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UNITED FOOD AND COMMERCIAL WORKERS LOCAL 400 AND EMPLOYERS HEALTH AND WELFARE PLAN SUMMARY PLAN DESCRIPTION PLAN 1 For eligibility on and after September 1, 2012: Employees hired on or before October 15, 2005 with five years of seniority from date of hire and who average a minimum of 18 hours per week Employees hired after October 15, 2005 and before January 1, 2012 with five years of seniority from date of hire and who average a minimum of 20 hours per week And Plan S and Plan V For Retired Employees January 2014 Edition [INSERT TO FRONT COVER] HOW TO FILE A MEDICAL CLAIM All Medical claims, other than Vision and Dental, should be submitted electronically by your provider to the local Blue Cross Blue Shield. Make sure you present your current Blue Cross Blue Shield card with Identification and Group numbers to your provider. For Dental and Vision claims, follow the procedures listed below: 1. Provider submits paper claim to the Plan Office at: 600 D Street, Suite 250, South Charleston, WV 25303 2. Provider submits any x-rays or doctor notes needed for processing. 3. You may submit all receipts and bills to the Plan Office if the provider does not bill for services. All Medical, Dental and Vision claims should be submitted as soon as possible after the date of service, and no later than the last day of the calendar year after the year of the date of service. Remember that your claims cannot be paid until all of the information needed to process the claim is given to the Plan Office. An annual Enrollment Form must also be on file. HOW TO FILE A PRESCRIPTION CLAIM Please refer to Page 85 of this booklet for information regarding the prescription drug benefits. If you are filing a Pharmacy paper claim, it must be submitted to the Plan Office within three months of the date the prescription is filled at a pharmacy. Submit the prescription receipt along with cash register receipts, tapes or computer printout for all drugs purchased. IMPORTANT: Keep a separate record of all medical expenses incurred for yourself and each of your dependents, such as bills for doctors, hospital, laboratory, services, drugs, etc. These must show the date the expense was incurred and the type of expense. Expenses for prescription drugs must show the date of purchase and name of the doctor who issued the prescription. UNITED FOOD AND COMMERCIAL WORKERS LOCAL 400 AND EMPLOYERS HEALTH AND WELFARE PLAN 600 D Street Suite 250 South Charleston, WV 25303 304-343-7682 BOARD OF TRUSTEES Union Trustees Mark Federici James Slivosky Charles Miller, Alternate Employer Trustees Steve Loeffler Mike Christle Steven Springer, Alternate Only the full Board of Trustees is authorized to interpret the Plan of Benefits described in this booklet. The provisions of this document are subject to amendment and interpretation by the Board of Trustees and to the rules, regulations or procedures of the Plan in effect at the time of a claim. The Board of Trustees has the power to interpret, apply, construe, and amend the provisions of the Plan and this Summary Plan Description (“SPD”) and make factual determinations regarding its construction, interpretation and application. The Board’s interpretation will be final and binding on all individuals dealing with or claiming a benefit from the Plan. No agent, representative, officer or other individual from a Union or an Employer has authority to speak for the Trustees or to act contrary to the written terms of the governing Plan documents. If you wish to receive any information regarding the Plan, such information must be submitted to you in writing by the Trustees, or if authorized by the Trustees, in writing signed by the Fund Office. Most of the benefits described in the Plan’s legal documents and in this booklet are self-funded. The benefits payable are limited to Plan assets available for such purposes. This booklet describes Plan 1 for active employees and Plans S and V for retired employees. Other booklets describe other plans of benefits. Be sure you have the booklet that applies to you. UNITED FOOD AND COMMERCIAL WORKERS LOCAL 400 AND EMPLOYERS HEALTH AND WELFARE PLAN TO ALL PARTICIPANTS: We are pleased to present you with this booklet to give you an up-to-date summary description of the benefits provided by the Health and Welfare Plan. This booklet is called the SPD. This SPD describes the benefits provided by the Plan in general terms. The Plan’s Rules and Regulations and Trust Agreement, which are available for your review at the Plan Office or by written request, comprise the legal documents of the Plan and contain a detailed description of the rules, regulations, benefits and provisions of the Plan. If there is any inconsistency between the SPD and the Plan and Trust, the Plan and Trust will control. The Plan is also required under federal law to provide you with other documents, including a Summary of Benefits and Coverage (“SBC”). In the event of an inconsistency between the SBC and the SPD, the SPD will govern. In the event of an inconsistency between the SBC or the SPD and the Plan document, the Plan document will govern. You will note that the term “benefits” is used and not “insurance.” The Health and Welfare Plan is not an insurance company. It is a self-funded health benefit program operated under federal law and guidelines and is not subject to state insurance regulations or laws. The Life Insurance and Accidental Death and Dismemberment and Loss of Sight portion of the Plan is insured under a contract with Hartford Life and Accident Insurance Company (The Hartford). Since the last SPD was printed, a number of important changes have been made to the Plan. The deductibles and copayments have been changed, a utilization and disease management provider, InforMed, has been added, pre-certification requirements have been modified, and other changes have been made to benefits as required by changes in the law. Please review this SPD carefully and keep it with your other important papers so that you will be familiar with the benefits available for you and your eligible dependents. While it is our hope that you and your family will enjoy good health, it is comforting to know that these benefits are available when needed. If you have any questions regarding the benefits to which you are entitled, how to file a claim, or eligibility, please contact the Plan Office. Sincerely, THE BOARD OF TRUSTEES 1 TABLE OF CONTENTS Page SCHEDULE OF BENEFITS ..................................................................................... Schedule I – Plan 1 (Active Employees) ....................................................... Schedule II – Plan S (Retired Employees Age 65 or Older).......................... Schedule III – Plan V (Retired Employees Under Age 65) ........................... 4 4 12 16 DEFINITIONS ........................................................................................................... 20 ELIGIBILITY ............................................................................................................ 30 Qualified Medical Child Support Orders (“QMCSO”) ................................. Uniformed Services Employment and Reemployment Rights Act of 1994 (“USERRA”) .................................................................................... Family and Medical Leave Act (“FMLA”) ................................................... 35 35 36 CONTINUATION OF COVERAGE UNDER THE CONSOLIDATED OMNIBUS BUDGET RECONCILIATION ACT (“COBRA”) ............................... 37 EXTENSION OF BENEFITS ................................................................................... 43 RETIREE COVERAGE ............................................................................................ 44 SURVIVING SPOUSE BENEFIT ............................................................................ 46 GENERAL EXCLUSIONS AND LIMITATIONS................................................... 49 LIFE INSURANCE BENEFIT .................................................................................. 55 ACCIDENTAL DEATH, DISMEMBERMENT AND LOSS OF SIGHT BENEFITS ................................................................................... 58 DISABILITY BENEFIT ............................................................................................ 61 RETIREE DEATH BENEFIT ................................................................................... 62 GENERAL RULES ................................................................................................... 64 PPO NETWORK OPTIONS ..................................................................................... 66 HOSPITAL AND PHYSICIAN PPO NETWORK ................................................... 66 PHARMACY NETWORK ........................................................................................ 67 HOSPITAL PREADMISSION CERTIFICATION REQUIREMENT (MATERNITY ADMISSIONS SEE PAGE 70) ....................................................... 67 PREAUTHORIZATION OF SURGICAL PROCEDURE AND OTHER BENEFITS 68 2 Page MAJOR MEDICAL EXPENSE BENEFITS............................................................. Overview ........................................................................................................ Deductible Requirement ................................................................................ Percentage Payable ........................................................................................ Benefits .......................................................................................................... 70 70 70 70 71 BASIC MEDICAL EXPENSE BENEFIT................................................................. 80 DENTAL EXPENSE BENEFIT................................................................................ Benefits .......................................................................................................... Covered Dental Services ................................................................................ Limitations ..................................................................................................... Exclusions ...................................................................................................... 81 81 81 82 83 PRESCRIPTION DRUG EXPENSE BENEFIT ....................................................... Benefits .......................................................................................................... Self-Injectable Drugs ..................................................................................... Step Therapy .................................................................................................. Exclusions and Limitations ............................................................................ 85 85 86 87 88 HOSPITAL SELF-AUDIT PROGRAM ................................................................... 90 COORDINATION OF BENEFITS ........................................................................... With Other Plans ............................................................................................ With Medicare ............................................................................................... 91 91 94 SUBROGATION AND REIMBURSEMENT .......................................................... 95 GENERAL PLAN INFORMATION ........................................................................ Plan Administration ....................................................................................... Financial Information..................................................................................... Plan Information ............................................................................................ HIPAA Certificates of Creditable Coverage from This Plan......................... Claims Filing and Appeal Procedure ............................................................. Review of Plan Documents ............................................................................ 99 99 101 101 103 104 112 NOTICE OF PRIVACY PRACTICES ...................................................................... 114 CERTIFICATE OF INSURANCE ............................................................................ 124 3 SCHEDULE I UNITED FOOD AND COMMERCIAL WORKERS LOCAL 400 AND EMPLOYERS HEALTH AND WELFARE PLAN PLAN 1 Schedule of Benefits for Eligible Full-Time Employees, Part-Time Employees and Eligible Dependents Where the Required Self-Contribution is Paid (Effective as of January 1, 2014) ELIGIBLE FULL-TIME EMPLOYEES ONLY Life Insurance Benefit: Total and Permanent Disability limited to $30,000.00 $50,000 Accidental Death, Dismemberment and Loss of Sight Benefit Disability Benefit: (Totally Disabled Employees Only) Maximum payment per month Maximum period $50,000 $200 5 months ELIGIBLE PART-TIME EMPLOYEES ONLY Life Insurance Benefit: $10,000 Accidental Death, Dismemberment and Loss of Sight Benefit $10,000 Disability Benefit: (Totally Disabled Employees Only) Maximum payment per month $200 Maximum period 5 months ELIGIBLE DEPENDENTS OF ELIGIBLE FULL-TIME EMPLOYEES ONLY Life Insurance Benefit: Spouse Dependent Child: Over 14 days but less than 6 months of age 6 months but less than 2 years of age 2 years but less than 3 years of age 3 years but less than 19 years of age Maximum Benefit $2,000 $ 200 $ 400 $ 800 $1,000 4 ELIGIBLE FULL-TIME EMPLOYEES, PART-TIME EMPLOYEES AND DEPENDENTS Benefits are payable only for Covered Charges. MAJOR MEDICAL EXPENSE BENEFITS MAXIMUM MAJOR MEDICAL EXPENSE BENEFIT Per Covered Family Member ALL ESSENTIAL HEALTH BENEFITS ARE APPLIED TOWARD THE ANNUAL AND LIFETIME MAXIMUMS ON NON-ESSENTIAL HEALTH BENEFITS UNDER THE MAJOR MEDICAL EXPENSE BENEFIT UNLESS OTHERWISE STATED There is no annual maximum for essential health benefits (see page 24 for more information). The annual maximum for non-essential health benefits is: (-----$400,000-----) LIFETIME MAXIMUM BENEFIT FOR NON-ESSENTIAL HEALTH BENEFITS (-----$400,000-----) LIFETIME MAXIMUM BENEFIT For eligible Surgeries by licensed podiatrists (DPM) Per Covered Family Member (--------$1,000-----) MAXIMUM IN-NETWORK OUT-OF-POCKET per Covered Family Member per Calendar Year (Covered Charges incurred during a calendar year in excess of the deductible are paid at 100% U&C after Calendar Year Out-of-Pocket Maximum is reached) Per Person Per Family (-------$3,000---------) (-------$6,000---------) MAXIMUM OUT-OF-NETWORK OUT-OF-POCKET per Covered Family Member per Calendar Year Per Person Per Family CALENDAR YEAR IN-NETWORK DEDUCTIBLE Single (Employee Only) Coverage Family (Employee and Dependents) Coverage 5 (----------$6,000------) (--------$12,000------) (--------$400-----) (--------$800-----) CALENDAR YEAR OUT-OF-NETWORK DEDUCTIBLE Single (Employee Only) Coverage Family (Employee and Dependents) Coverage (--------$800-----) (------$1,600-----) CO-INSURANCE PERCENTAGE PAYABLE AFTER DEDUCTIBLE Per Employee and Covered Family Member Covered Charges With an In PPO Network Provider or where No 80% of U&C before PPO Network applicable Calendar Year Outof-Pocket Maximum is reached (except if otherwise shown) Covered Charges With a Non PPO Network Provider URGENT CARE OFFICE VISITS In Network 50% of U&C before Calendar Year Outof-Pocket Maximum is reached (except if otherwise shown) 100% after $30.00 co-payment. Out-Of Network, 100% after $30.00 co-payment PRIMARY CARE PHYSICIAN OFFICE VISITS* In Network SPECIALIST OFFICE VISITS* In Network *Services administered the same day as the office visit in the same office by the same provider and for the same diagnosis would be covered within the 100% after co-pay in-network coverage. Copayments are not applied to the out-of-pocket maximums. 100% after $25.00 co-payment. Out-Of Network, 50% after deductible 100% after $30.00 co-payment. Out-Of Network, 50% after deductible All Hospital Covered Charges (subject to preadmission certification requirement) (Includes inpatient, outpatient and preadmission testing) Daily Room and Board Limit Average Semi-Private Room Charge or 100% U&C for Intensive Care Accommodations 6 Physician Covered Charges (subject to review for charges above base service) Chiropractors or physical therapists employed by or in same office as Chiropractors (subject to deductible and co-insurance and additional limits below) MAXIMUM NO. OF VISITS Per calendar year 30 Visits + additional visits subject to pre-certification. Physical Medicine (therapy) (subject to deductible and co-insurance and additional limits below) MAXIMUM NO. OF VISITS Per calendar year 20 Visits + additional visits subject to pre-certification. Durable Medical Supplies (any charge above $500 is subject to preauthorization requirement) U&C Diagnostic Laboratory & X-ray Expenses (Non-emergency MRIs, PET and CAT scans are subject to preauthorization requirement) U&C Convalescent Care Accommodations (subject to preauthorization requirement and following limits) CALENDAR YEAR MAXIMUM NO. OF DAYS 120 Days Home Health Care (Subject to preauthorization requirement and following limits) MAXIMUM NO. OF VISITS Per 12-Month Period 40 Visits Hospice Care (Subject to preauthorization requirement and following limits) MAXIMUM LIFETIME BENEFIT 6 Months Mental and Nervous Disorder/Alcohol and Substance Abuse - Inpatient and Outpatient Treatment All mental health and substance abuse benefits are provided according to the Major Medical Benefit rules under the Plan unless otherwise indicated. Office Visit 100% after $25 co-payment 7 Emergency Room Services In-Network Emergency 80%/20% In-Network Non-Emergency 50%/50% Out-of-Network Emergency 80%/20% Out-of-Network Non-Emergency 50%/50% Allergy Injections U&C Diabetes Education (subject to additional limits below) U&C CALENDAR YEAR MAXIMUM BENEFIT FOR REEDUCATION OR REFRESHER EDUCATION $100 U&C Ambulance Charges Hearing Expense Benefit (Must utilize an in-network Provider) Hearing Screening and Examination by a Licensed Audiologist Lifetime Maximum per person for Hearing Aid/Device 8 80% of U&C $1,500 BASIC MEDICAL EXPENSE BENEFIT PREVENTIVE -- IN-NETWORK without deductible (Participants, Dependent spouse and children, all subject to age and 100% NO MAXIMUM frequency limits) Please see www.healthcare.gov for more information about which preventive services are covered as required by the health care reform law. PREVENTIVE -- OUT-OF-NETWORK (except as provided under Wellness Benefit) Not Covered WELLNESS BENEFITS The Plan also provides for the following services to the extent not In-Network 100% covered by the above preventive services benefit: annual physical, diagnostic radiology and laboratory services related to routine exam, Out-Of-Network, 50% routine colonoscopies (up to age 50), routine mammograms (up to coverage after deductible age 40), PSA testing, testicular cancer screening. One examination per calendar year HOSPITAL ROOM & BOARD (Non Diagnosis Related Group (“DRG”) charges) (Effective 1/1/2009) $165.00 per day (70 days); ICU-$330, first ten days, $165 a day afterwards for 70 days, then coverage provided under Major Medical Vision Care Expense Benefit One examination and/or set of lenses and frames allowed during any two calendar year period up to MAXIMUM BENEFIT *For children up to age 19, only the expenses for lenses and frames will be counted towards the maximum benefit $200* DENTAL EXPENSE BENEFIT MAXIMUM BENEFIT Per Calendar Year *The maximum benefit only applies to adult dental benefits, not to dental benefits for children up to age 19 Maximum Plan Payment of $750* Diagnostic, Preventive & Emergency Services 100% of Schedule Basic (except periodontic), Major & TMJ Services 80% of Schedule Orthodontic and Periodontal Services *Lifetime maximum does not apply to periodontal services for children up to age 19 9 50% up to $1,250 per person lifetime maximum* RETAIL PRESCRIPTION DRUG EXPENSE BENEFIT Drug Classification Participant Co-Payment Amount* Generic drug Lesser of $7.50 or 10%* (See Below) Formulary Brand Name drug Lesser of $20 or 20%** Multi-source Brand Name drug Paid as Generic*** (See Below) Co-Payment Amount depends on Generic, Multi-Source Brand Name drug or Formulary Brand Name drug. Formulary Co-Payment is Greater of $15 or 15% with Max co-pay of $75.00****(See Below) Maintenance Medication Oral Contraceptives for birth control Generic Covered Erectile Dysfunction Medication (subject to pre-authorization) Mental and Nervous Disorders Paid as Generic Co-Payment Amount depends on Generic, Formulary Brand Name drug or Multi-source Brand Name drug Injectable Prescription Medications (non-self- injectable not available through a pharmacy) Medically Necessary Growth hormones Paid under Major Medical Benefit 50% Maximum Supply Per Retail Fill 34 Days Maximum Participant Co-Payment per fill $75.00 *The maximum Participant Co-Payment Amount (subject to the provisions and limitations of the Plan) is $7.50. **The maximum Participant Co-Payment Amount (subject to the provisions and limitations of the Plan) is $20.00. ***When a Covered Family Member, Physician or pharmacy chooses a Brand Name drug when a Generic equivalent is available, the Plan/KPP covers the amount it would pay for the Generic drug equivalent, and the Covered Family Member is responsible for the remainder of the cost. ****A Maintenance Medication is a prescription drug or medicine taken on a continual basis for treatment of a chronic health condition such as but not limited to, high blood pressure (anti-hypertensive), high cholesterol, asthma, glaucoma, osteoporosis, diabetes and diabetic related supplies. The minimum Participant Co-payment Amount (subject to the provisions and limitations of the Plan) is $15.00. If the Participant Co-Payment % for a prescription produces an amount less than $15.00, then the Participant Co-Payment is $15.00. 10 MAIL ORDER PRESCRIPTION DRUG EXPENSE BENEFIT FOR KROGER EMPLOYEES Drug Classification Participant Co-Payment Amount Generic drug Greater of $15 or 10%* Formulary Brand Name drug Greater of $40 or 20%** Multi-source Brand Name drug Paid as Generic*** (See Below) Maintenance Medication Greater of $30 or 15%**** Maximum Supply Per Fill 102 Days Maximum Participant co-payment per fill $150.00 *The minimum Participant Co-Payment Amount (subject to the provisions and limitations of the Plan) is $15.00. If the Participant Co-Payment % for a prescription produces an amount less than $15.00, then the Participant Co-Payment Amount is $15.00. **The minimum Participant Co-Payment Amount (subject to the provisions and limitations of the Plan) is $40.00. If the Participant Co-Payment % for a prescription produces an amount less than $40.00, then the Participant Co-Payment Amount is $40.00. ***When a Covered Family Member, Physician or pharmacy chooses a Brand Name drug when a Generic equivalent is available, KPP will pay the amount it would pay for the Generic drug equivalent, and the Covered Family Member is responsible for the remainder of the cost. ****A Maintenance Medication is a prescription drug or medicine taken on a continual basis for treatment of a chronic health condition such as but not limited to, high blood pressure (anti-hypertensive), high cholesterol, asthma, glaucoma, osteoporosis, diabetes and diabetic-related supplies. The minimum Participant Co-Payment Amount (subject to the provisions and limitations of the Plan) is $30.00. If the Participant Co-Payment % for a prescription produces an amount less than $30.00, then the Participant Co-Payment is $30.00. The Trustees reserve the right to amend, change, eliminate or decrease benefits from time to time and at any time for all eligible Employees and their eligible Dependents. 11 SCHEDULE II Retiree Coverage (Senior Program – Plan S) Schedule of Benefits for all Eligible Employees who Retired before March 1, 1990 and Eligible Dependents And Eligible Retired Employees Age 65 and Older and Eligible Dependents (Effective as of January 1, 2014) ELIGIBLE RETIRED EMPLOYEES ONLY Self-funded Death Benefit (Retirees Receiving Disability Pensions Excluded) $5,000 ELIGIBLE RETIRED EMPLOYEES AND DEPENDENTS Benefits are payable only for Covered Charges. MAJOR MEDICAL EXPENSE BENEFITS MAXIMUM MAJOR MEDICAL EXPENSE BENEFIT Per Covered Family Member ALL ESSENTIAL HEALTH BENEFITS ARE APPLIED TOWARD THE ANNUAL AND LIFETIME MAXIMUMS ON NON-ESSENTIAL HEALTH BENEFITS UNDER THE MAJOR MEDICAL EXPENSE BENEFIT UNLESS OTHERWISE STATED There is no annual maximum for essential health benefits (for more information, see page 24). The annual maximum for major medical benefits for nonessential health benefits is: (-----$350,000-----) LIFETIME MAXIMUM FOR NON-ESSENTIAL HEALTH BENEFITS (-----$350,000-----) LIFETIME MAXIMUM BENEFIT For eligible Surgeries by licensed podiatrists (DPM) Per Covered Family Member (-------$1,000------) 12 MAXIMUM OUT-OF-POCKET per Covered Family Member per Calendar Year (Covered Charges incurred during a calendar year in excess of the deductible are paid at 100% U&C after Calendar Year Out-of-Pocket Maximum is reached) Per Person Per Family CALENDAR YEAR DEDUCTIBLE (--------$4,000--------) (--------$8,000--------) Single (Employee Only) Coverage Family (Employee and Dependents) Coverage (--------$350--------) (--------$700--------) CO-INSURANCE PERCENTAGE PAYABLE AFTER DEDUCTIBLE Per Covered Family Member Covered Charges With an In PPO Network Provider or where 80% of U&C before No PPO Network applicable Calendar Year Outof-Pocket Maximum is reached (except if otherwise shown) Covered Charges With a Non PPO Network Provider 50% of U&C before Calendar Year Outof-Pocket Maximum is reached (except if otherwise shown) All Hospital Covered Charges (subject to preadmission certification requirement) (Includes inpatient, outpatient and preadmission testing) Daily Room and Board Limit Average Semi-Private Room Charge or 100% U&C for Intensive Care Accommodations Physician Covered Charges (subject to review for charges above base service) Chiropractors or physical therapists employed by or in same office as Chiropractors (subject to additional limits below) MAXIMUM NO. OF VISITS Per Calendar Year 30 Visits + additional visits subject to pre-certification. Subject to deductibles and coinsurance Physical Medicine (therapy) (subject to additional limits below)) MAXIMUM NO. OF VISITS Per Calendar Year 20 Visits + additional visits subject to pre-certification 13 Durable Medical Supplies (any charge above $500 subject to preauthorization requirement) U&C Diagnostic Laboratory & X-ray Expenses (Non-emergency MRIs, PET and CAT scans are subject to preauthorization requirement) U&C Convalescent Care Accommodations (subject to preauthorization requirement and following limits) CALENDAR YEAR MAXIMUM NO. OF DAYS 120 Days Home Health Care (Subject to preauthorization requirement and following limits) MAXIMUM NO. OF VISITS Per 12-Month Period 40 Visits Hospice Care (Subject to preauthorization requirement and following limits) MAXIMUM LIFETIME BENEFIT 6 months Mental and Nervous Disorder/Alcohol and Substance Abuse - Inpatient and Outpatient Treatment U&C All mental health and substance abuse benefits are provided according to the Major Medical Benefit rules under the Plan unless otherwise indicated. Allergy Injections U&C Diabetes Education (subject to additional limits below) U&C CALENDAR YEAR MAXIMUM BENEFIT FOR REEDUCATION OR REFRESHER EDUCATION $100 Ambulance Charges U&C PREVENTIVE -- IN-NETWORK without deductible (Participants, Dependent spouse and children subject to age limits) 100% NO MAXIMUM PREVENTIVE -- OUT-OF-NETWORK Not Covered 14 PRESCRIPTION DRUG EXPENSE BENEFIT Effective January 1, 2006, if you are eligible for Medicare, you are eligible to receive prescription benefits through the federal government Medicare Part D program and you will no longer receive prescription benefits from the Plan. However, your non-Medicare eligible spouse and/or other dependents will continue to receive prescription benefits from the Plan. Drug Classification Participant Co-Payment Amount* Generic drug Greater of $10 or 10%* Formulary Brand Name drug Greater of $20 or 20%* Multi-source Brand Name drug Paid as Generic **(See Below) Medically Necessary Growth hormones 50% Maximum Supply Per Fill 34 Days Maximum Participant Co-Payment Per Fill $75.00 *The minimum Generic drug Participant Co-Payment Amount is $10.00. If the Participant Co-Payment % for a prescription produces an amount less than $10.00, then the Participant Co-Payment Amount is $10.00. The Plan will pay the remainder, subject to the provisions and limitations of the Plan. This calculation also applies to the Formulary drug Co-Payment of $20.00. **When a Covered Family Member, Physician or pharmacy chooses a Brand Name drug when a Generic equivalent is available, the Plan will pay the amount it would pay for the Generic drug equivalent, and the Covered Family Member is responsible for the remainder of the cost. The Trustees reserve the right to amend, change, eliminate or decrease benefits from time to time and at any time for all eligible Employees and their eligible Dependents. 15 SCHEDULE III Retiree Coverage (Senior Program – Plan V) Schedule of Benefits for all Eligible Employees who Retired after February 28, 1990 and Before Age 65 and Eligible Dependents (Effective as of January 1, 2014) ELIGIBLE RETIRED EMPLOYEES ONLY Self-funded Death Benefit (Retirees Receiving Disability Pensions Excluded) $5,000 ELIGIBLE RETIRED EMPLOYEES AND DEPENDENTS Benefits are payable only for Covered Charges. MAJOR MEDICAL EXPENSE BENEFITS MAXIMUM MAJOR MEDICAL EXPENSE BENEFIT Per Covered Family Member ALL ESSENTIAL HEALTH BENEFITS ARE APPLIED TOWARD THE ANNUAL AND LIFETIME MAXIMUMS ON NON-ESSENTIAL HEALTH BENEFITS UNDER THE MAJOR MEDICAL EXPENSE BENEFIT UNLESS OTHERWISE STATED There is no annual maximum for essential health benefits (for more information, see page 24). The annual maximum for non-essential health benefits is: (-----$100,000-----) LIFETIME MAXIMUM BENEFIT FOR NON-ESSENTIAL HEALTH BENEFITS (-----$100,000-----) LIFETIME MAXIMUM BENEFIT For eligible Surgeries by licensed podiatrists (DPM) Per Covered Family Member (-----$1,000-----) MAXIMUM OUT-OF-POCKET per Covered Family Member per Calendar Year (Covered Charges incurred during a calendar year in excess of the deductible are paid at 100% U&C after Calendar Year Out-of-Pocket Maximum is reached) Per Person Per Family (----$4,000----) (----$8,000----) 16 CALENDAR YEAR DEDUCTIBLE Single (Employee Only) Coverage Family (Employee and Dependents) Coverage (----$350----) (----$700----) CO-INSURANCE PERCENTAGE PAYABLE AFTER DEDUCTIBLE Per Covered Family Member Covered Charges With an In PPO Network Provider or where No 80% of U&C PPO Network applicable before Calendar Year Out-ofPocket Maximum is reached (except if otherwise shown) Covered Charges With a Non PPO Network Provider 50% of U&C before Calendar Year Out-ofPocket Maximum is reached (except if otherwise shown) All Hospital Covered Charges (subject to preadmission certification requirement) (Includes inpatient, outpatient and preadmission testing) Daily Room and Board Limit Average Semi-Private Room Charge or 100% U&C for Intensive Care Accommodations Physician Covered Charges (subject to review for charges above base service) Chiropractors or physical therapists employed by or in same office as Chiropractors (subject to additional limits below) MAXIMUM NO. OF VISITS Per Calendar Year 30 Visits + additional visits subject to pre-certification Physical Medicine (therapy) (subject to additional limits below) MAXIMUM NO. OF VISITS Per Calendar Year 20 Visits + additional visits subject to pre-certification Durable Medical Supplies (any charge above $500 is subject to preauthorization requirement) U&C Diagnostic Laboratory & X-ray Expenses (Non-emergency MRIs, PET and CAT scans are subject to preauthorization requirement) U&C 17 Convalescent Care Accommodations (subject to preauthorization requirement and following limits) CALENDAR YEAR MAXIMUM NO. OF DAYS 120 Days Home Health Care (Subject to preauthorization requirement and following limits) MAXIMUM NO. OF VISITS Per 12-Month Period 40 Visits Hospice Care (Subject to preauthorization requirement and following limits) MAXIMUM LIFETIME BENEFIT 6 months Mental and Nervous Disorder/Alcohol and Substance Abuse - Inpatient and Outpatient Treatment U&C All mental health and substance abuse benefits are provided according to the Major Medical Benefit rules under the Plan unless otherwise indicated. Allergy Injections U&C Diabetes Education (subject to additional limits below) U&C CALENDAR YEAR MAXIMUM BENEFIT FOR REEDUCATION OR REFRESHER EDUCATION $100 Ambulance Charges U&C PREVENTIVE -- IN-NETWORK without deductible (Participants, Dependent spouse and children subject to age limits) 100% NO MAXIMUM PREVENTIVE -- OUT-OF-NETWORK Not Covered 18 PRESCRIPTION DRUG EXPENSE BENEFIT Effective January 1, 2006, if you are eligible for Medicare, you are eligible to receive prescription benefits through the federal government Medicare Part D program and you will no longer receive prescription benefits from the Plan. Drug Classification After Satisfaction of Calendar Year Deductible, Participant Co-Payment Amount* Generic drug Greater of $10 or 10%* Formulary Brand Name drug Greater of $20 or 20%* Multi-source Brand Name drug Paid as Generic **(See Below) Medically Necessary Growth hormones 50% Maximum Supply Per Fill 34 Days Maximum Participant Co-Payment Per Fill $75.00 *The minimum Generic drug Participant Co-Payment Amount is $10.00. If the Participant Co-Payment % for a prescription produces an amount less than $10.00, then the Participant Co-Payment Amount is $10.00. The Plan will pay the remainder, subject to the provisions and limitations of the Plan. This calculation also applies to the Formulary drug Co-Payment of $20.00. **When a Covered Family Member, Physician or pharmacy chooses a Brand Name drug when a Generic equivalent is available, the Plan will pay the amount it would pay for the Generic drug equivalent, and the Covered Family Member is responsible for the remainder of the cost. The Trustees reserve the right to amend, change, eliminate or decrease benefits from time to time and at any time for all eligible Employees and their eligible Dependents. 