Indian River County Florida
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Benefits - Forms and Links
* Note: Items marked with (ESS) are completed on the Employee Self Service Website

Medical Benefit Flex Benefit
Medical Plan Enrollment •  Flexible Spending Account Enrollment
Medical Plan Change • Advantages of Flexible Spending Account (FSA)
• Florida Blue Website: • Flex Benefit Website:
BlueOptions Schedule of Benefits  
BlueOptions Benefits Booklet Vision Benefit
BlueOptions SBC 10/1/2017 – 9/30/2018 •  Vision Plan Enrollment
  •  Vision Plan Summary of Benefits
Pharmacy Benefit • Vision Plan Website:
Notice of Pharmacy Benefit Moving to Express Scripts 5/1  
Express Scripts Formulary 5/1/18 Benefit Miscellaneous
  • Aflac Accident Wellness Claim Form
Voluntary Term Life Insurance / Disability • Aflac Cancer Screening Wellness Claim Form
•  Designation of Beneficiary  
•  Term Life & LTD Enrollment Florida Retirement System (FRS)
•  Voluntary Term Life Benefit Summary • Beneficiary Designation Pension Plan
• 90 day Benefit Summary • Beneficiary Designation Investment Plan
• 180 day Benefit Summary • Florida Retirement System website:
• Term Life & LTD Evidence of Insurability Hardcopy  
• Term Life & LTD Evidence of Insurability Online Version HIPPA
• Mutual of Omaha Website • HIPAA Notice of Privacy Practices
Dental Benefit Annual Notices
• Dental Plan Enrollment • 2017/2018 Summary of Benefits & Coverage
• Dental Plan Summary of Benefits • Notice of Special Enrollment Rights
• Certificate of Dental Insurance (Low Plan) • Women’s Health and Cancer Rights
• Certificate of Dental Insurance (High Plan) • Children’s Health Insurance Program (CHIP)
• Ameritas Dental Policy  
• Ameritas Website: