Retiree Health and/or Dental Insurance Applications
- Application for the Retired/Disabled Health and Dental Insurance Group
- Cancellation of Retiree Health and/or Dental Insurance
Sick Leave Insurance Program (SLIP)
- SLIP Enrollment Form
- SLIP Calculation Estimate Worksheet
- SLIP Retiree Rehire Authorization
Applications and Forms
Retiree Applications
Wellmark State of Iowa Retiree Application
Iowa Group MedicareBlue Rx Application (for Group Program F or N)
Iowa Group MedicareBlue Rx Application (for Iowa Choice/National Choice)
Delta Dental Application Delta Dental Application (fillable pdf form)
Electronic Funds Transfer (EFT) Forms
Wellmark Automatic Payment Authorization
Group MedicareBlue Rx Automatic Payment Authorization
Delta Dental Automatic Payment Authorization
Contact Information
- Department of Administrative Services, Human Resources Enterprise - 866-895-2464 or stateretirees@iowa.gov
- Wellmark, Blue Cross Blue Shield of Iowa – Customer Service - 800-622-0043
- MedicareBlue Rx – Customer Service - 877-838-3827
- Medicare website - www.medicare.gov/
- Senior Health Insurance Information Program (SHIIP) - 800-351-4664 or shiip.iowa.gov/