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MEDICAL & PRESCRIPTION

Blue Cross/Blue Shield

Personal Choice Medical Plan Coverage

Transparency in Coverage - MRF Provision

CVS/Caremark

NON-PESPA - CVS/Caremark Prescription Coverage

PESPA ONLY - CVS/Caremark Prescription Coverage

Creditable Coverage Notice

Enrollment Form

VISION COVERAGE

Vision Benefits of America #2469

Vision Coverage

Enrollment Form

DENTAL

Delta Dental - Plan # 10034

Dental Coverage - Employees

Dental Coverage - Dependents

Enrollment Form

FLEXIBLE SPENDING

Flexible Spending - Health Equity

Health Care Coverage

Dependent Care Coverage

Eligible Health Care Expenses

Eligible Dependent Care Expenses

Enrollment Form PESPA/AC93/MISC (26 Pays)

Enrollment Form PEA (22 pays)

Enrollment Form PESPA (20 pays)

LONG TERM DISABILITY

Madison National Life - Long Term Disability Coverage

PEA/MISC Certificate of Coverage

Enrollment Form - PEA/MSC

PESPA Certificate of Coverage

Enrollment Form - PESPA

Certificates of Coverage for Act 93 & Transportation

Option 1 - 14 Day Buy Down

Option 2 - 30 Day Buy Down

Option 3 - 60 Day Buy Down

Option 4 - 90 Day Buy Down

Option 5 - 180 Day Buy Down

Option 6 - 30 Day Buy Down 50% Benefit

TRANSPORTATION

Enrollment Form - Transportation

ACT 93

Enrollment Form - ACT 93

LIFE INSURANCE

Enrollment Form

Act 93: Benefit Summary Beneficiary Designation Form

PEA 60K: Benefit Summary Beneficiary Designation Form

PESPA/PEA/MISC/NSV 50K: Benefit Summary Beneficiary Designation Form

Employee Assistance Program

Health Advocate Brochure

Health Advocate Resources

WAIVING COVERAGE

Employees may opt out of employer-sponsored insurance. employees must complete, sign and date a waiver of coverage form, available at the link below. An employee can choose to opt out of any/all offered coverages – note: Medical and Prescription must be taken or waived as a set.

Waiver of Coverage Form

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