2021-22 Duncanville ISD Benefit Guide by Higginbotham Public Sector

DUNCANVILLE ISD

BENEFIT GUIDE EFFECTIVE: 09/01/2021 - 8/31/2022 WWW.MYBENEFITSHUB.COM/DUNCANVILLEISD 1

Table of Contents Benefit Contact Information How to Enroll Annual Benefit Enrollment 1. Benefit Updates 2. Section 125 Cafeteria Plan Guidelines 3. Annual Enrollment 4. Eligibility Requirements 5. Helpful Definitions 6. Health Savings Account (HSA) vs. Flexible Spending Account (FSA) TRS-ActiveCare and Scott & White HMO The Hartford Hospital Indemnity HSA Bank Health Savings Account (HSA) NBS Flexible Spending Account (FSA) MDLIVE Telehealth Cigna Dental VSP Vision The Hartford Disability APL Cancer Voya Accident The Hartford Critical Illness UNUM Life and AD&D Texas Life Individual Life LegalShield Identity Theft & Legal Protection 2

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

FLIP TO... PG. 4

HOW TO ENROLL

PG. 6

SUMMARY PAGES

PG. 12

YOUR BENEFITS

11 12-15 16-19 20-23 24-27 28-29 30-43 44-45 46-49 50-53 54-59 60-63 64-67 68-69 70-71

Benefit Contact Information DISD BENEFIT ADMINISTRATOR

VISION

INDIVIDUAL LIFE

Erica Dominguez (972)708-2014 Erdominguez@duncanvilleisd.org

VSP Group # 30020362 (800) 877-7195 www.vsp.com

Texas Life (800) 283-9233 www.texaslife.com

ENROLLMENT ADMINISTRATORS

DISABILITY

HEALTH SAVINGS ACCOUNT

Financial Benefit Services (866) 914-5202 www.mybenefitshub.com/duncanvilleisd

The Hartford Group # 395320 (800) 583-6908 File a Claim: (866) 278-2655 www.thehartford.com

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

TRS ACTIVECARE MEDICAL

CANCER

FLEXIBLE SPENDING ACCOUNT

Blue Cross Blue Shield of Texas ACT Care HD Group # 38500 ACT Primary+ Group # 385001 ACT Primary Group # 385003 ACT Care 2 Group # 385002 (866) 355-5999 www.bcbstx.com/trsactivecare

American Public Life Group # 15668 File a Claim (800) 256-8606 www.ampublic.com

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

TRS HMO MEDICAL

ACCIDENT

IDENTITY THEFT/LEGAL PROTECTION

Scott & White HMO Group # 085000 (800) 321-7947 www.trs.swhp.org Pharmacy 800-728-7947 prescriptionservices@sw.org

Voya Group # 70124-6 (972) 225-1524 www.voya.com

LegalShield Group # 47012 (800) 654-7757 www.legalshield.com

HOSPITAL INDEMNITY

CRITICAL ILLNESS

DENTAL

The Hartford Group # 395320 (866) 547-4205 www.thehartford.com

The Hartford Group # 460138 (877) 248-5077 www.thehartford.com

Cigna Group # 3336999 (800) 244-6224 www.mycigna.com

TELEHEALTH

LIFE AND AD&D

403(b)

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

UNUM Group # 469014 (800) 583-6908 www.unum.com

TCG Group Holdings (800) 943-9179 www.tcgservices.com 3

MOBILE APP DOWNLOAD Enrollment made simple through the new FBS Benefits App! Text “FBS DISD” to (800) 583-6908

and get access to everything you need to complete your benefits

Text “FBS DISD” to (800) 583-6908

enrollment: 

Enrollment Resources



Online Support



Interactive Tools



And more!

App Group #: FBSDISD

OR SCAN

How to Log In

1 BENEFIT INFO

INTERACTIVE TOOLS

2 3

www.mybenefitshub.com/duncanvilleisd

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.

ONLINE 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

SUMMARY PAGES

Benefit Updates - What’s New: TRS-ACTIVECARE - KEY PLAN CHANGES AC Primary This plan still has the lowest monthly costs and copays. Your Primary Care Provider copay is $30 and TRS Virtual Health is $0.

HSA/FSA UPDATES HSA maximum contributions increased to $3,600 Employee Only, $7,200 Family; 55+ $4,600 Employee Only, $8,200 Family.

FSA maximum contributions to $2,750 – AC Primary+ This plan still has copays and the lowest deductibles, minimum contribution $10 per month maximum out-of-pockets, and coinsurance rates. Your Primary Care Provider copay is $30 and TRS Virtual Health is $0. EVERGREEN ELECTIONS SUMMARY OF CHANGES TO FSA May I make new elections in future plan years? AC HD In-network deductible rose by $200 for individuals and $400 for families. In-network coinsurance rates rose from 20% to 30% and Out-of-network rates rose from 40% to 50%. Innetwork maximum out-of-pocket rose by $100 for individuals and $200 for families. AC 2 Remains closed to new enrollees.

Yes, you may. For each new Plan Year, you may change the elections that you previously made. You may also choose not to participate in the Plan for the upcoming Plan Year. If you do not make new elections during the election period before a new Plan Year begins, we will assume you want your elections for benefits under the Plan to remain for the upcoming Plan Year.

Central and North Texas Scott & White Care Plan EO and EC - $9/ month premium decrease! Deductible increasing to $1,150 Individual/$3,450 Family. Rx Deductible increasing to $200 (excludes generics). Generic copay increase to $10/$25.

• • • •

Login and complete your supplemental benefit enrollment from 07/12/2021 - 08/10/2021 Enrollment assistance is available by calling Financial Benefit Services at 866-914-5202 to speak to an enrollment representative Monday—Friday, 8am—7pm. Bilingual assistance is available. Update your profile information: home address, phone numbers, email. IMPORTANT!! Due to the Affordable Care Act (ACA) reporting requirements, please add your dependent’s social security numbers in the HUB. If you have questions, please contact your Benefits Administrator.

SUMMARY PAGES

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

CHANGES IN STATUS (CIS):

Marital Status

Changes in benefit elections can occur only if you experience a qualifying event. You must present proof of a qualifying event to your Benefit Office within 31 days of your qualifying event and meet with your Benefit 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.

Judgment/Decree/Order

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 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

Eligibility for Government Programs

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

SUMMARY PAGES

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

Where can I find forms?

to review, change or continue benefit elections each year.

For benefit summaries and claim forms, go to your school

Changes are not permitted during the plan year (outside of

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

annual enrollment) unless a Section 125 qualifying event occurs.

duncanvilleisd. Then click the benefit plan you need information on (i.e., Dental) and you can find the forms you

•

Changes, additions or drops may be made only during the

need under the Benefits and Forms section.

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

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

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

included in the dependent profile. Additionally, you must

duncanvilleisd. Then click on the benefit plan you need

notify your employer of any discrepancy in personal and/or benefit information.

•

For benefit summaries and claim forms, go to your school

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

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

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

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

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

SUMMARY PAGES

Employee Eligibility Requirements

Dependent Eligibility Requirements

Supplemental Benefits: Eligible employees must work 20 or more

Dependent Eligibility: You can cover eligible dependent

regularly scheduled hours each work week.

children under a benefit that offers dependent coverage,

Eligible employees must be actively at work on the plan effective date for new benefits to be effective, meaning you are physically capable of performing the functions of your job on the first day of work concurrent with the plan effective date. For example, if

provided you participate in the same benefit, through the maximum age listed below. Dependents cannot be double covered by married spouses within the district as both employees and dependents.

your 2021 benefits become effective on September 1, 2021, you must be actively-at-work on September 1, 2021 to be eligible for your new benefits. MAXIMUM AGE Please note, limits and exclusions may apply when obtaining coverage as a married couple or when

PLAN

CARRIER

Accident

Voya

Cancer

APL

Critical Illness The Hartford

obtaining coverage for dependents.

Dental

Cigna

Flexible Spending Account (FSA) Health Savings Account (HSA)

National Benefit Services

26 or IRS Tax Dependent

Identity Theft and Legal Protection

26 or IRS Tax Dependent 18 for full services ID Theft (26 for LegalShield restoration and Legal Protection only) HSA Bank

Individual Life

Texas Life

Life and AD&D

UNUM

Hospital Indemnity

The Hartford

Telehealth

MDLIVE

BCBSTX and TRS Medical Scott & White HMO Vision

VSP

26 18 (25 for full time students)

Potential Spouse Coverage Limitations: When enrolling in coverage, please keep in mind that some benefits may not allow you to cover your spouse as a dependent if your spouse is enrolled for coverage as an employee under the same employer. Review the applicable plan documents, contact Financial Benefit Services, or contact the insurance carrier for additional information on spouse eligibility. FSA/HSA Limitations: Please note, in general, per IRS regulations, married couples may not enroll in both a Flexible Spending Account (FSA) and a Health Savings Account (HSA). If your spouse is covered under an FSA that reimburses for medical expenses then you and your spouse are not HSA eligible, even if you would not use your spouse's FSA to reimburse your expenses. However, there are some exceptions to the general limitation regarding specific types of FSAs. To obtain more information on whether you can enroll in a specific type of FSA or HSA as a married couple, please reach out to the FSA and/or HSA provider prior to enrolling or reach out to your tax advisor for further guidance. Potential Dependent Coverage Limitations: When enrolling for dependent coverage, please keep in mind that some benefits may not allow you to cover your eligible dependents if they are enrolled for coverage as an employee under the same employer. Review the applicable plan documents, contact Financial Benefit Services, or contact the insurance carrier for additional information on dependent eligibility. Disclaimer: You acknowledge that you have read the limitations and exclusions that may apply to obtaining spouse and dependent coverage, including limitations and exclusions that may apply to enrollment in Flexible Spending Accounts and Health Savings Accounts as a married couple. You, the enrollee, shall hold harmless, defend, and indemnify Financial Benefit Services, LLC from any and all claims, actions, suits, charges, and judgments whatsoever that arise out of the enrollee's enrollment in spouse and/or dependent coverage, including enrollment in Flexible Spending Accounts and Health Savings Accounts.

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

Helpful Definitions

SUMMARY PAGES

Actively at Work

In-Network

You are performing your regular occupation for the employer

Doctors, hospitals, optometrists, dentists and other providers

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

who have contracted with the plan as a network provider.

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

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

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.

Plan Year September 1st through August 31st.

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

Calendar Year

orders to take drugs, or received medical care or services

January 1st through December 31st.

(including diagnostic and/or consultation services).

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.

SUMMARY PAGES

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

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

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

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

Employer Eligibility

A qualified high deductible health plan.

Duncanville ISD

Contribution Source

Employee

Account Owner Underlying Insurance Requirement

Individual

Duncanville ISD

Enrollment in ActiveCare 1-HD ONLY

None

Description

Minimum Deductible Maximum Contribution

Permissible Use Of Funds

$1,400 single (2021) $2,800 family (2021) $3,600 single (2021) $7,200 family (2021) Employees may use funds any way they wish. If used for non-qualified medical expenses, subject to current tax rate plus 20% penalty.

N/A $2,750 Reimbursement for qualified medical expenses (as defined in Sec. 213(d) of IRC).

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

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

Not permitted

Year-to-year rollover of account balance?

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

No, however, your plan does allow a $500 rollover provision.

Does the account earn interest?

Yes

Portable?

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

FLIP TO FOR HSA INFORMATION

PG. 20

FLIP TO FOR FSA INFORMATION

PG. 24 11

BCBSTX

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 12 details on covered expenses, limitations and exclusions are included in the summary plan description located on the Duncanville ISD Benefits Website: www.mybenefitshub.com/duncanvilleisd

Duncanville ISD Plan Year September 1, 2021—August 31, 2022 TRS Medical Insurance Rates include $333 district contribution 12 pay TRS-ActiveCare Primary +

TRS-ActiveCare Primary (NEW)

TRS-ActiveCare HD

Employee Only

$ 84.00

$ 96.00

$ 209.00

$ 680.00

$ 209.48

Employee + Spouse

$ 843.00

$ 876.00

$ 1,001.00

$ 2,069.00

$ 1,029.70

Employee + Child(ren)

$ 418.00

$ 439.00

$ 546.00

$ 1,174.00

$ 539.16

$ 1,072.00

$ 1,112.00

$ 1,342.00

$ 2,508.00

$ 1,235.42

Employee + Family

(Formerly 1- HD)

(Formerly Select)

TRS- ActiveCare 2 (Closed to new enrollees)

Scott & White HMO

26 pay TRS-ActiveCare Primary +

TRS-ActiveCare Primary (NEW)

TRS-ActiveCare HD

Employee Only

$ 42.00

$ 48.00

$ 104.50

$ 340.00

$ 104.74

Employee + Spouse

$ 421.50

$ 438.00

$ 500.50

$ 1,034.50

$ 514.85

Employee + Child(ren)

$ 209.00

$ 219.50

$ 273.00

$ 587.00

$ 269.58

Employee + Family

$ 536.00

$ 556.00

$ 671.00

$ 1,254.00

$ 617.71

(Formerly 1- HD)

(Formerly Select)

TRS- ActiveCare 2 (Closed to new enrollees)

Scott & White HMO

18 pay

TRS-ActiveCare Primary +

TRS-ActiveCare Primary (NEW)

TRS-ActiveCare HD

Employee Only

$ 56.00

$ 64.00

$ 139.33

$ 453.33

$ 139.65

Employee + Spouse

$ 562.00

$ 584.00

$ 667.33

$ 1,379.33

$ 686.47

Employee + Child(ren)

$ 278.67

$ 292.67

$ 364.00

$ 782.67

$ 359.44

Employee + Family

$ 714.67

$ 741.33

$ 894.67

$ 1,672.00

$ 823.61

(Formerly 1- HD)

(Formerly Select)

TRS- ActiveCare 2 (Closed to new enrollees)

Scott & White HMO

*Please note the rates above are per paycheck and after the district has contributed. Split Rates (Employee + Family) TRS-ActiveCare Primary (NEW) Employee + Family

TRS-ActiveCare HD (Formerly 1- HD)

TRS-ActiveCare Primary + (Formerly Select)

TRS- ActiveCare 2 (Closed to new enrollees)

Scott & White HMO

Contact the district Benefits Specialist for individual rates

Employee works for Duncanville ISD and their spouse works at another school district oﬀering TRS-ActiveCare Medical. Pooled Rates (Employee + Family) TRS-ActiveCare Primary (NEW) Employee + Family

TRS-ActiveCare HD (Formerly 1- HD)

TRS-ActiveCare Primary + (Formerly Select)

TRS- ActiveCare 2 (Closed to new enrollees)

Scott & White HMO

Contact the district Benefits Specialist for individual rates

Both employee and their spouse works for Duncanville ISD. 13

2021-22 TRS-ActiveCare Plan Highlights Sept. 1, 2021 — Aug. 31, 2022 All TRS-ActiveCare participants have three plan options. Each includes a wide range of wellness benefits. TRS-ActiveCare 2 TRS-ActiveCare Primary • Lowest premium of the •

Plan summary

• • • •

Monthly Premiums Employee Only Employee and Spouse Employee and Children Employee and Family

plans Copays for doctor visits before you meet deductible Statewide network PCP referrals required to see specialists Not compatible with a health savings account (HSA) No out-of-network coverage

Total Premium $417 $1,176 $751 $1,405

Your Premium $ $ $ $

(This plan is closed and not accepting new enrollees. If you’re currently enrolled in TRS-ActiveCare 2, you can remain in this plan.)

TRS-ActiveCare Primary+

TRS-ActiveCare HD

• Lower deductible than the HD and

• Compatible with a health savings

• • • • • •

Primary plans Copays for many services and drugs Higher premium than the other plans Statewide network PCP referrals required to see specialists Not compatible with a health savings account (HSA) No out-of-network coverage

Total Premium $542 $1,334 $879 $1,675

account (HSA) • Nationwide network with out-ofnetwork coverage • No requirement for PCPs or referrals • Must meet your deductible before plan pays for non-preventive care

• Closed to new enrollees • Current enrollees can choose to

stay in this plan

• Lower deductible • Copays for many drugs and

services

• Nationwide network with out-of-

network coverage

• No requirement for PCPs or

referrals

Your Premium $ $ $ $

Total Premium $429 $1,209 $772 $1,445

Your Premium $ $ $ $

Total Premium $1,013 $2,402 $1,507 $2,841

Your Premium $ $ $ $

Plan Features Type of Coverage Individual/Family Deductible

In-Network Coverage Only

In-Network

Out-of-Network

In-Network

Out-of-Network

$2,500/$5,000

$1,200/$3,600

$3,000/$6,000

$5,500/$11,000

$1,000/$3,000

$2,000/$6,000

You pay 30% after deductible

You pay 20% after deductible

You pay 30% after deductible

You pay 20% after deductible

$8,150/$16,300

$6,900/$13,800

Statewide Network

You pay 50% after deductible $20,250/ $7,000/$14,000 $40,500 Nationwide Network

You pay 40% after deductible $23,700/ $7,900/$15,800 $47,400 Nationwide Network

Yes

Primary Care

$30 copay

Specialist

$70 copay

$0 per consultation

$50 copay

You pay 30% after deductible

You pay 20% after deductible

You pay 30% after deductible

$0 per consultation

$30 per consultation

Integrated with medical $15/$45 copay; $0 for certain generics

$200 brand deductible

Integrated with medical You pay 20% after deductible; $0 for certain generics

Coinsurance Individual/Family Maximum Out-of-Pocket Network Primary Care Provider (PCP) Required

Doctor Visits

TRS Virtual Health

You pay 30% You pay 50% after deductible after deductible You pay 30% You pay 50% after deductible after deductible $30 per consultation

You pay 40% after deductible You pay 40% $70 copay after deductible $0 per consultation $30 copay

Immediate Care Urgent Care Emergency Care TRS Virtual Health

You pay 30% after deductible

You pay 50% after deductible

You pay 40% after deductible You pay a $250 copay plus 20% after deductible $0 per consultation $50 copay

Prescription Drugs Drug Deductible Generics (30-Day Supply/ 90-Day Supply)

$15/$45 copay

Preferred Brand

You pay 30% after deductible

You pay 25% after deductible

Non-preferred Brand

You pay 50% after deductible

Specialty

You pay 30% after deductible

You pay 20% after deductible

How to Calculate Your Monthly Premium

Wellness Benefits at No Extra Cost

Total Monthly Premium

Being healthy is easy with:

Your District and State Contributions

Your Premium Ask your Benefits Administrator for your district’s premiums.

Things to Know • •

TRS’s Texas-sized purchasing power creates broad networks without county boundaries. Specialty drug insurance means you’re covered, no matter what life throws at you. 14

• • • • •

$0 preventive care 24/7 customer service One-on-one health coaches Weight loss programs Nutrition programs

$200 brand deductible $20/$45 copay You pay 25% after deductible ($40 min/$80 max)/ You pay 25% after deductible ($105 min/$210 max) You pay 50% after deductible ($100 min/$200 max)/ You pay 50% after deductible ($215 min/$430 max) You pay 20% after deductible ($200 min/$900 max)

• • • •

Ovia® pregnancy support TRS Virtual Health Mental health support And much more!

Available for all plans. See your Benefits Booklet for more details.

