2018 DENTAL VISION IDENTITY THEFT

Transcription

1 2018 DENTAL VISION IDENTITY THEFT OPEN ENROLLMENT DENTAL INSURANCE VISION INSURANCE IDENTITY THEFT Learn more at: Call us at: Open Enrollment Ends October 31, 2017 Administered by:

2 Enrollment must be completed on or before October 31, 2017 Call: September 1, 2017 Dear Retirement Benefit Recipient, The North Carolina Department of State Treasurer is continuously working to enhance the benefits that are available to you in retirement. Pierce Insurance Agency Inc., our vendor for supplemental insurance products, will hold an open enrollment from October 1 through October 31, 2017, for retirees of the North Carolina Retirement Systems. Coverage will become effective January 1, If you have supplemental insurance and do not wish to make any changes, no action is needed. We are making available to you supplemental insurance plans for which your premium payment can be deducted directly from your monthly retirement benefit, direct billed or bank draft. This enrollment book summarizes the supplemental insurance plan benefits available to you as a North Carolina Retirement Systems retiree, including: Identity Theft Protection by LifeLock Dental Vision We encourage you to carefully review all of the enclosed materials from Pierce Insurance which outline the details of these products. It is important to note that to be eligible to participate in these optional benefits, you must complete your enrollment process by the following deadlines: For current retirees participating in supplemental insurance plans Complete open enrollment by October 31 by paper, online ( or ( ) only if you want to add, change or cancel your plan features. For current retirees not participating in supplemental insurance plans Complete the open enrollment process by October 31 if you want to obtain Dental, Vision or Identity Theft Protection insurance coverage. For new retirees Complete the enrollment process within 60 days after you have received your first retirement benefit payment. For additional details or specific questions, please contact Pierce Insurance Agency Inc. toll free at or online at Thank you for your service to the great state of North Carolina. Sincerely, Steven C. Toole Executive Director, North Carolina Retirement Systems 3200 ATLANTIC AVENUE, RALEIGH, NORTH CAROLINA Telephone (877) toll-free Fax (919)

3 Enrollment must be completed on or before October 31, 2017 North Carolina Retiree Benefit Overview Table of Contents Dental Vision Identity Theft Tips to Enroll Enrollment Form Who to Contact Resources NC Retiree Supplemental Benefits: Pierce Insurance Agency: NC Retirement Systems: ORBIT- Retirement Account Access: (then click the ORBIT button) State Health Plan: Life, Critical Illness, Accident: There is no association fee required to enroll in these supplemental benefits. Pierce Insurance is the trusted partner for the North Carolina Retirement Systems. Benefits offered are: Dental Vision Identity Theft Enrollment starts October 1, 2017 and ends October 31, Your first deduction will be December We have a special hot-line exclusively for NC retirees to enroll or ask questions. For the most up-to-date information visit or call toll free Detailed FAQ can be found at: Who is eligible? Retirees, spouses and unmarried children (eligible until the day they turn 26). Handicapped children with disabilities are eligible for identity theft protection, dental and vision insurance, regardless of age. As a surviving spouse, you must enroll in the plan through the normal enrollment process. You must complete a new enrollment form and submit to Pierce Insurance Agency or call (For detailed explanation on eligibility go to: Member must notify Pierce Insurance Agency when dependents no longer meet eligibility requirements. How are the monthly premiums collected? Pension deduction Direct bill (monthly, quarterly, semi-annually or bank draft) Firefighters and Rescue Squad Workers, National Guard or Register of Deeds Pension Funds benefit recipients qualify for direct bill only Life (with Money for Long Term Care) and Accident Insurance In order to streamline programs the NC Department of State Treasurer has decided to freeze the Life Insurance including Long Term Care, Critical Illness and Accident plans. If you currently have this coverage you may keep these plans on pension deduction or direct bill. Pierce Insurance offers Guarantee Issue Life and Guarantee Issue Accident Insurance plans on a direct basis. Learn more and enroll by calling or visit About This Guide This guide describes benefits offered through the North Carolina Retirement Systems. In the event of any discrepancy between what is written here and what is written in the plan document and insurance certificates, the plan document and insurance certificates will govern. Changes in the tax laws or other requirements might cause changes in the plan. 3

