Business and Administrative Services 5801 East Conifer Street, Oak Park, CA T: (818) F: (818)

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1 Business and Administrative Services 5801 East Conifer Street, Oak Park, CA T: (818) F: (818) TO: FROM: All Employees Eligible For Health Benefits Martin Klauss, Assistant Superintendent, Business and Administrative Services DATE: August 5, 2014 SUBJECT: IMPORTANT HEALTH BENEFITS INFORMATION OPEN ENROLLMENT: AUGUST 15 SEPTEMBER 15, 2014 Summer is quickly coming to an end, and we will soon be welcoming you back to the Oak Park Unified School District. We hope each of you has had an enjoyable and restful break. The dates for our open enrollment period for medical, dental, vision, the Section 125 Flexible Spending Account (FSA) plan, will be from August 15, 2014 through September 15, In , the District s Health Benefits Committee worked very hard to bring the excellent coverage that we now enjoy through California s Valued Trust (CVT). CVT is a statewide benefits trust that places the District in a larger participant pool, thereby offering more stable rates. In , the District s health benefits coverage offers a choice of ten medical plans, including seven Anthem Blue Cross PPO plans, three Kaiser plans, the CVT Bronze PPO Plan, as well as the Delta Dental and VSP Vision plans. CVT has released the renewal rates for OPUSD health benefit plans. After receiving a nearly 9% reduction to PPO premiums last year, this year CVT is passing along an average 12% increase to PPO plans in Kaiser Permanente HMO medical plans received a modest 0.5% increase, and VSP vision plan premiums rise by 2.7%, while Delta Dental premiums decrease by 2.9%. The Health Benefits Committee met in late June to discuss the CVT proposed renewal. Although disappointed by the increase in PPO rates, the Committee acknowledged the unprecedented 9% reduction in the prior year and high employee satisfaction with the plans. After deliberation, the Committee recommended renewal with CVT for , which the Board of Education accepted and approved at its meeting on June 17, Anthem Blue Cross PPO Plans As noted above, after receiving a 9% reduction in , CVT is increasing PPO plan premiums by 12% on average. When asked to explain the increase, CVT cited the Affordable Care Act, a 30-32% cost increase in Region 4 (which includes OPUSD) for emergency and non-emergency outpatient services, and a 45% growth in specialty care service costs. The complete CVT explanation for the increase can be found on the Business Office website. Kaiser HMO Plans Premiums for Kaiser 1, Kaiser 2, and Kaiser 6 plans have each increased by a modest 0.5%. The good news for employees is that all plans are still below the existing caps, so there is still no payroll deduction required for plan participants. Delta Dental Plan Dental plan premiums decrease by an average 2.9, while continuing all of the covered services provided in , including dental implants as part of the base dental benefit. VSP Vision Plan The vision plan premiums increase by 2.7% over last year, maintaining the same level of benefits offered in You are strongly encouraged to review the individual plan summaries attached to verify the benefits provided by each plan. AdmSvs/Health Benefits /Health Benefits Open Enrollment Memo final.docx

2 MEMO: HEALTH BENEFITS INFORMATION August 5, 2014 Page 2 ENCLOSED YOU WILL FIND THE FOLLOWING IMPORTANT INFORMATION REGARDING BENEFIT PLANS AND OPEN ENROLLMENT: OPEN ENROLLMENT - The dates for our open enrollment period for medical, dental, and vision benefits, and the Section 125 FSA plan, will be August 15, 2014 through September 15, ELIGIBILITY All full time employees must enroll in a medical, dental and vision plan. Eligible part-time employees (50% or higher FTE) may elect to enroll solely in medical, dental or vision, or in any combination of plans, or may decline coverage altogether. Open enrollment allows part-time employees who have chosen not to enroll in the past to enroll in a plan of their choice. It also permits currently enrolled employees to add dependents that are not presently covered under their plan and/or to change health plans. Family changes (i.e. marriage, divorce, birth or adoption of a child, added stepchild from a recent marriage) may be added during the first 30 days of the life status change any time during the year. IMPORTANT NOTE: CVT will require a copy of the marriage or birth/adoption certificates to be submitted with the enrollment change form. If the addition to the family is not added to the employee s health coverage within the first 30 days, except under special circumstances, coverage will not be available until the next open enrollment period. IMPORTANT NOTE: If an enrolled dependent ceases to be a dependent due to divorce, reaching the maximum age for dependent coverage of 26, or marries, the Business Office must be notified within 30 days. We are required by law to notify dependents of their rights to continued coverage under COBRA. HEALTH BENEFITS CAP Health benefit allocations for remain on a three-tiered sliding cap, unchanged from , and are determined by the number of dependents the employee enrolls in a medical plan. The cap for Employee Only medical is $7, annually, the cap for Employee + One Dependent medical is $12, annually, and the cap for Family Coverage (employee plus two or more dependents) is $16, annually. Eligible part-time employees (classified employees who work 20 or more hours a week but less than 40 hours, certificated employees who work less than 185 full-time days, but whose percent of contract is 50% or greater) will receive a pro-rata portion of the annual allowance based on the number of dependents enrolled as explained above. A payroll deduction for the months of September through June (10 deductions) will be taken for employees who select a plan that exceeds their cap or their pro-rata portion. Although the benefit plan year does not take effect until October 1, the need to begin the deductions with September payroll is governed by IRS codes for Section 125 benefit plans PREMIUMS AND PAYROLL DEDUCTIONS - Attached are the rates for the seven Anthem Blue Cross PPO plans (Plans 1B, 3B, 5B, 7B, Wellness PPO Plan 1, PPO High Deductible Health Plan 1, and Bronze PPO), the three Kaiser HMO plans (Plans 1, 2 and 6), the Delta Dental Plan, and VSP Vision Plan. Each chart includes premium costs and payroll deductions, if any, depending on the medical and dental plan you choose and the number of dependents you elect to enroll. This information is broken down for full-time and eligible part-time employees. Please note that the rate and payroll information is based on the benefits cap. Although contract negotiations with OPTA and OPCA are in process, there is no assurance of an adjustment to the cap amounts. TO ENROLL FOR Currently enrolled employees who wish their health benefit coverage to remain the same as last year DO NOT HAVE TO DO ANYTHING - your plan selections and eligible covered dependents will automatically roll over to the new benefit year. Employees enrolling for the first time or who want to change plans or dependent coverage MUST COMPLETE AND SUBMIT ENROLLMENT FORMS. AdmSvs/Health Benefits /Health Benefits Open Enrollment Memo final.docx

