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Total Rewards forms and guides

Browse Forms and Guides or filter by topic, audience, or program.

Audience
Program
Topic
Document Type
 
Name/Description File type
Vision slicksheet

One-page summary overview of the university Vision Plan.

PDF
Dental slicksheet

One-page summary overview of the university Dental Plan.

PDF
Affordable Care Act

No forms or guides are associated with the topic “Patient Protection and Affordable Care Act.” However, more information on PPACA is available on the Affordable Care Act page.  You may also read several FAQs related to the PPACA.

Other
Diabetes

No forms or guides are associated with the topic “diabetes.” However, the coverage for diabetes page offers information on obtaining diabetic supplies under your medical insurance plan or your prescription drug plan.

Other
Military leave

No forms or guides are associated with the topic “military leave”. However, you will find more information on options for university benefits available during a military leave of absence on the military page.  

Other
Health Savings Account (HSA) Enrollment/Change Form for calendar year 2017

This form is necessary for enrolling in a health savings account (HSA) for this first time, or to make a change to an existing HSA. It applies to calendar year 2017.

PDF
Health Savings Account (HSA) Enrollment/Change Form for calendar year 2018

This form is necessary for enrolling in a health savings account (HSA) for this first time, or to make a change to an existing HSA. It applies to calendar year 2018.

PDF
Retiree beneficiary designation form

Form for retirees to designate beneficiaries for basic life, supplemental life, and accidental death and dismemberment plans. Cannot be used during retirees’ Annual Enrollment period.

Note: This retiree beneficiary designation form is available on pg. 3 of a combo pack of forms.

PDF
Retiree Benefits Change Form and Retiree Beneficiary Designation Information (combo pack of forms)

Combo pack of forms, including: (1) Retiree benefits enrollment/change form to be used to change insurance elections. (2) Beneficiary designations form for basic life, supplemental life, and accidental death and dismemberment plans. Cannot be used during retirees’ Annual Enrollment period.

Note: The retiree beneficiary designation form is available on pg. 3.

PDF
Evidence of insurability—Group Life, Spouse Life, Child Life

Form to confirm evidence of insurability for group life/dependent life insurance.

PDF
Proof of relationship requirement

Proof of relationship requirements to confirm the individual or individuals to be covered are eligible under the specific definitions of the plans.

PDF
Dental claim form

Claim form for the university Dental Plan.

PDF
Medical claim form for retirees (Coventry) for 2016

Medical claim form for retirees under university medical insurance plans for calendar year 2016. Coventry is the administrator.

PDF
Medicare Part D prescription drug claims form

Express Scripts Medicare Part D prescription claims form.

PDF
Prescription drug claims form

Express Scripts prescription claims form.

PDF
Prescription drug mail-in form

Express Scripts prescription drug mail-in order form.

PDF
Release of health information form (HIPAA)

Form for authorization of release of personal health information under HIPAA.

PDF
University of Missouri Educational Assistance Form for Retired Employees (UM 177)

Form (as Excel spreadsheet) for eligible retirees to receive university tuition assistance. Locate Form 177 on the Human Resource Forms webpage.

Excel
Retiree Health PPO Plan Summary Plan Description (SPD) for calendar year 2017

Summary plan description for the Retiree Health PPO Plan for 2017.

PDF
Retiree Healthy Savings Plan Summary Plan Description (SPD) for calendar year 2017

Summary plan description for the Retiree Healthy Savings Plan for 2017.

PDF
What You Need to Know About Your Medicare Advantage Plan: 2017 Plan Guide

The enrollment guide for retirees and dependents enrolling in the university-sponsored Medicare Advantage Base Plan or Medicare Advantage Enhanced Plan. This document was produced and distributed by UnitedHealthcare, who is delivering the university-sponsored Medicare Advantage group plans. This document is for the 2017 calendar year, and provides both Summary Plan Description (SPD) and Summary of Benefits and Coverage (SBC) information for the two Medicare Advantage plans.

PDF
2017 preferred drug formulary - Custom Network, Healthy Savings, PPO, and Retiree Health PPO plans

Drug formulary (list of covered drugs) from Express Scripts for the 2017 calendar year for the following university medical insurance plans: Custom Network Plan, Healthy Savings Plan, PPO Plan, and Retiree Health PPO Plan.

PDF
2017 preferred drug formulary - Medicare Advantage Base and Enhanced plans

Drug formulary from Express Scripts Medicare, current as of August 22, 2016. This list of covered drugs is for these university group Medicare insurance plans: Medicare Advantage Base Plan (plan #13759) and Medicare Advantage Enhanced Plan (plan #13760).

