Page 36 - 2013 Wexford CCU PLAN DOC 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.
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 007015454/00 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
09/01/2013 Insurer.
See Plan/SPD See Plan/SPD See Plan/SPD
GROUP DENTAL BLUE CROSS BLUE 007015454/00 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
09/01/2013 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 007015454/00 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
materials
materials
benefit
09/01/2013 provided by provided by materials
INSURER/CLAIMS Insurer. Insurer. provided by
ADMINISTRATOR Insurer.
See Plan/SPD See Plan/SPD See Plan/SPD
SHORT-TERM SUN LIFE FINANCIAL 231961 and Certificates and Certificates and Certificates
DISABILITY BENEFITS of Insurance and of Insurance and of Insurance
INSURER/CLAIMS other benefit other benefit and other
materials
benefit
materials
09/01/2013 ADMINISTRATOR provided by provided by materials
Insurer. Insurer. provided by
Insurer.
See Plan/SPD See Plan/SPD See Plan/SPD
LONG-TERM SUN LIFE FINANCIAL 231961 and Certificates and Certificates and Certificates
DISABILITY BENEFITS of Insurance and of Insurance and of Insurance
INSURER/CLAIMS other benefit other benefit and other
benefit
materials
materials
09/01/2013 ADMINISTRATOR provided by provided by materials
Insurer. Insurer. provided by
Insurer.

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