Documents and Forms

Documents

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*

Cigna Tier 1 Benefit Summary*

Cigna Tier 2 Benefit Summary*

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 Step Therapy

OptumRx Quantity Limits

OptumRX Preventive Care Medications

Health Trust Fund Summary Annual Report

Summary Plan Description

Vision Plan Document

* 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.

Pension and 401(k)

Pension Plan and 401(k) Plan Summary Plan Description

Pension Plan Annual Funding Notice

401(k) Plan Summary Annual Report

Forms

Health

Cigna Claim Form

Cigna Dependent Coverage Form

Dental Claim Form

Dental Enrollment Form

Domestic Partnership Affidavit

Domestic Partnership Declaration of Financial Interdependence

HIP HMO Enrollment Form

HIPAA Request for PHI to Be Transmitted by Alternate Means Form

HIPAA Request for PHI Form

HIPAA Request for Restrictions, Use and Disclosure Form

HIPAA Authorized Rep Form

HIPAA Complaint 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)

New York COBRA Subsidy Application (Fillable PDF)

OptumRx Claim Form

QCIP Claim Form

Vision Claim Form

Supplemental Travel Claim Form

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) Rollover Form

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.