Health Benefits

Antelope Valley Union High School District is proud to offer a variety of health care providers and plan options, and pay a significant portion of the monthly health benefit cost for its employees. See below for specific teacher monthly contributions by tenure status and plan option.

2018/2019 certificated rates

HEALTH PLANS
INCLUDES DENTAL, VISION, EAP, AND LIFE INSURANCE
FULL &
PRELIMINARY
PIPS/STIP/
WAIVER/INTERN
     
Blue Cross PPO Opt 1 (90/10%)    
Deductible $100/$300, Co-ins $1000/$3000, Office Visit $10, RX $7/$25    
Delta Incentive $515.16 $1,088.70
Delta DPO $537.36 $1,133.10
Delta PMI $449.70 $957.78
     
Blue Cross PPO Opt 2 (100%)    
Deductible $100/$300, Co-ins $0, Office Visit $0, RX $7/$25    
Delta Incentive $614.76 $1,287.90
Delta DPO $636.96 $1,332.30
Delta PMI $549.30 $1,156.98
     
Blue Cross PPO Opt 3 (90/10%)    
Deductible $300/$600, Co-ins $1000/$3000, Office Visit $20, RX $7/$25    
Delta Incentive $347.16 $752.70
Delta DPO $369.36 $797.10
Delta PMI $281.70 $621.78
     
Blue Cross PPO Opt 4 (80/20%)    
Deductible $2000/$4000, co-ins $4000/$8000, Office Visit $30, RX $9/$35    
Delta Incentive $0.00 $45.54
Delta DPO $9.36 $77.10
Delta PMI $0.00 $0.00
     
Kaiser HMO Opt 1 (100%)    
Deductible $0, Co-ins $0, Office Visit $0, RX $5    
Delta Incentive $122.28 $302.94
Delta DPO $144.48 $347.34
Delta PMI $56.82 $172.02
     
Kaiser HMO Opt 2 (100%)    
Deductible $0, Co-ins $0, Office Visit $30, RX $10/$30    
Delta Incentive $7.08 $72.54
Delta DPO $29.28 $116.94
Delta PMI $0.00 $0.00

 

2018/19 Certificated Rates (TENTATIVE) Effective October 1, 2018

 

Benefits Forms

2018-19 Open Enrollment Change Form

Use this form if changing medical and/or dental plans

Blue Cross Enrollment Form

Use this form if changing from Kaiser to Blue Cross plan. If switching from a HMO to a PPO, there will be a deductible to satisfy.

Kaiser Enrollment Form

Use this form if changing from Blue Cross to Kaiser plan

Life Insurance Change Form

Use this form to update your beneficiaries. Can update anytime, does not have to be during Open Enrollment.

An employee can add a dependent outside of Open Enrollment due to qualifying events (loss of eligibility from elsewhere, new marriage, birth, adoption, or legal guardianship). Please notify Majella Nilo within 30 calendar days of the qualifying event, or you will have to wait until the next Open Enrollment period.

Dental Plans

Delta Premier-AKA Incentive:

Pays a yearly in-network maximum of $1700 per family member per calendar year. If you go out of network they will pay $1500 per calendar year. Benefits start paying at 70% and increase yearly by 10% as long as you see a dentist each year. If you change your plan at any time and return to this plan, you automatically start back at 70%. This plan does not have any Orthodontic benefits.

DPO-Aka PPO:

Pays 100% as long as you see an in-network dentist. They will pay 50% if you go outside of the network. The maximum yearly amount paid per person is $2000. This plan includes a $3000 lifetime Orthodontic benefit for adults and children.

PMI-Aka Delta Care USA:

This plan does not have a yearly maximum, and it does have a small Orthodontic benefit. There are a limited network of dentists who accept this plan. You must chose an in-network {PMI} dentist, or PMI will assign you a dentist. You must be seen by the dentist you are assigned or PMI will not pay. This is a very basic dental plan.

Please note: Always check with your dentist prior to your appointment for any co-pays, etc. Remember, even if your dentist accepts Delta Dental, it does not mean that you will not have a balance after your benefits pay.

