2016 Benefit Guide Frisco ISD by Higginbotham Public Sector

FRISCO ISD

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

Table of Contents Benefit Contact Information How to Enroll 1. Benefit Updates 2. Section 125 Cafeteria Plan Guidelines 3. Annual Enrollment 4. Eligibility Requirements 5. Helpful Definitions 6. Health Savings Account (HSA) vs. Flexible Spending Account (FSA) TRS Medical Premium Costs TRS ActiveCare Aetna Medical TRS Baylor Scott & White Medical HMO TRS Medical Enrollment Assistance Tool ALEX® APL-MEDlink® HSA Bank Health Savings Account (HSA) Telehealth MDLive Cigna Dental EyeMed Vision Care Hyatt Legal Plans AUL a OneAmerica Company Disability Loyal American Cancer AUL a OneAmerica Company Voluntary Life UNUM Critical Illness Axis Global AD&D Texas Life Permanent Life ID Watchdog ID Theft Protection NBS Flexible Spending Account (FSA) Section 125 Cafeteria Plan Rules FISD Additional Benefits Retirement Planning 2

3 4-7 8 9 10 11 12 13 14 15-16 17-18 19 20-23 24-27 28-29 30-35 36-37 38-39 40-41 42-45 46-49 50-51 52-55 56-57 58-59 60-63 64-65 66 67-69

FLIP TO... PG. 4 HOW TO ENROLL

PG. 8 BENEFIT UPDATES: WHAT’S NEW

PG. 14 YOUR MEDICAL BENEFITS

Benefit Contact Information

Benefit Contact Information FRISCO ISD BENEFIT ADMINISTRATORS

DENTAL

AD&D

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

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

Axis Global (800) 283-9233 www.axisaccidentalhealth.com

FRISCO ISD BENEFITS OFFICE

VISION

PERMANENT LIFE

Frisco ISD Benefits Admin. Brenna Rose (469) 633-6361 rosebr@friscoisd.net

EyeMed Vision Care (888) 581-3648 www.eyemedvisioncare.com

Texas Life (800) 821-6400 www.texaslife.com

TRS ACTIVECARE MEDICAL

LEGAL PLANS

IDENTITY THEFT

Aetna Baylor Scott & White Select (800) 222-9205 www.trsactivecareaetna.com

Hyatt Legal Services (800) 821-6400 info.legalplans.com Access code: 9310010

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

TRS HMO MEDICAL

DISABILTY

FLEXIBLE SPENDING ACCOUNT

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

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

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

MEDICAL SUPPLEMENT—MEDLINK ®

CANCER

COBRA (MEDICAL)

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

Loyal American (800) 366-8354

WellSystems (844) 752-5146

TELEHEALTH

VOLUNTARY LIFE

COBRA (DENTAL & VISION)

MDLive (800) 365-1663 www.consultmdlive.com

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

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

HEALTH SAVINGS ACCOUNT (HSA)

CRITICAL ILLNESS

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

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

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

TEXT

need to complete your enrollment.

“friscoisd” Avoid typing long URLs and scan

directly to your benefits website,

313131

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

TRY ME

SCAN:

On Your Computer Access THEbenefitsHUB from your

Our online benefit enrollment

computer, tablet or smartphone!

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

! 4

Open Enrollment Tip Please use your District Username and Password to begin your insurance enrollment.

Go to:

Click Login

Enter Username & Password

www.mybenefitshub.com/friscoisd

Please use your District Username and Password to begin your insurance enrollment. If you do not have an FISD

Sample Username smithwickl@friscoisd.org

Network login, use the instructions below. Username:

Sample Password

The first six (6) characters of your last name, followed by the first letter of your first name, followed by the last

smith1234

four (4) digits of your Social Security Number. If you have six (6) or less 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. Default Password: Last Name* (lowercase, excluding punctuation) followed by the last four (4) digits of your Social Security Number.

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

Enrollment Instructions

Please make sure to indicate if your child is a full-time student and/or claimed on your tax return as this could affect eligibility on some benefit plans. To revisit any of the sections mentioned select the button to return to the previous section.

Employee Guide to Enroll in Benefits with THEbenefitsHUB THEbenefitsHUB gives you access to your benefits 24 hours a day, 7 days a week from anywhere that you have Internet access. This guide is meant to see you through the simple enrollment process page-by-page, taking you through your enrollment screens and providing information on how to efficiently complete your enrollment walkthrough.

Logging In Employee Usage Agreement: The Employee Usage Agreement is displayed when you login to the system as an employee. Read this section carefully as it contains disclaimer information and requires an “Electronic Signature”. By clicking the button, you are agreeing to the terms. If you have login issues, you will need to contact the FISD Benefits office at 469-633-6369 or 6360.



Benefits Enrollment When you have completely entered all of your personal and dependent information, you will begin your online enrollment for any of the benefits in which you are eligible. Each benefit will appear on individual pages for your review. Choose your election and then click the button to proceed to the next benefit. 



Demographic Information The Employee Information Entry process requires you to enter demographic information. You will need to review any pre-filled information for accuracy. Complete new or missing information and click on the button when you are ready to proceed to the next step. Please Note: All 

 

fields in BOLD are required.

Personal Information: Enter an email address if you have one. If you need to use the Forgot Password link on the Login page, the system will deliver your new login credentials to this email address. Emergency Information: Enter an emergency contact and the preferred contact method. Dependent Information: To add a dependent, click on the icon. To edit an existing dependent, click on the icon or the name of the dependent listed. Click on the button after successfully adding information for each dependent. Dependents name in THEbenefitsHUB must match exactly the name on the social security card.

HOW TO ENROLL



View Benefit Descriptions: To view, click on the View Plan Outline of Benefit link or the icon next to the name of the plan you would like to review. This shows a plan summary and any available links or documentation related to this plan. View Plan Cost: Click on the checkbox next to each eligible family member or choose the coverage level you would like. The cost will automatically appear in the box to the right of the members’ names. Additionally, the “Election Summary” box will be updated as coverage adjustments are made. View Total Plan Cost: While selecting plans, the cost will automatically adjust in the “Election Summary” box in response to your selections. Forms: One or more of your Benefit Plans may require a paper form to be submitted with the Insurance Carrier. If this is the case, THEbenefitsHUB will prompt you to print the necessary forms during your online enrollment session. View Important Plan Information: Your benefits administrator will spotlight the importance of specific features in a plan or add any disclaimers that may be necessary in the “Plan Information” section. You may expand/collapse this information by clicking anywhere on the section. Product Summary Video: Videos are placed throughout the benefit election process. You can access product videos that explain the purpose, function and importance by clicking on the icon when available.

HOW TO ENROLL

Beneficiary Information Beneficiaries are required if you enroll in any of the life plans only. The designation page will come up only if you elect a plan that requires it.



Consolidated Enrollment Form Consolidated Enrollment Form: This form signals the end of your enrollment walkthrough and will display information from each of the sections listed above, including personal and enrollment information. If you need to make changes after you’ve clicked finished, you will need to click on the Benefit Plan information icon on your home page and then select the Benefit Plan Enrollment and click on the plan you wish to change. If you need assistance, please call 866-914-5202. Once you are finished with the enrollment process, you will be sent to the “Employee Menu” where you may make changes. (See Employee Menu section)

 

login at a later time. When you login again, you will walk through the same process. The information previously entered will be stored. WHAT ARE THOSE SYMBOLS? If you “toggle” the cursor/ arrow on the icons, the definition of the icons will be revealed. = Edit = View LINKS… Any words, names or phrases with your company’s primary color that becomes underlined when you click the highlighted link it will take you to designated section. SCREEN NAVIGATOR: This line is at the top of your screen. You may click on the links to quickly jump back to those previous screens.

When you have completed your benefit selections, click the button and you will be redirected to the Employee Menu screen.

Navigation and Information Entry Tips Below are tips to help you familiarize yourself with the THEbenefitsHUB:   

 

HELP? If you need assistance during the enrollment process, select HELP located at the upper right corner of the screen. BACK & FORTH: Please do not use the web browser’s “back” or “forward” arrows while in the system. Use the navigation buttons in the THEbenefitsHUB instead: REQUIRED INFORMATION: As noted on each screen, the BOLD items are required to allow continuation to the next page. The more information entered, the better the system will work for you; but you may skip non-bolded items if they do not apply. MOVING ON: When each election page is complete, go to the bottom of the page and select the button. UNABLE TO FINISH? If for any reason you are unable to complete the enrollment process you may LOGOUT and

SUMMARY PAGES

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

Where can I find forms?

to review, change or continue benefit elections each year.

For benefit summaries and claim forms, go to your benefit

Changes are not permitted during the plan year (outside of

website: www.mybenefitshub.com/friscoisd. Click on your

annual enrollment) unless a Section 125 qualifying event occurs.

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



Changes, additions or drops may be made only during the

Benefits and Forms section.

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

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

benefit website: www.mybenefitshub.com/friscoisd. Click on

included in the dependent profile. Additionally, you must

the benefit plan you need information on (i.e., Dental) and

notify your employer of any discrepancy in personal and/or

you can find provider search links under the Quick Links

benefit information.



For benefit summaries and claim forms, go to the Frisco ISD

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.

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 Frisco ISD 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

Medical

Aetna

To age 26

Medical

Scott and White

To age 26

Denta

MetLife

To age 26

Vision

EyeMed Vision Care

To age 26

Life

AUL a OneAmerica Company

To age 26

Cancer

Loyal American

To age 25

Critical Illness

UNUM

To age 26

AD&D

Axis Global

To age 25

Individual Life

Texas Life

To age 26

If your dependent is disabled, coverage may be able to continue past the maximum age under certain plans. If you have a disabled dependent who is reaching an ineligible age, you must provide a physicianâ&#x20AC;&#x2122;s statement confirming your dependentâ&#x20AC;&#x2122;s disability. Contact your HR/Benefit Administrator to request a continuation of coverage. 9

Annual Benefit Enrollment

SUMMARY PAGES

Benefit Updates - What’s New: 

GREAT NEWS! Frisco ISD will pay $325 per month to the cost of Medical premiums effective September 1. The TRS Activecare 1 HD premiums will remain the same; the premiums for the other 3 options will  increase slightly and some of the out of pocket maximums and copays will also increase. See the new plan information on the employee benefits portal for specific information. If you enroll in the AC1HD plan you are eligible to enroll in the Health Savings Account. The FSA is also available if you choose any of the other options or decline Medical altogether.