2021-22 Health Maintenance Organizations: Premiums for Regional Plans Remember: When you choose an HMO, you’re choosing a regional network. TRS also contracts with HMOs in certain regions of the state to bring participants in those areas another option. Central and North Texas Scott and White Care Plan

Blue Essentials — South Texas HMOSM

Brought to you by TRS-ActiveCare

You can choose this plan if you live in one of these counties: Austin, Bastrop, Bell, Blanco, Bosque, Brazos, Burleson, Burnet, Caldwell, Collin, Coryell, Dallas, Denton, Ellis, Erath, Falls, Freestone, Grimes, Hamilton, Hays, Hill, Hood, Houston, Johnson, Lampasas, Lee, Leon, Limestone, Madison, McLennan, Milam, Mills, Navarro, Robertson, Rockwall, Somervell, Tarrant, Travis, Walker, Waller, Washington, Williamson

Total Monthly Premiums Employee Only

Total Premium

Your Premium

You can choose this plan if you live in one of these counties: Cameron, Hildalgo, Starr, Willacy

Total Premium

Your Premium

Blue Essentials — West Texas HMOSM Brought to you by TRS-ActiveCare You can choose this plan if you live in one of these counties: Andrews, Armstrong, Bailey, Borden, Brewster, Briscoe, Callahan, Carson, Castro, Childress, Cochran, Coke, Coleman, Collingsworth, Comanche, Concho, Cottle, Crane, Crockett, Crosby, Dallam, Dawson, Deaf Smith, Dickens, Donley, Eastland, Ector, Fisher, Floyd, Gaines, Garza, Glasscock, Gray, Hale, Hall, Hansford, Hartley, Haskell, Hemphill, Hockley, Howard, Hutchinson, Irion, Jones, Kent, Kimble, King, Knox, Lamb, Lipscomb, Llano, Loving, Lubbock, Lynn, Martin, Mason, McCulloch, Menard, Midland, Mitchell, Moore, Motley, Nolan, Ochiltree, Oldham, Parmer, Pecos, Potter, Randall, Reagan, Reeves, Roberts, Runnels, San Saba, Schleicher, Scurry, Shackelford, Sherman, Stephens, Sterling, Stonewall, Sutton, Swisher, Taylor, Terry, Throckmorton, Tom Green, Upton, Ward, Wheeler, Winkler, Yoakum

Total Premium

Your Premium

$542.48

$524.00

$596.54

Employee and Spouse

$1,362.70

$1,264.28

$1,443.66

Employee and Children

$872.16

$819.60

$936.18

$1,568.42

$1,345.58

$1,532.74

Employee and Family

Plan Features Type of Coverage

In-Network Coverage Only

$1,150/$3,450

$500/$1,000

$950/$2,850

You pay 20% after deductible

You pay 25% after deductible

$7,450/$14,900

$4,500/$9,000

$7,450/$14,900

Primary Care

$20 copay

$25 copay

$20 copay

Specialist

$70 copay

$60 copay

$70 copay

$50 copay

$75 copay

$50 copay

$500 copay after deductible

You pay 20% after deductible

$500 copay before deductible and 25% after deductible

$200 (excl. generics)

$100

$150

30-day supply/90-day supply

Individual/Family Deductible Coinsurance Individual/Family Maximum Outof-Pocket

In-Network Coverage Only

Doctor Visits

Immediate Care Urgent Care

Emergency Care

Prescription Drugs Drug Deductible Day Supply Generics

$10/$25 copay

$10/$30 copay

$5/$12.50 copay; $0 for certain generics

Preferred Brand

You pay 30% after deductible

$40/$120 copay

You pay 30% after deductible

Non-preferred Brand

You pay 50% after deductible

$65/$195 copay

You pay 50% after deductible

You pay 15%/25% after deductible (preferred/non-preferred)

You pay 20% after deductible

You pay 15%/25% after deductible (preferred/non-preferred)

Specialty

trs.texas.gov 15

THE HARTFORD YOUR BENEFITS PACKAGE

Hospital Indemnity

About this Benefit Hospital Confinement Indemnity Insurance pays a daily benefit if you have a covered stay in a hospital*, critical care unit and rehabilitation facility. The benefit amount is determined based on the type of facility and the number of days you stay. Hospital Confinement Indemnity Insurance is a limited benefit policy. It is not health insurance and does not satisfy the requirement of minimum essential coverage under the Affordable Care Act.

The median hospital costs per stay have steadily grown to over $10,000.

$8,800

9,600

10,400

2003

2008

2012

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 16 details on covered expenses, limitations and exclusions are included in the summary plan description located on the Duncanville ISD Benefits Website: www.mybenefitshub.com/duncanvilleisd

Hospital Indemnity Plan GROUP VOLUNTARY HOSPITAL INDEMNITY INSURANCE BENEFIT HIGHLIGHTS Hospital Indemnity (HI) insurance pays a cash benefit if you or an insured dependent (spouse or child) are confined in a hospital for a covered illness or injury. Even with the best primary health insurance plan, out-of-pocket costs from a hospital stay can add up. The benefits are paid in lump sum amounts to you, and can help offset expenses that primary health insurance doesn’t cover (like deductibles, co-insurance amounts or copays), or benefits can be used for any non-medical expenses (like housing costs, groceries, car expenses, etc.). To learn more about Hospital Indemnity insurance, visit thehartford.com/employeebenefits.

A 4-day stay in the hospital could cost around $10,000.1

COVERAGE INFORMATION You have a choice of two hospital indemnity plans, which allows you the ﬂexibility to enroll for the coverage that best meets your needs. Benefit amounts are based on the plan in effect for you or an insured dependent at the time the covered event occurs. Unless otherwise noted, the benefit amounts payable under each plan are the same for you and your dependent(s). PLAN INFORMATION PLAN 1 PLAN 2 Coverage Type

On and off-job (24 hour)

Covered Events

Illness and injury

HSA Compatible

Yes

PLAN 1

PLAN 2

BENEFITS HOSPITAL CARE2 First Day Hospital Confinement

Up to 1 day per year

$1000

$2000

Daily Hospital Confinement (Day 2+)

Up to 90 days per year

$100

$200

FEATURES Ability Assist® EAP2 – 24/7/365 access to help for financial, legal or emotional issues

PLAN 2 Included

Included

COVERAGE TIER

PLAN 1

PLAN 2

Employee Only

$16.18 ($0.53 per day)

$32.37 ($1.06 per day)

Employee & Spouse/Partner

$31.27 ($1.03 per day)

$62.55 ($2.06 per day)

Employee & Child(ren)

$28.02 ($0.92 per day)

$56.04 ($1.84 per day)

Employee & Family

$45.07 ($1.48 per day)

$90.13 ($2.96 per day)

HealthChampionSM2 – Administrative & clinical support following serious illness or injury

PREMIUMS The amounts shown are monthly amounts (12 payments/deductions per year). 3

Hospital Indemnity Plan ASKED & ANSWERED IS THIS COVERAGE HSA COMPATIBLE? If you (or any dependent(s)) currently participate in a Health Saving Account (HSA) or if you plan to do so in the future, you should be aware that the IRS limits the types of supplemental insurance you may have in addition to a HSA, while still maintaining the tax-exempt status of the HSA. Both HSA compatible and non-HSA compatible plans are available to you, as indicated in the Plan Information section. If you have or plan to open an HSA, please consult your tax and legal advisors to determine which supplemental benefits may be purchased by employees with an HSA. WHO IS ELIGIBLE? You are eligible for this insurance if you are an active full-time employee who works at least 30 hours per week on a regularly scheduled basis. Your spouse and child(ren) are also eligible for coverage. Any child(ren) must be under age 26 (or under age 26 if a full-time student). CAN I INSURE MY DOMESTIC OR CIVIL UNION PARTNER? Yes. Any reference to “spouse” in this document includes your domestic partner, civil union partner or equivalent, as recognized and allowed by applicable law. AM I GUARANTEED COVERAGE? This insurance is guaranteed issue coverage – it is available without having to provide information about your or your family’s health. All you have to do is elect the coverage to become insured. HOW MUCH DOES IT COST AND HOW DO I PAY FOR THIS INSURANCE? Premiums are provided above. You have a choice of plan options. You may elect insurance for you only, or for you and your dependent(s), by choosing the applicable coverage tier. Premiums will be automatically paid through payroll deduction, as authorized by you during the enrollment process. This ensures you don’t have to worry about writing a check or missing a payment.

1“Hospital Adjusted Expenses per Inpatient Day.” Kaiser Family Foundation. 2015. Web. 2 Mar. 2017. 2For Hospital Care benefits, when an insured is eligible for more than one benefit in a single day, only the highest benefit will be paid. 3Rates and/or benefits may be changed. 4HealthChampionSM and Ability Assist® services are provided through The Hartford by ComPsych®. ComPsych is not affiliated with The Hartford and is not a provider of insurance services. The Hartford is not responsible and assumes no liability for the goods and services provided by ComPsych. Prepare. Protect. Prevail. With The Hartford. ® The Hartford® is The Hartford Financial Services Group, Inc. and its subsidiaries, including issuing companies Hartford Life Insurance Company and Hartford Life and Accident Insurance Company. Home Office is Hartford, CT. 5962h NS 08/16 © 2016 The Hartford Financial Services Group, Inc. All rights reserved. This Benefit Highlights document explains the general purpose of the insurance described, but in no way changes or affects the policy as actually issued. In the event of a discrepancy between this document and the policy, the terms of the policy apply. Benefits are subject to state availability. Policy terms and conditions vary by state. Complete details are in the Certificate of Insurance issued to each insured individual and the Master Policy as issued to the policyholder. Hospital does not include: convalescent homes, or convalescent, rest or nursing facilities; facilities affording primarily custodial, educational or rehabilitory care; or facilities primarily for care of the aged/elderly, persons with substance abuse issues/ disorders or mental/nervous disorders. Confinement means the assignment to a bed in a medical facility for a period of at least 20 consecutive hours. Required hours may vary by state. The Hartford compensates both internal and external producers, as well as others, for the sale and service of our products. For additional information regarding Hartford’s compensation practices, please review our website http://thehartford.com/group-benefitsproducer-compensation. Hospital Income Plan Form Series includes GBD-2800, GBD-2900, or state equivalent.

LIMITATIONS & EXCLUSIONS This insurance coverage includes certain limitations and exclusions. The certificate details all provisions, limitations, and exclusions for this insurance coverage. A copy of the certificate can be obtained from your employer. GROUP HOSPITAL INDEMNITY INSURANCE LIMITATIONS AND EXCLUSIONS The benefits payable are based on the insurance in effect on the date of the covered event, subject to the definitions, limitations, exclusions and other provisions of the policy. You and your dependent(s) must be citizens or legal residents of the United States, its territories and protectorates.

Other Hospital Indemnity Policy Limitation (Over-insurance Limitation): If an employee is insured under any other hospital indemnity policy You must be actively at work with your employer on the day your underwritten by The Hartford, any claim for benefit is only payable coverage takes effect. Your spouse and child(ren) must be performing under the one policy elected by the employee (or beneficiary or estate, normal activities and not be confined (at home or in a hospital/care in the event of death). We will return the amount of premium paid for facility). any other policy that is declined by the employee retroactive to the WHEN DOES THIS INSURANCE END? later of: This insurance will end when you or your dependents no longer satisfy • the last date any benefit was paid for any covered person under the applicable eligibility conditions, premium is unpaid, you are no the other policy longer actively working, you leave your employer, or the coverage is no • the effective date of insurance for the employee under the other longer offered. policy Exclusions. This insurance does not provide benefits for any loss that CAN I KEEP THIS INSURANCE IF I LEAVE MY EMPLOYER OR AM NO results from or is caused by: LONGER A MEMBER OF THIS GROUP? • Suicide or attempted suicide, whether sane or insane, or Yes, you can take this coverage with you. Coverage may be continued intentional self-inﬂiction for you and your dependent(s) under a group portability policy. Your • Voluntary intoxication (as defined by the law of the jurisdiction in spouse mayalso continue insurance in certain circumstances. The which the illness or injury occurred) or while under the inﬂuence specific terms and qualifying events for portability are described in the of any narcotic, drug or controlled substance, unless administered certificate. by or taken according to the instruction of a physician or medical professional 18

Hospital Indemnity Plan • •

• •

•

• •

•

Voluntary intoxication through use of poison, gas or fumes, whether by ingestion, injection, inhalation or absorption Voluntary commission of or attempt to commit a felony, voluntary participation in illegal activities (except for misdemeanor violations), voluntary participation in a riot, or voluntary engagement in an illegal occupation Incarceration or imprisonment following conviction for a crime Travel in or descent from any vehicle or device for aviation or aerial navigation, except as a fare-paying passenger in a commercial aircraft (other than a charter airline) on a regularly scheduled passenger flight or while traveling on business of the policyholder Ride in or on any motor vehicle or aircraft engaged in acrobatic tricks/stunts (for motor vehicles), acrobatic/stunt flying (for aircraft), endurance tests, off-road activities (for motor vehicles), or racing Participation in any organized sport in a professional or semiprofessional capacity Participation in abseiling, base jumping, Bossaball, bouldering, bungee jumping, cave diving, cliff jumping, free climbing, freediving, freerunning, hang gliding, ice climbing, Jai Alai, jet powered flight, kite surfing, kiteboarding, luging, missed climbing, mountain biking, mountain boarding, mountain climbing, mountaineering, parachuting, paragliding, parakiting, paramotoring, parasailing, Parkour, proximity flying, rock climbing, sail gliding, sandboarding, scuba diving, sepak takraw, slacklining, ski jumping, skydiving, sky surfing, speed flying, speed riding, train surfing, tricking, wingsuit flying, or other similar extreme sports or high risk activities Travel or activity outside the United States or Canada Active duty service or training in the military (naval force, air force or National Guard/Reserves or equivalent) for service/training extending beyond 31 days of any state, country or international organization, unless specifically allowed by a provision of the certificate Involvement in any declared or undeclared war or act of war (not including acts of terrorism), while serving in the military or an auxiliary unit attached to the military, or working in an area of war whether voluntarily or as required by an employer

This insurance also does not provide benefits, unless required by law, for: • Elective abortion or complications thereof • Artificial insemination, in vitro fertilization, test tube fertilization • Sterilization, tubal ligation or vasectomy, and reversal thereof • Aroma therapeutic, herbal therapeutic, or homeopathic services • Any mental and nervous disorder, unless specifically allowed by a provision of the certificate • Substance abuse, unless specifically allowed by a provision of the certificate • Medical mishap or negligence on the part of any physician, medical professional, or therapist, including malpractice; • Treatment, supplies or services provided by, through or, behalf of any government agency or program; unless payment is required by a covered person • Custodial care, unless specifically allowed by a benefit provision in

the certificate or any rider attached to the policy (if applicable) Elective or cosmetic surgery or procedures, except for reconstructive surgery:  Incidental to or following surgery for disease, infection or trauma of the involved body part  Due to congenital anomaly or disease of a dependent child which has resulted in a functional defect Dental care or treatment, except for:  Treatment due to an Injury to sound natural teeth within 12 months of an accident  Treatment necessary due to congenital disease or anomaly

•

Exclusions will vary by the jurisdiction/state in which the policy is issued.

Prepare. Protect. Prevail. With The Hartford. ® To learn more about Hospital Indemnity Insurance, visit Thehartford.com/employeebenefits NOTICES THE POLICY IS A HOSPITAL CONFINEMENT INDEMNITY POLICY. THE POLICY PROVIDES LIMITED BENEFITS. 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. The Policy may provide payment of several benefits as a result of claims from a single hospitalization or covered incident. Payment of one benefit under the Policy does not constitute acceptance of liability for all claims made under the Policy nor does it prohibit Us from further investigation of subsequent claims. Please note: For residents of CA, GA, NJ and NY, since this is a limited benefit health product, persons without comprehensive health benefits from an individual or group health insurance policy or an HMO, or an employer plan providing essential health benefits are not eligible for this insurance. For residents of CT, ID, ME, NH, and WV, a person covered by any Title XIX program (Medicaid or any similar name) is not eligible for this insurance. 5962h NS 08/16 © 2016.The Hartford Financial Services Group, Inc. All rights reserved. Hospital Income Plan Form Series includes GBD-2800, GBD-2900, or state equivalent. Prepare. Protect. Prevail. With The Hartford. ® The Hartford® is The Hartford Financial Services Group, Inc. and its subsidiaries, including issuing companies Hartford Life Insurance Company and Hartford Life and Accident Insurance Company. Home Office is Hartford, CT. This Benefit Highlights document explains the general purpose of the insurance described, but in no way changes or affects the policy as actually issued. In the event of a discrepancy between this document and the policy, the terms of the policy apply. Benefits are subject to state availability. Policy terms and conditions vary by state. Complete details are in the Certificate of Insurance issued to each insured individual and the Master Policy as issued to the policyholder.

HSA BANK

HSA (Health Savings Account)

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.

YOUR BENEFITS PACKAGE

The interest earned in an HSA is tax free.

Money withdrawn for medical spending never falls under taxable income.

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 This is a general overview of your plan benefits.inIfthe thesummary terms of plan this outline differlocated from your policy, the policy will govern. Additional plan description on the 20 details on covered expenses, limitations and exclusions included in the summary plan description located on the Duncanville ISD Benefits Website:are www.mybenefitshub.com/duncanvilleisd Duncanville ISD Benefits Website: www.mybenefitshub.com/duncanvilleisd

HSA (Health Savings Account) Start saving more on healthcare

2020 Annual HSA Contribution Limits

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

Individual: $3,550 Family: $7,100

How an HSA works: •

•

• •

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

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

2021 Annual HSA Contribution Limits Individual: $3,600 Family: $7,200 According to IRS guidelines, each year you have until the tax filing deadline to contribute to your HSA (typically April 15 of the following year). Online contributions must be submitted by 2:00 p.m., Central Time, the business day before the tax filing deadline. Wire contributions must be received by noon, Central Time, on the tax filing deadline, and contribution forms with checks must be received by the tax filing deadline.

Catch-Up Contributions: Accountholders who meet these qualifications are eligible to make an HSA catch-up contribution of $1,000: Health Savings accountholder; age 55 or older (regardless of when in the year an accountholder turns 55); not enrolled in Medicare (if an accountholder enrolls in Medicare mid-year, catch-up contributions should be prorated). Spouses who are 55 or older and covered under the accountholder’s medical insurance can also make a catch-up contribution into a separate HSA in their own name.

How can you benefit from tax savings? An HSA provides triple tax savings.3 Here’s how: • Contributions to your HSA can be made with pre-tax dollars and any after-tax contributions that you make to your HSA are tax deductible. • HSA funds earn interest and investment earnings are tax free. • When used for IRS-qualified medical expenses, distributions are free from tax.

IRS-Qualified Medical Expenses

You can use your HSA to pay for a wide range of IRS-qualified medical expenses for yourself, your spouse, or tax dependents. An IRS qualified medical expense is defined as an expense that pays for healthcare services, equipment, or medications. Funds Contributions made by all parties to an HSA cannot exceed the used to pay for IRS-qualified medical expenses are always taxannual HSA limit set by the Internal Revenue Service (IRS). free. Anyone can contribute to your HSA, but only the accountholder and employer can receive tax deductions on those contributions. HSA funds can be used to reimburse yourself for past medical expenses if the expense was incurred after your HSA was Combined annual contributions for the accountholder, employer, established. While you do not need to submit any receipts to and third parties (i.e., parent, spouse, or anyone else) must not HSA Bank, you must save your bills and receipts for tax purposes. exceed these limits.2

What are the annual IRS contribution limits?

