2016 Benefit Guide Beaumont ISD by Higginbotham Public Sector

BEAUMONT ISD

BENEFIT GUIDE EFFECTIVE: 09/01/2016 - 8/31/2017 www.mybenefitshub.com/beaumontisd

Table of Contents Benefit Contact Information How to Enroll Annual Benefit Enrollment 1. Benefit Updates 2. Section 125 Cafeteria Plan Guidelines 3. Annual Enrollment 4. Eligibility Requirements 5. Helpful Definitions 6. ACA Employee Responsibilities TRS Aetna Medical American Public Life MEDlink® Plan MDLIVE Telehealth Cigna Dental UnitedHealthCare Vision Aetna Long-Term Disability American Public Life Cancer American Public Life Accident AUL a OneAmerica Life and AD&D Texas Life Individual Life UNUM Critical Illness ID Watchdog Identity Theft Ceridian LifeWorks EAP NBS Flexible Spending Account

3 4-5 6-11 6 7 8 9 10 11 12-15 16-21 22-23 24-27 28-29 30-35 36-41 42-45 46-49 50-51 52-53 54-55 56-57 58-61

FLIP TO... PG. 4 HOW TO ENROLL

PG. 6 YOUR BENEFIT UPDATES: WHAT’S NEW

PG. 12 YOUR MEDICAL BENEFITS

Benefit Contact Information

Benefit Contact Information BENEFIT ADMINISTRATORS

EAP

PERMANENT LIFE

Financial Benefit Services (800) 583-6908 www.mybenefitshub.com/beaumontisd

Ceridian (855) 432-9367 www.ceridian.com

Texas Life (800) 283-9233 www.texaslife.com

TRS ACTIVECARE MEDICAL

VISION

TELEHEALTH

Aetna (800) 222-9205 www.trsactivecareaetna.com

UnitedHealthCare (800) 638-3120 www.myuhcvision.com

MDlive (888) 365-1663 www.consultmdlive.com

LIFE AND AD&D

EDUCATOR DISABILITY

IDENTIY THEFT

AUL a OneAmerica Company (800) 537-6442 www.oneamerica.com

Aetna (866) 326-1380 www.aetna.com

IDWatchdog (800) 237-1521 www.idwatchdog.com

MEDICAL SUPPLEMENT—MEDLINK ®

CANCER

COBRA (Medical)

American Public Life (800) 256-8606 www.ampublic.com

WellSystems (844) 752-5146

DENTAL

CRITICAL ILLNESS

FLEXIBLE SPENDING ACCOUNTS (FSA’S)

Cigna (800) 244-6224 www.cigna.com

UNUM (800) 275-8686 www.unum.com

National Benefit Services (800) 274-0503 www.nbsbenefits.com

How to Enroll On Your Device Enrolling in your benefits just got a lot easier! Text “bmontisd” to 313131 to receive everything you

TEXT

need to complete your enrollment.

“bmontisd” Avoid typing long URLs and scan

directly to your benefits website,

313131

to access plan information, benefit guide, benefit videos, and more!

TRY ME

SCAN:

On Your Computer Access THEbenefitsHUB from your

Our online benefit enrollment

computer, tablet or smartphone!

platform provides a simple and easy to navigate process. Enroll at your own pace, whether at home or at work. www.mybenefitshub.com/ beaumontisd delivers important benefit information with 24/7 access, as well as detailed plan information, rates and product videos.

! 4

Open Enrollment Tip For your User ID: If you have less than six (6) characters in your last name, use your full last name, followed by the first letter of your first name, followed by the last four (4) digits of your Social Security Number.

Go to:

Click Login

Enter Username & Password

www.mybenefitshub.com/beaumontisd

All login credentials have been RESET to the default described below:

Username:

Sample Username

lincola1234 Sample Password

The first six (6) characters of your last name, followed by the first letter of your first name, followed by the last four (4) digits of your Social Security Number.

lincoln1234

If you have six (6) or less characters in your last name,

If you have trouble

use your full last name, followed by the first letter of

logging in, click on the

your first name, followed by the last four (4) digits of

“Login Help Video”

your Social Security Number.

for assistance.

Default Password: Last Name* (lowercase, excluding punctuation) followed by the last four (4) digits of your Social Security Number.

Click on “Enrollment Instructions” for more information about how to enroll. 5

Annual Benefit Enrollment Benefit Updates - What’s New: NEW Cancer plan will be offered by American Public Life effective 9/1/16. Plan will be offered on guaranteed issued basis which means no application to complete or health questions to answer. High and Low plans will be offered and both plans offer a $50 Cancer Screening benefit one time per calendar year. 30 day waiting period applies to Internal Cancer first occurrence benefit and pre-existing conditions applies. Visit with an enroller on campus to learn more about plan and rates. No health questions to answer for the employee, spouse or dependents to obtain coverage. Pre-existing conditions apply only for new employees and those who have not been previously enrolled in the Allstate plan for 1 full year.  Current Allstate Cancer Plan will no longer be offered at

BISD effective 9/1/16. If you wish to continue your Allstate Cancer plan you will be required to contact Allstate at 800- 521-3535 and set-up a direct bill payment plan.  Employees currently enrolled in the Allstate plan will be automatically rolled into the same level of coverage in the new plan. Employees may change level and tier of coverage if desired.  Coverage is available for Employee, Employee & Spouse, Employee & Children, and Employee & Family.

Don’t Forget!  On site enrollment assistance will be available during August, please see enrollment schedule via

the benefits website at www.mybenefitshub.com/beaumontisd

SUMMARY PAGES

Section 125 Cafeteria Plan Guidelines A Cafeteria plan enables you to save money by using pre-tax dollars to pay for eligible group insurance premiums sponsored and offered by your employer. Enrollment is automatic unless you decline this benefit. Elections made during annual enrollment will become effective on the plan effective date and will remain in effect during the entire plan year.

CHANGES IN STATUS (CIS): Marital Status

Changes in benefit elections can occur only if you experience a qualifying event. You must present proof of a qualifying event to your Benefit Office within 31 days of your qualifying event and meet with your Benefit/HR Office to complete and sign the necessary paperwork in order to make a benefit election change. Benefit changes must be consistent with the qualifying event.

QUALIFYING EVENTS A change in marital status includes marriage, death of a spouse, divorce or annulment (legal separation is not recognized in all states).

A change in number of dependents includes the following: birth, adoption and placement for adoption. Change in Number of Tax You can add existing dependents not previously enrolled whenever a dependent gains eligibility as a Dependents result of a valid change in status event. Change in Status of Employment Affecting Coverage Eligibility

Change in employment status of the employee, or a spouse or dependent of the employee, that affects the individual's eligibility under an employer's plan includes commencement or termination of employment.

An event that causes an employee's dependent to satisfy or cease to satisfy coverage requirements Gain/Loss of Dependents' under an employer's plan may include change in age, student, marital, employment or tax dependent Eligibility Status status. If a judgment, decree, or order from a divorce, annulment or change in legal custody requires that you provide accident or health coverage for your dependent child (including a foster child who is your dependent), you may change your election to provide coverage for the dependent child. If the order Judgment/Decree/Order requires that another individual (including your spouse and former spouse) covers the dependent child and provides coverage under that individual's plan, you may change your election to revoke coverage only for that dependent child and only if the other individual actually provides the coverage. Eligibility for Government Gain or loss of Medicare/Medicaid coverage may trigger a permitted election change. Programs

SUMMARY PAGES

Annual Enrollment During your annual enrollment period, you have the opportunity

Where can I find forms?

to review, change or continue benefit elections each year.

For benefit summaries and claim forms, go to your benefit

Changes are not permitted during the plan year (outside of

website:

annual enrollment) unless a Section 125 qualifying event occurs.

www.mybenefitshub.com/beaumontisd. Click on the benefit plan you need information on (i.e., Dental) and you can find



Changes, additions or drops may be made only during the

the forms you need under the Benefits and Forms section.

annual enrollment period without a qualifying event. How can I find a Network Provider?

 Employees must review their personal information and verify that dependents they wish to provide coverage for are

ISD benefit website: www.mybenefitshub.com/beaumontisd.

included in the dependent profile. Additionally, you must

Click on the benefit plan you need information on (i.e.,

notify your employer of any discrepancy in personal and/or

Dental) and you can find provider search links under the Quick

benefit information.



For benefit summaries and claim forms, go to the Beaumont

Employees must confirm on each benefit screen (medical, dental, vision, etc.) that each dependent to be covered is selected in order to be included in the coverage for that particular benefit.

Links section. When will I receive ID cards? If the insurance carrier provides ID cards, you can expect to receive those 3-4 weeks after your effective date. For most dental and vision plans, you can login to the carrier website and print a temporary ID card or simply give your provider the insurance company’s phone number and they can call and

New Hire Enrollment All new hire enrollment elections must be completed in the online enrollment system within the first 31 days of benefit eligibility employment. Failure to complete elections during this timeframe will result in the forfeiture of coverage.

Q&A Who do I contact with Questions? For supplemental benefit questions, you can contact your Benefits Department or you can call Financial Benefit Services at 866-914-5202 for assistance.

verify your coverage if you do not have an ID card at that time. If you do not receive your ID card, you can call the carrier’s customer service number to request another card.

SUMMARY PAGES

your 2016 benefits become effective on September 1, 2016, you

Employee Eligibility Requirements

must be actively-at-work on September 1, 2016 to be eligible for your new benefits.

Medical Plans. Employees must work 20 regularly scheduled

Dependent Eligibility Requirements

hours each week for all supplemental benefits..

Dependent Eligibility: You can cover eligible dependent

Medical and Supplemental Benefits: Eligible employees must work 10 or more regularly scheduled hours each week for TRS

children under a benefit that offers dependent coverage, Eligible employees must be actively at work on the plan effective

provided you participate in the same benefit, through the

date for new benefits to be effective, meaning you are physically

maximum age listed below. Dependents cannot be double

capable of performing the functions of your job on the first day

covered by married spouses within Beaumont ISD as both

of work concurrent with the plan effective date. For example, if

employees and dependents.

PLAN

CARRIER

MAXIMUM AGE

Dental

Cigna

Vision

United Healthcare

Life

OneAmerica

MEDlink® Gap

American Public Life

Cancer

APL

Accident

American Public Life

Critical Illness

UNUM

Telehealth

MDLIVE

ID Theft Protection

IDWatchdog

If your dependent is disabled, coverage can continue past the maximum age under certain plans. If you have a disabled dependent who is reaching an ineligible age, you must provide a physician’s statement confirming your dependent’s disability. Contact your HR/Benefit Administrator to request a continuation of coverage. 9

SUMMARY PAGES

Helpful Definitions Actively at Work

In-Network

You are performing your regular occupation for the employer

Doctors, hospitals, optometrists, dentists and other providers

on a full-time basis, either at one of the employer’s usual

who have contracted with the plan as a network provider.

places of business or at some location to which the employer’s business requires you to travel. If you will not be actively at work beginning 9/1/2016 please notify your benefits administrator.

Annual Enrollment The period during which existing employees are given the opportunity to enroll in or change their current elections.

Annual Deductible The amount you pay each plan year before the plan begins to pay covered expenses.

Out of Pocket Maximum The most an eligible or insured person can pay in co-insurance for covered expenses.

Plan Year September 1st through August 31st

Pre-Existing Conditions Applies to any illness, injury or condition for which the participant has been under the care of a health care provider, taken prescriptions drugs or is under a health care provider’s orders to take drugs, or received medical care or services

Calendar Year January 1st through December 31st

Co-insurance After any applicable deductible, your share of the cost of a covered health care service, calculated as a percentage (for example, 20%) of the allowed amount for the service.

Guaranteed Coverage The amount of coverage you can elect without answering any medical questions or taking a health exam. Guaranteed coverage is only available during initial eligibility period. Actively-at-work and/or pre-existing condition exclusion provisions do apply, as applicable by carrier.

(including diagnostic and/or consultation services).

SUMMARY PAGES

ACA Employee Responsibilities Mandatory Medical Enrollment

ACA 101

After becoming eligible, you must elect or decline medical coverage offered through your employer.

Medical Election Employee chooses to elect on the Medical Plans offered.

Play or Pay Rules If you elect a medical plan offered through your employer, you will receive the IRS Tax Form 1095 -C. You will use this document to file your 1040 Tax Return. However, if you choose to decline medical coverage, you will be subject to the Individual Mandate Penalties, unless you have a minimum essential health plan.

Are you electing to enroll in the medical plan?

YES

RECEIVE 1095 -C NO PENALTIES

YES

RECEIVE 1095 -C NO PENALTIES

Are you receiving medical coverage elsewhere? *See examples below NO

ď&#x201A;ˇ

2016 & Beyond Penalty is $695 per adult and $347.50 per child ( up to $2,085 for a family) OR 2.5% of family income, whichever is greater.

PENALTIES ASSESSED

*Examples of other coverage: -Military -Medicare -Medicaid -Through a spouse -Marketplace exchange

AETNA

Medical

YOUR BENEFITS PACKAGE

About this Benefit Major medical insurance is a type of health care coverage that provides benefits for a broad range of medical expenses that may be incurred either on an inpatient or outpatient basis.

DID YOU KNOW?

More than 70% of adults across the United States are already being diagnosed with a chronic disease.

This is a general overview of your plan benefits. If the terms of this outline differ from your policy, the policy will govern. Additional plan details on covered expenses, limitations and exclusions are included in the summary plan description located on the Beaumont ISD Benefits Website: www.mybenefitshub.com/beaumontisd 12

2016-2017 TRS-ActiveCare Plan Highlights Effective September 1, 2016 through August 31, 2017 | In-Network Level of Benefits* Type of Service

ActiveCare 1-HD

ActiveCare Select or ActiveCare Select Whole Health

ActiveCare 2

(Baptist Health System and HealthTexas Medical Group; Baylor Scott & White Quality Alliance; Memorial Hermann Accountable Care Network; Seton Health Alliance) Deductible (per plan year)

$2,500 employee only $5,000 family

$1,200 individual $3,600 family

$1,000 individual $3,000 family

Out-of-Pocket Maximum (per plan year; does include medical deductible/ any medical copays/coinsurance/ any prescription drug deductible and applicable copays/coinsurance)

$6,550 individual $13,100 family (the individual out-of-pocket maximum only includes covered expenses incurred by that individual)

$6,850 individual $13,700 family

Coinsurance Plan pays (up to allowable amount) Participant pays (after deductible)

80% 20%

Office Visit Copay Participant pays

20% after deductible

$30 copay for primary $60 copay for specialist

$30 copay for primary $50 copay for specialist

Diagnostic Lab Participant pays

20% after deductible

Plan pays 100% (deductible waived) if performed at a Quest facility; 20% after deductible at other facility

Preventive Care See next page for a list of services

Plan pays 100%

Teladoc® Physician Services

$40 consultation fee (applies to deductible and out-of-pocket maximum)

Plan pays 100%

High-Tech Radiology (CT scan, MRI, nuclear medicine) Participant pays

20% after deductible

$100 copay plus 20% after deductible

Inpatient Hospital (preauthorization required) (facility charges) Participant pays

20% after deductible

$150 copay per day plus 20% after deductible ($750 maximum copay per admission)

$150 copay per day plus 20% after deductible($750 maximum copay per admission; $2,250 maximum copay per plan year)

Emergency Room (true emergency use) Participant pays

20% after deductible

$150 copay plus 20% after deductible (copay waived if admitted)

Outpatient Surgery Participant pays

20% after deductible

$150 copay per visit plus 20% after deductible

Bariatric Surgery Physician charges (only covered if performed at an IOQ facility) Participant pays

$5,000 copay plus 20% after deductible

Not covered

$5,000 copay (does not apply to out -of-pocket maximum) plus 20% after deductible

Prescription Drugs Drug deductible (per plan year)

Subject to plan year deductible

$0 for generic drugs $200 per person for brand-name drugs

Retail Short-Term (up to a 31-day supply) Participant pays • Generic copay • Brand copay (preferred list) • Brand copay (non-preferred list)

20% after deductible $20 $40** 50% coinsurance**

$20 $40** $65**

Retail Maintenance (after first fill; up to a 31-day supply) Participant pays • Generic copay • Brand copay (preferred list) • Brand copay (non-preferred list)

20% after deductible $35 $60** 50% coinsurance**

$35 $60** $90**

Mail Order and Retail-Plus (up to a 90-day supply) Participant pays • Generic copay • Brand copay (preferred list) • Brand copay (non-preferred list)

20% after deductible $45 $105*** 50% coinsurance

$45 $105*** $180***

Specialty Drugs Participant pays

20% after deductible

20% coinsurance per fill

$200 per fill (up to 31-day supply) $450 per fill (32- to 90-day supply)

A specialist is any physician other than family practitioner, internist, OB/GYN or pediatrician. *Illustrates benefits when in-network providers are used. For some plans non-network benefits are also available; there is no coverage for non-network benefits under the ActiveCare Select or ActiveCare Select Whole Health Plan; see Enrollment Guide for more information. Non-contracting providers may bill for amounts exceeding the allowable amount for covered services. Participants will be responsible for this balance bill amount, which maybe considerable. **If the patient obtains a brand-name drug when a generic equivalent is available, the patient will be responsible for the generic copayment plus the cost difference between the brand-name drug and the generic drug.

