Benefits Documents | City of Worcester, MA

Forms

File Name	File Size
Altus Dental - Active Employee Enrollment	140 kB
Blue Cross Blue Shield - Enrollment	378 kB
Blue Cross Blue Shield - Fitness Benefit	108 kB
Blue Cross Blue Shield - Retaining Coverage for Disabled Dependent Child	51 kB
Blue Cross Blue Shield - Student Certification	26 kB
Blue Cross Blue Shield - Weight Loss Benefit	140 kB
Cafeteria Plan Advisors - FSA Claim Voucher - "Benny Card"	70 kB
Caremark - Mail Service Order	77 kB
Caremark - Prescription Drug Claim	52 kB
Fallon - It Fits Reimbursement	301 kB
Fallon - Student Certification	82 kB
Intention to Retire	137 kB
Trustmark Service Request Plan C Universal Life Insurance	35 kB
UnitedHealthcare Vision	83 kB
UNUM Life Insurance Beneficiary	83 kB
UNUM Life Insurance Enrollment	59 kB

File Name	File Size
Tiered Plans FY2012	40 kB

File Name	File Size
Altus Dental High Option	167 kB
Altus Dental Low Option	164 kB
BCBS Blue Care Elect Preferred	193 kB
United Healthcare Vision Summary	4 MB

File Name	File Size
BCBS Hospital Tiering List	155 kB
BCBS Network Blue New England Summary Packet	372 kB
City of Worcester Advantage Direct Plan Hospital List	82 kB
City of Worcester Advantage Plan Hospital List	94 kB
City of Worcester Advantage Plans Summary Packet FY2012	76 kB
City of Worcester Enrollment Form FY2012	71 kB
Summary Chart FY2012 - Settled	29 kB

File Name	File Size
Altus Dental - Retiree Enrollment	138 kB
BCBS Blue Choice Retiree FY2012 Summary	189 kB
Blue Cross Blue Shield Medex Summary	238 kB
Caremark - Mail Service Order (Prescription Drug Plan for those on Non-Medicare plans)	479 B
Caremark - Prescription Drug Claim (Prescription Drug Plan for those on Non-Medicare plans)	494 B
Creditable Coverage 2012	65 kB
Fallon Direct Retiree FY2012 Summary	77 kB
Fallon Select Retiree FY2012 Summary	83 kB
Fallon Senior Plan - Quick Reference Guide	33 kB
Fallon Senior Plan - Schedule of Benefits	111 kB
Fallon Senior Plan - Summary of Benefits	254 kB
Fallon Senior Plan Disenrollment	55 kB
Fallon Senior Plan Premier Enrollment	98 kB
Medex, Tufts Medicare Complement, Tufts HMO & Fallon Senior Comparisons	75 kB
Medicare Eligible Retiree Rate Sheet	14 kB
Medicare Status Form	50 kB
Medicare Supplement Rate Sheet	75 kB
Non-Medicare Eligible Retiree FY2012 Comparisons	37 kB
Non-Medicare Eligible Retiree Rate Sheet	16 kB
Section 18 Info for Retirees	98 kB
SilverScript Evidence of Coverage	832 kB
SilverScript Formulary	961 kB
SilverScript Information Sheet	131 kB
SilverScript Prescription Drug Plan (Medex & Tufts Medicare Complement) Summary	192 kB
Tufts - Medicare Complement Enrollment	156 kB
Tufts Medicare Complement Summary	41 kB
Tufts Medicare Disenrollment	21 kB
Tufts Medicare Preferred HMO Enrollment	77 kB
Tufts Medicare Preferred HMO Rx Summary	156 kB
Tufts Medicare Preferred HMO Summary	3 MB

File Name	File Size
Cafeteria Plan Advisors - FSA Explained - "Benny Card"	74 kB
Children's Health Insurance Program (CHIP)	17 kB
City of Worcester Benefits Q&A	149 kB
New Tier Plans Rate Sheet FY2012	18 kB
Open Enrollment - FY2013 Flyer	94 kB
Regulations for Covering Spouses/Dependents	17 kB
United Healthcare Vision FAQs	29 kB
United Healthcare Vision Network List	109 kB
UNUM Life Insurance Announcement	52 kB
UNUM Life Insurance Rate Sheet	24 kB
Welcome New Employee - Letter	89 kB