3 MEMO: HEALTH BENEFITS INFORMATION August 5, 2014 Page 3 IF YOU ARE NEW OR WANT TO ADD/DROP DEPENDENTS OR CHANGE COVERAGE - If you are a new employee, or a returning employee who wants to add or drop dependents, or change benefit plans, please complete and submit the appropriate enrollment change forms to the Business Office. Please note that a marriage or birth/adoption certificate must accompany the enrollment form. Forms can be obtained on the Business Office page of the OPUSD website, requested by telephone at (818) , by fax at (818) , or by to asegal@oakparkusd.org or mklauss@oakparkusd.org. We will be happy to answer your questions and/or send you the appropriate paper work. Changes to coverage cannot occur without a signed form. IMPORTANT NOTE: Enrolling a dependent in a medical plan does not enroll them in the dental plan. An enrollment form for both medical and dental must be completed to have the dependent covered for both benefits. All changes in health benefit plans and/or dependent enrollment must be completed and returned to the Business Office not later than September 15, BENEFIT PLAN SUMMARIES A matrix is attached for each of the medical, dental, and vision plans outlined below, highlighting the coverage offered by the respective plans. Please review this summary carefully as there are variances in coverage, deductibles and copays, in all plans. IMPORTANT NOTE: IRS Section 125 allows payroll deductions for health benefit insurance to be taken pre-tax. Since your taxable income will then be less, your paycheck will reflect lower payment of Federal and State taxes. Payroll deductions, if applicable, will automatically be deducted pre-tax by the District payroll department. ANTHEM BLUE CROSS MEDICAL: As you will see in the attached information, there are seven PPO options available through Anthem Blue Cross. Plans 1B, 3B, 5B and 7B, are each paired with the Plan B prescription plan. Wellness PPO Plan 1 is paired with the Plan C prescription plan, and prescriptions for the High Deductible Health Plan 1 must comply with major medical deductible and coinsurance requirements. Each of the plans offers varying degrees of benefits. As there is no change in the caps, Plans 1B, 3B, 5B, 7B, and Wellness PPO Plan 1 will each require an employee payroll deduction. Depending upon the dependent coverage selected by the employee, High Deductible Health Plan 1 and Bronze PPO Plan may not require a payroll deduction. However, the deductibles and coinsurance are quite high, so it should be carefully considered before choosing this plan. Because caps are prorated for part-time employees, they will likely have a payroll deduction utilizing any of these plans, but the multiple options are intended to provide employees with choices to minimize the impact. Payroll deductions, if any, will automatically be deducted pre-tax. KAISER HMO Three Kaiser medical plans are offered. Plan 1 essentially provides the same coverage as Plan 2, but with lower copays and emergency room services. Plan 6, while offering frames and lenses not offered by Plans 1 and 2, otherwise provides somewhat less coverage. Although Plan 6 offers a modified vision plan, CVT requires that employees also select the VSP vision plan. There is no payroll deduction for full-time employees who opt for any of the Kaiser plans. Because caps are prorated for part-time employees, they may have a payroll deduction utilizing any of the three plans, but the options are intended to provide employees with choices to minimize the impact. Payroll deductions, if any, will automatically be deducted pre-tax. DENTAL: The dental plan offered through CVT is Delta Dental s standard school incentive plan. As indicated on the information sheet, the incentive plan pays 70% for the first year of enrollment, 80% in the second year, 90% in the third, and 100% in year 4. VISION: The vision plan offered through CVT is VSP Plan B. This plan offers great benefits, with exams, glasses or contacts every 12 months, and new frames every 24 months. AdmSvs/Health Benefits /Health Benefits Open Enrollment Memo final.docx

4 MEMO: HEALTH BENEFITS INFORMATION August 5, 2014 Page 4 SECTION 125 FLEXIBLE SPENDING ACCOUNT (FSA): The District s Section 125 Flexible Spending Account is administered by WageWorks. An FSA permits you to make a payroll deduction for estimated out-of-pocket expense for allowable childcare, and medical, vision, and dental procedures, using pre-tax dollars. Since your taxable income will then be less, your paycheck will reduce your Federal and State tax liability. The effective FSA plan year is October 1, 2014-September 30, IMPORTANT NOTE: If you intend to enroll in the Section 125 FSA plan, you must do so by September 15, 2014, in order for your payroll deduction to begin with the September payroll. As mandated by the IRS, anyone not enrolled during the September open enrollment period must wait one year until the next open enrollment period. Those who do enroll must understand they may not change or stop the deductions during the benefit year. However, there are exceptions to both caveats in the event of a major life change such as marriage, an addition to the family, etc. For more information on the FSA plan and enrollment, go to the Business Office page of the OPUSD website. Although no longer administering the District s FSA plan, AFLAC continues to offer opportunities for employees to purchase additional insurance policies to cover Accident, Cancer, Short Term Disability, Hospital, etc. If you would like information on AFLAC products, please contact AFLAC representative Chuck Boone at (805) or by at charles_boone@us.aflac.com. Chuck will also be available at each site September 8, 9, 10, and 12, 2014 to respond to your questions (site visit schedule forthcoming shortly via ). MORE INFORMATION For questions concerning the plans and coverage, coordination of benefits, etc. please contact our CVT Member Services Representative Isabel Parks (isabelp@cvtrust.org), or Account Manager Eric Fiedler (ericf@cvtrust.org). Both can be reached by telephone toll-free at (800) They are extremely knowledgeable and helpful in guiding you through complex coverage issues. Additionally, a CVT representative will be available at each site to answer questions September 8, 9, 10, and 12, 2014 (site visit schedule to follow shortly via district ). You may also contact Martin Klauss (mklauss@oakparkusd.org) or Annette Segal (asegal@oakparkusd.org) in the Business Office by , or by telephone at (818) for more information. AdmSvs/Health Benefits /Health Benefits Open Enrollment Memo final.docx

