Forms & Notices

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American Rescue Plan Act of 2021

Temporary COBRA Premium Assistance

Benefit Overviews

2023 Summary of Benefits and Coverage (SBC)

2023 Active Health Benefit Summary

2023 Retiree Health Benefit Summary

Health Insurance Coverage Outside of the United States - January 2015

Glossary of Health Coverage and Medical Terms - September 2017

Claims

Davis Vision Claim Form

Delta Dental Claim Form

Disability Claim Form

EmpiRx Prescripton Claim Form

Medical Claim Form

Other Insurance Information Form

Dental

Delta Dental Claim Form

Delta Dental Claim Payment Notice

Disability

Disability Claim Form

Hearing

Epic Hearing Benefit Summary - January 2023

Health Care Reform / Affordable Care Act

ACA Reporting Information for Employers

Affordable Care Act Requirement - Social Security Numbers Needed - July 2015

ACA Notice to Members - September 2013

ACA Notice to Employers - September 2013

Marketplace Form - Excavating, Grading and Asphalt Welfare - September 2013

Marketplace Form - Garage Attendants, Linen & Laundry Welfare - September 2013

Marketplace Form - Private Scavengers Welfare - September 2013

Legal Notices

Women's Cancer Act Notice - December 2022

Medicare Part D Notice

Privacy Permission Form for Family Members

BCBS Compliance Notice

Children's Health Insurance Program Reauthorization Act of 2009 (CHIPRA)

COBRA Act of 1985

Family and Medical Leave Act Notice

Genetic Information Nondiscrimination Act (GINA)

Mental Health Parity Act

Privacy Notice

Qualified Medical Child Support Order Procedures

Statement of ERISA Rights

Newborns and Mothers Health Protection Act

Womens' Health and Cancer Rights Act

Member Assistance Program (MAP)

Member Assistance Program Flyer - November 2023

Member Assistance Program Flyer - July 2020

Notices

2023 Fall Wellness Event - Announcement - September 2023

2023 Fall Wellness Event - Optional Tests - September 2023

Summary of Material Modifications - Hinge Health - July 2023

Summary of Material Modifications - COVID Change - May 2023

Summary of Material Modifications - Out of Pocket Wellness Reminder - December 2022

Summary of Material Modifications - OTC Covid Tests - January 2022

Summary of Material Modifications - Rx Copay Changes - January 2022

Summary of Material Modifications - OOP Wellness Reminder - December 2021

Summary of Material Modifications - Wellness Program - September 2021

Summary of Material Modifications - September 2021

Summary of Material Modifications - May 2021

Illinois COVID-19 Vaccine Update - January 2021

Summary of Material Modifications - December 2020

Flu Shot Notice - October 2020

Viveka Mobile App Announcement - July 2020

COVID-19 Coverage Announcement - May 2020

Health Plan Improvement - December 2019

Summary of Material Modifications - December 2019

"Building Bridges to Health" Health Fair - August 2019

Summary of Material Modifications - December 2018

New Prescription Drug Provider Effective February 1, 2018

Summary of Material Modifications - October 2018

Summary of Material Modifications - September 2017

Summary of Material Modifications - February 2017 (Updated 8/11/17)

Health Plan Improvements - November 2015

Health Plan Improvements - Diabetes Benefit - July 2014

Health Plan Improvements - December 2013

New Diagnostic Imaging Network - October 2013

Health Plan Improvements - May 2013

Summary of Material Modifications - June 2010

Other

Privacy Permission Form for Family Members

Benefit Provider Contact Information - November 2020

Address Change Form

Physical Therapy

Hinge Health Flyer

Prescription/Rx

At-Home COVID Test Reimbursement Form - January 2022

Over-the-Counter COVID Test Information - January 2022

EmpiRx Direct Member Reimbursement Form - January 2022

New Prescription Drug Provider Effective October 1, 2020 - October 2020

EmpiRx Processing Information - October 2020

EmpiRx Brochure - October 2020

EmpiRx Personal Representative Form - October 2020

EmpiRx Mail Order Form - October 2020

EmpiRx FAQs - October 2020

Radiology

Future Diagnostics Flyer - October 2021

Absolute Solutions Member Flyer - July 2020

Sleep Apnea

Sleep Apnea Equipment & Supplies - January 2015

Summary Plan Descriptions (SPD)

If you are unsure which Welfare Plan you belong to, please contact the Fund Office at (630) 887-4150

Summary Plan Description (SPD) Excavating, Grading and Asphalt Welfare - June 2016

Summary Plan Description (SPD) Garage Attendants, Linen & laundry Welfare - June 2016

Summary Plan Description (SPD) Private Scavengers Welfare - June 2016

Vision

Davis Vision Announcement

Davis Vision Flier

Davis Vision Claim Form

Wellness Program

2023 Fall Wellness Event - Announcement - September 2023

2023 Fall Wellness Event - Optional Tests - September 2023

Summary of Material Modifications - Wellness Program - September 2021

Wellness Program Explained - February 2021

Health Spending Account Reimbursement Form

Other

Address Change Form

Notices

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Getting Ready to Retire

Ready to Retire Checklist