UFCW LOCAL 1776 and PARTICIPATING EMPLOYERS
                                   HEALTH and WELFARE FUND
 

Benefits At A Glance

Benefits Amount    Who's Covered
Medical Coverage   
 Personal Choice-Plan A Preferred (Personal Choice Network or Blue Card PPO Program) Non- preferred

Participants  
& Dependents

  
Deductible None    $500  
Maximum out-of-pocket None    $3,000 single/$9,000 family  
Lifetime Maximum * None     $1,000,000  
*Lifetime maximum  includes benefits paid under the Fund for Mental, Nervous, Drug and Alcohol.
Hospital Care:       
Inpatient 100%     70% of covered expenses after deductible
Outpatient 100%     70% of covered expenses after deductible
Emergency Room $100 co-payment (not waived if admitted)      $100 co-payment (not waived if admitted)
Surgery:       
In-hospital 100%    70% of covered expenses after deductible
Same Day SPU 100%    70% of covered expenses after deductible
Office Procedure $10 co-pay    70% of covered expenses after deductible
Lab and X-Ray 100%     70% of covered expenses after deductible
Specialist Office Visits $20 co-pay     70% of covered expenses after deductible
Preventive Care $10 co-pay     70% of covered expenses after deductible
Pre-certification penalty        
Inpatient admission $1,000 reduction in benefits     $1,000 reduction in benefits  
All other services regarding pre-certification 20% reduction in benefits     20% reduction in benefits  
Exclusions Mental, Nervous, Drug &     
  Alcohol and Prescription Drug Benefits     
Benefits Amount    Who's Covered
Medical Coverage
Keystone Point of Service Program (Optional) For a description of this program, refer to the section titled "Keystone Point of Service (KPOS) Program." Participants & Dependents (if eligible under Flexible Benefits Plan)
Dual Income Option (Optional) For a description of this program, refer to the section titled "Dual Income Option." Participants & Dependents (if eligible under Flexible Benefits Plan)
Medical Flexible Spending Account (Optional) For a description of this program, refer to the section titled "Medical Flexible Spending Account." Participants & Dependents (if eligible under Flexible Benefits Plan)
Medical Emergency 100% of UCR if not covered under Personal Choice Participant & Dependents
Allergy Benefit      
Testing $1.25 per test, up to a maximum of 60 tests  Participant & Dependents
Injections $5 per injection, up to 2 injection per visit Participant & Dependents
Serum $3 per c.c. serum 20 % of UCR after $100 of benefits paid in calendar year Participant & Dependents
Benefits Amount    Who's Covered
Mental, Nervous,
Drug & Alcohol		 Mental Health Consultants, Inc.
Preferred Provider		 Non-preferred Provider Participants & Dependents
Inpatient 100% 25% of allowed charges after $100 deductible  
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 remainder  
Dental Participants & Dependents
Participating Dentists No co-pay for routine care; limited patient co-payment for more extensive care    
Non-Participating Dentists Reimbursement based on fee schedule    
Prescription Benefits Participants & Dependents
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
Prescription Incentive Program
Preferred Pharmacy 50% of net savings to Fund    
Non-Preferred Pharmacy 40% of net savings to Fund    
Benefits Amount    Who's Covered

Vision Care
(provided by GVA)

 Participants & Dependents
Exam 100% once every 12 months    
Basic Lenses 100% once every 24 months    
Frames or $25 allowance once every 24 months    
Contact Lenses $75 allowance once every 12 months instead of all other vision care benefits    
Disability Participant Only
Weekly Accident & Sickness  66-2/3% of weekly pay    
Limit 26 weeks    
Workers' Compensation Supplement Worker's Compensation    
Supplementary Benefits up to 66-2/3% of weekly pay    
Limit 26 weeks    
Benefits Amount    Who's Covered
Life Insurance Amount based on years of service Participant Only
Accidental Death & Dismemberment Amount based on years of service  Participant Only
Child Care
Network Centers
Non-Network Center		 Participant pays $6 per child per day
Allowance of $10 per child per day; participant pays remainder 		Participant'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		 Participants & Dependents

Children (after 10 yrs. of service)

Physical Well Being  
Participating Facility $300 allowance per calendar year-single
$500 allowance per calendar year- family		   Participant & Dependents
Non-participating Facility $250 reimbursement per calendar year