2018 Benefit Guide City of Alamo Heights by Higginbotham Public Sector

CITY OF ALAMO HEIGHTS

BENEFIT GUIDE EFFECTIVE: 01/01/2018 - 12/31/2018 WWW.MYBENEFITSHUB.COM/ CITYOFALAMOHEIGHTS

Table of Contents

Benefit Contact Information How to Enroll Annual Benefit Enrollment 1. Annual Enrollment 2. Eligibility Requirements 3. Helpful Definitions 4. Section 125 Cafeteria Plan Guidelines 5. Regulatory Notices 6. COBRA Rights Notice Blue Cross Blue Shield Medical Optum Bank Health Savings Account (HSA) MetLife Dental Davis Vision Dearborn National Short Term Disability Dearborn National Long Term Disability Dearborn National Employee Assistance Program APL Cancer The Hartford Accident The Hartford Critical Illness Dearborn National Life and AD&D 5Star Family Protection Plan Term Life Insurance with Quality of Life Rider

3 4-5 6-17 6 7 8 9 10-13 14-17 18-29 30-31 32-35 36-37 38-41 42-45 46-47 48-51 52-55 56-59 60-65 66-69

FLIP TO... PG. 4 HOW TO HOW TO ENROLL ENROLL

PG. 6 SUMMARY PAGES

PG. 12 YOUR BENEFITS

Benefit Contact Information CITY OF ALAMO HEIGHTS BENEFITS

VISION

ACCIDENT

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

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

The Hartford (877) 248-5077 www.thehartfordatwork.com

CITY OF ALAMO HEIGHTS BENEFITS

SHORT TERM DISABILITY

CRITICAL ILLNESS

Catto and Catto Deborah Lanier, Account Manager (210) 222-2161 x219

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

The Hartford (877) 248-5077 www.thehartfordatwork.com

MEDICAL

LONG TERM DISABILITY

LIFE AND AD&D

Blue Cross Blue Shield of Texas (800) 521-2227 www.bcbstx.com

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

HEALTH SAVINGS ACCOUNT

EMPLOYEE ASSISTANCE PROGRAM

FAMILY PROTECTION PLAN

Optum Bank (866) 234-8913 www.optumbank.com

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

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

DENTAL

CANCER

COBRA

MetLife (800) 942-0854 www.metlife.com/dental

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

Lori Harris, PHR Human Resources Manager (210) 882-1503 lharris@alamoheightstx.gov

MOBILE ENROLLMENT Enrollment made simple through your smartphone or tablet. Text “FBS CITYAH” to 313131 and get access to everything you need to complete your benefits enrollment: 

Benefit Information



Online Support



Interactive Tools



And more. PLAY VIDEO

Text “FBS CITYAH” to 313131 OR SCAN

How to Log In

1 BENEFIT INFO

INTERACTIVE TOOLS

2 3

www.mybenefitshub.com/ cityofalamoheights

CLICK LOGIN

ENTER USERNAME & PASSWORD All login credentials have been RESET to the default described below:

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

ONLIINE SUPPORT

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

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

Annual Benefit Enrollment

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Annual Enrollment

Q&A

During your annual enrollment period, you have the opportunity to review, change or continue benefit elections each year. Changes are not permitted during the plan year (outside of annual enrollment) unless a Section 125 qualifying event occurs.

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 1-800-583-6908 for assistance.



Changes, additions or drops may be made only during the annual enrollment period without a qualifying event.

 Employees must review their personal information and verify that dependents they wish to provide coverage for are included in the dependent profile. Additionally, you must notify your employer of any discrepancy in personal and/or benefit information.



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.

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

Where can I find forms? For benefit summaries and claim forms, go to your benefit website: www.mybenefitshub.com/cityofalamoheights. Click on the benefit plan you need information on (i.e., Dental) and you can find the forms you need under the Benefits and Forms section. How can I find a Network Provider? For benefit summaries and claim forms, go to your benefit website: www.mybenefitshub.com/cityofalamoheights. Click on the benefit plan you need information on (i.e., Dental) and you can find 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 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.

Don’t Forget!  Update your profile information: home address, phone numbers, email, beneficiaries  REQUIRED: Provide correct dependent social security numbers

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Employee Eligibility Requirements

Dependent Eligibility Requirements

Supplemental Benefits: Eligible employees must work 40 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 City of Alamo Heights

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

or as both employees and dependents.

work concurrent with the plan effective date. For example, if your 2018 benefits become effective on January 1, 2018, you must be actively-at-work on January 1, 2018 to be eligible for your new benefits.

PLAN

CARRIER

MAXIMUM AGE

Medical

BCBS

To age 26

Dental

MetLife

To age 26

Vision

Davis Vision

To age 26

Cancer

APL

To age 26

Individual Life

5Star

To age 23

Term Life and AD&D

Dearborn National

To age 26

Critical Illness

The Hartford

To age 26

Accident

The Hartford

To age 26

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

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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 1/1/2018 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 January 1st through December 31st

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

Calendar Year January 1st through December 31st

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

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

(including diagnostic and/or consultation services).

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

CHANGES IN STATUS (CIS): Marital Status

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

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

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.

Gain/Loss of Dependents' Eligibility Status

An event that causes an employee's dependent to satisfy or cease to satisfy coverage requirements under an employer's plan may include change in age, student, marital, employment or tax dependent status.

If a judgment, decree, or order from a divorce, annulment or change in legal custody requires that you provide accident or health coverage for your dependent child (including a foster child who is your dependent), you may change your election to provide coverage for the dependent child. If the order Judgment/Decree/Order requires that another individual (including your spouse and former spouse) covers the dependent child and provides coverage under that individual's plan, you may change your election to revoke coverage only for that dependent child and only if the other individual actually provides the coverage. Eligibility for Government Programs

Gain or loss of Medicare/Medicaid coverage may trigger a permitted election change.

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Regulatory Notices 1. 2. 3.

Initial Notice About Special Enrollment Rights Women’s Health & Cancer Rights Notice Medicaid and the Children’s Health Insurance Program (CHIP)

HIPAA Notice of Special Enrollment Rights If you decline enrollment for yourself or for an eligible dependent (including your spouse) while Medicaid coverage or coverage under a state children's health insurance program is in effect, you may be able to enroll yourself and your dependents in this plan if you or your dependents lose eligibility for that other coverage. However, you must request enrollment within 60 days after your or your dependents' coverage ends under Medicaid or a state children's health insurance program. If you or your dependents (including your spouse) become eligible for a state premium assistance subsidy from Medicaid or through a state children's health insurance program with respect to coverage under this plan, you may be able to enroll yourself and your dependents in this plan. However, you must request enrollment within 60 days after you or your dependents' determination of eligibility for such assistance. To request special enrollment or obtain more information, contact your company HR for more information and/or contact the carrier. Information can be obtained from your ID card. Women’s Health and Cancer Rights Act Notice If you have had or are going to have a mastectomy, you may be entitled to certain benefits under the Women’s Health and Cancer Rights Act of 1998 (WHCRA). For individuals receiving mastectomy-related benefits, coverage will be provided in a manner determined in consultation with the attending physician and the patient, for:  all stages of reconstruction of the breast on which the mastectomy was performed;  surgery and reconstruction of the other breast to produce a symmetrical appearance;  prostheses; and  treatment of physical complications of the mastectomy, including lymphedema.

These benefits will be provided subject to the same deductibles and coinsurance applicable to other medical and surgical benefits provided under this plan. If you would like more information on WHCRA benefits, call your Plan Administrator or HR Manager for the carrier phone number. Medicaid and the Children’s Health Insurance Program (CHIP) Offer Free Or Low-Cost Health Coverage To Children and Families If you are eligible for health coverage from your employer, but are unable to afford the premiums, some States have premium assistance programs that can help people who are eligible for employer-sponsored health coverage, but need assistance in paying their health premiums. If you or your dependents are already enrolled in Medicaid or CHIP and you live in a State listed below, you can contact your State Medicaid or CHIP office to find out if premium assistance is available. If you or your dependents are NOT currently enrolled in Medicaid or CHIP, and you think you or any of your dependents might be eligible for either of these programs, you can contact your State Medicaid or CHIP office or dial 1-877-KIDS NOW or www.insurekidsnow.gov to find out how to apply. If you qualify, you can ask the State if it has a program that might help you pay the premiums for an employer-sponsored plan. Once it is determined that you or your dependents are eligible for premium assistance under Medicaid or CHIP, your employer’s health plan is required to permit you and your dependents to enroll in the plan—as long as you and your dependents are eligible, but not already enrolled in the employer’s plan. This is called a “special enrollment” opportunity, and you must request coverage within 60 days of being determined eligible for premium assistance. TEXAS—Medicaid Website: https://www.gethipptexas.com/ Phone: 1-800-440-0493

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To see if any more States have added a premium assistance program since January 31, 2012, or for more information on special enrollment rights, you can contact either: U.S. Department of Labor Employee Benefits Security Administration www.dol.gov/ebsa 1-866-444-EBSA (3272) U.S. Department of Health and Human Services Centers for Medicare & Medicaid Services www.cms.hhs.gov 1-877-267-2323, Ext. 61565 City of Alamo Heights Notice of Privacy Practices THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. Our Companyâ&#x20AC;&#x2122;s Pledge to You This notice is intended to inform you of the privacy practices followed by City of Alamo Heights and the Planâ&#x20AC;&#x2122;s legal obligations regarding your protected health information under the Health Insurance Portability and Accountability Act of 1996 (HIPAA). The notice also explains the privacy rights you and your family members have as participants of the Plan. The Plan often needs access to your protected health information in order to provide payment for health services and perform plan administrative functions. We want to assure the plan participants covered under the Plan that we comply with federal privacy laws and respect your right to privacy. City of Alamo Heights requires all members of our workforce and third parties that are provided access to protected health information to comply with the privacy practices outlined below.

Protected Health Information Your protected health information is protected by the HIPAA Privacy Rule. Generally, protected health information is information that identifies an individual created or received by a health care provider, health plan or an employer on behalf of a group health plan that relates to physical or mental health conditions, provision of health care, or payment for health care, whether past, present or future. How We May Use Your Protected Health Information Under the HIPAA Privacy Rule, we may use or disclose your protected health information for certain purposes without your permission. This section describes the ways we can use and disclose your protected health information. Payment We use or disclose your protected health information without your written authorization in order to determine eligibility for benefits, seek reimbursement from a third party, or coordinate benefits with another health plan under which you are covered. For example, a health care provider that provided treatment to you will provide us with your health information. We use that information in order to determine whether those services are eligible for payment under our group health plan. Health Care Operations We use and disclose your protected health information in order to perform plan administration functions such as quality assurance activities, resolution of internal grievances, and evaluating plan performance. For example, we review claims experience in order to understand participant utilization and to make plan design changes that are intended to control health care costs. Treatment Although the law allows use and disclosure of your protected health information for purposes of treatment, as a health plan we generally do not need to disclose your information for treatment purposes. Your physician or health care provider is required to provide you with an explanation of how they use and share your health information for purposes of treatment, payment, and health care operations.

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As permitted or required by law We may also use or disclose your protected health information without your written authorization for other reasons as permitted by law. We are permitted by law to share information, subject to certain requirements, in order to communicate information on health-related benefits or services that may be of interest to you, respond to a court order, or provide information to further public health activities (e.g., preventing the spread of disease) without your written authorization We are also permitted to share protected health information during a corporate restructuring such as a merger, sale, or acquisition. We will also disclose health information about you when required by law, for example, in order to prevent serious harm to you or others. Pursuant to your Authorization When required by law, we will ask for your written authorization before using or disclosing your protected health information. If you choose to sign an authorization to disclose information, you can later revoke that authorization to prevent any future uses or disclosures. To Business Associates We may enter into contracts with entities known as Business Associates that provide services to or perform functions on behalf of the Plan. We may disclose protected health information to Business Associates once they have agreed in writing to safeguard the protected health information. For example, we may disclose your protected health information to a Business Associate to administer claims. Business Associates are also required by law to protect protected health information. To the Plan Sponsor We may disclose protected health information to certain employees of City of Alamo Heights for the purpose of administering the Plan. These employees will use or disclose the protected health information only as necessary to perform plan administration functions or as otherwise required by HIPAA, unless you have authorized additional disclosures. Your protected health information cannot be used for employment purposes without your specific authorization.

Your Right to Inspect and Copy In most cases, you have the right to inspect and copy the protected health information we maintain about you. If you request copies, we will charge you a reasonable fee to cover the costs of copying, mailing, or other expenses associated with your request. Your request to inspect or review your health information must be submitted in writing to the person listed below. In some circumstances, we may deny your request to inspect and copy your health information. To the extent your information is held in an electronic health record, you may be able to receive the information in an electronic format. Right to Amend If you believe that information within your records is incorrect or if important information is missing, you have the right to request that we correct the existing information or add the missing information. Your request to amend your health information must be submitted in writing to the person listed below. In some circumstances, we may deny your request to amend your health information. If we deny your request, you may file a statement of disagreement with us for inclusion in any future disclosures of the disputed information. Right to an Accounting of Disclosures You have the right to receive an accounting of certain disclosures of your protected health information. The accounting will not include disclosures that were made (1) for purposes of treatment, payment or health care operations; (2) to you; (3) pursuant to your authorization; (4) to your friends or family in your presence or because of an emergency; (5) for national security purposes; or (6) incidental to otherwise permissible disclosures. Your request to for an accounting must be submitted in writing to the person listed below. You may request an accounting of disclosures made within the last six years. You may request one accounting free of charge within a 12-month period. Right to Request Restrictions You have the right to request that we not use or disclose information for treatment, payment, or other administrative purposes except when specifically authorized by you, when

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required by law, or in emergency circumstances. You also have the right to request that we limit the protected health information that we disclose to someone involved in your care or the payment for your care, such as a family member or friend. Your request for restrictions must be submitted in writing to the person listed below. We will consider your request, but in most cases are not legally obligated to agree to those restrictions. However, we will comply with any restriction request if the disclosure is to a health plan for purposes of payment or health care operations (not for treatment) and the protected health information pertains solely to a health care item or service that has been paid for out of pocket and in full. Right to Request Confidential Communications You have the right to receive confidential communications containing your health information. Your request for restrictions must be submitted in writing to the person listed below. We are required to accommodate reasonable requests. For example, you may ask that we contact you at your place of employment or send communications regarding treatment to an alternate address. Right to be Notified of a Breach You have the right to be notified in the event that we (or one of our Business Associates) discover a breach of your unsecured protected health information. Notice of any such breach will be made in accordance with federal requirements. Right to Receive a Paper Copy of this Notice If you have agreed to accept this notice electronically, you also have a right to obtain a paper copy of this notice from us upon request. To obtain a paper copy of this notice, please contact Human Resources. Our Legal Responsibilities We are required by law to protect the privacy of your protected health information, provide you with certain rights with respect to your protected health information, provide you with this notice about our privacy practices, and follow the information practices that are described in this notice.

