S.C. PEBA Retiree packet │ 122019

To: Individuals eligible for retirement

From: S.C. Public Employee Benefit Authority

RE: Retiree insurance benefits for employee and their eligible dependents

_____________________________________________________________________________________

Before you retire, you need to consider how retirement may affect one of your most important assets, your insurance coverage. Eligibility for retirement is not the same as eligibility for retiree insurance coverage. If you retire from a participating employer (state agency, public school district, higher education institution or optional employer), you may be eligible to:

• Continue or enroll in health insurance with prescription drug coverage. If you or your dependent areeligible for Medicare, you should enroll in the Medicare Supplemental Plan.

• Continue or enroll in dental insurance.• Continue or enroll in the State Vision Plan.• Convert your $3,000 Basic Life insurance policy to an individual policy.• Continue your Optional Life insurance or convert it to an individual policy.• Convert any Dependent Life insurance you have to an individual policy.• Continue Supplemental Long Term Disability Insurance (in certain instances).

This packet contains the following information to help you make informed decisions about your insurance when you do retire:

• An Employment Verification Record form to confirm your eligibility for state retirement insurancebenefits;

• Retiree Eligibility, Funding flyers (one for state agency, public school district, and higher educationinstitution employees and the other for employees of optional employers); and

• Information on your prescription drug coverage when you enroll as a retiree.

Applying for coverage Retiree insurance coverage is not automatic. To enroll in retiree insurance, you will first need to confirm your eligibility for retiree group insurance by completing and submitting an Employment Verification Record to PEBA. This may be done up to six months prior to your anticipated retirement date. Determining retiree insurance eligibility is complicated and only PEBA can make that determination. It is very important to contact PEBA before making final arrangements for retirement.

If PEBA determines that you are eligible for retiree insurance coverage, you must complete and submit the Retiree Notice of Election and any other applicable forms within 31 days of your retirement date. The Retiree Notice of Election form is available on PEBA’s website at https://www.peba.sc.gov/assets/retireenoe.pdf. These completed forms should be submitted to PEBA if you work for a state agency, public school district or higher

S.C. PEBA Retiree packet │ 122019

education institution. These forms may be submitted to your employer’s benefits office if you work for an optional employer.

At retirement, MetLife will mail you a conversion/continuation packet. The packet will include instructions for your options. Call MetLife at 888.507.3767 if you do not receive their packet.

Please refer to the Retiree group insurance chapter of the Insurance Benefits Guide for a detailed description of benefits for retirees. If you are eligible for Medicare, please refer to the Insurance Coverage for the Medicare-eligible Member guide. Both of these publications are available on PEBA’s website at www.peba.sc.gov/iresources.html.

Retiree Insurance Eligibility, Funding

This document does not constitute a comprehensive or binding representation regarding the employee benefits offered by PEBA. The terms and conditions of insurance plans offered by PEBA are set out in the applicable plan documents and are subject to change. The language on this flyer does not create any contractual rights or entitlements for any person. PEBA complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 888.260.9430. 注意：如果您使用繁體中文，您可以免費獲得語言援助服務。請致電 888.260.9430

SCPEBA 082019 | Expires 12312020Data classification: public information

When reviewing the charts, keep these things in mind:• For any retiree coverage, your last five years of employment must have been served consecutively in a full-

time, insurance-eligible permanent position with an employer that participates in the State Health Plan.

• Changing jobs could effect your eligibility for funding. The information on Page 2 applies only if your last employer prior to retirement is a state agency, state institution of higher education, public school district or other employer that participates in the state’s Retiree Health Insurance Trust Fund. Contact your employer if you are unsure whether it participates in the Retiree Health Insurance Trust Fund.

• To receive state funding toward your premiums, your last five years of employment must have been in service with a state agency, state institution of higher education, public school district or other employer that participates in the state’s Retiree Health Insurance Trust Fund. Early retirement from the South Carolina Retirement System under the 55/25 provision will delay your eligibility for funding.

