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 - 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.

Active Clergy & Lay Employee Health Plan Information - 2022
Title
What is this for?
Pages
Mail It
Anthem BCBS BlueCard PPO 100 Summary - 2022
Summary of Benefits and Coverage (SBC)
6
Anthem BCBS BlueCard PPO 90 Summary - 2022
Summary of Benefits and Coverage (SBC)
6
Anthem BCBS BlueCard PPO 80 Summary - 2022
Summary of Benefits and Coverage (SBC)
6
Anthem BCBS BlueCard PPO 70 Summary - 2022
Summary of Benefits and Coverage (SBC)
6
Anthem BCBS CDHP15 HSA Summary - 2022
Summary of Benefits and Coverage (SBC)
6
Anthem BCBS CDHP20 HSA Summary - 2022
Summary of Benefits and Coverage (SBC)
6
Anthem BCBS CDHP40 HSA Summary - 2022
Summary of Benefits and Coverage (SBC)
6
Cigna PPO 100 Summary 2022
Summary of Benefits and Coverage (SBC)
6
Cigna PPO 90 Summary - 2022
Summary of Benefits and Coverage (SBC)
6
Cigna PPO 80 Summary 2022
Summary of Benefits and Coverage (SBC)
6
Cigna PPO 70 Summary - 2022
Summary of Benefits and Coverage (SBC)
6
Cigna CDHP15 HSA Summary - 2022
Summary of Benefits and Coverage (SBC)
6
Cigna CDHP20 HSA Summary - 2022
Summary of Benefits and Coverage (SBC)
6
Cigna CDHP40 HSA Summary 2022
Summary of Benefits and Coverage (SBC)
6
Kaiser High EPO Summary - 2022
Summary of Benefits and Coverage (SBC)
6
Kaiser EPO 80 Summary - 2022
Summary of Benefits and Coverage (SBC)
6
Kaiser CDHP Summary - 2022
Summary of Benefits and Coverage (SBC)
6
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
Active Clergy & Lay Employee Health Plan Information - 2021
Title
What is this for?
Pages
Mail It
Anthem BCBS Handbook 2021
Handbook of plan details
109
Anthem BCBS BlueCard PPO 70 - 2021
Summary of Benefits and Coverage (SBC)
6
Anthem BCBS BlueCard PPO 80 - 2021
Summary of Benefits and Coverage (SBC)
6
Anthem BCBS BlueCard PPO 90 - 2021
Summary of Benefits and Coverage (SBC)
6
Anthem BCBS BlueCard PPO 100 - 2021
Summary of Benefits and Coverage (SBC)
6
Anthem BCBS CDHP15 HSA - 2021
Summary of Benefits and Coverage (SBC)
6
Anthem BCBS CDHP20 HSA - 2021
Summary of Benefits and Coverage (SBC)
6
Anthem BCBS CDHP40 HSA - 2021
Summary of Benefits and Coverage (SBC)
6
Cigna Handbook 2021
Handbook of plan details
102
Cigna Open Access Plus PPO 70 - 2021
Summary of Benefits and Coverage (SBC)
6
Cigna Open Access Plus PPO 80 - 2021
Summary of Benefits and Coverage (SBC)
6
Cigna Open Access Plus PPO 90 - 2021
Summary of Benefits and Coverage (SBC)
6
Cigna Open Access Plus PPO 100 - 2021
Summary of Benefits and Coverage (SBC)
6
Cigna CDHP15 HSA - 2021
Summary of Benefits and Coverage (SBC)
6
Cigna CDHP20 HSA - 2021
Summary of Benefits and Coverage (SBC)
6
Cigna CDHP40 HSA - 2021
Summary of Benefits and Coverage (SBC)
6
Kaiser Handbook 2021
Handbook of plan details
181
Kaiser High EPO - 2021
Summary of Benefits and Coverage (SBC)
6
Kaiser CDHP HSA - 2021
Summary of Benefits and Coverage (SBC)
2
Kaiser EPO 80 - 2021
Summary of Benefits and Coverage (SBC)
6
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
2020-2021 CDHP/HSA Fact Sheet for Members
Information for members on Consumer Directed Health Plans (CDHP) and Health Savings Account (HSA)
6
Retired Clergy Health Plan Information - 2022
Title
What is this for?
Pages
Retiree 2022 Annual Enrollment Subsidy Letter
Annual Enrollment information for retirees who receive a Medicare Supplement Health Plan subsidy
4
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
Retired Clergy Health Plan Information - 2021
Title
What is this for?
Pages
Medicare Supplement Handbook 2021
Plan Handbook
115
Medicare Supplement Comparison Chart 2021
Medicare costs and Medicare Supplement plan comparisons
2
Retiree 2021 Annual Enrollment with Subsidy Letter-Sept 2020
Annual Enrollment information for retirees who receive a Medicare Supplement Health Plan subsidy
8
Retiree 2021 Annual Enrollment Non-Subsidy Letter-Sept 2020
Annual Enrollment information for retirees who do not receive a Medicare Supplement Health Plan subsidy
Medicare & You 2021
The official US Government Medicare Handbook for 2021
124
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
Retired Lay Employee Health Plan Information - 2021
Title
What is this for?
Pages
Retiree 2022 Annual Enrollment Non-Subsidy Letter
Annual Enrollment information for retirees who do not receive a Medicare Supplement Health Plan subsidy
4
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
Retired Lay Employee Health Plan Information - 2021
Title
What is this for?
