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.      

 

1. 2023 Anthem Blue Cross Select HMO SBC - Actives
2. 2023 Anthem Blue Cross EPO SBC - Actives, CA Residents
3. 2023 Anthem Blue Cross EPO SBC - Actives, Non-CA Residents
4. 2023 Prescription Drug Plan - SilverScript Medicare
5. 2023 Prescription Drug Plan for Anthem Blue Cross HMO - SilverScript Medicare
6.  2023 Health Net HMO SBC - Actives & Early Retirees
7. 2023 Kaiser HMO SBC - Actives, Southern California
8. 2023 Kaiser HMO SBC - Early Retirees, Southern California
9. 2023 Kaiser HMO SBC - Actives, Northern California
10. 2023 Kaiser HMO SBC - Early Retirees, Northern California
11. Sep 2021 - Aug 2022 Kaiser HMO SBC - Unit F
12. 2022 Kaiser Northwest HMO SBC - Early Retirees
13. 2022 Kaiser Hawaii HMO SBC - Early Retirees
14. 2023 Aetna Dental PPO SBC
15. 2023 Delta Dental
16. 2022 Western Dental
17. 2023 VSP
18. 2023 EyeMed - Actives
 

2023 SBCs will be updated on this page as they become available. 

  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.