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									                                                          Memorandum
New York City Transit



Qate   February 1,2007

TO     TWU Local 100 Retired Employees

From   Jim Masella, Assistant Vice President, Employee Benefit

Re     Health Benefit Changes                                     v
       Please note that the following health benefit changes are being implemented.
       This memo provides you with information and applicable forms relating to:


             I.    SPECIAL OPEN ENROLLMENT PERIOD


             II.   REIMBURSEMENTS


             111. MANDATORY PRESCRIPTION DRUG PROGRAM


             IV. CONTACT INFORMATION


             V.    IMPORTANT TELEPHONE NUMBERS AND WEB SITES


             VI. ADDRESS CHANGES
Health Plan Changes
February 1, 2007
Page 2



I. SPECIAL OPEN ENROLLMENT PERIOD
If you do not wish to change your medical coverage, no action is
required by you.
If you wish to change your health benefit coverage, you can do so during the
Special Open Enrollment Period from now through March 16, 2007. Your
chan,ge(s) will be effective April 1, 2007.

Please complete, sign, and return the attached 2007 Special Enrollment Form
[Attachment A], which must be received by MTA New York City Transit's
Employee Benefits Office no later than March 16,2007.

Your health plan choices are described below and on the attached:

A. Not Enrolled in Medicare (under age 65)
GHI Basic Option Enhancements
Pre-Medicare retirees enrolled in the GHI Basic Option may choose to receive
medical services from a participating or non-participating provider. If you use a
participating provider, you will only be charged a $15 copayrnent for
homeioffice visits and for outpatient hospital visits. A non-participating
provider will continue to file for a reimbursement for medical services; however
your reimbursement will be greater. For complete details, see GHI Retiree
Benefit Description [Attachment B] .
Elimination of PharmaCare Prescription Drug Plan Deductible
Your prescription drug plan's deductible of $200 for individual coverage and
$400 for family coverage has been eliminated.
Coverage of Reversible Contraceptives in the PharmaCare Prescription Dmg
plan
Your prescription drug plan has been expanded to include reversible
contraceptives. This includes oral, vaginal, transdermal, and injectable dosage
forms.
 I                  Medical/Hospital
 GHI BASIC OPTION
 hIP HMO (Must live in H P ' s service area)*                  PhamaCare                 GHI   I
                                                          1                                    I
 P ISTA Health Plan (Must live in Vista's service area:
  lorida counties of Broward, Miami-Dade, Palm Beach)
                                                               PharmaCare
                                                                                 I
                                                                                         GHI
                                                                                               I
"Your current HMO coverage will no longer be available to you when you andlor your
dependent(s) become Medicare eligible based on reaching age 65 or being disabled.
You must apply for the Medicare Advantage plan for your HMO in order to continue
your coverage. Your plan will contact you approximately three months before your 65'''
birthday with information on your options.
Health Plan Changes
February 1,2007
Page 3



B. Medicare Eligible (including those on Medicare Disability)

HIPNIP Disenrollment
If you decide to change from HIPIVIP to the GHI Basic Option, you must
disenroll from HIPIVIP by completing the HIPNIP Disenrollment Form
[Attachment C].

Coverage of Reversible Contraceptives in the PharmaCare Prescription Drug
plan
Your prescription drug plan has been expanded to include reversible
contraceptives. This includes oral, vaginal, transdermal, and injectable dosage
forms.

         Medical/Hospital                    Prescription Drup         Vision
GHI BASIC OPTION                                PharmaCare              GHI

  11"s service area)
                                                  HIPIVIP
                                                                  I
11. REIMBURSMENTS                                        i
   A. For GHI Basic Option Members:

   Enhancement
   If you were enrolled in the GHI Basic Option on or after March,any
   medical services you already incurred will automatically be reprocessed by
   GHI based on the enhanced benefits. You can expect a payment to be issued
   directly to you by GHI for the difference between the reimbursement you
   received and the new reimbursement by the end of June 2007. No action is
   required by you.

   Claims Not Filed
   If you incurred medical services since March 1, 2006 but never filed a claim
   with GHI, complete the GHI New Claim Form [Attachment Dl. Attach
   copies of your receipts and mail to GHI as soon as possible. You will then
   receive a reimbursement payment directly from GHI.

   COBRA
   If you were enrolled in GHI at any time since March 1, 2006 and purchased
   rnidical plan COBRA coverage, $ou will be entitled to a refund of a portion
   of that premium. You can expect this refund to be issued by the end of June
   2007.
Health Plan Changes
February 1, 2007
Page 4




   B. For PharrnaCare Prescription Drug Plan Members:      '




  2005 Reimbursement
  If you paid any amount towards the PharrnaCare prescription drug benefit
  deductible during 2005, PharrnaCare will automatically send you a lump
  sum payment of $300. You can expect to receive this payment by the end of
  June. No action is vequived by you.

