2016 Benefit Guide Grapevine Colleyville ISD by Higginbotham Public Sector

GRAPEVINE-COLLEYVILLE ISD

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

Table of Contents

Benefit Contact Information How to Enroll Annual Benefit Enrollment 1. Benefit Updates 2. Section 125 Cafeteria Plan Guidelines 3. Annual Enrollment 4. Eligibility Requirements 5. Helpful Definitions 6. Health Savings Account (HSA) vs. Flexible Spending Account (FSA) TRS-ActiveCare Scott & White HMO HSA Bank Health Savings Account (HSA) APL MEDlink® Medical Supplement Cigna Dental QCD Discount Dental Superior Vision The Hartford Disability APL Cancer Dearborn Life and AD&D TASC Flexible Spending Account (FSA)

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

FLIP TO... PG. 4 HOW TO ENROLL

11 12-15 16-17 18-21 22-25 24-27 26-31 32-33 34-37 38-41 42-45 46-49

PG. 6 BENEFIT UPDATES: WHAT’S NEW

PG. 12 YOUR BENEFITS PACKAGE

Benefit Contact Information

Benefit Contact Information GCISD BENEFITS

DENTAL PPO

LIFE AND AD&D

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

Group # 3335893 Cigna (800) 244-6224 www.mycigna.com

Group # GFZ03187 Dearborn National (800) 583-6908 www.dearbornnational.com

GCISD BENEFITS OFFICE

DISCOUNT DENTAL

FLEXIBLE SPENDING ACCOUNT

Grapevine Colleyville ISD (817) 251-5577 www.gcisd-k12.org

QCD (800) 299-0304 www.qcdofamerica.com

TASC (800) 933-3539 www.tasconline.com

TRS-ACTIVECARE MEDICAL

VISION

COBRA (MEDICAL)

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

Group # 30386 Superior Vision (800) 507-3800 www.superiorvision.com

WellSystems (844) 752-5146

TRS HMO MEDICAL

DISABILITY

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

Group # 395308 The Hartford (800) 583-6908 File a claim: (866) 278-2655 www.thehartford.com

National Benefit Services (800) 274-1503 www.nbsbenefits.com

HEALTH SAVINGS ACCOUNT

CANCER

403(B) / 457 PLANS

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

Group # 14828 American Public Life (800) 256-8606 www.ampublic.com

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

COBRA (DENTAL, VISION & MEDICAL FLEX CARD)

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

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

TEXT

need to complete your enrollment.

“gcisd”

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

! 4

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

Go to:

Click Login

Enter Username & Password

G O

www.gcisdbenefits.com

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

Username:

Sample Username

lincola1234 Sample Password

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

lincoln1234

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

If you have trouble

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

logging in, click on the

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

“Login Help Video”

your Social Security Number.

for assistance.

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

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

Annual Benefit Enrollment

SUMMARY PAGES

Benefit Updates - What’s New:  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 31 days of event).  Aetna remains the carrier for Medical Plans:

ActiveCare 1 HD, ActiveCare 2 and Select. The Scott & White HMO Plan is available for all employees working or residing in Dallas, Ellis, Denton, Collin, Rockwall and Tarrant counties. All eligible employees, including active, contributing TRS members and employees regularly working 10 hours per week MUST either enroll for coverage or decline coverage in the Benefits HUB. For TRS medical information, please visit: www.trs.state.tx.us

   

 Health Savings Accounts are administered by HSA Bank. If

enrolling for the first time, you will receive a welcome packet with verification instructions to receive your new debit card no earlier than mid-September. The IRS annual maximums are $3350 for an individuals or $6750 for your family. HSA funds can be used for medical, dental, vision and prescription expenses. If you enroll in the MEDlink® plan, you are not eligible to participate in an HSA. While balances at the end of the plan year will rollover from year to year, you must designate your monthly contribution amounts each year during open enrollment.  Flexible Spending Accounts are administered by TASC

Online. If you are already enrolled, you will not receive a new card. If you are electing this benefit for the first time, you will receive a new card no earlier than midSeptember. Your debit card will have the entire annual contribution uploaded when you receive your card. Remember these funds are “Use it or Lose it.” The 2016 max contribution has increased to $2,550.

Login and complete your supplemental benefit enrollment from 07/25/2016 - 08/22/2016 Enrollment assistance is available by calling Financial Benefit Services at 866-914-5202 to speak to an enrollment representative Monday—Friday, 8 AM—5 PM from 07/25/2016—08/22/2016. Bilingual assistance is available. Update your profile information: home address, phone numbers, email. IMPORTANT!! Due to the Affordable Care Act (ACA) reporting requirements, please add your dependent’s social security numbers in the online enrollment system. If you have questions, please contact your Benefits Administrator.

SUMMARY PAGES

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

CHANGES IN STATUS (CIS):

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

QUALIFYING EVENTS

Marital Status

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

Change in Number of Tax Dependents

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

Change in Status of Employment Affecting Coverage Eligibility

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

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

SUMMARY PAGES

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

Where can I find forms?

to review, change or continue benefit elections each year.

For benefit summaries and claim forms, go to your school

Changes are not permitted during the plan year (outside of

district’s benefit website: www.gcisdbenefits.com. Click on

annual enrollment) unless a Section 125 qualifying event occurs.

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



Changes, additions or drops may be made only during the

Forms section.

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

 Employees must review their personal information and verify

For benefit summaries and claim forms, go to your school

that dependents they wish to provide coverage for are

district’s website: www.gcisdbenefits.com. Click on the

included in the dependent profile. Additionally, you must

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

notify your employer of any discrepancy in personal and/or

can find provider search links under the Quick Links section.

benefit information. When will I receive ID cards?



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.

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 verify your coverage if you do not have an ID card at that

New Hire Enrollment All new hire enrollment elections must be completed in the online enrollment system within the first 31 days of benefit

eligibility employment. Failure to complete elections during this timeframe will result in the forfeiture of coverage.

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

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.

SUMMARY PAGES

Employee Eligibility Requirements

Dependent Eligibility Requirements

Supplemental Benefits: Eligible employees must work 15 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 Grapevine-Colleyville

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

ISD or as both employees and dependents.

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

CARRIER

MAXIMUM AGE

CONTINUATION

Medical

Aetna

COBRA—AETNA

Dental

Cigna

COBRA– NBS

MEDlink®

American Public Life

Vision

Superior Vision

Cancer

American Public Life

Medical Flex

TASC

IRS Tax Dependent

COBRA— NBS

Disability

The Hartford

N/A

Voluntary Life

Dearborn National

Conversion

Health Savings Account

HSA Bank

IRS Dependent covered on your HDHP

Contact HSA Bank for direct pay

COBRA—NBS

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

SUMMARY PAGES

Helpful Definitions Actively at Work

In-Network

You are performing your regular occupation for the employer

Doctors, hospitals, optometrists, dentists and other providers

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

who have contracted with the plan as a network provider.

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

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

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

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

Plan Year September 1st through August 31st

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

Calendar Year January 1st through December 31st

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

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

(including diagnostic and/or consultation services).

SUMMARY PAGES

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

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

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

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

Employer Eligibility

A qualified high deductible health plan.

All employers

Contribution Source Account Owner Underlying Insurance Requirement

Employee and/or employer Individual

Employee and/or employer Employer

High deductible health plan

None

Description

Minimum Deductible

Maximum Contribution

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

N/A

Varies per employer

Permissible Use Of Funds

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

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

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

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

Not permitted

Year-to-year rollover of account balance?

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

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

Does the account earn interest?

Yes

Portable?

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

FLIP TO… PG. 18

FLIP TO… PG. 46

FOR HSA INFORMATION

FOR FSA INFORMATION

AETNA

Medical

YOUR BENEFITS PACKAGE

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

DID YOU KNOW?

