Southern California IBEW-NECA Active Health Plan
Amendment # 37
To the Self-Funded IBEW-NECA Dental Plan
As Set Forth in the
Active Health Plan Summary Plan Description
Dated June 1, 2004  

The Self-Funded IBEW-NECA Dental Plan as set forth in the Southern California IBEW-NECA Health Plan Summary Plan Description for Eligible Active Participants and their Eligible Dependents effective June 1, 2004 is amended as follows:

Effective January 1, 2009, the Self-Funded IBEW-NECA Dental Plan is terminated and is replaced by the Delta Dental PPO Plan. Accordingly all members enrolled in the Self-Funded IBEW-NECA Dental Plan as of December 31, 2008 will be automatically enrolled in the Delta Dental PPO Plan and covered for dental services under the terms and conditions of that plan effective as of January 1, 2009.

Accordingly pages 89 – 101 are replaced in their entirety by pages 89 - 94 as attached to this Amendment.

APPROVED AND ADOPTED at the Board of Trustees’ meeting held on December 4, 2008.

BY: Signature on File
Chairman

BY: Signature on File
Secretary

Dental Plans Available to You

Whether you select Kaiser, PacifiCare, or the Self-Funded Indemnity Plan as your medical Plan, you have the option to enroll in one of the Dental Plans as part of your covered benefits.

You get a choice of one of the following dental plans:

• Delta Dental PPO Plan
• CIGNA Dental Plan (DHMO)
• DeltaCare USA Dental Plan (DHMO)
• United Concordia Dental Plan (DHMO)
• Safeguard Dental Plan (DHMO)

The Trust offers five dental plans from which to choose: a dental PPO plan and four Dental Health Maintenance Organizations (DHMO) plans. The dental PPO plan is provided by Delta Dental of California. The four DHMO plans are CIGNA, DeltaCare USA, United Concordia and Safeguard. We suggest that you carefully review all of the Plans, and discuss these different Plan options with your family members. A brief overview of the Delta Dental PPO Plan begins on page 90. A summary of the four DHMO plans (CIGNA, DeltaCare USA, United Concordia and Safeguard) begins on page 102.

Delta Dental PPO Plan

A Comprehensive Dental Benefits Plan with a Dental PPO

The Delta Dental PPO Plan works just like any other PPO plan. If you use dentists who belong to the Delta Dental PPO network, you will receive a greater benefit and incur less out-of-pocket costs for your dental care than if you use dentists who do not belong to Delta Dental’s PPO network.

Advantages of Using a Delta Dental PPO Dentist

• No annual or family deductible ; benefits are paid against the first dollar of eligible dental expenses you incur.
• Higher levels of benefits (with no deductible):
• Preventive dental services like routine exams, cleanings and X-rays paid at 100%;
• Basic dental services like extractions, fillings root canals and periodontic services paid at 95%;
• Major services like crowns, dentures, bridges and implants paid at 75%; and
• Maximum annual calendar-year benefit of $2,500 per person .
• No “balance” billing: you are only responsible to pay the difference between what Delta Dental pays the dentist and what Delta Dental allows for any particular procedure under the terms of their PPO contract with the dentist.

When You Use a Dentist Who Does Not Belong to the Delta Dental PPO Network

• Low annual calendar-year deductible: $25 per member, up to a maximum of $75 per family.
• High levels of benefits (subject to satisfying the annual calendar-year deductible):
• Preventive dental services like routine exams, cleanings and X-rays paid at 100% of Delta Dental’s allowance; deductible waived;
• Basic dental services like extractions, fillings root canals and periodontic services paid at 80% of Delta Dental’s allowance, deductible applies;
• Major services like crowns, dentures, bridges and implants paid at 50% of Delta Dental’s allowance, deductible applies; and
• Maximum annual calendar-year benefit of $2,000 per person .
• Greater out-of-pocket costs:In addition to the deductible and coinsurance charges, you will be responsible to pay the difference between what Delta Dental allows for any particular procedure and what the dentist charges for that procedure.

