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DEFINED BENEFIT RETIREE SUMMARY
NOVEMBER 2014
Benefits Edition
2015 Annual Enrollment
November 5 – December 5, 2014
November is the time to make changes to your benefits that will take effect January 1,
2015. You must submit any 2015 health enrollment changes (e.g. add, drop or change) by
Friday, December 5, 2014. This Benefits Edition provides you with the 2015 premiums and
plan benefits but also includes information about efforts taken to make sure OUC can
continue to provide affordable and sustainable benefits.
OUC has carefully reviewed our benefits programs to ensure we can continue to offer
comprehensive and sustainable options to employees and retirees. The medical plan, in
particular, has seen a continued rise in costs as the average age and the total number of
retirees increase.
New Pharmacy Manager
To provide more convenience to our employees, retirees and dependents, the OUC Prescription
Plan will be administered by Aetna Pharmacy Management effective January 1, 2015. By
having your pharmacy benefit with Aetna, you will have access to your medical, dental and
pharmacy information on your Aetna Navigator, www.aetnanavigator.com.
New Medical and Prescription Identification Cards
For 2015, Aetna will be mailing a new medical and prescription card by the last week of
December. If you need an extra card, you may print or order medical, pharmacy, and even
dental cards from your Aetna Navigator.
This plan will continue to provide mail order for maintenance prescriptions. As an added
value with our new Aetna Pharmacy, members can go to any CVS and fill their 90-day
prescription at the same price as the mail order co-pay.
Current Retail Pharmacy Prescriptions
If you are currently using a retail pharmacy to get your medicine and have an active
prescription with open refills, effective January 1, 2015, all you need to do is show the
pharmacist your new Aetna card. Don’t forget this step because your pharmacist needs to
know about your new provider, Aetna, effective January 1, 2015. Continue to use your
Express Scripts card for retail prescriptions on or thru December 31, 2014. If you have a new
prescription, take it to your local pharmacy and show your Aetna card.
Current Mail Order Maintenance Prescriptions
To help you make a smooth transition from the Express Scripts mail order service to Aetna,
as of January 1, 2015, your maintenance prescriptions will be transferred to Aetna
Prescription Home Delivery. You must contact Aetna to request your next 90-day refill.
You won’t need to get a new prescription. There are two ways to do this during the
transition:
1. Phone: Call Aetna Pharmacy Member Services toll free at 1-888-RX-AETNA (1888-792-3862). A customer service representative will ask for your member ID,
date of birth and details about your prescription.
2. Online: Log in to www.aetnanavigator.com, your secure member website. Click
on “I want to…Order Medications.”
You will get your medicine 10 to 14 days after Aetna Pharmacy Home Delivery confirms your
request. You can ask for faster delivery and pay an extra charge.
Maintenance Controlled Substances, Prescription Compounds and Expired Prescriptions
Certain controlled substances, prescription compounds and expired prescriptions cannot be transferred from
Express Scripts to Aetna Pharmacy. If you are required to have a new prescription for a controlled substance or
prescription compound, you will receive a letter from Aetna with instructions.
How to Start a New Mail Order Maintenance Prescription
To start your new prescription, follow these steps:
1. Your doctor may fax your prescription(s) to 1-877-270-3317. Only a doctor may fax a prescription.
2. You can mail your prescription along with a completed Mail Order Form which is located at
www.aetnanavigator.com. Click “Aetna Pharmacy” at the top of the page. Then click “Get an Order Form.”
These are the types of services you can receive from the Aetna Navigator/Pharmacy:
• Find plan details like your out-of-pocket costs and what’s covered
• Compare drug costs
• Get medicine mailed straight to your door
• Aetna Preferred Drug (formulary) List
Formulary Prescriptions
You can save on your medicine costs by choosing drugs from the Aetna
Formulary. This is a list of covered drugs Aetna chooses to help keep
members safe and lower costs. You get:
• A broad choice of generic and brand-name drugs
• A stamp of safety by the U.S. Food and Drug Administration
• Regular updates based on the latest medical findings
Most prescriptions on the Express Scripts formulary list are also on the Aetna
formulary list. To view the Aetna formulary list, go to your Aetna Navigator,
www.aetnanavigator.com. With the introduction of new drugs you can access an updated formulary list
throughout the year on Aetna Navigator.
