Benefits - By Plan
Forms
Resources
- ALEX
- Comparison of Medical Benefits
- Comparison of Pharmacy Benefits
- Federal Glossary/Medical Terms
- Guide to Office Visit Copays
- Plan Design Options eLearning (ETF)
- Health Plan Map
- State & Federal Notifications
- HDHP Questionnaire
- Patient Rights and Responsibilities
- Preventive Health Services
- Uniform Dental Benefits
- EEOC Notice: Wellness
Certificate of Coverage
Summary of Benefits & Coverage
- Health Plan and Access Plan Summary of Benefits & Coverage
- HDHP and Access HDHP Plan Summary of Benefits & Coverage
- Summary of Dental Benefits (Uniform Dental Benefits)
Plan Administrators
- State Group Health Insurance: Department of Employee Trust Funds | 1-877-533-5020
- Pharmacy Benefits: Navitus Health Solutions | 1-866-333-2757
- Uniform Dental Benefits: Delta Dental of Wisconsin | 1-844-337-8383
- Well Wisconsin: StayWell | 1-800-821-6591
last updated: 12/01/2017
- Certificate of Coverage
- Davis Affinity Vision Discount Program
- EPIC Specialty Benefits | 1-800-520-5750
- Delta Dental of Wisconsin | 1-800-236-3712
- Certificate of Coverage
- Davis Vision Affinity Discount Program
- EPIC Specialty Benefits | 1-800-520-5750
- Delta Dental of Wisconsin | 1-800-236-3712
- VSP | 1-800-877-7195
- TASC Online Portal | 1-844-786-3947
only available to individuals who are eligible for the HSA and enroll in either the HDHP or Access HDHP plan design
- TASC Online Portal | 1-844-786-3947
- Accelerated Death Benefit Form
- Aetna | 1-800-960-0052
Publications
Annual Reports
Forms
- – Complete and submit this form to your institution to request W/FMLA-protected leave. If you request a WFMLA leave to care for a domestic partner or a domestic partner’s parent, you must complete this form in order to certify the domestic partnership for WFMLA purposes.
- – Your health care provider must complete this form to certify your serious health condition if you are taking a concurrent FMLA and WFMLA leave. Note: if you are taking a WFMLA leave only – you should use the WFMLA Certification form (UWS 82a) to certify your own serious health condition.
- – If you are taking a WFMLA leave only – you should use this form to certify your own serious health condition.
- – Your family member’s health care provider must complete this form to certify their serious health condition if you are taking a concurrent FMLA and WFMLA leave. Note: if you are taking a WFMLA leave only – you should use the WFMLA Certification form (UWS 83a) to certify your family member’s serious health condition.
- – If you are taking WFMLA leave only – you should use this form to certify your family member’s serious health condition.
- – Complete and submit this form to your institution to certify that an exigency was created because a family member is on covered active military duty or has been notified of an impending call or order to active duty to a foreign country or international waters. The family member may be in either the regular or reserve component of the Armed Forces.
- – Complete and submit this form to your institution to request FMLA-protected leave to care for a current military servicemember or veteran, who is a family member or next of kin, who is seriously ill or injured due to military service.
- – Complete and submit this form to your institution to request FMLA-protected leave to care for a current military servicemember or veteran, who is a family member or next of kin, who is seriously ill or injured due to military service.
See Also
last updated: 11/17/17
Beneficiary Designations
What is a beneficiary?
A beneficiary is the person or entity you name in a life insurance policy or retirement plan to receive the benefit upon your death. The beneficiary designation on file at the time of your death is binding in the payment of your benefits.
Whenever there is a big life event, such as when you get married, divorced, have a child or a grandchild joins the family, you may want to review your beneficiary designations and update them if you wish. You can change your beneficiary at any time, in accordance with the plan requirements.
Beneficiary designation forms can be found below. Completed forms should be sent directly to the benefit plan vendor, not to your human resources office. The appropriate address can be found below and on each beneficiary designation form.
Please retain a copy of your beneficiary designation forms for your records. The UW System does not process or store the beneficiary designation forms. Please contact the plan administrator directly for questions about your beneficiary designations.
If you don’t designate a beneficiary, your benefit will be paid out according to Wisconsin law. This is called Standard Sequence and will pay to beneficiaries as follows*:
- Your surviving spouse, otherwise;
- Your surviving children equally, otherwise;
- Your surviving grandchildren equally, otherwise;
- Your surviving parents equally, otherwise;
- Your surviving siblings equally, otherwise;
- Your estate.