HSA (Health Savings Account) Examples of IRS-Qualified Medical Expenses4: Acupuncture Alcoholism treatment Ambulance services Annual physical examination Artificial limb or prosthesis Birth control pills (by prescription) Chiropractor Childbirth/delivery Convalescent home (for medical treatment only) Crutches Doctor’s fees Dental treatments (including x-rays, braces, dentures, fillings, oral surgery) Dermatologist Diagnostic services Disabled dependent care Drug addiction therapy Fertility enhancement (including in-vitro fertilization) Guide dog (or other service animal) Gynecologist Hearing aids and batteries Hospital bills Insurance premiums5 Laboratory fees Lactation expenses Lodging (away from home for outpatient care) Nursing home

Nursing services Obstetrician Osteopath Oxygen Pregnancy test kit Podiatrist Prescription drugs and medicines (over-the-counter drugs are not IRS-qualified medical expenses unless prescribed by a doctor) Prenatal care & postnatal treatments Psychiatrist Psychologist Smoking cessation programs Special education tutoring Surgery Telephone or TV equipment to assist the hearing or vision impaired Therapy or counseling Medical transportation expenses Transplants Vaccines Vasectomy Vision care (including eyeglasses, contact lenses, lasik surgery) Weight loss programs (for a specific disease diagnosed by a physician – such as obesity, hypertension, or heart disease) Wheelchairs X-rays

Please call the number on the back of your HSA Bank debit card or visit us at www.hsabank.com ¹ Investment accounts are not FDIC insured, may lose value and are not a deposit or other obligation of, or guarantee by the bank. Investment losses which are replaced are subject to the annual contribution limits of the HSA. 2

HSA funds contributed in excess of these limits are subject to penalty and tax unless the excess and earnings are withdrawn prior to the due date, including any extensions for filing Federal Tax returns. Accountholders should consult with a qualified tax advisor in connection with excess contribution removal. The Internal Revenue Service requires HSA Bank to report withdrawals that are considered refunds of excess contributions. In order for the withdrawal to be accurately reported, accountholders may not withdraw the excess directly. Instead, an excess contribution refund must be requested from HSA Bank and an Excess Contribution Removal Form completed. 3

Federal tax savings are available regardless of your state. State tax laws may vary. HSA Bank does not provide tax or legal advice. Please consult with a qualified tax or legal professional for tax related questions. 4

This list is not comprehensive. It is provided to you with the understanding that HSA Bank is not engaged in rendering tax advice. The information provided is not intended to be used to avoid Federal tax penalties. For more detailed information, please refer to IRS Publication 502 titled, “Medical and Dental Expenses”. Publications can be ordered directly from the IRS by calling 1-800-TAXFORM. If tax advice is required, you should seek the services of a professional. 5

Insurance premiums only qualify as an IRS-qualified medical expense: while continuing coverage under COBRA; for qualified long-term care coverage; coverage while receiving unemployment compensation; for any healthcare coverage for those over age 65 including Medicare (except Medicare supplemental coverage). © 2020 HSA Bank. HSA Bank is a division of Webster Bank, N.A., Member FDIC. HSA_Overview_Flyer_No_Cafeteria_Plan_072720 22

NBS

FSA (Flexible Spending Account)

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

FLIP TO… FOR HSA VS. FSA COMPARISON

PG. 11

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 24 details on covered expenses, limitations and exclusions are included in the summary plan description located on the Duncanville ISD Benefits Website: www.mybenefitshub.com/duncanvilleisd

FSA (Flexible Spending Account) How do I receive reimbursements? During the course of the plan year, you may submit requests for reimbursement of expenses you have incurred. Expenses are Congratulations! considered "incurred" when the service is performed, not Your employer has established a "flexible benefits plan" to help necessarily when it is paid for. You can get submit a claim online you pay for your out-of-pocket health and daycare expenses. at: my.nbsbeneits.com One of the most important features of the plan is that the Please note: Policies other than company sponsored policies (i.e. benefits being offered are paid for with a portion of your pay spouse’s or dependents’ individual policies) may not be paid before federal income or social security taxes are withheld. This through the flexible beneits plan. Furthermore, qualified longmeans that you will pay less tax and have more money to spend term care insurance plans may not be paid through the flexible and save. However, if you receive a reimbursement for an benefits plan. expense under the plan, you cannot claim a federal income tax NBS Benefits Card credit or deduction on your return. Your employer may Health Flexible spending account: sponsor the use of the The health flexible spending account (FSA) enables you to pay NBS Benefits Card, for expenses allowed under Section 105 and 213(d) of the making access to your Internal Revenue Code which are not covered by our insured flex dollars easier than medical plan. ever. You may use the The most that you can contribute to your Health FSA each plan card to pay merchants year is set by the IRS. This amount can be adjusted for increases or service providers in cost-of-living in accordance with Code Section 125(i)(2). that accept credit cards such as hospitals and pharmacies, so there is no need to pay cash up front then wait for Premium expense plan: reimbursement. A premium expense portion of the plan allows you to use preOrthodontic expenses that are paid fully up-front at the time of tax dollars to pay for specific premiums under various insurance initial service are reimbursable in full after the initial service has programs we offer you. been performed and payment has been made. Ongoing orthodontia payments are reimbursable only as they are paid. Dependent care Flexible spending account: The dependent care flexible spending account (DCFSA) enables Account Information you to pay for out-of-pocket, work-related dependent daycare Participants may call NBS and talk to a representative during our costs. Please see the Summary Plan Description for the regular business hours, Monday-Friday, 7 a.m. to 7 p.m. Central definition of an eligible dependent. The law places limits on the Time. Participants can also obtain account information using the amount of money that can be paid to you in a calendar year. Automated Voice Response Unit, 24 hours a day, 7 days a week Generally, your reimbursement may not exceed the lesser of: at (385) 988-6423 or toll free at (800) 274-0503. For immediate (a) $5,000 (if you are married filing a joint return or you are access to your account information at any time, log on to our head of a household) or $2,500 (if you are married filing website at my.nbsbenefits.com or download the NBS Mobile separate returns); (b) your taxable compensation; (c) your App. spouse's actual or deemed earned income. Also, in order to have the reimbursements made to you and be What can I save with an FSA? excluded from your income, you must provide a statement from FSA No FSA the service provider including the name, address and, in most Annual taxable income $24,000 $24,000 cases, the taxpayer identification number of the service provider as well as the amount of such expense and proof that Health FSA $1,500 $0 the expense has been incurred. Dependent care FSA $1,500 $0 Determining contributions Total pre-tax contributions -$3,000 $0 Before each plan year begins, you will select the benefits you Taxable income after FSA $21,000 $24,000 want and how much contributions should go toward each Income taxes -$6,300 -$7,200 benefit. It is very important that you make these choices carefully based on what you expect to spend on each covered After-tax income $14,700 $16,800 benefit or expense during the plan year. $0 -$3,000 Generally, you cannot change the elections you have made after After-tax health and welfare expenses Take-home pay $14,700 $13,800 the beginning of the plan year. However, there are certain limited situations when you can change your elections if you You saved $900 $0 have a "change in status". Please refer to your Summary Plan Description for a change in status listing.

Plan Highlights Flexible Spending Plans

FSA (Flexible Spending Account) NBS Mobile App When you're on the go, save time and hassle with the NBS Mobile App. Submit claims, check your balances, view transactions, and submit documentation using your device's camera.

Easy and convenient •

•

Designed to work just as other iOS and Android apps which makes it easy to learn and use. Shares user authentication with the NBS portal. Registered users can download the app and log in immediately to gain access to their benefit accounts, with no need to register their phone or your account.

It's secure •

No sensitive account information is ever stored on your mobile device and secure encryption is used to protect all transmissions.

Mobile app features The NBS mobile app supports a wide variety of features, empowering you to proactively manage your account. • View account balances • View claims • View reimbursement history • Submit claims • Submit documentation using your device's camera • Pay providers • Setup a variety of SMS alerts • Edit your personal information • View contribution details • View plan information • View calendar deadlines • Contact a service representative • View Benefits Card information

FSA (Flexible Spending Account) Sample Expenses Medical expenses • • • • • • • •

• • •

Acupuncture Addiction programs Adoption (medical expenses for baby birth) Alternative healer fees Ambulance Body scans Breast pumps Care for mentally handicapped Chiropractor Copayments Crutches

Dental expenses • • • • • • •

•

Artificial teeth Copayments Deductible Dental work Dentures Orthodontia expenses Preventative care at dentist office Bridges, crowns, etc.

Vision expenses • • • • • • • •

Braille - books & magazines Contact lenses Contact lens solutions Eye exams Eye glasses Laser surgery Office fees Guide dog and upkeep/other animal aid

Diabetes (insulin, glucose monitor) Eye patches Fertility treatment First aid (i.e. bandages, gauze) Hearing aids & batteries Hypnosis (for treatment of illness) Incontinence products (i.e. Depends, Serene) Joint support bandages and hosiery Lab fees Monitoring device (blood pressure, cholesterol)

• • • • • • • •

• •

Physical exams Pregnancy tests Prescription drugs Psychiatrist/psychologist (for mental illness) Physical therapy Speech therapy Vaccinations Vaporizers or humidifiers Weight loss program fees (if prescribed by physician) Wheelchair

• • • • • • • •

• •

Items that generally do not qualify for reimbursement • • • • • •

• • • • • •

• • •

Personal hygiene (deodorant, soap, body powder, sanitary products) Addiction products Allergy relief (oral meds, nasal spray) Antacids and heartburn relief Anti-itch and hydrocortisone creams Athlete's foot treatment Arthritis pain relieving creams Cold medicines (i.e. syrups, drops, tablets) Cosmetic surgery Cosmetics (i.e. makeup, lipstick, cotton swabs, cotton balls, baby oil) Counseling (i.e. marriage/family) Dental care - routine (i.e. toothpaste, toothbrushes, dental ﬂoss, anti-bacterial mouthwashes, ﬂuoride rinses, teeth whitening/ bleaching) Exercise equipment Fever & pain reducers (i.e. Aspirin, Tylenol) Hair care (i.e. hair color, shampoo, conditioner, brushes, hair loss

• • • • • • •

•

• • • • • •

• •

products) Health club or fitness program fees Homeopathic supplement or herbs Household or domestic help Laser hair removal Laxatives Massage therapy Motion sickness medication Nutritional and dietary supplements (i.e. bars, milkshakes, power drinks, Pedialyte) Skin care (i.e. sun block, moisturizing lotion, lip balm) Sleep aids (i.e. oral meds, snoring strips) Smoking cessation relief (i.e. patches, gum) Stomach & digestive relief (i.e. Pepto- Bismol, Imodium) Tooth and mouth pain relief (Orajel, Anbesol) Vitamins Wart removal medication Weight reduction aids (i.e. Slimfast, appetite suppressant

These expenses may be eligible if they are prescribed by a physician (if medically necessary for a specific condition).

MDLIVE

Telehealth

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

YOUR BENEFITS PACKAGE

75%

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

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 This is a general overview of your plan benefits.inIfthe thesummary terms of plan this outline differlocated from your policy, the policy will govern. Additional plan description on the 28 details on covered expenses, limitations and exclusions included in the summary plan description located on the Duncanville ISD Benefits Website:are www.mybenefitshub.com/duncanvilleisd Duncanville ISD Benefits Website: www.mybenefitshub.com/duncanvilleisd

Telehealth Welcome to MDLIVE!

Your virtual doctor is here. Join for free today!

With MDLIVE, you can visit with a doctor or counselor 24/7 from your home, office or on-the-go. You have a telehealth benefit giving you virtual care, anywhere. At a price you can afford. • Board-certified doctors • Available anytime, day or night • Consults by mobile app, video or phone • Prescriptions can be sent to your nearest pharmacy if medically necessary We treat over 50 routine medical conditions including: • Acne • Allergies • Cold/ﬂu • Constipation • Cough • Diarrhea • Ear problems • Insect bites • Nausea/vomiting • Pink eye • Rash • Respiratory problems • Sore throats • And more

Download the app. Join for Free. Visit a Doctor.

consultmdlive.com 888-365-1663

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CIGNA

Dental

YOUR BENEFITS PACKAGE

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

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.

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 This is a general overview of your plan benefits.inIfthe thesummary terms of plan this outline differlocated from your policy, the policy will govern. Additional plan description on the 30 details on covered expenses, limitations and exclusions included in the summary plan description located on the Duncanville ISD Benefits Website:are www.mybenefitshub.com/duncanvilleisd Duncanville ISD Benefits Website: www.mybenefitshub.com/duncanvilleisd

Dental PPO - High Plan Network Options Reimbursement Levels

Cigna Dental Choice In-Network Total Cigna DPPO Network Based on Contracted Fees

Out-of-Network See Non-Network Reimbursement Maximum Reimbursable Charge

Policy Year Benefits Maximum Applies to: Class II & III expenses

$1,500

$50 $150 Plan Pays You Pay

Annual Year Deductible Individual Family

Benefit Highlights Class I - Diagnostic & Preventive Oral Evaluations Prophylaxis: routine cleanings X-rays: routine X-rays: non-routine Fluoride Application Sealants: per tooth Space Maintainers: non-orthodontic Emergency Care to Relieve Pain

100% 100% No No Charge No No Charge Deductible Deductible

Class II - Basic Restorative Restorative: fillings Endodontics: minor and major Periodontics: minor and major Oral Surgery: minor and major Anesthesia: general and IV sedation Repairs: Bridges, Crowns and Inlays Repairs: Dentures Denture Relines, Rebases and Adjustments

80% 20% 80% 20% After After After After Deductible Deductible Deductible Deductible

Class III - Major Restorative Care Inlays and Onlays Prosthesis Over Implant Crowns: prefabricated stainless steel / resin Crowns: permanent cast and porcelain Bridges and Dentures

50% 50% 50% 50% After After After After Deductible Deductible Deductible Deductible

Class IV - Orthodontia

50% 50% 50% 50% After After After After Deductible Deductible Deductible Deductible

Coverage for Dependent Children to age 19 Lifetime Benefits Maximum: $1,500

Monthly Premiums EE Only

$62.07

EE + Spouse

$80.40

EE + Child(ren)

$91.91

Family Coverage

$156.19

Cigna Dental Benefit Summary Duncanville ISD #3336999 High Plan Renewal Date: 09/01/2021 Insured by: Cigna Health and Life Insurance Company This material is for informational purposes only and is designed to highlight some of the benefits available under this plan. Consult the plan documents to determine specific terms of coverage relating to your plan. Terms include covered procedures, applicable waiting periods, exclusions and limitations. Your plan allows you to see any licensed dentist, but using an in-network dentist may minimize your out-ofpocket expenses.

Benefit Plan Provisions: In-Network Reimbursement

Non-Network Reimbursement

Cross Accumulation Policy Year Benefits Maximum Policy Year Deductible Late Entrant Limitation Provision

For services provided by a Cigna Dental PPO network dentist, Cigna Dental will reimburse the dentist according to a Fee Schedule or Discount Schedule. For services provided by a non-network dentist, Cigna Dental will reimburse according to the Maximum Reimbursable Charge. The MRC is calculated at the 90th percentile of all provider charges in the geographic area. The dentist may balance bill up to their usual fees. All deductibles, plan maximums, and service specific maximums cross accumulate between in and out of network. Benefit frequency limitations are based on the date of service and cross accumulate between in and out of network. The plan will only pay for covered charges up to the yearly Benefits Maximum, when applicable. Benefit-specific Maximums may also apply. This is the amount you must pay before the plan begins to pay for covered charges, when applicable. Benefit-specific deductibles may also apply. Payment will be reduced by 50% for Class III and IV services for 12 months for eligible members that are allowed to enroll in this plan outside of the designated open enrollment period. This provision does not apply to new hires. 31

Dental PPO - High PPO Plan Pretreatment Review Alternate Benefit Provision

Oral Health Integration Program (OHIP)

Timely Filing

Pretreatment review is available on a voluntary basis when dental work in excess of $200 is proposed. When more than one covered Dental Service could provide suitable treatment based on common dental standards, Cigna HealthCare will determine the covered Dental Service on which payment will be based and the expenses that will be included as Covered Expenses. Cigna Dental Oral Health Integration Program offers enhanced dental coverage for customers with the following medical conditions: diabetes, heart disease, stroke, maternity, head and neck cancer radiation, organ transplants and chronic kidney disease. There’s no additional charge for the program, those who qualify get reimbursed 100% of coinsurance for certain related dental procedures. Eligible customers can also receive guidance on behavioral issues related to oral health and discounts on prescription and non-prescription dental products. Reimbursements under this program are not subject to the plan deductible, but will be applied to and are subject to the plan annual maximum. Discounts on certain prescription and non-prescription dental products are available through Cigna Home Delivery Pharmacy only, and you are required to pay the entire discounted charge. For more information including how to enroll in this program and a complete list of program terms and eligible medical conditions, go to www.mycigna.com or call customer service 24/7 at 1.800.CIGNA24. Out of network claims submitted to Cigna after 365 days from date of service will be denied.

Benefit Limitations: Missing Tooth Limitation

For teeth missing prior to coverage with Cigna, the amount payable is 50% of the amount otherwise payable until covered for 12 months; thereafter, considered a Class III expense. Oral Evaluations 2 per policy year X-rays (routine) Bitewings: 2 per policy year X-rays (non-routine) Complete series of radiographic images and panoramic radiographic images: Limited to a combined total of 1 per 36 months Diagnostic Casts Payable only in conjunction with orthodontic workup Cleanings 2 per policy year, including periodontal maintenance procedures following active therapy Fluoride Application 1 per policy year for children under age 19 Sealants (per tooth) Limited to posterior tooth. 1 treatment per tooth every 36 months for children under age 14 Space Maintainers Limited to non-orthodontic treatment for children under age 19 Replacement every 60 months if unserviceable and cannot be repaired. Benefits are based Inlays, Crowns, Bridges, Dentures and Partials on the amount payable for non-precious metals. No porcelain or white/tooth-colored material on molar crowns or bridges. Denture and Bridge Repairs Reviewed if more than once Denture Adjustments, Rebases and Relines Covered if more than 6 months after installation 1 every 60 months if unserviceable and cannot be repaired. Benefits are based on the Prosthesis Over Implant amount payable for non-precious metals. No porcelain or white/tooth colored material on molar crowns or bridges. Benefit Exclusions: Covered Expenses will not include, and no payment will be made for the following: Procedures and services not included in the list of covered dental expenses; Diagnostic: cone beam imaging; Preventive Services: instruction for plaque control, oral hygiene and diet; Restorative: veneers of porcelain, ceramic, resin, or acrylic materials on crowns or pontics on or replacing the upper and or lower first, second and/or third molars; Periodontics: bite registrations; splinting; Prosthodontics: precision or semi-precision attachments; initial placement of a complete or partial denture per plan guidelines; Implants: implants or implant related services; Procedures, appliances or restorations, except full dentures, whose main purpose is to: change vertical dimension; diagnose or treat conditions or dysfunction of the temporomandibular joint (TMJ); stabilize periodontally involved teeth; or restore occlusion; Athletic mouth guards; services performed primarily for cosmetic reasons; personalization; replacement of an appliance per benefit guidelines; Services that are deemed to be medical in nature; services and supplies received from a hospital; Drugs: prescription drugs Charges in excess of the Maximum Reimbursable Charge. This document provides a summary only. It is not a contract. If there are any differences between this summary and the official plan documents, the terms of the official plan documents will prevail. Cigna Dental PPO plans are insured and/or administered by Cigna Health and Life Insurance Company (CHLIC) or Connecticut General Life Insurance Company (CGLIC), with network management services provided by Cigna Dental Health, Inc. and certain of its subsidiaries. In Texas, the insured dental plan is known as Cigna Dental Choice, and this plan uses the national Cigna DPPO network. All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation “Cigna Home Delivery Pharmacy” refers to Tel-Drug, Inc. and Tel-Drug of Pennsylvania, L.L.C. Policy forms (for insured dental plans) in OK: HP-POL99 (CHLIC), GM6000 ELI288 et al (CGLIC); OR: HP-POL68; TN: HP-POL69/HCCER2V1 et al (CHLIC). The Cigna name, logo, and other Cigna marks are owned by Cigna Intellectual Property, Inc. © 2017 Cigna / version 06192017

Dental PPO - Low MAC Plan Network Options Reimbursement Levels

Cigna Dental Choice In-Network Total Cigna DPPO Network Based on Contracted Fees

Out-of-Network See Non-Network Reimbursement Maximum Allowable Charge

Policy Year Benefits Maximum $1,000

$1,000

$50 $150 Plan Pays You Pay

Applies to: Class II & III expenses

Annual Year Deductible Individual Family

100% No Deductible

No Charge

100% No Deductible

Class IV - Orthodontia Coverage for Dependent Children to age 19 Lifetime Benefits Maximum: $1,500

$39.78

EE + Spouse

$60.54

EE + Child(ren)

$69.21

Family Coverage

$117.66

Cigna Dental Benefit Summary Duncanville ISD #3336999 Low MAC Plan Renewal Date: 09/01/2021 Insured by: Cigna Health and Life Insurance Company This material is for informational purposes only and is designed to highlight some of the benefits available under this plan. Consult the plan documents to determine specific terms of coverage relating to your plan. Terms include covered procedures, applicable waiting periods, exclusions and limitations.

80%

20%

80%

20%

After Deductible

50%

After Deductible

50%

Class III - Major Restorative Inlays and Onlays Prosthesis Over Implant Crowns: prefabricated stainless steel / resin Crowns: permanent cast and porcelain Bridges and Dentures

EE Only

No Charge

Monthly Premiums

Your plan allows you to see any licensed dentist, but using an in-network dentist may minimize your out-ofpocket expenses.

No Deductible No Deductible No Deductible No Deductible

Benefit Plan Provisions: In-Network Reimbursement

For services provided by a Cigna Dental PPO network dentist, Cigna Dental will reimburse the dentist according to a Fee Schedule or Discount Schedule.

Non-Network Reimbursement

For services provided by a non-network dentist, Cigna Dental will reimburse according to the Maximum Allowable Charge. The dentist may balance bill up to their usual fees.

Cross Accumulation Policy Year Benefits Maximum Policy Year Deductible Late Entrant Limitation Provision

All deductibles, plan maximums, and service specific maximums cross accumulate between in and out of network. Benefit frequency limitations are based on the date of service and cross accumulate between in and out of network. The plan will only pay for covered charges up to the yearly Benefits Maximum, when applicable. Benefit-specific Maximums may also apply. This is the amount you must pay before the plan begins to pay for covered charges, when applicable. Benefit-specific deductibles may also apply. Payment will be reduced by 50% for Class III and IV services for 12 months for eligible members that are allowed to enroll in this plan outside of the designated open enrollment period. This provision does not apply to new hires.