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

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

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/#CoveredPreventive ServicesforAdults For purposes of this benefit, the current recommendations of the USPSTF regarding breast cancer screening and mammography and prevention will be considered the most current (other than those issued in or around November 2009). The preventive care services described above may change as USPSTF, CDC and HRSA guidelines are modified. (Examples of covered services included are: Routine annual physicals (one per year); immunizations; well-child care; breastfeeding support, services and supplies; cancer screening mammograms; bone density test; screening for prostate cancer and colorectal cancer (including routine colonoscopies); smoking cessation counseling services and healthy diet counseling; and obesity screening/counseling.

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 benefits are administered by Caremark.

Grapevine-Colleyville ISD 2016 - 2017 TRS Medical Rates TRS-ActiveCare Plan 1-HD

TRS Monthly Premium

GCISD Contribution

2016-2017 Employee Premium

Employee Only

$341.00

$285.00

$56.00

Employee & Spouse

$914.00

$285.00

$629.00

Employee & Child(ren)

$615.00

$285.00

$330.00

Employee & Family

$1,231.00

$285.00

$946.00

Deductible: Employee Only $2,500 & Employee Family $5,000 Max Out of Pocket: Employee Only $6,550 & Employee Family $13,100

TRS-ActiveCare SelectExclusive Provider Organization

TRS Monthly Premium

GCISD Contribution

2016-2017 Employee Premium

Employee Only

$484.00

$285.00

$199.00

Employee & Spouse

$1,147.00

$285.00

$862.00

Employee & Child(ren)

$779.00

$285.00

$494.00

Employee & Family

$1,361.00

$285.00

$1,076.00

Deductible: Employee Only $1,200 & Employee Family $3,600 Max Out of Pocket: Employee Only $6,850 & Employee Family $13,700

TRS-ActiveCare 2

TRS Monthly Premium

GCISD Contribution

2016-2017 Employee Premium

Employee Only

$645.00

$285.00

$360.00

Employee & Spouse

$1,552.00

$285.00

$1,267.00

Employee & Child(ren)

$1,042.00

$285.00

$757.00

Employee & Family

$1,597.00

$285.00

$1,312.00

Deductible: Employee Only $1,000 & Employee Family $3,000 Max Out of Pocket: Employee Only $6,850 & Employee Family $13,700

Scott and White HMO

TRS Monthly Premium

GCISD Contribution

2016-2017 Employee Premium

Employee Only

$530.16

$285.00

$245.16

Employee & Spouse

$1,192.82

$285.00

$907.82

Employee & Child(ren)

$839.16

$285.00

$554.16

Employee & Family

$1,322.98

$285.00

$1,037.98

Deductible: Employee Only $1,000 & Employee Family $3,000 Max Out of Pocket: Employee Only $5,000 & Employee Family $10,000

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

No Charge

Standard Lab and X-ray

No Charge

Disease Management and Complex Case Management

No Charge

Well Child Care Annual Exams

No Charge

Immunizations (age appropriate)

No Charge

Plan Provisions

Copay

Annual Deductible

$1,000 Individual/ $3,000 Family

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

Lifetime Paid Benefit Maximum

Outpatient Services

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

None

Copay $20 co-pay

Primary Care1

(First Primary Care Visit for Illness $0 Copay2)

Specialty Care

$50 co-pay

Other Outpatient Services

20% after deductible3

Diagnostic/Radiology Procedures

20% after deductible

Eye Exam (one annually) Allergy Serum & Injections

No Charge 20% after deductible

Outpatient Surgery

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

Maternity Care

Copay

Prenatal Care

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

Inpatient Delivery

Inpatient Services

Copay

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

Diagnostic & Therapeutic Services Physical and Speech Therapy 5

Manipulative Therapy

Equipment and Supplies

$150 per day4 and 20% of charges after deductible

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

Copay

Preferred Diabetic Supplies and Equipment

$3 copay; no deductible

Non-Preferred Diabetic Supplies and Equipment

30% after Rx deductible

Durable Medical Equipment/ Prosthetics

Copay

20% after deductible

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

Copay

Home Health Care Visit

$50 co-pay

Worldwide Emergency Care

Copay

Nurse Advice Line

1-877-505-7947

Online Services

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

After Hours Primary Care Clinics

$20 co-pay

Ambulance and Helicopter

$40 copay and 20% of charges after deductible

Emergency Room6

$150 copay and 20% of charges after deductible

Urgent Care Facility

$55 copay

Prescription Drugs

Copay

Annual Benefit Maximum

Unlimited

Rx Deductible

$100

Does not apply to preferred generic drugs

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

Maintenance Quantity

Retail Quantity (Up to a 30-day supply)

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

$3 copay

$6 copay

Preferred Brand

30% after Rx deductible

Non-preferred

50% after Rx deductible

Non-formulary

Greater of $50 or 50% after deductible

Not available

Preferred Generic7

Mail Order

Specialty Medications (Up to a 30-day supply)

1-800-707-3477

Copay 20% after Rx deductible

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

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 benefit website at www.gcisdbenefits.com

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

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

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

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

How an HSA works: 



 

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

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

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

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

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

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

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

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

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

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

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

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

AMERICAN PUBLIC LIFE YOUR BENEFITS PACKAGE

Medical Supplement

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

DID YOU KNOW?

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

MEDlink® Limited Benefit Medical Expense Supplemental Insurance Grapevine-Colleyville 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.

SUMMARY OF BENEFITS Base Policy

Option 1

Option 2

In-Hospital Benefit - Maximum In-Hospital Benefit

$1,500 per confinement

$2,500 per confinement

Outpatient Benefit

up to $200 per treatment

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

Physician Outpatient Treatment Benefit

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

Issue Ages 55-59

Issue Ages 60-69

Employee Only

$21.50

$32.00

$49.00

Employee + Spouse

$39.50

$59.00

$88.00

Employee + Child(ren)

$36.50

$47.00

$64.00

Family Coverage

$54.50

$74.00

$103.00

Issue Ages 17-54

Issue Ages 55-59

Issue Ages 60-69

Employee Only

$28.00

$44.50

$68.50

Employee + Spouse

$51.50

$81.50

$122.50

Employee + Child(ren)

$45.50

$62.00

$86.00

Family Coverage

$69.00

$99.00

$140.00

Option 2 Total Monthly Premiums by Plan* Hospital Emergency Room

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

APSB-22330(TX)-0116 MGM/FBS Grapevine-Colleyville ISD 23

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

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

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

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

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

APSB-22330(TX)-0116 MGM/FBS Grapevine-Colleyville ISD 24

Exclusions We will pay no benefits for any expenses incurred during any period the Covered Person does not have coverage under your Employer’s Medical Plan, except as provided in the Absence of your Employer’s Medical Plan provision or which result from: (a) suicide or any attempt, thereof, while sane or insane; (b) any intentionally self-inflicted injury or Sickness; (c) rest care or rehabilitative care and treatment; (d) outpatient routine newborn care; (e) voluntary abortion except, with respect to You or Your covered Dependent spouse: (1) where Your or Your Dependent spouse’s life would be endangered if the fetus were carried to term; or (2) where medical complications have arisen from abortion; (f) pregnancy of a Dependent child; (g) participation in a riot, civil commotion, civil disobedience, or unlawful assembly. This does not include a loss which occurs while acting in a lawful manner within the scope of authority; (h) commission of a felony; (i) participation in a contest of speed in power driven vehicles, parachuting, or hang gliding; (j) air travel, except: (1) as a fare-paying passenger on a commercial airline on a regularly scheduled route; or (2) as a passenger for transportation only and not as a pilot or crew member; (k) intoxication; (Whether or not a person is intoxicated is determined and defined by the laws and jurisdiction of the geographical area in which the loss occurred.) (l) alcoholism or drug use, unless such drugs were taken on the advice of a Physician and taken as prescribed; (m) sex changes; (n) experimental treatment, drugs, or surgery; (o) an act of war, whether declared or undeclared, or while performing police duty as a member of any military or naval organization; (This exclusion includes Accident sustained or Sickness contracted while in the service of any military, naval, or air force of any country engaged in war. We will refund the pro rata unearned premium for any such period the Covered Person is not covered.) (p) Accident or Sickness arising out of and in the course of any occupation for compensation, wage or profit; (This does not apply to those sole proprietors or partners not covered by Workers’ Compensation.) (q) mental illness or functional or organic nervous disorders, regardless of the cause; (r) dental or vision services, including treatment, surgery, extractions, or x-rays, unless: (1) resulting from an Accident occurring while the Covered Person’s coverage is in force and if performed within 12 months of the date of such Accident; or (2) due to congenital disease or anomaly of a covered newborn child. (s) routine examinations, such as health exams, periodic check-ups, or routine physicals, except when part of Inpatient routine newborn care; (t) any expense for which benefits are not payable under the Covered Person’s Employer’s Medical Plan; or (u) air or ground ambulance.

