Forms and Publications

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    Medical
    Document Office Publish Date File
    UT SELECT Medical Claim Form Employee Benefits UT SELECT Medical Claim Form
    UT SELECT Tobacco Cessation Program Employee Benefits UT SELECT Tobacco Cessation Program
    UT SELECT Weight Management Program Employee Benefits Weight Management 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
    UT Health Network Flyer Employee Benefits UT Health Network Flyer 2018-2019
    UT CONNECT ACO Benefits Summary Chart Employee Benefits UT CONNECT ACO Benefits Summary Chart 2019-2020
    UT CONNECT ACO Benefits Summary Chart 2018-2019
    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 SELECT Benefits Summary Chart Employee Benefits UT SELECT Benefits Summary Chart 2019-2020
    UT SELECT Benefits Summary Chart 2018-2019
    UT SELECT Benefits at a Glance Brochure Employee Benefits 2020-2021 UT SELECT Benefits At-a-Glance Brochure
    Out-of-Area Network Summary of Benefits and Coverage Employee Benefits 2020-2021 Summary of Benefits: Out-of-Area Plan
    2020-2021 Summary of Benefits and Coverage: Out-of-Area Plan (Spanish/Español)
    2019-2020 Summary of Benefits: Out-of-Area Plan
    2019-2020 Summary of Benefits and Coverage: Out-of-Area Plan (Spanish/Español)
    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)
    PPO Network Summary of Benefits and Coverage Employee Benefits 2020-2021 Summary of Benefits: PPO Plan
    2020-2021 Summary of Benefits: PPO Plan (Spanish/Español)
    2019-2020 Summary of Benefits: PPO Plan
    2019-2020 Summary of Benefits: PPO Plan (Spanish/Español)
    UT SELECT Omada Health Overview Employee Benefits Omada Health Brochure 2020
    Omada Health FAQs 2020
    UT CONNECT MDLIVE Information Employee Benefits UT CONNECT MDLIVE Information 2020-2021
    UT SELECT Hinge Health Overview Employee Benefits Hinge Health Brochure 2020
    Hinge Health Enrollment 2020
    UT SELECT Ovia Health Overview Employee Benefits UT SELECT Ovia Health Overview 2020-2021
    UT SELECT Ovia Health Maternity App 2020-2021
    UT CONNECT Benefit Chart Comparison Employee Benefits UT CONNECT Benefit Chart Comparison 2020-2021
    UT SELECT Health Advocacy Solutions Employee Benefits UT SELECT Health Advocacy Solutions Brochure 2020
    UT SELECT Health Advocacy Solutions Infographic 2020
    UT SELECT Livongo Overview Employee Benefits Livongo Brochure 2020
    Livongo Hypertension Brochure 2020
    Livongo FAQs
    UT CONNECT Ovia Health Overview Employee Benefits UT CONNECT Ovia Health Overview 2020-2021
    UT CONNECT Ovia Health Maternity App 2020-2021
    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 Highlights Brochure Employee Benefits UT CONNECT Highlights Brochure 2020-2021
    UT SELECT MDLIVE Overview Employee Benefits MDLIVE Brochure 2020
    Airrosti Brochure Employee Benefits Airrosti: Recover Faster with Airrosti 2020
    UT CONNECT ACO Medical Plan Guide with Prescription Drug Coverage Employee Benefits NEW! 2020-2021 UT CONNECT ACO Medical Plan Guide
    UT SELECT Medical Plan Guide with Prescription Drug Coverage Employee Benefits NEW! 2020-2021 UT SELECT Medical Plan Guide
    UT CONNECT ACO Medical Plan FAQs Employee Benefits UT CONNECT FAQs 2020-2021
    Pharmacy
    Document Office Publish Date File
    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 UT SELECT Part D Evidence of Coverage
    UT SELECT Part D Language Services UT SELECT Part D Language Services
    UT SELECT Part D Mail Order Form UT SELECT Part D Mail Order Form
    UT SELECT Part D Contacts UT SELECT Part D Contacts
    UT SELECT Part D Presentation UT SELECT Part D Presentation
    UT SELECT Part D Welcome Kit Letter Employee Benefits UT SELECT Part D Welcome Kit Letter
    Prescriptions by Mail Order Form Employee Benefits Prescriptions by Mail Order Form
    Prescription Drug Co-payments at a Glance Employee Benefits Prescription Drug Copayments at a Glance
    UT SELECT Prescription Drug Program at-a-Glance 2020-2021
    UT SELECT Medicare Part D Prescription Drug Program at-a-Glance 2020-2021
    UT CONNECT Prescription Drug Program at-a-Glance 2020-2021
    Dental
    Document Office Publish Date File
    Your Dental Plan Options Employee Benefits Dental Plan Options
    UT SELECT DENTAL Claim Form Employee Benefits UT SELECT DENTAL Claim Form
    DeltaCare Benefits Guide Employee Benefits DeltaCare Benefits Guide
    UT SELECT DENTAL Highlights Employee Benefits UT SELECT DENTAL Highlights 2020
    DeltaCare Highlights Employee Benefits DeltaCare Highlights 2020
    UT SELECT DENTAL Plus Highlights Employee Benefits UT SELECT DENTAL Plus Highlights 2020
