UFCW LOCAL 1776 and PARTICIPATING EMPLOYERS
HEALTH and WELFARE FUND

Who Provides My Benefits ?

The Fund provides health insurance benefits for hospitalization, doctor visits, and certain other medical care through the Personal Choice Program (or if you or your eligible dependents 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. Independence Blue Cross administers the Personal Choice Program and the Preferred Provider Organization Program and generally makes determinations with respect to claims for benefits. The address is:

Independence Blue Cross
1901 Market Street
Philadelphia, PA 19103
Participants who are eligible to participate in the UFCW Local 1776 and Participating Employers Flexible Benefits Plan may elect to forego their medical coverage under the Personal Choice Program and instead elect medical coverage under either the Keystone Point of Service Program, which is provided under a group contract with Independence Blue Cross, or the Dual Income Option, which is a self-insured program provided by the Fund.

The Fund provides life insurance and accidental death and dismemberment benefits through an insurance policy purchased from Standard Insurance Company. The address is:

Standard Insurance Company
460 East Swedesford Road, Suite 1090
Wayne, PA 19087

The Plan pays directly for, or self-insures, other benefits including dental, vision, prescription drugs, disability, mental health treatment, child care, physical fitness and education. The Board has contracted with outside providers to process the claims for certain of these benefits, including prescription drugs, mental health treatment, child care, and vision, as described in the appropriate sections of this booklet. When you submit a claim for a charge for these services, the applicable provider is responsible for following the schedule of benefits established by the Board of Trustees and making payment in accordance with that schedule. The Fund pays these providers a fee to perform these administrative services. The names and addresses of the providers that the Board of Trustees has hired to administer these benefits are:

PRESCRIPTION BENEFITS: National Prescription Administrators, Inc. 711 Ridgedale Avenue East Hanover, NJ 07936	MENTAL HEALTH BENEFITS: Mental Health Consultants, Inc. 2500 York Road Suite 110 Jamison, PA 18929
CHILD CARE BENEFITS: Time for Tots, Inc./Tot Time P.O. Box 796 Plymouth Meeting, PA 19462-0796	VISION BENEFITS: Group Vision Associates 2811 Lord Baltimore Drive Baltimore, MD 21244

If you disagree with an action taken or a final decision made by any provider that administers your benefits, you should write to the Fund Administrator to request a review of the provider's action or decision, as described in the section titled "Appealing a Denied Claim." (You must also follow the claims procedure to dispute a decision made by the Fund about any of your benefits.)