Health Benefits

2011-12 Benefit Plan Summary

2011-12 Insurance Rates and Contributions

2010-11 Insurance Rates and Contributions

Medical

Benefits Packets for 2011-12 (pdf)

• Anthem Blue Cross
  • Anthem HMO 1 (Classic HMO 30/250/3 day)
  • Anthem HMO 2 (Value HMO 30/40/500/3 day)
  • Anthem HMO 3 (Value HMO 30/45/1000/3 day)
  • Anthem Classic PPO
• Kaiser Permanente
  • Kaiser HMO 1 (Traditional plan)
  • Kaiser Southern California Guidebook (pdf)

Enrollment/Change Forms

• Anthem Blue Cross
  • Anthem Blue Cross HMO enrollment form 2011-12 (pdf)
    • Note - under “Type of Coverage”, check the box for “HMO (CaliforniaCare)” regardless of which HMO you are enrolling in. You will select the type of HMO on your open enrollment form.
  • Anthem Blue Cross PPO enrollment form (pdf)
  • Anthem Blue Cross change form (pdf)
• Kaiser Permanente
  • Kaiser Permanente enrollment/change form - English (pdf)
  • Kaiser Permanente enrollment/change form - Spanish (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)

Prescription Delivery Service

• Anthem Blue Cross HMO
  • Express Scripts home delivery service form (pdf)

Provider Directories

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

Dental

• Delta Dental benefits (pdf)
• Dental/Vision enrollment form (pdf)

Vision

• VSP coverage (pdf)
• Dental/Vision enrollment form (pdf)
• Out-of-network reimbursement form (pdf)
• List of participating VSP doctors

Retirees

• Health Net retiree enrollment form
• Anthem Blue Cross CompanionCare retiree form
• Retiree disenrollment form