4 Enrollment must be completed on or before October 31, 2017 Call: Dental Coverage Dental Plan Features Preventive and Diagnostic Services covered at 100% of UCR* Basic and restorative covered at 50% of UCR* Major services covered at 50% of UCR* $1,000 calendar year maximum and no waiting period Visit any dentist or dental specialist of your choice. Save money by seeing a network dentist. *Please note - Percentage is of Usual, Reasonable and Customary charges, based upon zip codes by geographic regions. Consumer MaxMultiplier This feature encourages you to seek preventive and diagnostic care through an awards-based program. There is a calendar year maximum award balance that can be carried forward each year so that accumulated funds are available when you need them. Each family member is eligible to earn his or her own awards. Paid claims must be less than $500 to earn award amount. This special feature increases benefits at the same low premium. You must use your dental benefit at least once between January 1, 2018, and December 31, 2018, to be eligible for this benefit. This award amount is available each year until you have reached a total combined regular calendar year maximum of $1,000.00, plus $1, award, for a maximum total of $2, * REASONABLE AND CUSTOMARY PLAN: A dental benefit plan that determines benefits based only on Reasonable and Customary fee criteria. USUAL FEE: The fee that an individual dentist most frequently charges for a given dental service. CUSTOMARY FEE: The fee level determined by the administrator of a dental benefit plan from actual submitted fees for a specific dental procedure to establish the maximum benefit payable under a given plan for that specific procedure. REASONABLE FEE: The fee charged by a dentist for a specific dental procedure that has been modified by the nature and severity of the condition being treated and by any medical or dental complications or unusual circumstances, and therefore may differ from the dentist s usual fee or the benefit administrator s customary fee. Summary of Dental Plan Benefits No deductible for Diagnostic and Preventive Services. A $25.00 deductible, per member per plan year, applies to Basic Restorative and Major Services. Please see the certificate of coverage on the website at for complete benefit information, including exclusions and limitations. Access Your Benefits & Claim Filings Register at: View and print explanation of benefits and ID cards Look up and nominate providers Obtain claim information Print claim forms View certificate of coverage View eligibility HEALTH TIP You Should Know: Your mouth reflects your overall health. Your dentist may detect health problems based on the health of your teeth and gums. Replace toothbrush every 3-4 months Brush teeth at least twice daily 4

5 Enrollment must be completed on or before October 31, 2017 Dental Coverage DIAGNOSTIC & PREVENTIVE SERVICES Covered at 100% of UCR* BASIC RESTORATIVE Covered at 50% of UCR* MAJOR SERVICES Covered at 50% of UCR* This includes: DIAGNOSTIC Initial Oral Exam Periodic Oral Exam Emergency Exams for Pain Relief Full Mouth X-Rays (1 procedure every 36 months) Bitewing X-Rays (once every 12 months) Single Tooth X-Rays PREVENTIVE Prophylaxis (2 per calendar year) Fluoride Treatments for children under age 19 (eligible until the day they turn 19) Sealants for children under age 16 (eligible until the day they turn 16) This includes: RESTORATIVE Amalgam Fillings (Silver Fillings) Composite Fillings (White Fillings) Anterior (front) Teeth Only Temporary Fillings Space Maintainers for children under age 14 (eligible until the day they turn 14) ORAL SURGERY Simple Extraction Surgical Extraction General Anesthesia PERIODONTICS Periodontal Surgery Scaling and Root Planing ENDODONTICS Root Canal Treatment Pulpatomy PROSTHETIC MAINTENANCE Bridge or Denture Repair Rebase or Reline of Dentures Re-cement of Crowns and Onlays This includes: GOLD/CAST RESTORATIONS Gold or Cast Restorations Crowns (when teeth cannot be restored with amalgam, composite or plastic restorations) PROSTHODONTICS Dentures Bridges Partials *Please note - Percentage is of Usual, Reasonable and Customary charges, based upon zip codes by geographic regions. Monthly Premiums Plan Coverage Retiree Retiree + 1 Retiree + Family Monthly Premiums $37.78 $89.52 $ New enrollees will receive identification card(s) prior to the effective date of their coverage. 5

