2021-22 Goose Creek CISD Benefit Guide by Higginbotham Public Sector

GOOSE CREEK CISD

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

Table of Contents Benefit Contact Sheet 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) Texas Schools Health Benefits (TSHB) Program TRS Medical Cigna Hospital Indemnity GCEFCU Health Savings Account (HSA) Lincoln Financial Group Dental EyeMed Vision The Hartford Disability MetLife Cancer MetLife Accident UNUM Critical Illness Lincoln Financial Group Life and AD&D Texas Life Individual Term Life MDLive Telehealth NBS Flexible Spending Account (FSA)

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

12-17 18-21 22-25 26-27 28-39 40-43 44-47 48-53 54-57 58-61 62-67 68-69 70-71 72-75

FLIP TO... PG. 4

HOW TO ENROLL

PG. 6

SUMMARY PAGES

PG. 12

YOUR BENEFITS

Benefit Contact Information TRS ACTIVECARE MEDICAL

HOSPITAL INDEMNITY

LIFE AND AD&D

Blue Cross Blue Shield (866) 355-5999 www.bcbstx.com/trsactivecare

Cigna (800) 997-1654 www.cigna.com

Lincoln Financial Group (800) 487-1485 www.lfg.com

TEXAS SCHOOLS HEALTH BENEFITS (TSHB) PROGRAM

DISABILITY

INDIVIDUAL LIFE

90 Degree Benefits (888) 803-0081 www.tshbp.org

The Hartford (800) 523-2233 www.thehartford.com

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

TELEHEALTH

CANCER

FLEXIBLE SPENDING ACCOUNT

MDLIVE (866) 365-1663 www.consultmdlive.com

MetLife (800) 638-5433 www.metlife.com

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

DENTAL

CRITICAL ILLNESS

HEALTH SAVINGS ACCOUNT

Lincoln Financial Group (800) 487-1485 www.lfg.com

Unum (866) 679-3054 www.unum.com

GCEFCU (800) 683-3863 www.gcefcu.org

VISION

ACCIDENT

COBRA

EyeMed (866) 939-3633 www.eyemed.com

MetLife (800) 638-5433 www.metlife.com

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

MOBILE APP DOWNLOAD Enrollment made simple through the new FBS Benefits App! Text “FBS GCCISD” to (800) 583-6908 and get access to everything you need to complete your benefits enrollment: •

Enrollment Resources

•

Online Support

•

Interactive Tools

•

And more!

App Group #: FBSGCCISD

Text

“FBS GCCISD” to (800) 583-6908 OR SCAN

How to Log In

1 BENEFIT INFO

2 3

www.mybenefitshub.com/ GooseCreekCISD

CLICK LOGIN

ENTER USERNAME & PASSWORD

INTERACTIVE TOOLS 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. If you have six (6) or less 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.

ONLINE SUPPORT

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 New! TPA—Financial Benefit Services New! Benefits Portal www.mybenefitshub.com/goosecreekcisd GCCISD ALTERNATIVE MEDICAL PLANS New Medical Plan Options! Goose Creek CISD has joined the Texas Schools Health Benefits Program (TSHBP) and will be offering alternate plans as medical options in addition to the TRS medical plans. Two plan options are available: a High Deductible HSA Compatible plan and a CoPay plan. On both plans, there is In and Out-of-Network Coverage and the plan does not require a primary care provider or referral to a specialist. Telehealth is provided at no cost for the CoPay plan and consults are $30 for the High Deductible plan. On both plans, once your deductible is met all other eligible medical expenses are covered at 100%. There is no coinsurance requirement. Preventative services are always covered at 100%. Specialty drugs are not covered after the first 90 days unless at a facility setting (at the hospital, outpatient facility) or if they are less than $670 (see plan summary for program options). All hospital and other medical facility-based services are scheduled via the assistance of your assigned Care Coordinator. Customer service number: 888-803-0081. Review your benefits website for additional details.

New! Supplemental Options GCCISD has enhanced the benefit offerings for its employees and their family members! • Dental - No waiting periods for any services on dental and New Low Dental plan option • Vision - Replace frames and contact lenses in the same plan year • Disability - Will now pay up to 4 weeks of benefit for pre-existing conditions for new enrollees • New Hospital Indemnity Plan - Pre-existing conditions waived • Voluntary Term Life - Guarantee issue for all employees, spouses, and dependent children this year spouse and dependent children • New Stand Alone Accidental Death & Dismemberment Guarantee issue for employee, spouse, and dependent children • Critical Illness - Lower cost and guarantee issue • H.S.A. - Now with Gulf Coast Educators Federal Credit Union • FLEX - Now with National Benefit Services

Important Enrollment assistance is available by calling Financial Benefit Services at (866) 914-5202 to speak to a representative. Spanish speaking representatives are also available. Annual Open Enrollment Benefit elections will become effective 9/1/2021 (elections requiring evidence of insurability, such as life Insurance, may have a later effective date, if approved). After annual enrollment closes, benefit changes can only be made if you experience a qualifying event (and changes must be made within 30 days of event). 6

SUMMARY PAGES

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

CHANGES IN STATUS (CIS):

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

QUALIFYING EVENTS

Marital Status

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

Change in Number of Tax Dependents

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

Change in Status of Employment Affecting Coverage Eligibility

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

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

SUMMARY PAGES

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

Where can I find forms?

to review, change or continue benefit elections each year.

For benefit summaries and claim forms, go to your benefit

Changes are not permitted during the plan year (outside of

website: www.mybenefitshub.com/goosecreekcisd. Click the

annual enrollment) unless a Section 125 qualifying event occurs.

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

•

Changes, additions or drops may be made only during the

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

Creek CISD benefit website: www.mybenefitshub.com/

included in the dependent profile. Additionally, you must

goosecreekcisd. Click on the benefit plan you need

notify your employer of any discrepancy in personal and/or

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

benefit information.

•

For benefit summaries and claim forms, go to the Goose

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.

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

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

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

SUMMARY PAGES

Employee Eligibility Requirements

Dependent Eligibility Requirements

Supplemental Benefits: Eligible employees must work 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. PLAN

CARRIER

MAXIMUM AGE

Medical

TRS-BCBS or TSHB

To age 26

Hospital Indemnity

Cigna

To age 26

Telehealth

MDLIVE

To age 26

Dental

Lincoln Financial Group

To age 26

Vision

EyeMed

To age 26

Cancer

MetLife

To age 26

Critical Illness

UNUM

To age 26

Accident

MetLife

To age 26

Life and AD&D

Lincoln Financial Group

To age 26

Individual Life

Texas Life

To age 26

Please note, limits and exclusions may apply when obtaining coverage as a married couple or when obtaining coverage for dependents. 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

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 tax-free.

Employer Eligibility

A qualified high deductible health plan.

All employers

Contribution Source Account Owner Underlying Insurance Requirement

Employee and/or employer Individual

Employee and/or employer Employer

High deductible health plan

None

Description

Minimum Deductible Maximum Contribution

$1,400 single (2021) $2,800 family (2021) $3,600 single (2021) $7,200 family (2021)

N/A $2,750

Permissible Use Of Funds

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

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

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

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

Not permitted

Year-to-year rollover of account balance?

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

No. However, GCCISD has a 45-day grace period.

Does the account earn interest?

Yes

Portable?

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

FLIP TO FOR HSA INFORMATION

PG. 26

FLIP TO FOR FSA INFORMATION

PG. 72 11

TSHBP

Alternative Medical Plan

YOUR BENEFITS PACKAGE

About this Benefit The TSHBP is proud to offer a variety of plans and benefits to meet school district needs. Plans for 2020-21 include our High Deductible Health Plan (HDHP) and our CoPay Plan (CPP). Both plans are designed so members can easily navigate through their health medical needs.

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 Goose Creek CISD Benefits Website: www.mybenefitshub.com/goosecreekcisd

Texas Schools Health Benefits Plan About Texas Schools Health Benefits Program (TSHBP) The Texas Schools Health Benefits Program is a regionally rated program developed for Texas school districts. Our purpose is to support the school children of Texas. We do this by providing health benefit solutions to our dedicated teachers, administrators, and support staff so they can concentrate on what they do best – teaching and supporting our kids. It is our desire to increase member health and well-being and provide tools necessary to identify and manage the health of each and every member. TSHBP plans are available for school district employees who are employed by participating districts and are active, contributing TRS members.

Both TSHBP Plans Include •

A Nationwide Network for Physician and Ancillary Services. Both In and Out of Network physician and Ancillary Services are covered

•

No primary care provider required or referral to a specialist. A member can use any provider in the network or out of the network

•

A Care Coordinator service (personal concierge) to support members with all their medical needs and specifically assist them with all facility care

•

Specialty drugs over $670 (30 day supply) are not covered, but the plan offers Patient Assistance and Co-Pay assistance

•

A patient advocate to help members with any balance bill and to pay the bill on the members behalf if necessary

•

ACA Preventative Services are paid at 100% and all copays and deductibles are waived

TSHBP High Deductible Highlights •

Significantly lower premium rates compared to the TRS-

TSHBP Co-Pay Highlights •

ActiveCare HD plan •

Lower out-of-pocket maximums since a member-only have

A unique plan that members pay only copayments for service. All copayments apply to the deductible

•

to meet their deductible (no coinsurance)

Lower out-of-pocket maximums since a member-only have to meet their deductible (no coinsurance)

•

TSHBP HD - $3,000

•

TSHBP CoPay - $3,500

•

In comparison with TRSAC HD - $7,000

•

In comparison with TRSAC Primary - $8,150

•

Telehealth at a $30 Consultation Fee

•

Telehealth at $0 Copay

•

All eligible prescriptions are paid at 100% after the

•

$0 copay for generic drugs at CVS, HEB, Wal-Mart, Sam’s,

deductible

and Costco ($10 copay at other network pharmacies)

Texas Schools Health Benefits Plan—HD Plan Plan Plan Summary TSHBP HD Plan Plan Features

HOW DOES TSHBP COMPARE TO TRS? Our unique embedded deductible health plans offer members lower out-of pocket maximums, bringing substantial savings without sacrificing care or quality.

Network Plan Deductible Feature Individual/Family Deductible Individual/Family Maximum Out-of- Pocket Health Savings Account (HSA) Eligible Required - Primary Care Provider (PCP) Required - PCP Referral to Specialist Prescription Drug Benefits

In-Network Coverage

Out-of-Network Coverage

HealthSmart - National Deductible, then Plan pays 100% $3,000/$9,000

N/A Deductible, then Plan pays 100% $3,500/$9,500

$3,000/$9,000

$3,500/$9,500

Yes

Yes - Deductible, then Plan pays 100%

Yes - $0 copay $30 per consultation Deductible, then Plan pays 100% Deductible, then Plan pays 100%

Deductible, then Plan pays 100% Deductible, then Plan pays 100% Deductible, then Plan pays 100% Deductible, then Plan pays 100% Deductible, then Plan pays 100% Deductible, then Plan pays 100%

Deductible, then Plan pays 100% Deductible, then Plan pays 100% Deductible, then Plan pays 100% Deductible, then Plan pays 100% Deductible, then Plan pays 100% Deductible, then Plan pays 100% Deductible, then Plan pays 100%

Deductible, then Plan pays 100% Deductible, then Plan pays 100% Deductible, then Plan pays 100% Deductible, then Plan pays 100% In-Network Only In-Network Only In-Network Only

Deductible, then Plan pays 100%

In-Network Only

Deductible, then Plan pays 100%

In-Network Only

Deductible, then Plan pays 100% Deductible, then Plan pays 100% Deductible, then Plan pays 100% Deductible, then Plan pays 100% Deductible, then Plan pays 100%

Deductible, then Plan pays 100%* Deductible, then Plan pays 100%* Deductible, then Plan pays 100%* Deductible, then Plan pays 100%* In-Network Only

Doctor Visits Preventive Care Virtual Health - Teladoc Primary Care Specialist

Office Services

WHAT ARE CARE COORDINATORS? The Care Coordinators act as a personal concierge for all TSHBP plans and members, and their job is to support the member as their healthcare advocate. Watch the below video to learn more.

Allergy Injections Allergy Serum Chiropractic Services Office Surgery MRI’s, Cat Scans, and Pet Scans Urgent Care Facility

Care Facilities Urgent Care Facility Freestanding Emergency Room Hospital Emergency Room Ambulance Services Outpatient Surgery Hospital Services Surgeon Fees

Maternity and Newborn Services Maternity Charges (prenatal and postnatal care) Routine Newborn Care

Rehabilitation/Therapy

https://tshbp.info/CCVideo

Occupational/Speech/Physical Cardiac Rehabilitation Chemotherapy, Radiation, Dialysis Home Health Care Skilled Nursing

Care Coordinator* The Care Coordinator program must be used to access facility services or no benefits will be available under the Plan. These services include routine colonoscopy and related services; hospital providers for MRIs, Cat Scans, and Pet Scans; hospital providers for outpatient Lab/Radiology Services; Inpatient Hospital Admissions; Outpatient Hospital/Ambulatory Surgical Facility Services; Maternity and Newborn Services; Rehabilitation/Therapy Services; Extended Care Services; and Other Services including durable medical equipment/supplies, orthotics/ prosthetics, facilities for diabetic self-management training, and sleep disorder services. To review the complete plan document and services that require access through the Care Coordinator program, please call 888-803-0081.

Texas Schools Health Benefits Plan—CoPay Plan Plan Summary TSHBP CoPay Plan Plan Features

HOW DOES TSHBP COMPARE TO TRS? Our unique embedded deductible health plans offer members lower out-of pocket maximums, bringing substantial savings without sacrificing care or quality.

In-Network Coverage

Out-of-Network Coverage

HealthSmart - National Copayments, then Plan pays 100% $3,500/$10,500

N/A Copayments, then Plan pays 100% $4,000/$11,000

$3,500/$10,500

$4,000/$11,000

Yes - Copayments, then Plan pays 100%

Yes - $0 copay $0 per consultation $35 copay $35 copay

Yes - $0 copay $0 per consultation $40 copay $40 copay

$5 copay $35 copay $35 copay $110 copay $275 copay $50 copay

$10 copay $40 copay $40 copay $125 copay $325 copay $75 copay

$50 copay $500 copay $500 copay $220 copay $500 copay $500 copay $100 copay

$75 copay $500 copay $500 copay $220 copay In-Network Only In-Network Only In-Network Only

$500 copay

In-Network Only

$250 copay

In-Network Only

$55 copay $110 copay $110 copay $55 copay $500 copay

$65 copay* $125 copay* $125 copay* $75 copay* In-Network Only

Doctor Visits Preventive Care Virtual Health - Teladoc Primary Care Specialist

Office Services

Allergy Injections Allergy Serum Chiropractic Services Office Surgery MRI’s, Cat Scans, and Pet Scans Urgent Care Facility

Care Facilities Urgent Care Facility Freestanding Emergency Room Hospital Emergency Room Ambulance Services Outpatient Surgery Hospital Services Surgeon Fees

Maternity and Newborn Services Maternity Charges (prenatal and postnatal care) Routine Newborn Care

Rehabilitation/Therapy

https://tshbp.info/CCVideo

Occupational/Speech/Physical Cardiac Rehabilitation Chemotherapy, Radiation, Dialysis Home Health Care Skilled Nursing

Goose Creek ISD Medical Rates 2021-22 The rates below are not inclusive of your district’s medical contribuƟon. Please visit your benefit website for more informaƟon regarding your district’s medical contribuƟon amounts.

TRS‐Ac veCare HD

$429

$772

$1,209

$1,445

TRS‐Ac veCare Primary +

$542

$879

$1,334

$1,675

TRS‐Ac veCare Primary

$417

$751

$1,176

$1,405

TSHBP

HD Plan

$360

$679

$1,000 $1,310

CoPay Plan

$401

$775

$1,125

$1,485

Maximum Out‐of‐Pocket Costs (In-Network) For 2021‐22 Cost for Families

Cost for Individuals $3,000 $3,500

TSHBP CoPay Plan

$9,000 $10,500

$7,000

TRS‐Ac veCare HD

$14,000

$6,900

TRS‐ActiveCare Primary +

$13,800

$8,150

TSHBP HD Plan

TRS‐Ac veCare Primary

$16,300

Texas Schools Health Benefits Cost Examples TRS

PEG IS HAVING A BABY

Deductible

TSHBP

Primary Primary+

Co Pay

$3,000

$2,500

$1,200

$3,000

$3,500

Specialist Coinsurance/Copayment

30%

$70

$35

Hospital Coinsurance/Copayment

30%

20%

$500

Other Coinsurance/Copayment

30%

20%

$250

Total Example Cost

$12,800

Deductibles

$3,000

$2,500

$1,200

$3,000

Copayments

$70

$1,285

Coinsurance

$2,940

$3,000

$2,300

$60

$6,000

$5,630

$3,630

$3,000

$1,285

Limits or Exclusions Total Cost

Compared to TRS-AC HD (savings)

$3,000

Compared to TRS-AC Primary (savings)

$2,345

Compared to TRS-AC Primary + (savings)

$4,345

TOM’S KNEE REPLACEMENT Deductible

TRS HD

TSHBP

Primary Primary+

Co Pay

$3,000

$2,500

$1,200

$3,000

$3,500

Specialist Coinsurance/Copayment

30%

$70

$35

Hospital Coinsurance/Copayment

30%

20%

$500

Other Coinsurance/Copayment

30%

20%

$250

Total Example Cost

$38,000

Deductibles

$3,000

$2,500

$1,200

$3,000

Copayments

$70

$1,385

Coinsurance

$10,500

$10,650

$7,360

$60

$7,000*

$8,150*

$6,900*

$3,000

$1,385

Limits or Exclusions Total Cost

Compared to TRS-AC HD (savings)

$4,000

Compared to TRS-AC Primary (savings)

$6,785

Compared to TRS-AC Primary + (savings)

$5,535

*Out-of-pocket limit

TRS | BCBSTX

TRS-ActiveCare

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

Medical Rate Comparison Medical

Monthly Premium

District Contribution

Employee Cost

TSHBP High Deductible Plan Employee Only Employee & Spouse Employee & Child(ren) Employee & Family

$360.00

$275

$85.00

$1,000.00

$275

$725.00

$679.00

$275

$404.00

$1,310.00

$275

$1,035.00

$401.00

$275

$126.00

$1,125.00

$275

$850.00

$775.00

$275

$500.00

$1,485.00

$275

$1,210.00

$429.00

$275.00

$154.00

$1,209.00

$275.00

$934.00

$772.00

$275.00

$497.00

$1,445.00

$275.00

$1,170.00

TSHBP CoPay Plan Employee Only Employee & Spouse Employee & Child(ren) Employee & Family

TRS ActiveCare HD Employee Only Employee & Spouse Employee & Child(ren) Employee & Family

TRS ActiveCare 2 Employee Only

$1,013.00

$275.00

$738.00

Employee & Spouse

$2,402.00

$275.00

$2,127.00

Employee & Child(ren)

$1,507.00

$275.00

$1,232.00

Employee & Family

$2,841.00

$275.00

$2,566.00

TRS ActiveCare Primary Employee Only Employee & Spouse Employee & Child(ren) Employee & Family

$417.00

$275.00

$142.00

$1,176.00

$275.00

$901.00

$751.00

$275.00

$476.00

$1,405.00

$275.00

$1,130.00

TRS ActiveCare Primary+ Employee Only Employee & Spouse

Employee & Child(ren) Employee & Family

$542.00

$275.00

$267.00

$1,334.00

$275.00

$1,059.00

$879.00

$275.00

$604.00

$1,675.00

$275.00

$1,400.00

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

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

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

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

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 $15/$45 copay

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.

