health & welfare - raley’s family of fine stores · your family stay healthy. on the...

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HEALTH & WELFARE BENEFITS

Food Source Non-Union Hourly Retail (FSH, FSN)

2014

Dear Employee and Family Members:

Raley’s is committed to our employees’ health and wellness. We are pleased to provide you with this description of your health and welfare benefits. Your benefits include medical, dental, prescription and vision coverage; group life and accidental death and dismemberment insurance; as well as our employee assistance program. These benefits are designed to help protect you and your family against the financial hardship that can accompany sickness or injury. We’re proud to offer you this kind of protection. Your health is important to us. In our stores, we provide healthy options for our customers. As a company, we work to provide you with the benefits to help you and your family stay healthy. On the following pages you’ll find general information about eligibility, coverage, and

participation. Because this booklet is a summary, it may not answer all of your questions

about your health and welfare benefits. For more information about the details of the

Plan, please contact the Employee Benefits Department. For your convenience, our

providers’ websites may be accessed through Raley’s internal website, or on

yourpantry.net.

If you need us, your benefits team is here for you–just a phone call or an email away. Email us at [email protected] Call toll-free at (888) 332-4894 To health,

Michelle Gonzalez Senior Manager, Employee Benefits

If there is a discrepancy between information included in this summary and information

contained in the actual Plan documents, the documents will govern.

If there is ever any conflict between an insurance policy providing benefits under the Plan and

either the Plan document or this summary plan description, the insurance policy will control

(unless otherwise required by applicable law). No statements contained in this summary plan

description or any summary of material modifications to this summary plan description

constitute terms of the Plan – all such terms are contained in the Plan document and any duly

authorized and adopted amendments to the Plan document.

TABLE OF CONTENTS

OVERVIEW ...................................................................................................................... 4

ELIGIBILITY ........................................................................................................................................................... 4 You ........................................................................................................................................................................ 4 Your Dependents ................................................................................................................................................... 1 Coordination of Benefits –Spousal Provision ....................................................................................................... 2 Employee Contribution ......................................................................................................................................... 2

ENROLLMENT ........................................................................................................................................................ 4 New Employees ..................................................................................................................................................... 4 Open Enrollment ................................................................................................................................................... 4 Special Enrollment Rights ..................................................................................................................................... 4

CHANGES IN EMPLOYMENT CLASSIFICATION.............................................................................................. 4 Reinstatement Provision ....................................................................................................................................... 4

YOUR MEDICAL PLAN ..................................................................................................... 6

RALEY’S PPO MEDICAL PLAN ............................................................................................................................ 6 Identification Card ................................................................................................................................................ 6 Annual Deductible ................................................................................................................................................ 6 Your Preferred Provider Option (PPO) ................................................................................................................ 6 Annual Co-payment Maximum ............................................................................................................................. 6 Overall Benefit Maximum ..................................................................................................................................... 6 Pre-Authorization Procedures .............................................................................................................................. 7 NURSEHELP 24/7 ................................................................................................................................................ 7 Medical Schedule of Benefits -Q- Classic ............................................................................................................. 8 Medical Schedule of Benefits – K – Premier ...................................................................................................... 12

PRESCRIPTION DRUG PLAN .............................................................................................................................. 16 Prescription Schedule of Benefits –J- Classic, Premier ..................................................................................... 17

RALEY’S HMO MEDICAL PLAN ............................................................................................................................... 19 Enrolling in Kaiser Permanente ......................................................................................................................... 19 Kaiser Vision Care .............................................................................................................................................. 19 Prescription Coverage ........................................................................................................................................ 20 Enrollment Requirements .................................................................................................................................... 20 Service Area Eligibility Requirements ................................................................................................................ 20

PATIENT PROTECTION .............................................................................................................................................. 20 Kaiser Medical Schedule Set 9-Premier Plus ..................................................................................................... 22

YOUR DENTAL PLAN .................................................................................................... 25

DELTA DENTAL ................................................................................................................................................... 25 Choosing Your Dentist ........................................................................................................................................ 25 Predeterminations ............................................................................................................................................... 25 Second Opinions ................................................................................................................................................. 26 Payment .............................................................................................................................................................. 26 Exclusion for Duplicate Coverage ...................................................................................................................... 27 Termination of Dental Benefits ........................................................................................................................... 27 Extension of Dental Benefits following benefit termination ................................................................................ 27 Dental Schedule Of Benefits –J- Classic ............................................................................................................ 28 Dental Schedule of Benefits –Q Premier ............................................................................................................ 31 General Limitation .............................................................................................................................................. 34

DELTACARE USA ................................................................................................................................................ 36 Overview ............................................................................................................................................................. 36 How the DELTACARE USA Program Works ..................................................................................................... 36 Provisions for Emergency Care .......................................................................................................................... 36 Choosing a Dentist .............................................................................................................................................. 36 Work in Progress ................................................................................................................................................ 37

Specialist Services ............................................................................................................................................... 37 Questions about the DeltaCare Program ........................................................................................................... 37 Termination of Dental Benefits ........................................................................................................................... 37 DeltaCare Schedule Of Benefits ......................................................................................................................... 38

YOUR VISION PLAN ...................................................................................................... 41

VISION SERVICE PLAN ....................................................................................................................................... 41 What are the Benefits? ........................................................................................................................................ 41 Obtaining VSP Services ...................................................................................................................................... 41 May I Use Any Doctor? ...................................................................................................................................... 42 Claims ................................................................................................................................................................. 42 Forms and Information ....................................................................................................................................... 42 Vision Schedule Of Benefits -C-Classic .............................................................................................................. 43 Vision Schedule Of Benefits -A- Premier ............................................................................................................ 44

HEALTH PLAN CLAIMS PROCEDURES (SELF-FUNDED PLANS) ................................. 46

Types of Claims ................................................................................................................................................... 46 Appointing an Authorized Representative ........................................................................................................... 46 Submitting Claims ............................................................................................................................................... 47 Initial Claims Determinations ............................................................................................................................. 48 Notice of Adverse Benefit Determinations .......................................................................................................... 49 Appealing an Adverse Benefit Determination ..................................................................................................... 50 The Review Process ............................................................................................................................................ 50 Timeframe for the Determination on Appeal ...................................................................................................... 51 Notification of Adverse Benefit Determination on Appeal .................................................................................. 51 Claims Inquires and Benefit Questions ............................................................................................................... 53

OTHER SPECIAL BENEFITS .......................................................................................... 54

SCHEDULE OF LIFE, ACCIDENTAL DEATH, AND DISMEMBERMENT BENEFITS .................................. 54 Employee Life, Accidental Death and Dismemberment Insurance Benefits ....................................................... 54 Conversion Options ............................................................................................................................................ 54 Dependent Life Insurance ................................................................................................................................... 54

EMPLOYEE ASSISTANCE RESOURCES PROGRAM ...................................................................................... 55

OTHER INFORMATION .................................................................................................. 56

ABOUT MEDICARE ............................................................................................................................................. 56 COORDINATION OF BENEFITS ......................................................................................................................... 56

Understanding “Coordination of Benefits” ........................................................................................................ 56 Coordination of Benefits –Spousal Provision ..................................................................................................... 57 Exclusion for Duplicate Coverage ...................................................................................................................... 57 Exceptions to COB .............................................................................................................................................. 58

CHANGE IN STATUS EVENTS ........................................................................................................................... 58 How to Make a Change....................................................................................................................................... 59 Effective Date of Coverage ................................................................................................................................. 59

THIRD PARTY LIABILITY .................................................................................................................................. 60 WHEN COVERAGE ENDS ................................................................................................................................... 60

You ...................................................................................................................................................................... 60 Dependents ......................................................................................................................................................... 61 Continued Coverage for an Incapacitated Child ................................................................................................ 61

CONTINUED COVERAGE FOR YOU AND YOUR DEPENDENTS ................................................................. 61 HEALTHCARE REFORM AND YOU ................................................................................................................. 61 COBRA ............................................................................................................................................................... 61 New Dependents and Open Enrollment .............................................................................................................. 62 To Elect Continuation Coverage......................................................................................................................... 63 When Continuation Coverage Ends .................................................................................................................... 63

FAMILY AND MEDICAL LEAVE ACT OF 1993 (FMLA) ............................................................................................. 63 NATIONAL DEFENSE AUTHORIZATION ACT OF 2008 (NDAA) ................................................................................. 64 EXTENSION OF BENEFITS FOR TOTAL DISABILITY (LEAVE OF ABSENCE CONCURRENT WITH FMLA) ..... 64 UNIFORMED SERVICES EMPLOYMENT AND REEMPLOYMENT RIGHTS ACT OF 1994 (USERRA) ............................. 64 NEWBORNS’ AND MOTHERS’ HEALTH PROTECTION ACT OF 1996 ......................................................... 65 QUALIFIED MEDICAL CHILD SUPPORT ORDERS ......................................................................................... 66 HIPAA .................................................................................................................................................................... 66 CHANGES TO THE PLAN .................................................................................................................................... 67 ERISA INFORMATION ......................................................................................................................................... 67

Receive Information About Your Plan and Benefits ............................................................................................ 67 Continue Group Health Plan Coverage .............................................................................................................. 67 Prudent Actions by Plan Fiduciaries .................................................................................................................. 67 Enforce Your Rights ............................................................................................................................................ 68

DEFINITIONS ................................................................................................................ 69

PLAN DIRECTORY ......................................................................................................... 74

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OVERVIEW

Raley’s Health and Welfare Plan (“Plan”) is designed to protect our employees and their families

against the financial burden of illness or injury.

ELIGIBILITY

You

To be eligible for benefits under the Raley’s Health and Welfare Plan – Classic level benefits,

you must work four (4) consecutive months with at least 92 eligible in the third and fourth

months.

If you are a newly hired or rehired employee on or after January 1, 2012, you would

then be eligible for “employee only or employee and children” coverage on the first day

of the next calendar month. Once enrolled, you will remain eligible for coverage as long

as you continue to work 92 eligible hours per month. Spousal coverage is not offered.

Premier Level Benefits

At the first Open Enrollment following the completion of twenty-four (24) months of

continuous service with the Company, you will be eligible for the Premier level plan of Blue

Shield or the Premier Plus level plan of Kaiser, which provide lower out-of-pocket expenses.

So, if you are hired on January 3, and work at least 92 eligible hours in March and April, you are

eligible as of May 1. You then have until May 31 to submit your enrollment form and all

necessary documentation.

For January Hrs: Dec 30 to Jan 26 For February Hrs: Jan 27 to Feb 23 For March Hrs: Feb 24 to Mar 30

For April Hrs: Mar 31 to April 27 For May Hrs: Apr 28 to May 25 For June Hrs: May 26 to June 29

Example RALEY’S Benefits Eligibility Calendar

Raley’s uses a benefits calendar to ensure equal time periods for hours counting are used through the year. This is an example calendar. The full calendar can be found on The Pantry or Yourpantry.net.

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If you are transferring from a union to a non-union position, you may be eligible on the first day

of the month following your transfer date. So, if you transfer from a union position to a non-

union position on September 3, you may be eligible for coverage October 1. You then have until

October 31 to submit your enrollment information and all necessary documentation.

If you do not submit your enrollment information and all necessary documentation within 31

days of becoming eligible, you will not be eligible to enroll in benefits until the next annual

Open Enrollment period (or, if you have special enrollment rights – see page 5).

Once enrolled, you will remain eligible for coverage as long as your continue to work 92 eligible

hours per month.

Eligible hours include straight time and overtime hours worked, hours credited for paid

holidays, vacation, jury duty, bereavement and sick pay.

If you change employment from an ineligible class to an eligible class, hours worked in the ineligible

status will apply toward hours required to become eligible under this Plan. Any money already paid

toward the deductible or percentage amount for the Plan provided by the Trust will be considered paid

toward this Plan.

Your Dependents

If you were hired prior to January 1, 2012, your dependents are also eligible for coverage under

this Plan. Dependents must be enrolled in the same Plan as the employee. In order to enroll

your dependents, you must provide a copy of your marriage certificate, child’s birth certificate

or court-approved adoption papers. Eligible dependents include the following:

Your spouse (Must have hire date prior to January 1, 2012) (if not legally separated);

Your dependent children up to age 26 (must provide a copy of birth certificate(s) and/or

adoption paperwork).

Your dependent children over the age limits specified above are also eligible for continued

coverage if all three of the following conditions are met:

They depend primarily upon you for their financial support and maintenance due to

mental retardation or physical handicap;

They are incapable of self-sustaining employment; and

Their mental retardation or physical handicap existed before they reached age 26.

Satisfactory documentation of these requirements must be furnished to the Employee Benefits

Department. For additional information, please contact the Employee Benefits Department toll-

free at (888) 332-4894 or email [email protected].

A “spouse” is defined as a person who is lawfully married to a covered employee under the

laws of the state in which they reside. Dependent children include natural children, legally

adopted children, stepchildren, and children of a qualified “registered domestic partner”. If you

have begun the process of adopting a child and you have custody of the child, that child is also

eligible for coverage. If there is a Qualified Medical Child Support Order (QMCSO) that

establishes your financial responsibility for the health care expenses of a child, that child will be

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eligible for coverage. Your spouse or child is not your qualified dependent while on active duty

in the armed forces of any country.

A “registered domestic partner” is defined as a person who has a valid registered domestic

partnership to a covered employee and meets the following criteria:

1. Each are eighteen (18) years of age or older in a committed same-sex relationship; or

2. If in a committed opposite-sex relationship, either the employee or the domestic

partner is age 62 or older.

A registered domestic partner as well as same-sex spouse may be able to enroll in the Kaiser

Permanente plan (but not in any of the other health plan options) and in the Raley’s Dependent

Life Insurance plan. Please contact the Employee Benefits Department to obtain more

information about eligibility of registered domestic partners or same-sex spouses.

Coordination of Benefits –Spousal Provision

The Raley’s Health and Welfare Plan contains a “Coordination of Benefits—Spousal Provision.”

This provision states that if your spouse is working and is eligible for health and welfare benefits

from their employer, your spouse must enroll in the best available plan offered by that

employer. If coverage is available to your working spouse and your spouse does not enroll in

the available coverage, you will be required to pay the single monthly COBRA premium rate,

through payroll deduction, to maintain coverage for your working spouse.

If you are enrolling your spouse in a Company-provided health plan, you will be required to

complete a Spousal Coordination of Benefits Questionnaire, which is included as part of the

Benefits Enrollment Form. This questionnaire must be completed in order to enroll your spouse

as a dependent. Failure to provide the requested information will result in your spouse not

being enrolled during the relevant Plan Year.

If you and your spouse are both employed by Raley’s and are eligible for Raley’s administered benefits, you may each make a benefit election and may cover yourselves, but no individual may carry “Dual Coverage”. For example, one employee may elect Employee Only coverage, and the other employee may elect Employee plus Children; or, one employee may elect Family coverage. No individual may be covered twice under a Raley’s administered Plan.

Employee Contribution

The Raley’s Health and Welfare Plan offers employees the flexibility to choose benefits that

meet the needs of your family. You may choose your medical, dental and vision coverage

separately under the Blue Shield, Delta Dental, Delta Care USA and Vision Service Plans. The

benefit offerings are unbundled, meaning you can mix and match your benefits. At this time,

Kaiser medical and vision coverage are bundled. Family members must be enrolled in the same

plan as the employee.

Please Note: If you are eligible for Premier level of benefits you have the option of electing to

stay at that level or “buy-down” to a health plan less expensive to fit your family needs. During

Open Enrollment you will have the opportunity to “buy-up” if you find that the less expensive

plan is not meeting your family’s needs.

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To determine your weekly medical premium deduction, see the chart below. Pretax weekly

deductions will be taken in the first 4 pay periods of each month.

Weekly Premium Rates

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Medical

Blue Shield - PPO

- Employee Only $134.68 $0.00 $118.52 $0.00 $9.25

- Employee + Child $234.34 $6.00 $206.22 $5.25 $9.25

- Employee + Children $311.10 $10.50 $273.77 $9.25 $9.25

- Employee + Spouse $234.34 $6.00 $206.22 $5.25

- Employee + Family $311.10 $10.50 $273.77 $9.25

Kaiser - HMO

- Employee Only $113.86 $0.00

- Employee + Child $227.71 $6.75

- Employee + Children $322.22 $12.50

- Employee + Spouse $227.71 $6.75

- Employee + Family $322.22 $12.50

Dental

Delta Dental - DPPO

- Employee Only $10.36 $0.00 $6.34 $0.00 $0.50

- Employee + Child $18.64 $1.75 $11.40 $1.00 $0.50


- Employee + Spouse $18.64 $1.75 $11.40 $1.00

- Employee + Family $29.00 $3.75 $17.74 $2.25

Delta Care USA DHMO

- Employee Only $5.02 $0.00 $5.02 $0.00 $0.50

- Employee + Child $8.64 $0.75 $8.64 $0.75 $0.50


- Employee + Spouse $8.19 $0.75 $8.19 $0.75

- Employee + Family $11.67 $1.25 $11.67 $1.25

Vision

Vision Service Plan

- Employee Only $1.42 $0.00 $0.81 $0.00 $0.25

- Employee + Child $2.85 $0.50 $1.62 $0.25 $0.25


- Employee + Spouse $2.85 $0.50 $1.62 $0.25

- Employee + Family $4.55 $1.25 $2.59 $0.75

As a participant in the Raley’s Health and Welfare Plans, your contribution will begin the first

pay period after your benefits become effective. These employee contributions are taken

directly from your paycheck, on a pre-tax basis, during the first four (4) pay periods of each

calendar month. By signing the last page of your Benefits Enrollment Form, or by checking the

“I agree” box if enrolling online, you are authorizing for these payroll deductions.

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Your election to participate in the benefits under the Raley’s Health and Welfare Plan is

irrevocable for the full Plan Year (January 1st through December 31st) unless there is an eligible

“Change in Family Status” as defined under the Plan.

ENROLLMENT

You will receive the necessary information so that you and your eligible dependents can enroll

for health coverage. You must complete either the paper form or submit your online

enrollment, including all required documentation, in order for your coverage to take effect

once you have satisfied eligibility.