The Patient Protection and Affordable Care Act (Health Care Reform)
Cost Sharing Limitations
There will be significant changes to your 2015 Medical Plan as a result of Health Care Reform which may lower
your overall medical expenses. The maximum amount that you will be responsible to pay in 2015 will now combine
medical and prescription medical expenses. You medical deductible, all medical and prescription co-payments and
co-insurance expenses will add to your calendar year payment limit. Once you have reached the calendar year
payment limit, the OUC Health Plan will pay 100% of applicable in-network health costs. Please remember that
out-of-network expenses are not subject to this payment limit.
Reinsurance Program Fees
The Patient Protection and Affordable Care Act (PPACA) require contributions to be paid by sponsors of selffunded group health plans (such as OUC’s) to fund a Transitional Reinsurance Program. This program, designed
to help stabilize premiums in the individual health insurance market for those with pre-existing conditions, will
be effective from 2014 through 2016. Even though each participant is subject to paying a reinsurance fee, OUC
will pay that fee for you and your dependents. The 2014 fee is $63 per participant in the medical plan for all
employees, retirees and dependents. This cost to OUC is approximately $252,000.
What to expect in 2015
OUC is proud to offer competitive benefits to our employees and retirees. One of the most important is
comprehensive health care for you and your family.
For your 2015 insurance premiums, refer to the 2015 Benefits Edition which is being mailed to you.
Page | 2
Health Benefits Choices …. At a Glance
Medical, Prescription and Dental Plan Design
2015 Medical &
Prescription Options
(In-Network Only)
Core Plan
($1,000 Deductible)
HRA Plan
($3,000 Deductible)
Premium Plan
($300 Deductible)
Routine Adult Physical
100%
100%
100%
Routine Well Child
Preventive Women
100%
100%
100%
100%
100%
100%
Primary Care Office Visit
2014: $20 co-pay
2015: $25 co-pay
$50 co-pay
$20 co-pay
Specialist Office Visit
$45 co-pay
$65 co-pay
$35 co-pay
Urgent Care
$65 co-pay
$35 co-pay
Convenience Clinics
(Take Care Clinic, Minute Clinic)
$45 co-pay
2014: $20 co-pay
2015: $25 co-pay
$50 co-pay
$20 co-pay
Diagnostic/Lab & X-ray
100%; deductible waived
100%; deductible waived
100%; deductible waived
Outpatient Surgery
80%; deductible waived
80%; deductible waived
80%; deductible waived
Emergency Room
80%; deductible waived
80%; deductible waived
80%; deductible waived
Deductible
$1,000 Individual
$3,000 Family
$3,000 Individual
$9,000 Family
$300 Individual
$900 Family
2014: $9,000/$16,000
2014: $11,000/$22,000
2014: $6,550/$10,400
2015: $6,600/$13,200*
2015: $6,600/$13,200*
2015: $4,500/$9,000*
80% after deductible
80% after deductible
80% after deductible
Inpatient Hospital
80% after deductible
80% after deductible
80% after deductible
Outpatient Hospital-Facility
80% after deductible
80% after deductible
80% after deductible
Non-Emergency Care in
Emergency Room
50% after deductible
50% after deductible
50% after deductible
Aetna Specialty Pharmacy
80% after deductible
80% after deductible
80% after deductible
Aetna Prescription Drugs
Retail:
$10/$50/$75
Mail Order: $20/$100/$150
Retail:
$10/$50/$75
Mail Order: $20/$100/$150
Retail:
$10/$30/$45
Mail Order: $20/$60/$90
Annual Health Reimbursement
Account (HRA)
n/a
$925
Combined Medical & Prescription
Calendar Year Payment Limit &
Medical Deductible
Individual/Family
Diagnostic X-ray Complex Imaging
Services (MRI)
n/a
* only in-network medical deductible, all medical and prescription copayments and coinsurance expenses will reduce
the calendar year payment limit
PPO DENTAL PLAN DESIGN
Benefits
In-Network Benefit
Out-of-Network Benefit
Deductible (Individual/Family)
$50 / $100
$50 / $100
Preventive Services
100%
100%
Basic Services
80%
80%
Major Services
50%
50%
Calendar Year Max
$1,500
$1,500
Orthodontia Lifetime Maximum
60% up to $1,500
60% up to $1,500
Page | 3
CHANGE IN STATUS
Choose your options carefully. The election you make for 2015 will be for the entire year. IRS rules will not
allow you to add or drop your dependent(s) during the plan year unless you experience a “qualifying status
change.” You are responsible to inform HR/Benefits within 30 days of the qualifying status change. The
qualifying status changes are:
• Marriage or fulfillment of all OUC same-sex domestic partner relationship requirements
• Divorce or termination of same-sex domestic partner relationship
• Birth or adoption of a child or change in custody of your child
• Termination of employment of your eligible dependent(s) that results in a change to benefits
• Significant change in coverage due to your spouse’s or domestic partner’s health care coverage
attributable to your spouse’s or domestic partner’s employment
• Change in employment status that results in a change to benefits
• Loss or gain of dependent eligibility
• Death of spouse, domestic partner or other dependent
DEPENDENT ELIGIBILITY & VERIFICATION
Please review the eligible dependent definition carefully to ensure that the dependents you wish to cover
will continue to meet the eligibility requirements during 2015. If you are eligible and you elect medical,
prescription and dental for yourself, you also may elect to cover your eligible dependents.
