Retirees & Survivors Enrolled in a SISC Plan

• 10.1.23-9.30.24_KP HMO $0 KPSA
• 10.1.23-9.30.24_KP HMO $10 KPSA

If you have questions about your coverage when you are away from home:

Call 1-951-268-3900

24 hours a day, seven days a week (except closed holidays)

Website Kp.org/travel

• DeltaCare - "Keep Smiling" Flyer

• 2024 KPSA Election Form

• Anthem Blue Cross PPO 100-A $0 RX
• Anthem Blue Cross PPO 100-A $10 RX

• SISC Anthem PPO Enrollment Form

Enrollees 65 and Over with Medicare A & B

• KP HMO $0 KPSA
• KP HMO $10 KPSA

Enrollees Under 65 (No Medicare)

• KP HMO $0 OV, $5 Rx, $150 Vis 2
• KP HMO $10 OV, $10 Rx, $150 Vis 3
• KP HMO $15 OV; $5-20(30) Rx, Vis 3

• 2024 KPSA Election Form
• Kaiser Enrollment Form

Please download the form and sign with a digital signature before submitting.

If you have questions about your coverage when you are away from home:

Call 1-951-268-3900

24 hours a day, seven days a week (except closed holidays)

Website Kp.org/travel

If the spouse/domestic partner turns 65 before the retiree, both members will be enrolled. If the retiree turns 65 before the spouse/domestic partner, only the retiree will be enrolled. Dependent children are not covered.

• DeltaCare - "Keep Smiling" Flyer

• Anthem Summaries

Please download the form and sign with a digital signature before submitting.

• SISC Anthem PPO Enrollment Form

• 10.1.23-9.30.24_KP HMO $0 OV, $5 Rx, $150 Vis
• 10.1.23-9.30.24_KP HMO $10 OV, $10 Rx, $150 Vis
• 10.1.23-9.30.24_KP HMO $15 OV; $5-20(30) Rx, Vis

• SBC_20231001_KP_2023 OV $0, $5 Rx, Vis
• SBC_20231001_KP_2023 OV $10, $10 Rx, Vis
• SBC_20231001_KP_2023 OV $15, $5-20(30) Rx, Vis_REVISED 8-31

• Kaiser Enrollment Form

Please download the form and sign with a digital signature before submitting.

You can submit your form in person or via mail to the PCCD Benefits office at 333 East 8th St, Oakland, CA 94606.

If you have questions about your coverage when you are away from home:

Call 1-951-268-3900

24 hours a day, seven days a week (except closed holidays)

Website Kp.org/travel

• BS_20231001_BC_2023-2024 Oct Blue Cross PPO 100-A $0 RX 0-0
• BS_20231001_BC_2023-2024 Oct Blue Cross PPO 100-A $10 RX 5-20
• BS_20231001_BC_2023-2024 Oct Blue Cross PPO 80-E $20 RX 5-20

• SBC_20231001_BC_2023-2024 Anthem PPO 100_A0 Rx 0-0
• SBC_20231001_BC_2023-2024 Anthem PPO 100_A10 Rx 5-20

• SISC Anthem PPO Enrollment Form

• SISC Evidence of Coverage Pharmacy Benefit