MOE SBCs Final

SUMMARIES OF BENEFITS AND
COVERAGE FOR MOE HEALTH PLAN
MARKETPLACE OPTIONS
Summaries of Benefits and Coverage for MOE Health Plan Marketplace Options 1

What’s Inside
Enclosed is the Summary of Benefits and Coverage (SBC) for each of the MOE Health Plan Marketplace options. The enclosed
notices are for informational purposes only. These notices are required annually and provide a summary of plan benefits,
coverage and cost-sharing arrangements, including exceptions, reductions, limitations and continuation of coverage information.
Please note each SBC contains information for the new Plan Year effective April 1, 2016 through March 31, 2017.
The following SBCs are included:
Current Plan A.........................................1
Platinum PPO .........................................9
EPO (Modified HMO)...........................17
Gold PPO................................................ 25
Silver PPO.............................................. 33
Silver PPO II (Narrow Network).........41
Bronze PPO............................................ 49
Summaries of Benefits and Coverage for MOE Health Plan Marketplace Options 2

Midwest Operating Engineers: Plan A
Summary of Benefits and Coverage: What this Plan Covers & What it Costs
Coverage Period: 04/01/2016 - 03/31/2017
Coverage for: Individual + Family | Plan Type: PPO
This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan
document at www.moefunds.com or by calling 1-708-482-7300.
Important Questions
Answers
Why this Matters:
What is the overall
deductible?
In-Network and Out-of-
Network: $300 person/$700
family. Prescription drugs,
durable medical equipment, TMJ,
balance billing, excluded services
do not count toward the
deductible.
You must pay all the costs up to the deductible amount before this plan begins to pay for
covered services you use. Check your policy or plan document to see when the deductible
starts over (usually, but not always, January 1st). See the chart starting on page 2 for how
much you pay for covered services after you meet the deductible.
Are there other
deductibles for specific
services?
Is there an out-ofpocket
limit on my
expenses?
No.
Yes. In-Network and Out-of-
Network Medical: $2,500
person/$6,000 family; In-
Network Prescription Drugs:
$2,000 person/$4,000 family;
Out-of-Network Prescription
Drugs: $4,000 person/$8,000
family.
You don’t have to meet deductibles for specific services, but see the chart starting on page 2
for other costs for services this plan covers.
The out-of-pocket limit is the most you could pay during a coverage period (usually one
year) for your share of the cost of covered services. This limit helps you plan for health care
expenses.
What is not included in
the out-of-pocket
limit?
Self-payments, balance billing,
health care this plan does not
cover, Family Supplemental
Benefit charges.
Even though you pay these expenses, they don’t count toward the out-of-pocket limit.
Is there an overall
annual limit on what the
plan pays?
No.
The chart starting on page 2 describes any limits on what the plan will pay for specific covered
services, such as office visits.
Questions: Call 1-708-482-7300 or visit us at www.moefunds.com.
If you aren’t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary 1 of 8
at www.dol.gov/ebsa/healthreform or call 1-708-482-7300 to request a copy.
Summaries of Benefits and Coverage for MOE Health Plan Marketplace Options 1

Important Questions Answers Why this Matters:
Does this plan use a
network of providers?
Do I need a referral to see
a specialist?
Are there services this
plan doesn’t cover?
Yes. For a list of in-network
providers, call 1-800-810-2583.
Yes. You need a referral to see
an acupuncture specialist.
Yes.
If you use an in-network doctor or other health care provider, this plan will pay some or all
of the costs of covered services. Be aware, your in-network doctor or hospital may use an
out-of-network provider for some services. Plans use the term in-network, preferred, or
participating for providers in their network. See the chart starting on page 2 for how this
plan pays different kinds of providers.
This plan will pay some or all of the costs to see a specialist for covered services but only if
you have the plan’s permission before you see the specialist.
Some of the services this plan doesn’t cover are listed on page 6. See your policy or plan
document for additional information about excluded services.
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Co-payments are fixed dollar amounts (for example, $15) you pay for covered health care, usually when you receive the service.
Co-insurance is your share of the costs of a covered service, calculated as a percent of the allowed amount for the service. For example, if
the plan’s allowed amount for an overnight hospital stay is $1,000, your co-insurance payment of 20% would be $200. This may change if
you haven’t met your deductible.
The amount the plan pays for covered services is based on the allowed amount. If an out-of-network provider charges more than the
allowed amount, you may have to pay the difference. For example, if an out-of-network hospital charges $1,500 for an overnight stay and
the allowed amount is $1,000, you may have to pay the $500 difference. (This is called balance billing.)
This plan may encourage you to use in-network providers by charging you lower deductibles, co-payments and co-insurance amounts.
Common
Medical Event
Service You May Need
Primary care visit to treat an injury or
illness
Specialist visit
Your Cost If You Use
an In-Network
Provider
Your Cost If You
Use an Out-of-
Network Provider
10% co-insurance 20% co-insurance -- None --
10% co-insurance 20% co-insurance -- None --
Limitations & Exceptions
If you visit a health
care provider's office
or clinic
Other practitioner office visit
10% co-insurance for
chiropractor
(manipulations and
necessary x-rays only),
acupuncture
20% co-insurance for
chiropractor
(manipulations and
necessary x-rays only),
acupuncture
Chiropractor: 24 visits/year up to
$60/visit & eligible only if over age 5;
Acupuncture: 12 treatments/year and
$125/visit.
Preventive care/
screening/immunization
No charge
No charge
Out-of-network only covers routine
physical exams for member and
spouse only, well-baby care.
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Summaries of Benefits and Coverage for MOE Health Plan Marketplace Options 2

Common
Medical Event
If you have a test
Service You May Need
Diagnostic test (x-ray, blood work)
Imaging (CT/PET scans, MRIs)
Your Cost If You Use
an In-Network
Provider
Your Cost If You
Use an Out-of-
Network Provider
10% co-insurance/test 20% co-insurance/test -- None --
10% co-insurance/test; no
charge if scan is
authorized by AIM
20% co-insurance/test -- None --
Limitations & Exceptions
If you need drugs to
treat your illness or
condition
More information
about prescription
drug coverage is
available at
www.caremark.com or
1-708-482-7300.
Generic drugs
Brand drugs
Maintenance Drugs (Limited to CVS
Pharmacy Stores or CVS Caremark
Mail Service Only)
$5 co-pay per 30-day
supply retail/$15 co-pay
per 90-day supply mail
order
$10 co-pay per 30-day
supply retail/$30 co-pay
per 90-day supply mail
order
Not covered
Not covered
Not covered
$15 co-pay per 90-day
supply generic/$30 co-pay
per 90-day supply brand
Maximum of up to two 30-day
supplies before a member is required
to obtain a 90-day supply. Member
seeking third refill must transition to
CVS Pharmacy or CVS Caremark
Mail Service Pharmacy, or pay 100%
of the cost of the prescription drug.
You must pay the difference between
the cost of a brand and generic if a
generic is available. Certain specialty
medications are subject to preauthorization
requirements. Call the
phone number listed or visit
Caremark's website for more
information.
If you have
outpatient surgery
Facility fee (e.g., ambulatory surgery
center)
Physician/surgeon fees
10% co-insurance 20% co-insurance Licensed facilities only.
10% co-insurance 20% co-insurance -- None --
If you need
immediate medical
attention
If you have a hospital
stay
Emergency room services
Emergency medical transportation
Urgent care
Facility fee (e.g., hospital room)
Physician/surgeon fee
10% co-insurance 10% co-insurance -- None --
10% co-insurance 20% co-insurance
Transfer between inter-health
facilities limited to $5,000.
10% co-insurance 20% co-insurance -- None --
10% co-insurance 20% co-insurance
Room allowances based on semiprivate
room rate.
10% co-insurance 20% co-insurance -- None --
3 of 8
Summaries of Benefits and Coverage for MOE Health Plan Marketplace Options 3

Common
Medical Event
Service You May Need
Your Cost If You Use
an In-Network
Provider
Your Cost If You
Use an Out-of-
Network Provider
Limitations & Exceptions
Mental/Behavioral health outpatient
services
10% co-insurance/office
visit, 10% co-insurance
other outpatient services
20% co-insurance/office
visit, 20% co-insurance
other outpatient services
-- None --
If you have mental
health, behavioral
health, or substance
abuse needs
If you are pregnant
Mental/Behavioral health inpatient
services
Substance use disorder outpatient
services
Substance use disorder inpatient
services
Prenatal and postnatal care
Delivery and all inpatient services
Home health care
Rehabilitation services
10% co-insurance 20% co-insurance -- None --
10% co-insurance/office
visit, 10% co-insurance
other outpatient services
20% co-insurance/office
visit, 20% co-insurance
other outpatient services
-- None --
10% co-insurance 20% co-insurance -- None --
10% co-insurance 20% co-insurance -- None --
10% co-insurance 20% co-insurance -- None --
10% co-insurance 20% co-insurance Case manager must pre-approve.
10% co-insurance 20% co-insurance Case manager must pre-approve.
If you need help
recovering or have
other special health
needs
Habilitation services
Skilled nursing care
10% co-insurance 20% co-insurance
10% co-insurance 20% co-insurance
Case manager must pre-approve.
Limited to 25 visits for plan year:
speech therapy for kids (ages 2-18)
with congenital neurological disorder.
45-day limit per confinement; must
be recommended by physician and
begin within 30 days of hospital
confinement; not covered if not preapproved.
Durable medical equipment
Hospice service
20% co-insurance 20% co-insurance $15,000 limit/electric wheelchair.
10% co-insurance 20% co-insurance Case manager must pre-approve.
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Summaries of Benefits and Coverage for MOE Health Plan Marketplace Options 4

Common
Medical Event
Service You May Need
Your Cost If You Use
an In-Network
Provider
Your Cost If You
Use an Out-of-
Network Provider
Limitations & Exceptions
If your child needs
dental or eye care
Eye exam
Glasses
Not covered
Not covered
Not covered
Not covered
Eye exams and glasses are
reimbursable under the Family
Supplemental Benefit. You can
receive basic vision care at no charge
from the Operator’s Health Center.
Dental check-up
No charge No charge Limited to 2 check-ups per year.
5 of 8
Summaries of Benefits and Coverage for MOE Health Plan Marketplace Options 5

Excluded Services & Other Covered Services:
Services Your Plan Does NOT Cover (This isn't a complete list. Check your policy or plan document for other excluded services.)
● Cosmetic surgery (Except for mastectomy, injuries
and to remove scar tissue)
● Hearing aids (Except for cochlear implants)
● Infertility treatment
● Long-term care
● Non-emergency care when traveling
outside the U.S.
● Private-duty nursing except transplant patients
● Routine foot care
● Weight loss programs
Other Covered Services (This isn't a complete list. Check your policy or plan document for other covered services and your costs for those
services.)
● Acupuncture ($125 per visit, 12 per year)
● Bariatric surgery (Prior authorization required)
● Chiropractic care (Limited to $60/visit and
24/visits per year) (manipulations and
necessary x-rays only)
● Dental care (Adult) ($1,000 annual limit)
● Routine eye care (Eligible for reimbursement
from Family Supplemental Benefit)
Your Rights to Continue Coverage:
If you lose coverage under the plan, then, depending upon the circumstances, Federal and State laws may provide protections that allow you to keep health
coverage. Any such rights may be limited in duration and will require you to pay a premium, which may be significantly higher than the premium you pay
while covered under the plan. Other limitations on your rights to continue coverage may also apply.
For more information on your rights to continue coverage, contact the plan at 1-708-482-7300. You may also contact your state insurance department, the
U.S. Department of Labor, Employee Benefits Security Administration at 1-866-444-3272 or www.dol.gov/ebsa, or the U.S. Department of Health and
Human Services at 1-877-267-2323 x61565 or www.cciio.cms.gov.
Your Grievance and Appeals Rights:
If you have a complaint or are dissatisfied with a denial of coverage for claims under your plan, you may be able to appeal or file a grievance. For
questions about your rights, this notice, or assistance, you can contact: (1) Administrative Manager, Midwest Operating Engineers Fringe Benefit Funds,
6150 Joliet Road, Countryside, IL 60525-3994, 1-708-482-7300; or (2) Department of Labor's Employee Benefits Security Administration at 1-866-444-
EBSA (3272) or www.dol.gov/ebsa/healthreform.
Does this Coverage Provide Minimum Essential Coverage?
The Affordable Care Act requires most people to have health care coverage that qualifies as “minimum essential coverage.” This plan or policy does
provide minimum essential coverage.
Does this Coverage Meet the Minimum Value Standard?
The Affordable Care Act establishes a minimum value standard of benefits of a health plan. The minimum value standard is 60% (actuarial value). This
health coverage does meet the minimum value standard for the benefits it provides.
Language Access Services:
SPANISH (Español): Para obtener asistencia en Español, llame al 1-708-482-7300.
–––––––––––––––––––––To see examples of how this plan might cover costs for a sample medical situation, see the next page.–––––––––––––––––––
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Summaries of Benefits and Coverage for MOE Health Plan Marketplace Options 6

About these Coverage
Examples:
These examples show how this plan might cover
medical care in given situations. Use these
examples to see, in general, how much financial
protection a sample patient might get if they are
covered under different plans.
This is
not a cost
estimator.
Don’t use these examples to
estimate your actual costs
under this plan. The actual
care you receive will be
different from these examples,
and the cost of that care will
also be different.
See the next page for
important information about
these examples.
Having a baby
(normal delivery)
■ Amount owed to providers: $7,540
■ Plan pays $6,330
■ Patient pays $1,210
Managing type 2 diabetes
(routine maintenance of
a well-controlled condition)
■ Amount owed to providers: $5,400
■ Plan pays $4,520
■ Patient pays $880
Sample care costs:
Sample care costs:
Hospital charges (mother) $2,700 Prescriptions $2,900
Routine obstetric care $2,100 Medical Equipment and Supplies $1,300
Hospital charges (baby) $900 Office Visits and Procedures $700
Anesthesia $900 Education $300
Laboratory tests $500 Laboratory tests $100
Prescriptions $200 Vaccines, other preventive $100
Radiology $200 Total $5,400
Vaccines, other preventive $40
Total $7,540 Patient pays:
Deductibles $300
Patient pays: Co-pays $200
Deductibles $300 Co-insurance $300
Co-pays $10 Limits or exclusions $80
Co-insurance $700 Total $880
Limits or exclusions $200
Total $1,210
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Summaries of Benefits and Coverage for MOE Health Plan Marketplace Options 7

