Washington University in St. Louis Retiree Benefits Summary

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2 Washington University in St. Louis Retiree Benefits Summary As a retiree of Washington University in St. Louis (the University ) you are eligible for various benefits that are outlined in this summary. The content found in this summary is not all-inclusive and is not intended to replace the plan documents and summary plan descriptions (SPD), which can be found on the Human Resources websites at and To be eligible for retiree benefits, faculty and staff must meet the "Rule of 65"; any combination of age and years of current consecutive benefits-eligible service (50% FTE or more) that equals 65 or more with two minimum requirements: 1) age 55 and 2) 5 years of current consecutive benefitseligible service. Only full years of age and full years of service with the University count towards the Rule of 65. Please direct questions about the University s retiree benefits program to the appropriate benefits representative. Contact information is located on page 10 of this summary. Table Of Contents Enrollment Health Plan Options. 3 COBRA... 3 Health Insurance Marketplace 4 Pre-65 Retiree Health Plan. 4 Prescription Drugs. 5 Post-65 Retiree Health Plan 5 Vision.. 6 Dental. 6 Health Savings Account (HSA).. 6 Retirement Medical Savings Account (RMSA) 7 Long Term Care 7 Dependent Child Tuition Assistance.. 7 Retirement Savings Plan. 7 Deferred Compensation.. 7 Term Life Insurance. 7 Group Variable Universal Life Insurance (GVUL) 7 Retiree Resources 7 Other Retiree Resources Monthly Premiums.. 9 Contact Information.. 10 Retirement Timeline. 11 Forms 14 W U S T L R E T I R E E B E N E F I T S S U M M A R Y PAGE 2

3 HEALTH PLAN ENROLLMENT As a retiree, you will have the option to elect coverage under COBRA, the Pre-65 health plan, or the Post 65 health plan. You may enroll in a University retiree health plan: 1) within 31 days following your retirement date, 2) within 31 days of a qualifying life event, including loss of COBRA coverage, or 3) during the annual Open Enrollment. Important Information about Medicare: If you are age 65 or older when your retire, please be sure to check with Medicare about when to sign up for Medicare Part B and Part D to avoid late enrollment penalties. Life Event You may enroll in, add or delete dependents from your health and dental plans within 31 days of a qualifying life event. Life events include, but are not limited to, marriage, death, divorce, birth, adoption, loss of other coverage and certain changes in employment status. For the birth of a child, you have 62 days from the date of birth to add the child to your health coverage. Supporting documentation may be required. You may cancel your coverage at any time. OPEN ENROLLMENT Retirees may enroll in a University-sponsored health plan during the annual open enrollment period in November without any pre-existing condition exclusions. Announcements are sent to all retirees. Please ensure your mailing address is current on the HRMS Self Service link 1. If you are having any difficulties with the HRMS Self Service link, Help Desk support is available from Systems and Procedures at (314) You may enroll in retiree benefits using the enrollment/change form located in the back of this summary and by submitting the completed form to the Benefits Office. If you are Medicare eligible and elect to enroll in the Medicare Supplement option, please include a copy of your Medicare card. The Electronic Fund Transfer (EFT) payment option is mandatory for retirees/surviving spouses and will automatically withdraw the premium payment each month for retiree health/dental coverage. The funds will be withdrawn from your checking or savings account provided on the EFT form along with a voided check. The premiums are deducted from the account on the 10 th day of each month. The bank will debit your bank account for the amount due. You will not receive billing statements from the Benefits Department while enrolled in EFT. If at any time you wish to change the account from which the funds are deducted you would need to contact the Benefits Department and complete a new EFT form. HEALTH PLAN OPTIONS University-sponsored health, Medicare supplement or dental only plans are available for retirees and eligible dependents. Retirees pay the full cost for their WUSTL retiree health care coverage. COBRA Retirees and their eligible dependents will be offered the opportunity to continue the coverage they were enrolled in during active employment, for up to 18 months, through COBRA. You may enroll in the applicable Pre-65 or Post-65 Retiree Health plan at the conclusion of COBRA coverage. COBRA enrollment materials will be sent approximately two weeks following your last day of coverage as an active employee. If you are age 65 or older, please be sure to check with Medicare about when to sign up for Medicare Part B and Part D to avoid late enrollment penalties. HEALTH INSURANCE MARKETPLACE The health care reform law requires most individuals to have health insurance or otherwise pay a penalty. If you are enrolled in Medicare, in COBRA, or in WUSTL s retiree health plan, you meet this requirement and will not be subject to a penalty. If you are not enrolled in Medicare or COBRA and are not eligible for or do not enroll in WUSTL s retiree health plan, you must obtain health insurance coverage from another source, such as a family member s employer-sponsored health plan or the public Health Insurance Marketplace that was established in connection with health care reform. A Health Insurance Marketplace Notice that provides required information about the Marketplace can be found on the Health Plan Comparisons page of our Human Resources website at To request a paper copy of the Notice, contact the Benefits Office at (314) Through HRMS Self Service you will be able to update your contact information. W U S T L R E T I R E E B E N E F I T S S U M M A R Y PAGE 3

