00 per visit
Laboratory procedures, prescribed imaging, and other
diagnostic services........................................................................................ $15.00 per department per day
Routine immunizations
   For children through 18 years of age..........................................................................................No Charge
  For adults 19 years of age and over.................................................................................. $10.00 per dose
Influenza (flu) and pneumococcal immunizations..........................................................................No Charge
Unexpected mass immunizations .................................................................50% of applicable plan charges
Chemotherapy medications for treatment of cancer
    If skilled administration is required ............................................................................................No Charge
    If self-administered ................................................................................................ $10.00 per prescription
Casts and dressings.......................................................................................................................No Charge
HOSPITAL SERVICES
Room and Board - Semiprivate, Private (when prescribed) or
Intensive Care Unit.................................................................................................................. $50.00 per day
Operating Room.............................................................................................................................No Charge
Doctor’s medical and surgical services.......................................................................................... No charge
Hospital anesthesia services.......................................................................................................... No charge
Drugs and dressings ...................................................................................................................... No charge
Laboratory procedures, prescribed imaging, and
other diagnostic services............................................................................... $15.00 per department per day
Radiation therapy ........................................................................................................................... No charge
Short-term physical, speech, and occupational therapy ................................................................ No charge
Special duty nursing when prescribed ........................................................................................... No charge
Blood transfusions.........................................................................................20% of applicable plan charges

EXTENDED CARE SERVICES
Up to 60 days of extended care services in a
 skilled nursing facility per benefit period ......................................................................................No Charge

EMERGENCY CARE SERVICES
Coverage for initial emergency treatment only
   Within the Hawaii service area ..........................................................................$50.00 per visit, plus other
                                                                                                        other applicable plan charges
   Outside the Hawaii service area........................................................... 20% of reasonable and customary
                                                                                 charges plus other applicable plan charges



                                                                         62
SERVICES                                                                                                                MEMBER CHARGES

OBSTETRICAL CARE, FAMILY PLANNING, AND INFERTILITY SERVICES
Doctors’ services after confirmation of pregnancy
(prenatal, delivery and care in hospital) .........................................................................................No Charge
Routine care for newborn during mother’s hospital stay................................................................No Charge
Caesarean sections (medically necessary) ...................................................................................No Charge
Elective interrupted pregnancy (limited to 2 procedures
 per lifetime) ...........................................................................................................................$15.00 per visit
In vitro fertilization .........................................................................................20% of applicable plan charges
   Limited to (one) 1 procedure per lifetime under Kaiser Permanente
   Limited to female members using spouse’s sperm
   Excluded for member or member’s spouse who have had
   voluntary surgically induced sterility (with or without reversal)
Family planning services.........................................................................................................$15.00 per visit
Infertility services (not including lab, prescription drugs) ........................................................$15.00 per visit
Contraceptive Aids and Devices (FDA approved to prevent
unwanted pregnancies).................................................................................50% of applicable plan charges

MENTAL HEALTH AND CHEMICAL DEPENDENT SERVICES
Outpatient Services
(up to 24 office visits per calendar year*)......................................................20% of applicable plan charges
Mental Health Services - Hospital Care
Coverage is up to 30 days per calendar year, which can include any
combination of hospital days and specialized facility services. (two
(2) days of Specialized Facility Care count as one hospital day) .............. 20% of applicable plan charges
    Hospital care includes services of physicians and mental health
    professionals or physician’s visits in a Specialized Facility
    Specialized Facility services include non-hospital residential
    services, partial hospitalization services, or day treatment
    services in a specialized mental health treatment unit or facility
    approved by the Hawaii Permanente Medical Group
Chemical Dependency Services – Hospital Care
Coverage is up to 30 days per calendar year which can include any
combination of hospital days and specialized facility services. (two
(2) days of Specialized Facility Care count as one hospital day) .................. 20% of applicable plan charges
    Hospital care includes services of physicians and mental health
    professionals or physician’s visits in a Specialized Facility
    Specialized Facility services include non-hospital residential
    services, partial hospitalization services, or day treatment
    services in a specialized mental health treatment unit or facility
    approved by the Hawaii Permanente Medical Group
    Services after medical detoxification are limited to two (2)
    treatment episodes per lifetime




*   A total of 24 outpatient visits is available under the Mental Health and Chemical Dependence benefits, combined.
    When all 24 outpatient visits are used, one (1) inpatient hospital day may be exchanged for two (2) additional
    outpatient visits, when authorized.




                                                                           63
SERVICES                                                                                                              MEMBER CHARGES
OTHER SERVICES
Prescribed drugs that are on the formulary and administered at
Kaiser Permanente Medical Offices, Emergency Department and
Urgent Care Centers ............................................................................... ...............No charge for most drugs.
                                                                                                  (Members must pay the registration
                                                                                                                      fee for the office visit)

Ambulance services ................................................................................. 20% of reasonable and customary
                                                                                                      charges plus any charges above
                                                                                                   reasonable and customary charges
Home Health Services (for home-bound members
when prescribed by a Kaiser Permanente physician)
Nurse and Home Health Aide Visits............................................................................ .................. No charge

Hospice Care (in lieu of any other plan benefits for the treatment
of a terminal illness ........................................................................................................................ No charge

Internal prosthetics, devices and aids...........................................................50% of applicable plan charges


Smoking Cessation Classes ......................................................................Members pay the prevailing rates




                                                                          64
                                         SENIOR ADVANTAGE BENEFITS
Retirees who are eligible for and enrolled in Medicare Parts A and B and reside in the Hawaii Senior
Advantage service area are covered under the Kaiser Permanente Senior Advantage Plan. However,
the Senior Advantage Plan is currently not available on the island of Kauai. In addition to the preceding
benefits, the Senior Advantage Plan has the following benefits:

SERVICES                                                                                                                   MEMBER CHARGES
OUTPATIENT SERVICES
Outpatient hospital services ....................................................................................................$15.00 per visit
Injections, allergy tests and allergy treatment................................................................................ No charge
Drugs and biologicals that cannot be self-administered ................................................................ No charge
Blood .............................................................................................................................................. No charge
Ostomy supplies............................................................................................20% of applicable plan charges
Corrective aids and appliances (such as splints, braces
and crutches) ................................................................................................20% of applicable plan charges
Prosthetic devices (such as contact lenses and eyeglasses
required after cataract surgery).....................................................................20% of applicable plan charges
   Intraocular lenses are covered at no charge
Durable medical equipment (such as wheelchairs, oxygen
tanks and walkers) ........................................................................................20% of applicable plan charges
INPATIENT SERVICES
Prosthetic devices .......................................................................................................................... No charge
Blood .............................................................................................................................................. No charge
MENTAL HEALTH SERVICES
Outpatient services
   First - 20th visit ..........................................................................................20% of applicable plan charges
 Beyond 20th visit ........................................................................................50% of applicable plan charges
Hospital Services (190 days lifetime benefit) ................................................................................. No charge
Hospital Services after 190 day lifetime benefit
is exhausted (30 days per calendar year).....................................................20% of applicable plan charges
CHEMICAL DEPENDENCY SERVICES
Outpatient visits.......................................................................................................................$15.00 per visit
Inpatient visits ................................................................................................................................ No charge
IN YOUR HOME
All prescribed Medicare-covered home health agency services.................................................... No charge
House calls by physician.........................................................................................................$15.00 per visit
SKILLED NURSING CARE
Room and board and other services and supplies (up to
100 days in a skilled nursing facility per benefit period as
defined by Medicare)...................................................................................................................... No charge
EMERGENCY CARE SERVICES
Coverage for emergency treatment only at any facility
within the service area and outside the service area ...................................................... $50.00 per visit plus
                                                                                                     applicable plan charges
Ambulance Services ...................................................................................................................... No charge


                                                                             65
However, under the Senior Advantage Plan you must go to Kaiser for your care. Neither Medicare
nor Kaiser will pay for any other care that you receive from a non-Kaiser facility or physician except for
referrals for covered services not available within Kaiser or emergency or urgent care and renal dialysis
care while you temporarily travel outside the Hawaii Senior Advantage service area.

SUPPLEMENTAL CHARGES MAXIMUM
Your out of pocket expenses for covered Basic Health Services are capped each year by the following
Supplemental Charges Maximum:
       Single (per member/per calendar year)............................................................ $2,000.00
       Family (3 or more members/per calendar year) ............................................... $6,000.00


  You must retain your receipts for the charges you have paid, and when the maximum amount has been
paid, you must present these receipts to Kaiser’s Business Office at the Moanalua Medical Center,
Honolulu Clinic, or to the cashier at other clinics. After verification that the Supplemental Charges
Maximum has been paid, you will be given a card which indicates that no additional Supplemental
Charges for covered Basic Health Services will be collected for the remainder of the calendar year. You
need to show this card at your visits to get the Supplemental Charges waived.
  All payments are credited toward the calendar year in which the services were received.
  Once you have met the Supplemental Charges Maximum, please submit your proof of payment as
soon as reasonably possible. No refunds will be made for receipts turned in after February 28 of
the year following the one in which the services were received.

  Basic Health Services include, but are not limited to covered office visits, hospital services, short-term
physical, speech and occupational therapy, obstetrical care, laboratory, diagnostic testing procedures, x-
rays, radiation therapy, emergency and ambulance services, in vitro fertilization (not including drugs),
immunizations, mental health and chemical dependency services (the first 24 outpatient visits combined
and the first 30 inpatient visits combined) and transplant donor services.

   Some benefits are not considered Basic Health Services. These include, but are not limited to:
excluded and non-covered services, allergy test and treatment materials, radioactive materials, charges
for blood, prescribed drugs, contraceptive drugs and devices, complementary alternative medicine, dental
services, mental health and chemical dependency services (except for the first 24 outpatient visits
combined and the first 30 inpatient visits combined), prostheses, durable medical equipment, braces,
diabetes supplies and equipment, medical foods, injectable and oral travel immunizations, charges above
reasonable and customary charges, charges above Medicare approved charges, and skilled nursing
facility charges. Your payments for these items do not count toward the Supplemental Charges
Maximum.




                                                       66
                 EMERGENCY OR URGENT CARE OBTAINED
                FROM NON-KAISER HEALTH PLAN PROVIDERS
GENERAL PROVISIONS
    A medical emergency is a potentially life threatening situation which requires immediate medical
attention such as:
        Heart attack or stroke symptoms
        Extreme difficulty breathing
        Sudden or extended loss of consciousness
        Uncontrollable bleeding
        Sudden loss of vision
    If you think you are having an emergency, go immediately to the emergency department. Do
not take the time to call Kaiser Permanente as precious time may be wasted. If you think you
need an ambulance, call 911.
  Emergency services (when judged to be an emergency) or ambulance services (when judged to be
medically necessary) will be paid in accordance with your health plan benefits. Emergency Room visits
that do not meet the prudent lay person definition of an emergency will be deemed non-emergent and will
not be covered.
  If you are admitted to a non-Kaiser Permanente facility, you or a family member must notify Kaiser
Permanente within 48 hours after care begins (or as soon as reasonably possible) by calling the phone
number on the back of your Kaiser Permanente identification card. This must be done, or your claim for
payment may be denied. Kaiser Permanente may arrange for your transfer to a Kaiser Permanente
facility as soon as it is medically appropriate to do so.
        Emergency care on Oahu is available seven days a week, 24 hours a day, at Kaiser Permanente’s
Moanalua Medical Center, 3288 Moanalua Road, Honolulu, Hawaii 96819, phone (808) 432-0000. On
the neighbor islands, emergency care is available seven days a week, 24 hours a day, at the following
facilities:

 ISLAND OF HAWAII
 Hilo Medical Center
 1190 Waianuenue Avenue
 Hilo, Hawaii 96720
 (808) 674-6800

 Kona Community Hospital
 Haukapila Street
 Kealakekua, Hawaii 96750
 (808) 332-4413

 North Hawaii Community Hospital
 67-1125 Mamalahoa Highway
 Kamuela, Hawaii 96743
 (808) 881-4730

 ISLAND OF MAUI
 Maui Memorial Medical Center
 221 Mahalani Street
 Wailuku, Hawaii 96793
 (808) 242-2343




                                                   67
   All necessary care, emergency or otherwise, should be obtained from a Kaiser facility. Out-of-Plan
Emergency benefits are provided for potentially life threatening illness or injuries only if delay in reaching
a Kaiser facility would result in death, disability or significant jeopardy to the member’s condition.
   Subject to the other provisions set forth below, Kaiser will pay 80% of the reasonable charges for
covered emergency services or out of area urgent care. Reimbursement is made according to your group
contract.

   The only care from non-Kaiser Permanente practitioners or providers that may be covered are:
   authorized referrals when your Kaiser Permanente physician refers you for care that is not available
   from Kaiser Permanente
   emergency care, and
   out-of-area urgent care when you temporarily travel outside the Hawaii service area.