Questions and answers about the Coverage Examples:
What are some of the
assumptions behind the
Coverage Examples?
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●
●
●
●
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Costs don’t include premiums.
Sample care costs are based on national
averages supplied by the U.S.
Department of Health and Human
Services, and aren’t specific to a
particular geographic area or health
plan.
The patient’s condition was not an
excluded or preexisting condition.
All services and treatments started and
ended in the same coverage period.
There are no other medical expenses for
any member covered under this plan.
Out-of-pocket expenses are based only
on treating the condition in the example.
The patient received all care from innetwork
providers. If the patient had
received care from out-of-network
providers, costs would have been
higher.
What does a Coverage Example
show?
For each treatment situation, the Coverage
Example helps you see how deductibles, copayments,
and co-insurance can add up. It
also helps you see what expenses might be left
up to you to pay because the service or
treatment isn’t covered or payment is limited.
Does the Coverage Example
predict my own care needs?
No. Treatments shown are just examples.
The care you would receive for this
condition could be different based on your
doctor’s advice, your age, how serious your
condition is, and many other factors.
Does the Coverage Example
predict my future expenses?
No. Coverage Examples are not cost
estimators. You can’t use the examples to
estimate costs for an actual condition. They
are for comparative purposes only. Your
own costs will be different depending on
the care you receive, the prices your
providers charge, and the reimbursement
your health plan allows.
Can I use Coverage Examples to
compare plans?
Yes. When you look at the Summary of
Benefits and Coverage for other plans,
you’ll find the same Coverage Examples.
When you compare plans, check the
“Patient Pays” box in each example. The
smaller that number, the more coverage
the plan provides.
Are there other costs I should
consider when comparing
plans?
Yes. An important cost is the premium
you pay. Generally, the lower your
premium, the more you’ll pay in out-ofpocket
costs, such as co-payments,
deductibles, and co-insurance. You
should also consider contributions to
accounts such as health savings accounts
(HSAs), flexible spending arrangements
(FSAs) or health reimbursement accounts
(HRAs) that help you pay out-of-pocket
expenses.
Questions: Call 1-708-482-7300 or visit us at www.moefunds.com.
If you aren’t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary 8 of 8
at www.dol.gov/ebsa/healthreform or call 1-708-482-7300 to request a copy.
Summaries of Benefits and Coverage for MOE Health Plan Marketplace Options 8

Midwest Operating Engineers: Platinum
Summary of Benefits and Coverage: What this Plan Covers & What it Costs
Coverage Period: 04/01/2016 - 03/31/2017
Coverage for: Individual + Family | Plan Type: PPO
This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan
document at www.moefunds.com or by calling 1-708-482-7300.
Important Questions
Answers
Why this Matters:
What is the overall
deductible?
In-Network: $500 person/$1,250
family; Out-of-Network: $1,000
person/$2,500 family. Prescription
drugs, durable medical equipment,
TMJ, balance billing, excluded services
do not count toward the deductible.
You must pay all the costs up to the deductible amount before this plan begins to pay
for covered services you use. Check your policy or plan document to see when the
deductible starts over (usually, but not always, January 1st). See the chart starting on
page 2 for how much you pay for covered services after you meet the deductible.
Are there other
deductibles for specific
services?
Is there an out-ofpocket
limit on my
expenses?
What is not included in
the out-of-pocket
limit?
No.
Yes. In-Network Medical: $3,500
person/$7,000 family; Out-of-
Network Medical: $7,000
person/$14,000 family. In-Network
Prescription Drugs: $2,000
person/$4,000 family; Out-of-
Network Prescription Drugs: $4,000
person/$8,000 family.
Self-payments, balance billing, health
care this plan does not cover, Family
Supplemental Benefit charges.
You don’t have to meet deductibles for specific services, but see the chart starting on
page 2 for other costs for services this plan covers.
The out-of-pocket limit is the most you could pay during a coverage period (usually
one year) for your share of the cost of covered services. This limit helps you plan for
health care expenses.
Even though you pay these expenses, they don’t count toward the out-of-pocket limit.
Is there an overall
annual limit on what the
plan pays?
No.
The chart starting on page 2 describes any limits on what the plan will pay for specific
covered services, such as office visits.
Questions: Call 1-708-482-7300 or visit us at www.moefunds.com.
If you aren’t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary 1 of 8
at www.dol.gov/ebsa/healthreform or call 1-708-482-7300 to request a copy.
Summaries of Benefits and Coverage for MOE Health Plan Marketplace Options 9

Important Questions Answers Why this Matters:
Does this plan use a
network of providers?
Do I need a referral to see
a specialist?
Are there services this
plan doesn’t cover?
Yes. For a list of in-network
providers, call 1-800-810-2583.
Yes. You need a referral to see
an acupuncture specialist.
Yes.
If you use an in-network doctor or other health care provider, this plan will pay some or all
of the costs of covered services. Be aware, your in-network doctor or hospital may use an
out-of-network provider for some services. Plans use the term in-network, preferred, or
participating for providers in their network. See the chart starting on page 2 for how this
plan pays different kinds of providers.
This plan will pay some or all of the costs to see a specialist for covered services but only if
you have the plan’s permission before you see the specialist.
Some of the services this plan doesn’t cover are listed on page 6. See your policy or plan
document for additional information about excluded services.
●
●
●
●
Co-payments are fixed dollar amounts (for example, $15) you pay for covered health care, usually when you receive the service.
Co-insurance is your share of the costs of a covered service, calculated as a percent of the allowed amount for the service. For example, if
the plan’s allowed amount for an overnight hospital stay is $1,000, your co-insurance payment of 20% would be $200. This may change if
you haven’t met your deductible.
The amount the plan pays for covered services is based on the allowed amount. If an out-of-network provider charges more than the
allowed amount, you may have to pay the difference. For example, if an out-of-network hospital charges $1,500 for an overnight stay and
the allowed amount is $1,000, you may have to pay the $500 difference. (This is called balance billing.)
This plan may encourage you to use in-network providers by charging you lower deductibles, co-payments and co-insurance amounts.
Common
Medical Event
If you visit a health
care provider's office
or clinic
Service You May Need
Primary care visit to treat an injury or
illness
Specialist visit
Other practitioner office visit
Preventive care/
screening/immunization
Your Cost If You Use
an In-Network
Provider
10% co-insurance 20% co-insurance -- None --
10% co-insurance 20% co-insurance -- None --
10% co-insurance for
chiropractor
(manipulations and x-rays
only), acupuncture
Your Cost If You Use
an Out-of-Network
Provider
20% co-insurance for
chiropractor
(manipulations and x-rays
only), acupuncture
No charge Not covered -- None --
Limitations & Exceptions
Chiropractor: 24 visits/year up to
$60/visit & eligible only if over age
5; Acupuncture: 12 treatments/year
up to $125/visit.
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Summaries of Benefits and Coverage for MOE Health Plan Marketplace Options 10

Common
Medical Event
If you have a test
Service You May Need
Diagnostic test (x-ray, blood work)
Imaging (CT/PET scans, MRIs)
Your Cost If You Use
an In-Network
Provider
Your Cost If You Use
an Out-of-Network
Provider
10% co-insurance/test 20% co-insurance/test -- None --
10% co-insurance/test; no
charge if scan is
authorized by AIM
20% co-insurance/test -- None --
Limitations & Exceptions
If you need drugs to
treat your illness or
condition
More information
about prescription
drug coverage is
available at
www.caremark.com or
1-708-482-7300.
Generic drugs
Brand drugs
Maintenance (Limited to CVS
Pharmacy Stores or CVS Caremark
Mail Service Pharmacy Only)
$5 co-pay per 30-day
supply retail/$15 co-pay
per 90-day supply mail
order
$10 co-pay per 30-day
supply retail/$30 co-pay
per 90-day supply mail
order
Not covered
Not covered
$15 co-pay per 90-day Not covered
supply generic/$30 co-pay
per 90-day supply brand
Maximum of up to two 30-day
supplies before a member is
required to obtain a 90-day supply.
Member seeking third refill must
transition to CVS Pharmacy or CVS
Caremark Mail Service Pharmacy,
or pay 100% of the cost of the
prescription drug. You must pay the
difference between the cost of a
brand and generic if a generic is
available. Certain specialty
medications are subject to preauthorization
requirements. Call the
phone number listed or visit
Caremark's website for more
information.
If you have
outpatient surgery
If you need
immediate medical
attention
If you have a hospital
stay
Facility fee (e.g., ambulatory surgery
center)
Physician/surgeon fees
Emergency room services
Emergency medical transportation
Urgent care
Facility fee (e.g., hospital room)
Physician/surgeon fee
10% co-insurance 20% co-insurance Licensed facilities only.
10% co-insurance 20% co-insurance -- None --
$100 co-pay per visit;
10% co-insurance
$100 co-pay per visit;
10% co-insurance
-- None --
10% co-insurance 20% co-insurance
Transfer between inter-health
facilities limited to $5,000.
10% co-insurance 20% co-insurance -- None --
10% co-insurance 20% co-insurance
Room allowances based on semiprivate
room rate.
10% co-insurance 20% co-insurance -- None --
3 of 8
Summaries of Benefits and Coverage for MOE Health Plan Marketplace Options 11

Common
Medical Event
Service You May Need
Your Cost If You Use
an In-Network
Provider
Your Cost If You Use
an Out-of-Network
Provider
Limitations & Exceptions
Mental/Behavioral health outpatient
services
10% co-insurance/office
visit, 10% co-insurance
other outpatient services
20% co-insurance/office
visit, 20% co-insurance
other outpatient services
-- None --
If you have mental
health, behavioral
health, or substance
abuse needs
If you are pregnant
If you need help
recovering or have
other special health
needs
Mental/Behavioral health inpatient
services
Substance use disorder outpatient
services
Substance use disorder inpatient
services
Prenatal and postnatal care
Delivery and all inpatient services
Home health care
Rehabilitation services
Habilitation services
Skilled nursing care
Durable medical equipment
Hospice service
10% co-insurance 20% co-insurance -- None --
10% co-insurance/office
visit,10% co-insurance
other outpatient services
20% co-insurance/office
visit, 20% co-insurance
other outpatient services
-- None --
10% co-insurance 20% co-insurance -- None --
10% co-insurance 20% co-insurance -- None --
10% co-insurance 20% co-insurance -- None --
10% co-insurance 20% co-insurance Case manager must pre-approve.
10% co-insurance 20% co-insurance Case manager must pre-approve.
10% co-insurance 20% co-insurance
Case manager must pre-approve.
Limit 25 visits per year: speech
therapy for kids (age 2-18) with
congenital neurological disorder.
10% co-insurance 20% co-insurance
45-day limit per confinement; must
be recommended by physician and
begin within 30 days of hospital
confinement; not covered if not preapproved.
20% co-insurance 20% co-insurance $15,000 limit/electric wheelchair.
10% co-insurance 20% co-insurance Case manager must pre-approve.
4 of 8
Summaries of Benefits and Coverage for MOE Health Plan Marketplace Options 12

Common
Medical Event
Service You May Need
Your Cost If You Use
an In-Network
Provider
Your Cost If You Use
an Out-of-Network
Provider
Limitations & Exceptions
If your child needs
dental or eye care
Eye exam
Glasses
Not covered
Not covered
Not covered
Not covered
Eye exams and glasses are
reimbursable under the Family
Supplemental Benefit. You can
receive basic vision care at no
charge from the Operator’s Health
Center.
Dental check-up
No charge No charge Limited to 2 check-ups per year.
5 of 8
Summaries of Benefits and Coverage for MOE Health Plan Marketplace Options 13

Excluded Services & Other Covered Services:
Services Your Plan Does NOT Cover (This isn't a complete list. Check your policy or plan document for other excluded services.)
● Cosmetic surgery (Except for mastectomy, injuries
and to remove scar tissue)
● Hearing aids (Except for cochlear implants)
● Infertility treatment
● Long-term care
● Non-emergency care when traveling
outside the U.S.
● Private-duty nursing except transplant patients
● Routine foot care
● Weight loss programs
Other Covered Services (This isn't a complete list. Check your policy or plan document for other covered services and your costs for those
services.)
● Acupuncture ($125 per visit, 12 per year)
● Bariatric surgery (Prior authorization required)
● Chiropractic care (Limited to $60/visit and
24/visits per year) (manipulations and
necessary x-rays only)
● Dental care (Adult) ($1,000 annual limit)
● Routine eye care (Eligible for reimbursement
from Family Supplemental Benefit)
Your Rights to Continue Coverage:
If you lose coverage under the plan, then, depending upon the circumstances, Federal and State laws may provide protections that allow you to keep health
coverage. Any such rights may be limited in duration and will require you to pay a premium, which may be significantly higher than the premium you pay
while covered under the plan. Other limitations on your rights to continue coverage may also apply.
For more information on your rights to continue coverage, contact the plan at 1-708-482-7300. You may also contact your state insurance department, the
U.S. Department of Labor, Employee Benefits Security Administration at 1-866-444-3272 or www.dol.gov/ebsa, or the U.S. Department of Health and
Human Services at 1-877-267-2323 x61565 or www.cciio.cms.gov.
Your Grievance and Appeals Rights:
If you have a complaint or are dissatisfied with a denial of coverage for claims under your plan, you may be able to appeal or file a grievance. For
questions about your rights, this notice, or assistance, you can contact: (1) Administrative Manager, Midwest Operating Engineers Fringe Benefit Funds,
6150 Joliet Road, Countryside, IL 60525-3994, 1-708-482-7300; or (2) Department of Labor's Employee Benefits Security Administration at 1-866-444-
EBSA (3272) or www.dol.gov/ebsa/healthreform.
Does this Coverage Provide Minimum Essential Coverage?
The Affordable Care Act requires most people to have health care coverage that qualifies as “minimum essential coverage.” This plan or policy does
provide minimum essential coverage.
Does this Coverage Meet the Minimum Value Standard?
The Affordable Care Act establishes a minimum value standard of benefits of a health plan. The minimum value standard is 60% (actuarial value). This
health coverage does meet the minimum value standard for the benefits it provides.
Language Access Services:
SPANISH (Español): Para obtener asistencia en Español, llame al 1-708-482-7300.
–––––––––––––––––––––To see examples of how this plan might cover costs for a sample medical situation, see the next page.–––––––––––––––––––
6 of 8
Summaries of Benefits and Coverage for MOE Health Plan Marketplace Options 14

