UFCW Midwest - Midwest Health and Pension Funds

United Food & Commercial Workers

Unions and Employers

Midwest Health and Pension Funds

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)