2016 Benefit Guide ESC Region 11 - Castleberry ISD Version by Higginbotham Public Sector

ESC REGION 11 EBC CASTLEBERRY ISD

BENEFIT GUIDE EFFECTIVE: Medical 09/01/2016 - 8/31/2017 Voluntary 10/01/2016 - 8/31/2017 www.region11bc.com

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. HSA and FSA Plan Availability 6. Health Savings Account (HSA) vs. Flexible Spending Account (FSA) 7. Helpful Definitions 8. Benefit Rates TRS-ActiveCare and Scott & White HMO NBS Flexible Spending Account (FSA) HSA Bank Health Savings Account (HSA) APL MEDlink® Medical Supplement MDLIVE Telehealth Cigna PPO Dental Guardian DHMO Dental Superior Vision Cigna Disability APL Cancer Loyal American Accident UNUM Life and AD&D ID Watchdog Identity Theft 2

3 4-5 6-13 6 7 8 9 10

FLIP TO... PG. 4 HOW TO ENROLL

11 12 13 14-19 20-21 22-23 24-27 28-29 30-33 34-37 38-39 40-43 44-47 48-51 52-55 56-57

PG. 6 BENEFIT UPDATES: WHAT’S NEW

PG. 14 YOUR BENEFITS PACKAGE

Benefit Contact Information

Benefit Contact Information ESC REGION 11 EBC BENEFITS

MEDICAL SUPPLEMENT—MEDLINK ®

DISABILITY

Financial Benefit Services (800) 583-6908 www.region11bc.com

Group # 13060 American Public Life (800) 256-8606 www.ampublic.com

Group # SLH100007 Cigna (800) 362-4462 www.cigna.com

TRS-ACTIVECARE MEDICAL

TELEHEALTH

CANCER

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

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

Group # 13060 American Public Life (800) 256-8606 www.ampublic.com

TRS HMO MEDICAL

PPO DENTAL

ACCIDENT

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

Group # 3335872 Cigna (800) 244-6224 www.mycigna.com

Loyal American (800) 366-8354

FLEXIBLE SPENDING ACCOUNT

DHMO DENTAL

LIFE AND AD&D

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

Group # 429340 Guardian (800) 541-7846 www.guardianlife.com

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

HEALTH SAVINGS ACCOUNT

VISION

IDENTITY THEFT

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

Group # 320580 Superior Vision (800) 507-3800 www.superiorvision.com

ID Watchdog (800) 237-1521 www.idwatchdog.com

How to Enroll On Your Device Enrollment has just become

SCAN:

easier! Avoid typing long URLs and scan directly to your benefits websites, videos, and benefit guides. Try it yourself! Scan the following code in the picture.

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.region11bc.com delivers important benefit information with 24/7 access, as well as detailed plan information, rates and product videos.

! 4

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

Go to:

Click Login

Enter Username & Password

G O

www.region11bc.com

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

Username:

Sample Username

lincola1234 Sample Password

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

lincoln1234

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

If you have trouble

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

logging in, click on the

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

“Login Help Video”

your Social Security Number.

for assistance.

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

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

Annual Benefit Enrollment

SUMMARY PAGES

Benefit Updates - What’s New:  Financial Benefit Services (FBS) is the NEW Third Party

Administrator for Castleberry ISD. FBS will conduct the annual enrollment and provide benefit support for Castleberry ISD employees. Also there is a new on-line enrollment system to enroll in your benefits.  For information regarding TRS-ActiveCare medical

plans, visit www.trsactivecareaetna.com or call (800) 222-9205. For information regarding Scott & White HMO medical plans, visit trs.swhp.org or call (800) 321-7947.  Eligible employees in Castleberry ISD receive $10,000

Basic Life and AD&D as an employer paid benefit. Voluntary Term Life is available for employees, spouses, and dependent children. THIS YEAR ONLY all employees can enroll on a Guarantee Issue (GI) basis (no health questions asked) for the new plan year. Employees can elect up to $230,000 and spouses up to $50,000 maximum GI without having to answer health questions. Coverage amounts over GI are subject to evidence of insurability.  Cigna is the NEW Disability provider. There are two

different plan options with benefits becoming available from the 1st day of disability to as late as the 180th day. Plans under 30 day elimination periods are eligible for the 24 hour hospital confinement exception. Eligible employees can elect up to a $7,500 monthly benefit, not to exceed 66 2/3% of your annual salary. If you were previously enrolled in the disability plan, then you will have continuation of coverage with Cigna.

 Tax-sheltered Flexible Spending Accounts (FSA) allow

an individual to set aside pre-tax dollars to pay for future health care and dependent care expenses. Eligible expenses must be incurred within the plan year and contributions are use it or lose it. The medical reimbursement maximum is $2,550 annually or $212.50 per month. The dependent care reimbursement maximum is $5,000 if married or $2,500 if single per plan year. Castleberry ISD offers a rollover for balances of $500 or less that can roll into the next plan year.  An HSA is a tax free savings account available to

employees enrolled in a high deductible health insurance plan (HDHP). Deposited funds are tax deductible and are used to pay for medical expenses. The annual contribution maximum for 2016 is $3,350 for individual and $6,750 for family. For individuals who are age 55 and up, there is an additional catch-up provision of $1,000 that can be contributed annually. Funds contributed to this plan are only available as they are deducted each month. This plan is only available if you are enrolled in the ActiveCare 1-HD. If you elect the HSA and FSA, then your FSA will be limited to dental, vision, and preventative care expenses.  MDLIVE offers 24/7/365 access to a national network

of doctors and pediatricians for you and your household members that can diagnose, recommend treatment, and prescribe medication. This benefit may be provided by your district at no cost to you or you can enroll for employee only or family coverage.

OPEN ENROLLMENT DATES Medical Enrollment: 8/1/16—8/22/16 Supplemental Enrollment: 9/1/16—9/18/16

PLAN YEAR DATES Medical Plan Year: 9/1/16—8/31/17 (SHORT) Supplemental Plan Year: 10/1/16—8/31/17 ← Don’t Forget! This is a short supplemental plan year.

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

CHANGES IN STATUS (CIS):

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 Government Programs

Gain or loss of Medicare/Medicaid coverage may trigger a permitted election change.

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.region11bc.com. Click on your

annual enrollment) unless a Section 125 qualifying event occurs.

district, then click 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

11 EBC benefit website: www.region11bc.com. Click on your

included in the dependent profile. Additionally, you must

district, then click on the benefit plan you need information

notify your employer of any discrepancy in personal and/or

on (i.e., Dental) and you can find provider search links under

benefit information.



For benefit summaries and claim forms, go to the ESC Region

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.

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 ESC Region 11 EBC or as

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

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

Medical

Scott & White HMO

Dental PPO

Cigna

Dental HMO

Guardian

25 (26 if Full-Time Student)

Vision

Superior Vision

Cancer

American Public Life

Accident

Loyal American

Voluntary Term Life/AD&D

UNUM

ID Theft Protection

ID Watchdog

MEDlink®

American Public Life

Telehealth

MDLIVE

Flexible Spending Account

National Benefit Services

26 (benefits terminate at the end of the plan year following the birthday)

Health Savings Account

HSA Bank

26 (benefits terminate at the end of the plan year following the birthday)

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. 9

HSA and FSA Plan Availability

SUMMARY PAGES

Employees of the following districts may participate in either the HSA or FSA, but not both: Alvord ISD

Erath Excels Academy

Poolville ISD

Argyle ISD

International Leadership of Texas

Santo ISD

Arlington Classics Academy

Lingleville ISD

Stephenville ISD

Bonham ISD

Little Elm ISD

Trinity Basin Preparatory

Callisburg ISD

Millsap ISD

Valley View ISD

Chico ISD

Muenster ISD

Van Alstyne ISD

CityScape Schools

Palmer ISD

Whitesboro ISD

East Fort Worth Montessori

Palo Pinto ISD

Education Center International Academy

Ponder ISD

Are you currently enrolled in an FSA? Do you want to elect an HSA next year? Just keep in mind, if you choose to waive the FSA and enroll in the HSA (and have funds under $500 remaining in FSA), those funds are not eligible for rollover and are forfeited.

Employees of the following districts may enroll in both the HSA and FSA where FSA becomes a limited expense account*: Castleberry ISD Era ISD Evolution Academy Lindsay ISD Treetops International *If your district offers this FSA, then you are only eligible to use funds towards dental, vision, and preventative care expenses. Selected districts have elected to offer their employees a $500 rollover for unused funds. These funds can roll into the next plan

year. Check with your benefit admin to see if this applies to you. Selected districts have elected to offer a 75-day grace period that you can use funds from the prior plan year up to 75 days after the plan ends. If you have additional questions about the differences between the limited and unlimited FSA plans, please call (800)274-0503. 10

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 taxfree.

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. 22

FLIP TO… PG. 20

FOR HSA INFORMATION

FOR FSA INFORMATION

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).

ESC Region 11 EBC Rates

SUMMARY PAGES

Plan Year September 1, 2016 - August 31, 2017

CIGNA DENTAL

NBS FLEXIBLE SPENDING ACCOUNT

High PPO

Healthcare Reimbursement Maximum: $2,550 Dependent Care Reimbursement Maximum: $2,500 or $5,000 (Dependent Care Maximum is based on marital/tax filing status.)

Employee Only Employee + Spouse Employee + Children Employee + Family

$30.90 $64.39 $70.06 $104.30

HSA BANK HEALTH SAVINGS ACCOUNT Employee Only Maximum Family Maximum

MAC Plan Employee Only Employee + Spouse Employee + Children Employee + Family

$23.52 $47.06 $49.41 $75.61

AMERICAN PUBLIC LIFE MEDLINKÂ® Rates: 45 year old participant

$12.78 $20.21 $27.71 $32.91

Employee Only Employee + Family Voluntary Term Life Employee Guarantee Issue: Spouse Guarantee Issue: Child Guarantee Issue:

Low Plan w/ ICU Rider $16.30 $22.80 $29.00

High Plan Employee Only Single Parent Fam. Family

Employee Only Single Parent Fam. Family

$19.60 $27.30 $35.90

High Plan w/ ICU Rider $32.40 $44.60 $56.60

Employee Only Single Parent Fam. Family

$35.70 $49.10 $63.50

LOYAL AMERICAN ACCIDENT Employee Only Employee + Spouse Employee + Children Employee + Family

$12.70 $19.50 $20.40 $27.20

UNUM LONG-TERM DISABILITY Premium Plan (Pays to Age 65) Elimination Period 0/7 14/14 30/30 60/60 90/90 180/180

$8.00 $16.00

UNUM TERM LIFE/AD&D

AMERICAN PUBLIC LIFE CANCER Employee Only Single Parent Fam. Family

$28.00 $51.50 $45.50 $69.00

MDLIVE TELEHEALTH

$8.86 $15.09 $15.97 $23.95

Low Plan

$21.50 $39.50 $36.50 $54.50

Check with your district to see if your employer offers this benefit at no cost.

SUPERIOR VISION Employee Only Employee + Spouse Employee + Children Employee + Family

$1,500 Benefit $2,500 Benefit

Employee Only Employee + Spouse Single Parent Family Family

GUARDIAN DENTAL Employee Only Employee + Spouse Employee + Children Employee + Family

$3,350 $6,750

Rates per/$500 $19.00 $16.10 $13.75 $11.00 $6.25 $4.35

$230,000 $50,000 $10,000

Employee and Spouse Rates per $10,000 0-30 31-34 35-39 40-44 45-49 50-54 55-59 60-64

$0.45 $0.60 $0.70 $0.80 $1.20 $2.00 $3.30 $5.10 Children

$5,000 $10,000

$0.90 $1.80 AD&D Rates per $10

Employee Only Family

$0.40 $0.70

ID WATCHDOG IDENTITY THEFT PROTECTION Plus Plan

Employee Only Employee + Family

$7.95 $14.95 Platinum Plan

Employee Only Employee + Family

$11.95 $22.95 13

AETNA

Medical

YOUR BENEFITS PACKAGE

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

DID YOU KNOW?

