Downloadable Resources

Summary Plan Description (SPD):

CWA Local 1180 Security Benefits Fund - SPD
CWA Local 1180 Retirees Benefits Fund - SPD

Prescription Drug Benefit Forms:

EnvisionRxOptions- Direct Reimbursement Forms
EnvisionRxOptions- Letter of Medical Necessity (LMN)

COSTCO PatientBrochure - For New Mail Order Enrollees
COSTCO ReorderForms - For Current Mail Order Enrollees

Dental Benefit Forms and Information:

Scheduled Dental Plan - Summary Plan Description (SPD) 
Scheduled Dental Plan Claim Form
Dentcare Dental Plan - Summary Plan Description (SPD)
Healthplex America S700 Dental Plan Provider List - FLORIDA Retirees
Healthplex America S700 Dental Plan Schedule of Benefits - FLORIDA Retirees

Other:

ACTIVE - DEPENDENT WAIVER OF COVERAGE
ACTIVE - DEPENDENT WAIVER OF PRESCRIPTION DRUG COVERAGE
ACTIVE - MEMBER WAIVER OF PRESCRIPTION DRUG COVERAGE

RETIREE - DEPENDENT WAIVER OF COVERAGE
RETIREE - DEPENDENT WAIVER OF PRESCRIPTION DRUG COVERAGE
RETIREE - RETIREE WAIVER OF PRESCRIPTION DRUG COVERAGE

NYC OLR  Basic Plan and Optional Rider Costs
NYC OLR Retirees Health Plan and Optional Rider Costs