Medical
You can find all the necessary forms and documents to manage your medical benefits here.
Form
Description
Commonly Used Forms
2024 premiums for medical and dental plans
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Retiree Health Reimbursement Form - Retirees use this form to request reimbursement from the HRA account after you have left the Choice plan. Premiums or qualified expenses may be used.
Form used to submit Medical claims to your health insurance.
Form used to submit Vision claims to your health insurance. (Fill with Acrobat)
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Non-CIGNA claims such as Vision claims and Dental Claims can be Faxed to: 630-286-4687
Continuity of Care - Request Form
When a provider changes network status, patients with complex care needs have up to a 90-day period of continued coverage at in-network rates to allow for a transition of care to an in-network provider. This form is to be completed by the patient and patient's physician.
Coordination of Benefits - Accident Form
Important form required by PBA to ensure accidents are not liable to another party's insurance (auto, business, homeowners, etc.)
Maintenance medications (taken for 3 months or more) are required to be filled using Serve You. Mail in forms can be used.
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As a plan member you can register for the Member Portal, information and instructions HERE.
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Updated July 2023
The brand-name medications below are excluded on the formulary. These brand-name medications have been identified as having available generic equivalents covered at Tier 1 on the formulary.
Speak with your pharmacist to have your excluded brand-name medication substituted with its generic equivalent or another preferred alternative.
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Exceptions:
Select formulary exclusion exceptions are solely based on medical necessity. Employees or their physicians can request initiation of a Prior Authorization by contacting Serve You.
Form used to submit dental claims.
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Non-CIGNA claims such as Vision claims and Dental Claims can be Faxed to: 630-286-4687
If you would like assistance filling out the form, call HR or email hr@cityoflakeforest.com
Download this fillable form to make changes to your enrollment information for your medical and dental insurance; i.e., add dependents, remove dependents, change marital status, address, etc.
Plan Documents & Other Forms
Choice Plan with HRA
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Choice Plan - Short Description
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Choice Plan - Full Plan Description
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The Plan will reimburse the Covered Person $100 on a one-time basis for successful completion of an approved weight loss and/or smoking cessation program. Goal weight must be maintained
for three months and all smoking stopped for at least six months.
Please see the Human Resources Department for approved program and necessary enrollment forms or contact the Plan Administrator.
An additional $200 will be paid if weight loss is maintained and/or smoking stopped for twelve months.
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Submit completed form to PBA with Medical Claim Form (Part A& C)
Mail to address on medical claim form and keep a copy of both forms for your records.
Easy-to-read description of most frequently used coverage in the Employee Choice/HRA Plan as required by Health Care Reform.
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Complete description of the Employee Choice medical plan and the coverage.
Explanation of terms used in the Summary Plan Description
Complete description of how the Health Reimbursement Account (HRA) works. 1/1/14 (Valid until updated)
Basic Health Plan with HSA Short Summary Plan Description
Easy-to-read description of Basic Health Plan with Health Savings Account Option.
Basic Health Plan with HSA Complete Summary Plan
1/1/18 (Valid until updated)
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Complete description of Basic Health Plan with Health Reimbursement Account Option
Dental Summary Plan Description
1/1/18 (Valid until updated)
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Complete description of the Dental Plan coverage
The Public Safety Employee Benefits Act (PSEBA) states that qualified sworn police and fire personnel injured in the line of duty may receive certain medical benefits if they can no longer perform their duties. This is the form used to apply for those benefits and the ordinance provides more details on the application process.
This benefits summary is intended to provide general information regarding benefits for full time employees and is not meant to be all-inclusive.
The City of Lake Forest complies with all HIPAA privacy requirements with regard to your personal health information. Our privacy practices are found here.
Our Notice about your Prescription Drug Coverage and Medicare Part D for the Employee Choice Plan is found here and for the Basic Plan is found here.
The Women's Health and Cancer Rights Act of 1998 requires that all employees be notified on an annual basis of their coverage, and can be found here.
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This is the form you sign to waive participation in the health insurance.
Please consult with HR before completing this form.