EMPLOYEE BENEFIT PROGRAM BENEFIT PLAN SUMMARY

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EMPLOYEE BENEFIT PROGRAM

2015- 2016 BENEFIT PLAN SUMMARY

F

OR

THE

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LAN

Y

EAR

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O

CTOBER

1, 2015 - S

EPTEMBER

30, 2016

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WHAT’S INSIDE

2015 Plan Year Updates….…………...3

What’s New for 2015?..…...………..………...3

Eligibility for Benefits………...….6

Rules for Benefit Changes During the Year……….………..……..…...7

Benefits Plan Comparison Chart…..……...8

Dental Plan Summary ………....…..12

Vision Plan Summary………...….…....13

Health Savings Account (HSA)….……...14

Life/ AD&D ………....…….…....16

Supplemental Life/AD&D…..………18

Flexible Benefits Plan……….….…….……....19

403 (B) and 457 (B) Plans.…….………..…....20

Employee Assistance Program...….…….…..20

Frequently Asked Questions…..…….……...21

Employee Self Service (ESS)….…….……...22

Required Federal Notices..…….……..……....23

Contacts……….…….……….24

Dear Santa Barbara Unified School District Employee:

The Santa Barbara Unified School District takes pride in offering its employees an array of benefit program options that provides flexibility for the diverse and changing needs of employees. It is our goal to provide you and your family members with a "best-in-class" benefits program at an affordable price.

To achieve that mission, the district offers comprehensive benefits. We provide medical, dental and vision plans. We encourage you to carefully review all the information provided in this booklet.

IMPORTANT NOTICE

The information in this brochure is a general outline of the benefits offered under the Santa Barbara Unified School District’s benefits program. This brochure may not include all relevant limitations and conditions. Specific details and limitations are provided in the plan documents, which may include a Summary Plan Description (SPD), Evidence of Coverage (EOC), and/or insurance policies. The plan documents contain the relevant plan provisions. If the information in this brochure differs from the plan documents, the plan documents will prevail.

If you (and/or your dependents) have

Medicare or will become eligible for

Medicare in the next 12 months, a

Federal law gives you more choices

about your prescription drug coverage.

Please see visit the SBUSD website,

www.sbunified.org/benefits

for more

details or call Human Resources at

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YOUR CHOICE, YOUR OPPORTUNITY

Open Enrollment is your once-a-year opportunity to:

● Continue your current benefits coverage if you are already enrolled ● Drop a plan you are in today if you have other coverage

● Change your benefits coverage

● Add or drop eligible family members to your benefits coverage

2015 PLAN YEAR UPDATES

Santa Barbara Unified School District (SBUSD) will continue to offer the Anthem PPO plans, the Anthem High Deductible Health Plan and the Kaiser HMO plan for the 2015 - 2016 plan year. Please refer to pages 8 - 11 for detailed plan information. Additionally, the benefit summaries can be found on the SBUSD website, www.sbunified.org/benefits, for your review. All enrollment forms must be completed and returned to the district office no later than Thursday, August 27, 2015.

SBUSD will continue to offer the Delta Dental PPO dental plan and the VSP vision plan with no benefit changes for the 2015-2016 plan year.

Your choice of benefit plans are listed below.

● Anthem Blue Cross (SISC)

◇ _{80-E PPO Plan 1} ◇ 80-G PPO Plan 2

◇ 80-M PPO Plan 3 - Annual Deductible and Out-of-Pocket Maximum are now lower.

◇ _{High Deductible Health Plan (HDHP) - the individual annual deductible will increase to $3.000.}

● Kaiser Permanente (SISC)

◇ HMO - Traditional Plan - now includes Chiropractic and Acupuncture

● Delta Dental (SISC) - Premier PPO Incentive dental plan ● VSP (SISC) - Vision Service Plan

● Cigna - Life/Accidental Death and Dismemberment / Dependent Life

- New Voluntary Life and AD&D plans

WHAT’S NEW FOR 2015?

Employee Self Service (ESS) - Online Enrollment

The District has implemented a new web-based application, Employee Self Service (ESS), that allows all employees to enroll online for their benefits. For Open Enrollment, all employees

must log into ESS in order to continue their medical, dental and vision coverage for the 2015 - 2016 plan year. Please refer to pages 22 and 23 for instructions on how to access and

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WHAT’S NEW FOR 2015?

Anthem 80-M PPO Plan - Annual Deductible and Out-of-Pocket Maximums

Due to Health Care Reform, the annual deductible and Out-of-Pocket maximums will be lower. The annual deductible will now be $3,000 for an individual and $6,000 for family. The annual Out-of-Pocket maximum will be reduced to $4,000 for an individual and $8,000 for a family.

Anthem HDHP Plan - Increase in Individual Deductible

The individual annual deductible will increase to $3,000; no changes to the family deductible.

Anthem Plans / Pharmacy - Diabetic Test Strips and Out-of-Pocket Maximums

If you use diabetic test strips, you will be notified by Navitus, 90-days prior to October 1, of a pharmacy benefit change regarding test strips. They will instruct you on how to switch to test strips from Abbot (Freestyle) and Lifescan (One Touch). These test strips will have a generic co-pay as of October 1 while all others will be covered at the brand co-co-pay amount. A new meter for these strips will be provided to you at no cost.

