Benefits Open Enrollment

Complete your benefits enrollment for the upcoming plan year. All fields marked with * are required.

Enrollment Details

Select your enrollment type and pay schedule — premiums will update automatically

Enrollment Type *

Pay Schedule *

Effective Date

04/01/2026

Employee Information

Your personal and contact information — all fields are required

First Name *

Last Name *

Middle Initial

Date of Birth *

Social Security Number *

Gender *

Email *

Phone Number *

Marital Status *

Date of Hire *

Street Address *

City *

State *

ZIP Code *

Medical Coverage

Anthem CSP Blue Open Access — $1,500/0%/$3,500

Deductible

$1,500 individual / $3,500 family

Coinsurance

Plan pays 100% after deductible

OOP Max

$3,500 individual / $7,000 family

Employer contributes $253.85 per semi-monthly period

Your cost after employer contribution (Semi-Monthly (24x/year)):

Employee Only:$0.00

Employee + Spouse:$485.80

Employee + Child(ren):$416.65

Family:$923.67

Anthem CSP Blue Open Access — $6,500/30%/$9,200

Deductible

$6,500 individual / $13,000 family

Coinsurance

Plan pays 70% after deductible

OOP Max

$9,200 individual / $18,400 family

Employer contributes $253.85 per semi-monthly period

Your cost after employer contribution (Semi-Monthly (24x/year)):

Employee Only:$0.00

Employee + Spouse:$316.92

Employee + Child(ren):$259.83

Family:$678.38

I wish to enroll in medical coverage — Anthem CSP Blue Open Access $1,500/0%/$3,500

I wish to enroll in medical coverage — Anthem CSP Blue Open Access $6,500/30%/$9,200

I wish to decline medical coverage.

Dental Coverage

Anthem CSP Essential Choice

Anthem CSP Essential Choice — Employee Rates (Semi-Monthly (24x/year))

Employee Only$23.49

Employee + Spouse$47.91

Employee + Child(ren)$55.22

Family$82.48

I wish to enroll in dental coverage.

I wish to decline dental coverage.

Vision Coverage

Anthem BlueView Vision

Anthem BlueView Vision — Employee Rates (Semi-Monthly (24x/year))

Employee Only$4.77

Employee + Spouse$9.53

Employee + Child(ren)$8.80

Family$13.81

I wish to enroll in vision coverage.

I wish to decline vision coverage.

By submitting this form, I certify that the information provided is accurate and complete. I understand that this enrollment is subject to the terms and conditions of the group health plan.