Note: All claims associated with the death of a covered family member will be paid to the employee.
*Note: If you wish to name a domestic partner as a beneficiary, you should complete the applicable beneficiary designation form(s).
Benefit plans with benefits that are payable to beneficiaries
Wisconsin Retirement System (WRS) and State Group Life Insurance
The WRS is administered by the Department of Employee Trust Funds (ETF). State Group Life Insurance is administered by the ETF and is underwritten by Securian Financial Group.
WRS and State Group Life Insurance share the same beneficiary designations.
- The allows you to name primary, secondary, and tertiary beneficiaries.
- The allows you to name primary and secondary beneficiaries. You can also name specific successors to those beneficiaries.
- Mail completed form to: Department of Employee Trust Funds, P.O. Box 7931, Madison, WI 53707-7931.
If you prefer to name different beneficiaries for these two benefit plans, you must complete a separate beneficiary designation form for each benefit plan. At the bottom of the beneficiary designation form, there is a line where you can specify the benefit plan.
State Group Life Insurance Policy Number: 2832-G
Individual and Family Life Insurance
Administered by The Board of Regents of the University of Wisconsin and underwritten by Securian Financial Group.
- Mail completed form to: University of Wisconsin System Human Resources, 780 Regent Street, Suite 224, Madison, WI 53715
Group Policy Number: 32871-G
UW Employees, Inc Life Insurance
Administered by University of Wisconsin Employees Inc., an employee-directed nonprofit corporation, and is underwritten by Securian Financial Group.
- Once you enroll in coverage, Securian will send you login information so you can name your beneficiary(ies) online through their secure LifeBenefits portal.
- – You can also mail a paper designation form directly to Minnesota Life Insurance Company (a Securian Company), Group Administration Department, 400 Robert Street North, St. Paul, MN 55101-2098 or fax to (651) 665-4827
Group Policy Number: 33977-G
University Insurance Association (UIA) Life Insurance
Administered by University Insurance Association Board and is underwritten by Securian Financial Group.
- Mail completed form to: Minnesota Life Insurance Company (a Securian Company), P.O. Box 259708, Madison, WI 53725-9708 or fax to (608) 277-8665
Group Policy Number: 32872-G
Accidental Death and Dismemberment (AD&D)
Administered by The Board of Regents of the University of Wisconsin and Hausmann-Johnson Insurance and underwritten by Zurich American Insurance Company.
- *Mail completed form to: University of Wisconsin System Human Resources, 780 Regent Street, Suite 224, Madison, WI 53715
Group Policy Number: GTU 8364005
*If you are an annuitant who continued your AD&D coverage after retirement, mail your completed beneficiary form directly to Hausmann-Johnson at: Hausmann-Johnson Insurance – Office of the Comptroller, P.O. Box 259408, Madison, WI 53725-9408
EPIC Benefits+
Administered by EPIC Specialty Benefits.
- Mail completed form to: The EPIC Life Insurance Company, Attention: Life & Disability Department, P.O. Box 8430, Madison, WI 53708-8430 or fax to (800) 236-7610
Group Policy Number: 318000
UNIVERSITY OF WISCONSIN Tax-Sheltered AnnuitY 403(b) Program
The Tax-Sheltered Annuity (TSA) Program is administered by UW System Human Resources. The TSA Review Committee functions as an advisory resource for the program.
Contact the TSA provider to obtain a beneficiary designation form.
Fidelity, T. Rowe Price and TIAA participants can update beneficiary designations through their online investment account.
Current Provider Contact Information:
- Ameriprise/RiverSource Life Insurance Company | (608) 819-0500
- Fidelity Investments | (800) 343-0860
- Lincoln National Life Insurance Company | (800) 967-2046
- TIAA | (800) 842-2776
- T. Rowe Price | (800) 922-9945
Frozen Provider Contact Information:
- AUL (OneAmerica) | (800) 249-6269
- Dreyfus Retirement Services | (800) 645-6561
- DWS (Scudder) ADP | (800) 541-7705
- Security Benefit Life | (800) 888-2461
- Wells Fargo (Strong) | (800) 222-8222
Wisconsin Deferred Compensation
The Wisconsin Deferred Compensation (WDC) program is administered by the Department of Employee Trust Funds (ETF) through a third-party administrator, Empower Retirement.
- Once enrolled, a password is mailed to the address on file. You can use your social security number (username) and this password to access your account information online at www.wdc457.org. In addition, you may update your beneficiary(ies) online.
- – You can also mail a paper designation form directly to Empower Retirement, P.O. Box 173764, Denver, CO 80217-3764 or fax to (866) 745-5766.
