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Insurance Information
Open Enrollment October 30, 2018 to November 27, 2018

OPEN ENROLLMENT MEMOS

Open enrollment information for employees and retirees is provided below. Click on the applicable link below for your specific coverage eligibility category.

Active Full-Time Employee Open Enrollment Information

Active Full-Time Employees, please click on the link above to obtain general information regarding open enrollment and rates for the 2019 plan year.

Active ACA Eligible Part-Time Employee Open Enrollment Information.

Active ACA Eligible Part-Time Employees, employees who have worked an average of 30 hours or more per week in an applicable 12-month measurement period, please click on the link above to obtain general information regarding open enrollment and rates for the 2019 plan year.

Under 65 Tier I Retiree Open Enrollment Information

Retirees under the age of 65 who retired on or before December 31, 2016, please click on the link above to obtain general information regarding open enrollment and rates.

Under 65 Tier II Retiree Open Enrollment Information

Retirees under the age of 65, who retired on or after January 1, 2017, please click on the link above to obtain general information regarding open enrollment and rates for the 2019 plan year.


OPEN ENROLLMENT PLAN SUMMARIES & ENROLLMENT FORMS

For eligible employees and enrollees, the 2019 enrollment forms, Summaries of Benefits and Coverages (SBC), and/or plan summaries are available by clicking on the applicable link(s) below. If you are not making any changes to your current enrollment in one of the Blue Shield plans or the Kaiser plan, you do not need to complete any forms.

Blue Shield Enrollment Form

If you currently are not enrolled in a Blue Shield plan and wish to enroll in one, please click on the link above to obtain a copy of the enrollment form.

Blue Shield Change Form

If you are currently enrolled in a Blue Shield plan and wish to change your enrollment, including transferring from the HMO to the PPO or from the PPO to the HMO, please click on the link above to obtain a copy of the change form.

Blue Shield Refusal of Coverage Form

If you do not plan to enroll or continue enrollment in a Blue Shield plan, please click on the link above to obtain a copy of the refusal form.

Blue Shield HMO - Plan Summary

Blue Shield HMO SBC

Blue Shield PPO - Plan Summary

Blue Shield PPO SBC

For additional Blue Shield information - click here.


Kaiser Enrollment Form

If you plan to enroll in or make a change to your enrollment in the Kaiser plan, please click on the link above to obtain a copy of the enrollment/change form.

Kaiser - Plan Summary

Kaiser HMO SBC


ACA Coverage Offer & Waiver Form

If you received an initial offer of coverage in 2018, you may be eligible for an offer of coverage for 2019. If so, you will receive an offer of coverage for 2019. However, if you misplace the offer form, you may click on the link above to obtain a new one.

Cash-In-Lieu Form

If you wish to waive coverage and take advantage of cash-in-lieu for the 2019 plan year, click on the link above to complete the form. The completed form must be accompanied by proof of other coverage when submitted to Human Resources in order to be processed. All 2018 Cash-in-Lieu forms expire on December 31, 2018.


Insurance Information - Active Employees

MEDICAL

2018 Medical Plan Premium Rates – Active Full-Time Employees

2018 Medical Plan Premium Rates – ACA Eligible Part-Time Employees

2018 Blue Shield HMO Enrollment Form

2018 Blue Shield HMO Plan Summary

2018 Blue Shield HMO SBC

2018 Blue Shield PPO Enrollment Form

2018 Blue Shield PPO Plan Summary

2018 Blue Shield PPO SBC

2018 Kaiser HMO Enrollment Form

2018 Kaiser HMO Plan Summary

2018 Kaiser HMO SBC

2018 ACA Eligible Part-Time Employees Election Form

2018 Cash-In-Lieu Form


DENTAL

Ameritas Enrollment Form

Ameritas Dental Highlights & Certificate

Ameritas Privacy Notice (English)

Ameritas Privacy Notice (Spanish)

Ameritas Vision Materials Reimbursement Request Form

Ameritas Notice for the California Language Assistance Program

Ameritas GLB Notice (English)

Ameritas GLB Notice (Spanish)


VISION

VSP Enrollment Form

VSP Member Benefits Summary

VSP Out-of-Network Claim Form

VSP How to Register for Member Access

VSP Extra $20 Flier with Coupon

VSP TruHearing Hearing Aid Discount Program

VSP Better Provider Choices


Insurance Information - Retirees Under Age 65

Retiree Medical Benefits Contribution & Eligibility Information

2018 Medical Plan Premium Rates & Contributions – Tier I Retirees Under 65

2018 Medical Plan Premium Rates & Contributions – Tier II Retirees Under 65

2018 Blue Shield HMO Enrollment Form

2018 Blue Shield HMO Plan Summary

2018 Blue Shield HMO SBC

2018 Blue Shield PPO Enrollment Form

2018 Blue Shield PPO Plan Summary

2018 Blue Shield PPO SBC

2018 Kaiser HMO Enrollment Form

2018 Kaiser HMO Plan Summary

2018 Kaiser HMO SBC

 

Insurance Information - Retirees Age 65 & Older

Retiree Medical Benefits Contribution & Eligibility Information

2018 Medical Plan Premium Rates & Contributions – Tier I Retirees Post 65

2018 Medical Plan Premium Rates & Contributions – Tier II Retirees Post 65

Benistar-Hartford Enrollment Form

2017 Benistar-Hartford Medicare Supplement Benefits Summary

2017 Benistar-Hartford Express Scripts Pharmacy Benefits Overview

2017 Benistar-Hartford Express Scripts 5-Tier Formulary