Health Plans: Monthly Rate 75% Married Rate Anthem Blue Cross 80% Plan 10A $ 1,021.00

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1 Certificated Administration Employees Eligibile for Health Coverage HEALTH INSURANCE RATE SHEET Plan Year 10/1/ /30/2018 Health Plans: Monthly Rate 75% Married Rate Anthem Blue Cross 100% Plan 1A $ 1, $ 1, Anthem Blue Cross 90% Plan 4A $ 1, $ 1, Anthem Blue Cross 80% Plan 6A $ 1, $ 1, Anthem Blue Cross 80% Plan 10A $ 1, $ Anthem Blue Cross 90% Plan Wellness $ 1, $ 1, Anthem Blue Cross HDHP1 $ $ Anthem Blue Cross Bronze $ $ Blue Shield HMO Plan 1 $ 1, N/A Kaiser North 1 $ 1, N/A Kaiser North 5 $ 1, N/A Kaiser North 6 $ 1, N/A Kaiser North 8 $ 1, N/A Kaiser North Wellness $ 1, N/A Dental Plans: Monthly Rate Delta Dental Standard Incentive $ $1,500 Annual Maximum, 4 cleanings per year, 100% diagnostic/preventive Delta DPO-100 $ $1,500 Annual Maximum, 4 cleanings per year, Ortho 100% children only, $3.000 Lifetime Max Vision Plan: Monthly Rate Vision $ exam for each person every 12 months, 1 set of frames and lenses every 12 months, $10 deductible Life Insurance Plan: Employee Portion Employer Portion Life Insurance $130,000 $ 3.42 $ Prepared 08/0/2017

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3 MANTECA UNIFIED SCHOOL DISTRICT INSURANCE WORKSHEET Plan Year 10/1/2017-9/30/2018 CERTIFICATED ADMINISTRATOR MEDICAL PLANS: CALIFORNIA S VALUED TRUST Attached to this worksheet is a list of medical plans offered by Manteca Unified School District as prepared by California s Valued Trust. Refer to the Monthly Health Plan Rates sheet to determine the cost of the monthly medical, dental, vision premiums and life insurance. Your personal choices Medical Plan includes prescriptions +$ Dental Plan +$ Vision Plan +$ Life Insurance +$ 3.42 Total =$ Monthly Insurance premium $ To determine your out-of-pocket cost, add the cost of your medical premium, dental premium, vision premium and life insurance premium, and subtract the district cap. The amount over the district cap is your out of pocket cost. This form is for your personal use and should be retained for your personal records.

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5 150% Rule Enhancement May 21, 2012 Currently, California s Valued Trust (CVT) offers a special reduced rate for eligible individuals called the 150% Rule. The rule is applied to married couples and qualified domestic partners who are both enrolled in a CVT PPO Plan and whose premiums are based on a composite rate structure. The current policy allows participants in the same district to pay a reduced rate of 150% of the two combined premiums based on the highest plan. This rule does not apply to two or three party rate structure or to an HMO, dental, vision, life insurance or an employee assistance program (EAP). Beginning October 1, 2012, the 150% Rule will be enhanced so that married couples and qualified domestic partners premiums will be 75% of each individual plan. This can result in savings for participants and districts if one of the premiums is currently lower than the other. In addition, the improved 150% rule will extend to married couples and qualified domestic partners who have CVT coverage and work in different districts. Plan Change Details: Will apply to married/domestic partner couples employed by the same or different CVT districts Individuals can be on different plans and: o Both individuals must be enrolled in a PPO plan o Both individuals must cover each other as a dependent o Both individuals must be on a composite rate structure CVT will calculate 75% of each individual plan This rule does not apply to two or three party rate structure or to an HMO, dental, vision, life insurance or an employee assistance program (EAP). No retroactive rate changes will be made CVT will attempt to identify all couples that meet the above criteria. For more information contact CVT Member Services at (800) Thank you for your continued participation in the Trust. 150% Flyer - KG

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7 MyCVT Online Member Open Enrollment Quick steps to apply for insurance coverage MyCVT is a web-based site where you can enroll as a member of California s Valued Trust (CVT), choose a plan from several options that have been selected by your district or unit and make changes to your plan such as adding dependents or a change of address. Before you can enroll online, you must first create your account. Getting started 1. To access the site directly from your browser, type: 2. You may also access the portal from Click on the MyCVT logo in the upper, righthand corner of the page to open up the main portal page. 3. You will need the following information to create your account: Unique address (you cannot use a shared or group ) Social Security number (do not use dashes in the form) Your district name and classification Password (six-digits minimum) Date of Birth Creating your account 1. From the MyCVT portal page, select Create new account. Complete the requested information and submit. 2. Verify your date of birth. 3. A registration link will be sent to the unique you submitted. 4. Click on the link in the to complete the registration process. Existing member open enrollment 1. Login to your MyCVT account at 2. A message box (example below) will appear during open enrollment letting you know what the open enrollment timeframe is as well as the numbers of days left for open enrollment. Click on the View or modify option in the open enrollment notification message if you wish to make any changes to your current coverage. 3. If you wish to keep your current coverage, click the Keep current coverage option.