Due to Health Care Reform, a pharmacy Out-of-Pocket maximum is now noted. Once you reach this maximum, your prescription will be covered at 100%.

Anthem - X-Ray & Lab, Durable Medical Equipment and Physical Medicine

(includes Chiropractic) Out-of-Network Benefit Change

For all PPO plans, X-rays, labs, durable medical equipment and physical medicine will no longer be covered Out-of-Network. Physical medicine includes chiropractic and physical and occupa-tional therapy. This change does not apply to emergencies.

Anthem - Hip, Knee, and Spine Inpatient Surgical Benefit Change

For all PPO plans, effective 10/01/2015, the Blue Distinction Specialty Care program will be implemented for inpatient hip and knee replacements and spine procedures. There will be no Out-of-Network benefit for these inpatient procedures. For detailed information, go to www.anthem.com/ca/sisc.

Anthem - Process Change for Member Also Covered by Other Plans

Effective 07/01/2015, Anthem members that have coverage under another medical plan need to provide Anthem with information on their other medical coverage. A response is required when you receive a letter requesting this information from Anthem. Failure to reply may cause a delay or denial of your claims processing and payment.

Kaiser HMO - Chiropractic and Acupuncture Benefit

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WHAT’S NEW FOR 2015?

New Benefit Offering - Cigna Voluntary Term Life Insurance and AD&D

SBUSD will be offering a group Voluntary Term Life and an Accidental Death & Dismemberment (AD&D) insurance benefit through Cigna Healthcare. All benefit eligible employees may enroll. We will be having a special one-time Open Enrollment for Voluntary Term Life/AD&D such that if you choose coverage up to the Guaranteed Issue amount, you will not have to answer any medical questions or have a medical exam. You will also be able to enroll your dependents without underwriting approval.

For any amount elected after this one-time Open Enrollment period, any amount above the Guarantee Issue, other than your initial new hire eligibility period, you must provide evidence of insurability and be approved by Underwriting.

LegalShield - New Identity Theft & Family Legal Plan Benefit

SBUSD is offering a new Identify Theft and Family Legal plan benefit.

To enroll or for more information, go to www.legalshield.com/info/sbunified.

Why enroll in Term Life Insurance and AD&D?

Ensure continued financial resources for your family if anything may happen to you. A lump sum amount will be paid to your beneficiary to use for ongoing daily household costs (mortgage), unexpected expenses (medical costs) or special expenses (college).

Cigna Voluntary Life Benefit Highlights:

● You may elect amounts in increments of $10,000 up to $500,000.

● Can elect up to the Guaranteed Issue amount of $100,000 without medical questions. ● Spouse coverage in increments of $5,000 up to $250,000 but no more than 50% of

the coverage amount you have elected.

● Dependent life coverage in increments $1,000 up to $10,000. ● Automatic payroll deductions.

● Higher maximum amounts than an individual policy, at a lower cost.

Legal plan covers:

 Free phone consultations with a law firm  Trial defense services

 Contract and document review by attorney  Document preparation such as a will, living

will and residential loan assistance

Identity theft plan covers:

 Triple-Bureau credit monitoring and alerts  Personal credit score with analysis  Help with restoring your credit if you

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ELIGIBILITY FOR BENEFITS

You are eligible for SBUSD’s group benefits if your classification is offered benefits.

● Dependent Eligibility

The definition of dependent includes your spouse, domestic partner (must be registered with the California State Registry), and child(ren) up to age 26 (coverage stops when they turn 26) regardless of student or marital status. Child(ren) includes stepchild(ren), child(ren) placed under a “qualified medical child support order,” adopted child(ren) or child(ren) placed for adoption.

● Adding and Excluding Dependents

Newly acquired dependents may be added to the plan during the year by completing the necessary forms within 30 days of them becoming eligible. If you do not add them within the 30-day period, they will need to wait to enroll until the next Open Enrollment period. You may only add them during this 30 day window, otherwise, you may enroll them during the next Open Enrollment period which would be August of 2016, to be effective October 1, 2016.

Important No ce on Dependent Termina ons:

It is the employee’s responsibility to notify the district of any changes in eligibility status for their spouse, domestic partner or dependent(s) at the end of the month of one of the following:

For spouse : event of death OR final divorce decree is reached;

For domestic partner : event of death OR the Notice of Termination of Domestic Partnership or

nullity of the domestic partnership is complete OR if a domestic partner no longer qualifies as a domestic partner because of qualifying as a dependent;

For dependent : event of death OR final divorce is reached when step-child OR legal

guardianship is terminated OR when reach age 26 unless they have a disabled certification.

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RULES FOR BENEFIT CHANGES DURING THE YEAR

Other than during annual open enrollment, you may only make changes to your benefit elections if you experience a qualifying event or qualify for a “special enrollment”. If you qualify for a mid-year benefit change, you may be required to submit proof of the change or evidence of prior coverage.

QUALIFYING EVENTS INCLUDE:

● Change in legal marital status, including marriage, divorce, legal separation, annulment, and death of

a spouse.

