Plan Documents

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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)

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Summary of Benefits & Coverage (SBC) Plan One

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Plan Documents (Plan Two)

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 Summary of Benefits & Coverage (SBC) Plan Two

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 Plan Documents (Plan Three)

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Summary of Benefits & Coverage (SBC) Plan Three

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Plan Documents (Retirees)

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 SBC Glossary 

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Prior Authorization List

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 Provider Directory

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Helpful Documents and Forms

HIPAA Authorized Representative Form

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Urgent Care Listings

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Coordination of Benefits (COB) Questionnaire

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Akamai Way Flier

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Frequently Asked Questions (FAQ’s)

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