2016 Benefit Guide ETXEBC - Arrow Academy Version by Higginbotham Public Sector

EAST TEXAS EMPLOYEE BENEFITS COOPERATIVE

BENEFIT GUIDE EFFECTIVE: 09/01/2016 - 8/31/2017 www.etxebc.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. Helpful Definitions 6. Health Savings Account (HSA) vs. Flexible Spending Account (FSA) 7. Health Savings Account (HSA) Participation 8. Flexible Spending Account (FSA) Participation TRS-ActiveCare Custom Link Medical Supplement NBS Health Savings Account (HSA) MDLIVE Telehealth Cigna Dental UHC Vision Cigna Long Term Disability Cigna Short Term Disability Loyal American Cancer UNUM Voluntary Life and AD&D 5Star Family Protection Plan Term Life Insurance with Quality of Life Rider UNUM Critical Illness UHC Accident ID Watchdog Identity Theft NBS Flexible Spending Account (FSA) MASA Medical Transport 2

3 4-5 6-13 6 7 8 9 10 11 12 13 14-15 16-17 18-19 20-21 22-25 26-27 28-31 32-33 34-39 40-41

FLIP TO... PG. 4 HOW TO ENROLL

PG. 6 YOUR BENEFIT UPDATES: WHATâ&#x20AC;&#x2122;S NEW

42-45

PG. 14

46-47 48-49 50-51 52-55 56-57

YOUR BENEFITS PACKAGE

Benefit Contact Information

Benefit Contact Information ETXEBC BENEFITS

VISION

ACCIDENT

Financial Benefit Services (800) 583-6908 Call Center (866) 914-5202 www.etxebc.com

Group # 12476 United Healthcare (800) 638-3120 www.myuhcvision.com

United Healthcare (888) 299-2070 www.myuhc.com

MEDICAL

DISABILITY

IDENTITY THEFT

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

Cigna File a Claim: (866) 562-8421 www.mycigna.com

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

MEDICAL SUPPLEMENT

CANCER

FLEXIBLE SPENDING ACCOUNT

Custom Link Special Insurance Services, Inc. (800) 767-6811 www.specialinc.com

Group # 1500 Loyal American (800) 366-8354

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

HEALTH SAVINGS ACCOUNT

LIFE AND AD&D

MEDICAL TRANSPORT

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

UNUM (800) 442-0915 www.unum.com

MASA (800) 423-3226 www.masamts.com

TELEHEALTH

FAMILY PROTECTION PLAN

COBRA

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

5Star Life Insurance Company (866) 863-9753 http://5starlifeinsurance.com

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

DENTAL

CRITICAL ILLNESS

Group # 3335825 Cigna (800) 244-6224 www.mycigna.com

UNUM (800) 583-6908 www.unum.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 the ETXEBC benefits website

Our online benefit enrollment

from your computer, tablet or

platform provides a simple and

smartphone!

easy to navigate process. Enroll at your own pace, whether at home or at work. www.etxebc.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

www.etxebc.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: 

Supplemental Benefit elections will become effective 9/1/2016 (elections requiring evidence of insurability, such as life Insurance, may have a later effective date, if approved). After annual enrollment closes, benefit changes can only be made if you experience a qualifying event (and changes must be made within 30 days of event). Medical annual enrollment is done during the summer for 9/1. For mid year changes, see your benefit administrator within 30 days of status change. For complete TRS medical information, visit the medical websites at www.trsactivecareaetna.com or www.firstcare.com/trs Online Benefit Access: www.etxebc.com You have access to benefit information 24/7 on the employee benefit website provided. You can review and print the consolidated enrollment form or (remove) benefit guide, download claim forms and plan summaries, link to carrier websites and provider searches. Please contact your Benefit Administrator for Group Meeting and Enrollment schedules/campus locations. CHANGE: Flexible Spending Accounts (FSA): Limit increased to $2,550/yr. If you currently participate in a Healthcare or Dependent Care FSA, you MUST re-elect a new contribution amount every year to continue to participate. Employees who currently participate must spend current plan year funds by the grace-period deadline of 4/15/16 to avoid forfeiture. You can view account balance using the CHECK FSA link on the



 



Benefit website or use the NBS smart phone app. Current Healthcare FSA participants, KEEP your FSA debit card! New participants in the Healthcare FSA will receive flex cards in late September/early October. NEW: United Healthcare Accident—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 any health questions. NEW: Masa—Medical Transportation Solutions will be offered through MASA. MASA provides medical emergency transportation solutions and covers your out of pocket medical transport cost when your insurance falls short. MASA does not use a network so you are covered nationwide. NEW: Family Protection-Terminal Illness Plan with Quality of Life Rider from 5Star Life is individual term life insurance protection that pays a lump sum advance benefit on terminal illness diagnosis and pays a monthly benefit if Long Term Care becomes necessary. Can be purchased for spouse, children and grandchildren thru 23. Telehealth: Remember, MDLIVE is a telehealth plan available for $9 if not covered by your employer. This plan has free telephone consultation for diagnosis & treatment for common conditions. Plan covers employee, spouse and all unmarried dependent children under the age of 26.

Login and complete your benefit enrollment from 08/01/2016 - 08/22/2016 Enrollment assistance is available by calling Financial Benefit Services at (866) 914-5202 between 8am – 5pm CST Update your profile information: home address, phone numbers, email, beneficiaries REQUIRED: Provide correct dependent social security numbers

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 30 days of your qualifying event and meet with your Benefit/HR Office to complete and sign the necessary paperwork in order to make a benefit election change. Benefit changes must be consistent with the qualifying event.

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 the ETXEBC

Changes are not permitted during the plan year (outside of

benefit website: www.etxebc.com. Click on your school

annual enrollment) unless a Section 125 qualifying event occurs.

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



Changes, additions or drops may be made only during the

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

benefit website: www.etxebc.com. Click on your school

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 ETXEBC

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 ETXEBC or as both

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

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

Accident

United Healthcare

Through 25

Cancer

Loyal American

Through 24

Critical Illness

UNUM

Through 24

Dental

Cigna

Through 25

Dependent Flex

National Benefit Services

12 or younger or qualified individual unable to care for themselves & claimed as a dependent on your taxes

Healthcare FSA

National Benefit Services

Through 25 or IRS Tax Dependent

Health Savings Account

National Benefit Services

IRS Tax Dependent

Medical

Aetna

Through 25

Telehealth

MDLIVE

Through 25

Vision

United Healthcare

Through 25

Voluntary Life and AD&D

UNUM

Through 25

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 physicianâ&#x20AC;&#x2122;s statement confirming your dependentâ&#x20AC;&#x2122;s disability. Contact your HR/Benefit Administrator to request a continuation of coverage.

Helpful Definitions

SUMMARY PAGES

Actively at Work

In-Network

You are performing your regular occupation for the employer

Doctors, hospitals, optometrists, dentists and other providers

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

who have contracted with the plan as a network provider.

places of business or at some location to which the employer’s business requires you to travel. If you will not be actively at work beginning 2/1/2016 please notify your benefits administrator.

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

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

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

Plan Year September 1st through August 31st

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

Calendar Year January 1st through December 31st

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

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

provisions do apply, as applicable by carrier.

(including diagnostic and/or consultation services).

SUMMARY PAGES

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

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

Description

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

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

$1,300 single (2016) $2,600 family (2016) $3,350 single (2016) $6,750 family (2016) Employees may use funds any way they wish. If used for non-qualified medical expenses, subject to current tax rate plus 20% penalty. Permitted, but subject to current tax rate plus 20% penalty (penalty waived after age 65).

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.

Minimum Deductible Maximum Contribution

Permissible Use Of Funds

N/A Varies per employer Reimbursement for qualified medical expenses (as defined in Sec. 213(d) of IRC). Not permitted

FLIP TO… PG. 18

FLIP TO… PG. 52

FOR HSA INFORMATION

FOR FSA INFORMATION

SUMMARY PAGES

HSA (Health Savings Account)

An HSA is a tax free savings account available to employees enrolled in a high deductible medical plan. The money is tax deductible, and these funds are used to pay for medical expenses. Any funds that are in the account after the employee reaches the age of 65 can be withdrawn for any purpose. See below for a list of participating districts to see if an HSA is available to you. Please keep in mind that if you participate in an HSA that FSAs may be limited or not available. You must be enrolled in the ActiveCare 1HD to participate in an HSA.

PARTICIPATING DISTRICTS

Arrow Academy

Franklin ISD

Madisonville CISD

Blue Ridge ISD

Gause ISD

Maud ISD

Bob Hope School

Groveton ISD

Montgomery ISD

Bremond ISD

Hearne ISD

New Boston ISD

Bridge City ISD

High Island ISD

Newton ISD

Buna ISD

Hulls-Daisetta ISD

Rice ISD

Centerville ISD

Jefferson ISD

Royal ISD

Clarksville ISD

Kennard ISD

Silsbee ISD

Deweyville ISD

Kirbyville CISD

Somerville ISD

East Chambers ISD

Leon ISD

West Hardin CCISD

Ehrhart School

Liberty ISD

Westwood ISD

FLIP TO… PG. 11

FLIP TO… PG. 18

FOR HSA VS. FSA COMPARISON

FOR MORE HSA INFORMATION

FSA (Flexible Spending Account)

SUMMARY PAGES

Tax-sheltered flexible spending accounts allow an individual to set aside 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. See below for a list of participating districts to see if an FSA is available to you. Please keep in mind that if you participate in an FSA that HSAs may be limited or not available.