2016-2017 TRS-ActiveCare Plan Highlights Effective September 1, 2016 through August 31, 2017 | In-Network Level of Benefits* TRS-ActiveCare Plans—Preventive Care Network Benefits When Using In-Network Providers

(Provider must bill services as “preventive care”)

Preventive Care Services

ActiveCare 1-HD

ActiveCare Select or ActiveCare Select Whole Health

ActiveCare 2 Network

(Baptist Health System and HealthTexas Medical Group; Baylor Scott & White Quality Alliance; Memorial Hermann Accountable Care Network; Seton Health Alliance) Evidence−based items or services that have in effect a rating of “A” or “B” in the current recommendations of the United States Preventive Services Task Force (USPSTF) www.uspreventiveservicestaskforce.org/Page/Name/uspstf-aand-b-recommendations Immunizations recommended by the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention (CDC) with respect to the individual involved. Evidence−informed preventive care and screenings provided for in the comprehensive guidelines supported by the Health Resources and Services Administration (HRSA) for infants, children and adolescents. Additional preventive care and screenings for women, not described above, as provided for in comprehensive guidelines supported by the HRSA www.hhs.gov/healthcare/facts-and-features/fact-sheets/ preventive-services-covered-under-aca/ #CoveredPreventiveServicesforAdults For purposes of this benefit, the current recommendations of the USPSTF regarding breast cancer screening and mammography and prevention will be considered the most current (other than those issued in or around November 2009). The preventive care services described above may change as USPSTF, CDC and HRSA guidelines are modified. (Examples of covered services included are: Routine annual physicals (one per year); immunizations; well-child care; breastfeeding support, services and supplies; cancer screening mammograms; bone density test; screening for prostate cancer and colorectal cancer (including routine colonoscopies); smoking cessation counseling services and healthy diet counseling; and obesity screening/counseling.

Plan pays 100% (deductible waived)

Plan pays 100% (deductible waived; no copay required)

Some examples of preventive care frequency and services:  Routine physicals – annually age 12 and over  Well-child care – unlimited up to age 12  Well woman exam & pap smear – annually age 18 and over  Mammograms – 1 every year age 35 and over  Colonoscopy – 1 every 10 years age 50 and over  Prostate cancer screening – 1 per year age 50 and over  Smoking cessation counseling – 8 visits per 12 months  Healthy diet/obesity counseling – unlimited to age 22; age 22 and over-26 visits per 12 months  Breastfeeding support – 6 lactation counseling visits per 12 months

Some examples of preventive care frequency and services:  Routine physicals – annually age 12 and over  Well-child care – unlimited up to age 12  Well woman exam & pap smear – annually age 18 and over  Mammograms – 1 every year age 35 and over  Colonoscopy – 1 every 10 years age 50 and over  Prostate cancer screening – 1 per year age 50 and over  Smoking cessation counseling – 8 visits per 12 months  Healthy diet/obesity counseling –unlimited to age 22; age 22 and over-26 visits per 12 months  Breastfeeding support – 6 lactation counseling visits per 12 months

Some examples of preventive care frequency and services:  Routine physicals – annually age 12 and over  Well-child care – unlimited up to age 12  Well woman exam & pap smear – annually age 18 and over  Mammograms – 1 every year age 35 and over  Colonoscopy – 1 every 10 years age 50 and over  Prostate cancer screening –1 per year age 50 and over  Smoking cessation counseling –8 visits per 12 months  Healthy diet/obesity counseling – unlimited to age 22; age 22 and over-26 visits per 12 months  Breastfeeding support –6 lactation counseling visits per 12 months

Examples of covered services for women with reproductive capacity are: Female sterilization procedures and specified FDA-approved contraception methods with a written prescription by a health care practitioner, including cervical caps, diaphragms, implantable contraceptives, intra-uterine devices, injectables, transdermal contraceptives and vaginal contraceptive devices. Prescription contraceptives for women are covered under the pharmacy benefits administered by Caremark. To determine if a specific contraceptive drug or device is included in this benefit, contact Customer Service at 1-800222-9205. The list may change as FDA guidelines are modified. Annual Vision Examination (one per plan year; performed by an opthalmologist or optometrist using calibrated instruments) Participant pays

After deductible, plan pays 80%; $60 copay for specialist participant pays 20%

$50 copay for specialist

Annual Hearing Examination Participant pays

After deductible, plan pays 80%; participant pays 20%

$30 copay for primary $50 copay for specialist

$30 copay for primary $60 copay for specialist

Note: Covered services under this benefit must be billed by the provider as “preventive care.” If you receive preventive services from a non-network provider, you will be responsible for any applicable deductible and coinsurance under the ActiveCare 1-HD and ActiveCare 2. Non-network preventive care is not paid at 100%. There is no coverage for non-network services under the ActiveCare Select plan or ActiveCare Select Whole Health. TRS-ActiveCare is administered by Aetna Life Insurance Company. Aetna provides claims payment services only and does not assume any financial risk or obligation with respect to claims. Prescription drug 14benefits are administered by Caremark.

Beaumont ISD 2016 - 2017 TRS Premiums and District Contributions TRS-ActiveCare Plan 1HD

Total Cost Benefit

District Pays

Employee Pays

Employee Only

$341.00

$0.00

Employee & Spouse

$914.00

$460.00

$454.00

Employee & Child(ren)

$615.00

$460.00

$155.00

Employee & Family

$1,231.00

$460.00

$771.00

TRS-ActiveCare Select-

Total Cost Benefit

District Pays

Employee Pays

Employee Only

$484.00

$460.00

$24.00

Employee & Spouse

$1,147.00

$460.00

$687.00

Employee & Child(ren)

$779.00

$460.00

$319.00

Employee & Family

$1,361.00

$460.00

$901.00

TRS-ActiveCare 2

Total Cost Benefit

District Pays

Employee Pays

Employee Only

$645.00

$460.00

$185.00

Employee & Spouse

$1,552.00

$460.00

$1,092.00

Employee & Child(ren)

$1,042.00

$460.00

$582.00

Employee & Family

$1,597.00

$460.00

$1,137.00

AMERICAN PUBLIC LIFE YOUR BENEFITS

MEDlinkÂŽIV

About this Benefit MEDlinkÂŽ is designed to help supplement your Employer's major medical plan. This plan provides supplemental coverage to help offset out-of-pocket costs that you may experience due to deductibles, co -payments and coinsurance of your medical plan.

DID YOU KNOW?

33% of total healthcare costs are paid out-of-pocket.

MEDlink® IV Enhanced

Limited Benefit Group Medical Expense Supplemental Insurance Beaumont ISD

THE POLICY UNDER WHICH THIS CERTIFICATE IS ISSUED IS NOT A POLICY OF WORKERS’ COMPENSATION INSURANCE. THE EMPLOYER DOES NOT BECOME A SUBSCRIBER TO THE WORKERS’ COMPENSATION SYSTEM BY PURCHASING THE POLICY AND IF THE EMPLOYER IS A NON-SUBSCRIBER, THE EMPLOYEE LOSES THOSE BENEFITS WHICH WOULD OTHERWISE ACCRUE UNDER THE WORKERS’ COMPENSATION LAWS. THE EMPLOYER MUST COMPLY WITH THE WORKERS’ COMPENSATION LAW AS IT PERTAINS TO NON-SUBSCRIBERS AND THE REQUIRED NOTIFICATIONS THAT MUST BE FILED AND POSTED.

ENHANCED PLAN SUMMARY OF BENEFITS*

Base Policy

Option 1

Maximum In-Hospital Benefits

$1,500 per Covered Person per Confinement

In-Hospital Ambulance Benefit

Up to $350 per trip for ground transportation or up to $1,000 per trip for air transportation where a Covered Person is Confined as an Inpatient. Limited to one trip per day.

In-Hospital Deductible

$0 per Covered Person per Confinement

Outpatient Benefit Rider Maximum Outpatient Benefits

$500 per Covered Person per Occurrence for Covered Outpatient Services

Outpatient Ambulance Benefit

Up to $350 per trip for ground transportation or up to $1,000 per trip for air transportation where a Covered Person resides less than 18 hours. Limited to one trip per day.

Outpatient Deductible

$0 per Covered Person Per Occurrence

Covered Outpatient Services Hospital Emergency Room

Payable up to the Maximum Outpatient Benefit, subject to the Outpatient Benefit Deductible, as shown above.

Urgent Care Facility

Maximum of three Urgent Care visits per Covered Person per Calendar Year. Maximum of six Urgent Care visits per Calendar Year for all Covered Persons combined. Payable up to the Maximum Outpatient Benefit, subject to the Outpatient Benefit Deductible, as shown above.

Outpatient Surgery

Outpatient Surgery in Hospital Outpatient Facility or Freestanding Outpatient Surgery Center. Payable up to the Maximum Outpatient Benefit, subject to the Outpatient Benefit Deductible, as shown above.

Diagnostic Testing

Diagnostic Testing in a Hospital Outpatient Facility or MRI Facility. Payable up to the Maximum Outpatient Benefit, subject to the Outpatient Benefit Deductible, as shown above.

Outpatient Treatment for a Serious Mental Illness in a Hospital Outpatient Facility

Maximum of 60 days of treatment per Covered Person per Calendar Year. Payable up to the Maximum Outpatient Benefit, subject to the Outpatient Benefit Deductible, as shown above.

Benefit Rider Physician Outpatient Treatment Benefit Rider

$25 per visit; Maximum of four visits per Covered Person per Calendar Year and eight visits per Calendar Year for all Covered Persons combined for treatment in a: s Hospital Outpatient Facility s Freestanding Emergency Care Clinic s Urgent Care Facility/Clinic s Physician Office

Total Monthly Premiums by Plan* Ages 18-54 Ages 55+

Employee

Employee & Spouse

Employee & Child

Employee & Family

$29.44

$68.16

$53.59

$92.20

$42.14

$97.36

$75.18

$130.30

*Total premium includes the Plan selected and any applicable rider premium. Premiums are subject to increase with notice. The premium and amount of benefits vary dependent upon the Plan selected at time of application.

Important Policy Provisions Eligibility

You are eligible to be covered under this Policy/Certificate if you are Actively At Work, qualify for coverage as defined in the Master Application, are covered under your Employer’s Medical Plan and are under age 70 (if you work for an employer employing less than 20 employees). Your Eligible Dependents, as defined in the Policy/Certificate, are eligible for coverage if they are covered under the Employer’s Medical Plan. You must apply for insurance during the Initial Enrollment period or on the date the person first becomes eligible for coverage. If you do not apply during the Initial Enrollment period or on the date you become eligible for coverage, you may be subject to additional underwriting by APL. Evidence of coverage under your Employer’s Medical Plan is required. APSB-22354(TX) MGM/FBS Beaumont ISD

When Coverage Begins

Coverage will begin on the requested Certificate Effective Date or the Certificate Effective Date assigned by us, upon approval of your application, if our underwriting rules are met, the premium has been paid and all persons to be insured are covered under your Employer’s Medical Plan and you are Actively At Work on the Certificate Effective Date. If you are not Actively At Work on the Certificate Effective Date due to disability, Injury, Sickness, temporary layoff, leave of absence or Family and Medical Leave of Absence, coverage begins on the date you return to Actively At Work.

Limitations & Exclusions No benefits will be payable for expenses incurred during any period the Covered Person does not have coverage under your Employer’s Medical Plan, except as provided in the Absence of the Insured’s Employer’s Medical Plan provision, described in the Policy. A hospital is not an institution, or part thereof, used as: a place for rehabilitation, a place for rest or for the aged, a nursing or convalescent home, a long term nursing unit or geriatrics ward, or an extended care facility for the care of convalescent, rehabilitative or ambulatory patients.

Pre-Existing Condition Limitation

No benefits are payable during the Pre-Existing Condition Exclusion Period following the Covered Person’s Effective Date for any loss resulting from a Pre-Existing Condition. The Pre-Existing Condition Limitation will apply only if the Covered Person is subject to a Pre-Existing Condition Limitation under the Employer’s Medical Plan. Therefore, any Pre-Existing Condition Limitation applied to the Major Medical plan would, in effect, limit coverage under this plan.

Exclusions

No benefits are payable for any loss resulting from or caused, whether directly or indirectly, by: s war or any act of war, whether declared or undeclared, or active service in the armed forces; (This exclusion includes Accident sustained or Sickness contracted while in the service of any military, naval or air force of any country engaged in war. If coverage is suspended for any Covered Person during a period of military service, APL will refund the pro-rata portion of any premium paid for any such Covered Person upon receipt of your written request) s an intentionally self-inflicted Injury or Sickness; s suicide or attempted suicide, while sane or insane; s rest care or rehabilitative care and treatment; s outpatient routine newborn care; s voluntary abortion except, with respect to you or your covered Eligible Dependent spouse: s where you or your Dependent spouse’s life would be endangered if the fetus were carried to term; or s where medical complications have arisen from abortion; s pregnancy of an Eligible Dependent child; s participating in a riot, insurrection, rebellion, civil commotion, civil disobedience or unlawful assembly; (This does not include a loss which occurs while acting in a lawful manner within the scope of authority.) s committing, or attempting to commit, an illegal act that is defined as a felony; (Felony is as defined by the law of the jurisdiction in which the act takes place.) s participation in a contest of speed in power driven vehicles, parachuting or hang gliding; s air travel, except: s as a fare-paying passenger on a commercial airline on a regularly scheduled route; or s as a passenger for transportation only and not as a pilot or crew member; s being intoxicated or under the influence of any narcotic unless administered by a Physician or taken according to the Physician’s instructions; (Intoxication means that which is determined and defined by the laws and jurisdiction of the geographical area in which the event that caused the loss occurred.) s alcoholism or drug addiction; s sex changes; s experimental treatment, drugs or surgery; s Accident or Sickness arising out of, and in the course of, any occupation for compensation, wage or profit; (This does not apply to those sole proprietors or partners not covered by Workers’ Compensation.) s dental or vision services, including treatment, surgery, extractions or x-rays, unless:

s resulting from an Accident occurring while the Covered Person’s coverage is in force and if performed within 12 months of the date of such Accident; or s due to congenital disease or anomaly of a covered newborn child. s routine examinations, such as health exams, periodic check-ups or routine physicals, except when part of Inpatient routine newborn care; s elective cosmetic surgery; s drugs (prescription and non-prescription for use outside of a covered facility as defined in this Policy/Certificate or any attached rider); s sterilization and reversal of sterilization; s an expense that does not meet the definition of Covered Charges; s an expense or service that exceeds any of the Maximum Benefits, as shown in the Schedule of Benefits; or s any expense for which benefits are not payable under your Other Medical Plan.