We may change our policies at any time. In the event that we make a significant change in our policies, we will provide you with a revised copy of this notice. You can also request a copy of our notice at any time. For more information about our privacy practices contact Human Resources. Complaints If you are concerned that we have violated your privacy rights, or you disagree with a decision we made about access to your records, you may contact the person listed above. You also may send a written complaint to the U.S. Department of Health and Human Services â&#x20AC;&#x201D; Office of Civil Rights. Human Resources can provide you with the appropriate address upon request or you may visit www.hhs.gov/ocr for further information. You will not be penalized or retaliated against for filing a complaint with the Office of Civil Rights or with us.

COBRA Rights Notice General Notice of COBRA Continuation Coverage Rights ** Continuation Coverage Rights Under COBRA** Dear Qualified Beneficiary: CONTINUATION COVERAGE RIGHTS UNDER COBRA Introduction You and your covered dependents, if any, are receiving this notice because you have recently become covered under TIPS Region VIII Cooperative (the Plan). This notice contains important information about your right to COBRA continuation coverage, which is a temporary extension of coverage under the Plan. This notice generally explains COBRA continuation coverage, when it may become available to you and your family, and what you need to do to protect the right to receive it. The right to COBRA continuation coverage was created by a federal law, Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA). COBRA continuation coverage can become available to you and to other members of your family who are covered under the Plan when you would otherwise lose your group health coverage. This notice generally explains COBRA continuation coverage, when it may become available to you and your family, and what you need to do to protect the right to receive it. This notice gives only a summary of your COBRA continuation coverage rights. For more information about your rights and obligations under the Plan and under federal law, you should either review the Plan's Summary Plan Description or get a copy of the Plan Document from the Plan Administrator. The Plan Administrator is: City of Alamo Heights 6116 Broadway San Antonio, TX 78209 What is COBRA Continuation Coverage? COBRA continuation coverage is a continuation of Plan coverage when coverage would otherwise end because of a life event known as a “qualifying event.” Specific qualifying

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events are listed later in the notice. COBRA continuation coverage must be offered to each person who is a “qualified beneficiary.” A qualified beneficiary is someone who will lose coverage under the Plan because of a qualifying event. Depending on the type of qualifying event, employees, spouses of employees, and dependent children of employees may be qualified beneficiaries. Under the Plan, qualified beneficiaries who elect COBRA continuation coverage must pay for COBRA continuation coverage. If you are an employee, you will become a qualified beneficiary if you will lose your coverage under the Plan because either one of the following qualifying events happen: 1. 2.

Your hours of employment are reduced, or Your employment ends for any reason other than your gross misconduct.

If you are the spouse of an employee, you will become a qualified beneficiary if you will lose your coverage under the Plan because any of the following qualifying events happens: 1. 2. 3. 4. 5.

Your spouse dies; Your spouse's hours of employment are reduced; Your spouse's employment ends for any reason other than his or her gross misconduct; Your spouse becomes enrolled in Medicare (Part A, Part B, or both); or You become divorced or legally separated from your spouse.

Your dependent children will become qualified beneficiaries if they will lose coverage under the Plan because any of the following qualifying events happens: 1. 2.   5. 6.

The parent-employee dies The parent-employee's hours of employment are reduced; The parent-employee's employment ends for any reason other than his or her gross misconduct; The parent-employee becomes enrolled in Medicare (Part A, Part B, or both); The parents become divorced or legally separated; or The child stops being eligible for coverage under the plan as a “dependent child.”

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When is COBRA Coverage Available? The plan will offer COBRA continuation to qualified beneficiaries only after the Plan Administrator has been notified that a qualifying event has occurred. When the qualifying event is the end of employment or reduction of hours of employment, death of the employee, or enrollment of the employee in Medicare (Part A, Part B, or both), the employer must notify the Plan Administrator of the qualifying event. In addition, if the Plan provides retiree health coverage, then commencement of a proceeding in a bankruptcy with respect to the employer is also a qualifying event where the employer must notify the Plan Administrator of the qualifying event. You Must Give Notice of Some Qualifying Events For the other qualifying events (divorce or legal separation of the employee and spouse or a dependent child's losing eligibility for coverage as a dependent child), you must notify the Plan Administrator. The Plan requires you to notify the Plan Administrator within 60 days after the qualifying event occurs. You must send this notice to: The Plan Administrator is: City of Alamo Heights 6116 Broadway San Antonio, TX 78209 How is COBRA Coverage Provided? Once the Plan Administrator receives notice that a qualifying event has occurred, COBRA continuation coverage will be offered to each of the qualified beneficiaries. For each qualified beneficiary who elects COBRA continuation coverage, COBRA continuation coverage will begin either (1) on the date of the qualifying event or (2) on the date that Plan coverage would otherwise have been lost, depending on the nature of the Plan. COBRA continuation coverage is a temporary continuation of coverage. When the qualifying event is the death of the employee, your divorce or legal separation, or a dependent child losing eligibility as a dependent child, COBRA continuation coverage lasts for up to 36 months.

When the qualifying event is the end of employment or reduction of the employee's hours of employment, and the employee became entitled to Medicare benefits less than 18 months before the qualifying event, COBRA continuation coverage for qualified beneficiaries other than the employee lasts until 36 months after the date of Medicare entitlement. For example, if a covered employee becomes entitled to Medicare 8 months before the date on which his employment terminates, COBRA continuation coverage for his spouse and children can last up to 36 months after the date of Medicare entitlement, which is equal to 28 months after the date of the qualifying event (36 months minus 8 months). Otherwise, when the qualifying event is the end of employment or reduction of the employee's hours of employment, COBRA continuation coverage generally lasts for only up to a total of 18 months. There are two ways in which this 18-month period of COBRA continuation coverage can be extended. Disability extension of 18-month period of continuation coverage If you or anyone in your family covered under the Plan is determined by the Social Security Administration to be disabled and you notify the Plan Administrator in a timely fashion, you and your entire family may be entitled to receive up to an additional 11 months of COBRA continuation coverage, for a total maximum of 29 months. The disability would have to have started at some time before the 60th day of COBRA continuation coverage and must last at least until the end of the 18-month period of continuation coverage. This notice should be sent to: The Plan Administrator is: City of Alamo Heights 6116 Broadway San Antonio, TX 78209 Second qualifying event extension of 18-month period of continuation coverage If your family experiences another qualifying event while receiving COBRA continuation coverage, the spouse and dependent children in your family can get additional months of COBRA continuation coverage, up to a maximum of 36 months. This extension is available to the spouse and dependent children if the former employee dies, or gets divorced or legally separated. The extension is also available to a dependent child when that child stops being eligible under the Plan as a dependent child. In all of these cases, you must make

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sure that the Plan Administrator is notified of the second qualifying event within 60 days of the second qualifying event. This notice must be sent to:

Health Plan under the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA). These provisions are as follows:

The Plan Administrator is: City of Alamo Heights 6116 Broadway San Antonio, TX 78209

Trade Act of 2002 If you qualify for Trade Adjustment Assistance (TAA) as defined by the Trade Act of 2002, then you will be provided with an additional 60-day enrollment period, with continuation coverage beginning on the date of such TAA approval. If You Have Questions If you have questions about your COBRA continuation coverage, you should contact National Benefit Services, LLC at 800-274-0503, or you may contact the nearest Regional or District Office of the U.S. Department of Labor's Employee Benefits Security Administration (EBSA). Addresses and phone numbers of Regional and District EBSA Offices are available through EBSA's website at www.dol.gov/ebsa. Keep Your Plan Informed of Address Changes In order to protect your family's rights, you should keep the Plan Administrator informed of any changes in the addresses of family members. You should also keep a copy, for your records, of any notices you send to the Plan Administrator. Plan Contact Information The Plan Administrator is: Lori Harris City of Alamo Heights 6116 Broadway San Antonio, TX 78209 Dear Qualified Beneficiary and qualified dependents, if any: The Health Insurance Portability and Accountability Act of 1996 (HIPAA) includes some provisions that may affect decisions you make about your participation in the Group

3. 4.

Under COBRA, if the qualifying event is a termination or reduction in hours of employment, affected qualified beneficiaries are entitled to continue coverage for up to 18 months after the qualifying event, subject to various requirements. Before HIPAA, this 18-month period could be extended for up to 11 months (for a total COBRA coverage period of up to 29 months from the initial qualifying event) if an individual was determined by the Social Security Administration, under the Social Security Act, to have been disabled at the time of the qualifying event and if the plan administrator was notified of that disability determination within 60 days of the determination and before the end of the original 18-month period. Under HIPAA, if a qualified beneficiary is determined by the Social Security Administration to be disabled under the Social Security Act at any time during the first 60 days of COBRA coverage, the 11-month extension is available to all individuals who are qualified beneficiaries due to the termination or reduction in hours of employment. The disabled individual can be a covered employee or any other qualified beneficiary. However, to be eligible for the 11-month extension, affected individuals must still comply with the notification requirements in a timely fashion. A child that is born to or placed for adoption with the covered employee during a period of COBRA coverage will be eligible to become a qualified beneficiary. In accordance with the terms of the employer's group health plan(s) and the requirements of Federal law, these qualified beneficiaries can be added to COBRA coverage upon proper notification to the Plan Administrator of the birth or adoption. HIPAA restricts the extent to which group health plans may impose preexisting condition limitations. If you were covered by a group health plan(s) prior to your employment with us, your previous employer their insurance carrier should have provided you with a Certificate of Creditable Coverage, a form required by the HIPAA law that describes the health coverage you and your dependents, if any, have or had, and the dates you were

SUMMARY PAGES

covered. IF YOU HAVE NOT RECEIVED A CERTIFICATE OF CREDITABLE COVERAGE AND ARE ENTITLED TO ONE, PLEASE CONTACT YOUR FORMER EMPLOYER. Once you deliver the Certificate of Creditable Coverage to us, you are exempt from any pre-existing condition exclusions in our group health plan(s), provided you had twelve months of creditable coverage (eighteen months if a late enrollment) and have not had more than a sixty three day gap in coverage. Under COBRA, your right to continuation coverage terminates if you become covered by another employer's group health plan that does not limit or exclude coverage for your pre-existing conditions. If you become covered by another group health plan and that plan contains a pre-existing condition limitation that affects you, your COBRA continuation coverage cannot be immediately terminated. However, if the other plan's pre-existing condition rule does not apply to you by reason of HIPAA's restrictions on pre-existing condition clauses, the employer's group health plan(s) may terminate your COBRA coverage. Sincerely, City of Alamo Heights 6116 Broadway San Antonio, TX 78209

BLUE CROSS BLUE SHEILD

Medical

YOUR BENEFITS PACKAGE

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

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

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

Medical - PPO Blue Choice PPO MM09 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage Period: 01/01/2018—12/31/2018 Coverage for: Individual/Family | Plan Type: PPO This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.bcbstx.com/member/policy-forms/ or by calling 1-800-521-2227. Questions

Answers

Why this Matters:

What is the overall deductible?

For Network: $1,000 Individual/$3,000 Family For Out-of-Network: $2,000 Individual/$6,000 Family Doesn't apply to In-Network preventive care, InNetwork office visits, or prescription drugs. Copays and prescription drug costs don't count toward the overall deductible.

You must pay all the costs up to the deductible amount before this plan begins to pay for covered services you use. Check your policy or plan document to see when the deductible starts over (usually, but not always, January 1st). See the chart starting on page 3 for how much you pay for covered services after you meet the deductible.

Are there other deductibles for specific services?

No.

You don’t have to meet deductibles for specific services, but see the chart starting on page 3 for other costs for services this plan covers.

Is there an out-of-pocket limit on my expenses?

Yes. For Network: $4,000 Individual/$10,200 Family For Out-of-Network: $8,000 Individual/$24,000 Family Rx Out-of-Pocket expense limit: $1,000 Individual/$3,000 Family

The out-of-pocket limit is the most you could pay during a coverage period (usually one year) for your share of the cost of covered services. This limit helps you plan for health care expenses.

What is not included in the out-of-pocket limit?

Premiums, balance-billed charges, and health care this plan doesn't cover.

Even though you pay these expenses, they don’t count toward the out-of-pocket limit.

Does this plan use a network of providers?

Yes. See www.bcbstx.com or call 1-800-810-2583 for a list of Network Providers.

If you use an in-network doctor or other health care provider, this plan will pay some or all of the costs of covered services. Be aware, your in-network doctor or hospital may use an out-of-network provider for some services. Plans use the term in-network, preferred, or participating for providers in their network. See the chart starting on page 3 for how this plan pays different kinds of providers.

Do I need a referral to see a specialist?

No. You don't need a referral to see a specialist.

You can see the specialist you choose without permission from this plan.

Are there services this plan doesn't cover?

Yes.

Some of the services this plan doesn’t cover are listed on page 5. See your policy or plan document for additional information about excluded services.

Questions: Call 1-800-521-2227 or visit us at www.bcbstx.com/coverage If you aren’t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary at www.dol.gov/ebsa/pdf/SBCUniformGlossary.pdf or call 1-855-756-4448 to request a copy.

