2016 Benefit Red Oak ISD by Higginbotham Public Sector

RED OAK ISD

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

Table of Contents Benefit Contact Information How to Enroll Annual Benefit Enrollment 1. Benefit Updates 2. Section 125 Cafeteria Plan Guidelines 3. Annual Enrollment 4. Eligibility Requirements 5. Helpful Definitions 6. Health Savings Account (HSA) vs. Flexible Spending Account (FSA) TRS-ActiveCare Scott & White HMO Century Healthcare Medical Supplement MDLIVE Telehealth Cigna Dental EyeMed Vision The Hartford Disability UNUM Life and AD&D 5Star Family Protection Plan Term Life Insurance with Quality of Life Rider Loyal American Cancer Loyal American Accident LifeWorks Employee Assistance Program (EAP) HSA Bank Health Savings Account (HSA) NBS Flexible Spending Account (FSA) NBS 403(b) Plan 2

3 4-5 6-11 6 7 8 9 10 11 12-13 14-15 16-19 20-21 22-25 26-27 28-31 32-35

FLIP TO... PG. 4 HOW TO ENROLL

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

36-39 40-43 44-47 48-49 50-53 54-57 58-59

PG. 12 YOUR MEDICAL BENEFITS

Benefit Contact Information

Benefit Contact Information RED OAK ISD BENEFITS

DENTAL

ACCIDENT

Financial Benefit Services (469) 385-4685 www.mybenefitshub.com/redoakisd

Policy # 3335837 Cigna Total DPPO Network (800) 244-6224 www.mycigna.com

Group # 1407 Loyal American (800) 366-8354 www.mybenefitshub.com/redoakisd

RED OAK ISD BENEFITS OFFICE

VISION

EMPLOYEE ASSISTANCE PROGRAM

Brenda Nicholson (972) 617-4640 www.redoakisd.org

EyeMed (866) 804-0982 www.eyemed.com

LifeWorks (888) 456-1324 https://portal.lifeworks.com

TRS ACTIVECARE MEDICAL

DISABILITY

HEALTH SAVINGS ACCOUNT

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

Policy # 395307 The Hartford (800) 583-6908 File a Claim: (866) 278-2655 www.thehartford.com

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

TRS HMO MEDICAL

LIFE AND AD&D

FLEXIBLE SPENDING ACCOUNT

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

Policy # 94674 UNUM (800) 583-6908 www.unum.com

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

MEDICAL SUPPLEMENT

FAMILY PROTECTION PLAN

403(B)/457 PLANS

Century Healthcare Claims: (800) 767-6811 www.centuryhealthcare.com

5Star Life Insurance Company (866) 863-9753 www.5starlifeinsurance.com

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

TELEHEALTH

CANCER

DENTAL/VISION/FLEX COBRA

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

Group # 1407 Loyal American (800) 366-8354 www.mybenefitshub.com/redoakisd

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

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

TEXT

need to complete your enrollment.

“redoakisd” 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/ redoakisd delivers important benefit information with 24/7 access, as well as detailed plan information, rates and product videos.

! 4

Open Enrollment Tip Your username is your primary email address. This address is your DISTRICT email address. Personal emails are not accepted!

Go to:

Click Login

Enter Username & Password

www.mybenefitshub.com/redoakisd

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

Username:

Sample Username

abe.lincoln@redoakisd.org Sample Password

Your username is your primary email address. This address is your DISTRICT email address. Personal emails are not accepted.

lincoln1234

Default Password:

If you have trouble

Last Name* (lowercase, excluding punctuation)

logging in, click on the

followed by the last four (4) digits of your Social

“Login Help Video”

Security Number.

for assistance.

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

Annual Benefit Enrollment

SUMMARY PAGES

Benefit Updates - What’s New:  Benefit elections will become effective 9/1/2016

(elections requiring evidence of insurability, such as Life Insurance, may have a later effective date, if approved). After annual enrollment closes, benefit changes can only be made if you experience a qualifying event (and changes must be made within 31 days of event with your district’s Benefit Department).  Aetna is the current carrier for TRS ActiveCare Medical

coverage. You MUST log on during the annual enrollment to either elect or waive your medical elections.

 UPDATE! Medical Supplement carrier changing to

Century Healthcare. Traditional and HSA Compatible plans available. Medical Supplement plans help pay your deductible & coinsurance due to hospitalization and outpatient treatment.  NEW! Individual Life Insurance from 5Star Life available

for employee, spouse, child & grandchildren to age 100. Guaranteed Issue with just a few medical questions for adults. Quality of Life Rider issuable to age 65, covers employee & spouse and pays a monthly benefit if you become unable to perform 2 of 6 activities of daily living.

 NEW! Health Savings Accounts administered by HSA

 UPDATE! Vision is changing from Superior Vision to Bank are available for employees participating in a High Eyemed. Out of network benefits included, can order Deductible Health Plan. You can use HSA funds for glasses and contacts online. New cards will be sent in medical, dental, vision & prescription drug expenses. mid-September. HSA funds accumulate month to month and rollover  UPDATE! Telehealth is changing from Teladoc to year to year. You are not eligible for an HSA if you are MDLIVE. This free plan gives you access to free also enrolled in the Traditional Medical Supplement Plan telephone consultations with a licensed physician for or Medical Flex Spending (or have funds available, evaluation, diagnosis and prescriptions, as appropriate, employee or spouse, due to an FSA rollover or grace for minor illnesses. This covers you, your spouse and period). An HSA Compatible Medical Supplement Plan is dependent children to age 26 regardless of group available. medical plan coverage.  NEW! Employee Assistance Plan provided at no charge by Red Oak ISD. LifeWorks by Ceridian offers assistance  UNUM Life Insurance is allowing increases up to Guaranteed Issue of 180,000 employee and 50,000 with fast, free confidential help 24/7, including 6 face to spouse without medical questions for existing face counseling sessions for employees, spouses and participants. Children are guaranteed issue with children up to 26 years of age. approved employee coverage.    

Login and complete your supplemental benefit enrollment from 07/21/2016 - 08/22/2016 Enrollment assistance is available by calling Financial Benefit Services at 866-914-5202 to speak to an enrollment representative Monday—Friday, 8 AM—5 PM from 07/21/2016—08/22/2016. Bilingual assistance is available. Update your profile information: home address, phone numbers, email. IMPORTANT!! Due to the Affordable Care Act (ACA) reporting requirements, please add your dependent’s social security numbers in the online enrollment system. If you have questions, please contact your Benefits Administrator. 6

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 or upon required underwriting approval and will remain in effect during the entire plan year. CHANGES IN STATUS (CIS):

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

QUALIFYING EVENTS

Marital Status

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

Change in Number of Tax Dependents

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

Change in Status of Employment Affecting Coverage Eligibility

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

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

SUMMARY PAGES

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

Where can I find forms?

to review, change or continue benefit elections each year.

For benefit summaries and claim forms, go to your school

Changes are not permitted during the plan year (outside of

district’s benefit website:

annual enrollment) unless a Section 125 qualifying event occurs.

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



Changes, additions or drops may be made only during 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:

included in the dependent profile. Additionally, you must

www.mybenefitshub.com/redoakisd. Click on the benefit plan

notify your employer of any discrepancy in personal and/or

you need information on (i.e., Dental) and you can find

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.

provider search links under 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 time frame 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 15 or more

Dependent Eligibility: You can cover eligible dependent

regularly scheduled hours each work week.

children under a benefit that offers dependent coverage, provided you participate in the same benefit, through the

Eligible employees must be actively at work on the plan effective

maximum age listed below. Dependents cannot be double

date for new benefits to be effective, meaning you are physically

covered by married spouses within the district 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

Medical Supplement

Century Healthcare

Telehealth

MDLIVE

EAP

LifeWorks

Dental

Cigna

Vision

EyeMed

Cancer

Loyal American

21 / 25 If Full Time Student

Accident

Loyal American

Voluntary Life

UNUM

AD&D

UNUM

Individual Life

5Star Life

Issue 23 / Keep to 100

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 order to take drugs, or received medical care or services

Calendar Year January 1st through December 31st

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

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

(including diagnostic and/or consultation services).

SUMMARY PAGES

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

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

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

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

Employer Eligibility

A qualified high deductible health plan.

