Document:

Officer Retiree Medical Plan Document and Summary Plan Description

 Exhibit 10.79 
 

 

  

 
 This document, when read together with the
applicable Evidences of Coverage and Certificates of Insurance of the plan options, constitutes both the official plan document and Summary Plan Description (SPD) for purposes of the Employee Retirement Income Security Act of 1974, as amended
(ERISA). The SPD is intended to describe the provisions of the Unified Grocers, Inc. Officer Retiree Medical Plan (the Plan) in clear language. These provisions are generally effective as of October 1, 2011, and supersede all previous
communications, written or oral, regarding retiree medical benefits provided to certain retired officers, their spouses/domestic partners and eligible dependents. In the event of any conflicts between other communications regarding officer retiree
medical benefits and the information contained in this document, this Plan document and SPD will govern. Unified Grocers, Inc. (the Plan Sponsor) reserves the right to suspend or terminate the Plan or to modify, amend or change the provisions, terms
and conditions of the Plan at any time without notice. This Plan and SPD is not a promise of future benefits and should not be read as such. 
  

 
  

  
 2 

 Table of Contents 
  

					
	 Introduction
	  	 	4	  
		
	 Eligibility
	  	 	4	  
	 Enrollment
	  	 	6	  
	 Open Enrollment
	  	 	6	  
	 Changing Your Coverage During the Year
	  	 	6	  
	 When Coverage Ends
	  	 	7	  
	 Monthly Contribution and Cost Sharing
	  	 	7	  
	 Tax Consequences of Benefits Received Under the Plan
	  	 	8	  
		
	 What You Need to Know About Medicare
	  	 	9	  
		
	 Enrolling for Medicare
	  	 	9	  
	 Coordination With Medicare
	  	 	10	  
	 Submitting Claims to Anthem Blue Cross When Medicare is Primary
	  	 	11	  
	 Medicare HMO Option
	  	 	11	  
	 Enrolling In a Medicare HMO
	  	 	11	  
		
	 Base Medical Plan Options
	  	 	12	  
		
	 Fully-Insured Medicare Base Medical HMO Plans—Kaiser Permanente and UnitedHealth
	  	 	12	  
	 Kaiser Permanente Senior Advantage
	  	 	12	  
	 UnitedHealth Secure Horizons
	  	 	12	  
	 Self-Insured Anthem Blue Cross PPO Base Medical Plan
	  	 	13	  
	 Covered Expenses and Limitations
	  	 	16	  
	 Pre-Authorization
	  	 	19	  
	 Utilization Review Program
	  	 	20	  
	 Exclusions
	  	 	26	  
	 Pre-Existing Condition Exclusions
	  	 	28	  
	 Executive Medcial Reimbursement Plan (EMRP)
	  	 	29	  
		
	 Medical Plan Comparisons
	  	 	30	  
		
	 Prescription Drug Benefits
	  	 	34	  
		
	 HMO Prescription Drug Program
	  	 	34	  
	 PPO Plan & Your CVS Caremark Card–Retirees Under 65
	  	 	34	  
	 Maximum Annual Benefit–Retirees Under 65
	  	 	34	  
	 What’s Covered
	  	 	35	  
	 Excluded Drugs
	  	 	37	  
	 PPO Plan & Your United Health Rx Card–Retirees Over 65
	  	 	39	  
		
	 Retiree Dental Benefits
	  	 	40	  
		
	 Retiree Vision Benefits
	  	 	44	  
		
	 General Information
	  	 	47	  
		
	 Statement of ERISA Rights
	  	 	48	  
	 Claims Appeal Procedures
	  	 	49	  
	 Continuation of Coverage (COBRA)
	  	 	55	  
	 Coordination of Benefits
	  	 	59	  
		
	 Addendum to Unified Grocers Inc. Officer Retiree Medical Plan
	  	 	60	  
		
	 Plan Administration
	  	 	62	  
		
	 Definitions
	  	 	66	  
		
	 Provider Contact Information
	  	 	68	  

  
 3 

 Introduction 

 

 Unified Grocers, Inc. provides medical, dental, vision and prescription drug benefits (collectively, referred to as the
Retiree Benefits) to certain elected officers under this Unified Grocers, Inc. Officer Retiree Medical Plan (the Plan) when they retire from the company. The Plan has been established solely for the benefit of those elected officers, which represent
a select group of management or highly compensated employees of the company. If you are an elected officer that is eligible for the Plan, it gives you the security of knowing that you’ll have help paying for your health care-related expenses
during retirement. The Plan provides you, your spouse/ domestic partner and eligible dependents with Retiree Benefits before and after you are eligible for Medicare. It has also been carefully designed to offer both you and Unified a way to better
control rapidly rising health care and insurance costs and to provide a measure of financial security for you and your family. 
 There are
several base plan options that provide Retiree Benefits under the Plan that consist of self-insured PPO options and fully-insured HMO/DMO options (each option referred to as a Base Medical Plan). Additionally, the Executive Medical Reimbursement
Plan (the EMRP) component of the Plan as described below, provides you with coverage that supplements the Retiree Benefits that are generally provided under the Base Medical Plan(s) in which you enroll. This Plan Document and Summary Plan
Description (SPD) describes the Plan’s coverage and benefit levels under the self-insured medical, prescription drug benefits, dental and vision PPO Base Medical Plan options. The self-insured medical PPO Base Medical Plan is a
“retiree-only plan”, and thus, is exempt from the insurance market reform requirements under the Patient Protection and Affordable Care Act (the “Health Care Reform Act”). 
 Coverage and benefit levels provided under the fully-insured HMO Base Medical Plans and the EMRP are described in the Evidences of Coverage (EOC) or Certificate of Insurance, as the case may be, that are
furnished to you upon enrollment by the applicable insurance carriers (i.e., UnitedHealth Secure Horizons or Kaiser Foundation Health Plan, Inc. for the fully-insured medical HMO Base Medical Plans, Safeguard for the fully-insured dental maintenance
organization (DMO) Base Medical Plan, and Anthem Blue Cross Life and Health Insurance Company for the EMRP).

 Please read this document, along with any applicable Evidences of Coverage and Certificates of Insurance
which are incorporated by this reference, as together, they constitute your official Summary Plan Description for the Plan. You should refer to your Summary Plan Description if you, your spouse/domestic partner and any covered dependents have
questions about your coverage. 
 Eligibility 

 
  

You must meet the following requirements at retirement to be eligible for the Plan: 

 

	 	n	You must be at least 55 years of age; and 

  

	 	n	Have completed at least 7 years of continuous service with Unified in an elected officer position. 

The Plan provides several Base Medical Plan options from which to choose (see “Base Medical Plan Options” below). Your geographic location and
Medicare eligibility status determine which options are available to you. You may also have an opportunity to elect a different Base Medical Plan option each year during the annual Open Enrollment period. 

If you are eligible for coverage as described above, and enroll in a Base Medical Plan option, you will be automatically enrolled in the EMRP.

 Dependent Eligibility 
 If you
are eligible for coverage and are enrolled in the Plan, you may also cover your spouse/domestic partner and eligible dependents. An eligible spouse is defined as the person to whom you are legally married at any time on or after your retirement, and
a registered domestic partner is defined as the person to whom you are in a registered domestic partnership at any time on or after your retirement. You must enroll your spouse/domestic partner and any eligible dependents in the same Base Medical
Plan option that you choose for yourself. If you remarry or enter into a new domestic partnership after your retirement, your new spouse or domestic partner will be eligible for coverage under the Plan. 

If you are a Unified Grocers retiree who is a spouse/ domestic partner of another Unified Grocers active employee or retiree, you are required to enroll
in single coverage or as a dependent of your spouse/domestic 

 

  
 4 

 
partner. You cannot have dual coverage under multiple group health plan sponsored by Unified. If you were eligible for retiree medical coverage when you retired from Unified and waived your
coverage to enroll as a dependent of your spouse/domestic partner, you will not forfeit your right to retiree coverage under this Plan in the future. If you experience a family status change due to the death of your spouse/domestic partner, divorce,
or termination of domestic partnership, you must enroll in your own retiree medical coverage within 31 days of the family status change. 

When you or your covered spouse/domestic partner become eligible for Medicare (usually age 65 or older), you must enroll in Medicare Part A and Part
B. You must also refrain from enrolling in Medicare Part D. Coverage under the Plan will continue, but Medicare becomes the primary payer and this Plan will be the secondary payer; provided, that, certain exceptions apply for outpatient prescription
drugs. 
 Subject to the provisions of the EMRP that is a “grandfathered plan” under the Health Care Reform Act, eligible
dependent coverage is available under the Plan for your children up to age 26, regardless of their marital, dependency or student status. 

Adoption 
 A child that is adopted will be
provided coverage from the date the child is legally placed with you for the purpose of adoption. “Placement” means that you have both physical custody and have assumed the financial responsibility for the support and care of the child.
You must enroll your adopted child for coverage under the Plan within 31 days of the placement. If the child’s placement is disrupted prior to legal adoption, coverage for the child will end on the date the child is removed from placement.

 Qualified Medical Child Support Order (QMCSO) 
 A QMCSO is a judicial or administrative order requiring you to cover your child under the Plan. A QMCSO must include, among other things, the name and address of the participant and child, a reasonable
description of the type of coverage, the period to which the order applies and identifies the Plan to which the order applies. 
 Per the QMCSO,
the Plan will enroll the child whether or not you elect dependent coverage for the child or 

 

 agree to pay for it. If the QMCSO requires you to pay for coverage, you will be required to make
arrangements with Unified to pay for the coverage. For more information please contact the Benefits Department. 
 Newborn Children

 A newborn child must be added to the Plan within 31 days of the child’s birth. If a newborn child is added to the Plan within 31 days
of birth, the child’s effective date for coverage will be retroactive to the date of birth. If you do not enroll your child within 31 days of birth, you will have to wait until the next open enrollment period and coverage will be effective
January 1 of the next year. 
 Domestic Partner Coverage 
 A registered domestic partnership is established between two same-sex individuals age 18 and older that share a common residence; are not married to, or in a domestic partnership, with another adult; are
not related by blood; and live in a State that allows registration of domestic partnerships. 
 Adding a registered domestic partner must be
done within 31 days from the date your certification of domestic partnership is approved by the State in which the certification is issued. Otherwise, you will have to wait until the next Open Enrollment period to add your domestic partner.

 If a domestic partner is entitled to Medicare on the basis of age and is covered under the Plan, Medicare is primary. The domestic partner
must enroll in Medicare Parts A and B in order to be eligible for coverage. 
 New Family Members 

A newly acquired spouse or domestic partner and any eligible dependents acquired by marriage or domestic partnership may be enrolled within 31 days of the
marriage or the date the domestic partnership is approved. Coverage for the new dependents will then become effective on the first day of the month following the date of marriage or certification of domestic partnership. 

Proof of Relationship 
 Proof of
relationship such as certified copies of marriage, domestic partnership, birth, or adoption is required. You have 31 days from the date you add your dependent to the Plan to provide proof. Failure to provide proof of relationship will result in the
removal 

 

  
 5 

 
of your dependent from coverage retroactive to the date the dependent’s coverage was effective under the Plan. 
 Medicare Secondary Payer (MSP) - Social Security Number 
 The Medicare, Medicaid and SCHIP
Extension Act of 2007 require group health plans to report all data of eligible members to the Centers for Medicare and Medicaid Services (CMS). The CMS is responsible for collecting this data, including social security numbers for individuals
covered under a group health plan. You must provide your spouse’s social security number when enrolling your spouse in a health plan. Failure to do so may result in your spouse being removed from your health insurance plan. 

Legal Separation, Divorced Spouse or Termination of Domestic Partnership 
 A legally separated spouse, divorced spouse or former domestic partner is covered until the end of the month in which the separation is approved by the court, the date the divorce becomes final, or the
date the termination of domestic partnership is approved. You should submit written notice and provide a copy of the document to the Plan with the date the court signs the separation or divorce decree or approves the termination of domestic
partnership. 
 You must remove your separated spouse, former spouse or former domestic partner within 31 days of the date the divorce decree is
signed or domestic partnership is terminated. If you fail to remove your former spouse or domestic partner, coverage will be cancelled retroactively to the actual cancellation date and any benefits paid must be reimbursed to the Plan. 

There will be no reimbursement of paid premiums if notice is given more than 31 days after the event date. 

Your divorced spouse may be eligible for continuation coverage under COBRA. However, your former domestic partner is not eligible for continuation
coverage under COBRA. 
 Enrollment 

 
  

When you retire from active employment with Unified, you will be given the opportunity to enroll in the Plan. You will receive an enrollment package that
will include information about your Base Medical Plan options, the cost, how to enroll yourself, your eligible spouse/ domestic partner and your dependents, and the date by which you must make your elections.

 You will also need to complete additional enrollment applications if any of the following apply to you:

  

	 	n	You were enrolled in an option while actively employed that is not available to you in retirement. 

 

	 	n	You wish to change to another option even if the option you had while actively employed is available to you (e.g. you are Medicare-eligible and you want to enroll in a
Medicare HMO). 

  

	 	n	You want to add or drop coverage for an eligible spouse/domestic partner or dependent. 

 Your coverage will be effective the first day of the month following your retirement date. You will need to elect coverage within 31 days of your benefit effective date. If you waive your coverage when
you are first eligible or you do not elect coverage in a timely manner, you will be considered as having waived your coverage and will not be able to enter this Plan at any time thereafter. 
 It is important to choose your Base Medical Plan option carefully because the choice you make will remain for the entire plan year. It cannot be changed until Open Enrollment unless you experience a
qualified family status change. 
 Open Enrollment 
 Each year, there is an Open Enrollment period during which you can make changes to your Base Medical Plan election for the upcoming plan year. You will receive an enrollment package that will include
information about the coverage options available to you under the Plan. You are required to complete an Open Enrollment form each year, even if you are not making any changes. If your form is not received during the Open Enrollment period, your
medical coverage will be waived and you will not be eligible for coverage under the Plan at any time in the future. Elections made during the Open Enrollment take effect on the first day of the next calendar year. 

Changing Your Coverage During the Year 
 You
may make mid-year changes to your election if you have a qualified family status change. A qualified family status change occurs if: 
  

	 	n	You get married or enter into a registered domestic partnership. 

  

	 	n	You get divorced, terminate your domestic partnership or have a legal separation.

 

  
 6 

	 	n	Your spouse/domestic partner dies. 

  

	 	n	Your spouse/domestic partner has a change in employment status that affects insurance coverage. 

 

	 	n	You move into or out of a plan’s service area. 

  

	 	n	You or your spouse/domestic partner gain or lose eligibility under Medicare or Medicaid. 

 Any changes you make must be consistent with the family status change. You will be required to provide proof of a family status change. Proof includes a certified copy of the following documents: birth
certificate, marriage certificate, domestic partnership registration, divorce decree, legal separation, termination of domestic partnership, death certificate, loss of other coverage, etc. 
 Plan Year 
 The Plan Year is from January 1 to December 31. 

When Coverage Ends 
  

 
 Your coverage under the Plan will terminate on
the earliest of the following dates: 
  

	 	n	The date on which the plan terminates. 

  

	 	n	The date of your death. 

  

	 	n	The last day of the month for which a timely payment was made. 

  

	 	n	The last day of the month in which you fail to enroll in Medicare Part A and Part B when you first became eligible. 

Your spouse’s/domestic partner’s and dependent’s coverage under the Plan will terminate on the earliest of the following dates:

  

	 	n	The date on which the plan terminates. 

  

	 	n	The date on which you are no longer eligible. 

  

	 	n	The last day of the month that your dependent is no longer eligible (e.g., attainment of age 26). 

 

	 	n	The last day of the month that the divorce decree is signed or termination of domestic partnership is approved (affects spouse/domestic partner coverage only).

  

	 	n	The last day of the month following your death. 

Please note: If you retire and elect retiree medical coverage and you are later rehired by Unified Grocers, your coverage under the Plan will end
and it will be 

 necessary for you, your spouse/domestic partner and your eligible dependents (if applicable) to move to a
medical plan for active employees. 
 If you die, your spouse and any covered dependents may be eligible for up to 36 months of continued
coverage under COBRA. If your surviving spouse and any covered dependents elect COBRA coverage, they will be required to pay applicable premiums at the same cost-sharing levels as described more fully below. During their COBRA continuation coverage
period, your surviving spouse and eligible dependents will be required to enroll in a Base Medical Plan option during each Open Enrollment and pay applicable premiums. It is important to note that domestic partnerships are not recognized under
Federal law, and therefore, your surviving domestic partner, if applicable, is not eligible for COBRA continuation coverage under the Plan. 

Monthly Contribution and Cost Sharing 

 
  

You are required to contribute twenty-five percent (25%) of the monthly cost for coverage under the Base Medical Plan option in which you and your
spouse/domestic partner (if applicable) enroll. The 25% cost-sharing requirement also applies to your surviving spouse and eligible dependents during their COBRA continuation period assuming that they elect COBRA coverage. The cost of coverage under
the EMRP will be paid solely by Unified. 
 During your lifetime, contributions must be deducted from your pension check. If you have elected to
defer receipt of your pension benefit until a later date or if your pension benefit is not sufficient to cover your contribution, then you are required to mail a check for the monthly amount to Unified’s third-party administrator. You will
receive a coupon book for the monthly amount. Payments must be received by the end of the month for which coverage is being paid for (e.g. premiums for January are due by January 31). Failure to make timely payments will result in the
cancellation of your retiree medical benefits, retroactive to the end of the month for which the last payment was received. 
 Your contribution
amount may change from year to year based on your election and on the price assessed to the Base Medical Plan options on January 1st of each year. Your contribution percentage, however, will remain the same.

 

  
 7 

 Upon your death, if your surviving spouse and any eligible dependents elect COBRA continuation coverage,
they must make arrangements with Unified to pay the applicable premium for their continuation coverage. See the Continuation of Coverage (COBRA) section later in this booklet for more details. 

Unified continues to reserve the right to change the current or new retiree medical plan benefits or cost-sharing levels at any time. 

Tax Consequences of Benefits Received Under the Plan 
 Due to applicable tax law governing employer-provided benefits to highly-compensated individuals, the benefits you and your family receive under the Plan may result in taxable income to you, which is
referred to as “imputed income”. Furthermore, your spouse, if applicable, may have imputed income as a result of the benefits he or she receives from the Plan (including benefits received by any eligible dependents) following your death.
In general, if you and/or your family receive a Plan benefit that is more favorable than the benefits available to non-highly compensated individuals, the imputed income will be the price assessed to the Base Medical Plan option(s) that you elected,
minus the cost that you contribute towards that coverage (i.e., the 25% contribution requirement). Unified will calculate any imputed income and report that amount on the appropriate earnings statement (e.g., Form W-2 or 1099), which will allow you
to prepare your personal income tax returns. 
 Unified does not guarantee any specific tax treatment with respect to the benefits you and your
family may receive under the Plan. You and your spouse acknowledge and agree that participation in the Plan is voluntary, and, by doing so, you understand that payment of any taxes owed on imputed income resulting from Plan benefits are solely your
responsibility. Unified does not provide tax advice and you are encouraged to consult with your own personal tax advisor to determine the tax consequences for participating in the Plan.

 
 

  
 8 

 What You Need to Know About Medicare 

 
  

 

 When you or your covered spouse/domestic partner becomes eligible for Medicare, it affects your coverage under the Plan in several ways. For example, it may affect your options, which plan pays first, how
you access services and file claims, and your premiums. Also, if you are Medicare-eligible and your spouse/domestic partner is not, there may be different processes for each person. 
 Medicare is a federal health insurance program that generally covers people who are: 
  

	 	n	Age 65 and older, 

  

	 	n	Have had end stage renal disease for 30 months, regardless of age, or 

  

	 	n	Are eligible for Medicare due to disability, regardless of age. 

 The Medicare program includes: 
  

	 	n	Medicare Part A, or Hospital Insurance, which helps pay for care during a hospital stay and for some follow up care after you leave the hospital.

  

	 	n	Medicare Part B, or Medical Insurance, which helps pay for physician fees, out-patient services and many other services and supplies not covered under Medicare Part A.

  

	 	n	Medicare Part C, Medicare HMO, which offers plan choices in addition to the original fee-for-service Medicare. These plans must offer the same benefit coverage as
Medicare Parts A and B, and may provide additional benefits. Unified currently offers Medicare HMOs only in selected geographic markets. 

  

	 	n	Medicare Part D, Prescription Insurance, which helps offset prescription drug costs through the use of a deductible and co-insurance. 

Enrolling for Medicare 
 For maximum
benefits, you must enroll for Medicare Part A and Part B as soon as you or your covered spouse/domestic partner become eligible as outlined above. Contact your local Social Security office for information on the time frame for enrollment.

 You must also refrain from enrolling in a Part D Prescription Drug Plan outside of the plan provided under
the Unified Grocers, Inc. Officer Retiree Medical Plan. 
 It is recommended that individuals under age 65 contact Social Security three
(3) months before their 65th birthday, whether retired or actively employed. Keep in mind, however, that Medicare is the secondary payer for Medicare-eligible individuals age 65 and older who are actively employed. 

Individuals who are eligible for Medicare due to disability should enroll for Medicare as soon as possible, regardless of age. 

Failure to enroll in Medicare Part A and B, and opting out of the Medicare approved prescription drug plan provided by Unified will result in the
forfeiture of your benefits under the Plan. Also, if you are found to be enrolled in Medicare Parts A and B and do not notify the Plan, you may forfeit your benefits under the Plan. 

 

 

  
 9 

 Coordination with Medicare 

 
 When you or your covered spouse/domestic partner
become eligible for Medicare (regardless of age), coverage under the Plan continues but becomes secondary to Medicare. This means that Medicare becomes the primary payer and the Plan becomes the secondary payer. 

When Medicare is the primary payer, depending on your medical plan option, your benefits will be determined as follows: 

 

	 	n	If you are enrolled in the Anthem Blue Cross PPO Base Medical Plan, benefits under the Plan are reduced by Medicare payment levels and processed up to the PPO benefit
levels. 

  

	 	n	If you are enrolled in an HMO Base Medical Plan, you may also be able to select coverage through a Medicare HMO if one is available in your area. The Plan currently
offers Medicare HMOs through UnitedHealth Secure Horizons in California, Kaiser Senior Advantage in California and Oregon. 

 When
you, your covered spouse/domestic partner become Medicare-eligible and the other person is not eligible for Medicare yet, coverage for each of you will differ as shown in the charts to the right. 

 

  

					
	 Retiree Medical
 Plan
Selected
	 	Medicare-Eligible Retiree
Benefits	 	Non-Medicare
Eligible Spouse Benefits
	
Anthem

Blue Cross PPO*
	 	
Anthem
 Blue Cross
PPO*
	 	 Anthem
 Blue Cross PPO

	 Medicare
HMO
	 	Medicare HMO	 	Regular
HMO

 *The Anthem Blue Cross PPO Base Medical Plan benefits are paid secondary to Medicare, and is not a supplement to
Medicare. 
  

					
	 Retiree Medical
 Plan
Selected
	 	Non-Medicare- Eligible Retiree
Benefits	 	Medicare-Eligible Spouse
Benefits
	
Anthem

Blue Cross PPO*
	 	
Anthem
 Blue Cross
PPO
	 	 Anthem
 Blue Cross PPO*

	 Medicare
HMO
	 	Regular HMO	 	Medicare
HMO

 *The Anthem Blue Cross PPO Base Medical Plan benefits are paid secondary to Medicare, and is not a supplement to
Medicare. 
  

									
	
Examples of Fee Payment when Medicare is Primary
	
  

	 	  	 	Example 1	  	  	 	Example 2	  
	 Physician charges:
	  	 	$100.00	  	  	 	$100.00	  
	 Medicare pays 80%:
	  	 	$80.00	  	  	 	$0.00	  
	Anthem Blue Cross PPO Base Medical Plan is secondary. Benefits re reduced by Medicare payment level. If expense is not covered
under Medicare but covered under Anthem Blue Cross Base Medical Plan, then Anthem Blue Cross pays for the expense.	     
	Anthem Blue Cross’ responsibility is:	  	 	$0.00	  	  	 	$80.00	  
	 Retiree’s responsibility is:
	  	 	$20.00	  	  	 	$20.00	  

 
 

  
 10 

 Submitting Claims to Anthem Blue Cross When Medicare is Primary 

When Medicare is primary, you must first submit your claims to Medicare. For secondary payment through Anthem Blue Cross, file the claims directly to:

 Anthem Blue Cross of California 

P.O. Box 60007 
 Los Angeles, CA 90060

 All claims must be submitted with copies of the 
 Explanation of Benefits (EOB) from Medicare. 
 Medicare HMO Option 

If you choose a fully-insured HMO Base Medical Plan option, you are required to follow your HMO’s rules for obtaining care. Unified shall have no
responsibility for the benefits provided or not provided by the HMO, or claims relating to HMO coverage. Once your have elected to participate in a HMO Base Medical Plan option, that HMO governs your retiree medical plan coverage in lieu of all Plan
provisions described in this SPD that apply to the self-insured PPO Base Medical Plan option. If you and/or your eligible spouse/domestic partner are Medicare eligible, you must enroll in a Medicare HMO. 

HMOs offer comprehensive medical care through an established network of doctors, hospitals and other health care providers. HMOs stress preventive care
and usually include wellness benefits such as annual physical examinations. You pay only a small co-payment for certain services, such as a visit to the doctor. Most care is paid at 100%. 
 If you choose an HMO, you must use the HMO’s network of doctors, hospitals, and other health care providers in order to receive benefits, except when there is an emergency. If you receive care
outside the HMO, you are responsible for paying for that care. There is no lifetime limit to the amount of covered medical benefits you receive while covered by Unified’s contracted HMO plans.

 A Medicare HMO is designed to work like a regular HMO and has many of the same features as an HMO. It must
also provide coverage for all the same services covered by Medicare Part A and Part B. In addition, a Medicare HMO must get special approval by the Center for Medicare and Medicaid Services (CMS). 

Medicare HMOs may provide benefits above and beyond what’s covered by Medicare. This is one of the key reasons that Unified decided to offer
Medicare HMOs through the Plan. 
 Enrolling In a Medicare HMO 
 To be eligible for the Medicare HMO option, you and 
 your covered spouse/domestic partner must be:

  

	 	n	Medicare-eligible (generally over age 65 or disabled) 

  

	 	n	Enrolled in Medicare Parts A and B 

  

	 	n	A permanent resident of a Medicare HMO service area 

 If you choose a Medicare HMO, it replaces coverage under Medicare Parts A and B. You will continue to pay the Part B premiums. 
 In addition, you are not eligible to enroll in a Medicare HMO if you have end stage renal disease, although if you are enrolled in a Medicare HMO and develop end stage renal disease, you may continue to
be enrolled. 
 Keep in mind that when you enroll or switch to a Medicare HMO, your non-Medicare-eligible spouse/ domestic partner will have
coverage through the regular HMO since you must enroll your spouse/domestic partner in the same coverage option and with the same health care company that you choose for yourself. 
 Failure to enroll in a Medicare HMO through Kaiser Senior Advantage or UnitedHealth Secure Horizons by the end of the month in which you become Medicare eligible, will result in the forfeiture of your
benefits under the Plan, and you will not be eligible for coverage under the Plan at any time in the future. 

 

  
 11 

 Base Medical Plan Options 

 

 Retiree Medical Benefits 

 
 The retiree medical benefits available to you, your spouse/domestic partner and eligible dependents, if applicable, are
divided into two categories based on the retiring employee’s age: 
  

	 	n	Coverage for Non-Medicare-Eligible Retirees (generally under age 65) 

  

	 	n	Coverage for Medicare-Eligible Retirees (generally age 65 and older) 

 Retirees and/or a covered spouse/domestic partner who are under age 65 are offered the same plan benefits as active employees (except for the Anthem Blue Cross PPO and CVS Caremark Drug Plan). Please
refer to the Anthem Blue Cross PPO and CVS Caremark section for more details. 
 Retirees and their covered spouse/domestic partner who are age
65 or older may select from the following Medicare Plan and Medicare HMOs: 
  

			
	 Medicare PPO
	  	Medicare HMOs
	 Anthem Blue

Cross PPO
	  	UnitedHealth Secure Horizons

(residents in California)

	 	  	Kaiser Permanente Senior Advantage
 (residents in California or Oregon)

 To participate in a Medicare HMO option, you must live within the HMO’s service area. If you live outside of the
HMOs’ service areas, you may enroll for coverage under the Anthem Blue Cross PPO plan. 
 Fully Insured Medicare Base Medical HMO
Plans— Kaiser Permanente and UnitedHealth 
  

 
 Kaiser Permanente Senior Advantage

 Kaiser Permanente Senior Advantage provides you with a variety of health care services, which include preventive care services,
hospitalization, skilled nursing, home-health care, and prescription drug coverage. There are low co-payments, no deductibles and no lifetime dollar maximums on your medical coverage. Kaiser’s preventive care services include routine physicals,
cholesterol screenings, and flu shots. Also, health education classes provide help with

 topics ranging from stress management and smoking cessation to nutrition and weight control. And if you
have a chronic condition such as diabetes or high blood pressure, Kaiser Permanente has special programs that will help you reduce symptoms and complications and improve your overall health and well being by increasing your understanding of your
condition. Facilities are conveniently located, and same day appointments and evening and weekend office hours make care easily accessible. 

