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UFCW LOCAL 1776 and
PARTICIPATING EMPLOYERS HEALTH and WELFARE FUND |
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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 |
| Deductible | None | $250 | |
| Maximum out-of-pocket | $500 | $2,500 | |
| Lifetime Maximum * | $1,000,000 combined in& out of network | ||
| *Lifetime maximum includes benefits paid under the Fund for Mental, Nervous, Drug and Alcohol. | |||
| Hospital Care: | |||
| Inpatient | 90% | 90% of covered expenses after | deductible |
| Outpatient | 90% | 80% of covered expenses after | deductible |
| Emergency Room | $35 co-pay (waived if admitted) |
$35 co-pay (waived if admitted) | |
| Surgery: | |||
| In-hospital | 90% | 80% of covered expenses after | deductible |
| Same Day SPU | 95% | 90% of covered expenses after | deductible |
| Office Procedure | $5 co-pay | 80% of covered expenses after | deductible |
| Lab and X-Ray | 90% | 80% of covered expenses after | deductible |
| Doctor Office Visits | $5 co-pay | 80% of covered expenses after | deductible |
| Preventive Care | $5 co-pay | 80% 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 | |||
| Mental,
Nervous, Drug & Alcohol |
Mental Health Consultants,
Inc. Preferred Provider |
Non-preferred Provider | Participants Only |
| 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 Only | ||
| 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 Only | ||
| 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 | |
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Vision Care |
Participants Only | ||
| 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 | ||
| Life Insurance | $3,000 | Participant Only | |
| Accidental Death & Dismemberment | $3,000 | Participant Only | |