2016 Benefit Buide CFB ISD by Higginbotham Public Sector

CARROLLTON-FARMERS BRANCH ISD

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

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. Health Savings Account (HSA) vs. Flexible Spending Account (FSA) TRS-ActiveCare and Scott & White HMO APL MEDlink® Medical Supplement Cigna Dental Superior Vision UNUM EAP (Employee Assistance Program) The Hartford Disability APL Cancer Lincoln Accident UNUM Whole Life w/ Long Term Care UNUM Group Term Life w/ AD&D HSA Bank Health Spending Account NBS Flexible Spending Account 2

3 4-5 6-11 6 7 8 9 10

FLIP TO... PG. 4 HOW TO ENROLL

11 12-15 16-19 20-23 24-25 26-29 30-33 34-41 42-43 44-45 44-45 46-49 50-53

PG. 6 BENEFIT UPDATES: WHAT’S NEW

PG. 12 YOUR BENEFITS PACKAGE

Benefit Contact Information

Benefit Contact Information C-FB ISD BENEFITS

DENTAL

CANCER

(972) 968-6167 www.mybenefitshub.com/cfbisd

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

APL (800)-256-8606 www.ampublic.com

MEDICAL

VISION

ACCIDENT

Aetna (800) 222-9205 www.trsactivecareaetna.com Caremark Pharmacy: (800) 222-9205

Superior Vision (800) 507-3800 www.superiorvision.com

Lincoln Financial (800) 423-2765 www.lfg.com

TRS HMO MEDICAL

EAP

LIFE AND AD&D

Scott & White HMO (800) 321-7947 www.trs.swhp.org

UNUM English: (800) 854-1446 Spanish: (877) 858-2147 www.lifebalance.com

UNUM (800) 583-6908 www.unum.com

HEALTH SAVINGS ACCOUNT

DISABILITY

FLEXIBLE SPENDING ACCOUNT

HSA Bank (800) 357-6246 www.nbsbenefits.com

The Hartford (800) 583-6908 File a claim: (866) 278-2655 www.thehartford.com

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

MEDICAL SUPPLEMENT—MEDLINK ® American Public Life (800) 256-8606 www.ampublic.com

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

TEXT

need to complete your enrollment.

“cfbisd”

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/ cfbisd 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: Please use your Carrollton-Farmers Branch district login credentials.

Go to:

Click Login

Enter Username & Password

www.mybenefitshub.com/cfbisd

For log in assistance, please contact the CarrolltonFarmers Branch Help Desk at helpdesk@cfbisd.edu or

Sample Username

District Username

(972) 968-4357

Sample Password

District Password

Click on â&#x20AC;&#x153;Enrollment Instructionsâ&#x20AC;? for more information about how to enroll. 5

Annual Benefit Enrollment

SUMMARY PAGES

Benefit Updates - What’s New:  Due to the Affordable Care Act (ACA), every employee is

required to login and complete the enrollment process, even if you are declining benefits! Benefit elections will become effective 9/1/2016 (elections requiring evidence of insurability, such as Life Insurance, may have a later effective date, if approved). After annual enrollment closes, benefit changes can only be made within 30 days of a qualifying event.  NEW BENEFIT! Health Savings Account (HSA) with HSA

 NEW CARRIER! UNUM Group Term Life w/AD&D: The

Group Term Life w/AD&D carrier is switching from Dearborn to UNUM. THIS YEAR ONLY, you will be able to elect seven times your salary, up to $200,000, life insurance coverage without completing a health questionnaire! Additional life insurance available for your spouse as well; up to $50,000 (not to exceed 100% of your amount) with no health questionnaire.  All new ID cards will arrive to the address listed in the

HUB in October. If you need an ID card sooner you can Bank: If you enroll in the ActiveCare 1HD Plan you can print a temporary ID card from THEbenefitsHUB. enroll in the HSA. HSA funds accumulate month to month and roll year to year. You can use HSA funds for  If you currently participate in a Health Care or medical, dental, vision and; prescription drug expenses. Dependent Care FSA, you MUST re-elect a new If an employee elects the HSA, they are no longer eligible contribution amount every year to continue to for FSA or MEDLink. If an employee is on Medicare or participate. If you elect the HSA you are NOT eligible for Medicaid, they cannot have an actively funded HSA. the Health Care FSA. There is a $1.75 administrative fee that will be deducted from your HSA account on a monthly basis.  Social Security Numbers for your dependents are required regardless if they are enrolled in coverage or not. Please  NEW BENEFIT! Whole Life with UNUM: Has a guaranteed make sure you have these items on hand when going death benefit that will never decrease, level premiums through your open enrollment. that will never increase, cash value accumulation, living benefits and other options up to age 120. It offers  For questions about benefits or enrollment assistance, protection beyond your working years, potentially for please call the FBS Call Center at 469-385- 4685 your lifetime. THIS YEAR ONLY, you can elect coverage without answering health questions. This product includes a long term care rider that provides a monthly benefit after a 90 day waiting period.

Don’t’ Forget!      6

Login and complete your benefit enrollment from 7/1/2016-8/17/2016 Enrollment assistance is available by calling Financial Benefit Services at (469) 385-4685 (This Is Not A District #!) to speak to a representative (bilingual assistance is also available). Double check your profile information: (change home address, phone numbers, email thru the CFB Staff portal). Update dependent social security numbers and student status for college-aged children. Update your beneficiary designation.

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):

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 30 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

Marital Status

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

Change in Number of Tax Dependents

A change in number of dependents includes the following: birth, adoption and placement for adoption. You can add existing dependents not previously enrolled whenever a dependent gains eligibility as a 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 Gain or loss of Medicare/Medicaid coverage may trigger a permitted election change. Government 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 school

Changes are not permitted during the plan year (outside of

district’s benefit website: www.mybenefitshub.com/cfbisd.

annual enrollment) unless a Section 125 qualifying event occurs.

Click on the benefit plan you need information on (i.e., Dental) and you can find the forms you need under the



Changes, additions or drops may be made only during 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

district’s benefit website: www.mybenefitshub.com/cfbisd.

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

benefit information.



For benefit summaries and claim forms, go to your school

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.

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

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.

If the insurance carrier provides ID cards, but there are no changes to the plan, you typically will not receive a new ID card each year.

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

SUMMARY PAGES

Employee Eligibility Requirements

Dependent Eligibility Requirements

Supplemental Benefits: Eligible employees must work 20 or more

Dependent Eligibility: You can cover eligible dependent

regularly scheduled hours each work week.

children under a benefit that offers dependent coverage, provided you participate in the same benefit, through the

Eligible employees must be actively at work on the plan effective

maximum age listed below. Dependents cannot be double

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

covered by married spouses within Carrollton-Farmers Branch

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

ISD or as both employees and dependents.

work concurrent with the plan effective date. For example, if your 2016 benefits become effective on September 1, 2016, you must be actively-at-work on September 1, 2016 to be eligible for your new benefits.

PLAN

CARRIER

MAXIMUM AGE

Medical

Aetna

To Age 26

Dental

Cigna

To Age 26

MEDlink®

American Public Life

To Age 26

Dental

Cigna

To Age 26

Vision

Superior Vision

To Age 26

Cancer

APL

To Age 26

UNUM Whole Life w/LTC

UNUM

To Age 26

UNUM Group Term Life w/AD&D

UNUM

To Age 26

Accident

Lincoln Financial

To Age 26

If your dependent is disabled, coverage may be able to 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.

Helpful Definitions

SUMMARY PAGES

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

HSA vs. FSA Health Savings Account (HSA) (IRC Sec. 223)

Flexible Spending Account (FSA) (IRC Sec. 125)

Approved by Congress in 2003, HSAs are actual bank accounts in employee’s names that allow employees to save and pay for unreimbursed qualified medical expenses tax-free.

Allows employees to pay out-of-pocket expenses for copays, deductibles and certain services not covered by medical plan, tax-free. This also allows employees to pay for qualifying dependent care tax-free.

Employer Eligibility

A qualified high deductible health plan.

All employers

Contribution Source Account Owner Underlying Insurance Requirement

Employee and/or employer Individual

Employee and/or employer Employer

High deductible health plan

None

Description

Minimum Deductible

Maximum Contribution

$1,300 single (2016) $2,600 family (2016) $3,350 single (2016) $6,750 family (2016)

N/A

Varies per employer

Permissible Use Of Funds

If used for non-qualified medical expenses, subject to current tax rate plus 20% penalty.

Reimbursement for qualified medical expenses (as defined in Sec. 213(d) of IRC).

Cash-Outs of Unused Amounts (if no medical expenses)

Permitted, but subject to current tax rate plus 20% penalty (penalty waived after age 65).

Not permitted

Year-to-year rollover of account balance?

Yes, will roll over to use for subsequent year’s health coverage.

No. Access to some funds can may be extended if your employer’s plan contains a 2 1/2 –month grace period or $500 rollover provision.

Does the account earn interest?

Yes

Portable?

Yes, portable year-to-year and between jobs.

FLIP TO… PG. 46

FLIP TO… PG. 50

FOR HSA INFORMATION

FOR FSA INFORMATION

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.

