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For more information regarding Prescription Benefits.
2025 SilverScript - Prescription Drug Plan EOC - Medicare
2025 SilverScript Prescription B033 EOC.pdf
860.29 KB
(Last Modified on Thursday at 8:14 AM)
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2025 SilverScript Annual Notice of Changes for 2025
2025 SilverScript Prescription B033 ANOC.pdf
114.58 KB
(Last Modified on Tuesday at 8:11 AM)
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2024 CVS Plan Summary (Anthem HMO) - Active & Early Retirees
Proof 2128942 7365 01 29 2024 10 57 22 AM HMO Select.pdf
54.66 KB
(Last Modified on February 1, 2024)
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2024 CVS Plan Summary (Anthem EPO) - Active & Early Retirees
Proof 2128907 7365 01 292024 10 40 24 AM EPO Select.pdf
54.77 KB
(Last Modified on February 1, 2024)
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2024 SilverScript Formulary - List of Covered Drugs
2024 Formulary.pdf
842.33 KB
(Last Modified on April 11, 2024)
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2024 SilverScript - Prescription Drug Plan EOC - Anthem HMO
2024 LAUSD Silverscript EOC - HMO.pdf
969.2 KB
(Last Modified on December 26, 2023)
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2024 SilverScript - Prescription Drug Plan EOC - Anthem PPO EPO
2024 LAUSD SilverScript EOC - PPO EPO.pdf
969.2 KB
(Last Modified on December 26, 2023)
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2024 SilverScript - Prescription Drug Plan SOB - Anthem HMO
2024 LAUSD SilverScript SOB - HMO.pdf
69.88 KB
(Last Modified on December 26, 2023)
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2024 SilverScript - Prescription Drug Plan SOB - Anthem PPO EPO
2024 LAUSD SilverSript SOB - PPO EPO.pdf
69.87 KB
(Last Modified on December 26, 2023)
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08-2023 Health Net 3 Tier Drug List
08.23 Health Net Prescription Drug Preferred List_Actives and Pre-Medicare Retirees.pdf
2.62 MB
(Last Modified on December 20, 2023)
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08-2023 Comprehensive Formulary - Health Net Seniority Plus
08.23 Health Net Prescription Drug Preferred List_Medicare Retirees.pdf
1.7 MB
(Last Modified on December 20, 2023)
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07-2024 CVS Caremark Performance Drug List (Anthem Plans)
07-2024 PDL SOO ACSF.pdf
187.76 KB
(Last Modified on July 2, 2024)
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07-2024 CVS Caremark Advanced Formulary (Anthem Plans)
07-2024 Advanced Control Specialty Formulary.pdf
143.4 KB
(Last Modified on July 2, 2024)
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Medicare Part D Notice of Creditable Coverage
2022 Part D Notice of Creditable Coverage.pdf
568.86 KB
(Last Modified on December 21, 2023)
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Transparency Coverage
Kaiser
Health Net
Summary of Benefits and Coverage
2025 Anthem Blue Cross Select HMO - Retirees
2025 Anthem Blue Cross Select HMO - Retirees.pdf
696.32 KB
(Last Modified on August 15, 2024)
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2025 Anthem Blue Cross EPO - Retirees Non-CA Residents
2025 Anthem Blue Cross EPO - Retirees Non-CA Residents.pdf
686.83 KB
(Last Modified on August 15, 2024)
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2025 Anthem Blue Cross EPO - Retirees, CA Residents
2025 Anthem Blue Cross EPO - Retirees CA Residents.pdf
685.93 KB
(Last Modified on August 15, 2024)
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2025 Anthem Blue Cross Select HMO - Actives
2025 Anthem Blue Cross Select HMO - Actives.pdf
683.14 KB
(Last Modified on August 15, 2024)
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2025 Anthem Blue Cross EPO - Actives, Non-CA Residents
2025 Anthem Blue Cross EPO - Actives Non-CA Residents.pdf
642.45 KB
(Last Modified on August 15, 2024)
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2025 Anthem Blue Cross EPO - Actives, CA Residents
2025 Anthem Blue Cross EPO - Actives CA Residents.pdf