About these Coverage
Examples:
These examples show how this plan might cover
medical care in given situations. Use these
examples to see, in general, how much financial
protection a sample patient might get if they are
covered under different plans.
This is
not a cost
estimator.
Don’t use these examples to
estimate your actual costs
under this plan. The actual
care you receive will be
different from these examples,
and the cost of that care will
also be different.
See the next page for
important information about
these examples.
Having a baby
(normal delivery)
■ Amount owed to providers: $7,540
■ Plan pays $6,130
■ Patient pays $1,410
Managing type 2 diabetes
(routine maintenance of
a well-controlled condition)
■ Amount owed to providers: $5,400
■ Plan pays $4,320
■ Patient pays $1,080
Sample care costs:
Sample care costs:
Hospital charges (mother) $2,700 Prescriptions $2,900
Routine obstetric care $2,100 Medical Equipment and Supplies $1,300
Hospital charges (baby) $900 Office Visits and Procedures $700
Anesthesia $900 Education $300
Laboratory tests $500 Laboratory tests $100
Prescriptions $200 Vaccines, other preventive $100
Radiology $200 Total $5,400
Vaccines, other preventive $40
Total $7,540 Patient pays:
Deductibles $500
Patient pays: Co-pays $200
Deductibles $500 Co-insurance $300
Co-pays $10 Limits or exclusions $80
Co-insurance $700 Total $1,080
Limits or exclusions $200
Total $1,410
7 of 8
Summaries of Benefits and Coverage for MOE Health Plan Marketplace Options 15

Questions and answers about the Coverage Examples:
What are some of the
assumptions behind the
Coverage Examples?
●
●
●
●
●
●
●
Costs don’t include premiums.
Sample care costs are based on national
averages supplied by the U.S.
Department of Health and Human
Services, and aren’t specific to a
particular geographic area or health
plan.
The patient’s condition was not an
excluded or preexisting condition.
All services and treatments started and
ended in the same coverage period.
There are no other medical expenses for
any member covered under this plan.
Out-of-pocket expenses are based only
on treating the condition in the example.
The patient received all care from innetwork
providers. If the patient had
received care from out-of-network
providers, costs would have been
higher.
What does a Coverage Example
show?
For each treatment situation, the Coverage
Example helps you see how deductibles, copayments,
and co-insurance can add up. It
also helps you see what expenses might be left
up to you to pay because the service or
treatment isn’t covered or payment is limited.
Does the Coverage Example
predict my own care needs?
No. Treatments shown are just examples.
The care you would receive for this
condition could be different based on your
doctor’s advice, your age, how serious your
condition is, and many other factors.
Does the Coverage Example
predict my future expenses?
No. Coverage Examples are not cost
estimators. You can’t use the examples to
estimate costs for an actual condition. They
are for comparative purposes only. Your
own costs will be different depending on
the care you receive, the prices your
providers charge, and the reimbursement
your health plan allows.
Can I use Coverage Examples to
compare plans?
Yes. When you look at the Summary of
Benefits and Coverage for other plans,
you’ll find the same Coverage Examples.
When you compare plans, check the
“Patient Pays” box in each example. The
smaller that number, the more coverage
the plan provides.
Are there other costs I should
consider when comparing
plans?
Yes. An important cost is the premium
you pay. Generally, the lower your
premium, the more you’ll pay in out-ofpocket
costs, such as co-payments,
deductibles, and co-insurance. You
should also consider contributions to
accounts such as health savings accounts
(HSAs), flexible spending arrangements
(FSAs) or health reimbursement accounts
(HRAs) that help you pay out-of-pocket
expenses.
Questions: Call 1-708-482-7300 or visit us at www.moefunds.com.
If you aren’t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary 8 of 8
at www.dol.gov/ebsa/healthreform or call 1-708-482-7300 to request a copy.
Summaries of Benefits and Coverage for MOE Health Plan Marketplace Options 16

Midwest Operating Engineers: EPO (Modified HMO)
Summary of Benefits and Coverage: What this Plan Covers & What it Costs
Coverage Period: 04/01/2016 - 03/31/2017
Coverage for: Individual + Family | Plan Type: EPO
This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan
document at www.moefunds.com or by calling 1-708-482-7300.
Important Questions
What is the overall
deductible?
Are there other
deductibles for specific
services?
Answers
No deductible.
No.
Why this Matters:
See the chart starting on page 2 for your costs for services this plan covers.
You don’t have to meet deductibles for specific services, but see the chart starting on page 2
for other costs for services this plan covers.
Is there an out-ofpocket
limit on my
expenses?
Yes. In-Network Medical:
$4,000 person/$10,000 family;
In-Network Prescription Drugs:
$2,000 person/$3,200 family
The out-of-pocket limit is the most you could pay during a coverage period (usually one year)
for your share of the cost of covered services. This limit helps you plan for health care
expenses.
What is not included in
the out-of-pocket
limit?
Self-payments, balance billing,
health care this plan does not
cover, Family Supplemental
Benefit charges.
Even though you pay these expenses, they don’t count toward the out-of-pocket limit.
Is there an overall
annual limit on what the
plan pays?
Does this plan use a
network of providers?
No.
Yes. For a list of in-network
providers, call 1-800-810-2583.
The chart starting on page 2 describes any limits on what the plan will pay for specific covered
services, such as office visits.
If you use an in-network doctor or other health care provider, this plan will pay some or all of
the costs of covered services. Be aware, your in-network doctor or hospital may use an out-ofnetwork
provider for some services. Plans use the term in-network, preferred, or
participating for providers in their network. See the chart starting on page 2 for how this
plan pays different kinds of providers.
Questions: Call 1-708-482-7300 or visit us at www.moefunds.com.
If you aren’t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary 1 of 8
at www.dol.gov/ebsa/healthreform or call 1-708-482-7300 to request a copy.
Summaries of Benefits and Coverage for MOE Health Plan Marketplace Options 17

Important Questions Answers
Do I need a referral to see
a specialist?
Are there services this
Yes.
plan doesn’t cover?
Yes. You need a referral to see an
acupuncture specialist.
Why this Matters:
This plan will pay some or all of the costs to see a specialist for covered services but only
if you have the plan’s permission before you see the specialist.
Some of the services this plan doesn’t cover are listed on page 6. See your policy or plan
document for additional information about excluded services.
●
●
●
●
Co-payments are fixed dollar amounts (for example, $15) you pay for covered health care, usually when you receive the service.
Co-insurance is your share of the costs of a covered service, calculated as a percent of the allowed amount for the service. For example, if
the plan’s allowed amount for an overnight hospital stay is $1,000, your co-insurance payment of 20% would be $200. This may change if
you haven’t met your deductible.
The amount the plan pays for covered services is based on the allowed amount. If an out-of-network provider charges more than the
allowed amount, you may have to pay the difference. For example, if an out-of-network hospital charges $1,500 for an overnight stay and
the allowed amount is $1,000, you may have to pay the $500 difference. (This is called balance billing.)
This plan may encourage you to use in-network providers by charging you lower deductibles, co-payments and co-insurance amounts.
Common
Medical Event
If you visit a health
care provider's office
or clinic
Service You May Need
Primary care visit to treat an injury or
illness
Specialist visit
Other practitioner office visit
Preventive care/
screening/immunization
Your Cost If You Use
an In-Network
Provider
$20 co-pay/visit Not covered -- None --
$40 co-pay/visit Not covered -- None --
$20 co-pay/visit for
chiropractor
(manipulations and
necessary x-rays only) and
accupuncture
Your Cost If You Use
an Out-of-Network
Provider
Not covered
No charge Not covered -- None --
Limitations & Exceptions
Chiropractor: 24 visits/year up to
$60 visit & eligible only if over age
5; Acupuncture: 12 treatments/year
and $125/visit
2 of 8
Summaries of Benefits and Coverage for MOE Health Plan Marketplace Options 18

Common
Medical Event
If you have a test
If you need drugs to
treat your illness or
condition
More information
about prescription
drug coverage is
available at
www.caremark.com or
1-708-482-7300.
If you have
outpatient surgery
If you need
immediate medical
attention
If you have a hospital
stay
Service You May Need
Diagnostic test (x-ray, blood work)
Imaging (CT/PET scans, MRIs)
Generic drugs
Brand drugs
Maintenance Drugs (Limited to CVS
Pharmacy Stores or CVS Caremark
Mail Service Pharmacy Only)
Facility fee (e.g., ambulatory surgery
center)
Physician/surgeon fees
Emergency room services
Emergency medical transportation
Urgent care
Facility fee (e.g., hospital room)
Physician/surgeon fee
Your Cost If You Use
an In-Network
Provider
Provider
No charge Not covered -- None --
No charge Not covered -- None --
$5 co-pay per 30-day
supply retail/$15 co-pay
per 90-day supply mail
order
$10 co-pay per 30-day
supply retail/$30 co-pay
per 90-day supply mail
order
Not covered
Not covered
$15 co-pay per 90-day
supply generic/$30 co-pay Not covered
per 90-day supply brand
Your Cost If You Use
an Out-of-Network
$20 co-pay/visit Not covered -- None --
$20 co-pay/visit Not covered -- None --
$100 co-pay/visit $100 co-pay/visit -- None --
20% co-insurance Not covered
Transfer between inter-health
facilities limited to $5,000.
$20 co-pay/visit Not covered -- None --
$250 co-pay/admission Not covered
Room allowances based on semiprivate
room rate.
$250 co-pay/admission Not covered -- None --
Limitations & Exceptions
Maximum of up to two 30-day
supplies before a member is
required to obtain a 90-day supply.
Member seeking third refill must
transition to CVS Pharmacy or CVS
Caremark Mail Service Pharmacy,
or pay 100% of the cost of the
prescription drug. You must pay the
difference between the cost of a
brand and generic if a generic is
available. Certain specialty
medications are subject to preauthorization
requirements. Call the
phone number listed or visit
Caremark's website for more
information.
3 of 8
Summaries of Benefits and Coverage for MOE Health Plan Marketplace Options 19

Common
Medical Event
If you have mental
health, behavioral
health, or substance
abuse needs
If you are pregnant
Service You May Need
Mental/Behavioral health outpatient
services
Mental/Behavioral health inpatient
services
Substance use disorder outpatient
services
Substance use disorder inpatient
services
Prenatal and postnatal care
Delivery and all inpatient services
Home health care
Rehabilitation services
Your Cost If You Use
an In-Network
Provider
Your Cost If You Use
an Out-of-Network
Provider
$20 co-pay/visit Not covered -- None --
$250 co-pay/admission Not covered -- None --
$20 co-pay/visit Not covered -- None --
$250 co-pay/admission Not covered -- None --
$20 co-pay/visit Not covered -- None --
$250 co-pay/admission Not covered -- None --
Limitations & Exceptions
$20 co-pay/visit Not covered Case manager must pre-approve.
$20 co-pay/visit Not covered Case manager must pre-approve.
Habilitation services
$20 co-pay/visit Not covered
Case manager must pre-approve.
Limit 25 visits/year: speech therapy
for kids (age 2-18) with congenital
neurological disorder.
If you need help
recovering or have
other special health
needs
Skilled nursing care
$250 co-pay/admission Not covered
45-day limit per confinement; must
be recommended by physician and
begin within 30 days of hospital
confinement; not covered if not preapproved.
Durable medical equipment
20% co-insurance Not covered $15,000 limit/electric wheelchair
Hospice service
$250 co-pay/admission
$20 co-pay/visit by a
nurse when outpatient at
home
Not covered
Case manager must pre-approve.
4 of 8
Summaries of Benefits and Coverage for MOE Health Plan Marketplace Options 20

Common
Medical Event
Service You May Need
Your Cost If You Use
an In-Network
Provider
Your Cost If You Use
an Out-of-Network
Provider
Limitations & Exceptions
If your child needs
dental or eye care
Eye exam
Glasses
Not covered
Not covered
Not covered
Not covered
Eye exams and glasses are
reimbursable under the Family
Supplemental Benefit. You can
receive basic vision care at no
charge from the Operator’s Health
Center.
Dental check-up
No charge No charge Limited to 2 check-ups per year.
5 of 8
Summaries of Benefits and Coverage for MOE Health Plan Marketplace Options 21

