CITY BENEFITS

The following files are in PDF file format and require Adobe Acrobat in order to be able to view them. If you don't have it, you can download it here.

	2010 Retiree Open Enrollment Cover Letter
	2010 Retiree Guide
	2009 Retiree Enrollment Change Form
	2010 Retiree Enrollment Change Form
	2009 Monthly Rates for Pre 01 01 08 Retirees
	2009 Monthly Rates for Post 12 31 07 Retirees
	UHC Preventive Care Report
	Important Contact List
	Change of address form
	Arlington Federal Credit Union Payment Authorization Form
	Arlington Federal Credit Union Payment Cancellation Form

UNDER 65 Plans Information

	Prescription Drug List Information
	Choice Core Plan Summary 2010
	Choice Plus Plan Summary 2010
	Choice Value Plan Summary 2010
	Specialty Pharmacy 2010
	2010 Under 65 Rates Retired Before 01-01-08
	2010 Under 65 Rates Retired After 12-31-07

OVER 65 Plans Information

	Secure Horizons 2009 Benefits Summary
	Secure Horizons 2010 Benefits Summary
	2010 Prescription Drug Plan Summary
	AARP 2009 Supplement Plan Information
	2009 UHC Medicare Rx Full Formulary
	2009 UHC Medicare Rx Plan Summary
	UHC Medicare Part D Rx Decline Form
	2010 Pharmacy Creditable Coverage Notice
	2010 65+ Rates - Retired Before 01-01-08
	2010 65+ Rates - Retired After 12-31-07

DENTAL Plan Information

Dental Waiting Periods
When you enroll in either of the dental PPO plans, you will be required to meet certain waiting periods for some services (Refer to the Workforce Services Portal or City website to review specific waiting periods.) However, if you have been covered for one full year in the City’s DHMO plan and effective 1/1/10 you want to select either of the PPO plans, the 12 month waiting period will be waived for all covered services.   

	2010 Dental and Vision Plan Rates
	Dental High Low PPO Plan Comparison
	Dental High PPO Schedule
	Dental DHMO Summary
	DHMO Evidence of Coverage (SPD)
	DHMO Summary of Benefits
	Dental High PPO Certificate of Coverage (SPD)
	Dental High PPO Summary of Benefits
	Dental PPOs - High & Low Plan Comparisons
	Dental PPOs - High & Low Plan Comparisons & Using Network Dentists
	Dental Low PPO - Max Allowable Charges - ADA Codes
	Dental Low PPO - Covered Services

UnitedHealthcare VISION Plan Information

Retiree UHC Vision Plan

Health Saving Account Informational Documents

	HSA_Contribution_Form_2010
	HSA Indexed Amounts for 2009
	HSA Indexed Amounts for 2010
	HSA Enrollment Link
	UHC_Health_eSaver_Fee_Schedule
	All About Health Savings Accounts
	Health Savings Account Presentation
	HSAs - Key Points
	IRS Publication 969
	IRS Publication 502
	IRS Form 8889
	IRS Form 8889 Instructions