MANAGEMENT & CONFIDENTIAL

Welcome!  Please review all plan information and rates when making a selection.  Check out our Benefit Cost Calculator for assistance Benefit Cost Calculator


Highlighted below are the required forms to enroll.  Full-time (8hr) employees are required to enroll in a medical plan.  If an employee has other coverage, they can enroll in a full-time waived option plan.  The waived option plan enrollment form is required with verification of other coverage.  Benefits are effective the first of the month following the date of hire.

All documents are DUE: 30-days from your date of hire

1. Medical Election Form

MEDICAL PLAN ELECTION FORM

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2. Medical Plan Enrollment Form 

(Kaiser, Anthem Blue Cross, full-time Waived Option Plan and part-time Waiver for  <7.2 hrs)
See below for plan descriptions

ANTHEM BLUE CROSS ENROLLMENT FORM

KAISER ENROLLMENT FORM

FULL-TIME WAIVED OPTION FORM

WAIVER FORM
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3. Dental Enrollment Form (if enrolling)
See below for plan descriptions
Delta Dental - ENROLLMENT FORM

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4. Vision Enrollment Form (if enrolling)
See below for plan descriptions

MES ENROLLMENT FORM

VSP ENROLLMENT FORM


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5. Minnesota Life Enrollment and Beneficiary Form (District-paid)
BENEFICIARY FORM
Minnesota Life Plan Summary and Rates
Minnesota Life Enrollment Form
Minnesota Life Evidence of Insurability Form 
(Evidence of Insurability is required if electing above the guaranteed issued amount)
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6. Disability Acknowledgement Form

Disability Acknowledgement Form

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IMPORTANT: If enrolling dependents, you must provide proof of dependent relationship. Please see dependent verification requirements: 
Dependent Verification Documents

Spouse: First page of the previous year Federal tax return showing the married filing status.

Child(ren): Birth Certificate naming employee or spouse as a parent.


Additional Information

INSURANCE BOOKLET - MANAGEMENT ACTIVE
21-22 PLAN RATES

Medical Plan Descriptions

KAISER $10

KAISER $20


ANTHEM PREMIER HMO

        Premier HMO Prescription Coverage

ANTHEM CLASSIC HMO
Classic HMO Prescription Coverage

ANTHEM CLASSIC PPO $20
Premier PPO Prescription Coverage

ANTHEM CLASSIC H.S.A.

Anthem Blue Cross Anthem Blue Cross

HMO Provider Finder   PPO Provider Finder

American Specialty Health (ASH) Chiropractic

All Medical Plan Members: 800-678-9133

Prescription Drug Program for non-Kaiser Members

NAVITUS CUSTOMER CARE

HOURS: 24 Hours a Day | 7 Days a Week

866-333-2757 (toll-free) TTY (toll-free) 711

MAILING ADDRESS: Navitus Health Solutions P.O. Box 999 | Appleton, WI 54912-0999

Anthem Blue Cross members have access to a MDLIve appointment for a $5 co-pay.

Please check the link here for more information: MDLive Appointment Information

Additional Medical Plan Forms and Information

IMPORTANT: If enrolling dependents, you must provide proof of dependent relationship. Please see dependent verification requirements: Dependent Verification Documents

Anthem Temp Medical ID Card

COSTCO Prescription Drug Flyer - Not valid for Kaiser members

Dental Plan Descriptions

DELTA CARE HMO PLAN

Please visit the Delta Dental website for provider directory, benefits, and claim forms:

Vision Plan Descriptions
Plan Summary - Medical Eye Services (MES)

Plan Summary - Vision Service Plan (VSP)