  2006 and 2007 Reimbursement
  If you paid any amount towards the PharrnaCare prescription drug benefit
  deductible from January 1,2006 through the present, PharrnaCare will
  automatically send you a lump sum reimbursement of the amount you paid        -
  toward the deductible, up to $200 for individual coverage and $400 for
  family coverage. You can expect to receive this payment by the end of June.
  No action is vequived by you.

  Reimbursement for Purchases since December 16, 2005
  You will receive a reimbursement for reversible contraceptives you
  purchased on or aRer December 16,2005 less the applicable copayrnent
  provided you complete the attached Prescription Drug - Reversible
  Contraceptive Reimbursement Form [Attachment El. Attach copies of
  your receipts and mail the completed form to PhannaCare as soon as
  possible. You will then receive a reimbursement payment directly from
  PharrnaCare.



111. MANDATORY PRESCRIPTION DRUG PROGRAM
     See Attachment F for a description of the PharrnaCare Mandatory
     Prescription Drug Program.
Health Plan Changes
February 1,2007
Page 5


IV. CONTACT INFORMATION
          To obtain detailed information about your benefits:
              Visit TENS/WhatYs New Human Resources Home
              PageIEnlployee BenefitsITWU Local 100
              Visit Extranet www.mta.info 1NYC Transit1 Employee Extranetl
              Announcements Employee Benefits1 TWU Local 100
         Contact Employee Benefits by:
                Calling: 1-347-643-8550
                         (8:OO a.m.-5:30 p.m., Mon. thru Fri.)
                Faxing: 1-347-643-8409
                Emailing: employeebenefits@,nyct.con~
         (Zontact TWU Local 100 Member Services by:
                 Calling: 1-347-643-8061 or 8062
                 Faxing: 1-347-643-8063


V. IMPORTANT TELEPHONE NUMBERS AND WEB SITES
   Carrier                      Telephone #               Web Site
 CHI                (2 12) 50 1-4GHI (4444)        rn.gl1i.com
 HIP                1-800-HIPTALK (800-447-8255) ) www.hipusa.com
 Vista              1-866-847-8235               1 rn.vistahealth~lan.com
 PharmaCare     1   1-866-898-6404               I www.pharmacare.com


VI. ADDRESS CHANGES
If you should change your address, you will need to complete the attached
Change of Address Form for Retirees [Attachment GI and submit to the MTA
New York City Transit Employee Benefits Office as noted on the form. If you
have access to the internet, you may obtain this form by going to
r n . M T A . i n f o and clicking on NYC Transit, Retiree Online, Forms Library,
Pensioner Forms.

Atts.
                                                                                                                         Attachment A

                                2007 SPECIAL OPEN ENROLLMENT FORM
                                               Retired Members of TWU Local 100
                                                      EMPLOYEE INFORMATION
Please Print
LAST NAME                      FIRST NAME                                                             MI        PASS #




                                                   COVERAGE ELECTION
MEDICAL:      INDIVIDUAL                        FAMILY
Check Only One:
      GHI BASIC OPTION
      HIPIHMO (Only available to those who live in the New York service area and not enrolled in Medicare)
    0 HIP VIP (Only available to those who live in the New York service area and enrolled in Medicare Parts A and B)
      VISTA HMO (Only available to those under age 65 and living in the Florida Counties of Broward, Miami-Dade, and
        Palm Beach)

                                                             WAIVING COVERAGE:
    O I do not wish to enroll in health coverage. If I need to enroll at a future date, I must contact Employee Benefits
        at 347-643-8550.

I ~ ~ o u s e l ~ o m e Partner's Employer (if applicable)
Name:
                        stic
                                                                   Address:
                                                                                                                                        1
Insurance Carrier (if applicable):
Name:                                                              Address:

1                                                 DEPENDENT INFORMATION                                                                                  I
List all dependents you wish to have on your new election through 2007. Required Documentation for                 dependents not listed on
your current coverage: marriage certificates for spouse, copies of birth certificates for child(ren) and proof of full-time student status for
child(ren) over age 19. You must list Social Security numbers for all dependents.