PARTICIPATING DISTRICTS Anderson-Shiro CISD

Ehrhart School

Leadership Prep School

Orangefield ISD

Arrow Academy

Franklin ISD

Leon ISD

Queen City ISD

Brazos ISD

Gause ISD

Liberty ISD

Richards ISD

Bremond ISD

Goodrich ISD

Lumberton ISD

Royal ISD

Bridge City ISD

Groveton ISD

Madisonville CISD

Sabine Pass ISD

Buna ISD

Hardin Jefferson ISD

Maud ISD

Sealy ISD

Burkeville ISD

Hearne ISD

McLeod ISD

Silsbee ISD

Burton ISD

High Island CISD

Milano ISD

Snook ISD

Centerville ISD

Hitchcock ISD

Montgomery ISD

Somerville ISD

Chester ISD

Hulls Daisetta ISD

New Boston ISD

Tioga ISD

Clarksville ISD

Iola ISD

Newton ISD

Vidor ISD

Damon ISD

Kennard ISD

Normangee ISD

West Hardin CCISD

Deweyville ISD

Kirbyville ISD

North Zulch ISD

Westwood ISD

East Chambers ISD

FLIP TO… PG. 11

FLIP TO… PG. 52

FOR HSA VS. FSA COMPARISON

FOR MORE FSA INFORMATION

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

ActiveCare 1-HD

ActiveCare Select or ActiveCare Select Whole Health

ActiveCare 2

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

$2,500 employee only $5,000 family

$1,200 individual $3,600 family

$1,000 individual $3,000 family

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

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

$6,850 individual $13,700 family

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

80% 20%

Office Visit Copay Participant pays

20% after deductible

$30 copay for primary $60 copay for specialist

$30 copay for primary $50 copay for specialist

Diagnostic Lab Participant pays

20% after deductible

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

Preventive Care See next page for a list of services

Plan pays 100%

Teladoc® Physician Services

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

Plan pays 100%

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

20% after deductible

$100 copay plus 20% after deductible

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

20% after deductible

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

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

Emergency Room (true emergency use) Participant pays

20% after deductible

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

Outpatient Surgery Participant pays

20% after deductible

$150 copay per visit plus 20% after deductible

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

$5,000 copay plus 20% after deductible

Not covered

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

Prescription Drugs Drug deductible (per plan year)

Subject to plan year deductible

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

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

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

$20 $40** $65**

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

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

$35 $60** $90**

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

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

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

Specialty Drugs Participant pays

20% after deductible

20% coinsurance per fill

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

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

TRS-ActiveCare Plans—Preventive Care

Network Benefits When Using In-Network Providers

(Provider must bill services as “preventive care”)

ActiveCare 1-HD Preventive Care Services

ActiveCare Select or ActiveCare Select Whole Health

ActiveCare 2 Network

(Baptist Health System and HealthTexas Medical Group; Baylor Scott & White Quality Alliance; Memorial Hermann Accountable Care Network; Seton Health Alliance) Evidence−based items or services that have in effect a rating of “A” or “B” in the current recommendations of the United States Preventive Services Task Force (USPSTF) www.uspreventiveservicestaskforce.org/Page/Name/uspstf-aand-b-recommendations

Plan pays 100% (deductible waived)

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.

CUSTOMLINK YOUR BENEFITS PACKAGE

Medical Supplement

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

DID YOU KNOW?

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

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

Medical Supplement Custom Link is a low‐cost program designed to help you pay for covered out‐of‐pocket expenses you may incur while you are either confined in a hospital or being treated as an out‐ patient for an injury or an illness. The East Texas Employee Benefits Cooperative has chosen a plan design that offers you an optimal offset of expenses due to high deductibles and high out‐of‐pocket maximums.

Basic Plan Benefits Offered The benefit options are:  $1,500 Plan  $2,500 Plan with HSA  $2,500 Plan with no HSA Hospital Confinement Benefit* This benefit is designed to offset the cost you incur as an in‐ patient in the hospital when your primary comprehensive major medical policy applies such expenses to your deductible or coinsurance maximum, up to the $1,500 or $2,500 calendar year maximum per insured person. Out‐Patient Benefit* This benefit offsets the cost you incur for out‐patient treatment when your primary comprehensive major medical policy applies such expenses to your deductible or coinsurance maximum, up to an amount equal to 50% of the Hospital Confinement Benefit limit. This benefit is a “per person per Calendar Year” maximum and is subject to a family calendar year maximum limitation that is equal to three (3) times the individual benefit. Expenses related to physician office visits are not included in this benefit. Covered expenses include:   

Surgery in an Out‐Patient Facility or a Physician’s Office Emergency Room visits Diagnostic testing, Lab & X‐ray at a diagnostic or hospital out‐patient facility or at a Physician’s office if the cost is not included in the global office visit fee and is not part of wellness/preventive care

*For expenses to be eligible under this plan they must be medically necessary for the treatment of an injury or illness. Expenses not covered by your group major medical plan are not covered. Deductible (only applicable for the $2,500 Plan with HSA) In order for your plan to be compatible with an Health Savings Account (HSA), your custom l ink plan has a deductible amount of $1,300 that must be satisfied before any benefits are payable. The deductible applies to inpatient and outpatient charges. When dependent coverage is elected, benefits are payable only after the entire family deductible has been satisfied. The family deductible may be satisfied by one or more insured persons. To be HSA compatible, the minimum per insured and family deductibles required by the IRS must be issued. This is subject to change by the IRS in future years.

How to File a Claim When you enroll in the custom link plan, you will receive a certificate of insurance, an ID card, and a claim form, along with specific instructions on how to file a claim. This form outlines the procedures you should follow and where you should send your claim. Simply stated, you will need to submit a completed claim form, itemized bills (NOT balance due statements), and EOB’s that correspond to the itemized bills. Claims may be filed at any time, but must be filed no longer than 12 months from the date of service in order to be eligible for coverage.

$1,500 Plan Monthly Rate Under Age 40: Insured Only Insured & Spouse Insured & Child(ren) Insured & Family Ages 40—49: Insured Only Insured & Spouse Insured & Child(ren) Insured & Family Age 50 & Above: Insured Only Insured & Spouse Insured & Child(ren) Insured & Family

$24.54 $44.18 $54.25 $73.89 $34.04 $61.28 $62.64 $89.87 $54.96 $98.92 $89.03 $133.00

$2,500 Plan with HSA Under Age 40: Insured Only Insured & Spouse Insured & Child(ren) Insured & Family Ages 40—49: Insured Only Insured & Spouse Insured & Child(ren) Insured & Family Age 50 & Above: Insured Only Insured & Spouse Insured & Child(ren) Insured & Family

$20.11 $36.19 $44.44 $60.53 $27.89 $50.19 $51.31 $73.62 $45.02 $81.03 $72.94 $108.95

$2,500 Plan with no HSA Under Age 40: Insured Only Insured & Spouse Insured & Child(ren) Insured & Family Ages 40—49: Insured Only Insured & Spouse Insured & Child(ren) Insured & Family Age 50 & Above: Insured Only Insured & Spouse Insured & Child(ren) Insured & Family

$36.09 $64.96 $74.76 $108.63 $50.04 $90.09 $92.09 $132.12 $80.80 $145.44 $130.90 $195.54

NBS

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) 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.

What is an HSA? 

 



A tax-advantaged savings account that you use to pay for eligible medical expenses as well as deductible, co-insurance, prescriptions, vision and dental care. Allows you to save while reducing your taxable income. Unused funds that will roll over year to year. There’s no “use it or lose it” penalty. Potential to build more savings through investing. If you maintain a minimum balance of $2,000, your additional funds may be invested in mutual funds yielding tax‐free earnings. A way to accumulate additional retirement savings. After age 65, funds can be withdrawn for any purpose without penalty.

Participant Account Web Access www.nbsbenefits.com A Health Savings Account (HSA) works with a high deductible health plan (HDHP) and lets you set aside a portion of your paycheck ‐ before taxes– into an account to help you pay for medical expenses before you reach your deductible or that you aren’t covered by your plan. It can also help you pay for future medical expenses.

A Health Savings Account (HSA):  

Grows with you. If you maintain a balance of $2,000, your additional funds may be invested in mutual funds yielding tax‐free earnings. Helps you plan for the future. Until you turn 65, withdrawals used for eligible expenses are tax free. After you turn 65, or if you become disabled, your HSA account becomes similar to a regular IRA. Withdrawals you use for noneligible expenses will be taxed at your regular income tax rate but won’t incur additional penalties.

Using Funds

For a list of sample expenses, please refer to the ETXEBC benefit website at www.etxebc.com

Pre-paid Debit Card: You may use the card to pay merchants or service providers that accept Master Card credit cards, so there is no need to pay cash up front and wait for reimbursements.

NBS Contact Information

2016 Annual HSA Contribution Limits 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.

P.O. Box 6980 West Jordan, UT 84084 Phone‐800‐274‐0503 Fax‐800‐478‐1528 Email: service@nbsbenefits.com

Will my HSA Funds be up fronted to me? Like a savings account, you can only withdrawal what you’ve contributed to the account. Funds are not up fronted. Are there any monthly fees? There is a $2.00 administrative fee that will be deducted from your HSA account on a monthly basis.

FLIP TO… PG. 12 FOR A LIST OF PARTICIPATING SCHOOL DISTRICTS

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 nonemergency medical issue  Your primary care physician is not available  At home, traveling, or at work  24/7/365, even holidays!

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

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

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

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

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

How much does it cost? One low employer or employee premium covers you and eligible family members. Can cost up to $9.00 if not covered by your employer. Consults are free!

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

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

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

Scan with your smartphone to get the app.

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

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

CIGNA

Dental

YOUR BENEFITS PACKAGE

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

DID YOU KNOW?

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

Dental PPO - High Option Cigna Radius Network Benefits

Cigna Dental Choice In-Network Out-of-Network Progressive Plan, Class I applies

Calendar Year Maximum (Class I, II, III, IX expenses) Calendar Year Deductible Individual Family

Monthly PPO Premiums

Tier

Rate

Year 1: $1,500 Year 2: $1,600 Year 3: $1,700 Year 4: $1,800

EE Only

$24.72

EE + Spouse

$52.53

EE + Child(ren)

$67.98

$50 per person $150 per family

Family Coverage

$92.70

Plan Pays

100%, No Deductible

80%, After Deductible

50%, After Deductible

Class I - Preventive & Diagnostic Care Oral Exams Cleanings Routine X-Rays Fluoride Application Emergency Care to Relieve Pain

Class II - Basic Restorative Care Sealants Non-Routine X-Rays Fillings Oral Surgery-Simple Extractions Brush Biopsy

Class III - Major Restorative Care Space Maintainers (limited to non-orthodontic treatment) Oral Surgery-All Except Simple Extraction Surgical Extraction of Impacted Teeth Anesthetics Major Periodontics Minor Periodontics Root Canal Therapy / Endodontics Relines, Rebases, and Adjustments Repairs- Bridges, Crowns, and Inlays Repairsâ&#x20AC;&#x201C; Dentures Crowns / Inlays / Onlays Dentures Bridges Stainless Steel/Resin Crowns

Class IV - Orthodontia Coverage for Eligible Children Only Lifetime Maximum

Class IX - Implants Plan Calendar Year Max

Missing Tooth Provision Late Entrant Limit Pretreatment Review Out-of-Network Reimbursement

