Northwest Retiree Benefit Trust 2014 Benefits Guide

Welcome to the 2014 Northwest Retiree Benefit Trust Medical Benefit Plans This guide includes detailed information regarding the benefit options available to you through the Northwest Retiree Benefit Trust. In this guide, you will find information on the following:

2014 Northwest Retiree Benefit Trust Medical Plan—Page 3 This plan is being offered through Monumental Life Insurance Company (nationwide)/ Transamerica Financial Life Insurance Company (New York residents).

2014 Prescription Drug Plan—Page 5 This plan is being offered through Medicare GenerationRx™ (Employer PDP) and is underwritten by Stonebridge Life Insurance Company.

2014 Dental Plan—Page 8 This plan is being offered through MetLife Dental PPO.

2014 Vision Plan—Page 9 This plan is being offered through Superior Vision.

Important Notes If you have any questions or need assistance as you review your information,

please contact us. The Northwest Retiree Service Center customer care representatives are available between the hours of 7:30 a.m. and 5:00 p.m. CT to assist you. Our dedicated toll-free customer care phone number is 1-866-305-1042. You must enroll in the prescription drug plan if you choose to enroll in the medical

plan option, unless you currently participate in a government-sponsored plan, such as VA or TRICARE. You must enroll in the medical and prescription drug plan to be eligible for the

vision plan. Northwest Retirees and their extended families can get discounted services for

hearing diagnostics, evaluations, and hearing aids through EPIC Discount Hearing Services. This is a FREE service, there are no enrollment forms to complete. Simply call EPIC at 1-866-956-5400. For more information on the benefit plans available, visit our website at www.nwretireebenefits65.com 2

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68722 B10135 (10/13)

2014 Northwest Retiree Benefit Trust Medical Plan Underwritten by Monumental Life Insurance Company, Cedar Rapids, IA a Transamerica Company MEDICARE (PART A) - HOSPITAL SERVICES - PER BENEFIT PERIOD* *A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row.

MEDICARE PAYS

PLAN PAYS

YOU PAY

All but the Medicare Part A deductible

100% of the Medicare Part A deductible

$0

61st thru 90th day

75% of the Medicare Part A deductible

25% of the Medicare Part A deductible

$0

91st day and after: While using 60 lifetime reserve days Once lifetime reserve days are used: Additional 365 days

50% of the Medicare Part A deductible

50% of the Medicare Part A deductible

$0

$0

100% of Medicare Eligible Expenses

$0

$0

$0

All costs

All approved amounts

$0

$0

87 1/2% of Medicare Part A deductible

12 1/2% of Medicare Part A deductible

$0

$0

$0

All costs

$0 100%

3 pints $0

$0 $0

$0

Balance

SERVICES HOSPITALIZATION* Semiprivate room and board, general nursing and miscellaneous services and supplies: First 60 days

Beyond the additional 365 days SKILLED NURSING FACILITY CARE* You must meet Medicare’s requirements, including having been in a hospital for at least 3 days and entered a Medicare-approved facility within 30 days after leaving the hospital: First 20 days 21st thru 100th day

101st day and after BLOOD First 3 pints Additional amounts HOSPICE CARE Available as long as your doctor certifies you are terminally ill and you elect to receive these services.

All but very limited coinsurance for outpatient drugs and inpatient respite care

Benefits will not be paid for any expenses which are not determined to be Medicare Eligible Expenses by the Federal Medicare Program or its administrators, except as otherwise specified. For complete details please see the Master Policy. This policy's renewability, cancellability and termination provisions are at the option of the group policy holder except in cases of non-payment of premium.

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MEDICARE (PART B) - MEDICAL SERVICES - PER CALENDAR YEAR* *Once you have been billed the applicable Medicare-Approved amounts for covered services (which are noted with an asterisk), your Medicare Part B Deductible will have been met for the calendar year.