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

This is a general overview of your plan benefits. If the terms of this outline differ from your policy, the policy will govern. Additional plan details on covered expenses, limitations and exclusions are included in the summary plan description located on the ESC Region 11 EBC Benefits Website: www.region11bc.com

ESC Region 11 EBC Plan Year September 1, 2016â&#x20AC;&#x201D;August 31, 2017 TRS Medical Insurance These rates do NOT include state and employer contributions. Monthly (12 pay) ActiveCare 1-HD

ActiveCare Select

ActiveCare 2

Scott & White HMO

FirstCare

Employee Only

$341

$484

$645

$530.16

$472.50

Employee + Spouse

$914

$1,147

$1,552

$1,192.82

$1,180.50

Employee + Child(ren)

$615

$779

$1,042

$839.16

$748.50

$1,231

$1,361

$1,597

$1,322.98

$1,190.50

Employee + Family

Semi-Monthly (24 pay) ActiveCare 1-HD

ActiveCare Select

ActiveCare 2

Scott & White HMO

FirstCare

$170.50

$242

$322.50

$265.08

$236.25

$457

$573.50

$776

$596.41

$590.25

Employee + Child(ren)

$307.50

$389.50

$521

$419.58

$374.25

Employee + Family

$615.50

$680.50

$798.5

$661.49

$595.25

Employee Only Employee + Spouse

18 pay ActiveCare 1-HD

ActiveCare Select

ActiveCare 2

Scott & White HMO

FirstCare

Employee Only

$227.33

$322.67

$430

$353.44

$315

Employee + Spouse

$609.33

$764.67

$1,034.67

$795.21

$787

$410

$519.33

$694.67

$559.44

$499

$820.67

$907.33

$1,064.67

$881.99

$793.67

Employee + Child(ren) Employee + Family

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

ActiveCare 1-HD

ActiveCare Select or ActiveCare Select Whole Health

ActiveCare 2

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

$2,500 employee only $5,000 family

$1,200 individual $3,600 family

$1,000 individual $3,000 family

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

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

$6,850 individual $13,700 family

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

80% 20%

Office Visit Copay Participant pays

20% after deductible

$30 copay for primary $60 copay for specialist

$30 copay for primary $50 copay for specialist

Diagnostic Lab Participant pays

20% after deductible

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

Preventive Care See next page for a list of services

Plan pays 100%

Teladoc® Physician Services

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

Plan pays 100%

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

20% after deductible

$100 copay plus 20% after deductible

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

20% after deductible

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

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

Emergency Room (true emergency use) Participant pays

20% after deductible

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

Outpatient Surgery Participant pays

20% after deductible

$150 copay per visit plus 20% after deductible

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

$5,000 copay plus 20% after deductible

Not covered

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

Prescription Drugs Drug deductible (per plan year)

Subject to plan year deductible

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

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

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

$20 $40** $65**

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

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

$35 $60** $90**

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

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

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

Specialty Drugs Participant pays

20% after deductible

20% coinsurance per fill

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

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

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

Network Benefits When Using In-Network Providers

(Provider must bill services as “preventive care”)

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)

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

Annual Vision Examination (one per plan year; performed by an opthalmologist or optometrist using calibrated instruments) Participant pays

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

$60 copay for specialist

$50 copay for specialist

Annual Hearing Examination Participant pays

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

$30 copay for primary $60 copay for specialist

$30 copay for primary $50 copay for specialist

Immunizations recommended by the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention (CDC) with respect to the individual involved. Evidence−informed preventive care and screenings provided for in the comprehensive guidelines supported by the Health Resources and Services Administration (HRSA) for infants, children and adolescents. Additional preventive care and screenings for women, not described above, as provided for in comprehensive guidelines supported by the HRSA www.hhs.gov/healthcare/facts-and-features/fact-sheets/ preventive-services-covered-under-aca/#CoveredPreventive ServicesforAdults For purposes of this benefit, the current recommendations of the USPSTF regarding breast cancer screening and mammography and prevention will be considered the most current (other than those issued in or around November 2009). The preventive care services described above may change as USPSTF, CDC and HRSA guidelines are modified. (Examples of covered services included are: Routine annual physicals (one per year); immunizations; well-child care; breastfeeding support, services and supplies; cancer screening mammograms; bone density test; screening for prostate cancer and colorectal cancer (including routine colonoscopies); smoking cessation counseling services and healthy diet counseling; and obesity screening/counseling. 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.

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

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) 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.

What Can I Use My Flexible Spending Account On? For a list of sample expenses, please refer to the ESC Region 11 EBC benefit website: www.region11bc.com

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!

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 and contributions are use-it-or- lose-it. Remember to retain all your receipts.

How Do I File a Claim? In most situations, you will be able to swipe your card however, in the event you loose your card or are waiting to received one you can visit www.region11bc.com and complete the “Claim Form” to send to NBS.

A few examples are listed below:

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

How Do I View My Account Balance? Go to: http://my.nbsbenefits.com

New User? Create a username and password. Employee ID: Please enter your Social Security Number Employer ID: Contact your benefits administrator for your districts Employer ID.

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

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 affordable health coverage option that helps you save on healthcare expenses. This plan is only available for those who are participating in the ActiveCare 1-HD medical plan. You may not enroll in the MEDlink® plan if you participate in the HSA. Depending on your district, you may or may not be able to participate in the FSA plan if you participate in HSA. Medicare, Medicaid, and Tricare participants are not eligible to participate in an HSA.

2016 Annual HSA Contribution Limits

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 medical expenses are always tax-free.

A HDHP, or high-deductible health plan, is a major-medical health insurance plan that has a lower premium than traditional health plans. Your HDHP:  Is a major-medical health plan that is HSA-compatible. That means it can be used with a health savings account from HSA Bank.  Has a higher annual deductible with lower monthly premiums, which means you’ll have less taken out of your paycheck and more to add to you HSA.  Covers 100% of preventative care, including annual physicals, immunizations, well-women and well-child exams, and more–all without having to meet your deductible.  Providers coverage for health screenings, such as blood pressure, cholesterol, diabetes, vision, and more.

What is an HSA? An HSA, or health savings account, is a unique tax-advantaged account that you can use to pay for current or future IRS qualified medical expenses. With an HSA, you’ll have:  A tax-advantaged savings account that you can use to pay for IRS-qualified medical expenses as well as deductibles, co-insurance, prescriptions, vision, and dental care.  Unused funds that will roll over year to year. There’s no “use it or lose it” penalty.  Potential to build more savings through investing. You can choose from a variety of HSA self-directed investment options with no minimum balance required.  Additional retirement savings. After you turn 65, funds can be withdrawn for any purpose without penalty. 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.

Individual: $3,350 Family: $6,750 Catch-Up Contributions: Account holders over the age of 55 who have not yet enrolled in Medicare are eligible to make an additional $1,000 “catch-up” contribution to their HSA.

What is a HDHP?

HSA Bank Contact Information 605 N. 8th Street, Ste 320 Sheboygan, WI 53081 Phone: 800-357-6246 Mon.-Fri. 7am to 9pm, and Saturday 9am to 1pm www.hsabank.com

For a list of sample expenses, please refer to the ESC Region 11 EBC website at: www.region11bc.com

Using Funds 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.

AMERICAN PUBLIC LIFE YOUR BENEFITS PACKAGE

MEDlinkÂŽ

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

DID YOU KNOW?

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

MEDlink® Limited Benefit Medical Expense Supplemental Insurance ESC Region 11 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.

SUMMARY OF BENEFITS Base Policy

Option 1

Option 2

In-Hospital Benefit - Maximum In-Hospital Benefit

$1,500 per confinement

$2,500 per confinement

Outpatient Benefit

up to $200 per treatment

$25 per treatment; $125 max per family per Calendar Year

Physician Outpatient Treatment Benefit

Option 1 Total Monthly Premiums by Plan* Issue Ages 17-54

Issue Ages 55-59

Issue Ages 60-69

Employee Only

$21.50

$32.00

$49.00

Employee + Spouse

$39.50

$59.00

$88.00

Employee + Child(ren)

$36.50

$47.00

$64.00

Family Coverage

$54.50

$74.00

$103.00

Issue Ages 17-54

Issue Ages 55-59

Issue Ages 60-69

Employee Only

$28.00

$44.50

$68.50

Employee + Spouse

$51.50

$81.50

$122.50

Employee + Child(ren)

$45.50

$62.00

$86.00

Family Coverage

$69.00

$99.00

$140.00

Option 2 Total Monthly Premiums by Plan* Hospital Emergency Room

Plans available to employees age 70 and over if You work for an employer employing 20 or more employees on a typical workday in the preceding Calendar Year. *Total premium includes the Plan selected and any applicable rider premium. Premiums are subject to increase with notice.

APSB-22330(TX)-0116 MGM/FBS ESC Region 11 25

MEDlink® Limited Benefit Medical Expense Supplemental Insurance Limitations Eligibility This policy will be issued to those persons who meet American Public Life Insurance Company’s insurability requirements. Evidence of insurability acceptable to us may be required. If our underwriting rules are met, you are on active service, you are covered under your Employer’s Medical Plan and premium has been paid, your insurance will take effect on the requested Effective Date or the Effective Date assigned by us upon approval of your written application, whichever is later. Covered Charges mean those charges that are incurred by a Covered Person because of an Accident or Sickness; are for necessary treatment, services and medical supplies and recommended by a Physician; are not more than any dollar limit set forth in the Schedule; are incurred while insured under the Policy, subject to any Extension of Benefits; and are not excluded under the Policy. A Hospital is not any institution 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.

In-Hospital Benefit Benefits payable are limited to any out-of-pocket deductible amount; any out-of-pocket co-payment or coinsurance amounts the Covered Person actually incurs after the Employer’s Medical Plan has paid; any out-of-pocket amount the Covered Person actually incurs for surgery performed by a Physician after the Employer’s Medical Plan has paid; and the Maximum In-Hospital Benefit shown in the Policy Schedule. The Covered Person must be an Inpatient and covered by your Employer’s Medical Plan when the Covered Charges are incurred.

Outpatient Benefits Treatment is for the same or related conditions, unless separated by a period of 90 consecutive days. After 90 consecutive days, a new Outpatient Benefit will be payable. The Covered Person must be covered by your Employer’s Medical Plan when the Covered Charges are incurred.

Physician Outpatient Treatment Benefit Benefit maximum of $125 per family per Calendar Year. The Covered Person must be covered by your Employer’s Medical Plan when the Covered Charges are incurred. The Covered Person must not be an Inpatient when the Covered Charges are incurred.

Premiums The premium rates may be changed by Us. If the rates are changed, We will give You at least 31 days advance written notice. If a change in benefits increases Our liability, premium rates may be changed on the date Our liability is increased. This plan may be continued in accordance with the Consolidated Omnibus Reconciliation Act of 1986.

APSB-22330(TX)-0116 MGM/FBS ESC Region 11 26

Exclusions We will pay no benefits for any 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 your Employer’s Medical Plan provision or which result from: (a) suicide or any attempt, thereof, while sane or insane; (b) any intentionally self-inflicted injury or Sickness; (c) rest care or rehabilitative care and treatment; (d) outpatient routine newborn care; (e) voluntary abortion except, with respect to You or Your covered Dependent spouse: (1) where Your or Your Dependent spouse’s life would be endangered if the fetus were carried to term; or (2) where medical complications have arisen from abortion; (f) pregnancy of a Dependent child; (g) participation in a riot, 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; (h) commission of a felony; (i) participation in a contest of speed in power driven vehicles, parachuting, or hang gliding; (j) air travel, except: (1) as a fare-paying passenger on a commercial airline on a regularly scheduled route; or (2) as a passenger for transportation only and not as a pilot or crew member; (k) intoxication; (Whether or not a person is intoxicated is determined and defined by the laws and jurisdiction of the geographical area in which the loss occurred.) (l) alcoholism or drug use, unless such drugs were taken on the advice of a Physician and taken as prescribed; (m) sex changes; (n) experimental treatment, drugs, or surgery; (o) an act of war, whether declared or undeclared, or while performing police duty as a member of any military or naval organization; (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. We will refund the pro rata unearned premium for any such period the Covered Person is not covered.) (p) 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.) (q) mental illness or functional or organic nervous disorders, regardless of the cause; (r) dental or vision services, including treatment, surgery, extractions, or x-rays, unless: (1) 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 (2) 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; (t) any expense for which benefits are not payable under the Covered Person’s Employer’s Medical Plan; or (u) air or ground ambulance.

