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common forms ALL FORMS Benefits Enrollment/Change Form (FT/PT) CBSA DCRA Claim Form Disability Self-Identification - Employees Disability Self-Identification - Students EBDS Claim Form FMLA Leave Application ID Cards for Family Members Request New SRA Salary Reduction Agreement Performance Improvement Plan Performance Review Form Position Description Guidelines SRA Online Student Certification/Verification TIAA-CREF GRA Enrollment Application TIAA-CREF GSRA Enrollment Application Tuition Benefits for Children Application Tuition Benefits for Staff Application Vanguard Enrollment/Change Form Workers' Comp Supervisor Injury Report

• New Employees
• HealthySolutions --
  Benefits Information & Guidelines
• Benefits - Insurance Plans
  • Health Insurance
  • Prescription Drug Coverage
  • Dental Insurance
  • Vision Insurance
  • Health Care Flexible Spending Account
  • Life Insurance and AD&D
  • Long Term Disability (LTD)
  • Dependent Care Reimbursement Account
  • International Medical Benefits
  • Retiree Medical Benefits
  • Local 95 Insurance Benefits
• Benefits - Work/Life Benefits
• Learning & Development
• Equal Opportunity Services

Health Insurance

UPMC Health Plan - Certificate of Coverage (Summary of Benefit)

• PPO Option 1 Summary of Benefits (.pdf)
• PPO Option 2 Summary of Benefits (.pdf)
• PPO Option 3 Summary of Benefits (.pdf)
• High Deductible PPO with HRA Summary of Benefits (.pdf)

UPMC HRA Claim Form (.pdf)

HealthAmerica - Schedule of Payments and Summary of Benefit Grids

• PPO Option 1 Summary of Benefits (.pdf)
• PPO Option 2 Summary of Benefits (.pdf)
• PPO Option 3 Summary of Benefits (.pdf)
• High Deductible PPO with HRA Summary of Benefits (.pdf)
• PPO Summary Plan Documents (.pdf)
• HMO Summary of Benefits (.pdf)
• HMO Summary Plan Documents (.pdf)

HealthAmerica HRA Claim Form (.pdf)

Highmark Blue Cross/Blue Shield - Summary of Benefit Grids and Plan Documents

The Highmark benefit summaries and plan documents listed below remain accurate for 2008, with the exception of the Therapy benefit, which was increased to 60 visits per year (physical, occupational and speech combined) in the PPO plans.

• PPO Option 1 (PPOBlue) Summary of Benefits (.pdf)
• PPO Option 1 Plan Summary Document (.pdf)
• PPO Option 2 (PPOBlue) Summary of Benefits (.pdf)
• PPO Option 2 Plan Summary Document (.pdf)
• PPO Option 3 (PPOBlue) Summary of Benefits (.pdf)
• PPO Option 3 Plan Summary Document (.pdf)
• High Deductible PPO with HRA (BlueAccount) Summary of Benefits (.pdf)
• High Deductible with HRA Plan Summary Document (.pdf)
• Comprehensive Plan Summary of Benefits (.pdf)
• Comprehensive Plan Plan Summary Document (.pdf)
• HMO Plan (KeystoneBlue) Summary of Benefits (.pdf)
• HMO (KeystoneBlue) Plan Summary Document (.pdf)

Highmark Medical Claim Form (.pdf)

No Carnegie Mellon Medical Coverage - Complete a medical waiver form (.pdf) to verify that you have coverage through another source.

International Medical Coverage

Retiree Medical Coverage

Union Local 95 Medical Coverage

Health Care Flexible Spending Account (HCFSA)

Carnegie Mellon also provides a Health Care Flexible Spending Account, where you can deposit pre-taxed salary dollars to be used towards your medical needs. This will reduce the amount you pay in taxes, which saves you money and helps you to plan for your health care expenses. The HCFSA can be used to cover deductibles, copayments or procedures not covered by your health, dental or vision plan. (However, because your monthly premiums are already paid pre-tax, they cannot be reimbursed by the HCFSA.) You need not participate in a Carnegie Mellon insurance plan to take advantage of the HCFSA.

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For more information:

• 2008 Benefits Workbook for Full-Time Employees (.pdf)
• 2008 Benefits Workbook for Part-Time Employees (.pdf)
• 2007 Benefits Workbook for Full-Time Employees (.pdf)
• 2007 Benefits Workbook for Part-Time Employees (.pdf)
• Receiving Health Care Outside of the Pittsburgh Area (.pdf)

© Carnegie Mellon Human Resources 2004