UFCW LOCAL 1776 and PARTICIPATING EMPLOYERS                                   HEALTH and WELFARE FUND

 

Plan Provisions Pre-existing conditions There are no pre-existing condition limitations under the Plan. Deductible amounts The deductible amount is the amount of covered expenses which you are required to satisfy before the Plan will pay any benefits. When you use a preferred provider, there is no deductible - benefits are paid as described in the section titled "What the Plan Covers." When you use a non-preferred provider, you must satisfy a calendar year deductible ($250) before the Plan will pay any benefits for covered services. A deductible will not be applied to any covered person in a calendar year after that person has satisfied the individual calendar year deductible. You are required to satisfy a separate deductible each calendar year, with the following special provision:    Any part of a deductible applied to expenses incurred during the last three months of a calendar year can be carried over and used to satisfy the deductible for the following calendar year. Out-of-pocket maximum The Plan is designed to limit the amount of money you have to pay for your eligible medical expenses in any calendar year. Once you have paid your deductible and any coinsurance amounts up to your out-of-pocket maximum in any calendar year, the Plan will pay 100% of your eligible medical expenses for the remainder of that calendar year. If you use preferred providers, your out-of-pocket maximum for covered services is $500.If you use non-preferred providers, your out-of-pocket maximum for covered services is $2,500. Please note: office visit and emergency room co-payments, ineligible charges, balance bills for amounts that exceed the Personal Choice covered expenses for services by non-preferred providers, and pre-certification penalties do not count towards your out-of-pocket expenses. IMPORTANT: Please review the list of General Exclusions in this booklet. Co-payments and Coinsurance Co-payments and coinsurance are part of the cost of the services and are your responsibility. A co-payment is an amount you pay to a provider at the time of the office or emergency room visit. Your coinsurance amount is the percentage of the Personal Choice covered expenses that you must pay. The coinsurance amount is determined after payment of any co-payment or deductible. The coinsurance amount payable by the Plan is identified in the "Benefits at a Glance" section and in this Medical Coverage section under "What the Plan Covers." Lifetime maximum benefit There is a lifetime maximum of $1,000,000 in benefits. Benefits paid under the Fund for mental, nervous, drug and alcohol disorders will be applied toward this lifetime maximum.