Use this form to manually submit a claim to American Fidelity FSA/HRA claims.

For more information about Caremark Mail Order Service please visit their website. www.caremark.com

For reimbursement of vision claims.

*WPAS only processes out of Caremark network claims that are member paid.

All other prescriptions member paid claims should be submitted to Caremark and there are various methods to submit claims on www.caremark.com  where an employee can register and create an account.

Under certain circumstances your Plan may provide benefits for reimbursement of travel expenses
for you or your dependent(s) to travel outside your locale for medical treatment. Travel may be
considered for: treatment not available locally, treatment at Alaska Regional Hospital, or travel
outside Alaska to use Aetna PPO providers.

If you are looking to make a withdrawal from your 401k please fill out and submit to Empower Retirement.

This document is needed if you are waiving Health Insurance.

Make sure and submit any supporting documents with your enrollment form! These include your marriage certificate, birth certificates for children, or a waiver form if applicable.