Benefit Information & Plan Booklets

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  Cigna Health Plan Book

  Delta Dental Book

  Standard Life Insurance Plan Book 

  Flexible Benefits Book

  Voluntary Benefits Brochure 

  Short/Long Term Disability Book

  2018 Summary Benefit Comparison (SBC) 500 Deductible (Updated 10/4/2017)

  2018 Summary Benefit Comparison (SBC) 900 Deductible (Updated 10/4/2017)

  2018 Summary Benefit Comparison (SBC) 2000 Deductible (Updated 10/4/2017)

  2018 Summary Benefit Comparison (SBC) 1500 High Deductible Health Plan (HDHP) (Updated 10/4/2017)

Premium Rates & Calculators

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  2018 Active & COBRA Premium Rates

  2017 Life Insurance Premium Rates

   2018 Rate Calculator (Excel) 

  2018 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.

  2018 Flexible Benefits Election Form

  Flex Benefits Change Form

  Link to Genworth site

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

  2018 Health Savings Account Election Form

  Long Term Disability Application Link

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Other Forms

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

  2018 Flexible Benefit Payment Schedule

Claims deadlines & check mail dates.

  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.

  HIPAA Privacy Authorization Form

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Website Links

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MedImpact Direct Mail Order & Specialty Pharmacy

www.medimpactdirect.com     

  

Frequently Asked Questions