UFCW LOCAL 1776 and PARTICIPATING EMPLOYERS                                   HEALTH and WELFARE FUND

Coordinating With Medicare If you are covered by Medicare and you are not retired, this Plan is the primary plan and Medicare is the secondary plan. If you are over age 65 and elect to continue coverage under this plan, your benefits remain the same as the benefits of active participants who are under age 65, as described in this booklet. If you are no longer employed by a contributing employer, and you are entitled to Medicare on the basis of disability, Medicare is the primary plan, except if the disability is based upon end-stage renal disease. If the disability is based upon end-stage renal disease, the Fund will be primary for 30 months, beginning with the first month in which you receive kidney dialysis and ending on the earlier of the 30th month thereafter or the date you receive a kidney transplant. Coordinating With Third Parties (Subrogation or Reimbursement) The Fund has the right of subrogation or full reimbursement for all costs and benefits paid or incurred, or which will be incurred in the future, when any claim for benefits is filed on your behalf where the event(s) that caused the claim are or may be the fault of, or the claim may be payable by, any other party, including but not limited to Workers’ Compensation, an insurance policy, another benefit plan, or any party that may be responsible for the event(s) related to the claim. In these cases, you must notify the Fund of the existence of any such party and/or the occurrence of any such event(s). You are also obligated to notify the Fund if you receive payment from any party. If you are involved in a lawsuit, insurance claim, other claim or settlement as a result of such events, you must notify the Fund of the name and address of any counsel you retain, insurance adjuster handling the claim, the progress of the case or claim, any settlement offers, trial dates, payments, etc. The Fund is entitled to 100% reimbursement of all costs and benefits, except as may be specifically agreed to by the Fund in writing, when you receive any payment from another party, if the Fund has paid or incurred, or will incur in the future, any such costs and/or benefits. The Fund’s rights of subrogation and reimbursement shall be honored regardless of whether the participant or beneficiary has been, or will be, made whole. So if you submit a claim and receive payment from another party for the same claim or as a result of the injury or illness, you must reimburse the Fund. You must provide the Fund with all documents and information, including but not limited to the name and address of any counsel you retain, insurance adjuster, or other persons, that may be related to the claim and the Fund’s reimbursement right, as requested by the Fund. You may not attempt to prejudice the Fund’s subrogation or reimbursement rights. If you do not honor the Fund’s subrogation or reimbursement rights, the Fund may bring an action against you to recover the costs and benefits paid, and/or you may be denied future benefits to the extent necessary to recover the costs and benefits paid by the Fund. If the Fund denies your future benefits in order to recover the costs and benefits paid by the Fund, your benefits will remain denied until such time as you have provided the Fund with information and documents on denied claims sufficient to fully satisfy your reimbursement obligations to the Fund. If legal action against you is necessary to protect the Fund’s rights, you will also be liable for all costs of collection, including reasonable attorneys’ fees. All disputes concerning reimbursement rights and obligations will be resolved in accordance with the claims review and appeal procedures. In addition, the Fund reserves the right to intervene in any action or to bring an action to protect its reimbursement rights.