MEDICARE PLAN PAYS PAYS

SERVICES MEDICAL EXPENSES—In or Out of the Hospital and Outpatient Hospital Treatment, such as Physician’s services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment: First Medicare Approved Amounts* Next Medicare Eligible expenses up to an annual out-ofpocket totaling $2,000 (includes Part B deductible). After payment of the standard Part B deductible plan pays 10% Medicare eligible expenses up to an annual out-ofpocket totaling $2,000 (includes Part B deductible); thereafter plan pays 20% Medicare eligible expenses. Part B Excess Charges (above Medicare approved amounts) BLOOD First 3 pints Next Medicare Approved Amounts* Next Medicare Eligible expenses up to an annual out-ofpocket totaling $2,000 (includes Part B deductible). After payment of the standard Part B deductible plan pays 10% Medicare eligible expenses up to an annual out-ofpocket totaling $2,000 (includes Part B deductible); thereafter plan pays 20% Medicare eligible expenses. CLINICAL LABORATORY SERVICES Blood tests for Diagnostic Services HOME HEALTH CARE Medicare Approved Services: Medically necessary skilled care services and medical supplies Durable medical equipment: First Medicare Approved Amounts* Next Medicare Eligible expenses up to an annual out-ofpocket totaling $2,000 (included Part B deductible). After payment of the standard Part B deductible plan pays 10% Medicare eligible expenses up to an annual out-ofpocket totaling $2,000 (includes Part B deductible); thereafter plan pays 20% Medicare eligible expenses. FOREIGN TRAVEL Medically necessary emergency services beginning during the first 60 days of each trip outside the USA: First $250 each calendar year Remainder of charges

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YOU PAY

$0

$0

Generally 80%

Generally 10%

100% of Part B deductible 10% up to $2,000

Generally 80%

Generally 20%

$0

$0

100%

$0

$0 $0

All costs $0

80%

10%

$0 100% of Part B deductible 10% up to $2,000

80%

20%

$0

100%

$0

$0

100%

$0

$0

$0

$0

80%

10%

100% of Part B deductible 10% up to $2,000

80%

20%

$0

$0 $0

$0 80% to a lifetime maximum of $100,000

$250 20% and amounts over $100,000 lifetime maximum

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2014 Prescription Drug Plan Medicare GenerationRx™ (Employer PDP) is a Medicare-approved Part D sponsor that is offered nationally in all 50 states except NY and the District of Columbia. This prescription drug plan is a group plan underwritten by a Transamerica affiliated company, Stonebridge Life Insurance Company (Rutland, VT). Whether you are looking for the local service of a neighborhood pharmacy, the convenience of prescriptions by mail or the clinical support of a specialty pharmacy, Medicare GenerationRx™ has options to match your preferences. Community Pharmacies Medicare GenerationRx™ has more than 60,000 community pharmacies for your use, including most chain drug stores and many independents. For your convenience, you may also receive an extended day supply at many of our retail pharmacies under our Value90Rx® program. Mail Order Pharmacy Ordering prescriptions by mail is like having a pharmacy at your door. It can save you trips to the pharmacy while providing confidentiality in your prescription needs. You’ll also reap copayment savings. Up to a 90-day supply of your prescriptions can be delivered to your mailbox for what you would normally pay for a 60-day supply at your community pharmacy. Ordering prescriptions by mail lowers your drug cost by 33%. Specialty Pharmacy Prescriptions If you are currently taking a medication that is on the specialty tier of your prescription benefit, you may wish to take advantage of Medicare GenerationRx™’s preferred specialty pharmacy, Diplomat Specialty Pharmacy. Diplomat uses pharmacists and nurses to provide specialized Patient Care Programs. These clinical management programs are designed by pharmacists and physicians to be a resource to you in managing and understanding your drug therapy and disease. Only you know what pharmacy options best suit you. Medicare GenerationRx™ is pleased to offer you the choice of local pharmacies, prescriptions by mail and a specialty pharmacy that supports you and your specific needs. If you have questions on any of these pharmacy options or your Medicare GenerationRx™ plan, our member services staff is here to help you at 1-877-633-7943 or by visiting www.MedicareGenerationRx.com/northwest.

