SDCERA Health Insurance Plans Enrollment form€¦ · condition of obtaining health insurance coverage. Acknowledgement and agreement: I understand and agree that by enrolling with

Medical Plans

Kaiser Permanente

UnitedHealthcare

Health Net

Dental Plans

CIGNA Dental

Delta Dental

HMO Non-Medicare

Signature Value HMO

HMO Non-Medicare

DHMO

Preferred PPO

Senior Advantage

Group Medicare Advantage

HMO Medicare

Senior Supplement

Seniority Plus

Persons to be enrolled Member Member and Spouse /Partner Member and Child Family

(Date) (Member Signature)

Please complete all sections of this form. You may submit your form online by selecting “Enrollment” on the Health page of www.sdcera.org or by mailing your form to the SDCERA Health Plans Service Center.

SECTION 1: Member Information

SDCERA Health Insurance Plans Enrollment form

Please Note: If you or your dependents are Medicare-eligible, you must provide the SDCERA Health Plans Service Center with a copy of both sides of each of your signed Medicare cards showing Part A and B coverage. To enroll your eligible spouse or domestic partner, you must provide a copy of the marriage certificate or Certificate of Registration of Domestic Partnership from the California Secretary of State. To enroll eligible dependent children, you must provide a copy of the birth certificate or proof of adoption for each child. If you have additional enrollees, please list their information on a separate sheet and attach to your completed enrollment form.

I elect the coverage as indicated above and certify that the information I have provided is true and accurate to the best of my knowledge. I also certify that I have read and understand the provisions of the medical plans, as detailed in the SDCERA Health Insurance Plans booklet and I agree to the terms and conditions stated therein. I agree to have my monthly retirement payment from SDCERA reduced by the required amount to pay my share (including covered dependent premiums) of the cost for the medical and/or dental plans(s) I have selected. I understand that I cannot change my coverage options until the next Open Enrollment period, but I can cancel my coverage at any time in writing or by calling the SDCERA Health Plans Service Center. Lastly, I also understand the SDCERA Board of Retirement reserves the right to modify or terminate the health insurance plans for my insurance coverage at any time.

First Name: MI: Last Name:

Permanent Residence Address:

City: State: ZIP:

Daytime Telephone: Email Address:

Date of Birth: S.S.# Desired Effective Date of Coverage:

SECTION 2: Plan Selection(s)

SECTION 3: Choose the coverage for yourself and eligible dependents

SECTION 4: Choose the coverage for yourself and eligible dependents

Name Relationship Birth date S.S.# Medicare # (if applicable)

SECTION 5: Signature & Authorization

Rev. 10/2018

SDCERA Health Plans Service Center1.866.751.0256PO Box 14464 Des Moines, IA 50306-3464

COBENRLLFM (3/18) FRM018778EO00 (Rev 5/18)1 of 8

Employer name:

Coverage effective date: Employer group number (Medical):

Important – Please print all sections in black ink. For the application to be valid, you must submit all applicable pages.

1. Select coverage1a: Check the desired plan as offered by your employer: (Write the plan number next to the product.)

HMO: ___________________________________ HMO: PremierCare ________________________ HMO: ExcelCare __________________________ HMO: SmartCare __________________________ HMO: Salud _____________________________ PPO: ____________________________________

EPO: ____________________________________ POS: Elect _______________________________ POS: Elect Open Access _____________________ POS: ExcelCare Elect Open Access ____________ POS: Select _______________________________ Flex Net: _________________________________

Reason for application: Retiree Open Enrollment Loss of prior coverage date: ________ COBRA effective date: ________ Qualifying event: ________ Qualifying event date: ________ Add dependent Qualifying event: ________ Qualifying event date: ________

Reason for change: Plan change Change address/name Delete dependent(s) (List names in Section 3.) Other: ________________________________________________________________________________

1b: Please provide your Medicare insurance information

Please take out your red, white and blue Medicare card to complete this section. • Fill out this information as it appears

on your Medicare card. - OR -

• Attach a copy of your Medicare card or your letter from Social Security or the Railroad Retirement Board.

