Newspaper Guild of New YorkThe New York Times

Benefits Fund • Pension Plan • Scholarship Fund

1501 Broadway, Suite 1724 • New York, NY 10036Phone (646) 237-1670 • Fax (212) 395-9299

!"#$%&%"'()*+,-(./(!"#(0.'1(2((34"(!"#(0.'1(3+5"$(6"!"/+3$(/*!-(

$*55&'0(./(5&3"'+&,(5.-+/+7&3+.!$(/.'('"3+'"-("5%,.0""$(&)"$(89(&!-(.:"'(

&!-(!.3+7"(3.(%&'3+7+%&!3$((

(;%(!?@(9ABC(D("+!C(BE2EAFGAG9H(

!"#$%&'!!"%(%)*%+!,,-!,./0!

"%#+!1#+$2(23#4$'!!54! "%(%)*%+! /6-! ,./0-! $7%! 8+9:$%%:! ;:3#3%+! ?92@&! ;! A;+B! C! 87%! =%>! A;+B!82)%:! D%4%2@@! P;! (5=>=RIMI>J(%L?RL=MO(!N!3+%:(+23$2;4!&+9P!3+;P+#):X! !1+2;+!O9$7;+2Y#$2;4(!T;:$! ;2$7;9$! 3+2;+! #9$7;+2Y#$2;4! #$! #! +%$#2@! 37#+)#(LX!Z;>%R%+-! :;)%! &+9P:! #+%! ;4@L! (;R%+%&! !L;9+!2@@!:$#+$!#!+%R2%>!$7#$!$L32(#@@L!$#B%:!$>;!$;!!)#L!$#B%!@;4P%+X!D;$7!L;9!#4&!L;9+!37L:2(2#4!>2@@!*%!4;$2+2$24P!;

2  

If  the  prescription  is  approved,  the  letter  will  tell  you  the  length  of  your  coverage  approval.   If  the  prescription  is  denied,  the  letter  will  include  the  reason  for  coverage  denial  and  instructions  on  how  to  submit  an  appeal,  if  you  choose  to  do  so.  If  you  want  the  prescription  immediately  without   waiting   for   the   prior   authorization,   you   will   have   to   pay   the   full   retail   price   at   the  pharmacy.   If   the   prescription   is   approved,   your   claim   should   be   sent   to   Express   Scripts   for  reimbursement.    Step  Therapy   For  certain  prescription  drugs  to  be  covered,  the  Plan  requires  covered  individuals  with  certain  conditions  –   including  high  blood  pressure,  nasal  allergies  or  acid  reflux  –  to  try  effective  and  more  affordable  prescription  drugs  first  before  “stepping  up”  to  more  expensive  drugs.    

• Step  1  drugs  –  These  front-‐line  drugs  are  generic  and  sometimes  lower-‐cost  brand  name  drugs  that  have  generally  proven  to  be  safe,  effective  and  affordable.  In  most  cases  you  should  try   these  drugs   first  because  they  usually  provide  the  same  health  benefit  as  a  more  expensive  drug,  at  a  lower  cost  to  you  and  the  Plan.    

• Step   2   and   Step   3   drugs   –   Second-‐line   drugs   are   brand   name   alternative   drugs   that  generally  are  necessary   for  only  a  small  number  of  patients   for  whom  front-‐line  drugs  have  failed.  Third-‐line  drugs  are  the  most  expensive  option  and  have  not  shown  greater  clinical  efficacy  than  lower  cost  drugs.  

 The  Plan’s   step   therapy   requirements  have  been  developed  and  are  updated   regularly  under  the   guidance   and   direction   of   licensed   physicians,   pharmacists   and   other   medical   experts.  Together  with   Express   Scripts,   they   review   the  most   current   research  on   thousands  of   drugs  tested   and   approved   by   the   FDA   for   safety   and   effectiveness.   Only   some   medications   are  subject  to  the  step  therapy  requirements,  and  the  prescription  drugs  that  are  may  change  from  time  to  time.  Your  pharmacist  can  tell  you  if  your  prescription  requires  step  therapy.  Or,  at  any  time  you  can   find  out  yourself  by   logging   in   to  www.express-‐scripts.com  and  clicking  “Price  a  Medication.”    With   step   therapy,   more   expensive   brand-‐name   drugs   are   usually   covered   as   second-‐line  alternative  drugs  if  any  of  the  following  applies:      

• You  have  already  tried  the  generic  drugs  covered  in  the  step  therapy  program  and  they  were  unsuccessful.    

• You  cannot  take  a  specific  generic  drug  (for  example,  because  of  a  documented  allergy).  • Your  physician  demonstrates,  for  medical  reasons,  that  you  need  a  brand-‐name  drug.  

 If  one  of  these  situations  applies  to  you,  your  physician  may  request  an  override  from  Express  Scripts,  allowing  you   to   take  a   second-‐line  prescription  drug.   If   the  override   is  approved,  you  will  pay  the  appropriate  copay  for  the  drug.  