Medical - PPO    

Copayments are fixed dollar amounts (for example, $15) you pay for covered health care, usually when you receive the service. Coinsurance is your share of the costs of a covered service, calculated as a percent of the allowed amount for the service. For example, if the health plan's allowed amount for an overnight hospital stay is $1,000, your coinsurance payment of 20% would be $200. This may change if you haven't met your deductible. The amount the plan pays for covered services is based on the allowed amount. If an out-of-network provider charges more than the allowed amount, you may have to pay the difference. For example, if an out-of-network hospital charges $1,500 for an overnight stay and the allowed amount is $1,000, you may have to pay the $500 difference. (This is called balance billing.) The plan may encourage you to use Network providers by charging you lower deductibles, copayments, and coinsurance amounts.

Common Medical Event

If you visit a health care provider's office or clinic

If you have a test

If you need drugs to treat your illness or condition More information about prescription drug coverage is available at www.bcbstx.com/member/ rx_drugs.html

If you have outpatient surgery

Services You May Need

Your cost if Your cost if you use an you use a Out-of-Network Network Provider Provider

Primary care visit to treat an injury or illness

$25 copay/visit

30% coinsurance

Specialist visit

$25 copay/visit

30% coinsurance

Other practitioner office visit

$25 copay/visit

30% coinsurance

Preventive care/ screening/ immunization

No Charge

30% coinsurance

Diagnostic test (x-ray, blood work)

No Charge

30% coinsurance

Limitations & Exceptions

None

There is No Charge for Out-ofNetwork immunizations from birth through the day of the 6th birthday.

None

Imaging (CT/PET scans, MRIs)

20% coinsurance

40% coinsurance

Generic drugs

$20 copay/ prescription

20% coinsurance plus copay

Preferred brand drugs

$35 copay/ prescription

20% coinsurance plus copay

Non-preferred brand drugs

$50 copay/ prescription

20% coinsurance plus copay

Specialty drugs

$20/$35/$50 copay/prescription

20% coinsurance plus copay

Facility fee (e.g., ambulatory surgery center)

20% coinsurance

40% coinsurance

Physician/ surgeon fees

20% coinsurance

One copay per 30-day supply - up to a 90-day supply for generic and brand drugs, up to a 30-day supply for specialty drugs. Payment of the difference between the cost of a brand name drug and a generic may also be required if a generic drug is available. Certain women's preventive services will be covered with no cost to the member. Rx Outof-Pocket expense limit: $1,000 Individual/$3,000 Family.

None 40% coinsurance

Medical - PPO

Common Medical Event

If you need immediate medical attention

Services You May Need

Your cost if Your cost if you use an you use a Out-of-Network Network Provider Provider

Emergency room services

20% coinsurance after $100 copay/visit

Emergency medical transportation

20% coinsurance

Limitations & Exceptions

Copay amount waived if admitted.

None Urgent care

$50 copay/visit

30% coinsurance

Facility fee (e.g., hospital room)

20% coinsurance

40% coinsurance

Preauthorization required Outof-Network; failure to preauthorize at least two business days prior to admission will result in $250 reduction in benefits.

Physician/ surgeon fee

20% coinsurance

40% coinsurance

None

Mental/behavioral health outpatient services

$25 copay for office visits or 20% coinsurance for other outpatient services

40% coinsurance

Mental/behavioral health inpatient services

20% coinsurance

40% coinsurance

Substance use disorder outpatient services

$25 copay for office visits or 20% coinsurance for other outpatient services

40% coinsurance

Substance use disorder inpatient services

20% coinsurance

40% coinsurance

Prenatal and postnatal care

$25 copay/visit

30% coinsurance

Delivery and all inpatient services

20% coinsurance

40% coinsurance

If you have a hospital stay

If you have mental health, behavioral health, or substance abuse needs

Outpatient: Preauthorization required for psychological testing, neuropsychological testing, electroconvulsive therapy, repetitive transcranial magnetic stimulation, and intensive outpatient treatment; failure to preauthorize at least two business days prior to service will result in 50% reduction in benefits (not to exceed $500). Inpatient: Preauthorization required Outof-Network; failure to preauthorize at least two business days prior to admission will result in $250 reduction in benefits.

Copay applies to first prenatal visit (per pregnancy).

If you are pregnant None

Medical - PPO

Common Medical Event

If you need help recovering or have other special health needs

If your child needs dental or eye care

Services You May Need

Your cost if you use a Network Provider

Your cost if you use an Out-of-Network Provider

Limitations & Exceptions

60 visit maximum per benefit period. Preauthorization required Out-of Network; failure to preauthorize at least two business days prior to service will result in 50% reduction in benefits (not to exceed $500).

Home health care

No Charge

30% coinsurance

Rehabilitation services

20% coinsurance

40% coinsurance

Habilitation services

20% coinsurance

40% coinsurance

Limited to combined 35 visits per year, including Chiropractic. 25 day maximum per benefit period. Preauthorization required Out-ofNetwork; failure to preauthorize at least two business days prior to admission will result in $250 reduction in benefits.

Skilled nursing care

No Charge

30% coinsurance

Durable medical equipment

20% coinsurance

40% coinsurance

None Preauthorization required Out-ofNetwork; failure to preauthorize at least two business days prior to admission will result in $250 reduction in benefits.

Hospice service

No Charge

30% coinsurance

Eye exam

Not Covered

Glasses

Not Covered

Dental check-up

Not Covered

None

Excluded Services & Other Covered Services Services Your Plan Does NOT Cover (This isn't a complete list. Check your policy or plan document for other excluded services.)  Abortions  Acupuncture  Bariatric surgery  Cosmetic surgery  Dental care (Adult)  Long term care  Private duty nursing  Weight loss programs

Other Covered Services (This isn't a complete list. Check your policy or plan document for other covered services and your costs for these services.)  Chiropractic care  Hearing aids  Infertility treatment (Invitro and artificial insemination are not covered unless shown in your plan document)  Non-emergency care when traveling outside the U.S.  Routine eye care (Adult)  Routine foot care (Only covered in connection with diabetes, circulatory disorders of the lower extremities, peripheral vascular disease, peripheral neuropathy, or chronic arterial or venous insufficiency)

Medical - PPO Your Rights to Continue Coverage: If you lose coverage under the plan, then, depending upon the circumstances, Federal and State laws may provide protections that allow you to keep health coverage. Any such rights may be limited in duration and will require you to pay a premium, which may be significantly higher than the premium you pay while covered under the plan. Other limitations on your rights to continue coverage may also apply. For more information on your rights to continue coverage, contact the plan at 1-800-521-2227. You may also contact your state insurance department, the U.S. Department of Labor, Employee Benefits Security Administration at 1-866-444-3272 or www.dol.gov/ebsa or the U.S. Department of Health and Human Services at 1-877-267-2323 x61565 or www.cciio.cms.gov.

Your Grievance and Appeals Rights: If you have a complaint or are dissatisfied with a denial of coverage for claims under your plan, you may be able to appeal or file a grievance. For questions about your rights, this notice, or assistance, you can contact Blue Cross and Blue Shield of Texas at 1-800-521-2227 or visit www.bcbstx.com or contact U.S. Department of Labor's Employee Benefits Security Administration at 1-866-444-EBSA (3272) or visit www.dol.gov/ebsa/ healthreform.

MM09 Plan Rates

CVS Pharmacy is no longer in the pharmacy network effective 1-1-17. Please refer to the on-line network provider listing to find your closest participating pharmacy.

Does this Coverage Provide Minimum Essential Coverage? The Affordable Care Act requires most people to have health care coverage that qualifies as “minimum essential coverage.” This plan or policy does provide minimum essential coverage.

Does this Coverage Meet the Minimum Value Standard? The Affordable Care Act establishes a minimum value standard of benefits of a health plan. The minimum value standard is 60% (actuarial value). This health coverage does meet the minimum value standard for the benefits it provides.

Questions Call 1-800-521-2227 or visit us at www.bcbstx.com/coverage. If you aren’t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary at www.dol.gov/ebsa/pdf/SBCUniformGlossary.pdf or call 1-855-756-4448 to request a copy.

Employee

Employee & Spouse

Employee & Child(ren)

Employee & Family

$308.62

$1,108.74

$735.46

$1,456.72

Medical - HSA Blue Choice BlueEdge HSA MTBCP608 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage Period: 01/01/2018—12/31/2018 Coverage for: Individual/Family | Plan Type: HSA This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.bcbstx.com/member/policy-forms/ or by calling 1-800-521-2227. Questions

Answers

Why this Matters:

What is the overall deductible?

For Network: $5,000 Individual/$10,000 Family For Out-of-Network: $10,000 Individual/$20,000 Family Doesn't apply to In-Network preventive care.

Are there other deductibles for specific services?

No.

You don’t have to meet deductibles for specific services, but see the chart starting on page 3 for other costs for services this plan covers.

Is there an out-of-pocket limit on my expenses?

Yes. For Network: $5,000 Individual/$10,000 Family For Out-of-Network: $20,000 Individual/$40,000 Family

The out-of-pocket limit is the most you could pay during a coverage period (usually one year) for your share of the cost of covered services. This limit helps you plan for health care expenses.

What is not included in the out-of-pocket limit?

Preauthorization penalties, premiums, balancebilled charges, and health care this plan doesn't cover.

Even though you pay these expenses, they don’t count toward the out-of-pocket limit.

Does this plan use a network of providers?

Yes. See www.bcbstx.com or call 1-800-810-2583 for a list of Network Providers.

Do I need a referral to see a specialist?

No. You don't need a referral to see a specialist.

You can see the specialist you choose without permission from this plan.

Are there services this plan doesn't cover?

Yes.

Some of the services this plan doesn’t cover are listed on page 5. See your policy or plan document for additional information about excluded services.

Medical - HSA    

Common Medical Event

If you visit a health care provider's office or clinic

If you have a test

If you need drugs to treat your illness or condition More information about prescription drug coverage is available at www.bcbstx.com/member/ rx_drugs.html

If you have outpatient surgery

Services You May Need

Your cost if Your cost if you use an you use a Out-of-Network Network Provider Provider

Primary care visit to treat an injury or illness

No charge after deductible

30% coinsurance after deductible

Specialist visit

No charge after deductible

30% coinsurance after deductible

Other practitioner office visit

No charge after deductible

30% coinsurance after deductible

Preventive care/ screening/ immunization

No charge after deductible

30% coinsurance after deductible

Diagnostic test (x-ray, blood work)

No charge after deductible

30% coinsurance after deductible

Limitations & Exceptions

None

There is No Charge for Out-ofNetwork immunizations from birth through the day of the 6th birthday.

None

Imaging (CT/PET scans, MRIs)

No charge after deductible

30% coinsurance after deductible

Generic drugs

No charge after deductible

Preferred brand drugs

No charge after deductible

Non-preferred brand drugs

No charge after deductible

Specialty drugs

No charge after deductible

Facility fee (e.g., ambulatory surgery center)

No charge after deductible

30% coinsurance after deductible

None Physician/ surgeon fees

No charge after deductible

30% coinsurance after deductible

Medical - HSA Common Medical Event

If you need immediate medical attention

Services You May Need

Your cost if Your cost if you use an you use a Out-of-Network Network Provider Provider

Emergency room services

No charge after deductible

Emergency medical transportation

No charge after deductible

Urgent care

No charge after deductible

30% coinsurance after deductible

None

Facility fee (e.g., hospital room)

No charge after deductible

30% coinsurance after deductible

Preauthorization required Outof-Network; failure to preauthorize at least two business days prior to admission will result in $250 reduction in benefits.

Physician/ surgeon fee

No charge after deductible

30% coinsurance after deductible

None

Mental/behavioral health outpatient services

No charge after deductible

30% coinsurance after deductible

Mental/behavioral health inpatient services

No charge after deductible

30% coinsurance after deductible

Substance use disorder outpatient services

No charge after deductible

30% coinsurance after deductible

Substance use disorder inpatient services

No charge after deductible

30% coinsurance after deductible

Prenatal and postnatal care

No charge after deductible

30% coinsurance after deductible

If you have a hospital stay

If you have mental health, behavioral health, or substance abuse needs

Limitations & Exceptions

If you are pregnant

None Delivery and all inpatient services

No charge after deductible

30% coinsurance after deductible

Medical - HSA

Common Medical Event

If you need help recovering or have other special health needs

If your child needs dental or eye care

Services You May Need

Your cost if you use a Network Provider

Your cost if you use an Out-of-Network Provider

Limitations & Exceptions

Home health care

No charge after deductible

30% coinsurance after deductible

Rehabilitation services

No charge after deductible

30% coinsurance after deductible

Habilitation services

No charge after deductible

30% coinsurance after deductible

Skilled nursing care

No charge after deductible

30% coinsurance after deductible

Durable medical equipment

No charge after deductible

30% coinsurance after deductible

None Preauthorization required Out-ofNetwork; failure to preauthorize at least two business days prior to admission will result in $250 reduction in benefits.

Hospice service

No charge after deductible

30% coinsurance after deductible

Eye exam

Not Covered

Glasses

Not Covered

Dental check-up

Not Covered

None

Medical - HSA Your Rights to Continue Coverage: If you lose coverage under the plan, then, depending upon the circumstances, Federal and State laws may provide protections that allow you to keep health coverage. Any such rights may be limited in duration and will require you to pay a premium, which may be significantly higher than the premium you pay while covered under the plan. Other limitations on your rights to continue coverage may also apply. For more information on your rights to continue coverage, contact the plan at 1-800-521-2227. You may also contact your state insurance department, the U.S. Department of Labor, Employee Benefits Security Administration at 1-866-444-3272 or www.dol.gov/ebsa or the U.S. Department of Health and Human Services at 1-877-267-2323 x61565 or www.cciio.cms.gov.

MTBCP608 Plan Rates

CVS Pharmacy is no longer in the pharmacy network effective 1-1-17. Please refer to the on-line network provider listing to find your closest participating pharmacy.

Employee

Employee & Spouse

Employee & Child(ren)

Employee & Family

$0.00

$444.52

$237.13

$637.83

Medical - HSA

OPTUM BANK

HSA (Health Savings Account)

YOUR BENEFITS PACKAGE

PLAY VIDEO

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.