6 Enrollment must be completed on or before October 31, 2017 Call: Dental Coverage 3 Easy Ways to Enroll Enroll online at Complete the attached enrollment form on pg. 14 and return to Pierce Insurance via postage-paid envelope inserted on pg. 8 Enroll by phone: Frequently Asked Questions Do I need to re-enroll each year? No, you will be continuously enrolled unless you are notified of a change by UnitedHealthcare Dental or you request to make a change to your plan. If my spouse is still working and has a dental plan, can that spouse still be enrolled under the Retirees dental plan? Yes, your spouse can be enrolled through the Retirees dental plan and have dual coverage. Coordination of benefits will apply. Where are my claims processed? Dentists will usually submit claims on behalf of our members. Should you need to submit claims, please send the claim form and bills to: UnitedHealthcare Dental, Attn: Claims Unit, P.O. Box 30567, Salt Lake City, UT If I have questions about my claims, eligible benefits and plan coverage, who do I call? Questions regarding your UnitedHealthcare Dental Policy and Claims can be answered by calling Customer Care at Must I choose between Diagnostic and Preventive, Basic or Major Restorative Services? No, all three types of coverage are included in your dental plan. What is the $25 deductible? The deductible is per person, per calendar year for Basic or Major Services. This deductible does not apply to Preventive and Diagnostic Services (such as exams and cleanings). How do I know if my provider participates with UnitedHealthcare Dental? To verify if your provider participates with UnitedHealthcare Dental, ask your provider or contact UnitedHealthcare Dental at before services are performed. You may also nominate your provider by calling UnitedHealthcare Dental, or visting myuhc.com and completing a Provider Nomination Form. If I am enrolled in another plan and I want to enroll in this plan, will the other plan be automatically canceled or replaced? No. New enrollees are responsible for cancelling other coverage even if the other coverage is pension-deducted from your retirement benefit. The new plan coverage will not automatically cancel or replace any other coverage you may have that is provided by other organizations or associations. What is a pre-determination? When you are anticipating expensive dental charges over $500, have your provider submit a pre-determination estimate to UnitedHealthcare. The response to this will tell you what the plan will pay for certain procedures and what charges you may have out of pocket. The dental product is underwritten by UnitedHealthcare Insurance Company. Our dental product is administered by Dental Benefit Providers, Inc. *Pierce Insurance Agency, Inc. is a licensed insurance agent in North Carolina that has been authorized to arrange this coverage, but it is not part of the North Carolina State Government or its Retirement Systems. 6

7 Enrollment must be completed on or before October 31, 2017 Vision Coverage Why You Should Consider Vision Insurance An eye exam can help identify not only eye and vision issues, but systemic diseases like diabetes, hypertension, high cholesterol, cancer and more. Get your eye exam and stay healthy! HEALTH TIP 1. Regular annual eye exams 2. Check diabetes and high blood pressure 3. Look for warning signs: red eye, blurred vision, etc. 4. Protection from harmful UV light 5. Exercise 6. Eat healthy Vision Plan Features Frequency of Services Visit to find the vision network providers near you. Save the most money by using a network provider. You can choose where to have an exam and where to purchase glasses or contacts. No waiting period. $130 frame allowance for frames available at a retail or private practice provider. Exam: Once every 12 months Lenses: Once every 12 months Frame: Once every 24 months Contact Lenses: Once every 12 months (contacts in lieu of lenses and frame) Access Your Benefits & Claim Filings Register at: Look up providers View eligibility View benefit summary Obtain claim information and provider nomination forms Print vision cards The vision product is underwritten by UnitedHealthcare Insurance Company. Our vision product is administered by Spectera, Inc. *Pierce Insurance Agency, Inc. is a licensed insurance agent in North Carolina that has been authorized to arrange this coverage, but it is not part of the North Carolina State Government or its Retirement Systems. 7

