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Optional Rider Claim Forms

Non-NYC Resident Rider Claim Form
This form should be completed if you are a UFT Welfare Fund Retiree and you or your spouse/domestic partner (DP) is paying premiums covering you for a Health Insurance Plan that covers prescriptions, other than from a NYC Health Plan.

NY Resident Rider Claim Form
This form should be completed only if you are a UFT Welfare Fund Retiree and paying for a NYC Optional Rider or NYC Health Plan through pension deduction/direct payment or if you are covered under your spouse's/domestic partner's NYC Health Plan.