For Producers - WTIA

206.448.3033 info@washingtontechnology.org

WTIA Health Insurance

For Producers

Program Information

Producer Onboarding Guide

Benefit Program Employer Guide

WTIA Benefits Program Information

New Group Setup Paperwork

AHP Enrollment

WTIA AHP New Group Setup Checklist

2024/2025 Group Master Application

2025/2026 Group Master Application

2024/2025 Employee Enrollment Form

2025/2026 Employee Enrollment Form

Enrollment Census

Late Submission Acknowledgement

Domestic Partnership Affidavit (for group records only)

EFT Authorization Form

SIMON Access Request Form

WTIA Medical & EAP Plan Information – UnitedHealthcare (UHC)

Sample Materials: For reference only – WTIA provides the below as a courtesy. Current versions are available upon member login at myuhc.com

2025/2026 Plan Year

UHC Uniform Modification Notice of Required Contract Changes Eff 12.1.25

UHC Certificates of Coverage - Will be posted February 2026

UHC encourages that members use the Certificates of Coverage that are posted to their member portal to ensure they are accessing the plans specific to their employer offerings.

WTIA Tech Premier Plan

WTIA Tech 90 $200 Plan

WTIA Tech 90 $500 Plan

WTIA Tech 90 $750 Plan

WTIA Tech 80 $250 Plan

WTIA Tech 80 $350 Plan

WTIA Tech 80 $500 Plan

WTIA Tech 80 $750 Plan

WTIA Tech 80 $1000 Plan

WTIA Tech 80 $1500 Plan

WTIA Tech 80 $2000 Plan

WTIA Tech 80 $2500 Plan

WTIA Tech 80 $3000 Plan

WTIA Tech 80 $4000 Plan

WTIA Premier HSA $4250 Plan

WTIA HSA $1700 Plan

WTIA HSA $2500 Plan

WTIA HSA $3400 Plan

WTIA HSA $4500 Plan

WTIA Tech E $1000 Plan

WTIA Tech E $2000 Plan

WTIA Tech E $2500 Plan

WTIA Tech E $3000 Plan

WTIA Tech E HSA $1700 Plan

WTIA Tech E HSA $3400 Plan

Medical Marketing Materials

8.1.2025 UHC Welcome Brochure

UHC Welcome Brochure – Spanish

WTIA UHC Overview Brochure

UHC First Choice Wrap In-Network Providers

UHC Member Programs Overview Flyer

8.1.2025 UHC Rewards Program Flyer

8.1.2025 UHC Rewards FAQ

8.1.2025 UHC Vital Medication Program Flyer

8.1.2025 UHC Vital Medication Program List

May 2025 UHC Preventative Drug List

8.1.2025 UHC Virtual Visits Flyer

Virtual Visits FAQ

UHC WA Network Strength Flyer

8.1.2025 Real Appeal Flyer: Weight Management Program

8.1.2025 UHC Optum Home Delivery Rx Flyer

One Pass Select Flyer

One Pass Select Flyer – Member Facing

UHC Commonly Used Forms

WTIA Deductible & OOPM Credit Form

OptumRx Claim Form

UHC Disabled Dependents Certification Form

Authorization for Release of Information Form

Out of Network Medical Claim Form

UHC Employee Assistant Program (EAP)

UHC EAP Employer Presentation

Pre-Member Website (Pharmacy/Provider Lookup)