Excluded Services & Other Covered Services:
Services Your Plan Does NOT Cover (This isn't a complete list. Check your policy or plan document for other excluded services.)
● Cosmetic surgery (Except for mastectomy, injuries
and to remove scar tissue)
● Hearing aids (Except for cochlear implants)
● Infertility treatment
● Long-term care
● Non-emergency care when traveling
outside the U.S.
● Private-duty nursing except transplant patients
● Routine foot care
● Weight loss programs
Other Covered Services (This isn't a complete list. Check your policy or plan document for other covered services and your costs for those
services.)
● Acupuncture ($125 per visit, 12 per year)
● Bariatric surgery (Prior authorization required)
● Chiropractic care (Limited to $60/visit and
24/visits per year) (manipulations and
necessary x-rays only)
● Dental care (Adult) ($1,000 annual limit)
● Routine eye care (Eligible for reimbursement
from Family Supplemental Benefit)
Your Rights to Continue Coverage:
If you lose coverage under the plan, then, depending upon the circumstances, Federal and State laws may provide protections that allow you to keep health
coverage. Any such rights may be limited in duration and will require you to pay a premium, which may be significantly higher than the premium you pay
while covered under the plan. Other limitations on your rights to continue coverage may also apply.
For more information on your rights to continue coverage, contact the plan at 1-708-482-7300. You may also contact your state insurance department, the
U.S. Department of Labor, Employee Benefits Security Administration at 1-866-444-3272 or www.dol.gov/ebsa, or the U.S. Department of Health and
Human Services at 1-877-267-2323 x61565 or www.cciio.cms.gov.
Your Grievance and Appeals Rights:
If you have a complaint or are dissatisfied with a denial of coverage for claims under your plan, you may be able to appeal or file a grievance. For
questions about your rights, this notice, or assistance, you can contact: (1) Administrative Manager, Midwest Operating Engineers Fringe Benefit Funds,
6150 Joliet Road, Countryside, IL 60525-3994, 1-708-482-7300; or (2) Department of Labor's Employee Benefits Security Administration at 1-866-444-
EBSA (3272) or www.dol.gov/ebsa/healthreform.
Does this Coverage Provide Minimum Essential Coverage?
The Affordable Care Act requires most people to have health care coverage that qualifies as “minimum essential coverage.” This plan or policy does
provide minimum essential coverage.
Does this Coverage Meet the Minimum Value Standard?
The Affordable Care Act establishes a minimum value standard of benefits of a health plan. The minimum value standard is 60% (actuarial value). This
health coverage does meet the minimum value standard for the benefits it provides.
Language Access Services:
SPANISH (Español): Para obtener asistencia en Español, llame al 1-708-482-7300.
–––––––––––––––––––––To see examples of how this plan might cover costs for a sample medical situation, see the next page.–––––––––––––––––––
6 of 8
Summaries of Benefits and Coverage for MOE Health Plan Marketplace Options 22

About these Coverage
Examples:
These examples show how this plan might cover
medical care in given situations. Use these
examples to see, in general, how much financial
protection a sample patient might get if they are
covered under different plans.
This is
not a cost
estimator.
Don’t use these examples to
estimate your actual costs
under this plan. The actual
care you receive will be
different from these examples,
and the cost of that care will
also be different.
See the next page for
important information about
these examples.
Having a baby
(normal delivery)
■ Amount owed to providers: $7,540
■ Plan pays $6,840
■ Patient pays $700
Managing type 2 diabetes
(routine maintenance of
a well-controlled condition)
■ Amount owed to providers: $5,400
■ Plan pays $4,620
■ Patient pays $780
Sample care costs:
Sample care costs:
Hospital charges (mother) $2,700 Prescriptions $2,900
Routine obstetric care $2,100 Medical Equipment and Supplies $1,300
Hospital charges (baby) $900 Office Visits and Procedures $700
Anesthesia $900 Education $300
Laboratory tests $500 Laboratory tests $100
Prescriptions $200 Vaccines, other preventive $100
Radiology $200 Total $5,400
Vaccines, other preventive $40
Total $7,540 Patient pays:
Deductibles $0
Patient pays: Co-pays $400
Deductibles $0 Co-insurance $300
Co-pays $500 Limits or exclusions $80
Co-insurance $0 Total $780
Limits or exclusions $200
Total $700
7 of 8
Summaries of Benefits and Coverage for MOE Health Plan Marketplace Options 23

Questions and answers about the Coverage Examples:
What are some of the
assumptions behind the
Coverage Examples?
●
●
●
●
●
●
●
Costs don’t include premiums.
Sample care costs are based on national
averages supplied by the U.S.
Department of Health and Human
Services, and aren’t specific to a
particular geographic area or health
plan.
The patient’s condition was not an
excluded or preexisting condition.
All services and treatments started and
ended in the same coverage period.
There are no other medical expenses for
any member covered under this plan.
Out-of-pocket expenses are based only
on treating the condition in the example.
The patient received all care from innetwork
providers. If the patient had
received care from out-of-network
providers, costs would have been
higher.
What does a Coverage Example
show?
For each treatment situation, the Coverage
Example helps you see how deductibles, copayments,
and co-insurance can add up. It
also helps you see what expenses might be left
up to you to pay because the service or
treatment isn’t covered or payment is limited.
Does the Coverage Example
predict my own care needs?
No. Treatments shown are just examples.
The care you would receive for this
condition could be different based on your
doctor’s advice, your age, how serious your
condition is, and many other factors.
Does the Coverage Example
predict my future expenses?
No. Coverage Examples are not cost
estimators. You can’t use the examples to
estimate costs for an actual condition. They
are for comparative purposes only. Your
own costs will be different depending on
the care you receive, the prices your
providers charge, and the reimbursement
your health plan allows.
Can I use Coverage Examples to
compare plans?
Yes. When you look at the Summary of
Benefits and Coverage for other plans,
you’ll find the same Coverage Examples.
When you compare plans, check the
“Patient Pays” box in each example. The
smaller that number, the more coverage
the plan provides.
Are there other costs I should
consider when comparing
plans?
Yes. An important cost is the premium
you pay. Generally, the lower your
premium, the more you’ll pay in out-ofpocket
costs, such as co-payments,
deductibles, and co-insurance. You
should also consider contributions to
accounts such as health savings accounts
(HSAs), flexible spending arrangements
(FSAs) or health reimbursement accounts
(HRAs) that help you pay out-of-pocket
expenses.
Questions: Call 1-708-482-7300 or visit us at www.moefunds.com.
If you aren’t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary 8 of 8
at www.dol.gov/ebsa/healthreform or call 1-708-482-7300 to request a copy.
Summaries of Benefits and Coverage for MOE Health Plan Marketplace Options 24

Midwest Operating Engineers: Gold
Summary of Benefits and Coverage: What this Plan Covers & What it Cost
Coverage Period: 04/01/2016 - 03/31/2017
Coverage for: Individual + Family | Plan Type: PPO
This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan
document at www.moefunds.com or by calling 1-708-482-7300.
Important Questions
What is the overall
deductible?
Are there other
deductibles for specific
services?
Answers
In-Network: $1,000 person/$2,500
family; Out-of-Network: $2,000
person/$5,000 family. Prescription
drugs, durable medical equipment, TMJ,
balance billing, excluded services do not
count toward the deductible.
No.
Why this Matters:
You must pay all the costs up to the deductible amount before this plan begins to pay
for covered services you use. Check your policy or plan document to see when the
deductible starts over (usually, but not always, January 1st). See the chart starting on
page 2 for how much you pay for covered services after you meet the deductible.
You don’t have to meet deductibles for specific services, but see the chart starting on
page 2 for other costs for services this plan covers.
Is there an out-ofpocket
limit on my
expenses?
Yes. In-Network Medical: $4,000
person/$8,000 family; Out-of-Network
Medical: $8,000 person/$16,000
family. In-Network Prescription Drugs:
$2,000 person/$4,000 family. Out-of-
Network Prescription Drugs: $4,000
person/$8,000 family.
The out-of-pocket limit is the most you could pay during a coverage period (usually one
year) for your share of the cost of covered services. This limit helps you plan for health
care expenses.
What is not included in
the out-of-pocket
limit?
Self-payments, balance billing, health
care this plan does not cover, Family
Supplemental Benefit charges.
Even though you pay these expenses, they don’t count toward the out-of-pocket limit.
Is there an overall
annual limit on what the
plan pays?
No.
The chart starting on page 2 describes any limits on what the plan will pay for specific
covered services, such as office visits.
Questions: Call 1-708-482-7300 or visit us at www.moefunds.com.
If you aren’t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary 1 of 8
at www.dol.gov/ebsa/healthreform or call 1-708-482-7300 to request a copy.
Summaries of Benefits and Coverage for MOE Health Plan Marketplace Options 25

Important Questions Answers Why this Matters:
Does this plan use a
network of providers?
Do I need a referral to see
a specialist?
Are there services this
plan doesn’t cover?
Yes. For a list of in-network
providers, call 1-800-810-2583.
Yes. You need a referral to see an
acupuncture specialist.
Yes.
If you use an in-network doctor or other health care provider, this plan will pay some or all
of the costs of covered services. Be aware, your in-network doctor or hospital may use an
out-of-network provider for some services. Plans use the term in-network, preferred, or
participating for providers in their network. See the chart starting on page 2 for how this
plan pays different kinds of providers.
This plan will pay some or all of the costs to see a specialist for covered services but only
if you have the plan’s permission before you see the specialist.
Some of the services this plan doesn’t cover are listed on page 6. See your policy or plan
document for additional information about excluded services.
●
●
●
●
Co-payments are fixed dollar amounts (for example, $15) you pay for covered health care, usually when you receive the service.
Co-insurance is your share of the costs of a covered service, calculated as a percent of the allowed amount for the service. For example, if
the plan’s allowed amount for an overnight hospital stay is $1,000, your co-insurance payment of 20% would be $200. This may change if
you haven’t met your deductible.
The amount the plan pays for covered services is based on the allowed amount. If an out-of-network provider charges more than the
allowed amount, you may have to pay the difference. For example, if an out-of-network hospital charges $1,500 for an overnight stay and
the allowed amount is $1,000, you may have to pay the $500 difference. (This is called balance billing.)
This plan may encourage you to use in-network providers by charging you lower deductibles, co-payments and co-insurance amounts.
Common
Medical Event
Service You May Need
Primary care visit to treat an injury or
illness
Specialist visit
Your Cost If You Use
an In-Network
Provider
Your Cost If You Use
an Out-of-Network
Provider
20% co-insurance 40% co-insurance -- None --
20% co-insurance 40% co-insurance -- None --
Limitations & Exceptions
If you visit a health
care provider's office
or clinic
Other practitioner office visit
20% co-insurance for
chiropractor
(manipulations and
necessary x-rays only),
acupuncture
40% co-insurance for
chiropractor
(manipulations and
necessary x-rays only),
acupuncture
Chiropractor: 24 visits/year up to
$60/visit & eligible only if over age
5; Acupuncture: 12
treatments/year up to $125 visit.
Preventive care/
screening/immunization
No charge Not covered -- None --
2 of 8
Summaries of Benefits and Coverage for MOE Health Plan Marketplace Options 26

Common
Medical Event
If you have a test
Service You May Need
Diagnostic test (x-ray, blood work)
Imaging (CT/PET scans, MRIs)
Your Cost If You Use
an In-Network
Provider
Your Cost If You Use
an Out-of-Network
Provider
20% co-insurance/test 40% co-insurance/test -- None --
20% co-insurance/test; no
charge if scan is
authorized by AIM
40% co-insurance/test -- None --
Limitations & Exceptions
If you need drugs to
treat your illness or
condition
More information
about prescription
drug coverage is
available at
www.caremark.com or
1-708-482-7300.
Generic drugs
Brand drugs
Maintenance Drugs (Limited to CVS
Pharmacy Stores or CVS Caremark Mail
Service Pharmacy Only)
$5 co-pay per 30-day
supply retail/$15 co-pay
per 90-day supply mail
order
$10 co-pay per 30-day
supply retail/$30 co-pay
per 90-day supply mail
order
Not covered
Not covered
$15 co-pay per 90-day Not covered
supply generic/$30 co-pay
per 90-day supply brand
name
Maximum of up to two 30-day
supplies before a member is
required to obtain a 90-day supply.
Member seeking third refill must
transition to CVS Pharmacy or
CVS Caremark Mail Service
Pharmacy, or pay 100% of the cost
of the prescription drug. You must
pay the difference between the
cost of a brand and generic if a
generic is available. Certain
specialty medications are subject to
pre-authorization requirements.
Call the phone number listed or
visit Caremark's website for more
information.
If you have
outpatient surgery
If you need
immediate medical
attention
Facility fee (e.g., ambulatory surgery
center)
Physician/surgeon fees
Emergency room services
Emergency medical transportation
Urgent care
20% co-insurance 40% co-insurance Licensed facilities only.
20% co-insurance 40% co-insurance -- None --
$100 co-pay per visit; 20%
co-insurance
$100 co-pay per visit; 20%
co-insurance
-- None --
20% co-insurance 40% co-insurance
Transfer between inter-health
facilities limited to $5,000.
20% co-insurance 40% co-insurance -- None --
3 of 8
Summaries of Benefits and Coverage for MOE Health Plan Marketplace Options 27

Common
Medical Event
Service You May Need
Your Cost If You Use
an In-Network
Provider
Your Cost If You Use
an Out-of-Network
Provider
Limitations & Exceptions
If you have a hospital
stay
Facility fee (e.g., hospital room)
Physician/surgeon fee
20% co-insurance 40% co-insurance
20% co-insurance 40% co-insurance -- None --
Room allowances based on semiprivate
room rate.
Mental/Behavioral health outpatient
services
20% co-insurance/office
visit, 20% co-insurance
other outpatient services
40% co-insurance/office
visit, 40% co-insurance
other outpatient services
-- None --
If you have mental
health, behavioral
health, or substance
abuse needs
Mental/Behavioral health inpatient
services
Substance use disorder outpatient
services
20% co-insurance 40% co-insurance -- None --
20% co-insurance/office
visit, 20% co-insurance
other outpatient services
40% co-insurance/office
visit, 40% co-insurance
other outpatient services
-- None --
If you are pregnant
If you need help
recovering or have
other special health
needs
Substance use disorder inpatient services
Prenatal and postnatal care
Delivery and all inpatient services
Home health care
Rehabilitation services
Habilitation services
Skilled nursing care
Durable medical equipment
Hospice service
20% co-insurance 40% co-insurance -- None --
20% co-insurance 40% co-insurance -- None --
20% co-insurance 40% co-insurance -- None --
20% co-insurance 40% co-insurance Case manager must pre-approve.
20% co-insurance 40% co-insurance Case manager must pre-approve.
20% co-insurance 40% co-insurance
Case manager must pre-approve.
Limit 25 visits per calendar year:
speech therapy for kids (age 2-18)
with congenital neurological
disorder.
20% co-insurance 40% co-insurance
45-day limit per confinement; must
be recommended by physician and
begin within 30 days of hospital
confinement; not covered if not
pre-approved.
40% co-insurance 40% co-insurance $15,000 limit/electric wheelchair.
20% co-insurance 40% co-insurance Case manager must pre-approve.
4 of 8
Summaries of Benefits and Coverage for MOE Health Plan Marketplace Options 28