    UT SELECT DENTAL Benefits Guide Employee Benefits 2020-2021 UT SELECT DENTAL Benefits Guide
    2019-2020 UT SELECT DENTAL Benefits Guide
    UT SELECT DENTAL Plus Benefits Guide Employee Benefits 2020-2021 UT SELECT DENTAL Plus Benefits Guide
    2019-2020 UT SELECT DENTAL Plus Benefits Guide
    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 Plan Highlights Employee Benefits Superior Vision Highlights
    Tips Caring for your Eyes Wearing Contacts Employee Benefits Tips for Caring for your Eyes While Wearing Contacts
    Finding-In-Network Providers Employee Benefits Find an In-Network Eye Care Professional 2020
    The Importance of an Eye Exam Employee Benefits Superior Vision: The Importance of an Eye Exam
    Superior Vision Online Retailers Employee Benefits Superior Vision Online Contacts and Lenses Retailers
    Superior Vision Mobile App Employee Benefits Superior Vision Mobile App 2020
    Superior Vision Member Discounts Employee Benefits Superior Vision Member Discounts
    Superior Vision Member Hearing Network Discount
    Flexible Spending Accounts
    Document Office Publish Date File
    UT FLEX Health Care Reimbursement Claim Form Employee Benefits UT FLEX HCRA Claim Form
    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 Maestro Health Brochure Employee Benefits UT FLEX Maestro Health Brochure 2020
    UT FLEX Benefits Guide Employee Benefits 2020-2021 UT FLEX Benefits Guide
    2019-2020 UT FLEX Benefits Guide
    Life and Accidental Death and Dismemberment (AD&D)
    Document Office Publish Date File
    Accidental Death & Dismemberment Certificate Employee Benefits Accidental Death & Dismemberment Certificate
    Group Term Life Certificate Employee Benefits Group Term Life Certificate
    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
    Life, AD&D, and Disability Insurance Overview Employee Benefits Life, AD&D, and Disability Highlights 2020
    Health Advocate Solutions (HAS) Disability Integration 2020
    Short-Term Disability (STD)
    Document Office Publish Date File
    Short-Term Disability Certificate Employee Benefits Short Term Disability Certificate
    Short Term Disability Brochure Employee Benefits Short Term Disability Brochure
    Long-Term Disability (LTD)
    Document Office Publish Date File
    Long-Term Disability Certificate Employee Benefits Long Term Disability Certificate
    Long-Term Disability Benefit Highlights Employee Benefits Long Term Disability Brochure
    Special Notices
    Document Office Publish Date File
    HIPAA Request for Amendment of Protected Health Information Employee Benefits HIPAA Request for Amendment of Protected Health 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 Confidential Communications of Medical Information Employee Benefits HIPAA Request for Confidential Communications of Medical Information Form
    Notice of Creditable Coverage (NOCC) Employee Benefits Medicare Part D Notice of Creditable Coverage
    HIPAA Request for Access to Protected Health Information Employee Benefits Request for Access Form
    HIPAA Revocation of Authorization Employee Benefits HIPAA Revocation of Authorization 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 Complaint Form Employee Benefits HIPAA Complaint 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
    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 Northeast 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
    Medicaid and the Children's Health Insurance Program (CHIP) Notice Employee Benefits Medicaid and the Children's Health Insurance Program (CHIP) Notice
    Legal Notices Employee Benefits UT Benefits - Legal Notices 2020
    UT Benefits - Legal Notices 2019
    UT Retirement Program
    Document Office Publish Date File
    DCP Catch-Up Provision Agreement Employee Benefits DCP Catch-Up Provision Agreement
    Purchase Change Agreement (All plans) Employee Benefits UT Retirement Purchase Change Agreement (All plans)
    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)
    UTSaver TSA Disclosure Form Employee Benefits UTSaver TSA Disclosure Form
    ORP Authorization for Reduction for Employee Contribution Employee Benefits ORP Authorization for Reduction for Employee Contribution
    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
    DCP Purchase Agreement Employee Benefits DCP Purchase Agreement
    Overview of TRS and ORP Employee Benefits TRS and ORP Overview - July 2019
    TRS Form 28 (Notice to Elect to Participate in Optional Retirement Program and/or Refund) Employee Benefits TRS Form 28
    Comparison of Traditional, Roth 403(b), and Roth IRA Contributions Employee Benefits Comparison of Traditional, Roth 403(b), and Roth IRA Contributions
