Benefits - By Plan
Forms
Resources
- 2021 Comparison of Health & Pharmacy Benefits
- Glossary of Health Coverage and Medical Terms
- Guide to Office Visit Copays
- Health Plan Search
- How to Get Care When You Need It eLearning (ETF)
- It’s Your Choice Decision Guide
- Patient Rights and Responsibilities
- Plan Design Options eLearning (ETF)
- Preventive Health Services
- State & Federal Notifications
- Summary of Benefits & Coverage
- Terms and Conditions
- Affordable Care Act (ACA)
- Health Insurance Marketplace Notice
Certificate of Coverage
- 2021 Health Plan and High Deductible Health Plan (HDHP)
- 2021 Access Health Plan
- 2021 Access HDHP
- 2021 Pharmacy Benefits
Plan Administrators
- State Group Health Insurance: Department of Employee Trust Funds | (877) 533-5020
- Pharmacy Benefits: Navitus Health Solutions | (866) 333-2757
- Uniform Dental Benefits: Delta Dental of Wisconsin | (844) 337-8383
last updated: 01/05/2021
- Certificate of Coverage - Uniform Dental
- Terms and Conditions
- Delta Dental | (844) 337-8383 | Find a Provider | Video
- Terms and Conditions
- DeltaVision/EyeMed | (855) 544-6035 | Find a Provider | Video
- State Group Life Insurance Application/Cancellation/Refusal (ET-2304)
- State Group Life Insurance Certificate of Coverage (ET-2101)
- State Group Life Insurance Living Benefits Brochure (ET-2327)
- State Group Life Insurance Medical Evidence of Insurability Form (ET-2305)
- Conversion Form – Contact UW-Shared Services, Service Operations at serviceoperations@uwss.wisconsin.edu or (888) 298-0141 (7:45-4:30 p.m. Monday-Friday) to obtain a conversion form.
- Continuation Form – Contact your human resources office if you need a continuation form. (Continuation at retirement is automatic)
- Conversion Form – Contact UW-Shared Services, Service Operations at serviceoperations@uwss.wisconsin.edu or (888) 298-0141 (7:45-4:30 p.m. Monday-Friday) to obtain a conversion form.
- Conversion Form – Contact UW-Shared Services, Service Operations at serviceoperations@uwss.wisconsin.edu or (888) 298-0141 (7:45-4:30 p.m. Monday-Friday) to obtain a conversion form.
-
- Conversion Form – Contact UW-Shared Services, Service Operations at serviceoperations@uwss.wisconsin.edu or (888) 298-0141 (7:45-4:30 p.m. Monday-Friday) to obtain a conversion form.
- (Policy number is GTU8364005)
- Continuation and Conversion Forms – Contact UW-Shared Services, Service Operations at serviceoperations@uwss.wisconsin.edu or (888) 298-0141 (7:45-4:30 p.m. Monday-Friday) to obtain a continuation or conversion form.
- Continuation Form – Contact UW-Shared Services, Service Operations at serviceoperations@uwss.wisconsin.edu or (888) 298-0141 (7:45-4:30 p.m. Monday-Friday) if you need a continuation form.
- Terms and Conditions
- Securian | (866) 295-8690
Flexible Spending Accounts (FSAs)
- IRS Publication 502: Medical and Dental Expenses
- 2020 Healthcare FSA Unsubstantiated Claims Process web page
Health Savings Accounts (HSAs)
An HSA is available to individuals enrolled in a High Deductible Health Plan (HDHP); it is a required component of the HDHP.
Parking and Transit Accounts
Plan Administrator
- FSA, HSA or Parking and Transit inquiries: Contact Optum Financial / ConnectYourCare (CYC) at (833) 881-8158 or service@of.optum.com or www.connectyourcare.com/ETF.
Plan documents
EZ Enrollment Form
Paper Applications
Salary Reduction Agreement
Other Resources
WDC accounts can be managed online or over the phone.
The following can be found on the WDC website without logging in:
- WDC Program Highlights
- WDC Investment Planning Guide
- WDC Investment Performance
- WDC Retirement Guide
- WDC Plan and Trust Document
After you log into your WDC account, you may:
- Submit or change your beneficiary
- Enroll in the Special Catch-up provision
- Consolidate accounts
- Update your account information, such as address, username, and password
You may also call WDC for the forms. WDC representatives are available Monday-Friday between 7 a.m. and 9 p.m., and Saturdays between 8 a.m. and 4 p.m. at (877) 457-9327. Press 0 and follow the prompts to speak to a representative. For local assistance in Madison, answer ‘yes’ to the prompts Monday through Friday between 8 a.m. and 4:30 p.m. Employees may also contact the WDC at wdcquestions@empower-retirement.com.
Visit the Edvest website for 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 to certify the domestic partnership for WFMLA purposes.
- – Your health care provider must complete this form to certify your serious health condition if you take a concurrent FMLA and WFMLA leave. If you take a WFMLA leave only, use the WFMLA Certification form (UWS 82a) to certify your own serious health condition.
- – If you take a WFMLA leave only, 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 take a concurrent FMLA and WFMLA leave. If you take a WFMLA leave only, use the WFMLA Certification form (UWS 83a) to certify your family member’s serious health condition.
- – If you take a WFMLA leave only, use this form to certify your family member’s serious health condition.
- – Complete and submit this form to your institution to certify 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 service member, 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 veteran, who is a family member or next of kin, who is seriously ill or injured due to military service.
Below are common payroll forms. Complete these forms through the MyUW portal or via paper. If completed via paper submit them to your human resources office at your institution.
- Direct Deposit
- Employee Self-Identification and W-4 Withholding Forms
- New Employees (paper forms):
- Current employees (use the MyUW portal):
Every effort has been made to ensure this information is current and correct. Information on this page does not guarantee enrollment, benefits and/or the ability to make changes to your benefits.
Updated: 04/13/2020