Premium Changes

The premium rates may be changed by APL at the first anniversary date of this Policy or any premium due date thereafter. No such increase in rates will be made unless 60 days prior notice is given to the Policyholder. Premiums will not increase during the initial 12 months of coverage.

Optionally Renewable

This Policy is renewable at the option of APL. The Policyholder or APL may terminate this Policy on any premium due date after the first anniversary following the Policy Effective Date, subject to 60 days written notice.

Termination of Certificate

Your insurance coverage under this Certificate and any attached riders will end on the earliest of these dates: s the date the Policy terminates; s the end of the grace period if the premium remains unpaid; s the date you no longer qualify as an Insured; s the date you attain age 70 (if you work for an employer employing less than 20 employees); s the date your coverage under your Employer’s Medical Plan ends; or s the date of your death.

Termination of Coverage

Your insurance coverage under this Certificate and any attached riders for a Covered Person will end as follows: s the date the Policy terminates; s the date the Certificate terminates; s the end of the Certificate Month in which APL receives a written request from you to terminate the Covered Person’s coverage; s the date a Covered Person no longer qualifies as an Insured or Eligible Dependent; or s the date of the Covered Person’s death. APL may end the coverage of any Covered Person who submits a fraudulent claim.

Cobra Continuation of Coverage

This plan may be continued in accordance with the Consolidated Omnibus Reconciliation Act of 1986.

2305 Lakeland Drive | Flowood, MS 39232 ampublic.com | 800.256.8606

Underwritten by American Public Life Insurance Company. This is a brief description of the coverage. For complete benefits, limitations, exclusions and other provisions, please refer to the certificate/policy and riders. This coverage does not replace Workers’ Compensation Insurance. This product is inappropriate for people who are eligible for Medicaid coverage. | This policy is considered an employee welfare benefit plan established and/or maintained by an association or employer intended to be covered by ERISA, and will be administered and enforced under ERISA. Group policies issued to governmental entities and municipalities may be exempt from ERISA guidelines. | Policy Form MEDlink® Series | Texas | Limited Benefit Group Medical Expense Supplemental Insurance | (10/14) | Beaumont ISD

APSB-22354(TX)18 MGM/FBS Beaumont ISD

MEDlink® IV Enhanced

Limited Benefit Group Medical Expense Supplemental Insurance Beaumont ISD

ENHANCED PLAN SUMMARY OF BENEFITS*

Base Policy

Option 2

Maximum In-Hospital Benefits

$2,500 per Covered Person per Confinement

In-Hospital Ambulance Benefit

Up to $350 per trip for ground transportation or up to $1,000 per trip for air transportation where a Covered Person is Confined as an Inpatient. Limited to one trip per day.

In-Hospital Deductible

$0 per Covered Person per Confinement

Outpatient Benefit Rider Maximum Outpatient Benefits

$500 per Covered Person per Occurrence for Covered Outpatient Services

Outpatient Ambulance Benefit

Up to $350 per trip for ground transportation or up to $1,000 per trip for air transportation where a Covered Person resides less than 18 hours. Limited to one trip per day.

Outpatient Deductible

$0 per Covered Person Per Occurrence

Covered Outpatient Services Hospital Emergency Room

Payable up to the Maximum Outpatient Benefit, subject to the Outpatient Benefit Deductible, as shown above.

Urgent Care Facility

Outpatient Surgery

Diagnostic Testing

Diagnostic Testing in a Hospital Outpatient Facility or MRI Facility. Payable up to the Maximum Outpatient Benefit, subject to the Outpatient Benefit Deductible, as shown above.

Outpatient Treatment for a Serious Mental Illness in a Hospital Outpatient Facility

Maximum of 60 days of treatment per Covered Person per Calendar Year. Payable up to the Maximum Outpatient Benefit, subject to the Outpatient Benefit Deductible, as shown above.

Benefit Rider Physician Outpatient Treatment Benefit Rider

Total Monthly Premiums by Plan* Ages 18-54 Ages 55+

Employee

Employee & Spouse

Employee & Child

Employee & Family

$34.73

$80.30

$62.57

$108.05

$50.06

$115.58

$88.64

$154.06

Important Policy Provisions Eligibility

When Coverage Begins

Pre-Existing Condition Limitation

Exclusions

Premium Changes

Optionally Renewable

Termination of Certificate

Termination of Coverage

Cobra Continuation of Coverage

This plan may be continued in accordance with the Consolidated Omnibus Reconciliation Act of 1986.

2305 Lakeland Drive | Flowood, MS 39232 ampublic.com | 800.256.8606

APSB-22354(TX)20 MGM/FBS Beaumont ISD

MEDlinkÂŽ IV Enhanced Limited Benefit Group Medical Expense Supplemental Insurance Beaumont ISD

MDLIVE YOUR BENEFITS PACKAGE

Telehealth

About this Benefit Telehealth provides 24/7/365 access to boardcertified doctors via telephone consultations that can diagnose, recommend treatment and prescribe medication. Whether you are at home, traveling or at work, Telehealth makes care more convenient and accessible for non-emergency care when your primary care physician is not available.

DID YOU KNOW?

75%

of all doctor, urgent care, and ER visits could be handled safely and effectively via telehealth.

Telehealth When should I use MDLIVE?

 If you’re considering the ER or urgent care for a non-emergency medical issue  Your primary care physician is not available  At home, traveling, or at work  24/7/365, even holidays!

What can be treated?         

Allergies Asthma Bronchitis Cold and Flu Ear Infections Joint Aches and Pain Respiratory Infection Sinus Problems And More!

Pediatric Care related to:       

Cold & Flu Constipation Ear Infection Fever Nausea & Vomiting Pink Eye And More!

Are children eligible? Yes. MDLIVE has local pediatricians on-call 24/7/365. Please note, a parent or guardian must be present during any interactions involving minors. We ask parents to establish a child record under their account. Parents must be present on each call for children 18 or younger.

How much does it cost? $10 Covers you, your spouse, and children up to age 26, with unlimited phone consultations.

Download the App Doctor visits are easier and more convenient with the MDLIVE App. Be prepared. Download today. www.mdlive.com/getapp     

Access to a doctor anywhere: at home, at work, or on the go Choose doctors from one of the nation's largest telehealth networks Available 24/7 by video or phone Private, secure and confidential visits Connect instantly with MDLIVE Assist

Who are our doctors? MDLIVE has the nation’s largest network of telehealth doctors. On average, our doctors have 15 years of experience practicing medicine and are licensed in the state where patients are located. Their specialties include primary care, pediatrics, emergency medicine and family medicine. Our doctors are committed to providing convenient, quality care and are always ready to take your call.

Scan with your smartphone to get the app.

Call us at (888) 365-1663 or visit us at www.consultmdlive.com

Disclaimers: MDLIVE does not replace the primary care physician. MDLIVE operates subject to state regulation and may not be available in certain states. MDLIVE does not guarantee that a prescription will be written. MDLIVE does not prescribe DEA controlled substances, non-therapeutic drugs and certain other drugs which may be harmful because of their potential for abuse. MDLIVE physicians reserve the right to deny care for potential misuse of services. For complete terms of use visit www.mdlive.com/pages/terms.html 010113

CIGNA

Dental

YOUR BENEFITS PACKAGE

About this Benefit Dental insurance is a coverage that helps defray the costs of dental care. It insures against the expense of routine care, treatment and dental disease.

DID YOU KNOW?

Good dental care may improve your overall health. Also Women with gum disease may be at greater risk of giving birth to a preterm or low birth weight baby.

Dental PPO - Low Option Benefits Network Plan Year Maximum (Class I, II, and III expenses) Annual Deductible Individual Family Reimbursement Levels**

Cigna Dental Choice In-Network Out-of-Network Total Cigna DPPO $750, Class I Applies

$750, Class I Applies

$50 per person $150 per family

Based on Reduced Contracted Fees

90th percentile of Reasonable and Customary Allowances

Plan Pays

You Pay

Plan Pays

You Pay

100%

No Charge

100%

No Charge

70%*

30%*

70%*

30%*

50%*

Monthly PPO Premiums Tier

Rate

EE Only

$22.28

EE + Spouse

$43.46

EE + Child (ren)

$49.04

EE + Family

$69.08

Class I - Preventive & Diagnostic Care Oral Exams Routine Cleanings Bitewing X-rays Full Mouth X-rays Emergency Care to Relieve Pain Panoramic X-ray Fluoride Application Sealants Space Maintainers (Limited to non-orthodontic treatment)

Class II - Basic Restorative Care Fillings Surgical Extractions of Impacted Teeth Brush Biopsies Oral Surgery - all except simple extractions Anesthetics Oral Surgery—Simple extractions

Class III - Major Restorative Care Crowns Root Canal Therapy/Endodontics Periodontal Scaling and Root Planing Denture Repairs Denture Relines, Rebases and Adjustments Repairs to Bridges, Crowns and Inlays Dentures Bridges Inlays/Onlays Prosthesis Over Implant

Class IV - Orthodontia Lifetime Maximum

$1,000 Dependent children to age 19

Missing Tooth Limitation – The amount payable is 50% of the amount otherwise payable until insured for 12 months; thereafter, considered a Class III expense. Pretreatment review is available on a voluntary basis when extensive dental work in excess of $200 is proposed. *Subject to annual deductible Dental Oral Health Integration Program (OHIP) - All dental customers = Clinical research shows an association between oral health and overall health. The Cigna Dental Oral Health Integration Program (OHIP)® is designed to provide enhanced dental coverage for customers with certain eligible medical conditions. Eligible conditions for the program include cardiovascular disease, cerebrovascular disease (stroke), diabetes, maternity, chronic kidney disease, organ transplants, and head and neck cancer radiation. The program provides:  100% coverage for certain dental procedures  guidance on behavioral issues related to oral health  discounts on prescription and non-prescription dental products For more information and to see the complete list of eligible conditions, go to www.mycigna.com or call customer service 24/7 at 1.800.CIGNA24. **For services provided by a Cigna Dental PPO network dentist, Cigna Dental will reimburse the dentist according to a Contracted Fee Schedule. For services provided by an out-ofnetwork dentist, Cigna Dental will reimburse according to Reasonable and Customary Allowances but the dentist may balance bill up to their usual fees.

Dental PPO - High Option Benefits Network Plan Year Maximum (Class I, II, and III expenses) Annual Deductible Individual Family Reimbursement Levels**

Cigna Dental Choice In-Network Out-of-Network Total Cigna DPPO $1,250, Class I Applies

$1,250, Class I Applies

$50 per person $150 per family

Based on Reduced Contracted Fees

90th percentile of Reasonable and Customary Allowances

Plan Pays

You Pay

Plan Pays

You Pay

100%

No Charge

100%

No Charge

80%*

20%*

80%*

20%*

50%*

50% $1,000 Adults and dependent children to age 19

50%

Monthly PPO Premiums Tier

Rate

EE Only

$26.58

EE + Spouse

$51.84

EE + Child (ren)

$58.48

Family

$82.42

Class I - Preventive & Diagnostic Care Oral Exams Routine Cleanings Bitewing X-rays Full Mouth X-rays Panoramic X-ray Emergency Care to Relieve Pain Fluoride Application Sealants Space Maintainers (Limited to non-orthodontic treatment)

Class II - Basic Restorative Care Fillings Surgical Extractions of Impacted Teeth Brush Biopsies Oral Surgery - all except simple extractions Anesthetics Oral Surgery—Simple extractions

Class III - Major Restorative Care Crowns Root Canal Therapy/Endodontics Denture Repairs Denture Relines, Rebases and Adjustments Repairs to Bridges, Crowns and Inlays Dentures Bridges Inlays/Onlays Prosthesis Over Implant

Class IV - Orthodontia Lifetime Maximum

50% $1,000 Adults and dependent children to age 19

Missing Tooth Limitation – The amount payable is 50% of the amount otherwise payable until insured for 12 months; thereafter, considered a Class III expense. Pretreatment review is available on a voluntary basis when extensive dental work in excess of $200 is proposed. * Subject to annual deductible Dental Oral Health Integration Program (OHIP) - All dental customers = Clinical research shows an association between oral health and overall health. The Cigna Dental Oral Health Integration Program (OHIP)® is designed to provide enhanced dental coverage for customers with certain eligible medical conditions. Eligible conditions for the program include cardiovascular disease, cerebrovascular disease (stroke), diabetes, maternity, chronic kidney disease, organ transplants, and head and neck cancer radiation. The program provides:  100% coverage for certain dental procedures  guidance on behavioral issues related to oral health  discounts on prescription and non-prescription dental products For more information and to see the complete list of eligible conditions, go to www.mycigna.com or call customer service 24/7 at 1.800.CIGNA24. **For services provided by a Cigna Dental PPO network dentist, Cigna Dental will reimburse the dentist according to a Contracted Fee Schedule. For services provided by an out-of-network dentist, Cigna Dental will reimburse according to Reasonable and Customary Allowances but the dentist may balance bill up to their usual fees.

Dental PPO - High and Low Options Procedure

Exclusions and Limitations

Late Entrants Limit Exams Prophylaxis (Cleanings) Fluoride X-Rays (routine) X-Rays (non-routine) Model Minor Perio (non-surgical) Perio Surgery Crowns and Inlays Bridges Dentures and Partials Relines, Rebases Adjustments Repairs - Bridges Repairs - Dentures Sealants Space Maintainers Prosthesis Over Implant

50% coverage on Class III and IV for 12 months Two per Plan year Two per Plan year 1 per Plan year for people under 19 Bitewings: 2 per Plan year Full mouth: 1 every 36 consecutive months., Panorex: 1 every 36 consecutive months Payable only when in conjunction with Ortho workup Various limitations depending on the service Various limitations depending on the service Replacement every 5 years Replacement every 5 years Replacement every 5 years Covered if more than 6 months after installation Covered if more than 6 months after installation Reviewed if more than once Reviewed if more than once Limited to posterior tooth. One treatment per tooth every three years up to age 14 Limited to non-Orthodontic treatment 1 per 60 consecutive months if unserviceable and cannot be repaired. Benefits are based on the amount payable for nonprecious metals. No porcelain or white/tooth colored material on molar crowns or bridges When more than one covered Dental Service could provide suitable treatment based on common dental standards, Cigna HealthCare will determine the covered Dental Service on which payment will be based and the expenses that will be included as Covered Expenses Dental Service on which payment will be based and the expenses that will be included as Covered Expenses

Alternate Benefit

Benefit Exclusions



  



 

              

 

Services performed primarily for cosmetic reasons Replacement of a lost or stolen appliance Replacement of a bridge or denture within five years following the date of its original installation Replacement of a bridge or denture which can be made useable according to accepted dental standards Procedures, appliances or restorations, other than full dentures, whose main purpose is to change vertical dimension, diagnose or treat conditions of TMJ, stabilize periodontally involved teeth, or restore occlusion Veneers of porcelain or acrylic materials on crowns or pontics on or replacing the upper and lower first, second and third molars Bite registrations; precision or semi-precision attachments; splinting A surgical implant of any type Instruction for plaque control, oral hygiene and diet Dental services that do not meet common dental standards Services that are deemed to be medical services Services and supplies received from a hospital Charges which the person is not legally required to pay Charges made by a hospital which performs services for the U.S. Government if the charges are directly related to a condition connected to a military service Experimental or investigational procedures and treatments Any injury resulting from, or in the course of, any employment for wage or profit Any sickness covered under any workers’ compensation or similar law Charges in excess of the reasonable and customary allowances To the extent that payment is unlawful where the person resides when the expenses are incurred; Procedures performed by a Dentist who is a member of the covered person’s family (covered person’s family is limited to a spouse, siblings, parents, children, grandparents, and the spouse’s siblings and parents); For charges which would not have been made if the person had no insurance; For charges for unnecessary care, treatment or surgery;



To the extent that you or any of your Dependents is in any way paid or entitled to payment for those expenses by or through a public program, other than Medicaid; To the extent that benefits are paid or payable for those expenses under the mandatory part of any auto insurance policy written to comply with a “no-fault” insurance law or an uninsured motorist insurance law. Cigna HealthCare will take into account any adjustment option chosen under such part by you or any one of your Dependents. In addition, these benefits will be reduced so that the total payment will not be more than 100% of the charge made for the Dental Service if benefits are provided for that service under this plan and any medical expense plan or prepaid treatment program sponsored or made available by your Employer.

