Forms to Submit for Enrollment

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This section will help you determine which forms below are needed to submit to enroll in the LACERS Health Plan of your choice, add or delete dependents from your plan, or cancel your coverage. You must submit the appropriate forms to LACERS to process your health plan selection. Health plan enrollment and family account change forms are available on this page as well as the Forms section, upon request by emailing LACERS.Health@lacers.org or calling LACERS at (800) 779-8328.

Outside of Open Enrollment period: Completed forms with applicable supporting documents must be received by the 10th of the month in order for the transaction to be effective the first of the following month.

If you are not adding/changing plans nor adding/deleting dependents, no action is needed on your part.

Enroll into a New Medical Plan

Medical Plan enrollment includes vision coverage.

1. Which Medical Plan will you select?

To enroll into the Kaiser or Kaiser Senior Advantage Plan, please use: 

To enroll into Anthem Blue Cross HMO or PPO, UnitedHealthcare, SCAN, or Anthem Blue Cross Medicare Preferred (PPO), please use:

2. Are you covering any dependents?

Members who will be, or are, covering one or more dependents on their Medical Plan will also need to submit:

3. Do you or your dependent have Medicare?

Members who are Medicare-eligible and/or have dependents who are Medicare-eligible will need to submit the Medicare Information Acknowledgement Form in addition to senior forms for the following Medicare plans:

  • Anthem Blue Cross Medicare Preferred (PPO)
  • Kaiser Permanente Senior Advantage
  • UnitedHealthcare Medicare Advantage
  • SCAN Medicare Advantage

Please contact LACERS to obtain the additional enrollment forms for the above Medicare plans.

Enroll into a New Dental Plan

1. Which Dental Plan will you select?

To enroll into either the DeltaCare USA HMO or the Delta Dental PPO dental plan submit LACERS Dental Plan Enrollment form:

2. Are you Covering any Dependents?

Members who will be covering one or more dependents on their Dental Plan will also need to submit:

Add or Delete Dependents from Your Current Plan

1. Which Health Plan(s) you will add/delete your dependent(s)?

To add or delete a dependent from your current Medical, Dental, or both plans, submit a LACERS Family Account Change form:

Members who are adding one or more dependents on their Medical or Dental Plan will also need to submit:

2. Do your dependent(s) have Medicare?

For dependents who are enrolled in Medicare, please contact LACERS to obtain senior forms for the following Medicare plans:

  • Anthem Blue Cross Medicare Preferred (PPO)
  • Kaiser Permanente Senior Advantage
  • UnitedHealthcare Medicare Advantage
  • SCAN Medicare Advantage

Cancel/Disenroll your Medical or Dental Plan

Members may cancel/disenroll their LACERS Health Plans at any time. Completed forms with applicable supporting documents must be received by the 10th of the month in order for the transaction to be effective the first of the following month.

1. Which Health Plan(s) will you be cancelling/disenrolling from?

Submit LACERS Medical/Dental Plan Cancellation Form (NOTE: If enrolled in a LACERS Medicare plan additional forms are required, see #2.): 

Additional forms are required if enrolled in a LACERS Medicare plan.  Contact LACERS for the additional forms.

2. Are you or your dependents enrolled in Medicare?

For Members or dependents who are enrolled in Medicare, please contact LACERS to obtain disenrollment request forms for the following Medicare plans:

  • Anthem Blue Cross Medicare Preferred (PPO)
  • Kaiser Permanente Senior Advantage
  • UnitedHealthcare Medicare Advantage
  • SCAN Medicare Advantage

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