The interest earned in an HSA is tax free.

Money withdrawn for medical spending never falls under taxable income.

HSA (Health Savings Account) You can use your Health Savings Account (HSA) to pay for a wide range of IRS-qualified medical expenses for yourself, your spouse or tax dependents. An IRS-qualified medical expense is defined as an expense that pays for healthcare services, equipment, or medications. Funds used to pay for IRS-qualified medical expenses are always tax-free.

What is an HSA? 

 



A tax-advantaged savings account that you use to pay for eligible medical expenses as well as deductible, co-insurance, prescriptions, vision and dental care. Allows you to save while reducing your taxable income. Unused funds that will roll over year to year. There’s no “use it or lose it” penalty. Potential to build more savings through investing. If you maintain a minimum balance of $1,000, your additional funds may be invested in mutual funds yielding tax‐free earnings. A way to accumulate additional retirement savings. After age 65, funds can be withdrawn for any purpose without penalty.

Are there any monthly fees? Monthly maintenance fee of $1.00—Waived if average balance is $500 or more*. Includes use of:  Health Savings Account Debit MasterCard® - to pay charges directly  Online Bill Payment and Mobile Access  Receipt Vault—allows you to upload and store images of receipts online ATM and Outbound Transfer Fee—$2.50 per ATM transaction. In addition to our fee, the bank/ATM you use to withdraw funds may charge you their own fee. $20.00 per Outbound Transfer or Rollover to another HSA Custodian. *The average balance to waive the monthly maintenance fee does not include investment funds.

A Health Savings Account (HSA): 

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

2018 Annual HSA Contribution Limits Individual: $3,450 Family: $6,900 Catch-Up Contributions: Account holders over the age of 55 who have not yet enrolled in Medicare are eligible to make an additional $1,000 “catch‐up” contribution to their HSA. City of Alamo Heights contributes $1,250 annually to your HSA, if you elect the high deductible plan. The maximum annual individual contribution that you can make is $2,200 and the maximum annual family contribution that you can make is $5,650. If you are over 55, you are entitled to make an additional $1,000 catch-up contribution. Will my HSA Funds be up fronted to me? Like a savings account, you can only withdrawal what you’ve contributed to the account. Funds are not up fronted. The city's contribution is deposited up-front, however, employee contributions will not be available until they are contributed to the account.



Works with a high deductible health plan (HDHP) and lets you set aside a portion of your paycheck ‐ before taxes– into an account to help you pay for medical expenses before you reach your deductible or that you aren’t covered by your plan. It can also help you pay for future medical expenses. Grows with you. If you maintain a balance of $1,000, your additional funds may be invested in mutual funds yielding tax‐free earnings. An additional investment fee of $3.00/month is charged on balances less than $2,000. Helps you plan for the future. Until you turn 65, withdrawals used for eligible expenses are tax free. After you turn 65, or if you become disabled, your HSA account becomes similar to a regular IRA. Withdrawals you use for non-eligible expenses will be taxed at your regular income tax rate but won’t incur additional penalties.

For a list of sample expenses, please refer to www.optumbank.com

Optum Bank Contact Information Phone‐866‐234‐8913 www.optumbank.com

METLIFE

Dental

YOUR BENEFITS PACKAGE

PLAY VIDEO

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.

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 In-Network1 % of PDP Fee2

Out-of-Network1 % of R&C Fee4

Type A - Preventive Type B - Basic Restorative Type C - Major Restorative Type D - Orthodontia

100% 80% 50% 50%

Individual Family

$50 $150

$5000

Coverage Type:

Deductible3

Annual Maximum Benefit: Per Individual

Child to age 19

Orthodontia Lifetime Maximum Ortho applies to Child Only

$1000 per Person

"In-Network Benefits" refers to benefits provided under this plan for covered dental services that are provided by a participating dentist. "Out-of-Network Benefits" refers to benefits provided under this plan for covered dental services that are not provided by a participating dentist. 2 Negotiated fee refers to the fees that participating dentists have agreed to accept as payment in full, subject to any copayments, deductibles, cost sharing and benefits maximums. Negotiated fees are subject to change. 3 Applies to Type B and C services only. 4 Out-of-network benefits are payable for services rendered by a dentist who is not a participating provider. The Reasonable and Customary charge is based on the lowest of:  the dentist’s actual charge (the 'Actual Charge'),  the dentist’s usual charge for the same or similar services (the 'Usual Charge') or  the usual charge of most dentists in the same geographic area for the same or similar services as determined by MetLife (the 'Customary Charge'). For your plan, the Customary Charge is based on the 90th percentile. Services must be necessary in terms of generally accepted dental standards.

TYPE A—Preventive

How Many/How Often:

Oral Examinations Full Mouth X-rays Bitewing X-rays (Adult/Child) Prophylaxis - Cleanings Topical Fluoride Applications

1 in 6 months 1 in 60 months 1 in 12 months - Child to age 14 1 in 6 months 1 in 12 months - Children to age 14

TYPE B—Basic Restorative

How Many/How Often:

Sealants Amalgam and Composite Fillings Endodontics Root Canal Periodontal Surgery Periodontal Scaling & Root Planing Periodontal Maintenance Oral Surgery (Simple Extractions) Oral Surgery (Surgical Extractions) Other Oral Surgery Emergency Palliative Treatment

1 in a lifetime - Children to age 14 1 in 24 months. All teeth 1 per tooth in 24 months 1 in 60 months per quadrant 1 in 60 month per quadrant 4 in 1 year, includes 2 cleanings

TYPE C—Major Restorative

How Many/How Often:

Space Maintainers Crowns/Inlays/Onlays Prefabricated Crowns Repairs Bridges Dentures General Anesthesia Consultations Implant Services

1 per lifetime per tooth area - Children up to age 14 1 per tooth in 10 years 1 per tooth in 10 years 1 in 12 months 1 in 10 years 1 in 10 years 1 in 12 months 1 service per tooth in 10 years - 1 repair per 10 years

TYPE D—Orthodontia

 Dependent children up to age 19. Age limitations may vary by state. Please see your Plan description for complete details. In the event of a conflict with this summary, the terms of the certificate will govern.

 All dental procedures performed in connection with orthodontic treatment are payable as Orthodontia.  Benefits for the initial placement will not exceed 20% of the Lifetime Maximum Benefit Amount for Orthodontia. Periodic follow-up visits will be payable on 

a monthly basis during the scheduled course of the orthodontic treatment. Allowable expenses for the initial placement, periodic follow-up visits and procedures performed in connection with the orthodontic treatment, are all subject to the Orthodontia coinsurance level and Lifetime Maximum Benefit Amount as defined in the Plan Summary. Orthodontic benefits end at cancellation of coverage

Monthly Rate

Employee

Employee & Spouse

Employee & Child(ren)

Employee & Family

$0.00

$27.27

$33.62

$63.56

*Alternate Benefits: Your dental plan provides that if there are two or more professionally acceptable dental treatment alternatives for a dental condition, your plan bases reimbursement, and the associated procedure charge, on the least costly treatment alternative. If you receive a more costly treatment alternative, your dentist may charge you or your dependent for the difference between the cost of the service that was performed and the least costly treatment alternative. The service categories and plan limitations shown above represent an overview of your Plan of Benefits. This document presents many services within each category, but is not a complete description of the Plan. Please see your Plan description/Insurance certificate for complete details. In the event of a conflict with this summary, the terms of your insurance certificate will govern.

Dental - DHMO The Schedule of Benefits lists the Covered Services available to You and Your Dependents under Your dental plan, as well as Your and Your Dependent’s costs for each Covered Service. Your and Your Dependent’s costs may include Co-Payments for a Covered Service. THIS IS A PARTIAL LIST ONLY. For the complete Schedule of Benefits, go to www.mybenefitshub.com/cityofalamoheights *Care under this plan is provided through a network of Selected General Dentists. Your Selected General Dentist is responsible for determining when the services of a Specialty Care Dentist are needed, and facilitating any necessary referral. You and Your Dependents will be advised of the name, address and telephone number of the Specialty Care Dentist in Your or Your Dependent’s Service Area. Missed Appointments: If You or Your Dependents need to cancel or reschedule an appointment, please notify the Selected General Dental Office as far in advance as possible. This will allow the Selected General Dental Office to accommodate another person in need of attention. If You or Your Dependents fail to do this in a timely fashion, You or Your Dependents may be charged a missed appointment fee.

Monthly Rate

Employee

Employee & Spouse

Employee & Child(ren)

Employee & Family

$0.00

$23.13

$24.35

$37.75

Code

Service Office visit – per visit (including all fees for sterilization and/or infection control)

Your and Your Dependent’s Co-Payment $5

Diagnostic Treatment D0120

Periodic oral evaluation – established patient

D0150

Comprehensive oral evaluation – new or established patient

Radiographs / Diagnostic Imaging (X-rays) D0210

Intraoral – complete series of radiographic images

D0240

Intraoral – occlusal radiographic image

D0274

Bitewings – four radiographic images

D0330

Panoramic radiographic image

$0 Preventive Services

D1110

D1120

D1351

Prophylaxis – adult

Additional – adult prophylaxis (maximum of 2 additional per year)

$45

Prophylaxis – child

Additional – child prophylaxis (maximum of 2 additional per year)

$35

Sealant repair – per tooth

$0 Restorative Treatment

D2140

Amalgam – one surface, primary or permanent

$12

D2330

Resin-based composite – one surface, anterior

$12

D2391

Resin-based composite – one surface, posterior

$30 Crowns

 An additional charge, not to exceed $150 per unit, will be applied for any procedure using noble, high noble or titanium metal. There is a $75 Co-Payment per molar, for the use of porcelain.

 Cases involving seven (7) or more Crowns, implants and/or fixed Bridge units in the same treatment plan require an additional $125 CoPayment per unit in addition to the specified Co-Payment for each Crown, implant or Bridge unit. D2510

Inlay – metallic – one surface

$270

D2542

Onlay – metallic – two surfaces

$270

D2740

Crown – porcelain/ceramic substrate

$310

D2792

Crown – full cast noble metal

$290

D2950

Core buildup, including any pins when required

$75

Dental - DHMO

Code

Service

Your and Your Dependent’s Co-Payment

Endodontics D3220

Therapeutic pulpotomy (excluding final restoration) – removal of pulp coronal to the dentinocemental junction and application of medicament

$40

D3221

Pulpal debridement, primary and permanent teeth

$55

D3330

Endodontic therapy, molar tooth (excluding final restoration)

$265

Periodontics

 Periodontal charting for planning treatment of periodontal disease is included as part of overall diagnosis and treatment. No additional charge will apply to You or Your Dependent or Us. D4211

Gingivectomy or gingivoplasty – one to three contiguous teeth or tooth bounded spaces per quadrant

$100

D4341

Periodontal scaling and root planing – four or more teeth per quadrant

$50

D4910

Periodontal maintenance

$40 Removable Prosthodontics

 Delivery of removable and fixed Prosthodontics includes up to 3 adjustments within 6 months of delivery date of service. D5110

Complete denture – maxillary

$440

D5120

Complete denture – mandibular

$440

D5211

Maxillary partial denture – resin base (including any conventional clasps, rests and teeth)

$405

D5212

Mandibular partial denture – resin base (including any conventional clasps, rests and teeth)

$405

Oral Surgery

 Includes routine post operative visits/treatment.  The removal of asymptomatic third molars is not a Covered Service unless pathology (disease) exists. D7111

Extraction, coronal remnants – deciduous tooth

D7140

Extraction, erupted tooth or exposed root (elevation and/or forceps removal)

D7210

Surgical removal of erupted tooth requiring removal of bone and/or sectioning of tooth and including elevation of mucoperiosteal flap if indicated

$50

D7220

Removal of impacted tooth – soft tissue

$50

D7240

Removal of impacted tooth – completely bony

$135 Orthodontics

 Benefits cover twenty-four (24) months of usual & customary Orthodontic treatment and an additional twenty four (24) months of retention.  Comprehensive Orthodontic benefits include all phases of treatment and fixed/removable appliances. D8080

Comprehensive orthodontic treatment of the adolescent dentition

$2,095

D8090

Comprehensive orthodontic treatment of the adult dentition

$2,095

D8670

Periodic orthodontic treatment visit

$35 Adjunctive General Services

D9110

Palliative (emergency) treatment of dental pain – minor procedure

$10

D9210

Local anesthesia not in conjunction with operative or surgical procedures

D9230

Inhalation of nitrous oxide/analgesia, anxiolysis

$15

D9310

Consultation – diagnostic service provided by dentist or physician other than requesting dentist or physician

D9430

Office visit for observation (during regularly scheduled hours) – no other services performed

D9440

Office visit – after regularly scheduled hours

$30

DAVIS VISION YOUR BENEFITS PACKAGE

Vision

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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.

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

Vision Benefit

Frequency In-network Once every Copay

In-network Coverage

Eye Examination

12 months

$10

After copay, covered in full. Includes dilation when professionally indicated.

Spectacle Lenses

12 months

$10

After copay, clear glass or plastic lenses in any single vision, bifocal, trifocal or lenticular prescription. (See below for additional lens options and coatings.) Covered in Full Frames:

Frame

24 months

$0 OR, Frame Allowance:

Contact Lens Evaluation, Fitting & Follow Up Care

Contact Lenses (in lieu of eyeglasses)

12 months

Davis Vision Collection Contacts: Standard, Soft Contacts: Specialty Contacts/3:

$10

Covered in Full Contacts: Planned Replacement Disposable OR, Contact Lens Allowance: 12 months

Any Fashion or Designer level frame from Davis Vision’s Collection/2 (retail value, up to $160).

OR, Medically Necessary Contacts:

$130 toward any frame from provider plus 20% off any balance./1 No copay required. After copay, covered in full. After copay, covered in full. $60 allowance less copay plus 15% off balance/1. From Davis Vision’s Collection/2, up to: Four boxes/multi-packs* Eight boxes/multi-packs* $130 allowance toward any contacts from provider’s supply plus 15% off balance./1 No copay required. Covered in full with prior approval. *Number of contact lens boxes may vary based on manufacturer’s packaging.

