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As you review the forms and documents, please note that benefits schedules and provider directories (e.g., the Dental Plan Schedule of Services) may change regularly. Be sure to check with the Fund Office if you have a question regarding a particular benefit or provider.
How the HRA Works / Earning Money for Your HRA
“Healthy Activity” Forms (you can complete online, print, and return to the Fund)
- Contact Information
- Healthy Lifestyle Activities
- Physical Exam and Health Screening
- Preventive Healthcare Services
HRA Prescription Option
No Surprise Billing Rights and Protection Notice
Preventive Care Information
Provider Information
Working Spouse Rule
Medical – Active Participants
Summaries of Benefits and Coverage (SBCs) – as required under the Affordable Care Act
Indemnity PPO Medical Plan
Kaiser HMO (offered to Platinum and Platinum Plus Participants only)
Anthem Blue Cross HMO (offered to Platinum Plus Participants only)
- Anthem Blue Cross SBC Select and CA Care (LC) Network Plan A Platinum Plus
- Anthem Blue Cross SBC Select and CA Care (LC) Network Plan B Platinum Plus
- Anthem Blue Cross SBC CA Care Network Plan A Platinum Plus
- Anthem Blue Cross SBC CA Care Network Plan B Platinum Plus
- Health Care Benefit Highlights booklet for Retirees Except Class E who are members of Kaiser Senior Advantage
- Notice of Creditable Coverage for Medicare-eligible except Class E Retirees
- Notice of Creditable Coverage for Medicare-eligible except Class E Retirees (2023)
- Notice of Non-Creditable Coverage for Class E Retirees who are enrolled in the Indemnity PPO Medical Plan or the Anthem Medicare Preferred PPO
- Notice of Non-Creditable Coverage for Class E Retirees who are enrolled in the Indemnity PPO Medical Plan or the Anthem Medicare Preferred PPO (2023)
- Notice of Creditable Coverage for Class E Retiree who are members of Kaiser Senior Advantage
- Notice of Creditable Coverage for Class E Retiree who are members of Kaiser Senior Advantage (2023)
- Plan Benefits Chart for Retirees Except Class E
- Summary Comparison of Medical & Dental Plans Booklet for Class E Retirees
- Dental Summary Plan Description (SPD) (2023)
- Dental Summary Plan Description (SPD) (2021-2022)
- Schedule of Dental Service Allowance (2023)
- Schedule of Dental Service Allowance (2022)
- Orthodontist Network Directory (Coming Soon)
- Prepaid Dental Offices
Delta Dental PPO Plan
Delta Dental Benefit Highlights
The coinsurance shown in the Delta Dental PPO Benefit Highlights below reflects your cost-sharing responsibility. Reimbursement is based on PPO contracted fees for PPO dentists, Premier contracted fees for Premier dentists and program allowance for non-Delta Dental dentists.
Podiatry benefits are available to Indemnity PPO Medical Plan Participants. HMO Participants should review their HMO’s Evidence of Coverage for additional information.
- Death Beneficiary Designation Initial Form (Signing up the first time)
- Death Beneficiary Designation Change Form (Changing a Beneficiary designation)