Insurance Information and Forms
Insurance Rates For FY 2010-2011
Insurance Eligibility Guidelines
Pre-tax vs. Post-tax Insurance Election Form
Contact Information - All Insurance Companies
Health Insurance Information
Group #90030 Active, Early Retiree Benefit Group & COBRA
Group #90031 Medicare Retirees
Group #90032 Early Retirees
Health insurance is Self-funded by Sioux City Community School District
Preferred Provider Organization (PPO) = Select First of Iowa
Third Party Administration (claim payments) – First Administrators, Inc., PO Box 9900, Sioux City IA 51102 www.firstadministrators.com (712) 279-8400 or 1-800-206-0827
First Administrators Summary Plan Description Booklet - Sioux City Schools
Health Insurance Plan B - Schedule of Benefits w/First Administrators, Inc.
Health Insurance Value Plan - Schedule of Benefits w/First Administrators, Inc.
Health Insurance Plan Comparison - Plan B and Value Plan
Health/Dental/Vision Insurance Enrollment Form
First Administrators Health Insurance Claim Form - Sioux City Schools
Guide to First Administrators On-Line Membership
First Administrators Notice of Privacy Practice
Medicare Supplement Plus Plan - Summary Plan Description
Medicare Supplement Plan F - Summary Plan Description
Express Scripts Prescription Drug Plan Information
Drug insurance is self-funded by Sioux City Community School District
Express Scripts – Group D4JA
Paper claim address: Express Scripts, PO Box 66773, St. Louis, MO 63166-6773
Mail order address: Express Scripts, PO Box 66773, St. Louis, MO 63166-6773
http://www.expressscripts.com/ 1-800-451-6245
Express Scripts Premium Rates and FAQ's
Express Scripts Drug Plan National Formulary 2010
Express Scripts Mail Order Information
Express Scripts Generic Drug Savings Info
Dental Insurance Information
Dental insurance is self-funded by Sioux City Community School District
Delta Dental of Iowa – Group 90350;
Address: Suite 13, 2401 SE Tones Dr., PO Box 9000, Johnston, IA 50131-9010
www.deltadentalia.com or www.claims@deltadentalia.com 1-800-544-0718.
Delta Dental Summary Plan Description Booklet - Sioux City Schools
Delta Dental Insurance Claim Form - Sioux City Schools
Delta Dental of IA Provider List - Sioux City Schools
Delta Dental Health Risk Assessment
Delta Dental Notice of Privacy Practice
Vision Insurance Information
Avesis, Inc., Group 60790-1048. Plan 905.
Vision Claims Dept., PO Box 7777, Phoenix AZ 85011-7777.
http://www.avesis.com/ 1-800-828-9341
Avesis Vision Summary of Plan - Sioux City Schools
Avesis Provider List - Sioux City Schools
Flexible Spending Account Information
First Administrators, PO Box 9900, Sioux City IA 51102
Group: 90030; www.firstadministrators.com
Claims Phone Number: (712) 279-8508 or 1-800-941-4404
Or E-mail: Flex@firstadministrators.com
What is a Flexible Spending Account?
Dependent Care Reimbursement Q&A
Flexible Spending Medical Reimbursement List
Flexible Spending Enrollment Instructions
First Administrators Flexible Spending Enrollment Form
Flex Spending Authorization for Direct Deposit Form
First Administrators Flexible Spending Reimbursement Form
Flexible Spending Weekly Calendar for Reimbursement Account 2010-2011
Tips For Easier Reimbursement on Flex
Flexible Spending Orthodontia Notice
Flexible Spending Orthodontia Payment Form
Term Life Insurance
Mutual of Omaha, Suite 502 East, 1600 S Hwy 100, St. Louis Park MN 55416
Coverage varies by job classification. Group GLUG68S3 Basic; GSL 68S3 Supplement
http://www.mutualofomaha.com/ 1-800-369-380
Basic Term Life / AD&D Insurance Plan Booklet
Voluntary Supplemental Term Life Insurance Plan Booklet
Life Insurance Enrollment Form
Life Insurance Evidence of Insurability Form
Life Insurance Waiver of Premium Claim Forms
Life Insurance Change of Beneficiary Form
Life Insurance Conversion of Coverage Form
Medicare Part D Yearly Notice - Plan F Supplement
Medicare Part D Yearly Notice - Plus Plan Supplement