• • • • •

$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 Employee and Spouse Employee and Children Employee and Family

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

$1,362.70

$1,264.28

$1,443.66

$872.16

$819.60

$936.18

$1,568.42

$1,345.58

$1,532.74

Plan Features Type of Coverage Individual/Family Deductible

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

$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)

Coinsurance Individual/Family Maximum Outof-Pocket

Doctor Visits

Immediate Care Urgent Care Emergency Care

Prescription Drugs Drug Deductible Day Supply Generics

Specialty

trs.texas.gov 21

CIGNA 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 $10,500 per day.

$9,600

$10,400

$10,700

2008

2012

2018

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 22 details on covered expenses, limitations and exclusions are included in the summary plan description located on the Goose Creek CISD Benefits Website: www.mybenefitshub.com/goosecreekcisd

Hospital Indemnity Offered by Life Insurance Company of North America, a Cigna Company Employee-Paid

HOSPITAL CARE COVERAGE SUMMARY OF BENEFITS Prepared for: Goose Creek Consolidated Independent School District Hospital Care coverage provides a benefit according to the schedule below when a Covered Person incurs a Hospital stay resulting from a Covered Injury or Covered Illness See State Variations (marked by *) below. Who Can Elect Coverage: You: All active, full-time Employees of the Employer who are regularly working in the United States a minimum of 20 hours per week and regularly residing in the United States and who are United States citizens or permanent resident aliens and their Spouse, Domestic Partner, or Civil Union Partner and Dependent Children who are United States citizens or permanent resident aliens and who are residing in the United States. You will be eligible for coverage on the first of the month after 30 days from the date of hire or active service. Your Spouse/Domestic Partner: Up to age 100, as long as you apply for and are approved for coverage yourself. Your Child(ren): Birth to age 26; 26+ if disabled, as long as you apply for and are approved for coverage yourself. Available Coverage: The benefit amounts shown in this summary will be paid regardless of the actual expenses incurred and are paid on a per day basis unless otherwise specified. Benefits are only payable when all policy terms and conditions are met. Please read all the information in this summary to understand the terms, conditions, state variations, exclusions and limitations applicable to these benefits. See your Certificate of Insurance for more information. Benefit Waiting Period:* None, unless otherwise stated. No benefits will be paid for a loss which occurs during the Benefit Waiting Period.

Hospitalization Benefits Hospital Admission No Elimination Period. Limited to 1 day, 1 benefit(s) every 365 days. Hospital Chronic Condition Admission No Elimination Period. Limited to 1 day, 1 benefit(s) every 90 days. Hospital Stay No Elimination Period. Limited to 30 days, 1 benefit(s) every 90 days. Hospital Intensive Care Unit (ICU) Stay No Elimination Period. Limited to 30 days, 1 benefit(s) every 90 days. Hospital Observation Stay 24 hour Elimination Period. Limited to 72 hours. Newborn Nursery Care Admission Limited to 1 day, 1 benefit per newborn child. This benefit is payable to the employee even if child coverage is not elected. Newborn Nursery Care Stay* Limited to 30 days, 1 benefit per newborn child. This benefit is payable to the employee even if child coverage is not elected.

Plan 1

Plan 2

$1,500

$2,500

$50

$100

$200

$300

$100 per 24hour period

$500

$100

Portability Feature:* You, your spouse, and child(ren) can continue 100% of your coverage at the time your coverage ends. You must be covered under the policy and be under the age of 100 in order to continue your coverage. Rates may change and all coverage ends at age 100. Applies to United States Citizens and Permanent Resident Aliens residing in the United States.

Employee’s Semi-Monthly Cost of Coverage: Tier Employee Only Employee & Spouse Employee & Child(ren) Employee & Family

Plan 1 $8.43 $15.06 $13.89 $20.52

Plan 2 $13.60 $23.99 $21.86 $32.24

Costs are subject to change. Actual per pay period premiums may differ slightly due to rounding. 23

Hospital Indemnity NOTE: The following are some of the important policy provisions, terms and conditions that apply to benefits described in the policy. This is not a complete list. See your Certificate of Insurance for more information.

suicide or any attempted threat while sane or insane; • Commission or attempt to commit a felony or an assault; • Declared or undeclared war or act of war;• A Covered Injury or Covered Illness that occurs while on active duty service in the military, naBenefit-Specific Conditions, Exclusions & Limi- val or air force of any country or international organization. Upon our receipt of proof of service, we will refund any premium tations (Hospital Care): paid for this time. Reserve or National Guard active duty training Hospital Admission: Must be admitted as an Inpatient due to a is not excluded unless it extends beyond 31 days;• Voluntary Covered Injury or Covered Illness. Excludes: treatment in an ingestion of any narcotic, drug, poison, gas or fumes, unless preemergency room, provided on an outpatient basis, or for rescribed or taken under the direction of a Physician and taken in admission for the same Covered Injury or Covered Illness accordance with the prescribed dosage (excludes WA resi(including chronic conditions). dents);• Operating any type of vehicle while under the influence of alcohol or any drug, narcotic or other intoxicant including any Hospital Chronic Condition Admission: Must be admitted as an prescribed drug for which the Covered Person has been providInpatient due to a covered chronic condition and treatment for a ed a written warning against operating a vehicle while taking it. covered chronic condition must be provided by a specialist in “Under the influence of alcohol”, for purposes of this exclusion, that field of medicine. Excludes: treatment in an emergency means intoxicated, as defined by the law of the state in which room, provided on an outpatient basis, or for re-admission for the Covered Injury or Covered Illness occurred. (excludes WA the same Covered Injury or Covered Illness (including chronic residents);• Those not necessary, as determined by Us in accordconditions). ance with generally accepted standards of medical practice, for Hospital Stay: Must be admitted as an Inpatient and confined to the diagnosis, care or treatment of the physical or mental condition involved. This applies even if they are prescribed, recomthe Hospital, due to a Covered Injury or Covered Illness, at the direction and under the care of a physician. If also eligible for the mended, or approved by the attending physician;• Elective or cosmetic surgery. ICU Stay Benefit, only 1 benefit will be paid for the same CovThis does not include reconstructive, cosmetic surgery: ered Injury or Covered Illness, whichever is greater. Hospital stays within 90 days for the same or a related Covered Injury or a) incidental to or following surgery for trauma, infection or other disease of the involved part; or b) due to congenital disease or Covered Illness is considered one Hospital Stay. anomaly of a Covered Dependent child which has resulted in a Intensive Care Unit (ICU) Stay: Must be admitted as an Inpatient functional defect;• Dental surgery, unless the surgery is the reand confined in an ICU of a Hospital, due to a Covered Injury or sult of an accidental injury. In addition, benefits will not be paid Covered Illness, at the direction and under the care of a physifor services or treatment rendered by a Physician, Nurse or any cian. If also eligible for the Hospital Stay Benefit, only 1 benefit other person who is: employed or retained by the Subscriber or will be paid for the same Covered Injury or Covered Illness, providing homeopathic, aroma- therapeutic or herbal therapeuwhichever is greater. ICU stays within 90 days for the same or a tic services or living in the Covered Person’s household or a parrelated Covered Injury or Covered Illness is considered one ICU ent, sibling, spouse or child of the Covered Person. stay. Hospital Observation Stay: Must be receiving treatment for a Covered Injury or Covered Illness in a Hospital, including an observation room, or ambulatory surgical center, for more than 24 hours on a non-inpatient basis and a charge must be incurred. This benefit is not payable if a benefit is payable under the Hospital Stay Benefit or Hospital Intensive Care Unit Stay Benefit.

Important Definitions:

Covered Illness: A physical or mental disease or disorder including pregnancy and complications of pregnancy that results in a covered loss. A Covered Illness includes medically-necessary quarantine in a Hospital in conjunction with medically-necessary preventive treatment due to an identifiable exposure to a lifethreatening contagious and infectious disease. Covered Injury: Any bodily harm that results in a covered loss. Newborn Nursery Care Admission and Newborn Nursery Care Stay: Must be admitted as an Inpatient and confined in a Hospi- Covered Person: An eligible person, as defined in the Schedule of Benefits, who is enrolled and for whom Evidence of Insurability, tal immediately following birth at the direction and under the where required, has been accepted by Us, required premium has care of a physician. been paid when due, and coverage under this Policy remains in Common Exclusions and Limitations: force. Exclusions:* In addition to any benefit-specific exclusion, benefits Elimination Period: The continuous period of time that must be will not be paid for any Covered Injury or Covered Illness which is satisfied before a benefit shown in the Schedule of Benefits is caused by or results from any of the following (unless otherwise payable. An Elimination Period may be satisfied during the Policy’s Benefit Waiting Period. provided for in the policy): • Intentionally self-inflicted injury, 24

Hospital Indemnity Hospital:* An institution that is licensed as a hospital pursuant to applicable law; primarily and continuously engaged in providing medical care and treatment to sick and injured persons; managed under the supervision of a staff of physicians; provides 24-hour nursing services by or under the supervision of a graduate registered Nurse (R.N.); and has medical, diagnostic and treatment facilities with major surgical facilities on its premises, or available to it on a prearranged basis. The term Hospital does not include a clinic or facility for: (1) rehabilitation, convalescent, custodial, educational, hospice, or skilled nursing care; (2) the aged, drug addiction or alcoholism; or (3) a facility primarily or solely providing psychiatric services to mentally ill patients. The term Hospital also does not include a unit of a Hospital for rehabilitation, convalescent, custodial, educational, hospice, or skilled nursing care.

portant Definitions (Hospital) may vary for residents of ID, NH, OR, WA and VT.

THIS POLICY PAYS LIMITED BENEFITS ONLY. IT DOES NOT CONSTITUTE COMPREHENSIVE HEALTH INSURANCE COVERAGE AND IS NOT INTENDED TO COVER ALL MEDICAL EXPENSES. THIS COVERAGE DOES NOT SATISFY “MINIMUM ESSENTIAL COVERAGE” OR INDIVIDUAL MANDATE REQUIREMENTS OF THE AFFORDABLE CARE ACT (ACA). THIS COVERAGE IS NOT A MEDICAID OR MEDICARE SUPPLEMENT POLICY. Series 1.0/1.1/1.2 This is not intended as a complete description of the insurance coverage offered. This is not a contract. Full terms and conditions of coverage are defined by and governed by Group Policy No.HC961033. Please see your Plan Sponsor to obtain a copy of Policy Provisions: the Policy. If there are any differences between this summary and When your coverage begins: Coverage begins on the later of the the Group Policy, the information in the Group Policy takes precprogram’s effective date, the date you become eligible, the first edence. Product availability, costs, benefits, riders and/or feaof the month following the date your completed enrollment form tures may vary by state. Please keep this material as a reference. is received or if evidence of insurability is required, the first of the Insurance coverage is issued on group policy form number: Policy month after we have approved you (or your dependent) for cov- Form GHIP-00-1000.00, GHIP-1.2-1000. Coverage is underwritten by Life Insurance Company of North America, 1601 Chestnut St. erage in writing unless otherwise agreed upon by Cigna. Your Philadelphia, PA 19192 coverage will not begin unless you are actively at work on the All Cigna products and services are provided exclusively by or effective date. Coverage for Covered Persons will not begin on the effective date if the covered person is confined to a hospital, through operating subsidiaries of Cigna Corporation, including Life Insurance Company of North America. The Cigna name, logo, facility or at home; disabled or receiving disability benefits or and other Cigna marks are owned by Cigna Intellectual Property, unable to perform activities of daily living. Deferral of the effecInc. tive date will not apply to the Newborn Nursery Care Admission and Stay Benefit. 887511 © 2021 Cigna. Some content provided under license. When your coverage ends: Coverage for any Covered Person ends on the earliest of the date they are no longer eligible, the date the group policy is no longer in force, or the date for the last period for which required premiums are paid. For your Spouse and Dependent Child(ren), if applicable, coverage also ends when your coverage ends, when their premiums are not paid or when they are no longer eligible. (Under certain circumstances, your coverage may be continued if you stop working. Be sure to read the Continuation of Insurance provisions in your Certificate.) 30 Day Right To Examine Certificate: If a Covered Person is not satisfied with the Certificate for any reason, it may be returned to us within 30 days after receipt. We will return any premium that has been paid and the Certificate will be void as if it had never been issued. *State Variations

Spouse definition includes civil union partners in New Hampshire and Vermont. Newborn Nursery Care Admission and Stay Benefits are not available to residents in ID, NH, OR, and WA. Portability in VT is referred to as Continuation due to loss of eligibility. VT residents are not subject to the age limit to continue coverage. Exclusions may vary for residents of MN, SC, SD, and WA. Im25

GCEFCU

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 26 details on covered expenses, limitations and exclusions are included in the summary plan description located on the Goose Creek CISD Benefits Website: www.mybenefitshub.com/goosecreekcisd

HSA (Health Savings Account) HEALTH SAVINGS ACCOUNTS HSAs for Goose Creek CISD Employees Gulf Coast Educators Federal Credit Union offers Health Savings Accounts (HSAs) to eligible Goose Creek CISD employees. You may qualify for an HSA if you select the High Deductible Health Plan (HDHP) option during open enrollment.

HOW A HEALTH SAVINGS ACCOUNT WORKS Benefits of an HSA • The ability to make deposits via payroll deduction, in person, online, or by mail • No monthly service charges • Instantly issued VISA debit card to access your money • Investment opportunities for your HSA funds • Online portal and mobile app to monitor your saving and spending Investment Options With an HSA from Gulf Coast Educators, you also have the option to invest a portion of your HSA dollars into mutual funds. Our partner, myHSAinvestments, offers a suite of widely recognized mutual funds to invest in, giving you the potential to grow your HSA balance and save for future health care expenses.

HSA vs FSA Unlike FSAs, HSAs have no "use it or lose it" stipulation, so your money rolls over each year tax-free. You can also invest these funds to earn even more money. The best part? You won t have to pay any federal taxes on your earnings as long as the funds are used to pay for qualified medical expenses. The contributions you make to your HSA are 100% yours, so even if you leave GCCISD for any reason, you will still have full access to your HSA funds.

ENROLL IN BENEFITS OUTLOOK If you believe an HSA is the right option for your healthcare needs, select the High Deductible Health Plan (HDHP) option during your open enrollment process in Benefits Outlook. To learn more about Gulf Coast Educators FCU or our Health Savings Accounts, you can do so online at www.texaseducatorshsa.com or by visiting any Gulf Coast Educators FCU location.

Gulf Coast Educators Federal Credit Union 281.487.9333 | www.gcefcu.org GCEFCU is federally insured by the NCUA. Funds transferred from GCEFCU to myHSAinvestments are not federally insured by NCUA. GCEFCU does not charge any month y fees, but myHSAinvestments may charge a fee on funds that are invested. Please consult with a licensed investment advisor for any investment related questions. 6/21

LINCOLN FINANCIAL GROUP

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 28 details on covered expenses, limitations and exclusions are included in the summary plan description located on the Goose Creek CISD Benefits Website: www.mybenefitshub.com/goosecreekcisd

Dental PPO– High High Plan of Goose Creek CISD

Benefits At-A-Glance Dental Insurance High Option The Lincoln DentalConnect® PPO Plan: • Covers many preventive, basic, and major dental care services • Also covers orthodontic treatment for children and adults • Features group coverage for Calallen Independent School District employees • Allows you to choose any dentist you wish, though you can lower your outof-pocket costs by selecting a contracting dentist • Does not make you and your loved ones wait six months between routine cleanings

Contracting Dentists Non-Contracting Dentists Individual: $50 Individual: $50 Calendar (Annual) Deductible Family: $150 Family: $150 Waived for: Preventive Waived for: Preventive Deductibles are combined for basic and major Contracting Dentists’ services. Deductibles are combined for basic and major Non-Contracting Dentists’ services. Annual Maximum $1,500 $1,500 MaxRewards® lets you and your covered family members roll a portion of unused dental benefits from one year into the next. So you have extra benefit dollars available when you need them most. • Eligible Range (claim threshold): $0 - $800 • Rollover Amount: $350 per calendar year • Rollover Amount with Preferred Provider: $500 per calendar year • Maximum Rollover Account Balance: $1,250 Lifetime Orthodontic Max $1,000 $1,000 Orthodontic Coverage is available for dependent children and adults. Waiting Period There are no benefit waiting periods for any service types Visit LincolnFinancial.com/FindADentist You can search by: • Location • Dentist name or office name • Distance you are willing to travel • Specialty, language and more Your search will automatically provide up to 100 dentists that most closely match your criteria. If your search does not locate the dentist you prefer, you can nominate one—just click the Nominate a Dentist link and complete the online form. Contracting Dentists Non-Contracting Dentists

Preventive Services Routine oral exams Routine cleanings Fluoride treatments Space maintainers for children Sealants Biopsy and examination of oral tissue (including brush biopsy) FDA approved oral cancer screening Basic Services Bitewing X-rays Full-mouth or panoramic X-rays Other dental X-rays (including periapical films) Problem focused exams Injections of antibiotics and other therapeutic medications Fillings Prefabricated stainless steel and resin crowns Biopsy and examination of oral tissue (including brush biopsy) Harmful habit appliances Occlusal guard Major Services Consultations Palliative treatment (including emergency relief of dental pain) Simple extractions Surgical extractions Oral surgery General anesthesia and I.V. sedation Prosthetic repair and recementation services Endodontics (including root canal treatment) Periodontal maintenance procedures Non-surgical periodontal therapy Periodontal surgery Bridges Full and partial dentures Denture reline and rebase services Crowns, inlays, onlays and related services Implant related services

100% No Deductible

Contracting Dentists

Non-Contracting Dentists

80% After Deductible

Contracting Dentists

Non-Contracting Dentists

50% After Deductible

Dental– High PPO Orthodontics Orthodontic exams X-rays Extractions Study models Appliances

This plan lets you choose any dentist you wish. However, your out-ofpocket costs are likely to be lower when you choose a contracting dentist. For example, if you need a crown…

• • • • •

Find a network dentist near you in minutes Have an ID card on your phone Customize the app to get details of your plan Find out how much your plan covers for checkups and other services Keep track of your claims

Lincoln DentalConnect® Online Health Center • • • •

Determine the average cost of a dental procedure Have your questions answered by a licensed dentist Learn all about dental health for children, from baby’s first tooth to dental emergencies Evaluate your risk for oral cancer, periodontal disease and tooth decay

Covered Family Members

Non-Contracting Dentists

50%

… you pay a deductible (if applicable), …you pay a deductible (if applicable), then 50% of the usual and customary fee, then 50% of the remaining which is the maximum expense covered discounted fee for PPO members. by the plan. You are responsible for the This is known as a PPO contracted difference between the usual and fee. customary fee and the dentist’s billed charge.