Nondiscrimination, Languages and Accessibility Notice

2024/2025 Plan Year

UHC Uniform Modification Notice of Required Contract Changes Eff 12.1.24

UHC Certificates of Coverage

WTIA 2024 Tech Premier Plan

WTIA 2024 Tech 90 $200 Plan

WTIA 2024 Tech 90 $500 Plan

WTIA 2024 Tech 90 $750 Plan

WTIA 2024 Tech 80 $250 Plan

WTIA 2024 Tech 80 $350 Plan

WTIA 2024 Tech 80 $500 Plan

WTIA 2024 Tech 80 $750 Plan

WTIA 2024 Tech 80 $1000 Plan

WTIA 2024 Tech 80 $1500 Plan

WTIA 2024 Tech 80 $2000 Plan

WTIA 2024 Tech 80 $2500 Plan

WTIA 2024 Tech 80 $3000 Plan

WTIA 2024 Tech 80 $4000 Plan

WTIA 2024 Premier HSA $4250 Plan

WTIA 2024 HSA $1700 Plan

WTIA 2024 HSA $2500 Plan

WTIA 2024 HSA $3400 Plan

WTIA 2024 HSA $4500 Plan

WTIA 2024 Tech E $1000 Plan

WTIA 2024 Tech E $2000 Plan

WTIA 2024 Tech E $2500 Plan

WTIA 2024 Tech E $3000 Plan

WTIA 2024 Tech E HSA $1700 Plan

WTIA 2024 Tech E HSA $3400 Plan

Medical Marketing Materials

UHC Welcome Brochure

UHC Welcome Brochure – Spanish

WTIA UHC Overview Brochure

UHC First Choice Wrap In-Network Providers

UHC Member Programs Overview Flyer

UHC Rewards Program Flyer

UHC Rewards FAQ

UHC Vital Medication Program Flyer

2024 Vital Medication Program List

2025 Vital Medication Program List

UHC Preventative Drug List

UHC Virtual Visits Flyer

Virtual Visits FAQ

UHC WA Network Strength Flyer

Real Appeal Flyer: Weight Management Program

OptumRx Home Delivery Flyer

One Pass Select Flyer

One Pass Select Flyer – Member Facing

UHC Commonly Used Forms

WTIA Deductible & OOPM Credit Form

OptumRx Claim Form

UHC Disabled Dependents Certification Form

Authorization for Release of Information Form

Out of Network Medical Claim Form

UHC Employee Assistant Program (EAP)

UHC EAP Employer Presentation

Pre-Member Website (Pharmacy/Provider Lookup)

