Alaska Teamster-Employer Welfare and Pension Trusts

5.11 TRANSPORTATION AND EXPENSES FOR MEDICALLY NECESSARY TREATMENT

Air Transportation for Parent of a Dependent Child

This benefit will pay for round-trip coach class air transportation for one parent of a minor Dependent child to allow the child to obtain Medically Necessary treatment that is not available locally. This provision does not apply to travel for diagnostic testing. While the Dependent child is confined in the Hospital or receiving outpatient treatment, the parent who accompanies the child will be eligible for reimbursement of reasonable expenses for meals, lodging and local ground transportation. The Plan also pays reasonable
expenses for meals, lodging and local ground transportation for the Dependent child if he or she is receiving outpatient treatment. The maximum combined reimbursement for the parent and the Dependent child is $75 per day. Original written receipts must be submitted to the Administrative Office in order to obtain reimbursement.

Air Transportation for Emergency Treatment

The Emergency Treatment Air Transportation benefit is available for all Participants. This benefit will pay for up to $500 for coach class air transportation to the nearest medical facility where Medically Necessary Emergency treatment can be given, when such treatment is not available without air transportation. This provision does not apply to travel for diagnostic testing.

Air Ambulance Transportation Services

For air ambulance services, the Plan’s preferred providers are Guardian and LifeFlight Air Ambulance Services in Alaska only, and must be utilized by calling 1(800) 478-9111. If the Plan’s preferred provider for air ambulance services is not utilized, the reimbursement rate will not exceed the Plan’s preferred provider’s retail rate.

Travel and Lodging and Waiver of Deductible and Co-Insurance for Certain Pre-Approved Medically Necessary Surgeries through BridgeHealth

The Plan has contracted with BridgeHealth Medical (BridgeHealth) to allow Participants and Dependents, when pre-approved by BridgeHealth and the Trust, to obtain certain medically necessary surgical treatments from approved BridgeHealth providers outside Alaska. When medically necessary and approved by BridgeHealth and the Trust in advance and in writing, the Trust will provide the following benefits for the patient and a medically-necessary companion:

• Transportation and Lodging – Round-trip air transportation and lodging for the patient and a medically-necessary companion are paid in full by the Trust when using a pre-approved BridgeHealth provider located more than 100 miles from his or her home. To be covered, any and all travel arrangements must be scheduled, reserved and specifically approved in advance and in writing by both BridgeHealth and the Trust.
• Waiver of Deductible and Co-Insurance for Approved Treatments – Because of the cost of savings to the Trust for approved BridgeHealth treatments, the deductible is waived and charges for the BridgeHealth provider are paid at 100% for BridgeHealth treatments approved in writing in advance by BridgeHealth and the Trust.
• Incidental Expenses – Incidental expenses of up to $50 per day during travel to obtain treatment at an approved BridgeHealth provider will be paid by the Trust.

Any medical services not performed by an approved BridgeHealth provider or not approved in advance in writing by BridgeHealth and the Trust, including pre- and post-surgery care, are subject to the usual deductibles, coverage limits, and other terms of the Plan. Orthopedic or podiatric surgeries that are not performed by an approved BridgeHealth provider or a Preferred Provider of this Plan are not covered at all by this Plan, unless provided in an emergency. A portion of the lodging and incidental expense benefits provided through the BridgeHealth program may be subject to income tax.