19 DEFINITIONS When used in this booklet, the following terms are defined as follows: Convalescent or Intermediate Care Facility. An institution that is exclusively reserved for patients following surgery or hospitalization, requiring only limited care as prescribed by the Physician attending the Participant or Dependent and that meets all of the following requirements: 1. is regularly engaged in providing skilled nursing care for ill and injured persons under 24-hour a day supervision of a Doctor of Medicine or a Registered Nurse (R.N.); 2. has available at all times the services of a Doctor of Medicine who is a staff member of a general hospital; 3. has on duty 24 hours a day a Registered Nurse (R.N.) and Licensed Practical Nurse (L.P.N.) on duty at least eight (8) hours per day; 4. maintains a complete daily medical record for each patient; 5. complies with all licensing and other legal requirements; and 6. is not, other than incidentally, a place of rest, a place for the aged or a nursing home. Covered Charges. The Usual and Customary (U&C) charges that a Participant or Dependent incurs while covered under the Plan for medical care, services and supplies and prescription drugs ordered by a Physician that are Medically Necessary for the treatment of a Non-occupational Injury or a Non-occupational Sickness. The term does not mean that all Covered Charges will be paid. Payments will be made only for Covered Charges up to the maximum benefit amount shown on the Schedules of Benefits and only according to any other limitations and rules that may apply. Covered Family Member. defined by the Plan. A Participant and the Dependents of that Participant as Dentist. A licensed D.D.S. or D.M.D. rendering services within the scope of his license. Dependent. A Participant’s: 1. Spouse, provided the Participant and the spouse are living together under the same household and in a common marital relationship. 2. Until age 26 and regardless of the child’s residency, financial status, student status or marital status, your (a) natural child; 20 (b) legally adopted child and a child who has been placed with you for adoption. For purposes of this section a child being “placed for adoption” means the assumption and retention by the Participant of a legal obligation for total or partial support of such child under age 18 in anticipation of adoption of such child. Your adult child under age 26 is eligible for this extended coverage even if he is otherwise eligible for employer-sponsored coverage (including employer-sponsored coverage offered through his spouse’s employer) even if he does not enroll in the employersponsored coverage. If your adult child is eligible for coverage under this Plan both as an Employee and as a Dependent child or spouse, the adult child can choose between coverage as an Employee, as a Dependent or as both an Employee and a Dependent. 3. 4. Your child who does not meet the rules under number 2 above, but is unmarried, under 19 years of age and living in a parent-child relationship with the Participant. The Plan may waive this living with Participant requirement if the child is under age 18 and the Participant is required by a “Qualified Medical Child Support Order (“QMCSO”) (a domestic relations or other court order) to provide primary health benefits for the child. This waiver will not be extended until a copy of the court order is received by the Plan Office. The term “child” includes: (a) a natural child; (b) a legally adopted child and a child who has been placed for adoption. For purposes of this section, a child being “placed for adoption” means the assumption and retention by the Participant of a legal obligation for total or partial support of such child under age 18 in anticipation of adoption of such child; (c) any other child, such as a step-child or foster child, if legitimately named as a dependent on the Participant’s Federal Income Tax return; and (d) a grandchild of a Participant who has been awarded permanent custody and care of the grandchild as the result of a court order. Unmarried child (as described in #3 above) age 19 to 23, if he is attending an educational institution as a full-time student (for at least 12 semester credits or full-time according to the school’s 21 standards). The child must continue to be dependent upon the Participant for support and maintenance and must have been covered under this Plan immediately prior to his 19th birthday. If a Dependent child, who is enrolled in Plan coverage under this paragraph, has full-time student status immediately before a medically necessary leave of absence from a post-secondary school and loses full-time student status because of a serious injury or illness, coverage under this Plan will be extended, during the leave of absence until the earlier of (i) the one-year anniversary of the date on which the leave of absence began, or (ii) the date on which the Dependent child’s coverage under the Plan would otherwise terminate. To be eligible for this extended coverage, the Participant must provide the Plan with written certification from the Dependent child’s treating physician that the leave of absence from school is medically necessary and is as a result of a serious illness or injury. The extended coverage commences on the date such certification is received by the Fund, but will be retroactive to the date on which the leave of absence began. As permitted by law, extended coverage under this paragraph will run concurrently with coverage under COBRA (See Section “Length of SelfContribution Period,” pg. 39. This means that if the Dependent child receives one year of coverage under this paragraph and, after the expiration of this one-year period, the Dependent child is not eligible for Plan coverage (for reasons such as, but not limited to, failing to return to school, attaining age 23 or getting married), the child can only elect to continue coverage under COBRA for up to an additional 24 months (for total of 36 months). 5. Unmarried child age 19 (in the case of a child described in #3 above) or 26 (in the case of a child described in #2 above) or older who is mentally or physically handicapped and who meets all of the following conditions: (a) the child must be dependent upon the Participant for support and maintenance; (b) the child must have become mentally or physically handicapped before he became age 19 (in the case of a child described in #3 above) or 26 (in the case of a child described in #2 above); (c) the child must remain mentally or physically handicapped; and (d) the child must be incapable of supporting himself. 22 The coverage of the physically or mentally handicapped child will continue as long as the Employee continues to be a Participant of the Plan and as long as the child remains incapable of supporting himself because of his handicap. The Participant must furnish proof to the Plan Administrator, at his own expense, of the child’s incapacity within 31 days of the date the child’s coverage under the Plan would end due to attainment of age 19 (in the case of a child described in #3 above) or 26 (in the case of a child described in #2 above). Proof must be furnished on an annual basis. For information on the procedure to be followed to prove incapacity and dependency, contact the Plan Administrator. Except as provided by a QMCSO, the Participant must be legally responsible to provide support for a “child.” Any child who loses dependent status will not be allowed to regain dependent status. A limited exception to this provision is available to a dependent child age 19 to 23 who meets the qualifications established by the Plan. For information on this limited exception, contact the Plan Office. The Plan may require acceptable proof that an individual is a dependent of the Participant before a claim will be processed. Durable Medical Supplies. Supplies or equipment which: 1) can withstand use; 2) is primarily and customarily used to serve a medical purpose; 3) generally is not useful to a person in the absence of illness or injury; and 4) is appropriate for use in the home. Eligible Expenses. Covered Charges incurred during a calendar year in excess of the deductible, up to the annual maximum. Employee. Any employee on whose behalf payments are required to be made to the Plan by an Employer pursuant to a collective bargaining or other written agreement which is adopted by the Trustees pursuant to the terms of the Trust Agreement. For Kroger Employees, high school students hired on or after October 13, 2006 will be excluded from coverage during the time that they are or remain high school students. Employer. Any employer, who (1) on or after the effective date of the Plan has a collective bargaining or other written agreement with the Union or the Trustees requiring periodic contributions to be made to the Plan; (2) otherwise meets the requirements of the Trust Agreement and (3) is accepted for participation in the Plan. An employer’s status as an Employer may be suspended or terminated for failure to make timely contributions. The term “Employer” may also include the Union and the Plan if such organization becomes obligated pursuant to a Participation Agreement with the Trustees to contribute to the Plan on behalf of its Employees on substantially the same basis upon which other participating Employers are contributing to the Plan and meets the requirements of the Trust Agreement. 23 Essential Health Benefits. Under PPACA, a group health plan is prohibited from imposing a lifetime dollar limit, effective for the first plan year after September 23, 2010, or an annual dollar limit, effective January 1, 2014, on certain health care services. Currently, such benefits shall include at least the following general categories and the items and services covered within the categories: 1. 2. 3. 4. 5. Ambulatory patient services Emergency services Hospitalization Maternity and newborn care Mental health and substance use disorder services; including behavioral health treatment 6. Prescription drugs 7. Rehabilitative and habilitative services and devices 8. Laboratory services 9. Preventive and wellness services and chronic disease management 10. Pediatric services, including oral and vision care Effective January 1, 2014, any annual limits on benefits that the Plan determines are Essential Health Benefits no longer apply. Lifetime and annual limits still apply to benefits that are not considered Essential Health benefits, however. Experimental. The use of any treatment, procedure, facility, equipment, drugs, devices or supplies not yet generally recognized as accepted medical practice and/or any items requiring federal or other governmental agency approval for which such approval had not been granted at the time services were rendered. Home Health Care Agency. A public agency or private organization (or a subdivision of such an agency or organization) that meets all of the following criteria: 1. it is primarily engaged in providing skilled nursing services and other therapeutic services in the homes of its patients; 2. it has established policies governing the services which it provides, such policies being established by a group of professional personnel associated with the agency or organization, including one or more doctors and one or more registered professional nurses; 3. it provides for the supervision of its services by a doctor or registered professional nurse; 4. it maintains clerical records of all patients; 5. it is licensed according to the applicable laws of the State of West Virginia or the state in which services are provided and of the locality in which it is located or provides services; and 6. it is eligible to participate under Medicare. 24 Home Health Aide. A person who has had specific training to be able to: 1. monitor and record patient’s vital signs, i.e., pulse and temperature; 2. plan and prepare nutritious meals with appropriate restrictions according to a Physician’s orders; 3. perform simple procedures, i.e., irrigating foley catheters, giving enemas, changing colostomy bags; and 4. assist the patient in personal care, i.e., bathing, eating, dressing and grooming. Hospice Care Agency. A public agency or private organization (or a subdivision of such an agency or organization) that meets all of the following criteria: 1. must have a staff which includes at least one doctor and one R.N.; 2. must maintain central clinical records on all patients; and 3. must meet the standards of the National Hospice Organization (“NHO”). Hospital. An institution that meets all of the following requirements: 1. is engaged primarily in providing medical care and treatment of sick and injured persons on an inpatient basis at the patient’s expense and maintains diagnostic and therapeutic facilities for surgical and medical diagnosis and treatment of such persons by or under the supervision of a staff of duly qualified Physicians; 2. continuously provides 24-hour a day nursing service by or under the supervision of registered graduate nurses and is operated continuously with organized facilities for operative surgery on the premises; and 3. is not, other than incidentally, a place of rest, a place for the aged or a nursing home. Illness (Sickness). The state of being sick or diseased, an ailment, being unwell. Any disability arising out of and as a result of any type of elective surgery or procedure will not be considered an “Illness.” Injury. Traumatic damage to some part of the body. Intensive Care Accommodation. An accommodation, including a coronary care accommodation, which (1) is exclusively reserved for critically and seriously ill patients requiring constant audio-visual observation as prescribed by the Physician attending the Participant or Dependent, (2) provides Room and Board, specialized registered nursing care and other nursing care and special equipment or supplies immediately available on a standby basis and (3) is segregated from the rest of the Hospital facilities. 25 Medical Emergency. A situation which arises suddenly and which poses a serious threat to life or health. Medical emergencies include heart attack, cardiovascular accidents, poisonings, loss of consciousness or respiration, convulsions, and other acute conditions. The diagnosis or the symptoms, and the degree of severity, must be such that immediate medical care would normally be required. Medically Necessary. Only those services, treatments or supplies provided by a Hospital or ordered by a Physician (or other licensed healthcare provider) that are required to identify or treat a Participant’s or Dependent’s injury or Illness and which are: 1. consistent with the symptoms or diagnosis and treatment of the Participant’s or Dependent’s condition, disease, ailment, or injury; 2. appropriate according to standards of good medical practice; 3. not solely for the convenience of a Participant, Dependent, Physician or Hospital; and 4. the most appropriate which can be safely provided to the Participant or Dependent. The fact that a service or supply is prescribed by a physician or another provider does not alone mean it is medically necessary. Mental and Nervous Disorder. An emotional disease or mental disorder of any kind including a neurosis, psychoneurosis, psychopathy, or psychosis. For purposes of the Plan, Mental and Nervous Disorder includes eating disorders, including, but not limited to, anorexia nervosa, bulimia and exogenous obesity. Non-occupational Injury. A bodily injury sustained while not doing any act or thing pertaining to any occupation or employment for remuneration or profit. Non-occupational Sickness. A sickness for which no benefits are payable in accordance with the provisions of any workers’ compensation or similar law. Other Hospital Services and Supplies. The actual charges made by a Hospital, on its behalf, for services and supplies rendered to the individual, and required for treatment of such person, for which the Participant or Dependent incurs a legal obligation to pay. These charges include charges made by a professional anesthetist and certified registered nurse anesthetist (CRNA) for the administration of anesthetics. These charges do not include charges for Room and Board and the professional services of any Physicians, private duty nurses or any individual or intensive nursing care, regardless of what it is called and regardless of whether such services are rendered under the direction of the Hospital or otherwise. Participant. Any Employee or former Employee who is eligible for benefits provided under this Plan, as set forth on pages 30-32. 26 Periods of Disability. Successive periods of disability will be considered within the same period of disability unless there was complete recovery from the cause of the previous disability or evidence satisfactory to the Trustees is furnished that: 1. the cause or causes of the latest disability is entirely dissimilar and unrelated to the cause or causes of any previous disability; 2. in the case of the Participant only, the latest period of disability commenced after the Participant had returned to active work for at least two continuous weeks since the previous period of disability; or 3. in the case of a Dependent or a retiree, the periods of disability are separated by three (3) months. Physician. A licensed doctor of medicine, osteopathy, chiropractor, dentistry, or clinical psychology who is licensed by the appropriate state agency of the state in which the services are performed and who is acting within the scope of his license. A doctor of optometry will not be recognized as a Physician under the Plan. A licensed doctor of podiatry will be recognized as a Physician under the Plan when the treatment in question is rendered by the podiatrist pursuant to a referral by a Physician and the treatment in question is preauthorized by the Plan Office. Plan. United Food and Commercial Workers Local 400 and Employers Health and Welfare Plan. PPACA. The Patient Protection and Affordable Care Act. Preferred Provider Organization (PPO). The Plan has contracted with a Preferred Provider Organization which has entered into an agreement with Physicians, Hospitals, clinics and pharmacies to provide quality medical care and services to Participants and Dependents in accordance with established and prearranged procedures and fees, a list of which is available from the Plan Office. Primary Care Physician (PCP). A Provider who is a practitioner specializing in Obstetrics, General Practice, Family Practice, Gynecology, Internal Medicine, Pediatrics, Clinical/Multi-Specialty who supervises, coordinates and provides initial care and basic medical services to a Member. The PCP is responsible for maintaining continuity of patient care. In addition to Physicians, a PCP may also include an Advanced Nurse Practitioner and Physician’s Assistant. Preventive Care. Those services which are determined to be preventive care that must be covered without a copayment, coinsurance or requirement to meet a deductible under PPACA. A complete list of the services can be found at www.healthcare.gov. Plan 1 will also pay for in-network Wellness Benefits as Preventive Care as defined in the Schedule of Benefits. Room and Board. All charges made by a Hospital, on its behalf, for room, board, general duty nursing and any other charges which are made at a daily or weekly rate, or which are 27 regularly made as a condition of occupancy of the class of accommodations occupied, for which the Participant or Dependent incurs a legal obligation to pay. Room and Board includes charges for intensive nursing care when combined with a charge for an Intensive Care Accommodation, but does not include charges for professional services by Physicians. Rules and Regulations. The Plan document as adopted by the Trustees and as thereafter amended from time to time by the Trustees. Schedule of Benefits. The benefits enumerated on pages 4 through 18. Self-Contributions. Payments made directly to the Plan by Employees, former Employees or Dependents for the purpose of continuing eligibility on a temporary basis or for the purpose of providing Dependent coverage. Specialist (Specialty Care Physician/SCP). A provider, other than a Primary Care Physician, who provides services within a designated specialty area of practice. Surgical Operation or Procedure. Any operation or procedure listed in the Annual Relative Values for Physicians—Relative Values Based on Physician Survey Data from Relative Value Studies, Inc. and any other Surgical Operation or Procedure in the categories listed below: 1. the incision, excision or electro cauterization of any organ or part of the body; 2. the manipulation or reduction of a fracture or dislocation; 3. the suturing of a wound; and 4. the removal by endoscopic means of a tumor, stone or foreign object from the larynx, bronchus, trachea, esophagus, stomach, urinary bladder or ureter, provided, however, that the term Surgical Operation or Procedure will not include any Experimental medical treatment, whether or not such Experimental medical treatment is in lieu of or accomplishes the same result as the performance of the corresponding Surgical Operation or Procedure. Total Disability. The complete inability of a Participant to perform any and every duty pertaining to his occupation or employment or the complete inability of a Dependent to perform the normal activities of a person of like age and sex. Trust. The assets of the Plan, held in trust by the Trustees. Trust Agreement. United Food and Commercial Workers Local 400 and Employers Health and Welfare Fund Trust Agreement as originally effective February 1, 1959, as amended from time to time. 28 Trustees. Those persons who are named according to the Trust Agreement and who have authority to control and manage the operation and administration of the Plan and who also have authority to control and manage the Trust. Union. United Food and Commercial Workers Local 400 or such other Union which qualifies as a participating Union under the terms of the Plan’s Trust Agreement. Urgent Care. An Urgent Care medical problem is an unexpected episode of illness or an injury requiring treatment, which cannot reasonably be postponed for regularly scheduled care but which is not considered a Medical Emergency. Urgent care medical problems include, but are not limited to, earache, sore throat, and fever (not above 104 degrees). Treatment of an Urgent Care medical problem is not an Emergency and does not require use of an emergency room at a Hospital. Usual and Customary (U&C). The usual charge made by the Hospital, facility, person, group or other entity rendering or furnishing the medical care, service or supply or prescription drug but in no event will it mean a charge in excess of the lesser of (1) actual charge or (2) the general level of charges made by others rendering or furnishing similar medical care, service or supply or prescription drug within the area in which the charge is incurred, for a Non-occupational Injury or for a Non-occupational Sickness comparable in severity and nature to the one being treated. The Plan uses AMA/CPT codes listed in the Annual Relative Value for Physicians—Relative Values Based on Physician Survey Data from Relative Value Studies, Inc. and Annual Health Care Consultants of America, Inc. Physician Fee and Coding Guide Comprehensive Fee and Coding Reference (“HCCA”) to determine payment to Physicians. Presently, the Plan uses the 90th percentile of the Usual and Customary Index. The Usual and Customary (U&C) charge for a PPO Hospital, PPO Physician or other PPO provider will not exceed the prearranged fee established under the PPO arrangement with the Plan. 29 ELIGIBILITY General Provisions. The Plan will provide the benefits described in this booklet to eligible Participants and Dependents without physical or medical examination or other requirement except the recipient’s compliance with the Rules and Regulations of the Plan. Employees Initial Eligibility. 1. A Full-Time or Part-Time Employee hired on or before October 15, 2005 with five years of seniority from date of hire who averages 18 or more hours per week will become a Participant, eligible for Full-Time Employee benefits or Part-Time Employee benefits, as appropriate, as described in Schedule I of the Schedule of Benefits, on the first day of the calendar month an Employer is required to make contributions to the Fund for Plan 1 benefits on his behalf as an Employee under its collective bargaining agreement and the Employee timely enrolls for such coverage. 2. A Full-Time or Part-Time Employee hired after October 15, 2005 and before January 1, 2012 with five years of seniority from date of hire who averages 20 or more hours per week (520 hours during a 26-week lookback) will become a Participant, eligible for Full-Time Employee benefits or Part-Time Employee benefits, as appropriate, as described in Schedule I of the Schedule of Benefits on the first day of the calendar month an Employer is required to make contributions to the Fund for Plan 1 benefits on his behalf as an Employee under its collective bargaining agreement and the Employee timely enrolls for such coverage. 3. For Kroger Employees, high school students hired on or after October 13, 2006 will be excluded from coverage during the time that they are or remain high school students. Initial Enrollment Requirement. In addition to the requirements described above, you must submit an enrollment form to the Plan within the time period established by the Trustees to be entitled to benefits under the Plan. If required by a collective bargaining agreement, you must also execute all enrollment forms required by the Trustees to authorize any payroll deduction. If you fail to execute any enrollment form within the time period established by the Trustees to enroll or to authorize any required payroll deduction when first eligible, you, the Employee, will not be entitled to enroll for benefits under the Plan until the earlier of: 1. The next Annual Open Enrollment as described on page 31; or 2. The day that you experience a “Life Event” as described on pages 33-34 provided you submit a written explanation of the event to the Plan and request enrollment 30 within 30 days or 60 days in the case of State premium assistance subsidy eligibility, or such other time period as established by the Trustees, of such event. Continuing Eligibility. Once an Employee becomes a Participant, his eligibility for Employee Benefits as described in Schedule I of the Schedule of Benefits, will continue for any month so long as the required contributions are made or other required amounts are remitted on his behalf as an Employee by an Employer and by any required payroll deduction by an Employee. In addition, the Plan will continue a Participant’s eligibility for Employee benefits for up to nine months during periods of personal Illness or Injury. If a Participant timely elected Dependent coverage and maintained that coverage uninterrupted, the Plan will also continue the Dependent’s coverage. Employee Contributions. Employees must make a contribution, via payroll deduction, in order to enroll in or maintain coverage under the Plan. Only those Employees who authorize a deduction for the Employee contribution will have coverage under the Plan. The Employer will collect the Employee contribution via payroll deduction on a pre-tax basis. The rate of the Employee contribution is determined by your collective bargaining agreement. Annual Open Enrollment. Each year, eligible Employees will need to elect their level of benefit coverage to be provided by the Fund. An Employee who does not complete the enrollment process when eligible to do so will not be able to enroll until the next open enrollment period (unless the employee experiences a “Life Event” as described on pages 32-33). Termination of Eligibility. A Full-Time or Part-Time Employee’s eligibility for FullTime Employee benefits or Part-Time Employee benefits, as appropriate, will terminate as of the earliest of the following dates: 1. the last day of the calendar month in which employment terminates; 2. the date he enters duty with the armed forces of any country (see pages 35-36 for more details regarding coverage during U.S. military service under the Uniformed Services Employment and Reemployment Rights Act of 1994 (“USERRA”)); 3. as of any month for which contributions are not paid, as noted above, including timely Employee or Self-Contributions; or 4. the last day of the calendar year if you fail to timely enroll for the next year during annual open enrollment (unless the Employee experiences a “Life Event” as described on page 33-34). Reinstatement of Eligibility. 1. An Employee whose benefits terminate due to termination of employment must requalify under the Initial Eligibility rules (see page 30). 31 2. An Employee returning from the armed forces will be reinstated for Full-Time, or Part-Time as appropriate, Employee benefits on the first day of any calendar month following return to active employment with an Employer, subject to the federal rules and regulations applicable to reemployment following military service (see pages 35-36 for more details regarding coverage during U.S. military service under USERRA). 3. An Employee whose benefits terminate in a month due to insufficient hours of service for a contribution to be required under the collective bargaining or other agreement and who remains employed will not be required to requalify under the Initial Eligibility rules. Such Employee will be eligible for benefits in any month in which a contribution is required to provide coverage for such month. Dependents Dependents of an Employee are eligible for benefits if the Employee (1) elects Dependent coverage and (2) makes payment of any necessary Employee Contribution within 30 days of the date he is first eligible for Plan 1 coverage, or if later, the date the Employee first acquires a Dependent. Coverage is effective on the date the Employee is first eligible and elects coverage for his Dependents or the date the Employee acquires the Dependent. If the Dependents are covered under another group health plan at the time the Employee’s eligibility for Dependent coverage becomes effective, the Participant may preserve the opportunity to later enroll the Dependents in the Plan by declining coverage for his Dependents under the Plan in writing, explaining that they are covered under a different group health plan within the 30-day enrollment period. If the Participant timely declines coverage in writing, the Dependents may be enrolled if there is a loss of coverage due to a “Life Event” as described on pages 33-34. Working Spouse Payment. If an Employee enrolls his or her spouse for primary coverage under the Plan and the spouse has coverage available through his or her employment but elects not to enroll in his or her employer-provided plan, a working spouse payroll deduction is required from the Employee. The amount of this Working Spouse payroll deduction will be determined by the collective bargaining agreement. To avoid this deduction, an Employee’s spouse must be enrolled in his or her employer’s plan. (The Plan pays as secondary if the spouse does not enroll and no working spouse payment is elected by the Employee.) In addition, the Plan will also permit a Dependent who does not exhaust COBRA coverage under another plan to enroll in the Plan within 30 days of the date that coverage terminates, but the Plan will coordinate benefits and pay only as secondary until the maximum period of time expires during which the Dependent could have maintained COBRA coverage. When a Participant who is eligible to elect Dependent coverage acquires a Dependent through marriage, birth, adoption or placement for adoption, the Participant must request enrollment of the Dependent within 30 days of the event along with evidence of acquiring 32 the new Dependent (such as a marriage certificate or birth certificate) and must authorize any necessary payroll deduction or pay any necessary Self-Contribution to provide coverage for Dependents at the time enrollment is requested. This is described more fully under “Life Events” on page 33-34. When the necessary enrollment form, evidence and Self-Contribution is made, the effective date of coverage will be: 1. marriage – date of marriage. 2. birth – date of birth; 3. adoption or placement for adoption – date of adoption or placement for adoption. The failure to make a timely election to enroll Dependents for coverage as described above prevents a Participant from providing Plan coverage for his Dependents until the next open enrollment period or the occurrence of a “Life Event” as described below. Life Event. A Life Event is: 1. Loss of Other Coverage. If you are an Employee eligible for benefits but did not enroll yourself or your eligible Dependent(s) for coverage when eligible to do so, you will be allowed to enroll yourself and/or your eligible Dependent(s) for coverage if all of the following four conditions are met: (a) You and/or the eligible Dependent were covered under a different group health plan or health insurance coverage at the last time the Employee was able to enroll for Plan coverage; and (b) You and/or the Dependent’s coverage subsequently ends because of any of the following: (1) Loss of eligibility, including legal separation, divorce, death, termination of employment, reduction in the number of hours of employment, or change in employment status; (2) Termination of an employer’s contribution toward such other coverage; (3) Exhaustion of the maximum period of COBRA continuation coverage; (4) Denial of a claim due to application of a lifetime limit on all benefits; (5) If coverage was provided by an HMO, you or the eligible Dependent is no longer residing, living, or working in the HMO service area and the HMO does not provide coverage for that reason; or (6) That plan no longer offers any benefits to you. 33 (c) You request enrollment in this Plan for yourself and/or eligible Dependent(s) no later than 30 days after the date other coverage was lost for one of the reasons listed in 1(b) above; and (d) You authorize the necessary payroll deduction or pay the SelfContribution for Dependent coverage, if required, to provide coverage for yourself and/or eligible Dependent(s) at the time enrollment is requested. 2. Loss of Medicaid or CHIP Coverage. Effective April 1, 2009, you may be able to enroll yourself and your dependents in this Plan if you or your dependents are eligible for Plan coverage, and lose eligibility for coverage under Medicaid or the State Children’s Health Insurance Program (“CHIP”) such as WVCHIP. You must request enrollment within 60 days of the date that CHIP or Medicaid coverage is terminated for you or your dependent. Written proof of the last day of coverage will be needed. Also effective April 1, 2009, you may be able to enroll yourself and your dependents in this Plan if you or your dependents are eligible for Plan coverage and become eligible to participate in a health insurance premium assistance program under Medicaid or CHIP. You must request enrollment within 60 days of the date you or your dependent is eligible for are determined to be eligible for the premium assistance through Medicaid or CHIP. 3. Acquisition of Eligible Dependent. An Employee, Dependent spouse, and Dependent children may enroll under the Plan following the acquisition of a new dependent at any time if all of the following four conditions are met: (a) You and your Dependents are eligible for coverage; (b) You acquire a Dependent through marriage, birth, adoption, or placement for adoption; (c) You request enrollment for yourself, Dependent spouse (whether or not previously eligible), and/or the child(ren) newly acquired through marriage, birth, adoption, or placement for adoption within 30 days of the event; and (d) You authorize the payroll deduction, if any, or pay the Self-Contribution for Dependent coverage, if required, to provide coverage for yourself and/or eligible Dependent(s). 