1. 2021 Employee Benefits Information / 2022 Employee Benefits Information
2. 2021 Health Benefits Enrollment (HB1) Form / 2022 Health Benefits Enrollment (HB1) Form - Active Employees
3. Unit F and Unit G Benefits Overview
4. 2022 Health Benefits Enrollment Form - Half-Time Active Employees
5. 2021 Request for Change of Dependent Status / 2022 Request for Change of Dependent Status - Actives
6. 2021 Domestic Partner Information, Declaration, and Enrollment Form
7. Change of Address Form
8. Update Your Personal Information
9. Retirement Eligibility Verification Form
10. 2021 Medical Opt-Out Cash Back Attestation Form
11. 2021-2022 Unit F - Benefits Opt-Out Cash Back Attestation Form
12. Mid Year Plan Changes / Major Life Events
13. 2021 Application for Retiree Benefits (HI-22) Form / 2022 Application for Retiree Benefits (HI-22) Form

 

1. 2021 Retiree Benefits Guide / 2022 Retiree Benefits Guide
2. 2021 Request for Change of Dependent Status / 2022 Request for Change of Dependent Status - Retirees
3. 2021 Application for Retiree Benefits (HI-22) Form / 2022 Application for Retiree Benefits (HI-22) Form
4. 2021 Change of Address Form / 2022 Change of Address Form (HBR10)
5. 2021 Domestic Partner Information, Declaration, and Enrollment Form
6. Mid Year Plan Changes / Major Life Events

 

 2022 COBRA Active Employees 2021 COBRA Active Employees
 2022 COBRA District Retirees 2021 COBRA District Retirees
 2022 Cal-COBRA 2021 Cal-COBRA
 2022 AB528 2021 AB528
 2021-22 COBRA Active Unit F & Unit G 2020-2021 COBRA Active Unit F & Unit G
   

 

  MetLife
1. Enrollment Form
2. Beneficiary Designation Form
3. Plan Benefits - At a Glance
4. MetLife Advantages - Additional No Cost Services Flyer
5. Statement of Health Form 

 

1. 403(b) Flyer
2. 403(b) List of Vendors
3. 403(b) Plan Information
4. 457(b) Flyer
5. 457(b) Enrollment Form
6. 457(b) Plan Information

 

1. 2021 Flexible Spending Account Newsletter / 2022 Flexible Spending Account Newsletter
2. FSA Enrollment Form
3. FSA Request for Change Form
4. Health Care FSA - How to Submit a Claim Instructions
5. Dependent Care FSA - How to Submit a Claim Instructions
6. Optum Financial Mobile
7. Online Account Portal Overview

 

1. Part D Notice of Creditable Coverage
2. Health Net Seniority Plus Enrollment Form
3. Health Net Seniority Plus Disenrollment Form
4. Kaiser Senior Advantage Enrollment Form California
5. Kaiser Senior Advantage Enrollment Form Hawaii
6. Kaiser Senior Advantage Enrollment Form NorthWest
7. Kaiser Senior Advantage Disenrollment Form California
8. Kaiser Senior Advantage Disenrollment Form Hawaii
9. Kaiser Senior Advantage Disenrollment Form NorthWest
10. SilverScript Employer Prescription Drugs Provider Medicare Part D Plan
 
 
1. 2020 CVS/CareMark Summary of Benefits for Anthem Blue Cross EPO
2. 2020 CVS/CareMark Summary of Benefits for Anthem Blue Cross HMO
3. 2022 CVS/CareMark Performance Drug List for Anthem Blue Cross Plans
4. 2022 CVS/CareMark Advanced Control Speciality Formulary for Anthem Blue Cross Plans
5. 2021 Prescription Drug Plan EOC for Anthem Blue Cross EPO/PPO - SilverScript Medicare
6. 2021 Prescription Drug Plan EOC for Anthem Blue Cross HMO - SilverScript Medicare
7. 2021 Prescription Drug Plan Formulary for Anthem Blue Cross  EPO/PPO - SilverScript
8. 2021 Prescription Drug Plan Fomulary for Anthem Blue Cross HMO - SilverScript
9. 2021 Health Net Active/Retirees Under 65 Drug Formulary
10. 2021 Health Net Retiree Over 65 Drug Formulary
11. Health Net Prescription Drug
12. SilverScript Employer Prescription Drug Provider Medicare Part D Plan

 

SUMMARY OF BENEFITS AND COVERAGE (SBC)

1. 2021 Anthem Blue Cross Select HMO SBC - Actives
2. 2021 Anthem Blue Cross EPO SBC - Actives CA Residents
3. 2021 Anthem Blue Cross EPO SBC - Actives Non CA Residents
4. 2021 Prescription Drug Plan for Anthem Blue Cross EPO- SilverScript Medicare
5. 2021 Prescription Drug Plan for Anthem Blue Cross HMO - SilverScript Medicare
6.  2021 Health Net HMO SBC - Actives
7. 2021 Health Net HMO SBC - Early Retirees
8. 2021 Kaiser HMO SBC - Actives
9. 2021 Kaiser HMO SBC - Early Retirees
10. 2021 Kaiser Hawaii HMO SBC - Early Retirees
11. 2021 Kaiser NW HMO SBC - Early Retirees
12. Sep 2021 - Aug 2022 Kaiser HMO SBC - Unit F
13 2021 VSP
14. 2021 Delta Dental
15. 2021 United Concordia PPO Benefit Summary - Active
16. 2021 United Concordia PPO Benefit Summary - Retiree
17. 2021 Western Dental

 

  MEDICAL
1. 2021 Anthem Blue Cross EPO - Active CA
2. 2021 Anthem Blue Cross EPO - Active Non-CA
3. 2021_Anthem Blue Cross EPO - Retiree CA
4. 2021 Anthem Blue Cross EPO - Retiree Non-CA
5. 2021 Anthem Blue Cross HMO - Active
6. 2021 Anthem Blue Cross HMO - Retiree
7. 2021 Anthem Medicare Preferred (PPO) Medical Plan - Medicare Retiree
8. 2021 Health Net HMO - Active
9. 2021 Health Net HMO - Early Retiree
10. 2021 Health Net HMO - Seniority Plus
11. 2021 Kaiser HMO EOC - Active
12. 2021 Kaiser HMO EOC - Early Retiree
13. Sep 2020 - Aug 2021 Kaiser HMO EOC - Unit F
14. Oct 2020 - Sept 2021 Kaiser HMO EOC - Student Body
15. 2021 Kaiser Senior Advantage EOC - Retiree Over 65 
16. 2020 Kaiser Senior Advantage EOC - Northwest
17. 2020 Kaiser Senior Advantage EOC - Hawaii
  DENTAL
17. United Concordia Dental Actives - CA
18. United Concordia Dental - MS, MT, LA, and TX
19. 2021 Delta Dental
  VISION
21. EyeMed - Active
22. EyeMed - Retiree
23. 2021 VSP

 2021 Evidence of Coverage documents will be updated on this page as they become available. 

1. MetLife Funeral Planning Flyer
2. Anthem Blue Cross Guest Membership Flyer
3. Kaiser Travel Coverage 
4. Kaiser Travel Coverage for Medicare Members
5. Kaiser Telehealth Flyer - Southern California
6. Kaiser Telehealth Flyer - Northern California
7. Kaiser Urgent Care Locations - Southern California
8. Kaiser Urgent Care Locations - Northern California