8 Enrollment must be completed on or before October 31, 2017 Call: Summary of Vision Plan Benefits Information Plan 1 Exam & Materials Plan Plan 2 Materials Only Plan In Network 1 Out of Network 2 In Network 1 Out of Network 2 Copayments Comprehensive Exam by an Ophthalmolgist (MD) or Optometrist (OD) $10.00 Exam Copayment $10.00 Materials Copayment Covered in Full (after copay) Not Applicable $10.00 Materials Copayment Not Applicable Up to $64.00 Not Applicable Not Applicable Standard Lenses (per pair) Single Vision Lined Bifocal Lined Trifocal Lenticular Up to $40.00 Up to $60.00 Up to $80.00 Up to $80.00 Up to $40.00 Up to $60.00 Up to $80.00 Up to $80.00 Frames - Standard Up to $ (after copay) 3 Up to $50.00 Up to $ (after copay) 3 Up to $50.00 Contact Lenses (in lieu of lenses and frame) Cosmetic Elective Necessary Covered in Full (after copay) 4 Covered in Full (after copay) 5 Up to $ Up to $ Covered in Full (after copay) 4 Covered in Full (after copay) 5 Up to $ Up to $ Patient Lens Options Standard Scratch Coating Tints UV Protective Lenses Standard Progressives Deluxe Progressive Lenses Polycarbonate Lenses Discounts available through network providers. For additional information contact or visit No Coverage Standard Scratch Coating Tints UV Protective Lenses Standard Progressives Deluxe Progressive Lenses Polycarbonate Lenses Discounts available through network providers. For additional information contact or visit No Coverage Laser Vision Correction No Coverage No Coverage Exam and Materials Plan / Materials Only Plan 1. Network Benefits: Materials copays and patient options are paid to the network provider by the plan participant. 2. Out-of-Network Benefits: The plan participant pays full fee to the provider and UnitedHealthcare Vision reimburses the retiree for services rendered up to maximum allowance. There are no copays or deductibles. 3. Frame Benefit: UnitedHealthcare Vision s frame benefit applies to virtually all of the frames on the market today, and most of those are covered in full, with no additional cost to the retiree, other than applicable co-pay. With UnitedHealthcare Vision s frame benefit, plan participants receive a $ retail or private practice frame allowance for frames purchased at retail chain or private practice providers, and for any frame above $130.00, the retiree will only pay the difference. 4. Contact Lens Benefit: Contact lenses are provided in lieu of eyeglasses (lenses and frame). UnitedHealthcare Vision s contact lens benefit covers in-full (after applicable copayment) the fitting/evaluation fees, contacts (including up to four boxes of disposables, depending on prescription), and up to two follow-up visits. An allowance is applied toward the fitting/evaluation fees and purchase of contact lenses outside of UnitedHealthcare Vision s covered-in-full contacts (materials copay does not apply). Toric, gas permeable and bifocal contact lenses are all examples of contacts that are outside of our covered-in-full selection. 5. Necessary contact lenses are determined at the eye care provider s discretion for one or more of the following conditions: Following cataract surgery without intraocular lens implant; To correct extreme vision problems that cannot be corrected with spectacle lenses; With certain conditions of anisometropia; With certain conditions of keratoconus. If an out-of-network provider considers contacts necessary, retirees should ask their out-of-network provider to contact UnitedHealthcare Vision concerning the reimbursement that UnitedHealthcare Vision will make before they purchase such contacts. 8

