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Insurance Information

Insurance Forms and Resources

Summary of Benefits and Coverage effective July 1, 2023

Summary of Benefits and Coverage effective July 1, 2022

Summary of Dental Plan

Dental Claim Form

Summary of Vision Plan

Vision Claim Form

Health Insurance Enrollment Form

Health Insurance Change Form

To update name, address, add or drop dependents

Adult Dependent Child Verification Form

Use this form to verify your child's eligibility for dependent health care coverage.

Other Coverage Form

To be used when covered individuals have a change in coverage through another employer, etc.

Life Insurance Beneficiary Change Form

Prescription Plan Booklet

Caremark Primary / Preferred Drug List

Understanding Your Dependent's Coverage

Glossary of Health Coverage and Medical Terms

Flexible Benefit Summary Plan Document

Medicare Part D Drug Coverage Notice

Women's Health and Cancer Rights Notice

VLSD Minimum Value (ACA) Plan with Wellness effective 7/1/2022

VLSD Minimum Value (ACA) Plan with Wellness effective July 1, 2023

Important Health and Prescription Links

Medical Mutual of Ohio Website

Caremark Pharmacy

Insurance Forms and Info

Health Insurance Waiver Form

Life Insurance Enrollment Form

Notice of Privacy Practices

HIPPA Required Notices

Health Insurance Marketplace Options

Delta Dental Summary of Benefits

Delta Dental PPO Program

Vision Coverage Summary

Medical Mutual Plan Booklets

MMO Premium Plan with Wellness

MMO Premium Plan without Wellness

MMO EyeMed Vision Plan

MMO ACA Plan with Wellness

Minimum Value Plan

MMO ACA Plan without Wellness

Minimum Value Plan