Health Plans

You can ask for a paper copy of your Summary of Benefits and Coverage (SBC) at any time, free of charge. Check the box next to the Summary you want and then click on Mail It to Me. You can also call Client Services at (800) 480-9967 Monday to Friday 8:30 AM to 8:00 PM ET to request a copy.

Translations are available in Spanish, Chinese, Tagalog, Navaho, and Pennsylvania Dutch.

 

Stay tuned for updated 2025 plan document handbooks.

2025 summaries of benefits and coverage are available below.

Active Clergy & Lay Employee Health Plan Information - 2025
Title
What is this for?
Pages
Mail It
Anthem BCBS CDHP 15 - 2025
Summary of Benefits and Coverage (SBC)
6
Anthem BCBS CDHP 20 - 2025
Summary of Benefits and Coverage (SBC)
6
Anthem BCBS CDHP 40 - 2025
Summary of Benefits and Coverage (SBC)
6
Anthem BCBS PPO 70 - 2025
Summary and Benefits and Coverage (SBC)
6
Anthem BCBS PPO 80 - 2025
Summary of Benefits and Coverage (SBC)
6
Anthem BCBS PPO 90 - 2025
Summary of Benefits and Coverage (SBC)
6
Anthem BCBS PPO 100 - 2025
Summary of Benefits and Coverage (SBC)
6
Cigna CDHP 15 - 2025
Summary of Benefits and Coverage (SBC)
6
Cigna CDHP 20 - 2025
Summary of Benefits and Coverage (SBC)
6
Cigna CDHP 40 - 2025
Summary of Benefits and Coverage (SBC)
6
Cigna PPO 70 - 2025
Summary of Benefits and Coverage (SBC)
6
Cigna PPO 80 - 2025
Summary of Benefits and Coverage (SBC)
6
Cigna PPO 90 - 2025
Summary of Benefits and Coverage (SBC)
6
Cigna PPO 100 - 2025
Summary of Benefits and Coverage (SBC)
6
Kaiser CDHP 20 - 2025
Summary of Benefits and Coverage (SBC)
6
Kaiser EPO 80 - 2025
Summary of Benefits and Coverage (SBC)
6
Kaiser EPO High - 2025
Summary of Benefits and Coverage (SBC)
6
HMSA HPH-A CM Drug Vision Dental HMO - 2025
Summary of Benefits and Coverage (SBC)
8
HMSA PPO CM Drug Vision Dental PPP - 2025
Summary of Benefits and Coverage (SBC)
8
HMSA HPH-A CM Drug Vision Dental PPP - 2025
Summary of Benefits and Coverage (SBC)
8
HMSA PPO CM Drug Vision Dental HMO - 2025
Summary of Benefits and Coverage (SBC)
8
2022-2023 CDHP/HSA Fact Sheet for Members
Information for members on Consumer Directed Health Plans (CDHP) and Health Savings Account (HSA)
7
Seminarian Health Plan Information - 2025
Title
What is this for?
Pages
Mail It
Anthem BCBS CDHP 20 - 2025
Summary of Benefits and Coverage (SBC)
6
Anthem BCBS CDHP 40 - 2025
Summary of Benefits and Coverage (SBC)
6
Anthem BCBS PPO 70 - 2025
Summary and Benefits and Coverage (SBC)
6
Anthem BCBS PPO 80 - 2025
Summary of Benefits and Coverage (SBC)
6
Cigna CDHP 20 - 2025
Summary of Benefits and Coverage (SBC)
6
Cigna CDHP 40 - 2025
Summary of Benefits and Coverage (SBC)
6
Cigna PPO 70 - 2025
Summary of Benefits and Coverage (SBC)
6
Cigna PPO 80 - 2025
Summary of Benefits and Coverage (SBC)
6
2022-2023 CDHP/HSA Fact Sheet for Members
Information for members on Consumer Directed Health Plans (CDHP) and Health Savings Account (HSA)
7
Dental Plan Information - 2025
Title
What is this for?
Pages
Mail It
Delta Dental Premium - 2025
Summary of Benefits and Coverage (SBC)
6
Delta Dental Comprehensive - 2025
Summary of Benefits and Coverage (SBC)
6
Delta Dental Basic - 2025
Summary of Benefits and Coverage (SBC)
6
Retired Clergy & Lay Employee Health Plan Information - 2025
Title
What is this for?
Pages
Mail It
UHC GMA Plan Guide - 2025
A guide to the 2025 UnitedHealthcare® Group Medicare Advantage (PPO) plan
120
UHC GMA Comprehensive (PPO) - 2025
Summary of Benefits and Coverage (SBC)
6
UHC GMA Premium (PPO) - 2025
Summary of Benefits and Coverage (SBC)
6
Active Clergy & Lay Employee Health Plan Information - 2024
Title
What is this for?
Pages
Mail It
Anthem BCBS CDHP 15 - 2024
Summary of Benefits and Coverage (SBC)
6
Anthem BCBS CDHP 20 - 2024
Summary of Benefits and Coverage (SBC)
6
Anthem BCBS CDHP 40 - 2024
Summary of Benefits and Coverage (SBC)
6
Anthem BCBS PPO 70 - 2024
Summary of Benefits and Coverage (SBC)
6
Anthem BCBS PPO 80 - 2024
Summary of Benefits and Coverage (SBC)
6
Anthem BCBS PPO 90 - 2024
Summary of Benefits and Coverage (SBC)
6
Anthem BCBS PPO 100 - 2024