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

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

APSB-22330(TX)-0116 MGM/FBS Grapevine-Colleyville ISD 25

CIGNA

QCD

Dental

Discount Dental

YOUR BENEFITS PACKAGE

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

DID YOU KNOW?

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

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

Cigna Dental Choice In-Network Out-of-Network Total Cigna DPPO $1,000

$1,000

$50 per person $150 per family

Based on Reduced Contracted Fees

80th percentile of Reasonable and Customary Allowances

Plan Pays

You Pay

Plan Pays

You Pay

100%

No Charge

100%

No Charge

80%*

20%*

80%*

20%*

50%*

Monthly PPO Premiums Tier

Rate

Employee

$44.48

EE + 1

$84.71

EE + 2 or more

$132.50

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

Class II - Basic Restorative Care Fillings Emergency Care to Relieve Pain Brush Biopsies Anesthetics Oral Surgery – Simple Extractions

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

Class IV - Orthodontia Lifetime Maximum

Class IX - Implants Deductible

Annual Maximum

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

50%*

50%

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

50%*

50%

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. 27

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

Cigna Dental Choice In-Network Out-of-Network Total Cigna DPPO $1,000

$1,000

$50 per person $150 per family

Based on Reduced Contracted Fees

Based on Maximum Allowable Charge (In-network fee level)

Plan Pays

You Pay

Plan Pays

You Pay

80%

20%

80%

20%

50%*

Not covered

100% of your dentist’s usual fees

Not covered

100% of your dentist’s usual fees

Monthly PPO Premiums Tier

Rate

Employee

$25.92

EE + 1

$49.35

EE + 2 or more

$77.28

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

Class II - Basic Restorative Care Fillings Emergency Care to Relieve Pain Brush Biopsies Anesthetics Oral Surgery – Simple Extractions

Class IV - Orthodontia Lifetime Maximum

Class IX - Implants Deductible Annual Maximum

50% Subject to plan deductible Subject to plan annual maximum

50% 50%

Subject to plan deductible Subject to plan annual maximum

50%

Dental PPO - High and Low Options Procedure

Exclusions and Limitations

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

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

Alternate Benefit

Benefit Exclusions     

                  



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

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: HPPOL82; IL: HP-POL62; KS: HP-POL84; LA: HPPOL86: MA: HP-POL 63; MI: HP-POL88; MO: HP- POL65; MS: HP-POL90; NC: HP-POL96; NE: HP-POL92; NH: HP-POL94; NM: HP-POL95; NV: HP-POL93; NY: HP-POL67; OH: HP-POL98; OK: HP-POL99; OR: HP-POL68; PA: HP-POL100; RI: HP-POL101; SC: HP-POL102; SD: HP-POL103; TN: HP-POL69; TX: HP-POL70; UT: HP-POL104; VA: HP-POL72; VT: HP-POL71; WA: POL-07/08; WI: HP-POL107; WV: HP-POL106; and WY: HP-POL108. “Cigna,” the “Tree of Life” logo and “Cigna Dental Care” are registered service marks of Cigna Intellectual Property, Inc., licensed for use by Cigna Corporation and its operating subsidiaries. All products and services are provided by or through such operating subsidiaries and not by Cigna Corporation. Such operating subsidiaries include Connecticut General Life Insurance Company (CGLIC), Cigna Health and Life Insurance Company (CHLIC), Cigna HealthCare of Connecticut, Inc., and Cigna Dental Health, Inc. and its subsidiaries. Cigna Dental PPO plans are underwritten or administered by CGLIC or CHLIC, with network management services provided by Cigna Dental Health, Inc. and certain of its subsidiaries. In Arizona and Louisiana, the insured Dental PPO plan offered by CGLIC is known as the “CG Dental PPO”. In Texas, the insured dental product offered by CGLIC and CHLIC is referred to as the Cigna Dental Choice Plan, and this plan utilizes the national Cigna Dental PPO network. Cigna Dental Care (DHMO) plans are underwritten or administered by Cigna Dental Health Plan of Arizona, Inc., Cigna Dental Health of California, Inc., Cigna Dental Health of Colorado, Inc., Cigna Dental Health of Delaware, Inc., Cigna Dental Health of Florida, Inc., a Prepaid Limited Health Services Organization licensed under Chapter 636, Florida Statutes, Cigna Dental Health of Kansas, Inc. (Kansas and Nebraska), Cigna Dental Health of Kentucky, Inc. (Kentucky and Illinois), Cigna Dental Health of Maryland, Inc., Cigna Dental Health of Missouri, Inc., Cigna Dental Health of New Jersey, Inc., Cigna Dental Health of North Carolina, Inc., Cigna Dental Health of Ohio, Inc., Cigna Dental Health of Pennsylvania, Inc., Cigna Dental Health of Texas, Inc., and Cigna Dental Health of Virginia, Inc. In other states, Cigna Dental Care plans are underwritten by CGLIC, CHLIC, or Cigna HealthCare of Connecticut, Inc. and administered by Cigna Dental Health, Inc. BSD46380 © 2015 Cigna

QCD Discount Dental The QCD Philosophy QCD believes that you should pay the lowest monthly cost possible for comprehensive dental and vision benefit coverage for your family. The member benefits from significant cost savings when and if services are used.

Monthly Cost MONTHLY Employee Only

$0.00

Employee and One Dependent

$10.00

Employee and Entire Household

$14.00

Why Select QCD? When selecting dental benefits, QCD makes good financial sense. QCD allows you to allocate more of your benefit expenditures to your rising medical costs. A single dental procedure (Root Canal and Crown) could cost you as much as $2000 with no coverage. The QCD program will allow you to save up to 60% on the total cost – that could be as much as $1200 in savings and enough to fund your family’s monthly dental and vision benefit costs for several years.

Need more information?   

Contact our Membership Services Department 972.726.0444 or 1.800.229.0304 See the last page for your enrollment form Visit our website at www.qcdofamerica.com

The Best Dental & Vision Benefit Value QCD offers over 3,000 highly qualified dental professionals. To locate a dentist in your area, visit www.qcdofamerica.com and type in your zip code The average appointment availability is less than two weeks QCD Client Services Team is ready and willing to assist you in all your needs such as:  Benefit Questions  Treatment plans  Coverage Levels QCD Membership Services Team is available for all general questions including:  Finding a Dentist  Setting Appointments  Vision Benefits If your dentist is not affiliated with QCD, please fill out the Dentist Referral Form and turn it into your HR Director or you can fax it to our Provider Relations Department at 972726-0448. For more information on your vision benefits, please contact Davis Vision Customer Service at 877-923-2847

QCD Discount Dental MONTHLY Employee Only

$0.00

Employee and One Dependent

$10.00

Employee and Entire Household

$14.00

No Claim Forms, Deductibles or Coverage Maximums Immediate Coverage for all Pre-Existing Conditions Orthodontics (Braces) for Children and Adults

SAMPLE DENTAL PROCEDURE

FEE PAID WITH QCD NATIONAL AVERAGE OF AMERICA DENTAL FEES2

SAVINGS WITH QCD OF AMERICA

Oral Exam

$35

74%

Full Mouth X-ray

$28

$77

64%

Teeth Cleaning

$24

$54

56%

Amalgam ( Surface)

$28

$79

65%

Simple Extraction

$36

$80

55%

Root Canal (1Canal)

$185

$387

55%

Porcelain w/ Metal Crown (lab fees additional)

$350

$652

46%

Complete Upper or Lower Denture (lab fees additional)

$400

$770

48%

1 2

A fee of $8.00 is charged per appointment for infection control costs. There will be an additional charge for all lab fees less a 20% discount. The schedule represents a sample of highly utilized dental procedures. The average costs are estimated from data gathered by the U.S. Bureau of Labor Statistics, the American Dental Association, and the American Chamber of Commerce Research Association.



