Plan Documents & Forms
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Enrollment Forms
BAAG Enrollment Form – Plan 08AD
BAAG Enrollment Form – Plan PPAV
BAAG Enrollment Form – Plan PPK
BAAG Enrollment Form – Plans 08MA, 09AA, 17AA, 23AA, 24A1, 24AA, 25AA, 34AA, PPAA, PPZA
BAAG Enrollment Form – Plans PPK+D, PPKVD
DeltaCare USA Dental Enrollment Form
Newport Bright Now Dental Enrollment Form
UHC Dental Enrollment Form
Other Forms
Notice of Creditable Coverage
Summary Annual Reports
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Plan Document
New Summary Plan Description coming soon.
Summary of Material Modifications:
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08AD
2012.08.01 ACA Plan Benefit Changes, IRO
2013.07.01 Mental Health, Substance Abuse, Domestic Partner
2014.03.01 ACA Plan Benefit Changes, IRO
2017.04.01 Anthem PPO Agreements, Disability Claim Procedures, Venue Selections
2020.03.01 Extended Coverage, COVID-19 Testing, Tele-Medicine
2020.06.01 Extended Coverage
2020.06.01 Extension of Deadlines re COVID-19
2020.07.01 Extended Coverage
2020.08.01 Extended Coverage
2021.06.01 Orthotics
2021.08.01 Expiration of Extension Deadlines
2022.01.01 No Surprise Act, Autism ABA Therapy, Gender Dysphoria
2022.06.02 End of COVID-19 and Wilderness Therapy
08MA
2012.08.01 ACA Plan Benefit Changes, IRO
2012.08.01 ACA Plan Benefits Changes, IRO (revised)
2013.07.01 Mental Health, Substance Abuse, Domestic Partner
2015.01.01 OOP Max, Mail Order Rx, COB wMC & COBRA, Opt-Out Dental & Vision
2017.04.01 Anthem PPO Agreements, Disability Claim Procedures, Venue Selections
2020.03.01 Extended Coverage, COVID-19 Testing, Tele-Medicine
2020.06.01 Extended Coverage
2020.06.01 Extension of Deadlines re COVID-19
2020.07.01 Extended Coverage
2020.08.01 Extended Coverage
2021.06.01 Orthotics
2021.08.01 Expiration of Extension of Deadlines
2022.01.01 No Surprise Act, Autism ABA Therapy, Gender Dysphoria
2022.06.02 End of COVID-19 and Wilderness Therapy
09AA
2012.08.01 ACA Plan Benefit Changes, IRO
2012.08.01 ACA Plan Benefit Changes, IRO (revised)
2013.07.01 Mental Health, Substance Abuse, Domestic Partner
2015.01.01 OOP Max, Mail Order Rx, COB wMc & COBRA, Opt-Out Dental & Vision
2017.04.01 Anthem PPO Agreements, Disability Claim Procedures, Venue Selections
2020.03.01 Extended Coverage, COVID-19 Testing, Tele-Medicine
2020.06.01 Extended Coverage
2020.06.01 Extension of Deadlines re COVID-19
2020.07.01 Extended Coverage
2020.08.01 Extended Coverage
2021.06.01 Orthotics
2021.08.01 Expiration of Extension Deadlines
2022.01.01 No Surprise Act, Autism ABA Therapy, Gender Dysphoria
2022.06.02 End of COVID-19 and Wilderness Therapy
17AA
2012.08.01 ACA Plan Benefit Changes, IRO
2012.08.01 ACA Plan Benefit Changes, IRO (revised)
2015.01.01 OOP Max, Mail Order Rx, COB wMC & COBRA, Opt-Out Dental & Vision
2017.04.01 Anthem PPO Agreements, Disability Claim Procedures, Venue Selections
2018.11.01 Dental Enhancement
2020.01.01 Dental Enhancement