UnitedHealth Secure Horizons 
 UnitedHealth
Secure Horizons offers a comprehensive health plan which features no deductible, low co-payments and no lifetime dollar maximums on your medical coverage. The plan provides for hospitalization, skilled nursing, home health care, preventive care
services, and prescription drug coverage with no maximum dollar limits. Other benefits provided include vision coverage that includes a routine eye exam and basic dental coverage that includes an examination, cleanings and x-rays. In addition,
UnitedHealth Secure Horizons offers a comprehensive array of special programs and services. 
 This booklet does not contain detailed
information about your HMO or Medicare HMO Base Medical Plan options and is not a Summary Plan Description of the HMOs. It does not fully describe your HMO benefit coverage. For details on your benefit coverage, please refer to the UnitedHealth
Secure Horizons or Kaiser Foundation Health Plan, Inc., Evidence of Coverage (EOC). The EOC is the binding document between the HMOs and their members. An HMO physician must determine that the services and supplies are medically necessary to
prevent, diagnose, or treat your medical condition. The services and supplies must be provided, prescribed, authorized, or directed by an HMO physician. You must receive the services and supplies at the HMO facility or skilled nursing facility
inside the Service Area, except where specifically noted in the EOC. For details on the benefit and claim review and adjudication procedures, please refer to the HMO’s Evidence of Coverage. For a copy of the EOC please contact your HMO
provider. 

 

  
 12 

 Self-Insured Anthem Blue Cross PPO Base Medical Plan 

 
 Preferred Provider Organizations (PPO) typically
pay benefits whether you receive care from within the network or outside of the network. Using in-network providers save you money and also affords you the highest level of benefits. In-network or “preferred” providers have agreed to
discount fees for the services that they provide. They have also agreed not to charge you for the difference of the discounted fee and his or her regular fees. You are free to use out-of-network providers but your share of the costs will be higher.

 Under the Anthem Blue Cross PPO Base Medical Plan, you will pay for the first part of medical expenses each year in the form of an annual
deductible. After you meet your deductible for the year, the plan generally pays 80% of your discounted in-network expenses or 60% for out-of-network services up to the allowable charge limits and you pay the balance, called the co-insurance. To
protect you from catastrophic medical expenses, there is a cap on how much you pay during the year, called the out-of-pocket maximum. There is also a limit on how much the plan will pay in benefits over your lifetime, called the lifetime maximum
benefit. 
 Plan Maximums 
 The
Plan pays up to $2,000,000 in benefits during the lifetime of any covered person over the age of 65 and up to $2,000,000 in benefits annually for any covered person under the age of 65. 
 Deductible 
 Each calendar year, you must satisfy the medical deductible amount before covered
services and supplies are provided under this Plan. The annual deductible is $400 per person and $800 per family, if you elect to cover your eligible spouse/domestic partner. Your in-network and out-of-network expenses are combined each year and
credited toward your annual deductible. Once the family deductible is met, benefits for all enrolled members will be available without further deductibles for that year 
 Maximum Allowable Amount 
 Plan benefits are based on the Maximum Allowed 

Amount. This section describes the term “maximum

 allowed amount” as used in this Summary Plan Description, and what the term means to you when
obtaining covered services under this Plan. The maximum allowed amount is the total reimbursement payable under the Plan for covered services you receive from participating and non-participating providers. It is Anthem Blue Cross’ payment
towards the services billed by your provider combined with any deductible or co-payment owed by you. In some cases, you may be required to pay the entire maximum allowed amount. For instance, if you have not met your deductible under this Plan, then
you could be responsible for paying the entire maximum allowed amount for covered services. In addition, if these services are received from a non-participating provider, you may be billed by the provider for the difference between their charges and
our maximum allowed amount. In many situations, this difference could be significant. 
 Two examples are provided below, which illustrate how
the maximum allowed amount works. These examples are for illustration purposes only. 

Example 1: The Plan has a
participant co-payment of 20% for participating provider services after the deductible has been met. 
 The participant receives services from a
participating surgeon. The charge is $2,000. The maximum allowed amount under the Plan for the surgery is $1,000. The participant’s co-payment responsibility when a participating surgeon is used is 20% of $1,000, or $200. This is what the
participant pays. The Plan pays 80% of $1,000, or $800. The participating surgeon accepts the total of $1,000 as reimbursement for the surgery regardless of the charges. 
 Example 2: The Plan has a participant co-payment of 40% for a non-participating provider services after the deductible has been met. 

The participant receives services from a non-participating surgeon. The charge is $2,000. The maximum allowed amount under the Plan for the surgery is
$1,000. The participant’s co-payment responsibility when a non-participating surgeon is used is 40% of $1,000, or $400. The Plan pays the

 

  
 13 

 remaining 60% of $1,000, or $600. In addition, the non-participating surgeon could bill the participant the
difference between $2,000 and $1,000. So the participant’s total out-of-pocket charge would be $600 plus an additional $1,000, 
 for a
total of $1,600. 
 When you receive covered services, Anthem Blue Cross, to the extent applicable, will apply claim processing rules to the
claim submitted. The rules are used to evaluate the claim information and determine the accuracy and appropriateness of the procedure and diagnosis codes included in the submitted claim. Applying these rules may affect the maximum allowed amount if
Anthem Blue Cross determines that the procedure and/or diagnosis codes used were inconsistent with procedure coding rules and/or reimbursement policies. For example, if your provider submits a claim using several procedure codes when there is a
single procedure code that includes all of the procedures that were performed the maximum allowed amount will be based on the single procedure code. 
 Provider Network Status - The maximum allowed amount may vary depending upon whether the provider is a participating provider, a non-participating
provider or other health care provider. 
 Participating Providers and Centers of Medical Excellence (CME) - For covered services
performed by a participating provider or CME the maximum allowed amount for the Plan will be the rate the participating provider or CME has agreed with Anthem Blue Cross to accept as reimbursement for the covered services. Because participating
providers have agreed to accept the maximum allowed amount as payment in full for those covered services, they should not send you a bill or collect for amounts above the maximum allowed amount. However, you may receive a bill or be asked to pay all
or a portion of the maximum allowed amount to the extent you have not met your deductible or have a co-payment. Please call the customer service telephone number on your ID card for help in finding a participating provider or visit
www.anthem.com/ca. 
 If you go to a hospital which is a participating provider, you should not assume all providers in that hospital are also
participating providers. To receive the greater benefits afforded when covered services are provided by a participating provider, you should request that all your provider services (such as services

 by an anesthesiologist) be performed by participating providers whenever you enter a hospital. 

If you are planning to have outpatient surgery, you should first find out if the facility where the surgery is to be performed is an ambulatory surgical
center. An ambulatory surgical center is licensed as a separate facility even though it may be located on the same grounds as a hospital (although this is not always the case). If the center is licensed separately, you should find out if the
facility is a participating provider before undergoing the surgery. 
 Non-Participating Providers and Other Health Care
Providers - For covered services you receive from a non-participating provider or other health care provider, other than emergency services, the maximum allowed amount will be based on the applicable Anthem Blue Cross
non-participating provider rate or fee schedule for the Plan, an amount negotiated by Anthem Blue Cross or a third party vendor which has been agreed to by the non-participating provider, an amount derived from the total charges billed by the
non-participating provider, or an amount based on information provided by a third party vendor. 
 Unlike participating providers,
non-participating providers and other health care providers may send you a bill and collect for the amount of the non-participating provider’s or other health care provider’s charge that exceed the maximum allowed amount under the Plan.
You may be responsible for paying the difference between the maximum allowed amount and the amount the non-participating provider or other health care provider charges. This amount can be significant. Choosing a participating provider will likely
result in lower out-of-pocket costs to you. 
 Please call the customer service number on your ID card for help in finding a participating
provider or visit the Anthem Blue Cross website at www.anthem.com/ca. Customer service is also available to assist you in determining this Plan’s maximum allowed amount for a particular covered service from a non-participating provider or other
health care provider. 
 Member Cost Share 
 For certain covered services, you may be required to pay all or a part of the maximum allowed amount as your cost share amount (deductibles or co-payments). Your cost share amount and the out-of-pocket
amounts 

 

  
 14 

 are different depending on whether you received covered services from a participating provider or
non-participating provider. Specifically, you may be required to pay higher cost-sharing amounts or may have limits on your benefits when using non-participating providers. Please see the Covered Expenses and Limitations section for your cost share
responsibilities and limitations, or call the customer service telephone number on your ID card to learn how the Plan’s benefits or cost share amount may vary by the type of provider you use. 

The Plan will not provide any reimbursement for non-covered services. You will be responsible for the total amount billed by your provider for
non-covered services, regardless of whether such services are performed by a participating provider or non-participating provider. Non-covered services include services specifically excluded from coverage by the terms of the Plan and services
received after benefits have been exhausted. Benefits may be exhausted by exceeding, for example, medical benefit maximums or day/visit limits. 

Authorized Referrals 
 In some circumstances
Anthem Blue Cross may authorize participating provider cost share amounts (deductibles or co-payments) to apply to a claim for a covered service you receive from a non-participating provider. In such circumstance, you or your physician must contact
Anthem Blue Cross in advance of obtaining the covered service. It is your responsibility to ensure that Anthem Blue Cross has been contacted. 

If Anthem Blue Cross authorizes a participating provider cost share amount to apply to a covered service received from a non-participating provider, you
also may still be liable for the difference between the maximum allowed amount and the non-participating provider’s charge. Please call the customer service telephone number on your ID card for authorized referral information or to request
authorization. 

 Here’s an example of how using an in-network Preferred 

Provider can save you money. 
  

					
	 	  	In-Network	 	Out-of-Network
	 Physician charges:
	  	$85	 	$125
	 Discounted rate:
	  	$51	 	Not applicable
	 New physician charge
	  	$51	 	Not applicable
	 Allowable amount:
	  	Not applicable	 	$100
	 Plan pays:
	  	$40.80 (80% of
discounted rate)	 	$60 (60% of allowable
amount)
	 You pay:
	  	$10.20	 	$65(40% of allowable

amount plus all charges
above the limit)

 This example is for illustrative purposes only for a Non-Medicare eligible retiree and assumes that the annual
deductible has already been met. 
 Out-of-Pocket Maximum 
 The annual out-of-pocket amount is the most you may be required to pay in covered expenses in one year. This limit does not include your annual deductible and does not include charges above the maximum
allowed amount. After you reach your annual out-of-pocket limit, the Plan pays 100% of eligible expenses for the rest of that calendar year up to the allowed expenses of the Plan. 

 

 

  
 15 

 Covered Expenses and Limitations 
 Covered medical expenses are paid after you satisfy the deductible. The following expenses are covered, provided they are medically necessary and meet other terms and conditions of this plan, (*
identifies covered expenses that must be pre-authorized by the Plan): 
 Accidental Injury to Natural Teeth or Fractured Jaw 

– The Plan pays after deductible 80% in-network and 60% of the maximum allowed amount out-of-network if treated during the 12-month period
immediately following injury. 
 Acupuncture – The Plan pays after deductible 80% in-network and 60% of the maximum allowed amount
out-of-network. (maximum of $60.00 per visit, maximum of 20 visits per year). 
 Ambulance Transportation – Due to a medical
emergency ground or air to the nearest medical facility equipped to render treatment of the condition, the Plan pays 80% after deductible. In areas where ground ambulance is not available, (such as an island), air ambulance to the nearest hospital
will be considered. The Plan pays after deductible 80% of the maximum allowed amount. 
 Anesthesia – The Plan pays after deductible
80% in-network and 60% of the maximum allowed amount out-of-network for supplies and administration of anesthesia by an anesthesiologist. 

Bereavement Counseling – See “Hospice Care” 
 Birthing Centers – The Plan pays after deductible 80% in-network and 60% of the maximum allowed amount out-of-network if a Certified Nurse Midwife and/or Medical Doctor perform the service and
if the facility meets the requirements of the State Licensing Body. 
 Blood or Blood Plasma (self-donated) – See “Diagnostic
X-Ray and Laboratory Services” 
 *Chemical/Drug Dependency – Inpatient or outpatient treatment (including detoxification) must
be preauthorized by the Plan. This benefit is limited to services furnished by a state-approved treatment facility (within a hospital or free-standing facility), physician (M.D. or D.O.), or licensed clinical psychologist. 

 

	 	n	Inpatient: The Plan pays after deductible and a $250 per admission charge 80% in-network and 60% of the maximum allowed amount out-of-network.

 The benefit payable is reduced to 50% if no pre-authorization is given for inpatient
services. 
  

	 	n	Outpatient: The Plan pays after deductible 80% in-network and 60% of the maximum allowed amount out-of-network. Outpatient physician visits will require pre-service
review after the first 12 visits. No benefits are payable if pre-service review is not obtained for visits after the 12th visit. 

See “Exclusions” for services relating to chemical dependency that are not covered. 
 Diagnostic X-ray and Laboratory Services – Related to treatment for an illness or accident. The Plan pays after deductible 80% in-network and 60% of the maximum allowed amount out-of-network.

 Self-donated Blood or Blood Plasma – Unless available to the hospital at no cost, the lab fees for the collection of self-donated blood
are covered, but not storage or shipment expenses. This benefit will apply only if the self-donated blood is used. The Plan pays 80% after deductible up to the maximum allowed amount.  
 Diabetes Education – The Plan pays a maximum of $100 per year. 
 *Durable Medical
Equipment (DME) Rental – For therapeutic use, including but not limited to wheelchair, crutches, splints, trusses, braces (but not for teeth), kidney dialysis equipment, hospital bed, iron lung, traction equipment and equipment for
providing oxygen. Purchase of such items requires prior Plan approval. The Plan pays after deductible 80% in-network and 60% of the maximum allowed amount out-of-network. 
 Emergency Room – After $75 co-pay the Plan pays after deductible 80% in-network and 60% of the maximum allowed amount out-of-network. If admitted, the emergency room co-payment will be waived.

 *Home Health – The Plan pays after deductible 80% in-network and 60% of the maximum allowed amount out-of-network to a maximum of
100 visits per calendar year. Pre-certification is required. 
 Hospice Care – Includes inpatient hospice care for terminally ill
patients (generally a patient with six months to live); services of a physician at home including nursing care; bereavement counseling; and

 

  
 16 

 physical and chemical therapies. The Plan pays 100% after deductible to a maximum benefit of $100 per day,
$5,000 lifetime maximum (combined hospice and bereavement benefit). 
 *Hospitalization – For a semi-private room and board,
and medical services and supplies. If the hospital does not have semi-private rooms available, coverage is limited to the most common semi-private rate in the community. Private room charges will be covered if the patient requires isolation to
protect the health of others or the patient. After deductible and a $250 per admission charge, the Plan pays 80% for in-network hospital and is subject to medical review. The Plan pays after deductible 60% of the maximum allowed amount for
non-network hospital and is subject to medical review. The benefit payable is reduced to 50% if no pre-authorization is given. 

*Imaging Centers – Such as Magnetic Resonance Imaging (MRI), cat scans and other procedures using a body scanner, when recommended as
medically necessary by the physician and the Plan. The Plan pays after deductible 80% for in-network and 60% of the maximum allowed amount out-of-network. 
 Infusion Therapy – The Plan pays after deductible 80% for in-network and 60% of the maximum allowed amount for out-of-network (out-of-network maximum of $600/day). 

*Inpatient Rehabilitative Care – To restore and improve lost functions following injury or disease, if the hospital has a specialized
department for rehabilitative care. After deductible the Plan pays 80% for in-network hospital and is subject to medical review. The Plan pays after deductible 60% of the maximum allowed amount for non-network hospital and is subject to medical
review. 
 Mammograms – Covered under preventive care. The Plan, after deductible, pays 80% in-network and 60% out-of-network.

 *Maternity Care – Including pre and post-natal care, screening and diagnostic procedures during pregnancy, obstetrical delivery,
cesarean section, miscarriage, complications resulting from pregnancy and related genetic counseling for prenatal diagnosis of congenital disorders. Maternity benefits are also available to dependent children. The Plan pays after deductible 80%
in-network and 60% of the maximum allowed amount 

 out-of-network. Pre and post natal visits are covered at 80% in-network and 60% of the maximum allowed
amount out-of-network. 
 Under the Newborns’ and Mothers’ Health Protection Act (NMHPA), group health plans and health insurance
issuers generally may not, under Federal law, restrict benefits for any hospital length of stay in connection with childbirth for the mother or newborn child to less than 48 hours following a vaginal delivery, or less than 96 hours following a
cesarean section. However, Federal law generally does not prohibit the mother’s or newborn’s attending physician, after consulting with the mother, from discharging the mother or her newborn earlier than 48 hours (or 96 hours as
applicable). In any case, plans and issuers may not, under Federal law, require that a provider obtain authorization from the Plan or the insurance issuer for prescribing a length of stay not in excess of 48 hours (or 96 hours). 

*Mental, Emotional and Psychiatric Conditions – 
 Inpatient or outpatient treatment (including anorexia nervosa, bulimia and other nervous and mental conditions) are limited to: 

 

	 	n	Inpatient: The Plan pays after deductible and a $250 per admission charge 80% in-network and 60% of the maximum allowed amount out-of-network. The benefit payable is
reduced to 50% if no pre-authorization is given for inpatient services. 

  

	 	n	Outpatient: The Plan pays after deductible 80% in-network and 60% of the maximum allowed amount out-of-network. Outpatient physician visits will require
pre-authorization review after the first 12 visits. No benefits are payable if pre-authorization review is not obtained for visits after the 12th visit. 

 *Non-Emergency, Inpatient or Outpatient Surgical Procedures and Confinements – The Plan pays after deductible 80% for in-network and 60% of the maximum allowed amount out-of-network.
Must be pre-authorized by the Plan prior to surgery, otherwise benefits will be reduced by 50%. 
 Other Special Items –
Including braces (but not for teeth); surgical and orthopedic appliances, colostomy bags and supplies; catheters; syringes and needles for diabetes or allergic conditions; dressings for surgical wounds, cancer, burns or diabetic ulcers; and oxygen.

 

  
 17 

 The Plan pays after deductible 80% for in-network and 60% of the maximum allowed amount out-of-network.

 Outpatient Rehabilitative Care – For physical therapy, functional occupational therapy and speech and hearing therapy to restore
or improve functions lost following an illness or injury (provided by a physician or a licensed or registered therapist) is covered provided: 
  

	 	n	The patient is not confined to a hospital, and 

  

	 	n	Treatment is a part of the formal written treatment program prescribed by a physician and approved by the Plan. 

The Plan pays for outpatient rehabilitation care after deductible 80% in-network and 60% of the maximum allowed amount out-of-network to a maximum of 60
days of treatment each calendar year. Payment will be made for only one treatment per day. 
 *Pain Centers – Treatment from
accredited institutions (and those accredited by the Commission of Accredited Rehabilitation Facilities) is covered at 50% after deductible if the treating physician provides a written treatment plan to the Plan requesting the referral. The request
must be pre-authorized by the Plan or no payment will be made. 
 Pap Smear / Pelvic Exam (Well Woman Exam) 

– Covered under preventive care. The Plan, after deductible, pays 80% in-network and 60% out-of-network. 

Prostate Exams – Covered under preventive care. The Plan, after deductible, pays 80% in-network and 60% out-of-network. 

Prosthetic Devices – The Plan pays after deductible 80% to replace all or part of an absent body limb or the function of a permanently
inoperative or malfunctioning body organ, as a result of an illness or injury, including but not limited to: artificial limbs or eyes, intraocular lens(es) following cataract surgery or to replace a missing portion of the eye, and breast implants.
Only the initial charge for the first prosthetic device will be included. 
 Radiation Therapy – Radium and radioactive isotope
therapy. The Plan pays after deductible 80% in-network and 60% of the maximum allowed amount out-of-network.

 *Reconstructive Surgery and Supplies – Including reconstructive services following an illness
or injury; or for congenital malformations that are functional in nature and not cosmetic. (For benefits covered under the Women’s Health and Cancer Rights Act (WHCRA) see the next section). All services must be pre-authorized by the Plan prior
to surgery; otherwise benefits will be reduced by 50%. The Plan pays after deductible 80% in-network and 60% of the maximum allowed amount out-of-network. 
 Women’s Health and Cancer Rights Act of 1998 (WHCRA) - WHCRA requires that if a plan covers mastectomies it must also cover: reconstruction of the breast on which the surgery was performed;
surgery and reconstruction of the other breast to produce a symmetrical appearance; and prostheses and physical complication of all stages of mastectomies including lymphodemas. These benefits will be covered under the Plan according to the same
coinsurance and deductibles that apply to other plan services. 
 *Skilled Nursing Facility – Services and supplies as indicated in
a certificate of medical necessity signed by the attending physician, unless otherwise specified in the “Exclusions” section. The Plan pays after deductible 80% in-network and 60% of the maximum allowed amount out-of-network. Calendar year
maximum is 100 days. 
 Sterilization – The Plan pays after deductible 80% in-network and 60% of maximum allowed amount
out-of-network for procedures including vasectomy and tubal ligation only. (Surgical reversal of sterilization procedures not covered. See “Exclusions”). 
 *Transplants – For the recipients of a liver, pancreas, kidney, heart, heart/lung, autologous bone marrow and/ or peripheral stem cells, must be pre-authorized by the Plan. Pre-authorization
should be completed prior to any pre-transplantation evaluation to determine eligibility for transplantation by the transplant team. 

Pre-authorization requirements are a part of the administration of the contract and not a treatment recommendation. The actual course of medical
treatment you choose remains strictly a matter between you and your physician. The Plan requires the use of Centers of Medical Excellence (CME).

 

  
 18 

 The Plan pays after deductible 80% in-network. If a covered procedure takes place without
pre-authorization, the Plan will be responsible for no greater than 50% of the cost related to the transplantation. Any benefit provided for donor costs will be charged against the recipients’ benefits. The following services will be covered:

  

	 	n	Surgical removal of the donor organ or bone marrow from the day of surgical removal up to a maximum of ten days while the donor remains hospitalized.

  

	 	n	Hospital and professional services during the recipient’s hospitalization. 

 

	 	n	Clinical evaluation at the transplant facility. 

  

	 	n	Follow-up care, including anti-rejection drug treatment, and 

  

	 	n	Chemotherapy for cancer given in conjunction with transplantation. 

 Transplant Travel Expense 
 For the Recipient and One Companion per Transplant Episode
(limited to 6 trips per episode). 
  

	 	n	For transportation to the CME: $250 per trip for each person for round trip coach airfare. 

 

	 	n	For hotel accommodations: $100 per day, for up to 21 days per trip, limited to one room, double occupancy. 

 

	 	n	For expenses such as meals: $25 per day for each person, for up to 21 days per trip. 

 For Donor per Transplant Episode (limited to one trip per episode). 
  

	 	n	For transportation to the CME: $250 for round trip coach airfare. 

  

	 	n	For hotel accommodations: $100 per day, for up to 7 days. 

  

	 	n	For expenses such as meals: $25 per day, for up to 7 days. 

 Wellness Exam/Annual Physical and Immunizations 
 – If done as a preventive service
covered at 80% in-network and 60% of the maximum allowed amount out-of-network. 

 

 If a procedure or service is not identified in the “Covered Expenses and Limitations” section,
do not assume that it is covered. If you have a question on whether something is covered, contact Anthem Blue Cross at (866) 940-9677. 

CoonditionCare 
 ConditionCare is a free,
voluntary, confidential program that provides you with access to registered nurses who can answer your questions and provide the ongoing education needed to better manage your condition and achieve optimal health. This program is available to you
and your family members who have asthma, diabetes, heart failure, coronary artery disease (CAD) or chronic obstructive pulmonary disease (COPD). 

MyHealth Coach 
 MyHealth Coach is a free,
voluntary program available to you and your covered dependents as part of your health plan. This program provides you and your covered dependents with a dedicated team of registered nurses and health coaches who are available to help you with
anything from answering routine health care questions, helping you create a healthy lifestyle, to managing your chronic condition. Program assistance is available by calling the toll-free number listed on your Anthem Blue Cross ID card. 

Pre-Authorization 
 Many of the covered
expenses require pre-authorization (sometimes called pre-service or pre-service review). All non-emergency inpatient or outpatient surgical procedures and/or confinements must be reported to Anthem Blue Cross before admission occurs. Please allow
five (5) working days to complete pre-authorization procedures. Anthem Blue Cross must preauthorize all non-emergency inpatient or outpatient surgical procedures and/or confinements. At the consultant’s discretion, additional mandatory
surgical opinions may be required. 
 Penalty for failure to comply with the pre-authorization requirements will result in the Plan paying after
deductible only 50% of eligible expenses related to the surgery and/or hospitalization. Non-emergency covered procedures (including surgery) that are called in the day of the procedure will not be considered pre-authorized. As a result, the benefit
payable will be reduced to 50% after deductible and up to the maximum allowed amount. 

 

  
 19 

 Please notify Anthem Blue Cross within 48 hours after an emergency hospital inpatient admission or as soon
as reasonably possible. Failure to notify Anthem Blue Cross will result in the Plan paying after deductible only 50% of eligible expenses related to the hospital inpatient admission. 
 To obtain pre-authorization: 
  

	 	n	You or your physician must call (866) 470-6244 prior to the date of scheduled surgery or procedure. 

 

	 	n	Provide your name, your identification number, physician’s name and phone number, and detailed information about your condition and/or your planned surgery or
procedure. 

 Medical Necessity 
 For a service to be considered Medically Necessary, the procedures, supplies equipment or services must be: 
  

	1.	Appropriate and necessary for the diagnosis or treatment of the medical condition; 

 

	2.	Provided for the diagnosis or direct care and treatment of the medical condition; 

 

	3.	Within standards of good medical practice within the organized medical community; 

 

	4.	Not primarily for your convenience, or for the convenience of your physician or another provider; and; 

 

	5.	The most appropriate procedure, supply, equipment or service which can safely be provided. The most appropriate procedure, supply, equipment or service must satisfy the
following requirements: 

  

	 	a.	There must be valid scientific evidence demonstrating that the expected health benefits from the procedure, supply, equipment or service are clinically significant and
produce a greater likelihood of benefit, without a disproportionately greater risk of harm or complications, for you with the particular medical condition being treated than other possible alternatives; and 

 

	 	b.	Generally accepted forms of treatment that are less invasive have been tried and found to be ineffective or are otherwise unsuitable; and

	 	c.	For hospital stays, acute care as an inpatient is necessary due to the kind of services you are receiving or the severity of your condition, and safe and adequate care
cannot be received by you as an outpatient or in a less intensified medical setting. 

 Utilization Review Program 

 
 Benefits are provided only for medically
necessary and appropriate services. Utilization Review is designed to work together with you and your provider to ensure you receive appropriate medical care and avoid unexpected out–of-pocket expense. 

No benefits are payable unless your coverage is in force at the time services are rendered. Payment of benefits is subject to all the terms and
requirements of the Plan. 
 Important: The Utilization Review Program requirements described in this section do not apply when
coverage under the Plan is secondary to another plan providing benefits for you or your dependents. 
 The utilization review program
evaluates the medical necessity and appropriateness of care and the setting in which care is provided. You and your physician are advised if the claims administrator has determined that services can be safely provided in an outpatient setting, or if
an inpatient stay is recommended. Services that are medically necessary and appropriate are certified by the claims administrator and monitored so that you know when it is no longer medically necessary and appropriate to continue those services.

 It is your responsibility to see that your physician starts the utilization review process before scheduling you for any service subject to
the utilization review program. If you receive any such service, and do not follow the procedures set forth in this section, your benefits will be reduced as shown in the “Pre-Authorization” section. 

Utilization Review Requirements 

Utilization reviews are conducted for the following services: 
  

	 	n	All inpatient hospital stays and residential treatment center admissions. 

 

	 	n	Facility-based care for the treatment of mental or nervous disorders and substance abuse.

 

  
 20 

	 	n	Transplant services. 

  

	 	n	Visits for physical therapy, physical medicine and occupational therapy beyond those described under the “Outpatient Rehabilitative Care” provision of your
Medical Benefits and Covered Benefits and Limitations. 

  

	 	n	Home infusion therapy. 

  

	 	n	Home health care. 

  

	 	n	Admissions to a skilled nursing facility. 

  

	 	n	Select imaging procedures, including but not limited to: Magnetic Resonance Imaging (MRI), Computerized Axial Tomography (CAT scan), Positron Emission Tomography (PET
scan), Magnetic Resonance Spectroscopy (MRS scan), Magnetic Resonance Angiogram (MRA scan) and Nuclear Cardiac Imaging. You may call the toll-free customer service telephone number on your identification card to find out if an imaging procedure
requires pre-service review. 

  

	 	n	Outpatient visits to a physician for the treatment of mental or nervous disorders or substance abuse after the first 12 visits in a year. 

Exceptions: Utilization review is not required for inpatient hospital stays for the following services: 

 

	 	n	Maternity care of 48 hours or less following a normal delivery or 96 hours or less following a cesarean section; and 

 

	 	n	Mastectomy and lymph node dissection. 