All employers

Contribution Source Account Owner Underlying Insurance Requirement

Employee and/or employer Individual

Employee and/or employer Employer

High deductible health plan

None

Description

Minimum Deductible Maximum Contribution

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

N/A Varies per employer

Permissible Use Of Funds

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

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

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

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

Not permitted

Year-to-year rollover of account balance?

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

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

Does the account earn interest?

Yes

Portable?

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

FLIP TO… PG. 50

FLIP TO… PG. 54

FOR HSA INFORMATION

FOR FSA INFORMATION

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

ActiveCare 1-HD

ActiveCare Select or ActiveCare Select Whole Health

ActiveCare 2

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

$2,500 employee only $5,000 family

$1,200 individual $3,600 family

$1,000 individual $3,000 family

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

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

$6,850 individual $13,700 family

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

80% 20%

Office Visit Copay Participant pays

20% after deductible

$30 copay for primary $60 copay for specialist

$30 copay for primary $50 copay for specialist

Diagnostic Lab Participant pays

20% after deductible

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

Preventive Care See next page for a list of services

Plan pays 100%

Teladoc® Physician Services

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

Plan pays 100%

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

20% after deductible

$100 copay plus 20% after deductible

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

20% after deductible

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

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

Emergency Room (true emergency use) Participant pays

20% after deductible

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

Outpatient Surgery Participant pays

20% after deductible

$150 copay per visit plus 20% after deductible

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

$5,000 copay plus 20% after deductible

Not covered

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

Prescription Drugs Drug deductible (per plan year)

Subject to plan year deductible

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

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

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

$20 $40** $65**

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

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

$35 $60** $90**

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

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

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

Specialty Drugs Participant pays

20% after deductible

20% coinsurance per fill

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

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

TRS-ActiveCare Plans—Preventive Care Network Benefits When Using In-Network Providers

(Provider must bill services as “preventive care”)

ActiveCare 1-HD Preventive Care Services

ActiveCare Select or ActiveCare Select Whole Health

ActiveCare 2 Network

(Baptist Health System and HealthTexas Medical Group; Baylor Scott & White Quality Alliance; Memorial Hermann Accountable Care Network; Seton Health Alliance) Evidence−based items or services that have in effect a rating of “A” or “B” in the current recommendations of the United States Preventive Services Task Force (USPSTF) www.uspreventiveservicestaskforce.org/Page/Name/uspstf-aand-b-recommendations Immunizations recommended by the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention (CDC) with respect to the individual involved.

Plan pays 100% (deductible waived)

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

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

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

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

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

$60 copay for specialist

$50 copay for specialist

Annual Hearing Examination Participant pays

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

$30 copay for primary $60 copay for specialist

$30 copay for primary $50 copay for specialist

Evidence−informed preventive care and screenings provided for in the comprehensive guidelines supported by the Health Resources and Services Administration (HRSA) for infants, children and adolescents. Additional preventive care and screenings for women, not described above, as provided for in comprehensive guidelines supported by the HRSA www.hhs.gov/healthcare/facts-and-features/fact-sheets/ preventive-services-covered-under-aca/ #CoveredPreventiveServicesforAdults For purposes of this benefit, the current recommendations of the USPSTF regarding breast cancer screening and mammography and prevention will be considered the most current (other than those issued in or around November 2009). The preventive care services described above may change as USPSTF, CDC and HRSA guidelines are modified. (Examples of covered services included are: Routine annual physicals (one per year); immunizations; well-child care; breastfeeding support, services and supplies; cancer screening mammograms; bone density test; screening for prostate cancer and colorectal cancer (including routine colonoscopies); smoking cessation counseling services and healthy diet counseling; and obesity screening/counseling. Examples of covered services for women with reproductive capacity are: Female sterilization procedures and specified FDA-approved contraception methods with a written prescription by a health care practitioner, including cervical caps, diaphragms, implantable contraceptives, intra-uterine devices, injectables, transdermal contraceptives and vaginal contraceptive devices. Prescription contraceptives for women are covered under the pharmacy benefits administered by Caremark. To determine if a specific contraceptive drug or device is included in this benefit, contact Customer Service at 1-800222-9205. The list may change as FDA guidelines are modified.

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

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

Copay

Preventive Services

No Charge

Standard Lab and X-ray

No Charge

Disease Management and Complex Case Management

No Charge

Well Child Care Annual Exams

No Charge

Immunizations (age appropriate)

No Charge

Plan Provisions

Copay

Annual Deductible

$1,000 Individual/ $3,000 Family

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

Lifetime Paid Benefit Maximum

Outpatient Services

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

None

Copay $20 co-pay

Primary Care1

(First Primary Care Visit for Illness $0 Copay2)

Specialty Care

$50 co-pay

Other Outpatient Services

20% after deductible3

Diagnostic/Radiology Procedures

20% after deductible

Eye Exam (one annually) Allergy Serum & Injections

No Charge 20% after deductible

Outpatient Surgery

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

Maternity Care

Copay

Prenatal Care

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

Inpatient Delivery

Inpatient Services

Copay

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

Diagnostic & Therapeutic Services Physical and Speech Therapy 5

Manipulative Therapy

Equipment and Supplies

$150 per day4 and 20% of charges after deductible

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

Copay

Preferred Diabetic Supplies and Equipment

$3 copay; no deductible

Non-Preferred Diabetic Supplies and Equipment

30% after Rx deductible

Durable Medical Equipment/ Prosthetics

20% after deductible

Home Health Services

Copay

Home Health Care Visit

$50 co-pay

Worldwide Emergency Care

Copay

Nurse Advice Line

1-877-505-7947

Online Services

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

After Hours Primary Care Clinics

$20 co-pay

Ambulance and Helicopter

$40 copay and 20% of charges after deductible

Emergency Room6

$150 copay and 20% of charges after deductible

Urgent Care Facility

$55 copay

Prescription Drugs

Copay

Annual Benefit Maximum

Unlimited

Rx Deductible

$100

Does not apply to preferred generic drugs

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

Maintenance Quantity

Retail Quantity (Up to a 30-day supply)

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

$3 copay

$6 copay

Preferred Brand

30% after Rx deductible

Non-preferred

50% after Rx deductible

Non-formulary

Greater of $50 or 50% after deductible

Not available

Preferred Generic7

Mail Order

Specialty Medications (Up to a 30-day supply)

1-800-707-3477

Copay 20% after Rx deductible

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

CENTURY HEALTHCARE YOUR BENEFITS PACKAGE

Medical Supplement

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

DID YOU KNOW?

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

This is a general overview of your plan benefits. If the terms of this outline differ from your policy, the policy will govern. Additional plan details on covered expenses, limitations and exclusions are included in the summary plan description located on the Red Oak ISD Benefits Website: www.mybenefitshub.com/redoakisd 16

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 $2,500 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 out-ofpocket 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 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

AGE BASED MONTHLY COST BY COVERAGE AMOUNT $1,500 $22.20 $40.75 $54.26 $72.31

$2,500 $30.68 $56.41 $75.81 $100.83

$29.35 $53.88 $58.36 $82.26

$39.56 $72.69 $86.30 $116.93

$61.60 $113.15 $107.25 $157.48

$85.39 $156.90 $149.63 $219.30

HSA Compatible Plan 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

AGE BASED MONTHLY COST BY COVERAGE AMOUNT $1,500 $11.77 $21.18 $26.00 $35.41

$2,500 $18.85 $33.93 $41.66 $56.74

$16.33 $29.37 $30.02 $43.07

$26.14 $47.06 $48.10 $69.01

$26.35 $47.42 $42.67 $63.74

$42.20 $75.96 $68.37 $102.13

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? $0 Covers you, your spouse, and children up to age 26, with unlimited phone consultations.

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

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

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

Scan with your smartphone to get the app.

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

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

CIGNA

Dental

YOUR BENEFITS PACKAGE

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

DID YOU KNOW?