Name (as it appears on your Medicare card) ___________________________________________

Medicare number

___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___

Is entitled to: Effective date

HOSPITAL (Part A) ________________________

MEDICAL (Part B) ________________________You must have Medicare Part A and Part B to join a Medicare Advantage plan.

Employer Group Medical Coordination of Benefits

Enrollment Request Form

2. Retiree personal informationLast name: First name: MI: Date of birth (MM/DD/YYYY):

Residence address: City: State: ZIP:


Retiree name:

2. Retiree personal information (continued)Mailing address (if different from residence): City: State: ZIP:

Home telephone #: ( )

Social Security #: Email address:

Male Female

Marital status: Single Married Domestic partner

Participating physician group/PPG #: Primary care physician/PCP #: N/A. I’m enrolling in a PPO or Flex Net plan.

Physician name (first, last): Is this your current MD? Yes No

Other health coverage? If “Yes,” please complete this section if you currently have or previously had coverage with any public or private health plan (including Medi-Cal or Individual coverage) immediately prior to becoming eligible for this plan. According to federal laws, if you had prior coverage, your employer or former carrier must provide you with a certificate that shows evidence of your coverage. We reserve the right to request a copy of this certificate.Name of subscriber: Prior coverage start date:

__ __/__ __/__ __ __ __ (M M / D D / Y Y Y Y)

Name and address of other insurance carrier:

Prior coverage end date: __ __/__ __/__ __ __ __ (M M / D D / Y Y Y Y)

Reason for ending coverage:

Group #/Policy ID #: Is this your primary coverage? Yes No

Does it cover medical? Yes No

Are you enrolling dependents? Yes No If “Yes,” complete and submit all pages of the form. If “No,” and you are declining coverage for yourself or a dependent, please complete the Declination of Coverage section at the bottom of page 4.3. Family information (Please list all eligible family members to be enrolled. To add additional dependents,

fill out the Health Net Dependent Information Form, and submit it along with this application.)Dependent 1

Spouse Domestic partner

Male Female

Last name: First name: MI:

Residence address ( Check here if same as employee.): City: State: ZIP:

Date of birth (MM/DD/YYYY): Social Security #/Matricula ID #:

Coverage type: Medical Medicare Part A

Medicare Part B Medicare Part D

Medicare number: Participating physician group/PPG #:

Primary care physician/PCP #:


3. Family information (continued)Dependent 1 (continued)


Dental HMO Provider ID # (Complete only if electing Health Net Dental.):

Does your dependent have other health care coverage? Yes No If “Yes,” complete the following:Name of insurance carrier: ______________________________ Prior coverage start date: ______________Dependent 2

Son Daughter

Last name: First name: MI:

Residence address ( Check here if same as employee.): City: State: ZIP:

Date of birth (MM/DD/YYYY): Totally disabled? Yes No

Social Security #/Matricula ID #:

Coverage type: Medical Medicare Part A

Medicare Part B Medicare Part D

Medicare number: Participating physician group/PPG #:

Primary care physician/PCP #:


Dental HMO Provider ID # (Complete only if electing Health Net Dental.):

Do you have other health care coverage? Yes No If “Yes,” complete the following:Name of insurance carrier: ______________________________ Prior coverage start date: ______________

4. Acceptance of coverage (Signature required.)The use and disclosure of protected health information: I acknowledge and understand that health care providers may disclose health information about me or my dependents to Health Net entities. Health Net entities use and may disclose this information for purposes of treatment, payment and health plan operations, including but not limited to, utilization management, quality improvement, and disease or case management programs. Health Net’s Notice of Privacy Practices is included in the Evidence of Coverage or Certificate of Insurance for coverage underwritten by Health Net entities. I may also obtain a copy of this notice on the website at www.healthnet.com or through the Health Net Customer Contact Center.

Notice: For your protection, California law requires the following to appear on this form. Any person who knowingly presents a false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison.

California law prohibits an HIV test from being required or used by health insurance companies as a condition of obtaining health insurance coverage.