EMERGENCY SERVICES FOR SENIOR ADVANTAGE MEMBERS
    Emergency care at Kaiser Permanente facilities ................................................................$50.00
    Out of Plan emergency care/post stabilization care............................................................$50.00
    The Senior Advantage program uses the Medicare definition of emergency medical condition which is
a condition which manifests itself by acute symptoms of sufficient severity (including severe pain) such
that a prudent layperson, with an average knowledge of health and medicine, could reasonably expect
the absence of immediate medical attention will result in any one of the following: serious jeopardy to the
health of the individual, or in the case of a pregnant woman, herself and her unborn child; serious
impairment to bodily functions; or serious dysfunction of any body organ or part.
   Emergency care is available from Kaiser Permanente facilities, 24 hours a day, 7 days a week, without
prior authorization. For life threatening conditions, you should get immediate medical care by calling
911. If you are not sure whether your situation is an emergency, call the emergency number of the
nearest Kaiser Permanente facility listed below.

                            Oahu:            (808) 432-0000            Moanalua Medical Center
                            Maui:            (808) 242-2343            Maui Memorial Hospital
                            Hawaii:          (808) 974-6800            Hilo Medical Center
                                             (808) 322-4413            Kona Community Hospital
                                             (808) 881-4730            North Hawaii Community Hospital

    Covered emergency care includes outpatient or inpatient services which are:
    Provided by a provider qualified to furnish emergency services, and
    Needed to evaluate or stabilize an emergency medical condition.
  If you have an emergency medical condition within Kaiser Permanente’s service area, you must receive
any follow-up care through Kaiser Permanente.
  In certain situations, Senior Advantage also covers out-of-Plan emergency care received from non-Plan
providers in the service area and out-of-Plan emergency care received worldwide from non-Plan
providers while you are temporarily outside the service area. Follow-up care will be covered out of the
service area as long as the care you require continues to meet the Medicare definition of emergency
medical condition.

  Out-of-Plan emergency care is limited to covered care required before your medical condition permits
you to travel or transfer to another facility designated by Kaiser Permanente. Any unauthorized
continuing or follow-up care outside or Kaiser Permanente is not covered unless that care continues to
meet the definition of emergency care. A decision to transfer you to another facility is made at Kaiser
Permanente’s discretion with the attending physician’s concurrence. The cost of medically necessary
special transportation to another facility is covered if Kaiser Permanente approves it in advance.




                                                              68
 Kaiser Permanente’s payment for covered emergency care out-of-Plan is based upon charges that
Kaiser Permanente determines to be reasonable under Medicare payment guidelines. Kaiser
Permanente’s payments for covered services will be reduced by the following amounts:
    i.    $50.00 (your copayment),
    ii.   Payments for take-home items like crutches or limb immobilizers you receive during your visit,
    iii. Amounts recoverable under any insurance policy or contract, any other contract, or any
         government program, except Medicaid, and
    iv. Amounts recovered by you or your legal representative from motor vehicle, third-party, or other
        liability insurance.
  To obtain payment for covered services out-of-Plan, you must submit a claim as described in the
section entitled “Filing Claims” in the Kaiser Senior Advantage Evidence of Coverage.


OUTSIDE THE SERVICE AREA
    Outside the Hawaii service area, benefits are limited to authorized referrals (when your Kaiser
Permanente physician determines the services you require are not available in the Hawaii service area),
emergency benefits, ambulance services, and out-of-area urgent care when you are temporarily away
from the Hawaii service area. Urgent care services means initial care for a sudden and unforeseen
illness or injury when:
   You are temporarily away from the Hawaii service area.
   The care is required to prevent serious deterioration of your health, and
   The care cannot be delayed until the member is medically able to safely return to the Hawaii service
   area or travel to a Kaiser Permanente facility in another Health Plan region.

    Continuing or follow-up treatment at a non-Kaiser Permanente facility is not covered. When you are
temporarily traveling outside the Hawaii service area, you may require medical services for emergency or
urgent problems. Please have your Kaiser ID card with you at all times. If you are admitted to a hospital,
you or a family member must call the toll-free number found on the back of your ID card within 48-hours
of your hospital admittance or your claim may be denied.

   Services at other Kaiser Permanente region’s facilities are provided while you are temporarily visiting
the area for less than 90 days. Visiting member services are different from the coverage you receive in
your home region. Be sure you have your ID card with you at all times. The visiting member program is
not a plan benefit, but a service offered to members as a courtesy. Changes to the program may occur at
any time.

   Kaiser Permanente will terminate the membership of members who move anywhere outside the
Hawaii service area. Until that time, you will only be covered for initial emergency care in accordance
with your Health Plan benefits. Before you move outside the Hawaii service area, you should contact the
Trust Fund Office to discuss your options.

   Kaiser must be notified within 48 hours of receiving hospital care at a non-Kaiser facility or as soon as
reasonably possible. Claims must be filed within 90 days after the first emergency or out of area urgent
care service for which payment is requested.




                                                     69
                                             EXCLUSIONS
     When a service is excluded, all services that are necessary or related to the excluded service are
also excluded. “Service” means any treatment, therapeutic or diagnostic procedure, drug, injectable,
facility, equipment, device, or supply. The following services are excluded:
   Acupuncture.
   Alternative medical services not accepted by standard allopathic medical practices including, but not
   limited to, hypnotherapy, behavior testing, sleep therapy, biofeedback, massage therapy,
   naturopathy, rest cure, and aromatherapy.
   All blood, blood products, blood derivatives, and blood components whether of human or
   manufactured origin and regardless of the means of administration, except units of whole blood, red
   cell products, cryoprecipitates, platelets, plasma, fresh frozen plasma, and Rh immune globulin.
   Donor directed units are not covered.
   Cardiac rehabilitation.
   Chiropractic services (except Medicare members are entitled to manual manipulation of the spine to
   correct subluxation when prescribed by a Kaiser Permanente physician and performed by a Health
   Plan designated provider).
   Certain contraceptive devices, contraceptive foams and creams, condoms or other non-prescription
   substances used individually or in conjunction with any other prescribed drug or device.
   Cosmetic services, such as plastic surgery to improve physical appearance, which will not result in
   significant improvement in physical function. However, Kaiser Permanente physician services to
   correct significant disfigurement resulting from an injury or medically necessary surgery or incident to
   a covered mastectomy are covered.
   Custodial services or intermediate level nursing facility services.
   Continuation in a course of treatment for members who are disruptive or physically abusive.
   Dental care services, including dental x-rays, dental implants, dental appliances and services relating
   to Temporomandibular Joint Dysfunction (TMJ) or Craniomandibular Pain Syndrome.
   Employer or Governmental Responsibility: Services that an employer is required by law to provide or
   that are covered by a Workers’ Compensation or employer liability law; services for any military
   service-connected illness, injury or condition when such services are reasonably available to the
   member at a Veterans Administration facility; services required by law to be provided only by, or
   received only from a government agency.
   Experimental or investigational services.
   Eye examinations for contact lenses and visual therapy (eye exercises).
   Routine foot care, unless medically necessary.
   Health Education – specialized health promotion classes and support groups (such as the bariatric
   surgery program).
   Homemaker services.
   The following costs and services for infertility treatment, in vitro fertilization or artificial insemination:
   -   The cost of equipment and of collection, storage, and processing of sperm.
   -   In vitro fertilization requiring the use of either donor sperm or donor eggs.
   -   In vitro fertilization that does not meet state law requirements.
   -   Services related to conception by artificial means other than artificial insemination or in vitro
       fertilization, such as ovum transplants, gamete intrafallopian transfer (GIFT) and zygote
       intrafallopian transfer (ZIFT); including prescription drugs related to such services and donor
       sperm and donor eggs used for such services.
   -   Services to reverse voluntary, surgically-induced infertility.



                                                       70
The following mental health costs and services:
-   Services that, in the opinion of a Kaiser Permanente physician, are not necessary or reasonably
    expected to improve the member’s condition.
-   Continuation in a course of treatment for members who are disruptive or physically abusive.
-   Services on court order or as a condition of parole or probation unless determined by a Kaiser
    Permanente physician to be medically necessary and appropriate.
-   Testing or treatment requested or required by a non-Kaiser Permanente outside agency/body, in
    connection with administrative or court proceedings (such as divorce or child custody
    proceedings), hearings, gun permit applications, employment or disability matters, unless the test
    or treatment is determined by a Kaiser Permanente physician to be medically necessary and
    appropriate.
-   Testing for ability, aptitude, intelligence, learning disability or interest.
-   Occupational therapy supplies.
-   Mental health services for mental retardation, after diagnosis.
The following residential chemical dependence costs and services:
-   Services that, in the opinion of a Kaiser Permanente Physician, are not necessary or reasonably
    expected to improve the member’s condition.
-   Continuation in a course of treatment for members who are disruptive or physically abusive.
-   Services on court order or as a condition of parole or probation unless determined by a Kaiser
    Permanente physician to be medically necessary and appropriate.
-   Testing or treatment requested or required in connection with administrative or court proceedings
    or hearings, including, but not limited to divorce, child custody proceedings, gun permit
    applications, employment or disability matters, or as a condition of parole or probation, unless the
    test or treatment is determined by a Kaiser Permanente physician to be medically necessary and
    appropriate.
-   Testing for ability, aptitude, intelligence, learning disability, or interest.
-   Occupational therapy supplies.
Certain exams, services, and related reports/paperwork, in connection with third party requests such
as those for: employment, participation in employee programs, sports, camp, insurance, disability,
licensing, or on court order or for parole or probation.
Radial keratotomy (RK), photo-refractive keratectomy (PRK), and similar procedures.
Long-term physical therapy, occupational therapy, speech therapy, and maintenance therapies;
physical, occupational, and speech therapy deficits due to developmental delay; therapies not
expected to result in significant, measurable improvement in physical function with short-term
therapy.
Services not generally and customarily available in the Hawaii Region service area.
Services and supplies not medically necessary.
All services, drugs, injections, equipment, supplies, and prosthetics related to treatment of sexual
dysfunction, except evaluations and health care practitioners’ services for treatment of sexual
dysfunction.
All services, drugs, injections, prosthetics, devices, or surgery related to gender reassignment.
Take-home supplies for home use, such as bandages, gauze, tape, antiseptics, ace type bandages,
drug and ostomy supplies, catheters and tubing, except Medicare covered take-home supplies for
Medicare members.




                                                    71
The following costs and services for transplants:
    Non-human and artificial organs and their implantation.
    Bone marrow transplants associated with high-dose chemotherapy for the treatment of solid
    tissue tumors, except for germ cell tumors and neuroblastoma in children.
Services for injuries or illnesses caused or alleged to be caused by third parties or in motor vehicle
accidents.
Transportation (other than covered ambulance services), lodging, and living expenses.
Services for which coverage has been exhausted, services not listed as covered, or excluded
services.
Oral travel immunizations.
Injectable travel immunizations.




                                                72
                           SENIOR ADVANTAGE EXCLUSIONS
    In addition to the exclusions listed above, Kaiser Senior Advantage does not cover the following items
and services:

    Services that are not covered under Original Medicare, unless such services are specifically listed as
    covered in the Senior Advantage benefit section
    Services that you get from non-Plan providers, except for care for a medical emergency and urgently
    needed care, rental (kidney) dialysis services that you get when you are temporarily outside of the
    Plan’s service area, and care from non-Plan providers that is arranged or approved by a Plan
    provider.
    Services not generally provided in our service area, unless it is generally accepted and authorized
    medical practice to refer patients outside our service area for such services.
    Services that you get without a referral from your Kaiser physician, when a referral from your Kaiser
    physician is required for getting that service.
    Services that you get without prior authorization, when prior authorization is required for getting that
    service.
    Services which are not reasonable and necessary according to the standards of Original Medicare
    unless these services are otherwise listed by Kaiser Permanente Senior Advantage as a covered
    service.
    Emergency facility services for non-authorized, routine conditions that do not appear to a reasonable
    person to be based on a medical emergency.
    Services for any military service connected illness, injury, or condition when such services are
    provided to the member at a Veterans Administration facility.
    Any service provided or arranged by criminal justice institutions for members confined therein, unless
    the service would be covered as emergency services as described in this Agreement.
    Surgical treatment of morbid obesity unless medically necessary and covered under Original
    Medicare or determined medically necessary by a Kaiser Permanente medical director designee.
    Private room in a hospital, unless medically necessary.
    Private duty nurses.
    Personal convenience items such as telephone, radio, or television in your room at a hospital or
    skilled nursing facility.
    Nursing care on a full-time basis in your home.
    Homemaker services.
    Charges imposed by immediate relatives or members of your household.
    Meals delivered to your home.
    Unless medically necessary, elective or voluntary enhancement procedures, services, incontinence
    supplies, other supplies, and medications including but not limited to weight loss, hair growth, sex
    change operations, sexual performance, athletic performance (including weight training and body
    building), cosmetic purposes, anti-aging, and mental performance.
    Routine dental care (such as cleanings, fillings, or dentures) or other dental services (such as
    implants).
    Chiropractic care is generally not covered under the Plan, (with the exception of manual manipulation
    of the spine according to Medicare guidelines).
    Routine foot care is generally not covered under the Plan and is limited according to Medicare
    guidelines.
    Orthopedic shoes unless they are part of a leg brace and are included in the cost of the leg brace.
    (Exception: Orthopedic or therapeutic shoes are covered for people with diabetic foot disease)


                                                      73
Supportive devices for the feet. (Exception: Orthopedic or therapeutic shoes are covered for people
with diabetic foot disease)
Eyeglasses (except after cataract surgery), Radial keratotomy, LASIK surgery, vision therapy, and
other low vision aids and services.
Self-administered prescription medication for the treatment of a sexual dysfunction, including erectile
dysfunction, impotence and anorgasmy or hporgasmy.




