2016 Benefit Guide - Mansfield ISD by Higginbotham Public Sector

MANSFIELD ISD

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

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 HSA Bank Health Savings Account (HSA) SISLink Medical Supplement MDLIVE Telehealth Cigna Dental Davis Vision AUL a OneAmerica Company Long Term Disability AUL a OneAmerica Company Life and AD&D 5Star Family Protection Plan Term Life Insurance with Quality of Life Rider APL Cancer Voya Accident Voya Critical Illness NBS Flexible Spending Account (FSA) 2

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

FLIP TO... PG. 4 HOW TO ENROLL

11 12-15 16-19 20-23 24-25 26-31 32-33 34-37 38-41

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

42-45

PG. 12

46-49 50-53 54-57 58-61

YOUR BENEFITS PACKAGE

Benefit Contact Information

Benefit Contact Information BENEFIT ADMINISTRATORS

DENTAL

CANCER

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

Group # 3339927 Cigna (800) 244-6224 www.mycigna.com

Group # 13041 American Public Life (800) 256-8606 www.ampublic.com

MEDICAL

VISION

ACCIDENT

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

Group # 7511 Davis Vision (877) 923-2847 www.davisvision.com

Group # 695149 Voya (800) 955-7736 www.voya.com

HEALTH SAVINGS ACCOUNT

DISABILITY

CRITICAL ILLNESS

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

Policy # G00614903 AUL a OneAmerica Company (800) 553-5318 Claims: (855) 517-6365 www.oneamerica.com

Group # 695149 Voya (800) 955-7736 www.voya.com

MEDICAL SUPPLEMENT

FAMILY PROTECTION PLAN

FLEXIBLE SPENDING ACCOUNT

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

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

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

TELEHEALTH

LIFE AND AD&D

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

Policy # G00614903 AUL a OneAmerica Company Customer Service: (800) 553-5318 Life/Life Waiver Claims: (800) 553-3522 Employee Assistance Program: (855) 387-9727 Travel Assistance Program: (866) 294-2469 www.oneamerica.com

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

TEXT

need to complete your enrollment.

“misd” TO

Avoid typing long URLs and scan directly to your benefits website,

313131

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

TRY ME

SCAN:

On Your Computer Access THEbenefitsHUB from your

Our online benefit enrollment

computer, tablet or smartphone!

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

! 4

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

Go to:

Click Login

Enter Username & Password

www.mybenefitshub.com/mansfieldisd

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: Everything!  Benefit elections will become effective 9/1/2016 (elections and the Low Plan. If you want to go to an out of Network requiring evidence of insurability, such as Life Insurance, dentist, the High Plan maybe a better choice. If you go to an may have a later effective date, if approved). After annual out of network dentist, the High plan may be the best choice enrollment closes, benefit changes can only be made if you because the Low plan only reimburses at negotiated experience a qualifying event (and changes must be made in-network fee schedule out-of-network and you will be within 30 days of event). billed for the difference in cost, which could be significant.  Aetna is the current carrier for TRS ActiveCare Medical The DHMO network is IN-NETWORK only with a schedule of coverage. You MUST log on during the annual enrollment benefits for services. to either elect or waive your medical elections.  Davis Vision is the new carrier for Vision. You will receive a  HSA Bank is the plan administrator for Health Savings new card in the mail for your new coverage. Davis Vision is Accounts. Monthly contribution are available each month also associated with Vision Works, located in Mansfield. and remaining contributions will roll to next year.  OneAmerica is the Life and AD&D provider. OneAmerica  SISLink Medical Supplement. This benefit will help with allows employees that are currently enrolled in the life meeting high deductibles and out-of-pocket costs for insurance and are below the Guaranteed Issue (GI) amount doctor’s visits and/or emergency care. to increase the coverage to the GI without evidence of  FSA with NBS. Flexible Spending Accounts use pre-tax dollars insurability. If you are not currently enrolled, you can enroll to help pay toward eligible medical expenses. The Medical subject to evidence of insurability for the lesser of FSA plan year maximum remains at $2,550. $200,000, up to $50,000 for spouse and up to $10,000 for  OneAmerica Disability will be the disability carrier effective children. For increases in coverage to take effect, 9/1/2016. The pre-existing benefit that provides coverage employees must be actively at work and spouse/child up to a maximum of 4 weeks will remain in place. The cannot be disabled. disability plan has a first day hospital benefit if you elect a  5 Star Term Life to 100 with Quality of Life Employees may 0/7, 14/14 or 30/30 plan. elect up to $150,000 and may elect $30,000 on their  Telehealth with MDLIVE. This plan gives you access to spouse. You may elect up to $20,000 for eligible children up telephone consultations with a licensed physician for to age 23. This plan includes a Quality of Life component evaluation, diagnosis and prescriptions, as appropriate, for which will pay up to 18 months of long term care if the minor illnesses. This covers you, your spouse and insured is unable to perform at least 2 of the 6 Activities of dependent children to age 26. Effective 9/1/2016, coverage Daily Living (ADLs) without substantial assistance or if the for you and your entire family is $10.00. insured suffers an impairment such as dementia,  Cigna is the Dental Carrier. You have a choice between a Alzheimer’s or other forms of senility requiring substantial High and a Low Plan and DHMO. There are different supervision. Quality of Life is not available for children. premiums and Calendar Year Maximums for the High Plan Premiums are locked and do not increase.

  

Login and complete your supplemental benefit enrollment from 07/01/2016 - 07/31/2016 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):

Marital Status

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

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

A change in number of dependents includes the following: birth, adoption and placement for adoption. Change in Number of Tax You can add existing dependents not previously enrolled whenever a dependent gains eligibility as a Dependents result of a valid change in status event. Change in Status of Employment Affecting Coverage Eligibility

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

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

annual enrollment) unless a Section 125 qualifying event occurs.

www.mybenefitshub.com/mansfieldisd. Click on the benefit plan you need information on (i.e., Dental) and you can find



Changes, additions or drops may be made only during the

the forms you need under the Benefits and Forms section.

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

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

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

included in the dependent profile. Additionally, you must

mansfieldisd. Click on the benefit plan you need information

notify your employer of any discrepancy in personal and/or

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

benefit information.



For benefit summaries and claim forms, go to your school

Employees must confirm on each benefit screen (medical, dental, vision, etc.) that each dependent to be covered is selected in order to be included in the coverage for that particular benefit.

the Quick Links section. When will I receive ID cards? If the insurance carrier provides ID cards, you can expect to receive those 3-4 weeks after your effective date. For most dental and vision plans, you can login to the carrier website and print a temporary ID card or simply give your provider the insurance company’s phone number and they can call and

New Hire Enrollment All new hire enrollment elections must be completed in the online enrollment system within the first 31 days of benefit eligibility employment. Failure to complete elections during this timeframe will result in the forfeiture of coverage.

verify your coverage if you do not have an ID card at that time. If you do not receive your ID card, you can call the carrier’s customer service number to request another card. If the insurance carrier provides ID cards, but there are no changes to the plan, you typically will not receive a new ID card each year.

Q&A Who do I contact with Questions? For supplemental benefit questions, you can contact your Benefits/HR department or you can call Financial Benefit Services

at 866-914-5202 for assistance.

SUMMARY PAGES

Employee Eligibility Requirements

Dependent Eligibility Requirements

Supplemental Benefits: Eligible employees must work 18 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 Mansfield ISD or as both

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

employees and dependents.

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

PLAN

CARRIER

MAXIMUM AGE

Medical

Aetna

Through 25

Medical Supplement

SISLink

Through 25

Telehealth

MDLIVE

Through 25

Dental

Cigna

Through 25

Vision

Davis Vision

Through 25

Accident

VOYA

Through 25

Cancer

American Public Life

Through 25

Life and AD&D

AUL a OneAmerica company

Through 25

Critical Illness

VOYA

Through 25

Health Savings Account (HSA)

HSA Bank

IRS Tax Dependent

Flexible Spending Account (FSA)

National Benefit Services

Through 25 or IRS Tax Dependent

Dependent Flex

National Benefit Services

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

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

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 taxfree.

Employer Eligibility

A qualified high deductible health plan.

All employers

Contribution Source Account Owner Underlying Insurance Requirement

Employee and/or employer Individual

Employee and/or employer Employer

High deductible health plan

None

Description

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

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

Year-to-year rollover of account balance?

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

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

Does the account earn interest?

Yes

Portable?

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

Minimum Deductible Maximum Contribution

Permissible Use Of Funds

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

FLIP TO… PG. 16

FLIP TO… PG. 58

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 Mansfield ISD Benefits Website: www.mybenefitshub.com/mansfieldisd

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

Plan pays 100% (deductible waived)

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

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

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

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

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

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

$50 copay for specialist

Annual Hearing Examination Participant pays

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

$30 copay for primary $50 copay for specialist

$30 copay for primary $60 copay for specialist

Note: Covered services under this benefit must be billed by the provider as “preventive care.” If you receive preventive services from a non-network provider, you will be responsible for any applicable deductible and coinsurance under the ActiveCare 1-HD and ActiveCare 2. Non-network preventive care is not paid at 100%. There is no coverage for non-network services under the ActiveCare Select plan or ActiveCare Select Whole Health.

TRS-ActiveCare is administered by Aetna Life Insurance Company. Aetna provides claims payment services only and does not assume any financial risk or obligation with respect to claims. Prescription drug benefits are administered by Caremark.

Medical Rates TRS ActiveCare 1-HD

Monthly Premium Cost

TRS Cost

Your Cost*

Employee Only

$341

$91

Employee and Spouse

$914

$664

Employee and Child(ren)

$615

$365

$1,231

$981

TRS Cost

Your Cost*

$484

$234

$1,147

$897

$779

$529

$1,361

$1,111

TRS Cost

Your Cost*

$645

$395

Employee and Spouse

$1,552

$1,302

Employee and Child(ren)

$1,042

$792

Employee and Family

$1,597

$1,347

Employee and Family

TRS ActiveCare Select Monthly Premium Cost Employee Only Employee and Spouse Employee and Child(ren) Employee and Family

TRS ActiveCare 2 Monthly Premium Cost

Employee Only

HSA BANK

HSA (Health Savings Account)

YOUR BENEFITS PACKAGE

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

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

Money withdrawn for medical spending never falls under taxable income.

HSA (Health Savings Account) HSA Bank has teamed up with your employer to create an affordable health coverage option that helps you save on healthcare expenses. This plan is only available for those who are participating in the Active Care 1-HD medical plan. You may not enroll in the Traditional Gap Plan if you participate in the HSA. You may not participate in the FSA plan if you participate in HSA. Medicare, Medicaid, and Tricare participants are not eligible to participate in an HSA. 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.

Authorized Signers who are 55 or older must have their own HSA in order to make the catch-up contribution Monthly Fee: Your account will be charged a monthly fee of $1.75, waived with an average daily balance at or above $3,000.

Examples of Qualified Medical Expenses      

Surgery Braces Contact lenses Dentures Eyeglasses Vaccines

For a list of sample expenses, please refer to the Mansfield ISD website at www.thebenefitshub.com/mansfieldisd

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

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

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)  Not enrolled in Medicare (if an accountholder enrolls in Medicare mid-year, catch-up contributions should be prorated) 17

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).

SISLINK 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.

Medical Supplement The Gap Plans provide coverage for medically necessary eligible out-of-pocket expenses related to the insured’s major medical plan’s co-insurance and deductibles up to the maximum benefit selected, provided such expenses are the result of treatment for a covered injury or sickness.