4 PRE-65 RETIREE HEALTH PLAN The following is a summary of the Washington University health plan offered to retirees under age 65 and their eligible dependents. The Pre-65 Retiree Health Plan, administered by Anthem Blue Cross/Blue Shield, includes dental, prescription drug and basic vision coverage. Annual Calendar Year Deductible Individual In-Network $1,000 Out-of-Network $1,000 Family In-Network $2,000 Out-of-Network $2,000 Out-Of-Pocket Maximum (includes deductible) Individual In-Network $4,000 Out-of-Network $7,000 Family In-Network $8,000 Out-of-Network $14,000 Co-Insurance Chiropractic/ Spinal Manipulation In-Network 20% Out-of-Network 40% Durable Medical Equipment In-Network 20% Out-of-Network 40% Emergency Care In-Network 20% Out-of-Network 20% (Covered as In-Network) Home Health Care In-Network 20% Out-of-Network 40% Hospital In-Network 20% Out-of-Network 40% Inpatient Rehabilitation/ Skilled Nursing In-Network 20% Out-of-Network 40% Lab & X-Ray Services In-Network 20% Out-of-Network 40% Medical Supplies In-Network 20% Out-of-Network 40% Mental Health and Substance Use Disorders IN-PATIENT In-Network 20% Out-of-Network 40% OUT-PATIENT In-Network 20% Out-of-Network 40% Office Visit In-Network 20% Out-of-Network 40% Preventive Exams In-Network No Cost Out-of-Network 40% Surgery IN-PATIENT In-Network 20% Out-of-Network 40% OUT-PATIENT In-Network 20% Out-of-Network 40% Therapy (Physical/Occupational/Speech) In-Network 20% Out-of-Network 40% Urgent Care In-Network 20% Out-of-Network 40% PRESCRIPTION DRUGS Prescription drug benefits, administered by Express Scripts, are included as part of your Pre-65 Retiree Health Plan. Drugs are categorized by tier. Tier One is primarily generic drugs, Tier Two is primarily preferred brand name drugs and Tier Three is primarily non-preferred brand name drugs. You pay 100% of the plan cost for covered prescription drugs until you have satisfied a calendar year deductible of $300. After you have satisfied the deductible, your copays are: 30 Day Supply - Retail 90 Day Supply - Mail Order Tier One $10 co-pay $20 co-pay Tier Two $25 co-pay $50 co-pay Tier Three $50 co-pay $100 co-pay W U S T L R E T I R E E B E N E F I T S S U M M A R Y PAGE 4

