Page 39 - KCCU Health & Welfare SPD
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APPENDIX A
BENEFIT PROGRAMS OFFERED: MEDICAL/PRESCRIPTION DRUG, DENTAL, VISION, SHORT-TERM DISABILITY
INSURANCE COVERAGE, LONG-TERM DISABILITY INSURANCE COVERAGE, GROUP TERM LIFE INSURANCE,
ACCIDENTAL DEATH & DISMEMBERMENT INSURANCE COVERAGE.
BENEFIT PROGRAM/ NAME OF INSURER/ POLICY OR CLAIMS
BENEFITS
EFFECTIVE DATE CLAIMS CONTRACT PROVIDED ELIGIBILITY PROCEDURE
OF COVERAGE ADMINISTRATOR NUMBER(S) & BENEFITS
See Plan/SPD See Plan/SPD See Plan/SPD
GROUP MEDICAL BLUE CROSS BLUE 007013426/00 and Certificates and Certificates and Certificates
INSURANCE SHIELD OF 00 of Insurance and of Insurance and of Insurance
MICHIGAN other benefit other benefit and other
benefit
materials
materials
PPO provided by provided by materials
INSURER/CLAIMS Insurer. Insurer. provided by
ADMINISTRATOR
01/01/2014 Insurer.
See Plan/SPD See Plan/SPD See Plan/SPD
GROUP DENTAL BLUE CROSS BLUE 007013426/00 and Certificates and Certificates and Certificates
INSURANCE SHIELD OF 00 of Insurance and of Insurance and of Insurance
MICHIGAN other benefit other benefit and other
materials
benefit
materials
01/01/2014 provided by provided by materials
INSURER/CLAIMS Insurer. Insurer. provided by
ADMINISTRATOR Insurer.
See Plan/SPD See Plan/SPD See Plan/SPD
GROUP VISION BLUE CROSS BLUE 007013426/00 and Certificates and Certificates and Certificates
BENEFITS SHIELD OF 00 of Insurance and of Insurance and of Insurance
MICHIGAN other benefit other benefit and other
(VSP/BLUE VISION) materials materials benefit
01/01/2014 provided by provided by materials
Insurer. Insurer. provided by
INSURER/CLAIMS Insurer.
ADMINISTRATOR
See Plan/SPD See Plan/SPD See Plan/SPD
SHORT-TERM CUNA MUTUAL 021-0898-4 and Certificates and Certificates and Certificates
DISABILITY BENEFITS GROUP of Insurance and of Insurance and of Insurance
other benefit other benefit and other
materials materials benefit
01/01/2014 INSURER/CLAIMS provided by provided by materials
ADMINISTRATOR Insurer. Insurer. provided by
Insurer.
See Plan/SPD See Plan/SPD See Plan/SPD
LONG-TERM CUNA MUTUAL 021-0898-4 and Certificates and Certificates and Certificates
DISABILITY BENEFITS GROUP of Insurance and of Insurance and of Insurance
other benefit other benefit and other
materials materials benefit
01/01/2014 INSURER/CLAIMS provided by provided by materials
ADMINISTRATOR Insurer. Insurer. provided by
Insurer.
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