8 Keep current coverage 1. If you selected to keep your current coverage, no other steps need to be taken. View or modify your coverage and dependent information 1. When viewing or modifying your current coverage, you will first verify your personal information,, then click Next to continue to your dependent page. 2. You can add or remove dependents. Add dependents by clicking on the blue Add Dependent button. Click the Terminate button next to any dependent you wish to remove form coverage. 3. If adding a dependent, enter all the required dependent information and click Save after each dependent has been added. 4. If you need to change any information, the forms can be opened again and edited by clicking the blue link of the dependent s name you want to update on the Dependent Information page. Always save every edit. 5. Click on I m ready for plan selection to view or modify your coverage 6. The next step is to select your plans from the plan choice page. The plan selection will include those bargained benefits available to your unit. 7. Click Show Plans next to the coverage types (Health, Dental, Vision, Life) to see a grid of drop down menus that contain the plans available to you. You can compare up to four different plans by clicking the drop down menus and selecting the plans you want to compare. Once you have decided which plan you are going to choose, click the blue Select this plan button above the drop down menu to select that plan for that coverage. If you are unsure about which plans to choose, consult your district office for a summary of plans and the options/costs. You can also call CVT Member Services for assistance. 8. If your district does not offer plans for a particular coverage type, the words No plans available will appear next to that coverage type. 9. Once you have completed selecting your plans for all of the available coverage types, click I m Ready to Review My Application to continue. Submit your completed enrollment 1. If you have completed all the information and are ready to submit your enrollment, click the I m Ready to Review My Application button located in the lower left side of the Plans page. 2. The Review page gives a summary of the plans selected and displays any dependents you have added. Click on the blue Submit button to submit your application. 3. Once your application has been submitted, any documents that are required will be listed. If you have the documents in a digital version available to upload, use the Browse and Upload buttons to upload the documents. When the document has been successfully uploaded, that document section will appear as green. 4. If you do not have the documents available at that time, you can login at a later time to upload them. There will be a count of documents required in the submitted enrollment section when you login. 5. You can print your enrollment form for your records by clicking the Print your enrollment button located on the bottom portion of the page. 6. Your submitted application and documents will be reviewed by your district and then submitted to CVT for review and approval. Questions If you have any questions about how to create your account, help is only a phone call away. Contact your district office or CVT Member Services at (800)

9 CVT Kaiser Health Plans Manteca Unified SD - CERTIFICATED ADMIN October 1, September 30, 2018 BENEFIT Kaiser 1 Kaiser 5 Kaiser 6 Kaiser 8 Kaiser Wellness Calendar Year Deductible $0 $0 $0 Individual: $1,000 Family: $2,000 Coinsurance Paid at 100%* Paid at 100%* Paid at 100%* Paid at 100%* Paid at 100%* Calendar Year Out of Pocket Maximum (includes medical/pharmacy deductible, coinsurance, and copays) Doctor Visits (Primary Care Physician) Doctor Visits (Specialty Physician) Preventive Care / Immunizations Outpatient Diagnostic Test / Imaging Radiation Therapy, Chemotherapy Individual: $1,500 (2) Individual: $1,500 (2) Individual: $1,500 (2) Individual: $3,000 (2) Individual: $1,500 (2) Family: $3,000 (2) Family: $3,000 (2) Family: $3,000 (2) Family: $6,000 (2) Family: $3,000 (2) $10 Copay $35 Copay $25 Copay $10 Copay $35 Copay $25 Copay Paid at 100%* Paid at 100%* Paid at 100%* Paid at 100%* Paid at 100%* Paid at 100%* Radiation Therapy: Paid at 100%* Chemotherapy: $10 Copay Radiation Therapy: Paid at 100%* Chemotherapy:$35 Copay Radiation Therapy: Paid at 100%* Chemotherapy:$25 Copay $20 Copay No deductible $20 Copay No Deductible Paid at 100%* No Deductible $10 Copay No Deductible Radiation Therapy: Paid at 100%*, after deductible is met Chemotherapy:Paid at 100%*, No deductible $0 $20 Copay $40 Copay Paid at 100%* $10 Copay Radiation Therapy: Paid at 100%* Chemotherapy: $40 Copay Durable Medical Equipment Paid at 100%* Paid at 100%* Paid at 100%* Paid at 80%*, No deductible Paid at 100%* Ambulance - Ground / Air Paid at 100%* If Medically Necessary Paid at 100%* If Medically Necessary Physical Therapy $10 Copay $35 Copay $25 Copay $50 Per Trip If Medically Necessary $150 Per Trip If Medically Necessary No deductible $20 Copay No Deductible If Medically Necessary $20 Copay Chiropractic Not Covered Not Covered Not Covered Not Covered Not Covered Acupuncture $10 Copay Referral by Plan Physician $35 Copay Referral by Plan Physician Outpatient Surgery $10 Copay $35 Copay $25 Copay Hospital Inpatient Paid at 100%* Paid at 100%* $250 Copay Hospital Emergency Room Copay waived if admitted as in-patient Copay waived if admitted as in-patient $25 Copay Referral by Plan Physician Copay waived if admitted as in-patient $20 Copay, No Deductible Referral by Plan Physician Paid at 80%* after deductible is met Paid at 80%* after deductible is met Paid at 80%* after deductible is met $40 Copay Referral by Plan Physician $500 Per Procedure Urgent Care $10 Copay $35 Copay $25 Copay $20 Copay $20 Copay Home Health Care Paid at 100%* (Limits) Paid at 100%* (Limits) Paid at 100%* (Limits) Paid at 100%* No Deductible (Limits) $500 Copay Per Admission Unlimited days, semi-private room (Copay waived if admitted as in-patient) Paid at 100%* (Limits)