9 Enrollment must be completed on or before October 31, 2017 Vision Coverage Monthly Premiums Plan Coverage/ Monthly Premiums Retiree Retiree + 1 Retiree + Family Plan 1 Exam & Materials Plan $7.35 $14.88 $16.71 Plan 2 Materials Only $5.13 $10.40 $ Easy Ways to Enroll New enrollees will receive identification card(s) prior to the effective date of their coverage Enroll online at Complete the attached enrollment form on pg. 14 and return to Pierce Insurance via postage-paid envelope inserted on pg. 8 Enroll by phone: Frequently Asked Questions Do I need to re-enroll every year? No, you will be continuously enrolled unless you are notified of a change by United Healthcare Vision or you request to make a change to your plan. How do I identify myself as a UnitedHealthcare Vision member utilizing a network provider? When contacting a network provider to make your appointment, simply give the provider the subscriber s unique identification number, the patient s name and date of birth and identify yourself as a member of the UnitedHealthcare Vision Plan. The network provider will verify your eligibility and coverage with UnitedHealthcare Vision prior to your scheduled appointment. What if my provider is not in-network? If your provider is not in-network, please call UnitedHealthcare Vision customer service at Your Customer Service Representative will assist you with finding a UnitedHealthcare Vision in-network provider. How do I know if my provider participates in UnitedHealthcare Vision? To verify if your provider participates with UnitedHealthcare Vision, ask your provider or contact UnitedHealthcare Vision at before services are performed. You may also nominate your provider by calling UnitedHealthcare Vision at , or by visiting the UnitedHealthcare Vision website at and completing a Provider Nomination Form. How do I file my out-of-network claims? For all out-of-network vision claims you will need to send your itemized paid receipts, with the primary insured s unique identification number, and the patient s name and date of birth to the address below. You do not need a claim form to submit receipts for reimbursement. UnitedHealthcare Vision, P.O. Box 30978, Salt Lake City, UT or Fax to:

10 Enrollment must be completed on or before October 31, 2017 Call: Identity Theft Protection Why You Should Consider Identity Theft Protection In today s world of online shopping, using public Wi-Fi and giving out Social Security numbers as a form of ID, our personal information can be exposed. Unfortunately, free credit monitoring simply alerts you to credit score changes. LifeLock not only has proprietary technology to detect a variety of identity threats, if you do have an ID problem, our U.S.-based team of specialists can help fix it. That s why it pays to protect with the best. Service Features LifeLock Benefit Elite LifeLock Identity Alert System Credit Card, Checking and Savings Account Activity Alerts Lost Wallet Protection Address Change Verification Black Market Website Surveillance Reduced Pre-Approved Credit Card Offers Live Member Agents 24/7 Identity Restoration Support LifeLock Privacy Monitor Tool Every two seconds someone s identity is stolen Identity fraud cost Americans $16 billion in Investment Account Activity Alerts Stolen Funds Reimbursement up to $1 Million * Service Guarantee for Lawyer and Experts * Personal Expense Compensation up to $1 Million * Fictitious Identity Monitoring Arrests and Court Records Alerts Data Breach Notifications One Bureau Annual Credit Report & Credit Score 1 The credit score provided is a VantageScore 3.0 credit score based on Equifax data. Third parties use many different types of credit scores and are likely to use a different type of credit score to assess your creditworthiness. *Indicates features included within the Million Dollar Protection Package have experienced identity theft. 3 No one can prevent all identity theft. LifeLock does not monitor all transactions at all businesses Identity Fraud Study, Javelin Strategy & Research. 3 Based on a monthly online consumer survey (n=2044) conducted for LifeLock by MSI International, Apr 2015 Oct

11 Enrollment must be completed on or before October 31, 2017 Identity Theft Protection LifeLock Benefit Elite Includes searching for threats to your identity and to financial assets your 401(k) and investment accounts, plus an annual credit report and score. Also includes scanning for misuse of your Social Security number, change of address and court records scanning for use of your identity to commit crimes. 3 Layers of Protection DETECT LifeLock uses advanced technology to constantly monitor millions of transactions per second to help detect suspicious use of your identity information to get loans, credit and services in your name. ALERT The patented LifeLock Identity Alert System is at the center of all LifeLock Services. We will send you a potential fraud alert by text, phone* or . If you confirm that the suspicious transaction is fraudulent, your LifeLock team will help you resolve the issue. RESTORE LifeLock s U.S.-based Agents are ready to help with identity theft restoration. And, if you re a victim of identity theft, LifeLock helps protect you with our Million Dollar Protection Package including our Service Guarantee to provide for experts and lawyers, if needed, as well as reimbursement for stolen funds up to $1 million based on the limits of your Benefit Elite plan. Monthly Premiums Plan Coverage Retiree Retiree + 1 Retiree + Family Monthly Premiums $8.49 $14.99 $

