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)
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 2022 to September 2023
90% PPO (Frozen) Benefit Summary (PDF)
100% PPO Benefit Summary (PDF)
H.S.A.- Plan A Individual - Benefit Summary (PDF)
H.S.A - Plan A Family - Benefit Summary (PDF)
H.S.A.- Plan B - Benefit Summary (PDF)
Anchor Bronze Benefit Summary (PDF)
October 2021 to September 2022
90% PPO (Frozen) Benefit Summary (PDF)
100% PPO Benefit Summary (PDF)
H.S.A.- Plan A Individual - Benefit Summary (PDF)
H.S.A - Plan A Family - Benefit Summary (PDF)
H.S.A - Plan A - Deductible Change Effective January 1, 2020 (PDF)
H.S.A.- Plan B - Benefit Summary (PDF)
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 health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only a summary.
October 2022 to September 2023
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)
2022-2023 Blue Shield Side-by-Side Comparison (PDF)
October 2021 to September 2022
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)
Kaiser Documents
Plan Comparisons
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 2022 to September 2023
$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)
October 2021 to September 2022
$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)
Chiropractic and Acupuncture Rider (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 2022 to September 2023
$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)
October 2020 to September 2021
$0 Office Visits, $5 Prescriptions (PDF)
$0 Office Visits, $10 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)
2022-2023 Plan Comparisons
COBRA Blue Shield PPO Rates (PDF)
COBRA Kaiser Rates Without Vision(PDF)
COBRA Kaiser Rates With Vision (PDF)
2021-2022 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, 2021, to September 30, 2022.
The Health Program includes Kaiser Permanente and Blue Shield plans sponsored through Self-Insured Schools of California (SISC). Kaiser 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. The Medicare 101 Seminar is scheduled for a 90-minute seminar on March 15, 2022, at a time to be determined later.