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Benefits

Form Description
2023-24 exceptional FACULTY benefits
2023-24 excpetional STAFF benefits
Address change form

Change your permanent address online using myUK, or submit the PDF form.

Name Change Form

Use this form for any name change(s). Note: The employee completes the form with the appropriate change. Then, employee takes form to HR Benefits Office for entering into SAP. HR Benefits Office enters change into SAP. HR Benefits Office then forwards form to Compensation. Compensation will forward form to Employee Records after processing, where the copy will be filed in the individual’s Employee Record File. To change home and work addresses, go to myUK at https://myuk.uky.edu and update using the Employee Self Service (ESS) portal.

Release of Health Information

For UK employees only. Authorize an individual to contact the HR Benefits office and receive information regarding UK benefits on employee’s behalf.

Employee Medical Plans

Form Description
Anthem manual claims form

Use this form to manually submit a health insurance claim with Anthem.

COBRA Enrollment form 2023-24

Plan year July 1, 2023 through June 30, 2024

Use this form to enroll in COBRA insurance coverage, available to UK employees which allows you to continue your group health, dental and vision insurance on an individual basis when you or your dependent(s) become ineligible for University benefits.

Employee benefits enrollment 2023-2024

Plan year July 1, 2023 through June 30, 2024 Enroll in UK health, dental and vision insurance. Qualifying dependent children may be covered to age 26.  You must download and save it to your computer to complete the digital signature. Viewing the form in a web browser will not allow a digital signature.

Health Savings Account Amendment Form 2023-2024

Plan year July 1, 2023 through June 30, 2024

Use this form at any time during the year to start, stop, increase, or decrease the amount you contribute to you HSA.
 

Health Savings Account Enrollment Form 2023-24

Plan year July 1, 2023 through June 30, 2024

Use this form if you are enrolling in the UK Saver HSA health plan and would like to make additional employee contributions. This also includes the option to open a limited flexible spending account. You must download the form and save it to your computer to complete the digital signature. Viewing the form in a web browser will not allow a digital signature.
 

Retiree Medical Plans

Form Description
ACH Bank Draft Authorization Form

Fill out and submit this form to enable automatic monthly payment of your UK Retiree Health Insurance premiums by bank draft (ACH).

Retiree Benefits Enrollment Form 2023-24

Plan year July 1, 2023 through June 30, 2024

Retirees should use this form to enroll in health, dental and vision plans.
 

Retiree Health Coverage Deferral

Fill out and submit this form to defer retiree health coverage one time and have the option to return to university coverage in the future.

More Great Benefits

Form Description
EAHP Application

This form allows UK Employees to apply for the Employer Assisted Housing Program.

EAHP map

This map outlines the area surrounding UK that defines the boundaries of the UK Employee Assisted Housing Program.

Family Education Program (FEP) Enrollment Form

As a UK employee, you have the opportunity to enroll a family member in the Family Education Program through UK.

Flexible Spending Account Enrollment Form 2022-23

Plan year July 1, 2022 through June 30, 2023

Use this form to enroll in health and/or dependent care flexible spending accounts (FSA). You must download the form and save it to your computer to complete the digital signature. Viewing the form in a web browser will not allow a digital signature.

Flexible Spending Account Enrollment Form 2023-24

Plan year July 1, 2023 through June 30, 2024

Use this form to enroll in health and/or dependent care flexible spending accounts (FSA). You must download the form and save it to your computer to complete the digital signature. Viewing the form in a web browser will not allow a digital signature.
 

Flexible Spending Claim Form

Use this form to manually submit a flexible spending account claim with ASI Flex.

Life Insurance and AD&D Beneficiaries Form

Use this form to name your beneficiaries for your optional life insurance and optional accidental death & dismemberment insurance.

Life Insurance and AD&D Enrollment Form 2022-23

Plan year July 1, 2022 through June 30, 2023

Use this form to enroll in additional life insurance coverage for yourself, spouse/sponsored dependent, or children. This form also allows you to enroll in separate accidental death & dismemberment insurance.

Life Insurance and AD&D Enrollment Form 2023-24

Plan year July 1, 2023 through June 30, 2024 Use this form to enroll in additional life insurance coverage for yourself, spouse/sponsored dependent, or children. Qualifying dependent children may be covered to age 26.  This form also allows you to enroll in separate accidental death & dismemberment insurance.  

MetLaw Enrollment Form 2022-23

Plan year July 1, 2022 through June 30, 2023

Use this form to enroll in legal services insurance or cancel it.

MetLaw Enrollment Form 2023-24

Plan year July 1, 2023 through June 30, 2024

Use this form to enroll in legal services insurance or cancel it.
 

One-time exception to allow 9 credit hours in one semester request form

This form allows enrolled participants in the Employee Education Program to request a one-time exemption from the semester limit to the number of hours an employee can take.

