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
Summary Plan Description
Summary of Material Modifications
- 04/2022 Summary of Material Modification – Autism - Hearing Aid PPO - At Home COVID Tests - Retiree Plans 1, 2, 3, 4
- 07/2021 Summary of Material Modification – Nutritional Counseling - Diabetes Programs – Retiree Plans 1, 2, 3, 4
- 02/2021 Summary of Material Modification – COVID-19 Vaccines – Retiree Plans 1, 2, 3, 4 Basic
- 02/2021 Summary of Material Modification – Vision - Basic Plan
- 02/2021 Summary of Material Modification – Bariatric & Vision – Retiree Plans 1, 2 & 4
- 02/2021 Summary of Material Modification – Bariatric – Retiree Plan 3
- 02/2021 Summary of Material Modification – MAP – Retiree Plans 1, 2, 3 & 4
- 04/2020 Summary of Material Modification - COVID-19
- 04/2017 Summary of Material Modification - Smoking Cessation Benefits
- 01/2017 Summary of Material Modification - Retiree Plan 1 RX Change
- 01/2017 Summary of Material Modification - Retiree Plan 2-4 RX Change
- 05/2015 Summary of Material Modification - Same Sex Marriage
- 06/2014 Summary of Material Modification - Retiree Plans
- 04/2013 Summary of Material Modification - Retiree Plans 1-4
- 12/2012 Summary of Material Modification - Retiree Plans 1-4
- 11/2011 Summary of Material Modification - VSP Retiree Plans
- 06/2011 Summary of Material Modification - Retiree Basic Plan
- 06/2011 Summary of Material Modification - Retiree Plan 1
- 06/2011 Summary of Material Modification - Retiree Plan 2 and 4
- 06/2011 Summary of Material Modification - Retiree Plan 3
- 03/2011 Summary of Material Modification - ERRP Cover Letter
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
- 11/2018 Self-Pay Rates for Spouses
- 03/2017 Diabetic Medical Supplies Letter
- 03/2017 Medicare Crossover Announcement
- 12/2016 Notice of Privacy Practices/Women’s Health & Cancer Rights/Nondiscrimination Notice – All Plans
- 12/2015 Womens Health Act
- 2015 COBRA and Self-Pay Rates
- 12/2012 Waiver Notice - Basic Retiree Plan
- 12/2012 Notice of Privacy Practices/Women's Health & Cancer Rights Act - All Plans
- Affordable Care Act Marketplace Notice
- Nondiscrimination Notice Under Section 1557 of the Affordable Care Act