New Employees

When you first become eligible for medical coverage, you will be given 31 days to enroll in the

Company-provided benefits. If you do not enroll within 31 days, you will not be eligible for

benefits until the next annual Open Enrollment period.

When enrollment information for a newly eligible employee is submitted without birth

certificates for children, the employee will have 31 days from the date of enrollment to submit

the required documentation in order to add the dependent(s) to the employee’s coverage. If

the documentation is received within the 31-day time period, the dependent(s) will be added to

the employee’s coverage. If the documentation is not received within the 31-day time period,

the next opportunity to enroll the dependent(s) would be during the next Open Enrollment

period in November, with coverage effective January 1 of the following Plan Year.

Open Enrollment

Each November, you will have an opportunity to add or drop dependents from your health and

welfare coverage as well as change between medical and dental plans based on their

availability in your area. Changes become effective on January 1 of the following year.

Special Enrollment Rights

If you are declining enrollment for yourself or your dependents because of other health

coverage, you may in the future be able to enroll yourself or your dependents in this Plan,

provided that you request enrollment within 31 days after your other coverage ends. In

addition, if you have a new dependent as a result of marriage, birth, adoption, or placement for

adoption, you may be able to enroll yourself and your dependents, provided that you request

enrollment within 31 days after the marriage, birth, adoption, or placement for adoption.

CHANGES IN EMPLOYMENT CLASSIFICATION

Reinstatement Provision

Employees who lose eligibility for medical benefits but continue working for the Company will

have special status when they re-qualify for the Plan. If you lose eligibility due to a lack of

qualifying hours, your benefits will be reinstated on the first day of the month following the

month in which you work at least 120 eligible hours (or 92 for Auxiliary). Your coverage will be

reinstated with the same medical and dental benefits including the same deductibles,

percentage co-payments, and maximum benefit limits. Employees who terminate employment

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and who are later rehired by the Company are not eligible for this Reinstatement Provision and

are treated as new employees.

Your PPO Medical Plan

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YOUR MEDICAL PLAN

RALEY’S PPO MEDICAL PLAN

Raley’s PPO Medical Plan is offered through Blue Shield of California. Covered preventive care

services (as defined by Blue Shield’s Preventive Health Services Policy) are not subject to your

calendar year medical plan deductible.

Identification Card

Once you are enrolled in one of the Raley’s PPO Medical Plans, you will receive an identification

card from Blue Shield of California.

Annual Deductible

The PPO Medical Plan contains an annual deductible, which is the amount of money a covered

person (or covered family members) must pay toward eligible medical expenses before the Plan

begins to pay.

Your Preferred Provider Option (PPO)

Preferred Providers are health care professionals (for example, physicians, medical specialists

and hospitals) who have agreed to discount their fees in exchange for your participation in the

program.

The Plan has contracted with Blue Shield of California, in association with Blue Cross/Blue

Shield of Nevada to give you a Preferred Provider Option (PPO). You can search for providers

online at blueshieldca.com or contact Blue Shield directly for provider information.

You are free to go to the doctor of your choice. However, by choosing a preferred provider, the

Plan will pay a greater percentage of the bill. For Preferred Providers, the Plan pays a

percentage of the allowable charges, and you pay only the remainder of the allowable amounts

(after your annual deductible has been satisfied). If you go to a non-preferred provider, the Plan

pays a smaller percentage of the allowable amount, and you pay the balance of the billed

amount.

Annual Co-payment Maximum

Once you have reached your out-of-pocket limit, the Plan pays 100% of all additional covered

allowable amounts for the rest of that year.

If you choose a provider who is not in the program your maximum out-of-pocket cost per year

will be greater and you will still be responsible for any charges over the allowable amounts.

Overall Benefit Maximum

Your Blue Shield PPO plans have no lifetime benefit maximums.


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If you have questions regarding the coverage

or the processing of a claim, call Blue Shield

Customer Service at (800) 358-9556.

●

Pre-Authorization Procedures

Prior authorization for non-emergency (planned) admissions or elective surgery may be

required. To request information about prior authorization for applicable services, please see

your Blue Shield Benefits Booklet or call Blue Shield’s toll-free number: (800) 358-9556.

For emergency hospitalizations, your or your Physician must notify Blue shield within 24 hours

or by the end of the first business day following emergency admissions, or as soon as it is

reasonably possible to do so.

Penalties for non-compliance may apply. Please see the ADDITIONAL AND REDUCED

PAYMENTS FOR FAILURE TO USE THE BENEFITS MANAGEMENT PROGRAM section of your

Benefits Booklet.

NURSEHELP 24/7

The NurseHelp 24/7 program provides Members with no charge, confidential, unlimited

telephone support for information, consultations, and referrals for health issues. Members may

obtain these services by calling 1-877-304-0504, a 24-hour, toll-free telephone number.


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Medical Schedule of Benefits -Q- Classic

Raley’s Health & Welfare Benefit Summary

THIS MATRIX IS A SUMMARY ONLY. THE ASO BENEFIT BOOKLET SHOULD BE CONSULTED FOR A DETAILED DESCRIPTION OF COVERAGE BENEFITS AND LIMITATIONS.

Blue Shield of California

Effective January 1, 2014

Preferred Providers1 Non-Preferred

Providers1

Calendar Year Medical Deductible (All providers combined)2 $600 per individual / $1,200 per family

$1,200 per individual / $2,400 per family

Calendar Year Co-payment Maximum2 (Co-payments for Preferred Providers accrue to both Preferred and Non-Preferred Provider Calendar-year Co-payment Maximum amounts.)

$5,000 per individual / $7,000 per 2 persons /

$8,000 per family

$10,000 per individual /

$14,000 per 2 persons $16,000 per family

LIFETIME BENEFIT MAXIMUM None

Covered Services Member Co-payment

PROFESSIONAL SERVICES Preferred Providers1

Non-Preferred Providers1

Professional (Physician) Benefits Physician and specialist office visits 30% 50% CT scans, MRIs, MRAs, PET scans, and cardiac

diagnostic procedures utilizing nuclear medicine3(prior

authorization is required)

30% 50%

Other outpatient X-ray, pathology and laboratory (Diagnostic

testing by providers other than outpatient laboratory, pathology, and

imaging departments of hospitals/facilities)3

30% 50%

Allergy Testing and Treatment Benefits Office visits (includes visits for allergy serum injections) 30% 50% Preventive Health Benefits Preventive Health Services (As required by applicable federal law.) No Charge

(Not subject to the Calendar-Year Deductible)

50%

OUTPATIENT SERVICES

Hospital Benefits (Facility Services) Outpatient surgery performed at an Ambulatory Surgery

Center4

30% 50%5

Outpatient surgery in a hospital $1002 + 30% $1002 + 50%5 Outpatient Services for treatment of illness or injury and

necessary supplies (Except as described under "Rehabilitation

Benefits")

30% 50%5

CT scans, MRIs, MRAs, PET scans, and cardiac diagnostic procedures utilizing nuclear medicine performed in a hospital (prior authorization is required)3

30% 50%5

Other outpatient X-ray, pathology and laboratory performed in a hospital3

30% 50%5

HOSPITALIZATION SERVICES

Hospital Benefits (Facility Services) Inpatient Physician Services 30% 50% Inpatient Non-emergency Facility Services (Semi-private room

and board, and medically-necessary Services and supplies, including Subacute Care)

$2002 + 30% $4002 + 50%7


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Skilled Nursing Facility Benefits8, 9 (Combined maximum of up to 120 prior authorized days per Calendar Year; semi-private accommodations) Services by a free-standing Skilled Nursing Facility 30% 30%9

Skilled Nursing Unit of a Hospital

30% 50%7

EMERGENCY HEALTH COVERAGE

Emergency room Services not resulting in admission (Co-

payment does not apply if the member is directly admitted to the hospital for inpatient services) (If ER services do not result in a direct admission the Calendar-Year Deductible does not apply)

$1502 + 30% $1502 + 30%

Emergency room Services resulting in admission (when the

member is admitted directly from the ER) $2002 + 30% $4002 + 50%7

Emergency room Physician Services 30% 30%

AMBULANCE SERVICES

Emergency or authorized transport 50% 50%

PRESCRIPTION DRUG COVERAGE

Outpatient Prescription Drug Benefits A description of your outpatient prescription drug coverage is provided separately. If you do not have the separate drug summary that goes with this benefit summary, please contact your benefits administrator or call Customer Service at 800-358-9556.

PROSTHETICS/ORTHOTICS

Prosthetic equipment and devices (Separate office visit copay

may apply) 30% 50%

Orthotic equipment and devices (Separate office visit copay may

apply) 30% 50%

DURABLE MEDICAL EQUIPMENT

Breast pump No Charge


50%

Other Durable Medical Equipment 30% 50%

MENTAL HEALTH SERVICES (PSYCHIATRIC)

Inpatient Hospital Services $2002 + 30% $4002 + 50%7 Outpatient Mental Health Services 30% 50%

CHEMICAL DEPENDENCY SERVICES (SUBSTANCE ABUSE)11

Inpatient Hospital Services

Residential Treatment Center Outpatient Mental Health Services

$2002 + 30% $2002 + 30%

30%

$4002 + 50%7

$4002 + 50%7

50%

HOME HEALTH SERVICES12

Home health care agency Services8 (up to 120 prior authorized

visits per Calendar Year) No Charge Not Covered12

Home infusion/home intravenous injectable therapy and infusion nursing visits provided by a Home Infusion Agency

No Charge Not Covered12


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OTHER

Hospice Program Benefits12 Routine home care 30% Not Covered12 Inpatient Respite Care 30% Not Covered12 24-hour Continuous Home Care 30% Not Covered12 General Inpatient care 30% Not Covered12 Chiropractic Benefits8 Chiropractic Services - (provided by a chiropractor)

(up to 20 visits per Calendar Year) $35/visit 50%

Acupuncture Benefits8 Acupuncture (provided by a acupuncturist)

(up to 12 visits per Calendar Year) $35/visit $35/visit

Rehabilitation Benefits (Physical, Occupational and Respiratory Therapy) Office location 30% 50%

Speech Therapy Benefits Office Visit - Services by licensed speech therapists 30% 50%

Pregnancy and Maternity Care Benefits Prenatal and postnatal Physician office visits

(For inpatient hospital services, see "Hospitalization Services.") 30% 50%

Family Planning Benefits Counseling and consulting10 No Charge


50%

Elective abortion Not Covered Not Covered Tubal ligation No Charge


50%

Vasectomy6 30% 50%

Diabetes Care Benefits Devices, equipment, and non-testing supplies (for testing

supplies see Outpatient Prescription Drug Benefits.) 30% 30%

Diabetes self-management training (If billed by your provider,

you will also be responsible for the office visit co-payment) 30% 50%

Care Outside of Plan Service Area (Benefits provided through the BlueCard®

Program for out-of-state emergency and non-emergency care are provided at the preferred level of the local Blue Plan allowable amount when you use a Blue Cross/Blue Shield provider) Within US: BlueCard Program See Applicable Benefit See Applicable Benefit Outside of US: BlueCard Worldwide See Applicable Benefit See Applicable Benefit

1 Member is responsible for co-payment in addition to any charges above allowable amounts. The co-payment percentage indicated is a percentage of allowable amounts. Preferred providers accept Blue Shield's allowable amount as full payment for covered services. Non-preferred providers can charge more than these amounts. When members use non-preferred providers, they must pay the applicable co-payment plus any amount that exceeds Blue Shield's allowable amount. Charges above the allowable amount do not count toward the calendar-year deductible or co-payment maximum.

2 Deductible and co-payments marked with this footnote do not accrue to calendar-year co-payment maximum. Co-payments and charges for services not accruing to the member's calendar-year co-payment maximum continue to be the member's responsibility after the calendar-year co-payment maximum is reached. Deductible does not apply toward the calendar-year maximum. Please refer to the ASO Benefit Booklet for exact terms and conditions of coverage.

3 Participating non Hospital based ("freestanding") outpatient X-ray, pathology and laboratory facilities centers may not be available in all areas. Regardless of their availability, you can obtain outpatient X-ray, pathology and laboratory services from a hospital or an ambulatory surgery center affiliated with a hospital, with payment according to your health plan's hospital services benefits.

4 Participating ambulatory surgery facilities centers may not be available in all areas. Regardless of their availability, you can obtain outpatient surgery services from a hospital or an ambulatory surgery center affiliated with a hospital, with payment according to your health plan's hospital services benefits.

5 6

The maximum allowed charges for non-emergency surgery and services performed in a non-participating Ambulatory Surgery Center or outpatient unit of a non-preferred hospital is $350 per day. Members are responsible for 50% of this $350 per day, plus all charges in excess of $350. Co-payment shown is for physician's services. If the procedure is performed in a facility setting (hospital or outpatient surgery center), an additional facility co-payment may apply. Services from non-participating providers and non-preferred facilities are not covered under this benefit.

7 The maximum allowed charges for non-emergency hospital or Residential Treatment Center services received from a non-preferred hospital or Residential Treatment Center is $600 per day. Members are responsible for 50% of this $600 per day, plus all charges in excess of $600.

8 For plans with a calendar-year medical deductible amount, services with a day or visit limit accrue to the calendar-year day or visit limit maximum regardless of whether the plan medical deductible has been met.

9 10

Services may require prior authorization by the Plan. When services are prior authorized, members pay the preferred or participating provider amount. Includes insertion of IUD as well as injectable contraceptives for women.

11 Inpatient services for acute detoxification are covered under the medical benefit; see hospitalization services for benefit details. Services for medical acute detoxification are accessed through Blue Shield using Blue Shield's preferred providers or non-preferred providers.

12 Out of network home health care, home infusion and hospice services are not covered unless pre-authorized. When these services are pre-authorized, the member pays the Preferred Provider co-payment.


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This is a summary of the most frequently asked about benefits. This chart does not explain benefits, cost sharing, out-of-pocket maximums, exclusions, or limitations, nor does it list all benefits and cost sharing. For a complete explanation, please refer to the EOC.


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Medical Schedule of Benefits – K – Premier

Raley’s Health & Welfare Benefit Summary

THIS MATRIX IS A SUMMARY ONLY. THE ASO BENEFIT BOOKLET SHOULD BE CONSULTED FOR A DETAILED DESCRIPTION OF COVERAGE BENEFITS AND LIMITATIONS.


Effective January 1, 2014

Preferred Providers1 Non-Preferred

Providers1

Calendar Year Medical Deductible (All providers combined)2 $400 per individual / $800 per family

$800 per individual / $1,600 per family

Calendar Year Co-payment Maximum2 (Co-payments for Preferred Providers accrue to both Preferred and Non-Preferred Provider Calendar-year Co-payment Maximum amounts.)


$6,000 per family


$12,000 per family

LIFETIME BENEFIT MAXIMUM None


PROFESSIONAL SERVICES Preferred Providers1

Non-Preferred Providers1

Professional (Physician) Benefits Physician and specialist office visits 25% 50% CT scans, MRIs, MRAs, PET scans, and cardiac

diagnostic procedures utilizing nuclear medicine3(prior

authorization is required)

25% 50%

Other outpatient X-ray, pathology and laboratory (Diagnostic

testing by providers other than outpatient laboratory, pathology, and

imaging departments of hospitals/facilities)3

25% 50%

Allergy Testing and Treatment Benefits Office visits (includes visits for allergy serum injections) 25% 50% Preventive Health Benefits Preventive Health Services (As required by applicable federal law.) No Charge


50%

OUTPATIENT SERVICES

Hospital Benefits (Facility Services) Outpatient surgery performed at an Ambulatory Surgery

Center4

25% 50%5

Outpatient surgery in a hospital $1002 + 25% $1002 + 50%5 Outpatient Services for treatment of illness or injury and

necessary supplies (Except as described under "Rehabilitation

Benefits")

25% 50%5

CT scans, MRIs, MRAs, PET scans, and cardiac diagnostic procedures utilizing nuclear medicine performed in a hospital (prior authorization is required)3

25% 50%5

Other outpatient X-ray, pathology and laboratory performed in a hospital3

25% 50%5

HOSPITALIZATION SERVICES

Hospital Benefits (Facility Services) Inpatient Physician Services 25% 50% Inpatient Non-emergency Facility Services (Semi-private room

and board, and medically-necessary Services and supplies, including Subacute Care)

$2002 + 25% $4002 + 50%7


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Skilled Nursing Facility Benefits8, 9 (Combined maximum of up to 120 prior authorized days per Calendar Year; semi-private accommodations) Services by a free-standing Skilled Nursing Facility 25% 25%9 Skilled Nursing Unit of a Hospital

25% 50%7

EMERGENCY HEALTH COVERAGE

Emergency room Services not resulting in admission (Co-

payment does not apply if the member is directly admitted to the hospital for inpatient services) (If ER services do not result in a direct admission the Calendar-Year Deductible does not apply)

$1502 + 25% $1502 + 25%

Emergency room Services resulting in admission (when the

member is admitted directly from the ER) $2002 + 25% $4002 + 50%7

Emergency room Physician Services 25% 25%

AMBULANCE SERVICES

Emergency or authorized transport 50% 50%

PRESCRIPTION DRUG COVERAGE

Outpatient Prescription Drug Benefits A description of your outpatient prescription drug coverage is provided separately. If you do not have the separate drug summary that goes with this benefit summary,please contact your benefits administrator or call Customer Service at 800-358-9556.