                                                74
                                       LIMITATIONS
Benefits and services are subject to the following limitations:
Services may be curtailed because of major disaster, epidemic, or other circumstances beyond
Kaiser Permanente’s control such as a labor dispute or a natural disaster.
Coverage is not provided for care for conditions for which a member has refused recommended
treatment for personal reasons when Kaiser Permanente physicians believe no professionally
acceptable alternative treatment exists. Coverage will be provided up to the point that the insured
followed the recommended treatment.
Chemical dependence treatment services after medical detoxification are limited to two treatment
episodes per lifetime.
Diabetes equipment and supplies necessary to operate them are subject to Medicare coverage
guidelines and limitations, must be preauthorized in writing by Kaiser Permanente, and obtained from
a Health Plan designated vendor.
Short-term physical, occupational, and speech therapy services means medical services provided for
those conditions which meet all of the following criteria:
    The therapy is ordered by a Physician under an individual treatment plan;
    In the judgment of a Physician, the condition is subject to significant, measurable improvement in
    physical function with short-term therapy;
    The therapy is provided by or under the supervision of a Physician-designated licensed physical,
    speech, or occupational therapist, as appropriate; and
    As determined by a Physician, the therapy must be necessary to sufficiently restore neurological
    and/or musculoskeletal function that was lost or impaired due to an illness or injury.
Tuberculin skin test is limited to one per calendar year, unless medically necessary.
Donor’s transplant expenses. Health Plan will pay for emergency services directly related to the
covered transplant that a donor receives from non-Kaiser Permanente practitioners inside a Health
Plan Region or Group Health service area.
-   Health Plan will pay for emergency services directly related to the covered transplant that a donor
    receives from non-Kaiser Permanente practitioners to treat complications.
-   The services are provided not later than three months after donation.
-   The services are provided while the transplant recipient is still a Member, except that this
    limitation will not apply if the Member’s membership terminates because he or she dies.
-   Health Plan will not pay for travel or lodging for donors or prospective donors.
-   Health Plan will not pay for services if the donor or prospective donor is not a Kaiser Permanente
    member and is a member under another health insurance plan, or has access to other sources of
    payment.
-   The above guidelines do not apply to blood donors.
Written authorization from Kaiser is required for referrals to outside providers for durable medical
equipment and external prosthetics.
The obstetrical care benefit covers only routine obstetrical care (e.g. prenatal visits at routine
scheduled intervals, uncomplicated delivery/hospital stay, routine post-partum visit). All other care is
subject to the copayments applicable to the service received.




                                                 75
           THIRD PARTY LIABILITY, MOTOR VEHICLE ACCIDENTS
                   AND SURROGACY ARRANGEMENTS
   Kaiser Permanente has the right to recover the cost of care for a member’s injury or illness caused by
another person or in an auto accident from a judgment, settlement, or other payment paid to the member
by an insurance company, individual or other third party. You must furnish information about the
existence and terms of any third party insurance policy or motor vehicle insurance policy covering the
injury or illness and complete and submit all claims, release, and other documents necessary for us to
comply with State or Federal law. It is your responsibility to ensure that charges you incur are paid either
by the third party or a motor vehicle insurance carrier.
   Kaiser Permanente has the right to recover the cost of care for Surrogacy Health Services. Surrogacy
Health Services are services the member received related to conception, pregnancy, or delivery in
connection with a Surrogacy Arrangement. The member must reimburse Kaiser Permanente for the
costs of Surrogacy Health Services, out of the compensation the member or member’s payee are entitled
to receive under the Surrogacy Arrangement.


                                       BINDING ARBITRATION
   If you, or someone with a relationship to you, believe that some conduct arising from Kaiser
Permanente’s relationship to you as a Health Plan Member or as a patient has caused any harm, or if any
claim (including but not limited to contract, medical malpractice, and premises liability claims) is made
against (i) Kaiser Foundation Health Plan, Inc., (ii) Kaiser Foundation Hospitals, (iii) Hawaii Permanente
Medical Group, Inc., (iv) the Permanente Federation, LLC, (v) the Permanente Company, LLC, and (vi)
any individual or organization that contracts with an organization named in (i), (ii), (iii), (iv), or (v) above to
provide services to health plan members, that claim is subject to binding arbitration, unless it is solely for
the money within the jurisdictional limit of the Small Claims Court. For all claims subject to binding
arbitration, all parties give up the right to jury or court trial. After exhausting Kaiser Permanente’s internal
appeals process, members with Employee Retirement Income Security Act (ERISA) benefit claims
(whose plans are governed by ERISA) have the option of choosing binding arbitration or filing a lawsuit.


                ADDITIONAL KAISER PERMANENTE INFORMATION
CUSTOMER SERVICE
  Specially trained personnel are available to assist you in selecting a personal physician, answering
questions about Kaiser’s benefits and how to obtain medical services by calling the Customer Service
Department at 432-5955 or 1-800-966-5955 from the neighbor islands.

IDENTIFICATION CARDS
  Your Kaiser Permanente identification card is all that’s needed to receive care and service from Kaiser
Permanente. Please carry it with you at all times. It’s good for a lifetime - as long as you remain a
member. If you lose or damage your ID card or were a previous Kaiser Permanente Hawaii member and
no longer have your ID card, call Customer Service Center at (808) 432-5955 (Oahu) or 1 (800) 966-5955
(Neighbor Islands) to request a new one. Both new and returning health plan members should carry a
temporary ID (found on the last page of the enrollment form) for at least 30 days or, for first time Kaiser
Permanente members, until the permanent one is mailed to your home.

YOUR CURRENT ADDRESS
   It is vitally important that Kaiser Permanente has your current address and phone number. “Partners in
Health” and other publications are mailed regularly. Kaiser Permanente also may need to contact you
quickly if a member of your family comes in for emergency treatment. Notify the Customer Service Center
of any changes.




                                                        76
CLAIMS FOR BENEFITS
  Specific information about Kaiser’s claims procedures are contained in the Kaiser Permanente Member
Handbook which is provided to you at no charge.

CONVERSION PRIVILEGE
  If your Kaiser Permanente Plan membership through the Hawaii Laborers Health and Welfare Trust
Fund is terminated for any reason, you may apply for a Kaiser Permanente conversion membership
under an individual account. However, you must apply within 30 days. Full details on how to retain your
Kaiser Permanente membership are available from the Customer Service Center at 432-5955.

OUTSTANDING BALANCE
  If you have a past due amount that you owe Kaiser, you may be charged a 12% simple interest on the
amounts that are 60 days past due and/or future non-urgent appointments may be rescheduled until the
past due amount has been paid or you have made other payment arrangements.




                                                  77
                          PRESCRIPTION DRUG BENEFITS
  The Kaiser Permanente Prescription Drug Plan partially covers the cost of drugs for which a
prescription by a Kaiser Permanente licensed prescriber is required by law when such prescriptions are
purchased at a Kaiser Permanente facility within the Hawaii service area. The drug benefit includes only
the drugs listed on the Kaiser Permanente list of covered drugs (Formulary) that meet Formulary criteria
and restrictions. Any other drugs will not be covered unless medically necessary and prescribed and
authorized by a Kaiser Permanente licensed prescriber. Kaiser Permanente pharmacies may substitute a
chemical or generic equivalent unless prohibited by the Kaiser Permanente licensed prescriber. If a
member wants a brand name drug that has a generic equivalent, or a member requests a drug that is not
on the Formulary, the member will be charged for these drugs since they are not covered under the
Prescription Drug Plan.

  If you have any questions on a particular drug, contact the Customer Service Center and/or a clinic
pharmacy.

BENEFITS                                                                   MEMBER COPAYMENT
Prescription Drug or Refill                                                     $10.00 per prescription
Quantity not to exceed:
   A 30-day consecutive supply of a prescribed drug, or
   One dose of a self-administered injectable drug, or
   One cycle of an oral contraceptive drug, or
   An amount as determined by the Formulary

Self-Administered Drugs                                                         $10.00 per prescription
Covered only when all of the following criteria are met:
    Prescribed by a Kaiser Permanente physician or licensed
    prescriber,
    On the Health Plan Formulary and used in accordance with
    Formulary criteria, guidelines, or restrictions,
    The drug is one for which a prescription is required by law,
    Obtained at pharmacies in the service area that are operated by
    Kaiser Foundation Hospital, or Kaiser Foundation Health Plan,
    Inc., or pharmacies Kaiser Permanente designates,
    Drug does not require administration by nor observation by
    medical personnel,
    Patient’s tolerance and response to the drug does not need to be
    tested, or has already been satisfactorily tested, and
    Patient or caregiver can be trained to self-administer the drug

Insulin and Certain Diabetic Supplies                                           $10.00 per prescription

Nicotine Patches                                                                       50% of charges
One (1) course of treatment per calendar year) only when all of the
following criteria are met:
    Prescribed by a Kaiser Permanente physician, and
    Member enrolls in a Kaiser Permanente approved smoking
    cessation program (members pay the prevailing rates for the
    smoking cessation classes)




                                                     78
Mail Order Prescriptions
   Members may also request refills of maintenance drugs through the mail order service, in which
members are entitled to a 90-day supply for a $20.00 copayment. (NOTE: Mail orders will not be sent
to any addresses outside the service area). Please mail your refill order before you are down to your
last 10 days supply. Allow one (1) week to receive your medication for refillable orders. The mail order
program does not apply to the delivery of certain pharmaceuticals (i.e., narcotics, tranquilizers, bulky
items, medication affected by temperature, and injectables).


                                           EXCLUSIONS
   Abortion Drugs.
   Contraceptive drugs and devices (to prevent unwanted pregnancies).
   Any packaging other than the dispensing pharmacy’s standard packaging.
   Drugs obtained from a non-Kaiser pharmacy.
   Drugs for which a prescription is not required by law (e.g., over-the-counter drugs) including condoms,
   contraceptive foams and creams or other non-prescription substances used individually or in
   conjunction with any other prescribed drug or device.
   Drugs and their associated dosage strengths and form in the same therapeutic category as a non-
   prescription drug that have the same indications as the non-prescription drug.
   Drugs or diabetes supplies not included in the Kaiser Permanente Hawaii Drug formulary unless a
   non-formulary drug or diabetes supply has been specifically prescribed and authorized by the licensed
   prescriber.
   Drugs and medications when used primarily for cosmetic purposes.
   Drugs to shorten the duration of the common cold.
   Medical supplies such as dressings and antiseptics.
   Brand name drugs requested by a member when there is a generic equivalent.
   Prescribed drugs or supplies that are necessary for or associated with excluded or non-covered
   services (including drugs used during an Intermediate Care Facility or non-covered Skilled Nursing
   Facility stay).
   Drugs related to sexual dysfunction.
   Drugs to enhance athletic performance (including weight training or bodybuilding).
   Medical supplies such as dressings and antiseptics.
   Medications injected by a physician or nurse in a medical office or in the home.        Self-injectable
   medications, except insulin.
   Reusable devices such as gluocose monitors and lancet cartridges.
   Replacement of lost, stolen or damaged drugs.
   Non-prescription vitamins.
   Immunizations, including injectable travel immunizations.
   Drugs and devices that are not approved by the U.S. Food and Drug Administration (FDA)

   Your Kaiser Permanente membership contract entitles you to a maximum one-month supply per
prescription (for each copayment, if applicable). It is the policy of Kaiser Permanente’s pharmacies, as a
convenience to Kaiser Permanente members, to dispense as much as a three-month supply of certain
prescriptions, if so requested. This is done in good faith, presuming the member will remain with Kaiser
Permanente throughout the three-month period. If you terminate your membership with Kaiser
Permanente before the end of the three-month period, you will be charged the retail price for your
remaining drugs that exceed the one-month allowable supply.




                                                   79
                     SENIOR ADVANTAGE MEDICARE PART D
                        PRESCRIPTION DRUG BENEFITS
   Your enrollment in Kaiser Permanente Senior Advantage does not affect Medicare coverage for drugs.
You are entitled to all medically necessary Medicare Parts A and B services including drugs that are
covered under Parts A and B. In addition, Kaiser Permanente Senior Advantage also covers your
Medicare Part D benefits when the following criteria are met:
      (a) Prescribed by a licensed prescriber in accordance with Medicare guidelines;
      (b) On the Kaiser Permanente Part D formulary and used in accordance with formula criteria,
          guidelines and restrictions;
      (c) The drug is one for which a prescription is required by law, except for insulin; and
      (d) Obtained at pharmacies in the Hawaii Senior Advantage service area, Kaiser Foundation
          Health Plan, Inc. or a pharmacy we designate.

Outpatient Prescription Drug Coverage
    For outpatient prescription drugs, you will pay a $10.00 copayment for generic and brand name drugs
on our formulary. One copayment covers oral and injectable drugs based on the prescription quantity, or
a 30-day supply, whichever is less. There is no deductible.

