Benefits

Enrollment Forms

NOTE: Health Benefit Enrollment is only available through the Maryland's Statewide Personnel System (SPS Workday).

• Retiree Enrollment Form (pdf)

Rates

• Employee and Retiree Rate Sheet (pdf)
• Retiree with State Subsidy (pdf)
• ORP Rates with 16-25 + Years (pdf)
• 10 Month Employee Rates (pdf)
• Direct Pay Rate Sheet (pdf)
• Contractual/ Variable Hours Rate Sheet (pdf)

Flexible Spending

• Flexible Spending Account Claim Form (pdf) 
• Flexible Spending FAQ's (pdf)
• Flexible Spending Accounts

Prescription

• CVS Healthcare Handbook (pdf)
• CVS FAQ's (pdf)
• CVS Evidence of Coverage (pdf)
• Prescription Claim Form (pdf)
• Medicare Prescription Claim Form (pdf)
• Mail Service Order Form (pdf)
• Medicare Mail Service Order Form (pdf)
• CVS Caremark Website
• Temporary ID Card Commercial Plan
• Temporary ID Card EGWP Medicare Part D

Dental

• 2022 Delta Dental Benefits book (pdf)
• 2022 United Concordia Benefits book (pdf)
• Dental United Concordia

Forms

• HIPAA Certificate Request Form (pdf)
• HIPAA Authorization Form (pdf)

Term Life Insurance and Accidental Death and Dismemberment

• Metlife Life Insurance (Employees)
• Metlife Life Insurance (Retirees)
• Metlife Added Services
• Metlife Accidental Death and Dismemberment

  Website: www.metlife.com/USMD

  USM Optional Term Life Insurance Facts & Stats

  USM FAQ Optional Term Life Insurance 
  

  USM Optional Life insurance Overview

  USM Long Term Disability Overview

  USM FAQ Long Term Disability 
  

Additional Benefits

• Additional Benefits (pdf)

Retirement Guides and Forms

• $600 Deferral Match

Handbooks

• Employees and Teachers (pdf)
• Law Enforcement Officers (pdf) 
• Optional Retirement Plan (pdf)

Supplemental Retirement Plans

Forms

• 403(b) Roth After-Tax SRA - Deduction Authorization Form - FIDELITY
• 403(b) Pre-Tax SRA - Deduction Authorization Form - FIDELITY
• 457(b) Pre-Tax SRA - Deduction Authorization Form - FIDELITY 
  
  
• 403(b) Roth After-Tax SRA - Deduction Authorization Form - TIAA  
• 457(b) Pre-Tax SRA - Deduction Authorization Form - TIAA  
• 403(b) Pre-Tax SRA - Deduction Authorization Form - TIAA  
  
  
• Nationwide Enrollment Form 403(b) 457(b) 401k (pdf)

Guides

• Fidelity 403(b) (pdf)
• Fidelity 457(b) (pdf)
• TIAA 403(b)/ 457(b) (pdf)
• Nationwide (MSRP) 403b 457(b) 401k (pdf)

Appointments

• TIAA
• Fidelity
• Nationwide

State of Maryland Health Assessment Wellness Plan

Department of Benefits Management (DBM) Wellness Program

• Co-pay Waiver and Specialist Reduction Process (pdf)
• Wellness Activity Cheat Sheet (pdf)
• Medical Carrier Added Benefits (pdf)

United Health Care

• Health and Wellness Guide (pdf)

CareFirst

• Health and Wellness Guide (pdf)

Kaiser Permanente

• Health and Wellness Guide (pdf)