Forms and Documents

General

• Overview Brochure
• Enrollment Form
• HMO Summary of Benefits and Coverage – effective January 1, 2019
• PPO Summary of Benefits and Coverage – effective January 1, 2019
• PHI Authorization Form
• Disability Claim Form
• LiveHealth Online Flyer
• Be Smart…Don’t Overpay for Urgent Care
• Notice of Privacy Practices

Summary Plan Description and Amendments

• Summary Plan Description
• Amendment #1 January 1, 2015
• Amendment #2 July 1, 2015
• Amendment #3 October 1, 2015
• Amendment #4 January 1, 2016
• Amendment #5 March 1, 2016
• Amendment #6 October 1, 2014
• Amendment #7 October 1, 2014
• Amendment #8 October 1, 2014
• Amendment #9 October 1, 2014
• Amendment #10 October 1, 2014
• Amendment #11 October 1, 2014
• EnvisionRx Prescription Drug Changes May 1, 2018