                 CHECK ONE: A(Add), D(De1ete)                                  CHECK ONE RELAT~ONSHIP       CHECK               DATE OF BIRTH
                                                                                                             ONE
                                                                                                            GENDER
                    NAME (Please Pr~nt)            Soc. Sec.#.                       Domestic       Child   F




                                                                         -
    A    D                                                               Spouse                                     M    Month          Day       Year
                                                                                     Partner*
                                                                                                                 -
                                                                                                                - -
                                                                         XXXXXXXXXXXX



                                                                          X-
                                                                         XX
*NOTE: Your Domestic Partner will not be enrolled in health coverage unless a properly completed application is submitted and
approved by Employee Benefits. Please return your completed form to:
                                                      MTA NYC Transit
                                               180 Livingston Street, Room 6008
                                                   Brooklyn, NY 11201-5861

    Signature:                                                                              Date:               I           I

                                                                 OFFICE USE ONLY
    Effective Date :                        Received By:                                            Date Received:              --I           I
               04/01/2007                   Entered By:                                             Date Entered:                I-p      I
                                            Verified By:                                            Date Verified:                I-p         I

        Revised 01/30/07
                                                                                                                                               Attachment B


                                             GHI Retiree Benefit Description
                               Retired Employees under Age 65 and Not Enrolled in Medicare
 Hospital Services

 Inpatient admissions*                                                  Covered up to 120 days per confinement after you pay $50 per
                                                                        admission to a maximum of $240 per person per calendar year
Emergency room treatment for medical emergency or                       Covered in full
accidental injury
Routine nursery care                                                    Covered in full
Care received in outpatient hospital facilities, including              Covered in full
minor surgery, chemotherapy, mammography, and PAP
smear screening

Treatment for mental and nervous disorders*                             Covered up to 30 days per person per calendar year subject to $50
                                                                        inpatient deductible
Outpatient chemical dependency treatment                                Covered up to 60 visits per person per calendar year
                                                                        Covered up to 30 days per person per calendar year subject to $50
lnpatient physical rehabilitation'                                      inpatient deductible
                                                                        Covered up to $1,000,000 per recipient per transplant. Costs
Organ transplants*                                                      associated with procurement of the organ are covered up to $10,000
                                                                        per transplant.
Home health care                                                        Covered up to 200 visits per person per calendar year
Hospice care
                                                                        Covered up to 210 visits per lifetime
Pre-admission certification requirement: For non-emergency hospital admissions, you or your physician must call GHI Coordinated Care. For emergency
admissions, the call must be made within two business days of the admission. Failure to comply with this requirement will reduce benefits by $250 per day up to a
maximum of $500 per confinement.


Medical Services                                                        When using a GHI Participating Provider
Home and office visits                                                  $15 copayment
Diagnostic x-ray and lab tests                                          $15 copayrnent (when two or more tests are provided on the same day by
                                                                        more than one Provider, you will be responsible for only two copayments)
Annual physical
                                                                       $15 copayrnent
In-hospital surgery                                                    Covered in full
In-hospital anesthesia                                                  Covered in full
In-hospital medical care                                               Covered in full
Out of hospital surgery                                                $15 copayment
Well-child care visits up to age 19                                    $15 copayrnent
Chiropractic - unlimited visits                                        $15 copayrnent
Speech therapy - 16 visits per year                                    $15 copayrnent
Allergy treatment - 16 visits per year                                 $1 5 copayment
Physical therapy - 8 visits per year                                   $1 5 copayrnent
Outpatient mental health                                               $20 copayrnent


When using a non-network provider: You will be reimbursed according to the out-of-network Type D3 schedule of allowances and the Extended Medical
Benefit (EM'). Reimbursement under EMB is subject to a $100 per person per calendar year deductible, 80% of the Allowed Charge, and a lifetime
maximum of $100,000 per covered person. You are responsible for paying any difference between the out-of-network reimbursement and the provider's
charge.


                                        Medicare-Eligible Retiree Coverage Summary

                                                                at
           A program that complements your Medicare Part A and P r B benefits

                                    at
           GHI covers the Medicare P r A hospital deductible and coinsurance up to 120 days

           GHI covers the Medicare Part B deductible and the 20% coinsurance for Medicare allowed
           service
HOSPITAL COVERAGE

Admissions for inpatient hospital care are covered up to 120 days of care during each single
confinement subject to the following deductible provision:

         $50 deductible per person per each single confinement
         $240 maximum deductible per person or family per calendar year

Non-Emergency hospital admissions require you or your physician to call GHl's Coordinated Care
Department at 1-212-615-4662 (1-800-223-9870 if calling from outside of New York) for pre-
admission certification before being admitted. For Emergency admissions, you or a member of
your family must contact GHI Coordinated care within two business days of the admission.

Outpatient treatment for emergency care is covered in full. In addition, you will be covered at
100% of the allowable charge for services performed by an Emergency Room attending
physician.



MEDICAL COVERAGE
PARTICIPATING PROVIDERS

You and your covered dependents are entitled to a full range of medical services through a
network of participating providers known as the GHI Comprehensive Benefits Plan (CBP). You
can visit GHI online at www.ghi.com to find participating providers in your area or call GHl's
Answerline at (212) 501-4444. If your participating medical provider refers you to another
physician, ask your referring physician to recommend a participating provider. If the physician
you are referred to is not a participating medical provider, you will have to pay that physician's full
fee and then file for a reimbursement through the Out-of-Network program.