This has been a brief overview, for additional information regarding Delta Dental, please visit their website at https://www.deltadentalins.com

 

INCENTIVE/PREMIER

Plan Benefit Highlights for: PPO Incentive ($1,700/$1,500) no Orthodontic
Group No: Active, Retirees, and Cobra
Network: PPO/Premier*

*The plan provides an additional $200 toward the calendar year maximum when you visit a PPO dentist. Look for this information for the dentist of your choice on the Delta find a provider website to take advantane of this additional amount: (Other network affiliations: Delta Dental PPO)

In this incentive plan, Delta Dental pays 70% of the contract allowance for covered basic services and major services during the first year of eligibility. The coinsurance percentage will increase by 10% each year (to a maximum of 100%) 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 70%.

Eligibility Primary enrollee, spouse (includes domestic partner) and eligible dependent children to age 26
Deductibles N/A
Deductibles waived for D&P? N/A
Maximums The maximum benefit paid per calendar year is $1,700* per person in-network
(this amount includes the additional $200 for using a PPO dentist. See note above under Network)
The maximum benefit paid per calendar year is $1,500 per person out-of-network
Waiting Period(s) Basic Benefits
None
Major Benefits
None

 

Benefits and Covered Services* Delta Dental PPO dentists** Non-Delta Dental dentists**
Diagnostic & Preventive Services (D&P)
Exams, 2 cleanings per cal year, x-rays
70-100% 70-100%
Basic Services
Fillings, simple tooth extractions, sealants
70-100% 70-100%
Endodontics (root canals)
Covered 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, implants
50% 50%
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 PPO dentists, Premier contracted fees for Premier dentists and program allowance for out-of-network dentists.

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.

DPO/PPO

Plan Benefit Highlights for: PPO $2,000 with Orthodontic
Group No: Active and Cobra, (Retirees - exclude Orthodontic)

 

Eligibility Primary enrollee, spouse (includes domestic partner) and eligible dependent children to age 26
Deductibles In-Network: N/A
Out-of-Network: $25 per person, $75 per family, per plan year
Deductibles waived for D&P? In-Network: N/A
Out-of-Network: No
Maximums The maximum benefit paid per calendar year is $2,000 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-PPO Network** Out-of-PPO Network**
Diagnostic & Preventive Services (D&P)
Exams, 2 cleanings, x-rays
100% 50%
Basic Services
Fillings, simple tooth extractions, sealants
100% 50%
Endodontics (root canals)
Covered Under Basic Services
100% 50%
Periodontics (gum treatment)
Covered Under Basic Services
100% 50%
Oral Surgery
Covered Under Basic Services
100% 50%
Major Services
Crowns, inlays, onlays, and cast restorations
100% 50%
Prosthodontics
Bridges, dentures, implants
50% 50%
Orthodontic Benefits
Adults and dependent children
100% 100%
Orthodontic Maximums Separate $3,000 Lifetime maximum per person
Dental Accident Benefits 100% (separate $1,000 maximum
per person per calendar year)
50%

* 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 PPO dentists, Premier contracted fees for Premier dentists and program allowance for non-Delta Dental dentists.

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.

PMI

DeltaCare® USA
Advantages

DeltaCare USA is our prepaid plan that features set copayments, no annual deductibles and no maximums for covered benefits. In most states, enrollees must select a primary care dentist in the DeltaCare USA network from whom they receive treatment as in a traditional dental HMO.1

Our DeltaCare USA plans promote great dental health for your employees and their families with quality dental benefits at an affordable cost. By covering many diagnostic and preventive services at no cost or with very low copayments, we encourage regular preventive dental visits. Enrollees select a DeltaCare USA dentist to provide most covered services1. All of our network dentists' offices are independently-owned, and must adhere to Delta Dental's standards of care, quality and service.

Benefits
  • Extensive benefits
  • No deductible or annual dollar maximums
  • No copayments or low copayments for most diagnostic and preventive services
  • Coverage for more than 250 procedures, including additional cleanings, bleaching, and tooth whitening
  • No exclusions for pre-existing conditions or missing teeth
  • Clearly defined out-of-pocket costs
  • Low turnover of network dentists; enrollees can establish a long-term relationship with their dentists
  • Ability to change selected or assigned network dentists via telephone or Internet
  • Easy referrals to a large specialty care network
  • No claim forms to complete
  • Expanded business hours for toll-free customer service
  • Outstanding quality assurance program that includes credentialing, a quality management program and regular office visits

1In Alaska, Connecticut, Louisiana, Maine, Mississippi, Montana, New Hampshire, Oklahoma, South Dakota and Vermont, DeltaCare USA is offered as an open access plan where enrollees can obtain treatment from any licensed dentist; however, deductibles and maximums may be applied to out-of-network treatment.