686.56 KB
(Last Modified on August 15, 2024)
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2024 Anthem Blue Cross Select HMO - Actives
2024 Anthem -C18445-Actives Select HMO Plan-20240101_20241231_SBC.pdf
699.99 KB
(Last Modified on December 6, 2023)
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2024 Anthem Blue Cross EPO - Actives, CA Residents
2024 Anthem -C18445-Actives EPO Plan CA Residents -20240101-20241231_SBC.pdf
704.71 KB
(Last Modified on December 6, 2023)
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2024 Anthem Blue Cross EPO - Actives, Non-CA Residents
2024 Anthem -C18445-Active EPO Plan Out of CA -20240101_20241231_SBC.pdf
704.17 KB
(Last Modified on December 6, 2023)
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2024 Anthem Blue Cross Select HMO - Retirees
2024 Anthem -276193-Retirees Select HMO Plan-20240101_20241231_SBC.pdf
700.34 KB
(Last Modified on December 7, 2023)
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2024 Anthem Blue Cross EPO - Retirees, CA Residents
2024 Anthem -276193 Retirees and AB528 EPO Plan CA Residents 20240101 20241231 SBC.pdf
703.71 KB
(Last Modified on December 7, 2023)
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2024 Anthem Blue Cross EPO - Retirees, Non-CA Residents
2024 Anthem -276193 Retirees and AB528 EPO Plan Out of CA 20240101 20241231 SBC.pdf
704.76 KB
(Last Modified on December 7, 2023)
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2024 Health Net HMO - Actives & Early Retirees
2024 Health Net - Actives and Pre-Medicare Retirees.pdf
742.15 KB
(Last Modified on December 7, 2023)
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2024 Health Net HMO - Seniority Plus - Retirees
2024 Health Net - Sen Plus.pdf
478.43 KB
(Last Modified on December 7, 2023)
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2024 Kaiser HMO SBC - Actives, Southern California
100990_SCAL_LAUSD_SBC Actives.pdf
1.07 MB
(Last Modified on December 7, 2023)
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2024 Kaiser HMO SBC - Early Retirees, Southern California
230837_SCAL_LAUSD_SBC Retirees.pdf
1.07 MB
(Last Modified on December 7, 2023)
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2024 Kaiser HMO SBC - Actives, Northern California
605553_NCAL_LAUSD_SBC Actives.pdf
1.07 MB
(Last Modified on December 7, 2023)
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2024 Kaiser HMO SBC - Early Retirees, Northern California
605554_NCAL_LAUSD_SBC Retirees.pdf
1.07 MB
(Last Modified on December 7, 2023)
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2024 Kaiser Northwest HMO - Early Retirees
2024 Kaiser NW SD_4674-001_TRAD HMO 2024.pdf
654.45 KB
(Last Modified on December 7, 2023)
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2024 Kaiser Northwest Senior Advantage - Retirees
2024 Kaiser NW SD_4674-001_Senior Advantage HMO 2024.pdf
157.25 KB
(Last Modified on May 6, 2024)
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2024 Kaiser Hawaii HMO SBC - Early Retirees
SBC 34704 LA Unified School District - Retiree 2024- HI.pdf
439.98 KB
(Last Modified on May 6, 2024)
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2024 Aetna Dental PPO SBC
Los Angeles Unified School District - 2024 SBC - Dental PPO_01012024.pdf
845.49 KB
(Last Modified on December 26, 2023)
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2024 Delta Dental
Delta Dental HL_DCU_CAD81_V24_W_EN_04.25.24_LTR Final.pdf
333.63 KB
(Last Modified on August 15, 2024)
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2024 Western Dental
2024 Western Dental Summary of Dental Benefits and Coverage Disclosure Matrix_LAUSD_2024.pdf
540.51 KB
(Last Modified on December 26, 2023)
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2024 EyeMed
2024 EyeMed Benefit Summary.pdf
2.76 MB
(Last Modified on December 26, 2023)
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2024 VSP
2024 VSP SBC.pdf
1.75 MB
(Last Modified on December 26, 2023)
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Evidence of Coverage
EOC's are updated as they become available.
