Amendment No. 10
To the Summary Plan Description of the Southern California IBEW-NECA Health Trust Fund Restated As Of September 1, 2017

This Amendment to the Southern California IBEW-NECA Health Trust Fund, Active Health Plan Summary Plan Description ("SPD”) (restated as of September 1, 2017, 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 Anthem Blue Cross PPO Plan, and the Kaiser Permanente and United HealthCare HMO Plans effective for all claims incurred on and after January 1, 2022.
2. 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, General Information, Article 8, Mandatory Generic Prescription Drug Plan, and Article 18, Disclosure Information, and elsewhere in the SPDare amended by removing "Citizens Rx”.
2. Article 1, Section 1.2 Subsection C, Appeals, 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 appeal 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, Plan Benefits Available to You, and all subsections are amended by deleting Prescription Drug Benefit Options -"Citizens Rx” and replacing the references to "Hospital/Medical Benefit” with "Health/Medical/Prescription Benefit Options”.
4. Article 6 of this SPD, Comparison of Anthem Blue Cross PPO, Kaiser HMO and UnitedHealthcare HMO Medical Plans, Section 6.1 Medical Benefits Comparison: Anthem Blue Cross, Kaiser and UnitedHealthcare is amended by replacing the existing table with the following table:

   Comparison of Medical Plan Offerings
   This is only a summary of the benefits available to you under the Anthem Blue Cross PPO Plan and the Kaiser and UnitedHealthcare HMO Plans. For a complete description of the respective PPO or HMO’s benefits, please refer to the carrier’s EVIDENCE OF COVERAGE AND DISCLOSURE DOCUMENT. The EVIDENCE OF COVERAGE AND DISCLOSURE DOCUMENT is the legal document that describes the benefits, exclusions and limitations and other coverage provisions including claims appeals, claims review and adjudication procedures. Additionally, the Summary of Benefits and Coverage (SBC) are available, routinely distributed and appear on the Trust Funds’ website at www.scibew-neca.org.
   Vendor	Anthem Blue Cross PPO		Kaiser HMO	UnitedHealthcare
   	In Network	Out-of-Network	In Network Only	In Network Only
   Member Customer Service Number	(800) 543-3037		(800) 464-4000	(800) 624-8822
   Website	www.bluecrossca.com		www.members.kp.org	www.uhcwest.com
   General Features
   Calendar Year Deductible	$200 per individual, $600 per Family		None	None
   Maximum Benefits	Unlimited		Unlimited	Unlimited
   Annual Co-payment Maximum	$1,000 per individual, $2,000 per family		$1500 per Individual, $3,000 per family	$1000 per Individual. $3,000 per family
   Hospital Benefits	10% co-payment. Hospital Pre-Certification Required.	20% co-payment. Additional $200 deductible for non-Anthem Blue Cross PPO Hospital or Residential Treatment Center and $500 no-preauthorization penalty (waived for emergency services) Hospital Precertification Required. 2	No Charge	No Charge
   Emergency Services	10% co-payment 1	10% co-payment. 2	$5 co-payment. Co-payment waived if admitted.	$50 co-payment. Co-payment waived if admitted.
   Preexisting Conditions	Not Applicable. All conditions are covered provided they are a covered benefit.
   Benefits Available While Hospitalized as an Inpatient
   Alcohol, Drug or Other Substance Abuse Detoxification	10% co-payment 1	20% co-payment 2	No Charge	No Charge
   Mental Health Services (As required by law, coverage includes treatment for Severe Mental Illness (SMI) of adults and children and the treatment of Serious Emotional Disturbance (SED).	10% co-payment 1	20% co-payment 2	No Charge	No Charge
   Newborn Care	10% co-payment 1	20% co-payment 2	No Charge	No Charge
   Physician Care	10% co-payment 1	20% co-payment 2	No Charge	No Charge
   Reconstructive Surgery	10% co-payment 1	20% co-payment 2	No Charge	No Charge
