Previous Plan Year 2020-2021

• Peralta-Community-College-Kaiser-HMO-10 SBC 
• Peralta-Community-College-Kaiser-HMO-15 SBC 
• Peralta-Community-College-Kaiser-HMO-  0 SBC 

• 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

Universal Benefit Enrollment Form – Retiree & Exceptional Processing

*Retirees enrolling in a Kaiser Permanente Senior Advantage Plan must complete the Kaiser Permanente Senior Advantage Enrollment form (above) and mail to the address on the form. If you are changing your medical plan during open enrollment also 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. Remember to enclose a copy of the Kaiser Permanente Senior Advantage Form mailed directly to Kaiser

• Kaiser Reimbursement Form
• Kaiser Permanente Senior Advantage (HMO) Enrollment Form

Universal Benefit Enrollment Form – Retiree & Exceptional Processing

*Retirees enrolling in a Kaiser Permanente Senior Advantage Plan must complete the Kaiser Permanente Senior Advantage Enrollment form (above) and mail to the address on the form. If you are changing your medical plan during open enrollment also 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. Remember to enclose a copy of the Kaiser Permanente Senior Advantage Form mailed directly to Kaiser

• 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 DHMO – Direct Compensation Dental Plan Evidence of Coverage
• UHC DHMO – Direct Compensation (DC) Contributory CA250/covered dental services CA D1065

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

*Open enrollment occurs annually November 1-30 for the following plan year (January – December).

CBIZ Open Enrollment 2021 Presentation

Current year forms & Documents:

CBIZ FSA – Transition Guide

CBIZ FSA Handbook with Enrollment Form- 2021

Flexible Spending SPD: 2014-spd-003

CBIZ FSA Claim-form Plan Year 2021

CBIZ Direct-deposit-authorization

CBIZ FSA Change in Status or Termination Form

CBIZ CONTACT INFORMATION

EMAIL: cbizflex@cbiz.com

TELEPHONE: 1-925-956-0514

CBIZ Open Enrollment 2021 Presentation

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

 The maximum amounts are:

 Parking Expenses $270/month

Transportation Expenses $270/month (Public transportation/vanpool)

CBIZ COMMUTER – Transition Guide

CBIZ Pre-Tax Commuter Handbook with Enrollment Form – 2021

Pre-Tax Commuter SPD: peralta-132-doc

CBIZ PRE-TAX COMMUTER (PARKING ONLY) Claim-form Plan Year 2021

*CBIZ debit card must be used for eligible transit expenses starting 1/1/2021.

CBIZ Direct-deposit-authorization

CBIZ CONTACT INFORMATION

EMAIL: cbizflex@cbiz.com

TELEPHONE: 1-925-956-0514

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

CBIZ Direct-deposit-authorization