Index of /webeci/166/plandocs/en

• Parent Directory
• 335_Change_Application.pdf
• 335_Enrollment_Application.pdf
• 335_Plan_Document_Amendment_1_Sleep_Apnea_Treatment.pdf
• 335_Plan_Document_Amendment_2_COVID19_Services.pdf
• 335_Plan_Document_Amendment_3_Specialty_Drugs.pdf
• 335_Plan_Document_and_Summary_Plan_Description.pdf
• 335_SBC_Summary_of_Benefits_and_Coverage.pdf
• 335_Schedule_of_Benefits.pdf
• 378_Change_Application.pdf
• 378_Enrollment_Application.pdf
• 378_Medical_Schedule_of_Benefits_PlanA_EPO_Plan.pdf
• 378_Medical_Schedule_of_Benefits_PlanB_PPO_Plan.pdf
• 378_Plan_Document_and_Summary_Plan_Description.pdf
• 378_SBC_Summary_of_Benefits_and_Coverage_PlanA_EPO_Plan.pdf
• 378_SBC_Summary_of_Benefits_and_Coverage_PlanB_PPO_Plan.pdf
• 378_Spousal_Application.pdf
• 384_Change_Application.pdf
• 384_Enrollment_Application.pdf
• 384_Plan_Document_Amendment_1.pdf
• 384_Plan_Document_Amendment_2.pdf
• 384_Plan_Document_Amendment_3.pdf
• 384_Plan_Document_Amendment_4.pdf
• 384_Plan_Document_Amendment_5.pdf
• 384_Plan_Document_and_Summary_Plan_Description.pdf
• 384_SBC_Summary_of_Benefits_and_Coverage.pdf
• 384_Schedule_of_Benefits.pdf
• 385_Change_Application.pdf
• 385_Enrollment_Application.pdf
• 385_Getting_Started_with_Teladoc.pdf
• 385_Plan_Document_and_Summary_Plan_Description.pdf
• 385_SBC_Summary_of_Coverage_and_Benefits_EPO_Plan_E.pdf
• 385_SBC_Summary_of_Coverage_and_Benefits_Gold_Plan_G.pdf
• 385_SBC_Summary_of_Coverage_and_Benefits_HDHP_Plans_SandF.pdf
• 385_Schedule_of_Benefits_EPO_Plan_E.pdf
• 385_Schedule_of_Benefits_Gold_Plan_G.pdf
• 385_Schedule_of_Benefits_HDHP_Plans_SandF.pdf
• 386_Change_Application.pdf
• 386_Enrollment_Application.pdf
• 386_Plan_Document_Amendment_1.pdf
• 386_Plan_Document_Amendment_2.pdf
• 386_Plan_Document_Amendment_3.pdf
• 386_Plan_Document_and_Summary_Plan_Description.pdf
• 386_SBC_Summary_of_Benefits_and_Coverage_PlanA_Base_Plan.pdf
• 386_SBC_Summary_of_Benefits_and_Coverage_PlanB_BuyUp_Plan.pdf
• 386_Schedule_of_Benefits_PlanA_Base_Plan.pdf
• 386_Schedule_of_Benefits_PlanB_BuyUp_Plan.pdf
• 392_Enrollment_and_Change_Application.pdf
• 396_Dental_Schedule_of_Benefits.pdf
• 396_Plan_Document_Amendment_1.pdf
• 396_Plan_Document_and_Summary_Plan_Description.pdf
• 396_Vision_Schedule_of_Benefits.pdf
• 426_Change_Application.pdf
• 426_Enrollment_Application_Hourly_BiWeekly_Deductions.pdf
• 426_Enrollment_Application_Hourly_Weekly_Deductions.pdf
• 426_Enrollment_Application_Salary_BiWeekly_Deductions.pdf
• 426_Enrollment_Application_Salary_Weekly_Deductions.pdf
• 426_MAP_Flyer.pdf
• 426_Plan_Document_Amend1_Employment_Waiting_Period.pdf