● Change in number of dependents, including birth, adoption, placement for adoption, or death of a

dependent child.

● Change in employment status that affects benefit eligibility, including the start or termination of

employment by you, your spouse, or your dependent child.

● Change in work schedule, including an increase or decrease in hours of employment by you, your

spouse, or your dependent child, including a switch between part-time and full-time employment that affects eligibility for benefits.

● Change in a child's dependent status, either newly satisfying the requirements for dependent child

status or ceasing to satisfy them.

● Change in place of residence or worksite, including a change that affects the accessibility of network

providers.

● Change in your health coverage or your spouse's coverage attributable to your spouse's

employment.

● Change in an individual's eligibility for Medicare or Medicaid.

● A court order resulting from a divorce, legal separation, annulment, or change in legal custody

(including a Qualified Medical Child Support Order) requiring coverage for your child.

● An event that is a “special enrollment” under the Health Insurance Portability and Accountability

Act (HIPAA) including acquisition of a new dependent by marriage, birth or adoption, or loss of

coverage under another health insurance plan.

● An event that is allowed under the Children's Health Insurance Program (CHIP) Reauthorization

Act. Under provisions of the Act, employees have 60 days after the following events to request

enrollment:

● Employee or dependent loses eligibility for Medicaid (known as Medi-Cal in CA) or CHIP (known

as Healthy Families in CA).

● Employee or dependent becomes eligible to participate in a premium assistance program under

Medicaid or CHIP.

Two rules apply to making changes to your benefits during the year:

●

Any change you make must be consistent with the change in status, AND

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Insurance Carrier Anthem Blue Cross 80-E PPO Plan

Anthem Blue Cross 80-G PPO Plan

Calendar Year Deductible $300 / $600 $500 / $1,000

Annual Maximum Out-of-Pocket $1,000/ $3,000¹ $2,000 / $4,000¹

Doctor Visits (Co-Payment) Primary Care Physician

Specialist Preventive $20² (deductible waived) $20² (deductible waived) $0 $30² (deductible waived) $30² (deductible waived) $0 Hospitalization Inpatient Hospitalization Outpatient Hospitalization 20% of charges 20% of charges 20% of charges 20% of charges

Lab and X-ray

Lab and X-ray 20% of charges 20% of charges

Chiropractic & Acupuncture

Chiropractic Care (subject to

medical necessity)

Acupuncture (limited to 12 visits

per calendar year)

20% of charges 20% (limited to $50 / visit)

20% of charges (limits apply) 20% of charges

(limit up to $50 / visit)

Durable Medical Equipment

Rental or purchase of DME (including dialysis equipment & supplies) Prosthetics 20% of charges 20% of charges 20% of charges 20% of charges

Emergency & Urgent Care

Emergency Room (copay waived

if admitted to hospital)

$100 copay + 20% of charges $100 copay + 20% of charges

Urgent Care $20² (deductible waived) $30²

Ambulance 20% of charges 20% of charges

Benefits at a Glance Comparison

This comparison chart shows a brief summary of the medical benefits available. Option 1 Option 2

Notes:

1. All deductibles, copayments and coinsurance amounts apply towards the out-of-pocket maximums.

2. The dollar copay applies only to the office visit. An additional 20% copay applies for any services performed in office (i.e. X-ray, lab, surgery), after any applicable deductible

The benefit summaries, which have detailed plan information, can be found at the

district’s website,

www.sbunified.org/benefits

. The Out-of-Network benefits are

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Anthem Blue Cross PPO 80-M PPO Plan

Anthem Blue Cross PPO HDHP Plan

Kaiser Permanente HMO Traditional Plan $3,000 / $6,000 $3,000 / $5,000 None $4,000 / $8,000¹ $5,000/ $10,000¹ $1,500 / $3,000 $40² (deductible waived) $40² (deductible waived) $0 10% of allowable charges 10% of allowable charges $0 $30 $30 $0 20% of charges 20% of charges 10% of allowable charges 10% of allowable charges $0 $30 per procedure

20% of charges 10% of allowable charges $0

20% of charges 20% (limited to $50 / visit) 10% of allowable charges 10% (limited to $50 / visit) $10 - see Acupuncture $10 - 30 visits/year (combined

Chiro and Acupuncture)

20% of charges 20% of charges 10% of allowable charges 10% of allowable charges 20% of charges $0

$100 copay + 20% of charges $100 copay + 10% of allowable charges

$100 copay

$40² (deductible waived) 10% of allowable charges $30

20% of charges 10% of allowable charges $50 / trip

This summary is for informational purpose only. It does not amend, extend, or alter the current policy in any way. In the event information in this summary differs from the Plan Document, the Plan Document will prevail.

Of All Medical Plans / In-Network Only

This comparison chart shows a brief summary of the medical benefits available.

