Division of Risk Management and Insurance Services
Page Navigation
- Los Angeles Unified School District
- Benefits Administration
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Active Employee Forms -
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District Retiree Forms -
1. 2023 Retiree Benefits Guide 2. 2023 Request for Change of Dependent Status - Retirees 3. 2023 Application for Retiree Benefits (HI-22) Form 4. 2023 Change of Address Form (HBR10) 5. 2023 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).8. PO Box Address Form ( Kaiser Permanente Senior Advantage only)
Required by retirees AND EACH of their >65 / Medicare-eligible dependents enrolling in the Kaiser Permanente Senior Advantage HMO. -
COBRA Rates -
Life Insurance -
Deferred Compensation Plans -
Flexible Spending Accounts (FSA) -
Medicare -
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Prescription Coverage -
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Summary of Benefits and Coverage -
2023 SBCs will be updated on this page as they become available.
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Evidence of Coverage -
MEDICAL 1. 2023 Anthem Blue Cross EPO - Active CA 2. 2023 Anthem Blue Cross EPO - Active Non-CA 3. 2023 Anthem Blue Cross EPO - Retiree CA 4. 2023 Anthem Blue Cross EPO - Retiree Non-CA 5. 2023 Anthem Blue Cross HMO - Active 6. 2023 Anthem Blue Cross HMO - Retiree 7. 2023 Anthem Medicare Preferred (PPO) - Medicare Retiree 8. 2023 Health Net HMO - Active 9. 2023 Health Net HMO - Early Retiree 10. 2023 Health Net HMO - Seniority Plus 11. 2023 Kaiser HMO EOC - Active, Southern California 12. 2023 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. 2023 Kaiser HMO EOC - Early Retiree, Southern California 16. 2023 Kaiser HMO EOC - Early Retiree, Northern California 17. 2022 Kaiser Northwest HMO EOC - Early Retiree 18. 2022 Kaiser Hawaii HMO EOC - Early Retiree 19. 2023 Kaiser Senior Advantage EOC - Retiree Over 65, Southern California 20. 2023 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.
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Miscellaneous Resources -
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 15. VSP - TruHearing Hearing Aid Discount