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

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

Class I - Preventive & Diagnostic Care Oral Exams Routine Cleanings Bitewing X-rays Fluoride Application Sealants Space Maintainers Class II - Basic Restorative Care (No Waiting Period) Fillings Emergency Care to Relieve Pain Full Mouth X-rays Panoramic X-ray Periapical X-rays Oral Surgery – Simple Extractions Class III - Major Restorative Care (No Waiting Period) Crowns/Bridges/Dentures Root Canal Therapy/Endodontics Osseous Surgery Periodontal Scaling and Root Planing Surgical Extractions of Impacted Teeth Brush Biopsies Oral Surgery - all except simple extractions Anesthetics Histopathologic Exams Denture Repairs Denture Relines, Rebases and Adjustments Repairs to Bridges, Crowns and Inlays Inlays/Onlays Prosthesis Over Implant Class IV - Orthodontia (12 Month Waiting Period) Lifetime Maximum

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

$1,000

$50 per person Unlimited

Based on Reduced Contracted Fees

90th percentile of Reasonable and Customary Allowances

Plan Pays

You Pay

Plan Pays

You Pay

100%

No Charge

100%

No Charge

80%*

20%*

80%*

20%*

50%*

50%

50% $1,000 Dependent children to age 19

50%

50% $1,000 Dependent children to age 19

Monthly PPO Premiums Tier

Rate

EE Only

$27.27

EE + 1 Dep

$53.14

EE + 2 or more Deps

$95.97

Missing Tooth Limitation – The amount payable is 50% of the amount otherwise payable until insured for 12 months; thereafter, considered a Class III expense. Pretreatment review is available on a voluntary basis when extensive dental work in excess of $200 is proposed. * Subject to annual deductible Dental Oral Health Integration Program (OHIP) - All dental customers = Clinical research shows an association between oral health and overall health. The Cigna Dental Oral Health Integration Program (OHIP)® is designed to provide enhanced dental coverage for customers with certain eligible medical conditions. Eligible conditions for the program include cardiovascular disease, cerebrovascular disease (stroke), diabetes, maternity, chronic kidney disease, organ transplants, and head and neck cancer radiation. The program provides:  100% coverage for certain dental procedures  guidance on behavioral issues related to oral health  discounts on prescription and non-prescription dental products For more information and to see the complete list of eligible conditions, go to www.mycigna.com or call customer service 24/7 at 1.800.CIGNA24. **For services provided by a Cigna Dental PPO network dentist, Cigna Dental will reimburse the dentist according to a Contracted Fee Schedule. For services provided by an out-of-network dentist, Cigna Dental will reimburse according to Reasonable and Customary Allowances but the dentist may balance bill up to their usual fees. 23

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

Class I - Preventive & Diagnostic Care Oral Exams Routine Cleanings Bitewing X-rays Fluoride Application Sealants Space Maintainers Class II - Basic Restorative Care (No Waiting Period) Fillings Full Mouth X-rays Panoramic X-ray Periapical X-rays Emergency Care to Relieve Pain Oral Surgery – Simple Extractions Class III - Major Restorative Care (No Waiting Period) Crowns/Bridges/Dentures Root Canal Therapy/Endodontics Osseous Surgery Periodontal Scaling and Root Planing Surgical Extractions of Impacted Teeth Brush Biopsies Oral Surgery - all except simple extractions Anesthetics Denture Repairs Denture Relines, Rebases and Adjustments Repairs to Bridges, Crowns and Inlays Inlays/Onlays Prosthesis Over Implant Class IV - Orthodontia (12 Month Waiting Period) Lifetime Maximum

Cigna Dental PPO In-Network Out-of-Network Total Cigna DPPO $750

$750

$50 per person Unlimited

Based on Reduced Contracted Fees

90th percentile of Reasonable and Customary Allowances

Plan Pays

You Pay

Plan Pays

You Pay

80%

20%

80%

20%

50%*

25%*

75%*

25%*

75%*

50%

50% $750 Dependent children to age 19

50%

50% $750 Dependent children to age 19

Monthly PPO Premiums Tier

Rate

EE Only

$19.01

EE + 1 Dep

$37.82

EE + 2 or more Deps

$74.30

Dental PPO - High & Low Options Procedure

Late Entrants Limit Exams Prophylaxis (Cleanings)

Fluoride Treatments Histopathologic Exams X-rays (routine) X-rays (non-routine) Periapical x-rays: Intraoral occlusal x-rays: Models Fillings Sealants Minor Perio (non-surgical) Perio Surgery Crowns and Inlays Stainless Steel & Resin Crowns Bridges Dentures and Partials Relines, Rebases Adjustments Repairs - Bridges Repairs - Dentures Endodontics Prosthesis Over Implant Alternate Benefit

Exclusions and Limitations

No coverage for 12 months 1 per 6-month consecutive period. 1 routine prophy or perio maintenance procedure per 6-month consecutive period (routine prophy is Class I; perio prophy is Class II). 1 per consecutive 12 months for participants younger than age 14. Payable if the biopsy is covered. No coverage for other diagnostic tests. Bitewings: 1 set in any consecutive 12 month period. Limited to a maximum of 4 films per set. Full mouth or Panorex: 1 per 60 consecutive months. 4 in 12 consecutive months if not performed in conjunction with an operative procedure. 2 in 12 consecutive months. Not covered. 1 per tooth per 12 consecutive months (applies to replacement of identical surface fillings only). No composite, white/tooth colored fillings on bicuspid or molar teeth. 1 treatment per tooth per lifetime. Payable on unrestored permanent bicuspid or molar teeth only up to age 14. Root planing-1 per quadrant per 36 consecutive months. 1 per 36 consecutive months per area of the mouth (same service). Replacement limited to 1 per 84 consecutive months. Benefits are based on the amount payable for non-precious metals. No porcelain or white/tooth-colored material on molar crowns or bridges. Replacement must be indicated by major decay. For participants less than age 16, benefits for crowns and inlays are limited to resin or stainless steel. 1 per 36 consecutive months for participants younger than age 16. Replacement limited to 1 per 84 consecutive months, if unserviceable and cannot be repaired. Benefits are based on the amount payable for non-precious metals. No porcelain or white/tooth-colored material on molar crowns or bridges. Replacement limited to 1 per 84 consecutive months, if unserviceable and cannot be repaired. Covered if more than 12 months after installation; 1 per 36 consecutive months. Covered if more than 12 months after installation; 1 per 12 consecutive months. Covered if more than 12 months after installation. Covered if more than 12 months after installation. Root canal re-treatment 1 per 24 consecutive months, if necessity demonstrated. 1 per 84 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.

Benefit Exclusions

Services performed primarily for cosmetic reasons; Replacement of a lost or stolen appliance; Initial placement of a full or partial denture unless it includes the replacement of a functioning natural tooth extracted while the person is covered under this plan; removal of only a permanent third molar will not qualify for an initial or replacement denture or bridge; Overdentures, personalization, precision or semi-precision attachments; Replacement of a bridge, denture or crown within 84 months following its initial date of insertion; Replacement of a bridge, denture or crown which can be made useable according to 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, the restoration of teeth which have been damaged by erosion, attrition or abrasion; bite registration; or bite analysis; Veneers of porcelain or acrylic materials on crowns or pontics on or replacing the upper and lower first, second and third molars; Core buildup, labial veneers; Precious or semi-precious metals for crowns, bridges, pontics and abutments; crowns and bridges other than stainless steel or resin for participants under 16 years old; Bite registrations; precision or semi-precision attachments; splinting; 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; Procedures for which a charge would not have been made in the absence of coverage, for 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; Procedures which are not necessary and which do not have uniform professional endorsement; 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; IV sedation or general anesthesia, except when medically or dentally necessary and when in conjunction with covered complex oral surgery; Fees charged for broken appointments, claim form submission or sterilization; Services not included in the list of covered dental expenses, unless Cigna HealthCare agrees to accept such expense as a covered dental expense, in which case payment will be made consistent with similar services which would provide the least expensive professionally satisfactory result; Crowns, inlays, cast restorations, or other laboratory prepared restorations on teeth unless the tooth cannot be restored with an amalgam or composite resin filling due to major decay or fracture; Replacement of teeth beyond the normal complement of 32; Prescription drugs; Athletic mouth guards; Myofunctional therapy; Charges for travel time; transportation costs; or professional advice given on the phone; 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); Any procedure, service, or supply which may not reasonably be expected to successfully correct the covered person’s dental condition for a period of at least three years, as determined by Cigna HealthCare; Temporary, transitional or interim dental services; Diagnostic casts, diagnostic models, or study models; Any charge for any treatment performed outside of the United States other than for Emergency Treatment (any benefits for Emergency Treatment which is performed outside of the United States will be limited to a maximum of ($100.00-$200.00) per 12 consecutive month period); Procedures that are a covered expense under any other medical plan which provides group hospital, surgical, or medical benefits whether or not on an insured basis; Any charges, including ancillary charges, made by hospital, ambulatory surgical center or similar facility; To the extent that payment is unlawful where the person resides when the expenses are incurred; 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 Dependentsis 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. Services or supplies received as a result of dental disease, defect or injury due to an act of war, declared or undeclared. 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. BSD47880 © 2015 Cigna

EYEMED YOUR BENEFITS PACKAGE

Vision

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

DID YOU KNOW?

