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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.