Instructions to Help You Complete a PERACare 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 Medicare Coverage booklet 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) with Medicare in any of the plans (health, dental, or vision) available through PERACare.

If you are enrolling your spouse and/or dependent child(ren) who do not have Medicare, you should complete the PERACare 2012 Combination Coverage Premium Information/Enrollment Form rather than this Medicare form. Combination premiums are different from Medicare premiums and can also be found in the form.

Medicare Information

Complete this section to provide information on what types of Medicare coverage you, your spouse, and/or dependent child(ren) have (or have applied for). Write your Medicare number (printed on your Medicare card) on the form and send a photocopy of the card(s) to PERA.

Important Additional Medical Questions

Answer the three questions in this section for all enrollees. 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, including premiums, is included in the PERACare 2012 Health Benefits Program Medicare Coverage booklet.

If you are enrolling in Rocky Mountain Health Plans: 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 Rocky Mountain Health Plans at 1-888-281-0720 for provider codes. If you do not complete a provider code, Rocky Mountain Health Plans will send you an ID card without a primary care physician selection, which may delay your ability to access health care services.

If you are enrolling in UnitedHealthcare: 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 UnitedHealthcare at 1-800-610-2660 for provider codes. If you do not complete a provider code, UnitedHealthcare will assign a provider to you.

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 Medicare Coverage booklet.

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 Medicare Coverage booklet. 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.