The District is changing dental plans to Cigna for the coming year. The cost of the plans is less than what you currently pay with MetLife. The Basic plan is a MAC plan which means if you choose to use a dentist who is not in the Network you may be balanced billed. You are encouraged to select a dentist in-Network on all the plans; remember that if you enroll in the DHMO you must select a dentist at the time you enroll. See the new dental summaries on the portal for more specific information.



The district is also changing the disability carrier this year to OneAmerica. It is a combination of short term and long term disability depending on the duration of your disability. You can choose up to 5 different benefit options with 5 elimination periods depending on what percentage of your salary you want to insure. If you are currently insured by Hartford you will be taken on the new plan at the same level of coverage and no pre-

existing condition limitations will apply. (Pre-existing limitations will apply to all increases or new coverage). The other supplemental plans including the Telehealth, Voluntary Life and AD&D, Cancer, Critical Illness, Identity Theft and the Legal plan are still available at the same cost.

Important Enrollment assistance is available by calling Financial Benefit Services at (469) 385-4685 to speak to a representative. Spanish speaking representatives are also available. Annual Open Enrollment 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). 10

SUMMARY PAGES

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

CHANGES IN STATUS (CIS):

Changes in benefit elections can occur only if you experience a qualifying event. You must present proof of a qualifying event to your Benefit Office within 30 days of your qualifying event and meet with your Benefit/HR Office to complete and sign the necessary paperwork in order to make a benefit election change. Benefit changes must be consistent with the qualifying event.

QUALIFYING EVENTS

Marital Status

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

Change in Number of Tax Dependents

A change in number of dependents includes the following: birth, adoption and placement for adoption. You can add existing dependents not previously enrolled whenever a dependent gains eligibility as a result of a valid change in status event.

Change in Status of Employment Affecting Coverage Eligibility

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

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

Helpful Definitions

SUMMARY PAGES

Actively at Work

In-Network

You are performing your regular occupation for the employer

Doctors, hospitals, optometrists, dentists and other providers

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

who have contracted with the plan as a network provider.

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

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

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

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

Plan Year September 1st through August 31st

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

Calendar Year January 1st through December 31st

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

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

(including diagnostic and/or consultation services).

SUMMARY PAGES

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

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

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

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

Employer Eligibility

A qualified high deductible health plan.

All employers

Contribution Source Account Owner Underlying Insurance Requirement

Employee and/or employer Individual

Employee and/or employer Employer

High deductible health plan

None

Description

Minimum Deductible Maximum Contribution

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

N/A $2,550

Permissible Use Of Funds

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

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

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

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

Not permitted

Year-to-year rollover of account balance?

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

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

Does the account earn interest?

Yes

Portable?

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

FLIP TO… PG. 24

FLIP TO… PG. 60

FOR HSA INFORMATION

FOR FSA INFORMATION

Employee Monthly Cost - Frisco ISD 2016 - 2017 TRS Medical Premium Costs - TRS ActiveCare

Effective 09/01/2016 - 08/31/2017 AC 1HD

AC Select

AC 2

HMO

Employee

$16

$159

$320

$205.16

Employee + Spouse

$589

$822

$1227

$867.82

Employee + Child (ren)

$290

$454

$717

$514.16

Employee &+Family

$906

$1036

$1272

$997.98

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

ActiveCare 1-HD

ActiveCare Select or ActiveCare Select Whole Health

ActiveCare 2

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

$2,500 employee only $5,000 family

$1,200 individual $3,600 family

$1,000 individual $3,000 family

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

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

$6,850 individual $13,700 family

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

80% 20%

Office Visit Copay Participant pays

20% after deductible

$30 copay for primary $60 copay for specialist

$30 copay for primary $50 copay for specialist

Diagnostic Lab Participant pays

20% after deductible

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

Preventive Care See next page for a list of services

Plan pays 100%

Teladoc® Physician Services

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

Plan pays 100%

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

20% after deductible

$100 copay plus 20% after deductible

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

20% after deductible

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

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

Emergency Room (true emergency use) Participant pays

20% after deductible

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

Outpatient Surgery Participant pays

20% after deductible

$150 copay per visit plus 20% after deductible

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

$5,000 copay plus 20% after deductible

Not covered

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

Prescription Drugs Drug deductible (per plan year)

Subject to plan year deductible

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

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

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

$20 $40** $65**

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

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

$35 $60** $90**

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

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

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

Specialty Drugs Participant pays

20% after deductible

20% coinsurance per fill

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

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

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

(Provider must bill services as “preventive care”)

Preventive Care Services

ActiveCare 1-HD

ActiveCare Select or ActiveCare Select Whole Health

ActiveCare 2 Network

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

Plan pays 100% (deductible waived)

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

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

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

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

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

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

$50 copay for specialist

Annual Hearing Examination Participant pays

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

$30 copay for primary $50 copay for specialist

$30 copay for primary $60 copay for specialist

Note: Covered services under this benefit must be billed by the provider as “preventive care.” If you receive preventive services from a non-network provider, you will be responsible for any applicable deductible and coinsurance under the ActiveCare 1-HD and ActiveCare 2. Non-network preventive care is not paid at 100%. There is no coverage for non-network services under the ActiveCare Select plan or ActiveCare Select Whole Health. TRS-ActiveCare is administered by Aetna Life Insurance Company. Aetna provides claims payment services only and does not assume any financial risk or obligation with respect to claims. Prescription drug 16benefits are administered by Caremark.

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

Home Health Services

Copay

Preventive Services

No Charge

Home Health Care Visit

$50 co-pay

Standard Lab and X-ray

No Charge

Worldwide Emergency Care

Disease Management and Complex Case Management

No Charge

Well Child Care Annual Exams

No Charge

Online Services

Immunizations (age appropriate)

No Charge

After Hours Primary Care Clinics

Fully Covered Health Care Services

Plan Provisions

$1,000 Individual/ $3,000 Family

Annual out-of-pocket maximum

$5,000 Individual/ $10,000 Family

(including medical and prescription co-pays and coinsurance)

(includes combined Medical and RX copays, deductibles and coinsurance)

Lifetime Paid Benefit Maximum

None

Outpatient Services

Copay (First Primary Care Visit for Illness $0 Copay2)

Specialty Care

$50 co-pay

Other Outpatient Services

20% after deductible3

Diagnostic/Radiology Procedures

20% after deductible

Allergy Serum & Injections Outpatient Surgery

Maternity Care Prenatal Care Inpatient Delivery

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

Diagnostic & Therapeutic Services Physical and Speech Therapy Manipulative Therapy5

Equipment and Supplies

No Charge â&#x20AC;&#x201D; go to www.trs.swhp.org $20 co-pay $40 copay and 20% of charges after deductible

Emergency Room6

$150 copay and 20% of charges after deductible

Urgent Care Facility

$55 copay

Prescription Drugs

Copay

Annual Benefit Maximum

Unlimited

Rx Deductible

$100

Does not apply to preferred generic drugs

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

No Charge 20% after deductible $150 co-pay and 20% of charges after deductible

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

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

$3 copay

$6 copay

Preferred Brand

30% after Rx deductible

Non-preferred

50% after Rx deductible

Non-formulary

Greater of $50 or 50% after deductible

Not available

Copay $150 per day4 and 20% of charges after deductible

Retail Quantity

Maintenance Quantity

(Up to a 30-day supply)

Preferred Generic7

Copay

Mail Order

1-800-707-3477

Copay Specialty Medications

$50 copay

(Up to a 30-day supply)

20% without office visit $40 plus 20% with office visit

Copay

Copay 20% after Rx deductible

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

Preferred Diabetic Supplies and Equipment

$3 copay; no deductible

Non-Preferred Diabetic Supplies and Equipment

30% after Rx deductible

Durable Medical Equipment/ Prosthetics

1-877-505-7947

Ambulance and Helicopter

$20 co-pay

Primary Care1

Eye Exam (one annually)

Nurse Advice Line

Copay

Annual Deductible

Copay

20% after deductible 17

TRS - Scott & White Health Plan Service Area Finding a health care provider has never been easier.

Our provider search tool allows you to: • Search by name, specialty, and/or ZIP code • Add filters for gender, board certification, accepting new patients, and more • See practice locations, contact information, and maps • Get details, including network participation and hospital affiliations 

Customize your own profile

Try it out. Go to www.trs.swhp.org and scroll down the page to “ Find a Provider,” and you will be on your way.

ALEX® The Benefit Administrator’s Best Friend What is ALEX®?

How can I talk to ALEX?

ALEX is your personal TRS-ActiveCare benefits expert. ALEX is

ALEX is available from any computer with an internet connection

funny, speaks in plain English—not insurance-talk—and is

– all you have to do is visit www.myalex.com/trsactivecare to get

available to help you and TRS-ActiveCare members figure out

started. Want to walk through your options with your family? You

which ActiveCare plan will best serve you and your families’ needs can talk to ALEX from your home computer or mobile device, 24 (anonymously, of course).

hours a day, 7 days a week.

Sounds great…but how does it work?

Ready to get started? ALEX will be available on June 24, 2016!

How ALEX works is simple. All you have to do is log on and respond to ALEX’s questions. ALEX will prompt you for some basic information about you and your family, ask a few questions about how your personal situation (everything you say remains confidential, of course), and help you figure out what to choose based on your responses.

What else can ALEX do? 

Help you and TRS-ActiveCare members understand and compare plan options



Explain complicated health insurance terms in jargon-free language



Show you how different plan features like deductibles, coinsurance and out-of-pocket maximums work



Walk you through estimating tax savings with a health savings account (if you’re considering the ActiveCare 1-HD plan)

Premiums for ALEX® Annual Cost

AC 1HD

AC Select

AC 2

Scott & White HMO

Employee

$192

$1908

$3840

$2461.92

Employee + Spouse

$7068

$9864

$14724

$10413.84

Employee + Child (ren)

$3480

$5448

$8604

$6169.92

Employee &+Family

$10872

$12432

$15264

$11975.76

AMERICAN PUBLIC LIFE YOUR BENEFITS

MEDlinkÂŽIV

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

DID YOU KNOW?

