Southern California IBEW-NECA Active Health Plan  
Amendment # 41
To the Southern California IBEW-NECA Active Health Plan
as Contained in the
Active Health Plan Summary Plan Description
Dated June 1, 2004  

Effective for services received on and after April 15, 2009, the following provision is added to the Southern California IBEW-NECA Active Health Plan:

Specialized Footwear Benefit

Eligible Expenses
Eligible expenses subject to reimbursement shall include expenses for the professional services provided by an orthotist, prosthetist, pedorthist or other provider certified by the American Board for Certification in Orthotics, Prosthetics and Pedorthics when professional services are in connection with the treatment of foot disfigurement. For purposes of this benefit, foot disfigurement means foot disfigurement resulting from cerebral palsy, arthritis, polio, spina bifida, diabetes, accidental injury or abnormal condition.

Specialized Footwear
Eligible services for specialized footwear shall include the cost of fabricating custom-made rigid (plastic or polypropylene) foot orthotics (shoe inserts) and/or custom-made standard orthopedic shoes.

Maximum Annual Benefit
The maximum annual benefit payable per Participant for eligible expenses incurred for the procurement of specialized footwear shall be $400.

Submission of Claims
Claims for eligible expense reimbursement under this provision shall be submitted to Allied Administrators at:

Allied Administrators, Inc.
P.O. Box 2500
San Francisco, CA 94126

Claims must include the name and address of the provider, the date services are rendered, the diagnosis or condition being treated, and an itemized listing of services rendered. Reimbursement shall be made directly to the Participant or Member and not to the provider.

Exclusions
No benefits shall be provided under the terms of this provision for:

• Dress shoes;
• Casual shoes (e.g., tennis shoes or deck shoes);
• Shoe inserts (except as provided above);
• Foot pads;
• Foot orthotics that are fabricated from soft plastic, cork or leather;
• Socks or any supplies that are not custom-made or of which the equivalent can be purchased without prescription; or
• Services provided to Participants that do not suffer from foot disfigurement as defined above under “Eligible Expenses.”

APPROVED AND ADOPTED at the Board of Trustees’ meeting held on April 15, 2009.

BY: Signature on File
Chairman

BY: Signature on File
Secretary