MEDlink® Limited Benefit Medical Expense Supplemental Insurance Termination of Coverage Your Insurance coverage will end on the earliest of these dates: the date You no longer qualify as an Insured; the end of the last period for which premium has been paid; the date the Policy is discontinued; the date You retire; if You work for an employer employing less than 20 employees on a typical work day in the preceding Calendar Year, the date You attain age 70; the date You cease to be on Active Service; the date Your coverage under Another Medical Plan ends; or the date You cease employment with the employer through whom You originally became insured under the Policy. Insurance coverage on a Dependent will end on the earliest of these dates: the date Your coverage terminates; the end of the last period for which premium has been paid; the date the Dependent no longer meets the definition of Dependent; the date the Dependent’s coverage under Another Medical Plan ends; or the date the Policy is modified so as to exclude Dependent coverage. We may end the coverage of any Covered Person who submits a fraudulent claim. We may end the coverage of a Subscribing Unit if fewer persons are insured than the Policyholder’s application requires.

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. | Policy Form MEDlink® Series | Texas | Limited Benefit Medical Expense Supplemental Insurance | (10/14) | ESC Region 11

APSB-22330(TX)-0116 MGM/FBS ESC Region 11 27

MDLIVE YOUR BENEFITS PACKAGE

Telehealth

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

DID YOU KNOW?

75%

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

Telehealth When should I use MDLIVE?

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

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

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

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

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

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

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

How much does it cost? $8 for Employee Only. $16 for Family coverage. This benefit is offered at no cost to you if you are an eligible employee in the following districts: Alvord ISD CitySacpe Schools Garner ISD Lake Dallas ISD Millsap ISD Palmer ISD Palo Pinto ISD Santo ISD Trinity Basin Preparatory Valley View ISD Van Alstyne ISD Westlake Academy Whitesboro ISD

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

   

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

Scan with your smartphone to get the app.

Call us at (888) 365-1663 or visit us at www.consultmdlive.com Disclaimers: MDLIVE does not replace the primary care physician. MDLIVE operates subject to state regulation and may not be available in certain states. MDLIVE does not guarantee that a prescription will be written. MDLIVE does not prescribe DEA controlled substances, non-therapeutic drugs and certain other drugs which may be harmful because of their potential for abuse. MDLIVE physicians reserve the right to deny care for potential misuse of services. For complete terms of use visit www.mdlive.com/pages/terms.html 010113

CIGNA

GUARDIAN

Dental PPO DHMO

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.

Cigna Dental PPO - High Plan Monthly PPO Premiums Tier

Rate

EE Only

$30.90

EE + Spouse

$64.39

EE + Child(ren)

$70.06

Family Coverage

$104.30

Receiving regular dental care can not only catch minor problems before they become major and expensive to treat - it may even help improve your overall health. Gum disease is increasingly being linked to complications for pre-term birth, heart disease, stroke, diabetes, osteoporosis and other health issues. That’s why this dental plan includes Cigna Dental WellnessPlusSM features. When you or your family members receive any preventive care in one plan year, the annual dollar maximum will increase in the following plan year. When you or your family members remain enrolled in the plan and continue to receive preventive care, the annual dollar maximum will increase in the following plan year, until it reaches the level specified below. Please refer to your plan materials for additional information on this plan feature.

Benefits Network Plan Year Maximum (Class I, II, and III expenses)

Cigna Dental Choice In-Network Cigna Choice—Radius Year 1: $1,000 Year 2: $1,100# Year 3: $1,200+ Year 4: $1,300

Annual Deductible Individual Family Reimbursement Levels**

Out-of-Network Cigna Savings—Radius Year 1: $1,000 Year 2: $1,100# Year 3: $1,200+ Year 4: $1,300

$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

Class I - Preventive & Diagnostic Care Oral Exams Routine Cleanings Bitewing X-rays Fluoride Application Space Maintainers

100%

No Charge

100%

No Charge

Class II - Basic Restorative Care Fillings Sealants Non Routine X-Rays Emergency Care to Relieve Pain Brush Biopsies Oral Surgery – Simple Extractions

70%*

30%*

70%*

30%*

Class III - Major Restorative Care Crowns/Bridges/Dentures Root Canal Therapy/Endodontics Minor/Major Periodontics Surgical Extractions of Impacted Teeth Oral Surgery - all except simple extractions Anesthetics Denture Repairs Denture Relines, Rebases and Adjustments Repairs to Bridges, Crowns and Inlays Inlays/Onlays Prosthesis Over Implant

40%*

60%*

40%*

60%*

Class IV - Orthodontia Lifetime Maximum—$1,000 Limited to Dependent Children only

50%

Cigna Dental - MAC Plan Monthly PPO Premiums Tier

Rate

EE Only

$23.52

EE + Spouse

$47.06

EE + Child(ren)

$49.41

Family Coverage

$75.61

Benefits Network Plan Year Maximum (Class I, II, and III expenses)

Cigna Dental Choice In-Network Cigna Choice—Radius Year 1: $1,000 Year 2: $1,100# Year 3: $1,200+ Year 4: $1,300

Out-of-Network Cigna Savings—Radius Year 1: $1,000 Year 2: $1,100# Year 3: $1,200+ Year 4: $1,300

$50 per person No Limit

Annual Deductible Individual Family Reimbursement Levels** Class I - Preventive & Diagnostic Care Oral Exams Routine Cleanings Bitewing X-rays Fluoride Application Space Maintainers Class II - Basic Restorative Care Fillings Sealants Full Mouth X-rays Panoramic X-ray Periapical X-rays Emergency Care to Relieve Pain Root Canal Therapy/Endodontics Osseous Surgery Periodontal Scaling and Root Planning Brush Biopsies Oral Surgery Class III - Major Restorative Care Crowns/Bridges/Dentures Anesthetics Stainless Steel/Resin Crowns Surgical Extractions of Impacted Teeth Denture Repairs Denture Relines, Rebases and Adjustments Repairs to Bridges, Crowns and Inlays Inlays/Onlays Prosthesis Over Implant Class IV - Orthodontia

Based on Reduced Contracted Fees

Based on Maximum Allowable Charge (In-network fee level) Plan Pays You Pay

Plan Pays

You Pay

100%

No Charge

100%

No Charge

80%*

20%*

80%*

20%*

50%*

Not Covered

100% of your dentist’s usual fees

Not Covered

100% of your dentist’s usual fees

Cigna Dental - High and MAC Plan Dependent/Student age limitation 26/26. Dental Network Savings Program(DNSP): Using an out-of-network dental health care professional will cost you more than using in-network care. You may be able to save some money on out-of-pocket expenses if you use a dental health care professional that participates in Cigna’s Dental Network Savings Program. 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. # Increase contingent upon receiving Preventive Services in Plan Year 1 + Increase contingent upon receiving Preventive Services in Plan Years 1 and 2

Procedure

Exclusions and Limitations

Late Entrants Limit 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

50% coverage on Class III and IV for 12 months Two per Plan year Two per Plan year 1 per Plan year for people under 19 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. 33

Guardian Dental DHMO Group Number: 00429340

About Your Benefits A visit to your dentist can help you keep a great smile and prevent many health issues. But dental care can be costly and you can be faced with unforeseen expenses. Did you know, a crown can cost as much as $1,4001? Guardian dental insurance will help you pay for it. With access to one of the largest network of dental providers in the country, who agreed to charge negotiated fees for their services of up to 30% less than

average charges in the same community, you will benefit from lower out-of-pocket costs, quality care from screened and reviewed dentist, no claim forms to file, and excellent customer service. Enroll today and smile next time you see your dentist! 1

http://health.costhelper.com/dental-crown.html

With your DHMO plan, you enjoy negotiated discounts from our network dentists. You pay a fixed copay for each covered service. Out-of-network visits are not covered.

Your Dental Plan

DHMO

Your Network Is

Managed DentalGuard

Your Monthly premium You and Spouse You and Child(ren) You, Spouse and Child(ren)

$12.78 $20.21 $27.71 $32.91

Calendar Year Deductible Individual Family Limit Waived For

No deductible

Charges covered for you (co-insurance) Preventive Care Basic Care Major Care Orthodontia

Network only You pay a copay for each covered procedure. See “Plan Details” for more information.

Annual Maximum Benefit

Unlimited

Office Visit Copay

Dependent Age Limits (Non-Student/Student)

25/26

Manage Your Benefits:

Find A Dentist:

Go to www.GuardianAnytime.com to access secure information about your Guardian benefits including access to an image of your ID Card. Your on-line account will be set up within 30 days after your plan effective date.

Visit www.GuardianAnytime.com Click on “Find A Provider”; You will need to know your plan and dental network, which can be found on the first page of your dental benefit summary.

Guardian Dental DHMO A Sample of Services Covered by Your Plan: Anesthesia* Bridges and Dentures Cleaning (prophylaxis) Frequency Fillings Fluoride Treatments Limits Inlays, Onlays, Veneers Oral Exams Orthodontia Limits Perio Surgery Periodontal Maintenance Frequency Repair & Maintenance of Crowns, Bridges & Dentures Root Canal Scaling & Root Planing (per quadrant) Sealants (per tooth) Simple Extractions Single Crowns Surgical Extractions X-rays

DHMO You Pay (Network Only) Not Covered $345-355 $0 2 times in 12 months^ $8 $0 Under Age 18 $235-250 $0 $2,285 Adults & Child(ren) $255 $30 2 times in 12 months^ (Standard) $65-120 $95-170 $30 $10 $8 $230 $50-80 $0

This is only a partial list of dental services. Your certificate of benefits will show exactly what is covered and excluded. When Orthodontia coverage is for "Child(ren)" only, the orthodontic appliance must be placed prior to the age limit set by your plan; If full-time status is required by your plan in order to remain insured after a certain age; then orthodontic maintenance may continue as long as full-time student status is maintained. If Orthodontia coverage is for "Adults and Child(ren)" this limitation does not apply. The total number of cleanings and periodontal maintenance procedures are combined in a 12 month period. *General Anesthesia – restrictions apply.

Exclusions and Limitations Important information about Guardian’s Managed DentalGuard Pre-Paid (Florida, New York) Plan, Guardian’s Managed DentalGuard (Colorado) Plan , Managed DentalGuard Inc.’s (Ohio) Plan, Managed Dental Care’s DHMO (California) Plan, Managed DentalGuard, Inc.’s Managed DentalGuard (New Jersey) Plan, Managed DentalGuard, Inc.’s Managed DentalGuard DHMO (Texas) Plan and Managed DentalGuard -LIBERTY Dental Plan of Nevada, Inc. (Nevada): This plan provides pre-paid dental benefits through a network of participating general dentists and specialty care dentists. All covered services must be provided by the member’s Primary Care Dentist. Specialty care services are covered only when referred by the member’s Primary Care Dentist and approved in advance by Managed DentalGuard. Only those services listed in the plan are covered. Certain services are subject to annual or other periodic limitations. Where orthodontic benefits are specifically included, the plan provides for one course of comprehensive treatment per lifetime, per member. Unless specifically included, the Managed DentalGuard plan does not provide orthodontic benefits if comprehensive orthodontic treatment or retention is in progress as of the member’s effective date under the Managed DentalGuard plan. The services, exclusions and limitations listed here do not constitute a contract and are a summary only. The Managed DentalGuard plan documents are the final arbiter of coverage. GP-1-MDG1, et al. or GP-1-MDG-FL-1-08, et al. (Florida), GP-1-MDG-NY1, et al. or GP-1-MDG-NY-1-08, et al. (New York), GP-1-MDG-CO-1, et al. (Colorado), GP-1MDC1, et al. or GP-1-MDC-CA-1-08, et al. (California), GP-1-MDG-1-NJ, et al. or GP-1-MDG-NJ-1-08, et al. (New Jersey), GP-1-MDG-TX1, et al. or GP-1-MDG-TX-1-08, et al. (Texas), GP-1-MDG-OH-1, et al. (Ohio), NV110717, et al (Nevada).

