Forms and Publications

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    Medical
    Document Office Publish Date File
    UT SELECT Health Advocate Solutions Infographic Employee Benefits 2021-2022 UT SELECT Health Advocate Solutions Infographic
    UT SELECT MDLIVE: How to Register Employee Benefits UT SELECT MDLIVE: Register today so you’re ready when you need care
    Learn to Live Resources for Your Mental Wellbeing Employee Benefits UT SELECT Learn to Live Resources for Your Mental Wellbeing 2022
    UT CONNECT Learn to Live Resources for Your Mental Wellbeing 2022
    UT CARE Medicare Welcome Letter Employee Benefits UT CARE Medicare Welcome Letter
    Progyny Fertility Benefits Brochure Employee Benefits Progyny Fertility Benefits Overview
    UT CARE Eligibility Groups Employee Benefits UT CARE Eligibility Groups
    UT CONNECT Wellness Guidelines Employee Benefits UT CONNECT Wellness Guidelines Perinatal 2021-2022
    UT CONNECT Wellness Guidelines Child 2021-2022
    UT CONNECT Wellness Guidelines Adult 2021-2022
    UT CARE Medicare Enrollment Brochure Employee Benefits UT CARE Medicare Enrollment Brochure
    UT SELECT Blue Access for Members Employee Benefits UT SELECT Blue Access for Members
    UT CARE Medicare Sample Enrollment Kit Employee Benefits UT CARE Medicare Sample Enrollment Kit
    UT SELECT Health Advocate Solutions FAQs Employee Benefits 2021-2022 UT SELECT Health Advocate Solutions FAQs
    Annual Enrollment Medical Plans Highlights Employee Benefits 2022 Annual Enrollment Medical Plans Highlights for Employees & Retirees
    Know Your Behavioral Health Network Employee Benefits UT SELECT Know Your Behavioral Health Network
    UT CONNECT Know Your Behavioral Health Network
    UT CARE Medicare Highlights Employee Benefits UT CARE Medicare Highlights
    UT SELECT Health Advocate at BCBSTX Employee Benefits UT SELECT Health Advocate at BCBSTX
    UT CARE Eligibility Flow Chart Employee Benefits UT CARE Eligibility Flow Chart
    UT SELECT Tobacco Cessation Program Employee Benefits UT SELECT Tobacco Cessation Program
    24/7 Nurseline Employee Benefits 24/7 Nurseline
    Glossary of Health Coverage and Medical Terms Employee Benefits Glossary of Health Coverage and Medical Terms
    Tobacco Premium Program Declaration Form Employee Benefits Tobacco Premium Program Declaration Form
    Physician Statement Concerning Tobacco Usage and Fitness to Participate in a Tobacco Cessation Program Employee Benefits Tobacco Cessation Program Physician Statement
    UT CONNECT ACO Network Summary of Benefits and Coverage Employee Benefits 2020-2021 Summary of Benefits: UT CONNECT ACO Plan
    2020-2021 Summary of Benefits: UT CONNECT ACO Plan (Spanish/Español)
    UT SELECT Health Advocacy Solutions Employee Benefits UT SELECT Health Advocacy Solutions Brochure
    UT CONNECT MDLIVE Information Employee Benefits UT CONNECT MDLIVE Flyer
    Seasons of Life Employee Benefits UT SELECT Seasons of Life Brochure
    UT SELECT Seasons of Life Presentation
    UT CONNECT Seasons of Life Brochure
    UT CONNECT Seasons of Life Presentation
    UT CONNECT ACO Benefits Summary Chart Employee Benefits UT CONNECT ACO Benefits Summary Chart 2020-2021
    UT CONNECT ACO Benefits Summary Chart 2019-2020
    UT CONNECT Highlights Brochure Employee Benefits UT CONNECT Highlights Brochure 2021-2022
    UT CONNECT Highlights Brochure 2020-2021
    UT SELECT Omada Health Overview Employee Benefits NEW! Omada Health Flyer 2021
    NEW! Omada Health FAQs 2021
    Omada Health Brochure 2020
    Omada Health FAQs 2020
    UT SELECT Hinge Health Overview Employee Benefits Hinge Health FAQs 2021-2022
    Hinge Health Highlights 2021-2022
    Hinge Health Brochure 2020
    Hinge Health Enrollment 2020