PROSTHETICS/ORTHOTICS

Prosthetic equipment and devices (Separate office visit copay

may apply) 25% 50%

Orthotic equipment and devices (Separate office visit copay may

apply) 25% 50%

DURABLE MEDICAL EQUIPMENT

Breast pump No Charge


50%

Other Durable Medical Equipment 25% 50%

MENTAL HEALTH SERVICES (PSYCHIATRIC)

Inpatient Hospital Services $2002 + 25% $4002 + 50%7 Outpatient Mental Health Services 25% 50%

CHEMICAL DEPENDENCY SERVICES (SUBSTANCE ABUSE)11

Inpatient Hospital Services

Residential Treatment Center Outpatient Mental Health Services

$2002 + 25% $2002 + 25%

25%

$4002 + 50%7

$4002 + 50%7

50%

HOME HEALTH SERVICES12

Home health care agency Services8 (up to 120 prior authorized

visits per Calendar Year) No Charge Not Covered12

Home infusion/home intravenous injectable therapy and infusion nursing visits provided by a Home Infusion Agency

No Charge Not Covered12


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OTHER

Hospice Program Benefits12 Routine home care 25% Not Covered12 Inpatient Respite Care 25% Not Covered12 24-hour Continuous Home Care 25% Not Covered12 General Inpatient care 25% Not Covered12 Chiropractic Benefits8 Chiropractic Services - (provided by a chiropractor)

(up to 20 visits per Calendar Year) 25% 50%

Acupuncture Benefits8 Acupuncture (provided by a acupuncturist)

(up to 12 visits per Calendar Year) 25% 25%

Rehabilitation Benefits (Physical, Occupational and Respiratory Therapy) Office location 25% 50%

Speech Therapy Benefits Office Visit - Services by licensed speech therapists 25% 50%

Pregnancy and Maternity Care Benefits Prenatal and postnatal Physician office visits

(For inpatient hospital services, see "Hospitalization Services.") 25% 50%

Family Planning Benefits Counseling and consulting10 No Charge


50%

Elective abortion Not Covered Not Covered Tubal ligation No Charge


50%

Vasectomy6 25% 50%

Diabetes Care Benefits Devices, equipment, and non-testing supplies (for testing

supplies see Outpatient Prescription Drug Benefits.) 25% 25%

Diabetes self-management training (If billed by your provider,

you will also be responsible for the office visit co-payment) 25% 50%

Care Outside of Plan Service Area (Benefits provided through the BlueCard®

Program for out-of-state emergency and non-emergency care are provided at the preferred level of the local Blue Plan allowable amount when you use a Blue Cross/Blue Shield provider) Within US: BlueCard Program See Applicable Benefit See Applicable Benefit Outside of US: BlueCard Worldwide See Applicable Benefit See Applicable Benefit

1 Member is responsible for co-payment in addition to any charges above allowable amounts. The co-payment percentage indicated is a percentage of allowable amounts. Preferred providers accept Blue Shield's allowable amount as full payment for covered services. Non-preferred providers can charge more than these amounts. When members use non-preferred providers, they must pay the applicable co-payment plus any amount that exceeds Blue Shield's allowable amount. Charges above the allowable amount do not count toward the calendar-year deductible or co-payment maximum.

2 Deductible and co-payments marked with this footnote do not accrue to calendar-year co-payment maximum. Co-payments and charges for services not accruing to the member's calendar-year co-payment maximum continue to be the member's responsibility after the calendar-year co-payment maximum is reached. Deductible does not apply toward the calendar-year maximum. Please refer to the ASO Benefit Booklet and the Employer SPD for exact terms and conditions of coverage.

3 Participating non Hospital based ("freestanding") outpatient X-ray, pathology and laboratory facilities centers may not be available in all areas. Regardless of their availability, you can obtain outpatient X-ray, pathology and laboratory services from a hospital or an ambulatory surgery center affiliated with a hospital, with payment according to your health plan's hospital services benefits.

4 Participating ambulatory surgery facilities centers may not be available in all areas. Regardless of their availability, you can obtain outpatient surgery services from a hospital or an ambulatory surgery center affiliated with a hospital, with payment according to your health plan's hospital services benefits.

5 6

The maximum allowed charges for non-emergency surgery and services performed in a non-participating Ambulatory Surgery Center or outpatient unit of a non-preferred hospital is $350 per day. Members are responsible for 50% of this $350 per day, plus all charges in excess of $350. Co-payment shown is for physician's services. If the procedure is performed in a facility setting (hospital or outpatient surgery center), an additional facility co-payment may apply. Services from non-participating providers and non-preferred facilities are not covered under this benefit.

7 The maximum allowed charges for non-emergency hospital or Residential Treatment Center services received from a non-preferred hospital or Residential Treatment Center is $600 per day. Members are responsible for 50% of this $600 per day, plus all charges in excess of $600.

8 For plans with a calendar-year medical deductible amount, services with a day or visit limit accrue to the calendar-year day or visit limit maximum regardless of whether the plan medical deductible has been met.

9 10

Services may require prior authorization by the Plan. When services are prior authorized, members pay the preferred or participating provider amount. Includes insertion of IUD as well as injectable contraceptives for women.

11 Inpatient services for acute detoxification are covered under the medical benefit; see hospitalization services for benefit details. Services for medical acute detoxification are accessed through Blue Shield using Blue Shield's preferred providers or non-preferred providers.

12 Out of network home health care, home infusion and hospice services are not covered unless pre-authorized. When these services are pre-authorized, the member pays the Preferred Provider co-payment.

Your Prescription Plan

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PRESCRIPTION DRUG PLAN

The Raley’s Prescription Drug Plan is provided for all eligible employees who are covered by

Raley’s PPO Medical Plan. By presenting your Blue Shield ID card, you may purchase your

prescriptions at any Company-owned pharmacy and pay a fixed co-payment based on whether

the prescription drug is generic, formulary brand or non-formulary brand. A formulary is a list

maintained by Blue Shield of the most cost-effective prescription drugs available to treat

medical conditions and diseases. To view Blue Shield’s prescription formulary, please visit Blue

Shield’s website at blueshieldca.com.

The Prescription Drug Plan requires the pharmacist to use a generic equivalent drug when filling

your prescription unless your physician indicates otherwise. If you should choose to have the

pharmacist fill your prescription with a brand name drug when a generic equivalent is available,

you will be required to pay the applicable brand co-payment, plus the difference in cost

between the brand name drug and the generic equivalent. In each case, you will receive

whatever quantity the physician writes your prescription for up to a 30-day supply (see

limitations section).

You do not need to satisfy your annual medical deductible before using your card to purchase

prescription drugs.

If you choose to purchase your prescriptions from a non-company owned pharmacy there will

be a 20% Co-insurance in addition to the applicable co-payments as stated previously.

The Raley’s Prescription Drug Plan coordinates with other prescription benefit plans. This

means that if you or your spouse/dependents are covered by more than one insurance plan,

Coordination of Benefits (COB) will determine which plan pays first. Generally, this will not

affect your coverage or what you pay under the Raley’s Prescription Drug Plan. If your spouse

or dependent has prescription coverage under any other plan or program, the other

prescription card must be presented in addition to the Raley’s Prescription Drug Card. This is

simply to identify the other benefit plan(s) so that the pharmacy can properly coordinate

prescription benefits.

If you have questions regarding the coverage or the processing of a claim, call Blue Shield

Customer Service at (800) 358-9556.


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Prescription Schedule of Benefits –J- Classic, Premier

Note: This plan's prescription drug coverage is on average equivalent to or better than the standard benefit set by the federal government for Medicare Part D (also called creditable coverage). Because this plan's prescription drug coverage is creditable, you do not have to enroll in a Medicare prescription drug plan while you maintain this coverage. However, you should be aware that if you have a subsequent break in this coverage of 63 days or more anytime after you were first eligible to enroll in a Medicare prescription drug plan, you could be subject to a late enrollment penalty in addition to your Part D premium.

Raley’s Health & Welfare Outpatient Prescription Drug Coverage

THIS DRUG SUMMARY IS INTENDED TO BE USED WITH THE RALEY’S HEALTH & WELFARE MEDICAL SCHEDULE BENEFIT SUMMARY AND COVERAGE MATRIX. THE ASO BENEFIT BOOKLET SHOULD BE CONSULTED FOR A DETAILED DESCRIPTION OF COVERAGE BENEFITS AND LIMITATIONS.



DEDUCTIBLES (Prescription drug coverage benefits are not subject to

the medical plan deductible.)

Calendar Year Brand Name Drug Deductible None

PRESCRIPTION DRUG COVERAGE1 Raley’s Company Pharmacy

Blue Shield Participating and Non-Participating

Pharmacy

Member pays 20% of billed amount plus a co-payment of:

Retail Prescriptions (up to a 30-day supply)

Contraceptive Drugs and Devices2 $0 per prescription See applicable drug tier co-payment

Formulary Generic Drugs $8 per prescription $8 per prescription

Formulary Brand Name Drugs3, 4 $30 per prescription $30 per prescription

Non-Formulary Brand Name Drugs3, 4 $50 per prescription $50 per prescription

Specialty Drugs

See applicable drug tier

co-payment

See applicable drug tier

co-payment

Maintenance Drugs

Maintenance Drugs ( If there is a history of 30 days fill of maintenance drug within the past 180 days )

2 x applicable drug tier co-payment

Up to 60 day supply

3 x applicable drug tier co-payment

Up to 90 day supply

See applicable drug tier co-payment

Up to 30 day supply

Mail Service Prescriptions

Not Covered

Not Covered

1 Co-payments and charges for these covered services are not included in the calculation of the member's medical calendar-year co-payment maximum and continue to be the member's responsibility after the calendar-year co-payment maximum is reached. Please refer to the ASO Benefit Booklet for exact terms and conditions of coverage. Please note that if you switch from another plan, your prescription drug deductible credit from the previous plan during the calendar year, if applicable, will not carry forward to your new plan.

2 Contraceptive Drugs and Devices covered under the outpatient prescription drug benefits will no longer require a co-payment and will not be subject to the calendar-year brand-name drug deductible. However, if a brand-name contraceptive is requested when a generic equivalent is available, the member will still be responsible for paying the difference between the cost to the Plan for the brand-name contraceptive and its generic drug equivalent. In addition, select contraceptives may need prior authorization to be covered without a co-payment.

3 Selected formulary and non-formulary drugs require prior authorization by Blue Shield for Medical Necessity, and when effective, lower cost alternatives are available.

4 If the member requests a brand-name drug and a generic drug equivalent is available, the member is responsible for paying the generic drug co-payment plus the difference in cost to Blue Shield between the brand-name drug and its generic drug equivalent.

5 Specialty Drugs are specific Drugs used to treat complex or chronic conditions which usually require close monitoring such as multiple sclerosis, hepatitis, rheumatoid arthritis, cancers, and other conditions that are difficult to treat with traditional therapies. Specialty Drugs are listed in the Blue Shield Outpatient Drug Formulary. Specialty Drugs may be self-administered in the home by injection by the patient or family member (subcutaneously or intramuscularly), by inhalation, orally or topically. Infused or Intravenous (IV) medications are not included as Specialty Drugs. These Drugs may also require special handling, special manufacturing processes, and may have limited prescribing or limited pharmacy availability. Specialty Drugs must be considered safe for self-administration by Blue Shield's Pharmacy & Therapeutics Committee, and may require prior authorization for Medical Necessity by Blue Shield.


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Important Prescription Drug Information

You can find details about your drug coverage three ways:

1. Check your ASO Benefit Booklet. 2. Go to blueshieldca.com and log onto My Health Plan from the home page. 3. Call Member Services at the number listed on your Blue Shield member ID card.

Go online to the Pharmacy section of blueshieldca.com and select the Drug Database and Formulary to access a variety of useful drug information that can affect your out-of-pocket expenses, such as:

Look up non-formulary drugs with formulary or generic equivalents;

Look up drugs that require step therapy or prior authorization;

Find specifics about your prescription co-payments;


Your HMO Medical Plan

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RALEY’S HMO MEDICAL PLAN

KAISER PERMANENTE

For California employees, as an alternative to the Raley’s PPO Medical Plans, the Company also

offers health and vision care through Kaiser Permanente (if available in your area). To see if

Kaiser coverage is available in your area, please refer to the Kaiser Coverage Area Zip Code List.

This list is available by contacting either Kaiser at (800) 464-4000 or the Raley’s Employee

Benefits Department at (888) 332-4894 or email [email protected].

As an HMO Plan (Health Maintenance Organization), the Kaiser Plan differs from coverage with

the Raley’s PPO Medical Plans in two ways:

Doctor & hospital choice: As a member of Kaiser Permanente, you obtain medical

services from doctors and hospitals associated with Kaiser Permanente. With the Raley’s

PPO Medical Plans, you can select almost any doctor or medical facility you wish.

Procedure for filing claims: Kaiser Permanente Premier Plus Plan doesn’t require claim

forms, and you usually don’t get a bill from your doctor once you’ve met your

deductible (for those enrolled in Premier Kaiser) because most of the administrative

details are handled by Kaiser Permanente.

Enrolling in Kaiser Permanente

To enroll in Kaiser Permanente, you must submit your enrollment information within 31 days of

satisfying your initial eligibility. You may also elect to enroll in a Kaiser Plan during the annual

enrollment period or transfer your membership from a Kaiser Permanente Plan to a Raley’s

PPO Medical Plan. The effective date of coverage would be January 1 of the following year.

If you acquire new dependents while covered by Kaiser Permanente, you must notify the

Raley’s Employee Benefits Department within 31 days of the date you acquired the new

dependent(s). Otherwise you will have to wait until the next Open Enrollment period to add the

eligible dependent(s).

Please note that the rules regarding Special Enrollment Rights described under the Raley’s PPO

Medical Plans also apply to coverage under the Kaiser Plans.

The information on the next few pages describes Kaiser Permanente’s benefits, coverage,

exclusions and limitations under both the Kaiser Premier Plan and the Kaiser Premier Plus Plan.

Identification Card

Once you are enrolled in a Kaiser Plan, you will receive an identification card from Kaiser

Permanente.

Kaiser Vision Care

When you elect Kaiser as your health care provider, vision care services are also coordinated

through Kaiser.


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Prescription Coverage

If you join Kaiser Permanente, your prescriptions will also be covered by Kaiser Permanente. By

presenting your Kaiser card, you may purchase your prescriptions at any Kaiser facility and pay

a fixed co-payment.

Enrollment Requirements

An eligible employee may enroll in Kaiser Permanente’s (KP’s) non-Medicare employer group

products if he/she lives or works in an area that is identified as part of KP’s Northern California

Region Service Area or Southern California Region Service Area at the time of enrollment.

Dependents do not have to live or work inside the Northern or Southern California Service Area

at the time of enrollment.

Service Area Eligibility Requirements

An employee or dependent (other than a dependent child) cannot enroll or continue

membership if he/she lives in or moves to a KP Region outside of California. If a subscriber

moves anywhere else outside of the Northern or Southern California Region Service Area, a

subscriber and his/her dependents can continue membership as long as they meet all other

eligibility requirements. However, members must receive covered services from Plan providers

inside their home Region (Northern or Southern California) Service Area, except for services

described in the Evidence of Coverage in the following sections:

* Authorized referrals

* Emergency ambulance services

* Emergency care, post-stabilization care, and out-of-area Urgent Care

* Hospice care (provided within 15 miles or 30 minutes from KP’s Northern or Southern

California Service Area)

PATIENT PROTECTION

HMO Kaiser Permanente generally requires the designation of a primary care provider. You

have the right to designate any primary care provider who participates in our network and who

is available to accept you or your family members. Until you make this designation, Kaiser

designates one for you. For information on how to select a primary care provider, and for a list

of the participating primary care providers, contact Kaiser at (800) 464-4000 or go on-line to

kaiserpermanente.org. For children, you may designate a pediatrician as the primary care

provider. You do not need prior authorization from Kaiser or from any other person (including

a primary care provider) in order to obtain access to obstetrical or gynecological care from a

health care professional in our network who specializes in obstetrics or gynecology. The health

care professional, however, may be required to comply with certain procedures, including

obtaining prior authorization for certain services, following a pre-approved treatment plan, or

procedures for making referrals. For a list of participating health care professionals who

specialize in obstetrics or gynecology, contact Kaiser at (800) 464-4000 or go on-line to

kaiserpermanente.org.


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If you have questions regarding eligibility, the coverage or the processing

of a claim, call Kaiser Permanente at (800) 464-4000


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Kaiser Medical Schedule Set 9-Premier Plus

Principal Benefits for Kaiser Permanente Deductible HMO Plan (1/1/14—12/31/14)

The Services described below are covered only if all of the following conditions are satisfied:

The Services are Medically Necessary

The Services are provided, prescribed, authorized, or directed by a Plan Physician and you

receive the Services from Plan Providers inside our Northern California Region Service Area

(your Home Region), except where specifically noted to the contrary in the Evidence of

Coverage (EOC) for authorized referrals, hospice care, Emergency Services, Post-

Stabilization Care, Out-of-Area Urgent Care, and emergency ambulance Services

Health Plan believes this coverage is a "grandfathered health plan" under the Patient Protection and Affordable Care Act. If you have questions about grandfathered health plans, please call our Member Service Call Center.

Annual Out-of-Pocket Maximum for Certain Services

For Services subject to the maximum, you will not pay any more Cost Sharing during a calendar year if the Co-payments and Co-insurance you pay for those Services, plus all your Deductible payments, add up to one of the following amounts: For self-only enrollment (a Family of one Member) ............................... $2,000 per calendar year For any one Member in a Family of two or more Members .............................................................................................. $2,000 per calendar year For an entire Family of two or more Members ...................................... $4,000 per calendar year

Deductible for Certain Services

For Services subject to the Deductible, you must pay Charges for Services you receive in a calendar year until you reach one of the following Deductible amounts: For self-only enrollment (a Family of one Member) ............................... $330 per calendar

year For any one Member in a Family of two or more Members ................... $330 per calendar

year For an entire Family of two or more Members ...................................... $660 per calendar

year

Lifetime Maximum None

Professional Services (Plan Provider office visits) You Pay

Most primary and specialty care consultations, exams, and treatment ................................................................................................ $35 per visit after Deductible

Routine physical maintenance exams ..................................................... No charge (Deductible doesn't apply)

Well-child preventive exams (through age 23 months) ............................ No charge (Deductible doesn't apply)

Family planning counseling ...................................................................... No charge (Deductible doesn't apply)

Scheduled prenatal care exams and first postpartum follow-up consultation and exam ............................................................

