Amendment No. 5
To the Summary Plan Description of the Southern California IBEW-NECA Health Trust Fund Retiree Health Plan

This Amendment to the Southern California IBEW-NECA Health Trust Fund, Retiree Health Plan Summary Plan Description ("SPD") (restated as of February 1, 2018, as amended), is made by the Board of Trustees of the Southern California IBEW-NECA Health Trust Fund ("Board of Trustees") with reference to the following facts and circumstances:

1. The Board of Trustees wishes to amend the SPD to reflect the termination of the self-funded mandatory generic prescription drug program managed by Citizens Rx and implement the insured prescription drug programs under the Kaiser Permanente and United HealthCare HMO Plans effective for claims and appeal of claims incurred on and after January 1, 2022.
2. The Board of Trustees wishes to amend the SPD to reflect the termination of the Medicare Supplement Plan and enroll all participants in the UnitedHealthcare Medicare Advantage Plan (referred to as the "Out-Of-Area Plan").
3. The Board of Trustees has reserved to themselves the ability to amend the SPD from time to time.

NOW THEREFORE, effective January 1, 2022, the SPD is amended as follows:

1. All references in the SPD appearing at Article 1, Introduction, Article 2, Summary of Benefits, Article 4, Medical Coverage, Article 5, Mandatory Generic Prescription Drug Plan, Article 8, Benefits for Disabled Retirees as of April 1, 2017, subsections 8.1 and 8.2, Article 9, Important Federal Laws, and Article 10, Plan Amendment Procedures and Disclosure Information, and elsewhere in the SPD are amended by removing "Citizens Rx". .
2. Article 1, subsection 1.3, third paragraph is amended by providing clarification of the language in the following paragraph to refer to claims and appeals for claims incurred prior to January 1, 2022.
   "Citizens Rx is a claims fiduciary and handles prescription drug claims and appeals under its claims and appeals rules for claims and appeals for claims incurred prior to January 1, 2022. Citizens Rx will decide appeals and obtain independent medical reviews requested by Participants. Citizens Rx will use an IMR company licensed in the State of California. Participants will be notified in writing of any adverse determinations within the time required by federal law and regulations.
3. Article 2, subsection 2.1.1 is amended to read as follows:
   
   Retirees Under Age 65 and not eligible or enrolled in Medicare
   
   Benefit Options
   Southern California residents may choose one of the options if you reside in the geographical jurisdiction as defined by the HMO you select.
   

   	Benefit Options	Prescription Drug Benefits
   Option 1	Kaiser Permanente HMO	Kaiser Permanente Prescription Drug Plan
   Option 2	UnitedHealthcare HMO	UnitedHealthcare Prescription Drug Program

   
   

   Summary of Benefits

   Early Retirees (Under Age 62 and not eligible or enrolled in Medicare)

   Prescription Drugs
   	Kaiser HMO	UnitedHealthcare HMO *
   Retail Pharmacy: Generic	$0 co-payment Up to a 100-day supply	$0 co-payment Up to a 30-day supply
   Retail Pharmacy: Brand -Formulary	$10 co-payment Up to a 30-day supply	$10 co-payment Up to a 30-day supply
   Retail Pharmacy — Brand- _Non-Formulary	N/A	N/A
   Mail Order: Generic	$0 co-payment Up to a 100-day supply	$0 co-payment Up to a 90-day supply
   Mail Order: Brand - Formulary	$20 co-payment Up to a 100-day supply	$20 co-payment Up to a 90-day supply
   Mail Order — Brand — Non-Formulary	N/A	N/A

4. Article 7, Medicare Supplement Plan Prior to January 1, 2016 is deleted in its entirety. All participants enrolled in this Plan will be transitioned to the Anthem Medicare Preferred Plan-Out-of-Area Retiree Plan of benefits effective for services on or after January 1, 2022.

All other terms and conditions of the Plan shall remain in full force and effect.

BY: Signature on File
Chairman

BY: Signature on File
Secretary