Retiree Information

HMO Medical Plans and Enrollment Forms

2020-21

• SISC III Enrollment Form for Blue Shield HMO Full Network
• Blue Shield HMO Full Network 10-0 Benefits Summary
• Enrollment Request For Blue Shield 65 (HMO) Employer Group/Union Health Plan Form
• Blue Shield Advantage Benefits Summary
• Kaiser Permanente Senior Advantage Enrollment Forms (One person with Medicare)
• Kaiser Permanente Senior Advantage Enrollment Form (Two persons with Medicare)
• Kaiser Permanente Senior Advantage Benefits Summary

 

PPO Medical Plans and Enrollment Forms

• SISC CompanionCare/PPO EGWP Rx Enrollment Form
• Blue Shield PPO EGWP 100G Benefits Summary
• Blue Shield PPO EGWP 100A Benefits Summary 
• Blue Shield Companion Care Benefits Summary

 

Prescription Coverage

• Navitus Medicare Rx Information

 

Additional Information

• HIPAA Notice of Privacy Practices

HMO Plan

• Delta Care HMO Benefits Summary

 

PPO Plans 

• Delta Dental PPO 1500 Benefits Summary
• Delta Dental PPO Unlimited Benefits Summary

• VSP Signature Plan C

HMO Medical Plans and Enrollment Forms

2021-22

• Kaiser Permanente $15; Rx $5-20 (30 Day) Benefits Summary
• Kaiser Permanente $0; Rx $5-20 (30 Day) Benefits Summary
• Kaiser Permanente Enrollment Form
• Blue Shield Trio Benefits Summary
• Blue Shield Full Network Benefits Summary
• SISC III Enrollment Form for Blue Shield

PPO Medical Plans and Enrollment Forms

2021-22

• SISC III Enrollment Form for Blue Shield
• Blue Shield 90G $20; Rx $5-20 (30 Day) Benefits Summary
• Blue Shield 100A $10; Rx $5-20 (30 Day) Benefits Summary
• Blue Shield 2-Tier Anchor Bronze Benefits Summary

Prescription Coverage

• Navitus Medicare Rx Information

 

Additional Information

• HIPAA Notice of Privacy Practices

HMO Plan

• Delta Care HMO Benefits Summary

 

PPO Plans

• Delta Dental PPO 1500 Benefits Summary
• Delta Dental PPO Unlimited Benefits Summary

2021-22

• VSP Signature Plan C

HMO Medical Plans and Enrollment Forms

2021-22

• Kaiser Permanente $15; Rx $5-20 (30 Day) Benefits Summary
• Blue Shield Trio Benefits Summary
• Blue Shield Full Network Benefits Summary

 

PPO Medical Plans and Enrollment Forms

2021-22

• Blue Shield 80G; $20; Rx $5-20 (30 Day) Benefits Summary
• Blue Shield 90G $20; Rx $5-20 (30 Day) Benefits Summary
• Blue Shield 100A $10; Rx $5-20 (30 Day) Benefits Summary
• Blue Shield 2-Tier Anchor Bronze Benefits Summary

Prescription Coverage

• Navitus Medicare Rx Information

 

Additional Information

• HIPAA Notice of Privacy Practices

 HMO Plan

• Delta Care HMO Benefits Summary

 

PPO Plans

•  Delta Dental PPO 1500 Benefits Summary
• Delta Dental PPO Unlimited Benefits Summary

2021-22

• VSP Signature Plan C