Health Plans

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
CDHP/HSA Fact Sheet for Members - 2018-2019 Information for members on Consumer Directed Health Plans (CDHP) and Health Savings Account (HSA) for 2018-2019

7

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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

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Retired Clergy Health Plan Information - 2019

  Title What is This For? Pgs
Medicare Supplement Handbook - 2019 Plan Handbook

1
N/A 2019 Annual Enrollment-Retiree Subsidy Letter Announcing Annual Enrollment dates and medicare supplement information for retirees

8
N/A 2019 Annual Enrollment-Retiree Non-Subsidy Letter Announcing Annual Enrollment dates and medicare supplement information for retirees not eligible for Subsidy

8
N/A Medicare & You 2019 The official US Government Medicare Handbook

120
N/A Medicare Comparison Chart 2019 Medicare costs and Medicare Supplement plan comparisons

2
Prescription Drug Benefit Fact Sheet for Retirees 2019 The Medical Trust Pharmacy Benefit Fact Sheet for Retirees

5

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Retired Clergy Health Plan Information - 2018

  Title What is This For? Pgs
Medicare Supplement Handbook 2018 Handbook of plan details

126
N/A Medicare Supplement Fact Sheet - Before July 1 2013 Retirement Medicare Supplement Fact Sheet - Retirement Before July 1, 2013

3
N/A Medicare Supplement Fact Sheet - After July 1 2013 Retirement Medicare Supplement Fact Sheet - Retirement After July 1, 2013

3
N/A Retiree Open Enrollment (Subsidy) Letter 2018 Open Enrollment information for retirees who receive a subsidy

8
N/A Retiree Open Enrollment (Non-Subsidy) Letter 2018 Open Enrollment information for retirees who do not receive a subsidy

8
Medicare & You 2018 The official US Government Medicare Handbook

136
Prescription Drug Benefit Fact Sheet for Retirees 2018 The Medical Trust Pharmacy Benefit Fact Sheet for Retirees

4

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Retired Lay Employee Health Plan Information - 2019

  Title What is This For? Pgs
Medicare Supplement Handbook - 2019 Plan Handbook

1
N/A 2019 Annual Enrollment-Retiree Non-Subsidy Letter Announcing Annual Enrollment dates and medicare supplement information for retirees not eligible for Subsidy

8
N/A Medicare & You 2019 The official US Government Medicare Handbook

120
N/A Medicare Comparison Chart 2019 Medicare costs and Medicare Supplement plan comparisons

2
Prescription Drug Benefit Fact Sheet for Retirees 2019 The Medical Trust Pharmacy Benefit Fact Sheet for Retirees

5

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

Retired Lay Employee Health Plan Information - 2018

  Title What is This For? Pgs
N/A Retiree Open Enrollment (Non-Subsidy) Letter 2018 Open Enrollment information for retirees who do not receive a subsidy

8
Medicare Supplement Handbook 2018 Handbook of plan details

126
Medicare & You 2018 The official US Government Medicare Handbook

136
Prescription Drug Benefit Fact Sheet for Retirees 2018 The Medical Trust Pharmacy Benefit Fact Sheet for Retirees

4

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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

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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

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

Seminarians Health Plan Information - 2019

  Title What is This For? Pgs
Anthem BCBS BlueCard PPO 80 - 2019 Summary of benefits

6
Anthem BCBS BlueCard PPO 70 - 2019 Summary of benefits

6
Anthem BCBS CDHP-40/HSA - 2019 Summary of benefits

6
Anthem BCBS CDHP-20/HSA - 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-40/HSA - 2019 Summary of benefits

6
Cigna Open Access Plus CDHP-20/HSA - 2019 Summary of benefits

6
CDHP/HSA Fact Sheet for Members - 2018-2019 Information for members on Consumer Directed Health Plans (CDHP) and Health Savings Account (HSA) for 2018-2019

7

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

Seminarians Health Plan Information – 2018

  Title What is This For? Pgs
Anthem BCBS Handbook - 2018 Handbook of plan details

109
Anthem BCBS 75/50 PPO Summary - 2018 Summary of benefits

1
Anthem BCBS 70 SLV Summary - 2018 Summary of benefits

1
Anthem BCBS CDHP-40 Summary - 2018 Summary of benefits

1

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Additional Benefits

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

4
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
United Healthcare Global Assistance Brochure Emergency assistance available when traveling

6
N/A Health Advocate Brochure A personal health advocate service to help you with healthcare and insurance issues

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

4

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Claims

Title What is This For? Contact Information
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
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

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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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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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Denominational Health Plan

  Title What is This For? Pgs
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

1
N/A DHP Annual Report 2016-Español 2016 Annual Report on the Denominational Health Plan (Español)

1
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
DHP Canon, Resolutions A177 and B026 and Model Denominational Health Plan

6

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Regulatory Notices

  Title What is This For? Pgs
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

4
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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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

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