No charge (Deductible doesn't apply)

Eye exams for refraction .......................................................................... No charge (Deductible doesn't apply)

Hearing exams ......................................................................................... No charge (Deductible doesn't apply)

Urgent care consultations, exams, and treatment ................................... $35 per visit after Deductible Physical, occupational, and speech therapy ............................................ $35 per visit after Deductible


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Outpatient Services You Pay

Outpatient surgery and certain other outpatient procedures .................... 20% Co-insurance after Deductible Allergy injections (including allergy serum) .............................................. No charge after Deductible Most immunizations (including the vaccine) ............................................ No charge (Deductible doesn't

apply) Most X-rays and laboratory tests ............................................................. $10 per encounter after Deductible Preventive X-rays, screenings, and laboratory tests as described in the EOC .............................................................................


MRI, most CT, and PET scans ................................................................ $50 per procedure after Deductible Health education:

Covered individual health education counseling ................................... No charge (Deductible doesn't apply)

Covered health education programs ..................................................... No charge (Deductible doesn't apply)

Hospitalization Services You Pay

Room and board, surgery, anesthesia, X-rays, laboratory tests, and drugs ...................................................................................... 20% Co-insurance after Deductible

Emergency Health Coverage You Pay

Emergency Department visits .................................................................. 20% Co-insurance after Deductible

Ambulance Services You Pay

Ambulance Services ................................................................................ $150 per trip after Deductible

Prescription Drug Coverage You Pay

Covered outpatient items in accord with our drug formulary guidelines: Most generic items at a Plan Pharmacy ................................................ $10 for up to a 30-day supply, $20

for a 31- to 60-day supply, or $30 for a 61- to 100-day supply (Deductible doesn't apply)

Most generic refills through our mail-order service ............................... $10 for up to a 30-day supply or $20 for a 31- to 100-day supply (Deductible doesn't apply)

Most brand-name items at a Plan Pharmacy ........................................ $35 for up to a 30-day supply, $70 for a 31- to 60-day supply, or $105 for a 61- to 100-day supply (Deductible doesn't apply)

Most brand-name refills through our mail-order service ........................ $35 for up to a 30-day supply or $70 for a 31- to 100-day supply (Deductible doesn't apply)

Durable Medical Equipment You Pay

Most covered durable medical equipment for home use in accord with our durable medical equipment formulary guidelines ...............................................................................................

20% Co-insurance (Deductible doesn't apply)

Mental Health Services You Pay

Inpatient psychiatric hospitalization ......................................................... 20% Co-insurance after Deductible Individual outpatient mental health evaluation and treatment ................................................................................................ $35 per visit after Deductible

Group outpatient mental health treatment ............................................... $17 per visit after Deductible


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Chemical Dependency Services You Pay

Inpatient detoxification ............................................................................. 20% Co-insurance after Deductible Individual outpatient chemical dependency evaluation and treatment ................................................................................................ $35 per visit after Deductible

Group outpatient chemical dependency treatment .................................. $5 per visit after Deductible

Home Health Services You Pay

Home health care (up to 100 visits per calendar year) ............................ No charge (Deductible doesn't apply)

Other You Pay

Eyewear purchased at Plan Medical Offices or plan optical sales offices every 24 months ................................................................

Amount in excess of $175 Allowance (Allowance not subject to Deductible)

Skilled nursing facility care (up to 100 days per benefit period) .................................................................................................... 20% Co-insurance after Deductible

Covered external prosthetic devices, orthotic devices, and ostomy and urological supplies...............................................................


All Services related to covered infertility treatment .................................. 50% Co-insurance (Deductible doesn't apply)

Hospice care ............................................................................................ No charge (Deductible doesn't apply)

This is a summary of the most frequently asked-about benefits. This chart does not explain benefits, Cost Sharing, out-of-pocket maximums, exclusions, or limitations, nor does it list all benefits and Cost Sharing. For a complete explanation, please refer to the EOC. Please note that we provide all benefits required by law (for example, diabetes testing supplies).

Your Dental Plan

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YOUR DENTAL PLAN

Your dental plan offers you a choice between a Delta Dental DPO Plan and DELTACARE USA

DeltaCare (California residents only).

DELTA DENTAL

The Delta Dental Plan covers several categories of benefits. Delta Dental will pay for these

services at the percentage indicated up to a specific maximum for each participant in each

calendar year. All services must be provided by a licensed dentist, and they must be necessary

and customary under the generally accepted standards of dental practice.

Choosing Your Dentist

You may choose any dentist for treatment, but it is to your advantage to choose a Delta Dental

DPO Participating Dentist because his or her fees are approved in advance by Delta Dental and

there is no “balance billing.” Balance billing is when a provider bills the member for any

amounts above and beyond the contracted rate. Selecting dentists in the DPO network will

guarantee that you are paying the lowest out-of-pocket costs. If you go to a non-participating

dentist, Delta Dental cannot assure what percentage of the fee may be covered. A list of

participating dentists is available by calling Delta Dental at (800) 765-6003. You may also access

the provider directory through Delta Dental’s website at deltadentalca.org.

Predeterminations

After an examination, your dentist will decide on the treatment you need. Delta Dental strongly

recommends that if extensive services are to be provided, such as crowns or bridges, or if the

cost of treatment will be greater than $200, you should have your dentist obtain a

predetermination for your treatment.

Your dentist will submit an Attending Dentist’s Statement, requesting a predetermination from

Delta Dental for the services you need. Delta Dental will inform your dentist exactly how much

of the proposed charges they will pay, and how much you will owe. You should review this

information carefully with your dentist before you schedule the treatment. After the treatment

has been completed, your dentist will return the Attending Dentist’s Statement to Delta Dental

for payment.

Predetermining extensive treatment is recommended to prevent any possible

misunderstanding about your treatment cost and your financial responsibility to your dentist. If

you are not satisfied with the way Delta Dental predetermined your treatment, be sure to call

them before the dental work is done, so Delta Dental can review your appeal thoroughly.

Benefits provided under the Delta Dental Plan as well as any exclusions and limitations are

listed on the following pages.

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Second Opinions

Delta Dental reserves the right to obtain second opinions through regional consultant members

of its Quality Review Committee. This committee conducts clinical examinations, prepares

objective reports of dental conditions, and evaluates treatment that is proposed or has been

proposed.

Delta Dental will authorize such an examination prior to treatment when necessary to make a

determination of benefit in response to a request for a predetermination of treatment cost by a

dentist. Delta Dental will also authorize a second opinion after treatment if you have a

complaint regarding the quality of care provided. Delta Dental will notify you and the treating

dentist when a second opinion is necessary and appropriate, and direct you to the regional

consultant selected by Delta Dental to perform the clinical examination. When Delta Dental

authorizes a second opinion through a regional consultant, Delta Dental will pay for all

associated charges.

You may otherwise obtain second opinions about treatment from any dentist you choose, and

claims for the examination or consultation may be submitted to Delta Dental for payment.

Delta Dental will pay such claims in accordance with the plan.

A copy of Delta Dental’s formal policy on second opinions is available from Delta Dental’s

Customer and Member Service Department, upon request.

Payment

If you go to a Participating Dentist, Delta Dental will pay the dentist directly. You will not be

responsible for any money owed by Delta Dental beyond your co-payment.

If you go to a nonparticipating dentist, the bill is your responsibility. Delta Dental will reimburse

you for the Allowable Amount in accordance with the Plan. You are responsible for any portion

of the cost that Delta Dental does not pay.

Payment for a single procedure that is covered will be made upon completion of that

procedure. Delta Dental does not make or prorate payments for treatment in progress or

incomplete procedures. The date the procedure is completed governs the calculation of any

benefit under your program. If there is a difference between what your dentist is charging you

and what Delta Dental says your portion should be, or if you are not satisfied with the dental

work you have received, contact Delta Dental’s Customer and Member Service Department at

(800) 765-6003.

Delta Dental will deny payment of an attending dentist’s statement for services submitted more

than twelve (12) months after the date the services were provided. If a claim is denied due to a

participating dentist’s failure to make a timely submission, you will not be liable to that dentist

for the amount that would have been payable by Delta Dental (unless you did not advise the

dentist of your eligibility at the time of treatment).

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Exclusion for Duplicate Coverage

If a covered dependent has other primary coverage, benefits payable under the Raley’s Health

and Welfare Plan will not exceed the difference between the primary plan’s benefit level and

the Raley’s Dental Plan benefit level.

Termination of Dental Benefits

Dental benefits terminate at the same time and under the same circumstances as those

benefits provided by the medical plan (see “When Coverage Ends”).

Extension of Dental Benefits following benefit termination

You may be eligible for an extension of benefits after your dental benefits have terminated if

you began receiving treatment for dental care before the termination. The total benefit payable

during the period of extended benefits will be one of the following, whichever is less:

• $100, or

• The covered dental expense incurred during the 30-day period immediately following

the date of termination of dental benefits.

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Dental Schedule Of Benefits –J- Classic

RALEY’S HEALTH & WELFARE PLAN PPO 2014

ANNUAL DEDUCTIBLE $50 individual; $100 family

ANNUAL MAXIMUM PER PERSON (includes orthodontic services)

$1,000

You will usually pay the lowest amount for services when you visit a PPO dentist. You are responsible for the difference between the amount Delta Dental pays and the amount your non-

Delta Dental dentist bills

Covered Benefits Member Co-payment1

DIAGNOSTIC & PREVENTIVE BENEFITS 1. Diagnostic benefits include the following: office visits and oral

examinations (including initial examinations, periodic

examinations and emergency examinations), X-rays and

pathology.

2. Preventive benefits include the following: routine cleaning,

fluoride treatment and space maintainers.

3. Limitations:

– Oral examinations, prophylaxes, and fluoride treatment (up

to age 14) – twice each calendar year.

– Only the first two oral examinations, including any office

visit for observations and specialist consultations, or

combination thereof, provided to the member during the

calendar year are covered.

– Full mouth X-rays – once every five (5) years unless special

need is shown.

– Bitewing X-rays – twice each calendar year for children

under age 18, and once each calendar year for adults age

18 and over.

PPO: 0% Non PPO: 20%

BASIC BENEFITS 1. Oral Surgery: extractions and certain other surgical procedures

including pre-operative and post-operative care.

2. Restorative: amalgam, silicate or composite restorations

(fillings) for treatment of cavities (decay).

3. Endodontic: treatment of tooth pulp.

4. Periodontic: treatment of gums and bones that support the

teeth.

5. Sealants: topically applied acrylic, plastic or composite material

used to seal developmental grooves and pits in teeth for the

purpose of preventing decay.

6. Nitrous oxide.

7. Adjunctive General Services: general anesthesia; office visit for


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observation; office visit after regularly scheduled hours;

therapeutic drug injection; treatment of post-surgical

complications (unusual circumstances); occlusal adjustment,

limited.

8. Limitations:

– Pit and fissure sealants are limited to covered dependent

children under age 15. Sealant benefits include application

of sealant only to permanent posterior molars with no

cavities (decay), and with no restorations, and with the

occlusal surface intact. Sealant benefits do not include the

repair or replacement of a sealant on any tooth within three

(3) years of application.

– Resin restorations are covered on anterior teeth and facial

surface of bicuspids. Any other posterior resin restorations

are optional services and Delta’s payment is limited to the

cost of the equivalent amalgam restorations.

CROWNS, JACKETS, INLAYS, ONLAYS and CAST RESTORATION BENEFITS

1. Crowns are available after one (1) year of continuous

employment.

2. Crowns, jackets, inlays, onlays and cast restorations are

covered if they are provided to treat cavities that cannot be

restored with amalgam, silicate or direct composite restorations

(fillings).

3. Limitations:

– Crowns, jackets, inlays, onlays and cast restorations are

covered on the same tooth only once every five (5) years,

unless Delta determines that replacement is required

because the restoration is unsatisfactory as a result of poor

quality of care, or because the tooth involved has

experienced extensive loss or changes to the tooth

structure or supporting tissues since the replacement of the

restoration.

Not covered

PROSTHODONTIC BENEFITS

1. Prosthodontic Benefits are available after one (1) year of

continuous employment.

2. Construction or repair of fixed bridges, partial dentures and

complete dentures are covered if provided to replace missing,

natural teeth.

3. Limitations:

– Prosthodontic appliances are covered only once every five

(5) years, unless Delta Dental determines that there has

been such an extensive loss of remaining teeth, or change

in supporting tissues, that the existing appliance cannot be

made satisfactory.

Not covered

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– Delta will pay 50% of the dentist’s fee for a standard partial

or complete denture up to a maximum fee allowance that

would satisfy the majority of Delta Dental’s Participating

Dentists. A “standard” partial or complete denture is defined

as a removable prosthetic appliance provided to replace

missing natural, permanent teeth and which is constructed

using accepted and conventional procedures and

materials.

Implants (appliances inserted into bone or soft tissue in the

jaw, usually to anchor a denture) or their removal, are not

covered by your program. However, if implants are

provided along with a covered prosthodontic appliance,

Delta Dental will allow the cost of a standard partial or

complete denture toward the cost of the implants and the

prosthodontic appliances when the prosthetic appliance is

completed. If Delta Dental makes such an allowance, Delta

will not pay for any replacement for five (5) years following

the completion of the service.

ORTHODONTIC BENEFITS

1. Procedures using appliances or surgery to straighten or

realign teeth, which would otherwise not function

properly.

2. Limitations:

– If orthodontic treatment is begun before you become

eligible for coverage, Delta Dental’s payment will

begin with the first payment due to the dentist

following your eligibility date.

– Delta Dental’s payments will stop when the first

payment is due to the dentist following either a loss of

eligibility or if treatment is ended for any reason

before it is completed.

– X-rays and extractions that might be necessary for

orthodontic treatment are not covered by orthodontic

benefits but may be covered under Diagnostic and

Preventive or Basic Benefits.

Not covered

NON-DUPLICATION OF BENEFITS PROVISION Yes

1 Member is responsible for co-payment or co-insurance in addition to any charge above the Allowable Amounts. The co-insurance percentage indicated is a percentage of Allowable Amounts. Delta Dental Participating Dentists accept Delta Dental’s allowable amount as full payment for covered services. Non-participating dentists can charge more than these amounts. When members use non-participating dentists, they must pay the applicable co-insurance plus any amount that exceeds Delta Dental’s allowable amount.

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Dental Schedule of Benefits –Q Premier

RALEY’S HEALTH & WELFARE PLAN

ANNUAL DEDUCTIBLE N/A

ANNUAL MAXIMUM PER PERSON (includes orthodontic services)

PPO: $2,000 Non PPO: $1,500

You will usually pay the lowest amount for services when you visit a PPO dentist. You are responsible for the difference between the amount Delta Dental pays and the amount your non-

Delta Dental dentist bills

Covered Benefits Member Co-payment1

DIAGNOSTIC & PREVENTIVE BENEFITS

1. Diagnostic benefits include the following: office visits and oral examinations

(including initial examinations, periodic examinations and emergency

examinations), X-rays and pathology.

2. Preventive benefits include the following: routine cleaning, fluoride treatment

and space maintainers.

3. Limitations:

– Oral examinations, prophylaxes, and fluoride treatment (up to age 14) –

twice each calendar year.

– Only the first two oral examinations, including any office visit for

observations and specialist consultations, or combination thereof,

provided to the member during the calendar year are covered.

– Full mouth X-rays – once every five (5) years unless special need is

shown.

– Bitewing X-rays – twice each calendar year for children under age 18,

and once each calendar year for adults age 18 and over.


BASIC BENEFITS

1. Oral Surgery: extractions and certain other surgical procedures including

pre-operative and post-operative care.

2. Restorative: amalgam, silicate or composite restorations (fillings) for

treatment of cavities (decay).

3. Endodontic: treatment of tooth pulp.

4. Periodontic: treatment of gums and bones that support the teeth.

5. Sealants: topically applied acrylic, plastic or composite material used to seal

developmental grooves and pits in teeth for the purpose of preventing

decay.

6. Nitrous oxide.

7. Adjunctive General Services: general anesthesia; office visit for observation;

office visit after regularly scheduled hours; therapeutic drug injection;

20%

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treatment of post-surgical complications (unusual circumstances); occlusal

adjustment, limited.

8. Limitations:

– Pit and fissure sealants are limited to covered dependent children under

age 15. Sealant benefits include application of sealant only to

permanent posterior molars with no cavities (decay), and with no

restorations, and with the occlusal surface intact. Sealant benefits do

not include the repair or replacement of a sealant on any tooth within

three (3) years of application.

– Resin restorations are covered on anterior teeth and facial surface of

bicuspids. Any other posterior resin restorations are optional services

and Delta’s payment is limited to the cost of the equivalent amalgam

restorations.

CROWNS, JACKETS, INLAYS, ONLAYS and CAST RESTORATION BENEFITS

1. Crowns, jackets, inlays, onlays and cast restorations are covered if they are

provided to treat cavities that cannot be restored with amalgam, silicate or

direct composite restorations (fillings).

2. Limitations:

– Crowns, jackets, inlays, onlays and cast restorations are covered on the

same tooth only once every five (5) years, unless Delta determines that

replacement is required because the restoration is unsatisfactory as a

result of poor quality of care, or because the tooth involved has

experienced extensive loss or changes to the tooth structure or

supporting tissues since the replacement of the restoration.


PROSTHODONTIC BENEFITS

1. Construction or repair of fixed bridges, partial dentures and complete

dentures are covered if provided to replace missing, natural teeth.

2. Limitations:

– Prosthodontic appliances are covered only once every five (5) years,

unless Delta Dental determines that there has been such an extensive

loss of remaining teeth, or change in supporting tissues, that the

existing appliance cannot be made satisfactory.

– Delta will pay 50% of the dentist’s fee for a standard partial or complete

denture up to a maximum fee allowance that would satisfy the majority

of Delta Dental’s Participating Dentists. A “standard” partial or complete

denture is defined as a removable prosthetic appliance provided to

replace missing natural, permanent teeth and which is constructed

using accepted and conventional procedures and materials.

Implants (appliances inserted into bone or soft tissue in the jaw, usually to anchor a denture) or their removal, are not covered by your program. However, if implants are provided along with a covered prosthodontic appliance, Delta Dental will allow the cost of a standard partial or complete denture toward the cost of the implants

50%

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and the prosthodontic appliances when the prosthetic appliance is completed. If Delta Dental makes such an allowance, Delta will not pay for any replacement for five (5) years following the completion of the service.

