UFCW LOCAL 1776 and PARTICIPATING EMPLOYERS                                   HEALTH and WELFARE FUND

 

Allergy Benefit Plan You are covered for certain expenses for the treatment of allergies. A doctor, or someone directly supervised by a doctor, must provide your care in order for you to receive benefits. If you are covered under any other insurance which may consider allergy related expenses, please check the section titled “Coordination of Benefits” to see how to submit your claims. The Allergy Benefit Plan includes benefits for allergy tests, injections and serum. Here is a summary of what is covered: Testing - The Plan pays a benefit for the initial survey of allergy tests up to a maximum of $75. For each test, the Plan pays $1.25, up to a maximum of 60 tests. Injections - The maximum benefit for one allergy injection is $5.If you have more than one injection during one visit, the maximum for all injections is $10. Serum - The Plan also pays up to $3 for each cubic centimeter (cc) of serum you receive. Once you receive $100 in benefits under the Allergy Benefit Plan as stated above in any calendar year, the Plan pays 20% of the usual, customary and reasonable (UCR) amount for covered services for the remainder of that calendar year. Filing an Allergy Claim To obtain a claim form for the Allergy Benefit Plan, contact the Fund office. You and your doctor must complete this form. If your doctor uses his or her own or a standardized form, be sure to check that it lists exact quantity amounts. Because the Allergy Benefit Plan pays dollar amounts for each test, injection and for the actual volume of serum by vials and ccs per vial, bills with unit amounts or doses do not provide the necessary information. Thus, filing your allergy expenses by using an approved claim form will reduce or eliminate delays in claim payments to you or your doctor. You must file a claim form and return these forms to the Fund office no later than one year from the date of service. Otherwise, the Plan will deny your claim. What is Not Covered The following expenses are not covered under the Allergy Benefit Plan:    Expenses for office visits, consultations, or check-ups.    Diagnostic X-rays or laboratory tests, such as chest X-rays, blood tests (e.g. RAST, RIST, IGE), etc.    Expenses incurred while you are in the hospital.    Services provided at no cost by a government program or agency, including services provided under Medicare.    Services for conditions which are covered under Workers’ Compensation.    Injections and/or medications, other than allergy serum.    Medical conditions other than allergies.    Pulmonary studies (e.g., spirometry, bronchospasm evaluation, peak flow and/or lung capacity tests.)