SISC Retiree Benefits

Mt. SAC Election Form

All benefit enrollment changes begin with the completion of the required Mt. SAC Retiree Election Form. This form initiates your request. Depending on the type of change, you may also be required to complete the applicable insurance carrier enrollment form before your request can be processed.

• 2025-26 Retiree Election Form: Classified and Auxiliary (Non-Medicare Eligible)

 

HMO Medical Plans

Carrier	Benefit Plan Summaries	Enrollment Form
Kaiser	Kaiser Permanente $15; Rx $5-20 (30 Day) (2025-26) Kaiser Permanente $0; Rx $5-20 (30 Day) (2025-26)	Kaiser Permanente Enrollment Form
Blue Shield	Blue Shield Trio (2025-26) Blue Shield Access+ Full Network (2025-26)	SISC III Enrollment Form for Blue Shield

 

PPO Medical Plan

Carrier	Benefit Plan Summaries	Enrollment Form
Blue Shield	Blue Shield 90G $20; Rx $5-20 (30 Day) Blue Shield 100A $10; Rx $5-20 (30 Day)	SISC III Enrollment Form for Blue Shield

Prescription Coverage

• Navitus Medicare Rx Information

HIPAA Privacy Notice

• HIPAA Notice of Privacy Practices

HMO Dental Plan

• Delta Care USA

PPO Dental Plans

• Delta Dental 1500
• Delta Dental Incentive Unlimited

• VSP Signature Plan C $0

• Declination of Coverage for Retirees Form
• Dependent Eligibility Documentation Checklist