12 Enrollment must be completed on or before October 31, 2017 Call: Identity Theft Protection 3 Easy Ways to Enroll Enroll online at Complete the attached enrollment form on pg. 14 and return to Pierce Insurance via postage-paid envelope inserted on pg. 8 Enroll by phone: Frequenty Asked Questions What is identity theft? Identity theft is when thieves steal your personal information in order to take over or open new accounts, file fake tax returns, rent or buy properties, or do other criminal things in your name. After enrolling with Pierce Insurance, how do we know that LifeLock is monitoring my identity? After completing the enrollment your information is sent over to LifeLock, and your membership is created. You will receive both a welcome (3-5 days) and welcome kit by regular mail (3-4 weeks) after enrollment. Once the welcome kit is received, you need to log-on or call LifeLock directly to set up an Account Portal This is where you register and enter any information you want LifeLock to have and monitor. Do I have to have an address to enroll in LifeLock? No, you do not need an address for LifeLock to monitor your identity. However, if you don t have access to you will not be able to have access to your Free Online Credit Score or your Free Online Credit Report. Do I have to enter all my information to the Account Portal? No, only information you want LifeLock to have and monitor. Do I have to give you all my credit card, bank information, etc. over the phone? No. You enter all the information to your Account Portal once you receive your welcome or welcome kit by postal mail. No one can prevent all identity theft. LifeLock does not monitor all transactions at all businesses. * Phone alerts made during normal local business hours. Million Dollar Protection Package benefits are provided by a Master Policy issued by United Specialty Insurance Company, Inc. (State National Insurance Company, Inc. for NY State members). The Master Policy provides coverage for Stolen Funds Reimbursement and Personal Expense Compensation, each with limits of up to $1 million for Benefit Elite members. If needed, LifeLock will provide lawyers and experts under the Service Guarantee. Please see the policy terms, conditions and exclusions at: LifeLock.com/legal. 12

13 Enrollment must be completed on or before October 31, 2017 Tips to Enroll If you are currently enrolled, you do not need to re-enroll. Your coverage will remain the same. Paper enrollment form is not required; you may enroll online at or by phone at If you would like to make changes to your benefits, you should call us at To check the status of your benefits, you can call us at , chat with us at or us at To prevent delays in processing, all fields for your personal information on the application must be completed. Your full social security number and your date of birth are required. For Identity Theft protection your address is required. When enrolling dependents, their information must also be completed. For Identity Theft protection dependent social security numbers are required. Dependents with incomplete information cannot be enrolled. Enrollment Checklist Complete your personal information. Select your benefits. Check Yes for each benefit that you want to enroll in. Select the plan and who is to be covered on each benefit. For Vision indicate Plan 1 or Plan 2. For all benefits indicate who is to be covered. RETIREE, RETIREE + ONE (1) or RETIREE + FAMILY Complete dependent information. Select billing method. Most retirees are pension deducted. If no selection is made, you will be set up on pension deduction. Please note that Firefighters and Rescue Squad Workers, National Guard or Register of Deeds Pension Funds benefit recipients do not qualify for pension deduction. Sign and date your application. Enrollment form is located on the following page. 13

