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Group Insurance Forms and Information

Group insurance is open to public libraries. Library must join group for employees to participate. Insurance benefits include: major medical, dental, long term disability, short term disability, and life insurance. Choose from Bronze, Silver, or Gold plans.

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Resource

Allied Benefit Systems, Inc.

Check status of your claims and deductibles or research medical conditions and procedures in the knowledge base.

Plans

Several plans are available. Choose the one that works best for you.

Gold Plan with 2010 Attachments

Silver Plan with 2010 Attachments

Bronze Plan with 2010 Attachments

Notice

Medicaid and the Children's Health Insurance Program (CHIP)

Notice of Privacy Practices

Preferred Provider Network (PPO)

Choose a physician or hospital in the selected network. Benefits are paid at a higher level.

Aetna Signature Adminstrators PPO

Forms

Medical

Allied Medical Claim
Allied Enrollment Application - Medical
Additions
Changes
Termination, Certification, and Cobra Initiation
Authorization To Release Medical Information

Dental

Dental Care Claim

Allied Enrollment Application - Dental

Prescription

Caremark / CVS (formerly AdvancePCS)
Refill a prescription online or check out the health resource section for drug interactions

Mail Order Prescription Form
Mail Form to:
Caremark
P.O. Box 3223
Wilkes-Bare, PA 18773-3223

Prescription Drug Claim Form

Jefferson Pilot Financial Insurance Co. / Lincoln Financial Group

New Enrollment Form
Request for Change Form