Plan Documents & Forms
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Enrollment Forms
Other Forms
Notice of Creditable Coverage
Other Notices
Summary Annual Reports
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Plan Document
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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
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
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
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
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
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
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
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
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
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
PPAV
Blue Cross SBC
Kaiser SBC
Medical Benefit Comparison
VSP Benefit Summary
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
2021.06.01 Orthotics
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
2021.06.01 Orthotics
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
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