Inpatient Hospital Benefit The benefit options are: $1,500 or $3,000 In-Hospital benefit per covered person per calendar year. Note: This coverage may not cover 100% of out-of-pocket expenses. BENEFITS INCLUDE:  Coverage for out-of-pocket expenses due to an inpatient hospital confinement  Coverage for inpatient hospital charges for eligible outof-pocket expenses resulting from the treatment of an accidental injury or sickness  Emergency room treatment and ambulance for a covered injury or sickness when it results in hospital confinement within 24 hours  Durable medical equipment (DME) when provided while confined in a hospital

Outpatient Hospital Benefit The Outpatient Hospital benefit limit is 50% of the In-hospital benefit amount selected and three times the individual outpatient benefit for dependent coverage. BENEFITS INCLUDE:  Emergency room treatment and ambulance as long as the person is NOT hospitalized within 24 hours of being transported to the hospital and ER treatment  Outpatient surgery in an outpatient surgical facility, emergency facility or physician’s office  Diagnostic testing, x-rays, labs, MRI’s, and CT scans  Outpatient radiation therapy or chemotherapy  Physical therapy or chiropractic care  Durable medical equipment (DME) if dispensed at the doctor’s office The Outpatient Benefit does not cover a physician’s office visit charge. Please note that in order for a service to be covered under the Gap Plan, it needs to be covered under the major medical plan.

Traditional Plan Example of Gap Plan Payout Vs. No Gap Plan How It Works INPATIENT HOSPITAL CLAIM EXAMPLE

WITHOUT GAP PLAN

Inpatient Hospital Bill Benefit Paid Patient Responsibility

$5,000 N/A $5,000

WITH DEDUCTIBLE RELIEF GAP PLAN $5,000 $2,500 $2,500

HSA Compatible Plan Deductible - In order for your gap plan to be compatible with a Health Savings Account (HSA), it has a deductible amount of $1,300 that must be satisfied before any benefits are payable. When dependent coverage is elected, benefits are payable only after the entire family deductible has been satisfied by one or more insured persons. Example of Gap Plan Payout Vs. No Gap Plan How It Works INPATIENT HOSPITAL CLAIM EXAMPLE

WITHOUT GAP PLAN

Inpatient Hospital Bill Deductible-Paid by Insured Benefit Paid Patient Balance

$5,000 N/A N/A $5,000

WITH DEDUCTIBLE RELIEF GAP PLAN $5,000 $1,300 $2,500 $1,200

Medical Supplement Traditional Plan AGE BASED MONTHLY COST BY COVERAGE AMOUNT Benefit Amount Under Age 40: Insured Only Insured & Spouse Insured & Child(ren) Insured & Family Ages 40—49: Insured Only Insured & Spouse Insured & Child(ren) Insured & Family Age 50 & Above: Insured Only Insured & Spouse Insured & Child(ren) Insured & Family

12 Pay Rates $22.20 $40.75 $54.26 $72.31

$1,500 18 Pay Rates $14.80 $27.17 $36.17 $48.21

26 Pay Rates $10.25 $18.81 $25.04 $33.37

12 Pay Rates $36.09 $66.31 $89.63 $119.05

$3,000 18 Pay Rates $24.06 $44.21 $59.75 $79.37

26 Pay Rates $16.66 $30.60 $41.37 $54.95

$29.35 $53.88 $58.36 $82.26

$19.57 $35.92 $38.91 $54.84

$13.55 $24.87 $26.94 $37.97

$46.59 $85.60 $95.01 $133.02

$31.06 $57.07 $63.34 $88.68

$21.50 $39.51 $43.85 $61.39

$61.60 $113.15 $107.25 $157.48

$41.07 $75.43 $71.50 $104.99

$28.43 $52.22 $49.50 $72.68

$102.23 $187.81 $178.51 $261.87

$68.15 $125.21 $119.01 $174.58

$47.18 $86.68 $82.39 $120.86

26 Pay Rates $10.20 $18.36 $22.54 $30.69

HSA Compatible Plan AGE BASED MONTHLY COST BY COVERAGE AMOUNT Benefit Amount Under Age 40: Insured Only Insured & Spouse Insured & Child(ren) Insured & Family Ages 40—49: Insured Only Insured & Spouse Insured & Child(ren) Insured & Family Age 50 & Above: Insured Only Insured & Spouse Insured & Child(ren) Insured & Family

12 Pay Rates $11.77 $21.18 $26.00 $35.41

$1,500 18 Pay Rates $7.85 $14.12 $17.33 $23.61

26 Pay Rates $5.43 $9.78 $12.00 $16.34

12 Pay Rates $22.10 $39.77 $48.84 $66.50

$3,000 18 Pay Rates $14.73 $26.51 $32.56 $44.33

$16.33 $29.37 $30.02 $43.07

$10.89 $19.58 $20.01 $28.71

$7.54 $13.56 $13.86 $19.88

$30.64 $55.15 $56.38 $80.88

$20.43 $36.77 $37.59 $53.92

$14.14 $25.45 $26.02 $37.33

$26.35 $47.42 $42.67 $63.74

$17.57 $31.61 $28.45 $42.49

$12.16 $21.89 $19.69 $29.42

$49.47 $89.01 $80.13 $119.70

$32.98 $59.34 $53.42 $79.80

$22.83 $41.08 $36.98 $55.25

Medical Supplement Plan Exclusions Benefits will not be paid for losses caused by or resulting from any one or more of the following:               

 

Declared or undeclared war or any act thereof Suicide or intentionally self-inflicted injury or any attempt, while sane or insane (while sane, in Colorado and Missouri) Any hospital confinement or other treatment for injury or sickness while an insured person is in the service of the armed forces of any country Confinement in a hospital or other treatment facility operated by an agency of the United States government or one of its agencies, unless the insured person is legally required to pay for the services Confinement or other treatment for injury or sickness which is not medically necessary Confinement or other treatment for dental or vision care not related to an accidental injury Confinement or other treatment for mental or nervous disorders Confinement or other treatment for alcoholism, drug addiction or complications thereof Any hospital confinement or other covered treatment for injury or sickness for which compensation is payable under any Worker's Compensation Law, any Occupational Disease Law, or similar legislation Any hospital confinement or other covered treatment for injury or sickness that is payable under any insurance that does not require deductible and/or coinsurance payments by the insured person Any hospital confinement or other covered treatment for injury or sickness for which benefits are not payable under the insured person's major medical plan Any hospital confinement or other covered treatment for injury or sickness if, on the insured person’s effective date of coverage, the insured person was not covered by a major medical plan An insured person engaging in any act or occupation which is a violation of the law of the jurisdiction where the loss or cause occurred. A violation of the law includes both misdemeanor and felony violations Prescription drugs Durable medical equipment, unless dispensed in a hospital, an outpatient surgical or emergency facility, a diagnostic testing facility, or a similar facility that is licensed to provide outpatient treatment Well newborn care, whether inpatient or outpatient Wellness or preventive care

This plan is underwritten by Companion Life Insurance Company arranged through Special Insurance Services, Inc.

MDLIVE YOUR BENEFITS PACKAGE

Telehealth

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

DID YOU KNOW?

75%

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

Telehealth When should I use MDLIVE?

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

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

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

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

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

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

How much does it cost? $10 per month; See your pay rate below. Covers you, your spouse, and children up to age 26, with unlimited phone consultations. 12 Pay Rate: $10.00 18 Pay Rate: $6.67 26 Pay Rate: $4.62

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

  

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

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

Scan with your smartphone to get the app.

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

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

CIGNA

Dental

YOUR BENEFITS PACKAGE

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

DID YOU KNOW?

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

Dental PPO - High Plan Benefits

Cigna Dental Choice In-Network Out-of-Network Total Cigna DPPO

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

$1,250

$50 per person $150 per family

Based on Reduced Contracted Fees

90th percentile of Reasonable and Customary Allowances

Plan Pays

You Pay

Plan Pays

You Pay

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

100%

No Charge

100%

No Charge

Class II - Basic Restorative Care Fillings Anesthetics Denture Repairs Repairs to Bridges, Crowns and Inlays Oral Surgery – Simple Extractions

80%*

20%*

80%*

20%*

50%*

12 Pay Rates

EE Only

$34.79

EE + Spouse

$69.07

EE + Child(ren)

$70.29

Family Coverage

$104.85

18 Pay Rates EE Only

$23.19

EE + Spouse

$46.05

EE + Child(ren)

$46.86

Family Coverage

$69.90

26 Pay Rates EE Only

$16.06

EE + Spouse

$31.88

EE + Child(ren)

$32.44

Family Coverage

$48.39

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

Class IV - Orthodontia Lifetime Maximum

Class IX - Implants Deductible Annual Maximum

50% $1,250 Covered for children & adults 50%* Subject to plan deductible Subject to plan annual maximum

50%

50%*

50% $1,250 Covered for children & adults 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 12 months; thereafter, considered a Class III expense. Pretreatment review is available on a voluntary basis when extensive dental work in excess of $200 is proposed. * Subject to annual deductible Dental Oral Health Integration Program (OHIP) - All dental customers = Clinical research shows an association between oral health and overall health. The Cigna Dental Oral Health Integration Program (OHIP)® is designed to provide enhanced dental coverage for customers with certain eligible medical conditions. Eligible conditions for the program include cardiovascular disease, cerebrovascular disease (stroke), diabetes, maternity, chronic kidney disease, organ transplants, and head and neck cancer radiation. The program provides:

  

100% coverage for certain dental procedures guidance on behavioral issues related to oral health

discounts on prescription and non-prescription dental products For more information and to see the complete list of eligible conditions, go to www.mycigna.com or call customer service 24/7 at 1.800.CIGNA24. **For services provided by a Cigna Dental PPO network dentist, Cigna Dental will reimburse the dentist according to a Contracted Fee Schedule. For services provided by an out-of-network dentist, Cigna Dental will reimburse according to the Contracted Fee Schedule but the dentist may balance bill up to their usual fees.