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

Vision Insight Network Member Cost

Out-of-Network Reimbursement

Exam With Dilation as Necessary

$10 Copay

Up to $40

Retinal Imaging

Up to $39

N/A

$0 Copay; $130 allowance; 20% off balance over $130

Up to $91

Single Vision

$25 Copay

Up to $30

Bifocal

$25 Copay

Up to $50

Trifocal

$25 Copay

Up to $70

Standard Progressive Lens

$90 Copay

Up to $50

Premium Progressive Lens

$110 Copay - $135 Copay

Vision Care Services

Frames

Standard Plastic Lenses

Tier 1

$110 Copay

Up to $50

Tier 2

$120 Copay

Up to $50

Tier 3

$135 Copay

Up to $50

Tier 4

$90 Copay, 80% of charge less $120 Allowance

Up to $50

$25 Copay

Up to $70

Lenticular

Lens Options

(paid by the member and added to the base price of lens)

UV Treatment

$15

N/A

Tint (Solid and Gradient)

$15

N/A

Standard Plastic Scratch Coating

$15

N/A

Standard Polycarbonate

$40

N/A

Standard Polycarbonate - Kids under 19

$40

N/A

Standard Anti-Reflective Coating

$45

N/A

Premium Anti-Reflective Coating

$57 - $68

N/A

$57

N/A

Tier 2

$68

N/A

Tier 3

80% of charge

N/A

Tier 1

Photochromic/Transitions

$75

N/A

Polarized

20% off retail price

N/A

Other Add-Ons and Services

20% off retail price

N/A

Contact Lens Fit and Follow-Up

(Contact lens fit and two follow up visits are available once a comprehensive eye exam has been completed)

Standar Contact Lens Fit and Follow-Up

Up to $55

N/A

Premium Contact Lens Fit and Follow-Up

10% off retail

N/A

$0 Copay; $130 allowance; 15% off retail price over $130

Up to $130

$0 Copay; $130 allowance; plus balance over $130

Up to $130

$0 copay, Paid in Full

Up to $210

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

N/A

Contact Lenses Conventional Disposable Medically Necessary

Laser Vision Correction Lasik or PRK from U.S. Laser Network

Frequency Examination

Once every 12 months

Lenses or Contact Lenses

Once every 12 months

Frame

Once every 24 months

Monthly Rates Employee Only

$5.58

Employee + 1 Dependent

$10.60

Employee + Family

$15.57 27

THE HARTFORD YOUR BENEFITS PACKAGE

Disability

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

DID YOU KNOW?

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

34.6 months is the duration of the average disability claim.

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



Pre-existing Conditions



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

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



Mental Illness, Alcoholism and Substance Abuse



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

What other benefits are included in my disability coverage? 



Your benefit payments will not be reduced by certain kinds of other income, such as:  Retirement benefits if you were already receiving them before you became disabled  Retirement benefits that are funded by your after-tax contributions  Your personal savings, investment, IRAs or Keoghs  Profit-sharing  Most personal disability policies  Social Security increases Coverage goes into effect subject to the terms and conditions of the policy. You must satisfy the definition of Actively at Work with your employer on the day your coverage takes effect.



Exclusions



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

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

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

Long Term Disability

Annual Earnings

MONTHLY PREMIUMS Rates effective 9/1/1016 (Based on 12 payments per year) Accident / Sickness Elimination Period in Days Monthly Earnings Monthly Benefit 0/7 14 / 14 30 / 30

60 / 60

90 / 90

180 / 180

$5.04

$4.48

$3.06

$2.30

$1.74

$7.95

$7.56

$6.72

$4.59

$3.45

$2.61

$10.60

$10.08

$8.96

$6.12

$4.60

$3.48

$13.25

$12.60

$11.20

$7.65

$5.75

$4.35

$600

$15.90

$15.12

$13.44

$9.18

$6.90

$5.22

$1,050

$700

$18.55

$17.64

$15.68

$10.71

$8.05

$6.09

$1,200

$800

$21.20

$20.16

$17.92

$12.24

$9.20

$6.96

$16,200

$1,350

$900

$23.85

$22.68

$20.16

$13.77

$10.35

$7.83

$18,000

$1,500

$1,000

$26.50

$25.20

$22.40

$15.30

$11.50

$8.70

$19,800

$1,650

$1,100

$29.15

$27.72

$24.64

$16.83

$12.65

$9.57

$21,600

$1,800

$1,200

$31.80

$30.24

$26.88

$18.36

$13.80

$10.44

$23,400

$1,950

$1,300

$34.45

$32.76

$29.12

$19.89

$14.95

$11.31

$25,200

$2,100

$1,400

$37.10

$35.28

$31.36

$21.42

$16.10

$12.18

$27,000

$2,250

$1,500

$39.75

$37.80

$33.60

$22.95

$17.25

$13.05

$28,800

$2,400

$1,600

$42.40

$40.32

$35.84

$24.48

$18.40

$13.92

$30,600

$2,550

$1,700

$45.05

$42.84

$38.08

$26.01

$19.55

$14.79

$32,400

$2,700

$1,800

$47.70

$45.36

$40.32

$27.54

$20.70

$15.66

$34,200

$2,850

$1,900

$50.35

$47.88

$42.56

$29.07

$21.85

$16.53

$36,000

$3,000

$2,000

$53.00

$50.40

$44.80

$30.60

$23.00

$17.40

$37,800

$3,150

$2,100

$55.65

$52.92

$47.04

$32.13

$24.15

$18.27

$39,600

$3,300

$2,200

$58.30

$55.44

$49.28

$33.66

$25.30

$19.14

$41,400

$3,450

$2,300

$60.95

$57.96

$51.52

$35.19

$26.45

$20.01

$43,200

$3,600

$2,400

$63.60

$60.48

$53.76

$36.72

$27.60

$20.88

$45,000

$3,750

$2,500

$66.25

$63.00

$56.00

$38.25

$28.75

$21.75

$46,800

$3,900

$2,600

$68.90

$65.52

$58.24

$39.78

$29.90

$22.62

$48,600

$4,050

$2,700

$71.55

$68.04

$60.48

$41.31

$31.05

$23.49

$50,400

$4,200

$2,800

$74.20

$70.56

$62.72

$42.84

$32.20

$24.36

$52,200

$4,350

$2,900

$76.85

$73.08

$64.96

$44.37

$33.35

$25.23

$54,000

$4,500

$3,000

$79.50

$75.60

$67.20

$45.90

$34.50

$26.10

$55,800

$4,650

$3,100

$82.15

$78.12

$69.44

$47.43

$35.65

$26.97

$57,600

$4,800

$3,200

$84.80

$80.64

$71.68

$48.96

$36.80

$27.84

$59,400

$4,950

$3,300

$87.45

$83.16

$73.92

$50.49

$37.95

$28.71

$61,200

$5,100

$3,400

$90.10

$85.68

$76.16

$52.02

$39.10

$29.58

$63,000

$5,250

$3,500

$92.75

$88.20

$78.40

$53.55

$40.25

$30.45

$64,800

$5,400

$3,600

$95.40

$90.72

$80.64

$55.08

$41.40

$31.32

$66,600

$5,550

$3,700

$98.05

$93.24

$82.88

$56.61

$42.55

$32.19

$68,400

$5,700

$3,800

$100.70

$95.76

$85.12

$58.14

$43.70

$33.06

$3,600

$300

$200

$5,400

$450

$300

$7,200

$600

$400

$9,000

$750

$500

$10,800

$900

$12,600 $14,400

$5.30

Long Term Disability

Annual Earnings

MONTHLY PREMIUMS Rates effective 9/1/1016 (Based on 12 payments per year) Accident / Sickness Elimination Period in Days Monthly Earnings Monthly Benefit 0/7 14 / 14 30 / 30

