Benefit Information & Plan Booklets

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  2017 Cigna Health Plan Book

  Delta Dental Book

  Standard Life Insurance Plan Book 

  NEW Flexible Benefits Book

  Voluntary Benefits Brochure 

  Short/Long Term Disability Book

  2017 Summary Benefit Comparison (SBC) 500 Deductible (Updated 1/6/2017)

  2017 Summary Benefit Comparison (SBC) 900 Deductible (Updated 1/6/2017)

  2017 Summary Benefit Comparison (SBC) 2000 Deductible (Updated 1/6/2017)

  2017 Summary Benefit Comparison (SBC) 1500 or 3000 High Deductible Health Plan (HDHP) (Updated 1/6/2017)

Premium Rates & Calculators

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  2017 Active & COBRA Premium Rates

  

2016 Active & COBRA Premium Rates

  2017 Life Insurance Premium Rates

  2016 Life Insurance Premium Rates

   2017 Rate Calculator (Excel) 

To open in Google Sheets CLICK on the link and at the top of the document CLICK on OPEN / OPEN WITH. 

  2016 Rate Calculator (Excel)

To open in Google Sheets CLICK on the link and at the top of the document CLICK on OPEN / OPEN WITH.   

  2017 Rate Calculator (Manual)

 

 2016 Rate Calculator (Manual)

  Disability Premium Calculator

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Applications & Enrollment

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  Active Benefits Application 

Health, Dental and Life Insurance Enrollment or Changes.

  Voluntary Benefits Application

Vision & Disability Enrollment or Changes.

  2017 Flexible Benefits Election Form

  

2016 Flexible Benefits Election Form 

 

  Flex Benefits Change Form

  Link to Genworth site

When prompted enter: Group Name: statewy   Access code: groupltc

  2017 Health Savings Account Election Form

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Other Forms

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  Medical Reimbursement & Dependent Care Claim Form (Updated 4/25/2017)

  2017 Flexible Benefit Payment Schedule

Claims deadlines & check mail dates

  Qualifying Event Matrix

What benefits can be changed based on a qualifying event.

  MedVantx Mail Order Brochure

Information regarding mail order prescriptions.

  MedVantx Mail Order Rx Order Form 

Order prescriptions from the mail order pharmacy. (effective 1/1/2012).

  MedImpact Prescription Claim Form

For use on prescriptions that did not go through a retail pharmacy.

  Postal Prescription Services (PPS)

2nd option for mail order prescriptions (available 11/1/2012).

  Delta Dental Claim Form

Used to send your claim to Delta Dental when your provider is non-participating.

  Direct Payment Authorization Information & Form

  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.

  HIPAA Privacy Authorization Form

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Website Links

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MedVantx Mail Order Pharmacy

www.medvantxrx.com     1-866-744-0621

  

www.diplomatpharmacy.com     1-877-319-6337

  

www.ppsrx.com     1-800-552-6694

  

Frequently Asked Questions