To find a contracting dentist near you, visit www.LincolnFinancial.com/ FindADentist.

With the Lincoln Dental Mobile App

Contracting Dentists

•

In certain situations, there may be more than one method of treating a dental condition. This summary plan description includes an alternative benefits provision that may reduce benefits to the lowest- cost, generally effective, and necessary form of treatment. • Certain conditions, such as age and frequency limitations, may impact your coverage. See the summary plan description for details. • This plan includes continuation of coverage for employees with dental coverage from a previous employer. The member is required to complete the Continuity of Coverage form located on www.lfg.com. The form must be provided to us prior to the effective date to be eligible for continuation of coverage. A complete list of benefit exclusions is included in the summary plan description. Questions? Call 800-423-2765 and mention Group ID: LIFESCHDAL.

When you choose coverage for yourself, you can also provide coverage for: • Your spouse. • Dependent children, up to age 26.

This is not intended as a complete description of the coverage offered. Controlling provisions are provided in the summary plan description, and this summary does not modify coverage. A summary plan description will be made available to you that describes the benefits in greater detail. Refer to your summary plan description for your Benefit Exclusions maximum benefit amounts. Like any coverage, this dental coverage does have some exclusions. Lincoln DentalConnect® health center Web content is provided by • The plan does not cover services started before coverage begins or after it ends. Benefits are limited to appropriate and necessary go2dental.com, Santa Clara, CA. Go2dental.com is not a Lincoln Financial Group® company. Coverage is subject to actual summary plan procedures listed in the summary plan description. Benefits are not payable for duplication of services. Covered expenses will not description language. Each independent company is solely responsible for its own obligations. exceed the summary plan description’s usual and customary The Lincoln National Life Insurance Company (Fort Wayne, IN), does allowances. • Plan benefits are not payable for a condition that is covered under not conduct business in New York, nor is it licensed to do so. In New York, business is conducted by Lincoln Life & Annuity Company of New Workers’ Compensation or a similar law; that occurs during the York (Syracuse NY). Both are Lincoln Financial Group Companies. course of employment or military service or involvement in an ©2020 Lincoln National Corporation LCN-2012491-013118 R 1.0 – illegal occupation, felony, or riot; or that results from a selfGroup ID: 1001048 inflicted injury.

Dental Rate

Coverage

Monthly Rate

Here’s how little you pay with group rates. As a Goose Creek CISD employee, you can take advantage of this dental coverage for less than $0.94 a day. Plus, you can add loved ones to the plan for just a little more. Your estimated cost is itemized below.

Employee only

$28.30

Employee & spouse

$54.12

Employee & child/children

$69.48

Employee & family

$80.90

Dental– Low PPO Low Plan of Goose Creek CISD

Benefits At-A-Glance Dental Insurance Low Option The Lincoln DentalConnect® PPO Plan: • Covers many preventive, basic, and major dental care services • Also covers orthodontic treatment for children and adults • Features group coverage for Calallen Independent School District employees • Allows you to choose any dentist you wish, though you can lower your outof-pocket costs by selecting a contracting dentist • Does not make you and your loved ones wait six months between routine cleanings

Contracting Dentists Non-Contracting Dentists Individual: $50 Individual: $50 Calendar (Annual) Deductible Family: $150 Family: $150 Waived for: Preventive Waived for: Preventive Deductibles are combined for basic and major Contracting Dentists’ services. Deductibles are combined for basic and major Non-Contracting Dentists’ services. Annual Maximum $750 $750 MaxRewards® lets you and your covered family members roll a portion of unused dental benefits from one year into the next. So you have extra benefit dollars available when you need them most. • Eligible Range (claim threshold): $1-$300 • Rollover Amount: $150 per calendar year • Rollover Amount with Preferred Provider: $200 per calendar year • Maximum Rollover Account Balance: $750 Waiting Period There are no benefit waiting periods for any service types Visit LincolnFinancial.com/FindADentist You can search by: • Location • Dentist name or office name • Distance you are willing to travel • Specialty, language and more Your search will automatically provide up to 100 dentists that most closely match your criteria. If your search does not locate the dentist you prefer, you can nominate one—just click the Nominate a Dentist link and complete the online form. Contracting Dentists Non-Contracting Dentists

80% No Deductible

Contracting Dentists

Non-Contracting Dentists

50% After Deductible

Contracting Dentists

Non-Contracting Dentists

50% After Deductible

Dental– Low PPO Orthodontics

Contracting Dentists

To find a contracting dentist near you, visit www.LincolnFinancial.com/ FindADentist. This plan lets you choose any dentist you wish. However, your out-ofpocket costs are likely to be lower when you choose a contracting dentist. For example, if you need a crown…

With the Lincoln Dental Mobile App • • • • •

Lincoln DentalConnect® Online Health Center • • • •

Covered Family Members

Non-Contracting Dentists

•

Questions? Call 800-423-2765 and mention Group ID: LIFESCHDAL.

When you choose coverage for yourself, you can also provide coverage for: • Your spouse. • Dependent children, up to age 26.

Dental Rate

Coverage

Monthly Rate

Here’s how little you pay with group rates. As a Goose Creek CISD employee, you can take advantage of this dental coverage for less than $0.66 a day. Plus, you can add loved ones to the plan for just a little more. Your estimated cost is itemized below.

Employee only

$19.70

Employee & spouse

$36.76

Employee & child/children

$42.90

Employee & family

$50.32

Dental– DHMO Now Available to Full-Time Employees of Goose Creek CISD: Dental insurance with affordable group rates

Simplify your dental care and save. Trips to the dentist are a little less scary when you know how much you’ll pay ahead of time. And easier, too, with no claim forms or deductibles.

The Lincoln DentalConnect® DHMO Plan: • • • • •

Covers most preventive and diagnostic care services at no charge Also covers a wide variety of specialty services - lowering your out-of-pocket costs with no deductibles or maximums Features group rates for Life School of Dallas employees Lets you choose a participating dentist from a regional network Saves you time and hassle with no waiting periods and no claim forms

Here’s how this important coverage works. •

• • • •

You choose your primary-care dentist when you enroll. To find a participating dentist, visit http://ldc.lfg.com, select Find a Dentist, and choose the Texas LDC Plan 5 network. (You can also print your dental ID card from this site once your coverage begins.) This dental plan offers a detailed list of covered procedures, each with a dollar copayment (see the Summary of Benefits for details). You pay for services provided during your visit. Emergency care away from home is covered up to a set dollar limit. You can change your primary-care dentist at any time by calling the customer service number listed on your dental ID card. A complete Summary of Benefits is included on the next few pages.

Here’s how little you pay with group rates. As a Life School of Dallas employee, you can take advantage of this dental insurance plan for less than $0.33 a day. Plus, you can add loved ones to the plan for just a little more.

Coverage Employee only Employee & spouse Employee & child/children Employee & family

Monthly Premium $12.60 $24.60 $26.60 $38.44

No money is due at enrollment. Your premium simply comes out of your paycheck.

Lincoln DentalConnect® DHMO (policy series TX-EOC 08 2010) is underwritten in Texas by National Pacific Dental, Inc., Houston, TX. National Pacific Dental is not a Lincoln Financial Group® company. Coverage is subject to actual contract language. Each independent company is solely responsible for its own obligations.

dental plan

Lincoln DentalConnect®

LDCTXC6c/LDCTXV6c DHMO LDCTXC6c/LDCTXV6c/covered dental services 888-877-7828 http://ldc.lfg.com ADA

DESCRIPTION

MEMBER’S COPAYMENT

DIAGNOSTIC SERVICES D0120 PERIODIC ORAL EVALUATION EST PT D0140 LTD ORAL EVALUATION - PROBLEM FOCUS D0150 COMP ORAL EVALUATION - NEW/EST PT D0160 DTL&EXT ORAL EVAL - PROB FOCUS RPT D0170 RE-EVALUATION - LTD PROBLEM FOCUSED D0180 COMP PERIODONTAL EVAL - NEW/EST PT D0210 INTRAORAL-COMPLETE SERIES D0220 INTRAORAL PERIAPICAL FIRST FILM D0230 INTRAORL PERIAPICAL EA ADD FILM D0240 INTRAORAL - OCCLUSAL FILM D0250 EXTRAORAL - FIRST FILM D0260 EXTRAORAL - EACH ADDITIONAL FILM D0270 BITEWING - SINGLE FILM D0272 BITEWINGS - TWO FILMS D0273 BITEWINGS - THREE FILMS D0274 BITEWINGS - FOUR FILMS D0277 VERTICAL BITEWINGS - 7 TO 8 FILMS D0330 PANORAMIC FILM D0415 COLLECT MICROORAGNISMS CULT & SENS D0425 CARIES SUSCEPTIBILITY TESTS D0431 ADJUNCT PREDX TST NO CYTOL/BX PROC D0460 PULP VITALITY TESTS D0470 DIAGNOSTIC CASTS D0472 ACCESS TISS-GROSS EXAM-PREP & REPRT D0473 ACCESS TISS-GROSS/MICRO-PREP/REPRT D0474 ACSS TISS GR&MIC SURG MARG PREP/RPT D0999 OFFICE VISIT FEE - PER VISIT PREVENTIVE SERVICES D1110 PROPHYLAXIS - ADULT 1 -------PROPHYLAXIS - ADULT 1 Add. Prophy within 6 months D1120 PROPHYLAXIS - CHILD 1 -------PROPHYLAXIS - CHILD 1 Add. Prophy within 6 months D1203 TOP FLUORIDE - CHILD D1204 TOP FLUORIDE - ADULT D1206 TOP FLUORIDE; TX APPL MOD-HI RISK D1310 NUTRIT CNSL CONTROL DENTAL DISEASE D1320 TOBACCO CNSL CNTRL&PREVION ORL DZ D1330 ORAL HYGIENE INSTRUCTIONS D1351 SEALANT - PER TOOTH D1510 SPACE MAINTAINER - FIXED-UNILATERAL D1515 SPACE MAINTAINER - FIXED-BILATERAL D1520 SPACE MAINTAINER - REMOVABLE-UNI D1525 SPACE MAINTAINER - REMOVABLE-BIL D1550 RECEMENTATION OF SPACE MAINTAINER D1555 REMOVAL OF FIXED SPACE MAINTAINER RESTORATIVE SERVICES* D2140 AMALGAM-ONE SURFACE PRIMARY/PERM D2150 AMALGAM-TWO SURFACES PRIMARY/PERM D2160 AMALGAM-3 SURFACES PRIMARY/PERM D2161 AMALGAM-FOUR/MORE SURF PRIM/PERM D2330 RESIN COMPOS - ONE SURFACE ANTERIOR D2331 RESIN COMPOS - 2 SURFACES ANTERIOR D2332 RESIN COMPOS - 3 SURFACES ANTERIOR 34 PLTX622C/D0623 02/2012

ADA

MEMBER’S COPAYMENT

DESCRIPTION

RESTORATIVE SERVICES* D2335 RSN COMPOS-4/> SURF/W/INCISAL ANG D2390 RESIN COMPOS CROWN ANTERIOR D2391 RESIN COMPOS - 1 SURFACE POSTERIOR D2392 RESIN COMPOS - 2 SURFACES POSTERIOR D2393 RESIN COMPOS - 3 SURFACES POSTERIOR D2394 RESIN COMPOS - 4/MORE SURFACES POST D2510 INLAY - METALLIC - ONE SURFACE D2520 INLAY - METALLIC - TWO SURFACES D2530 INLAY - METALLIC - 3/MORE SURFACES D2542 ONLAY - METALLIC - TWO SURFACES D2543 ONLAY METALLIC THREE SURFACES D2544 ONLAY METALLIC FOUR OR MORE SURF D2610 INLAY - PORCELN/CERAMIC - 1 SURFACE D2620 INLAY - PORCELN/CERAMIC - 2 SURF D2630 INLAY - PORCELN/CERAM - 3/MORE SURF D2642 ONLAY - PORCELN/CERAMIC - 2 SURF D2643 ONLAY - PORCELN/CERAMIC - 3 SURF D2644 ONLAY - PORCELN/CERAM - 4/MORE SURF D2650 INLAY-RSN COMPOS COMPOS/RSN-1 SURF D2651 INLAY-RSN COMPOS COMPOS/RSN-2 SURF D2652 INLAY-RSN COMPOS COMPOS/RSN-3/>SURF D2662 ONLAY-RSN COMPOS COMPOS/RSN-2 SURF D2663 ONLAY-RSN COMPOS COMPOS/RSN-3 SURF D2664 ONLAY-RSN COMPOS COMPOS/RSN-4/> D2710 CROWN RESINBASED COMPOSITE INDIRECT D2712 CROWN 3/4 RESNBASED COMPOS INDIRECT D2720 CROWN - RESIN WITH HIGH NOBLE METAL* D2721 CROWN - RESIN W/PREDOM BASE METAL D2722 CROWN - RESIN WITH NOBLE METAL* D2740 CROWN - PORCELAIN/CERAMIC SUBSTRATE D2750 CROWN - PORCELN FUSED HI NOBLE METL* D2751 CROWN-PORCELN FUSD PREDOM BASE METL D2752 CROWN - PORCELAIN FUSED NOBLE METAL * D2780 CROWN - 3/4 CAST HIGH NOBLE METAL* D2781 CROWN - 3/4 CAST PREDOM BASE METL D2782 CROWN - 3/4 CAST NOBLE METAL * D2783 CROWN - 3/4 PORCELAIN/CERAMIC D2790 CROWN - FULL CAST HIGH NOBLE METAL* D2791 CROWN - FULL CAST PREDOM BASE METL D2792 CROWN - FULL CAST NOBLE METAL * D2794 CROWN TITANIUM * D2910 RECEMENT INLAY ONLAY/PART COV REST D2915 RECEMENT CAST/PREFAB POST & CORE D2920 RECEMENT CROWN D2930 PRFABR STAINLESS STEEL CROWN-PRIM D2931 PRFABR STAINLESS STEEL CROWN-PERM D2932 PREFABRICATED RESIN CROWN D2933 PRFABR STNLSS STEEL CROWN RSN WNDOW D2940 PROTECTIVE RESTORATION D2950 CORE BUILDUP INCLUDING ANY PINS D2951 PIN RETN - PER TOOTH ADDITION REST D2952 POST & CORE ADD CROWN INDIRECT FAB D2953 EA ADD INDIRECT FAB POST SAME TOOTH

$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $20 $0 $0 $0 $0 $0 $5 $0 $25 $0 $25 $0 $0 $0 $0 $0 $0 $5 $25 $25 $45 $45 $10 $10 $0 $0 $0 $0 $0 $0 $0 1

$0 $40 $40 $50 $70 $90 $160 $160 $160 $215 $215 $215 $225 $225 $225 $225 $225 $225 $225 $225 $225 $225 $225 $225 $135 $135 $225 $225 $225 $285 $225 $225 $225 $225 $225 $225 $225 $225 $225 $225 $225 $0 $0 $0 $40 $40 $35 $40 $0 $40 $0 $70 $70

This plan is underwritten by National Pacific Dental, Inc.

ADA

DESCRIPTION

MEMBER’S COPAYMENT

D2954 PREFABR POST&CORE ADDITION CROWN D2955 POST REMOVAL D2957 EA ADD PREFABR POST - SAME TOOTH D2970 TEMPORARY CROWN D2971 ADD PROC NEW CROWN XST PART DENTURE ENDODONTIC SERVICES D3110 PULP CAP - DIRECT D3120 PULP CAP - INDIRECT D3220 TX PULPOT-CORONL DENTNOCEMENTL JUNC D3221 PULPAL DEBRID PRIMARY&PERM TEETH D3230 PULPAL THERAPY - ANT PRIMARY TOOTH D3240 PULPAL THERAPY - POST PRIMARY TOOTH D3310 ENDODONTIC THERAPY, ANTERIOR TOOTH(XCLD FINL REST) D3320 ENDODONTIC THERAPY, BICUSPID TOOTH (XCLD FINL REST) D3330 ENDODONTIC THERPAY, MOLAR (XCLD FINAL RESTORATION) D3331 TX RC OBSTRUCTION; NON-SURG ACCESS D3332 INCMPL ENDO TX;INOP UNRSTR/FX TOOTH D3333 INTRL ROOT REPAIR PERFORATION DEFEC D3346 RETX PREVIOUS RC THERAPY - ANTERIOR D3347 RETX PREVIOUS RC THERAPY - BICUSPID D3348 RETX PREVIOUS RC THERAPY - MOLAR D3351 APEXIFICAT/RECALCIFICAT/PULPAL REGENERTN - INTIAL VST D3352 APEXIFICAT/RECALC/PULP REGEN-INTRM MED REPLACMNT D3353 APEXIFICAT/RECALCIFICAT-FINAL VISIT D3410 APICOECT/PERIRADICULAR SURG - ANT D3421 APICOECT/PERIRADICULR SURG-BICUSPID D3425 APICOECT/PERIRADICULAR SURG - MOLAR D3426 APICOECTOMY/PERIRADICULAR SURGERY D3430 RETROGRADE FILLING - PER ROOT D3450 ROOT AMPUTATION - PER ROOT D3910 SURG PROC ISOLAT TOOTH W/RUBBER DAM D3920 HEMISECTION NOT INCL RC THERAPY D3950 CANAL PREP&FIT PREFORMED DOWEL/POST PERIODONTIC SERVICES D4210 GINGIVECT/PLSTY 4/>CNTIG TEETH QUAD D4211 GINGIVECT/PLSTY 1-3CNTIG TEETH QUAD D4240 GINGL FLP 4/>CNTIG/BOUND TEETH QUAD D4241 GINGL FLP 1-3 CNTIG/BND TEETH QUAD D4245 APICALLY POSITIONED FLAP D4249 CLIN CROWN LEN - HARD TISSUE D4260 OSSEOUS SURG 4/> CNTIG TEETH QUAD D4261 OSSEOUS SURG 1-3 CNTIG TEETH QUAD D4263 BONE REPLCMT GRAFT - 1 SITE QUAD D4264 BN REPLCMT GRAFT - EA ADD SITE QUAD D4270 PEDICLE SOFT TISSUE GRAFT PROCEDURE D4271 FREE SOFT TISSUE GRAFT PROCEDURE D4274 DISTAL OR PROXIMAL WEDGE PROCEDURE D4341 PRDNTL SCAL&ROOT PLAN 4/>TEETH-QUAD D4342 PRDONTAL SCAL&ROOT PLAN 1-3 TEETH D4355 FULL MOUTH DEBRID COMP EVAL&DX D4381 LOC DEL ANTIMICROBIAL AGT TOOTH BR D4910 PERIODONTAL MAINTENANCE D4920 UNSCHEDULED DRESSING CHANGE REMOVEABLE PROSTHODONTICS SERVICES* D5110 COMPLETE DENTURE - MAXILLARY D5120 COMPLETE DENTURE - MANDIBULAR D5130 IMMEDIATE DENTURE - MAXILLARY D5140 IMMEDIATE DENTURE - MANDIBULAR