Student/Dependent Age Progression

50%, 50%, No Ortho Deductible No Ortho Deductible $1,000 $1,000 50%, 50%, After Deductible After Deductible $1,000 $1,000 The amount payable is 50% of the amount otherwise payable until insured for a specified time period; thereafter, considered a Class III expense. 50% coverage on Class III and IV for a specified time period. Available on a voluntary basis when extensive work in excess of $200 is proposed. 90th Percentile 26/26 Members progress to the next level by utilizing Class I services in the prior year

Dental PPO - Low Option Cigna Radius Network Benefits

Cigna Dental Choice

In-Network Out-of-Network Progressive Plan, Class I applies Calendar Year Maximum (Class I, II, III, IX expenses) Calendar Year Deductible Individual Family

EE Only

$19.20

EE + Spouse

$40.80

EE + Child(ren)

$52.80

$50 per person $150 per family

Family Coverage

$72.00

Plan Pays

100%, No Deductible

50%, After Deductible

Not covered

Class IV - Orthodontia Class IX - Implants Plan Calendar Year Max

Missing Tooth Provision Late Entrant Limit Pretreatment Review Out-of-Network Reimbursement

Student/Dependent Age Progression

Rate

Year 1: $1,000 Year 2: $1,100 Year 3: $1,200 Year 4: $1,300

Class II - Basic Restorative Care Sealants Non-Routine X-Rays Fillings Oral Surgery-Simple Extractions Brush Biopsy

Tier

Year 1: $1,000 Year 2: $1,100 Year 3: $1,200 Year 4: $1,300

Class I - Preventive & Diagnostic Care Oral Exams Cleanings Routine X-Rays Fluoride Application Emergency Care to Relieve Pain

Monthly PPO Premiums

50%, 50%, After Deductible After Deductible $1,000 $1,000 The amount payable is 50% of the amount otherwise payable until insured for a specified time period; thereafter, considered a Class III expense. 50% coverage on Class III and IV for a specified time period. Available on a voluntary basis when extensive work in excess of $200 is proposed. 90th Percentile 26/26 Members progress to the next level by utilizing Class I services in the prior year

Dental PPO - High and Low Options Procedure

Exclusions and Limitations

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

Two per Calendar year Two per Calendar year 1 per Calendar year for people under 19 Bitewings: 2 per Calendar year Full mouth: 1 every 3 Calendar years., Panorex: 1 every 3 Calendar year 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 every 5 yeares if unserviceable and cannot be repaired. Benefits are based on the amount payable for nonprecious metals. No porcelain or white/tooth colored material on molar crowns or bridges When more than one covered Dental Service could provide suitable treatment based on common dental standards, Cigna HealthCare will determine the covered Dental Service on which payment will be based and the expenses that will be included as Covered Expenses

Alternate Benefit

Benefit Exclusions     

                   

Services performed primarily for cosmetic reasons Replacement of a lost or stolen appliance Replacement of a bridge or denture within five years following the date of its original installation Replacement of a bridge or denture which can be made useable according to accepted dental standards Procedures, appliances or restorations, other than full dentures, whose main purpose is to change vertical dimension, diagnose or treat conditions of TMJ, stabilize periodontally involved teeth, or restore occlusion Veneers of porcelain or acrylic materials on crowns or pontics on or replacing the upper and lower first, second and third molars Bite registrations; precision or semi-precision attachments; splinting A surgical implant of any type Instruction for plaque control, oral hygiene and diet Dental services that do not meet common dental standards Services that are deemed to be medical services Services and supplies received from a hospital Charges which the person is not legally required to pay Charges made by a hospital which performs services for the U.S. Government if the charges are directly related to a condition connected to a military service Experimental or investigational procedures and treatments Any injury resulting from, or in the course of, any employment for wage or profit Any sickness covered under any workers’ compensation or similar law Charges in excess of the reasonable and customary allowances To the extent that payment is unlawful where the person resides when the expenses are incurred; Procedures performed by a Dentist who is a member of the covered person’s family (covered person’s family is limited to a spouse, siblings, parents, children, grandparents, and the spouse’s siblings and parents); For charges which would not have been made if the person had no insurance; For charges for unnecessary care, treatment or surgery; To the extent that you or any of your Dependents is in any way paid or entitled to payment for those expenses by or through a public program, other than Medicaid; To the extent that benefits are paid or payable for those expenses under the mandatory part of any auto insurance policy written to comply with a “no-fault” insurance law or an uninsured motorist insurance law. Cigna HealthCare will take into account any adjustment option chosen under such part by you or any one of your Dependents. In addition, these benefits will be reduced so that the total payment will not be more than 100% of the charge made for the Dental Service if benefits are provided for that service under this plan and any medical expense plan or prepaid treatment program sponsored or made available by your Employer.

This benefit summary highlights some of the benefits available under the proposed plan. A complete description regarding the terms of coverage, exclusions and limitations, including legislated benefits, will be provided in your insurance certificate or plan description. Benefits are insured and/or administered by Con necticut General Life Insurance Company. "Cigna HealthCare" refers to various operating subsidiaries of Cigna Corporation. Products and services are provided by these subsidiaries and not by Cigna Corporation. These subsidiaries include Connecticut General Life Insurance Company, Cigna Health and Life Insurance Company, and HMO or service company subsidiaries of Cigna Health Corporation and Cigna Dental Health, Inc. DPPO insurance coverage is set forth on the following policy form numbers: AR: HP-POL77; CA: HP-POL57; CO: HP-POL78; CT: HP-POL58; DE: HP-POL79; FL: HP-POL60; ID: HPPOL82; IL: HP-POL62; KS: HP-POL84; LA: HP-POL86: MA: HP-POL 63; MI: HP-POL88; MO: HP- POL65; MS: HP-POL90; NC: HP-POL96; NE: HP-POL92; NH: HP-POL94; NM: HP-POL95; NV: HP-POL93; NY: HP-POL67; OH: HP-POL98; OK: HP-POL99; OR: HP-POL68; PA: HP-POL100; RI: HP-POL101; SC: HP-POL102; SD: HP-POL103; TN: HP-POL69; TX: HP-POL70; UT: HP-POL104; VA: HP-POL72; VT: HP-POL71; WA: POL-07/08; WI: HP-POL107; WV: HP-POL106; and WY: HP-POL108. “Cigna,” the “Tree of Life” logo and “Cigna Dental Care” are registered service marks of Cigna Intellectual Property, Inc., licensed for use by Cigna Corporation and its operating subsidiaries. All products and services are provided by or through such operating subsidiaries and not by Cigna Corporation. Such operating subsidiaries include Connecticut General Life Insurance Company (CGLIC), Cigna Health and Life Insurance Company (CHLIC), Cigna HealthCare of Connecticut, Inc., and Cigna Dental Health, Inc. and its subsidiaries. Cigna Dental PPO plans are underwritten or administered by CGLIC or CHLIC, with network management services provided by Cigna Dental Health, Inc. and certain of its subsidiaries. In Arizona and Louisiana, the insured Dental PPO plan offered by CGLIC is known as the “CG Dental PPO”. In Texas, the insured dental product offered by CGLIC and CHLIC is referred to as the Cigna Dental Choice Plan, and this plan utilizes the national Cigna Dental PPO network. Cigna Dental Care (DHMO) plans are underwritten or administered by Cigna Dental Health Plan of Arizona, Inc., Cigna Dental Health of California, Inc., Cigna Dental Health of Colorado, Inc., Cigna Dental Health of Delaware, Inc., Cigna Dental Health of Florida, Inc., a Prepaid Limited Health Services Organization licensed under Chapter 636, Florida Statutes, Cigna Dental Health of Kansas, Inc. (Kansas and Nebraska), Cigna Dental Health of Kentucky, Inc. (Kentucky and Illinois), Cigna Dental Health of Maryland, Inc., Cigna Dental Health of Missouri, Inc., Cigna Dental Health of New Jersey, Inc., Cigna Dental Health of North Carolina, Inc., Cigna Dental Health of Ohio, Inc., Cigna Dental Health of Pennsylvania, Inc., Cigna Dental Health of Texas, Inc., and Cigna Dental Health of Virginia, Inc. In other states, Cigna Dental Care plans are underwritten by CGLIC, CHLIC, or Cigna HealthCare of Connecticut, Inc. and administered by Cigna Dental Health, Inc. BSD46380 © 2015 Cigna

UNITED HEALTHCARE YOUR BENEFITS PACKAGE

Vision

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

DID YOU KNOW?

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

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

$7.02 $14.62 $15.19 $19.47

Co-Pays for In-Network Services Exam Materials

$10 $25

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

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

Frame Benefit Private Practice Provider Retail Chain Provider

$130.00 retail frame allowance $130.00 retail frame allowance

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

 

Lens Options

Contact Lens Benefit

Laser Vision Benefit UnitedHealthcare Vision has partnered with the Laser Vision Network of America (LVNA) to provide our members with access to discounted laser vision correction providers. Members receive 15% off usual and customary pricing, 5% off promotional pricing at over 500 network provider locations and even greater discounts through set pricing at LasikPlus locations. For more information, call 1-888-563-4497 or visit us at www.uhclasik.com. 1Coverage

for Covered Contact Lens Selection does not apply at Costco, Walmart or Sam’s Club locations. The allowance for non-selection contact lenses will be applied toward the fitting/ evaluation fee and purchase of all contacts. 2Necessary contact lenses are determined at the provider’s discretion for one or more of the following conditions: Following post cataract surgery without intraocular lens implant; to correct extreme vision problems that cannot be corrected with spectacle lenses; with certain conditions such as keratoconus, anisometropia, irregular corneal/astigmatism, aphakia, facial deformity or corneal deformity. If your provider considers your contacts necessary, you should ask your provider to contact UnitedHealthcare Vision confirming reimbursement that UnitedHealthcare Vision will make before you purchase such contacts. 3The out-of-network reimbursement applies to materials only. The fitting/evaluation is not included.

$150.00 $210.00

Important to Remember

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

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



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

CIGNA YOUR BENEFITS PACKAGE

Long Term Disability

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

DID YOU KNOW?

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

34.6 months is the duration of the average disability claim.

