• Cigna Health Plan Book
• Delta Dental Book
• Standard Life Insurance Plan Book
• Flexible Benefits Book
• Voluntary Benefits Brochure (updated 1/1/2019)
• VSP Vision 2019 Benefits Flyer
• Short/Long Term Disability Book
• 2020 Summary Benefits Comparison (SBC) 500 Deductible (Updated Oct 2019)
• 2020 Summary Benefits Comparison (SBC) 900 Deductible (Updated Oct 2019)
• 2020 Summary Benefits Comparison (SBC) 2000 Deductible (Updated Oct 2019)
• 2020 Summary Benefits Comparison (SBC) 1500 High Deductible Health Plan (HDHP) (Updated Oct 2019)

PREMIUM RATES & CALCULATORS

• January 2020 Active & Cobra Rates
• August 2020 Active & Cobra Rates
• January 2020 Rate Calculator (download, then open in Excel)
• August 2020 Rate Calculator -(download, then open in Excel)
• January 2020 Rate Calculator TP01/AWEC (download, then open in Excel)
• January 2020 Manual Rate Calculator
• August 2020 Manual Rate Calculator
• 2019 & 2020 Life Insurance Premium Rates
• Disability Premium Calculator

APPLICATION & ENROLLMENT

• Active Benefits Application Health, Dental and Life Insurance Enrollment or Changes.
• Voluntary Benefits Application (Updated 4/2019) Vision & Disability Enrollment or Changes.
• 2020 Flexible Benefits Election Form
• Flex Benefits Change Form
• Link to Genworth site When prompted enter: Group Name: statewy Access code: groupltc
• 2020 Health Savings Account Election Form
• Long Term Disability Application Link

OTHER FORMS

• Medical Reimbursement & Dependent Care Claim Form (Updated 4/25/2017)
  • Flex deadline is every Friday. Reimbursements are payable the the 2nd Thursday after deadline.
• Qualifying Event Matrix What benefits can be changed based on a qualifying event.
• MedImpact Direct Rx Mail Order Form For use on prescriptions that did not go through a retail pharmacy.
• MedImpact Claim Form Used for manual submission of prescription reimbursement.
• Delta Dental Claim Form Used to send your claim to Delta Dental when your provider is non-participating.
• Direct Payment Authorization
• Vision Out of Network Reimbursement Claim Form
• Short Term Disability Insurance Claim Form The Standard Company 1-800-368-2859
• Long Term Disability Claim Form The Standard Company 1-800-368-1135
• Cigna Claim Form Used to send medical claims to Cigna.
• Evidence of Insurability for Standard Life Insurance
• HIPAA Privacy Authorization Form

WEBSITE LINKS