ADA

REMOVEABLE PROSTHODONTICS SERVICES* D5211 MAX PARTIAL DENTURE - RESIN BASE D5212 MAND PARTIAL DENTUR - RESIN BASE D5213 MAX PART DENTUR-CAST METL W/RSN D5214 MAND PART DENTUR- CAST METL W/RSN D5225 MAXILLARY PARTIAL DENTURE FLEX BASE D5226 MANDIBULAR PART DENTURE FLEX BASE D5281 REMV UNI PART DENTUR-1 PC CAST METL D5410 ADJUST COMPLETE DENTURE - MAXILLARY D5411 ADJUST COMPLETE DENTUR - MANDIBULAR D5421 ADJUST PARTIAL DENTURE - MAXILLARY D5422 ADJUST PARTIAL DENTURE - MANDIBULAR D5510 REPAIR BROKEN COMPLETE DENTURE BASE D5520 REPL MISS/BROKEN TEETH-CMPL DENTUR D5610 REPAIR RESIN DENTURE BASE D5620 REPAIR CAST FRAMEWORK D5630 REPAIR OR REPLACE BROKEN CLASP D5640 REPLACE BROKEN TEETH - PER TOOTH D5650 ADD TOOTH EXISTING PARTIAL DENTURE D5660 ADD CLASP EXISTING PARTIAL DENTURE D5670 REPL ALL TEETH&ACRYLC FRMEWRK MAX D5671 REPL ALL TEETH&ACRYLC FRMEWRK MAND D5710 REBASE COMPLETE MAXILLARY DENTURE D5711 REBASE COMPLETE MANDIBULAR DENTURE D5720 REBASE MAXILLARY PARTIAL DENTURE D5721 REBASE MANDIBULAR PARTIAL DENTURE D5730 RELINE CMPL MAXIL DENTURE CHAIRSIDE D5731 RELINE CMPL MAND DENTURE CHAIRSIDE D5740 RELINE MAXIL PART DENTURE CHAIRSIDE D5741 RELINE MAND PART DENTURE CHAIRSIDE D5750 RELINE CMPL MAXIL DENTURE LAB D5751 RELINE CMPL MAND DENTRUE LABORATORY D5760 RELINE MAXIL PART DENTURE LAB D5761 RELINE MAND PART DENTURE LABORATORY D5820 INTERIM PARTIAL DENTURE MAXILLARY D5821 INTERIM PARTIAL DENTURE MANDIBULAR D5850 TISSUE CONDITIONING MAXILLARY D5851 TISSUE CONDITIONING MANDIBULAR FIXED PROSTHODONTICS SERVICES* D6210 PONTIC - CAST HIGH NOBLE METAL* D6211 PONTIC - CAST PREDOM BASE METAL D6212 PONTIC - CAST NOBLE METAL * D6214 PONTIC TITANIUM * D6240 PONTIC-PORCELN FUSED HI NOBLE METL * D6241 PONTIC-PORCLN FUSD PREDOM BASE METL D6242 PONTIC - PORCELN FUSED NOBLE METAL * D6245 PONTIC - PORCELAIN/CERAMIC D6250 PONTIC - RESIN W/HIGH NOBLE METAL * D6251 PONTIC RESIN W/PREDOM BASE METAL D6252 PONTIC RESIN W/NOBLE METAL * D6600 INLAY-PORCELAIN/CERAMIC 2 SURFACES D6601 INLAY - PORCELN/CERAMIC 3/MORE SURF D6602 INLAY - CAST HI NOBLE METAL 2 SURF D6603 INLAY-CAST HI NOBLE METL 3/> SURF D6604 INLAY-CAST PREDOM BASE METL 2 SURF D6605 INLAY-CAST PREDOM BASE METL 3/>SURF D6606 INLAY - CAST NOBLE METAL 2 SURFACES D6607 INLAY - CAST NOBLE METL 3/MORE SURF

$25 $10 $25 $0 $50 $0 $0 $0 $20 $35 $35 $85 $135 $250 $85 $85 $85 $105 $155 $270 $70 $50 $60 $105 $105 $105 $45 $50 $105 $15 $85 $12 $100 $65 $155 $105 $155 $175 $275 $165 $155 $105 $190 $205 $85 $40 $40 $45 $50 $40 $0 $285 $285 $305 $305 2

PLTX622C/D0623 02/2012

MEMBER’S COPAYMENT

DESCRIPTION

$295 $295 $315 $315 $315 $315 $275 $5 $5 $5 $5 $35 $35 $35 $35 $35 $35 $35 $35 $155 $155 $85 $85 $85 $85 $45 $45 $45 $45 $65 $65 $65 $65 $105 $105 $10 $10 $225 $225 $225 $225 $225 $225 $225 $285 $225 $225 $225 $245 $245 $160 $160 $160 $160 $160 $160

35 This plan is underwritten by National Pacific Dental, Inc.

ADA

DESCRIPTION

MEMBER’S COPAYMENT

FIXED PROSTHODONTICS SERVICES* D6608 ONLAY - PORCELN/CERAMIC 2 SURFACES D6609 ONLAY - PORCELN/CERAMIC 3/MORE SURF D6610 ONLAY - CAST HI NOBLE METAL 2 SURF D6611 ONLAY-CAST HI NOBLE METL 3/> SURF D6612 ONLAY-CAST PREDOM BASE METL 2 SURF D6613 ONLAY-CAST PREDOM BASE METL 3/>SURF D6614 ONLAY - CAST NOBLE METAL 2 SURFACES D6615 ONLAY - CAST NOBLE METL 3/MORE SURF D6624 INLAY TITANIUM D6634 ONLAY TITANIUM D6720 CROWN - RESIN WITH HIGH NOBLE METAL * D6721 CROWN RESIN PREDOM BASE METL-DENTUR D6722 CROWN - RESIN WITH NOBLE METAL * D6740 CROWN - PORCELAIN/CERAMIC D6750 CRWN PORCLN FUSD HI NOBL MTL-DENTUR * D6751 CROWN-PORCELN FUSD PREDOM BASE METL D6752 CROWN - PORCELAIN FUSED NOBLE METAL * D6780 CROWN - 3/4 CAST HIGH NOBLE METAL * D6781 CROWN-3/4 CAST PREDOM BASED METAL D6782 CROWN 3/4 CAST NOBLE METAL-DENTURE * D6783 CROWN 3/4 PORCELAIN/CERAMIC-DENTURE D6790 CROWN FULL CAST HI NOBL METL-DENTUR * D6791 CROWN FULL CAST BASE METAL-DENTURE D6792 CROWN FULL CAST NOBLE METAL-DENTURE * D6794 CROWN TITANIUM * D6930 RECEMENT FIXED PARTIAL DENTURE D6940 STRESS BREAKER D6970 POST&CORE ADD FIX PART DENTURE RET D6972 PRFAB POST&COR ADD PART DENTUR RETN D6973 CORE BUILD UP RETAIN INCL ANY PINS D6976 EA ADD INDIRECT FAB POST SAME TOOTH D6977 EACH ADD PRFAB POST SAME TOOTH ORAL SURGERY SERVICES D7111 XTRCT CORONL RMNNTS DECIDUOUS TOOTH D7140 EXTRAC ERUPTED TOOTH/EXPOSED ROOT D7210 SURG REMOVAL ERUPTED TOOTH D7220 REMOVAL IMPACT TOOTH - SOFT TISSUE D7230 REMOVAL IMPACT TOOTH - PARTLY BONY D7240 REMOVAL IMPACTED TOOTH - CMPL BONY D7241 REMV IMP TOOTH-CMPL BNY W/SURG COMP D7250 SURG REMOVAL RESIDUAL TOOTH ROOTS D7270 TOOTH REIMPL&/STBL ACC DISPLCD D7280 SURGICAL ACCESS AN UNERUPTED TOOTH D7282 MOBILZ ERUPT/MALPSTN TOOTH AID ERUP D7285 BIOPSY OF ORAL TISSUE HARD D7286 BIOPSY OF ORAL TISSUE SOFT D7288 BRUSH BIOPSY - TRANSEPITHELIAL SAMPLE COLLECTION D7310 ALVEOLOPLASTY W/EXT 4/> TEETH/SPACE D7311 ALVEOLOPLSTY CONJNC XTRCT 1-3 TEETH D7320 ALVEOLOPLASTY NO EXT 4/> TEETH/SPAC D7321 ALVEOLOPLSTY NOT W/XTRCT 1-3 TEETH D7471 REMOVAL OF LATERAL EXOSTOSIS D7472 REMOVAL OF TORUS PALATINUS

ADA

DESCRIPTION

MEMBER’S COPAYMENT

ORAL SURGERY SERVICES D7473 REMOVAL OF TORUS MANDIBULARIS D7485 SURGICAL RDUC OSSEOUS TUBEROSITY D7510 I&D ABSCESS-INTRAORAL SOFT TISS D7511 I & D ABSC INTRAORAL SOFT TISS COMP D7910 SUTURE RECENT SMALL WOUNDS UP 5 CM D7960 FRENULECTOMY-ALSO KNOWN AS FRENECTOMY OR FRENOTOMY-SEPAR PROCED NOT INCIDENTAL TO ANOTHER D7963 FRENULOPLASTY D7970 EXC HYPERPLASTIC TISSUE-PER ARCH D7971 EXCISION OF PERICORONAL GINGIVA D7972 SURGICAL RDUC FIBROUS TUBEROSITY ADJUNCTIVE GENERAL SERVICES D9110 PALLIATVE TX DENTAL PAIN-MINOR PROC D9211 REGIONAL BLOCK ANESTHESIA D9212 TRIGEMINAL DIVISION BLOCK ANES D9215 LOCAL ANESTHESIA D9220 DP SEDATION/GEN ANES-1ST 30 MIN D9221 DP SEDAT/GEN ANES-EA ADD 15 MIN D9241 IV CONSC SEDAT/ANALG -1ST 30 MIN D9242 IV CONSC SEDAT/ANALG-EA ADD 15 MIN D9310 CNSLT DX DENT/PHY NOT REQ DENT/PHY D9430 OV OBS - NO OTH SERVICES PERFORMED D9440 OV-AFTER REGULARLY SCHEDULED HRS D9450 CASE PRSATION DTL&EXT TX PLANNING D9930 TREATMENT OF COMPLICATIONS - POST SURG. D9940 OCCLUSAL GUARD BY REPORT

$255 $255 $160 $160 $160 $160 $160 $160 $225 $225 $225 $225 $225 $285 $225 $225 $225 $225 $225 $225 $285 $225 $225 $225 $225 $0 $105 $40 $25 $15 $45 $45

D9951 OCCLUSAL ADJUSTMENT - LIMITED D9952 OCCLUSAL ADJUSTMENT - COMPLETE D9972 EXTERNAL BLEACHING - PER ARCH D9999 BROKEN APPOINTMENT ORTHODONTIC SERVICES D8070 COMPREHENSIVE ORTHODONTIC TREATMENT TRANSITIONAL DENTITION D8080 COMPREHENSIVE ORTHODONTIC TREATMENT ADOLESCENT DENTITION D8090 COMPREHENSIVE ORTHODONTIC TREATMENT ADULT DENTITION D8680 ORTHODONTIC RETENTION (REMOVAL OF APPLIANCES, CONSTRUCTION, AND PLACEMENT OF RETAINERS) D8999 START-UP FEE (INCLUDING EXAM, BEGINNING RECORDS, X-RAYS, TRACING, PHOTOS, AND MODELS) D8999 POST TREATMENT RECORDS

$0 $0 $25 $50 $75 $105 $125 $30 $50 $85 $90 $125 $50 $0 $35 $10 $50 $20 $65 $50

$50 $50 $25 $25 $25 $40 $40 $50 $40 $95 $10 $0 $0 $0 $145 $65 $145 $65 $0 $0 $35 $0 $0 $75 $20 $90 $125 $20 $1,895 $1,895 $1,895 $300 $250 $150

1. Additional Prophy within 6 months will be based upon the necessity recommended by the provider. 2. Copays listed are also applicable in the specialist office. * The plan provides for the use of noble metals for inlays, onlays, crowns and fixed bridges. When high noble metal is used, the Covered Person must pay: (a) the Copayment for the inlay, onlay, crown or fixed bridge; and (b) an added charge equal to the actual laboratory cost of the high noble metal, not to exceed $150. 3 PLTX622C/D0623 02/2012 36

This plan is underwritten by National Pacific Dental, Inc.

Dental– DHMO Dental HMO exclusions and limitations Limitations of Benefits The following are the limitation of benefits, unless otherwise specifically listed as a covered benefit on this Plan’s Schedule of Benefits: 1. Dental Prophylaxis - Limited to 1 time per 6 months 2. Intraoral -Complete Series (including bitewings) - Limited to 1 time in any 2 year period. 3. Intraoral Bitewing Radiographs – Limited to 1 series of 4 films in any 6 month period 4. Fluoride Treatments – Limited to one time per calendar year 5. Scaling and Root Planing - Limited to 4 quadrants per calendar year. 6. Periodontal Maintenance - Limited to once every 6 months, following active therapy, exclusive of gross debridement 7. Removable Prosthetics/Fixed Prosthetics/Crowns, Inlays and Onlays (Major Restorative Services) - Replacement of complete dentures, fixed or removable partial dentures, crowns, inlays or onlays previously submitted for payment under the plan is limited to 1 time per 5 years from initial or supplemental placement 8. Removable Prosthetics/Fixed Prosthetics/Crowns, Inlays and Onlays (Major Restorative Services) - Replacement of complete dentures, and fixed and removable partial dentures or crowns if damage or breakage was directly related to provider error. This type of replacement is the responsibility of the Dentist. If replacement is Necessary because of patient non-compliance, the patient is liable for the cost of replacement. 9. Crowns - Retainers/Abutments - Limited to 1 time per tooth per 5 years. 10. Crowns – Restorations - Limited to 1 time per tooth per 5 years. Covered only when a filling cannot restore the tooth. 11. Temporary Crowns – Restorations - Limited to 1 time per tooth per 5 years. Covered only when a filling cannot restore the tooth. 12. Inlays/Onlays - Retainers/Abutments - Limited to 1 time per tooth per 5 years 13. Inlays/Onlays – Restorations - Limited to 1 time per tooth per 5 years. Covered only when a filling cannot restore the tooth... 14. Stainless Steel Crowns - Limited to 1 time per tooth per 5 years. Covered only when a filling cannot restore the tooth. Prefabricated esthetic coated stainless steel crown -primary tooth, are limited to primary anterior teeth. 15. Crowns and fixed bridges, the maximum benefit within a 12month period is any combination of 7 crowns or pontics (artificial teeth that are part of a fixed bridge). If more than 7 crowns and/or pontics are done for a Member within a 12 -month period, the dentist’s fee for any additional crowns within that period would not be limited to the listed Copay-

ment, but instead can reflect the Dentist’s Billed Charges... 16. Post and Cores - Covered only for teeth that have had root canal therapy. 17. Adjustments to Full Dentures, Partial Dentures, Bridges or Crowns Limited to repairs or adjustments performed more than 6 months after the initial insertion. 18. Intravenous Sedation or General Anesthesia - Administration of I.V. sedation or general anesthesia is limited to covered oral surgical procedures involving 1 or more impacted teeth (soft tissue, partial bony or complete bony impactions). 19. Adjunctive Pre-Diagnostic Test that aids in detection of mucosal abnormalities including premalignant and malignant lesions, not to include cytology or biopsy procedures - Limited to 1 time per year, to Covered Persons over the age of 30. 20. All Specialty Referral Services Must Be: (A) Pre-Authorized by us; and Coordinated by a Covered Person’s PCD. Any Covered Person who elects specialist care without prior referral by his or her PCD and approval by us is responsible for all charges incurred • In order for specialty services to be Covered by this plan, the following referral process must be followed: • A Covered Person’s PCD must coordinate all Dental Services. • When the care of a Network Specialist Dentist is required, the Covered Person’s PCD must contact us and request authorization... • If the PCD’s request for specialist referral is denied, the PCD and the Covered Person will be notified of the reason for the denial. If the service in question is a Covered service, and no limitations or exclusions apply, the PCD may be asked to perform the service. • Covered Person who receives authorized specialty services must pay all applicable Copayments associated with the services provided. When we authorize specialty dental care, a Covered Person will be referred to a Network Specialist Dentist for treatment. The Network includes Network Specialist Dentists in: (a) endodontics; (b) oral surgery; (c) pediatric dentistry; and • (d) orthodontics; and (e) periodontics, located in the Covered Person’s Service Area. If there is no Network Specialist Dentist in the Covered Person’s Service Area, we will refer the Covered Person to a Non-Participating Specialist of our choice. Except for Emergency Dental Services, in no event will we cover dental care provided to a Covered Person by a specialist not pre- authorized by us to provide such services. • Covered Person’s financial responsibility is limited to applicable Copayments. Copayments are listed in the Covered Person’s Schedule of Covered Dental Services.