 The
stages of utilization review are: 
  

	1.	Pre-authorization review (also called pre-service or pre-service review) determines in advance the medical necessity and appropriateness of certain procedures or
admissions and the appropriate length of stay, if applicable. Pre-authorization review is required for the following services: 

  

	 	n	Scheduled, non-emergency inpatient hospital stays and residential treatment center admissions (except inpatient stays for maternity care or mastectomy and lymph node
dissection). 

  

	 	n	Facility-based care for the treatment of mental or nervous disorders and substance abuse.

	 	n	Transplant services. 

  

	 	n	Visits for physical therapy, physical medicine and occupational therapy beyond those described under the “Outpatient Rehabilitative Care” provision of your
Medical Benefits and Covered Benefits and Limitations. 

  

	 	n	Home infusion therapy. 

  

	 	n	Home health care. 

  

	 	n	Admissions to a skilled nursing facility. 

  

	 	n	Select imaging procedures, including but not limited to: Magnetic Resonance Imaging (MRI), Computerized Axial Tomography (CAT scan), Positron Emission Tomography (PET
scan), Magnetic Resonance Spectroscopy (MRS scan), Magnetic Resonance Angiogram (MRA scan) and Nuclear Cardiac Imaging. 

  

	 	n	Outpatient visits to a physician for the treatment of mental or nervous disorders or substance abuse after the first 12 visits in a year. 

 

	2.	Concurrent review determines whether services are medically necessary and appropriate when the claims administrator is notified while service is ongoing, for
example, an emergency admission to the hospital. 

  

	3.	Retrospective review is performed to review services that have already been provided. This applies in cases when pre-authorization or concurrent review was not
completed, or in order to evaluate and audit medical documentation subsequent to services being provided. Retrospective review may also be performed for services that continued longer than originally certified. 

Utilization Review – Effects on Benefits 
 In order for the full benefits of this Plan to be payable, the following criteria must be met: 
  

	1.	The appropriate utilization reviews must be performed in accordance with this Plan. When pre-authorization review is performed and the admission, procedure or service
is determined to be medically necessary and appropriate, benefits will be provided for the following: 

  

	 	n	Scheduled, non-emergency inpatient hospital stays and residential treatment center admissions.

 

  
 21 

	 	n	Facility-based care for the treatment of mental or nervous disorders and substance abuse. 

 

	 	n	Transplant services as follows: 

  

	 	a.	For kidney, bone, skin or cornea transplants if the physicians on the surgical team and the facility in which the transplant is to take place are approved for the
transplant requested. 

  

	 	b.	For transplantation of liver, heart, heart-lung, lung, kidney-pancreas or bone marrow, including autologous bone marrow transplant, peripheral stem cell replacement and
similar procedures if the providers of the related preoperative and postoperative services are approved and the transplant will be performed at a Centers of Medical Excellence (CME) facility. 

 

	 	n	A specified number of additional visits for physical therapy, physical medicine and occupational therapy if you need more visits than are provided under the
“Outpatient Rehabilitative Care” provision under the Covered Benefits and Limitations section of this booklet. 

  

	 	n	Services of a home infusion therapy provider if the attending physician has submitted both a prescription and a plan of treatment before services are rendered.

  

	 	n	Home health care services if: 

  

	 	a.	The services can be safely provided in your home, as certified by your attending physician; 

 

	 	b.	Your attending physician manages and directs your medical care at home; and 

 

	 	c.	Your attending physician has established a definitive treatment plan which must be consistent with your medical needs and lists the services to be provided by the home
health agency. 

  

	 	n	Services provided in a skilled nursing facility if you require daily skilled nursing or rehabilitation, as certified by your attending physician.

  

	 	n	Select imaging procedures, including, but not limited to: Magnetic Resonance Imaging (MRI), Computerized Axial Tomography (CAT scans),

 Positron Emission Tomography (PET scan), Magnetic Resonance Spectroscopy (MRS scan),
Magnetic Resonance Angiogram (MRA scan) and nuclear cardiac imaging. 
  

	 	n	Outpatient visits to a physician for the treatment of mental or nervous disorders or substance abuse after the first 12 visits in a year. 

If you proceed with any services that have been determined to be not medically necessary and appropriate at any stage of the utilization review process,
benefits will not be provided for those services. 
  

	2.	Services that are not reviewed prior to or during service delivery will be reviewed retrospectively when the bill is submitted for benefit payment. If that review
results in the determination that part or all of the services were not medically necessary and appropriate, benefits will not be paid for those services. Remaining benefits will be subject to previously noted reductions that apply when the required
reviews are not obtained. 

 How to Obtain Utilization Reviews 
 Remember, it is your responsibility to confirm that the review has been performed. 

Pre-Authorization Reviews 
  

	1.	For all scheduled services that are subject to utilization review, you or your physician must initiate the pre-authorization review at least three working days prior to
when you are scheduled to receive services. 

  

	2.	You must tell your physician that this Plan requires pre-authorization review. Physicians who are participating providers will initiate the review on your behalf. A
non-participating provider may initiate the review for you, or you may call the claims administrator directly. The toll-free number for pre-authorization review is printed on your identification card. 

 

	3.	If you do not receive the reviewed service within 60 days of the certification, or if the nature of the service changes, a new pre-authorization review must be
obtained. 

  

	4.	 The claims administrator will determine if services are medically necessary and appropriate. For

 

  
 22 

 
inpatient hospital and residential treatment center stays, the claims administrator will, if appropriate, specify a specific length of stay for services. For facility-based care for the treatment
of mental or nervous disorders and substance abuse the claims administrator will, if appropriate, specify the type and level of services, as well as their duration. You, your physician and the provider of the service will receive a written
confirmation showing this information. 
 Concurrent Reviews 

 

	1.	If the pre-authorization review was not performed, you, your physician or the provider of the service must contact the claims administrator for concurrent review. For
an emergency admission or procedure, the claims administrator must be notified within one working day of the admission or procedure, unless extraordinary circumstances* prevent such notification within that time period. 

 

	2.	When participating providers have been informed of your need for utilization review, they will initiate the review on your behalf. You may ask a non-participating
provider to call the toll free number printed on your identification card or you may call directly. 

  

	3.	When the claims administrator determines that the service is medically necessary and appropriate, they will, depending upon the type of treatment or procedure, specify
the period of time for which the service is medically appropriate. The claims administrator will also determine the medically appropriate setting. 

  

	4.	If the claims administrator determines that the service is not medically necessary and appropriate, your physician will be notified by telephone no later than 24 hours
following their decision. The claims administrator will send written notice to you and your physician within two (2) business days following their decision. However, care will not be discontinued until your physician has been notified and a
plan of care that is appropriate for your needs has been agreed upon. 

 Extraordinary Circumstances. In determining
“extraordinary circumstances”, the claims administrator may take into account whether or not your condition

 was severe enough to prevent you from notifying them, or whether or not a member of your family was
available to notify them for you. You may have to prove that such “extraordinary circumstances” were present at the time of the emergency. 
 Retrospective Reviews 
  

	1.	Retrospective review is performed when the claims administrator is not notified of the service you received, and are therefore unable to perform the appropriate review
prior to your discharge from the hospital or completion of outpatient treatment. It is also performed when pre-authorization or concurrent review has been done, but services continue longer than originally certified. 

It may also be performed for the evaluation and audit of medical documentation after services have been provided, whether or not
pre-authorization or concurrent review was performed. 
  

	2.	Such services which have been retroactively determined to not be medically necessary and appropriate will be retrospectively denied certification.

 The Medical Necessity Reviews Process 
 The claims administrator will work with you and your health care providers to cover medically necessary and appropriate care and services. While the types of services requiring review and the timing of
the reviews may vary, the claims administrator is committed to ensuring that reviews are performed in a timely and professional manner. The following information explains the review process. 

 

	1.	A decision on the medical necessity of a pre-authorization request will be made no later than five (5) business days from receipt of the information reasonably
necessary to make the decision, and based on the nature of your medical condition. 

  

	2.	A decision on the medical necessity of a concurrent request will be made no later than one (1) business day from receipt of the information reasonably necessary to
make the decision, and based on the nature of your medical condition. However, care will not be discontinued until your physician has been notified and a plan of care that is appropriate for your needs has been agreed upon.

 

  
 23 

	3.	A decision on the medical necessity of a retrospective review will be made and communicated in writing no later than 30 days from receipt of the information necessary
to make the decision to you and your physician. 

  

	4.	If the claims administrator does not have the information they need, they will make every attempt to obtain that information from you or your physician. If
unsuccessful, and a delay is anticipated, the claims administrator will notify you and your physician of the delay and what is needed to make a decision. The claims administrator will also inform you of when a decision can be expected following
receipt of the needed information. 

  

	5.	All pre-authorization, concurrent and retrospective reviews for medical necessity are screened by clinically experienced, licensed personnel (called “Review
Coordinators”) using pre-established criteria and the claims administrator’s medical policy. These criteria and policies are developed and approved by practicing providers not employed by the claims administrator, and are evaluated at
least annually and updated as standards of practice or technology changes. Requests satisfying these criteria are certified as medically necessary. Review Coordinators are able to approve most requests. 

 

	6.	A written confirmation including the specific service determined to be medically necessary will be sent to you and your provider no later than two (2) business
days after the decision, and your provider will be initially notified by telephone within 24 hours of the decision for pre-authorization and concurrent reviews. 

 

	7.	If the request fails to satisfy these criteria or medical policy, the request is referred to a Peer Clinical Reviewer. Peer Clinical Reviewers are health professionals
clinically competent to evaluate the specific clinical aspects of the request and render an opinion specific to the medical condition, procedure and/or treatment under review. Peer Clinical Reviewers are licensed in California with the same license
category as the requesting provider. When the Peer Clinical Reviewer is unable to certify the service, the requesting physician is contacted by telephone for a discussion of the case. In many cases, services can be certified after this discussion.
If the Peer Clinical Reviewer is still unable to certify

 the service, your provider will be given the option of having the request reviewed by a
different Peer Clinical Reviewer. 
  

	8.	Only the Peer Clinical Reviewer may determine that the proposed services are not medically necessary and appropriate. Your physician will be notified by telephone
within 24 hours of a decision not to certify and will be informed at that time of how to request reconsideration. Written notice will be sent to you and the requesting provider within two (2) business days of the decision. This written notice
will include: 

  

	 	n	an explanation of the reason for the decision, 

  

	 	n	reference of the criteria used in the decision to modify or not certify the request, 

 

	 	n	the name and phone number of the Peer Clinical Reviewer making the decision to modify or not certify the request, 

 

	 	n	how to request reconsideration if you or your provider disagree with the decision. 

 

	9.	Reviewers may be plan employees or an independent third party chosen at the sole and absolute discretion of the claims administrator. 

 

	10.	You or your physician may request copies of specific criteria and/or medical policy by writing to the address shown on your plan identification card. Medical necessity
review procedures may be disclosed to health care providers through provider manuals and newsletters. 

 A determination of
medical necessity does not guarantee payment or coverage. The determination that services are medically necessary is based on the clinical information provided. Payment is based on the terms of your coverage at the time of service. These terms
include certain exclusions, limitations, and other conditions. Payment of benefits could be limited for a number of reasons, including: 
  

	 	n	The information submitted with the claim differs from that given by phone; 

 

	 	n	The service is excluded from coverage; or 

  

	 	n	You are not eligible for coverage when the service is actually provided.

 

  
 24 

 Revoking or modifying an authorization. An authorization for services or care may be revoked or
modified prior to the services being rendered for reasons including but not limited to the following: 
  

	 	n	Your coverage under this Plan ends; 

  

	 	n	The agreement with the group terminates; 

  

	 	n	You reach a benefit maximum that applies to the services in question; 

  

	 	n	Your benefits under the Plan change so that the services in question are no longer covered or are covered in a different way. 

Personal Case Management 
 The personal case
management program enables the claims administrator to authorize you to obtain medically appropriate care in a more economical, cost-effective and coordinated manner during prolonged periods of intensive medical care. Through a case manager, the
claims administrator has the right to recommend an alternative plan of treatment which may include services not covered under this Plan. It is not your right to receive personal case management, nor does the claims administrator have an obligation
to provide it; the claims administrator provides these services at their sole and absolute discretion. 
 How Personal Case Management Works

 Members may be identified for possible personal case management through the Plan’s utilization review procedures, by the attending
physician, hospital staff, or the claims administrator’s claims reports. The member or the member’s family may also call the claims administrator. 
 Benefits for personal case management will be considered only when all of the following criteria are met: 
  

	1.	You require extensive long-term treatment; 

  

	2.	The claims administrator anticipates that such treatment utilizing services or supplies covered under this Plan will result in considerable cost;

  

	3.	A cost-benefit analysis determines that the benefits payable under this Plan for the alternative plan of treatment can be provided at a lower overall cost than the
benefits you would otherwise receive under this Plan while maintaining the same standards of care; and

	4.	You (or your legal guardian) and your physician agree, in a letter of agreement, with the claims administrator’s recommended substitution of benefits and with the
specific terms and conditions under which alternative benefits are to be provided. 

 Alternative Treatment Plan. If the
claims administrator determines that your needs could be met more efficiently, an alternative treatment plan may be recommended. This may include providing benefits not otherwise covered under this Plan. A case manager will review the medical
records and discuss your treatment with the attending physician, you, and your family. 
 The claims administrator makes treatment
recommendations only; any decision regarding treatment belongs to you and your physician. The Plan will, in no way, compromise your freedom to make such decisions. 
 Effect on Benefits 
  

	1.	Benefits are provided for an alternative treatment plan on a case-by-case basis only. The claims administrator has absolute discretion in deciding whether or not to
authorize services in lieu of benefits for any member, which alternatives may be offered and the terms of the offer. 

  

	2.	An authorization of services in lieu of benefits in a particular case in no way commits the claims administrator to do so in another case or for another member.

  

	3.	The personal case management program does not prevent the claims administrator from strictly applying the expressed benefits, exclusions and limitations of this plan at
any other time or for any other member. 

 Note: The claims administrator reserves the right to use the services of one or
more third parties in the performance of the services outlined in the letter of agreement. No other assignment of any rights or delegation of any duties by either party is valid without the prior written consent of the other party. 

Disagreements with Medical Management Decisions 
  

	1.	If you or your physician disagree with a decision, or question how it was reached, you or your physician may request reconsideration. Requests for reconsideration
(either by telephone or in writing) must be directed to the reviewer making 

 

  
 25 

 the determination. The address and the telephone number of the reviewer are included on
your written notice of determination. Written requests must include medical information that supports the medical necessity of the services. 
  

	2.	If you, your representative, or your physician acting on your behalf finds the reconsidered decision still unsatisfactory, a request for an appeal of a reconsidered
decision may be submitted in writing to Anthem Blue Cross. 

  

	3.	If the appeal decision is still unsatisfactory, your remedy may be binding arbitration. (see Binding Arbitration) 

Quality Assurance 
 Utilization review
programs are monitored, evaluated, and improved on an ongoing basis to ensure consistency of application of screening criteria and medical policy, consistency and reliability of decisions by reviewers, and compliance with policy and procedure
including but not limited to timeframes for decision making, notification and written confirmation. The Board of Directors is responsible for medical necessity review processes through its oversight committees including the Strategic Planning
Committee, Quality Management Committee, and Physician Relations Committee. Oversight includes approval of policies and procedures, review and approval of self-audit tools, procedures, and results. Monthly process audits measure the performance of
reviewers and Peer Clinical Reviewers against approved written policies, procedures, and timeframes. Quarterly reports of audit results and, when needed, corrective action plans are reviewed and approved through the committee structure. 

Exclusions 
 The following services or items
are not covered under the medical benefits of this Plan: 
  

	 	n	Acupressure or services of a massage therapist. 

  

	 	n	Air conditioners, dehumidifiers, purifiers. 

  

	 	n	Any condition arising out of or resulting from the commission of a criminal/illegal act; any condition or treatment resulting from an intentionally self-inflected
injury or attempted suicide; or any condition caused by, or arising out of, an act of war, armed invasion or aggression.

	 	n	Birth control prescriptions, related supplies, and implantable pharmaceuticals used for contraceptive purposes. 

 

	 	n	Charges for procedures, services, drugs and other supplies which are experimental or still under clinical investigation by health professionals and the Food and Drug
Administration. 

  

	 	n	Charges incurred as a result of a work-related illness or injury covered under workers’ compensation. 

 

	 	n	Charges that exceed the maximum allowed amount and charges for services or supplies that are not medically necessary or that are not approved by the attending
physician. 

  

	 	n	Chiropractic spinal manipulation services. 

  

	 	n	Cosmetic surgery or services (unless for reconstructive purposes related to an illness or injury) including but not limited to: surgery for sagging skin of the eyelids
(blepharochalasis); face, neck, abdomen, hips, or extremities (meloplasty, rhytidectomy or lipectomy); breast enlargement or reduction or uplift procedures; reshaping the nose (rhinoplasty), or liposuction. 

 

	 	n	Custodial Care–care that assists the individual in activities of daily living or service that constitute personal care, including but not limited to: personal
hygiene, movement, bathing, eating, meal preparation, protection of the person from his or her own actions or from harming others, administration or supervision of medication which is, under usual circumstances, self-administered and other
activities which are not required to be provided by trained medical personnel. 

  

	 	n	Deluxe equipment such as motorized wheelchairs or beds and supplies or maintenance of durable medical equipment, including batteries & chargers. Services may
be covered only when criteria are met as recommended by Anthem’s Medical Policy. 

  

	 	n	Dental work or treatment, unless the charges are in connection with accidental injury of sound natural teeth or oral surgery for treatment of a fractured jaw due to an
injury while covered by the Plan. 

  

	 	n	Dietary formulas, services or supplies for obesity or weight reduction, including medical or surgical treatment for obesity, even though other systemic

 

  
 26 

 disorders are present, related or unrelated, and any illness or injury resulting from
such medical or surgical treatment. 
  

	 	n	Eye refractions are not covered under the medical portion of the policy. (see Vision Plan for coverage) 

 

	 	n	Experimental/Investigational treatments, procedures, equipment, drugs, devices or supplies (hereafter called “services”) which are, as determined by Anthem
Blue Cross, Experimental or Investigational for the diagnosis for which the Participant is being treated. Services, treatment or supplies not generally accepted in medical practice for the prevention, diagnosis or treatment of an illness or injury,
as determined Anthem Blue Cross. 

  

	 	n	Foot orthotics, routine foot care, arch supports, corrective shoes, cast impressions, and all related services. Services may be covered only when criteria are met as
recommended by Anthem’s Medical Policy. 

  

	 	n	Hearing aid, hearing aid batteries or cost of repair of hearing aid. 

  

	 	n	Heating pads, whirlpool-type baths or equipment, enuresis training equipment, and exercise equipment. 

 

	 	n	Home delivery of a child (services and supplies). 

  

	 	n	Hospitalization for diagnostic purposes when the patient is not ill enough to be hospitalized, or confinement for diet or rest cure. 

 

	 	n	Naturopathic, Homeopathic or Holistic treatments. 

  

	 	n	Nutritional counseling and nutritional supplements, such as Ensure or Total Parenteral Nutrition, which consists of various nutritional items, such as minerals,
vitamins, potassium, etc. 

  

	 	n	Organ, bone marrow, nonhuman or manufactured organs or other transplant expenses that are not mentioned in “Covered Expenses and Limitations”.

  

	 	n	Outpatient Rehabilitation for recreational or educational therapy or for non-medical self-help or training, or for treatment of psychotic or psychoneurotic conditions.

  

	 	n	Over-the-counter drugs or drugs not requiring a prescription; and prescriptions for non-medically necessary drugs.

	 	n	Personal services, such as charges for radio, telephone, television and guest meals. 

 

	 	n	Physicians or other professional services not specifically listed as being covered are excluded. 

 

	 	n	Private nursing care that consists primarily of bathing, feeding, exercising, homemaking, moving the patient or acting as a companion. 

 

	 	n	Private room charges exceeding the covered semi-private room rate (except when isolation is necessary to protect the patient or other patients’ health).

  

	 	n	Radial keratotomies or other surgeries to correct eye refraction. 

  

	 	n	Replacement of prosthetic devices, unless the existing device cannot be repaired or when recommended by a physician due to the patient’s condition.

  

	 	n	Routine physical examinations or other examinations or tests not connected with the treatment of an injury or illness in excess of the Wellness Benefit.

  

	 	n	Sales tax or mailing fees. 

  

	 	n	Services of a provider related to the patient by blood or marriage, or private nursing care or professional services from someone who resides in your home.

  

	 	n	Services or supplies for which government funding is available, except approved dependency treatment facility. 

 

	 	n	Services or supplies resulting from a motor vehicle accident, in which a third-party payer or insurance will pay benefits; (See “Third Party
Liability-Subrogation” section for more information). 

  

	 	n	Services, supplies, treatment and procedures for reproductive and sexual disorders, dysfunctions, and defects, whether or not the consequences of illness, disease or
injury, including but not limited to the following conditions or procedures: impotency; sexual prosthesis/implant; frigidity; infertility; sterility; surgical reversal of sterilization procedures; removal of devices; artificial insemination;
in-vitro fertilization and sex transformation. 

 

  
 27 

	 	n	Services relating to developmental (following birth) malformations including but not limited to: upper and lower jaw malformations (such as orthognathic surgery),
malocclusions, temporomandibular joint dysfunction (TMJ), enamel hypoplasia (lack of development) and fluorosis. This exclusion does not apply to the treatment by a physician for a fractured jaw due to an injury while covered by this Plan; (subject
to medical review). 

  

	 	n	Sleep clinics and treatment for diagnosed sleep disorders. Services may be covered only when criteria are met as recommended by Anthem’s Medical Policy.

  

	 	n	Smoking cessation programs or treatment of addiction to or dependency on tobacco, tobacco products, caffeine or foods of any type. 

 

	 	n	Temporomandibular Joint (TMJ) dysfunction and cranial mandibular disorder, and other conditions of the joint linking the jaw bone and skull, muscles, nerves and tissues
related to that joint. Services may be covered only when criteria are met as recommended by Anthem’s Medical Policy. 

  

	 	n	Vision therapy or eye exercises or any training to correct muscular imbalance of the eye (orthoptics) or pleoptics. Services may be covered only when criteria are met
as recommended by Anthem’s Medical Policy. 

  

	 	n	Voluntary support groups, court-ordered services, services related to deferred prosecution, deferred or suspended sentencing or to driving rights.

 Pre-Existing Condition Exclusions 
 Pre-existing condition means an illness, injury or condition which existed during the six-month period immediately prior to either (a) your effective date or (b) the first day of any waiting
period required by the Plan, whichever is earlier. A condition is considered to have existed when you: (1) sought or received medical advice for that condition; (2) received medical care or treatment for that condition; or
(3) received medical supplies, drugs or medicines for that condition. No payment will be made for services or supplies for the treatment of a pre-existing condition. However, this limitation does not apply to conditions of pregnancy.

 Credit for Prior Coverage (HIPAA) 
 Credit will be given for prior coverage under another group health plan, an individual health insurance policy, COBRA, Medicaid, Medicare or a public health plan, as long as there has not been a break in
coverage of 63 days or more. If more than 63 days has elapsed since your prior coverage ended, no credit will be given. 
 A Certificate of
Creditable Coverage or letter from the prior insurance carrier must be provided to the Plan to receive credit. The pre-existing condition 6-month limitation will be reduced by the number of days of the prior creditable coverage. 

Case Management 
 The Plan may make case
management services available to you when such services are appropriate. If you request it, and based upon the recommendation of the case manager, the Plan may agree to modify coverage provisions when such modification is cost effective and does not
deprive the member of medically necessary services. The Plan may require you to agree in writing to such modified coverage for a specified period of time. 
 How to File a Medical Claim under the Anthem Blue Cross Base Plan 
  

To provide you with prompt and accurate processing of your covered medical expenses, please read this section carefully so you will be acquainted with the
information and procedures necessary in handling your claims. 
 In-Network and Out-of-Network Hospital Claims – If you or a covered
dependent are hospitalized, present your Identification Card to the hospital-admitting clerk. When you are discharged, you may be expected to pay for any expenses not covered by the Plan. If you use an in-network hospital you will not be required to
file a claim form. 
 All Other Medical Claims – You may be billed directly or at the time you receive the care. You can send in a
copy of the bill and a claim form, which should include: 
  

	 	n	Your name and the name of the patient; 

  

	 	n	Group and Identification Numbers; 

  

	 	n	Procedure code, dates and description of services received and the expenses incurred; 

 

	 	n	If an accident, the date and circumstances of the accident.

 

  
 28 

 Payment for covered expenses will be made to the provider unless the claim states that it has been paid by
the patient. 
 Twelve Month Filing Limitation 
 A retiree and dependents are encouraged to submit medical claims to the Plan as soon as possible. The Plan shall not be required to furnish any benefits under this agreement unless request for such
benefits is made within twelve months (12) from the date on which the expenses were incurred. 
 Binding Arbitration with Respect to
the Anthem Blue Cross PPO Base Medical Plan 
 Any dispute involving an adverse benefit decision under the Anthem Blue Cross PPO Base Medical
Plan must be resolved under the plan’s claims procedure rules, and is not subject to mandatory binding arbitration. However, you may pursue voluntary binding arbitration after you have completed the plan’s administrative appeal procedures.
If you have any other dispute which does not involve an adverse benefit decision, this Binding Arbitration provision applies. 
 Anthem Blue
Cross, as the Claims Administrator of the Anthem Blue Cross PPO Base Medical Plan, requires any dispute or claim, of whatever nature, arising out of, in connection with, or in relation to this plan, or breach or rescission thereof, or in relation to
care or delivery of care, including any claim based on contract, tort or statute, to be resolved by arbitration if the amount sought exceeds the jurisdictional limit of the small claims court. Any dispute regarding a claim for damages within the
jurisdictional limits of the small claims court will be resolved in such court. 
 The Federal Arbitration Act shall govern the interpretation
and enforcement of all proceedings under this Binding Arbitration provision. To the extent that the Federal Arbitration Act is inapplicable, or is held not to require arbitration of a particular claim, state law governing agreements to arbitrate
shall apply. 
 As a participant under the Anthem Blue Cross PPO Base Medical Plan, you agree to be bound by this Binding Arbitration provision
and acknowledge that you are giving up your right to a trial by court or jury for any dispute or claim that does not otherwise involve an adverse benefit decision. 
 You also agree to give up the right to participate in class arbitration against the Claims Administrator.

 Even if applicable law permits class actions or class arbitrations, you waive any right to pursue, on a
class basis, any such controversy or claim against the Claims Administrator and the Claims Administrator waives any right to pursue on a class basis any such controversy or claim against you as a participant under this plan. The arbitration findings
will be final and binding except to the extent that state or Federal law provides for the judicial review of arbitration proceedings. 
 The
arbitration is begun by the member making written demand on the plan administrator. The arbitration will be conducted by Judicial Arbitration and Mediation Services (“JAMS”) according to its applicable Rules and Procedures. If, for any
reason, JAMS is unavailable to conduct the arbitration, the arbitration will be conducted by another neutral arbitration entity, by mutual agreement between you and the Claims Administrator, or by order of the court, you and the Claims Administrator
cannot agree. 
 The costs of the arbitration will be allocated per the JAMS Policy on Consumer Arbitrations. If the arbitration is not
conducted by JAMS, the costs will be shared equally by the parties, except in cases of extreme financial hardship, upon application to the neutral arbitration entity to which the parties have agreed, in which cases, the Claims Administrator will
assume all or a portion of the costs of the arbitration. 
 Executive Medical Reimbursement Plan (EMRP) 

 
 When you enroll in a retiree medical Base Medical
Plan option, whether it be one of the fully-insured HMOs or the self-insured PPO option, you will be automatically enrolled in the Executive Medical Reimbursement Plan, or EMRP for short. The EMRP is intended to supplement the coverage provided to
you, your spouse/ domestic partner and any eligible dependents, if applicable, under the retiree medical Base Medical Plan option in which you enroll (including for purposes of the prescription drug benefit program that is available in connection
with your retiree medical Base Medical Plan option). The EMRP generally covers deductibles, co-payments and portions of claims that are not covered by your retiree medical Base Medical Plan. The EMRP is a fully-insured component of the Plan that is
provided by Anthem Blue Cross Life and Health Insurance Company. For details of the benefits and coverage available under the EMRP, you should refer to the Certificate of Insurance issued by Anthem Blue Cross.

