Benefits Forms & Links
Click on the titles to view information available by Benefit
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Voluntary Benefits (Critical Illness, Hospital Indemnity & Accident)
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If you cannot read any of these files after downloading them, please call Human Resources at ext. 7757 and request the appropriate form.
To view Summary Plan Description (SPD) information for our Health & Welfare plans please visit: /human-resources/benefit-summary-plan-descriptions
2025 Benefits Guide
Medical Insurance - UnitedHealthcare
- UHC Website (to search in the Provider Directory, all Loyola plans use the UHC Choice Plus Network of providers)
- UnitedHealthcare Select Member Network Resource Guide
Other UHC information
- Transition of Care Form
- Provider Nomination Form
- Why is UHC calling me? Wellness & Disease Management Program Information
- UHC Health4Me app Information
- Behavioral Health Virtual Visit Trifold Flyer
- SafeTrip Travel- International Medical Coverage for Emergency Health Services Only
- UHC & Ochsner Fitness Center Membership Information (Valid through 2024)
Machine-Readable Files:
We are committed to supporting the Transparency in Coverage Rule by making MRFs (machine-readable files) available to you. UnitedHealthcare creates and publishes the Machine-Readable Files on behalf of Loyola University New Orleans.
To link to the Machine-Readable Files, please click on the URL provided: transparency-in-coverage.uhc.com
Pharmacy Coverage - MedImact (formerly Elixir)
- 2025 MedImact Formulary (effective 1/1/2025)
- MedImpact Member Information
- MedImpact Online Account & Mobile App (include *LOYOLA behind Prescription ID)
- Facts about Generics - Member Flyer
- Elixir Mail Order Brochure
- Elixir Specialty Pharmacy Care Flyer
- 2024 Step Therapy Enhancement Program
- Elixirsolutions.com - Online Registration
- Direct Member Reimbursement form
MedImpact Customer Care Dedicated Toll Free Number: 855-476-7903
ACA Contraceptive Services
Dental Insurance - Cigna
- Cigna Webpage
- DHMO Benefit Summary
- DHMO Plan Brochure
- DHMO Preventative Care Brochure
- DHMO Charge Schedule
- High DPPO Benefit Summary
- High DPPO Benefit Summary - TX
- Mid DPPO Benefit Summary
- Mid DPPO Benefit Summary - TX
- Benefit Summary (TX Residents)
- DPPO Plan Brochure
- PPO Claim Form
- PPO ID Card (generic)
- Privacy Notice
Vision Insurance - UNUM (formerly AlwaysCare)
Flexible Spending Account(s)- WageWorks
- WageWorks website
- WageWorks FSA Guide Website
- Health Care FSA Overview
- Dependent Care FSA Overview
- WageWorks Dependent Care FSA Website
- Benefits Card
- EZ Receipts FSA Mobile app
- FSA Store Flyer
- FSA Quick Start Guide
Life & AD&D - Lincoln Financial Group
Lincoln Life & Long Term Disability (LTD) Form
- Life & LTD Enrollment & Change Form
- Online Evidence of Insurability Form - Use Group # LOYOUNIVST
- Change of Beneficiary Form
- Evidence Of Insurability Form (for amounts over guaranteed issue only)
- TravelConnect Program Description
- Lincoln TravelConnect Brochure with ID Card
- TravelConnect Website Login Instructions
- Lincoln LifeKeys Brochure
- Lincoln Connect Slim Jim Brochure
Lincoln Life & Long Term Disability Informational Summaries
- Group Term Life (GTL) - Employee Coverage (University Paid) & Basic Dependent Term Life Coverage (Employee & University Share the cost)
- Voluntary Term Life 1-3x - Employee Paid (includes voluntary spouse and child coverage)
- Voluntary AD&D 1-10x - Employee Paid (includes employee or employee & family coverage)
- Long Term Disability (Taxable)
- Long Term Disability (non-Taxable)
- Lincoln LTD Progressive Income Brochure
- Lincoln Financial Group Privacy Practices Notice 2022
Lincoln Voluntary Benefits (effective 1/1/2025)
- Lincoln Critical Illness Covreage Summary
- Lincoln Accident Insurance Summary
- Lincoln Hospital Indemnity Insurance Summary
- Lincoln Voluntary Benefits Claim Instructions
Aflac Voluntary Benefits (ended 12/31/2024 )
- Aflac Enrollment Form
- Critical Illness Coverage
- Group Accident Insurance
- Hospital Indemnity Insurance
Aflac Claim forms:
- Electronic Aflac claim form
- Group Critical Illness
- Group Accident
- Group Hospital Indemnity
- Wellness Benefit
Retirement Account Information
- Change your contriubtion rate online: TIAA.org/LOYNO
- Choosing Your Investments Brochure
- Managing Your Accounts Online Brochure
- Marital Status Verification Form
- Online Enrollment Brochure
- TIAA-CREF Change of Address
- TIAA-CREF Roth Option Brochure
Employee Assistance Program (EAP) - Aetna Horizon Health
- EAP Website
- Username - loyola
- Password - eap
- Video - Resources and Services available through the EAP
- EAP Brochure
- EAP Flyer
Tuition Remission
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Online Tuition Waiver Form now located on the SSO Apps Page. Search "Tuition Waiver" after you log in.
- Statement of Dependency (Dangling Semester)
- Tax Dependency Affidavit
FACHEX/Tuition Exchange Program
- Policy Information
- Tuition Exchange Program Policy and Procedure
- FACHEX/TEP Export Student Application
Audubon Institute
EdNavigator Education Support
Adoption Assistance
Leave of Absence
Please contact Human Resources at extension 7757 to speak to a HR Representative if you may need a leave of absence.