Dental PPO - Low MAC Plan Pretreatment Review Alternate Benefit Provision

Oral Health Integration Program (OHIP)

Timely Filing

Benefit Limitations: Missing Tooth Limitation

For teeth missing prior to coverage with Cigna, the amount payable is 50% of the amount otherwise payable until covered for 12 months; thereafter, considered a Class III expense. Oral Evaluations 2 per policy year X-rays (routine) Bitewings: 2 per policy year X-rays (non-routine) Complete series of radiographic images and panoramic radiographic images: Limited to a combined total of 1 per 36 months Diagnostic Casts Payable only in conjunction with orthodontic workup Cleanings 2 per policy year, including periodontal maintenance procedures following active therapy Fluoride Application 1 per policy year for children under age 19 Sealants (per tooth) Limited to posterior tooth. 1 treatment per tooth every 36 months for children under age 14 Space Maintainers Limited to non-orthodontic treatment for children under age 19 Replacement every 60 months if unserviceable and cannot be repaired. Benefits are based Inlays, Crowns, Bridges, Dentures and Partials on the amount payable for non-precious metals. No porcelain or white/tooth-colored material on molar crowns or bridges. Denture and Bridge Repairs Reviewed if more than once Denture Adjustments, Rebases and Relines Covered if more than 6 months after installation 1 every 60 months if unserviceable and cannot be repaired. Benefits are based on the Prosthesis Over Implant amount payable for non-precious metals. No porcelain or white/tooth colored material on molar crowns or bridges. Benefit Exclusions: Covered Expenses will not include, and no payment will be made for the following: Procedures and services not included in the list of covered dental expenses; Diagnostic: cone beam imaging; Preventive Services: instruction for plaque control, oral hygiene and diet; Restorative: veneers of porcelain, ceramic, resin, or acrylic materials on crowns or pontics on or replacing the upper and or lower first, second and/or third molars; Periodontics: bite registrations; splinting; Prosthodontics: precision or semi-precision attachments; initial placement of a complete or partial denture per plan guidelines; Implants: implants or implant related services; Procedures, appliances or restorations, except full dentures, whose main purpose is to: change vertical dimension; diagnose or treat conditions or dysfunction of the temporomandibular joint (TMJ); stabilize periodontally involved teeth; or restore occlusion; Athletic mouth guards; services performed primarily for cosmetic reasons; personalization; replacement of an appliance per benefit guidelines; Services that are deemed to be medical in nature; services and supplies received from a hospital; Drugs: prescription drugs Charges in excess of the Maximum Allowable Charge. This document provides a summary only. It is not a contract. If there are any differences between this summary and the official plan documents, the terms of the official plan documents will prevail. Cigna Dental PPO plans are insured and/or administered by Cigna Health and Life Insurance Company (CHLIC) or Connecticut General Life Insurance Company (CGLIC), with network management services provided by Cigna Dental Health, Inc. and certain of its subsidiaries. In Texas, the insured dental plan is known as Cigna Dental Choice, and this plan uses the national Cigna DPPO network. All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation “Cigna Home Delivery Pharmacy” refers to Tel-Drug, Inc. and Tel-Drug of Pennsylvania, L.L.C. Policy forms (for insured dental plans) in OK: HP-POL99 (CHLIC), GM6000 ELI288 et al (CGLIC); OR: HP-POL68; TN: HP-POL69/HCCER2V1 et al (CHLIC). The Cigna name, logo, and other Cigna marks are owned by Cigna Intellectual Property, Inc. © 2017 Cigna / version 06192017

Dental DHMO This Patient Charge Schedule lists the benefits of the Dental Plan including covered procedures and patient charges.

Important Highlights •

This Patient Charge Schedule applies only when covered dental services are performed by your Network Dentist, unless otherwise authorized by Cigna Dental as described in your plan documents. Not all Network Dentists perform all listed services and it is suggested to check with your Network Dentist in advance of receiving services.

Monthly Premiums EE Only

$17.07

EE + Spouse

$22.61

EE + Child(ren)

$25.89

Family Coverage

$43.96

•

This Patient Charge Schedule applies to Specialty Care when an appropriate referral is made to a Network Specialty Periodontist or Oral Surgeon. You must verify with the Network Specialty Dentist that your treatment plan has been authorized for payment by Cigna Dental. Prior authorization is not required for specialty referrals for Pediatric, Orthodontic and Endodontic services. You may select a Network Pediatric Dentist for your child under the age of 7 by calling Customer Service at 1.800.Cigna24 to get a list of Network Pediatric Dentists in your area. Coverage for treatment by a Pediatric Dentist ends on your child’s 7th birthday; however, exceptions for medical reasons may be considered on an individual basis. Your Network General Dentist will provide care upon your child’s 7th birthday.

•

Procedures not listed on this Patient Charge Schedule are not covered and are the patient’s responsibility at the dentist’s usual fees.

•

If more than one professionally accepted and appropriate method of treatment can be used to treat a dental condition, coverage will be limited to the less costly Covered Service. If you choose the more costly service, the fee listed on the Patient Charge Schedule will not apply. Discuss your options and increased financial obligations with your dentist.

•

The administration of IV sedation, general anesthesia, and/or nitrous oxide is not covered except as specifically listed on this Patient Charge Schedule. The application of local anesthetic is covered as part of your dental treatment.

•

Cigna Dental considers infection control and/or sterilization to be incidental to and part of the charges for services provided and not separately chargeable.

•

This Patient Charge Schedule is subject to annual change in accordance with the terms of the group agreement.

•

All patient charges must correspond to the Patient Charge Schedule in effect on the date the procedure is initiated.

•

Procedures listed on the Patient Charge Schedule are subject to the plan limitations and exclusions described in your plan book/certificate of coverage and/or group contract.

•

The American Dental Association may periodically change CDT Codes or definitions. Different codes may be used to describe these covered procedures. The language in italics is intended to clarify the member’s benefit.

Code

Procedure Description

Patient Charge

Office visit fee (per patient, per office visit in addition to any other applicable patient charges) Office visit fee

$ 5.00

Diagnostic/preventive – Oral evaluations are limited to a combined total of 4 of the following evaluations during a 12 consecutive month period: Periodic oral evaluations (D0120), comprehensive oral evaluations (D0150), comprehensive periodontal evaluations (D0180), and oral evaluations for patients under 3 years of age (D0145). The frequency of certain Covered Services, like cleanings, is limited. If your Network General Dentist certifies to Cigna Dental that, due to medical necessity, you require certain Covered Services more frequently than the limitation allows, Cigna Dental will waive the applicable limitation. The relevant Covered Services are identified with a Δ. D9310

Consultation (diagnostic service provided by dentist or physician other than requesting dentist or physician)

$0.00

D9430

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

$0.00

Code

Procedure Description

D9450

Case presentation – Detailed and extensive treatment planning

Patient Charge $0.00

D0120

Periodic oral evaluation – Established patient

$0.00

D0140

Limited oral evaluation – Problem focused

$0.00

D0145

Oral evaluation for a patient under 3 years of age and counseling with primary caregiver

$0.00

D0150

Comprehensive oral evaluation – New or established patient

$0.00

D0160

Detailed and extensive oral evaluation – problem focused, by report (limit 2 per calendar year; only covered in conjunction with Temporomandibular Joint (TMJ) evaluation)

$0.00

D0170

Reevaluation – Limited, problem focused (not postoperative visit)

$0.00

Dental DHMO Code

Procedure Description

Patient Charge

D0180

Comprehensive periodontal evaluation – New or established patient

$33.00

D0210

X-rays intraoral – Complete series of radiographic images (limit 1 every 3 years) ❂

$0.00

D0220

X-rays intraoral – Periapical – First radiographic image

$0.00

D0230

X-rays intraoral – Periapical – Each additional radiographic image

$0.00

D0240

X-rays intraoral – Occlusal radiographic image

$0.00

D0270

X-rays (bitewing) – Single radiographic image

$0.00

D0272

X-rays (bitewings) – 2 radiographic images

$0.00

D0273

X-rays (bitewings) – 3 radiographic images

$0.00

D0274

X-rays (bitewings) – 4 radiographic images

$0.00

D0277

X-rays (bitewings, vertical) – 7 to 8 radiographic images

$0.00

D0330

X-rays (panoramic radiographic image) – (limit 1 every 3 years) ❂

$0.00

D0368

Cone beam CT capture and interpretation for TMJ series including two or more exposures (limit 1 per calendar year; only covered in conjunction with Temporomandibular Joint (TMJ) evaluation)

$240.00

D0431

Oral cancer screening using a special light source

$50.00

D0460

Pulp vitality tests

$14.00

D0470

Diagnostic casts

$0.00

D0472

Pathology report – Gross examination of lesion (only when tooth related)

$0.00

D0473

Pathology report – Microscopic examination of lesion (only when tooth related)

$0.00

D0474

Pathology report – Microscopic examination of lesion and area (only when tooth related)

$0.00

Prophylaxis (cleaning) – Adult (limit 2 per calendar year) ❂

$0.00

D1110

D1120

$45.00

Prophylaxis (cleaning) – Child (limit 2 per calendar year) ❂

$0.00

Procedure Description

Patient Charge

Topical application of fluoride varnish (limit 2 per calendar year). There is a combined limit of a total of 2 D1206s and/or D1208s per calendar year. ❂

$0.00

Additional topical application of fluoride varnish – In addition to any combination of two (2) D1206s (topical application of fluoride varnish) and/or D1208s (topical application of fluoride) per calendar year

$15.00

Topical application of fluoride (limit 2 per calendar year) There is a combined limit of a total of 2 D1208s and/or D1206s per calendar year. ❂

$0.00

Additional topical application of fluoride – In addition to any combination of two (2) D1206s (topical applications of fluoride varnish) and/or D1208s (topical application of fluoride) per calendar year

$15.00

D1330

Oral hygiene instructions

$0.00

D1351

Sealant – Per tooth

$12.00

D1352

Preventive resin restoration in a moderate to high caries risk patient – Permanent tooth

$12.00

D1510

Space maintainer – Fixed – Unilateral

$110.00

D1515

Space maintainer – Fixed – Bilateral

$170.00

D1555

Removal of fixed space maintainer

$0.00

D1206

D1208

Restorative (fillings, including polishing)

Additional prophylaxis (cleaning) – In addition to the 2 prophylaxes (cleanings) allowed per calendar year

Code

$30.00

D2140

Amalgam – 1 surface, primary or permanent

$0.00

D2150

Amalgam – 2 surfaces, primary or permanent

$0.00

D2160

Amalgam – 3 surfaces, primary or permanent

$0.00

D2161

Amalgam – 4 or more surfaces, primary or permanent

$0.00

D2330

Resin-based composite – 1 surface, anterior

$0.00

D2331

Resin-based composite – 2 surfaces, anterior

$0.00

D2332

Resin-based composite – 3 surfaces, anterior

$0.00

D2335

Resin-based composite – 4 or more surfaces or involving incisal angle, anterior

$88.00

D2390

Resin-based composite crown, anterior

$88.00

D2391

Resin-based composite – 1 surface, posterior

$47.00

D2392

Resin-based composite – 2 surfaces, posterior

$59.00

D2393

Resin-based composite – 3 surfaces, posterior

$82.00

D2394

Resin-based composite – 4 or more surfaces, posterior

$115.00

Dental DHMO Code

Procedure Description

Patient Charge

Code

Crown – 3/4 cast noble metal

$355.00

D2790

Crown – Full cast high noble meta

$330.00

D2791

Crown – Full cast predominantly base metal

$410.00

D2792

Crown – Full cast noble metal

$355.00

D2794

Crown – Titanium

$330.00

D2910

Recement inlay – Onlay or partial coverage restoration

$43.00

D2915

Recement cast or prefabricated post and core

$43.00

D2920

Recement crown

$43.00

D2929

Prefabricated porcelain/ceramic crown – Primary tooth

$165.00

D2930

Prefabricated stainless steel crown – Primary tooth

$105.00

D2931

Prefabricated stainless steel crown – Permanent tooth

$105.00

D2932

Prefabricated resin crown

$135.00

D2933

Prefabricated stainless steel crown with resin window

$165.00

D2934

Prefabricated esthetic coated stainless steel crown – Primary tooth

$165.00

$410.00

D2940

Protective Restoration

$13.00

$410.00

D2950

Core buildup – Including any pins

$135.00

D2951

Pin retention – Per tooth – In addition to restoration

$13.00

D2952

Post and core – In addition to crown, indirectly fabricated

$165.00

D2954

Prefabricated post and core – In addition to crown

$135.00

D2960

Labial veneer (resin laminate) – Chairside

$94.00

• •

No more than $80.00 per tooth for any noble metal alloys

•

No more than $100.00 per tooth for any porcelain fused to metal (only on molar teeth)

•

Porcelain/ceramic substrate crowns on molar teeth are not covered

No more than $130.00 per tooth for any high noble metal alloys, titanium or titanium alloys

In addition, you may be charged up to these additional amounts. • No more than $100.00 per tooth if an indirectly fabricated (“cast”) post and core is made of high noble metal alloy • No more than $150.00 per tooth for crowns, inlays, onlays, post and cores, and veneers if your dentist uses same day inoffice CAD/CAM (ceramic) services. Same day in-office CAD/ CAM (ceramic) services refer to dental restorations that are created in the dental office by the use of a digital impression and an in-office CAD/CAM milling machine $410.00

$470.00 $470.00 $470.00

Crown – Porcelain/ceramic substrate

Patient Charge

D2782

Crown and bridge – All charges for crowns and bridges (fixed partial dentures) are per unit (each replacement or supporting tooth equals 1 unit). Coverage for replacement of crowns and bridges is limited to 1 every 5 years. For single crowns, retainer (“abutment”) crowns, and pontics: The charges below include the cost of predominantly base metal alloy. You may be charged up to these additional amounts, based on the type of material the dentist uses for your restoration.

D2740

Procedure Description

$490.00

D2750

Crown – Porcelain fused to high noble metal

$320.00

D6210

Pontic – Cast high noble meta

$320.00

D2751

Crown – Porcelain fused to predominantly base metal

$400.00

D6211

Pontic – Cast predominantly base metal

$410.00

D6212

Pontic – Cast noble meta

$355.00

D2752

Crown – Porcelain fused to noble metal

$345.00

D6214

Pontic – Titanium

$330.00

D2780

Crown – 3/4 cast high noble meta

$330.00

D6240

Pontic – Porcelain fused to high noble metal

$320.00

D2781

Crown – 3/4 cast predominantly base meta

$410.00

D6241

Pontic – Porcelain fused to predominantly base meta

$410.00

Dental DHMO Code

Procedure Description

Patient Charge

Code

D6242

Pontic – Porcelain fused to noble metal

$355.00

D6791

Crown – Full cast predominantly base metal

$410.00

D6245

Pontic – Porcelain/ceramic

$455.00

D6792

Crown – Full cast noble metal

$355.00

D6602

Inlay – Cast high noble metal, 2 surfaces

$320.00

Crown – Titanium

$330.00

D6603

Inlay – Cast high noble metal, 3 or more surfaces

$330.00

D6604

Inlay – Cast predominantly base metal, 2 surfaces

$390.00

$135.00

D6605

Inlay – Cast predominantly base metal, 3 or more surfaces

$400.00

Complex rehabilitation – Additional charge per unit for multiple crown units/complex rehabilitation (6 or more units of crown and/or bridge in same treatment plan requires complex rehabilitation for each unit – ask your dentist for the guidelines) Recement fixed partial denture

$61.00

D6606

Inlay – Cast noble metal, 2 surfaces

$335.00

D6607

Inlay – Cast noble metal, 3 or more surfaces

$345.00

D6610

Onlay – Cast high noble metal, 2 surfaces

$310.00

D6611

Onlay – Cast high noble metal, 3 or more surfaces

$330.00

Onlay – Cast predominantly base metal, 2 surfaces

$390.00

D6794

D6930

Procedure Description

Patient Charge

Endodontics (root canal treatment, excluding final restorations)

D6612

D6613

Onlay – Cast predominantly base metal, 3 or more surfaces

$400.00

D6614

Onlay – Cast noble metal, 2 surfaces

$335.00

D6615

Onlay – Cast noble metal, 3 or more surfaces

$355.00

Inlay – Titanium

$320.00

D6624 D6634

Onlay – Titanium

Pulp cap – Direct (excluding final restoration)

$14.00

D3120

Pulp cap – Indirect (excluding final restoration)

$14.00

D3220

Pulpotomy – Removal of pulp, not part of a root canal

$72.00

D3221

Pulpal debridement (not to be used when root canal is done on the same day)

$72.00

D3222

Partial pulpotomy for apexogenesis – Permanent tooth with incomplete root development

$72.00

D3310

Anterior root canal – Permanent tooth (excluding final restoration)

$210.00

D3320

Bicuspid root canal – Permanent tooth (excluding final restoration)

$245.00

D3330

Molar root canal – Permanent tooth (excluding final restoration)

$335.00

D3331

Treatment of root canal obstruction – Nonsurgical access

$97.00

D3332

Incomplete endodontic therapy – Inoperable, unrestorable or fractured tooth

$97.00

D3333

Internal root repair of perforation defects

$97.00

D3346

Retreatment of previous root canal therapy – Anterior

$300.00

D3347

Retreatment of previous root canal therapy – Bicuspid

$345.00

D3348

Retreatment of previous root canal therapy – Molar

$430.00

$320.00

D6740

Crown – Porcelain/ceramic

D6750

Crown – Porcelain fused to high noble metal

$330.00

D6751

Crown – Porcelain fused to predominantly base metal

$410.00

D6752

Crown – Porcelain fused to noble meta

$355.00

D6780

Crown – 3/4 cast high noble metal

$330.00

D6781

Crown – 3/4 cast predominantly base metal

$410.00

D6782

Crown – 3/4 cast noble meta

$355.00

D6790

Crown – Full cast high noble metal

$330.00

D3110

$500.00

Dental DHMO Code

Procedure Description

Patient Charge

D3410

Apicoectomy/periradicular surgery – Anterior

$275.00

D3421

Apicoectomy/periradicular surgery – Bicuspid (first root)

$305.00

D3425

Apicoectomy/periradicular surgery – Molar (first root)

$340.00

D3426

Apicoectomy/periradicular surgery (each additional root)

$110.00

D3430

Retrograde filling – Per root

$72.00

Periodontics (treatment of supporting tissues [gum and bone] of the teeth) periodontal regenerative procedures are limited to 1 regenerative procedure per site (or per tooth, if applicable), when covered on the Patient Charge Schedule. The relevant procedure codes are D4263, D4264, D4266 and D4267. Localized delivery of antimicrobial agents is limited to 8 teeth (or 8 sites, if applicable) per 12 consecutive months when covered on the Patient Charge Schedule. If your Network Dentist certifies to Cigna Dental that, due to medical necessity, you require certain Covered Services more frequently than the limitation allows, Cigna Dental will waive the applicable limitation. The relevant Covered Services are identified with a ❂. Gingivectomy or gingivoplasty – 4 or more teeth per quadrant

$180.00

D4211

Gingivectomy or gingivoplasty – 1 to 3 teeth per quadrant

$91.00

D4212

Gingivectomy or gingivoplasty to allow access for restorative procedure, per tooth

$91.00

D4240

Gingival flap (including root planing) – 4 or more teeth per quadrant

$235.00

D4241

Gingival flap (including root planing) – 1 to 3 teeth per quadrant

$125.00

D4245

Apically positioned flap

$235.00

D4249

Clinical crown lengthening – Hard tissue

$255.00

D4260

Osseous surgery – 4 or more teeth per quadrant

$400.00

D4261

Osseous surgery – 1 to 3 teeth per quadrant

$240.00

D4263

Bone replacement graft – First site in quadrant

D4264

Bone replacement graft – Each additional site in quadrant

D4266

Guided tissue regeneration – Resorbable barrier per site

D4210

Code

Patient Charge

D4267

Guided tissue regeneration – Nonresorbable barrier per site (includes membrane removal)

$430.00

D4270

Pedicle soft tissue graft procedure

$300.00

D4275

Soft tissue allograft

$310.00

D4277

Free soft tissue graft procedure (including donor site surgery), first tooth or edentulous (missing) tooth position in graft

$310.00

D4278

Free soft tissue graft procedure (including donor site surgery), each additional contiguous tooth or edentulous (missing) tooth position in same graft site

$155.00

D4341

Periodontal scaling and root planing – 4 or more teeth per quadrant (limit 4 quadrants per consecutive 12 months) ❂

$83.00

D4342

Periodontal scaling and root planing – 1 to 3 teeth per quadrant (limit 4 quadrants per consecutive 12 months) ❂