• 426_Plan_Document_Amend2_ACA_Look_Back.pdf
• 426_Plan_Document_Amend4_Specialty_Drugs_and_Plan_Year_Change.pdf
• 426_Plan_Document_Amendment3_COVID19_Services.pdf
• 426_Plan_Document_and_Summary_Plan_Description.pdf
• 426_SBC_Summary_of_Benefits_and_Coverage_PlanB_Salary_Plan.pdf
• 426_SBC_Summary_of_Benefits_and_Coverage_PlanC_Hourly_Plan.pdf
• 426_Schedule_of_Benefits_PlanB_Salary_Plan.pdf
• 426_Schedule_of_Benefits_PlanC_Hourly_Plan.pdf
• 426_Teladoc_Getting_Started.pdf
• 426_Teladoc_Talk_to_a_Doctor.pdf
• 427_Change_Application.pdf
• 427_Enrollment_Application.pdf
• 427_Plan_Document_and_Summary_Plan_Description.pdf
• 427_SBC_Summary_of_Benefits and Coverage.pdf
• 427_Schedule_of_Benefits.pdf
• 430_Change_Application.pdf
• 430_Enrollment_Application.pdf
• 430_SBC_Summary_of_Benefits_and_Coverage.pdf
• 430_Schedule_of_Benefits.pdf
• 434_Change_Application.pdf
• 434_Enrollment_Application.pdf
• 434_Plan_Document_Amendment1.pdf
• 434_Plan_Document_and_Summary_Plan_Description.pdf
• 434_SBC_Summary_of_Benefits_and_Coverage.pdf
• 434_Schedule_of_Benefits.pdf
• 436_Plan_Doc_Amend2_PriceMDs_ International_Treatment_Medical Tourism.pdf
• 436_Plan_Document_Amendment1_Rehire_Period_Dependent Age.pdf
• 436_Plan_Document_Amendment3_COVID19_Services.pdf
• 436_Plan_Document_Amendment4_ExhibitB_KISx_Services.pdf
• 436_Plan_Document_and_Summary_Plan_Description.pdf
• 436_SBC_Summary_of_Benefits_and_Coverage.pdf
• 436_Schedule_of_Benefits_HSA_Plan_Plans SandF.pdf
• 437_Enrollment_Application.pdf
• 437_Plan_Document_Amendment1_ABA_Coverage.pdf
• 437_Plan_Document_Amendment2_COVID19_Services.pdf
• 437_Plan_Document_and_Summary_Plan_Description.pdf
• 437_SBC_Summary_of_Benefits_and_Coverage_HSA_Plan.pdf
• 437_Schedule_of_Benefits_HSA_Plan_Plans_SandF.pdf
• 438_Change_Application.pdf
• 438_Enrollment_Application.pdf
• 438_Plan_Document_and_Summary_Plan_Description.pdf
• 438_SBC_Summary_of_Benefits_and_Coverage.pdf
• 438_Schedule_of_Benefits.pdf
• 440_QSEHRA_Plan_Doc_and_SPD_8_2018.pdf
• 442_Change_Application.pdf
• 442_Enrollment_Application.pdf
• 442_Plan_Doc_Amend1_Eligibility_Requirements_for_Spouse.pdf
• 442_Plan_Document_Amend2_COVID19_Svcs.pdf
• 442_Plan_Document_Amend3_Autism_Spectrum_Svcs.pdf
• 442_Plan_Document_Amend4_Specialty_Drugs.pdf
• 442_Plan_Document_and_Summary_Plan_Description.pdf
• 442_SBC_Summary_of_Benef_and_Cov_PlanA_500_Deduct.pdf
• 442_SBC_Summary_of_Benef_and_Cov_PlanB_2500_Deduct.pdf
• 442_SBC_Summary_of_Benef_and_Cov_PlanC_3500_Deduct.pdf
• 442_Schedule_of_Benefits_PlanA_500_Deduct.pdf
• 442_Schedule_of_Benefits_PlanB_2500_Deduct.pdf