Common
Medical Event
Service You May Need
Your Cost If You Use
an In-Network
Provider
Your Cost If You Use
an Out-of-Network
Provider
Limitations & Exceptions
If your child needs
dental or eye care
Eye exam
Glasses
Not covered
Not covered
Not covered
Not covered
Eye exams and glasses are
reimbursable under the Family
Supplemental Benefit. You can
receive basic vision care at no
charge from the Operator’s Health
Center.
Dental check-up
No charge No charge Limited to 2 check-ups per year.
5 of 8
Summaries of Benefits and Coverage for MOE Health Plan Marketplace Options 29

Excluded Services & Other Covered Services:
Services Your Plan Does NOT Cover (This isn't a complete list. Check your policy or plan document for other excluded services.)
● Cosmetic surgery (Except for mastectomy, injuries
and to remove scar tissue)
● Hearing aids (Except for cochlear implants)
● Infertility treatment
● Long-term care
● Non-emergency care when traveling
outside the U.S.
● Private-duty nursing except transplant patients
● Routine foot care
● Weight loss programs
Other Covered Services (This isn't a complete list. Check your policy or plan document for other covered services and your costs for those
services.)
● Acupuncture ($125 per visit, 12 per year)
● Bariatric surgery (Prior authorization required)
● Chiropractic care (Limited to $60/visit and
24/visits per year) (manipulations and necessary
x-rays only)
● Dental care (Adult) ($1,000 annual limit)
● Routine eye care (Eligible for reimbursement
from Family Supplemental Benefit)
Your Rights to Continue Coverage:
If you lose coverage under the plan, then, depending upon the circumstances, Federal and State laws may provide protections that allow you to keep health
coverage. Any such rights may be limited in duration and will require you to pay a premium, which may be significantly higher than the premium you pay
while covered under the plan. Other limitations on your rights to continue coverage may also apply.
For more information on your rights to continue coverage, contact the plan at 1-708-482-7300. You may also contact your state insurance department, the
U.S. Department of Labor, Employee Benefits Security Administration at 1-866-444-3272 or www.dol.gov/ebsa, or the U.S. Department of Health and
Human Services at 1-877-267-2323 x61565 or www.cciio.cms.gov.
Your Grievance and Appeals Rights:
If you have a complaint or are dissatisfied with a denial of coverage for claims under your plan, you may be able to appeal or file a grievance. For
questions about your rights, this notice, or assistance, you can contact: (1) Administrative Manager, Midwest Operating Engineers Fringe Benefit Funds,
6150 Joliet Road, Countryside, IL 60525-3994, 1-708-482-7300; or (2) Department of Labor's Employee Benefits Security Administration at 1-866-444-
EBSA (3272) or www.dol.gov/ebsa/healthreform.
Does this Coverage Provide Minimum Essential Coverage?
The Affordable Care Act requires most people to have health care coverage that qualifies as “minimum essential coverage.” This plan or policy does
provide minimum essential coverage.
Does this Coverage Meet the Minimum Value Standard?
The Affordable Care Act establishes a minimum value standard of benefits of a health plan. The minimum value standard is 60% (actuarial value). This
health coverage does meet the minimum value standard for the benefits it provides.
Language Access Services:
SPANISH (Español): Para obtener asistencia en Español, llame al 1-708-482-7300.
–––––––––––––––––––––To see examples of how this plan might cover costs for a sample medical situation, see the next page.–––––––––––––––––––
6 of 8
Summaries of Benefits and Coverage for MOE Health Plan Marketplace Options 30

About these Coverage
Examples:
These examples show how this plan might cover
medical care in given situations. Use these
examples to see, in general, how much financial
protection a sample patient might get if they are
covered under different plans.
This is
not a cost
estimator.
Don’t use these examples to
estimate your actual costs
under this plan. The actual
care you receive will be
different from these examples,
and the cost of that care will
also be different.
See the next page for
important information about
these examples.
Having a baby
(normal delivery)
■ Amount owed to providers: $7,540
■ Plan pays $5,030
■ Patient pays $2,510
Managing type 2 diabetes
(routine maintenance of
a well-controlled condition)
■ Amount owed to providers: $5,400
■ Plan pays $3,620
■ Patient pays $1,780
Sample care costs:
Sample care costs:
Hospital charges (mother) $2,700 Prescriptions $2,900
Routine obstetric care $2,100 Medical Equipment and Supplies $1,300
Hospital charges (baby) $900 Office Visits and Procedures $700
Anesthesia $900 Education $300
Laboratory tests $500 Laboratory tests $100
Prescriptions $200 Vaccines, other preventive $100
Radiology $200 Total $5,400
Vaccines, other preventive $40
Total $7,540 Patient pays:
Deductibles $1,000
Patient pays: Co-pays $200
Deductibles $1,000 Co-insurance $500
Co-pays $10 Limits or exclusions $80
Co-insurance $1,300 Total $1,780
Limits or exclusions $200
Total $2,510
7 of 8
Summaries of Benefits and Coverage for MOE Health Plan Marketplace Options 31

Questions and answers about the Coverage Examples:
What are some of the
assumptions behind the
Coverage Examples?
●
●
●
●
●
●
●
Costs don’t include premiums.
Sample care costs are based on national
averages supplied by the U.S.
Department of Health and Human
Services, and aren’t specific to a
particular geographic area or health
plan.
The patient’s condition was not an
excluded or preexisting condition.
All services and treatments started and
ended in the same coverage period.
There are no other medical expenses for
any member covered under this plan.
Out-of-pocket expenses are based only
on treating the condition in the example.
The patient received all care from innetwork
providers. If the patient had
received care from out-of-network
providers, costs would have been
higher.
What does a Coverage Example
show?
For each treatment situation, the Coverage
Example helps you see how deductibles, copayments,
and co-insurance can add up. It
also helps you see what expenses might be left
up to you to pay because the service or
treatment isn’t covered or payment is limited.
Does the Coverage Example
predict my own care needs?
No. Treatments shown are just examples.
The care you would receive for this
condition could be different based on your
doctor’s advice, your age, how serious your
condition is, and many other factors.
Does the Coverage Example
predict my future expenses?
No. Coverage Examples are not cost
estimators. You can’t use the examples to
estimate costs for an actual condition. They
are for comparative purposes only. Your
own costs will be different depending on
the care you receive, the prices your
providers charge, and the reimbursement
your health plan allows.
Can I use Coverage Examples to
compare plans?
Yes. When you look at the Summary of
Benefits and Coverage for other plans,
you’ll find the same Coverage Examples.
When you compare plans, check the
“Patient Pays” box in each example. The
smaller that number, the more coverage
the plan provides.
Are there other costs I should
consider when comparing
plans?
Yes. An important cost is the premium
you pay. Generally, the lower your
premium, the more you’ll pay in out-ofpocket
costs, such as co-payments,
deductibles, and co-insurance. You
should also consider contributions to
accounts such as health savings accounts
(HSAs), flexible spending arrangements
(FSAs) or health reimbursement accounts
(HRAs) that help you pay out-of-pocket
expenses.
Questions: Call 1-708-482-7300 or visit us at www.moefunds.com.
If you aren’t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary 8 of 8
at www.dol.gov/ebsa/healthreform or call 1-708-482-7300 to request a copy.
Summaries of Benefits and Coverage for MOE Health Plan Marketplace Options 32

Midwest Operating Engineers: Silver
Summary of Benefits and Coverage: What this Plan Covers & What it Costs
Coverage Period: 04/01/2016 - 03/31/2017
Coverage for: Individual + Family | Plan Type: PPO
This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan
document at www.moefunds.com or by calling 1-708-482-7300.
Important Questions
What is the overall
deductible?
Are there other
deductibles for specific
services?
Answers
In-Network: $2,000 person/$5,000
family; Out-of-Network: $4,000
person/$10,000 family. Prescription
drugs, durable medical equipment, TMJ,
balance billing, excluded services do not
count toward the deductible.
No.
Why this Matters:
You must pay all the costs up to the deductible amount before this plan begins to pay
for covered services you use. Check your policy or plan document to see when the
deductible starts over (usually, but not always, January 1st). See the chart starting on
page 2 for how much you pay for covered services after you meet the deductible.
You don’t have to meet deductibles for specific services, but see the chart starting on
page 2 for other costs for services this plan covers.
Is there an out-ofpocket
limit on my
expenses?
Yes. In-Network Medical: $4,000
person/$8,000 family; Out-of-Network
Medical: $8,000 person/$16,000 family. The out-of-pocket limit is the most you could pay during a coverage period (usually
In-Network Prescription Drugs: $2,000 one year) for your share of the cost of covered services. This limit helps you plan for
person/$4,000 family; Out-of-Network health care expenses.
Prescription Drugs: $4,000
person/$8,000 family.
What is not included in
the out-of-pocket
limit?
Self-payments, balance billing, health care
this plan does not cover, Family
Supplemental Benefit charges.
Even though you pay these expenses, they don’t count toward the out-of-pocket limit.
Is there an overall
annual limit on what the
plan pays?
No.
The chart starting on page 2 describes any limits on what the plan will pay for specific
covered services, such as office visits.
Questions: Call 1-708-482-7300 or visit us at www.moefunds.com.
If you aren’t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary 1 of 8
at www.dol.gov/ebsa/healthreform or call 1-708-482-7300 to request a copy.
Summaries of Benefits and Coverage for MOE Health Plan Marketplace Options 33

Important Questions Answers Why this Matters:
Does this plan use a
network of providers?
Do I need a referral to see
a specialist?
Are there services this
plan doesn’t cover?
Yes. For a list of in-network
providers, call 1-800-810-2583.
Yes. You need a referral to see an
acupuncture specialist.
Yes.
If you use an in-network doctor or other health care provider, this plan will pay some or all
of the costs of covered services. Be aware, your in-network doctor or hospital may use an
out-of-network provider for some services. Plans use the term in-network, preferred, or
participating for providers in their network. See the chart starting on page 2 for how this
plan pays different kinds of providers.
This plan will pay some or all of the costs to see a specialist for covered services but only
if you have the plan’s permission before you see the specialist.
Some of the services this plan doesn’t cover are listed on page 6. See your policy or plan
document for additional information about excluded services.
●
●
●
●
Co-payments are fixed dollar amounts (for example, $15) you pay for covered health care, usually when you receive the service.
Co-insurance is your share of the costs of a covered service, calculated as a percent of the allowed amount for the service. For example, if
the plan’s allowed amount for an overnight hospital stay is $1,000, your co-insurance payment of 20% would be $200. This may change if
you haven’t met your deductible.
The amount the plan pays for covered services is based on the allowed amount. If an out-of-network provider charges more than the
allowed amount, you may have to pay the difference. For example, if an out-of-network hospital charges $1,500 for an overnight stay and
the allowed amount is $1,000, you may have to pay the $500 difference. (This is called balance billing.)
This plan may encourage you to use in-network providers by charging you lower deductibles, co-payments and co-insurance amounts.
Common
Medical Event
If you visit a health
care provider's office
or clinic
Service You May Need
Primary care visit to treat an injury or
illness
Specialist visit
Other practitioner office visit
Preventive care/
screening/immunization
Your Cost If You Use
an In-Network
Provider
30% co-insurance 50% co-insurance -- None --
30% co-insurance 50% co-insurance -- None --
30% co-insurance for
chiropractor
(manipulations and
necessary x-rays only),
acupuncture
Your Cost If You Use
an Out-of-Network
Provider
50% co-insurance for
chiropractor
(manipulations and
necessary x-rays only),
acupuncture
No charge Not covered -- None --
Limitations & Exceptions
Chiropractor: 24 visits/year up to
$60/visit & eligible only if over age
5; Acupuncture: 12
treatments/year up to $125/visit.
2 of 8
Summaries of Benefits and Coverage for MOE Health Plan Marketplace Options 34

Common
Medical Event
If you have a test
Service You May Need
Diagnostic test (x-ray, blood work)
Imaging (CT/PET scans, MRIs)
Your Cost If You Use
an In-Network
Provider
Your Cost If You Use
an Out-of-Network
Provider
30% co-insurance/test 50% co-insurance/test -- None --
30% co-insurance/test; no
charge if scan is
authorized by AIM
50% co-insurance/test -- None --
Limitations & Exceptions
If you need drugs to
treat your illness or
condition
More information
about prescription
drug coverage is
available at
www.caremark.com or
1-708-482-7300.
Generic drugs
Brand drugs
Maintenance Drugs (Limited to CVS
Pharmacy Stores or CVS Caremark Mail
Service Pharmacy Only)
$5 co-pay per 30-day
supply retail/$15 co-pay
per 90-day supply mail
order
$10 co-pay per 30-day
supply retail/$30 co-pay
per 90-day supply mail
order
$15 co-pay generic per 90-
day supply/$30 co-pay
per 90-day supply brand
Not covered
Not covered
Not covered
Maximum of up to two 30-day
supplies before a member is
required to obtain a 90-day supply.
Member seeking third refill must
transition to CVS Pharmacy or
CVS Caremark Mail Service
Pharmacy, or pay 100% of the cost
of the prescription drug. You must
pay the difference between the
cost of a brand and generic if a
generic is available. Certain
specialty medications are subject to
pre-authorization requirements.
Call the phone number listed or
visit Caremark's website for more
information.
If you have
outpatient surgery
If you need
immediate medical
attention
Facility fee (e.g., ambulatory surgery
center)
Physician/surgeon fees
Emergency room services
Emergency medical transportation
Urgent care
30% co-insurance 50% co-insurance Licensed facilities only.
30% co-insurance 50% co-insurance -- None --
$100 co-pay per visit; 30%
co-insurance
$100 co-pay per visit; 30%
co-insurance
-- None --
30% co-insurance 50% co-insurance
Transfer between inter-health
facilities limited to $5,000.
30% co-insurance 50% co-insurance -- None --
If you have a hospital
stay
Facility fee (e.g., hospital room)
Physician/surgeon fee
30% co-insurance 50% co-insurance
Room allowances based on semiprivate
room rate.
30% co-insurance 50% co-insurance -- None --
3 of 8
Summaries of Benefits and Coverage for MOE Health Plan Marketplace Options 35