5 POST-65 RETIREE HEALTH PLAN The following is a summary of the Anthem Blue Cross/Blue Shield Medicare Supplement plan offered to retirees age 65 and over. For specific details and exclusions of your Medicare plan, please visit Medicare s website at Your Medicare Supplement plan includes basic vision and dental coverage, but does not include prescription drug coverage. You will need to enroll in a Medicare Part D plan to have prescription drug coverage. Annual Calendar Year Deductibles Medicare Anthem BCBS Medicare Supplement Special Clauses Lifetime Maximum Foreign Travel Must Use Medicare Providers Approved Charge Medicare Parts A & B require that each covered individual meet an annual deductible under both A & B before Medicare will begin paying benefits for the year The Anthem BCBS Medicare Supplement plan will pay the Part A and Part B deductible amounts that Medicare will not pay each year Unlimited Pays up to $350 per year for Physician services and 75% of covered inpatient charges Yes The approved charge is the amount Medicare determines as the reasonable charge for a particular service. Your doctor or supplier may charge more than the approved charge. Neither Medicare nor your Anthem BCBS Medicare Supplement plan will pay for charges in excess of the Medicare approved charge amount. Co-Insurance Custodial Care Home Health Care Hospitalization Co-Insurance Lab & X-Ray Services Office Visit Skilled Nursing Surgery Not Covered Medicare will cover the first 100 days in full. No coverage beyond the first 100 days After you meet the Part A deductible, Medicare will pay for most medically necessary inpatient hospital services in a Medicare-participating hospital for up to 60 days each benefit period. For days Medicare will cover all eligible services except for a certain daily co-payment amount. Your Anthem BCBS Medicare Supplement will pay that daily co-payment amount. Medicare will generally pay 80% of the approved charge and your Anthem BCBS Medicare Supplement will pay the remaining 20% of the approved charge. Medicare will generally pay 80% of the approved charge and your Anthem BCBS Medicare Supplement will pay the remaining 20% of the approved charge. Assuming you meet the conditions established by Medicare, Medicare will pay the full cost of most medically necessary care received in a Medicare-participating skilled nursing facility for the first 20 days. For days , Medicare will pay for all but a daily copayment amount. Your Anthem BCBS Medicare Supplement will pay that daily copayment amount. Medicare will generally pay 80% of the approved charge and your Anthem BCBS Medicare Supplement will pay the remaining 20% of the approved charge. W U S T L R E T I R E E B E N E F I T S S U M M A R Y PAGE 5

6 VISION Basic coverage vision benefits are included as part of either the Pre 65 or Post 65 Retiree Health Care plans. The Vision Buy-Up is offered at an additional fee. VSP Vision Service Plan Co-Payment & Discounts Basic Coverage Buy-Up Coverage Routine Eye Exam In-Network $20 co-pay $20 co-pay Per Calendar Year Out-of-Network Allowance up to $50 Allowance up to $50 Per Calendar Year: $40 co-pay (single vision, lined bifocal, trifocal lenses) PRESCRIPTION EYEGLASSES In-Network 20% discount on lenses and frames Allowance up to $50 Frames- $150 allowance ($170 for featured brands) + 20% discount Out-of-Network Allowance up to $50 $50-$100 allowance, based on product -OR- CONTACT LENSES In-Network Allowance up to $50 $150 allowance Out-of-Network Allowance up to $50 Allowance up to $105 Contact Lens Exam & Fitting 15% discount on exam 15% discount - Exam not to exceed $60 DENTAL Dental benefits are included as part of either the COBRA, Pre-65 or Post-65 Retiree Health Care Plans. You may enroll in the Dental Only Plan if you do not wish to enroll in a health plan. Annual Calendar Year Deductible ADVANTICA DENTAL PPO PLAN Individual In-Network $50 Out-of-Network $50 Family In-Network $150 Out-of-Network $150 Employee Co-Insurance Preventive Care In-Network 0% Out-of-Network 10% Basic Expenses In-Network 20% Out-of-Network 40% Major Expenses In-Network 50% Out-of-Network 50% Benefit Plan Maximums Calendar year benefit maximum per person $1,500 Please Note: Out-of-Network benefits are subject to usual customary and reasonable (UCR) amounts. HEALTH SAVINGS ACCOUNT (HSA) Retirees who have participated in the HSA while actively employed may access their remaining account balance (if applicable) at US Bank or HSA Bank to pay for their out-of-pocket health expenses. FLEXIBLE SPENDING ACCOUNTS (FSA) To avoid forfeiture of contributed funds, retirees who participated in the FSA during the current calendar year may submit claims for expenses incurred through the end of the month in which they retire. RETIREMENT MEDICAL SAVINGS ACCOUNT (RMSA) Retirees who have participated in this Plan, and are enrolled in a retiree health plan (including COBRA), should submit a CLAIMS ACTIVATION FORM to begin using these funds to pay for retiree health premiums and other retiree out-of-pocket health, dental, vision, and prescription drug expenses. The form can be obtained on the Human Resources website, or by calling TIAA-CREF. The University will continue to pay associated administration fees for a WUSTL retiree s retirement medical savings account. LONG TERM CARE INSURANCE Retirees and their spouses who are currently participating in this program may continue their coverage through direct invoicing from the carrier. For more information and to set up individual pay arrangements, please contact your LTC provider prior to your retirement date. W U S T L R E T I R E E B E N E F I T S S U M M A R Y PAGE 6