ORTHODONTIC BENEFITS

1. Procedures using appliances or surgery to straighten or realign teeth, which

would otherwise not function properly.

2. Limitations:

– If orthodontic treatment is begun before you become eligible for

coverage, Delta Dental’s payment will begin with the first payment due

to the dentist following your eligibility date.

– Delta Dental’s payments will stop when the first payment is due to the

dentist following either a loss of eligibility or if treatment is ended for any

reason before it is completed.

– X-rays and extractions that might be necessary for orthodontic

treatment are not covered by orthodontic benefits but may be covered

under Diagnostic and Preventive or Basic Benefits.

Lifetime Maximum

PPO: $2,000 Non-PPO:

$1,500

NON-DUPLICATION OF BENEFITS PROVISION Yes

1 Member is responsible for co-payment or co-insurance in addition to any charge above the Allowable Amounts. The co-insurance percentage indicated is a percentage of Allowable Amounts. Delta Dental Participating Dentists accept Delta Dental’s allowable amount as full payment for covered services. Non-participating dentists can charge more than these amounts. When members use non-participating dentists, they must pay the applicable co-insurance plus any amount that exceeds Delta Dental’s allowable amount.

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DELTA DENTAL GENERAL LIMITATIONS (OPTIONAL SERVICES) AND

EXCLUSIONS

General Limitation – Optional Services

If you select a more expensive plan of treatment than is customarily provided or specialized techniques rather than standard procedures, Delta will pay the applicable percentage of the lesser fee and you will be responsible for the remainder of the Dentist’s fee. For example: a crown where an amalgam filling would restore the tooth.

Exclusions

The Delta Dental Plan covers a wide variety of dental care expenses, but the following services are not covered:

1. Injuries covered by Workers’ Compensation or services that are paid by any Federal, State or local

government agency, except Medicaid benefits.

2. Services for cosmetic purposes or for conditions that are a result of hereditary or developmental defects,

such as cleft palate, upper and lower jaw malformations, congenitally missing teeth, and teeth that are

discolored or lacking enamel.

3. Treatment that restores tooth structure that is worn; treatment that rebuilds or maintains chewing surfaces

that are damaged because the teeth are out of alignment or occlusion; or treatment that stabilizes the

teeth, for example, equilibration or periodontal splinting.

4. Any single procedure or bridge, denture, or prosthodontic service that was started before you were

covered by this program.

5. Prescribed or applied therapeutic drugs, premedication or analgesia.

6. Experimental procedures.

7. Charges by any hospital or other surgical treatment facility and any additional fees charged by the Dentist

for treatment in any such facility.

8. Anesthesia, except for general anesthesia given by a dentist for covered oral surgery procedures.

9. Grafting tissues from outside the mouth to tissue inside the mouth (extraoral grafts); implants, or removal

of implants, except as provided under “Limitations.”

10. Services for any disturbances of the jaw joints (temporomandibular joints or TMJ) or associated muscles,

nerves, or tissues.

11. Charges for replacement or repair of an orthodontic appliance paid in part or in full by this program.

12. Replacement of existing restorations for any purposes other than active tooth decay.

13. Intravenous sedation, occlusal guards and complete occlusal adjustment.

Note: Member is responsible for co-payment or Co-insurance in addition to any charge above the Allowable Amounts. The Co-insurance percentage indicated is a percentage of Allowable Amounts. Delta Dental Participating Dentists accept Delta Dental’s allowable amount as full payment for covered services. Non-participating dentists can charge more than these amounts. When members use non-participating dentists, they must pay the applicable Co-insurance plus any amount that exceeds Delta Dental’s Allowable Amount.

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DELTACARE USA

(CALIFORNIA RESIDENTS ONLY)

Overview

DELTACARE USA administers DeltaCare dental programs and is an affiliate of Delta Dental Plan

of California. The DELTACARE USA program is designed to encourage regular visits to the dentist

by having no co-payments on most diagnostic and preventive benefits.

Here are some features of DeltaCare coverage:

No Claim Forms – There are no claim forms to complete.

No Deductibles – In the DeltaCare program, there are no required deductibles to pay, so

your benefits begin immediately.

No Dollar Limit on Dental Benefits – There is no annual maximum for DeltaCare benefits.

How the DELTACARE USA Program Works

Delta Dental contracts with DeltaCare dentists to provide care for enrollees. When you enroll in

DeltaCare, you must select a contract dentist. Your selected contract dentist will take care of

your dental care needs. If you require treatment from a specialist, your contract dentist will

handle the referral for you.

After you have enrolled, you will receive a DELTACARE USA membership packet including an

identification card and an Evidence of Coverage booklet that fully describes the benefits of your

dental program. Also included in this packet are the name, address and phone number of your

contract dentist. Simply call the dental facility to make an appointment when you need

services.

Under the DeltaCare program, many services are covered at no cost, while others have co-

payments for certain benefits.

Dental services that are not performed by your selected contract dentist, or are not covered

under provisions for emergency care below, must be preauthorized by DELTACARE USA to be

covered by the DeltaCare program.

Provisions for Emergency Care

Under the DeltaCare program, you and your eligible dependents are covered for out-of-area

dental emergencies if you are 35 miles away or more from your participating dentist. The

DeltaCare program pays up to $100 for out-of-area emergency dental expenses per emergency

for each enrollee.

Choosing a Dentist

You must receive treatment from your selected DeltaCare contract dentist. Please note that

Delta dentists are not necessarily DeltaCare contract dentists. In California, DeltaCare has more

than 3,800 contracted general and specialist dentist in the DeltaCare Network.

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You and your eligible dependents may receive care from the same contract dentist, or if you

prefer, you may collectively select up to a maximum of three individual contract dental

facilities.

You may change contract dentists by notifying DELTACARE USA either by phone or in writing, or

by visiting DELTACARE USA’s website at deltadentalca.org/DeltaCare USA. If you contact

DELTACARE USA by the 21st of the month, the change will become effective the first of the

following month.

Work in Progress

Benefits are not provided for any dental treatment started before joining the program. This

work is considered “work in progress” and includes such things as preparations for crowns, root

canals and impressions for dentures.

Specialist Services

Your contract dentist will coordinate your specialty care needs for oral surgery, endodontics,

periodontics or pediatric dentistry with an approved contract specialist. If there is no contract

specialist within your service area, a referral to an out-of-network specialist will be authorized

at no extra cost, other than the applicable co-payment. If you or your dependent is assigned to

a dental school clinic for specialty services, those services may be provided by a dentist, a

dental student, a clinician or dental instructor.

Questions about the DeltaCare Program

If you have questions about your coverage under the DeltaCare program you are encouraged to

call DELTACARE USA Customer Service toll-free at (800) 422-4234. DELTACARE USA has

representatives available Monday through Friday from 5 a.m to 6 p.m. PST. DELTACARE USA

Customer Service representatives can answer benefits questions, as well as arrange facility

transfers and urgent care referrals.

Termination of Dental Benefits

Dental benefits terminate at the same time and under the same circumstances as those

benefits provided by the medical plan (see the section, “When Coverage Ends”).

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DELTACARE USA

DeltaCare Schedule Of Benefits

Similar to the Delta Dental Plan, DeltaCare covers several categories of benefits. The services must be

provided by a DeltaCare Contract Dentist, and they must be necessary and customary under generally

accepted standards of dental practice. This is only a brief summary of covered benefits. The group Dental

Service Contract must be consulted to determine the exact terms and conditions of coverage. For more

information, please contact Customer Service at (800) 422-4234.

Covered Services Member Co-payments

Diagnostic and Preventive Benefits:

Oral examination ...................................................................... No charge

X-rays ....................................................................................... No charge

Prophylaxis (adult/child) one per 6 month period ..................... No charge

Topical application of fluoride including/excluding prophylaxis to age 19; one per 6 month period .............................................No charge

Sealant, per tooth, limited to permanent molars through age 15 $10.00

Space maintainers .................................................................... $25.00

Oral Surgery

(Includes preoperative and postoperative evaluations

and treatment under local anesthetic)

Routine extraction – single tooth/each additional ..................... $5.00

Surgical removal of erupted tooth ............................................ $25.00

Removal of impacted tooth ....................................................... $50.00 – $110.00

Restorative

(Includes polishing, all adhesives and

bonding agents, indirect pulp capping, bases, liners

and acid etch procedures)

Amalgam .................................................................................. No charge

Resin – one, two, three, four or more surface anterior ............. No charge

Periodontics

(Includes preoperative and postoperative

evaluations and treatment under local anesthetic

Root planing, periodontal scaling, per quadrant ....................... $25.00

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DELTACARE USA

DENTAL SCHEDULE OF BENEFITS

Prosthodontics

(crowns, bridges and dentures)

Crowns .................................................................................... $50.00 – $240.00

Denture – complete upper or lower .......................................... $145.00

Denture – upper or lower partial ............................................... $120.00 – $210.00

Covered Services Member Co-payments

Denture adjustment (no charge if within six months of initial placement) ................. $10.00

Denture repair .......................................................................... $25.00

Partial denture repairs (per repair) ........................................... $20.00

Bridge pontic ........................................................................... $110.00

Bridge retainer ......................................................................... Based on Filed Fee

* Precious and semi-precious metals, if used, will be charged to the enrollee at the additional cost of the metal.

Endodontics

Root canal therapy ................................................................... $55.00 – $250.00

Retrograde filling – per root ...................................................... $60.00

Root amputation per root .......................................................... No charge

Orthodontics

Comprehensive orthodontic treatment of the dentition (child through age 19) ...................................... $1,700.00

Comprehensive orthodontic treatment of the dentition (adult) ............................................................... $1,900.00

Pre-orthodontic treatment visit ................................................. $25.00

Orthodontic retention (removal of appliances, construction and placement of retainers) ................................. $275.00

Unspecified orthodontic procedure, by report .......................... $100.00

Adjunctive General Services

Palliative (emergency) treatment of dental pain ....................... $5.00

Local anesthesia ...................................................................... No charge

Consultation ............................................................................. $10.00

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DELTACARE USA

DENTAL SCHEDULE OF BENEFITS

Office visits after regularly scheduled hours $25.00

Failed appointment without 24 hour notification, per 15 minutes of appointment time ......................................... $10.00


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YOUR VISION PLAN

Raley’s Vision plan is offered through Vision Service Plan (VSP). As a participant you can choose

to enroll in VSP. For California residents, if you choose to enroll in the Kaiser Medical Plan, your

vision coverage will be through Kaiser.

VISION SERVICE PLAN

Vision Service Plan (VSP) has an extensive network of doctors who agree to provide ophthalmic

care and materials to employees and their family members covered under the Plan. Your vision

care plan is designed to encourage you to maintain your vision through regular eye

examinations and to help with vision care expenses for required glasses or contact lenses.

What are the Benefits?

When you receive services from a doctor who is a member of the VSP Select Network, your VSP

coverage includes eye examinations and allowances for lenses and frames.

If medically necessary contact lenses are prescribed, they are covered in full for the following

conditions:

Following cataract surgery;

To correct extreme visual acuity problems that cannot be corrected with spectacle

lenses;

With certain conditions of Anisometropia;

With certain conditions of Keratoconus.

Note: The member doctor must obtain prior approval from VSP for medically necessary

contacts.

Contact lenses may be chosen instead of regular spectacle lenses and a frame. When selecting

contact lenses that are not medically necessary from a Member Doctor, an allowance will be

provided toward the standard eye examination, the contact lens evaluation fee, fitting cost and

materials. Any additional costs exceeding the allowance are the responsibility of the patient.

Obtaining VSP Services

To obtain vision care, simply contact your VSP Select doctor to make an appointment. If you

need help locating a VSP Select Network doctor, call VSP at (800) 877-7195. You may access the

provider directory at vsp.com.

When calling a doctor’s office for an appointment for you or your covered dependent(s), simply

identify yourself as a VSP patient. Indicate that Raley’s provides your benefits and give your VSP

identification number. The VSP Select doctor will obtain the necessary authorization and

information about your eligibility.

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You are not required to complete any up-front paperwork to obtain authorization to use your

VSP vision care benefit.

May I Use Any Doctor?

Most VSP patients receive services from Member Doctors. However, you may obtain covered

services or materials from any other licensed optometrist, ophthalmologist, or optician you

choose. If you choose to obtain covered services or materials from doctors who are not VSP

Select providers, you must pay the provider in full and submit an itemized receipt to VSP, at

P.O. Box 997100, Sacramento, CA 95899-7100. VSP will reimburse you up to the amounts

allowed under your Plan’s nonmember provider schedule.

Claims

Claims for vision services must be filed within six (6) months of the date that services were

completed. Reimbursement benefits are made directly to the covered member and are not

assignable to the provider.

Forms and Information

To verify benefit eligibility or inquire about a claim or benefits, call the VSP Customer Service

Department at (800) 877-7195 or visit VSP’s website at vsp.com.

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Vision Schedule Of Benefits -C-Classic


Covered Service

• Eye Exam — Once every 24 months from last date of service

• Eye Exam Deductible (per covered person) — $15 member co-payment

• Lenses — Once every 24 months; 100% Standard

• Frames — Once every 24 months; up to $105 allowance

• Contact Lenses (in lieu of glasses) — Once every 24 months; up to $105 allowance

Exclusions

• Orthoptics or vision training and any associated supplemental testing;

• Plano lenses (nonprescription);

• Two (2) pair of glasses in lieu of bifocals;

• Medical or surgical treatment of the eyes;

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

• Lenses and frames furnished under this program that are lost or broken will not be replaced except at the normal intervals when services are otherwise available.

• Laser Surgery – Although laser surgery is not a covered benefit under the Plan, VSP members have access to VSP’s Laser VisionCare Program which provides a discount for these services. To learn more about the Laser VisionCare Program and to locate a participating doctor, visit VSP’s website at vsp.com or call toll-free at (800) 877-7195.

Limitations

Because this Plan is designed to cover your vision rather than cosmetic materials, there will be an extra charge if you select any of the following:

• Blended lenses;

• Contact lenses (except as explained earlier);

• Oversized lenses;

• Progressive multifocal lenses;

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

• Coated or laminated lenses;

• Frame cost exceeding the Plan allowance;

• Certain limitations on low vision care;

• Cosmetic lenses;

• Optional cosmetic processes; or

• UV protected lenses

Your Vision Plan

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Vision Schedule Of Benefits -A- Premier


Covered Service

• Eye Exam – Once every 12 months from last date of service

• Eye Exam Deductible (per covered person) – $5 member co-payment

• Lenses – Once every 12 months; 100% Standard

– Polycarbonate lenses are covered for children up to age 18.

• Frames – Once every 24 months; up to $135 allowance

• Contact Lenses (in lieu of glasses) – Once every 12 months; up to $135 allowance

Exclusions

• Orthoptics or vision training and any associated supplemental testing;

• Plano lenses (nonprescription);

• Two (2) pair of glasses in lieu of bifocals;

• Medical or surgical treatment of the eyes;

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

employment;

• Lenses and frames furnished under this program that are lost or broken will not be replaced

except at the normal intervals when services are otherwise available.

• Laser Surgery – Although laser surgery is not a covered benefit under the Plan, VSP

members have access to VSP’s Laser VisionCare Program which provides a discount for

these services. To learn more about the Laser VisionCare Program and to locate a

participating doctor, visit VSP’s website at vsp.com or call toll free at (800) 877-7195.

Limitations

Because this Plan is designed to cover your vision rather than cosmetic materials, there will be

an extra charge if you select any of the following:

• Blended lenses;

• Contact lenses (except as explained earlier);

• Oversized lenses;

• Progressive multifocal lenses;

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

• Coated or laminated lenses;

• Frame cost exceeding the Plan allowance;

• Certain limitations on low vision care;

• Cosmetic lenses;

• Optional cosmetic processes; or

• UV protected lenses.

Health Plan Claims Procedure

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HEALTH PLAN

CLAIMS PROCEDURES

(SELF-FUNDED PLANS)

Under the Employee Retirement Income Security Act of 1974 (ERISA), the Plan is required to

establish and maintain reasonable claims procedures. A claims procedure will be considered

reasonable only if it satisfies certain specific requirements. The following procedures, for our

self-funded plans, are intended to comply with those requirements:

Types of Claims

ERISA recognizes three types of health claims, each of which is subject to different rules. The

three types of claims are as follows:

A Pre-Service Claim is a claim for a benefit for which, under the terms of the Plan, prior approval

is required as a condition of receiving the benefit.

An Urgent Care Claim is a type of Pre-Service Claim which, if the regular time periods for

handling such claim were adhered to (1) could seriously jeopardize your life or health or your

ability to regain maximum function or (2) would, in the opinion of a professional provider with

knowledge of your condition, subject you to severe pain that could not be adequately managed

without the care or treatment that is the subject of the claim.

A Post-Service Claim is a claim for benefits that is not a Pre-Service Claim. A Post-Service Claim

involves payment or reimbursement for health care that has already been provided.

Appointing an Authorized Representative

You may designate an authorized representative to act on your behalf at any stage of the claims

procedures. This designation must be made in writing, signed by you and must be submitted to

Blue Shield of California (“Blue Shield”), Delta Dental Plan (“Delta Dental”) or Vision Service Plan

(“VSP”). Blue Shield members can obtain a copy of Blue Shield’s authorization form at

mylifepath.com, under “Privacy” or by contacting Blue Shield directly. For purposes of an

Urgent Care Claim, a physician or other health care professional who is licensed, accredited, or

certified to perform specified health services consistent with state law and who has knowledge

of your medical condition will be acknowledged as your authorized representative even if no

written designation is submitted.

An assignment of benefits to your health care provider does not constitute a designation of

such provider as your authorized representative to act on your behalf in pursuing and appealing

a benefit determination. Any such designation must be made under the procedures described

above.

The Plan will send your authorized representative all materials regarding the claim that you are

entitled to receive under the claims procedures. You will receive copies of all notices regarding

determinations made under the claims procedures.

