Benefits Information & Forms
Health Plan Forms And SIMON Benefits Admin. Platform
Claim Forms
Enrollment & Changes
- Full Packet (Health/Life/STD/Accident) Enrollments
- Health Plan Enrollment Form - to add dependents to coverage
- PCP Selection Form - CCO plans only
- Domestic Partner FAQ - Domestic Partner coverage is determined at the employer level
- Domestic Partner Affidavit - Check with your employer to see if Domestic Partner coverage is allowed
- Termination of A Domestic Partnership Form
- Enrollment Template For Electronic Upload to SIMON
Waiving or Canceling Coverage
- Coverage Cancelation Form
- Medical Waiver-Employee Completes if Canceling Medical Coverage on Self
- Medical Waiver with Life Only and Accident Enrollment Form
Life, Short-Term Disability & Accident Forms
- Symetra Life & STD Application with Evidence of Insurability - use for increasing life & disability amounts
- Symetra Accident Enrollment Form
- Symetra Beneficiary Designation Change Form
Miscellaneous
SIMON Benefits Admin. Platform
Claim Forms
Enrollment & Changes
- Full Packet (Health/Life/STD/Accident) Enrollments
- Health Plan Enrollment Form - to add dependents to coverage
- PCP Selection Form - CCO plans only
- Domestic Partner FAQ - Domestic Partner coverage is determined at the employer level
- Domestic Partner Affidavit - Check with your employer to see if Domestic Partner coverage is allowed
- Termination of A Domestic Partnership Form
- Enrollment Template For Electronic Upload to SIMON
Waiving or Canceling Coverage
- Coverage Cancelation Form
- Medical Waiver-Employee Completes if Canceling Medical Coverage on Self
- Medical Waiver with Life Only and Accident Enrollment Form
Life, Short-Term Disability & Accident Forms
- Symetra Life & STD Application with Evidence of Insurability - use for increasing life & disability amounts
- Symetra Accident Enrollment Form
- Symetra Beneficiary Designation Change Form
Miscellaneous
SIMON Benefits Admin. Platform
Medical Benefits Information
2024 Medical Plan Documents
- 1000 Deductible PPO SBC
- 1000 Deductible PPO Benefit Outline
- 1000 Deductible PPO SPD
- 1250 Deductible PPO SBC
- 1250 Deductible PPO Benefit Outline
- 1250 Deductible PPO SPD
- 1750 Deductible PPO SBC
- 1750 Deductible PPO Benefit Outline
- 1750 Deductible PPO SPD
- 2250 Deductible PPO SBC
- 2250 Deductible PPO Benefit Outline
- 2250 Deductible PPO SPD
- 2750 Deductible PPO SBC
- 2750 Deductible PPO Benefit Outline
- 2750 Deductible PPO SPD
- 2750 Deductible Connected Care (CCO) SAHA SBC
- 2750 Deductible Connected Care (CCO) MVN SBC
- 2750 Deductible CCO Benefit Outline
- 2750 Deductible CCO SAHA SPD
- 2750 Deductible CCO MVN SPD
- 3200 Deductible HDHP (HSA Qualified) PPO SBC
- 3200 Deductible HDHP (HSA Qualified) PPO Benefit Outline
- 3200 Deductible HDHP (HSA Qualified) PPO SPD
- 3250 Deductible PPO SBC
- 3250 Deductible PPO Benefit Outline
- 3250 Deductible PPO SPD
- 4000 Deductible PPO SBC
- 4000 Deductible PPO Benefit Outline
- 4000 Deductible PPO SPD
- 4000 Deductible HDHP (HSA Qualified) PPO SBC
- 4000 Deductible HDHP (HSA Qualified) PPO Benefit Outline
- 4000 Deductible HDHP (HSA Qualified) PPO SPD
- 5000 Deductible PPO SBC
- 5000 Deductible PPO Benefit Outline
- 5000 Deductible PPO SPD
Miscellaneous
- 2023 Creditable Letter and Disclosure
- 2024 Health Insurance Marketplace Coverage Notice
- SBC Glossary of Terms
- Transparency In Coverage Information
- BCI Member Website Information
- ACA Preventive Drug List
- HSA Preventive Drug List
- Preventive Care Brochure
- Preventive Care Highlights
- CCO Option Flyer
- BCI Standard 6-Tier Formulary Rx
- Mail Order Pharmacy
- WONDR Weight Management
2024 Medical Plan Documents
- 1000 Deductible PPO SBC
- 1000 Deductible PPO Benefit Outline
- 1000 Deductible PPO SPD
- 1250 Deductible PPO SBC
- 1250 Deductible PPO Benefit Outline
- 1250 Deductible PPO SPD
- 1750 Deductible PPO SBC
- 1750 Deductible PPO Benefit Outline
- 1750 Deductible PPO SPD
- 2250 Deductible PPO SBC
- 2250 Deductible PPO Benefit Outline
- 2250 Deductible PPO SPD
- 2750 Deductible PPO SBC
- 2750 Deductible PPO Benefit Outline
- 2750 Deductible PPO SPD
- 2750 Deductible Connected Care (CCO) SAHA SBC
- 2750 Deductible Connected Care (CCO) MVN SBC
- 2750 Deductible CCO Benefit Outline
- 2750 Deductible CCO SAHA SPD
- 2750 Deductible CCO MVN SPD
- 3200 Deductible HDHP (HSA Qualified) PPO SBC
- 3200 Deductible HDHP (HSA Qualified) PPO Benefit Outline
- 3200 Deductible HDHP (HSA Qualified) PPO SPD
- 3250 Deductible PPO SBC
- 3250 Deductible PPO Benefit Outline
- 3250 Deductible PPO SPD
- 4000 Deductible PPO SBC
- 4000 Deductible PPO Benefit Outline
- 4000 Deductible PPO SPD
