Employee Insurances

BENEFITS INFORMATION AND FORM
Cancellation  Form-Voluntary Benefits
MEDICAL INSURANCE
Health Insurance Declination Form (MUST BE TURNED IN TO HUMAN RESOURCES)
Health Insurance Dependent Chg Form (MUST BE TURNED IN TO HUMAN RESOURCES)
Health Insurance Status Change Form (MUST BE TURNED IN TO HUMAN RESOURCES)
Health Insurance Cancellation Form (MUST BE TURNED IN TO HUMAN RESOURCES)
Health Insurance Enrollment Form (MSUT BE TURNED IN TO HUMAN RESOURCES)
Health Insurance Dependent Drop Form (MUST BE TURNED IN TO HUMAN RESOURCES)
Physician Screening Form (Wellness Screen)   WELLNESS

Blue Cross/Blue Shield   
Health Handbook               
Replacement Card(s)- Call Blue Cross at 1-800-321-4391                
Find a Doctor   
Prescription Reimbursement Form
OptumRx Member Portal
COBRA INFORMATION   Continuation of health care after loss of coverage

DENTAL INSURANCE    2020 Dental Handbook   Find a Dentist  Dental Claim Form        
VISION INSURANCE        Printable Flyer      Doctor Directory   
Vision coverage is an SEIB provided benefit.  The SEIB negotiated a discount price with the providers listed in the 'Doctor Directory' below.  There are no claim forms or insurance cards, the provider should            charge you as listed below:

*If needed, verification can be obtained from the SEIB at 1-866-836-9137.
Member Payment Responsibility:
Routine vision examination $40.00     
Routine vision examination with dilation $45.00
Initial contact lens fitting $25.00                        
Follow-up contact lens visit $25.00
                        Routine vision examination discounts, with or without dilation, are limited to one per year.                  25% discount off the retail price for each of the items listed below
                         Eyewear – one per year
                         Lenses (plastic or glass)/Single vision/Bifocal/Trifocal/Frames
                          Discounts are also available through 1-800 CONTACTS. For more                           information, you can visit www.1800contacts.com, or call 1(800) CONTACTS.
            All services listed require that you make your payment directly to the provider.

FLEXIBLE SPENDING ACCOUNTS & SECTION 125 PLAN  
FSA Informational Brochure and FSA Calculator                          FSA Enrollment Form   
FSA Direct Deposit Form for reimbursements                               FSA Request for Reimbursement Form            
FSA List of Eligible Expenses                                                                      FSA Plan Summary
Section 125 Pre-Tax Premium Opt-Out Form

LIFE & SUPPLEMENTAL INSURANCE         

FMLA-  FAMILY AND MEDICAL LEAVE REQUESTS
Leave Request Form                            FMLA Fact Sheet                         
Medical Release Form                        Return-to-Work Form