Healthcare Policy Forms for State Active Employees & Retirees
Attention members, to find Healthcare Policy Forms, visit https://carecompass.ct.gov
Select ‘State Employee’ (or ‘State Retiree’)
Select ‘Forms’
We are sharing forms commonly accessed in that portal.
WAIVERS
- CO-1315, rev 6/2023 - Emergency Room Copayment Waiver Request - Permalink
- CO-1331, rev 6/2023 - Lab Coinsurance Site of Service Waiver Request - Permalink
- CO-819; rev 08/2023 - Group Life Insurance Disability Premium Payment Waiver Application - Permalink
- Pru-01, rev 4/2023 - Prudent Rx Opt-out - Permalink
- CO-1316; rev 03/2024 - Health Enhancement Program Opt-Out - Permalink
GUARDIANSHIP
- CO-1321, rev 1/2023 - Annual Guardianship Certification Qualified Dependent - Permalink
- CO-1318, rev 5/2023 - Legal Guardianship Notification and Dependency Verification - Permalink
- CO-1048NQ, rev 1/2023 - Non-Qualified Child (Former Ward) Guardianship Enrollment Application - Permalink
PHARMACY
- CVS Pharmacy, rev 5/2017 - Coverage Exception Request - Permalink
- CVS Pharmacy, rev 10/2017 - CVS Caremark Mail Service Order Form - Permalink
- CVS Pharmacy, rev 10/2017 - Formulary Exception Prior Auth Request - Permalink
- CVS Pharmacy, rev 5/2023 - Mandatory Mail Exemption Request Form - Permalink
RETIREE HEALTH
- CO-1082, rev 12/2019 - Retiree/Annuitant Address Change - Permalink
- CO-744, rev 10/2023 - Retirees – Choice of Health Benefits After Retirement - Permalink
- CO-744OE, rev 10/2023 - Retirees – Open Enrollment Choice of Health Benefits After Retirement - Permalink
RETIREE HEALTH FUND
- CO-1305, rev 01/2021 - Rehired Employee’s Waiver Of Right To Restore Prior Service Credit For Retiree Healthcare Eligibility - Permalink
- CO-1303, rev 8/2023 - Retiree Health Fund – Affidavit - Permalink
- CO-1301, rev 8/2023 - Retiree Health Fund – Application for Contributions Refund - Permalink
- CO-1323, rev 8/2023 - Retiree Health Fund – Contribution Adjunct Faculty – Payment Adjustment - Permalink
- CO-1304, rev 8/2023 - Retiree Health Fund – Exemption Application and Waiver - Permalink
- CO-638, rev 8/2015 - Retiree Health Fund – Notice of Death – State Employee ( PDF | RTF ) - Permalink
- CO-1328, rev 08/2023 - Retiree Health Fund – Payment Adjustment - Permalink
- CO-1302, rev 8/2023 - Retiree Health Fund – Repayment of Retiree Health Fund for Prior Service Credit - Permalink
JANUARY 2023 UPDATE ON AETNA TRANSITION
On January 1st, anyone age 65 and over (i.e Medicare eligible) transitioned to the Aetna Medicare Advantage plan. This means that those who were enrolled in the UnitedHealthcare Medicare Advantage plan are now covered by Aetna. CSEA leaders have been working tirelessly to ensure that the transition goes smoothly. It is important to remember that coverage and benefits remain the same - it is only the insurance carrier that will change.
What exactly does that mean? Do I need to do anything?
The only thing you have to do is provide your new Aetna Medicare Advantage Card to your physicians and pharmacy. Any appointment or prescription you have in 2023 should be covered under your Aetna coverage. Your prescriptions and any procedures or surgeries you have scheduled should transfer right over and your physicians should not need to provide a new prescription or any additional prior authorizations though. If you have not received your card, please contact the dedicated customer service phone number for Aetna, 1-855-648-0391 Monday through Friday 8AM-9PM. You can also visit www.CT.AetnaMedicare.com to learn more.
There was also a letter from Aetna which provided information about opting out of this plan. It is a federal requirement from Medicare that you receive information on how to opt out. CSEA STRONGLY URGES THAT YOU DO NOT OPT OUT OF THE PLAN! THIS IS THE SAME COVERAGE THAT YOU HAVE NOW, JUST A DIFFERENT CARRIER. You’ve worked hard in your state career to achieve these retiree health benefits and you should not give those benefits up!
It is important to clarify that opting out does not allow you to stay with United because United will no longer administer our plan - instead, opting out means that you are giving up your state-provided health coverage altogether. As such, if you opt out you would need to wait another year to rejoin the plan, and in that period of time you will not have the same coverage you have now. Any other plan you choose would be inferior to your state retiree health insurance plan and MORE COSTLY.
Again, as with the last transition in 2018 to the UnitedHealthcare Medicare Advantage plan, we will be here to help you with any issues you may have and will provide you with any information you need to have!
AETNA MEETING SCHEDULE RELEASED!