After you sign and turn in your enrollment form, QCD will send you a membership card.



Please select any dentist within the QCD Affiliated Dentist Team and make an appointment.



Please be sure to identify yourself as a QCD member and the reduced fee schedule will apply to all charges.



Please call the QCD Member Services Department at 972.726.0444 or 1.800.229.0304 for assistance.



Information may be obtained from the website at www.qcdofamerica.com

SUPERIOR VISION YOUR BENEFITS PACKAGE

Vision

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

DID YOU KNOW?

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

Vision Benefits Exam (ophthalmologist) Exam (optometrist) Frames Contact Lens Fitting (standard₂) Contact Lens Fitting (specialty₂) Contact Lenses4

In-Network

Out-of-Network

Covered in full

Up to $42 retail

EE Only

$8.42

Covered in full $150 retail allowance

Up to $37 retail Up to $81 retail

EE + Spouse

$16.10

EE + Child(ren)

$16.89

Covered in full

Not Covered

EE + Family

$24.92

$50 retail allowance

Not Covered

Monthly Premiums

Co-Pays

$130 retail allowance Up to $100 retail

Exam

$10

Materials₁

$25

Contact Lens Fitting

$25

Lenses (standard) per pair Single Vision Bifocal Trifocal Progressive lens upgrade Scratch coat (factory) Polycarbonate— dependents to age 18

Covered in full Covered in full Covered in full

Up to $32 retail Up to $46 retail Up to $61 retail

See description3

Up to $61 retail

Covered in full

Not covered

Covered in full

Not covered

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

Services/Frequency Exam

12 months

Frame

12 months

Contact Lens Fitting

12 months

Lenses

12 months

Contact Lenses

12 months

₁ Materials co-pay applies to lenses & frames only, not contact lenses. ₂Visit FAQs on www.superiorvision.com for definitions of standard and specialty CLF. ₃Covered to the provider's retail amount for a standard lined trifocal lens; member pays the difference between the retail price of the progressive lens they have chose and their provider's standard lined trifocal lens, plus applicable copay. 4Contact lenses are in lieu of eyeglass lenses and frames benefit.

Discounts on Covered Materials5 Frames: Lens options: Progressives:

20% off amount over allowance 20% off retail 20% off amount over retail lined trifocal lens, including lens options

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

Discounts on Non-Covered Exam and Materials5 Exams, frames, and prescription lenses: Lens options, contacts, other prescription materials: Disposable contact lenses: 5Discounts

30% off retail 20% off retail 10% off retail

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

provider. 5Discounts

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

provider.

Refractive Surgery Maximum Member Out-of-Pocket Single Vision Bifocal & Trifocal Scratch coat $13 $13 Ultraviolet coat $15 $15 Tints, solid or gradients $25 $25 Anti-reflective coat $50 $50 Polycarbonate $40 20% off retail High index 1.6 $55 20% off retail Photochromics $80 20% off retail

Superior Vision has a nationwide network of refractive surgeons and leading LASIK networks who offer members a discount. These discounts range from 15%-50%, and are the best possible discounts available to Superior Vision. The Plan discount features are not insurance. All allowances are retail; member is responsible for any amount over the allowance, minus available discounts. Discounts are subject to change without notice. Disclaimer: All final determinations of benefits, administrative duties, and definitions are governed by the Certificate of Insurance for your vision plan. Please check with your Human Resources department if you have any questions. 33

THE HARTFORD YOUR BENEFITS PACKAGE

Long Term Disability

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

DID YOU KNOW?

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

34.6 months is the duration of the average disability claim.

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



Pre-existing Conditions



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

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



Mental Illness, Alcoholism and Substance Abuse



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

What other benefits are included in my disability coverage? 



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

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



Exclusions



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

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

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

Long Term Disability MONTHLY PREMIUMS Rates effective 9/1/1016 (Based on 12 payments per year) Accident / Sickness Elimination Period in Days

