Fisher's Landing Grocery - UFCW 555 Open Enrollment Booklet

UFCW LOCAL 555 EMPLOYERS HEALTH TRUST 2023 OPEN ENROLLMENT Newly Organized Fred Meyer store in Fisher’s Landing Grocery Department

2023 – Form N

UFCW LOCAL 555-EMPLOYERS HEALTH TRUST Administered by Zenith American Solutions 12205 SW Tualatin Road, Suite 200 Tualatin, OR 97062 (503) 486-2102 or (866) 796-7623 Fax: (971) 239-0672

May 2, 2023

RE:

Enrollment for Fred Meyer Fisher’s Landing Grocery Department Employees

Effective June 1, 2023 newly organized employees of Fred Meyer in Fisher’s Landing Grocery Department will begin receiving health and welfare benefits through the UFCW Local 555-Employers Health Trust and pension benefits through the Oregon Retail Employees Pension Trust per a collective bargaining agreement between Fred Meyer and the UFCW Local 555.

This will replace your current benefit coverage through the Fred Meyer Company Plan. The attached packet provides information about the transition, the benefits you will receive, and other important information.

In this packet you will find: • • • • • • •

An Enrollment Form A Summary of Benefits and Coverage for your Medical and Prescription Drug benefits Information about your Dental benefits Information about your Vision benefits Information about Weekly Disability benefits Information about your Life and AD&D benefits A Contact Sheet for your new Trust Office and benefit providers.

To receive coverage effective June 1, 2023, under the UFCW Local 555 – Employers Health Trust, you must return the enrollment form in this packet no later than May 23, 2023.

If you have questions, please contact the UFCW Local 555-Employers Health Trust Office at 1-866-796-7623.

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UFCW LOCAL 555-EMPLOYERS HEALTH TRUST ADMINISTRATIVE OFFICE c/o Zenith American Solutions 12205 SW Tualatin Rd, Suite 200, Tualatin, OR 97062 Phone: (503) 486-2102 * (866) 796-7623 * Fax: (971) 239-0672

Re: Enrollment Form for Health Benefits Please complete the enclosed application along with all requested documents that apply to you. These documents are necessary to process your application.

Please return your form by May 23, 2023 to ensure coverage begins June 1, 2023.

Document Checklist: All pages of the Enrollment Form Copy of Birth Certificates for Newborns Copy of Birth Certificates for children with a different last name than member Copy of Birth Certificate and Marriage Certificate for adding a Step-Child to the plan Copy of Marriage Certificate for new marriages Copy of Marriage Certificate for spouses with a different last name than member Proof of your name change, if applicable Your signature on Information about you

Sincerely, Trust Office

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IMPORTANT—YOUR COMPLETED FORM MUST BE RETURNED TO THE TRUST OFFICE WITHIN THE NEXT 30 DAYS UFCW LOCAL 555-EMPLOYERS HEALTH TRUST Enrollment Form—N Level 3 Coverage—Weekly Employee Share Required You are being provided this Enrollment Form because Trust records indicate you are eligible for Level 3 coverage from the Trust and your bargaining agreement requires payment of an employee weekly share for coverage.

If you do nothing, you will be "opted out" of coverage and only be eligible for Time Loss and Life and AD&D benefits. You will not be able to make any changes to dependent coverage or change your medical or dental coverage until the next annual Open Enrollment. Your completed form must be returned to the Trust Office by May 23, 2023.

Employees may elect changes to coverage outside of the annual enrollment provision only if one of the events that give rise to Special Enrollment rights occurs. Please refer questions directly to the Trust Office.

1.

Your Level 3 Benefits Medical, prescription drug, dental and vision coverage for Employee and Covered Dependents; and time loss, life and AD&D coverage for employee only.

2.

Coverage Options a.

Medical and Prescription Drug The Trust offers employees a choice between its self-funded medical and prescription drug plan and Kaiser. Kaiser is an option for those participants who live in the Kaiser service area. In general, the Kaiser service area is the Portland metropolitan area, Vancouver, Longview, Salem, and Eugene/Springfield. Kaiser is an HMO which means you must receive all your care through a Kaiser-affiliated hospital or provider.

For more details, review the Kaiser Summary of Benefits and Coverage that is enclosed. To determine if you reside in the Kaiser service area, please go to my.kp.org/ufcw555 or call 1-888-491-1124.

Please select which medical option you elect:  Trust Indemnity Medical and Prescription Drug

 Check one box only

 Kaiser Medical and Prescription Drug The employee weekly share required for the Trust’s indemnity medical and prescription drug coverage and Kaiser is the same.

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b.

Dental Options The Trust offers two dental options. The benefits available under each option can be reviewed in your Plan Booklet. Please select one of the options below:

 Check one

 Trust Dental

box only

 Willamette Dental

If no election is made, you will stay with your current option. If you have not previously had dental coverage and no selection is made, you will be placed in the Trust Dental.

3.

Select Who Will Be Covered Weekly Employee Share Required

Options

 Check one



Opt Out* (If you select this please review Section 4)



Employee Only

$10 per week



Employee & Dependent Children

$15 per week



Employee & Spouse/ Same-Sex Domestic Partner

$20 per week



Employee & Family

$25 per week

box only

$0

If you are covering a Spouse/Registered Same-Sex Domestic Partner and/or Dependent Children, please list their names, Social Security Numbers, gender and birth dates here.

If you are adding a newborn or a child with a different last name than yours, you will need to provide proof of birth. If adding a new spouse or a spouse with a different last name, you will need to provide a marriage certificate.

_________________________________

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________________________________

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______________________

_________________________

_________________________________

_________________________

_________________________

______________________

_________________________

_________________________________

_________________________

_________________________

______________________

_________________________

Print Name Print Name Print Name Print Name

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Social Security No. Social Security No.

Social Security No. Social Security No.

Birth Date Birth Date Birth Date Birth Date

Gender Gender Gender Gender

Relationship to You Relationship to You Relationship to You Relationship to You

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4.

What Opting Out Means—If You Are Opting Out, Please Review

You have the option to opt out of coverage from the Trust. You can opt out for any reason.

If you opt out you will pay no weekly employee share but you also will not be eligible for any benefit from the Health Trust other than life and AD&D and time loss benefits for the employee only. That means you and any dependents will not receive any medical, prescription drug, dental or vision benefits from the Trust for the period covered by your selection. If you opt out, you will not be able to change your selection until the annual Open Enrollment period, or if one of the events giving rise to special enrollment rights (described below) occurs.

If you opt out and decline coverage for yourself (or any of your Dependents) because of coverage under another group health plan or other health insurance, you may select coverage under this Trust for yourself and your dependents if you or your dependents exhaust COBRA continuation coverage, lose eligibility for the other coverage or the employer ceases contributing toward the cost of the other coverage. You must notify the Trust within 30 days of the other coverage (or the employer’s contribution for it) ending. You will be required to provide proof that you, or your Dependents, had the coverage at the time your selection to opt out was effective. You may also add a new dependent acquired through marriage, domestic partnership registration, birth, adoption or placement for adoption if you notify the Trust within 30 days of acquiring the new dependent.

5.

Special Enrollment Rights You may add eligible dependents if you have not covered them because they have other insurance. Special enrollment rights exist if your dependents lose coverage under this other insurance, exhaust COBRA continuation coverage or an employer ceases contributing towards the coverage. You may also add a new dependent acquired through marriage, domestic partner registration, birth, adoption or placement for adoption. To utilize special enrollment rights, you must notify the Trust within 30 days of the above events occurring.

6.

Other Health Insurance If you or any dependents have other health insurance, please complete.

Person(s) who has other insurance: Is it through employment?

 Yes

 No

Name of Other Carrier: 7.

Eligibility for Other Health Insurance Coverage—Spouse/Domestic Partner If you enroll in the Trust Dependent Spouse or Same-Sex Domestic Partner is eligible for other coverage and declines it, the Trust will charge the Employee $100 a month to cover his or her Spouse or Same-Sex Domestic Partner. If the amount is not paid, the Spouse or SameSex Domestic Partner will not be covered under the Trust.

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Has your Spouse or Same-Sex Domestic Partner declined other insurance coverage?  Yes

 No

Please note that the Trust will be doing an audit to confirm that all children, Spouses and Same-Sex Domestic Partners meet Plan eligibility requirements. If you have questions about what the Plan’s eligibility rules provide, please check your Plan Booklet or contact the Trust Office.

8.

Information About You

Print Employee’s Name

Social Security Number

Gender

Date of Birth

Your Mailing Address

City

State/Zip Code

Name of Your Employer

Store Location

Your Phone

Your E-Mail Address

Date of Hire

Your Signature 9.

10.

Today’s Date

Designate a Beneficiary for Your Life Insurance:

Beneficiary’s Name

Birth Date

Relationship to You

Your Name (Print)

Your Signature

Today’s Date

Complete Sections 2-9 and Return This Enrollment Form To: UFCW Local 555-Employers Health Trust c/o ZAS 12205 SW Tualatin Rd, Suite 200 Tualatin, OR 97062 (503) 486-2102 * (866) 796-7623 Fax: (971) 239-0672

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UFCW LOCAL 555-EMPLOYERS HEALTH TRUST SUMMARY OF MATERIAL MODIFICATIONS Effective January 1, 2023 Change in Pharmacy Benefit Manager Effective January 1, 2023, the Trust will be changing its Pharmacy Benefit Manager (PBM) from MagellanRx to OptumRx. Prior to January 1, 2023, you and your covered dependents (if applicable) will receive new member ID cards that includes information for OptumRx. Please be sure to replace your current ID cards with the new ID cards for prescription drug coverage on or after January 1, 2023.