7 DEPENDENT CHILD TUITION ASSISTANCE Retirees who have completed the service requirement under the Dependent Child Tuition Assistance Plan as of their retirement date may utilize the benefit for their eligible dependent children. The benefit will be based on your date of hire and your full-time or part-time job status prior to retirement. To begin utilizing this benefit, visit the Human Resources website at RETIREMENT SAVINGS PLAN Retirees may apply for their accumulated retirement account balances at retirement and may choose from many distribution options. Retirees are not required to begin their distributions from their retirement savings until they reach the age of 70 ½. Please contact your plan s representative for distribution options and plan restrictions. DEFERRED COMPENSATION Employees who participated in the University s Deferred Compensation Plan (457b or 457f) are required to make distribution elections within 60 days of separation from the University. The election form will be mailed directly to you from the appropriate vendor. TERM LIFE INSURANCE A paid-up policy (Non-Union $5,000 / Union $1,000), insured by MetLife, will be provided to retirees who were participating in the optional term life plan on their date of retirement. Within 31 days of retirement, you will be contacted by MetLife regarding conversion options for your current basic and/or optional term life insurance coverage. You can change your beneficiary through HRMS Self-Service. GROUP VARIABLE UNIVERSAL LIFE INSURANCE (GVUL) Retirees have the option to continue their group variable universal life (GVUL) insurance. Contact MetLife at (800) to set up payment arrangements. RETIREE RESOURCES ATHLETIC COMPLEX Professors emeriti and retired faculty and staff are eligible to use the Athletic Complex at no charge. Fees do apply for the use of the McWilliams Fitness Center and permanent lockers. For more details please contact the Athletic Department at (314) LIBRARIES All rights and privileges continue at the Olin Library on the Danforth Campus with a valid ID. All rights and privileges except for proxy access continue at the Becker Medical Library on the Medical School Campus with a valid ID. For Professors Emeriti, all rights and privileges including proxy access continue at the Becker Medical Library with a valid ID. Professors Emeriti may apply for a faculty study on an equal-competitive footing with other faculty members. Studies are assigned according to the importance of the need and availability of space. HRMS SELF-SERVICE - As a Retiree, you will retain access to HRMS Self-Service to view your W- 2 s, update your address and keep your life insurance beneficiaries up-to-date. If you have any problems with your login credentials, please contact the Help Desk at (314) ID CARDS - An updated ID card may be obtained following your retirement date. For Danforth Retirees, ID cards may be obtained at Campus Card Services, which is located in Green Hall, Room For more information, please contact Campus Card Services at (314) For Medical School Retirees, ID cards may be obtained at the Facilities Integrated Service Center at Olin Residence Hall. For more information, please contact the Facilities Integrated Service Center at (314) W U S T L R E T I R E E B E N E F I T S S U M M A R Y PAGE 7