Annual Earnings

Monthly Earnings

Monthly Benefit

0/7

14 / 14

30 / 30

60 / 60

90 / 90

180 / 180

$3,600

$300

$200

$6.32

$5.60

$4.94

$3.06

$2.28

$1.74

$5,400

$450

$300

$9.48

$8.40

$7.41

$4.59

$3.42

$2.61

$7,200

$600

$400

$12.64

$11.20

$9.88

$6.12

$4.56

$3.48

$9,000

$750

$500

$15.80

$14.00

$12.35

$7.65

$5.70

$4.35

$10,800

$900

$600

$18.96

$16.80

$14.82

$9.18

$6.84

$5.22

$12,600

$1,050

$700

$22.12

$19.60

$17.29

$10.71

$7.98

$6.09

$14,400

$1,200

$800

$25.28

$22.40

$19.76

$12.24

$9.12

$6.96

$16,200

$1,350

$900

$28.44

$25.20

$22.23

$13.77

$10.26

$7.83

$18,000

$1,500

$1,000

$31.60

$28.00

$24.70

$15.30

$11.40

$8.70

$19,800

$1,650

$1,100

$34.76

$30.80

$27.17

$16.83

$12.54

$9.57

$21,600

$1,800

$1,200

$37.92

$33.60

$29.64

$18.36

$13.68

$10.44

$23,400

$1,950

$1,300

$41.08

$36.40

$32.11

$19.89

$14.82

$11.31

$25,200

$2,100

$1,400

$44.24

$39.20

$34.58

$21.42

$15.96

$12.18

$27,000

$2,250

$1,500

$47.40

$42.00

$37.05

$22.95

$17.10

$13.05

$28,800

$2,400

$1,600

$50.56

$44.80

$39.52

$24.48

$18.24

$13.92

$30,600

$2,550

$1,700

$53.72

$47.60

$41.99

$26.01

$19.38

$14.79

$32,400

$2,700

$1,800

$56.88

$50.40

$44.46

$27.54

$20.52

$15.66

$34,200

$2,850

$1,900

$60.04

$53.20

$46.93

$29.07

$21.66

$16.53

$36,000

$3,000

$2,000

$63.20

$56.00

$49.40

$30.60

$22.80

$17.40

$37,800

$3,150

$2,100

$66.36

$58.80

$51.87

$32.13

$23.94

$18.27

$39,600

$3,300

$2,200

$69.52

$61.60

$54.34

$33.66

$25.08

$19.14

$41,400

$3,450

$2,300

$72.68

$64.40

$56.81

$35.19

$26.22

$20.01

$43,200

$3,600

$2,400

$75.84

$67.20

$59.28

$36.72

$27.36

$20.88

$45,000

$3,750

$2,500

$79.00

$70.00

$61.75

$38.25

$28.50

$21.75

$46,800

$3,900

$2,600

$82.16

$72.80

$64.22

$39.78

$29.64

$22.62

$48,600

$4,050

$2,700

$85.32

$75.60

$66.69

$41.31

$30.78

$23.49

$50,400

$4,200

$2,800

$88.48

$78.40

$69.16

$42.84

$31.92

$24.36

$52,200

$4,350

$2,900

$91.64

$81.20

$71.63

$44.37

$33.06

$25.23

$54,000

$4,500

$3,000

$94.80

$84.00

$74.10

$45.90

$34.20

$26.10

$55,800

$4,650

$3,100

$97.96

$86.80

$76.57

$47.43

$35.34

$26.97

$57,600

$4,800

$3,200

$101.12

$89.60

$79.04

$48.96

$36.48

$27.84

$59,400

$4,950

$3,300

$104.28

$92.40

$81.51

$50.49

$37.62

$28.71

$61,200

$5,100

$3,400

$107.44

$95.20

$83.98

$52.02

$38.76

$29.58

$63,000

$5,250

$3,500

$110.60

$98.00

$86.45

$53.55

$39.90

$30.45

$64,800

$5,400

$3,600

$113.76

$100.80

$88.92

$55.08

$41.04

$31.32

$66,600

$5,550

$3,700

$116.92

$103.60

$91.39

$56.61

$42.18

$32.19

$68,400

$5,700

$3,800

$120.08

$106.40

$93.86

$58.14

$43.32

$33.06

Long Term Disability MONTHLY PREMIUMS Rates effective 9/1/1016 (Based on 12 payments per year) Accident / Sickness Elimination Period in Days Annual Earnings

Monthly Earnings

Monthly Benefit

0/7

14 / 14

30 / 30

60 / 60

90 / 90

180 / 180

$70,200

$5,850

$3,900

$123.24

$109.20

$96.33

$59.67

$44.46

$33.93

$72,000

$6,000

$4,000

$126.40

$112.00

$98.80

$61.20

$45.60

$34.80

$73,800

$6,150

$4,100

$129.56

$114.80

$101.27

$62.73

$46.74

$35.67

$75,600

$6,300

$4,200

$132.72

$117.60

$103.74

$64.26

$47.88

$36.54

$77,400

$6,450

$4,300

$135.88

$120.40

$106.21

$65.79

$49.02

$37.41

$79,200

$6,600

$4,400

$139.04

$123.20

$108.68

$67.32

$50.16

$38.28

$81,000

$6,750

$4,500

$142.20

$126.00

$111.15

$68.85

$51.30

$39.15

$82,800

$6,900

$4,600

$145.36

$128.80

$113.62

$70.38

$52.44

$40.02

$84,600

$7,050

$4,700

$148.52

$131.60

$116.09

$71.91

$53.58

$40.89

$86,400

$7,200

$4,800

$151.68

$134.40

$118.56

$73.44

$54.72

$41.76

$88,200

$7,350

$4,900

$154.84

$137.20

$121.03

$74.97

$55.86

$42.63

$90,000

$7,500

$5,000

$158.00

$140.00

$123.50

$76.50

$57.00

$43.50

$91,800

$7,650

$5,100

$161.16

$142.80

$125.97

$78.03

$58.14

$44.37

$93,600

$7,800

$5,200

$164.32

$145.60

$128.44

$79.56

$59.28

$45.24

$95,400

$7,950

$5,300

$167.48

$148.40

$130.91

$81.09

$60.42

$46.11

$97,200

$8,100

$5,400

$170.64

$151.20

$133.38

$82.62

$61.56

$46.98

$99,000

$8,250

$5,500

$173.80

$154.00

$135.85

$84.15

$62.70

$47.85

$100,800

$8,400

$5,600

$176.96

$156.80

$138.32

$85.68

$63.84

$48.72

$102,600

$8,550

$5,700

$180.12

$159.60

$140.79

$87.21

$64.98

$49.59

$104,400

$8,700

$5,800

$183.28

$162.40

$143.26

$88.74

$66.12

$50.46

$106,200

$8,850

$5,900

$186.44

$165.20

$145.73

$90.27

$67.26

$51.33

$108,000

$9,000

$6,000

$189.60

$168.00

$148.20

$91.80

$68.40

$52.20

$109,800

$9,150

$6,100

$192.76

$170.80

$150.67

$93.33

$69.54

$53.07

$111,600

$9,300

$6,200

$195.92

$173.60

$153.14

$94.86

$70.68

$53.94

$113,400

$9,450

$6,300

$199.08

$176.40

$155.61

$96.39

$71.82

$54.81

$115,200

$9,600

$6,400

$202.24

$179.20

$158.08

$97.92

$72.96

$55.68

$117,000

$9,750

$6,500

$205.40

$182.00

$160.55

$99.45

$74.10

$56.55

$118,800

$9,900

$6,600

$208.56

$184.80

$163.02

$100.98

$75.24

$57.42

$120,600

$10,050

$6,700

$211.72

$187.60

$165.49

$102.51

$76.38

$58.29

$122,400

$10,200

$6,800

$214.88

$190.40

$167.96

$104.04

$77.52

$59.16

$124,200

$10,350

$6,900

$218.04

$193.20

$170.43

$105.57

$78.66

$60.03

$126,000

$10,500

$7,000

$221.20

$196.00

$172.90

$107.10

$79.80

$60.90

$127,800

$10,650

$7,100

$224.36

$198.80

$175.37

$108.63

$80.94

$61.77

$129,600

$10,800

$7,200

$227.52

$201.60

$177.84

$110.16

$82.08

$62.64

$131,400

$10,950

$7,300

$230.68

$204.40

$180.31

$111.69

$83.22

$63.51

$133,200

$11,100

$7,400

$233.84

$207.20

$182.78

$113.22

$84.36

$64.38

$135,000

$11,250

$7,500

$237.00

$210.00

$185.25

$114.75

$85.50

$65.25 37

AMERICAN PUBLIC LIFE

Cancer

YOUR BENEFITS PACKAGE

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

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

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

GC3 Limited Benefit Group Cancer Indemnity Insurance Grapevine-Colleyville 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.

Summary of Benefits Benefits

Level 1 Base Plan

Level 2 Base Plan

Radiation Therapy/Chemotherapy/ Immunotherapy Benefit

$500 per calendar month of treatment

$1,500 per calendar month of treatment

Hormone Therapy Benefit

$50 per treatment, up to 12 per calendar year

Surgical Schedule Benefit

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

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

Anesthesia Benefit

25% of the amount paid for covered surgery

Hospital Confinement Benefit

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

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

US Government/Charity Hospital/HMO

$100 per day in lieu of most other benefits

$300 per day in lieu of most other benefits

Outpatient Hospital or Ambulatory Surgical Center Benefit

$200 per day of surgery

$600 per day of surgery

Drugs & Medicine Benefit - Inpatient

$150 per confinement

Drugs & Medicine Benefit - Outpatient

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

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

Transportation & Outpatient Lodging Benefit

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

Family Member Transportation & Lodging Benefit

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

Blood, Plasma & Platelets Benefit

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

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

Bone Marrow/Stem Cell Transplant

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

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

Experimental Treatment Benefit

Pays as any non-experimental benefit

Attending Physician Benefit

$30 per day of confinement

$50 per day of confinement

Surgical Prosthesis Benefit

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

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

Hair Prosthesis Benefit

$50 per hair prosthetic, 2 lifetime max

Dread Disease Benefit

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

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

Hospice Care Benefit

$50 per day, $9,000 lifetime max

$100 per day, $18,000 lifetime max

Inpatient Special Nursing Services

$150 per day of confinement

Ambulance Ground Benefit

$200 per ground trip

Ambulance Air Benefit

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

Extended Care Benefit

$100 per day

$300 per day

Home Health Care Benefit

$100 per day

$300 per day

Second & Third Surgical Opinions

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

Waiver of Premium

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

Physical/Speech Therapy Benefit

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

Diagnostic Testing Benefit Rider

$50; 1 person, per calendar year

Critical Illness Rider: Heart Attack/Stroke

$2,500 lump sum benefit

Up to $600 max of 30 days per ICU confinement; $100 ambulance per ICU admission

Riders

Optional Benefit Rider Intensive Care Unit Rider Monthly Premium

Level 1

Level 1 + ICU Rider

Level 2

Level 2 + ICU Rider

Individual

$13.80

$17.10

$29.90

$33.20

One Parent

$19.10

$23.60

$40.90

$45.40

Two Parent

$24.30

$31.20

$51.90

$58.80

*Premium and amount of benefits provided vary dependent upon the level selected at time of application. **Total premium includes the policy and riders of the option selected.

