UA Local 190

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Health Care Documents

Health Care Enrollment Packet

	UA Local 190 Fringe Benefits Funds Welcome Letter

	UA Local 190 Vital Information Form

	Dependent Coverage Instructions

	Authorization Form Instructions

	DC Plan 401(k) Empower Beneficiary Form

	MetLife Beneficiary Form

	Pension Beneficiary Form

	Privacy Practices

	Protected Health Information Form

	Blue Cross Blue Shield MI Mobile App Flyer (BCBSM)

	BCBSM Prescription Preventative Drug List

	Delta Dental Plan Benefits

	Davis Vision Benefits

	Supplemental Unemployment Benefit Summary Plan Description (SPD) v.2017

	Supplemental Unemployment Benefit Payee Direct Deposit Form

	IHRA Pre-Authorization Form v.032725

	Language Assistance

	Health & Welfare (SPD) v.2017 - (Please also see "Amendments" in the box below)

	Self-Pay / COBRA Rates effective April 1, 2025

	Pension Summary Plan Description (SPD) v.2017

	Defined Contribution 401(k) Plan Summary Plan Description (SPD) v.2017

	Scholarship Plan Summary Plan Description (SPD) v.2017

	COBRA Rights

Health Care Recent Mailings

	Summary Plan Description (SMM) Self-Pay/COBRA Rates

	Summary of Benefits and Coverages - Enhanced

	Summary of Benefits and Coverages - Standard

	Privacy Practices

	No Surprise Medical Bill

	Third Party Administrator - Change Notification Letter 020425

Health Care Amendments and Changes

	Out of Pocket Maximums effective 060124-053125

	Medicare Retiree Prescription Amendment eff 010122

	Non-Bargaining Unit Employee Coverage

	CARES Act Amendment

	COVID Test Coverage 011522

Health Care Documents / Summary Plan Description

Benefit Fund Contact Information