2021 Employee Benefi ts Informa on - Los Angeles Unifi ed School District Benefi ts Administra on - Los Angeles Unified ...
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2021 Employee
Benefits InformaƟon
Los Angeles Unified School District
Benefits AdministraƟon
Email | benefits@lausd.net Tel | 213-241-4262
Web | benefits.lausd.net Fax | 213-241-4247A Closer Look At Your Medical Plan Options
Medical Plan Options Health Net HMO Kaiser Permanente HMO Anthem Blue Cross Select HMO1 Anthem Blue Cross EPO1
Provider Choice Health Net HMO providers only; each family Kaiser HMO providers only; each family member Anthem Blue Cross Select HMO providers only; Any Prudent Buyer PPO provider in
member may select his or her own doctor. may select his or her own doctor. each family member may select his or her own California; any National (BlueCard) PPO
doctor. provider outside of California.
Annual Deductible None None None 0.5% of gross fiscal earnings per active
member, rounded downward to the nearest
$50 increment ($100 minimum per
member - $800 maximum per member).
Family: 3x member deductible
Out-of-Pocket Limit $1,500 per member $1,500 per member $1,500 per member $7,500 per member
$3,000 per family $3,000 per family $3,000 for 2 members
$4,500 per family
Maximum Lifetime Benefit Unlimited Unlimited Unlimited Unlimited
Physician and Routine Services
Physician Office Visits $20 copay/visit for primary care physician; $20 copay/visit Physician office/LiveHealth online visit: Physician office/LiveHealth online visit:
$30 copay/visit for specialist $10 copay/visit Member pays 20% after deductible*
TeleHealth online visit: no copay
Well Baby Care No copay to age 2; $20 copay/visit thereafter No charge to 23 months No copay No copay
Adult Physical Exam $20 copay/visit $20 copay/visit No copay No copay
Well Woman Exam $20 copay/visit $20 copay/visit No copay No copay
Prescription Drugs Prescription for all Anthem Blue Cross plans is provided through CVS Caremark
Retail Prescription Drugs $5 copay/fill for generic up to 30-day supply; $10 copay/fill for generic medications up to 30- Fill up to 34-day supply: $5 generic; $25 Fill up to 34-day supply: $10 generic; $30
$25 copay/fill for brand up to 30-day supply; day supply. preferred brand; $45 non-preferred brand. preferred brand; $50 non-preferred brand.
$45 copay/fill for non-formulary medications up $25 copay/fill for brand name medications up to For maintenance drugs, after 2nd fill at any
to 30-day supply/formulary applies. 30-day supply. For maintenance drugs, after 2nd fill at any in- in-network retail pharmacy, there is a
network retail pharmacy, there is a mandatory mandatory 90-day supply by mail order or at
90-day supply by mail order or at local CVS/ local CVS/pharmacy store at mail order
pharmacy store at mail order copay. copay.
Home Delivery (Mail Order) Prescription $10 copay/fill for generic; $50 copay/fill for $10 copay/fill for generic medications up to 30- Fill up to 90-day supply: $10 generic; $50 preferred Fill up to 90-day supply: $20 generic;
brand/formulary applies; $90 copay/fill for non- day supply or $20 for a 31 to 100 day supply; brand; $90 non-preferred brand. $60 preferred brand; $100 non-preferred
formulary medications; mandatory 90-day supply $25 copay/fill for brand name medications up to brand.
of maintenance medications either through 30-day supply or $50 for a 31 to 100 day supply. For maintenance drugs, after 2nd fill at any in- For maintenance drugs, after 2nd fill at any
CVS Caremark Mail Service Pharmacy or at a network retail pharmacy, there is a mandatory in-network retail pharmacy, there is a
local CVS/pharmacy store after the third fill at a 90-day supply by mail order or at local CVS/ mandatory 90-day supply by mail order or at
retail pharmacy. pharmacy store at mail order copay. local CVS/pharmacy store at mail order
copay.
Hospital or Outpatient Facility
Inpatient Care, Room and Board, Surgery 10% coinsurance plus $100 copay per admission $100 per admission No copay Member pays 20% after deductible
and Other Hospital Charges (subject to utilization review)*
Outpatient Surgery $250 copay per outpatient surgery visit $100 per procedure $10 copay/visit Member pays 20% after deductible.*
Emergency Room Treatment $100 copay/visit (waived if admitted) $100 copay/visit (waived if admitted) $50 copay/visit (waived if admitted) $100 deductible per visit (waived if
admitted), then member pays 20%.
2
Mental Health Care and Substance Abuse Treatment (for AB88 and Non-AB88 diagnosis)
Outpatient Mental Health Care $20 copay/visit as medically necessary with no $20 per individual visit; $10 per group visit (no $10 copay per visit Member pays 20% after deductible
annual limit. annual limit)
No copay for Behavioral Analysis and Intensive
Outpatient Treatment.