10 Telehealth BENEFIT Kaiser 1 Kaiser 5 Kaiser 6 Kaiser 8 Kaiser Wellness Employee Assistance Program (EAP) through Beacon Health Options Prescription Drugs For after-hours advice, call Paid at 100% - Visit www. achievesolutions.net/cvt or call to access benefit (3) Retail $5 Generic $10 Brand (Up to 30 Day $10 Generic $20 Brand (31-60 Day $15 Generic $30 Brand ( Day Mail Order $5 Generic $10 Brand (30 Day $10 Generic $20 Brand ( Day For after-hours advice, call Paid at 100% - Visit www. achievesolutions.net/cvt or call to access benefit (3) Retail $10 Generic $20 Brand (Up to 30 Day $20 Generic $40 Brand (31-60 Day $30 Generic $60 Brand ( Day Mail Order $10 Generic $20 Brand (30 Day $20 Generic $40 Brand ( Day For after-hours advice, call Paid at 100% - Visit www. achievesolutions.net/cvt or call to access benefit (3) Retail $10 Generic $20 Brand (Up to 30 Day $20 Generic $40 Brand (31-60 Day $30 Generic $60 Brand ( Day Mail Order $10 Generic $20 Brand (30 Day $20 Generic $40 Brand ( Day For after-hours advice, call Paid at 100% - Visit www. achievesolutions.net/cvt or call to access benefit (3) Retail $10 Generic $30 Brand (Up to 30 Day $20 Generic $60 Brand (31-60 Day $30 Generic $90 Brand ( Day Mail Order $10 Generic $30 Brand (30 Day $20 Generic $60 Brand ( Day For after-hours advice, call Paid at 100% - Visit www. achievesolutions.net/cvt or call to access benefit (3) Retail $10 Generic $25 Brand (30-day supply)$20 Generic $50 Brand (31-60 day supply) $30 Generic $75 Brand ( day supply) Mail Order $10 Generic $25 Brand (up to 30 day supply) $20 Generic $50 Brand ( day supply) Kaiser Permanente Plans: * For Covered Expenses Only (2) The pharmacy copayments will not apply to out of pocket maximums for retirees enrolled in Medicare NOTES: Copays for Infertility: Plans 1 - $10 Copay; Plan 2 - $15 Copay; Plan 3-50% Copay; Plan 4 - $30 Copay;Plan 5 - $35 Copay; Plans 6-8 & Wellness - 50% Copay. Copays for Allergy Injections: Plans No Charge; Plans 6-7 & Wellness - $5 Per Visit; Plan 8 - No Charge. Plan 6 - $175 allowance for lenses, frames & contacts every 24 months (3) EAP - Up to 6 counseling sessions per covered member, per benefit year (max 2 episodes/courses of treatment). This summary is for comparison purposes only. Please refer to the actual benefit booklet for complete benefits at