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

(03/16)

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 Frisco ISD Benefits Website: www.mybenefitshub.com/friscoisd 20

MEDlink® IV Enhanced

Limited Benefit Group Medical Expense Supplemental Insurance Frisco ISD

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

ENHANCED PLAN SUMMARY OF BENEFITS*

Base Policy

Option 1

Maximum In-Hospital Benefits

$2,500 per Covered Person per Confinement

In-Hospital Ambulance Benefit

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

In-Hospital Deductible

$0 per Covered Person per Confinement

Outpatient Benefit Rider Maximum Outpatient Benefits

$500 per Covered Person per Occurrence for Covered Outpatient Services

Outpatient Ambulance Benefit

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

Outpatient Deductible

$0 per Covered Person Per Occurrence

Covered Outpatient Services Hospital Emergency Room

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

Urgent Care Facility

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

Outpatient Surgery

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

Diagnostic Testing

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

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

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

Total Monthly Premiums by Plan* Employee

Employee & Spouse

Employee & Child

Employee & Family

Ages 18-54

$30.68

$70.55

$52.15

$92.03

Ages 55+

$46.01

$105.83

$78.22

$138.04

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

APSB-22354(TX) MGM/FBS Frisco ISD

MEDlink® IV Enhanced

Limited Benefit Group Medical Expense Supplemental Insurance

Important Policy Provisions

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

s committing, or attempting to commit, an illegal act that is defined as a felony; (Felony is as defined by the law of the jurisdiction in which the act takes place.) s participation in a contest of speed in power driven vehicles, parachuting or hang gliding; s air travel, except: s as a fare-paying passenger on a commercial airline on a regularly scheduled route; or s as a passenger for transportation only and not as a pilot or crew member; s being intoxicated or under the influence of any narcotic unless administered by a Physician or taken according to the Physician’s instructions; (Intoxication means that which is determined and defined by the laws and jurisdiction of the geographical area in which the event that caused the loss occurred.) s alcoholism or drug addiction; s sex changes; s experimental treatment, drugs or surgery; s Accident or Sickness arising out of, and in the course of, any occupation for compensation, wage or profit; (This does not apply to those sole proprietors or partners not covered by Workers’ Compensation.) s dental or vision services, including treatment, surgery, extractions or x-rays, unless: s resulting from an Accident occurring while the Covered Person’s coverage is in force and if performed within 12 months of the date of such Accident; or s due to congenital disease or anomaly of a covered newborn child. s routine examinations, such as health exams, periodic check-ups or routine physicals, except when part of Inpatient routine newborn care; s elective cosmetic surgery; s drugs (prescription and non-prescription for use outside of a covered facility as defined in this Policy/Certificate or any attached rider); s sterilization and reversal of sterilization; s an expense that does not meet the definition of Covered Charges; s an expense or service that exceeds any of the Maximum Benefits, as shown in the Schedule of Benefits; or s any expense for which benefits are not payable under your Other Medical Plan.

Eligibility

When Coverage Begins

Coverage will begin on the requested Certificate Effective Date or the Certificate Effective Date assigned by us, upon approval of your application, if our underwriting rules are met, the premium has been paid and all persons to be insured are covered under your Employer’s Medical Plan and you are Actively At Work on the Certificate Effective Date. If you are not Actively At Work on the Certificate Effective Date due to disability, Injury, Sickness, temporary layoff, leave of absence or Family and Medical Leave of Absence, coverage begins on the date you return to Actively At Work. No benefits will be payable for expenses incurred during any period the Covered Person does not have coverage under your Employer’s Medical Plan, except as provided in the Absence of the Insured’s Employer’s Medical Plan provision, described in the Policy.

Limitations & Exclusions A hospital is not an institution, or part thereof, used as: a place for rehabilitation, a place for rest or for the aged, a nursing or convalescent home, a long term nursing unit or geriatrics ward, or an extended care facility for the care of convalescent, rehabilitative or ambulatory patients.

Pre-Existing Condition Limitation

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

Exclusions

No benefits are payable for any loss resulting from or caused, whether directly or indirectly, by: s war or any act of war, whether declared or undeclared, or active service in the armed forces; (This exclusion includes Accident sustained or Sickness contracted while in the service of any military, naval or air force of any country engaged in war. If coverage is suspended for any Covered Person during a period of military service, APL will refund the pro-rata portion of any premium paid for any such Covered Person upon receipt of your written request) s an intentionally self-inflicted Injury or Sickness; s suicide or attempted suicide, while sane or insane; s rest care or rehabilitative care and treatment; s outpatient routine newborn care; s voluntary abortion except, with respect to you or your covered Eligible Dependent spouse: s where you or your Dependent spouse’s life would be endangered if the fetus were carried to term; or s where medical complications have arisen from abortion; s pregnancy of an Eligible Dependent child; s participating in a riot, insurrection, rebellion, civil commotion, civil disobedience or unlawful assembly; (This does not include a loss which occurs while acting in a lawful manner within the scope of authority.) APSB-22354(TX)22 MGM/FBS Frisco ISD

Premium Changes

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

Optionally Renewable

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

Termination of Certificate

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

MEDlink® IV Enhanced

Limited Benefit Group Medical Expense Supplemental Insurance Termination of Coverage

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

Cobra Continuation of Coverage

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

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

APSB-22354(TX) MGM/FBS Frisco ISD

HSA BANK

HSA (Health Savings Account)

YOUR BENEFITS PACKAGE

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

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

Money withdrawn for medical spending never falls under taxable income.

HSA (Health Savings Account) HSA Bank has teamed up with your employer to create an  Not enrolled in Medicare (if an accountholder enrolls in affordable health coverage option that helps you save on Medicare mid-year, catch-up contributions should be healthcare expenses. This plan is only available for those who are prorated) participating in the Active Care 1-HD medical plan. You may not Authorized Signers who are 55 or older must have their own enroll in the MEDlink® plan if you participate in the HSA. HSA in order to make the catch-up contribution Depending on your district, you may or may not be able to participate in the FSA plan if you participate in HSA. Medicare, Monthly Fee: Your account will be charged a monthly fee of Medicaid, and Tricare participants are not eligible to participate $1.75, waived with an average daily balance at or above in an HSA. $3,000. You can use your Health Savings Account (HSA) to pay for a wide range of IRS-qualified medical expenses for yourself, your spouse or tax dependents. An IRS-qualified medical expense is defined as an expense that pays for healthcare services, equipment, or medications. Funds used to pay for IRS-qualified 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. A way to accumulate additional retirement savings. After age 65, funds can be withdrawn for any purpose without penalty.

Using Funds

Examples of Qualified Medical Expenses      

Surgery Braces Contact lenses Dentures Eyeglasses Vaccines

For a list of sample expenses, please refer to the Frisco ISD website at www.mybenefitshub.com/friscoisd

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

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

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

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

How an HSA works:



 

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

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

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

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

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

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

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

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

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

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

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

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

MDLIVE YOUR BENEFITS PACKAGE

Telehealth

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

DID YOU KNOW?

75%

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

Telehealth When should I use MDLIVE?

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

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

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

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

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

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

How much does it cost? $10.00 Covers you, your spouse, and children up to age 26, with unlimited phone consultations.

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

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

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

Scan with your smartphone to get the app.

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

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

CIGNA

Dental

YOUR BENEFITS PACKAGE

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

DID YOU KNOW?

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

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

RATES

Cigna Dental Choice In-Network Total Cigna DPPO

Out-of-Network

$1,000

$50 per person $150 per family

$50 per person $150 per family 80th percentile of Reasonable and Customary Allowances

Based on Reduced Contracted Fees

Plan Pays

You Pay

Plan Pays

You Pay

EE Only

$19.70

EE + 1 Dependent

$40.12

EE + 2 or more Dependents

$69.66

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

100%

No Charge

100%

Any amount over maximum allowable charge

80%*

20%*

80%*

20%*

Not covered

100% of your dentist's usual fees

Not covered

100% of your dentist’s usual fees

Class II - Basic Restorative Care Fillings Full Mouth X-rays Panoramic X-ray Periapical X-rays Emergency Care to Relieve Pain Osseous Surgery Periodontal Scaling and Root Planing Brush Biopsies Oral Surgery—Simple extractions

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

Class IV - Orthodontia

100% of your Not Covered dentist's usual fees

100% of your Not covered dentist’s usual fees

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

Dental PPO - Enhanced Option Benefits Network Plan Year Maximum

RATES

Cigna Dental Choice In-Network Total Cigna DPPO

Out-of-Network

$1,500

$50 per person $150 per family

Based on Reduced Contracted Fees

90th percentile of Reasonable and Customary Allowances

(Class I, II, and III expenses)

Annual Deductible Individual Family

Reimbursement Levels**

Plan Pays

You Pay

Plan Pays

You Pay

EE Only

$42.98

EE + 1 Dependent

$83.06

EE + 2 or more Dependents

$119.18

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

100%

No Charge

100%

Any amount over the Reasonable and Customary allowance

80%*

20%*

80%*

20%*

50%*

Class II - Basic Restorative Care Fillings Full Mouth X-rays Panoramic X-ray Periapical X-rays Emergency Care to Relieve Pain Brush Biopsies Oral Surgery – Simple Extractions

Class III - Major Restorative Care Crowns Root Canal Therapy Endodontics Osseous Surgery Periodontal Scaling and Root Planning Surgical Extractions of Impacted Teeth Oral Surgery - All except simple extractions Anesthetics Denture Repairs Denture Reclines, Rebases and Adjustments Repairs to Bridges, Crowns and Inlays Dentures Bridges Inlays/Onlays Prosthesis Over Implant

Class IV - Orthodontia Lifetime Maximum

Class IX - Implants Deductible

Plan Maximum

50% $1,000 Dependent children to age 19 50% Subject to plan deductible Subject to plan maximum