Significant savings on optional frames, lens types and coatings!

Member Price

Davis Vision Collection Frames: Premier

$25

Tinting of Plastic Lenses or Glass Grey #3 Lenses

Oversize Lenses

Scratch Resistant Coating

Ultraviolet Coating

Anti-Reflective Coating: Standard | Premium | Ultra

$35 | $48 | $60

Polycarbonate Lenses

High-index Lenses

$55

Progressive Lenses: Standard | Premium | Ultra

$50 | $90 | $140

Polarized Lenses

$75 /4

Photochromic Lenses (i.e. Transitions®, etc.) : Plastic | Glass

$65 | $20

Intermediate Lenses

$30

Blended Segment Lenses

$20

Scratch Protection Plan: Single Vision Lenses | Multifocal

Monthly Rate 1/ 2/ 3/ 4/

$20 | $40

Employee

Employee & Spouse

Employee & Child(ren)

Employee & Family

$0.00

$8.68

$9.16

$14.48

Additional discounts not applicable at Walmart, Sam’s Club or Costco locations. The Davis Vision Collection is available at most participating independent provider locations. Including, but not limited to toric, multifocal and gas permeable contact lenses. Transitions® is a registered trademark of Transitions Optical Inc.

Please note: Your provider reserves the right to not dispense materials until all applicable member costs, fees and copayments have been collected. Contact lenses: Routine eye examinations do not include professional services for contact lens evaluations. Any applicable fees are the responsibility of the member. If contact lenses are selected and fitted, they may not be exchanged for eyeglasses. Progressive lenses: If you are unable to adapt to progressive addition lenses you have purchased, conventional bifocals will be supplied at no additional cost; however, your copayment is nonrefundable. May not be combined with other discounts or offers.

DEARBORN NATIONAL

Short Term Disability

YOUR BENEFITS PACKAGE

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

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

Short Term Disability Voluntary Short Term Disability

Trial Work Day Period

Dearborn National's Group Voluntary Short Term Disability plans help replace lost income should an insured employee become disabled due to an accident or sickness, including pregnancy or complications from pregnancy.

To encourage employees to return to work, employees may attempt to return to work full-time during their elimination period, without being required to restart the elimination period. Employees can temporarily return to work for a period of up to ½ the elimination period, maximum 14 days, and not have to begin their elimination period again if they stop working due to the same condition.

Rate and Cost Summary Effective Date:

January 01, 2018

14/14 Day Elimination Period Age Band

Monthly Rates Per $10 Weekly Benefit

Below 20 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80-84 85-89 90-94 95-99 100 and above

$0.227 $0.227 $0.237 $0.220 $0.209 $0.218 $0.233 $0.287 $0.381 $0.479 $0.490 $0.554 $0.554 $0.554 $0.554 $0.554 $0.554 $0.554

Eligibility Eligibility is as indicated in the Plan Design Summary. To be eligible, employees must be legally working in the United States and regularly working the minimum number of hours as agreed. Employees may have to complete a Waiting Period. Seasonal, part-time and temporary employees are not eligible.

Elimination Period Elimination Period is the period of time from the onset of disability until benefits begin. The elimination period is indicated in the Plan Design Summary. Unless otherwise indicated, benefits begin upon exhaustion of all other sick leave, vacation, PTO or other salary continuation plans. Total Disability is not required during the elimination period and can be satisfied with days of Partial or Total Disability. Additionally, there is no earnings loss requirement during the elimination period.

Maximum Period Payable Voluntary STD benefits are payable for the complete number of weeks indicated on the Plan Design Summary, or until LTD benefits are payable, whichever occurs first. The Maximum Period shown does not include the elimination period.

Survivor Benefit If a disabled employee dies after receiving disability benefits for more than three consecutive weeks, we will pay the beneficiary of the disabled employee a lump sum benefit equal to the amount shown in the Plan Design Summary.

Worksite Modification Benefit This benefit assists in covering the cost of modifying the disabled employee's worksite to allow that employee to return to work. Once all parties agree on the modification to be performed, we will reimburse the employer the actual cost of the modification, up to the greater of two times the employee's weekly benefit, or $1,500, unless otherwise indicated.

Pre-Existing Condition Limitation Benefits are not payable for disability caused by conditions that existed on the employee's effective date as indicated below:  A sickness or injury for which the employee received medical treatment, or advice was rendered, prescribed or recommended whether or not the sickness was diagnosed at all or within the number of months shown in the Plan Design Summary prior to the employee's effective date, and  Begins within the number of months shown in the Plan Design Summary of the employee's effective date.

Short Term Disability Continuity of Coverage (No Loss/No Gain) If an employee was insured under the prior policy on the day before this policy's effective date due to a continuance or extension of coverage, the employee may have limited coverage under this policy even if they do not satisfy the actively at work requirement. Coverage will be extended to the earlier of the end of the month the employee becomes actively at work, end of any extension period under the prior policy, or the date coverage would otherwise end under this policy. If an employee becomes disabled due to a pre-existing condition, benefits may be payable under our policy if the employee was insured for Voluntary STD with the prior carrier, and was insured at the time coverage changed to this policy, and remained insured under this policy. For benefits to be payable, the employee must satisfy the pre-existing condition exclusion under either our policy, or the prior policy if benefits would have been payable had the prior policy remained in place. The benefit payable will be the lesser of the monthly benefit payable under the prior plan or the monthly benefit payable under our policy.

Definition of Disability Disabled means that the employee is Totally Disabled or Partially Disabled due to an injury or sickness. The employee must be under the regular care of a doctor who is appropriate for the disabling condition. Loss of professional license or certification does not in and of itself mean the employee is Disabled.

Total Disability To be considered Totally Disabled, the insured must be unable to perform the material and substantial duties of their regular occupation and have a loss of income.

Partial Disability To be considered Partially Disabled, the insured must have suffered an injury or sickness, is able to perform some but not all of the material and substantial duties of their regular occupation, and as a result is earning between 20% and the percentage of their pre- disability income indicated in the Plan Design Summary.

Work Incentive Benefit If the employee meets the definition of Partial Disability, they are eligible to receive a Work Incentive Benefit.

To encourage disabled employees to return to work in some capacity, we standardly offer a Work Incentive Benefit on all Voluntary STD contracts. The Work Incentive Benefit pays the full monthly benefit as long as the combination of the benefit plus earnings does not exceed 100% of their pre-disability income. If benefits are due for a period of less than one week, payments will be made at a daily rate of 1/7th of the weekly benefit.

Extension of Coverage for FMLA Leave If an insured employee is eligible for and received approval for leave under the Family and Medical Leave Act of 1993 (FMLA) or any applicable state family and medical leave law, insurance will continue (provided premium continues to be paid) for a period up to the later of:  The leave period permitted by FMLA and any amendments; or  The leave period permitted by applicable state law.

Exclusions

 Loss of professional license, occupational license or certification;  Pre-Existing condition;  Commission of, participation in, or an attempt to commit an assault or felony;  Intentionally self-inflicted injuries;  Attempted suicide, regardless of mental capacity;  Cosmetic surgery, except when required due to injury or sickness  Occupational injury or sickness  Participation in a war, declared or undeclared, or any act of war

Enhanced Product Services Included with Voluntary Short Term Disability Insurance Telephonic Claim Reporting To streamline Voluntary STD claim intake, we offer a telephonic claim intake process. To initiate the claim, the employee calls us toll-free and answers a few simple questions. After the claim number is assigned and medical record release authorization is obtained, we contact the employer and physician as needed. Online Claim Status Through our Benefits Manager web portal, employers have online access to Voluntary STD claim information. Two reports are available - Pending Disability Claim Report includes new claims awaiting evaluation, claims awaiting payment, and

Short Term Disability claims in the appeal process. Experience Disability Claim Report includes claims on which payments have been made and are still open, closed, or in the appeal process. W-2 Reporting Upon request, we will prepare and mail W-2 Wage and Tax Statements to employees at no additional charge to the employer. If we have agreed to pay the employer's share of FICA taxes, we will prepare and mail W-2 Wage and Tax Statements. We prepare W-2 Wage and Tax Statements using the applicable insuring company's federal tax identification number. A signed FICA Match / W2 Tax Agreement is required on all disability cases.

DEARBORN NATIONAL YOUR BENEFITS PACKAGE

Long Term Disability

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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.

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 Eligibility Eligibility is as indicated in the Plan Design Summary. To be eligible, employees must be employed by the city full-time for one year before becoming eligible for this benefit.

Elimination Period Elimination Period is the period of time from the onset of disability until benefits begin. The elimination period is indicated in the Plan Design Summary. Total Disability is not required during the elimination period and can be satisfied with days of Partial or Total Disability. Additionally, there is no earnings loss requirement during the elimination period.

Trial Work Day Period To encourage employees to return to work, employees may attempt to return to work fulltime during their elimination period, without being required to restart the elimination period. Employees can temporarily return to work for a period up to 1/2 the elimination period and do not have to begin their elimination period again if they stop working due to the same condition.

Maximum Period Payable Long Term Disability Benefits are payable based on the following schedule.

65/5/70 Age When Disability Begins Maximum Period Payable Less than 60 To age 65 60-64 5 years 65-69 To age 70 (but not less than 1 year) 70 and older 1 year

Total Disability During the Own Occupation Period as indicated in the Plan Design Summary, Totally Disabled means the insured must be unable to perform the material and substantial duties of their regular occupation and/or* have disability earnings less than 20%* of their predisability income.

After the own occ period, Totally Disabled means the insured must be unable to engage in any gainful occupation and/or* have disability earnings less than 20%* of their predisability income. * See Plan Design Summary for class specifics

Partial Disability During the Own Occupation Period as indicated in the Plan Design Summary, Partially Disabled means the insured must have suffered an injury or sickness and as a result is earning between 20%* and the percentage of their pre-disability income as indicated in the Plan Design Summary. Following the own occupation period, Partially Disabled means the insured is gainfully employed and earning between 20%* and the percentage of their predisability income indicated in the Plan Design Summary. During the elimination period, there does not need to be a loss of income to be considered either Partially or Totally Disabled. * See Plan Design Summary for class specifics

Recurrent Disability If disability for which benefits were payable ends but recurs due to the same or related causes less than 6 months after the end of a prior disability, it will be considered a resumption of the prior disability. Such recurrent disability shall be subject to the provisions of the policy that were in effect at the time the prior disability began. Disability which recurs more than 6 months after the end of a prior disability is subject to:  A new Elimination Period;  A new Maximum Period Payable; and  The other provisions of the policy that are in effect on the date the disability recurs. Disability must recur while the employee’s coverage is in force under the policy.

LTD Monthly Benefit If the employee meets the definition of Total Disability, they are eligible to receive an LTD Monthly Benefit.

Work Incentive Benefit If the employee meets the definition of Partial Disability, they are eligible to receive a Work Incentive Benefit.

Long Term Disability To encourage disabled employees to return to work in some capacity, a Work Incentive Benefit is offered to all Partially Disabled employees. For the number of months indicated in the Plan Design Summary, we will pay the full monthly benefit as long as the combination of the benefit plus earnings does not exceed 100% of their indexed pre-disability income. After this period, our benefit will be calculated by multiplying the benefit times the adjusted loss of salary ratio.

Rehabilitative Incentive Income A unique standard feature of the LTD contract is the Rehabilitation Incentive Income feature. If we identify a partially disabled employee as a candidate for a rehabilitation program, we will work with them to structure a voluntary rehabilitation plan that assists the employee in returning to employment. The Plan details the vocational rehabilitation services available to the employee. While the employee is participating in a voluntary rehabilitation plan, and continues to meet the obligations of the program, we will allow the employee to retain a combination of benefits and disability income in excess of 100% of their indexed pre-disability income, for 12 months. After 12 months, we will offset the LTD benefit by multiplying the benefit times the adjusted loss of salary ratio.

Pre-Existing Condition Exclusion Benefits are not payable for a disability caused by a condition that existed on the employee's effective date as indicated below: ď&#x201A;ˇ A sickness or injury for which the employee received medical treatment, or advice was rendered, prescribed or recommended whether or not the sickness was diagnosed at all or misdiagnosed within the number of months prior to the employee's effective date as indicated in the Plan Design Summary, and ď&#x201A;ˇ The condition results in a Disability that begins within the number of months after the employee's effective date as indicated in the Plan Design Summary.

Continuity of Coverage (No Loss/No Gain) If an employee was insured under the prior policy on the day before this policy's effective date due to a continuance or extension of coverage, the employee may have limited coverage under this policy even if they do not satisfy the actively at work requirement. Coverage will be extended to

the earlier of the end of the month the employee becomes actively at work, end of any extension period under the prior policy, or the date coverage would otherwise end under this policy. If an employee becomes disabled due to a pre-existing condition, benefits may be payable under our policy if the employee was insured for LTD with the prior carrier, and was insured at the time coverage changed to our policy, and remained insured under this policy. For benefits to be payable, the employee must satisfy the preexisting condition exclusion under either our policy, or the prior policy if benefits would have been payable had the prior plan remained in place. The benefit payable will be the lesser of the monthly benefit payable under the prior plan or the monthly benefit under our plan.

Mental and Nervous Disorder Limitation Disabilities due to Mental and/or Nervous disorders are limited to the number of months shown in the Plan Design Summary, unless the disabled employee is confined to a facility licensed for the treatment of Mental and Nervous disorders.

Substance Abuse Limitation (Drug and Alcohol) Disabilities due to Substance Abuse disorders are limited to the number of months shown in the Plan Design Summary, unless the disabled employee is confined to a facility licensed for the treatment of Substance Abuse disorders.

Special Conditions Limitation Disabilities due to condition identified as a Special Condition are limited to the number of months shown in the Plan Design Summary, unless the disabled employee is confined to a licensed medical facility licensed to provide treatment for the disabled employee's condition. Special Conditions include but are not limited to muscoskeletal and connective tissue disorders of the neck and back including any disease or disorder of the cervical, thoracic and lumbosacral back and its surrounding soft tissue including sprains and strains of joints and adjacent muscles. The lifetime cumulative maximum period payable for all disabilities due to a mental disorder, substance abuse or special conditions is indicated in the Plan Design Summary. Only that period of benefits will be paid for any combination of such disabilities even if the disabilities are not continuous or not related.

