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For more information regarding Prescription Benefits.
2026 SilverScript - Prescription Drug Plan SOB - Anthem HMO
2026 Formulary B033.pdf
1 MB
(Last Modified on September 19, 2025)
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2026 SilverScript - Prescription Drug Plan SOB - Anthem PPO EPO
2026 Summary of Benefits B030_B031_B036.pdf
399.5 KB
(Last Modified on September 19, 2025)
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2026 SilverScript - Prescription Drug Plan EOC - Anthem HMO
2026 Evidence of Coverage B033.pdf
1.76 MB
(Last Modified on September 19, 2025)
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2026 SilverScript - Prescription Drug Plan EOC - Anthem PPO EPO
2026 Evidence of Coverage B030_B031_B036..pdf
1.76 MB
(Last Modified on September 19, 2025)
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2026 Annual Notice of Change Anthem HMO
2026 Annual Notice of Change B033.pdf
479.3 KB
(Last Modified on September 19, 2025)
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2026 Annual Notice of Change Anthem EPO PPO
2026 Annual Notice of Change B030_B031_B036..pdf
479.29 KB
(Last Modified on September 19, 2025)
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2026 Formulary Anthem HMO
2026 Formulary B033.pdf
1 MB
(Last Modified on September 19, 2025)
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2026 Formulary Anthem PPO EPO
2026 Formulary B030_B031_B036..pdf
1 MB
(Last Modified on September 19, 2025)
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2025 SilverScript Formulary - List of Covered Drugs
LAUSD Formulary 2025.pdf
847.73 KB
(Last Modified on September 30, 2024)
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2025 SilverScript - Prescription Drug Plan EOC - Medicare
2025 SilverScript Prescription B033 EOC.pdf
860.29 KB
(Last Modified on September 5, 2024)
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2025 SilverScript Annual Notice of Changes for 2025
2025 SilverScript Prescription B033 ANOC.pdf
114.58 KB
(Last Modified on September 3, 2024)
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10 - 2025 Standard Opt-Out + Advanced Control Specialty Formulary
Opt Out ACSF 1550_Oct 2025.pdf
128.39 KB
(Last Modified on October 2, 2025)
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10 - 2025 CVS Caremark Performance Drug List (Anthem Plans)
10-2025 PDL SOO ACSF.pdf
176.46 KB
(Last Modified on October 2, 2025)
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10 - 2025 CVS Caremark Advanced Formulary (Anthem Plans)
10-2025 Advanced Control Specialty Formulary.pdf
141.67 KB
(Last Modified on October 2, 2025)
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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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2025 Health Net 3 Tier Drug List
hn-3-tier-drug-list.pdf
11.37 MB
(Last Modified on June 16, 2025)
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2024 Comprehensive Formulary - Health Net Seniority Plus
2024 comprehensive Formulary.pdf
4.17 MB
(Last Modified on June 16, 2025)
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Transparency Coverage
Kaiser
Health Net
Summary of Benefits and Coverage
2026 Health Net HMO - Actives & Early Retirees
2026 SBC LAUSD.pdf
888.02 KB
(Last Modified on October 2, 2025)
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2026 Medicare Advantage PPO - Annual Notice of Change
LAUSD_Medicare Advantage PPO_ANOC.pdf
727.67 KB
(Last Modified on September 26, 2025)
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2026 Anthem Medicare Advantage PPO
LAUSD_Medicare Advantage PPO_Summary of Benefits.pdf
387.85 KB
(Last Modified on September 26, 2025)
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2026 Anthem Blue Cross Select HMO - Retirees
2026 Anthem Blue Cross Select HMO - Retirees.pdf
696.8 KB
(Last Modified on September 26, 2025)
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2026 Anthem Blue Cross EPO Retirees Non-CA Residents
2026 Anthem Blue Cross EPO Retirees Non-CA Residents.pdf
703.64 KB
(Last Modified on September 26, 2025)
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2026 Anthem Blue Cross EPO Retirees CA Residents
2026 Anthem Blue Cross EPO Retirees CA Residents.pdf
701.59 KB
(Last Modified on September 26, 2025)
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2026 Anthem Blue Cross Select HMO - Actives
2026 Anthem Blue Cross Select HMO - Actives.pdf
703.58 KB
(Last Modified on September 26, 2025)
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2026 Anthem Blue Cross EPO - Actives Non-CA Residents
2026 Anthem Blue Cross EPO -Actives Non- CA Residents.pdf
707.28 KB
(Last Modified on September 26, 2025)
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2026 Anthem Blue Cross EPO - Actives CA Residents
2026 Anthem Blue Cross EPO- Actives CA Residents.pdf
703.58 KB
(Last Modified on September 26, 2025)
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2026 Kaiser HMO SBC - Early Retirees, Northern California
LAUSD 605554 Retiree Pre-65 SBC.pdf
1.25 MB
(Last Modified on September 15, 2025)
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2026 Kaiser HMO SBC - Actives, Northern California
LAUSD 605553 Actives SBC.pdf
1.24 MB
(Last Modified on September 15, 2025)
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2026 Kaiser HMO SBC - Early Retirees, Southern California
LAUSD 230837 Retiree Pre-65 SBC.pdf
1.25 MB
(Last Modified on September 15, 2025)
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2026 Kaiser HMO SBC - Actives, Southern California
LAUSD 100990 Actives SBC.pdf
1.24 MB
(Last Modified on September 15, 2025)
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2026 Kaiser Hawaii HMO SBC - Early Retirees
SBC 34704 LAUSD Retiree HI 2026.pdf
809.48 KB
(Last Modified on September 19, 2025)
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2026 Kaiser Northwest HMO SBC - Early Retirees
