Medical
Medical Forms and Information
MEDICAL BENEFITS
Medical Enrollment or Changes - CalPERS HBD-12 Form
Pre-Tax Election & Waiver Form for Medical Insurance Premium Payroll Deduction
Cash-In-Lieu of Medical Benefits
2022 CalPERS Health Benefit Summary Booklet
Summary of Benefits and Coverage Notice
Glossary of Health Coverage and Medical Terms
2022 Summary of Benefits and Coverage
- Anthem Select HMO
- Anthem Traditional HMO
- Blue Shield HMO
- Health Net Smart Care HMO
- Kaiser HMO
- United Healthcare HMO
- Western Health HMO - (Not available in Contra Costa County)
- Anthem Blue Cross PERS Platinum PPO
- Anthem Blue Cross PERS Gold PPO
2020-21 MEDICAL PLAN RATE SHEETS
2021 NEW MEDICAL ENROLLMENT
- JANUARY 1, 2021 START DATE
- FEBRUARY 1, 2021 START DATE
- MARCH 1, 2021 START DATE
- APRIL 1, 2021 START DATE
- MAY 1, 2021 START DATE
- JUNE 1, 2021 START DATE
- JULY 1, 2021 START DATE
SELF PAY (Unpaid Leave)
Self Pay Medical, Dental and Vision Rate Sheet (If on Unpaid Leave)
Self-Pay Agreement Dental & Vision (Unpaid Leave)
Self-Pay Agreement Medical CalPERS (Unpaid Leave)
OTHER
John Muir Behavioral Health Center, Outpatient Services
