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HISD Benefits Office

Bringing Benefits To Life

2021 Plan and Legal Documents

Prescription Drugs

2021 RX SPD Consumer Plan - Open Access

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

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2021 RX SPD Select

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

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Express Scripts National Preferred Formulary

National Preferred Alpha with Exclusions List 10-15-2020.pdf 113.59 KB (Last Modified on November 4, 2020)

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Express Scripts High Performance Formulary

High Performance Formulary List Updated 10-15-2020.pdf 52.2 KB (Last Modified on November 4, 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

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 Insurance Plans

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

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Aflac Benefits Guide Booklet

Aflac Booklet.pdf 690.48 KB (Last Modified on October 20, 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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Aflac Beneficiary Form

AFLAC Beneficiary Form.pdf 125.85 KB (Last Modified on October 20, 2020)

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Accident

Accident Claim Form

HISD_2016_Accident_Claim_Form.pdf 611.22 KB (Last Modified on November 6, 2020)

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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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Benefits Guide

2021 Benefits Guide

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

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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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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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Life Insurance

Houston ISD Term Life Policy Amendment

Houston ISD Term Life Policy 34018 Amd 12.pdf 1.95 MB (Last Modified on November 12, 2020)

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Houston ISD Certificate

Houston ISD Certificate - Eff 1-1-2021.pdf 571.44 KB (Last Modified on November 12, 2020)

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Medical Plan Summary

Kelsey Basic SPD

Kelsey Basic Final SPD 12-01-2020.pdf 1.4 MB (Last Modified on December 15, 2020)

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Kelsey Plus SPD

Kelsey Plus Final SPD 12-01-2020.pdf 1.31 MB (Last Modified on December 15, 2020)

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Kelsey Select SPD

Kelsey Select Final SPD 12-01-2020.pdf 1.4 MB (Last Modified on December 15, 2020)

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Memorial Hermann SPD

Memorial Hermann Final SPD 12-01-2020.pdf 1.02 MB (Last Modified on December 15, 2020)

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Texas Medical Neighborhood SPD

TMN Final SPD 12-01-2020.pdf 1.03 MB (Last Modified on December 15, 2020)

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2021 Kelsey Basic ACO Summary of Benefits and Coverage

Kelsey Basic ACO Summary of Benefits and Coverage 2021.pdf 796.89 KB (Last Modified on October 23, 2020)

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2021 Kelsey Plus ACO Summary of Benefits and Coverage

Kelsey Plus ACO Summary of Benefits and Coverage 2021.pdf 797.56 KB (Last Modified on October 23, 2020)

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2021 Kelsey Select ACO Summary of Benefits and Coverage

Kelsey Select ACO Summary of Benefits and Coverage 2021.pdf 779.3 KB (Last Modified on October 23, 2020)

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2021 Memorial Hermann Basic ACO Summary of Benefits and Coverage

Memorial Hermann Basic ACO Summary of Benefits and Coverage 2021.pdf 780.23 KB (Last Modified on October 23, 2020)

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2021 Memorial Hermann Plus ACO Summary of Benefits and Coverage

Memorial Hermann Plus ACO Summary of Benefits and Coverage 2021.pdf 780.98 KB (Last Modified on October 23, 2020)

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Dental

Cigna Dental Care (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 Care (DHMO) and (DPPO)

take the 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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Dental HMO Access Plus

Dental HMO Plus flyer.

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

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Access Plus Network Dentist

How to find a dentist flyer

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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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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2021 HISD summary of benefits - wellness plus CYM 1350

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

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2021 HISD summary of benefits - 2000 CYM.

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