Find the Cost of Your Drugs

Employees and Retirees without Medicare: learn how much you can expect to pay at the pharmacy.

Program Option
  • Local Annuitant Health Program (LAHP)
  • Local Deductible Health Plan (PO14) & Supplemental Benefits
  • Local Deductible Health Plan with Uniform Dental (PO4) & Supplemental Benefits
  • Local Health Plan (PO16) & Supplemental Benefits
  • Local Health Plan with Uniform Dental (PO6) & Supplemental Benefits
  • Local Traditional Health Plan (PO12) & Supplemental Benefits
  • Local Traditional Health Plan with Uniform Dental (PO2) & Supplemental Benefits
Plan Year
  • 2025

Find the Cost of Your Drugs (Medicare)

Retirees with Medicare: learn how much you can expect to pay at the pharmacy.

Program Option
  • Local Annuitant Health Program (LAHP)
  • Local Deductible Health Plan (PO14) & Supplemental Benefits
  • Local Deductible Health Plan with Uniform Dental (PO4) & Supplemental Benefits
  • Local Health Plan (PO16) & Supplemental Benefits
  • Local Health Plan with Uniform Dental (PO6) & Supplemental Benefits
  • Local High Deductible Health Plan (PO17) & Supplemental Benefits
  • Local High Deductible Health Plan with Uniform Dental (PO7) & Supplemental Benefits
  • Local Traditional Health Plan (PO12) & Supplemental Benefits
  • Local Traditional Health Plan with Uniform Dental (PO2) & Supplemental Benefits
  • State Employee and Retiree Health Plan & Supplemental Benefits
Plan Year
  • 2025
ET-4427
Form Active Employee / Retiree / Other Benefit Recipient

Statement of Incapacity for Finances and Property

Form for the member’s physician to complete if the member cannot manage property, finances or business affairs because of an impairment in the ability to receive and evaluate information or make or communicate decisions even with the use of technological assistance.

Your Spouse or Dependent Dies

Experiencing this life event may allow you to make changes to your accident plan or health, dental, vision, or long-term care insurance.

Program Option
  • Local Annuitant Health Program (LAHP)
  • Local Deductible Health Plan (PO14) & Supplemental Benefits
  • Local Deductible Health Plan with Uniform Dental (PO4) & Supplemental Benefits
  • Local Health Plan (PO16) & Supplemental Benefits
  • Local Health Plan with Uniform Dental (PO6) & Supplemental Benefits
  • Local High Deductible Health Plan (PO17) & Supplemental Benefits
  • Local High Deductible Health Plan with Uniform Dental (PO7) & Supplemental Benefits
  • Local Traditional Health Plan (PO12) & Supplemental Benefits
  • Local Traditional Health Plan with Uniform Dental (PO2) & Supplemental Benefits
  • State Employee and Retiree Health Plan & Supplemental Benefits

Pre-Tax Savings Accounts

Save on a wide variety of everyday medical, dental, vision, day care, parking, and transit expenses with a pre-tax savings account. It’s a tax break that’s simple to use.

Plan Year
  • 2025
Program Option
  • State Employee and Retiree Health Plan & Supplemental Benefits
ET-8945
Form Other Benefit Recipient

Vendor Privacy Incident Report

Use this form to report any possible or confirmed breaches of protected health information (PHI) or personally identifiable information (PII).

ET-7282
Form Active Employee / Retiree / Other Benefit Recipient

Direct Deposit Authorization

Authorize ETF and the financial institution you name to deposit funds such as annuity payments directly into your bank account.

Summary of Benefits and Coverage

A snapshot of a health plan's costs, benefits, covered healthcare services, and other important features.

Program Option
  • State Employee and Retiree Health Plan & Supplemental Benefits
Plan Year
  • 2025

Steps to Choosing Your Benefits

Not sure where to start? This page is a step-by-step guide to choosing your benefits.

Plan Year
  • 2025
Program Option
  • State Employee and Retiree Health Plan & Supplemental Benefits
ET-5306
Form Local Employer / State Employer

Request for Disability Premium Waiver

Employers should submit this form when first aware that an insured employee is unable to work due to illness or injury and will be unable to perform any work or to engage in any occupation for an indefinite period.