Summary Plan Description

• Active Plan 1 - restated 1/1/2020


• Active Plan 2 - restated 10/1/2004


• Active Plan 3 - restated 10/1/2004


• Active Plan 4 - restated 10/1/2004


• Delta Dental Benefits Booklet

Summary of Benefits & Coverages

• Active Plan 1


• Active Plan 2

Notice of Benefit Changes

• 04/2025 Summary of Material Modification – Speech, Physical, & Ocupational Therapy Coverage for Active Plan 1


• 04/2025 Summary of Material Modification – Speech, Physical, & Ocupational Therapy Coverage for Active Plan 2


• 01/2025 Summary of Material Modification – Reimbursable HRA for Non Network Expenses – Active Plan 1


• 07/2024 Summary of Material Modification – Death Benefit Beneficiary Designation – Active Plan 1


• 07/2024 Summary of Material Modification – Death Benefit Beneficiary Designation – Active Plan 2, 3, 4


• 05/2024 Summary of Material Modification – Physical Therapy Treatment – Active Plan 1


• 05/2024 Summary of Material Modification – Physical Therapy Treatment – Active Plan 2, 3, 4


• 04/2024 Summary of Material Modification – Diabetes Medication – Active Plan 1


• 04/2024 Summary of Material Modification – Diabetes Medication – Active Plan 2, 3, 4


• 01/2024 Summary of Material Modification - LOT Benefit Increase - Active Plan 1


• 01/2024 Summary of Material Modification - LOT Benefit Increase - Active Plan 2, 3, 4


• 02/2023 Summary of Material Modification – HRA and Dependent Contraception Accutane – Active Plan 1


• 02/2023 Summary of Material Modification – Dependent Contraception Accutane – Active Plan 2, 3, 4


• 08/2022 Summary of Material Modification – HRA Benefit Increase – Active Plan 1


• 08/2022 Summary of Material Modification – No Surprises Act – Active Plan 1


• 08/2022 Summary of Material Modification – No Surprises Act – Active Plan 2


• 08/2022 Summary of Material Modification – No Surprises Act – Active Plan 3


• 08/2022 Summary of Material Modification – 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 - Death Benefit Improvement Plan - Active Plan 4


• 06/2014 Summary of Material Modification - Active Plans


• 07/2013 Summary of Material Modification - Death Benefit Improvement Plan - Active Plan 2


• 04/2013 Summary of Material Modification - CVS Caremark "Maintenance Choice" - Active Plans 1-4

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Summary Plan Description

• Retiree Plan 1 - restated 1/1/2012


• Retiree Plan 2 - restated 2/1/2005


• Retiree Plan 3 - restated 2/1/2005


• Retiree Plan 4 - restated 2/1/2005

Notice of Benefit Changes

• 04/2025 Summary of Material Modification – Speech, Physical, and Ocupational Therapy Coverage for Retirees


• 06/2024 Summary of Material Modification – Death Benefit Improvement to $10,000 - Retiree Plans 1, 2, 3, 4


• 05/2024 Summary of Material Modification – Physical Therapy – Retiree Plans 1, 2, 3, 4


• 04/2024 Summary of Material Modification – Diabetes Medication – Retiree Plans 1, 2, 3, 4


• 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 - CVS Caremark "Maintanence Choice" - Retiree Plans 1-4


• 12/2012 Summary of Material Modification - Dependent Welness Benefits - 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

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Summary Plan Description – restated 2024. 

Summary of Material Modifications

• 6/2009 Summary of Material Modification


• 3/2018 Summary of Material Modification


• 6/2019 Summary of Material Modification


• 6/2021 and 6/2022 Summary of Material Modification


• 6/2023 Summary of Material Modification


• 6/2024 Summary of Material Modification


• 6/2025 Summary of Material Modification

Plan Rules and Regulations

• Restated 6/30/2014 (adopted 1/12/15)


• Notice to Interested Parties


• First Amendment effective 6/1/14, adopted 5/9/16


• Second Amendment effective 4/1/18, adopted 3/12/18


• Third Amendment effective 6/1/19, adopted 7/15/19


• Fourth Amendment effective 6/1/19, adopted 9/16/19


• Fifth Amendment effective 3/9/20, adopted 5/11/20


• Sixth Amendment effective 6/1/21 & 6/1/19, adopted 9/13/21


• Seventh Amendment effective 6/1/22, 3/9/20 & 1/1/20, adopted 7/11/22


• Eighth Amendment effective 6/1/23, 1/1/23 & 1/1/24, adopted 7/17/23


• Ninth Amendment effective 6/1/14 (clarifying) , adopted 1/15/24


• Tenth Amendment effective 6/1/24, adopted 7/15/24


• Eleventh Amendment effective 6/1/25, adopted 7/7/25

QDRO

• QDRO Procedures – Procedures for determining and implementing Qualified Domestic Relations Orders. 


• QDRO Guidelines for Separate Interest  - Follow these guidelines for participants who have not yet retired.


• QDRO Guidelines for Shared Interest - Follow these guidelines for participants who already receive pension benefits. 

Disqualifying Employment

• Summary about the Kinds of Work Not Allowed.

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