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)
SISC HealthX Web Portal Registration Form (PDF)
Affidavit of Domestic Partnership (PDF)
Termination of Domestic Partnership Affidavit (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 2018 to September 2019
100% PPO Benefit Summary (PDF)
H.S.A.- Plan A - Benefit Summary (PDF)
H.S.A.- Plan B - Benefit Summary (PDF)
Anchor Bronze Benefit Summary (PDF)
Navitus Prescription
Benefit Summaries
$9-$35 (80% PPO) Navitus Summary (PDF)
$7-$25 (100% & 90% PPO) Navitus Summary (PDF)
$9-$35 (H.S.A.- Plan A Family) Navitus Summary (PDF)
$9-$35 (H.S.A.- Plan B Family) Navitus Summary (PDF)
$9-$35 (H.S.A.- Plan A Single) Navitus Summary (PDF)
$9-$35 (Anchor Bronze & MVP) Navitus Summary (PDF)
Blue Cross 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 2018 to September 2019
80% - G PPO - $30 Office Visits, $9 to $35 Prescriptions (PDF)
90% - E PPO (Frozen) - $20 Office Visits, $7 to $25 Prescriptions (PDF)
100% - B PPO - $20 Office Visits, $7 to $25 Prescriptions (PDF)
HSA - Plan A PPO Individual (PDF)
Kaiser Documents
Plan Comparisons
Kaiser 3-tier Rate Comparison without Vision 2018 to 2019 (PDF)
Kaiser side-by-side comparison 2018 to 2019 (PDF)
Kaiser Medical Rate Comparison with Vision 2018 to 2019 (PDF)
Kaiser Forms
Kaiser Permanente Senior Advantage Application (PDF)
Medicare Supplemental Disenrollment Form (PDF)
Termination of Subscribers - Maintenance Activity Report (PDF)
Transfers - Maintenance Activity Report (PDF)
Affidavit of Domestic Partnership (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 2018 to September 2019
$0 Office Visits, $5 Prescriptions (PDF)
$10 Office Visits, $10 Prescriptions (PDF)
$20 Office Visits, $10 to $20 Prescriptions (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 2018 to September 2019
$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)
COBRA Documents
Plan Comparisons
COBRA Blue Shield PPO Rates (PDF)
COBRA Delta Dental - All Plans Comparison Sheet (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.
COBRA 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, 2016 to September 30, 2017.
The Health Program includes Kaiser and Blue Shield plans sponsored through Self-Insured Schools of California (SISC). Kaiser includes three HMO plans and a High Deductible Health Plan (H.D.H.P.); compatible with a Health Savings Account (H.S.A.). Blue Shield health plans include four PPO plans including an H.D.H.P. compatible with an H.S.A. The H.S.A. plans are administered by RESIG.
Two Kaiser Permanente Senior Advantage (KPSA), Blue Shield PPO 65+ and 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.