Plan Documents & Forms

Plan Documents & Amendments

Summary Plan Description & Plan Document

Forms

Anthem Member Claim Form
Change of Address
Change of Address (Spanish Form)
Continued Coverage for Incapacitated Child
COVID-19 OTC Reimbursement Claim Form
Enrollment Form
Kaiser Enrollment/Change Form
Short-Term Disability Form
Short-Term Disability Form (Spanish Form)
UHC Dental Enrollment Form

Notices

Notice of Creditable Coverage

2022 NOCC

Other Notices

COBRA Notice
December 2024 – Summary of Material Modification (Anthem Dental PPO Plan Improvements)
Kaiser Evidence of Coverage
Nondiscrimination Statement
Surprise Billing Notice (English)
Surprise Billing Notice (Spanish)
Women’s Health & Cancer Rights
2026 Notice of Privacy Policy

Reports

2021 Summary Annual Report

Summary of Benefits & Coverage (SBC)

Anthem Basic Indemnity SBC

Anthem Enhanced Indemnity SBC

Kaiser Permanente DHMO SBC

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