Summary of Benefits
		Election of Coverage and Eligibility Provisions
		Comprehensive Medical Benefits
		Income Protection Benefit
		Dental Benefit
		Dental Schedule of Benefits
		Prescription Drug Benefit
		Vision Benefit
		Life Insurance & AD&D Benefit
		General Exclusions and Limitations

		Summary of Benefits
		Election of Coverage and Eligibility Provisions
		Comprehensive Medical Benefits
		Prescription Drug Benefit
		General Exclusions and Limitations

		How to File a Claim
		When to Call Us
		Request an ID Card
		Continuation of Coverage (COBRA)
		Claim Appeal Procedure
		Coordination of Benefits
		Privacy Practices
		Health Benefits Plan Claim Procedures
		Summary of the Cafeteria Plan
		Forms & Publications

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COVERAGE FOR RETIREES

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Options for Retiree Coverage Plan M Benefits Who is Eligible When to Apply How to Apply	Coverage Effective Date Payment Methods Coverage Termination Additional Information

Your Options for Retiree Health Coverage

When an active employee-member covered by this Health Plan retires, there are two potential options for continuation of health coverage:

• The first is that the employee-member and any covered family member may exercise his or her rights to continuation coverage by making self-payments under the federal law commonly referred to as COBRA. COBRA coverage usually lasts up to 18 months.
• Another option is the Fund’s Plan M for pre-Medicare retirees. This page provides some information on Plan M. Get more detailed information by contacting the Benefits Fund Office or by requesting a Plan M booklet (Summary Plan Description) be sent to you.

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Benefits Under Plan M for Retirees

The Health Fund and the Pension Fund Boards of Trustees have adopted this optional health plan for retirees who are not yet eligible for Medicare. The plan provides some coverage during the time between retirement and eligibility for Medicare coverage (generally, age 65). If you elect this optional coverage, you are responsible for making the monthly payment.

Plan M pays limited medical benefits. The lifetime maximum benefit payable is $25,000. The maximum annual prescription drug benefit payable is $4,000. Dental, Vision and Life Insurance benefits are not included.

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Who is Eligible

You may elect the retiree health plan for yourself and/or for your eligible dependents if:

• at the time of your termination of active employment, you were covered under one of the health plans for active employee-members of the UFCW Midwest Health Benefits Fund; and
• you are now receiving or soon will be receiving a pension from a UFCW pension fund.

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When to Apply

At the time you leave active employment, you have the option to continue your coverage by making self-payments under COBRA directly to the Benefits Fund Office. Contact the Billing Department at the Benefits Fund Office for COBRA information and rates.

When your COBRA continuation coverage period ends, you may then apply for Plan M. Or you may apply for Plan M immediately after leaving employment.

You must apply for Plan M between the time you leave employment or stop making COBRA payments and 60 days after receipt of your first pension benefit. Your application period ends 60 days after receipt of your first pension benefit.

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How to Apply

To apply for Plan M, obtain an Application for Plan M—Optional Retiree Health Benefits Plan form. Return the completed application to the Benefits Fund Office along with a check or money order for the first monthly payment:

Retiree Only or Spouse Only Coverage	$552 per month
Family Coverage (retiree, spouse and any qualified dependents)	$845 per month

The monthly cost for Plan M may be changed from time to time. The above rates are effective 08/01/2007.

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Coverage Effective Date

After verification of your application, coverage will become effective on the first day of the month for which you receive, or are eligible to receive, your first pension benefit.

A physical examination is not required in order to obtain coverage.

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Payment Methods

The monthly payment will be deducted from your pension benefit.

If you are not receiving a pension from us or if the amount of your pension is less than the monthly payment, you may:

• have the payment sent to us automatically each month by electronic deduction from your bank account. Obtain an Authorization Agreement for Pre-Authorized Payments. Return the completed form to the Benefits Fund Office.
• send us a check or money order by the first of every month. You are responsible for making timely and accurate payments. Late payers will be terminated with no opportunity for reinstatement.

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Coverage Termination

Coverage will be terminated when:

• you, your spouse or your dependent become eligible for Medicare or become covered under any other group policy or plan as an employee; and/or
• when your dependent is no longer an eligible dependent, as defined in the Health Plan.

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Additional Information

If you have any questions about the coverage provided or about filing a claim for benefits, contact the Claims Department at the Benefits Fund Office.

The Board of Trustees may, at any time, change coverage or contribution levels required for coverage or terminate the retiree coverage portion of the Health Plan.

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