5 CVT PPO HEALTH PLANS OAK PARK UNIFIED SCHOOL DISTRICT October 1, 2014 September 30, 2015 BENEFIT PPO PLAN 1B PPO PLAN 3B PPO PLAN 5B PPO PLAN 7B PPO WELLNESS PLAN HDHP 1 Calendar Year Deductible $0 Individual: $100 Family: $300 Individual: $100 Family: $300 Individual: $250 Family: $750 Individual: $500 Family: $1,000 Individual: $1,250 Family: $3,000 (no individual limit applies to family) Coinsurance Paid at 100%* Paid at 100%* after deductible deductible deductible Calendar Year Out of Pocket Maximum (includes deductible, coinsurance, medical & pharmacy Copays) Individual: $1,250 Family: $12,700 / Affordable Care Act (ACA) mandated Out of Pocket Maximum Individual: $1,250 Family: $12,700 / Affordable Care Act (ACA) mandated Out of Pocket Maximum Individual: $1,250 Family: $12,700 / Affordable Care Act (ACA) mandated Out of Pocket Maximum Doctor Visits $10 Copay $20 Copay $30 Copay $30 copay Individual: $2,000 Family: $12,700 / Affordable Care Act (ACA) mandated Out of Pocket Maximum Individual: $1,750 Family: $12,700 Affordable Care Act (ACA) mandated Out of Pocket Maximum $20 Primary Care Physician Copay $40 Specialist Copay Individual: $4,250 Family: $10,100 Family = Employee with one or more covered dependent(s) deductible Immunizations Paid at 100%* Paid at 100%* Paid at 100%* Paid at 100%* Paid at 100%* Paid at 100%* Preventive Care for Children Paid at 100%* Paid at 100%* Paid at 100%* Paid at 100%* Paid at 100%* Paid at 100%* Preventive Care for Adults Paid at 100%* Paid at 100%* Paid at 100%* Paid at 100%* Paid at 100%* Paid at 100%* Telehealth MDLIVE - $5 Copay Call or visit mdlive.com/cvt for non- emergency medical conditions. MDLIVE - $5 Copay Call or visit mdlive.com/cvt for non- emergency medical conditions. MDLIVE - $5 Copay Call or visit mdlive.com/cvt for non- emergency medical conditions. MDLIVE - $5 Copay Call or visit mdlive.com/cvt for non- emergency medical conditions. MDLIVE - $5 Copay Call or visit mdlive.com/cvt for non- emergency medical conditions. MDLIVE - deductible Call or visit mdlive.com/cvt for non- emergency medical conditions Outpatient X- ray and Lab Paid at 100%* Paid at 100%* after deducible deductible deductible Radiation Therapy, Chemotherapy Paid at 100%* Paid at 100%* after deducible deductible deductible Durable Medical Equipment Paid at 100%* Paid at 100%* after deducible deductible deductible Ambulance Ground / Air Paid at 100%* of covered charges Paid at 100%* after deducible deductible deductible

6 Page 2 PPO PLAN 1B PPO PLAN 3B PPO PLAN 5B PPO PLAN 7B PPO WELLNESS PLAN HDHP 1 Physical Therapy** Paid at 100%* (Copay, if applicable.) Paid at 100%* after deducible (Copay, if applicable.) Paid at 90%* after deductible (Copay, if applicable.) deductible (Copay, if applicable) (Copay, if applicable) deductible Chiropractic** Paid at 100%* (Copay, if applicable) Paid at 100%* after deducible (Copay, if applicable) Paid at 90%* after deductible (Copay, if applicable) deductible (Copay, if applicable) (Copay, if applicable.) deductible Acupuncture Paid at 100%* (Copay, if applicable) Maximum of 12 visits per Paid at 100%* after deducible (Copay, if applicable) Maximum of 12 visits per Paid at 90%* after deductible (Copay, if applicable) Maximum of 12 visits per deducible (Copay, if applicable) Maximum of 12 visits per. (Copay, if applicable.) Maximum of 12 visits per deductible Maximum of 12 visits per Hospital (Inpatient, Outpatient, Surgical) Paid at 100%* Unlimited days; Semi private room Paid at 100%* after deducible Unlimited days, semi- private room Paid at 90%* after deductible Unlimited days, semi- private room deductible Unlimited days, semi- private room Paid at 90%* after deductible Unlimited days, semi- private room deductible Unlimited days, semi- private room Hospital Emergency Room $75 Copay (Copay waived if admitted as in- patient) $75 Copay (Copay waived if admitted as in- patient) Paid at 100%* after deductible $75 Copay (Copay waived if admitted as in- patient) Paid at 90%* after deductible $75 Copay (Copay waived if admitted as in- patient) deductible $75 Copay (Copay waived if admitted as in- patient) deductible Home Health Care Paid at 100%* Limited to 100 visits per Paid at 100%* after deducible Limited to 100 visits per Paid at 90%* after deductible Limited to 100 visits per deductible Limited to 100 visits per Limited to 100 visits per deductible Limited to 100 visits per Hospice Paid at 100%* Paid at 100%* Paid at 100%* Paid at 100%* Paid at 100%* deductible Prescription Drugs Retail $7 Generic $15 Pref $30 NonPref (30- day supply) Mail Order $15 Generic $35 Pref $70 NonPref (90- day supply) Retail $7 Generic $15 Pref $30 NonPref (30- day supply) Mail Order $15 Generic $35 Pref $70 NonPref (90- day supply) Retail $7 Generic $15 Pref $30 NonPref (30- day supply) Mail Order $15 Generic $35 Pref $70 NonPref (90- day supply) Retail $7 Generic $15 Pref $30 NonPref (30- day supply) Mail Order $15 Generic $35 Pref $70 NonPref (90- day supply) Retail $7 Generic $25 Pref $40 NonPref (30- day supply) Mail Order $15 Generic $60 Pref $90 NonPref (90- day supply) deductible *Explanation of Covered Expense: Plan payments are based on covered expense, which is the lesser of the charges billed by the provider or the following: PPO Providers - PPO negotiated rates. Members are not responsible for the difference between the provider's usual charges & the negotiated amount. Non- PPO Providers - For non- emergency services, the scheduled amount. For emergency services, same as other health care providers. Other Health Care Providers (includes those not represented in the PPO provider network) - The customary & reasonable charge for professional services or the reasonable charge for institutional services. 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. ** Physical Therapy & Chiropractic - Non- Par Providers limited to a combined maximum of 13 visits per year. This summary is for comparison purposes only. Please refer to the actual benefit booklet for complete benefits.