4. Effective Date of Coverage. If the enrollment is requested and any necessary payroll deduction is authorized in a timely fashion, the effective date of coverage will be, as applicable, the date of: (a) Marriage; (b) Birth; (c) Adoption or placement for adoption; or 34 (d) Loss of other coverage. Termination of Eligibility. Dependent benefits will terminate on the earliest of the following dates: 1. the date the Participant’s coverage under the Plan terminates; 2. the date the Dependent fails to meet the definition of Dependent; 3. the date the Dependent enters duty with the armed forces of any country; 4. the first day of the month in which the Participant fails to make the required SelfContribution for Dependent coverage; or 5. the last day of the calendar year if the Participant fails to timely enroll the Dependent for the next calendar year during the Annual Open Enrollment (unless the Employee experiences a “Life Event” as described on pages 33-34). Qualified Medical Child Support Order (“QMCSO”). A QMCSO may require that accidental death and dismemberment benefits payable by the Plan be paid to satisfy child support obligations with respect to your child. If the Plan receives such an order and benefits are currently payable, or become payable in the future while the order is in effect, the Plan will make payments either to the Child Support Agency, or the recipient listed in the order. The Plan will provide Dependent coverage to a child if it is required to do so under the terms of a QMCSO. A QMCSO is a court or state administrative agency order that complies with the requirements of federal law. The Plan will provide coverage to a child under a QMCSO even if the Participant does not have legal custody of the child, the child is not dependent on the Participant for support, or the child does not reside with the Participant. If the Plan receives a QMCSO and if the Participant does not enroll the affected child, the Plan will allow the custodial parent or state agency to complete the necessary enrollment forms on behalf of the child. A copy of the Plan’s procedures for determining whether an order is a QMCSO may be obtained from the Plan Office at no charge. The Uniformed Services Employment and Reemployment Rights Act of 1994 (“USERRA”) A Participant who is absent from employment due to military service in the uniformed services of the United States, including Reserve and National Guard Duty, as described in the Uniformed Services Employment and Reemployment Rights Act of 1994 (“USERRA”), can elect to continue coverage for himself and his Dependent(s) under the provisions of USERRA for the period of absence, up to 24 months, beginning on the date on which the absence begins. If the absence is for less than 31 days, Plan coverage will be continued and the Participant will be required to pay the same share of the monthly cost, if any, as if the Participant had not entered the military service. 35 If military service is for 31 days or more, the Participant must pay the full cost of coverage. This coverage will include the same health benefits offered under COBRA continuation coverage. The cost paid to continue benefits and the election period will be determined in the same manner as for coverage under COBRA. The period of coverage for the Participant and Dependent(s) ends on the earlier of: 1. the end of the 24 month period beginning on the date on which the absence begins; or 2. the day after the date on which the Participant is required to but fails to apply for or return to a position of Employment. For example, for periods of service over 180 days, generally the Participant must reapply for employment within 90 days of discharge. Please note that in order to be eligible for the rights provided by USERRA, the Participant must notify his Employer and the Plan that the Participant will be absent from employment due to military service unless the Participant cannot give notice because of military necessity or unless, under all the relevant circumstances, notice is impossible or unreasonable. The procedures for electing USERRA coverage and continuing this coverage generally are the same as the procedures for electing COBRA coverage (pages 37-42), unless the procedures are impossible or unreasonable for the person as a result of his military service and the Trustees agree to a waiver of the rule. The Participant also must notify the Plan if he wishes to elect continuation coverage for himself or his eligible Dependent(s) under the provisions of USERRA within sixty (60) days after the military absence begins, unless the Trustees agree to waive that requirement under the relevant circumstances. Even if the Participant chooses not to elect USERRA continuation coverage for himself or herself and the eligible Dependents, the Participant and each Dependent covered under the Plan have the independent right to elect COBRA continuation coverage. The health coverage under both USERRA and COBRA run concurrently (at the same time). Payment of the USERRA payment, retroactive to the date on which coverage under the Plan terminated, must be made within forty-five (45) days after the date of the election of USERRA coverage. Failure to pay the full payment by each due date (or within the thirty (30) day grace period thereafter) will result in loss of all USERRA coverage. However, for periods in which the Participant is entitled to both USERRA and COBRA continuation coverage, the more favorable coverage will apply to the period of military service. If the Participant satisfies the Plan’s eligibility requirements at the time he entered the uniformed services and he qualifies for coverage under USERRA, the Participant will not be subject to any additional exclusions or a waiting period for coverage under the Plan when he returns from uniformed service. Family and Medical Leave (“FMLA”) The Family and Medical Leave Act of 1993 (“FMLA”) requires employers with 50 or more employees to provide eligible employees with up to 12 weeks per year of unpaid leave: 36 1. to care for a newly born or adopted child; 2. to care for a spouse, child or parent who has a serious health problem; or 3. if a Participant has a serious health problem that prevents him from performing his job. An employee may also take a qualified FMLA leave of up to 26 weeks to care for a service member who is a family member, as further described by law. If a Participant is absent due to a qualified FMLA leave, the Employer must notify the Plan that the Participant is on leave, must continue to include the Participant on its monthly remittance report to the Plan, and must continue to make contributions on the Participant’s behalf. While the Participant is on FMLA leave, he (and other eligible Dependents, if any) will continue to participate in the Plan just as if employment has not stopped, unless the Participant’s Employer fails to make the required contribution for the Participant. Beginning on or after January 16, 2009, the FMLA requires employers with 50 or more employees to provide eligible employees with an FMLA leave for a qualifying exigency that arises in connection with the active military service or an impending call to active duty of the employee’s child, spouse, or parent. A qualifying exigency includes a variety of circumstances relating to a service member’s deployment, including: a) attending military events and related activities; b) childcare and school activities, such as arranging for or providing childcare; c) making financial and legal arrangements; d) up to 5 days’ leave to spend time with a covered military member during temporary rest and recuperation leave and; e) additional activities not specifically mentioned above, but agreed to by the employer and employee. If the Participant’s Employer ceases to make contributions on his behalf, or when the Participant exhausts FMLA leave, the Participant will be provided an opportunity to elect continuation coverage in accordance with COBRA. CONTINUATION OF COVERAGE UNDER THE CONSOLIDATED OMNIBUS BUDGET RECONCILIATION ACT (“COBRA”) The Consolidated Omnibus Budget Reconciliation Act, more commonly known as COBRA, generally requires that group health plans offer Participants and their Dependents the opportunity to temporarily continue their health coverage at group rates when coverage under the Plan would otherwise end. This extended coverage is called “COBRA coverage.” COBRA coverage will include all benefits that the person was entitled to before the “Qualifying Event” (defined below) except as provided below. If the Participant, his spouse and/or Dependent child(ren) are covered under the Plan, the Participant and/or his spouse or Dependent children can continue coverage for a time if coverage ends for one of the several reasons even if the Participant or his Dependents are already covered by another group health plan or Medicare. Plan 1 Employees and their Eligible Dependents. A Participant who is an Employee in Plan 1 may make COBRA Self-Contributions to the Plan in order to continue coverage 37 for the Participant and the Participant’s Dependents, if applicable, if the Employee loses coverage due to one of the following Plan 1 Qualifying Events: 1. the Participant’s termination of employment (unless due to gross misconduct), including retirement; 2. the Participant’s reduction in hours of employment to fewer than the number required for participation in the Plan; 3. the Participant becomes entitled to Medicare; 4. death of the Participant; 5. divorce or legal separation of the Participant; or 6. loss of status as a Dependent. (See the definition of Dependent on pages 20-23 for the qualifications for Dependent status.) Eligible Dependents of Plan S and Plan V Participants. Eligible Dependents of a Participant in either Plan V or Plan S may make COBRA Self-Contributions to the Plan in order to continue their coverage if coverage under the applicable Plan ceases due to one of the following Retiree Plan Qualifying Events: 1. death of the Participant; 2. divorce or legal separation of the Participant; or 3. loss of status as a Dependent. (See the definition of Dependent on pages 20-23 for the qualifications for Dependent status.) Notice Requirement. The Participant’s Employer must notify the Plan Office in writing of Plan 1 Qualifying Events (1) through (4) within 30 days of their occurrence. Information provided by the Employer should be sent to the attention of the COBRA Department and must include sufficient information for the Plan to be able to verify that the Plan is the appropriate entity to receive the notice, information sufficient to identify the Participant, the Qualifying Event and the date of the Qualifying Event. The Participant or Dependent must notify the Plan Office in writing within 60 days from the later of the Plan 1 Qualifying Events (5) or (6) or Retiree Plan Qualifying Events (1), (2) or (3), or the date in which there is a loss of coverage as a result of the Qualifying Event. Information provided by the Participant or Dependent should be sent to the attention of the COBRA Department at the Plan Office and must include sufficient information for the Plan to identify the Participant or Dependent, the Qualifying Event and the date of the Qualifying Event. The Participant or Dependent must also notify the Plan Office in writing of a second Qualifying Event or a disability after the Participant or Dependent is receiving COBRA coverage. This notice should be sent to the attention of the COBRA Department and must be provided in the same time frame and provide the same information as explained herein. 38 Financial Responsibility for Failure to Give Notice. If a Participant or Dependent fails to give written notice within 60 days of the date of the Qualifying Event, or an Employer within 30 days of the Qualifying Event, and as a result, the Plan pays a claim for a Participant or Dependent whose coverage terminated due to a Qualifying Event and who does not elect COBRA coverage under this provision, then the Participant, Dependent or the Employer, as appropriate, must reimburse the Plan for all claims that should not have been paid. If the Participant, Dependent or Employer does not reimburse the Plan, then all amounts due may be deducted from other benefits payable on behalf of that individual or on behalf of the Participant, if the individual was his Dependent. Length of Self-Contribution Period. 1. 2. In the case of the following events, a Participant or a Participant’s Dependent may continue coverage for a maximum period of 18 consecutive months from the date of the loss of coverage: (a) the Participant’s termination of employment (unless due to gross misconduct), including retirement; or (b) the Participant’s reduction in hours of employment (such as leaving fulltime employment and becoming part-time). In the case of the following events, a Dependent may continue coverage for a maximum period of 36 consecutive months from the date of the loss of coverage: (a) the death of the Participant; (b) the divorce or legal separation of the Participant; (c) the loss of status as a Dependent; or (d) the Participant becomes entitled to Medicare. A child born to, adopted by or placed with a Participant who has elected continuing coverage, may be added as a Dependent in the same manner as other Dependents. Extension of Self-Contribution Period. The following situations may extend the 18-month period described in paragraph 1 above: 1. if the death of the Employee, divorce or legal separation of the Employee, the Employee’s Medicare entitlement or the loss of status as a Dependent occurs within the 18-month period, the 18-month period for the Employee’s Dependents may be extended up to a maximum period of 36 months; 2. if the Social Security Administration determines that a Participant or Dependent was disabled at any time during the first 60 days of COBRA coverage, the 18-month period described above can be extended to a maximum of 29 months. To be eligible for the extra 11 months of coverage, the Participant or Dependent 39 must notify the Plan Office in writing within 60 days after the later of the following: 1) the date of the Social Security determination; or 2) the date on which the Participant or Dependent loses or would lose coverage; or 3) the date on which the Participant or Dependent is informed as to the obligation to provide notice of disability. Please note that such notification must be made before the expiration of the 18-month coverage period. If the disability ends during the 29-month period, the Participant or Dependent must notify the Plan Office within 30 days of the termination of the disability. COBRA Self-Contribution Advice. COBRA coverage requires timely election of the coverage within 60 days of the date of the COBRA election notice or the date of the termination of coverage, if later. Upon receiving notice from the Participant’s Employer, the Participant or the Participant’s Dependents, the Plan Office will send the Participant and/or Participant’s Dependents a notice informing such individuals of their right to make COBRA Self-Contributions. The due date for COBRA Self-Contributions is the first day of the month in which COBRA coverage begins. For example, payments for the month of November must be paid on or before November 1st. The payment due for the initial period of COBRA coverage must include payment for the period of time dating back to the date that coverage terminated. If you fail to pay the full payment by each due date (or within the thirty day grace period for payments other than your initial payment) you will lose all COBRA coverage. There is an initial grace period of 45 days to pay the first amounts due starting with the date COBRA coverage was elected. In determining whether to elect COBRA coverage, you should consider the following consequences if you fail to continue your group health coverage through COBRA and do not obtain other health coverage from another plan: You may have preexisting condition exclusions applied to you by other group health plans if you have more than a 63-day gap in health coverage. Election of COBRA Coverage may help you avoid such a gap. You may lose the guaranteed right to purchase individual health insurance policies that do not impose such preexisting condition exclusions if you do not elect COBRA Coverage for the maximum time available to you. You should take into account that you have special enrollment rights under federal law. You have the right to request special enrollment in another group health plan for which you are otherwise eligible (such as a plan sponsored by your spouse’s employer) within 30 days after your group health coverage ends because of the qualifying event. You will also have the same special enrollment rights at the end of continuation coverage if you elect COBRA Coverage for the maximum time available to you. The monthly cost of COBRA coverage is set by the Board of Trustees, based on the provisions of federal law. The COBRA self-contributions rate may be changed annually. If any individual or family coverage is extended beyond 18 months because of entitlement to Social Security disability income benefits, the cost of COBRA coverage may be increased in accordance with the provisions of federal law. The Plan Office will 40 provide the cost of COBRA coverage at the time notice of entitlement to COBRA coverage is sent. COBRA Self-Contributions are to be in the form of a check or money order payable to the Plan. The Trade Act of 2002 created a tax credit for certain individuals who become eligible for trade adjustment assistance and for certain retired employees who are receiving pension payments from the Pension Benefit Guaranty Corporation (“PBGC”) (“eligible individuals”). Under the tax provisions, eligible individuals can either take a tax credit or get advance payment of 65% of premiums paid for qualified health insurance, including continuation coverage. Additionally, the Trade Act generally provides a second 60-day COBRA election period for eligible individuals, and establishes different election periods and effective dates for COBRA coverage for such individuals. If you have questions about these tax provisions, you may call the Health Coverage Tax Credit Customer Contact Center toll-free at 1-866-628-4282. TTD/TTY callers may call toll-free at 1-866-626-4282. More information about the Trade Act is also available at www.doleta.gov/tradeact. Types of Benefits Provided. An individual eligible to make COBRA Self-Contributions for the 18 month or 36 month period can continue all benefits for which they were eligible on the date of the Qualifying Event except Life Insurance, and Accidental Death, Dismemberment and Loss of Sight and Disability Benefits. Termination of Eligibility for Self-Contribution. A Participant or Dependent who is eligible for continued coverage by COBRA Self-Contribution will no longer be entitled to make COBRA Self-Contributions upon the occurrence of the earliest of the following events: 1. the first date after the COBRA election date that the Participant or Dependent is covered under any group health benefit program, insured or self-funded, such as coverage maintained by the Participant’s spouse that does not contain an exclusion or limitation with respect to the Participant’s or Dependent’s preexisting condition or such exclusion does not apply to the Participant or Dependent as a result of federal law; 2. the date after the COBRA election date that the Participant becomes eligible for Medicare, except that Dependents of the Participant who are continuing Coverage will be able to continue coverage by COBRA Self-Contribution until the end of the 18-month period immediately after the first 18 months during which the Participant could have continued Coverage; 3. the date after the COBRA election date that the Participant or Dependent becomes eligible for Medicare; 4. the first day of any month for which a timely COBRA Self-Contribution is not made to the Plan; 5. the Plan is terminated or the Plan no longer provides coverage to similarly situated Participants or Dependents; 41 6. the Employer ceases to maintain any group health plan for any employee; 7. the expiration of the maximum COBRA Self-Contribution period as described above; or 8. if the Employer withdraws from the Plan and makes coverage available under any group health plan to a class of Employees formerly covered under the Plan, then that other plan (and not this Plan) is obligated from that date forward to make coverage available to the Employer’s COBRA beneficiaries. Additional Information. Additional information regarding COBRA coverage may be obtained by contacting the Plan Office, UFCW Local 400 and Employers Health and Welfare Fund, 600 D Street, Suite 250, South Charleston, WV 25303, (304) 343-7682. In order to ensure protection of rights under COBRA coverage, Participants and Dependents should keep the Plan Office informed of any changes in mailing addresses. Special Continuation Coverage for Employer Going Out of Business and Ceasing to Participate in the Plan In addition to any rights the Participant may have under COBRA, if an Employer stops making contributions to the Plan on behalf of a Participant who is an Employee because of the Employer’s going out of business that results in the Employer ceasing to provide any group health plan, the Participant may continue the same level of benefit coverage for six months by making Self-Contributions for a period of six consecutive months from the date his Employer ceased contributing to the Plan on his behalf. Amount of Self-Contribution. Each Self-Contribution, unless otherwise specified, will be in an amount equal to the current Employer contribution rate for such level of benefits. Time to Begin Self-Contributions. A Participant must begin making Self-Contributions beginning with the first month following termination of his Employer’s contribution on his behalf and must continue uninterrupted. A Participant making Self-Contributions may not resume payments after a payment is missed. Payments must be received at the Plan Office on or before the 15th day of each consecutive month. Termination of Eligibility for Self-Contribution. A Participant continuing coverage under this special provision will no longer be entitled to make Self-Contributions upon the occurrence of the earliest of the following events: 1. the Participant’s return to any type of gainful employment that qualifies him for health benefits coverage with his new employer; 2. the Participant’s eligibility for coverage under another group health benefit program, insured or self-funded, such as coverage maintained by the Participant’s spouse; 42 3. the first day of any month for which a timely Self-Contribution is not made to the Plan; or 4. the last day of the month for which a Self-Contribution is permitted under this section. EXTENSION OF BENEFITS If the coverage of a Participant or Dependent has terminated as a result of a Nonoccupational Injury or Non-occupational Sickness for which benefits are payable under this Plan and the Participant or Dependent suffers a Total Disability as a result of such Non-occupational Injury or Sickness, the Participant or Dependent will be entitled to whatever benefits would have been payable for the Totally Disabling condition had the coverage remained in effect for a period of 90 days following termination of coverage, except for the Life, Accidental Death, Dismemberment and Loss of Sight, Dental, and Major Medical Benefits. Major Medical Benefits will continue for the Totally Disabling condition for up to 12 months or until the maximum benefit (as shown on the Schedule of Benefits) is paid, if earlier. HOWEVER, no benefits will be extended under this Plan beyond the date on which the Participant or Dependent becomes eligible under another employer-sponsored plan or union/management negotiated plan, including any plan sponsored by any state, county, municipality or government agency except as required by law. 43 RETIREE COVERAGE (Senior Program) Eligibility. A Participant who is an Employee may be eligible for the benefits described in one of the Schedules of Benefits for retirees (also known as the Senior Program), provided the retired Employee makes the required Self-Contributions to the Plan and satisfied all of the following conditions: 1. the retired Employee must retire from employment covered by the Plan on or after attaining age 55 and be eligible to receive benefits from the United Food and Commercial Workers International Union-Industry Pension Fund or its successor or a retirement plan sponsored by an Employer; 2. the retired Employee must have been eligible for coverage under this Plan on the date of his retirement; 3. the retired Employee must have been eligible under this Plan as a result of Employer contributions made on his behalf for the three consecutive years immediately preceding the date of his retirement; 4. the retired Employee must make proper application for the Retiree Coverage on forms available at the Plan Office and agree to make the required SelfContributions; 5. the retired Employee must apply for continuation of eligibility at the same time application is made for retirement benefits under the United Food and Commercial Workers International Union-Industry Pension fund or its successor or the retirement plan sponsored by the Employer, whichever is the case; and 6. the retired Employee must reject the right to continue coverage under Continuation of Coverage on pages 37-42. (COBRA) A retired Employee may continue Coverage for his or her Dependents who are covered under the Plan if the required Self-Contributions for that level of Coverage is made by the retired Employee. Self-Contributions. The amount of Self-Contribution is determined by the Trustees in their sole discretion and may be changed by the Trustees from time to time to cover the increased costs of providing benefits. Advance notice of any change will be given to all Senior Program participants. Payments must be in the form of a check or money order made payable to the Plan. After initial enrollment, Self-Contributions must be received by the Plan Office by the 10th of the month for which coverage is to be provided. Self-contributions must be made consecutively. 44 Benefits Provided. 1. All Employees who retired before March 1, 1990 and their Dependents, and Employees retiring at age 65 or older and their Dependents will be eligible for the benefits described in Schedule II, the Plan S Schedule of Benefits. 2. Beginning March 1, 1990, Employees retiring before age 65 and their Dependents will be eligible for the benefits described in Schedule III, the Plan V Schedule of Benefits. Upon attainment of age 65, the retired Employee and his covered Dependents will become eligible for the benefits described in Schedule II, the Plan S Schedule of Benefits. 3. A retired Employee may elect single (Employee only) or family (Employee and all eligible Dependents) coverage. If a retired Employee has Dependents at the time of the election and chooses single coverage he or she may not, in the future change to family coverage. 4. Beginning February 1, 2001, a retired Employee who elects single coverage under the Senior Program and who acquired a dependent after this election may enroll the newly acquired dependent under the Plan’s Senior Program if all four of the following conditions are met: ■ The Employee is a participant in the Senior Program, and ■ A spouse and/or a child becomes a Dependent of the retired Employee through marriage, birth, adoption or placement for adoption; and ■ The retired Employee requests enrollment for his new Dependent acquired through marriage, birth, adoption or placement for adoption within 30 days of the event and supplies evidence of acquiring the Dependent (such as a marriage certificate or birth certificate); and ■ The retired Employee makes the necessary Self-Contribution to provide coverage for Dependents at the time enrollment is requested. If the necessary enrollment form, evidence and self-contribution is made within the 30 days, the effective date of coverage will be: 1. marriage – no later than the first day of the first calendar month beginning after receipt of completed request for enrollment. 2. birth – date of birth. 3. adoption or placement for adoption – date of adoption or placement for adoption. Termination of Coverage. Coverage for a retired Employee and his or her dependents will terminate upon the occurrence of the first of the following events: 1. on the date of discontinuance of the Senior Program or the Plan; or 45 2. on the last day of the calendar month in which the retired Employee ceases to be a Retiree (except as provided below under “Return to Employment”); or 3. on the last day of any calendar month for which the retired Employee failed to pay the required Self-Contribution in a timely manner; or 4. for a Dependent, on the date of the retired Employee’s death. However, benefits may continue for a surviving Dependent spouse as provided for under the Surviving Spouse Benefit as described on page 46 or under COBRA coverage as described on page 37-42; or 5. for a Dependent, the date of the divorce or legal separation of the retired Employee or loss of status as a Dependent (see the definition of Dependent on pages 20-23 for the qualifications for Dependent status). Benefits may continue under COBRA coverage as described on pages 37-42. Return to Employment. A retired Employee who returns to employment covered by the Plan for which coverage is provided as an active Employee may elect either (1) to continue coverage as a retired Employee in addition to Plan coverage as a result of the individual’s reemployment or (2) to suspend retiree coverage for himself and Dependents so that the individual’s only coverage under the Plan for himself and Dependents is that coverage available under the Plan as a result of the individual’s reemployment. If the individual maintains dual coverage as a retired Employee and active Employee, benefits shall be coordinated as set forth in the Coordination of Benefits section (see pages 9195). Upon subsequent retirement from employment covered by the Plan, a retired Employee who suspended such coverage under (2) above is allowed a one-time election to reinstate coverage under the Retiree Coverage for himself and his eligible Dependents. Such reinstated coverage must be uninterrupted with the individual’s coverage as an active Employee. SURVIVING SPOUSE BENEFIT Eligibility. The surviving spouse of: 1. an active Participant who was at least age 55 and who had at least ten years of continuous service under the Plan (an absence due to sick leave or other approved absences does not interrupt service) at the time of his or her death; or 2. a retired Participant who was at least age 55 at the time of his or her death and was eligible for coverage under the Plan’s Retiree Coverage which is also known as the Senior Program, may continue Retiree Coverage for himself/herself and any eligible dependents, if applicable, by making Self-Contributions if the spouse and dependents were covered by the Plan at the time of the Participant’s death and they reject the right to continue coverage under COBRA Continuation Coverage on page 37-42. The surviving spouse must elect to continue coverage and pay the initial Self-Contributions within 60 days of the date of the Participant’s death. 