$42.00

D4355

Full mouth debridement to allow evaluation and diagnosis (1 per lifetime)

$65.00

D4381

Localized delivery of antimicrobial agents per tooth

$45.00

D4910

Periodontal maintenance (limit 4 per calendar year) (only covered after active periodontal therapy) ❂

$53.00

Prosthetics (removable tooth replacement – dentures) includes up to 4 adjustments within first 6 months after insertion – Replacement limit 1 every 5 years. Characterization is considered an upgrade with maximum additional charge to the member of $225.00 per denture. D5110

Full upper denture

$400.00

D5120

Full lower denture

$400.00

D5130

Immediate full upper denture

$455.00

D5140

Immediate full lower denture

$455.00

D5211

Upper partial denture – Resin base (including clasps, rests and teeth)

$300.00

D5212

Lower partial denture – Resin base (including clasps, rests and teeth)

$300.00

D5213

Upper partial denture – Cast metal framework (including clasps, rests and teeth)

$490.00

$290.00 $225.00 $380.00

Procedure Description

Dental DHMO Code

Procedure Description

Patient Charge

D5214

Lower partial denture – Cast metal framework (including clasps, rests and teeth)

$490.00

D5225

Upper partial denture – Flexible base (including clasps, rests and teeth)

$380.00

D5226

Lower partial denture – Flexible base (including clasps, rests and teeth)

$380.00

D5410

Adjust complete denture – Upper

$43.00

D5411

Adjust complete denture – Lower

$43.00

D5421

Adjust partial denture – Upper

$46.00

D5422

Adjust partial denture – Lower

$46.00

Repairs to prosthetics D5510

Repair broken complete denture base

$88.00

D5520

Replace missing or broken teeth – Complete denture (each tooth)

$76.00

D5610

Repair resin denture base

$88.00

D5630

Repair or replace broken clasp

$110.00

D5640

Replace broken teeth – Per tooth

$81.00

D5650

Add tooth to existing partial denture

$88.00

D5660

Add clasp to existing partial denture

$110.00

Denture relining (limit 1 every 36 months) D5710

Rebase complete upper denture

$250.00

D5711

Rebase complete lower denture

$250.00

D5720

Rebase upper partial denture

$250.00

D5721

Rebase lower partial denture

$250.00

D5730

Reline complete upper denture – Chairside

$145.00

D5731

Reline complete lower denture – Chairside

$145.00

D5740

Reline upper partial denture – Chairside

$145.00

D5741

Reline lower partial denture – Chairside

$145.00

D5750

Reline complete upper denture – Laboratory

D5751

Reline complete lower denture – Laboratory

D5760 D5761

Code

Procedure Description

Patient Charge

Interim dentures (limit 1 every 5 years) D5810

Interim complete denture – Upper

$315.00

D5811

Interim complete denture – Lower

$315.00

D5820

Interim partial denture – Upper

$280.00

D5821

Interim partial denture – Lower

$280.00

Implant/abutment supported prosthetics – All charges for crowns and bridges (fixed partial dentures) are per unit (each replacement on a supporting implant(s) equals 1 unit). Coverage for replacement of crowns and bridges and implant supported dentures is limited to 1 every 5 years. For single crowns, retainer (“abutment”) crowns, and pontics: The charges below include the cost of predominantly base metal alloy. You may be charged up to these additional amounts, based on the type of material the dentist uses for your restoration. • No more than $80.00 per tooth for any noble metal alloys • No more than $130.00 per tooth for any high noble metal alloys, titanium or titanium alloys • No more than $100.00 per tooth for any porcelain fused to metal (only on molar teeth) • Porcelain/ceramic substrate crowns on molar teeth are not covered In addition, you may be charged up to these additional amounts. No more than $100.00 per tooth if an indirectly fabricated (“cast”) post and core is made of high noble metal alloy • No more than $150.00 per tooth for crowns, inlays, onlays, post and cores, and veneers if your dentist uses same day inoffice CAD/CAM (ceramic) services. Same day in-office CAD/ CAM (ceramic) services refer to dental restorations that are created in the dental office by the use of a digital impression and an in-office CAD/CAM milling machine D6053

Implant/abutment supported removable denture for completely edentulous arch

D6054

Implant/abutment supported removable denture for partially edentulous arch

$1,015.00

D6058

Abutment supported porcelain/ ceramic crown

$790.00

D6059

Abutment supported porcelain fused to metal crown (high noble metal)

$620.00

$210.00

D6060

Abutment supported porcelain fused to metal crown (predominantly base metal)

$700.00

Reline upper partial denture – Laboratory

$210.00

D6061

Abutment supported porcelain fused to metal crown (noble metal)

$645.00

Reline lower partial denture – Laboratory

$210.00

D6062

Abutment supported cast metal crown (high noble metal)

$620.00

$210.00

$925.00

Dental DHMO Code

Procedure Description

Patient Charge

Code

D6063

Abutment supported cast metal crown (predominantly base metal)

$700.00

D6092

Recement implant/abutment supported crown

$82.00

D6064

Abutment supported cast metal crown (noble metal)

$645.00

D6093

Recement implant/abutment supported fixed partial denture

$99.00

D6065

Implant supported porcelain/ceramic crown

$790.00

D6094

Abutment supported crown (titanium)

$620.00

Abutment supported retainer crown for fixed partial denture (titanium)

$620.00

D6066

Implant supported porcelain fused to metal crown (titanium, titanium alloy, high noble metal)

Implant supported metal crown (titanium, titanium alloy, high noble metal)

$620.00

$135.00

D6068

Abutment supported retainer for porcelain/ceramic fixed partial denture

$790.00

D6069

Abutment supported retainer for porcelain fused to metal fixed partial denture (high noble metal)

Complex rehabilitation on implant/ abutment supported prosthetic procedures – Additional charge per unit for multiple crown units/complex rehabilitation (6 or more units of crown and/or bridge in same treatment plan requires complex rehabilitation for each unit – ask your dentist for the guidelines)

$620.00

D6070

Abutment supported retainer for porcelain fused to metal fixed partial denture (predominantly base metal)

$700.00

D6071

Abutment supported retainer for porcelain fused to metal fixed partial denture (noble metal)

$645.00

D6072

Abutment supported retainer for cast metal fixed partial denture (high noble metal)

D6073

Abutment supported retainer for cast metal fixed partial denture (predominantly base metal)

D6074

Abutment supported retainer for cast metal fixed partial denture (noble metal)

$645.00

Implant supported retainer for ceramic fixed partial denture

$790.00

D6076

Implant supported retainer for porcelain fused to metal fixed partial denture (titanium, titanium alloy, high noble metal)

$620.00

D6077

Implant supported retainer for cast metal fixed partial denture (titanium, titanium alloy, high noble metal)

$620.00

D6078

Implant/abutment supported fixed denture for completely edentulous arch

$925.00

D6079

Implant/abutment supported fixed denture for partially edentulous arch

D6067

D6075

D6194

Procedure Description

Patient Charge

Oral surgery (includes routine postoperative treatment) Surgical removal of impacted tooth – Not covered for ages below 15 unless pathology (disease) exists. D7111

Extraction of coronal remnants – Deciduous tooth

$12.00

D7140

Extraction, erupted tooth or exposed root – Elevation and/or forceps removal

$12.00

$620.00

D7210

Surgical removal of erupted tooth – Removal of bone and/or section of tooth

$53.00

$700.00

D7220

Removal of impacted tooth – Soft tissue

$46.00

D7230

Removal of impacted tooth – Partially bony

$91.00

D7240

Removal of impacted tooth – Completely bony

$115.00

D7241

Removal of impacted tooth – Completely bony, unusual complications (narrative required)

$125.00

D7250

Surgical removal of residual tooth roots – Cutting procedure

$53.00

D7251

Coronectomy - Intentional partial tooth removal

$91.00

D7260

Oroantral fistula closure

$125.00

D7261

Primary closure of a sinus perforation

$125.00

D7270

Tooth stabilization of accidentally evulsed or displaced tooth

$14.00

D7280

Surgical access of an unerupted tooth (excluding wisdom teeth)

$14.00

$1,015.00

Dental DHMO Code

Procedure Description

D7283

Placement of device to facilitate eruption of impacted tooth

$8.00

D7285

Biopsy of oral tissue – Hard (bone, tooth) (tooth related – not allowed when in conjunction with another surgical procedure)

$78.00

D7286

Biopsy of oral tissue – Soft (all others) (tooth related – not allowed when in conjunction with another surgical procedure)

$65.00

D7287

Exfoliative cytological sample collection

$78.00

D7288

Brush biopsy – Transepithelial sample collection

$78.00

D7310

Alveoloplasty in conjunction with extractions – 4 or more teeth or tooth spaces per quadrant

$58.00

D7311

Alveoloplasty in conjunction with extractions – 1 to 3 teeth or tooth spaces per quadrant

$33.00

Alveoloplasty not in conjunction with extractions – 4 or more teeth or tooth spaces per quadrant

$78.00

D7320

Patient Charge

Code

Patient Charge

D7960

Frenulectomy – Also known as frenectomy or frenotomy – Separate procedure not incidental to another procedure

$14.00

D7963

Frenuloplasty

$20.00

Orthodontics (tooth movement) Orthodontic treatment (maximum benefit of 24 months of interceptive and/or comprehensive treatment. Atypical cases or cases beyond 24 months require an additional payment by the patient.) D8050

Interceptive orthodontic treatment of the primary dentition – Banding

$480.00

D8060

Interceptive orthodontic treatment of the transitional dentition – Banding

$480.00

D8070

Comprehensive orthodontic treatment of the transitional dentition – Banding

$500.00

D8080

Comprehensive orthodontic treatment of the adolescent dentition – Banding

$515.00

D8090

Comprehensive orthodontic treatment of the adult dentition – Banding

$515.00

D8660

Pre-orthodontic treatment visit

$67.00

Periodic orthodontic treatment visit – As part of contract Children – Up to 19th birthday:

D7321

Alveoloplasty not in conjunction with extractions – 1 to 3 teeth or tooth spaces per quadrant

D7450

Removal of benign odontogenic cyst or tumor – Up to 1.25 cm

$14.00

D7451

Removal of benign odontogenic cyst or tumor – Greater than 1.25 cm

$14.00

D7471

Removal of lateral exostosis – Maxilla or mandible

$14.00

D7472

Removal of torus palatinus

$14.00

D7473

Removal of torus mandibularis

$14.00

D7485

Surgical reduction of osseous tuberosity

$78.00

D7510

Incision and drainage of abscess – Intraoral soft tissue

$14.00

D7511

Incision and drainage of abscess – Intraoral soft tissue – Complicated

$20.00

D7880

Occlusal orthotic device, by report (limit 1 per 24 months; only covered in conjunction with Temporomandibular Joint (TMJ) treatment)

$330.00

$40.00

24-month treatment fee D8670

Procedure Description

$2,040.00

Charge per month for 24 months

$85.00

Adults: 24-month treatment fee

$2,376.00

Charge per month for 24 months

$99.00

D8680

Orthodontic retention – Removal of appliances, construction and placement of retainer(s)

$345.00

D8999

Unspecified orthodontic procedure – By report (orthodontic treatment plan and records)

$195.00

General anesthesia/IV sedation – General anesthesia is covered when performed by an oral surgeon when medically necessary for covered procedures listed on the patient charge schedule. IV sedation is covered when performed by a periodontist or oral surgeon when medically necessary for covered procedures listed on the patient charge schedule. Plan limitation for this benefit is 1 hour per appointment. There is no coverage for general anesthesia or intravenous sedation when used for the purpose of anxiety control or patient management. D9220

General anesthesia – First 30 minutes

$190.00

Dental DHMO Code

Procedure Description

Patient Charge

D9221

General anesthesia – Each additional 15 minutes

$84.00

D9241

IV conscious sedation – First 30 minutes

$190.00

D9242

IV conscious sedation – Each additional 15 minutes

$73.00

Emergency services D9110

Palliative (emergency) treatment of dental pain – Minor procedure

$0.00

D9440

Office visit – After regularly scheduled hours

$55.00

Miscellaneous services D9940

Occlusal guard – By report (limit 1 per 24 months)

$205.00

D9941

Fabrication of athletic mouthguard (limit 1 per 12 months)

$110.00

D9951

Occlusal adjustment – Limited

$40.00

D9952

Occlusal adjustment – Complete

$210.00

D9975

External bleaching for home application, per arch; includes materials and fabrication of custom trays (all other methods of bleaching are not covered)

$165.00

This may contain CDT codes and/or portions of, or excerpts from the nomenclature contained within the Current Dental Terminology, a copyrighted publication provided by the American Dental Association. The American Dental Association does not endorse any codes which are not included in its current publication.

After your enrollment is effective: Call the dental office identified in your Welcome Kit. If you wish to change dental offices, a transfer can be arranged at no charge by calling Cigna Dental at the toll free number listed on your ID card or plan materials. Multiple ways to locate a *DHMO Network General Dentist: • • •

Online provider directory at Cigna.com Online provider directory on myCigna.com Call the number located on your ID card to: — Use the Dental Office Locator via Speech Recognition — Speak to a Customer Service Representative

EMERGENCY: If you have a dental emergency as defined in your group’s plan documents, contact your Network General Dentist as soon as possible. If you are out of your service area or unable to contact your Network Office, emergency care can be rendered by any dental office, dental clinic or other comparable facility. Definitive treatment (e.g., root canal) is not considered emergency care and should be performed or referred by your Network General Dentist. Consult your group’s plan documents for a complete definition of dental emergency, your emergency benefit and a listing of Exclusions and Limitations. *The term “DHMO” is used to refer to product designs that may differ by state of residence of enrollee, including but not limited to, prepaid plans, managed care plans, and plans with open access features. “Cigna,”“GO YOU” and the “Tree of Life” logo are registered service marks, and “Cigna Dental” is a service mark, of Cigna Intellectual Property, Inc., licensed for use by Cigna Corporation and its operating subsidiaries. All products and services are provided exclusively by such operating subsidiaries, including Connecticut General Life Insurance Company (“CGLIC”), Cigna Health and Life Insurance Company (“CHLIC”), Cigna HealthCare of Connecticut, Inc., and Cigna Dental Health, Inc. (“CDHI”) and its subsidiaries, and not by Cigna Corporation. The Cigna Dental Care plan is provided by Cigna Dental Health Plan of Arizona, Inc.; Cigna Dental Health of California, Inc.; Cigna Dental Health of Colorado, Inc.; Cigna Dental Health of Delaware, Inc.; Cigna Dental Health of Florida, Inc., a Prepaid Limited Health Services Organization licensed under Chapter 636, Florida Statutes; Cigna Dental Health of Kansas, Inc. (Kansas and Nebraska); Cigna Dental Health of Kentucky, Inc.; Cigna Dental Health of Maryland, Inc.; Cigna Dental Health of Missouri, Inc.; Cigna Dental Health of New Jersey, Inc.; Cigna Dental Health of North Carolina, Inc.; Cigna Dental Health of Ohio, Inc.; Cigna Dental Health of Pennsylvania, Inc.; Cigna Dental Health of Texas, Inc.; and Cigna Dental Health of Virginia, Inc. In other states, the Cigna Dental Care plan is underwritten by CGLIC, CHLIC, or Cigna HealthCare of Connecticut, Inc., and administered by CDHI. 863980 09/13 © 2013 Cigna. Some content provided under license.

VSP

Vision

YOUR BENEFITS PACKAGE

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.

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 This is a general overview of your plan benefits.inIfthe thesummary terms of plan this outline differlocated from your policy, the policy will govern. Additional plan description on the 44 details on covered expenses, limitations and exclusions included in the summary plan description located on the Duncanville ISD Benefits Website:are www.mybenefitshub.com/duncanvilleisd Duncanville ISD Benefits Website: www.mybenefitshub.com/duncanvilleisd

Vision A LOOK AT YOUR VSP VISION COVERAGE

GET YOUR PERFECT PAIR

Your Monthly Contribution

SEE HEALTHY AND LIVE HAPPY WITH HELP FROM DUNCANVILLE ISD AND VSP.

Member only

$8.20

Member + 1

$16.40

Enroll in VSP® Vision Care to get personalized care from a VSP network doctor at low out-of-pocket costs.

Member + children

$18.91

Member + family

$30.22

EXTRA $20 TO SPEND ON FEATURED FRAME BRANDS* SEE MORE BRANDS AT VSP.COM/OFFERS.

UP TO 40% SAVINGS ON LENS ENHANCEMENTS

VALUE AND SAVINGS YOU LOVE. QUALITY VISION CARE YOU NEED. Save on eyewear and eye care when you see a VSP network doctor. Plus, You’ll get great care from a VSP network doctor, including a WellVision take advantage of Exclusive Member Extras for additional savings. Exam®—a comprehensive exam designed to detect eye and health conditions. PROVIDER CHOICES YOU WANT. It’s easy to find a nearby in-network doctor. Maximize your coverage with bonus offers and savings that are exclusive to Premier Program locations—including thousands of private practice doctors and over 700 Visionworks retail locations nationwide.

USING YOUR BENEFIT IS EASY! Create an account on vsp.com to view your in-network coverage, find the VSP network doctor who’s right for you, and discover savings with exclusive member extras. At your appointment, just tell them you have VSP.

YOUR VSP VISION BENEFITS SUMMARY DUNCANVILLE ISD and VSP provide you with an affordable vision plan.

BENEFIT

PROVIDER NETWORK: VSP Choice

DESCRIPTION

EFFECTIVE DATE: 09/01/2021

COPAY

FREQUENCY

$10 $10

Every plan year* See frame and lenses

YOUR COVERAGE WITH A VSP PROVIDER WELLVISION EXAM PRESCRIPTION GLASSES FRAME

LENSES LENS ENHANCEMENTS CONTACTS (INSTEAD OF GLASSES) DIABETIC EYECARE PLUS PROGRAM

EXTRA SAVINGS

• Focuses on your eyes and overall wellness • • • • • • • • • • • •

$130 allowance for a wide selection of frames Included in Every other plan year $150 allowance for featured frame brands Prescription Glasses 20% savings on the amount over your allowance Single vision, lined bifocal, and lined trifocal lenses Included in Every plan year Impact-resistant lenses for dependent children Prescription Glasses Standard progressive lenses $0 Premium progressive lenses $95 - $105 Every plan year Custom progressive lenses $150 - $175 Average savings of 20-25% on other lens enhancements $130 allowance for contacts; copay does not apply Up to $25 Every plan year Contact lens exam (fitting and evaluation) Services related to diabetic eye disease, glaucoma and age-related macular degeneration (AMD). Retinal screening for eligible $20 As needed members with diabetes. Limitations and coordination with medical coverage may apply. Ask your VSP doctor for details. Glasses and Sunglasses • Extra $20 to spend on featured frame brands. Go to vsp.com/offers for details. • 20% savings on additional glasses and sunglasses, including lens enhancements, from any VSP provider within 12 months of your last WellVision Exam. Retinal Screening • No more than a $39 copay on routine retinal screening as an enhancement to a WellVision Exam Laser Vision Correction • Average 15% off the regular price or 5% off the promotional price; discounts only available from contracted facilities

YOUR COVERAGE WITH OUT-OF-NETWORK PROVIDERS Get the most out of your benefits and greater savings with a VSP network doctor. Call Member Services for out-of-network plan details. Coverage with a retail chain may be different or not apply. Log in to vsp.com to check your benefits for eligibility and to confirm in-network locations based on your plan type. VSP guarantees coverage from VSP network providers only. Coverage information is subject to change. In the event of a conﬂict between this information and your organization’s contract with VSP, the terms of the contract will prevail. Based on applicable laws, benefits may vary by location. In the state of Washington, VSP Vision Care, Inc., is the legal name of the corporation through which VSP does business. *Plan year begins in September

Log in to vsp.com to find an in-network provider based on your plan type. Enroll today. Contact us: 800.877.7195 or vsp.com *Only available to VSP members with applicable plan benefits. Frame brands and promotions are subject to change. Savings based on doctor’s retail price and vary by plan and purchase selection; average savings determined after benefits are applied. Ask your VSP network doctor for more details. ©2020 Vision Service Plan. All rights reserved. VSP, VSP Vision Care for life, Eyeconic, and WellVision Exam are registered trademarks, VSP Diabetic Eyecare Plus Program is servicemark of Vision Service Plan. Flexon is a registered trademark of Marchon Eyewear, Inc. All other brands or marks are the property of their respective owners.

THE HARTFORD YOUR BENEFITS PACKAGE

Disability

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

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.