- 4000 Deductible HDHP (HSA Qualified) PPO SBC
- 4000 Deductible HDHP (HSA Qualified) PPO Benefit Outline
- 4000 Deductible HDHP (HSA Qualified) PPO SPD
- 5000 Deductible PPO SBC
- 5000 Deductible PPO Benefit Outline
- 5000 Deductible PPO SPD
Miscellaneous
- 2023 Creditable Letter and Disclosure
- 2024 Health Insurance Marketplace Coverage Notice
- SBC Glossary of Terms
- Transparency In Coverage Information
- BCI Member Website Information
- ACA Preventive Drug List
- HSA Preventive Drug List
- Preventive Care Brochure
- Preventive Care Highlights
- CCO Option Flyer
- BCI Standard 6-Tier Formulary Rx
- Mail Order Pharmacy
- WONDR Weight Management
Additional Coverages, Discount Services
Delta Dental of Idaho
- 2024 Delta Dental Summary - Core Benefits
- 2024 Delta Dental Summary - Buy-up Benefits
- 2024 Delta Dental SPD - Core Benefits
- 2024 Delta Dental SPD - Buy-up Benefits
- Health through Oral Wellness (HOW) - maximize oral health with no additional cost
- DDID Amplifon Hearing Aid
- Orthodontic Discount Program
- Mobile App
- Z Sonic Mouth Body Connection
- Teledentisry - 24/7 Access to Virtual Dental Care
VSP
- 2024 Vision Plan Benefits
- 2024 VSP Evidence of Coverage Certification
- VSP Exclusive Extras
- TruHearing Aid Discount Offer
- Eyeconic Overview-VSP Preferred Online Retailer
- Set Up Your VSP Account
- Check Out VSP.Com
- Use VSP Benefits for Non-Prescription Eyewear
- Get The Most Out of Your Vision Benefits
- Keep Your Eyes Healthy for Life
Symetra Life, Accident, and Short-Term Disability Forms
- Basic Life and AD&D Summary
- Optional Life Summary
- Symetra Life Certificate Class 1 - Inc. Dom. Part.
- Symetra Life Certificate Class 2 - Exc. Dom. Part.
- Short-Term Disability Summary
- Optional STD Buy-Up Rates - Class 1
- Optional STD Buy-Up Rates - Class 2
- Symetra STD Certificate $325/week
- Symetra STD Certificate $525/week
- Accident Summary
- Employee Assistance Program (EAP)
- Identify Theft Resolution Program
- Beneficiary Companion
- Health Champion
- Travel Assistance Program
- Consumer Privacy Statement
Blue Cross of Idaho Value-Added Discounts, Services & Programs
- Blue365
- Preventive Care Highlights
- Preventive Care Checklist
- BlueCard Travel Program
- Condition Support for Chronic Health Conditions
- Comprehensive Behavioral Health Program
- Solera Network Weight Loss Program
- WONDR Weight Management Program
- Blue Cross of Idaho Member App (Mobile)
- Prescription Cost Relief Program for Specialty Drugs
- Prescription Cost Relief Program FAQ
- Prescription Management Portal
- Maintenance Drug 90-day Home Delivery Service
- Prescription Cost Look-Up Information
- Specialty Pharmacy Program-Carelon Rx
Delta Dental of Idaho
- 2024 Delta Dental Summary - Core Benefits
- 2024 Delta Dental Summary - Buy-up Benefits
- 2024 Delta Dental SPD - Core Benefits
- 2024 Delta Dental SPD - Buy-up Benefits
- Health through Oral Wellness (HOW) - maximize oral health with no additional cost
- DDID Amplifon Hearing Aid
- Orthodontic Discount Program
- Mobile App
- Z Sonic Mouth Body Connection
- Teledentisry - 24/7 Access to Virtual Dental Care
VSP
- 2024 Vision Plan Benefits
- 2024 VSP Evidence of Coverage Certification
- VSP Exclusive Extras
- TruHearing Aid Discount Offer
- Eyeconic Overview-VSP Preferred Online Retailer
- Set Up Your VSP Account
- Check Out VSP.Com
- Use VSP Benefits for Non-Prescription Eyewear
- Get The Most Out of Your Vision Benefits
- Keep Your Eyes Healthy for Life
Symetra Life, Accident, and Short-Term Disability Forms
- Basic Life and AD&D Summary
- Optional Life Summary
- Symetra Life Certificate Class 1 - Inc. Dom. Part.
- Symetra Life Certificate Class 2 - Exc. Dom. Part.
- Short-Term Disability Summary
- Optional STD Buy-Up Rates - Class 1
- Optional STD Buy-Up Rates - Class 2
- Symetra STD Certificate $325/week
- Symetra STD Certificate $525/week
- Accident Summary
- Employee Assistance Program (EAP)
- Identify Theft Resolution Program
- Beneficiary Companion
- Health Champion
- Travel Assistance Program
- Consumer Privacy Statement
Blue Cross of Idaho Value-Added Discounts, Services & Programs
- Blue365
- Preventive Care Highlights
- Preventive Care Checklist
- BlueCard Travel Program
- Condition Support for Chronic Health Conditions
- Comprehensive Behavioral Health Program
- Solera Network Weight Loss Program
- WONDR Weight Management Program
- Blue Cross of Idaho Member App (Mobile)
- Prescription Cost Relief Program for Specialty Drugs
- Prescription Cost Relief Program FAQ
- Prescription Management Portal
- Maintenance Drug 90-day Home Delivery Service
- Prescription Cost Look-Up Information
- Specialty Pharmacy Program-Carelon Rx