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 open enrollment period is Wednesday, May 3 to May 21, 2021.
If you are making changes, please submit the forms to the business office.
If you are making changes and are an active employee, please submit to the forms to Martha Moran at firstname.lastname@example.org. If you are a retiree, please submit your form to Diane Hartman at email@example.com.
The forms below are provided in PDF format. If you encounter any difficulty attempting to access these files, contact Robert Hanlon at firstname.lastname@example.org.
Forms and Downloadable Information
- Letter about open enrollment for Scotia-Glenville staff
- Download the fillable Health Insurance Declination Form
- General Notice of COBRA Continuation Coverage Rights
- Fillable Online form for enrollment changes during open enrollment
- Blue Shield PPO
- Blue Shield Plan 815 PPO – $25 copay
- Blue Shield description
- Custom Formulary Prescription
- Express Scripts Prescription Drug Plan Co-Pay amounts
- Blue Shield Point of Service
- CDPHP Universal Benefits
- Cost comparison 2021-22 between the available plans including retirees
- Cost comparison 2020-21 between the available plans including retirees
- Health insurance contribution rates by bargaining unit
- Summary of coverage – Blue Shield Dental
- Summary of charges – Blue Shield Dental
- Online access to your health insurance plans
- Flexible Spending Accounts
4/30/2021 – Please be advised that the IRS has increased the maximum allowable amount for the medical expense annual election. The annual election maximum for medical expense is increasing to $2,750.00. Scotia- Glenville CSD will be adopting this maximum for the July 1, 2021 – June 30, 2022 year. Dependent care will remain the same at $5000.00.
- Fillable Flexible Spending Employee Election Agreement from Benetech
- Flexible Spending Update Regarding CARES Act and Over the Counter Drugs and Medicine – April 2021
- Five New Expenses Now Eligible For Your FSA, HRA & HSA Funds – April 2021
- Flexible Spending Account Dependent Care Expense Recovery Form from Benetech– fillable form
- Update for Dependent Care Expense Plan participants – April 2021
- 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
- Benetech: Save your receipts