Dental PPO - Low Plan Benefits

Cigna Dental Choice In-Network Out-of-Network Total Cigna DPPO

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

$1,250

$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

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

100%

No Charge

100%

No Charge

12 Pay Rates

EE Only

$31.06

EE + Spouse

$61.67

EE + Child(ren)

$62.76

Family Coverage

$93.62

18 Pay Rates EE Only

$20.71

EE + Spouse

$41.11

EE + Child(ren)

$41.84

Family Coverage

$62.41

26 Pay Rates

Class II - Basic Restorative Care Fillings Anesthetics Denture Repairs Repairs to Bridges, Crowns and Inlays Oral Surgery – Simple Extractions

80%*

20%*

80%*

20%*

50%*

EE Only

$14.34

EE + Spouse

$28.46

EE + Child(ren)

$28.97

Family Coverage

$43.21

Class IV - Orthodontia Lifetime Maximum

Class IX - Implants Deductible Annual Maximum

50% $1,000 Covered for children & adults 50%* Subject to plan deductible Subject to plan annual maximum

50%

50%*

50% $1,000 Covered for children & adults 50%* Subject to plan deductible Subject to plan annual maximum

50%

50%*

  

100% coverage for certain dental procedures guidance on behavioral issues related to oral health

Dental PPO - High and Low Plans Procedure

Exclusions and Limitations

Late Entrants Limit Exams Prophylaxis (Cleanings) Fluoride X-Rays (routine) X-Rays (non-routine) Model Minor Perio (non-surgical) Perio Surgery Crowns and Inlays Bridges Dentures and Partials Relines, Rebases Adjustments Repairs - Bridges 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 14 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 16 Limited to non-Orthodontic treatment 1 per 60 consecutive months if unserviceable and cannot be repaired. Benefits are based on the amount payable for nonprecious metals. No porcelain or white/tooth colored material on molar crowns or bridges When more than one covered Dental Service could provide suitable treatment based on common dental standards, Cigna HealthCare will determine the covered Dental Service on which payment will be based and the expenses that will be included as Covered Expenses

Alternate Benefit

Benefit Exclusions     

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

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

This benefit summary highlights some of the benefits available under the proposed plan. A complete description regarding the terms of coverage, exclusions and limitations, including legislated benefits, will be provided in your insurance certificate or plan description. Benefits are insured and/or administered by Con necticut General Life Insurance Company. "Cigna HealthCare" refers to various operating subsidiaries of Cigna Corporation. Products and services are provided by these subsidiaries and not by Cigna Corporation. These subsidiaries include Connecticut General Life Insurance Company, Cigna Health and Life Insurance Company, and HMO or service company subsidiaries of Cigna Health Corporation and Cigna Dental Health, Inc. DPPO insurance coverage is set forth on the following policy form numbers: AR: HP-POL77; CA: HP-POL57; CO: HP-POL78; CT: HP-POL58; DE: HP-POL79; FL: HP-POL60; ID: HPPOL82; IL: HP-POL62; KS: HP-POL84; LA: HPPOL86: MA: HP-POL 63; MI: HP-POL88; MO: HP- POL65; MS: HP-POL90; NC: HP-POL96; NE: HP-POL92; NH: HP-POL94; NM: HP-POL95; NV: HP-POL93; NY: HP-POL67; OH: HP-POL98; OK: HP-POL99; OR: HP-POL68; PA: HP-POL100; RI: HP-POL101; SC: HP-POL102; SD: HP-POL103; TN: HP-POL69; TX: HP-POL70; UT: HP-POL104; VA: HP-POL72; VT: HP-POL71; WA: POL-07/08; WI: HP-POL107; WV: HP-POL106; and WY: HP-POL108. “Cigna,” the “Tree of Life” logo and “Cigna Dental Care” are registered service marks of Cigna Intellectual Property, Inc., licensed for use by Cigna Corporation and its operating subsidiaries. All products and services are provided by or through such operating subsidiaries and not by Cigna Corporation. Such operating subsidiaries include Connecticut General Life Insurance Company (CGLIC), Cigna Health and Life Insurance Company (CHLIC), Cigna HealthCare of Connecticut, Inc., and Cigna Dental Health, Inc. and its subsidiaries. Cigna Dental PPO plans are underwritten or administered by CGLIC or CHLIC, with network management services provided by Cigna Dental Health, Inc. and certain of its subsidiaries. In Arizona and Louisiana, the insured Dental PPO plan offered by CGLIC is known as the “CG Dental PPO”. In Texas, the insured dental product offered by CGLIC and CHLIC is referred to as the Cigna Dental Choice Plan, and this plan utilizes the national Cigna Dental PPO network. Cigna Dental Care (DHMO) plans are underwritten or administered by Cigna Dental Health Plan of Arizona, Inc., Cigna Dental Health of California, Inc., Cigna Dental Health of Colorado, Inc., Cigna Dental Health of Delaware, Inc., Cigna Dental Health of Florida, Inc., a Prepaid Limited Health Services Organization licensed under Chapter 636, Florida Statutes, Cigna Dental Health of Kansas, Inc. (Kansas and Nebraska), Cigna Dental Health of Kentucky, Inc. (Kentucky and Illinois), Cigna Dental Health of Maryland, Inc., Cigna Dental Health of Missouri, Inc., Cigna Dental Health of New Jersey, Inc., Cigna Dental Health of North Carolina, Inc., Cigna Dental Health of Ohio, Inc., Cigna Dental Health of Pennsylvania, Inc., Cigna Dental Health of Texas, Inc., and Cigna Dental Health of Virginia, Inc. In other states, Cigna Dental Care plans are underwritten by CGLIC, CHLIC, or Cigna HealthCare of Connecticut, Inc. and administered by Cigna Dental Health, Inc. BSD46380 © 2015 Cigna

Dental DHMO Sampling of covered procedures

What You’ll Pay Estimated cost without dental Cost with Cigna Dental Care coverage

Adult cleaning (two per calendar year each at $0) (additional cleanings available at $45 each) Child cleaning (two per calendar year each at $0) (additional cleanings available at $30 each) Periodic oral evaluation Comprehensive oral evaluation Topical fluoride (two per calendar year each at $0) (additional topical fluoride available at $15 each) X–rays – (bitewings) 2 films X–rays – panoramic film Sealant – per tooth Amalgam filling (silver colored) – 2 surfaces Composite filling (tooth–colored) – 1 surface, Anterior Molar root canal (excluding final restoration) Comprehensive orthodontics – child (up to 19th birthday) – Banding Periodontal (gum) scaling & root planing – 1 quadrant Periodontal (gum) maintenance Removal/extraction of erupted tooth Removal/extraction of impacted tooth Crown – porcelain fused to high noble metal Implant supported retainer for porcelain fused to metal fixed partial denture Occlusal appliance, by report (for treatment of TMJ) Procedure Exams X-rays (routine) X-rays (non-routine) Crowns and inlays Bridges Dentures and partials Relines, rebases Adjustments Prosthesis over implant

$70–$136 each

$53–$102 each

$0 $0

$40–$76 $62–$118

$28–$53

$0 $0 $17 $28 $33 $595

$33–$63 $84–$161 $42–$80 $118–$226 $120–$231 $852–$1,640

$515

$1,042–$2,005

$135 $93 $64 $300 $480

$179–$344 $109–$209 $120–$231 $370–$712 $849–$1,634

$780

$1,097–$2,112

$575

$640–$1,233

Limit Two per plan year Bitewings: 2 per plan year Full mouth: 1 every 3 plan years. Panorex: 1 every 3 plan years Replacement every 5 years Replacement every 5 years Replacement every 5 years One every 36 months Four within the first 6 months after installation Replacement every 5 years if unserviceable and cannot be repaired

Temporomandibular Joint (TMJ) treatment

One occlusal orthotic device per 24 months

Athletic mouth guard

One athletic mouth guard per 12 months when listed on your PCS

12 Pay Rates EE Only

$10.32

EE + Spouse

$18.02

EE + Child(ren)

$22.30

Family Coverage

$32.04

18 Pay Rates EE Only

$6.88

EE + Spouse

$12.01

EE + Child(ren)

$14.87

Family Coverage

$21.36

26 Pay Rates EE Only

$4.76

Finding a network dentist is easy.

EE + Spouse

$8.32

There are several ways to choose your network general dentist:

EE + Child(ren)

$10.29

 Find a dentist at www.Cigna.com. Our online dental directory is updated weekly.  Call 1.800.Cigna24 (1.800.244.6224) to speak with a customer service representative. Our representatives can send you a customized dental directory listing via email.

Family Coverage

$14.79

Dental DHMO Under your plan, you have coverage for hundreds of dental procedures. This overview shows you a small sampling of covered services and what you will pay compared to your estimated cost without coverage. See savings below! Review your plan materials to understand how your plan works. For questions on the plan before enrollment, call 1.800.Cigna24 (1.800.244.6224) and select the “Enrollment Information” prompt.

 

    

Key plan features  There is a $5 office visit fee associated with your plan.  No deductibles – you don’t have to reach a certain level of out-of-pocket expenses before your insurance kicks in.  No dollar maximums – you don’t have to worry about your coverage running out after your covered expenses reach a certain dollar amount.  Easy to understand plan – the fees you pay your dentist are clearly listed on your Patient Charge Schedule (PCS).  There are no claim forms to fill and no waiting periods for coverage.  The network general dentist you choose will manage your overall dental care.  Covered family members can choose their own network general dentists – near home, work or school.  You don’t need a referral for children under seven to visit a network pediatric dentist. And you don’t need a referral to see a network orthodontist.  There’s no age limit on sealants, which help prevent tooth decay.  Your plan covers certain procedures to help detect oral cancer in its early stages.  24/7 access to the Dental Information Line—this line is staffed by trained professionals who can help you if you have questions about dental treatment and clinical symptoms.



Referrals are required for specialty care services. Specialty treatment plans require payment authorization for services to be covered under your plan, except for Pediatrics, Orthodontics and Endodontics. You should verify with your Network Specialty Dentist that your treatment plan has been authorized for payment by Cigna before treatment begins.



Listed below are the services or expenses which are NOT covered under your Dental Plan and which are your responsibility at the dentist’s usual fees. There is no coverage for:   

Or in connection with an injury arising out of, or in the course of, any employment for wage or profit Charges which would not have been made in any facility, other than a hospital or a correctional institution owned or operated by the United States government or by a state or municipal government if the person had no insurance To the extent that payment is unlawful where the person resides when the expenses are incurred or the services are received

        

    

         

The charges which the person is not legally required to pay Charges which would not have been made if the person had no insurance Due to injuries which are intentionally self-inflicted Services not listed on the PCS Services provided by a non-network dentist without Cigna Dental’s prior approval (except emergencies, as described in your plan documents) Services related to an injury or illness paid under workers’ compensation, occupational disease or similar laws Services provided or paid by or through a federal or state governmental agency or authority, political subdivision or a public program, other than Medicaid Services required while serving in the armed forces of any country or international authority or relating to a declared or undeclared war or acts of war Services performed primarily for cosmetic reasons unless specifically listed on your PCS General anesthesia, sedation and nitrous oxide, unless specifically listed on your PCS Prescription medications Replacement of filled and/or removable appliances (including filled and removable orthodontic appliances) that have been lost, stolen, or damaged due to patient abuse, misuse or neglect Surgical implant of any type unless specifically listed on your PCS Services considered to be unnecessary or experimental in nature or do not meet commonly accepted dental standards Procedures or appliances for minor tooth guidance or to control harmful habits Services and supplies received from a hospital The completion of crowns, bridges, dentures, or root canal treatment already in progress on the effective date of your Cigna Dental coverage The completion of implant supported prosthesis (including crowns, bridges and dentures) already in progress on the effective date of your Cigna Dental coverage, unless specifically listed on your PCS4 Consultations and/or evaluations associated with services that are not covered Endodontic treatment and/or periodontal (gum tissue and supporting bone) surgery of teeth exhibiting a poor or hopeless periodontal prognosis Bone grafting and/or guided tissue regeneration when performed at the site of a tooth extraction unless specifically listed on your PCS Bone grafting and/or guided tissue regeneration when performed in conjunction with an apicoectomy or periradicular surgery Intentional root canal treatment in the absence of injury or disease to solely facilitate a restorative procedure Services performed by a prosthodontist Localized delivery of antimicrobial agents when performed alone or in the absence of traditional periodontal therapy Any localized delivery of antimicrobial agent procedures when more than eight (8) of these procedures are reported on the same date of service. Infection control and/or sterilization The recementation of any inlay, onlay, crown, post and core or filled bridge within 180 days of initial placement The recementation of any implant supported prosthesis (including crowns, bridges and dentures) within 180 days of initial placement Services to correct congenital malformations, including the replacement of congenitally missing teeth The replacement of an occlusal guard (night guard) beyond one per any 24 consecutive month period, when this limitation is noted on the PCS Crowns, bridges and/or implant supported prosthesis used solely for splinting Resin bonded retainers and associated pontics 31

DAVIS 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 IN-NETWORK BENEFITS Every 12 months, Covered in full after $10 Eye Examination copayment EYEGLASSES Every 12 months, Covered in full Spectacle Lenses For standard single-vision, lined bifocal, or trifocal lenses after $25 copayment

Frames

Every 12 months, Covered in full Any Fashion, Designer or Premier frame from Davis Vision’s Collection1 (value up to $195) OR $150 retail allowance toward any frame from provider, plus 20% off balance2 OR $200 allowance, plus 20% off balance to go toward any frame from a Visionworks family of store locations.6

CONTACT LENSES Every 12 months, Collection Contacts: Covered in full Contact Lens OR Evaluation, Fitting Non Collection Contacts: & Follow Up Care Standard Contacts: Covered in full Specialty Contacts3: $60 allowance with 15% off balance2

Contact Lenses (in lieu of eyeglasses)

Every 12 months, Covered in full Any contact lenses from Davis Vision’s Contact Lens Collection1 OR $150 retail allowance toward provider supplied contact lenses, plus 15% off balance2

ADDITIONAL DISCOUNTED LENS OPTIONS & COATINGS MOST POPULAR OPTIONS Without With Davis Savings based on in-network usage and average retail values.