This benefit summary highlights some of the benefits available under the proposed plan. A complete description regarding the terms of coverage, exclusions and limitations, including legislated benefits, will be provided in your insurance certificate or plan description. Benefits are insured and/or administered by Connecticut General Life Insurance Company. "Cigna HealthCare" refers to various operating subsidiaries of Cigna Corporation. Products and services are provided by these subsidiaries and not by Cigna Corporation. These subsidiaries include Connecticut General Life Insurance Company, Cigna Health and Life Insurance Company, and HMO or service company subsidiaries of Cigna Health Corporation and Cigna Dental Health, Inc. DPPO insurance coverage is set forth on the following policy form numbers: AR: HP-POL77; CA: HP-POL57; CO: HP-POL78; CT: HP-POL58; DE: HP-POL79; FL: HP-POL60; ID: HP-POL82; IL: HP-POL62; KS: HP-POL84; LA: HP-POL86: MA: HP-POL 63; MI: HP-POL88; MO: HP- POL65; MS: HP-POL90; NC: HP-POL96; NE: HPPOL92; NH: HP-POL94; NM: HP-POL95; NV: HP-POL93; NY: HP-POL67; OH: HP-POL98; OK: HP-POL99; OR: HP-POL68; PA: HP-POL100; RI: HP-POL101; SC: HP-POL102; SD: HP-POL103; TN: HP-POL69; TX: HP-POL70; UT: HP-POL104; VA: HP-POL72; VT: HP-POL71; WA: POL-07/08; WI: HP-POL107; WV: HP-POL106; and WY: HP-POL108. “Cigna,” the “Tree of Life” logo and “Cigna Dental Care” are registered service marks of Cigna Intellectual Property, Inc., licensed for use by Cigna Corporation and its operating subsidiaries. All products and services are provided by or through such operating subsidiaries and not by Cigna Corporation. Such operating subsidiaries include Connecticut General Life Insurance Company (CGLIC), Cigna Health and Life Insurance Company

UNITEDHEALTHCARE YOUR BENEFITS PACKAGE

Vision

About this Benefit Vision insurance provides coverage for routine eye examinations and may cover all or part of the costs associated with contact lenses, eyeglasses and vision correction, depending on the plan.

DID YOU KNOW?

75% of U.S. residents between age 25 and 64 require some sort of vision correction.

Vision Monthly Premiums EE Only EE + Spouse EE + Child(ren) EE + Family

$3.87 $7.34 $8.61 $12.12

Co-Pays for In-Network Services Exam Materials

$10 $25

Benefit Frequency Comprehensive Exam Spectacle Lenses Frames Contact Lenses in Lieu of Eye Glasses

Once every 12 months Once every 12 months Once every 12 months Once every 12 months

Frame Benefit Private Practice Provider Retail Chain Provider

$150.00 retail frame allowance $150.00 retail frame allowance

Out-of-Network Reimbursements Up To: (copays do not apply) Exams Frames Single Vision Lenses Bifocal Lenses Trifocal Lenses Lenticular Lenses Elective Contacts in Lieu of Eye Glasses2 Necessary Contacts in Lieu of Eye Glasses3

 

Lens Options

Contact Lens Benefit

Laser Vision Benefit UnitedHealthcare Vision has partnered with the Laser Vision Network of America (LVNA) to provide our members with access to discounted laser vision correction providers. Members receive 15% off usual and customary pricing, 5% off promotional pricing at over 500 network provider locations and even greater discounts through set pricing at LasikPlus locations. For more information, call 1-888-563-4497 or visit us at www.uhclasik.com. 1Coverage for Covered Contact Lens Selection does not apply at Costco, Walmart or Sam’s Club locations. The allowance for non-selection contact lenses will be applied toward the fitting/ evaluation fee and purchase of all contacts. 2Necessary contact lenses are determined at the provider’s discretion for one or more of the following conditions: Following post cataract surgery without intraocular lens implant; to correct extreme vision problems that cannot be corrected with spectacle lenses; with certain conditions such as keratoconus, anisometropia, irregular corneal/astigmatism, aphakia, facial deformity or corneal deformity. If your provider considers your contacts necessary, you should ask your provider to contact UnitedHealthcare Vision confirming reimbursement that UnitedHealthcare Vision will make before you purchase such contacts. 3The out-of-network reimbursement applies to materials only. The fitting/evaluation is not included.

$150.00 $210.00

Important to Remember

Standard scratch-resistant coating, Glass coating -- covered in full. Other optional lens upgrades may be offered at a discount. (Discount varies by provider.) Covered-in-full elective contact lenses1 The fitting/evaluation fees, contact lenses, and up to two follow-up visits are covered in full (after copay). If you choose disposable contacts, up to 6 boxes are included when obtained from a network provider. All other elective contact lenses A $150.00 allowance is applied toward the fitting/evaluation fees and purchase of contact lenses outside the covered selection (materials copay does not apply). Toric, gas permeable and bifocal contact lenses are examples of contact lenses that are outside of our covered contacts. Necessary contact lenses2 Covered in full after applicable copay.

$40.00 $45.00 $40.00 $60.00 $80.00 $80.00



Benefit frequency based on last date of service. Your $150.00 contact lens allowance is applied to the fitting/evaluation fees as well as the purchase of contact lenses. For example, if the fitting/evaluation fee is $30, you will have $120.00 toward the purchase of contact lenses. The allowance may be separated at some retail chain locations between the examining physician and the optical store. You can log on to our website to print off your personalized ID card. An ID card is not required for service, but is available as a convenience to you should you wish to have an ID card to take to your appointment. Out-of-Network Reimbursement, when applicable: Receipts for services and materials purchased on different dates must be submitted together at the same time to receive reimbursement. Receipts must be submitted within 12 months of date of service to the following address: UnitedHealthcare Vision Attn. Claims Department P.O. Box 30978 Salt Lake City, UT 84130 FAX: 248.733.6060. At a participating network provider you will receive a 20% discount on an additional pair of eyeglasses or contact lenses. This program is available after your vision benefits have been exhausted. Please note that this discount shall not be considered insurance, and that UnitedHealthcare Vision shall neither pay nor reimburse the provider or member for any funds owed or spent. Not all providers may offer this discount. Please contact your provider to see if they participate. Discounts on contact lenses may vary by provider. Additional materials do not have to be purchased at the time of initial material purchase. Additional materials can be purchased at a discount any time after the insured benefit has been used.

AETNA YOUR BENEFITS PACKAGE

Long Term Disability

About this Benefit Disability insurance protects one of your most valuable assets, your paycheck. This insurance will replace a portion of your income in the event that you become physically unable to work due to sickness or injury for an extended period of time.

DID YOU KNOW?

Just over 1 in 4 of today's 20 year -olds will become disabled before they retire.

34.6 months is the duration of the average disability claim.

Long Term Disability Eligibility All active full time employees working 20 hours per week or more.

Purpose Long Term Disability insurance provides income replacement benefits for you and your family in the event you are unable to work due to an accident or sickness.

Maximizing Income Protection Long Term Disability (LTD) Insurance can offer an affordable way for educators and administrators to protect their lifestyles—and the people who depend upon them. Employees can choose from a selection of LTD features they feel best match their financial needs.  Employees can choose their Monthly Benefit Amount in $100 increments, from $200 to $7,500 (not to exceed 66 2/3% of monthly earnings).  Employees can choose from among four accident/ sickness Benefit Waiting Periods. A benefit waiting period is the period of time in which an employee must be continuously disabled before you are eligible for benefits. Accident Sickness 0 Days 7 Days 14 Days 14 Days 30 Days 30 Days 60 Days 60 Days

Maximum Benefit Period SSNRA for Disability due to Injury and Sickness: Your period of disability will end when the later of the following events occur:  The calendar month when you reach normal retirement age, as determined by the 1983 Amended Social Security Normal Retirement Age: or  The expiration of the number of months of disability, after the elimination period is met as figured from the following Schedule, if your disability starts on or after the date you reach age 62 . Age at Disability Maximum Duration of Benefits Age 62 but less than 63 42 months Age 63 but less than 64 36 months Age 64 but less than 65 30 months Age 65 but less than 66 24 months Age 66 but less than 67 21 months Age 67 but less than 68 18 months Age 68 but less than 69 15 months 69 and over 12 months 1983 Amended Social Security Normal Retirement Age Year of Birth Normal Retirement

Before 1938 1938 1939 1940 1941 1942 Year of Birth 1943 to 1954 1955 1956 1957 1958 1959 After 1959

65 65 and 2 months 65 and 4 months 65 and 6 months 65 and 8 months 65 and 10 months Normal Retirement 66 66 and 2 months 66 and 4 months 66 and 6 months 66 and 8 months 66 and 10 months 67

Limitations & Exclusions Benefits for Mental/Nervous/Substance Abuse/Self-Reported Illnesses are limited to 12 months lifetime combined.

Pre-Existing Exclusion There is a 3/12 pre-existing conditions clause. This is a look back period to see if you were treatment-free for a 3-month period prior to the effective date of your coverage. If you weren’t treatment-free, the pre-existing condition is excluded from coverage if you’re disabled within 12-months of first becoming insured. In addition, if during an annual enrollment period you apply for additional benefits or select a shorter elimination period, this plan will not cover the increase in your coverage if you have a pre-existing condition.

Occupational Injury or Illness Exclusion Long Term Disability coverage does not cover any disability that is due to and occupational illness or occupational injury.

Plan Features Maximum Benefit Employees can protect as much as $7,500 of their income as long as the benefit is not greater than 66 2/3% of their salary.

Definition of Disability 2 Year Own Occ with Residual. Covers Non-Occupational disabilities – not in lieu of Workers Compensation. During the Elimination Period and the Own Occupation Period – any day that an individual is unable to perform the material duties of his/ her own occupation; or while unable to perform the material duties of his/her own occupation, is performing at least one of the material duties of any occupation on a part-time or full-time basis and has lost at least 20% of their indexed pre-disability earnings due to a disable condition. During the any reasonable occupation period – any day that an individual is unable to

Long Term Disability perform the material duties of any occupation for which he/she is or may become fitted, based on training, education or experience; or while unable to perform the material duties of any reasonable occupation, is performing at least one of the material duties of any occupation on a part-time or full-time basis and has lost at least 40% of his/her pre-indexed earnings due to a disabling condition.

1st Day Hospital Benefit This feature waives the waiting period if an insured is hospitalized. Hospitalized means that, if because of your disability, you are hospital confined as an inpatient, benefits begin the first day of inpatient confinement. Inpatient means you are confined to a hospital room due to your sickness or injury, for 24 or more consecutive hours. This benefit is included in the 0/7, 14/14 and 30/30, waiting periods.

12 Month Return-to-Work Incentive This benefit gives an employee the opportunity to return to work part time earning some income plus receive LTD benefits allowing them to receive up to 100% income replacement during the first 12 months.

Deductible Income Income benefit sources payable to the employee, employee’s spouse, children and/or dependents due to the employee’s disability or retirement. Sources include, but are not limited to, benefits payable from: unemployment compensation, Workers’ Comp, statutory disability plans, veteran’s benefits, Assault Leave Benefits, and any other group or association disability or retirement plans.

but not more than $500 per month. This incentive will be paid up to 6 consecutive months for each period of disability.

Continuity of Coverage Insured individuals do not lose coverage due to an employer’s change in group insurance carriers.

Minimum Benefit Greater of 10% of gross maximum Monthly Benefit or $100.

Medical Treatment Benefit The benefit will be paid when you receive treatment by a doctor as a result of a sickness or injury, provided no other benefits are payable under the plan as a result of the condition for which the treatment was rendered. The charges must be for medically necessary care and treatment. The Medical Treatment Benefit will be the doctor’s actual charge for services rendered, up to a maximum benefit of $50 for sickness and $100 for injury. A maximum of 4 medical treatment benefits will be paid in a calendar year.

Child/Dependent Care Included ‐ After 6 months of benefit are paid, a benefit is available to reimburse an employee for dependent care expenses while participating in an approved rehabilitation program. An amount of $350 per month per dependent to a maximum of $1,000 is payable for up to 24 months.

Worksite Modification Benefit

This benefit allows Aetna to pay for expenses of worksite modifications that result in a disabled employee’s return to The following Income benefit sources have a 6 month deferral in work. which no offset will be applied. Employer provided sick leave or salary continuation, Auto Liability Insurance, Social Security, 3rd EAP party liability, statutory disability plans or any other group or Enhanced EAP for LTD Insured members includes 3 face-toassociation disability. All other offsets are immediate. face counseling sessions for LTD covered members & their immediate household members per year and unlimited Survivor Benefit telephonic EAP consultations. Pays a lump sum equal to 3 times the non-integrated LTD benefit after 180 days of disability.

Social Security Assistance

Waiver of Premium

Assistance for eligible employees with the application process for Social Security disability benefits.