The Trustees look forward to developing a long-standing relationship with OptumRx, and thank you in advance for your patience during the transition process.

Outpatient Dialysis Services The following benefits apply to outpatient dialysis services received on or after January 1, 2023.

The Trust covers all outpatient dialysis (including hemodialysis, peritoneal dialysis and home filtration services and supplies). Outpatient dialysis benefits are subject to the deductible and co-insurance requirements applicable to your level of benefits. As with other Trust benefits the co-insurance requirement is 10% less if a Preferred or Participating Provider is used.

For Preferred or Participating Providers whose contract specifies its terms supersede any Plan provisions, the amount paid will be determined pursuant to the Provider’s agreement with Regence. For Non-Participating Providers or for Participating Providers where contract does not specify that its terms supersedes the Trust’s benefit provisions, the Trust’s benefit for outpatient dialysis shall be 150% of the Medicare Allowed Amount.

For purposes of the benefit Medicare Allowed Amount is the amount that a Medicare-Contracted Provider agrees to accept for a Covered Service.

The Trust will pay primary to Medicare when required to do so by applicable federal law. In all other situations, the Trust will pay secondary. If the Trust is secondary to Medicare, it will not pay any part of a Covered Service to the extent it is actually paid under Medicare or would have been paid by Medicare if the Participant or Beneficiary had properly applied for or maintained Medicare Part A and B coverage. When paying secondary to Medicare, the maximum amount the Trust will pay for outpatient dialysis claims is the Medicare Allowed Amount.

If you are receiving outpatient dialysis, your diagnosis may make you eligible for Medicare. If you are eligible for Medicare and enrolled in Medicare Part B and receive dialysis from a Medicare-Contracted Provider, you may not be responsible for any additional out-of-pocket costs for outpatient dialysis beyond any deductible and co-insurance responsibilities and what is paid by the Trust.

If you are receiving outpatient dialysis services while the Trust is primary and are eligible for Medicare, you are eligible to have your Medicare Part A and B premiums reimbursed by the Trust. To receive reimbursement you will need to submit proof of payment to the Trust’s Claims Administrative Agent.

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Coverage Period: 01/01/2023 – 12/31/2023 Coverage for: Individual + Family | Plan Type: PPO

This plan covers some items and services even if you haven’t yet met the deductible amount. But a copayment or coinsurance may apply. For example, this plan covers certain preventive services without cost sharing and before you meet your deductible. See a list of covered preventive services at https://www.healthcare.gov/coverage/preventive-care-benefits/ You don’t have to meet deductibles for specific services.

The out-of-pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan, they have to meet their own out-of-pocket limits until the overall family out-of-pocket limit has been met.

Participating, Preferred and Non-Participating providers combined: $300/Individual; $600/Family

Yes. For Preferred and Participating Providers: Preventive care, diabetic education services, second opinions, the special accident benefit, birthing center facility services, outpatient dialysis treatment after 120 days, and both In-Network and Out-of-Network outpatient prescription drugs are covered before you meet your deductible.

No

Medical: Preferred Providers and Participating Providers: $3,300/Individual, $6,600/Family.

Outpatient prescription drugs: $5,400/Individual, $10,900/Family

Medical: All expenses for services from Non-Participating providers, premiums, balance-billing charges, penalties for failure to obtain preauthorization, outpatient prescription drug expenses, and health care this plan doesn’t cover.

Even though you pay these expenses, they don’t count toward the Outpatient prescription drugs: Premiums, balance-billing charges, out-of-pocket limit. all expenses for services from Non-Network pharmacies, amounts you pay above the standard copay for a Non-Preferred drug, penalties for failure to obtain preauthorization, medical expenses, and health care this plan doesn’t cover.

What is the overall deductible?

Are there services covered before you meet your deductible?

Are there other deductibles for specific services?

What is the out-ofpocket limit for this plan?

What is not included in the out-of-pocket limit?

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Generally, you must pay all of the costs from providers up to the deductible amount before this plan begins to pay. If you have other family members on the plan, each family member must meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family deductible.

Why This Matters:

Answers

Important Questions

The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately.

This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, contact Zenith at (503) 486-2102. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms see the Glossary. You can view the Glossary at www.dol.gov/ebsa/healthreform or call (503) 486-2102.

Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services UFCW Local 555 Employers Health Trust: Level 3 PPO

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Yes. See www.or.regence.com or call (503) 486-2102 for a list of Preferred or Participating providers.

No.

Will you pay less if you use a network provider?

Do you need a referral to see a specialist?

You can see the specialist you choose without a referral.

You pay the least if you use a provider in the Preferred Network.

You pay more if you use a provider who is a Participating Provider.

You will pay the most if you use a Non-Participating provider, and you might receive a bill from a provider for the difference between the provider’s charge and what your plan pays (balance billing). Be aware your network provider might use an out-of-network provider for some services (such as lab work). Check with your provider before you get services.

Why This Matters:

If you visit a health care provider’s office or clinic

Common Medical Event

No charge, deductible does not apply.

Specialist visit

Preventive care/screening/ Immunization

Preferred Provider (You will pay the least) $10 copayment/visit, then 15% coinsurance $10 copayment/visit, then 15% coinsurance

Primary care visit to treat an injury or illness

Services You May Need

No charge, deductible does not apply.

$10 copayment/visit, then 25% coinsurance plus balance billing

What You Will Pay Participating Non-Participating Provider (You will Provider (You will pay pay more) the most) $10 $10 copayment/visit, copayment/visit, then 25% coinsurance then 25% plus balance billing coinsurance $10 $10 copayment/visit, copayment/visit, then 25% coinsurance then 25% plus balance billing coinsurance

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You may have to pay for services that aren’t preventive. Ask your provider if the services needed are preventive. Then check what your plan will pay for. Preventive services covered at 100% are listed at https://www.healthcare.gov/what-are-mypreventive-care-benefits.

None.

None.

Limitations, Exceptions, & Other Important Information

All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies.

Answers

Important Questions

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If you need drugs to treat your illness or condition More information about prescription drug coverage is available at www.optumrx.com

If you have a test

Common Medical Event Preferred Provider (You will pay the least)

$20 copayment/script

Same as generic, Preferred or Nonpreferred copayments

Specialty drugs

$20 copayment/script

Preferred brand drugs

Non-preferred brand drugs

$10 copayment/script

Generic drugs

Diagnostic test (x15% coinsurance ray, blood work) Imaging (CT/PET 15% coinsurance scans, MRIs)

Services You May Need

You must pay 100% at time of purchase and submit a claim to OptumRx. You will be responsible for 20% of the Allowed Amount after the applicable copayment.

What You Will Pay Participating Non-Participating Provider (You will Provider (You will pay pay more) the most) 25% coinsurance plus 25% coinsurance balance billing 25% coinsurance plus 25% coinsurance balance billing

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• Deductible does not apply. Except as noted below, your cost sharing at network pharmacies applies to the prescription drug out-of-pocket limit. Copayments are charged per prescription based on the greater of 100 units or 34-day supply.

• No charge for FDA-approved generic contraceptives (or brand name contraceptives if a generic is medically inappropriate).

• Certain Over-the-Counter (OTC) drugs are covered without copayment if a prescription is received.

• A Market Priced Drug (MPD) program applies to certain prescription drug classes to encourage utilization of lower cost FDA-approved alternatives. Higher costs may apply if recommended alternatives are not utilized, and any extra cost sharing will not be included in the prescription drug out-of-pocket limit.

• You pay the lesser of the copayment or the drug cost.

• Weight loss drugs and Cialis require preauthorization by OptumRx to be covered.

• Deductible does not apply.

• Specialty drugs require preauthorization by OptumRx to be covered.

• Your cost sharing at network pharmacies counts toward the prescription drug out-of-pocket limit.

Some services may require preauthorization to be covered.

Limitations, Exceptions, & Other Important Information

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Preferred Provider (You will pay the least)

Urgent care

Emergency medical transportation

Emergency room care

If you have a hospital stay

Inpatient services

15% coinsurance

$10 copayment/visit, then 25% coinsurance plus balance billing

25% coinsurance

25% coinsurance plus balance billing 25% coinsurance plus 25% coinsurance balance billing Office visit: $10 Office visit: $10 copayment/visit, copayment/visit, then then 25% 25% coinsurance plus coinsurance. Other balance billing. Other outpatient outpatient services: 25% services: 25% coinsurance plus coinsurance balance billing.

25% coinsurance plus 25% coinsurance balance billing

$10 copayment/visit, then 25% coinsurance

$10 copayment/visit, then 15% coinsurance

Inpatient hospital admission requires preauthorization to be covered.

None.

None.

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• Professional/physician charges may be billed separately.

