1. Healthcare

2015 Annual Open Enrollment/Change Form
Active ATU 726
HR-BEN-369B
Section 1 - Information and Instructions
The purpose of this form is to enroll in or change health insurance, effective February 1, 2015.
Please email a signed copy of the form to [email protected] or fax to 212-852-8700 or drop off at the 180 Livingston Street Walk-in Center 8:30
a.m. to 5 p.m., Monday – Friday. If you have any questions, please contact the Business Service Center (BSC) at 646-376-0123.
Section 2 - Employee Information
BSC ID
Print Name
Last
Phone (H)
First
M.I.
Suffix
Pass #
Email
Phone (W)
If your address on your pay stub is incorrect, contact the Business Service Center OR log onto www.mtabsc.info and change your address
online OR complete HR-HRIS-012 Employee Data Change Form. An incorrect address will delay receipt of your new health insurance cards.
Section 3 – Coverage Election – Effective February 1, 2015
Medical
Individual
Family
Check One
EMPIRE BLUECROSS BLUESHIELD BASIC OPTION
EMPIRE BLUECROSS BLUESHIELD HIGH OPTION
(Bi-weekly pre-tax required contribution of $13.17 for Individual Coverage and $26.34 for Family Coverage)
UNITEDHEALTHCARE CHOICE OPTION (Live/work in the 5 boroughs of NY, the New York counties of Duchess, Nassau, Orange, Putnam, Rockland, Suffolk, Sullivan,
Ulster and Westchester and the States of New Jersey, Pennsylvania, Connecticut and Delaware)
OPT-OUT PROGRAM (for Medical/Hospital/Prescription Drugs)
I agree to the Terms and Conditions of the Opt-Out Program on the back of this form. Alternate medical information must be provided below.
Name of Policyholder:
Policy #:
Name of Insurance Carrier:
Employer of Policyholder:
Dental
Individual
Relationship:
SS# of Policyholder:
Date of Birth of Policyholder:
Family
Check one of the following dental plans ONLY if you did not enroll in the EmpireBCBS High Option, which includes dental coverage.
DENTCARE/HEALTHPLEX (DMO)
GHI SPECTRUM DENTAL (PPO)
Section 4 – Dependent Information
If you are found to be covering an ineligible dependent, coverage will be terminated retroactive to the date of the ineligibility and NYC Transit will
pursue financial restitution for claims and/or premiums for the ineligible dependent.
1. Please fill in all information for new dependents you wish to enroll and submit required documentation (see Section 6).
2. Please fill in all information for any dependents you wish to delete.
3. Please contact the Business Service Center for the Domestic Partnership Package if you wish to enroll a domestic partner.
NOTE: Your domestic partner will not be enrolled in health coverage unless an application is submitted and approved by the Benefits
Department.
Check One - Indicate (A) Add or (D) Delete
A D Name
SSN
Check One - Relationship
Spouse
Domestic Partner
Gender
Child
F
M
Date of Birth
Mo
Day
Section 5 - Authorization
My signature and date on this form certifies and warrants that all dependent eligibility information is true, correct, and current. I also certify that
dependent children from age 19 to 26 that I have enrolled in coverage are not eligible for another employer-sponsored coverage.
Employee Signature
Business Service Center
Last Revised: 08/15/2014
Date
Creation Date: 04/01/2012
Year
2015 Annual Open Enrollment/Change Form
Active ATU 726
HR-BEN-369B
Section 6 – Dependent Required Documentation
1. For a Spouse
A copy of Marriage Certificate, Social Security card, and, if your date of marriage is more than one year old:
 Your most recent Tax Return—Federal or State (including Puerto Rico Returns)
o Your most recent tax return showing “Married Filing Jointly” or “Married Filing Separately”. Your spouse’s name must appear on
the tax form on the line provided after the “married filing separately” status (or vice versa).
o Only submit page 1 of the tax return. This should include the 1040 form, eFile Confirmation page, Tax Preparer’s Summary, or
Federal Return Recap.
o Eliminate all financial information.
OR
 Proof of Joint Ownership
Both the enrollee’s and spouse’s name must be listed on the documentation of joint ownership and be dated within the past 90 days.
Examples include a copy of:
Homeowners/Renters Insurance Policy

 Mortgage Statement
Credit Card Statement

 Property Tax Document
Loan Obligation

 Rental/Lease Agreement
Bank Account Statement

 Utility/phone/internet/cable bills
Pension/life insurance/will designating spouse as beneficiary

If you are not able to provide the required documentation, complete and sign the affidavit enclosed in this package.
Have it notarized and return it with your Enrollment form.
2. For Children
For a Natural-Born Child, a copy of:


Birth Certificate showing employee’s name
Social Security card
For a Stepchild, or Legally Adopted Child, a copy of:
 Birth Certificate
 Social Security card
 Legal documentation concerning adoption
3. Dependent Children Coverage between ages 19 and 26

To enroll a dependent child from age 19 to 26 in your medical, hospital, and prescription drug coverage, add the child’s name on this form,
submit required documentation, and affirm by signing this form that your child is not eligible for other employer-sponsored coverage.