    UT SELECT Ovia Health Overview Employee Benefits UT SELECT Ovia Health General Overview
    UT SELECT Ovia Health Support for LGBTQ Families
    UT SELECT Ovia Health Maternity App
    UT SELECT Livongo Overview & FAQs Employee Benefits NEW! Livongo Overview Flyer 2021-2022
    NEW! Livongo Overview Poster 2021-2022
    NEW! Livongo Diabetes Management FAQs 2021-2022
    NEW! Livongo Hypertension FAQs 2021-2022
    Livongo Brochure 2020
    Livongo Hypertension Brochure 2020
    Livongo FAQs
    UT SELECT Benefits Summary Chart Employee Benefits UT SELECT Benefits Summary Chart 2021-2022
    UT SELECT Benefits Summary Chart 2020-2021
    UT CONNECT ACO Medical Plan Guide with Prescription Drug Coverage Employee Benefits 2021-2022 UT CONNECT ACO Medical Plan Guide
    UT Health Network Flyer Employee Benefits UT Health Network Flyer 2021
    UT SELECT Medical Plan Guide with Prescription Drug Coverage Employee Benefits 2021-2022 UT SELECT Benefits Guide
    UT SELECT Medical Claim Form Employee Benefits UT SELECT Medical Claim Form
    UT CONNECT Ovia Health Overview Employee Benefits UT CONNECT Ovia Health Overview
    UT CONNECT Ovia Health Maternity App
    UT CONNECT Ovia Health Support for LGBTQ Families
    UT CONNECT Ovia Health Mental Health Support
    Airrosti Brochure Employee Benefits Fix Pain Fast
    Complimentary Virtual Injury & Pain (VIP) Chat with a Provider
    UT CONNECT ACO Medical Plan FAQs Employee Benefits UT CONNECT FAQs 2022-2023
    UT CONNECT Benefit Chart Comparison Employee Benefits UT CONNECT Benefit Chart Comparison 2022-2023
    UT CONNECT Benefit Chart Comparison 2021-2022
    UT SELECT Benefits at a Glance Brochure Employee Benefits NEW! 2022-2023 UT SELECT Benefits At-a-Glance Brochure
    2021-2022 UT SELECT Benefits At-a-Glance Brochure
    UT SELECT MDLIVE Overview Employee Benefits NEW! UT SELECT MDLIVE Brochure 2022
    UT SELECT MDLIVE Brochure 2021
    PPO Network Summary of Benefits and Coverage Employee Benefits 2022-2023 Summary of Benefits: PPO Plan
    2021-2022 Summary of Benefits: PPO Plan
    2021-2022 Summary of Benefits: PPO Plan (Spanish/Español)
    Out-of-Area Network Summary of Benefits and Coverage Employee Benefits 2022-2023 Summary of Benefits: Out-of-Area Plan
    2021-2022 Summary of Benefits: Out-of-Area Plan
    2021-2022 Summary of Benefits and Coverage: Out-of-Area Plan (Spanish/Español)
    J-Visa Summary of Benefits and Coverage Employee Benefits 2022-2023 Summary of Benefits: J-Visa Plan
    Pharmacy
    Document Office Publish Date File
    Express Scripts: Manage Your Prescription Plan Employee Benefits Express Scripts: Manage Your Prescription Plan
    Express Scripts 90-Day Supply Employee Benefits Express Scripts: Relax with 90-day Supplies
    Express Scripts: How to Register Online Employee Benefits Express Scripts: How to Register Online
    Getting Started with Home Delivery from Express Scripts Pharmacy Employee Benefits Getting Started with Home Delivery from Express Scripts Pharmacy
    UT SELECT Part D Mail Order Form UT SELECT Part D Mail Order Form
    UT SELECT Part D Presentation UT SELECT Part D Presentation
    UT SELECT Part D Language Services UT SELECT Part D Language Services
    UT SELECT Part D Contacts Employee Benefits UT SELECT Part D Contacts
    UT SELECT Part D Welcome Kit Employee Benefits 2022 UT SELECT Part D Welcome Kit
    UT SELECT Part D Benefit Overview Employee Benefits 2022 UT SELECT Part D Benefit Overview
    UT SELECT Part D Welcome Kit Letter Employee Benefits 2022 UT SELECT Part D Welcome Kit Letter
    UT SELECT Part D Formulary Employee Benefits 2022 UT SELECT Part D Formulary
    Prescriptions by Mail Order Form Employee Benefits Prescriptions by Mail Order Form
