Automobile Mechanics' Local 701

Pre-Medicare Retirees Plan Documents:

• Schedule of Benefits- Enhanced Option
• Summary of Benefits and Coverage- Enhanced Option
• Surprise Billing Notice 10 2022
• CHIP Notice
• COBRA
• HIPAA Privacy Notice
• Medicare Part D Notice
• Nondiscrimination Notice
• Notice of COBRA Continuation Coverage Rights
• Summary of Benefits and Coverage- Standard Option
• Pre-Medicare Retirees - Summary Plan Description and Plan Document
• Summary of Material Modifications 12 2023
• Summary of Material Modifications 11 2023
• Summary of Material Modifications 7 2023
• Summary of Material Modifications 5 2023
• Summary of Material Modifications 1 2023
• Summary of Material Modifications 10 2022
• Summary of Material Modifications 12 2021
• Summary of Material Modifications 11 2021
• Summary of Material Modifications 9 2020
• Summary of Material Modifications 5 2020
• Summary of Material Modifications 1 2020
• Summary of Material Modifications 10 2019
• Summary of Material Modifications 6 2019
• Summary of Material Modifications 3 2018
• Summary of Material Modifications 7 2017
• Summary of Material Modifications 12 2016
• Schedule of Benefits- Standard Option
• Summary Annual Report
• Women’s Health and Cancer Rights Notice

Pre-Medicare Retirees Plan Forms:

• Accident Form
• Coordination of Benefits Form - 2024
• Coordination of Benefits Form - 2023
• Coordination of Benefits Form - 2022
• Coordination of Benefits Form - 2022 - Spanish
• Coordination of Benefits Form - 2021
• HIPAA Release Form
• HRA Reimbursement Form
• Prescription Drug Reimbursement Form