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Summary Plan Description (SPD)
Southern California IBEW-NECA Active Health Plan
Amendment # 28
To the Self-Funded Indemnity Plan as Contained
In the Active Health Plan Summary Plan Description
Dated June 1, 2004
This Amendment to the section of the Plan entitled “Mandatory Generic Prescription Drug Plan” as contained on pages 83 through 88 of the Active Health Plan Summary Plan Description, dated June 1, 2004 is effective for prescriptions filled on and after October 1, 2006.
The Mandatory Generic Prescription Drug Plan is amended throughout to delete the co-payments therein as shown below and replaced with the co-payments stated below:
|
Co-Payment |
Walk-In Pharmacy Plan |
|
Generic 30-day supply |
$0 |
Brand 30-day supply (no generic equivalent) |
$10 |
Brand 30-day supply (generic equivalent available) |
$10 + ingredient cost differential |
Maintenance Drugs 100-day Supply: |
|
Brand (generic equivalent available) |
$20 + ingredient cost differential |
Mail Service |
|
Maintenance Drugs 100-day Supply: |
|
APPROVED AND ADOPTED at the Board of Trustees’ meeting held on September 18, 2007.
BY: Signature on File
Chairman
BY: Signature on File
Secretary