UFCW Midwest - Midwest Health and Pension Funds

United Food & Commercial Workers

Unions and Employers

Midwest Health and Pension Funds

Summary of Benefits

Your eligible dependents are covered only if you elected Family Coverage and are working enough hours to qualify for full-time coverage.

The following chart highlights key features of your Plan.

Income Protection Benefit
For You
Maximum benefit 55% of weekly earnings up to $250 per week
Maximum payment period 26 weeks
Benefits begin 1st day of an accident
1st day of hospitalization
1st day of outpatient surgery
8th day of sickness
 

Life Insurance Benefit
For You   $15,000
For Your Dependents
Spouse   $2,500
Child 15 days but less than 1 year old $100
  1 year but less than 18 years old $2,500
 

Accidental Death & Dismemberment (AD&D) Benefit
For You Up to $7,500 determined by the severity of the injury
 

Comprehensive Medical Benefit
Annual Deductible:
per person $325
per family $975 (3 persons must each satisfy Annual Deductible)
Non-PPO Provider additional Annual Deductible $50
Non-PPO Provider additional Annual Deductible per family $150 (3 persons must each satisfy additional Annual Deductible)
Non-PPO Hospital Deductible $450
Non-Compliance Deductible $100
Percentage Paid:
PPO hospital Plan pays 85%, you pay 15%
Non-PPO hospital Plan pays 65%, you pay 35%
Non-PPO hospital–emergency Plan pays 80%, you pay 20%
Surgery when required Second Opinion not obtained Plan pays 50%, you pay 50%
Most other covered expenses Plan pays 80%, you pay 20%
Annual out-of-pocket maximum for PPO Providers $2,650 per person, including Annual Deducible
Annual additional out-of-pocket maximum for Non-PPO Providers $250 per person, including additional Non-PPO Provider Annual Deducible
 
The following benefits are paid at 100% by the Plan
and are not subject to the Annual Deductible
Well-child care Plan pays 100% up to age 2
Preventive care for you and your spouse Plan pays first $50 per calendar year (expenses in excess of $50, paid at 80% after Annual Deductible)
Seasonal Flu Shot for you and your spouse Plan pays up to $30 per calendar year
Screening mammogram Plan pays up to $130 per calendar year within age limits (expenses in excess of $130, paid at 80% after Annual Deductible)
Laboratory testing Plan pays 100% for tests that are not done by a hospital outpatient department
 
Covered Services and Supplies with Benefit Limitations
Chiropractic therapy $1,500 per calendar year
Physical therapy, occupational therapy, speech therapy 25 sessions per illness or injury
Cardiac and pulmonary rehabilitation 30 sessions per event
Nutritional counseling 4 counseling sessions per calendar year when certain medical conditions exist
Bariatric treatment and management 6 physician visits and 4 dietician visits per calendar year when history of obesity exists and other conditions are met
Bariatric surgery when provided through a Fund-approved program
Hearing aid $500 in any 5-consecutive year period
Intentionally destructive act Plan pays 50%
Hospital expenses for dental surgery Plan pays 50%
Treatment of varicose veins $2,500 per leg, lifetime maximum
Voice communication machine $7,500, lifetime maximum
 

Prescription Drug Benefit
Percentage paid Plan pays 100% after you pay any co-payment
Dispensing limitation 30-day supply; 90-day supply for maintenance drugs
Co-payment for 30-day supply:
Tier Zero—Preferred Drugs $5
Tier One—most Generic Drugs $12
Tier Two—most Brand Name Drugs $20
Tier Three—Non-Preferred Drugs $33
Co-payment for 90-day supply of a maintenance drug:
Tier Zero—Preferred Drugs $5
Tier One—most Generic Drugs $19
Tier Two—most Brand Name Drugs $40
Tier Three—Non-Preferred Drugs $67

Vision Benefit
Maximum benefit $135 per person per calendar year
Annual deductible none
Percentage paid Plan pays 100% up to maximum benefit

Dental Benefit
Annual Deductible:
Diagnostic and preventive treatment None
All other covered Dental charges, including Orthodontia $50 per person
Percentage paid Plan pays 100% up to scheduled amount
Orthodontia (including TMJ):
Percentage paid Plan pays 50%, you pay 50%
Maximum orthodontia benefit $1,000 per person, lifetime
Dental fees are discounted when you use a dentist who participates in the Labor Dental PPO Network through the Dental Network of America; discounted fees will reduce your out-of-pocket cost after UFCW benefits are paid.

 

(Updated 01/13/17)