SOUTHERN CALIFORNIA UNITED FOOD & COMMERCIAL WORKERS UNIONS AND DRUG EMPLOYERS TRUST FUNDS 2220 HYPERION AVENUE LOS ANGELES, CALIFORNIA 90027

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1 SOUTHERN CALIFORNIA UNITED FOOD & COMMERCIAL WORKERS UNIONS AND DRUG EMPLOYERS TRUST FUNDS 2220 HYPERION AVENUE LOS ANGELES, CALIFORNIA TEL (323) FAX (323) Administrative offices for: SOUTHERN CALIFORNIA UNITED FOOD & COMMERCIAL WORKERS UNIONS AND DRUG EMPLOYERS PENSION FUND SOUTHERN CALIFORNIA DRUG BENEFIT FUND Date April 30, 2013 To: All active Employees and their Dependents, including COBRA beneficiaries, in the Platinum Plus Indemnity Medical Plan of the Southern California Drug Benefit Fund From: Southern California Drug Benefit Fund This Summary of Material Modifications (SMM) will advise you of certain changes that have been made to the Platinum Plus Indemnity Medical Plan of the Southern California Drug Benefit Fund to comply with changes required by the health care reform law (Affordable Care Act) and Mental Health Parity regulations. The changes described in this notice are effective July 1, Please take the time to read this notice carefully and keep it with your important plan materials. Capitalized terms in this SMM have the same meaning as in your Summary Plan Description. EXPANDED COVERAGE FOR PREVENTIVE CARE SERVICES (INCLUDING PRESCRIPTION DRUGS AND DEVICES) EFFECTIVE JULY 1, 2013 Preventive Care Plan Changes, Effective July 1, 2013 Effective July 1, 2013, the list of services that are covered as Preventive Care Services is being broadened to include health reform mandated services and supplies related to contraceptives, well woman preventive care, and certain preventive medications. The services described below will be payable by the Plan at 100% of the Contract Rate, without cost sharing (i.e. no deductible, co-payment or co-insurance), when you use a PPO Provider (i.e. In-Network). Except as otherwise provided, your normal cost sharing (co-insurance, deductible) will apply to Preventive Care Services received from a Non-Contract Provider. For covered Preventive Drugs, including contraceptives obtained from a pharmacy, you must use a participating OptumRx pharmacy and you must have a prescription, or no benefits are payable. Participating OptumRx pharmacies are those pharmacies that have a collective bargaining agreement with a UFCW Local Union. For a directory of participating pharmacies in the OptumRx Network, see the Directory at under Downloads or contact the Fund Office. SMM.PLAT PLUS.2013.FIN = (IL) 1

2 1. Women s Preventive Care Services The Indemnity Medical Plan is now expanding women s preventive services to incorporate health reform mandated services related to contraceptives and well woman preventive care. Beginning July 1, 2013, the following services will be covered by the Plan without cost sharing, when you use a PPO Provider: FDA-approved Generic Contraceptive Drugs and Devices Purchased Through a Pharmacy: If you obtain generic contraceptive drugs or devices (e.g., birth control pills, jellies, foams, patch, diaphragm) from a participating OptumRx retail pharmacy, the cost of the generic contraceptive is entirely payable by the Plan (you must have a prescription). If a generic drug or device is not available or is medically inappropriate, the Fund will cover a brand name drug at no cost to you, but your physician must first submit to OptumRx the clinical information/rationale supporting the request. If approved by OptumRx, the brand name drug will be dispensed and covered at 100%. This coverage is only for contraceptive drugs and devices provided to females. There is no coverage for drugs purchased from a non-participating pharmacy or abortifacient drugs. FDA-approved Generic Contraceptive Drugs, Devices and Sterilization Services Provided by a PPO Provider. FDA-approved generic female contraceptive drugs, devices (like an intrauterine device) and female sterilization services (excluding abortifacient drugs), including the cost of implantation and removal (where applicable) are covered by the Plan at 100% of Contract Rates when you use a PPO Provider. If a generic drug or device is not available or is medically inappropriate, the Fund will cover a brand name drug at no cost to you, but your physician must first submit to OptumRx the clinical information/rationale supporting the request. If approved by OptumRx, the brand name drug will be provided. If you receive these services from a Non-PPO Provider, Plan payment will be based on Non-PPO Provider benefits. Breastfeeding Support: Breastfeeding support and counseling, including the provision of one standard (non-hospital grade) breast-pump per pregnancy. Preauthorization from the Fund Office or from Anthem Blue Cross is required in order to obtain a breast pump. Please call the Fund Office for more information about how to obtain a breast pump at no cost to you. Coverage is also provided for comprehensive lactation support and counseling by a trained provider, during pregnancy and/or in the postpartum period. Only female participants are eligible for this benefit. Well Woman and Prenatal Visits obtained from a PPO Provider. Normal cost-sharing still applies to all other maternity related services, including ultrasounds and delivery fees. Human Papillomavirus (HPV) DNA testing high risk HPV DNA testing no more frequently than once every three years starting at age 30. Additional preventive care services for all covered females including screening for gestational diabetes for women 24 to 28 weeks pregnant and those at high risk, counseling on sexually transmitted infections, annual HIV screening and counseling, education and counseling regarding contraceptive methods and procedures, plus annual screening and counseling for interpersonal and domestic violence. SMM.PLAT PLUS.2013.FIN = (IL) 2

