NECA/IBEW Family Medical Care Plan

1 NECA/IBEW Family Medical care PlanPLAN 1 SUMMARY plan DESCRIPTIONFor Benefits in Effect as ofJUNE 1, 2011 IMPORTANT CONTACT INFORMATION Fund Office/Board of Trustees/ Medical ClaimsBlue Card (Through BCBSGA) Medical PPO NetworkMed- care Management Utilization Review MetLife Dental Claims and Dental PPO NetworkVSP Vision Benefit ProgramSav-Rx Prescription Drug Program NECA/IBEW Family Medical care Plan5837 Highway 41 NorthRinggold, GA 30736 1-877-937-9602 or 1-706-937-9600 1-706-937-9601 (FAX)D The Fund Office handles Medical claims, vision claims, disability/life/AD&D claims, and Call the Fund Office if you need a Medical Send all self-payments to the Fund Contact the Fund Office if you or a dependent moves, if your Family /dependent status changes, if anyone in your Family acquires other coverage, or if you retire or enter active military service.

2 To find PPO providers 1-800-810-BLUE (2583) to find PPO providers 1-866-304-1881 for customer service 1-800-676-BLUE (2583) eligibility/benefits (for providers)D If you use a Blue Card PPO provider, covered services will be paid at the higher in-network benefit Providers should file claims through their local Blue Cross Your group identification number is on your card. 1-800-367-1934 for pre-certificationD Pre-certify inpatient hospitalizations, home health care and durable Medical A $250 benefit reduction applies to each inpatient hospitalization that is not pre-certified. MetLife Dental 981282El Paso, TX 79998-1282 1-800-942-0854 for customer service or to find a PPO provider MetLife handles all dental claims. Your group account number is 304133. 997105 Sacramento, CA 95899-7105 1-800-877-7195 for customer service & to find providers Do NOT send vision claims to the Fund Office or BCBS.

3 1-866-233- ibew (4239) for customer service Call Sav-Rx if you need a prescription drug card or have questions about your prescription drug TO NEW PARTICIPANTSNOTICE ABOUT YOUR cobra RIGHTSN otice About Your cobra rights - This letter is intended to inform you, in a summary fashion, of your rights andobligations under the cobra coverage provisions of the law. More information about cobra coverage is onpages to continue your group health coverage by electing cobra coverage will affect your future rights underfederal law. First, you can lose the right to avoid having preexisting condition exclusions applied to you by othergroup health plans if you have more than a 63-day gap in health coverage, and cobra coverage may help youavoid such a gap. Second, you will lose the guaranteed right to purchase individual health insurance policies thatdo not impose such preexisting condition exclusions if you do not get continuation coverage for the maximum timeavailable to you.

4 Finally, you should take into account that you have special enrollment rights under federal have the right to request special enrollment in another group health plan for which you are otherwise eligible(such as a plan sponsored by your spouse s employer) within 30 days after your group health coverage endsbecause of the qualifying event that is causing your loss of coverage under this plan . You will also have the samespecial enrollment right at the end of your cobra coverage period if you get cobra coverage for the maximumtime available to Events and Maximum Coverage Periods - You (the employee) and your eligible dependents are enti-tled to elect cobra coverage and to make self-payments for the coverage for up to 18 months after coveragewould otherwise terminate due to one of the following events (called qualifying events ): 1) a reduction in yourhours.

5 Or 2) termination of your you or an eligible dependent are disabled (as defined by the Social Security Administration for the purpose ofSocial Security disability payments) on the date of one of the qualifying events listed above, or if you or a depen-dent become so disabled within 60 days after an 18-month cobra coverage period starts, the maximum coverageperiod will be 29 months for all members of your Family who were covered under this plan on the date of that qual-ifying event. This 11-month extension rule does not apply to dependents during a 36-month maximum dependents (spouse or children) are entitled to elect cobra coverage and to make self-payments for the cov-erage for up to 36 months after coverage would otherwise terminate due to one of the following events (called qualifying events ): 1) a divorce from your spouse; 2) a dependent no longer meets the plan s definition of adependent child.