Services performed in the hospital (e.g, surgery, in-hospital medical visits) are generally covered
in full. For most out-of-hospital services, you will be charged a $15 copayment for horneloffice
visits (including outpatient hospital visits). In addition to a $15 copayment for a homelofice visit,
the most the same participating provider may charge you for tests performed on the date of the
visit is a $15 copayment regardless of the number of tests performed. If more than one
participating provider is seen, the maximum number of diagnostic copayments per date of service
is two ($30). Participating providers will collect the copayments directly from you.

    Example: If on the day of your medical examination by your participating provider one or
    more diagnostic tests are performed, you will be charged a total of $30 ($15 for the office visit
    and $15 for the diagnostic tests). Should you visit two participating providers on the same day
    and they both perform diagnostic tests, you will pay $60 ($30 for two office visits and $30 for
    diagnostic tests performed by two participatirlg providers on the same day. If you were to visit
    a third participating provider on the same day and that provider also performs diagnostic
    tests, you will pay $15 to the third provider for the office visit and nothing to that provider for
    the diagnostic tests - bringing your total out-of-pocket cost for that day to $75.

NON-PAR'I-ICIPKTING PROVIDERS

If you do not choose a participating provider for covered services, you must pay the non-
participating provider the full fee for covered services rendered and then file for a reimbursement
under Out-of-Network Care as described below.
OUT-OF-NETWORK CARE
Covered services provided by a non-participating medical provider are reimbursed in accordance
with Type D3 Schedule of Allowances and Extended Medical Benefits (EMB) Schedule of
Allowances. The EMB Schedule of Allowances is based on the 8othpercentile of the 2005 lnqenix
schedule. If you or your covered dependents use a non-participating medical provider, you will
need to submit a completed claim form to GHI. You may be required to pay the provider in full for
treatment at the time of the visit. You will be responsible for paying the medical provider the
difference between the provider's charge and the out-of-network reimbursement, in accordance
with GHl's allowances and protocols.
Claim forms can be obtained by calling the GHI AnswerLine at (212) 501-4444 or via the GHI
website at www.ahi.com. You will need your nine-digit certificate number indicated on your GHI
Identification Card when calling GHl's AnswerLine. If you have a question regarding your claim
reimbursement call the GHI AnswerLine.
Type D3 Schedule of Allowances
The Type D3 Schedule of Allowances provides a fixed dollar reimbursement amount based on
the particular covered service rendered. The reimbursement is not subject to a deductible,
copayment or coinsurance.
Extended Medical Benefits (EMB) Schedule of Allowances
The Extended Medical Benefits (ENIB) Schedule of Allowances supplements the Type D3
Schedule of Allowances for covered services. The EMB Schedule of Allowances is-based on the
8othpercentile of the 2005 lnnenix schedule The EMB Schedule of Allowances is reduced by any
amount paid under the Type D3 Schedule of Allowances. Then, 80% of the net EMB Allowance is
reimbursed after satisfaction of a $100 per person deductible* up to a lifetime maximum of
$100,000 per covered person.
The following examples show reimbursements for a member after satisfaction of the deductible.




                                                                 $15 Plus $84 = $99



                                                            $192 Plus $726.40 = $918.40



                                                              $17 Plus $66.40 = $83.40


   *Based on 8oth percentile of the 2005 lngenix schedule for the county of Queens, NY. Please
   note, the lngenix schedule is developed using data by geographic area and therefore will
   differ by geographic area.

   Each person is responsible for the first $100 of covered expenses incurred in a Calendar
   Year based on the allowed charge remaining after being processed under the Type D3
   Schedule of Allowances.
OUT-OF-NETWORK CARE
Covered services provided by a non-participating medical provider are reimbursed in accordance
with Type D3 Schedule of Allowances and Extended Medical Benefits (EMB) Schedule of
Allowances. The EMB Schedule of Allowances is based on the 8othpercentile of the 2005 lnqenix
schedule. If you or your covered dependents use a non-participating medical provider, you will
need to submit a completed claim form to GHI. You may be required to pay the provider in full for
treatment at the time of the visit. You will be responsible for paying the medical provider the
difference between the provider's charge and the out-of-network reimbursement, in accordance
with GHl's allowances and protocols.
Claim forms can be obtained by calling the GHI AnswerLine at (212) 501-4444 or via the GHI
website at www.ghi.com. You will need your nine-digit certificate number indicated on your GHI
Identification Card when calling GHl's AnswerLine. If you have a question regarding your claim
reimbursement call the GHI AnswerLine.
Tvpe D3 Schedule of Allowances
The Type D3 Schedule of Allowances provides a fixed dollar reimbursement amount based on
the particular covered service rendered. The reimbursement is not subject to a deductible,
copayment or coinsurance.
Extended Medical Benefits (EMB) Schedule of Allowances
The Extended Medical Benefits (EMB) Schedule of Allowances supplements the Type D3
Schedule of Allowances for covered services. The EMB Schedule of Allowances is based on the
8othpercentile of the 2005 lnnenix schedule The EMB Schedule of Allowances is reduced by any
amount paid under the Type D3 Schedule of Allowances. Then, 80% of the net EMB Allowance is
reimbursed after satisfaction of a $100 per person deductible* up to a lifetime maximum of
$100,000 per covered person.
The following examples show reimbursements for a member after satisfaction of the deductible.




