ET-4307
Form Active Employee / Retiree

Medicare Eligibility Statement

You and/or your insured dependents must be enrolled for both portions of Medicare (Hospital Part A and Medical Part B), when first eligible. Provide this information to ETF using this form.

You Marry

Experiencing this life event may allow you to make changes to your accident plan or health, dental, vision, or long-term care insurance.

Program Option
  • Local Annuitant Health Program (LAHP)
  • Local Deductible Health Plan (PO14) & Supplemental Benefits
  • Local Deductible Health Plan with Uniform Dental (PO4) & Supplemental Benefits
  • Local Health Plan (PO16) & Supplemental Benefits
  • Local Health Plan with Uniform Dental (PO6) & Supplemental Benefits
  • Local High Deductible Health Plan (PO17) & Supplemental Benefits
  • Local High Deductible Health Plan with Uniform Dental (PO7) & Supplemental Benefits
  • Local Traditional Health Plan (PO12) & Supplemental Benefits
  • Local Traditional Health Plan with Uniform Dental (PO2) & Supplemental Benefits
  • State Employee and Retiree Health Plan & Supplemental Benefits

Life Events Guide

Have you recently had a baby? Gotten married? Divorced? Moved? Throughout the year you may experience life events that allow you to change your benefits outside of the annual open enrollment period. The life events guide explains deadlines, required documentation, and which events allow you to make changes.

Program Option
  • Local Annuitant Health Program (LAHP)
  • Local Deductible Health Plan (PO14) & Supplemental Benefits
  • Local Deductible Health Plan with Uniform Dental (PO4) & Supplemental Benefits
  • Local Health Plan (PO16) & Supplemental Benefits
  • Local Health Plan with Uniform Dental (PO6) & Supplemental Benefits
  • Local High Deductible Health Plan (PO17) & Supplemental Benefits
  • Local High Deductible Health Plan with Uniform Dental (PO7) & Supplemental Benefits
  • Local Traditional Health Plan (PO12) & Supplemental Benefits
  • Local Traditional Health Plan with Uniform Dental (PO2) & Supplemental Benefits
  • State Employee and Retiree Health Plan & Supplemental Benefits

Find the Cost of Your Drugs

Employees and Retirees without Medicare: learn how much you can expect to pay at the pharmacy.

Program Option
  • Local High Deductible Health Plan (PO17) & Supplemental Benefits
  • Local High Deductible Health Plan with Uniform Dental (PO7) & Supplemental Benefits
Plan Year
  • 2025

Medicare Plan Designs Quick Comparison

Learn about the key differences between plan designs such as how much you'll pay per month, how much you can expect to pay when you visit the doctor, and if you will have nationwide coverage.
Plan Year
    2025
Program Option
    Local Traditional Health Plan (PO12) & Supplemental Benefits

Medicare Plan Designs Quick Comparison

Learn about the key differences between plan designs such as how much you'll pay per month, how much you can expect to pay when you visit the doctor, and if you will have nationwide coverage.
Plan Year
    2025
Program Option
    Local Deductible Health Plan with Uniform Dental (PO4) & Supplemental Benefits

Medicare Plan Designs Quick Comparison

Learn about the key differences between plan designs such as how much you'll pay per month, how much you can expect to pay when you visit the doctor, and if you will have nationwide coverage.
Plan Year
    2025
Program Option
    Local High Deductible Health Plan (PO17) & Supplemental Benefits

Medicare Plan Designs Quick Comparison

Learn about the key differences between plan designs such as how much you'll pay per month, how much you can expect to pay when you visit the doctor, and if you will have nationwide coverage.
Plan Year
    2025
Program Option
    Local Traditional Health Plan with Uniform Dental (PO2) & Supplemental Benefits

Medicare Plan Designs Quick Comparison

Learn about the key differences between plan designs such as how much you'll pay per month, how much you can expect to pay when you visit the doctor, and if you will have nationwide coverage.
Plan Year
    2025
Program Option
    Local Health Plan (PO16) & Supplemental Benefits