Resource Library

Medical summaries of benefits and coverage (SBC)
Prescription drug coverage (provided by CVS Caremark)
Plan descriptions and summaries
Schedule of benefits
Benefit forms
Compliance notices

Medical summaries of benefits coverage (SBC)

Aetna

• Aetna HDHP Standard (Choice POS II) – 2018 [PDF]
• Aetna HDHP Standard (Choice POS II) – 2019 [PDF]
• Aetna HDHP Premium (Choice POS II) – 2018 [PDF]
• Aetna HDHP Premium (Choice POS II) – 2019 [PDF]
• Aetna EPO (Select) – 2018 [PDF]
• Aetna EPO (Select) – 2019 [PDF]
• Aetna Indemnity (Traditional Choice) – 2018 [PDF]
• Aetna Indemnity (Traditional Choice) – 2019 [PDF]
• Aetna PPO (Choice POS II) – 2018 [PDF]
• Aetna PPO (Choice POS II) – 2019 [PDF]

HMSA

• HMSA (Hawaii) – 2018 [PDF]
• HMSA (Hawaii) – 2019 [PDF]

Kaiser

• Kaiser HMO (California) – 2018 [PDF]
• Kaiser HMO (California) – 2019 [PDF]
• Kaiser HMO (Oregon) – 2018 [PDF]
• Kaiser HMO (Oregon) – 2019 [PDF]

UnitedHealthcare (UHC)

• UHC EPO (Choice) – 2018 [PDF]
• UHC EPO (Choice) – 2019 [PDF]
• UHC HDHP Standard (Choice Plus) – 2018 [PDF]
• UHC HDHP Standard (Choice Plus) – 2019 [PDF]
• UHC HDHP Premium (Choice Plus) – 2018 [PDF]
• UHC HDHP Premium (Choice Plus) – 2019 [PDF]
• UHC PPO (Choice Plus) – 2018 [PDF]
• UHC PPO (Choice Plus) – 2019 [PDF]

Prescription drug coverage (provided by CVS Caremark)

Aetna

• Aetna HDHP Standard (Choice POS II) – 2018 [PDF]
• Aetna HDHP Premium (Choice POS II) – 2018 [PDF]
• Aetna PPO (Choice POS II) – 2018 [PDF]
• Aetna Indemnity (Traditional Choice) – 2018 [PDF]
• Aetna EPO (Select) – 2018 [PDF]

UnitedHealthcare (UHC)

• UHC HDHP Premium (Choice Plus) – 2018 [PDF]
• UHC HDHP Standard (Choice Plus) – 2018 [PDF]
• UHC EPO (Choice) – 2018 [PDF]
• UHC PPO (Choice Plus) – 2018 [PDF]

Plan descriptions and summaries

Medical: Aetna

• Aetna HDHP Standard – 2018 summary [PDF]
• Aetna HDHP Standard – 2019 summary [PDF]
• Aetna HDHP Premium – 2018 summary [PDF]
• Aetna HDHP Premium – 2019 summary [PDF]
• Aetna PPO – 2018 summary [PDF]
• Aetna PPO – 2019 summary [PDF]
• Aetna HDHP and PPO – 2017 booklet [PDF] 
• Aetna EPO – 2018 summary [PDF]
• Aetna EPO – 2019 summary [PDF]
• Aetna EPO – 2017 booklet [PDF] 
• Aetna Indemnity – 2018 summary [PDF]
• Aetna Indemnity – 2019 summary [PDF]
• Aetna Indemnity – 2017 booklet [PDF]
• Aetna Preventive Medicine List [PDF]

Medical: UnitedHealthcare (UHC)

• UHC EPO (Choice) – 2018 summary [PDF]
• UHC EPO (Choice) – 2019 summary [PDF]
• UHC EPO (Choice) – 2018 plan description [PDF]
• UHC PPO (Choice Plus) – 2018 summary [PDF]
• UHC PPO (Choice Plus) – 2019 summary [PDF]
• UHC PPO (Choice Plus) – 2018 plan description [PDF]
• UHC PPO (Options) Utah – 2018 plan description [PDF]
• UHC HDHP Standard (Choice Plus) – 2018 summary [PDF]
• UHC HDHP Standard (Choice Plus) – 2019 summary [PDF]
• UHC HDHP Standard (Choice Plus) – 2018 plan description [PDF]
• UHC HDHP Standard (Choice Plus) Utah – 2018 plan description [PDF]
• UHC HDHP Premium (Choice Plus) – 2018 summary [PDF]
• UHC HDHP Premium (Choice Plus) – 2019 summary [PDF]
• UHC HDHP Premium (Choice Plus) – 2018 plan description [PDF]
• UHC HDHP Premium (Choice Plus) Utah – 2018 plan description [PDF]

