Retiree Health Summary Plan Description
As of February 1, 2018
En Español (PDF)

Amendment No. 7
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") 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:

The Board of Trustees wishes to amend the SPD to reflect the following changes to the United Healthcare HMO Plan. The changes are summarized below:
United Healthcare
1. Annual Copayment Maximum — Increase to $2,500 per individual and $5,000 per family.
2. Emergency Services — Increase to $250 per visit.
3. Hospital Admission Copayment — Increase to $250 per visit.
4. Appointments/Services other than PCP Visits (specialty services) —$5 per visit for most primary care visits; $25 per visit for most physician specialist visits.
5. Prescription Drug Copayments — Increase the prescription drug copayments to $10 per generic retail prescription up to 30-day supply and $20 per brand-name prescription, 30-day supply; and $20 generic through mail order service up to 90-day supply and $40 brand name through mail order service up to 90-day supply
The Board of Trustees has reserved to themselves the ability to amend the SPD from time to time.

NOW THEREFORE, effective January 1, 2023, Article 2, Summary of Benefits, Section 2.2, Summary of Benefits Early Retirees (Under Age 62 and not eligible or enrolled in Medicare) is amended as follows:

Summary of Benefits

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

Summary of Benefits for Early Retirees (Under Age 62 and not eligible or enrolled in Medicare)
	Kaiser Permanente HMO (In Network Only)	UnitedHealthcare HMO (In Network Only)	Out-of-Area Plan UnitedHealthcare (In Network Benefits)
Member Customer Service Number	(800) 464-4000	(800) 624-8822	Northern California (800) 624-8822 Out-of-state (866)633-2446
Website	*www.kp.org*	*www.myuhc.com*	www.myuhc.com
General Features
Calendar Year Deductible	None	None	$500 per Individual $1,000 per Family
Maximum Benefits	Unlimited	Unlimited	Unlimited
Annual Co-payment Maximum	$1,500 per Individual $3,000 per Family	$2,500 per Individual $5,000 per Family	$4,500 per Individual $9,000 per Family
Hospital Benefits	No charge	$250 Co-Payment	80% after deductible has been met
Emergency Services Co-payment waived if admitted	$5 co-payment	$250 co-payment	$100 co-payment; deductible does not apply
Urgently Needed Services Medically Necessary services required outside geographic area service by Primary Medical Group	$5 co-payment	$50 co-payment	$50 co-payment; deductible does not apply
Pre-existing Conditions	All Medically Necessary conditions are covered provided they are a covered benefit
Inpatient Hospital Benefits
Alcohol, Drug or Other Substance Abuse Detoxification	No charge	No charge	80% after deductible
Mental Health Services As required by law, coverage includes treatment for Severe Mental Illness of adults and the treatment of Serious Emotional Disturbance.	No charge	No charge	80% after deductible
Physician Care	No charge	No charge	No charge
Reconstructive Surgery	No charge	No charge	80% after deductible
Rehabilitative Care Including physical, occupational and speech therapy	No charge	No charge	$20 co-payment
Skilled Nursing Facility Up to 100 Consecutive Days from the first treatment per disability	No charge	No charge	80% after deductible
Outpatient Benefits
Alcohol, Drug or Other Substance Abuse Detoxification	$5 per visit	No charge	$20 co-payment
Ambulance	No charge	No charge	80% after deductible
Durable Medical Equipment	No charge	No charge	80% after deductible
Voluntary Termination of Pregnancy (medical, medication, surgical): 1st Trimester	$5?co-payment	$75 co-payment	The amount you pay is based on where the covered service is provided.
Laboratory Services When available through or authorized by PCP	No charge	No charge	No charge
Maternity Care, Tests Procedures	No charge	No charge	The amount you pay is based on where the covered service is provided.

Prescription Drugs
	Kaiser HMO	UnitedHealthcare HMO *	Out-of-Area Plan UnitedHealthcare
Retail Pharmacy: Generic	$0 co-payment Up to a 100-day supply	$10co-payment Up to a 30-day supply	$10 co-payment Up to a 30-day supply
Retail Pharmacy: Brand — Formulary	$10 co-payment Up to a 30-day supply	$20 co-payment Up to a 30-day supply	$25 co-payment Up to a 30-day supply
Retail Pharmacy — Brand — Non-Formulary	N/A	N/A	$45 co-payment up to a 30-day supply

Mail Order: Generic	$0 co-payment Up to a 100-day supply	$20 co-payment Up to a 90-day supply	$25 co-payment Up to a 90-day supply
Mail Order: Brand - Formulary	$20 co-payment Up to a 100-day supply	$40 co-payment Up to a 90-day supply	$62.50 co-payment Up to a 90-day supply
Mail Order — Brand — Non-Formulary	N/A	N/A	$112.50 co-payment Up to a 90-day supply

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

Executed this 20th day of October 2022 at Pasadena, California.

BOARD OF TRUSTEES
SOUTHERN CALIFORNIA IBEW-NECA
HEALTH TRUST FUND

BY: Signature on File
Chairman

BY: Signature on File
Secretary

New Participant Portal

Retiree Health Summary Plan Description
As of February 1, 2018
En Español (PDF)

Amendment No. 7
To the Summary Plan Description of the Southern California IBEW-NECA Health Trust Fund Retiree Health Plan

New Participant Portal

New Participant Portal

Retiree Health Summary Plan DescriptionAs of February 1, 2018En Español (PDF)

Amendment No. 7 To the Summary Plan Description of the Southern California IBEW-NECA Health Trust Fund Retiree Health Plan

New Participant Portal

Retiree Health Summary Plan Description
As of February 1, 2018
En Español (PDF)

Amendment No. 7
To the Summary Plan Description of the Southern California IBEW-NECA Health Trust Fund Retiree Health Plan