Acknowledgement and agreement: I understand and agree that by enrolling with or accepting services from the Health Net entities, I and any enrolled dependents are obligated to understand and abide by the terms, conditions and provisions of the plan contract or insurance policy. I have read and understand the terms of this application, and my signature below indicates that the information entered in this application is complete, true and correct to the best of my knowledge, and I accept these terms.


If you are the authorized representative, you must sign above and provide the following information:

Name: ____________________________________________ Relationship to enrollee: _________________

Address: __________________________________________ Phone number: ( ____ ) ______ - __________

Retiree signature: ___________________________________________________________________________

Print retiree name: ____________________________________________________ Date: ________________

4. Acceptance of coverage (continued)

Complete this section only if any coverage is to be declined by you. Declining medical coverage

Reason: Other group coverage Individual coverage Other: Other group coverage by another group (i.e., spouse’s employer)

The available coverages have been explained to me by my employer. I have been given the chance to apply for the available coverages. I have decided not to enroll myself and/or my dependent(s). By declining coverage, I acknowlege that my dependents and I may have to wait to be enrolled until the next open enrollment period or qualifying event. Additionally, by signing below I certify that the reason I am declining coverage is accurate as indicated by the check marks above.Note: If you decline coverage for yourself or an eligible dependent because of coverage under other health insurance, you may be eligible for special enrollment rights if you or your dependent lose eligibility for that coverage. You must request special enrollment within 30 days of the loss of coverage or acquisition of a new dependent. Employee signature: ___________________________________________________ Date:

(ONLY IF DECLINING COVERAGE: If signed in error, please cross out and initial.)

Medical Coordination of Benefits HMO health plans are offered by Health Net of California, Inc. Medical Coordination of Benefits health insurance plans are underwritten by Health Net Life Insurance Company.

BINDING ARBITRATION AGREEMENT: I, the Applicant, understand and agree that any and all disputes between me (including any of my enrolled family members or heirs or personal representatives) and Health Net must be submitted to final and binding arbitration instead of a jury or court trial. This Agreement to arbitrate includes any disputes arising from or relating to the Evidence of Coverage or Certificate of Insurance or my Health Net membership or coverage, stated under any legal theory. This agreement to arbitrate any disputes applies even if other parties, such as health care providers or their agents or employees, are involved in the dispute. I understand that, by agreeing to submit all disputes to final and binding arbitration, all parties including Health Net are giving up their constitutional right to have their dispute decided in a court of law by a jury. I also understand that disputes that I may have with Health Net involving claims for medical malpractice (that is, whether any medical services rendered were unnecessary or unauthorized or were improperly, negligently or incompetently rendered) are also subject to final and binding arbitration. I understand that a more detailed arbitration provision is included in the Evidence of Coverage or Certificate of Insurance. Mandatory Arbitration may not apply to certain disputes if the Employer’s plan is subject to ERISA, 29 U.S.C. §§ 1001-1461. My signature below indicates that I understand and agree with the terms of this Binding Arbitration Agreement and agree to submit any disputes to binding arbitration instead of a court of law.


In addition to the State of California nondiscrimination requirements (as described in benefit coverage documents), Health Net of California, Inc. and Health Net Life Insurance Company (Health Net) comply with applicable federal civil rights laws and do not discriminate, exclude people or treat them differently on the basis of race, color, national origin, ancestry, religion, marital status, gender, gender identity, sexual orientation, age, disability, or sex.

Health Net: Provides free aids and services to people with disabilities to communicate effectively with us,such as qualified sign language interpreters and written information in other formats (largeprint, accessible electronic formats, other formats).Provides free language services to people whose primary language is not English, such asqualified interpreters and information written in other languages.