Eligible dependents include:
• Your legal spouse or same sex domestic partner
• Children under age 26 who:
° Are your biological children; or
° Are your stepchildren or domestic partner’s
children; or
° Are your legally adopted children; or
° Are your foster children; or
° Is a child for whom the employee is the courtordered legal guardian; or
° Live with you and whose parent is your child
and is covered as a dependent under the
plan
• Your unmarried child(ren) age 26 or older
if fully handicapped:
° He or she is not able to earn his or her own
living because of mental retardation or a
physical handicap which started prior to the
date he or she reaches the maximum age for
dependent children under your plan; and
° He or she depends on you for support,
maintenance and must live with you.
OUC KNOW YOUR NUMBERS WELLNESS PROGRAM
You are encouraged to continue to be active in the OUC Wellness Program by participating in education
opportunities offered by OUC such as community walks and other exercise programs. Your medical plan,
Aetna Choice POS II, plan offers health programs that help you become fit and healthy. The program also
offers direct access to registered nurses to answer questions about conditions and treatment. The
disease management program provides support to help people understand and stick with their
treatment. These programs and others not only help you and your family maintain a healthy lifestyle,
they help OUC lower the cost of medical claims. We are planning a 2015 Wellness Expo which will take
place in January. Stay tuned for more details.
RETIREE LIFE INSURANCE
OUC provides retiree term life insurance at no cost to you. The OUC Retiree Life Insurance for 2015 is still
$10,000. Please contact HR/Benefits if you would like to change your beneficiary designation.
Page | 4
HAVE YOU BECOME DISABLED OR REACHED THE AGE OF
Reminder to Retirees and Dependent(s) of Retirees Who Become Disabled or Approaching Age 65
If you become eligible for Medicare or disabled during your retirement years, it is your responsibility to enroll in
Medicare. Medicare becomes your primary insurance coverage and OUC (Aetna) retiree health insurance coverage will
become secondary. If you do not enroll in the Medicare insurance coverage, the OUC (Aetna) retiree health insurance
coverage will only be your supplementary insurance coverage.
Because OUC medical insurance coverage will become a supplement to your insurance coverage, do not decline Part B
(Medicare insurance). You do not want to be without primary insurance coverage.
In an effort to comply with Medicare regulations and continue to provide you and/or your dependent(s) the maximum
benefit available, you must do the following:
1. When you and/or your dependent(s) have become disabled or approaching the age of 65, you must contact OUC
immediately.
2. Member must inform Medicare that Medicare is primary and Aetna is secondary RETIREE insurance coverage.
3. Member must inform Aetna that Medicare is primary health coverage and Aetna is secondary health coverage.
Member must also enroll in Aetna’s electronic filing system with Medicare called Aetna Medicare Direct Program.