Common
Medical Event
Service You May Need
Your Cost If You Use
an In-Network
Provider
Your Cost If You Use
an Out-of-Network
Provider
Limitations & Exceptions
Mental/Behavioral health outpatient
services
30% co-insurance/office
visit, 30% co-insurance
other outpatient services
50% co-insurance/office
visit, 50% co-insurance
other outpatient services
-- None --
If you have mental
health, behavioral
health, or substance
abuse needs
If you are pregnant
If you need help
recovering or have
other special health
needs
Mental/Behavioral health inpatient
services
Substance use disorder outpatient
services
Substance use disorder inpatient services
Prenatal and postnatal care
Delivery and all inpatient services
Home health care
Rehabilitation services
Habilitation services
Skilled nursing care
Durable medical equipment
Hospice service
30% co-insurance 50% co-insurance -- None --
30% co-insurance/office
visit, 30% co-insurance
other outpatient services
50% co-insurance/office
visit, 50% co-insurance
other outpatient services
-- None --
30% co-insurance 50% co-insurance -- None --
30% co-insurance 50% co-insurance -- None --
30% co-insurance 50% co-insurance -- None --
30% co-insurance 50% co-insurance Case manager must pre-approve.
30% co-insurance 50% co-insurance Case manager must pre-approve.
30% co-insurance 50% co-insurance
Case manager must pre-approve.
Limit 25 visits per calendar year:
speech therapy for kids (age 2-18)
with congenital neurological
disorder.
30% co-insurance 50% co-insurance
45-day limit per confinement; must
be recommended by physician and
begin within 30 days of hospital
confinement; not covered if not
pre-approved.
50% co-insurance 50% co-insurance $15,000 limit/electric wheelchair.
30% co-insurance 50% co-insurance Case manager must pre-approve.
4 of 8
Summaries of Benefits and Coverage for MOE Health Plan Marketplace Options 36

Common
Medical Event
Service You May Need
Your Cost If You Use
an In-Network
Provider
Your Cost If You Use
an Out-of-Network
Provider
Limitations & Exceptions
If your child needs
dental or eye care
Eye exam
Glasses
Not covered
Not covered
Not covered
Not covered
Eye exams and glasses are
reimbursable under the Family
Supplemental Benefit. You can
receive basic vision care at no
charge from the Operator’s Health
Center.
Dental check-up
No charge No charge Limited to 2 check-ups per year.
5 of 8
Summaries of Benefits and Coverage for MOE Health Plan Marketplace Options 37

Excluded Services & Other Covered Services:
Services Your Plan Does NOT Cover (This isn't a complete list. Check your policy or plan document for other excluded services.)
● Cosmetic surgery (Except for mastectomy, injuries
and to remove scar tissue)
● Hearing aids (Except for cochlear implants)
● Infertility treatment
● Long-term care
● Non-emergency care when traveling
outside the U.S.
● Private-duty nursing except transplant patients
● Routine foot care
● Weight loss programs
Other Covered Services (This isn't a complete list. Check your policy or plan document for other covered services and your costs for those
services.)
● Acupuncture ($125 per visit, 12 per year)
● Bariatric surgery (Prior authorization required)
● Chiropractic care (Limited to $60/visit and
24/visits per year) (manipulations and necessary
x-rays only)
● Dental care (Adult) ($1,000 annual limit)
● Routine eye care (Eligible for reimbursement
from Family Supplemental Benefit)
Your Rights to Continue Coverage:
If you lose coverage under the plan, then, depending upon the circumstances, Federal and State laws may provide protections that allow you to keep health
coverage. Any such rights may be limited in duration and will require you to pay a premium, which may be significantly higher than the premium you pay
while covered under the plan. Other limitations on your rights to continue coverage may also apply.
For more information on your rights to continue coverage, contact the plan at 1-708-482-7300. You may also contact your state insurance department, the
U.S. Department of Labor, Employee Benefits Security Administration at 1-866-444-3272 or www.dol.gov/ebsa, or the U.S. Department of Health and
Human Services at 1-877-267-2323 x61565 or www.cciio.cms.gov.
Your Grievance and Appeals Rights:
If you have a complaint or are dissatisfied with a denial of coverage for claims under your plan, you may be able to appeal or file a grievance. For
questions about your rights, this notice, or assistance, you can contact: (1) Administrative Manager, Midwest Operating Engineers Fringe Benefit Funds,
6150 Joliet Road, Countryside, IL 60525-3994, 1-708-482-7300; or (2) Department of Labor's Employee Benefits Security Administration at 1-866-444-
EBSA (3272) or www.dol.gov/ebsa/healthreform.
Does this Coverage Provide Minimum Essential Coverage?
The Affordable Care Act requires most people to have health care coverage that qualifies as “minimum essential coverage.” This plan or policy does
provide minimum essential coverage.
Does this Coverage Meet the Minimum Value Standard?
The Affordable Care Act establishes a minimum value standard of benefits of a health plan. The minimum value standard is 60% (actuarial value). This
health coverage does meet the minimum value standard for the benefits it provides.
Language Access Services:
SPANISH (Español): Para obtener asistencia en Español, llame al 1-708-482-7300.
–––––––––––––––––––––To see examples of how this plan might cover costs for a sample medical situation, see the next page.–––––––––––––––––––
6 of 8
Summaries of Benefits and Coverage for MOE Health Plan Marketplace Options 38

About these Coverage
Examples:
These examples show how this plan might cover
medical care in given situations. Use these
examples to see, in general, how much financial
protection a sample patient might get if they are
covered under different plans.
This is
not a cost
estimator.
Don’t use these examples to
estimate your actual costs
under this plan. The actual
care you receive will be
different from these examples,
and the cost of that care will
also be different.
See the next page for
important information about
these examples.
Having a baby
(normal delivery)
■ Amount owed to providers: $7,540
■ Plan pays $3,730
■ Patient pays $3,810
Managing type 2 diabetes
(routine maintenance of
a well-controlled condition)
■ Amount owed to providers: $5,400
■ Plan pays $3,320
■ Patient pays $2,080
Sample care costs:
Sample care costs:
Hospital charges (mother) $2,700 Prescriptions $2,900
Routine obstetric care $2,100 Medical Equipment and Supplies $1,300
Hospital charges (baby) $900 Office Visits and Procedures $700
Anesthesia $900 Education $300
Laboratory tests $500 Laboratory tests $100
Prescriptions $200 Vaccines, other preventive $100
Radiology $200 Total $5,400
Vaccines, other preventive $40
Total $7,540 Patient pays:
Deductibles $1,200
Patient pays: Co-pays $200
Deductibles $2,000 Co-insurance $600
Co-pays $10 Limits or exclusions $80
Co-insurance $1,600 Total $2,080
Limits or exclusions $200
Total $3,810
7 of 8
Summaries of Benefits and Coverage for MOE Health Plan Marketplace Options 39

Questions and answers about the Coverage Examples:
What are some of the
assumptions behind the
Coverage Examples?
● Costs don’t include premiums.
● Sample care costs are based on national
averages supplied by the U.S.
Department of Health and Human
Services, and aren’t specific to a
particular geographic area or health
plan.
● The patient’s condition was not an
excluded or preexisting condition.
● All services and treatments started and
ended in the same coverage period.
● There are no other medical expenses for
any member covered under this plan.
● Out-of-pocket expenses are based only
on treating the condition in the example.
●
The patient received all care from innetwork
providers. If the patient had
received care from out-of-network
providers, costs would have been
higher.
What does a Coverage Example
show?
For each treatment situation, the Coverage
Example helps you see how deductibles, copayments,
and co-insurance can add up. It
also helps you see what expenses might be left
up to you to pay because the service or
treatment isn’t covered or payment is limited.
Does the Coverage Example
predict my own care needs?
No. Treatments shown are just examples.
The care you would receive for this
condition could be different based on your
doctor’s advice, your age, how serious your
condition is, and many other factors.
Does the Coverage Example
predict my future expenses?
No. Coverage Examples are not cost
estimators. You can’t use the examples to
estimate costs for an actual condition. They
are for comparative purposes only. Your
own costs will be different depending on
the care you receive, the prices your
providers charge, and the reimbursement
your health plan allows.
Can I use Coverage Examples to
compare plans?
Yes. When you look at the Summary of
Benefits and Coverage for other plans,
you’ll find the same Coverage Examples.
When you compare plans, check the
“Patient Pays” box in each example. The
smaller that number, the more coverage
the plan provides.
Are there other costs I should
consider when comparing
plans?
Yes. An important cost is the premium
you pay. Generally, the lower your
premium, the more you’ll pay in out-ofpocket
costs, such as co-payments,
deductibles, and co-insurance. You
should also consider contributions to
accounts such as health savings accounts
(HSAs), flexible spending arrangements
(FSAs) or health reimbursement accounts
(HRAs) that help you pay out-of-pocket
expenses.
Questions: Call 1-708-482-7300 or visit us at www.moefunds.com.
If you aren’t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary 8 of 8
at www.dol.gov/ebsa/healthreform or call 1-708-482-7300 to request a copy.
Summaries of Benefits and Coverage for MOE Health Plan Marketplace Options 40

Midwest Operating Engineers:
Silver II (Narrow Network)
Summary of Benefits and Coverage: What this Plan Covers & What it Costs
Coverage Period: 04/01/2016 - 03/31/2017
Coverage for: Individual + Family | Plan Type: PPO
This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan
document at www.moefunds.com or by calling 1-708-482-7300.
Important Questions
Answers
Why this Matters:
What is the overall
deductible?
In-Network: $2,000 person/$5,000
family; Out-of-Network: $4,000
person/$10,000 family. Prescription
drugs, durable medical equipment, TMJ,
balance billing, excluded services do not
count toward the deductible.
You must pay all the costs up to the deductible amount before this plan begins to
pay for covered services you use. Check your policy or plan document to see when
the deductible starts over (usually, but not always, January 1st). See the chart starting
on page 2 for how much you pay for covered services after you meet the deductible.
Are there other
deductibles for specific
services?
Is there an out-ofpocket
limit on my
expenses?
What is not included in
the out-of-pocket
limit?
No.
Yes. In-Network Medical: $4,000
person/$8,000 family; Out-of-
Network Medical: $8,000
person/$16,000 family. In-Network
Prescription Drugs: $2,000
person/$4,000 family; Out-of-
Network Prescription Drugs: $4,000
person/$8,000 family.
Self-payments, balance billing, health
care this plan does not cover, Family
Supplemental Benefit charges.
You don’t have to meet deductibles for specific services, but see the chart starting
on page 2 for other costs for services this plan covers.
The out-of-pocket limit is the most you could pay during a coverage period (usually
one year) for your share of the cost of covered services. This limit helps you plan for
health care expenses.
Even though you pay these expenses, they don’t count toward the out-of-pocket
limit.
Is there an overall
annual limit on what the
plan pays?
No.
The chart starting on page 2 describes any limits on what the plan will pay for specific
covered services, such as office visits.
Questions: Call 1-708-482-7300 or visit us at www.moefunds.com.
If you aren’t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary 1 of 8
at www.dol.gov/ebsa/healthreform or call 1-708-482-7300 to request a copy.
Summaries of Benefits and Coverage for MOE Health Plan Marketplace Options 41

Important Questions Answers Why this Matters:
Does this plan use a
network of providers?
Do I need a referral to see
a specialist?
Are there services this
plan doesn’t cover?
Yes. For a list of in-network
providers, call 1-800-810-2583.
Yes. You need a referral to see an
acupuncture specialist.
Yes.
If you use an in-network doctor or other health care provider, this plan will pay some or all
of the costs of covered services. Be aware, your in-network doctor or hospital may use an
out-of-network provider for some services. Plans use the term in-network, preferred, or
participating for providers in their network. See the chart starting on page 2 for how this
plan pays different kinds of providers.
This plan will pay some or all of the costs to see a specialist for covered services but only
if you have the plan’s permission before you see the specialist.
Some of the services this plan doesn’t cover are listed on page 6. See your policy or plan
document for additional information about excluded services.
●
●
●
●
Co-payments are fixed dollar amounts (for example, $15) you pay for covered health care, usually when you receive the service.
Co-insurance is your share of the costs of a covered service, calculated as a percent of the allowed amount for the service. For example, if
the plan’s allowed amount for an overnight hospital stay is $1,000, your co-insurance payment of 20% would be $200. This may change if
you haven’t met your deductible.
The amount the plan pays for covered services is based on the allowed amount. If an out-of-network provider charges more than the
allowed amount, you may have to pay the difference. For example, if an out-of-network hospital charges $1,500 for an overnight stay and
the allowed amount is $1,000, you may have to pay the $500 difference. (This is called balance billing.)
This plan may encourage you to use in-network providers by charging you lower deductibles, co-payments and co-insurance amounts.
Common
Medical Event
If you visit a health
care provider's office
or clinic
Service You May Need
Primary care visit to treat an injury or
illness
Specialist visit
Other practitioner office visit
Preventive care/
screening/immunization
Your Cost If You Use
an In-Network
Provider
30% co-insurance 50% co-insurace -- None --
30% co-insurace 50% co-insurace -- None --
30% co-insurance for
chiropractor
(manipulations and
necessary x-rays only),
acupuncture
Your Cost If You Use
an Out-of-Network
Provider
50% co-insurance for
chiropractor
(manipulations and
necessary x-rays only),
acupuncture
No charge Not covered -- None --
Limitations & Exceptions
Chiropractor: 24 visits/year up to
$60/visit & eligible only if over age
5; Acupuncture: 12
treatments/year up to $125/visit.
2 of 8
Summaries of Benefits and Coverage for MOE Health Plan Marketplace Options 42