                                                                 $15 Plus $84 = $99



                                                            $192 Plus $726.40 = $918.40



                                                              $17 Plus $66.40 = $83.40


   *Based on 8othpercentile of the 2005 lngenix schedule for the county of Queens, NY. Please
   note, the lngenix schedule is developed using data by geographic area and therefore will
   differ by geographic area.

   Each person is responsible for the first $100 of covered expenses incurred in a Calendar
   Year based on the allowed charge remaining after being processed under the Type D3
   Schedule of Allowances.
                                                                                       Attachment C
                   HIPMP Disenrollment Form
 Last Name: -

 First Name:                       Middle Initial

 Medicare #:                                  Birth Date:

 Sex: D M      F                        Home Phone Number:

If you request disenrollment, you must continue to receive all medical care from HIP
Health Plan until the effective date of disenrollment. Contact us to verify your
disenrollment before you seek medical services outside of HIP Health Plan's network.
We w l notify you of your effective date after we have received this form from you.
     il

Please carefully read and complete the following information before signing and
dating this disenrollment form:

 On the effective date s f enrollment in another Medicare Advantage or Medicare
 Prescription Drug Plan, I understand Medicare will automatically cancel my current
,membershipin HIP Health Plan. I understand that I might not be able to enroll in another
 plan at this time. I also understand that if I am disenrolling fiom my Medicare
prescription drug coverage and do not enroll in such coverage at this time, I may have to
pay a higher premium for this coverage in the future.


Your Signature*:                                            Date:
                           \


*Or the signature of the person authorized to act on behalf of the individual under the
laws of the State where the individual resides. If signed by an authorized individual (as
described above), this signature certifies that: 1) this person is authorized under State law
to complete this disenrollment and 2) documentation of this authority is available upon
request by HIP Health Plan or by Medicare.
If you are the authorized representative, you must provide the folIowing information:

Name:
Address:
PhoneNumber: ( )               -
Relationship to Enrollee


HIP Health Plan is an HMO with a Medicare Advantage Contract


H3330-HO5-114      12/05
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                                                                                                                    CJYES NO I
                         OF ILLNESS3 R INJURY. (RELATE KEYS 1.23 OR 4 TQ ISEM 24E BY LINE)                   2 .MfCflCRIL) RESUBMd816SW
                                                                                                              2
                                                                                                                   CODE                    ,     ORIGIMAL REF. NO.




              W
     (APPROVEDE AWfA COUNCIL ON MEDICAL SERV!CE 8WB)
 BECAUSE THIS FORM IS USED BY VARIOUS GOVERNMENT AND PRIVATE HEALTH PROGRAMS. SEE SEPARATE INSTRUCTIONS ISsuku ar
 &PPLICABLE PROGRAMS.

