DentAl cArefor Pef retIrees

www.buymbp.com

(518) 785-1900 or(800) 342-4306,

ext. 243

this guide was prepared by the Pef membershipbenefits Program. for additional copies of thisbooklet, please contact the membership benefitsProgram.

membership benefits Program1168-70 Troy-Schenectady Road

PO Box 12414Albany, NY 12212

1-518- 785-1900 or 1-800-342-4306, ext. 243Fax 1-518-783-5339

Web site: www.buymbp.com

Email address: mbrequests@pef.org

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Attn:retiree

Dentalcoordinator

1168-70Troy-Schenectady

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Box12414

Albany,N

Y12212-2414

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enroll toDAY!enrollment form

IncluDeD InsIDe

Please make sure you havesigned and fully completedthe enrollment form to start

enjoying this convenient andaffordable progam!

AfforDAbleYour PEF Retiree membership allows low group ratesfor dental care designed to provide you with themost coverage and minimal out-of-pocket costs.

convenIentPay your dental premiums through pension deductionand enjoy the freedom and time-saving convenience.Pension deduction also saves you check processingfees for dues (14% per year).

broAD Access to ghI network DentIstsGHI pioneered dental insurance in New York over 40years ago and has built a network of thousands ofqualified practitioners throughout the U.S. For moreinformation, visit the GHI’s Web site for a current list ofnetwork dentists: www.ghi.com.

on-DemAnD benefIt InformAtIonA personalized, online portal for instant access toclaims information, benefit eligibility, network dentistlistings and more.

free vIsIon DIscount PlAnEnroll in the PEF Retiree Dental Program and receivea Vision Discount Plan at no additional charge.Details on the vision services and savings can befound at www.buymbp.com/ghi.

the Pef retIreeDentAl ProgrAm Is…

InstructIons for PensIon checkDeDuctIon AuthorIzAtIon form

Social Security Number and Retirement Number arerequired by the ERS in order to process thisauthorization. The Retiree Office does not share theSocial Security Number with any otherorganizations and does not print the Social SecurityNumber on any records or documents. It onlyappears on computer screens when a record isdisplayed.

Retirement Number is provided in your final awardletter from the ERS and is also on your pensioncheck stub if you receive your pension by check. It isalso shown on any pension change notices that youreceive. If you can locate your Retirement Number,please write it in; if you cannot locate it, call the ERSat 1-518-474-4602 and ask them to provide youwith your Retirement Number.

Revocation forms are available by calling the RetireeOffice at 1-800-342-4306 ext. 289/288.

Completed and signed forms should be mailed to:PEF Retirees, 1168-70 Troy Schenectady Road, POBox 12414, Latham, NY 12414-2414.

ImPortAnt

1. If you previously authorized electronic fundtransfer from your checking account, this willautomatically be cancelled.

2. If you prepaid your dues and/or dental plan, wewill mail you a refund check for these prepayments(payments for and after January 2011).

Group Health Incorporated (GHI), HIP Health Plan of New York (HIP), HIP InsuranceCompany of New York and EmblemHealth Services Company, LLC are EmblemHealthcompanies. EmblemHealth Services Company, LLC provides administrative services tothe EmblemHealth companies.

Refer to GHI policy forms numbers PLD-1104-C, PLD-1103-C, et al.

PayMent oPtions

• Pension deduction —the most convenient option avail-able because it allows you to pay for both your retireedues and dental premiums. The form is located to theright of the dental enrollment form. (Please include acheck for two months of premiums to start.)

• Call PEF Membership Benefits at 1-800-342-4306,ext. 243, option 4 for other payment options.

Complete the following enrollment forms and return inthe attached envelope to PEF Membership Benefits:

• Coverage information for the PEF Retiree Dental Plan

• Sign the pension deduction authorization and bothdues and dental premiums will be deducted con-veniently. You will also receive these benefits FREEwith pension deduction:• Vision Discount Plan (EyeMed)• Identity Theft Protection Service

• Coverage starts the first of the month iF forms and acheck for the first two months’ premium are accu-rately completed and received and verified by us bythe 15th of the preceding month.

Questions?Billing Questions:call PeF Membership Benefits at:Phone: 1-518-785-1900, or 1-800-342-4306, ext. 243,option 4; Monday to Friday, 9:00 am to 5:00 pm EST

email: mbinsurance@pef.org

Web: www.buymbp.com/ghi

claiMs Questions:call PeF Membership Benefits at:Phone: 1-800-624-2414Monday to Friday, 9:00 am to 5:00 pm EST

Web/email: Register at www.ghi.com to contact customerservice via email, review benefits and claims information andsearch for a doctor.

enroll today

dental BeneFits at a glance:

Free vision discount Plan services

Preventive and diagnostic services• Examinations• X-rays• Cleanings

Basic services:100 percent coverage after $25 annual deductiblewhen you see in-network participating practitionersfor the following:• Fillings• Root canals• Extractions• Periodontal treatments

ProstheticsRider Options for Prosthetics:Bridges, dentures and crowns are covered servicesprovided you purchase a “rider” (see Eligibility sectionin the brochure for details on purchasing riders).Prosthetics are subject to a $25 annual deductible.• 50 percent—covering 50 percent of GHI’s allowance.• 80 percent—covering 80 percent of GHI’s allowance.• Above riders subject to a $25 deductible.