Long Term Disability Long Term Disability (LTD) Insurance Coverage Eligibility Eligibility Waiting Period

Active, full-time Employees of the Employer regularly working a minimum of 31 hours per week. No waiting period Benefit Amount

Up to 60% of your monthly covered earnings

Maximum

$5,000 per month

Monthly Benefit Benefit Period

You must be continuously disabled for 90 days before benefits may be payable.

Definition of Disability

Termination of Disability Benefits

Disability 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 60% or more of your indexed earnings. We will require proof of earnings and continued disability.

Your benefits will terminate on the earliest of any of the following dates: the date the insurance company determines you are no longer disabled; the date you earn from any occupation more than the percentage of indexed earnings as defined in your definition of disability; the date the maximum benefit period ends; the date you cease to get appropriate care; the date you die; the date you refuse to participate without good cause in all required phases of the rehabilitation plan; the date you fail to cooperate with us in the administration of the claim. Benefits may be resumed if you begin to cooperate in the rehabilitation plan within 30 days of the date benefits terminated.

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

Benefit Duration Once you qualify for benefits under this plan, you continue to receive them until the end of the benefit period shown below, or until you no longer qualify for benefits, whichever occurs first. Your benefit period begins on the first day after you complete your elimination period. Should you remain disabled, your benefits continue according to the following schedule, depending on your age at the time you become disabled. Age at Disability Duration of Payments Number of Months Benefits Paid

62 or Younger To age 65 or the date the 42nd monthly benefit is payable, if later

63 64 65 66 67 68 69+

Effects of Other Income Benefits The disability benefit provided by this plan is a total benefit; that is, it will be reduced by any disability benefits payable on behalf of you or your dependents, or a qualified third party on behalf of you or your dependents, whether or not you are actually receiving them. Other income sources that may reduce your benefits under this plan include:  Any Social Security disability or retirement benefits you or any third party receive (or are assumed to receive) on your own behalf; or which your dependents receive (or are assumed to receive) because of your entitlement to such benefits.  Benefits payable by a Canadian and/or Quebec provincial pension plan.  Amounts payable under the Railroad Retirement Act.  Amounts payable under local, state, provincial or federal government disability or retirement plan or law as it pertains to the employer.  Employer-paid portion of company retirement plan benefits.

Long Term Disability 

  



Amounts payable by company sponsored sick leave salary continuation plan. Amounts payable by any franchise or group insurance or similar plan. Benefits payable under work-loss provisions of any mandatory “no fault” auto insurance. Any amounts paid on account of loss of earnings or earning capacity through settlement, judgment, arbitration or otherwise, where a third party may be liable, regardless of whether liability is determined. Amounts payable under any workers’ compensation (including temporary or permanent disability benefits), occupational disease, and unemployment compensation. This includes damages, compromises or settlements paid in place of such benefits, whether or not liability is admitted.

Income sources that WILL NOT reduce your benefits under this plan are:  Benefits paid by personal, individual disability income policies.  Individual deferred compensation agreements.  Employee savings plans, including thrift plans, stock options or stock bonuses.  Individual retirement funds, such as IRA or 401(k) plans.  Profit-sharing, investment or other retirement or savings plans maintained in addition to an employer-sponsored pension plan.

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.

Pre-existing Conditions 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 preexisting 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.

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: Anxiety-disorders, delusional (paranoid) or depressive disorders, eating disorders, mental illness, somatoform disorders (including psychosomatic illnesses). 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 limit is exhausted. Once the 24-month benefits are exhausted, the plan pays no further benefits. Disabilities caused by or contributed to by any one or more of the following conditions are subject to a lifetime limit of 24 months: 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 limit is exhausted. Once the 24-month benefits are exhausted, the plan pays no further benefits.

Exclusions This plan does not pay benefits for a disability which results, directly or indirectly, from any of the following: Suicide, attempted suicide, or whenever you injure yourself on purpose; 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 your license, permit or certification necessary for you to perform the duties of your occupation, unless solely due to injury or sickness otherwise covered by the policy. In addition, we will not pay disability benefits for any period of disability during which you are incarcerated in a penal or corrections institution for any reason.

Plan Termination Coverage terminates if the group policy is terminated, if you cease to be in active service, if you are no longer a member of an eligible class of employees, the day after the last date for which premium has been paid by you or the employer, or the date you become eligible for a plan of benefits intended to replace this coverage.

Long Term Disability If you are disabled and receiving benefits under this plan, your benefits and coverage will continue until the expiration of your benefit period, or until you no longer qualify for benefits under the plan, whichever comes first.

When Coverage Takes Effect Your coverage takes effect on the later of the program’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 have to submit evidence of good health, your coverage takes effect on the date we agree, in writing, to cover you. If you’re not actively at work on the date your coverage would otherwise take effect, you’ll be covered on the date you return to work.

Family Survivor Benefit If you die while receiving disability benefits, we will pay a survivor benefit based on 100% of the total of your last month’s benefit plus the amount of any disability earnings by which this benefit had been reduced for that month. This plan pays a single lump sum equal to 3 months of benefits. We pay this benefit directly to your lawful spouse, or to your children in equal shares, if there is no lawful spouse. If you have no lawful spouse or children, we pay this benefit to your estate.

This information is a brief description of the important features of the plan. It is not a contract. Terms and conditions of insurance are set forth in Group Policy No. SGD 607106. Please refer to your Certificate of Insurance or Summary Plan Description for more detailed information. Coverage is underwritten by Life Insurance Company of North America, a Cigna company. “Cigna” and the Tree of Life logo are registered service marks of Cigna Intellectual Property, Inc. © Cigna 2015

CIGNA

Short Term Disability

YOUR BENEFITS PACKAGE

About this Benefit Disability insurance protects one of your most valuable assets, your ability to earn a living. This insurance will replace a portion of your income in the event that you become physically unable to work. Short term disability coverage provides benefits when you are unable to work for a short period of time due to a covered sickness or injury.

DID YOU KNOW?

60% of Americans do not have a â&#x20AC;&#x153;rainy dayâ&#x20AC;? fund to cover three months of unanticipated financial emergencies.

Short Term Disability Short Term Disability (STD) Insurance Coverage Eligibility

Eligibility Waiting Period Monthly Benefit Elimination Period Benefit Duration

Active, full-time Employees of the Employer regularly working a minimum of 20 hours per week.

No waiting period. Benefit Amount

Up to 60% of your weekly covered earnings

Maximum

$1,500 per week

You must be 8 days from accident and 8 days from sickness. Once you qualify for benefits under this plan, you continue to receive them until the end of the 12 week benefit period, or until you no longer qualify for benefits, whichever occurs first.

Definition of Disability - Disability means that, solely because of a

 Any amounts paid on account of loss of earnings or earning

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 covered earnings from working in your regular occupation. We will require proof of earnings and continued disability.

capacity through settlement, judgment, arbitration or otherwise, where a third party may be liable, regardless of whether liability is determined.  Amounts payable under any workers’ compensation (including temporary or permanent disability benefits), occupational disease, and unemployment compensation. This includes damages, compromises or settlements paid in place of such benefits, whether or not liability is admitted. Income sources that WILL NOT reduce your benefits under this plan are:  Benefits paid by personal, individual disability income policies.  Individual deferred compensation agreements.  Employee savings plans, including thrift plans, stock options or stock bonuses.  Individual retirement funds, such as IRA or 401(k) plans.  Profit-sharing, investment or other retirement or savings plans maintained in addition to an employer-sponsored pension plan.

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

Earnings While Disabled - Benefits will be reduced for any week that benefits plus income from employment exceeds 100% of weekly covered earnings.

Cost - The cost of this insurance program is paid by you. The cost of this coverage is $0.45 per $10 of weekly covered benefit. Costs are subject to change.

Termination of Disability Benefits - Your benefits will terminate on the earliest of any of the following dates: the date the insurance company determines you are no longer disabled; the date you earn from any occupation more than the percentage of covered earnings as defined in your definition of disability; the date the maximum benefit period ends; the date you cease to get appropriate care; the date you die; the date you refuse to participate without good cause in all required phases of the rehabilitation plan; the date you fail to cooperate with us in the administration of the claim. Benefits may be resumed if you begin to cooperate in the rehabilitation plan within 30 days of the date benefits terminated.

Exclusions - This plan does not pay benefits for a disability which results, directly or indirectly, from any of the following: Suicide, attempted suicide, or whenever you injure yourself on purpose; war or any act of war, whether or not declared; active participation in a riot; commission of a felony; the revocation, restriction or nonrenewal of your license, permit or certification necessary for you to perform the duties of your occupation, unless solely due to injury or sickness otherwise covered by the policy. In addition, we will not pay disability benefits for any period of disability during which you are incarcerated in a penal or corrections institution for any reason.

Effects of Other Income Benefits - The disability benefit provided by this plan is a total benefit; that is, it will be reduced by any disability benefits payable on behalf of you or your dependents, or a qualified third party on behalf of you or your dependents, whether or not you are actually receiving them. Other income sources that may reduce your benefits under this plan include:  Any Social Security disability or retirement benefits you or any third party receive (or are assumed to receive) on your own behalf; or which your dependents receive (or are assumed to receive) because of your entitlement to such benefits.  Benefits payable by a Canadian and/or Quebec provincial pension plan.  Amounts payable under the Railroad Retirement Act.  Amounts payable under local, state, provincial or federal government disability or retirement plan or law as it pertains to the employer.  Employer-paid portion of company retirement plan benefits.  Amounts payable by company sponsored sick leave or salary continuation plan.  Amounts payable by any franchise or group insurance or similar plan.  Benefits payable under work-loss provisions of any mandatory “no fault” auto insurance.

Plan Termination - Coverage terminates if the group policy is terminated, if you cease to be in active service, if you are no longer a member of an eligible class of employees, the day after the last date for which premium has been paid by you or the employer, or the date you become eligible for a plan of benefits intended to replace this coverage. If you are disabled and receiving benefits under this plan, your benefits and coverage will continue until the expiration of your benefit period, or until you no longer qualify for benefits under the plan, whichever comes first.

When Coverage Takes Effect - Your coverage takes effect on the later of the program’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 have to submit evidence of good health, your coverage takes effect on the date we agree, in writing, to cover you. If you’re not actively at work on the date your coverage would otherwise take effect, you’ll be covered on the date you return to work.

LOYAL AMERICAN

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.