 

  
 29 

 Unified Grocers Retiree Medical Plan Comparison–Retirees Over 65 

 

											
	  	  	Kaiser Senior
Advantage California	  	United Health Secure
Horizons
California	  	Kaiser Senior
Advantage Oregon	  	Anthem Blue Cross
PPO
	
Annual Deductible
	  		  	 	  		  	In-Network	  	Out-of-Network
	
Individual
	  	None	  	None	  	None	  	 
	 Family
	  	None	  	None	  	None	  	$400 per member not to exceed $800 for family
	 	  		  	 	  		  	 
	 Lifetime Maximum
	  	Unlimited	  	Unlimited	  	Unlimited	  	$2,000,000
per person
	 Out-of-Pocket
Maximum
	  		  	 	  		  	 
	
Individual
	  	$1,500	  	$6,700	  	$600	  	Plan pays 100% after you incur $10,000 in covered
charges**
	 Family
	  	$3,000	  	 	  	$1,200	  	Plan pays 100% after you incur $20,000 in
covered charges**
	 Office
Visits
	  		  	 	  		  		  	 
	 Plan
pays
	  	$10 co-pay	  	$10 co-pay	  	$10 co-pay	  	80% after deductible	  	60% after deductible
	 	  		  	(Primary Care Physician)	  		  		  	 
	 		 		 	 
	 	  		  	$20 co-pay	  		  		  	 
	 	  	 	  	(Specialist)	  	 	  	 	  	 
	 Preventive
Care/
	  		  	 	  		  		  	 
	 Wellness
Benefit
	  		  	 	  		  		  	 
	 Plan pays
	  	$10 co-pay	  	100%	  	100%	  	80% after deductible	  	80% after deductible
	 Inpatient Hospital
Care
	  		  	 	  		  		  	 
	 Plan
pays
	  	100%	  	$250 co-pay per admission	  	100%	  	80% after deductible and a	  	60% after deductible and a
	 	  	 	  	 	  	 	  	$250 per admission fee	  	$250 per admission fee
	 Emergency
Care
	  		  	 	  		  	 
	 Plan
pays
	  	$20 co-pay at plan facility	  	$50 co-pay	  	$50 co-pay at plan facility	  	$75 co-pay (waived if admitted)
	 	  	(waived if admitted)	  	(waived if admitted)	  	(waived if admitted)	  	Plan pays after deductible 80% In-Network
	 	  	 	  	 	  	 	  	60% Out-of Network
	 Mental
Health
	  		  	 	  		  	 
	
Inpatient
	  	100%	  	$250 co-pay per admission	  	100%	  	80% after deductible and a	  	60% after deductible and a
	
Plan pays annually
	  		  	 	  		  	$250 per admission fee	  	$250 per admission fee
	
Outpatient
	  		  	 	  		  		  	 
	
Plan pays annually
	  	$10 co-pay (individual visit)	  	$20 co-pay	  	$10 co-pay	  		  	 
	 	  	$5 co-pay (group visit)	  	 	  		  	80% after deductible	  	60% after deductible
	 Substance Abuse
	  	 	  	 	  	 	  	 	  	 
	
Inpatient
	  	100%	  	$250 co-pay per admission	  	100%	  	80% after deductible and a	  	60% after deductible and a
	 Plan pays
annually
	  		  	 	  		  	$250 per admission fee	  	$250 per admission fee
	
Outpatient
	  		  	 	  		  	80% after deductible	  	60% after deductible
	 Plan pays
annually
	  	$10 co-pay (individual visit)	  	$20 co-pay	  	$10 co-pay	  		  	 
	 	  	$5 co-pay (group visit)	  	 	  	 	  	 	  	 

  
 30 

											
	  	  	Kaiser Senior
Advantage California	  	United Health Secure
Horizons California	  	Kaiser Senior
Advantage Oregon	  	Anthem Blue Cross PPO
	 	 	 	 	 	 
	 	  	 	  	 	  	 	  	 In-Network
	  	Out-of-Network
	 		 		 	 
	 Dental
Care
	  		  	 	  		  	 	  	 
	 Plan
pays
	  	Not Covered	  	$20 co-pay for Medicare covered services. Refer to the Secure Horizons Dental HMO summary for copays on non-Medicare covered
services.	  	Not Covered	  	Not Covered	  	Not Covered
	 Vision Care
	  	 	  	 	  	 	  	 	  	 
	 Plan
pays
	  	$10 co-pay for a vision exam.	  	$20 co-pay for a vision exam	  	$10 co-pay for a vision exam.	  	Not Covered	  	Not Covered
	 		 		 	 
	 	  	$150 allowance every 24 months for lenses and frames	  	One exam per year	  	$150 allowance applied towards one prescription of lenses, frames and/or contact lenses (24 month)	  	 	  	 
	 		 		 
	 Prescription
Drugs
	  		  	 	  		  	United Health Rx:
	 		 		 
	
Retail–Plan pays
	  		  	 	  		  	Out-of-Pocket expense between $0 and $ 2,840
	 Generic
	  	$10 co-pay - 100-day supply	  	$5 co-pay - 31-day supply	  	$10 co-pay - 30-day supply	  	Retail Pharmacy
	 	  		  	 	  		  	 Tier 1 Drugs

	 	  		  	 	  		  	$10 co-pay for a 31-day and $20 co-pay for a 90-day supply
	 Preferred
Brand
	  	$20 co-pay - 100-day supply	  	$15 co-pay - 31-day supply	  	$20 co-pay - 30-day supply	  	Tier 2 Drugs
	 	  		  	 	  		  	$30 co-pay for a 31-day and $90 co-pay for a 90-day supply
	 	  		  	 	  	Not covered unless approved	  	Tier 3 Drugs
	 Non-Preferred
Brand
	  	Not covered unless approved by Kaiser Permanente as medically necessary	  	$30 co-pay - 31-day supply	  	by Kaiser Permanente as	  	$60 co-pay for a 31-day and $180 co-pay for a 90-day supply
	 	  	medically necessary	  	$30 co-pay 31-day supply for	  		  	Specialty Drugs
	 		 		 
	 	  		  	Specialty Drugs	  		  	33% co-insurance for a 31-day or 90-day supply
	 		 		 
	 Mail Order–Plan
pays
	  		  	 	  		  	 
	 Generic
	  	$10 co-pay - 100-day supply	  	$10 co-pay - 90-day supply	  	$20 co-pay - 90-day supply	  	Out-of-Pocket expense between $2,840 and $4,550:
	 		 		 
	 	  		  	 	  		  	Tier 1 Generic Drugs
	 		 		 
	 	  		  	 	  		  	$10 co-pay for a 31-day and $30 co-pay for a 90-day supply
	 Preferred
Brand
	  	$20 co-pay - 100-day supply	  	$30 co-pay - 90-day supply	  	$40 co-pay - 90-day supply	  	Tier 1 Brand-name Drugs
	 		 		 
	 	  		  	 	  		  	Discounted costs for a 31-day or 90-day supply
	 Non-Preferred
Brand
	  	Not covered unless approved by Kaiser Permanente as medically necessary	  	$60 co-pay - 90-day supply	  	Not covered unless approved by Kaiser Permanente as medically necessary	  	 
	 		 		 
	 	  		  	 	  		  	Tier 2, Tier 3 and Specialty Tier Drugs
	 		 		 
	 	  		  	$60 co-pay 31-day supply for Specialty Drugs	  		  	Discount on brand name drugs and you pay 93% of the costs of generic drugs
	 		 		 
	 	  		  	 	  		  	 
	 		 		 
	 	  		  	 	  		  	Out-of-pocket expense above $ 4,550
	 		 		 
	 	  		  	 	  		  	Generic Drugs (including brand name drugs treated asgeneric) - Greater of $2.50 or 5%
co-insurance
	 		 		 
	 	  		  	 	  		  	All other covered drugs - Greater of $6.30 or 5% co-insurance
	 		 		 
	 	  	 	  	 	  	 	  	Mail order co-pays are two times the cost of the
retailco-pays listed above.

  

	**	Your annual out-of-pocket maximum will depend on the type of expenses you incur and the co-insurance level paid by the Plan for those expenses.

 Please Note: This is only a summary. For a binding and detailed description of benefits, exclusions and limitations please
refer to your Evidence of Coverage and Disclosure Form. 

  
 31 

 Unified Grocers Medical Plan Comparison–Retirees Under Age 65 

 

									
	  	  	 Kaiser
HMO
 California
	  	 Kaiser
HMO
 Oregon
	  	Anthem Blue Cross
PPO
	 Annual
Deductible
	  	 	  	 	  	In-Network	  	Out-of-Network
	
Individual
	  	None	  	None	  		  	 
	 Family
	  	None	  	None	  	$400 per member not to exceed $800 for family
	 	 	 	 
	 Annual Maximum
	  	Unlimited	  	Unlimited	  	$2,000,000 per person
	 	 	 		 
	 Out-of-Pocket
Maximum
	  	 	  	 	  		  	 
	
Individual
	  	$ 1,500	  	$ 600	  	Plan pays 100% after you incur $10,000 in covered charges**
	 Family
	  	$ 3,000	  	$ 1,200	  	Plan pays 100% after you incur $20,000 in covered
charges**
	 	 	 		 
	 Office
Visits
	  	 	  	 	  		  	 
	 Plan pays
	  	$20 co-pay	  	$20 co-pay	  	80% after deductible	  	60% after deductible
	 	 	 		 
	 Preventive
Care/
	  	 	  	 	  		  	 
	 	 	 		 
	 Wellness
Benefit
	  	 	  	 	  		  	 
	 	 	 		 
	 Plan pays
	  	100%	  	100%	  	80% after deductible	  	60% after deductible
	 	 	 		 
	 Inpatient Hospital
Care
	  	 	  	 	  		  	 
	 Plan pays
	  	$250 per admission co-pay	  	$250 per admission co-pay	  	 80% after deductible and a

$250 per admission fee
	  	 60% after deductible and a

$250 per admission fee

	 	 	 		 
	 Emergency
Care
	  	 	  	 	  		  	 
	 Plan
pays
	  	$50 co-pay at plan facility	  	$75 co-pay at plan facility	  	$75 co-pay (waived if admitted)
	 	 	 	 
	 	  	Waived if admitted as an inpatient:	  	Waived if admitted as an inpatient:	  	Plan pays after deductible 80% In-Network
	 	 	 	 
	 	  	$250 hospital admission co-pay applies	  	$250 hospital admission co-pay applies	  	60% Out-of Network
	 	 	 		 
	 Mental
Health
	  	 	  	 	  		  	 
	
Inpatient
	  	 	  	 	  		  	 
	 Plan pays
annually
	  	$250 per admission co-pay	  	$250 per admission co-pay	  	 80% after deductible and a
 $250 per admission fee
	  	 60% after deductible and a

$250 per admission fee

	
Outpatient
	  	 	  	 	  		  	 
	 Plan pays
annually
	  	$20 co-pay (individual)	  	$20 co-pay	  		  	 
	 	 	 		 
	 	  	$10 co-pay (group) per visit	  	 	  	80% after deductible	  	60% after deductible
	 	 	 		 
	 Substance
Abuse
	  	 	  	 	  		  	 
	
Inpatient
	  	$250 per admission co-pay	  	$250 per admission co-pay	  	80% after deductible and a	  	60% after deductible and a
	 Plan pays
annually
	  	 	  	 	  	$250 per admission fee	  	$250 per admission fee
	 	 	 		 
	
Outpatient
	  	 	  	 	  		  	 
	 Plan pays annually
	  	 $20 co-pay (individual)

$5 co-pay (group) per visit
	  	$20 co-pay	  	80% after deductible	  	60% after deductible

  
 32 

							
	  	  	 Kaiser
HMO
 California
	  	 Kaiser
HMO
 Oregon
	  	Anthem Blue Cross
PPO
	 	 	 	 
	 Prescription
Drugs
	  	 	  	 	  	CVS Caremark***
	 	 	 	 
	 Retail-plan
pays
	  	 	  	 	  	 
	 	 	 	 
	 Generic
	  	$15 co-pay - 30-day supply(3)	  	$15 co-pay - 30-day supply	  	$5 co-pay - 30-day supply(4)
	 	 	 	 
	 Preferred
Brand
	  	 	  	 	  	 
	 	 	 	 
	 	  	$35 co-pay - 30-day supply(3)	  	$30 co-pay - 30-day supply	  	You pay 20% of drug cost - 30-day supply (2,4)
	 	 	 	 
	 	  	Not covered unless approved by Kaiser	  	Not covered unless approved by Kaiser	  	You pay 35% of drug cost - 30-day supply (2,4)
	 	 	 	 
	 Non-Preferred
Brand
	  	 	  	 	  	 
	 	 	 	 
	 	  	Permanente as medically necessary(1)	  	Permanente as medically necessary(1)	  	 
	 	 	 	 
	 Mail Order–Plan
pays
	  	 	  	 	  	 
	 	 	 	 
	 Generic
	  	$15 co-pay - 30-day supply(3)	  	$30 co-pay - 90-day supply	  	$10 co-pay- 90-day supply(4)
	 	 	 	 
	 Preferred
Brand
	  	$35 co-pay - 30-day supply(3)	  	$60 co-pay - 90-day supply	  	You pay 20% of drug cost - 90-day supply (2,4)
	 	 	 	 
	 Non-Preferred
Brand
	  	Not covered unless approved by Kaiser	  	Not covered unless approved by Kaiser	  	You pay 35% of drug cost - 90-day supply (2,4)
	 	  	Permanente as medically necessary(1)	  	Permanente as medically necessary(1)	  	 
	 	 	 	 
	 	  	 	  	 	  	(Rx — $ 2,000 annual maximum per person)
	 	 	 	 
	 	  	 	  	 	  	Specialty drugs are available via retail or mail order.
	 	 	 	 
	 	  	 	  	 	  	Retiree pays 20% of drug cost (maximum $100 per drug)

  

	1	For drugs in accordance with the Kaiser Permanente formulary process. 

  

	2	You must obtain generic drugs when available; otherwise, you also pay the difference in cost between the generic and brand-name drugs. 

 

	3	Generic drugs $30 co-pay for a 31-60 day supply; $45 co-pay for a 61-100 day supply; Brand name drugs $70 co-pay for a 31-60 day supply; $105 co-pay for a 61-100 day
supply. 

  

	4	You must fill your long-term prescriptions using the CVS Caremark Mail Order program. 

 

	5	Non-emergency out-of-network services will be paid at 60% up to the maximum allowable charge. 

 

	**	Your annual out-of-pocket maximum will depend on the type of expenses you incur and the co-insurance level paid by the Plan for those expenses.

  

	***	CVS Caremark is the prescription benefit for all Anthem Blue Cross members. For a complete list of participating pharmacies, go online to www.caremark.com.

  
 33 

 Prescription Drug Benefits

 HMO Prescription Drug Program 

 
 The HMO/Medicare HMO plans through Kaiser
Permanente and UnitedHealth both offer a prescription drug program with an extensive network of pharmacies. Under these plans, there is no annual deductible to satisfy and you may access benefits using either of two options: Submit your prescription
to a participating pharmacy and make a co-payment. Please refer to the provider packets or to the Medical Chart Comparison for more information on your co-payment amounts. 
 Submit your prescription using the Mail Order Prescription Drug Program. The mail order program allows you to order up to a 90-day supply of prescription drugs. Please refer to the provider packets for
co-payment amounts. When you’re placing an order for the first time, all you need to do is send your original prescription along with the order form and your medications will be delivered by mail to your home. Thereafter, you simply call to
request a refill. 
 PPO Plan & Your CVS Caremark Card 

 
 Retirees Under 65 

If you enroll in any of the Anthem Blue Cross medical plans, your prescription drug benefit is administered by CVS Caremark, the nation’s largest
independent provider of health improvement services. 
 You can access your prescription information, refills, Rx history, Performance Drug
List, drug costs, pharmacy information, and find answers to medication questions by enrolling the CVS Caremark member services website. To enroll please visit www.caremark.com and have your CVS Caremark ID number ready (this can be found on your
prescription benefit card). 
 Retail Pharmacy Program 
 Participating pharmacies have agreed to be part of CVS Caremark’s retail pharmacy network. You must use a network pharmacy to receive plan benefits. To locate a participating retail pharmacy in your
area, access the Pharmacy Locator on www.caremark.com by clicking on find a local pharmacy once you are signed in or call CVS Caremark at (800) 966-5772. 
 If there is not a participating pharmacy in your area, please contact customer care, or if you prefer, you may

 pay the cost of the medication, keep the receipt and turn in the receipt with a claim form. You can obtain
and print a claim form online at www.caremark.com. 
 The retail pharmacy program is typically for the purchase of short-term use medications
that you need to purchase immediately, such as antibiotics or certain pain medications. You may receive up to a 30-day supply of medication at a time. You must present your CVS Caremark ID card to the pharmacist when purchasing a prescription. The
amount of your co-payment depends on whether you purchase generic, preferred brand, or non-preferred brand drugs. Ask your doctor to consider prescribing a generic drug whenever possible since you can get the same quality as a brand-name drug at a
lower cost. 
 Maximum Annual Benefit 

 
 Retirees Under 65 

Under the CVS Caremark plan, a maximum annual benefit of $2,000 has been established for each participant during each plan year. Once a participant
receives prescription drug benefits totaling $2,000 in any plan year, there will be no additional prescription drug benefits available during the remainder of the plan year. This maximum annual benefit applies to non-Medicare-eligible retirees and
their covered spouse/domestic partner on the covered benefit that the Plan pays. 
 Mandatory Mail Order/Maintenance Choice 

: If you or your dependents are taking any maintenance or long-term medications, the CVS Caremark Mail Order Program is a simple and convenient way
to help you save money. 
 Employees and dependents are required to fill their prescriptions for long-term maintenance drugs using the CVS
Caremark Mail Order program. The mail order program allows you to order up to a 90-day supply of generic drugs paying a $10 co-payment. You pay 20% of the drug cost for preferred brand name drugs, 35% of the drug cost for non-preferred brand name
drugs and 20% of the drug cost for specialty drugs (capped at $100). 
 The mail service program offers you the convenience of home delivery,
saving you time and money. Your medications will be delivered by mail to your home or 

 

  
 34 

 you also have the option of picking up a 90-day supply of drugs at a CVS Retail Pharmacy where available.

 The first time you are prescribed a medication, you may wish to ask your doctor for two prescriptions, one for a long-term supply (up to 90
days) and another for immediate use (up to 30 days). You can fill the short-term prescription at a participating retail pharmacy and send in the long-term prescription to the mail order program. 

You can refill your prescription by contacting the CVS Caremark Customer Care department at (800) 966-5772 or have your prescriptions setup for auto
refill/renewal via the website. If you choose to have your refills automatically filled, you are responsible for stopping automatic refill requests. Any refills that are mailed to your home cannot be returned to CVS Caremark. 

When placing an order for the first time, visit the CVS Caremark website at www.caremark.com and follow the steps for registering a New Prescription or
call CVS Caremark’s Fast Start Program at (800) 875-0867. 
 CVS Caremark FastStart® 
 CVS
Caremark will contact your doctor on your behalf to request up to a 90-day supply of your long-term medicines. Many long-term medicines are taken for chronic conditions like high blood pressure, diabetes and high cholesterol. If you already have a
90-day prescription for pickup at your local CVS Pharmacy but would like to transfer to mail service you can contact Customer Care to make the switch. 
 To enroll in the program, call (800) 875-0867, 8:00 a.m. to 8:00 p.m. ET, Monday through Friday. Customer service representatives will work with your doctor to get you the new prescriptions you need.
When you call, be sure to have the medicine name and your doctor’s name, phone number and fax number available. 
 Your doctor can also
call in a prescription to the Mail Service Pharmacy at (800) 378-5697. 
 What is a Generic, Preferred Brand, Non-Preferred Brand Drug and
a Formulary? 
 A generic drug includes the same active ingredients as its brand-name equivalent, but at a lower cost. A generic drug is
named for its contents, while a brand-name drug is named by the manufacturer for marketing purposes.

 Most health care professionals believe that generic drugs are as safe and effective as brand-name drugs.

 A preferred brand drug is a brand-name drug that has been selected for its clinical appropriateness (i.e. safety and efficacy) and cost
effectiveness. 
 Non-preferred brand drugs are those which generally have generic equivalents and/or have one or more preferred brand name
drugs within the same therapeutic category. These medications are typically covered at the highest copy. 
 Drug manufacturers must comply with
Food and Drug Administration (FDA) standards, whether they are producing brand-name or generic drugs. These standards guarantee that generics are equivalent to their brand-name counterparts in substance and body absorption rates. 

A “Formulary” is a list of preferred pharmaceutical products (preferred brands and generics) covered at the preferred brand level that are
based on evaluations of the efficacy, safety, and cost-effectiveness of the drug. Caremark has created a formulary list that consists of “Covered Drugs” which is reviewed and approved by a separate Pharmacy and Therapeutic Committee.

 What’s Covered 
 The amount
you pay for this prescription drug coverage depends on whether you purchase generic, preferred brand, or non-preferred brand-name drugs. Your co-payments apply to each prescription you and your dependents purchase. 

Generic drugs will be dispensed whenever possible. Brand-name drugs will be dispensed only when there is no equivalent generic drug available for
substitution or you or your physician specifically requests a brand name drug. 
 **Remember- if you or your physician requests a brand name
drug when a generic alternative is available, your total out-of-pocket cost for your prescription will be considerably higher. You will pay the generic co-payment plus the difference in cost between the brand name medicine and the generic medicine.

 

  
 35 

							
	Plan Design Highlights
	 Participating Retail
	  		 	Mail Order/ CVS Retail
	 Pharmacy
	  	 	 	 	  	 
	 Generic
	  	$5	 	Generic	  	$10
				
	 Preferred Brand
	  	20%	 	Preferred Brand	  	20%
	 (with no generic available)
	 	(with no generic available)
	 Nonpreferred Brand
	  	35%	 	Nonpreferred Brand	  	35%
		
	 ** Up to a 30-day supply
	 	** Up to a 90-day supply

  
  

Dispense as Written (DAW 1)Rule 
 When a
generic is available but the pharmacy dispenses the preferred and non-preferred brand per the physician’s request, the plan participant will pay the difference between the preferred and non-preferred brand discount price and the generic
discount price, plus the generic co-payment. 
 **If there is no generic alternative then the DAW 1 rule does not apply. 

Dispense as Written (DAW 2) Rule 
 When a
generic is available but the pharmacy dispenses the preferred and non-preferred brand per the participant’s request, the plan participant will pay the difference between the preferred brand and non-preferred brand discount price and the generic
discount price, plus the brand co-payment. 
  
  

Claim Exceptions 
 Coordination of
Benefits – No 
 Assignment of Benefits – Yes 
 Nursing Home Claims – No 
 International Claims – Yes 

If you have a prescription filled outside the United States, keep the original receipt and turn the receipt in along with a claim form (print one
online or request the form from CVS Caremark) 
 Expiration Date – 365 days from the fill date. 

 
 Managed Drug Limitation Program 

This program is used to ensure an appropriate quantity is dispensed in keeping with the manufacturers and the FDA’s recommendation and accepted
medical practices. The limits on these drug classes only affect the amount the Plan will pay for, not whether you can obtain greater quantities.

 Step Therapy Program—Brand Medications Requiring Use of a Generic Drug First 

You can save money by using safe, effective generic medications when possible. In order for certain brand-name medications to be covered, you will have to
try a generic medication first. 
 **If the non-preferred brand drug is necessary, pre-authorization is required. Your physician will need to
contact CVS Caremark at (877) 203-0003 to submit a request for review for pre-authorization. 
 Specialty Prescription Drugs

 Every year, more and more people with chronic or genetic conditions are being prescribed “specialty” or biotech medicines that
they obtain from a retail or mail order pharmacy. People taking these drugs often have complex health conditions such as multiple sclerosis, rheumatoid arthritis, or hemophilia. Specialty prescription drugs that are self-administered are managed
through the CVS Caremark Specialty Guideline Management Program and are delivered directly to your home via a Caremark Specialty Pharmacy. In order to get started on a specialty drug, as well as for continued treatment with a specialty drug, a
clinical review is required. CVS Caremark will obtain the necessary clinical information from your doctor’s office and conduct the review. 

CVS Caremark provides not only your specialty medications, but also personalized pharmacy care management services including: 

 

	 	n	Access to an on-call pharmacist 24 hours a day, seven days a week 

  

	 	n	Coordination of care with you and your doctor 

  

	 	n	Convenient delivery directly to you or your doctor’s office 

  

	 	n	Medicine and disease specific education and counseling 

  

	 	n	Online support through www.caremark.com/ specialty, including disease-specific information and interactive areas to submit questions to pharmacists and nurses

 For more information visit www.caremark.com/specialty or call CVS Caremark Connect® at (800) 237-2767.

 

  
 36 

 What’s Not Covered 
 The prescription drug plan does not cover the following products because they are either: 1) covered under the medical plan, 2) intended solely for cosmetic appearance, 3) self care products, or 4)
available over-the-counter (OTC): 
  

	 	n	Cosmetic Products 

  

	 	n	Nutritional Supplements 

  

 

	 	n	Rx Devices 

  

	 	n	Vaccines/Toxoids 

 Excluded Drugs 

 

	 	n	Anti-wrinkle agents (i.e. Renova, Avage) 

  

	 	n	Blood products, blood serum 

  

	 	n	Charges for the administration or injection of any drug 

  

	 	n	CNS Stimulants such as Adderall for individuals 20 years of age or older 

  

	 	n	Contraceptives; Non-Oral Form 

  

	 	n	Diaphragms, kits, and cervical caps 

  

	 	n	Growth hormones 

  

	 	n	Hair removers and hair growth stimulants 

  

	 	n	Hematinics 

  

	 	n	Infertility drugs 

  

	 	n	Intrauterine devices (i.e. Mirena) 

  

	 	n	Medication which is to be taken by or administered to an individual, in whole or in part, while he or she is a patient in a licensed hospital, rest home, sanitarium,
extended care facility, convalescent hospital, nursing home or similar institution which operates on its premises, or allows to be operated on its premises, a facility for dispensing pharmaceuticals 

 

	 	n	Over-the-Counter (OTC) drugs (with the exception of diabetic testing agents and blood testing devices) 

 

	 	n	Smoking deterrent medications containing nicotine or any other smoking cessation aids, all dosage forms

	 	n	Therapeutic devices or appliances, including hypodermic needles, syringes, support garments, ostomy supplies, durable medical equipment, and non-medical substances
regardless of intended use 

  

	 	n	Therapeutic devices or appliances, including support garments and other non-medicinal substances, regardless of intended use 

 

	 	n	Tretinoin (i.e. Retin-A) for individuals 26 years of age or older 

  

	 	n	Vitamins and Minerals 

  

	 	n	Weight Loss Medications (i.e. phentermine, Meridia, Xenical) 

  

	 	n	Other exclusions may apply 

 How to File a Claim

 If you have paid for your prescription out of pocket and need to submit a paper claim, you can find the claim form on the web site,
www.caremark.com, and then submit it along with the receipts to: 
 CVS Caremark 
 P.O. Box 52116 
 Phoenix, AZ 85072-2116 
 Eligible Employees and their dependents are encouraged to submit prescription claims to the Plan as soon as possible. The Plan shall not be required to furnish any benefits under this agreement unless a
request for such benefits is made within twelve months (12) from the date on which the expenses were incurred. 
 CVS Caremark Appeal
Procedures 
 The Plan has delegated final claims and appeal authority for the prescription drug benefit component of the Plan to CVS
Caremark. Therefore, CVS Caremark, acting on behalf of the Plan, provides the following claims and appeals review services: 
  

	 	n	Pre-authorization Claim Review Services; 

  

	 	n	Pre-Service Appeals Review Services; and 

  

	 	n	Post-Service Appeals Review Services. 

Definitions 
 The following terms are used
herein to describe the claims and appeals review services provided by CVS Caremark: 

 

  
 37 

 Adverse Benefit Determination – A denial, reduction, or termination of, or a failure to provide
or make payment (in whole or in part) for, a Plan benefit. An adverse benefit determination includes a denial, reduction, or termination of, or failure to provide or make payment (in whole or in part) for, a Plan benefit based on the application of
a utilization review or on a determination of your eligibility to participate in the Plan. An adverse benefit determination also includes a failure to cover a Plan benefit because use of the benefit is determined to be experimental, investigative,
or not medically necessary or appropriate. 
 Claim – A request for a Plan benefit that is made in accordance with the Plan’s
established procedures for filing benefit claims. 
 Medically Necessary (Medical Necessity) – Medications, health care services or
products are considered Medically Necessary if: 
  

	 	n	Use of the medication, service, or product is accepted by the health care profession in the United States as appropriate and effective for the condition being treated;

  

	 	n	Use of the medication, service, or product is based on recognized standards for the health care specialty involved; 

 

	 	n	Use of the medication, service, or product represents the most appropriate level of care for you, based on the seriousness of the condition being treated, the frequency
and duration of services, and the place where services are performed; and 

  

	 	n	Use of medication, service or product is not solely for the convenience of you, your family, or provider. 

Post-Service Claim – A Claim for a Plan benefit that is not a Pre-Service Claim. 
 Pre-Authorization – CVS Caremark’s pre-service review of your initial request for a particular medication. CVS Caremark will apply a set of pre-defined criteria (provided by the Plan) to
determine whether there is need for the requested medication. 
 Pre-Service Claim – A Claim for a medication, service, or product
that is conditioned, in whole or in part, on the approval of the benefit in advance of obtaining the requested medical care or service. Pre-Service Claims include your requests for pre-authorization.

 Urgent Care Claim – A Claim for a medication, service, or product where a delay in processing
the Claim: (i) could seriously jeopardize your life or health, and/or could result in your failure to regain maximum function, or (ii) in the opinion of a physician with knowledge of your condition, would subject you to severe pain that
cannot be adequately managed without the requested medication, service, or product. 
 The CVS Caremark Claims and Appeals Process

 Pre-Authorization Review: 

CVS Caremark will implement the prescription drug cost containment programs requested by the Plan by comparing your requests for certain medicines and/or
other prescription benefits against pre-defined preferred drug lists or formularies before those prescriptions are filled. 
 If CVS Caremark
determines that your request for pre-authorization cannot be approved, that determination will constitute an Adverse Benefit Determination. 