11 CVT PPO Health Plans Manteca Unified SD - CERTIFICATED ADMIN October 1, September 30, 2018 BENEFIT PPO 1A PPO 4A PPO 6A PPO 10A Calendar Year Deductible $0 Individual: $100 Family: $300 Individual: $250 Family: $750 Individual: $2,000 Family: $6,000 Coinsurance Paid at 100%* Paid at 90%* after deductible is met Paid at 80%* after deductible is met Paid at 80%* after deductible is met Calendar Year Out of Pocket Maximum (includes medical/pharmacy deductible, coinsurance, and copays) Doctor Visits (Primary Care Physician) Doctor Visits (Specialty Physician) Individual: $1,250 (2) Individual: $1,250 (2) Individual: $2,000 (2) Individual: $6,350 (2) Family: $3,750 (2) Family: $3,750 (2) Family: $6,000 (2) Family: $12,700 (2) $10 Copay $20 Copay $20 Copay Paid at 80%* after deductible is met $10 Copay $20 Copay $20 Copay Paid at 80%* after deductible is met Preventive Care / Immunizations Paid at 100%* Paid at 100%* Paid at 100%* Paid at 100%* Outpatient Diagnostic Test / Imaging Paid at 100%* Paid at 90%* after deductible is met Paid at 80%* after deductible is met Paid at 80%* after deductible is met Radiation Therapy, Chemotherapy Paid at 100%* Paid at 90%* after deductible is met Paid at 80%* after deductible is met Paid at 80%* after deductible is met Durable Medical Equipment Paid at 100%* Paid at 90%* after deductible is met Paid at 80%* after deductible is met Paid at 80%* after deductible is met Ambulance - Ground / Air Paid at 100%* of covered charges Paid at 90%* after deductible is met Paid at 80%* after deductible is met Paid at 80%* after deductible is met Paid at 100%* (1) Paid at 90%* (1) after deductible is met Paid at 80%* (1) after deductible is met Paid at 80%* (1) after deductible is met Physical Therapy (Copay, if applicable.) (Copay, if applicable.) (Copay, if applicable.) (Copay, if applicable.) Chiropractic Acupuncture Paid at 100%* (1) (Copay, if applicable.) Paid at 100%* (Copay, if applicable) Maximum of 12 visits per calendar year Paid at 90%* (1) after deductible is met (Copay, if applicable.) Paid at 90%* after deductible is met (Copay, if applicable) Maximum of 12 visits per calendar year Paid at 80%* (1) after deductible is met (Copay, if applicable.) Paid at 80%* after deductible is met (Copay, if applicable) Maximum of 12 visits per calendar year Paid at 80%* (1) after deductible is met (Copay, if applicable.) Paid at 80%* after deductible is met (Copay, if applicable) Maximum of 12 visits per calendar year Outpatient Surgery Paid at 100%* Paid at 90%* after deductible is met Paid at 80%* after deductible is met Paid at 80%* after deductible is met Hospital Inpatient Hospital Emergency Room Paid at 100%* Unlimited days, Semi-private room (Copay waived if admitted as inpatient) Paid at 100%* Paid at 90%* after deductible is met; Unlimited days, Semi-private room (Copay waived if admitted as inpatient) Paid at 90%* after deductible is met Paid at 80%* after deductible is met; Unlimited days, Semi-private room (Copay waived if admitted as inpatient) Paid at 80%* after deductible is met Paid at 80%* after deductible is met; Unlimited days, Semi-private room (Copay waived if admitted as inpatient) Paid at 80%* after deductible is met Urgent Care $10 Copay $20 Copay $20 Copay Paid at 80%* after deductible is met Home Health Care Telehealth Employee Assistance Program (EAP) through Beacon Health Options Paid at 100%* Limited to 100 visits per calendar year MDLIVE - $5 Copay Call or visit mdlive. com/cvt for non-emergency medical conditions. Paid at 100% - Visit www. achievesolutions.net/cvt or call to access benefit (3) Paid at 90%* after deductible is met; Limited to 100 visits per calendar year MDLIVE - $5 Copay Call or visit mdlive. com/cvt for non-emergency medical conditions. Paid at 100% - Visit www. achievesolutions.net/cvt or call to access benefit (3) Paid at 80%* after deductible is met Limited to 100 visits per calendar year MDLIVE - $5 Copay Call or visit mdlive. com/cvt for non-emergency medical conditions. Paid at 100% - Visit www. achievesolutions.net/cvt or call to access benefit (3) Paid at 80%* after deductible is met; Limited to 100 visits per calendar year MDLIVE - $5 Copay Call or visit mdlive. com/cvt for non-emergency medical conditions. Paid at 100% - Visit www. achievesolutions.net/cvt or call to access benefit (3)

12 BENEFIT PPO 1A PPO 4A PPO 6A PPO 10A Retail (4) Mail Order (4) Retail (4) Mail Order (4) Retail (4) Mail Order (4) Retail (4) Mail Order (4) $5 Generic $10 Generic $5 Generic $10 Generic $5 Generic $10 Generic $5 Generic $10 Generic Prescription Drugs $22 Brand $44 Brand $22 Brand $44 Brand $22 Brand $44 Brand $22 Brand $44 Brand (30-Day (90-Day (30-Day (90-Day (30-Day (90-Day (30-Day (90-Day PPO Plans: * For Covered Expenses Only: When using Non-PPO & Other Health Care Providers, members are responsible for any difference between the covered expense and actual charges, as well as any deductible & percentage copay. All percentages are based on payments to preferred hospitals, physicians and other network providers. (1) Non-Par Providers limited to a combined maximum of 13 visits per year. (2) The pharmacy copayments will not apply to out of pocket maximums for retirees enrolled in Medicare. (3) EAP - Up to 6 counseling sessions per covered member, per benefit year (max 2 episodes/courses of treatment). This summary is for comparison purposes only. Please refer to the actual benefit booklet for complete benefits at PPO Plans 1 through 10: (4) Copays for certain specialty medications may be set to available manufacturer-funded copay assistance for prescription plans A, B, C (includes Wellness), D and ValuRx