Guardian Dental DHMO Managed DentalGuard Plan Schedule 35-M Orthodontic Plan Schedule 1 MDG Codes++ 0120 0120 0140 0140 0150 0150 0460 0470 0999 9310 9310 9430 9440 0210 0220 0230 0240 0270 0272 0274 0330 1110 1120 1999 1201 1203 1204 1310 1330 1351 9999 1510 1515 1550 2110 2120 2130 2131 2140 2150 2160 2161 2210 2330 2331 2332 2335

2336

Covered Services Appointments & Diagnostic Services Periodic oral evaluation, participating general dentist Periodic oral evaluation, participating specialty care dentist Limited oral evaluation - problem focused, participating general dentist Limited oral evaluation - problem focused, participating specialty care dentist Comprehensive oral evaluation, participating general dentist Comprehensive oral evaluation, participating specialty care dentist Pulp vitality tests Diagnostic casts Office visit - during regular hours - participating general dentist only Consultation (by dentist other than practitioner providing treatment), participating general dentist Consultation (by dentist other than practitioner providing treatment), participating specialty care dentist Office visit for observation - regular hours - no other service performed Emergency office visit - after regularly scheduled office hours Radiographs Intraoral - complete series (including bitewings) Intraoral - periapical - single film Intraoral - periapical - each additional film Intraoral - occlusal - each film Bitewing - single film Bitewings - two films Bitewings - four films Panoramic film Preventive & Space Maintenance Prophylaxis - adult (first 2 services in any 12 month period) + Prophylaxis - child (first 2 services in any 12 month period) + Prophylaxis - adult or child (with or without fluoride) (each additional service in same 12 month period) + Topical application of fluoride (including prophylaxis) â&#x20AC;&#x201C; child (first 2 services in any 12 month period) + Topical application of fluoride (prophylaxis not included) â&#x20AC;&#x201C; child (first 2 services in any 12 month period) + Topical application of fluoride (prophylaxis not included) â&#x20AC;&#x201C; child (each additional service in same 12 month period) + Nutritional counseling for control of dental disease Oral hygiene instruction Sealant - per tooth - molars only Sealant - per tooth - non-molars only Space maintainer - fixed - unilateral Space maintainer - fixed - bilateral Recementation of space maintainer Restorative Amalgam - one surface - primary Amalgam - two surfaces - primary Amalgam - three surfaces - primary Amalgam - four or more surfaces - primary Amalgam - one surface - permanent Amalgam - two surfaces - permanent Amalgam - three surfaces - permanent Amalgam - four or more surfaces - permanent Silicate cement - per restoration Resin/composite - one surface, anterior Resin/composite - two surfaces, anterior Resin/composite - three surfaces, anterior Resin/composite - four or more surfaces or incisal angle, anterior Composite resin crown, anterior - primary

Patient Charge No Charge $10.00 No Charge $25.00 No Charge $25.00 No Charge No Charge $5.00 $30.00 $45.00 No Charge $50.00 $5.00 No Charge No Charge No Charge No Charge No Charge No Charge $5.00 No Charge No Charge $60.00 No Charge No Charge $20.00 No Charge No Charge $10.00 $35.00 $65.00 $110.00 $15.00 $10.00 $10.00 $15.00 $15.00 $8.00 $12.00 $14.00 $17.00 $15.00 $20.00 $25.00 $30.00 $45.00 $45.00

MDG Codes++

Covered Services

Restorative (cont.) Resin/composite - one surface, posterior - primary Resin/composite - two surfaces, posterior - primary Resin/composite - three or more surfaces, posterior 2382 primary Resin/composite - one surface, posterior - permanent 2385 Resin/composite - two surfaces, posterior - permanent 2386 Resin/composite - three or more surfaces, posterior 2387 permanent Inlay - metallic - one surface ^ ** 2510 Inlay - metallic - two surfaces ^ ** 2520 Inlay - metallic - three or more surfaces ^ ** 2530 Onlay - metallic - three surfaces ^ ** 2543 Onlay - metallic - four or more surfaces ^ ** 2544 Crown - porcelain/ceramic substrate ^ 2740 Crown - porcelain fused to high noble metal ^ ** 2750 Crown - porcelain fused to predominantly base metal ^ 2751 Crown - porcelain fused to noble metal ^ 2752 Crown - full cast high noble metal ^ ** 2790 Crown - full cast predominantly base metal ^ 2791 Crown - full cast noble metal ^ 2792 Crown - 3/4 cast metallic ^ ** 2810 Crown supporting existing partial denture, in addition 2999 to crown Dental lab service - per inlay, onlay, crown or bridge 6199 unit Pontic - cast high noble metal ^ ** 6210 Pontic - cast metal predominantly base metal ^ 6211 Pontic - cast noble metal ^ 6212 Pontic - porcelain fused to high noble metal ^ ** 6240 Pontic - porcelain fused to predominantly base metal ^ 6241 Pontic - porcelain fused to noble metal ^ 6242 Inlay - abutment - metallic - two surfaces ^ ** 6520 Inlay - abutment - metallic - three or more surfaces ^ ** 6530 Onlay - abutment - metallic - three surfaces ^ ** 6543 Onlay - abutment - metallic - four or more surfaces ^ ** 6544 Crown - abutment - porcelain fused to high noble metal 6750 ^ ** Crown - abutment - porcelain fused to predominantly 6751 base metal ^ Crown - abutment - porcelain fused to noble metal ^ 6752 Crown - abutment - 3/4 cast metallic ^ ** 6780 Crown - abutment - full cast high noble metal ^ ** 6790 Crown - abutment - full cast predominantly base metal 6791 ^ Crown - abutment - full cast noble metal ^ 6792 Multiple crown and bridge unit treatment plan - per 6999 unit Other Restorative Services Recement inlay 2910 Recement crown 2920 Prefabricated stainless steel crown 2930 Prefabricated stainless steel crown - permanent tooth 2931 Prefabricated resin crown 2932 Sedative filling 2940 Core buildup, including any pins 2950 Pin retention - per tooth, in addition to restoration 2951 Cast post & core 2952 Prefabricated post & core 2954 Labial veneer (laminate) - chairside 2960 Recement bridge 6930 Cast post & core, in addition to abutment 6970 Prefabricated post & core, in addition to abutment 6972 Core buildup for abutment, including any pins 6973 Endodontics 3110/3120 Pulp cap Therapeutic pulpotomy 3220 Root canal - anterior 3310 Root canal - bicuspid 3320 Root canal - molar 3330 3346 Root canal - retreatment - anterior 2380 2381

Patient Charge $30.00 $35.00 $40.00 $35.00 $50.00 $70.00 $180.00 $235.00 $235.00 $250.00 $260.00 $250.00 $230.00 $230.00 $250.00 $230.00 $230.00 $250.00 $240.00 $125.00 $75.00 $230.00 $230.00 $250.00 $230.00 $230.00 $250.00 $260.00 $265.00 $275.00 $290.00 $230.00 $230.00 $250.00 $230.00 $230.00 $230.00 $250.00 $125.00 $20.00 $20.00 $60.00 $60.00 $90.00 $15.00 $50.00 $15.00 $95.00 $85.00 $235.00 $15.00 $95.00 $85.00 $55.00 $10.00 $30.00 $95.00 $160.00 $170.00 $310.00

Guardian Dental DHMO Managed DentalGuard Plan Schedule 35-M Orthodontic Plan Schedule 1 MDG Codes++ 3347 3348 3410 3421 3425 3426 3430 4210 4211 4220 4240 4249 4260 4270 4271 4341 4355 4910 4920 4999 9951 5110/5120 5130/5140

5211/5212 5213/5214 5410/11/21/22 5510/5610 5520/5640 5630 5650 5660 5710/11/20/21 5730/31/40/41 5750/51/60/61 5820/5821 5850/5851 5899 5999

Covered Services Endodontics (cont.) Root canal - retreatment - bicuspid Root canal - retreatment - molar Apicoectomy/periradicular surgery – anterior Apicoectomy/periradicular surgery - bicuspid - first root Apicoectomy/periradicular surgery - molar - first root Apicoectomy/periradicular surgery - each additional root Retrograde filling - per root Periodontics Gingivectomy or gingivoplasty - per quadrant Gingivectomy or gingivoplasty - per tooth Gingival curettage, surgical - per quadrant - by report Gingival flap procedure-including root planing - per quadrant Clinical crown lengthening - hard tissue Osseous surgery - including flap entry, closure - per quadrant - five to eight teeth Pedicle soft tissue graft procedure Free soft tissue graft procedure (including donor site surgery) Periodontal scaling & root planing - per quadrant Full mouth debridement to enable evaluation & diagnosis Periodontal maintenance procedures (following active therapy) Unscheduled dressing change (by other than treating dentist) Osseous surgery - including flap entry, closure - per quadrant - one to four teeth Occlusal adjustment - limited - per visit Prosthodontics (Removable) Complete denture (including routine post delivery care) ^ ^ Immediate denture (including routine post delivery care) ^ ^ Partial dentures (including routine post delivery care): Resin base - including clasps, rests, teeth ^ ^ Cast metal framework with resin base - including clasps, rests, teeth ^ ^ Repairs & adjustments: Denture adjustments Repair denture base ^ ^ ^ Replace missing or broken teeth - per tooth ^ ^ ^ Repair or replace clasp ^ ^ ^ Add tooth to existing partial ^ ^ ^ Add clasp to existing partial ^ ^ ^ Rebase denture ^ ^ ^ Reline denture (chairside) Reline denture (laboratory) ^ ^ ^ Interim partial denture (stayplate) Tissue conditioning Dental lab service - each new complete, immediate, or partial denture Dental lab service - denture repair, rebase or reline per denture

Patient Charge $370.00 $445.00 $135.00 $145.00 $155.00 $80.00 $35.00 $80.00 $25.00 $45.00 $190.00 $170.00 $255.00 $185.00 $205.00 $30.00 $35.00 $30.00 $25.00 $155.00 $20.00 $345.00 $345.00

$310.00 $355.00 $20.00 $45.00 $35.00 $60.00 $45.00 $45.00 $125.00 $65.00 $120.00 $95.00 $30.00 $165.00 $35.00

MDG Codes++

Covered Services

Oral Surgery Extraction - single tooth Extraction - each additional tooth Root removal - exposed roots Surgical removal of erupted tooth Removal of impacted tooth - soft tissue Removal of impacted tooth - partially bony Removal of impacted tooth - completely bony Removal of impacted tooth - completely 7241 bony, with unusual surgical complications Surgical removal of residual tooth roots 7250 (cutting procedure) Tooth reimplantation and/or stabilization of 7270 accidentally evulsed tooth Surgical exposure of impacted or unerupted 7280 tooth for orthodontic reasons Surgical exposure of impacted or unerupted 7281 tooth to aid eruption 7285 Biopsy of oral tissue - hard 7286 Biopsy of oral tissue - soft Alveoplasty in conjunction with extractions 7310 per quadrant Alveoplasty not in conjunction with 7320 extractions - per quadrant Removal of odontogenic cyst/tumor - up to 7450 1.25cm Removal of odontogenic cyst/tumor - over 7451 1.25cm 7470 Removal of exostosis - maxilla or mandible 7510 Incision & drainage of intraoral abscess 7960 Frenulectomy (separate procedure) Orthodontic Treatment (covers 24 months active treatment) Comprehensive orthodontic treatment, including fabrication and insertion of fixed banding appliance and periodic visits, up to 24 8070/8080/8090 months; dependent child to age 18 (as determined by the Member’s age on the date of banding) 7110 7120 7130 7210 7220 7230 7240

Comprehensive orthodontic treatment, including fabrication and insertion of fixed banding appliance and periodic visits, up to 24 8070/8080/8090 months; employee, spouse, or dependent child over age 18 (as determined by the Member’s age on the date of banding) 8660 Orthodontic evaluation and consultation Periodic comprehensive orthodontic 8670 treatment visit 8680 Orthodontic retention Orthodontic treatment plan and records, 8999 including x-rays, study model Miscellaneous Services 9110 Palliative (emergency) treatment - per visit 9215 Local anesthesia External bleaching - per arch - take home 9972 bleaching only

Patient Charge $8.00 $9.00 $25.00 $30.00 $50.00 $70.00 $80.00 $90.00 $40.00 $90.00 $130.00 $90.00 $70.00 $65.00 $50.00 $70.00 $85.00 $160.00 $125.00 $40.00 $95.00

$2,285.00

$100.00 No Charge $415.00 $150.00 $15.00 No Charge $165.00

++ Covered Services are subject to exclusions, limitations and Plan provisions. Other codes may be used to describe Covered Services. + The patient charges for codes 1110, 1120, 1201 and 1203 are limited to the first two services in any 12 month period. For each additional service in the same 12 month period, see codes 1204 and 1999 for the applicable patient charge ^ There is an additional dental lab service patient charge for these procedures. See code 6199 for the applicable patient charge. ^ ^ There is an additional dental lab service patient charge for these procedures. See code 5899 for the applicable patient charge. ^ ^ ^ There is an additional dental lab service patient charge for these procedures. See code 5999 for the applicable patient charge. ** If high noble metal is used, there may be an additional patient charge for the actual cost of the high noble metal. The total patient charge for high noble metal plus the applicable dental lab service charge may not exceed the general dentist’s actual lab •Plan Schedule 35-M is only valid for Covered Services rendered by Participating Dentists in the State of Texas. ••Orthodontic Plan Schedule 1 is only valid for Authorized Services rendered by Participating Orthodontic Specialty Care Dentists in the State of Texas.