Out-of-Network Pharmacies
    In limited situations as required by Medicare guidelines, members may access out-of-network
pharmacies for covered Part D drugs. Members accessing covered Part D drugs at out-of-network
pharmacies may be responsible for any differential between the out-of-network pharmacy’s usual and
customary price and Kaiser Permanente’s allowance. If you obtain covered Part D drugs at an out-of-
network pharmacy, you must pay the out-of-network pharmacy’s usual and customary price at the time of
purchase and submit a claim to Kaiser Permanente for reimbursement.


EXCLUSIONS FOR PART D
    By law, certain types of drugs or categories of drugs are not covered by Medicare Prescription Drug
plans. These drugs or categories of drugs are “Exclusions” or “Non-Part D Drugs”. The following drugs,
or categories of drugs, are not covered:

   Agents when used for anorexia, weight loss, or weight gain
   Nonprescription drugs, unless they are part of approved step therapy
   Agents when used to promote fertility
   Agents when used for cosmetic purposes or hair growth
   Agents when used for the symptomatic relief of cough or colds
   Agents when used for the treatment of sexual or erectile dysfunction, unless such agents are used to
   treat a condition other than sexual or erectile dysfunction for which the agents have been approved
   by the Food and Drug Administration
   Prescription vitamins and mineral products, except prenatal vitamins and fluoride
   Barbiturates
   Benzodiazepines
   Drugs not included in the Kaiser Permanente Part D Formulary, unless a non-formulary drug has
   been specifically prescribed and authorized by the licensed prescriber.
   Any drugs for which payments would be available under Parts A or B of Medicare




                                                    80
                        OTHER KAISER PERMANENTE INFORMATION

Kaiser Foundation Health Plan Office
  Contract and policy interpretations ............................................................................................. 432-5127

Customer Service
  Service assistance, individual plan enrollment, benefit information,
  out-of-plan emergency claims ........................................................................ 432-5955/1 (800) 966-5955

Membership Accounting
 Name and address changes, eligibility,
 group and direct pay billings ....................................................................................................... 432-5310

Patient Accounting
  Industrial, No-Fault, Tri-care, and filing other insurances ........................................................... 432-5340

Mainland Kaiser Facilities
  Kaiser Permanente offers medical care in the District of Columbia and nine (9) states (California,
Colorado, Georgia, Idaho, Maryland, Ohio, Oregon, Virginia and Washington). If you need more care
while you are in one of these service areas, call for information during normal business hours. Kaiser
Permanente service areas are subject to change at any time.




    The preceding medical benefits are fully insured under an insurance contract issued by Kaiser
Foundation Health Plan, Inc., 711 Kapiolani Boulevard, Honolulu, Hawaii 96813. The services provided
by Kaiser include the payment of claims, when necessary, and the handling of claims appeals.

    The preceding is a summary of coverage for informational purposes only. Its content is subject to the
provisions of the Group Medical and Hospital Service Agreement and Face Sheet, and Benefit Schedule
Kaiser Permanente Group Plan, Laboratory Services, Imaging Services and Testing Services Rider $15,
Benefit Schedule Kaiser Permanente Senior Advantage Plan and Prescription Drug Rider 10 which
contain all the terms and conditions of membership and benefits. These documents are on file with the
Hawaii Laborers Health and Welfare Trust Fund Office. Please refer to these documents for specific
questions about coverage.


                                                                     81
                                 WELLNESS PROGRAMS
                    (Paid for directly by the Hawaii Laborers Health and Welfare Trust Fund)

  The wellness program provides the following benefits:
        1. Smoking Cessation;
        2. Weight Watchers Program; and
        3. Fitness Center Reimbursement.
  A brief description of each benefit is described below.


SMOKING CESSATION
Eligibility
   All eligible retirees and dependents covered under the Hawaii Laborers Health and Welfare Trust
Fund Comprehensive Medical Plan and Indemnity Prescription Drug Plan.

Smoking Cessation Benefit
    Smoking Cessation Classes: You may be reimbursed up to $80.00 per series of classes when you
    submit a certificate of completion. (For a listing of classes and programs, please call the Trust Fund
    office)
    Reimbursement Requirements
     1.       A Wellness Claim Form must be signed by your Smoking Cessation representative or facilitator
              certifying that you have completed the series of smoking cessation classes.
     2.       You must submit your certificate of completion with your claim form. If you do not submit a
              certificate of completion, no reimbursement will be made.
     3.       All claims must be filed with the Trust Fund office within 90 days from the date you complete
              each series of smoking cessation classes.

    Smoking Cessation Prescription Drugs, Devices and Agents are covered under the Indemnity
    Prescription Drug Plan. Please refer to page 57 for a description of benefits, limitations and
    exclusions.

    For Kaiser members, please refer to the Kaiser section on pages 64 and 78 for a description of
    Smoking Cessation benefits.

WEIGHT WATCHERS PROGRAM
Eligibility
   All eligible retirees and spouses are covered under the Hawaii Laborers Health and Welfare Trust
Fund.

Weight Watchers Program Benefit
    You may be reimbursed up to $26.25 for each 10-week segment you complete, not to exceed
    $136.50 per 12-month period, and $273.00 per lifetime.
    -     You must pay a fee of $105.00 for the 10-week segment at the time of enrollment and then file
          for a reimbursement from the Trust Fund.
          NOTE: The $105.00 fee is a discounted rate for a 10-week segment. There is no additional
                enrollment fee.




                                                      82
    -   If you fail to attend a weekly session for six (6) consecutive weeks, Weight Watchers will require
        you to re-enroll. Should you choose to re-enroll for another 10-week segment, the discounted
        rate of $105.00 will apply.
    -   Reimbursement will be made only upon completion of a 10-week segment.

  For information on the program, contact Weight Watchers at (808) 487-3373 or visit their website at
  “www.weightwatchers.com”

Reimbursement Requirements

    1. A Wellness Claim Form must be signed by a Weight Watchers representative certifying that you
       have completed a 10-week segment.

    2. All claims must be filed with the Trust Fund office within 90 days from the date you complete
       each 10-week segment.


FITNESS CENTER REIMBURSEMENT
Eligibility
   All eligible retirees and dependents covered under the Hawaii Laborers Health and Welfare Trust
Fund.

Fitness Center Benefit
    If you are a member of a certified fitness center, you may submit a Wellness Claim Form for
    reimbursement of your monthly membership fees not to exceed $21.00 per month, with a maximum
    reimbursement of $252.00 per 12- month period.

Reimbursement Requirements
    1. A Wellness Claim Form must be submitted to the Trust Fund office along with copies of receipts
       and/or proof of payment of your membership fees for the month(s) in which you are seeking
       reimbursement. If you do not provide proof of payment with your claim form, no reimbursement
       will be made.

    2. All claims must be filed within ninety (90) days from the last day of the month for which you are
       submitting your reimbursement claim.




          To obtain a copy of the Wellness Claim Form, please contact the Hawaii Laborers
                                Health and Welfare Trust Fund office.




   The preceding wellness program benefits are self-insured. The preceding is a summary of coverage
for informational purposes only. Its content is subject to the provisions of the Wellness Program plan
document and all amendments thereto. This document is on file with the Hawaii Laborers Health and
Welfare Trust Fund office. Please refer to this document for specific questions about coverage.



                                                   83
                                           VISION CARE BENEFITS
                      (Paid for directly by the Hawaii Laborers Health and Welfare Trust Fund)


ELIGIBILITY
  Eligible retirees and their dependents who reside in the United States are eligible for vision care
benefits.

VISION CARE BENEFITS
   You and your dependents are eligible for one (1) eye examination every 12 months and one (1) pair of
lenses and frame, or one (1) pair of contact lenses every 24 months. However, if there is a change in
vision of more than plus (+) or minus (-) .50 diopter or a spherocylinder change of more than plus (+) or
minus (-) .50 diopter, lenses only will be provided every 12 months. In addition, if your eyeglasses are
accidently damaged or broken due to a nonwork-related accident, one (1) pair of replacement lenses and
frame will be allowed within the 24-month period.
  The Trust Fund will pay up to the following amounts:
                                                                                                                           Allowances
      Eye Examination
        Ophthalmologist (M.D.) ........................................................................................... $ 45.00
        Optometrist (O.D.)................................................................................................... $ 45.00
      Appliances
        Single vision lenses and frame ...............................................................................              $ 90.00
        Multifocal lenses and frame ....................................................................................            $ 110.00
        Contact lenses.........................................................................................................     $ 110.00
        Frame only ..............................................................................................................   $ 40.00
 If lenses are replaced without furnishing a new frame, the total allowance for both lenses and frame
may be used for the cost of the lenses, if required.

EXCLUSIONS
      Repair or replacement of frame parts and accessories
      Sunglasses
      Prescription inserts for diving masks
      Nonprescription industrial safety goggles or glasses
      Nonstandard items for lenses

HOW VISION CARE SERVICES ARE PROVIDED
   You may go to any licensed ophthalmologist (M.D.), optometrist (O.D.), or other vision care provider of
your choice. You should choose a provider who can help you obtain the vision care you need at a
reasonable cost. Your choice of vision care provider can make a difference in how much you will owe
after vision care benefit payments have been made.
   The Hawaii Laborers Health and Welfare Trust Fund has contracts with certain vision care providers in
the State of Hawaii. A list of these participating providers will be provided to you at no charge. When you
go to one of the participating providers, payment for the services and/or supplies is sent directly to the
provider. The only copayment you will be required to pay will be for trifocal and progressive multifocal
lenses, the balance of charges for frames not within a selected group of frames available at no charge,
contact lenses, and non-covered items.
  If you go to a nonparticipating provider, payment for the services and/or supplies is made directly to
you. You will then owe the provider the total charge for the services and/or supplies.



                                                                         84
HOW TO FILE A VISION CARE CLAIM
  If you go to a participating provider,
  Step 1:   Obtain a claim form from the provider.
  Step 2:   Complete Part I of the claim form.
  Step 3:   Have the provider complete Part II and/or Part III of the claim form.
  Step 4:   The provider will send the completed claim form to the Trust Fund Office.
 Step 5:    Payment will be made directly to the provider. However, you must arrange to pay the provider
            for any copayments that may be required.

  If you go to a nonparticipating provider,
  Step 1: Obtain a claim form from the Trust Fund Office or Union Office.
  Step 2: Complete Part I of the claim form.
  Step 3: Have the provider complete Part II and/or Part III of the claim form.
  Step 4: Send the completed claim form with the itemized bills to the Trust Fund Office.
  Step 5: Your reimbursement check, together with a statement showing charges and amounts paid,
          will be mailed to you. You must arrange to pay the provider the total charge for the services
          and/or supplies.


                All claims must be filed within one (1) year from the date of service.

             FOR INFORMATION ON THE CLAIMS AND APPEALS PROCEDURES FOR
               VISION CARE BENEFITS, SEE PAGES 104 - 107 OF THIS BOOKLET.




  Vision care benefits are self-insured. The preceding is a summary of coverage for informational
purposes only. Its content is subject to the provisions of the Vision Care Plan document and all
amendments thereto. These documents are on file with the Hawaii Laborers Health and Welfare Trust
Fund Office. Please refer to these documents for specific questions about coverage.




                                                     85
                            HEARING AID PROGRAM
                (Paid for directly by the Hawaii Laborers Health and Welfare Trust Fund)


ELIGIBILITY
    All Medicare retirees and spouses who are covered under either the HMSA 65C Plus Plan or the
Kaiser Senior Advantage plan are eligible for the hearing aid benefit.


WHAT IS THE HEARING AID PROGRAM BENEFIT?
   Coverage for hearing aid devices is limited to a reimbursement of up to $1,000 for one (1) hearing aid
   device per ear every five (5) years.


HOW TO OBTAIN BENEFITS
   You may use any Hearing Aid provider of your choice. The Trust Administrator has a listing of
   providers who may provide the hearing aid device at a discount and may be willing to file your claim
   directly with the Trust Fund office. Contact the Trust Fund office for a listing of those providers.

If you go to participating or nonparticipating provider,
   Step 1:    Obtain a claim form from the provider or the Trust Fund Office
   Step 2:    Complete Part I of the claim form
   Step 3:    Have the provider complete Part II and/or Part III of the claim form
   Step 4:    Send the completed claim form with your itemized bills to the Trust Fund office
   Step 5:    Your reimbursement check, together with a statement showing charges and amounts paid,
              will be mailed to you. You must arrange to pay the provider the total charge for the
              services and/or supplies.

                  All claims must be filed within 90 days from the date of service.




             FOR INFORMATION ON THE CLAIMS AND APPEALS PROCEDURES
    FOR THE HEARING AID PROGRAM BENEFITS, SEE PAGES 104 - 107 OF THIS BOOKLET.




    The Hearing Aid Program benefits are self-insured. The preceding is a summary of coverage for
informational purposes only. Its content is subject to the provisions of the Hearing Aid Plan document
and all amendments thereto. These documents are on file with the Hawaii Laborers Health and Welfare
Trust Fund Office. Please refer to these documents for specific questions about coverage.




                                                   86
                                    DENTAL BENEFITS

ELIGIBILITY
  Eligible retirees and spouses who reside in the United States are eligible for dental benefits.
Dependent children are not eligible for this benefit.

