Forms & Resources

Weekly and Biweekly Cost Comparison Charts

• 2021 Weekly Cost Chart
• 2021 Biweekly Cost Chart

Medical

• UnitedHealthcare Medical Claim Form
• HIPAA Authorization Form

Hawaii

• 2021 HMSA Summary of Benefits and Coverage
• 2020 HMSA Essential Prescription Formulary
• 2021 HMSA Prescription Drug Rider
• 2021 HMSA Medical Guide to Benefits

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
• 2021 CVS Performance Drug List
• 2020 ACA Preventive Services Drug List
• 2020 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)

• 401(k) Rollover Form

Work or Life Changes

• Full-Time Qualified Status Change Form
• Part-Time Qualified Status Change Form
• Beneficiary Change Form
• 2021 Benefits at Separation
• FAQ for Full-Time and Part-Time

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 (2021)
• SmartChoices Summary Plan Description
• Bind Supplement to SmartChoices Summary Plan Description
• Summary Annual Report
• SaveSmart 401(k) Summary Plan Description

PetSmart Summary of Benefits and Coverage (SBC)

• 2021 PPO1 SBC
• 2021 PPO2 SBC
• 2021 Bind SBC
• 2021 HDHP SBC
• 2021 HMSA SBC
• 2021 Indemnity SBC
• 2022 PPO1 SBC
• 2022 PPO2 SBC
• 2022 Bind SBC
• 2022 HDHP SBC
• 2022 HMSA SBC
• 2022 Indemnity SBC