If you need these services, contact Health Net’s Customer Contact Center at: Individual & Family Plan (IFP) Members On Exchange/Covered California

1-888-926-4988 (TTY: 711)Individual & Family Plan (IFP) Members Off Exchange

1-800-839-2172 (TTY: 711)Individual & Family Plan (IFP) Applicants

1-877-609-8711 (TTY: 711)Group Plans through Health Net

1-800-522-0088 (TTY: 711)If you believe that Health Net has failed to provide these services or discriminated in another way based on one of the characteristics listed above, you can file a grievance by calling Health Net’s Customer Contact Center at the number above and telling them you need help filing a grievance. Health Net’s Customer Contact Center is available to help you file a grievance. You can also file a grievance by mail, fax or email at:

Health Net of California, Inc./Health Net Life Insurance Company Appeals & Grievances PO Box 10348 Van Nuys, CA 91410-0348 Fax: 1-877-831-6019 Email: [email protected] (Members) or

[email protected] (Applicants)

For HMO, HSP, EOA, and POS plans offered through Health Net of California, Inc.: If your health problem is urgent, if you already filed a complaint with Health Net of California, Inc. and are not satisfied with the decision or it has been more than 30 days since you filed a complaint with Health Net of California, Inc., you may submit an Independent Medical Review/Complaint Form with the Department of Managed Health Care (DMHC). You may submit a complaint form by calling the DMHC Help Desk at 1-888-466-2219 (TDD: 1-877-688-9891) or online at www.dmhc.ca.gov/FileaComplaint.

For PPO and EPO plans underwritten by Health Net Life Insurance Company: You may submit a complaint by calling the California Department of Insurance at 1-800-927-4357 or online at https://www.insurance.ca.gov/01-consumers/101-help/index.cfm. If you believe you have been discriminated against because of race, color, national origin, age, disability, or sex, you can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights (OCR), electronically through the OCR Complaint Portal, at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services, 200 Independence Avenue SW, Room 509F, HHH Building, Washington, DC 20201, 1-800-368-1019 (TDD: 1-800-537-7697). Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.


EnglishNo Cost Language Services. You can get an interpreter. You can get documents read to you and some sent to you in your language. For help, call the Customer Contact Center at the number on your ID card or call Individual & Family Plan (IFP) Off Exchange: 1-800-839-2172 (TTY: 711). For California marketplace, call IFP On Exchange 1-888-926-4988 (TTY: 711) or Small Business 1-888-926-5133 (TTY: 711). For Group Plans through Health Net, call 1-800-522-0088 (TTY: 711).

Arabic

TTY: 711) 1-800-839-2172TTY: 711) 1-888-926-4988

TTY: 711) 1-888-926-5133TTY: 711) 1-800-522-0088 Health Net

Armenian

Chinese

Individual & Family Plan (IFP) 1-800-839-2172 711

IFP 1-888-926-4988 711

1-888-926-5133 711 Health Net

1-800-522-0088 711

Hindi

HmongTsis Muaj Tus Nqi Pab Txhais Lus. Koj tuaj yeem tau txais ib tus kws pab txhais lus. Koj tuaj yeem muaj ib tus neeg nyeem cov ntaub ntawv rau koj ua koj hom lus hais. Txhawm rau pab, hu xovtooj rau Neeg Qhua Lub Chaw Tiv Toj ntawm tus npawb nyob ntawm koj daim npav ID lossis hu rau Tus Neeg thiab Tsev Neeg Qhov Kev Npaj (IFP) Ntawm Kev Sib Hloov Pauv: 1-800-839-2172 (TTY: 711). Rau California qhov chaw kiab khw, hu rau IFP Ntawm Qhov Sib Hloov Pauv 1-888-926-4988 (TTY: 711) lossis Lag Luam Me 1-888-926-5133 (TTY: 711). Rau Cov Pab Pawg Chaw Npaj Kho Mob hla Health Net, hu rau 1-800-522-0088 (TTY: 711).

