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Insurance Information/Forms

Benefit Bank Plan Document (47 Kb)

Benefit Bank Plan Highlights (36 Kb)

Benefits Appeal Form (334 Kb)

College Dependent Form (28 Kb)

Computer Use Proof Form (5 Kb)

Dental Assistance Plan (891 Kb)

Flexible Spending Account Request for Reimbursement (59 Kb)

Formulary Drug List

Health and Dental Master Plan (499 Kb)

• Amendment 2: Reimbursement Check Processing Form
  
• Amendment 3: Deductibles, Coinsurance, Prescription Coverage; Medicare Enrollment
  
• Amendment 4: Podiatry and Orthotic Benefits
• Amendment 5: Plan A Prescription Drug Deductibles; Plan B Major Medical Out-Of-Pocket Amount
  
• Amendment 6: Retiree Prescription Drug Coverage; Major Medical Deductibles, Out-Of-Pocket Amounts
  
• Amendment 7: Morbid Obesity
• Amendment 8: Vision Benefit Revisions; Opt-Out Provision
• Amendment 9: Privacy

Health and Dental Plan Summary (244 Kb)

Mail Order Prescription Form (289 Kb)

Medical Benefit Request Form (347 Kb)

Prescription Reimbursement Form (373 Kb)

All files are in Adobe Acrobat (pdf) format.  If you don't have the Adobe Acrobat Reader, you can get it here.