APSB-22356(TX) MGM/FBS Grapevine-Colleyville ISD

GC3 Limited Benefit Group Cancer Indemnity Insurance Eligibility

Diagnostic Testing Benefit Rider

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

Critical Illness Rider

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

Base Policy

All diagnosis of cancer must be positively diagnosed by a legally licensed doctor of medicine certified by the American Board of Pathology or American Board of Osteopathic Pathology. This policy/certificate pays only for loss resulting from definitive cancer treatment including direct extension, metastatic spread or recurrence. Proof must be submitted to support each claim. This policy/certificate also covers other conditions or diseases directly caused by cancer or the treatment of cancer. No benefits are payable for any covered person for any loss incurred during the first year of this policy/certificate as a result of a Pre-Existing Condition. A PreExisting Condition is a specified disease for which, within 12 months prior to the covered person’s effective date of coverage, medical advice, consultation or treatment, including prescribed medications, was recommended by or received from a member of the medical profession, or for which symptoms manifested in such a manner as would cause an ordinarily prudent person to seek diagnosis, medical advice or treatment. Pre-Existing Conditions specifically named or described as excluded in any part of this contract are never covered. This policy/certificate contains a 30-day waiting period during which no benefits will be paid under this policy/certificate. If any covered person has a specified disease diagnosed before the end of the 30-day period immediately following the covered person’s effective date, coverage for that person will apply only to loss that is incurred after one year from the effective date of such person’s coverage. If any covered person is diagnosed as having a specified disease during the 30-day period immediately following the effective date, you may elect to void the policy/certificate from the beginning and receive a full refund of premium. All benefits payable only up to the maximum amount listed in the schedule of benefits in the policy/certificate. A Hospital is not an institution, or part thereof, used as: a hospice unit, including any bed designated as a hospice or a swing bed; a convalescent home; a rest or nursing facility; a rehabilitative facility; an extended-care facility; a skilled nursing facility; or a facility primarily affording custodial, educational care, or care or treatment for persons suffering from mental diseases or disorders, or care for the aged, or drug or alcohol addiction.

APSB-22356(TX) MGM/FBS Grapevine-Colleyville ISD 40

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

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

Hospital Intensive Care Unit Rider

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

GC3 Limited Benefit Group Cancer Indemnity Insurance Conditionally Renewable

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

Continuation Rider Continuation

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

Termination of Coverage

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

Termination of Rider Coverage

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

Conversion

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

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

This is a brief description of the coverage. For actual benefits, limitations, exclusions and other provisions, please refer to the policy and riders. This coverage does not replace Workers’ Compensation Insurance. This product is inappropriate for people who are eligible for Medicaid coverage. | This policy is considered an employee welfare benefit plan established and/or maintained by an association or employer intended to be covered by ERISA, and will be administered and enforced under ERISA. Group policies issued to governmental entities and municipalities may be exempt from ERISA guidelines. | Policy Form GC-3 Series | Texas | Limited Benefit Group Cancer Indemnity Insurance Policy | (11/14) | Grapevine-Colleyville ISD

APSB-22356(TX) MGM/FBS Grapevine-Colleyville ISD

DEARBORN NATIONAL YOUR BENEFITS PACKAGE

Life and AD&D

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

DID YOU KNOW? Motor vehicle crashes are the

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

Life and AD&D Basic Group Term Life and AD&D Insurance Class 1 - All eligible active employees are eligible for Basic Term Life and AD&D coverage equal to 100% of annual salary to a maximum of $50,000. Your employer pays for the cost for this benefit. Coverage reduces to 65% of the original benefit amount upon attainment of age 65, further reduces to 50% of the original amount upon attainment of age 70, and terminates at retirement. Your Basic Group Term Life coverage includes: Waiver of Premium Benefit: Your term life coverage may continue to age 65 at no cost to you if you become totally disabled prior to age 60, subject to the requirements of this benefit.

Accelerated Death Benefit: If you are diagnosed with a non-correctable health condition which with reasonable medical certainty will result in your death within 12 months, you may choose to accelerate up to 75% of your term life death benefit, up to $250,000. The amount of the accelerated payment will reduce the death benefit payable under the term life coverage by the amount of the requested payment. DISCLOSURE: The Accelerated Benefit offered under this group policy/certificate is intended to qualify for favorable tax treatment under the Internal Revenue Code of 1986. If the Accelerated Benefit qualifies for such favorable tax treatment, the benefits will be excludable from your income and not subject to federal taxation. Tax laws relating to Accelerated Benefits are complex. You are advised to consult with a qualified tax advisor about circumstances under which you could receive the Accelerated Benefit excludable from income under federal law. Receipt of an Accelerated Benefit payment may affect your, your spouse, or your familyâ&#x20AC;&#x2122;s eligibility for public assistance programs such as medical assistance (Medicaid), Aid to Families with Dependent Children (AFDC), supplemental social security income (SSI) and drug assistance programs. You are advised to consult with a qualified tax advisor and with social service agencies concerning how receipt of such a payment will affect your, your spouse, or your familyâ&#x20AC;&#x2122;s eligibility for public assistance. Conversion Privilege: Should you leave your employment with Grapevine Colleyville ISD, you may convert your term life coverage to an individual whole life insurance policy.

Voluntary Group Term Life Insurance Eligibility You are eligible to enroll if you work the minimum number of hours per week required by your employer, and have satisfied any waiting period. You must also be covered under the basic life insurance plan sponsored by your employer in Texas. Voluntary Term Life Insurance Employee Benefit - $10,000 increments to $500,000 Spouse Benefit - $5,000 increments to $500,000. The spouse benefit may not exceed the employee benefit amount. The Guarantee Issue amount for timely enrollees is $200,000 for employees and $25,000 for spouses. Coverage reduces to 65% of the original benefit amount upon attainment of age 65 and further reduces to 50% of the original amount upon attainment of age 70. Child Coverage Age 15 days to 6 months - $100 Ages 6 months to 25 years - $2,000 increments to $10,000 Cost - $0.40 per $2,000

