Forms & Resources

Weekly and Biweekly Cost Comparison Charts

• 2022 Weekly Cost Chart
• 2022 Biweekly Cost Chart

Medical

• UnitedHealthcare Medical Claim Form
• HIPAA Authorization Form

Hawaii

• HMSA Essential Prescription Formulary
• 2022 HMSA Prescription Drug Rider
• 2022 HMSA Medical Guide to Benefits
• 2020 SBC Addendum (COVID-19)

Medical Spending Accounts

• FSA Claim Form
• HRA Claim Form
• Dependent Care FSA Claim Form
• Managing Your HSA: Helpful Online Tools

Prescription

• CVS Caremark Mail Service Order Form
• Caremark RX Claim Form
• 2022 CVS Performance Drug List
• ACA Preventive Services Drug List
• HDHP Generics Preventive Drugs List
• Mandatory Maintenance Choice

Dental

• Cigna Dental Claim Form
• Cigna Dental Care Patient Charge Schedule

Vision

• VSP Member Reimbursement Form

Life and Accident Insurance

• Beneficiary Change Form

SaveSmart 401(k) & Retirement

• 401(k) Rollover Form
• SaveSmart 401(k) Summary Plan Description
• Long-Term Cash Retirement Provision

Work or Life Changes

• Full-Time Qualified Status Change Form
• Part-Time Qualified Status Change Form
• Beneficiary Change Form
• 2022 Benefits at Separation
• FAQ for Full-Time and Part-Time
• Domestic Partner Affidavit

Adoption Assistance Program

• Adoption Assistance Reimbursement Form

Tuition Assistance Program

• Tuition Assistance Program Application

Legal Notices

• Children’s Health Insurance Program (CHIP) Notice
• HIPAA Notice
• Initial Notice of COBRA Rights
• Medicare Part D Notice
• SmartChoices Summary Plan Description
• Bind Supplement to SmartChoices Summary Plan Description
• Summary Annual Report
• SaveSmart 401(k) Summary Plan Description
• 2022 Illinois Medical Coverage Disclosure 
• Transparency in Coverage – Machine Readable Files (MRFs)
  • UnitedHealthcare creates and publishes the MRFs on behalf of PetSmart for PPO, HDHP and Bind plans. To link to the Machine-Readable Files, please click on the URL provided:  transparency-in-coverage.uhc.com
    
  • Hawaii Medical Service Association (“HMSA”) creates and publishes the MRFs for the medical plan offered in Hawaii. To link to the Machine-Readable Files, please click on the URL provided: www.hmsa.com/transparencymrf

PetSmart Summary of Benefits and Coverage (SBC)

• 2023 Surest SBC
• 2023 HMSA SBC
• 2023 PPO1 SBC
• 2023 PPO2 SBC
• 2023 HDHP SBC
• 2023 Indemnity SBC
• 2023 Cigna Dental SBC
• 2022 PPO1 SBC
• 2022 PPO2 SBC
• 2022 Bind SBC
• 2022 HDHP SBC
• 2022 HMSA SBC
• 2022 Indemnity SBC