3 As a reminder, there is no requirement to obtain a referral or prior authorization before visiting an OB/GYN provider. Except as specifically provided otherwise, expenses for the pregnancy of an Employee s covered child and expenses for conditions arising from pregnancy of a covered child are excluded from coverage under the Plan. This means that the only pregnancy-related services that the Plan covers for your children are services that are covered as preventive care. 2. Coverage for Preventive Care Drugs The following medications are covered at 100%, with no co-payment or cost-sharing, if your physician prescribes the medication and you obtain the medication at a participating OptumRx pharmacy. You must present a written prescription from your physician to the pharmacy in order for the following medications to be covered, even if the medication is something you can ordinarily purchase over the counter. For a list of participating OptumRx pharmacies, please see the directory at under Downloads. Medication Coverage Description Aspirin Generic aspirin products are covered for men and women from age 45 to 79 years of age. Benefit maximum of 1 bottle of 100 tablets every 3 months. Fluoride Folic Acid Iron supplementation Contraceptives Generic fluoride supplementation for children 6 months to 6 years of age. Folic acid supplements for girls/women aged years. Liquid iron supplements for infants 6 months to 1 year in age. All forms of generic female contraceptives (see above for examples). No charge for brand name drugs if your physician demonstrates that the generic drug is medically inappropriate. Guidelines Applicable to Coverage for Preventive Care Services The following guidelines apply to the Plan s payment for preventive services: If a covered Preventive Service is billed separately from an office visit, the Plan may impose cost sharing on the office visit. If the Preventive Service is not billed separately from the office visit, and the office visit is primarily for the purpose of providing Preventive Service(s), then the Plan may not impose cost sharing on the office visit and will pay the office visit at 100% of the Contract Rate if you used a PPO Provider. If the Preventive Service is not billed separately from the office visit, and the main purpose of the office visit is not for providing Preventive Service(s), the Plan may impose cost sharing on the office visit. SMM.PLAT PLUS.2013.FIN = (IL) 3

4 Preventive Services are considered for payment when billed under the appropriate preventive service codes (benefit adjudication depends on accurate claim coding by the providers). The Plan will use reasonable medical management techniques - such as age, location for service and test frequency - for consideration of payable preventive services. Services not covered as a Preventive Service may be covered under another portion of the medical plan. ELIMINATION OF EXCLUSIONS, EFFECTIVE JULY 1, 2013 Effective July 1, 2013, the following exclusions and limitations are eliminated from the Plan: 1. The Prescription Drug Program will no longer exclude Progesterone used in the treatment of premenstrual syndrome (PMS). 2. The partial exclusion for penile prosthesis is removed from the medical Plan; however, preauthorization by Anthem Blue Cross is required before the Plan will provide coverage for penile prosthesis. EXPANDED MENTAL HEALTH AND SUBSTANCE ABUSE BENEFITS EFFECTIVE JULY 1, 2013 Effective July 1, 2013, the Mental Health Parity and Addiction Equity Act of 2008 requires the elimination of the Fund s previous day and visit limits applicable to mental health and substance abuse benefits. The changes to the Plan s mental health and substance abuse benefits that will be effective July 1, 2013 are described below. Your mental health and substance abuse benefits are provided through the Employee Member Assistance Program (EMAP) administered by HMC Health Works (HMC). Your network of providers for mental health and substance abuse benefits is the HMC/APS Network. You will have the lowest out of pocket costs if you use HMC/APS Network Providers (HMC/APS Providers). Call HMC at to find an HMC/APS Provider and to obtain preauthorization for services (where necessary). Effective July 1, 2013, your mental health and substance abuse benefits will be subject to the same Plan Deductible, copayments, co-insurance, and Annual Out-of-Pocket Maximum as comparable hospital and medical benefits provided under the Indemnity Medical Plan. 1 In addition: All inpatient mental health and substance abuse services, except emergency hospitalization, must be preauthorized by HMC. For example, preauthorization is required for: inpatient psychiatrist, inpatient detox, inpatient rehabilitation programs and residential treatment programs. To obtain 1 Benefits for emergency room services resulting from substance abuse and/or mental health disorders are payable as Emergency Room Services under the medical plan. SMM.PLAT PLUS.2013.FIN = (IL) 4