Common
Medical Event
If you have a test
Service You May Need
Diagnostic test (x-ray, blood work)
Imaging (CT/PET scans, MRIs)
Your Cost If You Use
an In-Network
Provider
Your Cost If You Use
an Out-of-Network
Provider
30% co-insurance/test 50% co-insurance/test -- None --
30% co-insurance/test; no
charge if scan is
authorized by AIM
50% co-insurance/test -- None --
Limitations & Exceptions
If you need drugs to
treat your illness or
condition
More information
about prescription
drug coverage is
available at
www.caremark.com or
1-708-482-7300.
Generic drugs
Brand drugs
Maintenance Drugs (Limited to CVS
Pharmacy Stores and CVS Caremark
Mail Service Pharmacy Only)
$20 co-pay per 30-day
supply retail/$50 co-pay
per 90-day supply mail
order
$40 co-pay per 30-day
supply retail/$100 co-pay
per 90-day supply mail
order
$50 co-pay per 90-day
supply generic/$100 copay
per 90-day supply
brand
Not covered
Not covered
Not covered
Maximum of up to two 30-day
supplies before a member is
required to obtain a 90-day supply.
Member seeking third refill must
transition to CVS Pharmacy or
CVS Caremark Mail Service
Pharmacy, or pay 100% of the cost
of the prescription drug. You must
pay the difference between the
cost of a brand and generic if a
generic is available. Certain
specialty medications are subject to
pre-authorization requirements.
Call the phone number listed or
visit Caremark's website for more
information.
If you have
outpatient surgery
If you need
immediate medical
attention
Facility fee (e.g., ambulatory surgery
center)
Physician/surgeon fees
Emergency room services
Emergency medical transportation
Urgent care
30% co-insurance 50% co-insurance Licensed facilities only.
30% co-insurance 50% co-insurance -- None --
$100 co-pay per visit;
30% co-insurance
$100 co-pay per visit;
30% co-insurance
-- None --
30% co-insurance 50% co-insurance
Transfer between inter-health
facilities limited to $5,000.
30% co-insurance 50% co-insurance -- None --
3 of 8
Summaries of Benefits and Coverage for MOE Health Plan Marketplace Options 43

Common
Medical Event
If you have a hospital
stay
Service You May Need
Facility fee (e.g., hospital room)
Physician/surgeon fee
Your Cost If You Use
an In-Network
Provider
Your Cost If You Use
an Out-of-Network
Provider
Limitations & Exceptions
30% co-insurance 50% co-insurance
Room allowances based on semiprivate
room rate.
30% co-insurance 50% co-insurance -- None --
Mental/Behavioral health outpatient
services
30% co-insurance/office
visit, 30% co-insurance
other outpatient services
50% co-insurance/office
visit, 50% co-insurance
other outpatient services
-- None --
If you have mental
health, behavioral
health, or substance
abuse needs
Mental/Behavioral health inpatient
services
Substance use disorder outpatient
services
30% co-insurance 50% co-insurance -- None --
30% co-insurance/office
visit, 30% co-insurance
other outpatient services
50% co-insurance/office
visit, 50% co-insurance
other outpatient services
-- None --
If you are pregnant
If you need help
recovering or have
other special health
needs
Substance use disorder inpatient services
Prenatal and postnatal care
Delivery and all inpatient services
Home health care
Rehabilitation services
Habilitation services
Skilled nursing care
Durable medical equipment
Hospice service
30% co-insurance 50% co-insurance -- None --
30% co-insurance 50% co-insurance -- None --
30% co-insurance 50% co-insurance -- None --
30% co-insurance 50% co-insurance Case manager must pre-approve.
30% co-insurance 50% co-insurance Case manager must pre-approve.
30% co-insurance 50% co-insurance
Case manager must pre-approve.
Limit 25 visits per calendar year:
speech therapy for kids (age 2-18)
with congenital neurological
disorder.
30% co-insurance 50% co-insurance
45-day limit per confinement; must
be recommended by physician and
begin within 30 days of hospital
confinement; not covered if not
pre-approved.
50% co-insurance 50% co-insurance $15,000 limit/electric wheelchair.
30% co-insurance 50% co-insurance Case manager must pre-approve.
4 of 8
Summaries of Benefits and Coverage for MOE Health Plan Marketplace Options 44

Common
Medical Event
Service You May Need
Your Cost If You Use
an In-Network
Provider
Your Cost If You Use
an Out-of-Network
Provider
Limitations & Exceptions
If your child needs
dental or eye care
Eye exam
Glasses
Not covered
Not covered
Not covered
Not covered
Eye exams and glasses are
reimbursable under the Family
Supplemental Benefit. You can
receive basic vision care at no
charge from the Operator’s Health
Center.
Dental check-up
Not covered Not covered Not covered.
5 of 8
Summaries of Benefits and Coverage for MOE Health Plan Marketplace Options 45

Excluded Services & Other Covered Services:
Services Your Plan Does NOT Cover (This isn't a complete list. Check your policy or plan document for other excluded services.)
● Cosmetic surgery (Except for mastectomy, injuries
and to remove scar tissue)
● Dental (Adult)
● Hearing aids (Except for cochlear implants)
● Infertility treatment
● Long-term care
● Non-emergency care when traveling
outside the U.S.
● Private-duty nursing except transplant patients
● Routine foot care
● Weight loss programs
Other Covered Services (This isn't a complete list. Check your policy or plan document for other covered services and your costs for those
services.)
● Acupuncture ($125 per visit, 12 per year)
● Bariatric surgery (Prior authorization required)
● Chiropractic care (Limited to $60/visit and
24/visits per year) (manipulations and
● Routine eye care (Eligible for remibursement
from Family Supplemental Benefit.)
necessary x-rays only)
Your Rights to Continue Coverage:
If you lose coverage under the plan, then, depending upon the circumstances, Federal and State laws may provide protections that allow you to keep health
coverage. Any such rights may be limited in duration and will require you to pay a premium, which may be significantly higher than the premium you pay
while covered under the plan. Other limitations on your rights to continue coverage may also apply.
For more information on your rights to continue coverage, contact the plan at 1-708-482-7300. You may also contact your state insurance department, the
U.S. Department of Labor, Employee Benefits Security Administration at 1-866-444-3272 or www.dol.gov/ebsa, or the U.S. Department of Health and
Human Services at 1-877-267-2323 x61565 or www.cciio.cms.gov.
Your Grievance and Appeals Rights:
If you have a complaint or are dissatisfied with a denial of coverage for claims under your plan, you may be able to appeal or file a grievance. For
questions about your rights, this notice, or assistance, you can contact: (1) Administrative Manager, Midwest Operating Engineers Fringe Benefit Funds,
6150 Joliet Road, Countryside, IL 60525-3994, 1-708-482-7300; or (2) Department of Labor's Employee Benefits Security Administration at 1-866-444-
EBSA (3272) or www.dol.gov/ebsa/healthreform.
Does this Coverage Provide Minimum Essential Coverage?
The Affordable Care Act requires most people to have health care coverage that qualifies as “minimum essential coverage.” This plan or policy does
provide minimum essential coverage.
Does this Coverage Meet the Minimum Value Standard?
The Affordable Care Act establishes a minimum value standard of benefits of a health plan. The minimum value standard is 60% (actuarial value). This
health coverage does meet the minimum value standard for the benefits it provides.
Language Access Services:
SPANISH (Español): Para obtener asistencia en Español, llame al 1-708-482-7300.
–––––––––––––––––––––To see examples of how this plan might cover costs for a sample medical situation, see the next page.–––––––––––––––––––
6 of 8
Summaries of Benefits and Coverage for MOE Health Plan Marketplace Options 46

About these Coverage
Examples:
These examples show how this plan might cover
medical care in given situations. Use these
examples to see, in general, how much financial
protection a sample patient might get if they are
covered under different plans.
This is
not a cost
estimator.
Don’t use these examples to
estimate your actual costs
under this plan. The actual
care you receive will be
different from these examples,
and the cost of that care will
also be different.
See the next page for
important information about
these examples.
Having a baby
(normal delivery)
■ Amount owed to providers: $7,540
■ Plan pays $3,720
■ Patient pays $3,820
Managing type 2 diabetes
(routine maintenance of
a well-controlled condition)
■ Amount owed to providers: $5,400
■ Plan pays $2,720
■ Patient pays $2,680
Sample care costs:
Sample care costs:
Hospital charges (mother) $2,700 Prescriptions $2,900
Routine obstetric care $2,100 Medical Equipment and Supplies $1,300
Hospital charges (baby) $900 Office Visits and Procedures $700
Anesthesia $900 Education $300
Laboratory tests $500 Laboratory tests $100
Prescriptions $200 Vaccines, other preventive $100
Radiology $200 Total $5,400
Vaccines, other preventive $40
Total $7,540 Patient pays:
Deductibles $1,200
Patient pays: Co-pays $800
Deductibles $2,000 Co-insurance $600
Co-pays $20 Limits or exclusions $80
Co-insurance $1,600 Total $2,680
Limits or exclusions $200
Total $3,820
7 of 8
Summaries of Benefits and Coverage for MOE Health Plan Marketplace Options 47

Questions and answers about the Coverage Examples:
What are some of the
assumptions behind the
Coverage Examples?
●
●
●
●
●
●
●
Costs don’t include premiums.
Sample care costs are based on national
averages supplied by the U.S.
Department of Health and Human
Services, and aren’t specific to a
particular geographic area or health
plan.
The patient’s condition was not an
excluded or preexisting condition.
All services and treatments started and
ended in the same coverage period.
There are no other medical expenses for
any member covered under this plan.
Out-of-pocket expenses are based only
on treating the condition in the example.
The patient received all care from innetwork
providers. If the patient had
received care from out-of-network
providers, costs would have been
higher.
What does a Coverage Example
show?
For each treatment situation, the Coverage
Example helps you see how deductibles, copayments,
and co-insurance can add up. It
also helps you see what expenses might be left
up to you to pay because the service or
treatment isn’t covered or payment is limited.
Does the Coverage Example
predict my own care needs?
No. Treatments shown are just examples.
The care you would receive for this
condition could be different based on your
doctor’s advice, your age, how serious your
condition is, and many other factors.
Does the Coverage Example
predict my future expenses?
No. Coverage Examples are not cost
estimators. You can’t use the examples to
estimate costs for an actual condition. They
are for comparative purposes only. Your
own costs will be different depending on
the care you receive, the prices your
providers charge, and the reimbursement
your health plan allows.
Can I use Coverage Examples to
compare plans?
Yes. When you look at the Summary of
Benefits and Coverage for other plans,
you’ll find the same Coverage Examples.
When you compare plans, check the
“Patient Pays” box in each example. The
smaller that number, the more coverage
the plan provides.
Are there other costs I should
consider when comparing
plans?
Yes. An important cost is the premium
you pay. Generally, the lower your
premium, the more you’ll pay in out-ofpocket
costs, such as co-payments,
deductibles, and co-insurance. You
should also consider contributions to
accounts such as health savings accounts
(HSAs), flexible spending arrangements
(FSAs) or health reimbursement accounts
(HRAs) that help you pay out-of-pocket
expenses.
Questions: Call 1-708-482-7300 or visit us at www.moefunds.com.
If you aren’t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary 8 of 8
at www.dol.gov/ebsa/healthreform or call 1-708-482-7300 to request a copy.
Summaries of Benefits and Coverage for MOE Health Plan Marketplace Options 48

Midwest Operating Engineers: Bronze
Summary of Benefits and Coverage: What this Plan Covers & What it Costs
Coverage Period: 04/01/2016 - 03/31/2017
Coverage for: Individual + Family | Plan Type: PPO
This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan
document at www.moefunds.com or by calling 1-708-482-7300.
Important Questions
Answers
Why this Matters:
What is the overall
deductible?
In-Network: $5,000
person/$10,000 family; Out-of-
Network: $10,000 person/$20,000
family. Prescription drugs, durable
medical equipment, TMJ, balance
billing, excluded services do not
count toward the deductible.
You must pay all the costs up to the deductible amount before this plan begins to pay for
covered services you use. Check your policy or plan document to see when the deductible
starts over (usually, but not always, January 1st). See the chart starting on page 2 for how
much you pay for covered services after you meet the deductible.
Are there other
deductibles for specific
services?
No.
You don’t have to meet deductibles for specific services, but see the chart starting on page 2
for other costs for services this plan covers.
Is there an out-ofpocket
limit on my
expenses?
Yes. In-Network Medical: $5,000
person/$10,000 family; Out-of-
Network Medical: $10,000
person/$20,000 family. In-Network
Prescription Drugs: $1,600
person/$3,200 family; Out-of-
Network Prescription Drugs: $4,000
person/$8,000 family
The out-of-pocket limit is the most you could pay during a coverage period (usually one
year) for your share of the cost of covered services. This limit helps you plan for health care
expenses.
What is not included in
the out-of-pocket
limit?
Self-payments, balance billing, health
care this plan does not cover, Family
Supplemental Benefit charges.
Even though you pay these expenses, they don’t count toward the out-of-pocket limit.
Is there an overall
annual limit on what the
No.
The chart starting on page 2 describes any limits on what the plan will pay for specific covered
services, such as office visits.
plan pays?
Questions: Call 1-708-482-7300 or visit us at www.moefunds.com.
If you aren’t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary 1 of 8
at www.dol.gov/ebsa/healthreform or call 1-708-482-7300 to request a copy.
Summaries of Benefits and Coverage for MOE Health Plan Marketplace Options 49

