Submit this form by mailing it to PO Box 34203, Seattle, WA 98124, or fax it to (206) 505-9727. You can also send it to the Physical Address: 7525 SE 24th Street, Suite 200, Mercer Island, WA 98040. For any questions or guidance, contact the Administration Office at (206) 441-7314 or (877) 441-1212. Ensure all required information is accurately filled out and all necessary documents are included before submission. My advice is to keep a copy of the form and any submitted documents for your records.

Key dates for this form include June 1, 2023, for benefit changes implementation, and the conclusion of the National Emergency on May 11, 2023. Stay updated on any additional important dates by regularly checking with the Administration Office.

This form serves as a Summary of Material Modification detailing the essential benefit changes adopted by the Board of Trustees. It includes modifications related to COVID-19 such as continuing benefits for OTC COVID Antigen tests, vaccines, and medications. Additionally, it outlines updates to telehealth services, hearing care expenses, and new prescription programs to ensure that plan participants remain well-informed of their health plan coverage.

• 1. COVID-19 At-Home Test Kits: Provides information on continued benefits for OTC COVID Antigen tests.
• 2. Telehealth/Telemedicine: Confirms coverage for telehealth services under standard plan provisions.
• 3. Hearing Care Expenses: Details coverage for hearing exams and hearing aid devices.
• 4. Dental Personal Protective Equipment (PPE): Discontinues coverage for dental PPE following the National Emergency conclusion.
• 5. Retail 90 Pharmacy: Introduces convenience of obtaining a 90-day supply of maintenance medications at a network retail pharmacy.
• 6. Rx Coupon Card Variable Co-pay Program: Describes the new prescription coupon card program for specialty medications.
• 7. Rx Price Edge Program: Details the prescription coupon card program for generic prescriptions.
• 8. Contact Information: Provides the Administration Office's contact information for any questions related to the form.
• 9. Reminder: Reminds participants to update their demographic data and provide necessary documentation for changes.

Failing to submit this form may result in delays or interruptions in your health plan benefits.

• Benefit Delays: Your health plan benefits may be delayed if the form is not submitted on time.
• Incomplete Coverage: Vital updates to your health plan may not be recorded, affecting your coverage.
• Communication Issues: Not providing updated information can prevent timely communication about your plan.

• 1. Updating Personal Information: Use this form to report any changes in your name, marital status, or dependents.
• 2. Verifying Coverage: Check updates on coverage for COVID-19, telehealth services, and hearing care.
• 3. Applying Prescription Programs: Inform yourself about the new prescription coupon card programs for better savings.
• 4. Contacting Administration Office: Use the provided contact details for any inquiries related to the benefit changes.
• 5. Keeping Plan Information Updated: Ensure your information is accurate and up-to-date to avoid any issues with your health plan.