If you become disabled, your premium payment for your insurance will be waived on any premium due date on which: (1) Late Entrant You remain Disabled for 90 consecutive days; and (2) Disability Employees who enroll for any contributory LTD coverage Benefits are being paid or are payable for the Disability. more than 60 days later than the date they are first eligible or elect to increase their coverage or who were previously Rehabilitation Plan Benefit declined for coverage are subject to the Pre‐ex rules. During the employee’s active participation in an Aetna Approved Rehab Program, Aetna will pay an additional 10% of the monthly benefit, after all applicable reductions for other income benefits, 32

Long Term Disability Accident/Sickness Benefit Waiting Period Semi-Monthly Cost

Beaumont Independent School District Annual Earnings

Monthly Earnings

Maximum Monthly Benefit

0/7

14 /14

30/30

60/60

$3,600

$300

$200.00

$6.00

$4.30

$3.44

$2.80

$5,400

$450

$300.00

$9.00

$6.45

$5.16

$4.20

$7,200

$600

$400.00

$12.00

$8.60

$6.88

$5.60

$9,000

$750

$500.00

$15.00

$10.75

$8.60

$7.00

$10,800

$900

$600.00

$18.00

$12.90

$10.32

$8.40

$12,600

$1,050

$700.00

$21.00

$15.05

$12.04

$9.80

$14,400

$1,200

$800.00

$24.00

$17.20

$13.76

$11.20

$16,200

$1,350

$900.00

$27.00

$19.35

$15.48

$12.60

$18,000

$1,500

$1,000.00

$30.00

$21.50

$17.20

$14.00

$19,800

$1,650

$1,100.00

$33.00

$23.65

$18.92

$15.40

$21,600

$1,800

$1,200.00

$36.00

$25.80

$20.64

$16.80

$23,400

$1,950

$1,300.00

$39.00

$27.95

$22.36

$18.20

$25,200

$2,100

$1,400.00

$42.00

$30.10

$24.08

$19.60

$27,000

$2,250

$1,500.00

$45.00

$32.25

$25.80

$21.00

$28,800

$2,400

$1,600.00

$48.00

$34.40

$27.52

$22.40

$30,600

$2,550

$1,700.00

$51.00

$36.55

$29.24

$23.80

$32,400

$2,700

$1,800.00

$54.00

$38.70

$30.96

$25.20

$34,200

$2,850

$1,900.00

$57.00

$40.85

$32.68

$26.60

$36,000

$3,000

$2,000.00

$60.00

$43.00

$34.40

$28.00

$37,800

$3,150

$2,100.00

$63.00

$45.15

$36.12

$29.40

$39,600

$3,300

$2,200.00

$66.00

$47.30

$37.84

$30.80

$41,400

$3,450

$2,300.00

$69.00

$49.45

$39.56

$32.20

$43,200

$3,600

$2,400.00

$72.00

$51.60

$41.28

$33.60

$45,000

$3,750

$2,500.00

$75.00

$53.75

$43.00

$35.00

$46,800

$3,900

$2,600.00

$78.00

$55.90

$44.72

$36.40

$48,600

$4,050

$2,700.00

$81.00

$58.05

$46.44

$37.80

$50,400

$4,200

$2,800.00

$84.00

$60.20

$48.16

$39.20

$52,200

$4,350

$2,900.00

$87.00

$62.35

$49.88

$40.60

$54,000

$4,500

$3,000.00

$90.00

$64.50

$51.60

$42.00

$55,800

$4,650

$3,100.00

$93.00

$66.65

$53.32

$43.40

$57,600

$4,800

$3,200.00

$96.00

$68.80

$55.04

$44.80

$59,400

$4,950

$3,300.00

$99.00

$70.95

$56.76

$46.20

$61,200

$5,100

$3,400.00

$102.00

$73.10

$58.48

$47.60

$63,000

$5,250

$3,500.00

$105.00

$75.25

$60.20

$49.00

$64,800

$5,400

$3,600.00

$108.00

$77.40

$61.92

$50.40

$66,600

$5,550

$3,700.00

$111.00

$79.55

$63.64

$51.80

Long Term Disability Accident/Sickness Benefit Waiting Period Semi-Monthly Cost

Beaumont Independent School District Annual Earnings

Monthly Earnings

Maximum Monthly Benefit

0/7

14 /14

30/30

60/60

$68,400

$5,700

$3,800.00

$114.00

$81.70

$65.36

$53.20

$70,200

$5,850

$3,900.00

$117.00

$83.85

$67.08

$54.60

$72,000

$6,000

$4,000.00

$120.00

$86.00

$68.80

$56.00

$73,800

$6,150

$4,100.00

$123.00

$88.15

$70.52

$57.40

$75,600

$6,300

$4,200.00

$126.00

$90.30

$72.24

$58.80

$77,400

$6,450

$4,300.00

$129.00

$92.45

$73.96

$60.20

$79,200

$6,600

$4,400.00

$132.00

$94.60

$75.68

$61.60

$81,000

$6,750

$4,500.00

$135.00

$96.75

$77.40

$63.00

$82,800

$6,900

$4,600.00

$138.00

$98.90

$79.12

$64.40

$84,600

$7,050

$4,700.00

$141.00

$101.05

$80.84

$65.80

$86,400

$7,200

$4,800.00

$144.00

$103.20

$82.56

$67.20

$88,200

$7,350

$4,900.00

$147.00

$105.35

$84.28

$68.60

$90,000

$7,500

$5,000.00

$150.00

$107.50

$86.00

$70.00

$91,800

$7,650

$5,100.00

$153.00

$109.65

$87.72

$71.40

$93,600

$7,800

$5,200.00

$156.00

$111.80

$89.44

$72.80

$95,400

$7,950

$5,300.00

$159.00

$113.95

$91.16

$74.20

$97,200

$8,100

$5,400.00

$162.00

$116.10

$92.88

$75.60

$99,000

$8,250

$5,500.00

$165.00

$118.25

$94.60

$77.00

$100,800

$8,400

$5,600.00

$168.00

$120.40

$96.32

$78.40

$102,600

$8,550

$5,700.00

$171.00

$122.55

$98.04

$79.80

$104,400

$8,700

$5,800.00

$174.00

$124.70

$99.76

$81.20

$106,200

$8,850

$5,900.00

$177.00

$126.85

$101.48

$82.60

$108,000

$9,000

$6,000.00

$180.00

$129.00

$103.20

$84.00

$109,800

$9,150

$6,100.00

$183.00

$131.15

$104.92

$85.40

$111,600

$9,300

$6,200.00

$186.00

$133.30

$106.64

$86.80

$113,400

$9,450

$6,300.00

$189.00

$135.45

$108.36

$88.20

$115,200

$9,600

$6,400.00

$192.00

$137.60

$110.08

$89.60

$117,000

$9,750

$6,500.00

$195.00

$139.75

$111.80

$91.00

$118,800

$9,900

$6,600.00

$198.00

$141.90

$113.52

$92.40

$120,600

$1,050

$6,700.00

$201.00

$144.05

$115.24

$93.80

$122,400

$10,200

$6,800.00

$204.00

$146.20

$116.96

$95.20

$124,200

$10,350

$6,900.00

$207.00

$148.35

$118.68

$96.60

$126,000

$10,500

$7,000.00

$210.00

$150.50

$120.40

$98.00

$127,800

$10,650

$7,100.00

$213.00

$152.65

$122.12

$99.40

$129,600

$10,800

$7,200.00

$216.00

$154.80

$123.84

$100.80

$131,400

$10,950

$7,300.00

$219.00

$156.95

$125.56

$102.20

$133,200

$11,100

$7,400.00

$222.00

$159.10

$127.28

$103.60

$135,000

$11,250

$7,500.00

$225.00

$161.25

$129.00

$105.00

Long Term Disability Find your annual/monthly earnings above to determine your Maximum Monthly Benefit. If your annual/monthly earnings are not shown, use the next lower annual/monthly earnings and corresponding Maximum Benefit.

This Summary of Benefits and the accompanying Brochure and Enrollment Form explain/explains the general purpose of the insurance described, but in no way changes or affects the policy as it is actually issued. In the event of any discrepancy between any of these documents and the policy, the terms of the policy apply. Life, AD&D Ultra, STD, and LTD products contain limitations and exclusions, complete coverage information can be found in your Booklet-Certificate if you become insured. Please read it carefully and keep it in a safe place with your other important papers.

AMERICAN PUBLIC LIFE

Cancer

YOUR BENEFITS

About this Benefit Cancer insurance offers you and your family supplemental insurance protection in the event you or a covered family member is diagnosed with cancer. It pays a benefit directly to you to help with expenses associated with cancer treatment.

DID YOU KNOW? Breast Cancer is the most commonly diagnosed cancer in women.

If caught early, prostate cancer is one of the most treatable malignancies.

(03/16)

GC14 Limited Benefit Group Cancer Indemnity Insurance Beaumont ISD THE POLICY UNDER WHICH THIS CERTIFICATE IS ISSUED IS NOT A POLICY OF WORKERS’ COMPENSATION INSURANCE. THE EMPLOYER DOES NOT BECOME A SUBSCRIBER TO THE WORKERS’ COMPENSATION SYSTEM BY PURCHASING THE POLICY AND IF THE EMPLOYER IS A NON-SUBSCRIBER, THE EMPLOYEE LOSES THOSE BENEFITS WHICH WOULD OTHERWISE ACCRUE UNDER THE WORKERS’ COMPENSATION LAWS. THE EMPLOYER MUST COMPLY WITH THE WORKERS’ COMPENSATION LAW AS IT PERTAINS TO NONSUBSCRIBERS AND THE REQUIRED NOTIFICATIONS THAT MUST BE FILED AND POSTED.

SUMMARY OF BENEFITS

Option 1

Option 2

Cancer Treatment Policy Benefits

Level 1

Radiation Therapy, Chemotherapy, Immunotherapy - Maximum per 12-month period

$10,000

$50 per treatment

Hormone Therapy - Maximum of 12 treatments per calendar year Experimental Treatment Cancer Screening Rider Benefits Diagnostic Testing - 1 test per calendar year Follow-Up Diagnostic Testing - 1 test per calendar year Medical Imaging - per calendar year Surgical Rider Benefits Surgical Anesthesia Bone Marrow Transplant - Maximum per lifetime Stem Cell Transplant - Maximum per lifetime Prosthesis - Surgical Implantation/Non-Surgical (not Hair Piece) 1 device per site, per lifetime Patient Care Rider Benefits Hospital Confinement Per day of Hospital Confinement (1-30 days) Per day for Eligible Dependent Children (1-30 days) Per day of Hospital Confinement (31+ days) Per day for Eligible Dependent Children (31+ days) Outpatient Facility - Per day surgery is performed Attending Physician - Per day of Hospital Confinement Dread Disease - Per day of Hospital Confinement (1-30 days / 31+ days)

paid in same manner and under the same maximums as any other benefit Level 1 Level 1 $50 per test

$50 per test

$100 per test

$500 per test / 1 per calendar year Level 1

$30 unit dollar amount Max $3,000 per operation

25% of amount paid for covered surgery $6,000

$6,000

$600

$1,000 / $100

Level 1

$100 $200 $100 $200 $200

$30

$100 / $100

Extended Care Facility - Up to the same number of Hospital Confinement Days

$100 per day

Donor

$100 per day

Home Health Care - Up to the same number of Hospital Confinement Days

$100 per day

Hospice Care - Up to maximum of 365 days per lifetime

$100 per day

US Government, Charity Hospital or HMO Per day of Hospital Confinement (1-30 days / 31+ days) Miscellaneous Care Rider Benefits

$100 / $100 Level 1

Cancer Treatment Center Evaluation or Consultation - 1 per lifetime

Not Included

Evaluation or Consultation Travel and Lodging - 1 per lifetime

Not Included

Second / Third Surgical Opinion - per diagnosis of cancer

$300 / $300

$150 per confinement $50 per prescription $150

actual coach fare or $.40 per mile $.40 per mile $50 per day actual coach fare or $.40 per mile $.40 per mile $50 per day

Drugs and Medicine - Inpatient / Outpatient (maximum $150 per month) Hair Piece (Wig) - 1 per lifetime Transportation - Maximum 12 trips per calendar year for all modes of transportation combined Travel by bus, plane or train Travel by car Lodging - up to a maximum of 100 days per calendar year Family Transportation - Maximum 12 trips per calendar year for all modes of transportation combined Travel by bus, plane or train Travel by car Family Lodging - up to a maximum of 100 days per calendar year

APSB-22339(TX)-0615 MGM/FBS Beaumont ISD

GC14 Limited Benefit Group Cancer Indemnity Insurance Option 1

Option 2

$300 per day

$200 / $2,000 per trip $150 per day

Outpatient Special Nursing Services - Up to same number of Hospital Confinement days

$150 per day

Medical Equipment - Maximum of 1 benefit per calendar year

Not Included

$25 per visit / $1,000

Waive Premium

Internal Cancer First Occurrence Rider Benefits

Level 1

Level 2

Lump Sum Benefit - Maximum 1 per Covered Person per lifetime

$2,500

$5,000

Lump Sum for Eligible Dependent Children - Maximum 1 per Covered Person per lifetime

$3,750

$7,500

Intensive Care Unit

$600 per day

Step Down Unit - Maximum of 45 days per Confinement for any combination of Intensive Care Unit or Step Down Unit

$300 per day

Miscellaneous Care Rider Benefits Con’t. Blood, Plasma and Platelets Ambulance - Ground/Air - Maximum of 2 trips per Hospital Confinement for all modes of transportation combined Inpatient Special Nursing Services - per day of Hospital Confinement

Physical, Occupational, Speech, Audio Therapy & Psychotherapy / Maximum per calendar year Waiver of Premium

Hospital Intensive Care Unit Rider Benefits

TOTAL MONTHLY PREMIUMS BY PLAN** Issue Ages 18+

Individual

Individual & Spouse

1 Parent Family

2 Parent Family

Option 1

Option 2

Option 1

Option 2

Option 1

Option 2

Option 1

Option 2

$19.80

$22.70

$41.70

$48.00

$25.78

$29.14

$47.62

$54.40

**Total premium includes the Plan selected and any applicable rider premium. Premiums are subject to increase with notice. The premium and amount of benefits vary dependent upon the Plan selected at time of application.

Benefits are only payable following a diagnosis of cancer for a loss incurred for the treatment of cancer while covered under the policy. A charge must be incurred for benefits to be payable. When coverage terminates for loss incurred after the coverage termination date, our obligation to pay benefits also terminates for a specified disease that manifested itself while the person was covered under the policy. All benefits are subject to the benefit maximums.

Pre-Existing Condition Exclusion

Cancer Treatment Benefits

No benefits are payable for any loss incurred during the pre-existing condition exclusion period, following the covered person’s effective date as the result of a pre-existing condition. Pre-existing conditions specifically named or described as excluded in any part of the policy are never covered. If any change to coverage after the certificate effective date results in an increase or addition to coverage, the time limit on certain defenses and pre-existing condition exclusion for such increase will be based on the effective date of such increase.

Eligibility

Waiting Period

You and your eligible dependents are eligible to be insured under this certificate if you and your eligible dependents meet our underwriting rules and you are actively at work with the policyholder and qualify for coverage as defined in the master application.

Limitations and Exclusions

No benefits will be paid for any of the following: treatment by any program engaged in research that does not meet the definition of experimental treatment; or losses or medical expenses incurred prior to the covered person’s effective date regardless of when specified disease was diagnosed.

Only Loss for Cancer

The policy pays only for loss resulting from definitive cancer treatment including direct extension, metastatic spread or recurrence. Proof must be submitted to support each claim. The policy also covers other conditions or diseases directly caused by cancer or the treatment of cancer. The policy does not cover any other disease, sickness or incapacity which existed prior to the diagnosis of cancer, even though after contracting cancer it may have been complicated, aggravated or affected by cancer or the treatment of cancer.

38 APSB-22339(TX)-0615 MGM/FBS Beaumont ISD

The policy and any attached riders contain a waiting period during which no benefits will be paid. If any covered person has a specified disease diagnosed before the end of the waiting period immediately following the covered person’s effective date, coverage for that person will apply only to loss that is incurred after one year from the covered person’s effective date. If any covered person is diagnosed as having a specified disease during the waiting period immediately following the covered person’s effective date, you may elect to void the certificate from the beginning and receive a full refund of premium. If the policy replaced group specified disease cancer coverage from any company that terminated within 30 days of the certificate effective date, the waiting period will be waived for those covered persons that were covered under the prior coverage. However, the pre-existing condition exclusion provision will still apply.

GC14 Limited Benefit Group Cancer Indemnity Insurance Termination of Certificate

Insurance coverage under the certificate and any attached riders will end on the earliest of these dates: the date the policy terminates; the end of the grace period if the premium remains unpaid; the date insurance has ceased on all persons covered under this certificate; the end of the certificate month in which the policyholder requests to terminate this coverage; the date you no longer qualify as an insured; or the date of your death.