Scratch-Resistant Coating Polycarbonate Lenses Standard Anti-Reflective (AR) Coating Standard Progressives (no-line bifocal) Photochromic Lenses (i.e. Transitions®, etc.)5

Davis Vision

Vision

$25 $66 $83

$0 $0/4-$30 $35

$198

$50

$110

$65

EMPLOYEE CONTRIBUTIONS

Monthly Rate

Employee Employee plus Spouse Employee plus Child(ren) Employee plus Family

$6.61 $11.25 $11.93 $17.87

18 Pay Rates

26 Pay Rates

Employee Employee plus Spouse Employee plus Child(ren) Employee plus Family

$4.41 $7.50 $7.95 $11.91

$3.05 $5.19 $5.51 $8.25

ADDITIONAL OPTIONS

Without Davis Vision

With Davis Vision

$100

$160

$195

$90

$78 $20 $25 $25 $66 $25

$0 $0 $0 $0 $01 or $30 $12

$83

$35

$104 $121

$48 $60

$198

$50

$247

$90

$369

$140

$120 $103

$55 $75

$110

$65

FRAMES Fashion Frame (from the Davis Vision Collection) Designer Frame (from the Davis Vision Collection) Premier Frame (from the Davis Vision Collection)

LENSES All Ranges of Prescriptions and Sizes Plastic Lenses Oversized Lenses Tinting of Plastic Lenses Scratch-Resistant Coating Polycarbonate Lenses Ultraviolet Coating Standard Anti-Reflective (AR) Coating Premium AR Coating Ultra AR Coating Standard Progressive Addition Lenses Premium Progressives Addition Lenses Ultra Progressive Addition Lenses High-Index Lenses Polarized Lenses Photochromic Lenses (i.e. Transitions®, etc.)2 Scratch Protection Plan (Single vision | Multifocal lenses)

$20 | $40

OUT-OF-NETWORK BENEFITS

OUT-OF-NETWORK REIMBURSEMENT SCHEDULE

You may receive services from an out-of-network provider, although you will receive the greatest value and maximize your benefit dollars if you select a provider who participates in the network. If you choose an out-of-network provider, you must pay the provider directly for all charges and then submit a claim for reimbursement to: Vision Care Processing Unit P.O. Box 1525 Latham, NY 12110

Eye Examination up to $40 | Frame up to $70 Spectacle Lenses (per pair) up to: Single Vision $40 Bifocal $60 Trifocal $80 Lenticular $100 Elective Contacts up to $105 Visually Required Contacts up to $225

1 The Davis Vision Collection is available at most participating independent provider locations. Collection is subject to change. Collection is inclusive of select toric and multifocal contacts. 2 Additional discounts not applicable at Walmart, Sam’s Club or Costco locations. 3 Including, but not limited to toric, multifocal and gas permeable contact lenses. 4 For dependent children, monocular patients and patients with prescriptions of 6.00 diopters or greater. 5 Transitions® is a registered trademark of Transitions Optical Inc. 6 Enhanced frame allowance available at all Visionworks Locations nationwide.

AUL A ONEAMERICA COMPANY 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 Eligible Employees

Partial Disability

This benefit is available for employees who are actively at work on the effective date and working a minimum of 18 hours per week.

You may be paid a partial disability benefit, if because of injury or sickness, you are unable to perform every material and substantial duty of your regular occupation on a full-time basis, are performing at least one of the material and substantial duties of your regular occupation, or another occupation, on a full or part- time basis, and are earning less than 80% of your predisability earnings due to the same injury or sickness.

Flexible Choices Since everyone's needs are different, these plans offer flexibility for you to choose a benefit option that fits your income replacement needs and budget.

Guaranteed Issue If you enroll timely, you may be eligible for coverage without having to answer any health questions. If you decline insurance coverage now and decide to enroll later, you will need to provide Evidence of Insurability.

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

Residual The elimination period can be satisfied by total disability, partial disability, or a combination of both.

Return to Work You may be able to return to work for a specified time period without having your partial disability benefits reduced according to the contract. The Return to Work Benefit is offered up to a maximum of 12 months.

Integration The method by which your benefit may be reduced by Other Income Benefits.

Evidence of Insurability

Pre-Existing Condition Limitations

If you do not enroll timely, you will need to submit a Statement of Insurability form for review. Based on health history, you will be approved or declined by AUL .

The pre-existing period is 3/12. Certain disabilities are not covered if the cause of the disability is traceable to a condition existing prior to your effective date of coverage. A pre-existing condition is any condition for which a person has received medical treatment or consultation, taken or were prescribed drugs or medicine, or received care or services, including diagnostic measures, within a time-frame specified in the contract.

Portability Should your coverage terminate, you may be eligible to take this disability insurance with you without providing Evidence of Insurability. You must apply within 31 days from the last day you are eligible.

Waiver of Premium If approved, this benefit waives your Disability insurance premium in case you become disabled and are unable to collect a paycheck.

You must also be treatment-free for a time-frame specified in some contracts following your individual effective date of coverage .

Elimination Period This is a period of consecutive days of disability before benefits may become payable under the contract

Total Disability You are considered disabled if, because of injury or sickness, you cannot perform the material and substantial duties of your regular occupation, you are not working in any occupation and are under the regular attendance of a physician for that injury or sickness.

Long Term Disability Group Educator Disability Insurance Coverage for Eligible Employees Monthly Payroll Deduction Illustration About your benefit options:   

Group Educator Disability benefits are illustrated and paid on a monthly basis. Amounts not requested timely will require Evidence of Insurability. Maximum benefit amounts are based upon a percentage of covered earnings. Potential benefits are reduced by other income offsets including but not limited to Social Security benefits. Monthly Payroll Deduction Amounts (based on Employee Age as of 09/01)

If your Annual Salary is at least:

You may select a Monthly Benefit of:

Opt 1 0/7

Opt 2 14/14

Opt 3 30/30

Opt 4 60/60

Opt 5 90/90

Opt 6 180/180

$3,600

$200

$6.00

$5.12

$4.40

$3.48

$1.96

$1.40

$5,400

$300

$9.00

$7.68

$6.60

$5.22

$2.94

$2.10

$7,200

$400

$12.00

$10.24

$8.80

$6.96

$3.92

$2.80

$9,000

$500

$15.00

$12.80

$11.00

$8.70

$4.90

$3.50

$10,799

$600

$18.00

$15.36

$13.20

$10.44

$5.88

$4.20

$12,599

$700

$21.00

$17.92

$15.40

$12.18

$6.86

$4.90

$14,399

$800

$24.00

$20.48

$17.60

$13.92

$7.84

$5.60

$16,199

$900

$27.00

$23.04

$19.80

$15.66

$8.82

$6.30

$17,999

$1,000

$30.00

$25.60

$22.00

$17.40

$9.80

$7.00

$19,799

$1,100

$33.00

$28.16

$24.20

$19.14

$10.78

$7.70

$21,599

$1,200

$36.00

$30.72

$26.40

$20.88

$11.76

$8.40

$23,399

$1,300

$39.00

$33.28

$28.60

$22.62

$12.74

$9.10

$25,199

$1,400

$42.00

$35.84

$30.80

$24.36

$13.72

$9.80

$26,999

$1,500

$45.00

$38.40

$33.00

$26.10

$14.70

$10.50

$28,799

$1,600

$48.00

$40.96

$35.20

$27.84

$15.68

$11.20

$30,598

$1,700

$51.00

$43.52

$37.40

$29.58

$16.66

$11.90

$32,398

$1,800

$54.00

$46.08

$39.60

$31.32

$17.64

$12.60

$34,198

$1,900

$57.00

$48.64

$41.80

$33.06

$18.62

$13.30

$35,998

$2,000

$60.00

$51.20

$44.00

$34.80

$19.60

$14.00

$37,798

$2,100

$63.00

$53.76

$46.20

$36.54

$20.58

$14.70

$39,598

$2,200

$66.00

$56.32

$48.40

$38.28

$21.56

$15.40

$41,398

$2,300

$69.00

$58.88

$50.60

$40.02

$22.54

$16.10

$43,198

$2,400

$72.00

$61.44

$52.80

$41.76

$23.52

$16.80

$44,998

$2,500

$75.00

$64.00

$55.00

$43.50

$24.50

$17.50

$46,798

$2,600

$78.00

$66.56

$57.20

$45.24

$25.48

$18.20

$48,598

$2,700

$81.00

$69.12

$59.40

$46.98

$26.46

$18.90

$50,397

$2,800

$84.00

$71.68

$61.60

$48.72

$27.44

$19.60

$52,197

$2,900

$87.00

$74.24

$63.80

$50.46

$28.42

$20.30

Long Term Disability Monthly Payroll Deduction Amounts (based on Employee Age as of 09/01)

If your Annual Salary is at least:

You may select a Monthly Benefit of:

