UFCW LOCAL 1776 and PARTICIPATING EMPLOYERS
                                   HEALTH and WELFARE FUND
 

Benefits At A Glance - Option A

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
Mental, Nervous, Drug & Alcohol - Referral Only
Initial Consultation  100% Participant Only
Inpatient/Outpatient Counseling Not Covered  
Physical Exam
$100 maximum; for participants under 40, once every two years;
for participants 40 or older, once each year		 Participant Only
Child Care
Network Centers Participant pays $6 per child per day Participant's Children
Non-Network Centers 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 dependant children of participants with over 10 years of service Participant & Dependent Children (after 10 yrs. of service)
 
Physical Well Being
Participating Facility $300 allowance
per calendar year		 Participant Only
Non-participating Facility $250 reimbursement
per calendar year		 Participant Only
 

YOU WILL AUTOMATICALLY BE COVERED UNDER OPTION A UNLESS YOU ELECT OTHERWISE. IF YOU WOULD LIKE OPTION B BENEFITS INSTEAD, YOU MUST COMPLETE AND RETURN THE PLAN SELECTION FORM WITHIN 60 DAYS OF THE DATE YOU BECOME ELIGIBLE FOR BENEFITS.