8 WHITTEMORE HOUSE Emeriti who are current members of the Faculty Conference Center Association are exempt from paying the monthly dues. To obtain more information please contact the Whittemore House at (314) PARKING Contact the Transportation Department regarding available options for retirees if you plan to be on campus regularly. WUSTL HEALTH SERVICES - The University Health Service provides immunizations for both active and emeritus staff on a fee for service basis. THE SOCIETY OF PROFESSORS EMERITI - Founded in 1978 to promote the common interests of its members. The Society provides social and intellectual opportunities. It also serves as a clearinghouse for information concerning University policies relevant to retirees. Retirees who are not Professors Emeriti but who have offered exceptional service to Washington University (from the Society s Constitution) may become members. Interested persons are encouraged to speak with the Society s President or Secretary whose names may be obtained from the Office of the Chancellor. The Society meets monthly during the academic year for lunch and to hear a speaker, usually drawn from the faculty. Modest annual dues cover mailing costs. LIFELONG LEARNING The Lifelong Learning Institute at Washington University offers a wide variety of courses that emphasize peer learning and active class participation by senior adults. For more information, please contact Lifelong Learning at (314) MEDICARE IF AGE 65 OR OVER Part A (Hospitalization Coverage) Part B (Physician and Outpatient Coverage) Medicare Part D (Prescription Drug Coverage) CALL TO APPLY ( ) or visit to download a handbook. SOCIAL SECURITY ADMINISTRATION Questions about Social Security may be directed to the Social Security Administration at MISSOURI CLAIM COMMUNITY LEADERS ASSISTING THE INSURED OF MISSOURI A non-profit organization provides information regarding Medicare enrollment and the options available to you. If you have any questions, CLAIM can be reached at either or (800) W U S T L R E T I R E E B E N E F I T S S U M M A R Y PAGE 8

9 2015 MONTHLY PREMIUM COSTS RETIREES UNDER AGE 65 1 Anthem BC Basic PPO Dental Only Vision Buy-Up Retiree UNDER 65 Retiree + Spouse UNDER 65 Retiree & Family UNDER Age 65 $ $1, $2, $31.87 $63.77 $ $6.53 $13.09 $22.44 RETIREES OVER AGE 65 MEDICARE SUPPLEMENT 2 Anthem BC Medicare Supplement BC Medicare Supplement and Anthem BC Basic PPO Dental Only Vision Buy-Up Retiree 65 & Over Retiree + Spouse 65 And Over Retiree & Spouse 1 Over & 1 Under 65 $ $ N/A N/A N/A $1, $31.87 $63.77 $63.77 $6.53 $13.09 $13.09 COBRA 1 Plan Individual Individual + Child/ren Individual + Spouse/Partner Family UHC Choice (HMO) $ $ $1, $1, UHC Choice Plus (POS) , , , UHC High Deductible (PPO) , Anthem Excel (PPO) , , , Anthem Basic (PPO) , Dental Only Vision Buy-Up Prescription Drug, Dental, and Basic Vision coverage included 2 Dental and Basic Vision coverage included W U S T L R E T I R E E B E N E F I T S S U M M A R Y PAGE 9

10 BENEFIT DEPARTMENT CONTACTS DANFORTH BENEFITS OFFICE CAMPUS BOX 1190 FAX (314) Jennifer Gang, Benefits Coordinator Health, Dental, Rx, Vision, Flex Spending, H.S.A.,COBRA / (314) Donna Bequette, Benefits Plan Manager Retirement Savings, Deferred Compensation / (314) Mary Stull, Sr. Benefits Manager Management Oversight of Accounting / Audits, RMSA marystull@wustl.edu / (314) SCHOOL OF MEDICINE BENEFITS OFFICE Sandra Allen, Benefits Assistant I Retiree/Inactive Billing, Payroll Deductions, MOST allensa@wustl.edu / (314) Mary Ulett, Benefits Manager Health, Dental, Rx, Vision, Flex Spending mary.ulett@wustl.edu / (314) Peggy Heck, Sr. Benefits Coordinator Life Insurance, Long Term Disability peggyheck@wustl.edu / (314) Kimberly Olivastro, Sr. Benefits Coordinator Tuition Assistance, MOST kolivastro@wustl.edu / (314) HRMS Self Service, Systems and Procedures (Help Desk) (314) CAMPUS BOX 8002 FAX (314) Pam Guntli, Benefits Coordinator Retirement Savings, Life Insurance, RMSA guntlip@wustl.edu / (314) PROVIDER CONTACTS HEALTH Anthem BCBS (800) RETIREMENT MEDICAL SAVINGS ACCT (RMSA) TIAA-CREF (877) LONG TERM CARE - METLIFE (888) PRESCRIPTION DRUGS RETIREMENT SAVINGS 403(B) LONG TERM CARE JOHN HANCOCK Express Scripts (ESI) (877) TIAA-CREF (800) (877) VISION RETIREMENT SAVINGS 403(B) LONG TERM CARE LEGACY SERVICES VSP (800) Vanguard (800) (800) , ext. 101 DENTAL Advantica (800) GROUP VARIABLE UNIVERSAL LIFE (GVUL) MetLife (800) TERM LIFE INSURANCE Metlife HEALTH SAVINGS ACCOUNT (HSA) HEALTH SAVINGS ACCOUNT (HSA) COBRA US Bank (877) ConnectYourCare (CYC) (866) Wageworks (877) W U S T L R E T I R E E B E N E F I T S S U M M A R Y PAGE 10

