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Benefits Materials and Cost Worksheets Medical Pharmacy Dental Vision Flexible Spending Accounts Life and Accidental Death and Dismemberment (AD&D)

Short-Term Disability (STD) Long-Term Disability (LTD) Long-Term Care Special Notices Other UT Retirement Program Retirement Plan Documents UT Benefits Billing

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Medical

Document	Office	Publish Date	File
24/7 Nurseline	Employee Benefits	Dec 17th, 2014	24/7 Nurseline
Physician Statement Concerning Tobacco Usage and Fitness to Participate in a Tobacco Cessation Program	Employee Benefits	Sep 1st, 2013	Tobacco Cessation Program Physician Statement
Tobacco Premium Program Declaration Form	Employee Benefits	Sep 1st, 2013	Tobacco Premium Program Declaration Form
UT Health Network Flyer	Employee Benefits	Sep 1st, 2017	UT Health Network Flyer
UT SELECT Benefits Summary Chart	Employee Benefits	Sep 1st, 2016	UT SELECT Benefits Summary Chart
UT SELECT Medical Claim Form	Employee Benefits	Sep 1st, 2013	UT SELECT Medical Claim Form
UT SELECT Medical Plan Guide with Prescription Drug Coverage	Employee Benefits	Oct 4th, 2016	2017-2018 UT SELECT Benefits Guide 2016-2017 UT SELECT Benefits Guide
UT SELECT Tobacco Cessation Program	Employee Benefits	Sep 1st, 2013	UT SELECT Tobacco Cessation Program
UT SELECT Weight Management Program		Sep 1st, 2013	Weight Management Program

Life and Accidental Death and Dismemberment (AD&D)

Document	Office	Publish Date	File
About Online Beneficiary Management	Employee Benefits	Sep 1st, 2013	Online Beneficiary Management
Accelerated Death Claim Form	Employee Benefits	Sep 1st, 2013	Accelerated Death Claim Form
Accidental Death & Dismemberment Benefits Guide	Employee Benefits	Sep 1st, 2013	Accidental Death & Dismemberment Benefits Guide
Accidental Dismemberment Claim Form	Employee Benefits	Sep 1st, 2013	Accidental Dismemberment Claim Form
Beneficiary Designation Form	Employee Benefits	Sep 1st, 2013	Beneficiary Designation Form
Create Your Own Will Online	Employee Benefits	Sep 1st, 2013	Create Your Own Will Online
Death Claim Form	Employee Benefits	Sep 1st, 2013	Death Claim Form
Group Term Life Benefits Guide	Employee Benefits	Sep 1st, 2016	Group Term Life Benefits Guide
Life Benefit Highlights for Retired Employees	Employee Benefits	Oct 5th, 2016	Life Benefit Highlights for Retired Employees
Life Conversion Application	Employee Benefits	Sep 1st, 2013	Application to Convert Group Life Insurance
Life Portability Application	Employee Benefits	Sep 1st, 2013	Life Portability Application
Life/AD&D Benefit Highlights for Active Employees	Employee Benefits	Oct 5th, 2016	Life/AD&D Benefit Highlights for Active Employees
Portability and Conversion of Life Insurance	Employee Benefits	Sep 1st, 2013	Portability and Conversion of Life Insurance

