There are five (5) options for choices for Open Enrollment. Select one that applies to you.

Option #1. I am changing my health insurance plan but am not adding/removing a dependent

Employee ID # and Highmark card are needed to complete this form.

Option #2. I am adding/removing a dependent to my health insurance

Employee ID # and SSN and DOB are needed to complete this form.
Eligibility documentation required. Your application will be declined for failure to attached documentation (i.e. - birth certificate, marriage certificate). These documents are required to show eligibility.
Consider updating your life insurance beneficiary.

Option #3. I am adding/removing a dependent to my health insurance and changing my insurance plan

Employee ID # and SSN and DOB are needed to complete this form.
Eligibility documentation required. Your application will be declined for failure to attached documentation (i.e. - birth certificate, marriage certificate). These documents are required to show eligibility.
Consider updating your life insurance beneficiary.

Option #4. Health Insurance Waiver- I am receiving health insurance coverage from another source

Payments for the Waiver are paid out every January for year prior.
If you are already enrolled in the Waiver Program, you will remain enrolled in the Waiver Program until you elect to enroll in District Group Health Insurance, or you separate employment from the Buffalo Public Schools. You do NOT need to re-enroll during Open Enrollment.

Option #5. I am not currently enrolled in health insurance and would like to enroll effective 1/1/2026

Employee ID # and SSN and DOB are needed to complete this form.
Eligibility documentation required if enrolling in family coverage. Your application will be declined for failure to attached documentation (i.e. - birth certificate, marriage certificate). These documents are required to show eligibility.
Review what plans are available to you at the BCSA Benefits webpage linked above

Life-Changing Events include marriage, divorce, birth, adoption, death, and/or when a child obtains their own insurance. You must complete a packet and submit it to the Benefits Office within 30 days to update your enrollment.

Rates

Eligible employees hired on or after 7/1/12 shall contribute to health insurance at the rate of 20% of the cost of the premium for the Base Plan. Employees who opt to enroll in the Enhanced Plan will be responsible for contributing 20% of the Base Plan plus the difference in premium between the Base and Enhanced Plans. All contributions will be taken pre-tax over the course of the payrolls in the fiscal year.

These contributions are over 21 paychecks throughout the school year.

BUFFALO

Local 264 Cook Managers Open Enrollment

HEALTH INSURANCE • FLEXIBLE SPENDING • DENTAL INSURANCE

Open Enrollment:

Health Insurance/ Waiver

Flexible Spending Account

Dental Insurance/ Waiver