Forms and Documents

Your Benefits During COVID-19

• Coronavirus Flyer

General

• Overview Brochure
• Enrollment Form
• HMO Summary of Benefits and Coverage – effective January 1, 2021
• PPO Summary of Benefits and Coverage – effective January 1, 2021
• Vision Benefit Summary
• Disability Claim Form
• LiveHealth Online Flyer
• NowClinic Telemedicine Flyer
• Be Smart…Don’t Overpay for Urgent Care
• Notice of Privacy Practices
• HIPAA Privacy Notice

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
• Vision Benefit Changes June 1, 2021

Required Notices

• No Surprises Act Notice 2022
• Teamsters Local 986 2022 Dependent Audit FAQs-v2.pdf