Documents & Forms

Plan Forms

2024 COBRA Rates - Carpenters - effective January 1, 2024

2024 Summary of Benefits and Coverage - effective January 1, 2024

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