2024 Anthem Medicare Preferred (PPO)
2024 Anthem Medicare Preferred PPO.pdf
3.19 MB
(Last Modified on April 29, 2024)
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2023 Anthem Blue Cross EPO - Active CA
2023 CA EPO - Active -anthem.pdf
1.44 MB
(Last Modified on December 7, 2023)
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2023 Anthem Blue Cross EPO - Active Non-CA
2023 Out-of-State EPO - Active anthem.pdf
1.42 MB
(Last Modified on December 7, 2023)
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2023 Anthem Blue Cross EPO - Retiree CA
2023 CA EPO - Retiree anthem.pdf
1.4 MB
(Last Modified on December 7, 2023)
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2023 Anthem Blue Cross EPO - Retiree Non-CA
2023 Out-of-State EPO - Retiree anthem.pdf
1.38 MB
(Last Modified on December 7, 2023)
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2023 Anthem Blue Cross HMO - Active
2023 HMO - Active anthem.pdf
1.52 MB
(Last Modified on December 7, 2023)
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2023 Anthem Blue Cross HMO - Retiree
1040014CASENABC_001_LAUSD_EOC_Final_508 anthem.pdf
3.27 MB
(Last Modified on December 7, 2023)
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2024 Health Net HMO - Active and Early Retiree
2024 LAUSD GSA Contract_Actives and Pre-Medicare Retirees_FINAL.pdf
1.43 MB
(Last Modified on May 6, 2024)
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2024 Health Net HMO - Seniority Plus
2024 LAUSD GSA_EOC Contract_Retirees_FINAL.pdf
2.71 MB
(Last Modified on May 6, 2024)
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2023 Kaiser HMO EOC - Active Southern California
2023 LAUSD 100990 SCAL Actives Traditional HMO EOC -Kaiser HMO EOC - Active Southern California.pdf
3.12 MB
(Last Modified on December 7, 2023)
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2023 Kaiser HMO EOC - Active Northern California
2023 LAUSD 605553 NCAL Actives Traditional HMO EOC -Kaiser HMO EOC - Active Northern California.pdf
3.13 MB
(Last Modified on December 7, 2023)
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2023 Kaiser HMO EOC - Early Retiree, Southern California
2023 LAUSD 230837 SCAL NonMedicare EOC Kaiser HMO EOC - Early Retiree Southern California.pdf
3.12 MB
(Last Modified on December 7, 2023)
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2023 Kaiser HMO EOC - Early Retiree, Northern California
2023 LAUSD 605554 NCAL Non-Medicare EOC Kaiser HMO EOC - Early Retiree Northern California.pdf
3.13 MB
(Last Modified on December 7, 2023)
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2024 Kaiser Northwest HMO - Early Retiree
KPNW_LAUSD_001_2024.pdf
1.13 MB
(Last Modified on February 28, 2024)
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2023 Kaiser Hawaii HMO EOC - Early Retiree
Kaiser - HI EOC 34704 LAUSD - Retirees 2023.pdf
1.76 MB
(Last Modified on December 8, 2023)
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2023 Kaiser Senior Advantage EOC - Retiree Over 65, Southern California
2023 LAUSD 230837 SCAL KPSA EOC.pdf
3.08 MB
(Last Modified on May 9, 2024)
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2023 Kaiser Senior Advantage EOC - Retiree Over 65, Northern California
2023 LAUSD 605554 NCAL KPSA EOC.pdf
3.1 MB
(Last Modified on May 9, 2024)
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2023 Aetna Dental PPO - LA and TX
2023 Aetna Dental PPO - LA and TX.pdf
338.75 KB
(Last Modified on December 26, 2023)
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2023 Aetna Dental PPO - Most US States
2023 Aetna Dental PPO - Most US States.pdf
340.38 KB
(Last Modified on December 26, 2023)
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2024 Delta Dental
Delta Dental EOC_CAD81_W_STM.20240601.pdf
290.5 KB
(Last Modified on August 15, 2024)
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2022 Western Dental
Western Dental - LAUSD Benefit Booklet 2021.pdf
1.57 MB
(Last Modified on December 26, 2023)
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2023 EyeMed - Employees
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2023 EyeMed - Retirees
Eyemed - RETIREES - 2020 Certificate Package REVISED 1-1-22 VC146.pdf
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2023 VSP
2023 VSP 2021_VSP_EOC_Evidence_Certificate_of_Coverage_January_1_2019 1.pdf
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