UFCW LOCAL 1776 and PARTICIPATING EMPLOYERS                                   HEALTH and WELFARE FUND

 

Benefits At A Glance - Option B

Benefits	Amount	Who's Covered
Dental
Participating Dentists	No co-pay for routine care; limited patient co-payment for more extensive care	Participant Only
Non-Participating Dentists	Reimbursement based on fee schedule	Participant Only
Vision Care (provided by GVA)
Exam	100% once every 12 months	Participant Only
Basic Lenses	100% once every 24 months	Participant Only
Frames	$25 allowance once every 24 months	Participant Only
OR Contact Lenses	$75 allowance once every 12 months instead of all other vision care benefits	Participant Only
Medical Coverage
Personal Choice - Plan B	Preferred (Personal Choice Network or Blue Card PPO Program)	Non- preferred
Deductible	None	$350		Participant Only
Maximum out-of-pocket	$2,500	$5,000		Participant Only
Lifetime Maximum*	$250,000 combined in & out-of-network			Participant Only
Hospital Care: Inpatient Outpatient	80%	65% of covered expenses after deductible		Participant Only
Emergency Room	$50 co-pay waived (if admitted)	$50 co-pay( waived if admitted)		Participant Only
Surgery: In-hospital Same day SPU	80%	65% of covered expenses after deductible		Participant Only
Office Procedure	$15 co-pay	65% of covered expenses after deductible		Participant Only
Lab and X-Ray	80%	65% of covered expenses after deductible		Participant Only
Doctor Office Visits	$15 co-pay	65% of covered expenses after deductible		Participant Only
Preventive Care	$15 co-pay	65% of covered expenses after deductible		Participant Only
Pre-certification penalty
Inpatient admission	$1,000 reduction in benefits	$1,000 reduction in benefits		Participant Only
All other services requiring pre-certification	20% reduction in benefits	20% reduction in benefits		Participant Only
Prescriptions	Not applicable	65% of covered expenses after $350  deductible		Participant Only
Exclusions	Mental, Nervous, Drug & Alcohol benefits			Participant Only
* Lifetime maximum includes benefits paid under the Fund for Mental, Nervous, Drug and Alcohol.
Benefits	Amount		Who's Covered
Mental, Nervous, drugs & Alcohol- Inpatient/Outpatient Coverage	Mental Health Consultants, INc. Preferred Provider	Non-preferred Provider	Participant Only
Inpatient	100%	25% of allowed changes after $100 deductible	Participant Only
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	Participant Only
IF YOU WOULD LIKE TO BE COVERED UNDER OPTION B, YOU MUST COMPLETE AND RETURN THE PLAN SELECTION FORM WITHIN 60 DAYS OF THE DATE YOU BECOME ELIGIBLE FOR BENEFITS.  IF YOU DO NOT RETURN THE PLAN SELECTION FORM WITHIN 60 DAYS, YOU WILL AUTOMATICALLY BE COVERED UNDER OPTION A.