WIN Group Insurance Information and Forms
Wellness Insurance Network (WIN) group insurance is open to all public libraries, no matter the size. A library must join the group for qualified employees to participate. Insurance benefits include: major medical, dental, long term disability, short term disability, and life insurance. Choose from Gold, Silver or Bronze plan levels for medical insurance.
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Resources for Medical and Dental Plans
Allied Benefit Systems
Check status of your claims and deductibles or research medical conditions and procedures in the knowledge base.
Preferred Provider Network (PPO)
Use the Aetna DocFind link below to easily locate participating network medical providers or hospitals. Benefits are paid at a higher level when using providers in-network.
Aetna Signature Adminstrators PPO
Medical Plans
Several plans are available. Choose the plan that works best for your needs.
* Gold Plan Summary Plan Document - effective 7/1/2011
* Silver Plan Summary Plan Document - effective 7/1/2011
* Bronze Plan Summary Plan Document- effective 7/1/2011
Medical Forms
* WIN/Allied Medical Claim Form
* WIN/Allied Medical Enrollment Application
* Allied/WIN Changes in Coverage Form
* WIN Termination, Certification & COBRA Initiation Form
* Allied Authorization to Release Medical Information
Dental Plan Information and Forms
* Dental Plan Summary Plan Document – effective 7/1/2011
* WIN/Allied Dental Claim Form
* WIN/Allied Dental Enrollment Application
Vision Plan Information
* Vision Summary Plan Document – effective 7/1/11
Notices:
Click here for updates to:
a) Medicare Part D Creditable Coverage Disclosure
b) Women’s Cancer Rights Notification
c) Children’s Health Insurance Program (CHIP) Notification
d) Semi-Annual Notice Regarding Health Insurance Coverage for Dependents
Prescription Coverage
* CVS/Caremark Prescription Mail-in Form
* CVS/Caremark Prescription Reimbursement Form
Use the link below to refill a prescription online or check out the health resource section for possible drug interactions.
CVS/Caremark web site
View the CVS/Caremark Performance Drug List Jan. 2011
CVS Caremark 2012 Formulary Exclusion List
Jefferson Pilot Financial Insurance Co. / Lincoln Financial Group
* LFG New Enrollment Form
* LFG Request to Change Beneficiary Form
Libraries interested in joining any of the WIN insurance plans should e-mail or call:
Dale Lawrence
224-848-4570
224-848-4571 Fax