Healthcare

Summary of Benefits Coverage

  1. Cigna Vision Summary of Benefits (applies to GEA members only) (PDF)
  2. HSA $2,000 to $4,000 with Rx Copay (Firefighters Only) (PDF)
  3. HSA $3,000 to $6,000 with Rx Copay (Firefighters Only) (PDF)
  4. State of Connecticut Partnership Plan Medical Benefit Summary (applies to GEA members only) (PDF)
  5. State of Connecticut Partnership Plan Medical Benefit Summary (PDF)
  6. State of Connecticut Partnership Plan UnitedHealthcare Oxford (PDF)

Forms

  1. Cigna - Physician Nomination Form (Firefighters Only) (PDF)
  2. Cigna Dental Claim Form (applies to GEA members only) (PDF)
  3. Cigna Home Delivery Rx Order Form (Firefighters Only) (PDF)
  4. Cigna Medical Claim Form (Firefighters Only) (PDF)
  5. Cigna Pharmacy Claim (Firefighters Only) (PDF)
  6. Cigna Vision Claim (PDF)
  7. CVS Caremark Mail Service Order Form (PDF)
  8. CVS caremark Prescription Reimbursement Claim Form (PDF)
  9. MetLife Dental Claim Form (PDF)
  10. UnitedHealthcare Oxford Claim Form (PDF)
  11. Vision Hardware Reimbursement GMEA (PDF)
  12. Vision Hardware Reimbursement LIUNA and MandC (PDF)
  13. Vision Hardware Reimbursement UPSEU (PDF)

Qualifying Life Events

  1. Enrollment Change Requirements (PDF)

Important Information & Annual Notices

  1. COBRA Notice (PDF)
  2. HIPAA Form Notice of Privacy Practices (PDF)
  3. HIPAA Special Enrollment Rights and Womens Cancer Rights Act (PDF)
  4. Medicare Part D Cigna Credible Coverage Notice (Firefighters Only) (PDF)
  5. Premium Assistance Under Medicaid And The Children (CHIPRA) (PDF)
  6. State Partnership Plan Medicare Part D Credible Coverage Notice (PDF)

Dental Plan Descriptions

  1. Firefighters Dental Plan Summary (PDF)
  2. GEA Dental (PDF)
  3. GMEA Dental Plan Summary (PDF)
  4. GOSA Dental Plan Summary (PDF)
  5. LIUNA BOE Dental Plan Summary (PDF)
  1. LIUNA Dental Plan Summary (PDF)
  2. M and C Dental (PDF)
  3. Police Dental Plan Summary (PDF)
  4. Teamsters Dental Plan Summary (PDF)
  5. UPSEU Dental Plan Summary (PDF)