Termination of Coverage

Insurance coverage for a covered person under the certificate and any attached riders for a covered person will end as follows: the date the policy terminates; the date the certificate terminates; the end of the grace period if the premium remains unpaid; the end of the certificate month in which the policyholder requests to terminate the coverage for an eligible dependent; the date a covered person no longer qualifies as an insured or eligible dependent; or the date of the covered person’s death. We may end the coverage of any Covered Person who submits a fraudulent claim.

Cancer Screening Benefits Limitations and Exclusions

No benefits will be paid for any of the following: treatment by any program engaged in research that does not meet the definition of experimental treatment; losses or medical expenses incurred prior to the covered person’s effective date of this rider; or loss incurred during the pre-existing condition exclusion period following the covered person’s effective date of this rider as a result of a pre-existing condition. For the purpose of benefits under this rider, the waiting period will begin on the covered person’s effective date of this rider.

Surgical Benefits Limitations and Exclusions

No benefits will be paid for any of the following: treatment by any program engaged in research that does not meet the definition of experimental treatment; losses or medical expenses incurred prior to the covered person’s effective date of this rider regardless of when a specified disease was diagnosed; or loss incurred during the pre-existing condition exclusion period following the covered person’s effective date of this rider as a result of a pre-existing condition. For the purpose of benefits under this rider, the waiting period will begin on the covered person’s effective date of this rider.

Patient Care Benefits A hospital is not an institution, or part thereof, used as: a hospice unit, including any bed designated as a hospice or a swing bed; a convalescent home; a rest or nursing facility; a rehabilitative facility; an extended-care facility; or a facility primarily affording custodial, educational care, or care of treatment for persons suffering from mental diseases or disorders, or care for the aged, or drug or alcohol addiction.

Limitations and Exclusions

No benefits will be paid for any of the following: treatment by any program engaged in research that does not meet the definition of experimental treatment; losses or medical expenses incurred prior to the covered person’s effective date of this rider regardless of when a specified disease was diagnosed; or loss incurred during the pre-existing condition exclusion period following the covered person’s effective date of this rider as a result of a pre-existing condition. For the purpose of benefits under this rider, the waiting period will begin on the covered person’s effective date of this rider.

Only Loss for Cancer or Dread Disease

Pays only for loss resulting from definitive cancer treatment including direct extension, metastatic spread or recurrence. Proof must be submitted to support each claim. This rider also covers other conditions or diseases directly caused by cancer or the treatment of cancer. This rider does not cover any other disease, sickness or incapacity which existed prior to the diagnosis of cancer, even though after contracting cancer it may have been complicated, aggravated or affected by cancer or the treatment of cancer except for conditions specifically provided in the dread disease benefit.

You must remain disabled for 60 continuous days before this benefit will begin. The waiver of premium will begin on the next premium due date following the 60 consecutive days of disability. This benefit will continue for as long as you remain disabled until the earliest of either of the following: the date you are no longer disabled; the date coverage ends according to the termination provisions in the certificate; or the date coverage ends according to the termination provisions in this rider. Proof of disability must be provided for each new period of disability before a new waiver of premium benefit is payable.

Limitations and Exclusions

No benefits will be paid for any of the following: treatment by any program engaged in research that does not meet the definition of experimental treatment; losses or medical expenses incurred prior to the covered person’s effective date of this rider regardless of when a specified disease was diagnosed; or loss incurred during the pre-existing condition exclusion period following the covered person’s effective date of this rider as a result of a pre-existing condition. For the purpose of benefits under this rider, the waiting period will begin on the covered person’s effective date of this rider.

Termination of Cancer Screening, Surgical, Patient Care & Miscellaneous Benefit Rider(s) The above listed rider(s) will terminate and coverage will end for all covered persons on the earliest of: the end of the grace period if the premium for the rider remains unpaid; the date the policy or certificate to which the rider is attached terminates; the end of the certificate month in which APL receives a request from the policyholder to terminate the rider; or the date of your death. Coverage on an eligible dependent terminates under the rider when such person ceases to meet the definition of eligible dependent.]

Internal Cancer First Occurrence Benefits Pays a lump sum benefit amount when a covered person receives a first diagnosis of internal cancer and the date of diagnosis occurs after the waiting period. Only one benefit per covered person, per lifetime is payable under this benefit and the lump sum benefit amount will reduce by 50% at age 70.

Limitations and Exclusions

We will not pay benefits for a diagnosis of internal cancer received outside the territorial limits of the United States or a metastasis to a new site of any cancer diagnosed prior to the covered person’s effective date, as this is not considered a first diagnosis of an internal cancer.

Pre-Existing Condition Exclusion

No benefits are payable for any loss incurred during the pre-existing condition exclusion period following the covered person’s effective date of this rider as the result of a pre-existing condition.

Waiting Period

This rider contains a 30-day waiting period during which no benefits will be paid. If any internal cancer is diagnosed before the end of the waiting period immediately following the covered person’s effective date of this rider, coverage will apply only to loss that is incurred after one year from the covered person’s effective date of this rider.

Termination

This rider will terminate and coverage will end for all covered persons on the earliest of any of the following: the end of the grace period if the premium for this rider remains unpaid; the date the policy or certificate to which this rider is attached terminates; the end of the certificate month in which we receive a request from the policyholder to terminate this rider; the date of covered person’s death or the date the lump sum benefit amount for internal cancer has been paid for all covered persons under this rider. Coverage on an eligible dependent terminates under this rider when such person ceases to meet the definition of eligible dependent.

Miscellaneous Benefits Waiver of Premium

When the certificate is in force and you become disabled, we will waive all premiums due including premiums for any riders attached to the certificate. Disability must be due to cancer and occur while receiving treatment for such cancer.

APSB-22339(TX)-0615 MGM/FBS Beaumont ISD

GC14 Limited Benefit Group Cancer Indemnity Insurance Hospital Intensive Care Unit Benefits

Portability (Voluntary Plans Only)

Pays a daily benefit amount, up to the maximum number of days for any combination of confinement, for each day charges are incurred for room and board in an intensive care unit (ICU) or step-down unit due to an accident or sickness. Benefits will be paid beginning on the first day a covered person is confined in an ICU or step-down unit due to an accident or sickness that begins after the effective date of this rider. This benefit will reduce by 50% at age 70.

When you no longer meet the definition of Insured, you will have the option to continue this coverage, including any attached riders. No Evidence of Insurability will be required. Portability must meet all of the following conditions: the certificate has been continuously in force for the last 12 months; we receive a request and payment of the first premium for the portability coverage no later than 30 days after the date you no longer qualify as an eligible insured; and the policy, under which this certificate was issued, continues to be in force on the date you cease to qualify for coverage. All future premiums due will be billed directly to you. You are responsible for payment of all premiums for the portability coverage.

Limitations and Exclusions

For a newborn child born within the 10-month period following the effective date, no benefits under this rider will be provided for confinements that begin within the first 30 days following the birth of such child. No benefits under this rider will be provided during the first two years following the effective date for confinements caused by any heart condition when any heart condition was diagnosed or treated prior to the end of the 30-day period following the covered person’s effective date. The heart condition causing the confinement need not be the same condition diagnosed or treated prior to the effective date. We will not pay benefits for any loss caused by or resulting from any of the following: intentionally self-inflicted bodily injury, suicide or attempted suicide, whether sane or insane; alcoholism or drug addiction; any act of war, declared or undeclared, or any act related to war, or active service in the armed forces, or military service for any country at war; participation in any activity or event while intoxicated or under the influence of any narcotic unless administered by a physician or taken according to the physician’s instructions; participation in, or attempting to participate in, a felony, riot or insurrection (a felony is defined by the law of the jurisdiction in which the activity takes place).

The benefits, terms and condition of the portability coverage will be the same as those elected under the certificate immediately prior to the date you exercised portability. Portability coverage may include any eligible dependents who were covered under the certificate at the time you ceased to qualify as an eligible insured. No new eligible dependents may be added to the portability coverage except as provided in the New Born and Adopted Children provision. No increases in coverage will be allowed while you are exercising your rights under this rider. The premium for the portability coverage will be based on the premium tables used for such coverage at the time of the portability request. Coverage under this rider will terminate in accordance with the provisions of the Termination of Coverage in the certificate. If the policy is no longer in force, then portability coverage is not available.

Termination

This rider will terminate and coverage will end for all covered persons on the earliest of any of the following: the end of the grace period if the premium for this rider remains unpaid; the date the policy or certificate to which this rider is attached terminates; the end of the certificate month in which we receive a request from the policyholder to terminate this rider or the date of the covered person’s death. Coverage on an eligible dependent terminates under this rider when such person ceases to meet the definition of eligible dependent.

Optionally Renewable This policy/riders are optionally renewable. The policyholder or we have the right to terminate the policy/riders on any premium due date after the first anniversary following the policy/riders effective date. We must give at least 60 days written notice to the policyholder prior to cancellation.

2305 Lakeland Drive | Flowood, MS 39232 ampublic.com | 800.256.8606 Underwritten by American Public Life Insurance Company. This is a brief description of the coverage. For detailed benefits, limitations, exclusions and other provisions, please refer to the policy/certificate/riders. This coverage does not replace Workers’ Compensation Insurance. This product is inappropriate for people who are eligible for Medicaid coverage. | This policy is considered an employee welfare benefit plan established and/or maintained by an association or employer intended to be covered by ERISA, and will be administered and enforced under ERISA. Group policies issued to governmental entities and municipalities may be exempt from ERISA guidelines. | Policy Form GC14 Series | TX | Limited Benefit Group Cancer Indemnity Insurance | (10/14) | MGM/FBS | Beaumont ISD

APSB-22339(TX)-0615 MGM/FBS Beaumont ISD 40

GC14 Limited Benefit Group Cancer Indemnity Insurance

A-3 Supplemental Limited Benefit Accident Expense Insurance Beaumont ISD

AMERICAN PUBLIC LIFE YOUR BENEFITS

Accident

Summary of Benefits* Benefit Description

Level 1 - 1 Unit

Level 4 – 4 Units

$5,000

$20,000

actual charges up to $500

actual charges up to $2,000

$75 per day

$300 per day

actual charges up to $1,250

actual charges up to $5,000

$500 $500 $2,500 $5,000

$2,000 $2,000 $10,000 $20,000

$2,500 $5,000

$10,000 $20,000

$100 upon admission $100 per unit

$400 upon admission $100 per unit

$150 per day / $150 per unit

$600 per day / $150 per unit

once per 24 hours $1,000 benefit

Accidental Death - per unit Medical Expense Accidental Injury Benefit - per unit Daily Hospital Confinement Benefit Air and Ground Ambulance Benefit Accidental Dismemberment Benefit Single finger or toe Multiple fingers or toes Single hand, arm, foot or leg Multiple hands, arms, feet or legs Accidental Loss of Sight Benefit - per unit Loss of Sight in one eye Loss of Sight in both eyes Optional Benefit Riders Hospital Admission Benefit Accident Only - Intensive Care Benefit Gunshot Wound Benefit Rider (Primary Insured Only/Public Safety Personnel Only)

About this Benefit Accident insurance is designed to supplement your medical insurance coverage by covering indirect costs that can arise with a serious, or a not-so-serious, injury. Accident coverage is low cost protection available to you and your family without evidence of insurability.

DID YOU KNOW?

2/3

of disabling injuries suffered by American workers are not work related.

American workers 36% ofreport they always or usually live paycheck to paycheck.

Individual

Individual & Spouse

1 Parent Family

2 Parent Family

Level 1 - 1 Unit

$10.80

$19.40

$21.20

$29.80

Level 4 - 4 Units

$24.50

$44.90

$52.00

$72.40

Optional Benefit Riders Hospital Admission Benefit

Accident Only –Intensive Care Benefit

$100

$400

Individual

$0.45

$1.80

Individual & Spouse

$0.65

One-Parent Family Two-Parent Family

$150

$600

Individual

$0.45

$2.60

Individual & Spouse

$0.75

$3.00

$0.95

$3.80

Gunshot Wound Benefit Rider

$1.80

Monthly Premium

Benefit per 24 Hour Period

$0.65

$2.60

$1.00

$1,000

One-Parent Family

$0.75

$3.00

Two-Parent Family

$0.95

$3.80

*The premium and amount of benefits vary dependent upon the Plan selected at time of application. Premiums are subject to increase with notice. APSB-22329(TX)-MGM/FBS Beaumont ISD

A-3 Supplemental Limited Benefit Accident Expense Insurance Beaumont ISD

AMERICAN PUBLIC LIFE YOUR BENEFITS

Accident

Summary of Benefits* High Plan / Level 4 – 4 Units

Accidental Death - per unit

Low Plan / Level 1 - 1 Unit $5,000

Medical Expense Accidental Injury Benefit - per unit

actual charges up to $500

actual charges up to $2,000

$75 per day

$300 per day

actual charges up to $1,250

actual charges up to $5,000

$500 $500 $2,500 $5,000

$2,000 $2,000 $10,000 $20,000

$2,500 $5,000

$10,000 $20,000

$100 upon admission $100 per unit

$400 upon admission $100 per unit

$150 per day / $150 per unit

$600 per day / $150 per unit

once per 24 hours $1,000 benefit

Benefit Description

Daily Hospital Confinement Benefit Air and Ground Ambulance Benefit Accidental Dismemberment Benefit Single finger or toe Multiple fingers or toes Single hand, arm, foot or leg Multiple hands, arms, feet or legs Accidental Loss of Sight Benefit - per unit Loss of Sight in one eye Loss of Sight in both eyes

$20,000

Optional Benefit Riders Hospital Admission Benefit Accident Only - Intensive Care Benefit Gunshot Wound Benefit Rider (Primary Insured Only/Public Safety Personnel Only)

DID YOU KNOW?

2/3

of disabling injuries suffered by American workers are not work related.

American workers 36% ofreport they always or usually live paycheck to paycheck.

Individual

Individual & Spouse

1 Parent Family

2 Parent Family

Level 1 - 1 Unit

$10.80

$19.40

$21.20

$29.80

Level 4 - 4 Units

$24.50

$44.90

$52.00

$72.40

Optional Benefit Riders Hospital Admission Benefit

Accident Only –Intensive Care Benefit

$100

$400

Individual

$0.45

$1.80

Individual & Spouse

$0.65

One-Parent Family Two-Parent Family

$150

$600

Individual

$0.45

$2.60

Individual & Spouse

$0.75

$3.00

$0.95

$3.80

Gunshot Wound Benefit Rider

$1.80

Monthly Premium

Benefit per 24 Hour Period

$0.65

$2.60

$1.00

$1,000

One-Parent Family

$0.75

$3.00

Two-Parent Family

$0.95

$3.80

*The premium and amount of benefits vary dependent upon the Plan selected at time of application. Premiums are subject to increase with notice. APSB-22329(TX)-MGM/FBS Beaumont ISD

A-3 Supplemental Limited Benefit Accident Expense Insurance

Eligibility

Gunshot Wound Benefit Rider Only

(8)

This policy will be issued to only those persons who meet American Public Life Insurance Company’s insurability requirements. Persons not meeting APL’s insurability requirements will be excluded from coverage by an endorsement attached to the policy.

This Rider does not pay benefits for: any non-fatal Gunshot Wound received in a non - occupational related shooting; or, non - fatal Gunshot Wounds received while on active duty in the armed services (the company will return any premium paid past the time of entry into the armed forces when notice is received).

(9)

No benefits are payable for a pre-existing condition. Pre-existing condition means an Injury that pertains solely to an Accidental Bodily Injury which resulted from an accident sustained before the Effective Date of coverage. Pre-Existing Conditions specifically named or described as permanently excluded in any part of this contract are never covered.

