Documents and Forms
Documents
Health
Cigna Medical and Optum RX Plan Summary Details*
Cigna Summary of Benefits ACA 2024 Tier 1*
Cigna Summary of Benefits ACA 2024 Tier 2*
Dental HMO Benefit Plan Summary
Dental PPO Benefit Plan Summary
Health Plan Eligibility Description (Information about the January 2024 Plan changes)
HIP HMO Summary of Benefits and Coverage Tier 1
HIP HMO Summary of Benefits and Coverage Tier 2
Kaiser Northern California HMO Summary of Benefits and Coverage
Kaiser Mid-Atlantic HMO Summary of Benefits and Coverage
Kaiser Southern California HMO Summary of Benefits and Coverage
OptumRx Standard Formulary 2024
OptumRx Prior Authorization list
OptumRX Preventive Care Medications
* This Cigna link leads to the machine readable files that are made available in response to the federal Transparency in Coverage Rule and includes negotiated service rates and out-of-network allowed- amounts between health plans and healthcare providers. The machine-readable files are formatted to allow researchers, regulators, and application developers to more easily access and analyze data. The files though are large in size in which they can take some time to download. Therefore, we recommend that if you need information about the cost of services, you should leverage the pricing tools that are made available to you within your mycigna.com account.
Forms
Health
Domestic Partnership Affidavit
Domestic Partnership Declaration of Financial Interdependence
HIPAA Request for PHI to Be Transmitted by Alternate Means Form
HIPAA Request for Restrictions, Use and Disclosure Form
HIPAA Request of Accounting of Disclosure of PHI Form
Kaiser Northern California Enrollment Form
Kaiser Southern California Enrollment Form
Kaiser Mid-Atlantic Enrollment Form
New York COBRA Subsidy Application (Standard PDF)
Pension
Redesignation of Former Spouse as Beneficiary Form
Domestic Partnership Affidavit
Domestic Partnership Declaration of Financial Interdependence
Pension Agreement for Electronic Deposits
Pension Beneficiary Designation Form
Preretirement Spousal Rejection Form
Request for Pension Information and Application Form
Withholding Certificate for Pension and Annuity Payments (W-4P)
Health Premium Withholding Form From Pension Benefit
Pension Reciprocity Form (for Canadian members)
Pension Reciprocity Form (for U.S. members working in Canada)
401(k)
401(k) Salary Deferral Agreement
401(k) Beneficiary Designation / Change Form
401(k) Designation of Former Spouse as Beneficiary
To request a withdrawal from your 401(k) Plan, please contact the Benefit Services Department. A representative will provide you with the form applicable to the withdrawal option for which you may qualify.