LMUSD CERTIFICATED PLANS

LMUSD CERTIFICATED PLANS 2017-2018 Plan A 100-A $20 Plan B 100-D $20 Plan C 90-G $20 Plan D 80-G $20 Plan E 80-M $40 2-Tier ANCH BRONZE MEDICAL - CALENDAR YEAR Deductibles & Maximums Member Pays Member Pays Member Pays Member Pays Member Pays Member Pays Individual/Family Deductibles $0/$0 $300/$600 $500/$1,000 $500/$1,000 Individual/Family Out-of-Pocket (OOP) Max (includes medical deductibles, co-insurance and co-pays) PROFESSIONAL SERVICES $1,000/ $3,000 $1,000/ $3,000 $1,000/ $3,000 $2,000/ $4,000 $3,000/ $6,000 $4,000/ $8,000 $5,000/ $10,000* $6,350/ $12,700* *Includes Rx Office Visit (OV) co-pay $20 $20 $20 $20 $40 Urgent Care co-pay $20 $20 $20 $20 $40 Specialists/Consultants co-pay $20 $20 $20 $20 $40 Prenatal, postnatal office visit co-pay $20 $20 $20 $20 $40 Scans: CT, CAT, MRI, PET etc. 1 3 Diagnostic X-ray & Laboratory Procedures 1 3 Infertility (diagnosis/treatment of causes of infertility) Not covered Not covered Not covered Not covered Not covered Not covered Preventive Care (includes physical exams & screenings) HOSPITAL & SKILLED NURSING FACILITY SERVICES Emergency Room visit (waived if admitted) 1 Inpatient Hospital (preauthorization required) 1 3 Outpatient Hospital 1 3 Surgery, Outpatient (performed in Surgery Center) 1 3 Surgery, Outpatient (performed in a Hospital) 1 3 3 MENTAL HEALTH & SUBSTANCE ABUSE TREATMENT INPATIENT: Facility Based Care (preauth required) 1 3 OUTPATIENT: Facility Based Care (preauth required) 1 3 OTHER SERVICES Acupuncture - Limits apply 1 3 Ambulance (Ground or Air) 1 Chiropractic - Limits apply 1 3 Durable Medical Equipment (DME) 1 3 Physical and Occupational Therapy - Limits apply 1 3 PHARMACY BENEFITS 3 Plan 200/10-35 200/10-35 200/10-35 200/10-35 200/10-35 Anchor Bronze Rx - Subject to Medical Ded. Individual/Family Brand & Specialty Rx Deductibles $200/$500 $200/$500 $200/$500 $200/$500 $200/$500 Included with Medical deductible Individual/Family Rx Out-of-Pocket (OOP) Max (includes Rx deductibles and co-pays) Included with Medical OOP Max Generic co-pay/30 days supply Brand co-pay/30 days supply $9 Specialty co-pay/up to 30 days supply Order (Generic-Brand co-pay/90 days supply) $0-$90 $0-$90 $0-$90 $0-$90 $0-$90 $18-$90

2 TIER ANCH BRONZE PLAN (70726B) Offer for Certificated Employees With the assistance of Self-Insured Schools of California (SISC), LMUSD is offering a plan in accordance with the Affordable Care Act effective 10/01/14. You are receiving this notice because our records indicate you fall within eligibility parameters. Enrollment in the plan is not required; however, in order to meet strict compliance requirements, you must return this form acknowledging receipt of the information providing the opportunity to enroll. If you wish to enroll please obtain enrollment paperwork from Human Resources. ELIGIBILITY - All Certificated employees holding one or more positions totaling 3 hours per day, five days per week are eligible to opt-in to this plan. Those opting in may elect a coverage level of employee or employee + child(ren); spouses, domestic partners and retirees may not be added. ENROLLMENT - Participation in the Bronze plan is voluntary. The plan year runs October 1 - September 30. Current staff and active subs eligible for the plan will be provided with a designated open enrollment period each year in which they may opt-in or out of the Bronze plan for the following plan year. If enrollment is elected, the employee must complete an enrollment form, provide required documentation (birth certificate) if enrolling dependent children, sign a payment agreement and remit the first premium payment due by the 20th of the month prior to the first coverage month. Those that choose to optout will be required to wait until the following year s open enrollment for the next opportunity to enroll. Newly-hired staff/subs falling within eligibility parameters of the plan will be provided the opportunity to enroll in time to begin coverage October 1st or the first day of the month following the date of hire (DOH) if hired mid-plan year, depending on DOH. 2 TIER ANCH BRONZE (70308B) Employees hired after 5/09/2000 are not eligible for the rebate per LMUTA CBA You Pay (10thly) Rebate EMPLOYEE ONLY $0.00 $203.25 EMPLOYEE + CHILD $0.00 $203.25 EMPLOYEE + CHILDREN. $0.00 $203.25 7 ANTHEM BLUE CROSS PLAN (GROUP #70308B) Medical & Prescription Deductible Calendar Year Out Of Pocket Max Office visit co-pay Prescriptions (generic / brand name) $5,000 indiv / $10,000 fam $6,350 indiv / $12,700 fam $60/visit for first 3 visits, then subject to deductible and co-insurance $9 / AFTER deductible is met