• If the charter school for which you work does not participate in a PEBA-administered retirement plan, and you meet the eligibility requirements for retiree group insurance, employer funding, if any, is at the discretion of your charter school.

• Earned service credit is time earned and established in one of the defined benefit pension plans PEBA administers; time worked while participating in the State Optional Retirement Program (State ORP); or time worked for an employer that participates in the State Health Plan, but not the retirement plans PEBA administers. Earned service credit does not include any purchased service credit not considered earned service in the retirement plans (e.g., non-qualified service.)

• For State ORP participants and members whose employer does not participate in a PEBA-administered retirement plan, eligibility is determined as if the participant were a member of the South Carolina Retirement System.

For members who work for a state agency, state institution of higher education or public school districtEligibility for retiree group insurance is not the same as eligibility for retirement. Determining retiree insurance eligibility is complicated, and only PEBA can make that determination. It is very important to contact PEBA before making final arrangements for retirement.

As an active employee, your employer pays part of the cost of your health and dental insurance. When you retire, several factors determine if you pay all or part of your insurance premiums. These factors include your years of earned service credit, the type of agency from which you retire and the date you were hired into an insurance-eligible position.

The charts on the back of this page illustrate eligibility and funding guidelines for retiree group insurance.

Employees hired into an insurance-eligible position before May 2, 2008

Retirement statusEarned service credit with an employer participating in the

State Health PlanResponsibility for paying premiums

Left employment after reaching service or disability retirement eligibilityLearn more about retirement eligibility at www.peba.sc.gov.

Five years, but less than 10 yearsYou pay the full premium (employee and employer share).

10 or more yearsYou pay only the employee share of the premium.

Left employment before reaching retirement eligibility

Less than 20 yearsYou are not eligible for retiree insurance coverage.

20 or more yearsYou pay only the employee share of the premium at retirement.

Employees hired into an insurance-eligible position on or after May 2, 2008

Retirement statusEarned service credit with an employer participating in the

State Health PlanResponsibility for paying premiums

Left employment after reaching service or disability retirement eligibilityLearn more about retirement

eligibility at www.peba.sc.gov.

Five years, but less than 15 yearsYou pay the full premium (employee and employer share).

15 years, but less than 25 yearsYou pay the employee share of the premium and 50% of the employer share of the premium.

25 or more yearsYou pay only the employee share of the premium.

Left employment before reaching retirement eligibility

Less than 20 yearsYou are not eligible for retiree insurance coverage.

20 years, but less than 25 years You pay the employee share of the premium and 50% of the employer share of the premium at retirement.

25 or more yearsYou pay only the employee share of the premium at retirement.

Retiree Insurance Eligibility, Funding

This document does not constitute a comprehensive or binding representation regarding the employee benefits offered by PEBA. The terms and conditions of insurance plans offered by PEBA are set out in the applicable plan documents and are subject to change. The language on this flyer does not create any contractual rights or entitlements for any person. PEBA complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 888.260.9430. 注意：如果您使用繁體中文，您可以免費獲得語言援助服務。請致電 888.260.9430

SCPEBA 082019 | Expires 12312020Data classification: public information

When reviewing the chart, keep these things in mind:• Your last five years of employment must have been served consecutively in a full-time, insurance-

eligible permanent position with an employer that participates in the State Health Plan.

• Changing jobs could affect your eligibility for funding. The information on Page 2 applies only if your last employer prior to retirement is an optional employer or other employer that does not participate in the state’s Retiree Health Insurance Trust Fund. Contact your employer if you are unsure whether it participates in the Retiree Health Insurance Trust Fund.

• Earned service credit is time earned and established in one of the defined benefit pension plans PEBA administers; time worked while participating in the State Optional Retirement Program (State ORP); or time worked for an employer that participates in the State Health Plan, but not the retirement plans PEBA administers. Earned service credit does not include any purchased service credit not considered earned service in the retirement plans (e.g., non-qualified service).