Special Notices

Document	Office	Publish Date	File
Affordable Care Act - Marketplace Notices	Employee Benefits	Sep 1st, 2017	UT Arlington ACA Notice UT Austin ACA Notice UT Dallas ACA Notice UT El Paso ACA Notice UT Health Houston ACA Notice UT Health San Antonio ACA Notice UT Health Northeast ACA Notice UT Medical Branch Galveston ACA Notice UT MD Anderson Cancer Center ACA Notice UT Permian Basin ACA Notice UT Rio Grande Valley ACA Notice UT San Antonio ACA Notice UT Southwestern Medical Center ACA Notice UT System Administration ACA Notice UT Tyler ACA Notice
BAC By-Laws	Employee Benefits	Mar 7th, 2017	BAC By-laws
HIPAA Breach Log	Employee Benefits	Sep 23rd, 2013	HIPAA Breach Log
HIPAA Complaint Form	Employee Benefits	Feb 1st, 2017	HIPAA Complaint Form
HIPAA General Authorization Form	Employee Benefits	Feb 1st, 2017	HIPAA General Authorization Form
HIPAA Request for Access to Protected Health Information	Employee Benefits	Feb 1st, 2017	Request for Access Form
HIPAA Request for Accounting of Disclosures	Employee Benefits	Feb 1st, 2017	HIPAA Request for Accounting of Disclosues Form
HIPAA Request for Amendment of Protected Health Information	Employee Benefits	Sep 23rd, 2013	HIPAA Request for Amendment of Protected Health Information Form
HIPAA Request for Confidential Communications of Medical Information	Employee Benefits	Sep 23rd, 2013	HIPAA Request for Confidential Communications of Medical Information Form
HIPAA Request for Restriction on Use or Disclosure of Protected Health Information	Employee Benefits	Sep 23rd, 2013	HIPAA Request for Restriction Form
HIPAA Revocation of Authorization	Employee Benefits	Feb 1st, 2017	HIPAA Revocation of Authorization Form
HIPAA Staff Assistance Authorization	Employee Benefits	Feb 1st, 2017	HIPAA Staff Assistance Authorization
Legal Notices	Employee Benefits	Jul 31st, 2017	UT Benefits - Legal Notices
Medicaid and the Children's Health Insurance Program (CHIP) Notice	Employee Benefits	Jul 28th, 2016	Medicaid and CHIP Notice
Nondiscrimination and Accessibility Notice	Employee Benefits	Jun 23rd, 2017	Nondiscrimination and Accessibility Notice
Notice of Creditable Coverage (NOCC)	Employee Benefits	Aug 26th, 2016	Medicare Part D Notice of Creditable Coverage

UT Retirement Program

Document	Office	Publish Date	File
Annual Eligibility Notice for Retirement Plans	Employee Benefits	Apr 13th, 2018	Annual Eligibility Notice for Retirement Plans
Comparison of Traditional, Roth 403(b), and Roth IRA Contributions	Employee Benefits	Dec 22nd, 2017	Comparison of Traditional, Roth 403(b), and Roth IRA Contributions
DCP Catch-Up Provision Agreement	Employee Benefits	Sep 1st, 2013	DCP Catch-Up Provision Agreement
DCP Purchase Agreement	Employee Benefits	Sep 1st, 2013	DCP Purchase Agreement
ORP Acknowledgement	Employee Benefits	Jan 1st, 2015	ORP Acknowledgement
ORP Authorization for Reduction for Employee Contribution	Employee Benefits	Sep 1st, 2013	ORP Authorization for Reduction for Employee Contribution
ORP Authorization for Reduction for Employee Contribution RETURNING EMPLOYEE	Employee Benefits	Sep 1st, 2013	ORP Authorization for Reduction for Employee Contribution RETURNING EMPLOYEE
Overview of TRS and ORP	Employee Benefits	Aug 1st, 2015	TRS and ORP Overview - August 2015
Purchase Change Agreement (All plans)	Employee Benefits	Sep 1st, 2013	UT Retirement Purchase Change Agreement (All plans)
Summary of Retirement Programs	Employee Benefits	Dec 22nd, 2017	Retirement Programs Summary
TRS Form 28 (Notice to Elect to Participate in Optional Retirement Program and/or Refund)	Employee Benefits	Sep 1st, 2016	TRS Form 28
UT Transfer Verification Form (All plans)	Employee Benefits	Sep 1st, 2013	UT Transfer Verification Form (All plans)
UTSaver TSA Disclosure Form	Employee Benefits	Sep 1st, 2013	UTSaver TSA Disclosure Form
Vendor Services	Employee Benefits	Oct 8th, 2014	Vendor Services for Retirement Participants
Vesting/Termination Status Form	Employee Benefits	Dec 8th, 2015	Vesting/Termination Status Form
Voluntary Retirement Programs At a Glance	Employee Benefits	Dec 22nd, 2017	Voluntary Retirement Programs
Voluntary Retirement Programs Loan and Hardship Options	Employee Benefits	Nov 8th, 2017	Voluntary Retirement Programs Loan and Hardship Options