TRS-ActiveCare Plans—Preventive Care Network Benefits When Using In-Network Providers

(Provider must bill services as “preventive care”)

ActiveCare 1-HD Preventive Care Services

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

Plan pays 100% (deductible waived)

Some examples of preventive care frequency and services:  Routine physicals – annually Immunizations recommended by the Advisory Committee on age 12 and over Immunization Practices of the Centers for Disease Control and  Well-child care – unlimited Prevention (CDC) with respect to the individual involved. up to age 12 Evidence−informed preventive care and screenings provided  Well woman exam & pap for in the comprehensive guidelines supported by the Health smear – annually age 18 and Resources and Services Administration (HRSA) for infants, over children and adolescents. Additional preventive care and  Mammograms – 1 every year screenings for women, not described above, as provided for in age 35 and over comprehensive guidelines supported by the HRSA  Colonoscopy – 1 every 10 www.hhs.gov/healthcare/facts-and-features/fact-sheets/ years age 50 and over preventive-services-covered-under-aca/#CoveredPreventive  Prostate cancer screening – 1 ServicesforAdults per year age 50 and over  Smoking cessation For purposes of this benefit, the current recommendations of counseling – 8 visits per 12 the USPSTF regarding breast cancer screening and months mammography and prevention will be considered the most  Healthy diet/obesity current (other than those issued in or around November counseling – unlimited to age 2009). 22; age 22 and over-26 visits The preventive care services described above may change as per 12 months USPSTF, CDC and HRSA guidelines are modified.  Breastfeeding support – 6 lactation counseling visits per (Examples of covered services included are: 12 months 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; 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

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 benefits are administered by Caremark.

2016-2017 Scott & White Health Plan Highlights Summary of Benefits for TRS-ActiveCare Fully Covered Health Care Services Preventive Services

No Charge

Standard Lab and X-ray

No Charge

Disease Management and Complex Case Management

No Charge

Well Child Care Annual Exams

No Charge

Immunizations (age appropriate)

No Charge

Plan Provisions

Copay

Annual Deductible

$1,000 Individual/ $3,000 Family

Annual out-of-pocket maximum (including medical and prescription co-pays and coinsurance)

Lifetime Paid Benefit Maximum

Outpatient Services

$5,000 Individual/ $10,000 Family (includes combined Medical and RX copays, deductibles and coinsurance)

None

Copay $20 co-pay

Primary Care1

(First Primary Care Visit for Illness $0 Copay2)

Specialty Care

$50 co-pay

Other Outpatient Services

20% after deductible3

Diagnostic/Radiology Procedures

20% after deductible

Eye Exam (one annually) Allergy Serum & Injections

No Charge 20% after deductible

Outpatient Surgery

$150 co-pay and 20% of charges after deductible

Maternity Care

Copay

Prenatal Care

No Charge $150 per day4 and 20% of charges after deductible

Inpatient Delivery

Inpatient Services

Copay

Overnight hospital stay: includes all medical services including semi -private room or intensive care

Diagnostic & Therapeutic Services Physical and Speech Therapy 5

Manipulative Therapy

Equipment and Supplies

$150 per day4 and 20% of charges after deductible

Copay $50 copay 20% without office visit $40 plus 20% with office visit

Copay

Preferred Diabetic Supplies and Equipment

$3 copay; no deductible

Non-Preferred Diabetic Supplies and Equipment

30% after Rx deductible

Durable Medical Equipment/ Prosthetics

Copay

20% after deductible

2016-2017 Scott & White Health Plan Highlights Summary of Benefits for TRS-ActiveCare Home Health Services

Copay

Home Health Care Visit

$50 co-pay

Worldwide Emergency Care

Copay

Nurse Advice Line

1-877-505-7947

Online Services

No Charge â&#x20AC;&#x201D; go to www.trs.swhp.org

After Hours Primary Care Clinics

$20 co-pay

Ambulance and Helicopter

$40 copay and 20% of charges after deductible

Emergency Room6

$150 copay and 20% of charges after deductible

Urgent Care Facility

$55 copay

Prescription Drugs

Copay

Annual Benefit Maximum

Unlimited

Rx Deductible

$100

Does not apply to preferred generic drugs

Ask an SWHP Pharmacy representative how to save money on your prescriptions.

Maintenance Quantity

Retail Quantity (Up to a 30-day supply)

BSWH Pharmacies Only (Up to a 90-day supply)

$3 copay

$6 copay

Preferred Brand

30% after Rx deductible

Non-preferred

50% after Rx deductible

Non-formulary

Greater of $50 or 50% after deductible

Not available

Preferred Generic7

Mail Order

Specialty Medications (Up to a 30-day supply)

1-800-707-3477

Copay 20% after Rx deductible

Including all services billed with office visit Does not apply to wellness or preventive visits 3 Includes other services, treatments, or procedures received at time of office visit 4 $750 maximum copay per admission and 20% after deductible 5 5 visits max per month, 35 max visit per year 6 Copay waived if admitted within 24 hours 7 If a brand name drug is dispensed when a generic is available, 50% copay applies 2

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.

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 Carrollton-Farmers Branch ISD Benefits Website: www.mybenefitshub.com/cfbisd 16

MEDlink® IV Enhanced

Limited Benefit Group Medical Expense Supplemental Insurance Carrollton-Farmers Branch 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

Option 2

Maximum In-Hospital Benefits

$1,500 per Covered Person per Confinement

$2,500 per Covered Person per Confinement

In-Hospital Ambulance Benefit Up to $350 per trip for ground transportation or up to $1,000 Up to $350 per trip for ground transportation or up to $1,000 per trip for air transportation where a Covered Person is per trip for air transportation where a Covered Person is Confined as an Inpatient. Limited to one trip per day. 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 $500 per Covered Person per Occurrence for Covered Outpatient Services Outpatient Services

Outpatient Ambulance Benefit Up to $350 per trip for ground transportation or up to $1,000 Up to $350 per trip for ground transportation or up to $1,000 per trip for air transportation where a Covered Person per trip for air transportation where a Covered Person resides resides less than 18 hours. Limited to one trip per day. 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 Payable up to the Maximum Outpatient Benefit, subject to the Outpatient Benefit Deductible, as shown above. 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.

$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: Hospital Outpatient Facility s s Freestanding Emergency Care Clinic s Urgent Care Facility/Clinic s Physician Office

Benefit Rider Physician Outpatient Treatment Benefit Rider

APSB-22354(TX) MGM/FBS Carrollton-Farmers Branch ISD

MEDlink® IV Enhanced

Limited Benefit Group Medical Expense Supplemental Insurance Option 1 Total Monthly Premiums by Plan* Ages 18+

Employee

Employee & Spouse

Employee & Child

Employee & Family

$33.50

$77.48

$60.48

$104.36

Option 2 Total Monthly Premiums by Plan* Ages 18+

Employee

Employee & Spouse

Employee & Child

Employee & Family

$40.32

$93.14

$72.06

$124.80

*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.

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.

18APSB-22354(TX) MGM/FBS Carrollton-Farmers Branch ISD

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;

MEDlink® IV Enhanced

Limited Benefit Group Medical Expense Supplemental Insurance

Exclusions continued 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

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.

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.

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) | Carrollton-Farmers Branch ISD

APSB-22354(TX) MGM/FBS Carrollton-Farmers Branch ISD 19

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 Benefits Network

Cigna Dental PPO Total Cigna DPPO Out-of-Network

Calendar Year Maximum (Class I, II, and III expenses) Annual Deductible Individual Family Reimbursement Levels**

$1,500

$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

80%

20%

80%

20%

60%*

40%*

60%*

40%*

60%*

40%*

60%*

40%*

50%

50% $1,000 Dependent children to age 19

50%

Monthly PPO Premiums Tier

Rate

EE Only

$36.55

EE + Spouse

$80.71

EE + Child(ren)

$73.12

Family Coverage

$121.49

Class I - Preventive & Diagnostic Care Oral Exams Routine Cleanings Bitewing X-rays Full Mouth X-rays Panoramic X-ray Fluoride Application Sealants Space Maintainers Histopathologic Exams

Class II - Basic Restorative Care Fillings Emergency Care to Relieve Pain Root Canal Therapy/Endodontics Osseous Surgery Periodontal Scaling and Root Planing Surgical Extractions of Impacted Teeth Brush Biopsies Oral Surgery - all except simple extractions Anesthetics Oral Surgery – Simple Extractions

Class III - Major Restorative Care Crowns 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 Dependent children to age 19

Dependents/Students up to age 26. 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 Procedure

Exclusions and Limitations

Exams Prophylaxis (Cleanings) Fluoride Histopathologic Exams 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

Two per Plan year Two per Plan year 1 per Plan year for people under 19 Various limits per Plan year depending on specific test 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

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 Con necticut 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: HPPOL82; IL: HP-POL62; KS: HP-POL84; LA: HPPOL86: MA: HP-POL 63; MI: HP-POL88; MO: HP- POL65; MS: HP-POL90; NC: HP-POL96; NE: HP-POL92; 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 (CHLIC), Cigna HealthCare of Connecticut, Inc., and Cigna Dental Health, Inc. and its subsidiaries. Cigna Dental PPO plans are underwritten or administered by CGLIC or CHLIC, with network management services provided by Cigna Dental Health, Inc. and certain of its subsidiaries. In Arizona and Louisiana, the insured Dental PPO plan offered by CGLIC is known as the “CG Dental PPO”. In Texas, the insured dental product offered by CGLIC and CHLIC is referred to as the Cigna Dental Choice Plan, and this plan utilizes the national Cigna Dental PPO network. Cigna Dental Care (DHMO) plans are underwritten or administered by Cigna Dental Health Plan of Arizona, Inc., Cigna Dental Health of California, Inc., Cigna Dental Health of Colorado, Inc., Cigna Dental Health of Delaware, Inc., Cigna Dental Health of Florida, Inc., a Prepaid Limited Health Services Organization licensed under Chapter 636, Florida Statutes, Cigna Dental Health of Kansas, Inc. (Kansas and Nebraska), Cigna Dental Health of Kentucky, Inc. (Kentucky and Illinois), Cigna Dental Health of Maryland, Inc., Cigna Dental Health of Missouri, Inc., Cigna Dental Health of New Jersey, Inc., Cigna Dental Health of North Carolina, Inc., Cigna Dental Health of Ohio, Inc., Cigna Dental Health of Pennsylvania, Inc., Cigna Dental Health of Texas, Inc., and Cigna Dental Health of Virginia, Inc. In other states, Cigna Dental Care plans are underwritten by CGLIC, CHLIC, or Cigna HealthCare of Connecticut, Inc. and administered by Cigna Dental Health, Inc. BSD46380 © 2015 Cigna

