Instructions to Help You Complete a PERACare Combination Pre-Medicare and Medicare Enrollment/Change Form

Please note: If you have already enrolled in PERACare and are using the form to make a change, complete only the coverage information that you wish to change. Any coverage you are not changing will remain in place.

Side 1 of Form

Your SSN

Print your Social Security number inside the boxes provided.

Complete your full name, date of birth, and daytime telephone number.

Signature

Sign the form. By doing so you are certifying that you have read the PERACare 2012 Health Benefits Program booklets and are agreeing to the terms and conditions of the PERACare program listed in the Signature Certification box.

Effective Date

This is the date that you want health care coverage under PERACare to become effective.

If you are not enrolling at retirement, the effective date should coincide with the date your prior coverage ends or the date you become Medicare-eligible. If the date you want coverage to be effective is different from your retirement effective date, you may have to complete a Certification of Previous Health Care Coverage form (see the PERACare Enrollment Eligibility Chart for details).

Dependent Enrollment Information

Complete this section if you want to enroll your spouse and/or dependent child(ren) in any of the plans (health, dental, or vision) available through PERACare.

Medicare Information

Complete this section for the Medicare participant: you, your spouse and/or dependent child(ren). Write the Medicare number (printed on the Medicare card) on the form and send a photocopy of the card(s) to PERA.

Important Additional Medical Questions

Complete this section for the Medicare participant: you, your spouse and/or dependent child(ren). If you answer "Yes" to any of the questions, PERA may contact you for more information.

Side 2 of Form

Health Plan Selection

Choose one option from the "What do you want to do" section.

Select your coverage level (who you want to enroll in a health plan). If you are enrolling your spouse and/or dependent child(ren), make sure you complete their information.

Select the plan in which you are enrolling. Information about each plan is included in the PERACare Health Benefits Program booklets. Premiums can be found in the PERACare 2012 Combination Coverage Premium Information/Enrollment Form.

If you are enrolling in the Anthem HMO Plan: You must select a primary care physician by completing the provider code section. Provider codes can be found on the provider directory page. You may also call Anthem at 1-877-PERABLU (1-877-737-2258) for provider codes.

Dental Plan Selection

Choose one option from the "What do you want to do" section.

Select your coverage level (who you want to enroll in a dental plan). If you are enrolling your spouse and/or dependent child(ren), make sure you complete their information.

Select the dental plan in which you are enrolling. Information about each plan, including premiums, is included in the PERACare 2012 Health Benefits Program booklets.

If you are enrolling in CIGNA Dental HMO: You must select a dentist for yourself as well as for your spouse and child(ren) (if applicable) by completing the provider code section. Provider codes can be found on the provider directory page. You may call CIGNA Dental at 1-877-635-PERA (7372) for provider code(s). PERA cannot complete your enrollment if you do not provide this information.

Vision Plan Selection

Choose one option from the "What do you want to do" section.

Select your coverage level (who you want to enroll in a vision plan). If you are enrolling your spouse and/or dependent child(ren), make sure you complete their information.

Select the vision plan in which you are enrolling. Information about each plan, including premiums, is included in the PERACare 2012 Health Benefits Program booklets. If you select a coverage level and do not select a plan here, you will be enrolled in VSP PPO#1.

Retirees may e-mail questions to Customer Service or call 1-800-759-7372 or 303-832-9550.