Health and Benefit Forms
OTC COVID-19 Test Reimbursement Claim Form
Click here to download a printable PDF.
Notice of Nondiscrimination
Click Here to download a printable PDF.
Your Rights and Protections Against Surprise Medical Bills
Click Here to download a printable PDF – Effective Date of January 1, 2023.
Click Here to download a printable PDF.
Important CIGNA Network Change – effective July 1, 2021 from PPO to Cigna’s Open Access Plus (OAP) network:
Click Here to download a printable PDF-detailing the change to the Network to OAP – effective July 1, 2021
Click Here to download a printable PDF-a temporary ID card memo to present to your providers on and after July 1, 2021
Plan Rules & Regulations:
Click Here to download a printable PDF-Health & Benefit Plan Rules and Regulations form.
Click here to download a printable PDF-Pension Plan Rules and Regulations form.
Click Here to download a printable PDF-Vacation Plan Rules and Regulations form.
Click Here to download a printable PDF-Adjustable Pension Plan Regulations form.
Summary Plan Descriptions:
Click Here to download a printable PDF-Health & Benefit Summary Plan Description form.
Click Here to download a printable PDF-Pension Summary Plan Description form.
Click Here to download a printable PDF-Vacation Summary Plan Description form.
Click Here to download a printable PDF-MM&P Adjustable Pension Plan Summary Plan Description.
Summary of Benefits and Coverage Forms (“SBC’s”):
Click Here to download a printable PDF-SBC for Actives/Non-Medicare Retirees form for 2024.
Click Here to download a printable PDF-SBC for Medicare-Eligible Retirees form for 2024.
Click Here to download a printable PDF-SBC for Actives/Non-Medicare Retirees form for 2025.
Click Here to download a printable PDF-SBC for Medicare-Eligible Retirees form for 2025.
Prescription Benefits – Important Update – Step Therapy effective January 1, 2019
Click Here to download a printable PDF- information on Step Therapy effective- January 1, 2019.
CVS Caremark – Formulary Exclusions – January 1, 2023:
Click Here to download a printable PDF- CVS Caremark Formulary Exclusions effective 1/1/2023.
Click Here to download a printable PDF- Control Specialty Formulary Exclusions effective 1/1/2023.
CVS Caremark – Formulary Exclusions – January 1, 2022:
Click Here to download a printable PDF- CVS Caremark Formulary Exclusions effective 1/1/2022.
Click Here to download a printable PDF- Control Specialty Formulary Exclusions effective 1/1/2022.
New Cigna website information – myCigna.com – operational – October 1, 2017:
Click Here to download a printable PDF- – myCigna.com – Flyer – October 1, 2017.
Other forms:
Click Here to download a printable PDF-Affidavit for Dependent Child form.
Click Here to download a printable PDF-Affidavit for Disabled Dependent form.
Click Here to download a printable PDF-Affidavit for Dependency form.
Click Here to download a printable PDF-Agreement of Re-Payment, Assignment and Subrogation form.
Click Here to download a printable PDF-Annual Health Examination and Immunization form.
Click Here to download a printable PDF-Coordination of Benefits Information form.
Click Here to download a printable PDF-Delta Dental form.
Click Here to download a printable PDF-Statement of Claim for Weekly Disability Benefits (Employee Statement) form.
Click Here to download a printable PDF-Injury Accident Form Agreement of Re-Payment, Assignment and Subrogation form.
Click Here to download a printable PDF-Direct Member Reimbursement form (Prescription Drugs).
Click Here to download a printable PDF-Scholarship Program Brochure 2025-2026 –filing deadline November 30, 2024.
Click Here to download a printable PDF-Permanent Data Form.
Click Here to download a printable PDF-CIGNA Provider Nomination Form.
Click Here to download a printable PDF-Enrollment Form for Eligible Adult Children 19-26.