Opt 1 0/7

Opt 2 14/14

Opt 3 30/30

Opt 4 60/60

Opt 5 90/90

Opt 6 180/180

$53,997

$3,000

$90.00

$76.80

$66.00

$52.20

$29.40

$21.00

$55,797

$3,100

$93.00

$79.36

$68.20

$53.94

$30.38

$21.70

$57,597

$3,200

$96.00

$81.92

$70.40

$55.68

$31.36

$22.40

$59,397

$3,300

$99.00

$84.48

$72.60

$57.42

$32.34

$23.10

$61,197

$3,400

$102.00

$87.04

$74.80

$59.16

$33.32

$23.80

$62,997

$3,500

$105.00

$89.60

$77.00

$60.90

$34.30

$24.50

$64,797

$3,600

$108.00

$92.16

$79.20

$62.64

$35.28

$25.20

$66,597

$3,700

$111.00

$94.72

$81.40

$64.38

$36.26

$25.90

$68,397

$3,800

$114.00

$97.28

$83.60

$66.12

$37.24

$26.60

$70,196

$3,900

$117.00

$99.84

$85.80

$67.86

$38.22

$27.30

$71,996

$4,000

$120.00

$102.40

$88.00

$69.60

$39.20

$28.00

$73,796

$4,100

$123.00

$104.96

$90.20

$71.34

$40.18

$28.70

$75,596

$4,200

$126.00

$107.52

$92.40

$73.08

$41.16

$29.40

$77,396

$4,300

$129.00

$110.08

$94.60

$74.82

$42.14

$30.10

$79,196

$4,400

$132.00

$112.64

$96.80

$76.56

$43.12

$30.80

$80,996

$4,500

$135.00

$115.20

$99.00

$78.30

$44.10

$31.50

$82,796

$4,600

$138.00

$117.76

$101.20

$80.04

$45.08

$32.20

$84,596

$4,700

$141.00

$120.32

$103.40

$81.78

$46.06

$32.90

$86,396

$4,800

$144.00

$122.88

$105.60

$83.52

$47.04

$33.60

$88,196

$4,900

$147.00

$125.44

$107.80

$85.26

$48.02

$34.30

$89,996

$5,000

$150.00

$128.00

$110.00

$87.00

$49.00

$35.00

$91,795

$5,100

$153.00

$130.56

$112.20

$88.74

$49.98

$35.70

$93,595

$5,200

$156.00

$133.12

$114.40

$90.48

$50.96

$36.40

$95,395

$5,300

$159.00

$135.68

$116.60

$92.22

$51.94

$37.10

$97,195

$5,400

$162.00

$138.24

$118.80

$93.96

$52.92

$37.80

$98,995

$5,500

$165.00

$140.80

$121.00

$95.70

$53.90

$38.50

$100,795

$5,600

$168.00

$143.36

$123.20

$97.44

$54.88

$39.20

$102,595

$5,700

$171.00

$145.92

$125.40

$99.18

$55.86

$39.90

$104,395

$5,800

$174.00

$148.48

$127.60

$100.92

$56.84

$40.60

$106,195

$5,900

$177.00

$151.04

$129.80

$102.66

$57.82

$41.30

$107,995

$6,000

$180.00

$153.60

$132.00

$104.40

$58.80

$42.00

$109,795

$6,100

$183.00

$156.16

$134.20

$106.14

$59.78

$42.70

$111,594

$6,200

$186.00

$158.72

$136.40

$107.88

$60.76

$43.40

$113,394

$6,300

$189.00

$161.28

$138.60

$109.62

$61.74

$44.10

$115,194

$6,400

$192.00

$163.84

$140.80

$111.36

$62.72

$44.80 37

AUL A ONEAMERICA COMPANY 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 Group Term Life Including matching AD&D Coverage     

Life and AD&D insurance coverage amount of $10,000 at no cost to you Waiver of premium benefit Accelerated life benefit Additional AD&D Benefits: Seat Belt, Air Bag, Repatriation, Child Higher Education, Child Care, Paralysis/Loss of Use, Severe Burns Optional Guaranteed issue amounts of dependent coverage as follows:

Eligible Employees This benefit is available for employees who are actively at work on the effective date and working a minimum of 18 hours per week.

by AUL.

Continuation of Coverage Options Portability Should your coverage terminate for any reason, you may be eligible to take this term life insurance with you without providing Evidence of Insurability. You must apply within 31 days from the last day you are eligible. The Portability option is available until you reach age 70. OR Conversion Should your life insurance coverage, or a portion of it, cease for any reason, you may be eligible to convert your Group Term Coverage to Individual Coverage without providing Evidence of Insurability. You must apply within 31 days from the last day you are eligible.

Accelerated Life Benefit

Since everyone's needs are different, this plan offers flexibility for you to choose a benefit amount that fits your needs and budget.

If diagnosed with a terminal illness and have less than 12 months to live, you may apply to receive 25%, 50% or 75% of your life insurance benefit to use for whatever you choose.

Accidental Death & Dismemberment (AD&D)

Waiver of Premium

Flexible Choices

If approved for this benefit, additional life insurance benefits may be payable in the event of an accident which results in death or dismemberment as defined in the contract.

If approved, this benefit waives your insurance premium in case you become totally disabled and are unable to collect a paycheck.

Guaranteed Issue Amounts

Reductions

This is the most coverage you can purchase without having to answer any health questions. If you decline insurance coverage now and decide to enroll later, you will need to provide Evidence of Insurability.

Upon reaching certain ages, your original benefit amount will reduce to a percentage as shown in the following schedule. The amounts of Dependent Life Insurance and Dependent AD&D Principal Sum will reduce according to the Employee's reduction schedule.

Employee Guaranteed Issue Amount: $200,000 Spouse Guaranteed Issue Amount: $50,000 Child Guaranteed Issue Amount: $10,000

Age 65 Reduces to: 65% Age 70 Reduces to: 50%

Evidence of Insurability If you elect a benefit amount over the Guaranteed Issue Amount shown above, or you do not enroll timely, you will need to submit a Statement of Insurability form for review. Based on health history, you will be approved or declined for insurance coverage

Life and AD&D Voluntary Term Life Coverage Monthly Payroll Deduction Illustration About your benefit options:    

You may select a minimum Life benefit of $10,000 up to a maximum amount of $500,000, in increments of $10,000. Life amounts requested above $200,000 for an Employee, $50,000 for a Spouse, or any amount not requested timely will require Evidence of Insurability. Employee must select coverage to select any Dependent coverage. Dependent coverage cannot exceed 100% of the Voluntary Term Life amount selected by the Employee.

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

0-19

20-24

25-29

30-34

35-39

40-44

45-49

50-54

55-59

60-64

65-69

70-74

75+

$10,000

$.40

$.56

$.64

$.72

$1.12

$1.68

$3.12

$4.72

$9.12

$14.80

$18.40

$20,000

$.80

$1.12

$1.28

$1.44

$2.24

$3.36

$6.24

$9.44

$18.24

$29.60

$36.80

$30,000

$1.20

$1.68

$1.92

$2.16

$3.36

$5.04

$9.36

$14.16

$27.36

$44.40

$55.20

$40,000

$1.60

$2.24

$2.56

$2.88

$4.48

$6.72

$12.48

$18.88

$36.48

$59.20

$73.60

$50,000

$2.00

$2.80

$3.20

$3.60

$5.60

$8.40

$15.60

$23.60

$45.60

$74.00

$92.00

$80,000

$3.20

$4.48

$5.12

$5.76

$8.96

$13.44

$24.96

$37.76

$72.96 $118.40 $147.20

$100,000

$4.00

$5.60

$6.40

$7.20

$11.20

$16.80

$31.20

$47.20

$91.20 $148.00 $184.00

$130,000

$5.20

$7.28

$8.32

$9.36

$14.56

$21.84

$40.56

$61.36 $118.56 $192.40 $239.20

$150,000

$6.00

$8.40

$9.60

$10.80 $16.80

$25.20

$46.80

$70.80 $136.80 $222.00 $276.00

$200,000

$8.00

$11.20 $12.80 $14.40 $22.40

$33.60

$62.40

$94.40 $182.40 $296.00 $368.00

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

Life Options

0-19

20-24

25-29

30-34

35-39

40-44

45-49

50-54

55-59

60-64

65-69

70-74

75+

$10,000

$.40

$.56

$.64

$.72

$1.12

$1.68

$3.12

$4.72

$9.12

$14.80

$18.40

$15,000

$.60

$.84

$.96

$1.08

$1.68

$2.52

$4.68

$7.08

$13.68

$22.20

$27.60

$20,000

$.80

$1.12

$1.28

$1.44

$2.24

$3.36

$6.24

$9.44

$18.24

$29.60

$36.80

$25,000

$1.00

$1.40

$1.60

$1.80

$2.80

$4.20

$7.80

$11.80

$22.80

$37.00

$46.00

$30,000

$1.20

$1.68

$1.92

$2.16

$3.36

$5.04

$9.36

$14.16

$27.36

$44.40

$55.20

$35,000

$1.40

$1.96

$2.24

$2.52

$3.92

$5.88

$10.92

$16.52

$31.92

$51.80

$64.40

$40,000

$1.60

$2.24

$2.56

$2.88

$4.48

$6.72

$12.48

$18.88

$36.48

$59.20

$73.60

$45,000

$1.80

$2.52

$2.88

$3.24

$5.04

$7.56

$14.04

$21.24

$41.04

$66.60

$82.80

$50,000

$2.00

$2.80

$3.20

$3.60

$5.60

$8.40

$15.60

$23.60

$45.60

$74.00

$92.00

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

Child(ren) live birth to 6 months

$10,000

Monthly Payroll Deduction Life Amount

$1,000

$1.80

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

Voluntary Term AD&D Coverage Monthly Payroll Deduction Illustration About your benefit options:   

You may select a minimum benefit of $10,000 up to a maximum amount of $500,000, in increments of $10,000. Employee must select coverage to select any Dependent coverage. The Spouse benefit is equal to 50% of the amount elected by the Employee, the Child benefit is equal to 10% of the amount elected by the Employee.

Employee Only AD&D

Family AD&D

Volume

Monthly Deduction

Employee Volume

Spouse Volume

Child Volume

Monthly Deduction

$10,000 $20,000 $30,000 $40,000 $50,000 $60,000 $70,000 $80,000 $90,000 $100,000 $150,000 $200,000 $250,000 $300,000 $350,000 $400,000 $450,000 $500,000

$0.300 $0.600 $0.900 $1.200 $1.500 $1.800 $2.100 $2.400 $2.700 $3.000 $4.500 $6.000 $7.500 $9.000 $10.500 $12.000 $13.500 $15.000

$10,000 $20,000 $30,000 $40,000 $50,000 $60,000 $70,000 $80,000 $90,000 $100,000 $150,000 $200,000 $250,000 $300,000 $350,000 $400,000 $450,000 $500,000

$5,000 $10,000 $15,000 $20,000 $25,000 $30,000 $35,000 $40,000 $45,000 $50,000 $75,000 $100,000 $125,000 $150,000 $175,000 $200,000 $225,000 $250,000

$1,000 $2,000 $3,000 $4,000 $5,000 $6,000 $7,000 $8,000 $9,000 $10,000 $15,000 $20,000 $25,000 $30,000 $35,000 $40,000 $45,000 $50,000

$0.600 $1.200 $1.800 $2.400 $3.000 $3.600 $4.200 $4.800 $5.400 $6.000 $9.000 $12.000 $15.000 $18.000 $21.000 $24.000 $27.000 $30.000

5STAR

Individual Life

YOUR BENEFITS PACKAGE

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

DID YOU KNOW? Experts recommend at least

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

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

Weekly Premium

Death Benefit

Accelerated Benefit

Your age at issue: 35

$10.00

$89,655

4% $3,586.20 a month

Affordability—With several options to choose from, select the coverage that best meets the needs of your family. Terminal Illness—This plan pays the insured 30% (25% in Connecticut and Michigan) of the policy coverage amount in a lump sum upon the occurrence of a terminal condition that will result in a limited life span of less than 12 months. Portability—You and your family continue coverage with no loss of benefits or increase in cost should you terminate employment after the first premium is paid. If this happens, we can simply bill you directly. Coverage can never be cancelled by the insurance company or your employer unless you stop paying premiums. Family Protection—Individual policies can be purchased on the employee, their spouse, children and grandchildren. Children & Grandchildren Plan—Policies can be purchased for children and grandchildren ages 15 days to age 24. Convenience—Premiums are taken care of simply and easily through payroll deductions. Protection You Can Count On—Within 24 hours after receiving notice of an insured’s death, an emergency death benefit of the lesser of 50% of the coverage amount, or $10,000, will be mailed to the insured’s beneficiary, unless the death is within the two-year contestability period and/or under investigation. This product also contains no war or terrorism exclusions.

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

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

Term Life with Terminal Illness and Quality of Life Rider

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

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

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

Term Life with Terminal Illness and Quality of Life Rider

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

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

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

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

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.