60 / 60

90 / 90

180 / 180

$70,200

$5,850

$3,900

$103.35

$98.28

$87.36

$59.67

$44.85

$33.93

$72,000

$6,000

$4,000

$106.00

$100.80

$89.60

$61.20

$46.00

$34.80

$73,800

$6,150

$4,100

$108.65

$103.32

$91.84

$62.73

$47.15

$35.67

$75,600

$6,300

$4,200

$111.30

$105.84

$94.08

$64.26

$48.30

$36.54

$77,400

$6,450

$4,300

$113.95

$108.36

$96.32

$65.79

$49.45

$37.41

$79,200

$6,600

$4,400

$116.60

$110.88

$98.56

$67.32

$50.60

$38.28

$81,000

$6,750

$4,500

$119.25

$113.40

$100.80

$68.85

$51.75

$39.15

$82,800

$6,900

$4,600

$121.90

$115.92

$103.04

$70.38

$52.90

$40.02

$84,600

$7,050

$4,700

$124.55

$118.44

$105.28

$71.91

$54.05

$40.89

$86,400

$7,200

$4,800

$127.20

$120.96

$107.52

$73.44

$55.20

$41.76

$88,200

$7,350

$4,900

$129.85

$123.48

$109.76

$74.97

$56.35

$42.63

$90,000

$7,500

$5,000

$132.50

$126.00

$112.00

$76.50

$57.50

$43.50

$91,800

$7,650

$5,100

$135.15

$128.52

$114.24

$78.03

$58.65

$44.37

$93,600

$7,800

$5,200

$137.80

$131.04

$116.48

$79.56

$59.80

$45.24

$95,400

$7,950

$5,300

$140.45

$133.56

$118.72

$81.09

$60.95

$46.11

$97,200

$8,100

$5,400

$143.10

$136.08

$120.96

$82.62

$62.10

$46.98

$99,000

$8,250

$5,500

$145.75

$138.60

$123.20

$84.15

$63.25

$47.85

$100,800

$8,400

$5,600

$148.40

$141.12

$125.44

$85.68

$64.40

$48.72

$102,600

$8,550

$5,700

$151.05

$143.64

$127.68

$87.21

$65.55

$49.59

$104,400

$8,700

$5,800

$153.70

$146.16

$129.92

$88.74

$66.70

$50.46

$106,200

$8,850

$5,900

$156.35

$148.68

$132.16

$90.27

$67.85

$51.33

$108,000

$9,000

$6,000

$159.00

$151.20

$134.40

$91.80

$69.00

$52.20

$109,800

$9,150

$6,100

$161.65

$153.72

$136.64

$93.33

$70.15

$53.07

$111,600

$9,300

$6,200

$164.30

$156.24

$138.88

$94.86

$71.30

$53.94

$113,400

$9,450

$6,300

$166.95

$158.76

$141.12

$96.39

$72.45

$54.81

$115,200

$9,600

$6,400

$169.60

$161.28

$143.36

$97.92

$73.60

$55.68

$117,000

$9,750

$6,500

$172.25

$163.80

$145.60

$99.45

$74.75

$56.55

$118,800

$9,900

$6,600

$174.90

$166.32

$147.84

$100.98

$75.90

$57.42

$120,600

$10,050

$6,700

$177.55

$168.84

$150.08

$102.51

$77.05

$58.29

$122,400

$10,200

$6,800

$180.20

$171.36

$152.32

$104.04

$78.20

$59.16

$124,200

$10,350

$6,900

$182.85

$173.88

$154.56

$105.57

$79.35

$60.03

$126,000

$10,500

$7,000

$185.50

$176.40

$156.80

$107.10

$80.50

$60.90

$127,800

$10,650

$7,100

$188.15

$178.92

$159.04

$108.63

$81.65

$61.77

$129,600

$10,800

$7,200

$190.80

$181.44

$161.28

$110.16

$82.80

$62.64

$131,400

$10,950

$7,300

$193.45

$183.96

$163.52

$111.69

$83.95

$63.51

$133,200

$11,100

$7,400

$196.10

$186.48

$165.76

$113.22

$85.10

$64.38

$135,000

$11,250

$7,500

$198.75

$189.00

$168.00

$114.75

$86.25

$65.25

UNUM YOUR BENEFITS PACKAGE

Life and AD&D

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

DID YOU KNOW? Motor vehicle crashes are the

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

Life and AD&D Eligibility All employees working at least 15 hours each week in active employment in the U.S. with the employer, and their eligible spouses and children to age 26.

Coverage Amounts Your Term Life coverage options are: Employee: Up to 5 times salary in increments of $10,000. Not to exceed $500,000. Spouse: Up to 100% of employee amount in increments of $5,000. Not to exceed $250,000. Benefits will be paid to the employee. Child: Up to 100% of employee coverage amount in increments of either $5,000 or $10,000. The maximum death benefit for a child between the ages of live birth and 6 months is $1,000. Benefits will be paid to the employee.

coverage up to $180,000 for yourself and any amount of coverage up to $50,000 for your spouse. Any Life insurance coverage over the Guarantee Issue amounts will be subject to evidence of insurability. If you and your eligible dependents do not enroll within 31 days of your eligibility date, you can apply for coverage only during an annual enrollment period and will be required to furnish evidence of insurability for the entire amount of coverage. AD&D coverage does not require evidence of insurability. If you and your eligible dependents enroll within 31 days of your eligibility date, and later, wish to increase your coverage, you may increase your Life insurance coverage, with evidence of insurability, at anytime during the year. However, you may wait until the next annual enrollment and only Life insurance coverage over the Guarantee Issue amounts will be subject to evidence of insurability. Please see your Plan Administrator for your eligibility date.

In order to purchase Life coverage for your spouse and/or child, you must purchase Life coverage for yourself.

Additional Benefits Life Planning Financial & Legal Resources

Your AD&D coverage options are: Employee: Up to 5 times salary in increments of $10,000. Not to exceed $500,000. You may purchase AD&D coverage for yourself regardless of whether you purchase Life coverage. Spouse: Up to 100% of employee amount in increments of $5,000. Not to exceed $250,000. Benefits will be paid to the employee. Child: Up to 100% of employee coverage amount in increments of either $5,000 or $10,000. The maximum death benefit for a child between the ages of live birth and 6 months is $1,000. Benefits will be paid to the employee.

This personalized financial counseling service provides expert, objective financial counseling to survivors and terminally ill employees at no cost to you. This service is also extended to you upon the death or terminal illness of your covered spouse. The financial consultants are master level consultants. They will help develop strategies needed to protect resources, preserve current lifestyles, and build future security. At no time will the consultants offer or sell any product or service.

In order to purchase AD&D coverage for your spouse and/or child, you must purchase AD&D coverage for yourself. AD&D Benefit Schedule: The full benefit amount is paid for loss of:  Life  Both hands or both feet or sight of both eyes  One hand and one foot  One hand and the sight of one eye  One foot and the sight of one eye  Speech and hearing Other losses may be covered as well. Please see your Plan Administrator. Coverage amount(s) will reduce according to the following schedule: Age: Insurance Amount Reduces to: 70 65% of original amount 75 50% of original amount

Guarantee Issue If you and your eligible dependents enroll within 31 days of your eligibility date, you may apply for any amount of Life insurance

Portability/Conversion If you retire, reduce your hours or leave your employer, you can take this coverage with you according to the terms outlined in the contract. However, if you have a medical condition which has a material effect on life expectancy, you will be ineligible to port your coverage. You may also have the option to convert your Term life coverage to an individual life insurance policy.

Accelerated Benefit If you become terminally ill and are not expected to live beyond a certain time period as stated in your certificate booklet, you may request up to 50% of your life insurance amount up to $750,000, without fees or present value adjustments. A doctor must certify your condition in order to qualify for this benefit. Upon your death, the remaining benefit will be paid to your designated beneficiary(ies). This feature also applies to your covered dependents.

Waiver of Premium If you become disabled (as defined by your plan) and are no longer able to work, your premium payments will be waived during the period of disability.

Retained Asset Account Benefits of $10,000 or more are paid through the Unum Retained Asset Account. This interest bearing account will be established in the beneficiary's name. He or she can then write a check for the full amount or for $250 or more, as needed. 33

Life and AD&D Additional AD&D Benefits Education Benefit: If you or your insured spouse die within 365 days of an accident, an additional benefit is paid to your dependent child (ren). Your child(ren) must be a full-time student beyond grade 12. (Not available in Illinois or New York.)