50%*

50%

50% $1,000 Dependent children to age 19 50% Subject to plan deductible

50%

Subject to plan maximum

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

Dental PPO - Enhanced and Basic Options Procedure

Exclusions and Limitations

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

50% coverage on Class III and IV for 24 months Two per Plan year Two per Plan year 1 per Plan year for people under 19 Bitewings: 2 per Plan year Full mouth: 1 every 36 consecutive months., Panorex: 1 every 36 consecutive months Payable only when in conjunction with Ortho workup Various limitations depending on the service Various limitations depending on the service Replacement every 5 years Replacement every 5 years Replacement every 5 years Covered if more than 6 months after installation Covered if more than 6 months after installation Reviewed if more than once Repairs - Dentures Reviewed if more than once Limited to posterior tooth. One treatment per tooth every three years up to age 14 Limited to non-Orthodontic treatment 1 per 60 consecutive months if unserviceable and cannot be repaired. Benefits are based on the amount payable for nonprecious metals. No porcelain or white/tooth colored material on molar crowns or bridges When more than one covered Dental Service could provide suitable treatment based on common dental standards, Cigna HealthCare will determine the covered Dental Service on which payment will be based and the expenses that will be included as Covered Expenses Dental Service on which payment will be based and the expenses that will be included as Covered Expenses

Alternate Benefit

Benefit Exclusions



  



 

              

 

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



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

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

Dental - DHMO This Patient Charge Schedule applies only when covered dental service are performed by your Network Dentist, unless otherwise authorized by Cigna Dental as described in your plan documents. Not all Network Dentists perform all listed services and its is suggested to check with your Network Dentist in advance of receiving services For a detailed list of services and fees please visit www.mybenefitshub.com/friscoisd

Code

Procedure Description

Patient Charge

Office Visit Fee (Per patient, per office visit in addition to any other applicable patient charges) Office Visit Fee

$5.00

Diagnostic/Preventive - Oral evaluations are limited to a combined total of 4 of the following evaluations during a 12 consecutive month period: Periodic Oral Evaluations (D0120), Comprehensive Oral Evaluations (D0150), Comprehensive Periodontal Evaluations (D0180), and Oral Evaluations for Patients Under 3 Years of Age (D0145). D9310 Consultation (Diagnostic Service Provided by Dentist or $0.00 Physician Other than Requesting Dentist or Physician) D0120 Periodic Oral Evaluation – Established Patient $0.00 D0150 Comprehensive Oral Evaluation – New or Established Patient $0.00 D0170 Re-evaluation – Limited, Problem Focused (Not Postoperative Visit) $0.00 D0210 X-Rays Intraoral – Complete Series (Including Bitewings) $0.00 (Limit 1 Every 3 Years) D0431 Oral Cancer Screening Using a Special Light Source $50.00 $0.00 D1110 Prophylaxis (Cleaning) – Adult (Limit 2 per Calendar Year)

D1120

Additional Prophylaxis (Cleaning) – In Addition to the 2 Prophylaxes (Cleanings) Allowed per Calendar Year Prophylaxis (Cleaning) – Child (Limit 2 per Calendar Year)

$50.00 $0.00

Additional Prophylaxis (Cleaning) – In Addition to the $40.00 2 Prophylaxes (Cleanings) Allowed per Calendar Year $0.00 D1203 Topical Application of Fluoride – Child (Up to 19th Birthday) (Limited to 2 per Calendar Year). There is a Combined Limit of a Total of 2 D1203s and/or D1206s per Calendar Year. D1206 Topical Fluoride Varnish – Therapeutic Application for $0.00 Moderate to High Caries Risk Patients – Child (Up to 19th Birthday) (Limited to 2 per Calendar Year). There is a Combined Limit of a Total of 2 D1203s and/or D1206s per Calendar Year. D1330 Oral Hygiene Instructions $0.00 D1351 Sealant – Per Tooth $11.00 D1352 Preventive Resin Restoration in a Moderate to High Caries Risk $11.00 Patient – Permanent Tooth D1510 Space Maintainer – Fixed – Unilateral $30.00 D1515 Space Maintainer – Fixed – Bilateral $30.00 D1555 Removal of Fixed Space Maintainer $6.00 Crown and Bridge - All charges for crown and bridge (fixed partial denture) are per unit (each replacement or supporting tooth equals 1 unit) – Replacement limit 1 every 5 years. The charges below include the cost of base metal. Noble metal and high noble metal (precious) or titanium metal, if used, will be charged to the Member at an additional maximum amount of $150.00 per tooth. If a cast post and core is made of high noble metal, an additional fee up to $100.00 per tooth may be charged for the upgraded post and core. Porcelain, if used on molar teeth, will be charged to the Member at an additional maximum amount of $75.00 per tooth. Porcelain/Ceramic substrate crowns on molar teeth are not covered. D2751 Crown – Porcelain Fused to Predominantly Base Metal $215.00 D2791 Crown – Full Cast Predominantly Base Metal $205.00 D2910 Recement Inlay – Onlay or Partial Coverage Restoration $0.00 D2940 Protective Restoration $6.00 D2950 Core Buildup – Including Any Pins $55.00 D6211 Pontic – Cast Predominantly Base Metal $205.00 D6624 Inlay – Titanium $210.00 D6634 Onlay – Titanium $195.00 D6751 Crown – Porcelain Fused to Predominantly Base Metal $195.00 D6930 Recement Fixed Partial Denture $0.00 Implant Supported Prosthetics - All charges for crown and bridge (fixed partial denture) are per unit (each replacement on a supporting implant(s) equals 1 unit) – Replacement limit 1 every 5 years. All charges for an implant supported denture are limited to replacement of 1 every 5 years. The charges below include the cost of base metal. Noble metal and high noble metal (precious) or titanium metal, if used, will be charged to the Member at an additional maximum amount of $150.00 per tooth. If a cast post and core is made of high noble metal, an additional fee up to $100.00 per tooth may be charged for the upgraded post and core. Porcelain, if used on molar teeth, will be charged to the Member at an additional maximum amount of $75.00 per tooth. Porcelain/Ceramic substrate crowns on molar teeth are not covered. D6058 Abutment Supported Porcelain/Ceramic Crown $595.00 D6065 Implant Supported Porcelain/Ceramic Crown $595.00 D6092 Recement Implant/Abutment Supported Crown $40.00

DHMO Monthly Premiums Tier EE Only EE + 1 Dependent EE + 2 or more Dependents

Low Plan $9.87 $18.75 $28.14

Dental - DHMO Code

Procedure Description

Patient Charge

Endodontics (Root Canal Treatment, Excluding Final Restorations) D3310

Anterior Root Canal – Permanent Tooth (Excluding Final Restoration)

$90.00

D3320

Bicuspid Root Canal – Permanent Tooth (Excluding Final Restoration)

$135.00

D3330

Molar Root Canal – Permanent Tooth (Excluding Final Restoration)

$275.00

D3331

Treatment of Root Canal Obstruction – Nonsurgical Access

$95.00

Periodontics (Treatment of Supporting Tissues [Gum and Bone] of the Teeth) Periodontal regenerative procedures are limited to 1 regenerative procedure per site (or per tooth, if applicable), when covered on the Patient Charge Schedule. The Relevant Procedure Codes are D4263, D4264, D4266 and D4267. Localized delivery of antimicrobial agents is limited to 8 Teeth (or 8 sites, if applicable) per 12 consecutive months, when covered on the Patient Charge Schedule. D0180 Comprehensive Periodontal Evaluation – New or Established Patient $0.00 D4355

Full Mouth Debridement to Allow Evaluation and Diagnosis (1 per Lifetime)

$45.00

D4381

Localized Delivery of Antimicrobial Agents per Tooth – By Report

$60.00

D4910

Periodontal Maintenance (Limited to 2 per Calendar Year) $35.00 (Only Covered after Active Therapy) Prosthetics (Removable Tooth Replacement – Dentures) Includes up to 4 adjustments within first 6 months after insertion – Replacement limit 1 every 5 years. Characterization is considered an upgrade with maximum additional charge to the Member of $200.00 per denture. D5110 Full Upper Denture $185.00 D5120

Full Lower Denture

$185.00

D5130

Immediate Full Upper Denture

$205.00

D5140

Immediate Full Lower Denture

$205.00

D5410

Adjust Complete Denture – Upper

$11.00

D5411

Adjust Complete Denture – Lower

$11.00

D5421

Adjust Partial Denture – Upper

$11.00

D5422

Adjust Partial Denture – Lower

$11.00

Repair Broken Complete Denture Base

$35.00

Repairs to Prosthetics D5510 D5520

Replace Missing or Broken Teeth – Complete Denture $35.00 (Each Tooth) Oral Surgery (Includes Routine Postoperative Treatment) Surgical Removal of Impacted Tooth – Not covered for ages below 15 unless pathology (disease) exists. D7111

Extraction of Coronal Remnants – Deciduous Tooth

$6.00

D7140

Extraction, Erupted Tooth or Exposed Root – Elevation and/or Forceps Removal

$6.00

D7210

Surgical Removal of Erupted Tooth – Removal of Bone and/or Section of Tooth

$35.00

D7250

Surgical Removal of Residual Tooth Roots – Cutting Procedure

$45.00

D7288

Brush Biopsy – Transepithelial Sample Collection

$50.00

Orthodontics (Tooth Movement) Orthodontic Treatment (Maximum benefit of 24 months of interceptive and/or comprehensive treatment. Atypical cases or cases beyond 24 months require an additional payment by the patient.) D8660 Pre-Orthodontic Treatment Visit D8670

$125.00

Periodic Orthodontic Treatment Visit – As Part of Contract Children – Up to 19th Birthday: 24-Month Treatment Fee