Inpatient Mental Health Care 10% coinsurance plus $100 copay $100 per admission No copay (no day limit) Member pays 20% after deductible (no day
per admission with no annual limit. limit)*
No copay for Partial Hospitalization and Day Treatment.
Inpatient: Member pays 20% after
Substance Abuse Treatment Inpatient treatment: 10% coinsurance plus $100 Inpatient Detoxification: $100 per admission Inpatient: No copay (no day limit)
copay per admission with no annual limit. deductible (no day limit)*
Residential Rehabilitation: $100 per admission
Outpatient: $10 copay per visit
Outpatient treatment: $20 copay per individual (no limit) Outpatient: Member pays 20% after
visit; $10 per group visit (unlimited visits/days Outpatient treatment: $20 copay per individual deductible
each calendar year). visit; $5 per group visit (unlimited visits/days
each calendar year).
Other Medical Care
Chiropractic Care $10 copay/visit; up to 20 visits/year through Not covered $10 copay per visit (covered under Rehabilitative Member pays 20% after deductible
American Specialty Health Plan (ASHP) network. Care benefit limited to 60 combined visits per (covered under Rehabilitative Care benefit
No referral needed. injury or illness; additional visits available when limited to 24 visits per calendar year;
approved by the medical group or Anthem Blue additional visits may be authorized)*
Cross)
Durable Medical Equipment No copay Member pays 10% Member pays 20% Member pays 20% after deductible
Hearing Aids 3
No copay of covered hearing aid expenses; Not covered Member pays 20% (limited to one pair every 3 Member pays 20% after deductible; one
replacement once every 3 years (one pair). years; batteries and repairs not covered). hearing aid per ear every three years.
(batteries and repairs not covered)
Note: This information is not a complete description of benefits. Contact the plan for more information. Limitations, co-payments, and restrictions may apply.
If there is any discrepancy between this chart and the plan documents, the plan documents will govern. Copies of the plan documents are on file with Benefits Administration.
1
Anthem Blue Cross pays the applicable percentage of the Anthem Blue Cross allowed amount for the in-network services. Anthem Blue Cross Select HMO and EPO network providers accept this amount as payment in full, less any deductible and copayment. Non-participating providers may bill
you for any amounts that exceed the “allowable” amount, plus any deductible and copayment amounts.
Under the EPO plan, members must receive health care services from Anthem Blue Cross PPO network providers, unless they receive authorized referrals or need emergency and/or out-of-area urgent care. Emergency services received from a non-PPO hospital and without an authorized referral
are covered only for the first 48 hours. Coverage will continue beyond 48 hours if the member cannot be moved safely.
2
Under California law AB88, LAUSD medical plans cover certain mental health diagnoses the same as other medical conditions. These include schizophrenia, schizoaffective disorder, bipolar disorder (manic-depressive illness), major depressive disorder, obsessive-compulsive disorder, pervasive
developmental disorder or autism, anorexia nervosa, and bulimia nervosa.
3 Consult your plan regarding the procedures for obtaining hearing aids and for information regarding limitations and exclusions.
*In certain states outside of California, members may be required to pay a 50% copay with some limited benefits. Please contact plan for more information.
.
Flexible Spending Accounts 457(b) and 403(b) Retirement Savings Plans
Flexible Spending Accounts (FSA) are voluntary plans that enable you to save money by paying for certain health care and The District offers voluntary retirement savings plans to help supplement your retirement income. The District sponsors both
dependent care expenses using pre-tax pay. The District offers two special tax-savings accounts to eligible employees: traditional 457(b) and Roth 457(b) plans and also offers a 403(b) plan. Both traditional 457(b) and 403(b) plans allow for
• Health Care FSA (min $120 / max $2,700) the investment of pre-tax earnings which may decrease your taxable income. Roth 457(b) contributions are made with
Dependent Care FSA (min $120 / max $5,000) post-tax earnings with the benefit that you may be able to withdraw from your account tax-free when you retire.
•
Contributions to any of the three plans are made through automatic payroll deductions. You are immediately eligible to
How the Accounts Work contribute to the 457(b), Roth 457(b), and/or the 403(b) plans. To enroll or obtain more information, please visit
When you enroll, you decide how much of your pay to set aside in the Health Care FSA and/or Dependent Care FSA. The benefits.lausd.net, click on “Active Employees”, then “Deferred Compensation Plans”.
money you elect to set aside is deducted throughout the year from your pay before federal income, state income, and
social security taxes are calculated.
When you have an eligible expense, you pay for the expense and file for reimbursement from your FSA. You are reimbursed
with your own money from the appropriate account and the money remains untaxed. In other words, you never pay taxes
on the money that flows through your FSA.