Summary of Benefits and Coverage (SBC)
6
Anthem BCBS Handbook 2024
Plan Document Handbook
120
Cigna CDHP 15 - 2024
Summary of Benefits and Coverage (SBC)
6
Cigna CDHP 20 - 2024
Summary of Benefits and Coverage (SBC)
6
Cigna CDHP 40 - 2024
Summary of Benefits and Coverage (SBC)
6
Cigna Open Access Plus PPO 70 - 2024
Summary of Benefits and Coverage (SBC)
6
Cigna Open Access Plus PPO 80 - 2024
Summary of Benefits and Coverage (SBC)
6
Cigna Open Access Plus PPO 90 - 2024
Summary of Benefits and Coverage (SBC)
6
Cigna Open Access Plus PPO 100 - 2024
Summary of Benefits and Coverage (SBC)
6
Cigna Handbook 2024
Plan Document Handbook
111
Kaiser CDHP 20 - 2024
Summary of Benefits and Coverage (SBC)
6
Kaiser EPO High - 2024
Summary of Benefits and Coverage (SBC)
6
Kaiser EPO 80 - 2024
Summary of Benefits and Coverage (SBC)
6
Kaiser Permanente Handbook 2024
Plan Document Handbook
177
Seminarian Health Plan Information - 2024
Title
What is this for?
Pages
Mail It
Anthem BCBS CDHP 20 - 2024
Summary of Benefits and Coverage (SBC)
6
Anthem BCBS CDHP 40 - 2024
Summary of Benefits and Coverage (SBC)
6
Anthem BCBS PPO 70 - 2024
Summary of Benefits and Coverage (SBC)
6
Anthem BCBS PPO 80 - 2024
Summary of Benefits and Coverage (SBC)
6
Anthem BCBS Handbook 2024
Plan Document Handbook
120
Cigna CDHP 20 - 2024
Summary of Benefits and Coverage (SBC)
6
Cigna CDHP 40 - 2024
Summary of Benefits and Coverage (SBC)
6
Cigna Open Access Plus PPO 70 - 2024
Summary of Benefits and Coverage (SBC)
6
Cigna Open Access Plus PPO 80 - 2024
Summary of Benefits and Coverage (SBC)
6
Cigna Handbook 2024
Plan Document Handbook
111
Dental Plan Information - 2024
Title
What is this for?
Pages
Mail It
Welcome to Delta Dental Flyer
Information about the switch to Delta Dental as our dental vendor in 2024
2
N/A
Delta Dental Handbook - 2024
Plan Document Handbook
60
Delta Dental Basic - 2024
Benefits Highlight Sheet (Summary)
2
Delta Dental Comprehensive - 2024
Benefits Highlight Sheet (Summary)
2
Delta Dental Premium - 2024
Benefits Highlight Sheet (Summary)
2
Retired Clergy & Lay Employee Health Plan Information - 2024
Title
What is this for?
Pages
Mail It
Plan Guide 2024
A guide to the 2024 UnitedHealthcare® Group Medicare Advantage (PPO) plan
84
UHC GMA Comprehensive (PPO) Summary 2024
Summary of benefits and coverage
12
UHC GMA Premium (PPO) Summary 2024
Summary of benefits and coverage
12
2024 Retiree Annual Enrollment Letter
Group Medicare Advantage Annual Enrollment information for retirees/post-65 former employees
5
N/A
2024 Kaiser Retiree Annual Enrollment Letter
Kaiser Annual Enrollment information for retirees
5
N/A
Understanding Health Plan Options for Employees Age 65+
To help employers and employees understand health plan coverage options for active clergy or lay employees, or those returning to work after retirement
5
N/A
Additional Benefits
Title
What is this for?
Pages
Mail It
100 Reasons to Call the Employee Assistance Program
100 Reasons to call EAP
3
N/A
Employee Assistance Program (EAP)
Get 24/7 help with behavioral health, family, and personal issues
2
N/A
Employee Assistance Program (EAP) For Clergy
For clergy to get 24/7 help with behavioral health, family, and personal issues
2
N/A
United Healthcare Global Assistance Brochure
Emergency assistance available when traveling
6
EyeMed Insight Network EMT Brochure and Summary of Benefits
EyeMed Insight Network benefits for The Episcopal Church Medical Trust
2
U.S. Medical Glossary
Understand common healthcare terms
6
Claims
Title
What is this for?
Contact Information
International Medical Claim Form (Anthem)
To submit a claim for international medical expenses
Medical Claim Form (Cigna)
To submit a claim for medical expenses
Mail form with itemized bills to Cigna address on your ID Card
Medical Claim Form (Kaiser Permanente)
To submit a claim for medical expenses
Kaiser Permanente Insurance Company (KPIC) Self-Funded Claims Administrator P.O. BOX 30547 Salt Lake City, UT 84130-0547 Phone: (866) 213-3062
Dental Claim Form (Delta Dental)
To submit a claim for dental services
For mailing address, call Customer Service at number listed on your ID Card