Benefits Handbooks and Cost Worksheet

Document	Office	Publish Date	File
Annual Enrollment & Resource Guide for Employees 2017-2018	Employee Benefits	Jul 6th, 2017	2017-2018 Annual Enrollment & Resources Guide for Employees
Annual Enrollment & Resource Guide for Retirees 2017-2018	Employee Benefits	Jul 6th, 2017	2017-2018 Annual Enrollment & Resources Guide for Retirees
Benefits Cost Worksheet for Employees 2017-2018	Employee Benefits	Jul 5th, 2017	Active Employee Cost Worksheet 2017-2018
Benefits Cost Worksheet for Retired Employees 2017-2018	Employee Benefits	Jul 5th, 2017	Retired Employee Cost Worksheet 2017-2018
Benefits Overview for Employees 2016-2017	Employee Benefits	Jul 6th, 2016	Benefits Overview for Employees 2016-2017
Benefits Overview for Retired Employees 2016-2017	Employee Benefits	Jul 6th, 2016	Benefits Overview for Retired Employees 2016-2017
UT Benefits Enrollment Guide for Employees 2017-2018	Employee Benefits	Dec 12th, 2017	UT Benefits Enrollment Guide for Employees 2017-2018
UT Benefits Enrollment Guide for Retiring Employees 2016-2017	Employee Benefits	Feb 1st, 2017	UT Benefits Enrollment Guide for Retiring Employees 2016-2017
UT Benefits Enrollment Guide for Retiring Employees 2017-2018	Employee Benefits	Feb 9th, 2018	UT Benefits Enrollment Guide for Retiring Employees 2017-2018

Other

Document	Office	Publish Date	File
COBRA Application FAQs	Employee Benefits	Jan 12th, 2018	COBRA Application FAQs
COBRA General Notice	Employee Benefits	Sep 1st, 2017	COBRA General Notice for the 2017-2018 Plan Year
Family Secure	Employee Benefits	Jun 15th, 2016	Family Secure® Online Credit Monitoring
Grandchild Certification Form	Employee Benefits	Jul 1st, 2012	Grandchild Certification Form
International Travel Quick Reference Sheet	Employee Benefits	Dec 21st, 2016	ut-system-foreign-coverage-quick-reference-sheet-12-2016.pdf
ProtectMyID	Employee Benefits	Jun 15th, 2016	ProtectMyID® – World-Class Identity Protection
UT System Cafeteria Plan Document	Employee Benefits	Jun 29th, 2015	UT System Cafeteria Plan Document