   Rehabilitative Care (including physical, occupational and speech therapy)	10% co-payment. Must obtain prior approval. 1	20% co-payment. Up to $35 max benefit per visit. Must obtain prior approval. 2	No Charge	No Charge
   Skilled Nursing	10% co-payment. 1	20% co-payment. 2	No Charge	No Charge
   Voluntary Termination of Pregnancy (Medical, Medication and surgical)	10% co-payment. 1	20% co-payment. 2	$5 Co-payment	$75 co-payment
   Benefits Available on an Outpatient Basis
   Ambulance	10% co-payment 1	10% co-payment 2	No Charge	No Charge
   Durable Medical Equipment	10% co-payment. 1	20% co-payment. 2	No Charge	No Charge
   Durable Medical Equipment for the Treatment of Pediatric Asthma (includes nebulizer, peak flow meters, face masks and tubing for Medically Necessary Treatment of Pediatric Asthma of dependent children under the age of 19)	10% co-payment. 1	20% co-payment. 2	No Charge	No Charge
   Immunizations (For Children Under two (2) years of age, refer to well-baby care)	No Charge	20% co-payment 2	$5 Office Visit Co-payment	No Charge
   Laboratory Services (When available through or authorized by PCP)	10% co-payment. 1	20% co-payment.2	No Charge	No Charge
   Mental Health Services (As required by law, coverage includes treatment for Severe Mental Illness (SMI) of adults and children and the treatment of Serious Emotional Disturbance (SED).	10% co-payment 1	20% co-payment 2	$5 Office Visit Co-payment	$5 Office Visit Co-payment
   Oral Surgery Services	10% co-payment 1	10% co-payment 2	No Charge	No Charge
   Outpatient Medical Rehabilitation Therapy at Participating Free Standing or Outpatient Surgery Facility	10% co-payment 1	20% co-payment 2	$5 Office Visit Co-payment	$5 Office Visit Co-payment
   Outpatient Surgery at Participating Free Standing or Outpatient Surgery Facility	10% co-payment. 1	20% co-payment.2	No Charge	No Charge
   Physician Office Visits (Physician, laboratory, radiology and related services as recommended by the American Academy of Pediatrics (AAP). Advisory Committee on Immunization Practices (ACIP) and U.S. Preventive Services Task Force and authorized through PCP for children).	10% co-payment 1	20% co-payment 2	$5 Office Visit Co-payment	$5 Office Visit Co-payment
   Prescription Drugs
   Retail – up to a 30-day supply
   Generic	$0 up to a 30 day supply	$5* up to a 30 day supply	$0 up to a 100 day supply	$0 up to a 30 day supply
   Brand-Name	$10 up to a 30 day supply	$15* up to a 30 day supply	$10 up to a 30 day supply	$10 up to a 30 day supply
   Mail Order (Maintenance Drugs) – up to a 90-day supply
   Generic	$0 up to a 90 day supply	N/A	$0 up to a 100 day supply	$0 up to a 90 day supply
   Brand-Name	$20 up to a 90 day supply	N/A	$20 up to a 100 day supply	$20 up to a 90 day supply
   Well-Baby Care (Preventive health service, including immunizations as recommended by the American Academy of Pediatrics (AA), Advisory Committee on Immunization Practices (ACIP) and U.S. Preventive Care Task Force and authorized through PCP for children).	0% co-payment 1	20% co-payment 2	No Charge	No Charge
   Well-Woman Care (includes PAP smear (By PCP or an OB/GYN in PMG and a referral by the PMG for screening mammography as recommended by the U.S. Preventive Services Task Force).	0% co-payment 1	20% co-payment 2	No Charge	No Charge
   1 Subject to the annual deductible.

   
   * Anthem Blue Cross non-network pharmacy claims -You must file a claim to be reimbursed for your drugs within 15 months of the purchase. This option is intended for emergencies or when travelling only. Reimbursement is limited by the Plan's average costs for prescriptions; you will pay for amounts over the limits in addition to the copay.
5. Article 8, Mandatory Generic Prescription Drug Plan, is deleted in its entirety. All references in the SPD appearing at Article 8 and elsewhere in the SPD to "Citizens Rx” shall be removed.

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