 NOTICE: Any person who knowingly files a statement of claim containing any misrepresentation or any false, incomplete or misleading information may
           f
 be gailty o a criminal act punishable under law and may be subject t o civil penalties.
                                                             REFERS TO GOVERNMENT PROGRAMSONLY                                                          Attachment D
 MEDICARE AND CHAMPUS PAYMENTS: A patient's signature requests that paymentbe made and authorizes releaseaof any information necessary to process
 the claim and certifies that the information provided in Blccks 1 through 12 is true, accurzte and complete. In the case of a Medicare clairn. the patient's signature
 authorizes any entity to release to Medicare medical and nonmedicalinformation, including employment status, and whetherthe person has employer group health
 insurance, liability, no-fault, worker's compensat~on other Insurance which Is responsible to pay for the services for which the Medicare claim is made. See 42
                                                         or
                                                                                                                           r
 CFR 41 1.24(a). If item 9 is compleied, the patient's signature authorizes release of the information to the health plan o agency shown. In Medicare assigned or
 CHAMPUS patiicipation cases, the physician agrees to accept the charge determinationof the Medicare carrier or CHAMPUS fiscal intermediaryas the full charge,
 and the patient is responsible only for the deductible, coinsurance and noncovered services.Coinsurar~ce and the deductible are based upon the charge
                of
 determinati~n the Medicare carrier or CHAMPUS fiscal intermediary if this is less than the charge submitted. CHAMPUS is not a heakh insurance program but
                                                                         with
 makes payment for health benefits providedthrough certainaffiliati~ns the UniformedServices. Informationon the patient's sponsor should be providedin those
 items captioned in 'Insured"; i.e., items la, 4, 6, 7, 9, and 11.
                                                            BLACK LUNG AND FECA CLAIMS
 The provider agrees to accept the amount paid by the Government as payment in full. See Black Lung and FECA instructions regarding required procedure and
 diagnosis coding systems.
                              SIGNATURE OF PHYSICIAN OR SUPPLIER (MEDICARE, CHAMPUS, FECA AND BLACK LUNG)
Icertify thattheservicesshown on this form were medicallyindicatedand necessaryforthe healthof the patientand were personallyfurnished by meorwere furnished
incident to my professional service by my employee under my immediatepersonal supervision, except as otherwise expressly permitted by Medicareor CHAMPUS
regulations.
For services to be considered as "incident" to a physician's professional service, 1) they must be rendered underthe physician's immediate personal supervision
by hislher employee, 2) they must be an integral, although incidentalpart of acovered physician's service. 3) they must be of kinds commonly furnishedin physician's
offices, and 4) the services of nonphysicians must be included on the physician'sbills.
  For CHAMPUS claims, Ifunher certify that I(or any employee) who rendered services am not an active duly memberof the UniformedServices or a civilian employee :
 of the United States Government or a contract employee of the United States Government, either civilian or military (refer to 5 USC 5536). For Black-Lungclaims,
  I further certify that the services pertorrnedwere for a Black Lung-related disorder.
 No Part B Medicare benefits may be paid unless this form is received as required by existing law and regulations (42 CFR 424.32).
  NOTICE: Any one whomisrepresents orfalslfies essentialinformationto receive payment from Federalfunds requested by this form may upon convictionbesubject
t o fine and imprisonment under applicable Federal laws.
               NOTICE TO PATIENT ABOUT THE COLLECTION AND USE OF MEDICARE, CHAMPUS, FECA, AND BLACK LUNG INFORMATION
                                                                       (PRIVACY ACT STATEMENV
 We are authorized by HCFA. CHAMPUS and OWCP to ask you for information needed in the administration of the Medicare, CHAMPUS. FECA, and Black Lung
.programs. Authority to collect information is in section 205(a), 1862.1872 and 1874 of the Social Security Act as amended. 42 CFR411.24(a) and 424.5(a) (6), and
 44 USC 3101;41 CFR.lO1 er seq and 10 USC 1079 and 1086; 5 USC 8101 et seq; and 30 USC 901 et seq; 38 USC 613; E.O. 9397.
                                                                                                                                                               f
 The information we obtain tocomplete claims under these programs is used to identify you and to determine your eligibility. It is also used to decide I the services
 and supplies you received are covered by these programs and to insure that proper payment is made.
 The informationmay also be given to other providers of services. carriers, intermediaries. medical review boards, heanh plans. and other organlzatlonsor Federal
 agencies. for the effective administration of Federal provisions that require other third parties payers to pay primary to Federalprogram, and as otherwise necessary
 to administerthese programs. Forexample. 11      may benecessarytodisclose informationabout the benefits you have usedtoa hospitalor doctor. Additionaldisclosums
 are made through routine uses for intormation contained in systems of records.
 FOR MEDICARE CLAIMS: See the noticemodifying system No. 09-70-0501, titled, 'Carrier Medicare Claims Record.' published in h,                te-                   Vol. 55
 No. 177, page 37549, Wed. Sept. 12,1990, or as updated and republished.
 FOR OWCP CLAIMS: Department of Labor, Privacy Act of 1974, "Republication of Notice of Systems of Records." Fedoral                           Vol. 55 No. 40, Wed Feb. 28.
 1990, See ESA-5, ESA-6, ESA-12, ESA-13, ESA-30, or as updated and republished.
 FOR CHAMPUSCLAIYS: PRlNClPl F PURPOSF(S);To evaluate eligibility for medicalcare providedby civilian sources and to issue payment upon establishment
 of eligibility and determination that the se~iceslsupplies    received are authorized by law.
                                                                                                                                                and
                         Informationfrom claims and related documents may be given to the Dept. of Veterans Affairs, the Dept. of ' ~ e a l t h Human Services andlor
 the Dept. of Transportation consistent with their statutory administrative responsibilitiesunder CHAMPUSICHAMPVA; to the Dept. of Justice tor representationof
the Secretary of Defense in civil actions; to the Internal Revenue Service, privatecoilection'agencies, and consumer reporting agenciesin connectionwith recoupment
 claims: and to CongressionalOffices in response to inquiries made at the request of the person to whom a record pertains. Appropriate disclosures may be made
to other federal, state, iocal, foreign government agencies, private business entities, and individual providers of care, on matters relating to entitlement, claims
adjudication, fraud, program abuse, utilization review, quality assurance. peer review, program integrity, third-party liability; coordinationof benefits, and civil and
criminal litigation related to the operation of CHAMPUS.
DlSCl 0   -           Voluntary; however, tallure to provide informationwill result in delay in payment or may result in denial of claim. With the one exception discussed
below, there are no penaltiesunder these programsfor refusingto supply information. However, failure to furnish information regarding the medicalservices rendered
or the amount charged would prevent payment of claims under these rograms. Failure to furnish any otherinformation, such as name ordaim number, would delay
payment of the claim. Failure to provide medical information under R c A could be deemed an obstruction.
It is mandatory that you tell us if you know that another party is responsiblefor paying for yourtreatment. Section 11288 of the Social Security Act and 31 USC 3801          -
3812 provide penalties for withholding this information.
You should beawaretbatP.L.100-503, theUComputer             Matching and Privacy ProtectionAct of'1988",permits thegovernment to verify informationbyway of computer
matches.
                                                         MEDICAID PAYMENTS (PROVIDER CERTIFICATION)
Ihereby agree l o keep such records as are necessary to disclose fully the extent of services provided to individuals under the State's Title XIX plan and to furnish
information regarding any payments claimed for providing such services as the State Agency or Dept, of Health and Humans Services may request.
I further agree to accept, as payment in full, the amount paid by the Medicaid program for those claims submitted for payment under that program, with the exception
of authorized deductible, coinsurance, co-payment:or similar cost-sharing charge.
SIGNATURE OF PHYSICIAN(OR SUPPLIER): Icertiiy that the services listed above were medically indicated and necessary to the health of this patient and were
personally furnished by me or my employee under my personal direction.
NOTICE: This is to certify that the foregoing information is true, accurate and complete. 1 understandthat payment and satisfaction ol this claim will be from Federaland State
           funds, and that any false claims, statements. or documents. or concealment of a material fact. may be prosecuted under applicable Federal or State laws.
Public reporting burden tor this collection of intormation is estimated to average 15 minutes per response. including time for reviewing instructions, searching existing
date sources, gathering and maintaining data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or
any other aspect of thls collection of information, including suggestionsfor reducing the burden, to HCFA, Office of Financial Management. P.O. 26684. Baltimore.
MD 21207; and to the Otfice of Management and Budget. Paperwork Reduction Project (OMB-0938-0008).             Washington. D.C. 20503.         . Box
                                                                                                                                                 4*
                                                                                                                                                  - 8      15006 500M 12/03
  I +C;Ei?TiFY                              TH1S CL4!fd I MADE: I A C3ifEFBE3 PERSON Ihl T3lS PFtESCRlPTlON DRgG
             THAT TttE PATIENT FOR \PdHi3i.Jf           S       S
  PROGRcaM AND THAT THE PRESCRlPTlON I FOR THE SOLE iiSE OF THE NAME3 f,,4T!E!47: i $,!-SO CERTIFY THAT ,THE
                                              S
  CLAIM(3) BEING SUBMITTED FGR WMZNT ARE NCIT ELI'GIBLE FOR PP.YMENT ENDERA I\lO-=AULTAGTOhlI;13blLEOR