CHOICE OF PLANS
  You may choose one (1) of two (2) dental plans:
  1.   The Hawaii Dental Service (HDS) fee for service plan available on all islands, or
  2.   The Gentle Dental prepaid plan available on Oahu only.
  The main benefit provisions of the HDS and Gentle Dental plans are summarized on the following
pages. The principal difference between the two (2) plans is that under the HDS Plan you may select any
dentist, however, only a percentage of your expenses may be covered. If you select the Gentle Dental
Plan, you must use one of the six (6) Gentle Dental facilities.

OPEN ENROLLMENT PERIOD
  You may change dental plans during the annual open enrollment period. If you wish to change plans,
contact the Trust Fund Office during the months of December and January of any year. The change will
become effective March 1. No change between dental plans may be made at any other time.




                                                    87
                                  DENTAL BENEFITS




                                      GETTING STARTED

EFFECTIVE DATE OF ELIGIBILITY
     The Hawaii Laborers Health and Welfare Trust Fund will let you know the start date (effective date)
of your dental coverage and an HDS member identification card will be mailed directly to you.
    At your first appointment, let your dental office know that you are covered by HDS through the
    Hawaii Laborers Health and Welfare Trust Fund and present your HDS member identification card.
    If you need dental services immediately after your effective date of dental coverage but have not
    received your HDS member identification card, you may request a temporary card through the HDS
    website at www.deltadentalhi.org or you may have your dentist confirm your eligibility with HDS prior
    to receiving services.


UPDATING INFORMATION
     To ensure that you and your family receive the full benefits of your plan and to ensure that HDS
processes your dental claims accurately, please notify the Hawaii Laborers Health and Welfare Trust
Fund office of any of the following:

            Name change
            Address change
            Add/remove a spouse
            Add/remove a dependent

COMPLETION OF PROCEDURES WHEN ELIGIBILITY ENDS
    If a dental procedure is in progress when your eligibility ends, coverage for services in progress
may continue for a maximum of 30 days after the date your eligibility ends.
      HDS will determine the applicable Plan Benefit for dental work within 30 days of the termination of
eligibility or Contract Agreement cancellation, as long as the specific dental procedure has been started
before the date of ineligibility or Contract Agreement cancellation.


                                   SELECTING A DENTIST
IN HAWAII, GUAM AND SAIPAN – CHOOSE AN HDS PARTICIPATING DENTIST
     You may select your dentist of choice, however, you save on your out-of-pocket costs when you visit
an HDS participating dentist for services received/rendered in Hawaii, Guam, and Saipan. HDS
participating dentists have agreed to partner with HDS to make oral health care more affordable by
limiting their fees to the Allowed Amount for services that are covered.

    About 96% of all licensed, practicing dentists in Hawaii participate with HDS, so it is more than likely
your dentist is an HDS participating dentist. For a current listing of HDS participating dentists, visit the
HDS website at ‘www.deltadentalhi.org’ or call the HDS Customer Service department.


                                                     88
ON THE MAINLAND – CHOOSE A DELTA DENTAL PARTICIPATING DENTIST
   HDS is a member of the Delta Dental Plans Association (DDPA), the nation’s largest and most
experienced dental benefits carrier with a network of more than 179,000 dentist locations.

    If your job takes you out of state or your child attends school on the Mainland, we recommend that
you or your dependents visit a Delta Dental participating dentist to receive the maximum benefit of your
plan.

     For a list of Delta Dental participating dentists, visit the HDS website at ‘www.deltadentalhi.org’ and
click on “Members: Search for a Dentist,” then “Delta Dental National Provider Database.” Select
“DeltaPremier” as your plan type and complete the remaining questions. Or you may call the HDS
Customer Service department.

VISITING A DELTA DENTAL PARTICIPATING DENTIST
    When visiting a dentist on the Mainland, let the dentist know that you have an HDS plan and present
    your HDS member identification card.
    If the dentist is a Delta Dental participating dentist, the claim will be submitted directly to HDS for you.
    Provide the dentist with the HDS mailing address and toll-free number located on the back of your
    member identification card.
    HDS’s payment will be based upon HDS’s participating dentist’s Allowed Amount.
    Your Patient Share will be the difference between the Delta Dental dentist’s Amount Charged and
    HDS’s payment amount.

VISITING A NON-PARTICIPATING DENTIST
    If you choose to have services performed by a dentist who is not an HDS or Delta Dental participating
dentist, you are responsible for the difference between the amount that the non-participating dentist
actually charges and the amount paid by HDS in accordance with your plan.
    Because non-participating dentists have no agreement with HDS limiting the amount they can charge
for services, your Patient Share is likely to be higher. Further, the amount reimbursed by HDS is
generally lower if a non-participating dentist renders the services.
    On your first visit, advise the non-participating dentist that you have an HDS dental plan and present
    your HDS member identification card.
    In most cases you will need to pay in full at the time of service.
    The non-participating dentist will render services and may send you the completed claim form
    (universal ADA claim form) to submit to HDS. Mail the completed claim form for processing to:

                                           HDS – Dental Claims
                                       700 Bishop Street, Suite 700
                                       Honolulu, Hawaii 96813-4196

    HDS payment will be based on the HDS non-participating dentist fee schedule and a reimbursement
    check will be sent to you along with your Explanation of Benefit (EOB) report.
    Whether you visit a participating or non-participating dentist, please be sure to discuss the total
charges and your financial obligations with your dentist before you receive treatment.




                                                      89
HELPING YOU MANAGE YOUR COSTS
     Your participating dentist may submit a preauthorization request to HDS before providing services.
With HDS’s response, your dentist should explain to you the treatment plan, the dollar amount your plan
will cover and the amount you will pay. This pre-authorization will reserve funds for the specified services
against your Plan Maximum. It will also help you to plan your dental services accordingly should you
reach your Plan Maximum.


QUESTIONS ON YOUR CLAIMS
   If you have any questions or concerns about your dental claims, please call our Customer Service
department at 529-9248 on Oahu or toll-free at 1-800-232-2533 extension 248. A copy of HDS’s claims
appeal process may be obtained from Customer Service.


                               HDS REPORTS AND PAYMENTS
EXPLANATION OF BENEFITS (EOB) REPORT
    You will receive an HDS Explanation of Benefits (EOB) Report that provides payment information
about the services you received from your dentist. It is important to note that the EOB report is not a bill.
Depending on your dentist’s practice, your dentist may bill you directly or collect any portion not covered
by your plan at the time of service.

CALCULATING YOUR BENEFIT PAYMENTS
  Determining the amount you should pay your HDS participating               Dentist’s Allowed Amount
dentist is based on a simple formula (see box to the right). HDS will
                                                                             X % plan covers
pay the “% Plan Covers” amount.
                                                                             HDS Payment
   You are responsible for the balance owed to your participating
dentist and taxes. Participating dentists are paid based upon their
Allowed Amount.                                                              Dentist’s Allowed Amount
                                                                             <minus HDS Payment>
   It is important to note that when determining payment, HDS may            Patient Share
consider your prior dental work performed under another plan and your
current plan’s limitations.

DUAL COVERAGE/COORDINATION OF BENEFITS
    Please be sure to let your dentist know if you are covered by any other dental benefit plan(s).
    When you are covered by more than one dental benefits plan, the amount paid will be coordinated
    with the other insurance carrier(s) in accordance with guidelines and rules of the National
    Association of Insurance Commissioners. Total payments or reimbursements will not exceed the
    participating dentist’s Allowed Amount when HDS serves as the second plan.
    There is a limit on the number of times certain covered procedures will be paid and payment will not
    be made beyond these plan limits.
    Coverage of identical procedures will not be combined in cases where there are multiple plans. For
    example, if you have two plans and each includes two cleanings during each calendar year, your
    benefits will cover two cleanings (not four) in each calendar year.

QUALITY ASSURANCE
    Quality assurance is taken seriously at HDS. In-office reviews are periodically conducted to ensure
that you are being charged in accordance with HDS’s contract agreements.




                                                     90
GLOSSARY
Allowed Amount:                    The amount the participating dentist agrees to accept for services that are
                                   covered benefits.

Amount Charged:                    The amount submitted by the dentist on the claim for each service performed.

Plan Maximum:                      The maximum amount HDS will pay within a plan year for services per member.
                                   When visiting a participating dentist, any covered benefits rendered after your
                                   Plan Maximum has been depleted will be processed with the Patient Share
                                   equal to the Allowed Amount.

Patient Share:                     Out-of-pocket amount for which the patient is responsible.

                                    SUMMARY OF DENTAL BENEFITS
                                                                                                                         PLAN COVERS

 DIAGNOSTIC
   Examinations – once per calendar year................................................................................... 100%
   Bitewing X-rays
   - Twice per calendar year through age 14;
   - Once (1) per calendar year thereafter
   Other x-rays (full mouth x-rays limited to once every five (5) years)

 PREVENTIVE
   Cleanings – twice per calendar year ........................................................................................ 100%
       Diabetic Patients – four (4) cleanings or periodontal maintenance*
       Expectant Mothers – three cleanings or periodontal maintenance*
       * Periodontal maintenance benefit level ............................................................................ 70%
     Topical fluoride (once per calendar year through age 17) ......................................................... 70%
     Fluoride Varnish – once per calendar year; limited to patients who
     Are at high risk of caries due to root exposure, dry mouth syndrome,
     History of radiation therapy or other condition as documented by the dentist ........................... 70%
     Sealants (through age 18).......................................................................................................... 70%
         One treatment application, once per lifetime only to permanent
         molar and bicuspid teeth with no cavities and no occlusal restorations
         regardless of the number of surfaces sealed.

 RESTORATIVE............................................................................................................................... 70%
   Amalgam fillings
   Composite fillings - limited to the anterior teeth (front) teeth
   Crowns and gold restorations (once every five years when teeth cannot
   be restored with amalgam or composite fillings)
   Note: Composite restorations or porcelain (white) crowns on posterior (back) teeth
   will be processed as the alternate benefit of the metallic equivalent – the patient is
   responsible for the cost difference up to the Amount Charged by the dentist.

 ENDODONTICS.............................................................................................................................. 70%
    Pulpal therapy
    Root canal filling

 PERIODONTICS* ........................................................................................................................... 70%
    Periodontal scaling and root planning, gingival curretage (once every two (2) years)
    Gingivectomy and osseous surgery (once every three (3) years)
    Periodontal Maintenance – twice per calendar year




                                                                        91
                                                                                                                        PLAN COVERS

 PROSTHODONTICS ...................................................................................................................... 70%
    Fixed bridges (once every five (5) years; ages 16 and older)
    Removable Dentures
    (complete and partial - once every five (5) years; ages 16 and older)
    Repairs and adjustments
    Relines and rebase
    Implants (covered as alternate benefit) when one tooth is missing between
    two natural teeth

 ORAL SURGERY ........................................................................................................................... 70%
   Extractions
   Other oral surgery procedures to supplement medical care plan

 ADJUNCTIVE GENERAL SERVICES ........................................................................................... 70%
    Consultations
    Office Visits (injury related)
    Sedation: General & IV
    Palliative (emergency) treatment (for relief of pain but not to cure) ....................................... 100%


     The maximum amount payable by Hawaii Dental Service for covered dental services rendered to an
eligible patient is $900.00 per contract year. The contract year is September 1st through August 31st.

                      All plan payments relate to a percentage of your dentist’s eligible fees.


EXCLUSIONS

1. Services for injuries or conditions that are covered under Workers’ Compensation or Employer’s
   Liability Laws; services provided by any federal or state government agency or those provided
   without cost to the eligible person by the government or any agency or instrumentality of the
   government.
2. Congenital malformations, medically related problems, cosmetic surgery or dentistry for cosmetic
   reasons.
3. Expenses for prosthodontic services or devices (including crowns and bridges) started prior to the
   date the patient became eligible under this Program.
4. Procedures, appliances or restorations other than those for replacement of structure loss from
   cavities that are necessary to alter, restore or maintain occlusion. Non-covered benefits include
   increasing vertical dimension, equilibration, periodontal splinting, restoration of tooth structure lost
   from attrition, restoration for tooth malalignment, gnathological recordings, and treatment of
   disturbances of the temporomandibular joint.
5. Hawaii general excise taxes imposed or incurred in connection with any fees charged, whether or
   not passed on to a patient by a dentist.
6. Orthodontic services.
7. All other services not specified in the Schedule of Benefits. The Schedule of Benefits is available
   from the Hawaii Laborers Health and Welfare Trust Fund.




                                                                       92
                                  HOW TO CONTACT HDS

HDS WEBSITE:               www.deltadentalhi.org

    You can visit the website to search for a participating dentist, check your eligibility and plan
benefits, access Explanation of Benefits (EOB) reports to view information about dental services you
have received, or even print your membership identification card.


HDS DENTEL:
      HDS DenTel is an automated phone service that allows HDS members to find out when they are
eligible for coverage for their next dental visit, to obtain claims information, or even to have a summary
of their plan benefits faxed or mailed to them, simply by following the prompts on the phone. Available
everyday, 24 hours a day.

        Automated Phone Line:
        From Oahu:            545-7711
        Toll-free:     1-800-272-7204

CUSTOMER SERVICE REPRESENTATIVES:
     Our local customer service representatives are available Monday through Friday from 7:30 a.m.
through 4:30 p.m., Hawaii Standard Time.

