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HISD Benefits Office

Bringing Benefits To Life

2021 Plan and Legal Documents

Benefits Dept. Guides

2021 New Hire Guide

NEW_HIRE_GUIDE_FINAL 2021.pdf 4.05 MB (Last Modified on March 30, 2022)

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2021 Benefits Guide

2021_Benefits Guide.pdf 46.28 MB (Last Modified on January 8, 2021)

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Prescription Drugs

National Preferred Formulary List

National Preferred Formulary List Updated 07-01-2021.pdf 141.71 KB (Last Modified on August 11, 2021)

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High Performance Formulary List

High Performance Formulary List Updated 07-01-2021.pdf 52 KB (Last Modified on August 11, 2021)

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2021 Prescription Basic & Plus Plans

2021 Rx SPD ConsumerPlan-OpenAccess FINAL 11-13-2020.pdf 610.37 KB (Last Modified on December 15, 2020)

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2021 Prescription Select Drug Plan

2021 Rx SPD_Select FINAL 11-13-2020.pdf 804.24 KB (Last Modified on December 15, 2020)

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Express Scripts Fax Order Form

Mail Order Fax Order Form.pdf 47 KB (Last Modified on September 29, 2020)

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Express Scripts Mail Order Form

Mail Order Form.pdf 734.37 KB (Last Modified on September 29, 2020)

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Aflac

Aflac Booklet 2021

HISD Bklt FINAL 9-2-21.pdf 704.54 KB (Last Modified on September 15, 2021)

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Aflac Insurance Plans

HISD_Bklt_FINAL_3-4-19.pdf 690.48 KB (Last Modified on November 4, 2020)

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Planes de Seguro Aflac

HISD_Bklt_ESP_FINAL_3-4-19.pdf 239.8 KB (Last Modified on November 4, 2020)

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Aflac Booklet Insert - New Features

Aflac Booklet Insert 2021.pdf 462.34 KB (Last Modified on October 19, 2020)

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Accident

Aflac Accident Certificate Low

HISD_2019_Acc_Cert_Low_101216.pdf 196.12 KB (Last Modified on November 4, 2020)

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Aflac Accident Certificate High

HISD_2019_Acc_Cert_High_101216.pdf 196.21 KB (Last Modified on November 4, 2020)

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Aflac Accident High Plan Dependent Rider

HISD_2019_AFLAC_Accident_High_Plan_Dependent_Rider.pdf 138.15 KB (Last Modified on November 4, 2020)

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Aflac Accident Low Plan Dependent Rider

HISD_2019_AFLAC_Accident_Low_Plan_Dependent_Rider.pdf 265.88 KB (Last Modified on November 4, 2020)

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Critical Illness

Critical Illness Claim Form

HISD_2016_Critical_Illness_ClaimForm.pdf 121.34 KB (Last Modified on November 6, 2020)

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Aflac Critical Illness Certificate

HISD_2019_CI_Cert_101216.pdf 922.44 KB (Last Modified on November 4, 2020)

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Life Insurance

Houston ISD Life Policy

Houston ISD Term Life Policy 34018 Amd 12.pdf 1.97 MB (Last Modified on February 9, 2021)

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Houston ISD Certificate

Houston ISD Certificate - Eff 1-1-2021.pdf 564.35 KB (Last Modified on February 9, 2021)

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Policy Plan Documents

HISD Cancer Master Policy

Houston ISD Cancer Master Policy.pdf 1.49 MB (Last Modified on February 9, 2021)

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HISD AC 7700 Master Policy High and Low

Houston ISD AC7700 Master Policy - High and Low.pdf 1.79 MB (Last Modified on February 9, 2021)

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Houston ISD 8500 Master Policy

Houston ISD 8500 Master Policy - High and Low.pdf 1.82 MB (Last Modified on February 9, 2021)

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Houston ISD 2800 Master Policy

Houston ISD 2800 Master Policy.pdf 2.1 MB (Last Modified on February 9, 2021)

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Legal Documents

HISD 2021 Legal Notices Disclosures

HISD 2021 Legal Notices Disclosures FINAL.pdf 989.72 KB (Last Modified on December 2, 2020)

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Dept. of Labor National Healthcare Exchange

department_of_labor_national_heath_care_exchange.pdf 163.18 KB (Last Modified on November 4, 2020)

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Notice for Employers Offering Health Plans

model-notice-for-employers-who-offer-a-health-plan-to-some-or-all-employees_FULL.pdf 162.55 KB (Last Modified on November 4, 2020)

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Medical Plan Summary

2021 Kelsey Basic ACO Summary Benefits Coverage (SBC)

2021-KelseyBasicACO-Summary-Benefits-Coverage-SBC-REV08-17-2021.pdf 1.54 MB (Last Modified on October 7, 2021)

