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Retirees Over 65 Plan Information and Forms

Health & Dental Insurance


Health & Dental Contributory Retirement Rate Chart
Insurance Rate Chart for Contributory Retirees. This does not include the Contributory Retirement Subsidy Amounts.

Health & Dental New Hampshire Retirement Rate Schedule
Insurance Rate Chart for New Hampshire State Retirees (Police & Fire) including the NH Subsidy Amounts.

United American Supplement Plan F Summary of Benefits
United American Supplemental Plan G Summary of Benefits
Summary of your Medicare (Part A) Hospital and (Part B ) Medical Services benefits and United American benefit coverage. Plan G is fonly or retirees turning 65 on 1/1/20 or after and who live in FL, MN or WA.

Express Scripts (Part D) Overview of Benefits
Summary of Benefits for your prescription drug coverage.

Prescription Plan Express Scripts Evidence of Coverage
Evidence of Coverage for your Medicare Prescription Drug Coverage with Express Scripts.

Express Scripts Prescription Formulary
This booklet covers information about the drugs that United American Covers.

Delta Dental Outline of Coverage
Delta Dental Outline of Benefits & Dental Outline of Coverage.

Delta Dental Plan Booklet
Detailed booklet explaining your dental coverage; what is covered and at what percentage it is covered, etc.

Delta Dental Vision Discount Program
Free Vision Discount Program offered by Delta Dental. Great savings of up to 35%.



Dental Enrollment/Change Form
This form is to terminate, enroll in or make changes to your dental insurance.

United American Enrollment Form
This form is to enroll into United American's Medicare Supplement F plan.

NH Retirement Annuity Deduction Authorization Form
Fire & Police retirees, you must complete this form if you are making any changes that affect your health and/or dental insurance premiums.

Health Insurance Cancelation Form
Read/sign this form and complete the Health Insurance Disenrollment form below if you wish to cancel your health insurance.

Health Insurance Disenrollment Form
Complete this form and read/sign the Health Insurance Cancelation form above if you wish to cancel your health insurance.

Prescription Home Delivery Form
If you want to do mail order/home delivery for your prescriptions with Express Scripts click here. 

www.Express-Scripts.com or call 1-888-345-2560