4. Upon Medicare enrollment, member must decide to keep or drop OUC (Aetna) dental insurance coverage.
5. Once you receive your Medicare card, you must send a copy of the Medicare card immediately to HR/Benefits.
Medicare is our country’s health insurance program for people age 65 or older. Certain people younger than age 65
can qualify for Medicare, too, including those who have disabilities and those who have permanent kidney failure or
amyotrophic lateral sclerosis (Lou Gehrig’s disease). Medicare has four parts:
• Part A – Hospital insurance that helped you pay for inpatient care in a hospital or skilled nursing facility, some home
health care and hospice care.
• Part B – Medical insurance that helps pay for doctors’ services and many other medical services and supply that are
not covered by hospital insurance.
• Part C (optional) – Medicare Advantage plans that are available in many areas.
• Part D (optional) – Prescription drug coverage that helps pay for medications doctors prescribe for treatment.
ADDITIONAL MEDICARE INFORMATION
WHEN SHOULD I APPLY?
If you are already getting Social Security retirement or Social Security disability benefits or railroad retirement checks,
you will be contacted by Medicare a few months before you become eligible for Medicare. You will be enrolled in
Medicare Parts A and B automatically. If you are not getting Social Security retirement benefits, you should contact
Medicare about three months before your 65th birthday to sign up. Please check with Medicare for special enrollment
situations.
INITIAL ENROLLMENT PERIOD FOR PART B
When you first become eligible for Part A, you have a seven month period (your initial enrollment period) in which
to sign up for medical insurance (Part B). A delay on your part will cause a delay in coverage and result in higher
premiums. If you are eligible at age 65, your initial enrollment period begins three months before your 65th birthday,
includes the month you turn age 65 and ends three months after that birthday. If you are eligible for Medicare
based on disability or permanent kidney failure, your initial enrollment period depends on the date your disability or
treatment began.
SPECIAL ENROLLMENT PERIOD FOR PEOPLE COVERED UNDER AN EMPLOYER GROUP HEALTH PLAN
If you are 65 or older and working and are covered under a group health plan, you have a “special enrollment period”
in which to sign up for Medicare Part B. This means that you may delay enrolling in Medicare Part B without having to
wait for a general enrollment period and paying the 10 percent premium surcharge for late enrollment as long as you
remain working. Please contact Medicare for detailed information.
MEDICARE CONTACT INFORMATION
Toll free number: 1.800.MEDICARE (1.800.633.4227)
Page | 5
Website: www.medicare.gov
TTY: 1.877.486.2048
IMPORTANT CREDITABLE COVERAGE (RETIREES) NOTICE FROM OUC
About Your Prescription Drug Coverage and Medicare
This is an important notice for retirees and/or dependents whom may be approaching 65 years of age or has just become disabled
and will be eligible for Medicare enrollment.
Please read this notice carefully and keep it where you can find it. This notice has information about your current prescription drug
coverage with OUC and about your options under Medicare’s prescription drug coverage. This information can help you decide
whether or not you want to join a Medicare drug plan. If you are considering joining, you should compare your current coverage,
including which drugs are covered at what cost, with the coverage and costs of the plans offering Medicare prescription drug
coverage in your area. Information about where you can get help to make decisions about your prescription drug coverage is at the
end of this notice.
There are two important things you need to know about your current coverage and Medicare’s prescription drug coverage:
1. Medicare prescription drug coverage became available in 2006 to everyone with Medicare. You can get this coverage if you join
a Medicare Prescription Drug Plan or join a Medicare Advantage Plan (like an HMO or PPO) that offers prescription drug
coverage. All Medicare drug plans provide at least a standard level of coverage set by Medicare. Some plans may also offer more
coverage for a higher monthly premium.
2. OUC has determined that the prescription drug coverage offered by the OUC Group Health Plan is, on average for all plan
participants, expected to pay out as much as standard Medicare prescription drug coverage pays and is therefore considered
Creditable Coverage. Because your existing coverage is Creditable Coverage, you can keep this coverage and not pay a higher
premium (a penalty) if you later decide to join a Medicare drug plan.
When Can You Join A Medicare Drug Plan?
th
th
You can join a Medicare drug plan when you first become eligible for Medicare and each year from October 15 to December 7 .
However, if you lose your current creditable prescription drug coverage, through no fault of your own, you will also be eligible for a
two (2) month Special Enrollment Period (SEP) to join a Medicare drug plan.
What Happens To Your Current Coverage If You Decide to Join A Medicare Drug Plan?