46 Effective Date. The effective date of coverage will be the first day of the month immediately following the month in which the eligible Participant died. Self-Contributions. The amount of Self-Contributions is determined by the Trustees in their sole discretion and may be changed by the Trustees from time to time to cover the increased costs of providing benefits. Advance notice of any change will be given to all surviving spouses. Payments must be in the form of a check or money order made payable to the Plan. After initial enrollment, Self-Contributions must be received by the Plan Office by the 10th of the month for which coverage is to be provided. Self-Contributions must be made consecutively. If a payment is missed, a surviving spouse cannot resume eligibility by continuing payments at a future time. Length of Coverage. A surviving spouse may continue coverage by Self-Contributions for a maximum period established by the Trustees after the Participant’s death if timely Self-Contributions are made. The Trustees may lengthen or shorten this maximum period of coverage at their sole discretion. As of April 1, 2008, the maximum period is not limited. If the surviving spouse is eligible for Medicare benefits, then the Plan’s coverage will be coordinated with Medicare Parts A and B whether or not actually elected. Medicare will be considered to pay first and the Plan second if the surviving spouse is at least age 65 (or under age 65 with Medicare disability). Termination of the Surviving Spouse Benefit. A surviving spouse’s eligibility for benefits will terminate upon the earliest of the following events: 1. the last day of the maximum period established by the Trustees following the Participant’s death; 2. the first day of any month for which a Self-Contribution is not received by the Plan Office on a timely basis; 3. the date the surviving spouse becomes eligible to enroll in a state or federal program (excluding Medicare) that the Trustees determine to be comparable to the Plan’s coverage; 4. the date the surviving spouse is eligible for employer-sponsored group health benefit coverage that the Trustees determined to be comparable to the Plan’s coverage; 5. the date of the surviving spouse’s remarriage; or 6. the date the Trustees discontinue the Surviving Spouse Benefit. A Dependent child’s eligibility for benefits will terminate as of the earlier of the following events: 47 1. the date the dependent no longer qualifies as a Dependent under the terms of the Plan; or 2. the date the surviving spouse’s coverage ceases. Benefits Provided. The Plan provides Major Medical Expense Benefits as described in Schedule II or Schedule III of the Schedule of Benefits. The Plan does not provide life insurance, accidental death, dismemberment and loss of sight, weekly disability income, dental care, and vision care and physical examination/wellness program expense benefits that are provided to active Participants except the preventative benefits required by law. 48 GENERAL EXCLUSIONS AND LIMITATIONS Limitations and Exclusions. Except as otherwise explicitly provided by the Plan or required by law, in addition to the exclusions and limitations listed in each section, no benefits will be payable under this Plan for charges: 1. incurred prior to the effective date of Plan coverage. Expenses are considered for payment only if the person who incurs them is eligible under the Plan at the time they are incurred (Participant or Dependent). An expense is incurred at the time the service or supply is provided to a person. Receipt of this SPD does not automatically qualify you for coverage under the Plan. See the eligibility rules on pages 30 to 37; 2. which are not prescribed and approved by a Physician who is attending the Participant or Dependent; 3. in or by a hospital that does not meet the definition of “Hospital” contained herein; 4. in or by a Hospital, institution or other facility owned or operated by the United States, or any agency, or instrumentality (including, without limitation, the Department of Veterans Affairs (VA)) provided, however, that if such charges are made by a VA hospital for care of a nonservice-related disability, such charges will be considered for reimbursement by the Plan to the extent required by law and to the extent the Plan would have considered such charges as eligible expenses had the VA not been involved; 5. which the Participant or Dependent would have no legal obligation to pay without this or any similar coverage; 6. for retirees, for or relating to “well baby care” except that if, because of premature birth, disease, injury, congenital abnormality or hereditary complications, a newborn Dependent child incurs charges for services over and above the normal cost of routine nursery charges, benefits will be payable from birth or whatever date such complications commence, whichever is later; 7. for blood or blood plasma for which the Hospital or other supplier makes a refund to or on behalf of the Participant or Dependent either as a result of the operation of a group blood bank, private donor or otherwise; 8. for or relating to medical care, services or supplies, received or furnished in connection with, or as a result of any cosmetic surgery, including, but not limited to, breast reconstruction, breast reduction or implants and tummy tucks, except for: (a) charges in connection with and as a result of the necessary repair of disfigurement caused by a Non-occupational Injury sustained in an 49 accident, provided such cosmetic surgery is received promptly after such accident; (b) charges in connection with and as a result of an abnormal congenital condition in a child; (c) charges in connection with breast reconstructive surgery following a mastectomy and charges on related surgery and reconstruction on the patient’s other breast to produce a symmetrical appearance and prostheses and physical complications at all stages of mastectomy, including lymphedemas; 9. for or relating to eye refraction, eye glasses (except as specifically provided under the Vision Care Expense Benefit), after cataract surgery consideration of lens only under the Major Medical Expense Benefit, hearing aids (except as specifically provided under the Major Medical Expense Benefit), dental prosthetic appliances, the fitting of any thereof, except as may be required on account of a Non-occupational Injury to a physical organ sustained in an accident; 10. for or relating to medical care, services or supplies received or furnished in connection with or as a result of any injury or sickness resulting from or caused, directly or indirectly, wholly or partly, by: 11. (a) war or any act of war, whether declared or undeclared; (b) service in any military, naval or air force of any country while such country is engaged in war, whether declared or undeclared unless required by law; (c) police duty as a member of any military, naval or air force organization; (d) insurrection; (e) any atomic explosion or other release of nuclear energy (except only when being used solely for medical treatment of a Non-occupational Injury or a Non-occupational Sickness) whether in peace or in war and whether intended or accidental; (f) participation in a riot; (g) participation in the commission of a felony; for or relating to any medical care, services or supplies received or furnished in connection with or as a result of: (a) any bodily injury that arises out of, or in the course of, any employment or occupation for compensation or profit, or 50 (b) any sickness for which benefits are payable under any Workers’ Compensation Law, Occupational Disease Law or any other legislation of similar purpose; 12. for or relating to prescription drugs, except as specifically provided under the Plan; 13. for a dental service or procedure, dental work or treatment, under the medical benefits of the Plan, except that: (a) charges in connection with the surgical removal of impacted teeth will be covered up to a maximum Covered Charge of $25. (b) charges in connection with and as a result of injuries to natural teeth, including the initial replacement of such natural teeth sustained in an accident, to the extent the dental work or treatment is received promptly after such accident, will be covered as any other medical expense under the Plan; 14. for or relating to surgical treatment rendered by a doctor of podiatry, except to the extent the treatment for which coverage is requested was rendered pursuant to a referral by a Physician for the specific surgery and the referral is documented to the satisfaction of the Trustees and such surgical treatment does not exceed a lifetime maximum of $1,000 per person; 15. with respect to Major Medical Expense Benefits, nonsurgical treatment of chronic foot conditions including but not limited to: care of corns, bunions (except capsular or bone surgery therefore), callouses, nails of the feet, fallen arches, weak feet, chronic foot strain, routine care for symptomatic complaints of the feet, except when major surgery is performed or in conjunction with the treatment of diabetes. Chronic conditions are those that develop over time, and do not end. Symptoms may be continual or intermittent, but the condition generally exists for life. 16. for or relating to routine care and other treatments or procedures which are not Medically Necessary; 17. for or relating to services and procedures which are Experimental in nature, except as required by law; 18. for or relating to any treatment by any method of jaw joint problems, including Temporomandibular Joint Syndrome and craniomandibular disorders, or other conditions of the joint linking the jawbone and skull and the complex of muscles, nerves or other tissues related to that joint except as stated in the Dental Expense Benefit; 51 19. for or relating to confinement, treatment or services related to the restoration of fertility or the promotion of conception, including any and all artificial insemination techniques; 20. for or relating to any service, supply, treatment or procedure which is not rendered for the treatment or correction of, or in connection with, an Illness or Injury, unless specifically identified as a Covered Charge in the Rules and Regulations; or 21. except in the case of special education regarding diabetes management, for or relating to any special education rendered to any eligible Participant or Dependent regardless of the type of education, the purpose of the education, the recommendation of the attending Physician or the qualifications of the individuals rendering the special education including, but not limited to, programs for the monitoring and managing of pain, including biofeedback; 22. for or relating to any service, supply, treatment or procedure which is rendered for: (a) penile implantation unless the Participant or Dependent establishes that the implant is Medically Necessary as a result of a demonstrated disability; (b) a sex change, including, but not limited to, sex changes, psychotherapy and analysis relating to a sex change and hormonal treatments relating to a sex change; 23. for or relating to introduction into the body of an organ or portion of any organ from an animal or from another human body, including but not limited to confinements, treatments, procedures, services, supplies and medicines provided in connection with pre-transplant evaluation, organ procurement (including donor expense), transportation of organ recipient, admission, surgery and post-transplant care, with the exception that a kidney or cornea transplant will be covered by the Plan; 24. for or relating to introduction into or attachment to the body of an artificial organ; 25. for or relating to removal of an organ or portion thereof for donor purposes; 26. where benefits or amounts would have been available to the Participant or Dependent under another group health program or plan if the person had acted to qualify for benefits—such as going to an HMO or PPO provider, using a utilization review service or enrolling in an employer’s health plan —and where the Plan would pay second under its Rules for Order of Benefit Determination (see pages 92-93). However, where treatment involves a Dependent child, then the coverage of the parent whose date of birth occurs earlier in the calendar year shall be primary to the coverage of the parent whose date of birth occurs later in the calendar year; 52 27. drugs to induce growth or growth hormones, except as specifically provided under the Prescription Drug Expense Benefit; 28. for services rendered or provided to a Participant or a Dependent by the Participant’s spouse or child, brother, sister or parent of the Participant or of the Participant’s spouse, or by any person who ordinarily resides in the Participant’s home; 29. for any non-emergency MRI, CAT or PET Scan that is not authorized in advance by the Plan Office; 30. for charges for care, services or supplies for treatment received by a Participant or Dependent outside the United States, except that the Plan shall provide benefits for care, services or supplies of a medical emergency rendered to a Participant or Dependent, provided that such coverage shall be limited to the extent and at the currency rate of exchange or appropriate value of services determined by the Trustees and provided that such care, services or supplies are not covered under the provisions of the health plan of any government or other national health coverage. For purposes of this exclusion, care, services or supplies for treatment of a medical emergency shall mean care or treatment for an injury or the sudden and unexpected onset of a sickness with symptoms so severe that immediate medical relief is necessary and for which immediate medical attention is normally required; 31. any service or treatment, the cost of which may be recoverable by, or on behalf of, a Participant or a Dependent in any action at law, any judgment, compromise, settlement of any claims against any party, or any other payment the Participant or Dependent or their attorney or legal representative may receive as a result of the Injury, no matter how these amounts are characterized or who pays these amounts, as provided beginning on page 95, “Subrogation and Reimbursement”; 32. any Injury or Sickness arising from an automobile, motorcycle or related accident if personal injury protection coverage or no-fault benefits are recoverable under state law, even if coverage is denied by the insurance carrier for any reason such as, for example, because the Participant or Dependent are injured while intoxicated, or there is a no-fault insurance deductible; 33. acupuncture, massage and aquatic therapy; 34. in excess of the maximum benefits shown on the Schedule of Benefits that applies to the Participant or Dependent; 35. not incurred within any applicable time limitations stated on the Schedule of Benefits, General Exclusions and Limitations Section or that are stated in any benefit explanation; 53 36. incurred by dependent children for maternity, pregnancy or pregnancy-related conditions, except as required by law; 37. for which the Plan’s preauthorization requirements are not met. Failure to get preauthorization may result in a denial of payment; 38. Injuries resulting from an act of domestic violence or from a medical condition, including mental health medical conditions, are not excluded solely because the source of the Injury was a medical condition or domestic violence; and 39. Effective January 1, 2011, if you make fraudulent statements or intentionally misrepresent material facts in any communications to the Plan Office, including benefit claims or enrollment forms, the Plan has the right to recover from you, or any dependents receiving benefits based on their relationship to you, any amounts that the Plan would not have paid, but for the fraudulent statements or misrepresentations. You have an obligation to notify the Plan of events that would give rise to a loss of coverage for you or your Dependents, including any change in the status of your Dependents. The Plan can also terminate your coverage retroactively for failure to pay premiums and contributions. 54 LIFE INSURANCE BENEFIT (Provided by Hartford Life and Accident Insurance Company) (Retirees Excluded) Eligible Employees Death Benefit. In the event of an eligible Employee’s death from any cause, the Amount of Insurance applicable, as shown in the applicable Schedule of Benefits, will be paid in a lump sum to the beneficiary last named by the Employee, as recorded. If an individual has individual life insurance in force on his life which was issued in accordance with the Conversion Privilege below, the amount of insurance applicable to such individual will be reduced by the amount of such individual life insurance. Any change in the amount of insurance due to an increase in the Employee’s age will become effective on the policy anniversary date coincident with or next following the date of the increase in such person’s age. Changes in coverage that are due to a change in employment status (for example, a PartTime Employee becoming a Full-Time Employee), earnings or this insurance will become effective on the date of such change, except that, with respect to an increase in coverage, a retroactive change in the rate of earnings will become effective on the date of determination of the change in the rate of earnings. Beneficiary. An eligible Employee may designate or change a beneficiary on the beneficiary card available from the Plan Office or any form satisfactory to Hartford Life and Accident Insurance Company (The Hartford) by giving written notice of such designation or change to the Plan Office. Once received, the designation or change will become effective as of the date the notice was signed. The consent of the beneficiary is not required for any change of beneficiary. If no beneficiary has been designated or if the beneficiary is not alive when the Participant dies, then Hartford may pay the death benefit in accordance with the terms of the Group Life Insurance Policy. A beneficiary also may be designated in an entered court order, provided that such order contains a clear designation of rights. The designation will become effective only when it is entered on the Plan’s records, as long as Hartford has not made payment or taken other action before the entry on its records was made. A beneficiary designation in a court order meeting the above requirements will supersede any prior or subsequent conflicting beneficiary designation that is filed with the Plan Office. A beneficiary may waive his or her rights as a beneficiary under the Plan in an entered court order, provided that such order contains a clear waiver of rights. The waiver will become effective only when it is entered on the Plan’s records, as long as Hartford has not made payment or taken other action before the entry on its records was made. A waiver in a court order meeting the above requirements will supersede any prior conflicting beneficiary designation that has been filed with the Plan Office. If a court order meeting the above requirements contains a waiver of rights by the beneficiary on file with the Plan Office, and the Participant subsequently dies without naming a new 55 beneficiary, then Hartford may pay the death benefit in accordance with the rules in this Section. The Trustees are the sole judges of the effectiveness of the designation, change or waiver of a beneficiary under this Section. Installments. For proceeds under $10,000, a lump sum payment will be issued to the beneficiary. For proceeds of at least $10,000, an interest bearing draftbook/checking account will be established for the beneficiary while deciding when and how to use the money. Your beneficiary will be able to write a draft at any time for any amount of $250 or more, up to the total amount in the account. A minimum balance of $1500 must remain in the account or a check for the balance will be issued to the beneficiaries and the account will be closed. Important information regarding the account will be provided to the beneficiary once the account is established. If interest earned on the account during the year equals $10 or more, The Hartford will mail a 1099 form to the account holder at the end of the year. Extension of Insurance if Disabled. If an Employee becomes totally disabled prior to age 60, while insured under the policy, and remains so disabled, his insurance will continue in force for one year from the date of termination of active employment as a result of the disability, without payment of further premiums. If, during the first year of total disability, due proof is furnished that the disability will be total and permanent until death, the amount of insurance in force at the time of commencement of the total disability will be paid to the Employee in 120 monthly installments, the first installment to be payable after receipt of proof, but in no event before total disability has continued for a period of at least five months. If the Employee ceases to be totally and permanently disabled and returns to work, the waiver of premium and monthly installments will automatically terminate on the date the total and permanent disability ceases, and the Employee’s insurance will be continued in a reduced amount. Any installments remaining unpaid at death will be paid to the designated beneficiary in a lump sum. Conversion Privilege. If the Employee’s insurance terminates because of termination of employment, the Employee will be entitled to convert his insurance to an individual policy on any one of the forms then customarily issued by The Hartford, except term insurance. However, if elected such policy may be preceded by single premium term insurance for a period of one year. Application for conversion and payment of the required premium must be made within 31 days of such termination. The premium will be that applicable to the class of risk to which the Employee belongs and to the form and amount at the then attained age. No evidence of insurability will be required. 56 If the Group Life Insurance Policy terminates or is amended so as to terminate the insurance of any eligible class, any Employee who has been insured under it for at least 3 years may convert his insurance under the conditions stated above, but not in excess of the smaller of (a) $2,000 and (b) the amount of his terminated insurance less any amount of life insurance for which he may be eligible under any other Group Life Insurance Policy. Additional Death Benefit. Should the Employee die during the 31 days allowed for conversion but before any individual policy has become effective, The Hartford will pay the Amount of Insurance for which the Employee would have been entitled to make application. Claims. Upon the Employee’s or Dependent’s death, the beneficiary will provide their address, Social Security number and a certified copy (raised seal) of the death certificate to the Plan Office. The appropriate claim form will be completed by the Plan Office and sent to The Hartford for processing. Eligible Dependents of Full-Time Employees Benefits. If one of the insured Dependents of an eligible Employee dies from any cause, The Hartford will pay (via a lump-sum check) the Employee the applicable amount of insurance, as shown in the Schedule of Benefits. The insurance will be paid to the Employee, if living at the time of payment, otherwise to the executors or administrators of the Employee’s estate or, at the option of The Hartford, to the Employee’s surviving spouse. Conversion Privilege. If an Employee’s Dependent’s insurance terminates because of termination of the Employee’s employment or because of his death, his dependent will be entitled to the issuance of an individual policy on any one of the forms then customarily issued by The Hartford, except term insurance. Application for the conversion policy and payment of the required premium must be made within 31 days of such termination. If Life Insurance for Dependents terminates under the Group Life Insurance Policy or the Group Life Insurance Policy terminates and if the individual has been insured under the policy for at least 3 years, a Dependent will be entitled to the issuance of an individual policy under the conditions stated above, except that the amount of the conversion policy will not exceed the smaller of (a) $2,000 and (b) the amount of insurance on the Dependent upon termination of the Life Insurance for Dependents less any amounts of life insurance for which the individual may be eligible with respect to his Dependent under any other Group Life Insurance Policy. Additional Death Benefit. Should the Employee’s Dependent die during the 31 days allowed for conversion but before any individual policy has become effective, The Hartford will pay the Amount of Insurance for which his Dependent would have been entitled to make application. 57 ACCIDENTAL DEATH, DISMEMBERMENT AND LOSS OF SIGHT BENEFITS (Provided by Hartford Life and Accident Insurance Company) (Retirees Excluded) Eligible Employees Benefits. The Hartford Life and Accident Insurance Company (The Hartford) agrees, with respect to accidental bodily injuries which an Employee sustains while covered under the policy, from which loss results directly and independently of all other causes, to pay a benefit determined from the Schedule of Losses and Benefits below, provided that such loss occurs within 90 days after the date of accident causing the loss. The Maximum Benefit will be the amount stated in the applicable Schedule of Benefits. This benefit is subject to the following exclusions: 1. any loss caused by sickness or disease or medical or surgical treatment therefore, except pyogenic infection that occurs through an accidental cut or wound; 2. any loss caused by intentionally self-inflicted injuries or suicide; 3. any loss caused or contributed to by: (a) war or act of war, whether war is declared or not; or (b) sickness contracted or injuries sustained while in any of the armed forces, whether land, water or air, of any country or international authority at war, whether war is declared or not, or engaged in any armed conflict. Any change in the amount of insurance due to an increase in the Employee’s age will become effective on the policy anniversary date coincident with or next following the date of the increase in such person’s age. Changes in coverage that are due to a change in employment status (for example, a Parttime Employee becoming a Full-Time Employee), earnings or this insurance will become effective on the date of such change, except that, with respect to an increase in coverage, a retroactive change in the rate of earnings will become effective on the date of determination of the change in the rate of earnings. Schedule of Losses and Benefits Description of Loss For loss of: Benefit Life ................................................................................... Maximum Benefit A hand ........................................................ One-Half the Maximum Benefit 58 A foot ......................................................... One-Half the Maximum Benefit An eye ........................................................ One-Half the Maximum Benefit More than one of the above resulting from one accident ................................... Maximum Benefit Loss of a hand or foot means the dismemberment by severance through or above the wrist or ankle joint. Loss of an eye means the entire and irrevocable loss of sight of the eye. Beneficiary. You may designate a beneficiary, or change your beneficiary, on the Designation Card available from the Plan Office or any form satisfactory to The Hartford by giving notice of such designation or change to the Plan Office. Claims. Written notice of claim must be given to The Hartford within 20 days after the occurrence or commencement of any loss covered by the policy, or as soon thereafter as is reasonably possible. Notice given by an Employee or on behalf of an Employee to The Hartford at its Home Office, or to any authorized agent of The Hartford, with information sufficient for identification purposes, will be considered notice to The Hartford. The Hartford, upon receipt of a written notice of claim, will furnish you the forms necessary for filing proof of loss. If these forms are not furnished within 15 days after the giving of notice, the Employee will be deemed to have complied with the requirements of the policy as to proof of loss upon submitting, within the time fixed in the policy for filing proofs of loss, written proof covering the occurrence, the character and the extent of the loss for which claim is made. Written proof of loss must be furnished to The Hartford in case of claim for any loss within 90 days after the date of such loss. Failure to furnish proof within the time required will not invalidate or reduce any claim if it was not reasonably possible to give proof within such time provided the proof is furnished as soon as reasonably possible and in no event, except in the absence of legal capacity, later than one year from the time proof is otherwise required. Indemnities. Indemnities payable under the policy for any loss will be paid as they accrue immediately upon receipt of due written proof of the loss. Indemnity for loss of life under any Accidental Death, Dismemberment and Loss of Sight Benefit included in this Plan will be payable in accordance with the beneficiary designation and the provisions respecting such payment which are prescribed therein and effective at the time of payment. If no such designation or provision is then effective, such indemnity will be payable to the Employee’s estate. Any other accrued indemnities unpaid at death may, at the option of The Hartford, be paid either to such beneficiary or to such estate. All other indemnities will be payable to the Employee. Right to Examine. The Hartford at its own expense will have the right and opportunity to examine the person of any individual whose injury or sickness is the basis of a claim 59 when and as often as it may reasonably require during the pendency of a claim under the policy and to make an autopsy in case of death, where it is not forbidden by law. Action of Law or In Equity. No action at law or in equity will be brought to recover on the policy prior to the expiration of 60 days after written proof of loss has been furnished in accordance with the requirements of the policy. No such action will be brought, after the expiration of the shortest period of time permitted by the laws of the State* in which the policy is issued, after the time written proof of loss is required to be furnished. *Kansas--5 years *Missouri--10 years *South Carolina--6 years *All other states--3 years 60 DISABILITY BENEFIT (Participants except for Retirees) If a Participant suffers a Disability (described below) due to a Non-occupational Injury or Non-occupational Sickness, the Plan will pay to the Participant monthly benefits at the rate shown in the Schedule of Benefits. Eligibility. Benefits are payable only to Participants who become entitled to either Social Security disability benefits or a disability pension under the United Food and Commercial Workers International Union-Industry Pension Fund or its successor. Period of Coverage. Benefits are payable for the period beginning with the inception date of the disability and terminating on the earlier of the maximum period in the Schedule of Benefits, or the Participant becoming eligible for Social Security disability benefits or the disability pension benefits provided under the United Food and Commercial Workers International Union-Industry Pension Fund or its successor. Under no conditions will payment be made for a period while the Participant is receiving sick pay benefits or weekly disability benefits from his Employer or any Employer-sponsored plan or a period of more than five consecutive months. 61 RETIREE DEATH BENEFIT (Retirees Receiving Disability Pensions Excluded) If a Participant covered under the Senior Program dies, the Plan will pay a death benefit in the amount shown on the applicable Schedule of Benefits to the Participant’s designated beneficiary. As noted above, the death benefit does not apply to persons covered under the Senior Program who are receiving a Disability Pension or a Vested Pension benefit due to termination of covered employment before age 55. The Plan will defer payment until a copy of the retired Employee’s certificate of death is received by the Plan. Beneficiary. Any Death Benefits payable to a minor or incompetent may be paid to the legally appointed guardian of the minor or the incompetent. If no such guardian exists, benefits may be paid to such adult or adults as have, in the Trustees’ opinion, assumed the custody and principal support of such minor or incompetent. If two or more beneficiaries become entitled to Death Benefits under this section, they shall share equally, unless otherwise designated on the retired Employee’s valid beneficiary designation form (i.e., duly signed and witnessed designation form). If there is no valid beneficiary designation form on file with the Plan Office, the Plan, upon receipt of a claim by the retired Employee’s estate, will pay the death benefit to the estate of the retired Employee. If at the time of death, there is no designated beneficiary with respect to all or any part of the benefits or if no designated beneficiary survives the retired Employee, upon the Plan’s receipt of a claim by the retired Employee’s estate, the Plan shall pay this death benefit to the retired Employee’s estate. Payment to one described above will release the Plan from all further liability to the extent of the payments made. The retired Employee may designate a beneficiary or may change a previously designated beneficiary by filing a valid beneficiary designation form. Such designation or change, when received by the Plan, shall take effect as of the date the written notice is received by the Plan, whether or not the retired Employee is living at the time of such receipt. However, any payment made by the Plan prior to such designation or change shall fully discharge the Plan to the extent of such payment. The right to change beneficiaries is reserved to the retired Employee and the consent of the beneficiary or beneficiaries shall not be required to change a beneficiary. A beneficiary also may be designated in an entered court order, provided that such order contains a clear designation of rights, as determined by the Trustees in their sole discretion. The designation will become effective when it is entered in the Plan’s records, as long as the Plan has not made payment or taken other action before the entry on its records was made. A beneficiary designation in a court order meeting the above requirements will supersede any prior conflicting beneficiary designation that is filed with the Plan Office. 62 A beneficiary may waive his or her rights as a beneficiary under the Plan in an entered court order, provided that such order contains a clear waiver of rights, as determined by the Trustees in their sole discretion. The waiver will become effective when it is entered on the Plan’s records, as long as the Plan has not made payment or taken other action before the entry on its records was made. A waiver in a court order meeting the above requirements will supersede any prior conflicting beneficiary designation that has been filed with the Plan Office. If a court order meeting the above requirements contains a waiver of rights by the beneficiary on file with the Plan Office, and the retired Participant subsequently dies without naming a new beneficiary, then the Plan will pay any death benefits as if there is no valid beneficiary designation form on file with the Plan Office. 63 GENERAL RULES The benefits provided under this Plan for Participants and Dependents are explained on the following pages. Each benefit explanation in the following sections tells you what is covered under that benefit and lists certain items that are not covered. The General Exclusions and Limitations section starting on page 49 lists the types of expenses for which benefits are limited or for which benefits are not payable under any of the Plan benefits. Be sure to read those limitations. Keep this list of rules in mind. These rules apply to all of your benefits. 1. Expenses incurred by female Participants and Dependent spouses of male Participants for maternity, pregnancy or pregnancy-related conditions are treated as expenses incurred for an Illness, except as required by law. 2. A listing of participating PPO Hospitals is available by contacting the Hospital PPO Network at the telephone number or website on the Inside Back Cover. 3. Some Hospitals, Physicians and other service providers “unbundle fees.” This means the provider breaks down one procedure into many small ones and charges separately for each one. In these cases, the Plan will treat all of the segments as one procedure and will pay its benefits accordingly. 4. All claims, enrollment forms and any other information submitted or provided to the Plan, directly or indirectly, must be accurate and complete. Any claim form submitted by or on the behalf of a Participant that contains a material alteration or forged information, including signatures, will be rejected by the Plan Office. If the Board of Trustees finds, at any time, that false or inaccurate information has been submitted or provided to the Plan, directly or indirectly, in support of a claim, such claim will be denied and the Trustees will offset the amount improperly paid and/or terminate future coverage for the affected individual and the affected individual’s Covered Family Members. The Board of Trustees reserves the right to forward the altered or forged document to the local law enforcement agency for whatever legal action said agency deems to be appropriate. 5. The Plan complies with the Women’s Health and Cancer Rights Act of 1998, by providing benefits for mastectomy-related services including reconstruction and surgery to achieve symmetry between the breast, prosthetic and complications resulting from a mastectomy (including lymphedemas). Call the Plan Office for more information. 6. The benefits payable under this Plan will not be subject in any manner to anticipation, alienation, sale, transfer, assignment, pledge, encumbrance or charge by any person. However, a Participant may direct that benefits due him be paid 64 directly to any provider of medical services or supplies in consideration for medical or hospital services rendered or to be rendered, or supplies furnished or to be furnished, provided the required assignment is received by the Plan Office prior to the benefit payment. 