Life and AD&D Employee Rates Age

<25

25-29

30-34

35-39

40-44

45-49

50-54

55-59

60-64

65-69*

70-74*

75+*

$10,000

$0.48

$0.41

$0.50

$0.72

$1.01

$1.61

$2.42

$3.87

$5.54

$6.12

$8.47

$17.91

$20,000

$0.96

$0.82

$1.00

$1.44

$2.02

$3.22

$4.84

$7.74

$11.08

$12.24

$16.94

$35.82

$30,000

$1.44

$1.23

$1.50

$2.16

$3.03

$4.83

$7.26

$11.61

$16.62

$18.36

$25.41

$53.73

$40,000

$1.92

$1.64

$2.00

$2.88

$4.04

$6.44

$9.68

$15.48

$22.16

$24.48

$33.88

$71.64

$50,000

$2.40

$2.05

$2.50

$3.60

$5.05

$8.05

$12.10

$19.35

$27.70

$30.60

$42.35

$89.55

$60,000

$2.88

$2.46

$3.00

$4.32

$6.06

$9.66

$14.52

$23.22

$33.24

$36.72

$50.82

$107.46

$70,000

$3.36

$2.87

$3.50

$5.04

$7.07

$11.27

$16.94

$27.09

$38.78

$42.84

$59.29

$125.37

$80,000

$3.84

$3.28

$4.00

$5.76

$8.08

$12.88

$19.36

$30.96

$44.32

$48.96

$67.76

$143.28

$90,000

$4.32

$3.69

$4.50

$6.48

$9.09

$14.49

$21.78

$34.83

$49.86

$55.08

$76.23

$161.19

$100,000

$4.80

$4.10

$5.00

$7.20

$10.10

$16.10

$24.20

$38.70

$55.40

$61.20

$84.70

$179.10

Spouse Rates

Age

<25

25-29

30-34

35-39

40-44

45-49

50-54

55-59

60-64

65-69*

70-74*

75+*

$5,000

$0.54

$0.45

$0.46

$0.59

$0.82

$1.29

$2.03

$3.13

$5.55

$6.33

$8.70

$16.80

$10,000

$1.08

$0.90

$0.92

$1.18

$1.64

$2.58

$4.06

$6.26

$11.10

$12.66

$17.40

$33.60

$15,000

$1.62

$1.35

$1.38

$1.77

$2.46

$3.87

$6.09

$9.39

$16.65

$18.99

$26.10

$50.40

$20,000

$2.16

$1.80

$1.84

$2.36

$3.28

$5.16

$8.12

$12.52

$22.20

$25.32

$34.80

$67.20

$25,000

$2.70

$2.25

$2.30

$2.95

$4.10

$6.45

$10.15

$15.65

$27.75

$31.65

$43.50

$84.00

$30,000

$3.24

$2.70

$2.76

$3.54

$4.92

$7.74

$12.18

$18.78

$33.30

$37.98

$52.20

$100.80

$35,000

$3.78

$3.15

$3.22

$4.13

$5.74

$9.03

$14.21

$21.91

$38.85

$44.31

$60.90

$117.60

$40,000

$4.32

$3.60

$3.68

$4.72

$6.56

$10.32

$16.24

$25.04

$44.40

$50.64

$69.60

$134.40

$45,000

$4.86

$4.05

$4.14

$5.31

$7.38

$11.61

$18.27

$28.17

$49.95

$56.97

$78.30

$151.20

$50,000

$5.40

$4.50

$4.60

$5.90

$8.20

$12.90

$20.30

$31.30

$55.50

$63.30

$87.00

$168.00

Life and AD&D Voluntary Group Accidental Death and Dismemberment Eligibility Voluntary AD&D is a separate election from the Voluntary Life. You must elect Voluntary Term Life to enroll for Voluntary AD&D. You may elect a Voluntary AD&D amount that is different than your VTL amount, or you can elect a matching amount. The Individual Plan covers you in the event of accidental death or dismemberment. Benefits are available in $10,000 increments to a maximum of $500,000. The Family Plan covers you and your eligible dependents in the event of Accidental death or dismemberment. The spouse benefit is equal to 50% of your benefit election, and the child benefit is equal to 10% of your benefit election. Premiums are calculated based on the amount of the employeeâ&#x20AC;&#x2122;s elected benefit amount.

Voluntary AD&D Monthly Rates Per $1,000 Individual Plan $0.03 Family Plan $0.05

Monthly Premium Cost (based on 12 payroll deductions per year) $10,000

$20,000

$30,000

$40,000

$50,000

$60,000

$70,000

$80,000

$90,000

$100,000

Employee

$0.30

$0.60

$0.90

$1.20

$1.50

$1.80

$2.10

$2.40

$2.70

$3.00

Family

$0.50

$1.00

$1.50

$2.00

$2.50

$3.00

$3.50

$4.00

$4.50

$5.00

$110,000

$120,000

$130,000

$140,000

$150,000

$160,000

$170,000

$180,000

$190,000

$200,000

Employee

$3.30

$3.60

$3.90

$4.20

$4.50

$4.80

$5.10

$5.40

$5.70

$6.00

Family

$5.50

$6.00

$6.50

$7.00

$7.50

$8.00

$8.50

$9.00

$9.50

$10.00

$210,000

$220,000

$230,000

$240,000

$250,000

$260,000

$270,000

$280,000

$290,000

$300,000

Employee

$6.30

$6.60

$6.90

$7.20

$7.50

$7.80

$8.10

$8.40

$8.70

$9.00

Family

$10.50

$11.00

$11.50

$12.00

$12.50

$13.00

$13.50

$14.00

$14.50

$15.00

$310,000

$320,000

$330,000

$340,000

$350,000

$360,000

$370,000

$380,000

$390,000

$400,000

Employee

$9.30

$9.60

$9.90

$10.20

$10.50

$10.80

$11.10

$11.40

$11.70

$12.00

Family

$15.50

$16.00

$16.50

$17.00

$17.50

$18.00

$18.50

$19.00

$19.50

$20.00

$410,000

$420,000

$430,000

$440,000

$450,000

$460,000

$470,000

$480,000

$490,000

$500,000

Employee

$12.30

$12.60

$12.90

$13.20

$13.50

$13.80

$14.10

$14.40

$14.70

$15.00

Family

$20.50

$21.00

$21.50

$22.00

$22.50

$23.00

$23.50

$24.00

$24.50

$25.00

TASC

FSA (Flexible Spending Account)

YOUR BENEFITS PACKAGE

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

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

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

FSA (Flexible Spending Account) Grapevine Colleyville allows employees to enroll in both an HSA and a FSA. If an employee enrolls in both, the FSA becomes limited and can be used for dental and vision expenses only. The HSA funds must be used for medical and prescription expenses.

MyTASC: Online Account Management TASC offers a variety of ways to manage your Flexible Spending Account! These include an online portal called MyTASC at www.tasconline.com, the MyTASC Mobile application for Kindle, Android, and Apple devices, and TXT Messaging using any SMS compatible device. A valid email is required to access each of these. If you or your employer provided your email address upon your initial enrollment, you will receive a Welcome New FlexSystem Participant email with instructions about how to set up your MyTASC account for the first time. If you did not receive the Welcome New FlexSystem Participant email with access instructions, please call Customer Care at 608-241-1900 or toll-free at 800-422-4661 to provide your email address so we may enter it in your Profile.

TXT Messaging: Account balance information may be retrieved via text message also. Once you’ve entered your mobile number in your account profile, simply send a text to 41411 with the message TASC BAL. Almost immediately, you will receive a text back with your current balance. Note: You must enter your mobile phone number in your Profile (see Email and Text Notification) to use this feature.

MyTASC: Online Account Management For a list of eligible expenses: go to www.tasconline. com, click Resources in the top menu bar, then select Eligible Expenses from the dropdown. Click the link for FlexSystem Guide to Deductible Expenses.

The TASC Card Your employer may have elected the TASC Card feature for your Plan. If so, the TASC Card request is implemented as soon as your enrollment is approved. The card is generated in your name and mailed directly to your home address, along with the Cardholder Agreement.

Profile Settings To access your profile settings, click on Profile from the Participant Manager page. Email and Text Notification services are available in MyTASC. From your Profile page, sign up to receive notifications concerning your account balances, reimbursement requests, and payments.

Account Summary Online: To view your current benefits and available funds through your MyTASC online account, click on the Account Management link from the Participant Manager page. MyTASC Mobile: For the ultimate convenience, you can access your account information from anywhere, at any time with the MyTASC Mobile app. And by using your phone or mobile device camera, you can submit Requests for Reimbursement along with any substantiation documents directly to FlexSystem. To download the MyTASC Mobile App, visit Amazon, Apple App Store, or Android Market and search for TASC. MyTASC Mobile runs on most Android-based phones and tablets, the Apple iPhone, iPad, and iPod Touch, and the Amazon Kindle. MyTASC Mobile provides fingertip access to the same features available through your online account.