GC14 Limited Benefit Group Cancer Indemnity Insurance Mansfield 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 NONSUBSCRIBERS AND THE REQUIRED NOTIFICATIONS THAT MUST BE FILED AND POSTED.

Summary of Benefits

Plan 1

Plan 2

Cancer Treatment Policy Benefits

Level 1

Level 4

Radiation Therapy, Chemotherapy, Immunotherapy - Maximum per 12-month period Hormone Therapy - Maximum of 12 treatments per calendar year

$10,000

$20,000

$50 per treatment

Experimental Treatment

paid in same manner and under the same maximums as any other benefit Level 1 Level 1

Cancer Screening Rider Benefits Diagnostic Testing - 1 test per calendar year

$50 per test

Follow-Up Diagnostic Testing - 1 test per calendar year

$100 per test

Medical Imaging - 1 test per calendar year

$500 per test

Internal Cancer First Occurrence Rider Benefits

Level 2

Level 4

Lump Sum Benefit - Maximum 1 per Covered Person per lifetime

$5,000

$10,000

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

$7,500

$15,000

Heart Attack/Stroke First Occurrence Rider Benefits

Level 2

Level 4

Lump Sum Benefit - Maximum 1 per Covered Person per lifetime

$5,000

$10,000

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

$7,500

$15,000

$600 per day $300 per day

Hospital Intensive Care Unit Benefit Rider Intensive Care Unit Step Down Unit - Maximum of 45 days per Confinement for any combination of Intensive Care Unit or Step Down Unit

Total Monthly Premiums by Plan** Issue Ages 18 +

Employee

Employee & Spouse

Employee & Child(ren)

Employee & Family

Plan 1

Plan 2

Plan 1

Plan 2

Plan 1

Plan 2

Plan 1

Plan 2

$15.96

$26.80

$34.26

$57.60

$20.38

$33.00

$38.66

$63.84

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

APSB-22339(TX)-0615 MGM/FBS Mansfield ISD

GC14 Limited Benefit Group Cancer Indemnity Insurance Benefits are only payable following a diagnosis of cancer for a loss incurred for the treatment of cancer while covered under the policy. A charge must be incurred for benefits to be payable. When coverage terminates for loss incurred after the coverage termination date, our obligation to pay benefits also terminates for a specified disease that manifested itself while the person was covered under the policy. All benefits are subject to the benefit maximums.

Cancer Treatment Benefits Eligibility

You and your eligible dependents are eligible to be insured under this certificate if you and your eligible dependents meet our underwriting rules and you are actively at work with the policyholder and qualify for coverage as defined in the master application.

Cancer Screening Benefits Limitations and Exclusions

No benefits will be paid for any of the following: treatment by any program engaged in research that does not meet the definition of experimental treatment; losses or medical expenses incurred prior to the covered person’s effective date of this rider; or loss incurred during the pre-existing condition exclusion period following the covered person’s effective date of this rider as a result of a pre-existing condition. For the purpose of benefits under this rider, the waiting period will begin on the covered person’s effective date of this rider.

Termination of Cancer Screening Benefit Rider

No benefits will be paid for any of the following: treatment by any program engaged in research that does not meet the definition of experimental treatment; or losses or medical expenses incurred prior to the covered person’s effective date regardless of when specified disease was diagnosed.

The above listed rider(s) will terminate and coverage will end for all covered persons on the earliest of: the end of the grace period if the premium for the rider remains unpaid; the date the policy or certificate to which the rider is attached terminates; the end of the certificate month in which APL receives a request from the policyholder to terminate the rider; or the date of your death. Coverage on an eligible dependent terminates under the rider when such person ceases to meet the definition of eligible dependent.

Only Loss for Cancer

Internal Cancer First Occurrence Benefits

Limitations and Exclusions

The policy pays only for loss resulting from definitive cancer treatment including direct extension, metastatic spread or recurrence. Proof must be submitted to support each claim. The policy also covers other conditions or diseases directly caused by cancer or the treatment of cancer. The policy does not cover any other disease, sickness or incapacity which existed prior to the diagnosis of cancer, even though after contracting cancer it may have been complicated, aggravated or affected by cancer or the treatment of cancer.

Pre-Existing Condition Exclusion

No benefits are payable for any loss incurred during the pre-existing condition exclusion period, following the covered person’s effective date as the result of a pre-existing condition. Pre-existing conditions specifically named or described as excluded in any part of the policy are never covered. If any change to coverage after the certificate effective date results in an increase or addition to coverage, the time limit on certain defenses and pre-existing condition exclusion for such increase will be based on the effective date of such increase.

Waiting Period

The policy and any attached riders contain a waiting period during which no benefits will be paid. If any covered person has a specified disease diagnosed before the end of the waiting period immediately following the covered person’s effective date, coverage for that person will apply only to loss that is incurred after one year from the covered person’s effective date. If any covered person is diagnosed as having a specified disease during the waiting period immediately following the covered person’s effective date, you may elect to void the certificate from the beginning and receive a full refund of premium. If the policy replaced group specified disease cancer coverage from any company that terminated within 30 days of the certificate effective date, the waiting period will be waived for those covered persons that were covered under the prior coverage. However, the pre-existing condition exclusion provision will still apply.

Termination of Certificate

Pays a lump sum benefit amount when a covered person receives a first diagnosis of internal cancer and the date of diagnosis occurs after the waiting period. Only one benefit per covered person, per lifetime is payable under this benefit and the lump sum benefit amount will reduce by 50% at age 70.

Limitations and Exclusions

We will not pay benefits for a diagnosis of internal cancer received outside the territorial limits of the United States or a metastasis to a new site of any cancer diagnosed prior to the covered person’s effective date, as this is not considered a first diagnosis of an internal cancer.

Pre-Existing Condition Exclusion

No benefits are payable for any loss incurred during the pre-existing condition exclusion period following the covered person’s effective date of this rider as the result of a pre-existing condition.

Waiting Period

This rider contains a 30-day waiting period during which no benefits will be paid. If any internal cancer is diagnosed before the end of the waiting period immediately following the covered person’s effective date of this rider, coverage will apply only to loss that is incurred after one year from the covered person’s effective date of this rider.

Termination

This rider will terminate and coverage will end for all covered persons on the earliest of any of the following: the end of the grace period if the premium for this rider remains unpaid; the date the policy or certificate to which this rider is attached terminates; the end of the certificate month in which we receive a request from the policyholder to terminate this rider; the date of covered person’s death or the date the lump sum benefit amount for internal cancer has been paid for all covered persons under this rider. Coverage on an eligible dependent terminates under this rider when such person ceases to meet the definition of eligible dependent.

Heart Attack/Stroke First Occurrence Benefits

Insurance coverage under the certificate and any attached riders will end on the earliest of these dates: the date the policy terminates; the end of the grace period if the premium remains unpaid; the date insurance has ceased on all persons covered under this certificate; the end of the certificate month in which the policyholder requests to terminate this coverage; the date you no longer qualify as an insured; or the date of your death.

Pays a lump sum benefit amount when a covered person receives a first diagnosis of heart attack or stroke and the date of diagnosis occurs after the waiting period. Only one benefit per covered person per lifetime is payable under this benefit and the lump sum benefit amount will reduce by 50% at age 70.

Termination of Coverage

Limitations and Exclusions

Insurance coverage for a covered person under the certificate and any attached riders for a covered person will end as follows: the date the policy terminates; the date the certificate terminates; the end of the grace period if the premium remains unpaid; the end of the certificate month in which the policyholder requests to terminate the coverage for an eligible dependent; the date a covered person no longer qualifies as an insured or eligible dependent; or the date of the covered person’s death. We may end the coverage of any Covered Person who submits a fraudulent claim.

48APSB-22339(TX)-0615

MGM/FBS Mansfield ISD

We will not pay benefits for any loss caused by or resulting from any of the following: intentionally self-inflicted bodily injury, suicide or attempted suicide, whether sane or insane; alcoholism or drug addiction; any act of war, declared or undeclared, or any act related to war, or active service in the armed forces, or military service for any country at war [(if coverage is suspended for any covered person during a period of military service, we will refund the pro-rata portion of any premium paid for any such covered person upon receipt of the policyholder’s written request)]; 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 defined by the law of the jurisdiction in which the activity takes place).

GC14 Limited Benefit Group Cancer Indemnity Insurance Pre-Existing Condition Exclusion

Optionally Renewable

Waiting Period

This policy/riders are optionally renewable. The policyholder or we have the right to terminate the policy/riders on any premium due date after the first anniversary following the policy/riders effective date. We must give at least 60 days written notice to the policyholder prior to cancellation.

No benefits are payable for any loss incurred during the pre-existing condition exclusion period following the covered person’s effective date of this rider as the result of a Pre-Existing Condition. This rider contains a 30-day waiting period during which no benefits will be paid. If any heart attack or stroke is diagnosed before the end of the waiting period immediately following the covered person’s effective date of this rider, coverage will apply only to loss that is incurred after one year from the covered person’s effective date.

Termination

This rider will terminate and coverage will end for all covered persons on the earliest of any of the following: the end of the grace period if the premium for this rider remains unpaid; the date the policy or certificate to which this rider is attached terminates; the end of the certificate month in which we receive a request from the policyholder to terminate this rider; the date of a covered person’s death or the date the lump sum benefit amount for heart attack or stroke has been paid for all covered persons under this rider. Coverage on an eligible dependent terminates under this rider when such person ceases to meet the definition of eligible dependent, as defined in the policy.

Hospital Intensive Care Unit Benefits Pays a daily benefit amount, up to the maximum number of days for any combination of confinement, for each day charges are incurred for room and board in an intensive care unit (ICU) or step-down unit due to an accident or sickness. Benefits will be paid beginning on the first day a covered person is confined in an ICU or step-down unit due to an accident or sickness that begins after the effective date of this rider. This benefit will reduce by 50% at age 70.

Limitations and Exclusions

For a newborn child born within the 10-month period following the effective date, no benefits under this rider will be provided for confinements that begin within the first 30 days following the birth of such child. No benefits under this rider will be provided during the first two years following the effective date for confinements caused by any heart condition when any heart condition was diagnosed or treated prior to the end of the 30-day period following the covered person’s effective date. The heart condition causing the confinement need not be the same condition diagnosed or treated prior to the effective date.

Optionally Renewable This policy/riders are optionally renewable. The policyholder or we have the right to terminate the policy/riders on any premium due date after the first anniversary following the policy/riders effective date. We must give at least 60 days written notice to the policyholder prior to cancellation.

Portability (Voluntary Plans Only) When you no longer meet the definition of Insured, you will have the option to continue this coverage, including any attached riders. No Evidence of Insurability will be required. Portability must meet all of the following conditions: the certificate has been continuously in force for the last 12 months; we receive a request and payment of the first premium for the portability coverage no later than 30 days after the date you no longer qualify as an eligible insured; and the policy, under which this certificate was issued, continues to be in force on the date you cease to qualify for coverage. All future premiums due will be billed directly to you. You are responsible for payment of all premiums for the portability coverage. The benefits, terms and condition of the portability coverage will be the same as those elected under the certificate immediately prior to the date you exercised portability. Portability coverage may include any eligible dependents who were covered under the certificate at the time you ceased to qualify as an eligible insured. No new eligible dependents may be added to the portability coverage except as provided in the New Born and Adopted Children provision. No increases in coverage will be allowed while you are exercising your rights under this rider. The premium for the portability coverage will be based on the premium tables used for such coverage at the time of the portability request. Coverage under this rider will terminate in accordance with the provisions of the Termination of Coverage in the certificate. If the policy is no longer in force, then portability coverage is not available.