  

The date your coverage under a plan ends; The date your dependent ceases to be an eligible dependent; For a spouse, the date of divorce or annulment.

Unum will provide coverage for a payable claim which occurs while you and your dependents are covered under the policy or plan.

Seat Belt/Air Bag Benefit: If you or your insured dependent(s) die in a car accident and are wearing a properly fastened seat belt and/or are in a seat with an air bag, an amount will be paid in addition to the AD&D benefit.

Next Steps How to Apply

Limitations/Exclusions/Termination of Coverage Suicide Exclusion

Newly Eligible Employees: To apply for coverage, complete your enrollment form within 31 days of your eligibility date.

Life benefits will not be paid for deaths caused by suicide in the first twenty-four months after your effective date of coverage. No increased or additional benefits will be payable for deaths caused by suicide occurring within 24 months after the day such increased or additional insurance is effective.

AD&D Benefit Exclusions AD&D benefits will not be paid for losses caused by, contributed to by, or resulting from:  Disease of the body or diagnostic, medical or surgical treatment or mental disorder as set forth in the latest edition of the Diagnostic and Statistical Manual of Mental Disorders;  Suicide, self-destruction while sane, intentionally self-inflicted injury while sane, or self-inflicted injury while insane;  War, declared or undeclared, or any act of war;  Active participation in a riot;  Attempt to commit or commission of a crime;  The voluntary use of any prescription or non-prescription drug, poison, fume, or other chemical substance unless used according to the prescription or direction of your or your dependent’s doctor. This exclusion does not apply to you or your dependent if the chemical substance is ethanol;  Intoxication. (“Intoxicated” means that the individual’s blood alcohol level equals or exceeds the legal limit for operating a motor vehicle in the state or jurisdiction where the accident occurred.)

Termination of Coverage Your coverage and your dependents’ coverage under the Summary of Benefits ends on the earliest of:  The date the policy or plan is cancelled;  The date you no longer are in an eligible group;  The date your eligible group is no longer covered;  The last day of the period for which you made any required contributions;  The last day you are in active employment unless continued due to a covered layoff or leave of absence or due to an injury or sickness, as described in the certificate of coverage;  For dependent’s coverage, the date of your death. In addition, coverage for any one dependent will end on the earliest of:

Current Employees: To apply for coverage, complete your enrollment form by the initial enrollment deadline

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

Delayed Effective Date of Coverage Employee: Insurance coverage will be delayed if you are not in active employment because of an injury, sickness, temporary layoff, or leave of absence on the date that insurance would otherwise become effective. Dependent: Insurance coverage will be delayed if that dependent is totally disabled on the date that insurance would otherwise be effective. Exception: infants are insured from live birth. “Totally disabled” means that, as a result of an injury, a sickness or a disorder, your dependent is confined in a hospital or similar institution; is unable to perform two or more activities of daily living (ADLs) because of a physical or mental incapacity resulting from an injury or a sickness; is cognitively impaired; or has a life threatening condition.

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

Questions Coverage will become effective September 1 or upon approval if evidence of insurability is required. For employees who become eligible after this date, please see your Plan Administrator for your effective date.

Life and AD&D Term Life Rates EMPLOYEE

$10,000

$20,000

$30,000

$40,000

$50,000

$70,000

$100,000

$130,000

$150,000

0-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64

$0.30 $0.30 $0.40 $0.70 $1.00 $1.60 $2.40 $3.70 $5.50

$0.60 $0.60 $0.80 $1.40 $2.00 $3.20 $4.80 $7.40 $11.00

$0.90 $0.90 $1.20 $2.10 $3.00 $4.80 $7.20 $11.10 $16.50

$1.20 $1.20 $1.60 $2.80 $4.00 $6.40 $9.60 $14.80 $22.00

$1.50 $1.50 $2.00 $3.50 $5.00 $8.00 $12.00 $18.50 $27.50

$2.10 $2.10 $2.80 $4.90 $7.00 $11.20 $16.80 $25.90 $38.50

$3.00 $3.00 $4.00 $7.00 $10.00 $16.00 $24.00 $37.00 $55.00

$3.90 $3.90 $5.20 $9.10 $13.00 $20.80 $31.20 $48.10 $71.50

$4.50 $4.50 $6.00 $10.50 $15.00 $24.00 $36.00 $55.50 $82.50

65-69 70-74 75+

$9.30 $16.50 $33.70

$18.60 $33.00 $67.40

$27.90 $49.50 $101.10

$37.20 $66.00 $134.80

$46.50 $82.50 $168.50

$65.10 $115.50 $235.90

$93.00 $165.00 $337.00

$120.90 $214.50 $438.10

$139.50 $247.50 $505.50

Age Band

ACCIDENTAL DEATH & DISMEMBERMENT RATES: 0-79+

$0.25

$0.50

$0.75

$1.00

$1.25

$1.75

$2.50

$3.25

$3.75

SPOUSE

$5,000

$10,000

$15,000

$20,000

$25,000

$30,000

$50,000

$55,000

$60,000

Age Band 0-24

$0.15

$0.30

$0.45

$0.60

$0.75

$0.90

$1.50

$1.65

$1.80

25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74

$0.15 $0.20 $0.35 $0.50 $0.80 $1.20 $1.85 $2.75 $4.65 $8.25

$0.30 $0.40 $0.70 $1.00 $1.60 $2.40 $3.70 $5.50 $9.30 $16.50

$0.45 $0.60 $1.05 $1.50 $2.40 $3.60 $5.55 $8.25 $13.95 $24.75

$0.60 $0.80 $1.40 $2.00 $3.20 $4.80 $7.40 $11.00 $18.60 $33.00

$0.75 $1.00 $1.75 $2.50 $4.00 $6.00 $9.25 $13.75 $23.25 $41.25

$0.90 $1.20 $2.10 $3.00 $4.80 $7.20 $11.10 $16.50 $27.90 $49.50

$1.50 $2.00 $3.50 $5.00 $8.00 $12.00 $18.50 $27.50 $46.50 $82.50

$1.65 $2.20 $3.85 $5.50 $8.80 $13.20 $20.35 $30.25 $51.15 $90.75

$1.80 $2.40 $4.20 $6.00 $9.60 $14.40 $22.20 $33.00 $55.80 $99.00

75+

$16.85

$33.70

$50.55

$67.40

$84.25

$101.10

$168.50

$185.35

$202.20

$0.50

$0.63

$0.75

$1.25

$1.38

$1.50

ACCIDENTAL DEATH & DISMEMBERMENT RATES: 0-79+

$0.13

$0.25

$0.38

CHILD(REN) LIFE AD&D

$5,000 $1.00 $0.18

$10,000 $2.00 $0.35

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 23. 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 Rider not available ages 66-70. Quality of Life Rider 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.

LOYAL AMERICAN

Cancer

YOUR BENEFITS PACKAGE

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

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

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

Cancer ADDITIONAL BENEFIT AMOUNTS

PLAN A Maximum

PLAN B Maximum

ANNUAL CANCER SCREENING BENEFIT RIDER (form LG-6041) A. Basic Benefit We will pay the expense incurred, but not to exceed the maximum benefit amount shown on the Certificate Schedule, once per calendar year per Insured Person for screening tests performed to determine whether Cancer exists in an $50 $100 Insured Person. Covered annual Cancer screening tests include but are not limited to: mammogram, pap smear, Per Calendar Year Per Calendar Year breast ultrasound, ThinPrep, biopsy, chest x-ray, thermography, colonoscopy, flexible sigmoidoscopy, hemocult stool specimen, PSA (blood test for prostate cancer), CEA (blood tests for colon cancer), CA125 (blood test for ovarian cancer), CA15-3 (blood test for breast cancer), serum protein electrophesis (blood test for myeloma).

Additional Benefit

We will pay the expense incurred, but not to exceed two times the maximum benefit amount per calendar year as shown on the Certificate Schedule, for one additional invasive diagnostic procedure required as the result of an abnormal cancer screening test for which benefits are payable under the Basic Benefit above for an Insured Person. This additional benefit is payable regardless of the results of the additional diagnostic procedure. However, the amount payable will be reduced dollar for dollar for any amount payable under the Positive Diagnosis Benefit contained in the base Certificate.

