Retiree Applications and Forms

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Retiree Health and/or Dental Insurance Applications 

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Sick Leave Insurance Program (SLIP)

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Applications and Forms  

Retiree Applications

Wellmark State of Iowa Retiree Application

Group MedicareBlue Rx for Iowa Application  (for Group Program F or N)

Group MedicareBlue Rx for Iowa 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 

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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/

 

 

 

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