• If your employer does not participate in a PEBA-administered retirement plan, your eligibility is determined as if you were a member of the South Carolina Retirement System.

For members who work for optional employers, such as county governments and municipalitiesEligibility for retiree group insurance is not the same as eligibility for retirement. Determining retiree insurance eligibility is complicated, and only PEBA can make that determination. It is very important to contact PEBA before making final arrangements for retirement.

As an active employee, your employer pays part of the cost of your health and dental insurance. As a retiree who meets the eligibility requirements for retiree group insurance, your employer determines if you pay all or part of your insurance premiums. Premiums for optional employers may vary. To verify your rates, contact your employer.

The chart on the back of this page illustrates eligibility and funding guidelines for retiree group insurance.

Employees hired into an insurance-eligible position

Retirement statusEarned service credit with an employer participating in the

State Health PlanResponsibility for paying for premiums

Left employment after reaching service or disability retirement eligibilityLearn more about retirement eligibility at www.peba.sc.gov.

At least five yearsYour portion of the premium, up to the full amount of the employee and employer share, is at your employer’s discretion.

Left employment before reaching retirement eligibility

Less than 20 yearsYou are not eligible for retiree insurance coverage.

20 or more yearsYour portion of the premium, up to the full amount of the employee and employer share, is at your employer’s discretion.

S.C. PEBA Retiree packet │ 122019

Your prescription drug coverage when you enroll in the State Health Plan as a retiree

1. It is important to send your Retiree Notice of Election form to PEBA at least 31 days before your retirement date. Once the Retiree Notice of Election form is processed by PEBA, it may take up to 10 business days to activate your prescription benefits as a retiree.

2. PEBA automatically enrolls Medicare‐eligible retirees and their Medicare‐eligible dependents in Express Scripts Medicare. This drug program is a Medicare Part D prescription drug program. PEBA does not charge an additional premium for prescription drug coverage.

3. New prescription ID cards will be sent to each Express Scripts Medicare participant. If you (or your dependent) are not eligible for Medicare, you will not receive a new prescription ID card.

4. If you (or your dependent) are eligible for Medicare, you will receive a letter from Express Scripts, the State Health Plan’s pharmacy benefits manager, when your prescription drug coverage is activated. If you do not want to remain enrolled in Express Scripts Medicare, you may opt out by calling Express Scripts by the deadline in the letter. Typically, a member has 21 days to opt out. If a member opts out, he will automatically be enrolled in the non‐Medicare prescription drug program offered by PEBA.

5. If you enroll in prescription drug coverage with another Medicare Part D plan (not the State Health Plan), you will lose all prescription drug benefits with the State Health Plan. Your monthly health premiums will remain the same.

6. For most members, Express Scripts Medicare is more advantageous than the non‐Medicare drug program offered to active employees.

S.C. PEBA Retiree packet │ 122019

Advantages of Express Scripts Medicare Express Scripts Medicare offers additional benefits to members. Some of the additional benefits are:

• Lower drug costs: The formulary, the list of drugs covered, and the tier ratings for the non‐Medicare plan are determined by PEBA; while the formulary and tier ratings for the Medicare Part D plan are determined by the Centers for Medicare and Medicaid Services (CMS). In some cases, CMS tier ratings for some drugs may be lower.

• Prorated copayments: Copayments for the non‐Medicare plan are based on a 30‐day supply of the drug. Copayments for Express Scripts Medicare are prorated based on the number of days the prescription will cover. For example, if a member is prescribed a Tier 2 medication and the doctor writes the prescription for 10 tablets to be taken for 10 days, the copayment is reduced to reflect a 10‐day supply ($14) instead of a 30‐day supply ($42).

• Larger formulary: Members enrolled in the Medicare Part D plan have access to all drugs available on the non‐Medicare plan plus any additional drugs covered by CMS. Members are not losing access to any drugs by enrolling in the Medicare Part D plan.