13 CVT Blue Shield HMO Plans Manteca Unified SD - CERTIFICATED, CERTIFICATED ADMIN, BOARD MEMBERS, CLASSIFIED ADMIN, SUPERINTENDENT, DEPUTY SUPT. October 1, September 30, 2018 BENEFIT HMO PLAN 1 Calendar Year Deductible $0 Coinsurance Paid at 100%* Calendar Year Out of Pocket Maximum (includes medical/pharmacy deductible, coinsurance, and copays) Doctor Visits (Primary Care Physician) Doctor Visits (Specialty Physician) Individual: $1,000 Family: $2,000 $10 Copay Preventive Care / Immunizations Paid at 100%* Outpatient Diagnostic Test / Imaging Paid at 100%* Radiation Therapy, Chemotherapy $30 Copay Access+ Specialist option (5) Doctor Visit - $10 Copay Outpatient - Paid in full Durable Medical Equipment Paid at 100%* Ambulance - Ground / Air Physical Therapy Chiropractic Acupuncture $10 Per Visit $10 copay limited up to 30 visits per calendar year (Prior authorization not required) (4) Not Covered Outpatient Surgery Paid at 100%* Hospital Inpatient Hospital Emergency Room Urgent Care Home Health Care Telehealth Employee Assistance Program (EAP) through Beacon Health Options Physician paid at 100%* Inpatient facility services - Paid at 100%* Skilled Nursing - Paid at 100%* Semi-private room (Copay waived if admitted as in-patient) $10 Copay $10 Per Visit (limited to 100 visits per calendar year) $5 Copay For non-emergency care, call Teledoc 24/7 at (800) Paid at 100% - Visit or call to access benefit (3)

14 BENEFIT HMO PLAN 1 Prescription Drugs Retail $5 Tier 1 $10 Tier 2 $25 Tier 3 Mail Order $10 Tier 1 $20 Tier 2 $50 Tier 3 Tier 4 Paid at 80%* (Up to $100 copayment maximum per prescription) 30-Day Supply Blue Shield HMO Plans: * For Covered Expenses Only (3) EAP - Up to 6 counseling sessions per covered member, per benefit year (max 2 episodes/courses of treatment). (4) Chiropractic benefits are offered through ASH. (5) To use the Access+ Specialist option, a member must select a primary care personal physician who is affiliated with a medical group or IPA that is an Access+ provider group that offers the Access+ Specialist feature. This summary is for comparison purposes only. Please refer to the actual benefit booklet for complete benefits at

15 Calendar Year Deductible CVT PPO Health Plans Manteca Unified SD - CERTIFICATED ADMIN October 1, September 30, 2018 BENEFIT PPO Wellness HDHP 1 PPO Bronze Individual: $500 Family: $1,000 Individual: $1,300 Family: $3,000 (No individual limit applies to family) Individual: $5,000 Family: $10,000 Coinsurance Paid at 90%* after deductible is met Paid at 80%* after deductible is met Paid at 70%* after deductible is met Individual: $4,250 (2) Calendar Year Out of Pocket Maximum (includes Individual: $1,750 (2) Family: $10,100 (2) Individual: $6,350 (2) medical/pharmacy deductible, coinsurance, and Family: $5,250 (2) Family = Employee with one or more covered Family: $12,700 (2) copays) dependents. No one individual will pay more than $6,850. Doctor Visits (Primary Care Physician) Doctor Visits (Specialty Physician) $20 Copay Paid at 80%* after deductible is met First 3 visits covered in full after $60 Copay per visit; Remaining visits - Paid at 70%* after deductible is met $40 Copay Paid at 80%* after deductible is met Subject to deductible then $70 copay Preventive Care / Immunizations Paid at 100%* Paid at 100%* Paid at 100%* Outpatient Diagnostic Test / Imaging Paid at 90%* after deductible is met Paid at 80%* after deductible is met Paid at 70%* after deductible is met Radiation Therapy, Chemotherapy Paid at 90%* after deductible is met Paid at 80%* after deductible is met Paid at 70%* after deductible is met Durable Medical Equipment Paid at 90%* after deductible is met Paid at 80%* after deductible is met Paid at 70%* after deductible is met Ambulance - Ground / Air Paid at 90%* after deductible is met Paid at 80%* after deductible is met Paid at 70%* after deductible is met Physical Therapy Chiropractic Acupuncture Paid at 90%* (1) after deductible is met (Copay, if applicable.) Paid at 90%* (1) after deductible is met (Copay, if applicable.) Paid at 90%* after deductible is met (Copay, if applicable) Maximum of 12 visits per calendar year Paid at 80%* (1) after deductible is met Paid at 80%* (1) after deductible is met Paid at 80%* after deductible is met. Maximum of 12 visits per calendar year Paid at 70%* (1) after deductible is met Paid at 70%* (1) after deductible is met Paid at 70%* after deductible is met Maximum of 12 visits per calendar year Outpatient Surgery Paid at 90%* after deductible is met Paid at 80%* after deductible is met Paid at 70%* after deductible is met Hospital Inpatient Hospital Emergency Room Paid at 90%* after deductible is met; Unlimited days, Semi-private room (Copay waived if admitted as inpatient) Paid at 90%* after deductible is met Paid at 80%* after deductible is met; Unlimited days, Semi-private room Paid at 80%* after deductible is met Paid at 70%* after deductible is met; Unlimited days, Semi-private room Subject to Deductible, then $250 Copay (copay waived if admitted as in-patient) Urgent Care $20 Copay Paid at 80%* after deductible is met Subject to deductible, then $120 Copay Home Health Care Telehealth Paid at 90%* after deductible is met; Limited to 100 visits per calendar year MDLIVE - $5 Copay Call or visit mdlive.com/cvt for non-emergency medical conditions. Paid at 80%* after deductible is met; Limited to 100 visits per calendar year MDLIVE - Paid at 80%* after deductible is met Call or visit mdlive.com/cvt for non-emergency medical conditions. Paid at 70%* after deductible is met; Limited to 100 visits per calendar year MDLIVE - $5 Copay Call or visit mdlive.com/cvt for non-emergency medical conditions.