Pages
Medicare Supplement Handbook 2021
Plan Handbook
115
Medicare Supplement Comparison Chart 2021
Medicare costs and Medicare Supplement plan comparisons
2
Retiree 2021 Annual Enrollment Non-Subsidy Letter-Sept 2020
Annual Enrollment information for retirees who do not receive a Medicare Supplement Health Plan subsidy
Medicare & You 2021
The official US Government Medicare Handbook for 2021
124
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
Seminarians Health Plan Information - 2022
Title
What is this for?
Pages
Mail It
Anthem BCBS BlueCard PPO 80 Summary - 2022
Summary of Benefits and Coverage (SBC)
6
Anthem BCBS BlueCard PPO 70 Summary - 2022
Summary of Benefits and Coverage (SBC)
6
Anthem BCBS CDHP40 HSA Summary - 2022
Summary of Benefits and Coverage (SBC)
6
Anthem BCBS CDHP20 HSA Summary - 2022
Summary of Benefits and Coverage (SBC)
6
Cigna PPO 80 Summary 2022
Summary of Benefits and Coverage (SBC)
6
Cigna PPO 70 Summary - 2022
Summary of Benefits and Coverage (SBC)
6
Cigna CDHP40 HSA Summary 2022
Summary of Benefits and Coverage (SBC)
6
Cigna CDHP20 HSA Summary - 2022
Summary of Benefits and Coverage (SBC)
6
Seminarians Health Plan Information - 2021
Title
What is this for?
Pages
Mail It
Anthem BCBS Handbook 2021
Handbook of plan details
109
Anthem BCBS BlueCard PPO 80 - 2021
Summary of Benefits and Coverage (SBC)
6
Anthem BCBS BlueCard PPO 70 - 2021
Summary of Benefits and Coverage (SBC)
6
Anthem BCBS CDHP40 HSA - 2021
Summary of Benefits and Coverage (SBC)
6
Anthem BCBS CDHP20 HSA - 2021
Summary of Benefits and Coverage (SBC)
6
Cigna Handbook 2021
Handbook of plan details
102
Cigna Open Access Plus PPO 80 - 2021
Summary of Benefits and Coverage (SBC)
6
Cigna Open Access Plus PPO 70 - 2021
Summary of Benefits and Coverage (SBC)
6
Cigna CDHP40 HSA - 2021
Summary of Benefits and Coverage (SBC)
6
Cigna CDHP20 HSA - 2021
Summary of Benefits and Coverage (SBC)
6
2020-2021 CDHP/HSA Fact Sheet for Members
Information for members on Consumer Directed Health Plans (CDHP) and Health Savings Account (HSA)
6
Dental Plan Information - 2022
Title
What is this for?
Pages
Cigna Preventive Dental - 2022
Summary of Benefits and Coverage (SBC)
3
Cigna Basic Dental - 2022
Summary of Benefits and Coverage (SBC)
3
Cigna Dental & Orthodontia - 2022
Summary of Benefits and Coverage (SBC)
3
Dental Plan Information - 2021
Title
What is this for?
Pages
Mail It
Cigna Dental Handbook 2021
Handbook of plan details
62
N/A
Cigna Preventive Dental - 2021
Summary of Benefits and Coverage (SBC)
3
Cigna Basic Dental - 2021
Summary of Benefits and Coverage (SBC)
3
Cigna Dental and Orthodontia - 2021
Summary of Benefits and Coverage (SBC)
3
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
Health Advocate Brochure
A personal health advocate service to help you with healthcare and insurance issues
2
N/A
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
Medical Claim Form (Anthem)
To submit a claim for medical expenses, or behavioral health expenses
Anthem Blue Cross and Blue Shield PO Box 105187 Atlanta, GA 30348
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 (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
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
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
Hearing Benefit Reimbursement Claim Form
Hearing Benefit Claim Form (UHC)
MAIL the Claim Form and the proof of payment attachments to: UnitedHealthcare, Atlanta Service Center, PO Box 740827, Atlanta, GA 30374
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
5
Medicare Secondary Payer SEE Letter to Members
Letter sent to members explaining Medicare Secondary Payer See program
2
Denominational Health Plan
Title
What is this for?
Pages
Mail It
DHP Annual Report 2020 - English
2020 Annual Report on the Denominational Health Plan
3
N/A
DHP Annual Report 2020 - Español
2020 Annual Report on the Denominational Health Plan
3
N/A
DHP Annual Report 2019 - English
2019 Annual Report on the Denominational Health Plan
3
N/A
DHP Annual Report 2019 - Español
2019 Annual Report on the Denominational Health Plan
3
N/A
DHP Annual Report 2018 - English
2018 Annual Report on the Denominational Health Plan
3
N/A
DHP Annual Report 2018 - Español
2018 Annual Report on the Denominational Health Plan
4
N/A
DHP Annual Report 2017 - English
2017 Annual Report on the Denominational Health Plan
4
N/A
DHP Annual Report 2017 - Español
2017 Annual Report on the Denominational Health Plan
4
N/A
DHP Annual Report 2016-English
2016 Annual Report on the Denominational Health Plan
3
N/A
DHP Annual Report 2016-Español
2016 Annual Report on the Denominational Health Plan (Español)
3
N/A
DHP Annual Report 2015 - English
2015 DHP Annual Report (English)
3
N/A
DHP Annual Report 2015 - Español
2015 DHP Annual Report (Español)
4
N/A
DHP Annual Report (English)
2014 DHP Annual Report (English)
8
N/A
DHP Annual Report (Español)
2014 DHP Annual Report (Español)
7
N/A
DHP Canon, Resolutions A177 and B026 and Model
Denominational Health Plan
6
Regulatory Notices
Title
What is this for?
Pages
Mail It
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
Notice of Nondiscrimination
Notice of Nondiscrimination
2
Women’s Health and Cancer Rights Act (WHCRA) Notice
Women’s Health and Cancer Rights Act Notice
1
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