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

In-Network

Out-of-Network

Exam Covered in full Up to $35 retail Frames $125 retail allowance Up to $70 retail Contact Lenses1 $150 retail allowance Up to $80 retail Medically Necessary Covered in full Up to $150 retail Contact Lenses Lasik Vision $200 allowance2 Correction

Lenses (standard) per pair Single Vision Bifocal Trifocal Progressive Lenticular

Monthly Premiums Emp. Only

$8.86

Emp. + Spouse

$15.09

Emp. + Child(ren)

$15.97

Emp. + Family

$23.95

Co-Pays Covered in full Covered in full Covered in full See description3 Covered in full

Up to $25 retail Up to $40 retail Up to $45 retail Up to $45 retail Up to $80 retail

Exam

$10

Materials

$10

Services/Frequency

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

Exam

12 months

Frame

12 months

Lenses

12 months

Contact Lenses

12 months

Covered to provider’s in-office standard retail lined trifocal amount; member pays difference between progressive and standard retail lined trifocal, plus applicable co-pay 2 Lasik Vision Correction is in lieu of eyewear benefit, subject to routine regulatory filings and certain exclusions and limitations. ₃ Covered to provider’s in-office standard retail lined trifocal amount; member pays difference between progressive and standard retail lined trifocal, plus applicable co-pay

(Based on date of service)

Discount Features Non-Covered Eyewear Discount: Members may also receive a discount of 20% from a participating provider’s usual and customary fees for eyewear purchases which exceed the benefit coverage (except disposable contact lenses, for which no discount applies). This includes eyeglass frames which exceed the selected benefit coverage, specialty lenses (i.e. progressives) and lens “extras” such as tints and coatings. Eyewear purchased from a Walmart Vision Center does not qualify for this additional discount because of Walmart’s “Always Low Prices” policy.

SuperiorVision.com Customer Service 800.507.3800

The Plan discount features are not insurance. 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 39

CIGNA 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.

Educator Disability Disability Insurance For Educators Employee-Paid Eligibility

Eligibility Waiting Period

Monthly Benefit Elimination Period

Benefit Duration

If you are an active employee who works at least 17.5 hours per week, you are eligible on the first of the month coincident with or next following the date of hire of actively at work. Select from Six Options: Accident/Sickness 0 days/7 days* 14 days/14 days* 30 days/30 days* 60 days/60 days 90 days/90 days 180 days/180 days Flat dollar benefit in $100 increments between $200 and $7,500 that cannot exceed Benefit Amount 66 2/3% of your current monthly earnings Maximum $7,500 per month You must be continuously Disabled for your elected benefit waiting period before benefits will be payable for a covered Disability. Once you qualify for benefits under this plan, you continue to receive them until the end of the benefit or until you no longer qualify for benefits, whichever occurs first. Should you remain Disabled, your benefits continue according to one of the following schedules, depending on your age at the time you become Disabled and the plan you select.

Select Plan—Maximum Benefit Period Schedule Age at Disability

Prior to age 65

Age 65 through 68

Age 69 and over

24 months

To age 70, but not less than 12 months

12 months

Duration of Payments (Accident and Sickness)

Premium Plan—Maximum Benefit Period Schedule Age at Disability Duration of Payments (Accident and Sickness)

Prior to age 63 To age 65 or 48 months, whichever is greater

63 To age 65 or 42 months, whichever is greater

69+

36 months

30 months

27 months

24 months

18 months

Definition of Disability

Covered Earnings

“Disability” or “Disabled” means that, solely because of a covered injury or sickness, you are unable to perform the material duties of your regular occupation and you are unable to earn 80% or more of your indexed earnings from working in your regular occupation. After benefits have been payable for 24 months, you are considered disabled if solely due to your injury or sickness, you are unable to perform the material duties of any occupation for which you are (or may reasonably become) qualified by education, training or experience, and you are unable to earn 80% or more of your indexed earnings. We will require proof of earnings and continued disability.

“Covered Earnings” means your wages or salary, not including bonuses, commissions, and other extra compensation.

When Coverage Takes Effect Your coverage takes effect on the later of the policy’s effective date, the date you become eligible, the date we receive your completed enrollment form, or the date you authorize any necessary payroll deductions. If you’re not actively at work on the date your coverage would otherwise take effect, your coverage will take effect on the date you return to work. If you have to submit evidence of good health, your coverage takes effect on the date we agree, in writing, to cover you.

Educator Disability Effects of Other Income Benefits

Termination of Disability Benefits

This plan is structured to prevent your total benefits and postdisability earnings from equaling or exceeding pre-disability earnings. Therefore, we reduce this plan’s benefits by Other Income Benefits payable to you, your dependents, or a qualified third party on behalf of you or your dependents. Disability benefits maybe reduced by amounts received through Social Security disability benefits payable to you, your dependents, or a qualified third party on behalf of you or your dependents. Your disability benefits will not be reduced by any Social Security disability benefits you are not receiving as long as you cooperate fully in efforts to obtain them and agree to repay any overpayment when and if you do receive them. Disability benefits will also be reduced by amounts received through other government programs, sick leave, employer’s sabbatical leave, employer’s assault leave plan, employer funded retirement benefits, workers’ compensation, franchise/group insurance, auto no-fault, and damages for wage loss. For details, see your outline of coverage, policy certificate, or your employer’s summary plan description. Note: Some of the Other Income Benefits, as defined in the group policy, will not be considered until after disability benefits are payable for 12 months.

Your benefits will terminate when your Disability ceases, when your benefit duration period is exceeded, or on the following events: (1) the date you earn from any occupation more than 80% of your Covered Earnings, or the date you fail to cooperate with us in a rehabilitation plan, or transitional work arrangement, or the administration of the claim.

Earnings While Disabled During the first 24 months that benefits are payable, benefits will be reduced if benefits plus income from employment exceeds 100% of pre-disability Covered Earnings. After that, benefits will be reduced by 50% of earnings from employment.

Limited Benefit Period Disabilities caused by or contributed to by any one or more of the following conditions are subject to a lifetime limit of 24 months for outpatient treatment: Anxiety-disorders, delusional (paranoid) or depressive disorders, eating disorders, mental illness, somatoform disorders (including psychosomatic illnesses) ,alcoholism, drug addiction or abuse. Benefits are payable during periods of hospital confinement for these conditions for hospitalizations lasting more than 14 consecutive days that occur before the 24-month lifetime outpatient limit is exhausted.

Pre-existing Condition Limitation Benefits are not payable for medical conditions for which you incurred expenses, took prescription drugs, received medical treatment, care or services (including diagnostic measures,) during the 3 months just prior to the most recent effective date of insurance. Benefits are not payable for any disability resulting from a pre-existing condition unless the disability occurs after you have been insured under this plan for at least 12 months after your most recent effective date of insurance.

Rehabilitation Requirement To be eligible for Disability benefits under this plan, you may be required to participate in a rehabilitation plan at the sole discretion and expense of the insurance company or company administering benefits under this plan. If you fail to fully cooperate with the rehabilitation plan, no Disability benefits will be paid, and coverage will end. For details, see your Certificate of Insurance.

Exclusions This plan does not pay benefits for a Disability which results, directly or indirectly, from any of the following:  Suicide, attempted suicide, or intentionally self-inflicted injury while sane or insane.  war or any act of war, whether or not declared.  active participation in a riot;  commission of a felony;  the revocation, restriction or non-renewal of an Employee’s license, permit or certification necessary to perform the duties of his or her occupation unless due solely to Injury or Sickness otherwise covered by the Policy.  any cosmetic surgery or surgical procedure that is not Medically Necessary.  an Injury or Sickness for which the Employee is entitled to benefits from Workers’ Compensation or occupational disease law.  an Injury or Sickness that is work related. In addition, the plan does not pay disability benefits any period of Disability during which you are incarcerated in a penal or corrections institution.

Educator Disability Premium Plan

Select Plan

Max. Option 1 Option 2 Option 3 Option 4 Option 5 Option 6 Option 1 Option 2 Option 3 Option 4 Option 5 Option 6 Select Select Select Select Select Benefit % 66.67% Premium Premium Premium Premium Premium Premium Select Elimination Period: Injury (Days) 0 14 30 60 90 180 0 14 30 60 90 180 Sickness (Days) 7 14 30 60 90 180 7 14 30 60 90 180 Gross Max. Annual Monthly Premium Plan Monthly Cost Select Plan Monthly Cost Salary Benefit $3,600 $5,400 $7,200 $9,000 $10,800 $12,600 $14,400 $16,200 $18,000 $19,800 $21,600 $23,400 $25,200 $27,000 $28,800 $30,600 $32,400 $34,200 $36,000 $37,800 $39,600 $41,400 $43,200 $45,000 $46,800 $48,600 $50,400 $52,200 $54,000 $55,800 $57,600 $59,400 $61,200 $63,000 $64,800 $66,600 $68,400 $70,200 $72,000 $73,800 $75,600 $77,400 $79,200 $81,000 $82,800 $84,600 $86,400 $88,200 $90,000

$200 $300 $400 $500 $600 $700 $800 $900 $1,000 $1,100 $1,200 $1,300 $1,400 $1,500 $1,600 $1,700 $1,800 $1,900 $2,000 $2,100 $2,200 $2,300 $2,400 $2,500 $2,600 $2,700 $2,800 $2,900 $3,000 $3,100 $3,200 $3,300 $3,400 $3,500 $3,600 $3,700 $3,800 $3,900 $4,000 $4,100 $4,200 $4,300 $4,400 $4,500 $4,600 $4,700 $4,800 $4,900 $5,000

$7.60 $11.40 $15.20 $19.00 $22.80 $26.60 $30.40 $34.20 $38.00 $41.80 $45.60 $49.40 $53.20 $57.00 $60.80 $64.60 $68.40 $72.20 $76.00 $79.80 $83.60 $87.40 $91.20 $95.00 $98.80 $102.60 $106.40 $110.20 $114.00 $117.80 $121.60 $125.40 $129.20 $133.00 $136.80 $140.60 $144.40 $148.20 $152.00 $155.80 $159.60 $163.40 $167.20 $171.00 $174.80 $178.60 $182.40 $186.20 $190.00

$6.44 $9.66 $12.88 $16.10 $19.32 $22.54 $25.76 $28.98 $32.20 $35.42 $38.64 $41.86 $45.08 $48.30 $51.52 $54.74 $57.96 $61.18 $64.40 $67.62 $70.84 $74.06 $77.28 $80.50 $83.72 $86.94 $90.16 $93.38 $96.60 $99.82 $103.04 $106.26 $109.48 $112.70 $115.92 $119.14 $122.36 $125.58 $128.80 $132.02 $135.24 $138.46 $141.68 $144.90 $148.12 $151.34 $154.56 $157.78 $161.00

$5.50 $8.25 $11.00 $13.75 $16.50 $19.25 $22.00 $24.75 $27.50 $30.25 $33.00 $35.75 $38.50 $41.25 $44.00 $46.75 $49.50 $52.25 $55.00 $57.75 $60.50 $63.25 $66.00 $68.75 $71.50 $74.25 $77.00 $79.75 $82.50 $85.25 $88.00 $90.75 $93.50 $96.25 $99.00 $101.75 $104.50 $107.25 $110.00 $112.75 $115.50 $118.25 $121.00 $123.75 $126.50 $129.25 $132.00 $134.75 $137.50

$4.40 $6.60 $8.80 $11.00 $13.20 $15.40 $17.60 $19.80 $22.00 $24.20 $26.40 $28.60 $30.80 $33.00 $35.20 $37.40 $39.60 $41.80 $44.00 $46.20 $48.40 $50.60 $52.80 $55.00 $57.20 $59.40 $61.60 $63.80 $66.00 $68.20 $70.40 $72.60 $74.80 $77.00 $79.20 $81.40 $83.60 $85.80 $88.00 $90.20 $92.40 $94.60 $96.80 $99.00 $101.20 $103.40 $105.60 $107.80 $110.00

$2.50 $3.75 $5.00 $6.25 $7.50 $8.75 $10.00 $11.25 $12.50 $13.75 $15.00 $16.25 $17.50 $18.75 $20.00 $21.25 $22.50 $23.75 $25.00 $26.25 $27.50 $28.75 $30.00 $31.25 $32.50 $33.75 $35.00 $36.25 $37.50 $38.75 $40.00 $41.25 $42.50 $43.75 $45.00 $46.25 $47.50 $48.75 $50.00 $51.25 $52.50 $53.75 $55.00 $56.25 $57.50 $58.75 $60.00 $61.25 $62.50