Medical Opt-out / Cash-Back Plan
Eligible expenses for the Health Care FSA include deductibles or co-pays; prescription drug co-pays; and co-pays for If you are an active employee and do not want to be covered by any of the District medical plan options, you can opt-out
orthodontia, prescription eyewear, and contact lenses. For a guide to eligible and ineligible health care expenses, visit of medical coverage and receive $3,000 cash back per calendar year. This amount will be considered taxable income and
irs.gov to retrieve the most current edition of the Internal Revenue Service (IRS) Publication 502.
will be paid in installments in your regular payroll check. You may still elect dental and vision coverage. If you enroll in the
Eligible expenses for the Dependent Care FSA include child or adult daycare services provided in your home, someone else’s Medical Opt-out/Cash-Back Plan, you must attest annually that you and your eligible dependents have “minimum essential
home (see IRS Publication 503 for exclusions), and expenses for a licensed daycare center including annual registration coverage” through a group health plan and that it is not part of the individual market coverage such as Covered California.
fees. To qualify daycare as an eligible expense, IRS requires that your qualified dependent must either be under 13 or The Medical Opt-Out Cash Back Attestation form may be found at achieve.lausd.net/benefits/forms.
physically or mentally disabled (regardless of age) and unable to be self reliant while you are working.
If you are paying for adult daycare outside your home, your dependent must live with you at least eight hours a day.
Daycare providers must claim the income on their tax return and you must include their Social Security number on your
COBRA / Continuation of Coverage Options
reimbursement request. For the most current guide of eligible and ineligible dependent care expenses, visit irs.gov and Under the Consolidated Omnibus Reconciliation Act (COBRA) of 1985, employees and covered dependents may be
retrieve IRS Publication 503. eligible to temporarily continue health benefits coverage at their own expense after the District-sponsored coverage ends.
Plan rates shown on your paycheck are not COBRA rates. COBRA rates are published on the District’s Benefits Administration
Enrollment in the Health Care FSA and/or Dependent Care FSA is not automatic! You must enroll every year during Open website. You may also be eligible to obtain affordable and quality health care coverage through the Health Care Exchange.
Enrollment in order to participate. Visit coveredca.com for more information and coverage options.A Closer Look At Your Dental Plan Options
Western
Western Dental
Dental DHMO
DHMO Western
Western Dental
Dental DHMO
DHMO United
United Concordia
Concordia Dental
Dental (PPO)
1
(PPO)11
Dental
Dental Plan
Plan Option
Option ® USA
DeltaCare® USA DHMO
DHMO
Plan
Plan Plus
Plus Centers
Centers Only
Only In-Network
In-Network Out-of-Network
Out-of-Network
Annual
Annual Deductible
Deductible None
None None
None None
None $100
$100 for
for the
the following
following Covered
Covered Services
Services Combined:
Combined:
Basic
Basic Restorative;
Restorative; Major
Major Restorative.
Restorative.
Maximum $2,000
$2,000 for
for the
the following
following Covered
Covered Services:
Services: Preventive
Preventive and
and Diagnostic;
Maximum Annual
Annual Benefit
Benefit None
None None
None None
None Basic
Diagnostic;
Basic Restorative;
Restorative; Major
Major Restorative
Restorative (excludes
(excludes most
most in-network
in-network
preventive services).
preventive services).
Provider
Provider Choice
Choice
Participants
Participants have
have thethe option
option Participants
Participants have
have the
the flexibility
flexibility Participants
Participants must
must useuse their
their Participants
Participants must
must use
use a
a Participants
Participants and
and family
family
to
to elect
elect a
a contracted
contracted private
private of
of visiting
visiting any
any Western
Western Dental
Dental
practice
practice dentist
dentist oror to
to elect
elect a
a Center (Open Access) assigned
assigned DeltaCare
DeltaCare® USA
®
USA United
United Concordia
Concordia Dental
Dental members
members may
may use
use any
any
Center (Open Access)
Western
Western Dental
Dental Center
Center which
which without
without thethe worry
worry of
of being
being DHMO
DHMO primary
primary care
care dentist.
dentist. (PPO)
(PPO) dentist;
dentist; family
family licensed dental provider.
allows flexibility to visit any members
allows flexibility to visit any
center
appointed
appointed to to a
a specific
specific office.
office. Family
Family members
members havehave the
the members may
may each
each
center (Open
(Open Access)
Access) without Family
Family members
members may may each select
the
the worry
worry of
of being
being assigned
without
assigned to select
each
ability
ability to
to select
select separate
separate select their
their own
own network
network
to select their
their own
own primary
primary care
care dentist.
a specific office. Family dentist. network dentist. Network
Network name:
name:
a specific office. Family
members
members maymay eacheach select
select
dentist. network dentists.
dentists. LAUSD
LAUSD PPO
PPO Network.
Network.
their
their own
own primary
primary care
care dentist.
dentist.
Specialist
Specialist Referral
Referral Pre-Authorization
Pre-Authorization Pre-Authorization
Pre-Authorization Direct
Direct referral
referral from
from No
No Pre-Authorization
Pre-Authorization Required
Required
Required
Required Required
Required Primary Care
Care Dentist
Dentist
Preventative
Preventative Services
Services Member
Member Pays
Pays Member
Member Pays
Pays Member
Member Pays
Pays Member
Member Pays
Pays Member
Member Pays
Pays
Includes
Includes Teeth
Teeth Cleaning,
Cleaning, No
No Cost
Cost (for
(for cleaning
cleaning -- up
up No
No Cost
Cost (for
(for cleaning
cleaning -- up
up No Cost
Cost (for
(for cleaning
cleaning -- up
up No
No Cost.