    Prescription Drug Reimbursement Form / Coordination of Benefits Claim Form Employee Benefits Prescription Drug Reimbursement Form / Coordination of Benefits Claim Form
    UT SELECT Part D Evidence of Coverage Employee Benefits UT SELECT Part D Evidence of Coverage
    Prescription Drug Co-payments at a Glance Employee Benefits NEW! UT SELECT Prescription Drug Program at-a-Glance 2022-2023
    NEW! UT CONNECT Prescription Drug Program at-a-Glance 2022-2023
    UT SELECT Prescription Drug Program at-a-Glance 2021-2022
    UT CONNECT Prescription Drug Program at-a-Glance 2021-2022
    UT SELECT Medicare Part D Prescription Drug Program at-a-Glance 2021-2022
    Dental
    Document Office Publish Date File
    Delta Dental Manage Your Plan Online Employee Benefits Delta Dental: Go online to manage your plan
    DeltaCare Description of Benefits & Highlights Employee Benefits DeltaCare Description of Benefits & Highlights
    UT SELECT DENTAL Claim Form Employee Benefits UT SELECT DENTAL Claim Form
    DeltaCare Benefits Guide Employee Benefits 2021-2022 DeltaCare Benefits Guide
    UT SELECT DENTAL Benefits Guide Employee Benefits 2021-2022 UT SELECT DENTAL Benefits Guide
    2020-2021 UT SELECT DENTAL Benefits Guide
    UT SELECT DENTAL Plus Benefits Guide Employee Benefits 2021-2022 UT SELECT DENTAL Plus Benefits Guide
    2020-2021 UT SELECT DENTAL Plus Benefits Guide
    UT SELECT DENTAL Highlights Employee Benefits NEW! UT SELECT DENTAL Highlights 2022-2023
    UT SELECT DENTAL Highlights 2021-2022
    UT SELECT DENTAL Plus Highlights Employee Benefits NEW! UT SELECT DENTAL Plus Highlights 2022-2023
    UT SELECT DENTAL Plus Highlights 2021-2022
    DeltaCare Highlights Employee Benefits NEW! DeltaCare Highlights 2022-2023
    DeltaCare Highlights 2021-2022
    Your Dental Plan Options Employee Benefits Dental Plan Options
    Vision
    Document Office Publish Date File
    Smart Alert - Partnering for Total Wellness Employee Benefits Superior Vision Smart Alert
    Getting Started with the Online Member Portal Employee Benefits Superior Vision Online Member Portal
    Superior Vison Claim Form Employee Benefits Superior Vison Claim Form
    Superior Vision Plan Brochure Employee Benefits Superior Vision Plan Brochure
    Quality LASIK for Texas Members Employee Benefits Quality LASIK for Texas Members
    Superior Vision Standard Benefits Guide Employee Benefits Superior Vision Basic Plan Certificate
    Superior Vision Plan Amendment (eff. 9/1/2017)
    Superior Vision Plus Benefits Guide Employee Benefits Superior Vision Plus Plan Certificate
    Superior Vision Plan Amendment (eff. 9/1/2017)
    Superior Vision Online Retailers Employee Benefits Superior Vision Online Contacts and Lenses Retailers
    Superior Vision Plan Highlights Employee Benefits Superior Vision Highlights 2022-2023
    Finding-In-Network Providers Employee Benefits Find an In-Network Eye Care Professional 2022
    Superior Vision Online Providers 2022
    Superior Vision Member Discounts Employee Benefits Superior Vision Member Discounts
    Superior Vision Member Hearing Network Discount
    The Importance of an Eye Exam Employee Benefits Superior Vision: The Importance of an Eye Exam
    Superior Vision Mobile App Employee Benefits Superior Vision Mobile App 2022
    Tips Caring for your Eyes Wearing Contacts Employee Benefits Tips for Caring for your Eyes While Wearing Contacts
    Flexible Spending Accounts
    Document Office Publish Date File
    UT FLEX How to Use Your Flexible Spending Account Employee Benefits UT FLEX How to Use Your Flexible Spending Account
    UT FLEX Dependent Care Reimbursement Claim Form Employee Benefits UT FLEX DCRA Claim Form
    UT FLEX Letter of Medical Necessity Form Employee Benefits Letter of Medical Necessity
