Medical Program Information
Blue Shield Documents
Plan Comparisons
Blue Shield Forms
Blue Shield Enrollment Form (PDF)
Existing Member Change Form (PDF)
Medical, Dental & Vision Address Change Form (PDF)
SISCconnect Registration Form (PDF)
SISC Affidavit of Marriage (PDF)
Transfers - Maintenance Activity Report (PDF)
Termination of Subscribers - Maintenance Activity Report (PDF)
Blue Shield Declaration of Disability for Over Age Dependent Child (PDF)
Blue Shield Benefit Summaries
These matrixes are intended to be used to help you compare coverage benefits and is a summary only. The plan contract should be consulted for a detailed description of coverage benefits and limitations.
October 2023 to September 2024
90% PPO (Frozen) Benefit Summary (PDF)
100% PPO Benefit Summary (PDF)
HSA - Plan A Individual - Benefit Summary (PDF)
HSA - Plan A Family - Benefit Summary (PDF)
HSA - Plan B - Benefit Summary (PDF)
2-Tier HSA (Formerly Anchor Bronze) Benefit Summary (PDF)
Blue Shield & Navitus Prescription
Summary of Benefits & Coverage
The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered healthcare services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only a summary.
October 2023 to September 2024
100-B PPO - $20 Office Visits, $7 to $25 Prescriptions (PDF)
90-E PPO (Frozen) - $20 Office Visits, $7 to $25 Prescriptions (PDF)
80-G PPO - $30 Office Visits, $9 to $35 Prescriptions (PDF)
2-Tier HSA (Formerly Anchor Bronze) (PDF)
Kaiser Documents
Plan Comparisons
Kaiser Forms
Kaiser Permanente Senior Advantage Application (PDF)
Medicare Supplemental Disenrollment Form (PDF)
Termination of Subscribers - Maintenance Activity Report (PDF)
Kaiser Benefit Summaries
These are summaries of the most frequently asked-about benefits. These charts do not explain benefits, Cost Share, out-of-pocket maximums, exclusions, or limitations, nor do they list all benefits and Cost Share amounts.
October 2023 to September 2024
$0 Office Visits, $5 Prescriptions (PDF)
$0 Office Visits, $5 Prescriptions with Optical (PDF)
$10 Office Visits, $10 Prescriptions (PDF)
$10 Office Visits, $10 Prescriptions with Optical (PDF)
$20 Office Visits, $10 to $20 Prescriptions (PDF)
$20 Office Visits, $10 to $20 Prescriptions with Optical (PDF)
$30 Office Visits, $10 to $30 Prescriptions (PDF)
$30 Office Visits, $10 to $30 Prescriptions with Optical (PDF)
Kaiser Summary of
Benefits & Coverage
The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only a summary.
October 2023 to September 2024
$0 Office Visits, $5 Prescriptions (PDF)
$10 Office Visits, $10 Prescriptions (PDF)
$10 Office Visits, $10 Prescriptions with Optical (PDF)
$20 Office Visits, $10 to $20 Prescriptions (PDF)
$20 Office Visits, $10 to $20 Prescriptions with Optical (PDF)
$30 Office Visits, $10 to $30 Prescriptions (PDF)
DHMO $1,000 with Optical (PDF)
COBRA Documents
COBRA Forms
COBRA/Retiree Notification Form (PDF)
2023-2024 Plan Comparisons
COBRA Blue Shield PPO Rates (PDF)
COBRA Kaiser Rates Without Vision(PDF)
COBRA Kaiser Rates With Vision (PDF)
Benefit Summaries &
Summary of Benefits and Coverage
Benefit Summaries & Summary of Benefits and Coverage can be found under the listing for each specific program: Medical, Dental, and Vision.
Notices & Rights
Medical Program Overview
RESIG’s broker, Alliant Insurance Services, negotiates with health benefit program carriers on an annual basis. The current plan period is October 1, 2023, to September 30, 2024.
The Health Program includes Kaiser Permanente and Blue Shield plans sponsored through Self-Insured Schools of California (SISC). Kaiser Permanente includes HMO plans and High Deductible Health Plan (HDHP) compatible with a Health Savings Account (HSA). Blue Shield health plans include PPO plans including an HDHP compatible with an HSA. The HSA plans are administered by RESIG.
Two Kaiser Permanente Senior Advantage (KPSA), two Blue Shield PPO 65+ and an Anthem Blue Cross Medicare supplemental (CompanionCare) plans are available for retirees over age 65 with Medicare Parts A & B or retirees who are Medicare-eligible prior to age 65.