Important note: you can reduce your out-of-pocket costs by using dentists who belong to the Delta Dental Premier network. This is not the same network as the Delta Dental PPO network. If you use a Delta Dental Premier dentist, you will still have to satisfy the annual calendar-year deductible and pay a greater percentage of the cost (see “Out of Network” benefits on the chart on p. 94). However the amount the dentist can charge you for any particular procedure is limited by his contract with Delta Dental. These contracted amounts are typically 10% less than what the dentist charges to patients who do not belong to a Delta Dental plan. So by using a Delta Dental Premier dentist you may be able to reduce your out-of-pocket costs significantly as compared to using a dentist who is not contracted with either the Delta Dental PPO network or the Delta Dental Premier network.

If you are not sure if your current dentist belongs to the Delta Dental PPO network, you can call Delta Dental at (800) 765-6003 and they can tell you if your dentist is a Delta Dental PPO participating dentist. You can also use Delta Dental’s web site to determine if your dentist belongs to the Delta Dental PPO network. You can access the Delta Dental web site at www.deltadentalins.com.

As the chart on page 94 illustrates, the Delta Dental PPO Plan provides a comprehensive plan of dental care, including orthodontic care for children. Under the Delta Dental PPO Plan, you can go to any licensed dentist. You will sign a claim form completed by your dentist who will submit the claim to Delta Dental. Delta Dental will process and pay all dental claims if you are enrolled in the Delta Dental PPO Plan. If your dentist does not participate in either the Delta Dental PPO network or the Delta Dental Premier network, you may have to pay for dental services when you receive the care, and you will be responsible for the difference in cost between what your dentist charges and what Delta Dental pays for the services you received.

Many dental conditions can properly be treated in more than one way. This Plan is designed to help pay your dental expenses, but not on the basis of treatment that is more expensive than necessary for good dental care. If a condition is being treated for which two or more procedures are suitable under customary dental practices, Delta Dental will pay benefits based on the least expensive of the procedures.

Below is an example of how this rule is applied.

To restore a tooth with decay, an amalgam (silver) filling would produce a satisfactory result, but the patient decides to have the tooth crowned for the sake of appearance. In this case, Delta would pay a benefit based on the allowed amount for an amalgam (silver) filling.

If you are enrolled in the Delta Dental PPO Plan, and wish to further reduce your out-of-pocket costs for dental care, we suggest that you ask your dentist if he is a member of one of the DHMOs under contract with the Plan. If your dentist is a member of a DHMO panel, you may save considerable out-of-pocket expense by switching to that particular Plan at open enrollment.

Orthodontic Benefits - Dependent Children

The Delta Dental PPO Plan will pay up to 50% of the cost of scheduled orthodontic treatment, up to a lifetime maximum benefit of $1,400 for each dependent child. There are no orthodontic benefits for adults. Orthodontic benefits are in addition to other dental benefits payable under the Delta Dental PPO Plan.

Predetermination of Benefits

After an examination, your dentist will talk with you about treatment you may need. The cost of treatment is something you may want to consider. If the recommended treatment is extensive and involves crowns or bridges, or if the treatment will cost more than $300, we encourage you to ask your dentist to request a predetermination of benefits from Delta Dental.

A predetermination of benefits does not guarantee payment by Delta Dental. It is an estimate of the amount Delta Dental will pay for the proposed treatment if you are eligible and meet all the requirements of your plan at the time the proposed treatment is completed.

Predetermining treatment helps prevent any misunderstanding about your financial responsibilities. If you have any concerns about the predetermination, contact Delta Dental before treatment begins so your questions can be answered before you incur any charges. More information about predetermination of benefits may be found in the Delta Dental Evidence of Coverage.    

Covered Dental Services

1. Diagnostic.
   Provides all the necessary procedures to assist the dentist in evaluating the existing condition and the necessary dental treatment. These services include visits and consultations, diagnostic services, and prophylaxis (teeth cleaning).
2. Oral Surgery.
   Provides for extractions and other oral surgery including pre- and post-operative care, subject to the exclusions and limitations set forth in the Delta Dental Evidence of Coverage.
3. Restorative Dentistry.
   Provides amalgam, silicate or composite (resin) restorations (fillings) for treatment of carious lesions (visible destruction of hard tooth structure resulting from the process of dental decay). Direct composite (resin) restorations are benefits on anterior teeth and the facial surface of bicuspids. Any other posterior direct composite (resin) restorations are optional services and Delta’s payment is limited to the cost of the equivalent amalgam restorations.
4. Endodontics.
   Includes necessary pulp capping and root canal therapy.
5. Periodontics.
   Includes procedures necessary for the treatment of diseases of gums and bone supporting the teeth.
6. Prosthodontics.
   Includes bridges, implants, partial and complete dentures.
7. Orthodontics - for dependent children only.
   Provides up to the maximum allowable payment divided by the number of months of the estimated treatment plan.