Lucia Mar Unified School District Certificated Delta Dental Plan (#7074-7716) Plan Benefit Highlights for: $1,500 without Orthodontic Group No: Active, Retiree, and Cobra Eligibility Primary enrollee, spouse (includes domestic partner) and eligible dependent children to age 26 Deductibles Deductibles waived for D & P? Maximums In-: N/A Out-of-: $25 per person, $75 per family, per plan year In-: N/A Out-of-: No The maximum benefit paid per calendar year is $1,500 per person in-network The maximum benefit paid per calendar year is $1,000 per person out-of-network Waiting Period(s) Basic Benefits None Major Benefits None Orthodontics None Benefits and Covered Services* In- ** Out-of- ** Diagnostic & Preventive Services (D & P) Exams, 3 cleanings, x-rays Basic Services Fillings, simple tooth extractions, sealants Endodontics (root canals) Covered Periodontics (gum treatment) Covered Oral Surgery Covered Major Services Crowns, inlays, onlays and cast restorations Prosthodontics Bridges, dentures, implants Dental Accident Benefits 50 % 50 % 10 (separate $1,000 maximum per person per calendar year) 5 * Limitations or waiting periods may apply for some benefits; some services may be excluded from your plan. Reimbursement is based on Delta Dental contract allowances and not necessarily each dentist s actual fees. ** Reimbursement is based on contracted fees for dentists, Premier contracted fees for Premier dentists and program allowance for non-delta Dental dentists. Delta Dental of California 100 First St. San Francisco, CA 94105 Customer Service 866-499-3001 Claims Address P.O. Box 997330 Sacramento, CA 95899-7330 deltadentalins.com This benefit information is not intended or designed to replace or serve as the plan s Evidence of Coverage or Summary Plan Description. If you have specific questions regarding the benefits, limitations or exclusions for your plan, please consult your company s benefits representative.

Lucia Mar Unified School District Certificated Delta Dental Premier Incentive Plan (#7074-7416) Plan Benefit Highlights for: Incentive ($1,700/$1,500) no Orthodontic Group No: Active, Retirees, and Cobra : /Premier *The plan provides an additional $200 toward the calendar year maximum when you visit a dentist. Look for this information for the dentist of your choice on the Delta find a provider website to take advantage of this additional amount: (Other network affiliations: Delta Dental ) In this incentive plan, Delta Dental pays 7 of the contract allowance for covered basic services and major services during the first year of eligibility. The coinsurance percentage will increase by 1 each year (to a maximum of 10) for each enrollee if that person visits the dentist at least once during the year. If an enrollee does not use the plan during the calendar year, the percentage remains at the level attained the previous year. If an enrollee becomes ineligible for benefits and later regains eligibility, the percentage will drop back to 7. Eligibility Deductibles Deductibles waived for D & P? Maximums Waiting Period(s) Primary enrollee, spouse (includes domestic partner) and eligible dependent children to age 26 N/A N/A The maximum benefit paid per calendar year is $1,700* per person in-network (this amount includes the additional $200 for using a dentist. See note above under ) The maximum benefit paid per calendar year is $ Basic Benefits None 1,500 per person out-of-network Major Benefits None Benefits and Covered Services* Diagnostic & Preventive Services (D & P) Exams, 3 cleanings per cal year, x-rays Basic Services Fillings, simple tooth extractions, sealants Endodontics (root canals) Covered Periodontics (gum treatment) Covered Oral Surgery Covered Major Services Crowns, inlays, onlays, and cast restorations Prosthodontics Bridges, dentures, implants Dental Accident Benefits In- Premier ** Non-Delta Providers** 50 % 5 UCR 10 (separate $1,000 maximum per person per calendar year) * Limitations or waiting periods may apply for some benefits; some services may be excluded from your plan. Reimbursement is based on Delta Dental contract allowances and not necessarily each dentist s actual fees. ** Reimbursement is based on contracted fees for dentists, Premier contracted fees for Premier dentists and program allowance for out-of-network dentists. Delta Dental of California 100 First St. San Francisco, CA 94105 Customer Service 866-499-3001 Claims Address P.O. Box 997330 Sacramento, CA 95899-7330 deltadentalins.com This benefit information is not intended or designed to replace or serve as the plan s Evidence of Coverage or Summary Plan Description. If you have specific questions regarding the benefits, limitations or exclusions for your plan, please consult your company s benefits representative.