PDF
2017 Specialty drug list

2017 calendar year Specialty Drug List from Accredo, an Express Scripts Company, regarding maintenance medications for active employees with the Custom Network Plan, Health Savings Plan, or PPO Plan. This list also covers retirees with the Healthy Savings Plan or Retiree Health PPO Plan, with Rx.

PDF
Long Term Disability absence reporting brochure

If you are absent or expect to be absent from work in excess of 149 calendar days due to sickness or accidental injury, you must report your absence. This guide from MetLife explains the process of reporting long-term absences.

PDF
Creditable coverage notice for university-sponsored Medicare Advantage Plans with Rx coverage

The University of Missouri System has determined that the prescription drug coverage offered in conjunction with the University-sponsored Medicare Advantage (Base or Enhanced) Plans are, on average for all plan participants, expected to pay out as much as the standard Medicare Part D prescription drug coverage will pay and is therefore considered Creditable Coverage. Because your existing coverage is Creditable Coverage, you can keep this coverage and not pay a higher premium (a penalty) if you later decide to join a Medicare drug plan.

PDF
Medical and Dental Benefits Plans notice of privacy practices

This notice of privacy practices describes how health information about employees may be used and disclosed and how individuals can access to this information.

PDF
Non-creditable coverage notice for university-sponsored Medicare Advantage Plans with no Rx

The University of Missouri System has determined that the prescription drug coverage offered by the University-sponsored Medicare Advantage (Base or Enhanced) Plans–no Rx is, on average, NOT expected to pay out as much as the standard Medicare Part D prescription drug coverage will pay and is considered Non-Creditable Coverage. This is important because, most likely, you will get more help with your drug costs if you join a Medicare drug plan. This also is important because it may mean that you may pay a higher premium (a penalty) if you do not join a Medicare drug plan when you first become eligible.

PDF
Retiree Medical Study timeline

Retiree Medical Study Timeline

PDF
Financial health presentation

Financial Health

Powerpoint
M4A Medicare presentation

Missouri Association of Area Agencies on Aging provides this presentation on Medicare.

PDF
2017 Benefit Plans for retirees/dependent - Medicare Advantage Base and Enhanced plans

Watch this online seminar to learn about the university-sponsored, group Medicare Advantage Base Plan and Medicare Advantage Enhanced Plan, available to Medicare-eligible retirees and dependents for the 2017 calendar year. This seminar was produced and distributed by UnitedHealthcare, who is delivering the university-sponsored Medicare Advantage group plans.

Video
Healthy Savings Plan summary of benefits and coverage (SBC) for calendar year 2017

Summary of benefits and coverage (SBC) document for active employees' Healthy Savings Plan for 2017.

PDF
Medicare Advantage Base & Enhanced plans summary of benefits and coverage (SBC) for 2017

The 2017 summary of benefits and coverage (SBC) for the university-sponsored Medicare Advantage Base Plan and Medicare Advantage Enhanced Plan are part of a broader document, titled What You Need to Know About Your Medicare Advantage Plan: 2017 Plan Guide. SBC-related information for the Medicare Advantage Base Plan (Plan #13759) is found on pp. 6-7 and 17-28. SBC-related information for the Medicare Advantage Enhanced Plan (Plan #13760) is found on pp. 8-9 and 29-40.

PDF
PPO Plan summary of benefits and coverage (SBC) for calendar year 2017

Summary of benefits and coverage document (SBC) for the PPO Plan for MU, MUHC, UMSL and UM System central administration for 2017.

PDF
Retiree Health PPO Plan summary of benefits and coverage (SBC) for calendar year 2018

Summary of benefits and coverage (SBC) document for the Retiree Health PPO Plan for 2018.

PDF
Retiree Healthy Savings Plan summary of benefits and coverage (SBC) for calendar year 2017

Summary of benefits and coverage (SBC) document, for retirees, for the Healthy Savings Plan for 2017. Active employees should reference the "Healthy Savings Plan SBC."

PDF
Educational assistance infographic

Informational image explaining aspects of the university tuition assistance discount for employees.

PDF
Flu Shots

You will find information about coverage, on-campus flu shot clinics for employees, necessary forms, and wellness incentive points on the flu shots and health screenings page.

Other
Service awards

No forms or guides are associated with the topic “service awards.” However, if you are a supervisor honoring an employees’ years of service, or an employee who has recently received a service award, you can find more information on the service awards page.  You may also read several FAQs related to service awards.

Other
Women’s health

Additional information associated with the topic “women’s health” can be found on the women’s preventive health care webpage.

Other