Appeals of Adverse Benefit Determinations: 
 If an Adverse Benefit Determination is rendered on your Claim, you may file an appeal of that determination. Your appeal of the Adverse Benefit Determination must be made in writing and submitted to CVS
Caremark within 180 days after you receive notice of the Adverse Benefit Determination. 
 If the Adverse Benefit Determination is rendered with
respect to an Urgent Care Claim, you and/or your attending physician may submit an appeal by calling CVS Caremark. 
 Your appeal should include
the following information: 
  

	 	n	Name of the person the appeal is being filed for; 

  

	 	n	CVS Caremark Identification Number; 

  

	 	n	Date of birth; 

  

	 	n	Written statement of the issue(s) being appealed; 

  

	 	n	Drug name(s) being requested; and 

  

	 	n	Written comments, documents, records or other information relating to the Claim.

 

  
 38 

 Your appeal and supporting documentation may be mailed or faxed to CVS Caremark: 

CVS Caremark 
 Appeals Department—MC109

 P.O. Box 52084 
 Phoenix, AZ
85072-2084 
 Fax Number (866) 689-3092 
 Physicians may submit urgent appeal requests by calling the physician-only toll-free number: (866) 443-1183. 
 CVS Caremark’s Review: 
 The review of your Claim or appeal of an Adverse Benefit
Determination will be conducted in accordance with the requirements of ERISA and any related laws. You will be accorded all rights granted to you under ERISA and any related laws. 
 Twelve Month Filing Limitation 
 A retiree and dependents are encouraged to submit prescription
drug benefit claims to the Plan as soon as possible. The Plan shall not be required to furnish any benefits under this agreement unless request for such benefits is made within twelve months (12) from the date on which the expenses were
incurred. 
 PPO Plan & Your UnitedHealth Rx Card 
 Retirees Over 65 
 If you enroll in the Anthem Blue Cross PPO Plan and are over age 65, your
prescription drug benefit is provided by UnitedHealth Rx. UnitedHealth Rx is a Medicare approved prescription drug provider managing over 2 million retiree lives nationally. The PPO plan, in conjunction with UnitedHealth Rx allows you to
receive your covered prescription drugs via retail, mail, or online. 
 When you need prescription drugs, either at a retail pharmacy or through
mail-order, go to a pharmacy that accepts the UnitedHealth Rx card or mail your original prescription along with an order form to UnitedHealth Rx. 
 You may also reorder your prescription drugs online at www.prescriptionsolutions.com. There is no deductible to satisfy, however, you are responsible your co-payment. 

Under the UnitedHeatlh Rx Plan, there is no annual maximum for prescription drugs .

	
	 UnitedHealth Rx Retail Pharmacy Co-Pays

 Out-of-pocket expenses between $0-$2,840 
 Tier 1 Drugs  
 $10 co-pay for a 31-day supply 

$20 co-pay for a 90-day supply 
 Tier 2 Drugs
 
 $30 co-pay for a 31-day supply 

$90 co-pay for a 90-day supply 
 Tier 3 Drugs
 
 $60 co-pay for a 31-day supply 

$180 co-pay for a 90-day supply 
 Specialty
Drugs 
 33% co-insurance for a 31-day supply 
 33% co-insurance for a 90-day supply 
  
 Out-of-pocket expenses after $2,840 
 Tier 1 Generic Drugs  

$10 co-pay for a 31-day supply 
 $30 co-pay for a
90-day supply 
 Tier 1 Brand-name Drugs 
 Discounted costs for a 31-day supply 
 Discounted costs for a 90-day supply 

Tier 2, Tier 3 and Specialty Tier Drugs 

Discount on brand name drugs and you pay 93% of the costs of generic drugs 

 
 Out-of-pocket expenses after $4,550; No limit

 Generic Drugs (including brand name drugs treated as generic) 
 Greater of $2.50 or 5% co-insurance 
 All Other Covered Drugs 

Greater of $6.30 or 5% co-insurance 

 

 

  
 39 

 Retiree Dental Benefits 

 

 The retiree dental benefits available to you, your spouse/domestic partner and eligible dependents, if
applicable, are provided under the fully-insured DMO Base Medical Plan or the self-insured PPO Base Medical Plan. 
 Fully-Insured Safeguard DMO
Base Medical Plan 
  
 Similar to the
medical HMOs, a Dental Maintenance Organization (DMO) offers dental care through an established network of dentists. You pay a co-payment for certain dental procedures, and then most services are paid at 100%. In addition, there is no annual maximum
limit to the amount of covered dental benefits you receive. Safeguard, a division of MetLife Dental, is the DMO plan available in California. 

This booklet does not contain detailed information about the Safeguard Dental Plan. If you choose Safeguard for your dental insurance, you can obtain a
Summary Plan Description for the Safeguard Dental Plan from the Benefits Department or from the carrier. The Evidence of Coverage (EOC) booklet contains detailed information about which dental services and supplies are covered – and those that
are not. 
 Self-Insured Delta Dental Preferred Option PPO Base Medical Plan 

 
 Dental expenses are payable under the Delta Dental
Preferred Option PPO Base Medical Plan only for covered expenses incurred while you, your spouse/ domestic partner and eligible dependent, if applicable, are participants in the Plan. All covered expenses must be medically necessary and performed
by a licensed dentist in a dental office. To determine benefits based on only services that are dentally necessary, the Plan reserves the right to review any relevant records of the patient. 

You are able to use Delta Dental’s extensive network of PPO providers. The deductible must be satisfied before dental benefits begin. Plan benefits
will not cover expenses that exceed the Usual, Customary and Reasonable (UCR) charges; you are responsible for paying this difference. Dental coverage is not cumulative and cannot be carried over from one calendar year to the next.

 Preventive/Diagnostic and Restorative services including oral examinations, cleanings, x-rays,
examinations of tissue biopsy, fluoride treatment, space maintainers, and specialist consultations will be paid at 100% with NO deductible when using a PPO provider or 80% of the UCR if a non-PPO provider provides services. 

Basic Restorative Services including oral surgery (extractions), tissue removal (biopsy), fillings, root canals, periodontic (gum) treatment, and
sealants will be paid at 90% after deductible when using a PPO provider and 80% of the UCR after deductible if a non-PPO provider provides services. 
 Major and Prosthodontic Services will be paid at 60% after deductible when using a PPO provider and 50% of the UCR after deductible if a non-PPO provider provides services. 

Plan Year Limits: Preventive/Diagnostic, restorative and prosthodontic benefits from this Plan will not exceed $1,500 per year for each covered
person. There is also an annual deductible of $50 per person or $100 for family per year. 
 Covered Expenses and Limitations 

The Delta Dental PPO pays for four types of dental services: 
  

	 	n	Preventive/Diagnostic Services 

  

	 	n	Restorative Services 

  

	 	n	Prosthodontic Services (dentures & bridges) 

  

	 	n	Orthodontic Services 

 Covered
Preventive/Diagnostic Services and Limitations 
 Oral examinations, cleanings (or “scaling/polishing teeth”) are limited to twice
in a calendar year. This does not include periodontal scaling. 
  

	 	n	Bitewing x-rays provided on request by the dentist (limited to twice in a calendar year). 

 

	 	n	Complete full mouth x-rays (limited to once every three eligibility years). 

 

	 	n	Diagnostic casts/study models except for TMJ or bruxism. 

  

	 	n	Emergency oral examination.

 

  
 40 

	 	n	Fluoride treatments (limited to twice in a calendar year). 

  

	 	n	Individual tooth x-rays and occlusal x-rays. 

  

	 	n	Initial oral examination. 

  

	 	n	Panoramic/panorex x-rays (limited to once every three eligibility years). 

  

	 	n	Routine oral examinations (limited to twice in a calendar year). 

  

	 	n	Sealants, such as topically applied acrylic, plastic or composite material used to seal developmental grooves and pits in teeth for the purpose of preventing dental
decay (available to covered persons on permanent first molars through age 8 and second molars through age 15). Does not include the repair or replacement of a sealant on any tooth within two years of its application. 

 

	 	n	Space maintainers. 

 Covered Restorative
Services and Limitations 
  

	 	n	Endodontic services (such as root canal treatment) 

  

	 	n	Fillings 

  

	 	-	Amalgam fillings 

  

	 	-	Silicate fillings 

  

	 	-	Composite resin filling s 

  

	 	n	Oral surgery (limited to minor surgical procedures) 

  

	 	-	Extractions 

  

	 	-	Root recovery 

  

	 	-	Incise and drainage of an abscess 

  

	 	n	Periodontal treatment 

  

	 	-	Periodontal maintenance procedure, full mouth, limited to twice in a calendar year but not in conjunction with additional charges for scaling and root planing, gingival
curettage, osseous surgery or cleaning. 

  

	 	-	Periodontal scaling and root planing per quadrant, limited to twice once every 24 months but not in conjunction with gingival curettage or periodontal maintenance or
cleaning. 

  

	 	-	The American Dental Association has deleted the code for gingival curettage from the 4th edition of the Current Dental Terminology and is referred to the code for root
planning. 

 All claims submitted for benefits for periodontal treatment are subject to review and require that a dated
current copy of the patient’s periodontal chart be attached. 
 Covered Prosthodontic Services & Limitations 

A pre-treatment estimate is recommended prior to major services. Benefits for crowns and bridges are based on date of placement/seating. 

 

	 	n	Fixed prosthodontics 

  

	 	n	Gold inlay/onlay restorations 

  

	 	n	Crowns 

  

	 	n	Bridges 

  

	 	n	Repairs 

  

	 	n	Replacement of inlays, crowns, bridges if more than five years old 

  

	 	n	Removable prosthodontics 

  

	 	n	Dentures, including partial dentures 

  

	 	n	Adjustments, reliners, repairs of dentures or partials 

  

	 	n	Implants, for implant surgical placement and removal; and implant supported prosthetics, including implant repair and recementation 

Covered Orthodontic Services 
 The
orthodontic benefit applies to both adults and dependent children. After you pay the annual deductible (the deductible is not combined with ortho and there is not separate deductible for ortho), orthodontic benefits are covered at 60% in-network and
50% out-of-network with a lifetime maximum benefit of $1,200. The following orthodontic services are covered under this Plan: 
  

	 	n	Services for a diagnosed malocclusion, if (1) provided to a covered dependent, and (2) the malocclusion is abnormal and correctable. 

 

	 	n	Initial and subsequent installations of orthodontic appliances (but excluding repairs). 

 

	 	n	Treatment related to the reduction or elimination of an existing malocclusion sequel through the correction of malposed teeth. 

The Plan reserves the right to review your dependent’s dental records (including x-rays, photographs and

 

  
 41 

 models). The Plan will stop making any payments for orthodontics if you are no longer eligible for coverage
under this Plan or if the patient stops receiving treatment. 
 Covered TMJ Treatment 

After you pay the annual dental deductible, TMJ treatment is covered at 90% after deductible if you see a PPO dentist or 80% of the UCR after deductible
if you see a non-network dentist. If you see a non-network dentist, your reimbursement will be based on the UCR. The maximum lifetime benefit for each covered person is $750. 
 The following limitations apply to TMJ benefits: 
  

	 	n	TMJ benefits cannot be authorized until the treating dentist submits documentation of the treatment plan and the necessity of the treatment, which needs to be approved
by the Plan. 

  

	 	n	No payment will be made for the repair or replacement of any appliance furnished in whole or in part under the Plan. 

 

	 	n	Benefits will be limited to those intra-oral services that would normally be provided by a licensed dentist to relieve oral symptoms associated with TMJ.

  

	 	n	Services provided under medical care, including (but not limited to) psychotherapy, special joint exams and x-rays, joint surgery and medications are not covered.

 Exclusions 
 The
following services or items are not covered under the dental benefits: 
  

	 	n	Accidental injury to natural teeth; 

  

	 	n	Appliances or restorations necessary to increase vertical dimensions; 

  

	 	n	Biopsy of oral tissue, removal of oral tumors, cysts (in lieu of medical coverage, consideration will be given to these services and must be authorized by the Plan);

  

	 	n	Broken appointments; 

  

	 	n	Cosmetic surgery or dentistry for purely cosmetic reasons, including but not limited to: 

 

	 	-	cleft palate 

  

	 	-	maxillary and mandibular malformations 

  

	 	-	enamel hypoplasia (lack of development)

	 	-	flourosis (a type of discoloration of the teeth) 

  

	 	-	anodontia (congenitally missing teeth); 

  

	 	n	Equilibration and periodontal splinting: 

  

	 	-	for restoring tooth structure lost from wear 

  

	 	-	for rebuilding or maintaining chewing surfaces due to teeth out of alignment or occlusion 

 

	 	-	for stabilizing the teeth; 

  

	 	n	Claims submitted more than twelve (12) months after the date of service; 

 

	 	n	Excess cost of materials or supplies selected when less expensive materials or supplies would provide appropriate results; 

 

	 	n	Excess cost of specialized or personalized prosthetics (covered expenses will be limited to the cost of standard devices); 

 

	 	n	Experimental procedures; 

  

	 	n	Extra-oral grafts (grafting of tissues from outside the mouth to oral tissue); 

 

	 	n	Gold restorations (such as gold foil) except for prosthodontic services (see “Covered Expenses and Limitations” above); 

 

	 	n	Home fluorides or home dental aids; 

  

	 	n	Hospital costs or any additional fees charged by the dentist because the patient is hospitalized; 

 

	 	n	General anesthesia or nitrous oxide sedation, as a separate charge, except for oral surgery; 

 

	 	n	Prescribed drugs, pre-medication or analgesia (nitrous oxide); 

  

	 	n	Prosthodontic services or any single procedure started prior to the date the person became eligible for such services under Delta; 

 

	 	n	Prophylaxis, if eligible patient has already received two Prophylaxes covered under Delta in the calendar year; 

 

	 	n	Repairs or replacements of an orthodontic appliance; 

  

	 	n	Replacement of necessary crowns, jackets, gold or cast restorations or any other covered prosthetic device, if less than five years old; 

 

	 	n	Replacement of existing restorations for any purposes other than restoring active carious lesions;

 

  
 42 

	 	n	Separate charges for acid etch; 

  

	 	n	Services or appliances for restoring tooth structure lost from attrition (wear), for rebuilding or maintaining chewing surfaces due to teeth out of alignment, occlusion
or for stabilizing the teeth (including TMJ and bruxism); 

  

	 	n	Services of a dentist who is a relative of the patient by blood or marriage; 

 

	 	n	Services rendered by a dentist beyond the scope of his or her license; 

  

	 	n	Services for injuries or conditions which are covered under Workers’ Compensation or Employers’ Liability Laws; 

 

	 	n	Services which are provided to the covered person without cost by any: 

  

	 	-	Federal or State Government Agency; or 

  

	 	-	Agency, municipality, county or other political subdivision; 

  

	 	n	Services with respect to hereditary or developmental malformations; 

  

	 	n	Temporary crowns, bridges, partials or dentures as a separate charge. 

 General Provisions 
 The Plan will not be liable for any claim or reimbursement for damages
arising out of or relating to any injuries suffered by you or a covered dependent while under the care of a dental provider. You may choose any licensed dentist except those dentists you are related to by blood or marriage. 

If you Have Other Dental Coverage 

If you are covered by another dental plan, you are not reimbursed for more than 100% of your out-of-pocket expenses. This provision is called
coordination of benefits. Under this provision, the Plan that pays first is called primary. The Plan that pays second is called secondary. 
 The following determines which plan is primary: 
  

	 	n	The plan that covers the person as anything other than a dependent is primary. 

 

	 	n	The program that covers the person as a dependent is secondary. 

  

	 	n	If a claim is for a dependent child, the plan of the parent whose birthday comes first in the year (not

 the year of birth) is primary. The other parent’s plan is secondary. 

 

	 	n	If the parents are separated or divorced but not remarried, the plan of the parent with custody of the child is primary, unless there is a court decree that establishes
financial responsibility for dental services with the other parent. 

  

	 	n	If the parent with custody has remarried, the plan of the parent with custody will pay first, and then the plan of the step-parent will pay second. The plan of the
parent without custody will pay last. 

  

	 	n	If you or your eligible dependents are covered by Unified’s PPO Dental Plan and by another group plan under that group’s COBRA continuation of benefits
provisions, Unified’s Plan is primary. 

  

	 	n	If the primary program cannot be determined by the rules described above, then the program that has covered the person the longest will be primary.

  

	 	n	If both parents are employed by Unified, the Plan will not have a coordination of benefits. 

 How to File a Dental Claim 
 Many dentists bill the Plan directly. However, if your dentist
does not bill the Plan directly, you may send the claim yourself. Please make sure your dentist’s itemize bill includes: 
  

	 	n	Name of the patient and Insured’s name 

  

	 	n	Group and identification number (enrollee social security number) 

  

	 	n	Dates and description of services received and the expenses you incurred 

  

	 	n	Dentist’s name, address and tax ID number 

You can obtain a claim form by contacting Delta Dental. Send dental claims to : 
 Delta Dental of California 
 Claims Department 

P.O. Box 997330 
 Sacramento, California
95899-7330 
 (888) 335-8227 

Twelve Month Claims Filing Limitations 

You are encouraged to submit dental claims to the Plan as soon as possible. The Plan shall not be required to furnish any benefits under this Plan unless
request for such benefits is made within twelve months (12) from the date on which the expenses were incurred.

 

  
 43 

 Retiree Vision Benefits 
 The retiree vision benefits available to you, your spouse/domestic partner and
eligible dependents, if applicable, are provided under the self-insured VSP Base Medical Plan. 
 Self-Insured Vision Service Plan (VSP) Base
Medical Plan 
  

 

 Unified offers you, your spouse/domestic partner and eligible dependents vision benefits through Vision
Service Plan (VSP). This Plan allows you to see a VSP eye care provider or a non-VSP eye care provider, depending on your preference. However, keep in mind that your benefits may be reduced if you go out-of-network. 

If you use a VSP Provider: 
 When you want
to see a VSP eye care provider, call VSP at (800) 877-7195 for a listing of VSP eye care providers in your area. 
 To access services call
the eye care provider to make an appointment. Tell your eye care provider that you are a VSP member and a retiree of Unified. Your eye care provider will contact VSP to confirm what benefits can be provided before you go in for your appointment.

 If You Use a Non-VSP Provider, make an appointment with your eye care provider. After your eye exam, pay the provider directly for his or her
services and materials. Send a copy of the itemized bill(s) to VSP. The following must be included in your documentation: 
  

	1.	Your name, mailing address and phone number 

  

	2.	Your identification number (the last 4 digits of your social security number) 

 

	3.	Patient’s name, relationship to member and date of birth

 You can obtain a claim form by contacting VSP. Send all required information to: 

Vision Service Plan 
 Attn: Out-of-Network
Provider Claims 
 P.O. Box 997100 

Sacramento, CA 95899-7100 
 (800) 877-7195

 Six Month Claims Filing Limitations 
 You are encouraged to submit vision care claims to the Plan as soon as possible. The Plan shall not be required to furnish any benefits under this agreement unless request for such benefits is made within
six months (6) from the date on which the services were incurred. 

 

  
 44 

 What the Plan Covers 

 
 If you use a VSP Provider: 

If you receive services from a VSP eye care provider, the Plan will pay 100% of covered expenses after you pay your co-payment for prescription glasses or
lenses. You do not pay a co-payment for exams. As outlined on the chart, not all services or products are covered at 100%. Be sure to check with your doctor about what you are receiving and its coverage level. 

 

			
	Service or Supply	  	Maximum Benefit.
	 Eye Examination
	  	 Covered in
full, no co-payment applies (once every 12
 months from last date of service).

	 Lenses

 
 •    Single
Vision
  

•    Lined Bifocal

 
 •    Lined
Trifocal
	  	 Covered in full
(once every 12 months from last date of
 service).

	 Frames*
	  	$120 Allowance after a $25.00 co-payment (frames benefit
once every 24 months from last date of service).
	 Elective Contact Lenses*
	  	$105 Allowance for contact lenses and fitting fee (once
every 12 months from last date of service and in lieu of other benefits for that eligibility period).
	 Laser Vision
Correction
  
	  	 Discount off
regular price from contracted facilities.
  

	 Medically Necessary
Contact Lenses
  
 Necessary contact lenses are covered in full when VSP
benefit criteria is met and verified by a VSP provider for eye conditions that would prohibit the use of glasses. The conditions covered include Aphakia, Anisometropia, High Ametropia, Nystagmus, Keratoconus and other eye conditions that make
contact lenses necessary.
	  	Covered in full after a $25.00 co-payment (once every 12
months from last date of service and in lieu of other benefits for that eligibility period).

 If you use a Non-VSP Provider: 
 If you choose a non-VSP eye care provider, services and supplies will be reimbursed up to the following maximums. These benefits are subject to the same time limits and co-payments as described for VSP
providers. You pay the non-VSP provider the full-fee. You will then be reimbursed according to the amount VSP would normally pay the VSP provider. There is no guarantee; however, that this amount will be within the 25% co-payment. 

 

			
	Service or Supply	  	Maximum Benefit.
	 Eye Examination
	  	$45 (once every 12 months from last date of
service).
	 Lenses

 
 •    Single
Vision
  

•    Lined Bifocal

 
 •    Lined
Trifocal
	  	 (Once every 12
months from last date of service).
  
 $ 45

 
 $ 65
  

$ 85

	 Frames*
	  	$47 (once every 24 months from last date of
service).
	 Elective Contact Lenses*
	  	$105 Allowance for contact lenses and fitting fee (once
every 12 months from last date of service and in lieu of other benefits for that eligibility period).
	 Medically Necessary
Contact Lenses
  
 Necessary contact lenses are covered in full when VSP
benefit criteria is met and verified by a VSP provider for eye conditions that would prohibit the use of glasses. The conditions covered include Aphakia, Anisometropia, High Ametropia, Nystagmus, Keratoconus and other eye conditions that make
contact lenses necessary.
	  	$210 Allowance towards contact lens evaluation fee, fitting
costs and materials).

 * If you choose contact lenses instead of frames, you will be eligible for frames 24 months from the date the contact
lenses were obtained. 

  
 45 

 Low Vision Benefit 
 Low Vision Benefits help covered individuals with severe visual problems. Severe visual problems are those that are not correctable with regular lenses. To receive Low Vision Benefits, you must receive
prior approval from VSP. The maximum benefit you can receive from the Plan is $1,000 every two years (excludes co-payment). 
  

			
	What is Covered?	  	VSP and Non-VSP* Provider.
	 Supplemental
Testing
	  	Covered up to $1,000 every two years.
	 Complete low vision
analysis and diagnosis that includes a comprehensive examination of visual functions, including the prescription of corrective eyewear or vision aids where indicated.

 
	  	 
	 Supplemental Care Aids
	  	Covered at 75%, you pay a 25% co-payment.
	Subsequent low vision therapy when
necessary or appropriate.	  	 

 What the Plan Does Not Cover 
 If you choose a non-VSP eye care provider, services and supplies will be reimbursed up to the following maximums. These benefits are subject to the same time limits and co-payments as described for VSP
providers. You pay the non-VSP provider the full-fee. You will then be reimbursed according to the amount VSP would normally pay the VSP provider. There is no guarantee; however, that this amount will be within the 25% co-payment. 

This Plan is designed to cover your visual needs rather than cosmetic materials. If you choose any of the following extra items, the basic cost of the
allowed lenses will be covered under the Plan, and you will be responsible for the remainder of the cost. The Plan does not cover: 

 

	 	•	 	 Blended Lenses; 

  

	 	•	 	 Anti-reflective coating; 

  

	 	•	 	 Color coating; 

  

	 	•	 	 Mirror coating; 

  

	 	•	 	 Scratch coating; 

  

	 	•	 	 Laminated lenses; 

  

	 	•	 	 Contact lenses (except as listed above); 

  

	 	•	 	 Oversize Lenses; 

  

	 	•	 	 Progressive multifocal lenses; 

  

	 	•	 	 Photochromic or tinted lenses other than Pink 1 or 2; 

 

	 	•	 	 A frame that exceeds the Plan allowance; 

  

	 	•	 	 Certain limitations on low vision care; 

  

	 	•	 	 Cosmetic lenses;

	 	•	 	 Optional cosmetic processes; 

  

	 	•	 	 UV protected lenses; 

  

	 	•	 	 Orthoptics or vision training and any associated supplemental testing; 

 

	 	•	 	 Plano lenses (non prescription); 

  

	 	•	 	 Two pair of glasses in lieu of bifocals; 

  

	 	•	 	 Lenses and frames furnished under the Plan which are lost or broken, except at the normal intervals when services are otherwise available;

  

	 	•	 	 Medical or surgical treatment of the eyes; 

  

	 	•	 	 Any eye examination, or any corrective eyewear, required by an employer as a condition of employment; and 

 

	 	•	 	 Corrective vision services, treatments, and materials of an experimental nature. 

 

 

  
 46 

 General Information Regarding the Unified Grocers, Inc. 

Officer Retiree Medical Plan 

 

 Any payment required under this Plan may, at the sole discretion of the Plan, be made to the Hospital, Skilled Nursing
Facility, Special Facility, Physician or other person or organization furnishing the service for which payment is provided or to the insured participant. 
 The Plan may require you to submit information concerning benefits you are entitled to receive under Medicare (U.S. Public Law 89-97) when such information is necessary to process claims. The Plan may
also require that you authorize any hospital or physician to furnish any information requested relating to any condition for which benefits are claimed under this Plan. 
 Plan Amendment/Termination 
 Unified Grocers, Inc., reserves the right to change, suspend or
terminate part or all of it at any time by appropriate action of its Board of Directors or other persons designated by the Board. Such right to change, amend or terminate the Plan includes, but is not limited to, changes in the eligibility
requirements, premiums or other retiree payments charged, benefits provided and termination of all or a portion of the coverage provided under the Plan. If any of the Plan changes or stops, any changes in your coverage, participation or benefits
will be in accordance with applicable law. If the Plan is changed, amended or terminated, you will be subject to all of the changes effective as a result of such change; amendment or termination and your rights will be reduced, terminated, altered
or increased accordingly, as if the effective date of the change, amendment or termination. You do not have ongoing rights to any Plan benefit, other than payment of any covered expenses you incurred prior to the Plan change, amendment or
termination. 
 Plan Administration 

The Plan Sponsor has appointed the Benefits Committee as the Plan Administrator to supervise the administration of the Plan. It shall be a principal duty
of the Plan Administrator to ensure that the Plan is carried out, in accordance with its terms, for the exclusive benefit of persons entitled to participate in the Plan without discriminating among them. Whenever, in the administration of the Plan,
any discretionary 

 action by the Plan Administrator is required, the Plan Administrator shall exercise its authority in a
nondiscriminatory manner so that all persons similarly situated shall receive substantially the same treatment. Subject to and in accordance with any applicable requirements of law, the Plan Administrator shall have the full discretionary power to
administer the Plan in all of its detail. For this purpose, the Plan Administrator’s powers and duties include, but shall not be limited to, the following authority in addition to all other powers provided by this Plan: 

 

	 	n	interpret the terms and provisions of the Plan, its good faith interpretation thereof to be final and conclusive on all persons claiming benefits under the Plan;

  

	 	n	make and enforce such rules and regulations it deems necessary or proper for the efficient administration of the Plan including the establishment of any claims
procedures that may be required by the provisions of any applicable law; 

  

	 	n	perform all acts necessary to meet the reporting and disclosure obligations imposed by ERISA Sections 101 through 111, if any, and Code Section 6039D, if any;

  

	 	n	delegate, in writing, specific responsibilities for the operation and administration of the Plan; 

 

	 	n	appoint such agents, counsel, accountants, consultants and other persons as may be required to assist in the administration of the Plan; 

 

	 	n	maintain records and accounts pertaining to the Plan; 

  

	 	n	receive, review and keep on file the annual reports of the Plan, if any; 

  

	 	n	determine eligibility under the Plan; such good faith determination to be binding and conclusive on all persons; and; 

 

	 	n	correct any defect, supply any omission, or reconcile any inconsistencies in the manner and to the extent the Plan Sponsor considers proper to carry the Plan into
effect. 

 

  
 47 

 
 Indemnification 
 As permitted by law, and as limited by any written agreement between the Plan Sponsor and the Plan Administrator, the Plan Sponsor agrees to indemnify and to defend any employee, individual, officer, or
director serving as the Plan Administrator or as a member of a committee designated as Plan Administrator (including any employee or former employee, individual, officer or director who formerly served as Plan Administrator or as a member of such
committee) against all liabilities, claims, loss, damages, costs and expenses (including attorneys’ fees and amounts paid in settlement of any claims approved by the Plan Sponsor) occasioned by any act or omission to act in connection with the
Plan, if such act or omission is in good faith. 
 Plan Expenses 
 All expenses incurred prior to termination of the Plan that shall arise in connection with the administration of the Plan, including but not limited to administrative expenses, and compensation and other
expenses and charges of any actuary, accountant, counsel, specialist or other person who shall be employed by the Plan Administrator in connection with the administration, shall be paid by the Plan Sponsor. 