Important Questions Answers Why this Matters:
Does this plan use a
network of providers?
Do I need a referral to see
a specialist?
Are there services this
plan doesn’t cover?
●
●
●
●
Yes. For a list of in-network
providers, call 1-800-810-2583.
Yes. You need a referral to see an
acupuncture specialist.
Yes.
If you use an in-network doctor or other health care provider, this plan will pay some or all
of the costs of covered services. Be aware, your in-network doctor or hospital may use an
out-of-network provider for some services. Plans use the term in-network, preferred, or
participating for providers in their network. See the chart starting on page 2 for how this
plan pays different kinds of providers.
This plan will pay some or all of the costs to see a specialist for covered services but only
if you have the plan’s permission before you see the specialist.
Some of the services this plan doesn’t cover are listed on page 6. See your policy or plan
document for additional information about excluded services.
Co-payments are fixed dollar amounts (for example, $15) you pay for covered health care, usually when you receive the service.
Co-insurance is your share of the costs of a covered service, calculated as a percent of the allowed amount for the service. For example, if
the plan’s allowed amount for an overnight hospital stay is $1,000, your co-insurance payment of 20% would be $200. This may change if
you haven’t met your deductible.
The amount the plan pays for covered services is based on the allowed amount. If an out-of-network provider charges more than the
allowed amount, you may have to pay the difference. For example, if an out-of-network hospital charges $1,500 for an overnight stay and
the allowed amount is $1,000, you may have to pay the $500 difference. (This is called balance billing.)
This plan may encourage you to use in-network providers by charging you lower deductibles, co-payments and co-insurance amounts.
Common
Medical Event
If you visit a health
care provider's office
or clinic
Service You May Need
Primary care visit to treat an injury or
illness
Specialist visit
Other practitioner office visit
Preventive care/
screening/immunization
Your Cost If You Use Your Cost If You Use
an In-Network an Out-of-Network Limitations & Exceptions
Provider
Provider
No charge after No charge after
deductible
deductible
-- None --
No charge after No charge after
deductible
deductible
-- None --
No charge after
deductible for
chiropractor
(manipulations and
necessary x-rays only),
acupuncture
No charge after
deductible for
chiropractor
(manipulations and
necessary x-rays only),
acupuncture
Chiropractor: 24 visits/year up to
$60/visit & eligible only over age
5; Acupuncture: 12
treatments/year up to $125/visit.
No charge (not subject to
deductible)
Not covered -- None --
2 of 8
Summaries of Benefits and Coverage for MOE Health Plan Marketplace Options 50

Common
Medical Event
If you have a test
Service You May Need
Diagnostic test (x-ray, blood work)
Imaging (CT/PET scans, MRIs)
Your Cost If You Use Your Cost If You Use
an In-Network an Out-of-Network
Provider
Provider
No charge after
deductible
No charge after
deductible
No charge after No charge after
deductible
deductible
Limitations & Exceptions
-- None --
-- None --
If you need drugs to
treat your illness or
condition
More information
about prescription
drug coverage is
available at
www.caremark.com or
1-708-482-7300.
If you have
outpatient surgery
If you need
immediate medical
attention
If you have a hospital
stay
Generic drugs
Brand drugs
Maintenance Drugs (Limited to CVS
Pharmacy Stores or CVS Caremark Mail
Service Pharmacy Only)
Facility fee (e.g., ambulatory surgery
center)
Physician/surgeon fees
Emergency room services
Emergency medical transportation
Urgent care
Facility fee (e.g., hospital room)
Physician/surgeon fee
$20 co-pay per 30-day
supply retail/$50 co-pay
per 90-day supply mail
order
$40 co-pay per 30-day
supply retail/$100 co-pay
per 90-day supply mail
order
$50 co-pay per 90-day
supply generic/$100 copay
per 90-day supply
brand
Not covered
Not covered
Not covered
No charge after No charge after
deductible
deductible
Licensed facilities only.
No charge after No charge after
deductible
deductible
-- None --
$100 co-pay per visit $100 co-pay per visit -- None --
No charge after
deductible
No charge after
deductible
Transfer between inter-health
facilities limited to $5,000.
No charge after No charge after
deductible
deductible
-- None --
No charge after
deductible
No charge after
deductible
No charge after
deductible
No charge after
deductible
Maximum of up to two 30-day
supplies before a member is
required to obtain a 90-day supply.
Member seeking third refill must
transition to CVS Pharmacy or
CVS Caremark Mail Service
Pharmacy, or pay 100% of the cost
of the prescription drug. You must
pay the difference between the
cost of a brand and generic if a
generic is available. Certain
specialty medications are subject to
pre-authorization requirements.
Call the phone number listed or
visit Caremark's website for more
information.
Room allowances based on semiprivate
room rate.
-- None --
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Summaries of Benefits and Coverage for MOE Health Plan Marketplace Options 51

Common
Medical Event
If you have mental
health, behavioral
health, or substance
abuse needs
If you are pregnant
If you need help
recovering or have
other special health
needs
Service You May Need
Your Cost If You Use
an In-Network
Provider
Mental/Behavioral health outpatient
services
No charge after
deductible
Mental/Behavioral health inpatient No charge after
services
deductible
Substance use disorder outpatient No charge after
services
deductible
No charge after
Substance use disorder inpatient services
deductible
Prenatal and postnatal care
No charge after
deductible
Delivery and all inpatient services
No charge after
deductible
Home health care
No charge after
deductible
Rehabilitation services
No charge after
deductible
Habilitation services
Skilled nursing care
Durable medical equipment
Hospice service
No charge after
deductible
No charge after
deductible
No charge after
deductible
No charge after
deductible
Your Cost If You Use
an Out-of-Network Limitations & Exceptions
Provider
No charge after
deductible
-- None --
No charge after
deductible
-- None --
No charge after
deductible
-- None --
No charge after
deductible
-- None --
No charge after
deductible
-- None --
No charge after
deductible
-- None --
No charge after
deductible
Case manager must pre-approve.
No charge after
deductible
Case manager must pre-approve.
No charge after
deductible
No charge after
deductible
No charge after
deductible
No charge after
deductible
Case manager must pre-approve.
Limit 25 visits per calendar year:
speech therapy for kids (age 2-18)
with congenital neurological
disorder.
45-day limit per confinement; must
be recommended by a physician
and begin within 30 days of
hospital confinement; not covered
if not pre-approved.
$15,000 limit/electric wheelchair.
Case manager must pre-approve.
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Summaries of Benefits and Coverage for MOE Health Plan Marketplace Options 52

Common
Medical Event
Service You May Need
Your Cost If You Use
an In-Network
Provider
Your Cost If You Use
an Out-of-Network
Provider
Limitations & Exceptions
If your child needs
dental or eye care
Eye exam
Glasses
Not covered
Not covered
Not covered
Not covered
Eye exams and glasses are
reimbursable under the Family
Supplemental Benefit. You can
receive basic vision care at no
charge from the Operator’s Health
Center.
Dental check-up
Not covered Not covered Not covered.
5 of 8
Summaries of Benefits and Coverage for MOE Health Plan Marketplace Options 53

Excluded Services & Other Covered Services:
Services Your Plan Does NOT Cover (This isn't a complete list. Check your policy or plan document for other excluded services.)
● Cosmetic surgery (Except for mastectomy, injuries
and to remove scar tissue)
● Dental care (Adult)
● Hearing aids (Except for cochlear implants)
● Infertility treatment
● Long-term care
● Non-emergency care when traveling outside
the U.S.
● Private-duty nursing except transplant patients
● Routine foot care
● Weight loss programs
Other Covered Services (This isn't a complete list. Check your policy or plan document for other covered services and your costs for those
services.)
● Acupuncture ($125 per visit, 12 per year)
● Bariatric surgery (Prior authorization required)
● Chiropractic care (Limited to $60/visit and
24/visits per year) (manipulations and
● Routine eye care (Eligible for reimbursement
from Family Supplemental Benefit)
necessary x-rays only)
Your Rights to Continue Coverage:
If you lose coverage under the plan, then, depending upon the circumstances, Federal and State laws may provide protections that allow you to keep health
coverage. Any such rights may be limited in duration and will require you to pay a premium, which may be significantly higher than the premium you pay
while covered under the plan. Other limitations on your rights to continue coverage may also apply.
For more information on your rights to continue coverage, contact the plan at 1-708-482-7300. You may also contact your state insurance department, the
U.S. Department of Labor, Employee Benefits Security Administration at 1-866-444-3272 or www.dol.gov/ebsa, or the U.S. Department of Health and
Human Services at 1-877-267-2323 x61565 or www.cciio.cms.gov.
Your Grievance and Appeals Rights:
If you have a complaint or are dissatisfied with a denial of coverage for claims under your plan, you may be able to appeal or file a grievance. For
questions about your rights, this notice, or assistance, you can contact: (1) Administrative Manager, Midwest Operating Engineers Fringe Benefit Funds,
6150 Joliet Road, Countryside, IL 60525-3994, 1-708-482-7300; or (2) Department of Labor's Employee Benefits Security Administration at 1-866-444-
EBSA (3272) or www.dol.gov/ebsa/healthreform.
Does this Coverage Provide Minimum Essential Coverage?
The Affordable Care Act requires most people to have health care coverage that qualifies as “minimum essential coverage.” This plan or policy does
provide minimum essential coverage.
Does this Coverage Meet the Minimum Value Standard?
The Affordable Care Act establishes a minimum value standard of benefits of a health plan. The minimum value standard is 60% (actuarial value). This
health coverage does meet the minimum value standard for the benefits it provides.
Language Access Services:
SPANISH (Español): Para obtener asistencia en Español, llame al 1-708-482-7300.
–––––––––––––––––––––To see examples of how this plan might cover costs for a sample medical situation, see the next page.–––––––––––––––––––
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Summaries of Benefits and Coverage for MOE Health Plan Marketplace Options 54

About these Coverage
Examples:
These examples show how this plan might cover
medical care in given situations. Use these
examples to see, in general, how much financial
protection a sample patient might get if they are
covered under different plans.
This is
not a cost
estimator.
Don’t use these examples to
estimate your actual costs
under this plan. The actual
care you receive will be
different from these examples,
and the cost of that care will
also be different.
See the next page for
important information about
these examples.
Having a baby
(normal delivery)
■ Amount owed to providers: $7,540
■ Plan pays $2,320
■ Patient pays $5,220
Managing type 2 diabetes
(routine maintenance of
a well-controlled condition)
■ Amount owed to providers: $5,400
■ Plan pays $2,120
■ Patient pays $3,280
Sample care costs:
Sample care costs:
Hospital charges (mother) $2,700 Prescriptions $2,900
Routine obstetric care $2,100 Medical Equipment and Supplies $1,300
Hospital charges (baby) $900 Office Visits and Procedures $700
Anesthesia $900 Education $300
Laboratory tests $500 Laboratory tests $100
Prescriptions $200 Vaccines, other preventive $100
Radiology $200 Total $5,400
Vaccines, other preventive $40
Total $7,540 Patient pays:
Deductibles $2,400
Patient pays: Co-pays $800
Deductibles $5,000 Co-insurance $0
Co-pays $20 Limits or exclusions $80
Co-insurance $0 Total $3,280
Limits or exclusions $200
Total $5,220
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Summaries of Benefits and Coverage for MOE Health Plan Marketplace Options 55

Questions and answers about the Coverage Examples:
What are some of the
assumptions behind the
Coverage Examples?
● Costs don’t include premiums.
● Sample care costs are based on national
averages supplied by the U.S.
Department of Health and Human
Services, and aren’t specific to a
particular geographic area or health
plan.
● The patient’s condition was not an
excluded or preexisting condition.
● All services and treatments started and
ended in the same coverage period.
● There are no other medical expenses for
any member covered under this plan.
● Out-of-pocket expenses are based only
on treating the condition in the example.
●
The patient received all care from innetwork
providers. If the patient had
received care from out-of-network
providers, costs would have been
higher.
What does a Coverage Example
show?
For each treatment situation, the Coverage
Example helps you see how deductibles, copayments,
and co-insurance can add up. It
also helps you see what expenses might be left
up to you to pay because the service or
treatment isn’t covered or payment is limited.
Does the Coverage Example
predict my own care needs?
No. Treatments shown are just examples.
The care you would receive for this
condition could be different based on your
doctor’s advice, your age, how serious your
condition is, and many other factors.
Does the Coverage Example
predict my future expenses?
No. Coverage Examples are not cost
estimators. You can’t use the examples to
estimate costs for an actual condition. They
are for comparative purposes only. Your
own costs will be different depending on
the care you receive, the prices your
providers charge, and the reimbursement
your health plan allows.
Can I use Coverage Examples to
compare plans?
Yes. When you look at the Summary of
Benefits and Coverage for other plans,
you’ll find the same Coverage Examples.
When you compare plans, check the
“Patient Pays” box in each example. The
smaller that number, the more coverage
the plan provides.
Are there other costs I should
consider when comparing
plans?
Yes. An important cost is the premium
you pay. Generally, the lower your
premium, the more you’ll pay in out-ofpocket
costs, such as co-payments,
deductibles, and co-insurance. You
should also consider contributions to
accounts such as health savings accounts
(HSAs), flexible spending arrangements
(FSAs) or health reimbursement accounts
(HRAs) that help you pay out-of-pocket
expenses.
Questions: Call 1-708-482-7300 or visit us at www.moefunds.com.
If you aren’t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary 8 of 8
at www.dol.gov/ebsa/healthreform or call 1-708-482-7300 to request a copy.
Summaries of Benefits and Coverage for MOE Health Plan Marketplace Options 56

Summaries of Benefits and Coverage for MOE Health Plan Marketplace Options 57

January 2016
6150 Joliet Road
Countryside, IL 60525