Some of the files below are PDF or MS Word files which require the free Adobe Reader and Word Viewer.
On this page:
- Health Benefits (for active employees & non-Medicare retirees)
- Health Benefits (for Medicare retirees)
- Dental Benefits
- Vision Benefits
- MaineSaves 457b
- Flexible Spending Accounts
- Health Credit Premium Program
- Retired Law Enforcement and Fire Fighter Subsidy Program
- Wellness Programs
- Other
Health Benefits (For Active Employees & Non-Medicare Retirees)
- Application Form (PDF) and Instructions (PDF) To enroll, add/delete members, address change, etc. Please note, incomplete forms will be returned.
- Employee Election to Cancel Health Insurance Form (PDF)
- Retiree Health Insurance Enrollment Form (PDF)
- Certification for Future Enrollment Form (PDF)
Health Benefits (For Medicare Retirees)
- Retiree Health Insurance Enrollment Form (PDF)
- Certification for Future Enrollment Form (PDF)
- 2022 Application Form (PDF)
- Prescription Drug Claim Form (PDF)
- Pharmacy Mail Order Form (PDF)
- State of Maine New Hire Letter
Dental Benefits
- Application Form (PDF) and Instructions (PDF) To enroll, add/delete members, address change, etc. Please note, incomplete forms will be returned.
- Claim Form (PDF)
Vision Benefits
- Application Form (PDF) and Instructions (PDF) To enroll, add/delete members, address change, etc. Please note, incomplete forms will be returned.
- Blue View Vision Claim Form (PDF) - To file a claim for services provided out of network
- EFT Form (MS-Word) - To sign up for automatic premium payment from your bank account
- Provider Recruitment Request Form (MS-Word)
MaineSaves 457b
(Voluntary Retirement Savings)
- Visit our website or contact a local representative.
Flexible Spending Accounts
- Enrollment Form (PDF)
- Change In Status Form (PDF) or Online Change In Status Form
- FSA Claim Form- Blank (PDF)
Health Credit Premium Program
- Health Credit Appeal Form (PDF) - appeals deadline August 8, 2022
Retired Law Enforcement and Fire Fighter Subsidy Program
(County & Municipal Employees Only)
For Employees:
- Status Change Form (MS-Word)
- Appeal Form (MS-Word)
- Application for Retirement Subsidy (MS-Word)
- Employee Election Application for the Health Insurance Subsidy Program
For Retirees:
- Retiree Application to Determine Eligibility (MS Word)
- Reimbursement Subsidy Form for Retiree Health Insurance (MS Word)
Wellness Programs
- Living Resources Training Request Form (Please submit to: paige.s.lamarre@maine.gov)
- Gym Membership Reimbursement Request Form (MS-Word)
- Gym Attendance Verification Worksheet (MS-Word)
- Wise & Well Nomination Form (PDF)