Benefit Forms & Information

Active Employee Plans

• 2025 Medical Premium Rates
• 2025 Active Plans Side by Side (Medical Plans Comparison) 
• 2024 Medical Premium Rates
• 2024 Active Plans Side by Side (Medical Plans Comparison)

Important Health Information

• Qualifying Events
• Dual Health Insurance FAQ'S
  

Medical

• About Generic Drugs
• Best Doctors
• Kaiser Care now at a Target Near You
• Kaiser Traveling Flyer
• UHC Journey Harmony Brochure
• UHC Journey Harmony Network Listing
• UHC Journey Harmony HRA Deductible Flyer
• HealthInvest Health Reimbursement Account
• Preventative Care Services
• Reimbursement Request Multi-District Part-Time Faculty Health Insurance Program
• VEBA Welcome Flyer
• VEBA Member App Flyer
• VEBA Healthy Reboot Flyer
• VEBA Well Being Services
  

Medical Plan Summaries

• • Kaiser Benefits Summary
  • United HealthCare Network 1 Summary of Benefits Coverage
  • United HealthCare Signature Value Harmony Summary of Benefits
  • United HealthCare Alliance HMO 20-30 Summary of Benefits Coverage
  • UHC Harmony HMO with HRA Summary of Benefits

Medical Enrollment Form

• • VEBA Universal Enrollment Form

Dental

• Delta Dental Benefits Summary
• Delta Dental Enrollment Form
• Delta Dental Premier ID card
  

Vision

• VSP Vision Benefits Summary
• VSP Reimbursement Form
  

Acupuncture/Chiropractic

• OptumHealth Acupuncture & Chiropractic Benefits
• Acupuncture & Chiropractic $10 Schedule of Benefits
• Acupuncture & Chiropractic $20 Schedule of Benefits
• Acupuncture & Chiropractic $30 Schedule of Benefits
  

Express Scripts Prescriptions (UHC Plans only)

• Express Scripts HMO Alliance Co-Payments
• Express Scripts Prescription Overview
• Express Scripts Home Delivery
• Express Scripts Network 1 Co-Payments
• Express Scripts PPO UMR
  

Employee Assistance Program

• EAP Services Overview
• VEBA EAP Benefits Summary
• VEBA EAP Brochure
  

MetLaw Pre-Paid Legal Plan

• Legal Plan Enrollment Form
• Legal Services Overview
• Legal Services Summary Plan Description

Beneficiary Designation Forms

• CalPERS Beneficiary Designation
• Recipient Designation Form CalSTRS
• Designation of Beneficiary for Final Pay Warrant

Minnesota Life Insurance

• Life Enrollment Form
• Group Term Life Insurance Policy
• Group Term Life Insurance Policy Amendment #1
• Group Term Life Certificate of Insurance
• Minnesota Beneficiary Designation Form
• Life Evidence of Insurability Form
• Conversion & Portability Comparison
• Minnesota Life Portability Form
• Minnesota Life Conversion Form

Domestic Partner

• Overview of Health Coverage for Domestic Partners
• Affidavit of Domestic Partnership
• Health Care Enrollment Statement

Flexible Spending Account (FSA) administered by Benefit Coordinators Corporation (BCC)

• Account Brochure
• Debit Card Request Form
• Direct Deposit Form
• Eligible Expenses
• FSA Plans: Grace Period
• My SmartCare Mobile App
• Notice of Change or Termination
• Over-the-Counter (OTC)
• Reimbursement Request Form
• SmartCare Registration

Commuter Benefit

• Account Brochure
• Transportation Request for Medical Reimbursement
• Transportation and Parking Enrollment
• Parking and Transportation Reimbursement Form

General Benefit Forms

• Address or Name Change Notice Form

Affordable Care Act

• How to Opt in to Receive Your 1095-C Electronically
• How to View and Print Your 1095-C

Insurance Waiver

• Waiver - Employee Group Health Insurance

Long Term Disability Insurance (for Classified Contract Employees Only)

• Hartford Long Term Disability

Family Medical Leave Act (FMLA) Information

• Employee Request for Family Medical Leave
• Family Care and Medical Leave Fact Sheet
• Employee Rights Under the Family Medical Leave Act
• Your Rights and Obligations as a Pregnant Employee
• Expanded Family And Medical Leave
• Pregnancy Disability Leave Fact Sheet