If you decide to join a Medicare drug plan, your current OUC coverage will not be affected. You can keep this coverage if you elect
Part D and this plan will coordinate with Part D coverage. To understand how Medicare will coordinate, you
may view the Medicare’s “Who Pays First” guide for additional information on coordination of benefits (the guide can be found at:
http://www.medicare.gov/publications/pubs/pdf/02179.pdf).
OUC PRESCRIPTION PLAN CO-PAYS
Prescription Plan Options
30-Day Supply – Retail Pharmacy
Generic/Formulary/ Non-Formulary
90-Day Supply – Home Delivery
Generic/Formulary/ Non-formulary
Core Plan
HRA Plan
Premium Plan
$10/$50/$75
$10/$50/$75
$10/$30/$45
$20/$100/$150
$20/$100/$150
$20/$60/$90
When Will You Pay A Higher Premium (Penalty) To Join A Medicare Drug Plan?
You should also know that if you drop or lose your coverage with OUC and don’t join a Medicare drug plan within 63 continuous days
after your current coverage ends, you may pay a higher premium (a penalty) to join a Medicare drug plan later.
If you go 63 continuous days or longer without creditable prescription drug coverage, your monthly premium may go up by at least
1% of the Medicare base beneficiary premium per month for every month that you did not have that cover- age. For example, if
you go nineteen months without creditable coverage, your premium may consistently be at least 19% higher than the Medicare
base beneficiary premium. You may have to pay this higher premium (a penalty) as long as you have Medicare prescription drug
coverage. In addition, you may have to wait until the following October to join.
For More Information About This Notice Or Your Current Prescription Drug Coverage…
Contact the person listed below for further information. NOTE: You’ll get this notice each year. You will also get it before the next
period you can join a Medicare drug plan, and if this coverage through OUC changes. You also may request a copy of this notice at
Page | 6
any time.
For More Information About Your Options under Medicare Prescription Drug Coverage…
More detailed information about Medicare plans that offer prescription drug coverage is in the “Medicare & You” hand- book. You’ll
get a copy of the handbook in the mail every year from Medicare. You may also be contacted directly by Medicare drug plans.
For more information about your options under the Medicare prescription drug coverage:
• Visit www.medicare.gov
• Call your State Health Insurance Assistance Program (see the inside back cover of your copy of the “Medicare & You” handbook
for their telephone number) for personalized help,
• Call 1.800.MEDICARE (1.800.633.4227). TTY users should call 1.877.486.2048.
If you have limited income and resources, extra help paying for Medicare prescription drug coverage is available. For
information about this extra help, visit Social Security on the web at www.socialsecurity.gov, or call them at 1.800.772.1213
(TTY 1.800.325.0778).
Remember: Keep this Creditable Coverage Notice. If you decide to join one of the Medicare drug plans, you may be required to
provide a copy of this notice when you join to show whether or not you have maintained creditable coverage and whether or not
you are required to pay a higher premium (a penalty).
Date:
Contact-Position/Office:
Name of Entity/Sender:
Address:
10/31/2014
Janie L. Wallace, HR Administrator, Phone Number: 407.434.2041
Orlando Utilities Commission
100 West Anderson Street, Orlando, Florida 32801
2015 NOTICE
OUC SUMMARY OF MATERIAL MODIFICATIONS (SMM)
Effective January 1, 2015
This Summary of Material Modification (SMM) provides a recap of 2015 changes to the OUC
Flexible Benefits (Medical) Plan and other pertinent notifications. This document should be
retained with your other benefits information. The summary plan descriptions are being revised to
reflect these changes and will be posted on the OUC Retiree website (www.ouc.com/retiree).
Co-pays
Pharmacy Manager
Combined Medical and Prescription
Calendar Year Payment Limits
Individual/Family
These limits include the medical
Core Plan Primary Care Office and Convenience Clinics Visit:
from $20 co-pay to $25 co-pay
From: Express Scripts
To: Aetna Pharmacy
Core Plan
HRA (High Deductible) Plan
Premium Plan
2014: $9,000/$16,000
2014: $11,000/$22,000
2014: $6,550/$10,400
2015: $6,600/$13,200
2015: $6,600/$13,200
2015: $4,500/$9,000
REMINDERS
• If you or your dependent becomes Medicare
• Update your beneficiary designation for your life
eligible, contact OUC HR/Benefits immediately.
insurance.