7. If any payment is made by the Plan to or on behalf of an individual who is not entitled to all of or part of this payment, the Plan is entitled to be reimbursed the amount of this erroneous payment. If necessary, the Plan can recover the erroneous payment by suspending or withholding payment of claims or reducing future benefit payments to or on behalf of this individual and/or his or her covered family members participating in the Plan by the amount of any erroneous payment and the amount incurred by the Plan in pursuing recovery of the overpayment. The Plan and Trustees may also take other actions to recover the erroneous payments and other amounts including, but not limited to, commencing a restitution action under ERISA. 65 PPO NETWORK OPTIONS The Plan provides a Preferred Provider Option (PPO) Network option for care rendered at Hospitals and by Physicians and certain other health care providers. The Plan provides a separate PPO Pharmacy Network option when prescription drugs must be obtained. A PPO Network Organization negotiates with physicians, clinics, hospitals, pharmacies, etc., to provide necessary medical care and services at a lower cost to you and the Plan. Therefore, by having covered treatment provided through a PPO provider, the cost of health care for both you and the Plan should be lower. Neither the Plan, the Trustees, Employers nor Union have conducted a quality review of the Hospitals, Physicians or other health care providers and facilities associated with the PPO Networks as part of the agreements with the Plan. In other words, while the Hospitals and Physicians or other health care provider and facilities associated with the PPO Networks make a discounted fee available, the Plan in no way guarantees the quality of care provided by them. Neither the Plan nor the Trustees have a financial interest in or direct control of any of the health care providers or facilities associated with the PPO Networks. HOSPITAL AND PHYSICIAN PPO NETWORK You can determine whether a hospital, radiology facility, physician or specialist participates in the PPO Network by calling the PPO Hotline listed on the inside back cover of this booklet. Because the list of participating hospitals, physicians and other providers changes from time to time, you should double check whether or not the hospital, physician or provider is in the PPO at the time of the treatment. IMPORTANT: Not all Physicians working out of a PPO Hospital are participating providers in the PPO Network. You should ask each Physician whether they participate to maximize your benefits under the Plan and reduce your out-of-pocket expenses. The PPO Co-Payment Percentage will only apply when care or treatment is provided by a PPO Provider. However, when treatment is provided for an Illness or Injury at a PPO Provider Hospital emergency room and the Participant or Dependent is admitted to the Hospital as a direct result of the visit, those emergency room and emergency room Physician Covered Charges will be payable at the PPO Co-Payment Percentage. When you use a PPO Physician, you can use the PPO Hotline listed on your I.D. card to confirm that the Physician and his office location participate in the PPO. Some of the Physicians have offices in several locations and not all locations may participate in the PPO. For example, a Physician who practices at two locations might have office hours at a participating PPO location on three days of the week but the location where he practices on the other days of the week does not participate in the PPO. Benefits for the Physician’s care will be paid under the PPO coverage only if you see the Physician at the participating location. 66 If a PPO Physician refers you or any of your Dependents for additional services (such as lab work, x-rays or referral to specialist) and you wish to have the services performed by a PPO Network provider, you should advise the physician to refer you to a PPO Network provider. It is very important that you (and your covered Dependents) show your I.D. card whenever you receive any type of health care. The I.D. card shows the name and phone number of both the Plan and the PPO Network and the Plan address. And the I.D. card identifies to providers that you are a member of the PPO so that they can send their bill to the PPO Network for initial processing. If you need I.D. cards, contact the Plan Office. PHARMACY NETWORK The Plan and KPP have entered into an arrangement with a Pharmacy Network to secure discounts on prescription drugs when you have a prescription filled at a pharmacy participating in this Network. Using a Network pharmacy is very important for you to receive the maximum benefits, or, in some cases, any benefits at all, except in emergency situations. See the Prescription Drug Expense Benefit, beginning on page 85 for more details. HOSPITAL PRE-ADMISSION CERTIFICATION REQUIREMENT (MATERNITY ADMISSIONS SEE PAGE 71). 1. Nonemergency Hospital Admissions. A Participant or Dependent who will be admitted as a Hospital inpatient must have all nonemergency Hospital admissions authorized in advance by InforMed at 1-877-687-9982 (“Preadmission Certification Requirement”). The Participant will then be notified of the authorized length of stay, which will be based on the diagnosis of the patient’s condition, information from the attending physician and guidelines adopted from time to time by the Plan for effective and necessary inpatient care. Failure to have an admission preauthorized will result in a disallowance of expenses that exceed the amount that would have been preauthorized plus a $250 deductible will be applied against expenses that would have been preauthorized. 2. Emergency Hospital Admissions. A Participant or Dependent who undergoes an emergency Hospital admission must have the admission authorized within 72 hours after admission by InforMed at 1-877-687-9982. The Participant will then be notified of the authorized length of stay, which will be based on the diagnosis of the patient’s condition, information from the attending physician and guidelines adopted from time to time by the Plan for effective and necessary care. Failure to have an emergency admission authorized within 72 hours after admission will result in a disallowance of expenses that exceed the amount that would have been authorized and a $250 deductible will be applied against expenses that would have been preauthorized. 67 With respect to coverage of emergency room visits, 50% co-insurance will apply (rather than 80%) if the emergency room visit is not the direct result of a medical emergency. 3. Continued Length of Stay. Approval of a length of stay for all Hospital admissions beyond that originally authorized must be obtained from InforMed at 1-877-687-9982 at least 24 hours in advance of the expiration of the authorized stay. In the event the authorized stay expires on a weekend or holiday, approval of a continued length of stay must be obtained by the last working day before the weekend or holiday. Failure to obtain approval will result in a disallowance of expenses that exceed the authorized amount. 4. Limitations and Exclusions. The Plan will not pay benefits for: (a) a Hospital inpatient length of stay beyond the approved length of stay as described above; (b) charges for a Hospital confinement for days prior to the date of surgery unless precertified as Medically Necessary by InforMed. PREAUTHORIZATION OF SURGICAL PROCEDURES AND OTHER BENEFITS The following Surgical Operations or Procedures must be preauthorized by InforMed at 1-877-687-9982. The preauthorization will also include a length of stay authorization under the Hospital Preadmission Certification Requirement. Failure to have a nonemergency Surgical Operation or Procedure preauthorized will result in a $400 deductible being applied against Covered Charges for the surgery. Adenoidectomy Hysterectomy Spinal or Vertebral Surgery Tonsillectomy Varicose Vein excision and ligation Repair of deviated septum Knee Surgery Prostatectomy Gastric bypass or lap band surgery Surgery of eyelids Bunionectomy Joint replacement Additional requirements apply to gastric bypass and lap band surgery (see page 72). In addition to the above preauthorization requirements, some Plan benefits require preauthorization. They are identified on the Schedule of Benefits and include non68 emergency MRIs, PET and CAT scans, convalescent care, home health care, hospice care, and durable medical equipment above $500. 69 MAJOR MEDICAL EXPENSE BENEFITS Overview. The Major Medical Expense Benefit provides Participants and Dependents coverage for Covered Charges incurred which exceed the deductible required under this section. The Major Medical Expense Benefit is subject to an annual maximum per person. Certain expenses are subject to separate individual lifetime maximums or limits. Please refer to the Schedule of Benefits. The total amount of benefits payable for all Covered Charges with respect to any one person (whether or not there is any interruption in the coverage with respect to such person under this Plan and whether or not there is any change in status of such person from Participant to Dependent or vice versa) will not exceed the maximums shown in the Schedule of Benefits. Deductible Requirement. 1. Calendar Year Deductible. (a) Single Coverage Deductible. The Single Coverage deductible requirement shown in Schedules I (Plan 1), II (Plan S) and III (Plan V) of the Schedule of Benefits will be applied against Covered Charges incurred in each calendar year. Unless the Plan’s Rules and Regulations provide otherwise, the deductible for the Participant shall be considered satisfied for the remainder of the calendar year after the out-of-pocket Covered Charges for the Participant total the amount of the Single Coverage deductible per calendar year shown in Schedules I, II, or III of the Schedule of Benefits (whichever applies to the Participant). (b) Family Coverage Deductible (Participants and Dependents). The Family Coverage deductible requirement shown in Schedules I, II, and III of the Schedule of Benefits will be applied against Covered Charges incurred in each calendar year to Participants covered by Family (Participant and Dependent) coverage. After the out-of-pocket Covered Charges for all Covered Family Members of the same family unit total the amount of the Family Coverage deductible per calendar year shown in Schedules I, II, or III of the Schedule of Benefits (whichever applies to the Participant and Dependents), the deductible for all Covered Family Members in the same family unit will be considered satisfied for the remainder of the calendar year. Percentage Payable. Once the deductible requirement as shown in the Schedule of Benefits is met, the Plan will provide benefits for Covered Charges at the percentage payable in the Schedule of Benefits not to exceed the maximums shown in the Schedule of Benefits. Reinstatement of Benefits. For benefits to which a lifetime limit is applicable, up to $1,000 annually is automatically restored to the Major Medical Expense Benefit lifetime 70 maximum as shown in the Schedule of Benefits for Participants or Dependents who have received benefits under Major Medical. The annual restoration is made on January 1 of each calendar year and will not be applicable to any retired Participant or his or her Dependent who, as of that time, has reached age 65. Also, a Participant or Dependent who has received Major Medical Expense Benefits in excess of $1,000 under the Plan will receive an automatic annual restoration of up to 5% of the lifetime maximum benefit, but not greater than the lifetime maximum benefit amount. Benefits. Benefits are payable only for Covered Charges (see page 20) that exceed the deductible but do not exceed any applicable annual or lifetime maximum shown in the Schedule of Benefits. Benefits are payable for the following: 1. Inpatient Expenses. If a Participant or Dependent has been confined as an inpatient in a Hospital, the Plan will provide benefits for Covered Charges in connection with any one period of Hospital confinement for: (a) Daily Hospital Room and Board; (b) Other Hospital Services and Supplies; and (c) Physician’s Expenses (excluding services rendered by the surgeon throughout the patient’s entire hospital stay that are covered under surgical expenses). Note about length of maternity hospitalizations– a female Participant or female Dependent spouse and her newborn infant are entitled to 48 hours of inpatient hospital care following normal vaginal delivery and 96 hours of inpatient hospital care following a Cesarean section without obtaining preauthorization. (The attending provider may, however, after consulting with the mother, discharge the mother and the newborn earlier than 48 hours following a vaginal delivery or 96 hours following a Cesarean section.) The Plan requires the provider (Hospital or Physician) to obtain preauthorization for a length of stay in excess of these periods. The Plan will provide benefits for the Covered Charges incurred during the prescribed time periods, subject to all applicable Plan benefit provisions, maximums and limitations. 2. Outpatient Expense. If a Participant or Dependent received care and treatment in a Hospital in connection with, and at the time of, a Surgical Operation or Procedure performed in the Hospital by a Physician and the Participant or Dependent was not confined as an inpatient in the Hospital, the Plan will provide benefits for the Covered Charges for Other Hospital Services and Supplies. 3. Pre-Admission Testing. The Plan will provide benefits for Covered Charges for diagnostic tests and x-rays performed in the outpatient department of a Hospital within seven days of an actual admission to the Hospital, provided the tests are ordered by a Physician, and the Participant or Dependent is scheduled for admission to the Hospital for treatment of the condition that made the tests necessary. In the event that the scheduled admission does not take place, the pre71 admission testing Covered Charges will not be covered unless the admission is postponed or cancelled for one or more of the following reasons: 4. 5. (a) the tests indicated that the condition requires medical treatment prior to admission; (b) the tests indicated that a medical condition has developed that delays the admission; (c) a Hospital bed is not available on the scheduled date of admission; or (d) the tests indicated that, contrary to the attending Physician’s expectation, the admission is not necessary. Gastric Bypass and Lap Band Surgery. Subject to preauthorization requirements, the Plan covers Gastric Bypass/lap band Surgery, if the Participant or Dependent meets certain criteria. In addition to meeting the requirements of being “Medically Necessary,” as discussed on page 26, all of the following must also be satisfied: ● the Participant or Dependent must possess a body mass index of at least 50; and ● the Participant or Dependent must first complete an integrated program approved by the Plan’s medical consultant on a preauthorization basis which shows that the candidate is prepared to make the lifestyle changes necessary for the gastric bypass/lap band surgery to successfully address morbid obesity; and ● the Participant or Dependent must be between the ages of 21 and 65; and ● the Participant or Dependent must exhibit a history of morbid obesity and confirm that all other lesser weight loss efforts have tried and failed. Operating Physician. The Plan will provide benefits for Covered Charges by a Physician as a surgical fee for performing a Surgical Operation or Procedure. Covered Charges will include all Medically Necessary pre- and post-operative visits. Out-of-Network Covered Charges for two or more Surgical Operations or Procedures due to the same or related cause or causes performed at different times during one Period of Disability will be paid up to the maximum amount per disability as shown in the Schedule of Benefits. However, two or more Out-ofNetwork Surgical Operations or Procedures performed through the same abdominal incision will be considered as one Surgical Operation or Procedure and the maximum amount payable will be the maximum amount shown in the Schedule of Benefits for the Surgical Operation or Procedure performed that has the largest applicable maximum amount. 72 Covered Charges, up to a lifetime maximum per Covered Family Member, will be payable by the Plan for surgical treatment performed by a doctor of podiatry provided that treatment is rendered pursuant to a referral by a Physician for the specific surgery and is so documented to the satisfaction of the Trustees. The Lifetime Maximum Benefit for this coverage is set forth in the Schedule of Benefits. Podiatrist Surgical Expenses are limited as explained on page 5. The Plan will pay the Covered Charges of a Surgical Assistant based on the U&C for the Surgical Operation or Procedure CPT Code. 6. Consulting Physician. The Plan will provide benefits for Covered Charges for Consulting Physician expenses. 7. Anesthesiology. The Plan will provide benefits for Covered Charges for the administration of anesthetics by a professional anesthetist, certified registered nurse anesthetist (CRNA) and Physician. However, if out-of-network charges from all providers for the administration of anesthetics exceed the U&C, the payment will be pro-rated to each provider. 8. Physician’s Expenses. The Plan will provide benefits for Covered Charges for Physician’s expenses. However, in situations where a Physician charges for different levels of office visits with respect to the same or related condition, any charge above the charge for the base service will only be paid to the extent that the Plan, based on advice from the Plan’s medical consultant, determines that such additional services were Medically Necessary. 9. Maternity Expenses (Female Participants and Dependent Spouses) Benefits. Covered Charges incurred as the result of pregnancy, childbirth or related medical conditions will be treated the same as any other medical Illness for a female Participant or female Dependent spouse of a Participant, except as required by law. No payment will be made to a female Participant or female Dependent spouse of a Participant on account of elective abortions, except where the life of the woman would be endangered if the fetus were carried to term or where medical complications arise from an abortion. Extension of Maternity Expense Benefits. Benefits resulting from pregnancy, childbirth, or related medical conditions will continue to be paid on the same basis as any other Illness if, on the date of termination of eligibility, the female Participant or Dependent spouse of a Participant or retiree is Totally Disabled as a result of pregnancy, childbirth, or related medical conditions. 10. Voluntary Sterilization (Participants and Dependent Spouses). The Plan will provide benefits for Covered Charges of Participant or a Dependent spouse who incurs expenses in connection with a Surgical Operation or Procedure for the purpose of sterilization of the reproductive system. Benefits will not be payable for the reversal of any such operation or procedure. 73 11. Chiropractor Services. The Plan will provide benefits for Covered Charges, not to exceed the maximum number of visits as shown in the Schedule of Benefits, for the professional services of a chiropractor (D.C.) or physiotherapist (RPT) employed by or in the same office as a chiropractor for administering physical medicine. 12. Physical Medicine (Therapy) and Speech Therapy Services. The Plan will provide benefits for Covered Charges for the professional services of a Physician or physiotherapist (RPT) for the administration of physical medicine (therapy) to a Covered Family Member, up to the maximum number of visits specified in the Schedule of Benefits. The Plan will provide benefits for Covered Charges for the professional services of a licensed speech therapist for loss of speech function as a result of Illness or Injury. If in the judgment of the Physician attending the Covered Family Member as further supported by the patient’s medical records and prognosis, significant improvement can be achieved, the Plan may permit an additional number of visits on a week-by-week basis, provided such additional visits are preauthorized by InforMed. The Plan reserves the right to have such additional visits reviewed by the Plan’s medical consultant before preauthorizing such visits. Benefits are not payable by the Plan for physical therapy services or speech therapy services to maintain a Covered Family Member’s function at the level to which it has been restored or when no further significant practical improvement can be expected. Physical therapy that is prescribed by a Physician in place of nonmedical treatment (for example, exercise) is not considered Medically Necessary treatment and is not payable by the Plan. 13. Diagnostic X-ray and Laboratory Examination Expenses. The Plan will provide benefits for Covered Charges for diagnostic x-ray and laboratory examination expenses. All nonemergency Magnetic Resonance Imaging (MRI), Positron Emission Tomography (PET Scan) and Computerized Axial Tomography (CAT Scan) diagnostic tests must be preauthorized by InforMed in order to be covered. The Plan reserves the right to have a request for a preauthorized test reviewed by the Plan’s medical consultant before preauthorizing such tests. 14. Durable Medical Supplies. The Plan will provide benefits for Covered Charges for medically necessary Durable Medical Supplies, subject to the limitations, exclusions, and preauthorization requirements below. All expenses for Durable Medical Supplies exceeding $500 must be preauthorized by InforMed. Where preauthorization by InforMed for Durable Medical Supplies is required, the Plan’s benefit is limited to the least costly supply or equipment appropriate for the Participant’s or Dependent’s condition. Limitations and Exclusions of Durable Medical Supplies: (a) prostheses, such as an artificial eye, limb, or portions of a limb and in the event of a mastectomy, breast prosthesis, must be preauthorized in advance by InforMed; 74 (b) a truss, brace or support must be preauthorized by InforMed; (c) rental of a manually operated wheelchair, manually operated Hospital type bed or other durable medical equipment must be preauthorized by InforMed; (d) rental of mechanical equipment required for the treatment of respiratory paralysis must be preauthorized by InforMed; (e) coverage for compression stockings is limited to two pairs per year; (f) the Plan will cover one wig when hair loss is due to chemotherapy, up to a maximum Covered Charge of $150. Note: If it is determined in advance by the Plan to be more cost effective to purchase, rather than rent, Durable Medical Supplies such as a manually operated wheel chair, Hospital type bed or other mechanical equipment, the Plan reserves the right to reclaim the equipment when the Participant or Dependent no longer requires the use of the equipment. 15. Expenses for the Services of a Registered Graduate Nurse, Licensed Practical Nurse or a Physiotherapist. Subject to the Plan’s limitations, the Plan will provide benefits for Covered Charges for services rendered to a Participant or Dependent by a registered graduate nurse, licensed practical nurse or a physiotherapist. 16. Convalescent Care Accommodations. The Plan will provide benefits for Covered Charges not to exceed the maximum as shown in the Schedule of Benefits made by a Convalescent or Intermediate Care Facility for its Room and Board accommodations, provided: 17. (a) the individual is confined as a registered bed patient on the certification of his Physician that such Convalescent Facility confinement is necessary; (b) Convalescent Facility confinement commences after discharge from a Hospital confinement of at least three consecutive days of acute care stay; and (c) Convalescent Facility confinement is necessary for the care or treatment of the Injury or Illness that was the cause of the preceding Hospital confinement. Home Health Care Services. The Plan will provide benefits for Covered Charges not to exceed the maximum as shown in the Schedule of Benefits for home health care services (as described below) provided the services meet all of the following requirements: (a) they are preauthorized by InforMed; 75 (b) they are furnished in the patient’s home because Hospital or Convalescent or Intermediate Care Facility accommodations would have been required if such services were not furnished at home; (c) they are given under a plan of care established, approved in writing and reviewed at least every two months by the attending Physician, unless such Physician determines that a longer interval between reviews is sufficient. If the patient was a Hospital inpatient immediately prior to the start of home health care, the plan of care must also be initially approved by the Physician who was the primary provider of services during the Hospital stay; (d) they are provided by a Hospital, a licensed or certified Home Health Care Agency, or a certified rehabilitation facility; (e) necessary care is not available from members of the person’s immediate family without causing undue hardship. Immediate family means the spouse, children, parents, grandparents, brothers and sisters of the Participant and the Participant’s spouse; and (f) they would have been covered if provided in a Hospital. Home health care services include: (a) nursing service by a registered nurse (R.N.) or by a licensed practical nurse; (b) Home Health Aide service consisting mainly of care of the patient; (c) physical, occupational, respiratory or speech therapy; (d) medical supplies, drugs and laboratory work; (e) nutritional counseling by or under the supervision of a registered dietician; and (f) evaluation of the need for and development of a plan for home health care by a registered nurse, physician extender or medical social worker when approved by or requested by the attending Physician. A “visit” as used in the Schedule of Benefits is either a visit by members of a home health care team or four consecutive hours of Home Health Aide services. For a person eligible for Medicare, the above benefits will be paid only for Home Health Care visits beyond those provided by Medicare, up to an aggregate total of 365 visits under Medicare and the Home Health Care benefit per 12-month period. 76 18. Hospice Care. Subject to preauthorization by InforMed, the Plan will provide benefits for Covered Charges not to exceed the maximum as shown in the Schedule of Benefits for the following hospice care services provided by a Hospice Care Agency: (a) nursing care; (b) medical social services; (c) counseling services; (d) chaplaincy; (e) physical therapy; (f) occupational therapy; (g) speech language pathology; (h) medical supplies and equipment; and (i) drugs and biologicals used for pain and symptom control. The Plan will not pay Covered Charges for the following: 19. (a) bereavement counseling; (b) inpatient care; (c) administrative expenses; (d) transportation (except in emergency situations); or (e) Surgical Operations or hospitalizations due to medical complications of the terminal condition. Mental and Nervous Disorders, Alcoholism and Substance Abuse Expenses. Subject to the Hospital preadmission requirements on pages 67-68, the Plan will provide benefits for Covered Charges for a Participant or Dependent who has incurred Covered Charges as a Hospital inpatient for treatment of psychosis and associated organic illness or for treatment of alcoholism or substance abuse. If a Participant or Dependent incurs Covered Charges for outpatient treatment of a Mental and Nervous Disorder, alcoholism or substance abuse, benefits will be payable under the Plan for the following: (a) Charges for services rendered on an outpatient basis for the treatment of alcoholism or substance abuse. 77 (b) Charges for services rendered on an outpatient basis by a Physician for treatment of Mental and Nervous Disorders. 20. Expenses for Administering Allergy Injections. The Plan will provide benefits for Covered Charges for the administration of allergy injections by a registered graduate nurse, licensed practical nurse or a Physician who are not family members. 21. Diabetes Self-Management Education. Charges actually made to the Participant for education for the care and self-management of diabetes, including nutritional counseling, that are provided to a Participant or Dependent after the initial diagnosis of the condition, shall be limited to the following: (a) visits Medically Necessary upon the diagnosis of diabetes; (b) visits under circumstances where a Physician identifies or diagnoses a significant change in the symptoms or conditions of a Participant or Dependent that necessitates changes in the person’s self-management; and (c) where a new medication or therapeutic process relating to the Participant’s or Dependent’s treatment and/or management of diabetes has been identified as Medically Necessary by a licensed Physician. Coverage for reeducation or refresher education shall be limited to a maximum Plan payment of $100 per calendar year. Diabetes education must be provided by the Physician as part of an office visit for diabetes diagnosis or treatment, by a licensed pharmacist for instructing and monitoring a Participant or Dependent regarding the properties of covered equipment, supplies and medications prescribed by a Physician, by a certified diabetes educator (i.e., certified by a national diabetes educator certification program), or by a registered dietitian (i.e., registered by a nationally recognized professional organization of dietitians) upon the referral of a Physician. The national diabetes education certification program or the nationally recognized professional association of dieticians must be certified to the commissioner of insurance by the commissioner of the bureau of public health. The Plan requires acceptable proof that a diabetes educator or a registered dietitian meets the appropriate certification or registration before a claim will be processed. 22. Ambulance Expenses. If the Participant or Dependent has been transported by an ambulance provided by the Hospital or by an ambulance service that customarily renders ambulance transportation in the usual course of its business to or from the Hospital in connection with a Hospital confinement for which Hospital Expense Benefits are payable, the Plan will provide benefits for Covered Charges. All nonemergency transportation and any special ambulance service, including air ambulance, other than to the nearest Hospital in the case of an emergency, must be preauthorized by InforMed . 78 23. Emergency Accident Expense Benefits. If a covered Participant or Dependent who sustained a Non-occupational Injury and, as a result of such injury, actually incurs charges for: (a) care and treatment by a Physician, or (b) outpatient charges for Other Hospital Services and Supplies and the Participant or Dependent is not entitled to similar benefits under the Plan, the Plan will provide benefits for Covered Charges. 24. Hearing Expenses (Retirees Excluded). The Plan will pay the Covered Charges not to exceed the maximum as shown in the Schedule of Benefits for hearing expenses when an in-network Provider is utilized. In addition to those items shown on the Schedule of Benefits, the Plan will pay Covered Charges for a Physician’s visit if a hearing problem is determined by the licensed audiologist and the patient is referred to the Physician by the audiologist. 25. Genetic Testing. In addition to any genetic counseling and evaluation for BRCA testing required under PPACA, the Plan will pay covered charges for BRCA mutation testing for breast and ovarian cancer susceptibility when an individual has either already been diagnosed with either breast or ovarian cancer or has a family history on the maternal side of breast or ovarian cancer, upon receipt of sufficient documentation. 79 BASIC MEDICAL EXPENSE BENEFITS 1. Preventive Care (In-network) services required by PPACA will be covered at 100%. The Plan will provide coverage for and not impose any cost sharing requirements for Preventive Care services at an in-network facility. The Plan will cover those services listed in the definition of Preventive Care on page 27. To the extent not covered as Preventive Care, the Plan will provide benefits for Covered Charges incurred by a Participant, eligible Dependent spouse and children subject to age limits for one examination for routine checkups and related diagnostic laboratory and radiology services, well baby care, immunizations, flu shots, colonoscopies, pap smears, mammograms, PSA testing, HPV vaccine, HIV screening, and testicular cancer screening. 2. Wellness Care Expense. The Plan will provide benefits for Covered Charges incurred by a Participant, eligible Dependent spouse and Children subject to age limits for one examination for routine checkup and related diagnostic laboratory and radiology services, routine colonoscopies (up to age 50), routine mammograms (up to age 40), PSA testing and testicular cancer screening not to exceed the maximum as shown in the Schedule of Benefits. 3. Vision Care Expenses. The Plan will provide benefits for Covered Charges not to exceed the maximum as shown in the Schedule of Benefits for a vision examination performed by a qualified optometrist or ophthalmologist and/or lenses and frames prescribed or provided by a qualified optometrist, ophthalmologist or optician. Only one examination and/or lenses and frames and/or contacts will be considered for payment during any two calendar year period. No vision care benefits will be payable by the Plan for vision training procedures, any lenses that did not require a prescription, or sunglasses, prescription or non-prescription. Retirees are excluded from these benefits except for the Preventive Care (Innetwork) services required by PPACA that will be covered at 100%. The Plan will cover those services referenced in the definition of Preventive Care on page 27. 80 DENTAL EXPENSE BENEFIT (Retirees Excluded) Benefits. The Plan will provide benefits for Covered Charges not to exceed the maximum as shown in the Schedule of Benefits for Covered Dental Services (described below) if performed by a Dentist. The total amount of benefits payable for all Covered Dental Services with respect to any one person (whether or not there is any interruption in coverage with respect to such person under this Plan or any change in status from Participant to Dependent or vice versa) will not exceed the maximums shown in the Schedule of Benefits. Covered Dental Services. The following services if performed by a Dentist: 1. Diagnostic Services. Procedures to assist the Dentist in evaluating the existing conditions to determine the required dental treatment. 