5 preauthorization call HMC at If you do not obtain preauthorization, and you receive services that are not Medically Necessary, no benefits will be payable. Preauthorization is also required for intensive outpatient treatment programs, partial hospitalization programs, ECT, psychological testing and neuropsychological testing. To obtain preauthorization call HMC at If you do not obtain preauthorization, and you receive services that are not Medically Necessary, no benefits will be payable. For services that require pre-authorization, you must obtain preauthorization from HMC even if you use a Non-HMC/APS Provider. For outpatient services that do not require preauthorization, we strongly encourage you to call HMC for help finding HMC/APS Providers, which will give you the lowest out-of-pocket costs. If you use a Provider who is not in the HMC/APS Network (i.e. a Non-HMC/APS Provider) you will pay more for services, as benefits will be subject to the cost-sharing (Deductible and coinsurance) that is applied to Non-PPO Providers under the medical plan. With Non-HMC/APS Providers, you are also responsible for any charges above the Allowed Amount, and there is no Outof-Pocket Maximum. We encourage you to obtain preauthorization from HMC and use HMC/APS Providers, as the Plan provides substantially better benefits if you use a Network Provider. Below, we have provided a summary of the mental health and substance abuse benefits available under the Gold and Platinum Indemnity Medical Plans effective July 1, SUMMARY OF INDEMNITY MEDICAL PLAN BENEFITS (GOLD & PLATINUM PLANS) Effective July 1, 2013 Preauthorization Requirement for Mental Health & Substance Abuse benefits. Your Cost if You Use An APS Provider Your Cost If You Use A Non-PPO Provider (i.e. Not in the APS Network)* Inpatient treatment, except emergency hospitalization, must be preauthorized by HMC. Preauthorization is also required for ECT, psychological testing, neuropsychological testing, intensive outpatient treatment programs, and partial hospitalization programs. Mental Health Inpatient Treatment No charge for first 120 days; after 120 days you pay 20% co-insurance; 50% co-insurance* for the first 120 days; after 120 days 20% co-insurance* Mental Health Outpatient Treatment $10 copay/visit; 20% co-insurance* after Fund pays the first $25.50/visit** Substance Abuse Inpatient No charge for first 120 days; after 120 days you pay 20% co-insurance; 50% co-insurance* for the first 120 days; after 120 days 20% co-insurance* Substance Abuse Outpatient $10 copay/visit; 20% co-insurance* after Fund pays the first $25.50/visit** SMM.PLAT PLUS.2013.FIN = (IL) 5

6 *If you use a Provider who is not in the HMC/APS Network (i.e. a Non-HMC/APS Provider), you are responsible for your share of co-insurance plus any charges above the Plan s Allowed Amount. This is because, for Non-HMC/APS Providers, the Plan pays a percentage of the Allowed Amount. The Plan s Allowed Amount may be less than the billed charges. When that happens, you are always responsible for any charges that exceed the Plan s Allowed Amount. **The Fund s payment will not be less $60.00 per visit or, if less, billed charges. * * * * Please keep this important notice with your SPD and other plan materials for easy reference to all Plan provisions. Should you have any questions, please contact the Trust Fund Office. In accordance with ERISA reporting requirements, this document serves as your Summary of Material Modifications to the Plan. Receipt of this notice does not constitute a determination of your eligibility. If you wish to verify eligibility, or if you have any questions regarding the Plan changes, please contact the Trust Fund Office. This group health plan believes this plan is a "grandfathered health plan" under the Patient Protection and Affordable Care Act (the Affordable Care Act). As permitted by the Affordable Care Act, a grandfathered health plan can preserve certain basic health coverage that was already in effect when that law was enacted. Being a grandfathered health plan means that your plan may not include certain consumer protections of the Affordable Care Act that apply to other plans, for example, the requirement for the provision of preventive health services without any cost sharing. However, grandfathered health plans must comply with certain other consumer protections in the Affordable Care Act, for example, the elimination of lifetime limits on benefits. Questions regarding which protections apply and which protections do not apply to a grandfathered health plan and what might cause a plan to change from grandfathered health plan status can be directed to the plan administrator by phone or in writing at So. Calif. Drug Benefit Fund, 2220 Hyperion Avenue, Los Angeles, CA 90027, (323) You may also contact the Employee Benefits Security Administration, U.S. Department of Labor at or This website has a table summarizing which protections do and do not apply to grandfathered health plans. SMM.PLAT PLUS.2013.FIN = (IL) 6