• Dental coverage ends when you become Medicare • In 2015, the DB Retiree’s COLA will be combined
eligible, you must re-enroll with HR/Benefits to
with their pension benefit. The COLA increase is
continue coverage.
1.5% for eligible DB Retirees, effective January 1,
• Medicare Open Enrollment is October 15th to
2015.
December 7th.
• Employee Utility Rate Program changes will take
• If your child is ineligible for any OUC benefits, it is
effect 1/1/15.
your responsibility to contact HR/Benefits.
• If you are making any changes (e.g. add,
• Update your address and phone number.
drop or change coverage option), submit the
• Add or update your e-mail address to receive the
2015 Health Enrollment/Change form to
OUC Update and Retiree eNewsletter.
HR/Benefits by Friday, December 5, 2014.
Page | 7
KEY CONTACTS
OUC’s HR/Benefits staff is here to assist you. If you have any questions concerning your
OUC Benefits, please contact the following staff:
407.434.2284
Human Resources/Benefits ([email protected])
Human Resources/Benefits Fax
407.434.2212
OUC HR/Benefits, P O Box 3193, Orlando, FL 32802
407.434.2042
Lara Rose Tierney, Sr. HR Specialist ([email protected])
Sonia P. Boyce, Sr. HR Specialist ([email protected])
407.434.2020
Rowena G. McMurray, Sr. HR Specialist ([email protected])
407.434.2019
Alison Roy, Wellness Coordinator ([email protected])
407.434.2039
Janie Wallace, HR Administrator ([email protected])
407.434.2041
CONTACT LIST:
Aetna Medical Choice POS II
Aetna Dental – PPO
Aetna Navigator
Aetna Pharmacy Management
Aetna Prescription Home Delivery (mail-order)
Aetna Specialty Pharmacy (ASRx)
www.aetnaspecialtypharmacy.com
Aetna Hearing Discount Program
Aetna Vision Discount Program
Health Reimbursement Account (HRA)
P&A Group
Aetna Resources for Living Employee Assistance Program
(EAP) www.mylifevalues.com
Wells Fargo (Defined Benefit (DB) Plan)
1.888.266.5519
1.877.238.6200
www.aetnanavigator.com
1.888.792.3862
1.888.792.3862
Fidelity Investment
Defined Contribution(DC)/Supplemental Retirement Plan(SRP)
Voya Financial Partners
www.ingretirementplans.com
Nationwide Retirement Solution
www.nrsretire.com
OUC Retiree Website
www.ouc.com/retiree
Medicare
www.medicare.gov
1.800.430.2363
www.fidelity.com/atwork
407.252.3151 or
1.800.215.1918
1.863.258.0321
Sandy Andaverde
Social Security Administration
www.ssa.gov
Page | 8
1.866.782.2779
1.888.432.7464
1.800.793.8616
1.800.688.2611
www.padmin.com/
1.800.272.7252
Log On: ouc Password: ouc
1.877.877.1207
[email protected]
1.800.633.4227
1.800.772.1213
OUC Retiree Health Insurance Enrollment/Change form
IF MAKING ENROLLMENT CHANGES, RETURN FORM TO HR/BENEFITS BY FRIDAY, DECEMBER 5, 2014.
RETIREE OR SURVIVING DEPENDENT
LAST NAME
(please print clearly)
FIRST NAME
MI SSN
HOME ADDRESS (APT. #)
CITY
CONTACT PHONE #
E-MAIL
STATE
ZIP CODE
HEALTH INSURANCE COVERAGE ELECTION
NOTE: The PLAN option RETIREE chooses is the same Plan for eligible dependent(s).
