Open Enrollment Information and Forms

The month of May is designated as an open enrollment period for health, dental and related dependent care and medical expenses covered under the IRS125 plan.

If you have been thinking of making any changes in your provider or family status, May is the only month in which you are allowed to make these changes without the benefit of a qualifying event.

The deadline for enrollment changes is Friday, May 18, 2018.

Health and dental insurance premium rates, informational brochures, declination forms and enrollment forms are currently available in the main office of each building.

If you are making changes, please submit to the forms to the business office.

If you have any questions, you should contact the Human Resource Dept. at 347-3600 ext. 73104 or email: HR@sgcsd.net. The Human Resource Department days and hours are: Tuesday, Wednesday, Friday 8:00 a.m. – 3:30 p.m.

The forms below are provided in PDF format. If you encounter any difficulty attempting to access these files, contact Robert Hanlon at (518) 386-4343 or (518) 347-3600, ext. 71111, or email rhanlon@sgcsd.net.

Forms and Downloadable Information

• Letter about open enrollment for Scotia-Glenville staff
• Health Insurance Declination Form
• Blue Shield PPO

• Blue Shield Plan 815 PPO – $25 copay – teachers, nurses only
• Blue Shield Plan 816 PPO – $20 copay

• Blue Shield Point of Service

• Blue Shield Point of Service 218 – $25 copay – teachers, nurses only
• Blue Shield Point of Service 213 – $15 copay

• Blue Shield prescription
• CanaRX – prescription option for Blue Shield plans
• CDPHP Universal Benefits

• CDPHP EPO – $25 copay – teachers, nurses only
• CDPHP EPO – $20 copay

• Cost comparison between the available plans
• Summary of coverage – Blue Shield Dental
• Summary of coverage – Blue Shield – 218 – $25 copay – teachers, nurses only
• Summary of coverage – Blue Shield Traditional – 213 – $15 copay
• Summary of coverage – Blue Shield – 815 – $25 copay – teachers, nurses only
• Summary of coverage – Blue Shield PPO – 816 – $20 copay
• Summary of coverage – Blue Shield Prescription
• Summary of coverage – CDPHP EPO – $25 copay – teachers, nurses only
• Summary of coverage – CDPHP – $20 copay
• Online access to your health insurance plans

• Flexible Spending Accounts

• Flexible Spending Agreement from Benetech
• Flexible Spending Account Dependent Care Expense Recovery Form from Benetech – fillable form
• Flexible Spending Account Medical Expense Expense Recovery Form from Benetech – fillable form
• Benny Prepaid Benefits Card – Substantiation Requirements from Benetech
• FSA Benecard brochure
• FSA Direct Deposit Form
• FSA Employee Guide
• FSA Spending Account Worksheet
• Benetech Mobile App
• FSA/HRA Eligible Costs