• Copayment applies to care in an urgent care office/facility (but not to urgent care services in an outpatient hospital setting).

Inpatient hospital admission requires preauthorization to be covered.

None.

20% coinsurance plus balance billing

20% coinsurance

$100 copayment/visit, then 15% coinsurance plus balance billing.

$100 $100 copayment/visit, copayment/visit, then then 15% 15% coinsurance coinsurance

20% coinsurance

• Professional/physician charges may be billed separately.

• Copayment waived if admitted.

• If you do not have an emergency medical condition, benefits may be reduced if services could have been provided in a less costly setting.

• The first $300 for treatment of an accident is paid at 100%, deductible is waived.

25% coinsurance plus balance billing

25% coinsurance

Some services may require preauthorization to be covered.

Limitations, Exceptions, & Other Important Information

25% coinsurance plus balance billing

What You Will Pay Participating Non-Participating Provider (You will Provider (You will pay pay more) the most) 25% coinsurance

Facility fee (e.g., ambulatory 15% coinsurance surgery center) Physician/surgeon 15% coinsurance fees

Services You May Need

Facility fee (e.g., 15% coinsurance hospital room) Physician/surgeon 15% coinsurance fees Office visit: $10 copayment/visit, then 15% coinsurance.

If you need Outpatient Other outpatient mental health, services service: 15% behavioral health, coinsurance or substance abuse services

If you need immediate medical attention

If you have outpatient surgery

Common Medical Event

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If you need help recovering or have other special health needs

If you are pregnant

Common Medical Event

15% coinsurance 15% coinsurance 15% coinsurance 15% coinsurance

Skilled nursing care

Durable medical equipment

Hospice services

15% coinsurance

Rehabilitation services

Habilitation services

25% coinsurance

15% coinsurance

Home health care

25% coinsurance

25% coinsurance

25% coinsurance

25% coinsurance

25% coinsurance

25% coinsurance

Childbirth/delivery 15% coinsurance, facility services

No charge, deductible does not apply.

25% coinsurance

No charge, deductible does not apply.

Preferred Provider (You will pay the least)

25% coinsurance plus balance billing

25% coinsurance plus balance billing

25% coinsurance plus balance billing

25% coinsurance plus balance billing

25% coinsurance plus balance billing

25% coinsurance plus balance billing

25% coinsurance plus balance billing

25% coinsurance plus balance billing

$10 copayment/visit, then 25% coinsurance plus balance billing

What You Will Pay Participating Non-Participating Provider (You will Provider (You will pay pay more) the most)

Childbirth/delivery professional 15% coinsurance services

Office visits

Services You May Need

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Cost sharing does not apply for preventive services.

• Depending on the type of services, a copayment, coinsurance, or deductible may apply.

• Maternity care may include tests and services described somewhere else in the SBC (i.e., ultrasound).

• Preauthorization is required if hospital stay is more than 48 hours for a vaginal delivery or 96 hours for a C-section to be covered.

• Delivery expenses of pregnant children are not covered.

• Deductible does not apply to a delivery in a birthing center facility.

Requires preauthorization to be covered.

Maximum benefit is 180 visits/calendar year.

Covered services include physical, occupational or speech therapy necessary to restore or improve lost function caused by an illness or injury.

Habilitation services covered for participants and dependents age 17 and younger.

After 14 days/confinement, preauthorization required for additional days to be covered.

Coverage is limited to 100 days/calendar year.

Some supplies require preauthorization to be covered.

Requires preauthorization to be covered.

Coverage is limited to 14 days for inpatient respite care.

•

Limitations, Exceptions, & Other Important Information

Services You May Need

Children’s eye exam Children’s glasses Children’s dental check-up

Common Medical Event

If your child needs dental or eye care

What You Will Pay Participating Non-Participating Provider (You will Provider (You will pay pay more) the most) Not covered Not covered Not covered

Preferred Provider (You will pay the least) Not covered Not covered Not covered

If you elect dental coverage, it will be through a separate dental plan.

If you elect vision coverage, it will be through a separate vision plan.

Limitations, Exceptions, & Other Important Information

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Does this plan provide Minimum Essential Coverage? Yes Minimum Essential Coverage generally includes plans, health insurance available through the Marketplace or other individual market policies, Medicare, Medicaid, CHIP, TRICARE, and certain other coverage. If you are eligible for certain types of Minimum Essential Coverage, you may not be eligible for the premium tax credit.

Your Grievance and Appeals Rights: There are agencies that can help if you have a complaint against your plan for a denial of a claim. This complaint is called a grievance or appeal. For more information about your rights, look at the explanation of benefits you will receive for that medical claim. Your plan documents also provide complete information on how to submit a claim, appeal, or a grievance for any reason to your plan. For more information about your rights, this notice, or assistance, contact the Trust Office at (503) 486-2102. You may also contact the Department of Labor’s Employee Benefits Security Administration at 1-866-444EBSA (3272) or www.dol.gov/ebsa/healthreform.

Your Rights to Continue Coverage: There are agencies that can help if you want to continue your coverage after it ends. The contact information for those agencies is the Department of Labor’s Employee Benefits Security Administration at 1-866-444-EBSA (3272) or www.dol.gov/ebsa/healthreform. Other coverage options may be available to you too, including buying individual insurance coverage through the Health Insurance Marketplace. For more information about the Marketplace, visit www.HealthCare.gov or call 1-800-318-2596.

Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.)

• Acupuncture  Chiropractic care  Non-emergency care when traveling outside the • Bariatric surgery (preauthorization required to be  Hearing aids U.S. covered)

Excluded Services & Other Covered Services: Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.)

• Routine eye care (Adult and Child) (through a • Infertility treatment separate vision plan) • Cosmetic surgery • Long-term care • Routine foot care • Dental care (through a separate dental plan) • Private-duty nursing • Weight loss programs (except as required by the health reform law)

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To see examples of how this plan might cover costs for a sample medical situation, see the next section.

Language Access Services: Spanish (Español): Para obtener asistencia en Español, llame al (503) 486-2102.

Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa (503) 486-2102.

Chinese (中文): 如果需要中文的帮助，请拨打这个号码 (503) 486-2102.

Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' (503) 486-2102.

Does this plan meet the Minimum Value Standards? Yes If your plan doesn’t meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace.

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$300 $10, 15% 15% 15%

In this example, Peg would pay: Cost Sharing Deductibles Copayments Coinsurance What isn’t covered Limits or exclusions The total Peg would pay is

Total Example Cost

$300 $10, 15% 15% 15%

In this example, Joe would pay: Cost Sharing Deductibles Copayments Coinsurance What isn’t covered Limits or exclusions The total Joe would pay is

Total Example Cost

$0 $1,090

$300 $680 $110

$5,600

This EXAMPLE event includes services like: Primary care physician office visits (including disease education) Diagnostic tests (blood work) Prescription drugs Durable medical equipment (glucose meter)

 The plan’s overall deductible  Specialist copay/coinsurance  Hospital (facility) coinsurance  Other coinsurance

Managing Joe’s type 2 Diabetes

(a year of routine in-network care of a wellcontrolled condition)

$300 $10,15% 15% $100

In this example, Mia would pay: Cost Sharing Deductibles Copayments Coinsurance What isn’t covered Limits or exclusions The total Mia would pay is

Total Example Cost

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$0 $840

$300 $150 $390

$2,800

This EXAMPLE event includes services like: Emergency room care (including medical supplies) Diagnostic test (x-ray) Durable medical equipment (crutches) Rehabilitation services (physical therapy)

 The plan’s overall deductible  Specialist copay/coinsurance  Hospital (facility) coinsurance  Other copayment (ER)

Mia’s Simple Fracture

(in-network emergency room visit and follow up care)

The plan would be responsible for the other costs of these EXAMPLE covered services.

$60 $2,000

$300 $10 $1,630

$12,700

This EXAMPLE event includes services like: Specialist office visits (prenatal care) Childbirth/Delivery Professional Services Childbirth/Delivery Facility Services Diagnostic tests (ultrasounds and blood work) Specialist visit (anesthesia)

 The plan’s overall deductible  Specialist copay/coinsurance  Hospital (facility) coinsurance  Other coinsurance

(9 months of in-network pre-natal care and a hospital delivery)

Peg is Having a Baby

This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be different depending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost sharing amounts (deductibles, copayments and coinsurance) and excluded services under the plan. Use this information to compare the portion of costs you might pay under different health plans. Please note these coverage examples are based on self-only coverage.

About these Coverage Examples:

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NON-DISCRIMINATION NOTICE AND FOREIGN LANGUAGE ASSISTANCE Nondiscrimination and Accessibility Requirements and Nondiscrimination Statement: Discrimination is Against the Law The UFCW Local 555-Employers Health Trust complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. The UFCW Local 555-Employers Health Trust does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex.

UFCW Local 555-Employers Health Trust: 

•

Provides free aids and services to people with disabilities to communicate effectively with us, such as: -

Qualified sign language interpreters

-

Written information in other formats (large print, audio, accessible electronic formats, other formats)

Provides free language services to people whose primary language is not English, such as: -

Qualified interpreters

-

Information written in other languages

If you need these services, contact Pati Piro at Zenith Administrators.