We will not pay benefits for any loss caused by or resulting from any of the following: intentionally self-inflicted bodily injury, suicide or attempted suicide, whether sane or insane; alcoholism or drug addiction; any act of war, declared or undeclared, or any act related to war, or active service in the armed forces, or military service for any country at war [(if coverage is suspended for any covered person during a period of military service, we will refund the pro-rata portion of any premium paid for any such covered person upon receipt of the policyholder’s written request)]; 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; participation in, or attempting to participate in, a felony, riot or insurrection (a felony is defined by the law of the jurisdiction in which the activity takes place).

Termination

This rider will terminate and coverage will end for all covered persons on the earliest of any of the following: the end of the grace period if the premium for this rider remains unpaid; the date the policy or certificate to which this rider is attached terminates; the end of the certificate month in which we receive a request from the policyholder to terminate this rider or the date of the covered person’s death. Coverage on an eligible dependent terminates under this rider when such person ceases to meet the definition of eligible dependent.

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 detailed benefits, limitations, exclusions and other provisions, please refer to the policy/certificate/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 GC14 Series | TX | Limited Benefit Group Cancer Indemnity Insurance | (10/14) | MGM/FBS | Mansfield ISD

APSB-22339(TX)-0615 MGM/FBS Mansfield ISD

VOYA YOUR BENEFITS PACKAGE

Accident

About this Benefit Accident insurance is designed to supplement your medical insurance coverage by covering indirect costs that can arise with a serious, or a not-so-serious, injury. Accident coverage is low cost protection available to you and your family without evidence of insurability.

DID YOU KNOW?

2/3 of disabling injuries suffered by American workers are not work related. American workers 36% ofreport they always or

usually live paycheck to paycheck.

Accident What accident benefits are available? The following list includes the benefits provided by Accident Insurance. The benefit amounts paid depend on the type of injury and care received. You may be required to seek care for your injury within a set amount of time. You must be insured under the policy for 30 days before benefits are payable. Note

EVENT

that there may be some variation by state. For a list of standard exclusions and limitations, go to the end of this document. For a complete description of your available benefits, along with applicable provisions, exclusions and limitations, see your certificate of insurance and any riders.

LOW OPTION

HIGH OPTION

$1,000

$2,500

$100

$250

$300 $900

$400 $1,400

$225

$300

$450

$600

$125

$175

$5,000

$7,000

$300

$400

$100

$150

$20

$30

$100

$250

$25

$50

$500

$1,200

$1,000

$2,400

$750

$1,250

$1,500

$2,500

$10,000

$18,000

25% of burn benefit

$150 crown, $50 extraction

$250 crown, $125 extraction

$50

$75

$200

$300

$100

$150

$500

$750

$25

$60

$50

$120

$200

$480

$400

$960

$400

$600

Accident Hospital Care Surgery Open abdominal, thoracic Surgery exploratory or without repair Blood, plasma, platelets Hospital admission Hospital confinement Per day up to 365 Critical care unit confinement per day, up to 15 days Rehabilitation facility confinement per day for 90 days Coma Duration of 14 or more days Transportation per trip, up to 3 per accident Lodging Per day, up to 30 days Family care per child, up to 45 days Follow-up Care Medical equipment duration of 14 or more days Physical therapy duration of 14 or more days Prosthetic device (one) Prosthetic device (two or more) duration of 14 or more days Common Injuries Burns second degree, at least 36% of the body Burns 3rd degree, at least 9 but less than 35 square inches of the body Burns 3rd degree, 35 or more square inches of the body Skin Grafts Emergency dental work while hospital confined Eye Injury removal of foreign object Eye Injury surgery Torn Knee Cartilage surgery with no repair or if cartilage is shaved Torn Knee Cartilage surgical repair Laceration1 treated no sutures Laceration1 sutures up to 2” Laceration1 sutures 2” – 6” Laceration1 sutures over 6” Ruptured Disk surgical repair

Accident EVENT Tendon/Ligament/Rotator Cuff One, surgical repair Tendon/Ligament/Rotator Cuff Two or more, surgical repair Tendon/Ligament/Rotator Cuff Exploratory Arthroscopic Surgery with no repair Concussion Paralysis quadriplegia Paralysis paraplegia Dislocations Hip joint Knee Ankle or foot bone(s) Other than toes Shoulder Elbow Wrist Finger/toe Hand bone(s) Other than fingers Lower jaw Collarbone Partial dislocations Fractures Hip Leg Ankle Kneecap Foot Excluding toes, heel Upper arm Forearm, Hand, Wrist Except fingers Finger, Toe Vertebral body Vertebral processes Pelvis Except coccyx Coccyx Bones of face Except nose Nose Upper jaw Lower jaw Collarbone Rib or ribs Skull â&#x20AC;&#x201C; simple Except bones of face Skull â&#x20AC;&#x201C; depressed Except bones of face Sternum Shoulder blade Chip fractures Emergency Care Benefits Ground ambulance Air ambulance Emergency room treatment Initial doctor visit Follow-up doctor visit

LOW OPTION

HIGH OPTION

$400

$600

$900

$100

$200

$100 $10,000 $5,000 Closed/open reduction2 $2,000/$4,000 $1,000/$2,000

$250 $15,000 $7,500 Closed/open reduction2 $2,500/$5,000 $1,500/$3,000

$800/$1,600

$1,200/$2,400

$300/$600 $300/$600 $300/$600 $100/$200

$500/$1,000 $500/$1,000 $500/$1,000 $150/$300

$300/$600

$500/$1,000

$300/$600 $300/$600 25% of the closed reduction amount Closed/open reduction3 $1,500/$3,000 $800/$1,600 $300/$600 $300/$600

$500/$1,000 $500/$1,000 25% of the closed reduction amount Closed/open reduction3 $2,500/$5,000 $1,250/$2,500 $500/$1,000 $500/$1,000

$300/$600

$500/$1,000

$350/$700

$550/$1,100

$300/$600

$500/$1,000

$50/$100 $800/$1,600 $300/$600

$100/$200 $1,200/$2,400 $500/$1,000

$800/$1,600

$1,200/$2,400

$200/$400

$350/$700

$550/$1,100

$100/$200 $350/$700 $300/$600 $300/$600 $250/$500

$150/$300 $550/$1,100 $500/$1,000 $500/$1,000 $450/$900

$1,000/$2,000

$1,500/$3,000

$2,500/$5,000

$5,000/$10,000

$300/$600 $300/$600 25% of the closed reduction amount

$500/$1,000 $500/$1,000 25% of the closed reduction amount

$100 $500 $150 $50 $50

$200 $1,000 $300 $80 $80

1 Laceration benefits are a total of all lacerations per accident. 2 Closed Reduction of Dislocation = Non-surgical reduction of a completely separated joint. Open Reduction of Dislocation = Surgical reduction of a completely separated joint. 3 Closed Reduction of Fracture = Non-surgical. Open Reduction of Fracture = Surgical.

Accident What does my Accident Insurance include? The benefits listed below are included with your accident coverage. For a list of standard exclusions and limitations, please refer to the end of this document. For a complete description of your available benefits, along with applicable provisions, exclusions and limitations, see your certificate of insurance and any riders. Spouse Accident Insurance: If you have coverage for yourself, you may enroll your spouse, as long as your spouse is under age 70 and is not covered under the Policy as an Employee.  Your spouse will receive the same base coverage as you.  Guaranteed Issue: No medical questions or tests required for coverage. Children’s Accident Insurance: As long as you have accident coverage on yourself, your natural child(ren), stepchild(ren), adopted child(ren) or child(ren) for whom you are a legal guardian are eligible to be covered under your employer’s plan, up to the age of 26.  Your child(ren) will receive the same base coverage as you.  Guaranteed Issue: No medical questions or tests required for coverage.  One premium amount covers all of your eligible children.  If both you and your spouse are covered under the policy as an employee, then only one, but not both, may cover the same child(ren) under this benefit. If the parent who is covering the child(ren) stops being insured as an employee then the other parent may apply for children’s coverage. Wellness Benefit: This provides an annual benefit payment if you complete a health screening test. You may only receive a benefit once per year, even if you complete multiple health screening tests.  Examples of health screening tests include but are not limited to: Pap test, serum cholesterol test for HDL and LDL levels, mammography, colonoscopy, and stress test on bicycle or treadmill.  The annual benefit is $50 for completing a health screening test.  If your spouse and/or children are/is covered for Accident Insurance, they are also covered by the Wellness Benefit. Your spouse’s benefit amount is also $50. The benefit for child coverage is 50% with an annual maximum of $100 for children’s benefits.

Accidental Death Benefits Low Option High Option Common Carrier* Employee $50,000 $120,000 Spouse $20,000 $48,000 Children $10,000 $24,000 Other Accident Employee $25,000 $60,000 Spouse $10,000 $24,000 Children $5,000 $12,000 *If the death occurs as a result of a covered accident on a common carrier a higher benefit will be paid. Common carrier means any commercial transportation that operates on a regularly scheduled basis between predetermined points or cities. Accidental Dismemberment Benefits Loss of both hand or both feet or sight $15,000 $25,000 in both eyes Loss of one hand or one foot AND the $15,000 $25,000 sight of one eye Loss of one hand AND one foot $15,000 $25,000 Loss of one hand OR one foot $7,500 $12,000 Loss of Two or more fingers or toes $1,500 $2,500 Loss of one finger or one toe $750 $1,200

How much does Accident Insurance cost? All employees pay the same rate, no matter their age. See the chart below for the premium amounts.

Low Option High Option

Monthly Rates (12 Pay Periods) Employee Employee Employee and Spouse and Children $11.54 $19.30 $21.84 $19.06 $31.34 $35.46 Semi-Monthly Rates (18 Pay Periods) Employee Employee Employee and Spouse and Children $7.69 $12.86 $14.55 $12.70 $20.89 $23.64 Semi-Monthly Rates (26 Pay Periods) Employee Employee Employee and Spouse and Children $5.33 $8.91 $10.08 $8.80 $14.46 $16.37

Family $29.60 $47.74 Family $19.73 $31.83 Family $13.66 $22.03

Accidental Death and Dismemberment (AD&D) Benefit: If you are severely injured or die as a result of a covered accident, an AD&D benefit may be payable to you or your beneficiary.  If your spouse and/or children are/is covered for Accident Insurance, they are covered for this additional benefit.

VOYA

Critical Illness

YOUR BENEFITS PACKAGE

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

DID YOU KNOW?

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

Critical Illness What is Critical Illness Insurance?

How can Critical Illness Insurance help?

Critical Illness Insurance pays a lump-sum benefit if you are diagnosed with a covered illness or condition. Critical Illness Insurance is a limited benefit policy. It is not health insurance and does not satisfy the requirement of minimum essential coverage under the Affordable Care Act.

Below are a few examples of how your Critical Illness Insurance benefit could be used (coverage amounts may vary):  Medical expenses, such as deductibles and copays  Child care  Home healthcare costs  Mortgage payment/rent and home maintenance

Features of Critical Illness Insurance include:  Guaranteed Issue: No medical questions or tests required for coverage.  Flexible: You can use the benefit money for any purpose you like.  Payroll deductions: Premiums are paid through convenient payroll deductions.  Portable: Should you leave your current employer or retire, you can take your coverage with you.