2. Preventive Services. Prophylaxis twice in each 12 months; topical application of fluoride solutions for Dependent children less than 19 years of age; and space maintainers. 3. Emergency Services. Treatment for relief of pain. 4. Basic Services. 5. (a) Oral Surgery. Procedures for extractions and other oral surgery including pre- and post-operative care. (b) General Anesthesia. Anesthesia administered by a Dentist for a covered oral surgery procedure. (c) Restorative. Amalgam, synthetic porcelain and plastic restorations for treatment of carious lesions. (d) Endodontic. Procedures for pulpal therapy and root canal filings (treatment of non-vital teeth). (e) Periodontic. Procedures for treatment of the tissues supporting the teeth. Major Services. (a) Prosthodontics. Procedures for construction of bridges, partial and complete dentures. (b) Restorative Crowns and Inlays. Gold restorations, crowns and jackets will be provided when teeth cannot be restored with amalgam, synthetic porcelain and plastic materials. 81 6. 7. TMJ Services. Intra-oral services provided by a Dentist when necessary and customary according to the standards of generally accepted dental practice for the treatment of acute dental symptoms associated with malfunction of temporomandibular (jaw) joint (TMJ). (a) Temporary Repositioning Appliance. A removable appliance to move any teeth that are obstructing the normal occlusion. (b) Occlusal Guard. grinding.” (c) Occlusal Adjustment. (d) Orthodontic Appliance. Where it can be established that such appliance was primarily for treatment of TMJ and was obtained in combination with other TMJ Services. (e) Removable Overlay Stabilizing Appliance. To relieve injurious effects of bruxism or “night- Orthodontic Services. Coverage is provided in connection with diagnostic services, the treatment plan, fitting, making and placing of the active appliance and related office visits up to the maximum benefit set forth in the Schedule of Benefits. Limitations. 1. X-rays. Complete mouth x-rays are provided only once in a three-year period, unless the Participant or Dependent demonstrates a special need. Supplementary bite-wing x-rays are provided upon request, but not more than four bite-wing x-rays once every six months. 2. Prosthodontics. Replacement of an existing prosthodontic appliance will be made only if the Participant or Dependent can demonstrate it is unsatisfactory and cannot be made satisfactory. Prosthodontic appliances (including partial and complete dentures, crowns and bridges) will be replaced only after five years have elapsed following any prior provision of such appliances. This limitation will not apply if replacement is necessary for reasons of health, i.e., excessive tissue change, extensive loss of remaining teeth or changes in supporting tissues, which renders the appliance unusable. 3. Orthodontic and Periodontic. Combined lifetime benefit as outlined in Schedule of Benefits. 4. Optional. In all circumstances in which the patient selects a more expensive treatment plan than the Plan customarily provides, the Plan will pay the applicable percentage of the lesser fee for the following treatments: 82 (a) Partial Dentures. The Plan will provide a standard cast chrome or acrylic partial denture or will allow the cost of such procedure toward a more complicated or precision appliance that the patient and Dentist may choose to use. Any denture for which a charge is made that exceeds the U&C fee will be considered an optional service. (b) Complete Dentures. If in the construction of a denture the Participant or Dependent and Dentist decide on “personalized” restorations or to imply “specialized techniques” as opposed to standard procedures, the Plan will allow the appropriate amount for the standard denture toward such treatment and the Participant or Dependent must bear the difference in cost. The term “complete dentures or standard dentures” will mean an acrylic based denture constructed by methods and with materials approved by the Council on Dental Materials and Devices of the American Dental Association, and the term “specialized techniques” as used in this paragraph, will mean those techniques employing but not limited to precision attachments, swing-lock attachments and precious metals. (c) Occlusion. The Plan will allow the appropriate amount for procedures necessary to eliminate oral disease and to replace missing teeth. Procedures or restorations necessary to increase vertical dimension and/or restore or maintain the occlusion are considered optional and the cost is the responsibility of the patient. Such procedures include but are not limited to equilibration, periodontal splinting, restoration of tooth structure lost from attrition, and restoration for malalignment of the teeth. (d) Implants. If implants are utilized, the Plan will allow the cost of a standard complete or partial denture toward the cost of implants and appliances constructed in association therewith. The Plan will not provide surgical removal of implants. Exclusions. In addition to the General Exclusions and Limitations beginning on page 49, no Dental Expense Benefits will be payable for a dental operation or procedure or for charges in connection with: 1. services with respect to developmental malformations or cosmetic surgery or dentistry for purely cosmetic reasons, including but not limited to cleft palate, maxillary and mandibular malformations, enamel hypoplasis, fluorosis and anodontia; 2. drugs and appliances other than prosthodontic appliances; 3. hygiene instruction and dietary instruction; 4. sealants, except for eligible children up to age 15 on permanent teeth only; 5. orthodontic treatment in excess of the Plan’s lifetime maximum, other than for extractions; 83 6. plaque control programs; 7. myofunctional therapy; 8. more than two prophylactic treatments during each 12-month period; 9. treatment by other than a legally qualified and licensed dentist (D.D.S. or D.M.D.), except charges for dental prophylaxis performed by a licensed dental hygienist, under the supervision and direction of a qualified and licensed dentist (D.D.S. or D.M.D.); 10. more than one full-mouth x-ray during any three-year period (unless special need is demonstrated) or for more than four bite-wing x-rays during any six-month period; 11. prosthodontic appliances (including partial and complete dentures, crowns and bridges) and related expenses for replacement made less than five years after the appliance was originally made or last replaced and cannot be made serviceable; 12. charges for anesthesia, other than general anesthesia administered by a Dentist in connection with covered oral surgery services; 13. charges for the repair or replacement of any appliance in whole or in part which is provided under TMJ Services; or 14. charges that may be associated with TMJ but that would normally be provided under medical care, including but not limited to, psychotherapy, special joint exams and x-rays, joint surgery and medications. 15. charges for services that exceed the Usual and Customary fee allowance. 84 PRESCRIPTION DRUG EXPENSE BENEFIT For Kroger Employees, your prescription drug benefit will be administered by the Kroger Prescription Plans (KPP) along with mail order prescriptions. You should contact KPP at the number in the inside back cover with any questions about a prescription drug claim or if you lose your card. For Employees of other Employers and Plan S and Plan V Retired Participants, your prescription drug benefits will continue to be administered by the Plan Office and you should contact the Plan Office at the number on the inside back cover with any questions about a prescription drug claim or if you lose your card. Refer to the Schedule of Benefits for appropriate benefits. The Plan and KPP have entered into an arrangement with a Pharmacy Network to secure discounts on prescription drugs when you have a prescription filled at a pharmacy participating in the Network. Present your separate Pharmacy Network identification card at the pharmacy when you have your prescription filled. To secure the greatest discount, you should have prescriptions filled at a Kroger pharmacy, which is the exclusive pharmacy within 5 miles of where you live or work. Using a Network pharmacy is very important to you to receive the maximum benefits, or, in some cases, any benefits at all, except in emergency situations. Benefits. The Plan covers the Covered Charges not to exceed the maximum as shown in the Schedule of Benefits for FDA approved legend drugs or medications (filled in bottles or containers which must be marked “Federal law prohibits dispensing without a prescription”) and injectable insulin requiring a written prescription when prescribed by a Physician to treat a Non-occupational Injury or Illness and when the Participant or Dependent also satisfies one of the following three requirements: 1. Where a Participant or Dependent lives or works within a five-mile radius of a Priority PPO Pharmacy, then the Participant’s or Dependent’s prescription is only covered by the Plan if it is filled at a Priority PPO Pharmacy. 2. Where a Participant or Dependent does not live or work within a five-mile radius of a Priority PPO Pharmacy but lives or works within a five-mile radius of a PPO Pharmacy, then the Participant’s or Dependent’s prescription is covered by the Plan if it is filled at a PPO Pharmacy. 3. Where a Participant or Dependent does not live or work within a five-mile radius of a Priority PPO Pharmacy or a PPO Pharmacy, then the prescription will be covered if it is filled at any licensed pharmacy. When a prescription is filled at a Priority PPO Pharmacy (#1 above) or a PPO Pharmacy (#2 above), A Participant or Dependent must pay the Participant Co-Payment Amount set forth in the applicable Schedule of Benefits when the prescription is filled. When a prescription is filled under the provisions of #3 above, the Participant or Dependent must first pay the prescription in full and then submit a claim for reimbursement to the Plan Office or KPP, depending on whether the Employee is a Kroger Employee or not. You will only be reimbursed for a covered prescription drug or medication based on the Usual 85 and Customary Charge less the Participant Co-Payment set forth in the applicable Schedule of Benefits. A Priority PPO Pharmacy means a Kroger Company pharmacy. A PPO Pharmacy means any pharmacy participating in the Pharmacy Network. See the inside back cover for the toll free number to call for information about other PPO participating pharmacies. A written prescription must be filled by a licensed pharmacist or by a Hospital pharmacy for take-home use. Mail Order Program (Plan 1 Kroger Employees Only). In addition to the Plan 1 benefits listed above, prescriptions may be submitted through KPP’s Mail Order Prescription Drug Program, in which case both the Participant CoPayment Amount and Maximum Supply Per Fill will be different from prescriptions filled at a retail pharmacy. Please see the Schedule of Benefits for a full description of these differences. Contact KPP for more information about the Mail Order Prescription Drug Program. Self-Injectable Drugs (All Plans) The Plan covers self-injectable drugs approved by the FDA for self-injection, in addition to insulin. A Covered Family Member can choose to receive self-injectable medications through the pharmacy benefit rather than administered in their Physician’s office or in the Hospital. Self-injectable drugs are those that have been approved by the FDA for self-injection or based on standard medical practice have been deemed appropriate and safe to be injected by the patient. Covering self-injectables through the pharmacy benefit allows a Covered Family Member the convenience of picking up most self-injectable medications at your local retail pharmacy. The self-administered injectable drug coverage extends to many injectable drugs approved by the FDA. These drugs must be prescribed by your Physician and dispensed by a PPO Pharmacy. The prescription benefit co-payment will apply if you receive your medication from your PPO Pharmacy. Because drugs obtained through the prescription benefit are subject to discounted pricing and those obtained from your Physician are not, your co-payment on the self-injectable will generally be lower if you get it through the pharmacy than from the doctor, even if your co-payment would be 20% for both prescription and medical benefits. See the applicable Schedule of Benefits for more information on your prescription drug co-payment amount. Quantity limits and Pre-Authorization for Medical Necessity apply to some drugs. A quantity limit means that the Plan will only pay for a set amount of a particular drug per prescription. Quantity limits are set in accordance with FDA approved prescribing limitations and standard medical practice. Prior authorization is the process of obtaining coverage approval for a particular self-injectable medication. The following selfinjectables require a prior authorization to be covered: Protropin (Somatren), 86 Norditropin, Nutropin, Nutropin AQ, (Promlintide), and Byetta (Exenatide.) Nutropin Depot (Somatropin), Symlin This list will be changed from time-to-time based on new drugs coming to market and clinical recommendations. The clinical staff normally issues authorizations after review of the Physician’s orders and other documentation to ensure that certain drugs are Medically Necessary, such as erectile dysfunction drugs. A set standard, or protocol, is used to determine if the medication will be approved or not. You can obtain a medication request form from the Plan Office. Your Physician will need to complete the form and fax it back to the Plan Office. Step Therapy The Plan uses step therapy on two types of drugs--Cox-2 Inhibitors and Angiotensin Receptor Blockers (ARBs) for Covered Family Members who have not used one of these types of drugs before. If a Covered Family Member has had a prescription filled for an ARB or a Cox-2 Inhibitor (before February 1, 2006), you will be allowed to continue using that type of drug without going through the Step Therapy process. The step-by-step procedure for how this process works is described below: ARBs (Angiotensin Receptor Blockers) ARBs (including, but not limited to Benicar, Benicar HCT, Avapro, Avalide, Cozaar, Hyzaar, Diovan, and Diovan HCT) will be covered by the Plan only after you try an ACE Inhibitor, an appropriate cost-effective alternative medication, first. Cox-2 Inhibitors Cox-2 Inhibitor drugs (including, but not limited to Celebrex) will be covered by the Plan only after you try a Non-Steroidal Anti-Inflammatory Drug (NSAID), an appropriate, cost-effective alternative medication, first. The step-by-step process: 1. Present a prescription for an ARB or a Cox-2 Inhibitor to the PPO pharmacy. 2. Pharmacy Team fills the prescription and adjudicates the prescription electronically. 3. The pharmacy system reviews your history for a: ARB Prescription a. Prior prescription for an ACE Inhibitor filled, or b. Prior prescription for an ARB filled. Cox-2 Inhibitors Prescription a. b. Prior prescription for a NSAID filled, or Prior prescription for a Cox-2 Inhibitor filled. 87 4. If either criteria is met, your prescription is approved. (If you have received either prescription in the past but the pharmacy system does not reflect it, please contact the Plan Office to help you get the prescription filled.) 5. If neither criteria is met, your prescription will not be covered by the Plan until you try an alternative drug for that ARB or the Cox-2 Inhibitor. For an ARB, the pharmacist should call the Physician and explain that you are required to try an alternative to the ARB drug, called an ACE Inhibitor, before the Plan will cover a prescription for an ARB. Most ACE Inhibitors are available generically. Generic alternatives include Accupril, Accuretic, Capoten, Capozide, Lotensin, Lotensin HCT, Monopril, Monopril HCT, Prinivil, Prinzide, Vasotec, Vasoretic, Zestril, and Zestoretic. Generics can save you money-the use of a brand name drug may result in a higher co-payment (see pages 10-11). For a Cox-2 Inhibitor, the pharmacist should call the Physician and explain that you are required to try an alternative to the Cox-2 Inhibitor drug, called an NSAID, before the Plan will cover a prescription for the Cox-2 Inhibitor. Most NSAIDs are available generically. Generic alternatives include: Anaprox, Anaprox DS, Ansaid, Clinoril, Daypro, Feldene, Indocin, Indocin SR, Lodine, Meclofenamate, Motrin, and Nalfon. Generics can save you money--the use of a brand name drug may result in a higher co-payment (see pages 10-11). If it is Medically Necessary for you to receive an ARB or a Cox-2 Inhibitor drug without trying an alternative first, contact the Plan Office for the necessary form. After it is completed, return it to the Plan Office. For questions, call the Pharmacy Network at the number on the inside back cover. If you have any questions or need further clarification of these benefits, contact the Plan Office or the Pharmacy PPO at the number on the back cover. Proton Pump Inhibitors The Plan provides a higher level of coverage for omeprazole (know by the trade name Prilosec). The co-pay for a one month supply is reduced from the normal level. In addition, a 90-day supply of omeprazole is be available with the payment of two co-pays rather than three. Other medications classified as proton pump inhibitors include Nexium, Prevacid, Aciphex, Zegerid, Kapidex, Dexilant, pantoprazole, and lansoprazole. Exclusions and Limitations. In addition to the General Exclusions and Limitations beginning on page 49, no prescription drug expense benefits will be paid for: 1. drugs which are legally obtainable without a prescription, except injectable insulin (including premeasured syringes) or as required by law; 88 2. therapeutic devices or appliances (including but not limited to hypodermic needles, syringes, support garments, over-the-counter patent medicines and other nonmedical substances) regardless of their intended use; 3. any charge for the administration of a prescription legend drug or injectable insulin; 4. drugs labeled “Caution-limited by Federal law to investigational use,” or Experimental drugs, even though a charge is made to the Participant or Dependent, except as required by law; 5. drugs and injectable insulin dispensed to a Participant or Dependent while confined in a Hospital or Convalescent Facility; 6. for Plan 1, contraceptives and contraceptive devices, except as required by law; 7. health foods, vitamins, dietary supplements, appetite suppressants or smoking cessation products, except as required by law; 8. drugs or medicines for which a benefit is payable under any other section of this Plan, except under the self-injectible benefit described above; 9. drugs or medicines for or relating to treatment to restore fertility or to promote conception, including, but not limited to, Pergonal; and 10. for or relating to drugs to induce growth or growth hormones, except if Medically Necessary. In such circumstance, the Plan will pay benefits but they will not exceed 50% of the Usual and Customary Charge.; 11. Lotronex, regardless of for whom prescribed; 12. Self-injectable drugs which are not on the list approved by the Plan or when a Participant or Dependent fails to comply with the guidelines and requirements adopted by the Plan; and 13. Cox-2 Inhibitors and ARBs for a Participant or Dependent who does not comply with the Plan’s step therapy program for these prescription drugs. 14. If Medicare is primary for a retired Participant or a Dependent of a retiree, no prescription coverage is available. 89 HOSPITAL SELF-AUDIT PROGRAM The Plan will pay a cash incentive to a Participant or Dependent for recovering overcharges made by a Hospital. Conditions and Limitations. 1. The Plan will pay to the Participant or Dependent 50% of the actual amount of the overcharge that the Hospital agrees is valid as a result of direct negotiations between the Participant or Dependent and the Hospital, up to $500 per calendar year. Hospital overcharges totaling less than $100 per Hospital confinement are not eligible for the cash incentive. 2. Only Hospital expenses that are covered under the Plan, not expenses such as telephone bills, television rental, newspapers, etc., will be eligible for a cash incentive. 3. Proof of eligibility for a cash incentive must be submitted to the Plan Office in the form of a copy of the initial itemized Hospital bill with the overcharges circled, and a copy of the adjusted bill showing that the Hospital agreed to reduce its billing. Such proof must be submitted to the Plan Office within 45 days following the date of discharge from the Hospital. If the Plan has already paid the overcharge, then the award is also conditioned on the Plan’s recovery of the overpaid amount. 4. Cash incentives will not be awarded if changes in a Hospital bill are initiated by the Hospital. 5. The Trustees reserve the right to modify or terminate this program at any time, including retroactively, if necessary, to comply with applicable law. 90 COORDINATION OF BENEFITS Coordination of Benefits with Other Plans Because of the growing number of group health plans and the increasing number of twoincome families, more and more people are becoming covered under two group plans. Under this coordination of benefits provision, if you or your eligible Dependents are covered under two or more plans, the total benefits received by any one person from all plans combined may not amount to more than 100% of the Allowable Expenses. You must report such duplicate coverage on the claim forms you submit for reimbursement of Allowable Expenses. Definitions for this Provision. 1. Plan. Any plan or program which provides health, prescription, dental, or vision benefits or services, including: (a) group or blanket insurance coverage; (b) service benefits, whether through Blue Cross Blue Shield, group practice, HMO or other prepayment coverage; (c) any coverage or program provided through a school or other educational institution; (d) any coverage or governmental programs required or provided by statute other than Medicare; (e) no-fault motor vehicle coverage; or (f) any other group coverage or program, whether on an insured or self-funded basis. Each policy, contract or other arrangement for benefits or services is considered a separate Plan, and that portion of any such Plan which reserves the right to consider other Plan benefits when determining its benefits will be considered as a separate Plan from that portion which does not. 2. Allowable Expense. Any necessary, Usual and Customary (U&C) charges which are covered, wholly or partially, under this Plan. 3. Benefits Payable. Benefits that would have been payable if a claim for them had been made under any Plan. Benefits Payable does not include Allowable Expenses which would have been covered by another Plan but which were not covered because the covered person failed to take the actions required under the Plan’s rules to qualify for benefits, unless the Working Spouse Rule applies. 91 How it Works. The Benefits Payable under any other Plan will be taken into account in determining the Benefits Payable for Allowable Expenses under this Plan. This Plan will pay benefits in accordance with its provisions or will pay a reduced amount which, when added to benefits provided under any other Plan, will reimburse up to 100% of the Allowable Expenses. Rules for Order of Benefit Determination. The following rules will be applied by this Plan to establish the order of benefit determination for Benefits Payable: 1. The Plan covering a person as an employee, as a laid-off employee or retired employee will determine its benefits before a Plan covering that person as a dependent. If a Dependent under this Plan has health care coverage available under his Employer’s Plan, this Plan will pay second whether or not the Dependent had elected coverage under his employer’s Plan, unless the spouse elects and pays for coverage under the Plan’s Working Spouse benefit. 2. The Plan covering a person as an active employee will determine its benefits before a Plan covering that person as a laid-off employee or retired employee. This rule also applies to the dependents of a person covered as both an active employee and as a laid-off or retired employee. 3. The Plan covering a person as an employee, member or subscriber or as the dependent of such person will determine its benefits before a Plan covering that person under a COBRA continuation coverage provision. This rule also applies if the person is offered COBRA coverage but does not elect it. 4. On claims involving dependent children of parents who are not separated or divorced and who are both Participants who are Employees eligible for benefits under this Plan, the Plan will determine its benefits using the “birthday rule.” Under this rule, benefits will first be determined for the child under the coverage of the Employee whose date of birth, excluding year of birth, occurs earlier in the year and then under the coverage of the Employee whose date of birth, excluding year of birth, occurs later in the calendar year. If the date is the same (excluding year of birth), the plan that has covered the parent the longer period of time shall determine its benefits before the plan that has covered the other parent the shorter period of time. 5. On claims involving dependent children of parents who are separated or divorced, the order of benefit determination will be as follows: (a) if the parent with custody of the child has not remarried, the Plan covering the child as a dependent of the parent with custody of the child will determine its benefits before a Plan covering that child as a dependent of the parent without custody; and (b) if the parent with custody of the child has remarried, the Plan covering the child as a dependent of the parent with custody will determine its benefits before a Plan covering the child as the dependent of the stepparent, and the 92 Plan covering the child as a dependent of the stepparent will determine its benefits before a Plan covering that child as a dependent of the parent without custody. However, if there is a court decree (such as a QMCSO, described on page 35) which establishes financial responsibility for the medical, dental or other health care expenses with respect to a dependent child, the Plan covering the child as a dependent of the parent with such financial responsibility will pay its benefits before any other plan which covers the child as a dependent child. 6. When this Plan covers injuries in a motor vehicle accident and the Participant or Dependent covered by this Plan is eligible for reimbursement under no-fault motor vehicle coverage, the no-fault motor vehicle coverage will pay its benefits before this Plan pays. If a Participant or Dependent is not eligible for reimbursement as a result of failure to purchase no-fault motor vehicle coverage when required, this Plan shall pay claims secondary to the extent benefits would have been paid if the Participant or Dependent had purchased such no-fault motor vehicle coverage. 7. Where (1) benefits would have been available to the Participant or the Dependent under another group health program or plan if the person had acted to qualify for benefits at the time of the claim --such as going to an HMO or PPO provider, using a utilization review service or enrolling in the employer’s group health program or plan; (2) the Participant or the Dependent has not acted to qualify for such benefits; and (3) where the Plan would pay second for the treatment involving a Dependent child if such other coverage existed, then the coverage for the parent whose date of birth, excluding year of birth, occurs earlier in the calendar year shall be deemed primary to the coverage of the parent whose date of birth, excluding year of birth, occurs later in the calendar year. 8. If none of the rules above establish the order of benefit determination, the Plan that has covered the person for the longer period of time will pay its benefits before a Plan which has covered the person for the shorter period of time. Coordination of Benefits with Noncomplying Plans. If it is determined that this Plan should pay second under the rules for order of benefit determination but this Plan is coordinating its benefits with a Plan that is unable or unwilling to pay benefits when due, always pays second or uses different rules for order of benefit determination, this Plan will pay its benefits first, but the amount of the Benefits Payable will be determined as if this Plan were the secondary Plan. In such a situation, such payment by this Plan will be the limit of this Plan’s liability. Additional rules may apply. Contact the Plan Office for additional information. Obtaining and Releasing Information. Without the consent of or notice to any person, the Plan may obtain or release information with respect to any person when it considers it necessary to do so to apply and implement this coordination of benefits provision (or a provision of similar purpose under another Plan). Any person claiming benefits under 93 this Plan is required to furnish this Plan with any such information which may be needed for that purpose and is treated as having consented to the release of information. Facility of Payment. Whenever it is determined that a payment which was made under another Plan should have been made under this Plan, in accordance with this coordination of benefits provision, the Plan will have the right (exercisable by it alone and at its sole discretion) to pay to the organization making that payment any amount this Plan determines is warranted to satisfy the intent of this provision. Any amount so paid will be considered a benefit paid under this Plan and this Plan will be released from further liability for that amount. Right of Recovery. Whenever the payments made by this Plan for Allowable Expenses are determined to be greater in total than the maximum amount of payment required to satisfy the intent of this coordination of benefits provision at that time, this Plan will have the right to recover the excess paid. Offset. If payment is made by the Plan to a Participant or Dependent who is not entitled to payment for whatever reason, the Plan has the right to reduce future payments due the Participant or Dependent by the amount of the erroneous payment. This right of offset does not limit the rights of the Plan to recover overpayments in any other manner. Coordination with Medicare Medicare (Title XVIII of the Social Security Act of 1965) provides a comprehensive program of health insurance for persons age 65 or over and disabled persons under age 65. In order to avoid duplicate payment of benefits, the Benefits Payable under this Plan for Allowable Expenses will be coordinated with the Benefits Payable under Medicare for the same expenses. “Allowable Expenses” under this provision will be the necessary, Usual and Customary (U&C) charges as determined by Medicare which are covered under both Medicare and this Plan. Rules for Order of Benefit Determination. The following rules apply to establish the order of benefit determination: 1. If a Participant continues to work for a contributing Employer after attaining age 65 and becoming eligible for Medicare, the Participant and his eligible Dependents are entitled to the same benefits as Employees under age 65 as long as he meets the regular eligibility rules on pages 30 to 37. This Plan will pay first and Medicare will pay second for Allowable Expenses. 2. If a Participant is age 65 or older, is eligible for Medicare and is not actively employed (retired), Medicare will pay first and this Plan will pay second for Allowable Expenses. 94 3. If a Participant or eligible Dependent is entitled to Medicare for reasons other than attaining age 65, federal law may require this Plan to pay first – for example, for a Totally Disabled person. Contact the Plan Office for more information. 