2020.03.01 Extended Coverage, COVID-19 Testing, Tele-Medicine
2020.06.01 Extended Coverage
2020.06.01 Extension of Deadlines re COVID-19
2020.07.01 Extended Coverage
2020.08.01 Extended Coverage
2021.06.01 Orthotics
2021.08.01 Expiration of Extension of Deadlines
2017.01.01 No Surprise Act, Autism ABA Therapy, Gender Dysphoria
2022.06.02 End of COVID-19 and Wilderness Therapy
23AA
2012.08.01 ACA Plan Benefit Changes, IRO
2012.08.01 ACA Plan Benefit Changes, IRO (revised)
2013.07.01 Mental Health, Substance Abuse, Domestic Partner
2015.01.01 OOP Max, Mail Order Rx, COB wMC & COBRA, Opt-Out Dental & Vision
2017.04.01 Anthem PPO Agreements, Disability Claim Procedures, Venue Selections
2020.03.01 Extended Coverage, COVID-19 Testing, Tele-Medicine
2020.06.01 Extended Coverage
2020.06.01 Extension of Deadlines re COVID-19
2020.07.01 Extended Coverage
2020.08.01 Extended Coverage
2021.06.01 Orthotics
2021.08.01 Expiration of Extension of Deadlines
2017.01.01 No Surprise Act, Autism ABA Therapy, Gender Dysphoria
2022.06.02 End of COVID-19 and Wilderness Therapy
24A1
2013.07.01 Mental Health, Substance Abuse, Domestic Partner
2014.03.01 ACA Plan Benefit Changes, IRO
2015.01.01 OOP Max, Mail Order Rx, COB wMC & COBRA, Opt-Out Dental & Vision
2017.04.01 Anthem PPO Agreements, Disability Claim Procedures, Venue Selections
2020.03.01 Extended Coverage, COVID-19 Testing, Tele-Medicine
2020.06.01 Extended Coverage
2020.06.01 Extension of Deadlines re COVID-19
2020.07.01 Extended Coverage
2020.08.01 Extended Coverage
2021.06.01 Orthotics
2021.08.01 Expiration of Extension of Deadlines
2017.01.01 No Surprise Act, Autism ABA Therapy, Gender Dysphoria
2022.06.02 End of COVID-19 and Wilderness Therapy
24AA
2012.08.01 ACA Plan Benefit Changes, IRO
2012.08.01 ACA Plan Benefit Changes, IRO (revised)
2013.07.01 Mental Health, Substance Abuse, Domestic Partner
2017.04.01 Anthem PPO Agreements, Disability Claim Procedures, Venue Selections
2020.03.01 Extended Coverage, COVID-19 Testing, Tele-Medicine
2020.06.01 Extended Coverage
2020.06.01 Extension of Deadlines re COVID-19
2020.07.01 Extended Coverage
2020.08.01 Extended Coverage
2021.06.01 Orthotics
2021.08.01 Expiration of Extension of Deadlines
2017.01.01 No Surprise Act, Autism ABA Therapy, Gender Dysphoria
2022.06.02 End of COVID-19 and Wilderness Therapy
25AA
2012.08.01 ACA Plan Benefit Changes, IRO
2012.08.01 ACA Plan Benefit Changes, IRO (revised)
2013.07.01 Mental Health, Substance Abuse, Domestic Partner
2015.01.01 OOP Max, Mail Order Rx, COB wMC & COBRA, Opt-Out Dental & Vision
2017.04.01 Anthem PPO Agreements, Disability Claim Procedures, Venue Selections
2020.03.01 Extended Coverage, COVID-19 Testing, Tele-Medicine
2020.06.01 Extended Coverage
2020.06.01 Extension of Deadlines re COVID-19
2020.07.01 Extended Coverage
2020.08.01 Extended Coverage
2021.06.01 Orthotics
2021.08.01 Expiration of Extension of Deadlines
2017.01.01 No Surprise Act, Autism ABA Therapy, Gender Dysphoria