Example: Choose 80 percent rider. Participating dentistcharges $100 for a crown and GHI’s allowed charge is $80;you pay dentist $20, after the $25 deductible, if applicable.

annual MaxiMuM$1,200 per person

coverage startsThe first of the month (completed form and a check for thefirst two months’premium must be received and verifiedby us by the 15th of the preceding month).

Note that dental implants and orthodontia services are excluded.

• The EyeMed Vision Care® Discount Plan is not insur-ance, but it offers PEF Retirees savings on exams,lenses, frames and certain services.

• Vision Plan discounts are administered by EyeMedVision Care.

• Visit www.buymbp.com/ghi for a complete summary.

These two panels stay blank.They are inside of theenvelope once it folds.

DesIgneD for Your unIque neeDs

the Pef retIree DentAl ProgrAm

The PEF Retiree Dental Plan, underwritten by GHI, hasbeen offering affordable dental care for PEF Retireessince 1991. The information in this brochure willintroduce you to the plan so you can best determine if itfits your needs. Please carefully review the portion onwhat coverage level you are eligible for at this time. Toenroll in the plan, complete the enclosed enrollmentform and sign the Pension Deduction authorization atthe bottom of the enrollment form (if you are choosingpension deduction) and return it to us in the attachedenvelope. Start enjoying the convenience of payingwith automatic pension deduction. Please note thePension Deduction authorization is at the right of theenrollment form.

Graham GoffinAdministratorPEF Membership Benefits ProgramRevised 1/11

Perf will go here AND on the other side ofthe pension deduction form AND on theother side of the enrollment form.

enrollment/chAnge form Pef retIree DentAl InsurAnce ProgrAmPlease print, complete all sections and return to PEF Membership Benefits using the enclosed envelope.

Last Name First Name MI Gender Social Security Number

Home address—Number & Street—Apt. #

City State Zip Code

Telephone Retirement Date Date of Birth

Pef retIree DentAl PlAn InformAtIonDo you currently have dental coverage? � No � Yes

Name/Address of other dental insurance coverage

Policy Number Effective Date

Does your spouse currently have dental coverage? � No � YesName/Address of other dental insurance coverage

Policy Number Effective Date

Please check one box: � Member � Member/Spouse � Family � Basic Dental Plan Only (after 90 days of retirement)

Upgrade Options (within 90 days of retirement or 30 days prior to COBRA termination):� Basic Dental Plus 50% Prosthetics � Basic Dental Plus 80% Prosthetics

COMPLETE ONLY IF PURCHASING SPOUSE or FAMILY COVERAGE:Spouse/Dependent children to be covered: Spouse Son Daughter

Last Name First Name MI DOB SSN

�

� �

� �

requested effective Date of Dental Plan:Note: The form must be received and verified by the 15th of the month for coverage to start on the 1st of the following month.

billing: Monthly pension deduction (Please sign the pension deduction authorization at right and return it with your check,made payable to PEF Membership Benefits Program (include two monthly premiums).

I have certified the above information is accurate:

PEF Retiree Signature Date

Please mail completed form using the attached envelope.*Payment: Two months of premium for the above selected plan.

monthlY cost

Member only Member with Family*(Single) Spouse

Basic: $23.61 $41.51 $63.86

Plus 50%Prosthetics: $33.27 $60.85 $95.27

Plus 80%Prosthetics: $49.78 $93.87 $148.93

• first year in the plan: Basic Dental Service unlessyou enroll in the dental program within 90 days afteryour retirement date (and you had a dental programprior to retirement). In that case, you are eligible toselect either the 50% or 80% prosthetics option.

• After 12 months in the plan, you are eligible toupgrade to the 50% prosthetic rider coverage(crowns, bridges, dentures).

• After two years, you are eligible to increase andupgrade to the 80% prosthetic rider coverage.

Note 1: When your time period to upgrade to a rideroption becomes available and you decline, you willno longer be eligible for either rider option.

Note 2: Dues-paying PEF Retirees are eligible toparticipate provided they did not previously have theplan, then leave it.

Note 3: Special COBRA offer: If you apply within 30days of your COBRA termination, you may selecteither the 50% or 80% Prosthetics option.Reimbursement is based upon the applicable percentage of the GHI PreferredSchedule of Allowances.

elIgIbIlItY

Please print, complete, detach and return in the attachedenvelope for processing.

PensIon check DeDuctIonAuthorIzAtIon form

Social Security Number

Retirement # (required)

Retirement Date (required)

Last Name First Name M.I.

Address

City State Zip

Telephone #, Including Area Code (required)

Email Address (By providing your email address, you are givingpermission to communicate with you electronically.)

To: The Comptroller of the State of New YorkPursuant to 110 of the Retirement and Social SecurityLaw, I hereby authorize deductions to be made from mymonthly allowance from the NYS and Local RetirementSystems in the amount necessary to cover membershipdues and/or insurance premiums payable on my behalfto the NYS Public Employees Federation Retirees.Authorization is also given to make any changes theunion certifies to the Retirees System as necessary inthe amount of such dues or insurance premiums. Iunderstand that the NYS Public Employees FederationRetirees is my agent and all requests to begin, modify,or revoke deductions must be submitted through theunion. This authorization shall remain in effect untilrevoked by me by written notice thorugh the union oruntil otherwise revoked pursuant to law.

Signature of PEF Retiree

Date

*Dependents covered through age 19 and dependent students covered through age 25.