Cost. Subject
Subject to
to 20%
20% based
based onon the
the
Panoramic or procedure
procedure limitations; reasonable
reasonable and
and customary
or Full
Full Mouth
Mouth to 3 per
per year)
year) to 3 per
per year)
year) to
to 3
3 per year)
year) limitations; customary
X-rays teeth
teeth cleaning
cleaning up
up to
to 2
2 per
per charge.
charge. Subject
Subject to
to
X-rays and
and Fluoride
Fluoride procedure
Treatment
year
year in
in and
and out
out of
of procedure limitations;
limitations;
Treatment teeth
network
network combined.
combined. teeth cleaning
cleaning up
up to
to 2
2 per
per
year
year in
in and
and out
out of
of
network
network combined.
combined.
Therapeutic
Therapeutic Services
Services Member
Member Pays
Pays Member
Member Pays
Pays Member
Member Pays
Pays Member
Member Pays
Pays Member
Member Pays
Pays
Extractions,
Extractions, Simple
Simple No
No Cost
Cost No
No Cost
Cost No
No Cost
Cost
(Single
(Single tooth)
tooth)
Extractions
Extractions for
for Not
Not Covered
Covered Not
Not Covered
Covered Not
Not Covered
Covered
Orthodontic Reasons
Reasons
Fillings
Fillings (Amalgam)
(Amalgam) No
No Cost
Cost No
No Cost
Cost No
No Cost
Cost 20%
20% of
of the
the maximum
maximum 40%
40% based
based onon thethe
Fillings
Fillings (Composite
(Composite for
for Up
Up to
to $140
$140 Up
Up to
to $140
$140 From
From $85
$85 to
to $140
$140 allowed
allowed charge.
charge. reasonable
reasonable andand
Molars) Composite
Composite fillings
fillings for
for customary
customary charge.
charge.
molars
molars will
will be
be covered
covered Composite
Composite fillings
fillings for
for
Root
Root Canal
Canal -- Molar
Molar $40
$40 $40
$40 $40
$40 molars
at
at the
the amalgam
amalgam level. level. molars will be covered
will be covered
Periodontics at the amalgam
at the amalgam level.level.
Periodontics (Scaling
(Scaling No
No Cost
Cost No
No Cost
Cost No
No Cost
Cost
and
and Root
Root Planning;
Planning; per
per
Quadrant)
Quadrant)
Osseous
Osseous Surgery
Surgery -- 4
4 or
or No
No Cost
Cost (once
(once every
every 36
36 No
No Cost
Cost (once
(once every
every 36
36 No
No Cost
Cost (once
(once every
every 36
36
More
More Contiguous
Contiguous Teeth
Teeth months)
months) months)
months) months)
months)
per Quadrant
Major
Major Services
Services Member
Member Pays
Pays Member
Member Pays
Pays Member
Member Pays
Pays Member
Member Pays
Pays Member
Member Pays
Pays
Crown
Crown $20-$165
$20-$165 (Cost
(Cost varies
varies based
based on
on metal
metal chosen.
chosen. No
No cost
cost for
for Clinical
Clinical Crown
Crown
Lengthening.)
Lengthening.)
Full
Full Denture,
Denture, Upper
Upper or
or $50
$50 $50
$50 $50
$50
Lower
Lower 50%
50% based
based on
on the
the
50%
50% of
of the
the maximum
maximum
Partial
Partial Denture,
Denture, Upper
Upper or
or $50-$63
$50-$63 $50-$63
$50-$63 $50-$63
$50-$63 reasonable and
and
allowed
allowed charge.
charge. customary
Lower
Lower customary charge.
charge.
Bridge
Bridge (3
(3 unit)
unit) $40-$165
$40-$165 per
per unit
unit $40-$165
$40-$165 per
per unit
unit Up
Up to
to 6
6 units
units with
with an
an additional
additional
$125
$125 per
per unit
unit after
after the
the 6th
6th unit
unit
(includes high
high noble
noble and
and (includes high
high noble
noble and
and (includes
(includes high noble and
high noble and noble
noble
noble
noble metal
metal charge).
charge). noble
noble metal
metal charge).
charge). metal
metal charge). Limitations may
charge). Limitations may
Limitations may apply. Limitations may apply. apply.
apply.