• 442_Schedule_of_Benefits_PlanC_3500_Deduct.pdf
• 442_Supplemental_Spouse_Application.pdf
• 443_Change_Application.pdf
• 443_Enrollment_Application.pdf
• 443_FSA_reimbursement_request_form.pdf
• 443_Plan_Document_and_Summary_PlanDescription.pdf
• 443_SBC_Summary_of_Benef_and_Cov_HSA_Plans_SFXandY.pdf
• 443_SBC_Summary_of_Benef_and_Cov_Traditional_Plan_PlansAandW.pdf
• 445_Change_Application.pdf
• 445_Enrollment_Application.pdf
• 445_Plan_Document_Amend1_DomesticPartners.pdf
• 445_Plan_Document_Amend3_Midyear_OpenEnrollment.pdf
• 445_Plan_Document_and_Summary_PlanDescription.pdf
• 445_SBC_Summary_of_Benef_and_Cov_GoldPlan_PlanA.pdf
• 445_SBC_Summary_of_Benef_and_Cov_SilverPlan_PlanB.pdf
• 445_Schedule_of_Benefits_GoldPlan_PlanA.pdf
• 445_Schedule_of_Benefits_SilverPlan_PlanB.pdf
• 446_Plan_Document_Amend1_Retirees.pdf
• 446_Plan_Document_Amend2_COVID19_Svcs.pdf
• 446_Plan_Document_Amend3_Coverage_for_Retirees_and_ DepOfRetirees.pdf
• 446_Plan_Document_and_Summary_Plan_Description.pdf
• 446_SBC_Summary_of_BenefitsandCoverage.pdf
• 446_Schedule_of_Benefits.pdf
• 447_Change_Applciation.pdf
• 447_Enrollment_Application.pdf
• 447_SBC_Summary_of_BenefitsAndCoverage.pdf
• 447_Schedule_of_Benefits.pdf
• 448_Change_Application.pdf
• 448_Enrollment_Application.pdf
• 448_Plan_Document_and_Summary_Plan_Desc.pdf
• 448_SBC_Summary_of_Benef_and_Cov_PlanA_CopaymentPlan.pdf
• 448_SBC_Summary_of_Benef_and_Cov_PlansSandF_HSAPlan.pdf
• 448_Schedule_of_Benef_PlanA_CopaymentPlan.pdf
• 448_Schedule_of_Benef_PlansSandF_HSAPlan.pdf
• 449_AIMM_Overview_Medical_Mgmt_and_PatientAdvocacy.pdf
• 449_Change_App_3_2019.pdf
• 449_Enrollment_App_3_2019.pdf
• 449_Low_Cost_Pharmacies.pdf
• 449_Plan_Document_and_Summary_PlanDescription.pdf
• 449_SBC_Summary_of_Benefits_and_Coverage.pdf
• 449_Schedule_of_Benefits_1_2020_RBRPlan_ClassA.pdf
• 449_USRx_Care_Mail_Order_Rx_Instructions_2019.pdf
• 449_USRx_Care_Member_FAQs.pdf
• 449_USRx_Care_Zero_CoPay_List_2019_eff_030119.pdf
• 449_USRx_PBM_Welcome_Letter_Westbrook_2019.pdf
• 454_Enrollment_Application.pdf
• 454_Getting_Started_with_Teladoc.pdf
• 454_SBC_Summary_of_Benefits_and_Coverage.pdf
• 454_Schedule_of_Benefits.pdf
• 457_Enrollment_Application.pdf
• 457_Plan_Doc_and_Summ_Plan_Desc_PlanA_PreventivePlan.pdf
• 457_Plan_Doc_and_Summ_Plan_Desc_PlanB_PlusBenefitPlan.pdf
• 457_SBC_Summary_of_Benef_and_Cov_PlanA_PreventivePlan.pdf
• 457_SBC_Summary_of_Benef_and_Cover_PlanB_PlusBenefitPlan.pdf
• 457_Schedule_of_Benef_PlanA_PreventivePlan.pdf
• 457_Schedule_of_Benef_PlanB_PlusBenefitPlan.pdf
• 457_Teladoc_10_copayment.pdf
• 458_Enrollment_Application.pdf