Dental– Low PPO Exclusion of Benefits The following procedures and services are excluded and not Covered Services, unless otherwise specifically listed as a covered benefit on this Plan’s Schedule of Benefits: 1. Dental Services that are not Necessary. Such decision is an adverse determination, which can be appealed. See your EOC for your appeal options. 2. Any Dental Services or Procedures not listed in the Schedule of Covered Dental Services 3. Any Dental Procedure not performed in a participating dental setting. An exception is made for Emergency Dental Care, as defined in this Evidence of Coverage. 4. Any Dental Procedure not directly associated with dental disease. 5. Procedures related to the reconstruction of a patient’s correct vertical dimension of occlusion (VDO) 6. Any service done for cosmetic purposes that is not listed as a Covered cosmetic service in the Schedule of Covered Dental Services 7. Costs for non-dental services related to the provision of dental services in hospitals, extended care facilities, or Member’s home are not covered. When deemed necessary by the Primary Care Dentist, the Member’s physician, and authorized by the Plan, covered dental services that are delivered in an inpatient or outpatient hospital setting are covered as indicated in the Schedule of Benefits 8. Setting of facial bony fractures and any treatment associated with the dislocation of facial skeletal hard tissue. 9. Replacement of a lost, missing or stolen appliance or prosthesis or the fabrication of a spare appliance or prosthesis 10. Removable Prosthetics/Fixed Prosthetics/Crowns, Inlays and Onlays (Major Restorative Services) - The plan provides for the use of noble metals for inlays, onlays, crowns and fixed bridges. When high noble metal is used, the Covered Person must pay: (a) the Copayment for the inlay, onlay, crown or fixed bridge; and (b) an added charge equal to the actual laboratory cost of the high noble metal. 11. Placement of fixed partial dentures solely for the purpose of achieving periodontal stability 12. Fixed or removable prosthodontic restoration procedures for complete oral rehabilitation or reconstruction 13. Services for injuries or conditions covered by Worker’s Compensation or employer liability laws, and services that are provided without cost to the Covered Person by any municipality, county, or other political subdivision. This exclusion does not apply to any services covered by Medicaid or Medicare 14. Dental Services otherwise Covered under the Contract, but rendered after the date individual Coverage under the Contract terminates, including Dental Services for dental conditions arising prior to the date individual Coverage under the Contract terminates 15. Treatment of benign neoplasms, cysts, or other pathology 38

involving benign lesions, except excisional removal. Treatment of malignant neoplasms or Congenital Anomalies of hard or soft tissue, including excision. Any Covered Person request for: (a) specialist services or treatment which can be routinely provided by the PCD; or (b) treatment by a specialist without referral from the PCD and our approval Placement of dental implants, implant-supported abutments and prostheses Drugs/medications, obtainable with or without a prescription, unless they are dispensed and utilized in the dental office during the patient visit. Services related to the temporomandibular joint (TMJ), either bilateral or unilateral. Upper and lower jaw bone surgery (including that related to the temporomandibular joint). No Coverage is provided for orthognathic surgery, jaw alignment, or treatment. Any endodontic, periodontal, crown or bridge abutment procedure or appliance requested, recommended or performed for a tooth or teeth with a guarded, questionable or poor prognosis Dental Services received as a result of war or any act of war, whether declared or undeclared or caused during service in the armed forces of any country. Relative analgesia (N2O2 - nitrous oxide) is not covered

16.

17. 18.

19.

20.

21.

22.

Orthodontic Exclusions & Limitations If you require the services of an orthodontist, a referral must first be obtained. If a referral is not obtained prior to the commencement of orthodontic treatment, the member will be responsible for all costs associated with any orthodontic treatment. If you terminate coverage after the start of orthodontic treatment, you will be responsible for any additional charges incurred for the remaining orthodontic treatment. 1.

The following are not Covered orthodontic benefits: Extractions required for orthodontic purposes • Surgical orthodontics or jaw repositioning • Myofunctional therapy • Cleft palate • Micrognathia • Macroglossia • Hormonal imbalances • Orthodontic retreatment when initial treatment was rendered under this plan or for changes in orthodontic treatment necessitated by any kind of accident • Palatal expansion appliances • Replacement or repair of lost, stolen or broken appliances or appliances damaged due to the neglect of the Covered Person If a treatment plan is for less than 24 months, then a prorat•

Dental– DHMO 3.

ed portion of the full Copayment shall apply. If Covered Person’s dental eligibility ends, for whatever reason, and the Covered Person is receiving orthodontic treatment under the plan, the remaining cost for that treatment will be prorated at the orthodontist’s usual fees over the number of months of treatment remaining. The Covered Person will be responsible for the payment of this balance under the terms and conditions pre-arranged with the orthodontist. If the Covered Person has the orthodontist perform a “diagnostic work-up” (a consultation and diagnosis) and then decides to forgo the treatment program, the Covered Person will be charged a $50 consultation fee, plus any lab costs incurred by the orthodontist. One orthodontic benefit under this plan is available per lifetime, per Covered Person. A Covered Person may access this benefit for either Interceptive Orthodontic Treatment or Comprehensive Orthodontic Treatment, or both. If both interceptive treatment and comprehensive treatment are necessary, and both are completed within a 24 month period, the Copayments listed will apply. If both are necessary and active treatment for both extends beyond 24 months, the provider is obligated to accept the plan Copayment only for the first 24 months of active therapy. The provider may charge usual and customary fees for active treatment extending beyond the 24 month benefit period.

PLTX622C/D0623 02/2012This plan is underwritten by National Pacifi c Dental, Inc.

EYEMED YOUR BENEFITS PACKAGE

Vision

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

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 40 details on covered expenses, limitations and exclusions are included in the summary plan description located on the Goose Creek CISD Benefits Website: www.mybenefitshub.com/goosecreekcisd

Vision GOOSE CREEK CISD SUMMARY OF BENEFITS VISION CARE SERVICES EXAM SERVICES Exam Retinal Imaging CONTACT LENS FIT AND FOLLOW-UP Fit & Follow-up - Standard Fit & Follow-up - Premium FRAME Frame STANDARD PLASTIC LENSES Single Vision Bifocal Trifocal Lenticular Progressive - Standard Progressive - Premium Tier 1 - 4 LENS OPTIONS Anti Reflective Coating - Standard Anti Reflective Coating - Premium Tier 1 - 3 Photochromic - Non-Glass Polycarbonate - Standard Polycarbonate - Standard < 19 years of age Scratch Coating - Standard Plastic Tint - Solid and Gradient UV Treatment All Other Lens Options CONTACT LENSES Contacts - Conventional Contacts - Disposable Contacts - Medically Necessary OTHER Hearing Care from Amplifon Network Lasik or PRK from U.S. Laser Network FREQUENCY Exam Frame Lenses Contacts Lenses

40% OFF additional complete pair of prescription eyeglasses

20% OFF non-covered items, including non- prescription sunglasses

IN-NETWORK MEMBER COST

OUT-OF-NETWORK MEMBER REIMBURSEMENT

$10 copay Up to $39

Up to $45 Not covered

Up to $40; contact lens fit and two follow-up visits 10% off retail price

Not covered

$0 copay; 20% off balance over $180 allowance

Up to $126

$10 copay $10 copay $10 copay $10 copay $65 copay $95-185 copay

Up to $30 Up to $50 Up to $70 Up to $70 Up to $50 Up to $50

$45 copay $57 - 85 copay $75 $40 $0 copay $15 $15 $15 20% off retail price

Up to $23 Up to $23 Not covered Not covered Up to $20 Not covered Not covered Not covered Not covered

$0 copay; 15% off balance over $180 allowance $0 copay; 100% of balance over $180 allowance $0 copay; paid-in-full

Up to $126 Up to $126 Up to $210

Discounts on hearing exam and aids; call 1.877.203.0675 15% off retail or 5% off promo price; call 1.800.988.4221 ALLOWED FREQUENCY –ADULTS Once every plan year Once every plan year Once every plan year Once every plan year

Not covered

Find an eye doctor (Insight Network) • eyemed.com • EyeMed Members App • For LASIK, call 1.800.988.4221

Heads up You may have additional benefits. Log into eyemed.com/member to see all plans included with your benefits.

Not covered

Not covered ALLOWED FREQUENCY –KIDS Once every plan year Once every plan year Once every plan year Once every plan year

EyeMed reserves the right to make changes to the products available on each tier. All providers are not required to carry all brands on all tiers. For current listing of brands by tier, call 866939-3633. No benefits will be paid for services or materials connected with or charges arising from: medical or surgical treatment, services or supplies for the treatment of the eye, eyes or supporting structures; Refraction, when not provided as part of a Comprehensive Eye Examination; services provided as a result of any Workers’ Compensation law, or similar legislation, or required by any governmental agency or program whether federal, state or subdivisions thereof; orthoptic or vision training, subnormal vision aids and any associated supplemental testing; Aniseikonic lenses; any Vision Examination or any corrective Vision Materials required by a Policyholder as a condition of employment; safety eyewear; solutions, cleaning products or frame cases; non-prescription sunglasses; plano (non-prescription) lenses; plano (non- prescription) contact lenses; two pair of glasses in lieu of bifocals; electronic vision devices; services rendered after the date an Insured Person ceases to be covered under the Policy, except when Vision Materials ordered before coverage ended are delivered, and the services rendered to the Insured Person are within 31 days from the date of such order; or lost or broken lenses, frames, glasses, or contact lenses that are replaced before the next Benefit Frequency when Vision Materials would next become available. Fees charged by a Provider for services other than a covered benefit and any local, state or Federal taxes must be paid in full by the Insured Person to the Provider. Such fees, taxes or materials are not covered under the Policy. Allowances provide no remaining balance for future use within the same Benefit Frequency. Some provisions, benefits, exclusions or limitations listed herein may vary by state. Plan discounts cannot be combined with any other discounts or promotional offers. In certain states members may be required to pay the full retail rate and not the negotiated discount rate with certain participating providers. Please see online provider locator to determine which participating providers have agreed to the discounted rate.

Vision Ready to live your best EyeMed Life? There’s so much more to your vision benefits than copays and coverage. Get ready to see the good stuff for your self. Your network is the place to start See who you want. when you want. You have thousands of providers to choose from -independent eye doctors, your favorite retail stores, even online options. Keep your eyes open for extra discounts Members already save an average 71% off retail using their EyeMed benefits.1 but our long list of special offers takes benefits even further. Remember, you're never alone We're always here to help you use your benefits like a pro. Stay in-the-know with text alerts or healthy vision resources from the experts. If it can make benefits easier for you. we do it. 1 Based on weighted average of sample transactions; EyeMed Insight network/$!0 exom copay/$10 materials copay/$120 frame or contact lens allowance.

Create a member account at eyemed.com Everything is right there in one spot. Check claims and benefits. see special offers and find an eye doctor-search for one with the hours. location and brands you want. For maximum mobility. try the EyeMed Members App (Google Play or App Store).

PDF-2004-M-377 42

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 44 details on covered expenses, limitations and exclusions are included in the summary plan description located on the Goose Creek CISD Benefits Website: www.mybenefitshub.com/goosecreekcisd

Long Term Disability Benefit Highlights for: FEATURES Goose Creek Consolidated Independent School District Benefit Amount

EDUCATOR DISABILITY INSURANCE OVERVIEW What is Educator Disability Income Insurance? Educator Disability insurance combines the features of a shortterm and long-term disability plan into one policy. The coverage pays you a portion of your earnings if you cannot work because of a disabling illness or injury. The plan gives you the flexibility to choose a level of coverage to suit your need. You have the opportunity to purchase Disability Insurance through your employer. This highlight sheet is an overview of your 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 Disability Insurance Coverage? More than half of all personal bankruptcies and mortgage foreclosures are a consequence of disability1 1 Facts from LIMRA, 2016 Disability Insurance Awareness Month

OF THE PLAN

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. Earnings are defined in The Hartford’s contract with your employer. Elimination Period You must be disabled for at least the number of days indicated by the elimination period that you select before you can receive a Disability benefit payment. 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. For those employees electing an elimination period of 30 days or less, if you 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 hospitalization.

Maximum Benefit Duration The average worker faces a 1 in 3 chance of suffering a job loss Benefit Duration is the maximum time for which we pay benefits 2 lasting 90 days or more due to a disability for disability resulting from sickness or injury. Depending on the 2 Facts from LIMRA, 2016 Disability Insurance Awareness Month age at which disability occurs, the maximum duration may vary. Only 50% of American adults indicate they have enough savings Please see the applicable schedules below based on the Premium benefit option. to cover three months of living expenses in the event they’re 3 Premium Option: For the Premium benefit option – the table not earning any income below applies to disabilities resulting from sickness or injury. 3 Federal Reserve, Report on the Economic Well-Being of U.S. Age Disabled Maximum Benefit Duration Households in 2018 Prior to 63 To Normal Retirement Age or 48 months if ELIGIBILITY AND ENROLLMENT greater Eligibility Age 63 To Normal Retirement Age or 42 months if You are eligible if you are an active employee who works at least greater 20 hours per week on a regularly scheduled basis. Age 64 36 months Age 65 30 months Enrollment Age 66 27 months You can enroll in coverage within 31 days of your date of hire or Age 67 24 months during your annual enrollment period. Age 68 21 months Age 69 and older 18 months Effective Date Coverage goes into effect subject to the terms and conditions of Mental Illness, Alcoholism and Substance Abuse, Self- Reported the policy. You must satisfy the definition of Actively at Work or Subjective Illness with your employer on the day your coverage takes effect. You can receive benefit payments for Long-Term Disabilities resulting from mental illness, alcoholism and substance abuse Actively at Work for a total of 12 months for all disability periods during your You must be at work with your Employer on your regularly lifetime. scheduled workday. On that day, you must be performing for wage or profit all of your regular duties in the usual way and for Any period of time that you are confined in a hospital or other facility licensed to provide medical care for mental illness, your usual number of hours. If school is not in session due to normal vacation or school break(s), Actively at Work shall mean alcoholism and substance abuse does not count toward the 12 you are able to report for work with your Employer, performing month lifetime limit. all of the regular duties of Your Occupation in the usual way for your usual number of hours as if school was in session.

Partial Disability Partial Disability is covered provided you have at least a 20% loss of earnings and duties of your job. 45

Long Term Disability Other Important Benefits Survivor Benefit - If you die while receiving disability benefits, a benefit will be paid to your spouse or child under age 26, equal to three times your 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. Workplace Modification provides for reasonable modifications made to a workplace to accommodate your disability and allow you to return to active full-time employment.

Recurrent Disability What happens if I Recover but become Disabled again? Periods of Recovery during the Elimination Period will not interrupt the Elimination Period, if the number of days You return to work as an Active Employee are less than one-half (1/2) the number of days of Your Elimination Period. Any day within such period of Recovery, will not count toward the Elimination Period. Benefit Integration Your benefit may be reduced by other income you receive or are eligible to receive due to your disability, such as: • Social Security Disability Insurance • State Teacher Retirement Disability Plans • Workers’ Compensation • Other employer-based disability insurance coverage you may have • Unemployment benefits • Retirement benefits that your employer fully or partially pays for (such as a pension plan) Your plan includes a minimum monthly benefit of $100. General 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

PROVISIONS OF THE PLAN Definition of Disability Disability is defined as 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, Termination Provisions pregnancy or other medical conditions covered by the insurance, Your coverage under the plan will end if: and as a result, your current monthly earnings are 80% or less of • The group plan ends or is discontinued your pre-disability earnings. • You voluntarily stop your coverage One you have been disabled for 24 months, you must be prevented • You are no longer eligible for coverage from performing one or more essential duties of any occupation, • You do not make the required premium payment and as a result, your monthly earnings are 66 2/3% or less of your • Your active employment stops, except as stated in the pre-disability earnings. continuation provision in the policy Pre-Existing Condition Limitation 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 been insured under this policy for 12 months before your disability begins. If your disability is a result of a pre-existing condition, we will pay benefits for a maximum of 4 weeks. Continuity of Coverage If you were insured under your district’s prior plan and not receiving benefits the day before this policy is effective, there will not be a loss in coverage and you will get credit for your prior carrier’s coverage. 46

The Hartford® is The Hartford Financial Services Group, Inc. and its subsidiaries, including underwriting company Hartford Life and Accident Insurance Company. Home Office is Hartford, CT. All benefits are subject to the terms and conditions of the policy. Policies underwritten by the underwriting company listed above detail exclusions, limitations, reduction of benefits and terms under which the policies may be continued in force or discontinued. This Benefit Highlights Sheet 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 Benefit Highlights Sheet and the policy, the terms of the policy apply. Complete details are in the Certificate of Insurance issued to each insured individual and the Master Policy as issued to the policyholder. Benefits are subject to state availability. © 2020 The Hartford.

Long Term Disability Jacksonville Independent School District Premium Option – Monthly Premium Cost (based on 12 payments per year) - Rates effective 9/1/2016 Accident / Sickness Elimination Period in Days Annual Monthly Monthly Earnings Earnings Benefit $3,600

$300

$200

0/7

14/14

30/30

60/60

90/90

180/180

$6.20

$5.28

$3.96

$2.24

$1.72

$1.36

Accident / Sickness Elimination Period in Days Annual Monthly Monthly Earnings Earnings Benefit