For what critical illnesses and conditions are benefits available? Critical Illness Insurance provides a benefit for the following illnesses and conditions. Covered illnesses/conditions are broken out into groups called “modules”. Benefits are paid at 100% of the Maximum Critical Illness Benefit amount unless otherwise stated. For a complete description of your benefits, along with applicable provisions, conditions on benefit determination, exclusions and limitations, see your certificate of insurance and any riders. Base Module  Heart attack  Stroke  Coronary artery bypass (25%)  Coma  Major organ failure  Permanent paralysis  End stage renal (kidney) failure Module A  Benign brain tumor  Deafness  Occupational HIV  Blindness Module B  Multiple sclerosis  Amyotrophic lateral sclerosis (ALS)  Parkinson’s disease  Alzheimer’s disease  Infectious disease Cancer Module  Cancer  Skin cancer (10%)  Carcinoma in situ (25%)

Who is eligible for Critical Illness Insurance?   

You—all active employees working 18 hours per week. Your spouse*— under age 70. Coverage is available only if employee coverage is elected. Your child(ren)— to age 26. Coverage is available only if employee coverage is elected.

*The use of “spouse” in this document means a person insured as a spouse as described in the certificate of insurance or rider.

What Maximum Critical Illness Benefit am I eligible for?  



For you You have the opportunity to purchase a Maximum Critical Illness Benefit of $5,000 - $30,000 in $5,000 increments. For your spouse You also have the opportunity to purchase a Maximum Critical Illness Benefit of $5,000 - $30,000 in $5,000 increments. For your children You also have the opportunity to purchase a Maximum Critical Illness Benefit of $1,000, $2,500, $5,000, $10,000 or $20,000 for each covered child.

How many times can I receive the Maximum Critical Illness Benefit? Usually you are only able to receive the Maximum Critical Illness Benefit for one covered illness or disease within each module. Your plan includes the Restoration Benefit, which provides a onetime restoration of 100% of the maximum benefit amount in order to pay an additional benefit if you experience a second covered illness for a different condition. Your plan also includes the Recurrence Benefit, which allows you to receive a benefit for the same condition a second time. It’s important to note that in order for the second covered illness or the second occurrence of the illness to be covered, it must occur after 12 consecutive months without the occurrence of any covered critical illness named in your certificate, including the illness from the first benefit payment. If a partial benefit is paid out, it will not reduce the available maximum benefit amount for the illnesses or diseases in that same module. If you have reached the benefit limit by receiving the maximum benefit in each module, you may choose to end your coverage; however, if you have coverage for your spouse and/or child(ren), you must continue your coverage in order to keep their coverage active. Please see the certificate of coverage for details. 55

Critical Illness What optional benefits are available? You may choose to include the optional benefits below with your critical illness coverage. For a list of standard exclusions and limitations, please refer to the end of this document. For a complete description of your available benefits, along with applicable provisions, exclusions and limitations, see your certificate of insurance and any riders. Spouse Critical Illness Insurance: If you have coverage for yourself, you may enroll your spouse, as long as your spouse is under age 70 and is not covered under the Policy as an employee.  Your spouse will receive coverage for the same covered conditions as you.  Your spouse will be able to receive a benefit the same number of times as you, as outlined above.  Guaranteed issue: No medical questions or tests required for coverage. *The use of “spouse” in this form means a person insured as a spouse as described in the certificate of insurance or benefit. Please contact your employer for more information. Children’s Critical Illness Insurance: As long as you have critical illness coverage on yourself, your natural child(ren), stepchild (ren), adopted child(ren) or child(ren) for whom you are a legal guardian are eligible to be covered under your employer’s plan, up to the age of 26.  Your children are covered for the same covered conditions as you are with the exception of carcinoma in situ and coronary artery bypass; however, actual benefit amounts may vary.  Your child(ren) will be able to receive a benefit the same number of times as you, as outlined above.  One premium amount covers all of your eligible children.  Guaranteed issue: No medical questions or tests required for coverage.  If both you and your spouse are covered under the policy as an employee, then only one, but not both, may cover the same child(ren) under this benefit. If the parent who is covering the child(ren) stops being insured as an employee then the other parent may apply for children’s coverage. Wellness Benefit: This provides an annual benefit payment if you complete a health screening test. You may only receive a benefit once per year, even if you complete multiple health screening tests.  Examples of health screening tests include but are not

 

limited to: Pap test, serum cholesterol test for HDL and LDL levels, mammography, colonoscopy, and stress test on bicycle or treadmill. The annual benefit is $75 for completing a health screening test. If your spouse and/or children are covered for Critical Illness Insurance, they are also covered by the Wellness Benefit. Your spouse’s benefit amount is also $75. The benefit for child coverage is 50% of your coverage with an annual maximum of $150 for children’s benefits.

Exclusions and Limitations Benefits are not payable for any critical illness caused in whole or directly by any of the following*:  Participation or attempt to participate in a felony or illegal activity.  Suicide, attempted suicide or any intentionally selfinflicted injury, while sane or insane.  War or any act of war, whether declared or undeclared, other than acts of terrorism.  Loss that occurs while on full-time active duty as a member of the armed forces of any nation. We will refund, upon written notice of such service, any premium which has been accepted for any period not covered as a result of this exclusion.  Alcoholism, drug abuse, or misuse of alcohol or taking of drugs, other than under the direction of a doctor. Benefits reduce 50% for the employee and/or covered spouse on the policy anniversary following the 70th birthday, however, premiums do not reduce as a result of this benefit change. *See the certificate of insurance and any riders for a complete list of available benefits, along with applicable provisions, exclusions and limitations.

Who do I contact with questions? For more information, please call the Voya Employee Benefits Customer Service Team at (800) 955-7736.

Critical Illness How much does Critical Illness Insurance cost? See the chart below for the premium amounts. Rates shown are guaranteed until September 1, 2018. Employee Coverage—Uni-Tobacco Monthly Rates (12 Pay Periods)

Spouse Coverage—Uni-Tobacco Monthly Rates (12 Pay Periods)

Issue $5,000 $10,000 $15,000 $20,000 $25,000 $30,000 Age

30 30-39 40-49 50-59 60-64 65-69 70+

$2.96

$5.90

$8.85

$11.82

$14.75

$17.70

$3.45 $6.90 $10.35 $13.80 $17.25 $5.96 $11.90 $17.85 $23.81 $29.75 $12.05 $24.11 $36.15 $48.20 $60.26 $19.10 $38.21 $57.30 $76.40 $95.51 $24.86 $49.70 $74.55 $99.41 $124.25 $35.90 $71.81 $107.70 $143.60 $179.51 Employee Coverage—Uni-Tobacco Semi-Monthly Rates (18 Pay Periods)

$20.70 $35.70 $72.30 $114.60 $149.10 $215.40

30 30-39 40-49 50-59 60-64 65-69 70+

$3.50 $3.95 $6.80 $14.96 $23.60 $26.96 $40.70

$7.01

$10.50

$14.00

$17.51

$21.00

$7.91 $11.85 $15.80 $19.76 $13.61 $20.40 $27.20 $50.51 $29.90 $44.85 $59.81 $74.75 $47.21 $70.80 $94.40 $118.01 $53.90 $80.85 $107.81 $134.75 $81.41 $122.10 $162.80 $203.51 Spouse Coverage—Uni-Tobacco Semi-Monthly Rates (18 Pay Periods)

$23.70 $40.80 $89.70 $141.60 $161.70 $244.20

Issue $5,000 $10,000 $15,000 $20,000 $25,000 $30,000 Age

$1.97 $3.93 $5.90 $7.88 $9.83 30 30-39 $2.30 $4.60 $6.90 $9.20 $11.50 40-49 $3.97 $7.93 $11.90 $15.87 $19.83 50-59 $8.03 $16.07 $24.10 $32.13 $40.17 60-64 $12.73 $25.47 $38.20 $50.93 $63.67 65-69 $16.57 $33.13 $49.70 $66.27 $82.83 70+ $23.93 $47.87 $71.80 $95.73 $119.67 Employee Coverage—Uni-Tobacco Semi-Monthly Rates (26 Pay Periods) Issue $5,000 $10,000 $15,000 $20,000 $25,000 Age

$2.33 $4.67 $7.00 $9.33 $11.67 30 30-39 $2.63 $5.27 $7.90 $10.53 $13.17 40-49 $4.53 $9.07 $13.60 $18.13 $33.67 50-59 $9.97 $19.93 $29.90 $39.87 $49.83 60-64 $15.73 $31.47 $47.20 $62.93 $78.67 65-69 $17.97 $35.93 $53.90 $71.87 $89.83 70+ $27.13 $54.27 $81.40 $108.53 $135.67 Spouse Coverage—Uni-Tobacco Semi-Monthly Rates (26 Pay Periods) Issue $5,000 $10,000 $15,000 $20,000 $25,000 Age

$1.36 $2.72 30 30-39 $1.59 $3.18 40-49 $2.75 $5.49 50-59 $5.56 $11.13 60-64 $8.81 $17.63 65-69 $11.47 $22.94 70+ $16.57 $33.14

$13.80 $23.80 $48.20 $76.40 $99.40 $143.60

$30,000

$4.08

$5.45

$6.81

$8.17

$4.78 $8.24 $16.68 $26.45 $34.41 $49.71

$6.37 $10.99 $22.24 $35.26 $45.88 $66.27

$7.96 $13.73 $27.81 $44.08 $57.34 $82.85

$9.55 $16.48 $33.37 $52.89 $68.82 $99.42

Coverage Amount $1,000 $2,500 $5,000 $10,000 $20,000

$11.80

$1.61 $3.23 30 30-39 $1.82 $3.65 40-49 $3.14 $6.28 50-59 $6.90 $13.80 60-64 $10.89 $21.79 65-69 $12.44 $24.87 70+ $18.78 $37.57

$14.00 $15.80 $27.20 $59.80 $94.40 $107.80 $162.80

$30,000

$4.85

$6.46

$8.08

$5.47 $9.42 $20.70 $32.68 $37.32 $56.35

$7.29 $12.55 $27.60 $43.57 $49.76 $75.14

$9.12 $10.94 $23.31 $18.83 $34.50 $41.40 $54.46 $65.35 $62.19 $74.63 $93.93 $112.71

Child(ren) Coverage Monthly Rates Semi-Monthly Rates (12 Pay Periods) (18 Pay Periods) $0.39 $0.26 $0.98 $0.65 $1.95 $1.30 $3.90 $2.60 $7.80 $5.20

$9.69

Semi-Monthly Rates (26 Pay Periods) $0.18 $0.45 $0.90 $1.80 $3.60 57

NBS

FSA (Flexible Spending Account)

YOUR BENEFITS PACKAGE

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

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

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

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

NBS Prepaid MasterCard® Debit Card

New Plan Participants

When Will I Receive My Flex Card? Expect Flex Cards to be delivered to the address listed in THEbenefitsHUB near the end of September. Don’t forget, Flex Cards Are Good For 3 Years!

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

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

FSA Annual Contribution Max:

DID YOU KNOW?

$2,550

Dependent Care Annual Max:

FSAs use tax-free funds to help pay for your Health Care Expenses.

$5,000

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

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

For a list of sample expenses, please refer to the Mansfield ISD benefit website: www.thebenfitshub.com/mansfieldisd

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

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

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

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

        

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

Dependent Care Expense Account Example Expenses:    

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

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

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

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

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

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

Get Your Money 1. 2. 3. 4.

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

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

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

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

NOTES