Member Resources
Plan Documents
Active Employee Plan - Challenger
2023 Plan Documents
60/30 Plus - For Early Retirees
2023 Plan Documents
ERMMB - For Early Retirees
2023 Plan Documents
Medicare
2023 Documents
2023 Medical - Annual Notice of Change (ANOC)
2023 Medical - Summary of Benefits
2023 Medical - Explanation of Coverage
2023 Medical - Summary Annual Report (SAR)
2023 Medical - Nondiscrimination / Multi-Language
2023 Pharmacy - Annual Notice of Change
2023 Pharmacy - Summary of Benefits
2023 Pharmacy - Explanation of Coverage
2023 Pharmacy - Quantity Limits (QL)
2023 Pharmacy - B vs D Criteria
2023 Pharmacy - Formulary Drug List - Abridged
2023 Pharmacy - Formulary Drug List - Comprehensive
2023 Pharmacy - Step Therapy (ST)
2023 Pharmacy - Prior Authorization (PA)
2024 United Healthcare Group Medicare Advantage Plan Documents
2024 Optum Rx Pharmacy Plan Documents
2024 Pharmacy Explanation of Coverage
2024 Pharmacy Annual Notice of Change
2024 Pharmacy Summary of Benefits
2024 Pharmacy Formulary Drug List Abridged
2024 Pharmacy Formulary Drug List Comprehensive
2024 Pharmacy B vs D Criteria
2024 Step Therapy
2024 Pharmacy Prior Authorization (PA)
2024 Pharmacy Quantity Limits (QL)
Forms & Publications
- Manage Health Information Authorizations
- Auto Dues Payment (ADPS) Enrollment Form
- COBRA Leave Plan Booklet - Non-Medicare members only
- COBRA Leave Plan Election Form Non-Medicare members only
- Complete Sleep - Home Sleep Test Order Form Non-Medicare members only
- Complete Sleep - Physicians CPAP Order Form Non-Medicare members only
- Coordination of Benefits (COB) Form
- Dependent Supplemental Plan Application Non-Medicare members only
- Dependent Supplemental Plan Non-Medicare members only
- Health Information Release Form
- Health Information Revocation Form
- List of Treatments / Services Requiring Prior Authorization Non-Medicare members only
- Possible Accident or Injury Form
- Quality of Care Complaint Form Medicare Only
- RX Drug Reimbursement Form (OptumRx)
- UPREHS Annual Report -2022
- Appeals Non-Medicare members only