Statement of ERISA Rights 
 As a participant
in the Plan, you are entitled to certain rights and protection under the Employment Retirement Income Act of 1974 (ERISA). ERISA provides that all participants in the above plans shall be entitled to: 

 

	 	n	Receive Information About the Plan and Benefits and examine, without charge, at the Plan Administrator’s office and at other specified locations, such as
worksites, all documents governing the Plan, including insurance contracts. 

  

	 	n	Obtain, upon written request to the Plan Administrator, copies of documents governing the operation of the plan, including insurance contracts and updated summary plan
description. The administrator may make a reasonable charge for the copies. 

 Continue Group Health Care Coverage 

You may be eligible to continue health care coverage for yourself, your spouse and any eligible dependents if there is a loss of coverage under the plan
as a result of a permitted life event change. You or your spouse

 may have to pay for such coverage. Review the COBRA section in each plan for the rules governing your COBRA
continuation coverage rights. You can also consult the documents governing the plans for more information. Reduction or elimination of exclusionary periods of coverage for pre-existing conditions under your group health plan will not apply if you
have creditable coverage from another plan. You should be provided a certificate of creditable coverage, free of charge, from your group heath plan or health insurance issuer 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
pre-existing 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 your 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, or any other person, may fire you or otherwise discriminate against you in any way to prevent you from obtaining a pension or welfare benefit or exercising your rights under ERISA. 
 Enforce Your Right 
 If your claim for a welfare benefit is denied or ignored, 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 periods. Under ERISA, there are steps you can take to enforce the above
rights. 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 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 administrator. If you have a claim for benefits that is denied or ignored, in whole
or in part, you may file suit in a state or Federal court. In addition, 

 

  
 48 

 
 if you disagree with the Plan’s decision or lack thereof concerning the qualified status of a domestic
relations order or a medical child support order, you may file suit in Federal court. If it should happen that Plan fiduciaries misuse the Plan’s money, or if you are discriminated against for asserting your rights, you may seek assistance form
the U.S. Department of Labor, or you may file suit in a Federal court. 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 you claim is frivolous. 
 Assistance with Your Questions

 If you have any questions about your plan, you should contact the Plan Administrator in Human Resources. 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 the telephone directory or the Division of Technical Assistance and Inquires, Employee Benefits Security Administration, U.S. Department of Labor, 200 Constitution Avenue N.W., Washington, D.C. 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. 

Claims Appeal Procedures 
  

Claim for Benefits 
 The following claims
appeal procedures apply to claims made under the self-insured Base Medical Plan options under the Plan. You should refer to the applicable Evidences of Coverage or Certificates of Insurance, as the case may be, for claims appeal procedures that
apply to claims made under any of the fully-insured HMO and DMO Base Medical Plan options or the EMRP. 
 A claim for benefits is a request for
a Plan benefit or benefits, made by a claimant or the claimant’s representative that complies with a Plan’s reasonable procedure for making benefit claims. A claim for benefits includes a request for a coverage determination, for
pre-authorization or approval of a Plan benefit, or for a utilization review determination in accordance with the terms of the Plan.

 Notification of Claims Decision 
 Urgent Care Claims. The Plan Administrator will notify the claimant of the Plan’s claims decision as soon as possible, but not later than 72 hours after receipt of the claim by the Plan.
However, if the claimant (or the claimant’s representative) does not provide sufficient information to decide the claim, the Plan Administrator will notify the claimant of the lack of information not later than 24 hours after receipt of the
claim by the Plan. Such notice will state the specific information necessary to complete the claim and may be made orally, by FAX or by other similarly expeditious method. The claimant will be afforded a reasonable amount of time, but not less than
48 hours, to provide the specified information. The Plan Administrator will notify the claimant of the Plan’s claims decision as soon as possible, but no later than 48 hours after the earlier of: (1) the Plan’s receipt of the
specified information, or (2) the end of the period afforded the claimant to provide the specified information. 
 Concurrent Health
Care Claims. If the Plan has approved a benefit or service to be provided for a specified or indefinite time period, any reduction or termination of the benefit or service (other than by Plan amendment or termination) before the end of such
period constitutes an adverse claims decision. To the extent that such decision denies an urgent care claim, the Plan Administrator will provide notice of the adverse claims decision sufficiently in advance to allow the claimant (or the
claimant’s representative) to appeal and obtain a determination on appeal before the benefit is reduced or terminated. In addition, any urgent care claim requesting an extension of a course of treatment beyond the initially prescribed time
period or number of treatments must be decided within not more than 24 hours of the request provided the claim is made at least 24 hours before the expiration of the initially prescribed period or number of treatments. 

Non-Urgent Care Claims 
 Concurrent Care.
If the Plan has approved a benefit or service to be provided for a specified or indefinite time period, any reduction or termination of the benefit or service (other than by Plan amendment or termination) before the end of such period
constitutes an adverse claims decision. 

 

  
 49 

 
 Pre-Service Claims. The Plan Administrator will notify the claimant of the Plan’s benefit
determination within a reasonable time period, but not later than 15 days after receipt of the claim by the Plan. This period may be extended by the Plan for up to 15 days, provided that the extension is necessary due to matters beyond the control
of the Plan and the Plan Administrator notifies the claimant in writing or electronically prior to the expiration of the initial 15-day period. The notice to the claimant will state the reason for the extension and the date by which the Plan expects
to provide a decision. If the extension is necessary because the claimant failed to submit the information necessary to decide the claim, the notice of extension will describe the required information. The claimant then has 45 days from receipt of
the notice within which to provide the specified information. A “pre-service claim” is any request for approval of a benefit with respect to which the terms of the Plan condition receipt of the benefit, in whole or in part, on approval of
the benefit in advance of obtaining medical care (e.g., pre-authorization). 
 Post-Service Claims. The Plan Administrator will notify
the claimant of the Plan’s benefit determination within a reasonable time period, but not later than 30 days after receipt of the claim by the Plan. This period may be extended by the Plan for up to 15 days, provided that the extension is
necessary due to matters beyond the control of the Plan and the Plan Administrator notifies the claimant in writing or electronically prior to the expiration of the initial 30-day period. The notice to the claimant will state the reason for the
extension and the date by which the Plan expects to provide a decision. If the extension is necessary because the claimant failed to submit the information necessary to decide the claim, the notice of extension will describe the required
information. The claimant then has 45 days from receipt of the notice within which to provide the specified information. “Post-service claims” are any group health plan claims that are not pre-service claims. 

Manner and Content of Notification of Claims Decision 
 The Plan Administrator will provide a claimant with written or electronic notification of the Plan’s claims decision. In the case of an adverse claims decision, the notification will include:

  

	 	n	The specific reasons for the adverse decision;

	 	n	Reference to the specific plan provisions on which the decision is based; 

  

	 	n	A description of any additional material or information necessary for the claimant to complete the claim and an explanation of why such material or information is
necessary; 

  

	 	n	A description of the Plan’s review procedures and the time limits applicable to such procedures, including a statement of the claimant’s right to bring a
civil action following an adverse claims decision on review; 

  

	 	n	If an internal rule, guideline, protocol, or other criterion was relied upon in the decision-making, either (1) a copy of such rule, guideline, or protocol or
(2) a statement that a copy of such rule, guideline, or protocol will be provided free of charge to the claimant upon request; 

  

	 	n	If the adverse claims decision was based on a medical necessity or experimental treatment or similar exclusion or limit, either (1) an explanation of the
scientific or clinical judgment for the determination, applying the terms of the Plan to the claimant’s medical circumstances, or (2) a statement that such explanation will be provided free of charge to the claimant upon request;

  

	 	n	For an adverse claims decision involving an urgent care claim, a description of the expedited review process applicable to such claims. 

In the case of an adverse claims decision involving an urgent care claim, the information may be provided to the claimant orally within the time frame
prescribed, provided that a written or electronic notification is furnished to the claimant not later than three (3) days after the oral notification. 
 Appeal of Adverse Claims Decisions 
 Upon receipt of an adverse claims decision, the claimant
has up to 180 days to file an appeal with the Plan Administrator. The claimant may submit written comments, documents, records, and other information relevant to the claim for benefits. In addition, the claimant will be provided, upon request and
free of charge, reasonable access to, and copies of, all documents, records, and other information relevant to the claim for benefits.

 

  
 50 

 
 The appeal will be reviewed by an appropriate named fiduciary (the “reviewer”) of the Plan who is
neither the party who made the adverse claims decision that is the subject of the appeal, nor the subordinate of such party. The decision on appeal of an adverse claims decision will take into account all comments, documents, records, and other
information submitted by the claimant (or the claimant’s representative) relating to the claim, without regard to whether such information was submitted or considered in the initial claims decision. The appeal will not afford deference to the
initial adverse claims decision. 
 In deciding the appeal of any adverse claims decision involving a medical judgment, including determinations
with regard to whether a particular treatment, drug, or other item is experimental, investigational, or not medically necessary or appropriate, the reviewer will consult with a health care professional, who has appropriate training and experience in
the field of medicine involved in the medical judgment. The health care professional engaged for purposes of a consultation will be independent of any health care professional who participated in the initial adverse claims decision. In addition, the
Plan will identify any medical or vocational experts whose advice was obtained on behalf of the Plan in connection with a claimant’s adverse claims decision, without regard to whether the advice was relied upon in making the claims decision.

 Appeals of adverse claims decision involving urgent care claims are subject to an expedited review process. The claimant may submit the
request for appeal orally or in writing or the claimant’s representative. All necessary information, including the plan’s claims decision on review of an urgent care claim, will be transmitted between the plan and the claimant by
telephone, facsimile, or other available similarly expeditious method. 
 Notification of Claims Decision on Review 

The Plan Administrator will notify the claimant of the Plan’s claims decision on review within a reasonable time period appropriate to the
circumstances.  
 Urgent Care Claims. For urgent care claims, the Plan Administrator will notify the claimant of the Plan’s
claims decision on review as soon as possible, but not later than 72 hours after receipt of the claimant’s request for review of an adverse claims decision. 

 

 Pre-Service Non-Urgent Care Claims. For pre-service claims, the Plan Administrator will notify the
claimant of the Plan’s claims decision on review no later than 30 days after receipt by the Plan of the claimant’s request for review of an adverse claims decision. 
 Post-Service Non-Urgent Care Claims. For post-service plan claims, the Plan Administrator will notify the claimant of the Plan’s claims decision on review no later than 60 days after receipt
by the Plan of the claimant’s request for review of an adverse. 
 Manner of Content of Notification of Claims Decision on Review

 The Plan Administrator will provide claimants with written or electronic notification of a Plan’s benefit determination on review. In
the case of an adverse claims decision, the notification must set forth: 
  

	 	n	The specific reasons for the adverse decision; 

  

	 	n	Reference to the specific Plan provisions on which the claims decision is based; 

 

	 	n	A statement that the claimant is entitled to receive, upon request and free of charge, reasonable access to, and copies of, all documents and records relevant to the
claimant’s claim for benefits, without regard to whether such records were considered or relied upon in making the adverse claims decision on review, including any reports, and the identities, of any experts whose advice was obtained;

  

	 	n	A statement describing any voluntary appeal procedures offered by the Plan and the claimant’s right to obtain the information about such procedures;

  

	 	n	A statement of the claimant’s right to bring a civil action following an adverse claims decision on review; 

 

	 	n	If an internal rule, guideline, protocol, or other criterion was relied upon in the decision-making, either (1) a copy of such rule, guideline, or protocol or
(2) a statement that a copy of such rule, guideline, or protocol will be provided free of charge to the claimant upon request; 

  

	 	n	 If the adverse benefit determination was based on a medical necessity or experimental treatment or similar exclusion or limit, either (1) an
explanation of the scientific or clinical judgment for the

 

  
 51 

 
determination, applying the terms of the Plan to the claimant’s medical circumstances, or (2) a statement that such explanation will be provided free of charge to the claimant upon
request; 
  

	 	n	You and your Plan may have other voluntary alternative dispute resolution options, such as mediation. One way to find out what may be available is to contract your
local U.S. Department of Labor Office and your State insurance regulatory agency. 

 Finality of Decisions, Legal Action and
Applicable Law 
 No legal action may be brought arising out of, relating to or resulting from a claim under the Plan unless and until the
claimant: 
  

	 	n	has submitted a written claim in accordance with the Plan’s claims procedures described above; 

 

	 	n	has been notified by the Plan Administrator that such claim is denied; 

  

	 	n	has filed a written request for review of the denied claim in accordance with the Plan’s appeals procedures described above; and 

 

	 	n	has been notified that the Plan Administrator has affirmed the denial of the claim. 

 The decision on appeal by the Plan Administrator shall be deemed final and shall be conclusive and binding on all parties. If any action by the Plan Administrator required under the Plan’s claims and
appeals procedures is not taken within the specified time limits, the claim will be deemed denied as of the latest date by which the action should have been completed if it were completed within the applicable time limits. 

No legal action may be brought after the earlier of either (i) one year after the Plan Administrator’s affirmation of a denial of the claim, as
set forth in the Plan’s appeals procedures described above, or (ii) four years after the claimant has full knowledge of the facts giving rise to the claim with respect to the Plan. 
 This Plan shall be construed, administered and enforced according to the federal laws, including ERISA, governing employee benefit plans and, to the extent not inconsistent therewith, in accordance with
the laws of the State of California. Any provision of this Plan

 in conflict with the law of any governmental body or agency which has jurisdiction over this Plan shall be
interpreted to conform to the minimum requirements of such law. 
 Important Note: For any self-insured Base Medical Plan option that is
not a “grandfathered plan” for purposes of the Health Care Reform Act, you may have expanded rights under the Plan’s benefits claim review process, which are described as follows. 

Your Right to Appeal 
 For purposes of these
Appeal provisions, “claim for benefits” means a request for benefits under the plan. The term includes both pre-service and post-service claims. 
  

	 	n	A pre-service claim is a claim for benefits under the plan for which you have not received the benefit or for which you may need to obtain approval in advance.

  

	 	n	A post-service claim is any other claim for benefits under the plan for which you have received the service. 

If your claim is denied or if your coverage is rescinded: 
  

	 	n	you will be provided with a written notice of the denial or rescission; and 

 

	 	n	you are entitled to a full and fair review of the denial or rescission. 

 The Claims Administrator will satisfy the following procedures, which meet the minimum requirements for a full and fair review under applicable federal regulations. 

Notice of Adverse Benefit Determination 
 If
your claim is denied, the Claims Administrator’s notice of the adverse benefit determination (denial) will include: 
  

	 	n	information sufficient to identify the claim involved; 

  

	 	n	the specific reason(s) for the denial; 

  

	 	n	a reference to the specific plan provision(s) on which the Claims Administrator’s determination is based; 

 

	 	n	 a description of any additional material or

 

  
 52 

 
information needed to perfect your claim; 
  

	 	n	an explanation of why the additional material or information is needed; 

  

	 	n	a description of the plan’s review procedures and the time limits that apply to them, including a statement of your right to bring a civil action under ERISA if
you appeal and the claim denial is upheld; 

  

	 	n	information about any internal rule, guideline, protocol, or other similar criterion relied upon in making the claim determination and about your right to request a
copy of it free of charge, along with a discussion of the claims denial decision; 

  

	 	n	information about the scientific or clinical judgment for any determination based on medical necessity or experimental treatment, or about your right to request this
explanation free of charge, along with a discussion of the claims denial decision; and 

  

	 	n	the availability of, and contact information for, any applicable office of health insurance consumer assistance or ombudsman who may assist you.

  

	 	For	claims involving urgent/concurrent care: 

  

	 	n	the Claims Administrator’s notice will also include a description of the applicable urgent/concurrent review process; and 

 

	 	n	the Claims Administrator may notify you or your authorized representative within 24 hours orally and then furnish a written notification. 

Appeals 
 You have the right to appeal an
adverse benefit determination (claim denial or rescission of coverage). You or your authorized representative must file your appeal within 180 calendar days after you are notified of the denial or rescission. You will have the opportunity to submit
written comments, documents, records, and other information supporting your claim. The Claims Administrator’s review of your claim will take into account all information you submit, regardless of whether it was submitted or considered in the
initial benefit determination. 
 The Claims Administrator shall offer a single mandatory level of appeal and an additional voluntary second
level of appeal which may be a panel review, independent review, or other process consistent with the entity

 reviewing the appeal. The time frame allowed for the Claims Administrator to complete its review is
dependent upon the type of review involved (e.g. pre-service, concurrent, post-service, urgent, etc.). 
 For pre-service claims involving
urgent/concurrent care, you may obtain an expedited appeal. You or your authorized representative may request it orally or in writing. All necessary information, including the Claims Administrator’s decision, can be sent between the Claims
Administrator and you by telephone, facsimile or other similar method. To file an appeal for a claim involving urgent/concurrent care, you or your authorized representative must contact the Claims Administrator at (866) 940-6544 and provide at
least the following information: 
  

	 	n	the identity of the claimant; 

  

	 	n	The date (s) of the medical service; 

  

	 	n	the specific medical condition or symptom; 

  

	 	n	the provider’s name; 

  

	 	n	the service or supply for which approval of benefits was sought; and 

  

	 	n	any reasons why the appeal should be processed on a more expedited basis. 

 All other requests for appeals should be submitted in writing by you or your authorized representative, except where the acceptance of oral appeals is otherwise required by the nature of the appeal
(e.g. urgent care). You or your authorized representative must submit a request for review to: 
 Anthem Blue Cross 

Attn: Appeals 
 P.O. Box 54159 

Los Angeles, CA 90054 
 Upon request, the Claims
Administrator will provide, without charge, reasonable access to, and copies of, all documents, records, and other information relevant to your claim. “Relevant” means that the document, record, or other information: 

 

	 	n	was relied on in making the benefit determination; or 

  

	 	n	was submitted, considered, or produced in the course of making the benefit determination; or

 

  
 53 

 

	 	n	demonstrates compliance with processes and safeguards to ensure that claim determinations are made in accordance with the terms of the plan, applied consistently for
similarly-situated claimants; or 

  

	 	n	is a statement of the plan’s policy or guidance about the treatment or benefit relative to your diagnosis. 

The Claims Administrator will also provide you, free of charge, with any new or additional evidence considered, relied upon, or generated in connection
with your claim. In addition, before you receive an adverse benefit determination on review based on a new or additional rationale, the Claims Administrator will provide you, free of charge, with the rationale. 

How Your Appeal Will Be Decided 
 When the
Claims Administrator considers your appeal, the Claims Administrator will not rely upon the initial benefit determination or, for voluntary second-level appeals, to the earlier appeal determination. The review will be conducted by an appropriate
reviewer who did not make the initial determination and who does not work for the person who made the initial determination. A voluntary second-level review will be conducted by an appropriate reviewer who did not make the initial determination or
the first-level appeal determination and who does not work for the person who made the initial determination or first-level appeal determination. 
 If the denial was based in whole or in part on a medical judgment, including whether the treatment is experimental, investigational, or not medically necessary, the reviewer will consult with a health
care professional who has the appropriate training and experience in the medical field involved in making the judgment. This health care professional will not be one who was consulted in making an earlier determination or who works for one who was
consulted in making an earlier determination. 
 Notification of the Outcome of the Appeal 

If you appeal a claim involving urgent/concurrent care, the Claims Administrator will notify you of the outcome of the appeal as soon as possible,
but not later than 72 hours after receipt of your request for appeal. 
 If you appeal any other pre-service claim, the Claims
Administrator will notify you of the outcome of the appeal within 30 days after receipt of your request for appeal.

 If you appeal a post-service claim, the Claims Administrator will notify you of the outcome of the
appeal within 60 days after receipt of your request for appeal. 
 Appeal Denial 
 If your appeal is denied, that denial will be considered an adverse benefit determination. The notification from the Claims Administrator will include all of the information set forth in the above section
entitled “Notice of Adverse Benefit Determination”. 
 Voluntary Second Level Appeals 

If you are dissatisfied with the Plan’s mandatory first level appeal decision, a voluntary second level appeal may be available. If you would like to
initiate a second level appeal, please write to the address listed above. Voluntary appeals must be submitted within 60 calendar days of the denial of the first level appeal. You are not required to complete a voluntary second level appeal prior to
submitting a request for an independent External Review. 
 External Review 
 If the outcome of the mandatory first level appeal is adverse to you, you may be eligible for an independent External Review pursuant to federal law. You must submit your request for External Review to
the Claims Administrator within four (4) months of the notice of your final internal adverse determination. A request for an External Review must be in writing unless the Claims Administrator determines that it is not reasonable to require a
written statement. You do not have to re-send the information that you submitted for internal appeal. However, you are encouraged to submit any additional information that you think is important for review. 

For pre-service claims involving urgent/concurrent care, you may proceed with an Expedited External Review without filing an internal appeal or while
simultaneously pursuing an expedited appeal through our internal appeal process. You or your authorized representative may request it orally or in writing. All necessary information, including the Claims Administrator’s decision, can be sent
between the Claims Administrator and you by telephone, facsimile or other similar method. To proceed with an Expedited External Review, you or your authorized representative must contact the Claims Administrator at (866) 940-6544 and provide at
least the following information: 

 

  
 54 

 

	 	n	the identity of the claimant; 

  

	 	n	The date (s) of the medical service; 

  

	 	n	the specific medical condition or symptom; 

  

	 	n	the provider’s name; 

  

	 	n	the service or supply for which approval of benefits was sought; and 

  

	 	n	any reasons why the appeal should be processed on a more expedited basis. 

 All other requests for External Review should be submitted in writing unless the Claims Administrator determines that it is not reasonable to require a written statement. Such requests should be submitted
by you or your authorized representative to: 
 Anthem Blue Cross 
 Attn: Appeals 
 P.O. Box 54159 
 Los Angeles, CA 90054 
 This is not an additional step that you must take in order to fulfill your
appeal procedure obligations described above. Your decision to seek External Review will not affect your rights to any other benefits under this health care plan. There is no charge for you to initiate an independent External Review. The External
Review decision is final and binding on all parties except for any relief available through applicable state laws or ERISA. 
 Requirement to
file an Appeal before 
 Filing a Lawsuit 
 No lawsuit or legal action of any kind related to a benefit decision may be filed by you in a court of law or in any other forum, unless it is commenced within three years of the Plan’s final
decision on the claim or other request for benefits. If the Plan decides an appeal is untimely, the Plan’s latest decision on the merits of the underlying claim or benefit request is the final decision date. You must exhaust the Plan’s
internal Appeals Procedure but not including any voluntary level of appeal, before filing a lawsuit or taking other legal action of any kind against the Plan. The Plan is subject to the Employee Retirement Income Security Act of 1974 (ERISA) and if
your appeal as described above results in an adverse benefit determination, you have a right to bring a civil action under Section 502(a) of ERISA.

 Unified reserves the right to modify the policies, procedures and timeframes in this section upon
further clarification from Department of Health and Human Services and Department of Labor. 
 Legal Process 

If it should become necessary for you or your beneficiary to take legal action against Unified Grocers over the terms of the Plan or your rights under
ERISA, legal process should be served to the Benefits Committee whose address and phone number are listed under Plan Administration. 
 Notices

 Any notice by the Plan shall be deemed given if mailed to the insured participant, their dependents or group at the last address appearing
on the records of the Plan. 
 Refunds 
 The Plan has the right to request a refund for any payment made in error. 
 Continuation of
Coverage (COBRA) 
 If you, your spouse (as defined under Federal law) or eligible dependents lose medical coverage under this Plan as a
result of a qualifying event, you, your spouse or eligible dependents may be eligible to continue coverage for a limited period of time, in accordance with the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA). The chart on the next
page shows the qualifying events, who is eligible for COBRA coverage, and the length of time it will be available. A domestic partner is not eligible for continuation of coverage under COBRA. 
 Coverage During the Election Period—As of the date coverage is terminated, you and your family members will not have any coverage until continuation coverage is properly elected and the
required premiums have been paid. This means no benefits or expenses will be paid during the election period. To receive uninterrupted coverage, it is important to elect continuation coverage and make the required premium payments as soon as
possible After all required premium payments are received, coverage becomes retroactive to the date coverage was terminated.

 

  
 55 

 
					
	If you can no longer participate due to...	 	These individuals may
continue to participate...	  	 For this length
 of time:

	 Your death
  
	 	
Your covered spouse
  
	  	 36 months

 

	 Your divorce* or legal separation
  
	 	 Your covered spouse

 
	  	 36 months

 

	 Your entitlement to Medicare*
  
	 	 Your covered spouse

 
	  	 36 months

 

	*If you are already on COBRA when you become eligible for Medicare, you will may lose your COBRA benefits when Medicare benefits begin. However,
your spouse may be entitled to continuation of coverage up to 36 months.

  

					
	Responsibility	  	Action	  	Timing
	 You must
	  	notify the Plan if you lose your coverage as a result of:	  	within 60 days of the event
	 	  	– divorce	  	
	 	  	 – legal separation

 
	  	 
	 The Plan
will
	  	 notify you if a termination of coverage entitles you to
continued coverage under COBRA.
  
	  	within 14 days after receiving notice of a qualifying event

 *Notice to your spouse constitutes notification to any beneficiary residing with your spouse, if
applicable. If your spouse has a different address, either you or your spouse must provide that address to the Plan. If you and your spouse are enrolled in the Retiree Medical Plan at the time of your death, your spouse may be eligible for up to 36
months of continued coverage. Unified will cover the cost of COBRA coverage for your surviving spouse for the first 12 months. Payments by the surviving spouse will begin on month 13. Enrollment in the COBRA plan is required. 

 

 Electing COBRA Continuation Coverage - You will receive a COBRA coverage election form, including
information about your right to elect COBRA coverage, the cost to continue coverage and a description of how to make payments. You and your covered family members need to make your elections to continue coverage within 60 days of the later of
(1) the date you receive notice of your right to continue coverage or (2) the date your coverage terminates. If the election is not completed within the 60-day period, you will not have continuation coverage and will have no further rights
to elect such coverage. Qualified beneficiaries may purchase coverage by completing and returning the appropriate election forms to the following address: 
 Tri-Ad 
 Attn: COBRA Department 
 221 West Crest Street, Suite 300 
 Escondido, CA 92025-1737 

Cost of Continuation Coverage - Subject to any cost-sharing provisions described earlier in this booklet, you and/or your family must pay the
entire cost of continuation coverage, including an additional 2% charge to cover administrative expenses. Premiums for the additional 11 months (due to disability) may be increased as discussed previously. You and your covered dependents will
receive written notice of the cost of continuation coverage at the time of eligibility.

 You may also request written verification of the cost of continuation coverage at any time during the
continuation coverage period. 
 Once you elect to continue coverage, you will have 45 days to make the first premium payment. Once payment is
made, coverage will be effective retroactive the date of the loss of coverage. After this initial 45-day period, premium payments are due monthly and must be received no later than the first day of each month. If these subsequent premiums are not
received within 30 days of the first day of the month, continuation coverage will be terminated and you or your covered dependents will have no further rights to elect continuation coverage. Even if continuation coverage is elected, benefits will
not be paid until all payments due have been paid without regard to any grace period. 
 Disability Extension of 18-month Period of
Continuation Coverage - You and/or your family may continue coverage under COBRA for an additional 11 months after the end of your initial 18-month period of coverage, if you, your covered spouse or eligible dependent is totally disabled when
you terminate employment or your hours are reduced so that Plan coverage is lost or within the first 60 days of COBRA continuation coverage. Under these circumstances, your costs to continue coverage for the additional 11 months will be 150% of the
full cost of providing coverage if 

 

  
 56 

 the disabled individual also continues coverage. If the disabled individual does not continue coverage for
the additional 11 months, the premium for those other individuals continuing coverage for the additional 11 months will remain at 102% of the full cost of providing coverage. To be eligible for this extension, you or your dependent must: 

 

	 	n	Receive a determination of disability benefits from the Social Security Administration that you were disabled on the date you lost coverage, or within the first 60 days
of COBRA continuation coverage, and 

  

	 	n	Notify the Plan within 60 days of receiving the disability determination letter and before the original 18-month period ends. 

Notification Requirements - Please note that continuation of coverage is not automatic. If you lose your coverage, you must take specific action
to ensure continuation of coverage. If you fail to notify the Plan you do not have the right to continue coverage. (See chart) 
 Changing
Coverage - If you or your family elect continuation of coverage, you will be able to change coverage during the annual open enrollment period, or if you have a qualified change in family status (see “Eligibility” for more information
on changes in family status). A new spouse will not have independent rights to continue COBRA coverage. 
 During the time you or your family
has COBRA coverage, there may be changes to the Plan, such as new deductibles or covered expenses. All changes to the Plan will also apply to your COBRA coverage. As with active employees, you will also be able to make a new choice of medical or if
applicable dental and vision plans during the annual open enrollment period. You may also have special enrollment rights for a newly acquired spouse. 
 To enroll a new spouse as a result of a special enrollment event, you must follow the process for special enrollment as stated in the enrollment section. If the addition of a spouse will result in a
higher applicable premium, COBRA rates reflect the higher amount. Your rights to continue coverage are the same as required by federal law or applicable state insurance law if health plan benefits are insured. The Plan and this summary do not grant
you more rights than the law requires. 