    UT FLEX Health Care Reimbursement Claim Form Employee Benefits UT FLEX HCRA Claim Form
    UT FLEX Benefits Guide Employee Benefits 2021-2022 UT FLEX Benefits Guide
    2020-2021 UT FLEX Benefits Guide
    UT FLEX Maestro Health Brochure Employee Benefits NEW! UT FLEX Maestro Health Brochure 2022
    Life and Accidental Death and Dismemberment (AD&D)
    Document Office Publish Date File
    Beneficiary Designation Form Employee Benefits Beneficiary Designation Form
    Life and AD&D Brochure for Active Employees Employee Benefits Life and AD&D Benefit Brochure for Active Employees
    Group Term Life Brochure for Retired Employees Employee Benefits Group Term Life Brochure for Retired Employees
    Life, AD&D, and Disability Insurance Overview Employee Benefits Life, AD&D, and Disability Highlights 2022
    Long-Term Disability (LTD) Highlights 2022
    Short-Term Disability (STD) Highlights 2022
    Group Term Life Certificate Employee Benefits Group Term Life Certificate
    Accidental Death & Dismemberment Certificate Employee Benefits Accidental Death & Dismemberment Certificate
    Short-Term Disability (STD)
    Document Office Publish Date File
    Short-Term Disability Certificate Employee Benefits NEW! Short Term Disability Certificate 2021-2022
    Short Term Disability Certificate 2020-2021
    Short Term Disability Brochure Employee Benefits NEW! 2021-2022 Short Term Disability Brochure
    2020-2021 Short Term Disability Brochure
    Long-Term Disability (LTD)
    Document Office Publish Date File
    Long-Term Disability Certificate Employee Benefits NEW! 2021-2022 Long Term Disability Certificate
    2020-2021 Long Term Disability Certificate
    Long-Term Disability Benefit Highlights Employee Benefits NEW! 2021-2022 Long Term Disability Brochure
    2020-2021 Long Term Disability Brochure
    Special Notices
    Document Office Publish Date File
    HIPAA Request for Confidential Communications of Medical Information Employee Benefits HIPAA Request for Confidential Communications of Medical Information Form
    HIPAA Request for Restriction on Use or Disclosure of Protected Health Information Employee Benefits HIPAA Request for Restriction Form
    HIPAA Breach Log Employee Benefits HIPAA Breach Log
    HIPAA Request for Amendment of Protected Health Information Employee Benefits HIPAA Request for Amendment of Protected Health Information Form
    HIPAA Request for Access to Protected Health Information Employee Benefits Request for Access Form
    HIPAA Complaint Form Employee Benefits HIPAA Complaint Form
    HIPAA Request for Accounting of Disclosures Employee Benefits HIPAA Request for Accounting of Disclosues Form
    HIPAA Staff Assistance Authorization Employee Benefits HIPAA Staff Assistance Authorization
    HIPAA Revocation of Authorization Employee Benefits HIPAA Revocation of Authorization Form
    HIPAA General Authorization Form Employee Benefits HIPAA General Authorization Form
    BAC By-Laws Employee Benefits BAC By-laws
    Nondiscrimination and Accessibility Notice Employee Benefits Nondiscrimination and Accessibility Notice
    Medicaid and the Children's Health Insurance Program (CHIP) Notice Employee Benefits Medicaid and the Children's Health Insurance Program (CHIP) Notice
    Affordable Care Act - Marketplace Notices Employee Benefits 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 Tyler 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
    Notice of Creditable Coverage (NOCC) Employee Benefits Medicare Part D Notice of Creditable Coverage
    Legal Notices Employee Benefits UT Benefits - Legal Notices 2022
    UT Benefits - Legal Notices 2021
    UT Retirement Program
    Document Office Publish Date File
