Left Navigation

 

Forms & Publications

You can ask for a paper copy of your Summary of Benefits and Coverage (SBC) at any time, free of charge. Go to Forms and Publications. 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 - Friday 8:30AM to 8:00PM ET (excluding holidays) to request a copy.

The Medical Trust can also provide an SBC in a Spanish, Chinese, Tagalog, and Navaho. Please see our Notice of Nondiscrimination policy page or call Client Services for more information.

 

To request a copy by mail, check the box next to the title and click 

Active Clergy & Lay Employee Health Plan Information - 2019

  Title What is This For? Pgs
Annual Enrollment Guide - 2019 Information about 2019 health plans and making a plan selection

26

Anthem BCBS BlueCard PPO 100 - 2019 Summary of benefits

6

Anthem BCBS BlueCard PPO 90 - 2019 Summary of benefits

6

Anthem BCBS BlueCard PPO 80 - 2019 Summary of benefits

6

Anthem BCBS BlueCard PPO 70 - 2019 Summary of benefits

6

Anthem BCBS CDHP-15/HSA - 2019 Summary of benefits

6

Anthem BCBS CDHP-20/HSA - 2019 Summary of benefits

6

Anthem BCBS CDHP-40/HSA - 2019 Summary of benefits

6

Cigna Open Access Plus PPO 100 - 2019 Summary of benefits

6

Cigna Open Access Plus PPO 90 - 2019 Summary of benefits

6

Cigna Open Access Plus PPO 80 - 2019 Summary of benefits

6

Cigna Open Access Plus PPO 70 - 2019 Summary of benefits

6

Cigna Open Access Plus CDHP-15/HSA - 2019 Summary of benefits

6

Cigna Open Access Plus CDHP-20/HSA - 2019 Summary of benefits

6

Cigna Open Access Plus CDHP-40/HSA - 2019 Summary of benefits

6

Kaiser High EPO - 2019 Summary of benefits

6

Kaiser EPO 80 - 2019 Summary of benefits

6

Kaiser CDHP-20 - 2019 Summary of benefits

6

Back to Top

 

To request a copy by mail, check the box next to the title and click 

Active Clergy & Lay Employee Health Plan Information - 2018

  Title What is This For? Pgs
Open Enrollment Guide - 2018 Information about 2018 health plans and making a plan selection

31

Anthem BCBS Handbook - 2018 Handbook of plan details

109

Cigna Handbook - 2018 Handbook of plan details

103

Kaiser Permanente Handbook - 2018 Handbook of plan details

114

Anthem BCBS BlueCard PPO 100 Summary - 2018 Summary of benefits

1

Anthem BCBS BlueCard PPO 90 Summary - 2018 Summary of benefits

1

Anthem BCBS BlueCard PPO 80 Summary - 2018 Summary of benefits

1

Anthem BCBS BlueCard PPO 70 Summary - 2018 Summary of benefits

1

Anthem BCBS 90/70 PPO Summary - 2018 Summary of benefits

1

Anthem BCBS 80/60 PPO Summary - 2018 Summary of benefits

1

Anthem BCBS 75/50 PPO Summary - 2018 Summary of benefits

1

Anthem BCBS High Option Summary - 2018 Summary of benefits

1

Anthem BCBS 70 SLV Summary - 2018 Summary of benefits

1

Anthem BCBS EPO 90 Summary - 2018 Summary of benefits

1

Anthem BCBS EPO 80 Summary - 2018 Summary of benefits

1

Anthem BCBS CDHP-15 Summary - 2018 Summary of benefits

1

Anthem BCBS CDHP-20 Summary - 2018 Summary of benefits

1

Anthem BCBS CDHP-40 Summary - 2018 Summary of benefits

1

Cigna Open Access Plus Summary - 2018 Summary of benefits

1

Cigna Open Access Plus In-Network (OAP-IN) Summary - 2018 Summary of benefits

1

Cigna CDHP-20 Summary - 2018 Summary of benefits

1

Kaiser Permanente EPO 80 Summary - 2018 Summary of benefits

1

Kaiser Permanente EPO High Summary - 2018 Summary of benefits

1

Kaiser Permanente CDHP-20 Summary - 2018 Summary of benefits

1

CDHP/HSA Fact Sheet for Members - 2017/2018 Information about Consumer Directed Health Plans and Health Savings Accounts for 2017-2018

6

Prescription Drug Benefit Fact Sheet 2018 The Medical Trust Pharmacy Benefit Fact Sheet

4

Back to Top

 

To request a copy by mail, check the box next to the title and click 

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

Back to Top

To request a copy by mail, check the box next to the title and click 

Medicare Secondary Payer  (SEE) Publications

Title What is This For? Pgs
Medicare Secondary Payer SEE Member Fact Sheet Medicare Secondary Payer - Small Employer Exception

5

Back to Top

To request a copy by mail, check the box next to the title and click 

Popular Forms

Title What is This For? Contact Information
Behavioral Health Out of Network Claim Form Member claim form

Cigna Behavioral Health, Inc.
Attn: Claims Service Dept.
P.O. Box 188022
Chattanooga, TN 37422

Behavioral Health Claim Form (Cigna) To submit a claim for behavioral health expenses