$1,460.00

Charge per Month for 24 Months

$61.00

Adults: 24-Month Treatment Fee

$2,160.00

Charge per Month for 24 Months

$61.00

General Anesthesia/IV Sedation – General anesthesia is covered when performed by an Oral Surgeon when medically necessary for covered procedures listed on the Patient Charge Schedule. IV sedation is covered when performed by a Periodontist or Oral Surgeon when medically necessary for covered procedures listed on the Patient Charge Schedule. Plan limitation for this benefit is 1 hour per appointment. There is no coverage for general anesthesia or intravenous sedation when used for the purpose of anxiety control or patient management. D9220 General Anesthesia – First 30 Minutes $160.00 D9221

General Anesthesia – Each Additional 15 Minutes

$75.00

D9241

IV Conscious Sedation – First 30 Minutes

$160.00

D9242

IV Conscious Sedation – Each Additional 15 Minutes

$75.00

D9110

Palliative (Emergency) Treatment of Dental Pain – Minor Procedure

$6.00

D9440

Office Visit – After Regularly Scheduled Hours

$35.00

Emergency Services

EYEMED 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 Vision Care Services

In-Network Member Cost

Out-of-Network Reimbursement

Exam With Dilation as Necessary

$10 Copay

Up to $35

Contact Lens Fit and Follow-Up (Contact lens fit and two follow up visits are available once a comprehensive eye exam has been completed) Standard Contact Lens Fit & Follow-Up Up to $55 N/A Premium Contact Lens Fit & Follow-Up 10% off retail

N/A

Retinal Imaging

Up to $39

N/A

Frames

$0 Copay; $125 allowance; 80% of charge over $125

Up to $70

Up to $25 Up to $40 Up to $45 Up to $40

Lenticular

$10 Copay $10 Copay $10 Copay $75 Copay $95 Copay - $120 Copay $95 Copay $105 Copay $120 Copay $75 Copay, 80% of charge less $120 Allowance $10 Copay

Lens Options (paid by the member and added to the base price of lens) UV Treatment Tint (Solid and Gradient) Standard Plastic Scratch Coating Standard Polycarbonate Standard Polycarbonate - Kids under 19 Standard Anti-Reflective Coating Premium Anti-Reflective Coatingr Tier 1 Tier 2 Tier 3 Photochromic/Transitions Polarized Other Add-Ons and Services

$15 $15 $0 $40 $0 $45 $57 - $68 $57 $68 80% of charge $75 20% off retail price 20% off retail price

N/A N/A Up to $8 N/A Up to $20 N/A N/A N/A N/A N/A N/A N/A N/A

$0 Copay; $150 allowance; 15% off retail price over $150 $0 Copay; $150 allowance; plus balance over $150 $0 copay, Paid in Full

Up to $80

15% off the retail price or 5% off the promotional price

N/A

Standard Plastic Lenses Single Vision Bifocal Trifocal Standard Progressive Lens Premium Progressive Lensr Tier 1 Tier 2 Tier 3 Tier 4

Contact Lenses Conventional Disposable Medically Necessary Laser Vision Correction Lasik or PRK from U.S. Laser Network Frequency Examination Lenses or Contact Lenses Frame

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

Up to $40 Up to $40 Up to $40 Up to $40 Up to $80

Up to $80 Up to $150

RATES EE Only

$7.08

EE + One Dependent

$12.38

EE + Family

$18.47

Benefits Snapshot

With Us

Out-of-Network Reimbursement

Exam with dilation as necessary (Once every

$10 Copay

Up to $35

Frames (Once every 12 months)

$0 Copay: $125 allowance; 80% of charge over $125

Up to $70

Single Vision Lenses (Once every 12 months)

$10 Copay

Up to $25

$0 Copay; $150 allowance; plus balance over $150

Up to $80

12 months)

Or Contacts (Once every 12 months)

HYATT GROUP YOUR BENEFITS PACKAGE

Legal Services

About this Benefit Having an affordable, qualified lawyer on your side can be an invaluable asset. Legal plans provide valuable benefits that cover the most common legal needs you may encounter - like creating a standard will, living will, healthcare power of attorney or buying a home. This plan also provides access to quality law firms for advice, consultation and representation.

DID YOU KNOW?

55% of American adults do not have a will or other estate plan in place.

Legal Services The Hyatt Legal Plan provides you, your spouse and dependents with fully covered legal services from attorneys experienced in estate planning documents, civil suits, adoption, creditor issues and much more. Sign up for a convenient payroll deduction of just $19.50 a month, and save hundreds over typical attorney fees...with no deductibles, no co-pays, no claim forms or usage limits when using a plan attorney. We’ll automatically deduct the cost from your paychecks.

COVERED SERVICES Administrative Hearings

Juvenile Court Defense

Adoption

Living Wills

Affidavits, Deeds

Mortgages

Boundary or

Name Change

Title Disputes

Personal Bankruptcy

Choose from 13,500 attorneys nationwide.

Civil Litigation Defense

Personal Property

Receive fully covered legal advice and representation for a wide range of legal matters. You can consult with your attorney on the phone or in person. You can also use a nonplan attorney and get reimbursed for covered services according to a set fee schedule.*

Consumer

Protection

Protection Matters

Powers of Attorney

Debt Collection

Prenuptial Agreement

Defense

Promissory Notes

Demand Letters

Property Tax

Divorce - Uncontested

Assessment

& Contested [20

Restoration

Hours]

of Driving Privileges

Document Review

Sale, Purchase or

Domestic Violence

Refinancing (primary,

Protection

secondary or vacation

Elder Law Matters

home)

Enforcement or

Security Deposit

Modification of Support

Assistance

Orders

(for tenants)

Eviction and Tenant

Small Claims

Problems (for tenants)

Assistance

Guardianship

Tax Audits

Home Equity Loans

Traffic Ticket Defense

(primary, secondary or

(excludes DUI)

vacation home)

Trusts

Identity Theft Defense

Wills, Codicils

Immigration Assistance

Zoning Applications

It’s easy to access the right attorney. Online. By Phone. In Person. Once you’re enrolled, simply go to info.legalplans.com. You can also call Hyatt Legal Plans toll-free at 1-800-821-6400 Monday through Friday from 8 a.m. to 7 p.m. EST. A representative will confirm your plan eligibility and give you a case number and the address and phone number of the appropriate attorney(s) near you. Service is just a click or call away.

Typical Family Savings for Basic Legal Needs Wills for Employee and Spouse

$5801

Medical Powers of Attorney

$1451

Traffic Ticket Defense

$2002

Home Refinancing

$5003

Total

$1,425

The Legal Plan for Frisco Independent School District Employees ($19.50 per month)

$234 per year

Potential Savings

$1,191

The Hyatt Legal Plan also provides coverage for a number of legal matters — buying or selling a primary home, document review, civil litigation defense and telephone and office consultations for numerous matters except employment related, business or pre-existing matters. Don’t miss out on this important benefit. 1 Average hourly rate of $290.00/hour based on years of legal experience, National Law Journal and ALM Legal Intelligence, Survey of Law Firm Economics (2011). 2 Based on information provided by www.costhelper.com/cost/finance/ traffic-ticket-attorney.html (2011). 3 Based on information provided by www.federalreserve.gov (2010).

Incompetency Defense

RATE Employee (covers spouse & dependents)

$19.50

AUL A ONE AMERICA COMPANY

YOUR BENEFITS PACKAGE

Educator Disability

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

DID YOU KNOW?

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

34.6 months is the duration of the average disability claim.

Educator Disability What you need to know about your Group Disability Benefits Elimination Period:

This is a period of consecutive days of disability before benefits may become payable under the contract. This is the length of time that you may be paid benefits if continuously disabled as outlined in the contract. A limited benefit will be paid if the Person’s Disability begins in the first 12 months following the Person’s Individual Effective Date of Insurance; and the Person’s Disability is caused by, contributed to by, or the result of a condition, whether or not that condition is diagnosed at all or is misdiagnosed, for which the Person received medical treat, consultation, care or services, including diagnostic measures, or was prescribed drugs or medicines in the 3 months just prior to the Person’s Individual Effective Date of Insurance. The monthly amount payable under this provision will be the lesser of: 1) The Person’s Monthly Benefit payable if the Person did not have a Pre-Existing Condition; or 2) The Person’s Gross Monthly Benefit. Benefits under this provision are payable for no more than 4 weeks during any one period of Disability. In no event will benefits be paid beyond the Maximum Benefit Duration.

Minimum Benefit Duration Existing Condition Period:

Group Educator Disability Options You may select a benefit percentage of 20%, 30%, 40%, 50% or 60% of your earnings, up to a maximum monthly benefit of $7,500. Elimination Period:

Maximum Benefit Duration Age When Total Disability Begins

Option 1: 14 days/ 14 days Option 2: 30 days / 30 days Option 3: 60 days / 60 days Option 4: 90 days /90 days Option 5: 180 days / 180 days

Less than age 60 60 61 62 63 64 65 66 67 68 69 and over

Pre-Existing Condition Period 3 Months/ 12 Months

Maximum Duration Greater Social Security Full Retirement Age or To age 65 5 years 4 years 3.5 years 3 years 2.5 years 2 years 21 months 18 months 15 months 12 months

Rates Per $100 of Monthly Benefit 20% Benefit Option:

Option 1 14 days / 14 days

Option 2 30 days / 30 days

Option 3 60 days / 60 days

Option 4 90 days / 90 days

Option 5 180 days / 180 days

Rate:

$2.46

$1.94

$1.55

$1.28

$0.94

30% Benefit Option:

Option 1 14 days / 14 days

Option 2 30 days / 30 days

Option 3 60 days / 60 days

Option 4 90 days / 90 days

Option 5 180 days / 180 days

Rate:

$2.46

$1.94

$1.55

$1.28

$0.94

40% Benefit Option:

Option 1 14 days / 14 days

Option 2 30 days / 30 days

Option 3 60 days / 60 days

Option 4 90 days / 90 days

Option 5 180 days / 180 days

Rate:

$2.46

$1.94

$1.55

$1.28

$0.94

50% Benefit Option:

Option 1 14 days / 14 days

Option 2 30 days / 30 days

Option 3 60 days / 60 days

Option 4 90 days / 90 days

Option 5 180 days / 180 days

Rate:

$2.74

$2.16

$1.73

$1.42

$1.05

60% Benefit Option:

Option 1 14 days / 14 days

Option 2 30 days / 30 days

Option 3 60 days / 60 days

Option 4 90 days / 90 days

Option 5 180 days / 180 days

Rate:

$3.22

$2.54

$2.03

$1.67

$1.23 41

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 ADDITIONAL BENEFIT AMOUNTS

PLAN A 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).

