RHC Forms and Publications

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  1. About LACERA

    About LACERA

    City of Los Angeles skyline
    Our mission is to produce, protect, and provide the promised benefits to our members.
    1. Who We Are

      1. News
      2. Careers
      3. Business Opportunities
      4. Contact Us
    2. Leadership

      1. Board of Retirement
      2. Board of Investments
      3. Board Meetings
      4. Executive Team
      5. Divisions
    3. Accountability

      1. Retirement Law
      2. Governing Documents
      3. Investments
      4. Annual Reports
      5. Public Records
  2. Active Members

    Active Members

    A busy crowd walking by buildings.
    Our defined benefit plans were created to provide you with financial security.
      1. General Plans

      2. Plans A/B/C
      3. Plan D
      4. Plan E
      5. Plan G
      6. Safety Plans

      7. Plans A/B
      8. Plan C
    1. Active Service

      1. Contributions
      2. Service Credit
      3. Compensation
      4. Reciprocity
      5. Terminating Service
      6. Felony Forfeiture
      7. Pre-Retirement Divorce
      8. Disability Retirement
    2. Retirement Planning

      1. Benefit Estimates
      2. Steps to Prepare
      3. Ready to Retire
      4. Workshops
      5. Retirement Options
      6. Beneficiaries
      7. Power of Attorney
  3. Retirees and Families

    Retirees and Families

    View of dock overlooking the water.
    Your monthly allowance is guaranteed, and benefits extend to families and survivors.
    1. Retirement Payments

      1. Cost of Living
      2. Direct Deposit
      3. Tax Requirements
      4. Returning to Work
      5. Divorce
      6. Admin Appeals
    2. Families and Survivors

      1. Benefits Process
      2. Eligible Beneficiaries
      3. Survivor Benefits
      4. Survivor Healthcare
      5. Taxability of Benefits
  4. Retiree Healthcare

    Retiree Healthcare

    The hallway of a hospital.
    We provide comprehensive healthcare plans and resources to keep you healthy in retirement.
    1. Program Basics

      1. Healthcare Eligibility
      2. Paying for Coverage
      3. Manage Your Enrollment
      4. Medicare
      5. COBRA
      6. Healthcare Resources
      7. Healthcare Legislation
    2. Healthcare Plans

      1. Anthem Blue Cross of CA
      2. CIGNA
      3. Kaiser Permanente
      4. SCAN
      5. United Healthcare
      6. Dental/Vision Plans

Program Basics

  1. Healthcare Eligibility
  2. Paying for Coverage
  3. Manage Your Enrollment
  4. Medicare
  5. COBRA
  6. Healthcare Resources
    1. Retiree Wellness Program
    2. Long-Term Care
    3. RHC Forms and Publications
  7. Healthcare Legislation
Begin content

To download (or print) a PDF of a document shown on this page, click on the link under the item. NOTE: If you are having difficulty accessing a PDF, you may need to upgrade to the most recent version of Adobe Reader; it's free.

Enrollment/Change/Cancellation Forms:

To initiate an enrollment, change, or cancellation of your dental/vision or medical plan, fill out the appropriate form below.

Sample forms: To help you complete your healthcare forms accurately, we have created detailed, step-by-step instructions and samples to use as a reference while filling out your forms. Please click on the appropriate sample below.

  • Medical Plan New Enrollment, Change, Cancellation (Form NC)
    • Medical Plan: New Enrollment Instructions and Sample Form
    • Medical Plan: Change Instructions and Sample Form
    • Medical Plan: Cancellation Instructions and Sample Form
  • Dental and Vision Plan - New Enrollment, Change, Cancellation (Form DCD)
    • Dental and Vision Plan: New Enrollment Instructions and Sample Form
    • Dental and Vision Plan: Change Instructions and Sample Form
    • Dental and Vision Plan: Cancellation Instructions and Sample Form
  • Medicare Advantage Prescription Drug Plan Enrollment Form
    • Medicare Advantage Prescription Drug Plan Enrollment Form and Sample Form
    • Kaiser Permanente Hawaii Arbitration Agreement

Brochures & Rate Tables

  • Medical & Dental/Vision Premium Rates
  • Medical Premium Rates - Out of Area
  • Dental Vision Chart
  • Plan Comparison
  • Plan Comparison - Medicare
  • Plan Comparison - Out of Area
  • Medicare Benefits Chart
  • How Your Anthem Blue Cross Plans I, II, and III Coordinate with Medicare
  • Changing Medical Plans

New Retiree Healthcare Packet

  • Exploring Your Healthcare Benefits Through LACERA
  • Contact Information
  • Decision Guide
  • Dental/Vision Plans
  • Medical Plans Overview
  • When You Travel
  • Request Enrollment Forms

Annual Retiree Healthcare Packet

  • Annual Healthcare Letter
  • Benefits Guide
  • Benefits Update
  • Notice of Creditable Coverage

To order healthcare forms and packets, call 800-786-6464, and press 1 for Retiree Healthcare.

To order other retirement information, visit the Forms and Publications page.

Contact Retiree Healthcare

Operating Hours: M – F, 7 a.m. – 5:30 p.m.

Call

Toll-free
800-786-6464
Local
626-564-6132

Email

Secure/Document Upload
My LACERA
General
healthcare@lacera.com

Fax

General
626-564-6155
Urgent Cases Only
626-564-6799

Mail

LACERA

Attn: Retiree Healthcare
P.O. Box 7060
Pasadena, CA 91109-7060

Mondays and Fridays are our busiest call days; for faster service, call us Tuesday through Thursday.

Los Angeles County Employees Retirement Association

Appointment Reservations
LACERA
Los Angeles County Employees Retirement Association

Member Service Center

M – F, 7 a.m. – 5 p.m. PT

Holiday Schedule

300 N. Lake Ave.
Pasadena, CA 91101

Contact Us

Member Services Call Center

M – F, 7 a.m. – 5:30 p.m. PT

800-786-6464

Retiree Healthcare

800-786-6464

Business

M – F, 8 a.m. – 5 p.m. PT

PO Box 7060
Pasadena, CA 91109-7060

Phone 626-564-6000

Fax 626-564-6155

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