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Insurance Carrier Anthem Blue Cross 80-E PPO Plan

Anthem Blue Cross 80-G PPO Plan

Mental Health/Substance Abuse

Inpatient 20% of charges 20% of charges

Outpatient $20² (deductible waived) $30² (deductible waived)

Prescription Drugs Pharmacy vendor: Costco/Navitus Pharmacy vendor: Costco/Navitus Deductible for Brand Drugs

Out-of-Pocket Maximum Retail – 30 day supply - Costco Pharmacy

Mail Order – Costco Pharmacy (90 day supply)

- Navitus

(30 day supply only)

$200 Individual / $500 Family $2,500 Ind / $3,500 Family $10 Generic/$35 Brand³ $0 Generic/$35 Brand³ ( 30-day supply 4 ) $0 Generic/$90 Brand³ ( 90-day supply4) $0 Generic/$90 Brand³ ( 90-day supply4 ) $35 Specialty $200 Individual / $500 Family $2,500 Ind / $3,500 Family $10 Generic/$35 Brand³ $0 Generic/$35 Brand³ ( 30-day supply4 ) $0 Generic/$90 Brand³ ( 90-day supply4) $0 Generic/$90 Brand³ ( 90-day supply4) $35 Specialty

Skilled Nursing Facility

Semi-private room - subject to

utilization review (limited to 100 days/calendar year)

20% of charges

Pregnancy and Maternity

Physician Office Visit $20² (deductible waived) $30² (deductible waived)

Therapy

Physical, occupational, speech 20% of charges 20% of charges

Hospice

Inpatient or outpatient $0 $0

Home Health Care

Services and supplies - subject

to utilization review (limited to 100 days/calendar year)

20% of charges 20% of charges

Benefits at a Glance Comparison

This comparison chart shows a brief summary of the medical benefits available. Option 1 Option 2

Notes:

1. All deductibles, copayments and coinsurance amounts apply towards the out-of-pocket maximums.

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Of All Medical Plans / In-Network Only

This comparison chart shows a brief summary of the medical benefits available.

Option 3 Option 4 Option 5

Anthem Blue Cross 80-M PPO Plan

Anthem Blue Cross PPO HDHP Plan

Kaiser Permanente HMO Traditional Plan

Pharmacy vendor: Costco/Navitus Pharmacy vendor: Anthem Blue Cross Pharmacy vendor: Kaiser $200 Individual / $500 Family $2,500 Ind / $3,500 Family $10 Generic/$35 Brand³ $0 Generic/$35 Brand³ ( 30-day supply4 ) $0 Generic/$90 Brand³ ( 90-day supply4) $0 Generic/$90 Brand³ ( 90-day supply4) $35 Specialty Combined Medical/Pharmacy Deductible & Out-of-Pocket

$7 Generic/$25 Brand³ $14 Generic/$60 Brand³ N/A None None $10 Generic/$30 Brand Up to 100 day supply $10 Generic/$30 Brand Up to 100 day supply N/A 20% of charges 10% of allowable charges $0

$0 $0 $0

The benefit summaries, which have detailed plan information, can be found at the

district’s website,

www.sbunified.org/benefits

. The Out-of-Network benefits are

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Santa Barbara Unified School District www.deltadentalins.com

Group No: 7075-5401 Effective Date: 10-1-2015

Eligibility Primary enrollee, spouse and eligible dependent children to age 26 (includes

domestic partners)

Maximums The maximum benefit paid per calendar year is $1,700 per person in-network

The maximum benefit paid per calendar year is $1,500 per person out-of-network Waiting Period(s) Basic Services

None Major Services None Prosthodontics None Orthodontic None Benefits and

Covered Services* In-PPO Network** Out-of-PPO Network**

Diagnostic & Preventive Services (D & P)

Exams, two (2) cleanings, x-rays

70 -100 % 70 -100 %

Basic Services - Fillings, simple tooth extractions, sealants

70 -100 % 70 -100 %

Endodontics - (root canals) Cov-ered Under Basic Services

70 -100 % 70 -100 %

Periodontics - (gum treatment) Covered Under Basic Services

70 -100 % 70 -100 %

Oral Surgery - Covered Under Basic Services

70 -100 % 70 -100 %

Major Services - Crowns, inlays, onlays and cast restorations,

70 -100 % 70 -100 %

Prosthodontics - Bridges, dentures and implants

50 % 50 %

Orthodontic Benefits - dependent children only

50 % 50 %

Orthodontic Maximums Separate $1,500 Lifetime maximum per person

Dental Accident Benefits 100% (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 PPO contracted fees for in-network dentists and program allowance for out-of-network dentists. Delta Dental of California

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SISC and Vision Service Plan (VSP) provide you an affordable eyecare plan.

WellVision Exam® focuses on your eye health and overall wellness...every calendar year

$5.00 eye exam

Prescription Glasses

Lenses...every calendar year

Single vision, lined bifocal, and lined trifocal lenses Polycarbonate lenses for dependent children.

Frame...every other calendar year

$130.00 allowance for frame of your choice

20% off the amount over your allowance. ~OR~

Contact Lens Care...every calendar year

$105.00 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.

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-Network Reimbursement Amounts:

Exam...Up to $35.00 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

Note: Contact lenses are in lieu of spectacle lenses and frame.