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 46 details on covered expenses, limitations and exclusions are included in the summary plan description located on the Duncanville ISD Benefits Website: www.mybenefitshub.com/duncanvilleisd

Long Term Disability Benefit Highlights for: Duncanville Independent School District #395320 What is Long-Term Disability Insurance? Long-Term Disability Insurance pays you a portion of your earnings if you cannot work because of a disabling illness or injury. You have the opportunity to purchase Long-Term Disability Insurance through your employer. This highlight sheet is an overview of your Long-Term Disability Insurance. Once a group policy is issued to your employer, a certificate of insurance will be available to explain your coverage in detail.

Why do I need Long-Term Disability Coverage? Most accidents and injuries that keep people off the job happen outside the workplace and therefore are not covered by worker’s compensation. When you consider that nearly three in 10 workers entering the workforce today will become disabled before retiring1 , it’s protection you won’t want to be without. 1 Social Security Administration, Fact Sheet 2009.

What is disability? Disability is defined in The Hartford’s* contract with your employer. Typically, disability means that you cannot perform one or more of the essential duties of your occupation due to injury, sickness, pregnancy or other medical condition covered by the insurance, and as a result, your current monthly earnings are 80% or less of your pre-disability earnings. Once you have been disabled for 24 months, you must be prevented from performing one or more of the essential duties of any occupation and as a result, your current monthly earnings are 66 2/3% or less of your pre-disability earnings.

Am I eligible? You are eligible if you are an active employee who works at least 30 hours per week on a regularly scheduled basis.

How long do I have to wait before I can receive my benefit? You must be disabled for at least the number of days indicated by the elimination period that you select before you can receive a Long-Term

Disability benefit payment. For those employees electing an elimination period of 30 days or less, if your are confined to a hospital for 24 hours or more due to a disability, the elimination period will be waived, and benefits will be payable from the first day of disability.

What is an elimination period? The elimination period that you select consists of two numbers. The first number shows the number of days you must be disabled by an accident before your benefits can begin. The second number indicates the number of days you must be disabled by a sickness before your benefits can begin.

I already have Disability coverage; do I have to do anything? If you are not changing the amount of your coverage or your elimination period option, you do not have to do anything. If you want to purchase Long-Term Disability insurance for the first time or change your coverage, please be sure to enroll online, which indicates your election.

What other benefits are included in my disability coverage?

•

• •

How much coverage would I have? You may purchase coverage that will pay you a monthly ﬂat dollar benefit in $100 increments between $200 and $8,000 that cannot exceed 66 2/3% of your current monthly earnings. Your plan includes a minimum benefit of 25% of your elected benefit Earnings are defined in The Hartford’s contract with your employer.

When can I enroll? If you choose not to elect coverage during your annual enrollment period, you will not be eligible to elect coverage until the next annual enrollment period without a qualifying change in family status.

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

What is does “Actively at Work” mean? You must be at work with your Employer on your regularly scheduled workday. On that day, you must be performing for wage or profit all of your regular duties in the usual way and for your usual number of hours. If school is not in session due to normal vacation or school break (s), Actively at Work shall mean you are able to report for work with your Employer, performing all of the regular duties of Your Occupation in the usual way for your usual number of hours as if school was in session.

•

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

How long will my disability payments continue? Can the duration of my benefit be reduced? Benefit Duration is the maximum time for which we pay benefits for disability resulting from sickness or injury. Depending on the schedule selected and the age at which disability occurs, the maximum duration may vary. Please see the applicable schedules below based on your election of the Premium benefit option. 47

Long Term Disability How long will my disability benefits continue if I elect the Premium benefit option? For the Premium benefit option – the table below applies to disabilities resulting from injury or sickness:

For the Premium benefit option – the table below applies to disabilities resulting from injury or sickness: Age Disabled Benefits Payable Prior to Age 63 To Normal Retirement Age or 48 months if greater Age 63 To Normal Retirement Age or 42 months if greater Age 64 36 months Age 65 30 months Age 66 27 months Age 67 24 months Age 68 21 months Age 69 18 months & older

Important Details Exclusions: You cannot receive Disability benefit payments for disabilities that are caused or contributed to by: • War or act of war (declared or not) • Military service for any country engaged in war or other armed conﬂict • The commission of, or attempt to commit a felony • An intentionally self-inﬂicted injury • Any case where your being engaged in an illegal occupation was a contributing cause to your disability • You must be under the regular care of a physician to receive benefits. Mental Illness, Alcoholism and Substance Abuse: • You can receive benefit payments for Long-Term Disabilities resulting from mental illness, alcoholism and substance abuse for a total of 24 months for all disability periods during your lifetime. • Any period of time that you are confined in a hospital or other facility licensed to provide medical care for mental illness, alcoholism and substance abuse does not count toward the 24 month lifetime limit.

Pre-existing Conditions: Your policy limits the benefits you can receive for a disability caused by a pre-existing condition. In general, if you were diagnosed or received care for a disabling condition within the 3 consecutive months just prior to the effective date of this policy, your benefit payment will be limited, unless: You have not received treatment for the disabling condition within 3 months, while insured under this policy, before the disability begins, or You have been insured under this policy for 12 months before your disability begins. You may also be covered if you have already satisfied the pre-existing condition requirement of your previous insurer. If your disability is a result of a pre -existing condition we will pay benefits for a maximum of 4 weeks. Your benefit payments may be reduced by other income you receive or are eligible to receive due to your disability, such as: • Social Security Disability Insurance (please see next section for exceptions) • Workers' Compensation • Other employer-based Insurance coverage you may have • Unemployment benefits • Settlements or judgments for income loss • Retirement benefits that your employer fully or partially pays for (such as a pension plan.) Your benefit payments will not be reduced by certain kinds of other income, such as: • Retirement benefits if you were already receiving them before you became disabled • The portion of your Long -Term Disability payment that you place in an IRS-approved account to fund your future retirement. • Your personal savings, investments, IRAs or Keoghs • Profit-sharing • Most personal disability policies • Social Security increases This Benefit Highlights Sheet is an overview of the Long-Term Disability 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 (your employer) 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. Underwritten by: Hartford Life and Accident Insurance Company 200 Hopmeadow Street Simsbury, CT 06089

PREMIUM OPTION – MONTHLY PREMIUM COST (based on 12 payments per year) - Effective 9/1/2017 d Accident/Sickness Elimination Period in Days Annual Monthly Monthly 0/3 14/14 30/30 60/60 90/90 180/180 Earnings Earnings Benefit $3,600 $5,400 $7,200 $9,000 $10,800 $12,600 $14,400 $16,200 $18,000 $19,800 $21,600 $23,400 $25,200 $27,000 $28,800 $30,600 $32,400 $34,200 48

$300 $450 $600 $750 $900 $1,050 $1,200 $1,350 $1,500 $1,650 $1,800 $1,950 $2,100 $2,250 $2,400 $2,550 $2,700 $2,850

$200 $300 $400 $500 $600 $700 $800 $900 $1,000 $1,100 $1,200 $1,300 $1,400 $1,500 $1,600 $1,700 $1,800 $1,900

$8.68 $13.02 $17.36 $21.70 $26.04 $30.38 $34.72 $39.06 $43.40 $47.74 $52.08 $56.42 $60.76 $65.10 $69.44 $73.78 $78.12 $82.46

$6.76 $10.14 $13.52 $16.90 $20.28 $23.66 $27.04 $30.42 $33.80 $37.18 $40.56 $43.94 $47.32 $50.70 $54.08 $57.46 $60.84 $64.22

$5.74 $8.61 $11.48 $14.35 $17.22 $20.09 $22.96 $25.83 $28.70 $31.57 $34.44 $37.31 $40.18 $43.05 $45.92 $48.79 $51.66 $54.53

$3.72 $5.58 $7.44 $9.30 $11.16 $13.02 $14.88 $16.74 $18.60 $20.46 $22.32 $24.18 $26.04 $27.90 $29.76 $31.62 $33.48 $35.34

$3.22 $4.83 $6.44 $8.05 $9.66 $11.27 $12.88 $14.49 $16.10 $17.71 $19.32 $20.93 $22.54 $24.15 $25.76 $27.37 $28.98 $30.59

$2.44 $3.66 $4.88 $6.10 $7.32 $8.54 $9.76 $10.98 $12.20 $13.42 $14.64 $15.86 $17.08 $18.30 $19.52 $20.74 $21.96 $23.18

Long Term Disability PREMIUM OPTION – MONTHLY PREMIUM COST (based on 12 payments per year) - Effective 9/1/2017 d Accident/Sickness Elimination Period in Days Annual Monthly Monthly 0/3 14/14 30/30 60/60 90/90 180/180 Earnings Earnings Benefit $36,000 $37,800 $41,400 $43,200 $45,000 $46,800 $48,600 $50,400 $52,200 $54,000 $55,800 $57,600 $59,400 $61,200 $63,000 $64,800 $66,600 $68,400 $70,200 $72,000 $73,800 $75,600 $77,400 $79,200 $81,000 $82,800 $84,600 $86,400 $88,200 $90,000 $91,800 $93,600 $95,400 $97,200 $99,000 $100,800 $102,600 $104,400 $106,200 $108,000 $109,800 $111,600 $113,400 $115,200 $117,000 $118,800 $120,600 $122,400 $124,200 $126,000 $127,800 $129,600 $131,400 $133,200 $135,000 $136,800 $138,600 $140,400 $142,200 $144,000

$3,000 $3,150 $3,450 $3,600 $3,750 $3,900 $4,050 $4,200 $4,350 $4,500 $4,650 $4,800 $4,950 $5,100 $5,250 $5,400 $5,550 $5,700 $5,850 $6,000 $6,150 $6,300 $6,450 $6,600 $6,750 $6,900 $7,050 $7,200 $7,350 $7,500 $7,650 $7,800 $7,950 $8,100 $8,250 $8,400 $8,550 $8,700 $8,850 $9,000 $9,150 $9,300 $9,450 $9,600 $9,750 $9,900 $10,050 $10,200 $10,350 $10,500 $10,650 $10,800 $10,950 $11,100 $11,250 $11,400 $11,550 $11,700 $11,850 $12,000

$2,000 $2,100 $2,300 $2,400 $2,500 $2,600 $2,700 $2,800 $2,900 $3,000 $3,100 $3,200 $3,300 $3,400 $3,500 $3,600 $3,700 $3,800 $3,900 $4,000 $4,100 $4,200 $4,300 $4,400 $4,500 $4,600 $4,700 $4,800 $4,900 $5,000 $5,100 $5,200 $5,300 $5,400 $5,500 $5,600 $5,700 $5,800 $5,900 $6,000 $6,100 $6,200 $6,300 $6,400 $6,500 $6,600 $6,700 $6,800 $6,900 $7,000 $7,100 $7,200 $7,300 $7,400 $7,500 $7,600 $7,700 $7,800 $7,900 $8,000

$86.80 $91.14 $99.82 $104.16 $108.50 $112.84 $117.18 $121.52 $125.86 $130.20 $134.54 $138.88 $143.22 $147.56 $151.90 $156.24 $160.58 $164.92 $169.26 $173.60 $177.94 $182.28 $186.62 $190.96 $195.30 $199.64 $203.98 $208.32 $212.66 $217.00 $221.34 $225.68 $230.02 $234.36 $238.70 $243.04 $247.38 $251.72 $256.06 $260.40 $264.74 $269.08 $273.42 $277.76 $282.10 $286.44 $290.78 $295.12 $299.46 $303.80 $308.14 $312.48 $316.82 $321.16 $325.50 $329.84 $334.18 $338.52 $342.86 $347.20

$67.60 $70.98 $77.74 $81.12 $84.50 $87.88 $91.26 $94.64 $98.02 $101.40 $104.78 $108.16 $111.54 $114.92 $118.30 $121.68 $125.06 $128.44 $131.82 $135.20 $138.58 $141.96 $145.34 $148.72 $152.10 $155.48 $158.86 $162.24 $165.62 $169.00 $172.38 $175.76 $179.14 $182.52 $185.90 $189.28 $192.66 $196.04 $199.42 $202.80 $206.18 $209.56 $212.94 $216.32 $219.70 $223.08 $226.46 $229.84 $233.22 $236.60 $239.98 $243.36 $246.74 $250.12 $253.50 $256.88 $260.26 $263.64 $267.02 $270.40

$57.40 $60.27 $66.01 $68.88 $71.75 $74.62 $77.49 $80.36 $83.23 $86.10 $88.97 $91.84 $94.71 $97.58 $100.45 $103.32 $106.19 $109.06 $111.93 $114.80 $117.67 $120.54 $123.41 $126.28 $129.15 $132.02 $134.89 $137.76 $140.63 $143.50 $146.37 $149.24 $152.11 $154.98 $157.85 $160.72 $163.59 $166.46 $169.33 $172.20 $175.07 $177.94 $180.81 $183.68 $186.55 $189.42 $192.29 $195.16 $198.03 $200.90 $203.77 $206.64 $209.51 $212.38 $215.25 $218.12 $220.99 $223.86 $226.73 $229.60

$37.20 $39.06 $42.78 $44.64 $46.50 $48.36 $50.22 $52.08 $53.94 $55.80 $57.66 $59.52 $61.38 $63.24 $65.10 $66.96 $68.82 $70.68 $72.54 $74.40 $76.26 $78.12 $79.98 $81.84 $83.70 $85.56 $87.42 $89.28 $91.14 $93.00 $94.86 $96.72 $98.58 $100.44 $102.30 $104.16 $106.02 $107.88 $109.74 $111.60 $113.46 $115.32 $117.18 $119.04 $120.90 $122.76 $124.62 $126.48 $128.34 $130.20 $132.06 $133.92 $135.78 $137.64 $139.50 $141.36 $143.22 $145.08 $146.94 $148.80

$32.20 $33.81 $37.03 $38.64 $40.25 $41.86 $43.47 $45.08 $46.69 $48.30 $49.91 $51.52 $53.13 $54.74 $56.35 $57.96 $59.57 $61.18 $62.79 $64.40 $66.01 $67.62 $69.23 $70.84 $72.45 $74.06 $75.67 $77.28 $78.89 $80.50 $82.11 $83.72 $85.33 $86.94 $88.55 $90.16 $91.77 $93.38 $94.99 $96.60 $98.21 $99.82 $101.43 $103.04 $104.65 $106.26 $107.87 $109.48 $111.09 $112.70 $114.31 $115.92 $117.53 $119.14 $120.75 $122.36 $123.97 $125.58 $127.19 $128.80

$24.40 $25.62 $28.06 $29.28 $30.50 $31.72 $32.94 $34.16 $35.38 $36.60 $37.82 $39.04 $40.26 $41.48 $42.70 $43.92 $45.14 $46.36 $47.58 $48.80 $50.02 $51.24 $52.46 $53.68 $54.90 $56.12 $57.34 $58.56 $59.78 $61.00 $62.22 $63.44 $64.66 $65.88 $67.10 $68.32 $69.54 $70.76 $71.98 $73.20 $74.42 $75.64 $76.86 $78.08 $79.30 $80.52 $81.74 $82.96 $84.18 $85.40 $86.62 $87.84 $89.06 $90.28 $91.50 $92.72 $93.94 $95.16 $96.38 $97.60 49

APL

Cancer

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.

YOUR BENEFITS PACKAGE

Breast Cancer is the most commonly diagnosed cancer in women.

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

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 50 details on covered expenses, limitations and exclusions are included in the summary plan description located on the Duncanville ISD Benefits Website: www.mybenefitshub.com/duncanvilleisd

GC13 Limited Benefit Group Cancer Indemnity Insurance Duncanville ISD

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

SUMMARY OF BENEFITS Benefits

Option 1

Option 2

Radiation Therapy/Chemotherapy/Immunotherapy Benefit Maximum per 12-month period

$15,000

$20,000

$50 per treatment

Hormone Therapy - Maximum of 12 treatments per Calendar Year Experimental Treatment Benefit Waiver of Premium

Paid in the same manner and under the same maximums as any other benefit Waive Premium

Waive Premium

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

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

Internal Cancer First Occurrence Benefit

Heart Attack/Stroke First Occurrence Benefit

Option 1

Option 2

Individual

Monthly Premium*

$13.66

$23.00

Individual & Spouse

$29.48

$49.94

1 Parent Family

$15.70

$26.50

2 Parent Family

$31.52

$53.48

*The premium and amount of benefits vary dependent upon the option selected at time of application. All benefits are per covered person, per calendar year unless otherwise stated.

APSB-22331(TX) MGM/FBS Duncanville ISD

GC13 Limited Benefit Group Cancer Indemnity Insurance Eligibility

You and your Eligible Dependents are eligible to be insured under the Certificate if you and your Eligible Dependents meet APL’s underwriting rules and you are Actively at Work and qualify for coverage as defined in the Master Application.

Limitations & Exclusions

No benefits will be paid for care or treatment received outside the territorial limits of the United States, 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 Cancer was diagnosed.

Only Loss for Cancer

The Policy/Certificate pays only for loss resulting from definitive Cancer treatment including direct extension, metastatic spread or recurrence. Proof must be submitted to support each claim. The Policy/Certificate also covers other conditions or diseases directly caused by Cancer or the treatment of Cancer. The Policy/Certificate 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/Certificate are never covered. If any change to coverage after the Certificate Effective Date results in an increase or addition to coverage, the Time Limit on Certain Defenses and Pre-Existing Condition Limitation for such increase will be based on the effective date of such increase.

Waiting Period

The Policy/Certificate contains 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, the Insured may elect to void the Certificate from the beginning and receive a full refund of premium. If the Policy/Certificate replaced Specified Disease Cancer coverage from another 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 Limitation will still apply.

Termination of Certificate

Insurance coverage under the Certificate and any attached riders will end on the earliest of any of the following 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.

APSB-22331(TX) MGM/FBS Duncanville ISD

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.

Optionally Renewable

The policy is optionally renewable. The Policyholder has the right to terminate the policy on any premium due date after the first Anniversary following the Policy Effective Date. APL must give at least 60 days written notice prior to cancellation.

Portability (Voluntary Plans Only)

When the Insured no longer meets the definition of Insured, he or she 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; APL receives a request and payment of the first premium for the portability coverage no later than 30 days after the date the Insured no longer qualifies as an eligible Insured. All future premiums due will be billed directly to the Insured. The Insured is responsible for payment of all premiums for the portability coverage; the Policy, under which this Certificate was issued, continues to be in force on the date the Insured ceases to qualify for coverage. The benefits, terms and conditions of the portability coverage will be the same as those elected under the Certificate immediately prior to the date the Insured exercised portability. Portability coverage may include any Eligible Dependents who were covered under the Certificate at the time the Insured ceased to qualify as an eligible Insured. No new Eligible Dependents may be added to the portability coverage except as provided in the Newborn and Adopted Children provision. No increases in coverage will be allowed while the Insured is exercising his or her rights under this rider. If the Policy is no longer in force, then portability coverage is not available.

Heart Attack/Stroke First Occurrence Benefit Rider

Pays a lump sum amount when a Covered Person receives a first diagnosis of Heart Attack/Stroke and the Date of Diagnosis occurs after the Waiting Period. The Heart Attack/Stroke lump sum benefit amount will reduce by 50% at age 70.

Exclusions & Limitations

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; 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).

GC13 Limited Benefit Group Cancer Indemnity Insurance 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 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 your 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.

Internal Cancer First Occurrence Benefit Rider

Pays a lump sum benefit amount when a Covered Person receives a first diagnosis of a covered Internal Cancer and the Date of Diagnosis occurs after the Waiting Period. The Internal Cancer lump sum benefit amount will reduce by 50% at age 70.

Exclusions & Limitations

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

Waiting Period

This rider contains a 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 your 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.

2305 Lakeland Drive | Flowood, MS 39232 ampublic.com | 800.256.8606 Underwritten by American Public Life Insurance Company. This is a brief description of the coverage. For complete benefits and other provisions, please refer to your policy/certificate/rider(s). This coverage does not replace Workers’ Compensation Insurance. This product is inappropriate for people who are eligible for Medicaid coverage. | This product contains Limitations and Exclusions | 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 GC13APL | Limited Benefit Group Cancer Indemnity Insurance Series | Texas | (10/14) | Duncanville ISD

APSB-22331(TX) MGM/FBS Duncanville ISD

VOYA YOUR BENEFITS PACKAGE

Accident

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

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

usually live paycheck to paycheck.

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 54 details on covered expenses, limitations and exclusions are included in the summary plan description located on the Duncanville ISD Benefits Website: www.mybenefitshub.com/duncanvilleisd

Accident For the employees of: Duncanville Independent School District, Group #70124-6 What is Accident Insurance?

