Benefit Forms

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
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