LAUSD_NW_4674_20 Ded Medical Plan 2026 SBC.pdf
652.9 KB
(Last Modified on September 22, 2025)
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2025 Kaiser HMO SBC - Actives, Southern California
2025 SBC_LAUSD 100990.pdf
1.07 MB
(Last Modified on November 27, 2024)
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2025 Kaiser HMO SBC - Early Retirees, Southern California
2025 SBC_LAUSD 230837_Retirees.pdf
1.07 MB
(Last Modified on November 27, 2024)
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2025 Kaiser HMO SBC - Actives, Northern California
2025 SBC_LAUSD 605553.pdf
1.07 MB
(Last Modified on November 27, 2024)
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2025 Kaiser HMO SBC - Early Retirees, Northern California
2025 SBC_LAUSD 605554_Retirees.pdf
1.07 MB
(Last Modified on November 27, 2024)
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2025 Kaiser Hawaii HMO SBC - Early Retirees
HI_SBC 34704 LAUSD Retiree 2025.pdf
689.42 KB
(Last Modified on November 27, 2024)
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2025 Kaiser Northwest HMO SBC - Early Retirees
NW_LAUSD_4674-001_Traditional Plan_SBC_2025.pdf
521.26 KB
(Last Modified on June 13, 2025)
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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, CA Residents
2025 Anthem Blue Cross EPO - Actives CA Residents.pdf
686.56 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
644.11 KB
(Last Modified on November 22, 2024)
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2025 Anthem Blue Cross Select HMO - Retirees
2025 Anthem Blue Cross Select HMO - Retirees.pdf
696.43 KB
(Last Modified on November 22, 2024)
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2026 Aetna Dental
2026 LAUSD Dental SDBC.pdf
468.51 KB
(Last Modified on September 19, 2025)
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2026 Delta Dental
HL_DCU_CAD81_V25_W_EN_06.20.25_LTR.pdf
331.92 KB
(Last Modified on September 10, 2025)
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2025 Aetna Dental
2025 LAUSD Dental SDBC.pdf
2.35 MB
(Last Modified on September 16, 2024)
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2025 Western Dental
LAUSD Member Copay_2025.pdf
560.12 KB
(Last Modified on September 16, 2024)
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2025 Delta Dental
Delta Summary of Benefits.pdf
331.92 KB
(Last Modified on June 23, 2025)
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2026 VSP
LAUSD_2026 MBS.pdf
1.23 MB
(Last Modified on September 15, 2025)
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2026 EyeMed
LAUSD EyeMed Benefit Summary.pdf
2.76 MB
(Last Modified on September 10, 2025)
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2025 VSP
LAUSD_ MBS 2025.pdf
561.42 KB
(Last Modified on September 16, 2024)
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2025 EyeMed
LAUSD EyeMed Benefit Summary.pdf
2.76 MB
(Last Modified on September 16, 2024)
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Evidence of Coverage
EOC's are updated as they become available.
2026 Anthem Medicare Preferred (PPO) - Retiree
LAUSD_Medicare Advantage PPO_EOC.pdf
3.8 MB
(Last Modified on October 2, 2025)
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2025 Anthem Blue Cross HMO - Active
2025 Anthem Blue Cross HMO - Active.pdf
1.63 MB
(Last Modified on April 10, 2025)
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2025 Anthem Blue Cross EPO - Active CA
2025 Anthem Blue Cross ECO - Active CA.pdf
1.57 MB
(Last Modified on April 10, 2025)
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2025 Anthem Blue Cross EPO - Active Non-CA
2025 Anthem Blue Cross ECO - Active Non-CA.pdf
1.55 MB
(Last Modified on April 10, 2025)
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2025 Anthem Blue Cross HMO - Retiree
2025 Anthem Blue Cross HMO - Retiree.pdf
1.61 MB
(Last Modified on April 10, 2025)
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2025 Anthem Blue Cross EPO - Retiree CA
2025 Anthem Blue Cross ECO - Retiree CA.pdf
1.49 MB
(Last Modified on April 10, 2025)
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2025 Anthem Blue Cross EPO - Retiree Non-CA
2025 Anthem Blue Cross ECO - Retiree Non-CA.pdf
1.46 MB
(Last Modified on April 10, 2025)
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2025 Anthem Medicare Preferred (PPO) - Retiree
2025LAUSDLPPOEOC.pdf
954.54 KB
(Last Modified on September 26, 2024)
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2025 Health Net HMO - Active and Early Retiree
2025 LAUSD EOC_Active Pre-Medicare Retiree.pdf
1.21 MB
(Last Modified on May 2, 2025)
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2025 Health Net HMO - Seniority Plus
2025 LAUSD EOC_Retirees Seniority Plus.pdf
2.58 MB
(Last Modified on May 2, 2025)
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2025 Kaiser HMO EOC - Active Southern California
LAUSD_100990_002_10_v126.pdf
3.29 MB
(Last Modified on November 22, 2024)
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2025 Kaiser HMO EOC - Active Northern California
LAUSD_605553_001_8_v23.pdf
3.29 MB
(Last Modified on November 22, 2024)
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2025 Kaiser HMO EOC - Early Retiree, Southern California
LAUSD_230837_001_6_v57_ER.pdf
3.29 MB
(Last Modified on November 22, 2024)
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2025 Kaiser HMO EOC - Early Retiree, Northern California
LAUSD_605554_001_9_v32_ER.pdf
3.29 MB
(Last Modified on November 22, 2024)
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2025 Kaiser Senior Advantage EOC - Retiree Over 65, Southern California
LAUSD_230837_001_1_v57_Medicare.pdf
1.37 MB
(Last Modified on November 22, 2024)
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2025 Kaiser Senior Advantage EOC - Retiree Over 65, Northern California
LAUSD_605554_001_1_v32_Medicare.pdf
1.37 MB
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