Teamsters Local 639 - Employers Health and Pension Trust Funds

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Employers Health Trust Fund Documents

Employers Health Trust Fund Recent Mailings

	SMM#23 Cigna Dental EPO and AS Benefits Change FINAL 5.12.2025

	SMM#22 Active Acupuncture Benefits Change 1.1.2025_final 2.24.2025

	SMM#21 02.01.2025 Cigna DHMO Dental Change Notice

	SMM#20 Expanded Contraception and Dental Coverage

	Teamsters-Local639-VSP Micro-Site Flier

	Improved Vision Benefits Effective December 1, 2023

	CVS Caremark OTC COVID Test Paper Claim Form

Employers Health Trust Fund Forms

	COB Form - Health

	Enrollment Application - Health

	Change of Address Form

	Medical Claim Form

	Affidavit of Spousal Health Care Coverage Form

	Dependent Verification Form

Employers Health Trust Fund Amendments and Changes

	2023 Disclosure Notice Regarding Patient Protections Against Surprise Billing

	SMM#1_EFF 7-1-2011 Mail Order Program For Maintenance Drugs

	SMM#2_EFF 1-1-2013 Improved Health Benefits

	SMM#3_EFF 1-1-2014 Improved Mental Health Benefits Network Provider Changes

	SMM#4_EFF 7-29-14 Limitation for Claim or Civil Action Fund or WC appeals

	SMM#5_EFF 6-1-2015 Compound Meds Pre-Auth

	SMM#6_EFF 4-1-2016 Specialty Pharmacy Guideline Management Program

	SMM#7_EFF 1-1-2018 Opioid MAP and YHF

	SMM#8_ EFF 10-1-2018 Outpatient Injectibles

	SMM#9_EFF 7-1-2019 Workers' Compensation

	SMM#10_EFF 1-1-2020 Specialty Prescription Drug Coverage

	SMM#11_EFF 3-1-2020 COVID-19 Notice

	SMM#12_EFF 3-1-2020 COVID-19 Cover 2nd Notice

	SMM#13_EFF 11-1-2020 Extended Telehealth Visits

	SMM#14 2022 Plan Improvement and Changes

	SMM#15 Over-the-Counter COVID19 Test Kits

	SMM#16 Mammogram and TeleHealth Coverage_2022

	SMM#17 Non-Seasonal Vaccines and Genetic Testing

	SMM#18 Telehealth Colonoscopies End of National Emergency

	SMM#19 Improved Vision Benefits

	SMM#20 Expanded Contraception and Dental Coverage

	SMM#21 02.01.2025 Cigna DHMO Dental Change Notice

	SMM#22 Active Acupuncture Benefit Change 1.1.2025

Employers Health Trust Fund Documents / Summary Plan Description

	Summary Annual Report for Teamsters Local 639 Employer Health Trust 2018

	Teamsters Local 639 Employers Health Creditable Coverage Notice 2019

	Teamsters Local 639 Employer Health Fund Annual Mastectomy Notice 2019

	Teamsters Local 639 Employers Health Fund - Summary Plan Description (SPD) 2011

Employers Health Trust Fund Summary of Benefits and Coverages

	2026 Teamsters Local 639 Summary of Benefits and Coverage (SBC)

	2025 Teamsters Local 639 Summary of Benefits and Coverage (SBC)

Employers Health Trust Fund Summary Annual Report

	2022 Teamsters Local 639 - Health Fund Summary Annual Report

	2021 Teamsters Local 639 - Health Fund Summary Annual Report

	2020 Teamsters Local 639 - Health Fund Summary Annual Report

	2019 Teamsters Local 639 - Health Fund Summary Annual Report

	2018 Teamsters Local 639 - Health Fund Summary Annual Report

SMM#23 Cigna Dental EPO and AS Benefits Change_06.01.2025

Teamsters Local 639 HIPAA Notice of Privacy Practices 2-2026