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Maricopa County Employee Benefits Division
301 W Jefferson St, Suite 3200
Phoenix, AZ 85003
2014 - 2015 Benefits Enrollment Worksheet
Open Enrollment Dates
04/14/2014 - 05/09/2014
Enrollment Instructions:
1. Review this Worksheet. You will be enrolled in the benefits coverage marked with a check
() unless you make a change.
2. Complete this Worksheet before you go online to make benefit changes.
3. Use the boxes on the left-hand side of the Worksheet to indicate the option name, cost, and
provider code (if applicable) for each benefit you select.
4. If you have not previously done so, you must register at https //portal.adp.com. Your
registration pass code is MCAZ-PRISM09.
5. Enroll online at https //portal.adp.com by the last day of Open Enrollment indicated above.
6. If you do not have access to a computer, check with your department HR Liaison for computer
resources that may be available for your use.
7. Paper enrollment or late enrollment will not be accepted. Contact the Employee Benefits
Division at 602-506-1010, then press 4 if you have enrollment questions.
8. For information regarding the benefits offered, visit www.maricopa.gov/benefits or the internal
Intranet at ebc.maricopa.gov/benefits.
9. This Worksheet represents all of your available options.
MCyWA
12BLR 0016
Printed:
Event:
Employee ID:
03/28/2014
Open Enrollment
Dependent Information
You are responsible for adding only eligible dependents and updating any incorrect or incomplete dependent information. The following list displays all
individuals who are currently enrolled in benefits under your plans.
No. Name
Relationship*
0
1
2
5
Birth Date
EE
SP
SC
LG
Sex
Disabled
Medical
Dental
Vision
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
M
F
F
F
*Relationship codes are
EE � Employee, SP � Spouse, CH � Child, SC � Step-Child, LG � Legal Guardian, CO � Court-Order, BN � Beneficiary
Medical with Pharmacy and Behavioral Health
Your Choice
Option Name
Cost
Provider Code*
Coverage Category/Cost Per Pay Period
Employee
Only**
Option Name
Cigna HMO Plan *
UnitedHealthcare PPO Plan
UnitedHealthcare HDHP with H.S.A. Plan
Waived Coverage
$39.35
$49.91
$30.00
Employee plus
Spouse**
Employee plus
Child (ren) **
$70.13
$102.75
$37.41
$57.50
$86.97
$34.10
Employee plus
Family**
$96.20
$142.95
$42.68
* you are required to provide the code or number found in the Online Provider Directory for your Primary Care Provider at the time
you enroll. The link to the Online Provider Directory can be found under the "Open Enrollment" page on the Employee Benefits
home page at www.maricopa.gov/benefits or ebc.maricopa.gov/benefits.
** Cost per pay period does not reflect premium reductions for Biometric Screening, Health Assessment and/or Non-Tobacco Use.
Pharmacy
Pharmacy coverage is provided as part of your enrollment in a County-sponsored medical plan. When you elect medical coverage, you
are automatically enrolled in pharmacy coverage. There is one combined rate for medical, pharmacy, and behavioral health coverage.
Behavioral Health
Behavioral health coverage is provided as part of your enrollment in a County-sponsored medical plan. When you elect medical
coverage, you are automatically enrolled in behavioral health coverage. There is one combined rate for medical, pharmacy and
behavioral health coverage.
Enroll online at https://portal.adp.com by 05/09/2014
12BLR 0016 001 004
MCyWA-ACTIVE
Benefits Enrollment Worksheet
Biometric Screening Premium Reduction
Employees (not including dependents) enrolled in a County-sponsored medical plan who participates in the annual Biometric
Screening may save up to $240 per Plan year on their medical insurance premium. The Biometric Screening consists of
completing a brief personal health history questionnaire as well as having your measurements taken for height, weight, blood
pressure, waist circumference, body fat composition, cholesterol, and glucose levels.
Health Assessment Premium Reduction
Employees (not including dependents) enrolled in a County-sponsored medical plan who participate in the annual Health Assessment
may save up to $240 per Plan year on their medical insurance premium. The Health Assessment is available online through
www.mycigna.com (for all medical plan enrollees ) and consists of a series of questions about your health and lifestyle. Your
confidential responses are then assessed by the online tool to determine your health risks.
Non-Tobacco User Premium Reduction
When employees (and all of their dependents) enrolled in a County-sponsored medical plan have not used tobacco products (regularly
or occasionally) for the past 6 consecutive months, and if employees take, or have previously taken and passed, the saliva test that
detects nicotine presence, they may save up to $240 per Plan year on their medical insurance premium. Tobacco use includes the use
of the following in the last six consecutive months cigarettes, cigars, pipes, snuff, chewing tobacco and any other product containing
nicotine.
Health Savings Account
Your Choice
Annual Goal
When you enroll in the UnitedHealthcare HDHP with H.S.A. Plan you may contribute to your Health Savings Account on an annual
basis. You may contribute up to $3,300 (individual) or $6,550 (family) to your account for calendar year 2014 minus theamount
contributed by Maricopa County. If you are age 55 or older, you may contribute an additional $1,000. Unused balances remain in
your account.