7 PPO BRONZE PLAN October 1, September 30, 2015 BENEFIT PPO BRONZE PLAN Calendar Year Deductible Individual: $5,000 Family: $10,000 Coinsurance Paid at 70%* after deductible Calendar Year Out of Pocket Maximum (includes deductible, coinsurance, medical & pharmacy copays) Individual: $6,350 Family: $12,700 Affordable Care Act (ACA) mandated Out of Pocket Maximum Doctor Visits Primary Care Physician First 3 visits covered in full after $60 copay per visit; Remaining visits Paid at 70%* after deductible Specialty Physician Subject to deductible, then $70 copay Immunizations Paid at 100%* Preventive Care for Children Paid at 100%* Preventive Care for Adults Paid at 100%* Telehealth Outpatient X-ray and Lab MDLIVE - $5 copay Call or visit mdlive.com/cvt for non-emergency medical conditions. Paid at 70%* after deductible Radiation Therapy, Chemotherapy Paid at 70%* after deductible Durable Medical Equipment Paid at 70%* after deductible Ambulance Ground/Air Paid at 70%* after deductible

8 PAGE 2 - BENEFIT PPO BRONZE PLAN Physical Therapy ** Paid at 70%* after deductible Chiropractic ** Paid at 70%* after deductible Acupuncture Paid at 70%* after deductible Maximum of 12 visits per Hospital Inpatient Hospital Emergency Room Urgent Care Home Health Care Paid at 70%* after deductible Unlimited days, semi-private room Subject to deductible, then $250 copay Subject to deductible, then $120 copay Paid at 70%* after deductible Limited to 100 visits per Hospice Paid at 100%* Prescription Drugs Retail Subject to deductible, then $25 copay generic $50 copay brand (30 day supply) Mail Order Subject to deductible, then $50 copay generic $100 copay brand (90 day supply) *Explanation of Covered Expense: Plan payments are based on covered expense, which is the lesser of the charges billed by the provider or the following: PPO Providers - PPO negotiated rates. Members are not responsible for the difference between the provider's usual charges & the negotiated amount. Non-PPO Providers - For non-emergency services, the scheduled amount. For emergency services, same as other health care providers. Other Health Care Providers (includes those not represented in the PPO provider network) - The customary & reasonable charge for professional services or the reasonable charge for institutional services. 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. ** Non-Par Providers limited to a combined maximum of 13 visits per year. This summary is for comparison purposes only. Please refer to the actual benefit booklet for complete benefits.

9 CVT KAISER PLANS OAK PARK UNIFIED SCHOOL DISTRICT October 1, 2014 September 30, 2015 BENEFIT KAISER PLAN 1 w/chiro KAISER PLAN 2 w/chiro KAISER 6 w/ CHIRO & OPTICAL Calendar Year Deductible $0 $0 $0 Coinsurance Paid at 100%* Paid at 100%* Paid at 100%* Calendar Year Out of Pocket Maximum (includes deductible, coinsurance & medical copays) Individual: $1,500 Family: $3,000 Individual: $1,500 Family: $3,000 Individual: $1,500 Family: $3,000 Doctor Visits $10 Copay $15 Copay $25 Copay Immunizations Paid at 100%* Paid at 100%* Paid at 100%* Preventive Care for Children Paid at 100%* Paid at 100%* Paid at 100%* Preventive Care for Adults Paid at 100%* Paid at 100%* Paid at 100%* Outpatient X- ray and Lab Paid at 100%* Paid at 100%* Paid at 100%* Radiation Therapy, Chemotherapy Radiation Therapy: Paid at 100%* Chemotherapy: $10 Copay Radiation Therapy: Paid at 100%* Chemotherapy: $15 Copay Radiation Therapy: Paid at 100%* Chemotherapy: $25 Copay Durable Medical Equipment Paid at 100%* Paid at 100%* Paid at 100%* Ambulance Ground/Air Paid at 100%* If Med. Necessary Paid at 100%* If Med. Necessary $50 Per Trip If Med. Necessary