VISION SERVICE PLAN THROUGH SISC

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HEALTH SAVINGS ACCOUNT (HSA)

A Health Saving Account (HSA) is available only to employees who participate in the Anthem Blue Cross High Deductible Health Plan (HDHP). An HSA is like an IRA for healthcare. It is a tax-advantaged personal savings or investment account that you can use to save and pay for qualified health expenses, now or in the future. Paired with a qualified high deductible health plan (HDHP), an HSA is a powerful financial tool that empowers you to be more actively involved in your healthcare decisions.

An HSA allows you to:

 Save toward medical expenses (including dental and vision), up to IRS maximums (see Table 1)

 Have your contributions deducted on a pre-tax basis  Change your contribution amount at any time

 Roll the funds to the following year (this is not a “use it or lose it” plan)  Keep the account; it is portable; it goes with you if you leave employment  Use a debit card to pay for qualified medical expenses

 Use the funds to pay for IRS tax dependents even if they are not enrolled in the HDHP

*These amounts are the maximum the IRS allows to contributed to your HSA.

IMPORTANT INFORMATION:

 If you have a Section 125 Flexible Benefit Plan (FBP) for 2015, you cannot open an HSA until the available funds in your 2015 FBP Healthcare account have been used, and the balance in your Healthcare FBP account is $0.

 You cannot have an HSA and be a dependent on another person’s health insurance plan, unless that plan is also a High Deductible Health Plan.

You must open an HSA account with Sterling HSA in order to make payroll contributions towards your HSA account. If you do not open an account, the district

will not be able to transfer your contributions into your HSA account. Table 1 - HSA Contribution Limits for 2016

Annual Single Contribution Maximum $3,350* Annual Family Contribution Maximum $6,750* Annual Catch-Up Contribution Maximum

(For HSA participants that are 55 years or older)

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HEALTH SAVINGS ACCOUNT (HSA)

How can I save by using an HSA?

Possible ways you will save:

 The monthly premium you pay may be lower  The money you place in your HSA is pre-taxed

 If you do not use the HSA funds, they roll-over year-to-year

Comparison of Out-of-Pocket Costs and Savings Per Plan Versus the HDHP Active Annual Cost

Including Medical & Rx Deductible HDHP Annual Cost Including Medical/Rx Deductible Estimated Annual Savings Classified: PPO - E Plan

Employee Only $5,768.36 $6,079.56 N/A

Employee + 1 $10,719.08 $10,601.48 $117.60

Family $13,463.12 $11,963.12 $1,500.00

PPO - G Plan

Employee Only $5,320.36 $6,079.56 N/A

Employee + 1 $9,808.68 $10,601.48 N/A

Family $11,991.12 $11,963.12 $28.00

PPO - M Plan

Employee Only $4,456.40 $6,079.56 N/A

Employee + 1 $11,309.48 $10,601.48 $708.00

Family $12,008.72 $11,963.12 $45.60

Certificated:

PPO - E Plan

Employee Only $5,768.36 $6,079.56 N/A

Employee + 1 $10,719.08 $10,601.48 $117.60

Family $13,463.12 $11,963.12 $1,500.00

PPO - G Plan

Employee Only $5,320.36 $6,079.56 N/A

Employee + 1 $9,808.68 $10,601.48 N/A

Family $11,991.12 $11,963.12 $28.00

PPO - M Plan

Employee Only $6,063.56 $6,079.56 N/A

Employee + 1 $11,309.48 $10,601.48 $708.00

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BASIC LIFE / ACCIDENTAL DEATH AND DISMEMBERMENT (AD&D)

Santa Barbara Unified School District provides Basic Life insurance and Accidental Death and Dismemberment insurance through Cigna at no cost to you. All eligible full-time benefits employees are automatically enrolled in the Basic Life and AD&D as long as a form has been completed and returned to the Human Resources department.

* Note age reduction schedule: when you reach age 65, benefits will be reduced to 65%, at age 70 your benefits will be reduced 40% and at age 75 your benefits will reduce to 25%.

Added Benefits available to you at no cost through your Life insurance:

Healthy Rewards

The Health Rewards program offers you a variety of discount programs were you can save money on alternative services and products.

This program is easy to use. You can choose from a wide network of conveniently located participating providers by visiting CIGNA.com/rewards (password: savings) or by calling 1.800.258.3312.

Eligible Group Life Insurance Benefit*

Certificated / Classified Employees $30,000

Management $100,000

Children - birth to 6 months $500

Spouse $1,500 Children - 6 months to 19 years and up to 25 years

if full time student $1,500

Eligible Group AD&D Benefit*

Certificated / Classified Employees $30,000

Management $100,000

Children - birth to 6 months $500

Spouse $1,500 Children - 6 months to 19 years and up to 25 years

if full time student $1,500

Weight Management and Nutrition Healthyroads Weight Management Program Registered Dietician Network

Jenny Craig

Vision and Hearing Care Exams, Eyewear and Contacts LASIK Vision Correction Hearing Exams and Aids

Alternative Medicine

Acupuncture / Chiropractic Care / Massage Therapy Mind/Body

Healthyroads Mind/Body Program Fitness

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BASIC LIFE / ACCIDENTAL DEATH AND DISMEMBERMENT (AD&D)