Log in to MyTASC (www.tasconline.com) and click TASC Card Management to view your card details, request a card for a dependent, reissue a card, request a PIN, and view allowed benefits. Your TASC Card is good for four years. So hang on to it! Even if you deplete this year’s benefits funds, you’ll be able to use the TASC Card again next year when you re-enroll in your Plan. Participants must notify FlexSystem immediately to report a lost or stolen TASC Card. To do so, (a) log in to MyTASC (www.tasconline.com), click TASC Card Management, Reissue Card, and select Lost/Stolen as the reason for reissue; or (b) submit an online MyService Request (from MyTASC, click Contact Us); or (c) call Customer Care at 608-241-1900 or tollfree 800-422-4661. A new card will arrive within 7-15 days and a $10 reissue fee will be withdrawn automatically from your FlexSystem account (pre-tax). MyBenefits The TASC Card works like a typical debit card, but is used as a credit card for eligible medical, dependent daycare, or transportation expenses, based on the funds available in your benefits account. All TASC Card transactions and services must occur within the Plan Year.

FSA (Flexible Spending Account) When using your TASC Card, the amount of the expense is automatically deducted from your Planâ&#x20AC;&#x2122;s balance and paid directly to the authorized provider. Please remember to save your receipts as you must retain records and documents that support and validate your TASC Card transactions. In some cases, you may be required to submit receipts and/or any other related documentation. If you pay for an eligible expense without the TASC Card, simply submit a request for reimbursement via the MyTASC Mobile App or the online Request for Reimbursement Wizard in MyTASC; or mail or fax your Request for Reimbursement Form to TASC. Reimbursements are deposited in your MyCash account.

You may request reimbursement any time a qualified expense has been incurred. The service related to the expense needs only to have taken place; it need not be paid before requesting reimbursement. Submit Requests for Reimbursements only for eligible expenses (a) incurred during the applicable Plan Year, (b) incurred by eligible Plan Participants, (c) not reimbursed previously under this or any other benefits plan, and (d) not claimed as an income tax deduction. It is your responsibility to comply with these guidelines and to avoid submitting duplicate or ineligible Requests for Reimbursement.

MyTASC Mobile App

Dependent TASC Card Give your dependent the flexibility of his/her own TASC Card. The additional TASC Card offers your spouse or dependent the same convenience and advantages you enjoy! You will receive one additional card for your spouse or dependent free of charge. A $10 fee will apply for each subsequent TASC Card generated. This fee will be deducted from your FlexSystem account upon the creation of the card(s). To request a TASC Card for your spouse or dependent, log in to your MyTASC account (www.tasconline.com) and click TASC Card Management, Issue Dependent Card, and follow the prompts.

TASC Card with exclusive MyCash access If your employer has not elected the TASC Card for your benefits Plan and you have not elected direct deposit for your reimbursements, you will receive a special TASC Card with exclusive MyCash access. The card serves as a reimbursement card only. It has no access to benefits funds. Reimbursements for eligible benefits expenses will be deposited into your MyCash account. You can access your MyCash funds with the swipe of your TASC Card at any merchant that accepts MasterCard, Maestro, or NYCE cards, or at an ATM (with a PIN). Or you may visit your MyCash Manager in MyTASC to set up a transfer.

Requests for Reimbursement When paying for an eligible expense, simply swipe your TASC Card at the point-of-purchase. The TASC Card automatically pays for and substantiates expenses, eliminating the need to submit reimbursement requests. On the rare occasion you pay for an expense without your TASC Card, simply submit a Request for Reimbursement via the online MyTASC Mobile App or Request for Reimbursement Wizard in MyTASC, or fax or mail your personalized Request for Reimbursement Form with substantiation to TASC

The MyTASC Mobile app provides the simplest and quickest method to request a reimbursement. Simply enter the required information as prompted and attach your receipt to the Request for Reimbursement by taking a photo using your mobile device camera.

Request for Reimbursement Wizard Itâ&#x20AC;&#x2122;s easy to submit reimbursement requests along with substantiation online! Follow these steps: 1. Log in to your MyTASC account and click Request for Reimbursement Wizard. 2. Enter all required information (Service Type, Service Date, Service Description, Service Provider, Amount Paid). Each expense incurred must be submitted individually. Do not combine several expenses into one total. 3. Upload receipts by attaching a scanned document (jpg, png, tif, or pdf). 4. Review your request carefully to ensure its accuracy, then click Submit. 5. View submitted requests at the bottom of the online Request for Reimbursement page.

Mail or Fax Download a personalized Request for Reimbursement form from your Participant Manager in MyTASC, complete, and submit with substantiation to TASC.

Reimbursement Disbursements Requests for Reimbursement are processed daily. Once a request is reviewed and approved, a reimbursement is issued to your MyCash account. For dependent care and nonemployer sponsored insurance premium reimbursements, the benefits account must contain sufficient funds for

FSA (Flexible Spending Account) reimbursement. If funds are insufficient in the account, reimbursement will be limited to that particular account’s balance. The outstanding balance of the request will remain as Pending until additional deposits are received, at which time an additional reimbursement will be initiated. Medical Out-ofPocket expenses will be reimbursed up to your total Plan Year election less prior reimbursements. 45 6 FlexSystem Participant Reference Guide.

MyCash All reimbursements are deposited in your MyCash account. You can access your MyCash funds in three ways: (1) swipe your TASC Card at any merchant that accepts MasterCard, (2) withdraw at an ATM using your TASC Card, or (3) transfer to a personal bank account. Click MyCash Manager in MyTASC to view and manage your MyCash funds. *Paper reimbursement checks are issued on a limited basis and only upon request. A convenience fee may be applied per check.

Direct Deposit To establish direct deposit of your MyCash funds to a personal bank account, visit MyCash Manager (in MyTASC) and click Schedule a Transfer. Enter your Bank Account information, then set up an Automatic Transfer to occur every time funds enter your MyCash account. With Automatic Transfer (direct deposit), funds are forwarded from your MyCash account to your bank within 48 to 72 hours of a complete submission. Remember to verify receipt of deposits before writing checks against expected payments. TASC is not responsible for any bank fees associated with overdraft charges.

Managing Your Requests To view your submitted Requests for Reimbursements and payments, click Account Management from the Participant Manager, then Reimbursements. Payments are in the Reimbursement Disbursements section and show the date payment was initiated, the amount, and how payment was made.

Click the Details link in the Request ID column to view additional information about the individual request, including: Date of Service, Service Type, Service Description, and Provider Name. You can also obtain this information from your mobile device using the MyTASC Mobile App.

MyCash Manager It’s easy to manage your MyCash reimbursement funds from the MyCash Manager within MyTASC. From MyCash Manager, you can view recent MyCash activity and card information, save bank account information, and transfer funds to a personal bank account. You can view MyCash activity and balance via MyTASC Mobile, too.

Change of Elections You may change your election during the Plan Year under certain circumstances only and only within 30 days of the qualifying event. For example, if you get married or divorced, have a child, or experience a change in work status, you may be able to make a change of elections. (See your employer for a complete list of circumstances and the appropriate form to use.)

Plan Year End and Carryover Typically there is a transitional period at the end of your Plan Year during which time you may be able to incur and/or submit expenses. Check with your employer for complete details pertinent to your Plan. The Plan Year is officially closed following a transitional period at the end of the Plan Year, or sooner if directed by your employer. At the end of the Plan Year, you may carry over a portion of your unused balance in your medical FSA from year to year. The maximum carryover allowed is $500; your employer may choose a lessor amount or no carryover. Any unused medical FSA funds (exceeding your employer’s carryover maximum) are forfeited to your employer. Near the end of the Plan Year, you will have the opportunity to re-enroll in your FlexSystem Plan. Please check with your employer on your specific re-enrollment procedure.

Submitted Requests for Reimbursement are shown in the Submitted RFRs section. Use the Filter by Benefit drop down box to view requests for one specific benefit or to see all requests. This summary table shows the Submitted Date, Request ID, Requested Amount, Benefit type, Veriflex Status, Paid Status, and how the request was received. You may also sort within each column by clicking on the column title. From this screen, click Upload Receipt next to a Submitted RFR to submit additional substantiation.

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