10 Page 2 KAISER PLAN 1 w/chiro KAISER PLAN 2 w/chiro KAISER 6 w/ CHIRO & OPTICAL Physical Therapy $10 Copay $15 Copay $25 Copay Chiropractic Chiro Benefit Offered through ChiroMetrics; $10 Office Visit Copay; $15 Daily Maxiumum for Out of Network; Up to 40 Visits Per Year After 12 th Visit Must be Precertified. Chiro Benefit Offered through ChiroMetrics; $10 Office Visit Copay; $15 Daily Maxiumum for Out of Network; Up to 40 Visits Per Year After 12 th Visit Must be Precertified. Chiro Benefit Offered through ChiroMetrics; $10 Office Visit Copay; $15 Daily Maxiumum for Out of Network; Up to 40 Visits Per Year After 12 th Visit Must be Precertified. Acupuncture $10 Copay Referral by Plan Physician $15 Copay Referral by Plan Physician $25 Copay Referral by Plan Physician Hospital Inpatient Paid at 100%* Paid at 100%* $250 Copay Hospital Emergency Room $35 Copay Copay waived if admitted as in- patient $50 Copay Copay waived if admitted as in- patient $50 Copay Copay waived if admitted as in- patient Home Health Care Paid at 100%*(Limits) Paid at 100%*(Limits) Paid at 100%*(Limits) Hospice Paid at 100%* Paid at 100%* Paid at 100%* Vision Exam Paid at 100%* No frame, lens, contact allowance Paid at 100%* No frame, lens, contact allowance Paid at 100%* $175 allowance for lenses, frames, & contacts every 24 months Prescription Drugs Retail $5 Generic $10 Brand (Up to 30 day supply) $10 Generic $20 Brand (31-60 day supply $15 Generic $30 Brand ( day supply) Mail Order $5 Generic $10 Brand (30 day supply) $10 Generic $20 Brand ( Day Supply) Retail $5 Generic $10 Brand (Up to 30 Day Supply) $10 Generic $20 Brand (31-60 Day Supply $15 Generic $30 Brand ( Day Supply) Mail Order $5 Generic $10 Brand (30 Day Supply) $10 Generic $20 Brand ( Day Supply) Retail $10 Generic $20 Brand (Up to 30 Day Supply) $20 Generic $40 Brand (31-60 Day Supply) $30 Generic $60 Brand ( Day Supply) Mail Order $10 Generic $20 Brand (30 Day Supply) $20 Generic $40 Brand ( Day Supply) * For Covered Expenses Only NOTES: COPAYS FOR INFERTILITY: Plans 1 $10 Copay; Plan 2 - $15 Copay; Plan 6 50% Copay. COPAYS FOR ALLERGY INJECTIONS: Plans 1 & 2 No Charge; Plan 6 - $5 Per Visit REFER TO THE ACTUAL SUMMARY PLAN DESCRIPTION FOR COMPLETE BENEFITS.

11 DELTA DENTAL PLAN OF CALIFORNIA INFORMATION SHEET OAK PARK UNIFIED SCHOOL DISTRICT PPO STANDARD SCHOOL INCENTIVE PLAN Usual, Customary and Reasonable Fee Concept Basic Services, Crowns and Cast Restorations: CoPayment Schedule: 70/30 First Year 80/20 Second Year 90/10 Third Year 100% Fourth Year Prosthodontics & Implants CoPayment: 50/50 (Prosthodontic base benefit includes Implants) $2,000 MAXIMUM PER PATIENT PER CALENDAR YEAR 2 CLEANINGS PER PATIENT PER CALENDAR YEAR ORTHODONTIC BENEFITS PAID AT 50%, ADULTS & CHILDREN, $1,000 LIFETIME MAXIMUM DELTA DENTAL PPO/PREMIER INCENTIVE PLAN In Network-(using Delta PPO provider s) you will receive an additional $200 annually toward your maximum over claims paid for providers in the Delta Premier Incentive Plan. Out of Network- (using Delta Premier Providers) your claims are paid at incentive level without additional $200 annual maximum. 100% payment for dental services rendered in case of an accident, subject to a SEPARATE $1000 Annual Maximum

12 Oak Park Unified School District Your affordable eyecare benefit is brought to you by California s Valued Trust and VSP. Your Coverage from a VSP Doctor $15.00 copay every 12 months WellVision Exam focuses on your eye health and overall wellness... every 12 months Prescription Glasses Lenses... every 12 months Single vision, lined bifocal, and lined trifocal lenses. Polycarbonate lenses for dependent children. Frame... every 24 months $ allowance for frame of your choice 20% off the amount over your allowance. $70.00 frame allowance at Costco ~OR~ Contact Lens Care... every 12 months $ allowance for contacts and the contact lens exam (fitting and evaluation). If you choose contact lenses you will be eligible for a frame 24 months from the date the contact lenses were obtained.. Extra Discounts and Savings Glasses and Sunglasses Average 35-40% savings on all non-covered lens options 30% off additional glasses and sunglasses, including lens options, from the same VSP doctor on the same day as your WellVision Exam. Or get 20% off from any VSP doctor within 12 months of your last WellVision Exam Contacts 15% off cost of contact lens exam (fitting and evaluation) 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 If you see a non-vsp provider, you ll receive a lesser benefit. Before seeing a non-vsp provider, call us at for more details. Out-of-Network Reimbursement Amounts: Exam... Up to $50.00 Single vision lenses... Up to $50.00 Lined bifocal lenses... Up to $75.00 Lined trifocal lenses... Up to $ Frame... Up to $70.00 Contacts... Up to $ VSP guarantees service from VSP doctors only. In the event of a conflict between this information and your organization's contract with VSP, the terms of the contract will prevail. VSP PLAN B15