Dental DHMO DHMO with Ortho Service Code

Cost with Cigna Dental Care

Patient Charge

D1110

Prophylaxis (cleaning) – Adult (limit 2 per calendar year)

No charge

D0120

Periodic Oral Evaluation - Established Patient

No charge

D0150

Comprehensive oral evaluation – New or established patient

No charge

D0210

X-rays intraoral – Complete series of radiographic images (limit 1 every 3 years)

No charge

D0274

X-rays (bitewings) – 4 radiographic images

No charge

D0330

X-rays (panoramic radiographic image) – (limit 1 every 3 years)

No charge

D1351

Sealant – Per tooth

$17.00

D1510

Space maintainer – Fixed – unilateral

$110.00

D2161

Amalgam – 4 or more surfaces, primary or permanent

$40.00

D6740

Crown – Porcelain/ceramic

$530.00

D6930

Recement fixed partial denture

$65.00

D3330

Molar root canal – Permanent tooth (excluding final restoration)

$595.00

D5110

Full upper denture

$450.00

D9220

General anesthesia – First 30 minutes

$190.00

D7140

Extraction, erupted tooth or exposed root - elevation and/or forceps removal

$64.00

Children—up to 19th birthday D8670

24-month treatment fee

$2,472.00

D8670

Charge per month for 24 months

$103.00

D8670

Periodic orthodontic treatment visit – As part of contract Adults 24-month treatment fee

$3,384.00

Charge per month for 24 months

$141.00

Monthly DHMO Premiums

Tier

Finding a network dentist is easy. Rate

Employee Only

$8.98

Employee + Spouse

$19.04

Employee + Child(ren)

$19.04

Employee + Family

$26.04

There are several ways to choose your network general dentist:  Find a dentist at Cigna.com. Our online dental directory is updated weekly.  Call 1.800.Cigna24 (1.800.244.6224) to speak with a customer service representative. Our representatives can send you a customized dental directory listing via email.

SUPERIOR VISION 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 Benefits Exam (ophthalmologist) Exam (optometrist) Frames Contact Lens Fitting (standard₂) Contact Lens Fitting (specialty₂) Progressive Lens Upgrade Contact Lenses4

In-Network

Out-of-Network

Covered in full

Up to $42 retail

Emp. Only

$10.28

Covered in full $140 retail allowance

Up to $37 retail Up to $53 retail

Emp. + Spouse

$18.37

Emp. + Child(ren)

$19.03

Covered in full

Not Covered

Emp. + Family

$26.48

$50 retail allowance

Not Covered

See description3

Up to $50 retail

$130 retail allowance Up to $100 retail

Lenses (standard) per pair Single Vision Bifocal Trifocal Polycarbonate for dependent children Photochromic Tints, solid or gradients

Covered in full Covered in full Covered in full

Up to $26 retail Up to $34 retail Up to $50 retail

Covered in full

Not Covered

Covered in full

Not Covered

Covered in full

Not Covered

Co-pays apply to in-network benefits; co-pays for out-of-network visits are deducted from reimbursements.

Monthly Premiums

Co-Pays Exam

$10

Materials₁

$25

Contact Lens Fitting (standard & specialty)

$25

Services/Frequency Exam

12 months

Frame

12 months

Contact Lens Fitting

12 months

Lenses

12 months

Contact Lenses

12 months

(Based on date of service)

Materials co-pay applies to lenses and frames only, not contact lenses ₂See your benefits materials for definitions of standard and specialty contact lens fittings ₃Covered to provider’s in-office standard retail lined trifocal amount; member pays difference between progressive and standard retail lined trifocal, plus applicable co-pay 4Contact lenses are in lieu of eyeglass lenses and frames benefit

Discount Features Look for providers in the Provider Directory who accept discounts, as some do not; please verify their services and discounts (range from 10%-40%) prior to service as they vary. Discounts on Covered Materials Frames: 20% off amount over allowance Lens options: 20% off retail Progressives: 20% off amount over retail lined trifocal lens, including lens options

The following options have out-of-pocket maximums5 on standard (not premium, brand, or progressive) plastic lenses.

Discounts on Non-Covered Exam and Materials Exams, frames, and prescription lenses: 30% off retail Lens options, contacts, other prescription materials: 20% off retail Disposable contact lenses: 10% off retail Refractive Surgery Superior Vision has a nationwide network of refractive surgeons and leading LASIK networks who offer members a discount. These discounts range from 15%-50%, and are the best possible discounts available to Superior Vision. The Plan discount features are not insurance.

5Discounts

and maximums may vary by lens type. Please check with your

provider.

Scratch coat Ultraviolet coat Anti-reflective coat Polycarbonate High index 1.6

Maximum Member Out-of-Pocket Single Vision Bifocal & Trifocal $13 $13 $15 $15 $50 $50 $40 20% off retail $55 20% off retail

All allowances are retail; the member is responsible for paying the provider directly for all non-covered items and/or any amount over the allowances, minus available discounts. These are not covered by the plan. Discounts are subject to change without notice. Disclaimer: All final determinations of benefits, administrative duties, and definitions are governed by the Certificate of Insurance for your vision plan. Please check with your Human Resources department if you have any questions. 25

UNUM

EAP (Employee Assistance Program)

YOUR BENEFITS PACKAGE

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.

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 Carrollton - Farmers Branch ISD Benefits Website: www.mybenefitshub.com/cfbisd

Work Life Balance Employee Assistance Program (EAP) Q. How does the work-life balance employee assistance program work? A. Help is only a call or a click away. Your employees are given a toll-free number and a website address to access — both are available 24 hours a day, 365 days a year. If your staff call, master’s-level consultants are available immediately to discuss their concerns. The EAP services are designed to help your managers and front line staff be healthier and more productive by helping them with problems at both work and home.

charged for calling a consultant, using the website or downloading materials. Also, employees can receive up to three local, face-to-face counseling sessions* for each problem (not just per year). However, if an employee or caller selects a referral to a child or elder care provider, attorney, social worker, etc., the caller is responsible for paying for services not included in this program. In addition, some services may be payable under the employee’s medical or health insurance plan, so the consultant will advise the caller to review his or her policy’s details.

Q. How can this service help my company?

Q. How do employees access the EAP service? A. The work-life balance employee assistance program can A. Employees call one of the central, toll-free numbers (1800-854-1446 for English, 1-877-858-2147 for Spanish and 1-800-999-3004 for TTY/TDD) or go online at www. lifebalance.net (ID and password are both “lifebalance”). There is also now a LifeWorks mobile app (user ID and password are both “lifebalance”).

Q. Who provides the work-life balance EAP services? A. The work-life balance employee assistance program is provided through Unum, as part of your group disability or life insurance, in partnership with Ceridian. The two companies began working together in 1992, when they offered the nation’s first work-life balance employee assistance program integrated with group insurance. The resulting service provides clients with an affordable and valuable offer that benefits both them and their employees. Established in 1932, Ceridian is the nation’s first provider of fully integrated EAP, work-life and wellness services. It partners with more than 42,000 organizations around the world on health and productivity solutions. Ceridian provides work-life services in 170 languages to over 14 million employees around the world. Ceridian is a leading provider of human resource solutions and support in the United States, Canada and the United Kingdom.

help you with increasing staff demands, administrative requirements, assisting employees on disability and addressing productivity. In addition to helping your employees become more productive by assisting them with their personal or professional problems, this program can also help your managers. Managers and supervisors can call the toll-free number around the clock to speak with master’s-level management consultants who can coach them on handling disciplinary actions, staff communications, performance problems, and corporate change. They can use these consultants to prepare for a difficult conversation, make a mandatory employee EAP referral, have a confidential sounding board and get an unbiased, third-party view. They also have unlimited website access to online guides, articles, web links, e-books and podcasts to help them manage their work force and their work load. This program is also part of a beneficial and valuable benefits package that can help recruit and retain high performance employees. From around-the-clock phone consultations with master’s-level consultants to elder-and child-care searches and referrals, the work-life balance EAP can help your staff balance the shifting priorities of work and home. Employees and their families will have unlimited access to resources — online and by phone — to help with work issues, child care, addiction, depression, elder care and other concerns. In addition to phone assistance, three local face-to-face counseling sessions* (per issue, not per year) are also included.

Q. Do employees have to pay to use the services? A. Unum is providing the program through your group disability or life insurance. Your employees are not 27

Work Life Balance Employee Assistance Program (EAP) Q. How can one toll-free number help employ- and work with them until a solution is found. Q. Can employees call more than once? ees located all over the country? A. When employees call the toll-free number, a consultant A. Yes. Employees and their immediate family members will talk to them about their problems and needs no matter where they reside in the U.S., no matter what time of day they call. Ceridian maintains a national database of local mental health providers contracted to provide face-to-face sessions as well as other referral sources.