Dental

Document	Office	Publish Date	File
Delta Dental Online Services	Employee Benefits	Sep 1st, 2013	Delta Dental Online Services
DeltaCare - Getting the Most from Your Dental HMO	Employee Benefits	Sep 1st, 2013	Getting the Most from Your Dental HMO
DeltaCare Benefits Guide	Employee Benefits	Sep 1st, 2013	DeltaCare Benefits Guide
DeltaCare Highlights	Employee Benefits	Sep 1st, 2013	DeltaCare Highlights
Recommend Your Dentist	Employee Benefits	Sep 1st, 2013	Recommend Your Dentist
SmileWaySM Wellness Program: Take the Challenge	Employee Benefits	Sep 1st, 2013	SmileWaySM Wellness Program
The Connection Between Your Oral and Overall Health	Employee Benefits	Sep 1st, 2013	Your Oral and Overall Health
UT SELECT DENTAL - Getting the Most from Your DPO Network	Employee Benefits	Sep 1st, 2013	Getting the Most from Your DPO Network
UT SELECT DENTAL Benefits Guide 2016-2017	Employee Benefits	Sep 1st, 2016	UT SELECT DENTAL Benefits Guide 2016-2017
UT SELECT DENTAL Benefits Guide 2017-2018	Employee Benefits	Oct 30th, 2017	UT SELECT DENTAL Benefits Guide 2017-2018
UT SELECT DENTAL Claim Form	Employee Benefits	Sep 1st, 2013	UT SELECT DENTAL Claim Form
UT SELECT DENTAL Highlights	Employee Benefits	Sep 1st, 2013	UT SELECT DENTAL Highlights
UT SELECT DENTAL Plus Benefits Guide 2016-2017	Employee Benefits	Sep 1st, 2016	UT SELECT DENTAL Plus Benefits Guide 2016-2017
UT SELECT DENTAL Plus Benefits Guide 2017-2018	Employee Benefits	Oct 30th, 2017	UT SELECT DENTAL Plus Benefits Guide 2017-2018
UT SELECT DENTAL Plus Highlights	Employee Benefits	Sep 1st, 2013	UT SELECT DENTAL Plus Highlights
Your Dental Plan Options	Employee Benefits	Sep 1st, 2013	Dental Plan Options

Short-Term Disability (STD)

Document	Office	Publish Date	File
Filing Your STD Claim	Employee Benefits	Mar 3rd, 2016	Filing Your STD Claim
Short-Term Disability Benefits Guide	Employee Benefits	Jan 1st, 2016	Short Term Disability Guide
STD Benefit Highlights	Employee Benefits	Sep 21st, 2017	STD Benefit Highlights
STD Integrated Medical/Disability		Dec 1st, 2014	STD Integrated Medical/Disability

Vision

Document	Office	Publish Date	File
Finding-In-Network Providers	Employee Benefits	Sep 1st, 2014	Finding-In-Network Providers
Getting Started with the Online Member Portal	Employee Benefits	Sep 1st, 2014	Superior Vision Online Member Portal
Provider Nomination Form	Employee Benefits	Sep 1st, 2014	Provider Nomination Form
Quality LASIK for Texas Members	Employee Benefits	Apr 27th, 2017	Quality LASIK for Texas Members
Smart Alert - Partnering for Total Wellness	Employee Benefits	Sep 1st, 2014	Superior Vision Smart Alert
Superior Vision Plan Brochure	Employee Benefits	Apr 27th, 2017	Superior Vision Plan Brochure
Superior Vision Plan Highlights	Employee Benefits	Sep 1st, 2015	Superior Vision Highlights
Superior Vision Plus Benefits Guide	Employee Benefits	Aug 11th, 2017	Superior Vision Plus Plan Certificate Superior Vision Plan Amendment (eff. 9/1/2017)
Superior Vision Standard Benefits Guide	Employee Benefits	Aug 11th, 2017	Superior Vision Standard Plan Certificate Superior Vision Plan Amendment (eff. 9/1/2017)
Superior Vison Claim Form	Employee Benefits	Sep 1st, 2014	Superior Vison Claim Form
SVContacts.com - Online Contact Lens Ordering	Employee Benefits	Apr 27th, 2017	Online Contact Lens Ordering

UT Benefits Billing

Document	Office	Publish Date	File
Helpful Hints for Completing the Direct Payment Agreement	Employee Benefits	Sep 1st, 2013	Helpful Hints for Completing the Direct Payment Agreement
Personal Information and Emergency Contact Form	Employee Benefits	Jul 17th, 2014	Personal Information and Emergency Contact Form
UT Benefits Billing Direct Payment/Debit Authorization Agreement	Employee Benefits	Sep 1st, 2013	Direct Payment/Debit Authorization Agreement
UT Benefits Billing for COBRA Direct Payment/Debit Authorization Agreement	Employee Benefits	Dec 7th, 2017	UT Benefits Billing for COBRA Direct Payment/Debit Authorization Agreement
UT Benefits Billing Reference Guide	Employee Benefits	Sep 1st, 2013	UT Benefits Billing Reference Guide