Any reference to “you” in these claims procedures is intended to include your authorized representative


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Submitting Claims

A claim for benefits is a specific request for a Plan benefit that is submitted in accordance with

the Plan’s procedures for filing claims. A general request for information regarding a benefit is

not a claim.

Pre-Service Claims. A Pre-Service Claim, including an Urgent Care Claim, will be considered

submitted when a request for prior approval is made pursuant to the Plan’s utilization review

procedures or as otherwise described in this Summary Plan Description.

Incorrectly Submitted Claims. Generally, only claims that are submitted in compliance with the

Plan’s claims procedures will be considered. However, under certain circumstances, you will be

notified if a Pre-Service Claim has been incorrectly submitted. This notice will be provided only

if the request for prior approval was received by a person or entity that is customarily

responsible for handling benefit matters, and only if the communication contains the following

information:

The name of the claimant

The specific health condition or symptom

The specific treatment, service or product for which approval is requested

Notice of an incorrectly submitted claim will be provided as soon as possible, but not later than

24 hours (in the case of an Urgent Care Claim) or five calendar days (in the case of all other Pre-

Service Claims). This notice may be oral, unless written notification is requested.

Post-Service Claims. Contracted health providers will generally submit their medical, dental or

vision claims directly to Blue Shield, Delta Dental or VSP at the following addresses:

California Residents Enrolled in PPO Medical Plan:


PO Box 272570

Chico, CA 95927-2570

Nevada Residents enrolled in PPO Medical Plan:

BCBS of Colorado

PO Box 173681

Denver, CO 80217

California and Nevada Residents enrolled in Delta Dental Plan:

Delta Dental Plan of California

PO Box 997330

Sacramento, CA 95899-7330

California and Nevada Residents enrolled in Vision Service Plan:

Vision Service Plan

PO Box 997100

Sacramento, CA 95899-7100


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However, in some cases, including all expenses from non-contracted providers and certain

outpatient expenses, you must submit the claim to Blue Shield, Delta Dental or VSP (as listed

above). Claim forms for the medical plans are available from the healthcare providers.

A Post-Service Claim for medical services (Blue Shield) or vision services (VSP) must be

filed within six (6) months from the date the expense was incurred unless it was not

reasonably possible to do so within that time period. In the event it was not reasonably

possible to submit the claim within the time period stated above, the claim must be filed

as soon as reasonably possible but no more than 12 months after the date the

treatment, service or supply was provided. This time limit does not apply in the case of

legal incapacity.

Initial Claims Determinations

The timeframes for making the initial determination regarding a claim and the procedures for

notifying you about that decision depend on the type of claim and whether the determination

is an “adverse benefit determination.”

For purposes of these claims procedures, an “adverse benefit determination” means a denial,

reduction or termination of a benefit or a failure to provide or make payment (in whole or in

part) for a benefit.

Urgent Care Claims. Blue Shield, Delta Dental or VSP will notify you of the Plan’s initial

determination involving an Urgent Care Claim (whether adverse or not) as soon as possible,

taking into account the medical exigencies, but not later than 72 hours after receipt of a claim.

If more information is needed in order for a determination to be made, you will be advised of

the specific information necessary to complete the claim as soon as possible but in no event

later than 24 hours after receipt of the claim. You will be allowed at least 48 hours to provide

the necessary information. A determination will be made within 48 hours after Blue Shield,

Delta Dental or VSP receives the requested information, or at the end of the period you were

given in which to provide the information, whichever is later. If you do not provide the

requested information within the specified timeframe, the claims administrator may decide the

claim without that information. Notification of any adverse benefit determination will be made

as described in the section called Notice of Adverse Benefit Determinations.

Previously Approved Treatment Involving Urgent Care. If you have an Urgent Care Claim that

involves a request for an extension of a previously approved course of treatment beyond the

period of time or number of treatments, the claims administrator will notify you of the

determination on such claim (whether adverse or not) as soon as possible, taking into account

the medical exigencies, but in no event more than 24 hours after receipt of the claim, provided

that you requested the extension at least 24 hours prior to the expiration of the prescribed

period of time or number of treatments. Notification of any Adverse Benefit Determination will

be made as described below in the section called Notice of Adverse Benefit Determinations.

If the request for an extension of previously approved treatment does not involve Urgent Care or is not

made at least 24 hours prior to the expiration of the prescribed period of time or number of treatments, a

determination on the claim will be made as described under Pre-Service Claims.


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Pre-Service Claims. Blue Shield, Delta Dental or VSP will notify you of the Plan’s determination

(whether adverse or not) regarding a Pre-Service Claim within a reasonable period of time

appropriate to the medical circumstances, but in no event later than 15 calendar days after

receipt of the claim or receipt of any information requested by the Plan as necessary to decide

the claim. The period may be extended an additional 15 calendar days if the claims

administrator determines that such an extension is necessary due to matters beyond the

control of the Plan and notifies you of the circumstances that require the extension prior to the

expiration of the initial 15-day period. If the extension is required due to your failure to submit

information necessary to decide the claim, the notice of the extension will specifically describe

the information necessary to complete the claim. You will be given at least 45 calendar days

from receipt of the notice to provide the information. If you do not provide the requested

information within the specified timeframe, the claims administrator may decide the claim

without that information. Notification of any Adverse Benefit Determination will be made as

described in the section called Notice of Adverse Benefit Determinations.

Previously-Approved Treatment. If the Plan has previously approved an ongoing course of

treatment that is to be provided over a period of time or that involves a specified number of

treatments, any reduction or termination of such course of treatment (other than by plan

amendment or termination) before the end of such period of time or number of treatments will

be considered to be an adverse benefit determination. The claims administrator will notify you

sufficiently in advance of such reduction or termination to allow you to appeal and obtain a

determination on review of the adverse benefit determination before the benefit is reduced or

terminated. Notification of any adverse benefit determination will be made as described in the

section called Notice of Adverse Benefit Determinations.

Post-Service Claims. Blue Shield, Delta Dental or VSP will provide you with written notification

of an adverse benefit determination involving a Post-Service Claim within 30 calendar days of

receiving the claim or receiving any information requested by the Plan as necessary to decide

the claim. This period may be extended an additional 15 calendar days when necessary due to

matters beyond the control of the Plan, provided that you are notified of the circumstances

that require the extension prior to the expiration of the initial 30-day period. If the extension is

due to your failure to submit information necessary to decide the claim, the notice will

specifically describe the information necessary to complete the claim. You will be given at least

45 calendar days from receipt of the notice to provide the information. Notification of any

adverse benefit determination will be made as described in the section called Notice of Adverse

Benefit Determinations.

Notice of Adverse Benefit Determinations

Written notification of an adverse benefit determination will be provided within the applicable

timeframes described above. The notice will contain the following information:

The specific reason or reasons for the adverse benefit determination;

References to the specific Plan provisions on which the adverse benefit determination is based;

A description of any additional material or information necessary for you to complete the claim

and an explanation of why such material or information is necessary;


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A description of the Plan’s appeals procedures, including applicable time limits, plus a statement

of your right to bring suit under Section 502 of ERISA with respect to any Adverse Benefit

Determination after an appeal;

A statement that you are entitled to receive, upon request and free of charge, reasonable access to

and copies of, all documents, records and other information relevant to the claim;

If the adverse benefit determination is based on an internal rule, guideline, protocol or other

similar criterion, either the specific rule, guideline, protocol or other similar criterion or a

statement that such rule, guideline, protocol or other similar criterion will be provided to you free

of charge upon request;

If an adverse benefit determination is based on medical necessity or a determination of

experimental treatment or similar exclusion or limit, either an explanation of the scientific or

clinical judgment for such determination applying the terms of the Plan to your medical

circumstances, or a statement that such explanation will be provided to you free of charge upon

request; and

If an adverse benefit determination involved an Urgent Care Claim, a description of the expedited

review process applicable to such claims.

Appealing an Adverse Benefit Determination

You have 180 calendar days following receipt of a notification of an adverse benefit

determination in which to appeal the determination to Blue Shield, Delta Dental or VSP. Except

in the case of an appeal involving an Urgent Care Claim, such appeal must be in writing. If you

do not file an appeal of the adverse benefit determination within the 180-day period, you will

lose the right to appeal the determination.

Special Procedures for Urgent Care Claims. You may request an expedited appeal of an adverse

benefit determination. This request may be oral or in writing. Under these expedited

procedures, all necessary information, including the Plan’s benefit determination on appeal,

may be transmitted by telephone, facsimile or other available similarly expeditious method.

You may submit written comments, documents, records and other information relating to the

claim. Upon request, you will be provided with reasonable access to and copies of, all

documents, records and other information relevant to the claim free of charge. You may also

request that the plan identify any medical or vocational expert from whom it received advice in

connection with the benefit determination, regardless of whether it relied on such advice in

making the initial benefit determination.

The Review Process

Review of your appeal will take into account all comments, documents, records and other

information that you submitted relating to the claim, without regard to whether such

information was submitted or considered in the initial benefit determination. The review will

not afford deference to the initial determination, and will be conducted by an individual acting

on behalf of the Plan who is neither the individual who made the initial determination nor a

subordinate of that individual.

If the initial determination was based on a medical judgment, including determinations with

regard to whether a particular treatment, drug or other item is experimental, investigational or

not medically necessary or appropriate, the Plan will consult with a health care professional


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who was not involved in the original benefit determination and who has appropriate training

and experience in the field of medicine involved in the medical judgment.

Timeframe for the Determination on Appeal

The timeframe in which the determination on appeal must be made will depend on the type of

claim involved. In all instances, the period of time for making the determination will begin at

the time the appeal is filed, without regard to whether all the necessary information

accompanies the filing.

Urgent Care Claims. In the case of an Urgent Care Claim, Blue Shield, Delta Dental or VSP will

notify you of the determination on appeal as soon as possible, taking into account the medical

exigencies, but in no event more than 72 hours after your appeal is received by the Plan. The

notification will be in writing or will be provided pursuant to the expedited procedures for

Urgent Care Claims described above.

Pre-Service Claims. In the case of a Pre-Service Claim, Blue Shield, Delta Dental or VSP will

notify you of the determination on appeal within a reasonable period of time appropriate to

the medical circumstances, but in no event later than 30 calendar days after your appeal is

received by the Plan.

Post-Service Claims. In the case of a Post-Service Claim, Blue Shield, Delta Dental or VSP will

notify you of the determination on review within a reasonable period of time but in no event

later than 60 days after your appeal is received by the Plan.

Notification of Adverse Benefit Determination on Appeal

You will receive written notification of an adverse benefit determination on appeal within the

applicable timeframes described above. The notice will contain the following information:

The specific reason or reasons for the adverse benefit determination;

The diagnosis code and its corresponding meaning, and the treatment code and its

corresponding meaning;

Information sufficient to identify the claim involved, including the date of the service,

the health care provider and the claim amount (if applicable);

The denial code and its corresponding meaning, as well as a description of the plan’s

standard that was used in denying the claim. In case of a final internal adverse benefit

determination, the description must also include a discussion of the decision;

A description of available internal appeals and external review processes, including

information regarding how to initiate an appeal,

Disclose the availability of, and contact information for, an applicable office of health

insurance consumer assistance or ombudsman established under Public Health Service

Act section 2793

References to the specific Plan provisions on which the adverse determination is based;


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A statement that you are entitled to receive, upon request and free of charge,

reasonable access to and copies of, all documents, records and other information

relevant to the claim;

A statement of your right to bring suit under Section 502(a) of ERISA;

If the adverse benefit determination is based on an internal rule, guideline, protocol or

other similar criterion, either the specific rule, guideline, protocol or other similar

criterion or a statement that such rule, guideline, protocol or other similar criterion will

be provided to you free of charge upon request;

If the adverse benefit determination is based on medical necessity or a determination of

experimental treatment or similar exclusion or limit, either an explanation of the

scientific or clinical judgment for such determination applying the terms of the Plan to

the individual’s medical circumstances or a statement that such explanation will be

provided to you free of charge upon request; and

A statement advising you of any available voluntary alternative dispute resolution

options, such as mediation, and directing you to your local United States Department of

Labor office or state insurance regulatory agency.

If you are dissatisfied with the administrative review determination by The Claims

Administrator, Blue Shield of California, the determination may be appealed in writing to Blue

Shield of California within 60 days after notice of the administrative review determination.

Such written request shall contain any additional information which you wish Blue Shield of

California to consider. Blue Shield of California will notify you in writing of the results of its

review and the specific basis therefore. In the event the Claims Administrator finds all or part

of the appeal to be valid, the Claims Administrator, on behalf of the Employer, shall reimburse

the Participant for those expenses which the Claim Administrator allowed as a result of its

review of the appeal. The Claims Administrator's determination shall be final and binding on all

parties. With respect to any other determination made by the Plan or the Claims Administrator

pursuant to the Plan Agreement, the Plan’s determination shall be final and binding on all

parties.

Note: Because the Plan is governed by the Employee Retirement Income Security Act (“ERISA”),

you may have the right to bring a civil action under Section 502(a) of ERISA if all required

reviews of your claim have been completed and your claim has not been approved.

If you are not satisfied with the final decisions made by Delta Dental or VSP, the dental and

vision claim administrators, or in relation to enrollment or benefit change actions taken by

Raley’s, you may send a written request for review to the Raley’s Administrative Committee

within 180 days to the following address:

Raley’s Health and Welfare Plan

Attn: Administrative Committee

PO Box 15618

Sacramento, CA 95852

The decision by the Raley’s Administrative Committee is final.


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Claims Inquires and Benefit Questions

If you have any questions regarding the processing of a claim for medical, dental or vision

benefits, you are encouraged to call:

Blue Shield PPO: (800) 358-9556

Kaiser Permanente: (800) 464-4000

Delta Dental Plan: (800) 765-6003

Delta Care USA: (800) 422-4234

Vision Service Plan: (800) 877-7195

You may also call the Employee Benefits Department toll-free at (888) 332-4894 or email

[email protected] if you have questions or need clarification on any information contained

in this Summary Plan Description.

Other Special Benefits

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OTHER SPECIAL BENEFITS

SCHEDULE OF LIFE, ACCIDENTAL DEATH, AND

DISMEMBERMENT BENEFITS

Employee Life, Accidental Death and Dismemberment Insurance Benefits

Upon satisfying initial eligibility, all hourly employees are also covered for Group Term Life and

Accidental Death and Dismemberment Insurance benefits up to $40,000. At age 70, benefits

are reduced by 50%. At retirement or termination of employment, your benefits terminate on

your last day worked. Upon a reduction in work hours, your benefits will terminate on the last

day of the month.

This coverage includes both a waiver of premium and accelerated benefit (terminal illness)

provision. For more information regarding either of these provisions, please refer to your Group

Term Life and Accidental Death and Dismemberment Insurance Certificate of Coverage booklet.

To request a copy of this booklet, please contact the Raley’s Benefits Department toll-free at

(888) 332-4894 or email [email protected].

If you wish to change your beneficiary, you must fill out a Change In Family Status/Beneficiary

Form available from the Employee Benefits Department, or on our internal website.

Conversion Options

You have 31 days from the date your insurance ends to either convert your coverage to an

individual policy or to buy portable Group Life Insurance and pay the appropriate premium to

the life insurance company. If you have applied for a waiver of premium, you may wish to

convert your policy in the event you are not approved for the waiver of premium.

An application for conversion is available by contacting the Employee Benefits Department. For

more information regarding conversion, please refer to your Group Term Life and Accidental

Death and Dismemberment Insurance Certificate of Coverage booklet.

Dependent Life Insurance

Upon satisfying eligibility, all hourly employees are covered for Dependent Life Insurance.

Spouses are covered for $2,000; children, from birth to 26 years, are covered for $1,000.

*In order for step-children to be covered under Dependent Life, they must have their primary residence with the employee.

Other Special Benefits

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EMPLOYEE ASSISTANCE RESOURCES PROGRAM

The Company offers an Employee Assistance Program (EAP). This short-term counseling

program provides personal resources of support for eligible employees and their immediate

families.

EAP offers preventive care in promoting voluntary self-referral to individuals who seek

assistance. An employee or family member and an EAP counselor talk, assess the problem, and

work together toward a solution.

The process of self-referral is available to employees whenever they require professional,

confidential counseling before their job performance is negatively affected. Eligible family

members are also provided with this valuable benefit.

Each employee and eligible dependent is entitled to three (3) free face-to-face counseling

sessions per person, per issue, per 6-month period. The program provides confidential

assessment, counseling, and if needed, referral services. Examples of such problems include

emotional, psychological, marriage and family, substance abuse and other problems. Additional

counseling sessions are covered according to the schedule of benefits section for the Raley’s

PPO Medical Plan.

To schedule an appointment or ask questions about the program, call:

ComPysch Guidance Resources (866) 379-0893 guidanceresources.com (company ID is ZH3636D)

Other Information

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OTHER INFORMATION

PLAN ADMINISTRATION

The Plan is administered by Raley’s and benefits under the Plan are payable through the

insurance company(ies), whose name(s) and address(es) are shown above or on a self-funded

basis from the Employer's general assets. The Employer has no obligation under the insured

portions of this Plan beyond the payment of the Employer's share of the appropriate insurance

company premiums and the remittance of each eligible employee's share of the premiums, if

any, to the insurance companies to the extent that such premiums have been paid to the

Employer by the employee or withheld from the employee's wages.

ABOUT MEDICARE

Medicare consists of three parts:

Part A – Covers hospital care, extended care facilities, home health care; and

Part B – Covers doctor’s bills, some health care services, and other medical services, for

example, ambulances; and

Part D – Provides certain prescription drug benefits.

You are automatically eligible for Part A, B and D when you reach age 65, whether you continue

working or retire. However, you must enroll before your eligibility date for Medicare coverage.

There is a monthly charge for Part B coverage. All three parts of Medicare require you to pay

some expenses, and there are coverage limits. Additional information will be provided

separately on Part D.

COORDINATION OF BENEFITS

Understanding “Coordination of Benefits”

Coordination of benefits establishes the priority or sequence in which medical benefit claims

are paid. The benefit plan of a person’s employer is the primary insurance and is required to

pay first on medical claims.

