The Open Enrollment period is May 1 through May 31. All Open Enrollment changes are effective July 1.
Based on your benefits eligibility, this is your opportunity to add or remove an eligible dependent (spouse, domestic partner or child up to age 26), update your spouse’s eligibility for employer health coverage (attestation) or switch between medical plans without a qualifying event. Premium co-shares apply and are based on rates as of July 1, 2019.
All requested changes can be emailed to firstname.lastname@example.org or faxed to (215) 400-4631 or made in person Monday through Thursday from 9-5. Requests must be received by May 31. Documents received after May 31 will not be processed.
If submitting by fax, please call 215-400-4630 or email email@example.com to confirm receipt. Employees submitting Open Enrollment requests should keep of a copy of the request(s) and proof of submission.
District 1201/32 BJ employees: medical coverage is provided by your national union. You will need to contact 32 BJ at 877-605-8300 for medical Open Enrollment information.
Forms and Documents
- Health and Attestation Application
- Letter of Attestation (on the reverse side of Health and Attestation Application)
- Keystone HMO Summary of Benefits
- Personal Choice
Check the FAQs for common Open Enrollment related questions.
Check the required Dependent Eligibility Documents.
Check the current Premium Co-Shares(per pay employee costs)