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Benefits Documents

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Health Plan - Active Employee & Retiree (Non-Medicare) - FY2018

  • BCBS Blue Care Elect Preferred (PPO) only for those residing out of New England (or dependents residing out of New England). For enrollment in this plan you must provide documentation at the time of enrollment confirming out-of-New England address (Driver's license, electric bill, rental agreement, etc.). Recertification of this documentation during the Annual Spring Open Enrollment will be required for continuation coverage under this plan.
  • If you are unsure which plan (A, B or C) that pertains to you, please check the bottom of the rate sheets for a list of covered groups or call Human Resources at 508-799-1030.
File Name File Size
BCBS ahealthyme 774 kB
BCBS Blue Care Elect Preferred (PPO) - Newly Settled Summary of Benefits & Coverage (SBC) 131 kB
BCBS Blue Care Elect Preferred (PPO) - Non-Settled Summary of Benefits & Coverage (SBC) 113 kB
BCBS Blue Care Elect Preferred (PPO) - Settled Summary of Benefits & Coverage (SBC) 113 kB
BCBS Enrollment 378 kB
BCBS Fitness Reimbursement 171 kB
BCBS Hospital Listing 901 kB
BCBS Network Blue New England - Newly Settled Summary of Benefits & Coverage (SBC) 140 kB
BCBS Network Blue New England - Non-Settled Summary of Benefits & Coverage (SBC) 122 kB
BCBS Network Blue New England - Settled Summary of Benefits & Coverage (SBC) 123 kB
BCBS Non-Hospital Imaging Labs 938 kB
BCBS Weight Loss Benefit 155 kB
COW Advantage - Newly Settled Summary of Benefits & Coverage (SBC) 433 kB
COW Advantage - Non-Settled Summary of Benefits & Coverage (SBC) 424 kB
COW Advantage - Settled Summary of Benefits & Coverage (SBC) 421 kB
COW Advantage Direct - Newly Settled Summary of Benefits & Coverage (SBC) 433 kB
COW Advantage Direct - Non-Settled Summary of Benefits & Coverage (SBC) 425 kB
COW Advantage Direct - Settled Summary of Benefits & Coverage (SBC) 421 kB
COW Advantage Enrollment 110 kB
COW Advantage It Fits! Reimbursement 144 kB
COW Advantage Participating Hospitals 91 kB
COW Advantage Plan Healthy Health 79 kB
COW Advantage Plans - Newly Settled Summary of Benefits 95 kB
COW Advantage Plans - Non-Settled Summary of Benefits 76 kB
COW Advantage Plans - Settled Summary of Benefits 99 kB

Health Plan - Retiree (Medicare) - CY2017

File Name File Size
BCBS Medex - Blue MedicareRx Enrollment 178 kB
BCBS Medex - Blue MedicareRx Formulary 768 kB
BCBS Medex - Blue MedicareRx Mail Order Form 72 kB
BCBS Medex - Blue MedicareRx Summary 1 MB
BCBS Medex - Enrollment 732 kB
BCBS Medex - Summary 530 kB
Fallon Senior Plan Premier HMO - Cover Letter 59 kB
Fallon Senior Plan Premier HMO - Enrollment 159 kB
Fallon Senior Plan Premier HMO - Enrollment Instructions 55 kB
Fallon Senior Plan Premier HMO - Notice of Nondiscrimination 290 kB
Fallon Senior Plan Premier HMO - Quick Reference 156 kB
Fallon Senior Plan Premier HMO - Request for Plan Termination 69 kB
Fallon Senior Plan Premier HMO - Service Area & Network Hospitals 4 MB
Fallon Senior Plan Premier HMO - Star Ratings 42 kB
Fallon Senior Plan Premier HMO - Summary 404 kB
Tufts - Disenrollment Form 19 kB
Tufts - Notice of Privacy Practices 138 kB
Tufts - Utilization Management 77 kB
Tufts Medicare Complement - Discrimination is Against the Law 301 kB
Tufts Medicare Complement - Enrollment 164 kB
Tufts Medicare Complement - Member Discounts 510 kB
Tufts Medicare Complement - Summary 86 kB
Tufts Medicare Complement PDP - Formulary 1 MB
Tufts Medicare Complement PDP - Group Election Form 551 kB
Tufts Medicare Complement PDP - Highlights 160 kB
Tufts Medicare Complement PDP - Summary 588 kB
Tufts Medicare Preferred - Appeals and Grievances 79 kB
Tufts Medicare Preferred HMO - Cover Letter 28 kB
Tufts Medicare Preferred HMO - Doctor Search 1 MB
Tufts Medicare Preferred HMO - Enrollment 200 kB
Tufts Medicare Preferred HMO - Formulary 1 MB
Tufts Medicare Preferred HMO - Group Election Form 551 kB
Tufts Medicare Preferred HMO - Healthy Living Essentials 179 kB
Tufts Medicare Preferred HMO - Rx Plus Drug Addendum 187 kB
Tufts Medicare Preferred HMO - Rx Plus Highlights 181 kB
Tufts Medicare Preferred HMO - Silver Sneakers 593 kB
Tufts Medicare Preferred HMO - Star Ratings 137 kB
Tufts Medicare Preferred HMO - Summary 623 kB

Dental

  • Available to all benefit eligible employees.
  • ONLY Retirees can have a two person plan.
File Name File Size
Enrollment - Altus - Active Employee 140 kB
Enrollment - Altus - Retiree 138 kB
Highlights - Altus - High Option 167 kB
Highlights - Altus - Low Option 164 kB
Notice - Altus - Maximum Carry Over Provision 265 kB
Notice - Altus - Online Management 163 kB
Student Certification - Altus 39 kB

Vision

  • Available to all benefit eligible employees and retirees.
File Name File Size
Enrollment - UnitedHealthcare Vision - FY2018 102 kB
FAQs - UnitedHealthcare Vision 29 kB
Network - UnitedHealthcare Vision 164 kB
Summary - UnitedHealthcare Vision 4 MB
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