0/7

14/14

30/30

60/60

90/90

180/180

$75,600 $6,300

$4,200 $130.20 $110.88 $83.16

$47.04

$36.12

$28.56

$4,300 $133.30 $113.52 $85.14

$48.16

$36.98

$29.24

$5,400

$450

$300

$9.30

$7.92

$5.94

$3.36

$2.58

$2.04

$77,400 $6,450

$7,200

$600

$400

$12.40

$10.56

$7.92

$4.48

$3.44

$2.72

$79,200 $6,600

$4,400 $136.40 $116.16 $87.12

$49.28

$37.84

$29.92

$9,000

$750

$500

$15.50

$13.20

$9.90

$5.60

$4.30

$3.40

$81,000 $6,750

$4,500 $139.50 $118.80 $89.10

$50.40

$38.70

$30.60

$10,800

$900

$600

$18.60

$15.84

$11.88

$6.72

$5.16

$4.08

$82,800 $6,900

$4,600 $142.60 $121.44 $91.08

$51.52

$39.56

$31.28

$12,600 $1,050

$700

$21.70

$18.48

$13.86

$7.84

$6.02

$4.76

$84,600 $7,050

$4,700 $145.70 $124.08 $93.06

$52.64

$40.42

$31.96

$14,400 $1,200

$800

$24.80

$21.12

$15.84

$8.96

$6.88

$5.44

$86,400 $7,200

$4,800 $148.80 $126.72 $95.04

$53.76

$41.28

$32.64

$16,200 $1,350

$900

$27.90

$23.76

$17.82

$10.08

$7.74

$6.12

$88,200 $7,350

$4,900 $151.90 $129.36 $97.02

$54.88

$42.14

$33.32

$5,000 $155.00 $132.00 $99.00

$56.00

$43.00

$34.00

$18,000 $1,500

$1,000

$31.00

$26.40

$19.80

$11.20

$8.60

$6.80

$90,000 $7,500

$19,800 $1,650

$1,100

$34.10

$29.04

$21.78

$12.32

$9.46

$7.48

$91,800 $7,650

$5,100 $158.10 $134.64 $100.98 $57.12

$43.86

$34.68

$21,600 $1,800

$1,200

$37.20

$31.68

$23.76

$13.44

$10.32

$8.16

$93,600 $7,800

$5,200 $161.20 $137.28 $102.96 $58.24

$44.72

$35.36

$5,300 $164.30 $139.92 $104.94 $59.36

$45.58

$36.04

$23,400 $1,950

$1,300

$40.30

$34.32

$25.74

$14.56

$11.18

$8.84

$95,400 $7,950

$25,200 $2,100

$1,400

$43.40

$36.96

$27.72

$15.68

$12.04

$9.52

$97,200 $8,100

$5,400 $167.40 $142.56 $106.92 $60.48

$46.44

$36.72

$27,000 $2,250

$1,500

$46.50

$39.60

$29.70

$16.80

$12.90

$10.20

$99,000 $8,250

$5,500 $170.50 $145.20 $108.90 $61.60

$47.30

$37.40

$5,600 $173.60 $147.84 $110.88 $62.72

$48.16

$38.08

$28,800 $2,400

$1,600

$49.60

$42.24

$31.68

$17.92

$13.76

$10.88

$100,800 $8,400

$30,600 $2,550

$1,700

$52.70

$44.88

$33.66

$19.04

$14.62

$11.56

$102,600 $8,550

$5,700 $176.70 $150.48 $112.86 $63.84

$49.02

$38.76

$32,400 $2,700

$1,800

$55.80

$47.52

$35.64

$20.16

$15.48

$12.24

$104,400 $8,700

$5,800 $179.80 $153.12 $114.84 $64.96

$49.88

$39.44

$34,200 $2,850

$1,900

$58.90

$50.16

$37.62

$21.28

$16.34

$12.92

$106,200 $8,850

$5,900 $182.90 $155.76 $116.82 $66.08

$50.74

$40.12

$6,000 $186.00 $158.40 $118.80 $67.20

$51.60

$40.80

$36,000 $3,000

$2,000

$62.00

$52.80

$39.60

$22.40

$17.20

$13.60

$108,000 $9,000

$37,800 $3,150

$2,100

$65.10

$55.44

$41.58

$23.52

$18.06

$14.28

$109,800 $9,150

$6,100 $189.10 $161.04 $120.78 $68.32

$52.46

$41.48

$39,600 $3,300

$2,200

$68.20

$58.08

$43.56

$24.64

$18.92

$14.96

$111,600 $9,300

$6,200 $192.20 $163.68 $122.76 $69.44

$53.32

$42.16

$6,300 $195.30 $166.32 $124.74 $70.56

$54.18

$42.84

$41,400 $3,450

$2,300

$71.30

$60.72

$45.54

$25.76

$19.78

$15.64

$113,400 $9,450

$43,200 $3,600

$2,400

$74.40

$63.36

$47.52

$26.88

$20.64

$16.32

$115,200 $9,600

$6,400 $198.40 $168.96 $126.72 $71.68

$55.04

$43.52

$45,000 $3,750

$2,500

$77.50

$66.00

$49.50

$28.00

$21.50

$17.00

$117,000 $9,750

$6,500 $201.50 $171.60 $128.70 $72.80

$55.90

$44.20

$6,600 $204.60 $174.24 $130.68 $73.92

$56.76

$44.88

$46,800 $3,900

$2,600

$80.60

$68.64

$51.48

$29.12

$22.36

$17.68

$118,800 $9,900

$48,600 $4,050

$2,700

$83.70

$71.28

$53.46

$30.24

$23.22

$18.36

$120,600 $10,050 $6,700 $207.70 $176.88 $132.66 $75.04

$57.62

$45.56

$50,400 $4,200

$2,800

$86.80

$73.92

$55.44

$31.36

$24.08

$19.04

$122,400 $10,200 $6,800 $210.80 $179.52 $134.64 $76.16

$58.48

$46.24

$59.34

$46.92

$52,200 $4,350

$2,900

$89.90

$76.56

$57.42

$32.48

$24.94

$19.72

$124,200 $10,350 $6,900 $213.90 $182.16 $136.62 $77.28

$54,000 $4,500

$3,000

$93.00

$79.20

$59.40

$33.60

$25.80

$20.40

$126,000 $10,500 $7,000 $217.00 $184.80 $138.60 $78.40

$60.20

$47.60

$55,800 $4,650

$3,100

$96.10

$81.84

$61.38

$34.72

$26.66

$21.08

$127,800 $10,650 $7,100 $220.10 $187.44 $140.58 $79.52

$61.06

$48.28

$57,600 $4,800

$3,200

$99.20

$84.48

$63.36

$35.84

$27.52

$21.76

$129,600 $10,800 $7,200 $223.20 $190.08 $142.56 $80.64

$61.92

$48.96

$62.78

$49.64

$59,400 $4,950

$3,300 $102.30 $87.12

$65.34

$36.96

$28.38

$22.44

$131,400 $10,950 $7,300 $226.30 $192.72 $144.54 $81.76

$61,200 $5,100

$3,400 $105.40 $89.76

$67.32

$38.08

$29.24

$23.12

$133,200 $11,100 $7,400 $229.40 $195.36 $146.52 $82.88

$63.64

$50.32

$63,000 $5,250

$3,500 $108.50 $92.40

$69.30

$39.20

$30.10

$23.80

$135,000 $11,250 $7,500 $232.50 $198.00 $148.50 $84.00

$64.50

$51.00

$65.36

$51.68

$64,800 $5,400

$3,600 $111.60 $95.04

$71.28

$40.32

$30.96

$24.48

$136,800 $11,400 $7,600 $235.60 $200.64 $150.48 $85.12

$66,600 $5,550

$3,700 $114.70 $97.68

$73.26

$41.44

$31.82

$25.16

$138,600 $11,550 $7,700 $238.70 $203.28 $152.46 $86.24

$66.22

$52.36

$68,400 $5,700

$3,800 $117.80 $100.32 $75.24

$42.56

$32.68

$25.84

$140,400 $11,700 $7,800 $241.80 $205.92 $154.44 $87.36

$67.08

$53.04

$142,200 $11,850 $7,900 $244.90 $208.56 $156.42 $88.48

$67.94

$53.72

$144,000 $12,000 $8,000 $248.00 $211.20 $158.40 $89.60

$68.80

$54.40

$70,200 $5,850

$3,900 $120.90 $102.96 $77.22

$43.68

$33.54

$26.52

$72,000 $6,000

$4,000 $124.00 $105.60 $79.20

$44.80

$34.40

$27.20

$73,800 $6,150

$4,100 $127.10 $108.24 $81.18

$45.92

$35.26

$27.88

METLIFE

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 48 details on covered expenses, limitations and exclusions are included in the summary plan description located on the Goose Creek CISD Benefits Website: www.mybenefitshub.com/goosecreekcisd

Cancer GOOSE CREEK ISD GROUP CANCER MONTHLY RATES Effective Date - 09/01/2021 Situs State - TX Variable Benefit Elections Benefit Low High Hospital Confinement $100 per day $200 per day up Surgical up to $1,500 to $3,000 Radiation/Chemotherapy $500 per day $500 per day First Diagnosis $2,500 $5,000 Colony Stimulating Factors $500 per month $1,000 per month Miscellaneous Diagnostic $5,000 $5,000 Services Self-Administered Drugs $1,000 per month $1,000 per month Wellness $50 per year $50 per year Combined Premiums Base Plan + Intensive Care Rider (ICR- $325 per day) Coverage Tier Low + $325 ICR High + $325 ICR Employee $16.28 $21.84 Employee + Spouse $33.17 $44.54 Employee + Child(ren) $22.80 $29.74 Family $39.66 $52.42 Residents of most states will be covered by the situs state plan. Residents of certain states will be covered by a state specific certificate of insurance due to these states having extraterritorial laws. Underwritten by: Metropolitan Life Insurance Company Administered by: Bay Bridge Administrators P.O. Box 161690 - Austin, Texas 78716 - (800) 845-7519

Please be aware that the Group Policy and Certificate contain specific conditions, definitions, maximums, limitations, exclusions and proof requirements for the benefits described below. Throughout this outline, “you” and “your” refer to the employee who becomes insured for cancer and specified disease expense insurance. The term “covered person” refers to a person for whom insurance is in effect under the Group Policy. 4. EXCLUSIONS AND LIMITATIONS. Exceptions and Other Limitations. The Group Policy and Certificate pay benefits only for diagnoses, treatment and services resulting from cancer or specified diseases, as defined in the policy. It does not cover: • any other disease or sickness; • injuries; • unless otherwise defined in the certificate, any disease, condition, or incapacity that has been caused, complicated, worsened, or affected by: • specified disease or specified disease treatment; or • cancer or cancer treatment; • care and treatment received outside the United States or its territories; • care and treatment performed by You, Your Spouse or any member of Your immediate family including Your and/or Your Spouse’s parents, children (natural, step or adopted); siblings; grandparents; or grandchildren; or • treatment not prescribed by a physician; or experimental treatment by any program that does not qualify as new and experimental treatment as defined in the policy.

GROUP CANCER AND SPECIFIED DISEASE EXPENSE INSURANCE

Pre-Existing Condition Limitation. During the first 12 months that coverage under the certificate is in effect for a covered person no benefits will be payable for a loss due to a Pre-Existing Condition. GROUP POLICY FORM NO: GP18-BB-SD Pre-Existing Condition - means a disease or physical condition, for which GROUP CERTIFICATE FORM NO: GCERT18-BB-SD/CAN a covered person has received medical advice, treatment, care, services, THE CERTIFICATE OF INSURANCE PROVIDES LIMITED BENEFITS – BENEFITS or for which diagnostic test(s) have been recommended during the 12 PROVIDED ARE SUPPLEMENTAL AND ARE NOT INTENDED TO COVER ALL MEDICAL months immediately preceding the effective date of insurance for each EXPENSES. YOU SHOULD HAVE MEDICAL COVERAGE IN FORCE WHEN YOU covered person. ENROLL FOR THIS INSURANCE. THE CERTIFICATE IS NOT A MEDICARE SUPPLEMENT CONTRACT. IF YOU ARE ELIGIBLE FOR MEDICARE, REVIEW THE GUIDE TO HEALTH INSURANCE FOR PEOPLE WITH MEDICARE AVAILABLE FROM METLIFE. RECEIPT OF GROUP CANCER AND SPECIFIED DISEASE EXPENSE INSURANCE BENEFITS MAY AFFECT ELIGIBILITY FOR MEDICAID AND OTHER GOVERNMENTAL BENEFITS AND ENTITLEMENTS. ACCORDINGLY, PERSONS WHO WISH TO MAINTAIN ELIGIBILITY FOR SUCH BENEFITS SHOULD NOT PURCHASE THE COVERAGE MADE AVAILABLE UNDER THE GROUP POLICY.

TERMINATION DATES. Your insurance under the Group Policy and Certificate will automatically terminate on the earliest of the following dates: • the date that the policy terminates; • the date of termination of any section or part of the policy with respect to insurance under such section or part; • the premium due date that coincides with or next follows the date OUTLINE OF COVERAGE that you cease to be a member of an eligible class; or 1. READ YOUR CERTIFICATE CAREFULLY! This outline of coverage provides • any premium due date, if premium remains unpaid by the end of a very brief description of the important features of the coverage. This the grace period. is not the insurance contract and only the actual provisions of the The Certificate also sets forth termination provisions for dependents. Group Policy and Certificate under which you have coverage will control. The Certificate sets forth in detail the rights and obligations of PORTABILITY. If your insurance ends, you may keep it in force under certain circumstances as described in the Certificate. both you and Metropolitan Life Insurance Company (“MetLife”).

2. CANCER AND SPECIFIED DISEASE INSURANCE COVERAGE. Policies of this category are designed to provide to persons insured, restricted coverage, paying benefits only when certain losses occur as a result of diagnosis of cancer or a specified disease.

ADMINISTRATION OF INSURANCE. Some services in connection with this insurance may be performed by our third-party administrator(s). This service arrangement in no way alters Metropolitan Life Insurance Company's obligation to you. Services will not be performed by our third -party administrator(s) if prohibited by mutual agreement with a group customer.

3. BENEFITS. The benefits listed in the attached Benefits Summary are primarily payable for certain losses as a result of a diagnosis of cancer PREMIUMS. Premium rates are based on your age on the effective date or a specified disease covered under the policy. Benefits are payable based on a positive diagnosis of cancer or specified disease made after of coverage and are shown in the enclosed materials. Premium rates are subject to change as stated in the policy. 49 the covered person’s effective date of insurance.

Cancer- Low Plan BENEFITS SUMMARY Low Plan The term “Incurred Expense” refers to charges that are solely your responsibility, or expenses that are a combination of insurance reimbursement and your responsibility such as deductibles or co-payments. The fee negotiated between your major medical insurer and medical providers, as reflected on an explanation of benefits from such insurer, would be considered the Incurred Expense. BENEFIT Positive Diagnosis Test Second and Third Surgical Opinions Non-Local Transportation

Adult Companion Lodging and Transportation

Ambulance Donor Benefit Bone Marrow and Stem Cell Transplant

Bone Marrow and Peripheral Stem Cell Transplant Anesthesia

Ambulatory Surgical Center Drugs and Medicine Outpatient Anti-Nausea Drugs Miscellaneous Diagnostic Services Self-Administered Drugs Blood, Plasma, and Platelets Physician's Attendance Private Duty Nursing Services National Cancer Institute Designated Comprehensive Cancer Treatment Center Evaluation/Consultation Benefit

BENEFIT AMOUNT The provider’s actual billed charge, up to $300 per covered person per calendar year The Incurred Expense for the opinion a) The actual billed charges for round trip coach fare on a common carrier; or b) 50 cents per mile for round-trip personal vehicle transportation for round trips over 60 miles a) For lodging: The actual billed charges up to $75 per day for a single room in a motel, hotel, or other accommodations, to a maximum stay of 60 days. b) For transportation: • the actual billed charges for a round trip coach fare on a common carrier; or • a personal vehicle allowance of 50 cents per mile for up to 700 miles per hospital stay The Incurred Expenses for the ambulance service a) Two times the hospital confinement benefit shown on the Certificate schedule for each day both the covered person and the donor are hospitalized for the transplant b) For transportation: • actual billed charges for round trip coach fare on a common carrier to the city where the transplant is performed; or • personal vehicle allowance of 50 cents per mile up to 700 miles per hospital stay; and (c) actual billed charges for lodging and meals for the donor to remain near hospital up to $50 per day The Incurred Expense up to a combined lifetime maximum per covered person of $15,000 a) For anesthesia for skin cancer that is not invasive melanoma: $100 per covered person. b) For anesthesia for all other surgery: 25% of the amount paid by us for the surgery $250 per covered person $25 per day per covered person for each day of confinement for a calendar year maximum per covered person of $600 The actual billed charges, up to $250 per covered person per calendar year The Incurred Expense up to a lifetime maximum of $5,000 per covered person The Incurred Expense up to $1,000 per calendar month per covered person The Incurred Expense up to $200 per covered person per day $35 per covered person per day $100 per covered person per day a) For the evaluation: The actual billed charges, up to a lifetime maximum per covered person up to $750 b) For transportation and lodging: The actual billed charges, up to a lifetime maximum per covered person up to $350

Cancer BENEFIT Breast Prosthesis Artificial Limb or Prosthesis Physical Therapy or Speech Therapy Extended Benefits Extended Care Facility At Home Nursing

New and Experimental Treatment Hospice Care Government or Charity Hospital or Outpatient Clinic Hairpiece Rental or Purchase of Durable Goods Waiver of Premium Surgery

First Diagnosis Benefit Radiation/Chemotherapy/Immunotherapy

Hospital Confinement

The Incurred Expense up to $500 per day per covered person The Incurred Expense up to $500 per calendar month per covered person The daily benefit amount $100 per day per covered person

Wellness Benefit

For dependent children under the age of 21 the benefit is two (2) times the daily hospital confinement benefit $50 per calendar year per covered person.

Colony-Stimulating Factors

BENEFITS PROVIDED BY RIDER RIDER INTENSIVE CARE UNIT (ICU) BENEFIT RIDER Included

BENEFIT ICU daily benefit amount (used to determine benefits payable): $325 per covered person per day of confinement. Confinement for treatment of Cancer or Specified Disease pays 2 times the ICU daily benefit amount per day of confinement. Payable for up to 45 days of confinement per period of confinement.

Cancer- Low Plan BENEFITS SUMMARY High Plan The term “Incurred Expense” refers to charges that are solely your responsibility, or expenses that are a combination of insurance reimbursement and your responsibility such as deductibles or co-payments. The fee negotiated between your major medical insurer and medical providers, as reflected on an explanation of benefits from such insurer, would be considered the Incurred Expense. BENEFIT Positive Diagnosis Test Second and Third Surgical Opinions Non-Local Transportation

Adult Companion Lodging and Transportation

Ambulance Donor Benefit Bone Marrow and Stem Cell Transplant

Bone Marrow and Peripheral Stem Cell Transplant Anesthesia

Cancer BENEFIT Breast Prosthesis Artificial Limb or Prosthesis Physical Therapy or Speech Therapy Extended Benefits Extended Care Facility At Home Nursing

New and Experimental Treatment Hospice Care Government or Charity Hospital or Outpatient Clinic Hairpiece Rental or Purchase of Durable Goods Waiver of Premium Surgery

First Diagnosis Benefit Radiation/Chemotherapy/Immunotherapy Colony-Stimulating Factors Hospital Confinement

Wellness Benefit BENEFITS PROVIDED BY RIDER RIDER INTENSIVE CARE UNIT (ICU) BENEFIT RIDER Included

BENEFIT AMOUNT The Incurred Expenses The actual billed charges, up to $1,500 lifetime maximum per covered person per amputated limb $35 per covered person per day Three times the hospital confinement benefit shown on the Certificate schedule $50 per covered person per day, not to exceed the number of days that the hospital confinement benefit was paid $100 per day per covered person, not to exceed the number of days that the hospital confinement benefit was paid The actual billed charges, up to $7,500 per covered person per calendar year $50 per covered person per day $200 per covered person per day The actual billed charges up to the lifetime maximum of $150 per covered person The Incurred Expenses up to $1,500 per covered person per calendar year Included Up to $3,000 per covered person for surgery based on the following: For inpatient surgery: The lesser of: • the amount listed on the surgical schedule shown in the Certificate for the applicable surgery; and • the surgeon’s actual billed charges for the surgery. For outpatient surgery: 150% of the surgery benefit payable for inpatient surgery. However, we will not pay an amount which exceeds the surgeon’s actual billed charges for the surgery. $5,000 per covered person The Incurred Expense up to $500 per day per covered person The Incurred Expense up to $1,000 per calendar month per covered person The daily benefit amount $100 per day per covered person For dependent children under the age of 21 the benefit is two (2) times the daily hospital confinement benefit $50 per calendar year per covered person. BENEFIT ICU daily benefit amount (used to determine benefits payable): $325 per covered person per day of confinement. Confinement for treatment of Cancer or Specified Disease pays 2 times the ICU daily benefit amount per day of confinement. Payable for up to 45 days of confinement per period of confinement.