13 CVT Benefits Plan Anthem Blue Cross PPO Plan 1B Health Benefits Cap and Estimated Payroll Deductions for Full Time and Part-Time Employees IF YOU CHOOSE DENTAL VISION THE COST OF PREMIUMS WILL BE: 1.0 FTE PAYROLL DEDUCTION 0.9 FTE PAYROLL DEDUCTION THIS MEDICAL AND COVERAGE COVERAGE Medical Dental Vision Total District Payroll Deduction Pro-rated Payroll Deduction VISION COVERAGE: Cost Cost Cost Cost Cap (100%) Annual Monthly Cap (90%) Annual Monthly Employee Only Emp Emp 9, , $7, , , , Employee Only Emp+1 Emp+1 9, , , $7, , , , Employee Only Family Family 9, , , $7, , , , Employee+1 Dependent Emp Emp 16, , $12, , , , Employee+1 Dependent Emp+1 Emp+1 16, , , $12, , , , Employee+1 Dependent Family Family 16, , , $12, , , , Family Coverage Emp Emp 20, , $16, , , , Family Coverage Emp+1 Emp+1 20, , , $16, , , , Family Coverage Family Family 20, , , $16, , , , IF YOU CHOOSE DENTAL VISION 0.8 FTE PAYROLL DEDUCTION 0.75 FTE PAYROLL DEDUCTION 0.60 FTE PAYROLL DEDUCTION 0.50 FTE PAYROLL DEDUCTION THIS MEDICAL AND COVERAGE COVERAGE Pro-rated Payroll Deduction Pro-rated Payroll Deduction Pro-rated Payroll Deduction Pro-rated Payroll Deduction VISION COVERAGE: Cap (80%) Annual Monthly Cap (75%) Annual Monthly Cap (60%) Annual Monthly Cap (50%) Annual Monthly Employee Only Emp Emp 5, , , , , , , , Employee Only Emp+1 Emp+1 5, , , , , , , , Employee Only Family Family 5, , , , , , , , Employee+1 Dependent Emp Emp 10, , , , , , , , , Employee+1 Dependent Emp+1 Emp+1 10, , , , , , , , , , Employee+1 Dependent Family Family 10, , , , , , , , , , Family Coverage Emp Emp 13, , , , , , , , , , Family Coverage Emp+1 Emp+1 13, , , , , , , , , , , Family Coverage Family Family 13, , , , , , , , , , , , NOTES: Benefits Cap: The District benefits cap allocation for 2014/2015 is a three-tiered sliding cap. The cap is determined by the number of enrolled (the employee plus any dependents) in a medical plan (Blue Cross PPOs or Kaiser HMOs). The cap is $7,371 for employee-only medical coverage, $12,724 for employee plus one dependent, $16,483 for employee plus two or more dependents. Eligible part-time employees receive a pro-rata share of the annual allowance. A monthly payroll deduction will be taken September through June for employees who select a plan that exceeds the selected cap. Eligible Part-Time Employees: Eligible part-time employees are those who work 0.5 FTE or greater. OPUSD Enrollment Employee Payroll Deducts xlsx Page 3 of 12 8/4/14 8:40 AM

14 CVT Benefits Plan Anthem Blue Cross PPO Plan 3B Health Benefits Cap and Estimated Payroll Deductions for Full Time and Part-Time Employees IF YOU CHOOSE DENTAL VISION THE COST OF PREMIUMS WILL BE: 1.0 FTE PAYROLL DEDUCTION 0.9 FTE PAYROLL DEDUCTION THIS MEDICAL AND COVERAGE COVERAGE Medical Dental Vision Total District Payroll Deduction Pro-rated Payroll Deduction VISION COVERAGE: Cost Cost Cost Cost Cap (100%) Annual Monthly Cap (90%) Annual Monthly Employee Only Emp Emp 8, , $7, , , , Employee Only Emp+1 Emp+1 8, , , $7, , , , Employee Only Family Family 8, , , $7, , , , Employee+1 Dependent Emp Emp 15, , $12, , , , Employee+1 Dependent Emp+1 Emp+1 15, , , $12, , , , Employee+1 Dependent Family Family 15, , , $12, , , , Family Coverage Emp Emp 19, , $16, , , , Family Coverage Emp+1 Emp+1 19, , , $16, , , , Family Coverage Family Family 19, , , $16, , , , IF YOU CHOOSE DENTAL VISION 0.8 FTE PAYROLL DEDUCTION 0.75 FTE PAYROLL DEDUCTION 0.60 FTE PAYROLL DEDUCTION 0.50 FTE PAYROLL DEDUCTION THIS MEDICAL AND COVERAGE COVERAGE Pro-rated Payroll Deduction Pro-rated Payroll Deduction Pro-rated Payroll Deduction Pro-rated Payroll Deduction VISION COVERAGE: Cap (80%) Annual Monthly Cap (75%) Annual Monthly Cap (60%) Annual Monthly Cap (50%) Annual Monthly Employee Only Emp Emp 5, , , , , , , , Employee Only Emp+1 Emp+1 5, , , , , , , , Employee Only Family Family 5, , , , , , , , Employee+1 Dependent Emp Emp 10, , , , , , , , Employee+1 Dependent Emp+1 Emp+1 10, , , , , , , , , Employee+1 Dependent Family Family 10, , , , , , , , , Family Coverage Emp Emp 13, , , , , , , , , , Family Coverage Emp+1 Emp+1 13, , , , , , , , , , Family Coverage Family Family 13, , , , , , , , , , NOTES: Benefits Cap: The District benefits cap allocation for 2014/2015 is a three-tiered sliding cap. The cap is determined by the number of enrolled (the employee plus any dependents) in a medical plan (Blue Cross PPOs or Kaiser HMOs). The cap is $7,371 for employee-only medical coverage, $12,724 for employee plus one dependent, $16,483 for employee plus two or more dependents. Eligible part-time employees receive a pro-rata share of the annual allowance. A monthly payroll deduction will be taken September through June for employees who select a plan that exceeds the selected cap. Eligible Part-Time Employees: Eligible part-time employees are those who work 0.5 FTE or greater. OPUSD Enrollment Employee Payroll Deducts xlsx Page 4 of 12 8/4/14 8:40 AM