If commencement of treatment occurred prior to the member's effective date, benefits will be limited to the remaining estimated months of treatment after that date based on the original plan of treatment.

When the Orthodontic Treatment is approved for dependent child, payment may be continued, up to the approved amount of payment by the Plan, if the member changes coverage to a DHMO Plan, and maintains active eligibility. In order for a dependent child to be eligible for this extension of benefits, orthodontic work must be continuous and without interruption of treatment.

How to File a Claim With Delta Dental

A Delta Dental Dentist will file the claim for you. You do not have to file a claim or pay Delta Dental’s co-payment for covered services if the services are provided by a Delta Dental Dentist. Delta Dental of California’s agreement with Delta Dental Dentists ensures that you will not be responsible to the dentist for any money Delta Dental owes.

If the covered service is provided by a dentist who is not a Delta Dental Dentist, you are responsible for filing the claims and paying your dentist. Claims should be filed with Delta Dental of California at P. O. Box 997330, Sacramento, CA 95899-7330 and Delta Dental will reimburse you. However, if for any reason Delta Dental fails to pay a dentist who is not a Delta Dental Dentist, you may be liable for that portion of the cost. Payments made to you are not assignable (in other words, Delta Dental will not grant requests to pay non-Delta Dental Dentists directly).

Payment for claims exceeding $500 for services provided by dentists located outside the United States may, at Delta Dental’s option, be conditioned upon a clinical evaluation at Delta Dental’s request (see Delta Dental’s Evidence of Coverage for more information about Second Opinions). Delta Dental will not pay benefits for such services if they are found to be unsatisfactory or medically unnecessary.

The process Delta Dental uses to determine or deny payment for services is distributed to all Delta Dental Dentists. It describes in detail which dental procedures are covered under Delta Dental’s contract, the conditions under which coverage is provided, and the limitations and exclusions applicable to the plan. Claims are reviewed for eligibility and are paid according to these processing policies. Those claims which require additional review are evaluated by Delta Dental’s dentist consultants. If any claims are not covered, or if limitations or exclusions apply to services you have received from a Delta Dental Dentist, you will be notified by an adjustment notice on the Notice of Payment or Action. You may contact Delta Dental’s Customer Service department at (800) 765-6003 for more information regarding Delta Dental’s processing policies. More information about how Delta Dental processes and pays claims may be found in the Delta Dental Evidence of Coverage.

Coordination of Benefits

Some individuals have dental expense coverage in addition to coverage under the Delta Dental PPO Plan. In that situation, Delta Dental will take the benefits from the "Other Plan" into account in determining the benefit they will pay under this Plan. This is called coordination of benefits and is done to assure that no participant receives dental benefits that exceed 100% of the reasonable and customary costs of dental services. Delta Dental’s Evidence of Coverage which participants in this Plan will receive provides detailed information about the rules governing Delta Dental’s coordination of benefits procedures.

Exclusions and Limitations

Delta Dental’s PPO Plan limits certain services based on age, frequency or elapsed time between services.

Services that may be subject to age limitations include orthodontic services and application of fluoride and sealants. Services that may be subject to frequency limitations include oral examinations, prophylaxis (teeth cleaning) and bitewing X-rays as well as full-mouth X-rays. Services that may be limited based upon elapsed time include restorations involving crowns, inlays, onlays, as well as certain endodontic procedures (such as root canals) and certain prosthodontic services (such as fabrication of dentures).

Excluded services include services covered under Workers Compensation, services performed for cosmetic purposes, and diagnosis and treatment of any condition related to or involving the temporomandibular joint (TMJ) or associated muscles or nerves.

A complete listing of Delta Dental’s limitations and exclusions is set forth in the Evidence of Coverage document provided by Delta Dental which is incorporated into this Summary Plan Description by reference.

- The next valid page in the Summary Plan Description is page 102 -