Q. Are all calls confidential?

can call the service as often as they wish for information and referrals. They can also call to discuss their current arrangements, concerns regarding day-to-day issues and problems balancing the demands of work against those of a personal nature.

Q. Can employees talk to the same consultant? A. Yes. Actually, they are encouraged to talk with the same

A. Yes, within the constraints of the law.** No information consultant. Usually toward the end of the first call, the about your employees or what they discuss with the consultants will be available to anyone without their explicit written consent — not even to their family.

Q. What information do employees need to give consultants? A. The consultant will ask for name, phone number, email address, city and the nature of the call. This helps the consultant address the caller personally, email requested information and make referrals to local resources. It also helps the consultant in subsequent calls. Each caller is screened for risk to ensure they are not in danger. All information provided is confidential from the employer.

consultant will ask whether the caller wants to talk again. If the caller does, he or she decides who will call whom, when, where, and whether the consultant can leave his or her name and a message on the caller’s answering machine.

Q. Can employees give the 800-number to just anyone? A. You and your employees decide who gets the number. The service is for all of your staff that is covered by the Unum group insurance plan and anyone close to them — children, parents, domestic partners, and spouses — whose situation causes them stress and concern.

Q. Can the service help if the employee’s fami- Q. Can young children and teenagers call? ly lives in another state? A. Many parents give this number to older children. A. Absolutely. A consultant will provide information on various options and alternatives available in the caller’s community (or in a community he or she specifies) when direct services related to legal resources, child care, elder care, disability assistance or mental health counseling are necessary.

Q. Can the service help with special needs? A. Yes. Programs available for special needs children and adults vary considerably depending on the family’s location. In many areas, resources are scarce. Nevertheless, a consultant will help the family identify all possible options available to meet their special need —

Consultants usually encourage children to talk to their parents, or maybe an aunt or grandparent, etc. When they get calls from children, they may ask who gave them the number and if they can talk to a parent to get permission to speak with the child. If a child needs to see a counselor in person, the consultant will require parental permission to refer a child to an EAP provider. We also require that the parent attend at least the first session with the child. An exception to this is if a minor is emancipated. By law, minors cannot be referred to resources without their parents’ permission. An exception would be if the consultant felt a child were in danger then the consultant may call local law enforcement officials on the child’s behalf.

Work Life Balance Employee Assistance Program (EAP) * In California and Nevada, employees and their family members may confer with a local consultant up to three times in a six-month time period. ** The consultants must abide by federal regulations regarding duty to warn of harm to self or others. In these instances, the consultant may be mandated to report a situation to the appropriate authority. The work-life balance employee assistance program is provided by Ceridian and is available with selected Unum insurance offerings. Exclusions, limitations and prior notice requirements may apply, and service features, terms and eligibility criteria are subject to change. The service is not valid after termination of coverage and may be withdrawn at any time. Please contact your Unum representative for full details. Insurance products are underwritten by the subsidiaries of Unum Group. Unum, Chattanooga, Tennessee unum.com ÂŠ 2013 Unum Group. All rights reserved. Unum is a registered trademark and marketing brand of Unum Group and its insuring subsidiaries.

THE HARTFORD

YOUR BENEFITS PACKAGE

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 Disability is designed to provide a monthly income to an individual that is disabled due to an accident or illness. There are different plans available with benefits becoming available from the 1st day of disability to as late as the 180th day. For specific details on how benefits are paid, refer to carrier brochure. Your disability coverage amount and premium can be accessed during your enrollment.



Pre-existing Conditions



Your policy limits the benefits you can receive for a disability caused by a pre-existing condition. In general, if you were diagnosed or received care for a disabling condition within the 3 consecutive months just prior to the effective date of this policy, your benefit payment will be limited, unless: You have not received treatment for the disabling condition within 3 months, while insured under this policy, before the disability begins, or You have been insured under this policy for 12 months before your disability begins. You may also be covered if you have already satisfied the pre-existing condition requirement of your previous insurer. If your disability is a result of a pre-existing condition we will pay benefits for a maximum of 4 weeks.

Benefit Reductions Your benefit payments may be reduced by other income you receive or are eligible to receive due to your disability, such as:  Social Security Disability Insurance (please see www.mybenefitshub.com/cfbisd for exceptions)  Workers' Compensation  Other employer-based Insurance coverage you may have  Unemployment benefits  Settlements or judgments for income loss  Retirement benefits that your employer fully or partially pays for (such as a pension plan.)



Mental Illness, Alcoholism and Substance Abuse



You can receive benefit payments for Long-Term Disabilities resulting from mental illness, alcoholism and substance abuse for a total of 24 months for all disability periods during your lifetime. Any period of time that you are confined in a hospital or other facility licensed to provide medical care for mental illness, alcoholism and substance abuse does not count toward the 24 month lifetime limit.

What other benefits are included in my disability coverage? 



Your benefit payments will not be reduced by certain kinds of other income, such as:  Retirement benefits if you were already receiving them before you became disabled  Retirement benefits that are funded by your after-tax contributions  Your personal savings, investment, IRAs or Keoghs  Profit-sharing  Most personal disability policies  Social Security increases

Coverage goes into effect subject to the terms and conditions of the policy. You must satisfy the definition of Actively at Work with your employer on the day your coverage takes effect.



Exclusions



You cannot receive Disability benefit payments for disabilities that are caused or contributed to by:  War or act of war (declared or not)  Military service for any country engaged in war or other armed conflict  The commission of, or attempt to commit a felony  An intentionally self-inflicted injury

Any case where your being engaged in an illegal occupation was a contributing cause to your disability You must be under the regular care of a physician to receive benefits

Workplace Modification provides for reasonable modifications made to a workplace to accommodate your disability and allow you to return to active full-time employment. Survivor Benefit - If you die while receiving disability benefits, a benefit will be paid to your spouse or in equal shares to your surviving children under the age of 25, equal to three times the last monthly gross benefit. Travel Assistance Program – Available 24/7, this program provides assistance to employees and their dependents who travel 100 miles from their home for 90 days or less. Services include pre-trip information, emergency medical assistance and emergency personal services. The Hartford's Ability Assist service is included as a part of your group Long Term Disability (LTD) insurance program. You have access to Ability Assist services both prior to a disability and after you’ve been approved for an LTD claim and are receiving LTD benefits. Once you are covered you are eligible for services to provide assistance with child/elder care, substance abuse, family relationships and more. In addition, LTD claimants and their immediate family members receive confidential services to assist them with the unique emotional, financial and legal issues that may result from a disability. Ability Assist services are provided through ComPsych®, a leading provider of employee assistance and work/life services. Waiver of Premium – Once your disability claim is approved and you have satisfied your elimination period, your coverage premiums will be waived. Identity Theft Protection – An array of identity fraud support services to help victims restore their identity. Benefits include 24/7 access to an 800 number; direct contact with a certified caseworker who follows the case until it’s resolved; and a personalized fraud resolution kit with instructions and resources for ID theft victims.

Long Term Disability Option 1: Premium Option For the Premium benefit option â&#x20AC;&#x201C; Benefits are payable for disabilities resulting from Sickness or Injury to normal retirement age if you are disabled prior to age 63. The table below details the applicable benefit duration based on the age you are disabled.

Age Disabled

Benefits Payable

Prior to Age 63

To Normal Retirement Age or 48 months if greater

Age 63

To Normal Retirement Age or 42 months if greater

Age 64

36 months

Age 65

30 months

Age 66

27 months

Age 67

24 months

Age 68

21 months

Age 69 and older

18 months

MONTHLY PREMIUMS Accident / Sickness Elimination Period in Days

Annual Earnings

Monthly Earnings

Monthly Benefit

0/7

14 / 14

30 / 30

60 / 60

90 / 90

180 / 180

$3,600

$300

$200

$6.80

$6.52

$5.40

$3.96

$3.08

$2.40

$9,000

$750

$500

$17.00

$16.30

$13.50

$9.90

$7.70

$6.00

$18,000

$1,500

$1,000

$34.00

$32.60

$27.00

$19.80

$15.40

$12.00

$27,000

$2,250

$1,500

$51.00

$48.90

$40.50

$29.70

$23.10

$18.00

$36,000

$3,000

$2,000

$68.00

$65.20

$54.00

$39.60

$30.80

$24.00

$45,000

$3,750

$2,500

$85.00

$81.50

$67.50

$49.50

$38.50

$30.00

$54,000

$4,500

$3,000

$102.00

$97.80

$81.00

$59.40

$46.20

$36.00

$63,000

$5,250

$3,500

$119.00

$114.10

$94.50

$69.30

$53.90

$42.00

$72,000

$6,000

$4,000

$136.00

$130.40

$108.00

$79.20

$61.60

$48.00

Long Term Disability Option 2: Select Option For the Select benefit option â&#x20AC;&#x201C; Benefits are payable for disabilities resulting from Sickness for 5 years & Injury to normal retirement age if you are disabled prior to age 63. The table below details the applicable benefit duration based on the age you are disabled. Age Disabled Prior to Age 63 Age 63 Age 64 Age 65 Age 66 Age 67 Age 68 Age 69 and older Age Disabled Prior to Age 65 Age 65 to 69 Age 69 and older

Benefits Payable for a Disability Caused by Injury To Normal Retirement Age or 48 months if greater To Normal Retirement Age or 42 months if greater 36 months 30 months 27 months 24 months 21 months 18 months Benefits Payable for a Disability Caused by Sickness 5 Years To Age 70, but not less than one year 1 Year

MONTHLY PREMIUMS Accident / Sickness Elimination Period in Days Annual Earnings

Monthly Earnings

Monthly Benefit

0/7

14 / 14

30 / 30

60 / 60

90 / 90

180 / 180

$3,600

$300

$200

$5.60

$5.28

$3.96

$2.88

$2.24

$1.76

$9,000

$750

$500

$14.00

$13.20

$9.90

$7.20

$5.60

$4.40

$18,000

$1,500

$1,000

$28.00

$26.40

$19.80

$14.40

$11.20

$8.80

$27,000

$2,250

$1,500

$42.00

$39.60

$29.70

$21.60

$16.80

$13.20

$36,000

$3,000

$2,000

$56.00

$52.80

$39.60

$28.80

$22.40

$17.60

$45,000

$3,750

$2,500

$70.00

$66.00

$49.50

$36.00

$28.00

$22.00

$54,000

$4,500

$3,000

$84.00

$79.20

$59.40

$43.20

$33.60

$26.40

$63,000

$5,250

$3,500

$98.00

$92.40

$69.30

$50.40

$39.20

$30.80

$72,000

$6,000

$4,000

$112.00

$105.60

$79.20

$57.60

$44.80

$35.20

AMERICAN PUBLIC LIFE

Cancer

YOUR BENEFITS PACKAGE

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.