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2021 Kelsey Plus ACO Summary Benefits Coverage (SBC)

2021-Kelsey-Plus-ACO-Summary-Benefits-Coverage-SBC-REV 08-17-2021.pdf 1.54 MB (Last Modified on October 7, 2021)

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2021 Kelsey Select ACO Summary Benefits Coverage (SBC)

2021-Kelsey-Select-ACO-SummaryBenefits-Coverage-SBC-REV08-17-2021.pdf 1.5 MB (Last Modified on October 7, 2021)

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2021 Memorial Hermann Basic ACO SummaryBenefits-Coverage (SBC)

2021-MemorialHermann-Basic-ACO-SummaryBenefits-Coverage-SBC-REV08-17-2021.pdf 1.5 MB (Last Modified on October 7, 2021)

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2021 Memorial Hermann Plus ACO Summary-Benefits Coverage (SBC)

2021-MemorialHermann-Plus ACO-Summary-BenefitsCoverage-SBC-REV08-17-2021.pdf 1.5 MB (Last Modified on October 7, 2021)

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2021 Texas Medical Neighborhood Basic Summary Benefits Coverage (SBC)

2021-TXMedicalNeighborhood-BasicSummary-BenefitsCoverage-SBC-REV08-17-2021.pdf 1.5 MB (Last Modified on October 7, 2021)

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2021 Texas Medical Neighborhood Plus Summary Benefits Coverage (SBC)

2021-TXMedicalNeighborhood-Plus-Summary-Benefits-Coverage-SBC-REV08-17-2021.pdf 1.5 MB (Last Modified on October 7, 2021)

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Dental

Cigna Dental DHMO or DPPO

Take this quiz to find the right dental plan.

DHMO DPPO Dual Option Decision Guide Access Plus Network.pdf 192.02 KB (Last Modified on September 4, 2020)

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Cigna Dental DHMO plan

View this flyer for savings and coverage.

DHMO Product Customer Brochure - Access Plus Network.pdf 545.15 KB (Last Modified on September 4, 2020)

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Cigna Dental DHMO Access Plus

Dental DHMO Plus

DHMO Access Plus Promotional Customer Flyer.pdf 457.57 KB (Last Modified on September 4, 2020)

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Cigna Dental DHMO Access Plus Network

How to find a dentist

DHMO Access Plus Network Dentist How to Find a Dentist Customer Flyer.pdf 47.56 KB (Last Modified on September 4, 2020)

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Cigna Dental DHMO Access Plus Network Español

DHMO Product Customer Brochure - Access Plus Network - Spanish.pdf 383.58 KB (Last Modified on October 23, 2020)

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Cigna Dental DPPO Calendar Year Maximums

Houston ISD - Current Wellness Plus DPPO.pdf 61.3 KB (Last Modified on October 23, 2020)

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Cigna Dental DPPO Wellness Plus Calendar Year Maximums

Houston ISD SOB - 2000 CYM.PDF 59.25 KB (Last Modified on October 23, 2020)

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Cancer & Specified Diseases

Cancer Claim Form

HISD_2012_Cancer_Claim_Form.pdf 223.39 KB (Last Modified on November 6, 2020)

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Aflac Cancer Certificate Low

HISD_2019_CA_Cert_Low_101216.pdf 885.35 KB (Last Modified on November 4, 2020)

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Aflac Cancer Certificate High

HISD_2019_CA_Cert_High_101216.pdf 884.32 KB (Last Modified on November 4, 2020)

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Disability

UNUM Certificate of Coverage

UNUM Certificte of Coverage.pdf 202.55 KB (Last Modified on December 10, 2020)

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Hospital Indemnity

Hospital Indemnity Claim Form

HISD_2016_Hospital_Indemnity_ClaimForm.pdf 714.32 KB (Last Modified on November 6, 2020)

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Aflac Hospital Indemnity Certificate Low

HISD_2019_SHI_Cert_Low_101216.pdf 865.8 KB (Last Modified on November 4, 2020)

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Aflac Hospital Indemnity Certificate High

HISD_2019_SHI_Cert_High_101216.pdf 865 KB (Last Modified on November 4, 2020)

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Health Insurance Marketplace Coverage Options

New Health Insurance Marketplace Coverage Options

model-notice-for-employers-who-offer-a-health-plan-to-some-or-all-employees.pdf 162.55 KB (Last Modified on November 4, 2020)

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Nuevas opciones de cobertura en el mercado de seguros médicos

model-notice-for-employers-who-offer-a-health-plan-to-some-or-all-employees-spanish.pdf 161.09 KB (Last Modified on November 4, 2020)

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