Health & Insurance

Costs & Coverage

For costs and coverage information, please click on your home state of residence from the list below:

For plan year 2020

Summaries of Benefits & Coverage

For plan year 2020

Cigna - International Medical and Dental Plan

Access to this plan is limited to eligible participants only

• 2020 Benefits at a Glance
• 2020 Cigna Rates

Summary Plan Descriptions

• Cigna - International Medical and Dental Plan
• Fully-Insured HMO SPD Wrapper
  • 2020 Cigna Medical OAPIN Certificate
  • 2020 Cigna Medical OAPIN Rider
• Map Plus Option 1 and Option 2
  • Appendix A for: Option 1 Low Deductible Plan
  • Appendix A for: Option 2 High Deductible Plan
  • Summary of Material Modification for MAP Plus Option 1 and Option 2
  • Recognized Chard Amendment for MSA 868755
  • Recognized Chard Amendment for MSA 865282
  • Recognized Chard Amendment for MSA 479236
  • Recognized Chard Amendment for MSA 479235
• Self-Funded HMO SPD Wrapper (applies to all self-funded HMO’s)
  • Appendix A for: Blue Cross Blue Shield of Michigan (for Illinois) Self Funded Plan
  • Appendix A for: Blue Care Network (Midland/Tri-Cities Michigan) Self-Funded Plan
  • Appendix A for: Cigna Self-Funded HMO
  • Appendix A for: Health Partners Minnesota Plan
  • Appendix A for: Humana Self-Funded Plan
• Reimbursement Account – Health Care (HCRA)
• Reimbursement Account - Dependent Care (DCRA)

COBRA

For plan year 2020

Forms

• Mail Order Prescription Drugs
• Medical
• Retail Prescription Drugs
• Aetna Transition of Care Form
• FSA PayFlex Reimbursement Form – Healthcare, Limited Purpose & Dependent Day Care
• Reimbursement Account/Health Savings
• Account Final Deduction Form
• Statement of Domestic Partner Relationship
• Documentation Needed for Dependent Eligibility

Resources

Reimbursement Programs

• RHCAP Funds Performance

Cost & Coverage

For plan year 2020

• Dental Summaries

Summary Plan Descriptions

• Cigna - International Medical and Dental Plan
• Dental Assistance Program
• Delta Dental Appendix A
• Dental Maintenance Organization (DMO) Wrapper
  • 2020 Cigna DHMO Certificate
  • 2020 Cigna DHMO ET Rider

COBRA

For plan year 2020

• Dental Plan

Forms

• Aetna Claim Form - Dental

Contacts

Delta Dental (Basic Plus and PPO High)

• Member Services: 800-524-0149
• Website: www.deltadentalmi.com
• App: Apple App Store | Google Play

Aetna Dental (DMO)

• Phone: 877-238-6200
• Website: www.aetna.com
• Aetna Health app: Apple App Store | Google Play

Cigna Dental Health (DMO)

• Phone: 800-244-6224
• Website: www.cigna.com
• App: Apple App Store | Google Play

Cost & Coverage

• Vision

Summary Plan Descriptions

• Fully-Insured HMO SPD Wrapper
  • 2019 Cigna Vision Certificate
• Vision

Contacts

VSP Vision

• Phone: 800-877-7195
• Website: http://dow.vspforme.com
• App: Apple App Store | Google Play

Life Insurance

• Life Insurance Plans

Life Insurance Extras

• Dignity Funeral Planning provides information on funeral discounts and planning services available through MetLife Advantages ‐ at no additional cost to you.
• Funeral Planning Guide provides an easy-to-use format for documenting information your survivors will need upon your death
• Grief Counseling can provide you, your dependents or beneficiaries with support, comfort, tools and services to help get back to a productive life after experiencing any major loss

Will Preparation and Estate Resolution Services

Employees who are enrolled in Employee-Paid Life Insurance can prepare or update a standard will for little or no cost, and probate assistance is available for their estate.

• Estate Resolution Services FAQ
• Will Prep FAQ
• Will Prep Attorney Map

Accident Insurance

• Accident Insurance Plans

Cost & Coverage/SPDs/Forms

• Life Insurance
  • Summary of Material Modification (SMM) - Life Insurance
• VGA (AD&D) Conversion Form
• COLI Incentive Beneficiary Form
• Voluntary Group Accident (VGA)
• Business Travel / Occupational Accident Insurance
• COLI Incentive Benefit Program

Long Term Disability

• Long Term Disability Plan

Summary Plan Descriptions

Group Legal Plan

The Group Legal Plan provides personal legal services for eligible Employees, their Spouses and Dependent Children.

• Group Legal Plan

Long Term Care Insurance

• Enrolled on or after 07/01/07
• Enrolled prior to 07/01/07
• Dow AgroSciences Long Term Care

Long Term Disability Insurance

• Dow AgroSciences long term disability
• Disabled on or after 01/01/08
• Disabled prior to 01/01/08
• Rohm and Haas bargained-for Kilbourn, disabled prior to 1/1/10
• Rohm and Haas bargained-for Philadelphia, Louisville, Bristol/Croyden, Knoxville, Houston, disabled prior to 1/1/10
• Rohm and Haas non-bargained prior to 01/01/10
• Union Carbide disabled prior to 1/1/2002