Plan Documents and Forms

Benefits

Benefits Information Guide—Summary Plan Description [PDF]

Anthem Medical Plans

Anthem Base California Summary Plan Description [PDF]
Anthem Base Non-California Summary Plan Description [PDF]
Anthem Base PPO Benefit Summary 2021 [PDF]
Anthem Base PPO Silfex Summary Plan Description [PDF]
Anthem Base PPO Summary of Benefits Coverage 2021 [PDF]
Anthem CDHP California Summary Plan Description [PDF]
Anthem CDHP Non-California Summary Plan Description [PDF]
Anthem CDHP Silfex Summary Plan Description [PDF]
Anthem CDHP with HSA Benefits Summary 2021 [PDF]
Anthem CDHP with HSA Summary of Benefits Coverage 2021 [PDF]
CVS Caremark Preventive Drug List 2020 [PDF]
CVS Caremark RX Base CDHP Summary Plan Description 2020 [PDF]
CVS Caremark RX Base PPO Summary Plan Description 2020 [PDF]

Kaiser Medical Plans

Kaiser California CDHP 2016 Summary Plan Description [PDF]
Kaiser California HMO—Chiropractic 2016 Summary Plan Description [PDF]
Kaiser CDHP with HSA—Northern California Benefit Summary 2021 [PDF]
Kaiser CDHP with HSA—Northern California Summary of Benefits Coverage 2021 [PDF]
Kaiser CDHP with HSA—Oregon and Washington Benefit Summary 2021 [PDF]
Kaiser CDHP with HSA—Oregon and Washington Summary of Benefits Coverage 2021 [PDF]
Kaiser HMO—Northern California Benefit Summary 2021 [PDF]
Kaiser HMO—Northern California Summary of Benefits Coverage 2021 [PDF]
Kaiser HMO—Northern California Summary Plan Description [PDF]
Kaiser HMO—Oregon and Washington Benefit Summary 2021 [PDF]
Kaiser HMO—Oregon and Washington Summary of Benefits Coverage 2021 [PDF]
Kaiser Permanente Northwest Mail Order Pharmacy [PDF]

Dental

Delta Dental Enhanced Plan Benefit Summary 2021 [PDF]
Delta Dental Enhanced Plan Evidence of Coverage (EOC) 2021 [PDF]
Delta Dental Premium Plan Benefit Summary 2021 [PDF]
Delta Dental Premium Plan Evidence of Coverage (EOC) 2021 [PDF]
Delta Dental Preventive Plan Benefit Summary 2021 [PDF]
Delta Dental Preventive Plan Evidence of Coverage (EOC) 2021 [PDF]

Vision

VSP Base Plan Benefit Summary 2021 [PDF]
VSP Enhanced Plan Benefit Summary 2021 [PDF]

Critical Illness and Life Insurance

Critical Illness Insurance Plan FAQs [PDF]
Critical Illness Outline of Coverage [PDF]
Standard Insurance Company Group Life Insurance 2017 Summary Plan Description [PDF]

Disability Coverage

California VDI Statement of Coverage 2020 [PDF]
California Voluntary Disability Plan Summary Plan Description [PDF]
Long-Term Disability Insurance [PDF]
Short-Term Disability Plan Document 2021 [PDF]
Short-Term Disability Plan Summary Annual Report (Lam) [PDF]
Short-Term Disability Plan Summary Plan Description 2020 [PDF]

Policies, Practices, and Forms

Adoption Reimbursement Form [PDF]
Leave of Absence and Accommodation Practice [PDF]
Time Off Practice [PDF]

State Supplements

Arizona State Supplement [PDF]
California State Supplement [PDF]
Idaho State Supplement [PDF]
New York State Supplement [PDF]
Oregon State Supplement [PDF]
Texas State Supplement [PDF]

Required Notices

Cafeteria Plan Document [PDF]
Children's Health Insurance Program (CHIP) Notice [PDF]
ESPP Prospectus [PDF]
Family and Medical Leave Act (FMLA) Notice [PDF]
Group Welfare Benefit Plan Document [PDF]
Health and Welfare Plans Summary Annual Report (Lam) [PDF]
Health and Welfare Plans Summary Annual Report (Silfex) [PDF]
Health Insurance Marketplace Notice [PDF]
HIPAA Privacy Notice [PDF]
Medicare Creditable Coverage Notice 2021 [PDF]