Previous Plan Year 2019-2020

• Peralta Community College 65 HMO $0 SR ADV Benefit Summary
• Peralta Community College 65 HMO $10 SR ADV Benefit Summary
• Peralta Community College 65 HMO $15 SR ADV Benefit Summary

• Peralta Self Funded Traditional PPO SBC $15 Plan (Local 1021 & Confidentials
• Peralta Self Funded Traditional PPO SBC $10 Plan (PFT, Management & Trustees)
• Peralta Self Funded Traditional PPO SBC $15 Plan (Local 39)
• Peralta Self Funded Lite PPO SBC $15 Plan (Local 1021 & Confidentials)
• Peralta Self Funded Lite PPO SBC $10 Plan (PFT, Management & Trustees)
• Peralta Self Funded Lite PPO SBC $15 Plan (Local 39)

Universal Benefit Enrollment Form – Retiree & Exceptional Processing

*Retirees changing medical plans during open enrollment must complete the Universal Benefit Enrollment Form (above) and mail to the PCCD Benefits Office at the address on the form along with any required dependent documents if applicable.

CASH IN-LIEU OF MEDICAL & DENTAL BENEFITS FORM

If you are an active employee waiving medical and dental benefits please uploaded the completed form with all required insurance verifications during your BenefitBridge online enrollment.

• Delta Dental PPO Plan – Plan Summary 
• UHC Dental – Direct Compensation DHMO Dental Plan Evidence of Coverage

Kaiser Vision Plan & UHC Vision Plans – Benefits Summary

VSP (Voluntary Vision) – Benefits Summary

Click here for additional information

District-Paid Life Insurance

Life Insurance Certificate

District-Paid Disability Insurance

Long Term Disability Certificate

EAP Evidence of Coverage

• Handbook with Enrollment Form- 2020
• Flexible Spending SPD: 2014-spd-003
• Claim-form
• Direct-deposit-authorization

The maximum amount you may contribute to each account cannot exceed the maximum amount specified in Code Section 132(f).

The maximum amounts are:

1. Parking Expenses $270/month
2. Transportation Expenses $270/month (Public transportation/vanpool)

• Handbook with Enrollment Form – 2020
• Pre-Tax Commuter SPD: peralta-132-doc
• Direct-deposit-authorization

• Medicare A, B & D Premium Reimbursement Plan Summary Plan Description (SPD) 2015
• Medicare-A-and-B-and-D-Premium-Claim-Form-Revised-11-24-20
• Medicare Reimbursement Plan Policy Statement 10.2015