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If you are retiring from your active position, below are all the forms you will need:

New Retiree Election Form

2018-19 Retiree Monthly Premium Rate Sheet (effective 10/01/2018)

2018-19 Plan Comparison - Retirees UNDER 65      

2018-19 Plan Comparison - Retirees OVER 65 or w/ Medicare AB

 -    Blue Shield Enrollment Form (if changing from Kaiser to Blue Shield)

 -    Blue Shield PPO 65+ EGWP  (REQUIRED if BOTH parties are over 65 and/or have Medicare AB)


 -    Blue Shield Companion Care (requires 45 day advance notice and Medicare A/B)

 -    Kaiser Enrollment Form (if changing from Blue Shield to Kaiser)

 -    2019 Kaiser Permanente Senior Advantage Enrollment Form - (KPSA)  For any Kaiser members over 65 &/or with Medicare AB.  IMPORTANT! Return enrollment form and copy of Medicare Card to BENEFITS! Do not send directly to Kaiser!!

Retiree Emergency Contact Form

All about Your Retiree Benefits

Setting Up Bill-Pay Instructions 

Change Form (changing name, address or add/drop dependents - contact Benefits for regulations and requirements)



Some forms are in the interactive PDF format. If further assistance is required, please contact the Benefits Office at (209) 575-6981.

NOTE:  General Retiree Forms are at the BOTTOM of this page

Eligibility Guidelines  -  Updated guidelines coming soon

Change Form (changing name, address or add/drop dependents - contact Benefits for regulations and requirements)


General Information:




Retirees Over 65 - Blue Shield Companion Care Option:

Click HERE for link to more information


For RETIREES BEYOND DISTRICT CONTRIBUTION - turning 65/70 and no longer receive District-paid Medical Plans:

You may CONTINUE your health insurance through the District if you pay the full premium.  For information on the new Blue Shield Companion Care option, click here.

2018-2019 Retiree Monthly Premium Rate Sheet - Rates effective 10/01/2018.

If you wish to CHANGE your health plan upon your retirement, please complete the Retiree Election Form.  Otherwise, changes can only be made at Open Enrollment.

Exception:  You may switch to Blue Shield Companion Care at any time with a 45-60 day notice.  If you make this switch, you can only switch back to a District Plan at Open Enrollment.



Remember that any premiums are due by the 1st of every month.  Checks should be made payable to: YCCD and mailed to YCCD Attn: Fiscal Services, PO Box 4065, Modesto, CA  95352.  Please write "Retiree Benefits" and the month for which you are paying in the memo line of your check.

Although we do not yet have the capacity for you to pay on-line, here are the instructions for setting up automatic bill-pay with your bank:  Bill-Pay Instructions 



Navitus Pharmacy Benefit Information



2018-2019 NEW RETIREE Election Form

Blue Shield PPO Enrollment Form

Blue Shield Companion Care Enrollment (over age 65/70)

Kaiser Enrollment Form (Retirees Under Age 65)

Kaiser Senior Advantage Form (Retirees Over age 65 &/or with Medicare A & B)

Change Form (Name, address, dependent changes)

Blue Shield Claim Form

Prescription Claim Form



Note: The following form is due in the Benefits Office by the 15th of the month prior to the termination month.  Account must be current at the time of request.

Request for Termination of Benefits


Website & Contact Information:

Blue Shield PPO
Member Services:1-800-642-6155
Member Services: 1-866-333-2757
BIN#: 610602
RXGroup#: RX4S ISC
Member Services: 1-800-464-4000