14 Dental and Vision Benefits A UTH O RIZ E D US E O N LY Policy Group Numbers: Plan Variation/Reporting Code: Enrollment must be completed on or before LifeLock October Identity 31, 2017 Theft Plan PVRC Call: PVRC Complete form and mail, fax or to: Pierce Insurance Agency, Inc. info@pierceins.com ATTN: NCRS Phone: P.O. Box 727 Fax: Farmville, NC IDENTITY THEFT, DENTAL, AND VISION ENROLLMENT FORM SOCIAL SECURITY NUMBER: DATE OF RETIREMENT / / (Month/Day/Year) PVRC PVRC Dental Plan Code: Effective Date: ENROLL CANCEL CHANGE ADDRESS CHANGE PVRC PVRC NAME CHANGE P3271 LAST NAME: FIRST NAME: M.I.: DATE OF CHANGE: / / (Month/Day/Year) ADDRESS: CITY: DATE OF BIRTH: / / (Month/Day/Year) STATE: ZIP: MALE FEMALE ADDRESS: TELEPHONE NUMBER: ( ) LIFELOCK IDENTITY THEFT PLAN YES NO IF YES, CHECK COVERAGE: RETIREE RETIREE + ONE (1) RETIREE + FAMILY DENTAL COVERAGE Underwritten by United Healthcare Insurance Company PLAN 1: VISION EXAM & MATERIALS PLAN Underwritten by United Healthcare Insurance Company PLAN 2: VISION MATERIALS ONLY PLAN Underwritten by United Healthcare Insurance Company YES NO IF YES, CHECK COVERAGE: RETIREE RETIREE + ONE (1) RETIREE + FAMILY YES NO IF YES, CHECK COVERAGE: RETIREE RETIREE + ONE (1) RETIREE + FAMILY YES NO IF YES, CHECK COVERAGE: RETIREE RETIREE + ONE (1) RETIREE + FAMILY Dependent Coverage spouse and unmarried dependent children only. (Include Date of Birth & SSN) For court-ordered dependents, documentation must be attached. First Name M.I. Last Name (if different) M/F Date of Birth (Month/Day/Year) Relationship If child is over age 26, please indicate status Enroll in: Change or Cancel Other Dental Coverage Other Dental Insurance: Wife ID Theft Change M / / Husband Handicapped Dental F Child Vision SOCIAL SECURITY NUMBER: Cancel CARRIER NAME M F / / Wife Husband Child Handicapped ID Theft Dental Vision Change Other Dental Insurance: SOCIAL SECURITY NUMBER: Cancel CARRIER NAME M F / / Wife Husband Child Handicapped ID Theft Dental Vision Change Other Dental Insurance: SOCIAL SECURITY NUMBER: Cancel CARRIER NAME I confirm that the information I have provided on this form is complete and accurate. Any person who knowingly and with intent to injure, defraud or deceive any insurer, files a statement of claim or an application containing any false, incomplete or misleading information may be prosecuted as allowed by appropriate state law. THIS SECTION MUST BE SIGNED AND DATED TO RECEIVE BENEFIT. PENSION DEDUCTION AUTHORIZATION - I hereby authorize the North Carolina Retirement Systems to deduct my identity theft, dental and/or vision premiums from my retirement benefit. To the best of my knowledge, I confirm that the information I have provided on this form is complete and accurate. Firefighters and Rescue Squad Workers, National Guard or Register of Deeds Pension Funds benefit recipients do not qualify for pension deduction. Please select the Direct Bill option. DIRECT BILL OPTION - Please place the benefits that I have applied for on direct bill. Firefighters and Rescue Squad Workers, National Guard or Register of Deeds Pension Funds benefit recipients do not qualify for pension deduction. Please select the Direct Bill option. SIGNATURE DATE NCRS-01 (REV ) 14 The UnitedHealthcare Dental plan is administered by Dental Benefit Providers, Inc.

15 Enrollment must be completed on or before October 31, 2017 Contact Information Pierce Insurance Agency Enroll or Ask Questions About Your Benefits Call: Fax: Visit: Write to: Pierce Insurance, Attn: NCRS PO Box 727 Farmville, NC Identity Theft Protection by LifeLock Member Services Membership questions / Profile Updates / Alert Responses / Identity Theft Incidences Call: Fax: (Attn: Document Dept.) Write to: LifeLock, Inc. Attn: Member Services 60 E. Rio Salado Pkwy, Suite 400 Tempe, AZ UnitedHealthcare Dental Dental Claim Questions Call: Visit: Write to: UnitedHealthcare Dental, Attn: Claims Unit PO Box Salt Lake City, UT UnitedHealthcare Vision Vision Claim and Provider Network Questions Call: Fax: Visit: Write to: UnitedHealthcare Vision PO Box Salt Lake City, UT Featured Services on Enroll: online, paper, phone Access benefit videos Access ORBIT to change address Print claim and service forms Review FAQ View brochures and certificates DENTAL VISION IDENTITY THEFT REMEMBER Enrollment must be completed on or before October 31,

16 NSIDE 2018 OPEN ENROLLMENT Your Open ENROLLMENT ENDS October 31, 2017 DENTAL VISION IDENTITY THEFT Time-Sensitive Information Inside To Enroll Call: or Visit: Administered by: Authorized by: