Benefits Enrollment Change Form Page 3
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42016 Benefits Enrollment/Change Form
Section D: Health Plans
1
Provider (Check one)
Medical Plans
Coverage Level
EPO
PPO
HSA
(Check one)
(Check one)
Enroll
Employee
Aetna
Aetna
Aetna
Decline/Cancel
Employee + Adult
BCBSAZ
To enroll in the HealthFund
BCBSAZ
Health Savings Account, go
Change
Employee + Child
CIGNA
UnitedHealthcare
to Section F.
No Change
Employee + Family
UnitedHealthcare
2
Provider
(Check one)
Dental Plans
Coverage Level
PPO
DHMO
(Check one)
(Check one)
Enroll
Employee
Delta Dental
Total Dental Administrators*
Decline/Cancel
Employee + Adult
*Available only in AZ and UT
Change
Employee + Child
No Change
Employee + Family
3
Vision Plans
Coverage Level
Provider
(Check one)
(Check one)
Enroll
Employee
Avesis Advantage Program
Decline/Cancel
Employee + Adult
If you decline Avesis Advantage coverage, you will automatically be enrolled in the Avesis
Discount Program at no charge, and you will receive an Avesis discount card.
Change
Employee + Child
No Change
Employee + Family
Section E: Flexible Spending Accounts (FSA)
Elect calendar-year annual amounts, not per-pay-period amounts
Healthcare FSA
1
Enroll - Annual election: $
Decline
Change annual election, From: $
To: $
Minimum $26; Maximum $2,550 per employee
No Change
Child/Adult Day Care FSA
2
Decline
Enroll - Annual election: $
Change annual election, From: $
To: $
No Change
Minimum $26; Maximum $5,000 per household
3
Limited Healthcare FSA
Enroll - Annual election: $
Decline
Change annual election, From: $
To: $
Minimum $26; Maximum $2,550 per employee
No Change
Section F: HealthFund Health Savings Account (HSA)
Available only to Aetna HSA medical plan participants
Elect a calendar-year annual amount, not a per-pay period amount
Decline
Enroll - Annual election: $
Change annual election, From: $
To: $
No Change
Section G: Short-Term Disability Insurance (STD)
Select only one STD provider (Unum or The Hartford)
STD PLAN
Provider (Check only one option)
(Check one)
Unum
The Hartford
Enroll
The Hartford (Maximum Weekly Benefit: $769.27)
Option A (Maximum Weekly Benefit: $750)
Decline/Cancel
Option B (Maximum Weekly Benefit: $1,500)
Change
Option C (Maximum Weekly Benefit: $2,000)
No Change
Weekly Benefit: 70% of covered salary subject to maximums
Weekly Benefit: 66 2/3% of covered salary subject to maximums
Office of Human Resources | Benefits Design & Management
Page 3 of 4
Coverage effective on/after Jan. 1, 2016
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Parent category: Business