16 BENEFIT PPO Wellness HDHP 1 PPO Bronze Employee Assistance Program (EAP) through Beacon Health Options Prescription Drugs Paid at 100% - Visit net/cvt or call to access benefit (3) Retail (4) $7 Generic $25 Pref $40 Non-Pref (30-Day Mail Order (4) $15 Generic $60 Pref $90 Non-Pref (90-Day Paid at 100% - Visit net/cvt or call to access benefit (3) Paid at 80%* after deductible is Paid at 100% - Visit net/cvt or call to access benefit (3) Retail Subject to deductible, then $25 Generic Copay $50 Brand Copay (30-Day Mail Order Subject to deductible, then $50 Generic Copay $100 Brand Copay (90-Day PPO Plans: * For Covered Expenses Only: When using Non-PPO & Other Health Care Providers, members are responsible for any difference between the covered expense and actual charges, as well as any deductible & percentage copay. All percentages are based on payments to preferred hospitals, physicians and other network providers. (1) Non-Par Providers limited to a combined maximum of 13 visits per year. (2) The pharmacy copayments will not apply to out of pocket maximums for retirees enrolled in Medicare. (3) EAP - Up to 6 counseling sessions per covered member, per benefit year (max 2 episodes/courses of treatment). This summary is for comparison purposes only. Please refer to the actual benefit booklet for complete benefits at PPO Wellness Plan: (4) Copays for certain specialty medications may be set to available manufacturer-funded copay assistance for prescription plans A, B, C (includes Wellness), D and ValuRx

17 Manteca Unified School District Certificated Administrative Delta Dental PPO Incentive Plan Summary of Benefits Effective October 1, 2017 to September 30, 2018 Benefits and Covered Services* Calendar Year Deductible Calendar Year Maximum Benefit Diagnostic & Preventive Services Oral Examinations: 2 Annual Cleanings: 4 X rays Basic Services Fillings Posterior Composite Restorations Sealants PPO Network ** None $1,700 Paid at: 100% * Paid at: 70% 100% * Premier Network and Out of Network ** Paid at: None $1,500 Paid at: 100% * 70% 100% * Periodontics (gum treatment) Covered Under Basic Services Endodontics (root canals) Paid at: Paid at: 70% 100% * 70% 100% * Paid at: Paid at: 70% 100% * 70% 100% * Oral Surgery (extraction) Covered Under Basic Services Major Services Paid at: 70% 100% * Paid at: 70% 100% * Crowns, Inlays, Onlays & Cast Restorations Paid at: 70% 100% * Paid at: 70% 100% * Prosthodontics Bridges Dentures Implants Paid at: 50% * Paid at: 50% * Paid at: 100% * Paid at: 100% * Dental Accident Benefits ($1,000 maximum per enrollee ($1,000 maximum per enrollee each calendar year) each calendar year) * This summary is for comparison purposes only. The Evidence of Coverage should be consulted for a detailed description of the covered benefits and is available at ** See back for additional details 520 E. Herndon Avenue Fresno, CA P F CVT 9870 cvtrust.org