If you believe that the UFCW Local 555-Employers Health Trust has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Pati Piro Zenith Administrators 12205 S.W. Tualatin Road, Suite 200 Tualatin, OR 97062 Phone: 503-486-2045 Fax: 503-612-0855 ppirobosley@zenith-american.com You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, Pati Piro, Civil Rights Coordinator, is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services, 200 Independence Avenue SW., Room 509F, HHH Building, Washington, DC 20201, 1-800-868-1019, 800-537-7697 (TDD).

Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

6350.000 doc sa041101

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Regence Customer Service can help with translation services. Call 888-977-2583 for assistance in all languages.

ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-503-4862102 (TTY: 1-503-486-2102).

CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số 1-503-486-2102 (TTY: 1-503-486-2102). 注意：如果您使用繁體中文，您可以免費獲得語言援助服務。請致電 1-503-486-2102（TTY：1-503-486-2102 ）。 ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните 1503-486-2102 (телетайп: 1-503-486-2102). 주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수 있습니다. 1-503-486-2102 (TTY: 1-503-486-2102)번으로 전화해 주십시오. УВАГА! Якщо ви розмовляєте українською мовою, ви можете звернутися до безкоштовної служби мовної підтримки. Телефонуйте за номером 1-503-486-2102 (телетайп: 1-503-486-2102). 注意事項：日本語を話される場合、無料の言語支援をご利用いただけます。1-503-486-2102（TTY:1-503486-2102）まで、お電話にてご連絡ください。 503-486-2102-1 503-486-2102-1

ATENȚIE: Dacă vorbiți limba română, vă stau la dispoziție servicii de asistență lingvistică, gratuit. Sunați la 1-503486-2102 (TTY: 1-503-486-2102).

1-503-486-2102

1-503-486-2102

XIYYEEFFANNAA: Afaan dubbattu Oroomiffa, tajaajila gargaarsa afaanii, kanfaltiidhaan ala, ni argama. Bilbilaa 1503-486-2102 (TTY: 1-503-486-2102).

ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung.

Rufnummer: 1-503-486-2102 (TTY: 1-503-486-2102).

-503-486-2102

-503-486-2102

ATTENTION : Si vous parlez français, des services d'aide linguistique vous sont proposés gratuitement. Appelez le 1503-486-2102 (ATS : 1-503-486-2102). เรียน: ถ ้าคุณพูดภาษาไทยคุณสามารถใช ้บริการช่วยเหลือทางภาษาได ้ฟรี โทร 1-503-486-2102 (TTY: 1-503-486-21 6350.000 doc sa041101

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Coverage for: Individual / Family | Plan Type: EPO

Coverage Period: 01/01/2023-12/31/2023

The out-of-pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan, they have to meet their own out-of-pocket limits until the overall family out-of-pocket limit has been met.

Even though you pay these expenses, they don’t count toward the out–of–pocket limit.

This plan uses a provider network. You will pay less if you use a provider in the plan’s network. You will pay the most if you use an out-of-network provider, and you might receive a bill from a provider for the difference between the provider’s charge and what your plan pays (balance billing).Be aware your network provider might use an out-ofnetwork provider for some services (such as lab work). Check with your provider before you get services.

$300 Individual / $600 Family

Yes. Preventive care and services indicated in chart starting on page 2.

No. $3,000 Individual / $6,000 Family Premiums, health care this plan doesn’t cover, and services indicated in chart starting on page 2.

Yes. See www.kp.org or call 1-800813-2000 (TTY: 711) for a list of Participating Providers.

What is the overall deductible?

Are there services covered before you meet your deductible?

Are there other deductibles for specific services?

What is the out-of-pocket limit for this plan?

What is not included in the out-of-pocket limit?

Will you pay less if you use a network provider?

12023_19678-005_KONX_SBC-O-LG-DED-XX_{615822}_{AC23 - C DED AA 150-15-20%-1650}_1118202214336 Rev. (11/16)

You don’t have to meet deductibles for specific services.

Page 1 of 6

Generally, you must pay all of the costs from providers up to the deductible amount before this plan begins to pay. If you have other family members on the plan, each family member must meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family deductible.

This plan covers some items and services even if you haven’t yet met the deductible amount. But a copayment or coinsurance may apply. For example, this plan covers certain preventive services without cost-sharing and before you meet your deductible.

See a list of covered preventive services at https://www.healthcare.gov/coverage/preventive-care-benefits/.

Why This Matters:

Answers

Important Questions

The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately.

This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage see www.kp.org/plandocuments or call 1-800-813-2000 (TTY: 711). For definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms see the Glossary. You can view the Glossary at http://www.healthcare.gov/sbc-glossary or call 1-800-813-2000 (TTY: 711) to request a copy.

: UFCW Local 555-Empl HLTH Trust – AC23 – Level 3 All plans offered and underwritten by Kaiser Foundation Health Plan of the Northwest

Summary of Benefits and Coverage: What this Plan Covers & What You Pay for Covered Services

22

Yes, but you may self-refer to certain specialists.

This plan will pay some or all of the costs to see a specialist for covered services but only if you have a referral before you see the specialist.

Generic drugs

Imaging (CT/PET scans, MRIs)

Diagnostic test (x-ray, blood work)

Preventive care/screening/ immunization

Specialist visit

Primary care visit to treat an injury or illness

Services You May Need

Not covered Not covered

Applicable Generic or Preferred brand drug cost shares apply.

Not covered

Not covered

Not covered

Not covered

Not covered

Applicable Generic or Preferred brand drug cost shares apply.

X-ray: $10 / visit, deductible does not apply.

Lab tests: $10 / visit, deductible does not apply. $10 / visit, deductible does not apply. $10 (retail); $20 (mail order) / prescription, deductible does not apply. $20 (retail); $40 (mail order) / prescription, deductible does not apply.

No charge, deductible does not apply.

What You Will Pay Participating Provider Non-Participating Provider (You will pay the least) (You will pay the most) $15 / visit, deductible does not Not covered apply. $25 / visit, deductible does not Not covered apply.

12023_19678-005_KONX_SBC-O-LG-DED-XX_{615822}_{AC23 - C DED AA 150-15-20%-1650}_1118202214336 Rev. (11/16)

Specialty drugs

If you need drugs to treat your illness Preferred brand drugs or condition More information about prescription drug coverage is Non-preferred brand drugs available at www.kp.org/formulary

If you have a test

If you visit a health care provider’s office or clinic

Common Medical Event

Page 2 of 6

Some services may require prior authorization.

Up to a 30-day supply (retail); up to a 90-day supply (mail order). Subject to formulary guidelines.

Up to a 30-day supply (retail); up to a 90-day supply (mail order). Subject to formulary guidelines.

Up to a 30-day supply (retail); up to a 90-day supply (mail order). Subject to formulary guidelines, when approved through exception process.

Up to a 30-day supply (retail). Subject to formulary guidelines, when approved

None

You may have to pay for services that aren’t preventive. Ask your provider if the services needed are preventive. Then check what your plan will pay for.

None

None

Limitations, Exceptions, & Other Important Information

All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies.

Do you need a referral to see a specialist?

23

Common Medical Event

15% coinsurance 15% coinsurance, deductible does not apply.

Not covered

15% coinsurance 15% coinsurance, deductible does not apply. $35 / visit, deductible does not apply.

15% coinsurance 15% coinsurance

Emergency room care

Urgent care

Facility fee (e.g., hospital room)

Physician/surgeon fees

Childbirth/delivery professional services Childbirth/delivery facility services

If you need help Home health care recovering or have other special needs Rehabilitation services

If you are pregnant

Office visits

Not covered

Outpatient: $25 / visit

12023_19678-005_KONX_SBC-O-LG-DED-XX_{615822}_{AC23 - C DED AA 150-15-20%-1650}_1118202214336 Rev. (11/16)

Not covered

20% coinsurance

Not covered

15% coinsurance

Not covered

No charge, deductible does not apply.

Not covered

Not covered

15% coinsurance

15% coinsurance

Not covered

$15 / visit, deductible does not apply.

Not covered

Not covered

Not covered

15% coinsurance

Physician/surgeon fees

Emergency medical transportation

Not covered

What You Will Pay Participating Provider Non-Participating Provider (You will pay the least) (You will pay the most)

Facility fee (e.g., ambulatory 15% coinsurance surgery center)

Services You May Need

If you need mental Outpatient services health, behavioral health, or substance Inpatient services abuse services

If you have a hospital stay

If you need immediate medical attention

If you have outpatient surgery

24

Page 3 of 6

130 visit limit / year. Prior authorization required.

Outpatient: 20 visit limit / therapy / year.

None

None

Depending on the type of services, a copayment, coinsurance, or deductible may apply. Maternity care may include tests and services described elsewhere in the SBC (i.e., ultrasound).

Prior authorization required.

None

Prior authorization required.

Prior authorization required.

Non-Participating Providers covered when temporarily outside the service area: $35 / visit, deductible does not apply.

None

None

Prior authorization required.

Prior authorization required.

through exception process.

Limitations, Exceptions, & Other Important Information

Common Medical Event

Not covered

15% coinsurance 15% coinsurance No charge, deductible does not apply. $15 / visit for refractive exam, deductible does not apply.