GC12 Limited Benefit Group Cancer Indemnity Insurance Carrollton-Farmers Branch ISD

Summary of Benefits Benefits

Option 1 Base Plan

Option 2 Base Plan

Level 1

Diagnostic Testing - 1 test per Calendar Year

$50 per test

Follow-Up Diagnostic Testing - 1 test per Calendar Year

$100 per test

Medical Imaging – 1 per Calendar Year

$500 per test

Cancer Treatment Benefits

Level 1

Level 4

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

$10,000

$20,000

$50 per treatment

Level 1

$30 Unit Dollar Amount Maximum $3,000 per operation

25% of amount paid for covered surgery

$6,000

$600

Prosthesis Surgical Implantation – 1 device per site, per lifetime Non-Surgical (not hair piece) – 1 device per site, per lifetime

$1,000 $100

Patient Care Benefits

Level 1

$100 $200 $100 $200

Outpatient Facility - Per day surgery is performed

$200

Attending Physician - Per day of Hospital Confinement

$30

Dread Disease Per day of Hospital Confinement (1-30 days) Per day of Hospital Confinement (31+ days)

$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

$100 $100

Cancer Screening Benefits

Hormone Therapy - Maximum of 12 treatments per Calendar Year Surgical Benefits Surgical Anesthesia Bone Marrow Transplant - Maximum per lifetime Stem Cell Transplant - Maximum per lifetime

Hospital Confinement Per day of Hospital Confinement (1-30 days) Per day for Eligible Dependent children Per day of Hospital Confinement (31+ days) Per day for Eligible Dependent children

US Government, Charity Hospital or HMO Per day of Hospital Confinement (1-30 days) Per day of Hospital Confinement (31+ days)

APSB-22338(TX) MGM/FBS Carrollton-Farmers Branch ISD

GC12 Limited Benefit Group Cancer Indemnity Insurance Miscellaneous Benefits

Level 1

Cancer Treatment Center Evaluation or Consultation - 1 per lifetime

N/A

Evaluation or Consultation Travel and Lodging - 1 per lifetime

N/A

$300 per Diagnosis of Cancer $300 per Diagnosis of Cancer

$150 per Confinement $50 per Prescription

$150

Actual coach fare or $.40 per mile

Travel by car Maximum of 12 trips per Calendar year for all modes of transportation combined

$.40 per mile

Lodging - up to a maximum of 100 days per Calendar Year

$50 per day

Actual coach fare or $.40 per mile

$.40 per mile

$50 per day

Blood, Plasma and Platelets

$300 per day

Experimental Treatment

Paid in the same manner and under the same maximums as any other benefit

Second and Third Surgical Opinion Second Surgical Opinion Third Surgical Opinion Drugs and Medicine Inpatient Outpatient - Maximum $150 per month Hair Piece (Wig) - 1 per lifetime Transportation Travel by bus, plane or train

Family Transportation Travel by bus, plane or train Travel by car Maximum of 12 trips per Calendar year for all modes of transportation combined Family Lodging - up to a maximum of 100 days per Calendar Year

Ambulance Ground Air Maximum of 2 trips per Hospital Confinement for all modes of transportation combined

$200 per trip

$2,000 per trip

Inpatient Special Nursing Services - Per day of Hospital Confinement

$150 per day

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

$150 per day

N/A

$25 per visit $1,000

Waive Premium

Medical Equipment - Maximum of 1 benefit per Calendar Year Physical, Occupational, Speech, Audio Therapy & Psychotherapy Maximum per Calendar Year Waiver of Premium

36APSB-22338(TX)

MGM/FBS Carrollton-Farmers Branch ISD

GC12 Limited Benefit Group Cancer Indemnity Insurance Benefit Riders Internal Cancer First Occurrence Benefit Rider

Level 1

Level 2

Lump Sum Benefit Maximum 1 per Covered Person per lifetime

$2,500

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

$3,750

Heart Attack/Stroke First Occurrence Benefit Rider

Level 1

Lump Sum Benefit Maximum 1 per Covered Person per lifetime

$2,500

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

$3,750

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

Optional Hospital Intensive Care Unit Rider

APSB-22338(TX) MGM/FBS Carrollton-Farmers Branch ISD

GC12 Limited Benefit Group Cancer Indemnity Insurance Option 1 Monthly Premium By Plan* OPTION 1 WITHOUT HOSPITAL INTENSIVE CARE RIDER TOTAL MONTHLY PREMIMS BY PLAN**

Issue Ages

Individual

Individual & Spouse

1 Parent Family

2 Parent Family

18+

$23.12

$49.26

$27.76

$53.88

OPTION 1 WITH HOSPITAL INTENSIVE CARE RIDER TOTAL MONTHLY PREMIMS BY PLAN**

Issue Ages

Individual

Individual & Spouse

1 Parent Family

2 Parent Family

18+

$24.84

$52.88

$31.50

$59.52

Option 2 Monthly Premium By Plan* OPTION 2 WITHOUT HOPSITAL INTENSIVE CARE RIDER TOTAL MONTHLY PREMIUMS BY PLAN**

Issue Ages

Individual

Individual & Spouse

1 Parent Family

2 Parent Family

18+

$39.34

$84.22

$47.36

$92.28

OPTION 2 WITH HOPSITAL INTENSIVE CARE RIDER TOTAL MONTHLY PREMIUMS BY PLAN**

Issue Ages

Individual

Individual & Spouse

1 Parent Family

2 Parent Family

18+

$41.08

$87.84

$51.10

$97.92

*The premium and amount of benefits vary dependent upon Plan selected at time of application. **Total premium includes the Plan selected and any applicable rider premium.

38 APSB-22338(TX)

MGM/FBS Carrollton-Farmers Branch ISD

GC12 Limited Benefit Group Cancer Indemnity Insurance

Plan Benefit Highlights Cancer Screening Benefits Diagnostic Testing

Pays the indemnity amount for one test per Calendar Year when a Covered Person receives a screening test that is generally medically recognized to detect internal cancer. The test must be performed after the 30-day period following the Covered Person’s effective date for this benefit to be paid. This benefit is payable without a diagnosis of Cancer. This benefit ONLY pays for a screening test and does not include any test payable under the Medical Imaging benefit.

Follow-Up Diagnostic Testing Pays the indemnity amount for one follow-up invasive screening test per Calendar Year when a Covered Person receives abnormal results from a covered screening test. For tests involving an incision or surgery, this benefit will only be paid for a test that results in a negative diagnosis of Cancer. Diagnostic surgeries that result in a positive diagnosis of Cancer will be paid under the Surgical benefit.

Anesthesia Pays 25% of the paid Surgical benefit amount for services of an anesthesiologist as a result of a covered surgery. Services of an anesthesiologist for Bone Marrow or Stem Cell Transplants are covered under the Bone Marrow or Stem Cell Transplant benefits. Services of an anesthesiologist for Skin Cancer or surgical prosthesis implantation are not covered under this benefit.

Bone Marrow/Stem Cell Transplant Pays an indemnity amount once per lifetime when a bone marrow or stem cell transplant is performed on a Covered Person as treatment for a diagnosed Cancer. This benefit is payable in or out of the Hospital and is payable in lieu of the Surgical and Anesthesia benefits. If a bone marrow and a stem cell transplant are performed on the same day, only the Bone Marrow Transplant benefit will be payable.

Prosthesis

Pays the indemnity amount, up to the maximum number of tests per Calendar Year, when a Covered Person has been diagnosed with Cancer and receives a MRI, CT scan, CAT scan or PET scan. These tests must be at the request of a Physician.

Pays an indemnity amount once per lifetime for a non-surgical or a surgically implanted prosthetic device prescribed by a Physician as a direct result of surgery for Cancer. The Cancer must have manifested after the 30 days following the Effective Date. This benefit does not cover prosthetic related supplies. Artificial limbs will be paid under the surgical implantation portion of this benefit. Temporary prosthetic devices used as tissue expanders are covered under the Surgical benefit. Benefits for hair prosthesis will only be covered under the Hair Piece benefit.

Cancer Treatment Benefits

Patient Care Benefits

Medical Imaging

Radiation Therapy, Chemotherapy or Immunotherapy Pays actual charges, up to the maximum benefit per 12-month period, when a Covered Person receives treatment and incurs a charge for covered Radiation Therapy, Chemotherapy or Immunotherapy. The 12-month period begins on the first day the Covered Person receives covered Radiation Therapy, Chemotherapy or Immunotherapy. Chemotherapy or Immunotherapy coverage will be limited to drugs only. This benefit does not cover other procedures related to Radiation Therapy, Chemotherapy, Immunotherapy, anti-nausea drugs or any drugs or medicines covered under the Drugs and Medicine benefit or Hormone Therapy benefit.