18 What are my Delta Dental Network options? The Delta Dental PPO plan allows you the option to visit any licensed dentist. You will usually save more on your outof pocket costs when you visit a Delta Dental PPO dentist. The Delta Dental Premier network also provides costsaving features and is the next best option when you can t find a PPO dentist. Non Delta Dental (Out of Network) dentists have no fee agreements with Delta Dental, so you will usually have the highest out of pocket costs when you visit a non Delta Dental dentist. You are responsible for the difference between what Delta Dental pays and the dentist s fee. How do I find a Delta Dental dentist? To locate a Delta Dental dentist near you, check the dentist directory on the Delta Dental website (deltadentalins.com), which also provides a map to the dental office. Or, to hear or receive a faxed listing of dentists in your area, call Follow the automated instructions to search for a dentist. How does my Delta Dental incentive plan work? Your dental benefit incentive plan is designed to encourage regular visits to the dentist to keep your teeth and gums healthy. Here is an example of how an incentive plan works. (This is the most common incentive plan. Check your benefits information for details of your particular incentive plan.) What are my online resources? The full Delta Dental website is a one stop shop for plan and oral health information. Also available in Spanish: es.deltadentalins.com. Create a free Online Services account at deltadentalins.com to: Locate a Delta Dental dentist Check benefits, eligibility, and claim status Opt for paperless statements View or print your ID card Check average dental costs in your area Check out Your Dental Plan Support Guide for money saving tips and treatment information. And, don t miss mysmileway.com a great resource for oral health related tools and tips. Mobile? Get the information you need on the go. Bookmark or add a shortcut to the mobile site to return in just one tap from your phone. Download the free, convenient smartphone Delta Dental app from the App Store or Google Play. 520 E. Herndon Avenue Fresno, CA P F CVT 9870 cvtrust.org

19 Manteca Unified School District Certificated Administrative Delta Dental PPO 100 Plan Summary of Benefits October 1, 2017 through September 30, 2018 Benefits and Covered Services* PPO Network ** Premier Network and Out of Network ** Calendar Year Deductible None $25 per person / $75 per family per calendar year Calendar Year Maximum Benefit $1,500 $1,500 Diagnostic & Preventive Services Oral Examinations: 2 Annual Cleanings: 4 X rays Basic Services Fillings Posterior Composite Restorations Sealants Paid at: 100% * Paid at: 100% * Paid at: 80% * Paid at: 80% * Periodontics (gum treatment) Covered Under Basic Services Endodontics (root canals) Oral Surgery (extraction) Covered Under Basic Services Major Services Crowns, Inlays, Onlays & Cast Restorations Prosthodontics Bridges Dentures Implants Orthodontic Benefits Children Only Lifetime Maximum: $3, Month Wait: No Dental Accident Benefits Paid at: 80% * Paid at: 80% * Paid at: 80% * Paid at: 50% * Paid at: 50% * Paid at: 50% * Paid at: 50% * Paid at: 100% * Paid at: 100% * Paid at: 100% * Paid at: 100% * ($1,000 maximum per enrollee each calendar year) Paid at: 80% * Paid at: 80% * Paid at: 80% * ($1,000 maximum per enrollee each calendar year) *This summary is for comparison purposes only. The Evidence of Coverage should be consulted for a detailed description of the covered benefits and is available at ** See back for additional details 520 E. Herndon Avenue Fresno, CA P F CVT 9870 cvtrust.org

20 What are my Delta Dental network options? The Delta Dental PPO plan allows you the option to visit any licensed dentist. You will usually save more on your out of pocket costs when you visit a Delta Dental PPO dentist. The Delta Dental Premier network also provides cost saving features and is the next best option when you can t find a PPO dentist. Most potential savings with Delta Dental PPO dentists Delta Dental PPO dentists agree to accept Delta Dental PPO contracted fees as full payment. You ll usually pay less when you visit a Delta Dental PPO dentist. When you visit your dentist, you should ask specifically if he or she is a contracted Delta Dental PPO dentist. Some savings with Delta Dental Premier dentists Premier dentists contracted fees are usually slightly higher than PPO dentists contracted fees. Premier dentists will not bill you above their contracted fees, so you still receive some cost protections not available with a non Delta Dental dentist. No savings with non Delta Dental dentists Non Delta Dental dentists have no fee agreements with Delta Dental, so you will usually have the highest outof pocket costs when you visit a non Delta Dental dentist. You are responsible for the difference between what Delta Dental pays and the dentist s fee. How do I find a Delta Dental dentist? To locate a Delta Dental dentist near you, check the dentist directory on the Delta Dental website (deltadentalins.com), which also provides a map to the dental office. Or, to hear or receive a faxed listing of dentists in your area, call Follow the automated instructions to search for a dentist. What are my online resources? The full Delta Dental website is a one stop shop for plan and oral health information. Also available in Spanish: es.deltadentalins.com. Create a free Online Services account at deltadentalins.com to: Locate a Delta Dental dentist Check benefits, eligibility, and claim status Opt for paperless statements View or print your ID card Check average dental costs in your area Check out Your Dental Plan Support Guide for money saving tips and treatment information. And, don t miss mysmileway.com a great resource for oral health related tools and tips. Mobile? Get the information you need on the go. Bookmark or add a shortcut to the mobile site to return in just one tap from your phone. Download the free, convenient smartphone Delta Dental app from the App Store or Google Play. 520 E. Herndon Avenue Fresno, CA P F CVT 9870 cvtrust.org

