Benefits and Insurance Information

• BC/BS plans, forms and information
• HMO Deductible – Summary of Benefits and Coverage
• PPO Deductible – Summary of Benefits and Coverage
• Medex III – Schedule of Benefits
• BC/BS Enrollment form
• Fitness Benefit form
• Weight Loss Benefit form
• Preventive screening Adult information
• Living Healthy Vision information
• Preventive screening Children information
• Cancellation request form
• Delta Dental forms and information
• Delta Dental enrollment form
• Delta Dental Basic Plan
• Delta Dental Enhanced Plan
• FSA plan (Flexible Spending Medical & Dependent Care plans ) (administered by Crosby Benefits)
• Enrollment form
• FSA Plan information
• FSA Eligible items listing
• Medical reimbursement request form
• Dependent care reimbursement request form
• HRA plans (administered by Crosby Benefits)
• HRA #1 notice – Subscribers with High Out of Pocket Health Care Costs
• HRA #2 notice – Low Income Subscribers
• HRA #3 notice – Non-Medicare Eligible Retirees who are age 65 and over
• HRA Reimbursement Request form
• Mail order prescription services
• Express Scripts form
• CanaRX form
• Qualifying event information
• Rate Notices- FY’14
• Employee notice
• Retiree notice
• Rate matrix

Qualifying Event:

An event that permits a person to modify their health benefits coverage category. Examples include, but are not limited to, the birth of a child, divorce, marriage, new hire, involuntary loss of coverage from another source, court decree (as part of a divorce or custody agreement).

If no qualified event occurs as described above, the only opportunity to change your health insurance plan is during an Open Enrollment Period. Normally Open Enrollment occurs during late spring/early summer with an effective date of July 1.

All employees are notified of the Open Enrollment Period through an email and departmental posting.

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Cancellation Request:

If you wish to cancel your current coverage of health, life or dental insurance, a written request must be submitted to the HR Office at City Hall Room 306.  Form is available here.

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