Special  Retiree Plan

Serving retirees of Local Funds

                1035   191   404    443  493 559  671A  677                      

609 West Johnson Ave

2nd floor

Cheshire CT 06410  

 Hours

Monday - Friday

      8:30 a.m. - 4:30 p.m.

 

Phone: 800-292-8340

Fax:      203-250-1232

Retiree

Prescription changes all plans 

Please show your ID card to the health care provider

      Your id starts with TSJ followed by 7 numbers.

          

Important information is located on back of card

                                

Directions to Health Services office 

           Fill in forms to print and mail  

The below forms are here for your convenience. Please contact Retiree Health services office first when submitting a claim or providing information.

Medical Massage Reimbursement

 Prescription

Reimbursement

Annual Information Request

Beige House

Change of address

Hot Air Balloons

Designation of Beneficary

Dollar Bill in Jar

Benefit payment via Pension 

Lighthouse

Benefit Cancellation

Authorization to release PHI 

Business Meeting

Summary Annual Report

                                        

                             Document & Information Check list

 

                                                            Complete Annual Information Request form                               

                                                                                           

             Address(you or your dependents)                                                     Birth ,Marriage,Death Certificate

             Telephone                                                                                              Beneficiary designation

             Family status (such as marriage)                                                      Divorce Decrees

             Covered by other insurance                                                                Court Ordered Health Coverage

             

                                                                       Claims payment may require:

                                                                   How, When and Where an injury occurred

                                                                   Information about other Insurance 

                                                                   Information about any action against Third Party 

                                                                   Reimbursement Agreement form

         

                                                          Claim filing limit is 2 years from date incurred

                                                  Request an appeal within 180 days from the claim denial 

Please contact Retiree Health Services office for questions concerning eligibility,  benefits and claim payment.

Please review the Summary Plan Description for further information regarding your plan of benefits.