Additional Benefit

We will pay the expense incurred, but not to exceed two times the maximum benefit amount per calendar year as shown on the Certificate Schedule, for one additional invasive diagnostic procedure required as the result of an 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 onehalf times the First Occurrence benefit amount shown on the Certificate Schedule.

$50 Per Calendar Year

$100 Per Calendar Year

$2,000 Once per Lifetime $3,000 Once per Lifetime

DAILY RADIATION, CHEMOTHERAPY, IMMUNOTHERAPY and EXPERIMENTAL TREATMENT BENEFIT RIDER (form LG-6046) We will pay the Actual Charge, but not to exceed the maximum benefit amount shown on the Certificate Schedule for each day that an Insured Person receives one or more of the following treatments for Cancer: (1) Chemotherapy (including Hormonal Therapy) or Immunotherapy; (2) Self-injected Chemotherapy or Immunotherapy drugs, limited to the maximum daily benefit amount per treatment; (3) Chemotherapy or Immunotherapy drugs dispensed by a pump or implant, limited to the maximum daily benefit amount for the initial prescription and an equal amount for each refill; (4) Oral Chemotherapy or Immunotherapy, limited to the maximum daily benefit amount per prescription; (5) Radiation Treatment. Benefits payable for interstitial or intracavitary applications of Radiation Treatments are payable on the day of insertion only and not for each day the Radiation Treatment remains in the body; or (6) Experimental Treatment. The benefit amount shown on the Certificate Schedule is the maximum daily benefit available per Insured Person regardless of the number or types of Cancer treatments received on the same day.

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.

$600 Per Calendar Year

$5,000 Procedure Maximum

$1,250 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 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.

$4,500 Procedure Maximum

Per Procedure

$200 Per Day

$400 Per Day $400/ $800 Per Day 43

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. 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. 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.

$1,000 Per Day

$2,000 Per Day

$500 Per Day

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. 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.

Cancer *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 Personâ&#x20AC;&#x2122;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 Only

Employee + Children

Employee + Family

Base Plan

$22.86

$27.86

$38.50

Base Plan + ICU

$27.51

$34.25

$47.30

AUL A ONEAMERICA COMPANY

Voluntary Life

YOUR BENEFITS PACKAGE

About this Benefit Life insurance provides a cash death benefit to your beneficiary upon your death. 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 wellbeing of your family. If you are covered, you may apply for coverage on your spouse and eligible dependent children.

DID YOU KNOW? Experts recommend at least

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

Voluntary Life AUL's Group Voluntary Term Life Insurance Terms and Definitions

Continuation of Coverage Options:

This benefit is available for employees who are actively at work on the effective date and working a minimum of 20 hours per week.

Portability Should your coverage terminate for any reason, you may be eligible to take this term life insurance with you without providing Evidence of Insurability. You must apply within 31 days from the last day you are eligible. The Portability option is available until you reach age 70. See policy for specific information on continuing coverage upon termination.

Flexible Choices:

Eligible Employees:

Since everyone's needs are different, this plan offers flexibility for you to choose a benefit amount that fits your needs and budget. Conversion Should your life insurance coverage, or a portion of it, cease for any reason, you may be eligible to convert your Group Term Guaranteed Issue Amounts: Coverage to Individual Coverage without providing Evidence of This is the most coverage you can purchase without having to Insurability. You must apply within 31 days from the last day you answer any health questions. If you decline insurance coverage now and decide to enroll later, you will need to provide Evidence are eligible. of Insurability. Employee Guaranteed Issue Amount

$400,000

Spouse Guaranteed Issue Amount

$80,000

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

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

Accelerated Life Benefit: If diagnosed with a terminal illness and have less than 12 months to live, you may apply to receive 25%, 50% or 75% of your life insurance benefit to use for whatever you choose. Waiver of Premium: If approved, this benefit waives your and your dependents' insurance premium in case you become totally disabled and are unable to collect a paycheck. Reductions: Upon reaching certain ages, your original benefit amount will reduce to a percentage as shown in the following schedule. Age:

Reduces To:

65%

50%

This invitation to inquire allows eligible employees an opportunity to inquire further about AUL's group insurance and is If eligible, this benefit allows you to increase your coverage every limited to a brief description of any losses for which benefits are year as your life insurance needs change. You may be able to payable. The contract has exclusions, limitations reduction of increase your benefit amount by $10,000 every year until you benefits, and terms under which the contract may be continued reach the guaranteed issue amount, without providing Evidence in force or discontinued. of Insurability.

Guaranteed Increase in Benefit:

NOTE: If Evidence of Insurability is applied for and denied, please be aware Guaranteed Increase in Benefits will not be made available to you in the future.

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

You may select a minimum benefit of $10,000 up to a maximum amount of $500,000, in increments of $10,000, not to exceed 7 times your annual base salary only, rounded to the next higher $10,000. Amounts requested above $400,000 for an Employee, $80,000 for a Spouse, or any amount not requested timely will require Evidence of Insurability. Employee must select coverage to select any Dependent coverage. Dependent coverage cannot exceed 100% of the Voluntary Term Life amount selected by the Employee.

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

0-19

20-24

25-29

30-34

35-39

40-44

45-49

50-54

55-59

60-64

65-69

70-74

75+

$10,000

$.50

$.70

$.80

$.90

$1.40

$2.10

$3.90

$6.00

$11.50

$18.50

$22.00

$20,000

$1.00

$1.40

$1.60

$1.80

$2.80

$4.20

$7.80

$12.00

$23.00

$37.00

$44.00

$30,000

$1.50

$2.10

$2.40

$2.70

$4.20

$6.30

$11.70

$18.00

$34.50

$55.50

$66.00

$40,000

$2.00

$2.80

$3.20

$3.60

$5.60

$8.40

$15.60

$24.00

$46.00

$74.00

$88.00

$50,000

$2.50

$3.50

$4.00

$4.50

$7.00

$10.50

$19.50

$30.00

$57.50

$92.50 $110.00

$80,000

$4.00

$5.60

$6.40

$7.20

$11.20

$16.80

$31.20

$48.00

$92.00 $148.00 $176.00

$100,000

$5.00

$7.00

$8.00

$9.00

$14.00

$21.00

$39.00

$60.00 $115.00 $185.00 $220.00

$200,000

$10.00 $10.00 $10.00 $14.00 $16.00 $18.00 $28.00

$42.00

$78.00 $120.00 $230.00 $370.00 $440.00

$300,000

$15.00 $15.00 $15.00 $21.00 $24.00 $27.00 $42.00

$63.00 $117.00 $180.00 $345.00 $555.00 $660.00

$400,000

$20.00 $20.00 $20.00 $28.00 $32.00 $36.00 $56.00

$84.00 $156.00 $240.00 $460.00 $740.00 $880.00

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

0-19

20-24

25-29

30-34

35-39

40-44

45-49

50-54

55-59

60-64

65-69

70-74

75+

$5,000

$.25

$.35

$.40

$.45

$.70

$1.05

$1.95

$3.00

$5.75

$9.25

$11.00

$10,000

$.50

$.70

$.80

$.90

$1.40

$2.10

$3.90

$6.00

$11.50

$18.50

$22.00

$15,000

$.75

$1.05

$1.20

$1.35

$2.10

$3.15

$5.85

$9.00

$17.25

$27.75

$33.00

$20,000

$1.00

$1.40

$1.60

$1.80

$2.80

$4.20

$7.80

$12.00

$23.00

$37.00

$44.00

$25,000

$1.25

$1.75

$2.00

$2.25

$3.50

$5.25

$9.75

$15.00

$28.75

$46.25

$55.00

$40,000

$2.00

$2.80

$3.20

$3.60

$5.60

$8.40

$15.60

$24.00

$46.00

$74.00

$88.00

$50,000

$2.50

$3.50

$4.00

$4.50

$7.00

$10.50

$19.50

$30.00

$57.50

$92.50 $110.00

$60,000

$3.00

$4.20

$4.80

$5.40

$8.40

$12.60

$23.40

$36.00

$69.00 $111.00 $132.00

$70,000

$3.50

$4.90

$5.60

$6.30

$9.80

$14.70

$27.30

$42.00

$80.50 $129.50 $154.00

$80,000

$4.00

$5.60

$6.40

$7.20

$11.20

$16.80

$31.20

$48.00

$92.00 $148.00 $176.00

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

$10,000

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

Monthly Payroll Deduction Life Amount $1.00

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

UNUM

Critical Illness

YOUR BENEFITS PACKAGE

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

DID YOU KNOW?

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

Critical Illness Coverage Amounts

Benefit Waiting Period



30 days

 

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

Included

Premium

Guarantee Issue  

Portability

Paid by the Employee

Employee – $30,000 Spouse - $15,000

Pre-Existing Condition Employee 12/12 exclusion

Monthly Rates per $1,000 Without Cancer Issue Ages

Monthly Rates

< 25

.29

25 - 29

.29

30 - 34

.43

35 - 39

.58

40 - 44

.84

45 - 49

1.10

50 - 54

1.41

55 - 59

1.82

60 - 64

2.32

65 - 69

2.62

70 +

4.90

This plan highlight is a summary provided to help you understand your insurance coverage from Unum. Details may differ from state to state. Please refer to your certificate booklet for your complete plan description. If the terms of this plan highlight summary or your certificate differ from your policy, the policy will govern. 51

AXIS GLOBAL YOUR BENEFITS PACKAGE

AD&D

About this Benefit 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.

AD&D Overview Accidental Death & Dismemberment (AD&D) Insurance:

Eligibility:

pays a benefit for a critical or fatal injury caused by a covered accident, and pays in addition to most other insurance available, including disability or life insurance.

All active full time Employees of the Employer working 20 plus hours per week who are domiciled in the United States, its territories and protectorates, excluding temporary, lease or seasonal employees.

