Health Care Publications & Forms
Brochures
Forms
Plan Coverage Documents
2023 coverage documents will be posted as they become available from the plans.
Aetna Medicare Plan
PPO Enrollees
- 2023 Aetna Medicare Plan PPO Schedule of Cost Sharing (Medicare Parts A & B)
- 2023 Aetna Medicare Plan PPO Evidence of Coverage (Medicare Parts A & B)
- 2023 Aetna Medicare Plan PPO Annual Notice of Changes (Medicare Parts A & B)
- 2023 Aetna Medicare Plan PPO Schedule of Cost Sharing (Medicare Part B-Only)
- 2023 Aetna Medicare Plan PPO Evidence of Coverage (Medicare Part B-Only)
- 2023 Aetna Medicare Plan PPO Annual Notice of Changes (Medicare Part B-Only)
ESA PPO Enrollees
- 2023 Aetna Medicare Plan ESA PPO Schedule of Cost Sharing (Medicare Parts A & B)
- 2023 Aetna Medicare Plan ESA PPO Evidence of Coverage (Medicare Parts A & B)
- 2023 Aetna Medicare Plan ESA PPO Annual Notice of Changes (Medicare Parts A & B)
- 2023 Aetna Medicare Plan ESA PPO Schedule of Cost Sharing (Medicare Part B-Only)
- 2023 Aetna Medicare Plan ESA PPO Evidence of Coverage (Medicare Part B-Only)
- 2023 Aetna Medicare Plan ESA PPO Annual Notice of Changes (Medicare Part B-Only)
All Enrollees
Aetna Basic
- 2023 Aetna Basic Benefit Plan Description (Non-Medicare)
- 2023 Aetna Basic PPO Summary of Benefits and Coverage (Non-Medicare)
- 2023 Aetna Basic PPO Schedule of Benefits (Non-Medicare)
- 2023 Aetna Basic Indemnity Summary of Benefits and Coverage (Non-Medicare)
- 2023 Aetna Basic Indemnity Schedule of Benefits (Non-Medicare)
- Aetna Member Notice
- Aetna Basic Transform Oncology Program
- Required Notice for the Women’s Health and Cancer Rights Act of 1998
Medical Mutual Basic
- 2023 Medical Mutual Basic Medical Plan Description
- Preventive Services
- Required Notice for the Women’s Health and Cancer Rights Act of 1998
AultCare PPO
- 2023 AultCare PPO Schedule of Benefits (Non-Medicare)
- 2023 AultCare PPO Certificate of Coverage and Benefits (Non-Medicare)
AultCare PrimeTime Health Plan
- 2023 AultCare PrimeTime Health Plan Summary of Benefits (Medicare)
- 2023 AultCare PrimeTime Health Plan Annual Notice of Changes (Medicare)
- 2023 AultCare PrimeTime Health Plan Evidence of Coverage (Medicare)
Paramount Health Care
- 2023 Paramount Health Care Schedule of Benefits (Non-Medicare)
- 2023 Paramount Health Care Certificate of Coverage (Non-Medicare)
Paramount Elite
- 2023 Paramount Elite Summary of Benefits (Medicare)
- 2023 Paramount Elite Annual Notice of Changes (Medicare)
- 2023 Paramount Elite Evidence of Coverage (Medicare)
Health Care Assistance Program (HCAP)
Express Scripts Prescription Drug Program
All Enrollees
- 2023 STRS Ohio Prescription Drug Program Overview
- 2023 Express Scripts Low-Cost Generic Drug List for Home Delivery
Non-Medicare Enrollees
- 2022 Express Scripts Prescription Medication Description (Non-Medicare)
- 2023 Express Scripts National Preferred Formulary (Non-Medicare)
- 2023 SaveOnSP Drug List
Medicare Enrollees
- 2022 Express Scripts Medicare Evidence of Coverage (Medicare)
- 2023 Express Scripts Medicare Benefit Overview (Medicare)
- 2023 Express Scripts Medicare Annual Notice of Changes (Medicare)
- 2023 Express Scripts Medicare Formulary (List of Covered Drugs)
- Notice of Medicare Part D Creditable Coverage
Delta Dental
- 2023–2024 Delta Dental Summary of Dental Plan Benefits
- 2023–2024 Delta Dental Certificate of Coverage
- Delta Dental Special Health Care Needs Benefit
Vision Service Plan (VSP)
- 2023–2024 Vision Service Plan Evidence of Coverage
- VSP Special Offers on Glasses, Contacts, LASIK & More