How can Accident Insurance help? Below are a few examples of how your Accident Insurance benefits could be used: • Medical expenses, such as deductibles and copays • Home healthcare costs • Lost income due to lost time at work • Everyday expenses like utilities and groceries

Accident Insurance pays you benefits for specific injuries and events resulting from a covered accident that occurs while you are not at work, on or after your coverage effective date. The benefit amount depends on the type of injury and care received. You have the option to elect Accident Insurance to meet your What accident benefits are available? needs. Accident Insurance is a limited benefit policy. It is not health insurance and does not satisfy the requirement of The following list is a summary of the benefits provided by minimum essential coverage under the Affordable Care Act. Accident Insurance. You may be required to seek care for your injury within a set amount of time. Note that there may be some Features of Accident Insurance include: variations by state. For a list of standard exclusions and • Guaranteed issue: No medical questions or tests are limitations, go to the end of this document. For a complete required for coverage. description of your available benefits, exclusions and limitations, • Flexible: You can use the benefit payments for any purpose see your certificate of insurance and any benefits. you like. • Portable: If you leave your current employer or retire, you can take your coverage with you.

EVENT

BENEFIT

Accident Hospital Care Surgery Open abdominal, thoracic Surgery exploratory or without repair

$1,200

$175 $600

Blood, plasma, platelets

$1,250

Hospital admission Hospital confinement Per day up to 365 Critical care unit confinement per day, up to 15 days Rehabilitation facility confinement per day for 90 days Coma Duration of 14 or more days Transportation per trip, up to 3 per accident Lodging Per day, up to 30 days Family care per child, up to 45 days

$375 $600 $200 $17,000 $750 $180

$25 Accident Care

Initial doctor visit

$90

Urgent care facility treatment

$225

Emergency room treatment

$225

Ground ambulance

$360

Air ambulance Follow-up doctor treatment

$1,500 $90

Chiropractic treatment up to six per accident

$45

Medical equipment

$120

Physical or occupational therapy up to six per accident

$45 55

Accident EVENT

BENEFIT

Speech therapy up to 6 per accident

$45

Prosthetic device (one)

$750 $1,200

Prosthetic device (two or more) Major diagnostic exam

$240

Outpatient surgery (one per accident)

$225

X-ray

$45 Common Injuries

Burns second degree, at least 36% of the body

$1,250

Burns 3rd degree, at least 9 but less than 35 square inches of the body

$7,500

Burns 3rd degree, 35 or more square inches of the body

$15,000 25% of burn benefit

Skin Grafts

$350 crown, $90 extraction

Emergency dental work Eye Injury removal of foreign object

$100

Eye Injury surgery

$350

Torn Knee Cartilage surgery with no repair or if cartilage is shaved

$225

Torn Knee Cartilage surgical repair

$800

Laceration1 treated no sutures

$30

Laceration1 sutures up to 2”

$60

Laceration sutures 2” – 6”

$240

Laceration1 sutures over 6”

$480

Ruptured Disk surgical repair

$800

Tendon/Ligament/Rotator Cuff Exploratory Arthroscopic Surgery with no repair Tendon/Ligament/Rotator Cuff One, surgical repair Tendon/Ligament/Rotator Cuff Two or more, surgical repair

$425 $825 $1,225 $225

Concussion

Paralysis—paraplegia

$16,000

Paralysis—quadriplegia

$24,000 Dislocations

Closed/open reduction2

Hip joint

$3,850/$7,700

Knee

$2,400/$4,800

Ankle or foot bone (s) Other than toes

$1,500/$3,000

Shoulder

$1,600/$3,200

Elbow

$1,100/$2,200 56

Accident EVENT

BENEFIT $1,100/$2,200

Wrist

$275/$550

Finger/toe Hand bone(s) Other than fingers

$1,100/$2,200

Lower jaw

$1,100/$2,200

Collarbone

$1,100/$2,200 25% of the closed reduction amount

Partial dislocations Fractures

Closed/open reduction3

Leg

$3,000/$6,000 $2,500/$5,000

Ankle

$1,800/$3,600

Kneecap

$1,800/$3,600

Foot Excluding toes, heel

$1,800/$3,600

Upper arm

$2,100/$4,200

Forearm, Hand, Wrist Except fingers

$1,800/$3,600

Finger, Toe

Vertebral processes

$240/$480 $3,360/$6,720 $1,440/$2,880

Pelvis Except coccyx

$3,200/$6,400

Hip

Vertebral body

Coccyx

$400/$800

Bones of face Except nose

$1,200/$2,400

Nose

Rib or ribs

$600/$1,200 $1,500/$3,000 $1,440/$2,880 $1,440/$2,880 $400/$800

Skull – simple Except bones of face

$1,400/$2,800

Skull – depressed Except bones of face

$3,000/$6,000

Upper jaw Lower jaw Collarbone

Sternum Shoulder blade Chip fractures

1 2 3

$360/$720 $1,800/$3,600 25% of the closed reduction amount

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

Accident Who is eligible for Accident Insurance? •

You—All active employees working 30+ hours per week**.

•

Your spouse*—If you have coverage on yourself, you may enroll your spouse, as long as your spouse is not covered under your employer’s plan as an employee. Your spouse will be covered for the same Accident benefits as you are.

•

Your children**—If you have coverage on yourself; your natural children, stepchildren, adopted children or children for whom you are a legal guardian are eligible to be covered under your employer’s plan, up to the age of 26. Your children will be covered for the same Accident benefits as you are and one premium amount covers all of your eligible children. If both you and your spouse are covered under this policy as an employee; then only one, but not both, may cover the same children under this benefit. If the parent who is covering the children stops being insured as an employee, then the other parent may apply for children’s coverage.

*The use of “spouse” in this document means a person insured as a spouse as described in the certificate of insurance or rider. This may include domestic partners or civil union partners as defined by the group policy. Please contact your employer for more information. **The definition of “child” may vary by state. Please contact your employer for more information.

Accidental Death Benefits

Benefit

Employee

$100,000

Spouse

$50,000

Children

$25,000

Other Accident Employee

$50,000

Spouse

$20,000

Children

$10,000

Accidental Dismemberment Benefits

Benefit

Loss of both hand or both feet or sight in both eyes

$28,000

Loss of one hand or one foot AND the sight of one eye

$22,000

Loss of one hand AND one foot

$22,000

Loss of one hand OR one foot

$12,500

Loss of Two or more fingers or toes

$1,800

Loss of one finger or one toe

$1,250

What does my Accident Insurance include? The benefits listed below are included with your Accident Insurance coverage. For a list of standard exclusions and limitations, please refer to the end of this document. For a complete description of your available benefits, exclusions and limitations, see your certificate of insurance and any benefits. •

•

Sports Accident Benefit: If your accident occurs while participating in an organized sporting activity as defined in the certificate; the accident hospital care, accident care or common injuries benefit will be increased by 25%; to a maximum additional benefit of $1000.

Accidental Death and Dismemberment (AD&D) coverage: If you are severely injured or die as a result of a covered accident, an AD&D benefit may be payable to you or your beneficiary. 

Common carrier: If the death occurs as a result of a covered accident on a common carrier, a higher benefit will be payable. Common carrier means any commercial transportation that operates on a regularly scheduled basis between predetermined points or cities.

How much does Accident Insurance cost? All employees pay the same rate, no matter their age. See the chart below for the premium amounts. Rates shown are guaranteed until September 1st, 2020. Monthly Rates (12 Pay Periods) Employee

Employee and Spouse

Employee and Children

Family

$11.40

$18.32

$20.20

$27.12

Semi-Monthly Rates (24 Pay Periods) Employee

Employee and Spouse

Employee and Children

Family

$5.70

$9.16

$10.10

$13.56

18 Pay Periods Employee

Employee and Spouse

Employee and Children

Family

$7.60

$12.21

$13.47

$18.08

Accident Exclusions and limitations Exclusions for the Certificate, Spouse Accident Insurance, and Children’s Accident Insurance and AD&D are listed below. (These may vary by state.) Benefits are not payable for any loss caused in whole or directly by any of the following*: •

Participation or attempt to participate in a felony or illegal activity.

•

An accident while the covered person is operating a motorized vehicle while intoxicated. Intoxication means the covered person’s blood alcohol content meets or exceeds the legal presumption of intoxication under the laws of the state where the accident occurred.

•

Suicide, attempted suicide or any intentionally self-inﬂicted injury, while sane or insane.

•

War or any act of war, whether declared or undeclared, other than acts of terrorism.

•

Loss sustained while on active duty as a member of the armed forces of any nation. We will refund, upon written notice of such service, any premium which has been accepted for any period not covered as a result of this exclusion.

•

Alcoholism, drug abuse, or misuse of alcohol or taking of drugs, other than under the direction of a doctor.

•

Riding in or driving any motor-driven vehicle in a race, stunt show or speed test.

•

Operating, or training to operate, or service as a crew member of, or jumping, parachuting or falling from, any aircraft or hot air balloon, including those which are not motor-driven. Flying as a fare-paying passenger is not excluded. Performing these acts as part of your employment with the employer is not excluded.

•

Engaging in hang-gliding, bungee jumping, parachuting, sail gliding, parasailing, parakiting, kite surfing or any similar activities.

•

Practicing for, or participating in, any semi-professional or professional competitive athletic contests for which any type of compensation or remuneration is received.

•

Any sickness or declining process caused by a sickness.

•

Work for pay, profit or gain.

*See the certificate of insurance and riders for a complete list of available benefits, exclusions and limitations.

Questions? Where do I get more information? For more information or to access the certificate of insurance, please call the Voya Employee Benefits Customer Service Team at (877) 236-7564.

This is a summary of benefits only. A complete description of benefits, limitations, exclusions and termination of coverage will be provided in the certificate of insurance and riders. All coverage is subject to the terms and conditions of the group policy. If there is any discrepancy between this document and the group policy documents, the policy documents will govern. To keep coverage in force, premiums are payable up to the date of coverage termination. Accident Insurance is underwritten by ReliaStar Life Insurance Company, a member of the Voya® family of companies. Policy Form #RL-ACC3-POL-16; Certificate Form #RL-ACC3-CERT16; and Rider Forms: Spouse Accident Rider Form #RL-ACC3-SPR-16, Children's Accident Rider Form #RL-ACC3-CHR-16, Accidental Death & Dismemberment (AD&D) Rider Form #RL-ACC3-ADR-16. Form numbers, provisions and availability may vary by state. ReliaStar Life Insurance Company, a member of the Voya® family of companies. CN0221-31181-0218 Duncanville Independent School District, Group #70124-6, Date Prepared: 5/8/2017 177546-04/01/2017

THE HARTFORD

Critical Illness

YOUR BENEFITS PACKAGE

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

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

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 60 details on covered expenses, limitations and exclusions are included in the summary plan description located on the Duncanville ISD Benefits Website: www.mybenefitshub.com/duncanvilleisd

Critical Illness Benefit Highlights For Employees of: Duncanville Independent School District Prepare today. Help protect tomorrow.

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.

Who is eligible? You are eligible if you are an active full-time employee who works at least 30 hours per week on a regularly scheduled basis, and are less than age 80. Your spouse’s eligibility is based upon your age, and your dependent child(ren) must be under age 26 to be eligible.

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 $5,000, $10,000, $20,000 or $30,000 in coverage. You may also enroll your dependent(s) for the following amounts of coverage: • Spouse: 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 $30,000. 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.

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

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.

Critical Illness •

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 preexisting condition limitation.

Covered Illness

Benefit

Cancer Conditions Invasive Cancer; Benign Brain Tumor Non-Invasive Cancer

100% of coverage amount 25% of coverage amount

• • • •

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.

Vascular Conditions Heart Attack; Heart Transplant; Stroke Coronary Artery Bypass Graft; Angioplasty/Stent; Aneurysm

100% of coverage amount 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

Bone Marrow Transplant

25% of coverage amount

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), then a 12 month separation period applies 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: 62

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.

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. The Hartford® is The Hartford Financial Services Group, Inc. and its subsidiaries including issuing companies Hartford Life Insurance Company, Hartford Life and Accident Insurance Company and Hartford Fire Insurance Company. Home Office is Hartford, CT. Duncanville Independent School District Critical Illness BHS_Creation Date: 06/13/2016 (Version 6/15)

Critical Illness Monthly Cost Rate Chart $5,000

Non Tobacco User Monthly Cost

Age

Employee

18-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79

$0.85 $1.16 $1.61 $2.46 $4.13 $6.69 $9.81 $13.62 $20.01 $28.15 $19.69 $26.16

$10,000

Employee & Spouse $1.70 $2.30 $3.19 $4.85 $8.19 $13.44 $19.94 $27.99 $41.37 $58.03 $40.58 $53.74

Employee & Child $2.08 $2.39 $2.85 $3.69 $5.37 $7.93 $11.04 $14.86 $21.24 $29.39 $20.33 $26.79

Tobacco User Monthly Cost Employee & Family $3.23 $3.83 $4.72 $6.38 $9.72 $14.97 $21.47 $29.52 $42.91 $59.56 $41.37 $54.52

Employee $0.93 $1.34 $2.01 $3.30 $6.12 $11.09 $17.72 $26.19 $40.54 $60.22 $41.24 $49.11

Non Tobacco User Monthly Cost

Age

Employee

18-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79

$1.67 $2.28 $3.17 $4.83 $8.15 $13.22 $19.41 $27.00 $39.70 $55.94 $38.97 $51.92

$20,000

Employee & Spouse $2.53 $3.42 $4.75 $7.22 $12.21 $19.97 $29.54 $41.37 $61.07 $85.81 $59.86 $79.50

Employee & Child $2.91 $3.51 $4.41 $6.07 $9.38 $14.46 $20.64 $28.24 $40.94 $57.17 $39.60 $52.56

Age

Employee

18-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79

$3.32 $4.52 $6.29 $9.58 $16.17 $26.28 $38.61 $53.76 $79.09 $111.51 $77.53 $103.45

$30,000

Employee & Child $4.56 $5.75 $7.52 $10.82 $17.41 $27.51 $39.84 $54.99 $80.33 $112.75 $78.16 $104.08

Employee $1.84 $2.64 $3.95 $6.52 $12.09 $21.95 $35.09 $51.90 $80.37 $119.52 $81.46 $97.41

Age

Employee

18-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79

$4.98 $6.76 $9.40 $14.34 $24.20 $39.34 $57.81 $80.51 $118.49 $167.08 $116.09 $154.97

Employee & Child $6.21 $8.00 $10.64 $15.57 $25.44 $40.57 $59.04 $81.75 $119.72 $168.32 $116.72 $155.60

Employee & Family $3.40 $4.21 $5.55 $8.17 $13.96 $24.37 $38.18 $55.92 $85.83 $126.37 $86.51 $102.87

Employee & Spouse $2.78 $3.98 $5.97 $9.86 $18.40 $33.70 $54.02 $80.10 $124.13 $184.14 $125.96 $150.38

Employee & Child $3.07 $3.87 $5.19 $7.75 $13.32 $23.19 $36.32 $53.14 $81.61 $120.75 $82.09 $98.04

Employee & Family $4.31 $5.51 $7.50 $11.39 $19.93 $35.23 $55.55 $81.63 $125.66 $185.67 $126.74 $151.17

Tobacco User Monthly Cost Employee & Family $6.54 $8.30 $10.93 $15.83 $25.72 $41.17 $60.23 $83.81 $123.08 $172.45 $119.70 $159.00

Employee $3.65 $5.24 $7.85 $12.95 $24.03 $43.67 $69.83 $103.32 $160.05 $238.11 $161.92 $194.00

Non Tobacco User Monthly Cost Employee & Spouse $7.49 $10.12 $14.05 $21.37 $36.18 $59.31 $87.85 $123.18 $182.03 $256.03 $177.97 $236.93

Employee & Child $2.16 $2.57 $3.24 $4.54 $7.35 $12.32 $18.95 $27.43 $41.77 $61.46 $41.87 $49.74

Tobacco User Monthly Cost Employee & Family $4.06 $4.95 $6.28 $8.75 $13.74 $21.50 $31.07 $42.90 $62.60 $87.34 $60.65 $80.28

Non Tobacco User Monthly Cost Employee & Spouse $5.01 $6.77 $9.40 $14.30 $24.19 $39.64 $58.70 $82.28 $121.55 $170.92 $118.92 $158.22

Employee & Spouse $1.87 $2.68 $4.02 $6.64 $12.43 $22.84 $36.65 $54.39 $84.30 $124.84 $85.73 $102.09

Employee & Spouse $5.51 $7.89 $11.83 $19.55 $36.53 $66.98 $107.38 $159.27 $246.92 $366.49 $249.94 $299.16

Employee & Child $4.88 $6.47 $9.08 $14.18 $25.27 $44.91 $71.06 $104.56 $161.28 $239.35 $162.55 $194.63

Employee & Family $7.04 $9.42 $13.36 $21.08 $38.06 $68.51 $108.91 $160.80 $248.45 $368.02 $250.72 $299.94

Tobacco User Monthly Cost Employee & Family $9.02 $11.65 $15.58 $22.90 $37.71 $60.84 $89.38 $124.72 $183.56 $257.57 $178.75 $237.71

Employee $5.46 $7.84 $11.74 $19.38 $35.97 $65.40 $104.57 $154.74 $239.72 $356.71 $242.37 $290.59

Employee & Spouse $8.24 $11.79 $17.68 $29.24 $54.67 $100.26 $160.74 $238.45 $369.72 $548.83 $373.92 $447.94

Employee & Child $6.70 $9.07 $12.98 $20.61 $37.21 $66.63 $105.80 $155.98 $240.95 $357.94 $243.00 $291.23

Employee & Family $9.77 $13.32 $19.21 $30.77 $56.20 $101.79 $162.27 $239.98 $371.25 $550.36 $374.71 $448.72 63

UNUM

Life and AD&D

YOUR BENEFITS PACKAGE

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.

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 64 details on covered expenses, limitations and exclusions are included in the summary plan description located on the Duncanville ISD Benefits Website: www.mybenefitshub.com/duncanvilleisd

Basic Life and AD&D Duncanville Independent School District Policy # 469013

Accelerated Benefit

Eligibility

If you become terminally ill and are not expected to live beyond a certain time period as stated in your certificate booklet, you may request up to 75% of your life insurance amount up to $500,000, without fees or present value adjustments. A doctor must certify your condition in order to qualify for this benefit. Upon your death, the remaining benefit will be paid to your designated beneficiary(ies).

All employees working at least 30 hours each week in active employment in the U.S. with the employer.

Waiver of Premium

Please read carefully the following description of your Unum Term Life and AD&D insurance plan.

YOUR PLAN

Coverage Amounts Employee Life Employee AD&D

$10,000 $10,000

AD&D Benefit Schedule: The full benefit amount is paid for loss of: • Life • Both hands or both feet or sight of both eyes • One hand and one foot • One hand and the sight of one eye • One foot and the sight of one eye • Speech and hearing Other losses may be covered as well. Please see your Plan Administrator Life and AD&D coverage amount(s) will reduce according to the following schedule: Age: 70 Insurance Amount Reduces to: 50% of original amount Coverage may not be increased after a reduction.

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

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

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

Additional AD&D Benefits Education Benefit: If you or your insured spouse die within 365 days of an accident, an additional benefit is paid to your dependent child(ren). Your child(ren) must be a full-time student beyond grade 12. (Not available in Illinois or New York.) Seat Belt/Air Bag Benefit: If you or your insured dependent(s) die in a car accident and are wearing a properly fastened seat belt and/or are in a seat with an air bag, an amount will be paid in addition to the AD&D benefit.

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

AD&D Benefit Exclusions

AD&D benefits will not be paid for losses caused by, contributed to by, or resulting from: • Disease of the body or diagnostic, medical or surgical treatment or mental disorder as set forth in the latest edition of the Diagnostic and Statistical Manual of Mental Disorders; Portability/Conversion • Suicide, self-destruction while sane, intentionally selfIf you retire, reduce your hours or leave your employer, you can inﬂicted injury while sane, or self-inﬂicted injury while take this coverage with you according to the terms outlined in insane; the contract. However, if you have a medical condition which • War, declared or undeclared, or any act of war; has a material effect on life expectancy, you will be ineligible to • Active participation in a riot; port your coverage. You may also have the option to convert • Attempt to commit or commission of a crime; your Term life coverage to an individual life insurance policy. • The voluntary use of any prescription or non-prescription

Voluntary Life and AD&D

•

drug, poison, fume, or other chemical substance unless Duncanville Independent School District used according to the prescription or direction of your or Voluntary Life Insurance your dependent’s doctor. This exclusion does not apply to you or your dependent if the chemical substance is ethanol; Plan Highlights Policy Number 469014 Intoxication. (“Intoxicated” means that the individual’s blood alcohol level equals or exceeds the legal limit for Who is eligible for this coverage? operating a motor vehicle in the state or jurisdiction where All actively employed employees working at least 30 hours each the accident occurred.) week for your employer in the U.S. and their eligible spouses and children up to age 26.

