Plan Documents
These printable forms are in PDF format. You need the Adobe Acrobat Reader to read and print them. If you do not have Adobe Acrobat Reader installed in your system, you need to install it by clicking on the download icon.
Summary Annual Report
- Plan Year 2021-2022
- Plan Year 2020-2021
- Plan Year 2019-2020
- Plan Year 2018-2019
- Plan Year 2017-2018
- Plan Year 2016-2017
- Plan Year 2015-2016
- Plan Year 2014-2015
- Plan Year 2013-2014
- Plan Year 2012-2013
- Plan Year 2011-2012
- Plan Year 2010-2011
- Plan Year 2009-2010
Summary of Benefits and Coverage
Combined Plan Document and Summary Plan Description
Summary of Material Modifications
- 02/2023 Summary of Material Modifications – HRA and Dependent Contraception Accutane – Active Plan 1
- 02/2023 Summary of Material Modifications – Dependent Contraception Accutane – Active Plan 2, 3, 4
- 08/2022 Summary of Material Modifications – HRA Benefit Increase – Active Plan 1
- 08/2022 Summary of Material Modifications – No Surprises Act – Active Plan 1
- 08/2022 Summary of Material Modifications – No Surprises Act – Active Plan 2
- 08/2022 Summary of Material Modifications – No Surprises Act – Active Plan 3
- 08/2022 Summary of Material Modifications – No Surprises Act – Active Plan 4
- 04/2022 Summary of Material Modification – Autism - Infertility - Hearing Aid PPO - COVID Test – Active Plan 1
- 04/2022 Summary of Material Modification – Autism - Infertility - Hearing Aid PPO - COVID Test – Active Plan 2, 3, 4
- 11/2021 Summary of Material Modification – HRA Benefit Increase – Active Plan 1
- 07/2021 Summary of Material Modification – Nutritional Counseling - Diabetes Programs – Active Plan 1
- 07/2021 Summary of Material Modification – Nutritional Counseling - Diabetes Programs – Active Plans 2, 3, 4
- 02/2021 Summary of Material Modification – COVID-19 Vaccines – Active Plan 1
- 02/2021 Summary of Material Modification – COVID-19 Vaccines – Active Plans 2, 3, 4
- 02/2021 Summary of Material Modification – MAP – Active Plan 1
- 02/2021 Summary of Material Modification – MAP – Active Plans 2, 3 & 4
- 02/2021 Summary of Material Modification – Bariatric, HRA & Vision – Active Plan 1
- 02/2021 Summary of Material Modification – Bariatric & Vision – Active Plans 2 & 4
- 02/2021 Summary of Material Modification – Bariatric – Active Plan 3
- 04/2020 Summary of Material Modification - COVID-19
- 02/2020 Summary of Material Modification - Rx Plan Design Change
- 03/2018 Summary of Material Modification - Disability Claims Appeal
- 04/2017 Summary of Material Modification - Smoking Cessation and Infertility Treatment Benefits
- 01/2017 Summary of Material Modification - Active Plans RX Change
- 05/2015 Summary of Material Modification - Same Sex Marriage
- 06/2014 Summary of Material Modification - Active Plan 4
- 06/2014 Summary of Material Modification - Active Plans
- 07/2013 Summary of Material Modification - Active Plan 2
- 04/2013 Summary of Material Modification - Active Plans 1-4
General Notices
- 12/2021 Privacy Notice
- 12/2021 Womens Health Act
- 12/2020 Womens Health Act
- 12/2019 Womens Health Act
- 12/2018 Privacy Notice
- 03/2017 Diabetic Medical Supplies Letter
- 12/2016 Notice of Privacy Practices/Women’s Health & Cancer Rights/Nondiscrimination Notice – All Plans
- 12/2015 COBRA Rates
- 12/2015 Womens Health Act
- 12/2012 Notice of Privacy Practices/Women's Health & Cancer Rights Act - All Plans
- 12/2012 Waiver Notice - Basic Retiree Plan
- Affordable Care Act Marketplace Notice
- Nondiscrimination Notice Under Section 1557 of the Affordable Care Act
Highlights Brochure