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Summary Plan Description
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Documents & Forms
Plan Forms
2023 Beneficiary Designation Form
Affidavit of Retirement Form August 2025
2026 HRA Reimbursement Form
- effective January 1, 2026
2026 HRA Reimbursement Form for Providers
- effective January 1, 2026
Disability Claim Form
Other Insurance Form
IRS Publication 502 - Medical and Dental Expenses (Including the Health Coverage Tax Credit)
Plan Documents
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
No Surprises Act - Out of Network Providers and Balance Billing Prohibitions
Notice of Privacy Practices
Annual WHCRA Breast Reconstruction Notice
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