Cancer BENEFIT PROVISIONS. We will pay the benefits described in the Certificate for the treatment of an Insured Person’s Cancer, provided he or she is covered under an issued Certificate which remains in force. Payment will be made in accordance with all applicable policy provisions. Benefits are payable for a positive diagnosis that begins after the Effective Date. The positive diagnosis must be for Cancer as defined in the policy. 1. POSITIVE DIAGNOSIS BENEFIT. We will pay the Actual Charge but not to exceed $300 per Calendar Year for one test that confirms the Positive Diagnosis of Cancer in an Insured Person. This benefit is not payable for multiple diagnoses of the same Cancer or for Cancer that metastasizes or for recurrence of the same Cancer. 2. NATIONAL CANCER INSTITUTE DESIGNATED COMPREHENSIVE CANCER TREATMENT CENTER EVALUATION/CONSULTATION BENEFIT. We will pay the Actual Charge, but not to exceed a lifetime maximum of $750, if an Insured Person is diagnosed with Internal Cancer and seeks evaluation or consultation from a National Cancer Institute designated Comprehensive Cancer Treatment Center. If the Comprehensive Cancer Treatment Center is located more than 30 miles from the Insured Person’s place of residence, We will also pay the transportation and lodging expenses incurred but not to exceed a lifetime maximum of $350. This benefit is not payable on the same day a Second or Third Surgical Opinion Benefit is payable and is in lieu of the Non-Local Transportation and Lodging Expense Benefits of the Policy. This benefit is payable one time during the lifetime of the Insured Person. 3. SECOND AND THIRD SURGICAL OPINION EXPENSE BENEFIT. We will pay the Actual Charge for a written second surgical opinion concerning the recommendation of Cancer surgery and if the second surgical opinion is in conflict with that of the Physician originally recommending the surgery and the Insured Person desires a third opinion, We will the Actual Charge for a written third surgical opinion. The Physician providing the second or third surgical opinion cannot be associated with the Physician who originally recommended the surgery. This benefit is not payable the same day the National Cancer Institute Evaluation/Consulting Benefit is payable. 4. MEDICAL IMAGING, TREATMENT PLANNING AND MONITORING EXPENSE BENEFIT. We will pay the Actual Charge, but not to exceed $1,000 per Calendar Year, for laboratory tests, diagnostic X-rays, medical images, when used in Cancer treatment plannings related to Radiation Treatment, Chemotherapy or Immunotherapy. 5. ANTI-NAUSEA MEDICATION EXPENSE BENEFIT. We will pay the Actual Charge for anti-nausea medication, but not to exceed $150 per calendar month, when an Insured Person is prescribed such medication as the result of Radiation Treatment, Chemotherapy or Immunotherapy treatments for Cancer. 6. COLONY STIMULATING FACTOR OR IMMUNOGLOBULIN EXPENSE BENEFIT. We will pay the Actual Charge but not to exceed $1,000 per Calendar Month for Colony Stimulating Factor Drugs or Immunoglobulins prescribed by a Physician or Oncologist during an Insured Person’s Cancer treatment regimen for which benefits are payable under the Radiation, Chemotherapy and Immunotherapy Benefit of this Policy or rider attached to it.

7. OUTPATIENT HOSPITAL OR AMBULATORY SURGICAL CENTER EXPENSE BENEFIT. We will pay the Actual Charge from an Ambulatory Surgical Center or Outpatient department of a Hospital for the use of its facilities for the performance of a surgical procedure covered under this Policy but not to exceed $350 per day. 8. PROSTHESIS EXPENSE BENEFIT (A.) Surgically Implanted Breast Prosthesis We will pay the Actual Charge for a surgically implanted prosthetic device required and prescribed to restore normal body contour lost as the direct result of an Insured Person’s breast removal for the treatment of Cancer. The Surgically Implanted Breast Prosthesis Benefit does not include coverage for breast reconstruction surgery which may be covered under the Surgical Schedule within the Surgical and Anesthesia Benefits Rider. (B.) Non-Surgically Implanted Prosthesis We will pay the Actual Charge incurred not to exceed $2,000 per amputation for an artificial limb or other non-surgically implanted prosthetic device that is prescribed and required to restore normal body function lost as the direct result of an Insured Person’s amputation for the treatment of Cancer. We will pay a lifetime maximum of $2,000 per amputation. The cost of replacement of a prosthetic device is not covered. Hairpieces or wigs are not covered under this benefit. 9. NON-LOCAL TRANSPORTATION EXPENSE BENEFIT. We will pay the Actual Charge, but not to exceed the coach fare on a Common Carrier for the Insured Person and one adult companion’s travel to a Hospital, Radiation Therapy Treatment Center, Chemotherapy Treatment Center, Oncology Clinic or any other specialized treatment center where the Insured Person receives treatment for Cancer. This benefit is payable only if the treatment is not available Locally but is available Non-Locally. The adult companion may include the live donor of bone marrow or stem cells used in a bone marrow or stem cell transplant for the Insured Person. At the option of the Insured Person, We will pay a single private vehicle mileage allowance of $.50 per mile for Non-Local transportation in lieu of the common carrier coach fare. 10. LODGING EXPENSE BENEFIT. We will pay the Actual Charge not to exceed $75 per day for a room in a motel, hotel or other appropriate lodging facility (other than a private residence), when an Insured Person receives treatment for Cancer at a Non-Local Hospital, Radiation Therapy Treatment Center, Chemotherapy Treatment Center, Oncology Clinic or any other specialized treatment center. The room must be occupied by the Insured Person or an adult companion which may include the live donor of bone marrow or stem cells used in a bone marrow or stem cell transplant for the Insured Person. This benefit is not payable for lodging expense incurred more than 24 hours before the treatment nor for lodging expense incurred more than 24 hours following treatment. This benefit is limited to 100 days per Calendar Year. 11. INPATIENT BLOOD, PLASMA AND PLATELETS EXPENSE BENEFIT. We will pay the Actual Charge not to exceed $300 per day for the procurement cost, administration, processing and cross matching of blood, plasma or platelets administered to an Insured Person in the treatment of Cancer while an Inpatient. 12. OUTPATIENT BLOOD, PLASMA AND PLATELETS EXPENSE BENEFIT. We will pay the Actual Charge not to exceed $300 per day for the procurement cost, administration, processing and cross matching of

Cancer blood, plasma or platelets administered to an Insured Person in the treatment of Cancer while an Outpatient. 13. BONE MARROW DONOR EXPENSE BENEFIT. We will pay the Daily Hospital Confinement Benefit shown on the Certificate Schedule for each day a live donor, other than the Insured Person, is confined in a Hospital for the harvesting of bone marrow or stem cells used in a bone marrow or stem cell transplant for the treatment of an Insured Person’s Cancer. 14. BONE MARROW OR STEM CELL TRANSPLANT EXPENSE BENEFIT. We will pay the Actual Charge not to exceed a lifetime maximum of $15,000 for surgical and anesthesia procedures (including the harvesting and subsequent re-infusion of blood cells or peripheral stem cells) performed for a bone marrow transplant and/or a peripheral stem cell transplant for the treatment of an Insured Person’s Cancer. This benefit will be paid in lieu of the Surgical Expense Benefit and the Anesthesia Expense Benefit which may be described in a rider attached to an issued Certificate. 17. ATTENDING PHYSICIAN EXPENSE BENEFIT. We will pay the Actual Charge not to exceed $40 per day for the professional services of a Physician or Oncologist rendered to an Insured Person while he or she is confined in a Hospital for the treatment of Cancer. This benefit is payable only if the Physician or Oncologist personally visits the Hospital room occupied by the Insured Person and the amount stated is the maximum amount that will be payable for each day of Hospital confinement regardless of the number of visits made by one or more Physicians or Oncologists. 18. INPATIENT PRIVATE DUTY NURSING EXPENSE BENEFIT. We will pay the Actual Charge not to exceed $150 per day for the full time service of a Nurse that is required and ordered by a Physician when an Insured Person is confined in a Hospital for the treatment of Cancer. The Nurse must provide services other than those normally provided by the Hospital and the Nurse may not be an employee of the Hospital or an Immediate Family Member of the Insured Person. 19. OUTPATIENT PRIVATE DUTY NURSING EXPENSE BENEFIT. We will pay the Actual Charge not to exceed $150 per day limited to the same number of days of the prior Hospital confinement for the full time service of a Nurse that is required and ordered by a Physician when an Insured Person is confined indoors at home as the result of Cancer . This benefit is not payable if the services of the Nurse are custodial in nature or to assist the Insured Person in the activities of daily living. This benefit is not payable when the Nurse is a member of the Insured Person’s Immediate Family. Charges must begin following a period of Hospital confinement for which benefits are payable under this Certificate. 20. CONVALESCENT CARE FACILITY EXPENSE BENEFIT. We will pay the Actual Charge not to exceed $100 per day for an Insured Person’s confinement in a Convalescent Care Facility. The maximum number of days for which this benefit is payable will be the number of days in the last Period of Hospital Confinement that immediately preceded admission to a Convalescent Care Facility. The Convalescent Care Facility Confinement must: be due to Cancer ; begin within 14 days after the Insured Person has been discharged from a Hospital for the treatment of Cancer ; be authorized by a

