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Benefits Info & Forms

141 S. Main St.• 570-408-4644 (T) • 570-408-7879 (F) • Email

The following information and forms are in .pdf format unless otherwise noted.
(AcrobatReader is needed to download .pdf forms.)

Please turn in signed paperwork to the Human Resources Department for all changes.

Insurance | Medical, Vision, Dental
A Life Event change must be reported within 30 days of the event, or the change will not become effective until the next Open Enrollment period. 

Benefit Summaries
(2014-2015 Plan Year)


Faculty

Administrators and Professional (Exempt) Staff

Non-Exempt Staff

Non-Exempt-Staff (Facilities and Public Safety)

Flexible Benefits Worksheet (2014 - 2015)

Summary Annual Report

Summary Plan Description

Legally Required Notifications

 

 
Blue Care PPO ($300 deductible)


Quick Fact Sheet


Enrollment/Change Form

Claim Form

Dependent Supplement

Mail Order Pharmacy Application

Tier Zero Prescription Drugs

PPO $300 Deductible Summary of Benefits and Coverage

PPO $300 Deductible SPD

2012-2013 Summary of Materials Modifications

2013-2014 Summary of Materials Modifications

2014-2015 Summary of Materials Modifications

Website: www.bcnepa.com ; www.bcbs.com
Phone Number: 1-888-338-2211

 

Blue Care® HMO


Quick Fact Sheet


Enrollment/Change Form

Dependent Supplement

Mail Order Pharmacy Application

Tier Zero Prescription Drugs

Blue Cross of NEPA HMO Summary of Benefits and Coverage

HMO SPD

2012-2013 Summary of Materials Modifications

2013-2014 Summary of Materials Modifications

2014-2015 Summary of Materials Modifications

Website: www.bcnepa.com
Phone Number: 1-800-822-8753

Blue Care PPO ($1000 Deductible)


Quick Fact Sheet


Enrollment/Change Form

Dependent Supplement

Mail Order Pharmacy Application

Tier Zero Prescription Drugs

PPO $1000 Deductible Summary of Benefits and Coverage

PPO $1000 Deductible SPD

2012-2013 Summary of Material Modifications

2013-2014 Summary of Materials Modifications

2014-2015 Summary of Materials Modifications

Website: www.bcnepa.com
Phone Number: 1-800-822-8753

 

United Concordia Dental


Basic Dental Booklet

Enhanced Dental Booklet 

2013 United Concordia Summary of Material Modifications

Enrollment/Change Form 

Identification Card Information

Website: www.ucci.com
Phone Number: 1-800-332-0366

Vision Benefits of America


Benefit Summary

Enrollment/Change Form

Claims Process

Search for Providers

To Request A Benefit Form

Website: www.visionbenefits.com
Phone Number: 1-800-432-4966

 

Flexible Spending Accounts
(AmeriFlex 06/01/2014- 05/31/2015)

Enrollment Form 

Claim Form

Eligible Expenses (Medical FSA)

Change to Benefit AND/OR Election

Summary Plan Description

Health Care Reform - Over the Counter Changes


Website: www.flex125.com
Phone Number: 1-888-868-FLEX (3539)

SunLife (Life and AD&D)


Beneficiary Form

Optional Life Enrollment Form

Summary Core Life and Accidental Death and Dismemberment

Summary Voluntary Accidental Death and Dismemberment

Evidence of Insurability

Additional ADD Enrollment

Summary Optional Life

Summary LTD with 403 (b) Participation

Summary LTD with out 403 (b) Participation

2014-2015 Summary of Materials Modifications Life Insurance

2014-2015 Summary of Materials Modifications Long Term Disability

TIAA-CREF


2014 Contribution Information

TIAA-CREF Retirement Plan for Faculty and Administrators of Wilkes University
(103455 SPD)

Wilkes University Pension TDA 103457 SPD

Salary Reduction Agreement (.pdf)

2013 SAR DC

2013 SAR TDA

403(b) Universal Availiblity Notice
 

Tuition Remission


Tuition Benefit Policy

Employee Tuition Remission Form 2013-2014

Spouse/Dependant Tuition Remission Form 2013-2014

Employee Tuition Remission Form 2014-2015

Spouse/Dependant Tuition Remission Form 2014-2015


Workers' Compensation


Policy/Procedures

Workers' Compensation General Information

Employee Injury Report 

Notice of Rights and Duties 

Panel Providers 

Release of Medical Information 

Supervisor Checklist

 

 

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