2022.06.02 End of COVID-19 and Wilderness Therapy
34AA
2012.08.01 ACA Plan Benefit Changes, IRO
2012.08.01 ACA Plan Benefit Changes, IRO (revised)
2013.07.01 Mental Health, Substance Abuse, Domestic Partner
2015.01.01 OOP Max, Mail Order Rx, COB wMC & COBRA, Opt-Out Dental & Vision
2017.04.01 Anthem PPO Agreements, Disability Claim Procedures, Venue Selections
2019.01.01 Dental Enhancement
2020.03.01 Extended Coverage, COVID-19 Testing, Tele-Medicine
2020.06.01 Extended Coverage
2020.06.01 Extension of Deadlines re COVID-19
2020.07.01 Extended Coverage
2020.08.01 Extended Coverage
2021.06.01 Orthotics
2021.08.01 Expiration of Extension of Deadlines
2022.01.01 No Surprise Act, Autism ABA Therapy, Gender Dysphoria
2022.06.02 End of COVID-19 and Wilderness Therapy
PPAA
2017.04.01 Anthem PPO Agreements, Disability Claim Procedures, Venue Selections
2020.03.01 Extended Coverage, COVID-19 Testing, Tele-Medicine
2020.06.01 Extended Coverage
2020.06.01 Extension of Deadlines re COVID-19
2020.07.01 Extended Coverage
2020.08.01 Extended Coverage
2021.06.01 Orthotics
2021.08.01 Expiration of Extension of Deadlines
2017.01.01 No Surprise Act, Autism ABA Therapy, Gender Dysphoria
2022.06.02 End of COVID-19 and Wilderness Therapy
PPAV
2017.04.01 Anthem PPO Agreements, Disability Claim Procedures, Venue Selections
2020.03.01 Extended Coverage, COVID-19 Testing, Tele-Medicine
2020.06.01 Extended Coverage
2020.06.01 Extension of Deadlines re COVID-19
2020.07.01 Extended Coverage
2020.08.01 Extended Coverage
2021.06.01 Orthotics
2021.08.01 Expiration of Extension of Deadlines
2017.01.01 No Surprise Act, Autism ABA Therapy, Gender Dysphoria
2022.06.02 End of COVID-19 and Wilderness Therapy
PPK
2017.04.01 Anthem PPO Agreements, Disability Claim Procedures, Venue Selections
2020.03.01 Extended Coverage, COVID-19 Testing, Tele-Medicine
2020.06.01 Extended Coverage
2020.06.01 Extension of Deadlines re COVID-19
2020.07.01 Extended Coverage
2020.08.01 Extended Coverage
2021.08.01 Expiration of Extension of Deadlines
2017.01.01 No Surprise Act, Autism ABA Therapy, Gender Dysphoria
PPK+D
2017.04.01 Anthem PPO Agreements, Disability Claim Procedures, Venue Selections
2020.03.01 Extended Coverage, COVID-19 Testing, Tele-Medicine
2020.06.01 Extended Coverage
2020.06.01 Extension of Deadlines re COVID-19
2020.07.01 Extended Coverage
2020.08.01 Extended Coverage
2021.08.01 Expiration of Extension of Deadlines
2017.01.01 No Surprise Act, Autism ABA Therapy, Gender Dysphoria
PPZA
2017.04.01 Anthem PPO Agreements, Disability Claim Procedures, Venue Selections
2020.03.01 Extended Coverage, COVID-19 Testing, Tele-Medicine
2020.06.01 Extended Coverage
2020.06.01 Extension of Deadlines re COVID-19
2020.07.01 Extended Coverage
2020.08.01 Extended Coverage
2021.06.01 Orthotics
2021.08.01 Expiration of Extension of Deadlines
2017.01.01 No Surprise Act, Autism ABA Therapy, Gender Dysphoria
2022.06.02 End of COVID-19 and Wilderness Therapy
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