Benefits

Direct Deposit Form for Pension

Use this form to directly deposit your pension checks to your savings or checking account.  If your current direct deposit account changes, use this form to inform Prudential of the change.  Send the form to the address located on the form.  Prudential will send you a confirmation within 10 days of completing your authorization advising you of when your pension payments will start being sent to your bank via Direct Deposit. 

Beneficiary Designation Form - Contingent Beneficiary

This form allows you to name contingent (alternative or secondary) beneficiary(s) in the event that the primary beneficiary(s) predeceases the insured. Complete the form and send the original to Corporate Benefits at:  Bausch & Lomb, One Bausch & Lomb Place,  Rochester,  NY  14604-2701. Retain a copy for your records and update as needed.

Beneficiary Designation Form - Life Insurance & 401(k)

Use this form to name a beneficiary(s) for your life insurance and/or 401(k) plans. You may use the Standard Beneficiary Designation or you may customize your designation. Once the form is completed, send the original to Corporate Benefits at:  Bausch & Lomb, One Bausch & Lomb Place, Rochester,  NY  14604-2701. Save a copy for yourself and be sure to update it if a change is necessary.

Medical providers can file claims electronically with UnitedHealthCare, whether they are participating providers or not. If your provider does not file directly, use this form to submit medical expenses for reimbursement

Handicapped Dependent Form for UnitedHealthCare

If you have a child who is eligible for coverage beyond age 19 due to mental retardation or a physical handicap, completion of this form will provide substantiation of the medical condition.

Application for Transition of Care for UnitedHealthCare

If you are in a course of treatment with a physician who doesn’t contract with UnitedHealthCare, this form will allow you to receive time-limited care from the non-participating provider, paid at the participating level.

Medco Health Reimbursement Form (updated 4/2007)

For initial requests of ordering maintenance prescription drugs through the mail.  Refills can be ordered using this form, visiting www.myuhc.com or calling 1-800-4REFILL or 1-800-473-3455.

UHC Customer Issue Submission Form

Use this form to file a question or complaint about your claim, or to appeal a denied claim.  Follow the directions and mailing instructions with the form.  The group number is 702553.

HMO Plan Enrollment/Change Form
(updated 1/2007)

Use this form to record the names of your covered dependents and their primary care physicians; or to add or delete dependents’ from coverage. Click here for a listing of locations to send the form to. Note that enrollment in the plan is NOT complete until this form is received by the HMO.

Pharmacy Reimbursement Form  (updated 4/2007)

This form serves two purposes. Use if you have paid 100% of the cost of your drugs and are seeking reimbursement for all but the copayment; or if you have more than one pharmacy plan and UHC's plan through Bausch & Lomb is the secondary coverage. Follow the instructions on the form for submitting your expenses.

Preferred Care TriVantage Health Dollars Reimbursement Form

Use this form when seeking reimbursement for your Active Lifestyles or Family Focus Benefits.

Contact Lens Form

Any benefit eligible Bausch & Lomb retiree, and/or covered dependent, as defined under the medical benefit plan, is eligible to receive an annual supply of Bausch & Lomb soft contact lenses as prescribed by their eye care practitioner.

1. Print form (pages 1 and 2)
2. Complete employee information on Section I
3. Obtain HR approval from Corporate Benefits.  Form MUST have approval prior to processing.
4. Provide both pages of the form to your eye care practitioner.