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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 - 2018

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

31

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 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

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

Active Clergy & Lay Employee Health Plan Information - 2017

  Title What is This For? Pgs
Anthem Blue Cross and Blue Shield PPO 90/70 Summary - 2017 Summary of benefits

8

Anthem Blue Cross and Blue Shield PPO 90/70 Handbook - 2017 Handbook of plan details

1

Anthem Blue Cross and Blue Shield PPO 80/60 Summary - 2017 Summary of benefits

8

Anthem Blue Cross and Blue Shield PPO 80/60 Handbook - 2017 Handbook of plan details

1

Anthem Blue Cross and Blue Shield PPO 75/50 Summary - 2017 Summary of benefits

8

Anthem Blue Cross and Blue Shield PPO 75/50 Handbook - 2017 Handbook of plan details

1

Anthem Blue Cross and Blue Shield PPO High Option Summary - 2017 Summary of benefits

8

Anthem Blue Cross and Blue Shield PPO High Option Handbook - 2017 Summary of benefits

1

Anthem Blue Cross and Blue Shield 70 SLV Summary - 2017 Summary of benefits

8

Anthem Blue Cross and Blue Shield 70 SLV Handbook - 2017 Handbook of plan details

1

Anthem Blue Cross and Blue Shield EPO 90 Summary - 2017 Summary of benefits

8

Anthem Blue Cross and Blue Shield EPO 90 Handbook - 2017 Handbook of plan details

1

Anthem Blue Cross and Blue Shield EPO 80 Summary - 2017 Summary of benefits

8

Anthem Blue Cross and Blue Shield EPO 80 Handbook - 2017 Handbook of plan details

1

Anthem Blue Cross and Blue Shield CDHP-15/HSA Summary - 2017 Summary of benefits

8

Anthem Blue Cross and Blue Shield CDHP-15/HSA Handbook - 2017 Handbook of plan details

1

Anthem Blue Cross and Blue Shield CDHP-20/HSA Summary - 2017 Summary of benefits

8

Anthem Blue Cross and Blue Shield CDHP-20/HSA Handbook - 2017 Handbook of plan details

1

Anthem Blue Cross and Blue Shield CDHP-40/HSA Summary - 2017 Summary of benefits

8

Anthem Blue Cross and Blue Shield CDHP-40/HSA Handbook - 2017 Handbook of plan details

1

Cigna Open Access Plus (OAP) Summary - 2017 Summary of benefits

8

Cigna Open Access Plus (OAP) Handbook - 2017 Handbook of plan details

1

Cigna Open Access Plus In-Network (OAP-IN) Summary - 2017 Summary of benefits

8

Cigna Open Access Plus In-Network (OAP-IN) Handbook - 2017 Handbook of plan details

1

Cigna CDHP-20/HSA Summary - 2017 Summary of benefits

8

Cigna CDHP-20/HSA Handbook - 2017 Handbook of plan details

1

Kaiser EPO High Summary - 2017 Summary of benefits

8

Kaiser EPO High Handbook - 2017 Handbook of plan details

1

Kaiser EPO 80 Summary - 2017 Summary of benefits

8

Kaiser EPO 80 Handbook - 2017 Handbook of plan details

1

Kaiser CDHP-20/HSA Summary - 2017 Summary of benefits

8

Kaiser CDHP-20/HSA Handbook - 2017 Handbook of plan details

1

UnitedHealthcare Choice Plus Summary - 2017 Summary of benefits

8

UnitedHealthcare Choice Plus Handbook - 2017 Handbook of plan details

1

CDHP/HSA Fact Sheet for Members - 2016/2017 Information about Consumer Directed Health Plans and Health Savings Accounts

6

N/A 2017 CDHP/HSA Benefits - Member Education Webinar To help inform you about CDHP/HSA health plan benefits

52

N/A Anthem BCBS Telemedicine Brochure Information about Anthem BCBS telemedicine benefit

1

N/A Anthem BCBS Telemedicine FAQ Sheet Frequently Asked Questions regarding Anthem BCBS telemedicine benefit

2

N/A Cigna Telemedicine Brochure Information about Cigna telemedicine benefit

2

N/A UnitedHealthcare Telemedicine Brochure Information about UnitedHealthCare telemedicine benefit

1

N/A Pharmacy Benefit FAQs The Medical Trust Pharmacy Benefit FAQs

2

Prescription Drug Benefit Fact Sheet 2017 The Medical Trust Pharmacy Benefit Fact Sheet

4

Open Enrollment Guide - 2017 To help inform you about 2017 plan choices

1

N/A Plan Comparison Chart 2017 Medical Plan Comparison Chart 2017

5

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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

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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

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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

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 To file a claim for dental services

Use address on your dental plan membership 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

Express Scripts Prescription Drug Claim Form To submit a claim for prescription drugs

Express Scripts, Inc.
P.O. Box 66583
St. Louis, MO 63166-6583
ATTN: NGC STD ACCTS

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 To submit a healthcare claim

Mail to your health plan

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

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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 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

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Dental Plan Information - 2017

  Title What is This For? Pgs
Cigna Dental Preventive Summary - 2017 Summary of benefits

1

Cigna Dental Preventive Handbook - 2017 Handbook of plan details

1

Cigna Dental Basic Summary - 2017 Summary of benefits

1

Cigna Dental Basic Handbook - 2017 Handbook of plan details

1

Cigna Dental and Orthodontia Summary - 2017 Summary of benefits

1

Cigna Dental and Orthodontia Handbook - 2017 Handbook of plan details

1

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

Vision

  Title What is This For? Pgs
EyeMed Vision Care Summary - 2017 Summary of benefits

1

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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

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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

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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

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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

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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

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

Health News

  Title What is This For? Pgs
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

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* 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.

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