2012-13 Health Benefits

Medical

2012-13 Benefit Plan Summary (pdf)

2012-13 Rates and Contributions (pdf)

Benefits Overviews and Booklets for 2012-13

• Anthem Blue Cross
  • PPO1 80% D $30
    • Overview (pdf)
    • Benefits booklet (pdf)
    • Plan Summary (pdf)
  • PPO2 80% G $30
    • Overview (pdf)
    • Benefits booklet (pdf)
    • Plan Summary (pdf)
  • PPO3 80% M $40
    • Overview (pdf)
    • Benefits booklet (pdf)
    • Plan Summary (pdf)
  • HMO 30/45/1000/3 day
    • Benefits packet
    • Plan Summary (pdf)
• Kaiser Permanente
  • Kaiser HMO 1 Traditional plan (pdf)
  • Kaiser Southern California Guidebook (pdf)
  • Plan Summary (pdf)

Enrollment/Change Forms

• Anthem Blue Cross
  • Anthem Blue Cross HMO/PPO enrollment form (pdf)
    • Note - current enrollees only need to fill out an enrollment form if switching from a PPO to an HMO, or from an HMO to a PPO
  • Anthem Blue Cross change form (pdf)
• Kaiser Permanente
  • Kaiser Permanente enrollment/change form - English (pdf)
  • Kaiser Permanente enrollment/change form - Spanish (pdf)

Claim Forms

• Anthem Blue Cross claim form (pdf)

Domestic Partnership Forms

• SISC Affidavit of Domestic Partnership (pdf)
• California Declaration of Domestic Partnership (pdf)

Dependent Forms

• Anthem Disabled Dependent Certification (pdf)

Flex (Section 125) Plan

• American Fidelity website
• Flex reimbursement form (pdf)

Prescriptions

• Delivery service
  • Medco Mail Order Form 2012
  • Medco Reimbursement Form 2012
  • Medco Brochure 2012
• Claim forms
  • HMO Prescription Claim Form
  • PPO Prescription Claim Form

Provider Directories

• Anthem Blue Cross HMO provider directory (pdf)
• Anthem Blue Cross PPO/HMO on-line provider directory
• Kaiser Permamente on-line provider directory

Dental

• Delta Dental benefits (pdf)
  • Delta Dental group number: 7075-5400
  • Customer service: (866) 499-3001
• Dental/Vision enrollment form (pdf)
• Dental change form (pdf)
• Evidence of Coverage:
  • For active employees (pdf)
  • For retirees (pdf)

Vision

• VSP coverage (pdf)
  • VSP group number: 2465606A
  • Customer service: (800) 877-7195
• Dental/Vision enrollment form (pdf)
• Out-of-network reimbursement form (pdf)
• VSP Providers
  • VSP Network Doctor List (pdf)
  • Online search for VSP Network Doctors
• Vision change form (pdf)

Retirees

• Over 65
  • Health Net retiree enrollment form (pdf)
  • Anthem Blue Cross CompanionCare retiree form (pdf)
• Under 65
  • Anthem Blue Cross HMO/PPO enrollment form (pdf)
• Retiree disenrollment form (pdf)
• Delta Dental Evidence of Coverage for Retirees (pdf)