Benefits - By Plan
Forms
Resources
- 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
- It’s Your Choice Decision Guide
- State & Federal Notifications
- Patient Rights and Responsibilities
- Preventive Health Services
Certificate of Coverage
Summary of Benefits & Coverage
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
last updated: 12/11/2018
- Dental Comparison Chart
- Delta Dental of Wisconsin | 1-800-236-3712
- VSP | 1-800-877-7195
- Conversion Form – Contact the UW Service Center at servicecenter@uwsa.edu or (888) 298-0141 (7:45-4:30 p.m. Monday-Friday) to obtain a conversion form.
- Accelerated Death Benefit Form
- Conversion Form – Contact the UW Service Center at servicecenter@uwsa.edu or (888) 298-0141 (7:45-4:30 p.m. Monday-Friday) to obtain a conversion form.
- LifeBenefits portal (can update beneficiary designation online)
- Conversion Form – Contact the UW Service Center at servicecenter@uwsa.edu or (888) 298-0141 (7:45-4:30 p.m. Monday-Friday) to obtain a conversion form.
-
- Conversion Form – Contact the UW Service Center at servicecenter@uwsa.edu or (888) 298-0141 (7:45-4:30 p.m. Monday-Friday) to obtain a conversion form.
- Income Continuation Insurance Application (ET-2307)
- The Hartford | 1-800-960-0052
- TASC Online Portal | 1-844-786-3947
A Health Savings Account (HSA) is only available to individuals who enroll a High Deductible Health Plan (HDHP) plan design.
Publications
Annual Reports
Forms
Please visit the Edvest website for forms.
Note: These plans are closed to new enrollments and contributions effective June 1, 2018.
- TASC Online Portal | 1-844-786-3947
- – 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, 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.
See Also
last updated: 11/17/17
Every effort has been made to ensure this information is current and correct. This page does not guarantee enrollment or the ability to make changes to your benefits.
Beneficiary Designations
The Beneficiary Designations page has moved and can be found by clicking here.
Terms & Conditions
The Terms & Conditions page has moved and can be found by clicking here.