        Phone Line:
           From Oahu:            529-9248
           Toll-free:      1-800-232-2533 (extension 248)

        Fax Line:
            From Oahu:           529-9366
            Toll-free:     1-866-590-7988

SEND WRITTEN CORRESPONDENCE TO:
        Hawaii Dental Service
        Attn: Customer Service
        700 Bishop Street, Suite 700
        Honolulu, Hawaii 96813-4196




   The preceding dental benefits are fully insured under a contract issued by Hawaii Dental Service
(HDS), 700 Bishop Street, Suite 700, Honolulu, Hawaii 96813-4196. The services provided by HDS
include the payment of claims and the handling of claims appeals.

   The preceding is a summary of coverage for informational purposes only. Its content is subject to the
provisions of the Contract for Dental Services which contains the terms and conditions of membership
and benefits. The document is on file with the Hawaii Laborers Health and Welfare Fund Office. Please
refer to this document for specific questions about coverage.


                                                    93
                                                       GENTLE DENTAL
WHAT IS THE DENTAL CARE PROGRAM?
  It is a prepaid dental coverage program designed and provided by the same health care professionals
delivering your dental care. Who else is better qualified to understand your needs more than your dentist?


HOW DOES THE PROGRAM WORK?
  When you fill out the enrollment form provided by the Trust Fund Office, that’s all the paperwork you
have to do. Quality dental care, without cost to you, is waiting for your whole family whenever you’re
ready to use it. Just call and make an appointment with any one of the six (6) Gentle Dental locations.


CHOOSING YOUR OWN PERSONAL DENTIST
  Each dental center has a staff of dentists from which you may choose. The dentist you choose
coordinates the entire dental treatment program for your family. All dentists are members of both the
Hawaii Dental Association and the American Dental Association.


IS THERE A PREAUTHORIZED WAITING PERIOD?
  No. Unlike other dental plans that often require a waiting period for permission to do your dental work,
there are no claim forms to fill out or send in.


                          MAJOR BENEFITS AND COVERED SERVICES
BENEFIT                                                                                                                      COPAYMENT

DIAGNOSTIC
   Office visits ........................................................................................................................... $10.00
   Oral examinations........................................................................................................... No charge
   Full mouth x-ray .............................................................................................................. No charge
   Panorgraphic x-ray ......................................................................................................... No charge
   Each additional film ........................................................................................................ No charge
   Emergency treatment ..................................................................................................... No charge

PROPHYLAXIS (teeth cleaning)
   Regular cleaning (semi-annual)...................................................................................... No charge
   Topical fluoride ............................................................................................................... No charge
   Scaling and polishing...................................................................................................... No charge

RESTORATIVE DENTISTRY (amalgam fillings)
   Cavities involving one surface ........................................................................................ No charge
   Cavities involving two surfaces....................................................................................... No charge
   Cavities involving three surfaces .................................................................................... No charge

ENDODONTICS
   Root canals..................................................................................................................... No charge
   Pulp capping ................................................................................................................... No charge
   Pulpotomy....................................................................................................................... No charge

ORAL SURGERY
  Simple extractions .......................................................................................................... No charge
  Surgical........................................................................................................................... No charge
  Third molars/wisdom teeth ............................................................................................. No charge


                                                                           94
BENEFIT                                                                                                                        COPAYMENT

PERIODONTICS (gum treatment)
   Emergency treatment ..................................................................................................... No charge
   Scaling and Curettage .................................................................................................... No charge
   Periodontal surgery ........................................................................................................ No charge
CROWN AND BRIDGE
  3
   ⁄4 or full metal cast crown...............................................................................................           No charge
  Porcelain fused to metal crown (molars not included)....................................................                              No charge
  Stainless steel crown......................................................................................................           No charge
  Space maintainers ..........................................................................................................          No charge
REMOVABLE PROSTHODONTICS (partials and dentures)
  Complete upper denture.................................................................................................               No charge
  Complete lower denture .................................................................................................              No charge
  Partial denture ................................................................................................................      No charge
  Relines............................................................................................................................   No charge
  Denture adjustment after six months of delivery ............................................................                          No charge
  Denture repairs ...............................................................................................................       No charge
ORTHODONTICS (braces)
  A discounted orthodontic program which covers 24 months of usual and customary treatment for
  your family at predetermined fees is available.

PRINCIPAL EXCLUSIONS AND LIMITATIONS
      1.     Orthodontics
      2.     Cosmetic dentistry performed solely to improve appearance.
      3.     Dispensing of drugs.
      4.     Hospitalization when desired by the patient for any dental procedure.
      4.     Services reimbursable under any other insurance or health care plan.
      6.     Services for injuries or conditions covered by Workers’ Compensation or any employer’s liability
             law.
      7.     Services which Gentle Dental dentists do not feel are necessary for dental health.
      8.     Services that cannot be performed due to the general health of the patient.
      9.     Treatment required for conditions resulting from a major disaster or epidemic.

WHAT IF I ALREADY HAVE DENTAL COVERAGE?
  Some families have coverage with two (2) or more dental plans. The Gentle Dental Plan considers the
other plan the primary carrier, responsible for dental charges incurred by those members with dual
coverage.

OFFICE FACILITIES
  The office facilities are ready to accommodate patients easily and efficiently. The facilities feature
thoroughly computerized appointment control, scheduling, and record keeping.




                                                                             95
GENTLE DENTAL LOCATIONS
  Gentle Dental Pearlridge
  Bank of Hawaii Building
  98-211 Pali Momi Street, Suite 715
  Aiea, Hawaii 96701
  Phone: 488-8119


  Gentle Dental Honolulu
  1136 Union Plaza, Suite 502
  Honolulu, Hawaii 96813
  Phone: 536-3405
  Gentle Dental Kapolei
  92-605 Makakilo Drive
  Makakilo, Hawaii 96707
  Phone: 672-0397
  Gentle Dental Mililani
  The Town Center of Mililani
  95-1249 Meheula Parkway, Suite A-12
  Mililani, Hawaii 96789
  Phone: 623-2888
  Gentle Dental Waianae
  86-078 Farrington Highway, #210
  Waianae, Hawaii 96792
  Phone: 697-1310


  Provider:
  Pali Palms Dental Center
  970 North Kalaheo Avenue, Suite A108
  Kailua, Hawaii 96734
  Phone: 254-6477




  The preceding dental benefits are fully insured under a contract issued by Gentle Dental Hawaii, Inc.,
95-1249 Meheula Parkway, Suite 115 Mililani, Hawaii 96789. The services provided by include the
payment of claims, when necessary, and the handling of claims appeals.

  The preceding is a summary of coverage for informational purposes only Its content is subject to the
provisions of the Agreement for Dental Services which contains all the terms and conditions of
membership and benefits. This document is on file with the Hawaii Laborers Health and Welfare Trust
Fund Office. Please refer to this document for specific questions about coverage.




                                                  96
                                     PACIFIC GUARDIAN LIFE
                                      INSURANCE COMPANY



                                                      LIFE INSURANCE
COVERAGE
  Retired employees and spouses are covered for life insurance in accordance with the following
schedule:

                                                                                                                BENEFIT
           Retired Employees
                Retirement prior to October 1, 1995 ................................................. $7,500
                Retirement on or after October 1, 1995............................................ $5,000
           Spouse ...................................................................................................... $1,000

   For the purpose of life insurance, the term retired employee is an employee who is receiving a pension
from the Hawaii Laborers Pension Trust Fund or the Laborers International Union of North American
National (Industrial) Pension Fund and is no longer eligible for benefits as an active employee under the
eligibility rules of the Hawaii Laborers Health and Welfare Trust Fund.

BENEFICIARY
   On your enrollment form, you may name anyone you wish as your beneficiary to receive your life
insurance. You may change your beneficiary at any time by submitting a new enrollment form to the Trust
Fund Office. The change is effective on the date you sign the card. Pacific Guardian Life will honor a
beneficiary change request only if it is recorded before any payment has been made.
   When Pacific Guardian Life receives due proof of your death, the amount of life insurance on your life
will be paid.
  Unless you request otherwise in your filed beneficiary designation, payment shall be made as follows:
     (1)   If more than one beneficiary is named, each will be paid an equal share.
     (2)   If any named beneficiary dies before you, his/her share will be divided equally among the
           named beneficiaries who survive you.
     (3)   If no beneficiary is named, or if no named beneficiary survives you, Pacific Guardian Life will
           pay the first of the following classes of successive preference beneficiaries who survive you:
           (a)    All to your surviving spouse; or
           (b)    If your spouse does not survive you, in equal shares to your surviving children; or
           (c)    If no child survives you, in equal shares to your surviving parents; or
           (d)    If no parent survives you, in equal shares to your surviving brothers and sisters; or
           (e)    Your estate.




                                                                       97
   The life insurance on your spouse is payable to you in the event of his or her death. If you do not
survive your spouse, Pacific Guardian Life will pay your estate. However, Pacific Guardian Life may, at
its option, pay your surviving relatives in the following order:
     (1)   Equal shares to your surviving children; or
     (2)   If no child survives you, in equal shares to your surviving parents.
  If the beneficiary is a minor or is otherwise incapable of giving a valid release for any payment due,
Pacific Guardian Life may pay the legal guardian.


CONVERSION RIGHTS
   If you become ineligible for coverage, your life insurance and that of your dependents will be continued
for 31 days following the termination of your eligibility.
  During this 31-day period, you and your spouse have the right to obtain any regular individual policy
(without disability or other supplementary benefits) issued by Pacific Guardian Life (except Term
Insurance). The individual policy will be issued without medical examination at Pacific Guardian Life’s
regular premium rates. The amount of your individual policy cannot exceed the amount of insurance for
which you and your spouse were covered under the group policy. You must apply and pay for the first
premium within 31 days after your insurance terminates.




  The preceding life insurance benefits are fully insured under an insurance contract issued by Pacific
Guardian Life (PGL), 1440 Kapiolani Boulevard, Suite 1700, Honolulu, Hawaii 96814. The services
provided by PGL include the payment of claims and the handling of claims appeals.

  The preceding is a summary of coverage for informational purposes only. Its content is subject to the
provisions of the Group Life Insurance Master Contract with Pacific Guardian Life, and all amendments
thereto, which contain all of the terms and conditions governing life insurance benefits. These documents
are on file with the Hawaii Laborers Health and Welfare Trust Fund Office. Please refer to these
documents for specific questions about coverage.




                                                      98
                     UNUM LIFE INSURANCE COMPANY
                              OF AMERICA



                                LONG TERM CARE BENEFITS
ELIGIBILITY
    Effective April 1, 2005, retired employees who are covered for health and welfare benefits under the
Hawaii Laborers Health and Welfare Trust Fund and who reside in the United States may be eligible to
enroll in the voluntary long term care “base” plan offered through UNUM.
     You must apply for coverage and submit information on your health status to the insurance company
which has the right to decide whether to accept or deny your request for coverage based on the
information provided. If you are approved to enroll in the voluntary long term care plan, a copayment of
$13.00 per month will be charged for your voluntary base plan benefits.
     Once eligible, you will continue to be covered for voluntary “base” plan benefits as long as you make
the required monthly copayment.


                                                BASE COVERAGE
The Voluntary Base Plan coverage is as follows:
        Elimination (Waiting Period).....................................................................90 consecutive days

        Monthly Benefit Maximums
        - Long Term Care Facility ................................................................... $1,000.00 per month
        - Professional Home Care Services ..................................................... $ 500.00 per month

        Professional Home Care Services .......................................................... $ 500.00 per month

        Lifetime Maximum Amount .................................................................................... $24,000.00


                      ADDITIONAL BUY-UP COVERAGE OPTIONS
   In addition to the Base Plan coverage, you may also apply for the following Additional Buy Up
Coverage Options, however, you will be responsible for the entire cost of any Additional Buy Up
Coverage Option that you select.

BUY-UP COVERAGE OPTIONS

    1. Increased Monthly Benefit Maximum
             Long Term Care Facility Benefit ................................................... Additional $1,000 increments
                                                                                             up to a Total Benefit Maximum
                                                                                                          of $4,000 per month

             -    Your Assisted Living Facility Monthly Benefit Maximum will be 60% of the above Long
                  Term Care Facility Monthly Benefit.

             -    Your professional Home Care Services Monthly Benefit Maximum will be 50% of the
                  above Long Term Care Facility Monthly Benefit.



                                                                99
    2. Total Home Care. If you choose this option, those services covered under Professional Home
       Care Services may also be provided by an informal caregiver, such as a friend or relative.

    3. Five Percent (5%) annual Simple Growth Inflation Protection.

            As long as your coverage remains in effect, these inflation increases will occur automatically
            regardless of your health or whether or not you are disabled.

            Your Monthly Benefit Maximum and Lifetime Maximum Amount will be adjusted to include
            any inflation option increases, if applicable.

            Example: A monthly benefit amount of $1,000 will be increased by $50.00 on January 1st of
            the next calendar year and by another $50.00 every January 1st thereafter.

Eligibility for Family Members
    As long as you are eligible for coverage under the Long Term Care plan, your family members may
also apply for coverage. Eligible family members are: your spouse, your children, your parents,
stepparents, siblings, parents-in-law, grandparents, and grandparents-in-law. However, all family
members applying must be between the ages of 18 through 80. All applications for coverage for your
family members must include information on health status and the insurance company has the right to
decide whether to accept or deny such requests for coverage. You or your family member will be
responsible for the entire cost of any family member coverage.