By now all state retirees should have received a letter from the Office of the State Comptroller stating that anyone age 65 and over (i.e Medicare eligible) will be transitioning to the Aetna Medicare Advantage plan effective January 1, 2023. This means that those currently enrolled in the UnitedHealthcare Medicare Advantage plan will be transitioning to Aetna at that time. CSEA leaders are working hard to assure that the transition goes smoothly. It is important to remember that coverage and benefits remain the same - it is only the insurance carrier that will change.
What exactly does that mean? Do I need to do anything?
The only thing you will have to do is provide your new Aetna Medicare Advantage Card to your physicians and pharmacy. Your prescriptions and any procedures or surgeries you have scheduled should transfer right over and your physicians should not need to provide a new prescription or any additional prior authorizations. You will receive your new card in December. You do not need to request this new Aetna card; it will automatically be sent.
The Comptroller’s letter provided a customer service phone number for Aetna, that you can call in advance if you have any specific questions. That phone number is 1-855-648-0391 Monday through Friday 8AM-9PM, or you can visit www.CT.AetnaMedicare.com to learn more. In addition, in the coming weeks, Aetna will hold regional meetings for retirees to learn about the transition and to ask questions.
The letter from Aetna also provided information about opting out of this plan. It is a federal requirement from Medicare that you receive information on how to opt-out. CSEA STRONGLY URGES THAT YOU DO NOT OPT-OUT OF THE PLAN! THIS IS THE SAME COVERAGE THAT YOU HAVE NOW, JUST A DIFFERENT CARRIER. You’ve worked hard in your state career to achieve these retiree health benefits and you should not give those benefits up!
It is important to clarify that opting out does not allow you to stay with United because United will no longer administer our plan - instead, opting out means that you are giving up your state-provided health coverage altogether. As such, if you opt-out you would need to wait another year to rejoin the plan, and in that period of time, you will not have the same coverage you have now. Any other plan you choose would be inferior to your state retiree health insurance plan and MORE COSTLY.
Again, as with the last transition in 2018 to the UnitedHealthcare Medicare Advantage plan, we will be here to help you with any issues you may have and will provide you with any information you need to have!
In a meeting CSEA SEIU Local 2001 had with Aetna and the Comptroller's Office in September, we were notified about upcoming informational presentations including opportunities to meet one on one with Aetna Representatives.
Aetna is asking you to bring a list of your doctors/specialists and a list of your current prescriptions. Aetna and the Connecticut Comptroller's Office are asking those who plan to attend to RSVP, so it is important that you register in advance by phone or email which are provided below. That will allow them to make sure there are enough staff available to speak to everyone that needs additional assistance.
These meetings will be held in Connecticut, Massachusetts and Florida. For those outside of CT, MA or FL, virtual meetings and teleconferences will be held (information is below).
Aetna Informational Meetings October 2022
*To RSVP for in-person meetings, just call 1-855-648-0391 (TTY: 711), Mon – Fri, 8 am – 9 pm ET or use this link to register online: aet.na/soctrsvp
Connecticut Meetings will be held at both 10am & 2pm
Tuesday, 10/4/22
Hilton Garden Inn Hartford South Glastonbury
85 Glastonbury Blvd.
Glastonbury, CT 06033
Wednesday, 10/5/22
Ethan Allen Hotel
21 Lake Ave Ext.
Danbury, CT 06811
Thursday, 10/6/22
The Litchfield Inn
432 Bantam
Litchfield, CT 06759
Friday, 10/7/22
Norwalk Inn
99 East Ave
Norwalk, CT 06851
Tuesday, 10/11/22
Trumbull Marriott Shelton
180 Hawley Lane
Trumbull, CT 06611
Wednesday, 10/12/22
Wyndham Southbury
1284 Strongtown Road
Southbury, CT 06488
Thursday, 10/13/22
Cascade Fine Catering
480 Sherman Ave
Hamden, CT 06514
Monday, 10/17/22
Saybrook Point Resort & Marina
2 Bridge St.
Old Saybrook, CT 06475
Tuesday, 10/18/22
Holiday Inn Norwich
10 Laura Blvd
Norwich, CT 06360
Wednesday, 10/19/22
Great Neck Country Club
28 Lamphere Rd
Waterford, CT 06385
Monday, 10/24/22
The Farmington Gardens
999 Farmington Ave
Farmington, CT 06032
Tuesday, 10/25/22
Graduate Hotel Storrs
855 Bolton Road
Storrs, CT 06268
Wednesday, 10/26/22
Delamar West Hartford
1 Memorial Road
West Hartford, CT 06107
Thursday, 10/27/22
Hilton Garden Inn Hartford North
Bradley International Airport
555 Corporate Drive
Windsor, CT 06095
Massachusetts and Florida Meetings will only be held at 10am
*To RSVP for in-person meetings, just call 1-855-648-0391 (TTY: 711), Mon – Fri, 8 am – 9 pm ET