Cigna Behavioral Health, Inc.
Attn: Claims Service Dept.
P.O. Box 188022
Chattanooga, TN 37422

Or follow mailing instructions 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

Dental Claim Form (Cigna) To submit a claim for dental services

For mailing address, call Customer Service at number listed on your ID Card

Employee Medical and Dental Enrollment Form To enroll a new employee or late enrollment in medical and/or dental plans

The Episcopal Church Medical Trust
19 East 34th Street
New York, NY 10016

Express Scripts Home Delivery Order Form (Active Employees) Express Scripts Home Delivery Order Form (Active Employees)

EXPRESS SCRIPTS
PO BOX 747000
CINCINNATI, OH 45274-7000

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

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

Medical Claim Form (Anthem) To submit a claim for medical expenses

Anthem Blue Cross and Blue Shield
PO Box 105187
Atlanta, GA 30348

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: 1-866-213-3062

Medical Information Authorization Form To authorize use or disclosure of your medical information

JoAnn Goetz,
Clinical Management
The Episcopal Church Medical Trust
19 East 34th Street
New York, NY 10016
Confidential Fax: (212) 592-1831

Back to Top

 

To request a copy by mail, check the box next to the title and click 

Dental Plan Information - 2019

  Title What is This For? Pgs
Cigna Preventive Dental PPO - 2019 Summary of benefits

6

Cigna Basic Dental PPO - 2019 Summary of benefits

6

Cigna Dental & Orthodontia PPO - 2019 Summary of benefits

6

Back to Top

 

To request a copy by mail, check the box next to the title and click 

Dental Plan Information - 2018

  Title What is This For? Pgs
Cigna Dental Handbook - 2018 Handbook of plan details

1

Cigna Preventive Dental Summary - 2018 Summary of benefits

1

Health-Cigna Basic Dental Summary - 2018 Summary of benefits

1

Cigna Dental and Orthodontia Summary - 2018 Summary of benefits

1

Back to Top

 

To request a copy by mail, check the box next to the title and click 

Vision

  Title What is This For? Pgs
EyeMed Insight Network EMT Brochure and Summary of Benefits EyeMed Insight Network benefits for the Episcopal Church Medical Trust

2

Back to Top

 

To request a copy by mail, check the box next to the title and click 

Hearing

Title What is This For? Pgs
Amplifon Hearing Health Care Flyer About the Amplifon Hearing Health Care provider network

1

Amplifon Hearing Health Care Spring 2015 Newsletter Amplifon Hearing Health Care Newsletter: Spring 2015

4

Amplifon Hearing Health Care Summer 2015 Newsletter Amplifon Hearing Health Care Newsletter: Summer 2015

3

Back to Top

 

To request a copy by mail, check the box next to the title and click 

Mental Health

Title What is This For? Pgs
100 Reasons to Call the Employee Assistance Program 100 Reasons to call EAP

4

Employee Assistance Program (EAP) Get 24/7 help with behavioral health, family, and personal issues

2

Employee Assistance Program (EAP) For Clergy For clergy to get 24/7 help with behavioral health, family, and personal issues

2

Back to Top

 

To request a copy by mail, check the box next to the title and click 

Travel Medical Assistance

  Title What is This For? Pgs
United Healthcare Global Assistance Brochure Emergency assistance available when traveling

6

Back to Top

Health Advocate

Title What is This For? Pgs
Health Advocate Brochure A personal health advocate service to help you with healthcare and insurance issues

6

Back to Top

Your Health Records

Title What is This For? Contact Information
Charting a Healthy Course Personal Health Record

Personal Health Record To maintain and organize personal health records and information

Personal Medical Record Personal Medical Record

Back to Top

To request a copy by mail, check the box next to the title and click 

Health News

  Title What is This For? Pgs
N/A Health-Health News, Spring 2018 Exploring strength in community

1

N/A Health News, Winter 2018 Inspiration to meet your goals

1

N/A Health News, Fall 2017 Fall colors: The changing seasons of life. Preparing for the times ahead.

1

N/A Health News, Summer 2017 Summer wellness: what to do when the heat is on!

1

Health News, Spring 2017 Planting the Seeds for Your Tomorrow

1

Health News, Winter 2017 Being SMART about the New Year

1

Health News, Fall 2016 Putting Your Fears in Perspective

3

Health News, July/Aug 2016 Finding Freedom Across Your Life

5

Health News, Spring 2016 Springing into Action: Check In, Check Out, Check-up

5

Health News, Summer 2015 Health & Wellness News - Summer 2015

3

Health News, Spring 2015 Health & Wellness News - Spring 2015

3

Health News, Winter 2015 Setting Up for Success in 2015

3

Health News, Summer 2014 Health and Wellness Spotlight

3

Health News, Fall 2014 Fall edition of Health & Wellness News

3

Health News, November 2013 Member Stories

1

Health News, July/August 2013 Healthy Living

3

Back to Top

 


* Our online documents are available for immediate download and viewing using Adobe's FREE Acrobat Reader.

Health benefits are offered through plans maintained by Church Pension Group Services Corporation (doing business as The Episcopal Church Medical Trust), 19 East 34th Street, New York, NY 10016.

The Episcopal Church Medical Trust Disclaimer