Medical: Kaiser

• Kaiser (CA) Acupuncture and Chiropractic – 2018 summary [PDF]
• Kaiser (CA) Acupuncture and Chiropractic – 2019 summary [PDF]
• Kaiser HMO (CA) – 2018 summary [PDF]
• Kaiser HMO (CA) – 2019 summary [PDF]
• Kaiser HMO (Oregon) – 2018 summary [PDF]
• Kaiser HMO (Oregon) – 2019 summary [PDF]

Medical: HMSA

• HMSA (Hawaii) – 2017 Acupuncture Booklet [PDF]
• HMSA (Hawaii) – 2017 Booklet [PDF]

International

• Cigna International – 2017 booklet [PDF] 
• Cigna International Benefits Summary [PDF]
• Cigna Medical Benefits Abroad (MBA) [PDF]

Dental

• Delta – 2018 summary [PDF]
• Delta – 2019 summary [PDF]
• Delta Dental – 2018 booklet [PDF]

Vision

• VSP Standard – 2018 summary [PDF]
• VSP Standard – 2019 summary [PDF]
• VSP Premium – 2018 summary [PDF]
• VSP Premium – 2019 summary [PDF]
• VSP – 2017 booklet [PDF]

Employee Assistance Program

• CONCERN – Evidence of coverage [PDF]
• CONCERN – 2018 summary [PDF]
• CONCERN – 2019 summary [PDF]

Life and Accident

• Life and AD&D Prudential – 2017–2018 summary [PDF]
• Life and AD&D Prudential – 2017–2018 booklet [PDF]
• Business Travel Accident – 2015–2018 summary [PDF]
• BTA Renewal [PDF]

Disability

• Short-Term Disability Plan – 2018 booklet [PDF]
• Short-Term Disability Plan – 2019 booklet [PDF]
• Short-Term Disability Plan – 2018 summary [PDF]
• Short-Term Disability Plan – 2019 summary [PDF]
• Long-term Disability Standard – booklet [PDF] 
• Long-term Disability Standard – summary [PDF]
• Long-term Disability FAQ [PDF]
• CA Voluntary Disability Plan – 2018 booklet [PDF]
• CA Voluntary Disability Plan – 2019 booklet [PDF]
• CA Voluntary Disability Plan – 2018 summary [PDF]
• CA Voluntary Disability Plan – 2019 summary [PDF]
• Individual Disability Insurance Plan [PDF]

401(k)

• 401(k) Summary Plan Description [PDF]
• Enrollment Guide [PDF]

Summary Plan Descriptions

• Summary Plan Description (Cafeteria Plan) 2016-2017 [PDF] 
• Summary Plan Description (Wrap) – 2016-2017 [PDF]

Schedule of benefits

• Aetna HDHP Standard (Choice POS II) – 2018 [PDF]
• Aetna HDHP Premium (Choice POS II) – 2018 [PDF]
• Aetna EPO (Select) – 2018 [PDF]
• Aetna Indemnity (Traditional Choice) – 2018 [PDF]
• Aetna PPO (Choice POS II) – 2018 [PDF]

Benefit forms

• Affidavit of Dependent Status of Domestic Partner [PDF]
• Affidavit of Termination of Domestic Partner [PDF]
• Dependent Care Account Claim and Provider Documentation Form [PDF]
• Domestic Partner Declaration [PDF]
• FSA-HSA Transition Flyer [PDF]
• Healthcare Security Ordinance Form (San Francisco Only) [PDF]
• HSA Rollover Form [PDF]
• Mail Order Pharmacy Form [PDF]
• Paid Family Leave Insurance Program [PDF]

Compliance notices

• Summary Annual Report—Health and Welfare Plan [PDF]
• CA VDI Rejection Notice [PDF]
• CHIP Model notice [PDF]
• Domestic Partner Benefits Status Memo [PDF]
• HIPAA Reminder Notice [PDF]
• Legal Notices [PDF]
• Medicare Part D [PDF]
• New Health Insurance Marketplace Coverage Options and Your Health Coverage [PDF]
  • YOU HAVE COVERAGE THROUGH SALESFORCE THAT FAR EXCEEDS THE MINIMUM STANDARD. We are legally obligated to send this notice to you but suggest that you focus your limited time on making smart choices about your company benefits.
• Notice Privacy of Practices [PDF]
• Summary Annual Report—Exact Target [PDF]