RETIREE COVERAGE OPTIONS
(CHECK BOX)
CORE PLAN ($1000 deductible)
HRA PLAN ($3000 deductible)
PREMIUM PLAN ($300 deductible)
RETIREE
NOT MEDICARE (MC)
RETIREE
MEDICARE (MC)






DEPENDENT COVERAGE
NOT MC DEPENDENT MC DEPENDENT NOT MC FAMILY
SURVIVING DEPENDENT
COVERAGE (CHECK BOX)
NOT MC DEPENDENT MC DEPENDENT NOT MC FAMILY

(CHECK BOX)
CORE PLAN ($1000 deductible)
HRA PLAN ($3000 deductible)
PREMIUM PLAN ($300 deductible)











MC FAMILY

MC FAMILY



DENTAL - MEDICARE ELIGIBLE RETIREE and/or DEPENDENT(S)
Retiree Dental
✔

Dependent Dental
✔

Retiree & Dependent Dental
✔

Retiree & Family
✔

ENROLLMENT Of ELIGIBLE DEPENDENT(S) please print
RELATIONSHIP CODE: SP=Spouse, S=Son, D=Daughter, SS=Step-Son, SD=Step-Daughter, GS=Grandson,
GD=Granddaughter, DP=Domestic Partner , DPS=DP Son, DPD=DP Daughter
ADD/DROP RELATIONSHIP
LAST NAME
FIRST NAME
MI
TURN PAGE TO COMPLETE!
Page | 9
SSN
DATE OF BIRTH
HEALTH INSURANCE COVERAGE ENROLLMENT INFORMATION
IF MAKING ENROLLMENT CHANGES, RETURN THIS FORM TO HR/BENEFITS BY FRIDAY, DECEMBER 5, 2014.
 You may ADD or DROP dependents or CHANGE COVERAGE OPTION on this form.
 You have the choice to Elect or Decline OUC’s Health Insurance Coverage.
 To add a dependent, write an A, dependent information and forward to HR/Benefits the required
documents.
 To drop a dependent, write a D, reason for dropping, and the dependent information.
 Eligible dependents include:
o Your legal spouse or same sex domestic partner
o Children under age 26 who are your biological children; or are your stepchildren or domestic
partner’s children; or are your legally adopted children; or are your foster children; or is a child
for whom the retiree is the court ordered legal guardian; or live with you and whose parent is
your child and is covered as a dependent under the plan; or is fully handicapped and the child
is not able to earn his/her own living because of mental retardation or a physical handicap
which started prior to the date he/she reaches the maximum age for dependent children
under your plan and he/she depends chiefly on you for support and maintenance and must
live with you.
 On an annual basis, a child who lives with you and whose parent is your child and is covered as a
dependent under the plan must complete the Dependent Eligibility Questionnaire Form.
 If adding dependent(s): copy of social security card(s) and birth certificate(s) must be provided. If
adding spouse marriage certificate must also be provided. If you are adding a same sex domestic
partner or same sex domestic partner and partner’s eligible child(ren), the Domestic Partner Affidavit
Forms must be completed, notarized and returned to HR/Benefits in order to commence coverage.
 When you become Medicare eligible you must enroll in Medicare Part A and Part B. OUC medical
insurance coverage will become secondary and dental insurance coverage will become optional.
 If you and/or your dependent become Medicare eligible and want to enroll in dental coverage for a
premium cost, please complete this form and check the Dental box that applies to you. Dental
coverage must remain in effect for a minimum of two (2) years.
 During the rest of the plan year, a change to your enrollment can only be made if the change falls
into the definition of a qualifying status change. It is the retiree’s responsibility to inform
HR/Benefits of a qualifying status change within 30 days of change date.
 Mail or fax (407.434.2212) your signed form(s): OUC HR/Benefits, PO BOX 3193, Orlando, FL 32802.
DECLINE OUC HEALTH PLAN
I do not want to enroll myself and (if applicable) dependents in the OUC Health Insurance Coverage.
I
understand I will not have the opportunity to enroll again unless I have a qualifying event during the Plan
Year or at annual enrollment and I must provide proof of other health insurance coverage. Please sign and
date below.
RETIREE AUTHORIZATION
I hereby elect the plan(s) indicated above. I understand that this election applies to the retiree and/or any
covered dependent. I authorize OUC to adjust the monthly health deduction in my pension benefit or if
applicable OUC will invoice for the monthly amount necessary to cover my contributions for medical and/
or dental coverage. I understand that if I cease to make the required monthly payments, coverage will be
dropped. This authorization will remain in effect for Plan Year 2015. My signature below affirms that all information and statements provided on this form are full, complete and true to the best of my knowledge.
Retiree (or Surviving Dependent) Signature: _____________________________________ Date: __________
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