GOC18-BB-SD/CAN

METLIFE 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 Goose Creek CISD Benefits Website: www.mybenefitshub.com/goosecreekcisd

Accident Accident Insurance Benefits that may help cover costs such as those not covered by your medical plan.

PLAN SUMMARY Goose Creek CISD Effective 9/1/2021

Accident Insurance Benefits With MetLife, you’ll have a choice of two plans (called the “Low Plan” and the “High Plan”) that provide payments in addition to any other insurance payments you may receive1. Here are just some of the covered events/services2. Benefit Type Accidental Injury Benefits Fracture* (depending on the fracture and type of repair) Dislocation* (depending on the dislocation and type of repair) Second- or Third- Degree Burn (depending on degree of burn and percentage of burnt skin) Concussion Coma Laceration (depending on the length of the cut and type of repair) Broken Tooth

Eye Injury Accident - Medical Services & Treatment Benefits Ambulance Emergency Care (depending on location of care) Non-Emergency Initial Care Physician Follow-Up Therapy Services (including physical therapy) Medical Testing Medical Appliances (depending on the appliance) Transportation Benefit Type Pain Management (for epidural anesthesia) Prosthetic Device Modification Blood/Plasma/Platelets Surgical Repair (depending on the type of surgery) Exploratory Surgery Other Outpatient Surgery Hospital Benefits* Admission Intensive Care Unit (ICU) Supplemental Admission Confinement (paid for up to 15 days per accident) ICU Supplemental Confinement (paid for up to 15 days per accident) Inpatient Rehabilitation (paid for up to 15 days per accident)

Low Plan Benefits

High Plan Benefits

$100 – $8,000

$200 – $10,000

$100 – $8,000

$200 – $10,000

$75 – $10,000 $250 $7,500

$100 – $15,000 $500 $10,000

$50 – $400 Crown: $200 / Filling: $25 / Extraction: $100 $300

$75 – $700 Crown: $300 / Filling: $50 / Extraction: $150 $400

Ground: $300 / Air: $1,000 $75 – $150 $75 $75 $35 $150 $75 – $750 $300 Low Plan Benefits $75 One device: $750 More than one device: $1,500 $1,000 $400

Ground: $400 / Air: $1,250 $100 – $200 $100 $100 $50 $200 $150 – $1,000 $400 High Plan Benefits $100 One device: $1,000 More than one device: $2,000 $1,500 $500

$150-$1,500 $150 $300

$200-$2,000 $200 $400

$1,000 for the day of admission $1,000 for the day of admission $200 per day

$1,500 for the day of admission $1,500 for the day of admission $300 per day

$200 per day

$300 per day

$150 per day

$200 per day 55

Accident Benefit Type Accidental Death Benefit Accidental Death Benefit* Accidental Dismemberment, Functional Loss & Paralysis Benefits Dismemberment/Functional Loss (depending on the injury) Paralysis (depending on the number of limbs) Other Benefits Lodging Benefit* - for a companion of a covered person who is hospitalized

Low Plan Benefits

High Plan Benefits

$25,000 $75,000 for accidental death on common carrier* Accidental Dismemberment, Functional Loss & Paralysis Benefits

$50,000 $150,000 for accidental death on common carrier* Accidental Dismemberment, Functional Loss & Paralysis Benefits

$750 - $20,000

$1,000 - $40,000

$10,000 - $20,000 Other Benefits $100 per day

$20,000 - $40,000 Other Benefits $200 per day

Organized Sports Activity Injury Benefit Rider This coverage includes an Organized Sports Activity Benefit Rider. The rider increases the amount payable under the Certificate for certain benefits by 25% for injuries resulting from an accident that occurred while participating as a player in an organized sports activity. The rider sets forth terms, conditions and limitations, including the covered persons to whom the rider applies. * Notes Regarding Certain Benefits • Fracture and Dislocation benefits – Chip fractures are paid at 25% of the applicable fracture benefit and partial dislocations are paid at 25% of the applicable dislocation benefit. • Hospital Benefits – Hospital does not include certain facilities such as nursing homes, convalescent care or extended care facilities. See MetLife’s Disclosure Statement or Outline of Coverage/Disclosure Document for full details. • Accidental Death Benefit – The benefit amount will be reduced by the amount of any accidental dismemberment/functional loss/paralysis benefits and modification benefit paid for injuries sustained by the covered person in the same accident for which the accidental death benefit is being paid. • Common Carrier Benefit - Common Carrier refers to airplanes, trains, buses, trolleys, subways and boats. Certain conditions apply. See your Disclosure Statement or Outline of Coverage/Disclosure Document for specific details. Be sure to review other information contained in this booklet for more details about plan benefits, monthly rates and other terms and conditions. • Lodging Benefit – The lodging benefit is not available in all states. It provides a benefit for a companion accompanying a covered insured while hospitalized, provided that lodging is at least 50 miles from the insured’s primary residence. • Organized Sports Activity Injury Benefit Rider – The rider is not available in all states. Proof of registration in an Organized Sports Activity in which an Accident occurred is required at time of claim. See your certificate for details.

Accident Benefit Payment Example Kathy’s daughter, Molly, was riding her bike to school. On her way there she fell to the ground, was knocked unconscious, and was taken to the local emergency room (ER) by ambulance for treatment. The ER doctor diagnosed a concussion and a broken tooth. He ordered a CT scan to check for facial fractures too, since Molly’s face was very swollen. Molly was released to her primary care physician for follow-up treatment, and her dentist repaired her broken tooth with a crown. Depending on her health insurance, Kathy’s out-of-pocket costs could run into hundreds of dollars to cover expenses like insurance co-payments and deductibles. MetLife Group Accident Insurance payments can be used to help cover these unexpected costs. Covered Event3 Ambulance (ground) Emergency Care Physician Follow-Up ($100 x 2) Medical Testing Concussion Broken Tooth (repaired by crown) Benefits paid by MetLife Group Accident Insurance

Benefit Amount $400 $200 $200 $200 $500 $300 $1,800

Benefit amount is based on a sample MetLife plan design. Actual plan design and benefits may vary.

Questions & Answers Q. Who is eligible to enroll for this accident coverage? A. You are eligible to enroll yourself and your eligible family members!4 You need to enroll during your Enrollment Period and to be actively at work for your coverage to be effective. Q. How do I pay for my accident coverage? A. Premiums will be paid through payroll deduction, so you don’t have to worry about writing a check or missing a payment. Q. What happens if my employment status changes? Can I take my coverage with me? A. Yes, you can take your coverage with you.5 You will need to continue to pay your premiums to keep your coverage in force. Your coverage will only end if you stop paying your premium or if your employer offers you similar coverage with a different insurance carrier. Q. Who do I call for assistance? A. Contact a MetLife Customer Service Representative at 1 800- GET-MET8 (1-800-438-6388), Monday through Friday from 8:00 a.m. to 8:00 p.m., EST. Or visit our website: mybenefits.metflife.com.

Insurance Rates MetLife offers group rates and payroll deduction, so you don’t have to worry about writing a check or missing a payment! Your employee rates are outlined below. Accident Insurance Coverage Options Employee Employee & Spouse Employee & Child(ren) Employee & Spouse/Child(ren)

Monthly Cost to You Low Plan $5.22 $10.32 $12.04 $14.68

High Plan $7.48 $14.70 $17.06 $20.84

1 Covered services/treatments must be the result of a covered accident as defined in the group policy/certificate. See your Disclosure Statement or Outline of Coverage/Disclosure Document for full details. 2 Availability of benefits varies by state. See your Disclosure Statement or Outline of Coverage/Disclosure Document for state variations. 3 Benefits and amounts are based on sample MetLife plan design. Plan design and plan benefits may vary. 4 Coverage is guaranteed provided (1) the employee is actively at work and (2) dependents to be covered are not subject to medical restrictions as set forth on the enrollment form and in the Certificate. Some states require the insured to have medical coverage. Children may be covered to age 26. There are benefit reductions that may begin at age 65. 5 Eligibility for portability through the Continuation of Insurance with Premium Payment provision may be subject to certain eligibility requirements and limitations. For more information, contact your MetLife representative. METLIFE’S ACCIDENT INSURANCE IS A LIMITED BENEFIT GROUP INSURANCE POLICY. The policy is not intended to be a substitute for medical coverage and certain states may require the insured to have medical coverage to enroll for the coverage. The policy or its provisions may vary or be unavailable in some states. Like most group accident and health insurance policies, policies offered by MetLife may include waiting periods and contain certain exclusions, limitations and terms for keeping them in force. For complete details of coverage and availability, please refer to the group policy form GPNP12-AX or contact MetLife. Benefits are underwritten by Metropolitan Life Insurance Company, New York, NY. Hospital does not include certain facilities such as nursing homes, convalescent care or extended care facilities. See MetLife’s Disclosure Statement or Outline of Coverage/Disclosure Document for full details.

UNUM YOUR BENEFITS PACKAGE

Critical Illness

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 58 details on covered expenses, limitations and exclusions are included in the summary plan description located on the Goose Creek CISD Benefits Website: www.mybenefitshub.com/goosecreekcisd

Critical Illness Goose Creek Consolidated Independent Critical Illness Plan Highlights Critical Illness insurance provides financial protection by paying a lump sum benefit if you are diagnosed with a covered critical illness.

Who is eligible for this coverage?

All employees in active employment in the United States working at least 20 hours per week and their eligible spouses and children (up to age 26 regardless of student or marital status).

What are the Critical Illness coverage amounts?

The following coverage amounts are available. For you: Select one of the following $10,000, $20,000 or $30,000 For your Spouse: 100% of employee coverage amount For your Children: 100% of employee coverage amount

Can I be denied coverage?

Coverage is guarantee issue.

When is coverage effective?

Please see your Plan Administrator for your effective date of coverage. 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 critical illness conditions are covered?

Covered Conditions* Percentage of Coverage Amount Critical Illnesses Coronary Artery Disease (major) 50% Coronary Artery Disease (minor) 10% End Stage Renal (Kidney) Failure 100% Heart Attack (Myocardial Infarction) 100% Major Organ Failure Requiring Transplant 100% Stroke 100% Supplemental Critical Illnesses Benign Brain Tumor 100% Coma 100% Loss of Hearing 100% Loss of Sight 100% Loss of Speech 100% Infectious Disease 25% Occupational Human Immunodeficiency Virus (HIV) or Hepatitis 100% Permanent Paralysis 100% Progressive Diseases Amyotrophic Lateral Sclerosis (ALS) 100% Dementia (including Alzheimer’s Disease) 100% Functional Loss 100% Multiple Sclerosis (MS) 100% Parkinson’s Disease 100% Additional Critical Illnesses for your Children Cerebral Palsy 100% Cleft Lip or Palate 100% Cystic Fibrosis 100% Down Syndrome 100% Spina Bifida 100% *Please refer to the policy for complete definitions of covered conditions. Covered Condition Benefit The covered condition benefit is payable once per covered condition per insured. Unum will pay a covered condition benefit for a different covered condition if: • the new covered condition is medically unrelated to the first covered condition; or • the dates of diagnosis are separated by more than 180 days.

Critical Illness Reoccurring Condition Benefit We will pay the reoccurring condition benefit for the diagnosis of the same covered condition if the covered condition benefit was previously paid and the new date of diagnosis is more than 180 days after the prior date of diagnosis. The benefit amount for any reoccurring condition benefit is 100% of the percentage of coverage amount for that condition. The following Covered Conditions are eligible for a reoccurring condition benefit:

• • • • •

Benign Brain Tumor Coma Coronary Artery Disease (Major) Coronary Artery Disease (Minor) End Stage Renal (Kidney) Failure Option 1: How much does the coverage cost? $10,000 EE, $10,000 SP Age Employee Cost Spouse Cost Less than age 25 $1.10 $1.10 25-29 $1.40 $1.40 30-34 $1.80 $1.80 35-39 $2.50 $2.50 40-44 $3.40 $3.40 45-49 $4.80 $4.80 50-54 $6.60 $6.60 55-59 $8.50 $8.50 60-64 $12.50 $12.50 65-69 $19.90 $19.90 70-74 $37.10 $37.10 75-79 $64.00 $64.00 80-84 $110.60 $110.60 85 or over $202.90 $202.90 Option 2: $20,000 EE, $20,000 SP Age Employee Cost Spouse Cost Less than age 25 $2.20 $2.20 25-29 $2.80 $2.80 30-34 $3.60 $3.60 35-39 $5.00 $5.00 40-44 $6.80 $6.80 45-49 $9.60 $9.60 50-54 $13.20 $13.20 55-59 $17.00 $17.00 60-64 $25.00 $25.00 65-69 $39.80 $39.80 70-74 $74.20 $74.20 75-79 $128.00 $128.00 80-84 $221.20 $221.20 85 or over $405.80 $405.80

• Heart Attack (Myocardial Infarction) • Major Organ Failure Requiring Transplant • Stroke

Option 3: $30,000 EE, $30,000 SP Age Employee Cost Spouse Cost Less than age 25 $3.30 $3.30 25-29 $4.20 $4.20 30-34 $5.40 $5.40 35-39 $7.50 $7.50 40-44 $10.20 $10.20 45-49 $14.40 $14.40 50-54 $19.80 $19.80 55-59 $25.50 $25.50 60-64 $37.50 $37.50 65-69 $59.70 $59.70 70-74 $111.30 $111.30 75-79 $192.00 $192.00 80-84 $331.80 $331.80 85 or over $608.70 $608.70

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 your Spouse’s insurance age, which is their age immediately prior to and including the anniversary date/effective date.

Critical Illness Do my critical illness insurance benefits decrease with age?

Critical Illness benefits do not decrease due to age.

Are there any exclusions or limitations?

We will not pay benefits for a claim that is caused by, contributed to by, or occurs as a result of any of the following: • committing or attempting to commit a felony; • being engaged in an illegal occupation or activity; • injuring oneself intentionally or attempting or committing suicide, whether sane or not; • active participation in a riot, insurrection, or terrorist activity. This does not include civil commotion or disorder, injury as an innocent bystander, or Injury for self-defense; • participating in war or any act of war, whether declared or undeclared; • combat or training for combat while serving in the armed forces of any nation or authority, including the National Guard, or similar government organizations; • voluntary use of or treatment for voluntary use of any prescription or nonprescription drug, alcohol, poison, fume, or other chemical substance unless taken as prescribed or directed by the Insured’s Physician; • being intoxicated; and • a Date of Diagnosis that occurs while an Insured is legally incarcerated in a penal or correctional institution. Additionally, no benefits will be paid for a Date of Diagnosis that occurs prior to the coverage effective date. Pre-existing Conditions We will not pay benefits for a claim when the covered loss occurs in the first 12 months following an insured’s coverage effective date and the covered loss is caused by, contributed to by, or occurs as a result of any of the following: • a pre-existing condition; or • complications arising from treatment or surgery for, or medications taken for, a pre-existing condition. An insured has a pre-existing condition if, within the 3 months just prior to their coverage effective date, they have an injury or sickness, whether diagnosed or not, for which: • medical treatment, consultation, care or services, or diagnostic measures were received or recommended to be received during that period; • drugs or medications were taken, or prescribed to be taken during that period; or • symptoms existed. The pre-existing condition provision applies to any Insured’s initial coverage and any increases in coverage. Coverage effective date refers to the date any initial coverage or increases in coverage become effective.

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

If you have been insured for at least 12 months and your employment with your employer ends or you are no longer in an eligible group you can apply for ported coverage and pay the first premium within 31 days to continue coverage for yourself, your spouse and your children. If your spouse’s coverage ends as a result of your death, divorce or annulment, your spouse may elect to continue spouse and children coverage, as long as premium is paid as required.

When does my coverage end?

If you choose to cancel coverage, it will end on the first of the month following the date you provide notification to your employer. Otherwise, coverage ends on the earliest of: • the date the policy is cancelled by your employer; • the date you no longer are in an eligible group; • the date your eligible group is no longer covered; • the date of your death • the last day of the period any required contributions are made; • the last day you are in active employment. If you choose to cancel your Spouse’s coverage, it will end on the first of the month following the date you provide notification to your employer. Otherwise, your spouse’s coverage will end on the earliest of: • the date your coverage ends; • the date your spouse is no longer eligible for coverage; • the date your spouse no longer meets the definition of a spouse; • the date of your spouse’s death; or • the date of divorce or annulment. Your children’s coverage will end on the earliest of: • the date your coverage ends; • the date your children are no longer eligible for coverage; or • the date your children no longer meet the definition of children.

The limited benefits provided are a supplement to major medical coverage and are not a substitute for major medical coverage or other minimal essential coverage as required by federal law. Lack of minimal essential coverage may result in an additional tax payment being due. 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 GCIP16-1 et al or contact your Unum representative.© 2018 Unum Group. All rights reserved. Unum is a registered trademark and marketing brand of Unum Group and its insuring subsidiaries. Underwritten by Unum Insurance Company, Portland, MaineAE-1226 FOR EMPLOYEES

LINCOLN FINANCIAL GROUP

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 62 details on covered expenses, limitations and exclusions are included in the summary plan description located on the Goose Creek CISD Benefits Website: www.mybenefitshub.com/goosecreekcisd

Basic Life Goose Creek CISD provides this valuable benefit at no cost to you. Full-Time Employees

Term Life Insurance Safeguard the most important people in your life. Think about what your loved ones may face after you’re gone. Term life insurance can help them in so many ways, like covering everyday expenses, paying off debt, and protecting savings.

AT A GLANCE: • •

A cash benefit of $30,000 without providing evidence of insurability to your loved ones in the event of your death AD&D Plus - If you suffer an AD&D loss in an accident, you may also receive benefits for the following on top of your core AD&D benefits: coma, plegia, education, child care, spouse • training and more. • LifeKeys® services, which provide access to counseling, financial, and legal support • TravelConnect® services, which give you and your family access to emergency medical assistance when you're on a trip 100+ miles from home You also have the option to increase your cash benefit by securing additional coverage at affordable group rates. See the enclosed life insurance information for details.

ADDITIONAL DETAILS Conversion: You can convert your group term life coverage to an individual life insurance policy without providing evidence of insurability if you lose coverage due to leaving your job or for another reason outlined in the plan contract.