Long Term Disability Worksite Modification Benefit

Exclusions

This benefit assists in covering the cost of modifying the disabled employee's worksite to allow that employee to return to work. Once all parties agree on the modification to be performed, We will reimburse the employer the actual cost of the modification, up to the amount shown in the Plan Design Summary.

The policy does not cover any loss or Disability caused by, resulting from, arising out of or substantially contributed, directly or indirectly, to by any one or more of the following:

Survivor Income Benefit If a disabled employee dies after having been disabled for a minimum of 180 consecutive days and was receiving benefits under the policy, we will pay a lump sum benefit equal to the number of months of gross benefit as indicated in the Plan Design Summary.

Day Care Expense Benefit To assist employees taking advantage of our Rehabilitative Incentive Income feature, we offer Day Care Expense Benefits. This benefit reimburses claimants for any day care expenses they may incur for children under age 13 while participating in the rehabilitation program. The benefit pays up to the amount indicated in the Plan Design Summary, to an overall monthly maximum of $1,000.

Rehabilitation Benefit If the disabled employee is participating in a formal rehabilitation plan while receiving benefits, we will pay an additional monthly benefit equal to the percentage of their benefit indicated in the Plan Design Summary, up to the amount indicated. This additional benefit is payable for a maximum of the number of months indicated in the Plan Design Summary.

 A Pre-Existing Condition  Commission of, participation in, or an attempt to commit an assault or felony;  Intentionally Self-Inflicted Injuries  Participation in a war, declared or undeclared;  Active military duty;  Active Participation in a Riot;  Commission of a Felony for which the insured has been convicted.

Disability Resource Services - Telephonic and Face-to-Face Support for Behavioral Health Issues Provided to all groups with Long-Term Disability coverage:  24 Hour telephonic support (for all Long-Term Disability insureds) for behavioral health issues. A staff of master degree clinicians is available to provide each caller with assessment, counseling and referral advice for face-to-face counseling. Offered at no additional charge, these services enhance the value of an employee benefit program while helping to manage employee productivity and minimize absences.  Face-to-face counseling. Up to 3 face-to-face counseling sessions per year to address appropriate behavioral health issues.  Guidance Resources ® Online is a secure, passwordprotected interactive Web site that contains selfassessments, search tools, extensive content on personal health and powerful tools to help with personal, relational, legal, health and financial concerns. This service is free of charge to you, your insured employees and their families. Assistance through Guidance Resources ® Online is available 24 hours a day, 7 days a week. Enhanced Employee Assistance Programs (EAPs) are available. Contact your Dearborn National representative for more information.

DEARBORN NATIONAL

EAP (Employee Assistance Program)

YOUR BENEFITS PACKAGE

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.

38%

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

Employee Assistance Program Beneficiary Resource ServicesTM: A Wellness Plan for Life When a loved one dies, families often face complex issues ranging from estate planning, legal questions, funeral planning, coping with grief and financial uncertainties. That's why Dearborn National offers Beneficiary Resource Services, a program that combines family wellness and security at the most difficult of times. Services include grief and financial counseling, funeral planning, legal support as well as online will preparation. Beneficiary Resource Services is provided by Bensinger, DuPont & Associates (BDA). Services for insureds and their families: Online Will Preparation - A will is one of the most important documents every adult should have, and creating one has never been easier. Insureds and their families will have access to a full legal library with many estate planning documents, including an online will. Insureds can create their own wills online in a safe and secure way, right from their homes. The will can be saved and updated as family situations change. Creating a will provides security and peace of mind for several reasons:  Appoints a guardian for children  Controls where property and assets go  Provides family security  Without one, the state can make these decisions Funeral Planning - Insureds and beneficiaries have access to an online funeral planning site that features a variety of helpful tools and information, such as:  A downloadable funeral planning guide for insureds to document vital information their loved ones will need when making final arrangements  Calculators to estimate and compare expenses for various types of funeral arrangements  Information on funeral requirements and various religious customs  Directories to locate funeral homes and cemeteries in the insured's area Services for beneficiaries (and their families) after a death claim or for those that qualify for an accelerated death benefit: Unlimited Phone Contact - Available for up to one year with a grief counselor, legal advisor or financial planner. Face-to-Face Working Sessions* - Five face-to-face working sessions are available to the insured person or beneficiary. All five sessions may be used with one grief

counselor or legal advisor, or they may be split among the two types of counselors or advisors in geographically accessible locations. A one-hour financial consultation on the phone is also available. *May include face-to-face sessions, over-the-phone sessions or time taken for research or document preparation.

Referrals and Support Services - BDA maintains a comprehensive directory of qualified and accessible grief counselors and legal and financial consultants. Follow Up - Counselors will initiate follow-up calls when necessary for up to one full year from the date of initial contact. BDA's nationwide network of experienced professionals can offer counseling for individuals facing difficult emotional, financial or legal issues. BDA's counselors are available 24 hours a day, 365 days a year. All calls are completely confidential.

Travel Resource Services1 In today's global economy, the need for world travel is now greater than ever. However, a trip, whether for business or pleasure, can be disrupted by the unexpected. A medical emergency, a lost prescription or even emergencies involving a spouse, child or traveling companion can jeopardize a trip. To provide the support people need while traveling on business or pleasure, we provide Travel Resource Services2, a program that assists travelers if the unexpected happens. Services are available to insureds and their families traveling 100 or more miles from their primary residence, and include:  Medical Search and Referral  Medical Monitoring  Medical Evacuation/Return Home

 Traveling Companion Assistance  Dependent Children Assistance  Visit by Family Member/ Friend  Return of Mortal Remains

 Replacement of Medication and Eyeglasses

 Emergency Message Relay  Emergency Travel     

Arrangements Emergency Cash Locating Lost or Stolen Items Legal Assistance/Bail Interpretation/Translation Pre-Trip Information

Travel Assistance Services are provided to groups with 50 or more employees; Not available in all states. 2 We contract with Europ Assistance USA, Inc. to provide the Travel Resource Services. We do not provide any part of the Travel Resource Services.

APL

Cancer

YOUR BENEFITS PACKAGE

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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.

Breast Cancer is the most commonly diagnosed cancer in women.

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

GC14 Limited Benefit Group Cancer Indemnity Insurance City of Alamo Heights THE POLICY UNDER WHICH THIS CERTIFICATE IS ISSUED IS NOT A POLICY OF WORKERS’ COMPENSATION INSURANCE. THE EMPLOYER DOES NOT BECOME A SUBSCRIBER TO THE WORKERS’ COMPENSATION SYSTEM BY PURCHASING THE POLICY AND IF THE EMPLOYER IS A NON-SUBSCRIBER, THE EMPLOYEE LOSES THOSE BENEFITS WHICH WOULD OTHERWISE ACCRUE UNDER THE WORKERS’ COMPENSATION LAWS. THE EMPLOYER MUST COMPLY WITH THE WORKERS’ COMPENSATION LAW AS IT PERTAINS TO NONSUBSCRIBERS AND THE REQUIRED NOTIFICATIONS THAT MUST BE FILED AND POSTED.

Summary of Benefits

Plan 1

Plan 2

Cancer Treatment Policy Benefits

Level 3

Level 4

Radiation Therapy, Chemotherapy, Immunotherapy - Maximum per 12-month period

$15,000

$20,000

$50 per treatment

paid in same manner and under the same maximums as any other benefit Level 2

paid in same manner and under the same maximums as any other benefit Level 4

Hormone Therapy - Maximum of 12 treatments per calendar year Experimental Treatment Internal Cancer First Occurrence Rider Benefits Lump Sum Benefit - Maximum 1 per Covered Person per lifetime

$5,000

$10,000

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

$7,500

$15,000

Heart Attack/Stroke First Occurrence Rider Benefits

Level 2

Level 4

Lump Sum Benefit - Maximum 1 per Covered Person per lifetime

$5,000

$10,000

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

$7,500

$15,000

$600 per day $300 per day

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

Total Monthly Premiums by Plan** Issue Ages 18 +

Individual

Individual & Spouse

1 Parent Family

2 Parent Family

Plan 1

Plan 2

Plan 1

Plan 2

Plan 1

Plan 2

Plan 1

Plan 2

$15.46

$24.80

$33.24

$53.70

$19.60

$30.40

$37.38

$59.34

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

APSB-22339(TX)-0615 MGM/FBS City of Alamo Heights 49

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

Cancer Treatment Benefits Eligibility

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

Limitations and Exclusions

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

Only Loss for Cancer

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

Pre-Existing Condition Exclusion

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

Waiting Period

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

Termination of Certificate

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

Termination of Coverage

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

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

Limitations and Exclusions

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

Pre-Existing Condition Exclusion

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

Waiting Period

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

Termination

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

Heart Attack/Stroke First Occurrence Benefits Limitations and Exclusions

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

Pre-Existing Condition Exclusion

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

APSB-22339(TX)-0615 MGM/FBS City of Alamo Heights 50

GC14 Limited Benefit Group Cancer Indemnity Insurance Waiting Period

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

Termination

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

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

Limitations and Exclusions

For a newborn child born within the 10-month period following the effective date, no benefits under this rider will be provided for confinements that begin within the first 30 days following the birth of such child. No benefits under this rider will be provided during the first two years following the effective date for confinements caused by any heart condition when any heart condition was diagnosed or treated prior to the end of the 30-day period following the covered person’s effective date. The heart condition causing the confinement need not be the same condition diagnosed or treated prior to the effective date. We will not pay benefits for any loss caused by or resulting from any of the following: intentionally self-inflicted bodily injury, suicide or attempted suicide, whether sane or insane; alcoholism or drug addiction; any act of war, declared or undeclared, or any act related to war, or active service in the armed forces, or military service for any country at war [(if coverage is suspended for any covered person during a period of military service, we will refund the pro-rata portion of any premium paid for any such covered person upon receipt of the policyholder’s written request)]; participation in any activity or event while intoxicated or under the influence of any narcotic unless administered by a physician or taken according to the physician’s instructions; participation in, or attempting to participate in, a felony, riot or insurrection (a felony is defined by the law of the jurisdiction in which the activity takes place).

Termination

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

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

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

2305 Lakeland Drive | Flowood, MS 39232 ampublic.com | 800.256.8606 Underwritten by American Public Life Insurance Company. This is a brief description of the coverage. For detailed benefits, limitations, exclusions and other provisions, please refer to the policy/certificate/riders. This coverage does not replace Workers’ Compensation Insurance. This product is inappropriate for people who are eligible for Medicaid coverage. | This policy is considered an employee welfare benefit plan established and/or maintained by an association or employer intended to be covered by ERISA, and will be administered and enforced under ERISA. Group policies issued to governmental entities and municipalities may be exempt from ERISA guidelines. | Policy Form GC14 Series | TX | Limited Benefit Group Cancer Indemnity Insurance | (10/14) | MGM/FBS | City of Alamo Heights

APSB-22339(TX)-0615 MGM/FBS City of Alamo Heights

THE HARTFORD YOUR BENEFITS PACKAGE

Accident

PLAY VIDEO

About this Benefit

2/3

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

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

usually live paycheck to paycheck.

Accident What is accident insurance? Accident insurance offers financial protection by paying a cash benefit if you or an insured dependent are unexpectedly injured in a covered accident. This coverage is offered by your employer which you pay for through convenient deductions from your paycheck. The benefits are paid in lump sum amounts to you (or your beneficiary), and can be used to help pay for health care expenses not covered by your major medical insurance, help replace income lost while not working, or however you choose. This highlight sheet is an overview of your accident insurance. A certificate of insurance will be available after you enroll to explain your coverage in detail.

Who is eligible? You are eligible if you are an active employee who works at least 40 hours per week on a regularly scheduled basis, and are less than age 80. Your spouse (includes domestic partner) must also be less than age 80 to be eligible for coverage, and your dependent child(ren) must be under age 26 to be eligible.

When can I enroll? You can enroll during any scheduled enrollment period, within 31 days of the date you have a change in family status, or within 31 days of the completion of any eligibility waiting period established by your employer.

How much coverage can I purchase? Three accident plans are available to you, Option 1: Plan 1, Option 2: Plan 2, and Option 3: Plan 3. You have the flexibility to enroll for the plan that best meets your financial protection needs. Unless otherwise noted, the benefit amounts payable under each plan are the same for you and your dependent(s).

Am I guaranteed coverage? During designated enrollment periods, this coverage is offered without having to provide information about your or your family’s health. This is called “guaranteed issue” coverage – all you have to do is check the box to enroll and become insured.

I already have medical and disability insurance. Why do I need this too? Costs associated with an accident can add up even with other types of insurance. Once treatment for an injury begins, deductibles and cost sharing (co-pays and/or

coinsurance), and limitations on benefits found in some medical insurance plans may quickly lead to high out-of-pocket costs. In addition, disability insurance will only replace a portion of your income, not all of it. Accident insurance benefits can help cover what other insurance products don’t.

What is covered? This insurance provides benefits for medical treatment and services related to accidental injuries Benefits for specific types of injuries and catastrophic injuries (including accidental death) are also available. Please refer to the benefits table on the following page for more detailed plan information.

Can I keep this insurance if I leave my employer? Yes, you can take this coverage with you. If you leave your employer, you may continue coverage for you and your dependent(s) under a group portability policy. Your spouse may also continue insurance in certain circumstances.