The Raley’s Health and Welfare Plan contains a Coordination of Benefits (COB) provision that

applies whenever two (2) or more group health plans (including Medicare) are available to pay

benefits. COB is used to determine which plan pays first (the primary carrier) and which plan

pays second (the secondary carrier). COB allows payment for all justified health care claims,

while preventing duplicate benefit payments. When other primary coverage exists, the Plan, as

secondary payer, coordinates benefits up to the lowest Allowable Amount. While on COBRA

continuation coverage, the Plan will pay as secondary to Medicare when the covered person is

Medicare eligible, whether or not enrolled in Medicare coverage.

When a claim involving COB occurs, benefits under the Raley’s Health and Welfare Plan are paid

in the following order:

Other Information

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1. A plan that has no COB provision pays first.

2. The plan covering the patient as an employee pays benefits before a plan covering that

person as a dependent.

3. Where a child lives with both parents and is covered under both parents’ health plans, the

plan of the parent having the earlier birthday in a calendar year is primary. When both

parents’ birthdays fall on the same calendar day, then the plan of the parent that has been

covered the longest is primary.

4. If the parents are divorced or separated, the benefits for a child are determined as follows:

• First, the plan of the parent with custody of the child;

• Then, the plan of the spouse of the parent with custody of the child; and

• Finally, the plan of the parent not having custody of the child.

5. The benefits of a plan that cover the person as an employee are determined before those of

a plan that cover that person who is laid off or retired or who is a dependent of a laid off or

retired employee.

6. The benefits of a plan that covered the person longer are determined before those of the

plan that covered that person for the shorter time.

If there is a court decree or QMCSO that establishes one parent having financial responsibility

for the health care expenses of a child, then that parent’s plan will pay benefits before any

other plan that covers the child as a dependent.

Coordination of Benefits –Spousal Provision

When your working spouse is eligible for health and welfare benefits from their employer, your

spouse must enroll in the best available plan offered by that employer. If coverage is available

to your working spouse, and your spouse does not enroll in the available coverage, you will be

required to pay the single monthly COBRA premium rate, through payroll deduction, to

maintain benefit coverage for your working spouse.

Annually, you will receive a Spousal Coordination of Benefits Questionnaire. The questionnaire

must be promptly completed and returned if there are any changes or updates to maintain

benefit coverage for your working spouse.

Exclusion for Duplicate Coverage

If a covered dependent has other primary coverage, then benefits payable under the Raley’s

Health and Welfare Plan will not exceed the difference between the primary plan’s benefit level

and the Raley’s Plan benefit level.

If you and your dependents do not wish to enroll because of other coverage (for example,

through your spouse’s employer), you must submit your enrollment information electing to

waive your Company-provided medical, dental, vision, and prescription drug benefits and may

be required to provide satisfactory evidence of other medical coverage.

Other Information

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Exceptions to COB

If any employee or dependent covered under this Plan also has coverage under a Prepaid Plan

of Benefits, this Plan will reimburse only co-payments and deductibles required to be paid by

persons enrolled in the prepaid plan.

Further, if this Plan is coordinating benefits with another plan that has an agreement with a

preferred provider organization, allowable expenses paid by this Plan will be limited to the

lesser of (1) the discounted rate the preferred provider organization charges the other plan (2)

this Plan’s allowable expense.

CHANGE IN STATUS EVENTS

You may be eligible to make changes to all or a portion of your benefit elections during a Plan

year if you experience an eligible “Change in Status Event” as defined by IRS regulations. An

eligible “Change in Status Event” includes:

Change in employee’s legal marital status—including:

Marriage – employee may add spouse and/or dependents;

Death of a spouse, or divorce, legal separation, or annulment. Employee is required to

remove the spouse from coverage.

Change in number of tax dependents – including:

Birth – employee may add newborn, spouse and all eligible dependents;

Adoption, or placement for adoption – employee may add newly adopted dependent,

spouse and all eligible dependents;

Death of a spouse or dependent. Employee is required to remove the spouse or

dependent from coverage.

Change in employment status—including termination or commencement of employment by

the employee, spouse or dependent(s); a strike or lock-out, a commencement of or return

from an unpaid leave of absence, a change in worksite. In addition, if eligibility is conditioned

upon an individual’s employment status and that status changes resulting in that individual

becoming (or ceasing to be) eligible, such change qualifies as a change in employment status

(e.g. “salaried” to “union”). Employee may add or remove the spouse and/or dependent(s)

from coverage.

Dependent satisfies (or ceases to satisfy) dependent eligibility requirements—attainment of

age. Employee may add or remove dependent(s).

Change in residence or worksite of employee, spouse, or dependent. If employee, spouse or

dependent moves in or outside the HMO service area mid-year, employee may add, remove

or modify benefits.

A change required by judgment, decree, or order. Employee may add, remove or modify

benefits.

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Entitlement to Medicare or Medicaid by an employee, spouse, or dependent. Employee may

remove eligible participant from plan.

Is covered under Medicaid or a state Children’s Health Insurance Program (CHIP) and loses

eligibility for Medicaid or CHIP coverage. Employee may add eligible dependent to plan.

Becomes eligible for state premium assistance (to purchase group health coverage) under

Medicaid or CHIP. Employee may remove eligible participant from plan.

Note: The change in benefits must be consistent with the reason you are making the change.

In addition, if the cost of a benefit provided under the Plan increases or decreases during a Plan

Year, then the Plan will automatically increase or decrease your contributions to correspond

with the change. However, if the cost increase is significant or if coverage under a benefit is

significantly curtailed or ceases during a Plan year; you will have the option to revoke your

election and choose another coverage option.

How to Make a Change

To change your benefit elections due to an eligible “Change in Status Event”, you must notify

the Employee Benefits Department within 31 days (60 days for divorce, separation, loss of

dependent status, loss of eligibility for Medicaid, CHIP or eligibility for state premium assistance

under Medicaid or CHIP) of the event by submitting a Change in Family Status/Beneficiary Form

with all required documentation. You can obtain a Change in Family Status/Beneficiary Form by

contacting the Employee Benefits Department, on Raley’s internal website, or on

yourpantry.net. Any change forms requesting the addition of a spouse and/or dependent(s)

that are not submitted with all required documentation within 31 days of the event, cannot be

processed until the next annual Open Enrollment period. For assistance with the required

documentation, you may contact the Employee Benefits Department toll-free at (888) 332-

4894 or email [email protected].

Effective Date of Coverage

Provided that a Change in Family Status/Beneficiary Form with all appropriate documentation

has been received by the Employee Benefits Department within 31 days (60 days for loss of

eligibility for Medicaid, CHIP or eligibility for state premium assistance under Medicaid or CHIP)

of the date of the event, the effective date of the change in coverage is as follows:

Marriage—first of the following month

Birth—date of event

Adoption or Placement for Adoption—date of event

Divorce, Legal Separation or Annulment—date of event

Death of Spouse (or Dependent)—date of event

Change in Employment Status—date of event

Loss of Dependent Status—date of event

Gaining of Dependent Status—first of the following month

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Change in residence or worksite—first of the following month

Change required by judgment, decree or order—as specified under the judgment decree

or order

Entitlement to Medicare or Medicaid—date of event

Loss of entitlement to Medicare, Medicaid or CHIP—first of the following month

Eligibility for state premium assistance under Medicaid or CHIP—first of the following

month

Significant cost or coverage change—date of event

Again, all benefit changes due to a status change event (except divorce, death and loss of

dependent status – which allow 60 days) must be submitted with all required documentation to

the Employee Benefits Department within 31 days of the event. Otherwise, you must wait until

the next annual Open Enrollment period to make a change to your benefits.

You are also obligated to submit a completed Change in Family Status/Beneficiary Form within

60 days of an event that causes one of your dependents to lose coverage. Examples of such

events include: divorce or death of a spouse/dependent. If this notification is not completed

within the required period, then it will be considered insurance fraud and rights to continuation

coverage (COBRA) will be forfeited.

THIRD PARTY LIABILITY

If a covered employee or dependent is injured through the negligent act or omission of another

person (a “third party”), the Plan will provide benefits as necessary for the injury only on the

following conditions:

The covered employee or dependent agrees in writing to reimburse the Company

and/or its claims administrators for payment made by any third party for damages; and

The covered employee or dependent provides the Company’s administrator with a lien,

to the extent of benefits provided by the Plan, upon the covered employee or

dependent’s claim against the third party. The lien may be filed with the third party, the

third party’s agent, or the court.

If a covered employee or dependent recovers from a third party the reasonable value for

covered services rendered by a participating provider, the provider is not required to accept the

amount paid by the Plan

as payment in full, but may collect from the covered employee or dependent the difference, if

any, between the amount paid by the Plan and the amount collected by the covered employee

or dependent for these services.

WHEN COVERAGE ENDS

You

Your coverage under the Plan automatically ends on the date any one of the following occurs:

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The last day you worked as a covered employee of Raley’s or any of its affiliated

companies.

The date the Plan or group contract providing medical coverage is terminated.

The last day of the calendar month during which membership in an eligible class of

employees terminates.

The last day of the month during which you stop working the required number of

eligible hours in a benefits calendar month

The date you enter full-time military service.

Dependents

Your dependents’ coverage ends when your coverage ends or when they no longer meet the

eligibility requirements under the Plan.

Continued Coverage for an Incapacitated Child

If your incapacitated dependent qualifies for continued coverage (according to the

requirements under Eligibility), you must provide proof of this incapacity within 31 days of the

date his or her dependent coverage would normally stop. If you do so, the child will continue as

a qualified dependent for as long as the incapacity lasts, provided you remain insured under the

Plan.

CONTINUED COVERAGE FOR YOU AND YOUR

DEPENDENTS

HEALTHCARE REFORM AND YOU

As a result of Health Care Reform, almost every American will have to be enrolled in a medical plan in 2014, or pay a penalty. To help more people obtain coverage, the law requires that each state open a health insurance marketplace, or exchange, where consumers can shop for medical plans. (The federal government is running the marketplaces for states that decline to set one up.)

COBRA coverage counts toward the coverage requirement. However, given the cost of COBRA coverage, you may want to consider purchasing a marketplace plan instead. Please be sure to carefully compare the plan design features of each option before making an election. You can access your state marketplace to shop for plans from www.healthcare.gov.

Keep in mind, though, if you drop COBRA coverage to purchase a marketplace plan, you cannot

regain COBRA coverage at a later date.

COBRA

The Consolidated Omnibus Budget Reconciliation Act (COBRA) allows you and your dependents

who are no longer covered under the Raley’s Health and Welfare Plan to continue coverage at

your or their own expense. Under COBRA, health care coverage remains the same; however,

you or your eligible family member(s) must pay the full cost of the premiums plus an

http://www.healthcare.gov/

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administrative fee of at least 2%. While on COBRA, the Plan will pay as secondary to Medicare

when the covered person is Medicare eligible, whether or not enrolled in the available

Medicare coverage.

Under COBRA, you and your covered dependent(s) have the opportunity to extend health care

coverage for up to 18, 29, or 36 months beyond the time coverage would normally stop

because you or they lose coverage, as follows:

Coverage can be extended up to 18 months only if one of the following events occurs:

Your employment with the Company ends (either voluntarily or involuntarily) for

reasons other than gross misconduct.

Your work hours decrease below the minimum number of paid hours required to

maintain coverage.

Coverage can be extended beyond the initial 18 months up to a total of 29 months if you or one

of your covered dependents is totally disabled at any time during the first 60 days of COBRA

continuation coverage. The Social Security Act defines total disability. If you or your covered

dependent becomes totally disabled, you or your covered dependent is required to supply the

Employee Benefits Department with written proof from the Social Security Administration

within 60 days of its determination of the total disability, but no later than the end of the 18-

month COBRA continuation coverage period. You must also pay an additional administrative fee

of 50%, rather than 2%, during the 11 months of extended coverage. If, after the 18th month of

continuation coverage, the Social Security Administration later determines that you or your

covered dependent is no longer disabled, coverage will cease commencing with the first month

that begins at least 30 days after the final determination by the Social Security Administration

that the individual is no longer disabled.

Coverage for your covered dependents can be extended up to a total of 36 months if one of the

following qualifying events occurs:

You die while still employed (or while covered under COBRA);

You and your spouse become legally separated or divorced; or

A dependent child becomes ineligible according to the eligibility requirements of the

Plan (attains age 26, gains insurance through their employer).

New Dependents and Open Enrollment

If, during a period of continuation coverage, a qualified beneficiary acquires new dependents

(such as through marriage, birth or adoption), the new dependent(s) may be added to the

continuation coverage according to the rules of the Plan. Please refer to the Change in Status

Events section for more information.

In addition, should an Open Enrollment period occur during your continuation coverage period,

the Employee Benefits Department will notify you of that right as well. Each qualified

beneficiary will have independent rights to select any of the options or plans that are available

for similarly situated non-COBRA participants.

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To Elect Continuation Coverage

If you or your eligible family member(s) qualifies for continuation coverage:

In the event of divorce, legal separation or a child losing dependent status, you or your

dependent(s) must notify the Employee Benefits Department within 60 days of the qualifying

event.

For all qualifying events, the Employee Benefits Department will provide you or your eligible

family members with written notification of your rights and responsibilities under COBRA

(including the cost of coverage).

You and your dependents have 60 days from the later of: (a) the date coverage is lost, (b) the

date of notification to submit an application for continuation of health coverage.

If you decide not to elect continuation coverage, medical coverage ends on the last day you

work for Raley’s or any of its affiliated companies. If you do elect COBRA coverage, the first

payment for the coverage must be received within 45 days of the date of the application

requesting continuation coverage.

The initial premium must cover the period retroactive to the date of loss of coverage. Monthly

payments thereafter are due on the first of each month and are considered late if received

more than 30 days following the due date.

When Continuation Coverage Ends

Normally COBRA continuation coverage ends on the last day of the month you are eligible for

such coverage as summarized previously. However, coverage will end earlier when any of the

following events occur:

After the date of the qualifying event, you or your dependent obtains medical coverage

under another group health plan (for example, through employment or marriage).

After the date of the qualifying event, you or your dependent becomes entitled to

benefits under Medicare.

All Raley’s-provided medical coverage is terminated.

You do not pay the premium when it is due (allowing for the 30-day grace period).

Once COBRA continuation coverage has been canceled, it cannot be reinstated.

COBRA continuation coverage may also be terminated for any reason the Plan would

terminate coverage of a participant or beneficiary not receiving COBRA continuation

coverage (such as fraud).

FAMILY AND MEDICAL LEAVE ACT OF 1993 (FMLA)

If you are on a leave of absence covered by the Family and Medical Leave Act of 1993 (the

“FMLA”), you may continue to participate in and receive coverage under the health plan during

the leave if the following conditions are met:

Any required contributions for the cost of your coverage is paid by you when due; and

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Your leave has been approved in writing by the Company.

You may continue to participate in the Plan until the end of the leave period required by the

FMLA. If you cancel your coverage while you are on an approved FMLA leave and you return to

work as an eligible employee immediately following your approved FMLA leave or your

approved leave of absence that includes an approved FMLA leave, you can restore coverage as

an employee. Coverage will be restored as soon as your return to work for one full day.

If you do not return to work following an approved FMLA leave, you (and your spouse and

dependent children, if any) may be eligible for COBRA continuation coverage as of the date you

terminate.

NATIONAL DEFENSE AUTHORIZATION ACT OF 2008

(NDAA)

National Defense Authorization Act amends the Family and Medical Leave Act of 1993 (FMLA) to permit a "spouse, son, daughter, parent, or next of kin" to take up to 26 workweeks of leave during a 12 month period to care for a "member of the Armed Forces, including a member of the National Guard or Reserves, who is undergoing medical treatment, recuperation, or therapy, is otherwise in outpatient status, or is otherwise on the temporary disability retired list, for a serious injury or illness" and because of qualifying exigencies arising out of the fact that a covered military member is on active duty or has been notified of an impending call or order to active duty in support of a contingency operation.

EXTENSION OF BENEFITS FOR TOTAL DISABILITY

(LEAVE OF ABSENCE CONCURRENT WITH FMLA)

Employees who qualify for an approved Family Medical Leave (under FMLA) while covered by

the Raley’s Medical Plan will be eligible for three (3) one-month extensions; four (4) one month

extension for maternity; of benefits from the date benefits would have otherwise ceased due to

a reduction in eligible hours.

Employees are limited to three (3) one-month extensions; four (4) one month extension for

maternity within any twelve (12) month period. During this period when benefits are extended,

benefits for both the employee and dependent(s) will be the same as for active employees.

For information on the requirements to qualify for a Family Medical Leave (under FMLA), please contact

your Human Resources Manager or contact the benefits department at 888-332-4894 or

[email protected].

UNIFORMED SERVICES EMPLOYMENT AND

REEMPLOYMENT RIGHTS ACT OF 1994 (USERRA)

If you voluntarily or involuntarily leave employment to serve in the uniformed services, you and

your covered dependents’ medical coverage may continue for up to 24 months. This period is

considered a leave of absence. This provision applies to:

Employees on active duty;

Employees on active duty for training;

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Employees on initial active duty for training and inactive duty training in the Armed

Forces (including the Reserve components), the Army or Air National Guard and the

commissioned corps of the Public Health Service, and to full-time National Guard duty,

and;

Absences needed to determine the employee’s fitness for duty in the uniformed service.

USERRA does not apply to service in a state National Guard or another state military

organization. If the military leave of absence is for less than 31 days, you may continue your

coverage by paying the amount of premiums you would be required to pay if you had not been

on leave. If the military leave of absence is longer than 30 days, you may be required to pay for

the full cost of the premium (your share and your employer’s share) plus a 2% administrative

fee. Failure to pay your required premium will result in termination of coverage.

You and your dependents may also be eligible to continue medical coverage under COBRA

while you are on a military leave of absence. Continuation coverage under COBRA and USERRA

will run concurrently.

Coverage will end if you fail to return to or reapply for work at the end of your military leave of

absence or are discharged from the service under conditions that result in loss of

reemployment rights under the law.

