Benefits
Plan year begins January 1, 2021
Health Insurance Plans
Enrollment Forms
NOTE: Health Benefit Enrollment is only available through the Maryland's Statewide Personnel System (SPS Workday).
Rates
- Employee and Retiree Rate Sheet (pdf)
- Retiree with State Subsidy (pdf)
- ORP Rates with 16-25 + Years (pdf)
- SLEOLA Addendum and Rates (pdf)
- Direct Pay Rate Sheet (pdf)
- Contractual/ Variable Hours Rate Sheet (pdf)
Flexible Spending
- Connect Your Care Dependent Claim Form (pdf)
- Connect Your Care Heath Care FSA Paper Claim Form (doc)
- Flexible Spending FAQ's (pdf)
- Flexible Spending Accounts
Prescription
- CVS Healthcare Handbook (pdf)
- CVS FAQ's (pdf)
- CVS Evidence of Coverage (pdf)
- Prescription Claim Form (pdf)
- Medicare Prescription Claim Form (pdf)
- Mail Service Order Form (pdf)
- Medicare Mail Service Order Form (pdf)
- CVS Caremark Website
Dental
Forms
Term Life Insurance and Accidental Death and Dismemberment
- Metlife Life Insurance (Employees)
- Metlife Life Insurance (Retirees)
- Metlife Added Services
- Metlife Accidental Death and Dismemberment
- UNUM - Group Term Life Insurance or Long Term Disability Insurance
- Website: http://w3.unum.com/enroll/usm
- Plan Highlights
- Enrollment Form
- Beneficiary Form
- Incapacitated Child Form
- LTD Claim Form
Additional Benefits
Retirement Guides and Forms
Handbooks
Supplemental Retirement Plans
Forms
- 403(b) Roth After-Tax SRA - Deduction Authorization Form - FIDELITY 2-18-2020
- 403(b) Pre-Tax SRA - Deduction Authorization Form - FIDELITY 2-18-2020
- 457(b) Pre-Tax SRA - Deduction Authorization Form - FIDELITY 2-18-2020
- 403(b) Roth After-Tax SRA - Deduction Authorization Form - TIAA 2-18-2020
- 457(b) Pre-Tax SRA - Deduction Authorization Form - TIAA 2-18-2020
- 403(b) Pre-Tax SRA - Deduction Authorization Form - TIAA 2-18-2020
- Nationwide Enrollment Form 403(b) 457(b) 401k (pdf)
Guides
- Fidelity 403(b) (pdf)
- Fidelity 457(b) (pdf)
- TIAA 403(b)/ 457(b) (pdf)
- Nationwide (MSRP) 403b 457(b) 401k (pdf)
Appointments
State of Maryland Health Assessment Wellness Plan
Department of Benefits Management (DBM) Wellness Program
- Co-pay Waiver and Specialist Reduction Process
- Wellness Activity Cheat Sheet (pdf)
- Medical Carrier Added Benefits (pdf)