Nondiscrimination, Languages and Accessibility Notice

WTIA Dental Plan Information – Delta Dental of WA

2025/2026 Plan Year

Dental Benefit Summaries

Delta Dental Benefit Summary – WTIA Voluntary 1500

Delta Dental Benefit Summary – WTIA Dental 750

Delta Dental Benefit Summary – WTIA Dental 750 w/ Ortho

Delta Dental Benefit Summary – WTIA Dental 1000

Delta Dental Benefit Summary – WTIA Dental 1000 w/ Ortho

Delta Dental Benefit Summary – WTIA Dental 1500

Delta Dental Benefit Summary – WTIA Dental 1500 w/ Ortho

Delta Dental Benefit Summary – WTIA Dental 2000

Delta Dental Benefit Summary – WTIA Dental 2000 w/ Ortho

Delta Dental Benefit Summary – WTIA Dental 2500

Delta Dental Benefit Summary – WTIA Dental 2500 w/ Ortho

Dental Plan Booklets

Delta Dental Benefit Booklet – WTIA Voluntary 1500

Delta Dental Benefit Booklet Insert eff 5/1/2025 – WTIA Voluntary 1500

Delta Dental Benefit Booklet – WTIA Dental 750

Delta Dental Benefit Booklet Insert eff 5/1/2025 – WTIA Dental 750

Delta Dental Benefit Booklet – WTIA Dental 750 w/ Ortho

Delta Dental Benefit Booklet Insert eff 5/1/2025 – WTIA Dental 750 w/ Ortho

Delta Dental Benefit Booklet – WTIA Dental 1000

Delta Dental Benefit Booklet Insert eff 5/1/2025 – WTIA Dental 1000

Delta Dental Benefit Booklet – WTIA Dental 1000 w/ Ortho

Delta Dental Benefit Booklet Insert eff 5/1/2025 – WTIA Dental 1000 w/ Ortho

Delta Dental Benefit Booklet – WTIA Dental 1500

Delta Dental Benefit Booklet Insert eff 5/1/2025 – WTIA Dental 1500

Delta Dental Benefit Booklet – WTIA Dental 1500 w/ Ortho

Delta Dental Benefit Booklet Insert eff 5/1/2025 – WTIA Dental 1500 w/ Ortho

Delta Dental Benefit Booklet – WTIA Dental 2000

Delta Dental Benefit Booklet Insert eff 5/1/2025 – WTIA Dental 2000

Delta Dental Benefit Booklet – WTIA Dental 2000 w/ Ortho

Delta Dental Benefit Booklet Insert eff 5/1/2025 – WTIA Dental 2000 w/ Ortho

Delta Dental Benefit Booklet – WTIA Dental 2500

Delta Dental Benefit Booklet Insert eff 5/1/2025 – WTIA Dental 2500

Delta Dental Benefit Booklet – WTIA Dental 2500 w/ Ortho

Delta Dental Benefit Booklet Insert eff 5/1/2025 – WTIA Dental 2500 w/ Ortho

Dental Marketing Material

Digital ID Flyer

Delta Orthodontic Takeover Policy

Delta MySmile Online Account Flyer

Delta MySmile Online Account Flyer 2

Delta Dental Benefit Guide

Delta Dental FAQ for WTIA Employers

Overall Health Flyer

Delta Dental FAQ for WTIA Members

Virtual Dentistry Flyer

TotalHealth Wellness Program Flyer

2024/2025 Plan Year

Dental Benefit Summaries

Delta Dental Benefit Summary – WTIA Voluntary 1500

Delta Dental Benefit Summary – WTIA Dental 750

Delta Dental Benefit Summary – WTIA Dental 750 w/ Ortho

Delta Dental Benefit Summary – WTIA Dental 1000

Delta Dental Benefit Summary – WTIA Dental 1000 w/ Ortho

Delta Dental Benefit Summary – WTIA Dental 1500

Delta Dental Benefit Summary – WTIA Dental 1500 w/ Ortho

Delta Dental Benefit Summary – WTIA Dental 2000

Delta Dental Benefit Summary – WTIA Dental 2000 w/ Ortho

Delta Dental Benefit Summary – WTIA Dental 2500

Delta Dental Benefit Summary – WTIA Dental 2500 w/ Ortho

Dental Plan Booklets

Delta Dental Benefit Booklet – WTIA Voluntary 1500

Delta Dental Benefit Booklet Insert eff 5/1/2025 – WTIA Voluntary 1500

Delta Dental Benefit Booklet – WTIA Dental 750

Delta Dental Benefit Booklet Insert eff 5/1/2025 – WTIA Dental 750

Delta Dental Benefit Booklet – WTIA Dental 750 w/ Ortho

Delta Dental Benefit Booklet Insert eff 5/1/2025 – WTIA Dental 750 w/ Ortho

Delta Dental Benefit Booklet – WTIA Dental 1000

Delta Dental Benefit Booklet Insert eff 5/1/2025 – WTIA Dental 1000

Delta Dental Benefit Booklet – WTIA Dental 1000 w/ Ortho

Delta Dental Benefit Booklet Insert eff 5/1/2025 – WTIA Dental 1000 w/ Ortho

Delta Dental Benefit Booklet – WTIA Dental 1500

Delta Dental Benefit Booklet Insert eff 5/1/2025 – WTIA Dental 1500

Delta Dental Benefit Booklet – WTIA Dental 1500 w/ Ortho

Delta Dental Benefit Booklet Insert eff 5/1/2025 – WTIA Dental 1500 w/ Ortho

Delta Dental Benefit Booklet – WTIA Dental 2000

Delta Dental Benefit Booklet Insert eff 5/1/2025 – WTIA Dental 2000

Delta Dental Benefit Booklet – WTIA Dental 2000 w/ Ortho

Delta Dental Benefit Booklet Insert eff 5/1/2025 – WTIA Dental 2000 w/ Ortho

Delta Dental Benefit Booklet – WTIA Dental 2500

Delta Dental Benefit Booklet Insert eff 5/1/2025 – WTIA Dental 2500

Delta Dental Benefit Booklet – WTIA Dental 2500 w/ Ortho

Delta Dental Benefit Booklet Insert eff 5/1/2025 – WTIA Dental 2500 w/ Ortho

Dental Marketing Material

Delta Orthodontic Takeover Policy

Delta MySmile Online Account Flyer

Delta MySmile Online Account Flyer 2

Delta Dental Benefit Guide

Delta Dental FAQ for WTIA Employers

Overall Health Flyer

Delta Dental FAQ for WTIA Members

Virtual Dentistry Flyer

TotalHealth Wellness Program Flyer

WTIA Vision Plan Information – VSP

WTIA Life/AD&D & Disability (LTD & STD) – MetLife

2025/2026 Plan Year

Life/Supp Life/AD&D

Life/Supp Life/AD&D Plan Summaries

Basic Life $25K

Basic Life $50K

Basic Life $100K

Basic Life $250K

Supplemental Life

Life/Supp Life/AD&D Forms

Life Insurance Claim Form

AD&D Claim Form

Statement of Health Form

Supp Life Enrollment Form

Portability Application Form

Life Conversion Form

Life/Supp Life/AD&D Certificates

Basic Life $25K

Basic Life $50K

Basic Life $100K

Basic Life $250K

Supplemental Life

Long Term Disability (LTD)

