Duke Medical Form

Return the completed form within 30 days of the qualifying event to: Progress Energy Employee Service Center – PEB 16 ESC, P.O. Box 1551, Raleigh, NC 27602-1551. If you have questions, call 800-546-5705. Changes received in the Employee Service Center after the 15th of the month may not be reflected until the next pension payroll cycle.

A. General Information:

B. Reason for coverage change

Check the qualifying event that applies:

You, your spouse or domestic partner, or dependent loses eligibility or becomes eligible to participate in a premium assistance program under Medicaid or Children’s Health Insurance Program (CHIP) coverage (must notify Employee Service Center within 60 days of change; other qualifying events are 30 days)

* Please give details in comments section. ** Request declaration form

C. Medical Enrollment

Check the box next to your chosen retiree medical option and coverage level

HEALTH SAVINGS ACCOUNT (only available if you elect the BCBS High Deductible Health Plan)

D. Participant Information

List below all participants to be covered under your retiree medical coverage

* Medical PCP - If you are changing plans or adding dependents, you must name a Primary Care Physician for each participant under the AvMed HMO or BlueCare HMO medical plans. Children may designate a pediatrician as their PCP. BlueCare and AvMed require a PCP #.

OB/GYN Care - Female members can obtain access to in-network OB/GYN care without prior authorization. The HMO plans do not allow an OB/GYN to be selected as the PCP. AvMed only allows Obstetricians as PCPs during pregnancy.

The following provisions apply to your retiree medical coverage

If you elect or keep your HMO or HDHP Option:

1. You may keep HMO or HDHP coverage up to the month of the calendar year either you or your spouse/domestic partner (if covered) will reach age 65 or become Medicare eligible due to disability. At that time you, your spouse/domestic partner and dependents (if applicable) must move to the BU BCBSF PPO-750 Plan or an outside Medicare Advantage Plan.

2. At annual enrollment, you may elect to change your coverage option for yourself, your spouse/domestic partner, and dependents (if covered) to the BU BCBSF-750 or BCBSNC HDHP Plans or one of the available HMO options.

If you elect or keep your BU BCBSF-750 Plan:

1. At annual enrollment you, your spouse/domestic partner, and dependents (if covered) may elect to change medical coverage to one of the available HMO or HDHP Plans, if you meet the HMO and HDHP eligibility.

2. As each covered employee or spouse/domestic partner becomes eligible for Medicare Part A & B, your BU BCBSF-750 Plan coverage will be a secondary payer after Medicare Part A & B.

Payment of Medical Premiums:

1. Any contributions you must pay towards your medical coverage can be deducted from your pension check as long as your contribution amount does not exceed your pension check.

2. If you are eligible for company subsidized retiree medical, the age/service matrix is used to determine the percentage of the premium you and the company will share up to the medical funding caps.

3. Employees who retired on or after January 1, 1998 are subject to retiree medical funding caps of $6,500 for pre-65 retirees and $3,500 for post-65 retirees.

Change in Status:

You will be permitted to make changes to your coverage in certain instances. You must notify the Employee Service Center within 30 days of a qualifying event.

A qualifying event includes:

• Legal marriage status – marriage, death of spouse, divorce, legal separation, or annulment.
• Number of dependents – birth, adoption, placement for adoption or death of a dependent.
• Dependent child no longer meets the dependent eligibility requirements.
• Dependent child meets the dependent eligibility requirements.
• Declaration or termination of domestic partner relationship.

Surviving Spouse’s/Domestic Partner’s Medical Coverage Provision:

1. If the employee has 15 years or more of eligible service as of his/her retirement date, the surviving spouse/domestic partner will be offered continued post-retirement medical coverage if he/she is covered at the time of the retiree’s death.

2. If the employee has less than 15 years of eligible service as of his/her retirement date, the surviving spouse/domestic partner will not be offered continued post-retirement medical coverage at the time of the retiree’s death.

3. If an employee dies while in active service, the same 15-year rule applies with regard to post-retirement medical coverage and COBRA benefits.

4. There are two ways that a surviving spouse/domestic partner could lose post-retirement medical coverage:

• Remarriage/new domestic partner relationship (permanent loss of coverage).
• Eligibility for coverage under another employer plan (temporary loss of coverage).

AUTHORIZATION

The information furnished by me is true and complete to the best of my knowledge. I understand that if I elect benefits for ineligible dependents as defined by the health benefit plans, I will be in violation of the company's Code of Ethics. I agree that I and my dependents will abide by the provisions of the agreement for the Plans in which I am enrolling. I have read and understand the information noted above and I will keep a copy of this document for my records.