21 Protect your vision with VSP. Get the best in eye care and eyewear with CALIFORNIA'S VALUED TRUST Plan C, $10.00 copay and VSP Vision Care. At VSP, we invest in the things you value most the best care at the lowest out-of-pocket costs. Because we re the only national not-for-profit vision care company, you can trust that we ll always put your wellness first. You ll like what you see with VSP. Value and Savings. You ll enjoy more value and the lowest out-of-pocket costs. High Quality Vision Care. You ll get the best care from a VSP provider, including a WellVision Exam the most comprehensive exam designed to detect eye and health conditions. Choice of Providers. The decision is yours to make choose a VSP doctor, a participating retail chain, or any out-of-network provider. Great Eyewear. It s easy to find the perfect frame at a price that fits your budget. Using your VSP benefit is easy. Create an account at vsp.com. Once your plan is effective, review your benefit information. Find an eye care provider who s right for you. To find a VSP provider, visit vsp.com or call At your appointment, tell them you have VSP. There s no ID card necessary. If you d like a card as a reference, you can print one on vsp.com. That s it! We ll handle the rest there are no claim forms to complete when you see a VSP provider. Choice in Eyewear From classic styles to the latest designer frames, you ll find hundreds of options. Choose from featured frame brands like bebe, Calvin Klein, 1 Cole Haan, Flexon, Lacoste, Nike, Nine West, and more. Visit vsp.com to find a Premier Program location who carries these brands. See why we re consumers #1 2 choice in vision care. Contact us vsp.com

22 Your VSP Vision Benefits Summary Manteca Unified - Cert, Clsfd, Cert Admin, Dept Supt, Supt & Trustees Benefit WellVision Exam Description Your Coverage with a VSP Provider Focuses on your eyes and overall wellness VSP Provider Network: VSP Signature Copay $10 for exam and glasses Frequency Every 12 months Prescription Glasses Frame $150 allowance for a wide selection of frames $170 allowance for featured frame brands 20% savings on the amount over your allowance $80 Costco frame allowance Combined with exam Every 12 months Lenses Lens Enhancements Single vision, lined bifocal, and lined trifocal lenses Polycarbonate lenses for dependent children Tints/Photochromic adaptive lenses Standard progressive lenses Premium progressive lenses Custom progressive lenses Average savings of 35-40% on other lens enhancements Combined with exam $0 $50 $80 - $90 $120 - $160 Every 12 months Every 12 months Contacts (instead of glasses) $120 allowance for contacts and contact lens exam (fitting and evaluation) 15% savings on a contact lens exam (fitting and evaluation) $0 Every 12 months Extra Savings Glasses and Sunglasses Extra $20 to spend on featured frame brands. Go to vsp.com/specialoffers for details. 30% savings on additional glasses and sunglasses, including lens enhancements, from the same VSP provider on the same day as your WellVision Exam. Or get 20% from any VSP provider within 12 months of your last WellVision Exam. Retinal Screening No more than a $39 copay on routine retinal screening as an enhancement to a WellVision Exam Laser Vision Correction Average 15% off the regular price or 5% off the promotional price; discounts only available from contracted facilities After surgery, use your frame allowance (if eligible) for sunglasses from any VSP doctor Your Coverage with Out-of-Network Providers Visit vsp.com for details, if you plan to see a provider other than a VSP network provider. Exam... up to $50 Frame... up to $70 Single Vision Lenses... up to $50 Lined Bifocal Lenses... up to $75 Lined Trifocal Lenses... up to $100 Progressive Lenses... up to $75 Contacts... up to $105 Tints... up to $5 Coverage with a participating retail chain may be different. Once your benefit is effective, visit vsp.com for details. Coverage information is subject to change. In the event of a conflict between this information and your organization s contract with VSP, the terms of the contract will prevail. Based on applicable laws, benefits may vary by location. Contact us vsp.com 1 Brands/Promotion subject to change. 2 Blueocean Market Intelligence National Vision Plan Member Research, Vision Service Plan. All rights reserved. VSP, VSP Vision care for life, and WellVision Exam are registered trademarks of Vision Service Plan. Flexon is a registered trademark of Marchon Eyewear, Inc. All other company names and brands are trademarks or registered trademarks of their respective owners.