• Dispense as Written protection: If a generic equivalent is available, but the member’s physician wants the member to take the brand name, the member enrolled in Express Scripts Medicare is not required to pay‐the‐difference in most cases as he would if he were enrolled in the non‐Medicare prescription drug plan. The member will pay the brand copay. For example, Diovan HCT has a generic equivalent. As of May 26, 2017, the brand‐name Vytorin is a Tier 3 ($70) drug on Express Scripts Medicare formulary. A member who is not enrolled in Express Scripts Medicare would pay the difference, and the drug would cost the member more.

• Low‐income subsidies: Some people with limited resources and income may be able to get extra help to pay for the costs—monthly premiums, annual deductibles and prescription copayments—related to a Medicare prescription drug plan. The member’s resources must be limited to $14,390 for an individual or $28,720 for a married couple living together. If you would like to find out if you are eligible for extra help, contact the Social Security Administration.

Reasons a member might consider opting out of the Medicare Part D plan • Manufacturer discount cards/programs: Under CMS regulations, manufacturer coupons cannot be used

with a Medicare Part D prescription drug plan. If you use coupons or discount cards to obtain prescriptions, you should determine if the additional benefits of Express Scripts Medicare offset the savings of any coupons or discount cards.

• TRICARE members: Prescription benefits offered through TRICARE and TRICARE for Life do not coordinate with Medicare Part D plans. Express Scripts Medicare is a Part D plan. If you would like to use both prescription drug plans, you must opt out of Express Scripts Medicare. You will then be enrolled in PEBA’s non‐Medicare prescription drug program.

• IRMAA (Income Related Monthly Adjustment Amounts): High‐income earners enrolled in a Medicare Part D plan may pay a monthly fee to the Social Security Administration. Check with Social Security for information about income thresholds and monthly adjustments (www.socialsecurity.gov/online/ssa‐44.pdf). If you will pay an IRMAA fee, you should determine if the additional benefits of the Medicare Part D plan outweigh the monthly adjustment.

5/20/2019 S.C. PEBA │ Employment verification record

Employment verification record If you are within six months of your anticipated retirement date, please complete this form as thoroughly as possible. The information will be used to assist us in determining your insurance eligibility at retirement. Please sign and date this form before returning it to PEBA.

1. BIN or last four digits of SSN 2. Last name 3. First name

4. Current Address (Street, City, State, Zip)

Use this address for:

Both Insurance and Retirement Insurance only Retirement only

5. Date of birth 6. Telephone number 7. Email address

8. Actual or anticipated date of retirement: _____________________________

9. Have you applied, or do you intend to apply, for disability retirement? Yes No

10. System enrolled (check all that apply):

SCRS PORS JSRS GARS State ORP None Other retirement plan

11. Name of current employer Dates of employment (example March 2001 to January 2009)

Status Permanent Temporary

Hours per week

Benefits administrator’s signature: __________________________________________________ Date: ____________________

(required for State ORP participants and employees of non-PEBA retirement benefit employers)

12. List previous employment with employers participating in one of the retirement systems administered by PEBA and/or with an optional employer participating in PEBA’s insurance benefits.

Name of employer Dates of employment (ex. March 2001 to January 2009)

Status Hours per week

Permanent Temporary

Permanent Temporary

Permanent Temporary

Permanent Temporary

Permanent Temporary

13. Have you purchased, or do you intend to purchase, service credit? Yes (list time) No

Please explain any breaks in the last five years: __________________________________________________________________________________________________________

__________________________________________________________________________________________________________

__________________________________________________________________________________________________________

Employee signature: ____________________________________________________ Date: ____________________

(required if updating your address)

SCPEBA 09242019 S.C. PEBA │ Certification Regarding Tobacco or E-cigarette Use

Certification Regarding Tobacco or E-cigarette Use Check the appropriate box, sign and return to S.C. PEBA, 202 Arbor Lake Drive, Columbia, SC 29223.