11 RETIREMENT TIMELINE FIVE - TEN YEARS BEFORE RETIREMENT Health Care Planning: Anticipate the cost of health care. After retirement you will be paying the full cost of your healthcare expenses. Consider enrolling in the RMSA to save for retiree health care expenses while you are still working. Think About Long Term Care Insurance: Purchasing a plan is an additional way for people to manage the costs of long term care. Assess Life Insurance Needs: Theoretically, you'll have most of your expenses paid off by the time you retire. A life insurance policy may be instrumental in estate planning or other purposes. Revise Investment Strategy: The way you have handled investments over the past 30 years is not the same way you should handle them for the next 30. While preparing for retirement, you were focused on asset accumulation. When you are in retirement, you need to focus on income and keeping on pace with the increasing cost of living. Assets must be flexible and liquid so you can meet needs you did not anticipate. Review Estate Plan: Review your will and your trust. These documents can protect you and your assets while you are alive and benefit your spouse and children when you pass on. Look at the Big Picture: Before planning a date to retire, see a financial expert and get a broad comprehensive perspective on your whole financial situation and determine if everything is in order. Prepare a Budget: Realistically determine how much money you will spend monthly. Prepare a budget or spending plan to give yourself an idea of what your actual living expenses will be once you are not working. Contact past employers and, if appropriate, the military to find out whether you qualify for retirement income under their plans. Review your annual Personal Earning and Benefit Estimate Statement from Social Security. This can be obtained online at THREE YEARS BEFORE RETIREMENT Review your annual Personal Earning and Benefit Estimate Statement from Social Security. Calculate projected living expenses in detail and compare them to anticipated income from all sources. Continue to prepare financially for the transition. Continue to consider and explore housing options, lifestyle choices, leisure activities, and volunteer or work opportunities. Gather required documentation, including your birth certificate, Social Security card, and, if applicable, marriage certificate (or divorce decree) or documentation of your domestic partnership, which you may need when you elect a benefit. Obtaining records can be timeconsuming, particularly if the records must come from foreign countries. Once gathered, keep these documents in a secure location. W U S T L R E T I R E E B E N E F I T S S U M M A R Y PAGE 11

12 ONE YEAR BEFORE RETIREMENT Make a Retirement Budget - Estimate a retirement living budget. Though this step should have been done previously, it s most important to update/revise this document! Why? Changes in your personal situation or slower investment growth may necessitate the need to delay retirement. Consult the Social Security Administration at this point to determine what your options are, and what the specific monthly income should be. The SSA can also explain the income resulting from several retirement scenarios. Decide if you will need to change health plans during the annual open enrollment period, as you cannot change plans outside of the open enrollment period simply because you retire. Double-check your eligibility for Social Security and Medicare benefits. Reconsider decisions about relocation, family, lifestyle, work/volunteer and leisure time activities. Meet with your tax advisor and/or financial planner to inform them of your impending retirement. Review your retirement account options and make changes if necessary. THREE SIX MONTHS BEFORE RETIREMENT Employers should be notified of the intent to retire. Workers should also notify the Social Security office if they have elected to begin taking retirement benefits at this point. You may apply to begin receiving this benefit if you are age 62 or age 60, if widow or widower. Visit their website Health insurance options should be comparison shopped. If you are age 65 or older and are planning to enroll in Medicare when you retire, start this process two three months prior to your retirement date. If you plan to enroll in the retiree Medicare Supplement health benefits through WUSTL, you must apply for Medicare. Once you have proof of your Medicare enrollment, send a copy of your card along with the enrollment forms to the Benefits Department. Further discuss your retirement plan options with your family and a trusted financial advisor. AFTER YOU RETIRE Keep your address current by updating through the HRMS Self Service Link. W U S T L R E T I R E E B E N E F I T S S U M M A R Y PAGE 12