Continuation of Coverage: You may be able to continue your coverage if you leave your job for any reason other than sickness, injury, or retirement. Benefit Reduction: Coverage amounts begin to reduce at age 75 and benefits terminate at retirement. See the plan certificate for details. For complete benefit descriptions, limitations, and exclusions, refer to the certificate of coverage. This is not intended as a complete description of the insurance coverage offered. Controlling provisions are provided in the policy, and this summary does not modify those provisions or the insurance in any way. This is not a binding contract. A certificate of coverage will be made available to you that describes the benefits in greater detail. Refer to your certificate for your maximum benefit amounts. Should there be a difference between this summary and the contract, the contract will govern. LifeKeys® services are provided by ComPsych® Corporation, Chicago, IL. ComPsych®, EstateGuidance® and GuidanceResources® are registered trademarks of ComPsych® Corporation. TravelConnect® services are provided by On Call International, Salem, NH. ComPsych® and On Call International are not Lincoln Financial Group® companies. Coverage is subject to actual contract language. Each independent company is solely responsible for its own obligations. Insurance products (policy series GL1101) are issued by The Lincoln National Life Insurance Company (Fort Wayne, IN), which does not solicit business in New York, nor is it licensed to do so. Product availability and/or features may vary by state. Limitations and exclusions apply. Lincoln Financial Group is the marketing name for Lincoln National Corporation and its affiliates. Affiliates are separately responsible for their own financial and contractual obligations. Limitations and exclusions apply. Benefits Overview | The Lincoln National Life Insurance Company GP-ERPD-FLI001-TX - ©2020 Lincoln National Corporation - LCN-1821793-061517-Q1.0

Voluntary Life Full-Time Employees of Goose Creek CISD

What your benefits cover

Employee Coverage Guaranteed Life Insurance Coverage Amount The Lincoln Term Life Insurance Plan: • Initial Open Enrollment: When you are first offered this • Provides a cash benefit to your loved ones in the event of coverage, you can choose a coverage amount up to your death $300,000 without providing evidence of insurability. • Provides an additional cash benefit to your loved ones if • Annual Limited Enrollment: If you are a continuing you die — or to you if you lose a limb or your eyesight — in employee, you can increase your coverage amount by a covered accident $10,000 or • Features group rates for Goose Creek CISD employees • $20,000 without providing evidence of insurability . If you • Includes LifeKeys® services, which provide access to submitted evidence of insurability in the past and were counseling, financial, and legal support services declined for medical reasons, you may be required to • Also includes TravelConnect® services, which give you and submit evidence of insurability. your family access to emergency medical assistance when • If you decline this coverage now and wish to enroll later, you’re on a trip 100+ miles from home evidence of insurability may be required and may be at your own expense. • You can increase this amount by up to $20,000 during the Benefits At-A-Glance next limited open enrollment period. Employee Maximum Life Insurance Coverage Amount Guaranteed coverage amount • during initial offering or $300,000 approved special enrollment See the Evidence of Insurability page for details. period • Your coverage amount will reduce by 50% when you reach Newly hired employee $300,000 age 75 . guaranteed coverage amount Continuing employee Choice of $10,000 or $20,000 Spouse Coverage - You can secure term life insurance for your guaranteed coverage annual spouse if you select coverage for yourself. increase amount Guaranteed Life and AD&D Insurance Coverage Amount Maximum coverage amount 7 times your annual salary • Initial Open Enrollment: When you are first offered this ($500,000 maximum in coverage, you can choose a coverage amount up to 100% increments of $10,000) of your coverage amount ($75,000 maximum) for your Minimum coverage amount $10,000 spouse without providing evidence of insurability. • Annual Limited Enrollment: If you are a continuing Spouse employee, you can increase the coverage amount for your Guaranteed coverage amount spouse by during initial offering or $75,000 approved special enrollment • $5,000 or $10,000 without providing evidence of period insurability. If you submitted evidence of insurability in the Newly hired employee $75,000 past andwere declined for medical reasons, you may be guaranteed coverage amount required to submit evidence of insurability. Continuing employee Choice of $5,000 or $10,000 • If you decline this coverage now and wish to enroll later, guaranteed coverage annual evidence of insurability may be required and may be atyour increase amount own expense. 50% of the employee • You can increase this amount by up to $10,000 during the Maximum coverage amount coverage amount ($500,000 next limited open enrollment period. maximum in increments of Maximum Life Insurance Coverage Amount $5,000) • You can choose a coverage amount up to 50% of your Minimum coverage amount $5,000 coverage amount ($250,000 maximum) for your spouse Dependent Children with evidence of insurability 6 months to age 19 (to age 25 if full-time student) $10,000 Dependent Children Coverage - You can secure term life guaranteed coverage amount insurance for your dependent children when you choose Age 14 days to 6 months $500 coverage for yourself. guaranteed coverage amount Guaranteed Life Insurance Coverage Options: $10,000

Voluntary Term Life Insurance

Voluntary Life Additional Plan Benefits Accelerated Death Benefit Premium Waiver Conversion Portability

Included Included Included Included

Benefit Exclusions Like any insurance, this term life insurance policy does have exclusions. A suicide exclusion may apply. A complete list of benefit exclusions is included in the policy. State variations apply. This is not intended as a complete description of the insurance coverage offered. Controlling provisions are provided in the policy, and this summary does not modify those provisions or the insurance in any way. This is not a binding contract. A certificate of coverage will be made available to you that describes

the benefits in greater detail. Refer to your certificate for your maximum benefit amounts. Should there be a difference between this summary and the contract, the contract will govern. LifeKeys® services are provided by ComPsych® Corporation, Chicago, IL. TravelConnect® travel assistance services are provided by On Call International, Salem NH. On Call International must coordinate and provide all arrangements in order for eligible services to be covered. ComPsych® and On Call International are not Lincoln Financial Group companies and Lincoln Financial Group does not administer these Services. Each independent company is solely responsible for its own obligations. Coverage is subject to contract language that contains specific terms, conditions, and limitations. Insurance products (policy series GL1101) are issued by The Lincoln National Life Insurance Company (Fort Wayne, IN), which does not solicit business in New York, nor is it licensed to do so. Product availability and/or features may vary by state. Limitations and exclusions apply. ©2019 Lincoln National Corporation LCN-2016746-020518 R 1.0 – Group ID: 997734 Voluntary Life Insurance Benefits At-A-Glance LFE-ENRO-BRC001-TX

Monthly Voluntary Life Insurance Premium Here’s how little you pay with group rates. Employee |Monthly Premiums for Select Life Insurance Coverage Amounts Employee Age $10,000 $50,000 $150,000 $300,000 Range 0 -24 $0.41 $2.05 $6.15 $12.30 25-29 $0.52 $2.60 $7.80 $15.60 30-34 $0.74 $3.70 $11.10 $22.20 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 Employee Age Range 75 -79 Employee Age Range 80 -99

$400,000 $500,000 $16.40 $20.80 $29.60

$20.50 $26.00 $37.00

$0.86 $0.97 $1.52 $2.40 $4.61 $7.15 $13.89 $22.62

$4.30 $12.90 $25.80 $34.40 $4.85 $14.55 $29.10 $38.80 $7.60 $22.80 $45.60 $60.80 $12.00 $36.00 $72.00 $96.00 $23.05 $69.15 $138.30 $184.40 $35.75 $107.25 $214.50 $286.00 $69.45 $208.35 $416.70 $555.60 $113.10 $339.30 $678.60 $904.80

$43.00 $48.50 $76.00 $120.00 $230.50 $357.50 $694.50 $1131.00

$5,000

$25,000 $75,000 $150,000 $200,000 $250,000

$11.31

$56.55

$5,000

$25,000 $75,000 $150,000 $200,000 $250,000

$11.31

$56.55

$169.65 $339.30 $452.40 $565.50

Group Rates for Your Dependent Children

One affordable monthly premium covers all of your eligible dependent children. Note: You must be an active Goose Creek ISD employee to select coverage for a spouse and/or dependent children. To be eligible for coverage, a spouse or dependent child cannot be confined to a health care facility or unable to perform the typical activities of a healthy person of the same age and gender.

Spouse |Monthly Premiums for Select Life Insurance Coverage Amounts Employee Age $5,000 $20,000 $75,000 $250,000 Range 0 -24 $0.21 $0.82 $3.08 $10.25 25-29 $0.26 $1.04 $3.90 $13.00 30-34 $0.37 $1.48 $5.55 $18.50 35-39 $0.43 40-44 $0.49 45-49 $0.76 50-54 $1.20 55-59 $2.31 60-64 $3.58 65-69 $6.95 70-74 $11.31 Employee Age $2,500 Range 75 -79 $5.66 Employee Age $2,500 Range 80 -99 $5.66

$1.72 $1.94 $3.04 $4.80 $9.22 $14.30 $27.78 $45.24

$6.45 $7.28 $11.40 $18.00 $34.58 $53.63 $104.18 $169.65

$21.50 $24.25 $38.00 $60.00 $115.25 $178.75 $347.25 $565.50

$350,000 $500,000 $14.35 $18.20 $25.90

$20.50 $26.00 $37.00

$30.10 $33.95 $53.20 $84.00 $161.35 $250.25 $486.15 $791.70

$43.00 $48.50 $76.00 $120.00 $230.50 $357.50 $694.50 $1131.00

$10,000 $37,500 $125,000 $175,000 $250,000 $22.62

$84.83

$282.75 $395.85 $565.50

$10,000 $37,500 $125,000 $175,000 $250,000 $22.62

$84.83

$282.75 $395.85 $565.50

Dependent Children Monthly Premium for Life Insurance Coverage Coverage Amount

Monthly Premium

$10,000

$1.23

The Lincoln National Life Insurance Company Please see prior page for product information. Voluntary Life Insurance At-A-Glance LFE-ENRO-BRC001-TX

Voluntary AD&D Full-Time Employees of Goose Creek CISD

Benefit Exclusions

Like any insurance, this AD&D insurance policy does have exclusions. Benefits will not be paid if death results from The Lincoln AD&D Insurance Plan: suicide, or death/dismemberment occurs while: • Provides a cash benefit to your loved ones if you die in an • Intentionally inflicting or attempting to inflict injury to accident • one’s self • Provides a cash benefit to you if you suffer a covered loss • Participating in a war, act of war, or riot in an accident • Serving on full-time active duty in the armed forces of any • Features group rates for Goose Creek CISD employees state or country (this does not include duty of 30 days or • Includes LifeKeys® services, which provide access to less training in the Reserves or National Guard) counseling, financial, and legal support • Flying on any non-commercial airplane or aircraft, such as a SM • Also includes TravelConnect services, which give you and hot air balloon or glider (see the contract for details and your family access to emergency medical assistance when exceptions) you’re on a trip 100+ miles from home • Flying on a commercial airline or aircraft as a pilot or crewmember Benefits At-A-Glance • Committing or attempting to commit a felony Employee • Deliberately inhaling gas (such as carbon monoxide) or 7 times your annual salary using drugs other than those taken as prescribed by a Maximum coverage amount ($500,000maximum) in licensed physician $10,000 increments • Driving while intoxicated, impaired, or under the influence Minimum coverage amount $10,000 of drugs Your employee AD&D coverage amount will reduce by 50% In addition, this AD&D insurance policy does not cover sickness when you reach age 75. Benefits end when you retire. or disease, including the medical and surgical treatment of a disease. Spouse A complete list of benefit exclusions is included in the policy. 100% of the employee State variations apply. Maximum coverage amount coverage amount($500,000 maximum) in $5,000 increments This is not intended as a complete description of the insurance coverage Minimum coverage amount $5,000 offered. Controlling provisions are provided in the policy, and this summary You can secure AD&D insurance for your spouse if you select does not modify those provisions or the insurance in any way. This is not a coverage for yourself. binding contract. A certificate of coverage will be made available to you that describes the benefits in greater detail. Refer to your certificate for your The spouse AD&D coverage amount will reduce by 50% when maximum benefit amounts. Should there be a difference between this you reach age 75. Benefits end when you retire.

Voluntary AD&D Insurance

Dependent Children 6 months to age 26 Maximum coverage amount $10,000 Age 14 Days to 6 months Maximum coverage amount $500 You can secure AD&D insurance for your dependent children when you choose coverage for yourself. Additional Plan Benefits Safe Driver Benefit Education Benefit Spouse Training Benefit Child Care Benefit Coma Benefit Disappearance Benefit Common Carrier Benefit Repatriation Benefit

Included Included Included Included Included Included Included Included

Note: See the policy for details and specific requirements for each of these benefits 66

summary and the contract, the contract will govern. LifeKeys® services are provided by ComPsych® Corporation, Chicago, IL. TravelConnect® travel assistance services are provided by On Call International, Salem NH. On Call International must coordinate and provide all arrangements in order for eligible services to be covered. ComPsych® and On Call International are not Lincoln Financial Group companies and Lincoln Financial Group does not administer these Services. Each independent company is solely responsible for its own obligations. Coverage is subject to contract language that contains specific terms, conditions, and limitations. Insurance products (policy series GL1101) are issued by The Lincoln National Life Insurance Company (Fort Wayne, IN), which does not solicit business in New York, nor is it licensed to do so. Product availability and/or features may vary by state. Limitations and exclusions apply. ©2020 Lincoln National Corporation - LCN-2016756-020518-07 – R1.0 – Group ID: 997734 Voluntary AD&D Insurance At-A-Glance LFE-ADD-BRC001-TX

Voluntary AD&D Voluntary Accidental Death & Dismemberment Insurance Here’s how little you pay with group rates. Monthly Premium for You Monthly Premium $0.015 Monthly Premium for Your Spouse Monthly Premium $0.015 Monthly Premium for Your Dependent Children Monthly Premium $0.015

Note: You must be an active Goose Creek CISD employee to select coverage for a spouse and/or dependent children. To be eligible for coverage, a spouse or dependent child cannot be confined to a health care facility or unable to perform the typical activities of a healthy person of the same age and gender.

The Lincoln National Life Insurance Company Please see prior page for product information. Voluntary AD&D Insurance At-A-Glance LFE-ADD-BRC001-TX 67

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 This is is aa general general overview overview of of your your plan plan benefits. benefits. If If the the terms terms of of this this outline outline differ differ from from your your policy, policy, the the policy policy will will govern. govern. Additional Additional plan plan details on on covered covered expenses, expenses, limitations limitations and and exclusions exclusions are are included included in in the the summary summary plan plan description description located located on on the the 68 details Angleton ISD Benefits Goose Creek CISD BenefitsWebsite: Website:www.mybenefitshub.com/angletonisd www.mybenefitshub.com/goosecreekcisd

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 the following features: •

High Death Benefit. With one of the highest death benefits available at the worksite,1 purelife-plus gives your loved ones peace of mind, knowing there will be life insurance in force when you die.

•

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 tax-favored retirement plans as 403(b), 457 and 401(k).

•

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, purelife-plus offers you a refund of 10 years’ premium, should you surrender the contract if the premium you pay when you buy the contract 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 coverage, not only for yourself, but also for your spouse, children and grandchildren.5 DURING THE LAST SIX MONTHS, HAS THE PROPOSED INSURED: 1. Been actively at work on a full time basis, performing usual duties? 2. Been absent from work due to illness or medical treatment for a period of more than 5 consecutive working days? 3. 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, 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 2 Guarantees are subject to product terms, exclusions and limitations and the insurer’s claimspaying ability and financial strength. 3After the guaranteed period, premiums may go down, stay the same, or go up. 4Coverage 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. See the purelife-plus brochure for details.

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 70 details on covered expenses, limitations and exclusions are included in the summary plan description located on the Goose Creek CISD Benefits Website: www.mybenefitshub.com/goosecreekcisd

Telehealth Welcome to MDLIVE! Your anytime, anywhere doctor’s office. Avoid waiting rooms and the inconvenience of going to the doctor’s office. Visit a doctor by phone, secure video, or MDLIVE App. Pediatricians are available 24/7, and family members are also eligible. • U.S. board-certified doctors with an average of 15 years of experience. • Consultations are convenient, private and secure. • Prescriptions can be sent to your nearest pharmacy, if medically necessary.

Need a doctor? No long wait. No big bill. Always open. With MDLIVE, you can visit with a doctor 24/7 from your home, office or on-the-go.

We treat over 50 routine medical conditions including: • • • • • • •

Acne Allergies Cold / Flu Constipation Cough Diarrhea Ear Problems

• • • • • •

Fever Headache Insect Bites Nausea / Vomiting Pink Eye Rash

• • • • •

Respiratory Problems Sore Throats Urinary Problems / UTI Vaginitis And More

Welcome to MDLIVE Behavioral Health! Managing stress or life changes can be overwhelming but it’s easier than ever to get help right in the comfort of your own home. Visit a counselor or psychiatrist by phone, secure video, or MDLIVE App. • Talk to a licensed counselor or psychiatrist from your home, office, or on the go! • Affordable, confidential online therapy for a variety of counseling needs. • The MDLIVE app helps you stay connected with appointment reminders, important notifications and secure messaging.

Confidential, convenient online therapy. With MDLIVE, you can visit with a counselor or psychiatrist 24/7 from your home, office or on-the-go.

We can help you address: • • • • •

Addictions Bipolar Disorders Child and Adolescent Issues Depression Eating Disorders

• • • • • •

Introducing the MDLIVE App Sick in bed? Sick at work? Got a smartphone? Doctor visits are easier than ever with the MDLIVE App. • Access to a doctor anywhere: at home, at work, or on the go • Choose doctors from one of the nation's largest telehealth networks • Available 24/7 by video or phone Private, secure and confidential visits • Connect instantly with MDLIVE Assist

• • • • •

Relationship and Marriage Issues Stress Trauma and PTSD Women’s Issues And more

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NBS

FSA (Flexible Spending Account)

YOUR BENEFITS PACKAGE

About this Benefit A Cafeteria Plan is designed to take advantage of Section 125 of the Internal Revenue Code. It allows you to pay certain qualified expenses on a pre-tax basis, thereby reducing your taxable income. You can set aside a pre-established amount of money per plan year in a Healthcare Flexible Spending Account (FSA). Funds allocated to a healthcare FSA must be used during the plan year or are forfeited. However, your plan contains a 45 day grace period provision.

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

FLIP TO…

PG. 11

FOR HSA VS. FSA COMPARISON

This is a general overview of your plan benefits. If the terms of this outline differ from your policy, the policy will govern. Additional plan 72 details on covered expenses, limitations and exclusions are included in the summary plan description located on the Goose Creek CISD Benefits Website: www.mybenefitshub.com/goosecreekcisd

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 cases, the taxpayer identification number of the service Annual taxable income $24,000 $24,000 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 want and how much contributions should go toward each Taxable income after FSA $21,000 $24,000 benefit. It is very important that you make these choices Income taxes -$6,300 -$7,200 carefully based on what you expect to spend on each covered benefit or expense during the plan year. After-tax income $14,700 $16,800 Generally, you cannot change the elections you have made after After-tax health and welfare expenses $0 -$3,000 the beginning of the plan year. However, there are certain limited situations when you can change your elections if you Take-home pay $14,700 $13,800 have a "change in status". Please refer to your Summary Plan You saved $900 $0 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).

8523 South Redwood Road, West Jordan, Utah 84088 (800) 274-0503 service@nbsbenefits.com www.nbsbenefits.com