Subscriber name:____________________________________ Subscriber BIN/SSN: ______________________

Non-tobacco or e-cigarette user

❑ I certify that I am eligible for the non-tobacco-use premium by checking this box and returning this form to

PEBA. By checking this box, I certify truth and understanding of the following:

• I certify that all persons covered on my health insurance coverage through PEBA (including myself and any

dependents) are not currently using, and have not used, any tobacco products or electronic cigarettes in

any form (cigarettes, cigars, pipe, oral tobacco products, etc.) within the last six months.

• I certify that if this information changes at any time in the future, while I have health insurance coverage

through PEBA, I will notify PEBA of such change within 31 days through completion and resubmission of

this form.

• I certify that this information is true and correct to the best of my knowledge.

• I understand that if it is determined that I (or any of my covered dependents) have used tobacco products

or electronic cigarettes within the last six months or if I (or any of my covered dependents) start using

tobacco products or electronic cigarettes subsequent to the date of this certification without notifying

PEBA, I will be subject to penalties including, but not limited to, payment of premium difference since last

certification plus a 10 percent penalty and elimination of the user’s out-of-pocket maximum for current

year and subsequent year.

• I understand that this change in premiums will be prospective (apply only to premiums I pay in the

future). I will not be refunded any part of the tobacco-use premium I have already paid.

❑ I certify that I am eligible for the non-tobacco-use premium by checking this box and returning this form to PEBA. By checking this box, I certify truth and understanding of the following:

• I certify that all covered individuals who use tobacco or electronic cigarettes have completed the Quit for

Life® smoking cessation program.

• I certify that this information is true and correct to the best of my knowledge.

• I understand that this change in premiums will be prospective (apply only to premiums I pay in the

future). I will not be refunded any part of the tobacco-use premium I have already paid.

Tobacco or e-cigarette user

❑ I acknowledge that I will pay the tobacco-use premium by checking this box. I declare that one or more

persons covered on my health insurance coverage through PEBA uses tobacco products or electronic

cigarettes in some form or that I choose not to disclose my status as it relates to tobacco or e-cigarette use. I

understand that by not making an election I am choosing to pay the tobacco-use premium. Please do not send

me this certification again unless upon request.

Subscriber signature: ________________________________________ Date: ___________________________

Benefits administrator signature: _______________________________ Date: ___________________________

The language used in this document does not create an employment contract between the employee and the agency. This document does not create any

contractual rights or entitlements. The agency reserves the right to revise the content of this document in whole or in part. No promises or assurances, whether

written or oral, which are contrary to or inconsistent with the terms of this paragraph create any contract of employment.

REV. 7/10/2019 ORIGINAL TO PEBA COPY TO ENROLLEE

You must also complete a Certification Regarding Tobacco Use form within 31 days of enrolling in health coverage and whenever the status of tobacco use changes for you or a dependent covered under your health insurance.

1. Social Security number or BIN 2. Last Name 3. Suffix

RETIREE NOTICE OF ELECTION (NOE) SOUTH CAROLINA PUBLIC EMPLOYEE BENEFIT AUTHORITY

RSee Instructions - if completing

by hand use black ink

Select OneRegular RetireeDisability Retiree

ELIG

IBIL

ITY

ENR

OLL

EE IN

FOC

OVE

RA

GE

MF

4. First Name 5. M.I. 6. Date of Birth (MM/DD/YYYY)

10. Email Address9. Home Phone #7. Sex

12. Apt.11. Mailing Address 13. City 14. State 15. Zip Code 16. County Code

17. HEALTH PLAN (Refuse or select one plan and one level of coverage)

PLAN COVERAGE LEVEL

StandardRefuse

Savings (not Medicare-eligible)

TRICARE Supplement (not Medicare-eligible)

Retiree

19. VISION CARE (select one)

Police Retiree

Select OneIndicate Record of Service (Attach Employment Record)

8. Marital StatusWidowedSingle Divorced

Married Separated

Retiree/SpouseRetiree/Child(ren)Family

RetireeRetiree/SpouseRetiree/Child(ren)Family

Refuse18. DENTAL (Refuse or select one plan and one level of coverage)