Dental
Dental Implants
Implants Cost
Cost varies
varies based
based on
on dental
dental implant
implant treatment
treatment Not
Not Covered
Covered Not
Not Covered
Covered Not
Not Covered
Covered
(available
(available only
only at
at Western
Western Dental
Dental Implant
Implant Centers)
Centers)
Orthodontia
Orthodontia Member
Member Pays
Pays Member
Member Pays
Pays Member
Member Pays
Pays Member
Member Pays
Pays Member
Member Pays
Pays
24
24 Month
Month Treatment
Treatment Plan
Plan $1,000
$1,000 copay
copay -- $1,000
$1,000 copay
copay -- $1,000
$1,000 copay
copay (children)/
(children)/
-- Children
Children (to
(to age
age 19)/
19)/ comprehensive
comprehensive treatment
treatment comprehensive
comprehensive treatment
treatment $1,250
$1,250 copay
copay (adults)
(adults) -- 50%
50% up
up to
to the
the $750
$750 individual
individual lifetime
lifetime maximum,
maximum, then
then
Adults
Adults only
only for
for both
both children
children and
and only
only for
for both
both children
children and
and comprehensive
comprehensive treatment
treatment you
you pay
pay 100%
100% for
for both
both children
children and
and adults
adults
adults
adults adults
adults only
only
Additional
Additional Benefits
Benefits Member
Member Pays
Pays Member
Member Pays
Pays Member
Member Pays
Pays Member
Member Pays
Pays Member
Member Pays
Pays
Deep
Deep Sedation/
Sedation/ $80
$80 first
first 15
15 minutes;
minutes; $80
$80 first
first 15
15 minutes;
minutes; $68
$68 each
each 15
15 minutes
minutes 20%
20% of
of the
the maximum
maximum 40%
40% based
based on
on the
the
General Anesthesia
Anesthesia $68
$68 each
each subsequent
subsequent 15
15 $68
$68 each
each subsequent
subsequent 15
15 allowed charge.
charge. reasonable and
and customary
customary
minutes
minutes minutes
minutes charge.
charge.
External
External Bleaching,
Bleaching, per
per $125
$125 $125
$125 $125
$125 Not
Not Covered
Covered Not
Not Covered
Covered
Arch
Occlusal
Occlusal Guards
Guards $85
$85 $85
$85 $85
$85 50%
50% of
of the
the maximum
maximum 50%
50% based
based on
on the
the
allowed
allowed charge.
charge. reasonable
reasonable and
and customary
customary
charge.
charge.
1
1
1 In
In certain
certain states
states outside
outside of
of California,
California, state
state regulations
regulations mandate
mandate that
that the
the benefits
benefits levels
levels be
be the
the same
same in
in and
and out
out of
of network.
network. Please
Please contact
contact United
United Concordia
Concordia Dental
Dental for
for
more information.
more information.A Closer Look At Your Vision Plan Options
EyeMed Vision
EyeMed Vision Care
Care VSP®
VSP® Vision
Vision Care
Care
Vision
Vision Plan
Plan Options
Options
EyeMed
EyeMed Provider
Provider Non-EyeMed
Non-EyeMed Provider
Provider Choice
Choice Network
Network Provider
1,
1, 2,
Provider 1, 2, 4
2, 4
4 Non-VSP
Non-VSP Provider
3,
3, 4
Provider 3, 4
4
OfÀce More
More than
than 102,600
102,600 providers Choose
Choose from
from 98,000
98,000 provider
OfÀce Locations
Locations nationwide,
providers Freedom
Freedom toto receive
receive services
services provider Freedom
Freedom toto see
see any
any provider
provider
nationwide, including
including Pearle
Pearle at
at the
the provider
provider of
of your
your choice. access points including including
including the
the out-of-network
Vision, choice. including Indepen-
Indepen- out-of-network
Vision, LensCrafters,
LensCrafters, Target
Target provider
Optical
Optical as
as well
well as
as online
online providers
providers
dent
dent Doctors,
Doctors, Costco
Costco Optical,
Optical, provider of
of your
your choice.
choice.
such
such as
as ContactsDirect.com,
ContactsDirect.com, Walmart, Visionworks, Linden Opto-
Glasses.com,
Glasses.com, TargetOptical, and
TargetOptical, and
RayBan.com
Optometry
metry A P.C., A and
P.C.,VSP’s
and VSP’s
online
RayBan.com
online eyewear
eyewear store, Eyeconic
store, Eyeconic ®
® ®
Annual
Annual Deductible
Deductible None
None None
None $25
$25 $25
$25
Examination
Examination (1
(1 every
every 12
12 Plan
Plan pays
pays 100%
100% Plan
Plan pays
pays up
up to
to $20
$20 Plan
Plan pays
pays 100%
100% Plan
Plan pays
pays up
up to
to $55
$55
months)
months)
months))
Lenses (1 pair every 12 months
Single
Single Vision
Vision Plan
Plan pays
pays 100%
100% Plan
Plan pays
pays up
up to
to $20
$20 Plan
Plan pays
pays 100%
100% Plan
Plan pays
pays up
up to
to $40
$40
Lined Bifocal Plan
Plan pays
pays 100%
100% Plan
Plan pays
pays up
up to
to $30
$30 Plan
Plan pays
pays 100%
100% Plan
Plan pays
pays up
up to
to $60
$60
Lined
Lined Trifocal
Trifocal Plan
Plan pays
pays 100%
100% Plan
Plan pays
pays up
up to
to $40
$40 Plan
Plan pays
pays 100%
100% Plan
Plan pays
pays up
up to
to $80
$80
Lenticular
Lenticular Plan
Plan pays
pays 100%
100% Plan
Plan pays
pays up
up to
to $50
$50 Plan
Plan pays
pays 100%
100% Plan
Plan pays
pays up
up to
to $125
$125
Standard
Standard Progressive
Progressive $65
$65 copay
copay Plan
Plan pays
pays up
up to
to $30
$30 No
No copay
copay Plan
Plan pays
pays up
up to
to $80
$80
Frames
Frames (1 every
every 24
24 months)
months) Plan
Plan pays
pays up
up to
to $100;
$100; plus
plus Plan
Plan pays
pays up
up to
to $40
$40 Plan pays
pays up
up to
to $100,
$100, plus
plus 20%
20% Plan
Plan pays
pays up
up to
to $45
$45
20%
20% off
off the
the balance
balance over
over $100.