Exclusions This insurance does not provide benefits for any loss that results from or is caused by:  Suicide or attempted suicide, whether sane or insane, or intentionally self-inflicted injury  War or act of war, whether declared or undeclared, or a nuclear, chemical, biological, or radiological event  A covered person's participation in a felony, riot or insurrection  A covered person's service in the armed forces or units auxiliary to it  A covered person's taking drugs, unless as prescribed by or administered by a physician, or being intoxicated as defined by the jurisdiction in which the cause of loss was incurred  While a covered person is on any aircraft: as a pilot, crewmember or student pilot; as a flight instructor or examiner; if it is owned, operated or leased by or on behalf of the policyholder, or any employer or organization whose eligible persons are covered under the policy; or being used for tests, experimental purposes, stunt flying, racing or endurance tests  Operating, learning to operate, serving as a crew member of or jumping or falling from any aircraft  Riding in or driving any motor-driven vehicle in a race, stunt show or speed test All exclusions may not be applicable, or may be adjusted, as required by state regulations in the situs state of a group. Please refer to the certificate for a full listing of exclusions.

Accident Plan Information

Option 1

Plan Type

Option 2

Option 3

Plan 1 Plan 2 Plan 3 On and off-job On and off-job On and off-job (24 hour) (24 hour) (24 hour)

Coverage Type

Benefits Emergency, Hospital & Treatment Care

Option 1 Plan 1

Option 2 Plan 2

Option 3 Plan 3

Accident Follow-Up Acupuncture /Chiropractic Care Ambulance – Air Ambulance – Ground Blood/Plasma/Platelets Child Care Daily Hospital Confinement Daily ICU Confinement Diagnostic Exam Emergency Dental – Crown/Extraction Emergency Room Hospital Admission Initial Physician Office Visit Lodging Medical Appliance Physical Therapy Rehabilitation Facility Transportation Urgent Care X-ray

$50 $25 $600 $200 $150 $25 $100 $300 $100 Up to $150 $100 $500 $50 $100 $50 $25 $50 $200 $50 $50

$75 $25 $900 $300 $200 $25 $200 $400 $200 Up to $300 $150 $1,000 $75 $125 $100 $25 $100 $300 $75 $50

$100 $50 $1,200 $400 $300 $30 $300 $600 $300 Up to $450 $200 $1,500 $100 $150 $150 $50 $150 $500 $100 $75

Plan 1

Plan 2

Plan 3

$1,000 $200

$1,500 $300

$2,000 $400

$500

$1,000

$1,500

$5,000

$10,000

$15,000

Up to 3 visits/accident within 90 days Up to 10 visits each/accident within 365 days Once/accident within 72 hours Once/accident within 90 days Once/accident within 90 days Up to 30 days/accident while insured is confined Up to 365 days/lifetime (Total daily and ICU) Up to 30 days/accident Once/accident within 90 days Once/accident within 90 days Once/accident within 72 hours Once/accident within 90 days Once/accident within 90 days Up to 30 nights/lifetime Once/accident within 90 days Up to 10 visits/accident within 90 days Up to 15 days/lifetime Up to 3 trips/accident Once/accident within 72 hours Once/accident within 90 days

Specified Injury & Surgery Abdominal/Thoracic Surgery Arthroscopic Surgery Burn – 2nd degree (≥ 34% of body surface) Burn – 3rd degree (≥ 18% of body surface) Burn – Skin graft (For 3rd degree burn) Concussion Dislocations – Open (Surgical) Dislocations – Closed (Non-surgical) Eye Injury – Surgery/Object Removal Fractures – Open (Surgical) Fractures – Closed (Non-surgical) Hernia Repair Joint Replacement Knee Cartilage – With Repair Knee Cartilage – Without repair Laceration – 2” to 6” Laceration – 6” or greater Ruptured Disc Tendon/Ligament/Cuff – Single Tendon/Ligament/Cuff – 2 or more

Once/accident within 90 days Once/accident within 90 days Once/accident within 72 hours

Once/accident Up to 3/year within 72 hours Once/joint/lifetime Once/accident within 90 days Once/bone/accident within 90 days Once/accident within 365 days Once/accident within 90 days Highest benefit once/accident within 365 days Highest benefit once/accident within 72 hours Once/accident within 365 days Highest benefit once/accident within 365 days

25% of burn benefit $100 Up to $2,000 Up to $1,000 Up to $300 Up to $3,000 Up to $1,500 $100 $1,500 $500 $100 $100 $400 $500

$150 Up to $4,000 Up to $2,000 Up to $400 Up to $6,000 Up to $3,000 $150 $2,000 $750 $150 $300 $600 $750

$200 Up to $8,000 Up to $4,000 Up to $600 Up to $9,000 Up to $4,500 $200 $3,000 $1,000 $200 $500 $600 $1,000

$600

$800

$1,000

$800

$1,000

$1,500

Accident Benefits (cont.) Catastrophic Accidental Death Common Carrier Death Coma (≥ 168 continuous hours) Dismemberment – Double Losses Dismemberment – Single Losses Dismemb. – Thumb & Index Finger Home Health Care Paralysis – Quadriplegia Paralysis – Paraplegia Prosthesis – Single Prosthesis – 2 or more

Within 90 days; Spouse benefits are 50% and child benefits are 25% of employee amount Within 90 days Once/accident within 90 days Once/accident within 90 days Up to 30 days/accident Highest benefit once/accident within 90 days Highest benefit once/accident within 365 days

Option 1 Plan 1

Option 2 Plan 2

Option 3 Plan 3

$20,000

$30,000

$50,000

$5,000 $20,000 $10,000 $2,500 $50 $5,000 $2,500 $500 $1,000

3 times death benefit $10,000 $30,000 $15,000 $5,000 $50 $10,000 $5,000 $750 $1,500

$15,000 $50,000 $25,000 $10,000 $50 $15,000 $7,500 $1,000 $2,000

Notices THIS IS A LIMITED BENEFIT POLICY This limited health benefit plan (1) does not constitute major medical coverage, and (2) does not satisfy the individual mandate of the Affordable Care Act (ACA) because the coverage does not meet the requirements of minimum essential coverage. This benefit highlights sheet is an overview of the insurance being offered and is provided for illustrative purposes only and is not a contract. It in no way changes or affects the policy as actually issued. Only the insurance policy issued to the policyholder can fully describe all of the provisions, terms, conditions, limitations and exclusions of your insurance coverage. In the event of any difference between the benefit highlights sheet and the insurance policy, the terms of the insurance policy apply.

Rate Chart Employee

Employee & Spouse

Employee & Child(ren)

Employee & Family

Option 1 Monthly Cost

$9.00

$14.12

$14.58

$23.68

Option 2 Monthly Cost

$15.00

$23.58

$24.76

$40.02

Option 3 Monthly Cost

$22.40

$35.18

$37.00

$59.76

THE HARTFORD

Critical Illness

YOUR BENEFITS PACKAGE

PLAY VIDEO

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

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

Critical Illness What is critical illness insurance? Critical illness insurance is coverage offered by your employer which you pay for through convenient deductions from your paycheck. It can assist you financially if you or a covered dependent are ever diagnosed with a covered critical illness (shown below). The benefits are paid in lump sum amounts and can serve as a source of cash to use as you wish, whether to help pay for health care expenses not covered by your major medical insurance, help replace income lost while not working, or however you choose. This highlight sheet is an overview of your critical illness insurance. A certificate of insurance will be available after you enroll to explain your coverage in detail.

When can I enroll? You can enroll during your scheduled enrollment period, within 31 days of the date you have a change in family status, or within 31 days of the completion of your eligibility waiting period established by your employer.

How much coverage can I purchase? You may enroll for $10,000, $15,000 or $20,000 in coverage. You may also enroll your dependent(s) for the following amounts of coverage:  Spouse: the greater of $5,000 or 50% of your elected coverage amount  Child(ren): $5,000 A benefit reduction of 50% will apply to the coverage amount for you and your dependent(s) when you reach the age of 70.

Am I guaranteed coverage? During designated enrollment periods, this coverage is offered without having to provide information about your health for coverage amounts up to $20,000. This is called “guaranteed issue (GI)” coverage – all you have to do is check the box to enroll and become insured. All amounts of dependent coverage are guaranteed issue.

I already have medical and disability insurance. Why do I need this too? Costs associated with critical illness can pile up even with other types of insurance. Once treatment for an illness begins, deductibles and cost sharing (co-pays and/or coinsurance), and limitations on benefits found in some medical insurance plans may quickly lead to high out-of-pocket costs. In addition, disability insurance will only replace a portion of your income, not all of it. Critical illness insurance benefits can help cover what other insurance products don’t.

How many times will the policy pay? This insurance will pay a benefit multiple times, in the unfortunate event you or a dependent are diagnosed with more than one covered illness. The total amount of benefits payable for covered illnesses for each covered person under the policy is subject to a maximum, as follows:  You – 500% of the coverage amount  Spouse – 500% of the coverage amount  Child(ren) – 300% of the coverage amount If the benefits paid for a dependent reach the coverage maximum, coverage for the dependent will end. If the benefits paid for you reach the coverage maximum, coverage for you and your dependent(s) will end.

What illnesses are covered? This insurance will pay a lump sum benefit if you or a dependent are diagnosed with any of the following covered illnesses while insurance is in effect, subject to any pre-existing condition limitation. Covered Illness

Benefit

Cancer Conditions Invasive Cancer; Benign Brain Tumor

100% of coverage amount

Non-Invasive Cancer

25% of coverage amount

Vascular Conditions Heart Attack; Heart Transplant; Stroke

100% of coverage amount

Coronary Artery Bypass Graft; Angioplasty/Stent; Aneurysm

25% of coverage amount

Other Specified Conditions Major Organ Transplant; End Stage Renal Failure; Coma; Paralysis; Loss of Vision; Loss of Hearing; Loss of Speech

100% of coverage amount

Critical Illness Are any other benefits available? The following benefits are also included with this insurance:  Expanded Cancer Benefits – Offers a benefit if a second opinion is sought for a cancer diagnosis, and a benefit for a prosthesis/wig  Recurrence Benefit – Pays a benefit for a subsequent diagnosis of a covered illness for which a benefit has already been paid under the policy  Health Screening Benefit – Pays a benefit once each year for each covered person when one (or more) of over 25 specified health screening tests occurs

Important Details Benefit Separation Periods. If a covered person is diagnosed with a covered illness, and is subsequently diagnosed with another covered illness, the following separation periods apply between benefit payments. If the subsequent diagnosis is for:  A different, non-related covered illness than the first diagnosis (e.g. a cancer illness then a vascular illness), then no separation period applies  A covered illness that is related to the first (e.g. two vascular illnesses, like heart attack and stroke), then a 30 day separation period applies  The same covered illness as the first (e.g. two heart attacks), a benefit for the subsequent illness is not available Pre-Existing Condition Limitation. We will not pay a benefit or any increase in benefits for any critical illness for a preexisting condition, unless at the time of a positive diagnosis a covered person has been continuously insured under the policy for 12 months. Pre-existing condition, as used in this limitation, means any critical illness for which medical care is received within the 12 month period prior to the effective date of insurance for a covered person, or within the 12 month period prior to the effective date of any increase in coverage for a covered person. Exclusions. This insurance does not provide benefits for any covered illness that results from or is caused by:  Suicide, attempted suicide or intentionally self-inflicted injury, whether sane or insane  War or act of war, declared or undeclared  A covered person's participation in a felony, riot or insurrection

 

A covered person's engaging in any illegal occupation A covered person's service in the armed forces or units auxiliary to them

All exclusions may not be applicable, or may be adjusted, as required by state regulations in the situs state of a group. Please refer to the certificate for a full listing of exclusions. General Limitations. Benefits under the policy are not payable for any covered illness:  Diagnosed prior to the effective date of insurance for a covered person (except for newborn children)  Diagnosed during an applicable benefit separation period  For which a covered person has already received a benefit payment under the policy, unless the covered illness is included in a recurrence provision  For which a covered person has already received a benefit payment under the recurrence provision In addition, benefits are not payable for any critical illness not included as a covered illness in your certificate.

Critical Illness Your cost may change when you move into a new age category. $10,000