Japanese


Khmer

Korean

ID(IFP) Off Exchange:

1-800-839-2172(TTY: 711)IFP On Exchange 1-888-926-4988(TTY: 711) 1-888-926-5133(TTY: 711)

Health Net 1-800-522-0088(TTY: 711)

NavajoDoo b33h 7l7n7g00 saad bee h1k1 ada’iiyeed. Ata’ halne’7g77 da [a’ n1 h1d7d0ot’88[. Naaltsoos da t’11 sh7 shizaad k’ehj7 shich9’ y7dooltah n7n7zingo t’11 n1 1k0dooln77[. !k0t’4ego sh7k1 a’doowo[ n7n7zingo Customer Contact Center hooly4h7j8’ hod77lnih ninaaltsoos nanitingo bee n44ho’dolzin7g77 hodoonihj8’ bik11’ 47 doodago koj8’ h0lne’ Individual & Family Plan (IFP) Off Exchange: 1-800-839-2172 (TTY: 711). California marketplace b1h7g77 koj8’ h0lne’ IFP On Exchange 1-888- 926-4988 (TTY: 711) 47 doodago Small Business b1h7g77 koj8’ h0lne’ 1-888-926-5133 (TTY: 711). Group Plans through Health Net b1h7g77 47 koj8’ h0lne’ 1-800-522-0088 (TTY: 711).

Persian (Farsi)

IFP) Off Exchange 1-888-926-4988 IFP On Exchange TTY:711) 1-800-839-2172

TTY:711) 1-888-926-5133 TTY:711)TTY:711) 1-800-522-0088 Health Net

Panjabi (Punjabi)

TTYIFPTTYTTY


Russian

SpanishServicios de idiomas sin costo. Puede solicitar un intérprete, obtener el servicio de lectura de documentos y recibir algunos en su idioma. Para obtener ayuda, comuníquese con el Centro de Comunicación con el Cliente

Mercado de Seguros de Salud al 1-800-839-2172 (TTY: 711). Para planes del mercado de seguros de salud de California, llame al plan individual y familiar que pertenece al Mercado de Seguros de Salud al 1-888-926-4988 (TTY: 711); para los planes de pequeñas empresas, llame al 1-888-926-5133 (TTY: 711). Para planes grupales a través de Health Net, llame al 1-800-522-0088 (TTY: 711).

TagalogWalang Bayad na Mga Serbisyo sa Wika. Makakakuha kayo ng interpreter. Makakakuha kayo ng mga dokumento na babasahin sa inyo sa inyong wika. Para sa tulong, tumawag sa Customer Contact Center sa numerong nasa ID card ninyo o tumawag sa Off Exchange ng Planong Pang-indibidwal at Pampamilya (Individual & Family Plan, IFP): 1-800-839-2172 (TTY: 711). Para sa California marketplace, tumawag sa IFP On Exchange 1-888-926-4988 (TTY: 711) o Maliliit na Negosyo 1-888-926-5133 (TTY: 711). Para sa mga Planong Pang-grupo sa pamamagitan ng Health Net, tumawag sa 1-800-522-0088 (TTY: 711).

Thai

2019 SilverScript® Insurance Company SilverScript Employer PDP sponsored by Health Net (SilverScript) Medicare Part D Enrollment Form

Section 1: Please Read This Important Information Typically, you may enroll in a Medicare Prescription Drug Plan only during the Annual Enrollment Period between October 15 and December 7 of each year. Please check with your former Employer Group, Union, or Trust regarding their designated enrollment period as it may be tied to other retiree benefits. Additionally, there are exceptions that may allow you to enroll in a Medicare Prescription Drug Plan outside of the Annual Enrollment Period. Please read the following statements carefully and check the box if the statement applies to you. By checking any of the following boxes you are certifying that, to the best of your knowledge, you are eligible for that reason which will help us determine your enrollment period. If we later determine that this information is incorrect, you may be disenrolled.

Reasons for Annual Enrollment Period Eligibility � I am enrolling between 10/15/18 and 12/7/18, the current Annual Enrollment Period. Please check with your former Employer Group, Union, or Trust regarding their designated enrollment period as it may be tied to other retiree benefits.

Reasons for Initial Enrollment Period Eligibility � I am new to Medicare. � I have previously had Medicare but am now turning 65.

Reasons for Special Enrollment Period Eligibility (Select reason and enter date if applicable)

� I am enrolled in a Medicare Advantage plan and want to make a change during the Medicare Advantage Open Enrollment Period (MA OEP).

