Documents & Forms

Medical and Benefit Forms

• Medical & Vision Claim Form
• Enrollment Form – Actives
• Enrollment Form – Non-Medicare Retirees
• Enrollment Change Form
• Life-AD&D-LTD Enrollment/Change Form
  • Life-AD&D-LTD Medical History

Plan Booklets and Policies

• 2024-Plan Booklet – Dental
• Life and Disability Insurance Policy through SFFBT
• ERHC 2025 Plan-Guidebook-Actives
• Plan Booklet-Group Long Term Disability Insurance (WSCFF policy)
  • LTD – Claim FAQ
  • LTD – Claim Packet
  • LTD – Claim Employer Statement

Notices & Letters

• 2024-Letter-Summary of Benefits and Coverage
• 2024 Prescription Drug Coverage and Medicare Creditable Coverage
• 2024 Plan Changes to All Plans

Guides & Benefit Summaries

• Summary of Benefits and Coverage – Classic – 2024 (brief overview)
• Summary of Benefits and Coverage – Economy – 2024 (brief overview)
  • Glossary of Health Coverage Terms
• Delta Dental PPO Benefit Plan Summary – Actives 2024
• Delta Dental Benefit Plan Summary – Retirees 2019
• Enrollment Guide Active 2024
• Enrollment Guide Retiree 2025
• Life ADD and Long Term Disability (WSCFF Guide)
• BPAS – VEBA – Enrollment Guide 2024
  • BPAS – FAQ VEBA HRA
• The Standard

Other

• Summary Annual Report – PYE 2022
• Home – Non Discrimination Notice-2020
• Home – Pin Request Dependent Web
• Pin Request Form
• Home Shared Admin and Website Email
• Premium Assistance – Medicaid & CHIP 2024