Contact Information:
- Wisconsin Deferred Compensation at (877) 457-9327
Health Savings Account (HSA)
Administered by TASC.
- Beneficiary Designation Form
- Mail completed form to: TASC, P.O. Box 7511, Madison, WI 53707-7511 or fax to (877) 231-1287
Resources
last updated: 4/2/2018
Terms & Conditions
Each of the offered benefit plans includes the plan’s Terms and Conditions provision as part of the contract. These provisions are typically included on the paper enrollment application for the plan. By signing the paper application or by submitting your enrollment elections via Benefits Self Service, you are agreeing to the Terms and Conditions of the plans in which you enroll.
The Terms and Conditions are provisions included in the insurance policy that place limitations on the insurer’s promise to pay or perform. These may include rules of conduct, duties and obligations for the member. If the policy conditions are not met, the insurer can deny the claim.
Common conditions in a policy may include the statement that all information is correct to the best of the applicant’s knowledge and/or belief, the agreement to have premiums deducted from payroll and to cooperate during the plan’s investigation of the claim.
If you wish to review the Terms and Conditions of any of the benefit plans, the applicable contract language and/or a link to the plans’ provision are provided below.
More information about all of the benefit plans can be found at https://www.wisconsin.edu/ohrwd/benefits/, including plans’ certificates of coverage and other documents.
State Group Health Insurance
See the Terms and Conditions on pages 3 and 4 of the health insurance application, ET-2301.
Dental Wisconsin
I apply for the coverage elected above. I understand that Wis. Stats. §943.395 provides criminal penalties for knowingly making false or fraudulent claims on this form and hereby certify that, to the best of my knowledge and belief, the information is true and correct. I agree to the provisions of the plan and hereby authorize deduction of the monthly premium.
EPIC Benefits+
I apply for the coverage elected above. I understand that Wis. Stats. §943.395 provides criminal penalties for knowingly making false or fraudulent claims on this form and hereby certify that, to the best of my knowledge and belief, the information is true and correct. I agree to the provisions of the plan and hereby authorize deduction of the monthly premium.
VSP Vision Insurance
By signing below, I agree that all information is true. I understand that I am enrolling in a voluntary plan and that VSP will automatically deduct the entire monthly vision premiums from my paycheck. I agree to continue enrollment in the vision plan through December 31 of the current calendar year. To cancel my coverage, I must submit a request for cancellation prior to December 1 of the current year to cancel coverage beginning January 1 of the following year.
Employee Reimbursement Account
See the Terms and Conditions.
Health Savings Account
See the Terms and Conditions.
State Group Life Insurance
I understand that Wis. Stat. §943.395 provides criminal penalties for knowingly making false or fraudulent claims on this form and hereby certify that, to the best of my knowledge and belief, the information is true and correct.
Individual and Family Life Insurance
I understand that Wis. Stats §943.395 provides criminal penalties for knowingly making false or fraudulent claims on this form and herby certify that, to the best of my knowledge and belief, the information is true and correct. I agree to the provisions of the plan and hereby authorize deduction of the monthly premium from my salary.
UW Employees, Inc. Life Insurance
I authorize my employer to make these change(s) and to withdraw any premiums from my salary to pay for supplemental insurance coverage.
UIA Life Insurance
Any statements made in your application as defined in this certificate will be considered representations not warranties. Also, any statement made will not be used to void your insurance nor defend against a claim unless the statement is contained in the application attached to your certificate.
This certificate is issued in consideration of your application and payment of the required premium.
Accidental Death and Dismemberment (AD&D)
I understand that Wis. Stats §943.395 provides criminal penalties for knowingly making false or fraudulent claims on this form and hereby certify that, to the best of my knowledge and belief, the information is true and correct. I agree to the provisions of the plan and hereby authorize deductions of the monthly premium from my salary.
Income Continuation Insurance
I understand that Wis. Stat. §943.395 provides criminal penalties for knowingly making false or fraudulent claims on this form and hereby certify that, to the best of my knowledge and belief, the above information is true and correct. I authorize the monthly employee share premium deduction (indicated below) from my earnings to provide ICI and Supplemental ICI coverage (if selected). I understand that if premiums are not deducted, I do not have ICI coverage.
Tax-Sheltered Annuity (TSA) 403(b) Plan
See the Terms and Conditions on the Salary Reduction Agreement, form UWS-31.
Deferred Compensation 457 Plan
See Wisconsin Plan and Trust Document.
last updated: 10/18/16