Benefit Forms and Plan Documents

Benefit Provider Contact Information

Plan and Customer Service Contact Sheet

Employee Forms

• Employee Benefit Enrollment/Change Form
• Employee FSA Enrollment Form
• Employee Supplemental Life Enrollment/Change Form
• Life Insurance Beneficiary Form
• Life Insurance Beneficiary Form - Spousal Consent, as applicable
• Staff Development Reimbursement eForm
• P & A Group Health Reimbursement Arrangement (HRA) Form
• Domestic Partner Affidavit (SEIU only)

Extra Help Forms

• Extra Help Benefit Enrollment Change Form

Retiree Forms

• Retiree Enrollment/Change Form
• Retiree HRA Premium Reimbursement Auto-Pay Request Form
• P&A Group Direct Deposit Form
• Kaiser Permanente Senior Advantage Enrollment Form
• Kaiser Permanente Senior Advantage Disenrollment Form
• Western Health Advantage MyCare Enrollment Form
• Life Insurance Beneficiary Form

Documents

Summary of Benefits and Coverage (SBC)

• Kaiser Permanente Traditional HMO
• Kaiser Permanente Hospital Services DHMO
• Kaiser Permanente Deductible First HDHP
• Kaiser Permanente Northwest Traditional HMO
• Kaiser Permanente Hawaii Traditional HMO
• Sutter Health Plus Traditional HMO
• Sutter Health Plus Hospital Services DHMO
• Sutter Health Plus Deductible First HDHP
• Western Health Advantage Traditional HMO
• Western Health Advantage Hospital Services DHMO
• Western Health Advantage Deductible First HDHP Self
• Western Health Advantage Deductible First HDHP Family
• County Health Plan EPO
• County Health Plan PPO

Evidence of Coverage (EOC)

• County Health Plans EPO & PPO Summary Plan Document (SPD)
• County Health Plans Formulary Drug List October 2023 - subject to change without notice
• County Health Plans Formulary Drug List January 2024 - subject to change without notice
• Kaiser Permanente Traditional HMO
• Kaiser Permanente Hospital Services DHMO
• Kaiser Permanente Deductible First HDHP
• Kaiser Permanente Hawaii Senior Advantage
• Kaiser Permanente Hawaii Traditional HMO
• Kaiser Permanente Northern California Senior Advantage
• Kaiser Permanente Northwest Traditional HMO
• Sutter Health Plus Traditional HMO
• Sutter Health Plus Hospital Services DHMO
• Sutter Health Plus Deductible First HDHP
• Western Health Advantage
• Delta Dental Employees
• Delta Dental Retiree PPO
• Delta Dental Retiree DeltaCare USA
• Vision Service Plan (VSP)

Summary Plan Description (SPD) and Drug Formulary List

Life Insurance Ceritifcates

Full Time Employees -

• UHC Life Class 2 - DSA (46, 47)
• UHC Life Class 3 - Confidential (51), Law Library Non-Management
• UHC Life Class 4 - Admin Management (50), BOS (49), Dept/Agency Heads (52), DSLEM (43), SCDPDAA (60), SCLEMA (44), SCPA (45), SCTA Management, Law Library Management 
• UHC Life Class 5 - Local 39 (85), SEIU (01,05,10,25,80,95), SCLEA (30,40,41,70), SCPDIA (55)
• UHC Life Class 7 - ESC (75)
• UHC Life Class 10 - WCE (21)
• UHC Life Class 11 - Unrepresented (00), SCTA Non-Management

Part Time Employees - 

• UHC Life Class 6 - SCLEA (30, 40, 41, 70)
• UHC Life Class 8 - ESC (75)
• UHC Life Class 9 - DSA (46,47)

Retirees - 

• UHC Life Retiree

Required Notices