$1.74 $2.61 $3.48 $4.35 $5.22 $6.09 $6.96 $7.83 $8.70 $9.57 $10.44 $11.31 $12.18 $13.05 $13.92 $14.79 $15.66 $16.53 $17.40 $18.27 $19.14 $20.01 $20.88 $21.75 $22.62 $23.49 $24.36 $25.23 $26.10 $26.97 $27.84 $28.71 $29.58 $30.45 $31.32 $32.19 $33.06 $33.93 $34.80 $35.67 $36.54 $37.41 $38.28 $39.15 $40.02 $40.89 $41.76 $42.63 $43.50

$6.26 $9.39 $12.52 $15.65 $18.78 $21.91 $25.04 $28.17 $31.30 $34.43 $37.56 $40.69 $43.82 $46.95 $50.08 $53.21 $56.34 $59.47 $62.60 $65.73 $68.86 $71.99 $75.12 $78.25 $81.38 $84.51 $87.64 $90.77 $93.90 $97.03 $100.16 $103.29 $106.42 $109.55 $112.68 $115.81 $118.94 $122.07 $125.20 $128.33 $131.46 $134.59 $137.72 $140.85 $143.98 $147.11 $150.24 $153.37 $156.50

$5.08 $7.62 $10.16 $12.70 $15.24 $17.78 $20.32 $22.86 $25.40 $27.94 $30.48 $33.02 $35.56 $38.10 $40.64 $43.18 $45.72 $48.26 $50.80 $53.34 $55.88 $58.42 $60.96 $63.50 $66.04 $68.58 $71.12 $73.66 $76.20 $78.74 $81.28 $83.82 $86.36 $88.90 $91.44 $93.98 $96.52 $99.06 $101.60 $104.14 $106.68 $109.22 $111.76 $114.30 $116.84 $119.38 $121.92 $124.46 $127.00

$3.96 $5.94 $7.92 $9.90 $11.88 $13.86 $15.84 $17.82 $19.80 $21.78 $23.76 $25.74 $27.72 $29.70 $31.68 $33.66 $35.64 $37.62 $39.60 $41.58 $43.56 $45.54 $47.52 $49.50 $51.48 $53.46 $55.44 $57.42 $59.40 $61.38 $63.36 $65.34 $67.32 $69.30 $71.28 $73.26 $75.24 $77.22 $79.20 $81.18 $83.16 $85.14 $87.12 $89.10 $91.08 $93.06 $95.04 $97.02 $99.00

$2.64 $3.96 $5.28 $6.60 $7.92 $9.24 $10.56 $11.88 $13.20 $14.52 $15.84 $17.16 $18.48 $19.80 $21.12 $22.44 $23.76 $25.08 $26.40 $27.72 $29.04 $30.36 $31.68 $33.00 $34.32 $35.64 $36.96 $38.28 $39.60 $40.92 $42.24 $43.56 $44.88 $46.20 $47.52 $48.84 $50.16 $51.48 $52.80 $54.12 $55.44 $56.76 $58.08 $59.40 $60.72 $62.04 $63.36 $64.68 $66.00

$1.36 $2.04 $2.72 $3.40 $4.08 $4.76 $5.44 $6.12 $6.80 $7.48 $8.16 $8.84 $9.52 $10.20 $10.88 $11.56 $12.24 $12.92 $13.60 $14.28 $14.96 $15.64 $16.32 $17.00 $17.68 $18.36 $19.04 $19.72 $20.40 $21.08 $21.76 $22.44 $23.12 $23.80 $24.48 $25.16 $25.84 $26.52 $27.20 $27.88 $28.56 $29.24 $29.92 $30.60 $31.28 $31.96 $32.64 $33.32 $34.00

$0.82 $1.23 $1.64 $2.05 $2.46 $2.87 $3.28 $3.69 $4.10 $4.51 $4.92 $5.33 $5.74 $6.15 $6.56 $6.97 $7.38 $7.79 $8.20 $8.61 $9.02 $9.43 $9.84 $10.25 $10.66 $11.07 $11.48 $11.89 $12.30 $12.71 $13.12 $13.53 $13.94 $14.35 $14.76 $15.17 $15.58 $15.99 $16.40 $16.81 $17.22 $17.63 $18.04 $18.45 $18.86 $19.27 $19.68 $20.09 $20.50 43

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.

GC3 Limited Benefit Group Cancer Indemnity Insurance ESC Region 11 Benefits Co-op Group

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.

SUMMARY OF BENEFITS Benefits

Level 1 Plan

Level 2 Plan

Radiation Therapy/Chemotherapy/ Immunotherapy Benefit

$500 per calendar month of treatment

$1,500 per calendar month of treatment

Hormone Therapy Benefit

$50 per treatment, up to 12 per calendar year

Surgical Schedule Benefit

$1,600 max per operation; $15 per surgical unit

$4,800 max per operation; $45 per surgical unit

Anesthesia Benefit

25% of the amount paid for covered surgery

Hospital Confinement Benefit

$100 per day 1-90 days; $100 per day, 91+ days in lieu of other benefits

$300 per day 1-90 days; $300 per day, 91+ days in lieu of other benefits

US Government/Charity Hospital/HMO

$100 per day in lieu of most other benefits

$300 per day in lieu of most other benefits

Outpatient Hospital or Ambulatory Surgical Center Benefit

$200 per day of surgery

$600 per day of surgery

Drugs & Medicine Benefit - Inpatient

$150 per confinement

Drugs & Medicine Benefit - Outpatient

$50 per prescription, up to $50 per cal month

$50 per prescription, up to $150 per cal month

Transportation & Outpatient Lodging Benefit

$0.50 per mile per round trip $100 per day, up to 100 days per calendar year

Family Member Transportation & Lodging Benefit

$0.50 per mile per round trip $100 per day, up to 100 days per calendar year

Blood, Plasma & Platelets Benefit

$150 per day, up to $7,500 per calendar year

$250 per day, up to $12,500 per calendar year

Bone Marrow/Stem Cell Transplant

Autologous - $500 per calendar year Non-Autologous - $1,500 per calendar year

Autologous - $1,500 per calendar year Non-Autologous - $4,500 per calendar year

Experimental Treatment Benefit

Pays as any non-experimental benefit

Attending Physician Benefit

$30 per day of confinement

$50 per day of confinement

Surgical Prosthesis Benefit

$1,000 per device (includes surgical fee); max 1 device per site, 2 lifetime max

$3,000 per device (includes surgical fee); max 1 device per site, 2 lifetime max

Hair Prosthesis Benefit

$50 per hair prosthetic, 2 lifetime max

Dread Disease Benefit

$100 per day, 1-90 days of hospital confinement

$300 per day, 1-90 days of hospital confinement

Hospice Care Benefit

$50 per day, $9,000 lifetime max

$100 per day, $18,000 lifetime max

Inpatient Special Nursing Services

$150 per day of confinement

Ambulance Ground Benefit

$200 per ground trip

Ambulance Air Benefit

$2,000 per air trip; up to 2 trips per hospital confinement (any combination of ground/air)

Extended Care Benefit

$100 per day

$300 per day

Home Health Care Benefit

$100 per day

$300 per day

Second & Third Surgical Opinions

$300 per diagnosis; additional $300 if third opinion required

Waiver of Premium

Premium waived after 90 days of primary insured continuous total disability due to cancer

Physical/Speech Therapy Benefit

$25 per visit, up to 4 visits per calendar month, $1,000 lifetime max

Diagnostic Testing Benefit Rider

$50; 1 person, per calendar year

Critical Illness Rider: Heart Attack/Stroke

$2,500 lump sum benefit

$600 up to a max of 30 days per confinement

Riders

Optional Benefit Rider Intensive Care Unit Rider

APSB-22356(TX) MGM/FBS ESC Region 11 Benefits Co-op

GC3 Limited Benefit Group Cancer Indemnity Insurance Monthly Premium

Level 1

Level 1 + ICU Rider

Level 2

Level 2 + ICU Rider

Individual

$16.30

$19.60

$32.40

$35.70

One-Parent Family

$22.80

$27.30

$44.60

$49.10

Two-Parent Family

$29.00

$35.90

$56.60

$63.50

*Premium and amount of benefits provided vary dependent upon the level selected at time of application.

Eligibility

Diagnostic Testing Benefit Rider

If You are working either under contract to or as a Full-Time Employee for the Policyholder, or You are a member in or employed by the association, You are eligible for insurance provided You qualify for coverage as defined in the Master Application. You must apply for insurance within thirty (30) days of the Policy Effective Date or the date that You become eligible for coverage. If You do not apply within thirty (30) days of the Policy Effective Date or the date You become eligible for coverage, You may be subject to additional underwriting by Us.

Critical Illness Rider

This policy/certificate will be issued only to those persons who meet American Public Life Insurance Company’s insurability requirements. The policy/certificate and the Internal Cancer coverage under the Critical Illness Rider will not be issued to anyone who has been diagnosed or treated for Cancer in the previous ten years. The Heart Attack or Stroke coverage under the Critical Illness Rider will not be issued to anyone who has been diagnosed or treated for any heart or stroke related conditions. The Hospital Intensive Care Unit Rider will not cover heart conditions for a period of two years following the Effective Date of coverage for anyone who has been diagnosed or treated for any heart related condition prior to the 30th day following the Covered Person’s Effective Date of coverage.

Base Policy

All diagnosis of cancer must be positively diagnosed by a legally licensed doctor of medicine certified by the American Board of Pathology or American Board of Osteopathic Pathology. This 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. This policy/certificate also covers other conditions or diseases directly caused by cancer or the treatment of cancer. No benefits are payable for any covered person for any loss incurred during the first year of this policy/certificate as a result of a Pre-Existing Condition. A PreExisting Condition is a specified disease for which, within 12 months prior to the covered person’s effective date of coverage, medical advice, consultation or treatment, including prescribed medications, was recommended by or received from a member of the medical profession, or for which symptoms manifested in such a manner as would cause an ordinarily prudent person to seek diagnosis, medical advice or treatment. Pre-Existing Conditions specifically named or described as excluded in any part of this contract are never covered. This policy/certificate contains a 30-day waiting period during which no benefits will be paid under this policy/certificate. If any covered person has a specified disease diagnosed before the end of the 30-day 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 effective date of such person’s coverage. If any covered person is diagnosed as having a specified disease during the 30-day period immediately following the effective date, you may elect to void the policy/certificate from the beginning and receive a full refund of premium. All benefits payable only up to the maximum amount listed in the schedule of benefits in the policy/certificate. A Hospital is not an institution which is primarily a place for alcoholics or drug addicts; the aged; a nursing, rest or convalescent nursing home; a mental institution or sanitarium; a facility contracted for or operated by the United States Government for treatment of members or ex-members of the armed forces (unless You are legally required to pay for services rendered in the absence of insurance); or, a long-term nursing unit or geriatrics ward.

APSB-22356(TX) 46

MGM/FBS ESC Region 11 Benefits Co-op

We will pay the indemnity amount for one generally medically recognized internal cancer screening test per covered person per calendar year. Screening test include, but limited to: mammogram; breast ultrasound; breast thermography; breast cancer blood test (CA15-3); colon cancer blood test (CEA); prostate-specific antigen blood test (PSA); flexible sigmoidoscopy; colonoscopy; virtual colonoscopy; ovarian cancer blood test (CA-125); pap smear (lab test required); chest x-ray; hemocult stool specimen; serum protein electrophoresis (blood test for myeloma); thin prep pap test. Screening tests payable under this benefit will only be paid under this benefit. Benefits will only be paid for tests performed after the 30-day period following the covered person’s effective date of coverage.

Benefits will only be paid for a covered critical illness as shown on the policy/ certificate schedule page in the policy. No benefits will be provided for any loss caused by or resulting from: intentionally self-inflicted bodily injury, suicide or attempted suicide, whether sane or insane; or alcoholism or drug addiction; or any act of war, declared or undeclared , or any act related to war; or military service for any country at war; or a pre-existing condition; or a covered critical illness when the date of diagnosis occurs during the waiting period; or participation in any activity or event while intoxicated or under the influence of any narcotic unless administered by a physician or taken according to the physician’s instructions; or participation in, or attempting to participate in a felony, riot or insurrection (a felony is as defined by the law of the jurisdiction in which the activity takes place). Internal cancer does not include: other conditions that may be considered pre-cancerous or having malignant potential such as: acquired immune deficiency syndrome (AIDS); or actinic keratosis; or myelodysplastic and non-malignant myeloproliferative disorders; or aplastic anemia; or atypia; or non-malignant monoclonal gamopathy; or Leukoplakia; or Hyperplasia; or Carcinold; or Polycythemia; or carcinoma in situ or any skin cancer other than invasive malignant melanoma into the dermis or deeper. For a pre-existing condition no benefits are payable.

