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UFCW LOCAL 1776 and
PARTICIPATING EMPLOYERS HEALTH and WELFARE FUND |
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The Fund provides health insurance for hospitalization, doctors' visits, and certain other medical care for you through the Personal Choice Program (or if you live outside the Personal Choice Preferred Provider Network area, through the Preferred Provider Organization Program) administered by the QCC Ins. Co., a subsidiary of Independence Blue Cross ("IBC"). The Personal Choice Program is structured as a Preferred Provider Organization (PPO), as described in further detail in this section. If you are covered under any other medical plan, check the section titled "Coordination of Benefits" to see how you should submit your medical claims. This section summarizes the current provisions of the Personal Choice Program. As a summary, it cannot contain all the details and provisions of the program. The underlying documents with respect to the program are incorporated by reference as if fully set forth in this booklet. If there are any differences between the benefit descriptions set forth in this booklet and the underlying documents, the underlying documents prevail. If you wish to review the underlying documents, please contact the Fund office. For further details about specific coverages, you should contact the IBC/UFCW Local 1776 Dedicated Customer Service Unit at 1-800-335-9596. Personal Choice Preferred Provider Network Personal Choice has a selected group of physicians, hospitals and other ancillary providers to provide most of the covered medical services described in this booklet. A list of these participating providers can be found in the Personal Choice doctor and hospital directory, which will be furnished to you automatically. You may also visit IBC's web site at www.ibx.com for provider information online. You may choose to receive medical care from any preferred provider. When you use preferred providers, the care you receive will be monitored to ensure that it is the most appropriate and cost-effective treatment required for your particular medical condition. You may receive care from any preferred provider without a referral from a primary care physician. Utilization of preferred providers is totally voluntary on your part. However, if you use a preferred provider, you will realize the following advantages:  Preferred providers will file the claim for you. Preferred providers will accept payment for covered
services directly from Personal Choice, along with your co-payment. You will not be billed for the balance of any covered expenses
in excess of the coinsurance amounts. Your out-of-pocket costs for covered services provided by
a preferred provider will be less than your out-of-pocket costs for
the same services provided by a non-preferred provider.
Personal Choice preferred providers will take care of any
required pre-certification for you.In order to encourage utilization of the Personal Choice Preferred Provider Network, there are separate benefit levels for using preferred and non-preferred providers. The benefits for using preferred providers are generally higher than those for using non-preferred providers. The benefit amounts and limits for covered services by both preferred and non-preferred providers are described in the section titled "What the Plan covers." Preferred providers have an agreement with Independence Blue Cross to accept payment for covered services based on a pre-determined fee schedule. If you use preferred providers, the Personal Choice covered expenses will be the amount determined under the agreement between the provider and Independence Blue Cross. You will not be responsible for any charges which exceed the preferred provider's fee schedule. When you use a non-preferred provider, however, Independence Blue Cross determines the amount that Personal Choice will treat as covered expenses. Any difference between the Personal Choice covered expenses and the non-preferred provider's actual charge will be your responsibility, and the provider may bill you for this balance. |