Principle Sum: $10,000 to $500,000 in units of $10,000 - to a maximum of $500,000. Principal Sum amounts above $250,000 may not exceed 10 times Basic Earnings.

Core Benefits Accidental Death & Dismemberment Schedule of Benefits

Loss of Life

100% of the Principal Sum

Loss of or Loss of use of Two or more Hands or Feet

100% of the Principal Sum

Loss of Sight Both Eyes

100% of the Principal Sum

Loss of One Hand or One Foot and Sight in One Eye

100% of the Principal Sum

Loss of Speech and Hearing (both ears)

100% of the Principal Sum

Loss of or Loss of use of One Hand or Foot

50% of the Principal Sum

Loss of Sight in One Eye

50% of the Principal Sum

Loss of Speech

50% of the Principal Sum

Loss of Hearing (both ears)

50% of the Principal Sum

Loss of Thumb and Index Finger of the Same Hand

25% of the Principal Sum

Loss of all Four Fingers of the Same Hand

25% of the Principal Sum

Loss of all the Toes of the Same Foot

20% of the Principal Sum

Exposure and Disappearance Benefit

Included

AD&D Overview Medical Evacuation and Repatriation Benefits

Additional Benefits



Travel Assistance Services You and your family have access to travel assistance services for emergencies that occur while traveling almost anywhere in the world, at least 100 miles from home. Comprehensive services are available locally in over 200 countries and through 40 assistance centers open 24/7, these comprehensive services offer support to help travelers in an emergency. Refer to the travel assurance flyer provided by your employer which includes information on the services available, as well as a wallet card with important contact information.

Rates: Employee Only: per employee, per month per $1,000 Principal Sum Family Plan: per employee, per month per $1,000 Principal Sum

$0.02/$1,000 $0.04/$1,000

Your coverage includes Additional Benefits beyond the Principal Sum that can be paid if an Accidental Death or Accidental Dismemberment Benefit is payable under the Policy. Certain other conditions may apply.

Paralysis Benefit 

If bereavement and trauma counseling is needed due to a covered loss, you could qualify for 10 - $100 sessions with a maximum benefit of $1,000.

100% of the Principal Sum 75% of the Principal Sum Hemiplegia (total paralysis of upper and 50% of the Principal lower limbs on one side of body Sum Uniplegia (total paralysis of one upper 25% of the Principal or lower limb) Sum

Rehabilitation Benefit 

Your Dependent Child attending a child care center facility could qualify for this benefit: an additional 3% of the Principal Sum, up to a maximum of $3,000 per year for a maximum of 5 years until age 13.



COMA



If you become comatose or suffer a covered loss that results in coma you could receive a monthly benefit of 1% of the Principal Sum for the first 11 months, 100% of the Principal Sum in the 12th Month.

If you suffer a covered loss and require home alteration and vehicle modification, you could qualify for an additional 10% multiplied by the portion of the Benefit Amount applicable to the covered loss for Accidental Death and Dismemberment, Coma or Paralysis up to a maximum of $25,000.

If you die in a covered accident while traveling in a private passenger vehicle and properly wearing a seatbelt, you could qualify for an additional 10% of the Principal Sum, up to a maximum of $50,000 If you die in a covered accident while traveling in a private passenger vehicle equipped with a properly functioning airbag, you could qualify for an additional 10% of the Principal Sum, up to a maximum of $25,000.

Special Education Benefits 

Home Alteration and Vehicle Modification Benefit 

If you require rehabilitation after sustaining a covered loss, you could qualify for an additional 10% multiplied by the portion of the Benefit Amount applicable to the covered loss for Accidental Death and Dismemberment, Coma or Paralysis up to a maximum of $25,000.

Seatbelt and Airbag Benefits

Child Care Center Benefit 

If you become paralyzed or suffer a covered loss that results in paralysis you could qualify for:

Quadriplegia (total paralysis of both upper and lower limbs) Paraplegia (total paralysis of both lower limbs)

Bereavement & Trauma



If a covered accident occurs while traveling that results in the need for your emergency medical evacuation or a repatriation of your remains, you could qualify for an additional benefit of 100% of the Usual and Customary charges for such an expense.



Surviving Dependent Child  If you die in a covered accident your dependent child attending school could qualify for an additional 5% of the Principal Sum, up to a maximum of $5,000 per year for up to 4 years. Spouse Retraining Benefit  If you die in a covered accident your surviving spouse attending school could qualify for an additional 5% of the Principal Sum, up to a maximum of $7,500.

AD&D Overview Family Plan Only COBRA Medical insurance Continuation Expense Benefit ď&#x201A;ˇ

Reimburses COBRA Insurance Continuation expenses if you die in a covered accident and are survived by a spouse or dependent child(ren). You could qualify for $3,000 per policy year for a maximum of 36 months.

TEXAS LIFE

Individual Life

YOUR BENEFITS PACKAGE

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

DID YOU KNOW?

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

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

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

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

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



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



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



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



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

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

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

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 LIFELOCK BASIC

LIFELOCK ULITMATE

IDENTITY GUARD

INFO ARMOUR

IDW PLUS

IDW PLATINUM

INDIVIDUAL PLAN

$7.95/mo

$11.95/mo

FAMILY PLAN

$14.95/mo

$22.95/mo

Basic Identity Monitoring Advanced Identity Monitoring Alternative Monitoring Zero Hour Identity Monitoring Cyber Monitoring Credit Report Monitoring Credit Reports & Scores Lost Wallet Full-Service Identity Restoration NPI Monitoring

True Identity Protection Basic Identity Monitoring: Standard monthly scans of public records databases searching for new information associated with your Social Security Number. Advanced Identity Monitoring: Advanced scans of the National Change of Address (NCOA) database identifies new addresses associated with your personal information.

Credit Reports & Scores (Platinum Plan Only): Access to your credit reports and scores from the three primary credit reporting agencies; Equifax, Experian and TransUnion.

Extended Identity Protection Lost Wallet: Online safe box securely stores credit card, driver license info and more. Includes cancellation and request for new credit cards in the event your wallet or purse is stolen.

Alternative Monitoring: Identity thieves actions are not always imme‐ diately detected through mainstream credit and identity monitoring. Today we scan Non-Credit Payday loan databases which provide highinterest, quick cash transactions and require minimal personal information to obtain. We are expanding our fraud detection network to include monitoring Auto Pawn, Buy-Here- Pay Here auto dealers and Rent-To-Own store transactions. This is the most comprehensive alternative credit monitoring in the ID theft protection industry.

Proactive Zero Hour Identity Monitoring: Continuous monitoring from daily scanning of billions of transactions and data points will pro‐ vide an early warning alerting customers of high risk transactions. Be‐ cause this system is monitoring in real time you will be able to detect potential fraud as it is happening or immediately after it has happenedat the source- so that our dedicated team can help you stop it in its tracks and prevent the damage that can occur with identity theft. Cyber Monitoring: Scans social networking sites, hacker forums, under‐ ground websites and other illicit online sources that buy, sell, and trade personal information including (but not limited to) credit card numbers, password, and SSN.

Full-Service Identity Restoration: A dedicated team of trained in-house Certified Identity Theft Resolution Specialists (CITRS) who work on your behalf to restore your identity by addressing record- keeping and reporting agencies, removing erroneous and fraudulent records that appear in your name. ID Watchdog has a flawless record in restoring victim’s identities- and to date we have never failed to completely restore an identity. A benefit of our concierge level service is few costs associated with identity restora‐ tion. However, we know peace of mind is important. All our ID Protec‐ tion Plans include a $1,000,000 expense reimbursement insurance* to cover those rare instances when expenses may arise during a restora‐ tion. NPI Monitoring: Monitors National Provider Identifiers (NPI) for healthcare professionals. * Maximum $1 Million reimbursement insurance under a Master Insurance Policy underwritten by American International Group Inc. Please reference ID Watchdog benefits website for claim submission instructions and policy 43 details regarding applicable terms, conditions, and exclusions.

Credit Report Monitoring: Monitors your credit and notifies you when changes such as new accounts, delinquent accounts and other creditrelated information is recorded. Plus plan is single-bureau credit moni‐ toring and Platinum plan is tri-bureau monitoring.

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.

FLIP TOâ&#x20AC;Ś PG. 13 FOR HSA VS. FSA COMPARISON

FSA (Flexible Spending Account) NBS Flexcard

When Will I Receive My Flex Card?

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

NBS Prepaid MasterCard® Debit Card

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

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

Expect Flex Cards to be delivered to the address listed in THEbenefitsHUB near the end of September. Don’t forget, Flex Cards Are Good For 3 Years! For a list of sample expenses, please refer to the Frisco ISD benefit website: www.mybenefitshub.com/friscoisd

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

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

FSA Annual Contribution Max: $2,550

Dependent Care Annual Max: $5,000

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

Detailed claim history and processing status Health Care and Dependent Care account balances Claim forms, Direct Deposit form, worksheets, etc. Online claim FAQs 61

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

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

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

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

        

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

Dependent Care Expense Account Example Expenses:    

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

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

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

How Do I File A Claim? In most situations, you will be able to swipe your card however, in the event you lose your card or are waiting to receive one, you can visit www.mybenefitshub.com/friscoisd 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.

Section 125 Cafeteria Plan INTRODUCTION In this section you will find an overview of the district’s Section 125 Cafeteria Plan, available through Financial Benefit Services, LLC.

WHAT IS A CAFETERIA PLAN? It allows you to deduct certain premium amounts for benefits from your gross earnings before federal withholding taxes are figured. It is a way for you to pay for certain benefits while lowering your taxable income. Please see the following “sample paycheck,” which illustrates the benefit of participating in Section 125.

WHAT BENEFITS ARE AVAILABLE? A summary of available benefits follows. Please read all information carefully and always refer to the brochure on a particular coverage for more detailed information. HOW DO I ENROLL? An open enrollment period will take place at approximately the same time each year at which time you may make changes to your benefits and/or add new benefits.