Hormone Therapy Pays an indemnity amount, up to 12 treatments per calendar year, when hormone therapy treatment is prescribed by a Physician for a Covered Person. This benefit covers drugs and medicine only. This benefit does not cover associated administrative processes or any drugs or medicines covered under the Drugs and Medicine benefit or Radiation Therapy, Chemotherapy or Immunotherapy benefit.

Surgical Benefits

Hospital Confinement

Pays an indemnity amount when a Covered Person is confined to a Hospital for the treatment of a covered Cancer or the treatment of a condition or disease directly caused by Cancer or the treatment of Cancer. Outpatient treatment or a stay of less than 18 hours in an observation unit or an Emergency Room is not covered. 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.

Outpatient Facility Pays an indemnity amount when a facility fee is charged for a surgical procedure performed on an outpatient basis in a Hospital or at an Ambulatory Surgical Center on a Covered Person for a diagnosed Cancer. Surgical procedures for Skin Cancer performed on an outpatient basis in a Hospital or Ambulatory Surgical Center are not covered under this benefit.

Surgical

Attending Physician

Pays an indemnity amount when a surgical operation is performed on a Covered Person for a covered diagnosed Cancer, Skin Cancer or for reconstructive surgery due to Cancer. The indemnity amount is payable up to the maximum per operation amount chosen and will be calculated by multiplying the surgical unit value assigned to the procedure, as shown in the most current Physician’s Relative Value Table, by the Unit Dollar Amount. This benefit will be paid for surgery performed in or out of the Hospital.

Extended Care Facility

Two or more surgical procedures performed through the same incision will be considered one operation and benefits will be limited to the most expensive procedure. Diagnostic surgeries that result in a negative diagnosis of Cancer are not covered under this benefit. Bone Marrow or Stem Cell Transplant surgeries are paid under the Bone Marrow or Stem Cell Transplant benefits. Surgeries required to implant a permanent prosthetic device are covered under the Prosthesis benefit. This benefit is payable for reconstructive breast surgery performed on a non-diseased breast to establish symmetry with a diseased breast when the reconstructive surgery of the diseased breast is performed while covered under this policy. Reconstructive surgery to the non-diseased breast must occur within 24 months of the reconstructive surgery of the diseased breast.

APSB-22338(TX) MGM/FBS Carrollton-Farmers Branch ISD

Pays an indemnity amount for one Physician’s visit per day of Hospital confinement when a Covered Person requires the services of a Physician, other than a surgeon, while confined in a Hospital for the treatment of Cancer. Pays the indemnity amount when a Covered Person is confined to an Extended Care Facility due to Cancer. Confinement must be at the direction of a Physician and begin within 14 days after a Hospital Confinement. This benefit is payable for the same number of days benefits were paid for the Covered Person’s preceding Hospital Confinement.

Home Health Care Pays the indemnity amount when a Covered Person requires Home Health Care in lieu of Hospital Confinement due to Cancer. Home Health Care must be prescribed by a Physician and provided by a Nurse or by a home health Nurse’s aide under the supervision of a registered Nurse. Confinement must begin within 14 days after a covered Hospital Confinement and is payable up to the same number of days benefits were paid for the Covered Person’s preceding Hospital Confinement. The caregiver may not be a member of the Insured’s Immediate Family. This benefit does not include physical, speech or audio therapy, or psychotherapy as these therapies are covered under the Physical, Occupational, Speech or Audio Therapy or Psychotherapy benefit. If the Covered Person qualifies for coverage under the Hospice Care benefit, the Hospice Care benefit will be paid in lieu of this benefit.

GC12 Limited Benefit Group Cancer Indemnity Insurance Hospice Care

Family Transportation & Lodging

Pays the indemnity amount, up to the maximum number of days per lifetime, when a Covered Person is diagnosed by a Physician as terminally ill and requires Hospice Care due to Cancer. Care must be directed by a licensed hospice organization in the patient’s home or on an outpatient or short-term Inpatient basis in a hospice facility. The Covered Person is considered terminally ill if expected to live six months or less.

Pays the actual coach fare for transportation by bus, plane or train, or the per mile amount for transportation by car for one adult family member to be near a Covered Person who is receiving covered Radiation Therapy, Chemotherapy, Immunotherapy, Bone Marrow Transplant, Stem Cell Transplant or surgery due to Cancer in a Hospital that is at least 50 miles away from the Covered Person’s residence, using the most direct route. Travel must be by scheduled bus, plane or train, or by car and be within the United States or its Territories. If the family member travels by bus, plane or train, the Insured will have the option to receive the coach fare benefit or the per mile benefit. If the Insured is unable to provide proof of coach fare, the per mile benefit will be paid. Travel by car will be paid at the stated rate per mile for up to 1,000 miles round trip. Benefits will be provided for only one mode of transportation per round trip, up to the maximum number of trips per Calendar year. If the Covered Person receives treatment while Hospital Confined, benefits for travel and/or lodging will be paid once per Hospital Confinement.

US Government, Charity Hospital or H.M.O. Pays an indemnity amount if an itemized list of services is not available because a Covered Person is confined in a charity Hospital or U.S. Government owned Hospital or covered under a Health Maintenance Organization (H.M.O.) or a Diagnostic Related Group (D.R.G.) where no charges are made to the Covered Person. If this option is elected and the Covered Person is confined as an Inpatient in a Hospital as a result of Cancer or Dread Disease, benefits for each full day of confinement will be paid. If outpatient services are provided, we will pay the benefit for each day that outpatient surgery is performed or outpatient therapy is received for Cancer covered by the Policy. This benefit will be paid in lieu of most benefits under the Policy/Certificate.

Miscellaneous Benefits

Cancer Treatment Cancer Evaluation or Consultation Pays the indemnity amount once per lifetime when a Covered Person obtains a treatment opinion at a National Cancer Institute designated Comprehensive Cancer Treatment Center. If the center is located more than 50 miles from the Covered Person’s place of residence, we will also pay a transportation and lodging indemnity amount in lieu of the Transportation and Lodging benefit and Family Member Transportation and Lodging benefit.

If treatment for the Covered Person is received on an outpatient basis, we will pay the indemnity amount for lodging, subject to the maximum number of days, for the family member’s lodging in a single room in a motel, hotel or other accommodation acceptable to us. If treatment is received on an outpatient basis, benefits for travel and/or lodging will be paid only on those days the Covered Person received outpatient treatment. If the family member and the Covered Person who is receiving treatment travel in the same car or lodge in the same room, benefits for travel and lodging will only be paid under the Transportation and Lodging benefit.

Second & Third Surgical Opinion

Blood, Plasma & Platelets

Pays the indemnity amount for a second surgical opinion when the attending Physician recommends surgery for a Covered Person as treatment of a diagnosed Cancer. The second surgical opinion must be obtained from the consulting Physician prior to surgery. If the second surgical opinion does not agree with the first surgical opinion and a third surgical opinion is required, we will pay an indemnity amount for a third surgical opinion. Each surgical opinion is payable once per diagnosis of Cancer. Surgical opinions for reconstructive, Skin Cancer or prosthesis surgeries are not covered under this benefit.

Ambulance

Drugs & Medicine Pays the indemnity amount when anti-nausea and pain medication are prescribed by a Physician and administered to a Covered Person who is also receiving Radiation Therapy, Chemotherapy, Immunotherapy, a covered surgery, Bone Marrow Transplant or Stem Cell Transplant. This benefit does not cover associated administrative processes. This benefit does not include drugs or medicines covered under the Radiation Therapy, Chemotherapy or Immunotherapy benefit or the Hormone Therapy benefit.

Transportation & Lodging Pays the actual coach fare for transportation for a Covered Person by bus, plane or train or the per mile amount for transportation by car, to receive covered Radiation Therapy, Chemotherapy, Immunotherapy, Bone Marrow Transplant, Stem Cell Transplant or surgery in a Hospital that is at least 50 miles away from the Covered Person’s residence, using the most direct route. The Hospital must be prescribed by a Physician and be the nearest Hospital which offers the specialized treatment. If the Covered Person travels by bus, plane or train, the Insured will have the option to receive the coach fare benefit or the per mile benefit. If the Insured is unable to provide proof of coach fare, the per mile benefit will be paid. Travel must be by scheduled bus, plane or train, or by car and be within the United States or its Territories. Travel by car will be paid at the stated rate per mile for up to 1,000 miles round trip. Benefits will be provided for only one mode of transportation per round trip, up to the maximum number of trips per Calendar year. If the Covered Person receives treatment while Hospital Confined, benefits for transportation will be paid once per Hospital Confinement. Pays the indemnity amount for lodging, up to the maximum number of days, when treatment is received on an outpatient basis. The Covered Person’s lodging must be in a single room in a motel, hotel or other accommodation acceptable to us and will be paid only while the Covered Person is receiving the specialized treatment as an outpatient. 40 APSB-22338(TX)

Pays the indemnity amount for blood, plasma and platelets. This benefit does not include coverage for any laboratory processes or colony stimulating factors. Benefits for Blood, Plasma and Platelets are ONLY provided under this benefit. Pays the indemnity amount, up to two trips per confinement, for either licensed air or ground ambulance transportation of a Covered Person to a Hospital or from one medical facility to another where the Covered Person is admitted as an Inpatient and Hospital confined for at least 18 consecutive hours for the treatment of Cancer. If both air and ground ambulance is required on the same day, we will only pay the highest benefit amount.