    Voluntary Retirement Programs At a Glance Employee Benefits Voluntary Retirement Programs
    Summary of Retirement Programs Employee Benefits Retirement Programs Summary
    Voluntary Retirement Programs Loan and Hardship Options Employee Benefits Voluntary Retirement Programs Loan and Hardship Options
    Annual Eligibility Notice for Retirement Plans Employee Benefits Annual Eligibility Notice for Retirement Plans
    Retirement Program Sales Solicitation Agreement Employee Benefits Retirement Program Sales Solicitation Agreement
    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
    UT Benefits Billing Direct Payment/Debit Authorization Agreement Employee Benefits Direct Payment/Debit Authorization Agreement
    Personal Information and Emergency Contact Form Employee Benefits Personal Information and Emergency Contact Form
    Benefits Handbooks and Cost Worksheet
    Document Office Publish Date File
    Annual Enrollment & Resource Guide for Employees Employee Benefits NEW! 2020-2021 Annual Enrollment & Resource Guide for Employees
    2019-2020 Annual Enrollment & Resource Guide for Employees
    Annual Enrollment Highlights for Employees Employee Benefits 2020-2021 Annual Enrollment Highlights for Employees
    Annual Enrollment & Resource Guide for Retired Employees Employee Benefits NEW! 2020-2021 Annual Enrollment & Resource Guide for Retired Employees
    2019-2020 Annual Enrollment & Resource Guide for Retired Employees
    Annual Enrollment Highlights for Retired Employees Employee Benefits 2020-2021 Annual Enrollment Highlights for Retired Employees
    Benefits Cost Worksheet for Employees Employee Benefits NEW! 2020-2021 Active Employee Cost Worksheet
    2019-2020 Active Employee Cost Worksheet
    Benefits Cost Worksheet for Retired Employees Employee Benefits NEW! 2020-2021 Retired Employee Cost Worksheet
    2019-2020 Retired Employee Cost Worksheet
    UT Benefits Enrollment Guide for Employees Employee Benefits NEW! 2020-2021 UT Benefits Enrollment Guide for Employees
    2019-2020 UT Benefits Enrollment Guide for Employees
    UT Benefits Enrollment Guide for Retiring Employees Employee Benefits NEW! 2020-2021 UT Benefits Enrollment Guide for Retiring Employees
    2019-2020 UT Benefits Enrollment Guide for Retiring Employees
    Other
    Document Office Publish Date File
    UT System Cafeteria Plan Document Employee Benefits UT System Cafeteria Plan Document
    International Travel Quick Reference Sheet Employee Benefits ut-system-foreign-coverage-quick-reference-sheet-12-2016.pdf
    COBRA Application FAQs Employee Benefits COBRA Application FAQs
    COBRA General Notice Employee Benefits COBRA General Notice for the 2018-2019 Plan Year
    COBRA Rates Employee Benefits COBRA Rates 2019-2020
    COBRA Rates 2018-2019
    Living Well Resources Guide Employee Benefits Living Well Resources Guide 2020-2021
    Naturally Slim Overview Employee Benefits Naturally Slim Teaser 2020
    Blue Cross and Blue Shield of Texas Fitness Program Employee Benefits BCBSTX Fitness Program for UT SELECT
    BCBSTX Fitness Program for UT SELECT (Español)
    BCBSTX Fitness Program for UT CONNECT
    BCBSTX Fitness Program for UT CONNECT (Español)
    Office of Employee Benefits Organizational Chart Employee Benefits Office of Employee Benefits Organizational Chart
    BCBSTX Identity Protection Services Employee Benefits BCBSTX Identity Protection Services
    Grandchild Certification Form Employee Benefits Dependent Grandchild Certification Form
    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 Agent Listing Employee Benefits UT Retirement Provider Agent Listing
    Retirement Plan Publications
    Document Office Publish Date File
    UT CARES Act Employee Benefits UT CARES Act
    AIG Retirement Services Information Employee Benefits 2020 AIG Retirement Services Brochure
    2020 AIG Retirement Services Highlights
    Fidelity Investments Information Employee Benefits 2020 Fidelity Investments Brochure
    2020 Fidelity Investments Mobile app Flyer
    2020 Fidelity Investments Virtual Benefits
    TIAA Information Employee Benefits TIAA Benefit of Saving Now
    TIAA Benefits of One Percent
    TIAA Diversification and Market Volatility
    TIAA Staying on Track
    TIAA Unprecedented Time of Uncertainty
    UTSaver Retirement Plans Brochure Employee Benefits 2020-2021 UTSaver Retirement Plans: The Best Start
    Lincoln Financial Information Employee Benefits Lincoln Financial Virtual Benefits Booth 2020
    Voya Financial Information Employee Benefits Voya Financial Brochure 2020
    Voya Financial: Your Journey to Financial Wellness
    Voya Financial: 10 Reasons to Enroll in Your Employer’s Retirement Plan