FIRST OCCURRENCE BENEFIT RIDER (form LG-6043) If an Insured Person receives a positive diagnosis of Internal Cancer, We will pay the First Occurrence benefit amount shown on the Certificate Schedule. If the Insured Person receiving the positive diagnosis of Internal Cancer is a child under the age of 21, we will pay one and one-half times the First Occurrence benefit amount shown on the Certificate Schedule.

$100 $200 Per Calendar Year Per Calendar Year

$2,000 $5,000 Once per Lifetime Once per Lifetime $4,000 $10,000 Once per Lifetime Once per Lifetime

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

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

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

$200 Per Day

$400 Per Day

$1,000 Procedure Maximum

$2,500 Procedure Maximum

$250 Procedure Maximum

$625 Procedure Maximum

$900 Procedure Maximum

$2,250 Procedure Maximum

Per Procedure

$150 Per Day

$250 Per Day

$300 Per Day

$500 Per Day

$300/ $600 Per Day

$500/ $1,000 Per Day

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

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

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

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

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

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

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

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

Benefits Initial Hospitalization Benefit We will pay a benefit of $1,500 selected when an Insured Person is confined to a hospital (for 12 or more hours) as a result of receiving treatment for a Specified Disease. This benefit is payable only once per period of confinement and once per calendar year for each Insured Person. Hospital Confinement Benefit We will pay a benefit of $300 per day per unit of coverage selected when an Insured Person is hospitalized during any continuous period of 30 days or less for the treatment of a covered Specified Disease. Benefits will double per day beginning with the 31st day of continuous confinement. If the hospital confinement follows a previously covered confinement, it will be deemed a continuation of the first confinement unless it is the result of an entirely different Specified Disease, or unless the confinements are separated by 30 days or more.

Monthly Rates

Employee

Single Parent

Employee and Spouse

Family

Plan A

$14.67

$18.41

$24.99

Plan A + ICU

$16.99

$21.61

$29.39

Plan B

$25.03

$30.27

$41.68

Plan B + ICU

$27.36

$33.46

$46.08

Cancer

OPTIONAL BENEFITS YOU MAY SELECT FOR ADDITIONAL PREMIUM

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

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

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

$500 Per Day

$1,000 Per Day

$250 Per Day

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

LOYAL AMERICAN YOUR BENEFITS PACKAGE

Accident

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

DID YOU KNOW?

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

Accident Summary of Benefits

Plan A Pays

Plan B Pays

Ambulance Ground Ambulance Benefit: Loyal American will pay this benefit if you require transportation by a licensed professional ambulance company to or from a hospital or $150 $75 between medical facilities within 90 days for injuries sustained after a covered accident. Payable once per accident. Air Ambulance Benefit: Loyal American will pay this benefit if you require transportation by a license professional air ambulance company to or from a hospital or between medical $600 $300 facilities within 48 hours for injuries sustained after a covered accident. Payable once per accident. Indemnity Benefits Emergency Room Treatment Benefit: Loyal American will pay this benefit if you received Insured/Spouse: Insured/Spouse: hospital emergency room treatment within 72 hours of injuries sustained in a covered $150 $75 accident and for which charges are submitted. Child: $75 Child: $40 Accident Follow-Up Treatment Benefit: Loyal American will pay this benefit for three additional treatments of injuries sustained in a covered accident over and above emergency $50 $25 treatment administered during the first 72 hours following the accident. Treatment must per visit per visit begin within 30 days of the covered accident and must be within the 6 month period following the covered accident. Specific Sum Injuries Benefit: The specific indemnity amount as listed in the policyâ&#x20AC;&#x2122;s Benefit Schedule will be paid according to the type of injury received in a covered accident. Loyal See Benefit See Benefit American will pay for dislocations (separated joint), burns, tendon (torn, ruptured, severed, Schedule Schedule ligaments, or rotator cuff), torn knee cartilage, eye injuries, lacerations, and fractures (broken bones). Blood, Plasma, Platelets Benefit: Loyal American will pay this benefit if you require transfusion, administration, cross matching, typing and processing of blood, plasma or $100 $50 platelets when administered within 90 days for injuries sustained in a covered accident. Payable once per accident. Hospital Benefits Initial Accident Hospitalization Benefit: Loyal American will pay this benefit if hospital confinement is required within six (6) months for injuries sustained in a covered accident. $500 $250 Payable once per accident. Hospital Confinement Benefit: Loyal American will pay this benefit for a maximum of 180 $200 $100 days per confinement.* if you require confinement in a hospital or in a hospital intensive per day per day care unitâ&#x20AC;&#x201C; sub acute within six (6) months for injuries sustained in a covered accident. Intensive Care Hospital Intensive Care Unit Confinement Benefit: Loyal American will pay this benefit for a maximum of 15 days per confinement* if you are confined in a hospital intensive care unit $400 $200 within 30 days because of injuries received in a covered accident. per day per day *Confinements separated by less than 90 days will be considered as the same period of confinement. Physical Therapy Physical Therapy Benefit: Loyal American will pay this benefit, not to exceed five treatments per accident, for services prescribed by a doctor and rendered by a licensed $50 per $25 per physical therapist. Physical therapy must be for injuries sustained in a covered accident and treatment treatment must start within 60 days after the accident. Treatment must be completed within 6 months after the accident. Prostheses Benefit: Loyal American will pay this benefit if a doctor prescribes the use of a 1 prosthetic 1 prosthetic prosthetic device due to the loss of a hand, foot or sight of an eye in a covered accident. The device/artificial device/artificial prosthetic must be received within 1 year of the covered accident. This benefit is payable limb: $100 limb: $50 once per accident and is not payable for hearing aids, dental aids, false teeth or for cosmetic More than 1: More than 1: prosthesis (e.g. hair wigs). We will not pay for joint replacement (e.g. artificial hip or knee). $500 $250 Appliance Benefit: Loyal American will pay this benefit if a doctor advises you to use a medical appliance as an aid to personal locomotion within 90 days as a result of injuries $50 $25 sustained in a covered accident. Benefits are payable for crutches, wheelchairs, braces, etc. Benefits are payable for crutches and wheelchairs once per accident. 45

Accident Summary of Benefits

Plan A Pays

Plan B Pays

$100 per day

$50 per day

$300

$150

Family Lodging & Transportation Family Lodging Benefit: Loyal American will pay this benefit for a maximum of 30 days per accident, during the time you are confined in a hospital, for one motel/ hotel room for a family member to accompany you if injuries sustained in a covered accident require hospital confinement, and if the hospital and motel/ hotel are more than 100 miles from your residence. Transportation Benefit: Loyal American will pay this benefit for a maximum of three trips per calendar year if you require special treatment and confinement in a hospital located more than 100 miles from your residence or site of the accident for injuries sustained in a covered accident. Accidental Death Accidental Death* Benefit: This policy will pay the following benefit for death if it is the result of injuries sustained in a covered accident. Death must occur within 90 days of a covered accident. Common-Carrier: You must be a fare paying passenger on a common-carrier. Common-carrier vehicles are limited to commercial airplanes, trains, buses, Insured: $100,000 Insured: $50,000 trolleys, subways, ferries and boats that operate on a regularly scheduled basis Spouse: $50,000 Spouse: $25,000 between predetermined points or cities. Taxis and privately chartered vehicles Child: $15,000 Child: 7,500 are not included. Other Accidents: Other Accidents are those not classified as common-carrier and Insured: $25,000 Insured: $12,500 are not specifically excluded in the limitations and exclusions section of the Spouse: $10,000 Spouse: $5,000 policy. Child: $5,000 Child: $2,500 Dismemberment Accidental Dismemberment* Benefit This policy will pay a percentage of the Accidental Death-Other Accidents Benefit for the selected plan. Both arms and both legs