 Termination Before the End of the Maximum Coverage Period - A covered person’s continuation of
coverage under COBRA will stop before the end of the indicated time period if: 
  

	 	n	Premium payments are not paid on time (the maximum grace period is 30 days after the payment is due), or 

 

	 	n	The covered person becomes covered under another group Medical Plan (as a retiree or otherwise) that has no exclusion or limitation with respect to any preexisting
condition that the individual has, after the date continuation coverage is elected, or 

  

	 	n	The covered person becomes entitled to Medicare benefits, or 

  

	 	n	Unified Grocers, Inc., terminates the Plan and no longer provides group health care coverage to any retiree, 

 

	 	n	The first day of the month beginning more than 30 days after the date an individual on the 11-month extension previously described is determined to be no longer
disabled according to Social Security Administration. You must notify the COBRA administrator within 30 days of such determination. 

 COBRA and Medicare - If you have COBRA coverage and you become eligible for and enroll in Medicare, your group health coverage under COBRA may end. The length of time your spouse can continue
coverage when you enroll in Medicare coverage may change. 
 If you elect COBRA coverage after you enroll in Medicare, you can keep your COBRA
coverage. If you are age 65 or older and have Medicare and COBRA coverage, Medicare is the primary payer. If you or your dependent have Medicare due to end-stage renal disease, COBRA is primary and Medicare is secondary for the first 30 months of
coverage. 
 Address Changes - If continuation coverage is elected, you and your family member must notify the COBRA Administrator if
your address changes. Under some circumstances, if you or your family members relocate while receiving coverage, you may be eligible to change your coverage option to another coverage option available to similarly situated participants residing in
the area to which you relocated. 

 

  
 57 

 If you have any questions about continuation coverage, contact Tri-Ad, Unified’s third-party
administrator at: 
 Tri-Ad 
 Attn:
COBRA Department 
 221 West Crest Street, Suite 300 
 Escondido, CA 92025-1737 
 (888) 844-1372 

California Continuation of Coverage (Cal-COBRA) 
 You, your spouse (and your former spouse) and any covered dependents may be eligible for an additional extension of continuing coverage under California law (Cal-COBRA) beyond the date federal COBRA
continuation coverage is scheduled to end if the following conditions are satisfied: 
  

	 	n	You and family are covered under federal COBRA, you exhaust federal COBRA, and you have less than 36 months of COBRA coverage, and; 

 

	 	n	You and family are covered under a health maintenance organization (HMO). 

 You may have the opportunity to continue coverage for up to a total of 36 months through a combination of federal COBRA and Cal-COBRA. For more information on how to elect this additional extension of
coverage, contact the Benefits Department in writing within 30 days prior to the date that COBRA continuation coverage is scheduled to end. 

Medical Conversion Privileges 
 When medical
coverage under Unified ends for you or any dependent, you may apply for an individual medical policy. Converting to individual coverage will not require proof of insurability if: 

 

	 	n	You do not choose COBRA continuation coverage and you or your enrolled eligible dependents apply for an individual policy within 31 days after you or your
dependents’ group coverage ends. 

  

	 	n	You choose COBRA continuation coverage and you or your enrolled eligible dependents apply for an individual policy within 180 days before your COBRA coverage ends, but
no later than 31 days after your COBRA coverage ends. 

  

	 	n	an individual policy within 180 days before your COBRA coverage ends, but no later than 31 days after your COBRA coverage ends.

 The coverage (and benefits) will not necessarily be the same as those provided by Unified, and the rates
will vary depending on your age and where you live. 
 Third Party Liability–Subrogation 

In the event any person covered by this Plan incurs any condition for which one or more third parties may be responsible, the Plan is entitled, up to the
amount it has paid for benefits for the condition, to the proceeds of any settlement or judgment that results in recovery from a Third Party, a Liability Insurer, an Underinsured, or an Uninsured Motorist Insurer, and the Plan has a first lien
against the cause of action. The insured participant and other covered members of the family shall cooperate fully with the Plan in recovering the amounts that have been paid. Cooperation shall include, but is not limited to: 

 

	 	n	Providing names and addresses of any party who caused injury, the facts about the accident, and prior notice of any intended settlement and use of insured
participant’s name in the event the Plan must pursue the claim directly against the Third Party. Lack of cooperation will result in insured participant foregoing additional benefits for such condition. 

 

	 	n	Such person shall hold the rights of recovery and all sums received in trust for the benefit of the Plan up to the amount the Plan has paid for benefits, less any
reasonable amount for attorney fees incurred. 

  

	 	n	Such person shall execute and deliver to the Plan such instruments and papers submitted by the Plan as may be appropriate to secure the rights and obligations of such
person and the Plan established by this Provision. The execution of an agreement to hold recovery proceeds in trust for the Plan, if requested by the Plan, shall be a condition precedent to the furnishing of benefits for such conditions by the Plan.

 Non-Duplication of Motor Vehicle Coverage 
 State laws require many motor vehicle insurance policies to provide medical payments, including personal injury protection payments, up to a minimum amount set by law as primary coverage for the insured
and members of his family residing in the same household. The Plan benefits will be excess coverage over and above the medical payments coverage of motor vehicle insurance

 

  
 58 

 policy. As to benefits furnished, the Plan shall be entitled to any reimbursement from any motor vehicle
insurer required by said law. The insured participant shall furnish information concerning medical insurance payments to the Plan upon request. 

Coordination of Benefits 
 When you are
covered by two medical plans, and both plans have the coordination of benefits feature, one plan is the primary payer and the other plan is the secondary payer. In some cases, this means that a higher level of coverage results when the two
plans’ benefits are coordinated. However, in other situations there may be no additional benefit to you, particularly when our Anthem Blue Cross Plan is the secondary payer (sometimes called non-duplication). This Plan does not coordinate
benefits. 
 This plan will be secondary to any other medical insurance coverage the retired officer has a an active employee of another
company. Retired executives (and surviving spouses) must enoll in Medicare Parts A and B when they reach age 65. At age 65, Medicare becomes the primary carrier and the Retiree Benefits become secondary. 

The amount of payment to be made by the coverage paying first, and the coverage paying second, is also determined by definite rules: 

 

	1.	If your Unified coverage has first responsibility, the Plan will pay the normal benefits of this program. 

 

	2.	If your Unified coverage has secondary responsibility, the benefits that would be payable for eligible expenses for you and/or your eligible dependents from
Unified’s plan in the absence of Coordination of Benefits will be reduced by the benefits payable for those expenses from all other plans. 

 Example: Let’s assume you have a dependent that is covered by the PPO Plan offered by Unified and another medical plan that is determined to be the primary plan (the plan that will pay benefits
first). The dependent incurs an eligible expense of $100 and the primary plan pays $80 dollars. If the Unified plan had been the only coverage and therefore primary, the Unified plan would have paid $90 dollars. However, with Coordination of
Benefits, the Unified plan is secondary and will pay $10 to make the total reimbursement to the participant $90.

 Which plan pays first? 

 

	 	n	For the Unified retiree, the Anthem Blue Cross plan is the primary payer. 

 

	 	n	For the spouse or domestic partner, the Anthem Blue Cross Plan is the secondary payer. 

 

	 	n	For eligible dependents, the primary plan is determined by the Birthday Rule. 

 What is the Birthday Rule? 
 Determining which plan is the primary payer for eligible
dependents is based on the Birthday Rule. The medical plan of the parent whose birth month and day that is earliest in the year is the primary payer. For example, if your birthday is in January and your spouse’s or domestic partner’s
birthday is in August, the Anthem Blue Cross plan would be the primary plan and pay first. 
 What happens if the Anthem Blue Cross Plan
is the secondary payer? 
 The Anthem Blue Cross Plan pays only benefits to the level it would have paid as though it were the primary
payer. This means that if the primary plan has already paid benefits equal to or greater than benefits payable by the Anthem Blue Cross Plan had it been the primary plan, the Anthem Blue Cross Plan will not provide any additional payment.

 Genetic Information Nondiscrimination Act of 2008 (GINA) 
 Group health plans, such as the Plan, are prohibited from using genetic information to discriminate in health benefits. GINA prohibits the use of genetic information to discriminate in health benefits,
including charging a person higher premiums based solely on a genetic predisposition to developing a disease in the future. Under GINA, the Plan is prohibited from requesting or requiring an individual or family member of an individual from
undergoing a genetic test. However, GINA does not limit the authority of a health care professional to request an individual to undergo a genetic test as part of the treatment of the individual, nor does it preclude a group health plan from
obtaining or using the results of a genetic test in making a determination regarding payment. In any event, GINA requires the Plan to request only the minimum amount of information necessary to accomplish the intended purpose.

 

  
 59 

 Addendum to Unified Grocers Inc. 
 Officer Retiree Medical Plan 

 

 This Addendum is made part of the Unified Grocers, Inc. Officer Retiree Medical Plan document as required under the Administrative Simplification requirements of the Health Insurance Portability and
Accountability Act of 1996 (“HIPAA”), to allow the disclosure of Protected Health Information (“PHI”) as defined under HIPAA, to Unified Grocers, Inc. (the “Plan Sponsor”) for the purposes specified below. If the terms
or conditions of the Plan document conflict with this Addendum, this Addendum shall control. 
  

	1.	Disclosure of PHI to Plan Sponsor. Plan shall disclose PHI to Plan Sponsor only to the extent necessary for Plan Sponsor, except for treatment, payment, health
plan operations (collectively known as “TPO”), as permitted or required by other state and federal law, or to business associates to help administer the Plan. 

 

	2.	Use and Disclosure of PHI by Plan Sponsor. Plan Sponsor shall use and/or disclose PHI only to the extent necessary to perform the following Plan Administration
Functions, which it performs on behalf of the Plan: 

  

	 	n	Payment of health care operations (both internally and externally) 

  

	 	n	To another covered entity for its payment activities 

  

	 	n	To a Business Associate for the health plan’s payment of health care operations 

 

	 	n	With other group health plans sponsored by when for payment or health care operations 

 

	 	n	Answer plan participant questions 

  

	 	n	Assist with claims 

  

	 	n	Disclose PHI to the subject of the PHI 

  

	3.	Plan Sponsor Certification. The Plan agrees that it will only disclose PHI to the Plan Sponsor upon receipt of a certification that this addendum has been
adopted and the Plan Sponsor agrees to abide by such conditions. Plan Sponsor is subject to the following:

 I. Prohibition on Unauthorized Use or Disclosure of PHI. The Plan Sponsor will not use or
disclose any PHI received from the Plan, except as permitted in these documents or required by law. 
 II. Subcontractors and
Agents. The Plan Sponsor will require each of its subcontractors or agents to whom the Plan Sponsor may provide PHI to agree to written contractual provisions that impose at least the same obligations to protect PHI as are imposed on the Plan
Sponsor. 
 III. Permitted Purposes. The Plan Sponsor will not use or disclose PHI for employment-related actions and
decisions or in connection with any other of Plan Sponsor’s benefits or employee benefit plans. 
 IV. Reporting. The
Plan Sponsor will report to the Plan any impermissible or improper use or disclosure of PHI not authorized by the plan documents. 
 V. Access to PHI by Participants. The Plan Sponsor will make PHI available to the Plan to permit participants to inspect and copy their PHI contained in the designated record set. 

VI. Correction of PHI. The Plan Sponsor will make a participant’s PHI available to the Plan to permit participants to amend or
correct PHI contained in the designated record set that is inaccurate or incomplete and Plan Sponsor will incorporate amendments provided by the Plan. 
 VII. Accounting of PHI. The Plan Sponsor will make a participant’s PHI available to permit the Plan to provide an accounting of disclosures. 

VIII. Disclosure to Government Agencies. The Plan Sponsor will make its internal practices, books and records relating to the use and
disclosure of PHI available to the Plan and to DHHS or its designee for the purpose of determining the Plan’s compliance with HIPAA.

 

  
 60 

 IX. Return or Destruction of Health Information. When the PHI is no longer needed for the
purpose for which disclosure was made, the Plan Sponsor must, if feasible, return to the Plan or destroy all PHI that the Plan Sponsor received from or on behalf of the Plan. This includes all copies in any form, including any compilations derived
from the PHI. If return or destruction is not feasible, the Plan Sponsor agrees to restrict and limit further uses and disclosures to the purposes that make the return or destruction infeasible. 

X. Minimum Necessary Requests. The Plan Sponsor will use best efforts to request only the minimum necessary type and amount of PHI to
carry out the functions for which the information is requested. 
  

	4.	Adequate Separation. The Plan Sponsor represents that adequate separation exists between the Plan and Plan Sponsor so that PHI will be used only for plan
administration. The following employees or persons under the control of the Plan Sponsor have access to participants’ PHI for the purposes set forth under number 1: 

 

	 	Vice	President, Human Resources 

Executive Director, Labor & Employee Relations 
 Executive Director, Talent Resources 
 Director, Environmental Health &
Safety 
 Director, Human Resources 
 Manager, Benefits 
 Manager, Health & Safety 

Manager, HRIS 

Manager, Human Resources 
 Manager, Labor Relations 
 Benefits Administrator 

Benefits Representative

 Benefits Assistant 

Environmental Health & Safety Specialist 
 Environmental Health & Safety Coordinator 
 Environmental
Health & Safety Assistant 
 Human Resources Assistant 

HRIS Assistant 
 Labor Relations Representative 
  

	5.	Adequate Separation Certification. The Plan requires the Plan Sponsor to certify that the employees identified above are the only employees that will access and
use participants’ PHI. The Plan Sponsor must further certify that such employees will only access and use PHI for the purposes set forth under number 1. 

 

	6.	Reports of Non-Compliance. Anyone who suspects an improper use or disclosure of PHI may report the occurrence to the Plan’s Privacy Official:

 Privacy Officer: 
 Erika Berglund 
 Executive Director, Talent Resources 

E-mail: eberglund@unifiedgrocers.com 
 5200 Sheila Street, Commerce, CA 90040 
 Phone: (323) 264-5200

 

 Notice of Privacy Practices — Unified takes the protection of your health information
seriously. Federal law requires your health plan(s) to provide a Notice of Privacy Practices, which describe how your health information is safeguarded, the circumstances in which your health information may be used, and your legal rights. We have
posted our Notice of Privacy Practices online or you may request a copy by contacting the Benefits Department. 

  
 61 

 Plan Administration 
  

			
	 Self Insured Preferred Provider Organization (PPO) Plan Base
Medical Plan
  

		
	 Plan Name
	  	Unified Grocers, Inc. Officer Retiree Medical Plan – Self-Insured Anthem Blue Cross PPO Base Medical Plan
	 Plan Number
	  	 511

 

	 Type of Plan
	  	 Welfare Plan–Medical

 

	 Type of Administration
	  	 Self-funded medical plan

 

	 Plan Administrator
	  	 The Benefits Committee

Unified Grocers
 5200 Sheila Street Commerce, CA
90040
 (323) 264-5200 Office hours: 7:30 a.m. to 4:00 p.m. Monday through Friday

		
	 	  	 The Plan Sponsor and the Plan Administrator shall be the “named fiduciaries” under
the Plan for purposes of ERISA section 402(a)(1).
  

	 Plan Sponsor/Employer
	  	 Unified Grocers, Inc.
 Unified has adopted the plan and has the right to terminate
 or amend its provisions. The
Company’s address and telephone number are listed above.
  

	 Plan Sponsor EIN
	  	 95-0615250

 

	 Plan Year
	  	 January 1 to December 31

 

	 Claim Administrator
	  	 BC Life & Health Insurance Company

21555 Oxnard Street
 Woodland Hills, California
91367

	Agent for the Service of Legal Process	  	 Service of legal process may be made on
 the Plan Administrator (the Benefits Committee)
  

	 Plan Premium
	  	 The premium for coverage is based on the expected cost of claims that will be incurred during
the year plus the Anthem Blue Cross administrative charges for processing claims. Unified Grocers sets an annual budget and, on an annual basis, will establish a total amount it will pay toward the cost of health care coverage and then will pay a
percentage, to be determined annually, of the cost for coverage. Your cost for coverage will be provided to you during annual enrollment.

 

	 Plan Financing
	  	 The premium for coverage is based on the expected cost of claims that will be incurred during
the year plus the Anthem Blue Cross administrative charges for processing claims. Unified Grocers sets an annual budget and, on an annual basis, will establish a total amount it will pay toward the cost of health care coverage and then will pay a
percentage, to be determined annually, of the cost for coverage. Your cost for coverage will be provided to you during annual enrollment.

 

  
 62 

			
	 Self Insured Delta Dental Preferred Option PPO Plan Base
Medical Plan
  

	 Plan Name
	  	Unified Grocers, Inc. Officer Retiree Medical Plan – Self-Insured Delta Dental Preferred Option PPO Base Medical
Plan
	 Plan Number
	  	 511

 

	 Type of Plan
	  	 Welfare Plan–Dental

 

	 Type of Administration
	  	 Self-funded dental plan, administered by Delta Dental as a third party provider (See
“Claims Administrator”)
  

		
	 Plan Administrator
	  	 The Benefits Committee

Unified Grocers
 5200 Sheila Street Commerce, CA
90040
 (323) 264-5200 Office hours: 7:30 a.m. to 4:00 p.m. Monday through Friday

		
	 	  	 The Plan Sponsor and the Plan Administrator shall be the “named fiduciaries” under
the Plan for purposes of ERISA section 402(a)(1).
  

	 Plan Sponsor/Employer
	  	 Unified Grocers, Inc.
 Unified has adopted the plan and has the right to terminate
 or amend its provisions. The
Company’s address and telephone number are listed above.
  

	 Plan Sponsor EIN
	  	 95-0615250

 

	 Plan Year
	  	 January 1 to December 31

 

	 Claim Administrator
	  	 Delta Dental
 P.O. Box 997330
 Sacramento, CA 95899
 www.deltadentalca.org
  
 The
Plan has a contract with Delta Dental to provide administrative services.
  

	Agent for the Service of Legal Process	  	 Service of legal process may be made on the Plan Administrator (the Benefits
Committee)
  

	 Plan Premium
	  	 The premium for coverage is based on the expected cost of claims that will be incurred during
the year plus Delta Dental administrative charges for processing claims. Unified sets an annual budget and, on an annual basis, will establish a total amount it will pay toward the cost of dental care coverage and then will pay a percentage, to be
determined annually, of the cost for coverage. Your cost for coverage will be provided to you during annual enrollment.
  

	 Plan Financing
	  	 The Plan is self-funded by Unified’s contributions and by premiums paid by retirees and
their families.
  

  
 63 

			
	 Self Insured Vision Service Plan (VSP) Base Medical
Plan
  

	 Plan Name
	  	Unified Grocers, Inc. Officer Retiree Medical Plan – Self-Insured Vision Service Plan (VSP) Base Medical Plan
	 Plan Number
	  	 511

 

	 Type of Plan
	  	 Welfare Plan–Vision

 

	 Type of Administration
	  	 Self-funded vision plan, administered by Vision Service Plan as a third party provider (See
“Claims Administrator”)
  

	 Plan Administrator
	  	 The Benefits Committee

Unified Grocers
 5200 Sheila Street Commerce, CA
90040
 (323) 264-5200 Office hours: 7:30 a.m. to 4:00 p.m. Monday through Friday

		
	 	  	 The Plan Sponsor and the Plan Administrator shall be the “named fiduciaries” under
the Plan for purposes of ERISA section 402(a)(1).
  

	 Plan Sponsor/Employer
	  	 Unified Grocers, Inc.
 Unified has adopted the plan and has the right to terminate or amend its provisions. The Company’s address and telephone number are listed above.

 

	 Plan Sponsor EIN
	  	 95-0615250

 

	 Plan Year
	  	 January 1 to December 31

 

	 Claim Administrator
	  	 Vision Service Plan
 P.O. Box 997100
 Sacramento, CA 95899-7100
 (800) 877-7195
 www.vsp.com

 
 The Plan has a contract with Vision Service Plan to provide administrative
services.
  

	 Agent for the Service of Legal Process
	  	Service of legal process may be made on the Plan Administrator (the Benefits Committee)
	 Plan Premium
	  	 The premium for coverage is based on the expected cost of claims that will be incurred during
the year plus VSP administrative charges for processing claims. Unified sets an annual budget and, on an annual basis, will establish a total amount it will pay toward the cost of vision care coverage and then will pay a percentage, to be determined
annually, of the cost for coverage. Your cost for coverage will be provided to you during annual enrollment.
  

	 Plan Financing
	  	 The Plan is self-funded by Unified’s contributions and by premiums paid by retirees and
their families.
  

  
 64 

 The Fully-Insured Health Maintenance Organization (HMO) Base Medical Plan options are as follows:

  

			00000000000000000000000000		00000000000000000000000000		00000000000000000000000000
	HMO/Insurance Carrier	 	Type of Plan	 	Contact Address	  	Contract Number
	 Kaiser Permanente (So Cal)
	 	Retiree Medical	 	P.O. Box 7102
 Pasadena, CA 91109
  
	  	101709

	 Kaiser Permanente (No Cal)
	 	Retiree Medical	 	P.O. Box 12923
Oakland, CA 94604
 
	  	22231

	 Kaiser Permanente (Oregon)
	 	Retiree Medical	 	500 NE Multnomah
St, Ste 100 Portland,
OR 97232  
	  	1944

	 UnitedHealthcare—Secure Horizons
	 	Retiree Medical	 	P.O. Box 6090
Cypress, CA 90630
 
	  	515431 (CA)

	 UnitedHealthcare
	 	Post-65 Retiree
Prescription Benefits	 	2300 Main Street
Irvine, CA 92614
 
	  	ID 338

 The Fully-Insured Dental Maintenance Organization (DMO) Base Medical Plan options are as follows: 

 

			00000000000000000000000000		00000000000000000000000000		00000000000000000000000000
	HMO/Insurance Carrier    	  	Type of Plan	 	Contact Address	  	Contract Number
	 Safeguard
Dental        
	  	Retiree Dental        	 	Safeguard Dental
 P.O. Box 30920
Laguna Hills, CA 92654
	  	3137

 Executive Medical Reimbursement Plan: 
  

			00000000000000000000000000		00000000000000000000000000		00000000000000000000000000
	HMO/Insurance Carrier	  	Type of Plan	 	Contact Address	  	Contract Number
	 Anthem Blue Cross Life and Health Insurance Company
	  	Supplemental Retiree
Medical            	 	21555 Oxnard Street
Woodland, CA 91367	  	WL14816

 This booklet does not contain detailed information about the EMRP, nor is it by itself a Summary Plan Description of
the EMRP. The terms and conditions of the Certificate of Insurance governing the EMRP are incorporated by this reference, and, when read together with this booklet and the Evidence of Coverage of your HMO Base Medical Plan option (if applicable),
constitute your official Summary Plan Description of the Plan. 

  
 65 

 Definitions

 Accidental Bodily Injury – an injury to your body caused by an accident. 

Calendar Year – the 12 month period beginning on January 1 of each year. 
 Center of Medical Excellence (CME) –Facilities that are recognized for their distinguished care in the specific areas including transplant centers. 

Chemical Dependency – a condition characterized by a physiological or psychological dependence, or both, on alcohol or a state-regulated
controlled substance in which case a person: 
  

	 	n	Loses self control over the amount and circumstances of use, 

  

	 	n	Develops symptoms of tolerance, or 

  

	 	n	Substantially impairs or endangers his or her health or disrupts him or her socially. 

 Claims Administrator – refers to Anthem Blue Cross Life and Health Insurance Company. On behalf of Anthem Blue Cross Life and Health Insurance Company, Anthem Blue Cross shall perform all
administrative services in connection with the processing of claims under the Plan. 
 COBRA–Consolidated Omnibus Budget
Reconciliation Act of 1985 as amended from time to time by the federal government. 
 Coordination of Benefits (COB) – (also called

 Non-Duplication) a method of determining the amount your medical and dental plan coverage pays if you are also covered by another medical or
dental plan. COB is designed to ensure that covered, out-of-pocket expenses are paid according to Plan provisions, without reimbursing a covered employee for more than the allowed amount of all medical costs. 

Co-payment – means the fixed dollar amount or relative percentages paid by you and the Plan. 

Custodial Care – is care designed to assist an individual in meeting his or her daily needs or services that constitute personal care such
as: help with walking, dressing, getting into and out of bed, assistance with bathing, eating, preparation of meals, separation of an individual from others, and supervision of medication which can usually be self-administered and which does not
entail or require continual attention of trained medical personnel. 
 Deductible – the amount of expense you must incur for covered
services and supplies before benefits are provided under this Plan.

 Domestic Partner – means your registered same-sex domestic partner if you live in a State that
allows the registration or certification of domestic partnerships. 
 Durable Medical Equipment – mechanical equipment which can
stand repeated use and is used in connection with the direct treatment of an illness or accidental injury. 
 Eligible Dependent –
your children up to age 26 regardless of their marital, dependency or student status, or over age 26 if incapable of self-care with the disability occurring prior to age 26. For purposes of this definition, the term “children” includes
your adopted child, step-child or foster child. 
 Emergency Room – An emergency is a sudden, serious, and unexpected acute illness,
injury, or condition (including without limitation sudden and unexpected severe pain), or a psychiatric emergency medical condition, which the member reasonably perceives, could permanently endanger health if medical treatment is not received
immediately. Final determination as to whether services were rendered in connection with an emergency will rest solely with the claims administrator. 
 ERISA – the Employee Retirement Income Security Act of 1974 as amended from time to time by the federal government.  
 Experimental – procedures are those that are mainly limited to laboratory and/or animal research. 
 HIPAA – the Health Insurance Portability and Accountability Act of 1996 as amended from time to time by the federal government. 
 Hospital – is an acute care facility accredited by and operated in accordance with the laws of the jurisdiction in which the hospital is located. The facility must be primarily engaged in
providing diagnostic and therapeutic facilities for surgical and medical diagnosis and treatment of injured and sick persons on an inpatient basis. These services are provided by or under the supervision of physicians and a 24-hour staff of
registered, graduated nurses. Any facility which is primarily a resting place or a place for the aged, a nursing home, a convalescent home or any facility operated by the federal government or its agencies will not be considered a hospital under
this definition. 
 Illness – a sickness, disease, medical condition, complication of pregnancy, or pregnancy. 

Inpatient – confined in a medical facility as an overnight bed patient. 
 Investigative – procedures or medications are those that have progressed to limited use on humans, but which are not widely accepted as proven and effective within the organized medical
community. 

 

  
 66 

 Maximum Allowed Amount – charges for services or supplies not exceeding the prevailing charge
or fee for services as determined by the Plan. 
 Medical Emergency – a sudden onset of a medical condition or accidental injury
manifested by acute, severe symptoms which, left untreated, could reasonably result, in the judgment of the Plan, in one of the following: 
  

	 	n	Placing the person’s life in jeopardy; 

  

	 	n	Causing serious impairment to bodily functions; or 

  

	 	n	Causing serious and permanent dysfunction of any body organ or part  

 Medically Necessary – care, supplies, or equipment not Medically Necessary, as determined by Anthem Blue Cross, for the treatment of an Injury or illness. This includes, but is not limited to,
care which does not meet Anthem Blue Cross medical policy, clinical coverage guidelines, or benefit policy guidelines. 
 Non-Emergency
Surgery/Confinement – services which need not be performed as an emergency, but may be required in process of recovery from injury or disease and are medically necessary. 
 Out-of-Pocket Expenses – the amount an individual pays toward Plan benefits in any given Calendar Year. The co-payments for wellness benefits do not accumulate towards your out-of-pocket
expenses. 
 Outpatient – treatment received in a setting other than an inpatient in a medical facility. 

Physician – one of the following licensed practitioners (unless otherwise specified): 

Doctor of Medicine, M.D. 
 Doctor of Osteopathy, D.O. 
 Doctor of Dentistry, D.D.S., or D.M.D. 

Denturist 

Podiatrist, D.P.M. 
 Psychologist, PhD, or PsyD 
 licensed according to state law. 

Registered and Certified Clinical Social Worker, 
 R.C.S.W., C.C.S.W., L.C.S.W., or A.C.S.W. 
 Doctor of Chiropractic, D.C.

 Certified Registered Nurse Anesthesiologist 
 Certified Registered Nurse Practitioner 
 Certified Pediatric Nurse Practitioner

 Registered Physical Therapist 

ASHA Certified Speech Therapist 
 Acupuncturist 
 Physicians Assistant 

Prescription Drug – any medical substance bearing a label which, under the Federal Food, Drug and Cosmetic Act as amended, is required to
bear the legend, “Caution: federal law prohibits dispensing without a prescription.” This includes insulin. It does not include any drugs labeled, “Caution–limited by federal law to investigational use.” It consists of
legend drugs. 
 Sickness – a covered illness or disease. 
 Skilled Nursing Care – care that requires the services of an R.N. or L.P.N., such as injections, change of I.V., central lines, or N.G. tubes, dressing changes, etc. These are services that
cannot be performed by an aide. 
 Skilled Nursing Facility – a facility approved for payment under the Medicare Act. This does not
include any facility or institution owned, operated or maintained by any government or governmental agency. It is a medical facility providing services requiring the direction of a physician and nursing supervision by registered nurses. 