Physician as being medically necessary for the treatment of Cancer. 21. RENTAL OR PURCHASE OF MEDICAL EQUIPMENT EXPENSE. BENEFIT We will pay the lesser of the Actual Charge not to exceed $1,500 per Calendar Year for either the rental or purchase of covered medical equipment designed for home use, required and ordered by the Insured Person’s attending Physician as the direct result of the treatment of Cancer. Covered medical equipment includes wheel chair, oxygen equipment, respirator, braces, crutches or hospital bed. 22. HOME HEALTH CARE EXPENSE BENEFIT. We will pay benefits for the following Covered Charges when a Insured Person requires Home Health Care for the treatment of Cancer. 1. Home Health Care Visits - We will pay the Actual Charge for Home Health Care Visits not to exceed $75 for each day on which one or more such visits occur. We will not pay this benefit for more than 60 days in any Calendar Year. 2. Medicine and Supplies - We will pay the Actual Charge not to exceed $450 in any Calendar Year for drugs, medicine, and medical supplies provided by or on behalf of a Home Health Care Agency. 3. Services of a Nutritionist - We will pay the Actual Charge not to exceed a lifetime maximum of $300 for the services of a nutritionist to set up programs for special dietary needs. 23. HOSPICE CARE EXPENSE BENEFIT. We will pay the Actual Charge for Hospice Care not to exceed $100 per day, when such care is required because of Cancer . This benefit is payable whether confinement is required in a Hospice Center or services are provided in the Insured Person’s home by a Hospice Team. Eligibility for payments will be based on the following conditions being met:(1) the Insured Person has been given a prognosis as being Terminally Ill with an estimated life expectancy of 6 months or less; and (2) We have received a written summary of such prognosis from the attending Physician. We will not pay this benefit while the Insured Person is confined to a Hospital or Convalescent Care Facility. The lifetime maximum benefit is 365 days of Hospice Care. 24. HAIRPIECE EXPENSE BENEFIT. We will pay the Actual Charge not to exceed a lifetime maximum of $150 for the purchase of a wig or hairpiece that is required as the direct result of hair loss due to Cancer treatment. THIS IS A CANCER ONLY POLICY, which should be used to supplement your existing health care protection. RENEWABILITY. Coverage will terminate when the Group Master Policy terminates or when required premium remains unpaid after expiration of the Grace Period. PREMIUM RATES. We may change the premium rates for coverage only if we also change the rates for all other Certificates issued under the Group Master Policy. EXCLUSIONS AND LIMITATIONS. No benefits will be paid under the Certificate or any attached riders for: 1. any loss due to any disease or illness other than Cancer, or a listed covered Specified Disease; 2. care and treatment received outside the territorial limits of the United States; 3. treatment by any program engaged in research that does not meet the criteria for Experimental Treatment as defined; 4. treatment that has not been approved by a Physician as being medically necessary; or 5. losses or medical expenses incurred prior to the Certificate Effective Date of an Insured Person’s coverage regardless of the Date of Positive Diagnosis. PRE-EXISTING CONDITIONS LIMITATION. Relative to any Insured Person, We will not pay benefits for expenses resulting from Pre-existing Conditions during the 12 months after coverage becomes effective. “Pre-existing Condition” means Cancer, or a listed Specified Disease if that optional rider is issued, which was diagnosed by a Physician or for which medical consultation, advice or treatment was recommended by or received from or sought from a Physician within 1 year prior to the effective date of coverage for each Insured Person.

Cancer ADDITIONAL BENEFIT AMOUNTS

PLAN A Maximum

PLAN B Maximum

PLAN C Maximum

ANNUAL CANCER SCREENING BENEFIT RIDER (form LG-6041) A. Basic Benefit We will pay the expense incurred, but not to exceed the maximum benefit amount shown on the Certificate Schedule, once per calendar year per Insured Person for screening tests performed to determine whether Cancer exists in an Insured Person. Covered annual Cancer screening tests include but are not limited to: mammogram, pap smear, breast ultrasound, ThinPrep, biopsy, chest x-ray, thermography, colonoscopy, flexible sigmoidoscopy, hemocult stool specimen, PSA (blood test for prostate cancer), CEA (blood tests for colon cancer), CA125 (blood test for ovarian cancer), CA15-3 (blood test for breast cancer), serum protein electrophesis (blood test for myeloma).

$50 $50 $50 Per Calendar Per Calendar Per Calendar Year Year Year

Additional Benefit

$100 We will pay the expense incurred, but not to exceed two times the maximum benefit amount per calendar year as Per Calendar shown on the Certificate Schedule, for one additional invasive diagnostic procedure required as the result of an Year abnormal cancer screening test for which benefits are payable under the Basic Benefit above for an Insured Person. This additional benefit is payable regardless of the results of the additional diagnostic procedure. However, the amount payable will be reduced dollar for dollar for any amount payable under the Positive Diagnosis Benefit contained in the base Certificate. FIRST OCCURRENCE BENEFIT RIDER (form LG-6043) If an Insured Person receives a positive diagnosis of Internal Cancer, We will pay the First Occurrence benefit amount shown on the Certificate Schedule. If the Insured Person receiving the positive diagnosis of Internal Cancer is a child under the age of 21, we will pay one and one-half times the First Occurrence benefit amount shown on the Certificate Schedule.

$2,500 Once per Lifetime $3,750 Once per Lifetime

$100 $100 Per Calendar Per Calendar Year Year

$5,000 Once per Lifetime $7,500 Once per Lifetime

$7,000 Once per Lifetime $10,500 Once per Lifetime

ANNUAL RADIATION, CHEMOTHERAPY, IMMUNOTHERAPY and EXPERIMENTAL TREATMENT BENEFIT RIDER (form LG-6045) We will pay the expense incurred, but not to exceed the maximum benefit amount shown on the Certificate Schedule, per calendar year per Insured Person for Radiation Treatment, Chemotherapy, Hormonal Therapy, Immunotherapy or Experimental Treatment. The Radiation Treatment, Chemotherapy, Hormonal Therapy, Immunotherapy or Experimental Treatment must be for the treatment of an Insured Personâ&#x20AC;&#x2122;s Cancer. The benefit amount shown on the Certificate Schedule is the maximum calendar year benefit available per Insured Person regardless of the number or types of Cancer treatments received in the same year.

SURGICAL BENEFIT RIDER (form LG-6048) Surgical Expense We will pay the Surgical Expense benefit for a surgical procedure for the treatment of an Insured Personâ&#x20AC;&#x2122;s Cancer (except Skin Cancer) according to the Surgical Schedule shown in this rider. However, in no event will the amount payable exceed the maximum Surgical Expense benefit shown on the Certificate Schedule, nor will it exceed the expense incurred.

Anesthesia Expense We will pay the anesthesia expense incurred, not to exceed 25% of the covered Surgical Expense benefit for the operation performed. This includes the services of an anesthesiologist or of an anesthetist under supervision of a physician for the purpose of administering anesthesia.

$5,000 $12,500 $20,000 Per Calendar Per Calendar Per Calendar Year Year Year

$2,000 Procedure Maximum

$3,500 Procedure Maximum

$5,000 Procedure Maximum

$500 Procedure Maximum

$875 Procedure Maximum

$1,250 Procedure Maximum

$1,800 Procedure Maximum

$2,700 Procedure Maximum

$4,500 Procedure Maximum

Breast Reconstruction With transverse rectus adominis myocutaneous flap (TRAM), single pedicle, including closure of donor site, with microvascular anastomosis (supercharging) is one of the surgical procedures listed in the Surgical Schedule. If this procedure is performed on an Insured Person as the result of a mastectomy for which We paid a Surgical Expense benefit for the treatment of Breast Cancer, We will pay the expense incurred not to exceed $900 per $1,000 of the Surgical Benefit issued.

Skin Cancer Surgery Expense

We will pay the expense incurred, not to exceed the procedure amount listed in this rider ($125 to $750 depending on Per Procedure Per Procedure Per Procedure the procedure) when a surgical operation is performed on an Insured Person for treatment of a diagnosed Skin Cancer. This benefit is payable in lieu of any benefits for Surgical Expense and Anesthesia Expense which are not applicable to Skin Cancer.

DAILY HOSPITAL CONFINEMENT BENEFIT RIDER (form LG-6042) Confinements of 30 Days or Less We will pay the Daily Hospital Confinement benefit amount shown on the Certificate Schedule for each of the first 30 days in each period of hospital confinement during which an Insured Person is confined to a hospital, including a government or charity hospital, for the treatment of Cancer.

Confinements of 31 Days or More If an Insured Person is continuously confined to a hospital, including a government or charity hospital, for longer than 30 consecutive days for the treatment of Cancer, We will pay two times the Daily Hospital Confinement benefit amount shown on the Certificate Schedule. This benefit payment will begin on the 31st continuous day of such confinement and continue for each day of confinement until the Insured Person is discharged from the Hospital.

Benefits for an Insured Dependent Child under Age 21 The amount payable under this benefit will be double the Daily Hospital Confinement benefit shown on the Certificate Schedule if the Insured Person so confined is a dependent child under the age of 21.

$100 Per Day

$200 Per Day

$200/ $400 Per Day

$200/ $400 Per Day 37

Cancer Additional Benefits Amounts SPECIFIED DISEASE BENEFIT RIDER (form LG-6052) If an Insured Person is first diagnosed with one or more covered Specified Diseases and is hospitalized for the definitive treatment of any covered Specified Disease, We will pay benefits according to the provisions of this rider. Covers These 38 Specified Diseases Addison’s Disease Amyotrophic Lateral Sclerosis Botulism Bovine Spongiform Encephalopathy Budd-Chiari Syndrome Cystic Fibrosis Diptheria Encephalitis Epilepsy Hansen’s Disease Histoplasmosis Legionnaire’s Disease Lyme Disease

Lupus Erythematosus Malaria Meningitis Multiple Sclerosis Muscular Dystrophy Myasthenia Gravis Neimann-Pick Disease Osteomyelitis Poliomyelitis Q Fever Rabies Reye’s Syndrome Rheumatic Fever

Rocky Mountain Spotted Fever Sickle Cell Anemia Tay-Sachs Disease Tetanus Toxic Epidermal Necrolysis Tuberculosis Tularemia Typhoid Fever Undulant Fever West Nile Virus Whipple’s Disease Whooping Cough

Benefits If an Insured Person is first diagnosed with one or more covered Specified Diseases and is hospitalized for the definitive treatment of any covered Specified Disease, We will pay benefits according to the provisions of this rider. An applicant may select 1, 2 or 3 units of coverage. Initial Hospitalization Benefit We will pay a benefit of $1,500 per unit of coverage selected when an Insured Person is confined to a hospital (for 12 or more hours, not applicable in SD) as a result of receiving treatment for a Specified Disease. This benefit is payable only once per period of confinement and once per calendar year for each Insured Person. Hospital Confinement Benefit We will pay a benefit of $300 per day per unit of coverage selected when an Insured Person is hospitalized during any continuous period of 30 days or less for the treatment of a covered Specified Disease. Benefits will double per day beginning with the 31st day of continuous confinement. If the hospital confinement follows a previously covered confinement, it will be deemed a continuation of the first confinement unless it is the result of an entirely different Specified Disease, or unless the confinements are separated by 30 days or more.

Monthly Rates

Employee

Single Parent

Employee and Spouse

Family

Base Plan A

$16.61

$20.55

$28.10

Base Plan B

$26.09

$31.34

$43.39

Base Plan C

$35.02

$41.52

$57.83

Cancer

OPTIONAL BENEFITS YOU MAY SELECT FOR ADDITIONAL PREMIUM

HOSPITAL INTENSIVE CARE UNIT BENEFIT RIDER (form LG-6047) Intensive Care Unit Benefit We will pay the daily Hospital Intensive Care Unit Benefit shown on the Certificate Schedule for an Insured Person’s confinement in an ICU for sickness or injury.