Not covered Not covered

Skilled nursing care

Durable medical equipment

Children’s glasses Children’s dental checkups

Children’s eye exam

Hospice services

Not covered

$25 / visit

Habilitation services

Not covered Not covered

Not covered

Not covered

Not covered

What You Will Pay Participating Provider Non-Participating Provider (You will pay the least) (You will pay the most) Inpatient: 15% coinsurance

Services You May Need

None None

None

Prior authorization required.

Prior authorization required.

Inpatient: Prior authorization required.

20 visit limit / therapy / year. Prior authorization required.

100 day limit / year. Prior authorization required.

Subject to formulary guidelines. Prior authorization required.

Limitations, Exceptions, & Other Important Information

Acupuncture Children's glasses Chiropractic care Cosmetic surgery   

Dental care (Adult and Child) Long-term care Non-emergency care when traveling outside the U.S

  

Private-duty nursing Routine foot care Weight loss programs

Bariatric surgery Hearing aids (Adult: $2,000 limit / ear / 3 years) (dependents under age 26: 1 aid / ear, every 36 months) 

Infertility treatment



12023_19678-005_KONX_SBC-O-LG-DED-XX_{615822}_{AC23 - C DED AA 150-15-20%-1650}_1118202214336 Rev. (11/16)

 

Routine eye care (Adult)

Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.)

   

Page 4 of 6

Excluded Services & Other Covered Services Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.)

If your child needs dental or eye care

25

1-866-444-EBSA (3272) or www.dol.gov/ebsa/healthreform 1-877-267-2323 x61565 or www.cciio.cms.gov 1-888-877-4894 or www.dfr.oregon.gov 1-800‑ 562‑ 6900 or www.insurance.wa.gov

Department of Labor’s Employee Benefits Security Administration

Department of Health & Human Services, Center for Consumer Information & Insurance Oversight

Oregon Division of Financial Regulation

Washington Department of Insurance

12023_19678-005_KONX_SBC-O-LG-DED-XX_{615822}_{AC23 - C DED AA 150-15-20%-1650}_1118202214336 Rev. (11/16)

To see examples of how this plan might cover costs for a sample medical situation, see the next section.

Language Access Services: Spanish (Español): Para obtener asistencia en Español, llame al 1-800-813-2000 (TTY: 711).

Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 1-800-813-2000 (TTY: 711).

Chinese (中文): 如果需要中文的帮助，请拨打这个号码 1-800-813-2000 (TTY: 711).

Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 1-800-813-2000 (TTY: 711).

Does this plan meet the Minimum Value Standards? Yes If your plan doesn’t meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace.

Page 5 of 6

Does this plan provide Minimum Essential Coverage? Yes Minimum Essential Coverage generally includes plans, health insurance available through the Marketplace or other individual market policies, Medicare, Medicaid, CHIP, TRICARE, and certain other coverage. If you are eligible for certain types of Minimum Essential Coverage you may not be eligible for the premium tax credit.

Contact Information for Your Rights to Continue Coverage & Your Grievance and Appeals Rights:

1-800-813-2000 (TTY: 711) or www.kp.org/memberservices

Kaiser Permanente Member Services

Your Grievance and Appeals Rights: There are agencies that can help if you have a complaint against your plan for a denial of a claim. This complaint is called a grievance or appeal. For more information about your rights, look at the explanation of benefits you will receive for that medical claim. Your plan documents also provide complete information on how to submit a claim, appeal, or a grievance for any reason to your plan. For more information about your rights, this notice, or assistance, contact the agencies in the chart below.

Your Rights to Continue Coverage: There are agencies that can help if you want to continue your coverage after it ends. The contact information for those agencies is shown in the chart below. Other coverage options may be available to you, too, including buying individual insurance coverage through the Health Insurance Marketplace. For more information about the Marketplace, visit www.HealthCare.gov or call 1-800-318-2596.

26

$0 $770

$70 $700 $0

$300 $25 15% $10

In this example, Mia would pay: Cost Sharing Deductibles Copayments Coinsurance What isn’t covered Limits or exclusions The total Mia would pay is

Total Example Cost

Page 6 of 6

$0 $700

$300 $200 $200

$2,800

This EXAMPLE event includes services like: Emergency room care (including medical supplies) Diagnostic test (x-ray) Durable medical equipment (crutches) Rehabilitation services (physical therapy)

 The plan’s overall deductible  Specialist copayment  Hospital (facility) coinsurance  Other (x-ray) copayment

(in-network emergency room visit and follow up care)

Mia’s Simple Fracture

[The plan would be responsible for the other costs of these EXAMPLE covered services.]

$60 $1,630

$300 $70 $1,200

In this example, Joe would pay: Cost Sharing Deductibles Copayments Coinsurance What isn’t covered Limits or exclusions The total Joe would pay is

In this example, Peg would pay: Cost Sharing Deductibles Copayments Coinsurance What isn’t covered Limits or exclusions The total Peg would pay is

$5,600

Total Example Cost

$12,700

$300 $25 15% $10

Total Example Cost

 The plan’s overall deductible  Specialist copayment  Hospital (facility) coinsurance  Other (blood work) copayment This EXAMPLE event includes services like: Primary care physician office visits (including disease education) Diagnostic tests (blood work) Prescription drugs Durable medical equipment (glucose meter)

$300 $25 15% $10

(a year of routine in-network care of a wellcontrolled condition)

Managing Joe’s Type 2 Diabetes

This EXAMPLE event includes services like: Specialist office visits (prenatal care) Childbirth/Delivery Professional Services Childbirth/Delivery Facility Services Diagnostic tests (ultrasounds and blood work) Specialist visit (anesthesia)

 The plan’s overall deductible  Specialist copayment  Hospital (facility) coinsurance  Other (blood work) copayment

(9 months of in-network pre-natal care and a hospital delivery)

Peg is Having a Baby

This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be different depending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost sharing amounts (deductibles, copayments and coinsurance) and excluded services under the plan. Use this information to compare the portion of costs you might pay under different health plans. Please note these coverage examples are based on self-only coverage.

About these Coverage Examples:

27

28

29

UFCW Local 555-Employers Health Trust c/o Zenith American Solutions 12205 SW Tualatin Rd, Suite 200, Tualatin, OR 97062

2,000

50

30

service area. If different treatments are available, Necessary Dental Care includes the concept that the Trust will only cover the least costly alternative treatment that can be safely provided.

The Plan will determine the amount payable for any Covered Services not listed in the Schedule of Allowances based on the amount payable for an equivalent procedure that is listed. The Plan covers the following Basic Services: •

Oral Examination- Exam of the mouth and teeth;

•

Prophylaxis-Cleaning, scaling and polishing of the teeth;

•

Topical Fluoride Application-Applying fluoride to the exposed teeth surfaces;

•

Periapical and Bitewing X-Rays-Dental x-rays of the inside of the mouth. Periapical x-rays reveal the entire tooth and surrounding bone and gum tissue. Bitewing x-rays reveal some of the upper and lower teeth in the same film;

•

Extractions - The removal or pulling ofteeth;

•

Fillings- The Plan will cover fillings of silver amalgam, silicate or plastic restorative material. If the Participant elects to have another restorative material such as gold foil, the Plan will cover up to the cost of a silver amalgam filling;

•

Palliative Emergency Treatment-Emergency treatment primarily for relief, rather than cure;

•

Space Maintainers -An appliance to preserve the space between the teeth caused by premature loss of a primary tooth. The primary teeth are the first set of teeth, sometimes known as baby teeth. The Plan does not cover space maintainers used to create a space between teeth and used in orthodontics, except as provided under "Orthodontic Benefits." Space maintainer benefits are limited to children only;

•

Repair of Dentures and Bridges - Repair of artificial teeth;

•

Oral Surgery-Surgery pertaining to the gums, teeth or tooth structure for dental purposes and treatment of fractures and dislocations;

•

Apicoectomy-Surgical removal of the tip of the tooth root;

•

Endodontics- The prevention, diagnosis, and treatment of diseases and injuries of the tooth pulp, root and surrounding tissue. This includes pulpotomy, pulp capping and root canal treatment; and

•

Periodontic Services -Services of the connective tissue around and supporting the teeth. The Plan covers surgical periodontic exams, gingival curettage, gingivectomy, osseous surgery including flap entry and closure, mucogingivoplastic surgery, and management of acute infection and oral lesions related to the toothstructure.

Prosthetic Services Prosthetic services are services relating to an artificial device that replaces a missing dental part. The Plan will pay 100% of the amount listed in the Schedule of Allowances. The Plan will determine the amount payable for any Covered Services not listed in the Schedule based on the amount payable for an equivalent procedure that is listed. Covered prosthetic services are: •

Inlays, onlays;

•

Crowns consisting of a casting procedure;

•

Bridges, fixed and removable;and 51

31

•

Dentures, full and partial.

The Plan will provide benefits for dental implants and related procedures, up to the denture benefit, for dental implants which are deemed by the Plan to be necessary and appropriate. This allowance includes the crowns necessary for the implants.

The following four prosthetic services are not covered: •

Replacement, within five years, of a prosthetic appliance or fixed bridge {furnished under the Plan) by either a prosthetic appliance or fixed bridge, more often than once in five years;

•

Duplication Qump case) of an existing denture more often than once in five years;

•

Replacement of a prosthetic appliance which is or can be made satisfactory; or

•

Procedures started prior to becoming covered.