    NOTE:     A surviving spouse of a deceased retiree is not eligible to enroll in the voluntary long term
              care plan.

WHEN YOU ARE ELIGIBLE FOR A MONTHLY BENEFIT
    A Monthly Benefit will become payable when all of these requirements are met:
    You become Disabled;
    You are receiving services in a Long Term Care Facility or Assisted Living Facility; or Professional
    Home Care Services if your plan includes a Professional Home Care Service Benefit; or Total Home
    Care if your plan includes a Total Home Care Benefit;
    You have satisfied your Elimination Period; and
    A Physician has certified that you are unable to perform (without Substantial Assistance from another
    individual) two or more Activities of Daily Living (ADLs) for a period of at least 90 days, or that you
    require Substantial Supervision by another individual to protect you and others from threats to health
    or safety due to Severe Cognitive Impairment. You will be required to submit a Physician certification
    every 12 months.
    The treatment and services you receive for your Disability must be provided pursuant to a written plan
of care developed by a Licensed Health Care Practitioner.

    NOTE: If you have a loss of ADLs or Severe Cognitive Impairment before your effective date of
         coverage, that loss or impairment will never be covered.




                                                   100
                              DEFINITIONS AND BENEFITS
Bed Reservation Benefit
    If you are receiving a Long Term Care Facility or Assisted Living Facility monthly benefit and your
stay in the Facility is interrupted because you are hospitalized, UNUM will continue to pay the monthly
benefit if a charge is made to reserve your accommodations in the facility, up to a maximum of 15 days
per calendar year.

Elimination Period
   The number of consecutive days during which you must be Disabled and under the regular care of a
Physician before benefits become payable.

Professional Home Care Services
    Each calendar week that you receive at least one day of these services will be counted as seven
days towards completing the Elimination Period. However, if you do not receive these services for at least
one day within a calendar week, the Elimination Period will begin again.

    The amount of your monthly benefit will be based on the coverage options you chose.
    For Professional Home Care Services, the benefit payment will be based on the number of days you
receive these services each month. A monthly benefit payable for less than one month will be paid at
1/30th of the monthly benefit amount for each day you are eligible for a monthly benefit.

Recurrent Disability
    You will not have to complete a new Elimination Period if you become Disabled again after the date
we stopped making monthly benefit payments to you for your previous Disability.

Rehabilitation and Alternative Care Plans
     While you are Disabled, UNUM may contact you to suggest special services and/or equipment
designed to help you regain the ability to independently perform the Activities of Daily Living. The use of
such services/equipment must be medically necessary and appropriate for your Disability and provided
pursuant to a written plan of care developed by a licensed health care practitioner. The
services/equipment must be intended to assist you in living at home or other residential housing by
eliminating your need for Substantial Assistance. The services or equipment cannot be covered by other
Insurance or Medicare. The terms of an alternate care plan and the actual expenses that UNUM will pay
will be subject to written mutual agreement between UNUM, you and your Physician.

    If, for any reason, you do not wish to participate in an Alternate Care Plan, your benefits will continue
according to the coverage options you chose.

Respite Care Benefits
     Care provided to you for a short period to allow your informal caregiver a break from his or her care
giving responsibilities. Respite Care may be provided to you by a formal caregiver, such as a Home
Health Care Provider, Adult Day Care Facility, registered nurse, licensed practical nurse, or an informal
caregiver, such as a friend or relative.

    If you are not yet receiving monthly Home Care payments because you: 1) have not yet completed
the Elimination Period or 2) have completed the Elimination Period but have chosen to postpone receipt
of benefits in order to preserve your Lifetime Maximum Amount, you may request UNUM to pay you a
benefit equal to 1/30th of your home care benefit for each day that you receive Respite Care up to a
maximum of 15 days per calendar year. Respite Care payments made to you count toward your Lifetime
Maximum Amount.




                                                    101
IMPORTANT: If you have a loss of ADL’s or severe cognitive impairment before your effective date of
coverage, that loss or impairment will never be covered unless you completely recover from that loss or
impairment.



                        ACTIVITIES OF DAILY LIVING (ADL)
    The Activities of Daily Living (ADL’s) are:

        1.   BATHING                   Washing oneself by sponge bath; or in either a tub or shower,
                                       including the task of getting into or out of the tub or shower with or
                                       without equipment or adaptive devices.
        2.   DRESSING                  Putting on and taking off all items of clothing, any necessary
                                       braces, fasteners, or artificial limbs.
        3.   TOILETING                 Getting to and from the toilet, getting on and off the toilet, and
                                       performing associated personal hygiene.
        4.   TRANSFERRING              Moving into or out of bed, chair, or wheelchair with or without
                                       equipment such as canes, walkers, crutches or grab bars or other
                                       supportive devices including mechanical or motorized devices.
        5.   CONTINENCE                The ability to maintain control of bowel or bladder function; or, when
                                       unable to maintain control of bowel or bladder functions, the ability
                                       to perform associated personal hygiene (including caring for
                                       catheter or colostomy bag).
        6.   EATING                    Feeding oneself by getting food into the body from a receptacle
                                       (such as a plate, cup, or table), by a feeding tube or intravenously.


WAIVER OF PREMIUM
    Once benefits become payable, there will be no more cost for your coverage as long as you are
Disabled. If you do not receive Professional Home Care Services for a period of 30 consecutive days,
premium payments will again become due. If benefits are no longer payable, you must resume premium
payments to continue your coverage. Premiums are not waived while you are receiving a payment for
Respite Care.


WHEN MONTHLY BENEFITS END
    Monthly benefit payments will end on the earliest of the following dates:
   1. the date you are no longer Disabled;
   2. the expiration of your Physician certification;
   3. the date you are no longer eligible for a monthly benefit under the coverage you chose;
   4. the date your total benefit payments equal the Lifetime Maximum Amount; or
   5. the date you die.


CHANGES IN COVERAGE
    You can apply at any time to increase your coverage by filling out a new Benefit Election Form and
Application for Long Term Care Insurance. Your request is subject to approval by UNUM. If approved,
the premium rate to be paid for the new coverage is based on your insurance age. To determine your
insurance age, subtract your date of birth from your date of application for the increase in coverage.




                                                    102
                                    HOW TO FILE CLAIMS

    If you become Disabled, you must fill out a Long Term Care Claim Form and send it to UNUM. Claim
forms are available at the Hawaii Laborers Health and Welfare Trust Fund Office. You must send UNUM
the claim form no later than 90 days after the date you become Disabled or as soon as it is reasonably
possible to do so, but in no event more than one (1) year after the time this proof is required.

    You will be required to give UNUM information on your continued Disability, when requested. UNUM
may also require a claims assessment, which is a review done by UNUM to help in evaluating the
Disability. A face-to-face interview or examination by a Physician may also be required. If required,
however, UNUM will pay the cost of the interview or examination.



                                           EXCLUSIONS
    Coverage is not provided for:
    Disability caused by war (whether declared or not) or any act of war;
    Disability caused by attempted suicide (while sane or insane) or self-destruction
    Disability caused by a commission of a crime for which you have been convicted under state or
    federal law or attempting to commit a crime under state or federal law;
    Disabilities or confinements during which you are outside the United States, its territories or
    possessions for longer than 30 days;
    Disability caused by alcoholism or alcohol abuse;
    Disability caused by voluntary use of any controlled substance unless the controlled substance is
    prescribed for you by a Physician. (“Controlled substance” is defined in Title II of the Comprehensive
    Drug Abuse Prevention and Control Act of 1970 and all amendments.);
    Period in which you are confined in a hospital other than if you are confined in a nursing facility that is
    a distinctly separate part of a hospital, (this exclusion does not apply to those period covered under
    the Bed Reservation Benefit).




     The preceding long-term care benefits are fully insured under an insurance contract issued by the
UNUM Life Insurance Company of America, 2211 Congress Street, Portland, ME 04122. The services
provided by UNUM Life Insurance Company of America includes the payment of claims and the handling
of claims appeals.

    The preceding is a summary of long term care coverage for informational purposes only. Its content is
subject to the provisions of the group insurance policy with UNUM Life Insurance Company of America,
and all amendments thereto, which contain all the terms and conditions governing long term care
benefits. These documents are on file with the Hawaii Laborers Health and Welfare Trust Fund Office.
Please refer to these documents for specific questions about coverage.


                                                     103
                    CLAIMS AND APPEALS PROCEDURES
  SELF-INSURED CLAIMS FOR BENEFITS PROVIDED DIRECTLY FROM THE HAWAII LABORERS
                             HEALTH AND WELFARE TRUST FUND
                (i.e., medical, prescription drug, vision, wellness and hearing aid)


                                               CLAIMS
REVIEW OF CLAIMS
   The Trust Fund has the discretionary authority to determine all questions of eligibility, to determine the
amount and type of benefits payable to any beneficiary or provider in accordance with the terms of the
plan and related regulations, and to interpret the provisions of this plan as necessary to determine
benefits.
   If your claim for any medical, prescription drug, vision care, wellness or hearing aid benefit is wholly or
partially denied by the Claims Administrator, you will be provided with a written determination explaining
the reasons for denial.

Designation of an Authorized Representative
   You can designate another person to act on your behalf in the handling of your benefit claims. In order
to do so, you must complete and file a form that identifies the individual that is authorized to act on your
behalf as your authorized representative. If you designate an authorized representative to act on your
behalf, all correspondence and benefit determinations will be directed to your authorized representative,
unless you direct otherwise. You may also request that this information be provided to both you and your
authorized representative.
  In the case of a claim for urgent care, where you are not able to act on your own behalf, a health care
professional who has knowledge of your condition will be recognized by the Plan as your authorized
representative.

INITIAL CLAIMS
  Upon the filing of a claim for benefits, and all necessary information required to make a determination
on your claim, a decision will be made within the following time periods:

  Urgent Care Claims: 72 hours
  You will be notified within 72 hours from the receipt of your claim whether your claim is approved or
  denied. If you fail to follow the Plan’s claims filing procedure or submit an incomplete urgent care claim,
  you will receive oral notification (or written notification, if you request) within 24 hours of the day the
  claim was received. The notification will indicate the proper procedures for filing claims, and/or the
  additional information needed to complete your claim. You will be given forty-eight (48) hours from the
  date you are notified to complete your claim.
  Once the necessary information has been submitted, you will receive a decision within 48 hours from
  the earlier of the following events:
  • Receipt of the necessary information from you; or
  • Expiration of the 48-hour period provided to you to submit the necessary information.
  A claim for “urgent care” is any claim for care where failure to provide the services could seriously
  endanger your life, health, or ability to regain maximum functions, or could subject you to serious pain
  that could not be managed without the requested care. Your claim will be treated as “urgent” if a
  physician with knowledge of your medical condition says it is so, or if the Claims Administrator, in
  applying the judgment of a reasonable individual with an average knowledge of health and medicine,
  determines that your claim involves urgent care.




                                                     104
  Pre-Service Claims: 15 calendar days (with possible 15-day extension)
  A pre-service claim is any claim which requires approval before care is rendered. Pre-service claims
  include pre-authorizations and utilization review decisions. For specific procedures on obtaining prior
  approvals for benefits, pre-authorizations or utilization reviews, refer to the specific sections of the self-
  insured benefits described in this booklet. If you fail to follow the Plan’s claims filing procedure, you will
  receive oral notification (or written notification, if you request) within five (5) days of the day the claim
  was received. The notification will indicate the proper procedures for filing claims.

  Post-Service Claims: 30 calendar days (with possible 15-day extension)
  A post-service claim is any claim submitted after services have been provided to you.
  Extensions for Pre-Service and Post-Service Claims
  The Plan may extend the time to respond to a pre-service or post-service claim by fifteen (15) days
  only if there are circumstances beyond the Plan’s control that interfere with a timely determination of
  the claim. The Plan must provide you with a notice of extension setting forth the basis for the extension
  and the date that the Plan is expected to make its decision, prior to the extension period taking effect.
  If the extension is necessary due to insufficient information to decide the claim, the notice of extension
  will indicate the information needed to complete your claim. You will be given 45 days from the date
  you are notified to submit the additional information to complete your claim.

  Concurrent Care Claims
  If you are currently receiving ongoing treatment under the Plan, you will receive advance notice of any
  determination to terminate or reduce your treatment. The notice will be provided to you, in advance, to
  allow you to appeal the determination and have a decision rendered prior to the termination or
  reduction of your treatment. Any claim involving both urgent care and a request to extend a course of
  treatment previously approved by the Plan, must be decided as soon as possible, given the urgency of
  the medical conditions involved. You will receive notification within 24 hours after the receipt of your
  urgent and concurrent care claim provided your claim is received at least 24 hours prior to the
  expiration of your treatment. If your claim is received less than 24 hours prior to the expiration of
  treatment, you will be notified of the decision within 72 hours after receipt of the claim.

