Benefits Employee Benefits

Group #3333634  

Medical Reimbursement Claim Form

Pharmacy Reimbursement Claim Form

Prescription Drug List Changes Effective 01.01.2021

3-Tier Pharmacy Value Prescription Drug 

Cigna 90 Now - 90 Day Presciption Fill

Cigna 90 Now - Pharmacy Directory

Dental DHMO Reimbursement Claim Form

Dental DHMO Ortho in Progress

Dental DHMO Patient Charge Schedule

Dental PPO Reimbursement Claim Form

Dental PPO Ortho in Progress

HSA Change Form - 2023

IRS - Health Care Qualified Expenses

Group #SA-03260 

Short Term Disability Claim Form

Short Term Disability Claim Instructions

Short Term Disability Benefit Booklet

Benefits and Enrollment Guide 2022-2023   (Plan Year 7/1/2022-6/30/2023)

Mesa Public Schools Benefits Plan Document/Summary Plan Description

Flex Benefits Program Summary Plan Description

Mesa Unified School District #4 403(b) Plan Document

BenefitPlace Mobile App Instructions

BenefitPlace Online Enrollment Instructions

Effective July 1, 2022-June 30, 2023

2022-2023 OAP - SBC

2022-2023 HDHP 1500 - SBC

2022-2023 HDHP 2500 - SBC

Long Term Disability -Employer #300040 

LTD Claim  Application - [Employee Claim]

Long Term Disability Employee Guide

Beneficiary Form - Online submission

Address/Name Change - Paper form

Beneficiary Spousal Consent Form

Group #213993

Sun Life Certificate of Life Insurance Coverage

Sun Life Evidence of Insurability Form        (online submission)

Sun Life Evidence of Insurability Form         (paper form)

Sun Life Death Claim - Claimant Statement    (paper form)

Portability vs. Conversion

Conversion Notice  (paper form)

Portability Notice  (paper form)

Supplemental Life Insurance Rates

United Pet Care Website

Member Change Form