Benefits are limited to the charge for the standard procedure for the replacement of missing teeth with a full or partial denture. Personalized restoration and special techniques are not covered.

Orthodontic Services

Orthodontic services are services for the installation of orthodontic appliances (not including space maintainers for primary teeth) and treatment to reduce or eliminate malocclusion. Benefits are payable only when a treatment plan has been submitted.

Once an individual is accepted for care under the orthodontic program, foll benefits will be paid, even though coverage may terminate. A 60-day extension period is also allowed for final placement after coverage is terminated.

For Orthodontic Services, the Plan will pay 70% of Usual and Customary Charges for necessary orthodontic treatment up to a maximum of $825 per individual Usual and Customary Charges are charges the Plan determines fall within a range of those most frequently made for services and supplies in our service area by those who supply them. After an individual reaches the $825 maximum, the Plan will not provide further orthodontic benefits until a period of five years has elapsed from the date of the .first orthodontic payment under the Scheduled Dental Plan.

For more Information on your Dental Benefits, call: UFCW Local 555-Employers Health Trust c/o Zenith American Solutions 12205 SW Tualatin Rd, Suite 200 Tualatin, OR 97062 Phone (503) 486-2102 * Fax: (971) 239-0671

www.zenith-american.com

32

Most Common Scheduled Dental Plan Schedule of Allowances* CLINICAL ORAL EXAMINATION 0110 Initial oral exam $ 33.00 0150 Comprehensive oral exam $ 45.00 RADIOGRAPHS 0210 Intraoral - complete series (including $ 77.00 bitewings) 0274 Bitewings - four films $ 45.00 DENTAL PROPHYLAXIS 1110 Adults (including scaling & polishing) $ 59.00 1120 Children (to age 14) $ 44.00 FLUORIDE TREATMENTS (Office Procedure) 1203 Topical application of fluoride (excluding $ 21.00 prophylaxis) children to age 14 OTHER PREVENTIVE SERVICES 1351 Sealants - per tooth $ 24.00 AMALGAM RESTORATIONS (Including Polishing) 2140 Amalgam - 1 surface, permanent $ 113.00 2150 Amalgam - 2 surfaces, permanent $ 133.00 2160 Amalgam - 3 surfaces, permanent $ 185.00 2161 Amalgam - 4 or more surfaces, permanent $ 317.00 CROWNS - SINGLE RESTORATIONS ONLY 2740 Crown - porcelain/ceramic substrate $ 655.00 OTHER RESTORATIVE SERVICES 2930 Prefabricated stainless steel crown $ 119.00 primary tooth ROOT CANAL THERAPY (Includes Treatment Plan, Clinical Procedures and Follow-Up Care; Excludes Final Restoration) 3330 Molar - (excluding final restoration) $ 640.00 PERIODONTIC SURGICAL SERVICES (Includes Usual Post-Operative Services) 4120 Periodontal examination $ 26.00 ADJUNCTIVE PERIODONTAL SERVICES 4341 Periodontal scaling and root planing per $ 139.00 quadrant OTHER PERIODONTIC SERVICES 4910 Periodontal maintenance after active $ 111.00 COMPLETE DENTURES (Including Routine Post-Delivery Care) 5110 Complete upper $ 668.00 5120 Complete lower $ 668.00 PARTIAL DENTURES (Including Routine Post-Delivery Care) 5211 Upper partial - resin base (including any $ 730.00 conventional clasps, rests and teeth) 5212 Lower partial - resin base (including any $ 726.00 conventional clasps, rests and teeth) FIXED BRIDGES (Each Abutment and Each Pontic Constitutes a Unit in a Bridge) BRIDGE PONTICS 6240 Pontic - porcelain fused to high noble $ ABUTMENT CROWNS 6720 Crown - porcelain fused to high noble $ EXTRACTIONS (Including Local Anesthesia and Routine Post-Operative Care) 7110 Single tooth $

*Please contact the Trust office for the full Dental Plan Schedule of Allowances

655.00 655.00 62.00

33

Option 2: Williamette Dental Plan

Instead of the Scheduled Dental Plan, an Employee may choose to enroll in the Willamette Dental Plan. The Employee may change from one Dental Plan option to the other only during the Annual Open Enrollment period or within 30 days of adding a new Dependent.

Willamette Dental is a group practice Dental Plan which provides all dental services through contracted Dentists practicing at specified offices. The Willamette Dental Plan option is offered through Regence BlueCross BlueShield of Oregon. In addition to the Willamette Dental contact information, Regence Customer Service is available to provide information on benefits and Willamette Dental locations.

Except for a small visit charge and copayments for certain procedures, Willamette Dental provides all necessary dental services without charge to Participants.

How to Use the Willamette Dental Plan •

Willamette Dental services are provided only at Willamette Dental offices. The available locations are shown in the Willamette Dental Provider list available from the Trust Office or by contacting Willamette Dental's Patient Relations Department (800-460-7644).

•

Most dental offices are open from 7:00 a.m. until 6:00 p.m., Monday through Saturday. Evening appointments are available for all locations. To make an appointment, call the Appointment Center at 503-952-2100 or 1-800-461-8994.

•

Regence BlueCross BlueShield of Oregon Customer Service is also available from 6:00 a.m. to 6:00 p.m. to assist with benefit questions and to provide assistance in finding a Willamette Dental location. Regence Customer Service can be reached at 1-888-977-2583, for members only press 2. If you are a Provider, you have to call 1-866-227-0913.

•

When an Employee first enrolls in the Willamette Dental Plan, the Employee should make a dental appointment for himself or herself (and any eligible Dependents) whether or not the individual is then in need of dental care. The purpose of this early visit is to acquaint the individual with the Dentist and help determine the individual's dental care needs. Appointments can be made by calling the following telephone number: 1-800-461-8994.

•

At the first visit, most or all of the following can be expected, depending on the individual's particular needs: a review of the Participant's medical and dental history; an oral examination; any necessary x-rays; emergency treatment, if required; teeth cleaning or a scheduled appointment for teeth cleaning; and a personal dental hygiene program with instruction in home care.

•

If a Participant does not make a reasonable effort to follow the treatment program recommended by his or her dentist, the management of the Willamette Dental Plan has the option of asking the Participant to transfer to the Scheduled Dental Plan (or to seek another source of dental care) at the end of a Plan year.

Benefits Provided Each patient pays a $15 charge for each dental appointment. Certain procedures also require a copayment. Visit charges and copayments are listed below. There are no other charges. Under the Willamette Dental Plan preventative dental services are covered at 100% and require no copayment.

These services include: dental examinations; x-rays, cleaning; fluoride treatments; sealants; oral hygiene instruction; periodontal charting; periodontal evaluation; fillings; and simple extractions.

Note: If you need to cancel an appointment, you must notify the dental office 24 hours advance or a $10 missed appointment charge will apply.

in

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Group Managed Care Dental Insurance Benefit Summary Group Managed Care Dental Insurance LifeMap Assurance Company Group Managed Care Dental Plan provides employees and their family members the opportunity to receive dental services through Willamette Dental Group providers.

Summary of Covered Services and Service Copayments

General Dentist Visit Charge Specialist Dentist Visit Charge

$15 per visit $30 per visit

Annual Maximum

None

Benefit Waiting Period

None

Deductible

None

Covered Services

Service Copayment Charged per service in addition to the Visit Charge

Diagnostic and Preventive Services Oral examinations, Dental Cleanings, and All X-Rays

$0

Restorative Services Amalgam & Resin anterior, posterior primary, &resin based crowns

$0

Resin - 2 to 4 surfaces, posterior permanent

$52

Inlay/Onlay (cast restorations)

$95

Crowns

$95

Endodontic Services Root canal therapy, Retreatment and Apiectomy - anterior

$45

Root canal therapy, Retreatment and Apiectomy- bicuspid

$75

Root canal therapy, Retreatment and Apiectomy - molar

$95

Periodontal Services Periodontal scaling and root planing

$45

Preliminary full-mouth debridement & Periodontal maintenance

$0

Prosthetic Services Complete, Immediate and Partia

$95

Interim Dentures

$48

Bridges

$95

Dental Implants Dental Implant Surgery

1 implant per calendar year $1500 maximum per calendar year

Oral Surgery Extraction - coronal remnants primary or erupted tooth

$0

Surgical extraction - erupted tooth or impacted tooth

$70

Orthodontic Services Comprehensive Orthodontic Service Copay

$1,200

Coverage is available to you and, if you choose, eligible family members including a spouse and children under age 26. All premiums will be paid through payroll deduction.

Participating Providers include Willamette Dental Group, P.C., and the providers who are employed by or are under contract with Willamette Dental Group, P.C., or any of its affiliates. To receive the excellent benefits of this plan, you must receive care from a Willamette Dental Group provider. Willamette Dental Group has over 50 office locations throughout Oregon, Washington, and Idaho. You are free to select your Willamette Dental Group provider and whichever location is best foryou.

This summary is provided for your convenience only and is not intended to be inclusive of all policy provisions. Please see your certificate for complete details. If there is any discrepancy between this document and the master policy, the master policy provisions will prevail.

