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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)
Comments (-1)
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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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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10-2024 CVS Caremark Performance Drug List (Anthem Plans)
10-2024 PDL SOO ACSF.pdf
179.31 KB
(Last Modified on September 30, 2024)
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10-2024 CVS Caremark Advanced Formulary (Anthem Plans)
10-2024 Advanced Control Specialty Formulary.pdf
143.41 KB
(Last Modified on September 30, 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 Kaiser Hawaii HMO SBC - Early Retirees
HI_SBC 34704 LAUSD Retiree 2025.pdf
689.42 KB
(Last Modified Yesterday at 10:44 AM)
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2025 Kaiser HMO SBC - Early Retirees, Northern California
2025 SBC_LAUSD 605554_Retirees.pdf
1.07 MB
(Last Modified Yesterday at 10:43 AM)
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2025 Kaiser HMO SBC - Actives, Southern California
2025 SBC_LAUSD 100990.pdf
1.07 MB
(Last Modified Yesterday at 10:41 AM)
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2025 Kaiser HMO SBC - Actives, Northern California
2025 SBC_LAUSD 605553.pdf
1.07 MB
(Last Modified Yesterday at 10:42 AM)
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2025 Kaiser HMO SBC - Early Retirees, Southern California
2025 SBC_LAUSD 230837_Retirees.pdf
1.07 MB
(Last Modified Yesterday at 10:42 AM)
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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 Select HMO - Retirees
2025 Anthem Blue Cross Select HMO - Retirees.pdf
696.43 KB
(Last Modified on Friday at 10:59 AM)
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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 Friday at 11:00 AM)
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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 Friday at 11:01 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, Non-CA Residents
2025 Anthem Blue Cross EPO - Actives Non-CA Residents.pdf
644.11 KB
(Last Modified on Friday at 11:01 AM)
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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 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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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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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 Aetna Dental
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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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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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.
2025 Anthem Medicare Preferred (PPO) - Retiree
2025LAUSDLPPOEOC.pdf
954.54 KB
(Last Modified on September 26, 2024)
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2024 Anthem Medicare Preferred (PPO) - Retiree
2024 Anthem Medicare Preferred PPO.pdf
3.19 MB
(Last Modified on April 29, 2024)
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2024 Anthem Blue Cross EPO - Active CA
2024 Anthem Blue Cross EPO - Active CA.pdf
1.35 MB
(Last Modified on Friday at 10:51 AM)
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2024 Anthem Blue Cross EPO - Active Non-CA
2024 Anthem Blue Cross EPO - Active Non-CA.pdf
1.45 MB
(Last Modified on Friday at 10:51 AM)
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2024 Anthem Blue Cross EPO - Retiree CA
2024 Anthem Blue Cross EPO - Retiree CA.pdf
1.45 MB
(Last Modified on Friday at 10:51 AM)
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2024 Anthem Blue Cross EPO - Retiree Non-CA
2024 Anthem Blue Cross EPO - Retiree Non-CA.pdf
1.43 MB
(Last Modified on Friday at 10:52 AM)
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2024 Anthem Blue Cross HMO - Active
2024 Anthem Blue Cross HMO - Active.pdf
1.42 MB
(Last Modified on Friday at 10:52 AM)
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2024 Anthem Blue Cross HMO - Retiree
2024 Anthem Blue Cross HMO - Retiree.pdf
1.58 MB
(Last Modified on Friday at 10:53 AM)
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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)
Comments (-1)
2025 Kaiser HMO EOC - Active Southern California
LAUSD_100990_002_10_v126.pdf
3.29 MB
(Last Modified on Friday at 11:20 AM)
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2025 Kaiser HMO EOC - Active Northern California
LAUSD_605553_001_8_v23.pdf
3.29 MB
(Last Modified on Friday at 11:21 AM)
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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 Friday at 11:23 AM)
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