CIGNA Will Preparation Program

Cigna’s Will Center is secure, easy to use and available at CIGNAWillCenter.com seven days a week, 365 days a year. Employees can complete life and health care legal documents online, such as:

● Last Will & Testament - specifies what can be done with property, appoints an estate executor and

identifies a guardian for minor children

● Living Will - contains your wishes regarding use of extraordinary life support or other life-sustaining

medical treatment when there’s no hope of recovery

● Health Care Power of Attorney - grants someone permission to make medical decisions if you are

unable to do so

● Financial Power of Attorney - grants someone permission to make financial decisions on your

behalf if you are unable to do so

● Medical Authorization for Minors - allows parents/guardians to provide authorization for medical

personnel to treat a child in the event they are not present

Secure Travel Program

This free of cost program offers you peace of mind when you travel in the event that an unfortunate situation arises - injury, illness, death , theft, natural disaster, disease outbreak or terrorism. To access benefits please call 888.226.4567 (Group #57). Program will assist with:

Identity Theft Program

The Identity Theft Program provides access to personal case managers who give step-by-step assistance and guidance if you have had your identity stolen. You may call 888.226.4567 (Group #57) for assistance. This program will help with the following:

◇ Medical evacuation

◇ 24-hour multilingual assistance

◇ Pre-departure services, including foreign travel

◇ Medical referrals

◇ Prescription refill services

◇ Lost or stolen items

◇ Translation services

◇ Emergency travel services

◇ Embassy/consular referrals

◇ Travel/tourist advisories

◇ Cultural information

◇ Transportation of remains

● Determine if an ID theft has occurred

● Provide an Identify Theft kit

● Furnish an ID theft affidavit

● Reporting to credit agencies

● Placing fraud alerts

● Canceling lost/stolen credit cards

● Replacing credit cards

● Replacing stolen/lost documents

● Accessing free credit reports

● $1000 cash advance if traveling more than 100 miles from home

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NEW

‐ SUPPLEMENTAL LIFE / ACCIDENTAL DEATH AND DISMEMBERMENT (AD&D)

Santa Barbara Unified School District is offering a new group voluntary Life Insurance and Accidental Death and Dismemberment (AD&D) Insurance through Cigna. All benefit eligible employees may enroll. You may choose to enroll in the voluntary Life and/or the voluntary AD&D. Premiums are determined by your age and will be withheld from your paycheck.

* Note age reduction schedule: when you reach age 65, benefits will be reduced to 65%, at age 70 your benefits will be reduced 40% and at age 75 your benefits will reduce to 25%.

Class Amount of Supplemental Life Insurance*

Full Amount of AD&D Insurance*

Eligible Employees ● Can elect from $10,000 to

$500,000 in $10,000 increments

● Guaranteed issue amount is

$100,000

● Can elect from $10,000 to

$500,000 in increments of $10,000 not to exceed Basic Yearly Earnings

Spouse or

Domestic Partner

$250,000 in increments of $5,000 not to exceed 50% of Employee’s Supplemental Life Insurance amount

● Guaranteed issue amount is

$25,000

$250,000 in increments of $5,000

● Spouse coverage terminates

at age 70

Child ● Birth to 6 months - benefit is $500

● Age from 6 months to 26 years -

can elect from $1,000 to $10,000 in increments of $1,000

● All amounts are Guaranteed issue

● Can elect from $1,000 to $10,000 in increments of $1,000

Why voluntary Term Life Insurance?

Life Insurance is an important part of any financial plan. It can help insure continued financial resources for your loved ones should something happen to you. Your family would receive a lump sum that they can use to pay funeral expenses, pay off a mortgage and other debts, cover their living expenses or take care of your children’s education.

Why voluntary Accident and Dismemberment (AD&D)?

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HEALTHCARE AND DEPENDENT CARE

SECTION 125 FLEXIBLE BENEFIT PLAN

Santa Barbara Unified School District offers you the opportunity to participate in a Healthcare and /or Dependent Care Flexible Benefit Plan (FBP) through American Fidelity.

REMEMBER! Enrollment in an FBP is not automatic; you must re-enroll

each new plan year if you wish to participate in an FBP for that plan year.

How your Flexible Benefit Plan (FBP) Works

Each year during the Open Enrollment period, you decide how much you want to contribute to one or both of the Flexible Benefit Plans.

Healthcare FBP

The Healthcare FBP is used to pay medical, dental, or vision expenses not paid for by your insurance such as deductibles, co-payments, and co-insurance amounts. Each pay period, the amount you designate is deducted from your paycheck before taxes are withheld in equal increments and then deposited to your Healthcare FBP. You can elect to contribute up to $2,500 annually into this account.

Dependent Care FBP

The Dependent Care FBP can be established to pay for certain expenses to care for dependents who live with you while you are at work. While this most commonly means child care, for children under the age of 13, it can also be used for children of any age who are physically or mentally incapable of self-care, as well as adult day care for elderly dependents who live with you, such as parents or grandparents. The Dependent Care FBP does NOT pay for medical care for your dependents. The amount that you decide to contribute to this account is deducted from your paycheck before taxes in equal increments and deposited into your Dependent Care FBP. You may elect to contribute up to $5,000 per household annually.

Be Cautious!!