Those who enroll in the High Option are not required to submit student verification from age 19 to 21 to cover dependent children in dental
coverage.
Section 7 – The Opt-Out Program Terms and Conditions
Incentive for Opt-Out
You may opt out of medical coverage and receive a lump sum incentive payment. Opting out of medical coverage means that you elect not to
participate in medical, hospital, and prescription drug coverage. You will however retain coverage in dental and vision plans. To be eligible, you
must document that you will be covered by another medical plan sponsored by:



a spouse or domestic partner’s employer
another employer
armed forces
Lump Sum Incentive Payment
Payment of the lump sum incentive will be made at the end of the Opt-Out year in the following amount:

$550 for an employee who receives medical coverage through spouse/domestic partner who is also employed


$550 if you opt-out of individual medical coverage
$1,100 if you opt-out of family medical coverage
by NYC Transit or another MTA agency
If you participate in the Opt-Out Program and either re-enroll or retire during that same year, you will not be eligible to receive any part of the
incentive payment.
Terms of Agreement
I understand that this election will be effective from January 1 st through December 31, 2015 unless I am no longer allowed by law or as a result of a
qualifying event or such other events as the Authority determines will permit a change or revocation of an election.
I understand that the lump sum payment will be subject to all applicable Federal, State and Local taxes. I also understand that these monies will not
be considered income for pension purposes and will not be included in any calculation therein.
This agreement is subject to the terms of the employer's plan, as amended from time to time in effect, shall be governed by and construed in
accordance with applicable laws, shall take effect as a sealed instrument under applicable laws and revokes any prior election and compensation
agreement relating to such plan. The health benefits waiver will be administered as permissible under IRS section 125.
Business Service Center
Last Revised: 08/15/2014
Creation Date: 04/01/2012
ATU Local 726 Health Plan Highlights 1
MEDICAL
Bi-Weekly Pre-Tax
Deductions
Monthly Pre-Tax Deductions
Type of Plan
Office Visit
Specialist Office Visit
Diagnostic Service
Hospital Service
Well-Child Care Visits up to
Chiropractic
Outpatient Mental Health
Inpatient Alcohol and
Substance Abuse
Physical Therapy
PRESCRIPTION DRUGS
for all medical plans
Retail
Generic
Name Brand Formulary
Name Brand Non-Formulary
Mail Order2
Generic
Name Brand Formulary
Name Brand Non-Formulary
Empire BlueCross BlueShield
Basic Option
Empire BlueCross BlueShield
High Option
United HealthCareChoice
United HealthCareChoice Plus
Not Open to New Enrollees
$0
$13.17 Individual, $26.34 Family
$0
NA
NA
NA
NA
$25.00
In-Network and Out-of-Network
In-Network Highlights 1
$15 copay
$15 copay
$15 copay
$50 deductible, Up to 120 days
$0 copay
$15 copay
In-Network and Out-of-Network
In-Network Highlights 1
In-Network and Out-of-Network
Highlights1
$15 copay
$15 copay
$15 copay
$50 deductible, Up to 365 days
$0 copay
$15 copay
HMO In-Network only
Highlights1
$0 copay
$0 copay
$0 copay
$0 deductible 365 days
$0 copay
$0 copay
$20 copay, 60 visits per year
$20 copay, 60 visits per year
No copay, 60 visits per year
$20 copay, 20 visits
$0 copay, 5 days per year
$0 copay, 5 days per year
$0 copay, 7 days per year
$300 copay
$15 copay, 8 visits per year
$15 copay, 8 visits per year
$0 copay, 90 visits per year
$20 copay, 60 consecutive visits
OPTUM RX
Up to 30 days supply
$0 copay
$10 copay
$15 copay
Up to 90 days supply
$0 copay
$20 copay
$30 copay
OPT-OUT PROGRAM
Coverage
Opt-out
Retain
Incentive
Individual
Family
Medical, Hospital and
Prescription Drugs
Dental and Vision
Lump sum at end of year
$550
$1,100
$15 copay
$20 copay
$20 copay
$300 copay
$0 copay
$20 copay
ATU Local 726 Health Plan Highlights 1
DENTAL
HealthPlex/Dentcare
Type of Plan
Deductible
Yearly Maximum
Orthodontics
Oral Examination & Diagnosis
X-Rays
Prophylaxis (cleaning)
Filling
Root Canal
Crowns and Bridges
VISION
Every 12 months
Eye Exam
Frames
Lenses
Single Vision
Kryptok Bifocal
Trifocal
Dependent Coverage
when coverage ends
MEDICAL
PPO Basic/High Option and HMO
Vision In-Network/Out-ofNetwork/DME
Medical/Hospital
High Option
Dental/Vision/Out-of-Network
/DME
PRESCRIPTION
Optum RX
DENTAL
HealthPlex/Dentcare 3
GHI Spectrum Plus Dental
1
DMO In-Network only
GHI Spectrum Plus Dental
PPO In-Network and
Out-of-Network
Highlights1
$0
None
In-Network Highlights1
$0
None
$950 copay-Up to 24 months
Covered in full
Covered in full
Covered in full
Covered in full
Covered in full
$50 copay on bridges
Not Covered
Covered in full
Covered in full
Covered in full
Covered in full
Covered in full
Covered in full
High Option Dental
(this is the only dental choice for
those enrolled in High Option medical
plan)
PPO In-Network and
Out-of-Network
In-Network Highlights1
$50 per person, per year
$1,200
$1,500 lifetime max
Covered in full
Covered in full
Covered in full
80%
80%
50%
UHC
In-Network
(General Vision Service)
Covered in full
Up to $100
Out-of-Network
Maximum Reimbursement
$40
See below
Covered in full
Covered in full
$73.00 (includes frames & exam)
$81.00 (includes frames & exam)
Covered in full
$89.00 (includes frames & exam)
Age 19
Age 21
Age 26
N/A
N/A
End of Month
End of Month
N/A
N/A
N/A
End of Month
End of Month
N/A
N/A
N/A
End of Month
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
For detailed information on In-Network and Out-of-Network coverage, please refer to your Summary Plan Description (SPD).
If you are on a maintenance medication that has been filled two times at a retail pharmacy (original prescription plus one refill), mail order is mandatory.
3
If Full-time student verification is submitted, coverage continues to end of year they reach age 23.
2