UFCW LOCAL 1776 and PARTICIPATING EMPLOYERS
                                   HEALTH and WELFARE FUND
 

Benefits At A Glance

    Benefits         Amount   Who's Covered
Dental
Participating Dentists 		$5 office visit co-pay for routine care; additional patient co-payment for more extensive care Participant & Dependents
Non-Participating Dentists  Reimbursement based on fee schedule Participant  & Dependents
    
Vision Care (provided by GVA)
 Exam  100% once every 12 monthsParticipant & Dependents
 Basic Lenses  100% once every 24 monthsParticipant & Dependents
 Frames  $25 allowance once every 24 monthsParticipant & Dependents
 OR   
Contact Lenses $75 allowance once every 12 months instead of all other vision care benefitsParticipant & Dependents
    
Mental, Nervous,
Drug & Alcohol 		            Mental Health Consultants, Inc.  
  Preferred Provider          Non-preferred           Provider  
Inpatient 100%25% of allowed charges after $100 deductibleParticipant & Dependents
Outpatient

$10 co-pay, up to
50 visits per year.

 50% of allowed charges up to $12.50 per visit after $100 deductible; participant pays remainderParticipant & Dependents
    Benefits         Amount   Who's Covered
Disability     
Weekly accident & Sickness 66 - 2/3 % of weekly pay Participant only
Sickness Limit 26 weeksParticipant only
Workers' Compensation Supplements Workers' CompensationParticipant only
Supplementary Benefits up to Limit 66 - 2/3 % of weekly pay  26 weeklyParticipant only
    
Life Insurance Amount based on years of serviceParticipant only
Accidental Death & Dismemberment Amount based on years of serviceParticipant only
    
Child Care
Network Centers 		Participant pays $6 per child per dayParticipant's Children
Non-Network Centers Allowance of $10 per child per day; participant pays remainderParticipant's Children
Educational Benefit Program $1,000 maximum per calendar year for participants;
$300 maximum per calendar year for dependent children of participants with over 10 years of service		Participant & Dependent Children (after 10 years  of service)
Physical Well Being    
Participating Facility $300 allowance per calendar year - singleParticipant only
Non-participating Facility $250 reimbursement per calendar yearParticipant only
    Benefits         Amount   Who's Covered
Prescription Benefits (OPTIONAL)  
            Deductible $5 co-pay at preferred pharmacies*
$7 co-pay at non-preferred pharmacies*
* Plus the difference between generic and
brand cost if generic equivalent is available		 Participant & Dependents 
Prescription Incentive Program
Preferred Pharmacy  50% of net savings to Fund Participant & Dependents 

Non-Preferred Pharmacy 40% of net savings to Fund 
     
Optional - Keystone Point of Service
If you elect Keystone point of service medical coverage, you must complete and return to Plan Selection Form within 60 days of the date you are notified that you are eligible for benefits.
IMPORTANT: Dependents are only covered if you choose Option III