Physical, Occupational, Speech, Audio Therapy or Psychotherapy Pays the indemnity amount, up to the maximum per Calendar Year, when a Covered Person is advised by a Physician to seek physical, occupational, speech, audio therapy or psychotherapy as a result of Cancer or the treatment of Cancer. These therapies must be performed by a caregiver licensed in physical, occupational, speech, audio therapy or psychotherapy. If two or more therapies occur on the same day, only one benefit will be paid.

Waiver of Premium When the Certificate is in force and the Insured becomes 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 for which benefits are payable under the Policy. The Insured 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 the Insured remains Disabled until the earliest of either the date the Insured is no longer Disabled or the date coverage ends according to the Termination provisions in the Certificate. Proof of Disability must be provided for each new period of Disability before a new Waiver of Premium benefit is payable. Other Benefits include: s Donor s Dread Disease s Experimental Treatment s Hair Piece s Inpatient Special Nursing Services s Medical Equipment s Outpatient Special Nursing Services See your Policy/Certificate for more information regarding the benefits listed above.

MGM/FBS Carrollton-Farmers Branch ISD

GC12 Limited Benefit Group Cancer Indemnity Insurance Important Policy Provisions Eligibility

You and your Eligible Dependents are eligible to be insured under the Certificate if you and your Eligible Dependents meet APL’s underwriting rules and you are Actively at Work and qualify for coverage as defined in the Master Application.

Limitations & Exclusions No benefits will be paid for any of the following: s care or treatment received outside the territorial limits of the United States s treatment by any program engaged in research that does not meet the definition of Experimental Treatment s losses or medical expenses incurred prior to the Covered Person’s Effective Date regardless of when Cancer was diagnosed

Only Loss for Cancer or Dread Disease The Policy/Certificate 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/Certificate also covers other conditions or diseases directly caused by Cancer or the treatment of Cancer. The Policy/Certificate 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.

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 as the result of a PreExisting Condition. Pre-Existing Conditions specifically named or described as excluded in any part of the Policy/Certificate 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 Limitation for such increase will be based on the effective date of such increase.

Waiting Period The Policy/Certificate contains 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, the Insured may elect to void the Certificate from the beginning and receive a full refund of premium.

Termination of Coverage Insurance coverage for a Covered Person under the 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 grace period if the premium remains unpaid s the end of the Certificate Month in which the Policyholder requests to terminate the coverage for an Eligible Dependent s the date a Covered Person no longer qualifies as an Insured or Eligible Dependent s the date of the Covered Person’s death

Optionally Renewable The policy is optionally renewable. The Policyholder has the right to terminate the policy on any premium due date after the first Anniversary following the Policy Effective Date. APL must give at least 60 days written notice prior to cancellation.

Portability (Voluntary Plans Only) When the Insured no longer meets the definition of Insured, he or she 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: s the Certificate has been continuously in force for the last 12 months s APL receives a request and payment of the first premium for the portability coverage no later than 30 days after the date the Insured no longer qualifies as an eligible Insured. All future premiums due will be billed directly to the Insured. The Insured is responsible for payment of all premiums for the portability coverage s the Policy, under which this Certificate was issued, continues to be in force on the date the Insured ceases to qualify for coverage The benefits, terms and conditions of the portability coverage will be the same as those elected under the Certificate immediately prior to the date the Insured exercised portability. Portability coverage may include any Eligible Dependents who were covered under the Certificate at the time the Insured ceased to qualify as an eligible Insured. No new Eligible Dependents may be added to the portability coverage except as provided in the Newborn and Adopted Children provision. No increases in coverage will be allowed while the Insured is exercising his or her rights under this rider.If the Policy is no longer in force, then portability coverage is not available.

If the Policy/Certificate replaced Specified Disease Cancer coverage from another 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 Limitation will still apply.

Termination of Certificate Insurance coverage under the Certificate and any attached riders will end on the earliest of any of the following dates: s the date the Policy terminates s the end of the grace period if the premium remains unpaid s the date insurance has ceased on all persons covered under this Certificate s the end of the Certificate Month in which the Policyholder requests to terminate this coverage s the date you no longer qualify as an Insured s the date of your death

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 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. | This product contains Limitations & Exclusions | Policy Form GC12APL Limited Benefit Group Cancer Indemnity Insurance Series | Texas | (04/13) | Carrollton-Farmers Branch ISD

APSB-22338(TX) MGM/FBS Carrollton-Farmers Branch ISD

LINCOLN YOUR BENEFITS PACKAGE

Accident

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.

Accident Accident insurance coverage provides a cash benefit when an insured is injured due to a covered accident. Issue ages are 17-80 and coverage is guaranteed renewable. For exclusions and limitations please visit www.mybenefitshub.com/cfbisd Emergency Care Ambulance/Air Ambulance Initial physician office visit/ER visit Major diagnostic care Treatment Care Hospital admission Hospital confinement daily benefit Intensive care daily benefit Alternate care and rehabilitative facility daily benefit

Choice Plan $150/$600 $50/$150 $100 Choice Plan $1,000 $200 $400

$100

Follow-up doctor/patient care up to 6 sessions

$50

Transportation for care (up to 3x per accident)

$175

Companion lodging (up to 30 days per accident) Family care per child (up to 30 days) Specific Injuries or Treatments Transfusions Burns Skin Grafts Joint replacement Coma Concussion Dental crown once per accident Dental extraction once per accident Eye (removal of foreign body) once per eye/accident Eye (surgical repair) once per eye/ accident Laceration Surgery Surgical repair of knee cartilage, rotator cuff, ruptured disc, ligaments/tendons

Fractures Per fracture

$125/$6,000

Chip fractures Dislocationsâ&#x20AC;&#x201D; per injury Dislocationsâ&#x20AC;&#x201D; partial dislocation Transitional Care Benefits

25% of fracture benefit $125/$3,000 25% of dislocation benefit Choice Plan

Crutches, wheelchair, other

$25-$350

Prosthesis per limb/device

$500

Reasonable modifications to home or vehicle Accidental Death & Dismemberment (AD&D)

$100

Choice Plan

$2,500 Choice Plan

Accidental Death

$20 Choice Plan $150 $100-$6,400 25% of burn benefits $1,500-$2,000 $2,000 $100 $150 $50

Employee

$30,000

Spouse

$10,000

Child

$5,000

Loss of or loss of use of one hand, arm, leg, eye Loss of loss of use of any one finger, thumb or toe Common carrier enhanced death benefit Transportation of remains

$100

Seat belt/helmet AD&D benefit $300

Common disaster enhanced benefit

$50-400 $250-$1,000 $300-$400

Catastrophic loss

$7,000 $300 2x benefit amount $5,000 10% of AD&D 2x benefit amount $50,000

Additional Services

Choice Plan

Accident EAP services & TravelConnect SM

Included

Monthly Premiums EE Only

$16.12

EE + Spouse

$22.54

EE + Child(ren)

$27.30

Family Coverage

$36.14

UNUM YOUR BENEFITS PACKAGE

Life and 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.

Life and AD&D Whole Life Unum’s Whole Life insurance offers protection beyond an individual’s working years, potentially for your lifetime. With a guaranteed death benefit that will never decrease, level premiums that will never increase, cash value accumulation, living benefits and other options, Whole Life goes beyond typical term life insurance. Purchase Option Type Benefit Amount

Volume Purchase Employee - $5,000—$200,000 Spouse - $5,000—$50,000 Child(ren) - $5,000—$50,000

Guarantee Issue

Employee Ages: 15-50: $125,000 Ages: 51-80: $70,000 Spouse* Ages: 15-50: $25,000 Ages: 51-80: $10,000 *One qualifying health question must be answered for any level of coverage.

Waiver of Premium Long Term Care Rider Premium

Child $25,000 Included Included Paid by Employee

Group Term Life with AD&D Eligibility Base Life/AD&D Benefit Buy-Up Option

Spouse Benefit Child(ren) Employee Guarantee Issue Spouse Guarantee Issue Child Guarantee Issue Age Reduction Schedule Portability Survivor Support Waiver of Premium Accident Death Benefit Employee Premium

Full Time Employee working 20+ hours per week. Flat $20,000 Additional Life/AD&D coverage equal to the lesser of 7 times your annual earnings in increments of $10,000 to an overall Life/AD&D maximum of $500,000 (base and additional combined). Amounts in $5,000 increments to a maximum benefit of $100,000, not to exceed 100% of the Employee Life amount. $10,000 $200,000 $50,000 $10,000 50% at age 70 Included Included Included 75% of the Life amount to a maximum of $500,000 Base Plan Paid by the District Buy-Up Paid by Employee Dependent Coverage paid by Employee

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.

HSA BANK

HSA (Health Savings Account)

YOUR BENEFITS PACKAGE

About this Benefit A Health Savings Account is a tax-advantaged medical savings account available to employees who are enrolled in a high-deductible health plan. The funds contributed to the account are not subject to federal income tax at the time of deposit. Unlike a flexible spending account (FSA), funds roll over and accumulate year to year if not spent.

DID YOU KNOW? The interest earned in an HSA is tax free.

Money withdrawn for medical spending never falls under taxable income.