                                                                                                      ESEiPS that was; on your medicaiicrn bag at




                        ABDUT YOUR GUBMmED CLAI?&
 fh$P#RyAr$TiHFOR@j#+hjON
" Vcs'ilI sniy reirnbum;.eat ihe se~aif
                                      day suppf~i
                                                allowance.
* !Hi]!an& h reimbursnd far medications cdvered kinder the plan or madtcations ahat alrsedy have bfen au'rhorimsi.d.
* Sl;~mit  this form for !.rjimburc,ern%ntbecauss fi wras necessary to purchase a pm.sciipQisn ~ h you did nct have you;..id@ni,ification
                                                                                                   b        e ~
        or because tile phar~racy h e . ~ p~scriptio;:has fifled is o non-pzplicipsting pharmacy,jPiar! ~pecBic,piease chsci.,
                                      w    youp
  individuei plans).
* Submit a separate claim form for eantl patient.
* ~ J b ~ this .f a n aa soar! as you haye your prescriadon(sgfllEe3. Sliaims may n3t S3 ~eirnbtr:ssc! after on6 year,
            i f                                                                            t
" Claim fans; subrnitk'red wrtriraw the required isrfomai;!or vdli cause pqntent delays or          b.;- retumec;: to p ,
                                                                                                                       u
* [f you have ;my questions or concerns reg~rriing     your cbirn, pleas2 call i h e foil4ree telophsna number on :?our
  p~es~riptio~i                card.
                 id~ntifi~at1671~
FOR COMPOUND PRESCRIFTlDNS ONLY
If yaur p h a m ~ c i stdls you this b 8 carnpsundod pw,acription, nave your pharrnscist cample?e the area Selov;. Shotrid yoti har/e
                        t
more than twu compalsndsd pwscriptions, please use addiiona! fCmr~s,           -