4. Participants or eligible Dependents who become eligible for Medicare as an End Stage Renal Disease (ESRD) beneficiary should contact the Plan Office to determine if this Plan or Medicare will pay its benefits first. Generally this Plan will be primary for the first 30 months of ESRD treatment. After the 30 month period, regardless of your age, Medicare becomes primary and the Plan is secondary. If a Participant is covered by Medicare, except as an ESRD beneficiary, and by this Plan under the provisions of COBRA continuation coverage, Medicare will pay first and this Plan will pay second for Allowable Expense. Participants and eligible Dependents are responsible for enrolling in Part A and Part B of Medicare. If a Participant and his eligible Dependents fail to enroll, this Plan will coordinate with Medicare benefits and if this Plan is determined to pay second, will reduce its benefits regardless of whether the Participant and/or his eligible Dependents have enrolled for Medicare benefits. At present, there is no cost for Part A, which provides hospital benefits. Part B covers such items as doctors’ and nurses’ services. There is a monthly charge for Part B. If you or your spouse wants information about Medicare enrollment or about the voluntary prescription drug program available through Medicare (Medicare Part D), contact your local Social Security office (at least two months before your 65th birthday, if possible, or two years after your disability benefits begin). SUBROGATION AND REIMBURSEMENT If a Participant or Dependent is injured in an accident or in any other manner where someone else is liable, such as a car accident, that person (or his/her insurance) is responsible for paying the Participant’s or Dependent’s medical and disability expenses and these expenses would not be covered under the Plan. However, waiting for a third party to pay for these injuries may be difficult. Recovery from a third party may take a long time (the Participant or Dependent may have to go to court) and creditors may not wait patiently. Because of this, as a service to Participants and Dependents, the Plan will advance benefit payments based on the understanding that the Participant or the Dependent is required to reimburse the Plan in full from any recovery received, no matter how it is characterized. This process is called “subrogation.” The Plan may step into the shoes of a Participant or Dependent, or the trustee, guardian or representative of a Participant or Dependent or a Trust set aside for the benefit of a Participant or Dependent. The Plan’s subrogation and reimbursement rights apply with regard to all rights of recovery of a Participant or Dependent, or representatives, guardians, beneficiaries, fiduciaries, trustees, estate representatives, heirs, executors, administrators of any special needs trusts, and any other agents, persons or entities that may receive a benefit on behalf of the Participant or Dependent (collectively, for purposes of this section, “Individual”) to the extent of any amounts which the Plan has paid or may become obligated to pay on 95 account of any claim against any person, organization or other entity in connection with the Injury, Illness (Sickness), accident or condition, including accidental death or dismemberment, to which the claim relates. The Plan's subrogation and reimbursement rights apply on a priority, first-dollar basis to any recovery, whether by suit, settlement or otherwise, whether a partial or full recovery and regardless whether the claimant is made whole, from any source liable for making a payment related to the Injury, Illness (Sickness), accident or condition to which the claim relates ("Source") regardless of whether liability is admitted to or contested by any Source. A Source includes, but is not limited to, a responsible party and/or a responsible party's insurer (or self-funded protection), no fault protection, personal injury protection, medical reimbursement of coverage, financial responsibility, uninsured motorist coverage, and underinsured motorist coverage. Participants or Dependents are required to notify the Plan within ten days of any accident or Injury for which someone else and/or any Source may be liable or responsible. Further, the Plan must be notified within ten days of the initiation of any lawsuit arising out of the accident. The Participant or Dependent must immediately notify the Plan of any settlement offer, judgment or payment relating to the accident. If the Individual receives any benefit payments from the Plan for an Injury or Illness and the Individual recovers any amount from any third party and/or Source in connection with such Injury or Illness, the Individual must reimburse the Plan from that recovery the total amount of all benefit payments the Plan made or will make on the Participant’s or Dependent’s behalf in connection with such Injury or Illness. This is referred to as the Plan’s right of reimbursement. In addition, if the Individual receives any benefit payments from the Plan for an Injury or Illness for which someone else may be liable, the Plan is subrogated to all rights of recovery available arising out of any claim, demand, cause of action or right of recovery which has accrued, may accrue or which is asserted in connection with such Injury or Illness, to the extent of any and all related benefit payments made or to be made by the Plan on the Participant’s or Dependent’s behalf. This means that the Plan has an independent right to bring an action in connection with such Injury or Illness in the Individual’s name and also has a right to intervene in any such action brought by the Individual, including any action against an insurance carrier under any uninsured or underinsured motor vehicle policy. The Plan’s rights of reimbursement and subrogation apply regardless of the terms of the claim, demand, right of recovery, cause of action, judgment, award, settlement, compromise, insurance or order, regardless of whether the third party is found responsible or liable for the Injury or Illness, regardless of whether the injured person has been made whole, and regardless of whether the Individual actually obtains the full amount of such judgment, award, settlement, compromise, insurance or order. The Plan’s rights of reimbursement and subrogation provide the Plan with first priority to any and all recovery from any Source in connection with the Injury and Illness with first priority to any and all recovery in connection with the Source, whether such recovery is full or partial and no matter how such recovery is characterized, why or by whom it is 96 paid, or the type of expense for which it is specified. The Plan specifically disavows any claims that an Individual may make under any federal or state common law defense, including but not limited to the common fund doctrine, the double-recovery rule, the make whole doctrine or any similar doctrine or theory, including the contractual defense of unjust enrichment. Accordingly, the Plan’s subrogation and reimbursement rights apply on a priority, first-dollar basis to any recovery of the Individual from any Source without regard to legal fees and expenses of the Individual and the Individual will be solely responsible for paying all legal fees and expenses. The Plan shall have a priority, first dollar security interest and a lien on any recovery received from any Source, whether by suit, settlement or otherwise, whether there is a full or partial recovery and regardless of whether the amounts are characterized or described as payment for medical expenses or as amounts other than for medical expenses of such injury, sickness, accident or condition and regardless of whether liability is admitted to or contested by any Source. The Plan’s rights of reimbursement and subrogation are for the full amount of all related benefits payments. This amount is not offset by legal costs, attorneys’ fees or other expenses incurred by the Individual in obtaining recovery. The Plan has an equitable interest and lien on any amount received by the Participant or Dependent (or their representatives) that is due to the Plan under this provision. Any amount received by you or your representative that is due to the Plan under this provision will be considered to be held in trust by you or your representative for the benefit of the Plan. The Plan’s equitable lien by agreement imposes a constructive trust upon the assets received as a result of a recovery by the Individual, as opposed to the general assets of the Individual, and enforcement of the equitable lien by agreement does not require that any of these particular assets received or identifiable amounts be traced to a specific account or other destination after they are received by the Individual. If the injured person can no longer care for himself or herself, the Plan’s rights apply to a special needs trust set up for the benefit of that person, and the appointed representative of the trust must comply with the Plan’s rules to the same extent as the injured person. This includes special needs trusts which include funds recovered from another party or any Source. Consistent with the Plan’s rights set forth in this section, if the Participant or Dependent submit claims for or receive any benefit payments from the Plan for an Injury or Illness that may give rise to any claim against any third party and/or Source, the Participant or Dependent will be required to execute a Subrogation, Assignment of Rights, and Reimbursement Agreement (“Subrogation Agreement”) affirming the Plan’s rights of reimbursement and subrogation with respect to such benefit payments and claims. This Subrogation Agreement must also be executed by the Participant’s or Dependent’s attorney, if applicable. If a Participant or Dependent had not retained an attorney at the time the Subrogation Agreement was signed, the Participant or Dependent must notify the Plan within 10 days of retaining an attorney. Because benefit payments are not payable unless the Participant or Dependent signs a Subrogation Agreement, the Participant’s or Dependent’s claims will not be considered filed and will not be paid until the fully signed Subrogation Agreement that has not been modified in any way without consent of the Plan is received by the Plan. This means 97 that, if the Participant or Dependent file a claim and the Subrogation Agreement is not received promptly, the claim will be untimely and will not be paid if the time period for filing claims passes before the Subrogation Agreement is received. However, in its sole discretion, if the Plan advances claims in the absence of a Subrogation Agreement, or if the Plan advances claims in error, said payments will not waive, compromise, diminish, release, or otherwise prejudice any of the Plan’s rights to reimbursement or subrogation. If the Individual is a minor or incompetent to execute the Subrogation Agreement, that person’s parent, the Individual (in the case of a minor dependent child), the Individual’s spouse, or legal representative (in the case of an incompetent adult) must execute the Subrogation Agreement upon request of the Plan. An Individual must comply with all terms of the Subrogation Agreement, including the establishment of a trust for the benefit of the Plan. In this regard, the Individual agrees that out of any Source, the identified amount that the Plan has advanced or is obligated to advance in benefits will be immediately deposited into a trust for the Plan’s benefit and the Plan shall have an equitable lien by agreement which shall be enforceable under legal, equitable and/or injunctive action to ensure that these amounts are preserved and not disbursed. The Plan’s subrogation and reimbursement rights shall apply regardless whether the Individual executes a Subrogation Agreement. Under this provision, the Individual is obligated to take all necessary action and cooperate fully with the Plan in its exercise of its rights of reimbursement and subrogation, including notifying the Plan of the status of any claim or legal action asserted against any party or insurance carrier and of the Participant’s or Dependent’s receipt of any recovery. The Individual also must do nothing to impair or prejudice the Plan’s rights. For example, if the Individual chooses not to pursue the liability of a third party, or potential reimbursement from any Source, the Individual may not waive any rights covering any conditions under which any recovery could be received. If the Individual is asked to do so, they must contact the Plan Office immediately. If the Individual refuses to reimburse the Plan from any recovery or refuses to cooperate with the Plan regarding its subrogation or reimbursement rights, the Plan has the right to recover the full amount of all benefits paid for that Injury or Illness by methods which include, but are not necessarily limited to, offsetting the amounts paid against future benefit payments under the Plan to a Participant or any eligible Dependent as well as pursuing legal and equitable claims. “Non-cooperation” includes the failure of any party to execute a Subrogation Agreement and the failure of any party to respond to the Plan’s inquiries concerning the status of any claim or any other inquiry relating to the Plan’s rights of reimbursement and subrogation, and the failure or refusal to provide the Plan with its portion of any recovery. The Trustees of the Plan may waive the above right to subrogation and reimbursement if they determine that doing so is in the best interest of the Plan and its participants. 98 GENERAL PLAN INFORMATION Plan Administration Name of the Plan. United Food and Commercial Workers Local 400 and Employers Health and Welfare Plan. Type of Plan. This Plan is a multiemployer health and welfare plan maintained for the purpose of providing medical, dental, vision care, prescription drug and death benefits. Board of Trustees. 1. 2. Members. A Board of Trustees is responsible for the operation of the Plan. The Board of Trustees consists of an equal number of Employer and employee representatives, selected by the Employers and the Union(s) which have entered into collective bargaining agreements that relate to the Plan. The Trustees of the Plan are: UNION TRUSTEES EMPLOYER TRUSTEES Mark Federici United Food and Commercial Workers Local 400 4301 Garden City Drive Landover, MD 20785 Steve Loeffler The Kroger Co. 4111 Executive Parkway Westerville, OH 43081 James Slivosky United Food and Commercial Workers Local 400 4301 Garden City Drive Landover, MD 20785 Michael Christle The Kroger Co. P.O. Box 14002 Roanoke, VA 24038 Charles Miller, Alternate United Food and Commercial Workers Local 400 4301 Garden City Drive Landover, MD 20785 Steven Springer, Alternate The Kroger Co. P.O. Box 14002 Roanoke, VA 24038 Address and Telephone Number. If you wish to contact the Board of Trustees, you may use the address and telephone number below: 600 D Street, Suite 250 South Charleston, WV 25303 (304) 343-7682 A complete list of the employers and employee organizations sponsoring the Plan may be examined at this address. A Plan Participant or beneficiary may obtain a copy of this list for a reasonable charge by writing to the Trustees at this address. 99 In addition, upon written request to the Trustees at this address, a Plan Participant or beneficiary may obtain information as to whether a particular Employer or employee organization is a sponsor, and the Trustees will furnish the sponsor’s address to the Participant or the beneficiary. Plan Administrator. The name, address and telephone number of the Plan Administrator is: Board of Trustees United Food and Commercial Workers Local 400 and Employers Health and Welfare Plan 600 D Street, Suite 250 South Charleston, WV 25303 (304) 343-7682 Plan Office. United Food and Commercial Workers Local 400 and Employers Health and Welfare Plan 600 D Street, Suite 250 South Charleston, WV 25303 (304) 343-7682 The Plan Office has been designated as the Plan’s Agent for service of legal process. Accordingly, if legal disputes involving the Plan arise, any legal document should be served upon the Plan at the Plan Office. In addition, service of legal process may be made upon any member of the Board of Trustees at the address of the Plan Office listed above. Statute of Limitations and Forum for Disputes. If you wish to file suit for a denial of a claim of benefits, you must do so within five years of the date the Trustees denied your appeal. For all other actions, you must file suit within five years of the date on which the violation of Plan terms is alleged to have occurred. Additionally, if you wish to file suit against the Plan or the Trustees, you must file suit in a federal district court in the state of West Virginia. These rules apply to you, your spouse, dependent, or beneficiary, and any provider who provided services to you or your spouse, dependent or beneficiary. This Section applies to all litigation against the Plan, including litigation in which the Plan is named as a third party defendant. Identification Numbers. The Employer Identification Number assigned by the Internal Revenue Service to the Board of Trustees is 55-0393244. The Plan number assigned by the Board of Trustees is 501. Plan Year. For purposes of maintaining the Plan’s records, the fiscal year of the Plan begins on February 1st of each year and ends on January 31st of the next year. Collective Bargaining Agreements. This Plan is maintained pursuant to one or more collective bargaining agreements. Plan Participants and beneficiaries may examine these 100 collective bargaining agreements at the Plan Office address listed above and may obtain a copy of any such agreement for a reasonable charge by writing to the Board of Trustees at this address. Financial Information Funding Medium. Most of the benefits that are described in this Summary Plan Description are provided from the Plan’s assets that are accumulated under the provisions of the collective bargaining agreements and the Trust Agreement and held in a Trust Fund for the purpose of providing benefits to covered participants and defraying reasonable administrative expenses. Major Medical, Basic, Dental, and Vision Benefits are provided directly by the Plan. For Kroger Employees, the Prescription Drug benefit for Plan 1 is funded directly by the employer and is administered by KPP. For Plan 1 Employees employed by other Employers and all Retirees, the Prescription Drug Benefit is funded directly by the Plan and is administered by the Plan Office. The Plan has entered into an insurance contract for Life Insurance and Accidental Death and Dismemberment Benefits with Hartford Life and Accident Insurance Company. The complete terms of the Plan’s Rules and Regulations (Plan Document) and copies of the Insurance Contracts are available for review, upon request at the Plan Office. Type of Administration. The administrative operations of the Plan are handled by the Plan Office employees. For Kroger Employees, the Prescription Drug Benefit for Plan 1 is administered by KPP. For Plan 1 Employees employed by other Employers and all Retirees without Medicare, the Prescription Drug Benefit is administered by the Plan Office. Contribution Source. Contributions to the Plan are made by Employers in accordance with collective bargaining agreements between the Union and Employer and, in some instances, by direct Employee payments. The amount of the Employer contributions is determined by the provisions of the collective bargaining agreements. Plan Information Eligibility. The Plan’s requirements with respect to eligibility as well as circumstances that may result in disqualification, ineligibility, or denial or loss of any benefits are fully described on pages 30 through 37 of this booklet. Rights and Protections Under the Employee Retirement Income Security Act of 1974. As a participant in the United Food and Commercial Workers Local 400 and Employers Health and Welfare Plan, you are entitled to certain rights and protections under the Employee Retirement Income Security Act of 1974 (“ERISA”). ERISA provides that all Plan Participants shall be entitled to: 101 Receive Information about the Plan and Benefits 1. Examine, without charge, at the Plan administrative office and at other specified locations, such as worksites and union halls, all documents governing the Plan, including insurance contracts and collective bargaining agreements, and a copy of the latest annual report (Form 5500 series) filed by the Plan with the U.S. Department of Labor and available at the Public Disclosure Room of the Employee Benefits Security Administration. 2. Obtain, upon written request to the Plan Administrator, copies of documents governing the operation of the Plan, including insurance contracts and collective bargaining agreements, and copies of the latest annual report (Form 5500 series) and updated summary plan description. The Plan Administrator may make a reasonable charge for such copies. 3. Receive a summary of the Plan’s annual financial report. The Plan Administrator is required by law to furnish each participant with a copy of the summary annual report. 4. Continue Group Health Plan Coverage. You may continue health care coverage for yourself, spouse or dependents if there is a loss of coverage under the plan as a result of a qualifying event. You and your dependents may have to pay for such coverage. Review this summary plan description and the documents governing the Plan on the rules governing your COBRA continuation coverage rights. There can be a reduction or elimination of exclusionary periods of coverage for preexisting conditions under your group health plan, if you have creditable coverage from another plan. You should be provided a certificate of creditable coverage, free of charge, from your group health plan or health insurance insurer when you lose coverage under the Plan, when you become entitled to elect COBRA continuation coverage, when your COBRA continuation coverage ceases, if you request it before losing coverage, or if you request it up to 24 months after losing coverage. Without evidence of creditable coverage, you may be subject to a preexisting condition exclusion for 12 months (18 months for late enrollees) after your enrollment date in your coverage. Prudent Actions by Plan Fiduciaries In addition to creating rights for Plan Participants, ERISA imposes duties upon the people who are responsible for the operation of the employee benefit plan. The people who operate the Plan, called “fiduciaries” of the Plan, have a duty to do so prudently and in the interest of you and other Plan Participants and beneficiaries. No one, including your Employer, your union or any other person, may fire you or otherwise discriminate against you in any way to prevent you from obtaining welfare benefits under the Plan or exercising your rights under ERISA. Enforce Your Rights. If your claim for welfare benefits is denied in whole or in part, you have a right to know why this was done, to obtain copies of documents relating to the decision without charge and to appeal any denial, all within certain time schedules. 102 Under ERISA, there are steps you can take to enforce the rights listed above. For instance, if you request a copy of Plan documents or the latest annual report from the Plan and do not receive them within 30 days, you may file suit in a federal court in accordance with the Statute of Limitations and Forum Selection provision on page 100. In such a case, the court may require the Plan Administrator to provide the materials and pay you up to $110 a day until you receive the materials, unless the materials were not sent because of reasons beyond the control of the Plan Administrator. If you have a claim for benefits that is denied or ignored, in whole or in part, you may file suit under ERISA 502(a), in accordance with the Statute of Limitations and Forum Selection provision. In addition, if you disagree with the Plan’s decision or lack thereof concerning the qualified status of a medical child support order, you may file suit in federal court in accordance with the Statute of Limitations and Forum Selection provision. If it should happen that the Plan fiduciaries misuse the Plan’s money, or if you are discriminated against for asserting your rights, you may seek assistance from the U.S. Department of Labor, or you may file suit in a federal court in accordance with the Statute of Limitations and Forum Selection provision. The court will decide who should pay court costs and legal fees. If you are successful, the court may order the person you have sued to pay these costs and fees. If you lose, the court may order you to pay these costs and fees, for example, if it finds your claim is frivolous. Assistance with your Questions. If you have any questions about the Plan, you should contact the Plan Administrator. If you have any questions about this statement or about your rights under ERISA, or if you need assistance in obtaining documents from the Plan Administrator, you should contact the nearest office of the Employee Benefits Security Administration, U.S. Department of Labor, listed in your telephone directory or the Division of Technical Assistance and Inquiries, Employee Benefits Security Administration, U.S. Department of Labor, 200 Constitution Avenue, NW, Washington, DC 20210. You may also obtain certain publications about your rights and responsibilities under ERISA by calling the publications hotline of the Employee Benefits Security Administration. HIPAA CERTIFICATES OF CREDITABLE COVERAGE FROM THIS PLAN In certain circumstances, federal law requires that the Plan provide you and your Dependent(s) with evidence of your coverage under the Plan for use as proof of prior coverage when beginning coverage under another health plan. Accordingly, the Plan will provide a Certificate of Creditable Coverage to you and your Dependent(s) within a reasonable time after the occurrence of any of the following events: 1. loss of coverage under the Plan in the absence of COBRA Continuation Coverage; 2. loss of coverage under the Plan; 3. loss of COBRA Continuation Coverage; 103 4. upon written request within the first two (2) years of the loss of coverage under the Plan. The Certificate of Creditable Coverage may be necessary or reduce any exclusion for preexisting conditions that may apply to you or your Dependents under a new group health plan or health insurance policy and will indicate the period of coverage under this Plan and certain additional information that is required by law. The Certificate of Creditable Coverage will be sent to you or your Dependents by first class mail. To request a Certificate, write to the Plan Office. If you request a Certificate, the Plan will send it within a reasonable and prompt period of time. You can request a free copy of the Plan’s procedure for requesting a HIPAA Certificate of Creditable Coverage from the Plan Office. CLAIMS FILING AND APPEAL PROCEDURE To make a claim for benefits under this Plan, follow these instructions. The Plan Office must have a recent Enrollment Form on file. Forms are available from the Plan Office. Medical Benefit Claims Initial Claim for Medical Benefits. All medical claims, other than Dental and Vision, should be submitted electronically by your provider to the Local Blue Cross Blue Shield. Make sure you present your current Blue Cross Blue Shield card with Identification and Group numbers to your provider. For Dental and Vision claims, you must follow the following procedure: (a) Dental. A. B. C. (b) Provider submits paper claim to the Plan Office. Provider submits any x-rays or doctor notes needed for processing of claim. Dental claims must be mailed to the Plan Office at 600 D Street, Suite 250, South Charleston, WV 25303. Vision. A. B. C. Provider submits paper claim to the Plan Office. Insured must submit all receipts and bills to the Plan Office if the provider does not bill. Vision claims must be mailed to the Plan Office at 600 D Street, Suite 250, South Charleston, WV 25303. All Medical, Dental and Vision claims should be submitted as soon as possible after the date of service, and no later than the last day of the calendar year after the year of the date of service. Remember that your claim cannot be paid until all of the information needed to process the claim is given to the Plan Office. This includes the Enrollment Form, 104 which you must complete annually, and which must also be on file at the Plan Office. Initial Prescription Drug Claims. To receive benefits under the Prescription Drug Expense Benefit, you must present your prescription ID Card at the time your prescription is filled. (a) Covered Employees and Eligible Dependents Employed by the Kroger Company: Your prescription drug benefit is administered by the Kroger Prescription Plans (KPP). You should contact KPP at the number on the inside back cover with any questions about a prescription drug claim or if you lose your prescription ID Card. (b) Covered Employees and Eligible Dependents Employed By Other Employers: Contact KPP if you lose your prescription ID Card. If you are filing a paper claim, it must be submitted to the Plan Office within three months of the date the prescription is filled at a pharmacy. Submit prescription receipt along with cash register receipts, tapes or computer printouts for all drugs purchased and attach them to the claim form. (c) Retirees and Eligible Dependents Not Eligible for Medicare: Contact KPP if you lose your prescription ID Card. If you are filing a paper claim, it must be submitted to the Plan Office within three months of the date the prescription is filled at a pharmacy. Complete the Statement of Prescription Drug Charges Licensed Pharmacist’s Statement (available from the Plan Office) with cash register receipts, tapes or computer printouts for all drugs purchased and attach them to the claim form. Medical Benefit Review and Appeal Procedure The Plan and Board of Trustees, in making decisions on claims and on appeal, will apply the terms of the Plan and any applicable guidelines, rules, and schedules, and will periodically verify that benefit determinations are made in accordance with such documents, and where appropriate, applied consistently with respect to similarly situated claimants. Additionally, the Plan and Trustees will take into account all information you submit in making decisions on claims and on appeal. You may name a representative to act on your behalf. To do so, you must notify the Plan in writing of the representative’s name, address and telephone number. (1) Claim Denial. The length of time required to process the claim depends upon the type of claim. A claim can fall into one of the following categories: 1. Pre-service claim – A Pre-service claim is one that requires preapproval before services are performed under the terms of the Plan 105 of benefits. The requirements for preauthorization or preapproval are described elsewhere in the Summary Plan Description. Your Pre-service claims will be decided within 15 days of receipt by InforMed. If InforMed determines that an extension of this time is necessary, the claim will be decided within 30 days of receipt (unless the period is tolled while InforMed waits for information it requested from you). You will be notified of the need for an extension within 15 days of receipt of the claim and the reasons why the extension is needed. If InforMed needs more information from you to process the claim, you will have 45 days to provide the needed information to InforMed. If you do not provide the information requested, InforMed will have to decide the claim on the information it has, and your claim may be denied. InforMed will issue its decision within 15 days of the earlier of your submission of the requested information or the end of the 45-day period. If your claim is filed improperly, you will be notified within five days of filing the deficient claim and told how to correct it. Urgent Care claim – An Urgent Care claim is a pre-service claim that must be processed quickly to prevent serious jeopardy to you or your Dependent’s life or health. Urgent Care claims also include those claims that, in the opinion of your doctor, would subject you to severe pain that cannot be managed without the care or treatment requested under the claim. Your Urgent Care claims will be processed within 72 hours after receipt by InforMed. If InforMed needs more information from you to process the claim, you will have 48 hours to provide the necessary information. InforMed then has 48 hours to decide the claim after receiving this information. An Urgent Care claim to extend Concurrent Care (described below) will be decided within 24 hours (if you make the claim at least 24 hours before treatment expires). If your Urgent Care claim is filed improperly, then you will be notified by telephone, told how to correct it and given a chance to correct it within 24 hours. If you do not provide the information requested, or do not properly refile the claim, InforMed will have to decide the claim on the information it has, and your claim may be denied. Due to the nature of an Urgent Care claim, you may be notified of a decision via telephone. This will be followed by a 106 written notice of the same information within three days of the oral notice. 2. Post-service claim – A Post-service claim is any other type of claim under the Plan, such as a payment for covered services after a doctor visit and whenever you have already received the treatment or supply for which payment is now being requested. You will be notified if your claim is denied within 30 days after receipt of the claim by InforMed. If InforMed determines that an extension of this time is necessary to decide the claim, the claim will be decided within 45 days of receipt (unless the period is tolled while InforMed waits for information it requested from you). You will be notified of the need for an extension within 30 days of receipt of the claim and the reasons why the extension is needed. 3. Concurrent Care claim – A Concurrent Care claim is one for which the Plan is requested to approve, or has already approved and is requested to extend such approval, for coverage of an ongoing course of treatment to be provided over a period of time or a certain number of treatments. If the Plan determines that course of treatment will be stopped or reduced before the previously approved number of treatments or period of time expires, you will be notified within a sufficient amount of time to allow an appeal before the Plan stops or reduces coverage for the ongoing treatment. If you request that a Concurrent Care treatment be extended beyond the initially determined time, your claim will be decided no later than 24 hours after your claim is received by the Plan (if you make the claim at least 24 hours before the period or number of treatments expires). (2) Notice of Claim Denial. If all or part of your claim is denied, you will receive a written explanation that describes information sufficient to identify the claim involved, the specific reason for the denial, the specific provisions of the Plan document on which the decision was based, any additional information necessary to reconsider your claim (and the reasons why that information is necessary), the Plan’s appeal procedures and the time limits for use of those procedures and explaining the initial decision is final unless the decision is appealed according to the appeal procedures. The explanation will also advise you of your right to bring an action under ERISA if you decide to appeal and that appeal is denied, or, for certain health claims only, to request an external review with an independent review organization. If the Plan relied on an internal rule, guideline or protocol in making the decision, you will receive either a copy of the rule, etc., or a 107 statement that it was relied upon and is available upon request and free of charge. Additionally, if the Plan based its decision on medical necessity, experimental treatment or a similar exclusion or limit, you will receive either an explanation of the scientific or clinical judgment related to your condition or a statement that such an explanation is available upon request and free of charge. If the Plan received the advice of any medical or vocational expert with respect to your claim, the Plan will identify the expert upon your request. (3) Appeal Procedure. If your claim is not an Urgent Care claim and is denied, you (or your authorized representative) may, within 180 days from receipt of the denial, request a review by writing to the Board of Trustees. If you are appealing an Urgent Care claim denial, you may do so orally by calling the Plan Office at the number on the Inside Back Cover or in writing. Your written appeal should state the reason for your appeal. You (or your authorized representative) may receive, upon request and free of charge, reasonable access to and copies of any documents relevant to your claim and may submit issues and comments in writing. You (or your authorized representative) will also receive copies of all new or additional information considered, relied upon or generated during the appeal as well as any new or additional rationale for the denial, if any. The Board of Trustees will determine all requests for review for claims that were denied on the basis of the Plan’s eligibility rules. If the Trustees review your appeal, the amount of time the Trustees have to issue a decision after receiving your appeal will depend on the type of claim. 1. Pre-service claims – Appeals of Pre-service claims will be decided within 30 days after the Trustees or its authorized Committee receive the appeal. Urgent Care claims – Appeals of Urgent Care claims will be decided within 72 hours after the Trustees or its authorized Committee receives the appeal. You may appeal denials of Urgent Care claims either orally by calling the Plan Office at 1-304-343-7682 or in writing. All information necessary to decide the appeal may be transmitted via telephone, facsimile or other available method. 