Termination of Coverage

Your coverage under the Summary of Benefits ends on the earliest of: • The date the policy or plan is cancelled; • The date you no longer are in an eligible group; • The date your eligible group is no longer covered; • The last day of the period for which you made any required contributions; • The last day you are in active employment unless continued due to a covered layoff or leave of absence or due to an injury or sickness, as described in the certificate of coverage; Unum will provide coverage for a payable claim which occurs while you are covered under the policy or plan.

Delayed Effective Date of Coverage Employee: Insurance coverage will be delayed if you are not in active employment because of an injury, sickness, temporary layoff, or leave of absence on the date that insurance would otherwise become effective.

What are the coverage amounts? Employee: up to 5 times salary in increments of $10,000; not to exceed $500,000. Spouse: up to 100% of employee amount in increments of $5,000; not to exceed $100,000. Child: up to 100% of employee coverage amount in increments of $2,000; not to exceed $10,000. The maximum death benefit for a child between the ages of live birth and six months is $1,000.

Can I be denied coverage? Current employees: If you and your eligible dependents are enrolled in the plan and wish to increase your life insurance coverage, you may apply on or before the enrollment deadline for any amount of additional coverage up to $200,000 for yourself and any amount of additional coverage up to $50,000 for your spouse. Any life insurance coverage over the guaranteed amount(s) will be subject to answers to health questions.

If you and your eligible dependents are not currently enrolled in the plan, you may apply for coverage on or before the If you should have any questions about your coverage or how to enrollment deadline and will be required to answer health enroll, please contact your Plan Administrator. questions for any amount of coverage.

Questions

New employees: To apply for coverage, complete your This plan highlight is a summary provided to help you understand your insurance enrollment within 31 days of your eligibility period. If you apply coverage from Unum. Some provisions may vary or not be available in all states. for coverage after 31 days, or if you choose coverage over the Please refer to your certificate booklet for your complete plan description. If the amount you are guaranteed, you will need to complete a terms of this plan highlight summary or your certificate differ from your policy, medical questionnaire which you can get from your plan the policy will govern. For complete details of coverage, please refer to policy administrator. You may also be required to take certain medical form number C.FP-1, et al. tests at Unum’s expense. Life Planning is provided by Ceridian Incorporated. The services are subject to availability and may be withdrawn by Unum without prior notice. Underwritten by: Unum Life Insurance Company of America, 2211 Congress Street, Portland, Maine 04122, www.unum.com Unum is a registered trademark and marketing brand of Unum Group and its insuring subsidiaries. ©2007 Unum Group. All rights reserved.

How do I apply? Please see your plan administrator.

Voluntary Life and AD&D When is coverage effective? Please see your plan administrator for your effective date. Insurance coverage will be delayed if you are not in active employment because of an injury, sickness, temporary layoff, or leave of absence on the date that insurance would otherwise become effective. For your dependent spouse and children, insurance coverage will be delayed if that dependent is totally disabled on the date that insurance would otherwise be effective. Totally disabled means that as a result of an injury, sickness or disorder, your dependent spouse and children: are confined in a hospital or similar institution; are confined at home under the care of a physician for a sickness or injury; or your spouse has a life threatening condition. Exception: Infants are insured from live birth.

Is the coverage portable (can I keep it if I leave my employer)?

<25

Term life Employee rate per $1,000 $0.05

Spouse rate per $1,000 $0.05

25-29

$0.05

30-34

$0.06

Age band

Do my life insurance benefits decrease with age? Coverage amounts will reduce according to the following schedule: Age: Insurance amount reduces to: 70 65% of original amount 75 45% of original amount 80 30% of original amount 85 20% of original amount Coverage may not be increased after a reduction.

Are there any life insurance exclusions or limitations? Life insurance benefits will not be paid for deaths caused by suicide within the first 24 months after the date your coverage becomes effective. If you increase or add coverage, these enhancements will not be paid for deaths caused by suicide within the first 24 months after you make these changes.

Will my premiums be waived if I’m disabled? If you become disabled (as defined by your plan) and are no longer able to work, your life premium payments will be waived until your disability period ends.

When does my coverage end?

You and your dependents’ coverage under the Summary of Benefits ends on the earliest of: 40-44 $0.12 $0.12 • the date the policy or plan is cancelled; 45-49 $0.17 $0.17 • the date you no longer are in an eligible group; • the date your eligible group is no longer covered; 50-54 $0.27 $0.27 • the last day of the period for which you made any required 55-59 $0.41 $0.41 contributions; 60-64 $0.52 $0.52 • the last day you are in active employment unless continued due to a covered layoff or leave of absence or due to an 65-69 $1.01 $1.01 injury or sickness, as described in the certificate of 70-74 $1.01 $1.01 coverage. 75+ $1.01 $1.01 In addition, coverage for any one dependent will end on the earliest of: If you retire, reduce your hours or leave your employer, you can • the date your coverage under a plan ends; continue coverage for yourself your spouse and your dependent • the date your dependent ceases to be an eligible dependent; children at the group rate. Portability is not available for people • for a spouse, the date of a divorce or annulment; who have a medical condition that could shorten their life • for dependent coverage, the date of your death. expectancy — but they may be able to convert their term life Unum will provide coverage for a payable claim that occurs policy to an individual life insurance policy. while you and your dependents are covered under the policy or plan. How much does the coverage cost? 35-39

$0.08

Child life monthly rate is $0.16 per $1,000. One life premium covers all children. Your rate is based on your insurance age, which is your age immediately prior to and including the anniversary/effective date. Spouse rate is based on employee’s insurance age.

This information is not intended to be a complete description of the insurance coverage available. The policy or its provisions may vary or be unavailable in some states. The policy has exclusions and limitations which may affect any benefits payable. For complete details of coverage and availability, please refer to Policy Form C.FP-1 et al or contact your Unum representative. © 2017 Unum Group. All rights reserved. Unum is a registered trademark and marketing brand of Unum Group and its insuring subsidiaries. Underwritten by Unum Life Insurance Company of America, Portland, Maine EN-1773 (8-17) FOR EMPLOYEES

TEXAS LIFE

Individual Life

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.

YOUR BENEFITS PACKAGE

Experts recommend at least

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

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 68 details on covered expenses, limitations and exclusions are included in the summary plan description located on the Duncanville ISD Benefits Website: www.mybenefitshub.com/duncanvilleisd

Individual Life Life Insurance Highlights for the Employee Flexible Premium Life Insurance to Age 121 Policy Form PRFNG-NI-10 Voluntary permanent life insurance can be an ideal complement to the group term and optional term your employer might provide. Designed to be in force when you die, this voluntary universal life product is yours to keep, even when you change jobs or retire, as long as you pay the necessary premium. Group and voluntary term, on the other hand, typically are not portable if you change jobs and, even if you can keep them after you retire, usually cost more and decline in death benefit. The policy, PURELIFE-plus, is underwritten by Texas Life Insurance Company, and it has these outstanding features:

Been disabled or received tests, treatment or care of any kind in a hospital or nursing home or received chemotherapy, hormonal therapy for cancer, radiation therapy, dialysis treatment, or treatment for alcohol or drug abuse?

Like most life insurance policies, Texas Life policies contain certain exclusions, limitations, exceptions, reductions of benefits, waiting periods and terms for keeping them in force. Please contact a Texas Life representative for costs and complete details. 1

Voluntary and Universal Whole Life Products, Eastbridge Consulting Group, October 2012 Guarantees are subject to product terms, exclusions and limitations and the insurer’s claims -paying ability and financial strength. 3 After the guaranteed period, premiums may go down, stay the same, or go up. 4 Coverage and spouse/domestic partner eligibility may vary by state. Texas Life complies with all state laws regarding marriages, domestic and civil union partnerships, and legally recognized familial relationships. Coverage not available on children and grandchildren in Washington. 2

•

High Death Benefit. High Death Benefit. With one of the highest death benefits available at the worksite,1 PURELIFEplus gives your loved ones peace of mind.

DID YOU KNOW?

•

Minimal Cash Value. Minimal Cash Value.Designed to provide a high death benefit at a reasonable premium, PURELIFE-plus provides peace of mind for you and your beneficiaries while freeing investment dollars to be directed toward such taxfavored retirement plans as 403(b), 457 and 401(k).

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

•

Long Guarantees. 2 Enjoy the assurance of a policy that has a guaranteed death benefit to age 121 and level premium that guarantees coverage for a significant period of time.3

•

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

•

Accelerated Death Benefit Rider. Should you be diagnosed as terminally ill with the expectation of death within 12 months (24 months in Illinois), you will have the option to receive 92% (84% in Illinois) of the death benefit, minus a $150 ($100 in Florida) administrative fee. This valuable living benefit gives you peace of mind knowing that, should you need it, you can take the large majority of your death benefit while still alive. (Conditions apply.) (Form ICC07-ULABR-07 or Form Series ULABR-07

You may apply for this permanent, portable coverage, not only for yourself, but also for your spouse, children and grandchildren by answering just 3 questions:4 During the last six months, has the proposed insured: a. Been actively at work on a full time basis, performing usual duties? b. Been absent from work due to illness or medical treatment for a period of more than five consecutive working days? 69

LEGAL SHIELD

Identity Theft

YOUR BENEFITS PACKAGE

About this Benefit Identity theft protection monitors and alerts you to identity threats. Resolution services are included should your identity ever be compromised while you are covered.

An identity is stolen every 2 seconds, and takes over

300 hours

to resolve, causing an average loss of $9,650.

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 70 details on covered expenses, limitations and exclusions are included in the summary plan description located on the Duncanville ISD Benefits Website: www.mybenefitshub.com/duncanvilleisd

Identity Theft Have you ever? • • • • • •

LegalShield

Family Price (pay period) $15.95

Individual Price (pay period) $15.95

IDShield

$15.95

$8.45

Combined

$28.40

$24.90

Plan

Needed your Will prepared or updated? Worried about being a victim of Identity theft? Signed a contract? Been concerned about your child’s identity? Received a moving traffic violation? Lost your wallet?

The LegalShield® Membership Includes: The IDShieldSM Membership Includes: • • • • • • • • • •

• •

Dedicated Law Firm Direct access, no call center Legal Advice/Consultation on unlimited personal issues Letters/Calls made on your behalf Contracts/Documents Reviewed up to 15 pages Residential Loan Document Assistance for the purchase of your primary residence Will Preparation - Will/Living Will/Health Care Power of Attorney Speeding Ticket Assistance (15 day waiting period) IRS Audit Assistance (begins with the tax return due April 15th of the year you enroll) Trial Defense (if named defendant/respondent in a covered civil action suit) Uncontested Divorce, Separation, Adoption and/or Name Change Representation (available 90 days after enrollment) 25% Preferred Member Discount (bankruptcy, criminal charges, DUI, personal injury, etc.) 24/7 Emergency Access for covered situations

Put your law firm and identity theft protection in the palm of your hand with the LegalShield & IDShield mobile apps

•

• • • • • •

• •

High Risk Application and Transaction Monitoring We can detect fraud up to 90 days earlier than traditional credit monitoring services; we carefully watch all your accounts, reorders, loans and more. If a new account is opened, you will receive an alert. Social Media Monitoring for privacy concerns and reputational risks Credit Monitoring continuous credit monitoring through TransUnion Monthly Score Tracker watch your credit score and map your credit trends Credit Inquiry Alerts (instant hard inquiry alerts) Consultation on any cyber security question $1 Million Insurance (coverage for lost wages, legal defense fees, stolen funds and more) Full Service Restoration & Unlimited Service Guarantee We don’t give up until your identity is restored! 24/7 Emergency Access in the event of an identity theft emergency

For more information, contact your Independent Associate: Mark Seguin Mark@MyLegalShieldUSA.com 903.533.9123 x 101

LegalShield legal plans cover the member; member’s spouse; never married dependent children under 26 living at home; de-pendent children under the age 18 for whom the member is the legal guardian; never married dependent children up to age 26 if a full-time college student; or physically or mentally disabled dependent children. IDShield is a product of Pre-Paid Legal Services, Inc. d/b/a LegalShield (“LegalShield”). LegalShield provides access to identity theft protection and restoration services. For complete terms, coverage and conditions, please see www.idshield.com. All Licensed Private Investigators are licensed in the state of Oklahoma. A $1 million insurance policy is issued through a nationally recognized carrier. LegalShield/IDShield is not an insurance carrier. Certain limitations apply. IDShield plans are available at individual or family rates. A family rate covers the member, member’s spouse and up to 10 dependents up to the ages 18. It also provides consultation and restoration for dependent children age 18 to 26. This is a general overview and is for illustrative purposes only. Plans and services vary from state to state. See plan details for your state of residence for complete terms, coverage, amounts, conditions and limitations. FLIER_LS+IDS_1895_USA_051519 71

LEGALSHEILD

YOUR BENEFITS PACKAGE

Legal Services

About this Benefit Finding the right type of attorney when a need arises can be one of the more stressful tasks when dealing with a legal matter. The right help is essential. There are many types of attorneys depending upon what type of issue someone may be facing. We help with this first step. We use our experience and relationships with our network providers to match you to the right type of attorney you need in the right location, with availability to set up a consultation with you. We see this step as a way to save you time, so you can get back to your busy schedule of work, kids or whatever may be just as important.

$1,500 Is the average cost of a basic will and estate planning package. The average yearly premium paid by Texas Legal Members is only $300.

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 72 details on covered expenses, limitations and exclusions are included in the summary plan description located on the Hillsboro ISD Benefits Website: www.mybenefitshub.com/hillsboroisd

Legal Services We protect and empower. Who We Are Our mission for over 45 years has been to be an innovater and disrupter in the market of legal services. In a perfect world, you’d never need a lawyer, but in an unpredictable world it helps to have a unique delivery model giving you direct access. LegalShield has made smart legal coverage simplier, easier and more affordable. A Team Of Lawyers We’re taking legal representation and making it; accessible, affordable, full-service coverage. LegalShield has a network of dedicated law firms in 50 states and 4 Canadian provinces made up of seasoned lawyers with an average of 22 years’ experience. Our Provider Law Firms provide legal protection to over a million members, even in covered emergency situations, 24/7/365 days a year. Why Legalshield For one low monthly cost, LegalShield puts an attorney in the palm of your hand. LegalShield created a model for legal coverage in which you know exactly what you’re getting and precisely how much you’re paying for it. Once you sign up, you can sit back, relax, and know you’re covered by an entire law firm.

What your Legal Plan Covers Advice, Consultation & Representation Landlord not treating you fairly or maybe getting the run-around on an insurance claim? Your team of lawyers can help with these services; Advice Phone consultations with your law firm for any personal legal matter, even pre-existing matters. Letters and Phone Calls on Your Behalf Available at the discretion of your Provider Lawyer Contract and Document Review Contract/document review up to 15 pages each Representation Representation by your provider law firm if you or your spouse are named defendant/ respondent in a covered civil action. YEAR 1 2 3 4 5

PRE-TRIAL TIME 2.5 3 3.5 4 4.5

TRIAL TIME 57.5 117 176.5 236 295.5

TOTAL 60 120 180 240 300

24/7 Emergency Assistance Legal Emergency? Yes, your legal team even services you 24/7/365 days a year. Yes, your legal team even services you 24/7/365 days a year in the following emergency situations:

• • • •

Arrested or detained Seriously injured in an auto accident Served with a criminal warrant State attempts to take your child(ren)

Family Matters Relationships can be complicated so let your team of lawyers work out the details. Uncontested Name Change Assistance* Preparation and if required, representation at the initial hearing by your provider law firm for uncontested name change. Uncontested Adoption Representation* Representation by your provider law firm for uncontested adoption proceedings Uncontested Separation/Divorce Representation* Representation by your provider law firm for uncontested legal separation, uncontested civil annulment and uncontested divorce proceedings Document Preparation Let your law firm assist with getting your legal paperwork in order before a problem arises. Your membership provides document preparation from a lawyer for: Standard Will Preparation • Will preparation/annual reviews and updates • Living Will • Health Care Power of Attorney Residential Loan Document Assistance Mortgage documents (as required of the borrower by the lending institution) prepared by your provider law firm for the purchase of your primary residence Traffic Accidents happen. So, do speed traps. Your LegalShield membership provides lawyer assistance when you are faced with the following situations: Moving Traffic Assistance • Non-criminal moving traffic violation • assistance • Motor vehicle-related criminal charge assistance • 2.5 hours to help with driver’s license reinstatement • 2.5 hours to help with property damage collection assistance of $5,000 or less per claims • Available for members with a valid driver’s license and driving a non-commercial motor vehicle IRS IRS and taxes don’t have to be frightening with a team of lawyers on your side. IRS Audit Assistance • 1 hour of advice, consultation and assistance when notified of an audit • 2.5 hours of additional assistance if a settlement • is not achieved in the first 30 days • 46.5 hours of assistance if your case goes to court 73

Legal Services •

Coverage for this service begins with the tax return due April 15th of the year you enroll

Additional Benefits Additional legal coverage needed? Don’t worry, your legal membership has that too! 25% Preferred Member Discount • 25% preferred member discount is provided off the providers standard hourly rate. You can live more and worry less knowing you may continue to use your provider law firm for legal situations that extend beyond what is already outlined. Your law firm will let you know when the 25% discount applies, so you are never surprised with an unexpected bill.

Who We Cover: Legal Plan: • The member • The member’s spouse/domestic partner • Never-married dependent children under age 26 living at home • Dependent children under age 18 for whom the member is legal guardian • Never married, dependent, children who are full-time college students up to age 26 • Physically or mentally disabled children living at home *These services are available 90 consecutive days from the effective date of your membership. This plan provides personal legal assistance; however plans providing business services are also available.

Access LegalShield on the go! The LegalShield app puts your law firm in the palm of your hand. Tap to call your law firm directly, access free legal forms, and send info directly to your law firm with features like an easy to complete Will and Snap (for speeding tickets). The LegalShield app makes it easy to access legal guidance you can trust. Download the free app from the App Store or Google Play.

Save with these incredible MEMBERPERKS Your LegalShield and IDShield memberships are simply amazing. And in addition to the privileges that are already yours, we have added these MEMBERPERKS with hundreds of merchants and thousands of discounts. Members can access savings at both national and local companies on everyday purchases such as tickets, electronics, apparel, travel and more. Members have the opportunity to save, on average, over $2,000 per year. MEMBERPERKS can save you enough to pay for your membership for years to come! RECEIVE EXCLUSIVE DISCOUNTS Access your members-only discounts in categories such as: • • • • • • • • •

APPAREL AUTOMOTIVE BOOKS, MOVIES & MUSIC CELL PHONES ELECTRONICS FINANCE FLOWERS & GIFTS FOOD HEALTH & WELLNESS

• • • • • • • • •

HOME SERVICES INSURANCE & PROTECTION SERVICES OFFICE & BUSINESS REAL ESTATE & MOVING SERVICES SPORTS & OUTDOORS TICKETS & ENTERTAINMENT TRAVEL

WHAT MEMBERS ARE SAYING: “MEMBERPerks pays for my membership!” — Martha S. “I saved 20% at Advance Auto and I also saved 30% on movie tickets on date night with my wife. This membership is it!” — Andre E. “I am receiving 8% oﬀ my Verizon cell phone monthly charge!” — Paulette M. Enjoy preferred member pricing on some of your favorite brands and services.

Apple and the Apple logo are trademarks of Apple Inc., registered in the U.S. and other countries. App Store is a service mark of Apple Inc., registered in the U.S. and other countries. Android is a trademark of Google Inc.

• • • • • •

Getting Started To sign up, simply login at legalshield.com, click on the Resources tab, then click on MEMBERPERKS. If you don’t already have an account, follow the simple on-screen instructions to make an account with your personal or work email and LegalShield membership number.

Office Depot®/OfficeMax® Ghirardelli Harry & David AMC Theaters® Skechers Direct Holiday Inn Club Vacations

• • • • •

VIVIDSEATS Verizon Blue Apron Major League Baseball™ And many more!

These benefits are for LegalShield and IDShield members. All offers or promotions are subject to change without notice. SHEET_MEMBERPerks_051818