$100. off the balance over
over $100.
$100.
$150 allowance on featured
frame brands or $70 allowance
at Costco/Walmart.
Contact Plan
Plan pays
pays 100%
100% for
for medically
Contact Lenses
Lenses Plan
Plan pays
pays 100%
100% for
for medically
medically Plan
Plan pays
pays up
up to
to $50
$50 for
for elective
elective medically Plan
Plan pays
pays up
up to
to $210
$210 for
for
EyeMed
EyeMed -- In In lieu
lieu of
of lenses.
lenses. necessary contact
contact lenses.
lenses. Plan
Plan contacts and
and upup to
to $40
$40 for
for necessary contact
contact lenses
lenses after
after medically necessary
necessary contact
contact
VSP deductible or plan pays up to
VSP -- In
In lieu
lieu of
of glasses.
glasses. pays up to $105 for elective contact lens fitting/follow-up lenses after deductible or up
Available $105 for elective contact lenses,
Available every
every 1212 months.
months. lenses; standard contact lens to $105 for elective contact
fitting covered in full. plus you’ll receive 15% off your lenses.
lenses.
contact
contact lens
lens exam.
exam.
Optional
Optional Features:
Features: Plan
Plan pays
pays 100%
100% for
for tint
tint and
and Tinted
Tinted lenses:
lenses: plan
plan pays
pays up
up to
to Plan
Plan pays
pays 100%
100% for
for Standard
Standard Not
Not covered
covered
(Tinted
(Tinted lenses,
lenses, scratch
scratch resistant,
resistant, scratch-resistant coating;
coating; you
you $5. Standard scratch
scratch resistant
resistant Progressive Lenses.
Lenses. VSP
VSP also
also
ultra-violet coatings,
coatings, retinal
retinal pay $15 to $65 for additional Plan
Plan pays
pays up
up to
to $5
$5 saves you 20-25% on non-
imaging,
imaging, polycarbonate,
polycarbonate, features.
features. covered lens enhancements
photochromatic lenses and with copays
with copays averaging
averaging $15-$70
$15-$70
standard
standard progressive
progressive lenses.)
lenses.) for
for standard
standard options.
options.
Laser
Laser Vision
Vision Discounts
Discounts on
on PRK
PRK or
or LASIK.
LASIK. Not
Not covered
covered Discounts
Discounts on
on PRK,
PRK, LASIK
LASIK and
and Not
Not covered
covered
Correction
Correction Please call
call (877)
(877) 5LASER6.
5LASER6. Custom LASIK surgery
surgery at
at con-
con-
tracted
tracted VSP
VSP centers;
centers; contact
contact
VSP directly for information.
Note:
Note: This
This information
information is is not
not a
a complete
complete description
description of
of benefits.
benefits. Contact
Contact thethe plan
plan for
for more
more information.
information. Limitations
Limitations and
and restrictions
restrictions may
may apply.
apply. IfIf there
there is
is any
any discrepancy
discrepancy
between
between this
this chart
chart and
and the the plan
plan documents,
documents, thethe plan
plan documents
documents shallshall govern.
govern. Copies
Copies ofof the
the plan
plan documents
documents are are on
on Àle
Àle with
with BeneÀts
BeneÀts Administration.
Administration.
1
1 Based
Based on
on applicable
applicable state
state laws,
laws, benefits
benefits may
may vary
vary by
by location.
location.
2
2 Coverage
Coverage with
with a
a participating
participating retail
retail chain
chain may
may bebe different.
different. Visit
Visit vsp.com
vsp.com for
for details.
details.
3
3 Copayment
3
Copayment of of $25
$25 will
will bebe deducted
deducted from
from any
any reimbursement
reimbursement amount
amount whenwhen services
services are
are received
received from
from aa non-VSP
non-VSP provider.
provider.
4
4 Contact
4
Contact lenses are in lieu of standard lenses and frames. If you select contact lenses,
lenses are in lieu of standard lenses and frames. If you select contact lenses, you
you are
are not
not eligible
eligible for
for standard
standard lenses
lenses and
and frames
frames for
for 12
12 and
and 24
24 months
months respectively,
respectively,
from your last date of service.
from your last date of service.