Hospital Intensive Care Unit Rider

No benefits will be provided during the first two years of this rider for hospital intensive care unit confinement caused by any heart condition when any heart condition was diagnosed or treated prior to the 30th day following the covered person’s effective date of this rider. The heart condition causing the confinement need not be the same condition diagnosed or treated prior to the effective date. No benefits will be provided if the loss results from: attempted suicide, whether sane or insane; or intentional self-injury; or alcoholism or drug addiction; or any act of war, declared or undeclared, or any act related to war; or military service for a country at war. No benefits will be paid for confinements in units such as surgical recovery rooms, progressive care, burn units, intermediate care, private monitored rooms, observation units, telemetry units or psychiatric units not involving intensive medical care; or other facilities which do not meet the standards for intensive care unit as defined in the rider. For a newborn child born within the tenmonth period following the effective date of this rider, no benefits will be provided for hospital intensive care unit confinement that begins within the first 30 days following the birth of such child.

GC3 Limited Benefit Group Cancer Indemnity Insurance Conditionally Renewable

This policy/certificate is conditionally renewable. This means that We have the right to terminate your policy/certificate on any premium due date after the first Policyholder’s Anniversary Date. We must give the Policyholder at least 60 days written notice prior to cancellation. We cannot cancel Your coverage because of a change in Your age or health. We can change Your premiums if We change premiums for all similar Certificates issued to the Policyholder. We must give the Policyholder at least 60 days written notice before We change Your premiums.

Continuation Rider Continuation

Coverage is continued when the Insured (You) cease employment with the employer through whom You originally became insured under the Policy. You will have the option to continue this Certificate (including any Riders, if applicable) by paying the premiums directly to Us at Our home office. Premiums must be paid within thirty-one (31) days after employment with your employer terminates. Premium rates required under this Continuation provision will be the same rates as those charged under the Employer’s Policy as if You had continued employment. We will bill You for these premiums after You notify Us to continue this coverage. Coverage will continue until the earlier of: (1) the Policy under which You originally became insured ends; or (2) You stop paying premiums under this option (subject to the terms of the Grace Period).

Termination of Coverage

Your Insurance coverage will end on the earliest of these dates: (a) the date You no longer qualify as an Insured; (b) the last day of the period for which a premium has been paid, subject to the Grace Period; (c) the date the Policy terminates (See Conversion provision); (d) the date You retire; (e) the date You cease employment, or terminate Your contract with the employer through whom You originally became insured under the Policy (See Conversion provision); or (f) the date We receive Your written request for termination. Termination of Dependent(s) Insurance coverage on Your Dependent(s) will end on the earliest of these dates: (a) the date the coverage under the Certificate terminates; (b) the date the Dependent no longer meets the definition of Dependent, as defined in the Policy/Certificate (See Conversion provision); (c) the date We receive Your written request for termination.

Termination of Rider Coverage

This rider terminates: (a) when Your coverage terminates under the Policy/ Certificate to which this Rider is attached; or, (b) when any premium for this rider is not paid before the end of the Grace Period; or, (c) when You give Us a written request to do so. Coverage on a Dependent terminates under this rider when such person ceases to meet the definition of Dependent, as defined in the Policy.

Conversion

If the Employer’s Policy is terminated, this Certificate will terminate. Upon termination of the Employer’s Policy, the employee (You) will be entitled to convert to an individual policy of insurance issued by Us without evidence of insurability provided the required premiums have been paid on your behalf and You notified Us in writing within thirty-one (31) days of the Employer’s Policy termination. Premiums for the individual policy of insurance will be figured from the premium rate table in effect on the date of conversion. Subject to the terms of this provision, a covered child who ceases to be eligible may convert to an individual policy of insurance and a covered spouse who ceases to be eligible for coverage because of divorce or annulment may convert to an individual policy. Terms of this provision include: (1) Application for the individual policy and payment of the first premium must be made within 60 days after coverage ceases under the Policy/Certificate. Premiums will be figured from the premium rate table in effect on the date of conversion. (2) The individual policy will be issued without proof of insurability. It will provide benefits that most nearly approximates those of the Policy/Certificate. (3) The individual policy will take effect the day after coverage ceases under the Policy/Certificate. However, no benefits will be payable under the individual policy for any loss for which benefits are payable under the Policy/Certificate. (4) The Pre-Existing Condition Limitation and Time Limit on Certain Defenses provisions for the individual policy will be figured from the Covered Person’s Effective Date of coverage under the Policy/ Certificate. (5) Any benefit maximums will be figured from the Effective Date of the Policy/Certificate. This rider is subject to all the provisions of the Policy and Certificate to which it is attached that are not in conflict with this rider.

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. | Policy Form GC-3 Series | Texas | Limited Benefit Group Cancer Indemnity Insurance Policy | (11/14) | ESC Region 11 Benefits Co-op

APSB-22356(TX) MGM/FBS ESC Region 11 Benefits Co-op

LOYAL AMERICAN 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 Monthly Premiums Available for Issue Ages 18-64 Employee Only

$12.70

Employee + Spouse

$19.50

Employee + Child(ren)

$20.40

Employee + Family

$27.20

Plan pays benefit amounts for covered medical expenses as a result of an accident, directly to you! Coverage is available for ages 18-64 and is portable, you can choose to keep your benefit even if you leave the district or retire. This policy does not pay for losses resulting from sickness, only accident. Always refer to your policy for detailed terms and conditions. This policy is guaranteed renewable.

Summary of Benefits

Plan Pays

Ambulance Ground Ambulance Benefit: Loyal American will pay this benefit if you require transportation by a licensed professional ambulance company to or from a hospital or between medical facilities within 90 days for injuries sustained after a covered accident. Payable once per accident. Air Ambulance Benefit: Loyal American will pay this benefit if you require transportation by a license professional air ambulance company to or from a hospital or between medical facilities within 48 hours for injuries sustained after a covered accident. Payable once per accident.

$150

$600

Indemnity Benefits Emergency Room Treatment Benefit: Loyal American will pay this benefit if you received hospital emergency Insured/Spouse: room treatment within 72 hours of injuries sustained in a covered accident and for which charges are $150 submitted. Child: $75 Accident Follow-Up Treatment Benefit: Loyal American will pay this benefit for three additional treatments of injuries sustained in a covered accident over and above emergency treatment administered during the first $50 72 hours following the accident. Treatment must begin within 30 days of the covered accident and must be per visit within the 6 month period following the covered accident. Blood, Plasma, Platelets Benefit: Loyal American will pay this benefit if you require transfusion, administration, cross matching, typing and processing of blood, plasma or platelets when administered within $100 90 days for injuries sustained in a covered accident. Payable once per accident.

Hospital Benefits Initial Accident Hospitalization Benefit: Loyal American will pay this benefit if hospital confinement is required within six (6) months for injuries sustained in a covered accident. Payable once per accident. Hospital Confinement Benefit: Loyal American will pay this benefit for a maximum of 180 days per confinement.* if you require confinement in a hospital or in a hospital intensive care unitâ&#x20AC;&#x201C; sub acute within six (6) months for injuries sustained in a covered accident.

$500 $200 per day

Intensive Care Hospital Intensive Care Unit Confinement Benefit: Loyal American will pay this benefit for a maximum of 15 days per confinement* if you are confined in a hospital intensive care unit within 30 days because of injuries received in a covered accident. *Confinements separated by less than 90 days will be considered as the same period of confinement.

$400 per day

Physical Therapy Physical Therapy Benefit: Loyal American will pay this benefit, not to exceed five treatments per accident, for services prescribed by a doctor and rendered by a licensed physical therapist. Physical therapy must be for $50 per injuries sustained in a covered accident and must start within 60 days after the accident. Treatment must be treatment completed within 6 months after the accident. Prostheses Benefit: Loyal American will pay this benefit if a doctor prescribes the use of a prosthetic device 1 prosthetic due to the loss of a hand, foot or sight of an eye in a covered accident. The prosthetic must be received within device/artificial 1 year of the covered accident. This benefit is payable once per accident and is not payable for hearing aids, limb: $100 dental aids, false teeth or for cosmetic prosthesis (e.g. hair wigs). We will not pay for joint replacement (e.g. More than 1: artificial hip or knee). $500 Appliance Benefit: Loyal American will pay this benefit if a doctor advises you to use a medical appliance as an aid to personal locomotion within 90 days as a result of injuries sustained in a covered accident. Benefits are $50 payable for crutches, wheelchairs, braces, etc. Benefits are payable for crutches and wheelchairs once per accident.

Accident Summary of Benefits

Plan Pays

Family Lodging & Transportation Family Lodging Benefit: Loyal American will pay this benefit for a maximum of 30 days per accident, during the time you are confined in a hospital, for one motel/hotel room for a family member to accompany you if injuries sustained in a covered accident require hospital confinement, and if the hospital and motel/hotel are more than 100 miles from your residence.

$100 per day

Transportation Benefit: Loyal American will pay this benefit for a maximum of three trips per calendar year if you require special treatment and confinement in a hospital located more than 100 miles from your residence or site of the accident for injuries sustained in a covered accident.

$300

Accidental Death Accidental Death* Benefit: This policy will pay the following benefit for death if it is the result of injuries sustained in a covered accident. Death must occur within 90 days of a covered accident. Common-Carrier: You must be a fare paying passenger on a common-carrier. Common-carrier vehicles are limited to commercial airplanes, trains, buses, trolleys, subways, ferries and boats that operate on a regular scheduled basis between predetermined points or cities. Taxies and privately chartered vehicles are not included.

Insured: $100,000 Spouse: $50,000 Child: $15,000

Other Accidents: Other Accidents are those not classified as common-carrier and are not specifically excluded in the limitations and exclusions section of the policy.

Insured: $25,000 Spouse: $10,000 Child: $5,000

Dismemberment Accidental Dismemberment* Benefit This policy will pay a percentage of the Accidental Death-Other Accidents Benefit for the selected plan.

Both arms and both legs

100%

Two arms or legs

50%

Sight of two eyes, hands, or feet

50%

Sight of one eye, hand, foot, arm, or leg

20%

One or more fingers and/or one or more toes

*Death or dismemberment must occur within 90 days of the accident. Only the highest single benefit will be paid for accidental dismemberment.

Accident This is a limited benefit policy. This policy does not pay for losses resulting from sickness. RENEWABILITY CONDITIONS: The policy is guaranteed renewable. Premium rates may be changed on a class basis. A class may be defined by age, sex, occupation, premium payment method, issue state, elimination period, benefit period, etc. WHAT IS NOT COVERED BY THIS POLICY. We will not pay benefits for any injury as a result of you(r):  Operating, learning to operate, serving as a crew member of or jumping or falling from any aircraft. Aircraft includes those which are not motor-driven.  Engaging in hang gliding, bungee jumping, parachuting, sailgliding, parakiting, or hot-air ballooning.  Participating or attempting to participate in an illegal activity.  Riding in or driving any motor-driven vehicle in a race, stunt show, or speed test.  Intentionally causing a self-inflicted injury.  Having any sickness or declining process caused by a sickness, including physical or mental infirmity. We also will not pay benefits to diagnose or treat the sickness. Sickness means any disease or disorder that is not caused by an injury.  Practicing for or participating in any semi-professional or professional competitive athletic contest for which any type of compensation or remuneration is received.  Committing or trying to commit suicide, whether sane or insane.  Being in an accident which occurs more than 40 miles outside the territorial limits of the United States, Canada, Puerto Rico, and Virgin Islands.  Involvement in any period of armed conflict, even if it is not declared. This brochure contains a summary of the Accident Insurance Policy form L-6020. Coverage as described in the brochure is provided only through the issuance of a policy. The policy should be consulted for full terms and conditions of coverage.

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 Basic Group Term Life and AD&D All full time active employees working at least 17.5 hours each week are eligible for Basic Group Life and Accidental Death and Dismemberment (AD&D). Life and AD&D benefits reduce to 65% at age 70; and 50% at age 75. Coverage is equal to the following Option 1 Option Based on Employer Schools

$10,000

Option 2 Option Based on Employer Schools

$30,000

Option 3 Option Based on Employer Schools

$40,000

Your Basic Group Term Life Insurance automatically includes: Life Planning Financial & Legal Resources: This personalized financial counseling service provides expert, objective financial counseling to survivors and terminally ill employees at no cost to you. This service is also extended to you upon the death or terminal illness of your covered spouse. Work/Life Balance Employee Assistance Program: Work‐life balance is a comprehensive resource providing access to professional assistance for a wide range of personal and work‐ related issues.

