Benefits Information Portal

Documents

Use the library below to search, filter, and download important PDFs and files related to your benefits.

Results:

Performance Drug List – Standard Control

EN

Performance Drug List – Standard Control

PDF

253.90 KB

Updated 12 months ago

2025 San Francisco PPO Plan Summary of Benefits and Coverage

EN

2025 San Francisco PPO Plan Summary of Benefits and Coverage

The Summary of Benefits and Coverage (SBC): The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only a summary.

PDF

599.59 KB

Updated 1 year ago

2025 Protect PPO Plan Summary of Benefits and Coverage

EN

2025 Protect PPO Plan Summary of Benefits and Coverage

The Summary of Benefits and Coverage (SBC): The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only a summary.

PDF

599.38 KB

Updated 1 year ago

2025 Essential PPO Plan Summary of Benefits and Coverage

EN

2025 Essential PPO Plan Summary of Benefits and Coverage

The Summary of Benefits and Coverage (SBC): The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only a summary

PDF

629.15 KB

Updated 1 year ago

2025 Advantage HSA Family Plan Summary of Benefits & Coverage

EN

2025 Advantage HSA Family Plan Summary of Benefits & Coverage

The Summary of Benefits and Coverage (SBC): The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only a summary.

PDF

595.24 KB

Updated 1 year ago

2025 Advantage HSA Individual Summary of Benefits & Coverage

EN

2025 Advantage HSA Individual Summary of Benefits & Coverage

The Summary of Benefits and Coverage (SBC): The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only a summary.

PDF

597.18 KB

Updated 1 year ago

2025 Intent to Retire Form

EN

2025 Intent to Retire Form

PDF

59.34 KB

Updated 1 year ago

2025 Children’s Health Insurance Program (CHIP) Notice

EN

2025 Newborns’ and Mothers’ Health Protection Act Notice

EN

2025 Flexible Spending Accounts (FSA) Summary Plan Description (SPD)

EN

2025 Genetic Information Nondiscrimination Act (GINA) Notice

EN

2025 Health Insurance Portability and Accountability Act (HIPAA) Special Enrollment Notice

EN

2025 Health Insurance Marketplace Notice

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2025 Health Insurance Marketplace Notice

PDF

254.32 KB

Updated 1 year ago

Adoption and Surrogacy Plan Document

EN

Adoption and Surrogacy Plan Document

PDF

825.88 KB

Updated 1 year ago

Puerto Rico Triple S Medical Summary of Benefits and Coverage – English

EN

Puerto Rico Triple S Medical Summary of Benefits and Coverage – English

The Summary of Benefits and Coverage (SBC): The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only a summary.

PDF

406.16 KB

Updated 1 year ago

Puerto Rico Triple S Medical Summary Of Benefits

EN

2025 Puerto Rico Summary of Benefits Changes

EN

2025 Puerto Rico Summary of Benefits Changes

PDF

289.99 KB

Updated 1 year ago

Puerto Rico Triple S Medical Change Request Form

EN

Puerto Rico Triple S Medical Health Plan Summary

EN

Puerto Rico Triple S Medical Service Center Locations

EN

Puerto Rico Triple S Medical Preventive Care Centers

EN

Puerto Rico Triple S Medical Online Health Portal

EN

Puerto Rico Triple S Medical New Enrollment Form

EN

Resumen de cobertura de Delta Dental de Puerto Rico/Delta Dental Coverage Summary

EN