NEWBORNS’ AND MOTHERS’ HEALTH PROTECTION ACT

OF 1996

Group health plans and health insurance issuers generally may not, under Federal law, restrict

benefits for any hospital length of stay in connection with childbirth for the mother or newborn

child to less than 48 hours following a vaginal delivery, or less than 96 hours following a

cesarean section. However, Federal law generally does not prohibit the mother’s or newborn’s

attending provider, after consulting with the mother, from discharging the mother or her

newborn earlier than 48 hours (or 96 hours as applicable). In any case, plans and issuers may

not, under Federal law, require that a provider obtain prior authorization from the plan or the

insurance issuer for prescribing a length of stay not in excess of 48 hours (or 96 hours).

WOMEN'S HEALTH AND CANCER RIGHTS ACT.

The Women's Health And Cancer Rights Act Of 1998 requires that group health plans and

health insurance issuers providing benefits for a mastectomy must also provide, in connection

with the mastectomy, coverage for (i) reconstruction of the breast on which the mastectomy

has been performed, (ii) surgery and reconstruction of the other breast to produce a

symmetrical appearance, and (iii) prostheses and physical complications of mastectomy,

including lymphedemas, in a manner determined in consultation with the attending physician

and the patient. Such coverage may be subject to annual deductibles and Co-insurance

provisions that are appropriate and consistent with other benefits under the plan.

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QUALIFIED MEDICAL CHILD SUPPORT ORDERS

A Qualified Medical Child Support Order (QMCSO) is an order from a court or state

administrative agency requiring a group health plan to provide benefits to the child of a

participant. An order is qualified if it meets the requirement specified in the Plan document.

The QMCSO must clearly specify:

The name and last known mailing address of the participant and the name and mailing address

of each alternative recipient covered by the order;

A reasonable description of the type of coverage the plan is to provide to each alternate

recipient or the manner in which the coverage is to be determined;

The period to which the QMCSO applies; and

Each health care plan to which the QMCSO applies.

A QMCSO must not require the Plan to provide any type or form of benefit, or any option, not

otherwise provided under the Plan, except to the extent necessary to meet the requirements of

a state law relating to medical child support.

You may request a copy of the Plan’s QMCSO procedures, free of charge, by contacting the

Employee Benefits Department.

HIPAA

A federal law, the Health Insurance Portability and Accountability Act of 1996 (HIPAA), requires

that health plans protect the confidentiality of your private health information. A complete

description of your rights under HIPAA can be found in the Plan’s privacy notice, which was

distributed to you upon enrollment and is available from the Employee Benefits Department or

on our internal website.

This Plan, and the Plan Sponsor, will not use or further disclose information that is protected by

HIPAA (“protected health information”) except as necessary for treatment, payment, health

plan operations and plan administration, or as permitted or required by law. By law, the Plan

has required all of its business associates to also observe HIPAA’s privacy rules. In particular,

the Plan will not, without authorization, use or disclose protected health information for

employment-related actions and decisions or in connection with any other benefit or employee

benefit plan of the Plan Sponsor.

Under HIPAA, you have certain rights with respect to your protected health information,

including certain rights to see and copy the information, receive an accounting of certain

disclosures of the information and, under certain circumstances, amend the information. You

also have the right to file a complaint with the Plan or with the Secretary of the U.S.

Department of Health and Human Services if you believe your rights under HIPAA have been

violated.

This Plan maintains a privacy notice, which provides a complete description of your rights under

HIPAA’s privacy rules. For a copy of the notice, please contact the Employee Benefits

Department toll-free at (888) 332-4894. If you have questions about the privacy of your health

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information or you wish to file a complaint, please contact the Privacy Office toll-free at (866)

708-5653 or email [email protected]

CHANGES TO THE PLAN

Raley’s has modified the coverage provisions of its health plan from time to time in the past and

retains the right to modify or discontinue the Plan in the future. It does not guarantee that you

will be eligible for the benefits described in this Summary Plan Description for the duration of

your employment. The benefits described are those currently available under the Plan. The

Company will notify you of any changes in accordance with applicable law.

ERISA INFORMATION

As a participant in the Raley’s Health and Welfare Plan, you are entitled to certain rights and

protection under the Employee Retirement Income Security Act of 1974 (ERISA). ERISA provides

that all plan participants shall be entitled to:

Receive Information About Your Plan and Benefits

Examine, without charge, at the office of the Plan Administrator and at other specified

locations, such as worksites and union halls, all Plan documents including insurance

contracts, collective bargaining agreements and a copy of the latest annual report (Form

5500 series) filed by the Plan with the U.S. Department of Labor and available at the

Public Disclosure Room of the Employee Benefits Security Administration.

Obtain, upon written request to the Plan Administrator, copies of all Plan documents

including insurance contracts and collective bargaining agreements, and copies of the

latest annual report (Form 5500 series) and updated Summary Plan Description. The

Plan Administrator may make a reasonable charge for the copies.

Receive a summary of the Plan’s annual financial report. The Plan Administrator is

required by law to furnish each participant with a copy of this Summary Annual Report

(SAR).

Continue Group Health Plan Coverage

Continue health care coverage for yourself, spouse or dependents if there is a loss of

coverage under the Plan as a result of a qualifying event. You or your dependents may

have to pay for such coverage. Review this Summary Plan Description and all Plan

documents on the rules governing your COBRA continuation coverage rights.

Prudent Actions by Plan Fiduciaries

In addition to creating rights for Plan participants, ERISA imposes duties upon the people who

are responsible for the operation of the Plan. These persons, called “fiduciaries” of the Plan,

have a duty to do so prudently and in the interest of you and other Plan participants and

beneficiaries. No one, including your employer, your union, or any other person, may fire you

or otherwise discriminate against you in any way to prevent you from obtaining a benefit or

exercising your rights under ERISA.

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Enforce Your Rights

If your claim for a benefit is denied or ignored, in whole or in part, you have a right to know

why this was done, to obtain copies of documents relating to the decision without charge, and

to appeal any denial, all within certain time schedules.

Under ERISA, there are steps you can take to enforce the above rights. For instance, if you

request a copy of the Plan Document or the latest annual report from the Plan and do not

receive them within 30 days, you may file suit in a Federal court. In such a case, the court may

require the Plan Administrator to provide materials and pay you up to $110 a day until you

receive the materials, unless the materials were not sent because of reasons beyond the

control of the Administrator. If you have a claim for benefits that is denied or ignored, in whole

or in part, you may file suit in a state or Federal court. In addition, if you disagree with the

Plan’s decision or lack thereof concerning the qualified status of domestic relations order or a

medical child support order, you may file suit in Federal court. If it should happen that Plan

fiduciaries misuse the Plan’s money, or if you are discriminated against for asserting your rights,

you may seek assistance from the U.S. Department of Labor, or your may file suit in a Federal

court. The court will decide who should pay court costs and legal fees. If you are successful, the

court may order the person you have sued to pay these costs and fees. If you lose, the court

may order you to pay these costs and fees, for example, if it finds your claim is frivolous.

If you have any questions about your Plan, you should contact the Plan Administrator. If you

have any questions about this statement or about your rights under ERISA or if you need

assistance in obtaining documents from the Plan Administrator, you should contact the nearest

office of the Employee Benefits Security Administration, U.S. Department of Labor, listed in

your telephone directory of the Division of Technical Assistance and Inquiries, Employee

Benefits Security Administration, U.S. Department of Labor, 200 Constitution Avenue N.W.,

Washington, D.C. 20210. You may also obtain certain publications about your rights and

responsibilities under ERISA by calling the publications hotline of the Employee Benefits

Security Administration.

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DEFINITIONS

Allowable Amount:

1. For Physicians:

a. An amount determined by Blue Shield, based upon billed charge data for the same or similar

services submitted to Blue Shield during a period of time determined by Blue Shield, which

physicians who have contracted with Blue Shield are obligated to accept as payment in full for

the service provided;

b. If an amount is not determined as described in subparagraph (a) above, the amount Blue Shield

determines is appropriate considering the particular circumstances and services provided and

which physicians who have contracted with Blue Shield are obligated to accept as payment in

full.

2. For Alternative Care Service Providers:

An amount that Blue Shield determines is appropriate considering the services provided and

which such providers who have contracted with Blue Shield are obligated to accept as

payment in full.

Calendar Year: The twelve (12) months beginning January 1 and ending on December 31.

Co-insurance: The specified ratio of eligible charges shared by the Plan participant and the Plan.

For example, if the Plan covers 90% of eligible charges, the participant pays a 10% co-insurance.

Out-of-Pocket Maximum: The specified maximum the Plan participant must pay in a Plan Year.

Once the co-insurance maximum has been met, the Plan pays 100% of covered services for the

remainder of the Plan Year.

Deductible: The amount of money that a covered person must pay toward eligible medical

expenses before the Plan begins to make payments.

Doctor: A licensed practitioner of the healing arts acting within the scope of the license.

Emergency Admission: An inpatient hospital admission for a condition which, unless promptly

treated on an inpatient basis, would (a) put the patient’s life in danger; or (b) cause serious

damage to a bodily function of the patient.

Eligible Expense: charges for Covered Health Services that are provided while the Plan is in effect, determined as follows:

For Network Benefits: - Eligible Expenses are Based On Contracted rates with the provider.

For Non-Network Benefits: Eligible Expenses are based on negotiated rates agreed to by the non-Network provider and either the Claims Administrator or one of its vendors, affiliates or subcontractors, and the following: - selected data resources which, in the judgment of the Claims Administrator, represent

competitive fees in that geographic area; - fee(s) that are negotiated with the provider; or - Non-Network Reimbursement 60% of the billed charge;

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These provisions do not apply if you receive Covered Health Services from a non-Network

Provider in an Emergency. In that case, Eligible Expenses are the amounts billed by the

Provider, unless Blue Shield negotiates lower rates.

For certain Covered Health Services, you are required to pay a percentage of Eligible Expenses in the form of Co-insurance.

Eligible Expenses are subject to Blue Shield's reimbursement policy guidelines. You may request a copy of the guidelines related to your claim from Blue Shield.

Eligible Hours: Hours that are credited towards benefit eligibility include straight time and

overtime hours worked, hours credited for paid holidays, vacation, jury duty, bereavement and

sick pay.

Home Health Care Agency: Meets one of the following criteria:

1. It is licensed as a home health agency where the home health care is given.

2. It is a home health agency as defined by Medicare.

3. It administers a Home Health Care Plan and meets all of these requirements:

• The person’s doctor certifies that it is a proper provider of home health care.

• It has a full-time administrator.

• It keeps written files of services and supplies furnished to a person.

• Either its staff includes at least one registered nurse (RN) or it has access to nursing care by a

registered nurse.

Hospital: An institution that meets any of these four tests:

1. It is accredited as a hospital under the Hospital Accreditation Program of the Joint

Commission on Accreditation of Hospitals.

2. It is legally operated, is supervised by a staff of doctors, has 24-hour-a-day nursing services,

and complies with the following (a) or (b):

a) It mainly provides general inpatient medical care and treatment of sick and injured persons by

the use of medical, diagnostic and major surgical facilities. All such facilities are in it or under its

control.

b) It mainly provides specialized inpatient medical care and treatment of sick or injured persons by

the use of medical and diagnostic facilities (including X-ray and laboratory).

All such facilities are in it, under its control, or available to it under a written agreement with a

Hospital (as defined above) or with a specialized provider of those facilities.

3. It is an Intermediate Care Facility that provides care and treatment of mental,

psychoneurotic and personality disorders; alcoholism; or drug abuse through one or more

specialized programs and meets all of these tests:

a) It must be staffed by registered graduate nurses and other mental health professionals.

b) Its programs must be supervised by licensed doctors.

c) Each of its specialized programs must:

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a. Provide treatment between 3 and 12 hours per day;

b. Furnish a written, individual treatment plan that states specific goals and objectives;

c. Maintain, at a minimum, ongoing weekly progress notes that demonstrate periodic

review and direct patient evaluation by the attending doctor; and

d. Either be (a) accredited by the Joint Commission on Accreditation of Healthcare

Organizations (JCAHO) to provide the type of specialized program described above; or (b)

licensed, accredited or approved by the appropriate agency in the state in which it is

located to provide the type of specialized program described above.

4. It is an alcoholism, drug abuse or mental illness treatment center that complies with (a), (b),

or (c):

a) It is licensed as a Hospital.

b) It is a facility licensed, certified or approved to provide services for the care and treatment of

alcoholism, drug abuse or mental illness by the appropriate agency of the state in which it is

located.

c) It is accredited as an alcoholism, drug abuse or mental illness treatment center by the Joint

Commission on Accreditation of Hospitals.

Hospital does not include a nursing home. Neither does it include an institution, or part of one,

which: (a) is used mainly as a place for convalescence, rest, nursing care, or for the aged; or (b)

furnishes mainly homelike or custodial care, or training in the routines of daily living; or (c) is

mainly a school.

Inpatient Stay: A Hospital stay for which a room and board charge is made by the Hospital.

Medically Necessary: The service or supply is:

• Consistent with the diagnosis of, and prescribed course of treatment for, the patient’s

condition or mental disorder;

• Supported by evidence based medical research using valid scientific methods that

demonstrate a health benefit from the service, or when none is available based on nationally

accepted standards of care;

• Provided by a licensed provider with the appropriate training and experience for the service;

• Not otherwise excluded in this plan.

Medicare: Title XVII (Health Insurance for the Aged and Disabled) of the United States Social

Security Act, as amended from time to time. There are two forms of coverage under Medicare:

• Part A – The program of Hospital Insurance Benefits for the Aged and Disabled;

• Part B – The voluntary program of Supplementary Medical Insurance Benefits for the Aged

and Disabled; and

• Part D – The voluntary program of Medicare Prescription Drug Improvement and

Modernization Act (Effective January 1, 2006).

Member Doctor: A doctor who is a member of Vision Service Plan.

Definitions

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Member Responsibility: The portion of the deductible that the participant must pay out-of-

pocket on covered health services after the benefit dollars in the HRA are depleted and before

the Health Coverage component begins to pay toward covered health services.

Non-Emergency Admission: A Hospital admission for an Inpatient Hospital Stay that is not

made on an emergency basis.

Non-Preferred Provider: A provider of health care services or supplies that is not under

contract with the Plan as a preferred provider.

Plan Administrator: Raley’s is the Employee Retirement Income Security Act of 1974 (ERISA)

"Plan Administrator." The Plan Administrator is responsible for the overall operation of the

plan. The Plan Administrator has the right to make rules and decisions concerning the

operation of the plan and the eligibility for benefits. The Plan Administrator has the

discretionary authority to interpret the plan and to make benefit determinations, including, but

not limited to, factual determinations. Decisions, interpretations and determinations made by

the Plan Administrator shall be afforded the maximum deference afforded by law.

Plan Year: The twelve (12) consecutive month period ending on December 31 of each year.

Preferred Provider: Health care professionals (for example, physician, medical specialists and

hospitals) who are in contract with the Plan and have agreed to discount their fees in exchange

for your participation in the program.

Preferred Provider Organization: A group of hospitals and physicians who contract on a fee-for-

service basis with employers, insurance plans, or other third party administrators to provide

comprehensive medical services.

Primary Care Physician: A General or Family Practitioner, Internist, or Pediatrician who is

responsible for the initial and primary care you receive, maintaining the continuity of care, and

initiating referrals to a specialist.

Registered Domestic Partner: A person who has a valid registered domestic partnership with a

covered employee and meets the following criteria:

• Each are eighteen (18) years of age or older in a committed same-sex relationship; or

• If in a committed opposite-sex relationship, either the employee or the domestic partner is

age 62 or older.

Service Area: The geographical area within which health care services and supplies are

furnished to covered persons by providers.

Sickness: Any disorder of the body or mind of a covered person, but not an injury; pregnancy of

a covered person, including childbirth, miscarriage or abortion.

Spouse: A person who is lawfully married to a covered employee under the laws of the state in

which they reside.

Surgical Procedure: This means cutting, suturing, treatment of burns, correction of fracture,

reduction of dislocation, manipulation of joint under general anesthesia, electrocauterization,

Definitions

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tapping (paracentesis), application of plaster casts, administration of pneumothorax,

endoscopy or injection of sclesoring solution.

Plan Directory

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PLAN DIRECTORY

Official Plan Name

Raley’s Health and Welfare Plan

Employer Number

94-1316611

Plan Number

501 – Medical, Dental, Prescription, Vision,

and Life Insurance

Effective Date of Plan

May 1, 1985

Summary Plan Description

Revised January 1, 2014

Plan Year

January 1 through December 31

Type of Plan

Health and Welfare Benefit Plan

Plan Sponsor

Raley’s

500 W. Capitol Avenue

West Sacramento, CA 95605

(916) 373-3333

Agent for Service of Legal Process

General Counsel

Raley’s

500 W. Capitol Avenue

West Sacramento, CA 95605

(916) 373-3333

Plan Costs

Paid with a combination of Employer and

Employee contributions

Plan Benefits Administered Through:


50 Beale Street

San Francisco, CA 94105

(800) 358-9556

blueshieldca.com

BCBS of Nevada

P.O. Box 5747

Denver, CO 80217

(800) 358-9556

blueshieldca.com

Kaiser Foundation Health Plan

1950 Franklin Street

Oakland CA, 94612

(800) 464-4000

kaiserpermanente.org

Delta Dental of California

100 First Street

San Francisco, CA 94105

(800) 765-6003

deltadentalca.org

DeltaCare USA

PO Box 1810

Alpharetta, GA 30023

(800) 422-4234

deltadentalca.org

ComPsych Guidance Resources

(866) 379-0893

guidanceresources.com

Principal Life Insurance Company

711 High Street

Des Moines, IA 50392-002

(800) 245-1522

www.principal.com

Vision Service Plan

3333 Quality Drive

Rancho Cordova, CA 95670

(800) 877-7195

vsp.com

75

Employee Benefits Department

PO Box 15618

Sacramento, CA 95852

[email protected]

888-332-4894

mailto:[email protected]

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