2025 Open Enrollment begins on November 4, 2024 and ends on November 22, 2024 For information on What’s New in 2025 see News & Announcements
Benefit Forms For Active Employees Form Category Description Submit To BCBSRI Out-of-Network Claims Medical No form required—please submit an itemized statement and a receipt instead to BCBSRI. See the "Claims" tab on the Medical page for submission instructions BCBSRI CVS Caremark Mail Order Prescription Fill a 90-day maintenance prescription under the Maintenance Choice program CVS Caremark CVS Caremark Rx Claim Prescription Obtain reimbursement for out-of-network prescription claims CVS Caremark VSP Out-of-Network Reimbursement Form Vision Obtain reimbursement for out-of-network vision claims VSP FSA Claim Form FSA Submit claims for FSA-eligible expenses ASIFlex Letter of Medical Necessity FSA Submit claims for FSA general purpose or limited purpose health expenses that require a Letter of Medical Necessity ASIFlex Unforeseeable Emergency Withdrawal Request Deferred compensation(Fidelity only) Withdraw from your Fidelity deferred compensation account if you are experiencing a qualifying unforeseeable emergency OEB Over Age 50 Catch Up Request Deferred compensation No paper form required—visit Retirement@Work to increase your contribution amount. N/A Special Three-Year Catch Up Contribution Form Deferred compensation Contact Retirement@Work for form to increase your contribution limit if you are within three years of normal retirement age, not including the year of retirement OEB Death Claim Form (obtain from provider) Deferred compensation For the beneficiary to submit claims if the plan participant is deceased OEB The Hartford Beneficiary Designation Life insurance Designate beneficiary for your life insurance policy The Hartford RIPTA Payroll Deduction RIPTA transit passes Purchase RIPTA passes via payroll deductions Your HR office For Retirees Form Category Description Submit To Pre-65 Retiree Health Coverage Election Form (State Employees, Public School Teachers, and Disabled Retirees - Date of Retirement ON OR AFTER 10/1/08) Pre-65 (non-Medicare-eligible) retiree health coverage Enroll in State-sponsored pre-65 retiree health coverage OEB Pre-65 Retiree Health Coverage Election Form (State Employees, Public School Teachers, and Disabled Retirees – Date of Retirement BEFORE 10/1/08) Pre-65 (non-Medicare-eligible) retiree health coverage Enroll in State-sponsored pre-65 retiree health coverage OEB Pre-65 Retiree Health Coverage Election Form (Judges and Legislators) Pre-65 (non-Medicare-eligible) retiree health coverage (For retired judges and legislators ONLY) Enroll in State-sponsored pre-65 retiree health coverage OEB Retiree Health Coverage Election Form (State Police) Pre-65 (non-Medicare-eligible) retiree health coverage (For retired State police ONLY) Enroll in State-sponsored pre-65 retiree health coverage OEB Retiree Health Coverage Cancellation Pre-65 (non-Medicare-eligible) retiree health coverage Cancel your State-sponsored pre-65 retiree health coverage OEB Medicare Exchange Eligibility Post-65 (Medicare-eligible) retiree health coverage Complete this form if you are planning to purchase a Medicare Supplement (Medigap) policy, Medicare Advantage policy, and/or a Part D prescription drug plan through the State’s Medicare exchange vendor, or if you are already retired from State service and your spouse would also like to purchase a plan through the State’s vendor. OEB The Hartford Beneficiary Designation Life insurance Designate beneficiary for your life insurance policy The Hartford Over Age 50 Catch Up Request Deferred compensation No paper form required—visit Retirement@Work to increase your contribution amount. N/A Special Three-Year Catch Up Contribution Form Deferred compensation Make a catch-up contribution if you are within three years of normal retirement age, not including the year of retirement; cannot be combined with other catch up requests OEB Death Claim Form (obtain from provider) Deferred compensation For the beneficiary to submit claims if the plan participant is deceased Plan provider Basic Group Life Insurance Election (obtain form from ERSRI) Life insurance Maintain life insurance coverage when you retire from State service ERSRI