Basic DentalDental Plus

FamilyRetiree/Child(ren)Retiree/SpouseRetiree

PLANRefuse

COVERAGE LEVEL

MED

ICA

RE Name Medicare # Eligible due to

Part A (MM/DD/YYYY) Part B (MM/DD/YYYY)

DisabilityAge Renal Disease

20. List yourself and any other persons to be covered who are eligible for Medicare Part A and/or Part B.

Effective Date

Enrollee/Guardian Signature DateCER

TIFI

CA

TIO

N &

AU

THO

RIZ

ATI

ON

DisabilityAge Renal Disease

DEP

END

ENTS

21. Always list spouse. List eligible children to be covered. If they are not listed, they will not be covered. For a child age 19-24 to be eligible for Dependent Life-Child coverage, your child must be eligible according to the requirements on the instructions page for this NOE.

Dependent SSN Last Name Date of Birth (MM/DD/YYYY)

First Name

Incapacitated

Indicate Special StatusAdd (A) or Delete (D)

Incapacitated

Incapacitated

RelationshipSex

Does PEBA Insurance Benefits already cover your spouse? No

Yes

Incapacitated

Spouse

Child

Child

Child

Child

22. CERTIFICATION: I have read this NOE and made authorizations herein and selected the coverage noted. I have provided Social Security numbers and documentation establishing my dependent(s)' eligibility for the plan(s) selected. I understand and agree that all selected plans will not become effective unless and until this NOE is submitted and the first payment is made. I understand my COBRA continuation coverage rights and responsibilities, as explained in the election notice and attachments provided to me. I also understand that the State reserves the right to alter benefits or premiums at any time to preserve the financial stability of the Plan. I further acknowledge that the eligibility status of any covered individual is subject to audit at any time.

AUTHORIZATION: I authorize any healthcare provider, prescription drug dispenser and claims administrator to release any information necessary to evaluate, administer and process claims for any benefits.

DISCLAIMER: THE LANGUAGE USED IN THIS DOCUMENT DOES NOT CREATE AN EMPLOYMENT CONTRACT BETWEEN THE EMPLOYEE AND THE AGENCY. THIS DOCUMENT DOES NOT CREATE ANY CONTRACTUAL RIGHTS OR ENTITLEMENTS. THE AGENCY RESERVES THE RIGHT TO REVISE THE CONTENT OF THIS DOCUMENT IN WHOLE OR IN PART. NO PROMISES OR ASSURANCES, WHETHER WRITTEN OR ORAL, WHICH ARE CONTRARY TO OR INCONSISTENT WITH THE TERMS OF THIS PARAGRAPH CREATE ANY CONTRACT OF EMPLOYMENT.

AC

TIO

N

Verification of eligibility (required of retirees from employers other than state agencies and school districts)

Benefits Administrator Signature Employer ID:

New Subscriber - Date of Retirement

Change (Specify)

Termination

Date of Change Event

PEBA Use Only

SSN Change - Incorrect # (Attach copy of Social Security card)

Effective Date:

Employer ID:

Group ID:

Select One

Yrs. Mos. Days Age 55/25 Years Retiree Ending Date15-24 Year Retiree5-14 Year Retiree

Previously Enrolled as a Retiree - returning to Retiree status

Medicare Supplement

INSTRUCTIONS FOR COMPLETING THE RETIREE NOTICE OF ELECTION (NOE)

