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Documents & Forms

Plan Forms

2023 Beneficiary Designation Form
2023 COBRA Rates - Carpenters - effective January 1, 2023
Affidavit of Retirement Form August 2022
2022 Summary of Benefits and Coverage - effective January 1, 2022
2022 COBRA Rates - Carpenters - effective January 1, 2022
2021 Summary of Benefits and Coverage - effective January 1, 2021
2021 COBRA Rates - Carpenters - effective January 1, 2021
2021 HRA Reimbursement Form - effective January 1, 2021
2021 HRA Reimbursement Form for Providers - effective January 1, 2021
Disability Claim Form
Other Insurance Form
IRS Publication 502 - Medical and Dental Expenses (Including the Health Coverage Tax Credit) - For use in preparing 2013 Returns

Plan Documents

Eligibility Walkthrough
Children’s Health Insurance Program (CHIP)

Summary of Material Modifications

Summary of Material Modification - Continuous Glucose Monitors - effective January 1, 2024
Summary of Material Modification - Public Employees & Incarceration Change - effective September 1, 2023
Summary of Material Modification - 2023 Increase in Contribution Rate - effective August 1, 2023
Summary of Material Modification - 2023 Plan Changes - effective January 1, 2023
Summary of Material Modification - Autism Spectrum Disorder Treatment - effective August 1, 2022
Summary of Material Modification - Disability Benefits for Pregnancy - effective September 1, 2018
Summary of Material Modification - Updated Opioid Management Procedures - effective September 1, 2018
Summary of Material Modification - Increase in Contribution Rate - effective July 1, 2022
Summary of Material Modification - Increase in Contribution Rate - effective July 1, 2018
Summary of Material Modification - HRA - effective January 1, 2017
Summary of Material Modification - Change in Premium Rate v2 - March 29, 2016
Summary of Material Modification - Pediatric Dental and Vision - September 1, 2015
Summary of Material Modification - Change in Premium Rate - April 2015
Summary of Material Modification - Eligible Classes of Dependents - April 2014
Summary of Material Modification - Affordable Care Act Amendment - effective January 1, 2014
Summary of Material Modification - Retiree Benefits and Cost
Summary of Material Modification - effective July 1, 2012

Notices

2023 Annual Notices
Machine Readable Transparency in Coverage
Medicare Part D Notice
Premium Assistance Under Medicaid and the Children’s Health Insurance Program (CHIP)
No Surprises Act - Out of Network Providers and Balance Billing Prohibitions
Notice of Privacy Practices
Annual WHCRA Breast Reconstruction Notice
$0 Copay for Telahealth Services - effective January 1, 2019
HIPAA - Notice of Privacy - effective October 1, 2018
Premium Assistance Under Medicaid and the Children’s Health Insurance Program (CHIP) - effective July 31st, 2018
Change to Wellmark - effective November 1, 2016
Nondiscrimination Notice 2017 - effective January 1, 2017
Catamaran Plan Update Notification - April 2015
Cancer Rights Act - effective January 2015
Catamarans Home Delivery Program - effective January 2015
Catamarans Auto Refill and Auto Renewal - effective January 2015
Medicare Creditable Coverage - effective October 2013
Health Care Exchanges Notice - effective October 2013
HIPAA - Notice of Privacy - effective September 2013
Grandfathered Health Plan Notice - effective September 2013
Change in Pharmacy Benefit Manager to Informed℞ - effective September 1, 2012
Important Notice on Walgreens - effective January 1, 2012
Health Care Reform Information for Members of Five River Carpenters
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