    ORP Authorization for Reduction for Employee Contribution RETURNING EMPLOYEE Employee Benefits ORP Authorization for Reduction for Employee Contribution RETURNING EMPLOYEE
    UT Transfer Verification Form (All plans) Employee Benefits UT Transfer Verification Form (All plans)
    ORP Authorization for Reduction for Employee Contribution Employee Benefits ORP Authorization for Reduction for Employee Contribution
    DCP Catch-Up Provision Agreement Employee Benefits DCP Catch-Up Provision Agreement
    UTSaver TSA Disclosure Form Employee Benefits UTSaver TSA Disclosure Form
    Vendor Services Employee Benefits Vendor Services for Retirement Participants
    ORP Acknowledgement Employee Benefits ORP Acknowledgement
    Vesting/Termination Status Form Employee Benefits Vesting/Termination Status Form
    TRS Form 28 (Notice to Elect to Participate in Optional Retirement Program and/or Refund) Employee Benefits TRS Form 28 (Oct 2019)
    Retirement Program Sales Solicitation Agreement Employee Benefits Retirement Program Sales Solicitation Agreement
    Overview of TRS and ORP Employee Benefits TRS and ORP Overview - July 2021
    Summary of Retirement Programs Employee Benefits Retirement Programs Summary
    Voluntary Retirement Programs At a Glance Employee Benefits Voluntary Retirement Programs
    Comparison of Traditional, Roth 403(b), and Roth IRA Contributions Employee Benefits Comparison of Traditional, Roth 403(b), and Roth IRA Contributions
    UTSaver Loan and Inservice Distribution Options Employee Benefits UTSaver Loan and Inservice Distribution Options
    Weathering the Storm Employee Benefits Weathering the Storm
    Annual Leave Deferral Agreement Employee Benefits Annual Leave Deferral Agreement
    Purchase Change Agreement (All plans) Employee Benefits UT Retirement Purchase Change Agreement (All plans)
    Annual Eligibility Notice for Retirement Plans Employee Benefits Annual Eligibility Notice for Retirement Plans
    UT Benefits Billing
    Document Office Publish Date File
    UT Benefits Billing Reference Guide Employee Benefits UT Benefits Billing Reference Guide
    Helpful Hints for Completing the Direct Payment Agreement Employee Benefits Helpful Hints for Completing the Direct Payment Agreement
    UT Benefits Billing for COBRA Direct Payment/Debit Authorization Agreement Employee Benefits UT Benefits Billing for COBRA Direct Payment/Debit Authorization Agreement
    Personal Information and Emergency Contact Form Employee Benefits Personal Information and Emergency Contact Form
    TRS Annuity Deduction Form Employee Benefits TRS Annuity Deduction Form
    UT Benefits Billing Sample Monthly Statement Employee Benefits UT Benefits Billing Sample Monthly Statement
    UT Benefits Billing Direct Payment/Debit Authorization Agreement Employee Benefits Direct Payment/Debit Authorization Agreement
    Benefits Handbooks and Cost Worksheet
    Document Office Publish Date File
    UT Benefits Enrollment Guide for Retiring Employees Employee Benefits 2021-2022 UT Benefits Enrollment Guide for Retiring Employees
    2020-2021 UT Benefits Enrollment Guide for Retiring Employees
    UT Benefits Enrollment Guide for Employees Employee Benefits 2021-2022 UT Benefits Enrollment Guide for Employees
    2020-2021 UT Benefits Enrollment Guide for Employees
    Annual Enrollment Highlights for Employees Employee Benefits NEW! 2022-2023 Annual Enrollment Highlights for Employees
    2021-2022 Annual Enrollment Highlights for Employees
    Annual Enrollment & Resource Guide for Retired Employees Employee Benefits NEW! 2022-2023 Annual Enrollment & Resource Guide for Retired Employees
    2021-2022 Annual Enrollment & Resource Guide for Retired Employees
    Annual Enrollment Highlights for Retired Employees Employee Benefits NEW! 2022-2023 Annual Enrollment Highlights for Retired Employees