LTD Plan Summaries

LTD Plan 1 – 180 EP

LTD Plan 2 – 180 EP

LTD Plan 3 – 180 EP

LTD Plan 4 – 180 EP

LTD Plan 1 – 90 EP

LTD Plan 2 – 90 EP

LTD Plan 3 – 90 EP

LTD Plan 4 – 90 EP

LTD Forms

LTD – Employee Statement Claim Form

LTD – Employer Statement Claim Form

LTD – Physician Statement Claim Form

LTD Certificates

LTD Plan 1 – 90 EP

LTD Plan 2 – 90 EP

LTD Plan 3 – 90 EP

LTD Plan 4 – 90 EP

LTD Plan 1 – 180 EP

LTD Plan 2 – 180 EP

LTD Plan 3 – 180 EP

LTD Plan 4 – 180 EP

Short Term Disability (STD)

STD Plan Summaries

STD Plan 1 – 13 WD

STD Plan 2 – 13 WD

STD Plan 3 – 13 WD

STD Plan 4 – 13 WD

STD Plan 1 – 26 WD

STD Plan 2 – 26 WD

STD Plan 3 – 26 WD

STD Plan 4 – 26 WD

STD Forms

STD Certificates

STD Plan 1 – 13 WD

STD Plan 2 – 13 WD

STD Plan 3 – 13 WD

STD Plan 4 – 13 WD

STD Plan 1 – 26 WD

STD Plan 2 – 26 WD

STD Plan 3 – 26 WD

STD Plan 4 – 26 WD

Marketing Material

View

MetLife Supporting Beneficiaries Flyer

MetLife Pregnancy FAQ

MetLife Grief Counseling Flyer

MetLife Travel Assistance Flyer

Will Preparation FAQ – For Supp Life Clients Only

MetLife Contact Sheet

Portability vs. Conversion Flyer

2024/2025 Plan Year

Life/Supp Life/AD&D

Life/Supp Life/AD&D Plan Summaries

Basic Life $25K

Basic Life $50K

Basic Life $100K

Basic Life $250K

Supplemental Life

Life/Supp Life/AD&D Forms

Life Insurance Claim Form

AD&D Claim Form

Statement of Health Form

Supp Life Enrollment Form

Portability Application Form

Life Conversion Form

Life/Supp Life/AD&D Certificates

Basic Life $25K

Basic Life $50K

Basic Life $100K

Basic Life $250K

Supplemental Life

Long Term Disability (LTD)

LTD Plan Summaries

LTD Plan 1 – 180 EP

LTD Plan 2 – 180 EP

LTD Plan 3 – 180 EP

LTD Plan 4 – 180 EP

LTD Plan 1 – 90 EP

LTD Plan 2 – 90 EP

LTD Plan 3 – 90 EP

LTD Plan 4 – 90 EP

LTD Forms

LTD – Employee Statement Claim Form

LTD – Employer Statement Claim Form

LTD – Physician Statement Claim Form

LTD Certificates

LTD Plan 1 – 90 EP

LTD Plan 2 – 90 EP

LTD Plan 3 – 90 EP

LTD Plan 4 – 90 EP

LTD Plan 1 – 180 EP

LTD Plan 2 – 180 EP

LTD Plan 3 – 180 EP

LTD Plan 4 – 180 EP

Short Term Disability (STD)

STD Plan Summaries

STD Plan 1 – 13 WD

STD Plan 2 – 13 WD

STD Plan 3 – 13 WD

STD Plan 4 – 13 WD

STD Plan 1 – 26 WD

STD Plan 2 – 26 WD

STD Plan 3 – 26 WD

STD Plan 4 – 26 WD

STD Forms

STD Certificates

STD Plan 1 – 13 WD

STD Plan 2 – 13 WD

STD Plan 3 – 13 WD

STD Plan 4 – 13 WD

STD Plan 1 – 26 WD

STD Plan 2 – 26 WD

STD Plan 3 – 26 WD

STD Plan 4 – 26 WD

Marketing Material

View

MetLife Supporting Beneficiaries Flyer

MetLife Pregnancy FAQ

MetLife Grief Counseling Flyer

MetLife Travel Assistance Flyer

Will Preparation FAQ – For Supp Life Clients Only

MetLife Contact Sheet

Portability vs. Conversion Flyer

Producer Communication Archive

2025/2026

09.17.25 – 2025/2026 Renewal Broker Communication

09.17.25 – Producer Communication FAQ

03.31.25 – Important: WTIA Health Program Transition to Universal Renewal

Legal Notices

View

2024/2025 WTIA Creditable Coverage Letter

2024/2025 WTIA Creditable Coverage Notice

2025/2026 Summary Plan Description

2024/2025 Summary Plan Description