Worldwide Emergency Travel Assistance Services: Whether your travel is for business or pleasure, our worldwide emergency travel assistance program is there to help you when an unexpected emergency occurs. Waiver of Premium: Life insurance premiums will be waived for insured employees who become disabled prior to a specified age, and who remain disabled during an elimination period. Accelerated Death Benefit: Pays a portion of the insured employee’s or dependent’s Life benefit in the event the insured employee or dependent becomes terminally ill and the employee’s or dependent’s life expectancy has been reduced to less than 12 months. The employee’s or dependent’s death benefit will be reduced by the Accelerated Life Benefit paid. Portability Privilege: Allows an insured employee and their dependents to elect portable coverage at group rates, if the employee terminates employment, reduces hours or retires from the employer. Employees and their dependents are not eligible for portable coverage if they have an injury or sickness, under the terms of this plan, that has a material effect on life expectancy.

Conversion Privilege: When an insured employee’s group coverage ends, employees and their dependents may convert their coverage to individual life policies without providing evidence of insurability. See contract for additional plan and coverage details.

Term Life and AD&D Please read carefully the following description of your Unum Term Life and AD&D insurance plan. Eligibility All employees working at least 17.5 hours each week in active employment in the U.S. with the employer, and their eligible spouses and children to age 26. Coverage Amounts Your Term Life coverage options are: Employee: Up to 7 times salary in increments of $10,000. Not to exceed $500,000. Spouse*: Up to 100% of employee amount in increments of $10,000. Not to exceed $500,000. Benefits will be paid to the employee. Child*: Two options available.  Option 1: $5,000 or  Option 2: $10,000 Not to exceed 100% of employee amount, to a maximum of $10,000. Your AD&D coverage options are: Employee: Up to 7 times salary in increments of $10,000. Not to exceed $500,000. You may purchase AD&D coverage for yourself regardless of whether you purchase Life coverage. Employee and Family: Spouse*: 50% of employee amount, not to exceed $250,000. Benefits will be paid to the employee. Child*: 10% of employee amount, not to exceed $10,000. *Child age is 6 months to 26 years. The maximum death benefit for a child between the ages of live birth and 6 months is $1,000. Benefits will be paid to the employee. In order to purchase AD&D coverage for your spouse and/or child, you must purchase AD&D coverage for yourself.

Life and AD&D AD&D Benefit Schedule:

The full benefit amount is paid for loss of:  Life  Both hands or both feet or sight of both eyes  One hand and one foot  One hand and the sight of one eye  One foot and the sight of one eye  Speech and hearing

wait until the next annual enrollment and only Life insurance coverage over the Guarantee Issue amount(s) will be subject to evidence of insurability. Please see your Plan Administrator for your eligibility date.

How to Apply Current employees: To apply for coverage, complete your enrollment form by the enrollment deadline.

Other losses may be covered as well. Please see your Plan Administrator.

New Hires: To apply for coverage, complete your enrollment form within 31 days of your eligibility date.

Coverage amount(s) will reduce according to the following schedule:

All employees: If you apply for coverage after your effective date, or if you choose coverage over the guarantee issue amount, you will need to complete a medical questionnaire which you can get from your Plan Administrator. You may also be required to take certain medical tests at Unum’s expense.

Age: 70 75

Insurance Amount Reduces to: 65% of original amount 50% of original amount

Coverage may not be increased after a reduction.

Effective Date of Coverage Please see your Plan Administrator for your effective date.

Guarantee Issue Current Employees: If you and your eligible dependents enroll on or before the enrollment deadline, you may apply for any amount of Life insurance coverage up to $230,000 for yourself and any amount of coverage up to $50,000 for your spouse. Any Life insurance coverage over the Guarantee Issue amount (s) will be subject to evidence of insurability. If you and your eligible dependents do not enroll on or before the enrollment deadline, you can apply for coverage only during an annual enrollment period and will be required to furnish evidence of insurability for the entire amount of Life insurance coverage. AD&D coverage does not require evidence of insurability. If you and your eligible dependents enroll on or before the enrollment deadline, and later wish to increase your Life insurance coverage, you may increase your coverage with evidence of insurability at anytime during the year. However, you may wait until the next annual enrollment and only coverage over the Guarantee Issue amount(s) will be subject to evidence of insurability.

Delayed Effective Date of Coverage Employee: Insurance coverage will be delayed if you are not in active employment because of an injury, sickness, temporary layoff, or leave of absence on the date that insurance would otherwise become effective.

Dependent: Insurance coverage will be delayed if that dependent is totally disabled on the date that insurance would otherwise be effective. Exception: infants are insured from live birth. “Totally disabled” means that, as a result of an injury, a sickness or a disorder, your dependent is confined in a hospital or similar institution; is unable to perform two or more activities of daily living (ADLs) because of a physical or mental incapacity resulting from an injury or a sickness; is cognitively impaired; or has a life threatening condition.

Changes to Coverage

New Hires: If you and your eligible dependents enroll within 31 days of your eligibility date, you may apply for any amount of Life insurance coverage up to $230,000 for yourself and any amount of coverage up to $50,000 for your spouse. Any Life insurance coverage over the Guarantee Issue amount(s) will be subject to evidence of insurability. If you and your eligible dependents do not enroll within 31 days of your eligibility date, you can apply for coverage only during an annual enrollment period and will be required to furnish evidence of insurability for the entire amount of coverage. AD&D coverage does not require evidence of insurability.

Each year you and your spouse will be given the opportunity to change your Life coverage and AD&D coverage. You and your spouse may purchase additional Life coverage up to the Guarantee Issue amounts without evidence of insurability if you are already enrolled in the plan. Life coverage over the Guarantee Issue amounts will be medically underwritten and will require evidence of insurability and approval by Unum’s Medical Underwriters. The suicide exclusion will apply to any increase in coverage. AD&D coverage does not require evidence of insurability for increase amounts.

If you and your eligible dependents enroll within 31 days of your eligibility date, and later, wish to increase your coverage, you may increase your Life insurance coverage, with evidence of insurability, at anytime during the year. However, you may

If you should have any questions about your coverage or how to enroll, please contact your Plan Administrator.

Questions

Life and AD&D Monthly Payroll Deduction EMPLOYEE $10,000

$20,000

$30,000

$40,000

$50,000

$70,000

$100,000

$130,000

$150,000

$0.45 $0.45 $0.60 $0.70 $0.80 $1.20 $2.00 $3.30 $5.10 $9.50 $15.50 $20.60

$0.90 $0.90 $1.20 $1.40 $1.60 $2.40 $4.00 $6.60 $10.20 $19.00 $31.00 $41.20

$1.35 $1.35 $1.80 $2.10 $2.40 $3.60 $6.00 $9.90 $15.30 $28.50 $46.50 $61.80

$1.80 $1.80 $2.40 $2.80 $3.20 $4.80 $8.00 $13.20 $20.40 $38.00 $62.00 $82.40

$2.25 $2.25 $3.00 $3.50 $4.00 $6.00 $10.00 $16.50 $25.50 $47.50 $77.50 $103.00

$3.15 $3.15 $4.20 $4.90 $5.60 $8.40 $14.00 $23.10 $35.70 $66.50 $108.50 $144.20

$4.50 $4.50 $6.00 $7.00 $8.00 $12.00 $20.00 $33.00 $51.00 $95.00 $155.00 $206.00

$5.85 $5.85 $7.80 $9.10 $10.40 $15.60 $26.00 $42.90 $66.30 $123.50 $201.50 $267.80

$6.75 $6.75 $9.00 $10.50 $12.00 $18.00 $30.00 $49.50 $76.50 $142.50 $232.50 $309.00

Age Band 0-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75+

$230,000 IS THE MAXIMUM THAT MAY BE ISSUED WITHOUT ANSWERING HEALTH QUESTIONS.

EMPLOYEE ONLY ACCIDENTAL DEATH & DISMEMBERMENT RATES 0-79+

$0.40

$0.80

$1.20

$1.60

$2.00

$10,000

$20,000

$30,000

$40,000

$0.45 $0.45 $0.60 $0.70 $0.80 $1.20 $2.00 $3.30 $5.10 $9.50 $15.50 $20.60

$0.90 $0.90 $1.20 $1.40 $1.60 $2.40 $4.00 $6.60 $10.20 $19.00 $31.00 $41.20

$1.35 $1.35 $1.80 $2.10 $2.40 $3.60 $6.00 $9.90 $15.30 $28.50 $46.50 $61.80

$1.80 $1.80 $2.40 $2.80 $3.20 $4.80 $8.00 $13.20 $20.40 $38.00 $62.00 $82.40

$2.80

$4.00

$5.20

$6.00

$50,000

$70,000

$100,000

$130,000

$150,000

$2.25 $2.25 $3.00 $3.50 $4.00 $6.00 $10.00 $16.50 $25.50 $47.50 $77.50 $103.00

$3.15 $3.15 $4.20 $4.90 $5.60 $8.40 $14.00 $23.10 $35.70 $66.50 $108.50 $144.20

$4.50 $4.50 $6.00 $7.00 $8.00 $12.00 $20.00 $33.00 $51.00 $95.00 $155.00 $206.00

$5.85 $5.85 $7.80 $9.10 $10.40 $15.60 $26.00 $42.90 $66.30 $123.50 $201.50 $267.80

$6.75 $6.75 $9.00 $10.50 $12.00 $18.00 $30.00 $49.50 $76.50 $142.50 $232.50 $309.00

SPOUSE Age Band 0-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75+

$50,000 IS THE MAXIMUM THAT MAY BE ISSUED WITHOUT ANSWERING HEALTH QUESTIONS.

CHILD(REN)* $5,000

$10,000

$0.90

$1.80

*NOTE: The premium paid for child coverage is based on the cost of coverage for one child, regardless of how many children you have.

FAMILY ACCIDENTAL DEATH & DISMEMBERMENT RATES $10,000

$20,000

$30,000

$40,000

$50,000

$70,000

$100,000

$130,000

$150,000

$0.70

$1.40

$2.10

$2.80

$3.50

$4.90

$7.00

$9.10

$10.50

NOTE: FINAL RATES MAY VARY SLIGHTLY DUE TO ROUNDING. THESE GRIDS ARE PRICES OF FREQUENTLY SELECTED AMOUNTS. YOU MAY CHOOSE ANY INCREMENT OF $10,000 UP TO $500,000 (NOT TO EXCEED 5 TIMES YOUR ANNUAL SALARY). TO PURCHASE AN AMOUNT OTHER THAN THOSE LEVELS INDICATED ABOVE, SIMPLY COMPLETE THE FOLLOWING.

x # of 10,000 units

= Your age cost per 10,000 unit

MONTHLY COST

* AGE = AGE ON POLICY ANNIVERSARY 55

ID WATCHDOG

Identity Theft

YOUR BENEFITS PACKAGE

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

DID YOU KNOW?

An identity is stolen every 2 seconds, and takes over

300 hours

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

Identity Theft Identity theft can strike anyone, at any time. More than 11 million Americans were victimized by identity theft in 2011, including more than 500,000 children.

Identity theft devastates its victims financially. The average victim will lose $4,841, and spend an additional $1,400 in out-of-pocket expenses resolving their case.

Repairing the damage caused by identity theft is frustrating and time consuming. The average victim spends 330 hours repairing the damage from identity theftâ&#x20AC;&#x201D;the equivalent of working a full-time job for more than 2 months.

ID Watchdog Dual Monthly Pricing Plus

Platinum

Individual Plan

$7.95

$11.95

Family Plan

$14.95

$22.95

ID Watchdog Services Basic & Advanced Identity Monitoring Cyber Monitoring Full-Service Identity Restoration Non-Credit Loan Monitoring Address Monitoring Credit Report Monitoring 100% Resolution Guarantee

The impact of identity theft follows victims for years. 50% of identity theft victims experience trouble getting loans or credit cards as a result of identity theft. 12% of identity theft victims end up having warrants issued by law enforcement in their name for crimes committed by the identity thief.

Whoâ&#x20AC;&#x2122;s Evaluating your Credit Report? Potential Creditors, Potential Employers, Insurance Companies, Current Creditors, Government Agencies

NOTES