3  

If  your  physician’s  request  for  an  override  is  denied,  you  may  follow  the  appeals  process.  If  you  choose   not   to   appeal   or   your   appeal   is   denied,   you   can   talk   to   your   physician   again   about  prescribing  one  of  the  front-‐line  drugs  covered  by  the  step  therapy  program.  Or  you  can  choose  to  pay  the  full  price  for  the  drug.    Drug  Quantity  Management    The  drug  quantity  management  program  helps  make   the  use  of   prescription  drugs   safer   and  more  affordable  by  limiting  the  quantity  dispensed  for  certain  medications.    This  provides  the  right   amount   to   take   the   daily   dose   considered   safe   and   effective,   according   to   the  recommendations  of  the  U.S.  Food  and  Drug  Administration  (FDA).    For  more  information  or  a  list  of  drugs  that  are  subject  to  quantity  limits,  you  may  call  Express  Scripts  at  (866)  544-‐2926.    3.  Special  Enrollment  Right    Normally  you  can  only  change  your  coverage  elections  during  open  enrollment   (which  begins  February  15th  each  year,  with  changes  effective  April  1st).    However,   if  this  change  results   in  a  significant  increase  in  the  cost  of  your  coverage  within  the  meaning  of  the  tax  law,  you  may  be  permitted  to  drop  your  coverage  effective  February  1,  2018.    Contact  the  Fund  Administrator  at  (646)  237-‐1670  immediately  if  you  wish  to  do  so.    Please   place   this   information  with   your   Summary   Plan   Description   document   for   permanent  reference.     If   you  have  any  questions   concerning   the   changes   summarized  above,  please   call  the  Fund  Administrator  at  (646)  237-‐1670.    

        Sincerely,    

        BOARD  OF  TRUSTEES  OF  THE           NEWSPAPER  GUILD  OF  NEW  YORK  –    

THE  NEW  YORK  TIMES  BENEFITS  FUND  

4  

ACA Section 1557 Notice of Nondiscrimination

The Newspaper Guild of New York – The New York Times Benefits Plan (“the Plan”) complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. The Plan does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex.

The Plan:

• Provides free aids and services to people with disabilities to communicate effectively with us, such as: • Qualified sign language interpreters • Written information in other formats (large print, audio, accessible electronic

formats, other formats)

• Provides free language services to people whose primary language is not English, such as: • Qualified interpreters • Information written in other languages

If you need these services, contact the Fund Administrator at (646) 237-1670

If you believe that the Plan has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with:

Robert Costello C&R Consulting, Inc. 1501 Broadway, Suite 1724 New York, NY 10036

You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, Robert Costello is available to help you.

You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:

U.S. Department of Health and Human Services 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C. 20201 1-800-368-1019, 800-537-7697 (TDD)

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

5

ATTENTION: FREE LANGUAGE ASSISTANCE

This chart displays, in various languages, the phone number to call for free language assistance services for individuals with limited English proficiency.

Language Message About Language Assistance

1. Spanish ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 212-924-2473

2. Chinese

注意：如果您使用繁體中文，您可以免費獲得語言援助服務。請致電 212-924-2473

3. French ATTENTION : Si vous parlez français, des services d'aide linguistique vous sont proposés gratuitement. Appelez le 212-924-2473

4. Italian ATTENZIONE: In caso la lingua parlata sia l'italiano, sono disponibili servizi di assistenza linguistica gratuiti. Chiamare il numero 212-924-2473

5. German ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: 212-924-2473

6. Tagalog PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa 212-924-2473

7. Arabic ةظوحلم: اذإ تنك ثدحتت ركذا ،ةغلال نإف تامدخ ةدعاسمال ةیوغلال رفاوتت كل ناجمالب. لصتا مقرب 212-924-2473

8. Korean

주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수 있습니다.

212-924-2473 번으로 전화해 주십시오.

9. Russian ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните 212-924-2473

10. Polish UWAGA: Jeżeli mówisz po polsku, możesz skorzystać z bezpłatnej pomocy językowej. Zadzwoń pod numer 212-924-2473

11. Urdu 2473-924-212 نیرک رادربخ: رگا پآ ودرا ےتلوب ،نیہ وت پآ وک نابز یک ددم یک تامدخ تفم نیم بایتسد نیہ ۔ الک

12. Yiddish ביוא ריא טדער שידיא, ןענעז ןאהראפ ראפ ךייא ךארפש ףליה סעסיוורעס יירפ ןופ לאצפא. טפור -1 212-924-2473 םאזקרעמפיוא:

13. Bengali লয্ করনঃ যযদ আযিন বাাংলা, কথা বললত িাল রন, তালেল য নঃখরচায় ভাষা সোয়তা যিলরষবা

উিল আআছ। আ ফান করন 212-924-2473

14. French Creole (Haitian)

ATANSYON: Si w pale Kreyòl Ayisyen, gen sèvis èd pou lang ki disponib gratis pou ou. Rele 212-924-2473

15. Portuguese ATENÇÃO: Se fala português, encontram-se disponíveis serviços linguísticos, grátis. Ligue para 212-924-2473

THIS PAGE INTENTIONALLY LEFT BLANK