Long-Term Care

Document	Office	Publish Date	File
Long-Term Care Benefits Guide	Employee Benefits	Sep 1st, 2013	ltcguide.pdf
Long-Term Care Highlights	Employee Benefits	Sep 1st, 2013	LTC Highlights
Long-Term Care Outline of Coverage	Employee Benefits	Sep 1st, 2013	LTC Outline of Coverage

Long-Term Disability (LTD)

Document	Office	Publish Date	File
Long-Term Disability Benefit Highlights	Employee Benefits	Sep 12th, 2017	LTD Benefit Highlights 2017.pdf
Long-Term Disability Benefits Guide	Employee Benefits	Jan 1st, 2016	Long Term Disability Guide
Long-Term Disability Conversion Kit	Employee Benefits	Sep 1st, 2013	LTD Conversion Kit
LTD Conversion Calculator	Employee Benefits	Sep 1st, 2013	LTD Conversion Calculator
LTD Employee Claim Form	Employee Benefits	Sep 1st, 2013	LTD Employee Claim Form
LTD Employer Claim Form	Employee Benefits	Mar 3rd, 2016	LTD Employer Claim Form

Retirement Plan Documents

Document	Office	Publish Date	File
Optional Retirement Program (ORP) Plan Document	Employee Benefits	Sep 1st, 2013	Optional Retirement Program (ORP) Plan Document
UTSaver DCP - 457(b) Plan Document	Employee Benefits	Sep 1st, 2013	UTSaver DCP - 457(b) Plan Document
UTSaver TSA - 403(b) Plan Document	Employee Benefits	Sep 1st, 2013	UTSaver TSA - 403(b) Plan Document

Pharmacy

Document	Office	Publish Date	File
Prescription Drug Co-payments at a Glance	Employee Benefits	Aug 6th, 2014	Prescription Drug Copayments at a Glance
Prescription Drug Reimbursement Form / Coordination of Benefits Claim Form	Employee Benefits	Jul 19th, 2016	Prescription Drug Reimbursement Form / Coordination of Benefits Claim Form
Prescriptions by Mail Order Form	Employee Benefits	Sep 1st, 2015	Prescription Mail Order Form 2015-2016
UT SELECT Part D Contacts		Nov 18th, 2016	UT SELECT Part D Contacts
UT SELECT Part D Evidence of Coverage		Nov 18th, 2016	UT SELECT Part D Evidence of Coverage
UT SELECT Part D Language Services		Nov 18th, 2016	UT SELECT Part D Language Services
UT SELECT Part D Mail Order Form		Nov 18th, 2016	UT SELECT Part D Mail Order Form
UT SELECT Part D Presentation		Nov 18th, 2016	UT SELECT Part D Presentation
UT SELECT Part D Welcome Kit Letter	Employee Benefits	Nov 18th, 2016	UT SELECT Part D Welcome Kit Letter

Flexible Spending Accounts

Document	Office	Publish Date	File
UT FLEX Benefits Guide	Employee Benefits	Oct 30th, 2017	UT FLEX Benefits Guide
UT FLEX Dependent Care Reimbursement Claim Form	Employee Benefits	Sep 1st, 2016	UT FLEX DCRA Claim Form
UT FLEX Health Care Reimbursement Claim Form	Employee Benefits	Sep 1st, 2016	UT FLEX HCRA Claim Form
UT FLEX Letter of Medical Necessity Form	Employee Benefits	Sep 1st, 2016	Letter of Medical Necessity