    2021-2022 Annual Enrollment Highlights for Retired Employees
    Annual Enrollment & Resource Guide for Employees Employee Benefits NEW! 2022-2023 Annual Enrollment & Resource Guide for Employees
    2021-2022 Annual Enrollment & Resource Guide for Employees
    Benefits Cost Worksheet for Retired Employees Employee Benefits 2022-2023 Retired Employee Cost Worksheet
    2021-2022 Retired Employee Cost Worksheet
    Benefits Cost Worksheet for Employees Employee Benefits NEW! 2022-2023 Active Employee Cost Worksheet
    2021-2022 Active Employee Cost Worksheet
    Other
    Document Office Publish Date File
    Wondr Health Program Employee Benefits Wondr Health Program (formerly Naturally Slim)
    UT System Cafeteria Plan Document Employee Benefits UT System Cafeteria Plan Document
    Grandchild Certification Form Employee Benefits Dependent Grandchild Certification Form
    BCBSTX Identity Protection Services Employee Benefits BCBSTX Identity Protection Services
    Blue Cross and Blue Shield of Texas Fitness Program Employee Benefits BCBSTX Fitness Program for UT SELECT 2021-2022
    BCBSTX Fitness Program for UT CONNECT
    Living Well Resources Guide Employee Benefits Living Well Resources Guide 2022-2023
    COBRA Rates Employee Benefits COBRA Rates 2022-2023
    COBRA Rates 2021-2022
    COBRA General Notice Employee Benefits COBRA General Notice for the 2022-2023 Plan Year
    Office of Employee Benefits Organizational Chart Employee Benefits Office of Employee Benefits Organizational Chart
    COBRA Application FAQs Employee Benefits COBRA Application FAQs 2022-2023
    Retirement Plan Documents
    Document Office Publish Date File
    Optional Retirement Program (ORP) Plan Document Employee Benefits Optional Retirement Program (ORP) Plan Document
    UTSaver DCP - 457(b) Plan Document Employee Benefits UTSaver DCP - 457(b) Plan Document
    UTSaver TSA - 403(b) Plan Document Employee Benefits UTSaver TSA - 403(b) Plan Document
    UT Retirement Provider Advisor Listing Employee Benefits UT Retirement Provider Advisor Listing
    New Retirement Manager Admin Login Employee Benefits Guide to New Retirement Manager Admin Login
    Fund Performance Summary Employee Benefits Q2 2022 Fund Performance Report (.xlsx)
    Retirement Plan Publications
    Document Office Publish Date File
    Logging Into Retirement Manager Employee Benefits Logging Into Retirement Manager
    UT CARES Act Employee Benefits UT CARES Act
    TIAA Information Employee Benefits TIAA Unprecedented Time of Uncertainty
    NEW! TIAA Benefits of One Percent
    NEW! TIAA Benefit of Starting Now
    NEW! TIAA Diversification and Market Volatility
    NEW! TIAA Staying on Track
    UTSaver Retirement Plans Brochure Employee Benefits 2022-2023 UTSaver Retirement Plans: The Best Start
    AIG Retirement Services Information Employee Benefits AIG Retirement Services Highlights
    AIG: Could a Roth 457(b) Fit in your Future?
    AIG: Double Your Tax-Deferred Retirement Savings
    Voya Financial Information Employee Benefits Voya Financial: Brochure 2022
    Voya Financial: The Cost of Waiting
    Voya Financial: UTSaver 457(b) Deferred Compensation Plan
    Voya Financial: Pre-Retirement Steps
    Voya Financial: Weathering the Storm
    Fidelity Investments Information Employee Benefits Fidelity Investments Mobile App 2021
    Fidelity Investments Fact Sheet 2022
    Ways to Work with Fidelity Investments: Call, Click, or Visit
    Enroll in UT Retirement with Fidelity Investments
    Getting Started with your Fidelity Account
    Lincoln Financial Information Employee Benefits 2022 Lincoln Financial Group Brochure
    2021 Lincoln Financial Group Plan Representative & Support