15 CVT Benefits Plan Anthem Blue Cross PPO Plan 5B Health Benefits Cap and Estimated Payroll Deductions for Full Time and Part-Time Employees IF YOU CHOOSE DENTAL VISION THE COST OF PREMIUMS WILL BE: 1.0 FTE PAYROLL DEDUCTION 0.9 FTE PAYROLL DEDUCTION THIS MEDICAL AND COVERAGE COVERAGE Medical Dental Vision Total District Payroll Deduction Pro-rated Payroll Deduction VISION COVERAGE: Cost Cost Cost Cost Cap (100%) Annual Monthly Cap (90%) Annual Monthly Employee Only Emp Emp 8, , $7, , , , Employee Only Emp+1 Emp+1 8, , , $7, , , , Employee Only Family Family 8, , , $7, , , , Employee+1 Dependent Emp Emp 14, , $12, , , , Employee+1 Dependent Emp+1 Emp+1 14, , , $12, , , , Employee+1 Dependent Family Family 14, , , $12, , , , Family Coverage Emp Emp 18, , $16, , , , Family Coverage Emp+1 Emp+1 18, , , $16, , , , Family Coverage Family Family 18, , , $16, , , , IF YOU CHOOSE DENTAL VISION 0.8 FTE PAYROLL DEDUCTION 0.75 FTE PAYROLL DEDUCTION 0.60 FTE PAYROLL DEDUCTION 0.50 FTE PAYROLL DEDUCTION THIS MEDICAL AND COVERAGE COVERAGE Pro-rated Payroll Deduction Pro-rated Payroll Deduction Pro-rated Payroll Deduction Pro-rated Payroll Deduction VISION COVERAGE: Cap (80%) Annual Monthly Cap (75%) Annual Monthly Cap (60%) Annual Monthly Cap (50%) Annual Monthly Employee Only Emp Emp 5, , , , , , , , Employee Only Emp+1 Emp+1 5, , , , , , , , Employee Only Family Family 5, , , , , , , , Employee+1 Dependent Emp Emp 10, , , , , , , , Employee+1 Dependent Emp+1 Emp+1 10, , , , , , , , Employee+1 Dependent Family Family 10, , , , , , , , , Family Coverage Emp Emp 13, , , , , , , , , Family Coverage Emp+1 Emp+1 13, , , , , , , , , , Family Coverage Family Family 13, , , , , , , , , , NOTES: Benefits Cap: The District benefits cap allocation for 2014/2015 is a three-tiered sliding cap. The cap is determined by the number of enrolled (the employee plus any dependents) in a medical plan (Blue Cross PPOs or Kaiser HMOs). The cap is $7,371 for employee-only medical coverage, $12,724 for employee plus one dependent, $16,483 for employee plus two or more dependents. Eligible part-time employees receive a pro-rata share of the annual allowance. A monthly payroll deduction will be taken September through June for employees who select a plan that exceeds the selected cap. Eligible Part-Time Employees: Eligible part-time employees are those who work 0.5 FTE or greater. OPUSD Enrollment Employee Payroll Deducts xlsx Page 5 of 12 8/4/14 8:40 AM

16 CVT Benefits Plan Anthem Blue Cross PPO Plan 7B Health Benefits Cap and Estimated Payroll Deductions for Full Time and Part-Time Employees IF YOU CHOOSE DENTAL VISION THE COST OF PREMIUMS WILL BE: 1.0 FTE PAYROLL DEDUCTION 0.9 FTE PAYROLL DEDUCTION THIS MEDICAL AND COVERAGE COVERAGE Medical Dental Vision Total District Payroll Deduction Pro-rated Payroll Deduction VISION COVERAGE: Cost Cost Cost Cost Cap (100%) Annual Monthly Cap (90%) Annual Monthly Employee Only Emp Emp 7, , $7, , , , Employee Only Emp+1 Emp+1 7, , , $7, , , , Employee Only Family Family 7, , , $7, , , , Employee+1 Dependent Emp Emp 13, , $12, , , , Employee+1 Dependent Emp+1 Emp+1 13, , , $12, , , , Employee+1 Dependent Family Family 13, , , $12, , , , Family Coverage Emp Emp 17, , $16, , , , Family Coverage Emp+1 Emp+1 17, , , $16, , , , Family Coverage Family Family 17, , , $16, , , , IF YOU CHOOSE DENTAL VISION 0.8 FTE PAYROLL DEDUCTION 0.75 FTE PAYROLL DEDUCTION 0.60 FTE PAYROLL DEDUCTION 0.50 FTE PAYROLL DEDUCTION THIS MEDICAL AND COVERAGE COVERAGE Pro-rated Payroll Deduction Pro-rated Payroll Deduction Pro-rated Payroll Deduction Pro-rated Payroll Deduction VISION COVERAGE: Cap (80%) Annual Monthly Cap (75%) Annual Monthly Cap (60%) Annual Monthly Cap (50%) Annual Monthly Employee Only Emp Emp 5, , , , , , , , Employee Only Emp+1 Emp+1 5, , , , , , , , Employee Only Family Family 5, , , , , , , , Employee+1 Dependent Emp Emp 10, , , , , , , , Employee+1 Dependent Emp+1 Emp+1 10, , , , , , , , Employee+1 Dependent Family Family 10, , , , , , , , Family Coverage Emp Emp 13, , , , , , , , Family Coverage Emp+1 Emp+1 13, , , , , , , , , Family Coverage Family Family 13, , , , , , , , , NOTES: Benefits Cap: The District benefits cap allocation for 2014/2015 is a three-tiered sliding cap. The cap is determined by the number of enrolled (the employee plus any dependents) in a medical plan (Blue Cross PPOs or Kaiser HMOs). The cap is $7,371 for employee-only medical coverage, $12,724 for employee plus one dependent, $16,483 for employee plus two or more dependents. Eligible part-time employees receive a pro-rata share of the annual allowance. A monthly payroll deduction will be taken September through June for employees who select a plan that exceeds the selected cap. Eligible Part-Time Employees: Eligible part-time employees are those who work 0.5 FTE or greater. OPUSD Enrollment Employee Payroll Deducts xlsx Page 6 of 12 8/4/14 8:40 AM