Spouse – means your husband or wife, determined under the state of your residence. An eligible spouse under the Plan is defined as the person
to whom you are legally married.  
 The Plan – means this Unified Grocers, Inc. Officer Retiree Medical Plan. 

Transplant – means a procedure or a series of procedures by which an organ, tissue, bone marrow or peripheral stem cell is either removed
from the body of one person and implanted in the body of another person, or removed from and replaced in the same person’s body. In treatment of cancer, the term transplant includes any chemotherapy and related course of treatment, which the
transplant supports. 
 Usual and Customary Charges (U&C) – A Usual fee is the amount which an individual dentist regularly
charges and receives for a given service or the fee actually charges, whichever is less. A Customary fee is within the range of usual fess charged and received for a particular service by dentists of similar training in the same geographic area. A
Reasonable fee schedule is reasonable if it is Usual and Customary. 
 War – declared or undeclared war, whether civil or
international, and any substantial armed conflict between organized forces of a military nature. 

 

  
 67 

 Provider Contact Information 

 

							
	    Medical Plan	  	Group Number	  	Phone	  	Web Site
	     Anthem Blue Cross PPO
	  		  	(866) 940-6544	  	www.anthem.com/ca
	
    California
	  	 	  	 	  	 
	     Under 65
	  	1220CH	  		  	
	
    65+
	  	1122KM	  	 	  	 
	     Oregon
	  		  		  	
	     Under
65
	  	1220CM	  	 	  	 
	     65+
	  	1220CN	  		  	
	     Other
States
	  	 	  	 	  	 
	     Under 65
	  	1220CJ	  		  	
	
    65+
	  	1220CC	  	 	  	 
	     EMRP
	  	1220CG	  	 	  	 
				
	     CVS Caremark Rx
	  		  	(800) 966-5772	  	www.caremark.com
	     Under
65
	  	4678-0002	  	 	  	 
	     Mail Order
	  		  		  	
	     Maintenance Choice
	  	 	  	(800) 966-5772	  	 
	     Specialty Drug -
	  		  		  	
	     Caremark Connect
	  		  	(800) 237-2767	  	
	     UnitedHealth
Rx
	  	 	  	(888) 556-6648	  	www.uhcmedicarerxforgroups.com
	     65+
	  	338	  	 	  	 
				
	     Kaiser Permanente
	  		  	(800) 464-4000	  	www.kaiserpermanente.org
	 	 	 	 
	     Northern CA
	  	 	  	 	  	 
				
	     Under 65
	  	22231-0000	  		  	
	 	 	 	 
	     65+
	  	22231-0001	  	 	  	 
				
	     Southern CA
	  		  		  	
	 	 	 	 
	     Under 65
	  	101709-0000	  	 	  	 
				
	     65+
	  	101709-0060	  		  	
	 	 	 	 
	     Kaiser OR
	  	 	  	(800) 813-2000	  	 
				
	     Under 65
	  	1944-001	  		  	
	 	 	 	 
	     65+
	  	1944-002	  	 	  	 
				
	     UnitedHealth
	  		  		  	
				
	     Secure Horizons
	  		  	(888) 422-6000	  	www.uhcretiree.com
	 	 	 	 
	     65+
	  	5515433	  	 	  	 
	     Prescription Solutions
	  	 	  	(888) 736-7430	  	 

  
 68mPhase Technologies, Inc. - Exhibit 10.71 - Filed by newsfilecorp.com

Exhibit 10.71 

THIS CONVERTIBLE NOTE AND THE SECURITIES ISSUABLE UPON
CONVERSION OF THIS CONVERTIBLE NOTE HAVE NOT BEEN REGISTERED UNDER THE
SECURITIES ACT OF 1933, AS AMENDED (THE “SECURITIES ACT”), OR UNDER THE
SECURITIES LAWS OF APPLICABLE STATES. THESE SECURITIES ARE SUBJECT TO
RESTRICTIONS ON TRANSFERABILITY AND RESALE AND MAY NOT BE TRANSFERRED OR RESOLD
EXCEPT AS PERMITTED UNDER THE SECURITIES ACT AND THE APPLICABLE STATE SECURITIES
LAWS, PURSUANT TO REGISTRATION OR EXEMPTION THEREFROM. INVESTORS SHOULD BE AWARE
THAT THEY MAY BE REQUIRED TO BEAR THE FINANCIAL RISKS OF THIS INVESTMENT FOR AN
INDEFINITE PERIOD OF TIME. THE ISSUER OF THESE SECURITIES MAY REQUIRE AN OPINION
OF COUNSEL IN FORM AND SUBSTANCE SATISFACTORY TO THE ISSUER TO THE EFFECT THAT
ANY PROPOSED TRANSFER OR RESALE IS IN COMPLIANCE WITH THE SECURITIES ACT AND ANY
APPLICABLE STATE SECURITIES LAWS. 

CONVERTIBLE NOTE
OF 

  mPHASE TECHNOLOGIES, INC. 

	$25,000.00 	Made as of August 10, 2011

          mPhase
Technologies, Inc., a New Jersey corporation (the “Company”),
hereby promises to pay to Jay O. Wright (the “Holder”), or his
registered assigns, six (6) months from the date of this Note (i.e. February 10,
2012) (the “Maturity Date”), the principal sum of $25,000.00 (the
“Principal Amount”), or such lesser amount as shall then equal the
outstanding Principal Amount hereunder, together with interest on the unpaid
principal balance equal to one percent (1.00%) per month prior to maturity, and
upon default or after maturity two percent (2.00%) per month, in both cases
compounded monthly, computed on the basis of the actual number of days elapsed
and a year of 365 days from the date of this Convertible Note unless the
Principal Amount and all interest accrued thereon and all other amounts owed
hereunder are converted, as provided in Section 6 hereof. All payments received
by the Holder hereunder will be applied first to costs of collection, if any,
then to interest and the balance to principal. Principal and interest shall be
payable in lawful money of the United States of America. 

          This
Convertible Note may be prepaid in whole at any time by the Company at a price
equal to 105% of the amount of principal and accrued interest then outstanding
upon ten (10) days actual notice to the Holder.

          The
Company has issued and herewith delivers to the Holder, in consideration of his
purchase of this Note, a warrant to purchase 3,676,471 shares of its Common
Stock at an exercise price equal to the Conversion Price, as set forth in
Section 14 hereof ("Warrant"). 

          The
following is a statement of the rights of the Holder and the conditions to which
this Convertible Note is subject, and to which the Holder hereof, by the
acceptance of this Convertible Note, agrees: 

          1.    
    DEFINITIONS. The following
definitions shall apply for all purposes of this Convertible Note: 

          
           1.1.      “Closing”
means the date on which the purchase and sale of the Convertible Note occurred,
or August 10, 2011. 

                
     1.2.     
“Company” means the “Company” as defined above and
includes any corporation which shall succeed to or assume the obligations of the
Company under this Convertible Note. 

                 
     1.3.      “Common
Stock” means the shares of common stock of the Company.

                 
     1.4.      “Conversion
Price” means $0.0068 per share of Common Stock. 

                 
     1.5.      “Conversion
Stock” means the Common Stock into which any unpaid Principal Amount and
the accrued and unpaid interest due under this Convertible Note convert. The
number of shares of Conversion Stock are subject to adjustment as provided
herein. 

                  
    1.6.      “Convertible
Note” means this Convertible Note.

                 
     1.7.      “Holder”
means any person who shall at the time be the registered holder of this
Convertible Note. 

          2.       
REPRESENTATIONS AND WARRANTIES OF THE COMPANY. The
Company hereby represents and warrants to Holder that the statements in the
following paragraphs of this Section 2 are all true and complete as of
immediately prior to the Closing: 

    
                2.1.      Organization,
Good Standing and Qualification. The Company has been duly
organized, and is validly existing and in good standing, under the laws of the
State of New Jersey. The Company has the power and authority to own and operate
its properties and assets and to carry on its business as currently conducted
and as presently proposed to be conducted. 

        
            2.2.     
Due Authorization. All corporate action on the part of the
Company’s directors and stockholders necessary for the authorization, execution,
delivery of, and the performance of all obligations of the Company under the
Convertible Note has been taken or will be taken prior to the Closing, and the
Convertible Note when executed and delivered, will constitute, valid and legally
binding obligations of the Company, enforceable in accordance with their
respective terms, except as may be limited by (i) applicable bankruptcy,
insolvency, reorganization or other laws of general application relating to or
affecting the enforcement of creditor’s rights generally and (ii) the effect of
rules of law governing the availability of equitable remedies. 

           
         2.3.      Corporate
Power. The Company has the power and authority to execute and
deliver this Convertible Note to be purchased by the Holder hereunder, to issue
the Convertible Note and to carry out and perform all its obligations under the
Convertible Note. 

          
          2.4.      Valid
Issuance. The Convertible Note and the Conversion Stock issued upon
conversion of the Convertible Note, when issued, sold and delivered in
accordance with the terms of this Convertible Note for the consideration
provided for herein, will be duly and validly issued, fully paid and
nonassessable. 

           
         2.5.      Securities
Law Compliance. Based in part on the representations made by the
Holder in Section 3 hereof, the offer and sale of the Convertible Note solely to
the Holder in accordance with the terms herein are exempt from the registration
and prospectus delivery requirements of the U.S. Securities Act of 1933, as
amended (the “1933 Act”) and the securities registration and
qualification requirements of the currently effective provisions of the
securities laws of the states in which the Holder is a resident based upon the
address set forth herein. 

             
         2.6.     
  Use of Proceeds. The Proceeds of the Note will be used for working
  capital of EIP and to pay brokerage fees to Source Capital Group.

          3.      
 REPRESENTATIONS, WARRANTIES AND CERTAIN AGREEMENTS OF
HOLDER. Holder hereby represents and warrants to, and agrees with,
the Company, that: 

       
             3.1.      Authorization.
This Convertible Note constitutes such Holder’s valid and legally binding
obligation, enforceable in accordance with its terms except as may be limited by
(i) applicable bankruptcy, insolvency, reorganization or other laws of general
application relating to or affecting the enforcement of creditors’ rights
generally and (ii) the effect of rules of law governing the availability of
equitable remedies. Holder represents that such Holder has full power and
authority to enter into this Convertible Note. 

       
             3.2.      Purchase
for Own Account. The Convertible Note and the shares of the
Company’s Common Stock issuable upon conversion of this Convertible Note
(collectively, the “Securities”) are being acquired for investment
for Holder’s own account, not as a nominee or agent, and not with a view to the
public resale or distribution thereof within the meaning of the 1933 Act, and
such Holder has no present intention of selling, granting any participation in,
or otherwise distributing the same. 

      
              3.3.     
Disclosure of Information. Such Holder has received or has had
full access to all the information it considers necessary or appropriate to make
an informed investment decision with respect to the Securities. Such Holder
further has had an opportunity to ask questions and receive answers from the
Company regarding the terms and conditions of the offering of the Securities and
to obtain additional information (to the extent the Company possessed such
information or could acquire it without unreasonable effort or expense)
necessary to verify any information furnished to such Holder or to which such
Holder had access. The foregoing, however, does not in any way limit or modify
the representations and warranties made by the Company in Section 2. 

                
    3.4.      Investment
Experience. Such Holder understands that the purchase of the
Securities is highly speculative and involves substantial risk. Such Holder has
such knowledge and experience in financial and business matters that
it is capable of evaluating the merits and risks of its investment in the
Company and has the capacity to protect its own interests and the ability to
bear the economic risk of its investment. 

                    
3.5.      Restricted
Securities. Such Holder understands that the Securities are
characterized as “restricted securities” under the 1933 Act and Rule 144
promulgated thereunder inasmuch as they are being acquired from the Company in a
transaction not involving a public offering, and that under the 1933 Act and
applicable regulations thereunder such securities may be resold without
registration under the 1933 Act only in certain limited circumstances. In this
connection, such Holder is familiar with Rule 144, as presently in effect, and
understands the resale limitations imposed thereby and by the 1933 Act.

          4.      
 FURTHER LIMITATIONS ON DISPOSITION. Without in any
way limiting the representations set forth above, such Holder further agrees not
to make any disposition of all or any portion of the Securities unless and
until: 

                    
4.1.      there is then in effect
a registration statement under the 1933 Act covering such proposed disposition
and such disposition is made in accordance with such registration statement; or

                    
4.2.      such Holder
shall have notified the Company of the proposed disposition, and shall have
furnished the Company with a statement of the circumstances surrounding the
proposed disposition, and, at the expense of such Holder or its transferee, with
an opinion of counsel, reasonably satisfactory to the Company, that such
disposition will not require registration of such securities under the 1933 Act.

Notwithstanding the provisions of paragraphs (a) and (b) above,
no such registration statement or opinion of counsel shall be required: (i) for
any transfer of any Convertible Note or Conversion Stock in compliance with Rule
144 or Rule 144A; (ii) for any transfer of any Convertible Note or Conversion
Stock by a Holder that is a partnership or a corporation to (A) a partner of
such partnership or shareholder of such corporation, (B) a controlled affiliate
of such partnership or corporation, (C) a retired partner of such partnership
who retires after the date hereof, (D) the estate of any such partner or
shareholder; or (iii) for the transfer by gift, will or in testate succession by
any Holder to his or her spouse or lineal descendants or ancestors or any trust
for any of the foregoing; provided that in each of the foregoing cases the
transferee agrees in writing to be subject to the terms of this Section 4 to the
same extent as if the transferee were an original Holder hereunder. The Company
acknowledges and agrees that for purpose of calculating the Rule 144 holding
period, that any period of Holder holding its investment in the form of this
Note shall be “tacked” to the period that Holder holds Conversion Stock. 

          5.      LEGENDS.
Such Holder understands and agrees that the certificates evidencing the
Securities will bear legends substantially similar to those set forth below:

THE SECURITIES REPRESENTED HEREBY HAVE NOT BEEN
REGISTERED UNDER THE SECURITIES ACT OF 1933, AS AMENDED (THE “ACT”), OR UNDER
THE SECURITIES LAWS OF APPLICABLE STATES. THESE SECURITIES ARE SUBJECT TO
RESTRICTIONS ON TRANSFERABILITY AND RESALE AND MAY NOT BE TRANSFERRED OR RESOLD
EXCEPT AS PERMITTED UNDER THE ACT AND THE APPLICABLE STATE SECURITIES LAWS,
PURSUANT TO REGISTRATION OR EXEMPTION THEREFROM. INVESTORS SHOULD BE AWARE THAT
THEY MAY BE REQUIRED TO BEAR THE FINANCIAL RISKS OF THIS INVESTMENT FOR AN
INDEFINITE PERIOD OF TIME. THE ISSUER OF THESE SECURITIES MAY REQUIRE AN OPINION
OF COUNSEL IN FORM AND SUBSTANCE SATISFACTORY TO THE ISSUER TO THE EFFECT THAT
ANY PROPOSED TRANSFER OR RESALE IS IN COMPLIANCE WITH THE ACT AND ANY APPLICABLE
STATE SECURITIES LAWS. 

The legend set forth above shall be removed by the Company from
any certificate evidencing the Securities upon delivery to the Company of an
opinion of counsel, reasonably satisfactory to the Company, that a registration
statement under the 1933 Act is at that time in effect with respect to the
legended security or that such security can be freely transferred in a public
sale (other than pursuant to Rule 144 or Rule 145 under the 1933 Act) without
such a registration statement being in effect and that such transfer will not
jeopardize the exemption or exemptions from registration pursuant to which the
Company issued the Securities. 

          6.       
CONVERSION. 

          
          6.1.      Optional
Conversion. Upon the request of the Holder, this Convertible Note
may be converted, in whole or in part, into shares of Common Stock at the
Conversion Price. 

            
        6.2.      Issuance
of Conversion Stock. Within two (2) business days after conversion
of this Convertible Note in whole or in part, the Company at its expense will
cause to be issued in the name of and delivered to the Holder, a certificate or
certificates for the Common Stock to which the Holder shall be entitled upon
such conversion or, at the Holder’s request and if eligible under Rule 144,
shares shall be DWAC’d to a brokerage account designated by the Holder, together
with any other securities and property to which the Holder is entitled upon such
conversion under the terms of this Convertible Note. If upon any conversion of
this Convertible Note (and all other Convertible Notes held by the same Holder,
after aggregating all such conversions), a fraction of a share of Common Stock
would otherwise result, then in lieu of such fractional share of Common Stock
the Company will pay the cash value of that fractional share, calculated on the
basis of the applicable Conversion Price. 

          7.       
DEFAULT; ACCELERATION OF OBLIGATION. The Company will be
deemed to be in default under this Convertible Note and the outstanding unpaid
principal balance of this Convertible Note, together with all interest accrued
thereon, will immediately become due and payable in full, without the need for
any further action on the part of Holder, upon the occurrence of any of the
following events (each an “Event of Default”): (a) failure to make
payment of principal and interest when due under this Convertible Note; (b) upon
the filing by or against the Company of any voluntary or involuntary petition in
bankruptcy or any petition for relief under the federal bankruptcy code or any other state or
federal law for the relief of debtors; provided, however, with respect to an
involuntary petition in bankruptcy, such petition has not been dismissed within
ninety (90) days after the filing of such petition; (c) upon the execution by
the Company of an assignment for the benefit of creditors or the appointment of
a receiver, custodian, trustee or similar party to take possession of the
Company’s assets or property; (d) if the Company ceases to trade on the OTC
Bulletin Board, Nasdaq or the American Stock Exchange; or (e) the breach of any
provision of this Convertible Note. 

          8.       
REMEDIES ON DEFAULT; ACCELERATION; ADJUSTMENTS. Upon any
Event of Default, the Holder will have, in addition to its rights and remedies
under this Convertible Note, full recourse against any real, personal, tangible
or intangible assets of the Company, and may pursue any legal or equitable
remedies that are available to Holder, and may declare the entire unpaid
principal amount of this Convertible Note and all unpaid accrued interest under
this Convertible Note to be immediately due and payable in full. 

            
        8.1.     
Adjustment Provisions. The number and character of shares of
Conversion Stock issuable upon conversion of this Convertible Note (or any
shares of stock or other securities or property at the time receivable or
issuable upon conversion of this Convertible Note) and the Conversion Price
therefor are subject to adjustment upon occurrence of the following events
between the date this Convertible Note is issued and the date it is converted.
If there is an event of default under this Convertible Note, then the Conversion
Price shall be immediately reduced to $.0025 per share. 

            
        8.2.     
Adjustment for Stock Splits, Stock Dividends, Recapitalizations,
etc. If a stock dividend, stock split, reclassification,
recapitalization or other similar event affecting the number of outstanding
shares of Conversion Stock occurs other than a reverse stock split, the
Conversion Price of this Convertible Note and the number of shares of Conversion
Stock issuable upon conversion of this Convertible Note (or any shares of stock
or other securities at the time issuable upon conversion of this Convertible
Note) shall each be proportionally adjusted on a full-ratchet basis to reflect
any stock dividend, stock split, reverse stock split, reclassification,
recapitalization or other similar event affecting the number of outstanding
shares of Conversion Stock (or such other stock or securities). If a reverse
stock split occurs, a similar adjustment shall be made, provided however, that
if the closing bid stock price of the Company on the date that the reverse stock
split goes effective (the “New Price”) is more than 10% below the Conversion
Price after giving effect to the reverse stock split, then the Conversion Price
shall be reduced to that New Price. 

            
        8.3.      Adjustment
for Other Dividends and Distributions. In case the Company shall
make or issue, or shall fix a record date for the determination of eligible
holders entitled to receive, a dividend or other distribution payable with
respect to the Common Stock that is payable in (a) securities of the Company
(other than issuances with respect to which adjustment is made under Section 8),
or (b) assets (other than cash dividends paid or payable solely out of retained
earnings), then, and in each such case, the Holder, upon conversion of this
Convertible Note at any time after the consummation, effective date or record
date of such event, shall receive, in addition to the shares of Conversion Stock
issuable upon such exercise prior to such date, the securities or such other
assets of the Company to which the Holder would have been entitled upon such date if the Holder had converted this
Convertible Note immediately prior thereto (all subject to further adjustment as
provided in this Convertible Note). 

            
        8.4.      Adjustment
for Reorganization, Consolidation, Merger. In case of any
reorganization of the Company (or of any other entity the securities of which
are at the time receivable on the conversion of this Convertible Note), after
the date this Convertible Note, or in case, after such date, the Company (or any
such corporation) shall consolidate with or merge into another corporation or
convey all or substantially all of its assets to another corporation and then
distribute the proceeds to its interest holders, then, and in each such case,
the Holder, upon the conversion of this Convertible Note (as provided in Section
6) at any time after the consummation of such reorganization, consolidation,
merger or conveyance, shall be entitled to receive, in lieu of the Conversion
Stock or other securities and property receivable upon the conversion of this
Convertible Note prior to such consummation, the stock or other securities or
property to which the Holder would have been entitled upon the consummation of
such reorganization, consolidation, merger or conveyance if the Holder had
converted this Convertible Note immediately prior thereto, all subject to
further adjustment as provided in this Convertible Note, and the successor or
purchasing corporation in such reorganization, consolidation, merger or
conveyance (if other than the Company) shall duly execute and deliver to the
Holder a supplement hereto acknowledging such corporation’s obligations under
this Convertible Note; and in each such case, the terms of the Convertible Note
shall be applicable to the Common Stock or other securities or property
receivable upon the conversion of this Convertible Note after the consummation
of such reorganization, consolidation, merger or conveyance. 

          
          8.5.      Adjustment
for Dilutive Issuances. If the Company, at any time after the date
of this Convertible Note, shall issue any shares of Common Stock or securities
of the Company convertible into shares of Common Stock at a price per share of
Common Stock less than the Conversion Price in effect immediately prior to such
issuance, in any case other than an Excluded Issuance (as hereinafter defined)
(a “Dilutive Issuance”), then, and in each such case, the
Conversion Price shall be reduced to the effective per share price of the Common
Stock in connection with such additional issuance of securities. 

           9.       
NOTICE OF ADJUSTMENTS. The Company shall promptly give
written notice of each adjustment or readjustment of the Conversion Price or the
number of shares of Common Stock or other securities issuable upon conversion of
this Convertible Note. The notice shall describe the adjustment or readjustment
and show in reasonable detail the facts on which the adjustment or readjustment
is based. 

          10.      NO
CHANGE NECESSARY. The form of this Convertible Note need not be
changed because of any adjustment in the Conversion Price or in the number of
shares of Common Stock issuable upon its conversion. 

          11.      NO
RIGHTS OR LIABILITIES AS STOCKHOLDER. This Convertible Note does
not by itself entitle the Holder to any voting rights or other rights as a
stockholder of the Company. In the absence of conversion of this Convertible
Note, no provisions of this Convertible Note, and no enumeration herein of the
rights or privileges of the Holder, shall cause the Holder to be a stockholder
of the Company for any purpose.

          12.     
NO IMPAIRMENT. The Company will not, by amendment of its
Certificate of Incorporation, or through reorganization, consolidation, merger,
dissolution, issue or sale of securities, sale of assets or any other voluntary
action, willfully avoid or seek to avoid the observance or performance of any of
the terms of this Convertible Note, but will at all times in good faith assist
in the carrying out of all such terms and in the taking of all such action as
may be necessary or appropriate in order to protect the rights of the Holder
under this Convertible Note against wrongful impairment. Without limiting the
generality of the foregoing, the Company will take all such action as may be
necessary or appropriate in order that the Company may duly and validly issue
fully paid and nonassessable shares of Common Stock upon the conversion of this
Convertible Note. 

          13.     
PREPAYMENT. The Company may at any time, without penalty, upon
at least five (5) days’ advance written notice to the Holder, prepay in whole or
in part the unpaid balance of this Convertible Note at a price equal to 105% of
par. All payments will first be applied to the repayment of accrued fees and
expenses, then to accrued interest until all then outstanding accrued interest
has been paid, and then shall be applied to the repayment of principal. The
Holder shall have the right to convert this Note prior to such prepayment. 

          14.     
WARRANT. Simultaneously with the execution of this Note, the
Company shall issue a Warrant in the form attached hereto as Exhibit
A, exercisable for five years to purchase 3,333,334 shares of Common
Stock at an exercise price equal to the Conversion Price. 

          15.     
WAIVERS. The Company and all endorsers of this Convertible Note
hereby waive notice, presentment, protest and notice of dishonor. 

          16.     
ATTORNEYS’ FEES. In the event any party is required to engage
the services of any attorneys for the purpose of enforcing this Convertible
Note, or any provision thereof, the prevailing party shall be entitled to
recover its reasonable expenses and costs in enforcing this Convertible Note,
including attorneys’ fees. 

          17.      TRANSFER.
Neither this Convertible Note nor any rights hereunder may be assigned, conveyed
or transferred, in whole or in part, without the Company’s prior written
consent, which the Company may withhold in its sole discretion. The rights and
obligations of the Company and the Holder under this Convertible Note shall be
binding upon and benefit their respective permitted successors, assigns, heirs,
administrators and transferees. 

          18.      GOVERNING
LAW; JURISDICTION; VENUE. This Convertible Note shall be governed
by and construed under the internal laws of the State of New Jersey as applied
to agreements among New Jersey residents entered into and to be performed
entirely within New Jersey, without reference to principles of conflict of laws
or choice of laws. Each of the parties irrevocably consents that any legal
action or proceeding for equitable relief which may be brought against any of
them pursuant to the terms of this Convertible Note which arise out of or are in
any manner related to this Convertible Note may be brought in the federal and
state courts of New Jersey. Each party by the execution and delivery of this
Convertible Note, expressly and irrevocably consents and submits to the personal
jurisdiction of any of such courts in any such action or proceeding. Each party
hereby expressly and irrevocably waives any claim or defense in any such action or proceeding based on any alleged lack of
personal jurisdiction, improper venue or forum non conveniens or any similar
basis. 

          19.     
HEADINGS. The headings and captions used in this Convertible
Note are used only for convenience and are not to be considered in construing or
interpreting this Convertible Note. All references in this Convertible Note to
sections and exhibits shall, unless otherwise provided, refer to sections hereof
and exhibits attached hereto, all of which exhibits are incorporated herein by
this reference. 

          20.     
NOTICES. Unless otherwise provided, any notice required or
permitted under this Convertible Note shall be given in writing and shall be
deemed effectively given (i) at the time of personal delivery, if delivery is in
person; (ii) one (1) business day after deposit with an express overnight
courier for United States deliveries, or two (2) business days after such
deposit for deliveries outside of the United States, with proof of delivery from
the courier requested; or (iii) three (3) business days after deposit in the
United States mail by certified mail (return receipt requested) for United
States deliveries when addressed to the party to be notified at the address
indicated for such party or, in the case of the Company, at 587 Connecticut
Avenue, Norwalk, CT 06854, or at such other address as any party or the Company
may designate by giving ten (10) days’ advance written notice to all other
parties, and if to the Holder, at 6701 Democracy Blvd., Suite 300, Bethesda, MD
20817. 

          21.      AMENDMENTS
AND WAIVERS. Any term of this Convertible Note may be amended, and
the observance of any term of this Convertible Note may be waived (either
generally or in a particular instance and either retroactively or prospectively)
only with the written consent of the Company and the Holder. Any amendment or
waiver effected in accordance with this Section shall be binding upon the
Holder, each future holder of such securities, and the Company. 

          22.      SEVERABILITY.
If one or more provisions of this Convertible Note are held to be unenforceable
under applicable law, such provision(s) shall be excluded from this Convertible
Note and the balance of the Convertible Note shall be interpreted as if such
provision(s) were so excluded and shall be enforceable in accordance with its
terms. 

          23.      PIGGYBACK
REGISTRATION. If (but without any obligation to do so) the Company
elects to register (including for this purpose a registration effected by the
Company for shareholders) any of its stock or other securities under the
Securities Act in connection with a public offering of such securities solely
for cash other than (a) a registration on Form S-8 (or other similar successor
form) relating solely to the sale of securities to participants in a Company
stock plan or to other compensatory arrangements to the extent includable on
Form S-8 (or other similar successor form); or (b) a registration on Form S-4
(or other similar successor form), the Company shall, at least thirty (30) days
prior to finalizing a registration statement, promptly give the Holder written
notice of such registration. Upon the written request of each Holder given
within twenty (20) days after mailing of such notice by the Company in
accordance with Section 20, the Company shall cause to be registered under the
Securities Act all of the Conversion Stock not otherwise freely tradable under
Rule 144 of the Securities Act that such Holder thereof has requested to be
registered. In the event that the underwriters advise the Company that marketing
factors require a limitation of the number of shares to be underwritten, the
Company shall use its best commercial efforts to include as many shares of Conversion
Stock as is reasonable in the opinion of the underwriter. The Company shall have
no obligation under this Section 23 to make any offering of its securities, or
to complete an offering of its securities that it proposes to make, and shall
incur no liability to any Holder for its failure to do so. 

[Signature Page Next] 

          IN
WITNESS WHEREOF, the Company has caused this Convertible Note to be signed
in its name as of the date first above written. 

MPHASE TECHNOLOGIES, INC.

	 	By: 	Ronald A. Durando 
	 	 	 
	 	Title: 	CEO 

Exhibit A 

FORM OF WARRANT

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