Life Insurance Reasonable Accommodations
Basic
Basic Life
Life Insurance
Insurance The District is committed to providing equal employment
The District is committed to providing equal employment
As
As an
an eligible
eligible District
District employee,
employee, you
you automatically
automatically receive
receive Basic
Basic Life
Life Insurance
Insurance coverage
coverage up up to
to opportunities for individuals with disabilities and does not
opportunities for individuals with disabilities and does not
$20,000.
$20,000. MetLife
MetLife underwrites
underwrites this
this life
life insurance
insurance coverage.
coverage. The
The District
District pays
pays the
the full
full cost
cost of
of your
your Basic
Basic Life
Life discriminate on the basis of a disability in the admission, access,
discriminate on the basis of a disability in the admission, access,
Insurance which provides a lump sum payment to your designated beneÀciary if you die while treatment or employment in its programs or activities. The District
treatment or employment in its programs or activities. The District
employed with the District. The District will pay the premiums for your Basic Life Insurance coverage has implemented the Stay at Work/Return to Work Program to
has implemented the Stay at Work/Return to Work Program to
for up to 12 months if you are on an approved unpaid illness or industrial injury leave. It is your assist injured and/or ill employees with gainful, productive and
assist injured and/or ill employees with gainful, productive and
responsibility to keep your beneÀciary designation up to date. rewarding employment. Participation in the program is
rewarding employment. Participation in the program is
mandatory for both the District and its employees.
Supplemental
Supplemental Life
Life Insurance
mandatory for both the District and its employees.
Insurance
You
You may may useuse the
the supplemental
supplemental life
life insurance
insurance plan
plan (paid
(paid for
for through
through your
your payroll
payroll deduction)
deduction) to
to obtain:
obtain: Also, the District maintains a Reasonable Accommodation
•• upup toto 5x
5x your
your salary
salary ($500,000
($500,000 max)
max) in
in additional
additional coverage
coverage for
for yourself;
Also, the District maintains a Reasonable Accommodation
yourself; Committee if an employee believes that a reasonable
•• life
life insurance
insurance for
for your
your eligible
eligible dependents
dependents (spouse/domestic
(spouse/domestic partner
partner and
and children);
children);
Committee if an employee believes that a reasonable
accommodation for a disability has not been provided at the
•• accident
accident death
death and
and dismemberment
dismemberment protection
protection for
for you
you and/or
and/or your
your eligible
eligible dependents.
dependents.
accommodation for a disability has not been provided at the
work site or that the interactive process to determine whether a
work site or that the interactive process to determine whether a
Filing
Filing a
a Claim
Claim reasonable accommodation is available has been insufficient. For
reasonable accommodation is available has been insufficient. For
If additional information about the Reasonable Accommodation
If you
you or
or an
an eligible
eligible dependent
dependent dies
dies while
while covered
covered under
under the
the life
life insurance
insurance plan(s),
plan(s), the
the designated
designated additional information about the Reasonable Accommodation
Committee, reasonable accommodations, the interactive process
beneÀciary should
should contact
contact the
the insurance
insurance company,
company, who
who will
will assist
assist with
with Àling
Àling a
a claim
claim for
for benefits
benefits Committee, reasonable accommodations, the interactive process
under or the Stay at Work/Return to Work Program, please contact
under the
the plan.
plan. or the Stay at Work/Return to Work Program, please contact
Integrated Disability Management at
For
For additional
additional information
information about
about the
the District’s
District’s Life
Life Insurance
Insurance program,
program, call
call MetLife
MetLife Employee
Employee Benefits
Benefits Integrated Disability Management at
at disabilitymanagement@lausd.net.
at (866)
(866) 492-6983.
492-6983. disabilitymanagement@lausd.net.Important Contact Information
Plan Name Address Web Address Phone
P.O. Box
P.O. Box 60007
60007
Anthem
Anthem Blue
Blue Cross
Cross Los Angeles,
Angeles, CA
CA 90060-0007
90060-0007 anthem.com/ca
anthem.com/ca (800)
(800) 700-3739
700-3739
Los
CVS Caremark
CVS Caremark (prescription
(prescription CVS Caremark
CVS Caremark Customer
Customer Care
Care
drug provider
drug provider for
for Anthem
Anthem Blue
Blue P.O. Box
P.O. Box 6590
6590 caremark.com
caremark.com (888) 752-7229
(888) 752-7229
Cross Plans
Cross Plans only)
only) Lees Summit,
Lees Summit, MO
MO 64064-6590
64064-6590
P.O. Box
P.O. Box 10348
10348
Health Net
Health Net HMO
HMO Van Nuys,
Nuys, CA
CA 91410-0348
91410-0348 healthnet.com/lausd
healthnet.com/lausd (800) 654-9821
(800) 654-9821
Van
Health Net
Net Seniority
Seniority Plus
Plus P.O.
