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Documents & Forms

Plan Forms

2017 HRA Reimbursement Form for Providers - effective January 1, 2017
HRA Reimbursement Form and HRA Information - posted June 22, 2012
Disability Claim Form
Optum℞ Claim Form
Optum℞ Order Form
Catamaran Claim Form
Catamaran Order 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

2019 Cobra Rates - Carpenters - effective January 1, 2019
2017 Cobra Rates - Carpenters - effective January 1, 2017
Eligibility Walkthrough
Optum℞ Temporary ID Card - posted November 9, 2018
Catamaran Temporary ID Card - effective September 1, 2012
Children’s Health Insurance Program (CHIP)
Summary of Benefits and Coverage 2018 - effective January 1, 2018
Summary of Benefits and Coverage 2017 - posted November 9, 2018
Summary of Benefits and Coverage 2017 - effective January 1, 2017
Summary of Benefits and Coverage 2015 - effective September 1, 2015
Summary of Benefits and Coverage 2015 - effective January 1, 2015
Summary of Benefits and Coverage 2014 - effective January 1, 2014
Summary of Benefits Coverage 2013

Summary of Material Modifications

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, 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
COBRA Rates 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

$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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