RLH GMCD-S OR EE Page 1 of 3 35

Group Managed Care Dental Insurance Benefit Summary Exclusions: No Benefits will be provided for any of the following conditions, treatments, services, supplies, or accommodations, including any direct complications or consequences that arise from them, unless otherwise specified.

Aesthetic Dental Procedures and complications arising out of such services. Including services and supplies provided in connection with dental procedures that are primarily aesthetic, including bleaching of teeth and labial veneers.

Benefits not stated meaning services and supplies that are not identified as Benefits under the Policy.

Charges by any person other than a Participating Provider except for those instances indicated in the Benefits section of this Policy.

Cosmetic/Reconstructive Services and Supplies, except in the treatment of the following: 1. to treat a congenital anomaly for Members up to age 18; or 2. to restore a physical bodily function lost as result of injury or illness.

Cosmetic means services or supplies that are applied to normal structures of the body primarily to improve or change appearance and that do not primarily restore an impaired function of the body.

Reconstructive means: 1. services, procedures, and surgery performed on abnormal structures of the body that were caused by congenital defects; or 2. developmental abnormalities, trauma, infection, tumors, or disease.

Reconstructive services are generally performed to restore function, but also may be done to approximate a normal appearance.

For the purposes of this exclusion, psychological factors (for example, poor self-image, difficult social or peer relations) are not relevant and are not considered a physical bodily function.

Coverage that is available under any federal, state, or other governmental program if application is duly made therefore, except where required by law, such as for cases of emergency or for coverage provided by Medicaid.

Dental implants supported prosthetics or abutment-supported prosthetics (crowns, bridges, and dentures) Dental implants, an implant surgically placed prior to the member’s effective date of coverage that has not received final restoration or dental implant for treatment of a primary or transitional definition.

Dental services which are not Necessary Dental Services as defined by this Policy.

Diagnostic Casts or Study Models Endodontics, implants, bridges, crowns, or other service or prosthetic devices requiring multiple treatment dates or fittings if treatment was started or ordered prior to the Member’s Effective Date under this Policy or if the item was installed or delivered more than 60 days after the Member’s coverage under this Policy has terminated. Root canal treatment will be covered if the tooth canal was opened prior to termination and treatment is completed within 60 days after termination.

Excision of a tumor; biopsy of soft or hard tissue; removal of a cyst, nonodontogenic or exostosis.

Experimental/Investigational treatments, procedures and services, supplies, and accommodations provided in connection with Experimental/Investigational treatments or procedures.

Extraction of permanent teeth for tooth guidance procedures; procedures for tooth movement, regardless of purpose; correction of malocclusion; preventive orthodontic procedures; craniomandibular orthopedic treatment; and other orthodontic treatment, unless specified in the Schedule of Covered Services and Copays.

Full-mouth reconstruction.

General Anesthesia, including conscious sedation and intravenous sedation, unless specified in the Schedule of Covered Services and Copays.

Habit-breaking or stress-breaking appliances Hospitalization for dentistry.

Maxillofacial prosthetic services.

Medication and Supply Charges including take home drugs, pre-medications, therapeutic drug injections, and supplies.

Military Service-Related Conditions which includes services and supplies for treatment of an illness or injury caused by or incurred during service in the armed forces of any state or country.

This summary is provided for your convenience only and is not intended to be inclusive of all policy provisions. Please see your certificate for complete details. If there is any discrepancy between this document and the master policy, the master policy provisions will prevail.

RLH GMCD-S OR EE Page 2 of 3 36

Group Managed Care Dental Insurance Benefit Summary

Exclusions: Motor Vehicle Coverage and Other Insurance Liability means any expenses for services and supplies that are payable under any: 1. automobile medical, personal injury protection (“PIP”), automobile no-fault, underinsured or uninsured motorist coverage; 2. homeowner’s coverage; 3. commercial premises coverage; or 4. similar policy or insurance.

This applies when the policy or insurance is either issued to, or makes benefits available to a Member, whether or not the Member makes a claim under such coverage. Further, the Member is responsible for any cost-sharing required by the motor vehicle coverage, unless applicable state law requires otherwise. Once benefits under such policy or insurance are exhausted or deemed to no longer be injury-related under the no-fault provisions of the Policy, We will provide Benefits according to the Policy.

Non-Direct Patient Care and services that are not direct patient care, including: 1. charges for appointments scheduled and not kept ("missed appointments"); 2. charges for preparing medical reports, itemized bills or claim forms (even at Our request); or 3. visits or consultations that are not in person (including telephone consultations and e-mail exchanges) whether initiated by the Member or the Member’s provider.

Occlusal Treatment and supplies provided in connection with dental occlusion, including the following: 1. complete occlusal adjustments; and 2. occlusal guards.

Personalized restorations, precision attachments, and special techniques.

Repair or Replacement Services and supplies provided in connection with the repair or replacement of any dental appliance (including but not limited to dentures and retainers), whether lost, stolen, or broken.

Replacement of sound restorations.

Riot, Rebellion, War and Illegal Acts including services and supplies for treatment of: 1. an illness or injury caused by a Member’s unlawful instigation and/or active participation in a riot or war, whether declared or undeclared; armed invasion or aggression, insurrection, or rebellion; or 2. services and supplies for treatment of an illness or injury sustained by a Member while in the act of committing an illegal act.

Services for accidental injury to natural teeth that are provided more than 12 months after the date of the accident.

Services or supplies and related exams or consultations that are not within the prescribed treatment plan and/or are not recommended and approved a Participating Provider.

Services or supplies where there is no evidence of pathology, dysfunction, or disease other than covered preventive services.

Temporomandibular Joint (TMJ) Dysfunction Treatment. Services and supplies provided in connection with Temporomandibular Joint (TMJ) dysfunction.

Transseptal fiberotomy.

Treatment started prior to the Member’s Effective Date under this Policy or completed after this Policy terminates, unless otherwise stated.

Work-Related Injuries and expenses for services and supplies incurred as a result of any work-related injury, including any claims that are resolved pursuant to a disputed claim settlement for which a Member has or had a right to compensation. We may require the Member to file a claim for workers’ compensation benefits prior to providing any Benefits under the Policy.

Services and supplies received for work-related injuries are not covered even if the service or supply is not a covered workers’ compensation benefit. The only exception is if a Member is exempt from state or federal workers’ compensation law.

This summary is provided for your convenience only and is not intended to be inclusive of all policy provisions. Please see your certificate for complete details. If there is any discrepancy between this document and the master policy, the master policy provisions will prevail.

RLH GMCD-S OR EE Page 3 of 3 37

A LOOK AT YOUR VSP VISION COVERAGE

SEE HEALTHY AND LIVE HAPPY WITH HELP FROM UFCW LOCAL 555 EMPLOYERS HEALTH TRUST AND VSP. As a VSP® member, you get personalized care from a VSP network doctor at low out-of-pocket costs.

VALUE AND SAVINGS YOU LOVE. Save on eyewear and eye care when you see a VSP network doctor. Plus, take advantage of Exclusive Member Extras for additional savings.

PROVIDER CHOICES YOU WANT. With an average of five VSP network doctors within six miles of you, it’s easy to find a nearby in-network doctor. Plus, maximize your coverage with bonus offers and additional savings that are exclusive to Premier Program locations.

USING YOUR BENEFIT IS EASY! Create an account on vsp.com to view your in-network coverage, find the VSP network doctor who’s right for you, and discover savings with exclusive member extras. At your appointment, just tell them you have VSP.

Like shopping online? Go to eyeconic.com and use your vision benefits to shop over 50 brands of contacts, eyeglasses, and sunglasses.

QUALITY VISION CARE YOU NEED. You’ll get great care from a VSP network doctor, including a WellVision Exam®—a comprehensive exam designed to detect eye and health conditions.

GET YOUR PERFECT PAIR

EXTRA $20 + TO SPEND ON FEATURED FRAME BRANDS*

UP TO

40%

SAVINGS ON LENS ENHANCEMENTS

SEE MORE BRANDS AT VSP.COM/OFFERS.

Contact us: 800.877.7195 or vsp.com

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YOUR VSP VISION BENEFITS SUMMARY UFCW LOCAL 555 EMPLOYERS HEALTH TRUST and VSP provide you with an affordable vision plan.

PROVIDER NETWORK: VSP Signature EFFECTIVE DATE: 01/01/2022

BENEFIT

DESCRIPTION

COPAY

FREQUENCY

Focuses on your eyes and overall wellness

$0

Every 12 months

FRAME

$170 featured frame brands allowance $150 frame allowance 20% savings on the amount over your allowance

$0

Every 24 months

LENSES

Single vision, lined bifocal, and lined trifocal lenses Impact-resistant lenses for dependent children

$0

Every 12 months

LENS ENHANCEMENTS

Standard progressive lenses Premium progressive lenses Custom progressive lenses Average savings of 40% on other lens enhancements

CONTACTS (INSTEAD OF GLASSES)

$130 allowance for contacts; copay does not apply Contact lens exam (fitting and evaluation)

ESSENTIAL MEDICAL EYE CARE

Retinal screening for members with diabetes Additional exams and services for members with diabetes, glaucoma, or age-related macular degeneration.