6 Or 3) your your dependents are covered under an 18-month cobra coverage period and a second qualifying event (one ofthe events listed in the paragraph above) occurs, their cobra coverage maximum coverage period may beextended up to a maximum of 36 months minus the number of months of cobra coverage already received underthe 18-month continuation. The maximum period of time that a dependent can have cobra coverage is 36months, even if one or more new qualifying events occur to the person while he is covered under cobra coverage. cobra coverage may not be elected by anyone who was not covered under this plan on the day before the occur-rence of a qualifying event except that, if a child is born to you, adopted by you, or placed for adoption with youafter you become covered under an 18-month cobra period, the child will have the same election rights as yourother dependents who were covered on the day before the first qualifying event if a second qualifying event Responsibilities - You, your spouse, or child, as applicable, must provide written notification to theFund Office if you get divorced or if a child loses dependent status.

7 Notification must be provided within 60 days ofthe event or within 60 days of the date coverage for the affected person(s) would terminate, whichever date is the Fund Office is not notified within 60 days, the dependent will lose the right to cobra coverage. If yourdependents are covered under an 18-month maximum cobra period and then a second qualifying event occurs, itis the affected dependent s responsibility to notify the Fund Office within 60 days after the second qualifying eventoccurs. If the Fund Office is not notified within 60 days, the dependent will lose the right to extend cobra coverage beyond the original 18-month period. In order to qualify for the 11-month disability extension, the Fund Office must be notified within 60 days ofthe disability determination by Social Security and before the end of the initial 18-month period.

8 They mustalso be notified within 30 days of the date Social Security determines that you or the dependent are nolonger disabled. In order to protect your Family s rights , you should keep the Fund Office informed of any changes in theaddresses of Family members. Additional Rules Governing cobra Coverage - Each member of your Family who would lose coveragebecause of a qualifying event is entitled to make a separate election of cobra coverage. If you electCOBRA coverage for yourself and your dependents, your election is binding on your dependents. A persondoes not have to show that he is insurable to elect cobra coverage. If coverage is going to terminate dueto termination of your employment or a reduction in your hours and you don t elect cobra coverage foryour dependents when they are entitled to the coverage, your dependent spouse has the right to electCOBRA coverage for up to 18 months for herself and any children within the time period that you couldhave elected cobra cobra Coverage - If you don t have sufficient employer contributions to continue coverage, orwhen the Fund Office is notified of any other qualifying event, you and/or your dependents will be sent anelection notice that explains when coverage will terminate.

9 It will also explain your right to elect cobra coverage, the due dates, and the amount of the self-payments. An election form will be sent along with theelection notice. Complete the election form and return to the Fund Office if you want to elect cobra . Aperson has 60 days after he is sent the election notice or 60 days after his coverage would terminate,whichever is later, to return the completed election form. A cobra election is considered to be made onthe date of the postmark on the returned election form. If the election form is not returned within the allow-able time period, you and/or your dependents will not be entitled to elect cobra . cobra Coverage Self-Payment Rules - cobra self-payments must be made monthly. The amount of themonthly cobra self-payment is determined by the Trustees and is subject to change, but not usually moreoften than once a year.

10 The amount due will be shown on the election notice. A person has 45 days after thedate of the election to make the initial self-payment. Your first cobra self-payment will be applied to yourfirst month of cobra coverage not the month in which you make the payment. Termination of cobra Coverage - cobra coverage for a covered person will end sooner than the endof the applicable maximum coverage period when the first of the following events occurs: 1) a correct andon-time payment is not made to the Fund; 2) the Fund is terminated and no longer provides group healthcoverage to any employees; 3) if a person is receiving extended coverage for up to 29 months due to his oranother Family member s disability, Social Security determines that he or the Family member is no longerdisabled; 4) after electing cobra coverage, the person becomes entitled to Medicare benefits.