Vision
Coverage Category/Cost Per Pay Period
Your Choice
Option Name
Cost
Employee Only
Option Name
Avesis Vision Plan
Waived Vision
$0.66
Dental
Cost
Provider Code*
Employee plus Employee plus
Child(ren)
Family
$1.45
$1.09
$1.95
Coverage Category/Cost Per Pay Period
Your Choice
Option Name
Employee plus
Spouse
Employee Only
Employee plus
Spouse
Employee plus
Child(ren)
$2.28
$7.47
$14.21
$4.29
$16.43
$31.34
$5.59
$17.80
$33.90
Option Name
Cigna Pre-Paid Dental Plan (DHMO) *
Cigna Dental Plan (PPO)
Delta Dental Plan (PPO)
Waived Dental
Employee plus
Family
$6.44
$22.89
$43.67
* You are required to provide the code or number found in the Online Provider Directory for your Primary Care Dentist at the time you
enroll. The link to the Online Provider Directory can be found under the "Open Enrollment" page on the Employee Benefits home page at
www.maricopa.gov/benefits or ebc.maricopa.gov/benefits.
Enroll online at https://portal.adp.com by 05/09/2014
12BLR 0016 002 004
Benefits Enrollment Worksheet
Additional Life Insurance
Your Choice
Option Name
Basic Life Insurance of 1X your Annual Base Salary is provided to you at no cost. You may elect additional coverage from the
following options. Evidence of Insurability is required for some coverage levels.
Cost
Coverage Level
1X Annual Base Salary
2X Annual Base Salary
3X Annual Base Salary
4X Annual Base Salary
5X Annual Base Salary
Waived
Additional Accidental Death and Dismemberment
Your Choice
Option Name
Cost
Coverage Category/Cost Per Pay Period
Non Tobacco
User
$2.33
$4.66
$6.99
$9.32
$11.66
Basic Accidental Death and Dismemberment (AD&D) Insurance of 1X your Annual Base Salary is provided to you at no cost. You
may elect additional coverage from the following options. Accidental Death and Dismemberment coverage does not require
Evidence of Insurability.
Employee Only
1X Annual Base Salary
2X Annual Base Salary
3X Annual Base Salary
4X Annual Base Salary
5X Annual Base Salary
Waived
Spouse Life Insurance
Option Name
Cost
$4.88
$9.77
$14.65
$19.53
$24.41
Coverage Category/Cost Per Pay Period
Coverage Level
Your Choice
Tobacco User
$0.63
$1.26
$1.89
$2.52
$3.15
Employee Plus
Family
$1.10
$2.21
$3.31
$4.41
$5.51
Coverage Category/Cost Per Pay Period
If there is not a spouse listed on file, the rates on this Worksheet are based on the employee s age. Once your spouse is on file, the
rates will be adjusted based on the spouse s age and tobacco user status. The rates on the Confirmation Statement will be the
adjusted rate. If you are married to a Maricopa County employee, you are not eligible to elect Spouse Life coverage, unless your
spouse is not eligible for benefits. Evidence of Insurabillity is required for some coverage levels.
Coverage Level
$10,000
$20,000
$30,000
$40,000
$50,000
$60,000
$70,000
$80,000
$90,000
$100,000
Waived
Non Tobacco
User
$0.37
$0.74
$1.11
$1.48
$1.85
$2.22
$2.59
$2.96
$3.33
$3.70
Enroll online at https://portal.adp.com by 05/09/2014
Tobacco User
$0.78
$1.55
$2.33
$3.10
$3.88
$4.65
$5.43
$6.20
$6.98
$7.75
12BLR 0016 003 004
Benefits Enrollment Worksheet
Child Life Insurance
Your Choice
Option Name
Cost
Coverage Category/Cost Per Pay Period
If you are married to a Maricopa County employee, your dependent child(ren) can only be covered by one of you under this group
policy. Evidence of Insurabillity is required for some coverage levels.
Cost Per
Pay Period
Coverage Option
$5,000
$10,000
$15,000
$20,000
Waived
$0.25
$0.50
$0.75
$1.00
Short-Term Disability
Your Choice
Option Name
Cost
Coverage Category/Cost Per Pay Period
You may only enroll, increase, decrease or drop coverage from the Short-Term Disability Plan during Open Enrollment. If you
increase your coverage level and you have a pre-existing condition, your benefit payment will be based on the lower benefit
coverage level for 12 months following the effective date of the increase in your coverage.
Coverage Level
Cost Per
Pay Period
40% STD Coverage
50% ST0 Coverage
$7.31
$11.49
Coverage Level
60% STD Coverage
Waived
Cost Per
Pay Period
$19.32
Health Care Flexible Spending Account
Your Choice
Annual Goal
(Pre-Tax Contribution)
When you enroll in the Health Care Flexible Spending Account, you may contribute from $240 to $2,500 for the Plan year. The
annual amount you elect will be divided by 24 pay periods and deductions will be taken from each paycheck.
You will default to no contribution if you do not make an election.
*UnitedHealthcare H0HP enrollees with a Health Savings Account cannot enroll in a Health Care Flexible Spending Account, but
they have the option of electing the Limited Scope Flexible Spending Account. Dental and vision care costs are the only expenses
eligible for reimbursement under the Limited Scope Flexible Spending Account. All other expenses normally eligible for
reimbursement under a "general purpose" Health Care Flexible Spending Account are NOT eligible.
Dependent Care Flexible Spending Account
Your Choice
Annual Goal
(Pre-Tax Contribution)
When you enroll in the Dependent Care Flexible Spending Account for day care expenses, you may contribute from $240 to $5,000
for the Plan year. The annual amount you elect will be divided by 24 pay periods and deductions will be taken from each paycheck.
You are not eligible to enroll if your dependent child is age 13 or older.
You will default to no contribution if you do not make an election.
Employee Assistance Program
The Employee Assistance Program is provided to you at no cost.
Group Legal Services
Coverage Category/Cost Per Pay Period
Your Choice
Option Name
Coverage Option
Cost
Group Legal Services
Waived
Enroll online at https://portal.adp.com by 05/09/2014
Cost Per
Pay Period
$7.87
12BLR 0016 004 004