* Only qualifying medical expenses incurred during the plan year will be eligible for reimbursement.

* Expenses will only be reimbursed if they are incurred during the 2015-2016 plan year (October 1, 2015 through September 30, 2016), or during the 90 days grace period. You will have till December 30, 2016 to submit reimbursement requests.

* You must spend all the money in your accounts, or you will lose it. IRS rules do not allow you to carry over an FBP balance from one year to the next, so be sure to estimate your contributions carefully.

* Once you enroll, you can only change your elected payroll contributions if there is a change in family status, such as: Marriage, Divorce, Death, Birth, Adoption, or Change in Employment Status.

* Money can not be transferred between the Health Care and Dependent Care FBP.

* You cannot open a Health Savings Account until the available fund in your FBP Healthcare account has been used and the balance is $0.

* If your employment with the district terminates, you can only be reimbursed for claims incurred up to your last day of employment.

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403 (B) AND 457 (B) PLANS

Santa Barbara Unified School District sponsors voluntary retirement plans that include a 403 (b) Plan and 457 (b) Deferred Compensation plan. Participation is completely voluntary.

403 (b) Plan

A 403 (b) plan is a way for you to save for retirement and other long-term financial needs. Payroll deductions are contributed on a tax-deferred basis which reduce your current income tax and allows the money in the plan to grow untaxed until you withdraw it after retirement. If you do not have internet access or need assistance, please call CalSTRS 403 (b) Comply at 888.892.7494 and they can assist you by phone. To make a 403 (b) salary reduction election or a change online, please follow the instructions below.

1. Go to www.CalSTRS403bComply.com

2. Click on “Login to Retirement Solution” on the left side of the screen 3. If you are currently a participant in the 403(b) plan:

a. Click on “Login”

b. Enter your Social Security Number as the User ID and the last four numbers of your Social Security Number for the Password, then click on “Participant”

4. If you are not currently a participant in the 403(b) plan: a. Click on “Login”

b. Choose “New to the System, Enroll Now”

c. Enter Your Social Security Number as the User ID

d. Enter Your Social Security Number as the User ID and the Plan Password for your employer (this is available online under “Plan Description”)

5. If you have any problems, please call CalSTRS 403b Comply Customer Service at (888) 892-7494

457 (b) Plan

To obtain 457 (b) plan information, please call Plan Member Securities Corporation at 805.845.8172 or online at www.planmember.com.

The Save A Valuable Employee (SAVE) Employee Assistance Program (EAP) offers free, professional, confidential assistance with personal and workplace problems. The program is available to employees and their immediate family members. You have 24 hour toll-free phone access to EAP professionals seven days a week. This program is voluntary, completely confidential, and the initial consultation is available at no cost to you.

EAP has trained counselors who can assist with:

- Child & elder care assistance - Organizing life’s affairs

- Financial issues - Drug and alcohol dependency - Stress, anxiety, and depression - Legal services

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I am currently enrolled in an Anthem Blue Cross HMO medical plan and need to switch to a PPO, what do I do?

You check the appropriate box on Employee Self Service (ESS) Open Enrollment for the PPO medical plan that you desire and no change form is needed.

I am currently enrolled in a PPO medical plan and wish to switch to a different PPO plan, what do I do?

You check the appropriate box on ESS online Open Enrollment for the PPO medical plan that you desire and no change form is needed.

I am currently on a PPO medical plan and wish to switch to the Kaiser Permanente HMO medical plan, what do I do?

If enrolling in the Kaiser HMO medical plan, you must check the appropriate box on ESS online Open Enrollment and complete a Kaiser medical enrollment form, available online at the District website, www.sbunified.org/benefits.

I wish to remain on the same plans, what do I do?

You check the appropriate boxes on ESS online Open Enrollment for continued plan.

If I am adding/deleting a dependent, what do I do?

You need to complete a change form, add dependent information online, and provide appropriate documentation (i.e. birth certificate, marriage certificate, domestic partnership forms). All forms are available online at District website, www.sbunified.org/benefits.

What do I do if I want to change my Kaiser Primary Care Physician?

You must call Kaiser Permanente Customer Service at (800) 464-4000 and change providers. You must call before the 15th of the month in order for this change to be effective the 1st of the following month.

How do I find a Medical Provider on an Anthem plan?

Log onto www.anthem.com/ca/sisc and click on Find a Doctor, enter the information requested with criteria you want. A list of doctors will be produced so you can view or print.

What if I have a problem with a doctor’s bill?

The first thing that you should do is contact your Primary Care Physician or call your carrier’s Customer Service telephone number listed on your insurance card.

I need to change my mailing address? Call the Santa Barbara Unified School District Human Resources Office to change your address or change on Employee Self Service (ESS).

What do I do if I need a new medical card?

Call Anthem Blue Cross Customer Service at (800) 322-5709 or Kaiser Permanente Customer Service at (800) 464-4000.

What do I do if I need a new dental card?

Delta Dental does not provide a dental insurance card. You may download a card from their website: www.deltadentalins.com. The Customer Service telephone number is (866) 499-3001.

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EMPLOYEE SELF SERVICE (ESS)

What do I do if I need a vision insurance card? Or need to find a Vision Provider?

