Plan Documents

Here you’ll find the UFCW documents and forms you need in Adobe PDF format. Don’t have Adobe Reader? Get it here

UFCW Health Plan Documents

Plan Documents (Plan One) Download PDF	Summary of Benefits & Coverage (SBC) Plan One Download PDF
Plan Documents (Plan Two) Download PDF	Summary of Benefits & Coverage (SBC) Plan Two Download PDF
Plan Documents (Plan Three) Download PDF	Summary of Benefits & Coverage (SBC) Plan Three Download PDF
Plan Documents (Retirees) Download PDF	SBC Glossary  Download PDF
Prior Authorization List Download PDF	Provider Listing HMN Directory

Helpful Documents and Forms

HIPAA Authorized Representative Form Download PDF	Urgent Care Listings Download PDF
Coordination of Benefits (COB) Questionnaire Download PDF	Akamai Way Flier Download PDF
Frequently Asked Questions (FAQ’s) Download PDF