Division of Risk Management and Insurance Services / Forms/Publications

1.	2022 Employee Benefits Information
2.	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.	2022 Request for Change of Dependent Status - Actives
6.	2022 Domestic Partner Information, Declaration, and Enrollment Form
7.	Change of Address Form
8.	Update Your Personal Information
9.	Retirement Eligibility Verification Form
10.	2022 Medical Opt-Out Cash Back Attestation Form
11.	2022-2023 Unit F - Benefits Opt-Out Cash Back Attestation Form
12.	Mid Year Plan Changes / Major Life Events
13.	2022 Application for Retiree Benefits (HI-22) Form

1.	2022 Retiree Benefits Guide
2.	2022 Request for Change of Dependent Status - Retirees
3.	2022 Application for Retiree Benefits (HI-22) Form
4.	2022 Change of Address Form (HBR10)
5.	2022 Domestic Partner Information, Declaration, and Enrollment Form
6.	Mid Year Plan Changes / Major Life Events
7.	PO Box Attestation Form (Anthem PPO only) Required by retirees AND EACH of their >65 / Medicare-eligible dependents enrolling in the Anthem Medicare Preferred (PPO).

	MetLife
1.	Enrollment Form
2.	Beneficiary Designation Flyer
3.	Beneficiary Designation Form
4.	Plan Benefits - At a Glance
5.	MetLife Advantages - Additional No Cost Services Flyer
6.	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
7.	457(b) Mobile App Flyer
8.	457(b) Beneficiary Designation Form

1.	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.	2022 CVS/CareMark Performance Drug List for Anthem Blue Cross Plans
2.	2022 CVS/CareMark Advanced Control Speciality Formulary for Anthem Blue Cross Plans
3.	2022 Prescription Drug Plan EOC for Anthem Blue Cross EPO/PPO - SilverScript Medicare
4.	2022 Prescription Drug Plan EOC for Anthem Blue Cross HMO - SilverScript Medicare
5.	2022 Prescription Drug Plan Formulary for Anthem Blue Cross EPO/PPO - SilverScript
6.	2022 Prescription Drug Plan Fomulary for Anthem Blue Cross HMO - SilverScript
7.	2021 Health Net Active/Retirees Under 65 Drug Formulary
8.	2021 Health Net Retiree Over 65 Drug Formulary
9.	Health Net Prescription Drug
10.	SilverScript Employer Prescription Drug Provider Medicare Part D Plan

1.	2022 Anthem Blue Cross Select HMO SBC - Actives (rev. 3.7.22)
2.	2022 Anthem Blue Cross EPO SBC - Actives, CA Residents (rev. 3.7.22)
3.	2022 Anthem Blue Cross EPO SBC - Actives, Non-CA Residents (rev. 3.7.22)
4.	2022 Prescription Drug Plan - SilverScript Medicare
5.	2022 Prescription Drug Plan for Anthem Blue Cross HMO - SilverScript Medicare
6.	2022 Health Net HMO SBC - Actives
7.	2022 Health Net HMO SBC - Early Retirees
8.	2022 Kaiser HMO SBC - Actives, Southern California
9.	2022 Kaiser HMO SBC - Early Retirees, Southern California
10.	2022 Kaiser HMO SBC - Actives, Northern California
11.	2022 Kaiser HMO SBC - Early Retirees, Northern California
12.	Sep 2021 - Aug 2022 Kaiser HMO SBC - Unit F
13.	2022 Kaiser Northwest HMO SBC - Early Retirees
14.	2022 Kaiser Hawaii HMO SBC - Early Retirees
15.	2022 Aetna Dental PPO SBC
16.	2022 Delta Dental
17.	2022 Western Dental
18.	2022 VSP

	MEDICAL
1.	2022 Anthem Blue Cross EPO - Active CA
2.	2022 Anthem Blue Cross EPO - Active Non-CA
3.	2022 Anthem Blue Cross EPO - Retiree CA
4.	2022 Anthem Blue Cross EPO - Retiree Non-CA
5.	2022 Anthem Blue Cross HMO - Active
6.	2022 Anthem Blue Cross HMO - Retiree
7.	2022 Anthem Medicare Preferred (PPO) - Medicare Retiree
8.	2022 Health Net HMO - Active
9.	2022 Health Net HMO - Early Retiree
10.	2022 Health Net HMO - Seniority Plus
11.	2022 Kaiser HMO EOC - Active, Southern California
12.	2022 Kaiser HMO EOC - Active, Northern California
13.	Sep 2021 - Aug 2022 Kaiser HMO EOC - Unit F
14.	Oct 2021 - Sept 2022 Kaiser HMO EOC - Student Body
15.	2022 Kaiser HMO EOC - Early Retiree, Southern California
16.	2022 Kaiser HMO EOC - Early Retiree, Northern California
17.	2022 Kaiser Northwest HMO EOC - Early Retiree
18.	2022 Kaiser Hawaii HMO EOC - Early Retiree
19.	2022 Kaiser Senior Advantage EOC - Retiree Over 65, Southern California
20.	2022 Kaiser Senior Advantage EOC - Retiree Over 65, Northern California
21.	2022 Kaiser Senior Advantage Northwest EOC
22.	2022 Kaiser Senior Advantage EOC - Hawaii
	DENTAL
23.	Aetna Dental PPO - Most US States
24.	Aetna Dental PPO - LA and TX
25.	Delta Dental
	VISION
26.	EyeMed - Active
27.	EyeMed - Retiree
28.	VSP

2022 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.	Anthem Blue Cross Sydney Health Flyer
4.	Anthem Blue Cross Virtual Support Flyer
5.	Kaiser Travel Coverage
6.	Kaiser Travel Coverage for Medicare Members
7.	Kaiser Travel Coverage through Cigna PPO
8.	Kaiser Telehealth Flyer - Southern California
9.	Kaiser Telehealth Flyer - Northern California
10.	Kaiser Urgent Care Locations - Southern California
11.	Kaiser Urgent Care Locations - Northern California
12.	VSP - Essential Medical Eye Care
13.	VSP - How to Create an Online Account
14.	VSP - Eyeconic Overview

Division of Risk Management and Insurance Services