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14 Retiree Enrollment/Change Form (A) PERSONAL INFORMATION Last Name First Name MI Social Security No. (Required) Street Address City State Zip Home Phone No. University Status: Retiree Surviving Spouse Retirement Date: (B) HEALTH INSURANCE I Elect To: Enroll in Health/Dental Enroll in Dental Only Change Plan or Coverage Level Terminate All Coverage Reason: Plan Type: Anthem BCBS Medicare Supplement Anthem BCBS Basic PPO Coverage Level: Retiree Over 65 Retiree + Spouse Over 65 Retiree Under 65 Retiree + 1 Dependent Under 65 Retiree + Spouse, One Over & One Under 65 Retiree + 2 or more, Under 65 Enroll in Vision Buy-Up Option (You must be enrolled in a Health Plan to Elect Vision Buy-Up) (C) DEPENDENT INFORMATION Please list covered dependents only Action Relationship Date of Birth Name Last (if different), First, MI Gender Is Dependent Enrolled in Medicare? Add Delete Add Delete Add Delete Spouse Domestic Partner Child-1 Child-2 / / / / / / NAME SSN NAME SSN NAME SSN Male Female Male Female Male Female Yes No Yes No Yes No (D) MEDICARE INFORMATION Please list those enrolled in Medicare and include a copy of Medicare card(s) Name Effective Date(s) Part A / Part B: / Medicare Number Name Effective Date(s) Part A / Part B: / Medicare Number (E) AUTHORIZATION My signature below indicates that I have received, read and understand the materials describing the options available to me. I hereby certify that all the information provided is true and correct to the best of my knowledge. I realize that I am making a binding election for the coming calendar year, which can only be changed if I experience a family status change. SIGNATURE: DATE: HUMAN RESOURCES USE ONLY Entered by Date Entered Effective Date W U S T L R E T I R E E B E N E F I T S S U M M A R Y PAGE 14

15 Electronic Funds Transfer (EFT) Form For automatic payment of Health, Dental, and/or Supplemental Life Insurance premiums Please choose one of these options: ELECT EFT Payments CHANGE EFT Information TERMINATE EFT Payments 1. Employee Information First Name: Last Name: Employee ID: Home Phone Number: Monthly premium amount: 2. Bank Information Bank name: Account type: Checking Savings Please attach a voided check or savings deposit slip with VOID written on it. When providing the account and routing/transfer numbers, please refer to the series of numbers located at the bottom of your check and insert those numbers located between the symbols shown. Bank Transit Routing number (9 digits) Account number (10 to 17 digits) 3. Signature I give permission to Washington University to begin withdrawing funds on the 10 th day of each month, out of the account described above, in the amount of my monthly premium. I understand that the amount deducted from my account could vary due to initiating a change to my insurance coverage, and that Washington University will notify me of any plan rate changes at least ten calendar days prior to the amount being debited from my account. This authorization is to remain in force and effective until Washington University has received written notice to discontinue the monthly EFT or upon termination of benefits. Signature Date Submit completed form to: Washington University Benefits Department 7509 Forsyth Blvd., Suite 150 St. Louis, MO or Fax to: (314) (Danforth) (314) (Med School) W U S T L R E T I R E E B E N E F I T S S U M M A R Y PAGE 15