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2014 Prescription Drug Plan Benefit Category

Outpatient Prescription Drugs

General

This plan uses a formulary. The plan will send you a formulary. You can also see the formulary at www.MedicareGenerationRx.com/northwest. You must go to certain pharmacies for a limited number of drugs, due to special handling, provider coordination, or patient education requirements that cannot be met by most pharmacies in your network. These drugs are listed on the plan’s website, formulary and printed materials. If the actual cost of a drug is less than the normal cost-sharing amount for that drug, you will pay the actual cost, not the higher cost-sharing amount.

Yearly Deductible

Your annual deductible is $0.

Initial Coverage

Because you have no deductible, you pay the following until your total yearly drug costs reach $2,850.

Retail Pharmacy— Up to 31 day supply

Tier 1: Generic Drugs $15 copayment for a 31-day supply of drugs in this tier Tier 2: Preferred Brand Drugs $25 copayment for a 31-day supply of drugs in this tier Tier 3: Non-Preferred Brand Drugs $55 copayment for a 31-day supply of drugs in this tier Tier 4: Specialty Tier Drugs 33% coinsurance for a 31-day supply of drugs in this tier

Mail Order— 84-90 day supply

Tier 1: Generic Drugs $30 copayment for a 90-day supply of drugs in this tier Tier 2: Preferred Brand Drugs $50 copayment for a 90-day supply of drugs in this tier Tier 3: Non-Preferred Brand Drugs $110 copayment for a 90-day supply of drugs in this tier Tier 4: Specialty Tier Drugs 33% coinsurance for a 90-day supply of drugs in this tier

Retail Pharmacy— 84-90 day supply

Tier 1: Generic Drugs $45 copayment for a 90-day supply of drugs in this tier Tier 2: Preferred Brand Drugs $75 copayment for a 90-day supply of drugs in this tier Tier 3: Non-Preferred Brand Drugs $165 copayment for a 90-day supply of drugs in this tier Tier 4: Specialty Tier Drugs 33% coinsurance for a 90-day supply of drugs in this tier

After your Initial Coverage Limit Level drug costs reach $2,850, you receive a discount on brand name drugs and pay 72% of the plan's costs for all generic drugs until your yearly True-Out-OfPocket drug costs reach $4,550, which is needed to enter catastrophic coverage. A 52.5% discount on the negotiated price will be available for those brand name drugs from manufacturer's that have agreed to pay the discount. 6

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Notice about the Coverage Gap (Donut Hole) During the INITIAL COVERAGE LIMIT your co-pays for the Value Plan will be: $15 Generic, $25 Preferred Brand, $55 Non-Preferred Brand, and 33% Specialty. When the shared costs (what your co-pays and what the Medicare GenerationRx™ Plan actually pays) for your drugs exceed $2,850 you leave the Initial Coverage Phase and enter the Donut Hole. Please note: the cost-sharing is for a 31-day supply. EXAMPLE OF HOW YOU COULD GET IN THE DONUT HOLE: Assume that during the calendar year in the Initial Coverage Phase, Medicare GenerationRx™ has paid $2,200 in drug costs and you have paid $770 in copays. $2,200 + $770 = $2,850 (you have reached the Initial Coverage Limit) Please note: this is only an illustration of how the $2,970 Initial Coverage Limit can be reached; it could be a different combination of shared costs between you and Medicare GenerationRx™, depending on how your co-pays add up and how much the Medicare GenerationRx™ Plan pays for the drugs, but the total limit is $2,850. WHAT HAPPENS WHEN I AM IN THE DONUT HOLE? For the 2014 Value Plan in the Donut Hole: PREFERRED BRAND & NON-PREFERRED BRAND DRUGS: You pay 47.5% of the cost; the pharmaceutical companies have committed through healthcare reform to pay the other 52.5%. GENERIC DRUGS: You pay 72% of the cost of Generics. CATASTROPHIC COVERAGE LIMIT In 2014, the limit is $4,550. Because of healthcare reform, what you pay and some of the payments made by the Medicare Coverage Gap Discount Program are included as out-of-pocket spending and help you to get out of the coverage gap. Prior to healthcare reform, it was only your costs that counted. After the drug costs have exceeded $4,550, the costs of your drugs will be the greater of: 5% or $2.55 for generic/preferred multi-source drugs, and the greater of 5% or $6.35 for all other drugs.

