Tuesday, May 13, 2025

Health Care Documents

Health Care Recent Mailings
Health Care Recent Mailings
Retiree Self-Pay Rates 2024
Notice of Non-Discrimination
2023 Summary Annual Report
Medicare Part D Creditable Coverage Notice
SMM: Short Hour Extension
SMM: Termination of Self Pay Extension
SMM: Death Benefits
Health Care Forms
Health Care Forms
Reciprocity Authorization Form.Home
Reciprocity Authorization Form.Traveler
COBRA Extended ARPA
Address Verification Form
Authorization for Self-Payment Deduction
Disability Physician Statement Form
Enrollment Form - Actives
Vital Information Form
Disabled Dependent Information
Beneficiary Form
New Member Packet
Health Care Documents / Summary Plan Description
Health Care Documents / Summary Plan Description
Health & Welfare SPD 2023
1st Amendment - Gene Therapy
2nd Amendment - Reimbursement Rights
3rd Amendment - COVID Screening & Testing
4th Amendment - Self Payment Provision
5th Amendment - Ground Ambulance
6th Amendment - Dependent Dental OOP Max
7th Amendment - 10k ADD Death Benefit
8th Amendment - Extending Short Hour Provision
9th Amendment - HIPAA Reproductive Privacy
Newsletters
Newsletters
Sav-Rx Mobile App Flyer
Summary of Benefits and Coverages
Summary of Benefits and Coverages
PPO SBC 7/1/2024 to 6/30/2025
Kaiser SBC 3/1/2025 to 02/28/2026