Lucia Mar Unified School District Certificated Vision Plan SISC and VSP provide you an affordable eyecare plan. Signature Plan C Dual Copay $20/$25 Your Coverage from a VSP Doctor WellVision Exam focuses on your eye health and overall wellness... every calendar year Prescription Glasses Lenses... every calendar year Single vision, lined bifocal, lined trifocal lenses and tints. Polycarbonate lenses for dependent children. Frame... every calendar year $150.00 allowance for frame of your choice $170.00 featured frame brands off the amount over your allowance $80 allowance at Costco ~~ Contact Lens Allowance... every calendar year $105.00 allowance for contacts and the contact lens exam (fitting and evaluation).. Extra Discounts and Savings Glasses and Sunglasses Average 35-4 savings on all non-covered lens options 3 off additional glasses and sunglasses, including lens options, from the same VSP doctor on the same day as your WellVision Exam. Or get 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 Co-Payments Exam Copay $xx.xx Materials Copay (Glasses) $xx.xx If you see a non-vsp provider, you ll receive a lesser benefit. Before seeing a non-vsp provider, call us at 800.877.7195 for more details. Out-of- Reimbursement Amounts: Exam... Up to.00 Single vision lenses... Up to $25.00 Lined bifocal lenses... Up to $40.00 Lined trifocal lenses... Up to $50.00 Frame... Up to $30.00 Contacts... Up to $90.00 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.

LUCIA MAR UNIFIED SCHOOL DISTRICT 2017-2018 CERTIFICATED Insurance Rates YOUR ANNUAL DISTRICT PAID BENEFIT (FULL-TIME EMPLOYEES): $10,000.00 MEDICAL PLAN A 40316J NE EMPLOYEE ONLY $0.00 $4.65 $0.00 $20.25 EMPLOYEE + 1 DEP. $784.65 $0.00 $769.05 $0.00 EMPLOYEE + 2 ME DEP. $1,439.85 $0.00 $1,424.25 $0.00 MEDICAL PLAN B 40726E EMPLOYEE ONLY $0.00 $41.85 $0.00 $57.45 EMPLOYEE + 1 DEP. $712.65 $0.00 $697.05 $0.00 EMPLOYEE + 2 ME DEP. $1,336.65 $0.00 $1,321.05 $0.00 MEDICAL PLAN C 40308A EMPLOYEE ONLY $0.00 $110.25 $0.00 $125.85 EMPLOYEE + 1 DEP. $573.45 $0.00 $557.85 $0.00 EMPLOYEE + 2 ME DEP. $1,138.65 $0.00 $1,123.05 $0.00 MEDICAL PLAN D (40308D) EMPLOYEE ONLY $0.00 $155.85 $0.00 $171.45 EMPLOYEE + 1 DEP. $484.65 $0.00 $469.05 $0.00 EMPLOYEE + 2 ME DEP. $1,011.45 $0.00 $995.85 $0.00 MEDICAL PLAN E (40726C) NEW EMPLOYEE ONLY $0.00 $203.25 $0.00 $203.25 EMPLOYEE + 1 DEP. $202.65 $0.00 $187.05 $0.00 EMPLOYEE + 2 ME DEP. $609.45 $0.00 $593.85 $0.00 Packages A-E include $50,000 Life Ins, Vision, Behavioral Health & Supplemental Cancer coverage **Employees hired after 5/09/2000 are not elgible for the rebate per LMUTA CBA**