Benefits Info & Forms

UCOM • 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 (2013-2014 Plan Year)	Faculty Administrators and Professional (Exempt) Staff Non-Exempt Staff Non-Exempt-Staff (Facilities and Public Safety) Flexible Benefits Worksheet (2013 - 2014) Summary Annual Report Summary Plan Description
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 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 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 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 06/01/2012- 05/31/2013)	Enrollment Form  Claim Form Eligible Expenses (Medical FSA) Change to Benefit AND/OR Election Summary Plan Description Health Care Reform - Over the Counter Changes Form FAQ  Website: www.flex125.com Phone Number: 1-888-868-FLEX (3539)
SunLife (Life and AD&D)	Beneficiary Form Optional Life Enrollment Form Evidence of Insurability Additional ADD Enrollment Group Booklet ADD Booklet
TIAA-CREF	2013 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) 2011 SAR DC 2011 SAR TDA 403(b) Universal Availiblity Notice
Tuition Remission	Tuition Benefit Policy Employee Tuition Remission Form 2012-2013 Spouse/Dependant Tuition Remission Form 2012-2013 Employee Tuition Remission Form 2013-2014 Spouse/Dependant Tuition Remission Form 2013-2014
Workers' Compensation	Policy/Procedures Workers' Compensation General Information Employee Injury Report  Notice of Rights and Duties  Panel Providers  Release of Medical Information  Supervisor Checklist