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2014 Dental Plan MetLife Dental PPO In-Network Annual deductible per person for Minor $50 care and Major care combined

Out-of-Network $50

Preventive Care Exam - (twice per calendar year) Prophylaxis - (twice per calendar year) X-Rays - (Bitewing-as part of routine exam, twice per year; full mouth-once every 36 months)

No Deductible The Plan pays 100% of discounted in-network fees

No Deductible The Plan pays 80% of reasonable and customary (R&C) charges

Minor Care Oral surgery Extractions Amalgams Endodontics Periodontics

The Plan pays 80% of discounted in-network after annual Deductible

The Plan pays 80% of R&C charges, after annual Deductible

Major Care Bridgework Dentures Crowns Inlays and onlays Reparation and replacement of bridges, crowns, inlays, onlays, Dentures Implants—1. Provided no more than once for the same tooth position in a 60 month period. 2. Repaired not more than once in a 12 month period. 3. Supported prosthetics but no more than once for the same tooth position in a 5 year period.

The Plan pays 50% of discounted In-network fees after annual Deductible

The Plan pays 50% of R&C charges, after annual Deductible

Annual Benefit Maximum

$1,500/person

$1,000/person

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2014 Vision Plan Superior Vision In-Network

Out-of-Network

Co-payments

$10 Comprehensive Eye Exams; $25 Materials

Comprehensive Eye Exam Ophthalmologist (MD)

Covered in Full

Up to $37

Comprehensive Eye Exam Optometrist (OD)

Covered in Full

Up to $28

Standard Lenses (Per pair): Single Vision Bifocal Trifocal Lenticular

Covered in Full Covered in Full Covered in Full Covered in Full

Up to $32 Up to $46 Up to $57 Up to $90

Contact Lenses (Per pair):* Medically Necessary Elective**

Covered in Full Up to $100

Up to $210 Up to $100

Frames—Standard**

Up to $125

Up to $47

Plan Frequency Comprehensive Exam Lenses Frames Contact Lenses

Lens Options and Upgrades (covered pair of lenses) Factory scratch coat Ultraviolet coat Standard anti-reflective coat High Index 1.6 Polycarbonate Standard photochromic Glass coloring Plastic, tints, solid, or gradients

Member pays 20% off retail up to: $13 $15 $50 $55 $40 Materials Discount SVP8-20 $80 These discounts apply to upgrades on the covered frame and lenses only. For discounts on additional $35 pairs, please refer to the Discounts on Additional $25 Purchases. Member pays: Power over 4.00 Sphere, 2.00D 20% discount off retail Frames 20% off the difference between the Cylinder & 5.00 Prism covered frame allowance and the retail price of Cosmetic finishing, beveling, 20% discount off retail the edging & mounting selected frame. Miscellaneous options 20% discount off retail Note: Discounts do not apply when prohibited by the manufacturer. Higher end or brand name lens upgrades are at an additional expense to you. These upgrades will be available at a 20% discount off retail. Materials Discounts on Additional Purchases Discounts up to 20% on Materials and 30% on Additional Purchases are available through Superior View your benefits and provider listing at Vision contracted providers identified in the provider www.superiorvision.com directory. 12 Months 12 Months 24 Months 12 Months

All final determinations of benefits, administrative duties, and definitions are governed by the Certificate of Insurance Coverage for your vision plan.

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