or use this link to register online: aet.na/soctrsvp
Massachusetts
Thursday, 10/20/2022
DoubleTree by Hilton Cape Cod
287 Iyannough Road
Hyannis, MA 02601
Florida
Tuesday, 10/4/2022
Hilton Ocala
3600 Southwest 36th Avenue
Ocala, FL 34474
Wednesday, 10/5/2022
Holiday Inn & Suites Daytona Beach
930 North Atlantic Avenue
Daytona Beach, FL 32118
Thursday, 10/6/2022
Embassy Suites by Hilton West
Palm Beach Central
1607 Belvedere Road
West Palm Beach, FL 33406
Tuesday, 10/11/2022
Embassy Suites Fort Myers-Estero
10450 Corkscrew Commons Dr.
Estero, FL 33928
Thursday, 10/13/2022
Hyatt Regency Sarasota
1000 Boulevard of the Arts
Sarasota, FL 34326
VIRTUAL MEETINGS
Website: aet.na/soct
Friday, 10/7/2022 10 AM - 11 AM
Friday, 10/14/2022 2 PM - 3 PM
Friday, 10/21/2022 10 AM - 11 AM
Friday, 10/28/2022 2 PM - 3 PM
Teleconferencing
Call-in and listen to presentation using 1-800-768-8691
Friday, 10/14/2022 10 AM - 11 AM
Friday, 10/28/2022 10 AM - 11 AM
In addition to these meetings, Aetna has pledged to attend all 27 of our local CSEA Council 400 Chapter Meetings. CSEA Council 400 will continue to keep you posted and informed about this upcoming change in healthcare providers. Keep an eye on the CSEA News and our website CSEA-CT.com
***
On June 1st, Governor Lamont and members of the Healthcare Cost Containment Committee, which is a joint labor-management committee tasked with overseeing the state’s health plan, announced the results of the Request for Proposals (RFP) process to decide the carrier for the Medicare Advantage program for State of Connecticut retirees 65 years and older.
Aetna Inc. has been chosen to be the new carrier and will replace UnitedHealthcare as the administrator of the State’s Group Medicare Advantage program starting on January 1, 2023.
With absolutely no changes to your plans or benefits, the State will be saving about $130 million a year. Savings like these help us preserve and expand the benefits that we rely on in our retirement and stand as yet another example of a “win-win” coming out of the Healthcare Cost Containment Committee. A change to your carrier does not mean there will be a change to your benefits. The only change should be that you will receive a new Medicare Advantage card that you will need to submit to your physician's offices and pharmacy. That includes maintaining the Silver Sneakers Program and the zero cost Hearing Aid benefit!
CSEA Council 400 represents about 12,000 State of Connecticut retirees and as we prepared for this RFP process, we surveyed our membership and had important conversations at our chapter and council meetings. Our Executive Director, David Glidden represented CSEA on the RFP team and used this information to advocate for us throughout this process.
The Aetna contract will be in effect from January 1, 2023 until December 31, 2025 with an option for a one-year renewal to December 31, 2026.
CSEA is working tirelessly to collect all of the information you will need in order to ensure a smooth transition. We will be working closely with Aetna to optimize your experience and make sure that every question you have is answered before the January 1, 2023 effective date. In the meantime, please keep an eye out for information at your local chapter meetings, in your email and the CSEA News.
Those that are retired but under the age of 65 will remain on Anthem until they turn 65, at which point they will be moved onto the Medicare Advantage carrier (which will remain UnitedHealthcare until December 31, 2022 and then will be Aetna starting January 1, 2023). If you are on disability insurance and currently covered by UnitedHealthcare you will also be switched to Aetna starting on January 1, 2023.
Remember, you should NEVER sign up for any other plan, as doing so would jeopardize your plan with the State of Connecticut.
In order for a potential carrier to be successful in the RFP process, they must meet all of the requirements of our plan and they must clearly demonstrate the capability to administer it. From there, the inherently competitive nature of the RFP process drives the bidders to provide the same services at a lower cost to the State. Aetna met all of the requirements of the plan and demonstrated an excellent track record of administering similar plans in other states - and Aetna was able to provide all of this while delivering dramatic savings. The savings are critical to protecting our benefits long-term and were only agreed upon because they maintained the complete integrity of the plan. Bottom line, savings come from the competition - NOT from any decrease in your coverage.
The Healthcare Cost Containment Committee was set up with the goal of identifying “win-win” healthcare plans, programs, and strategies that serve to save money while maintaining, and in some cases, improving coverage. This committee set out on the RFP process to identify a carrier that matched the current coverage for Medicare Advantage members but reduced the overall plan cost to the state.
We understand that you will have questions about what this means for you and CSEA will work tirelessly to ensure that you have the answers you need in order to give you the peace of mind that comes with understanding your healthcare plan. There will also be informational meetings to make sure there is a smooth transition for each of our members.
Remember, there were many of the same concerns when the change was made to UnitedHealthcare for coverage of over 65 retirees several years ago. Our union, CSEA, worked tirelessly to get our members' questions and concerns addressed and to assure as smooth a transition as possible between providers. The result was a very high overall approval rating of the health care coverage by United when we surveyed our members. We can expect the same level of effort from our union to affect a smooth transition as we go forward.
In the meantime, the best way to stay up-to-date is to keep an eye on your email and the CSEA News. As more information becomes available, we will send out detailed emails, include articles in the CSEA News, and will also keep this webpage updatedwith all of the available resources and information.
Once again, our membership raising our voices and coming together has resulted in an important win for our union members.