You must also complete a Certification Regarding Tobacco Use form within 31 days of enrolling in health coverage and whenever the status of tobacco use changes for you or a dependent covered under your health insurance. ELIGIBILITY: For new retirees only. Select a retiree type to indicate your eligibility as a retiree. Enter the length of service, and complete and attach the Employment Verification Record form. If you initially became eligible for insurance before May 2, 2008, and you have fewer than 10 years service credit, or if you initially became eligible for insurance on or after May 2, 2008, and you have fewer than 15 years service credit, check the 5-14 year retiree block. If you initially became eligible for insurance on or after May 2, 2008, and you have less than 25 years service credit, check the 15-24 year retiree block. Check the age 55/25 years retiree block if you are retiring under the Age 55 with 25 years service credit provision, and enter the date you will reach age 60 or 28 years, whichever occurs first. Employer verification of eligibility is required only for retirees of participating cities, counties, disabilities and special needs boards, water and sewer districts, alcohol and drug abuse agencies, special hospital districts, special purpose districts, recreation districts and municipalities. ACTION: If you are enrolling as a retiree for the first time, check New Subscriber and enter your date of retirement. If you are already enrolled as a retiree and are making a change, check Change and indicate the type of change and date of the event causing the change. If you were previously enrolled as a retiree and are now returning to retiree coverage, check Previously enrolled as a Retiree - returning to Retiree status. If you wish to end your retiree coverage, check Termination. ENROLLEE INFO: Blocks 1-16 must be completed for all transactions including terminations. In block 16, enter the county code (listed below) of your mailing address. COUNTY CODES: COVERAGE. ALTERATIONS IN THIS SECTION ARE NOT ALLOWED: Block 17. HEALTH: Select one health plan and one level of coverage or check Refuse. If you refuse health coverage or fail to enroll yourself and all eligible dependents within 30 days of eligibility, you can enroll yourself and/or your dependent(s) only during an open enrollment period or within 30 days of a special eligibility situation. Changes from one health plan to another are allowed only during designated enrollment periods (exceptions: changing plans due to Medicare eligibility). The Savings Plan is available only to non-Medicare-eligible enrollees and dependents. Block 18. DENTAL: If you refuse dental when first eligible, you can apply for coverage for yourself and your dependent(s) only during an open enrollment period during an odd-numbered year or within 31 days of a special eligibility situation. For dependents to be covered, they must be listed in Block 21, and the appropriate level of coverage must be selected. Block 19. VISION CARE: Select a level of vision care coverage to enroll or Refuse. If you refuse coverage or fail to enroll yourself and all eligible dependents within 30 days of eligibility, you can enroll yourself and/or your dependents during the next enrollment period (October) or within 30 days of a special eligibility situation. MEDICARE: List yourself and any other persons to be covered who are eligible for Part A and/or Part B of Medicare. Block 21. DEPENDENTS: Legal documentation is required for all dependents. If you select a level of coverage that includes a spouse and/or dependent child(ren), they must be listed to be covered. A spouse can only be covered as a dependent if he is not an employee or retiree of an employer that participates in the state of South Carolina Insurance Benefits Program. If your spouse is an employee or retiree of an employer covered by PEBA insurance, check Yes. A child younger than 26 is eligible for health, dental and vision coverage. Misstatements on the NOE may result in termination of the dependent's coverage and recoupment of benefits paid on behalf of the ineligible dependent. CERTIFICATION AND AUTHORIZATION: Read this block carefully, sign and date form. Send the original form and any required documentation to PEBA Insurance Benefits, P.O. Box 11661, Columbia, SC 29211. Keep a copy for your records.

43 Sumter 44 Union 45 Williamsburg 46 York 99 Out of S.C

37 Oconee 38 Orangeburg 39 Pickens 40 Richland 41 Saluda 42 Spartanburg

31 Lee 32 Lexington 33 McCormick 34 Marion 35 Marlboro 36 Newberry

25 Hampton 26 Horry 27 Jasper 28 Kershaw 29 Lancaster 30 Laurens

19 Edgefield 20 Fairfield 21 Florence 22 Georgetown 23 Greenville 24 Greenwood

13 Chesterfield 14 Clarendon 15 Colleton 16 Darlington 17 Dillon 18 Dorchester

07 Beaufort 08 Berkeley 09 Calhoun 10 Charleston 11 Cherokee 12 Chester

01 Abbeville 02 Aiken 03 Allendale 04 Anderson 05 Bamberg 06 Barnwell