HSA (Health Savings Account) HSA Bank has teamed up with your employer to create an  Not enrolled in Medicare (if an accountholder enrolls in affordable health coverage option that helps you save on Medicare mid-year, catch-up contributions should be healthcare expenses. This plan is only available for those who are prorated) participating in the Active Care 1-HD medical plan. You may not Authorized Signers who are 55 or older must have their own enroll in the MEDlink® plan if you participate in the HSA. You may HSA in order to make the catch-up contribution or may not be able to participate in the FSA plan if you participate in HSA. Medicare, Medicaid, and Tricare participants Monthly Fee: Your account will be charged a monthly fee of are not eligible to participate in an HSA. $1.75, waived with an average daily balance at or above $3,000. You can use your Health Savings Account (HSA) to pay for a wide range of IRS-qualified medical expenses for yourself, your spouse or tax dependents. An IRS-qualified medical expense is defined as an expense that pays for healthcare services, equipment, or medications. Funds used to pay for IRS-qualified  Surgery medical expenses are always tax-free.  Braces

Examples of Qualified Medical Expenses

What is an HSA? 

 

A tax-advantaged savings account that you use to pay for eligible medical expenses as well as deductible, co-insurance, prescriptions, vision and dental care. Allows you to save while reducing your taxable income. Unused funds that will roll over year to year. There’s no “use it or lose it” penalty. A way to accumulate additional retirement savings. After age 65, funds can be withdrawn for any purpose without penalty.

Using Funds

   

Contact lenses Dentures Eyeglasses Vaccines

For a list of sample expenses, please refer to the C-FBISD website at www.mybenefitshub.com/cfbisd

HSA Bank Contact Information 605 N. 8th Street, Ste 320 Sheboygan, WI 53081 Phone: 800-357-6246 www.hsabank.com

Debit Card  You may use the card to pay merchants or service providers that accept VISA credit cards, so there is no need to pay cash up front and wait for reimbursements.  You can make a withdrawal at any time. Reimbursements for qualified medical expenses are tax free. If you are disabled or reach age 65, you can receive non-medical distributions without penalty, but you must report the distributions as taxable income. You may also use your funds for a spouse or tax dependent not covered by your HDHP.

2016 Annual HSA Contribution Limits Individual: $3,350 Family: $6,750 Catch-Up Contributions: Accountholders who meet the qualifications noted below are eligible to make an HSA catch-up contribution of an additional $1,000.  Health Savings accountholder  Age 55 or older (regardless of when in the year an accountholder turns 55)

How the HSA Plan Works A Health Savings Account (HSA) is an individually-owned, tax-advantaged account that you can use to pay for current or future IRS-qualified medical expenses. With an HSA, you’ll have the potential to build more savings for healthcare expenses or additional retirement savings through self-directed investment options1.

How an HSA works: 



 

You can contribute to your HSA via payroll deduction, online banking transfer, or by sending a personal check to HSA Bank. Your employer or third parties, such as a spouse or parent, may contribute to your account as well. You can pay for qualified medical expenses with your HSA Bank Debit Card directly to your medical provider or pay out-of-pocket. You can either choose to reimburse yourself or keep the funds in your HSA to grow your savings. Unused funds will roll over year to year. After age 65, funds can be withdrawn for any purpose without penalty (subject to ordinary income taxes). Check balances and account information via HSA Bank’s Internet Banking 24/7.

Are you eligible for an HSA? If you have a qualified High Deductible Health Plan (HDHP) either through your employer, through your spouse, or one you’ve purchased on your own - chances are you can open an HSA. Additionally:  You cannot be covered by any other non-HSA-compatible health plan, including Medicare Parts A and B.  You cannot be covered by TriCare.  You cannot have accessed your VA medical benefits in the past 90 days (to contribute to an HSA).  You cannot be claimed as a dependent on another person’s tax return (unless it’s your spouse).  You must be covered by the qualified HDHP on the first day of the month. When you open an account, HSA Bank will request certain information to verify your identity and to process your application.

What are the annual IRS contribution limits? Contributions made by all parties to an HSA cannot exceed the annual HSA limit set by the Internal Revenue Service (IRS). Anyone can contribute to your HSA, but only the accountholder and employer can receive tax deductions on those contributions. Combined annual contributions for the accountholder, employer, and third parties (i.e., parent, spouse, or anyone else) must not exceed these limits2.

2016 Annual HSA Contribution Limits Individual = $3,350 Family = $6,750

Catch-up Contributions Accountholders who meet these qualifications are eligible to make an HSA catch-up contribution of $1,000: Health Savings accountholder; age 55 or older (regardless of when in the year an accountholder turns 55); not enrolled in Medicare (if an accountholder enrolls in Medicare mid-year, catch-up contributions should be prorated). Authorized signers who are 55 or older must have their own HSA in order to make the catch-up contribution. According to IRS guidelines, each year you have until the tax filing deadline to contribute to your HSA (typically April 15 of the following year). Online contributions must be submitted by 2:00 p.m., Central Time, the business day before the tax filing deadline. Wire contributions must be received by noon, Central Time, on the tax filing deadline, and contribution forms with checks must be received by the tax filing deadline.

How can you benefit from tax savings? An HSA provides triple tax savings3. Here’s how:  Contributions to your HSA can be made with pre-tax dollars and any after-tax contributions that you make to your HSA are tax deductible.  HSA funds earn interest and investment earnings are tax free.  When used for IRS-qualified medical expenses, distributions are free from tax.

IRS-Qualified Medical Expenses You can use your HSA to pay for a wide range of IRS-qualified medical expenses for yourself, your spouse, or tax dependents. An IRS-qualified medical expense is defined as an expense that pays for healthcare services, equipment, or medications. Funds used to pay for IRS-qualified medical expenses are always tax-free. HSA funds can be used to reimburse yourself for past medical expenses if the expense was incurred after your HSA was established. While you do not need to submit any receipts to HSA Bank, you must save your bills and receipts for tax purposes.

How the HSA Plan Works Examples of IRS-Qualified Medical Expenses4: Acupuncture Alcoholism treatment Ambulance services Annual physical examination Artificial limb or prosthesis Birth control pills (by prescription) Chiropractor Childbirth/delivery Convalescent home (for medical treatment only) Crutches Doctor’s fees Dental treatments (including x-rays, braces, dentures, fillings, oral surgery) Dermatologist Diagnostic services Disabled dependent care Drug addiction therapy Fertility enhancement (including in-vitro fertilization) Guide dog (or other service animal)

Gynecologist Hearing aids and batteries Hospital bills Insurance premiums5 Laboratory fees Lactation expenses Lodging (away from home for outpatient care) Nursing home Nursing services Obstetrician Osteopath Oxygen Pregnancy test kit Podiatrist Prescription drugs and medicines (over-the-counter drugs are not IRSqualified medical expenses unless prescribed by a doctor) Prenatal care & postnatal treatments Psychiatrist Psychologist Smoking cessation programs

Special education tutoring Surgery Telephone or TV equipment to assist the hearing or vision impaired Therapy or counseling Medical transportation expenses Transplants Vaccines Vasectomy Vision care (including eyeglasses, contact lenses, lasik surgery) Weight loss programs (for a specific disease diagnosed by a physician – such as obesity, hypertension, or heart disease) Wheelchairs X-rays

For assistance, please contact the Client Assistance Center 800-357-6246 Monday – Friday, 7 a.m. – 9 p.m., and Saturday, 9 a.m. - 1 p.m., CT www.hsabank.com | 605 N. 8th Street, Ste. 320, Sheboygan, WI 53081

1 Investment accounts are not FDIC insured, may lose value and are not a deposit or other obligation of, or guarantee by the bank. Investment losses which are replaced are subject to the annual contribution limits of the HSA. 2 HSA funds contributed in excess of these limits are subject to penalty and tax unless the excess and earnings are withdrawn prior to the due date, including any extensions for filing Federal Tax returns. Accountholders should consult with a qualified tax advisor in connection with excess contribution removal. The Internal Revenue Service requires HSA Bank to report withdrawals that are considered refunds of excess contributions. In order for the withdrawal to be accurately reported, accountholders may not withdraw the excess directly. Instead, an excess contribution refund must be requested from HSA Bank and an Excess Contribution Removal Form completed. 3 Federal Tax savings are available no matter where you live and HSAs are taxable in AL, CA, and NJ. HSA Bank does not provide tax advice. Consult your tax professional for tax‐related questions. 4 This list is not comprehensive. It is provided to you with the understanding that HSA Bank is not engaged in rendering tax advice. The information provided is not intended to be used to avoid Federal tax penalties. For more detailed information, please refer to IRS Publication 502 titled, “Medical and Dental Expenses”. Publications can be ordered directly from the IRS by calling 1-800-TAXFORM. If tax advice is required, you should seek the services of a professional. 5 Insurance premiums only qualify as an IRS-qualified medical expense: while continuing coverage under COBRA; for qualified long-term care coverage; coverage while receiving unemployment compensation; for any healthcare coverage for those over age 65 including Medicare (except Medicare supplemental coverage).

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.

FLIP TOâ&#x20AC;Ś PG. 11 FOR HSA VS. FSA COMPARISON

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.

NBS Prepaid MasterCard® Debit Card

Current plan participants: KEEP YOUR CARDS! NBS debit cards are good for 3 years. If you need a replacement card please contact NBS directly at (800) 274-0503.

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.

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!

For a list of sample expenses, please refer to the C-FBISD benefit website: www.mybenefitshub.com/cfbisd

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

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

FSA Annual Contribution Max: $2,550

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 claims FAQs 51

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 account 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.

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

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

        

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/cfbisd

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 receipts for card swipes).

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/cfbisd 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!

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 or rollover after the Plan year ends for you to submit qualified claims for any unused funds.

NOTES