                                                                                              Carnocznd Ingreajenk
                Claim #                               NElC #
                                                                                          Dag tqainifts                      Cliy            Ccs:
                                                                                                                     t
                                       t
PRlVACY NOTB'JE: We wiil use the address provided above tr; send p u r reimbursemani, svm if contrary to any csnfidentiai communications
inst;tru&;irqns YOU may have ~ l fiia wiih PhnmsSart?. 1 p u dssira this reimhursernenf tcr be sent tcj a wnfidenlial address the4 tics previously beer)
                                  i                        :
comn;unr=t& to PharmaC~r~,          plsas~  indicate that Bdrt~zs this f o m trt any case, the edire??rsLqat y provide here will be used oniy mr
                                                                on                                            u
                         Elired Msmba: R@inburcjernsn!.
maiiifigs ~~318ted t h j ~
 PWESCRIIPTDOM D R U G B E N E F I T


                                                                                     h
PharmaCare's mail service program i administered through PhrmaCarc Direct. T e progain
is designed mainIy for rhose on maintenance medicarions rbr the umunenr of chronic, long-
term conditions such as - but nor h i t e d to - diabetes, arrhrids, high blood pressure and
h m conditions. You d receive up t6 a 30-day supply a: a time char is delivered directly to
your home. A record of YOUT prescriptions is mmah~dncd P h a n n a b e to monitor for
                                                           by
adverse reactions 554th other prescriptions you may receive from the mail order o rc-d
                                                                                  r
network pbrnacy. A pharmacist will conmct your doctor or you before dispensing a
medication if &ere is concern far possible drug inre;i~,Tions adverse reactions.
                                                              or




for up to a %&daysq~ply-%mmber,
phamaq d be xejead


    I . If your doclar prescribes a maintenance drug, have it wrincn for up to a 90-day
        supply wiEh t h e e (3) rzfds. By law, a prcscriprion can only b:: filled for the quandry
                                                                  h:
        indicated by your doctor and is d i d for one year fram t: dare on the prescription.
    2. If you need medicarion immediaretiy, ask your doccor far two (2) sepzrare
        prac+dons - one ZQ be fiUed zt a n m o r k d l pharrnac);, &e other to be fded by
        mail service,
    3. Examine rhe prescription to mdce sure            it includes h e dosage, the docrot's
        sipxure, your name, your address and your telephone numbcr.
    4. Complete h e CanfxdenciaI Parient Profile and E n r o h e n t Form. Ynd can obtain this
        form by contacting PharmaGre Customer Service at 866-838-6404.
    5. Ifyour medications are not delivered to your home within seven m ren working days
        call P h a r m h Customer Service.
    6 . Order refills by eirhcr cailins h e m toll fie. a 866-898-6404 ['I'DD-E-ieuing
                                                         t
        InapdrcdNumber 800-238-0756] or through their website ac v.ww.PharrnaCm.com
        as nored in the fmr paragraph of dlis semion. Be prepared r provide your.
                                                                         o
         * member ILP number
        * presuipt;on numbc:(s)
           your credir card information
Psipenas Yon MWX      Make
     Plan copaymenk (Z     applicable)
     Cost of medimrions not covered under your prescriprion bug pmgam
     Cost of a prscpiprion when you use an our-of-network pharmacy .
Day Phone #                                                                    Evening fionane #


New Address:
h Care of




Previous Address:
in Care of
(ifapplicable),                                        I                  ,$             t~                       a          I   a                   ,
Adhssi,,            f   I   I        #   t         E   9   8   * ,    t   %      f   t   ,        8     ,     a   tApt.Nwber,            _   ,   !   (   1

c i t y I ,             ,   I       I        a     t   1          t   t   r      I   r   t    1   JShfe,          tZipCode,          8   8   8       1   3



Are you currently receiving a supplment pttyyment &om MIA WX'CTMaBSTOA Treaswy Department
         0 Yes                   No


Signature of Retiree                                                                                  Date:
                                                                                                              L a L $ w + T - y

                                                  Do Not Complete. FOPOmce use only.


                                                                           Date Entered an MSA

                                                                           Date C1-teck.edon MSA

                                                                           Date Entered on PeopleSoft


Sipawro of Employer's Authorized representat~ve                                                                       Datc


In use beginning November 2004                                 fom *I08                                                                  Page 1 of 7

								
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