Insurance Information and Forms
Insurance Rates For FY 2011-2012
Insurance Rates For FY 2012-2013
Open Enrollment Packet 2012-2013
Open Enrollment Forms 2012-2013
~ Health, Dental & Vision Insurance Enrollment Change Form 2012-2013
~ Long Term Disability and Life Insurance Enrollment Form 2012-2013
~ Flexible Spending Enrollment Form (for plan year 9/1/12 - 8/31/13)
Insurance Eligibility Guidelines
Contact Information - All Insurance Companies
IPERS (Iowa Public Employers Retirement System)
7401 Register Drive, PO Box 9117, Des Moines, IA 50306-9117
Phone: 800-622-3849 Fax: 515-281-0053
http://www.ipers.org
IPERS Enrollment / Change of Beneficiary Form
IPERS Name and Address Change Form
Request for IPERS Benefit Estimate
Family Medical Leave Act (FMLA) Forms
Employee Rights and Responsibilities under the Family and Medical Leave Act
Family Medical Leave (FMLA) - Sioux City Community School District Policy
Family Medical Leave (FMLA) - Procedure
Family Medical Leave (FMLA) Frequently Asked Questions
Request for FMLA Leave (for employee)
Personal Illness/Maternity Leave Form (for physician)
Medical Certification for Family Member Illness (for physician)
Employee Leave of Absence Information
Leave of Absence Policy - Sioux City Community School District
Employee Assistance Program (EAP) - Mercy Medical
3500 Singing Hills Blvd, Sioux City, IA 51105
Phone: 274-4300 or 800-369-8800
http://www.mercycare.org/services/eap/index.aspx
Counseling available for employees and/or their immediate family members.
Frequently Asked Questions - Mercy EAP
Health Insurance Information
Group #90030 Active, Early Retiree Benefit Group & COBRA
Group #90031 Medicare Retirees
Group #90032 Early Retirees
Health insurance is Self-funded by Sioux City Community School District
Preferred Provider Organization (PPO) = Select First of Iowa
Third Party Administration (claim payments) – First Administrators, Inc., PO Box 9900, Sioux City IA 51102 www.firstadministrators.com (712) 279-8400 or 1-800-206-0827
First Administrators Summary Plan Description Booklet - Sioux City Schools
Health Insurance Plan B - Schedule of Benefits w/First Administrators, Inc.
Health Insurance Value Plan - Schedule of Benefits w/First Administrators, Inc.
Health Insurance Plan Comparison - Plan B and Value Plan 2011-2012
Health Insurance Plan Comparison - Plan B and Value Plan 2012-2013
Health/Dental/Vision Insurance Enrollment Form
Pre-Tax vs. Post-Tax Election Form
First Administrators Health Insurance Claim Form - Sioux City Schools
Guide to First Administrators On-Line Membership
First Administrators Notice of Privacy Practice
Medicare Supplement Plus Plan - Summary Plan Description
Medicare Supplement Plan F - Summary Plan Description
Medicare Part D Yearly Notice - Plan F Supplement
Medicare Part D Yearly Notice - Plus Plan Supplement
Mercy Business Health Urgent Care
Express Scripts Prescription Drug Plan Information
Drug insurance is self-funded by Sioux City Community School District
Express Scripts – Group D4JA
Paper claim address: Express Scripts, PO Box 66773, St. Louis, MO 63166-6773
Mail order address: Express Scripts, PO Box 66773, St. Louis, MO 63166-6773
http://www.expressscripts.com/ 1-800-451-6245
Express Scripts Premium Rates and FAQ's
Express Scripts Drug Plan National Formulary - Updated 1/1/12
Express Scripts Specialty Drug Formulary updated 1/1/12
Express Scripts Participating Pharmacy List
Express Scripts Mail Order Information
Express Scripts Co-Pay, Covered Services and Exclusions
Express Scripts Generic Drug Savings Info
CuraScript Specialty Drug Pharmacy
Dental Insurance Information
Dental insurance is self-funded by Sioux City Community School District
Delta Dental of Iowa – Group 90350;
Address: Suite 13, 2401 SE Tones Dr., PO Box 9000, Johnston, IA 50131-9010
www.deltadentalia.com or www.claims@deltadentalia.com 1-800-544-0718.
Delta Dental Schedule of Benefits - One Page Summary
Delta Dental Summary Plan Description Booklet - Sioux City Schools
Delta Dental Insurance Claim Form - Sioux City Schools
Delta Dental of IA Provider List - Sioux City Schools
Delta Dental Health Risk Assessment
Delta Dental Notice of Privacy Practice
Vision Insurance Information
Avesis, Inc., Group 60790-1048. Plan 905.
Vision Claims Dept., PO Box 7777, Phoenix AZ 85011-7777.
http://www.avesis.com/ 1-800-828-9341
Avesis Vision Summary of Plan - Sioux City Schools
Avesis Provider List - Sioux City Schools
COBRA Information
COBRA Administration - First Administrators, PO Box 8150, Rapid City, SD 57709-8150, Phone: 800-658-3073 Fax: 605-399-7920
Flexible Spending Account Information
First Administrators, PO Box 9900, Sioux City IA 51102
Group: 90030 (Active Employees), 90031 (Medicare Retirees), 90032 (under 65 Retirees); www.firstadministrators.com
Claims Phone Number: (712) 279-8508 or 1-800-941-4404
E-mail: Flex@firstadministrators.com
Flexible Spending Account - Summary Plan Description SCCSD
What is a Flexible Spending Account?
Dependent Care Reimbursement Q&A
Flexible Spending Medical Reimbursement List
Updated Over the Counter Medicines & Drug
Flexible Spending Enrollment Instructions
First Administrators Flexible Spending Enrollment Form 2012-2013
Flex Spending Authorization for Direct Deposit Form
First Administrators Flexible Spending Reimbursement Form
Flexible Spending Weekly Calendar for Reimbursement Account 2011-2012
Flexible Spending Weekly Calendar for Reimbursement Account 2012-2013
Tips For Easier Reimbursement on Flex
Flexible Spending Orthodontia Notice
Flexible Spending Orthodontia Payment Form
Term Life Insurance
Madison National Life Insurance Company, Inc., PO Box 5008, Madison, WI 53705
Coverage varies by salary. Group 3981
Phone: 800-356-9601 Fax: 608-238-1503
Madison Life Insurance Policy Plan Booklet - Principals, Directors
Madison Life Insurance Policy Plan Booklet - Admin Support Staff
Madison Life Insurance Policy Plan Booklet - Bus Drivers & Food Service
Madison Life Insurance Policy Plan Booklet - Certified Personnel/Teachers
Madison Life Insurance Policy Plan Booklet - Operations and Maintenance
Madison Life Insurance Policy Plan Booklet - Secretaries/Instructional Assistants
Life Insurance Enrollment Form
Life Insurance Evidence of Insurability Form
Life Insurance Waiver of Premium & Claim Form
Life Insurance Change of Beneficiary Form
Life Insurance Conversion Quote Request Form
Long Term Disability Insurance
Madison National Life Insurance Company, Inc., PO Box 5008, Madison, WI 53705
Coverage varies by salary. Group 0381
Phone: 800-356-9601 Fax: 608-238-1503
Long Term Disability Summary of Benefits
Long Term Disability Claim Form
Long Term Disability Enrollment Form
Long Term Disability Evidence of Insurability Form
403b Retirement Investments
Preventing Sexual Harassment & Discrimination