Treatment and diagnoses of eye conditions, including pink eye, vision loss, and cataracts available for all members Limitations and coordination with your medical coverage may apply. Ask your VSP doctor for details

YOUR COVERAGE WITH A VSP PROVIDER WELLVISION EXAM PRESCRIPTION GLASSES

$0 $80 - $90 $120 - $160

Up to $60

Every 12 months

Every 12 months

$0 $20 per exam As needed

Glasses and Sunglasses Extra $20 to spend on featured frame brands. Go to vsp.com/offers for details.

30% savings on additional glasses and sunglasses, including lens enhancements, from the same VSP provider on the same day as your WellVision Exam. Or get 20% from any VSP provider within 12 months of your last WellVision Exam.

EXTRA SAVINGS

Routine Retinal Screening No more than a $39 copay on routine retinal screening as an enhancement to a WellVision Exam Laser Vision Correction Average 15% off the regular price or 5% off the promotional price; discounts only available from contracted facilities After surgery, use your frame allowance (if eligible) for sunglasses from any VSP doctor

YOUR COVERAGE WITH OUT-OF-NETWORK PROVIDERS Get the most out of your benefits and greater savings with a VSP network doctor. Call Member Services for out-of-network plan details.

Coverage with a retail chain may be different or not apply. Log in to vsp.com to check your benefits for eligibility and to confirm in-network locations based on your plan type. VSP guarantees coverage from VSP network providers only. Coverage information is subject to change. In the event of a conflict between this information and your organization’s contract with VSP, the terms of the contract will prevail. Based on applicable laws, benefits may vary by location. In the state of Washington, VSP Vision Care, Inc., is the legal name of the corporation through which VSP does business.

*Only available to VSP members with applicable plan benefits. Frame brands and promotions are subject to change. Savings based on doctor’s retail price and vary by plan and purchase selection; average savings determined after benefits are applied. Ask your VSP network doctor for more details.

Classification: Restricted ©2021 Vision Service Plan. All rights reserved.

VSP, VSP Vision Care for life, Eyeconic, and WellVision Exam are registered trademarks, VSP Diabetic Eyecare Plus Program is servicemark of Vision Service Plan. Flexon is a registered trademark of Marchon Eyewear, Inc. All other brands or marks are the property of their respective owners.

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Use this sheet to find the assistance you need U.A. UNION LOCAL NO. 290 PLUMBER, STEAMFITTER AND SHIPFITTER INDUSTRY PENSION TRUST QUICK REFERENCE CHART 12205 SW Tualatin Road, Suite 200 Information Needed Whom to Contact Tualatin, OR 97062 ELIGIBILITY QUESTIONS: - Eligibility for Coverage - Enrollment for Coverage - Demographic Changes (Names/Addresses etc.)

- Obtaining ID Cards - Medical/Dental/Claims Appeals that were initially denied by Carrier.

- Proof of Insurance & Medicare D Notice.

- COBRA Information and Premium Payments - Accident and Disability Weekly Benefits and Claims - Death and AD&D Benefits and Claims - Retirement Information & Premium Payments

BENEFIT AND CLAIMS QUESTIONS: FOR TRUST INDEMNITY PLAN: - Medical Benefits - Medical Claims Submission - Medical Claims Appeal - ID Cards

--------------------------------------------------------KAISER HMO PLAN

- Kaiser Benefits & Claims - Kaiser Claims Appeals - ID Cards

DENTAL BENEFITS: -Dental Benefits -Dental Claims Submission -Initial Dental Claims Appeals -ID Cards *Note, Dental Benefits are only available once you attain Level 2 coverage and above

---------------------------------------------------------

-Benefit Office Locations and Appointments -ID Cards

PRESRT STD US POSTAGE PAID PERMIT 243 PORTLAND OR

Zenith American Solutions, Inc. Contributions Accounting Department 12205 SW Tualatin Rd. Suite 200 Tualatin, OR 97062 Phone: 503-486-2102 Toll Free: 866-796-7623 Fax: 971-239-0672 www.zenith-american.com

Zenith American Solutions, Inc. Benefits & Claims Department 12205 SW Tualatin Rd. Suite 200 Tualatin, OR 97062 Phone: 503-486-2102 Toll Free: 866-796-7623 Fax: 971-239-0671 www.zenith-american.com

--------------------------------------------------------Kaiser Permanente Member Services 500 NE Multnomah St Suite 100 Portland, OR 97232 503-813-2000 or 800-813-2000 www.kp.org Trust Self-Funded Dental Plan 12205 SW Tualatin Rd. Suite 200 Tualatin, OR 97062 Phone: 503-486-2102 Toll Free: 866-796-7623 Fax: 971-239-0671 www.zenith-american.com

--------------------------------------------------------Willamette Dental Phone: (855) 433-6825 www.willamettedental.com

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CLAIMS ADMINISTRATOR FOR PRESCRIPTION DRUGS : TRUST INDEMNITY PLAN -Information on Benefits -Participating Pharmacies -Claims Submissions for Prescriptions -ID Cards -Mail Order Pharmacy -Market Place RX Program -Specialty Drug Benefits (Precert. and Ordering)

VISION BENEFITS:

-Benefits/Vision Network Providers -Claims Submission -Claims Appeal for Vision Benefits *Note: Vision Benefits are only available once you attain Level 3 coverage

PENSION BENEFITS:

-Information regarding Pension Eligibility -Information Regarding Current Pension -Applications and Forms -Change in Personal Information -Death Benefits for pre-and post-retirement -Check and/or direct deposit status

WEEKLY DISABILITY INCOME: -Apply for Weekly Disability Benefits -Check Status of Disability Payment

LEVEL II CLAIMS APPEALS If you are unsuccessful appealing your claim, Level 2 Claim Appeals for Medical, Prescription Drug, Dental, Vision, Death, Accidental Death and Dismemberment (AD&D) and Weekly Disability Benefit can be heard by the Board of Trustees.

MEDICARE

-Contact Medicare with questions regarding Medicare Part A, B, and/or D coverage.

HIPAA PRIVACY & SECURITY OFFICERS -HIPAA Notice of Privacy Practice

Optum RX PO Box 650334

Dallas, TX 85034-0334

www.optumrx.com (866) 328-2005

Vision Service Plan (VSP)

PO Box 385018 Birmingham, AL 35238-5018 www.vsp.com (800) 877-7195

Zenith American Solutions, Inc. Pension Department 12205 SW Tualatin Rd. Suite 200 Tualatin, OR 97062 Phone: 503-486-2102

Toll Free: 866-796-7623 Fax: 971-239-5566 www.zenith-american.com

Zenith American Solutions, Inc. 12205 SW Tualatin Rd. Suite 200 Tualatin, OR 97062 Phone: 503-486-2102 Toll Free: 866-796-7623 Fax: 971-239-0671 www.zenith-american.com The Board of Trustees UFCW Local 555 Trust Funds 12205 SW Tualatin Rd. Suite 200 Tualatin, OR 97062 Phone: 503-486-2102 Toll Free: 866-796-7623 Medicare 1-800-633-4227 www.medicare.gov

Zenith American Solutions, Inc. 12205 SW Tualatin Rd. Suite 200 Tualatin, OR 97062 Phone: 503-486-2102

Toll Free: 866-796-7623

www.zenith-american.com

41

UFCW LOCAL 555 - EMPLOYERS HEALTH TRUST 12205 SW Tualatin Rd, Suite 200 Tualatin, OR 97062 Phone: (503) 486-2102 * 1-866-796-7623 Fax: (971) 239-0672

Welcome to UFCW 555 Member Online Access, sponsored by Zenith American Solutions (ZAS).

UFCW-ZAS is your one-stop shop for: • • • • • • •

Eligibility Information Covered Family Members and Dependents Work History Benefits Summary Claims and Short-term Disability Claim Status Pension Important Plan Documents

42

To access UFCW-ZAS, please follow the directions below: 1. Go to: http://www.zenith-american.com/ 2. Click on “Login to your Account” 3.

This takes you to the Account drop down menu. Select “Participant Edge (ZAS/ABPA)”.

Note: This will take you to the secure website URL: https://edge.zenith-american.com/page.php?p=members/index.php&ac=login 4. The first time that you visit the website, you will need to “Register” by selecting the “Register Form” link.

43

5. Complete the Website Registration Form To complete the online registration, you will need the following information: • • • • •

Full Name SSN (or Alternate ID) Date of Birth State Zip Code

Note: Your Registration Information must match the Participant Information that the Trust has on record. Please contact the Trust if you need to change your address.

44

6. Next you will create your unique Username and Password, and also select a Security question and answer (to use in case you ever forget your password).

7. After you have registered successfully, you will now have access to the Secure UFCW Member website.

You can “Log In” using in your new username and password.

The Secure UFCW Member website can be used to check your Work History, Eligibility, Claims and Pension information online, in addition to accessing important Trust Documents and Links.

45

UFCW LOCAL 555-EMPLOYERS HEALTH TRUST 12205 SW Tualatin Rd., Suite 200 Tualatin, OR 97062

PRESRT STD US POSTAGE PAID PERMIT 243 PORTLAND ORG