Benefits Forms

SpecialtyPharmacy

Specialty RX Pharmacy.pdf — PDF document, 146 KB (150175 bytes)

NoCostPreventiveDrugs

PrevRx Enhanced (Essential)Drug List.pdf — PDF document, 429 KB (440124 bytes)

ACAPreventive

ACA Prev Drug List.pdf — PDF document, 1.56 MB (1636387 bytes)

AnthemMailOrder

Mail Order 27832VAMENBVA.PDF — PDF document, 1.37 MB (1440758 bytes)

2019DeltaDentalClaim

2019DentalClaim.pdf — PDF document, 834 KB (854327 bytes)

SpecialtyDrugs

Specilaty List.pdf — PDF document, 413 KB (423484 bytes)

Manage Spending Accounts

Anthem HSA Access and Management.pdf — PDF document, 513 KB (525701 bytes)

Anthem_Pharmacy_Claim_Form.pdf

Anthem_Pharmacy_Claim_Form.pdf — PDF document, 108 KB (111263 bytes)

Anthem_Medical_Claim_Form.pdf

Anthem_Medical_Claim_Form.pdf — PDF document, 51 KB (52240 bytes)

Anthem_Vision_Claim_Form.pdf

Anthem_Vision_Claim_Form.pdf — PDF document, 41 KB (42409 bytes)

LTDSummary2020

LTD_Benefit Summary_All Classes_Associated Universities_LFG.pdf — PDF document, 137 KB (140592 bytes)

Will Prep

LifeKeys Services - Will Prep.pdf — PDF document, 1.06 MB (1113221 bytes)

2020 HSA Form

23- HSA_2020_Fillable.pdf — PDF document, 84 KB (86996 bytes)

IngenioRx Details

IngenioRx - Member Transition details.pdf — PDF document, 172 KB (177075 bytes)

DentalHigh2021

6 - AUI NRAO Associated Universities High Plan 2021.pdf — PDF document, 135 KB (138596 bytes)

DentalLow2021

5 - AUI NRAO Associated Universities Low Plan 2021.pdf — PDF document, 131 KB (134344 bytes)

AnthemVision2020

3- AUI Buyup Vision plan Summary.pdf — PDF document, 229 KB (235387 bytes)

LTD_2020

8 -LTD_Benefit Summary_All Classes_Associated Universities_LFG.pdf — PDF document, 137 KB (140592 bytes)

LifeInsurance2020

7- lfg_Life Benefit Summary.pdf — PDF document, 295 KB (302306 bytes)

403bTraditional_2020

403bTraditional_2020_Fillable.pdf — PDF document, 66 KB (68019 bytes)

403bRoth_2020_Fillable

26- Roth403b_2020_Fillable.pdf — PDF document, 66 KB (67778 bytes)

403bTraditional_2020

403bTraditional_2020_Fillable.pdf — PDF document, 66 KB (68019 bytes)

SummaryofBenefits_2020

2- UPDATED Anthem HSA HRA 1500 10 3750 Custom AUI.pdf — PDF document, 944 KB (967548 bytes)

EmbeddedVision_2020

4- AUI Exam Only Vision Summary.pdf — PDF document, 345 KB (353975 bytes)

PrevRx Enhanced (Essential)Drug List.pdf

PrevRx Enhanced (Essential)Drug List.pdf — PDF document, 429 KB (440124 bytes)

AnnualNotices2020

9 - FINAL AUI 2020 Be Healthy Notices v1 UNSECURE.pdf — PDF document, 225 KB (230836 bytes)

2020LifeRates

Life Premium Cost Sheet Semi-Monthly 2020.pdf — PDF document, 195 KB (200295 bytes)

Family-ParentalLeavePolicy2017.pdf — PDF document, 131 KB (134679 bytes)

DirectDeposit

4_DirectDepositPayroll.pdf — PDF document, 106 KB (108730 bytes)

2020_OpenEnrollmentGuide.pdf

2020_OpenEnrollmentGuide.pdf — PDF document, 1.05 MB (1104374 bytes)

2019 Vision Claim Form

2019_ADA_Compliant_OON_Forms_Anthem-Blue-View3_FA.PDF — PDF document, 633 KB (648763 bytes)

DirectDeposit

Direct deposit form.pdf — PDF document, 134 KB (137301 bytes)

CredibleCoverage2019

CredibleCoverageNotice_2020.pdf — PDF document, 36 KB (37359 bytes)

403bTraditional_Fillable_2020

25- 403bTraditional_2020_Fillable.pdf — PDF document, 66 KB (67862 bytes)

Coronavirus Client Flyer 3.2020.pdf — PDF document, 58 KB (59946 bytes)

EAP April Webinars.pdf — PDF document, 541 KB (554920 bytes)

2018AnnualSummaryReports.pdf

2018AnnualSummaryReports.pdf — PDF document, 45 KB (46809 bytes)

2020 CHIP Notice.pdf

2020 CHIP Notice.pdf — PDF document, 81 KB (83328 bytes)

EEO_NonDiscHarrassAntiBullying_2020.pdf

EEO_NonDiscHarrassAntiBullying_2020.pdf — PDF document, 50 KB (52129 bytes)

Veterans Policy Statement 2020 Updated.pdf

Veterans Policy Statement 2020 Updated.pdf — PDF document, 90 KB (92999 bytes)

PrivacyNotice-11x17.pdf

PrivacyNotice-11x17.pdf — PDF document, 376 KB (386015 bytes)

2020 Summary of Benefits

2- UPDATED Anthem HSA HRA 1500 10 3750 Custom AUI.pdf — PDF document, 944 KB (967548 bytes)

2020 Anthem Medical Booklet

1-1-2020 Associated Universities HSA 1500 10 3750.pdf — PDF document, 3.33 MB (3492267 bytes)

2021 HSA

HSA_2021_Fillable.pdf — PDF document, 85 KB (87636 bytes)

2021 Benefit Limits & Accruals

2021 Limits & Leave Reminders.pdf — PDF document, 64 KB (65831 bytes)

2023 HSA

14_HSA_2023_Fillable.pdf — PDF document, 91 KB (93972 bytes)

2022 403b Traditional

15_403bTraditional_2022_Fillable.pdf — PDF document, 90 KB (92310 bytes)

2022 403b Roth

16_Roth403b_2022_Fillable.pdf — PDF document, 78 KB (80041 bytes)

2023BenefitsSummary

2023BenefitSummary.pdf — PDF document, 370 KB (379693 bytes)

2022 Climate Survey Results

2022 Climate Survey Results_Final_Sept2022_Web.pdf — PDF document, 615 KB (630116 bytes)

14_HSA_2023_Fillable

14_HSA_2023_Fillable.pdf — PDF document, 91 KB (93972 bytes)

15_403bTraditional_2023_Fillable

15_403bTraditional_2023_Fillable.pdf — PDF document, 76 KB (78301 bytes)

16_Roth403b_2023_Fillable

16_Roth403b_2023_Fillable.pdf — PDF document, 78 KB (80326 bytes)

14_HSA_2024_Fillable.pdf

14_HSA_2024_Fillable.pdf — PDF document, 88 KB (90357 bytes)

2024 Traditional 403b

15_403bTraditional_2024_Fillable.pdf — PDF document, 80 KB (82263 bytes)

2024 Roth 403b

16_Roth403b_2024_Fillable.pdf — PDF document, 82 KB (84725 bytes)

2024 Benefit Summary

1_2024BenefitSummary.pdf — PDF document, 368 KB (377819 bytes)

2024 Benefit Summary

1_2024BenefitSummary.pdf — PDF document, 368 KB (377819 bytes)