Benefits Information & Forms

Claim Forms

• Blue Cross of Idaho Claim Form
• Prescription Drug Claim Form
• VSP Out-Of-Network Reimbursement Form
• Equitable Accelerated Life Claim Form-For claims after 1/1/2025
• Equitable Accident Claim Form-For claims after 1/1/2025
• Equitable Critical Illness Claim Form-For claims after 1/1/2025
• Equitable Wellness Benefit Claim Form-For claims after 1/1/2025
• Equitable Life Claim Form - Please Contact Idaho AGC-(208) 344-9755
• Equitable STD Claim Form - Please Contact Idaho AGC-(208) 344-9755

Enrollment & Changes

• Full Packet (Health/Life/AD&D/STD/Accident/Critical Illness) 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 Equitable Enrollment Form-For 2025 open enrollment and new enrollees in 2025

***New For 2025***  Equitable Forms

• Equitable Enrollment Form
• Equitable Beneficiary Designation Form
• Equitable Evidence of Insurability Form
• Equitable Life Conversion Form
• Equitable Life Portability Form

Symetra Forms (Only to be used for 2024 enrollments or claims)

*****Do Not Use For open enrollment 2025 or new enrollees effective 1/1/2025 and after******

• Symetra Life & STD Application with Evidence of Insurability -  use for increasing life & disability amounts
• Symetra Accident Enrollment Form
• Symetra Beneficiary Designation Change Form
• Symetra Life Conversion Form
• Symetra Life Portability Form

Miscellaneous

• Leave of Absence Form-Must accompany STD Claim form

SIMON Benefits Admin. Platform

• Employer User Guide
• Employer User Guide-Manage Employees with Self-Service
• Employee User Guide
• Link to SIMON Video Resources

2025 Medical Plan Documents

• 1000 Deductible PPO SBC
• 1250 Deductible PPO SBC
• 1750 Deductible PPO SBC
• 2250 Deductible PPO SBC
• 2750 Deductible PPO SBC
• 3250 Deductible PPO SBC
• 3300 Deductible HDHP (HSAQ) PPO SBC
• 4000 Deductible HDHP (HSAQ) PPO SBC
• 4000 Deductible PPO SBC
• 5000 Deductible PPO SBC
• 2750 Deductible Connected Care (CCO) MVN SBC

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

• 2024 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 
• Musculoskeletal Solutions (MSK) 2025
   

Delta Dental of Idaho

• 2025 Delta Dental Summary - Core Benefits
• 2025 Delta Dental Summary - Buy-up Benefits
• 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

• 2025 Vision Plan Benefit Summary
• 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

***New for 2025-Equitable - Life, Short-Term Disability, Accident, Critical Illness

• Basic Life and AD&D Summary
• Supplemental Life Summary 
• Core Short-Term Disability Summary
• $200 Short-Term Disability Buy-Up Summary
• $400 Short-Term Disability Buy-Up Summary
• Accident Benefit Summary
• Critical Illness Benefit Summary
• Employee Assistance Program (EAP)
• Travel Assistance Brochure
• Beneficiary Designation Form

Symetra Life, Accident, and STD Forms-****Benefits end 12/31/2024****

• 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