17 Anthem Blue Cross Wellness PPO Plan 1 RxC CVT Benefits Plan Health Benefits Cap and Estimated Payroll Deductions for Full Time and Part-Time Employees IF YOU CHOOSE DENTAL VISION THE COST OF PREMIUMS WILL BE: 1.0 FTE PAYROLL DEDUCTION 0.9 FTE PAYROLL DEDUCTION THIS MEDICAL AND COVERAGE COVERAGE Medical Dental Vision Total District Payroll Deduction Pro-rated Payroll Deduction VISION COVERAGE: Cost Cost Cost Cost Cap (100%) Annual Monthly Cap (90%) Annual Monthly Employee Only Emp Emp 7, , $7, , , , Employee Only Emp+1 Emp+1 7, , , $7, , , , Employee Only Family Family 7, , , $7, , , , Employee+1 Dependent Emp Emp 13, , $12, , , , Employee+1 Dependent Emp+1 Emp+1 13, , , $12, , , , Employee+1 Dependent Family Family 13, , , $12, , , , Family Coverage Emp Emp 17, , $16, , , , Family Coverage Emp+1 Emp+1 17, , , $16, , , , Family Coverage Family Family 17, , , $16, , , , IF YOU CHOOSE DENTAL VISION 0.8 FTE PAYROLL DEDUCTION 0.75 FTE PAYROLL DEDUCTION 0.60 FTE PAYROLL DEDUCTION 0.50 FTE PAYROLL DEDUCTION THIS MEDICAL AND COVERAGE COVERAGE Pro-rated Payroll Deduction Pro-rated Payroll Deduction Pro-rated Payroll Deduction Pro-rated Payroll Deduction VISION COVERAGE: Cap (80%) Annual Monthly Cap (75%) Annual Monthly Cap (60%) Annual Monthly Cap (50%) Annual Monthly Employee Only Emp Emp 5, , , , , , , , Employee Only Emp+1 Emp+1 5, , , , , , , , Employee Only Family Family 5, , , , , , , , Employee+1 Dependent Emp Emp 10, , , , , , , , Employee+1 Dependent Emp+1 Emp+1 10, , , , , , , , Employee+1 Dependent Family Family 10, , , , , , , , Family Coverage Emp Emp 13, , , , , , , , Family Coverage Emp+1 Emp+1 13, , , , , , , , , Family Coverage Family Family 13, , , , , , , , , NOTES: Benefits Cap: The District benefits cap allocation for 2014/2015 is a three-tiered sliding cap. The cap is determined by the number of enrolled (the employee plus any dependents) in a medical plan (Blue Cross PPOs or Kaiser HMOs). The cap is $7,371 for employee-only medical coverage, $12,724 for employee plus one dependent, $16,483 for employee plus two or more dependents. Eligible part-time employees receive a pro-rata share of the annual allowance. A monthly payroll deduction will be taken September through June for employees who select a plan that exceeds the selected cap. Eligible Part-Time Employees: Eligible part-time employees are those who work 0.5 FTE or greater. Wellness PPO 1 RxC.xlsx Page 1 of 1 8/6/ :37 AM

18 CVT Benefits Plan Anthem Blue Cross PPO HDHP 1 Rx Health Benefits Cap and Estimated Payroll Deductions for Full Time and Part-Time Employees IF YOU CHOOSE DENTAL VISION THE COST OF PREMIUMS WILL BE: 1.0 FTE PAYROLL DEDUCTION 0.9 FTE PAYROLL DEDUCTION THIS MEDICAL AND COVERAGE COVERAGE Medical Dental Vision Total District Payroll Deduction Pro-rated Payroll Deduction VISION COVERAGE: Cost Cost Cost Cost Cap (100%) Annual Monthly Cap (90%) Annual Monthly Employee Only Emp Emp 6, , $7, , Employee Only Emp+1 Emp+1 6, , , $7, , , Employee Only Family Family 6, , , $7, , , , Employee+1 Dependent Emp Emp 11, , $12, , Employee+1 Dependent Emp+1 Emp+1 11, , , $12, , , Employee+1 Dependent Family Family 11, , , $12, , , , Family Coverage Emp Emp 14, , $16, , Family Coverage Emp+1 Emp+1 14, , , $16, , , Family Coverage Family Family 14, , , $16, , , IF YOU CHOOSE DENTAL VISION 0.8 FTE PAYROLL DEDUCTION 0.75 FTE PAYROLL DEDUCTION 0.60 FTE PAYROLL DEDUCTION 0.50 FTE PAYROLL DEDUCTION THIS MEDICAL AND COVERAGE COVERAGE Pro-rated Payroll Deduction Pro-rated Payroll Deduction Pro-rated Payroll Deduction Pro-rated Payroll Deduction VISION COVERAGE: Cap (80%) Annual Monthly Cap (75%) Annual Monthly Cap (60%) Annual Monthly Cap (50%) Annual Monthly Employee Only Emp Emp 5, , , , , , , , Employee Only Emp+1 Emp+1 5, , , , , , , , Employee Only Family Family 5, , , , , , , , Employee+1 Dependent Emp Emp 10, , , , , , , , Employee+1 Dependent Emp+1 Emp+1 10, , , , , , , , Employee+1 Dependent Family Family 10, , , , , , , , Family Coverage Emp Emp 13, , , , , , , , Family Coverage Emp+1 Emp+1 13, , , , , , , , Family Coverage Family Family 13, , , , , , , , NOTES: Benefits Cap: The District benefits cap allocation for 2014/2015 is a three-tiered sliding cap. The cap is determined by the number of enrolled (the employee plus any dependents) in a medical plan (Blue Cross PPOs or Kaiser HMOs). The cap is $7,371 for employee-only medical coverage, $12,724 for employee plus one dependent, $16,483 for employee plus two or more dependents. Eligible part-time employees receive a pro-rata share of the annual allowance. A monthly payroll deduction will be taken September through June for employees who select a plan that exceeds the selected cap. Eligible Part-Time Employees: Eligible part-time employees are those who work 0.5 FTE or greater. OPUSD Enrollment Employee Payroll Deducts xlsx Page 9 of 12 8/4/14 8:40 AM