Dental Claim Form (Cigna)
To submit a claim for dental services
For mailing address, call Customer Service at number listed on your ID Card
Colleague Group Claim Form
Colleague Group Reimbursement Claim Form
The Episcopal Church Medical Trust 19 East 34th Street, New York, NY, 10016; or fax to (212) 251-8891
Prescription Drug Claim Form (Express Scripts)
To submit a claim for prescription drugs
Express Scripts, Inc. P.O. Box 66583 St. Louis, MO 63166-6583 ATTN: NGC STD ACCTS
Prescription Drug Claim Form (Kaiser Permanente)
To request reimbursement for covered medications purchased at retail cost
Send completed form with pharmacy receipt(s) to: OptumRx Claims Department P.O. Box 29044 Hot Springs, AR 71903
Medicare Part D Prescription Drug Claim Form
Prescription Claim Form for Medicare Part D
Express Scripts ATTN: Medicare Part D P.O. Box 14718 Lexington, KY 40512-4718 FAX: (608) 741-5483
EyeMed Out of Network Vision Services Claim Form
Out of Network Vision Services Claim Form
EyeMed Vision Care Attn: OON Claims P.O. Box 8504 Mason, OH 45040-7111
UnitedHealthcare Medical Reimbursement Request Form
Group Medicare Advantage (GMA) members requesting reimbursement for covered medical care and supplies. Use for claims claims within, and outside of the US.
Send completed form and paperwork to the address on the back of your member ID card.
UnitedHealthcare Optum Rx PDP Prescription Reimbursement Request Form
Group Medicare Advantage (GMA) members requesting reimbursement for covered medications purchased at retail cost. Use for claims claims within, and outside of the US.
OptumRx Claims Department, P.O. Box 29046, Hot Springs, AR 71903
International Travel Claim Submission Form-Medicare Supplement Plans Only
Submitting international travel claims for Retirees participating in Medicare Supplement plans only
Episcopal Church Medical Trust Travel Protection Benefit Coordinator PO Box 2745 New York, NY 10163
Medicare Secondary Payer (SEE) Forms
Title
What is this for?
Contact Information
Medicare Secondary Payer Eligibility Certification Form
Eligibility for the Episcopal Health Plan for Qualified Small Employer Exception Members (the SEE Plan)
The Episcopal Church Medical Trust 19 East 34th Street, New York, NY, 10016 or fax to (212) 251-8891
Medicare Secondary Payer (SEE) Publications
Title
What is this for?
Pages
Medicare Secondary Payer SEE Member Fact Sheet
Medicare Secondary Payer - Small Employer Exception
3
Medicare Secondary Payer SEE Letter to Members
Letter sent to members explaining Medicare Secondary Payer See program
2
Denominational Health Plan (DHP) Annual Reports
Title
What is this for?
Pages
DHP Annual Report 2023 - English
2023 Annual Report on the Denominational Health Plan
7
DHP Annual Report 2023 - Espanol
2023 Annual Report on the Denominational Health Plan
8
DHP Annual Report 2022 - English
2022 Annual Report on the Denominational Health Plan
7
DHP Annual Report 2022 - Espanol
2022 Annual Report on the Denominational Health Plan
7
DHP Annual Report 2021 - English
2021 Annual Report on the Denominational Health Plan
6
DHP Annual Report 2021 - Espanol
2021 Annual Report on the Denominational Health Plan
6
DHP Annual Report 2020 - English
2020 Annual Report on the Denominational Health Plan
3
DHP Annual Report 2020 - Español
2020 Annual Report on the Denominational Health Plan
3
DHP Annual Report 2020 - French
2020 Annual Report on the Denominational Health Plan
3
DHP Annual Report 2020 - Chinese
2020 Annual Report on the Denominational Health Plan
3
Regulatory Notices
Title
What is this for?
Pages
Mail It
Your Rights and Protections Against Surprise Medical Bills
No Surprises Act Notice
2
N/A
Children’s Health Insurance Program (CHIP) Information
Children's Health Insurance Program
3
HIPAA Notice of Special Enrollment Rights
HIPAA Notice of Special Enrollment Rights
1
HIPAA Privacy Notice
HIPAA Notice of Privacy Practices
5
Women’s Health and Cancer Rights Act (WHCRA) Notice
Women’s Health and Cancer Rights Act Notice
1
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