This Rider does not pay benefits for self-inflected Gunshot Wound.

(11)

A Hospital is not an institution which is primarily a place for alcoholics or drug addicts; the aged; a nursing, rest or convalescent nursing home; a mental institution or sanitarium; a facility contracted for or operated by the United States Government for treatment of members or ex-members of the armed forces (unless You are legally required to pay for services rendered in the absence of insurance); or, a long-term nursing unit or geriatrics ward.

Gunshot Wound Benefit Rider is only available through payroll deduction.

Base Policy and Optional Benefits

Medical Expense Accidental Injury Benefit

This Rider is subject to all the Provisions, Conditions, Limitations and Exclusions of the Policy to which it is attached, which are not in conflict with those of the Rider.

The Gunshot Wound Benefit Rider is guaranteed renewable to age 65 or age 70, if actively at work. While this Rider is in effect, premiums are due according to the terms of the Policy. We reserve the right to change premium rates by class.

Hospital Admission Benefit The maximum benefit is 4 units.

Expenses must commence within 60 days of the covered accident. The maximum benefit amount payable for any one accident for the Insured Person shall not exceed the Medical Expense Benefit.

The maximum benefit is 4 units. The maximum benefit period for this benefit is up to 30 days for any one accident.

Air and Ground Ambulance Benefit

Exclusions

Emergency transportation must occur within 21 calendar days of the accident causing such Injury.

Benefits otherwise provided by this Policy will not be payable for services or expenses or any such Loss resulting from or in connection with:

Daily Hospital Confinement Benefit The maximum benefit period for this benefit is 30 days per covered accident.

Accidental Death Accidental Death must result within 90 days of the covered accident causing the injury.

Accidental Dismemberment Benefit The total amount payable for all Losses resulting from the same accident will not exceed the Maximum Dismemberment Benefit of $5,000 cumulative per unit, per Accident. Loss must be within 90 days of the accident causing such Injury.

APSB-22329(TX)-MGM/FBS Beaumont ISD 44

Accident Only – Intensive Care Benefit

(1) (2) (3) (4) (5) (6)

(7)

sickness, illness or bodily infirmity; suicide, attempted suicide or intentional self-inflicted Injury, whether sane or insane; dental care or treatment unless due to accidental Injury to natural teeth; war or any act of war (whether declared or undeclared) or participating in a riot or felony; alcoholism or drug addiction; travel or flight in or descent from any aircraft or device which can fly above the earth’s surface in any capacity other than as a fare paying passenger on a regularly scheduled airline; Injury originating prior to the effective date of the Policy;

(10)

(12) (13) (14)

(15)

(16)

Injury occurring while intoxicated (Intoxication means that which is determined and defined by the laws and jurisdiction of the geographical area in which the loss or cause of loss is incurred.); Voluntary inhalation of gas or fumes or taking of poison or asphyxiation; Voluntary ingestion or injection of any drug, narcotic or sedative, unless administered on the advice and taken in such doses as prescribed by a Physician; Injury sustained or sickness which first manifests itself while on full-time duty in the armed forces; (Upon notice, We will refund the proportion of unearned premium while in such forces.) Injury incurred while engaging in an illegal occupation; Injury incurred while attempting to commit a felony or an assault; Injury to a covered person while practicing for or being a part of organized or competitive rodeo, sky diving, hang gliding, parachuting or scuba diving; driving in any race or speed test or while testing an automobile or any vehicle on any racetrack or speedway; hernia, carpal tunnel syndrome or any complication therefrom;

If You are entitled to benefits under this Policy as a result of sprained or lame back, or any intervertebral disk conditions, such benefits shall be payable for a maximum period of time, not exceeding in the aggregate three (3) months for any Injury.

Guaranteed Renewable You have the right to renew this Policy until the first premium due date on or after Your 69th birthday, if you pay the correct premium when due or within the Grace Period. When an Insured’s coverage terminates at age 70, coverage for other Insured Persons, if any, shall continue under this Policy. We have the right to change premium rates by class.

2305 Lakeland Drive | Flowood, MS 39232 ampublic.com | 800.256.8606

Underwritten by American Life Insurance Company. This is a brief description of the coverage. For complete benefits, limitations, exclusions and other provisions, please refer to the certificate/policy and riders. This coverage does not replace Workers’ Compensation Insurance. | This product is inappropriate for people who are eligible for Medicaid coverage. | Policy Form A3 Series | Texas | Supplemental Limited Benefit Accident Expense Insurance Policy | (10/14) | Beaumont ISD

APSB-22329(TX)-MGM/FBS Beaumont ISD

A-3 Supplemental Limited Benefit Accident Expense Insurance

Eligibility

Gunshot Wound Benefit Rider Only

(8)

(9)

This Rider does not pay benefits for self-inflected Gunshot Wound.

(11)

Gunshot Wound Benefit Rider is only available through payroll deduction.

Base Policy and Optional Benefits

Medical Expense Accidental Injury Benefit

This Rider is subject to all the Provisions, Conditions, Limitations and Exclusions of the Policy to which it is attached, which are not in conflict with those of the Rider.

Hospital Admission Benefit The maximum benefit is 4 units.

Expenses must commence within 60 days of the covered accident. The maximum benefit amount payable for any one accident for the Insured Person shall not exceed the Medical Expense Benefit.

The maximum benefit is 4 units. The maximum benefit period for this benefit is up to 30 days for any one accident.

Air and Ground Ambulance Benefit

Exclusions

Emergency transportation must occur within 21 calendar days of the accident causing such Injury.

Benefits otherwise provided by this Policy will not be payable for services or expenses or any such Loss resulting from or in connection with:

Daily Hospital Confinement Benefit The maximum benefit period for this benefit is 30 days per covered accident.

Accidental Death Accidental Death must result within 90 days of the covered accident causing the injury.

APSB-22329(TX)-MGM/FBS Beaumont ISD

Accident Only – Intensive Care Benefit

(1) (2) (3) (4) (5) (6)

(7)

(10)

(12) (13) (14)

(15)

(16)

2305 Lakeland Drive | Flowood, MS 39232 ampublic.com | 800.256.8606

APSB-22329(TX)-MGM/FBS Beaumont ISD

AUL A ONE AMERICA COMPANY

YOUR BENEFITS PACKAGE

Life & AD&D

About this Benefit Group term life is the most inexpensive way to purchase life insurance. You have the freedom to select an amount of life insurance coverage you need to help protect the well-being of your family. Accidental Death & Dismemberment is life insurance coverage that pays a death benefit to the beneficiary, should death occur due to a covered accident. Dismemberment benefits are paid to you, according to the benefit level you select, if accidentally dismembered.

DID YOU KNOW? Motor vehicle crashes are the

cause of accidental deaths in the US, followed by poisoning, falls, drowning, and choking.

Voluntary Life AUL's Group Voluntary Term Life Insurance Terms and Definitions Eligible Employees: This benefit is available for employees who are actively at work on the effective date and working a minimum of 20 hours per week.

Flexible Choices:

Continuation of Coverage Options: Portability Should your coverage terminate for any reason, you may be eligible to take this term life insurance with you without providing Evidence of Insurability. You must apply within 31 days from the last day you are eligible. The Portability option is available until you reach age 70.

Since everyone's needs are different, this plan offers flexibility for Conversion you to choose a benefit amount that fits your needs and budget. Should your life insurance coverage, or a portion of it, cease for any reason, you may be eligible to convert your Group Term Coverage to Individual Coverage without providing Evidence of Accidental Death & Dismemberment (AD&D): If approved for this benefit, additional life insurance benefits may Insurability. You must apply within 31 days from the last day you are eligible. be payable in the event of an accident which results in death or dismemberment as defined in the contract.

Guaranteed Issue Amounts:

Accelerated Life Benefit: If diagnosed with a terminal illness and have less than 12 months to live, you may apply to receive 25%, 50% or 75% of your life insurance benefit to use for whatever you choose.

This is the most coverage you can purchase without having to answer any health questions. If you decline insurance coverage now and decide to enroll later, you will need to provide Evidence Waiver of Premium: of Insurability. If approved, this benefit waives your and your dependents' insurance premium in case you become totally disabled and are Employee Guaranteed Issue Amount $200,000 unable to collect a paycheck. Spouse Guaranteed Issue Amount $50,000

Timely Enrollment: Enrolling timely means you have enrolled during the initial enrollment period when benefits were first offered by AUL, or as a newly hired employee within 31 days following completion of any applicable waiting period.

Reductions: Upon reaching certain ages, your original benefit amount will reduce to a percentage as shown in the following schedule. Age:

Reduces To:

67%

45%

Evidence of Insurability: If you elect a benefit amount over the Guaranteed Issue Amount shown above for you or your eligible dependents, or you do not enroll timely, you will need to submit a Statement of Insurability form for review. Based on health history, you and / or your dependents will be approved or declined for insurance coverage by AUL.

This invitation to inquire allows eligible employees an opportunity to inquire further about AUL's group insurance and is limited to a brief description of any losses for which benefits are payable. The contract has exclusions, limitations reduction of benefits, and terms under which the contract may be continued in force or discontinued.

Annual Increase in Benefit: If eligible, this benefit allows you to increase your coverage every year as your life insurance needs change. You may be able to increase your benefit amount by $10,000 every year until you reach the guaranteed issue amount, without providing Evidence of Insurability. NOTE: If Evidence of Insurability is applied for and denied, please be aware Guaranteed Increase in Benefits will not be made available to you in the future.

Voluntary Life Monthly Payroll Deduction Illustration About your benefit options:    

You may select a minimum benefit of $20,000 up to a maximum amount of $500,000, in increments of $10,000, not to exceed 7 times your annual base salary plus permanent stipends, rounded to the next higher $10,000. You may select an amount in $10,000 increments for your spouse not to exceed your benefit amount. Voluntary AD&D amounts are available for you and your spouse to a maximum of $500,000. Your spouses Voluntary AD&D amount cannot exceed your benefit amount. The child(ren) Voluntary AD&D amount is $10,000. Voluntary Life Amounts requested above $200,000 for an Employee, $50,000 for a Spouse, or any amount not requested timely will require Evidence of Insurability. Voluntary AD&D amounts are all guaranteed issue. Employee must select coverage to select any Dependent coverage.

EMPLOYEE ONLY OPTIONS (based on Employee's age as of 09/01) Life Options

0-19

20-24

25-29

30-34

35-39

40-44

45-49

50-54

55-59

60-64

65-69

70-74

AD&D

$20,000

$1.08

$1.30

$1.94

$2.16

$2.38

$3.46

$5.40

$9.94

$15.12

$29.60

$.52

$30,000

$1.62

$1.95

$2.91

$3.24

$3.57

$5.19

$8.10

$14.91

$22.68

$44.40

$.78

$40,000

$2.16

$2.60

$3.88

$4.32

$4.76

$6.92

$10.80

$19.88

$30.24

$59.20

$1.04

$50,000

$2.70

$3.25

$4.85

$5.40

$5.95

$8.65

$13.50

$24.85

$37.80

$74.00

$1.30

$60,000

$3.24

$3.90

$5.82

$6.48

$7.14

$10.38

$16.20

$29.82

$45.36

$88.80

$1.56

$70,000

$3.78

$4.55

$6.79

$7.56

$8.33

$12.11

$18.90

$34.79

$52.92 $103.60

$1.82

$80,000

$4.32

$5.20

$7.76

$8.64

$9.52

$13.84

$21.60

$39.76

$60.48 $118.40

$2.08

$100,000

$5.40

$6.50

$9.70

$10.80 $11.90

$17.30

$27.00

$49.70

$75.60 $148.00

$2.60

$150,000

$8.10

$9.75

$14.55 $16.20 $17.85

$25.95

$40.50

$74.55 $113.40 $222.00

$3.90

$200,000

$10.80 $10.80 $10.80 $13.00 $19.40 $21.60 $23.80

$34.60

$54.00

$99.40 $151.20 $296.00

$5.20

SPOUSE ONLY OPTIONS (based on Employee's Age as of 09/01 Life Options

0-19

20-24

25-29

30-34

35-39

40-44

45-49

50-54

55-59

60-64

65-69

70-74

AD&D

$20,000

$1.08

$1.30

$1.94

$2.16

$2.38

$3.46

$5.40

$9.94

$15.12

$29.60

$.52

$30,000

$1.62

$1.95

$2.91

$3.24

$3.57

$5.19

$8.10

$14.91

$22.68

$44.40

$.78

$40,000

$2.16

$2.60

$3.88

$4.32

$4.76

$6.92

$10.80

$19.88

$30.24

$59.20

$1.04

$50,000

$2.70

$3.25

$4.85

$5.40

$5.95

$8.65

$13.50

$24.85

$37.80

$74.00

$1.30

Voluntary Life CHILD(REN) OPTIONS (Premium shown for Child(ren) reflects the cost for all eligible dependent children) Child(ren) 6 months to age 26 Option 1:

$10,000

Child(ren) live birth to 6 months $1,000

Monthly Payroll Deduction Child Life

Monthly Payroll Deduction Child AD&D

$1.51

$0.26

About Premiums: The premiums shown above may vary slightly due to rounding; actual premiums will be calculated by American United Life Insurance CompanyÂŽ (AUL), and may increase upon reaching certain age brackets, according to contract terms, and are subject to change.

TEXAS LIFE

Individual Life

YOUR BENEFITS PACKAGE

About this Benefit Individual life is a policy that provides a specified death benefit to your beneficiary at the time of death. The advantage of having an individual life insurance plan as opposed to a group supplemental term life plan is that this plan is guaranteed renewable, portable and typically premiums remain the same over the life of the policy.

DID YOU KNOW?

1/3 of Americans would be financially impacted by the loss of the primary wage earner in just one month.

Individual Life Life Insurance Highlights Voluntary permanent life insurance can be an ideal complement to the group term and optional term your employer might provide. Designed to be in force when you die, this voluntary universal life product is yours to keep, even when you change jobs or retire, as long as you pay the necessary premium. Group and voluntary term, on the other hand, typically are not portable if you change jobs and, even if you can keep them after you retire, usually costs more and declines in death benefit.

DID YOU KNOW? Those with no life insurance think it’s 3 times more expensive than it actually is.

The policy, PureLife-plus, is underwritten by Texas Life Insurance Company, and it has these outstanding features: 

High Death Benefit. With one of the highest death benefit available at the worksite,1 PureLife-plus gives your loved ones peace of mind, knowing there will be significant life insurance in force should you die prematurely.



Minimal Cash Value. Designed to provide high death benefit, PureLife-plus does not compete with the cash accumulation in your employer-sponsored retirement plans.



Long Guarantees. Enjoy the assurance of a policy that has a guaranteed death benefit to age 121 and level premium that guarantees coverage for a significant period of time (after the guaranteed period, premiums may go down, stay the same, or go up).



Refund of Premium. Unique in the marketplace, PureLife-plus offers you a refund of 10 years’ premium, should you surrender the policy if the premium you pay when you buy the policy ever increases. (Conditions apply.)



Accelerated Death Benefit Rider. Should you be diagnosed as terminally ill with the expectation of death within 12 months (24 months in Illinois), you will have the option to receive 92% (84% in Illinois) of the death benefit, minus a $150 ($100 in Florida) administrative fee. This valuable living benefit gives you peace of mind knowing that, should you need it, you can take the large majority of your death benefit while still alive. (Conditions apply.)