100%

Two arms or legs

50%

Sight of two eyes, hands, or feet

50%

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

20%

One or more fingers and/or one or more toes

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

Accident This is a limited benefit policy. This policy does not pay for losses resulting from sickness. RENEWABILITY CONDITIONS: The policy is guaranteed renewable. Premium rates may be changed on a class basis. A class may be defined by age, sex, occupation, premium payment method, issue state, elimination period, benefit period, etc. WHAT IS NOT COVERED BY THIS POLICY. We will not pay benefits for any injury as a result of you(r):  Operating, learning to operate, serving as a crew member of or jumping or falling from any aircraft. Aircraft includes those which are not motor-driven.  Engaging in hang gliding, bungee jumping, parachuting, sailgliding, parakiting, or hot-air ballooning.  Participating or attempting to participate in an illegal activity.  Riding in or driving any motor-driven vehicle in a race, stunt show, or speed test.  Intentionally causing a self-inflicted injury.  Having any sickness or declining process caused by a sickness, including physical or mental infirmity. We also will not pay benefits to diagnose or treat the sickness. Sickness means any disease or disorder that is not caused by an injury.  Practicing for or participating in any semi-professional or professional competitive athletic contest for which any type of compensation or remuneration is received.  Committing or trying to commit suicide, whether sane or insane.  Being in an accident which occurs more than 40 miles outside the territorial limits of the United States, Canada, Puerto Rico, and Virgin Islands.  Involvement in any period of armed conflict, even if it is not declared. This brochure contains a summary of the Accident Insurance Policy form L-6020. Coverage as described in the brochure is provided only through the issuance of a policy. The policy should be consulted for full terms and conditions of coverage. Payroll Deduction Rates - Available for Issue Ages 18 - 64

PLAN A High Option

PLAN B Low Option MONTHLY

SEMI MONTHLY

INDIVIDUAL

$9.00

$4.50

$10.20

SINGLE PARENT

$14.20

$7.10

$19.50

$9.75

INSURED & SPOUSE

$13.50

$6.75

$27.20

$13.60

FAMILY

$18.70

$9.35

MONTHLY

SEMI MONTHLY

INDIVIDUAL

$12.70

$6.35

SINGLE PARENT

$20.40

INSURED & SPOUSE FAMILY

LIFEWORKS YOUR BENEFITS PACKAGE

EAP (Employee Assistance Program)

About this Benefit An Employee Assistance Plan (EAP) is an employee benefit program offered to help employees manage personal and professional problems that might adversely impact their work performance, health, and well-being. Employee Assistance Plans generally include short-term counseling and referral services for employees and their household members. Your Employee Assistance Program benefit is provided to you by your employer.

DID YOU KNOW?

38%

of employees have missed life events because of bad worklife balance.

Employee Assistance Program With LifeWorks Integrated EAP and Work-life services, employees and their families will have access to confidential assistance and support on a wide range of issues in the areas of life, health, family, work and money. Topic

Description

Emotions and Stress

Relationship issues, depression and anxiety – even an online “calm room”

Parenting

Parenting skills, adoption, talking with your teenager, help in finding child care

Midlife and Retirement

Financial considerations, work and career in midlife, relationships with adult children, growing as a couple

Addictive Behaviors

Drug and alcohol abuse, eating disorders, gambling

Education

Applying to college, understanding financial aid and scholarships, advocating in the schools

Caring of Older Adults

Caregiver support, referrals to in-home and other services, and federally funded programs

Disability

Special needs programs, advocacy and specific disabilities information

Everyday Issues

Community resources and consumer information

Financial Issues

Credit management, budget analysis, 401(k) plan questions, basic estate planning, and questions about federal tax planning and preparation

Legal Issues

On-staff attorneys provide information and referrals for family matters, real estate, consumer credit and criminal matters. Also online program with forms, guides and simple wills.

Work

Special content for managers includes employee relations, interpersonal conflicts, performance issues, discrimination and workplace change. Also general support for co-worker relationships and stress.

Employees and their families have anytime access to LifeWorks Integrated EAP and Work-life services in a variety of ways that fit their preferences and unique needs.



Telephone   

All calls are answered live by Ceridian employees who are trained clinical consultants with master’s/doctorate degrees. LifeWorks is a 24/7 operation, so there are no changes in our  service delivery during non-business hours — your employees will not be directed to leave messages. A fully staffed bilingual clinical consultant team answers calls from service centers in St. Petersburg, FL; Minneapolis, MN;  Blue Bell, PA; Toronto, Winnipeg and Montreal, Canada.

Mobile 

An app for mobile devices makes the LifeWorks.com site accessible from anywhere at any time for iPhone, Android and Blackberry users.

In-Person 



Ceridian develops close relationships and carefully evaluates the national network of EAP providers who deliver in-person counseling to your employees. This cohesive team includes consultants that complete the initial screening assessment and connect participants to the EAP provider and EAP affiliate managers to ensure a high quality experience. Ceridian also employs a Clinical Supervisor within Provider Network Services for case consultation and assistance to the local EAP affiliate. Our North American network of 11,300 EAP providers includes all 50 U.S. states, Puerto Rico, the Virgin Islands, Mexico, Canada and U.S. Territories. Our entire network is composed of licensed mental health professionals. Minimum qualifications include a license to practice independently in the state in which services are provided along with five years post graduate experience and three years providing EAP services. Our counselors and providers possess strong EAP and worklife skills, and we aggressively recruit Certified Employee Assistance Professionals (CEAPs) whose focus is on helping employees quickly resolve issues that may interfere with their work.

Employees and their families will have access to face-to-face assessments and short- term, solution-focused counseling with EAP clinicians. 49

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 Century Gap Plan if you participate in the HSA. You may not participate in the HSA plan if you enroll in the Medical Flexible Spending Account plan or if you have access to FSA funds through a spouse, rollover or grace period. 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 your school district’s benefits website at: www.mybenefitshub.com/redoakisd

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) 51

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: 

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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).

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 will be forfeited unless used during the plan year or 75 day 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 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 Red Oak ISD Benefits Website: www.mybenefitshub.com/redoakisd 54

FSA (Flexible Spending Account) NBS Flexcard

When Will I Receive My Flex Card?

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

NBS Prepaid MasterCard® Debit Card

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

For a list of sample expenses, please refer to the Red Oak ISD benefit website: www.mybenefitshub.com/redoakisd

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

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

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

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

Medical FSA Annual Contribution Max: $2,550

Dependent Care Annual Max: $5,000

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

Detailed claim history and processing status Health Care and Dependent Care account balances Claim forms, Direct Deposit form, worksheets, etc. Online claim FAQs 55

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

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

Dependent Care Expense Account Example Expenses:    

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

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

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

How Do I File A Claim? In most situations, you will be able to swipe your card however, in the event you lose your card or are waiting to receive one, you can visit www.mybenefitshub.com/redoakisd 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 allows a 75 day grace period after the Plan year ends for you to submit qualified claims for any unused funds.

NBS

403(b) Plan

YOUR BENEFITS PACKAGE

About this Benefit A 403(b) plan is a U.S. tax-advantaged retirement savings plan available for public education organizations.

DID YOU KNOW?

38% of Americans donâ&#x20AC;&#x2122;t actively save for retirement at all.

403(b) Who is NBS?

How to enroll in the plan?

National Benefit Services (NBS) is an independent Third Party Administrator (TPA). We maintain an administrative team specializing in plans for government, education, not-forprofit, and church employers including 403(b), 457, and FICA Alternative plans. As an independent TPA, NBS does not sell investment products and works in the best interest of our client plan sponsor.

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What are the tax advantages of participating in the 403(b) plan?

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Your gross salary is reduced by the amount of pre-tax 403(b) contribution, thus lowering your current tax responsibilities and delaying them until retirement or such time that you decide to withdraw the contribution.

What are the tax disadvantages of participating in the 403(b) plan? 403(b) contributions distributed to you may be subject to IRS penalties if withdrawn prior to age 59 1/2. Additional IRS penalties may apply if you fail to begin distributions at your required beginning date.

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In order to participate in the 403(b) or 457 plan, you will first need to determine which company you would like to invest your contributions with. A list of approved vendors can be found by visiting the National Benefit Services website at www.NBSbenefits.com/403b. Please contact the vendor directly to obtain and submit all necessary paperwork to open the account. Secondly, you must decide how much you wish to contribute. Lastly, you must complete and submit to NBS the Salary Reduction Agreement (available for download at www.NBSbenefits.com/403b). The form will be sent to your employer via NBS, and your employer will then withhold the requested amount from your pay going forward.

Transaction Assistance (Distributions, Hardships, Loans, etc.) NBS provides Service Center Assistants who will be familiar with your plan and respond to inquiries from employees, advisors, and vendors weekdays from 8:00 AM to 5:00 PM Mountain Standard Time (excluding major holidays). Please don’t hesitate to let your Account Manager or the 403(b) service center know if you have any additional questions.

National Benefit Services, LLC 8523 S. Redwood Road, West Jordan, UT 84088 Phone: (800) 274-0503 option 5 Fax: (800) 597-8206