Tuition waiver FERPA release form

This form is for use by students who are also employed by the University of Kentucky as regular employees using the tuition waiver benefit to attend other Kentucky state-funded institutions. Students who wish to use the tuition waiver benefit must release their academic records in order for University of Kentucky Human Resources to receive academic records from these other Kentucky public institutions. The information is for internal use only, related to benefit eligibility and administration and will not be shared with any parties outside of the University of Kentucky.

Tuition waiver form for classes at UK (EEP form)

This fillable form allows UK Employees to enroll in the Employee Education Program (EEP) at UK.

Retirement

Form Description
90 Day Waiver Request
Allocated Spending Goals

Write a list of everything you would like to do from most important to least important. When you get extra money from any source, apply it to these goals. Item one may be new clothes for $100, item two could be a weekend trip away for $300, and item three could be pay off a credit card for $800. If you receive a $600 tax refund, you could do the first two items and put the remaining $200 towards the credit card debt.

Basic Cash Flow Plan

More than a budget, this will help plan what bills will be paid with each paycheck.

Debt Snowball Form

This form can give you a game plan to pay off your debt. List debts from smallest to largest, pay as much as you can on the smallest and the minimum on the rest.  As one debt is paid off, add the amount you were paying monthly on that debt to the minimum payment on the next debt on the list.

Fidelity Matching 403(b) Enrollment Form

Employees should complete this form to make matching 403(b) retirement savings plan contributions to Fidelity Investments and designate beneficiaries.

Fidelity Voluntary 403(b) Enrollment Form

Employees should complete this form to make voluntary 403(b) retirement savings plan contributions to Fidelity Investments and designate beneficiaries.

Fidelity Voluntary 457(b) Enrollment Form

Employees should complete this form to enroll in voluntary 457(b) retirement savings plan through Fidelity. This form is also used for designating a beneficiary.

Income and Expense worksheet

This worksheet will give you a good basic understanding of what your current income and expenses really are.

Matching 403(b) Salary Reduction Authorization

Complete this form to authorize payroll deductions as contributions to UK's Matching Retirement Savings Plan.

Phased Retirement Agreement

This form allows staff or faculty of UK to enter a Phased Retirement process.

TIAA Matching 403(b) Enrollment Form

Employees should complete this form to make matching 403(b) retirement savings plan contributions to TIAA and designate beneficiaries.

TIAA Voluntary 403(b) Enrollment Form

Employees should complete this form to make voluntary 403(b) retirement savings plan contributions to TIAA Investments and designate beneficiaries.

TIAA Voluntary 457(b) Enrollment Form

Employees should complete this form to enroll in voluntary 457(b) retirement savings plan through TIAA. This form is also used for designating a beneficiary.

Voluntary 403(b) Salary Reduction Authorization - 2022

Use this form for additional voluntary contributions, over and above the standard 5 percent 403(b) employee contribution.

Voluntary 403(b) Salary Reduction Authorization - 2023

Use this form for additional voluntary contributions, over and above the standard 5 percent 403(b) employee contribution.

Voluntary 457(b) Salary Reduction Authorization - 2022

Use this form for voluntary contributions to a UK 457(b) retirement savings plan, separate from UK's 403(b) retirement plan.

Voluntary 457(b) Salary Reduction Authorization - 2023

Use this form for voluntary contributions to a UK 457(b) retirement savings plan, separate from UK's 403(b) retirement plan.

Prescription

Form Description
Mail order form – active employees and under 65 retirees
Mail order form – Medicare retirees
Manual claim form for employees and retirees under age 65

Under some circumstances it may be necessary to manually file a prescription claim.  For example if you are out of town and cannot locate your Express Scripts ID card, it may be necessary to pay for the prescription and manually file for reimbursement once you return. 

Please note claims must be filed within twelve (12) months of receiving a prescription.

Manual claim form for retirees age 65 and over (Medicare Advantage Plan)

Under some circumstances it may be necessary to manually file a prescription claim.  For example if you are out of town and cannot locate your Express Scripts ID card, it may be necessary to pay for the prescription and manually file for reimbursement once you return. 

Please note claims must be filed within twelve (12) months of receiving a prescription.

Medicare Rx EOC 2022
Medicare Rx EOC 2023
Prescription formulary 2023-2024 (active employees and under 65 retirees)

Prescription formularies for UK health plan members on either HMO, PPO, RHP, EPO, Saver or Indemnity plans.

If you have any questions, call our pharmacists with the Know Your Rx Coalition at (859) 218-5979 or (855) 218-5979 for information specific to your medication, formulary and costs.

Saveon SP Non-Essential Coverage Specialty Drug List
UK Medicare Part D Prescription Formulary 2024

Health insurance

Form Description
Summary of benefits and coverage - Saver HSA

What the Saver HSA plan covers and what you pay for covered services.