You may apply for this permanent, portable coverage, not only for yourself, but also for your spouse, minor children and grandchildren. Like most life insurance policies, Texas Life policies contain certain exclusions, limitations, exceptions, reductions of benefits, waiting periods and terms for keeping them in force. Please contact a Texas Life representative for costs and complete details. 1

Voluntary and Universal Whole Life Products, Eastbridge Consulting Group, October 2008

UNUM

Critical Illness

YOUR BENEFITS PACKAGE

About this Benefit Critical illness insurance is designed to supplement your medical and disability coverage easing the financial impacts by covering some of your additional expenses. It provides a benefit payable directly to the insured upon diagnosis of a covered condition or event, like a heart attack or stroke.

DID YOU KNOW?

$16,500 Is the aggregate cost of a hospital stay for a heart attack.

Critical Illness Coverage Amounts

Portability



Included

 

Employee - $10,000 to $30,000 in increments of $5,000 Spouse - $5,000 to $15,000 in increments of $5,000 Child – 25% of Employee Coverage Amount

Guarantee Issue  

Employee – $30,000 Spouse - $15,000

Pre-Existing Condition

Recurrence Benefit Included – 25% of the coverage amount for an additional payout for a subsequent occurrence of benign brain tumor, coma, heart attack or stroke.

Premium Paid by the Employee

Employee 12/12 exclusion

Benefit Waiting Period 30 days

Without Cancer Monthly Rates per $1,000 Issue Ages

Non-Tobacco

Tobacco

< 25

.29

25 - 29

.30

30 - 34

.44

35 - 39

.60

40 - 44

.89

45 - 49

1.17

50 - 54

1.53

55 - 59

1.98

60 - 64

2.54

65 - 69

2.91

70 +

5.44

This plan highlight is a summary provided to help you understand your insurance coverage from Unum. Details may differ from state to state. Please refer to your certificate booklet for your complete plan description. If the terms of this plan highlight summary or your certificate differ from your policy, the policy will govern. 53

ID WATCHDOG

Identity Theft

YOUR BENEFITS PACKAGE

About this Benefit Identity theft protection monitors and alerts you to identity threats. Resolution services are included should your identity ever be compromised while you are covered.

DID YOU KNOW?

An identity is stolen every

2 seconds, and takes over

300 hours to resolve, causing an average loss of $9,650.

Identity Theft ADVANCED TOOLS

DUAL MONTHLY PRICING Plus

Platinum



Breach Notification

Individual

$7.95

$11.95

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Solicitation Reduction

Family

$14.95

$22.95

CREDIT PROTECTION SERVICES

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Tri-bureau monitoring and TransUnion® report and score.

Monthly Credit Score Tracker Historical view of TransUnion scores.

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Credit Freeze Fraud Alert Assistance & Reminders

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Assistance with setting credit bureau fraud alerts and reminders.

PROACTIVE IDENTITY MONITORING 

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Public Records & NCOA Monitoring We monitor the National Change of Address Registry and public records databases (over 37 billion consumer records). Direct network access enables us to detect potential fraud faster.

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Payday Loan Monitoring We work directly with alternative credit bureaus that service the under-banked market. Our network monitors the largest database so we can alert faster.

Enhanced Non-Credit Loan Monitoring

Our expanded fraud detection network includes monitoring of  auto pawn, rent-to-own, sub-prime, and cell phone accounts. Protection is increased by scanning for these common transactions that require minimal information to obtain.

High-Risk Application & Transaction Monitoring Real-time alerts cover new account applications such as financial and wireless. Real-time alerts inform you of critical transactions including bank password resets, online healthcare, payroll account, or insurance records access. We catch potential identity theft up to 90 days sooner.

Cyber Monitoring

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Instant-On promptly activates all monitoring on the benefit effective date without any further action required by the employee.

2-Step Authentication

Identity Profile Report Our report helps surface any pre-existing conditions going back 30 years or more.

Social Network Alerts Add alert customizations to Facebook, LinkedIn, Instagram, and Twitter accounts to stay on top of potential cyberbullying, cyber predators, and reputation-damaging items directed at you and your family. Our exclusive identity exposure report highlights PHI published on social sites and calls out increased potential for identity theft.

Registered Sex Offender Reporting & Alerts Run a report for a specific address showing location, photo ID, and the offense committed. Search for sex offenders in your area and receive alerts when new offenders move into your neighborhood. We track and report offenders who move from state to state who can be missed in an online state search. Real-time reporting is available for all ID Watchdog plans. Collect maximum information from one source to keep loved ones safe.

National Provider Identifier (NPI) Alerts We monitor the NPI database for activity that indicates potential fraud. We are the only vendor who monitors this database and provides alerts to physicians, pharmacists, and more if their credentials are compromised.

Password Manager Securely store and use login information and access it with a single master password. COMING IN 2016

ADVANCED CUSTOMER CARE CENTER 

Underground websites are scanned daily in search of personal information being sold. When detected in our scans, we send a compromised credentials alert.

Instant-On™ Monitoring

Lost Wallet Vault & Replacement

To ensure your information is accurate and secure, we require a 2-step authentication process when logging in to and registering your account.

Rapid Credit Alerts Credit alerts provided within minutes of detected activity change.

Opt in or out of the National Do Not Call Registry, preapproved credit offers, junk mail, or email. Store your wallet contents in our secure digital vault. Lost Wallet Replacement will assist with cancelling and replacing contents from the Lost Wallet Vault.

Credit Monitoring, Report & Score(s)

Assistance with putting a security freeze on your credit report. Credentials are securely stored for easy access.

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Receive email notification of prominent data breaches.

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Fully Managed Resolution Service Dedicated CITRMS work with you to assess your identity theft situation and will manage your case until it is completely restored.

$1M Expense Reimbursement Insurance The plan covers financial damages incurred as a result of the theft.

Call Center Commitment to Excellence Real-time language support ensures clear communication with over 100 languages.

24/7 Call Center Reach an identity theft protection specialist when you need help.

CERIDIAN LIFEWORKS YOUR BENEFITS PACKAGE

EAP (Employee Assistance Program)

About this Benefit An Employee Assistance Plan (EAP) is an employee benefit program offered to help employees manage personal and professional problems that might adversely impact their work performance, health, and well-being. Employee Assistance Plans generally include short-term counseling and referral services for employees and their household members. Your Employee Assistance Program benefit is provided to you by your employer.

DID YOU KNOW?

38%

of employees have missed life events because of bad worklife balance.

Employee Assistance Program With LifeWorks Integrated EAP and Work-life services, employees and their families will have access to confidential assistance and support on a wide range of issues in the areas of life, health, family, work and money. Topic

Description

Emotions and Stress

Relationship issues, depression and anxiety – even an online “calm room”

Parenting

Parenting skills, adoption, talking with your teenager, help finding child care

Midlife and Retirement

Financial considerations, work and career in midlife, relationships with adult children, growing as a couple

Addictive Behaviors

Drug and alcohol abuse, eating disorders, gambling

Education

Applying to college, understanding financial aid and scholarships, advocating in the schools

Caring for older adults

Caregiver support, referrals to in-home and other services, and federally funded programs

Disability

Special needs programs, advocacy and specific disabilities information

Everyday Issues

Community resources and consumer information

Financial Issues

Credit management, budget analysis, 401(k) plan questions, basic estate planning, and questions about federal tax planning and preparation

Legal Issues

On-staff attorneys provide information and referrals for family matters, real estate, consumer credit and criminal matters. Also online program with forms, guides and simple wills.

Work

Special content for managers includes employee relations, interpersonal conflicts, performance issues, discrimination and workplace change. Also general support for co-worker relationships and stress.

Employees and their families have anytime access to LifeWorks Integrated EAP and Work-life services in a variety of ways that fit their preferences and unique needs.

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Telephone   

All calls are answered live by Ceridian employees who are trained clinical consultants with master’s/doctorate degrees. LifeWorks is a 24/7 operation, so there are no changes in  service delivery during non-business hours — you will not be directed to leave messages. A fully staffed bilingual clinical consultant team answers calls  from service centers in St. Petersburg, FL; Minneapolis, MN; Blue Bell, PA; Toronto, Winnipeg and Montreal, Canada.

Mobile 

An app for mobile devices makes the LifeWorks.com site accessible from anywhere at any time for iPhone, Android and Blackberry users.

In-Person 

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Ceridian develops close relationships and carefully evaluates the national network of EAP providers who deliver in-person counseling. This cohesive team includes consultants that complete the initial screening assessment and connect participants to the EAP provider and EAP affiliate managers to ensure a high quality experience. Ceridian also employs a Clinical Supervisor within Provider Network Services for case consultation and assistance to the local EAP affiliate. Our North American network of 11,300 EAP providers includes all 50 U.S. states, Puerto Rico, the Virgin Islands, Mexico, Canada and U.S. Territories. Our entire network is composed of licensed mental health professionals. Minimum qualifications include a license to practice independently in the state in which services are provided along with five years post graduate experience and three years providing EAP services. Our counselors and providers possess strong EAP and worklife skills, and we aggressively recruit Certified Employee Assistance Professionals (CEAPs) whose focus is on helping employees quickly resolve issues that may interfere with their work.

Employees and their families will have access to face-to-face assessments and short- term, solution-focused counseling with EAP clinicians.

NBS

FSA (Flexible Spending Account)

YOUR BENEFITS PACKAGE

About this Benefit A Cafeteria Plan is designed to take advantage of Section 125 of the Internal Revenue Code. It allows you to pay certain qualified expenses on a pre-tax basis, thereby reducing your taxable income. You can set aside a pre-established amount of money per plan year in a Healthcare Flexible Spending Account (FSA). Funds allocated to a healthcare FSA must be used during the plan year or are forfeited unless your plan contains a $500 rollover or grace period provision.

Unlimited FSA (Non HSA Compatible) The funds in the unlimited healthcare FSA can be used to pay for eligible medical expenses like deductibles, co-payments, orthodontics, glasses and contacts.

FSA (Flexible Spending Account) NBS Flexcard

When Will I Receive My Flex Card?

You may use the card to pay merchants or service providers that accept MasterCard® credit cards, so there is no need to pay cash up front, then wait for reimbursement. If you are participating in the Dependent Care portion, the money isn’t loaded to the card. You must file web or paper claims or enroll in continual reimbursement.

New Participants can expect Flex Cards to be delivered to the address listed in THEbenefitsHUB near the end of September. Don’t forget, Flex Cards Are Good For 3 Years!

NBS Prepaid MasterCard® Debit Card

Current plan participants: KEEP YOUR CARDS! NBS debit cards are good for 3 years. If you throw away your cards, there is a $5.00 fee to replace them.

For a list of sample expenses, please refer to the Beaumont ISD benefit website: www.mybenefitshub.com/beaumontisd

NBS Contact Information: 8523 South Redwood Road West Jordan, UT 84088 Phone (800) 274‐0503 Fax (800) 478‐1528 Email: claims@nbsbenefits.com

New Plan Participants NBS will mail out your new benefit cards to the address listed in THEbenefitsHUB. They will be sent in unmarked envelopes so please watch for them as they should arrive within 21 business days of effective date. NBS debit cards are good for 3 years.

Medical FSA Annual Contribution Max:

DID YOU KNOW? FSAs use tax-free funds to help pay for your Health Care Expenses.

$2,550, 75 day Grace Period

Dependent Care Annual Max: $5,000

Account Information: Participant Account Web Access: www.participant.nbsbenefits.com Participants may call NBS and talk to a representative during regular business hours, Monday-Friday, 8 am to 7 pm Central Time. Participants can also obtain account information using the Automated Voice Response Unit, 24 hours a day, 7 days a week at (801) 838-7324 or toll free (800) 274-0503. For immediate access to your account information at any time, log on to the NBS website: www.NBSbenefits.com    

Detailed claim history and processing status Health Care and Dependent Care account balances Claim forms, Direct Deposit form, worksheets, etc. Online claim FAQs

FSA Frequently Asked Questions What is a Flexible Spending Account? A Flexible Spending Account allows you to save money by paying out-of-pocket health and/or dependent care related expenses with pre-tax dollars. Your contributions are deducted from your pay before taxes are withheld and your medical FSA is up fronted with an annual amount. Because you are taxed on a lower amount of pay, you pay less in taxes and you have more to spend.

How does a Flexible Spending Account Benefit Me? A Cafeteria plan enables you to save money on group insurance, health-related expenses, and dependent-care expenses. You may save as much as 35 percent on the cost of each benefit option! Eligible expenses must be incurred within the plan year and contributions are use-it-or- lose-it. Remember to retain all your receipts, including payments made with your flex card.

Health Care Expense Account Example Expenses:          

Acupuncture Body scans Breast pumps Chiropractor Co-payments Deductible Diabetes Maintenance Eye Exam & Glasses Fertility treatment First aid

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Hearing aids & batteries Lab fees Laser Surgery Orthodontia Expenses Physical exams Pregnancy tests Prescription drugs Vaccinations Vaporizers or humidifiers

Dependent Care Expense Account Example Expenses:    

Before and After School and/or Extended Day Programs The actual care of the dependent in your home. Preschool tuition. The base costs for day camps or similar programs used as care for a qualifying individual.

What Can I Use My Flexible Spending Account On? For a full list of eligible expenses, please refer to www.mybenefitshub.com/beaumontisd

What Happens If I Don’t Use All of My Funds by The End of the Plan Year (August 31st)? Eligible expenses must be incurred within the plan year +75 day grace period. Contributions are use-it-or- lose-it. Remember to retain all your receipts, including payments made with your flex card.

How Do I File A Claim? In most situations, you will be able to swipe your card however, in the event you lose your card or are waiting to receive one, you can visit www.mybenefitshub.com/beaumontisd and complete the “Claim Form” to send to NBS or use the web or phone app to file online.

How To Receive Your Dependent Care Reimbursement Faster. A Direct Deposit form is available on the Benefits Website which will help you get reimbursed quicker! Dependent Care reimbursements can only be made after your deductions are received by NBS. Dependent Care accounts are not prefunded.

How the FSA Plan Works You designate an annual election of pre-tax dollars to be deposited into your health and dependent-care spending accounts. Your total election is divided by the number of pay periods in the Plan year and deducted equally from each paycheck before taxes are calculated. By the end of the Plan year, your total election will be fully deposited. However, you may make a claim for eligible health FSA expenses as soon as they are incurred during the Plan year. Eligible claims will be paid up to your total annual election even if you have not yet contributed that amount to your account.

Get Your Money 1. 2. 3. 4.

Complete and sign a claim form (available on our website) or an online claim. Attach documentation; such as an itemized bill or an Explanation of Benefits (EOB) statement from a health insurance provider. Fax or mail signed form and documentation to NBS. Receive your non-taxable reimbursement after your claim is processed either by check or direct deposit.

NBS Flexcard—FSA Pre-paid Benefit Card Your employer may sponsor the use of the NBS Flexcard, making access to your flex dollars easier than ever. You may use the card to pay merchants or service providers that accept credit cards, so there is no need to pay cash up front then wait for reimbursement.

Account Information Participants may call NBS and talk to a representative during our regular business hours, Monday–Friday, 7am to 6pm Mountain Time. Participants can also obtain account information using the Automated Voice Response Unit, 24 hours a day, 7 days a week at (801) 838-7324 or toll free (800) 274-0503. For immediate access to your account information at any time, log on to our website: www.NBSbenefits.com Information includes:  Detailed claim history and processing status  Health Care and Dependent Care account balances  Claim forms, worksheets, etc.  Online Claim Submission

Enrollment Considerations After the enrollment period ends, you may increase, decrease, or stop your contribution only when you experience a qualifying “change of status” (marriage status, employment change, dependent change). Be conservative in the total amount you elect to avoid forfeiting money that may be left in your account at the end of the year. Your employer may allow a short grace period after the Plan year ends for you to submit qualified claims for any unused funds.

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