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For more information regarding Prescription Benefits.
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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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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04-2025 CVS Caremark Performance Drug List (Anthem Plans)
04-2025 PDL SOO ACSF.pdf
180.51 KB
(Last Modified on March 26, 2025)
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04 -2025 CVS Caremark Advanced Formulary (Anthem Plans)
04-2025 Advanced Control Specialty Formulary.pdf
137.47 KB
(Last Modified on March 26, 2025)
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01-2025 CVS Caremark Performance Drug List (Anthem Plans)
01-2025 PDL SOO ACSF.pdf
169.92 KB
(Last Modified on December 20, 2024)
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01-2025 CVS Caremark Advanced Formulary (Anthem Plans)
01-2025 Advanced Control Specialty Formulary.pdf
136.46 KB
(Last Modified on December 20, 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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2025 Health Net 3 Tier Drug List
hn-3-tier-drug-list.pdf
11.37 MB
(Last Modified Today at 9:25 AM)
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2024 Comprehensive Formulary - Health Net Seniority Plus
2024 comprehensive Formulary.pdf
4.17 MB
(Last Modified Today at 9:28 AM)
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Transparency Coverage
Kaiser
Health Net
Summary of Benefits and Coverage
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 Friday at 10:10 AM)
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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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2025 Anthem Medicare PPO - Retirees
2025_LAUSD_LPPO_SOB.pdf
401.91 KB
(Last Modified on September 26, 2024)
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2025 Anthem Blue Cross EPO - Retirees, CA Residents
2025 Anthem Blue Cross EPO - Retirees CA Residents.pdf
686.42 KB
(Last Modified on November 22, 2024)
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2025 Anthem Blue Cross EPO - Retirees Non-CA Residents
2025 Anthem Blue Cross EPO - Retirees Non-CA Residents.pdf
686.87 KB
(Last Modified on November 22, 2024)
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2025 Health Net HMO - Actives & Early Retirees
2025 SBC HealthNet Actives n Pre-Medicare Retirees.pdf
703.11 KB
(Last Modified on October 1, 2024)
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2025 Health Net HMO - Seniority Plus - Retirees
Seniority Plus Medicare Advantage Summary of Benefits.pdf
1.16 MB
(Last Modified Today at 8:58 AM)
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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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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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2025 EyeMed
LAUSD EyeMed Benefit Summary.pdf
2.76 MB
(Last Modified on September 16, 2024)
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2025 VSP
LAUSD_ MBS 2025.pdf
561.42 KB
(Last Modified on September 16, 2024)
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Evidence of Coverage
EOC's are updated as they become available.
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
(Last Modified on November 22, 2024)
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2025 Aetna Dental PPO - Most US States
2025 LAUSD Aetna Dental PPO Plan.pdf
509.65 KB
(Last Modified on September 26, 2024)
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2025 Aetna Dental PPO - LA and TX
2025 LAUSD Aetna Dental Passive PPO Plan for LA and TX.pdf
509.66 KB
(Last Modified on September 26, 2024)
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2025 Western Dental
LAUSD EOC_2025.pdf
853.45 KB
(Last Modified on September 16, 2024)
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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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2024 VSP
Evidence_Certificate_of_Coverage_January_1_2024.pdf
306.04 KB
(Last Modified on September 16, 2024)
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2025 EyeMed
Los Angeles Unified School District - 2020 Policy Package REVISED 1-1-25 VC146.pdf
5.73 MB
(Last Modified about 3 hours ago)
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