UFCW Unions & Participating Employers Health and Welfare Fund

MemberXG Benefit system

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Summary Plan Description (“SPD”) Booklets

SMMs (Benefit Changes) for Plan JS SPD
SMMs (Benefit Changes) to Plan JSS2 SPD
Plan Y SPD
SMMs (Benefit Changes) to Plan Y SPD
Plan Y20 SPD
SMMs (Benefit Changes) to Plan Y20 SPD
Plan Y30 SPD
Plan Y40 SPD
Plan T SPD
SMMs (Benefit Changes) to Plan T SPD
Plan Z SPD

Shoppers Dependent Audit Verification

Dependent Audit Initial Notice and Verification Notice
Frequently Asked Questions

Summary of Benefits and Coverage (“SBC”)

2018 SBC for Plan JS
2018 SBC for Plan JSS2
2018 SBC for Plan Y
2018 SBC for Plan Y20
2018 SBC for Plan Y30

Shoppers Open Enrollment

Plan JSS2 Full Time
Plan JSS2 Part Time
Plans Y and Y20 Full Time
Plan Y Part Time
Plan Y 20 Part Time

Payroll Deduct Plans Y and Y20 PT IND 6-2015
Payroll Deduction Shoppers JSS2 6-2015
Payroll Deduction Shoppers Y and Y20 FT

Shoppers 1st Req Re-Enroll Plan Y PT FAM Spousal Surcharge
Shoppers 1st Req Re-Enroll Plan Y20 FT FAM Spousal Surcharge
Spousal Surcharge Authorization Form 6-2015

UW FT T Z Y Enrollment Form
UW JS JSS S Enrollment Form
UW PT FAM T Z Y Enrollment Form

Downloads (Forms)

Coordination of Benefits Form
HIPAA Authorization Form
LabCorp Facility List (Plan Y20 Participants Only)
Notice of Continuation or Termination of Disability for Group Accident & Sickness Benefits
Subrogation Agreements
Weekly Accident and Sickness Claim Form

Important Notices

Notice of Privacy Practices
Preventive Services Benefits for Plans Y, Y20 and JSS2
Notice of Creditable Coverage

Retiree Information

Non-Discrimination Notice

Useful Links

CareFirst PPO
GVS – Group Vision Service
Kaiser Permanente
Informed Rx
UFCW Local 400
UFCW Local 27
Value Options

Useful Numbers

Catamaran Rx 800-645-3332
Group Dental Service 800-242-0450
InforMed 866-290-8147
Value Options 800-454-8329
Group Vision Service 866-265-4626

For Your Benefit Newsletters

September 2017
June 2017
March 2017
December 2016
September 2016
June 2016
March 2016
December 2015
September 2015
June 2015
March 2015
December 2014
September 2014
June 2014
March 2014
December 2013
September 2013
June 2013
March 2013
December 2012
September 2012
June 2012
March 2012


These forms are published on this page by Associated Administrators, LLC
on behalf of the Client Fund and are meant solely for the use of their participants.