$600 Per Day

Double Intensive Care Unit Benefit We will pay double the daily Hospital Intensive Care Unit benefit amount shown on the Certificate Schedule for an Insured Person’s confinement in an ICU as a result of Cancer. We will also double this ICU benefit for only the initial ICU confinement resulting from an Insured Person’s travel related injury, provided that the ICU confinement begins within 24 hours of the accident causing the travel related injury. A travel related injury includes being struck by an automobile, bus, truck, van, motorcycle, train or airplane; or being involved in an accident where the Insured Person was the operator or passenger in or on such vehicle.

$1,000 Per Day

Step Down Unit Benefit We will pay one-half of the daily Hospital Intensive Care Unit benefit amount shown on the Certificate Schedule for an Insured Person’s confinement in a Step Down Unit for a sickness or injury.

$250 Per Day

Additional Limitations and Exclusions for the Hospital Intensive Care Unit Benefit Rider If the rider is issued and coverage is in force, it will provide benefits if an Insured Person goes into a hospital Intensive Care Unit (including a Cardiac Intensive Care Unit or Neonatal Intensive Care Unit). Benefits start the first day of confinement in an ICU for sickness or injury. Any combination of benefits payable under this rider is limited to a maximum of 45 days per each period of confinement. ALL BENEFITS CONTAINED IN THIS HOSPITAL INTENSIVE CARE UNIT BENEFIT RIDER REDUCE BY ONE-HALF AT AGE 75. Benefits are not payable for any ICU or Step Down Unit confinement that results from intentional self-inflicted injury; or the Insured Person’s being intoxicated or under the influence of alcohol, drugs or any narcotics, unless administered on and according to the advice of a medical practitioner. THIS IS A LIMITED RIDER.

Monthly Rates

Employee

Single Parent

Employee and Spouse

Family

Base Plan A with ICU

$18.93

$23.75

$32.50

Base Plan B with ICU

$28.42

$34.53

$47.79

Base Plan C with ICU

$37.35

$44.72

$62.23

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 UNUM Base Life and AD&D Your district provides full-time employees with Basic Life coverage. You benefit amount is viewable during your enrollment or on your Consolidated Enrollment Form. Base Life and AD&D Eligibility Life and AD&D Benefit Amount Portability & Conversion Survivor Support Benefit Reduction Scheduled Accelerated Death Benefit

Full Time Employee working 15+ hours per week. Minimum $10,000 benefit to an overall maximum of $50,000 in increments of $5,000, varies by District Included Included 65% at age 65 and 50% at age 70 100% of life benefit amount

UNUM Voluntary Life and AD&D Voluntary Life and AD&D Eligibility Life Benefit Amount

AD&D Benefit Amount

Life Guarantee Issue

Portability and Conversion Survivor Support Benefit Reduction Schedule Accelerated Death Benefit

Full Time Employee working 15+ hours per week. Employee - Up to 7 times annual earnings 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. Child(ren) - Up to 100% of employee coverage amount in increments of $5,000. Not to exceed $10,000. Employee - Up to 10 times annual earnings 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. Child(ren) - Up to 100% of employee coverage amount in increments of $5,000. Not to exceed $10,000. Employee - $250,000 Spouse - $50,000 Child - $10,000 Included Included 65% at age 65; 50% at age 70 100% of life benefit amount to a maximum of $250,000

Voluntary Life and AD&D Rates EE & Spouse Monthly Life Rates per $10,000 Under 25 $0.37 25-29 $0.37 30-34 $0.56 35-39 $0.65 40-44 $0.93 45-49 $1.40 50-54 $2.14 55-59 $4.00 60-64 $6.14 65-69 $11.07 70-74 $17.67 75+ $17.67 $0.80 per $5,000. Cost for your One life premium covers Child(ren) all eligible children Age

AD&D

Monthly Rate

Employee Spouse Children

$0.17 per $10,000 $0.17 per $10,000 $0.085 per $5,000

5STAR

Individual Life

YOUR BENEFITS PACKAGE

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

DID YOU KNOW? Experts recommend at least

x 10 your gross annual income in coverage when purchasing life insurance.

Term Life with Terminal Illness and Quality of Life Rider The Family Protection Plan: Term Life Insurance with Terminal Illness Coverage to Age 100 With the Family Protection Plan (FPP), you can provide financial stability for your loved ones should something happen to you. You have peace of mind that you are covered up to age 100.* No matter what the future brings, you and your family will be protected. If faced with a chronic medical condition that required continuous care, would you be able to protect yourself? Traditionally, expenses associated with treatment and care necessitated by a chronic injury or illness have accounted for 86% of all health care spending and can place strain on your assets when you need them most. To provide protection during this time of need, 5Star Life Insurance Company (5Star Life) is pleased to offer the Quality of Life Rider, which is included with your FPP life insurance coverage. This rider accelerates a portion of the death benefit on a monthly basis - 4% each month as scheduled by your employer at the group level, and payable directly to you on a tax favored basis. You can receive up to 75% of the current face amount of the life benefit, following a diagnosis of either a chronic illness or cognitive impairment that requires substantial assistance. Benefits are paid for the following:  Permanent inability to perform at least two of the six Activities of Daily Living (ADLs) without substantial assistance, or  A permanent severe cognitive impairment, such as dementia, Alzheimer’s disease and other forms of senility requiring substantial supervision. Example

Weekly Premium

Death Benefit

Accelerated Benefit

Your age at issue: 35

$10.00

$89,655

4% $3,586.20 a month

Affordability—With several options to choose from, select the coverage that best meets the needs of your family. Terminal Illness—This plan pays the insured 30% (25% in Connecticut and Michigan) of the policy coverage amount in a lump sum upon the occurrence of a terminal condition that will result in a limited life span of less than 12 months. Portability—You and your family continue coverage with no loss of benefits or increase in cost should you terminate employment after the first premium is paid. If this happens, we can simply bill you directly. Coverage can never be cancelled by the insurance company or your employer unless you stop paying premiums. Family Protection—Individual policies can be purchased on the employee, their spouse, children and grandchildren. Children & Grandchildren Plan—Individual life policies can be purchased for children and grandchildren ages newborn through 23. They are not eligible for the Quality of Life Rider. Convenience—Premiums are taken care of simply and easily through payroll deductions. Protection You Can Count On—Within 24 hours after receiving notice of an insured’s death, an emergency death benefit of the lesser of 50% of the coverage amount, or $10,000, will be mailed to the insured’s beneficiary, unless the death is within the two-year contestability period and/or under investigation. This product also contains no war or terrorism exclusions.

For example, in case of chronic illness, you would receive $3,586 each month up to $67,241.25. The remainder death benefit of $22,413.75 would be made payable to your beneficiary.

* Life insurance product underwritten by 5Star Life Insurance Company (a Baton Rouge, Louisiana company). Product may not be available in all states or territories. Request FPP insurance from Dell Perot, Post Office Box 83043, Lincoln, Nebraska 68501, (866) 863-9753.

Family Protection Plan - Terminal Illness

Age on App. Date 18-25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65

$10,000 $7.56 $7.58 $7.65 $7.74 $7.88 $8.07 $8.27 $8.49 $8.73 $9.00 $9.30 $9.64 $10.02 $10.41 $10.84 $11.31 $11.83 $12.41 $13.00 $13.63 $14.28 $14.97 $15.69 $16.43 $17.22 $18.08 $19.04 $20.16 $21.40 $22.79 $24.27 $25.93 $27.66 $29.42 $31.23 $33.12 $35.08 $37.13 $39.31 $41.68 $44.33

MONTHLY RATES WITH QUALITY OF LIFE RIDER DEFINED BENEFIT Employee Coverage Amounts Spouse Coverage Amounts $25,000 $50,000 $75,000 $100,000 $10,000 $20,000 $30,000 $12.40 $20.46 $28.52 $36.58 $7.56 $10.78 $14.01 $12.46 $20.58 $28.71 $36.83 $7.58 $10.83 $14.08 $12.63 $20.92 $29.21 $37.50 $7.65 $10.97 $14.28 $12.85 $21.38 $29.90 $38.42 $7.74 $11.15 $14.56 $13.21 $22.08 $30.96 $39.83 $7.88 $11.43 $14.98 $13.67 $23.00 $32.33 $41.67 $8.07 $11.80 $15.53 $14.17 $24.00 $33.83 $43.67 $8.27 $12.20 $16.13 $14.73 $25.13 $35.52 $45.92 $8.49 $12.65 $16.81 $15.31 $26.29 $37.27 $48.25 $8.73 $13.12 $17.51 $16.00 $27.67 $39.33 $51.00 $9.00 $13.67 $18.33 $16.75 $29.17 $41.58 $54.00 $9.30 $14.27 $19.23 $17.60 $30.88 $44.15 $57.42 $9.64 $14.95 $20.26 $18.54 $32.75 $46.96 $61.17 $10.02 $15.70 $21.38 $19.52 $34.71 $49.90 $65.08 $10.41 $16.48 $22.56 $20.60 $36.88 $53.15 $69.42 $10.84 $17.35 $23.86 $21.77 $39.21 $56.65 $74.08 $11.31 $18.28 $25.26 $23.08 $41.83 $60.58 $79.33 $11.83 $19.33 $26.83 $24.52 $44.71 $64.90 $85.08 $12.41 $20.48 $28.56 $26.00 $47.67 $69.33 $91.00 $13.00 $21.67 $30.33 $27.56 $50.79 $74.02 $97.25 $13.63 $22.92 $32.21 $29.19 $54.04 $78.90 $103.75 $14.28 $24.22 $34.16 $30.92 $57.50 $84.08 $110.67 $14.97 $25.60 $36.23 $32.73 $61.13 $89.52 $117.92 $15.69 $27.05 $38.41 $34.56 $64.79 $95.02 $125.25 $16.43 $28.52 $40.61 $36.54 $68.75 $100.96 $133.17 $17.22 $30.10 $42.98 $38.69 $73.04 $107.40 $141.75 $18.08 $31.82 $45.56 $41.10 $77.88 $114.65 $151.42 $19.04 $33.75 $48.46 $43.90 $83.46 $123.02 $162.58 $20.16 $35.98 $51.81 $47.00 $89.67 $132.33 $175.00 $21.40 $38.47 $55.53 $50.48 $96.63 $142.77 $188.92 $22.79 $41.25 $59.71 $54.17 $104.00 $153.83 $203.67 $24.27 $44.20 $64.13 $58.33 $112.33 $166.33 $220.33 $25.93 $47.53 $69.13 $62.65 $120.96 $179.27 $237.58 $27.66 $50.98 $74.31 $67.04 $129.75 $192.46 $255.17 $29.42 $54.50 $79.58 $71.56 $138.79 $206.02 $273.25 $31.23 $58.12 $85.01 $76.29 $148.25 $220.21 $292.17 $33.12 $61.90 $90.68 $81.19 $158.04 $234.90 $311.75 $35.08 $65.82 $96.56 $86.31 $168.29 $250.27 $332.25 $37.13 $69.92 $102.71 $91.77 $179.21 $266.65 $354.08 $39.31 $74.28 $109.26 $97.71 $191.08 $284.46 $377.83 $41.68 $79.03 $116.38 $104.33 $204.33 $304.33 $404.33 $44.33 $84.33 $124.33