Vision Service Plan (VSP) does not provide insurance cards. You inform the vision provider that you have VSP through SISC and they will look you up by your social security number. To find a provider, call Vision Service Plan (VSP) at (800) 877-7195 or use their website: www.vsp.com.

I will be turning 65 and become eligible for Medicare, what will I need to do?

Upon reaching age 65, you will continue to be on the Anthem Blue Cross or Kaiser Permanente medical plans unless you want to cancel your coverage through SBUSD or you retire.

All forms and information are available at the SBUSD website, www.sbunified.org/benefits.

FREQUENTLY ASKED QUESTIONS (FAQ)

How do I log onto Employee Self Service (ESS)?

Enrolling for Benefits Using Employee Self Service (ESS) ?

Employee Self Service (ESS) is a web-based application that allows employees to privately access personal and payroll information. In addition to enrolling for benefits, you can access the following information: View Certifications, Pay/Tax Information, Personal Information, Leave Balances, etc. This application serves as a 24/7 resource for all employees to access from any device at their convenience.

How to Access Employee Self Service (ESS)

User name is your employee identification number, which is located in the top left hand corner of your paycheck. For a more secure system, employees should memorize this number to avoid using your social security number.

Open internet browser and in the URL address field, type: https://selfservice.sbunified.org/ mss// enter.

Follow the instructions below:

First time users, enter the last four digits of your Social Security Number as the default

password. Returning users, enter your six digit employee identification number and password. If you have forgotten your password, call 963-4338 ext. 4357.

Click Log In. First time users will be prompted to change their password. Your new password must contain a minimum of eight characters, alphanumeric with upper and lower case letters, and at least one special character such as @,#,$,%,*. Passwords cannot start with a special character.

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EMPLOYEE SELF SERVICE (ESS)

REQUIRED FEDERAL NOTICES

The Santa Barbara Unified School District (SBUSD) is required every year to inform our employee of specific federal notices. You may find a copy of these notices on the SBUSD website, www.sbunified.org/benefits. If you would like a paper copy of any one of the notices, please contact our Human Resources and they will supply you with a hardcopy.

The required federal notices that can be found on our website are: 1. The Women’s Health and Cancer Rights Act

2. Notice of Availability of HIPPA Privacy Notice

3. The Premium Assistance Under Medicaid and the Children’s Health Insurance Program (CHIP)

4. Important Notice about Your Prescription Drug Coverage and Medicare 5. The Summary of Benefits and Coverage (SBC) for all of our medical plans

How do I enroll on Employee Self Service (ESS)?

To begin the enrollment process:

- Click on the Employee Self-Service link

- Click on the Benefits tab (this tab shows you your current elections for 2014-15) - Click on the Open Enrollment tab

Once in the Open Enrollment Section:

You will see several columns: Benefit, Current Election, and New Election. 1. Review your current elections listed in the Current Benefit column.

2. When you make your elections for 2015-16, your choices and costs per pay period will show up in the New Election column.

3. You will need to reconfirm your medical benefit election and click on the Add Coverage for each of your dependents. Please have you dependents Social Security Number with you. 4. On all benefit options, you will have the option of “No Changes” which means you want your

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Employee Benefits Brochure designed and developed by

In conjunction with the Santa Barbara Unified School District, October 2015

The information in this brochure is a general outline of the benefits offered under the Santa Barbara Unified School District benefits program. Specific details and plan limitations are provided in the Summary Plan Description (SPD), which is based on the official Plan Documents that may include policies, contracts and plan procedures. The SPD and Plan Documents contain all the specific provisions of the plans. In the event that the information in this brochure differs from the Plan Documents, the Plan Documents will prevail.

KEY CONTACT

TELEPHONE

WEBSITE

Santa Barbara Unified School District

Human Resources/Benefits: Noemi Vazquez

(805) 963-4338,

Ext. 6242 nvazquez@sbsdk12.org

Anthem Blue Cross of California PPO

(HDHP members call Anthem for Pharmacy questions)

(800) 322-5709 www.anthem.com/ca/sisc

Kaiser Permanente (800) 464-4000 www.kp.org

Delta Dental - SISC (866) 499-3001 www.deltadentalins.com

Vision Service Plan (VSP) (800) 877-7195 www.vsp.com

American Fidelity (Flexible

Spending) (800) 365-9180 www.afadvantage.com

SAVE - Employee Assistance

Program (805) 962-5387 www.savesb.org

CalSTRS403bComply (888) 892-7494 www.calSTRS403bComply.

com

JEM Resources (800) 943-9179 www.jemtpa.com

Plan Member Securities Corp. (805) 845-8172 www.planmember.com

Pacific Educators, Inc. (800) 722-3365 www.PEinsurance.com

Sterling HSA (800) 617-4729 www.sterlinghsa.com

Navitus Health Solutions -

Pharmacy vendor for Anthem 80-E PPO, 80-G PPO and 80-M PPO

(866) 333-2757 www.navitus

LegalShield (866) 288-5229 www.legalshield.com/info/

EMPLOYEE BENEFIT PROGRAM BENEFIT PLAN SUMMARY