2. Post-service claims – Appeals of Post-service claims will be decided at the next quarterly meeting of the Trustees or its authorized Committee immediately following the receipt of your appeal unless your appeal was received by the Trustees within 108 30 days of the date of the meeting. In this case, your appeal will be reviewed at the second quarterly meeting following receipt of the appeal. If special circumstances require an extension of the time for review by the Trustees, you will receive a decision no later than the third quarterly meeting, and you will be notified in writing of the need for the extension, why the extension is needed, and when a decision is expected. The Trustees will send you a notice of this decision within 5 days of the decision. 3. Concurrent Care claims – Appeals of Concurrent Care claims are governed by the provisions above for Urgent Care, Pre-service or Post-service claims, whichever applies to the particular claim. (4) Notice of Appeal Denial. If all or part of your claim is denied on appeal, you will receive a written explanation that describes information sufficient to identify the claim involved, the specific reason for the denial, a discussion of the decision, the specific provisions of the Plan document on which the decision was based, any additional information necessary to reconsider your claim (and why that information is necessary), notice that you may receive on request access to and free copies of documents and records relevant to your claim, and a statement of your right to bring a lawsuit under ERISA, or, for certain health claims, to request an external review from an independent review organization. If the Trustees relied on an internal rule, guideline or protocol in making the decision, you will receive either a copy of the rule, guideline or protocol, or a statement that it was relied upon and is available upon request and free of charge. If the Trustees based their decision on a medical claim on medical necessity, experimental treatment or a similar exclusion or limit, you will receive either an explanation of the scientific or clinical judgment related to your condition or a statement that such an explanation is available upon request and free of charge. If the initial decision on a medical claim was based in whole or in part on a medical judgment, the Trustees will consult with a health care professional in the appropriate field who was not consulted in the initial determination (but not a subordinate of such person). In reviewing a denied medical claim, the Trustees will not automatically presume that the Plan’s initial decision was correct. Rather, the medical claim will be reviewed independently based on all information you provided to the Trustees, including any new information that you provide that was not reviewed during the Plan’s initial decision. If your claim is denied, in whole or in part, you are not required to appeal the decision to the Board of Trustees. However, it is important to note that you must exhaust your administrative remedies by 109 appealing the denial of your claim for benefits to the Board of Trustees before you have the right to file suit under Section 502(a) of ERISA in accordance with the Statute of Limitations and Forum Selection provision on page 100. Failure to exhaust these administrative remedies will result in the loss of your right to file suit, as described in the ERISA Rights statement in the SPD. The Board of Trustees’ decision will be final and binding on all individuals dealing with or claiming a benefit from the Plan. (5) External Review of a Denied Health Claim. The Plan offers claimants covered by Plan 1 the right to request an external review of their denied health claim. The Plan will offer this right in accordance with and to the extent required by federal law. Only health claims that have been denied for medical judgment or rescission of coverage are eligible for external review. Disability and all other benefit claims are not eligible for external review. If a claimant wants to have the denied health claim reviewed, the claimant must send a written request for an external review of the claim denial to the Plan no later than four months after the date the claimant receives the notice of denial. Any claimant filing a timely request for review may submit additional materials for consideration on review, including a written explanation of and comments on the issues. Participants covered by Plans S and V may not request an external review of a denied health claim. Life Insurance Benefit Claims and Accidental Death, Dismemberment and Loss of Sight Benefit Claims (1) Claim Denial. Claims for benefits should first be submitted to The Hartford. For claims filed on or after January 1, 2002, if a claim for benefits is denied, in whole or in part (or benefits reduced or terminated), the claimant will receive a written explanation of the reason(s) it was denied within 90 days after the claim has been received by The Hartford. If additional time (up to 90 days) is required because of special circumstances, the claimant will be notified in writing of the reason for the delay, and the date that The Hartford expects to issue a final decision. A decision will be made with respect to the claim no more than 180 days from the date the claim is first filed with The Hartford. If the claim is denied, the claimant will receive a written explanation that describes the specific reason for the denial, the specific provisions of the plan document on which the decision was based, any additional information necessary to reconsider the claim, The Hartford’s appeal procedures, and also the claimant’s right to bring an action under ERISA if the claimant decides to appeal and that appeal is denied. (2) Appeal Procedure. The claimant can appeal the claim denial directly to The Hartford. If the claimant decides to appeal within 60 days after the claimant receives written notice that the claim has been denied the claimant must send a request for review (appeal) to: 110 The Hartford Employee Benefits Division The Falls 125 Sanctuary Parkway, Suite 450 Alpharetta, GA 30004 The claimant must include in the written appeal all the facts regarding the claim as well as the reason(s) the claimant feels the denial was incorrect. The claimant will receive, if requested, reasonable access to and free copies of documents relevant to the claim. The claimant may submit issues and comments in writing, and documents, relating to the claim. The claimant may name a representative to act on his behalf. To do so, the claimant must notify The Hartford in writing of the representative’s name, address, and telephone number. The claimant may, at his own expense, have legal representation at any stage of these review procedures. Regardless of the outcome of the appeal, neither The Hartford nor the Plan will be responsible for paying any legal expenses incurred during the course of the appeal. The Hartford, in making its decisions on claims and on appeal, will apply the terms of the Plan’s document and any applicable guidelines, rules and schedules, and will periodically verify that benefit determinations are made in accordance with such documents, and where appropriate, applied consistently with respect to similarly situated claimants. The Hartford will take into account all information the claimant submits in making its decision. The Hartford will make a decision as to the claim within 60 days after receipt of the request for review. If there are special circumstances requiring delay, the claimant will be notified of the final decision no later than 120 days after the request for review is received. The claimant will receive written notice of the decision explaining the basis for upholding or for modifying the original disposition of the claim. The decision of The Hartford is final and binding. Disability Benefit Claims and Retiree Death Benefit Claims All claims by Participants and Beneficiaries for benefits under the Plan shall be filed in writing on forms provided by the Trustees. If a claim for benefits is denied, in whole or in part (or benefits are reduced or terminated), the claimant will receive a written explanation of the reason(s) it was denied, within 90 days after the claim has been received by the Plan Office. If additional time of up to 90 days is required because of special circumstances, the claimant will be notified in writing of the reason for the delay, and the date that the Plan expects to issue a final decision. A decision will be made with respect to the claim no more than 180 days from the date the claim is first filed with the Plan Office. If the claim is denied, the claimant will receive a written explanation that describes the specific reason for the denial, the specific provisions of the plan document on which the decision was based, any additional information necessary to reconsider the claim, the 111 Plan’s appeal procedures, and also the right to bring an action under ERISA if the claimant decides to appeal and that appeal is denied. The claimant can appeal the claim denial directly to the Board of Trustees. If the claimant decides to appeal, he must make written request for a review within 60 days after he received written notice the claim has been denied. The claimant must send his request for review (appeal) to: Board of Trustees United Food and Commercial Workers Local 400 and Employers Health and Welfare Plan 600 D Street, Suite 250 South Charleston, WV 25303 The claimant must include in his written appeal all the facts regarding the claim as well as the reason(s) the claimant feels the denial was incorrect. The claimant will receive, if requested, reasonable access to and copies of documents relevant to the claim at no charge. The claimant may submit issues and comments in writing, and documents, relating to the claim. The claimant may name a representative to act on his behalf. To do so, the claimant must notify the Plan in writing of the representative’s name, address, and telephone number. The claimant may, at his own expense, have legal representation at any stage of these review procedures. Regardless of the outcome of the appeal, neither the Board of Trustees nor the Plan will be responsible for paying any legal expenses that the claimant incurs during the course of the appeal. The Board of Trustees or its authorized Committee will take into account all information submitted in making its decision. The Board of Trustees or its authorized Committee will review the appeal at the next regular meeting following receipt of the appeal. However, if the claimant submits the appeal less than 30 days before the next scheduled meeting, it will be reviewed at the next following meeting. If special circumstances require a further extension of time, a determination will be made no later than the third Board of Trustees meeting following the date the Plan Office receives the appeal. If the Board of Trustees requires a postponement of the decision to the next meeting, the claimant will be sent a notice describing the reason for the delay and an expected date of the decision. The Plan will notify you in writing of the Trustees’ decision within 5 days after a decision is made. If the appeal is denied, you have the right to bring a civil action under ERISA section 502(a) in accordance with the Statute of Limitations and Forum Selection provision on page 100. The decision of the Board of Trustees is final and binding. Review of Plan Documents You may examine the following documents at the Plan Office during regular business hours, Monday through Friday, except holidays: 1. Trust Agreement and all Amendments, 112 2. Collective Bargaining Agreements(s), 3. Plan Document, or Rules and Regulations, and all Amendments, 4. Current Summary Plan Description and subsequent Summary of Material Modifications, 5. The latest Form 5500 or full Annual Report filed with the Internal Revenue Service and Department of Labor. You may also obtain copies of the documents by writing for them and paying the reasonable cost of duplication. You should find out what the charges will be before requesting copies. If you prefer, you can arrange to examine the documents during business hours at your union office or at your Employer’s establishment, if at least 50 plan Participants are employed there. To make such arrangements, call or write the Administrator at the Plan Office. A summary of the annual report which gives details of the financial information about the Plan’s operations is furnished free of charge to all participants. 113 NOTICE OF PRIVACY PRACTICES THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. Effective Date of Notice September 23, 2013 The United Food and Commercial Workers Local 400 and Employers Health and Welfare Fund (the “Plan”) is required by law to take reasonable steps to ensure the privacy of your personally identifiable health information and to inform you about: 1. the Plan’s uses and disclosures of Protected Health Information (PHI); 2. your privacy rights with respect to your PHI; 3. the Plan’s duties with respect to your PHI; 4. your right to file a complaint with the Plan and to the Secretary of the U.S. Department of Health and Human Services; and 5. the person or office to contact for further information about the Plan’s privacy practices. The term “Protected Health Information” (PHI) includes all individually identifiable health information transmitted or maintained by the Plan, regardless of form (oral, written, electronic). Section 1. Notice of PHI Uses and Disclosures Required PHI Uses and Disclosures Upon your request, the Plan is required to give you access to your PHI in order to inspect and copy it. Use and disclosure of your PHI may be required by the Secretary of the Department of Health and Human Services to investigate or determine the Plan’s compliance with the privacy regulations. Uses and disclosures to carry out treatment, payment and health care operations. 114 The Plan and its business associates will use PHI without your authorization to carry out treatment, payment and health care operations. The Plan and its business associates (and any health insurers providing benefits to Plan participants) may also disclose the following to the Plan’s Board of Trustees: (1) PHI for purposes related to Plan administration (payment and health care operations); (2) summary health information for purposes of health or stop loss insurance underwriting or for purposes of modifying the Plan; and (3) enrollment information (whether an individual is eligible for benefits under the Plan). The Trustees have amended the Plan to protect your PHI as required by federal law. Treatment is the provision, coordination or management of health care and related services. It also includes but is not limited to consultations and referrals between one or more of your providers. For example, the Plan may disclose to a treating physician the name of your treating radiologist so that the physician may ask for your X-rays from the treating radiologist. Payment includes but is not limited to actions to make coverage determinations and payment (including billing, claims processing, subrogation, reviews for medical necessity and appropriateness of care, utilization review and preauthorizations). For example, the Plan may tell a treating doctor whether you are eligible for coverage or what percentage of the bill will be paid by the Plan. Health care operations include but are not limited to quality assessment and improvement, reviewing competence or qualifications of health care professionals, underwriting, premium rating and other insurance activities relating to creating or renewing insurance contracts. It also includes case management, conducting or arranging for medical review, legal services and auditing functions including fraud and abuse compliance programs, business planning and development, business management and general administrative activities. However, no genetic information can be used or disclosed for underwriting purposes. For example, the Plan may use information to project future benefit costs or audit the accuracy of its claims processing functions. Uses and disclosures that require that you be given an opportunity to agree or disagree prior to the use or release. Unless you object, the Plan may provide relevant portions of your protected health information to a family member, friend or other person you indicate is 115 involved in your health care or in helping you receive payment for your health care. Also, if you are not capable of agreeing or objecting to these disclosures because of, for instance, an emergency situation, the Plan will disclose protected health information (as the Plan determines) in your best interest. After the emergency, the Plan will give you the opportunity to object to future disclosures to family and friends. Uses and disclosures for which your consent, authorization or opportunity to object is not required. The Plan is allowed to use and disclose your PHI without your authorization under the following circumstances: (1) For treatment, payment and health care operations. (2) Enrollment information can be provided to the Trustees. (3) Summary health information can be provided to the Trustees for the purposes designated above. (4) When required by law. (5) When permitted for purposes of public health activities, including when necessary to report product defects and to permit product recalls. PHI may also be disclosed if you have been exposed to a communicable disease or are at risk of spreading a disease or condition, if required by law. (6) When required by law to report information about abuse, neglect or domestic violence to public authorities if there exists a reasonable belief that you may be a victim of abuse, neglect or domestic violence. In such case, the Plan will promptly inform you that such a disclosure has been or will be made unless that notice would cause a risk of serious harm. For the purpose of reporting child abuse or neglect, it is not necessary to inform the minor that such a disclosure has been or will be made. Disclosure may generally be made to the minor’s parents or other representatives although there may be circumstances under federal or state law when the parents or other representatives may not be given access to the minor’s PHI. (7) The Plan may disclose your PHI to a public health oversight agency for oversight activities required by law. This includes uses or disclosures in civil, administrative or criminal investigations; inspections; licensure or disciplinary actions (for example, to investigate complaints against providers); and other activities necessary for appropriate oversight of government benefit programs (for example, to investigate Medicare or Medicaid fraud). 116 (8) The Plan may disclose your PHI when required for judicial or administrative proceedings. For example, your PHI may be disclosed in response to a subpoena or discovery request. (9) When required for law enforcement purposes, including for the purpose of identifying or locating a suspect, fugitive, material witness or missing person. Also, when disclosing information about an individual who is or is suspected to be a victim of a crime but only if the individual agrees to the disclosure or the Plan is unable to obtain the individual’s agreement because of emergency circumstances. Furthermore, the law enforcement official must represent that the information is not intended to be used against the individual, the immediate law enforcement activity would be materially and adversely affected by waiting to obtain the individual’s agreement and disclosure is in the best interest of the individual as determined by the exercise of the Plan’s best judgement. (10) When required to be given to a coroner or medical examiner for the purpose of identifying a deceased person, determining a cause of death or other duties as authorized by law. Also, disclosure is permitted to funeral directors, consistent with applicable law, as necessary to carry out their duties with respect to the decedent. (11) When consistent with applicable law and standards of ethical conduct if the Plan, in good faith, believes the use or disclosure is necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public and the disclosure is to a person reasonably able to prevent or lessen the threat, including the target of the threat. (12) When authorized by and to the extent necessary to comply with workers’ compensation or other similar programs established by law. Except as otherwise indicated in this notice, uses and disclosures will be made only with your written authorization subject to your right to revoke such authorization. Uses and disclosures that require your written authorization. Other uses or disclosures of your protected health information not described above will only be made with your written authorization. For example, in general and subject to specific conditions, the Plan will not use or disclose your psychiatric notes; the Plan will not use or disclose your protected health information for marketing; and the Plan will not sell your protected health information, unless you provide a written authorization to do so. You may revoke written authorizations at any time, so long as the revocation is in writing. Once the Plan receives your written revocation, it will only be effective for future uses and disclosures. It will 117 not be effective for any information that may have been used or disclosed in reliance upon the written authorization and prior to receiving your written revocation. Section 2 Rights of Individuals Right to Request Restrictions on Uses and Disclosures of PHI You may request the Plan to restrict the uses and disclosures of your PHI. However, the Plan is not required to agree to your request (except that the Plan must comply with your request to restrict a disclosure of your confidential information for payment or health care operations if you paid for the services to which the information relates in full, out of pocket). You or your personal representative will be required to submit a written request to exercise this right. Such requests should be made to the Plan’s Privacy Official. Right to Request Confidential Communications The Plan will accommodate reasonable requests to receive communications of PHI by alternative means or at alternative locations if necessary to prevent a disclosure that could endanger you. You or your personal representative will be required to submit a written request to exercise this right. Such requests should be made to the Plan’s Privacy Official. Right to Inspect and Copy PHI You have a right to inspect and obtain a copy of your PHI contained in a “designated record set,” for as long as the Plan maintains the PHI. If the information you request is in an electronic designated record set, you may request that these records be transmitted electronically to yourself or a designated individual. “Protected Health Information” (PHI) includes all individually identifiable health information transmitted or maintained by the Plan, regardless of form. “Designated Record Set” includes the medical records and billing records about individuals maintained by or for a covered health care provider; enrollment, 118 payment, billing, claims adjudication and case or medical management record systems maintained by or for the Plan; or other information used in whole or in part by or for the Plan to make decisions about individuals. Information used for quality control or peer review analyses and not used to make decisions about individuals is not in the designated record set. The requested information will be provided within 30 days if the information is maintained on site or within 60 days if the information is maintained off site. A single 30-day extension is allowed if the Plan is unable to comply with the deadline. You or your personal representative will be required to submit a written request to request access to the PHI in your designated record set. Such requests should be made to the Plan’s Privacy Official. If access is denied, you or your personal representative will be provided with a written denial, setting forth the basis for the denial, a description of how you may appeal the Plan’s decision and a description of how you may complain to the Secretary of the U.S. Department of Health and Human Services. The Plan may charge a reasonable, cost-based fee for copying records at your request. Right to Amend PHI You have the right to request the Plan to amend your PHI or a record about you in your designated record set for as long as the PHI is maintained in the designated record set. The Plan has 60 days after the request is made to act on the request. A single 30-day extension is allowed if the Plan is unable to comply with the deadline. If the request is denied in whole or part, the Plan must provide you with a written denial that explains the basis for the denial. You or your personal representative may then submit a written statement disagreeing with the denial and have that statement included with any future disclosures of your PHI. Such requests should be made to the Plan’s Privacy Official. You or your personal representative will be required to submit a written request to request amendment of the PHI in your designated record set. Right to Receive an Accounting of PHI Disclosures At your request, the Plan will also provide you an accounting of disclosures by the Plan of your PHI during the six years prior to the date of your request. 119 However, such accounting will not include PHI disclosures made: (1) to carry out treatment, payment or health care operations (except as noted in the following paragraph); (2) to individuals about their own PHI; (3) pursuant to your authorization; (4) prior to April 14, 2003; and (5) where otherwise permissible under the law and the Plan’s privacy practices. In addition, the Plan need not account for certain incidental disclosures. If the accounting cannot be provided within 60 days, an additional 30 days is allowed if the individual is given a written statement of the reasons for the delay and the date by which the accounting will be provided. If you request more than one accounting within a 12-month period, the Plan will charge a reasonable, cost-based fee for each subsequent accounting. Such requests should be made to the Plan’s Privacy Official. Right to Receive a Paper Copy of This Notice Upon Request You have the right to obtain a paper copy of this Notice. Such requests should be made to the Plan’s Privacy Official. A Note About Personal Representatives You may exercise your rights through a personal representative. Your personal representative will be required to produce evidence of his/her authority to act on your behalf before that person will be given access to your PHI or allowed to take any action for you. Proof of such authority may take one of the following forms: 1. a power of attorney for health care purposes; 2. a court order of appointment of the person as the conservator or guardian of the individual; or 3. an individual who is the parent of an unemancipated minor child may generally act as the child’s personal representative (subject to state law). The Plan retains discretion to deny access to your PHI by a personal representative to provide protection to those vulnerable people who depend on others to exercise their rights under these rules and who may be subject to abuse or neglect. 120 Section 3 The Plan’s Duties The Plan is required by law to maintain the privacy of PHI and to provide individuals (participants and beneficiaries) with notice of the Plan’s legal duties and privacy practices. This Notice is effective September 23, 2013, and the Plan is required to comply with the terms of this Notice. However, the Plan reserves the right to change its privacy practices and to apply the changes to any PHI received or maintained by the Plan prior to that date. If a privacy practice is changed, a revised version of this Notice will be provided to all participants for whom the Plan still maintains PHI. The revised Notice will be distributed in the same manner as the initial Notice was provided or in any other permissible manner. If the revised version of this Notice is posted on the Plan’s website, ufcwl400healthandwelfare.org, you will also receive a copy of the Notice, or information about any material change and how to receive a copy of the Notice in the Plan’s next annual mailing. Otherwise, the revised version of this Notice will be distributed within 60 days of the effective date of any material change to the Plan’s policies regarding the uses or disclosures of PHI, the individual’s privacy rights, the duties of the Plan or other privacy practices stated in this Notice. Minimum Necessary Standard When using or disclosing PHI or when requesting PHI from another covered entity, the Plan will make reasonable efforts not to use, disclose or request more than the minimum amount of PHI necessary to accomplish the intended purpose of the use, disclosure or request, taking into consideration practical and technological limitations. When required by law, the Plan will restrict disclosures to the limited data set, or otherwise as necessary, to the minimum necessary information to accomplish the intended purpose. However, the minimum necessary standard will not apply in the following situations: 1. disclosures to or requests by a health care provider for treatment; 2. uses or disclosures made to the individual; 3. disclosures made to the Secretary of the U.S. Department of Health and Human Services; 4. uses or disclosures that are required by law; and 121 5. uses or disclosures that are required for the Plan’s compliance with legal regulations. De-Identified Information This notice does not apply to information that has been de-identified. De-identified information is information that does not identify an individual and with respect to which there is no reasonable basis to believe that the information can be used to identify an individual. Summary Health Information The Plan may disclose “summary health information” to the Trustees for obtaining insurance premium bids or modifying, amending or terminating the Plan. “Summary health information” summarizes the claims history, claims expenses or type of claims experienced by participants and excludes identifying information in accordance with HIPAA. Notification of Breach The Plan is required by law to maintain the privacy of participants’ PHI and to provide individuals with notice of its legal duties and privacy practices. In the event of a breach of unsecured PHI, the Plan will notify affected individuals of the breach unless the Plan determines that there is a low probability that the unsecured PHI has been compromised. Section 4 Your Right to File a Complaint With the Plan or the HHS Secretary If you believe that your privacy rights have been violated, you may complain to the Plan. Such complaints should be made to the Plan’s Privacy Official. You may file a complaint with the Secretary of the U.S. Department of Health and Human Services, Hubert H. Humphrey Building, 200 Independence Avenue SW, Washington, D.C. 20201. The Plan will not retaliate against you for filing a complaint. Section 5 Whom to Contact at the Plan for More Information If you have any questions regarding this notice or the subjects addressed in it, you may contact the Plan’s Privacy Official. Such questions should be directed to the Plan’s Privacy Official at: 122 United Food and Commercial Workers Local 400 and Employers Health and Welfare Fund 600 D Street, Suite 250 South Charleston, WV 25303 Conclusion PHI use and disclosure by the Plan is regulated by a federal law known as HIPAA (the Health Insurance Portability and Accountability Act). You may find these rules at 45 Code of Federal Regulations Parts 160 and 164. The Plan intends to comply with these regulations. This Notice attempts to summarize the regulations. The regulations will supersede any discrepancy between the information in this Notice and the regulations. Nothing in this booklet is meant to interpret or extend or change in any way the provisions expressed in the Plan documents. The Trustees reserve the right to amend, modify or discontinue all or part of the Plan whenever, in their judgment, conditions so warrant. Unless otherwise indicated, the benefits described in the Plan document and in this Summary Plan Description are self-funded by the Plan. The benefits payable are limited to Plan assets available for such purposes. 123 HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY Hartford, Connecticut (Herein called The Hartford) _______________________________________________________________ CERTIFICATE OF INSURANCE Under Group Insurance Policy GL-19282 Effective December 1, 1981 Issued by The Hartford to UNITED FOOD AND COMMERCIAL WORKERS LOCAL 400 AND EMPLOYERS HEALTH AND WELFARE PLAN (Herein called the Policyholder) THIS IS TO CERTIFY that The Hartford has issued and delivered to the Policyholder the above specified group policy insuring certain employees of the Policyholder. Provisions of the Policy principally affecting the insurance of the employee are summarized in the Schedule of Benefits and participants can request a full copy of the Certificate from the Plan Office.* Beneficiary: The Beneficiary designated by the employee in writing and filed at the office where the records of insurance are maintained. This individual Certificate is furnished in accordance with and subject to the terms of said group policy and is merely evidence of insurance provided under said group policy which insurance if effective only if the employee is eligible for insurance and becomes and continues insured in accordance with the terms, provisions and conditions of said policy. The coverage with respect to an Insured Person’s dependents will be applicable only if such person is eligible, has enrolled, and is insured for such coverage. This Certificate replaces any and all Certificates previously issued for delivery to the employee by the Policyholder. Hartford Life and Accident Insurance Company Christine Hayer Repasy, Secretary Thomas M. Marra, President * The Certificate, in full, may be examined at the Plan Office during regular business hours, Monday through Friday, except holidays. 124 [INSIDE BACK COVER] IMPORTANT ADDRESSES AND TELEPHONE NUMBERS PLAN OFFICE United Food and Commercial Workers Local 400 and Employers Health and Welfare Plan 600 D Street, Suite 250 South Charleston, WV 25303 1-304-343-7682 Member Assistance 1-866-343-7682 Member Assistance Outside Charleston Area INFORMED UTILIZATION AND DISEASE MANAGEMENT Including Pre-certifications: 1-877-687-9982 HOSPITAL AND PHYSICIAN PPO NETWORK Anthem Blue Cross and Blue Shield Provider Assistance: 1-800-518-1638 Provider Access Information: 1-800-810-BLUE or www.anthem.com PHARMACY NETWORK Plan 1 Kroger Employees Kroger Prescription Plans (KPP) and Mail Order Information 1-800-575-7712 Plan 1 Employees of Other Employers and Plan S and Plan V Retirees Contact Plan Office or Kroger Prescription Plans (KPP) 1-800-482-1285 20069621v1 125