� I recently moved outside of the service area for my current plan or I recently moved and this plan is a new option for me. I moved on _ _/_ _ /_ _ _ _.

� I recently was released from incarceration. I was released on _ _/_ _ /_ _ _ _.

� I recently returned to the United States after living permanently outside of the U.S. I returned to the U.S. on _ _/_ _ /_ _ _ _.

� I recently obtained lawful presence status in the United States. I got this status on _ _/_ _ /_ _ _ _.

� I recently had a change in my Medicaid (newly got Medicaid, had a change in level of Medicaid assistance, or lost Medicaid) on _ _/_ _ /_ _ _ _.

� I recently had a change in my Extra Help paying for Medicare prescription drug coverage (newly got Extra Help, had a change in the level of Extra Help, or lost Extra Help) on _ _/_ _ /_ _ _ _.

� I have both Medicare and Medicaid (or my state helps pay for my Medicare premiums) or I get Extra Help paying for my Medicare prescription drug coverage, but I haven’t had a change.

� I live in or recently moved out of a Long-Term Care Facility (for example, a nursing home or long term care facility). I moved/will move into/out of the facility on _ _/_ _ /_ _ _ _.

� I recently left a PACE program on _ _/_ _ /_ _ _ _. � I recently involuntarily lost my creditable

prescription drug coverage (as good as Medicare’s). I lost my drug coverage on _ _/_ _ /_ _ _ _.

� I am leaving employer or union coverage on _ _/_ _ /_ _ _ _.

� I belong to a pharmacy assistance program provided by my state

� My plan is ending its contract with Medicare, or Medicare is ending its contract with my plan.

� I was enrolled in a plan by Medicare (or my state) and I want to choose a different plan. My enrollment in that plan started on _ _/_ _ /_ _ _ _.

� I was affected by a weather-related emergency or major disaster (as declared by the Federal Emergency Management Agency (FEMA). One of the other statements here applied to me, but I was unable to make my enrollment because of the natural disaster.

� None of these statements apply to me. Please contact SilverScript Insurance Company at 1-888-648-9626, 24 hours a day, 7 days a week. (TTY users call 711).

Y0080_52039_ENR_1.CLT_2019_M_9104 PLEASE RETURN TO COMPANY 1

Section 2: To Enroll in SilverScript Provide the Following Information

Please check the SilverScript plan in which you wish to enroll. � SilverScript

Group Name: ________________________________________ Group ID: ___________________________

Today’s Date _ _/_ _ /_ _ _ _ Requested Coverage Effective Date _ _/_ _ /_ _ _ _

Section 3: Complete the Information Below Exactly as it Appears on Your Medicare Card Use your Medicare card to complete this section. Please fill in these blanks so they match your red, white and blue Medicare card. – OR – Attach a copy of your Medicare card or your letter from Social Security or the Railroad Retirement Board. You must have Medicare Part A or Part B (or both) to join a Medicare Prescription Drug Plan. Last Name __ __ __ __ __ __ __ __ __ __ __ __ __ __ Suffix __ __ __ First Name __ __ __ __ __ __ __ __ __ __ __ __ __ __ MI __ Medicare Number __ __ __ __ __ __ __ __ __ __ __ __ __ Is Entitled to Effective Date Hospital Insurance (Part A) __ __ / __ __ /__ __ __ __ Medical Insurance (Part B) __ __ / __ __ /__ __ __ __

Please Provide the Following Information

Birth Date _ _ / _ _ / _ _ _ _

M M / D D / Y Y Y Y

Sex � M � F

Primary Phone Number (_ _ _) _ _ _ – _ _ _ _

Cell Phone Number (_ _ _) _ _ _ – _ _ _ _

Permanent Residence / Long-term Care Facility Address (PO Box is not allowed) Street Number Street Name __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __

Apt/Suite/Unit __ __ __ __ __ __ __ __ __ __ __

City __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __

County __ __ __ __ __ __ __ __ State __ __ ZIP Code __ __ __ __ __ - __ __ __ __

Long-term Care Facility Name __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __

