United Food & Commercial Workers

Unions and Employers

Midwest Health and Pension Funds

UFCW Calumet Region Insurance Fund

Summary of Benefits

The following chart highlights key features of your Plan.

Comprehensive Medical Benefit
Annual Deductible $325
Non-PPO Provider additional Annual Deductible $50
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, including Annual Deducible
Annual additional out-of-pocket maximum for Non-PPO Providers $250, 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
Preventive care Plan pays first $50 per calendar year (expenses in excess of $50, paid at 80% after Annual Deductible)
Seasonal Flu Shot 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%
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 drug
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

 

(Updated 01/13/17)