Initial Benefit Determination
  Upon approval of a pre-service or urgent care claim, you will receive a notice informing you of the
approval. No approval notice will be provided for post-service claims.
  If your claim is denied, you will be provided written notice of the denial at no cost to you. Examples of a
denied claim include a determination to reduce or terminate a benefit or a failure to make whole or partial
payment of a benefit by the Plan. In the case of urgent care claims, the Plan may first notify you orally,
with a written notice to follow in three (3) days. The notice of denial, whether oral or written, will contain
the following information:
     1. The specific reason(s) for the denial, with reference(s) to the specific Plan provisions;
     2. A description of any additional material or information necessary to complete your claim and why
        the information is needed;
     3. A statement that you may request, free of charge, an explanation of the clinical or scientific
        judgment used to make the determination applying the terms of the Plan to your medical
        circumstances, if the denial was based on medical necessity, experimental treatment, or similar
        exclusion;
     4. The identification of any internal rule, guideline, protocol, or other criteria the Plan relied upon in
        making the determination, and a statement that such rule, guideline, protocol, or other criteria is
        available to you, free of charge, upon your request;
     5. A description of the Plan’s review procedures, the applicable time limits, and a statement of your
        right to bring civil action under Section 502(a) of ERISA to appeal a denial based on the review
        of an earlier decision; and
     6. A description of the expedited review process applicable to the claim, if the denial involved a
        claim for urgent care.

                                                     105
                                             APPEALS

SELF-INSURED CLAIMS
   If you wish to appeal the denial of any claim for benefits by the Claims Administrator, you have 180
days from the date the Claims Administrator processed the initial claim to file an appeal with the Board of
Trustees. The Board of Trustees has appointed the Benefits and Appeals Committee to hear all appeals
of denied claims.

   The appeal will be conducted by the Benefits and Appeals Committee without any preferential
treatment given to the determination of the initial claim. The determination on appeal will be made by
individuals who were not involved in the determination of the initial claim and who are not subordinates of
anyone involved in the initial claim determination.

  In considering the appeal, the Benefits and Appeals Committee is required to consider all evidence
submitted by you or your authorized representative, whether or not the information was submitted or
considered in the initial benefit determination. You have the right to submit written comments, documents,
records, and other information relating to your claim for benefits.

   If the initial denial involved medical judgment, the Benefits and Appeals Committee must consult with a
health care professional who has the appropriate training and experience in the field of medicine.
Examples of medical judgment include whether a treatment, drug, or other item is experimental,
investigational, or medically necessary or appropriate. If a health care professional is required to be
consulted on the appeal, the professional must not be the same individual that was involved in the initial
determination of the claim, nor a subordinate of that individual.

Your Right to Information
  Upon your request, the Plan will provide you with the following, free of charge:
     1. Reasonable access to, and copies of all documents, records, and other information relevant to
        your claim for benefits; and
     2. The identity of any medical or vocational experts that were hired on behalf of the Plan to provide
        advice in connection with your initial benefit determination, whether or not their advice was relied
        upon in making the determination.

Appeal of an Urgent Care Claim
  If you are appealing a denial of an urgent care claim, you have the option of submitting your appeal
orally or in writing. All necessary information will be communicated to you through the quickest method
available, such as telephone or fax. The Benefits and Appeals Committee must issue its decision as soon
as possible, but not later than 72 hours from the time the appeal is received.

Appeal of a Pre-Service Claim
   If you are appealing a denial of a pre-service claim, you must submit a written request for review of the
initial denial. The Benefits and Appeals Committee must issue its decision no later than 30 days from the
time the appeal is received.

Appeal of a Post-Service Claim
   If you are appealing a denial of a post-service claim, you must submit a written request for review of the
initial denial. The Benefits and Appeals Committee must issue its decision no later than the date of the
meeting of the Committee or Board that immediately follows the Plan’s receipt of a request for review,
unless the request for review is filed within 30 days preceding the date of such meeting. In such case, a
benefit determination may be made no later than the date of the second meeting following the Plan’s
receipt of the request for review.




                                                    106
   If special circumstances (such as the need to hold a hearing, if the Plan’s procedures provide for a
hearing) require a further extension of time for processing, a benefit determination shall be rendered no
later than the third meeting of the Committee or Board following the Plan’s receipt of the request for
review. If such an extension of time for review is required because of special circumstances, the Plan
Administrator shall notify the claimant, in writing, of the extension describing the special circumstances
and the date as of which the benefit determination will be made, prior to the commencement of the
extension. The Plan Administrator shall notify the claimant with written or electronic notification of a
Plan’s benefit determination on review as soon as possible, but not later than five (5) calendar days after
the benefit determination is made.

Notification of Determination on Appeal
   You will receive written notification informing you of the determination of the appeal. The notification will
be written in plain language and will essentially contain the same types of information provided in the
initial benefit determination listed on page 105, as well as a description of any voluntary appeals
procedure that may be available to you.
  NOTE: For all appeals on self-insured claims, the decision of the Board of Trustees (or subcommittee
thereof) shall be final.

OTHER APPEALS
   You have the right to appeal any decision of the Administrator based on action taken by the Board of
Trustees (e.g., denial of eligibility or loss of eligibility) by filing a written request for review with the Board
of Trustees. Your written request must be filed within 60 days after receipt of the Administrator’s decision
and describe your version of the facts and reasons why you feel the decision was not proper.

  Upon receipt of your written request for review, the Board of Trustees (or a subcommittee thereof) will
review your case. The Board of Trustees (or a subcommittee thereof) will determine whether or not a
hearing will be held on your case. If a hearing is to be held, you will be notified of the time and place of
the hearing at least two (2) weeks in advance of the hearing (unless you agree in writing to a shorter
notification period). You and/or your authorized representative may appear at the hearing.

   The decision of the Board of Trustees (or a subcommittee thereof) will be made within 60 days after
receipt of your written request, unless special circumstances require an extension of time for reviewing
your case, in which case the decision will be rendered as soon as possible, but not later than 120 days
after receipt of your written request.

 The decision of the Board of Trustees (or a subcommittee thereof) on your appeal will be in
writing and include specific reasons for their decision and shall be final.




  The preceding is a summary of the claims and appeals procedures for informational purposes only.
This summary is subject to the provisions of the Plan Documents and all amendments made thereto,
which are on file with the Hawaii Laborers Health and Welfare Trust Fund office. In the event of a conflict
between the information contained in this booklet and the Plan Documents, the Plan Document will
control. Please refer to these documents for specific questions about claims and appeals procedures.




                                                       107
INSURED CLAIMS
   Participants who have selected the Kaiser Health Plan, Kaiser Senior Advantage Plan, or HMSA’s 65C
Plus Plan for medical and prescription drug coverage, or Hawaii Dental Service or Gentle Dental for
dental coverage, or who are covered by Pacific Guardian Life for temporary disability and/or life
insurance, or by UNUM for long term care insurance may file an appeal with their respective insurance
carrier upon receipt of a benefit denial. For information concerning appeals procedures for these
insurance plans, contact the carrier at the address below:

                            HAWAII MEDICAL SERVICE ASSOCIATION
                                         P.O. Box 860
                                 Honolulu, Hawaii 96808-0860
                                    Attn: Customer Service

                            KAISER FOUNDATION HEALTH PLAN, INC.
                                    711 Kapiolani Boulevard
                                    Honolulu, Hawaii 96813
                                     Attn: Customer Service

                                     HAWAII DENTAL SERVICE
                                     700 Bishop Street, Suite 700
                                    Honolulu, Hawaii 96813-4196
                                   Attn: Customer Service Manager

                                         GENTLE DENTAL
                                     The Town Center of Mililani
                                95-1249 Meheula Parkway, Suite 115
                                       Mililani, Hawaii 96789
                               Attn: Membership Services Department

                                     PACIFIC GUARDIAN LIFE
                                1440 Kapiolani Boulevard, Suite 1700
                                       Honolulu, Hawaii 96814
                                   Attn: Group Claims Department

                                     PACIFIC GUARDIAN LIFE
                                1440 Kapiolani Boulevard, Suite 1700
                                       Honolulu, Hawaii 96814
                                    Attn: TDI Claims Department

                         UNUM LIFE INSURANCE COMPANY OF AMERICA
                                     2211 Congress Street
                                        Mail Stop C467
                                      Portland, ME 04122
                              Attn: Long Term Care Benefit Center




  The decision of the insurance carrier shall be final.




                                                 108
                            USE AND DISCLOSURE OF
                           YOUR HEALTH INFORMATION

    The Hawaii Laborers Health and Welfare Trust Fund is required by the Health Insurance Portability
and Accountability Act of 1996 (HIPAA), a federal law, to maintain the privacy of your health information.
The Trust and its business associates may use or disclose your health information for the following
purposes:

        Treatment;
        Payment;
        Health plan operations and plan administration; and
        As permitted or required by law.

    Other than for the purposes stated above, your health information will not be used or disclosed
without your written authorization. If you authorize the Trust to use or disclose your health information,
you may revoke that authorization at any time in writing.

    Under HIPAA, you have the following rights regarding your health information. You have the right to:
        Request restrictions on certain uses and disclosures of your health information;
        Receive confidential communications of your health information;
        Inspect and copy your health information;
        Amend your health information if you believe your health records are inaccurate or incomplete;
        and
        Request a list of certain disclosures by the Trust of your health information.

    You also have the right to make complaints to the Trust as well as to the Secretary of the Department
of Health and Human Services if you believe that your privacy rights have been violated. Any complaints
to the Trust should be made in writing to: Privacy Officer, Hawaii Laborers Health and Welfare Trust
Fund Office, 1440 Kapiolani Boulevard, Suite 800, Honolulu, Hawaii 96814. You will not be retaliated
against, in any way, for filing a complaint.

    The Trust has designated Pacific Administrators, Inc. as the Trust Fund’s Privacy Officer and its
contact person for all issues regarding patient privacy and your privacy rights. For a copy of the privacy
notice which provides a complete description of your rights under HIPAA’s privacy rules, contact the Trust
Fund’s Privacy Officer at 1440 Kapiolani Boulevard, Suite 800, Honolulu, Hawaii 96814, phone:
(808)441-8600 (Oahu), and 1 (888) 520-8078 (neighbor islands), Monday through Friday, 8:00 a.m. to
4:30 p.m.

FOR BENEFITS PROVIDED THROUGH CARRIERS
   For any questions or complaints regarding your health information and privacy rights related to the
benefits provided through the plans listed below, contact the following:



                                          HMSA 65C Plus Plan
                                             Privacy Officer
                                    Hawaii Medical Service Association
                                              P.O. Box 860
                                      Honolulu, Hawaii 96808-0860
                                            Phone: 948-6111




                                                    109
     Kaiser Medical and Prescription Drug Plans
                    Privacy Officer
          Kaiser Foundation Health Plan, Inc.
               711 Kapiolani Boulevard
               Honolulu, Hawaii 96813
                  Phone: 432-5090


                 HDS Dental Plan
                   Privacy Officer
                Hawaii Dental Service
            700 Bishop Street, Suite 700
              Honolulu, Hawaii 96813
         Phone: 529-9248 (Customer Service)


                   Gentle Dental
                 Compliance Officer
            Interdent Service Corporation
        222 N. Sepulveda Boulevard, Suite 740
         El Segundo, California 90245-4354
Phone: 625-8630 (Gentle Dental Executive Office-Hawaii)


      Pacific Guardian Life Insurance Company
                    Privacy Officer
         1440 Kapiolani Bouelvard, Suite 1700
               Honolulu, Hawaii 96814
                  Phone: 955-2236


     UNUM Life Insurance Company of America
                Attn: Privacy Office
         Long Term Care Quality Review
           2211 Congress Street, C467
                Portland, ME 04122
             Phone: 1 (800) 227-4165




                         110
                      STATEMENT OF ERISA RIGHTS
  As a participant in the Hawaii Laborers Health and Welfare Trust 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 a copy 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 Employee Benefits
Security 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 administrator 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, your spouse, or dependents if there is a 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 pre-existing 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, become entitled to elect COBRA continuation coverage, or when your
COBRA continuation coverage ceases, if you request a certificate within 24 months after losing coverage.
Without evidence of creditable coverage, you may be subject to a pre-existing condition exclusion in your
coverage for 12 months (18 months for late enrollees) after your enrollment date.

Prudent Actions by Plan Fiduciaries
   In addition to creating rights for plan participants, ERISA imposes duties upon the individuals who are
responsible for the operation of the employee benefit plan. The individuals 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 a welfare benefit or
exercising your rights under ERISA.

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.




                                                     111
   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
which is denied or ignored, in whole or in part, you may file suit in a state or Federal court. In addition, if
you disagree with the plan’s decision or lack thereof concerning the qualified status of a domestic
relations order or a medical child support order, you may file suit in Federal court. If it should happen that
plan fiduciaries misuse the plan’s money, or if you are discriminated against for asserting your rights, you
may seek assistance from the U.S. Department of Labor, or you may file suit in a Federal court. The court
will decide who should pay court costs and legal fees. If you are successful, the court may order the
person you have sued to pay these costs and fees. If you lose, the court may order you to pay these
costs and fees, for example, if it finds your claim is frivolous.

ASSISTANCE WITH YOUR QUESTIONS
  If you have any questions about your plan, you should contact the plan administrator. 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 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 Benefits 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.




                                                     112

				
DOCUMENT INFO
Shared By:
Categories:
Tags:
Stats:
views:4
posted:12/22/2011
language:
pages:113