Family Protection Plan - Terminal Illness

Age on App. Date 66* 67* 68* 69* 70*

$10,000 $44.93 $48.25 $52.03 $56.33 $61.17

MONTHLY RATES WITH QUALITY OF LIFE RIDER DEFINED BENEFIT Employee Coverage Amounts Spouse Coverage Amounts $25,000 $50,000 $75,000 $100,000 $10,000 $20,000 $30,000 $105.81 $207.29 $308.77 $410.25 $44.93 $85.52 $126.11 $114.13 $223.92 $333.71 $443.50 $48.25 $92.17 $136.08 $123.58 $242.83 $362.08 $481.33 $52.03 $99.73 $147.43 $134.31 $264.29 $394.27 $524.25 $56.33 $108.32 $160.31 $146.42 $288.50 $430.58 $572.67 $61.17 $118.00 $174.83

*Qualify of Life not available ages 66-70. Quality of Life benefits not available for children. Child life coverage available only on children and grandchildren of employee (age on application date: full term new born to 23 years). $4.98 monthly for $10,000 coverage and $9.97 monthly for $20,000 coverage.

UNUM

Critical Illness

YOUR BENEFITS PACKAGE

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

DID YOU KNOW?

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

Critical Illness How can critical illness insurance help? Critical illness insurance can pay a lump sum benefit at the diagnosis of a critical illness. You can choose the level of coverage from $10,000 to $50,000 - and you can use the money any way you see fit.

Covered Conditions       

Heart attack Major organ failure Occupational HIV Benign brain tumor Blindness End-stage renal (kidney) failure Coronary artery bypass surgery; pays 25% of lump sum benefit

Covered Conditions With Time Limitations   

Stroke—Evidence of persistent neurological deficits confirmed by a neurologist at least 30 days after the event Coma—Coma resulting from severe traumatic brain injury lasting for a period of 14 or more consecutive days Permanent paralysis—Complete and permanent loss of the use of two or more limbs for continuous 90 days as a result of a covered accident

individual’s 70th birthday. Premiums will not be reduced. For coverage purchased after age 70, benefit amounts will not be reduced.

Benefit Overview Critical illness insurance is designed to help employees offset the financial effects of a catastrophic illness with a lump sum benefit if an insured is diagnosed with a covered critical illness. The Critical Illness benefit is based on the amount of coverage in effect on the date of diagnosis of a critical illness or the date treatment is received according to the terms and provisions of the policy. Coverage Amounts

Guarantee Issue Pre-Existing Condition Portability Recurrence Benefit

Benefit Reduction

Available Family Coverage Who can have it? Employees who are actively at work Dependent children newborn until their 26th birthday, regardless of marital or student status All eligible children are automatically covered at 25% of the employee benefit amount (no additional cost) Spouse ages 17 through 64 with purchase of employee coverage

Benefit $5,000 to $50,000 in $1,000 increments Eligible children are covered for the same conditions as employee and the following specific childhood conditions: cerebral palsy, cleft lip or palate, cystic fibrosis, Down syndrome and spina bifida. Diagnosis must occur after the child’s coverage effective date. From $5,000 to $30,000 in $1,000 increments

Reduction of Benefits The benefit amount for the employee and spouse reduces by 50% on the first policy anniversary date after the insured

Premium Rate Information

Employee - $5,000 to $50,000 in increments of $1,000 Spouse - $5,000 to $30,000 in increments of $1,000 Child - 25% of Employee Coverage Amount Employee - $15,000 Spouse - $10,000 12/12 exclusion Included Included - 25% of the coverage amount for an additional payout for a subsequent occurrence of benign brain tumor, coma, heart attack or stroke. Benefit reduces to 50% on the policy anniversary date following the insured’s 70th birthday Paid by the Employee Wellness benefit premium is in addition to the base premium.

Monthly Premium for Lump Sum Benefit Issue Age Blended Tobacco Rates Under 25 $0.49 $0.49 25-29 $0.51 $0.51 30-34 $0.67 $0.67 35-39 $0.91 $0.91 40-44 $1.31 $1.31 45-49 $1.73 $1.73 50-54 $2.22 $2.22 55-59 $2.85 $2.85 60-64* $3.62 $3.62 65-69 $4.10 $4.10 70+ $7.63 $7.63 Same rates apply for Spouse. Spouse issue age 17-64.

UNITED HEALTHCARE 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 Gold Plan Coverage Gold Accident Protection Plan1 coverage Base Plan coverage

Enhanced Plan coverage

 Ambulance (ground)

$300

Includes Base Plan coverage plus

$510

 Emergency room visit

$150

 Diagnostic X-ray exam

$300

 Initial physician visit

$60

 Wrist fracture treatment

$720

 Surgical ligament tear repair

$600

 Knee brace

$210

 Follow-up physician visit

$60

 Physical therapy sessions ($60 per day up to 6 days)

$270

 Organized sports injury benefit2

$540

Platinum Plan Coverage Platinum Accident Protection Plan1 coverage Base Plan coverage

Enhanced Plan coverage

 Ambulance (ground)

$400

Includes Base Plan coverage plus

$680

 Emergency room visit

$200

 Diagnostic X-ray exam

$400

 Initial physician visit

$80

 Wrist fracture treatment

$960

 Surgical ligament tear repair

$800

 Knee brace

$280

 Follow-up physician visit

$80

 Physical therapy sessions ($60 per day up to 6 days)

$360

 Organized sports injury benefit2

$720

1 Benefit amounts may vary by state. 2 Organized sports injury benefit provides an additional 25% coverage up to $10,000. In the Gold coverage example, the organized sports injury enhanced benefit provides an additional $540 ($2,160 X 25% = $540). In the Platinum coverage example, the organized sports injury enhanced benefit provides an additional $720 ($2,880 X 25% = $720).

Monthly Rates Gold Plan

Platinum Plan

Employee Only

$13.64

$18.19

Employee + Spouse

$20.22

$26.96

Employee + Child(ren)

$18.39

$24.52

Family

$24.97

$33.29

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.

ID Watchdog Monthly Rates 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 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.

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

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. 13 FOR A LIST OF PARTICIPATING SCHOOL DISTRICTS

FSA (Flexible Spending Account) NBS Flexcard

When Will I Receive My Flex Card?

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

NBS Prepaid MasterCard® Debit Card

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

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

For a list of sample expenses, please refer to the ETXEBC benefit website: www.etxebc.com

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

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

FSA Annual Contribution Max:

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

$2,550

Dependent Care Annual Max: $5,000

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

Detailed claim history and processing status Health Care and Dependent Care account balances Claim forms, Direct Deposit form, worksheets, etc. Online claims FAQs 53

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

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

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

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

        

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

Dependent Care Expense Account Example Expenses:    

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

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

What Happens If I Don’t Use All of My Funds by The End of the Plan Year (August 31st)? Eligible expenses must be incurred within the plan year +75 day grace period. Contributions are use-it-or- lose-it. Remember to retain all your receipts (including receipts for card swipes). Please contact your benefits admin to determine if your district has the grace period or the $500 Roll-Over option. If your district does not have the roll-over, your plan contributions are use-it-or-lose-it.

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

How To Receive Your Dependent Care Reimbursement Faster. A Direct Deposit form is available on the Benefits Website which will help you get reimbursed quicker!

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

Get Your Money 1. 2. 3. 4.

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

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

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

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

MASA YOUR BENEFITS PACKAGE

Medical Transport

About this Benefit Medical Transport covers emergency transportation to and from appropriate medical facilities by covering the out-of-pocket costs that are not covered by insurance. It includes emergency transportation via ground ambulance, air ambulance and helicopter.

DID YOU KNOW?

A ground ambulance can cost up to

$2,400

and a helicopter transportation fee can cost

over $30,000

Medical Transport MASA provides medical emergency transportation solutions and covers your out of pocket medical transport cost when your insurance falls short. MASA does not use a network, which means you are covered anywhere.

THE TRUTH... Americans today suffer from a false sense of security that their medical coverage will pay for all costs associated with emergency or critical care transport. The reality is that a majority of Americans are only partially covered for these high costs. Most healthcare policies will only pay based off of the “Usual and Customary Charges” while Medicare pays based off a set fee schedule, both leaving you with the remainder of the bill. You face the possibility that your medical coverage will deny the claim leaving you responsible for the ENTIRE bill. We provide medical emergency transportation solutions AND cover your out of pocket medical transport cost when your insurance falls short. “All I had to do was send the bill which was never paid by Medicare and TriCare for Life --- and the rest is history. When MASA received that bill, it was paid and all amounts owed satisfied.” --- MASA Member, 2015

How Much Does It Cost? Emergent Plan $9.00 per employee only/family coverage Platinum Plan $24.50 per employee only coverage $32.50 per family coverage

MASA MTS for Employees Ensures...      

NO health questions NO age limits NO claim forms NO deductibles NO provider network limitations NO dollar limits on emergency transport costs

What is Covered? BENEFIT Emergency Helicopter Transport Emergency Ground Ambulance Transport Fixed Wing (Airplane) Transport Minor Child/Grandchild Return Organ Recipient Transport

EMERGENT

PLATINUM

✔

✔ ✔ ✔ ✔

Organ Retrieval Repatriation/Recuperation with worldwide coverage Non-injury Transport

✔

Pet Return

✔

Vehicle Return

✔

Return Transportation

✔

Escort Transportation

✔

Mortal Remains Transport

✔

✔ ✔

NOTES