CHANGES TO BENEFITS Mid-year changes in benefit elections can occur only if you experience a family status change, as detailed in this benefit guide. You must present proof of a family status change to the Frisco ISD benefits office within 30 days of your family status change and meet with benefit office staff to complete and sign the necessary paperwork in order to make any benefit election changes. The example below shows how a married employee claiming one exemption saves taxes when he/she pays for his/her insurance coverages on a pre-tax basis.

WITHOUT SECTION 125 Monthly Salary Less TRS

$2,000 -128

Taxable Income Less Taxes Less Insurance TAKE HOME PAY

WITH SECTION 125 Monthly Salary Less TRS Less Insurance

$2,000 -128 -250

$1,872 -261 -250

Taxable Income Less Taxes

$1,622 -223

$1,361

TAKE HOME PAY

$1,399

You save $38 per month in taxes by paying for your benefits on a pre-tax basis. This means more spendable income at the end of the month to use for addi‐ tional benefits or to increase your take home pay.

SPECIAL RULES REGARDING FRISCO ISD SECTION 125 CAFETERIA PLAN Mid-year changes in benefit elections can occur only if you experience a family status change, as detailed in this benefit guide. You must present proof of a family status change to the Frisco ISD benefits office within 30 days of your family status change and meet with benefit office staff to complete and sign the necessary paperwork in order to make any benefit election changes. There are two very important issues to keep in mind: 1. 2.      

Although all coverage is voluntary (you may pick and choose), every employee is required to sign their Section 125 Benefit Election Form, even if they select no benefits or choose to keep current benefits the same. All benefit elections will remain in effect and cannot be revoked or changed during the current plan year, September 1, 2016 through August 31, 2014, unless you have one of the following changes in family status: Marriage Divorce Birth Adoption Death Termination or change in employee or spouse’s employment. (A change in the number of hours worked per week)

Section 125 Cafeteria Plan   3.

Change in eligibility status of a dependent. (Dependent attains maximum age and/or ceases to meet full-time student status) Loss or curtailment in health coverage of an employee or spouse due to change in spouse’s employment, upon meeting a required eligibility period. New hires must make benefit elections within 30 days from their date of hire. After 30 days, an employee will not be allowed to enroll in benefits until the next open enrollment period without a family status change.

TOLL-FREE HELP LINE AVAILABLE In an effort to give you a faster response to questions concerning your benefits, there is a toll-free number to call. If you have a question concerning how your benefits work, how to file a claim, or if you need other policy information, call Financial Benefit Services, LLC at 469-385-4685 / 800-583-6908. For information on the medical and dependent care reimbursement accounts, call NBS at (800) 274-0503.

Frisco ISD Additional Employee Benefits Retirement Benefit/State & Local Days When an employee with ten or more years of service with FISD officially retires from the Teacher Retirement System of Texas and is no longer employed by the District, the employee shall be reimbursed for unused, accumulated State and Local leave days at a rate of $50.00 per day not to exceed a maximum of $5,000.00.

Sick Leave Bank The purpose of the Sick Leave Bank is to provide additional sick leave to members of the Bank in the event of a serious extended illness, surgery, or a temporary disability due to an injury. Days may be requested from the Bank only after the member has exhausted all accumulated state and local sick leave days. All District employees who work a minimum of 20 hours per week and are in an allocated budgetary position are eligible for membership. Membership in the Sick Leave Bank is voluntary. To become a member of the bank, an employee must contribute three days from his/her accrued local leave. For a detailed explanation of the Sick Leave Bank, including eligibility, joining and applying for leave days, please visit www.friscoisd.org/staff and select Home Room Intranet, Internal Forms & Documents, Payroll/Time/Time Off/Leave, Voluntary District Sick Leave Bank Handbook 2014.

Frisco Athletic Center & YMCA of Frisco & McKinney Frisco ISD has partnered with the Frisco Athletic Center and the YMCA’s located in Frisco and McKinney to offer membership benefits to FISD employees. FISD will reimburse a portion of an individual membership ($17.50 per month) to employees who access the center a minimum of 10 days per calendar month. The benefit will be available to all FISD employees working in a position that guarantees 20 hours per week or more.

How the Program Works:       

Enroll as a member at one of the participating facilities. Be sure to provide the facility with your FISD employee ID # at the time of enrollment. An ID card will be issued by the facility. Scan the identification card each time the facility is used. Access the facility a minimum of 10 days per calendar month. The City of Frisco and the YMCA will monitor attendance of FISD employees per calendar month. Attendance records will be reported to FISD Benefit Department. Reimbursements for participation will be paid one month in arrears. Reimbursements will appear on checks issued on the 15th of each month.

403B/457 Voluntary Retirement Information This is to inform you that Frisco ISD offers 403B and 457 Voluntary Retirement plans to its employees. These plans allow employees to save designated amounts of their paychecks before tax and place them into a variety of mutual funds, variable annuities and fixed annuities. All funds grow tax deferred until withdrawn and are intended to supplement your TRS Pension Plan. As an FISD employee, you are eligible to participate in these plans through salary deferral. Please visit http://tcgservices.com for detailed information and enrollment instructions or contact the FISD Third Party Administrator: TCG Group Holdings 900 South Capital of Texas Hwy, Suite 350 Austin, TX 78746 800-943-9179

Retirement Planning Frisco ISD

Summary Plan Description

Plan Type

Plan Administrator

Excluded Employees

Internal Revenue Code Section 403(b)

TCG Administrators

No Exclusions

Plan Password for Enrolling Online

Written Plan Effective Date

Plan Year End

frisc403-if enrolling for Pre-tax fri403xR-if enrolling for Roth

1/1/2009

2016

Contribution Tax Treatment

Contribution Sources

Roth 403(b)

Pre-Tax

Employee Only

Available

Contribution Limit

Catch-Up Contribution Limit

Automatic Enrollment

$18,000 per year

Available for Age 50+

Not Available

Exchanges in Plan

Transfers Into Plan

Transfers Out of Plan

Available only with companies listed in Appendix I

Available from another employers 403(b) plan

Not Available

Distributions

Loans

Automatic Distributions

Available under the following conditions: Separation of Service, Death, Disability, or Retirement

Available, subject to availability and any additional conditions applied by individual vendors

Not available

Hardship

Disability

Beneficiaries

Available if request meets IRS definition pursuant to ยง 1.401(k)- 1(d)(3)(iii)(B) of the Income Tax Regulations

Designated by each vendor and not by the 403(b) plan.

Administrative Fees

Fees Paid By:

$1.50 per 403(b) participant per month, $150 per month minimum

Employer

For more information please contact TCG Administrators, the Plan Administrator

This document is designed to inform Participants about the Plan in non-technical language. Every attempt is made to convey the Plan accurately. If anything in this Summary Plan Description varies from the Plan Documents, Plan Documents govern. 67

Retirement Planning Frisco ISD

Summary Plan Description

Plan Type

Plan Administrator

Excluded Employees

Internal Revenue Code Section 457(b)

TCG Administrators

No Exclusions

Plan Password for Enrolling Online

Plan Effective Date

Plan Year End

frisc457

7/1/2007

2016

Contribution Tax Treatment

Contribution Sources

Contribution Limit

Pre-Tax

Employee Only

$18, 000 per year

Catch-Up Contribution Limit $6,000 for employees age 50+

Rollovers Into Plan

Rollovers Out of Plan

Available from another qualified plan

Available to another qualified plan, upon termination of service

Distributions

Unforeseeable Emergency Distributions

Available under the following conditions: Separation of Service, Death, Disability

Inactivity Distributions

Available as defined by the IRS for this type of plan

Available for accounts with balances of less than $5,000, and no activity for 2 years

Loans

Beneficiaries

Grandfathered Vendors

Available, see the Loan Agreement and Application Form

A Designation of Beneficiary Form is only required if Spouse is not the Primary Beneficiary

AUL/ One Source (contact AUL regarding any questions about the fees for these accounts)*

TCG Administrators, TPA $18.50 per participant per year 0.25% of assets, paid by the participant

TCG Advisors, Investment Advisor Sliding Scale (0.45% -0.25%), currently 0.35%, paid by participant

Other Fees $30 Distribution Fee $50 Loan Set up All of the above paid by participant

Matrix Trust Custodian/Trustee 0.10%, paid by participant

ESC Region 10, Plan Coordinator $0.10 per participant per month, paid by participant

Fees of Service Plan Providers

For more information please contact TCG Administrators, the Plan Administrator

Retirement Planning Frisco ISD

Summary Plan Description

Plan Type

Plan Administrator

Excluded Employees

Internal Revenue Code Section 401(a)

TCG Administrators

Employees who contribute to a 403(b) or 457(b) with Frisco ISD

Online Account Access

Written Plan Effective Date

Plan Year End

To view your account online: -go to www.region10rams.org -click "Login" and select your employer from the navigation bar -Under the 401(a) tab, click "Login" -The User ID is your SSN; the Password is the last 4 digits of your SSN

9/1/2006

12/31

Matching Contributions Rules Effective September 1, 2011, the Employer will match any contribution made to a 403(b) or 457(b) on behalf of participant into the 401(a) Base Match is 25% of contribution up to 1% of Base Salary.

Vesting Contributions made to a Plan Participant's account are subject to vesting requirements (the ownership of the contributions and earnings). The following schedule shows when a Participant will become the owner of the account balance. Years of Service - Vesting % Yr 1 Yr 2 Yr 3 Yr 4 Yr 5 0% 0% 50% 75% 100%

Distributions

Loans

Automatic Distributions

Available under the following conditions: Separation of Service, Death, Disability, or Retirement

Not Available

Not available

Hardship

Disability

Beneficiaries

Not Available

Determined by TRS

Record Keeperâ&#x20AC;&#x201D;TCG

TCG Advisors, LP - Investment Advisor Sliding Scale (.45%-.24% of assets) Currently .40% Paid from plan assets

ESC Region 10 Plan Coordinator $.10 per participant per month, paid by participant

Administrative Fees TCG Administrators- Record Keeper $1.40 per participant per month Paid by Frisco ISD Wilmington Trust Custodian .10% of assets paid by plan assets

Distribution Fee $25, paid the participant

For more information please contact TCG Administrators, the Plan Administrator

NOTES