Health Plan Documents

All forms are in Adobe PDF format. Click here to download the free Adobe Acrobat Reader.

Health Plan Documents

March 2020 Health Plan Summary Plan Description	Describes the benefits offered through the DGA-Producer Health Plan
Adult Dependent Authorization Form	This form is for use by an adult Health Plan participant who is eligible as a dependent and who wishes to have all of his/her Health Plan mail (including Explanations of Benefits and other claims information) sent to and checks made out to his/her parent or spouse who is the primary Plan participant.
Claim Form – Dental	When you visit a non-Delta Dental dentist, this form must be filled out and be accompanied by an itemized bill. If you visit a Delta Dental dentist, the dentist will take care of the paperwork.
Claim Form – Medical – Services Received in the U.S.	This form needs to be completed when submitting medical claims for services received in the United States.
Claim Form – Medical – Services Received Outside the U.S.	This form needs to be completed when submitting medical claims for services received outside the U.S. Claim forms along with any itemized bills do not have to be translated into English or dollars.
Claim Form – Prescription	When you obtain prescription drugs from a non-Express Scripts pharmacy, you will have to pay the full amount of the purchase to the pharmacy and then fill out this claim form and submit it to Express Scripts, formerly known as Medco, for partial reimbursement. If you visit an Express Scripts pharmacy, there is no paperwork.
Claim Form – Vision	When you visit a non-VSP vision provider, this form must be filled out and accompanied by an itemized bill. If you visit a VSP provider, the provider will take care of all of the necessary paperwork.
Coordination of Benefits Form	This form is submitted prior to the Health Plan processing claims for you and your dependents to provide the Health Plan with information regarding your other health insurance, if any. This information is required so that we can coordinate benefit payment with your other insurance.
Dental Election Form	California participants can complete and return this form during their open enrollment period to switch from the Delta Dental PPO Plan to the DeltaCare Dental HMO Plan, or vice-versa.
Dependent Enrollment Form	This form must be submitted to the Health Plan when enrolling new dependents under your health coverage.
HIPAA Authorization Form	This form authorizes the Health Plan to release Protected Health Information to designated individuals or institutions.
Life Events Fact Sheets
Death Disability Divorce Marriage New Child Retirement	Getting married. Having a baby. Preparing for retirement. These are the moments in life when your benefits matter most. With that in mind, we have developed the Life Events fact sheets to help ensure that you get all of the information that you need regarding how these events will affect your benefits as well as what action, if any, you need to take.
List of Additional Services and Assistance	This document lists sources of medical services and assistance for individuals without health coverage. Listed organizations are not affiliated with the DGA-Producer Pension and Health Plans; therefore, the Plans cannot offer assurance you will meet established qualifications.
Pension Deduction Authorization Form	This form authorizes the Health Plan to collect your health care premium directly from your Basic Plan monthly pension benefit each month. This is only for participants on regular or retiree self-pay coverage. This option is not available for dependent premium payment.
Summaries of Benefits and Coverage (SBCs)
SBC Premier Plan SBC Choice Plan SBC Silver Plan SBC Bronze Plan SBC Glossary	Eight-page plan summaries including information about covered benefits, cost sharing and exclusions, accompanied by a standard glossary of common insurance and medical terms.