Non Tobacco User Monthly Cost

Tobacco User Monthly Cost

Age

Employee

Employee & Spouse

Employee & Child

Employee & Family

Employee

Employee & Spouse

Employee & Child

18-24

$3.17

$5.39

$5.72

$8.56

$3.35

$5.66

$5.90

$8.83

25-29

$3.93

$6.56

$6.49

$9.72

$4.33

$7.17

$6.89

$10.34

30-34

$4.96

$8.12

$7.52

$11.29

$5.82

$9.46

$8.38

$12.63

35-39

$6.81

$10.88

$9.37

$14.05

$8.67

$13.78

$11.23

$16.95

40-44

$10.56

$16.58

$13.12

$19.74

$14.89

$23.39

$17.45

$26.56

45-49

$16.23

$25.32

$18.78

$28.49

$25.83

$40.43

$28.38

$43.59

50-54

$23.04

$35.88

$25.60

$39.05

$40.29

$62.80

$42.85

$65.97

55-59

$31.41

$48.91

$33.96

$52.08

$58.80

$91.51

$61.36

$94.68

60-64

$45.38

$70.59

$47.94

$73.75

$90.12

$139.95

$92.67

$143.12

65-69

$63.24

$97.81

$65.80

$100.98

$133.18

$205.96

$135.74

$209.13

70-74

$44.58

$69.26

$46.47

$71.61

$91.32

$141.97

$93.21

$144.31

75-79

$58.83

$90.86

$60.72

$93.21

$108.86

$168.84

$110.75

$171.18

$15,000

Non Tobacco User Monthly Cost

Age

Employee

Employee & Spouse

Employee & Child

18-24

$4.08

$6.75

25-29

$5.17

$8.40

30-34

$6.68

35-39

$9.43

40-44 45-49

Employee & Family

Tobacco User Monthly Cost Employee & Family

Employee

Employee & Spouse

Employee & Child

Employee & Family

$6.63

$9.92

$4.34

$7.17

$6.90

$10.33

$7.72

$11.57

$5.76

$9.32

$8.32

$12.49

$10.68

$9.23

$13.85

$7.97

$12.68

$10.52

$15.85

$14.78

$11.98

$17.94

$12.21

$19.11

$14.76

$22.28

$14.97

$23.17

$17.53

$26.34

$21.46

$33.36

$24.02

$36.53

$23.41

$36.14

$25.96

$39.31

$37.77

$58.73

$40.33

$61.90

50-54

$33.60

$51.91

$36.16

$55.08

$59.40

$92.15

$61.95

$95.31

55-59

$46.12

$71.41

$48.68

$74.58

$87.08

$135.06

$89.64

$138.23

60-64

$67.05

$103.85

$69.60

$107.02

$133.94

$207.49

$136.49

$210.66

65-69

$93.81

$144.62

$96.36

$147.79

$198.41

$306.26

$200.96

$309.42

70-74

$65.79

$101.74

$67.68

$104.09

$135.57

$210.16

$137.46

$212.50

75-79

$87.17

$134.16

$89.06

$136.50

$161.99

$250.66

$163.88

$253.01

$20,000

Non Tobacco User Monthly Cost

Tobacco User Monthly Cost

Employee & Spouse

Employee & Child

Employee & Family

Employee

Employee & Spouse

Employee & Child

Employee & Family

$4.98

$8.12

$7.54

$11.29

$6.40

$10.24

$8.96

$13.41

$5.34

$8.67

$7.90

$11.84

$7.19

$11.47

$9.75

$14.64

30-34

$8.39

$13.24

$10.95

35-39

$12.04

$18.67

$14.60

$16.40

$10.11

$15.91

$12.66

$19.07

$21.83

$15.74

$24.45

$18.30

$27.61

40-44

$19.39

$29.76

45-49

$30.59

$46.96

$21.94

$32.93

$28.03

$43.34

$30.59

$46.50

$33.14

$50.13

$49.72

$77.03

$52.28

50-54

$44.16

$80.20

$67.95

$46.72

$71.12

$78.50

$121.50

$81.06

$124.66

55-59 60-64

$60.84

$93.91

$63.39

$97.08

$115.36

$178.61

$117.92

$181.77

$88.71

$137.11

$91.27

$140.28

$177.76

$275.02

$180.31

$278.19

65-69

$124.37

$191.43

$126.93

$194.60

$263.63

$406.55

$266.19

$409.71

70-74

$86.99

$134.22

$88.89

$136.57

$179.82

$278.35

$181.71

$280.69

75-79

$115.50

$177.45

$117.40

$179.80

$215.11

$332.49

$217.00

$334.84

Age

Employee

18-24 25-29

DEARBORN NATIONAL YOUR BENEFITS PACKAGE

Life and AD&D

PLAY VIDEO

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.

Motor vehicle crashes are the

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

Life and AD&D Basic and Supplemental Life Eligibility Eligibility is as indicated in the Plan Design Summary. To be eligible, employees must be legally working in the United States and meet the eligibility requirements indicated in the Plan Design Summary. Insured Persons may have to complete a Waiting Period. Seasonal, part-time and temporary employees are not eligible.

Effective Date If an insured person is absent from work due to injury or sickness on the last day of work prior to their effective date, the effective date of coverage will be delayed until 12:01 a.m. on the day coinciding with or next following their return to active work for a period of one day.

Guarantee Issue Life Insurance Amounts up to the Guarantee Issue amount stated in the Plan Design Summary are offered with no need for Evidence of Insurability. Amounts in excess of the Guarantee Issue amount are subject to underwriting approval before becoming effective.

Conversion Insureds who terminate employment, or lose a portion of their life coverage, may be able to convert their Life coverage to individual policies. Upon coverage termination administrators have 31 days after coverage ends to inform the insureds of their right to convert to an individual policy without evidence of insurability. Conversion does not apply to AD&D or Waiver of Premium amounts.

Portability - Supplemental Life If Life coverage ceases for reasons other than retirement, sickness, injury or termination of the policy, eligible insured persons can purchase portable term life insurance without Evidence of Insurability. As long as premiums are paid, portable coverage continues until the insured reaches the maximum age indicated in the plan design summary.

Accelerated Benefits Insureds who are diagnosed as being terminally ill can access a portion of their life insurance benefits while they are alive. The insured can accelerate a percentage of their life insurance amount, up to the maximum amount, as indicated in the Plan Design Summary. If life insurance benefits are subject to age reductions within 12 months of receiving proof of terminal illness, the accelerated death benefit will reduce accordingly. The minimum amount that can be accelerated and the definition of Terminally Ill are shown in the Additional Plan Features.

Waiver of Premium We will continue coverage for insureds who become totally disabled and complete the Elimination Period shown on the Plan Design Summary. Life Insurance will be extended to the age as indicated in the Plan Design Summary, with no premium charge. The onset of the disability must occur before the insured reaches the age indicated in the Additional Plan Features and they must meet the definition of disability for the entire elimination period. The amount of insurance extended will be the amount of Life Insurance in force immediately prior to the date of the Total Disability. This amount is subject to any reductions under the policy.

Consolidated Claim Management for Life and Long Term Disability For those insured under our Life and Long Term Disability programs, we have a seamless claim process for filing claims for Waiver of Premium and Long Term Disability. The claimant simply completes one claim form, and we handle the rest.

Reduction of Benefits The Insured's life insurance amount will reduce upon reaching the ages as indicated in the Plan Design Summary. All reduction percentages are calculated from the original amount.

Limitations and Exclusions Supplemental Life benefits, including Waiver of Premium, are not payable for a loss which is caused by a suicide or attempted suicide within one year of the effective date of coverage.

Termination of Coverage The insured's life insurance will terminate on the earliest of the following dates:  The date the policy is terminated;  The date the insured stops making any required contribution toward payment of premiums;  The date the insured is no longer a member of an eligible class;  The date the insured requests termination of coverage.  The date the insured is no longer covered as a result of a disability, layoff, leave of absence, sabbatical or military leave.

Extension of Coverage If an employee is no longer Actively at Work as a result of a disability, layoff, leave of absence, sabbatical or military duty, they may be able to continue to be eligible for group Life insurance coverage as follows: Disability - Until the end of the month following the period indicated in the Additional Plan Features after which the

Life and AD&D disability began, provided all premiums have been paid and the policy is still in force and has not been replaced with a new carrier. Layoff - Until the end of the month following the period indicated in the Additional Plan Features after which the layoff began, provided all premiums have been paid and the policy is still in force and has not been replaced with a new carrier. Leave of Absence - Until the end of the month following the period indicated in the Additional Plan Features after which the leave of absence began or the period of time in accordance with FMLA, provided all premiums have been paid and the policy is still in force and has not been replaced with a new carrier. Sabbatical - Until the end of the month following the period indicated in the Additional Plan Features after which the sabbatical began, provided all premiums have been paid and the policy is still in force and has not been replaced with a new carrier. Military Leave - Until the end of the month following the period indicated in the Additional Plan Features after which the disability began, provided all premiums have been paid and the policy is still in force and has not been replaced with a new carrier.

Extension of Coverage for FMLA Leave If an insured is eligible for and receives approval for leave under the Family and Medical Leave Act of 1993 (FMLA) or any applicable state, family and medical leave law, insurance will continue (provided premium continues to be paid) for a period up to the later of: ď&#x201A;ˇ The leave period permitted by FMLA and any amendments; or ď&#x201A;ˇ The leave period permitted by applicable state law.

Transition of Coverage from a Previous Carrier As an established group life insurance carrier, it has been our experience that most carriers have standardized procedures when it comes to determining responsibility for employee transition situations. Our position has been that the terminating carrier is responsible for anyone who was insured under their contract, but is disabled and does not meet the requirements of becoming insured under our contract. This person may or may not be eligible for Waiver of Premium under the prior policy.

It is our recommendation that this issue be discussed with the terminating carrier to identify any insured's who may not be eligible for coverage on the effective date of our policy. While awaiting the decision of the terminating carrier, it is recommended that the impacted employee apply for conversion. We will cover any eligible insureds who may be on vacation, leave of absence, observing a holiday, etc. on the effective date of our policy.

Basic and Supplemental Accidental Death and Dismemberment Accidental Death and Dismemberment (AD&D) plan pays an additional benefit when a covered insured loses their life, or a limb due to an accident. Benefits are paid based on the following schedule. AD&D SCHEDULE OF LOSSES BENEFIT AMOUNT Loss of Life 100% Loss of Both Hands or Both Feet 100% Loss of One Hand and One Foot 100% Loss of Speech and Hearing 100% Loss of Sight of Both Eyes 100% Loss of One hand and the Sight of One Eye 100% Loss of One Foot and the Sight of One Eye 100% Quadriplegia 100% Paraplegia 75% Hemiplegia 50% Loss of Sight of One Eye 50% Loss of One Hand or One Foot 50% Loss of Speech or Hearing 50% Loss of Thumb and Index Finger of Same Hand 25% Uniplegia 25%

The following additional benefits are included with our Accidental Death & Dismemberment plan. For amount and availability of benefits, please refer to the Plan Design Summary. Benefit maximums for Supplemental AD&D benefits include those maximums for Basic AD&D benefits.

Seat Belt Benefit Pays an additional benefit, up to the percentage and maximum amounts indicated in the Plan Design Summary, if the covered insured dies in an automobile accident while wearing a properly worn seat belt.

Air Bag Benefit Pays an additional benefit, up to the percentage and maximum amounts indicated in the Plan Design Summary, if

Life and AD&D the covered insured dies in an automobile accident while seated in a seat containing a factory installed air bag.

Education Benefit Pays an additional benefit, up to the percentage and annual maximum indicated in the Plan Design Summary, if a covered insured dies in an accident and has qualified dependent children attending a school of higher learning. The benefit is payable for each insured child and up to four annual payments.

Repatriation If a covered insured dies as a result of an accident more than 75 miles from their principal place of residence, the benefit pays the actual costs, up to the maximum amount indicated in the Plan Design Summary, for the preparation and transportation of the insured employee's body back to their home.

In the Line of Duty Benefit If a covered insured dies as the result of an accident, is employed as a public safety officer for the policyholder and is killed in the line of duty, an additional benefit, up to the percentage and maximum shown in the Plan Design Summary, is payable.

Felonious Assault Benefit If a covered insured dies as the result of an accident while on the business of the policyholder, an additional benefit, up to the amount shown in the Plan Design Summary, is payable.

Reduction Schedule Benefits reduce according to the schedule indicated in the Plan Design Summary. All reduction percentages are from the original amount.

Exclusions Unless specifically covered in the policy, or required by state law, we will not pay any AD&D benefit for any loss that, directly or indirectly, results in any way from or is contributed to by:  Disease of the mind or body, or any treatment thereof;  Infections, except those from an accidental cut or wound;  Suicide or attempted suicide;  Intentionally self-inflicted injury;  War or act of war;  Travel or flight in any aircraft while a member of the crew;  Commission of or participation in a felony;

 Under the influence certain drugs, narcotics or hallucinogens unless properly used as prescribed by a physician;  Intoxication as defined in the jurisdiction where the accident occurred;  Participation in a riot.

Dependent Life Dependent Effective Date of Coverage If the insured meets the effective date requirements, then the dependents are eligible for coverage unless confined to a hospital. If hospitalized dependent coverage will become effective on the date the eligible dependent is no longer hospital confined.

Spouse Coverage A covered spouse , which includes Domestic Partners where permitted, will be covered for the amount indicated in the Plan Design Summary. In order for a spouse to be covered, the eligible insured person must also be covered. A spouse cannot be insured for more than 100% of the amount the insured person is eligible for.

Spouse Guarantee Issue Spouse amounts up to the Guarantee Issue amount stated in the Plan Design Summary are offered with no need for Evidence of Insurability. Amounts in excess of the Guarantee Issue amount are subject to underwriting approval before becoming effective.

Dependent Child Coverage Eligible Dependent Children will be covered for the amounts as indicated in the Plan Design Summary. Dependent children are covered until reaching the ages indicated in the Plan Design Summary.

Conversion Dependents whose coverage terminates may be able to convert their Life coverage to individual policies. Upon coverage termination administrators have 31 days after coverage ends to inform the dependents of their right to convert to an individual policy without evidence of insurability. Conversion does not apply to AD&D amounts.

Dependent Accidental Death and Dismemberment Our Accidental Death and Dismemberment (AD&D) plan pays an additional benefit when a covered dependent loses their life, or a limb due to an accident.

Life and AD&D Termination of Dependent Life Insurance

Guarantee Issue Amount

Dependent Life insurance will end on the earliest of the following:  The date the insured person is no longer covered under the policy;  The date the Policy is terminated;  The date any required premiums cease to be paid; or  The date the dependent is no longer an eligible dependent under the policy.

Basic Life and AD&D Employee: 1 times your annual salary up to a maximum of $150,000

Supplemental AD&D Employee: Up to $500,000 (subject to eligibility rules and enrollment status guidelines

Rate and Cost Summary Effective Date:

January 01, 2018 Supplemental Life

Age Band

Employee Rates Per $1,000 Monthly

Spouse Rates Per $1,000 Monthly

Below 20 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80-84 85-89 90-94 95-99 100 and above

$0.058 $0.058 $0.070 $0.094 $0.105 $0.117 $0.175 $0.269 $0.503 $0.772 $1.485 $2.409 $2.409 $2.409 $2.409 $2.409 $2.409 $2.409

Supplemental AD&D Age Band All Ages

Employee Rates Spouse Rates Per $1,000 Monthly Per $1,000 Monthly $0.033

Supplemental Term Life Employee: $100,000 (subject to eligibility rules and enrollment status guidelines)

$0.033

Dependent Child(ren) Life and AD&D Coverage

Child(ren) Rates Per $1,000 Monthly

Life AD&D

$0.202 $0.048

Life and AD&D

5STAR

Individual Life

YOUR BENEFITS PACKAGE

PLAY VIDEO

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.

Experts recommend at least

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

Individual 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

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.

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

Term Life with Terminal Illness and Quality of Life Rider

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

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

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

Term Life with Terminal Illness and Quality of Life Rider

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

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

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

*Qualify of Life not available ages 66-70. Quality of Life benefits not available for children. Child life coverage available only on children and grandchildren of employee (age on application date: 14 days through 23 years). $4.98 monthly for $10,000 coverage and $9.97 monthly for $20,000 coverage.

NOTES