Page 41 - 2013 Adv1FCU Health and Welfare SPD

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,
HEALTH REIMBURSEMENT ARRANGEMENT.
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 007018186/00 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
materials
benefit
CDHP w/ HRA provided by provided by materials
INSURER/Claims Insurer. Insurer. provided by
Administrator
01/01/2013 Insurer.
See Plan/SPD See Plan/SPD See Plan/SPD
GROUP DENTAL MET LIFE - SMALL TM- and Certificates and Certificates and Certificates
INSURANCE BUSINESS CENTER 05989325-G of Insurance and of Insurance and of Insurance
other benefit other benefit and other

materials materials benefit
01/01/2013 INSURER/Claims provided by provided by materials
Administrator Insurer. Insurer. provided by
Insurer.
See Plan/SPD See Plan/SPD See Plan/SPD
GROUP VISION BLUE CROSS BLUE 007018186/00 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
01/01/2013 provided by provided by materials
Insurer. Insurer. provided by
INSURER/Claims Insurer.
Administrator

See Plan/SPD See Plan/SPD See Plan/SPD
SHORT-TERM MET LIFE - SMALL TM- and Certificates and Certificates and Certificates
DISABILITY BENEFITS BUSINESS CENTER 05989325-G of Insurance and of Insurance and of Insurance
other benefit other benefit and other

materials materials benefit
01/01/2013 INSURER/Claims provided by provided by materials
Administrator Insurer. Insurer. provided by
Insurer.
See Plan/SPD See Plan/SPD See Plan/SPD
LONG-TERM MET LIFE - SMALL TM- and Certificates and Certificates and Certificates
DISABILITY BENEFITS BUSINESS CENTER 05989325-G of Insurance and of Insurance and of Insurance
other benefit other benefit and other

materials materials benefit
01/01/2013 INSURER/Claims provided by provided by materials
Administrator Insurer. Insurer. provided by
Insurer.

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