P.O. Box
Box 10344
10344 healthnet.com/lausd
Enrollment
Enrollment Info
Info (800)
(800) 596-6565
596-6565
Health Van healthnet.com/lausd
Van Nuys, CA
Nuys, CA 91410-0344
91410-0344 After
After Enrollment (844)
Enrollment (844) 542-0102
542-0102
Kaiser
Kaiser Foundation
Foundation Health
Health Plans,
Plans, Inc.
Inc.
Kaiser
Kaiser Permanente
Permanente HMO
HMO and
and (800) 464-4000
(800) 464-4000
1950 Franklin St. kp.org
kp.org
Kaiser Senior
Kaiser Senior Advantage
Advantage Senior Advantage
Senior (877) 425-0717
Advantage (877) 425-0717
Oakland, CA
Oakland, CA 94612
94612
P.O. Box
P.O. Box 1810
1810
DeltaCare
DeltaCare®® USA
USA DHMO
DHMO deltadentalins.com/lausd (844)
(844) 697-0580
697-0580
Alpharetta, GA
Alpharetta, GA 30023
30023
United Concordia P.O.
P.O. Box
Box 69425
69425 unitedconcordia.com
unitedconcordia.com (844)
(844) 397-4176
397-4176
Dental PPO Harrisburg,
Harrisburg, PA
PA 17106-9425
17106-9425
Western
Western Dental
Dental Services
Services
Western
Western Dental
Dental DHMO
DHMO
Attn:
Attn: Customer Service
Customer Service
Centers Only
Centers Only and
and westerndentalbenefits.com
westerndentalbenefits.com (866) 901-4416
(866) 901-4416
530 South Main Street
Western
Western Dental Plan Plus
Dental Plan Plus Orange, CA 92868
4000 Luxottica
4000 Luxottica Place
Place Inquiries (866)
Inquiries (866) 723-0514
723-0514
EyeMed
EyeMed Vision
Vision Care
Care Mason, OH
OH 45040
45040 eyemed.com
Mason, LASIK -- (877)
LASIK (877) 5LASER6
5LASER6
VSP® P.O. Box 997100
VSP® Vision
Vision Care
Care Sacramento, CA
CA 95899-7100
95899-7100
vsp.com
vsp.com (800)
(800) 877-7195
877-7195
Sacramento,
ConnectYourCare Health care
P.O. BoxP.O. Box 622317
622337 (877)
(877) 292-4040
292-4040
Claims: connectyourcare.com
connectyourcare.com
FSA Plans Orlando, FLOrlando, FL 32862
32862-2337 (443)
(443) 681-4601
681-4602 (fax)
(Health fax)
Dependent Care P.O. Box 622337 (443) 681-4601 (Dependent fax)
Claims: Orlando, FL 32862
457(b) Savings Plan - P.O. Box 24747 (844) 525-2873
457(b) Savings Plan - Attn: LAUSD 457(b) Deferred Compensation Plan 457b.lausd.net
Voya Financial Jacksonville, FL 32241-4747
P.O. Box 389 (844)
(844) 525-2873
265-5838 (fax)
457b.lausd.net
Voya Financial Hartford, CT 06141 (844) 265-5838 (fax)
403(b) Savings Plan - Attn: 28
Participant Services
Ferry Rd. SE, (888) 796-3786
P.O. Box 4037, 403b.lausd.net (866) 741-0645 (fax)
TSA Consulting Group Fort Walton Beach, FL 32548
Fort Walton Beach, FL 32549-4037
MetLife Recordkeeping Center
MetLife Life Insurance P.O. Box
P.O. Box 14401
14401 metlife.com/mybenefits
metlife.com/mybenefits (866) 492-6983
(866) 492-6983
Lexington, KY
Lexington, KY 40512-4401
40512-4401
OTHER RESOURCES
Forms: P.O. Box 226101
WageWorks, LAUSD
WageWorks, LAUSD P.O. Box 226101
Dallas, TX 75222 wageworks.com
mybenefits.wageworks.com (888) 678-4881
COBRA/AB528 Administrator
COBRA/AB528 Administrator Dallas,P.O.
Payments: TXBox
75222
660212
Dallas, TX 75266
Social Security
Social Security Administration
Administration ssa.gov
ssa.gov (800) 772-1213
(800) 772-1213
Medicare
Medicare medicare.gov
medicare.gov (800) 633-4227
(800) 633-4227
Public Employees Retirement calpers.ca.gov (888) 225-7377
System
System (PERS)
(PERS)
State
State Teachers
Teachers Retirement
Retirement calstrs.com
System (STRS)
System (STRS) calstrs.com (800) 228-5453
LAUSD
LAUSD P.O. Box
P.O. Box 513307
513307 web: beneÀts.lausd.net (213) 241-4262
BeneÀts Los Angeles, CA 90051 beneÀts.lausd.net
BeneÀts Administration
Administration email: beneÀts@lausd.net (213) 241-4247 (fax)You can also read