Mailing Street Address Street Number Street Name __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __

Apt/Suite/Unit __ __ __ __ __ __ __ __ __ __ __

City __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __

County __ __ __ __ __ __ __ __ State __ __ ZIP Code __ __ __ __ __ - __ __ __ __

E-mail Address (optional) __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __

2019 PLEASE RETURN TO COMPANY 2

Section 4: Paying Your Plan Premium If you are assessed a Part D-Income Related Monthly Adjustment Amount, you will be notified by the Social Security Administration. You will be responsible for paying this extra amount. You will be billed directly by Medicare. Do NOT pay the Part D-IRMAA extra amount to SilverScript Insurance Company. People with limited incomes may qualify for Extra Help to pay for their prescription drug costs. If you qualify, Medicare could pay for 75% or more of your drug costs including monthly prescription drug premiums, deductibles and coinsurance. Additionally, those who qualify won’t have a coverage gap or a late enrollment penalty. Many people are eligible for these savings and don’t even know it. For more information about this Extra Help, contact your local Social Security office, or call Social Security at 1-800-772-1213. TTY users should call 1-800-325-0778. You can also apply for Extra Help online at www.socialsecurity.gov/prescriptionhelp. If you qualify for Extra Help with your Medicare prescription drug coverage costs, Medicare will pay all or part of your plan premium. If Medicare pays only a portion of this premium, we will bill you for the amount that Medicare does not cover.

Section 5: Please Read and Answer These Important Questions

Some individuals may have other drug coverage, including other private insurance, TRICARE, Federal employee health benefits coverage, VA benefits, or State Pharmaceutical Assistance Programs.

Will you have other prescription drug coverage in addition to SilverScript Employer PDP? � Yes � No

If “yes,” please list your other coverage and your identification (ID) number(s) for this coverage. The shaded line shows how this may appear on your card.

Plan Name Effective Date Term Date RxBin RxPCN RxGroup RxID# ABC Insurance 10/01/2009 12/31/2018 123456 0049876912 ABC1234 123456789

¿Le gustaría recibir esta información en español? � Yes � No

If you need information in an alternate language or accessible format, such as Braille, audio tape or large print, please contact SilverScript Customer Care at 1-888-648-9626, 24 hours a day, 7 days a week. (TTY users call 711).

STOP! Section 6: Please Read This Important Information STOP!

If you are a member of a Medicare Advantage Plan (such as an HMO or PPO), you may already have prescription drug coverage from your Medicare Advantage Plan that will meet your needs. By joining SilverScript Employer PDP, your membership in your Medicare Advantage Plan may end. This will affect both your doctor and hospital coverage as well as your prescription drug coverage. Read the information that your Medicare Advantage Plan sends you and if you have questions, contact your Medicare Advantage Plan.

If you currently have health coverage from another employer or union, joining SilverScript Employer PDP could affect your other employer or union health benefits. You could lose your employer or union health coverage if you join SilverScript Employer PDP. Read the communications your employer or union sends you. If you have questions, visit their website, or contact the office listed in their communications. If there isn’t information on whom to contact, your benefits administrator or the office that answers questions about your coverage can help.


Section 7: Please Read Terms and Sign on Page 6

By completing this enrollment form, I agree to the following: SilverScript Employer PDP is a Medicare drug plan and has a contract with the federal government. I understand that this prescription drug coverage is in addition to my coverage under Medicare; therefore, I will need to keep my Medicare Part A or Part B coverage. It is my responsibility to inform SilverScript of any prescription drug coverage that I have or may get in the future. I can only be in one Medicare Prescription Drug Plan at a time – if I am currently in a Medicare Prescription Drug Plan, my enrollment in SilverScript will end that enrollment. Enrollment in this plan is generally for the entire year. Once I enroll, I may leave this plan or make changes if an enrollment period is available, generally during the Annual Enrollment Period (October 15 until December 7), unless I qualify for certain special circumstances.

