Below are links to resources and downloadable forms related to WELS VEBA. These forms are also available from the Benefit Plans Office and will be mailed upon your request.
Summary Plan Descriptions (SPDs)
Summaries of Benefits and Coverage (SBCs)
Plan Option 1 SBC - 2024Summary of Plan Option 1 for 2024 plan year.
- Plan Option 2 SBC - 2024Summary of Plan Option 2 for 2024 plan year.
- Plan Option 3 SBC - 2024Summary of Plan Option 3 for 2024 plan year (compliant for use with Health Savings Accounts).
- Plan Option 4 SBC - 2024Summary of Plan Option 4 for 2024 plan year.
- Plan Option 1 SBC - 2023Summary of Plan Option 1 for 2023 plan year.
- Plan Option 2 SBC - 2023Summary of Plan Option 2 for 2023 plan year.
- Plan Option 3 SBC - 2023Summary of Plan Option 3 for 2023 plan year.
- Plan Option 4 SBC - 2023Summary of Plan Option 4 for 2023 plan year.
- Routine Vision Benefits Summary - 2024Summary of routine vision benefits through Vision Service Plan (VSP).
Forms
- Anthem BCBS Claim Form for General Medical ServicesFor claims incurred in the United States. Please contact Anthem Blue Cross Blue Shield at 1-877-512-7875 for the mailing address of your local BCBS plan.
- Blue Cross Blue Shield Global Core Claim FormFor claims incurred outside the United States. Send the completed claim form and itemized bills to the WELS Benefit Plans Office at N16W23377 Stone Ridge Dr, Waukesha, WI 53188.
- Express Scripts Prescription Drug Reimbursement FormMail this completed reimbursement form and itemized bill to the Express Scripts address listed at the bottom of this form.
- Express Scripts Prescription Drug Mail Service FormFor use when obtaining a 90-day supply of a covered prescription drug to be delivered by mail. Mail the completed form and the doctor’s prescription to the Express Scripts address listed at the bottom of this form.
- Vision Service Plan (VSP) Routine Vision Expense Reimbursement FormMail this completed reimbursement form to the VSP address listed at the top of the form.
- WELS VEBA Health Information Release FormMail this completed release of information form to the WELS Benefit Plans Office at N16W23377 Stone Ridge Dr, Waukesha, WI 53188.