• 458_Plan_Doc_Amend1_SpecialtyDrugCosts.pdf
• 458_Plan_Doc_and_Summ_PlanDescription.pdf
• 458_SBC_Summary_of_Benefits_and_Coverage.pdf
• 458_Schedule_of_Benefits.pdf
• 459_Enrollment_Application.pdf
• 459_SBC_Summ_of_Benef_and_Cov_MECPlan.pdf
• 459_Schedule_of_Benef_MECPlan.pdf
• 460_Enrollment_Application.pdf
• 460_Schedule_of_Benefits.pdf
• 461_Change_Application.pdf
• 461_Enrollment_Application.pdf
• 461_Getting_Started_with_Teladoc.pdf
• 461_Plan_Doc_Amend1_EmploymentWaitingPeriod.pdf
• 461_Plan_Doc_and_Summ_PlanDescription.pdf
• 461_Schedule_of_Benef_PlanA_PPOPlatinumPlan.pdf
• 461_Schedule_of_Benef_PlanB_PPOGoldPlan.pdf
• 461_Schedule_of_Benef_PlanC_EPOBronzePlan.pdf
• 461_Schedule_of_Benef_PlanD_EPOSilverPlan.pdf
• 461_Summ_of_Benef_and_Cov_PlanA_PPOPlatinumPlan.pdf
• 461_Summ_of_Benef_and_Cov_PlanB_PPOGoldPlan.pdf
• 461_Summ_of_Benef_and_Cov_PlanC_EPOBronzePlan.pdf
• 461_Summ_of_Benef_and_Cov_PlanD_EPOSilverPlan.pdf
• 462_Change_Application.pdf
• 462_Enrollment_Application.pdf
• 462_Schedule_of_Benefits.pdf
• 463_Hospital_Indem_Plan_Req_for_Reimbursement_form.pdf
• 463_Vision_Plan_Req_for_Reimbursement_form.pdf
• 465_Plan_Doc_and_Summ_PlanDescription.pdf
• 465_Schedule_of_Benef_PlanA_BasePlan.pdf
• 465_Schedule_of_Benef_PlanB_MidPlan.pdf
• 465_Schedule_of_Benef_PlanC_HighPlan.pdf
• 465_Summ_of_Benef_and_Cov_PlanA_BasePlan.pdf
• 465_Summ_of_Benef_and_Cov_PlanB_MidPlan.pdf
• 465_Summ_of_Benef_and_Cov_PlanC_HighPlan.pdf
• 465_Teladoc_Talk_to_a_Doctor.pdf
• 466_Change_Application.pdf
• 466_Enrollment_Application.pdf
• 466_Schedule_of_Benefits.pdf
• 467_Change_Application.pdf
• 467_Enrollment_Application.pdf
• 467_HSTConnect_Mobile_App.pdf
• 467_HSTs_Patient_Advocacy_Center_FAQ.pdf
• 467_How_to_Install_HSTConnect.pdf
• 467_Schedule_of_Benefits.pdf
• 467_Summ_of_Benef_and_Coverage.pdf
• 468_Schedule_of_Benef_PlanA_Plan1000_80.pdf
• 468_Schedule_of_Benef_PlanB_Plan2000_80.pdf
• 468_Schedule_of_Benef_PlanC_Plan3000_70.pdf
• 468_Summ_of_Benef_and_Cov_PlanA_Plan1000_80.pdf
• 468_Summ_of_Benef_and_Cov_PlanB_Plan2000_80.pdf
• 468_Summ_of_Benef_and_Cov_PlanC_Plan3000_70.pdf
• 468_Teladoc_Getting_Started_0.pdf
• AIMM_Overview_Medical_Mgmt_and_Patient_Advocacy.pdf
• Healthcare_Bluebook_Frequently_Asked_Questions.pdf
• KISx_0_Cost_Surgery_Benefit.pdf
• QSEHRA_Documentation_of_Coverage_Form.pdf
• QSEHRA_Reimbursement_Request_Form.pdf
• Teladoc_Getting_Started.pdf
• Teladoc_Getting_Started_0.pdf
• Teladoc_Getting_Started_45.pdf
• Types_of_Minimum_Essential_Coverage_MEC.pdf
• UCM_Telemedicine_How_to_Get_Started.pdf
• UCM_Telemedicine_Information.pdf