SilverScript serves a specific service area. If I move out of the area that SilverScript serves, I need to notify the plan so I can disenroll and find a new plan in my new area. I understand that I must use network pharmacies, except in an emergency when I cannot reasonably use SilverScript network pharmacies. Once I am a member of SilverScript, I have the right to appeal plan decisions about payment or services if I disagree. I will read the Evidence of Coverage document from SilverScript when I get it to know which rules I must follow to get coverage.

I understand that if I leave this plan and don’t have or get other Medicare prescription drug coverage or creditable prescription drug coverage (as good as Medicare’s), I may have to pay a late enrollment penalty for Medicare prescription drug coverage in the future.

I understand that if I am getting assistance from a sales agent, broker, or other individual employed by or contracted with SilverScript, he or she may be paid based on my enrollment in SilverScript.

Counseling services may be available in my state to provide advice concerning Medicare supplement insurance or other Medicare Advantage or Prescription Drug Plan options, medical assistance through the state Medicaid program, and the Medicare Savings Program.

Release of Information By joining this Medicare Prescription Drug Plan, I acknowledge that SilverScript will release my information to Medicare and other plans as is necessary for treatment, payment and health care operations. I also acknowledge that SilverScript will release my information, including my prescription drug event data, to Medicare, who may release it for research and other purposes which follow all applicable federal statutes and regulations. The information on this enrollment form is correct to the best of my knowledge. I understand that if I intentionally provide false information on this form, I will be disenrolled from the plan.

I understand that my signature (or the signature of the person authorized to act on my behalf under state law where I live) on this application means that I have read and understand the contents of this application. If signed by an authorized individual (as described above), this signature certifies that:

1) This person is authorized under state law to complete this enrollment and

2) Documentation of this authority is available upon request by Medicare.


Applicant’s Signature Your Signature Today’s Date

Print Name (please print) __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __

Section 8: Power of Attorney / Authorized Representative

If you are legally authorized to represent the enrollee, you must provide the following information (not for agent use)

Name __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __

Address __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __

City __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ State __ __ ZIP Code __ __ __ __ __

Phone Number __ __ __ — __ __ __ — __ __ __ __

Relationship to Enrollee � Child � Friend � Spouse � Other __ __ __ __ __ __ __ __ __

Signature _____________________________________________ Today’s Date __ __ / __ __ / __ __ __ __

� Please check if authorized representative should receive duplicate copy of plan materials.

STOP! Agent/Prescription Drug Plan Use Only – Please Complete STOP!

Application Received Date __ __ / __ __ / __ __ __ __ � IEP � AEP � SEP (type) __________________

Agent ID # __________________ Plan ID # __________________ Agent Name (please print) _________________________ Agent Signature _____________________________

Agent Portal Confirmation # ___________________________________________________________

SCOPE OF APPOINTMENT (You must check one).

� A Scope of Appointment is included with this enrollment form.

� A Scope of Appointment was NOT completed because the agent did not have an individual or one-on-one marketing appointment (whether in person, telephonically or otherwise) with the applicant.

When you’ve completed your Enrollment Form, sign, date and return it to your Employer Group Administrator.

SilverScript Insurance Company complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. ATTENTION: If you speak English or other languages, language assistance services, free of charge, are available to you. Call 1-888-648-9626 (TTY: 711), 24 hours a day, 7 days a week. ATENCIÓN: Si usted habla español o otros idiomas, tenemos servicios de asistencia lingüística disponibles para usted sin costo alguno. Llame al 1-888-648-9626 (TTY: 711), las 24 horas del día, los 7 días de la semana. 小贴士: 如果您说中文，欢迎使用免费语言协助

服务。请拨 1-888-648-9626 (TTY: 711)。一周7天，每天24小时随时受理。 SilverScript Employer PDP is a Prescription Drug Plan. This plan is offered by SilverScript Insurance Company, which has a Medicare contract. Enrollment depends on contract renewal.


Documents

SDCERA Health Insurance Plans Enrollment form€¦ · condition of obtaining health insurance coverage. Acknowledgement and agreement: I understand and agree that by enrolling with